Labour and Delivery Flashcards
What is the lie of the fetus? What are the types?
Relationship of fetal long axis to uterus long axis
Longitudinal
Oblique
Transverse
What is the presentation of the fetus? What are the types?
Fetal part that enters the maternal pelvis
Cephalic is the safest
Face, Brow, Breech, Shoulder
What is the vertex/position of the fetus?
Position of the fetal head as it exits the birth canal
Occipito-anterior is safest
What are the stages of labour?
First stage - from onset - true contractions, until 10cm cervical dilatation
Second stage - from 10cm cervical dilatation until delivery of the baby
Third stage - from delivery of baby until delivery of placenta
What are the phases of first stage of labour?
Latent phase - onset involves cervical dilation and effacement. Show - mucus plug falls out and creates space for baby to pass through. Irregular contractions.
From 0-3cm; progresses at 0.5cm per hour.
Active phase - from 3cm to 7cm dilatation, progresses at around 1cm per hour, regular contractions.
Transition phase - from 7cm to 10cm, progresses around 1cm per hour, strong regular contractions.
What are Braxton-Hicks contractions?
Occasional irregular contractions of the uterus
Usually felt during the second and third trimester
Temporary and irregular tightening or mild cramping in the abdomen, do not indicate onset of labour.
What are the signs of the onset of labour?
Show - mucus plug from the cervix
Rupture of membranes
Regular, painful contractions
Dilating cervix on examination
What is ROM?
Rupture of membranes, the amniotic sac has ruptured
What is SROM?
Spontaneous rupture of membranes
What are the types of premature rupture of membranes?
Premature rupture of membranes - >1hr before onset of labour at >=37 weeks gestation
Pre-term premature rupture of membranes - rupture occur before 37 weeks gestation
How common is premature rupture of membranes?
10-15% of term pregnancies
Minimal risk to mother and fetus
How common is preterm premature rupture of membranes?
~2%
Higher rates of maternal and fetal complications
What are the risk factors associated with premature rupture of membranes?
Multiple pregnancy
Lower GU infection
Smoking Vaginal bleeding during pregnancy Polyhydramnios Cervical insufficiency Invasive procedures - amniocentesis
What are the differentials for premature rupture of membranes?
Urinary incontinence
Loss of mucus plug
Normal vaginal secretions
Secretions associated with infection
What is the pathophysiology of premature rupture of membranes?
Normal weakening occurs earlier than normal due to:
- Higher levels of apoptotic markers in amniotic fluid
- Infection - cytokines weaken membrane
- Genetic disposition
How is a premature rupture of membranes diagnosed?
Maternal history of rupture and positive examination findings
Sterile speculum examination - amniotic fluid draining from cervix and pooling in vagina when lying down for 30 mins
Reduced amniotic fluids suggestive
What is important to investigate if you suspect premature rupture of membranes and what should you avoid?
High vaginal swab done - look for group B strep
Avoid digital vaginal exam until in labour –> poss. intrauterine infection
What does premature rupture of membranes cause?
Amniotic fluid stimulate uterus and labour occur within 24-48 hours
If labour doesn’t occur following premature rupture of membranes, what should be done?
<34 weeks - aim for increased gestation
34 weeks + - induce labour
How should premature rupture of membranes before 36 weeks be managed?
Monitor for chorioamnionitis
Advise against sexual intercourse
Prophylactic erythromycin
Corticosteroids (dexamethasone) - fetal lung development
How should premature rupture of membranes >36 weeks be managed?
Monitor for chorioamnionitis
What are the complications of premature rupture of membranes?
Prematurity
Sepsis
Pulmonary hypoplasia
How can premature rupture of membranes be prevented?
Intravaginal progesterone and cervical cerclage - if history of Preterm-PROM
What is chorioamnionitis?
Result of ascending bacterial infection of amniotic fluid, membranes or placenta
What are the risk factors for chorioamnionitis?
Preterm premature rupture of membranes
How is chorioamnionitis managed?
Prompt delivery of foetus
IV antibiotics
What occurs in preterm labour with intact membranes?
Regular painful contractions and cervical dilatation without the rupture of the amniotic sac
How can preterm labour with intact membranes be diagnosed?
Speculum examination for cervical dilatation
Less than 30 weeks - clinical assessment enough
More than 30 weeks - TV USS, assess cervical length
If less than 15mm - management can be offered
What is fetal fibronectin?
An alternative test to vaginal ultrasound, found in the vagina during labour it is between the chorion and uterus
Result of less than 50mg/ml considered negative - indicates preterm labour unlikely
What are the management options for improving outcomes in preterm labour?
Fetal monitoring - CTG or intermittent auscultation
Tocolysis with nifedipine
Maternal corticosteroids offered before 35 weeks
IV magnesium sulphate given before 34 weeks
Delayed cord clamping or cord milking
What is tocolysis?
Using medications to stop uterine contractions
Nifedipine - Ca channel blocker
Atosiban - oxytocin receptor antagonist
Can be used between 24 and 33 + 6 weeks in preterm labour
What corticosteroids are given in preterm labour?
