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MRCOG PART 2 SBAs and EMQs

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Essay 365

Essay 365 Posted by Farrukh G.

 

A healthy 34 year old woman presents with spontaneous rupture of the membranes and uterine contractions at 39 weeks gestation. She has two previous vaginal deliveries and one previous caesarean section. She has been counseled and vaginal birth is planned. At 00:20, her cervix was 5cm dilated. You are asked to review her at 04:40 because the cervix is 6cm dilated. (a) Discuss your assessment of this patient [8 marks]. (b) Critically evaluate your management options [12 marks] 

Answer to Essay 365 Posted by ALi S.
A)I will ask in details about her obstetric history especially her previous caesarean section indication as well as reviewing her previous section surgical notes for any complications. Then her general condition since she had spontaneous rupture of membranes,symptoms like fever ,abnormal or offensive liquor drainage,diminished fetal movements and frequency and durations of contractions. Generally examined her temperature,pulse rate, blood pressure followed by abdominal palpation for scar tenderness and fetal lie presentation as well as assessment of engagement.. Vaginal examination after consent to confirm presentation and position , station and colour of the draining liquor. Baseline blood test after inserting IV cannula to check her Hb level and white cell count as well as CRP.I will review her CTG for any abnormalities in fetal heart and frequency and duration of her contractions. All initial assessment findings will be documented in her notes as well as discussion about her coping with pain and if any request for regional analgesia and her wishes for the delivery. B) options for management will depend on the assessment of her labour and if she still fit for VBAC Or not. If baby in cephalic presentation and delay of her first stage of labour is due to in coordinate uterine contractions ,I will discuss starting oxytocin infusion with her and with the on call consultant after expaliining the increased risk of scar rupture , and her limited mobility during the infusion and need for continuous monitoring and repeat examinations . If abnormal presentation as breech is found at vaginal examination plan will be changed to CS to minimise the perinatal and maternal mortality and morbidity If contractions were regular and c-ordinate ,her delay in progress can be due to cephalopelvic disproportion and plan for Caesarean delivery will be mandated to avoid the risk of rupture scar and fetal mortality and HIE . Explain that plan can be changed to emergency LSCS If fetal distress arises during the oxytocin infusion or when if any signs of scar rupture as increased tenderness ,vaginalbleeding or maternal tachycardia. Reassessment of the progress of labour 2 hours from labour augmentation . Delay in progress or no response will be indication for LSCS. ensure adequate analgesia before starting oxytocin infusion after disscusion the various method of analgesia. Available and her view to it. Ensure that there is enough support with her as well as care given to her by midwife as 1-1 care. Monitor her temperature every 4 hours and pulse rate and Bp hourly all will be charted in her partogram . Explain that VBAC success rate is about 60-72% and the benefit versus risk of having it. Ensure that all the details of examinations and the disscusion had been documemted in her notes
Posted by Ghida R.

A- I will ask the patient about the antenatal course during this pregnancy whether she had gestational diabetes, estimated fetal weight for her baby, I will also enquire about previous vaginal deliveries if they were assisted or spotaneous, the weight of the babies, difficult vaginal deliveries as this will point out to the adequacy of her pelvis, what was the interval from the previous c/section.

I will also have to assess patient height, weight and check her BMI as obesity (BMI>30) is associated with increased risk of failed VBAC.

I will check the general condition of the patient, as well as her vital signs searching for exhaustion and dehydration, shock, and assess if she has excessive pain, its location, back pain is associated with occipitoposterior position, and pain over uterine scar especially if it persists in between contraction might denote uterine scar rupture.

Abdominal examination will help to assess how much of the head is palpable, if 2/5 or more is palpable might denote an element of cephalopelvic disproportion.

then pelvic exam is to be done, to look for the position of the head by trying to feel the sagittal suture and the fontanelles. occipitoposterior position are associated with prolonged labours. Also signs of obstructed labour include excessive capput and moulding should be looked for.  I will also check for liquor if became meconium stained might point out to fetal compromise, vaginal bleeding and  change in fetal head station as these point to uterine rupture.  

I will review the CTG looking for fetal heart rate abnormalities as these might be the earliest signs of uterine rupture, as well as presence of contractions, frequency, whether she has adequate labour. Sudden cessation of uterine contractions might also denote uterine rupture.

B- the delivery should occur in fully equipped and staffed obstetric unit with the ability to perform emergency cesarean and with the possibility of requiring neonatal ICU. 

Multidisciplinary input from the consultant, anesthetist, operating theater, senior midwife, blood bank  should be sought.

In the absence of fetal distress and signs of obstructed labour, the patient should be allowed to labour and be timely reassessed in 2 hours to avoid in delay in diagnosis of labour dystocia which may predispose patient to ruputre of uterine scar. Pain management should be done, and epidural analgesia is not contraindicated in women with previous c/section admitted for trial of labour. IV line and continuous fetal heart monitoring should be instituted if not already done, blood should be sent for group and save, in the event of uterine rupture and bleeding, patient should be kept updated with her labour progress. Decision to sart oxytocin should be taken by the most senior physician. An intrauterine pressure catheter may need to be inserted to monitor uterine contractions.

in case of confirmed labour dystocia, cesarean delivery should be recommended after explaining the benefits versus increased risk of uterine rupture, hysterectomy and blood transfusion. A surgical consent should be signed before proceeding.

in the event of non reassuringe fetal heart rate and suspected maternal bleeding due to uterine rupture, emergency cesarean should be undertaken to safeguard the maternal life.

proper documentation on the CTG and in the records for maternal condition, fetal heart rate changes, pelvic exam and counselling of the patient should be done.

after delivery the baby's condition should be checked  and debriefing of the patient and her partber should be done by the surgeon as soon as possible after delivery.

365 Posted by LAILA C.

 

A) Cervical dilatation of less than 2 cm in 4 hours suggests delay in the established first stage of labour .

The woman should be asked about the time since leaking, color and smell of the liquor.  She  should be enquired about nature of pain, intermittent or continuous and  adequacy of pain relief. She should be asked if she has any shoulder tip pain suggesting scar dehiscence. 

 Maternal records are reviewed to note the weight of the previous babies, any evidence of macrosomia or complicated by shoulder dystocia.  Details of previous caesarean section  are noted if available. Antenatal records are reviewed  for fundal height measurements and growth scans to identify any suspicion of big baby.  Her emotional requirements are enquired. Her wishes regarding mode of delivery are determined.

Assessment includes recording temparature, pulse and blood pressure . Sunken eyes and dry mucous membranes indicate dehydration. Abdominal examination is done for subjective assessment of size  of the baby and to determine the fifths palpable per abdomen.  During abdominal examination, strength of the contractions and palpable palpable fifths of the head is assessed. Clinical evidence of big baby with high head suggests obstructed labour.

Vaginal examination is performed to note cervical dilatation, application to the presenting part. Position and station of the presenting part is identified.  Malpresentation such as brow presentation should be excluded. Marked caput and severe degrees of moulding suggests obstructed labour.

CTG recording is reviewed to identify any evidence of fetal compromise.

Colour of the amniotic fluid is seen for meconium stained liquor.

 FBC , group and Rh typing are done in case she requires any blood transfusion.

 

B)

After excluding malpresentation and obstructed labour, expected management can be adopted by performing vaginal examination every 2-4 hours.  Although vaginal delivery is less likely to happen with expectant management, this avoids complications associated with oxytocin.

 

The other option is augmentation of labour by oxytocin which is considered after discussion with the woman and consultant obstetrician. A successful vaginal birth carries better future obstetric performance as she has more chances of having vaginal delivery in her future pregnancies.  If she delivers vaginally, probably reduces the risk of neonatal respiratory problems.

The plan for the time intervals for serial vaginal examination and parameters of progress and indications for emergency C/S should be discussed with the woman and documented. The woman should be informed that the risk of rupture of uterus is 2-3 fold in augmented labours.

Oxytocin augmentation is abandoned and C/S is indicated in case of abnormal CTG, severe abdominal pain persisting between contractions, acute onset of scar tendernesss which suggest uterine rupture. Other signs of uterine rupture include abnormal vaginal bleeding or haematuria, cessation of previously efficient uterine activity with loss of presenting part. Maternal tachycardia, hypotension or shock indicates uterine rupture and necessitate emergency CS.

Cervical examination should done every 2-3 hours, preferably by the same person. It is ensured that Obstetric, midwifery, anaesthetic, operating theatre, neonatal and haematological support should be continuously available  The risk of blood transfusion and endometritis is about 1 %  

 

In the presence of obstructed labour or fetal compromise immediate arrangements should be made to deliver the baby by emergency caesarean section. CS is associated with anesthetic complications and operative morbidity. The decision of early caesarean section avoids difficult operative vaginal delivery and morbidity associated with late CS such as PPH.The risk of wound infection, haemorrhage, visceral injury and thrombo-embolism are increased in emergency intra-partum caesarean section. The risk of thromboembolism is 3 to 5 times more compared to vaginal delivery. CS is associated with adherent placenta in future pregnancies.

Posted by Lola B.

a) I will take a quick history, enquiring about the order or pregnancies which the caesarean section took place, and the indication for it. A previous classical scar will preclude trial of normal vaginal birth. Ask about estimated fetal weight and if there is adequate pain relief.

On physical examination, I will assess the skin turgidity, eyes for sunken eyes and mucosal membranes for dehydration. The fundal height and fetal size is palpated, as well as how many fifths the fetal head is palpable. On vaginal examination, I will note the position of the fetal head, look for any malposition or malpresentation, deliation, station, liqour colour and presence of caput and moulding, the presence of which will point towards cephalopelvic disproportion. Scar tenderness will be elicited. 

