Stages of Labour

Define the first stage of labour

• Onset of regular, painful contractions of 3-4: 10.

• The cervix (if examined by midwife or other authorised clinician ) would be 4cm dilated and ends when 10cm (full dilatation) is reached.

• In the primip lasts 10-12 hrs, in multip 6-10 hrs however this is individual and different for every woman.

Identifying the first stage of labour

• There will be 3-4 contractions in 10 minutes.

• No pressure will be felt in the rectum.

• The woman will be able to rest and speak between contractions.

Management of the first stage of labour

• Provide support and reassurance

• Provide analgesia

• Observe and monitor contractions

• Monitor any vaginal loss

• Record all findings

Define the second stage of labour

• From full dilatation of the cervix until the birth of the baby

• The woman will have strong urges to push that she will not be able to stop

Identifying the second stage of labour

• The woman will have pressure in the rectum, with strong urges to push

• The presenting part will be visible

• There are also several features that may or may not present (time dependent!) these are:

• vomiting,

• heavy blood stained show,

• bulging of the vaginal entrance and anus,

• rupture of membranes

• the purple line (see above) may also be visible reaching the natal cleft indicating full dilitation

• women at this point of transition often become very distressed and will become uncooperative

Management of the second stage of labour

• Preparations made for the birth of the baby; heating on, close windows and warm the birth environment as much as possible

• Assist her into a position where she is comfortable. The ideal position for birth is squatting or all fours so she is off her back and not laying down. This allows the pelvis room to open up fully.

• Prepare all equipment (maternity pack, extra towels/sheets, neonatal resus equipment,)

• Maintain mother's dignity as much as possible keep her covered if there is no need for exposure, and ensure there is no one in the room who does not need to be there!! it does not take 5 clinicians to catch a baby, 2 is sufficient.

• Only encourage pushing when the presenting part is visible, this is to prevent the woman pushing prior to the full dilatation of the cervix. This is because certain malpresentations of the fetus can cause a premature urge to push

As the point of birth approaches you will see the presenting part appear and it may slip back and forward as the muscles stretch to accommodate the birth. Do not worry if the back and forth movements take some time this is perfectly normal!

As the crowning approaches this is when the widest part of the head is being born, as if the baby were wearing a crown. Encourage slow steady breaths or to breath or pant so the head births slowly. This helps to prevent the rapid birth of the head but also helps to prevent tearing to the perineum.

Following the birth of the head there is a generally a break in the contractions of around 60-90 seconds as the shoulders align internally. DO NOT pull on the baby's head or encourage pushing before she has a contraction.

With the next contraction the baby is born. If the mother is on all fours the baby should be dried and then passed through the mothers legs to prevent them becoming tangled in the cord. DO NOT Clamp the cord!!! Wait until it has stopped pulsating before it is clamped or cut. See below as to why.

• The baby should then be lifted up onto the mothers abdomen upon birth, dried fully and mother encouraged to have skin to skin contact. The benefits of skin to skin are:

• Thermoregulation for baby

• Regulation of baby’s HR, RR, BM

• Bonding with mum

• Assistance with increasing hormone levels

• Makes breastfeeding more likely

• Most babies, if left to nature will deliver themselves without any assistance

• Ensure the baby is dried thoroughly and kept warm

Being upright during labour and birth can increase the available space within your pelvis by 28-30% giving more room for baby

Define the third stage of labour

• From the birth of the baby to the expulsion of the placenta and membranes

Identifying the third stage of labour

• Once the baby is born the third stage starts, in the case of twins or higher order births the third stage does not commence until the birth of the last fetus is born. In the case of concealed pregnancies care must be taken in the administration of oxytocics (if used by (i.e) midwife/doctor) to prevent demise of unknown twins.

