Module 11 - Management of Delivery Flashcards by Andrew Simon

What is the incidence of maternal postpartum haemorrhage in deliveries complicated by shoulder dystocia?

10%

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What is the incidence of 3rd & 4th degree perineal tears in deliveries complicated by shoulder dystocia?

3.8%

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What is the incidence of brachial plexus injury in deliveries complicated by shoulder dystocia?

2.3 - 16%

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Contraindications to ARM?

High presenting part (risk of cord prolapse)
Preterm labour
Known HIV carrier
Caution is taken with polyhydramnios or any malposition or malpresentation
Placenta praevia
Vasa praevia

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What percentage of babies will have permanent neurological dysfunction as a result of brachial plexus injury secondary to shoulder dystocia?

<10%

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What nerve roots are involved in Erb’s palsy from shoulder dystocia?

Injury to C5 and C6 of the brachial plexus (C5 to T1)

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Prolonged third stage of labour?

Not completed within 30 minutes of birth with active management OR
Not completed within 60 minutes of the birth with physiological management

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What is the rate of shoulder dystocia in women who have had a previous pregnancy complicated by shoulder dystocia?

10x higher than that of the general population

Reported recurrence rates are variable but are up to 25%

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Incidence of cerebral palsy in 22-27/40 gestation?

14.6%

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Incidence of cerebral palsy in 28-31/40 gestation?

6.2%

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Incidence of cerebral palsy in 32-36/40 gestation?

0.7%

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Incidence of cerebral palsy at term?

0.1%

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Who should be given IV magnesium sulphate?

From 24+0 - 29+6 (<30+0) who are in established pre-term labour or having a planned pre-term birth within 24 hours

Consider 30+0 - 33+6 if in established pre-term labour or having a planned preterm birth within 24 hours

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How to give MgSO4?

4g IV bolus over 15 minutes

Followed by IV infusion of 1 g/hour until birth or for 24 hours (whichever is sooner)

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What are the monitoring requirements for women on MgSO4?

4 hourly pulse rate, resp rate, BP and deep tendon reflexes.

Monitor urine output

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When to give Antenatal corticosteroids?

Between 24+0 - 34+6 weeks’ gestation in whom delivery is expected within 7 days, and in the absence of infection

For women undergoing ELCS birth between 37+0 and 38+6 weeks an informed discussion should take place with the woman about the potential risks and benefits of a course of antenatal corticosteroids

Give:
1) 2x Betamethasone 12mg I.M. 24 hours apart
2) Dexamethasone 6mg I.M. 12 hours apart - 4x doses

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What are the benefits of given antenatal corticosteroids from 24-34+6/40 for women with suspected pre-term labour?

Highly likely to:
1) Reduce neonatal mortality
2) Reduce perinatal mortality
3) Reduce RDS

Likely to:

1) Reduce Intraventricular haemorrhage
2) Developmental delay

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What are the benefits of antenatal corticosteroids from 37-38+6/40 in women undergoing ELCS?

Reduced admission to Neonatal unit for respiratory problems/morbidity

Uncertain if there is any reduction in:

1) Respiratory distress syndrome
2) Transient tachypnoea of the newborn
3) Neonatal unit admission overall

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What are the potential risks to the baby of antenatal corticosteroids given from 37-38+6 in women who are undergoing cs?

1) Potential developmental delay

2) Neonatal hypoglycaemia

?insulin resistance

?Hypertension

?Hardened aorta (decreased aortic distensibility)

?altered glucose metabolism

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Is Tocolysis associated with a clear reduction in perinatal or neonatal morbidity or mortality?

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What is the incidence of umbilical cord prolapse in breech presentation?

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What percentage of second twins are delivered via caesarean section after a first twin was delivered vaginally?

3-5%

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A G3P2 lady delivers her first twin vaginally. How long should you wait for delivery of the second twin after successful ECV before proceeding to caesarean section?

30 minutes

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What proportion of women with IUD will go into labour within 3 weeks?

> 85%

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What proportion of women with IUD will go into labour within 3 weeks?

>85%

What is the risk of DIC of women with IUD within the first 4 weeks?

10%

How are women on lithium managed in labour?

Stop lithium once in labour and measure plasma levels 12 hours after last dose

What is the risk of infection with CS?

2-7 in 100

What proportion of deliveries in the UK are via CS?

