Complications in Delivery

Question 1

Breech Presentation

Answer 1

Occurs when Buttocks lie over Maternal Pelvis in a Longitudinal Lie, with Head within Fundus
o Extended (70%) – Both legs extended with feet by head; Presenting part is Buttocks
o Flexed (15%) – Legs flexed at knees so Buttocks and Feet are presenting
o Footling (15%) – One leg flexed, one leg extended
▪ Greatest risk of Cord Prolapse

Question 2

When is breech presentation most commonly?

Answer 2

Decreasingly common with gestation (3 – 4%); More common in preterm
o Most commonly Idiopathic; RF: Previous Breech, Uterine Abnormalities, Placenta
Praevia and Pelvic Obstruction, Foetal Abnormalities, Multiple Pregnancy

Question 3

Consequences of breech presentation

Answer 3

Increased risk of Hypoxia and Trauma in Labour; Increased Neonatal and
Longer-term risks; Might be due to association with Congenital Abnormalities, or Prem; Most Breech deliveries are performed by CS

Question 4

Breech Presentation: O/E

Answer 4

Commonly undiagnosed before labour (30%); On examination, Longitudinal Lie, Head palpated in Fundus and Presenting part is not hard; FHR best heart high up on Uterus
o <36/40 Breech is not important unless in labour
o Ultrasound confirms diagnosis; Assess growth
and anatomy for abnormalities

Question 5

External Cephalic Version

Answer 5

Manual turning of Breech or Transverse into Cephalic
Presentation; Performed from 36/40 in Primiparous
and 37/40 if Multiparous; Aims to reduce need of CS

Question 6

Success rate of ECV

Answer 6

50% Success rate, with 3% spontaneous reversion to
Breech Presentation
o More difficult if Primiparous, Difficulty
palpating head, High Uterine Tone, Engaged
Breech, Less Amniotic fluid and White
o ±Tocolytic drugs given (E.g. Salbutamol)
o ~0.5% require immediate CS delivery due to
FHR abnormalities or PV bleeding

Question 7

Contraindications to ECV

Answer 7

Antepartum Haemorrhage, Foetal Compromise,
Oligohydramnios, Rh Isoimmunisation, Pre-Eclampsia;
Relative CI: One previous CS, Foetal Abnormalities,
Maternal HTN

Question 8

Management of Breech Delivery

Answer 8

CS reduces Neonatal Mortality and Short-term Morbidity, although not in long term; Based on current best evidence; Elective CS > NVD under best conditions

Question 9

Management of Breech Delivery: Advanced Labour

Answer 9

Breech in advanced labour, or second twin, or preterm not necessarily best by CS

Question 10

Management of Breech Delivery: Vaginal Delivery

Answer 10

Oxytocin Augmentation not advised; Failure of Buttocks to Descend is sign
that delivery might be difficult

Question 11

Management of Breech Delivery: Delivery of buttocks

Answer 11

Baby encouraged to remain back upwards, but should not otherwise be touched until Scapula is visible
Arms are then hooked down by index finger at Foetal Elbow, bringing them to Chest; Body is then allowed to hang; If arms stretched above and cannot be reached – Lovset’s Manoeuvre (Rotation and Counter-rotation to allow Shoulders to enter pelvis)
• Once neck visible, Apply Mauriceau-Smellie-Veit Manoeuvre to deliver head; Instrumentation if failed; Gentle and slow delivery of
head to avoid rapid decompression

Question 12

Shoulder Dystocia

Answer 12

Delivery that requires additional Obstetric

Manoeuvres after gentle downward traction of the head has failed to deliver

Question 13

Consequences of Shoulder Dystocia

Answer 13

Foetal Hypoxia, HIE, Brachial Plexus Injury, Fractured Clavicle or Humerus, Intracranial Haemorrhage, Cervical Spine Injury, rarely Foetal Death
• Maternal PPH, Genital Tract Trauma E.g. Perineal Tears

Question 14

How does shoulder dystocia arise?

