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*Medicine: Obstetrics + Gynaecology > Intrapartum Care II > Flashcards

Intrapartum Care II Flashcards

1
Q

There are two main instruments used in operative deliveries – the ventouse and the forceps.

In general, the first instrument used is the most likely to succeed. The choice is operator dependent, but forceps tend to have a lower risk of fetal complications, and a higher risk of maternal complications. The general rule is, if after three contractions and pulls with any instrument there is no reasonable progress, the attempt should be abandoned.

What is the ventouse and how is it used?

A
  • instrument that attaches a cup to foetal head via a vacuum
  • A) an electrical pump attached to a siliastic cup - only suitable if foetus in an occipital-anterior position
  • B) a hand-held, disposable device AKA “Kiwi” - an omni-cup, can be used for all foetal positions and rotational deliveries
  • to use ventouse, cup is applied with its centre over the flexion point on foetal skull (in midline, 3cm anterior to posterior fontanelle)
  • during uterine contractions, traction is applied perpendicular to cup

Ventouse deliveries are associated with: lower success rate, less maternal perineal injuries, less pain, more cephalhaematoma, more subgaleal haematoma + more foetal retinal haemorrhage

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2
Q

The decision to perform an operative vaginal delivery should be based on the entire clinical scenario in the 2nd stage of labour - is there a valid clinical indication to intervene? Is the patient a suitable case for an instrumental delivery?

What are the common indications of operative/assisted vaginal delivery?

A
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3
Q

What are forceps, how are they used and what are they associated with?

A
  • double-bladed instruments
  • Rhodes, Neville-Barnes or Simpsons → used for OA positions
  • Wrigley’s → used at caesarian section
  • Kielland’s → for rotational deliveries
  • blades are introduced into pelvis, taking care not to cause trauma to maternal tissue + applied around sides of foetal head w/ blades then locked together
  • gentle traction applied during uterine contractions, following J shape of the maternal pelvis

Use of forceps associated with: higher rate of 3rd/4th degree tears, less often used to rotate + doesn’t require maternal effort.

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4
Q

In general, what are the pre-requisites for instrumental delivery?

A
  • fully dilated
  • ruptured membranes
  • cephalic presentation
  • defined foetal position
  • foetal head at least level of ischial spines, and no more than 1/5 palpable per abdomen
  • empty bladder
  • adequate pain relief
  • adequate maternal pelvis
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5
Q

What are contraindications for instrumental delivery?

A
  • ABSOLUTE:
    • unengaged foetal head in singleton pregnancies
    • incompletely dilated cervix in singleton pregnancies
    • true cephalo-pelvic disproportion (where foetal head is too large to pass through maternal pelvis)
    • breech + face presentations, and most brow presentations
    • preterm gestation (<34wks) for ventouse
    • high likelihood of any foetal coagulation disorder for ventouse
  • RELATIVE:
    • severe non-reassuring foetal status w/ station of head above level of pelvic floor - ie. foetal scalp not visible
    • delivery of second twin when head has not quite engaged or the cervix has reformed
    • prolapse of umbilical cord w/ foetal compromise when cervix is completely dilated and station is mid-cavity
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6
Q

What are the foetal and maternal complications of operative vaginal delivery?

A
  • FOETAL:
    • neonatal jaundice
    • scalp lacerations
    • cephalhaematoma
    • subgaleal haematoma
    • facial bruising
    • facial nerve damage
    • skull fractures
    • retinal haemorrhage
  • MATERNAL:
    • vaginal tears
    • 3rd/4th degree tears (1:100 normal delivery, 4:100 ventouse, 10:100 forceps)
    • VTE
    • incontinence
    • PPH
    • shoulder dystocia
    • infection
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7
Q

The rate of caesarean section has increased significantly in recent years, largely secondary to an increased fear of litigation.

What are the two main types of C-section?

A
  • lower segment caesarean section → now comprises 99% of cases
  • classic caesarean section → longitudinal incision in upper segment of uterus
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8
Q

How are C-sections classified?

A

Emergency Caesarean sections are most commonly for failure to progress in labour or suspected/confirmed fetal compromise

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9
Q

What are the indications for caesarean section?

A
  • absolute cephalopelvic disproportion
  • placenta praevia grades 3/4
  • pre-eclampsia
  • post-maturity
  • IUGR
  • foetal distress in labour/prolapsed cord
  • failure of labour to progress
  • malpresentations: brow
  • placental abruption: only if foetal distress; if dead deliver vaignally
  • vaginal infection eg. active herpes
  • cervical cancer
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10
Q

What are the immediate complications of C-Section?

A
  • postpartum haemorrhage (>1000ml)
  • wound haematoma (inc inpt w/ large BMI/diabetes/immunocompromised)
  • intra-abdominal haemorrhage
  • bladder/bowel trauma (more common in pts who have had prev abdo surgery)
  • neonatal:
    • transient tachypnoea of newborn
    • foetal lacerations (1-2% risk, higher w/ prev membrane rupture)
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11
Q

What are the intermediate and late complications of C-section?