25% 15% - emergency 10% - elective

What is the risk of emergency hysterectomy with caesarean section?

15 in 10,000

What is the risk of VTE after CS?

4-16 in 10,000 (rare)

What is the risk of haemorrhage after CS?

5 in 1,000 (uncommon)

What is the risk of infection after CS?

2-7 in 100 (common)

What is the risk of bladder injury after CS?

1 in 1,000 (uncommon)

What is the risk of ureteric injury after CS?

1 in 1,000

What proportion of caesarean sections are emergencies?

60%

What percentage of neonates require SCBU admission following CS at full dilatation?

11%

What percentage of neonates require SCBU admission following operative vaginal delivery?

What is the perinatal mortality rate with planned vaginal breech delivery?

2 in 1,000

What is the perinatal mortality rate with CS after 39+0 weeks?

0.5 in 1,000

What is the perinatal mortality rate with planned cephalic vaginal delivery?

1 in 1,000

What is the risk of maternal haemorrhage (>1000ml) with operative vaginal delivery?

What is the risk of maternal haemorrhage (>1000ml) with CS at full dilatation?

10% The risk of maternal haemorrhage (>1000ml) with operative vaginal delivery is significantly lower than with CS at full dilatation (3% vs 10%)

What is the incidence of cerebral palsy in babies born between 28 and 31 weeks?

What proportion of women having a CS for placenta praevia will require a hysterectomy?

11% 11 in 100

What proportion of women (with a previous hx of CS) that are having a planned CS for placenta praevia will require a hysterectomy?

27% 27 in 100

What proportion of women having a CS for placenta praevia will have a massive obstetric haemorrhage >2L?

21%

A 29 year old patient goes into labour. She has had an uneventful pregnancy with normal antenatal ultrasound scans. You are called to see the patient as fresh vaginal bleeding started when the membranes ruptured spontaneously. You suspect vasa previa. What is the fetal mortality associated with vasa previa when it is not diagnosed in the antenatal period?

mortality rate 50-60% survival rate 44%

What is the risk of DIC occurring within 4 weeks of Intrauterine death?

10%

What is the incidence of 3rd/4th degree tears in women who have a forceps delivery without an episotomy?

22%

What is the incidence of 3rd/4th degree tears in women who have a forceps delivery with an episotomy?

What is the overall incidence of 3rd/4th degree perineal tears?

What is the incidence of 3rd/4th degree perineal tears in nulliparous women?

What is the incidence of 3rd/4th degree perineal tears in VBACs?

What is the incidence of 3rd/4th degree perineal tears in multiparous women?

1.7%

What is the incidence of placenta praevia with no CS?

0.25% 1 in 400

What is the incidence of placenta praevia with 1 CS?

0.6% 1 in 160

What is the incidence of placenta praevia with 2 CS?

1.6% 1 in 60

What is the incidence of placenta praevia with 3 CS?

3.3% 1 in 30

What is the incidence of placenta praevia with 4 CS?

10% 1 in 10

What is the overall incidence of umbilical cord prolapse at delivery?

0.3%

A woman has just had a ventouse delivery because of maternal exhaustion. What is the acceptable pre-ductal oxygen saturation in the baby after delivery in 2 minutes?

65%

A woman has just had a ventouse delivery because of maternal exhaustion. What is the acceptable pre-ductal oxygen saturation in the baby after delivery in 5 minutes?

85%

A woman has just had a ventouse delivery because of maternal exhaustion. What is the acceptable pre-ductal oxygen saturation in the baby after delivery in 10 minutes?

90%

A number of antenatal and intrapartum characteristics have been reported to be associated with shoulder dystocia, but statistical modelling has shown that these risk factors have a low positive predictive value, both singularly and in combination. What is the proportion of babies of birthweight <4kg complicated by shoulder dystocia?

50%

A diabetic pregnant woman presents to labour ward in her first pregnancy. What is her increased risk of having shoulder dystocia in her current pregnancy when she is compared to the general population?

2-4x increase

A 35 year old primigravida woman who is pregnant with DCDA twins attends the antenatal clinic at 32 weeks gestation. She is requesting CS as she is worried of needing a CS anyway or the second twin. What is the risk of needing EMCS to deliver second twin after a vaginal delivery of the first twin?