Management of the third stage of labour

Allow the cord to fully cease pulsating before it is clamped and cut. When the placenta separates there are several features you may see:

• the cord will lengthen at the vaginal entrance

• the uterus may rise up on abdominal palpation making it easier to palpate

• there will be a gush of blood which can be 100-200mls

• she may get an urge to push as the placenta descends into the lower segment of the uterus

Assist her into an upright position as gravity will assist with the delivery

• Do not pull on the cord in any way

• Encourage her to push with the contraction to assist with the delivery

• This can also be very painful so appropriate analgesia should be provided

• place the delivered placenta into a suitable bag, ensuring the woman’s name is on the bag

• note the time of the delivery and document all findings

The APGAR score is not calculated at birth – there is a reason you wait one minute. In the first 60 seconds of the baby’s life after birth the newborn circulation changes significantly. Blood flows into the right ventricle at a high rate as it had previously been moving across the atria through the foramen ovale as there had been a ‘bypass’ of the pulmonary system because the placenta had been providing the fetus with oxygen in utero. Now that the baby needs to breathe independently there is a moment during the birth where this adjustment takes place and you literally have to wait for the baby to ‘catch its breath’. This is not always a huge cry out after the birth and the onset of regular respirations needs to be monitored. It can be quite an anxious period, but remember that while the cord is still pulsating the baby is still receiving an oxygenated supply of blood from the placenta and its mother.

The test is repeated at 5 minutes of age. This is mainly a tool for the baby requiring resuscitation in order to show improvement; in the healthy baby the score may remain constant. A score of 7 or less at 1 minute shows a baby in need of resuscitation; a baby scoring more than 7 will not.

The term baby will have to remove approximately 100ml of fluid from the lungs and airway. This is done by a combination of the squeeze from the birth process and the initial cry made by the newborn.

The component parts of the APGAR test can be difficult to remember however, make sure they are all complete as you will not get a score if you are missing one element. If you find it hard to remember each of the component parts, you may find it easier to remember the mantra: colour, tone, breathing, heart rate. This gives all the elements needed to help work out the score, apart from the grimace which is the element that ambulance crews are most commonly unsure about. In most basic terms this refers to how the baby is responding to extra-uterine life – whether they are pulling away, sneezing or crying appropriately. If you are not in attendance for the birth then the APGAR score must not be filled in in retrospect, but it is always worth documenting a score on your arrival time if the baby is already born.

How to assess the newborn infant

• Remember that assessment of the baby forms part of the clinical assessment once it is born

• The baby will lose heat rapidly so keeping the baby covered as much as possible and dressing the baby once assessment is complete is recommended.

• If the baby is allowed to cool, the baby will metabolise its brown fat stores. If these are used the baby is at risk of hypoglycaemia. This makes the infant lethargic and will prevent the baby from feeding, which in turn will cause further hypoglycaemia.

• At birth the caucasian baby will often appear centrally pink with bluish extremities due to peripheral cyanosis, which may last for several hours following delivery

• If the birth has been very rapid this can lead to the baby having significant facial congestion and swollen eyes and lips. There can also be petechiae rash over the face due to the pressure in the rapid birth

• Documentation of all of the findings of the assessment must be recorded on the Patient Record.

Respiratory and heart rates

Respiratory and heart rates need to be taken with a stethoscope; normal values for a newborn are a heart rate of 110–160 bpm and a respiratory rate of 30–40 per minute. It is important that the rate and volume are checked with a stethoscope as this leaves no room for error. Checking the rate should ideally be done when the newborn is at rest and not crying.

The Resuscitation Council also recommends the use of an ECG to assess heart rate during the resuscitation of the newborn, as this will provide and accurate indication of heart rate.

Blood glucose

Newborns have a naturally low blood glucose level, and therefore do not routinely need a capillary blood glucose test. A newborn is born with essential supplies of glucose to provide them with a supply until breastfeeding is established, which is normally on day 3.

A newborn's blood glucose at the age of 1–2 hours will be just under 2 mmol/L.

The newborns that do need some form of resuscitation will require a BM test to rule out other potential causes of the requirement for resuscitation.

Resuscitation

Around 85% of babies born at term will spontaneously initiate breathing within 10 to 30 seconds of birth, with most babies pinking up and crying or establishing regular respirations within 90 seconds.

Another 10% of babies will respond through drying and stimulation with a further 3% responding to positive pressure ventilations; only 0.1% will require chest compressions.

In the event of resuscitation being required aeration of the lungs is key, as without this no further action can take place. The initial inflation breaths can and should be performed, if logistically possible, with the cord intact. This will allow for the oxygenated blood to feed the newborn while they are not breathing for themselves. The cord should only be cut once chest compressions are commenced (if logistically possible, of course).

