Complications of labour Flashcards
What are the complications of shoulder dystocia
Brachial plexus damage → Erb’s, Klumpke’s
Hypoxia / hypoxic ischaemic encephalopathy (HIE)
Fracture of clavicle/humerus
Maternal post-partum haemorrhage (PPH)
Maternal complex tears: 3rd/4th degree perineal tears, lacerations, haematoma, uterine rupture
What is the epidemiology of shoulder dystocia
Affects 0.5-0.7% of births
Brachial plexus damage occurs in 4-16% of shoulder dystocia cases
Fracture occurs in 10%
PPH occurs in 11%
What are the risk factors for shoulder dystocia
Previous shoulder dystocia
Macrosomia
Gestational diabetes or DM
Narrow pelvic outlet
Short stature/high BMI
Induction of labour
Greater gestational age
What is the management for shoulder dystocia
- Sound the alert alarm and announce a shoulder dystocia
- Direct two people to place mum into McRobert’s position and ask mum to push
- Apply suprapubic pressure and attempt to deliver
- Assess for episiotomy and carry out if needed
- Posterior arm delivery
- Internal rotation manoeuvre
- Change position to all fours and repeat
- Have another operator repeat maneouvres
- Deliberate fracture of the clavicle
- Symphysiotomy
- Zavanelli
What is the post-delivery management for shoulder dystocia
Neonatal review of baby
Paired cord pH
Anticipate and prevent PPH (Observe and administer syntometrine/syntocinon)
Document
Debrief patient
Datex
Describe McRobert’s position
Woman lies flat and the hips are hyperflexed so that the thighs are as close to the abdomen as possible
Increases the AP diameter of the pelvis
Describe suprapubic pressure
Bed needs to be low enough to place adequate pressure onto the shoulders to dislodge it
Apply pressure behind the anterior foetal shoulder, downward and lateral
Attempts to abduct the anterior shoulder towards the chest by pushing on its posterior aspect
Aims to decrease the bisacromial diameter, rotating the anterior shoulder into the wider oblique angle of the pelvis
Describe posterior arm delivery
place hand into the birth canal and pull the arm through by the inferior hand. Once arm is delivered, ask mum to push and attempt delivery
Reduces the diameter of the foetal shoulders or bisacromial diameter
Describe the internal rotation manoeuvre
insert a hand over the posterior shoulder and push forward, then placing a hand on the anterior shoulder and pushing back to rotate baby
What is meconium aspiration and what is the management
Meconium is aspirated into the lungs of the foetus → severe pneumonitis
Management: thick meconium → amniofusion of saline into the uterus to dilute the meconium to reduce aspiration (rarely performed due to unknown risk to mother)
What defines delayed first stage of labour
<2cm in 4 hours for nullis
<2cm in 4 hours or slowing in the progress of labour for multis
What defines delayed second stage of labour
> 2 hours from the start of the active second stage for nullis
1 hour from the start of the active second stage for multis
What are the causes of delayed labour
Inefficient uterine action (most common)
Issues with position:
- Malposition (occiput transverse or posterior)
- Malpresentation (brow or face)
- large baby
Cephalopelvic disproportion (pelvis too small to allow the head to pass through) - more common in macrosomia, short women, high head
Describe the endocrine axis during labour
- Oestrogen from ovaries → induction of oxytocin receptors on the uterus
- Oxytocin release from foetus and maternal posterior pituitary
- Oxytocin stimulates uterine contraction
- oxytocin stimulates the placenta to produce prostaglandins → stimulates more contractions → stimulates prostaglandins (and so on)
- Positive feedback of prostaglandins on oxytocin release from PP
What should be assessed in delayed labour
Review history
Abdominal palpation (size of baby and engagement)
Frequency and duration of contractions
- The active first stage of labour should not last >16 hours
- Review foetal conditions - foetal heart rate and colour of amniotic fluid
- Review maternal condition
- Vaginal assessment - cervical effacement, dilatation, caput, moulding, position and station
What is the management for delayed first stage
- ARM
- Move to labour ward
- Syntocinon IV + CTG monitoring
What is the management for delayed second stage
- Syntocinon
- Consider instrumental birth
How often are vaginal examinations performed during labour?