4-10%

A pregnant woman who has placenta praevia in this pregnancy attends the delivery suite with abdominal pain and mild vaginal bleeding. What is the risk of associated placental abruption in her case?

10%

A pregnant woman has had two placental abruptions in her previous 2 pregnancies. What is the recurrence rate in her current pregnancy?

20%

What is the chance of survival for a baby born at 24 weeks?

45-50%

What is the chance of survival without disability for a baby born at 24 weeks?

28-30%

At what gestation should MCMA twins be electively delivered?

32 - 34 weeks By C/S, due to the risk of cord entanglement

What proportion of twin pregnancies deliver before 37 weeks gestation?

58-60%

At what gestation should MCDA twins be electively delivered?

36+0 weeks

At what gestation should DCDA twins be electively delivered?

37+0 weeks

At which gestation can you perform fetal fibronectin to diagnose pre-term labour?

24 - 34 weeks If the woman has INTACT membranes AND cervix <3cm dilated

What is the risk of placental abruption having had one previously?

4.4%

What is the risk of placental abruption having had two previously?

19-25%

When should the delivery of monochorionic diamniotic twin pregnancies complicated by TTTS take place?

34 - 36+6 weeks

At which gestation can women be offered tocolysis in threatened pre-term labour?

Give: 26 - 33+6 weeks Consider: 24 - 25+6 weeks

When should delivery of a vaginal breech be expedited?

1) Evidence of poor fetal condition 2) Extended arms 3) Extended neck 4) >5 mins from delivery of buttock to head 5) >3 mins from delivery of umbilicus to head

Woman at 24+3 weeks gestation with threatened pre-term labour. On scan the baby is breech presentation. What mode of delivery should she have?

Routine CS for breech presentations at 22 - 25+6 weeks is not recommended Women should be informed that caesarean section for breech presentation in spontaneous preterm labour at the threshold of viability (22–25+6weeks of gestation) is not routinely recommended Consider CS: 26 - 36+6 weeks

Woman with PPROM needs IAP for prevention of GBS. She is allergic to pencillin, which antibiotics do you give?

Cefuroxime 1.5g i.v. loading dose Followed by 750mg TDS (every 8 hours) until delivery

Woman with PPROM needs IAP for prevention of GBS. She has a severe allergy to pencillin, which antibiotics do you give?

Vancomycin 1g BD i.v.

What is the success rate for a planned VBAC?

72-75%

What is the success rate for a VBAC with a history of fetal distress?

73%

What is the success rate for a VBAC with a history of previous vaginal delivery?

85-90%

What is the success rate for VBAC with a history of labour dystocia?

64%

What is the success rate for a VBAC with a history of malpresentation?

84%

A woman attended with suspected pre-term labour and received a course of antenatal corticosteroids at 31 weeks. She presents a week later in threatened pre-term labour. Do you repeat the course of steroids?

You can give a second course of ACS if: 1) Received one course >7 days ago 2) High risk of pre-term delivery within 48 hours Do not give more than 2 courses

At what gestation should antenatal corticosteroids be offered for women with established pre-term labour, PPROM or planned pre-term delivery?

Give: 24 - 33+6 weeks Consider: 34 - 35+6 weels

What are the benefits of administration of antenatal corticosteroids for planned ELCS at term?

Reduced admission to NICU for respiratory morbidity No association/decreased risk of: - Respiratory distress syndrome - Transient tachypnoea of the newborn - NICU admission

What adverse effects on the neonate are there from administration of antenatal corticosteroids?

1) Lower birth weight 2) Neonatal hypoglycaemia 3) Reduced aortic distensibility 4) Raised BP 5) Insulin resistance 6) Developmental delay

After ventouse delivery what is the acceptable pre-ductal oxygen saturation at 2 mins of life?

60%

After ventouse delivery what is the acceptable pre-ductal oxygen saturation at 3 mins of life?

70%

After ventouse delivery what is the acceptable pre-ductal oxygen saturation at 4 mins of life?

80%

After ventouse delivery what is the acceptable pre-ductal oxygen saturation at 5 mins of life?

85%

After ventouse delivery what is the acceptable pre-ductal oxygen saturation at 10 mins of life?

90%

What proportion of women with IUFDs will have a vaginal delivery within 24 hours of induction?

90%

What is the risk of wound infection with CS?

