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MRCOG PART 2 SBAs and EMQs

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Essay 342

Essay 342 Posted by PAUL A.

A healthy 20 year old woman with one previous vaginal delivery has presented in spontaneous labour at term.  She remains undelivered 2 hours after the diagnosis of full dilatation. (a) Discuss your assessment of this woman [7 marks]. (b) Discuss the indications for delivery by emergency caesarean section [5 marks]. (c) How will you minimise maternal morbidity from second stage caesarean section? [8 marks].

Posted by BHAWANA  P.

The assessment will include looking for growth of the baby in growth chart  to get an idea whether it is average/good size baby.Also it is worth noting weight of previous child(h/o macrosomia) and any difficult /instrumental delivery even though it was a vaginal delivery.

During intrapartum period it is essential to work out the problem with power, passenger or passage.It is important to note the progres of labour and whether or not the need of oxytocin in labour. If she is on oxytocin the duration and dose of oxytocin.The frequency, amplitude and strength of contractions will help to diagnose the cause for failure to progress in second stage. Also, if she in active/latent  phase of pushing will help us to decide whether or not she can be given more time. As she is multiparous, delivery should be acheived in 2hours of active pushing though she can be given 3 hours in total in second stage if vaginal delivery is acheivable.If contractions are going off or there is appearance of Bandl's ring,it can be a sign of obstruction.

 I will make sure that there are no signs of foetal distress on cardiotocograph.Also i will check pulse, blood pressure and hydration of mother to make sure there are no signs of maternal distress. I will ask about pain relief in labour as epidural associated with increased chance of instrumental deliveries and if I need to do instrumental delivery in room she has good anagesia on board.

I will do abdominal examination to clinically assess the size of baby and engagement of head.I will do vaginal examination to rule out any malposition and malpresentation,assess station and position of baby and notice any signs of obstruction( caput, moulding, vulval, vaginal oedema). I will also ensure that she has indwelling catheter and notice colour of urine. ( haematuria, concentrated urine can point towards obstruction). 

B)The indication in this case will be if she has been in active phase of second stage (pushing for >2 hours) and vaginal delivery is not imminent.To acheive vaginal delivery following requisites should be acheived after ruling out any malpresentation and malposition: head palpable <= 1/5 and on vaginal examination head is below spines.Maternal request because of exhaustion/distress should be considered as well. Even though vaginal delivery might be acheived by giving her more time if maternal request is done at this point, I will consider caeserean section after full discussion with the mother about second stage caeserean section.

C)Maternal morbidity from second stage caeserean section can be reduced by proper selection of cases.If expertise is available to do keilland's /rotational deliveries,carefully selected cases can be delivered vaginally avoiding caeserean section.Also if difficult vaginal delivery is anticipated they can done as trial of instrumental in theatre rather than just going for caeserean section.

If, howerver, decision is made for caeserean,it should be performed by senior obstetrician available.Also difficulty in section should be anticipated.Liasion with anaesthesist beforehand to give oxytocics as soon as the baby is delivered and start the oxytocin drip can minimize blood loss.Also cell salvage can be used if facilities are available.Multidisciplinary involvement of anaethesist, senior midwife, scrub midwife,obstetrician and neonatologist can acheive good outcome.Intraoperatively, high incision in uterus, adequate size of incision, reflection of bladder properly can avoid unnecessary extensions of tears in vagina and bladder injuries. If head is quite low, an assisstant can be asked to push the head vaginally to facilitate delivery of baby and avoid traumatic delivery to baby and tears in uterus, vagina.  

Also early identification of intraoperative difficulties and seekly timely help from senior obstetrician/consultants can reduce morbidity.Proper supervision and training of junior staff is important to reduce maternal morbidity and mortality.Last but not the least communication to the patient and mode of delivery for future reference( suitable for VBAC/ elective caserean) should be documented in the notes to avoid future morbidity.

 

Tnfay Posted by Tnfay C.
Delayed second stage is more likely to be associated with maternal exhaustion. She should be communicated in supporting manner. Enquiry is made about the degree of pain relief. Timing of onset of labour pains is asked. Information is obtained about rupture of membranes, if ruptured, time since ruptured is noted. She should be asked about the colour and smell of the liquor. Temperature, pulse and BP are recorded. Dry mucous membranes, tachycardia, and raised temperature suggests maternal dehydration. Partogram is reviewed to assess the progress of labour as slow progress indicates CPD and associated risk of shoulder dystocia. Maternal record is reviewed to note down BMi and any clinical or sonological suspicion of big baby. Abdomen is palpated to assess the nature of contractions, size of the baby and palpable fifths of fetal head. Palpable bladder is excluded. Fetal well being is assessed by recording CTG. Vaginal examination is undertaken to identify vulval edema, presence or absence of membranes, position and station of the head. Colour of the liquor is observed if membranes are absent. Caput and degree of moulding suggest CPD. B) Evidence of cephalopelvic disproportion suggested by suspcion of big baby with significant moulding and caput formation is an indication for caesarean delivery.Abnormal presentation such as brow or face in the mentoposterior position also indicate delivery by caesarean section. Other indication for caesarean section is fetal distress evidenced by abnormal CTG and meconium stained liqour. If the mother is exhausted, unwilling to continue to labour and vaginal delivery is not imminent caesarean delivery is advisable. C) injury to bladder is common at CS during second stage as it would have been pulled up and edematous due to prolonged labour. Preoperative emptying bladder by foley's catheter and opening the parietal peritoneum as high as possible can reduce the risk of bladder injury. Lower uterine segment Lacerations, extending to vagina is associated with significant maternal morbidity requiring extensive repair for longer duration at the time of surgery.Performing CS by experienced surgeon, opening the lower segment 1 cm below the peritoneal reflection can minimise morbidity associated with this complication. Another complication associated with maternal morbidity is PPH. Anticipation, active management of 3 rd stage, oxytocin infusion for uterine contraction and arrangement of blood transfusion can reduce the morbidity. Sepsis is another important entity which adds to maternal morbidity. Avoiding repeated vaginal examinations, following strict aseptic technique during surgery and prophylactic use of pre operative antibiotics reduces the morbidity. Venous thromboembolism is identified factor leading to maternal morbidity. Appropriate thromboprophylaxis with LMWH is advised to reduce the risk.  
H H Posted by H H.

Will look at her notes regarding her previous obstetric history,her previous pregnancy,was there gestational diabetes, weight of baby at delivery and was there shoulder dystocia and how was managed and if any complications(post partum hemorrhage or 3rd or 4th degree perineal tear that was repaired and now healthy)

Will see if she had scans in this pregnancy and if there is a fetal macrosomia on scan.

Will ask her how she is coaping with labour and if exhausted or need pain relief. Will examine her for pulse(tachycardia in dehydration),blood pressure,temperature and look for dry mucous membranes.Dehydration need correction. Will do abdominal examination for fundal hight and tenderness,and for fetal head engagement(no of fifths either head not palpable or only one fifth). Will look at the CTG for fetal heart abnormalities.

Will take verbal consent to perform an internal examination. Will look if there is meconium stained liquor(thin or thick). Will do vaginal examination for presentation,position any malposition(eg Brow or face mento post), station(feel the lowest bony part and its relation to ischial spine), moulding and caput which indicate cephalopelvic disproportion and dystocia.

Will see regarding what pain relief taken and medications given.

B) Indicated if there is cephalo pelvic disproportion as evidenced by non engaged head with excess caput and moulding. Also indicated if there is evidence of fetal compromise and it is dangerous to perform instrumental delivery ,specially if it needs rotational forceps.

In presence of Brow,it is safer to deliver by C/S and not to convert as in the old days.

Emergency C/S also indicated after failure of instrumental delivery, and also if mother wish not to have instrumental delivery and want a C/S.

 

C) Second stage c/s can be dangerous specially if head is impacted down in the pelvis and associated with more bleeding due to manipulations  that and the consultant is informed ,help will be needed to push the head up from vagina and to bring blood if needed. Unless there is extreme emergency, the WHO criteria for safe surgery are done(sign in,time out,sign out).Blood group and save done and will ask anesthetist to put wide bored IV lines.Will put indwelling urinary catheter. Will make an adequate skin incision for delivery of a big head. Will dissect blader down. Will make my uterine incision in lower segement high. Will deliver the head with  the help of someone pushing the head  from the vagina . Some obstetricians  use the forceps. After clamping the will give prophylactic antibiotics. Will secure hemostasis and if extension occur wil exteriorize the uterus to secure bleeding. Will not lose face in asking assistance from collegues as stated in the maternal mortality report saving mothers. Will see regarding post operative thromboprophylaxis for 7 days.  

hbadran Posted by HAnaa B.

My clinical assessment of this patient includes history and examination.

The past obstetric history in relation to her last delivery either difficult or instrumental delivery may give claw about the expected progress in this delivery.

Revising her antenatal chart   for: excessive weight gain during current pregnancy, diabetes or abnormal glucose tolerance with expecting big baby may give hint about her progress in labour.

Ultrasound report indicating foetal macrosomia more than 4.5kg in diabetic and 5 kg in non-diabetic although its reliability is not considered but it may appoint t the case of unsatisfactory progress in labour.

Revision of current delivery progress chart may appoint insufficient uterine contractions and the need for augmentation by oxytocin. Defect in the power

Examination includes abdominal: to assess the longitudinal lie and the possible clinical EFW possible big size baby (defect in the passenger) degree of engagement of the PP, And vaginal examination to assess the cervical dilation, position of the presenting part and the its station in relation to the ischeal spine, presence of moulding and or caput formation, indicating obstructed labour (defect in the passage).

Patient may be under epidural analgesia and 2hrs in the 2ndstage is still acceptable.

Active pushing may not be started yet and need to be encouraged.

Maternal satisfaction of her pain management should be assisted and her hydration status as prolonged second stage is accompanied by maternal excursion and dehydration.

 

B

Indication of Cs may be related to maternal or foetal cases

Maternal causes may include maternal disease like diabetes, specially uncontrolled accompanied by foetal macrosomia, sever preeclampsia not responding to the usual measures, eclampsia need urgent delivery.

Maternal pushing in 2ndstage for more than 2hrs in multiparas.

Signs of obstructed labour which may include slow progress, cervical oedema, moulding of the foetal bones with progressive caput formation.

Abnormalities in the CTG warrant urgent delivery, cord prolapse, failed instrumental delivery

Especially, if wrong assessment of the patient, before applying the instruments.

Active vaginal bleeding suspecting  apratio placentae.

 

C

Doing cs in the 2ndstage after 2hrs of maternal pushing and dehydration carries big risk to the mother and should be done by senior obstetrician for rapid interference , with good assistance which may need to push the head of the baby from down to help disengage the foetal head from the pelvis making its extraction easy.

Wound of the uterus should be C shaped not too much down in the pelvis and the extension should be towards the upper angels to decrease the risk of extension to the vagina and broad ligaments.

Blood should be available after taking consent for the rapid replacement in case of sever postpartum bleeding.

Tissues handling should be very genital due to sever tissues oedema and risk of bleeding and infection

Antibiotics should be given before the cut skin to decrease the risk of infection as well as anticoagulant in the form of LMWH should be given for all emergencies Cs to decrease the risk of VTE.

Maternal hydration and Good choice of the anathesia should be done by experienced anathesiologist.

Senior design for doing Cs in the 2ndstage of labour should be done by senior Ob. And rapid counselling of patients and families at easy words made their choice easier and gain their trust and decrease the number of complains.

Good documentation of the discussion and the advices should be done in details as soon as operation finished including the outcome, foetal Apgar and cord PH with maternal blood transfusion if ever.

answer by hbadran, sorry for the previous unadjusting copy Posted by HAnaa B.

My clinical assessment of this patient includes history and examination.
The past obstetric history in relation to her last delivery either difficult or instrumental delivery may give claw about the expected progress in this delivery.
Revising her antenatal chart   for: excessive weight gain during current pregnancy, diabetes or abnormal glucose tolerance with expecting big baby may give hint about her progress in labour.
Ultrasound report indicating foetal macrosomia more than 4.5kg in diabetic and 5 kg in non-diabetic although its reliability is not considered but it may appoint t the case of unsatisfactory progress in labour.
Revision of current delivery progress chart may appoint insufficient uterine contractions and the need for augmentation by oxytocin. Defect in the power
Examination includes abdominal: to assess the longitudinal lie and the possible clinical EFW possible big size baby (defect in the passenger) degree of engagement of the PP, And vaginal examination to assess the cervical dilation, position of the presenting part and the its station in relation to the ischeal spine, presence of moulding and or caput formation, indicating obstructed labour (defect in the passage).
Patient may be under epidural analgesia and 2hrs in the 2ndstage is still acceptable.
Active pushing may not be started yet and need to be encouraged.
Maternal satisfaction of her pain management should be assisted and her hydration status as prolonged second stage is accompanied by maternal excursion and dehydration.

B
Indication of Cs may be related to maternal or foetal cases
Maternal causes may include maternal disease like diabetes, specially uncontrolled accompanied by foetal macrosomia, sever preeclampsia not responding to the usual measures, eclampsia need urgent delivery.
Maternal pushing in 2ndstage for more than 2hrs in multiparas.
Signs of obstructed labour which may include slow progress, cervical oedema, moulding of the foetal bones with progressive caput formation.
Abnormalities in the CTG warrant urgent delivery, cord prolapse, failed instrumental delivery
Especially, if wrong assessment of the patient, before applying the instruments.
Active vaginal bleeding suspecting  apratio placentae.

C
Doing cs in the 2ndstage after 2hrs of maternal pushing and dehydration carries big risk to the mother and should be done by senior obstetrician for rapid interference , with good assistance which may need to push the head of the baby from down to help disengage the foetal head from the pelvis making its extraction easy.
Wound of the uterus should be C shaped not too much down in the pelvis and the extension should be towards the upper angels to decrease the risk of extension to the vagina and broad ligaments.
Blood should be available after taking consent for the rapid replacement in case of sever postpartum bleeding.
Tissues handling should be very genital due to sever tissues oedema and risk of bleeding and infection
Antibiotics should be given before the cut skin to decrease the risk of infection as well as anticoagulant in the form of LMWH should be given for all emergencies Cs to decrease the risk of VTE.
Maternal hydration and Good choice of the anathesia should be done by experienced anathesiologist.
Senior design for doing Cs in the 2ndstage of labour should be done by senior Ob. And rapid counselling of patients and families at easy words made their choice easier and gain their trust and decrease the number of complains.
Good documentation of the discussion and the advices should be done in details as soon as operation finished including the outcome, foetal Apgar and cord PH with maternal blood transfusion if ever 
 

Posted by SARO K.

 

Ans  to  essay 342:

(a)I will get her antenatal record to know about  birth weight of previous baby,any h/o instrumental delivery,any h/o perineal degree tear.I will go through her SFH chart and usg finding to know about the weight of the baby.I will see her partogram to get an idea about the total duration of labour ,time of rupture of membranes-color and amt of liquor,abt the contraction,drugs used,type of analgesia(epidural prolongs secong stage),need for oxytocics and time of active pushing. I will see her previous p/v finding to know abut station, position,caput ,moulding  .I will ask about the time of last passage of urine,amt and color(dehydration if little and conc yellow),hematuria (s/o obstructed labour)

I will assess her temp,pulse rate,hydration and signs of exhaustion&  distress.   I will examine her abdomen to know how many fifths palpable, strenghth ,freq of contraction,any palpable rings per abd.and palpable bladder even after emptying the bladder.Iwill see her CTG trace .I will do per vaginal examination to look for any vulval edema,hot vagina,station,position of fetal head,caput,moulding and finally color&amt of liquor(nil means dry labour ).