Every 4 hours
How long should third stage of labour last for
<30 minutes
Describe active third stage of labour
Started if third stage >30 minutes
1. IM syntocinon/ergometrine injection (if active already planned, give with delivery of anterior shoudler)
2. Controlled cord traction
3. Manual removal: a hand in the uterus under general or spinal anaesthesia gently separates the placenta from the uterus, with the second hand on the abdomen to prevent the uterus from being pushed up
What are the types of breech presentation
Frank/extended (65-70%): legs flexed at the hip and extended at the knees with buttocks presenting
Complete/flexed (30%): hips and knees flexed, feet ticket beside the buttocks
Footling: one or both feet/knees are presenting
(Shoulder)
What is the epidemiology and prognosis for breech presentation
Incidence decreases with gestation (prem at higher risk)
3-4% pregnancies at term
Higher perinatal morbidity and mortality
Mortality risk ~ 0.5/1000 with CS and 2/1000 with planned vaginal birth
What are the risk factors for a breech baby
Previous breech birth
Premature labour
High parity
Multiple pregnancies
Polyhydramnios, oligohydramnios
Uterine abnormalities
Maternal pelvic tumours or fibroids
Placenta praevia
Hydrocephaly/anencephaly
Foetal neuromuscular disorders
Foetal head and neck tumours
What are the management options for breech position
External cephalic version
Planned vaginal breech delivery
Caesarean section
Describe external cephalic version
External manipulation of foetus through maternal abdomen to achieve a cephalic presentation
From 36 weeks (primip), 37 (multip), more successful earlier
50% success rate
Sometimes terbutaline (?) is given to relax the uterus
What are the contraindications for external cephalic version
Absolute contraindications:
- Any requirement for C-section regardless
- Abnormal CTG
- APH <7 days
- Major uterine abnormality
- Ruptured membranes
- Multiple pregnancy
Relative contraindications (ECV may be complicated):
- SGA
- Pre-eclampsia
- Oligohydramnios
- Major foetal abnormalities
- Scarred uterus
- Unstable lie
What are the risks of external cephalic version
Generic: procedural failure, necessity to repeat
Placental abruption
Uterine rupture
Foeto-maternal haemorrhage
Give examples of tocolytics
Nifedipine (CCB)
Atosiban (oxytocin receptor antagonist)
Terbutaline (beta-agonist; NOT given in ASTHMA)
Describe planned breech delivery
- Ask mum to push until the buttocks have descended and are emerging from the canal
- Place thumbs behind the popliteal fossae of the legs as they emerge and pull the legs out
- Allow baby to come out free as mum pushes. If necessary, rotate baby with hands on the pelvis (NOT the abdomen) to keep sacrum anterior (Do NOT pull)
- As you see the scapula come through, perform Lovsett’s by rotating baby (by the pelvis) and then pulling each arm through
- Let baby come through (no direct support)
As you see the nape of the neck, perform Mariceau-Smellie-Veit (MSV) manoeuvre by placing one hand above the head and the other underneath, manually flexing the head and pulling through
What is the management for brow presentation
Caesarean section
What is the management for face presentation
Mentum anterior: may have vaginal delivery (+ syntocinon)
Mentum posterior: caesarean
What is the management for face presentation
Mentum anterior: may have vaginal delivery (+ syntocinon)
Mentum posterior: caesarean
What defines premature delivery
24-37 weeks
What are the risk factors for premature delivery
Previous preterm delivery
Previous cervical surgery
Maternal:
- Extremes of maternal age
- LLETZ or cone biopsy procedure
- Lower SES
- Short interpregnancy interval
- Maternal medical disease e.g. renal failure, diabetes and thyroid disease
- High haemoglobin
Pregnancy complications
- pre-eclampsia or IUGR
- STIs or vaginal infection or UTI
- Uterine abnormalities and fibroids
- Antepartum haemorrhage
Foetal:
- Multiple pregnancy
- Polyhydramnios
- Congenital foetal abnormalities
What is PPROM and what is its epidemiology
Preterm prelabour rupture of membranes (PPROM) = Rupture of membranes before 37 weeks gestation
3% pregnancies
Associated with 30-40% of preterm births
What defines a prolonged rupture of membranes
Anything over 24 hours
What are the causes of PPROM
Infection (most common)
Cervical incompetence
Abruption
What investigations should be done for PPROM
Admit to hospital for at least 48 hrs
1. Examination and obs
- Pooling of liquor on speculum
2. Bedside: amnisure swab OR foetal fibronectin swab, high vaginal swab, urine dip and cultures ± throat swab
3. Bloods: FBC, CRP, U&Es, G&S, blood cultures, blood gas, coagulation screen,
4. Consider LP if signs of meningitis
5. Consider if they have signs of chorioamnionitis
What is the management for PPROM without evidence of chorioamnionitis
- Admit to hospital (Depending on gestation) (at least 48hrs)
- Inform the neonatal team
- Steroids (betamethasone)
- CONSIDER Tocolysis with nifedipine or oxytocin receptor antagonists (atosiban) can be given to allow steroids time to act - IV antibiotics (PO erythromycin for 10 days or until established labour) to reduce risk of pre-term labour