The CTG will be reviewed to ensure there is no suspicious or pathological trace. The frequence and amplitude of contractions will be noted. Also, if IV oxycotin infusion has been started for the patient. I will look at the urine bag for blood stained urine that will point towards CPD. I will look at the partogram for the progress of the labour thus far. 

b) The first option will be expectant management, to aloow a further trial of labour for a total of 8 hours. This has to be in line with the paitnet's wishes. The patient must be informed of the risk of scar rupture given the previous history of caesarean section. This option is also favouralbe if there are no overt signs of CPD like irreducible moulding or blood stained urine, and if there are factors unaddressed, like pain relief. The CTG must be reassuring . I will review her progress regularly,. as least every 1 hour, and will enrol the help fo a senior obstetrician in deicding the end of the period of trial of labour.

Next, we can consider the judicious use of low dose oxytocin infusion for labour augmentation. Especially if progress has been slow due to inadequate frequency and amplitude of contractions. The risk of scar rupture is further increased here. The CTG has to be watched very closely thoughout. I will perform regular vaginal examinations to monitor response, and examine the patient regularly for scar tenderness. If necessary, an FSE  can be insertd to help with monitoring of FHR.

Lastly, an emergency caesarean section can be called for, especially if ths is in line witht he patient's wishes and there are signs of CPD. This is made easier if a combine spinal epidural catheter is already in situ-- a quick top up is all that is required for regional anesthesia. This option will avert the risk of a long labour, which is scar rupture. But this has to be balanced against the risk of surgery, which is bleeding, infection and injury to surrounding viscera. Also to consider the future risks of 2 previous caesarean sections -- namely incresed risk of placenta praevia and accreta, and scar rupture. Steps must be taken to previous PPH, an active management of the third stage is carried out, together with a group and save of blood.

essay 365 Posted by sujata B.

Assesment of the patient

The findings in the case are suggestive of a suspicious delay in first stage. I will look through the case file to see if her vaginal deliveries were after the C Section or before it as it would indicate the favorability to wait. I will ask her if she is feeling intermittent pains or a continuos pain ,and if she is perceiving  foetal movements. I will recheck her partogram to note her vital signs, fluid intake , outpiut and if the urine was clear, any of which could suggest signs of rupture,/ dehydration. I will check her BP, pulse and temperature, assess her contractions note how much of the head is palpable per abdomen, and recheck herPV findings in the file to note station of head.,presence of caput.I will recheck her blood reports and send a urine sample for ketones

Management 

The options for management could be to 1. If the findings are favorable rgarding position of head,normal CTG -  to reassess after 2 hrs without any interference and confirm a delay in the first stage. The problems then would be a)  need for augmentation if her contractions are not 4/10mts. I would call a senior obstetrician if such a decision should be made as she is a case of VBAC..b)I will offer epidural analgesia, and call for the obsteric anaesthetist to see her. The advantage would be that in case of an emergency the conversion to anaesthesia would be quick, but the disadvantage would be failure to subjectively recognise a rupture. I  will realert the OT. The discussion would be made with the patient and documented in the records.

2. In view of VBAC and a suspicious delay and with a risk of rupture in case of augmentation, also an increase risk in the perinatal morbidity the option would be a caesarean section with no furthur wait, explaining to the woman her chances of her next pregnacy  being a VBAC are reduced. the chances of her having placenta previa/accreta are increased.

3.. expectant management with on interference.. In view of absent membranes her chances for chourioamnionitis increase thereby increasing the perinatalmorbidity furthur.

essay 365 Posted by sujata B.

Assesment of the patient

The findings in the case are suggestive of a suspicious delay in first stage. I will look through the case file to see if her vaginal deliveries were after the C Section or before it as it would indicate the favorability to wait. I will ask her if she is feeling intermittent pains or a continuos pain ,and if she is perceiving  foetal movements. I will recheck her partogram to note her vital signs, fluid intake , outpiut and if the urine was clear, any of which could suggest signs of rupture,/ dehydration. I will check her BP, pulse and temperature, assess her contractions note how much of the head is palpable per abdomen, and recheck herPV findings in the file to note station of head.,presence of caput.I will recheck her blood reports and send a urine sample for ketones

Management 

The options for management could be to 1. If the findings are favorable rgarding position of head,normal CTG -  to reassess after 2 hrs without any interference and confirm a delay in the first stage. The problems then would be a)  need for augmentation if her contractions are not 4/10mts. I would call a senior obstetrician if such a decision should be made as she is a case of VBAC..b)I will offer epidural analgesia, and call for the obsteric anaesthetist to see her. The advantage would be that in case of an emergency the conversion to anaesthesia would be quick, but the disadvantage would be failure to subjectively recognise a rupture. I  will realert the OT. The discussion would be made with the patient and documented in the records.

2. In view of VBAC and a suspicious delay and with a risk of rupture in case of augmentation, also an increase risk in the perinatal morbidity the option would be a caesarean section with no furthur wait, explaining to the woman her chances of her next pregnacy  being a VBAC are reduced. the chances of her having placenta previa/accreta are increased.

3.. expectant management with on interference.. In view of absent membranes her chances for chourioamnionitis increase thereby increasing the perinatalmorbidity furthur.

Posted by SHABANA  A.

a) I will review her obstetric notes for birthweight of previous babies, previous spontaneous or operative vaginal delivery any complications like shoulder dystocia or post partum haemorrhage. I will see her antenatal notes for height of uterus and any growth scans. Enquire about maternal pain and wishes for pain relief.I will look for her hydration status,pulse, blood pressure. Abdominal examination to look for uterine contractions,assessment of fetal size,lie, presentation and head palpable per abdomen,auscultate fetal heart rate. Vaginal examination for station,position, colour of liquor,caput and moulding.

b)A delay in first stage is suspected.If a repeat vaginal examination after 2 hours shows<1cm progress, delay is diagnosed. The plan for further management should take into account womans wishes offering her adequate support and effective pain relief.There are three options-expectant management, oxytocin augmentation and caesarean section. Expectant management includes a vaginal examination after 4 hrs-it has a low likelihood of successful vaginal delivery,risk of scar rupture of 5 in 1000 but avoids the risks of oxytocin and caesarean section.Oxytocin augmentation is appropriate only after fetopelvic disproportion has been excluded and after discussion with consultant. This may enable vaginal delivery to be accomplished but has a risk of scar rupture(8 in 1000) , shoulder dystocia and PPH. Lastly, caesarean section is indicated if there is evidence of obstruction or fetal compromise.CS is associated with increased operative morbidity and implications for future pregnancies like placenta praevia and accreta.However an early CS may prevent a more difficult CS or  operative delivery later on.

Answer to essay 365 Posted by Pulkit N.

A) I will first introduce myself to the labouring women and ask how she is feeling. I will ask about the adequacy of pain relief and judge her emotional and psychological state. Her partogram should be reveiwed for the trend in pulse, blood pressure , temperature ,  uterine contractions and cervical dilation, also drugs given. After obtaining her consent , i will proceed with my examination of woman. Dehydration should be ruled out. Pulse, blood pressure checked. Per abdomen examination should be done for confirming cephalic lie of fetus, any generalised tenderness of abdomen, tone of abdominal muscles, Fetal heart rate, intensity and frequency of uterine contractions. Scar tenderness should also checked. Bladder fullness checked to rule out full bladder. Per speculum examination is done to see for any vaginal bleeding and colour of liquor. Per vaginum examination done to see cervical dilation and effacement , position , rotation and station of fetal head. Her CTG shoud be reviewed . Previous obstetric history for the indication of previous caesarean section and operative notes to look for type of uterine scar should be rechecked. Rule out any sign of uterine rupture like abnormal CTG, hamaturia, continous pain . I will review her notes for FBC, Blood group, urine analysis and antibody status as she might require caeserean section later on.

B) One to one suppourt  and encouragement should be offered to the woman as this has shown to decrease ceaserean section rates. Hydration should be optimised by oral or intravenous route . The woman should be told to adopt any position she is comfortable in , as supine or non supine position have same ceaserean section rate. Adequte pain relief should be acheived, preferably by epidural analgesia as this woman has increased chances of ceaserean section. Intermittent voiding of bladder should be encouraged because full bladder may decrease uterine contractions. If any malpresentation is detected, decision for ceaserean section should be taken. Reassessment of cervical dilation done after 2 hours. If delay is confirmed, option of oxytocin augmentation or direct ceaserean section is there. If inadequacy of uterine contractions in frequency or intensity, I will inform the consultant obstetrician to assess the woman and determine the need of oxytocin augmentation as oxytocin augmentation leads to 1.5 times increades risk of uterine rupture. If oxytocin aumentation is done , A frequency of 3-4 contractions in 10 mins should be acheived and augmentation should not be done for more than 8 hours because longer than this no increase in vaginal delivery rates are seen. Assessment of cervical dilation should be done by the same person. Anaesthetist, theatre staff and blood bank should be alerted as she may require a ceaserean section. Group and save should be sent, if presence of irregular antibodies crossmatch done.

If any sign of uterine rupture Immediate recourse to laparotomy taken.

Posted by Christa R.

a)

Vaginal birth after Caesarean (VBAC) is becoming more frequent following an increase in the caesarean section (C/S) rate, which nationally is approaching 30%.  Overall the success of VBAC is ~74% and this increases to 85-90% with antecedent vaginal delivery (VD), as with this lady.  Attempting VBAC does however carry risk of both maternal and perinatal morbidity and mortality, namely through that of uterine rupture.  This risk of uterine rupture is in the order of 0.2-0.74%.  There is a risk of hypoxic ischaemic encephalopathy (HIE) of ~ 0.08% and delivery related death of  0.02%.

Assessment would therefore initially ensure there is no immediate maternal or fetal compromise.  Cardiotocograph (CTG) would be assessed since fetal heart rate abnormalities are the most consistent feature of uterine rupture (>55%).  Maternal observations would be taken including pulse, blood pressure , temperature, respiratory rate and O2 saturations.  Tachycardia, hypotension, increased respiratory rate, peripheral vasoconstriction and decreased O2 sats may indicate haemodynamic compromise and prompt immediate intervention. 

