Complicated Pregnancy: abnormal delivery and labour complications Flashcards
Breech, operative delivery and VBAC Multiple pregnancy Prematurity Prolonged labour Suspected fetal compromise Retained placenta PPH
1
Q
At how many weeks is a baby considered premature?
A
<37 weeks
2
Q
At how many weeks is a baby considered:
1) Extremely preterm
2) Very preterm
3) Moderate to late preterm?
A
1) Extremely preterm= <28 weeks
2) Very preterm = 28-32
3) Moderate to late preterm = 32-36+6
3
Q
Why is baby being preterm a serious issue?
A
Single biggest cause of neonatal mortality and morbidity in UK. Major long term consequence = neurodevelopmental disability
4
Q
What are some neonatal complications form being born preterm?
A
Neonatal death
Respiratory distress syndrome
Chronic lung disease
Intraventricular haemorrhage
Necrotizing enterocolitis
sepsis
retinopathy of prematurity
5
Q
What are some neonatal risk of prematurity specifically when delivered BEFORE 28 weeks? (extremely premature)
A
Physical disabilities
Learning difficulties
Behavioural problems
visual and hearing problems
6
Q
How many pregnancies and pre-term births are affected by PPROM (preterm prelabour rupture of membranes)?
A
3% pregnancies
associated with 30-40% preterm births
7
Q
What is the medium latency after PPROM? i.e. the number of days for delivery to start after a PPROM?
A
7 days
shortens as gestational age of baby increases
8
Q
PPROM can result in neonatal morbidity and mortality…why? Please give examples of complications PPROM can lead to?
A
Prematurity
Sepsis and chorioamnionitis
Cord prolapse
Pulmonary hypolasia
9
Q
If you are assessing a lady in MAU with suspected PPROM what details in the clinical history might suggest PPROM?
A
They may mention:
- Gush of fluid from vagina
- Leaking vaginal fluid
- Increased watery discharge
- Concern or uncertainty about urinary
incontinence
10
Q
What examination and investigations to do for a pt with suspected PPROM?
A
Examination:
- DONT do a digital vaginal examination (increased risk of introducing microorganisms
- DO a sterile speculum examination
- pool of fluid in posterior vaginal vault = confirmed
-No fluid seen = test e.g. ActimPROM
Investigations:
- FBC
- CRP
- High vaginal swab
11
Q
- What is ACTIM- PROM?
- Is it sensitive?
- When can you use it?
A
- What is ACTIM- PROM?
– insulin-like growth factor binding protein-1
– Produced by decidual cells
– Present in amniotic fluid in high amounts
– Not normally found in vagina - Is it sensitive?
- yes sensitive and specific as does no react with blood or other fluids - When can you use it?
at any gestational age
12
Q
How do you manage a pt with PPROM?
A
13
Q
What is preterm labour? PTL
A
Labour/regular contractions resulting in changes in
cervix (effacement and dilatation) before 37/40
– Threatened - up to 4cm
– Established - > 4cm
(active phase of stage 1 labour begins at 4 cm dilatation)
14
Q
What are the epidemiological outcomes of preterm labour PLT?
A
- Leading cause of perinatal death and disability
- Psychosocial and emotional effects on the family
- Increased cost for health service
15
Q
What are some maternal factors / conditions that might make preterm labour more likely?
A
16
Q
Women with a history of which 4 things are at high risk of pre-term labour ?
A
Any previous hx of the following:
- Spontaneous preterm birth
- Mid-trimester loss (16+) - 24 weeks
- PPROM
- Cervical trauma
17
Q
What increased monitoring will women we are worried about, need to prevent preterm labour?
A
- Trans vaginal USS - assess cervical length
- HVS looking for BV which is associated with poor outcomes
18
Q
We are worried about a woman at risk of preterm labour. We note on TV USS that her cervix is shortening at a scan during week 16-24 of her pregnancy. What can you do to prevent a preterm labour?
A
- Prophylactic vaginal progesterone (pre-gestation!)
- Perform a cervical cerclage ( needs to removed before labour around week 36-37) which puts a suture around cervix to keep it closed.
19
Q
You are assessing a woman in MAU for pre-term labour. What specific things do you need to ask her about that might indicate PLT?
