Management of Labour and Delivery Max Brinsmead MB
![Management of Labour and Delivery Max Brinsmead MB BS Ph. D May 2015 Management of Labour and Delivery Max Brinsmead MB BS Ph. D May 2015](https://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-1.jpg)
Management of Labour and Delivery Max Brinsmead MB BS Ph. D May 2015
![Subjects to be covered: n n n Induction of labour Delay in the first Subjects to be covered: n n n Induction of labour Delay in the first](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-2.jpg)
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?
![Resources: n n n Cochrane database RCOG Guidelines NICE (UK) Guidelines Lawson, Harrison and Resources: n n n Cochrane database RCOG Guidelines NICE (UK) Guidelines Lawson, Harrison and](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-3.jpg)
Resources: n n n Cochrane database RCOG Guidelines NICE (UK) Guidelines Lawson, Harrison and Bergstrom (2001) “Maternity Care in Developing Countries” My personal experience
![Why is this subject important? n n Difficulties in labour is responsible for 30 Why is this subject important? n n Difficulties in labour is responsible for 30](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-4.jpg)
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 Predicting outcome in labour is still difficult: n n n Clinical examination is limited](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-5.jpg)
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 Antenatal Risk Factors n n n n n Young and older nulliparas Short stature](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-6.jpg)
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 When to induce labour: n n n When the risks of continuing the pregnancy](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-7.jpg)
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 term For maternal diabetes at term – This includes gestational diabetes
![When to induce labour 2: n n For IUGR at term when there is When to induce labour 2: n n For IUGR at term when there is](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-8.jpg)
When to induce labour 2: n n For IUGR at term when there is absent Doppler EDF Macrosomia? n n Multiple pregnancy? n n No data Unstable lie? n n No data Previous precipitate delivery? n n No significant data No data Cholestasis of pregnancy?
![How to induce labour: n n For prolonged pregnancy first sweep the membranes For How to induce labour: n n For prolonged pregnancy first sweep the membranes For](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-9.jpg)
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 After one previous lower segment Caesarean: n n n For spontaneous labour the risk](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-10.jpg)
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 (Based on 2119 American women 1992 1998) n Foley catheter is an acceptable alternative
![For Oxytocin Infusion: n n n n Use a single standard dilution in N For Oxytocin Infusion: n n n n Use a single standard dilution in N](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-11.jpg)
For Oxytocin Infusion: n n n n Use a single standard dilution in N saline IV by infusion pump All instructions in m. U/minute Commence at 1 – 2 m. U/min Increase at 30 minute intervals Review at 16 – 20 m. U/min Discontinue after 5 units if not in labour Monitor the fetus
![Oral Misoprostol (Cochrane April 2006) n n 41 trials, 8606 patients CF other methods Oral Misoprostol (Cochrane April 2006) n n 41 trials, 8606 patients CF other methods](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-12.jpg)
Oral Misoprostol (Cochrane April 2006) n n 41 trials, 8606 patients CF other methods of IOL Shorter labour n n Less likely to need Caesarean n n RR 0. 16, CI 0. 05 – 0. 49 RR 0. 62, CI 0. 40 – 0. 96 More likely to have hyperstimulation n RR 1. 63, CI 1. 09 – 2. 44
![Oral Misoprostol (Cochrane April 2006) n More meconium n n RR 1. 72, CI Oral Misoprostol (Cochrane April 2006) n More meconium n n RR 1. 72, CI](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-13.jpg)
Oral Misoprostol (Cochrane April 2006) n More meconium n n RR 1. 72, CI 1. 08 – 2. 74 When compared to vaginal PG’s Less likely to have hyperstimulation n More likely to require oxytocin n n Conclusions… It is unlicensed in most countries Dosage is still uncertain Should not exceed 50 mcg
![Delay in the 1 st stage of labour n n n Back to basics… Delay in the 1 st stage of labour n n n Back to basics…](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-14.jpg)
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 Evaluation is all about P’s… n Powers? Uterine contractions n Oxytocin augmentation? n Safe](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-15.jpg)
