Labour Flashcards

Question

When should an artificial rupture of membranes be arranged? When should it be avoided and what is the risk?

Answer 1

**Artificial Rupture of Membranes** (ARM) aka **Amniotomy** * Should not be used first-line for induction * Only possible if the cervix is beginning to dilate and efface * Avoid if the presenting part is mobile or high * Risk of umbilical cord prolapse * (Can also be used to augment or accelerate labour)

Answer 2

* Should not be used first-line for induction * **Offered if 2 hours after membranes have ruptured,** labour has not ensued * To increase uterine contractions, until 3-4 contractions are achieved every 10mins * **Risk**: uterine hyperstimulation, ↑ risk of uterine rupture (esp. in VBAC or previous uterine myomectomy) * (Can also be used to augment or accelerate labour)

Answer 3

* Induction: * Membrane sweep to stimulate physiological prostaglandins * Vaginal PGE2 or Mechanical balloon * If still no ROM, then ARM * After 2hrs of ARM, start IV Syntocinon * If induction fails: * Rest period followed by attempting induction again (only if there is no major threat to foetal or maternal condition) * C-section

Answer 4

**Mifepristone** (anti-progesterone) and **misoprostol** (prostaglandin) Often used to induce labour following intrauterine foetal death when you would give vaginal prostaglandins.

Answer 5

Breech presentation refers to when the presenting part of the fetus (the lowest part) is the legs and bottom. * nulliparity * low-lying placenta, placenta praevia * polyhydramnios * multiple pregnancy *

Answer 6

* 1 in 4 breech at 28 weeks * 3-5% still breech at term (37 weeks gestation)

Answer 7

* ***Complete breech (full breech)***, where the legs are fully flexed at the hips and knees * ***Extended breech (frank breech)*** with both legs flexed at the hip and extended at the knee * ***Footling breech***, with a foot is presenting through the cervix with the leg extended * ***Incomplete breech***, with one leg flexed at the hip and extended at the knee

Answer 8

External cephalic version (***ECV***) is a technique used to attempt to turn a fetus from the breech position to a cephalic position using pressure on the pregnant abdomen

Answer 9

Performed at 36 weeks if nulliparous, or 37 weeks if multiparous 50% success rate

Answer 10

* Where C-section delivery is required (irrespective of ECV outcome) * Abnormal CTG * Major uterine anomaly * Recent antepartum haemorrhage (last 7 days) * Ruptured membranes * Multiple pregnancy

Answer 11

1. Women are given ***tocolysis*** to relax the uterus before the procedure. 2. Tocolysis is with ***subcutaneous terbutaline***. Terbutaline is a ***beta-agonist*** similar to salbutamol. 3. It reduces the ***contractility*** of the ***myometrium***, making it easier for the baby to turn. 4. ***Rhesus-D negative*** women require ***anti-D prophylaxis*** when ECV is performed. 5. A ***Kleihauer test*** is used to quantify how much fetal blood is mixed with the maternal blood, to determine the dose of anti-D that is required.

Answer 12

* planned caesarian section * planned breech vaginal birth * footling breech * baby is larger or smaller than average * baby is in a certain position, for example, if its neck is very tilted back (hyper extended) * low-lying placenta (placenta praevia) * you have pre-eclampsia or any other pregnancy problems;

Answer 13

Prematurity is defined as birth before ***37 weeks gestation***.

Answer 14

Babies are considered ***non-viable*** below 23 weeks gestation. Generally, from 23 to 24 weeks, resuscitation is not considered in babies that do not show signs of life. Babies born at 23 weeks have around a 10% chance of survival. From **24 weeks onwards**, there is an increased chance of survival, and full resuscitation is offered.

Answer 15

* Under 28 weeks: ***extreme preterm*** * 28 – 32 weeks: ***very preterm*** * 32 – 37 weeks: ***moderate to late preterm***

Answer 16

* Regular or frequent sensations of abdominal tightening (contractions) * Constant low, dull backache * A sensation of pelvic or lower abdominal pressure * Mild abdominal cramps * Vaginal spotting or light bleeding * Preterm rupture of membranes — in a gush or a continuous trickle of fluid after the membrane around the baby breaks or tears * A change in type of vaginal discharge — watery, mucus-like or bloody

Answer 17

* Previous preterm labor or premature birth, particularly in the most recent pregnancy or in more than one previous pregnancy * Pregnancy with twins, triplets or other multiples * Shortened cervix * Problems with the uterus or placenta * Smoking cigarettes or using illicit drugs * Certain infections, particularly of the amniotic fluid and lower genital tract * Some chronic conditions, such as high blood pressure, diabetes, autoimmune disease and depression * Stressful life events, such as the death of a loved one * Too much amniotic fluid (polyhydramnios) * Vaginal bleeding during pregnancy * Presence of a fetal birth defect * An interval of less than 12 months — or of more than 59 months — between pregnancies * Age of mother, both young and older * Black, non-Hispanic race and ethnicity

