Management of Management of Labour and Labour and

DeliveryDelivery

Max Brinsmead MB BS PhDMax Brinsmead MB BS PhD

May 2015May 2015

Subjects to be covered:Subjects to be covered:

Induction of labourInduction of labour Delay in the first stage of labourDelay in the first stage of labour When & How to intervene in the When & How to intervene in the

second stagesecond stage Who needs a Caesarean section?Who needs a Caesarean section? Risks associated with Caesarean Risks associated with Caesarean

deliverydelivery Why are there so many Why are there so many

Caesareans?Caesareans?

Resources:Resources:

Cochrane databaseCochrane database RCOG GuidelinesRCOG Guidelines NICE (UK) GuidelinesNICE (UK) Guidelines Lawson, Harrison and Bergstrom Lawson, Harrison and Bergstrom

(2001) “(2001) “Maternity Care in Maternity Care in Developing Countries”Developing Countries”

My personal experienceMy personal experience

Why is this subject important?Why is this subject important? Difficulties in labour is responsible for 30 Difficulties in labour is responsible for 30

– 50% of maternal deaths– 50% of maternal deaths Morbidity in survivorsMorbidity in survivors

FistulasFistulas AnaemiaAnaemia InfertilityInfertility

Also has Also has fetal and neonatal risksfetal and neonatal risks CS in western countries is the simple & CS in western countries is the simple &

safe option but…safe option but… Late presentationLate presentation ResourcesResources

Make it less appropriate elsewhereMake it less appropriate elsewhere

Predicting outcome in labour is still difficult:Predicting outcome in labour is still difficult:

Clinical examination is limitedClinical examination is limited X-ray and CT Pelvimetry is X-ray and CT Pelvimetry is

disappointingdisappointing Estimates of fetal weight have a Estimates of fetal weight have a

wide margins of errorwide margins of error Antenatal risk screening is still Antenatal risk screening is still

importantimportant But mostly to decide place of But mostly to decide place of

birth rather than mode of deliverybirth rather than mode of delivery

Antenatal Risk FactorsAntenatal Risk Factors Young and older nulliparasYoung and older nulliparas Short statureShort stature Previous difficult birth or CaesareanPrevious difficult birth or Caesarean Previous stillbirth or neonatal deathPrevious stillbirth or neonatal death Multiple pregnancyMultiple pregnancy Nutritional deficiency, severe anaemia etcNutritional deficiency, severe anaemia etc Large for datesLarge for dates Obvious pelvic deformityObvious pelvic deformity MalpresentationMalpresentation High ParityHigh Parity

When to induce labour:When to induce labour:

When the risks of continuing When the risks of continuing the pregnancy outweigh the the pregnancy outweigh the risks of inductionrisks of induction

At 41+ weeksAt 41+ weeks Within 96 hrs of ruptured Within 96 hrs of ruptured

membranes at termmembranes at term For pre eclampsia at termFor pre eclampsia at term For maternal diabetes at termFor maternal diabetes at term

– This includes gestational diabetesThis includes gestational diabetes

When to induce labour 2:When to induce labour 2:

For IUGR at term when there is For IUGR at term when there is absent Doppler EDFabsent Doppler EDF

Macrosomia?Macrosomia? No significant dataNo significant data

Multiple pregnancy?Multiple pregnancy? No dataNo data

Previous precipitate delivery?Previous precipitate delivery? No dataNo data

Unstable lie?Unstable lie? No dataNo data

Cholestasis of pregnancy?Cholestasis of pregnancy?

