1. Management of Labour and Delivery for Undergraduates Max Brinsmead MB BS PhD May 2015

2. Subjects to be covered: Induction of labour Induction of labour Delay in the first stage of labour Delay in the first stage of labour When & How to intervene in the second stage When & How to intervene in the second stage Who needs a Caesarean section? Who needs a Caesarean section? Risks associated with Caesarean delivery Risks associated with Caesarean delivery Why are there so many Caesareans? Why are there so many Caesareans?

3. Why is this subject important? Difficulties in labour is responsible for 30 – 50% of maternal deaths Difficulties in labour is responsible for 30 – 50% of maternal deaths Morbidity in survivors Morbidity in survivors Fistulas Fistulas Anaemia Anaemia Infertility Infertility Also has  fetal and neonatal risks Also has  fetal and neonatal risks CS in western countries is the simple & safe option but… CS in western countries is the simple & safe option but… Late presentation Late presentation Resources Resources Make it less appropriate elsewhere Make it less appropriate elsewhere

4. Predicting outcome in labour is still difficult: Clinical examination is limited Clinical examination is limited X-ray and CT Pelvimetry is disappointing X-ray and CT Pelvimetry is disappointing Estimates of fetal weight have a wide margins of error Estimates of fetal weight have a wide margins of error Antenatal risk screening is still important Antenatal risk screening is still important But mostly to decide place of birth rather than mode of delivery But mostly to decide place of birth rather than mode of delivery

5. Antenatal Risk Factors Young and older nulliparas Young and older nulliparas Short stature Short stature Previous difficult birth or Caesarean Previous difficult birth or Caesarean Previous stillbirth or neonatal death Previous stillbirth or neonatal death Multiple pregnancy Multiple pregnancy Nutritional deficiency, severe anaemia etc Nutritional deficiency, severe anaemia etc Large for dates Large for dates Obvious pelvic deformity Obvious pelvic deformity Malpresentation Malpresentation High Parity High Parity

6. When to induce labour: When the risks of continuing the pregnancy outweigh the risks of induction When the risks of continuing the pregnancy outweigh the risks of induction At 41+ weeks At 41+ weeks Within 96 hrs of ruptured membranes at term Within 96 hrs of ruptured membranes at term For pre eclampsia at 36 completed weeks For pre eclampsia at 36 completed weeks For maternal diabetes at 37 completed weeks For maternal diabetes at 37 completed weeks

7. How to induce labour: For prolonged pregnancy first sweep the membranes For prolonged pregnancy first sweep the membranes For ruptured membranes… For ruptured membranes… Oxytocin by IV infusion Oxytocin by IV infusion Although wait-and-see and vaginal PG’s are acceptable Although wait-and-see and vaginal PG’s are acceptable For all other patients (except those with a uterine scar)… For all other patients (except those with a uterine scar)… Vaginal prostaglandins Vaginal prostaglandins Regardless of the state of the cervix or the parity of the patient Regardless of the state of the cervix or the parity of the patient Amniotomy followed by oxytocin infusion 3 – 12 hours later is likely to be the most cost effective when the cervix is ripe Amniotomy followed by oxytocin infusion 3 – 12 hours later is likely to be the most cost effective when the cervix is ripe

8. After one previous lower segment Caesarean: For spontaneous labour the risk of scar rupture is 1:200 For spontaneous labour the risk of scar rupture is 1:200 With oxytocin infusion the risk is 1:100 With oxytocin infusion the risk is 1:100 With prostaglandins the risk is 1:40 With prostaglandins the risk is 1:40 More difficult to induce? More difficult to induce? Direct effect of PG’s on connective tissue? Direct effect of PG’s on connective tissue? Foley catheter is an acceptable alternative Foley catheter is an acceptable alternative

9. Delay in the 1 st stage of labour Back to basics… Back to basics… Best diagnosed by reference to a partograph Best diagnosed by reference to a partograph Defined as dilatation less than 1 cm/hour in the active phase Defined as dilatation less than 1 cm/hour in the active phase This represents the lowest 10 th centile This represents the lowest 10 th centile Is regardless of parity Is regardless of parity But the biggest difficulty is deciding when to start the partograph But the biggest difficulty is deciding when to start the partograph