Answer 18

Neonatal  Intensive care  Cerebral palsy  Death  Chronic lung disease  Blindness  Minor disability  At 24 weeks: 1/3 handicapped, 1/3 die Maternal * Infection * Severe illness * Endometritis * CS rate

Answer 19

* Vaginal Progesterone * Cervical cerclage Offer if: * *Hx of spontaneous preterm birth (\<34 weeks) or mid-trimester loss (16+ weeks) AND* * *TVUSS between 16-24 weeks show cervical length \<25mm*

Answer 20

* This is offered to women with a cervical length less than 25mm on vaginal ultrasound between 16 and 24 weeks gestation. * Progesterone can be given vaginally via gel or pessary as prophylaxis for preterm labour * Progesterone has a role in maintaining pregnancy and preventing labour by decreasing activity of the myometrium and preventing the cervix remodelling in preparation for delivery. NICE: Offer to women who have * a history of spontaneous preterm birth (up to 34⁺⁰ weeks of pregnancy) or mid-trimester loss (from 16⁺⁰ weeks of pregnancy onwards) **or** * results from a transvaginal ultrasound scan carried out between 16⁺⁰ and 24⁺⁰ weeks of pregnancy that show a cervical length of 25 mm or less. When using vaginal progesterone, start treatment between 16⁺⁰ and 24⁺⁰ weeks of pregnancy and continue until at least 34 weeks.

Answer 21

Cervical cerclage involves putting a stitch in the cervix to add support and keep it closed. This involves a spinal or general anaesthetic. The stitch is removed when the woman goes into labour or reaches term. Cervical cerclage is offered to women with a cervical length less than 25mm on vaginal ultrasound between 16 and 24 weeks gestation, who have had a previous premature birth or cervical trauma (e.g. colposcopy and cone biopsy). “***Rescue***” cervical cerclage may also be offered between 16 and 27 + 6 weeks when there is cervical dilatation without rupture of membranes, to prevent progression and premature delivery. If prophylactic cervical cerclage is used, ensure that a plan is in place for removal of the suture

Answer 22

Preterm prelabour rupture of membranes is where the ***amniotic sac*** ruptures, releasing ***amniotic fluid***, before the onset of labour and in a preterm pregnancy (under 37 weeks gestation).

Answer 23

Only if 30+ weeks - Offer a speculum examination to look for pooling of amniotic fluid and: * if pooling of amniotic fluid is observed, do not perform any diagnostic test but offer care consistent with the woman having P‑PROM * if pooling of amniotic fluid is not observed, perform an insulin-like growth factor binding protein‑1 test or placental alpha-microglobulin‑1 test of vaginal fluid * ***Insulin-like growth factor-binding protein-1*** (***IGFBP-1***) is a protein present in high concentrations in amniotic fluid, which can be tested on vaginal fluid if there is doubt about rupture of membranes * ***Placental alpha-microglobin-1*** (***PAMG-1***) is a similar alternative to IGFBP-1 If negative, explain to the woman that it is unlikely that she has P‑PROM, but that she should return if she has any further symptoms suggestive of P‑PROM or preterm labour

Answer 24

* Prophylactic antibiotics * Offer women with P‑PROM **oral erythromycin 250 mg 4 times a day for a maximum of 10 days** or until the **woman is in established labour** (whichever is sooner). * For women with P‑PROM who cannot tolerate erythromycin or in whom erythromycin is contraindicated, consider an **oral penicillin** for a maximum of 10 days or until the woman is in established labour (whichever is sooner). * Do not offer women with P‑PROM co‑amoxiclav as prophylaxis for intrauterine infection. * Use a combination of clinical assessment and tests (C‑reactive protein, white blood cell count and measurement of fetal heart rate using cardiotocography) to **diagnose intrauterine infection** * If the results of the clinical assessment or any of the tests are not consistent with each other, continue to observe the woman and consider repeating the tests. * Offer maternal corticosteroids * 1st line = IM betamethasone 24 mg 24 hours apart * Women who have PPROM between 24⁺⁰ and 33⁺⁶ weeks’ gestation should be offered corticosteroids; steroids can be considered up to 35⁺⁶weeks’ gestation. * Offer IV magnesium sulphate * 24hrs before delivery in 24⁺⁰ and 29⁺⁶ weeks of gestation * DO NOT administer tocolytics - increased risk of infection * Induction of labour may be offered from 34 weeks to initiate the onset of labour • **Intense clinical surveillance** for signs of chorioamnionitis and pre-term labour o There is a lack of consensus whether this is best inpatient or outpatient o Within Imperial NHS trust, best practice is to admit until 28 weeks, after which 2- 3x/week outpatient monitoring until delivery