Antepartum Haemorrhage (APH)

Describe APH

An APH is any frank blood loss from the genital tract, after 24 completed weeks of pregnancy, until the onset of labour. The APH occurs and complicates 2-5% of pregnancies, its often unpredictable and due to the nature of compensation in a pregnant patient deterioration is often rapid and unexpected. The common causes of minor APH (< 50mls that has settled) include cervical erosion, marginal placental bed bleeding or a blood stained show. Major APH (50-1000mls) are mainly due to placental abruption and placental praevia. Uterine rupture can also lead to major haemorrhage by either forces of labour or blunt trauma, RTC or assault. The blood loss from A PH can be either revealed or concealed. The revealed blood loss is more commonly due to the placental praevia due to the location of the placenta making an easy exit for blood loss. The concealed haemorrhage is normally due to that of trauma assault or any blunt force to uterus causing the placenta to shear off the uterine wall. Any blood loss over 30mls will be investigated in an attempt to determine its source.

Identify the main risk factors for APH

• Maternal age over 40

• Presence of complex medical problems

• Multigravida

• Previous Caesarian section

• Known placenta previa

• Use of crack cocaine

• Coagulopathies

• Previous history of APH

• Hypertension

• Polyhydramnios

Treatment and management of the APH

Rapid assessment of the patient is vital when dealing with a major APH. This is a time critical, life threatening emergency and rapid transport to an obstetric facility is vital.

Following an ABC approach as with a normal primary assessment, ensure the mother is always placed in a left lateral position in order to avoid further fetal compromise. If it's oxygen saturations fall remember to ensure oxygen therapy is used in order to prevent any further fetal compromise. Do not delay time on scene for cannulation. This should be done on route if bleeding is serious. Access with two large bore cannulas should be sought early as maternal shutdown often occurs quickly due to sudden onset of hypovolaemic shock. The use of intravenous fluid therapy should be used in order to maintain a systolic BP above 90mmHg by giving 250ml bolus doses of sodium chloride. But it's important to remember that pregnant patients may lose up to 50% of their circulating blood volume without a significant change in their observations. Careful assessment of fetal movements should be made in order to assess fetal viability however, it's important to remember to be tactful in this situation as further anxiety and alarm may cause exacerbation of the situation.

It is important to remember the patient's pain and titrate pain relief accordingly. That utilisation of morphine should be done with caution especially if the patient is hypotensive and at risk of respiratory depression.

A concise pre-alert to the receiving obstetric facility is important, including an estimation of blood loss is key as staff can gather the required assistance needed to deal with specific events.

Identifying the cord prolapse

A prolapsed cord is defined as the umbilical cord below the presenting part of the fetus in association with ruptured membranes. It is not always visible as a long loop of cord protruding from the vagina in cases where midwives are present the cord may have just been felt on the internal examination. The prolapsed cord is a time critical emergency and rapid extrication and transport is required. The umbilical cord is the babies only source of oxygen so by decreasing the amount of oxygen received by putting pressure on the cord puts the baby at increased risk of asphyxia and brain injury. It occurs in 0.1 - 0.6% of births with 0.4% in vertex presentation with 1% occurring in the breach presentation. Even when obstetric facilities are available the outcome from a cord prolapse is usually poor. Prognosis is even worse if this occurs outside a maternity hospital.

Identify the main risk factors for cord prolapse

• Breach presentation

• Unstable lie

• Oblique or transverse lie

• Polyhydramnios (excess amniotic fluid around the baby)

• External cephalic Version

• Previous cord prolapse

• Premature and prelabour rupture of membranes

• Second twin

• Low-birth-weight

• Prematurity

• Fatal abnormality

• Unengaged presenting part

• Low-lying placenta, abnormal placentation

• Longer umbilical cord

This is a time critical emergency it requires immediate intervention and rapid removal and transfer to consultant obstetric unit.

Using two fingers gently try to replace the cord back into the vagina. This should be attempted only ONCE as the cord should be handled minimally to prevent spasm.

If the loop of protruding cord is too long and not possible to replace into the vagina, a dry pad should be utilised to prevent further prolapse.