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… So in my practice I will: n Make a personal evaluation of the patient…](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-16.jpg)
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 @ 1 or 8 m. U/m Arrange continuous CTG Review in 4, 6 or 8 hours
![When to intervene in the second stage of labour n n n A few When to intervene in the second stage of labour n n n A few](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-17.jpg)
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 Fetal welfare in the second stage n n n Must take into account the](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-18.jpg)
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 Forceps or Ventouse? n n n Cochrane database 1999 Ten trials Less maternal trauma](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-19.jpg)
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
![Ventouse equipment is a problem Ventouse equipment is a problem](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-20.jpg)
Ventouse equipment is a problem
![The Kiwi Omnicup Ventouse n n BJOG 2006 206 women in 2 London hospitals The Kiwi Omnicup Ventouse n n BJOG 2006 206 women in 2 London hospitals](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-21.jpg)
The Kiwi Omnicup Ventouse n n BJOG 2006 206 women in 2 London hospitals Randomised to Kiwi Omnicup or conventional Ventouse Conventional Ventouse more successful n n RR 1. 58, CI 1. 10 – 2. 24 Omnicups had more detachments No difference in maternal trauma No serious neonatal injuries
![Trial of ventouse in theatre n When fetal compromise is suspected n n n Trial of ventouse in theatre n When fetal compromise is suspected n n n](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-22.jpg)
Trial of ventouse in theatre n When fetal compromise is suspected n n n An even better option is scalp sampling When there is marked caput and moulding When you are not absolutely certain of the position – There is a role for intrapartum ultrasound n When there is 2/5 th head or more palpable above the brim
![Advances in Caesarean section: n n n n Spinal anaesthesia Joel Cohen-type incision* Cord Advances in Caesarean section: n n n n Spinal anaesthesia Joel Cohen-type incision* Cord](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-23.jpg)
Advances in Caesarean section: n n n n Spinal anaesthesia Joel Cohen-type incision* Cord traction for the placenta* Peritoneum not sutured* Suture fat if >2 cm but do not drain* Prophylactic antibiotics* Early oral fluids and ambulation Rectal NSAID for analgesia n *Confirmed by RCT
![So who needs a Caesarean section? n n n I really don’t know But So who needs a Caesarean section? n n n I really don’t know But](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-24.jpg)
So who needs a Caesarean section? n n n I really don’t know But many of my obstetric colleagues seem to know So 50 – 70% of Caesareans are now elective procedures And we should be aiming for 100% elective CS Because non elective CS is the worst of the 3 options
![Absolute indications for Caesarean: n n n Two or more previous CS Transverse lie Absolute indications for Caesarean: n n n Two or more previous CS Transverse lie](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-25.jpg)
Absolute indications for Caesarean: n n n Two or more previous CS Transverse lie Repeat APH unless placenta previa can be absolutely excluded Known contracted pelvis Complex twin presentations e. g. breech and transverse (Source: Lawson, Harrison & Bergstrom)
![Vaginal Birth after Caesarean n Maternal Risk of death n n Scar rupture n Vaginal Birth after Caesarean n Maternal Risk of death n n Scar rupture n](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-26.jpg)
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
![Vaginal Birth after Caesarean n n Smith et al from Cambridge UK in JAMA Vaginal Birth after Caesarean n n Smith et al from Cambridge UK in JAMA](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-27.jpg)
Vaginal Birth after Caesarean n n Smith et al from Cambridge UK in JAMA 2002: Reviewed 313, 238 singleton births, 37 - 43 w, cephalic presentation in the Scottish Morbidity Register 1992 -1997 excluding congenital malformations Rate of perinatal death 11 X higher with VBAC vs Elect CS This is 2 X higher than for multiparas having a vaginal birth BUT n n This is equivalent to Primips having their first birth Absolute risk is only 4. 5 per 10, 000 births Confidence limits were wide All emergency CS were classified as attempted VBAC
![Vaginal Birth after Caesarean n Guise et al from Portland Oregan in BMJ July Vaginal Birth after Caesarean n Guise et al from Portland Oregan in BMJ July](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-28.jpg)