Answer 25

Offer a clinical assessment to women reporting symptoms of preterm labour who have intact membranes. This should include: * clinical history taking * the observations described for the initial assessment of a woman in labour * a speculum examination (followed by a digital vaginal examination if the extent of cervical dilatation cannot be assessed; be aware that if a swab for fetal fibronectin testing is anticipated -the swab should be taken before any digital vaginal examination.). If the clinical assessment suggests that the woman is in suspected preterm labour and she is 29⁺⁶ weeks pregnant or less, advise treatment for preterm labour If the clinical assessment suggests that the woman is in suspected preterm labour and she is 30⁺⁰ weeks pregnant or more, consider transvaginal ultrasound measurement of cervical length as a diagnostic test to determine likelihood of birth within 48 hours. Act on the results as follows: * if cervical length is more than 15 mm, explain to the woman that it is unlikely that she is in preterm labour and: * think about alternative diagnoses * discuss with her the benefits and risks of going home compared with continued monitoring and treatment in hospital * advise her that if she does decide to go home, she should return if symptoms suggestive of preterm labour persist or recur * if cervical length is 15 mm or less, view the woman as being in diagnosed preterm labour and offer treatment Consider fetal fibronectin testing as a diagnostic test to determine likelihood of birth within 48 hours for women who are 30⁺⁰ weeks pregnant or more if transvaginal ultrasound measurement of cervical length is indicated but is not available or not acceptable. * if fetal fibronectin testing is negative (concentration 50 ng/ml or less), explain to the woman that it is unlikely that she is in preterm labour and: “ ” * if fetal fibronectin testing is positive (concentration more than 50 ng/ml), view the woman as being in diagnosed preterm labour and offer treatment If a woman in suspected preterm labour who is 30⁺⁰ weeks pregnant or more does not have transvaginal ultrasound measurement of cervical length or fetal fibronectin testing to exclude preterm labour, offer treatment consistent with her being in diagnosed preterm labour Do not use transvaginal ultrasound measurement of cervical length and fetal fibronectin testing in combination to diagnose preterm labour.

Answer 26

There are several options for improving the outcomes in preterm labour: * ***Fetal monitoring*** (CTG or intermittent auscultation) * ***Tocolysis with nifedipine***: nifedipine is a calcium channel blocker that suppresses labour * ***Maternal corticosteroids***: can be offered before 35 weeks gestation to reduce neonatal morbidity and mortality * ***IV magnesium sulphate***: can be given before 34 weeks gestation and helps protect the baby’s brain * ***Delayed cord clamping*** or ***cord milking***: can increase the circulating blood volume and haemoglobin in the baby at birth ***\<29 weeks:*** * ***Immediate tocolysis – don’t bother with other Ix*** * ***Give corticosteroids + magnesium sulphate*** ***30+ weeks:*** * ***TVUSS 🡪 Cervical length \>15mm suggests unlikely she is in preterm labour*** * ***Consider fetal fibronectin testing to determine likelihood of birth in 48 hours if TVUSS not possible (\<50 suggests unlikely)*** * ***Tocolysis with PO nifedipine for 24-34 weeks with intact membranes*** * IV Atosiban - Oxytocin receptor antagonists 2^nd line * Antenatal steroids 24-34 weeks, consider up to 36 weeks * Intrapartum Abx: Benzylpenicillin * Magnesium sulphate 4g IV bolus then 1g/hour IV 24-30 weeks, consider up to 34 weeks for 24hrs until delivery * Cord clamping asap after 30 secs **If meconium or known GBS (21% of pregnancies) or pyrexia:** * **\>34 weeks: Expedite delivery immediately (Abx if known GBS/pyrexia)** * Post-natal: observe the baby for 12 hours

Answer 27

* Tocolysis involves using medications to _stop uterine contractions._ * ***Nifedipine***, a calcium channel blocker, is the medication of choice for tocolysis. * ***Atosiban*** is an ***oxytocin receptor antagonist*** that can be used as an alternative when nifedipine is contraindicated. * Tocolysis can be used between 24 and 33 + 6 weeks gestation in preterm labour to delay delivery and buy time for further fetal development, administration of maternal steroids or transfer to a more specialist unit (e.g. with a neonatal ICU). * It is only used as a short term measure (i.e. less than 48 hours).

Answer 28

* Giving the mother ***corticosteroids*** helps to develop the fetal lungs and reduce ***respiratory distress syndrome*** after delivery. * They are used in women with suspected preterm labour of babies ***less than 36 weeks gestation***. * An example regime would be **two doses** of **intramuscular** ***betamethasone***, 24 hours apart.

