1. Gemma Adams & Gabrielle Zealand
Obstetrics part 2
Gemma Adams & Gabrielle Zealand

2. What we are going to cover
Normal labour
Premature & post-maturity
Puerperium
Complications – multiple pregnancy, abnormal fetal presentations, instrumental & operative delivery
Emergencies – prolapsed cord, shoulder dystocia, uterine rupture, pre-eclampsia
Covered in other one - antenatal screening – bloods, USS, Down’s syndrome etc, Rhesus disease, Infections, Complications of pregnancy – Miscarriages, Ectopic pregnancies, Molar pregnancies. Maternal disorders – especially pre-eclampsia and other hypertensive diseases, Obstetric shock – APH, disorders of the placenta, include PPH here
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3. Normal labour What is normal labour? Spontaneous onset Low-risk
Vertex position
Between 37 and 42 weeks
Good condition after birth
(without induction of labour, spinal/epidural/general anaesthesia, forceps/ventouse/ caesarean delivery or episiotomy)
WHO definition
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4. Normal labour General care in labour: Low BP? Maternal positioning?
Hydration/ eating?
Pyrexia?
Urinary tract?
Psychological well-being
Low BP may be associated with epidural analgesia
Pregnant women should not lie flat on their back as the gravid uterus compresses the IVC reducing cardiac output causing hypotension and often fetal distress
Hydration – encourage oral intake, IV fluids if epidural. Eating encouraged during latent phase, discouraged during active, many receive ranitidine.
Pyrexia temperature >37.5, assoc with increased risk of neonatal illness, may be chorioamnionitis, more common with epidural analgesia and prolonged labour, cultures of vagina, urine and blood, give antipyretics, IV antibiotics if >38
Urinary – encourage regular voiding, retention can damage detrusor muscle, if epidural may require catheterisation
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5. Normal labour Phases of labour? 1st stage 2nd stage 3rd stage
Latent phase
Active phase
Transitional phase
2nd stage
From full cervical dilatation to birth
3rd stage
After the foetus is expelled until just after the placenta is expelled
Latent phase - irregular contractions, ‘show’, 6 hours-2-3 days, cervix is effacing and thinning, encouraged to stay at home, paracetamol, position, water, snacks
Effacement starts in fundus, shortening of fibres, builds in amplitude throughout labour
Active labour - 4cm dilated, regular, frequent contractions, progressive, dependent on 3Ps
Transitional phase - Irritable, anxious,distressed. Start to feel pressure. Contractions can slow/stop. Need good support and reassurance
2nd stage
3rd stage -
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6. Partogram

7. Normal labour 3 Ps? Powers Passage
Too little – nulliparous, amniotomy, oxytocin
Too much – oxytocin, placental abruption, tocolytics
Passage
Cephalopelvic disproportion, pelvic mass, cervical incompetence
Powers – too little or too much. Too little common in nulliparous women, give continuous support, encourage mobility, if waters haven’t gone can perform amniotomy then use oxytocin
Too much – think hyperstimulation if lasting seconds and occurring every 2-3 minutes (normally longer at seconds and every 3-5 minutes), not enough time for uterus to relax leading to diminished placental blood flow and fetal distress. Associated with too much oxytocin, and is a side effect of prostaglandins used to induce labour, can induce placental abruption. Treat underlying cause, use tocolytic unless evidence of abruption – commonly used tocolytics include terbutaline, nifedipine, salbutamol
Passage – CPD: pelvis is too small to allow the head to pass through, retrospective diagnosis. Cervical incompetence: painless, pre-term delivery
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8. Passenger/ fetal presentation
Normal presentation?
occipito-posterior – longer and more painful labour, backache, early desire to push. Can rotate to OA with ventouse/ forceps
occipito-transverse – rotate with ventouse
Brow presentation – c section
Face presentation – fetal compromise common, c section
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9. Abnormal fetal presentation
Other abnormal presentations?
breech
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10. Abnormal fetal presentation
Risk factors?
Prematurity, multiple pregnancy, abnormalities of uterus, fetal abnormality, placenta praevia, smoking, polyhydramnios/oligohydramnios, IUGR, prev. breech
Breech
Confirm with USS
ECV
C-section
Fetal abnormality e.g. hydrocephalus
Breech with extended legs (frank) - 85% of cases
Breech with fully flexed legs (complete)
Footling (incomplete) with one or both thighs extended
ECV – external cephalic version - placental abruption, uterine rupture and fetomaternal haemorrhage. Offered at 36/37 weeks.
Breech can deliver vaginally, however usually only occurs when women present too far along for c-section.