Two doses of intramuscular betamethasone, 24 hours apart
Why is magnesium sulfate given in preterm labour?
Helps protect the fetal brain
Reduces risk and severity of cerebral palsy
Given within 24 hours of delivery in preterm babies less than 34 weeks
Given as bolus and then infusion for 24 hours in lead up to birth
What are the signs of magnesium sulfate toxicity?
Reduced respiratory rate
Reduced blood pressure
Absent reflexes - check patella reflex
What are the methods of induction?
Vaginal prostaglandins - gel, tablet (Prostin) or pessary (propess)
Membrane sweep
Cervical ripening balloon - silicone balloon gently inflated to dilate cervix
Amniotomy +- oxytocin
Only be used if not to use vaginal prostaglands
Oral mifepristone (anti progesterone) plus misoprostol used to induce labour where intrauterine death occurred
How do vaginal prostaglandins induce labour?
Ripen cervix and role in contractions
Taken as tablet, gel or pessary
Induction can take days
How does a membrane sweep induce labour?
Adjunct to induction
Gloved finger rotate against fetal membrane - aim to separate from decidua and release prostaglandins
Explain the use of an amniotomy to induce labour
Used if vaginal prostaglandins CI
Membranes ruptures using hook - release prostaglandins to stimulate labour
Oxytocin given to increase strength and freq. of contractions
Only performed once cervix is ripe
What are the absolute contraindications for induction of labour?
Cephalopelvic disproportion
Major placenta praevia
Transverse lie
Vasa praevia
Cord prolapse
Active primary genital herpes
What are the relative contraindications for induction of labour?
Breech
Triplet or higher order pregnancy
2 or more previous low transverse C sections
What is the bishop’s score?
Scoring system used to assess cervical ripeness
Score >9 - labour likely commence spontaneously
Score <5 - labour unlikely to start without induction
Describe the factors in bishop’s score
Cervix: 0 points, 1 point, 2 point, 3 point
Position - posterior, midline, anterior, NA Consistency - firm, medium, soft, NA Effacement - 0-30%, 40-50%, 60-70%, >80% Dilation - closed, 1-2cm, 3-4cm, >5cm Station - -3, -2, -1 and 0, +1 and +2
What complications are associated with induction of labour?
Uterine hyperstimulation
Failure of induction - req. C Section
Uterine rupture
Cord prolapse - occur in amniotomy with rush of fluid
Intrauterine infection - prolonged membrane rupture and repeated vaginal examinations
What is uterine hyperstimulation associated with and how is it managed?
Fetal distress
Contraction of the uterus is prolonged and frequent
Terbutaline - anti-contraction agent
Removing the vaginal prostaglandin or stopping the oxytocin infusion
When is IOL offered?
Between 41 and 42 weeks
When might induction of labour be offered early?
Prelabour rupture of membranes Fetal growth restriction Pre-eclampsia Obstetric cholestasis Existing diabetes Intrauterine fetal death
What monitoring is required during the induction of labour?
CTG to assess the fetal heart rate and uterine contractions
Bishops score before and during to monitor progress
What can be the consequences of uterine hyperstimulation?
Fetal compromise with hypoxia and acidosis
Emergency c-section
Uterine rupture
What do the following abbreviations stand for in CTG monitoring?
DR C BRa V A D O
Define Risk
Contractions
Baseline Rate Variability Accelerations Decelerations Overall impression
What is define risk on CTG?
Defining whether a pregnancy is high or low risk. It gives you context to the CTG and may change your threshold for intervention
What do you need to record about contractions?
Number in a 10 minute period (seen as peaks of uterine activity on CTG)
Strength and duration
What is a normal fetal heart rate?
110-160
How is a baseline fetal heart rate calculated?
Average in 10 minute window
Ignore accelerations and decelerations
How is prolonged severe bradycardia in a fetus defined?
<80bpm for >3 mins
What conditions are associated with fetal tachycardia?
Fetal hypoxia
Chorioamnionitis
Maternal or fetal anaemia
Hyperthyroidism
What conditions are associated with fetal bradycardia?
Prolonged gestation
Transverse or posterior occiput presentation
(100-120 bpm)
What conditions are associated with prolonged severe fetal bradycardia?
Prolonged cord compression
Cord prolapse
Epidural
Rapid fetal descent
What does baseline variability on a CTG tell you? What is a normal variability?
How a fetus’ HR varies from one beat to the next
Indicate fetus is adapting to environment due to input from nervous system, baroreceptors and chemoreceptors
Normal is 5-25
What could cause reduced fetal variability?
Fetus sleeping
Fetal acidosis - hypoxia
Fetal tachycardia
Congenital heart defect
Prematurity
Maternal medication - opiates, benzo, methyldopa, magnesium sulphate
What is a fetal acceleration?
Abrupt increase in baseline fetal HR
> 15bpm for >15s
They are reassuring
What is a fetal deceleration?
Abrupt decrease in baseline fetal HR of >15bpm for >15s
Why do fetuses reduce their heart rate?