(b)I will decide to do CS if there are signs of CPD and obstructed labour,signs of fetal compromise as

 suggested by CTG, patient is not willing to wait and requesting CS,High station with high degree of caput and moulding which doesn t favour instrumental vaginal delivery,lack of skill and experience in rotational instrumental delivery,

© Anticipation,prevention , early diagnosis and  prompt treatment are the ways in prevention of maternal morbidity.Inform the theatre,anesthetist,nurse and consultant abt second stage cs.Anticipate genital tract injuries ,PPH ,infection,and thromboembolism .Alert blood bank  .CS should be done by the skilled person and the proper technique does matter.Plan proper size incision at reflection of peritoneum which will PREVENT further extension INTO THE ANGLES AND CERVIX.While delivering the deeply impacted head,second assistant can help in pushing from  below and gentle delivery will prevent extension of incision.As soon as baby is delivered,give antibiotics and oxytocics .After removal of placenta,explore for extension in to cervix,angle,bladder,posterior wall.Avoid blind clamping if increased bleeding.Suturing should be  patiently done  after ensuring no extension  .If  bleeding  persists despite suturing ,there  should not be delay in treatment of PPH  as per the protocol. Early decision about hysterectomy and interventional radiology  should be made .Postop –early mobilisation,continous bladder drainage  for 24 hrs, thromboprophylaxis as per protocol.Proper documentation  of the events in the notes and Discharge summary  will prevent morbidity in future pregnancy.                   

jsk.

ANSWER TO ESSAY 342 Posted by DHARSHITHA J.

(a)The assessment includes fetal, maternal  and the assessment of the progress of the labour including  reviewing the partogram and reviewing important information from her history.

Fetal assessment includes assessing the foetal heart rate using continuous CTG monitoring and foetal blood sampling appropriately to exclude any foetal distress.

Maternal assessment include, observation of vital signs- BP , pulse, temperature, respiratory rate,level of hydration, also urinalysis to exclude any ketone bodies.(To exclude maternal exhaustion) Also make sure she is emptying her bladder regularly and the bladder is not full.

Assessment of the progress- includes abdominal and pelvic examination to assess the descent of the presenting part and assessing the frequency and the duration of contractions every five minutes. Also use the partogram to evaluate the overall progress.

By abdominal examination it should be confirmed that head is not palpable,as it is a prerequirsite for an instrumental delivery.

By pelvic examination,confirm the presentation of the fetus and the fully dialatation and ascertain the position of the baby , exclude any malpresentation and malposition, also assess the descent of the presenting part,and exclude any signs of obstruction such as caput and moulding, swelling of the cervix.

Confirm whether she has good pain relief ( eg. epidural)-which can be helpful for an operative delivery.

Confirm whether the is actively pushing or having an urge to push-signs of active second stage.

Review mother,s ideas-eg. willingness for pain relief and assisted vaginal delivery/caesarian section appropriately.

Also inquire about other important aspects of the history(medical problems-PET, Diabetes, infection)

(b) When there is foetal distress(evidence of pathalogical CTG or abnormal FBS) and the high head, which is not feasible to instrumental delivery,(More than 1/5th of the head palpable abdominally or presenting part above the sacral spine vaginally), is an indication for CS(caesarian Section).

Also failed instrumental delivery(pop off of ventouse cuff twice, or failure to descent in ventouse or forceps), inexperienced  operator, or no facilities or instruments for assisted vaginal delivery or maternal decline of instrumental vaginal delivery or any contraindication for assisted vaginal delivery(risk of infection-primary HSV at term).

Certain malpresentation  malpositions such as persisting  brow, mento-posterio rface positions and compound presentation, which cannot be delivered vaginally.

Signs of maternal exhaustion,and diminished or absent contractions.(as good contractions are needed to perform successful assisted vaginal delivery)

(c)Steps can be categorised as preoperative, intra operative and postoperative.

Preoperative- This caesarian section should be performed by  an experienced senior obstetrician,and  theatre staff, anaesthetist paediatrician should be alerted regarding the risks.

Mother should be explained regarding possible risks(Bleeding, damage to internal organs, thromboembolism), during consenting.

Blood for grouping and save and for cross matching, anticipating the risk of major haemorrhage.Bladder catheterization to prevent inadverent  bladder injury. Propylactic antibiotics including metronidazole against  infections, including gram negatives.

Paediatrician to present at the time of delivery. Arrange an assistant to push the head from down to facilitate the delivery.

Intermittent pneumatic compression device in lower limbs during the surgery to prevent thromboembolism.

Intra operative measures- Appropriate wider incision in the skin for the adequate access, for manipulation during delivery and repair.

Identification of bladder, opening in to visceral peritoneum, pushing the bladder down, use Doyen,s retractor to keep the bladder away from the field-to avoid possible bladder injury.

Opening in to the uterine cavity in an upper level to avoid accidental opening in to vagina as cervix and vaginal walls may be flushed together, and difficult to differentiate in the 2nd stage.Use a "smiley" curved incision to enter in to the uterine cavity. Extend it upwards if needed . This prevents lateral extention of the incision during the delivery of the presenting part.

Pushing the presenting part from down below by an assistant to facilitate the delivery of the deeply engaged head.

At the time of the delivery, lift the head of the baby applying pressure using the palm of the hand on the head, carefully,avoiding sudden release of vaccuum  pressure. Also turning the baby,s head in to O-A position , before the delivery facilitate the easy delivery of the head.In addition forceps may be used to lift the deeply engaged head up.

Controlled cord traction to deliver placenta  and advise the anaesthetist to give oxytocics -syntocinon infusion/ergometrine depending on the situation.

Proper and careful examination to identify the angles of the incision and any extention /tears reaching broad ligaments or ureters. Identify the lower edge of the uterine incision precisely. Make sure no damage to the bladder.If suspected can use methylene blue instillation to exclude any involvement.

Careful examination of tissue layers for bleeding points and ligation and cauterization and achieving complete haemostasis helps to reduce the morbidity.Use of haemostatic agents, drains to confirm no bleeding also can be considered depending on the situation.

Subcutucular skin closure with absorbable  suture material shown to enhance the rapid healing and recommended.

Post op measures- Continuous bladder drainage till she is mobile will prevent bladder damage.

Assessment for thromboprpylaxis and commencement of LMWH, TED stockings and early mobilization to prevent thromboembolism.

Close observation of vital signs including BP, pulse, temperature,and urine out put and colour during early post-op. Routine examination of the wound site to exclude any signs of infection.

Counselling, debriefing and advise regarding possible mode of delivery in next pregnancy. Also incident reporting and risk management issues.

Posted by miss T.

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(a)

In multiparous women, second stage should not last more than 2 hours in total or 3 hours if regional analgesia is given.

At this point I need to review her history including age, documented BMI any antenatal suspicion of marcosomia as they all are associated with prolonged labour. Was her previous delivery operative as I will thing of relative CPD.

Has she received epidural analgesia now as it is associated with delay in the second stage of labour. I will review her partogram to see how the first stage has progressed, if it was a slow labour then malpositioning may be a possibility. Was the labour augmented? Was she examined by junior physician who may miss diagnose the findings? Has she been actively pushing all this time because maternal exhaustion itself is an indication of operative vaginal delivery.

Next I will review the CTG how is the fetal heart trace, reassuring or not because in later case delivery need to be expedited. Is uterine activity adequate (4 in 10 minutes lasting 45 seconds)? Dose of syntocinon need to be increased if there are insufficient contractions but NICE do not recommend staring oxytocin in second stage of labour.

With verbal consent of patient I will examine her. First abdomen for estimated fetal weight, engagement of the head and how much of it is palpable per abdomen, any distended bladder that may need to be evacuated? Pelvic assessment for confirmation of full dilatation, station and position pf presenting part, any presence of caput or moulding. These findings will be co-related to previous pelvic assessments as newly formed caput and moulding suggest element of obstruction. If position is direct OP then it is associated with long second stage.

(b)

Emergency cesarean delivery would be needed if there is fetal compromise on fetal heart trace and examination findings are not suitable for operative delivery, fetal head more than 1/5th palpable per abdomen, vertex station is above ischial spines, there is significant caput or moulding that may render application of vaccum technically difficult. The findings are suitable but there is lack of equipment or an experienced clinician to conduct operative vaginal delivery.

The operative vaginal delivery is carried out but the vaccum cup has slipped 3 times or 3 pulls has not caused any decent of fetal heart.

If mother has refused for operative vaginal delivery or has opted of emergency CS.

(c)

PreOP

Emergency cesarean should be conducted by senior obstetrician. Early resort to cesarean delivery by clinical judgement as initial trial of vaccum or forceps may bring head down and make abdominal delivery more difficult. Right indication of CS and avoid emergency CS if operative delivery can be conducted easily.

IntraOP

The bladder will be catheterized before starting CS to minimize risk of bladder injury. The bladder will be dissected down after opening abdominal wall. Uterus will be opened higher and baby delivered by gentling flexing the head and then bringing it toward uterine incision. Help form another staff can be taken who will push it vaginally. Left hand can be used to delivery baby’s head as it follow the curve of pelvis and is less likely to cause extension of uterine scar.

After delivery of baby antibiotic prophylaxis be given to mother, a second generation cephalosporin. Active third stage management by giving ueterotonics, syntocinon in drip and ergometrine 0.5mg IM if there is no contraindication as prolonged second stage is associated with risk or post partum hemorrhage secondary to atonic uterus. Ensure adequate hemostasis during cesarean.

Post OP

Give thromboprophylaxis and encourage early ambulation. Early patient feeding to avoid paralytic ileus. Chest physiotherapy or incentive spirometery to avoid chest infection secondary to collection of secretions. Adequate analgesia to reduce post OP pain.

Proper debriefing of patient regarding the need of emergency CS delivery.

essay 342 ss Posted by sofia  S.

 

Ans a: Review the records of patient about weight of previous  baby and h/o difficult  or instrumental delivery.  Her ultrasound to rule out possible anomaly like hydrocephalus and growth chart to know about possible macrosomia. Review her partogram for progress of labor, as a protracted progress may indicate cephalopelvic disproportion. Enquire about pain relief and urge to push.

Examination will include general condition , hydration  and vital parameters. Abdominal exam to confirm presentation,frequency and strength of contraction,  fifth of head palpable. Fetal heart rate for fetal wellbeing and start continous monitoring if not  on ctg. Pelvic exam after evacuation of bladder if full. Assess station, rotation  of presenting part, color of liqor  pelvic assessment for adequacy. Presence of caput ,moulding and dry vagina will indicate signs of obstruction.debrief the patient about her condition.

Ans  b: indications for cesarean section in second stage will be suspected cephalopelvic disproportion that would be evident from big size of baby and signs of obstruction like caput and molding. Second indication would be signs of fetal compromise and vaginal delivery not imminent i.e. head above ischial spine. Malpresentation like brow will require delivery by cesarean.  Failed  trial of instrumental delivery is an indication for cesarean section. Patient refusal for instrumental delivery is indication for cesarean section.

Ansc: many second stage cesareans can be avoided by opting for instrumental delivery when circumstances  are favorable. This requires training of the staff and assessment of competence in using  vaccum and forceps. Appropriate selection of cases. Involvement of senior obstetrician and conducting it as trial in theatre when difficult delivery anticipated .  catheterization of bladder prior to incision and opening peritoneum at highest point to avoid bladder trauma. Planning incision  with upward curve and away from cervix. Assistant to disimpact head vaginally if deeply impacted in pelvis. Early calling for senior assistance in case of complication like extension.antibiotic prophylaxis to reduce chances of sepsis. More risk of atony and PPH. Anticipation and vigorous management by oxytocis and  bimanual massage. Post partum thromboprohylaxis risk assessment and avoiding dehydration and immobility.debreifing patient about the circumstances  to reduce psychological  morbidity with such situations. Plans for follow up including  care plan for future pregnancy management should be provided.

essay 342 by N Posted by Sherif N.

1) proper re-assessment of the patient through adequate history taking, whether she has any medical trouble (diabetes, hypertension, cardiac problem, asthma, poiomyelitis), undergone any previous uterine or pelvic surgery

proper history of her previous vaginal delivery, hoe long did it  lasted, whether it was smooth normal, or instrumental, how about the weight of her previous baby by the time of delivery, if she had any post partum complications

general examination of the patient to detect sighns of dehydration, measure her pulse, BP, T, urine output

abdominal examination for the size of her abdomen, baby, detect the position and whether the head is engaged, any suprapubic fullness and evacuate the urinary bladder

vaginal examination for pelvimetry, confirm full cervical dilatation, condition of the membranes (if not ruptured till now, and the conditions are suitable for vaginal delivery, it should be ruptured), position of the presenting part, confirm it is cephalic, vertex and suitab;le for vaginal delivery, detect the presence of caput, sighns of dehydration of the vagina

examin her CTG,baseline of the fetal heart, normal or abnormal variability,  whether there is any type of deceleration,  acceleration.  detect the frequency and regularity of uterine contraction , if not regular or strong enough, consider augmentation of labour by giving oxytocin starting by 2miu/min and titrate regularly until get ting 3 contractions per 10minutes (if oxytocin isn't contraindicated and circumstances are favourable for vaginal delivery)

2)there are fetal and maternal indications for emergency cesarean section

fetal: occurance of fetal distress (and position isn't suitable for instrumental delivery)

abnormal CTG, and fetal pH<7.2

oversized abdomen, and large sized fetus

abnormal presentation or position, not suitable for vaginal delivery (eg, transverse lie, breech not suitable for vaginal delivery, brow presentation, face mentoposterior, persistent oblique occipitoposterior)

cord prolapse

maternal indications: contracted pelvis, with failed trial of vaginal delivery

dehydration and deteriorating maternal vital signs and conditions are not suitable for instrumental delivery

3)maternal morbidity that may occur includes: injury during the cesarean, postpartum haemorrhage, infection, DVT or PE

-cross match and save blood urgently as it may be required during the operation

-prophylactic antibiotic is required after cord clamping to prevent postpartum, infection

-insert Foley's catheter, and mobilisation of urinary bladder to prevent its injury

higher uterine incision, which should be c shaped or J shaped, to prevent extension of the incision to uterine angles and uterine arteries

-administer oxytocin 20units to ensure uterine contraction and don't close the abdomen except after full uterine contraction

-early mobilisation and gine LMWH fro 7days (if there is no other risk factors, other than emegency cesarean, otherwise, LMWH should be continued for 6weeks)

 

 

Essay 342 Posted by Gulshan K.

G.K

My plan to answer this question will be as follow:

a)   ASSESSMENT OF WOMEN

History

Previous delivery notes

Current pregnancy antenatal notes

EXAMINATION

Maternal wellbeing

Abdominal exam

Vaginal exam

CTG

b) INDICATION FOR DELIVERY BY C.S

Maternal wishes

Maternal condition

Fetal condition

c:  MINIMISE MATERNAL MORBIDITY BY

Proper procedure

Experienced person

Antibiotic

Thromboprophylaxis

Perioperative Care

 

My answer to this question will be:

 

a; First thing should be to see maternal condition and fetal condition and deal if any emergency. I will review her previous delivery notes for birth weight of first baby, mode of delivery whether spontaneous or operative vaginal delivery or any obstetrics complications such as shoulder dystosia, or perineal tear.

I will review her antenatal notes for fundal height measurements, growth scan or if third trimester growth scan done. Review her blood results especially Hb, glucose level. I will find women wishes for mode of delivery.