9 in 100

What is the estimated survival rate following amniotic fluid embolism?

>80%

What is the risk of 3rd/4th degree tears with vacuum delivery?

1-4%

What is the risk of 3rd/4th degree tears with forceps delivery?

8-12%

A woman is on prophylactic LMWH. What is her risk of APH and PPH?

Risk of APH 0.5% Risk of PPH 1%

A woman is on treatment dose LMWH. What is her risk of APH and PPH?

Risk of APH 1.5% Risk of PPH 2%

What is the maximum number of attempts that can be done for an ECV?

Woman is booked for an ELCS at 39 weeks. What is the risk that she goes into labour prior to this?

10%

Post rotational forceps delivery, patient developed bleeding which was coming above the piriformis muscle. Which artery was damaged?

Superior gluteal artery

What is the stillbirth rate at 37 weeks gestation?

1 in 1,000

What is the stillbirth rate at 42 weeks gestation?

3 in 1,000

What is the stillbirth rate at 43 weeks gestation?

6 in 1,000

What is the commonest cause of stillbirth?

SGA Over 1/3 of still births are small for gestational age

What proportion of deliveries in the UK are by CS?

25-30%

What proportion of deliveries in the UK are by Elective CS?

10%

What proportion of deliveries in the UK are by Emergency CS?

15%

What is the risk of infection with CS?

6 per 100 (common)

What is the risk of haemorrhage in CS?

5 per 1,000 (uncommon)

What is the risk of need of repeat surgery following CS?

5 per 1,000 (uncommon)

What is the risk of ITU admission following CS?

9 per 1,000 (uncommon)

What is the risk of fetal laceration with CS?

What is the version rate to cephalic after an unsuccessful ECV?

<5%

What is the reversion rate back to breech following a successful ECV?

<5%

What are the rates of operative vaginal delivery in the UK?

10-13%

What is the incidence of cord prolapse?

0.1-0.6%

What is the incidence of cord prolapse with breech deliveries?

What is the fetal mortality associated with vasa previa when it is not diagnosed in the antenatal period?

60%

What is the fetal survival rate associated with vasa previa when it is diagnosed in the antenatal period?

97% survival rate 3% mortality Ideally deliver at 35/40 or before

What proportion of vasa praevia are diagnosed antenatally?

40%

Dilation of the cervix beyond what point is associated with a high risk of emergency cervical cerclage failure?

>4cm

A woman has an IUD at 36 weeks. She would like to be managed conservatively. What is her likelihood of going into spontaneous labour within 3 weeks?

>85%

A woman has an IUD at 36 weeks. She would like to be managed conservatively. What is her risk of developing DIC within 4 weeks?

10%

When do you NOT perform fetal fibronectin to diagnose pre-term labour?

1) Cervix >3cm dilated 2) SROM 3) Vaginal bleeding 4) Sex or VE within 24 hours 5) <24 weeks or >34 weeks

At which gestation should you not use FSE (fetal scalp electrode)?

<34 weeks

At which gestation should you not use vacuum delivery?

<32 weeks Consider 34 - 36 weeks Operators should be aware that there is a higher risk of subgaleal haemorrhage and scalp trauma with vacuum extraction compared with forceps at preterm gestational ages.

For Rh -ve women which blood products also need to be Rh -ve?

1) Packed red cells 2) Platelets Rh D- women can receive Rh D+ FFP or Platelets

When is intraoperative cell salvage (IOCS) indicated?

If the anticipated blood loss is expected to induce anaemia or be >20% of blood volume

If CS delivery takes place between 37+0 and 38+6 weeks a single course of antenatal corticosteroids reduces the rate of Respiratory Distress Syndrome by how much?

From 6.7% to 2.7% Absolute Risk Reduction of RDS of 4%

What is the risk of neonatal herpes if the mother has primary herpes at the time of delivery?

40%

What is the incidence of PPROM?

2% of pregnancies

What is the risk of EMCS for women undergoing planned vaginal breech delivery?

40%

What is the acceptable pre-ductal SpO2 for baby at 2 minutes of life?

65%

What is the acceptable pre-ductal SpO2 for baby at 5 minutes of life?

85%

What is the acceptable pre-ductal SpO2 for baby at 10 minutes of life?

90%

What is the risk of death with VBAC?

4 in 100,000

What is the risk of death with CS?

13 in 100,000