In response to hypoxia to reduce myocardial demand and preserve myocardial oxygenation and perfusion
Fetus can’t change respiratory depth or rate
What is an early deceleration?
Start when uterus contract and recover when contraction stop
Due to fetal RICP and increasing vagal tone
Physiological deceleration
What is a variable deceleration?
Rapid fall in heart rate with variable recovery phase
May not have any relationship to contractions
Seen in labour and with oligohydramnios patients
What are “shoulders of decelerations”?
Accelerations occur before and after deceleration
Indicate fetus still able to adapt and not yet hypoxic
What causes the acceleration, deceleration, acceleration in shoulders of decelerations?
Umbilical vein occluded - acceleration
Umbilical artery occluded - deceleration
Pressure off cord - acceleration
What is a late deceleration?
Begin at peak of contraction and recover after it has ended
Indicate lack of blood supply to uterus and placenta - hypoxia and acidosis
What causes late decelerations?
Maternal hypotension
Pre-eclampsia
Uterine hyperstimulation
What must you do if you see a late deceleration?
Fetal blood sampling for pH
What is a prolonged deceleration?
Deceleration lasting >3mins
Fetal blood sampling or emergency C section needs to be arranged
What is a sinusoidal pattern on a CTG?
Smooth regular wave like pattern with no beat to beat variability
What can cause a sinusoidal CTG pattern?
Severe fetal hypoxia
Severe fetal anaemia
Haemorrhage
Very concerning and associated with high levels of morbidity and mortality
What would be seen on a reassuring CTG?
110-160bpm
5-25 variability
No or early decelerations
Variable decelerations with no concerning characteristics <90 mins
What characteristics of variable decelerations are concerning?
> 60s
Reduced baseline variability within deceleration
Fail to return to baseline
Biphasic (W) shape
No Shouldering
What features of a CTG would be considered non-reassuring?
100-109bpm OR 160-181bpm
Variability <5 for 30-50mins or >25 for 15-25mins
Variable decelerations with no concerns >90mins
Variable decelerations with concerns in <50% of contractions >30mins
Variable decelerations with concerns in >50% of contractions <30mins
Late in >50% of contractions for <30 mins with no clinical risk factors (bleeding or meconium)
What features of a CTG would be considered abnormal?
<100 or >180 bpm
Variability <5 for >50 mins OR >25 for >25mins OR sinusoidal pattern
Variable decelerations with concerns >50% of contractions for >30 mins
Late decelerations >30mins
Acute bradycardia
Single prolonged deceleration >3mins
What is a normal CTG and what is the management?
All features reassuring
Continue CTG and usual care
What is a suspicious CTG and how is it managed?
1 non-reassuring AND 2 reassuring features
Seek advice from obstetrician or senior midwife, correct underlying causes, full set of maternal obs
What is a pathological CTG?
1 abnormal feature OR 2 non reassuring features
How is a pathological CTG managed?
Seek advice - obstetrician or senior midwife
Correct underlying cause
Exclude acute events - cord prolapse, placental abruption, uterine rupture
Offer digital fetal scalp stimulation
If still pathological after scalp stimulation, consider fetal blood sample and expediting birth
What CTG requires urgent intervention?
Acute bradycardia
Single prolonged deceleration >3mins
What is done if a CTG requires urgent intervention
Urgently seek obstetrician help
Correct underlying causes
Expedite birth if acute event
Prepare for urgent birth
Expedite birth if bradycardia >9mins
Discuss expedited birth if bradycardia recover
What are the CI’s for fetal blood sampling?
Risk of maternal-fatal infection
Fetal bleeding disorders
What results are in a normal fetal blood sample? What is the next step?
Lactate <=4.1mmol/L
pH >= 7.25
Repeat in an hour
What results are in a Borderline fetal blood sample? What is the next step?
Lactate 4.2-4.8mmol/L
pH 7.21-7.24
Repeat in 30 mins
What results are in an abnormal fetal blood sample? What is the next step?
Lactate >=4.9 mmol/L
pH <=7.20
Expedite birth
What are the indications for continuous CTG monitoring in labour?
Sepsis Maternal tachycardia >120 Significant meconium Pre-eclampsia - particularly blood pressure >160/110 Fresh antepartum haemorrhage Delay in labour Use of oxytocin Disproportionate maternal pain
What is the rule of three for fetal bradycardia?
For prolonged fetal bradycardia 3 mins - call for help 6 mins - move to theatre 9 mins - prepare for delivery 12 mins - deliver baby, by 15 mins
What are late decelerations?
Gradual falls in heart rate after the uterine contraction has already begun.
Delay between uterine contraction and deceleration, lowest point of deceleration occurs after peak of contraction.
Due to hypoxia in the fetus.
May be caused by excessive uterine contractions, maternal hypotension or maternal hypoxia.
What are prolonged decelerations?
Last between 2 and 10 minutes
With a drop of more than 15 bpm from baseline
Often indicates compression of umbilical cord, causing fetal hypoxia.
What is a normal baseline variability in CTG?
5-25 bpm
What is a suspicious CTG?