Provided mother and baby are stable information pertaining to previous deliveries would be obtained.  This would be via history, but also review of medical notes.  This is important since previous obstetric history influences VBAC success rate.  The date of C/S would be noted since a C/S-to-delivery interval of <2yrs carries a higher chance of VBAC failure.  Likewise, the order of previous births is important, since C/S followed by successful VBAC carries a better prognosis as VBAC has already been achieved.  Indication for the previous C/S would be noted.  Labour dystocia for example compares less favourably to fetal distress or malpresentation.  I would note uterine activity, specifically frequency, duration and intensity of contractions all of which may impact on decision making.   I would enquire about any scar tenderness or abdominal pain outside of contractions which could indicate dehissence/rupture.  I would note current analgesia used.  I would also note BMI since BMI >30 inversely correlates with VBAC success.

Following consent, I would examine the abdomen for areas of tenderness and hypertonus.  I would assess fetal lie, presentation & engagement.  I would check the colour of liquor, noting any meconium or heavy blood staining which may indicate impending uterine rupture.  I would check for fresh vaginal bleeding and the presence of any haematuria which may suggest uterine rupture.  I would perform a vaginal examination (VE) to confirm cervical dilatation, fetal presentation and position, station to ischial spines and the presence or absence of caput and moulding.  Loss of engagement of the presenting part may also suggest uterine rupture.

 

b)

From the given history it appears that there has been lack of adequate progress during the first stage of labour (1cm over 4hrs, with the expected in a multiparous being 4cm).  Lack of good progress in a multiparous  is potentially concerning, but even more so with a uterine scar.

Fetal stauts is paramount in any decision making and therefore continuous fetal monitoring is necessary via CTG (which should already be in progress).  A pathological  CTG warrants delivery, but even a suspicious trace, combined with the noted poor progress and previous C/S would realistically not have a place for fetal blood sampling (FBS) and C/S would be a recommended management.  If fetal status is reassuring, careful attention to hydration status with commencement of an intravenous infusion (Hartmanns 1L  6-8hourly) would be the initial line of management since it has been shown to improve progress in ~40% of women with poor progress.    Re-assessment would be appropriate at 2 hrs to ensure persistent poor progress is not overlooked.  Any re-assessment should be performed by the same person if possible to minimse inter-person discrepancy.  If progress is still sub-optimal at this stage, ongoing management options would be between C/S or augmentation with oxytocin (synto).    Synto appears to increase the risk of scar rupture by ~ 2-3 fold and therefore any decision for its use needs to be carefully considered with consultant obstetrician involvement and discussion with the woman herself.  If synto is commenced, there would certainly be a role for  earlier re-assessment at 2hrs (instead of 4 hrs) since there is some evidence that early intervention for static progress over 2 hrs following augmentation may minimise risk of uterine rupture.  Synto should not be continued for >8hrs, as after this evidence suggests Vaginal delivery is less likely.

Discussion regarding epidural analgesia would be recommended.  The National Institute of Child Health and Human Development (NICHD) have postulated that planned VBAC success rates are  higher in those who have an epidural, without conclusive evidence that such might mask signs of uterine rupture.

Gentle use of synto should be titrated to effect 3-4:10 contractions and no more.  Any cessation of previous effective uterine activity should prompt re-evaluation as it may indicate uterine rupture and the need for immediate laparotomy, resuscitation and delivery.

If at any stage the woman requests a C/S this would be entirely reasonable.

 

Posted by R S.

She is having secondry arrest of labour ,assessment would be  to find the cause and any risks of scar rupture.

A look into her notes about the previous deliveries ,the indication fot the c/s ,the type of incision to be notd as a previous vbac has a high chances of vaginal delivery ,and a previous vertical uterine incision has a high risk of scar ruptue .Examination would include the BMI as obesity itself can cause slow progress,general examination would include to look for signs of dehydrtion ,and exhaution, pallor,pulse rate as tachycardia may suggest impending scar rupture ,the B.P as hypotention may also indicate rupture.Abdominal examination to look for size of baby a big baby may be a cause of slow progress ,the presenting part ,engagement has to be noted ,the contractions if they are hypotonic ,and inadequate,look for features of rupture like loss of presenting part ,sudden cessation of contractions ,pain between contractions and constant pain in the abdomen to be looked for .Any abnormal bleeding would suggest rupture ,presence of haematuria should also be loked for .Any evidence of infection as it could cause slow progress.It is important to look for CPD .,and any malpresentstion to be the cause off slow progress.

A look into the medications, analgesia ,if epidural has been sited ,wether she is getting oxytocin and the partogram to be reveiwed,to assess the progress of labour .If she is on contioous CTG the trace to be analysed ,tp look for persistent tachycardia as it would indicate  uterine ruptue .A suspsious  or pathological ctg tracing would indicate foetal distress.

(B)

The magement options to be discusseed with the women and her decision to be considered .The options would inclde ,Expectant management ,if all parameters are normal ,it would include assessment after 2 hrs preferably by the same person ,with one to one support ,hydration . Analgesia to be discussed ,epidural may be sited as VBAC is not a contraindiction to epidural.The benefit of expectant mangement is that since she has previous two vaginal birth she has a high chance( about 80%)  of successful VBAC .the drawback is she may land up with second stage c/s which is associated with high risk of injury ,infection and haemorrage .           The other option would mean Augmentation of labourr with oxytocin ,which should be decided upon only after dissscussion with the consultant ,and ruling out CPD,The oxytocin should be be so titrarted that she does not get contrations more than 3-4/10mins ,This opton is useful if she was having hypotonic contraction,but the drawback is that there is a risk of scar rupture,C/S would be indicated in the presence of foetal distress or cephalopelic disprotionn ,occiputo transerse position .The benefit would be it would prevent scar rupture ,fotel distress ,reduced perinatal mortality and morbidity.drwback would be icreades risk of haemorrage ,infection ,injury to other organs and in the future the risk of placenta praevia and need of further operatve delivey .but if the patient does not plan further pregnanies she can opt for a c/s..In cases of uterine rupture she would need laprotomy with repair or hysterectomy depending on the amount of bleeding  The consultant obtetrician ,and anesthetist and theatre to be alerted.Blood should be crossmatched and saved ,I.V assess should be ready .If the patinet is haemodymically unstable blood for platelet count ,lft ,urea ,creat and coagulation screen should be done . The patients decision and consent should be considerd at each step of mangement decision.

Posted by FAUZIA  T.

History from the patient

Obstetric history- To know the indication of caeserean section and whether it was followed by vaginal  delivery, time interval from the previous delivery.weight of the previous babies, any complications during delivey, previous caeserian section intraoperative notes.

I will also review the antenatal records to see the consultant led plan about this woman

Examination -Genaral examination-to see the state of hydration, inquire whether woman received analgesia and the typeo f analgesia . review the partogram to check foer the pulse, blood pressure, temperature, assessment of cervix.p/a- fundal height and to note for scar tenderness, engagement of head.See if CtG is reactive and showing contractions.p/v- whether cephaloic or breech, if cephalic, position, moulding or caput, station, colour and smell of the liquour, any p/v bleeding and colour of urine.Note if cevical examination was done by the same person.

Investigation-FBC, Group and save

(b)- Mangement of the woman will depend on the findings of the initial assessment , If the woman is dehydrated, I wil correct her hydration. Give her analgesia if she haven't received one. Assess her contractions, duration and intensity of contractions. Keep a close observation, one to one midwifery support. Manage the woman according to the consultant led plan about the interval of vaginal examination and vaginal examination preferably by the same person.

Start the woman on oxytocin if the contractions are not effective that is 3-4 contractions in 10 minutes.revaluate her after 2 hours or as advised by the consultant. continuous fetal monitoring . note for any signs of scar rupture. If still the progress is slow even after good contractions then woman has to be taken for caeserean section. The woman should be fully informed about her condition and her wishes should be respected.documentation should be done.

Answer to essay 365 Posted by uzma sultana M.

A] The assesment of this patient will be as follows ,her previous assesment and documented notes are reviewed to check her details like the previous reason for ceasearean section,her obstretic history.any intra operative or post operative complications ,the duration from her ceasearean setion.usually if her ceasearean section was for labour dystotia her chance of delivering vaginally will be less,even though 72-74/% can have avaginal delivery following ceasearean section,The risk of uterus rupture is 26-74% andmore so if she had intra and post operative fever,and depending on her incision on the uterus if it is classical she will not be advised to deliver normally,if the ceaserean section duration was less than 2yrs,if she had delivered a baby who was more than 4000grm,if she recived epidural anaesthetia or not,since she has delivered 2 times before the section there is no reason that she cannot deliver vaginally.  The patients general condition is seen if she is in pain or in state of shock , The risk factors for ruptured uterus are ruled out ,her 4th hrly vitals chart for pulse ,bp, temperature  is seen ,if the patient is febrile to rule out intrauterine infection,hypotension for any hypovolumic condition. The abdomen is palpated to feel the lie,presentation, any tenderness especially scar tenderness,the fetal heart, feel for uterine contrations if regular or inadequate, check her CTG tracing to rule out tachycardia,Then do a vaginal examination for cervical assesment like effacement,dilation preferably by the same person who did it before,colour of the liquor any blood stained and any foul smell for infection,the station of the presentig part wheather descended or moved up in case of ruptured uterus,the partogram is reviewed, since this patient has poor progress of labour she might need an induction of labour for another 2hrs to see if she goes into active labour the consultant obstretian is called to review her.              B] The management of this patient will be by multidiscliplinary team like consultant obstretian,aneasthetist,haematologist ,mid wife,most experienced staff,neonatologist,The consultant will review her previous operative notes to see if her previous ceaserean section was uneventful and the agreed delivery plan in which they must have mentioned about induction of labour under supervisionand emergency ceasearean setion if there is maternal or fetal distressor failed induction,the consultant obstretician willagain counsel the patient and her partner  and explain the benefits and disadvantager of induction of labourand also explain them about uterine rupture and proceeding for hysterectmy in case of crises, since vaginal delivery  itself after ceaserean secton has 2-3 times maternal risk and perinatal death rate increased twice, advantage of vaginal delivery is the mother can deliver vaginally in future pregnancies and neonate will not have transient tachypnoea  . and induce the patient  and review her in another 2 hrs for progress with syntocinon and titrated until 3-4 contactions in 10 mins ,epidural anaesthetia is given in case the patient had not taken before,the fetus is monitored continously ,the patient is monitored by most experienced and senior staff ,blood is extracted and sent for haemoglobin level,group and cross match and save blood in case she needs it,the labour is monitored closely for scar rupture in case she has pain abdomen between contractions,chest pain shoulder tip pain,loss of contraction,tender abdomen,abnormal CTG like tachycardia,fetus easily palpable  difficult to asses the lie ,vaginal bleeding,and the presenting part moved up in this case she will go for emergency ceasearean section,The patient is seen again in 2 hrs if she has dilated without any complication she is allowed for further progress, if she had labour dystocia before she is unlikely to deliver vaginally there is lack of evedience for this,mostly this patient will end up with ceasearean section post operatively she is advised about early ambulation for risk of vte ,all the events are documented in the notes and the incident form is filled.Before discharge the patient is advised about breast feeding and contraception,post operative followup appointment is given to discuss about future pregnancy and delivery possibly by elective ceasearean section. early anc booking.