Examination includes maternal BP, Pulse, temp and hydration status. Abdominal examination for fetal size and head engagement. Frequency and strength of contractions. Evidence of macrosomic fetus or high head suggestive of obstructed labour. Vaginal examination to find cervical dilatation, to confirm absent membrane, fetal presentation, station of presentation, colour of liquor, and presence of caput and moulding. Exclude malpresentation like brow or face. Assess fetal wellbeing by fetal heart rate. Commence CTG if not started yet.

b; Indications for delivery by CS are maternal wishes and delay in second stage of labour with maternal exaution. Early CS prevents difficult CS later or difficult operative vaginal delivery. Evidence of obstructed labour due to cephalopelvic disproportion suggestive from abdominal and vaginal examination. Malpresentation like brow, face mainly mentoposterior. Fetal compromise from pathological CTG or meconium stained or blood stained liquor

c: Cesarean section in second stage of labour is associated with high maternal morbidity, fetal trauma caused by difficulty in delivering impacted fetal head. It can be extremely difficult. Appropriate selection of case. CS by experienced person or under continuous supervision of senior obstetrician. Proper pre operative assessment by checking Hb, prescribe prophylactic antibiotic one dose of cephalosporin or ampicillin. Assess for thromboembolic risk and offer TED OR prophylactic  LMWH. Insert in dwelling catheter. Apropriate anesthesia. Selection of appropriate abdominal incision and uterine incision. To avoid entering too low and inadvertently go into vagina identify uterovesical fold and then incision should be made 3cm below it. In case of impacted fetal head consider pushing the head from below in relaxed uterus. Good surgical technique with good haemostasis. Continue post operative monitoring until women become stable. Provide support to help breastfeeding. Provide analgesia. Monitor wound healing. Discuss reasons for CS and implications for future pregnancy.

  

essay 342 Posted by Yingjian C.

(a) There is a delay in the second stage of labour in this case. I would assess her by taking a history, focusing on her previous delivery. I would like to know if it was a normal vaginal delivery or operative delivery and if there were any birth complications such as shoulder dystocia, 3rdor 4thdegree perineal tears, as well as the birthweight of the previous baby. I would also like to ascertain if there are any anticipated problems in her current pregnancy such as possible coagulopathy in the fetus that would preclude any instrumental assisted vaginal delivery.

 

Next I would assess her progress in the first stage of labour, whether membranes were ruptured or it was augmented with oxytocin, and whether she has effective epidural analgesia. I would also find out the duration of time she has spent pushing, and if she is exhausted. Maternal wellbeing would be ensured by looking at her temperature, vital signs such as her blood pressure and heart rate. I would carry out an examination of her abdomen to palpate for the fetal head and to estimate the size of the fetus, as well as palpate the frequency of contractions. I would ensure that her bladder has been adequately drained. I would do a vaginal examination to confirm the presentation, station and position of the fetal head. I would like to ascertain fetal wellbeing by auscultation of the fetal heart, look out for any meconium staining in the liquor, and to review fetal scalp blood sampling results if any.

 

b) The indications for delivery by emergency caesarean section would be that of no progress in the second stage of labour in the presence of factors (such as fetal head more than 1/5thpalpable abdominally, station that is above +1, clinically inadequate pelvis, lack of expertise for operative vaginal delivery)  that would preclude a safe operative vaginal delivery, fetal distress, failed instrumental vaginal delivery or maternal informed choice of caesarean delivery over instrumental delivery in cases deemed suitable for operative vaginal delivery. Rarely, if there is cord presentation or mentoposterior face/ brow presentation, an emergency caesarean section would be indicated.

 

c) I would minimise maternal morbidity from Caesarean Section by ensuring that the risk of infection is minimised by administering a prophylactic dose of perioperative broad spectrum antibiotic and trying to avoid manual removal of the placenta. I would minimise her risk of bleeding surgically by trying to avoid the risk of lateral/ downward extension of the uterine wound by making a high transverse incision that is U shaped, using uterine relaxants or trying to disengage the fetal head vaginally prior to surgery in a case of a deeply engaged fetal head, sending blood for group and match, and to actively manage the 3rdstage of labour by giving intravenous oxytocin in a slow bolus and deliver the placenta by controlled cord traction. An infusion of oxytocin would be considered thereafter.

 

I would minimise risk of aspiration and pneumonia and the risks of intubation by advocating regional anaesthesia. Deep venous thrombosis risk would be minimized by doing a risk assessment for her and starting appropriate prophylactic measures like mechanical calf compressors or low molecular weight heparin at a suitable timing. Bladder injury would be minimised by a high transverse incision as well as ensuring that the bladder is drained with a urinary catheter prior to surgery. Lastly, I would ensure that a consultant obstetrician has been informed of the case as a second stage Caesarean section can be challenging so that he or she can avail himself/ herself if there is any difficulty encountered. 

answer to essay 342 Posted by swaleha S.

Assesment will include history and examination.Review of her antenatal card for record of previous delivery and for the baby weight.Her antenatal record  during this pregnancy,checking her BMI at booking,OGCT,and any recent fetal wight estmation.Examination ; General exam ,how the women apperas,is she distressed ,exhausted or tired.Has she recieved any analgesia(epiduarl).Check her vital signs.Abdominal exam,to asses the size of baby,frequency and  strength of contractions,presentation ,how much palpable abdominaly,or if the bladder is palpable.Vaginal exam ;empty bladder if palpable before ve,check urine for ketones.On ve asses for any malpresentation,malposition,station,caput,moulding and color of liqour.Fetal assessment through CTG.Check if the patient is on synto infusion,if she is ,for how many hours & how much units on flow now.Is epidural analgesia sited,if yes,when & how well it is working.When patient has taken her last meals(if planning for LSCS)

Indications for emergency LSCS would  be Abnormal CTG,Non-progress of labour in 2nd stage inspite of good uterine contractions,relative CPD as would be indicated by caput and high head,maternal exhaustion,meconium stained liq along with abnormal CTg and fetal malposition.

Senior obsterician ,should be present.Blood sample should be sent for group & cross match.Patient should be catheterized with Indwelling foleys  catheter .Prophylactic antiobiotics pre-operatively.Second stage LSCS are associated with bladder injuries,extension of uterine angles,extension to cervix and vagina,and PPH.During LSCS parietal peritoneum should be opened high up to prevent bladder injury,uterine insicion should not be very low,it should be J-shaped.Head should be pushed from down by assistant, if very low in vagina,to prevent extension of uterine angles.20 units IV synto infusion to prevent PPH.Post operatively  LMWH for thromboprophylaxis should be given.

nm Posted by Ali Naveed Haq H.

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Ali Naveed Haq Posted by Ali Naveed Haq H.

In the assesment  I will quickly go through the notes of this patient , her past history of labour , size of the previous baby and instrumental delivery. The general assesment including , epidural usage ,  maternal exhaustion, signs of distress, vital sign record, cardiotocographic trace, partogram will be reviewed to assess the overall condition of the patient and the fetus if there are signs of maternal and fetal distress the delivery will need to be expidated. I  will assess the fetal postion per abdominally and if the presenting part is still high that is 5/5th palpable or 4/5ths palpable the the delivery is highly unlikely. The number of contractions adequate conbtractions are 4-5 per 10 minutes of 40- 45 sec duration . Any thing less than this can be augmented with oxytocin infusion. Upon the vaginal examination i will look for the adequacy of the pelvis with respect to the clinical assesment of the baby size. , i will feel for the moulding , caput , and station of the fetal presenting part, if the station is low i.e 2+ and 1+ there is a high chance that the fetus may deliver. However if there is a malpositionj like brow or face  with chin posterior presentation then decision for emergency caesarean section can be taken .

b) In case of fetal distress with type II decelerations and high presenting part  delivery by caesarean section is warrented.

2. Signs of obstructed labour , malposition , malpresentation , cephalopelvic disproportion all should be noted. Brow presentation is an absolute indication for caesarean section. 

3 . If there is failure of instrumental delivery.  After three applications if there is failure than an emergency caesarean section should be performed.

 

c) Morbidity related to  second stage caesarean section is higher than elective and regular emergency caesarean sections.

the following measures will be undertaken to minimize the morbidity :

1. Informed consent to be understood and signed by the patient and partner. 

experienced obstetrician to perform the caesarean section.

2. Insertion of foleys catheter .

3. I/v antibiotics prophylactically  to minimize risks of infection before cord clamping.

4. Thromboembolism risks are highest following emergency caesarean sections. Ted stocking s and Low molecular weight heparin to be given to the patient 12 hours postoperatively.

5. Request for  urgent  x matching of  blood .

6.  openning perital peritoneum high up to avoid  bladder injury.

7. A second operator may be required to push the presenting part up .

8. Prevention of post partum heamorrhage,  by early resort to medical methods , if not effective than Surgical options like application of B Lynch / modified Blynch should be resorted to at an early stage.

9 Rarely internal ilac artery ligation or a hysterectomy may be required to stop heammorhage, for this a full postpartum heamorrhage drill should be undertaken. 

essay 342 Posted by vaneeza K.

A)Patient  should be asked about complications encountered during last delivery including prolonged second stage of labour,instrumental delivery and baby weight.antenatal notes of current pregnancy should be reviewed for any sonographic evidence of macrosomic baby.Progress of labour should be assessed by reviewing partogram,time and dose of syntocinon infusion and analgesia recieved.Patient will be assessed  clinically by checking vital signs and hydration status.Examine per abdominally  and assessed clinically size of fetus,proportion of palpable head,intensity,duration and interval between  uterine contractions and any tenderness.Foetal assessment should be done by reviewing CTG to exclude foetal disstress.On vaginal examination vulval oedema,vaginal bleeding,colour of liqour and urine should be observed.Vaginal hottness,cervical oedema and dilatation,position and station of presenting part along with caput and moulding should be assessed and relative CPD should be ruled out.

B).Foetal distress is one of commonest indication of delivery for emergency LSCS.Foetal malposition(brow,face,compond presentation and deep transverse arrest) and failed instrumental delivery is another indication for emergency C/S.Maternal exhaustion and wishes will also  end up in emergency LSCS.

C)Maternal morbidity for second stage C/S can be minimised if it is taken by senior obstetrician and senior anaesthetist with blood grouped and cross matched before.Bladder injury can be prevented  by catheterization prior to surgery  and mobilization of bladder during surgery.High opening of the parietal peritonium  will prevent vaginal and cervical laceration.PPH can be prevented by oxytocin infusion meticulous haemostasis can be secured.Prophylactic antibiotics should be gived to prevent post partum sepsis.LMWH for  7 days(provided no other risk factors) along with early mobilization and preventing dehydration will reduce risk of thromboembolism.

Posted by Bee Fong C.

 

A:

            Prolonged 2nd stage is associated with maternal and perinatal morbidity and mortality. This can commonly occur in nulliparous and occasionally in multiparous women.           

            The assessment of this patient will involve a review of her antenatal history.  Any concern antenatally including heavy vaginal bleeding or repeated reduced fetal movements are noted as it may indicate an already compromised fetus. Growth of the fetus  and liquor volume of the fetus if she had ultrasound scan antenatally is noted for the same reason as well as to rule out macrosomia.

            The gestation age of the fetus is noted as the baby may be postmature or premature before 37 weeks. Induction of labour is considered high risk. The colour of the liquor should be enquired as meconium stained liquor may suggest a compromised baby and will need delivering sooner and duration of rupture of membrane as may suggest impending infection. The progress of labour and strength  and  length of contraction are also assessed to look for abnormal labour dystocia and possibility of developing infection.

            Maternal well-being need to be assessed with temperature and heart rate which may suggest infection. Abdominal palpation is done to rule out macrosomia and check for lie, position and engagement of the baby. Vaginal examination will need to be performed to look for obstructed labour with caput, moulding and maldescent of the baby. The position of the fetal head will direct us as to try for instrumental delivery in the room or theatre or may justify caesarean section.

            Fetal well being need to assessed with continous electronic fetal monitoring if she has not had it yet. If there is any delay in delivering this lady, fetal blood sampling may be indicated.

 

B:

            Indication for caesarean section is justified if there is fetal or maternal morbidity or mortality involved. However, maternal request and wishes need to be considered in the decision making process.

            One the main reason for caesarean secion is fetal compromise where there is abnormal CTG or fetal blood sampling needing urgent delivery of the baby. This includes cord prolapse. Presentation of the baby may prevent the head from descending ie deflexed OP position, brow or mento-posterior face presentation.

Women who had planned for caesarean section may come in labour and having to have it as an emergency ie breech presentaion or previous caesarean sections. It may be needed to resuscitate the women in placenta abruption or placenta praevia. Women with obstructed labour and cephalo-pelvic disproportion are justified to have caesearen section.

 

C:

            Early recognition of any complications is the key to prevent maternal morbidity and mortality. Therefore, an experienced surgeon and anaesthetist need to be informed and present at the delivery. Baby’s head will be often impacted into the pelvis and may be difficult doing  an abdominal delivery. This can cause extension to the uterine incision or even bladder injury. This can be prevented by adjusting the operating table to a suitable height and a second person may be required and be ready to push the baby up vaginally.  Injury to the bladder can also be prevented by putting a catheter in and ensuring the bladder is reflected back.

            With any extension of the incision as well prolonged 2nd stage, there is high risk of postpartum haemorrhage. Blood should be crossmatched and anaemia should be rule out with full blood count. Anaesthetist need to be informed to give 5-10 units of syntocinon for 3rd stage and infusion of 10 units syntocinon an hour to maintain uterine contraction. Further drugs may be need such as ergometrine and haemabate. We should have low threshold to call for senior help and to give transfusion if necessary.

There is a risk of infection from being in labour for a long time as well as from the opertion. Broad speectum antibiotics should be given prophylactically to prevent infection. They are also at risk of developing venous thromboembolism. Hence the women should be kept hydrated in labour and prophylaxis anticougulant postnatally should be given according the national guidelines and local protocol.

 

Ans essay 342 Posted by Gomathy G.

a, I would start my assessment by gathering more information, like her hydration status, When was bladder emptied or when and how much volume urine passed, as full bladder can act as tocolytic and obstruct decent, Number and duration of contractions in 10 minutes and compare them with previous contractions, if it is slowing, Any recent analgesia, that made labour to slow down. Then I will assess her generally for Hydration, Alertness and pain relief and CTG if one is started or advice for one. Proceed to Abdominal examination for Uterine contour, tone between contractions, contractions, Lie, palpability of Presenting part abdominally, full bladder and any signs of obstruction or dystocia. Proceed to Internal examination with consent for cervical dilatation, presenting part, station, position, Caput or moulding, colour of liquor, general adequecy of pelvis, if possible decent during a contraction.

b,Indications for caesarean section could be broadly based on urgency (mayernal or fetal) or Non deliverability by vaginal route.They are signs of obstruction like Bandls ring, severe moulding with or with out caput, deep transverse arrest, undiagnosed malpresentation like brow or mento-anterior or High head at or above spines, signs of Abruption with fetal distress and fetal distress.

c, In her case, if she has ranitidine, known to prevent incidence of Gastric content aspiration, Group and save and inform the blood transfusion service about indication clearly, alert co-ordinator, theatre staff and scrub nurse about risk of excess bleeding high in her case,  by performing LSCS under spinal rather than GA, Appropriate education or discussion (about crucial steps of assessting) with the assissent, informing consultant on-call for standby, adopting steps to minimise unnecessary blood loss form skin level, optimal technique for extraction of fetal head by being cautious about angle extension, by seeking help appropriately and early if there is angle extension or atonicity noted after delivery of baby, By adminstering prophylactic synto 40 IU infusion immediate post delivery, if in any doubt leave gravity drain (intra-abdominal), Prompt estimation and replacement of blood loss from surgary, TEDS and Thromboprophylaxis, encourage, Breast feeding, Early mobilisation and Debriefing to patient which helps her to identify signs of infection or collection at a later stage.

Essay342 Posted by zaitouni L.

a)Assessment of the woman

Reveiw of obestatric history for birth weight of prevouse baby.Antenatal history should be reviewed from the notesand any US scanes.reviewed witch may indicate a  cause of dystocia as macrosomia

Inquire about maternal pain and wishes for pain relief.CHICK MATERNAL CONDITION. 

Determine womans WISHES about mode of delivary .

Check CTG to make sure that  there is no sign of foetal distress.

Complete abdominal and vaginal examination should be performed to palpate duration frequency and strength of uterine contractions  To  see if any fifth of the head can be palpated per abdomen

A vaginal examination to confirm full cx dilatation, to ascertain station of the head, position and presence of any asynclitism.

All findings should be documented and signed.