How to induce labour:How to induce labour: For prolonged pregnancy first For prolonged pregnancy first

sweep the membranessweep the membranes For ruptured membranes…For ruptured membranes…

Oxytocin by IV infusionOxytocin by IV infusion Although wait-and-see and vaginal PG’s Although wait-and-see and vaginal PG’s

are acceptableare acceptable For all other patients (except For all other patients (except

those with a uterine scar)…those with a uterine scar)… Vaginal prostaglandinsVaginal prostaglandins Regardless of the state of the cervix or Regardless of the state of the cervix or

the parity of the patientthe parity of the patient Amniotomy followed by oxytocin infusion Amniotomy followed by oxytocin infusion

3 – 12 hours later is likely to be the most 3 – 12 hours later is likely to be the most cost effective when the cervix is ripecost effective when the cervix is ripe

After one previous lower segment After one previous lower segment Caesarean:Caesarean: For spontaneous labour the risk of scar For spontaneous labour the risk of scar

rupture is 1:200rupture is 1:200 With oxytocin infusion the risk is 1:100With oxytocin infusion the risk is 1:100 With prostaglandins the risk is 1:40With prostaglandins the risk is 1:40

More difficult to induce?More difficult to induce? Direct effect of PG’s on connective tissue?Direct effect of PG’s on connective tissue?

(Based on 2119 American women 1992 -1998)(Based on 2119 American women 1992 -1998) Foley catheter is an acceptable Foley catheter is an acceptable

alternativealternative

For Oxytocin Infusion:For Oxytocin Infusion:

Use a single standard dilution in N Use a single standard dilution in N salinesaline

IV by infusion pumpIV by infusion pump All instructions in mU/minuteAll instructions in mU/minute Commence at 1 – 2 mU/minCommence at 1 – 2 mU/min Increase at 30 minute intervalsIncrease at 30 minute intervals Review at 16 – 20 mU/minReview at 16 – 20 mU/min Discontinue after 5 units Discontinue after 5 units if not in labourif not in labour Monitor the fetusMonitor the fetus

Oral Misoprostol Oral Misoprostol (Cochrane April 2006)(Cochrane April 2006)

41 trials, 8606 patients CF other 41 trials, 8606 patients CF other methods of IOLmethods of IOL

Shorter labourShorter labour RR 0.16, CI 0.05 – 0.49RR 0.16, CI 0.05 – 0.49

Less likely to need CaesareanLess likely to need Caesarean RR 0.62, CI 0.40 – 0.96RR 0.62, CI 0.40 – 0.96

More likely to have More likely to have hyperstimulationhyperstimulation

RR 1.63, CI 1.09 – 2.44RR 1.63, CI 1.09 – 2.44

Oral Misoprostol Oral Misoprostol (Cochrane April 2006)(Cochrane April 2006)

More meconiumMore meconium RR 1.72, CI 1.08 – 2.74RR 1.72, CI 1.08 – 2.74

When compared to vaginal PG’sWhen compared to vaginal PG’s Less likely to have hyperstimulationLess likely to have hyperstimulation More likely to require oxytocinMore likely to require oxytocin

Conclusions…Conclusions… It is unlicensed in most countriesIt is unlicensed in most countries Dosage is still uncertainDosage is still uncertain Should not exceed 50 mcgShould not exceed 50 mcg

Delay in the 1Delay in the 1stst stage of labour stage of labour

Back to basics…Back to basics… Best diagnosed by reference to a Best diagnosed by reference to a

partographpartograph Defined as dilatation less than 1 Defined as dilatation less than 1

cm/hour in the active phasecm/hour in the active phase This represents the lowest 10This represents the lowest 10thth centile centile Is regardless of parityIs regardless of parity

But the biggest difficulty is But the biggest difficulty is deciding when to start the deciding when to start the partographpartograph

Evaluation is all about P’s…Evaluation is all about P’s…

Powers?Powers? Uterine contractionsUterine contractions Oxytocin augmentation?Oxytocin augmentation? Safe enough in most nulliparasSafe enough in most nulliparas

Passenger, Presentation and Passenger, Presentation and PositionPosition

Estimating fetal weightEstimating fetal weight Beware the multiparaBeware the multipara

Passages?Passages? Is this labour obstructedIs this labour obstructed

PsychologyPsychology Pain reliefPain relief Re hydration etc.Re hydration etc.