10. Evaluation is all about P’s… Powers? Powers? Uterine contractions Uterine contractions Oxytocin augmentation? Oxytocin augmentation? Safe enough in most nulliparas Safe enough in most nulliparas Passenger, Presentation and Position Passenger, Presentation and Position Estimating fetal weight Estimating fetal weight Beware the multipara Beware the multipara Passages? Passages? Is this labour obstructed Is this labour obstructed Psychology Psychology Pain relief Pain relief Re hydration etc. Re hydration etc.

11. So in my practice I will: Make a personal evaluation of the patient… Make a personal evaluation of the patient… Begin with the AN record Begin with the AN record Talk to the patient & the midwife Talk to the patient & the midwife Evaluate uterine activity Evaluate uterine activity Examine abdomen and VE Examine abdomen and VE Arrange analgesia if required Arrange analgesia if required Commence oxytocin Commence oxytocin Arrange continuous CTG Arrange continuous CTG Review in 4, 6 or 8 hours Review in 4, 6 or 8 hours

12. When to intervene in the second stage of labour A few patients should not push at all A few patients should not push at all Otherwise, there is no reason to interfere unless there is failure to progress Otherwise, there is no reason to interfere unless there is failure to progress This usually means arrest after 60 minutes of active pushing This usually means arrest after 60 minutes of active pushing Not just full dilatation plus 1 – 2 hrs Not just full dilatation plus 1 – 2 hrs When the patient (and others) are ready for intervention When the patient (and others) are ready for intervention

13. Fetal welfare in the second stage Must take into account the total clinical scenario Must take into account the total clinical scenario For me this begins with the AN record For me this begins with the AN record Than the partograph, prior CTG etc. Than the partograph, prior CTG etc. The depth and width of FHR dips is more important than their type The depth and width of FHR dips is more important than their type Explain to the mother why you are intervening… Explain to the mother why you are intervening…

14. Forceps or Ventouse? Cochrane database 1999 Cochrane database 1999 Ten trials Ten trials Less maternal trauma Less maternal trauma RR 0.41, CI 0.33 – 0.50 RR 0.41, CI 0.33 – 0.50 Less anaesthesia required Less anaesthesia required More vaginal deliveries More vaginal deliveries RR 1.69, CI 1.31 – 2.19 RR 1.69, CI 1.31 – 2.19 More neonatal cephalhaematomas and retinal haemorrhage More neonatal cephalhaematomas and retinal haemorrhage But serious injury is rare But serious injury is rare

15. Vaginal Birth after Caesarean Maternal Risk of death Maternal Risk of death 2.8 per 10,000 with trial of scar 2.8 per 10,000 with trial of scar 2.4 per 10,000 for elective CS 2.4 per 10,000 for elective CS No maternal death ever attributed to scar rupture No maternal death ever attributed to scar rupture Scar rupture Scar rupture Much confusion in the literature over the definition Much confusion in the literature over the definition Rate of asymptomatic scar rupture the same whether VBAC or elect CS Rate of asymptomatic scar rupture the same whether VBAC or elect CS Overall rate approx. 0.5% or 1:200 Overall rate approx. 0.5% or 1:200 Was 0.35% in the largest combined contemporary study Was 0.35% in the largest combined contemporary study Hysterectomy Hysterectomy Additional risk from trial of scar is 3.4 per 10,000 Additional risk from trial of scar is 3.4 per 10,000 Requires 2941 elective CS to prevent one hysterectomy Requires 2941 elective CS to prevent one hysterectomy

16. Risks of Caesarean Delivery Difficult to quantify because: Difficult to quantify because: Most studies do not distinguish between elective and emergency operations Most studies do not distinguish between elective and emergency operations The reason for the CS needs to be considered The reason for the CS needs to be considered Some events are rare Some events are rare The question will only be resolved by: The question will only be resolved by: A randomised trial A randomised trial With long term follow up With long term follow up

