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Topics 1. Normal labour, Preterm labour & Induction of Labour 2. Complications during delivery – Breech Intrumental Delivery, PPHstocia, Cord Prolapse, 3. Maternal problems during pregnancy  Diabetes in pregnancy (including GDM)  Hypertension in pregnancy (including Pre-eclampsia)  Itching in pregnancy Stages Of Labour True labour: painful contractions at regular intervals, increasing intensity and duration, show/ cervical plug, effacement and dilatation of cervix Stages Of Labour STAGE 1: STAGE 2: • Uterus contracts every 2- 3 minutes • From full dilatation (10 cm) to delivery of fetus • Latent phase: cervical • Passive: in the absence of effacement + dilatation up pushing to 3-4 cm • Active phase: 4 cm • Active second stage: when onwards head reaches the pelvic floor STAGE 3: •Progress: 2 cm every 4 hours • Until delivery of placentaLabour: Useful diagramsFetal monitoring: NICE guidelines ESTABLISHED 1 STAGE • Immediately after a palpated contraction for at least 1 minute • Repeated every 15 minutes • Record accelerations and decelerations if heard • Palpate maternal pulse hourly SECOND STAGE • Repeated every 5 minutesated contraction for at least 1 minute • Palpate maternal pulse simultaneouslyFetal Monitoring: CardiotocographCTG InterpretationMCQMCQ Answer: D Preterm Labour What causes it? Risk of prematurity • Infection • Respiratory distress • Multiple pregnancy syndrome • APH •NEC • IUGR •Neonatal jaundice • Polyhydramnios •Failure to thrive • Previous surgery on the •Cerebral palsy cervix can increase risk Preterm Prelabour Rupture Of Membranes What is it? Defined as rupture of membranes between 24 and 37 weeks in the absence of uterine activity (labour) Why is it a problem? Risk of infection! + Risk of prematurity in the neonate How do we investigate? •Bloods – FBC, CRP risk of premature birth)ranes on speculum, or fetal fibronectin (predicts How do we treat it? •Erythromycin for 10 days •Consider steroidsMCQMCQ Answer: E Induction Of Labour • Indications – why do we induce labour? • Risk of continuing with a pregnancy > risk of delivery for mother/fetus • Obstetric Indications: IUGR (Placental insufficiency), Prolonged pregnancy, Non-reassuring CTG, severe pre-eclampsia, Obstetric Cholestasis • Medical reasons: GDM (on insulin/poorly controlled) •Bishop’s score: to assess favourability for induction (>8 = favourable cervix) •How do we do it? • Membrane sweep (offered to women if >40 weeks, 41 if multiparous) • Prostaglandins --> cause uterine contractions (Propess pessary + Prostin gel) • Oxytocin infusion • Amniotomy – artifical rupture of membranes using an amnihookInduction Of Labour: Bishop’s Score Induction Of Labour: Things To Consider • Need for CTG monitoring and monitoring of uterine contractions • Assess Bishop’s score before starting Induction • Check for umbilical cord during VE examination (you want to rule out a cord prolapse) • Check previous scans for low lying placenta • Women informed that IOL likely to be more painful than spontaneous labour - offered pain relief (e.g. epidural) • Need to assess progress by VE – 24 hours after pessary or 6 hours after the gel. • Complications: •Uterine hyperstimulation: tocolysis, reducing oxytocin infusion rate •Uterine rupture •Failure of induction: repeat induction, offer CSMCQ Which of the following are NOT a risk factors for a breech presentation? A. Multiple pregnancy B. Previous caesarean section C. Polyhydramnios D. Placenta praevia E. Uterine malformationsMCQ Which of the following are NOT a risk factors for a breech presentation? A. Multiple pregnancy B. Previous caesarean section C. Polyhydramnios D. Placenta praevia E. Uterine malformationsBreech Presentation What is it? • When the buttocks, foot or feet are presenting instead of the head in a longitudinal lie. • Is normal in preterm pregnancy <37 weeks! What are some of the Risk factors? • Uterine: Multiparity, Malformations (septate uterus), Fibroids, Placenta