So in my practice I will:So in my practice I will:

Make a personal evaluation of the Make a personal evaluation of the patient…patient…

Begin with the AN recordBegin with the AN record Talk to the patient & the midwifeTalk to the patient & the midwife Evaluate uterine activityEvaluate uterine activity Examine abdomen and VEExamine abdomen and VE

Arrange analgesia if requiredArrange analgesia if required Commence oxytocin @ 1 or 8 mU/mCommence oxytocin @ 1 or 8 mU/m Arrange continuous CTGArrange continuous CTG Review in 4, 6 or 8 hoursReview in 4, 6 or 8 hours

When to intervene in the second stage of labourWhen to intervene in the second stage of labour

A few patients should not push at allA few patients should not push at all Otherwise, there is no reason to Otherwise, there is no reason to

interfere unless there is failure to interfere unless there is failure to progressprogress

This usually means arrest after 60 This usually means arrest after 60 minutes of active pushingminutes of active pushing

Not just full dilatation plus 1 – 2 hrsNot just full dilatation plus 1 – 2 hrs When the patient (and others) are When the patient (and others) are

ready for interventionready for intervention

Fetal welfare in the second stageFetal welfare in the second stage

Must take into account the total Must take into account the total clinical scenarioclinical scenario

For me this begins with the AN For me this begins with the AN recordrecord

Than the partograph, prior CTG etc.Than the partograph, prior CTG etc. The depth and width of FHR dips is The depth and width of FHR dips is

more important than their typemore important than their type Explain to the mother why you are Explain to the mother why you are

intervening…intervening…

Forceps or Ventouse?Forceps or Ventouse?

Cochrane database 1999Cochrane database 1999 Ten trialsTen trials Less maternal traumaLess maternal trauma

RR 0.41, CI 0.33 – 0.50RR 0.41, CI 0.33 – 0.50 Less anaesthesia requiredLess anaesthesia required More vaginal deliveriesMore vaginal deliveries

RR 1.69, CI 1.31 – 2.19RR 1.69, CI 1.31 – 2.19 More neonatal cephalhaematomas More neonatal cephalhaematomas

and retinal haemorrhageand retinal haemorrhage But serious injury is rareBut serious injury is rare

Ventouse equipment is a problemVentouse equipment is a problem

The Kiwi Omnicup VentouseThe Kiwi Omnicup Ventouse

BJOG 2006BJOG 2006 206 women in 2 London hospitals206 women in 2 London hospitals Randomised to Kiwi Omnicup or Randomised to Kiwi Omnicup or

conventional Ventouseconventional Ventouse Conventional Ventouse more Conventional Ventouse more

successfulsuccessful RR 1.58, CI 1.10 – 2.24RR 1.58, CI 1.10 – 2.24

Omnicups had more detachmentsOmnicups had more detachments No difference in maternal traumaNo difference in maternal trauma No serious neonatal injuriesNo serious neonatal injuries

Trial of ventouse in theatreTrial of ventouse in theatre

When fetal compromise is suspectedWhen fetal compromise is suspected An even better option is scalp samplingAn even better option is scalp sampling

When there is marked caput and When there is marked caput and mouldingmoulding

When you are not absolutely certain When you are not absolutely certain of the positionof the position– There is a role for intrapartum ultrasoundThere is a role for intrapartum ultrasound

When there is 2/5When there is 2/5thth head or more head or more palpable above the brimpalpable above the brim

Advances in Caesarean section:Advances in Caesarean section:

Spinal anaesthesiaSpinal anaesthesia Joel Cohen-type incision*Joel Cohen-type incision* Cord traction for the placenta*Cord traction for the placenta* Peritoneum not sutured*Peritoneum not sutured* Suture fat if >2cm but do not drain*Suture fat if >2cm but do not drain* Prophylactic antibiotics*Prophylactic antibiotics* Early oral fluids and ambulationEarly oral fluids and ambulation Rectal NSAID for analgesiaRectal NSAID for analgesia

*Confirmed by RCT*Confirmed by RCT

So who needs a Caesarean section?So who needs a Caesarean section?

