Management of Labour and Delivery

Question 1

Have a detailed knowledge of the mechanisms, diagnosis and management of normal and abnormal labour.

Question 2

Have a detailed knowledge of the anatomy and physiology of normal labour and delivery.

(Consider the 3 Ps)

Answer 2

Question 3

Have a detailed knowledge of the indications for pain relief/anaesthesia.

Answer 3

Question 4

Understand and have some practical experience of the methods of induction and augmentation of labour; indications, contraindications and complications.

Answer 4

Question 5

Understand and have some practical experience of the structure and use of partograms.

(what is monitored and how frequently - 1^st and 2^nd stages of labour)

Answer 5

Partograph is commenced at 4 cm dilation (1st stage of labour)

Foetal HR: Auscultated every 15 minutes in the 1st stage and after every contraction, for 1 minute, in the 2nd stage of labour

Maternal pulse: Every hour

Maternal BP and temperature: Every 4 hours

Maternal urine dip: Every 4 hours (check for proteins and ketones)

VE offered every 4 hours

Monitors cervical dilation: Alert and action lines may be used as a guide for slow progress

Monitors descent of the head/engagement

Liquor colour

Number of contractions in a 10 minute period: Obtained from CTG

Notes when ROM has occured

Question 6

Understand and have some practical experience of the assessment of fetal wellbeing

Answer 6

Meconium-stained liquor: Release of foetal bowel contents into the amniotic fluid

• More common at 36-41 weeks gestation, rare in pre-term
  
  • Associated with infection and chorioamnionitis.
• Hypoxia can induced bowel peristalsis and relaxation of the anal sphincter, leading to release of meconium
• Diluted meconium is not concerning
• Undiluted (‘pea soup’) is concerning
• Meconium staining is associated with meconium aspiration syndrome (→ pneumonia and hypoxia)
• Management: Induction of PROM has occured, continuous foetal monitoring

Foetal HR monitoring

• Baseline HR is tachycardic (110-160)
  
  • Indicates fever, foetal infection and potentially hypoxia (if occuring alongside other abnormalities)
• Reduced variability (< 25 beats variation from the baselines in 1 minute)
  
  • Indicates hypoxia
  • Indicates that the foetal nervous system is not intact
• Deceleration (> 15 beats from the baselines for > 15 seconds)
  
  • Late decelerations indicate foetal hypoxia
  • Deceleration lasting > 3 minutes is worrying
  • Variable decelerations may indicate cord compression
• Prolonged bradycardia

Feotal scalp blood sampling

• pH < 7.2 indicates need for rapid delivery (foetal hypoxia)

Question 7

Understand and have some practical experience of the diagnosis, impact and management of intrapartum haemorrhage.

Answer 7

Definition: PV bleeding occuring after 24 weeks gestation.

DDx: Placental abruption/praevia, genital tract bleeding, miscarriage, severe pre-eclampsia, chorioamnionitis

Diagnosis:

Hx: PV bleeding +/- pain

Examination: Inspection, PV examination, speculum, abdominal palpation

Investigations:

• Maternal: Kleihauer², FBC, group and save, coagulation screen
• Foetal: USS¹, CTG, foetal artery doppler

Impact:

• Pre-term labour
• Maternal blood loss, hypotension, foetal hypoxia
• IUD
• Anaemia

Management:

Spotting/minimal blood loss, bleeding ceased, no compromise → discharge after assessment

Heavier bleeding or continued bleeding → ongoing monitoring

1: Used to confirm the position of the placenta
2: Check amount of anti-D required (if rhesus negative)

Question 8

Understand and have some practical experience of the diagnosis, impact and management of preterm labour.

Answer 8

Definition: Onset of labour before 37 weeks gestation

Diagnosis:

Hx: Regular contractions (3-4 in 10 minutes), pain, ROM, risk factors for pre-term labour

Examination: Pooling of liquor in the vagina on speculum, cervical dilation on VE

Investigations for PPROM:

• Elevated IGFBP-1 (or PAMG-1) on vaginal swab if membanes have ruptured
• Elevated FFN - can be used to confirm preterm labour but also to assess the risk of preterm labour in those with Hx of preterm or cervical shortening
• Vaginal swab to check for infection

Impact:

• Premature birth → RDS, increased risk of sepsis/infection, intellectual disability
• Loss of life