If the cord has been replaced, again a dry pad should be used then the mother need to position herself in the right lateral position with her hips raised as much as possible to relieve pressure on the cord.

The woman should be assisted to walk ideally to the ambulance stretcher as sitting on a chair may cause further pressure on the already compromised cord.

The administration of entonox may help to prevent the woman from pushing which would again increase the pressure on the cord.

Do not delay time on scene to cannulate.

Pre-alert the nearest obstetric facility and it's very important to state "visible cord prolapse".

Pre-eclampsia

Pre-eclampsia is defined as pregnancy induced hypertension occurring after 20 weeks of pregnancy, although commonly most onset is between 24 and 28 weeks. The underlying pathophysiology of pre-eclampsia is not fully understood although primarily a placental disorder it's associated with poor placental perfusion which often results in a fetus with growth restriction so defeatists will be smaller than expected because of the poor placental blood flow. The diagnosis of pre-eclampsia is not made prehospitally, it is carefully monitored in the antenatal period and may develop into severe pre-eclampsia or eclampsia with very little prior warning.

The complications of pre-eclampsia include;

• Intracranial haemorrhage(leading cause of death from severe pre-eclampsia in the UK)

• Placental abruption

• Eclampsia

• HELLP syndrome

• Disseminated intravascular coagulation

• Renal failure

• Pulmonary oedema

• Acute respiratory distress syndrome

The fetal complications include;

• Fetal growth restriction

• Oligohydramnios (little of no fluid around the baby)

• Hypoxia from placental insufficiency

• Placental abruption

• Premature delivery

The symptoms of severe pre-eclampsia i.e. Significantly raised BP 160/110 mmHg with proteinurea, will often occur with the following symptoms;

• Severe frontal headache

• Visual disturbances

• Epigastric pain, often mistaken for heartburn

• Right-sided upper abdominal pain- due to stretching of the liver capsule

• Muscle twitching or tremor

• Nausea/ vomiting

• Confusion

• Rapidly progressive pitting oedema

Eclampsia

Eclampsia is defined as one or more convulsions in association with pre-eclampsia. Most women in the UK who have had an eclamptic seizure will not have established hypertension and proteinuria prior to their first eclamptic seizure. Many Women will have existing pre-eclampsia but as already stated many cases will present acutely without prior warning. 44% of seizures will occur postpartum with 38% antenatally and 18% in the intrapartum period. The recurrence rate of seizures is 5 to 30% even with treatment. Eclampsia occurrence is approximately 2.7:10,000 deliveries and usually beyond 24 weeks. It is one of the most dangerous complications of pregnancy with a significant mortality rate of 2% in the UK. Convulsions are usually self-limiting, resolve within 90 seconds and present as a grand mal type seizure identical to that of an epileptic convulsion. The hypoxia caused during a tonic clonic convulsion may lead to significant fetal compromise and even death.

This video is great to explain the pathology behind pregnancy related blood pressure problems.

Identify the main risk factors for pre-eclampsia / eclampsia

Pre-eclampsia

• Primiparity or first child with a new partner

• Previous pre-eclampsia

• Essential hypertension

• Diabetes

• Obesity

• Twins or higher order multiples

• Renal disease

• Maternal age over 40 years old

• Young maternal age less than 16 years old

• Pre-existing cardiovascular disease

Eclampsia

• Known pre-eclampsia

• Same as for pre-eclampsia

Treatment and management of pre-eclampsia / eclampsia

Pre-eclampsia

Although the diagnosis of pre-eclampsia will not be made prehospital - if a blood pressure is detected over 140/90mmHg, then discussion with the woman's booked obstetric unit should be sought. If the woman presents with a significantly raised BP (=/>160/110mmHg) and has symptoms as discussed earlier this should be treated as a time critical transfer. Oxygen should be administered as per guidelines. Cannulation should be performed en route with a large bore cannula but intravenous fluid must not be administered due to the risk of provoking pulmonary oedema. A pre-alert to the nearest obstetric unit should be placed giving symptoms and the woman's current BP.