Answer 14

Usually – Anterior Shoulder impacted against
Symphysis Pubis, often due to Failure of Internal Rotation of Shoulders; Rarely Posterior Shoulder (against Sacral Promontory)
o Foetal Deterioration is rapid largely due to Cord Compression and Trauma

Question 15

How is shoulder dystocia anticipated?

Answer 15

Anticipated by Limited or
Slow Delivery of Head; McRoberts’ Manoeuvre
Prophylactically

Question 16

Risk Factors for Shoulder Dystocia

Answer 16

Previous Dystocia, Foetal Macrosomia, Maternal Obesity, DM and Post-dates

Question 17

Management of Shoulder Dystocia

Answer 17

Aim to Facilitate Entry of Anterior (or Posterior) Shoulder into Pelvis and Rotation
• Call for Help; Episiotomy (may help internal manoeuvres), Legs into McRoberts’
• Suprapubic Pressure applies to Posterior Aspect of Anterior Shoulder to dislodge
o 80% should be able to delivery at this point
• Enter with Internal Maneouvres – Rubin II (Pressure on Posterior Aspect of Anterior Shoulder); Woods’ Screw (Combine
with Pressure on Anterior Aspect of Posterior Shoulder); If Failed, Reverse-Wood’s Screw (=Rubin I)
• Flex Posterior Elbow, Sweep Foetal Arm across Chest and Face to release Posterior Shoulder
• Roll over onto All-four may help delivery (Gaskin Manoeuvre)
• Other Manoeuvres – Zanvanelli with CS, Symphysiotomy
• PPH should be anticipated and can be prevented with Oxytocin infusion; Paediatrics must be summoned as need for Neonatal Resuscitation anticipated

Question 18

Cord Prolapse

Answer 18

Umbilical Cord protrudes below Presenting Part after Rupture of Membranes; Compression of Umbilical Vessels by Presenting Part and Vasospasm due to Exposure leads to Acute
Compromise of Foetal Circulation; For Immediate Delivery

Question 19

Risk Factors of Cord Prolapse

Answer 19

Abnormal Lie/Presentation, Multiple Pregnancy,

Polyhydramnios, Prem, High Head, Unusually long cord

Question 20

Prevention of Cord Prolapse

Answer 20

Stabilising Induction when Presenting Part is high

or if Polyhydramnios

Question 21

Management of Cord Prolapse

Answer 21

• Rapid Delivery-Instrumental or Cat 1 CS
• Prevent Cord Compression during transfer to CS by Knee-to-chest position, Filling bladder with 500ml warm NaCl to displace presenting part (Unclamp cath before entering Peritoneum
in CS to reduce risk to bladder)
• Prevent spasm by avoiding Cord Exposure – Reduce Cord into Vagina, Insert Warm NaCl swab
• Tocolytics (E.g. Terbutaline 250micrograms SC) – Abolish contractions to improve foetal oxygenation but risk of PPH due to Uterine Atony
• Neonatal Team present at delivery

Question 22

Uterine Inversion Risk Factors

Answer 22

Strong Cord Traction with Excessive Fundal Pressure, Abnormal Adherence of Placenta, Uterine Abnormalities, Fundal Implantation, Short Cord,
Previous Inversion

Question 23

Consequences of Uterine Inversion

Answer 23

Haemorrhage present in 94%; Severe Lower Abdominal Pain in Third Stage, Shock out-of-proportion to Blood loss (increased Vagal Tone); Uterine Fundus non-palpable; Mass in Vagina on examination

Question 24

Management of Uterine Inversion

Answer 24

• Call for Help; Immediate Replacement by pushing
Fundus through Cervix with palm of hand (Johnson
Maneouvres)
• Two Large Bore IV; FBC, Coagulation, XM 4 – 6U;
Immediate Fluid Replacement
• Transfer to Theatre; Leave Placenta In-situ if not
delivered; Removal attempted only after replacement of Uterus (Which may be easier with Tocolytics or GA
• Hydrostatic Repositioning, after ruling out Uterine
Rupture – Warm NaCl rapidly infused into vagina, and Labia sealed (O’Sullivan’s Technique)