Answer 29

Giving the mother ***IV*** ***magnesium sulfate*** helps protect the ***fetal brain*** during premature delivery. It reduces the risk and severity of ***cerebral palsy***. Magnesium sulphate is given within 24 hours of ***delivery*** of preterm babies between 24⁺⁰ and 29⁺⁶ weeks of gestation. It is given as a bolus, followed by an infusion for up to 24 hours or until birth. Mothers need close monitoring for ***magnesium toxicity*** at least four hourly. This involves close monitoring of observations, as well as ***tendon reflexes*** (usually ***patella reflex***). Key signs of toxicity are: * Reduced respiratory rate Reduced blood pressure * Absent reflexes ANTIDOTE: 10ml 10% calcium gluconate over 10 mins (stop infusion)

Answer 30

* Complications for mother*: sepsis and placental abruption * Foetal:* chorioamnionitis, cord prolapse. PTL, pulmonary hypoplasia, limb contractures, death

Answer 31

Rupture of membranes at least one hour before the onset of contractions.

Answer 32

Gush or clear fluid followed by uncontrollable intermittent trickle

Answer 33

* smoking * APH * trauma * UTI * previous PROM * uterine abnormalities * cervical incompetence * smoking * multiple pregnancies * polyhydramnios

Answer 34

Prolonged premature rupture of membranes is the rupture of membranes more than 24 hours before the onset of labour.

Answer 35

* Cord prolapse * Transverse or breech = higher risk * Presence of GBS and increased duration of rupture → high risk ascending vaginal infection

Answer 36

* Clinical diagnosis * Identify liquor * Check lie and presentation

Answer 37

* Admit to antenatal ward for speculum, 4hrly temperature and 24hr foetal monitoring. * Await SL or IOL * IOL does not increase risk of CS and associated with lower chance of maternal infection and NICU admission * Waiting for spontaneous labour is common practice * 40% women do not undergo SL in 24h * If more than 24 hrs - offer IOL * After 18h – usual to prescribe abx against GBS - Intense clinical surveillance for signs of chorioamnionitis * • If Meconium: Induce labour ASAP. * Monitor neonate for at least 12 hours after delivery (when the risk of infection is greatest)

Answer 38

Offer an immediate birth (by induction of labour or caesarean birth) to women who are between 34 and 37 weeks' gestation who: * have prolonged prelabour rupture of membranes, **and** * have group B streptococcal colonisation, bacteriuria or infection at any time in their current pregnancy * IV Abx: Benzylpenicillin + gentamicin + metronidazole until delivery

Answer 39

* Vaginal birth after cesarian section (VBAC) * Elective repeat c-section

Answer 40

Planned VBAC is appropriate for and may be offered to the majority of women with a singleton pregnancy of cephalic presentation at 37+0 weeks or beyond who have had a single _previous lower segment caesarean delivery_, with or without a history of previous vaginal birth.

Answer 41

Planned VBAC is contraindicated in women with: * previous uterine rupture * classical caesarean scar * women who have other absolute contraindications to vaginal birth that apply irrespective of the presence or absence of a scar (e.g. major placenta praevia). In women with complicated uterine scars, caution should be exercised and decisions should be made on a case-by-case basis by a senior obstetrician with access to the details of previous surgery

Answer 42

* Women who have had two or more prior lower segment caesarean deliveries may be offered VBAC after counselling by a senior obstetrician. * This should include the risk of uterine rupture and maternal morbidity, and the individual likelihood of successful VBAC (e.g. given a history of prior vaginal delivery). * Labour should be conducted in a centre with suitable expertise and recourse to immediate surgical delivery

Answer 43

Previous successful VBAC is the single best predictor of successful VBAC and has a success rate of 85-90%

Answer 44

Women should be made aware that: * successful VBAC has the fewest complications and therefore the chance of VBAC success or failure is an important consideration when choosing the mode of delivery. * the greatest risk of adverse outcome occurs in a trial of VBAC resulting in emergency caesarean delivery. * planned VBAC is associated with an approximately 1 in 200 (0.5%) risk of uterine rupture. * the absolute risk of birth-related perinatal death associated with VBAC is extremely low and comparable to the risk for nulliparous women in labour. * ERCS is associated with a small increased risk of placenta praevia and/or accreta in future pregnancies and of pelvic adhesions complicating any future abdominopelvic surgery. * The risk of perinatal death with ERCS is extremely low, but there is a small increase in neonatal respiratory morbidity when ERCS is performed before 39+0 weeks of gestation. * The risk of respiratory morbidity can be reduced with a preoperative course of antenatal corticosteroids.