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11. Mechanism of labour Do frogs in Canada ride in a pink limo Descent
Flexion
Internal rotation
Crowning
Restitution
Internal rotation of shoulders
Anterior shoulder
Posterior shoulder
Lateral flexion
Do frogs in canada ride in a pink limo
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12. 3rd stage Active/physiological Retained placenta Perineal trauma
Active – uterotonic drugs, early clamping and cutting, controlled cord traction
Lower risk of PPH with active management
Retained placenta
Perineal trauma
Active management – uterotonic drugs e.g. syntocinon, early clamping and cutting of cord, controlled cord traction + suprapubic pressure to prevent uterine inversion
Physiological – no routine use of uterotonic drugs, no clamping of card until pulsation ceased, delivery of placenta by maternal effort
Retained placenta mentioned in other presentation. NICE - >30 minutes if active management, >60 minutes if physiological management
Last resort manual removal Perineal trauma – 1st – 4th degree.
1st degree – injury to skin only, minor tear
2nd degree – involves perineal muscle, not anal sphincter
Episiotomy
3rd degree – involves anal sphincter
4th degree – involves anal sphincter and anal epithelium
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13. Pain relief Pain relief methods in labour? Non-pharmacological Entonox
Opioids
Pudendal nerve block
Epidural
- Non-pharmacological - relaxation, imagery, hypnosis, hypnobirthing, hydrotherapy, TENS, birth environment-setting, environment, massage, acupuncture, reflexology, aromatherapy, reflexology
- Entonox-most widely used, high satisfaction levels self administration - Side effects-nausea and vomiting
Opioids - Pethidine/morphine/ diamorphine - Side effects Fetal - Respiratory depression, Diminishes breast-seeking, breast-feeding behaviours. Side effects-maternal - Euphoria & dysphoria, Nausea/vomiting, Longer 1st and 2nd stage labour
Pudendal nerve block - local anaesthetic injected bilaterally around pudendal nerve near ischial spines, suitable for instrumental delivery
Epidural - most effective form pain relief, injection of local anaesthetic into epidural space between L3 and L4, can be infused continuously or topped up intermittently. Gives complete sensory (except pressure) and partial motor blockade.
Side effects-maternal Increase length 1st & 2nd stage, Need for more oxytocin, Increase incidence malpositon, Increase instrumental rate. Loss of mobility, Loss of bladder control, Hypotension, pyrexia. Fetal side effects Tachycardia due to maternal temp, Diminishes breast feeding behaviours.
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14. Instrumental delivery
Most commonly due to prolonged second stage  1 hour of pushing has failed to deliver the baby
Maternal exhaustion
Fetal distress in 2nd stage
Level 1
Intermittent auscultation
Level 2
Continuous CTG
Level 3
Fetal blood sampling
Level 4
Delivery by quickest route
- Fetal distress - “hypoxia that might result in fetal damage or death if not reversed or the fetus delivered urgently”
Aetiology of fetal distress - long labour, excessive time pushing, placental abruption, hypertonic uterine states, oxytocin, umbilical cord prolapse, maternal hypotension
Signs: “pea soup” liquor, abnormal fetal heart rate on auscultation (if abnormalities detected use CTG), CTG: baseline, tachycardias, variability, decelerations, fetal blood sampling: if pH <7.20 deliver by fasted route possible
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15. Instrumental/ operative delivery
Ventouse
Forceps
Episiotomy
Chignon on scalp that has been drawn into the cup by suction, scalp lacerations, haematoma and fetal jaundice more common with ventouse
Jaundice
Cervix must be 10cm dilated and head must be engaged
Empty bladder
Facial nerve palsy
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16. Contraindications to vaginal delivery
Multiple previous c-sections
Vertical uterine scar
Placenta praevia
Severe antenatal fetal compromise
Uncorrectable abnormal lie
Gross pelvic deformity
3 or more c-sections is guidance by RCOG
Placenta praevia – placenta partially or wholly inserted in lower segment, leading cause of antepartum haemorrhage, often present with painless bright red bleeding. Placenta should be >2cm away from os for vaginal delivery. Placenta accreta (attach to myometrium) /increta (penetrate through myometrium)/ percreta (through myometrium into peritoneum).
