Delivery (Labour) and Delivery Complications

Overview Labour is the period from the onset of regular uterine contractions until expulsion of the placenta. Labour can be either:

• Spontaneous labour
• Induced labour (Discussed at the end)

Labour can be a "true" labour or a "false" labour. Braxton Hicks contractions are mild, often irregular contraction that may occur from 30weeks gestation and often confused as true labour. True labour is characterised by:

• Painful uterine contractions at REGULAR intervals
• Contraction with increasing intensiry and duration
• The show occuring
• Progressive effacement and dilatation of the cervix
• Formation of the bag of waters

Labor is determined by assessing the cervical change versus time. Labour is initiated by the stretching of the cervix causing the release of oxytocin from the posterior pituitary gland

Stages of Labour - three stages

• 1st Stage
  • Latent phase (cervical effacement and dilatation up to 3/4cm)
  • Active phase (3/4cm to full dilatation)
• 2nd Stage - Full cervix dilatation until baby is born
• 3rd Stage - Placental delivery

Stages of Labour

The foetus ready for a normal labour

• The foetal lie is longitudinal
• The presentation is cephalic
• The position is right or left occipitoanterior

Mechanism of normal labour - Movement of baby through the pelvis during labour

• Engagement
• Descent
• Internal Rotation
• Crowning and extension
• Restitution
• External Rotation
• Delivery of anterior shoulder
• Delivery of posterior shoulder

Monitoring during labour

• CTG throughout - assessed every 30min
• Contraction - assessed every 30min
• Maternal pulse - assessed every 30min
• Maternal Blood pressure and Temperature - assessed 4 hourly (or hourly if complicated)
• Maternal urine - assessed 4 hourly
• Vaginal Examination - offered 4 hourly to see progress of cervical dilatation.

Labour can be either:

• Spontaneous labour
• Induced labour - medical intervention helps induce labour

Induction of Labour As a general principle, induction of labour is undertaken when continuing a pregnancy is associated with greater level of maternal or foetal risk than delivery. 20% of all pregnancies are induced. The Bishops score helps assess the favourability for induction of labour.

Indications for Labour Induction (IOL)

• Obstetric indication
  • Uteroplacental insufficiency (most common)
  • Prologed pregnancy (>40weeks)
  • Interuterine Growth Restriction
  • Non-reassuring CTG
  • Severe Pre-eclampsia
• Medical Indication
  • Gestational Diabetes (If on insulin and poorly controlled)
  • Pre-eclampsia and eclampsia

Methods of labour induction

• Prostaglandins (dinoprostone) → causes uterine contraction (can be either administered via vaginal gel/orally)
• Oxytocin infusion → causes uterine contraction
• Cervical ripening. Either:
  • Stretch and sweep
  • Artificial rupture of membranes (Amniotomy)
  • Transcervical Foley catheter

When labour has progressed to full dilatation and concerns exist regarding wellbeing of the fetus, mother, or both, three options exist

• Allow the labour to proceed as normal aiming for spontaneous vaginal birth
• Proceed to instrumental vaginal birth also known as operative
• Perform a caesarean section

Instrumental Vaginal Delivery Labour is divided into 3 stages. Stage 2 of labour (the stage from full cervical dilatation to the expulsion of the baby from the uterus) sometimes can be difficult and prolonged. Instrumental vaginal delivery helps with this stage and reduced need for caesarean section which is associated with more complications.

Indications for instrumental vaginal delivery

• Suspected or anticipated fetal compromise
• Maternal Exhaustion
• Prolonged 2nd stage (>1hr of active pushing in multiparous women or >2hr in primiparous women
• Medical intervention to avoid Valsalva (cardiac disease, hypertensive crisis, spinal injury)

Criteria for Intrumental vaginal delivery - FORCEPS

• Fully dilated cervix
• Obstruction should be excluded
• Ruptured membranes
• Consent, Catheterized bladder, Check instruments prior to application
• Epidural anaesthesia, Explained the procedure, Examine the vagina area for signs of trauma
• Presentation and postiion of fetal head, Power of uterine contraction, Placement of forceps bladers or venouse cup
• Station of the presenting part, Senior help if needed