Answer 45

Women should be advised that: * planned VBAC should be conducted in a suitably staffed and equipped delivery suite with continuous intrapartum care and monitoring with resources available for immediate caesarean delivery and advanced neonatal resuscitation * Women with an unplanned labour and a history of previous caesarean delivery should have a discussion with an experienced obstetrician to determine feasibility of VBAC. * Epidural analgesia is not contraindicated in a planned VBAC, although an increasing requirement for pain relief in labour should raise awareness of the possibility of an impending uterine rupture * to have continuous electronic fetal monitoring for the duration of planned VBAC, commencing at the onset of regular uterine contractions

Answer 46

Women should be informed of: * the two- to three-fold increased risk of uterine rupture and around 1.5-fold increased risk of caesarean delivery in induced and/or augmented labour compared with spontaneous VBAC labour. * the decision to induce labour, the proposed method of induction, the decision to augment labour with oxytocin, the time intervals for serial vaginal examination and the selected parameters of progress that would necessitate discontinuing VBAC. * Clinicians should be aware that induction of labour using mechanical methods (amniotomy or Foley catheter) is associated with a lower risk of scar rupture compared with induction using prostaglandins

Answer 47

* ERCS delivery should be conducted after 39+0 weeks of gestation. * Antibiotics should be administered before making the skin incision in women undergoing ERCS * All women undergoing ERCS should receive thromboprophylaxis according to existing RCOG guidelines * Early recognition of placenta praevia, adopting a multidisciplinary approach and informed consent are important considerations in the management of women with placenta praevia and previous caesarean delivery.

Answer 48

post-dates, twin gestation, fetal macrosomia, antepartum stillbirth or maternal age of 40 years or more Women who are preterm and considering the options for birth after a previous caesarean delivery should be informed that planned preterm VBAC has similar success rates to planned term VBAC but with a lower risk of uterine rupture.

Answer 49

* Discuss options: elective repeat C-section (ERCS) or attempted vaginal birth after Csection (VBAC) * Explain the risks of VBAC (uterine rupture risk of 1 in 200, success rate 70-75% remainder require emergency CS) * Explain the risks of ERCS (implications for future pregnancies)

Answer 50

* Uterine rupture is a complication of labour, where the muscle layer of the uterus (myometrium) ruptures. * With an ***incomplete rupture***, or ***uterine dehiscence***, the ***uterine serosa*** (***perimetrium***) surrounding the uterus remains intact. * With a ***complete rupture***, the serosa ruptures along with the myometrium, and the contents of the uterus are released into the ***peritoneal cavity***.

Answer 51

Risk of uterine rupture = 1 in 200 (increased to 1 in 100 with the use of syntocinon)

Answer 52

* Increased HR * Low BP * Cold * Increased pain * pain in between contractions * pain on or around scar * blood

Answer 53

Maternal complications include major obstetric haemorrhage, with possible need for peripartum hysterectomy; Fetal complications include hypoxic ischaemic encephalopathy, permanent brain injury and even death

Answer 54

Shoulder dystocia is when the ***anterior shoulder*** of the baby becomes stuck behind the ***pubic symphysis*** of the pelvis, after the head has been delivered. “Shoulder dystocia is defined as a vaginal cephalic delivery that requires additional obstetric manoeuvres to deliver the fetus after the head has delivered and gentle traction has failed”

Answer 55

 Macrosomia  50% cases in babies \>4kg  Previous shoulder dystocia  Increased Maternal BMI  Labour induction  Low height  Maternal DM  Instrumental delivery

Answer 56

1. Inform: - Midwife Coordinator on Delivery Suite - Obstetric Consultant - Anaesthetist Consultant and ODA - Neonatal Registrar 2. Resuscitation: - Insert 2 large bore intravenous cannulae - IV fluids infusion as clinically indicated - Request 6 units of group specific blood and alert Blood Bank - Send urgent bloods for FBC, Clotting/FDP’s, U&E’s 3. Emergency Laparotomy (Aim for delivery of baby within 15 minutes) Aim to repair the uterus; decision for hysterectomy should be confirmed by and performed by a Consultant 4. Thromboprophylaxis as per protocol for a high risk woman

Answer 57

* Shoulder dystocia presents with difficulty delivering the face and head, and obstruction in delivering the shoulders after delivery of the head. * There may be ***failure of restitution***, where the head remains face downwards (occipito-anterior) and does not turn sideways as expected after delivery of the head. * Turtle-neck sign -head is delivered but then retracts back into the vagina.