Prophylaxis of Pre-term labour

• Vaginal progesterone: Cervical length < 25mm on VUS between 16 and 24 weeks gestation
• Cervical cerclage: Cervical length < 25mm on VUS, previous premature birth or cervical trauma (colposcopy and cone biopsy) between 16 and 24 weeks gestation

Acute Management of PPROM

• Prophylactic to prevent the development of chorioamnionitis
• Induction of labour may be offered from 34 weeks

​Acute management of preterm labour with intact membranes¹

• Perform speculum examination to check for cervical dilatation. At more than 30 weeks gestation a TUV can be used to assess cervical length
• Fetal fibronectin can also be used. <50ng/ml is considered negative, indicating that labour is unlikely
• Provide:
  
  • ​Foetal monitoring (CTG or intermittent auscultation)
  • Tocolysis (Nifedipine) can be used between 24 - 34 weeks to allow increased time for foetal development, administration of maternal steroids or transfer to a more specialist unit. Short term use only, < 48hrs.
  • Antenatal steroids: For gestation < 36 weeks². Regimes such as 2 doses of IM betamethasone 24 hours apart
  • Magnesium sulfate³: Can be used for foetal neuroprotection. Given within 24 hours of delivery of preterm babies of < 34 weeks gestation.
• REMEMBER: USS to check position of baby. More likely to be breech when pre-term

​

1: Preterm labour with intact membranes involves regular painful contractions and cervical dilatation without rupture of the amniotic sac
2: Act to reduce the risk of respiratory distress syndrome
3: Must monitor for signs of MgSO₄ toxicity - reduced RR, reduced BP and absent reflexes

Key definitions

Rupture of membranes (ROM): The amniotic sac has ruptured.

Spontaneous rupture of membranes (SROM): The amniotic sac has ruptured spontaneously.

Prelabour rupture of membranes (PROM): The amniotic sac has ruptured before the onset of labour.

Preterm prelabour rupture of membranes (P‑PROM): The amniotic sac has ruptured before the onset of labour and before 37 weeks gestation (preterm).

Prolonged rupture of membranes (also PROM): The amniotic sac ruptures more than 18 hours before delivery.

Question 9

Understand and have some practical experience of the diagnosis, impact and management of pre-eclampsia and eclampsia.

Answer 9

Diagnosis: New onset hypertension (> 140/90 mmHg), oedema and proteinuria after 20 weeks gestation

Low levels of placental growth factor (PlGF) between 20-35 weeks suggests pre-eclampsia.

Maternal symptoms such as headache, visual disturbances, nausea/vomiting, abdominal pain, oedema, reduced urine output and brisk reflexes

Eclampsia: Development of seizures in association with pre-eclampsia

RFs for development:

• High risk: Pre-existing HTN, previous HTN in pregnancy, existing autoimmune conditions, DM, CKD
• Medium risk: >40 years old, BMI >35, multiple pregnancy, first pregnancy, FHx of pre-eclampsia

Impact:

Maternal: Symptoms (headache, visual disturbance, oedema, RUQ/epigastric pain, nausea/vomiting, hyperreflexia), hepatic/coagulation problems, renal failure, convulsions, pre-term labour, death

Foetal: Placenta abruption, IUGR, hypoxia, prematurity

Management:

1. Aspirin from 12 weeks gestation for ‘at risk groups’ (1 of high risk or 2 of medium risk - see above)
2. Antihypertensives: Labetalol, nifedipine, methyldopa
   
   • ​​BP monitored at least every 48 hrs
3. Increased foetal monitoring: USS scans, umbilical artery doppler, amniotic fluid volume, foetal movements
   
   • ​​US scan of foetus, amniotic fluid and doppler performed every 2/52
4. ?Admit to hospital - use fullPIERS or PREP-S to assess risk
5. Birth by 37 weeks gestation

Epidural analgesia will help to lower BP in labour, active pushing should not be allowed in the 2nd stage of labour if BP is > 160/110 mmHg

6. Seizure control in eclampsia: Magnesium sulphate (preserves cerebral perfusion) in labour and the following 24hrs to prevent seizures
7. Delivery of the placenta
   
   1. Severe pre-eclampsia may take up to 24 hours to resolve following delivery of the placenta
   2. Syntocinon (oxytocin) should be used, not syntometrine (ergometrine +ocytocin) - as the latter causes an elevation in BP
8. Admission during pregnancy if indicated - see fullPIERS and PREP-S
   
