Management of Labour and Delivery for Undergraduates Max

Management of Labour and Delivery for Undergraduates Max Brinsmead MB BS Ph. D May 2015

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

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

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

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

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

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

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

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

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

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

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

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

Forceps or Ventouse? n n n Cochrane database 1999 Ten trials Less maternal trauma n n n Less anaesthesia required More vaginal deliveries n n n RR 0. 41, CI 0. 33 – 0. 50 RR 1. 69, CI 1. 31 – 2. 19 More neonatal cephalhaematomas and retinal haemorrhage But serious injury is rare

Vaginal Birth after Caesarean n Maternal Risk of death n n Scar rupture n n n 2. 8 per 10, 000 with trial of scar 2. 4 per 10, 000 for elective CS No maternal death ever attributed to scar rupture Much confusion in the literature over the definition Rate of asymptomatic scar rupture the same whether VBAC or elect CS Overall rate approx. 0. 5% or 1: 200 Was 0. 35% in the largest combined contemporary study Hysterectomy n n Additional risk from trial of scar is 3. 4 per 10, 000 Requires 2941 elective CS to prevent one hysterectomy

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

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

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

More Likely with Vaginal Birth: Perineal pain 2. 5 -fold Urinary incontinence 1. 6 -fold Uterovaginal prolapse 2 -fold

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

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

Caesarean Sections are Popular because: n Vaginal Birth is Painful n 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? n “Vaginal Birth Ruins your Sex Life” n “Vaginal Birth Destroys the Pelvic Floor”

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

More Caesarean Sections occur when: n n n Fetal distress is diagnosed by CTG 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 Patients are privately insured GPs and midwives compete with specialists

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

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