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O&G– NormalLabour& rd Delivery,3 T rimesterBleeding andEmergencyC-Section Laura Bretherton 5 Year Medical Student University of ManchesterNormallabouranddelivery 1. Stages of labour 2. Mechanisms of labour 3. Slow progress in labour 4. Induction of labour 5. PPHWhatarethestagesof labour? First stage: Second stage: Third stage: Contraction 10cm Delivery of and dilatation to placenta dilatation delivery of period babyFirststageoflabour • Normal onset of labour is between.... 37- and 42-weeksgestation • Onset of labour • Show – expulsion of the mucus plug • ROM – rupture of membranes • Cervix dilatesand effaces Latentstage Active phase Transition phase 0-3cm 3-7cm 7-10cm 0.5cm/hr 1cm/hr 1cm/hr Contractions areirregular Contractions regular– 4 in 10 Strong regular contractions Established first stageof labour – 4cm onwards + regular painful contractionsMonitoringduringthefirststage What monitoringis required in the first stageof labour? • Vaginal examination every 4 hours to assess cervical dilatation and position of fetal head in relation to ischial spines (-4 to +3) • Maternal urine every 4 hours • Ketones • Proteins • Maternal BP and temp • Fetal heart rate – doppler or CTG • Monitoring and observations plotted on partogramFetalmouldingandcaput Used to assess the progression of labour • Moulding: extent of overlapping fetal skull bones • Caput: swelling the areathat was pressed againstthe cervix during labour and delivery. Normal even in labour that is progressing adequately Moulding classification– recordedon partogram Sutures apposed - +1 Adjacent skull bones are touching but not overlapping Sutures overlapped but reducible - +2 One skull bone overlapping another, but when you press it moves back into normal position Sutures overlapped and not reducible - +3 Overlapping skull bones that do not move back into position when pressed May indicatelabour is at riskof obstructionMechanismoflabour As the fetus moves downwards,it must change positions to negotiate the differentdimensions of the pelvis. Not essential to learn, but can help understandingof how labour progresses 1. Descent and engagementhead is occipito-transverse 2. Neck flexion 3. Internal rotation so head is now occipito-anterior 4. Crowning 5. Extension of presentingpart 6. Rshoulders rotate from transverse to verticaltes to face medial thigh; 7. Delivery of shoulder and bodySecondstageof labour • 10cm dilatationuntil delivery of baby • Mum will feel urge to push, midwife will guide her through pushing • Duration– how long should it last? • 45-120 minutes in a primip • 15-60 minutes in a multip • What is the most common fetalposition at birth? Left occipito anterior • Baby is head down, occiput is somewhere between spine and left hipThirdstageof labour • Deliveryof the placenta and membranes • Physiological oractive management Active management: Shortens 3 stage, reduced risk of bleeding Steps • IM oxytocin/Syntometrine • Cord clamped and cut within 5 mins of birth • Abdo palpated to assess for uterine contraction • Controlled cord traction to deliver placenta • Uterine massageSlowprogressin Delay in first Less than 2cmof cervical stage dilatationin4 hours labour(FTP) Slowing of progressin a multiparouswoman. • Labourthat is not developing at a Delay in Activesecond stage(pushing) satisfactoryrate second stage lastsover: • Morelikelyin primips •2 hours nulliparous* •1 hour multiparous • 4 P’s – power, passenger,position, Delay in third Morethan30 minutes with passage,psyche • Alert andaction lines on partogram stage activemanagement • Interventionsinclude Morethan60 minutes with • ARM if membranes intact physiologicalmanagement • Oxytocin • Instrumental *Delay is commonin nulliparouswomenwith epidural – • C-section 1-2 hourscan be allowed beforepushingto allow fetal descentInductionof labour • Offered between41 and 42 weeks, or wheresituations whereearlier labour is beneficial • Scoring system? • BISHOP • Determineswhether to induce labourbased on ‘cervicalripeness’ • Factors e.g., fetal station,cervicalposition, cervicaldilatation,effacement • Scoreof 8 ormore predictssuccessful induction • Options for induction? • Sweep • Vaginalprostaglandinpessary • ARM– oxytocin infusion + amniotomy • Cervicalripening balloonA 28-year-old G2P1 female on a labour wardcomplains of bleeding following a recentdelivery. Sheappears unwell and needs immediate treatment.Post- partum haemorrhage(PPH) seemsto be the likely cause. Which of the following defines a major primary post-partum haemorrhage? a) Blood loss <900 ml, within 24 hours of delivery b) Blood loss 500 ml, within 24 hours of delivery c) Blood loss >1000 ml