A
- Menstrual-like cramping
- Mild, irregular contractions
- Low back ache
- Pressure sensation in the vagina or pelvis
- Vaginal discharge of mucus, which may be clear, pink, or slightly bloody (ie, mucus plug,
bloody show) - Spotting, light bleeding
20
Q
When assessing a woman for preterm labour what to do you need to include and note when examining her?
A
- Abdomen:
– assess firmness, tenderness, fetal size, and fetal position - Contractions:
– Frequency, intensity, duration - Review fetal heart rate (if >26 weeks HR and uterine activity
- Speculum:
– Estimate cervical dilation
– Assess for blood or fluid
21
Q
What investigations to do for a woman suspect of preterm labour?
A
Bedside
- fetal fibronectin
- Actim partus
Transvaginal Ultrasound for cervical length ( Gold standard NICE)
- > 15 mm - unlikely PTL (discuss benefits and risk / going home / monitored in hospital)
- < 15 mm - confirmed PTL - offer treatment
22
Q
Where do you swab when performing an actim-partus bedside test for preterm labour?
A
Endocervix
23
Q
What does the actim- partus test looki for when investigating suspected preterm labour?
What interferes with the test? (i.e. don’t do it is blood is present)
A
24
Q
What is the management for preterm labour?
A
24
What is the management for preterm labour?
25
What is prolonged labour or failure to progress?
when labour is not developing at a satisfactory rate.
- Adequate progress is 2cm dilatation per 4 hours of active labour
- slowing of progress in multiparous woman
(Remember the 1st stage of labour is divided into latent stage and active stage 3-10 cm dilatation).
26
What are the causes of poor progress of labour - The 3 Ps......
1. Power (uterine contractions)
2. Passenger (size, presentation and malposition of the baby)
3. Passage (the shape and size of the pelvis and soft tissues)
Psyche can be a fourth P - support and antenatal preparation for labour and delivery.
27
Remind yourself of the phases of the first stage of labour...
(Z2F, passmed and oxford handbook slightly vary on details - here I have used passmed)
Stage 1 - from onset of true labour to when the cervix is fully dilated.
(primigravida: 10-16 hours)
- Latent phase = 0-3 cm dilation, normally takes 6 hours
- Active phase = 3-10 cm dilation, normally 1cm/hr
28
How are women monitored for their progress in 1st stage of labour?
Using a partogram
29
What is recorded on a partogram?
- Cervical dilatation (measured by a 4-hourly vaginal examination)
- Descent of the fetal head (in relation to the ischial spines)
- Maternal pulse, BP, temp and urine output
- Fetal HR
- Frequency of contractions
- Status of the membranes, ( liquor? blood or meconium in liquor?)
- Drugs / fluids that have been given
30
There are 2 lines on a partogram labelled "alert" and "action" which indicate if labour not progressing. (results are plotted taking into account dilation of cervix and time.)
what is indicated if
1) alert line
2) action line
is crossed?
1. Alert line - amniotomy (artifical rupture of membranes) and repeat examination in 2 hours
2. Action line - escalate care to obstetric led care for action
31
A woman's 1st stage of labour is not progressing as planned. Management of amniotomy and re-examination in 2 hours is decided.
What else needs to be done?
Empty bladder with catheter if she is unable to
- full bladder can be injured during labour and can also stop descent of head and reduce frequency of contractions
32
a woman is delayed in first stage of labour but her membranes have already ruptured. What management should she be given?
Oxytocin infusion (to correct malposition or insufficient uterine activity)
- reassess in 4 hours (may need 8 hours of oxytocin before see big change)
- Start CTG continuous monitoring with infusion
33
Why do you need senior advice before giving a woman with delay in 1st stage of labour oxytocin infusion if she is
a) multiparous
b) has had a lower segment caesarean section
risk of uterine rupture
(oxytocin stimulates uterine contractions - but it can become overstimulated and strained -> lead to rupture)
34
A woman is having a delayed 1st stage of labour and there are fetal compromise concerns on CTG. What needs to be done?
Foetal blood sampling before oxytocin infusion
35
If a woman is having a delayed labour and amniotomy and oxytocin infusion have not helped. What are the remaining management options?
Instrumental delivery
Caesarean section (ox handbook just says CS)
36
Oxytocin is used to stimulate uterine contractions during labour. What number of contractions is the aim for?