Exclude disproportion as big size baby ,sever caput ,moulding and loosly applied cervix .

b) INDICATION for delivary by ceserian section :

If examination showed malpresentation or signs of obstruction as moulding or caput .If malposition of the head or asynclitism is diagnosed .If foetal distress as CTG abnormalities or thick meconium occured .

If maternal condition not stable. if mother wishes for CS.

C)Maternal morbidity from cs be reduced by:

Good surgical technique is key factor in reducing the morbidity.The lower segment incision should be high to avoid opening into the vagina.Wide lateral dissection should be avoided . The uterine incision should be concave upward rather than by tearing digitally .The foetal head should be delivered through the uterine incision in occipito anterior position , disengaging the foetal head  from the pelvis and rotating it to occipitoanterior position.Oxytocic agents should be given in third stage. If uterine atony occured vigorous uterine massage along with intramyometrial injectin of carpoprost .Direct pressure on bleeding pointes in placental bed  and figure 8 sutures should be taken.

Senior help should be summond in case of persistent haemorrhage and consideration for intrenal iliac artery ligation .B LYCH sutures should also be considerd to stem the haemorrhage.

Bahawana Posted by PAUL A.

The assessment will include looking for growth of the baby in growth chart  (1) to get an idea whether it is average/good size baby.Also it is worth noting weight of previous child(h/o macrosomia) and any difficult /instrumental delivery (1) even though it was a vaginal delivery.

During intrapartum period it is essential to work out the problem with power, passenger or passage.It is important to note the progres of labour and whether or not the need of oxytocin in labour. If she is on oxytocin the duration and dose of oxytocin (What difference will this make? 2 hours or 8 hours???).The frequency, amplitude (? Relevance?? How do you assess this?)  and strength of contractions will help to diagnose the cause for failure to progress in second stage. Also, if she in active/latent  phase (what would you expect?) of pushing will help us to decide whether or not she can be given more time. As she is multiparous, delivery should be acheived in 2hours of active pushing (one hour) though she can be given 3 hours (is that what the NICE guidelines say?) in total in second stage if vaginal delivery is acheivable.If contractions are going off or there is appearance of Bandl's ring,it can be a sign of obstruction.

 I will make sure that there are no signs of foetal distress on cardiotocograph (why should she be on CTG?).Also i will check pulse, blood pressure and hydration of mother (1) to make sure there are no signs of maternal distress. I will ask about pain relief in labour as epidural associated with increased chance of instrumental deliveries (is this the reason for asking about pain relief? Blame the epidural??) and if I need to do instrumental delivery in room she has good anagesia on board(1).

I will do abdominal examination to clinically assess the size of baby and engagement of head (1).I will do vaginal examination to rule out any malposition and malpresentation,assess station and position of baby and notice any signs of obstruction( caput, moulding(1), vulval, vaginal oedema). I will also ensure that she has indwelling catheter (NOT NECESSARY) and notice colour of urine. ( haematuria, concentrated urine can point towards obstruction(this tells you she is dehydrated, not obstructed (-1)). 

B)The indication in this case will be if she has been in active phase of second stage (pushing for >2 hours) and vaginal delivery is not imminent (not an indication for CS).To acheive vaginal delivery following requisites should be acheived after ruling out any malpresentation and malposition: head palpable <= 1/5 and on vaginal examination head is below spines.Maternal request (1) because of exhaustion/distress should be considered as well. Even though vaginal delivery might be acheived by giving her more time if maternal request is done at this point, I will consider caeserean section after full discussion with the mother about second stage caeserean section.

C)Maternal morbidity from second stage caeserean section can be reduced by proper selection of cases (??? So if her BMI is 45 you will not do CS?).If expertise is available to do keilland's /rotational deliveries,carefully selected cases can be delivered vaginally avoiding caeserean section.Also if difficult vaginal delivery is anticipated they can done as trial of instrumental in theatre rather than just going for caeserean section.

If, howerver, decision is made for caeserean,it should be performed by senior obstetrician available.Also difficulty in section should be anticipated.Liasion with anaesthesist beforehand to give oxytocics as soon as the baby is delivered and start the oxytocin drip can minimize blood loss (1).Also cell salvage (1) can be used if facilities are available.Multidisciplinary involvement of anaethesist, senior midwife, scrub midwife,obstetrician and neonatologist can acheive good outcome(What are they supposed to do?).Intraoperatively, high incision in uterus, adequate size of incision, reflection of bladder properly can avoid unnecessary extensions of tears in vagina and bladder injuries(1). If head is quite low, an assisstant can be asked to push the head vaginally to facilitate delivery of baby and avoid traumatic delivery to baby and tears in uterus, vagina.  

Also early identification of intraoperative difficulties and seekly timely help from senior obstetrician/consultants can reduce morbidity.Proper supervision (1) and training of junior staff is important to reduce maternal morbidity and mortality.Last but not the least communication to the patient and mode of delivery for future reference( suitable for VBAC/ elective caserean) should be documented in the notes to avoid future morbidity.

Tnfay Posted by PAUL A.

Delayed second stage is more likely to be associated with maternal exhaustion. She should be communicated in supporting manner. Enquiry is made about the degree of pain relief (1). Timing of onset of labour pains is asked (why?). Information is obtained about rupture of membranes, if ruptured, time since ruptured is noted (why? What will you do differently?). She should be asked about the colour and smell of the liquor. Temperature, pulse and BP are recorded. Dry mucous membranes, tachycardia, and raised temperature suggests maternal dehydration (1). Partogram is reviewed to assess the progress of labour as slow progress indicates (can suggest) CPD and associated risk of shoulder dystocia. Maternal record is reviewed to note down BMi and any clinical or sonological suspicion of big baby(1). Abdomen is palpated to assess the nature of contractions, size of the baby and palpable fifths of fetal head(1). Palpable bladder is excluded. Fetal well being is assessed by recording CTG(should she have been on CTG?). Vaginal examination is undertaken to identify vulval edema, presence or absence of membranes, position and station of the head. Colour of the liquor is observed if membranes are absent. Caput and degree of moulding (1) suggest CPD. B) Evidence of cephalopelvic disproportion suggested by suspcion of big baby with significant moulding and caput formation is an indication for caesarean delivery(1).Abnormal presentation such as brow or face in the mentoposterior position (1) also indicate delivery by caesarean section. Other indication for caesarean section is fetal distress evidenced by abnormal CTG and meconium stained liqour(why not vaginal operative?). If the mother is exhausted, unwilling to continue to labour and vaginal delivery is not imminent caesarean delivery is advisable(why not vaginal operative?). C) injury to bladder is common (is it??) at CS during second stage as it would have been pulled up and edematous due to prolonged labour. Preoperative emptying bladder by foley's catheter and opening the parietal peritoneum as high as possible can reduce the risk of bladder injury(1). Lower uterine segment Lacerations, extending to vagina is associated with significant maternal morbidity requiring extensive repair for longer duration at the time of surgery.Performing CS by experienced surgeon, opening the lower segment 1 cm below the peritoneal reflection can minimise morbidity associated with this complication. Another complication associated with maternal morbidity is PPH. Anticipation, active management of 3 rd stage(1), oxytocin infusion for uterine contraction and arrangement of blood transfusion can reduce the morbidity(cell salvage). Sepsis is another important entity which adds to maternal morbidity. Avoiding repeated vaginal examinations, following strict aseptic technique during surgery and prophylactic (1) use of pre operative antibiotics reduces the morbidity. Venous thromboembolism is identified factor leading to maternal morbidity. Appropriate thromboprophylaxis with LMWH (1) is advised to reduce the risk. Â

H H Posted by PAUL A.

Will look at her notes regarding her previous obstetric history,her previous pregnancy,was there gestational diabetes, weight of baby at delivery and was there shoulder dystocia and how was managed and if any complications(post partum hemorrhage or 3rd or 4th degree perineal tear that was repaired and now healthy)(1 do not ask the examiner questions)

Will see if she had scans in this pregnancy and if there is a fetal macrosomia (1) on scan.

Will ask her how she is coaping with labour and if exhausted or need pain relief (1). Will examine her for pulse(tachycardia in dehydration),blood pressure,temperature and look for dry mucous membranes(1).Dehydration need correction. Will do abdominal examination for fundal hight and tenderness,and for fetal head engagement(no of fifths either head not palpable or only one fifth)(1). Will look at the CTG for fetal heart abnormalities(should she be on CTG?).

Will take verbal consent to perform an internal examination. Will look if there is meconium stained liquor(thin or thick). Will do vaginal examination for presentation,position any malposition(eg Brow (is this a mal-position???) or face mento post), station(feel the lowest bony part and its relation to ischial spine), moulding and caput which indicate cephalopelvic disproportion (1) and dystocia.

Will see regarding what pain relief taken and medications given.

B) Indicated if there is cephalo pelvic disproportion as evidenced by non engaged head with excess caput and moulding(1). Also indicated if there is evidence of fetal compromise and it is dangerous to perform instrumental delivery ,specially if it needs rotational forceps.

In presence of Brow(1),it is safer to deliver by C/S and not to convert as in the old days.

Emergency C/S also indicated after failure of instrumental delivery, and also if mother wish (1) not to have instrumental delivery and want a C/S.

 

C) Second stage c/s can be dangerous specially if head is impacted down in the pelvis and associated with more bleeding due to manipulations  that and the consultant is informed ,help will be needed to push the head up from vagina and to bring blood if needed. Unless there is extreme emergency, the WHO criteria for safe surgery are done(sign in,time out,sign out).Blood group and save done and will ask anesthetist to put wide bored IV lines.Will put indwelling urinary catheter. Will make an adequate skin incision for delivery of a big head. Will dissect blader down. Will make my uterine incision in lower segement high (You are describing your operation – that is not answering the question). Will deliver the head with  the help of someone pushing the head  from the vagina . Some obstetricians  use the forceps. After clamping the will give prophylactic antibiotics. Will secure hemostasis and if extension occur wil exteriorize the uterus to secure bleeding. Will not lose face in asking assistance from collegues as stated in the maternal mortality report saving mothers. Will see regarding post operative thromboprophylaxis for 7 days.  

You have not answered the question

Hbdran Posted by PAUL A.

hbadran Posted byHAnaa B.
Sat Jan 15, 2011 03:31 pm

My clinical assessment of this patient includes history and examination (waste of time & space).

The past obstetric history in relation to her last delivery either difficult or instrumental delivery (birth weight) may give claw about the expected progress in this delivery.

Revising her antenatal chart   for: excessive weight gain during current pregnancy, diabetes (healthy) or abnormal glucose tolerance with expecting big baby (1) may give hint about her progress in labour.

Ultrasound report indicating foetal macrosomia more than 4.5kg in diabetic and 5 kg in non-diabetic although its reliability is not considered but it may appoint t the case of unsatisfactory progress in labour.

Revision of current delivery progress chart may appoint insufficient uterine contractions and the need for augmentation by oxytocin (not recommended – see NICE guidelines). Defect in the power

Examination includes abdominal: to assess the longitudinal lie and the possible clinical EFW possible big size baby (defect in the passenger) degree of engagement of the PP(what is this??), And vaginal examination to assess the cervical dilation (given in question), position of the presenting part and the its station in relation to the ischeal spine, presence of moulding and or caput formation(1), indicating obstructed labour (defect in the passage).

Patient may be under epidural analgesia and 2hrs in the 2ndstage is still acceptable.

Active pushing may not be started yet and need to be encouraged.

Maternal satisfaction of her pain management should be assisted (poor English) and her hydration status as prolonged second stage is accompanied by maternal excursion and dehydration.

 

B

Indication of Cs may be related to maternal or foetal cases

Maternal causes may include maternal disease like diabetes (HEALTHY), specially uncontrolled accompanied by foetal macrosomia, sever preeclampsia not responding to the usual measures, eclampsia need urgent delivery.

Maternal pushing in 2ndstage for more than 2hrs in multiparas.

Signs of obstructed labour which may include slow progress, cervical oedema(??? Fully dilated), moulding of the foetal bones with progressive caput formation.

Abnormalities in the CTG warrant urgent delivery(not indication for CS), cord prolapse, failed instrumental delivery

Especially, if wrong assessment of the patient, before applying the instruments.

Active vaginal bleeding suspecting  apratio placentae.

 

C

Doing cs in the 2ndstage after 2hrs of maternal pushing and dehydration carries big risk to the mother and should be done by senior obstetrician for rapid interference , with good assistance which may need to push the head of the baby from down to help disengage the foetal head from the pelvis making its extraction easy.

Wound of the uterus should be C shaped not too much down in the pelvis and the extension should be towards the upper angels to decrease the risk of extension to the vagina and broad ligaments.

Blood should be available after taking consent for the rapid replacement in case of sever postpartum bleeding.

Tissues handling should be very genital due to sever tissues oedema and risk of bleeding and infection

Antibiotics (1) should be given before the cut skin to decrease the risk of infection as well as anticoagulant (THROMBOPROPHYLAXIS) in the form of LMWH should be given for all emergencies Cs to decrease the risk of VTE (1).

Maternal hydration and Good choice of the anathesia (What is the best choice?) should be done by experienced anathesiologist.

Senior design for doing Cs in the 2ndstage of labour should be done by senior Ob. And rapid counselling of patients and families at easy words made their choice easier and gain their trust and decrease the number of complains.

Good documentation of the discussion and the advices should be done in details as soon as operation finished including the outcome, foetal Apgar and cord PH with maternal blood transfusion if ever.

SARO K Posted by PAUL A.

(a)I will get her antenatal record to know about  birth weight of previous baby(1),any h/o instrumental delivery,any h/o perineal degree tear.I will go through her SFH chart and usg (??) finding to know about the weight of the baby(1).I will see her partogram to get an idea about the total duration of labour ,time of rupture of membranes (what difference will this make?) -color and amt of liquor,abt the contraction (what about?),drugs used,type of analgesia(epidural prolongs secong stage),need for oxytocics and time of active pushing. I will see her previous p/v finding to know abut station, position,caput ,moulding  .I will ask about the time of last passage of urine,amt (??) and color(dehydration if little and conc yellow),hematuria (s/o obstructed labour)

I will assess her temp,pulse rate,hydration (1) and signs of exhaustion&  distress.   I will examine her abdomen to know how many fifths palpable (fetal size), strenghth ,freq of contraction (what difference will this make?),any palpable rings per abd.and palpable bladder even after emptying the bladder.Iwill see her CTG trace (why should she be on CTG?).I will do per vaginal examination to look for any vulval edema,hot vagina,station,position of fetal head,caput,moulding (1) and finally color&amt of liquor(nil means dry labour (what is this?)).

(b)I will decide to do CS if there are signs of CPD (what are these?) and obstructed labour,signs of fetal compromise as

 suggested by CTG, patient is not willing to wait and requesting CS (1),High station with high degree of caput and moulding (1) which doesn t favour instrumental vaginal delivery,lack of skill and experience in rotational instrumental delivery,

© Anticipation,prevention , early diagnosis and  prompt treatment are the ways in prevention of maternal morbidity.Inform the theatre,anesthetist,nurse and consultant abt second stage cs.Anticipate genital tract injuries ,PPH ,infection,and thromboembolism .Alert blood bank  .CS should be done by the skilled person and the proper technique does matter.Plan proper size incision at reflection of peritoneum which will PREVENT further extension INTO THE ANGLES AND CERVIX.While delivering the deeply impacted head,second assistant can help in pushing from  below and gentle delivery will prevent extension of incision.As soon as baby is delivered,give antibiotics (1) and oxytocics (which drugs?).After removal of placenta,explore for extension in to cervix,angle,bladder,posterior wall.Avoid blind clamping if increased bleeding.Suturing should be  patiently done  after ensuring no extension  .If  bleeding  persists despite suturing ,there  should not be delay in treatment of PPH  as per the protocol. Early decision about hysterectomy and interventional radiology  should be made .Postop –early mobilisation,continous bladder drainage  for 24 hrs, thromboprophylaxis (1) as per protocol.Proper documentation  of the events in the notes and Discharge summary  will prevent morbidity in future pregnancy.

jsk.