Instruments used for Vaginal Delivery

• Forceps
• Ventouse (vacuum)

Complications of instrumental vaginal delivery

• Maternal trauma
  • Vaginal trauma
  • Postpartum haemorrhage
  • Urinary tract injury
  • Damage to pelvic floor and anal sphincter
• Fetal complication (rare)
  • Shoulder dystocia and its consequences
  • Subaponeurotic/subgaleal haemorrhage
  • Facial nerve palsy, corneal abrasion, retinal haemorrhage
  • Skull fracture and/or intracranial haemorrhage
  • Cervical spine injury

Risk Factors for failed instrumental vaginal delivery

• Obese women (BMI >30)
• Macrosomia
• Occiptoposterior position
• Mid-cavity, or when 1/5 of the fetal head is palpable abdominally

Overview Episiotomy is a surgically planed cut to enlarge the vaginal introitus so as to facilitate easy and safe delivery of the foetus.

Consider episiotomy in the following circumstances:

• High likelihood of severe laceration
• Soft tissue dystocia
• Requirement to accelerate the birth delivery of a compromised foetus
• Need to facilitate operative (instrumental) vaginal delivery
• History of female genital mutilation

Type of episiotomy 

• Mediolateral episiotomy
• Midline episiotomy

Complications of episiotomy

• Extension of the incision to involve th rectum
• Vulval haematoma
• Infection
• Wound dehiscence
• Injury to anal sphincter causing incontinence of flatus or faeces
• Rectovaginal fistula (rare)
• Necrotising fascitis
• Dysparenuia
• Chance of perineal lacerations
• Scar endometriosis (rare)

Perineal tears

• There are four classes

Repair of perineal tears

• Done as soon as possible
• Examine the rectum to make sure no trauma to anal sphincter complex

Overview Failure to progress also known as labour arrest, labour dystocia or abnormal labour is used to describe a labour pattern deviating from the observed (normal) in the majority of women who have a spontaneous vaginal delivery. About 20% of all labors ending in a live birth involve failure to progress.

Risk Factors

• Hypocontractile uterine activity
• Older maternal age
• Nulliparous women
• Short stature
• Maternal obesity
• Macrosomia
• Cephalopelvic disproportion
• Non- occiput anterior position
• Bandl's ring 
• Uterine abnormality
• Postterm pregnancy

Diagnosis

Labour pattern deviating from the above normal labour parameters is considered abnormal labour or failure to progress. Other interventions are indicated such as instrumental delivery or most often caesarean section.

Overview Caesarian delivery is the surgical removal of the infant from the uterus through an incision made in the abdominal wall and an incision made in the uterus. Incidence is 15-30%. Caesarean sections can be done as a planned procedure (elective) or as an emergency.

Types of Caesarean Delivery

• Low segment transverse  - incision made transversely in lower segment of uterus (most common)
• Classic - vertical incision is made directly into the wall of the body of the uterus (not common)

Indications

• Previous caesarean section
• Dystocia or dysfunctional labour
• Fetal distress
• Breech presentation
• Antepartum haemorrhage
• Maternal problems
• Caesarean section on demand

Anaesthesia

• Spinal Anaesthesia
• Epidural Anaesthesia
• General Anaesthesia

Intrapartum Complications

• Primary haemorrhage
• Injury to internal organs
• Injury to the baby
• Difficulty in delivery of the head
• Anaesthetic complications

Postoperative Complications

• Paralytic ileus
• Respiratory complications
• Infections
• Peritonitis
• Pelvic abscess
• Pelvic thrombophlebitis
• Deep vein thrombosis and pulmonary embolism
• Wound dehiscence

Overview Occipitoposterior Position (OP) is the most common foetal malposition. Before labour, 15-20% of term foetuses in cephalic presentation are OP, but only 5% at vaginal delivery remain OP because most spontaneously rotate to Occipitoanterior position during labour.