The aim is for 4 – 5 contractions per 10 minutes.
Too few contractions will mean that labour does not progress.
37
What is the risk of too many contractions in labour?
fetal compromise - fetus does not have the opportunity to recover between contractions
38
What is the management of fetal compromise?
emergency caesarean section
39
When do we decide that the second stage of labour is delayed?
when the active second stage (when woman starts pushing) lasts over:
2 hours in a nulliparous woman
1 hour in a multiparous woman
40
What does the success of second stage rely on?
Again 3 ps:
power - uterine contractions
passenger - size / lie / presentation / attitude
Passage - size and shape of pelvis
41
What can cause a delay in 2nd stage of labour?
Same as for 1st stage (3 ps)
But here maternal exhaustion from pushing is also a factor
42
What are management options for delayed second stage of labour?
Changing positions
Encouragement
Analgesia
Oxytocin
Episiotomy
Instrumental delivery
Caesarean section
43
How is delay in 3rd stage of labour defined?
The third stage of labour is from delivery of the baby to delivery of the placenta.
> 30 minutes with active management
> 60 minutes with physiological management
44
What can be a cause of delayed 3rd stage of labour?
Retained placenta
45
What is the biggest danger of a retained placenta?
Haemorrhage
46
What are associations / RF for retained placenta?
Previous retained placenta or uterine surgery
preterm delivery
maternal age >35 yrs
placental weight >.600g
Parity > 5
induced labour
Pethidine use in labour
47
What is the management of retained placenta (conservative not drug or surgical yet pls)
- avoid excessive cord traction incase it snaps
- check placenta not in vagina
- palpate abdomen
- rub up a contraction and encourage breast feeding (stimulates oxytocin)
48
What is the management of retained placenta (drugs pls)
Give 20 units of oxytocin in 20 ml of saline into umbilical vein and clamp cord proximally to injection site.
Empty bladder (cause atony)
49
What do you do if medical management of retained placenta has not worked in 30 mins?
Worried about PPH so examine to see if manual removal is needed
-IV access / FBC / G&S / consent woman for manual removal
- Take woman to theatre regional anaesthesia (epidural or top up) and manually remove.
50
How should woman be placed for a manual removal of placenta?
in lithiotomy position
51
What antibiotic cover is needed when doing a manual removal of retained placenta?
e.g. metronizadole 500 mg IV
52
What is shoulder dystocia?
'a delivery needing additonal obstetric manoeuvres to release shoulders after gentle downward traction has failed'
Head is delivered but shoulder is stuck. often the anterior fetal shoulder on the maternal pubic symphysis.
53
What are risk factors for shoulder dystocia?
fetal macrosomia (hence association with maternal diabetes mellitus)
high maternal BMI
diabetes
prolonged labour
54
What is management of shoudler dystocia?
- Senior help (midwives, obstetricians, anaesthetist and scribe for timings)
- McRobert's manoeuvre - hyperflexed lithotomy position (thighs towards abdomen)- increases angle of pelvis to help delivery
- episiotomy for better access for internal manoeuvres (wont help shoulder dystocia itself)
- Suprapubic pressure / internal manoeuvres to rotate shoulders / woman on all fours
55
What are potential maternal and fetal complications of shoulder dystocia ?
maternal:
postpartum haemorrhage
perineal tears 3rd / 4th degree
fetal:
brachial plexus injury - e.g. erbs palsy
clavicle damage
neonatal death
56
Why is fetal monitoring done in labour?
To detect fetal compromise
either intermittent auscultation (low risk women)
CTG (increased risk maternal and neonatal of fetal compromise)
57
Why is important to detect fetal compromise?
10% cerebal palsy due to intrapartum hypoxia
uterine contractions constrict blood supply to fetus especially in second stage of labour
58
What are maternal and neonatal risk factors for foetal compromise and hence CTG during labour?
Induction of labour
post maturity >42 weeks
Previous lower segment CS
Maternal cardiac problems
Pre-eclampsia / HTN
Prematurity <37 weeks
Prolonged rupture of membranes >2 hr
Diabetes
antepartum or intrapartum haemorrhage
SGA
Oligohydraminos
abnormal umbilical artery dopplers
multiple pregnancy
meconium stained liquour
abnormal lie e.g. breech
oxytocin augmentation
epidural
pyrexia
abnormality on intermittent auscultation
59
Is CTG always accurate at telling if there is fetal compromise?