Answer 58

* There can be significant perinatal morbidity and mortality associated with the condition, even when it is managed appropriately * Maternal morbidity is increased, particularly the incidence of postpartum haemorrhage (11%) as well as third and fourth-degree perineal tears (3.8%). * Brachial plexus injury (BPI) is one of the most important fetal complications of shoulder dystocia, complicating 2.3% to 16% of such deliveries. * Others: Erb's palsy, fetal hypoxia

Answer 59

* Induction of labour at term can reduce the incidence of shoulder dystocia in women with gestational diabetes (not in non-diabetic patients) * Either caesearian section or vaginal birth can be appropriate for women with previous shoulder dystocia

Answer 60

* Lie woman flat and tell her to STOP pushing = as pushing can increase risk of foetal complications. 1. Call for senior and neonatal help (press the emergency buzzer or 2222). 2. External manoeuvres: the whole point is to increase the relative anterior-posterior diameter of the pelvis. 1. McRobert’s manoeuvre – place patient with hips hyper-flexed and abducted (“thighs to abdomen, successful in 90% of cases). 2. Suprapubic pressure – this is used to improve McRobert’s. You apply pressure down and forward to decrease the shoulder diameter. 3. Consider episiotomy if this will make internal manoeuvres easier 4. Internal manoeuvres: the whole point is to reduce the shoulder diameter by abducting the shoulder and allowing rotation into the wider oblique pelvis diameter. 1. Rubin II manoeuvre – insert a hand behind the anterior shoulder and push it towards baby’s chest. 2. Wood’s screw manoeuvre – Rubin 2 + insert second hand to apply pressure to front of posterior shoulder to aid further rotation. 3. Deliver posterior arm – this reduces shoulder diameter by arm width. The baby’s wrist should be grasped, and the posterior arm should be gently tugged from the vagina in a straight line. Risk of humeral Fractures! 5. Change position to all fours – this may help dislodge the anterior shoulder. 6. Third-line manoeuvres should be considered very carefully to avoid unnecessary maternal morbidity and mortality, particularly by inexperienced practitioners: foetal cleidotomy, maternal symphisiotomy or Zavanelli (vaginal replacement of the foetal head followed by a CS – this can be used in bilateral shoulder dystocia)

Answer 61

Birth attendants should be alert to the possibility of postpartum haemorrhage and severe perineal tears. The baby should be examined for injury by a neonatal clinician. An explanation of the delivery should be given to the parents

Answer 62

Primary postpartum haemorrhage

Answer 63

Definied as \>500ml blood loss \<24h after delivery, or \>1000ml after C section

Answer 64

PPH can be **minor** (500–1000 ml) or **major** (more than 1000 ml). Major can be further subdivided into **moderate (**1001–2000 ml) and **severe** (more than 2000 ml).

Answer 65

Secondary PPH is defined as abnormal or excessive bleeding from the birth canal between 24 hours and 12 weeks postnatally

Answer 66

* **T** – ***Tone*** (***uterine atony*** – the most common cause) * **T** – ***Trauma*** (e.g. perineal tear) * **T** – ***Tissue*** (retained placenta) * **T** – ***Thrombin*** (bleeding disorder)

Answer 67

* Tone * Multiple pregnancy * Previous PPH * Fetal macrosomia * Failure to progress in 2nd stage * Prolonged third stage of labour * General anaesthesia * Trauma * Episiotomy * Perineal laceration * Tissue * Retained placenta * Placenta accreta * Thrombin * Pre-eclampsia

Answer 68

* **Treat antenatal anaemia -** Antenatal anaemia should be investigated and treated appropriately as this may reduce the morbidity associated with PPH. * **Reduce blood loss at delivery** * Prophylactic uterotonics (**oxytocin (10 iu by intramuscular injection)** should be routinely offered in the management of the third stage of labour in all women as they reduce the risk of PPH. * For women delivering by caesarean section, **oxytocin (5 iu by slow intravenous injection)** should be used to encourage contraction of the uterus and to decrease blood loss. * **Ergometrine–oxytocin** may be used in the _absence of hypertension_ in women at increased risk of haemorrhage as it reduces the risk of minor PPH (500–1000 ml). * Clinicians should consider the use of **intravenous tranexamic acid (0.5–1.0 g),** in addition to oxytocin, at caesarean section to reduce blood loss in women at increased risk of PPH.

Answer 69

1. **_MDT Involvement_** 1. The **midwife in charge** and the **first-line obstetric** and **anaesthetic staff** should be alerted when women present with **minor PPH** (blood loss 500–1000 ml) without clinical shock. 2. A m**ultidisciplinary team** involving **senior members of staff** should be summoned to attend to women with **major PPH** (blood loss of more than 1000 ml) and ongoing bleeding or clinical shock.