DHARSHITHA Posted by PAUL A.

(a)The assessment includes fetal, maternal  and the assessment of the progress of the labour including  reviewing the partogram and reviewing important information from her history (waste of time & space).

Fetal assessment includes assessing the foetal heart rate using continuous CTG (why should she have been on CTG?)  monitoring and foetal blood sampling appropriately to exclude any foetal distress.

Maternal assessment include, observation of vital signs- BP , pulse, temperature, respiratory rate,level of hydration(1), also urinalysis to exclude any ketone bodies.(To exclude maternal exhaustion (why not ask the woman? She will tell you if she is exhausted)) Also make sure she is emptying her bladder regularly and the bladder is not full.

Assessment of the progress- includes abdominal and pelvic examination to assess the descent of the presenting part and assessing the frequency and the duration of contractions every five minutes (what difference will this make??). Also use the partogram to evaluate the overall progress.

By abdominal examination it should be confirmed that head is not palpable,as it is a prerequirsite for an instrumental delivery (IS IT????).

By pelvic examination,confirm the presentation of the fetus and the fully dialatation and ascertain the position of the baby , exclude any malpresentation (like what?) and malposition, also assess the descent of the presenting part,and exclude any signs of obstruction such as caput and moulding, swelling of the cervix (fully dilated).

Confirm whether she has good pain relief ( eg. epidural)-which can be helpful for an operative delivery (assess pain and need for pain relief).

Confirm whether the is actively pushing or having an urge to push-signs of active second stage (fully dilated for 2h – what do you expect???).

Review mother,s ideas-eg. willingness for pain relief and assisted vaginal delivery/caesarian section appropriately(1).

Also inquire about other important aspects of the history(medical problems-PET, Diabetes, infection (HEALTHY))

(b) When there is foetal distress(evidence of pathalogical CTG or abnormal FBS) and the high head, which is not feasible to instrumental delivery,(More than 1/5th of the head palpable abdominally (YOU SAID 0/5 ABOVE) or presenting part above the sacral (ISCHIAL) spine vaginally), is an indication for CS(caesarian Section).

Also failed instrumental delivery(pop off of ventouse cuff twice, or failure to descent in ventouse or forceps), inexperienced  operator, or no facilities or instruments for assisted vaginal delivery or maternal decline (1) of instrumental vaginal delivery or any contraindication for assisted vaginal delivery(risk of infection-primary HSV at term (??? YOU WILL ALLOW HER TO LABOUR TO FULL DILATATION THEN DO CS?? (-1)).

Certain malpresentation  malpositions such as persisting  brow, mento-posterio rface positions and compound presentation, which cannot be delivered vaginally (1).

Signs of maternal exhaustion,and diminished or absent contractions.(as good contractions are needed to perform successful assisted vaginal delivery)

(c)Steps can be categorised as preoperative, intra operative and postoperative.

Preoperative- This caesarian section should be performed by  an experienced senior obstetrician (1? Supervision),and  theatre staff, anaesthetist paediatrician (? Maternal morbidity??) should be alerted regarding the risks.

Mother should be explained regarding possible risks(Bleeding, damage to internal organs, thromboembolism), during consenting (how does this prevent morbidity?).

Blood for grouping and save and for cross matching, anticipating the risk of major haemorrhage.Bladder catheterization to prevent inadverent  bladder injury (1). Propylactic antibiotics (1) including metronidazole against  infections, including gram negatives.

Paediatrician to present at the time of delivery. Arrange an assistant to push the head from down to facilitate the delivery.

Intermittent pneumatic compression device in lower limbs during the surgery to prevent thromboembolism.

Intra operative measures- Appropriate wider incision in the skin for the adequate access, for manipulation during delivery and repair.

Identification of bladder, opening in to visceral peritoneum, pushing the bladder down, use Doyen,s retractor to keep the bladder away from the field-to avoid possible bladder injury.

Opening in to the uterine cavity in an upper level to avoid accidental opening in to vagina as cervix and vaginal walls may be flushed together, and difficult to differentiate in the 2nd stage.Use a "smiley" curved incision to enter in to the uterine cavity. Extend it upwards if needed . This prevents lateral extention of the incision during the delivery of the presenting part(1).

Pushing the presenting part from down below by an assistant to facilitate the delivery of the deeply engaged head.

At the time of the delivery, lift the head of the baby applying pressure using the palm of the hand on the head, carefully,avoiding sudden release of vaccuum  pressure. Also turning the baby,s head in to O-A position , before the delivery facilitate the easy delivery of the head.In addition forceps may be used to lift the deeply engaged head up.

Controlled cord traction to deliver placenta  and advise the anaesthetist to give oxytocics -syntocinon infusion/ergometrine depending (on what??) on the situation.

Proper and careful examination to identify the angles of the incision and any extention /tears reaching broad ligaments or ureters. Identify the lower edge of the uterine incision precisely. Make sure no damage to the bladder.If suspected can use methylene blue instillation to exclude any involvement.

Careful examination of tissue layers for bleeding points and ligation and cauterization and achieving complete haemostasis helps to reduce the morbidity.Use of haemostatic agents, drains to confirm no bleeding also can be considered depending on the situation.

Subcutucular skin closure with absorbable  suture material shown to enhance the rapid healing and recommended.

Post op measures- Continuous bladder drainage till she is mobile will prevent bladder damage.

Assessment for thromboprpylaxis and commencement of LMWH, TED stockings and early mobilization to prevent thromboembolism(1).

Close observation of vital signs including BP, pulse, temperature,and urine out put and colour during early post-op. Routine examination of the wound site to exclude any signs of infection.

Counselling, debriefing and advise regarding possible mode of delivery in next pregnancy. Also incident reporting and risk management issues.

miss T Posted by PAUL A.

(a)

In multiparous women, second stage should not last more than 2 hours in total or 3 hours if regional analgesia is given. (is this what the NICE guidelines state???)

At this point I need to review her history including age (given in question. What will do differently in a 20 year old compared to a 45 year old? ), documented BMI any antenatal suspicion of marcosomia (1) as they all are associated with prolonged labour. Was her previous delivery operative as I will thing of relative CPD.

Has she received epidural analgesia now as it is associated with delay in the second stage of labour(so what will you do differently? Do you manage delay differently in a woman with an epidural?). I will review her partogram to see how the first stage has progressed, if it was a slow labour then malpositioning may be a possibility. Was the labour augmented? (do not ask the examiner questions) Was she examined by junior physician who may miss diagnose the findings? (The examiner has given you the findings – do not question them) Has she been actively pushing all this time because maternal exhaustion itself is an indication of operative vaginal delivery.

Next I will review the CTG (why should she be on a CTG?) how is the fetal heart trace, reassuring or not because in later case delivery need to be expedited (does it? Do you classify CTGs as reassuring and non-reassuring???). Is uterine activity adequate (4 in 10 minutes lasting 45 seconds)? Dose of syntocinon need to be increased if there are insufficient contractions but NICE do not recommend staring oxytocin in second stage of labour(so why bring it up?).

With verbal consent of patient I will examine her. First abdomen for estimated fetal weight, engagement of the head (1) and how much of it is palpable per abdomen (what is the difference?), any distended bladder that may need to be evacuated? Pelvic assessment for confirmation of full dilatation, station and position pf presenting part, any presence of caput or moulding(1). These findings will be co-related to previous pelvic assessments as newly formed caput and moulding suggest element of obstruction. If position is direct OP then it is associated with long second stage(so what? what will you do differently?).

(b)

Emergency cesarean delivery would be needed if there is fetal compromise on fetal heart trace and examination findings are not suitable for operative delivery, fetal head more than 1/5th palpable per abdomen, vertex station is above ischial spines(1), there is significant caput or moulding that may render application of vaccum technically difficult (so why not use forceps??). The findings are suitable but there is lack of equipment or an experienced clinician to conduct operative vaginal delivery (how do you have equipment to perform CS but not vaginal operative delivery? You get the equipment or a senior clinician).

The operative vaginal delivery is carried out but the vaccum cup has slipped 3 times or 3 pulls has not caused any decent of fetal heart.

If mother has refused for operative vaginal delivery (1) or has opted of emergency CS.

(c)

PreOP

Emergency cesarean should be conducted by senior obstetrician (You are expected to be able to do the operation). Early resort to cesarean delivery by clinical judgement as initial trial of vaccum or forceps may bring head down and make abdominal delivery more difficult. Right indication of CS and avoid emergency CS if operative delivery can be conducted easily.

IntraOP

The bladder will be catheterized (1) before starting CS to minimize risk of bladder injury. The bladder will be dissected down after opening abdominal wall. Uterus will be opened higher and baby delivered by gentling flexing the head and then bringing it toward uterine incision. Help form another staff can be taken who will push it vaginally. Left hand can be used to delivery baby’s head as it follow the curve of pelvis and is less likely to cause extension of uterine scar.

After delivery of baby antibiotic prophylaxis (1) be given to mother, a second generation cephalosporin. Active third stage management (1) by giving ueterotonics, syntocinon in drip and ergometrine 0.5mg IM if there is no contraindication as prolonged second stage is associated with risk or post partum hemorrhage secondary to atonic uterus. Ensure adequate hemostasis during cesarean. (cell salvage)

Post OP

Give thromboprophylaxis and encourage early ambulation(1). Early patient feeding to avoid paralytic ileus. Chest physiotherapy or incentive spirometery to avoid chest infection secondary to collection of secretions. Adequate analgesia to reduce post OP pain.

Proper debriefing of patient regarding the need of emergency CS delivery.

Sofia Posted by PAUL A.

Ans a: Review the records of patient about weight of previous  baby (1) and h/o difficult  or instrumental delivery.  Her ultrasound to rule out possible anomaly like hydrocephalus and growth chart to know about possible macrosomia(1). Review her partogram for progress of labor, as a protracted progress may indicate cephalopelvic disproportion. Enquire about pain relief (1) and urge to push.

Examination will include general condition , hydration  (1) and vital parameters(what are these?). Abdominal exam to confirm presentation,frequency and strength of contraction,  fifth of head palpable(1). Fetal heart rate for fetal wellbeing (1) and start continous monitoring if not  on ctg. Pelvic exam after evacuation of bladder if full. Assess station, rotation  of presenting part, color of liqor  pelvic assessment for adequacy. Presence of caput ,moulding (1) and dry vagina will indicate signs of obstruction.debrief the patient about her condition.

Ans  b: indications for cesarean section in second stage will be suspected cephalopelvic disproportion that would be evident from big size of baby and signs of obstruction like caput and molding (excessive). Second indication would be signs of fetal compromise and vaginal delivery not imminent i.e. head above ischial spine(1). Malpresentation like brow (1) will require delivery by cesarean.  Failed  trial of instrumental delivery is an indication for cesarean section. Patient refusal for instrumental delivery is indication for cesarean section(1).

Ansc: many second stage cesareans can be avoided by opting for instrumental delivery when circumstances  are favorable. This requires training of the staff and assessment of competence in using  vaccum and forceps (you were asked about CS). Appropriate selection of cases (How??). Involvement of senior obstetrician and conducting it as trial in theatre (You were asked about second stage CS) when difficult delivery anticipated .  catheterization of bladder (1) prior to incision and opening peritoneum at highest point to avoid bladder trauma. Planning incision  with upward curve and away from cervix. Assistant to disimpact head vaginally if deeply impacted in pelvis. Early calling for senior assistance in case of complication like extension.antibiotic prophylaxis (1) to reduce chances of sepsis. More risk of atony and PPH. Anticipation and vigorous management by oxytocis (which drug?) and  bimanual massage. Post partum thromboprohylaxis risk assessment and avoiding dehydration and immobility(?? LMWH).debreifing patient about the circumstances  to reduce psychological  morbidity with such situations (? evidence). Plans for follow up including  care plan for future pregnancy management should be provided.

Sherif N Posted by PAUL A.

1) proper re-assessment of the patient through adequate history taking, whether she has any medical trouble (diabetes, hypertension, cardiac problem, asthma, poiomyelitis), undergone any previous uterine or pelvic surgery (HEALTHY 20 year old)

proper history of her previous vaginal delivery, hoe long did it  lasted, whether it was smooth normal, or instrumental, how about the weight (1) of her previous baby by the time of delivery, if she had any post partum complications

general examination of the patient to detect sighns of dehydration(1), measure her pulse, BP, T, urine output

abdominal examination for the size of her abdomen, baby, detect the position and whether the head is engaged(1), any suprapubic fullness and evacuate the urinary bladder

vaginal examination for pelvimetry, confirm full cervical dilatation (given in question), condition of the membranes (if not ruptured till now, and the conditions are suitable for vaginal delivery, it should be ruptured), position of the presenting part, confirm it is cephalic, vertex and suitab;le for vaginal delivery, detect the presence of caput (moulding), sighns of dehydration of the vagina

examin her CTG (why should she be on CTG?),baseline of the fetal heart, normal or abnormal variability,  whether there is any type of deceleration,  acceleration.  detect the frequency and regularity of uterine contraction , if not regular or strong enough, consider augmentation of labour by giving oxytocin (NO – SEE NICE GUIDELINES) starting by 2miu/min and titrate regularly until get ting 3 contractions per 10minutes (if oxytocin isn't contraindicated and circumstances are favourable for vaginal delivery)

2)there are fetal and maternal indications for emergency cesarean section

fetal: occurance of fetal distress (and position (Which position is unsuitable??) isn't suitable for instrumental delivery)

abnormal CTG, and fetal pH<7.2

oversized abdomen, and large sized fetus

abnormal presentation or position, not suitable for vaginal delivery (eg, transverse lie (not presentation or position), breech not suitable for vaginal delivery, brow presentation, face mentoposterior, persistent oblique occipitoposterior(vaginal delivery possible))

cord prolapse

maternal indications: contracted pelvis, with failed trial of vaginal delivery

dehydration and deteriorating maternal vital signs and conditions are not suitable for instrumental delivery (You will not do instrumental delivery but you will do CS??? (-1)

3)maternal morbidity that may occur includes: injury during the cesarean, postpartum haemorrhage, infection, DVT or PE

-cross match and save blood urgently as it may be required during the operation

-prophylactic antibiotic (1) is required after cord clamping to prevent postpartum, infection

-insert Foley's catheter, and mobilisation of urinary bladder to prevent its injury(1)

higher uterine incision, which should be c shaped or J shaped, to prevent extension of the incision to uterine angles and uterine arteries

-administer oxytocin 20units (?? Bolus???) to ensure uterine contraction and don't close the abdomen except after full uterine contraction

-early mobilisation and gine LMWH (1) fro 7days (if there is no other risk factors, other than emegency cesarean, otherwise, LMWH should be continued for 6weeks)

Posted by j  .

a. I will enquire about the previous obstetric history including the weight of the baby and duration of labour. Present obstetric history will be reviewed from the hand held notes. .Type of pain relief will be enquired which would be of use in decision during delivery. Partogram will be seen to note the progress of labour. Abdomen examination to confirm fifths palpable, size of the baby to decide on mode of delivery will be done.CTG will be reviewed and gentle vaginal examination will be done after consent to assess the position, station, presence of moulding and caput, descent with contraction and decide for the mode of delivery.

b. Pathological CTG and the station of the head above the ischial spine will be an indication for caesarian section. Malpresentations like brow is also an indication. Failed instrumental delivery after a trial and maternal wishes are also indication for a caesarian section.

c.The main reasons for maternal mortality are hemorrhage, infection and thromboembolism. Preoperatively bladder should be catheterised. A stat dose of prophylactic antibiotic should be given during induction to prevent infection. During the procedure, I will be careful in separating the uterovescical fold of peritoneum, pushing the bladder down and incision higher in the lower segment to avoid bladder damage. Difficulty in delivery of head will be anticipated and can be resolved by pushing the head from vagina or delivering as breach. Active management of 3rd stage by given syntocinon infusion will be done. Postoperatively thromboembolism will be prevented by TEDS stockings and prophylactic Enoxapirin. Debriefing about the entire event after the procedure will be done to prevent psychological morbidity. 