Lacking at least one feature of normality, but with no pathological features
Low probability of having hypoxia/acidosis
What is a pathological CTG?
Two non-reassuring features or a single abnormal feature
Above 180bpm or below 100bpm
Baseline less than 5 >50 mins, more than 25 >30 mins or sinusoidal for >30 mins
Repetitive, late or prolonged decelerations with any concerning characteristics >30 mins or >20 mins if reduced variability
Single prolonged deceleration below 100bpm lasting 3 mins or more
Fetus with high probability of having hypoxia or acidosis
what is the management following a suspicious CTG?
Full set of maternal observations Consider risk factors Immediate conservative measures - change maternal position, reduce or stop oxytoxin, remove propess, consider tocolysis, paracetamol if sepsis, oral fluids/IV Escalate to coordinator, document Correct hypotension Communicate with women regards to plan Review in 30 mins or before
What is the management following a pathological CTG?
Full set of maternal observations
Consider risk factors
Immediate conservative measures
Escalate immediately to obstetric team
Consider FSE and FBS - fetal blood sampling and scalp electrode.
Correct hypotension
If pushing - stop to see if improvement made
VE - offer digital stimulation
Consider expediting delivery if indicated
Describe the MOA, side effects and CI’s for syntocinon
Synthetic oxytocin - stimulate myometrium contraction
Stimulates ripening of cervix, also plays role in lactation during breastfeeding.
Used to induce labour, progress labour, improve freq and strength of uterine contractions, prevent or treat PPH.
SE - N&V, headache, hypertension
CI - hypertonic uterus, severe CVS disease
Describe the MOA, side effects and CI’s for ergometrine
Alpha adrenergic, dopamine and serotonin receptor action to stimulate contraction of uterus
May be used during third stage and post partum to treat PPH. Only used after delivery of baby.
SE - Hypertension, nausea, bradycardia
CI - Hypertension, eclampsia, vascular disease
Describe the MOA, side effects and CI’s for carboprost
Prostaglandin analogue
SE - bronchospasm, pulmonary oedema, HTN, cardiovascular collapse
CI - Cardiac/pulmonary disease
Describe the MOA, side effects and CI’s for misoprostol
Prostaglandin analogue
Binds to prostaglandin receptors and activates them
Used alongside mifepristone for abortions, and IOL after intrauterine fetal death.
SE - diarrhoea
What is mifepristone?
Anti-progestogen that blocks the action of progesterone, halting pregnancy and ripening cervix
Not used during pregnancy with healthy living fetus
What is nifedipine?
Calcium channel blocker acts to reduce smooth muscle contraction in blood vessels and the uterus
Reduces blood pressure in hypertension and pre-eclampsia
Tocolysis in premature labour
What is progress in labour influenced by?
Power - uterine contractions
Passenger - size, presentation and position of baby
Passage - shape and size of pelvis and soft tissue
When is there considered to be a delay in the first stage of labour?
Less than 2cm of cervical dilatation in 4 hours
Slowing of progress in multiparous women
What is the importance of a partogram?
Measures cervical dilatation, descent of fetal head, maternal and fetal obs, status of membranes
Crossing alert line indicates need for amniotomy
Crossing action line means need for obstetric led care
When is there considered to be a delay in the second stage of labour?
If active second stage pushing lasts over 2 hours in a nulliparous woman or 1 hour in multiparous woman
What are the causes of a delayed second stage of labour?
Power - poor contractions
Passenger
Size - macrosomia, should dystocia
Attitude - how rounded back is, limbs and head flexed
Lie - longitudinal, transverse or oblique and presentation.
What can be some interventions if there is a delayed second stage of labour?
Changing positions Encouragement Analgesia Oxytocin Episiotomy Instrumental delivery C-section
When is it defined that there is a delay in the third stage of labour?
More than 30 mins with active management
More than 60 mins with physiological management
What are management options in failure to progress?
Amniotomy
Oxytocin infusion
Instrumental delivery
C-section
What pain relief is available in labour?
Simple analgesia - paracetamol, codeine, avoid NSAIDs
Gas and air - nitrous oxide and oxygen
IM pethidine or diamorphine
Can cause drowsiness or nausea in the mother, and respiratory depression in the neonate if given too close to birth, may make first feed more difficult.
Patient controlled analgesia - remifentanil, bolus of short acting opiate medication.
Need naloxone for resp depression and atropine for bradycardia if adverse events occur.
Epidural - placed in epidural space, outside dura mater infused into catheter
Bupivacane, mixed with fentanyl
What can be the adverse effects of an epidural?
Headache after insertion Hypotension Motor weakness in legs Nerve damage Prolonged second stage Increased probability of instrumental delivery
What are the types of cord prolapse?
Occult - cord drop alongside baby but may not be seen in advance
Overt - cord come before baby’s head can come out
How does fetal hypoxia occur in cord prolapse?
Occlusion - fetus press on umbilical cord occluding blood flow
Arterial vasospasm - exposure of cord to cold atmosphere results in umbilical arterial vasospasm
What are the risk factors for cord prolapse?