Eclampsia

Once the primary survey has been completed assess for time critical features such as recurrent convulsions. As always correct A and B problems before the transport to a consultant led obstetric unit, obtain large bore cannulation and again do not administer fluids due to the risk of pulmonary oedema. The patient should be placed in a 30° left lateral tilt or if unconscious the recovery position. Oxygen should be administered as per guidelines with the target saturation of 94 to 98%.

If the patient convulses for longer than 2 to 3 minutes or has a second or subsequent convulsion administer diazepam IV or PR titrated against effect as per JRCALC dosage guidelines. In hospital IV magnesium sulphate will be given and it's better to avoid multiple drugs if at all possible. Only administer diazepam is the convulsions are prolonged or recurrent.

When are women most at risk of Eclamptic Seizures?

Identifying the shoulder dystocia

Shoulder dystocia occurs when, after the delivery of the fetal head, the shoulders fail to deliver and additional manoeuvres are required in order to facilitate the birth. The baby fails to be born due to the impaction of the anterior shoulder on the maternal symphysis pubis. Prediction of shoulder dystocia occurrence is poor however there are certain risk factors that may increase the risk of a shoulder dystocia and these will be discussed in the next section. The incidence of shoulder dystocia varies greatly with certain studies saying between 0.58 and 0.7% whereas others state between 0.15 and 2%.

The key factor in identifying shoulder dystocia is the failure of spontaneous delivery of the body however there are certain other features that also appear; the most common being the turtle neck sign where the fetus pulls its head backwards burrowing the chin into the perineum like a turtle pulling its head back into it's shell.

Discuss the factors increasing the chance of shoulder dystocia

As previously stated there are no hard and fast rules with regard to who will and who won't suffer a shoulder dystocia. There are however certain factors which make it more likely to happen:

• Previous shoulder dystocia (reported to be 10 times higher than in the general population)

• Macrosomic fetus

• Diabetes

• Obesity

• Prolonged pregnancy

• Advanced maternal age

• Male fetus

• Excessive weight gain

• Previous large baby

• Prolonged Second stage

Treatment and management of shoulder dystocia

First and foremost it is important to remember in this situation to keep calm. If you are panicking, the adrenaline is more likely to cause you to damage the fetus.

• Do not cut the umbilical cord before the delivery is completed

• Do not put pressure on the uterine fundus as this will just cause further impaction on the shoulder

• Do not pull on the baby's head, over extension by excessive traction can cause a brachial plexus injury

1. Lay the mother flat with one pillow under her head bringing her knees up towards her chest causing the natural action of abduction around the abdomen into the McRoberts position.

2. For 30 seconds attempt to deliver the baby's body with axial traction. This must be timed by a colleague and must take 30 seconds.

3. If the baby has failed to deliver then suprapubic pressure should next be added with the mother remaining in McRoberts. To perform suprapubic pressure firstly identify the fetal back and ask your assistant to apply steady constant pressure. Use the CPR hand grip, two fingers above the symphysis pubis in the direction of the fetal face. The concept is to reduce the shoulder diameter in order for the anterior shoulder to be delivered under the symphysis. This again should be used in conjunction with axial traction to attempt to deliver the baby for 30 seconds.

4. If after 30 seconds using constant pressure, this has not facilitated birth of the baby then a further 30 seconds should be attempted by applying intermittent pressure. The assistant now uses a gentle rocking motion backwards and forwards in order to apply the pressure.

5. The mother should be encouraged to empty her bladder if possible.

6. If after 30 seconds of using intermittent pressure the shoulders have still not delivered the mother should be assisted to turn over in to the all fours position.

7. Position the mother on her hands and knees with her hips well flexed and bottom elevated with her head as low as possible. Now for the last 30 seconds apply traction to the babies head in order to try and deliver the posterior shoulder from the sacral hollow first.

8. If after 30 seconds the shoulders still fail to deliver, undertake a time critical transfer to the nearest consultant led obstetric unit.

9. Do not await the arrival of the midwife.

10. A pre-alert should be performed including an estimated time of how long the head has been born for.

The mother will not be able to sit on a carry chair if she has to be extricated from the property with the baby still in situ. It may be necessary for her to be helped walk a short distance and removed from the scene using the stretcher. Remember that this movement may facilitate and precipitate the birth therefore it's important to remember not to move your hands too far away from babies head. Once on the stretcher place her in the right lateral position with padding under the hips to raise the pelvis.