Vaginal Birth after Caesarean n Guise et al from Portland Oregan in BMJ July 2004: n Reviewed 568 publications on VBAC vs elective CS but found only 71 had useful data n Concluded that the additional risk of perinatal death from attempted VBAC was 1. 4 per 10, 000 (95 percent confidence limits 0 - 9. 8) n In only 5% of uterine ruptures did the baby die n AND n This means that one has to perform 7142 elective CS to prevent one baby death
![Breech Presentation (Cochrane April 2003) n n n Three trials, 2396 patients 45% of Breech Presentation (Cochrane April 2003) n n n Three trials, 2396 patients 45% of](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-29.jpg)
Breech Presentation (Cochrane April 2003) n n n Three trials, 2396 patients 45% of those attempting vaginal delivery had CS Risk of perinatal death was lower with elective CS n n RR 0. 33, CI 0. 19 – 0. 56 Rate of maternal morbidity was increased by CS n RR 1. 29, CI 1. 03 – 1. 61
![Breech Presentation n n However… 97% of babies born by the breech are fine Breech Presentation n n However… 97% of babies born by the breech are fine](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-30.jpg)
Breech Presentation n n However… 97% of babies born by the breech are fine And the trial differences had disappeared after 2 years follow up And the trial data cannot be generalised to settings where CS is not readily available Provided that breech delivery skills are maintained
![Selection of patients for vaginal breech birth: n n n Singleton, at term Breech Selection of patients for vaginal breech birth: n n n Singleton, at term Breech](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-31.jpg)
Selection of patients for vaginal breech birth: n n n Singleton, at term Breech with extended legs EFW <3600 g Adequate pelvis Hyper extended head excluded Informed and co operative patient NB A Role for External Cephalic Version
![Risks of Caesarean Delivery n Difficult to quantify because: Most studies do not distinguish Risks of Caesarean Delivery n Difficult to quantify because: Most studies do not distinguish](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-32.jpg)
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 More likely with Caesarean birth: Hospital stay 2 -fold Intensive care 9 -fold Maternal](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-33.jpg)
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 Same rate for vaginal and CS Birth: Postpartum haemorrhage Endometritis Genital tract injury Faecal](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-34.jpg)
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 More Likely with Vaginal Birth: Perineal pain 2. 5 -fold Urinary incontinence 1. 6](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-35.jpg)
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 More likely with Caesarean birth No Difference whether CS or Vaginal More likely with](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-36.jpg)
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 Caesarean Sections are Popular because: n Caesarean Section is Convenient n Caesarean Section is](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-37.jpg)
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 Caesarean Sections are Popular because: n Vaginal Birth is Painful n Vaginal Birth is](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-38.jpg)
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 Caesarean Sections are Popular because: n “Once a Caesarean always a Caesarean” n The](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-39.jpg)
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 More Caesarean Sections occur when: n n n Fetal distress is diagnosed by CTG](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-40.jpg)
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 Caesarean Sections are Popular because: n The Power of Choice n Fathers have influence](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-41.jpg)
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 Caesarean Sections are increasing because: n There is an obesity epidemic n Maternal age](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-42.jpg)
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?
![Caesarean Sections are increasing because: n “My mother and my sisters all had Caesareans” Caesarean Sections are increasing because: n “My mother and my sisters all had Caesareans”](http://slidetodoc.com/presentation_image_h2/69aaf1d0989b634ac40b1fc8e2e9aff3/image-43.jpg)
Caesarean Sections are increasing because: n “My mother and my sisters all had Caesareans” n “This is an IVF baby” n Evolution of the species?
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