Breech
Artificial rupture of membranes
High fetal station
Polyhydramnios
Prematurity
Long umbilical cord
How may cord prolapse present?
Fetal heart rate abnormal - subtle decelerations on contraction and bradycardia
Cord felt vaginally
Presence of blood suggest alternate diagnosis
How is cord prolapse managed?
Avoid handling cord - avoid vasospasm
Knee-chest position for mother
Manually lift presenting part by digital vaginal exam
Tocolysis - terbutaline - relax uterus and stop contractions
Delivery - usually emergency c-section
If fully dilated - can encourage vaginal/instrumental delivery
What is shoulder dystocia?
Anterior shoulder of baby becomes stuck behind the pubic symphysis of the pelvis after the head has been delivered
What are the types of shoulder dystocia?
Anterior shoulder impacted on maternal pubic symphysis
Posterior shoulder impacted on sacral promontory (less common)
What are the risk factors associated with shoulder dystocia?
Macrosomia
Maternal diabetes
Maternal BMI >30
Previous Hx of shoulder dystocia
Induction of labour
Prolonged labour
What are the risks of shoulder dystocia?
Fetus
- Delay in delivery - hypoxia
- Brachial plexus injury - traction to head
- Humerus/clavicle fracture
Mum
- Perineal tears
- PPH
- Pelvic floor weakness
What should be immediately done if the shoulders get stuck in delivery?
Call for help
Stop pushing
Avoid downward traction - only apply axial traction
Consider episiotomy
What is the first line management for shoulder dystocia?
McRoberts manoeuvre - hyperflex maternal hips (knees to chest)
+ suprapubic pressure - apply pressure behind anterior shoulder
What is the second line management for shoulder dystocia?
Insert hand into sacral hollow and grasp posterior arm
Internal rotation - corkscrew manoeuvre - turn shoulders 180 degrees
What is the last resort for shoulder dystocia?
Cleidotomy - fracture fetal clavicle
Symphysiotomy - cut pubic symphysis
Zavenelli - return fetal head to pelvis for C-Section
What is the presentation of shoulder dystocia?
Failure of restitution where the head remains facing downwards - occipito-anterior and does not turn sideways as expected after the delivery of the head.
Turtle neck sign - head is delivered but then retracts back into the vagina.
How can instrumental deliveries be categorised?
Classified by degree of fetal descent - lower they are, lower risk of complications
Outlet
Low
Midcavity
What does it mean if a instrumental delivery is classified as outlet?
Fetal scalp visible with labia parted
Fetal skull reached pelvic floor
Fetal head on perineum
What does it mean if a instrumental delivery is classified as Low?
Leading point at +2 station or lower
Subdivided depending on rotation - more or less than 45 degrees
What does it mean if a instrumental delivery is classified as midcavity?
Head 1/5 palpable abdominally
Leading point between 0 and +2
Subdivided depending on rotation - more or less than 45 degrees
What are the indications for instrumental delivery?
Maternal
- Inadequate progress of 2nd stage of labour
- Exhaustion
- Hypertensive crisis
- CVS disease
- Myasthenia gravis and spinal cord injury
Fetal - Compromise
- Protect head during breech
When should instrumental delivery be abandoned for C Section?
No descent seen in 3 pulls
What are the contraindications for instrumental delivery?
Bleeding or fracture predisposition of fetus
Face delivery
<34 weeks if ventouse
What are the requirements for instrumental delivery?
Fully dilated cervix
Occipito-anterior position
Ruptured membranes Cephalic presentation Engaged presenting part Pain relief adequate Sphinter (bladder) empty
What maternal complications are associated with instrumental delivery?
Maternal mental health - can develop tocophobia
Urinary and faecal incontinence
3rd/4th degree tears
Pelvic organ prolapse
What fetal complications are associated with instrumental delivery?
Cephalhaematoma
Facial bruising
Retinal haemorrhage
What is the difference between caput seccedaneum and cephalhaematoma?
Caput secumdum
- Soft puffy swelling due to oedema
- Present at birth, cross the midline and resolve within days
Cephalhaematoma
- Bleeding between periosteum and skull
- Present within hours, doesn’t cross midline and resolve within months
What nerve injuries can occur during instrumental delivery?
Femoral nerve - compressed against inguinal canal, leads to weakness of knee extension, loss of patella reflex, numbness of anterior thigh and medial lower leg.
Obturator nerve - compressed by forceps or fetal head, causes weakness of hip adduction and rotation, numbness of medial thigh.
Lateral cutaneous nerve of the thigh, lumbosacral plexus, common peroneal - foot drop.
How is perineal injury classified?
1st degree - injury to skin
2nd degree - injury to perineal muscles but not anal sphincter
3a - <50% of external anal spincter
3b - >50% external anal sphincter
3c - internal anal sphincter
4 - injury to perineum inc. anal sphincter and epithelium
What are the risk factors for perineal injury?
Primigravida
Large babies
Precipitant labour
Shoulder dystocia
Forceps delivery
What is the relative risk of perineal trauma to women with a history of severe perineal trauma?
Risk not increased
When/how is an episiotomy done?