Occipitoposterior Position (OP) and consequences on labour

• OP position can cause protraction of the 1st or 2nd stages of labour, or even arrest the second stage
• Women with an OP foetus are more likely to undergo interventions to hasten labour progress
• Other delivery complications: ↑risks of anal sphincter injuries, failed forceps or vacuum delivery, and inadvertent extension of the hysterotomy at caesarean
• ↑Neonatal adverse outcomes - Low APGAR, birth trauma

Management OP position antepartum is not predictive of foetal position at delivery or adverse outcome, as 95% rotate to OA by delivery. Intrapartum management occur in second stage of labour and include:

• Digital manual rotation (to rotate to OA prior to vaginal delivery)
• Operative vaginal delivery from OP position
• Caesarean delivery

Overview Breech presentation is normal in preterm pregnancy (<37 weeks gestation) and should not be considered abnormal, requiring intervention, until 37 weeks pregnancy is reached (at term). Breech presentation incidence of 40% at 20 wks gestation but incidence decreases with gestational

Breech Classification:

• Frank breech: where the hips are flexed and legs extended (65-70%)
• Complete breech: hips & knees are flexed + feet not below the level of the fetal buttocks (30%)
• Footling breech (incomplete): where hips are not completely flexed and one or both feet are presenting as the lowest part of the fetus

Diagnosis

• Abdominal palpation
• Pelvic examination: head not felt in pelvis (buttocks and/or feet may be felt)
• Ultrasound scan will confirm diagnosis

Management

• Perform External Cephalic Version at 37 weeks → vaginal delivery
• Planned caesarean section for 39 weeks
• Vaginal breech delivery

Major causes of Maternal mortality

• Postpartum haemorrhage
• Heart disease
• Pregnancy induced hypertension
• Amniotic embolism

Overview Uterine rupture occurs in 2 per 10,000 of all pregnancies. It is a rare but significant event. It may occur before or after birth and can vary in size.

Risk Factors

• High parity
• Multiple pregnancy
• Previous uterine trauma
• Previous uterine surgery
• Induction and/or augemntation of labour
• High or mid cavity forceps
• Obstructed labour (with or without Bandl's Ring)
• Direct trauma
• Extension of a cervical laceration
• Internal manipulation to correct unstable lie or malpresentation

Signs and Symptoms

• Cessation of previously effective contractions
• Tonic/hypertonic contractions
• Pain unrelated to contractions
• Pain over the uterine scar
• Should tip pain (rupture)
• Antepartum haemorrhage
• Post partum haemorrhage
• Haematuria
• Fetus palpated in maternal abdomen
• Loss of station of the presenting part
• Abnormal fetal heart rate pattern

Management

• Call of help!
• Resuscitate
• Cease oxytoxin if in progress
• Monitor ongoing blood loss
• Monitor foetus
• Prepare for immediate transfer to theatre to expedite birth
• Surgical repair or hysterectomy

Complications

• Maternal haemorrhage (concealed or revealed)
• Damage to other pelvic structures
• Hysterectomy
• Fetal compromise and possible demise
• Maternal death

Overview Uterine inversion occurs when the uterine fundus inverts within the endometrial cavity. 1 in every 2,500 births.

Stages of uterine inversion

• 1st degree - the fundus inverts/dimples and reaches the internal os
• 2nd degree - the body of the uterus is inverted and protrudes through the cervix
• 3rd degree - the uterus completely inverted and appears outside the vulva

Risk Factors

• Adherent placenta
• Uterine abnormalities
• Precipitate labour and birth
• Multiparity
• Prolonged labour
• Short umbilical cord
•  Performing controlled cord traction prior to placental seperation
• Manual removal of placenta

Signs and Symptoms

• Lower abdominal and/or bakc pain
• Excessive blood loss
• Fundus feels dimpled or not its proper position on abdominal palpation or vaginal examination
• Uterine protrusion through the cervix visible on speculum or palpated on vaginal examination
• Uterine protrusion at the introitus
• Shock disproportion to observed blood loss

Management

• Call for help
• Resuscitate
• Manual replacement
• Consider uterine relaxation with beta-mimetic agents (tetrabutaline, nitroglycerin)
• Hydrostatic replacement
• Remove placenta in operating theatre
• After placenta removal, commence aggressive PPH
• Commence antibiotics

Complications

• Maternal shock and collapse
• Post partum haemorrhage
• Pain
• Hysterectomy
• Endometritis
• Damage to intestines and/or other pelvic anatomy

Overview Umbilical cord prolapse is a true obstetric emergency requiring immediate delivery. It is when the umbilical cord descends through the cervix alongside or past the presenting fetal part in the presence of ruptured membranes. If the cord is compressed, the foetus will die within 5-10 mins.