Praevia • Fetal: Prematurity, Macrosomia, Polyhydramnios, Abnormality How do we manage this? • ECV at 37 weeks (50% success rate) (36 for nulliparous) • If failed, elective C section around 39 weeks • Vaginal breech delivery MCQ You are the junior doctor on the labour ward, and are called by a midwife to a delivery in which the baby's head has been delivered, but the shoulders will not deliver with normal downward traction. Which of these is your first step in management of this condition? • Caesarean section • Symphisiotomy • Episiotomy • Ask the mother to hyperflex their legs and apply suprapubic pressure • Wood's screw manouvere MCQ You are the junior doctor on the labour ward, and are called by a midwife to a delivery in which the baby's head has been delivered, but the shoulders will not deliver with normal downward traction. Which of these is your first step in management of this condition? • Caesarean section • Symphisiotomy • Episiotomy • Ask the mother to hyperflex their legs and apply suprapubic pressure • Wood's screw manouvereShoulder Dystocia • Anterior shoulder becomes impacted behind the maternal pubic symphysis • Biggest risk factor is MACROSOMIA, particularly in woman with GDM • Maternal complications: • PPH • 3rd/4 degree tears • Fetal complications: • Brachial plexus palsy • Fracture: clavicle, humerus • Fetal hypoxiaShoulder Dystocia • CALL FOR HELP! • Ask the mother to stop pushing • Consider episiotomy? – can make manoeuvres easier • Mc Robert’s Manoeuvre: • Knees to chest position • Widens pelvic outlet • Success rate of 90% (even higher when combined with suprapubic pressure)MCQ A 30-year-old woman who is 41 weeks pregnant is being induced in the labour ward. She has an artificial rupture of membranes, but the midwife is brought for an emergency caesarean section. What is the correctina. She position for her to be in while being prepared for surgery? • Flat on her back • McRobert's position • On her back with head lowered and lower half of bed raised • On her knees and elbows • StandingMCQ A 30-year-old woman who is 41 weeks pregnant is being induced in the labour ward. She has an artificial rupture of membranes, but the midwife is brought for an emergency caesarean section. What is the correctina. She position for her to be in while being prepared for surgery? • Flat on her back • McRobert's position • On her back with head lowered and lower half of bed raised • On her knees and elbows • Standing Cord Prolapse What is it? The umbilical cord descends through the cervix, on or before the presenting part Why is this a problem? •High mortality rate – linked to the risk factors •Fetal hypoxia via: Occlusion (cord compression) + Arterial vasospasm (exposure to cold atmosphere) What are the risk factors? • Breech presentation • Unstable lie: in >37 weeks, consider inpatient admission until delivery due to risk of cord prolapse • ARM – particularly when presenting part is high in pelvis • Polyhydramnios • Prematurity Cord Prolapse - Management • Consider this: Pathological CTG/ non-reassurng FHR trace and absent membranes • Confirmed: External inspection or VE (strongly associated with prolapse due to occlusion)bvious fetal bradycardia • CALL FOR HELP – THIS IS AN EMERGENCY! • Avoid handling the cord – to reduce vasospasm • Manually elevate the presenting part off the cord during VE • Positions: Left lateral or Knee to chest – relieves pressure off the cord • Consider tocolysis • Delivery usually via Emergency C SectionCord Prolapse – ManagementMCQ A 36-year-old nulliparous woman is admitted in labour at 37 weeks gestation. the foetal station is at +1 and the head is 0/5 ths palpable per abdomen. Therior, cardiotocogram shows late decelerations and a foetal heart rate of 100 beats/min which continue for 15 minutes. How should this situation be managed? • Caesarean section • Instrumental delivery • Continue pushing • Vaginal prostaglandin (PGE2) • Oxytocin infusionMCQ A 36-year-old nulliparous woman is admitted in