       

S G essay answer VBAC Posted by gouthaman S.

 

Cervical dilatation of less than  2cm is  suggestive of delay in progress of first stage of labour. History must include  need for analgesia, wishes,presenceof shortness of breath ,shoulder tip painwhich are signs of rupture.She  is  assessed  for  adequacy  of  pain  relief and  dehydration.Temperature,PR,BP,RR  are  checked.Tachycardia and increase  in temperature would suggest infection,dehydration.Hypotension  and  tachycardia  would suggest dehiscence or rupture which would warrant urgent intervention.Per abdominal examination is done to assess how many fifths  of presenting part is palpable, effective uterine contractions,uterine tenderness for choriamnionitis,tenderness in the scar for dehiscence.Vaginal examination is  done to assess dilatation,effacement,positionof the head.Presence of caput grade 3 moulding would suggest cephalopelvic disproportion which warrant delivery by LSCS.Colour of liquor is assessed and bleeding.CTG is assessed for fetal well being and the presence of late deceleration is an early sign of scardehiscence which would warrant urgent delivery by LSCS.

 

 Prior vaginal deliveries is associated with VBAC success  rate of 87-90% provided fetal and maternal wellbeing are maintained .Management options are explained to the patient and her wishes recorded.Aim for vaginal delivery if no signs of scar dehiscence,cephalo pelvic disproportion,fetal distress. Vitals are monitored by MOEWS Chart which would identify need for intervention.Anaesthetist ,theatre staff,consultant obstetrician ,neonatologist informed  due to chance of failure of VBAC.Group and sAve due to risk of rupture (22-74/10000) and PPH.Epidural analgesia is not contraindicated  for pain relief as it is not associated with increase risk of rupture and does not mask signs of dehiscence.If  inadequate uterine contractions  oxytocin  commenced  after  explaining  increased risk of  rupture 1.5 fold  and after discussion with consultant .She  is  reassessed  after  2hrs  for  progress  of  labour.CEFM  is  done  since  CTG  changes  are  the most  consistent  findings  in  uterine  rupture.Instrumental  vaginal  delivery  with  forceps  or  vacuum  if  indicated  and  is  explained  to  the  patient.,No  routine  exploration of scar recommended  and  active  management  ot third  stage    due  to increased  risk  of  uterine  PPH.If  there  are  signs  of  scar dehiscence or  rupture,fetal  distress, non progression  of  labour  emergency LSCS  is  performed.In  case  of  rupture  incident  report is  filled  with  debriefing .Thromboprophylaxis  and  prophylactic  antibiotics  given  if  emergency  cesarean section.       

 

Answer to 365 from moon Posted by doaa A.

a)Detailed past obstetric history in regards previous LSCS ,including indication and weather or not the cause persisted in the current preg.,and it's order (e.i wether or not it's followed by normal delivery)as this will give better chance of success of VBAC ,interval between deliveries.As this patient had SROM timing since she starts leaking should be obtained,colour of liquor if meconium stained and any foul smelling loss.

Examination should include set of observation BP,Pulse,temperature, pain status of the patient should be assessed and assured  it's controlled by epidural analgesia or nitrous gas+opioid. Abdominal examination for symphsio-fundal hight to assess foetal size,presentaion ,if presenting part was engaged or not, as well as pelvic examination to  assess the status of the cervix(bishop score),dilatation,effacement ,consistency,confirm presentation vertex,position  and the station of presenting part.Avoidance of repeated vaginal examination should be practised to avoid ascending infection .As the patient has slow progress consultant obstetician should be informed and alerted .

CTG monitoring should be observed  and continued for the foetal heart  status and wellbeing as well as uterine contractions if she is getting regular strong and frequent contractions.

Ensure that the patient has an Iv access and blood is taken for FBC and group and save in case she goes for emergency LSCS

b)This is high risk patient,Provided CTG monitoring is normal and there's  no indication to intervene so allowing vaginal delivery should be the aim.Re assessment in an hour time and if its same finding

Augmentation may be carefully practised to avoid uterine rupture and scar dehiscence,Consultant obstetrician should be informed and oxytocin dose/titration should be decreased as patient is multipara+ had previous LSCS to avoid uterine rupture and scar dehiscence.it should be adjusted against uterine contractions.

 if  it's  still same finding .Threshold for em LSCS should be lowered, if  any sign of foetal distress or failure to progress occured to dectease maternal morbidity and mortality.pt should give informed consent and explaination should be gived about the reason to have LSCS and  it's benifits in this situation outweigh the risks.Theatre nurses should be informed as well as paediatrician to attend the delivery.

care should be taken to record the finding with it's partcular timing in patient's note.

Answer Posted by Shivamalar  V.

(a)I would ask the patient if she feels any contractionand the frequency of her contraction. I would ask if she feels continuos abdominal pain in between her contraction which may suggest scar dehiscence. I will  then examine her to check her vital signs include blood pressure, pulse, and temperature. Then I will examine her abdomen to feel for presentation, the fundal height to assess if baby clinically appears 'big baby', I will feel for the engagement of the presenting part. I will also perd=form vaginal examination to assess for cervical dilatation, the effacement of the cervix, the position of fetal head if its is occiput posteriro which may explain the porolonged stage of labour, the station of the presenting part in relation to the ishial spine and assess for the presence of moulding and caput which may indicate obstructed labour. I will aso assess the CTG to see if any fetal distress and check on the contraction, the strngth and it's frequency.

 

(b) I will discuss with the patient the option to continue the trial of vaginal delivery if there are no sign of scar dehiscence or obstructed labour or fetal distress. But I will reassess her sooner - within an hour's time to check on her progress. This is because she had 2 previous vaginal delivery which is single predictor for successful subsequent vaginal delivery. I will also take into consideration her future fertility plan as vaginal delivery allows higher number of subsequent deliveries.This as well will alleviate the risk of caesarean section for both mother and baby. I will take careful consideration of not augmenting her because it increases the risk of scar rupture. Whereas, if clinical assessment shows big baby with obstructed labour and fetal distress, I will counsel patient for urgent caesarean section to expedite delivery as it reduces risk of perinatal mortality.. caesarean section does not carry risk of scar rupture. But other risk in caesarean section includes bleeding, visceral organ injury, wound dehiscence and infetion, venousthromboembolism and fetal laceration. Repear caesarean section also reduces number of future fertility and carries risk to future pregnancy including p;acenta praevia and accreta. Increase number of caesarean section also carries higher risk of scar rupture with future pregnancy and trial of vaginal birth. And I will take maternal request and patient's decision into consideration for my management option.

answer Posted by Yingjian C.

a)

I would review patient’s case notes and take further history. I would ask the indication of her previous caesarean section, if classical caesarean incision was used, any complications during delivery or labour. I would ask the birthweights of her 3 children at delivery, any antenatal problems such as gestational diabetes or abnormal placentation. I would ask if she has any other previous operations or medical problems. Regarding this current pregnancy, I would check her antenatal scan reports regarding fetal growth and estimated fetal weight, fetal anomalies, presentation at last scan and placental position and if she had antenatal problems such as gestational diabetes mellitus, pregnancy induced hypertension, antepartum haemorrhage.I would check how long have her membranes ruptured, if she has any group B streptococcal infection and any antibiotics started. I would ask patient if her pain relief is adequate, frequency of contractions, any caesarean section scar tenderness. I will check her the type of analgesia she was given and when was it started, if any oxytocin was started.

 

I would check patient’s vital parameters such as blood pressure, heart rate, temperature. I would do an abdominal palpation to assess presenting part and how many fifths palpable it is, any caesarean section scar tenderness, estimated fetal weight. I would check if her urine is bloodstained, any brisk vaginal bleeding and do a vaginal examination to reassess cervical dilation, cervical effacement, any caput or moulding, station and postion of presenting part, colour of liquor (any meconium staining). I would check fetal heart rate for any fetal distress such as decelerations.

 

b) The patient has poor progress in first stage of labor and opting for vaginal birth after caesarean section with risks of scar rupture.

I would catheterise patient. I would explain patient’s progress of labor to her and provide supportive care. I would provide adequate analgesia such as epidural: epidural will not prolong 1st stage of labor but may mask signs of scar tenderness.  I would monitor her vital parameters (blood pressure, pulse rate)continuously and ensure she has adequate midwifery support. I would put her on continuous external fetal monitoring if not on. I would set 2 large bore IV cannulas on her and take blood for group cross match. I would ensure she is on intravenous iv crystalloids for hydration. I would monitor her for risks of scar rupture such as scar pain, bloodstained urine, fetal distress on CTG. If her contractions are suboptimal, I would discuss with consultant regarding judicious use of oxytocin. I would insert a STAN for monitoring any fetal ST events. I would review patient in 2 hours, if cervix  is<1cm further dilated, I would consider a cesarean section delivery for poor progress in first stage of labor. If I suspect scar dehiscence at any point, patient would be delivered by emergency caesarean section. I would explain this to patient and keep her nil by mouth if needed. I would inform the anesthetist and neonatologist if she needs a caesarean section and ensure there are facilities for blood transfusion, caesarean section and neonatal special care. I would start her on iv antibiotics if she has ruptured membranes for >12hours or has group B streptococcal infection.   