Aetiology Mechanism of Foetal Death is from compression of the umbilical vessels by the presenting part and/or umbilical arterial vasospasm due to exposure of cord → acutely compromised foetal circulation→ foetal death or neurological sequelae unless immediate delivery.

Difference between Cord presentation and Cord prolapse In both conditions, a loop of the cord is below the presenting part. Difference is condition of membranes:

• If membranes intact - cord presentation
• If membranes ruptured - cord prolapse

Incidence Cord Prolapse

• 0.1-0.6% overall incidence
• Higher in breech ~1%
• Perinatal mortality rates up to 20-30%

Clinical Identification of Cord Prolapse

• Visual inspection or palpation during vaginal exam - Umbilical cord is visualised or felt below or beside the presenting part
• Abnormal CTG changes:Bradycardia and Severe decelerations (atypical, variable, prolonged)

Complications

• Foetal Hypoxia
• Foetal Death
• Neonatal Hypoxic Ischaemic Encephalopathy
• Neonatal Death
• Maternal - increased operative birth and associated complications

Management

1. Recognise and call for help!
2. Initiate immediate assessment of clinical circumstances (gestation, presentation, cervical dilatation, foetal wellbeing. Immediate delivery is necessary when the foetus is viable)
3. Relieve pressure on cord to prevent compression:
   • Trained person to place hand in vagina to push presenting part out of the pelvis to maintain blood flow → continue until delivery
   • Roll the women into either: Knee chest, exaggerated Sim's or Trendelenberg position
   • Urinary bladder may be filled with fluid via catheter to elevate presenting part - If there will be a long DELAY in delivery
     

     Side note Excessive handling of the cord may cause it to spasm

4. Administer oxygen to the woman via a mask
5. Discontinue oxytocics if present
6. Tocolytics to abolish uterine contractions
7. DELIVERY MUST BE EXPEDITED TO REDUCE MORBIDITY AND MORTALITY TO THE FOETUS

Overview Shoulder dystocia is defined as a vaginal cephalic delivery that requires additional obstetric manoeuvres to deliver the foetus after the head has delivered and gentle traction has failed. Shoulder dystocia cannot be predicted nor prevented in the majority of cases. Brachial plexus injury (BPI) is one of the most important fetal complications of shoulder dystocia. Maternal morbidity is increased, particularly the incidence of postpartum haemorrhage as well as third and fourth-degree perineal tears

Management (HELPERR

• Call for Help
• Evaluate for Episiotomy
• Legs: McRoberts Maneuver
• External Pressure - suprapubic
• Enter: rotational maneuvers
• Remove the posterior arm
• Roll the patient to her hands and kness

Overview Amniotic fluid embolism is a rare and potentially catastrophic, but poorly understood condition that is unique to pregnancy. It may range from a relatively minor subclinical episode through to one which is rapidly fatal.

Risk Factors - not really well understood could be an interplay of:

• Advanced maternal age
• Placenta praevia
• Placental abruption
• Operative delivery
• Induction of labour

Clinical Presentation often occur in the intrapartum and immediate postpartum period

• Hypotension
• Fetal distress
• Pulmonary oedema or ARDS
• Cardiopulmonayr arrest
• Cyanosis
• Coagulopathy
• Dyspnoea
• Seizure
• Uterine atony
• Bronchospasm

Diagnosis The diagnosis of AFE is a clinical one, based on the presence of cardiovascular and respiratory compromise and coagulopathy after the exclusion of other causes.

Management Supportive and advanced life suport

Overview Invasive implantation increases following caesarean section and is incrementally linked to the number of caesarean sections the woman has had.