If clinical need - instrumental delivery or fetal compromise
Mediolateral approach originating at vaginal fourchette directed to right
Why should a perineal tear be repaired as soon as possible?
Minimise risk of infection and blood loss
What is the management of perineal tears?
First degree usually no sutures
Third or fourth likely need repairing in theatre
Broad spectrum antibiotics to reduce risk of infection
Laxatives to reduce risk of constipation and wound dehiscence
Physio to reduce risk and severity of incontinence
Follow up
Women symptomatic after third or fourth degree tears offered elective c-section in subsequent pregnancies.
What are the short term complications after perineal injury repair?
Pain
Infection
Bleeding
Wound dehiscence or wound breakdown
What are the lasting complications of perineal tears?
Urinary incontinence
Anal incontinence and altered bowel habit in third and fourth degree tears
Fistula between vagina and bowel
Sexual dysfunction and dyspareunia
Psychological and mental health consequences
What is a perineal massage?
Massaging skin and tissues between vagina and anus - perineum, done in a structured way from 34 weeks onwards to stretch and prepare the tissues for delivery.
What is the third stage of labour and the management options?
From the completed birth of the baby to delivery of the placenta.
Physiological management - placenta delivered by maternal effort
Active management
Dose of IM oxytocin to help uterus to contract, and traction to the umbilical cord
Shortens third stage, reduces risk of bleeding, increased chance of n+v
When is active management offered?
Offered routinely to all women to reduce the risk of PPH
Initiated if haemorrhage
More than 60 min delay in delivery of the placenta
What are the steps in active management of third stage of labour?
IM dose of oxytocin after delivery
Cord clamped and cut within 5 minutes; there should be a delay of 1-3 mins between delivery and clamping
Abdomen palpated to assess for a uterine contraction before delivery of the placenta
Controlled cord traction, stopping if resistance
One hand presses uterus upwards to prevent uterine prolapse
Uterus massaged until contracted and firm
What is a minor PPH?
Under 1000ml blood loss
What is a major PPH?
Over 1000ml blood loss
What is a moderate and severe PPH?
Further subdivision of major PPH, moderate is 1000ml-2000ml
Severe - over 2000ml
What is a primary and secondary PPH?
Primary - within 24 hours of birth
Secondary from 24 hours to 12 weeks after birth
What are the causes of PPH?
Tone - uterine atony
Trauma - perineal tear
Tissue - retained placenta
Thrombin - bleeding disorder
What are the risk factors of PPH?
Previous PPH Multiple pregnancy Obesity Large baby Failure to progress during second stage of labour Prolonged third stage Pre-eclampsia Placenta accreta Retained placenta Instrumental delivery General anaesthesia Episiotomy or perineal tear
What measures can be taken to reduce the risks and consequences of PPH?
Treating anaemia during antenatal period
Giving birth with an empty bladder, as full bladder reduces uterine contraction
Active management of third stage, with oxytocin
Intravenous tranexamic acid during c-section in third stage in higher risk patients
What is the management of PPH?
Major haemorrhage protocol, gives rapid access to 4 units of crossmatched or O neg blood. Resus, A-E approach Two large bore cannulas Bloods for FBC, UE, clotting G&S, cross match 4 units Warmed IV fluid and blood Oxygen FFP
Mechanical, medical or surgical treatment to stop the bleeding
What treatment is needed to stop the bleeding in PPH?
Mechanical - rubbing the uterus to stimulate contraction
catheterisation to prevent bladder distention
Medical Oxytocin IV or IM - 40 units in 500mls Carboprost - caution in asthma Misoprostol sublingual Tranexamic acid IB
Surgical Intrauterine balloon tamponade B-lynch suture - put suture around uterus to compress it Uterine artery ligation Hysterectomy
What are the likely causes of a secondary PPH?
Retained products of conception
Infection i.e. endometritis
What are the investigations for secondary post partum haemorrhage?
Ultrasound for retained products of conception
Endocervical and high vaginal swabs for infection
What is the management of secondary post partum haemorrhage?
Surgical evaluation of retained products of conception
Antibiotics for infection
How may secondary post partum haemorrhages present?
Usually spotting
Gush of blood or major haemorrhage possible
Endometritis - fever, lower abdomen pain, foul smelling lochia
Retained products - fundus felt on examination
How are malpresentation of the fetus managed?
Brow - C Section
Shoulder - C-section
Face - if chin anterior then normal labour possible, chin posterior then C Section
What happens in most malpositions?
90% spontaneously rotate to occipito-anterior as labour progress
What is the management if a malposition doesn’t rotate?
Rotation and operative vaginal delivery attempted
C Section can be performed
How common is breech presentation?
20% at 28 weeks
3-4% at term - majority spontaneously turn
What are the risk factors associated with breech presentation?
85% spontaneous
Uterine abnormality
Lax uterus - multiparty
Placenta praevia
Abnormal amniotic fluid
How is breech presentation identified?
Palpation of abdomen
Fetal heart auscultated higher in abdomen
USS
20% not diagnosed until labour - fetal distress or foot felt
What should happen if a breech is identified at 35/36 week scan?