No, a fetus with an abnormal CTG will be hypoxic and therefore acidotic on fetal blood sampling only 50% of the time
60
What are signs look for to classify CTG as normal or abnormal?
61
How to improve CTG accuracy / correct any insults ?
put woman in left lateral position to take weight off the great vessels // correct any cord compression
Iv fluids
reduce / stop oxytocin in > 5 contractions in 10 mins or bradycardia
(Terbutaline 250mcg SC can be used in an emergency to stop / reduce contractions)
62
What to do is CTG is abnormal?
Fetal scalp stimulation (+ve response will show acceleration on CTG)
Foetal blood sampling
consider speeding up delivery
63
Why do we do fetal blood sampling?
To improve specificity of CTG in detecting hypoxia (if bradycardia >3 min immediate CS)
64
How to perform fetal blood sampling?
woman in Left lateral positon
speculum with light against fetal scalp
small scratch made
collected and analysed in blood gas machine
(woman needs to be 4cm dilated w/ ruptured membranes)
if FBS fails - deliver emergency CS
65
When is fetal blood sampling contraindicated?
if suspect idiopathic thrombocyotpenic purpura
blood borne viruses
pyrexia (caution)
66
What is normal value for FBS result ?
normal PH >7.25 repeat is CTG remains abnormal
67
What is borderline FBS result (PH value)
7.21 - 7.24
repeat in 30 mins if CTG stays abnormal
68
What is abnormal FBS result (PH value)
<7.20
IMMEDIATE delivery
69
Indications for elective c-section?
Previous caesarean
Symptomatic after a previous significant perineal tear
Placenta praevia
Vasa praevia
Breech presentation
Multiple pregnancy
Uncontrolled HIV infection
Cervical cancer
70
What anaesthetic is used for c-section?
Spinal- goes in the subarachnoid space, will be transported around the body quicker than epidural, due to the fluid medium
71
What are the categories of the emergency c-section?
* Category 1: Immediate threat to the life of mother or baby- decision to delivery time: 30 mins
* Category 2: Not an imminent threat to life, but c-section is required urgently due to compromise of mother or baby. Decision to delivery time is 75 mins
* Category 3: Delivery required, but mother and baby are stable
* Category 4: Elective c-section
72
What incisions do you use in c-section?
Pfannenstiel incision is a curved incision two fingers width above the pubic symphysis
Joel-cohen incision is a straight incision that is slightly higher (this is the recommended incision)
73
When do you use blunt dissection in a c-section?
* after the inital incision
* Uses fingers, blunt instruments and traction to tear them apart
* results in less bleeding and shorter operating times and less injury to baby
74
Layer of abdoment that need to be dissected during c-section?
* Skin
* Subcutaneous tissue
* Fascia / rectus sheath (the aponeurosis of the transversus abdominis and external and internal oblique muscles)
* Rectus abdominis muscles (separated vertically)
* Peritoneum
* Vesicouterine peritoneum (and bladder) – the bladder is separated from the uterus with a bladder flap
* Uterus (perimetrium, myometrium and endometrium)
* Amniotic sac
75
Serious maternal risks of c-section?
emergency hysterectomy
need for further surgery at a later date, including curettage (retained placental tissue)
admission to intensive care unit
thromboembolic disease
bladder injury
ureteric injury
death (1 in 12,000)
76
What are the risks of c-section on future pregnancy?
* increased risk of uterine rupture during subsequent pregnancies/deliveries
* increased risk of antepartum stillbirth
* increased risk in subsequent pregnancies of placenta praevia and placenta accreta)
77
Frequent Maternal risk of c-section?
persistent wound and abdominal discomfort in the first few months after surgery
increased risk of repeat caesarean section when vaginal delivery attempted in subsequent pregnancies
readmission to hospital
haemorrhage
infection (wound, endometritis, UTI)
78
Frequent fetal risks of C-section?
Lacerations, one to two babies in every 100
79
How many women go onto have a VBAC?
70-75%
80
How would you manage a VBAC compared to a normal vaginal birth?