Overview Postpartum Haemorrhage is potentialy life-threatening and is one of the leading causes of maternal death. The incidence of PPH may be underestimated by up to 50%, due to the clinical difficulty in accurately estimating blood loss

• Minor PPH: blood loss of 500-1000mls
• Major PPH: blood loss of >1000mls

Causes of post partum haemorrhage

• Tone - Uterine atony (90%)
• Trauma - Lacerations of the genital tract (6%) - Trauma-related bleeding can be due to lacerations, surgical incisions, or uterine rupture.
• Tissue - Retained placenta and abnormal placenta (3-4%)
• Thrombin - Coagulation disorders, thromcytopaenia associated with pre-eclampsia, amniotic fluid embolism, severe infection

Maternal morbidity and mortaility from PPH is caused by:

• Hypovolaemia → ↓cardiac return → ↓Cardiac output→ ↓BP → ↓Renal/hepatic organ failure, Acute respiratory syndrome, Sheehan's Syndrome and DIC

Prevention 

• Antenatal detection and correction of anaemia (morbidoty ↑ for anaemic women)
• Active management of 3 rd stage of labour for all women- MOST effective as it ↓ risk PPH by 50%
  • Adminstering an Oxytocic with the anterior should
  • Early cord clamping and cutting
  • Delivery of placenta by controlled cord traction whilst guarding the uterus
• Post-delivery - check & repair genital trauma early, confirm placenta & membranes complete, observe any blood loss for clotting, regular observations

Management

• Call for help
• Lie women flat, uterine massage, keep women warm
• Resuscitate (O2 , IV access, fluids, catheter, monitor vitals)
• Assess Aetiology - 4Ts - Treat depending on Aetiology
  • Abdominal assessment of uterus
  • fundal massage to expel any products and promote contraction
  • explore lower genital tract for trauma
  • check placenta and membrane for completeness (tissue)
  • review history and observe clots (thrombin)

Atony PPH Management Adminstration of medicine: promotes contraction of the uterine corpus - decreases the likelihood of uterine atony

• Massage the fundus and expel clots and products
• Oxytocin agents
• Ergometrine
• Prostagladins
• Mechanical stimulation of uterine contraction (massage of uterus through the abdomen and bimanual compression
• Surgical methods (If all methods above fail)
  • Ligation of the uterine arteries
  • Ligation of the hypogastric arteries
  • Selective arterial embolisation
  • Hysterectomy

Overview The diagnosis of preterm labour is generally based upon clinical criteria of regular, painful uterine contractions accompanied by cervical dilation and/or effacement between 24-27 weeks.

Investigations  of preterm labour

• Transvaginal ultrasound
• Fetal fibronectin - positive are more likely to deliver. Fetal fibronectin is not usually present in cervicovaginal secretion before 22weeks

Aetiology of Preterm labour

• Multiple pregnancy
• Antepartum Haemorrhage
• Intrauterine growth restriction
• Cervical incompetence
• Chorioamnionitis
• Abnormal baby
• Congenital uterine anomaly
• Polyydramnios
• Infections - Bacterial vaginosis
• Iatrogenic
• Idiopathic

Prevention of preterm labour

• Infection is a cause of preterm labour - could antibiotics against bacterial vaginosis have a role?
• Progesterone
• Cervical cerclage
• Reduction of pregnancy numbers (as multi-pregnancy is associated with increased risk of preterm labour)
• Cessation of smoking/illicit drug use

Management of preterm labour

• Aim to prolong gestation but also to improve perinatal outcome
• Steroid therapy (IM dexamethasone to mother) - To induce pulmonary surfactant in the lungs of the immature fetus and prevent respiratory syndrome
• Tocolytics - β Sympathomimetic, nitrates, calcium channel blockers (Nifedipine), Oxytocin anatagonist

Complication of Premature baby (as a result of preterm delivery)

• Respiratory Distress Syndrome
• Intraventricular Haemorrhage
• Necrotizing enterocolitis
• Neonatal jaundice
• Failure to thrive
• Cerebral Palsy

Preterm prelabour rupture of membranes

• Occurs in 33% of preterm deliveries
• 33% of PPROM associated with infection - do investigations!

Investigations

• FBC
• CRP
• Vaginal swab
• Urine analysis
• Ultrasound

Prelabour rupture of membranes