 

assay365 Posted by huaida A.

A healthy 34 year old woman presents with spontaneous rupture of the membranes and uterine contractions at 39 weeks gestation. She has two previous vaginal deliveries and one previous caesarean section. She has been counseled and vaginal birth is planned. At 00:20, her cervix was 5cm dilated. You are asked to review her at 04:40 because the cervix is 6cm dilated. (a) Discuss your assessment of this patient [8 marks]. (b) Critically evaluate your management options [12 marks] 

a/ I would    revise her note  looking for the last estimated foetal wt as cephalopelvic disproportion may be a cause of her delayed progress.

I would assess her analgesia as pain may adversely affect labour.

I would assess the general condition of the pt PR, bp  and mucous membranes for evidence of dehydration.

Iwould examine the abdomen  for the lie and presentation of the foetus,estimated foetal wt,and how many fifth of the head is palpable per abdomen.

 

Would assess the foetalwellbeing and the contractions with CTG .

Then would perform per vaginal examination for the cx dilatation liquor colour,presence of caput  or 

moulding,and the head station,whether membrane ruptured or not.

B/

Management options depend on the underlying cause of the slow progress.

emergent c/s will be the  option of choice in some conditions.

If there is any evidence of obstruction such oedematous cx, caput and moulding  c/s will be the option.

Foetal compromise  shown by CTG and confirmed by foetal blood sample is another cause for em c/s.

If no foetal compromise or evidence of obstruction, the pt should  kept  well dehydrated.Analgesia should be topped up if not sufficient or should provided if not given before as pain  may delay labour progress.

.Accelaration by ARM_+ Synticinon will be the management  if  the CTG showed inefficient uterine contractions .

Then pt should be re-assessed after 4 hours.

 

 

Ali Posted by PAUL A.

 

A)I will ask in details about her obstetric history especially her previous caesarean section indication (1) as well as reviewing her previous section surgical notes for any complications. Then her general condition since she had spontaneous rupture of membranes,symptoms like fever ,abnormal or offensive liquor drainage she has presented with ruptured membranes & labour – there is no reason to screen for infection,diminished fetal movements ? value during labour and frequency and durations of contractions. Generally examined her temperature,pulse rate, blood pressure followed by abdominal palpation for scar tenderness and fetal lie presentation as well as assessment of engagement (1).. Vaginal examination after consent to confirm presentation and position , station and colour of the draining liquor caput / moulding – you are looking for evidence of obstructed labour. Baseline blood test after inserting IV cannula to check her Hb level and white cell count as well as CRP. Not indicated I will review her CTG for any abnormalities in fetal heart (1) and frequency and duration of her contractions. All initial assessment findings will be documented in her notes as well as discussion about her coping with pain (1) history and if any request for regional analgesia and her wishes for the delivery. B) options for management will depend on the assessment of her labour and if she still fit for VBAC Or not. If baby in cephalic presentation and delay of her first stage of labour is due to in coordinate uterine contractions ,I will discuss starting oxytocin infusion with her and with the on call consultant (1) after expaliining the increased risk of scar rupture (1), and her limited mobility during the infusion and need for continuous monitoring and repeat examinations . If abnormal presentation as breech is found at vaginal examination plan will be changed to CS to minimise the perinatal and maternal mortality and morbidity If contractions were regular and c-ordinate ,her delay in progress can be due to cephalopelvic disproportion and plan for Caesarean delivery (1) will be mandated to avoid the risk of rupture scar and fetal mortality and HIE . you just said you will do CS Explain that plan can be changed to emergency LSCS If fetal distress arises during the oxytocin infusion or when if any signs of scar rupture as increased tenderness ,vaginalbleeding or maternal tachycardia. Reassessment of the progress of labour 2 hours (1) from labour augmentation ? logic – you discussed oxytocin then CS then back to oxytocin. Delay in progress or no response will be indication for LSCS. ensure adequate analgesia before starting oxytocin infusion after disscusion the various method of analgesia. Available and her view to it. Ensure that there is enough support with her as well as care given to her by midwife as 1-1 care. Monitor her temperature every 4 hours and pulse rate and Bp hourly all will be charted in her partogram . Explain that VBAC success rate is about 60-72% and the benefit versus risk of having it. Ensure that all the details of examinations and the disscusion had been documemted in her notes you have not presented a critical evaluation – what is the value of the different options? What are the risks / disadvantages?

Ghida Posted by PAUL A.

 

A- I will ask the patient about the antenatal course during this pregnancy whether she had gestational diabetes healthy woman, estimated fetal weight for her baby do you expect her to know this?, I will also enquire about previous vaginal deliveries if they were assisted or spontaneous how will this alter your management?, the weight of the babies, difficult vaginal deliveries as this will point out to the adequacy of her pelvis ?? 2 previous vaginal births, what was the interval from the previous c/section.

I will also have to assess patient height, weight and check her BMI as obesity (BMI>30) is associated with increased risk of failed VBAC.

I will check the general condition of the patient,what does this mean? as well as her vital signs searching for exhaustion what are signs of exhaustion? and dehydration, shock why should she be in shock??, and assess if she has excessive pain, its location, back pain is associated with occipitoposterior position, and pain over uterine scar especially if it persists in between contraction might denote uterine scar rupture.

Abdominal examination will help to assess how much of the head is palpable, if 2/5 or more is palpable might denote an element of cephalopelvic disproportion.Is there anything else you would determine on abdominal exam?

then pelvic exam is to be done, to look for the position of the head by trying to feel the sagittal suture and the fontanelles. occipitoposterior position are associated with prolonged labours. Also signs of obstructed labour include excessive capput and moulding should be looked for (1).  I will also check for liquor if became meconium stained might point out to fetal compromise, vaginal bleeding and  change in fetal head station as these point to uterine rupture. 

I will review the CTG (1) looking for fetal heart rate abnormalities as these might be the earliest signs of uterine rupture, as well as presence of contractions, frequency, whether she has adequate labour. Sudden cessation of uterine contractions might also denote uterine rupture. See answer below for a more systematic Hx, exam & Ix

B- the delivery should occur in fully equipped and staffed obstetric unit with the ability to perform emergency cesarean and with the possibility of requiring neonatal ICU. 

Multidisciplinary input from the consultant, anesthetist, operating theater, senior midwife, blood bank  should be sought. Why?? Slow progress in the first stage certainly does not need input from blood bank

In the absence of fetal distress and signs of obstructed labour, the patient should be allowed to labour and be timely reassessed in 2 hours (1) to avoid in delay in diagnosis of labour dystocia which may predispose patient to ruputre of uterine scar. Pain management should be done, and epidural analgesia is not contraindicated in women with previous c/section admitted for trial of labour. IV line and continuous fetal heart monitoring should be instituted if not already done, blood should be sent for group and save, in the event of uterine rupture and bleeding, patient should be kept updated with her labour progress. Decision to sart oxytocin should be taken by the most senior physician. An intrauterine pressure catheter may need to be inserted to monitor uterine contractions. Not recommended – no benefit and increased risk of infection

in case of confirmed labour dystocia how do you confirm this?, cesarean delivery should be recommended after explaining the benefits which are?? versus increased risk of uterine rupture, hysterectomy and blood transfusion is CS associated with increased risk of uterine rupture / hysterectomy???. A surgical consent should be signed before proceeding.

in the event of non reassuringe fetal heart rate and suspected maternal bleeding due to uterine rupture, emergency cesarean should be undertaken to safeguard the maternal life.

proper documentation on the CTG and in the records for maternal condition, fetal heart rate changes, pelvic exam and counselling of the patient should be done.

after delivery the baby's condition should be checked  and debriefing of the patient and her partber should be done by the surgeon as soon as possible after delivery. Options are expectant management, oxytocin and CS – you need to critically evaluate these options

LAILA Posted by PAUL A.

 

A) Cervical dilatation of less than 2 cm in 4 hours suggests delay in the established first stage of labour .

The woman should be asked about the time since leaking, color and smell of the liquor she has been in labour for 4h in your unit.  She  should be enquired about nature of pain, intermittent or continuous and  adequacy of pain relief (1). She should be asked if she has any shoulder tip pain suggesting scar dehiscence. 

 Maternal records are reviewed to note the weight of the previous babies, any evidence of macrosomia or complicated by shoulder dystocia.  Details of previous caesarean section (1)  are noted if available. Antenatal records are reviewed  for fundal height measurements and growth scans to identify any suspicion of big baby (1).  Her emotional requirements are enquired. Her wishes regarding mode of delivery are determined.

Assessment includes recording temparature, pulse and blood pressure (1). Sunken eyes and dry mucous membranes indicate dehydration. Abdominal examination is done for subjective assessment of size  of the baby and to determine the fifths palpable per abdomen.  During abdominal examination, strength of the contractions and palpable palpable fifths of the head is assessed (1). Clinical evidence of big baby with high head suggests obstructed labour.

Vaginal examination is performed to note cervical dilatation, application to the presenting part. Position and station of the presenting part is identified.  Malpresentation such as brow presentation should be excluded. Marked caput and severe degrees of moulding suggests obstructed labour (1).

CTG recording (1) is reviewed to identify any evidence of fetal compromise.

Colour of the amniotic fluid is seen for meconium stained liquor.

 FBC , group and Rh typing are done in case she requires any blood transfusion.

 

B)

After excluding malpresentation and obstructed labour (1), expected management can be adopted by performing vaginal examination every 2-4 hours when will you repeat VE? After 2 or 3 or 4h? you need to make a decision.  Although vaginal delivery is less likely to happen with expectant management, this avoids complications associated with oxytocin.