- Maternal obs 4x a day (CTG, WCC, CRP)
Offer IOL at 37 weeks (GBS +ve → 34-36 weeks)
What is the management for PPROM if there is evidence of chorioamnionitis
- Admit to labour ward (at least 48hrs)
- IV antibiotics (PO erythromycin for 10 days or until established labour), fluids, paracetamol
- <34 weeks: Steroids and magnesium sulphate for neuroprotection
- Deliver IOL or LSCS
NO TOCOLYSIS - increases risk of infection
How is the risk of premature labour assessed
USS scan to assess Cervical length <24mm
Foetal fibronectin (FFN): >50 - high risk
Online assessment tool
What can be done to prevent premature delivery in a mother with risk factors
Cervical cerclage
- Insertion of one or more sutures in the cervix to strengthen it and keep it closed
1. Elective (12-14w)
2. Regular scanning and placement if there is significant shortening
3. Rescue cerclage (16-28w): placed when there are advance cervical changes/dilation to prevent delivery
Note: This can be really difficult if the cervix is short
Early pregnancy: prophylactic vaginal progesterone (16-24wks) as gel or pessary
What are the risks of PPROM
Pre-term delivery (follows within 48h in >50% of cases)
Cord prolapse
Absence of liquor → pulmonary hypoplasia and postural deformities
Neonatal infection
Intensive care admission (accounts for 80%)
Cerebral palsy (accounts for 50%)
Perinatal mortality (accounts for 20%)
Chronic lung disease
Blindness
Minor disability
What is the management for prelabour, term rupture of membranes
Confirm and identify liquor
Check lie and presentation (avoid digital examination)
CTG
Either wait for spontaneous onset of labour OR Induce labour
Meconium or evidence of infection → immediate induction
What can be tested if there is no amniotic fluid on speculum after suspected PPROM
Insulin-like growth factor-binding protein 1 (IGFBP-1) - a protein present in high conc in amniotic fluid, can be tested on vaginal fluid if there is doubt of ROM
OR
Placental a-microglobulin-1 test (PAMG-1) - similar to IGFBP-1
What is the management for preterm labour
Foetal monitoring with CTG
Tocolysis (nifedipine, atosiban)
Maternal coritcosteroids <34w
IV magnesium sulphate <34w
What are the indications for instrumental delivery
Maternal
- Exhaustion
- Delay in second stage (>2hrs nullip, >1hrs multip)
- Maternal conditions that require short second stage or avoidance of Valsalva e.g. NYHA class III or IV cardiac disease, myasthenia gravis
Foetal
- Foetal compromise
- Breech delivery (occasionally)
What are the requirements for instrumental delivery to be allowed
FORCEPS
Fully dilated cervix generally the second stage of labour must have been reached
OA position preferably OP delivery is possible with Keillands forceps and ventouse.
Ruptured Membranes
Cephalic presentation, contracting 3-4 in 10
Engaged presenting part i.e. head at or below ischial spines the head must not be palpable abdominally
Pain relief (consider LA for episiotomy if low forceps/ventouse)
Sphincter (bladder) empty this will usually require catheterization
+ Consent from mother
What are the types of instrument for delivery
Forceps: Wrigley’s, Simpson, Keilland’s
Ventouse: sialastic cup, kiwi omni cup, metal cup
Describe the types of forceps used for instrumental delivery
Low-cavity (Wrigley’s): used in C-S for the head
Mid-cavity non-rotational (Neville-Barnes, Simpson): when baby is in OA or direct OP (if rotating, do it before)
Mid cavity rotational (keilland’s): reduced pelvic curve to allow rotation
Describe the types of ventouse instruments
Sialastic: soft, easier to apply, for OA babies
Kiwi: single-use, pressure created with a hand pump, allows rotation
Metal: pressure created by suction pump, can cause foetal trauma if excessive traction
What are the contraindications to instrumental delivery
<34 weeks
Foetal bleeding disorders
Face presentation
Maternal infection (relative CI)
What are the benefits of forceps delivery
Kinder to baby
Less likely to fail
Don’t require much maternal effort
Position must be direct OP/OA
What are the risks fo forceps delivery
Facial nerve palsy
Skull fracture
Orbital injury
Intracranial haemorrhage
Vaginal and sphincter trauma to mother
What are the benefits of ventouse delivery
Kinder to mother
Less need for analgesia
Less need for episiotomy
What are the risks of ventouse delivery
Scalp lacerations and avulsions
Cephalohaematoma
Neonatal jaundice
Retinal haemorrhage
Subgaleal and or intracranial haemorrhage
Chignon (swelling of the scalp that was drawn into the cup)
What are the benefits and risks of delivery in a room vs theatre
Room:
- Quicker, one room, closer to a routine postnatal, comfort for the mother
- Harder to get out if emergency, Slower to complete CS if needed
Theatre:
- Easy to bale out
- slower to effective delivery, high dense block
What should be given to all women with instrumental delivery
Vaginal delivery (No risk factors for PPH) - IM Oxytocin 10IU
Caesarean - IV oxytocin 5IU
Increased risk of haemorrhage - ergometrine-oxytocin