The breech presentation is where the presenting part of the fetus is the feet or buttocks. The incidence of breech presentation in the UK is 3 to 4%, although it is much higher early in pregnancy at 28 weeks gestation, 20% of babies are in the breach presentation.

The breech baby will labour the same as a head down presentation, however on inspection at the introitus the following may be visible:

• The buttocks

• Feet or souls of the feet

• Swollen or bruised genitalia

• Meconium

Discuss the factors increasing the chance of breech birth

As with all of areas of obstetrics there are no hard and fast rules however, there are certain factors that predispose a breach presentation to be more common:

• Prematurity

• Previous breech delivery

• High parity

• Multiple pregnancy

• Polyhydramnios/ oligohydramnios

• Uterine abnormalities

• Pelvic tumour or fibroids

• Placenta praevia

• Hydrocephaly / anencephaly

• Fetal neuromuscular disorders

• Fetal Head and neck tumours

• Bicornuate uterus

Treatment and management of the breech birth

If a known breech presentation and delivery is not in progress but the patient is in labour A decision must be made by the clinician as to transfer the woman or if labour is too far advanced the baby should be born at the home.

The baby is in the breech presentation, with the bottom being born first. This occurs in appropriately 3 to 4% of babies at term although it is more common in the preterm birth (RCOG 2017). Labour with a baby in the breech position will progress in labour the same as a head down or cephalic presentation, however on inspection at the vaginal opening the following may be visible:

• The buttocks,

• Feet or souls of the feet,

• Swollen or bruised genitalia,

• Frank meconium, in a string like black toothpaste.

The recommended position to assist with a breech birth is in the all fours position. This position allows gravity to play a really important role and allows the clinician to remain hands off as long as the progress is normal. If the mother declines to move into all fours, then position the woman on the edge of a chair or sofa or bed, to insure that the baby has sufficient space to be able to hang, and allow gravity to perform most of the birth.

The baby in the breech presentation has to have enough room to allow gravity to assist with the birth. There needs to be minimal handling of the baby as it is birthing, to prevent stimulation of the baby, however if there is slow or no progress do not be afraid to touch the baby to assist in the birth if there is a need. Gravity assists in making sure that the baby's head descends into the pelvis in the correct diameters. If there is pulling on the body this can cause extension of the head and if there is holding of the body this can prevent the descending altogether.

Once the presenting part is visible (the bottom) it will advance and withdraw in a similar way to a head. When the widest part of the bottom is born, known as the “rumping”, like crowning as the head is born just the opposite way!

Once the rumping has occurred the bottom will twist and the legs should now be directly facing you. This is where you need to remember the mantra ‘baby’s tum to mums bum or baby’s bum to mum’s tum’ this will help you to remember the way the baby should be positioned they should always be looking at one another.

Once the baby is born up to the umbilicus then a timer should be started. The baby should be born within 3-5 minutes of the umbilicus becoming visible. So these births are a lot quicker than a head down birth.

Do not touch the baby at this point nor should you pull or touch the cord for any reason. Most definitely do not cut or clamp the umbilical cord until the head is born, even if you think it looks tight in any way.

If the baby is in the frank position then the legs should birth within 30 seconds of each other. Encourage the mother to bear down and push with her contractions and don’t touch the baby.

There are several points you can look for that will give you an indication as to the condition of the baby at this point:

• The baby will have good tone

• The baby will be a good colour ie purple / blue

• The cord will be full

• The valley of the cord is visible (the crease that runs up the chest wall will be like a valley)

• The baby will do the characteristic “tummy crunches” movement that is normal to encourage the birth of the arms and head.

Do not interfere with the baby during the crunches. These are the natural movements that the baby will make in order to get them into the position needed to get the arms and head born. Don’t worry if the baby doesn’t crunch but this will lead to a slower decent and the baby that will more likely to need resuscitation.

Do not pull on the infants trunk or hold on to them in an attempt to expedite the birth as this may cause the baby to raise its arms in utero causing nuchal arms (arms which are raised over the head).

With the mother in the upright position with effective contraction then the arms should birth spontaneously following the baby performing the abdominal crunches. The arms will normally follow each other together in a prayer position with the hands together. Once the arms are free then again leave the baby and do not interfere with the natural physiology.