 

The other option is augmentation of labour by oxytocin which is considered after discussion with the woman and consultant obstetrician (1). A successful vaginal birth carries better future obstetric performance as she has more chances of having vaginal delivery in her future pregnancies.  If she delivers vaginally, probably reduces the risk of neonatal respiratory problems. This is the wrong approach to counseling but remains common in obstetrics. If the woman has a 10% chance of vaginal birth, you tell her if she is in the lucky 10% then great. This is wrong. This is why many obstetricians continue to think VBAC is great because they compare successful VBAC with planned CS. They should compare planned VBAC with planned CS.

The plan for the time intervals for serial vaginal examination what will your plan be? and parameters of progress and indications for emergency C/S should be discussed with the woman and documented. The woman should be informed that the risk of rupture of uterus is 2-3 fold in augmented labours (1).

Oxytocin augmentation is abandoned and C/S is indicated in case of abnormal CTG, severe abdominal pain persisting between contractions, acute onset of scar tendernesss which suggest uterine rupture. Other signs of uterine rupture include abnormal vaginal bleeding or haematuria, cessation of previously efficient uterine activity with loss of presenting part. Maternal tachycardia, hypotension or shock indicates uterine rupture and necessitate emergency CS.

Cervical examination should done every 2-3 hours (1), preferably by the same person. It is ensured that Obstetric, midwifery, anaesthetic, operating theatre, neonatal and haematological support should be continuously available  The risk of blood transfusion and endometritis is about 1 % is it? She has a 1% risk of uterine rupture and ~50% risk of emergency CS!

 

In the presence of obstructed labour or fetal compromise immediate arrangements should be made to deliver the baby by emergency caesarean section (1). CS is associated with anesthetic complications and operative morbidity. Any benefits? Evaluate The decision of early caesarean section avoids difficult operative vaginal delivery and morbidity associated with late CS (1) such as PPH.The risk of wound infection, haemorrhage, visceral injury and thrombo-embolism are increased in emergency intra-partum caesarean section. The risk of thromboembolism is 3 to 5 times more compared to vaginal delivery. CS is associated with adherent placenta in future pregnancies.

Lola Posted by PAUL A.

 

a) I will take a quick history,why does it have to be quick? enquiring about the order or pregnancies which the caesarean section took place, and the indication for it (1). A previous classical scar will preclude trial of normal vaginal birth even though the question says she has been counseled and vaginal birth is planned?. Ask about estimated fetal weight do you expect her to know this? and if there is adequate pain relief (1).

On physical examination, I will assess the skin turgidity, eyes for sunken eyes and mucosal membranes for dehydration P, BP. The fundal height and fetal size is palpated, as well as how many fifths the fetal head is palpable (1). On vaginal examination, I will note the position of the fetal head, look for any malposition or malpresentation, deliation, station, liqour colour and presence of caput and moulding, the presence of which will point towards cephalopelvic disproportion 1+ caput and 1+ moulding?. Scar tenderness will be elicited. 

The CTG (1) will be reviewed to ensure there is no suspicious or pathological trace. The frequence and amplitude what is the relevance of amplitude?? of contractions will be noted. Also, if IV oxycotin infusion has been started for the patient. Why should this have been started? I will look at the urine bag why should she have a catheter? for blood stained urine that will point towards CPD. I will look at the partogram for the progress of the labour thus far given in the question

b) The first option will be expectant management, to aloow a further trial of labour for a total of 8 hours why not 9 or 7h? Do you know how long she has been in labour?. This has to be in line with the paitnet's wishes (1). The patient must be informed of the risk of scar rupture given the previous history of caesarean section. This option is also favouralbe if there are no overt signs of CPD (1) like irreducible moulding or blood stained urine, and if there are factors unaddressed, like pain relief. The CTG must be reassuring . I will review her progress regularly,. as least every 1 hour do VE every hour??, and will enrol the help fo a senior obstetrician in deicding the end of the period of trial of labour.

Next, we can consider the judicious use of low dose oxytocin infusion for labour augmentation. Especially if progress has been slow due to inadequate frequency and amplitude amplitude tells you nothing about contractions of contractions. The risk of scar rupture is further increased here (1). The CTG has to be watched very closely thoughout what does this mean? What should the midwife do differently?. I will perform regular how often? vaginal examinations to monitor response, and examine the patient regularly for scar tenderness. If necessary, an FSE  can be insertd to help with monitoring of FHR.

Lastly, an emergency caesarean section can be called for, especially if ths is in line witht he patient's wishes and there are signs of CPD which are?. This is made easier if a combine spinal epidural catheter is already in situ-- a quick top why does it have to be quick??? up is all that is required for regional anesthesia. This option will avert the risk of a long labour, which is scar rupture (1). But this has to be balanced against the risk of surgery (1), which is bleeding, infection and injury to surrounding viscera. Also to consider the future risks of 2 previous caesarean sections -- namely incresed risk of placenta praevia and accreta, and scar rupture. Steps must be taken to previous PPH, an active management of the third stage is carried out, together with a group and save of blood.

Sujata Posted by PAUL A.

 

Assesment of the patient

The findings in the case are suggestive of a suspicious delay consistent / indicate suspected delay – note that this is not a ‘normal labour’ and NICE guidelines should not apply in first stage. I will look through the case file to see if her vaginal deliveries were after the C Section or before it as it would indicate the favorability to wait. I will ask her if she is feeling intermittent pains or a continuos pain ,and if she is perceiving  foetal movements ? value in labour. I will recheck her partogram to note her vital signs which are??, fluid intake , outpiut and if the urine was clear, any of which could suggest signs of rupture,/ dehydration clear urine suggests uterine rupture??. I will check her BP, pulse (1) and temperature, assess her contractions note how much of the head is palpable per abdomen (1), and recheck herPV findings in the file to note station of head.,presence of caput moulding.I will recheck her blood reports and send a urine sample for ketones

Management 

The options for management could be to 1do not number your answer or write bullet points. If the findings are favorable rgarding position of head this should cause greater concern because there is no explanation for delay. What about caput / moulding?,normal CTG -  to reassess after 2 hrs (1) without any interference and confirm a delay in the first stage. The problems then would be a)  DO NOT WRITE A LIST!!! need for augmentation if her contractions are not 4/10mts ???. I would call a senior obstetrician if such a decision should be made as she is a case of VBAC..b)I will offer epidural analgesia, and call for the obsteric anaesthetist to see her. The advantage would be that in case of an emergency the conversion to anaesthesia would be quick NO IT WOULD NOT – it will take 20 minutes for epidural top-up to be effective and if there was an emergency, GA would be needed, but the disadvantage would be failure to subjectively recognise a rupture by who?. I  will realert the OT. The discussion would be made with the patient and documented in the records.

2. In view of VBAC and a suspicious delay and with a risk of rupture in case of augmentation, also an increase risk in the perinatal morbidity the option would be a caesarean section with no furthur wait, explaining to the woman her chances of her next pregnacy  being a VBAC are reduced. the chances of her having placenta previa/accreta are increased.

3.. expectant management with on interference.. In view of absent membranes her chances for chourioamnionitis increase thereby increasing the perinatalmorbidity furthur.

Shabana Posted by PAUL A.

 

a) I will review her obstetric notes for birthweight of previous babies, previous spontaneous or operative vaginal delivery any complications like shoulder dystocia or post partum haemorrhage. I will see her antenatal notes for height of uterus and any growth scans (1). Enquire about maternal pain and wishes for pain relief (1).I will look for her hydration status,pulse, blood pressure why? There is no discussion. Abdominal examination to look for uterine contractions,assessment of fetal size,lie, presentation and head palpable per abdomen (1),auscultate fetal heart rate. Vaginal examination for station,position, colour of liquor,caput and moulding you need some discussion to indicate that you understand the implications of these findings.

b)A delay in first stage is suspected.If a repeat vaginal examination after 2 hours shows<1cm progress, delay is diagnosed NO – this is not a normal labour and NICE guidelines do not apply. The plan for further management should take into account womans wishes (1) offering her adequate support and effective pain relief.There are three options-expectant management, oxytocin augmentation and caesarean section. Expectant management includes a vaginal examination after 4 hrs so the fact that she has a previous CS makes no difference to your management -it has a low likelihood of successful vaginal delivery,risk of scar rupture of 5 in 1000 but avoids the risks of oxytocin and caesarean section (1).Oxytocin augmentation is appropriate only after fetopelvic disproportion has been excluded and after discussion with consultant (1). This may enable vaginal delivery to be accomplished but has a risk of scar rupture(8 in 1000) (1), shoulder dystocia and PPH. Lastly, caesarean section is indicated if there is evidence of obstruction such as? or fetal compromise.CS is associated with increased operative morbidity and implications for future pregnancies (1) like placenta praevia and accreta.However an early CS may prevent a more difficult CS or  operative delivery later on (1) or uterine rupture.

Pulkit Posted by PAUL A.

 

A) I will first introduce myself to the labouring women and ask how she is feeling.Not necessary I will ask about the adequacy of pain relief and judge her emotional and psychological state (1). Her partogram should be reveiwed for the trend in pulse, blood pressure , temperature (1),  uterine contractions and cervical dilation, also drugs given. After obtaining her consent , i will proceed with my examination of woman. Dehydration should be ruled out how?. Pulse, blood pressure checked. Per abdomen examination should be done for confirming cephalic lie presentation!!! of fetus, any generalised tenderness of abdomen, tone of abdominal muscles ? relevance, Fetal heart rate, intensity and frequency of uterine contractions. Scar tenderness should also checked. Bladder fullness checked how? to rule out full bladder. Per speculum examination do you do speculum examination in labour? is done to see for any vaginal bleeding and colour of liquor. Per vaginum examination done to see assess cervical dilation and effacement , position , rotation and station of fetal head caput & moulding. Her CTG shoud be reviewed (1). Previous obstetric history why are you back to Hx after exam and Ix? for the indication of previous caesarean section and operative notes to look for type of uterine scar should be rechecked. Rule out any sign of uterine rupture like abnormal CTG, hamaturia, continous pain . I will review her notes for FBC, Blood group, urine analysis and antibody status as she might require caeserean section later on.