Refer for scan and specialist opinion
What are the types of breech delivery?
Complete breech
Frank breech
Footling breech
How are breech babies delivered?
Try ECV first
C Section or Vaginal depending on woman and specific presentation
Footling breach - vaginal contraindicated
How is a breech baby delivered vaginally?
Hand off baby - traction can lead to neck hyperextension and head getting trapped
Flex fetal knees - deliver legs
Lovsetts - rotate body to deliver shoulders
MSV - flex head
What complications are associated with breech delivery?
Cord prolapse
Fetal head entrapment
Premature rupture of membranes
Birth asphyxia
When is external cephalic version carried out?
36 weeks if nulliparous - 40% success
37 weeks if multiparous - 60% success
What is the result of external cephalic version?
Reduce risk of non-cephalic birth or need for caesarian
Still higher risk of complications than spontaneous cephalic
Safe with no risk of intra-uterine death
<5% revert to breech
What are the CI’s for external cephalic version?
APH within last week
Ruptured membranes
Major uterine abnormalities
Abnormal CTG
Multiple pregnancy
What are the complications associated with external cephalic version?
Placental abruption
Uterine rupture
Fetal-maternal haemorrhage
Fetal distress
What are the conditions where the placenta is retained?
Placenta adherens
Trapped placenta
Partial accreta
What happens in placenta adherens?
Myometrium fair to contract behind placenta
What happens in trapped placenta?
Detached placenta trapped behind closed cervix
What happens in partial accreta?
Part of placenta adhered to myometrium
What are the complications associated with retained placenta?
PPH
Infection
What are the signs the placenta has separated?
Sudden rush of blood
Fundus move higher and become more rounded
Increase length of visible umbilical cord
Raising fundus doesn’t cause cord to decrease in length
What should be done if a placenta has separated?
Deliver placenta by rubbing up uterus
Push towards vagina with expulsion of placenta and membranes
What should be done if the placenta can’t be removed?
Vaginal exam - assess if detached
What should be done if the placenta hasn’t detached?
IV access - oxytocin if excess bleeding
Manual removal under general anaesthesia
What are the risk factors for the uterus failing to contract post delivery?
Age >40
BMI >35
Asian
Uterine over-distention - multiple pregnancy, macrosomia, polyhydramnios
Prolonged labour
Placenta praevia or abruption
What are the risk factors for thrombin/trauma related post partum haemorrhage?
Placental abruption
Hypertension
Pre-eclampsia Coagulopathies Instrumental vaginal delivery Epsiotomy C-Section
What should you be aware of if surgical evacuation of retained products is required for a secondary post partum haemorrhage?
Higher risk of uterine perforation due to uterus being softer and thinner
Generally when is an emergency c-section carried out?
Failure to progress through labour
Fetal compromise
How can emergency c-sections be characterised?
1 - immediate threat to life of mother or fetus, 20-30 mins
2 - maternal or foetal compromise that isn’t immediately life threatening 60-75mins
3 - No maternal or foetal compromise but need early delivery
4 - elective
Why may an elective c-section be planned?
Usually after 39 weeks
- malpresentation
- twins or higher order pregnancy
- placenta praevia
- uterine abnormality
- cephalo-pelvic disproportion
- maternal condition - can’t cope with pregnancy
- herpes simplex in trimester 3
- HIV
- fetal weight estimated >4.5kg
What should be done before a C-Section is carried out?
G&S - usually 500-1000ml blood loss
Prescribe ranitidine - lying flat with gravid uterus increase risk of gastric content aspiration
VTE assessment - stockings and LMWH
What anaesthesia is used for a c-section?
Epidural or Spinal
General if CI to regional or category 1 emergency
How is the woman position in a c-section?
Left lateral tilt of 15 degrees - reduce risk of supine hypotension due to aortocaval compression
What is done in the operating theatre prior to incision in a c-section?
Catheter - drain bladder so less likely to be injured
Abx administered
What incision is used for a c-section?
Pfannenstiel - transverse lower abdominal
What layers must you dissect through in a C-section?
Skin
Camper’s fascia - superficial subcutaneous fat
Scarpa’s fascia - deep membranous layer of subcutaneous tissue
Rectus sheath and muscle
Abdominal peritoneum - parietal
What happens to the visceral peritoneum in a c-section?
Incised
Pushed down to reflect bladder
Where is the uterine incision in a c-section?
Lower uterine segment beneath line of peritoneal reflection
How is the baby delivered in a c-section?
Fundal pressure
De Lee’s incision (lower vertical) if lower uterine incision poorly formed
What are the final steps of a c-section after delivery?
IV oxytocin - aid delivery of placenta
Placental delivery by controlled cord traction
Uterine cavity emptied
Closure
What are the main benefits of a c-section?
Lower risk of:
Perineal trauma
Incontinence
Uterovaginal prolapse
Late stillbirth
What are the immediate complications associated with a c-section?
PPH
Bladder/bowel trauma
Wound haematoma
Transient tachypnoea of newborn
Laceration of fetus
Need for hysterectomy
What are the intermediate complications associated with c-sections?