within 24 hours of delivery d) Blood loss >500 ml, 48 hours following delivery e) Blood loss <500 ml, 72 hours following deliveryPostpartumhaemorrhage(PPH) • PrimaryPPH - > 500ml PV bleeding within 24 hours of delivery • 4 Ts? Minor PPH Under1000ml bloodloss • Tone • Tissue Major PPH Over1000ml bloodloss • Trauma •Severe> 2000 ml2000ml • Thrombin • Secondary PPH? • 24 hours post delivery – 12 weeks after birth • Mostly caused by retained products or infectionManagementofPPH Preventative General Stopping bleeding • Treat anaemia inantenatal • A to E Mechanical – rubuterus, period • Lie womanflat, keep warm, catheterise • Empty bladder - full bladder communicate Medical reduces uterine contraction • Two large bore cannulas • Oxytocin • Active management of third • Bloods – FBC, UE, groupand • Ergometrine stage save, coag screen • Carboprost • IV tranexamic acid during C- • IV fluids and blood • Misoprostol section in thirdstagein high- • Oxygen • TXA riskpatients. • FFP after 4 units of blood Surgical • Severe–activate major • B-lynchsuture haemorrhage protocol • Intrauterine balloon tamponade • Uterine artery ligation • Hysterectomy Thirdtrimesterbleeding • Placenta praevia • Placental abruption • Placenta accreta • Vasa praevia • Don’t forget about non obstetriccauses – cervical/vaginal/vulval pathology!3 TrimesterBleeding •1/10 womenwill have vaginal bleeding during 3 trimester •Can signifyserious underlying cause including: • PlacentaPrevia • PlacentaAccreta Spectrum • Vasa Previa • PlacentalAbruption • UterineRupture PlacentaPrevia • Occurs when placenta attaches to lower part of uterus • Placenta praevia vs low lying placenta? • Placenta lies within 20mm of internalos= low lying placenta • Placenta lying overthe internalos = placenta previa How does it present? • Presents with painless vaginal bleeding in 3 trimesterPlacentaPrevia What are the risk factors? What are the complications? • Previous C-Section • Multiparity • Antepartum hemorrhage • Previous placenta • Emergency C-Section previa • Emergency hysterectomy • Older maternal age • Maternal anemia and • Maternal smoking transfusions • Structural uterine • Preterm birth and low birth abnormalities weight • Assisted reproduction (e.g., IVF) • Still birthPlacentaPrevia • Grades: • 1 – Minor Previa – placenta is low in uterus but not reaching the internal os • 2 – Marginal previa – placenta is reaching but not covering internal os • 3 – Partial previa – placenta is partially covering internal os • 4 – Complete previa – placenta is completely covering internal osPlacentaPrevia • Diagnosis? • Usually 20-week anomaly scan used to assess placenta position • If found, repeat scan recommended at 32 weeks and 36 weeks • Management? • Corticosteroids given at 34 and 35 weeks • Planned C-section considered between 36 and 37 weeks • Emergency C-Section may be required (antepartum hemorrhage and preterm labour) • May also require blood transfusions, intrauterine balloon pump, uterine artery occlusion or even emergency hysterectomyPlacentaAccretaSpectrum • Abnormal invasion of trophoblastic tissue into uterine wall • Types? Placenta Attached to myometrium accreta without invading it Placenta Partially invades into increta myometrium Placenta Completely invades through percreta myometrium and serosaPlacentaAccretaSpectrum • Risk Factors • Previousplacentaaccreta • Previousendometrialcurettageprocedures • Previousplacentaprevia • Previousc-section • Multiparity/multigravida • Increasingmaternalage • Typically, does not cause symptoms duringpregnancy • Can cause 3 trimester bleeding • severepost-partum hemorrhageafter attemptedmanual removal oftal delivery and placenta – often extracted in piecesPlacentaAccretaSpectrum • Diagnosed on antenatalUSS • MRI scans can be used to assess depth of invasion • Specialist MDT management • C-Section planned between 35 – 36 weeks • Antenatalsteroids • Options during C-Section: • Hysterectomy • Uterus Preserving surgery • Expectant management – risky (bleeding and infection)VasaPrevia • Fetal vessels travel within fetal membranes run over,or <2cm of the internal os • 2 instances where this may happen: • Velamentous umbilical cord (type 1) • Bilobed/succenturiate placenta (type 2) • Fetal vessels exposed and not protected by umbilical cord or placenta • Prone to bleeding particularly when membranes ruptureVasaPrevia • Risk Factors: • Low lying placenta • IVF pregnancy • Multiple pregnancy • Diagnosis: • USS but nor very reliable • Presentation: • Antepartum hemorrhage • Detected during vaginalexamination when in labour • Detected during labour after rupture of membranes -> fetal distress + dark- red bleedingVasaPrevia • Management: • Corticosteroids from 32 weeks gestation • Elective C-section for 34-36 weeks • If antepartum hemorrhage occurs -> emergency c-section PlacentalAbruption • Premature separation of placenta from uterus priorto fetal delivery • Life threatening to both mother and fetus • bleeding with abrupt,painfulvaginal • Classically‘woody’abdomen on palpationPlacentalAbruption • Risk Factors: • Previous placental abruption • Pre-eclampsia/maternal hypertension • Smoking • Cocaine use • Abdominal trauma (consider domestic violence) • Multiple pregnancyPlacentalAbruption • Severity: • Spotting • Minor hemorrhage (<50ml) • Major hemorrhage (50-1000ml) • Massive hemorrhage (>1000ml or signs of shock) • Diagnosis: • No reliable tests - clinical diagnosis • Remember to consider concealed hemorrhage- cervical os remains closed, and any bleeding that occurs remains within the uterine cavity.PlacentalAbruption • Management: • Obstetric emergency -> involve senior help (obstetrician, midwife and anesthetist) • Major hemorrhage protocol • CTG monitoring • Emergency c-section if mother unstable or fetal distress • Increased risk of post-partum hemorrhage in abruption UterineRupture • Full thickness disruption of uterine wall • Risk factors: • Previousc-section • Abdominaltrauma • Presentswith painful vaginal bleeding, fetal HR abnormalities, easily palpable fetal parts, loss of fetal station • May be life threateningto both mother and fetus • Management -> emergentc-sectionA 22-year-oldprimigravid womanat 32 weeks gestationcomes to the emergency department because of heavy vaginal bleedingand abdominalpain. Pregnancy course so far has been normal including 20-week scan. Physical examination shows contracteduterus with hypertonus. CTG shows severelatedecelerations.Which of the followingis the next best step in management? a) Expectant management b) Magnesium sulphate c) Oxytocin d) Terbutaline e) C-section EmergencyC-section OperativevaginaldeliveryOperativevaginaldelivery • What are the two modes of operativedelivery? Forceps Ventouse (Kiwi) • Rhodes, Neville-Barnes, Simpsons • Kielland’s • Wrigley’sIndicationsforoperativedelivery Maternalindications Fetalindications Inadequate progress Fetalcompromise in the second stage • Nullip– delivery after 2 hours of pushing (+/- 1 • Concerning CTG hour of descent if no urge to push felt on • Abnormal fetal blood samples diagnosis of secondstage) • Multip – delivery after 1 hour of pushing (+/-1 Suspected fetal compromisedue to things like hour of descent prior to active pushing) significantantepartum haemorrhage Maternalexhaustion Maternalmedical conditions that mean active pushing or prolonged exertion should be limitedRequirementsforsuccessfuloperativedelivery Maternal Fetal • Fully dilated • Cephalic • Ruptured membranes • Fetal head at least at level • Adequate pelvis size of ischial spines • Adequate pain relief • Fetal head less than 1/5h palpable abdominally • Empty bladder • +/- EpisiotomyComplicationsof operativedelivery? Maternal Fetal Vaginal tears – 3 and Neonatal jaundice th 4 degree Scalp lacerations VTE Cephalhematoma Damage to structures Subgaleal causing incontinence haematoma Infection Facial bruising PPH Facial nerve damage Skull fractures Retinal haemorrhageEmergencyC-section • What are the categoriesof C-section? Category 1 Baby born within 30 minutes Immediate threat tothe life of the woman or fetus Category 2 Baby born within 60-75 minutes Maternal or fetal compromise that is not immediately life-threatening Category 3 No maternal or fetal compromise but needs early delivery Category 4 ElectiveC-sectioninthesecondstage • C-section when baby is descended and engaged – head can become lodged in the maternal pelvis • IFH- impacted fetal head. Complications of IFH Maternalcomplications Fetalcomplications Structural injury Fetal skull injury • Vagina Subgaleal and intracranial haemorrhage • Cervix Hypoxic injury • Uterus • Hypoxic ischaemicencephalopathy • Bladder Riskof PPH Infection Extended uterine excisionT echniquesusedfordis-impaction • Vaginal dis-impaction(Pre-incision) • Manual – placing a hand intothe vagina and pushing baby’s head upwards • Fetal pillow – balloon which is inflated and placed under the baby’s head to gently push it upwards • Tocolyticagents– sublingual/IVGTN • Reversebreechextraction • Delivering feet first through incision followed by head • Risk of fetal hip and shoulder injuryMaternalcareduringemergencysections • Goodcommunication with mother and partner • Preparation • Experienced obstetricians, midwives and theatre team • Paediatric/neonatologist involvement • Prepare to managepost-partum haemorrhage • Debrief with mother and partner afterthe section.