A
  • infection → UTI, endometritis, respiratory
  • venous thromboembolism
  • urintary tract trauma (fistula)
  • subfertility
  • regret + other negative psychological sequelae
  • rupture/dehiscence of scar at next labour VBAC
  • placenta praevia/accreta
  • caesarean scar ectopic pregnancy
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12
Q

What is the issue with vaginal birth after caesarean section (VBAC)?

A
  • planned VBAC associated w/ 1/200 risk of uterine scar rupture
  • there is small inc risk of placenta praevia +/- accreta in future pregnancies and of pelvic adhesions
  • success rate of planned VBAC is 72-75%, however this is as high as 85-90% in women who have had a previous vaginal delivery
  • all women undergoing VBAC should have continuous foetal monitoring in labour as change in foetal heart rate can be first sign of impending scar rupture
  • risks of scar rupture is higher in labours that are augmented or induced w/ prostaglandins or oxytocin
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13
Q

In a breech presentation the caudal end of the fetus occupies the lower segment. Whilst around 25% of pregnancies at 28 weeks are breech it only occurs in 3% of babies near term.

What are the different types of breech presentation?

A
  • A frank breech is the most common presentation with the hips flexed and knees fully extended
  • A footling breech, where one or both feet come first with the bottom at a higher position, is rare but carries a higher perinatal morbidity
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14
Q

What are the risk factors for breech presentation?

A
  • uterine malformations, fibroids
  • placenta praevia
  • polyhydramnios or oligohydramnios
  • foetal abnormality (eg. CNS malformation, chromosomal disorders)
  • prematurity (due to increased incidence earlier in gestation)
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15
Q

What are the risks/complications of breech presentation?

A
  • cord prolapse (breech less effective as a “plug” in cervix)
  • difficulty delivering head (“head entrapment”)
  • foetal hypoxia due to head entrapment
  • increased foetal mortality and morbidity (“term breech trial”)
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16
Q

What is the management of breech?

A
  • if <36 weeks, many foetuses will turn spontaneously
  • if still breech at 36wks → NICE recommend ECV*
  • if baby still breech then delivery options include planned caesarean section or vaginal delivery

*on next slide

17
Q

What is the success rate of external cephalic version (ECV)?

A
  • offered @ 36wks in nulliparous women and 37-38wks in multiparous
  • uterine relaxants often given prior to or during procedure (eg. terbutaline or salbutamol)
  • foetal heart monitored w/ CTG pre + post procedure
  • benefits → may prevent c-section or vaginal breech delivery + associated risks
  • risks → foetal distress (cord entlanglement/retro-placental clot); sometimes transient
  • emergency c-section rate 1:200
  • success rate approx 50% (40% nulliparous; 60% multip)
18
Q

What do the RCOG recommend when providing information to help decision making, for management of breech pregnancies?

A
  • ‘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.’
19
Q

What are the absolute contraindications to ECV?

A
  • where caesarean delivery is required
  • antepartum haemorrhage within last 7 days
  • abnormal cardioctography
  • major uterine anomaly
  • ruptured membranes
  • multiple pregnancy
20
Q

Postpartum haemorrhage (PPH) is defined as blood loss of > 500mls and may be primary or secondary.

What is primary postpartum haemorrhage?

A
  • loss >500ml blood within 24hrs of delivery
  • minor means 500-1000ml
  • major means >1000ml
  • massive obstetric haemorrhage means 1500ml+

Affects around 5-7% deliveries

21
Q

What is secondary postpartum haemorrhage?

A
  • loss of excessive blood between 24hrs and 12wks following delivery
  • due to retained placental tissue or endometritis
22
Q

What are the causes of primary PPH (4 Ts)?

A
  • Tone - atonic uterus (most common)
  • Tissue - retained placenta w/ prolonged third stage
  • Trauma - vaginal or cervical tear
  • Thrombin - associated w/ pre-eclampsia or DIC
23
Q

What are the risk factors for primary PPH?

A
  • prev PPH
  • prolonged labour
  • pre-eclampsia
  • increased maternal age
  • polyhydramnios
  • emergency C-Section
  • placenta praevia, placenta accreta
  • macrosomia
  • ritodrine (a beta-2 adrenergic receptor agonist used for tocolysis)
24
Q

What is the management of PPH?

A
  • ABC including 2x peripheral cannulae, 14G
  • IV syntocinon (oxytocin) 10 units or IV ergometrine 500mcg
  • IM carboprost
  • if med options fail to control → surgical options urgently
  • RCOG state intrauterine balloon tamponade is appropriate first-line ‘surgical’ intervention for most women where uterine atony is only or main cause of haemorrhage
  • other options include: B-Lynch suture, ligation of uterine arteries or internal iliac arteries
  • if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure
25
Q

Cord prolapse involves the umbilical cord descending ahead of the presenting part of the fetus. This occurs in 1/500 deliveries. Left untreated, this can lead to compression of the cord or cord spasm, which can cause fetal hypoxia and eventually irreversible damage or death.

What is the management of cord prolapse?

