Intrapartum Care (FRANZCOG lecture)

Question 1

Incidence of breech at term?

Answer 1

3%

Question 2

Maximum number of attempts of ECV?

Answer 2

4 attempts max

no longer than 10 minutes

Question 3

Neonatal morbidity and mortality term breech trial?

Answer 3

5% vaginal delivery

1.6% CS

Question 4

Contraindications term vaginal breech delivery?

Answer 4

cord presentation
FGR
macrosomia >3.8kg
presentation not extended or flexed breech
hyperextension fetal neck on USS
fetal compromise
fetal anomaly incompatible with vaginal delivery

Question 5

Management of second stage vaginal breech?

Answer 5

passive second stage until breech on perineum.

If not visible within 2 hours of passive second stage, CS should be recommended.

Question 6

Recommended timing during fetal breech delivery from buttocks to head, umbilicus to head?

Answer 6

b–> h 5 min

u –> h 3 min

Question 7

Factors that increase probability of successful ECV?

Answer 7

race
parity
uterine tone
liquor volume
engagement of breech
palpable head
use of tocolysis

Question 8

Cumulative proportion of spontaneous labours that started by 40-40+6?

Answer 8

82.8%

Question 9

Risks of continuing pregnancy beyond 41 weeks?

Answer 9

increased likelihood of caesarean birth
increased likelihood of NICU admission
Increased likelihood of SB and NND

Question 10

NICE comparison 39w + 40-42 weeks. Findings?

Answer 10

no difference maternal m&m
no difference perinatal m&m
no difference NICU admission

increased maternal satisfaction earlier induction
lower incidence CS 39/40

Question 11

NICE comparison 41 weeks versus 42 weeks IOL. Findings?

Answer 11

no evidence

• maternal m&m
• neonatal morbidity
• NICU
• assisted delivery or CS

decreased risk perinatal mortality (moderate)

• OR 0.19 (0.06-0.63) 95% CI
• 3 fewer per 1000
• 42w= +0.3%

decreased risk NICU admission (low)
-RR 0.69 (0.53-0.90) 95% CI
- 1.4 fewer per 1000
- 42w = +.14%
Trend towards reduce Meconium aspiration syndrome.

Question 12

NICE guideline post-hoc analyses for:

• IOL maternal age 35y+
• IOL BMI 30+

Findings?

Answer 12

41 vs 42w IOL

• OR 0.19 (0.06-0.62) perinatal death
• OR 0.20 (0.06-0.64) perinatal death

Question 13

Risk difference of CS and NICU admission after IOL at 39w vs. 40-42w?

Answer 13

CS=
186 vs 222 per 1000
3.6/100 extra women in 40-42 w IOL would need CS

NICU =
117 vs 130 per 1000 babies
1.3/100 extra babies in 40-42w IOL would need NICU

Question 14

Risk difference for IOL at 41w vs 42w for

• perinatal death
• nicu admission

Answer 14

PND =
4 babies per 10,000 vs. 35 babies per 10,000
+0.3%
9969/10,000 babies have the same outcome

NICU admission
30 babies per 1000 vs. 44 babies per 1000. +3%
986 babies would have the same outcome.

Question 15

Cochrane findings regarding IOL vs. expectant post-term management?

Answer 15

PND RR 0.31 (0.15-0.64)
NNT 544 to prevent one SB

Stillbirth RR 0.30 (0.12-0.75)
NICU RR 0.88 (0.80-0.96)
Apgars <7 @5min RR 0.73 (0.56-0.96)
LSCS RR0.90 (0.85-0.95)

Shorter LOS
no difference in operative vaginal births, perineal trauma, PPH, breastfeeding at discharge.

Question 16

Balloon IOL vs. PGE2?

• vaginal deliveries
• LSCS
• hyperstimulation
• neonatal morbidity
• perinatal death
• NICU admission

Answer 16

no difference in vaginal delivery
no difference in LSCS

Reduces risk:
uterine hyperstimulation RR0.35
serious neonatal morbidity/perinatal death RR 0.48
NICU admission (RR 0.82)

low to moderate evidence. Balloon safer.

Question 17

Amniotomy +/- IV oxytocin for IOL

• vaginal deliveries
• instrumental deliveries
• PPH
• maternal dissatisfaction

Answer 17

ARM vs ARM + oxytocin
decreased vaginal deliveries in 24 hrs vs amniotomy w oxytocin (RR 0.03)

ARM + oxytocin vs. placebo
reduced instrumental deliveries (RR 0.18)
increased PPH (RR5.5)

ARM + oxytocin vs. PGE2
increased maternal dissatisfaction with ARM oxygen (RR53)

Question 18

LSCS consent risks

Answer 18

<1%
hysterectomy
repeat surgery
ICU admission
uterine rupture
stillbirth in future pregnancy
placenta praevia
urinary tract injury

<0.1%
death
blood clots

Question 19

Risk of infection with CS?

Answer 19

8%.
Reduced with chlorhex vs. iodine (RR 0.72)
vaginal prep (RR 0.41)

Joel Cohen post op fever reduction
RR 0.35

MROP vs. CCT placenta
endometritis RR 1.64 (1.42-1.90)

Question 20

compare 3 neonatal outcomes of ventouse vs. forceps.

Answer 20

1. increased cephalohaematoma OR 2.4
2. increased retinal haemorrhage
3. reduced facial injury
4. same Apgar, phototherapy

Question 21

Risk of OASIS in forceps vs. vacuum?

Answer 21

OASIS RR 1.89

altered continence RR 1.77 (5y FU no diff)

Question 22

Finding of ANODE trial

Answer 22

RR 0.58 maternal infection with augmentin IV at assisted deliveries

Question 23

Rate of subgaleal haemorrhage in vacuum delivery?

Answer 23

3-6/1000

Question 24

Risk of intracranial haemorrhage for vacuum and forceps?

Answer 24

5-15 per 10,000

Question 25

Red flag symptoms of subgaleal haemorrhage?

Answer 25

5 min Apgar <7
no evidence asphyxia

later: tachycardia, tachypnoea, poor activity, pallor, anaemia, coagulopathy, hypotension, acidosis.

localised scalp swelling, laxity, fluctuant, ballotable across sutures.