This is often the most unnerving time and the point at which most clinicians want to take hold and lift the baby upward as they fear it will damage the neck. This is the worst thing you can do right now!! By holding the baby at this point the head will not engage in the pelvis and it may stop the baby from being born at all.

Once you see the chin the head is almost there, the head has to contend with the curve of the pelvis the same way as the cephalic birth, just the opposite way round!!

So the first time that you have to touch this baby is as the head emerges and you are there to catch the baby as the head is freed from the birth canal.

If there is slow decent of the baby then there are a few key tips recommended by the breech birth network.

Encourage movement: get the mother to rock her hips side to side to shake the baby downward.

Get the mother to adopt the “running start” position like a runner in the blocks of a race with one knee lifted, this will open the outlet of the pelvis

Postpartum Haemorrhage

Definition of Postpartum Haemorrhage (PPH)...

PPH is blood loss over 500 mls within the first 24 hours post delivery. In the UK 18% of births will suffer a PPH and a major PPH (over 1000 ml of blood loss) complicates 1.3% of deliveries.

Blood loss is notoriously difficult to estimate especially at delivery as there is often contamination from amniotic fluid and urine. It is often better to overestimate the blood loss rather than underestimate. Maternal physiological changes, including a significant increase in circulating blood volume means that during pregnancy and immediately after delivery women do not exhibit warning signs of imminent collapse so maternal observations may not change until 50% of their circulating volume is lost.

Identify the women at risk of a PPH

• Previous retained placenta

• Previous PPH

• Placenta praevia or back accreta

• APH especially from placental abruption

• Overdistention of the uterus (multiple pregnancy, polyhydramnios, macrosomic fetus)

• Pre-eclampsia

• BMI over 35

• Advanced maternal age

• Existing uterine abnormalities i.e. Fibroids

• Low maternal haemoglobin level below 9 g/dl (less able to tolerate haemorrhage)

• Grand multiparity

• Prolonged labour

• Precipitate labour

• Previous Caesarean section

• Placental abruption

• Pyrexia in labour

HOWEVER, most cases of PPH have no identifiable risk factors!

Treatment and management of the PPH

Full ABC assessment should be carried out as would normally.

Consider the causes for the PPH the most common being uterine atony. Feel for the uterine fundus, this is performed by placing the left-hand just about at the umbilicus then moving behind and downwards towards the symphysis. The contracted uterus should feel hard and firm and sit just below the umbilicus, however if the uterus feels soft and boggy the uterus is atonic and will bleed.

If the placenta has been expelled then the process of fundal massage can take place while your crew mate gathers the treatment drugs if available. This would be syntometrine or misoprostal. Before the administration of either then the woman’s BP must be taken as syntometrine is contraindicated in women with a BP over 140/90.

If the placenta has not been expelled then fundal massage must not take place as this can cause the placenta to break up.

Discuss the physiological changes of pregnancy

Airway

Although the airway itself does not change anatomically physiological changes in later pregnancy causes increasing levels of fatty deposits around the neck causing it to appear short and obese. The pregnant woman is likely to have engorged breasts particularly in late pregnancy causing pressure on the rib cage and increased oedema to the neck. Pregnant patients tend to be young and therefore have full dentition.

Breathing

By 12 weeks of pregnancy tidal volume has increased by 20% and this increases further to 40% by 40 weeks. Because the total lung capacity is unchanged this increase in tidal volume is at the expense of a proportionate decrease in inspiratory and expiratory reserve, and residual capacity. Therefore, the patient will have a reduced ability to compensate for any increase in oxygen demand due to illness or injury. The shape of the rib cage also changes causing a splaying of the rib cage at its base in order to accommodate the gravid uterus. This reduces the costal exertion and so the diaphragm plays an increasingly significant role in supporting respiration as the pregnancy progresses.

Circulation

By the third trimester of pregnancy blood volume has increased by 50%. Red blood cell numbers also increase but much less than the plasma volume increase causing a relative haemodilution and anaemia may result. By 20 weeks cardiac output rises by approximately 40% due to an increase in stroke volume which causes increase in the pulse rate to approximately 85 to 100 BPM by the end of the third trimester. However the workload of the heart is not increased due to the reduction of the blood viscosity due to the haemodilution.