ESSAY 342 Posted by Dr Dyslexia V.

X

a)      She has a delay in second stage of labor. Pertinent history in regards to the delay in the first stage of labor is important. The presence of any epidural anesthesia for pain relief the use of diamorphin or entonox for analgesia must be assessed. The labor must be classified as spontaneous or part of an induction should also be important. Use of oxytocins in labor and its dilution and dosage is also important. The current estimation of fetal weight in her previous ultrasound scan or clinical estimation is also important for future intervention. Previous history of shoulder dystocia, extended tears in previous pregnancy or post partum hemorrhage and complication is important for this pregnancy as well. Examination should include her body mass index as difficulty of anesthesia and technical difficulty for assisted vaginal delivery would be anticipated. Her hydration status should be assessed as well based on her tongue coating, urine output in labor. Fundal height and clinical estimation of fetal weight is important to predict macrosomia. Engagement of the fetal head if 0/5 palpable is a prerequisite for operative vaginal delivery. Vaginal examination to assess the position of the fetus either occiput anterior or occiput posterior which could predict the technical delivery and the choice of the assisted vaginal delivery. The station of the presenting part, presence of caput and moulding will be useful for assessing for choice of assistant vaginal delivery.

b)      The indication for caesarean section include if patient refuses for a instrumental delivery. If the prerequisite for instrumental delivery is not met such as still 2/5th palpable per abdomen and station is above the ischial spine. If clinically suspecting a macrosomic baby , or cephalopelvic disproportion is also and indication for caesarean section which would be evident with severe moulding, and caput 3+ with swollen vulva. Other indication include malposition such as face presentation or brow presentation which would be very difficult for instrumental delivery. If the accoucher is not skilled with the instrumental delivery would also be an indication for casarean section.  If fetus is suspected to have any bleeding diathesis such as hemophilia or von willebrand disease is also a indication for caesarean section

c)       The maternal morbidity is reduced if it is done by a trained and senior doctor . The use of proper analgesia and relaxant such as general anesthesia could be beneficial to deliver a deeply engaged fetal head. In technicas aspect the fetal head could be delivered by the surgeon with an assistant dislodging the head in between contraction thus preventing any extended uterine tear. Another important aspect is also proper catheterization and drainage of urine is paramount important as inserting an indwelling bladder catheter is difficult in a deeply engaged head. The uterus must be closed in the usual manner and the use of syntometrine and uterine massage would be beneficial to reduce uterine atony which is common in second stage casarean section. The use of intrapartum antibiotics would be beneficial to prevent any infection due to the excessive manipulation in this type of casarean section.  Prolong catheterization some time would be required for bladder healing and occasionally for urinary retention in this type of caesarean section.  She would also require VTE  prophylaxis with low molecular weight heparin, TED socks and hydration as it was aemergency caesarean section .  Proper documentation of notes and difficulty should be recorded and audited  for future references.  The patient should also be debriefed in regards to the event so she would be psychologicaly accepting to the events.

 

delay in second stage Posted by dr sheela N.

a =initial assessment include reviw the antenatal recode to check for the fetal weight  ,risk factor gdm, past obst historty ,m/o/d instrumental ,difficulty in labour weight of previous babies, history gdm cephalopelvic dispropotion may the cause.documented plan if previousely made.

 i will assess her general condation bmi , dehydration ,about need for pain relif ,assess abdomen   uterine contraction strenght ,frequency. any fifth palpable of the head . partogram slow progres in first stage ,ctg for any s/o fetal distress,

v/e confirm full dilatation,presenting part ,postion ,station ,caput ,moulding ,membrane intact or rupture ,liqure color

pt is on epidural or not ,wishes of the pt.

b- indication fr c/s if there is(1) s/o obstructed labour ,such as bandle ring ,more then one fifth head is palpable ,caput ,exessive mouding ,p/p above ischeal spine ,(2)  malpresention brow  (3) fetal distress pathological ctg with high p/p (4) maternal wish (5)there is no decsent of p/p with an attempted vaginal delivery or with three pull with instrumental delivery.

c - maternal morbidity can be reduced by  proper assessment of the risk factor from pt antenatal record with her clinical condition,and partogram .correction of dehydration ,adequate analgesia to avoid c/s in advance second stage .

   -early involvement of senior in decision making for second c/s.

   -supervised  training of the junior staff of difficult c/s

 -  intra operatively uterine uterus should be stablised before incision ,bladder should be reflected down to avoid injury to bladder and ureter .

 - uterine incision should be high up in lowersegment because lower segment is usuaselly streched in second stage c/s to avoid inadvertant incision in vagina  ...

- u -shaped or crecent incision can be used to open uterus to avoid lateral extension ,vasculer injury

-in case head is deeply impacted deliver by pull method traction on shouder ,operator hand should below head and flex the head deliver or push by assestant from below .   

-proper haemostatis ,in case of extension os incision ,use of drain ,bladder catheterisation

-prophylactic antiboitcs .thromboprophylaxis.

-clear documentation ,incident report ,

-hdu care and monitorig

-debriefing of patient and family

 

 

 

 

 

 

 

Essay 342 Posted by Samira  K.

1-My assessment will start with review of her clinical records esp.Wt.of previous baby,previous spontaneous or instrumental delivery,previous shoulder dystocia,any 3rd or 4th degree perineal tears,PPH with blood transfusion.

Regarding current pregnancy any fetal concern like Small for gestational age,Macrosomia,(i will check if any recent Scan available for Estimation of fetal age).I will examine B.P.,pulse,temperature,pain score and any sign of dehydration.If Pain relief is adequate any sign of distress.I will check the trace if is just suspicious or abnormal .I will palpate abdomen for fetal Wt.and engagement by 5ths.On vaginal examination if membranes are intact or ruptured,position,presentation of fetal head,station,caput and moulding.colour of liquor,amount of bleeding if any.Check HB level and if Type & Save is done.

2-If women is pushing actively for 2 hrs.with good anagesia,suppot and encouagement and still head is >1/5th palpable and above ischial spines.

clinician not trained in instrumental delivery.

Maternal request

Fetal malposition (deep transverse arrest).Malpresentation(Mento posterioror brow)

If sign of CPD like pelvis is not clinically adequate or significant caput & moulding,vulval edema,hematuria,bandal'"s ring present.

Fetal tracing is abnormal with Meconium stained liquor or bleeding or FBS shows ph <7.2 and instrumantal delivery is not a safe option.

3-Clinician should be trained for instrumental deliveries to avoid cesarean Section.But if is is necessary than multidesciplonary approah can reduce morbidity .In order to reduce PPH alert blood bank,call senior obstetrician for help,Ask anaesthesist to give regional anaesthesia if not on epidural.Apply good surgical technique transverseincision(Smiling incision) high in lower segment,Active management of 3rd stage,CCT and 10 units of i/m oxytocin at delivery of shoulder.Dissect bladder down before uterine incision.

To reduce risk of infection apply general infection control measures together with Proper srubbing of abdomen & prophylactic antibiotics.

To reduce risk of VTE advice LMWH together with early ambulation & stockings.

Indwelling catheter for 12 hrs to avoid urinary retention as bladder will be edematous with prolong second stage.

To avoid Psycological impact on women incidents should be explained later on in a sensitive way & suppot provided.Help of social worker if needed.

Essay 342 Posted by Samira  K.

Sorry for Estimated fetal age.It is fetal Wt. Some words has missing letters sorry.

Essay 342 answer Posted by Mohamed A.

 

A) Assessment:

undue prolongation of the second stage of labour can potentially result in maternal and or fetal compromise. and the decision  to intervene should balance the risks and benefits of continuing pushing as against operative delivery.

Assessment should include maternal behavior, effectiveness of pushing and fetal well being

I will review previous obstetric history, mode of delivery, weight of the baby and complications as shoulder dystocia or perineal injuries.

I will review obstetric notes  for estimated fetal weight and suspected large baby.

I will assess general maternal condition including pulse blood pressure and temperature,is she started pushing or not.

Her level of hydration, level of pain and need for pain relief. epidural anesthesia if placed may be  associated with prolonged second stage. I'll check for bladder fullness, amount and color of urine (hamematuria indicating obstructed labour)

 

I will perform abdominal examination to assess the frequency and duration of contractions, any tenderness, the fetal size, presentation, engagement and if there is a pathological retraction ring (bandle's ring). Fetal heart rate may be assessed by intermittent auscultation for 1 minute after a contraction at least every 5 minutes or by reviewing the CTG if attached.

I'll perform vaginal examination after her consent for  vulval & vagina edema  indicating obstructed labour. condition of membranes and color of liquor. Assess the bony pelvis, fetal presentation, position and station, flexion, caput  and moulding

I will enquire about the woman expectations and concerns if an operative delivery or cesarean section is considered.

 

B) Indications for emergency C.S.:

 

Evidence of cephalopelvic disproportion as severe caput and moulding and non-engaged head. Malpositions and malpresentations as brow presentation where the presenting diameter is mento-vertical measuring 13.5 cms which is incompatible with vaginal delivery. Mentoposterior position is an indication of emergency c.section as extension can't occur. 

Evidence of fetal distress where operative delivery failed or not suitable (more than 1/5th of the head palpable abdominally and vertex above the ischial spines.

Maternal request for c.section or refusal of operative delivery. Signs of obstructed labour and impending rupture uterus as bandle's ring, hard and tender uterus maternal and fetal distress. 

 

 

C) Minimizing maternal morbidity from second stage caesarean section

Site in-dwelling urinary catheter is important to decrease the incidence of bladder injury. Pre-operative IV antibiotics (1st generation Cephalsporins oar ampicillin) to be given after delivery of the baby.

Assess thromboembolic risk , offer TEDs, early mobilization, good hydration (intra and post-operative) and LMWH where appropriate.

Cross match 2 units packed RBCs, cell salvage may be used if available where woman refuses donated blood. In extreme cases the use of O Rh negative red cells can be used. Also recombinant factor VIIa can be used in life threatening postpartum hemorrhage.

The use of epidural anesthesia has the advantage of decreasing blood loss due to lower arterial and venous pressure, reducing the rate of DVT and better pain control may allow earlier ambulation.

Operative measures include using the Joel Cohen incision, uterine incision should be C-shaped to minimize the incidence of angle extensions. Non-closure of the visceral and parietal peritoneum.

Active management of the 3rd stage as there is an increased risk of uterine atony using Oxytocin 10 IU intramuscularly, syntocinon infusion and  Methergine 0.5 mg i.m. provided there are no contraindications

Proper training is important, call for help from a senior obstetrician in the event of postpartum bleeding should not be considered as loosing face.

Anti-D should be given to Rh negative mothers where the baby is Rh positive.

 
anuradha n Posted by anuradha N.

I would like to take her previous delivery history for any difficulties encountered or review labor record if available.Present antenatal record of suspected macrosomia,diabetes should be seen.During labor her progress in 1 stage,partogram assessment,latest pv findings to be looked.Clinical examination should include dry tongue for  sign of dehydration,pulse,BP.Abdomial examination-uterine contractions,strength,duration,relaxation phase,level of fetal desent(head palpable or not),bladder distention,streched lower segment ,FHS is assessed.Per vaginal examintion to look for vulval edema,confirm presention and position,level of head,position of occiput,amount of deflexion,caput,moulding,color of liqor,any fresh vaginal bleeding.Enquiry of epidural in situ to be made as delay could be due to epidural flow. 

b)Indications for cesarean in her are-Signs of obstructed labor(streched lower segment,severe degree of moulding),

deep transeverse arrest,brow presention due to marked deflection,presence of mento posterior position,macrosomic babay with anticipated shoulder dystocia,non descant of head below 0 station,inexperiance to perform mid cavity operative delivary if fetal distres arises,failed operative vaginal delivary

c)To minimise maternal morbidity from cesarean the  following precautions are taken.

      *prefer regional anesthesia in preference to general anesthesia(GA) as risk of aspiration,bleeding are more with GA

       *If GA is used ,prior adminitration of antacids,antiemetics,use of cuff endotracheal tube

        *arrange for blood,take crossmatched sample

        *Call for help of senior obstetician,anesthetist,ot staff,

         *Prior bladder catheteristion to reduce the the risk of damage to bladder

         *Use of adequate curved upward incision over uterus to prevent lateral extension.The incicion should be slightly below UV fold of peritonium to avoid injury into vagina.An assisstant can push the head from vagina to minimise difficult head delivary and lateral extentions.

        *Immediate clamping of bleeding vessels to minimise bleeding,use of oxytocics after cord clamping,Withholding manual removal of placenta minimises the risk of endometritis.

*Early identification of bladder injury by suspected hematuria

*Use prophylactic antibiotics after cord clamping prevents infection

*use of prophylactic heparin post operatively to pevent risk of thrombosis

*Encourage post op early mobilisation and oral feeds accordingly

essay 342 answer Posted by SRABANI M.
  1. Assesment includes H/O previous delivery of any big baby or instrumental delivery, size of the baby of present pregnancy including IUGR or large for date, how long she is actively pushing and amount of urine output;Genaral examination includes BMI,pulse for tachycardia, BP, temperarture, sign of dehydration; Frequency, strength and duration of uterine contraction and partogram should be  checked along with mode of pain relief including entonox, epidural or without anything; P/A examination includes presentation, engagement, how much fetal head is palpable per abdomen or full bladder; P/V should be done with consent and chaperon to confirm presentation, position, station, status of membrane, if head caput and moulding and clinical assessment of pelvis;FHR should be monitored by auscultation or CTG to detect early of any abnormality;
  2. Emergency LSCS is indicated in fetal distress including pathological CTG, scalp ph less than 7.2 and contraindication of instrumental delivery like fetal head more than 1/5thpalpable per abdomen and also after failure of instrumental delivery
  3. LSCS should be done by experience obstetrician with good assistance and proper exposure preferably with consultant’s presence along with proper relaxation after anesthesia by experienced anesthesist; Antibiotic prophylaxis, thromboprophylaxis, use of antacid, anti-emetic and regional anesthesia will reduce morbidity; Bladder should be catheterise and should be kept post-operatively till mobile; Surgical technique includes pushing bladder down, making uterine incision higher on lower segment, blunt extension of uterine incision, safe technique to lift up the deep down head or pushing from below reduce complication; Urosurgeon or general surgeon should be involved if any bladder or bowel injury; Noting and placing suture properly at the uterine angles reduces bleeding; If any extension of incision early involvement of consultant is necessary; hemostasis  should be secured and if necessary abdominal drain will be put; If any massive hemorrage early blood transfusion with the help of blood bank and involvement of haematologist is required; Post natal debriefing by senior obstetrician reduces psychological morbidity
Gulshan Posted by PAUL A.

My plan to answer this question will be as follow:

a)   ASSESSMENT OF WOMEN

History

Previous delivery notes

Current pregnancy antenatal notes

EXAMINATION

Maternal wellbeing

Abdominal exam

Vaginal exam

CTG

b) INDICATION FOR DELIVERY BY C.S

Maternal wishes

Maternal condition (Not indication)

Fetal condition (not indication)

c:  MINIMISE MATERNAL MORBIDITY BY

Proper procedure ? meaning

Experienced person

Antibiotic

Thromboprophylaxis

Perioperative Care ?? I would look at causes of morbidity – haemorrhave, infection, visceral injury, VTE

 

My answer to this question will be:

 

a; First thing should be to see maternal condition and fetal condition and deal if any emergency First thing in your plan was Hx. I will review her previous delivery notes for birth weight (1) of first baby, mode of delivery whether spontaneous or operative vaginal delivery or any obstetrics complications such as shoulder dystosia, or perineal tear.

I will review her antenatal notes for fundal height measurements, growth scan or if third trimester growth scan done(1). Review her blood results especially Hb, glucose level. I will find women wishes for mode of delivery.