Answer 70

* **intravenous access (one 14-gauge cannula)** * **urgent venepuncture (20 ml) for:** * **-group and screen** * **-full blood count** * **-coagulation screen, including fibrinogen** * **pulse, respiratory rate and blood pressure recording every 15 minutes** * **commence warmed crystalloid infusion.**

Answer 71

1. Call for senior **help** and initiate **major obstetric haemorrhage MOH protocol** (obstetric consultant, anaesthetic team, haematologist and blood transfusion lab) 2. **ABCDE approach** 1. Position the patient flat 2. 2x large bore IV cannulae 3. Urgent bloods for: FBC, clotting, G&S (if not done previously) and cross-match 4. Transfuse blood as soon as possible 3. _Continuous_ HR, BP and RR monitoring 4. If the placenta is undelivered → attempt removal by controlled cord traction 5. If the placenta is delivered → check for completeness (empty uterus and vagina of clots) 6. **Massage the uterus** to stimulate uterine contractions 7. Stepwise approach to pharmacological and surgical options: o **Step 1**: IV/IM syntocinon or IM ergometrine or syntometrine (last 2 are contraindicated in asthma and HTN) o **Step 2**: IM carboprost (not in asthmatics) o **Step 3**: intrauterine balloon tamponade i.e. Bakri balloon. o **Step 4**: other surgical measures (e.g. iliac artery ligation, uterine artery embolization IR, hysterectomy) * ***Oxytocin*** (slow injection followed by continuous infusion) * ***Ergometrine*** (intravenous or intramuscular) stimulates smooth muscle contraction (contraindicated in hypertension) * ***Carboprost*** (intramuscular) is a ***prostaglandin analogue*** and stimulates uterine contraction (caution in asthma) * ***Misoprostol*** (sublingual) is also a ***prostaglandin analogue*** and stimulates uterine contraction * ***Tranexamic acid*** (intravenous) is an ***antifibrinolytic*** that reduces bleeding * ***Intrauterine balloon tamponade*** – inserting an inflatable balloon into the uterus to press against the bleeding * ***B-Lynch suture*** – putting a suture around the uterus to compress it * ***Uterine artery ligation*** – ligation of one or more of the arteries supplying the uterus to reduce the blood flow * ***Hysterectomy*** is the “last resort” but will stop the bleeding and may save the woman’s life

Answer 72

* In women presenting with secondary PPH, an assessment of **vaginal microbiology** should be performed (high vaginal and endocervical swabs) and appropriate use of antimicrobial therapy should be initiated when endometritis is suspected. * A **pelvic ultrasound** may help to exclude the presence of retained products of conception (RPOC), although the diagnosis of retained products is unreliable. * **Surgical evacuation of retained placental tissue** should be undertaken or supervised by an experienced clinician.

Answer 73

Face presentation: * If chin anterior (mento-anterior position) = vaginal delivery is possible with delivery by flexion * If chin posterior (mento-posterior position) = delivery by C-section Brow presentation: • Delivery by C-section

Answer 74

**the frequent changing of fetal lie and presentation in late pregnancy**. (usually refers to pregnancies \> 37 weeks)

Answer 75

Consider ECV or ELCS

Answer 76

Cord prolapse has been defined as the descent of the umbilical cord through the cervix alongside (occult) or past (overt) the presenting part in the presence of ruptured membranes.

Answer 77

Cord presentation is the presence of the umbilical cord between the fetal presenting part and the cervix, with or without intact membranes

Answer 78

The overall incidence of cord prolapse ranges from 0.1–0.6%. In the case of breech presentation, the incidence is higher at 1% The incidence is influenced by population characteristics and is higher when there is a greater percentage of multiple gestations

Answer 79

Cases of cord prolapse consistently feature in **perinatal mortality** enquiries. Prematurity and congenital malformation birth asphyxia - thought to be cord compression and umbilical arterial vasospasm preventing venous and arterial blood flow to and from the fetus

Answer 80

* With transverse, oblique or unstable lie, **elective admission to hospital after 37+0 weeks of gestation** should be discussed and women in the community should be advised to **present urgently** if there are **signs of labour or suspicion of membrane rupture.** * Women with non-cephalic presentations and preterm prelabour rupture of membranes should be recommended inpatient care. * Artificial membrane rupture should be avoided whenever possible if the presenting part is mobile and/or high. → if still done, arrangements in place for immediate c-section * Upward pressure on the presenting part should be kept to a minimum in women during vaginal examination and other obstetric interventions in the context of ruptured membranes because of the risk of upward displacement of the presenting part and cord prolapse. * Rupture of membranes should be avoided if on vaginal examination the cord is felt below the presenting part. When cord presentation is diagnosed in established labour, caesarean section is usually indicated.

Answer 81

Cord presentation or prolapse should be excluded at every vaginal examination in labour and after spontaneous rupture of membranes if risk factors are present. Cord prolapse should be suspected when there is an abnormal fetal heart rate pattern, especially if such changes commence soon after membrane rupture, either spontaneous or artificial. Speculum and/or digital vaginal examination should be performed when cord prolapse is suspected.