VTE
UTI - catheter
Endometritis
What are the late complications associated with c-sections?
Subfertility
Dehiscence of scar in next labour
Regret/psychological
Placenta praevia
Ectopic pregnancy on scar
How successful/safe is vaginal birth after a C-Section?
Clinically safe for majority of women with 1 lower segment c-section
75% success rate
90% success rate if previous vaginal birth after c-section
What are the contraindications for vaginal birth after a c-section?
Previous uterine rupture
Classical caesarian scar
Relative CI - >2 lower segment caesarians or complex uterine scars
What are the advantages of vaginal birth after c-section?
Shorter hospital stay
Lower risk of maternal death
Lower risk of neonatal respiratory difficulties
What are the risks to vaginal birth after a c-section?
Uterine rupture
Anal sphincter injury
Risks of waiting for spontaneous labour
What are the risks associated with having an anaesthetic?
Allergic reactions or anaphylaxis Hypotension Headache Urinary retention Nerve damage (spinal anaesthetic) Haematoma (spinal anaesthetic) Sore throat (general anaesthetic) Damage to the teeth or mouth (general anaesthetic)
What are the key causes of maternal sepsis?
Chorioamnionitis - abdominal pain, uterine tenderness, vaginal discharge
UTIs - UTI symptoms
What is the aetiology of chorioamnionitis?
Ascending migration of cervicovaginal flora
Haemtogenous spread to intervillous space
Direct infection after invasive procedures e.g. amniocentesis
Descending infection from the peritoneum via fallopian tubes
What are the risk factors for chorioamnionitis?
Prolonged rupture of membranes Prolonged labour Preterm PROM Multiple digital exams Use of internal uterine fetal monitors Genital tract pathogens Tobacco and alcohol use
What is the clinical presentation of chorioamnionitis?
Fever Uterine fundal tenderness Purulent or foul smelling fluid from the cervical os Maternal tachycardia, fetal tachycardia Reduced fetal heart rate variability
What is. thecriteria for a confirmed intraamniotic infection?
Positive amniotic fluid test Positive culture Positive gram stain Decrease in glucose Raised WCC Histopathology after delivery shows inflammatory iniltrates in membranes
What is the management of chorioamnionitis?
Antimicrobial agents Antipyretics Expedition of delivery Management of symptoms Ampicillin and gentamicin Vaginal delivery preferable
What are the complications of chorioamnionitis?
Dysfunctional labour as infected uterus does not contract well Operative delivery PPH Maternal sepsis Postpartum endometritis Adult RDS
Neonatal complications e.g. pneumonia, cerebral palsy, sepsis, premature birth complications
What is an amniotic fluid embolism?
Amniotic fluid passes into the mother’s blood, occurs around labour and delivery.
Contains fetal tissue causing immune reaction
What are the risk factors for amniotic fluid embolism?
Increasing maternal age
Induction
C-section
Multiple pregnancy
What is the presentation of amniotic fluid embolism?
Shortness of breath Hypoxia Hypotension Coagulopathy Haemorrhage Tachycardia Confusion Seizures Cardiac arrest
What is the management of amniotic fluid embolism?
Supportive
A-E approach
Provide oxygen for hypoxia, IV fluids, treat seizures
Cardiopulmonary resuscitation and immediate c-section required if cardiac arrest occurs
How should stillbirth’s be managed?
Allow parents time and space for reflection away from normal ward
Allow to dress and spend time with child
Hospital protocols - wrap baby, offer to hold, photos, hair and palm prints
Funeral arrangements
Hospital counsellors and chaplains - comfort to families
Bereavement midwives
Consent for post mortem
Inform GP practice
What is uterine rupture?
Incomplete or complete rupture where the muscle layer of the uterus ruptures
Contents in complete can be released into the peritoneal cavity
What are the risks of uterine rupture?
Anything causing the uterus to be weaker
Main RF is previous c-section
VBAC Previous uterine surgery High BMI High parity Increased age IOL Use of oxytocin
What is the presentation of uterine rupture?
Acutely unwell mother Abnormal CTG Abdominal pain Vaginal bleeding Ceasing of uterine contractions Hypotension Tachycardia Collapse
What is the management of uterine rupture?
Resuscitation
Transfusion
Emergency c-section
Repair or remove uterus
What is uterine inversion?
Rare complication of birth
Fundus of uterus drops down through uterine cavity and cervix, turning the uterus inside out
What are the two types of uterine inversion?
Incomplete - partial inversion where fundus descends inside uterus or vagina but not as far as the introitus (opening of vagina)
Complete - descends through the vagina, into the introitus
What is the presentation of uterine inversion?
PPH
Maternal shock
Collapse
May be felt on vaginal examination if incomplete
What is the management of uterine inversion?
Johnson manoevre - use hand to push fundus back up, whole hand and forearm inserted and held in place for several minutes with oxytocin given for a contraction
If this fails; hydrostatic manoeuvre, vagina filled with fluid to inflate back into normal place
If this fails, surgery with laparotomy