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17. C-section IV fluids, consider crossmatch
Ranitidine if elective section
Catheterisation
Lower uterine segment incision
Abx prophylaxis
Thromboembolism prophylaxis
LCSC – unless anterior placenta praevia over site of incision
Thromboprophylaxis – not everybody but most people, huge list of indications, 7 days postnatally
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18. Multiple pregnancy Single fertilised egg divides (monozygotic) twins
Two or more ova fertilised (dizygotic) twins
In dizygotic each fetus has its own placenta, amnion & chorion
In monozygotic this depends on timing of division of ovum
Multiple pregnancy occurs when two or more ova are fertilised to form dizygotic (non-identical) twins or a single fertilised egg divides to form monozygotic (identical) twins. In dizygotic multiple pregnancies, each fetus has its own placenta (either separate or fused), amnion and chorion. In monozygotic multiple pregnancies, the situation is more complex depending on the timing of the division of the ovum:
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19. Multiple pregnancy Risk factors? Presentation?
Previous multiple pregnancy, FH, assisted conception
Presentation?
Ultrasound, hyperemesis, enlarged uterus, polyhydramnios
Twin to twin transfusion syndrome
Monochorionic twins
Disproportionate bloody supply
Serial amniocentesis, laser therapy
Risk factors for multiple pregnancy – previous multiple pregnancy, family history (maternal side), increasing maternal age, assisted conception
Early multiple pregnancy presentations: ultra sound scan, hyperemesis, uterus may be able to be palpated earlier than 12 weeks, later presentations – high weight gain, more than one fetal pole/ fetal heart rate
Twin to twin transfusion syndrome occurs in monochorionic twins (chorion meaning they share a placenta). Imbalance causes donor twin to have decreased blood volume  growth restriction, decreased urinary output and oligohydramnios. Recipient twin blood volume is increased  strain on heart, heart failure, polyuria, polyhydramnios
Photo – monochorionic diamniotic twins
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20. Prematurity
Born <37 weeks- 70% are spontaneous, 30% due to medical/obstetric disorder.
Risk factors?
APH, multiple pregnancy, previous preterm, cervical weakness, smoking, genital infection (BV).
Diagnosis
Persistent uterine activity and a change in cervical dilation and/or effacement.
Fetal fibronectin, cervical length scanning.
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21. Prematurity Management Progesterone and antibiotics
Tocolytic drugs- nifedipine and atosiban- can delay labour for up to 7 days
Allows time to give corticosteroids (increase surfactant) and make plans for post delivery.
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22. Postmaturity & induction
Beyond 41 weeks, placental function may decline and become insufficient
Risk factors?
Previous post-term pregnancy, high maternal BMI, primigravidity
May be reduced fetal movements
Increased risk of meconium aspiration, neonatal hypoglycaemia, fetal macrosomia
- Beyond around 41 weeks, placental function may decline and become insufficient, reducing the supply of oxygen and nutrients to the fetus.
There is also increased risk of meconium aspiration syndrome and neonatal hypoglycaemia, increased risk of fetal macrosomia
Fetal skull more ossified so less mouldable
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23. Induction of labour CTG Bishop’s score Offer induction at 41 weeks
Methods of induction?
Sweep of the membranes, prostaglandin gel/pessary, ARM ± oxytocin
Complications?
Uterine hyperstimulation, uterine rupture, infection, prolapsed cord, amniotic fluid embolism
CTG at term +10 days to determine fetal wellbeing
Vaginal examination for bishop’s score - Cervical dilation, Cervical effacement, Cervical consistency, Cervical position, Fetal station
If the score is >8, the probability of successful delivery with induction is the same as spontaneous onset of labour but score >5 considered “ripe”. Once cervix is ripe you can ARM.
Methods of induction – sweeping of the membranes, prostaglandins – misoprostol, artifical rupture of membranes with oxytocin if labour hasn’t started within 2 hours
Misoprostol useful in nulliparous women and multiparous women with unfavourable cervixs, if one dose does not increase cervical ripeness another may be given 6 hours later providing no uterine activity, do not give more than 2 doses  c-section
Complications – uterine hyperstimulation leading to fetal distress, uterine rupture, infection if prolonged membrane rupture without delivery, prolapsed cord, amniotic fluid embolism
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24. Puerperium 6 week period following giving birth Lochia Problems?
Perineal pain
Urinary & bowel problems
Mastitis ± infection
Endometritis
Psychiatric
PPH – primary/secondary
Thromboembolism
Contraception
After delivery of the placenta, the uterus is at the size of 20-week pregnancy, but reduces in size on abdominal examination by 1 finger-breadth each day, such that on the 12th day it cannot be palpated
Lochia – blood and tissue, becomes yellow at approx 2 weeks post delivery
Perineal pain – if perineum has been damaged and repaired may be considerable pain, check not infected.