B) One to one suppourt  and encouragement should be offered to the woman as this has shown to decrease ceaserean section rates. Hydration should be optimised by oral or intravenous route . The woman should be told to adopt any position she is comfortable in , as supine or non supine position have same ceaserean section rate  where are the options that you are critically evaluating?. Adequte pain relief should be acheived, preferably by epidural analgesia as this woman has increased chances of ceaserean section. Intermittent voiding of bladder should be encouraged because full bladder may decrease uterine contractions. If any malpresentation is detected, decision for ceaserean section should be taken. Reassessment of cervical dilation done after 2 hours this is not a normal labour so NICE guidelines should not be applied. If delay is confirmed, option of oxytocin augmentation or direct ceaserean section is there. If inadequacy of uterine contractions in frequency or intensity, I will inform the consultant obstetrician to assess ? you will ask the consultant to come and assess the woman?? the woman and determine the need of oxytocin augmentation as oxytocin augmentation leads to 1.5 times increades risk of uterine rupture. If oxytocin aumentation is done , A frequency of 3-4 contractions in 10 mins should be acheived and augmentation should not be done for more than 8 hours where did you get 8h from? Surely if she has not progressed after 3h you should recommend CS – you will certainly do so in a multip without a previous CS let alone a multip with a previous CS because longer than this no increase in vaginal delivery rates are seen this statement cannot possibly be true!!!. Assessment of cervical dilation should be done by the same person. Anaesthetist, theatre staff and blood bank do you phone blood bank because a woman might need cs?? should be alerted as she may require a ceaserean section. Group and save should be sent, if presence of irregular antibodies crossmatch done.

If any sign of uterine rupture Immediate recourse to laparotomy taken.

Christa Posted by PAUL A.

 

a)

Vaginal birth after Caesarean (VBAC) is becoming more frequent following an increase in the caesarean section (C/S) rate, which nationally is approaching 30%.  Overall the success of VBAC is ~74% and this increases to 85-90% with antecedent vaginal delivery (VD), as with this lady.  Attempting VBAC does however carry risk of both maternal and perinatal morbidity and mortality, namely through that of uterine rupture.  This risk of uterine rupture is in the order of 0.2-0.74%.  There is a risk of hypoxic ischaemic encephalopathy (HIE) of ~ 0.08% and delivery related death of  0.02%. You know that this does not earn any marks and is a waste of time. If these facts are needed, they will be examined in the MCQ paper. Someone else may present a different set of impressive facts about VBAC – not asked for so no marks.

Assessment would therefore initially ensure there is no immediate maternal or fetal compromise.  Cardiotocograph (CTG) would be assessed since fetal heart rate abnormalities are the most consistent feature of uterine rupture (>55%) you are not answering the question. You were asked to see her because she has not progressed, not because there is a suspicion of rupture. There is no reason to deviate from Hx, exam, Ix.  Maternal observations would be taken including pulse, blood pressure , temperature, respiratory rate and O2 saturationsWhen the midwife calls you in this situation, do you really check the woman’s resps and SO2?? Tachycardia, hypotension, increased respiratory rate, peripheral vasoconstriction and decreased O2 sats may indicate haemodynamic compromise and prompt immediate intervention. 

Provided mother and baby are stable information pertaining to previous deliveries would be obtained.  This would be via history, but also review of medical notes.  This is important since previous obstetric history influences VBAC success rate.  The date of C/S would be noted since a C/S-to-delivery interval of <2yrs carries a higher chance of VBAC failure.  Likewise, the order of previous births is important, since C/S followed by successful VBAC carries a better prognosis as VBAC has already been achieved.  Indication for the previous C/S would be noted (1).  Labour dystocia for example compares less favourably to fetal distress or malpresentation.  I would note uterine activity, specifically frequency, duration and intensity of contractions (1) this is examination all of which may impact on decision making.   I would enquire this is Hx – this is not systematic. When you phone the consultant, you will not give them the Hx then exam then a bit more Hx…about any scar tenderness or abdominal pain outside of contractions which could indicate dehissence/rupture.  I would note current analgesia used.  I would also note BMI since BMI >30 inversely correlates with VBAC success.

Following consent, I would examine the abdomen for areas of tenderness and hypertonus.  I would assess fetal lie, presentation & engagement fundal ht.  I would check the colour of liquor, noting any meconium or heavy blood staining which may indicate impending uterine rupture.  I would check for fresh vaginal bleeding and the presence of any haematuria which may suggest uterine rupture.  I would perform a vaginal examination (VE) to confirm cervical dilatation, fetal presentation and position, station to ischial spines and the presence or absence of caput and moulding (1).  Loss of engagement of the presenting part may also suggest uterine rupture. You were asked to assess a woman who has not progressed in labour and your focus is almost entirely on uterine rupture.

 

b)

From the given history it appears that there has been lack of adequate progress during the first stage of labour (1cm over 4hrs, with the expected in a multiparous being 4cm).  Lack of good progress in a multiparous  is potentially concerning, but even more so with a uterine scar.

Fetal stauts is paramount in any decision making and therefore continuous fetal monitoring is necessary via CTG (which should already be in progress) so you are not adding anything.  A pathological  CTG warrants delivery, but even a suspicious trace, combined with the noted poor progress and previous C/S would realistically not have a place for fetal blood sampling (FBS) why should you consider FBS in the first place if the CTG is SUSPICIOUS??? and C/S would be a recommended management.  If fetal status is reassuring, careful attention to hydration status with commencement of an intravenous infusion (Hartmanns 1L  6-8hourly) would be the initial line of management since it has been shown to improve progress in ~40% of women with poor progress can you please quote the RCT that showed this? Why is this not part of the NICE algorithm for managing delay in first stage? If you are quoting an observational study, then the reason for this is that 40% of women with suspected delay subsequently have normal progress when you do nothing. Nothing to do with iv fluids.    Re-assessment would be appropriate at 2 hrs (1) to ensure persistent poor progress is not overlooked.  Any re-assessment should be performed by the same person if possible to minimse inter-person discrepancy.  If progress is still sub-optimal at this stage, ongoing management options would be between C/S or augmentation with oxytocin (synto).    Synto you gain nothing by writing 3 letters less & simply irritate the examiner appears to increase the risk of scar rupture by ~ 2-3 fold (1) and therefore any decision for its use needs to be carefully considered with consultant obstetrician(1)  involvement and discussion with the woman herself.  If synto is commenced, there would certainly be a role for  earlier re-assessment at 2hrs (1) (instead of 4 hrs) since there is some evidence what is the evidence?? Can you quote the paper? that early intervention for static progress over 2 hrs following augmentation may minimise risk of uterine rupture.  Synto should not be continued for >8hrs, as after this evidence suggests Vaginal delivery is less likely  again, what is the evidence? This is potentially dangerous. Using some random figure of 8h in a multip (+cs) who has not progressed after 3-4h of oxytocin is dangerous. Labour should be managed on progress not on arbitrary cut-offs..

Discussion regarding epidural analgesia would be recommended.  The National Institute of Child Health and Human Development (NICHD) Who are they? Recent NICE CS guidelines covered VBAC and contain no such statement. have postulated that planned VBAC success rates are  higher in those who have an epidural, without conclusive evidence that such might mask signs of uterine rupture.

Gentle use of synto should be titrated to effect 3-4:10 contractions and no more.  Any cessation of previous effective uterine activity should prompt re-evaluation as it may indicate uterine rupture and the need for immediate laparotomy, resuscitation and delivery.

If at any stage the woman requests (1) a C/S this would be entirely reasonable. You have not answered the questions. What are the options? What are their value & limitations (critically evaluate). Cut out the use of the word evidence unless you are aware of a meta-analysis / RCT/ a statement in an RCOG or NICE guideline.

R S Posted by PAUL A.

 

She is having secondry arrest of labour ,assessment would be  to find the cause and any risks of scar rupture.

A look into her notes about the previous deliveries ,the indication fot the c/s (1),the type of incision to be notd as a previous vbac has a high chances of vaginal delivery ,and a previous vertical uterine incision has a high risk of scar ruptue .Examination would include the BMI as obesity itself can cause slow progress,general examination would include to look for signs of dehydrtion ,and exhaution,which are?? Pallor is this a sign of dehydration? ,pulse rate as tachycardia may suggest impending scar rupture ? evidence?? ,the B.P as hypotention may also indicate rupture.Abdominal examination to look for size of baby a big baby may be a cause of slow progress ,the presenting part ,engagement has to be noted ,the contractions if they are hypotonic frequency & strength ,and inadequate,look for features of rupture like loss of presenting part ,sudden cessation of contractions ,pain between contractions and constant pain in the abdomen to be looked for how do you look for pain on examination? Pain is a symptom not a clinical sign. Any abnormal bleeding would suggest rupture ,presence of haematuria should also be loked for how? .Any evidence of infection these vague statements do not earn marks – how does the examiner know that you know what is evidence of infection? Does UTI cause slow progress? as it could cause slow progress.It is important to look for CPD how?.,and any malpresentstion to be the cause off slow progress.

A look into the medications, analgesia ,if epidural has been sited ,wether she is getting oxytocin why should she be on oxytocin?? and the partogram to be reveiwed,to assess the progress of labour .If she is on contioous CTG the trace to be analysed ,tp look for persistent tachycardia as it would indicate  uterine ruptue is this what you will expect to see in the event of rupture???. A suspsious  or pathological ctg tracing would indicate foetal distress so you will manage a suspicious CTG in the same way as a pathological CTG? Why are they classified differently?? (-1).