Gastrointestinal

Due to the increased level of progesterone produced in pregnancy the gastro-oesophageal sphincter is relaxed. An increased intragastric pressure and delayed gastric emptying time due to the upward pressure from the gravid uterus all cause a significant risk of regurgitation and aspiration known as Mendelssohn's syndrome due to the combination of all of these factors.

Other

Another effect of progesterone is the relaxation of smooth-muscle tissue of the veins causing varicose veins to appear in the legs. The weight of the gravity uterus can compress the inferior vena cava causing reduced Venus return and can result in supine hypotension due to aortocaval compression. Therefore pregnant patients should never be laid flat on their back always with a pillow underneath the right buttock or tilted in a 15 to 30° tilt.

Women at risk of a cardiac event / arrest

Cardiac disease is generally described as congenital or acquired. Due too many advances in medicine and medication many women with congenital heart conditions are living to childbearing age, conceiving and giving birth. Pregnant women with any pre-existing cardiac disease may suffer an exacerbation of symptoms as a result of the pressures of pregnancy. From 2003 to 2005, 81 out of 432 maternal deaths (18.8%) were as a result of cardiac disease. This was the leading cause of death in the 2007 CEMACH report. Conditions which caused mortality include; MI, peripartum cardiomyopathy, sudden adults death syndrome, aortic dissection and congenital disease. It is important to be aware that with the increased level of asylum seekers are at an increased risk of cardiac disease due to the incidence of childhood rheumatic fever.

Risk factors include:

• Pre-existing cardiac disease

• Obesity

• Marfan's syndrome

• Smoking

• Family history

• Diabetes

• Hypertension

• Hypercholesterolaemia

• Maternal age over 35 years

• Socially disadvantaged/poorer communities

• Ethnic minorities

• Late bookers and women with minimal antenatal care

• Victims of domestic violence

• Substance misusers

Treatment and management of the pregnant arrested woman

Regardless of the stage of pregnancy the protocols for resuscitating the pregnant patient are identical to any other adult in cardiac arrest. During the third trimester additional consideration must be made to maximise the efficiency of resuscitation, in recognition that there are two patients involved. Although the fetus can tolerate quite significant levels of hypoxia, it is still 100% reliant on maternal oxygen delivery. This means that resuscitation of the mother should always be immediately initiated even if her injuries appear unsurvivable. Resuscitation should not be terminated in the prehospital setting to maximise both maternal and fetal survival.

At term the inferior vena cava is completely occluded in 90% of supine women, resulting in a decrease in cardiac stroke volume of up to 70%. This means that during cardiopulmonary resuscitation if the woman is flat/supine then compressions would be worthless. Therefore to ensure aortocaval compression is kept to a minimum whilst still maintaining good quality effective chest compressions the woman must be kept supine with the uterus manually displaced to the left by an assistant. Alternatively if the woman is on a spinal board that can be tilted, a 30° tilt to the left may be utilised but the emphasis is on performing good quality CPR.

As stated previously the cardiac arrest is managed as per standard ALS guidelines and assessment should include treatable causes of cardiac arrest.

Caution should be taken when using a BVM for ventilation due to the increased risk of regurgitation as discussed previously, early intubation is recommended to reduce the risk of gastric aspiration.

Pre-alert should be passed to the nearest emergency department stating maternal cardiac arrest and request for an obstetrician on standby to perform a resuscitative hysterotomy

Discuss resuscitative hysterotomy

Reuscative hysterotomy is a modified type of Caesarian used after 24 weeks in cases of maternal cardiac arrest when there has been no response to CPR. The primary aim of resuscitative hysterotomy is to facilitate maternal resuscitation and maximise the chance of maternal survival.

Although survival of the fetus is possible, the prime aim of this procedure would be considered for maternal survival reasons as there is little chance of maternal resuscitation being effective whilst the uterus is full.

There is little published evidence to base practice on, however, studies have would suggest that the old “4 minute rule” to extract the fetus by is a myth, with studies indicating good outcomes for both mother and fetus when the resuscitative hysterotomy was performed up to 32 minutes following the initial arrest.