Examination includes maternal BP, Pulse, temp and hydration status(1). Abdominal examination for fetal size and head engagement (1). Frequency and strength of contractions. Evidence of macrosomic fetus or high head suggestive of obstructed labour. Vaginal examination to find cervical dilatation (fully), to confirm absent membrane, fetal presentation, station of presentation, colour of liquor, and presence of caput and moulding(1). Exclude malpresentation like brow or face. Assess fetal wellbeing by fetal heart rate(1). Commence CTG if not started yet.

b; Indications for delivery by CS are maternal wishes (1)and delay in second stage of labour with maternal exaution (why not vaginal operative???). Early CS prevents difficult CS later or difficult operative vaginal delivery. Evidence of obstructed labour due to cephalopelvic disproportion suggestive from abdominal and vaginal examination. Malpresentation (1)like brow, face mainly mentoposterior. Fetal compromise from pathological CTG or meconium stained or blood stained liquor(why not vaginal operative??)

c: Cesarean section in second stage of labour is associated with high maternal morbidity, fetal trauma (asked about MATERNAL)caused by difficulty in delivering impacted fetal head. It can be extremely difficult. Appropriate selection of case (which ones will you not do and what would happen to these women???). CS by experienced person or under continuous supervision (1)of senior obstetrician. Proper pre operative assessment by checking Hb, prescribe prophylactic antibiotic (1)one dose of cephalosporin or ampicillin. Assess for thromboembolic risk and offer TED OR prophylactic  LMWH (?? Pre-op??). Insert in dwelling catheter. Apropriate anesthesia (what is appropriate??). Selection of appropriate abdominal incision and uterine incision (what is appropriate?). To avoid entering too low and inadvertently go into vagina identify uterovesical fold and then incision should be made 3cm below it (?? Where did you get this from???). In case of impacted fetal head consider pushing the head from below in relaxed uterus. Good surgical technique with good haemostasis. Continue post operative monitoring until women become stable. Provide support to help breastfeeding (how does this affect morbidity? Where is it in your plan?). Provide analgesia (where is it in your plan?). Monitor wound healing. Discuss reasons for CS and implications for future pregnancy (where are these in your plan??).

Yingjian Posted by PAUL A.

(a) There is a delay in the second stage of labour in this case. I would assess her by taking a history, focusing on her previous delivery. I would like to know if it was a normal vaginal delivery or operative delivery and if there were any birth complications such as shoulder dystocia, 3rdor 4thdegree perineal tears, as well as the birthweight of the previous baby(1). I would also like to ascertain if there are any anticipated problems in her current pregnancy such as possible coagulopathy in the fetus that would preclude any instrumental assisted vaginal delivery.

Next I would assess her progress in the first stage of labour, whether membranes were ruptured or it was augmented with oxytocin, and whether she has effective epidural analgesia(is epidural the only effective analgesia in labour?). I would also find out the duration of time she has spent pushing, and if she is exhausted. Maternal wellbeing would be ensured by looking at her temperature, vital signs such as her blood pressure and heart rate (hydration). I would carry out an examination of her abdomen to palpate for the fetal head (more precise detail - engagement)and to estimate the size of the fetus, as well as palpate the frequency of contractions. I would ensure that her bladder has been adequately drained. I would do a vaginal examination to confirm the presentation, station and position of the fetal head (caput, moulding). I would like to ascertain fetal wellbeing by auscultation of the fetal heart (1), look out for any meconium staining in the liquor, and to review fetal scalp blood sampling results if any.

b) The indications for delivery by emergency caesarean section would be that of no progress in the second stage of labour in the presence of factors (such as fetal head more than 1/5thpalpable abdominally, station that is above +1 (is zero station indication for CS?), clinically inadequate pelvis, lack of expertise for operative vaginal delivery) (get someone with expertise – not indication for CS)  that would preclude a safe operative vaginal delivery, fetal distress (? WHY NOT VAGINAL OPERATIVE?), failed instrumental vaginal delivery or maternal informed choice of caesarean delivery over instrumental delivery (1)in cases deemed suitable for operative vaginal delivery. Rarely, if there is cord presentation or mentoposterior face/ brow presentation(1), an emergency caesarean section would be indicated.

 

c) I would minimise maternal morbidity from Caesarean Section by ensuring that the risk of infection is minimised by administering a prophylactic dose of perioperative broad spectrum antibiotic (1) and trying to avoid manual removal of the placenta. I would minimise her risk of bleeding surgically by trying to avoid the risk of lateral/ downward extension of the uterine wound by making a high transverse incision that is U shaped, using uterine relaxants Would this not cause PPH?or trying to disengage the fetal head vaginally prior to surgery in a case of a deeply engaged fetal head, sending blood for group and match, and to actively manage the 3rdstage of labour (1)by giving intravenous oxytocin in a slow bolus and deliver the placenta by controlled cord traction. An infusion of oxytocin would be considered thereafter.

 

I would minimise risk of aspiration and pneumonia and the risks of intubation by advocating regional anaesthesia (1). Deep venous thrombosis risk would be minimized by doing a risk assessment for her and starting appropriate prophylactic measures like mechanical calf compressors or low molecular weight heparin at a suitable timing (when??). Bladder injury would be minimised by a high transverse incision as well as ensuring that the bladder is drained with a urinary catheter prior to surgery(1). Lastly, I would ensure that a consultant obstetrician has been informed of the case as a second stage Caesarean section can be challenging so that he or she can avail himself/ herself if there is any difficulty encountered(1).

Swaleha Posted by PAUL A.

Assesment will include history and examination (not necessary).Review of her antenatal card for record of previous delivery and for the baby weight(1).Her antenatal record  during this pregnancy,checking her BMI at booking,OGCT (?? Why??),and any recent fetal wight estmation(1).Examination ; General exam ,how the women apperas,is she distressed ,exhausted or tired.Has she recieved any analgesia(epiduarl)(do not ask the examiner questions).Check her vital signs.Abdominal exam,to asses the size of baby,frequency and  strength of contractions,presentation ,how much palpable abdominaly(1),or if the bladder is palpable.Vaginal exam ;empty bladder if palpable before ve,check urine for ketones.On ve asses for any malpresentation,malposition,station,caput,moulding (1)and color of liqour.Fetal assessment through CTG (why should she be on a CTG?).Check if the patient is on synto infusion,if she is ,for how many hours & how much units on flow now (what difference will this make?).Is epidural analgesia sited,if yes,when & how well it is working.When patient has taken her last meals(if planning for LSCS (what difference will this make? Will you wait 4h before doing CS???))

Indications for emergency LSCS would  be Abnormal CTG (NO),Non-progress of labour in 2nd stage inspite of good uterine contractions (no – vaginal operative if possible),relative CPD (as opposed to absolute CPD? What is relative CPDand why not correct it?)as would be indicated by caput and high head,maternal exhaustion,meconium stained liq along with abnormal CTg and fetal malposition (none of these is an indication for CS – you will do vaginal operative delivery).

Senior obsterician ,should be present.Blood sample should be sent for group & cross match.Patient should be catheterized with Indwelling foleys  catheter (1).Prophylactic antiobiotics pre-operatively.Second stage LSCS are associated with bladder injuries,extension of uterine angles,extension to cervix and vagina,and PPH.During LSCS parietal peritoneum should be opened high up to prevent bladder injury,uterine insicion should not be very low,it should be J-shaped.Head should be pushed from down by assistant, if very low in vagina,to prevent extension of uterine angles.20 units IV synto infusion to prevent PPH (would you give a bolus dose?).Post operatively  LMWH for thromboprophylaxis should be given(1).

Answer 1 Posted by Murad A.

 

Upon arrival , i will start by taking a history from the patient , relativea and attending nurse . History include the general health status of the mother , any medical comorbidities , any previous surgeries i.e myomectomy or pelvic surgeries. Special consideration to the history of previous delivery , the birth weight and delvery details of the frst child .

 I will review the antenatal records for the dates and growth and the latest estimated fetal weight .Any antepartum events should be reviewed and taken under consideration .  I will review the intrapartum events with the attending midwives to check the admission presentation , pelvic exam , adnf the total duration of labour . Patients who has protracted fisrt stage have higher incidence of prologed difficult second stage . The use of oxytocics or not and the time initiated . The status of membranes whether ruptured spontaneously or artificially . 

 Bed side assesment should include general exam and status evaluaton of the patient . Abominal examination to assess presentation and a rough estimation of the fetal weight and special attention to the head engagment I.e how many fifths is passing by the pubis . The CTG should be reviewed from the start of labour to make sure no signs of suspected fetal jeopardy  exists .

Palvis exam should confirn the full dilattion , and station of the presenting part . Signs of obstructed abour like excessive molding and caput succedanum > +2 should be roled out . The membranes status and liqour color should be noted . The pelvimetry is nonconclusive at the second stage and taking in consideration that the patient had a previuos vaginal delivey it is likely to be adequate .

 Caesarean section is indicated if there is fetal indication for immediate delivery without possible instrumental delivey including suspected fetal jeopardy " abnormal CTG or thick meconium " , Abnormal presentation " non-cephalic . persistant abnormal position " . Maternal indication if the mother in distress or requesting caeserean section . or any medical indication that preclude prolonged delivey . If signs of cephalopelvic disproportion is suspected with signs of obstruction , No attempt for instrumental delivey should be attempted and Caesarean section should be done

Caesarean section  in second stage should be done by a senior obstetrician as risks of bleeding and extentions are higher . Regional anesthesia is preferred neverthe less if General anesthesia is required it is imperative to us prophylactic measures including antacids and careful intubation . a surgeons assistant should be available to push the head " presenting part from the pelvis " . the uterine insicion should be higher then usual as the lower uterine sigment is mostly balooning from prolonged second stage  . Antibiotics should be given to minimize postpartum endometritis . Bladder catheterization and thromboprophylaxis as local protocols .

     or o 

 

 

 

Ali Naveed Posted by PAUL A.

In the assesment  I will quickly why do you need to do it quickly? go through the notes of this patient , her past history of labour , size of the previous baby (1) and instrumental delivery. The general assesment including , epidural usage ,  maternal exhaustion, signs of distress(what are these?), vital sign record, cardiotocographic trace (why should she have been on a ctg?), partogram will be reviewed to assess the overall condition of the patient and the fetus if there are signs of maternal and fetal distress the delivery will need to be expidated. I  will assess the fetal postion per abdominally and if the presenting part is still high that is 5/5th palpable or 4/5ths palpable the the delivery is highly unlikely (what about 3/5? Or 2/5?). The number of contractions adequate conbtractions are 4-5 per 10 minutes of 40- 45 sec duration (what will you do if contractions are ‘inadequate’?). Any thing less than this can be augmented with oxytocin infusion (NO – SEE NICE GUIDELINES). Upon the vaginal examination i will look for the adequacy of the pelvis with respect to the clinical assesment of the baby size. , i will feel for the moulding , caput , and station of the fetal presenting part, if the station is low i.e 2+ and 1+ there is a high chance that the fetus may deliver. However if there is a malpositionj like brow or face  (these are mal-presentations) with chin posterior presentation then decision for emergency caesarean section can be taken .

b) In case of fetal distress with type II decelerations (no such thing!!!) and high presenting part  delivery by caesarean section is warrented.

2. Signs of obstructed labour , malposition , malpresentation , cephalopelvic disproportion all should be noted. Brow presentation is an absolute indication for caesarean section(1)

3 . If there is failure of instrumental delivery.  After three applications if there is failure than an emergency caesarean section should be performed.

 (DO NOT NUMBER YOUR ANSWER)

c) Morbidity related to  second stage caesarean section is higher than elective and regular emergency caesarean sections.(WASTE OF TIME & SPACE)

the following measures will be undertaken to minimize the morbidity :

1. Informed consent to be understood and signed by the patient and partner. 

experienced obstetrician to perform the caesarean section.

2. Insertion of foleys catheter .

3. I/v antibiotics prophylactically  to minimize risks of infection before cord clamping.

4. Thromboembolism risks are highest following emergency caesarean sections. Ted stocking s and Low molecular weight heparin to be given to the patient 12 hours postoperatively.

5. Request for  urgent  x matching of  blood .

6.  openning perital peritoneum high up to avoid  bladder injury.

7. A second operator may be required to push the presenting part up .

8. Prevention of post partum heamorrhage,  by early resort to medical methods , if not effective than Surgical options like application of B Lynch / modified Blynch should be resorted to at an early stage.

9 Rarely internal ilac artery ligation or a hysterectomy may be required to stop heammorhage, for this a full postpartum heamorrhage drill should be undertaken. 

WHY DID YOU NOT NUMBER YOUR ANSWER  IN PART A? WHAT IN THE QUESTION PROMPTED YOU TO NUMBER YOUR ANSWER?

VANEEZA Posted by PAUL A.

A)Patient  should be asked about complications encountered during last delivery including prolonged second stage of labour,instrumental delivery and baby weight (1).antenatal notes of current pregnancy should be reviewed for any sonographic evidence of macrosomic baby(1).Progress of labour should be assessed by reviewing partogram,time and dose of syntocinon infusion and analgesia recieved.Patient will be assessed  clinically by checking vital signs and hydration status(1).Examine per abdominally  (1) and assessed clinically size of fetus,proportion of palpable head,intensity,duration and interval between  uterine contractions and any tenderness.Foetal assessment should be done by reviewing CTG (why should she have been on a CTG?) to exclude foetal disstress.On vaginal examination vulval oedema,vaginal bleeding,colour of liqour and urine should be observed.Vaginal hottness,cervical oedema and dilatation,position and station of presenting part along with caput and moulding should be assessed and relative CPD (what is this??) should be ruled out.

B).Foetal distress is one of commonest indication of delivery for emergency LSCS (why not vaginal operative delivery??).Foetal malposition(brow,face (THESE ARE MAL-PRESENTATIONS!!!!),compond presentation and deep transverse arrest) and failed instrumental delivery is another indication for emergency C/S.Maternal exhaustion (why not vaginal operative?) and wishes (1) will also  end up in emergency LSCS.

C)Maternal morbidity for second stage C/S can be minimised if it is taken by senior obstetrician and senior anaesthetist with blood grouped and cross matched before.Bladder injury can be prevented  by catheterization prior to surgery  and mobilization of bladder during surgery(1).High opening of the parietal peritonium  will prevent vaginal and cervical laceration.PPH can be prevented by oxytocin infusion (what about bolus dose?) meticulous haemostasis can be secured.Prophylactic antibiotics (1) should be gived to prevent post partum sepsis.LMWH for  7 days(provided no other risk factors) along with early mobilization and preventing dehydration will reduce risk of thromboembolism(1).

Bee Fong Posted by PAUL A.

A:

            Prolonged 2nd stage is associated with maternal and perinatal morbidity and mortality. This can commonly occur in nulliparous and occasionally in multiparous women.  (THIS IS A TOTAL WASTE OF TIME AND SPACE)

            The assessment of this patient will involve a review of her antenatal history.  Any concern antenatally including heavy vaginal bleeding or repeated reduced fetal movements are noted as it may indicate an already compromised fetus (DO you really do this when you are asked to review a woman in the second stage of labour???). Growth of the fetus  and liquor volume of the fetus if she had ultrasound scan antenatally is noted for the same reason as well as to rule out macrosomia(1).

            The gestation age of the fetus is noted as the baby may be postmature or premature before 37 weeks (read the question). Induction of labour (read the question!!!!!) is considered high risk. The colour of the liquor should be enquired as meconium stained liquor may suggest a compromised baby and will need delivering sooner and duration of rupture of membrane as may suggest impending infection. The progress of labour and strength  and  length of contraction are also assessed to look for abnormal labour dystocia and possibility of developing infection.

            Maternal well-being need to be assessed with temperature and heart rate which may suggest infection. Abdominal palpation is done to rule out macrosomia and check for lie, position and engagement of the baby(1). Vaginal examination will need to be performed to look for obstructed labour with caput, moulding and maldescent of the baby. The position of the fetal head will direct us as to try for instrumental delivery in the room or theatre or may justify caesarean section(what about malpresentation?).

