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.
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