17. More likely with Caesarean birth: Hospital stay 2-fold  Intensive care 9-fold  Maternal death 2-10 fold  Bladder or ureter damage 30-fold  Hysterectomy 40-fold  Thromboembolism 4 – 16 fold  Stillbirth in next pregnancy 2-fold  Placenta previa in next pregnancy 2-fold  Placenta accreta in future pregnancies

18. Same rate for vaginal and CS Birth: Postpartum haemorrhage Endometritis Genital tract injury Faecal incontinence Postnatal depression Back pain Dyspareunia

19. More Likely with Vaginal Birth: Perineal pain 2.5-fold  Urinary incontinence 1.6-fold  Uterovaginal prolapse 2-fold 

20. More likely with Caesarean birth No Difference whether CS or Vaginal More likely with Vaginal Birth Hospital stay 2-fold  Postpartum haemorrhage Perineal pain 2.5-fold  Intensive care 9-fold  Endometritis Urinary incontinence 1.6-fold  Death 2-10 fold  Genital tract injury Uterovaginal prolapse 2-fold  Bladder or Ureter damage 30-fold  Faecal incontinence Hysterectomy 40-fold  Postnatal depression Thromboembolism 4 – 16 fold  Back pain Placenta previa in next pregnancy 2-fold  Dyspareunia Stillbirth in next pregnancy 2-fold  Placenta accreta Source: UK Nice Guidelines

21. Caesarean Sections are Popular because: Caesarean Section is Convenient Caesarean Section is Convenient Caesarean Section is Simple Caesarean Section is Simple Caesarean Section is Safe Caesarean Section is Safe Caesarean Section is better for babies Caesarean Section is better for babies When you have done a Caesarean you have done everything possible – the medicolegal imperative When you have done a Caesarean you have done everything possible – the medicolegal imperative

22. Caesarean Sections are Popular because: Vaginal Birth is Painful Vaginal Birth is Painful Vaginal Birth is Unpredictable - If there is a 1:3 or even a 1:5 chance of requiring a CS why not just do one? Vaginal Birth is Unpredictable - If there is a 1:3 or even a 1:5 chance of requiring a CS why not just do one? “Vaginal Birth Ruins your Sex Life” “Vaginal Birth Ruins your Sex Life” “Vaginal Birth Destroys the Pelvic Floor” “Vaginal Birth Destroys the Pelvic Floor”

23. Caesarean Sections are Popular because: “Once a Caesarean always a Caesarean” “Once a Caesarean always a Caesarean” The Term Breech Trial The Term Breech Trial Loss of Obstetric Skills Loss of Obstetric Skills Pressures on Medical Resources Pressures on Medical Resources

24. More Caesarean Sections occur when: Fetal distress is diagnosed by CTG Fetal distress is diagnosed by CTG There is concern about transmission of an infection e.g. Herpes, Hep C, HIV There is concern about transmission of an infection e.g. Herpes, Hep C, HIV There are medical problems and non obstetricians are involved e.g. diabetes, back pain, epilepsy There are medical problems and non obstetricians are involved e.g. diabetes, back pain, epilepsy Patients are privately insured Patients are privately insured GPs and midwives compete with specialists GPs and midwives compete with specialists

25. Caesarean Sections are Popular because: The Power of Choice The Power of Choice Fathers have influence Fathers have influence It is Fashionable It is Fashionable Reduced Family Size Reduced Family Size

26. Caesarean Sections are increasing because: There is an obesity epidemic There is an obesity epidemic Maternal age is increasing Maternal age is increasing Epidurals sometimes fail Epidurals sometimes fail Induction of labour sometimes fails Induction of labour sometimes fails An epidemic of sexual abuse? An epidemic of sexual abuse?

27. Caesarean Sections are increasing because: “My mother and my sisters all had Caesareans” “My mother and my sisters all had Caesareans” “This is an IVF baby” “This is an IVF baby” Evolution of the species? Evolution of the species?

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