            Fetal well being need to assessed with continous electronic fetal monitoring if she has not had it yet (1). If there is any delay in delivering this lady, fetal blood sampling may be indicated (is delay in delivery an indication for FBS?? (-1).

 

B:

            Indication for caesarean section is justified if there is fetal or maternal morbidity or mortality involved (? meaning). However, maternal request and wishes(1)  need to be considered in the decision making process.

            One the main reason for caesarean secion is fetal compromise where there is abnormal CTG or fetal blood sampling needing urgent delivery of the baby(why not use a pair of forceps??). This includes cord prolapse. Presentation of the baby may prevent the head from descending ie deflexed OP position, brow or mento-posterior face presentation(1).

Women who had planned for caesarean section may come in labour and having to have it as an emergency ie breech presentaion or previous caesarean sections. It may be needed to resuscitate the women in placenta abruption or placenta praevia (is this what you were asked about?). Women with obstructed labour and cephalo-pelvic disproportion (how do you make this diagnosis?) are justified to have caesearen section.

 

C:

            Early recognition of any complications is the key to prevent maternal morbidity and mortality. Therefore, an experienced surgeon and anaesthetist need to be informed and present at the delivery. Baby’s head will be often impacted into the pelvis and may be difficult doing  an abdominal delivery. This can cause extension to the uterine incision or even bladder injury. This can be prevented by adjusting the operating table to a suitable height and a second person may be required and be ready to push the baby up vaginally.  Injury to the bladder can also be prevented by putting a catheter in and ensuring the bladder is reflected back(1).

            With any extension of the incision as well prolonged 2nd stage, there is high risk of postpartum haemorrhage. Blood should be crossmatched and anaemia should be rule out with full blood count. Anaesthetist need to be informed to give 5-10 units of syntocinon for 3rd stage and infusion of 10 units syntocinon an hour to maintain uterine contraction(1). Further drugs may be need such as ergometrine and haemabate. We should have low threshold to call for senior help and to give transfusion if necessary.

There is a risk of infection from being in labour for a long time as well as from the opertion. Broad speectum antibiotics should be given prophylactically (1) to prevent infection. They are also at risk of developing venous thromboembolism. Hence the women should be kept hydrated in labour and prophylaxis anticougulant postnatally should be given according the national guidelines and local protocol(1).

Gomathy Posted by PAUL A.

a, I would start my assessment by gathering more information, like her hydration status, When was bladder emptied or when and how much volume urine passed, as full bladder can act as tocolytic and obstruct decent, Number and duration of contractions in 10 minutes and compare them with previous contractions, if it is slowing, Any recent analgesia, that made labour to slow down. Then I will assess her generally for Hydration(1), Alertness and pain relief and CTG if one is started (1) or advice for one. Proceed to Abdominal examination for Uterine contour, tone between contractions, contractions, Lie, palpability of Presenting part (1) abdominally, full bladder and any signs of obstruction or dystocia. Proceed to Internal examination with consent for cervical dilatation, presenting part, station, position, Caput or moulding(1), colour of liquor, general adequecy of pelvis, if possible decent during a contraction.

b,Indications for caesarean section could be broadly based on urgency (mayernal or fetal) or Non deliverability by vaginal route.They are signs of obstruction like Bandls ring, severe moulding (1) with or with out caput, deep transverse arrest, undiagnosed malpresentation like brow or (1) mento-anterior or High head at or above spines, signs of Abruption with fetal distress and fetal distress(why not vaginal operative? Maternal wishes).

c, In her case, if she has ranitidine, known to prevent incidence of Gastric content aspiration, Group and save and inform the blood transfusion service about indication clearly, alert co-ordinator, theatre staff and scrub nurse about risk of excess bleeding high in her case,  by performing LSCS under spinal rather than GA(1), Appropriate education or discussion (about crucial steps of assessting) with the assissent, informing consultant on-call for standby, adopting steps to minimise unnecessary blood loss form skin level, optimal technique for extraction of fetal head by being cautious about angle extension, by seeking help appropriately and early if there is angle extension or atonicity noted after delivery of baby, By adminstering prophylactic synto 40 IU infusion immediate post delivery(would you give bolus dose? ), if in any doubt leave gravity drain (intra-abdominal), Prompt estimation and replacement of blood loss from surgary, TEDS and Thromboprophylaxis (with what?), encourage, Breast feeding, Early mobilisation and Debriefing to patient which helps her to identify signs of infection or collection at a later stage.(This is all one sentence – there isn’t a single full stop in this entire paragraph. It does not make sense )

ZAITOUNI Posted by PAUL A.

a)Assessment of the woman

Reveiw of obestatric history for birth weight of prevouse baby(1).Antenatal history should be reviewed from the notesand any US scanes.reviewed witch may indicate a  cause of dystocia as macrosomia(1)

Inquire about maternal pain and wishes for pain relief(1).CHICK MATERNAL CONDITION (how?)

Determine womans WISHES about mode of delivary .

Check CTG (why should she have been on CTG?) to make sure that  there is no sign of foetal distress.

Complete abdominal and vaginal examination should be performed to palpate duration frequency and strength of uterine contractions  To  see if any fifth of the head can be palpated per abdomen (fetal size??)

A vaginal examination to confirm full cx dilatation, to ascertain station of the head, position and presence of any asynclitism (presentation, caput, moulding).

All findings should be documented and signed.

Exclude disproportion as big size baby ,sever caput ,moulding (1) and loosly applied cervix .

b) INDICATION for delivary by ceserian section :

If examination showed malpresentation (like what?) or signs of obstruction as moulding or caput (? Any degree of caput or moulding?).If malposition of the head or asynclitism is diagnosed (these can be corrected with instruments).If foetal distress as CTG abnormalities or thick meconium occured (why not use a pair f forceps??).

If maternal condition not stable (are you going to do CS in a woman who is not stable?). if mother wishes for CS(1).

C)Maternal morbidity from cs be reduced by:

Good surgical technique is key factor in reducing the morbidity.The lower segment incision should be high to avoid opening into the vagina.Wide lateral dissection should be avoided . The uterine incision should be concave upward rather than by tearing digitally .The foetal head should be delivered through the uterine incision in occipito anterior position , disengaging the foetal head  from the pelvis and rotating it to occipitoanterior position.Oxytocic agents should be given in third stage(1). If uterine atony occured vigorous uterine massage along with intramyometrial injectin of carpoprost .Direct pressure on bleeding pointes in placental bed  and figure 8 sutures should be taken.

Senior help should be summond in case of persistent haemorrhage and consideration for intrenal iliac artery ligation .B LYCH sutures should also be considerd to stem the haemorrhage.

(is haemorrhage the only cause of morbidity? Infection, VTE, visceral injury…)

J Posted by PAUL A.

a. I will enquire about the previous obstetric history including the weight of the baby(1)  and duration of labour. Present obstetric history will be reviewed from the hand held notes. .Type of pain relief will be enquired which would be of use in decision during delivery. Partogram will be seen to note the progress of labour. Abdomen examination to confirm fifths palpable, size of the baby (1) to decide on mode of delivery will be done.CTG will be reviewed (why should she be on CTG?) and gentle vaginal examination will be done after consent to assess the position, station, presence of moulding and caput, descent (1? presentation) with contraction and decide for the mode of delivery.

b. Pathological CTG and the station of the head above the ischial spine (1) will be an indication for caesarian section. Malpresentations like brow (1) is also an indication. Failed instrumental delivery after a trial and maternal wishes (1) are also indication for a caesarian section.

c.The main reasons for maternal mortality are hemorrhage, infection and thromboembolism. Preoperatively bladder should be catheterised(1). A stat dose of prophylactic antibiotic (1) should be given during induction to prevent infection. During the procedure, I will be careful in separating the uterovescical fold of peritoneum, pushing the bladder down and incision higher in the lower segment to avoid bladder damage. Difficulty in delivery of head will be anticipated and can be resolved by pushing the head from vagina or delivering as breach. Active management of 3rd stage (1) by given syntocinon infusion will be done. Postoperatively thromboembolism will be prevented by TEDS stockings and prophylactic Enoxapirin (1). Debriefing about the entire event after the procedure will be done to prevent psychological morbidity.

X Posted by PAUL A.

X

a)      She has a delay in second stage of labor. Pertinent history in regards to the delay in the first stage of labor is important. The presence of any epidural anesthesia for pain relief the use of diamorphin or entonox for analgesia must be assessed. The labor must be classified as spontaneous or part of an induction should also be important (? meaning). Use of oxytocins in labor and its dilution and dosage is also important (why??). The current estimation of fetal weight in her previous ultrasound scan or clinical estimation (1) is also important for future intervention. Previous history of shoulder dystocia, extended tears in previous pregnancy or post partum hemorrhage and complication is important for this pregnancy as well. Examination should include her body mass index as difficulty of anesthesia and technical difficulty for assisted vaginal delivery would be anticipated. Her hydration status (1) should be assessed as well based on her tongue coating, urine output in labor. Fundal height and clinical estimation of fetal weight is important to predict macrosomia. Engagement of the fetal head if 0/5 palpable is a prerequisite for operative vaginal delivery (what if it is 1/5 palpable?). Vaginal examination to assess the position of the fetus either occiput anterior or occiput posterior which could predict the technical delivery and the choice of the assisted vaginal delivery. The station of the presenting part, presence of caput and moulding (1) will be useful for assessing for choice of assistant vaginal delivery.

b)      The indication for caesarean section include if patient refuses for a instrumental delivery(1). If the prerequisite for instrumental delivery is not met such as still 2/5th palpable per abdomen (you said 0/5 above) and station is above the ischial spine(1). If clinically suspecting a macrosomic baby , or cephalopelvic disproportion (how do you diagnose this?) is also and indication for caesarean section which would be evident with severe moulding(1), and caput 3+ with swollen vulva. Other indication include malposition such as face presentation or brow presentation (are these malpositions or malpresentations????) which would be very difficult for instrumental delivery. If the accoucher is not skilled with the instrumental delivery would also be an indication for casarean section (no – they should get someone with the skills ).  If fetus is suspected to have any bleeding diathesis such as hemophilia or von willebrand disease is also a indication for caesarean section

c)       The maternal morbidity is reduced if it is done by a trained and senior doctor (? supervision). The use of proper analgesia and relaxant such as general anesthesia could be beneficial to deliver a deeply engaged fetal head (do you think GA is the safer option in this situation??? (-1). In technicas aspect the fetal head could be delivered by the surgeon with an assistant dislodging the head in between contraction thus preventing any extended uterine tear. Another important aspect is also proper catheterization and drainage of urine is paramount important as inserting an indwelling bladder catheter is difficult in a deeply engaged head(so what would you do?). The uterus must be closed in the usual manner and the use of syntometrine and uterine massage would be beneficial to reduce uterine atony which is common in second stage casarean section. The use of intrapartum antibiotics would be beneficial to prevent any infection (1) due to the excessive manipulation in this type of casarean section.  Prolong catheterization some time would be required for bladder healing and occasionally for urinary retention in this type of caesarean section.  She would also require VTE  prophylaxis with low molecular weight heparin,(1)  TED socks and hydration as it was aemergency caesarean section .  Proper documentation of notes and difficulty should be recorded and audited  for future references.  The patient should also be debriefed in regards to the event so she would be psychologicaly accepting to the events.

Sheela Posted by PAUL A.

a =initial assessment include reviw the antenatal recode to check for the fetal weight  ,risk factor gdm (??), past obst historty ,m/o/d (???) instrumental ,difficulty in labour weight of previous babies (1), history gdm cephalopelvic dispropotion may the cause.documented plan if previousely made (do not expect the examiner to fill in the gaps – this is a competitive exam).

 i will assess her general condation bmi , dehydration (1),about need for pain relif (1),assess abdomen   uterine contraction strenght ,frequency. any fifth palpable (fetal size) of the head . partogram slow progres in first stage ,ctg for any s/o (??) fetal distress,

v/e confirm full dilatation,presenting part ,postion ,station ,caput ,moulding(1)  ,membrane intact or rupture ,liqure color

pt is on epidural or not ,wishes of the pt.

b- indication fr c/s if there is(1) s/o obstructed labour ,such as bandle ring ,more then one fifth head is palpable ,caput ,exessive mouding ,p/p above ischeal spine ,(2)  malpresention brow  (3) fetal distress pathological ctg with high p/p (4) maternal wish (5)there is no decsent of p/p with an attempted vaginal delivery or with three pull with instrumental delivery. (You were not asked to write a list)

c - maternal morbidity can be reduced by  proper assessment of the risk factor from pt antenatal record with her clinical condition,and partogram .correction of dehydration ,adequate analgesia to avoid c/s in advance second stage .

   -early involvement of senior in decision making for second c/s.

   -supervised  training of the junior staff of difficult c/s

 -  intra operatively uterine uterus should be stablised before incision ,bladder should be reflected down to avoid injury to bladder and ureter .

 - uterine incision should be high up in lowersegment because lower segment is usuaselly streched in second stage c/s to avoid inadvertant incision in vagina  ...

- u -shaped or crecent incision can be used to open uterus to avoid lateral extension ,vasculer injury

-in case head is deeply impacted deliver by pull method traction on shouder ,operator hand should below head and flex the head deliver or push by assestant from below .   

-proper haemostatis ,in case of extension os incision ,use of drain ,bladder catheterisation

-prophylactic antiboitcs .thromboprophylaxis.

-clear documentation ,incident report ,

-hdu care and monitorig

-debriefing of patient and family

(DO NOT WRITE BULLET POINTS)

Samira Posted by PAUL A.

1-My assessment will start with review of her clinical records esp.Wt.of previous baby (1),previous spontaneous or instrumental delivery,previous shoulder dystocia,any 3rd or 4th degree perineal tears,PPH with blood transfusion.

Regarding current pregnancy any fetal concern like Small for gestational age(? Relevance to delay in second stage),Macrosomia,(i will check if any recent Scan available for Estimation of fetal age (? weight)).I will examine B.P.,pulse,temperature,pain score and any sign of dehydration (1 which sign?).If Pain relief is adequate any sign of distress.I will check the trace if is just suspicious or abnormal (is this how you classify CTG? Why should she be on CTG?).I will palpate abdomen for fetal Wt.and engagement by 5ths(1).On vaginal examination if membranes are intact or ruptured,position,presentation of fetal head,station,caput and moulding(1).colour of liquor,amount of bleeding if any.Check HB level and if Type & Save is done (why??).

2-If women is pushing actively for 2 hrs.with good anagesia,suppot and encouagement and still head is >1/5th palpable and above ischial spines(1).

clinician not trained in instrumental delivery (get someone who is trained).

Maternal request(what??)

Fetal malposition (deep transverse arrest(not indication for CS)).Malpresentation(Mento posterioror brow (what about mento-anterior brow?))

If sign of CPD like pelvis is not clinically adequate or significant caput & moulding (1),vulval edema,hematuria,bandal'"s ring present.

Fetal tracing is abnormal with Meconium stained liquor or bleeding or FBS shows ph <7.2 and instrumantal delivery is not a safe option.

3-Clinician should be trained for instrumental deliveries to avoid cesarean Section.But if is is necessary than multidesciplonary approah can reduce morbidity .In order to reduce PPH alert blood bank,call senior obstetrician for help,Ask anaesthesist to give regional anaesthesia (1) if not on epidural.Apply good surgical technique transverseincision(Smiling incision) high in lower segment,Active management of 3rd stage(1),CCT and 10 units of i/m oxytocin at delivery of shoulder.Dissect bladder down before uterine incision(? catheter).

To reduce risk of infection apply general infection control measures together with Proper srubbing of abdomen & prophylactic antibiotics(1).

To reduce risk of VTE advice LMWH (1) together with early ambulation & stockings.

Indwelling catheter for 12 hrs to avoid urinary retention as bladder will be edematous with prolong second stage (what about before the op?).

To avoid Psycological impact on women incidents should be explained later on in a sensitive way & suppot provided.Help of social worker if needed.