I really don’t knowI really don’t know But many of my obstetric But many of my obstetric

colleagues seem to knowcolleagues seem to know So 50 – 70% of Caesareans are So 50 – 70% of Caesareans are

now elective proceduresnow elective procedures And we should be aiming for And we should be aiming for

100% elective CS100% elective CS Because non elective CS is the Because non elective CS is the

worst of the 3 optionsworst of the 3 options

Absolute indications for Caesarean:Absolute indications for Caesarean:

Two or more previous CSTwo or more previous CS Transverse lieTransverse lie Repeat APH unless placenta previa Repeat APH unless placenta previa

can be absolutely excludedcan be absolutely excluded Known contracted pelvisKnown contracted pelvis Complex twin presentations e.g. Complex twin presentations e.g.

breech and transversebreech and transverse

(Source: Lawson, Harrison & Bergstrom)(Source: Lawson, Harrison & Bergstrom)

Vaginal Birth after CaesareanVaginal Birth after Caesarean Maternal Risk of deathMaternal Risk of death

2.8 per 10,000 with trial of scar2.8 per 10,000 with trial of scar 2.4 per 10,000 for elective CS 2.4 per 10,000 for elective CS No maternal death ever attributed to scar ruptureNo maternal death ever attributed to scar rupture

Scar ruptureScar rupture Much confusion in the literature over the definitionMuch confusion in the literature over the definition Rate of asymptomatic scar rupture the same Rate of asymptomatic scar rupture the same

whether VBAC or elect CSwhether VBAC or elect CS Overall rate approx. 0.5% or 1:200Overall rate approx. 0.5% or 1:200 Was 0.35% in the largest combined contemporary Was 0.35% in the largest combined contemporary

studystudy HysterectomyHysterectomy

Additional risk from trial of scar is 3.4 per 10,000Additional risk from trial of scar is 3.4 per 10,000 Requires 2941 elective CS to prevent one Requires 2941 elective CS to prevent one

hysterectomyhysterectomy

Vaginal Birth after CaesareanVaginal Birth after Caesarean Smith et al from Cambridge UK in JAMA 2002:Smith et al from Cambridge UK in JAMA 2002:

Reviewed 313, 238 singleton births, 37 - 43w, cephalic Reviewed 313, 238 singleton births, 37 - 43w, cephalic presentation in the Scottish Morbidity Register 1992 -presentation in the Scottish Morbidity Register 1992 -1997 excluding congenital malformations1997 excluding congenital malformations

Rate of perinatal death 11X higher with VBAC vs Rate of perinatal death 11X higher with VBAC vs Elect CSElect CS

This is 2X higher than for multiparas having a This is 2X higher than for multiparas having a vaginal birthvaginal birth

BUTBUT

This is equivalent to Primips having their first This is equivalent to Primips having their first birthbirth

Absolute risk is only 4.5 per 10,000 birthsAbsolute risk is only 4.5 per 10,000 births Confidence limits were wideConfidence limits were wide All emergency CS were classified as attempted All emergency CS were classified as attempted

VBACVBAC

Vaginal Birth after CaesareanVaginal Birth after Caesarean Guise et al from Portland Oregan in BMJ July 2004:Guise et al from Portland Oregan in BMJ July 2004:

Reviewed 568 publications on VBAC vs elective CS but Reviewed 568 publications on VBAC vs elective CS but found only 71 had useful datafound only 71 had useful data

Concluded that the additional risk of Concluded that the additional risk of perinatal death from attempted VBAC was perinatal death from attempted VBAC was 1.4 per 10,000 (95 percent confidence limits 1.4 per 10,000 (95 percent confidence limits 0 - 9.8)0 - 9.8)