Question 25

Failure to resituate uterus

Answer 25

Failure requires Laparotomy (Haultain’s or | Huntingdon’s Procedures)

Question 26

Obstetric Haemorrhage

Answer 26

Severe =Loss of 30-40% of maternal blood volume (~2L); Caused by insult leading to Hypovolaemia/Coagulopathy, rarely direct coagulation failure could be primary cause Haemodynamic state of pregnancy leads to increased rate of loss; 500ml – 1L well tolerated • Pulse Rate is better for assessing degree of blood loss, especially if Occult • Loss >1L – Acute Hypovolaemia, Shock, Loss of Clotting Factors (Washout), DIC, Hypoxia (Leading to Lactic Acidosis) and MOF

Question 27

Consequences of Haemorrhage

Answer 27

``` Leads to Acute Hypovolaemia, CVS Decompensation, DIC; Iatrogenic from Fluid Replacement and Transfusion (Oedema, Reactions, ARDS), Sheehan Syndrome (Pituitary Infarct) ```

Question 28

Antepartum causes of Massive Obstetric Haemorrhage

Answer 28

Placental Abruption, Placenta Praevia, Severe Chorioamnionitis or Sepsis, Severe Pre- Eclampsia, RPOC/Foetus o Defined as any bleeding between 24/40 and Delivery of baby

Question 29

Intrapartum causes of Massive Haemorrhage

Answer 29

o Intrapartum – Abruption, Uterine Rupture, Amniotic Fluid Embolism, Complications of CS, Adherent Placenta (Accreta, Percreta)

Question 30

Post partum causes of Massive Haemorrhage

Answer 30

Tone, Trauma, Thrombin, Tissue, also can be due to Infection, or rarely GTD or Uterine AVM o Defined as more than 500ml loss o Primary if within 24h of delivery o Secondary if between 24h and 6 weeks

Question 31

Resuscitation in Massive Obstetric Haemorrhage

Answer 31

• Call for help and Code Red Massive Transfusion protocol initiated; Left Lateral Tilt if Antepartum • High-flow Oxygen, Airway and Breathing (Intubate if reduced LOC from Hypotension) • Two Large-bore Cannula; FBC, XM, U/Es, LFTs, Coagulopathy screen; IV NaCl • Catheterise and monitor Hourly UO • Transfusion – O negative used until XM available; Replace Clotting Factors (1U FFP per 1-2U RBC); Consider Cryoprecipitate and Platelets • Transfer to theatre; Assess need for CVP line; Once haemorrhage controlled, should be managed in HDU or ICU

Question 32

Disseminated Intravascular Coagulopathy

Answer 32

Mainly due to Blood loss; Depletion of Fibrinogen, Platelets and Coagulation factors consumed or lost in blood; Infusions further dilute; Hypotension-mediated Endothelial Injury may also trigger DIC • Diagnosis by FDPs, Fibrinogen, PTT and aPTT • Replacement of Blood Products – 1U FFP with each unit of rapidly transfused blood, Cryoprecipitate, Platelet Concentrate, Recombinant Factor VII • Consider Tranexamic acid 1g IV

Question 33

Management of Massive Obstetric Haemorrhage

Answer 33

Most commonly Uterine Atony due to RPOC; Empty | Uterus, Treat Atony, Repair Trauma

Question 34

Management of Massive Obstetric Haemorrhage: Medical Management

Answer 34

Physical Maneouvres, IV/IM Ergometrine 500 micrograms, Oxytocin Infusion 40IU; 10IU more if bleeding continues; If still persistent, or Ergometrine CI, Misoprostol PR 800 micrograms o If still persistent, Carboprost 250 micrograms IM; 15 min interval, max 4 doses

Question 35

Management of Massive Obstetric Haemorrhage: Tamponade Test

Answer 35

Rusch Balloon Cath (or other devices) filled with warm saline; If bleeding stops within 15 mins, left in-situ for 12-24hrs and then removed; Stops bleeding in 80%

Question 36