* Lower threshold for how long labour should last
* Lower threshold for foetal compromise
* Wouldn't do a FBS
* If 2 previous c-sections, will not induce labour or use oxytocin
* want IV access and continuous monitoring
80
How would you manage a VBAC compared to a normal vaginal birth?
* Lower threshold for how long labour should last
* Lower threshold for foetal compromise
* Wouldn't do a FBS
* If 2 previous c-sections, will not induce labour or use oxytocin
* want IV access and continuous monitoring
81
Risks of doing a VBAC?
* 1/200 scar rupture
* baby may not survive labour (2/1000) BUT this is the same as 1st time labour, planned c-section is 1/1000 chance so not much difference
82
Benefits of VBAC?
* no major abdo surgery
* recovery is a lot easier
* less bleeding risk
* less risk to subsequent pregnancies
83
How do we reduce the risks in a c-section?
* H2 receptor antagonists (e.g. ranitidine) or proton pump inhibitors (e.g. omeprazole) before the procedure
* Prophylactic antibiotics during the procedure to reduce the risk of infection
* Oxytocin during the procedure to reduce the risk of postpartum haemorrhage
* Venous thromboembolism (VTE) prophylaxis with low molecular weight heparin
84
Why do we give PPIs before a c-section?
Due to risk of aspiration pneumonitis caused by reflux and aspiration during the prolonged period lying flat
85
When do you perform an instrumental delivery?
* failure to progress
* fetal distress
* maternal exhaustion ( also if mother has risks and you don't want her to push too hard e.g. previous pneumothoraces, retinal detachment)
* control of head in various fetal positions
* Increased risk with epidural
86
When can you use an instrumental delivery?
If mother fully dilated
87
Where do you do an instrumental delivery?
Room or theatre
* theatre if baby is malpresentation/ not sure if it will come out vaginally, do in theatre as quick turnaround for c-section
88
Maternal risk of instrumental delivery?
Maternal trauma more common in forceps delivery
* Postpartum haemorrhage
* Episiotomy
* Perineal tears
* Injury to the anal sphincter
* Incontinence of the bladder or bowel
* Nerve injury (obturator or femoral nerve)
89
Fetal risks in instrumental delivery?
Cephalohaematoma with ventouse
Facial nerve palsy with forceps
Transient tachyypnoea of the newborn- risk decreases after 39 weeks
Serious risks (rare):
Subgaleal haemorrhage (most dangerous)
Intracranial haemorrhage
Skull fracture
Spinal cord injury
90
Symptoms of femoral nerve injury post instrumental delivery?
* Weakness of knee extension
* loss of patella reflex
* numbness of the anterior thigh and medial lower leg
91
Symptoms of obtruator nerve delivery in instrumental delivery?
Weakness hip adduction and rotation
numbness of medial thigh
92
What is induction of labour?
the process of starting labour artificially.
Whilst most women will go into labour spontaneously by week 42 of gestation, roughly 1 in 5 pregnancies will require an induction.
93
Why induce labour?
* baby will be safer delivered than remaining in utero.
* may be for reasons concerning the mother’s health.
94
Indications for
Induction of labour?
Prolonged gestation
* offer IOL between 40+0 to 40+14 weeks’ gestation
Premature rupture of membranes
* (>37 weeks’) offer IOL, or xpectant management - max 24 hours (due to risk of ascending infection – chorioamnionitis).
Maternal health problems
* hypertension, pre-eclampsia, diabetes and obstetric cholestasis.
Fetal growth restriction
* second most common reason
* aim to delvier prior to fetal compromise
Intrauterine Fetal Death
* if mother is well with intact membranes
95
Induction of laboour with PPROM (preterm premature rupture of membranes)
* <34 weeks’ gestation – delay IOL unless obstetric factors indicate otherwise e.g. fetal distress.
* >34 weeks’ gestation – the timing of IOL depends on risks vs benefits of delaying pregnancy further e.g. increased risk of infection.
96
Contraindications for induction of labour?
97
Methods of induction of labour?
* vaginal prostaglandins
* amniotomy
* membrane sweep
98
Induction on labour: vaginal prostaglandins
| how worksm rough idea of preparation and how given
* first line method
* prepare cervix for labour by ripening it and contraction of uterus
* Table, gel or controlled release pessary
e.g.