Urinary problems – 50% of women will develop some form of urinary incontinence (ranging from very mild to severe) – encourage pelvic floor exercises
Bowel problems – constipation, haemorrhoids may initially become more painful
Mastitis – may be due to failure to express milk from one part of breast, can get a superimposed infection
Endometritis – lower abdominal pain, offensive lochia, tender uterus on bimanual examination
Psychiatric – day 3-5 “baby blues”, postnatal depression, puerpural psychosis
PPH – primary >500ml blood loss during first 24 hours post birth, secondary – abnormal bleeding from 24 hours – 6 weeks, may be retained placenta. Ergotmetrine plus Abx if signs of infection
Contraception – not necessary in first 21 days following childbirth, cannot have combined pill if breast feeding as interrupts lactation
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25. Obstetric emergencies
Uterine rupture
Eclamptic seizure
Haemorrhage
Cord prolapse
Sepsis
DIC
Amniotic fluid embolism
Fetal distress
Uterine inversion
Shoulder dystocia PE
Placental abruption
Adrenal haemorrhage
HELLP syndrome
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26. Cord Prolapse Occult – Lies alongside the presenting part
Funic – lies below the presenting part before the ROM
Overt- present at cervix or descending into the vagina.
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27. Cord Prolapse Cord seen at vaginal entrance on examination
Risk Factors?
2nd twin, breech, polyhydramnios, unengaged head, abnormal lie, artificial amniotomy, low lying placenta.
If in the Overt presentation there is intermittent
cord compression and fetal asphyxia.
Signs?
Cord seen at vaginal entrance on examination
Fetal bradycardia and variable decelerations.
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28. Cord Prolapse Management
If occult or funic haven’t corrected- C section.
In Overt- Stop the presenting part pressing on the cord with manual upward pressure.
Patient in the knee-chest position.
If cord outside of the body keep warm and moist
Give Tocolytics- to delay contractions.
Proceed to Surgery
Tocolytics- Terbutaline
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29. Shoulder dystocia
Inability to deliver the shoulders after delivery of the head, after the shoulder becomes stuck behind the pubic symphysis
Risk factors?
Previous shoulder dystocia, maternal diabetes, fetal macrosomnia, BMI >30, induction of labour, prolonged early labour, assisted vaginal delivery.
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30. Shoulder dystocia Complications Fetal
Brachial plexus injury- Erb’s palsy.
Hypoxia- cord compression, reduced ability for chest expansion.
Fractured clavicle.
Maternal
Post partum haemorrhage
3rd and 4th degree perineal tears
Erb’s palsy- can be caused by excessive traction whilst trying to deliver the shoulder. C5-6 damage causing arm paralysis.
Hypoxia - shoulder causing cord compression, reduced ability for chest expansion.
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31. Shoulder dystocia Stop the mother pushing
Management
Stop the mother pushing
McRoberts position with suprapubic pressure and gentle downward traction
Episiotomy
Internal manoeuvres
Symphisiotomy
Zavanelli manoeuvre – firm pressure on fetal head to reverse and allow C section
Rotates the symphysis superiorly helping the impacted shoulder to enter the pelvis
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32. Uterine Rupture Risk factors?
Previous C sections, scarred uterus, uterine abnormalities, oxytocin use.
Presentation?
Constant pain and tenderness over uterus, small amount of vaginal bleeding, maternal tachycardia and signs of shock, cessation of contractions, fetal hypoxia.
Management
Stabilise mother with IV fluids and cross match bloods.
Delivery via C Section.
Bleeding (intraperitoneal)
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33. Preeclampsia
Pregnancy induced hypertension in association with proteinuria with/without oedema
Risk factors?
1st pregnancy, previous preeclampsia, over 40, BMI >35, FH, underlying HTN, renal disease, diabetes.
Presentation?
BP >140/90 in 2nd half of pregnancy with proteinuria
Severe frontal headache, sudden swelling (hand ,feet ,face), visual disturbance, fetal distress, liver tenderness and deranged LFTs, epigastric pain, papilloedema.
Eclamptic Seizure- occurs in less than 1%, Grand Mal seizure, risk of fetal hypoxia and maternal death.
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34. Preeclampsia Management Eclampsia Management Conservative monitoring
Anti HTN
Magnesium sulphate (seizure prevention)
Fluid balance
Delivery
Eclampsia Management
Resuscitation
Magnesium sulphate
Fluid therapy
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35. Preeclampsia Complications?
HELLP- haemolysis, elevated liver enzymes, low platelet count.
DIC
Renal Failure
ARDS
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36. Any questions?
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