Management of Massive Obstetric Haemorrhage: EUA

Answer 36

EUA with possible surgery if all measures fail – Removal of Retained Tissues, Undersewing, Compression Sutures, Systematic Pelvic Devascularisation, Hysterectomy as last resort

Question 37

Management of Massive Obstetric Haemorrhage: Arterial Embolisation

Answer 37

Femoral Artery Access and contrast dye added to identify bleeding vessels; Embolisation with Gelatin sponge (Reabsorbed in about 10 days) o Can be done Prophylactically, where balloons are placed in Internal Iliac or Uterine Vessels in advance electively; E.g. in Major Praevia with Accreta

Question 38

Preterm Labour

Answer 38

Delivery between 24 and 37/40; Delivery <34/40 associated with more adverse outcomes o 1/3 Medically indicated (e.g. For Severe Pre-Eclampsia) while remainder spontaneous o 5 – 10% of births, but 50% Perinatal death; Also linked to Long-term Disabilities – Blindness, Deafness, Cerebral Palsy o >50% with Painful, Preterm contractions will not delivery preterm

Question 39

Risk Factors for Preterm Labours

Answer 39

Previous Prem/Late Miscarriage, Multiple Pregnancy, Cervical Surgery, Uterine Abnormalities, Pre-Eclampsia, IUGR (Iatrogenic and Spontaneous)

Question 40

Risk associated with Preterm Labour

Answer 40

Associated with Infection, Inflammation, Abruption

Question 41

Acute Preterm Labour

Answer 41

Preterm Labour associated with Cervical Weakness – Increased Vaginal Discharge, Mild Lower Abdominal Pain, Bulging Membranes SROM is a common presentation of preterm labour

Question 42

Managing Acute Preterm Labour

Answer 42

Hx, O/E (Maternal, Foetal Presentation, Speculum Examination) • Investigations – FBC, CRP, Swabs, MSU, Ultrasound for Foetal Presentation and EFW • Foetal Fibronectin (FFN) – Protein from Cervicovaginal Secretions; Not present at 22 – 36/40 o If Negative, unlikely to be in labour; Predicts Preterm within 7 – 10 days • TV USS – Cervical Length <15mm risk of Delivery within 7 days ~50%

Question 43

Management of Preterm Labour

Answer 43

• Admit if High Risk; Inform Neonatal Unit • Check Foetal Presentation with Ultrasound; 12mg Betamethasone IM OD 2× o Antenatal Steroids reduces rates of Respiratory Distress, Intraventricular Haemorrhage and Neonatal Death • Consider Tocolytics if not >24hrs – Nifedipine or Atosiban IV o Allows for time for steroid action and transfer o Trials have not shown improvement; Aim should be prolongation of Gestation, and Improvement of Perinatal Morbidity and Mortality • Senior Help, Neonatology; Especially if margins if Viability (23 – 26/40); Clear plan regarding Mode of Delivery, Monitoring and Paediatric Intervention • IV Antibiotics – Only if Labour is confirmed; ORACLE Trial recommends Erythromycin; Co- Amoxiclav should be avoided due to increased risk of NEC • If PPROM plus evidence of Chorioamnionitis – Steroids 1×, Delivery, Broad-spectrum Cover o EPICure – If Gestation <20/40, few survivors; If >22/40, Survival up to 50%

Question 44

Prevention of Preterm Labour

Answer 44

• Treatment of Bacterial Vaginosis – Reduce incidence of PPROM and Low Birthweight; Clindamycin rather than Metronidazole is used • Progesterone – For High Risk Women (Previous Hx) to reduce recurrence, as well as low-risk women with Short Cervix; Not effective for Multiple Pregnancy • Cervical Sutures and Pessaries – Electively, Ultrasound-indicated or Rescue • Reduction of Pregnancy number – However, slightly increases risk of early miscarriage