labour at 37 weeks gestation. the foetal station is at +1 and the head is 0/5 ths palpable per abdomen. Therior, cardiotocogram shows late decelerations and a foetal heart rate of 100 beats/min which continue for 15 minutes. How should this situation be managed? • Caesarean section • Instrumental delivery • Continue pushing • Vaginal prostaglandin (PGE2) • Oxytocin infusionInstrumental Deliveries – Pre- requisites + Indications MATERNAL INDICATIONS: • Prolonged second stage: usually allow 2 hours of active pushing in nulliparous and 1 hour in multi • Maternal exhaustion • Mintracranial pathologyions: severe HTN, FETAL INDICATIONS: • Suspected fetal compromise in the second stage • Fetal blood samplingInstrumental Deliveries - Kiwi • 2 main instruments: Kiwi/Ventouse + Forceps • Forceps have lower fetal complications and greater maternal complications • 3 contractions and pulls – if no reasonable progess then attempt abandoned • Kiwi: • Hand held disposable ventouse • Can be used for all fetal positions and rotational • Maternal risks: lower pain and perineal injury • Fetal risks: higher cephalhaematoma, higher retineal haemorrhageCephalhaematoma, Caput Succedeneum, Subgalael HaemorrhageInstrumental Deliveries – Forceps • Types: • Non-rotational: used for OA presentation • Wrigley’s – at C Section • Kielland’s for rotational deliveries • Higher rate of 3 and 4 degree tears with forceps – need to protect perineum when inserting the bladesMCQMCQ Answer: D Uterine Rupture RISK FACTORS – WHAT ARE THE SIGNS? • Full thickness tear of the uterine muscle anything that makes the • Typically occurs during labour uterus weaker • Sudden + Severe abdo • Rare but significant maternal and fetal pain, persists between risks • Previous C Section contractions • Myomectomy •Shoulder tip pain • Induction of labour •Vaginal bleeding • Multiple pregnancy • O/E: regression of the • Multiparity presenting part, scar tenderness, palpable MANAGEMENT: fetal parts • Obs: hypovolaemic • AtoE approach shock, tachycardia • EMCS • Fetal monitoring: distress Episiotomies A surgically planned incision on the perineum ndd the posterior vaginal wall during 2 stage of labour When should you consider an episiotomy:  High likelihood of severe laceration  Accelerate delivery of a compromised fetus  Instrumental delivery Complications: • Extension of incision to involve the rectum • Vulval haematoma • Infection • Dyspareunia • Injury to anal sphincter - incontinence Perineal Tears  Four degrees st nd  1 and 2 degree and uncomplicated episiotomy: sutured under LA  Important to do a PR to assess for damage to anal sphincter rd th  Referral to physio for 3 and 4 degree tearsMCQ A 36-year-old woman with a background of pre-eclampsia suffers from a major postpartum haemorrhage after delivering twins. The obstetric consultant examines her and suspects uterine atony to be the cause. The protocol for major PPH is initiated. Bimanual uterine compression fails to control the haemorrhage. Which of the following drugs should be avoided in this case to manage her PPH? A. Carboprost B. Misoprostol C. Oxytocin D. ErgometrineMCQ A 36-year-old woman with a background of pre-eclampsia suffers from a major postpartum haemorrhage after delivering twins. The obstetric consultant examines her and suspects uterine atony to be the cause. The protocol for major PPH is initiated. Bimanual uterine compression fails to control the haemorrhage. Which of the following drugs should be avoided in this case to manage her PPH? A. Carboprost B. Misoprostol C. Oxytocin D. ErgometrinePRIMARY POST PARTUM HAEMORRHAGE How do we define it? Blood loss of > 500 mls after SVD or > 1L after C Section Risk factors for uterine atony: • Maternal: High BMI, age > 40, Asian ethnicity • Uterine over-distension: polyhydramnios, multiple pregnancy, macrosomia • Labour: Induction, Prolonged • Placental problems: Praevia, Abruption, Previous PPHMANAGEMENT OF PPH UTERINE ATONY: • Bimanual compression to stimulate uterine contraction • Drugs: Oxytocin, Ergometrine, Carboprost, Misoprostol • Surgical measures: Intruterine balloon tamponade, Haemostatic suture, Hysterectomy TRAUMA • Primary repair of laceration • If rupture: laparotomy + repair/hysterectomyMANAGEMENT OF PPH TISSUE: • IV Oxytocin • Manual removal of placenta • Prophylactic Abx in theatre THROMBIN: • Correct coagulation abnormalities with blood products • Discuss with haematologyMCQ A 32-year-old pregnant woman of South Asian origin is 10+0 weeks into her second pregnancy. She has had one natural delivery at 39 weeks to a healthy child, and no other previous pregnancies. Since she has a strong family history of type 2 diabetes mellitus, she is offered a fasting glucose test at her booking visit. Her fasting glucose level is 7.2 mmol/L. What is the most appropriate initial management given her fasting glucose level? • Advice on diet and exercise • Advice on diet and exercise plus daily blood glucose monitoring • Gliclazide • Insulin • Metformin Case 1: Gestational Diabetes GDM risk factors + screening 34 year old South Asian, Primip, BMI 35 questions: Antenatal booking appointment • BMI > 30 What questions would you ask her to determine her risk of GDM? • Family history of diabetes (1 degree relative) How would you screen for GDM? • Ethnicity – South Asian, Screening & Diagnosis of GDM Chinese, African-Caribbean, Middle East • 75 g 2 hour OGTT at 24-28 weeks • Previous macrosomic baby (> 4.5 kg) • Fasting plasma glucose level:>/= 5.6 • Previous GDM • 2 hour OGTT: >/= 7.8MCQ A 32-year-old pregnant woman of South Asian origin is 10+0 weeks into her second pregnancy. She has had one natural delivery at 39 weeks to a healthy child, and no other previous pregnancies. Since she has a strong family history of type 2 diabetes mellitus, she is offered a fasting glucose test at her booking visit. Her fasting glucose level is 7.2 mmol/L. What is the most appropriate initial management given her fasting glucose level? • Advice on diet and exercise • Advice on diet and exercise plus daily blood glucose monitoring • Gliclazide • Insulin • Metformin Her fasting glucose was 5.6 and 2 hour OGTT at 24 weeks comes back as 8.5 CASE 1: What would you do next? Management of GDM: 1. Offer the woman an appointment in the diabetes antenatal clinic within 1 week 2. Counselling on complications of diabetes, self-monitoring of glucose and importance of glycaemic control Fasting plasma glucosermin, Insulin Management <7 at diagnosis Diet and exercise trial for 1-2 weeks Metformin Insulin >7 at diagnosis Insulin +/- Metformin + Diet and Exercise 6.0– 6.9 + complications such as macrosomia aInsulin +/- Metformin + Diet and Exercise polyhydramnios What are the complication of CASE 1: gestational diabetes for me and for my baby? MATERNAL COMPLICATIONS FETAL COMPLICATIONS • Increased risk of pre-eclampsia • Increased risk of infections • Increased risk of malformations X3 • Higher rates of Induction of labour Macrosomia & Caesarean section • Shoulder dystocia • Higher rates of miscarriage • Polyhydramnios • Preterm birth • Stillbirth • Hypoglycaemia after birth • Increased risk of diabetes and obesity in later life  Will I have any extra scans during my pregnancy?  Does this mean I have to have a Caesarean section? CASE 1:  Will I have diabetes for the rest of my life? ANTENATAL CARE DELIVERY/LABOUR • Appointments with diabetic clinic every • Women with GDM advised to give birth 1-2 weeks by 40+6 weeks • Scans: • Offer elective birth by induction or CS if • Detailed anomaly scan at 18-20 they have not given birth by this time weeks with 4 chamber heart view at • If maternal or fetal complications – the anomaly is sufficient consider elective birth before 40+6 • Growth scans every 4 weeks from 28 • Corticosteroids if preterm (why? what is weeks onwards – Monitor AC as the risk?) most sensitive marker of • During labour: continuous CTG, consider macrosomia sliding scale insulin, requirements • Self-monitoring: decrease post delivery • Fasting (Target: 5.3) and 1-hour post- meal (Target: 7.8) levels daily  Will I have any extra scans during my pregnancy? CASE 1:  Does this mean I have to have a Caesarean section?  