Intrapartum Care (FRANZCOG lecture) Flashcards
Incidence of breech at term?
3%
Maximum number of attempts of ECV?
4 attempts max
no longer than 10 minutes
Neonatal morbidity and mortality term breech trial?
5% vaginal delivery
1.6% CS
Contraindications term vaginal breech delivery?
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
Management of second stage vaginal breech?
passive second stage until breech on perineum.
If not visible within 2 hours of passive second stage, CS should be recommended.
Recommended timing during fetal breech delivery from buttocks to head, umbilicus to head?
b–> h 5 min
u –> h 3 min
Factors that increase probability of successful ECV?
race parity uterine tone liquor volume engagement of breech palpable head use of tocolysis
Cumulative proportion of spontaneous labours that started by 40-40+6?
82.8%
Risks of continuing pregnancy beyond 41 weeks?
increased likelihood of caesarean birth
increased likelihood of NICU admission
Increased likelihood of SB and NND
NICE comparison 39w + 40-42 weeks. Findings?
no difference maternal m&m
no difference perinatal m&m
no difference NICU admission
increased maternal satisfaction earlier induction
lower incidence CS 39/40
NICE comparison 41 weeks versus 42 weeks IOL. Findings?
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.
NICE guideline post-hoc analyses for:
- IOL maternal age 35y+
- IOL BMI 30+
Findings?
41 vs 42w IOL
- OR 0.19 (0.06-0.62) perinatal death
- OR 0.20 (0.06-0.64) perinatal death
Risk difference of CS and NICU admission after IOL at 39w vs. 40-42w?
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
Risk difference for IOL at 41w vs 42w for
- perinatal death
- nicu admission
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.
Cochrane findings regarding IOL vs. expectant post-term management?
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.
Balloon IOL vs. PGE2?
- vaginal deliveries
- LSCS
- hyperstimulation
- neonatal morbidity
- perinatal death
- NICU admission
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.
Amniotomy +/- IV oxytocin for IOL
- vaginal deliveries
- instrumental deliveries
- PPH
- maternal dissatisfaction
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)
LSCS consent risks
<1% hysterectomy repeat surgery ICU admission uterine rupture stillbirth in future pregnancy placenta praevia urinary tract injury
<0.1%
death
blood clots
Risk of infection with CS?
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)
compare 3 neonatal outcomes of ventouse vs. forceps.
- increased cephalohaematoma OR 2.4
- increased retinal haemorrhage
- reduced facial injury
- same Apgar, phototherapy
Risk of OASIS in forceps vs. vacuum?
OASIS RR 1.89
altered continence RR 1.77 (5y FU no diff)
Finding of ANODE trial
RR 0.58 maternal infection with augmentin IV at assisted deliveries
Rate of subgaleal haemorrhage in vacuum delivery?
3-6/1000
Risk of intracranial haemorrhage for vacuum and forceps?
5-15 per 10,000
Red flag symptoms of subgaleal haemorrhage?
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.