* Tablet/gel regimen: 1 cycle = 1st dose, plus a 2nd dose if labour has not started 6 hours later.
* Pessary regimen: 1 cycle = 1 dose over 24 hours.
99
Induction of labour - amniotomy
* membranes ruptured artifically with amnihook
* performed once cervix is 'ripe' (bishops score)
* Oxytocin can be given alongisde to increase strength and frequency of contractions
* not primary method of IOL as risk of uterine hyperstimualtion (first line is prostaglandin use contraindicated)
100
Induction of labour : membrane sweep
* offered at 40 and 41 weeks to nulliparous and 41 to multiparous
* performing increases chance of spontaenous delivery
* performed by inserting a gloved finger through cervix and rotating it against the fetal membranes, aiming to separate the chorionic membrane from the decidua. The separation helps to release natural prostaglandins in an attempt to kick-start labour.
101
Monitoring in induction of labour ?
Score system
* Bishop score - for cervical ripeness
* checked prior to induction, and during induction to assess progress (6 hours post-table/gel, 24 hours post-pessary):
* Score ≥ 7 – cervix is ripe– high chance of a response to IOL
* Score of <4 – labour is unlikely to progress naturally and prostaglandin tablet/gel/pessary will be required
## Footnote
Failure of a cervix to ripen despite use of prostaglandins may result in the need for a caesarean section.
102
Monitoring of baby before IOL?
* CTG
* needed before starting IOL
* After initiation of IOL, when contractions begin assess fetal heart rate using continuous CTG until a normal rate is confirmed.
* Subsequently assess using intermittent auscultation.
If an oxytocin infusion is started, monitor using continuous CTG throughout labour.
103
Complications of Induction of labour?
104
What is a breech presentation?
A breech presentation is when the fetus presents buttocks or feet first (rather than head first – a cephalic presentation).
It has significant implications in terms of delivery – especially if it occurs at term (>37 weeks). Breech deliveries carry a higher perinatal mortality and morbidity, largely due to birth asphyxia/trauma, prematurity and an increased incidence of congenital malformations.
105
Different types of breech presentation ?
1. Complete (flexed) breech – both legs are flexed at the hips and knees (fetus appears to be sitting ‘crossed-legged’).
2. Frank (extended) breech – both legs are flexed at the hip and extended at the knee. This is the most common type of breech presentation.
3. Footling breech – one or both legs extended at the hip, so that the foot is the presenting part.
106
RF for breech presentation: divide into uterine and fetal
107
Are you worried about breech presentation prior to 32-35 weeks?
NO - the fetus is likely to revert to a cephalic presentation before delivery
108
How is breech presentation identified?
Clinical examination
* palpation and feeling fetal heart in upper part of uterus
* irregular mass (buttocks and legs) in pelvis
* if fetal heart is ausculted higher on maternal abdomen
20% not identidified until labour
* signs of fetal distress e.g. meconium liquor
109
Differenicals for breech?
* oblqiue lie
* transverse lie
* unstable lie
110
Investigations for breech?
* ultrasound scan
* identify the type of breech (flexed/extended/footling).
* reveal any fetal or uterine abnormalities that may predispose to breech presentation.
111
What are the management options for breech presentation?
*if < 36 weeks: many fetuses will turn spontaneously
* external cephalic version
* Caesarean section
* vaginal breech birth.
112
What should you tell women to help made decison about breech presentation management?
Iformation to help decision making - the RCOG recommend:
* 'Women should be informed that planned caesarean section carries a reduced perinatal mortality and early neonatal morbidity for babies with a breech presentation at term compared with planned vaginal birth.'
* 'Women should be informed that there is no evidence that the long term health of babies with a breech presentation delivered at term is influenced by how the baby is born.'
113
RCOG absolute contraindications to ECV in breech presentation:
* where caesarean delivery is required
* antepartum haemorrhage within the last 7 days
* abnormal cardiotocography
* major uterine anomaly
* ruptured membranes
* multiple pregnancy
114
complications of breech presentation?
* MAJOR: cord prolapse 1%
* Fetal head entrapment
* Premature rupture of membranes
* Birth asphyxia – usually secondary to a delay in delivery.
* Intracranial haemorrhage – as a result of rapid compression of the head during delivery.