Will I have diabetes for the rest of my life? POSTPARTUM CARE • Discontinue blood glucose lowering therapy immediately after birth • Counsel about risk of GDM in future pregnancies, moderate risk of Type 2 DM • Offer lifestyle advice • GP to check fasting plasma glucose at 6 week postnatal check/ HbA1C if after 13 weeks • If fasting glucose between 6.0-6.9 – high risk of developing Type 2 diabetes • If fasting glucose >7 then likely to have Type 2 DM Considerations For Women With Pre-existing Diabetes ANTENATAL CARE & DELIVERY • Hypoglycaemia counselling PRE-CONCEPTION COUNSELLING • Exclude ketoacidosis if unwell •Aim for a HbA1C of </= 48 • Assess renal function and retinal screen mmol/mol (6.5%) • Type 1 or Type 2 DM with no complications: Elective birth •High dose folic acid 5 mg daily (IOL/CS) between 37 and 38+6 weeks preconception • Before 37 weeks if any complications •Arrange dietician review POSTPARTUM metformin, also stop statins and • Return to pre-pregnancy regimen – reduce insulin dose ACEi/ARBs immediately after birth • Advise to snack before and after feeds to reduce risk of hypos screenopathy and nephropathy with breastfeeding • Insulin and metformin are safe to use in breastfeedingMCQMCQ Answer: BMCQMCQ Answer: BCase 2: High Blood Pressure 37 year old lady, 23/40 weeks G3P1+1 (I previous SVD and 1 miscarriage at 8 weeks) 145/95 and protein ++ in her urine. What do you think is wrong? How would you investigate this further? Case 2: Pre-eclampsia What is the • Hypertension (>140/90) and proteinuria or if pathophysiology of pre- there has been (also consider booking BP) eclampsia? • Develops after 20 weeks and resolves within 6 weeks of delivery Case 2: Pre-eclampsia What are some of the risk factors for developing pre- eclampsia? HIGH RISK MODERATE RISK If 1 high or 2 moderate: • Previous severe or early st aspirin 150 mg OD onset pre-eclampsia • 1 pregnancy from 12 weeks until • Chronic hypertension or • >40 years delivery. MUST be hypertension in previous • Pregnancy interval pregnancy of >10 years started < 16 weeks to • CKD • BMI >30 be effective (aspirin is • FHx of pre- thought to aid effective • Diabetes eclampsia trophoblastic invasion • Autoimmune disease • Multiple pregnancy (SLE, APS, which happens in the Thrombophilia) first trimester) Clinical Presentation SYMPTOMS SIGNS • Might be absent in mild pre- eclampsia • Hypertension + • To ask in every consultation: proteinuria • Headache • Epigastric tenderness • Flashing lights/ Blurring • Epigastric or RUQ pain/ • Brisk reflexes • Confusion, fits severe pain just below • Placental abruption ribs • IUGR (estimated fetal • Nausea and vomiting th • Sudden swelling of face, weight <10 centile) fingers or lower limbs • Stillbirth Ix & Admission How do we investigate pre- eclampsia? What would you When do we admit someone to find in these blood test results? hospital? • FBC • Sustained systolic blood pressure • Clotting >/= 160 mmHg • LFTs • Concerning biochemical Ix • Signs of pulmonary oedema • Urine PCR >30 • Signs of impending eclampsia • Serum uric acid • Suspected fetal compromise • Signs of severe pre-eclampsia Management How do we treat pre- eclampsia? Fetal monitoring in pre-eclampsia st • 1 Line: Labetalol • At diagnosis: USS for fetal growth and amniotic • 2 line: Nifedipine fluid + Doppler • 3 line: Methyldopa • Repeat this every 2 weeks OR earlier if any of the following symptoms: • Target BP: 135/85 or less • Change in fetal movements • Vaginal bleeding • BP monitoring at least every 48 • Abdo pain hours • Deterioration in maternal condition • Blood tests twice a week Delivery&Birth DELIVERY & TIMING OF BIRTH • If no complications deliver women after 37 weeks • When would you consider delivering women before 37 weeks? • Difficulty in controlling BP despite 3 or more anti- hypertensives • Deterioration in bloods • Neuro symptoms including eclampsia • Abruption • Doppler: reversed end diastolic flow or abnormal CTG • Considerations for preterm delivery: • Discuss with neonates • IV Mag sulphate if before 30 weeks • Corticosteroids between 24 and 34+6 weeks Delivery&Birth INTRAPARTUM POSTPARTUM • Regular monitoring of blood pressure: 1 • BP monitoring hourly in HTN, every 15-30 minutes in • Repeat PET bloods severe hypertension • Consider reducing if BP falls below • Continue antihypertensives 140/90 • Consider operative or assisted delivery in • If discharged on treatment, GP review second stage for uncontrolled in 2 weeks or 6 weeks routine review if hypertension no meds Eclampsia ABCDE - continuously monitor oxygen saturation and BP Magnesium sulphate IV bolus and then infusion. OTHER CAUSES OF SEIZURES: Repeated seizures treated with diazepam • Cerebral venous sinus Regular observations + catheter to monitor urine output thrombosis • Intracranial mass Bloods: FBC, U&E, LFT, creatinine, clotting • Stroke • Hypoglycaemia Monitor for signs of MgSO4 toxicity: RR<12, tendon relfex loss, urine • Hyponatraemia output <20 ml/h, ANTIDOTE? • Infection CTG for fetal heart rate monitoring Deliver once mother is stableMCQ A 26-year-old woman was admitted at 34 weeks gestation with preterm labour. 3+ proteinuria. She is commenced on magnesium sulphate and labetalol. She is now complaining of reduced foetal movements. A cardiotocogram shows late decelerations and a foetal heart rate of 90 beats/minute. What should be the next step in the management? • Give further Magnesium Sulphate • Elective caesarian section • Emergency caesarian section • Foetal scalp pH testing • Induce labourMCQ A 26-year-old woman was admitted at 34 weeks gestation with preterm labour. 3+ proteinuria. She is commenced on magnesium sulphate and labetalol. She is now complaining of reduced foetal movements. A cardiotocogram shows late decelerations and a foetal heart rate of 90 beats/minute. What should be the next step in the management? • Give further Magnesium Sulphate • Elective caesarian section • Emergency caesarian section • Foetal scalp pH testing • Induce labourMCQ A woman complains of severe itching at 34 weeks gestation. The itching started 2 weeks previously and has been preventing her from sleeping. She is itchy all over her body, especially in her hands and feet. She has not noticed any rashes. Her mother reports similar symptoms when she was pregnant with her 2nd child. She is otherwise well. What is the most appropriate action? A. Dermatology referral B. Treat with topical steroids C. Check uric acid levels D. Check renal function tests E. Check bile acidsMCQ A woman complains of severe itching at 34 weeks gestation. The itching started 2 weeks previously and has been preventing her from sleeping. She is itchy all over her body, especially in her hands and feet. She has not noticed any rashes. Her mother reports similar symptoms when she was pregnant with her 2nd child. She is otherwise well. What is the most appropriate action? A. Dermatology referral B. Treat with topical steroids C. Check uric acid levels D. Check renal function tests E. Check bile acidsDerm differentials Obstetric Cholestasis Features of the itch: ● 3rd trimester ● Palms and soles ● Worse at night ● Severe with excoriations Other features: jaundice, malaise, anorexia, dark urine + pale stools, steatorrhea Ix: Raised bile acids +/- Abnormal LFTs Mx: ● Repeat LFTs every 1-2 weeks ● Consider Ursodeoxycholic acid for symptomatic relief ● Induction of labour depending on bile acid levels (if >100 then IOL at 35-36 weeks)Topics 1. Normal labour, Preterm labour & Induction of Labour 2. Complications during delivery – Breech Intrumental Delivery, PPHstocia, Cord Prolapse, 3. Maternal problems during pregnancy 1. Diabetes in pregnancy (including GDM) 2. Hypertension in pregnancy (including Pre-eclampsia) 3. Itching in pregnancyUseful Resources FEEDBACK Thank you for listening!