A
  • majority occur at artifical rupture of membranes
  • diagnosis made when foetal HR becomes abnormal + cord palpable vaginally or if cord visible beyond level of introitus
  • presenting part of foetus may be pushed back into uterus to avoid compression
  • tocolytics may be used eg. terbutaline
  • if cord is past level of introitus, it should be kept warm + moist but not pushed back inside
  • pt asked to go on all 4s until prep for an immediate C-section done
  • instrumental vaginal delivery possible if cervix fully dilated + head is low
  • if treated early, foetal mortality in cord prolapse is low
  • incidence reduced by increase in C-sections being used in breech presentations
26
Q

Shoulder dystocia refers to a situation where, after delivery of the head, the anterior shoulder of the fetus becomes impacted on the maternal pubic symphysis, or (less commonly) the posterior shoulder becomes impacted on the sacral promontory.

It is an obstetric emergency, with an incidence of approximately 0.6-0.7% in all deliveries.

What are the clinical features of shoulder dystocia?

A

Shoulder dystocia is defined by a delay in delivery of the shoulders following the head during a vaginal delivery with the next contraction after using normal traction.

On examination, signs that may occur to aid the diagnosis are:

  • Difficulty in delivery of foetal head or chin
  • Failure of restitution - foetus remains in OA position after delivery by extension + therefore does not ‘turn to look to side’
  • ‘Turtle Neck’ sign - foetal head retracts slightly back into pelvis, so that neck is no longer visible, akin to a turtle retreated into its shell
27
Q

Complications of shoulder dystocia include 3rd/4th degree tears and PPH. To the foetus they include humerus or clavicle fracture, brachial plexus injury and hypoxic brain injury.

What are the immediate steps in the management of shoulder dystocia?

A
  • call for help
  • advise mother to stop pushing
  • avoid downwards traction on foetal head – only use routine axial traction ie. keep head in line with baby’s spine + do not apply fundal pressure
  • consider episiotomy - this will not relieve obstruction but can make access for maneouveres easier
28
Q

What are the first-line manoeuvres for shoulder dystocia?

A
  • McRobert’s manoeuvre → Hyperflex maternal hips (knees to chest position) + tell pt to stop pushing. This widens pelvic outlet by flattening the sacral promontory + increasing lumbosacral angle. This single manoeuvre has success rate of 90% + is even higher when combined with ‘suprapubic pressure’
  • Suprapubic pressure → Applied in either a sustained or rocking fashion to apply pressure behind anterior shoulder to disimpact it from underneath the maternal symphysis
29
Q

What are the second-line (‘internal’) manoeuvres?

A
  • Posterior arm - insert hand posteriorly into sacral hollow + grasp posterior arm to deliver
  • Internal rotation (“corkscrew manoeuvre”) - apply pressure simultaneously in front of one shoulder + behind the other to move baby 180 degrees or into an oblique position

If above manoeuvres fail then roll patient onto all fours and repeat (this may widen the pelvic outlet as the legs are abducted and flexed)

30
Q

What are the further manoeuvers to be considered when the previous measures have been unsuccessful?

A
  • cleidotomy → fracturing foetal clavicle
  • symphysiotomy → cutting pubic symphysis
  • zavenelli → returning foetal head to pelvis for delivery of baby via C-Section
31
Q

There are two main classifications of premature membrane rupture - PROM and P-PROM.

What is PROM?

A
  • premature rupture of membranes (PROM)
  • rupture of foetal membranes at least 1hr prior to onset of labour
  • at ≥37 wks gestation
  • occurs in 10-15% of term pregnancies + is associated w/ minimal risk to mother and foetus due to advanced gestation
32
Q

What is P-PROM?

A
  • pre-term premature rupture of membranes (P-PROM)
  • rupture of foetal membranes occurring at <37weeks gestation
  • complicates ~2% of pregnancies + has higher rates of maternal + foetal complications
  • associated w/ 40% of preterm deliveries
33
Q

Diagnosis of PROM or P-PROM is usually made by; (i) maternal history of membrane rupture and; (ii) positive examination findings.

What are clinical features of premature rupture of membranes?

A
  • broken waters → painless popping sensation w/ gush of watery fluid leaking from vagina
  • can be gradual leakage / damp underwear +/- change of consistency
  • speculum → fluid pooling in posterior vaginal fornix
  • for adequate examination, lie woman on bed for 30 mins to allow pooling to top of vagina
  • asking woman to cough can expel amniotic fluid

If suspecting PROM/PPROM → AVOID performing digital vaginal exam until woman in active labour as otherwise this might stimulate labour to come quicker and increase risk of introducing ascending uterine infection

34
Q

What is the management of PROM + PPROM?

A
35
Q

Describe how drug treatment of women in premature labour can help prevent respiratory distress syndrome of the newborn

A
  • single course of corticosteroids for women between 24wks and up to 34wks gestation if at risk of preterm delivery in next 7 days
  • betamethasone + dexamethasone
  • may consider in women at 23wks gestation who are at risk of preterm delivery within 7 days
  • single course of betametasone for pregnant women at risk of premature labour within 7 days, from 34 weeks’ and up to 37 weeks’ gestation
  • optimal clinical benefit of antenatal corticosteroids is likely to be from 24 hours to 7-14 days after administration

*Medicine: Obstetrics + Gynaecology (12 decks)

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