In only 5% of uterine ruptures did the baby In only 5% of uterine ruptures did the baby diedie

ANDAND

This means that one has to perform 7142 This means that one has to perform 7142 elective CS to prevent one baby deathelective CS to prevent one baby death

Breech PresentationBreech Presentation (Cochrane April 2003)(Cochrane April 2003)

Three trials, 2396 patientsThree trials, 2396 patients 45% of those attempting 45% of those attempting

vaginal delivery had CSvaginal delivery had CS Risk of perinatal death was Risk of perinatal death was

lower with elective CSlower with elective CS RR 0.33, CI 0.19 – 0.56RR 0.33, CI 0.19 – 0.56

Rate of maternal morbidity was Rate of maternal morbidity was increased by CSincreased by CS

RR 1.29, CI 1.03 – 1.61RR 1.29, CI 1.03 – 1.61

Breech PresentationBreech Presentation

However…However… 97% of babies born by the breech 97% of babies born by the breech

are fineare fine And the trial differences had And the trial differences had

disappeared after 2 years follow updisappeared after 2 years follow up And the trial data cannot be And the trial data cannot be

generalised to settings where CS is generalised to settings where CS is not readily availablenot readily available

Provided that breech delivery skills Provided that breech delivery skills are maintainedare maintained

Selection of patients for vaginal breech Selection of patients for vaginal breech birth:birth:

Singleton, at termSingleton, at term Breech with extended legsBreech with extended legs EFW <3600gEFW <3600g Adequate pelvisAdequate pelvis Hyper extended head excludedHyper extended head excluded Informed and co operative patientInformed and co operative patient

NB A Role for External Cephalic NB A Role for External Cephalic VersionVersion

Risks of Caesarean Risks of Caesarean DeliveryDelivery

Difficult to quantify because:Difficult to quantify because: Most studies do not distinguish between Most studies do not distinguish between

elective and emergency operationselective and emergency operations The reason for the CS needs to be consideredThe reason for the CS needs to be considered Some events are rareSome events are rare

The question will only be resolved by:The question will only be resolved by: A randomised trialA randomised trial With long term follow upWith long term follow up

More likely with Caesarean birth:More likely with Caesarean birth:

Hospital stay 2-foldHospital stay 2-fold Intensive care 9-foldIntensive care 9-fold Maternal death 2-10 foldMaternal death 2-10 fold Bladder or ureter damage 30-fold Bladder or ureter damage 30-fold Hysterectomy 40-foldHysterectomy 40-fold Thromboembolism 4 – 16 foldThromboembolism 4 – 16 fold Stillbirth in next pregnancy 2-foldStillbirth in next pregnancy 2-fold Placenta previa in next pregnancy 2-foldPlacenta previa in next pregnancy 2-fold Placenta accreta in future pregnanciesPlacenta accreta in future pregnancies

Same rate for vaginal and CS Birth:Same rate for vaginal and CS Birth:

Postpartum haemorrhagePostpartum haemorrhage

EndometritisEndometritis

Genital tract injuryGenital tract injury

Faecal incontinenceFaecal incontinence

Postnatal depressionPostnatal depression

Back painBack pain

DyspareuniaDyspareunia

More Likely with Vaginal Birth:More Likely with Vaginal Birth:

Perineal pain 2.5-foldPerineal pain 2.5-fold

Urinary incontinence 1.6-foldUrinary incontinence 1.6-fold

Uterovaginal prolapse 2-foldUterovaginal prolapse 2-fold

More likely with More likely with Caesarean birthCaesarean birth

No Difference No Difference whether CS or whether CS or

VaginalVaginalMore likely with More likely with

Vaginal BirthVaginal BirthHospital stay 2-foldHospital stay 2-fold Postpartum Postpartum

haemorrhagehaemorrhagePerineal pain 2.5-foldPerineal pain 2.5-fold

Intensive care 9-foldIntensive care 9-fold

EndometritisEndometritis Urinary incontinence Urinary incontinence 1.6-fold1.6-fold

