Labour/C section/PPH/Perineal tears

Question 1

Postpartum haemorrhage

Answer 1

Postpartum haemorrhage (PPH) is defined as blood loss of > 500 ml after a vaginal delivery and may be primary or secondary.

Primary postpartum haemorrhage

Primary PPH occurs within 24 hours. It affects around 5-7% of deliveries.

The causes of PPH are said to be the 4 Ts:
Tone (uterine atony): the vast majority of cases
Trauma (e.g. perineal tear)
Tissue (retained placenta)
Thrombin (e.g. clotting/bleeding disorder)

Risk factors for primary PPH include*:
previous PPH
prolonged labour
pre-eclampsia
increased maternal age
polyhydramnios
emergency Caesarean section
placenta praevia, placenta accreta
macrosomia
the effect of parity on the risk of PPH is complicated. It was previously thought multiparity was a risk factor but more modern studies suggest nulliparity is actually a risk factor

Management
PPH is a life-threatening emergency - senior members of staff should be involved immediately
ABC approach
two peripheral cannulae, 14 gauge
lie the woman flat
bloods including group and save
commence warmed crystalloid infusion
mechanical
palpate the uterine fundus and rub it to stimulate contractions (‘rubbing up the fundus’)
catheterisation to prevent bladder distension and monitor urine output
medical
IV oxytocin: slow IV injection followed by an IV infusion
ergometrine slow IV or IM (unless there is a history of hypertension)
carboprost IM (unless there is a history of asthma)
misoprostol sublingual
there is also interest in the role tranexamic acid may play in PPH
surgical: if medical options fail to control the bleeding then surgical options will need to be urgently considered
the RCOG state that the intrauterine balloon tamponade is an appropriate first-line ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage
other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure

Secondary postpartum haemorrhage

Secondary PPH occurs between 24 hours - 12 weeks. It is typically due to retained placental tissue or endometritis.

Question 2

Labour (normal)

Answer 2

Labour (normal)

Labour may be defined as the onset of regular and painful contractions associated with cervical dilation and descent of the presenting part

Signs of labour include
regular and painful uterine contractions
a show (shedding of mucous plug)
rupture of the membranes (not always)
shortening and dilation of the cervix

Labour may be divided in to three stages
stage 1: from the onset of true labour to when the cervix is fully dilated
stage 2: from full dilation to delivery of the fetus
stage 3: from delivery of fetus to when the placenta and membranes have been completely delivered

Monitoring

Monitoring in Labour
FHR monitored every 15min (or continuously via CTG)
Contractions assessed every 30min
Maternal pulse rate assessed every 60min
Maternal BP and temp should be checked every 4 hours
VE should be offered every 4 hours to check progression of labour
Maternal urine should be checked for ketones and protein every 4 hours

Question 3

Caesarean section

Answer 3

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

There are two main types of caesarean section:
lower segment caesarean section: now comprises 99% of cases
classic caesarean section: longitudinal incision in the upper segment of the uterus

Indications (apart from cephalopelvic disproportion/praevia, most are relative)
absolute cephalopelvic disproportion
placenta praevia grades 3/4
pre-eclampsia
post-maturity
IUGR
fetal distress in labour/prolapsed cord
failure of labour to progress
malpresentations: brow
placental abruption: only if fetal distress; if dead deliver vaginally
vaginal infection e.g. active herpes
cervical cancer (disseminates cancer cells)

Caesarean sections may be categorised by the urgency
Category 1
an immediate threat to the life of the mother or baby
examples indications include: suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia or persistent fetal bradycardia
delivery of the baby should occur within 30 minutes of making the decision
Category 2
maternal or fetal compromise which is not immediately life-threatening
delivery of the baby should occur within 75 minutes of making the decision
Category 3
delivery is required, but mother and baby are stable
Category 4
elective caesarean

Vaginal birth after Caesarean (VBAC)
planned VBAC is an appropriate method of delivery for pregnant women at >= 37 weeks gestation with a single previous Caesarean delivery
around 70-75% of women in this situation have a successful vaginal delivery
contraindications include previous uterine rupture or classical caesarean scar

Question 4

Perineal tears

Answer 4

classification of perineal tears:
first degree
superficial damage with no muscle involvement
do not require any repair
second degree
injury to the perineal muscle, but not involving the anal sphincter
require suturing on the ward by a suitably experienced midwife or clinician
third degree
injury to perineum involving the anal sphincter complex (external anal sphincter, EAS and internal anal sphincter, IAS)
3a: less than 50% of EAS thickness torn
3b: more than 50% of EAS thickness torn
3c: IAS torn
require repair in theatre by a suitably trained clinician
fourth degree
injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa
require repair in theatre by a suitably trained clinician

Risk factors for perineal tears
primigravida
large babies
precipitant labour
shoulder dystocia
forceps delivery

Question 5

Rhesus negative pregnancy

Answer 5

Anti-D immunoglobulin should be given as soon as possible (but always within 72 hours) in the following situations:
-delivery of a Rh +ve infant, whether live or stillborn
-any termination of pregnancy
-miscarriage if gestation is > 12 weeks
-ectopic pregnancy (if managed surgically, if managed medically with methotrexate anti-D is not required)
-external cephalic version
-antepartum haemorrhage
-amniocentesis, chorionic villus sampling, -fetal blood sampling
-abdominal trauma

Tests
all babies born to Rh -ve mother should have cord blood taken at delivery for FBC, blood group & direct Coombs test
Coombs test: direct antiglobulin, will demonstrate antibodies on RBCs of baby
Kleihauer test: add acid to maternal blood, fetal cells are resistant

Affected fetus
oedematous (hydrops fetalis, as liver devoted to RBC production albumin falls)
jaundice, anaemia, hepatosplenomegaly
heart failure
kernicterus
treatment: transfusions, UV phototherapy

Question 6

Severe pre-eclampsia features

Answer 6

Features of severe pre-eclampsia
hypertension: typically > 160/110 mmHg and proteinuria as above
proteinuria: dipstick ++/+++
headache
visual disturbance
papilloedema
RUQ/epigastric pain
hyperreflexia
platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome

Question 7

Shoulder dystocia:
What is the first line management for shoulder dystocia?

Answer 7

McRoberts manoeuvre (hyperflexion of the maternal legs) is the first management approach
Episiotomy is required if this is unsuccessful.