   • Symptomatic, severe hypertension (>160/110 mmHg), IUGR + abnormal umbilical artery doppler/abnormal CTG, abnormal xFlt-1/PIGF assay (increased ratio)
9. ​HELLP syndrome may arise as a complication: Haemolytic, elevated liver enzymes and low platelet syndrome

Question 10

Understand and have some practical experience of the diagnosis, impact and management of episiotomy

Answer 10

Indication for episiotomy:

• Expediation of delivery required due to evident foetal distress
• Instrumental delivery indicated (forceps, ventouse), such as due to prolonged 2nd stage, foetal distress
• Complicated vaginal delivery: Breech, shoulder dystocia
• Extensive lower genital tract scarring: FGM, poorly healed 3rd or 4th degree tears

MUST be performed close to the time of delivery - helps to minimise blood loss

Impact/consequences

• Blood loss
• Haematoma
• Infection
• Scarring
• Dyspareunia
• Rarely fistula formation

Management

Local anaesthetic, pudendal nerve block, incision at 45-60º from centre of the vaginal fourchette - a mediolateral episiotomy (protects the anal sphincter from damage)

Should be repaired as soon as possible.

Question 11

Understand and have some practical experience of the diagnosis, impact and management of perineal repair

Answer 11

Diagnosis:

1^st degree: Perineum skin only

2^nd degree: Skin and smooth muscle of the perineum

3^rd degree: Skin, smooth muscle and anal sphincter

4^th degree: Skin, smooth muscle, anal sphincter and anal epithelium

Impact/possible complications of perineal tears

• Incontinence
• Fistula formation
• Dyspareunia
• Scarring
• Pain

Management:

Repair to the tear should be provided as soon as possible

3rd and 4th degree tears require repair in surgery

Abx and laxatives should be provided following tears - helps reduce the likelihood of infection and eases the passage of faeces

Question 12

Understand and have some practical experience of types of, indications for and complications of caesarean section.

Answer 12

Types of C-section:

• Lower uterine segment incision
• Classical (vertical incision)

Indications:

Complications:

• Blood loss
• Infection
• Laceration of internal organs: Bladder, bowel, uterus
• Decrease mobility (DVT, PE)
• Increased risk of uterine rupture, placenta praevia, placenta accreta and antepartum stillbirth in future pregnancies

Question 13

Understand and have some practical experience of the diagnosis, impact and management of pain relief options and methods.

Question 14

Be aware of the impact of analgesia and anaesthesia on labour.

Question 15

Be aware of the causes and management of maternal collapse

Answer 15

(e.g. massive obstetric haemorrhage, cardiac problems, pulmonary and amniotic embolism)

Question 16

Be aware of the indications and methods of instrumental deliveries

Answer 16

Aim: To reduce damage to the perieum, particularly the anal sphincter - allowing for continence to be maintained. Emergecy CS in the 2nd stage is associated with increased maternal morbidity and mortality. Instrumental delivery helps to decrease this.

Indications:

• Maternal exhaustion
• Prolonged 2nd stage of labour
  
  • > 1 hr active pushing in multiparous
  • > 2 hr active pushing in prinip
• Foetal distress (CTG or pH < 7.2)
• Breech presentation - to control the after coming head of the baby, due to the reduced size compared to the body the head may become trapped by the cervix (failed/refused ECV and CS)
• Multiple pregnancy

CAUTION: Full dilation and lack of obstruction (head must be < 1/5 palpable) must be confirmed prior to intrumental delivery

Methods:

• Forceps
  
  • ?Requires local anaesthetic: Lidocaine and pudendal nerve block
  • May be used alongside an episiotomy
• Ventouse/kiwi cup

Question 17

Be aware on the indications and methods for operative delivery

Answer 17

Elective

• Post-dates
• Multiple pregnancy
• Breech presentation when ECV is contraindicated or unsuccessful
• Previous C-section (especially vertical)
• Placenta praevia/low-lying placenta
• Vasa praevia
• Placenta accreta/increta/percreta
• Prevent mother-to-child transfer of infections:
  
  • HIV positive with no HAART or viral copies > 400 per mL
  • HSV occuring in the 3rd trimester (risk of neonatal HSV infection)

Emergency

• 3 minutes of foetal bradycardia on CTG
• Foetal compromise: Scalp pH < 7.2
• Uterine rupture
• Placental abruption
• Cord prolapse
• Failure to progress in labour with pathological CTG
  
  • Otherwise an instrumental delivery may first be considered

Incision types

• Lower uterine
• Vertical: Indicated for pre-term labour, when uterus is poorly accessible e.g. fibroids