Death 2-10 foldDeath 2-10 fold Genital tract injuryGenital tract injury Uterovaginal Uterovaginal prolapse 2-foldprolapse 2-fold

Bladder or Ureter Bladder or Ureter damage 30-fold damage 30-fold

Faecal incontinenceFaecal incontinence

Hysterectomy 40-foldHysterectomy 40-fold

Postnatal depressionPostnatal depression

Thromboembolism 4 – Thromboembolism 4 – 16 fold16 fold

Back painBack pain

Placenta previa in Placenta previa in next pregnancy 2-foldnext pregnancy 2-fold

DyspareuniaDyspareunia

Stillbirth in next Stillbirth in next pregnancy 2-foldpregnancy 2-fold

Placenta accretaPlacenta accreta Source: UK Nice Source: UK Nice GuidelinesGuidelines

Caesarean Sections are Popular because:Caesarean Sections are Popular because:

Caesarean Section is ConvenientCaesarean Section is Convenient

Caesarean Section is SimpleCaesarean Section is Simple

Caesarean Section is SafeCaesarean Section is Safe

Caesarean Section is better for babiesCaesarean Section is better for babies

When you have done a Caesarean you When you have done a Caesarean you have done everything possible – the have done everything possible – the medicolegal imperativemedicolegal imperative

Caesarean Sections are Popular because:Caesarean Sections are Popular because:

Vaginal Birth is PainfulVaginal Birth is Painful

Vaginal Birth is Unpredictable - If there Vaginal Birth is Unpredictable - If there is a 1:3 or even a 1:5 chance of is a 1:3 or even a 1:5 chance of requiring a CS why not just do one?requiring a CS why not just do one?

““Vaginal Birth Ruins your Sex Life”Vaginal Birth Ruins your Sex Life”

““Vaginal Birth Destroys the Pelvic Floor”Vaginal Birth Destroys the Pelvic Floor”

Caesarean Sections are Popular because:Caesarean Sections are Popular because:

““Once a Caesarean always a Once a Caesarean always a CaesareanCaesarean””

The Term Breech TrialThe Term Breech Trial

Loss of Obstetric SkillsLoss of Obstetric Skills

Pressures on Medical ResourcesPressures on Medical Resources

More Caesarean Sections occur when:More Caesarean Sections occur when:

Fetal distress is diagnosed by CTGFetal distress is diagnosed by CTG There is concern about transmission of There is concern about transmission of

an infection e.g. Herpes, Hep C, HIVan infection e.g. Herpes, Hep C, HIV There are medical problems and non There are medical problems and non

obstetricians are involved e.g. obstetricians are involved e.g. diabetes, back pain, epilepsydiabetes, back pain, epilepsy

PPatients are privately insuredatients are privately insured GPs and midwives compete with GPs and midwives compete with

specialistsspecialists

Caesarean Sections are Popular because:Caesarean Sections are Popular because:

The Power of ChoiceThe Power of Choice

FathersFathers have influence have influence

It It is Fashionableis Fashionable

Reduced Family SizeReduced Family Size

Caesarean Sections are increasing because:Caesarean Sections are increasing because:

TheThere is anre is an oobesity besity eepidemicpidemic

Maternal Maternal aagege is increasing is increasing

Epidurals sometimes failEpidurals sometimes fail

Induction of labour sometimes failsInduction of labour sometimes fails

An epidemic of sexual abuse?An epidemic of sexual abuse?

Caesarean Sections are increasing because:Caesarean Sections are increasing because:

““My mother and my sisters all My mother and my sisters all had Caesareans”had Caesareans”

““This is an IVF baby”This is an IVF baby”

Evolution of the species?Evolution of the species?

Any Questions or Any Questions or Comments?Comments?

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