Answer 82

1. When cord prolapse is diagnosed before full dilatation, **assistance should be immediately** called and preparations made for **immediate birth in theatre.** 1. There are insufficient data to evaluate manual replacement of the prolapsed cord above the presenting part to allow continuation of labour. _This practice is not recommended._ 2. To prevent vasospasm, there should be minimal handling of loops of cord lying outside the vagina. 3. To prevent cord compression: 1. it is recommended that the presenting part be elevated either manually or by filling the urinary bladder. 2. can be further reduced by the mother adopting the knee–chest or left lateral (preferably with head down and pillow under the left hip) position. 4. Tocolysis can be considered while preparing for caesarean section if there are persistent fetal heart rate abnormalities after attempts to prevent compression mechanically, particularly when birth is likely to be delayed. 5. Although the measures described above are potentially useful during preparation for birth, they must not result in unnecessary delay.

Answer 83

1. Caesarean section is the recommended mode of delivery in cases of cord prolapse when vaginal birth is not imminent in order to prevent hypoxic acidosis. 2. A category 1 caesarean section should be performed with the aim of achieving birth within 30 minutes or less if the cord prolapse is associated with a suspicious or pathological fetal heart rate pattern but without compromising maternal safety. 3. Category 2 caesarean birth can be considered for women in whom the fetal heart rate pattern is normal, but continuous assessment of the fetal heart trace is essential. 1. If the cardiotocograph (CTG) becomes abnormal, re-categorisation to category 1 birth should immediately be considered. 2. Discussion with the anaesthetist should take place to decide on the appropriate form of anaesthesia. 3. Regional anaesthesia can be considered in consultation with an experienced anaesthetist. 4. Verbal consent is satisfactory for category 1 caesarean section. 4. Vaginal birth, in most cases operative, can be attempted at full dilatation if it is anticipated that birth would be accomplished quickly and safely, using standard techniques and taking care to avoid impingement of the cord when possible. 5. Breech extraction is appropriate under some circumstances, for example, after internal podalic version for a second twin. 6. A practitioner competent in the resuscitation of the newborn should attend all births that follow cord prolapse. 7. Paired cord blood samples should be taken for pH and base excess measurement

Answer 84

Delayed cord clamping can be considered if a baby is uncompromised at birth. Immediate resuscitation should take priority over DCC when the baby is unwell at birth.

Answer 85

A perineal tear occurs where the external vaginal opening is too narrow to accommodate the baby. This leads to the skin and tissues in that area tearing as the baby’s head passes.

Answer 86

* First births (nulliparity) * Large babies (over 4kg) * Shoulder dystocia * Asian ethnicity * Occipito-posterior position * Instrumental deliveries

Answer 87

* ***First-degree*** – injury limited to the ***frenulum of the labia minora*** (where they meet posteriorly) and superficial skin * ***Second-degree*** – including the ***perineal muscles***, but not affecting the anal sphincter * ***Third-degree*** – including the ***anal sphincter***, but not affecting the rectal mucosa * ***3A*** – less than 50% of the ***external anal sphincter*** affected * ***3B*** – more than 50% of the ***external anal sphincter*** affected * ***3C*** – external and internal anal sphincter affected * ***Fourth-degree*** – including the ***rectal mucosa***

Answer 88

First-degree tears usually do not require any sutures. When a perineal tear larger than first degree occurs, the mother usually requires sutures to correct the injury. A second degree tear requires suturing on the ward by a suitably experienced midwife or clinician A third or fourth-degree tear is likely to need repairing in theatre. Additional measures are taken to reduce the risk of complications: * ***Broad-spectrum antibiotics*** to reduce the risk of infection * ***Laxatives*** to reduce the risk of constipation and wound dehiscence * ***Physiotherapy*** to reduce the risk and severity of incontinence * ***Follow-up*** to monitor for longstanding complications Women that are symptomatic after third or fourth-degree tears are offered an ***elective caesarean section*** in subsequent pregnancies.

Answer 89

Short term complications after repair include: * Pain * Infection * Bleeding * Wound dehiscence or wound breakdown Perineal tears can lead to several lasting complications: * Urinary incontinence * Anal incontinence and altered bowel habit (third and fourth-degree tears) * Fistula between the vagina and bowel (rare) * Sexual dysfunction and dyspareunia (painful sex) * Psychological and mental health consequences

Answer 90

**Perineal Massage** ## Footnote Perineal massage is a method for reducing the risk of perineal tears. It involves massaging the skin and tissues between the vagina and anus (perineum). This is done in a structured way from 34 weeks onwards to stretch and prepare the tissues for delivery.