(B)

The magement options to be discusseed with the women and her decision to be considered (1) .The options would inclde ,Expectant management ,if all parameters are normal ,it would include assessment after 2 hrs (1) preferably by the same person ,with one to one support ,hydration . Analgesia to be discussed ,epidural may be sited as VBAC is not a contraindiction to epidural.The benefit of expectant mangement is that since she has previous two vaginal birth she has a high chance( about 80%)  of successful VBAC is this still 80% when you already have slow progress? .the drawback is she may land up with second stage c/s which is associated with high risk of injury ,infection and haemorrage or uterine rupture or first stage CS.           The other option would mean Augmentation of labourr with oxytocin ,which should be decided upon only after dissscussion with the consultant (1),and ruling out CPD How?,The oxytocin should be be so titrarted that she does not get contrations more than 3-4/10mins ,This opton is useful if she was having hypotonic contraction (1),but the drawback is that there is a risk of scar rupture same as without oxytocin?,C/S would be indicated in the presence of foetal distress or cephalopelic disprotionn ,occiputo transerse position is OT position an indication for CS?.The benefit would be it would prevent scar rupture (1),fotel distress ,reduced perinatal mortality and morbidity.drwback would be icreades risk of haemorrage ,infection ,injury to other organs compared to what? Is the risk of haemorrhage higher in CS compared to oxytocin? and in the future the risk of placenta praevia and need of further operatve delivey .but if the patient does not plan further pregnanies she can opt for a c/s..In cases of uterine rupture she would need laprotomy with repair or hysterectomy depending on the amount of bleeding  The consultant obtetrician ,and anesthetist and theatre to be alerted.Blood should be crossmatched and saved ,I.V assess should be ready .If the patinet is haemodymically unstable blood for platelet count ,lft ,urea ,creat and coagulation screen should be done . The patients decision and consent should be considerd at each step of mangement decision.

FAUZIA Posted by PAUL A.

 

History from the patient

Obstetric history- To know the indication of caeserean section (1) and whether it was followed by vaginal  delivery, time interval from the previous delivery.weight of the previous babies, any complications during delivey, previous caeserian section intraoperative notes.

I will also review the antenatal records to see the consultant led plan about this woman stated in question

Examination-Genaral examination-to see the state of hydration,inquire this is history not examination whether woman received analgesia and the typeo f analgesia . review the partogram to check foer the pulse, blood pressure, temperature, assessment of cervix.p/a- fundal height and to note for scar tenderness, engagement of head (1).See if CtG is reactive obsolete terminology and showing contractions.p/v- whether cephaloic or breech, if cephalic, position, moulding or caput, station (1), colour and smell of the liquour, any p/v bleeding and colour of urine.Note if cevical examination was done by the same person what difference will this make?.

Investigation-FBC, Group and save

(b)- Mangement of the woman will depend on the findings of the initial assessment , If the woman is dehydrated, I wil correct her hydration. Give her analgesia if she haven't received one. Assess her contractions, duration and intensity of contractions. That is why you were asked about assessment in (a) Keep a close observation what does this mean? What will you do?, one to one midwifery support. Manage the woman according to the consultant led plan you have been asked to make a plan  about the interval of vaginal examination and vaginal examination preferably by the same person.

Start the woman on oxytocin if the contractions are not effective how do you assess effectiveness of contractions? that is 3-4 contractions in 10 minutes this is frequency, not effectiveness .revaluate her after 2 hours (1) or as advised by the consultant. continuous fetal monitoring . note for any signs of scar rupture. If still the progress is slow even after good contractions then woman has to be taken for caeserean section. The woman should be fully informed about her condition and her wishes should be respected (1).documentation should be done.

UZMA Posted by PAUL A.

 

A] The assesment of this patient will be as follows ,her previous assesment and documented notes are reviewed to check her details like the previous reason for ceasearean section (1),her obstretic history.any intra operative or post operative complications ,the duration from her ceasearean setion.usually if her ceasearean section was for labour dystotia her chance of delivering vaginally will be less,even though 72-74/% can have avaginal delivery following ceasearean section  ? meaning ,The risk of uterus rupture is 26-74% IS IT??? andmore so if she had intra and post operative fever,and depending on her incision on the uterus if it is classical she will not be advised to deliver normally so why did the question say vaginal birth is planned?,if the ceaserean section duration was less than 2yrs,if she had delivered a baby who was more than 4000grm,if she recived epidural anaesthetia or not,since she has delivered 2 times before the section did the question say this? there is no reason that she cannot deliver vaginally that is why vaginal birth was planned. You have not moved on from the question itself..  The patients general condition is seen if she is in pain or in state of shock do you think if she was in shock the midwife will ask you to see her because she has not progressed?, The risk factors for ruptured uterus are ruled out ,her 4th hrly vitals chart for pulse ,bp, temperature  is seen ,if the patient is febrile to rule out intrauterine infection,hypotension for any hypovolumic condition. The abdomen is palpated to feel the lie,presentation, any tenderness especially scar tenderness,the fetal heart, feel for uterine contrations if regular or inadequate you can only assess frequency, and maybe strength of contractions. You cannot assess adequacy., check her CTG tracing to rule out tachycardia so later decelerations or bradycardia are alright but tachycardia is what will concern you??,Then do a vaginal examination for cervical assesment like effacement,dilation preferably by the same person who did it before  so you are going to come in and ask the midwife to repeat the VE?? ,colour of the liquor any blood stained and any foul smell for infection,the station of the presentig part wheather descended or moved up in case of ruptured uterus,the partogram is reviewed, since this patient has poor progress of labour she might need an induction you do not induce something which has already happened – she is already in labour of labour for another 2hrs to see if she goes into active labour the consultant obstretian is called to review her.              B] The management of this patient will be by multidiscliplinary team like consultant obstretian,aneasthetist,haematologist why do you need a haematologist? ,mid wife,most experienced staff,neonatologist,The consultant will review her previous operative notes to see if her previous ceaserean section was uneventful assessment was part (a) and in (b) you are asked about management options and the agreed delivery plan in which they must have mentioned about induction of labour under supervisionand emergency ceasearean setion if there is maternal or fetal distressor failed induction,the consultant obstretician will NO, otherwise they will not be asking you the question in the exam! again counsel the patient and her partner  and explain the benefits and disadvantager of induction of labourand also explain them about uterine rupture and proceeding for hysterectmy in case of crises, since vaginal delivery  itself after ceaserean secton has 2-3 times maternal risk of what?? and perinatal death rate increased twice, advantage of vaginal delivery is the mother can deliver vaginally in future pregnancies and neonate will not have transient tachypnoea   so TTN does not occur after vaginal birth?. and induce the patient  and review her in another 2 hrs for progress with syntocinon and titrated until 3-4 contactions in 10 mins ,epidural anaesthetia is given in case the patient had not taken before,the fetus is monitored continously ,the patient is monitored by most experienced and senior staff ,blood is extracted and sent for haemoglobin level,group and cross match and save blood in case she needs it,the labour is monitored closely how? What should be done? for scar rupture in case she has pain abdomen between contractions,chest pain shoulder tip pain,loss of contraction,tender abdomen,abnormal CTG like tachycardia,fetus easily palpable  difficult to asses the lie ,vaginal bleeding,and the presenting part moved up in this case she will go for emergency ceasearean section,The patient is seen again in 2 hrs (1) if she has dilated without any complication she is allowed for further progress, if she had labour dystocia before she is unlikely to deliver vaginally there is lack of evedience for this,mostly this patient will end up with ceasearean section post operatively she is advised about early ambulation for risk of vte ,all the events are documented in the notes and the incident form is filled what is the trigger for an incident form? .Before discharge the patient is advised about breast feeding and contraception,post operative followup appointment is given to discuss about future pregnancy and delivery possibly by elective ceasearean section. early anc booking. Your punctuation is poor, making your essay difficult to understand. You need to improve your understanding of basic concepts like the difference between induction and augmentation of labour; active & latent phase of labour…

S G Posted by PAUL A.

 

Cervical dilatation of less than  2cm is  suggestive of delay in progress of first stage of labour. History must include  need for analgesia, wishes,presenceof shortness of breath ,shoulder tip painwhich are signs of rupture. Are her wishes a sign of rupture? She  is  assessed  for  adequacy  of  pain  relief (1)  and  dehydration.Temperature,PR,BP,RR  do you really assess RR in a woman with slow progress in the first stage? are  checked.Tachycardia and increase  in temperature would suggest infection,dehydration.Hypotension  and  tachycardia  would suggest dehiscence or rupture which would warrant urgent intervention.Per abdominal examination is done to assess how many fifths  of presenting part is palpable, effective uterine contractions, if they were effective she would have made progress. You can only assess frequency and maybe strength not effectiveness uterine tenderness for choriamnionitis,tenderness in the scar for dehiscence.Vaginal examination is  done to assess dilatation,effacement,positionof the head.Presence of caput grade 3 moulding (1) would suggest cephalopelvic disproportion which warrant delivery by LSCS.Colour of liquor is assessed and bleeding.CTG is assessed for fetal well being (1) and the presence of late deceleration is an early sign of scardehiscence which would warrant urgent delivery by LSCS.

 

 Prior vaginal deliveries is associated with VBAC success  rate of 87-90% in a woman with slow progress in the first stage? provided fetal and maternal wellbeing are maintained .Management options are explained to the patient and her wishes recorded. You may record her wishes but it does not mean you will consider them. Aim for vaginal delivery if no signs of scar dehiscence,cephalo pelvic disproportion,fetal distress so you have just recorded her wishes and proceeded with your objective to achieve vaginal birth. Vitals are monitored by MOEWS Chart instead of a partogram? which would identify need for intervention will it??? How does the chart do this? .Anaesthetist ,theatre staff,consultant obstetrician ,neonatologist informed  due to chance of failure of VBAC. You are going to phone neonatologist and tell them that a woman has slow progress – what do you expect them to do? Group and sAve due to risk of rupture (22-74/10000) and PPH.Epidural analgesia is not contraindicated  for pain relief as it is not associated with increase risk of rupture and does not mask signs of dehiscence. If  inadequate uterine contractions  (1) oxytocin  commenced  after  explaining  increased risk of  rupture 1.5 fold  and after discussion with consultant (1)  .She  is  reassessed  after  2hrs  (1) for  progress  of  labour.CEFM ??? is  done  since  CTG  changes  are  the most  consistent  findings  in  uterine  rupture.Instrumental  vaginal  delivery  with  forceps  or  vacuum  if  indicated  and  is  explained  to  the  patient.,No  routine  exploration of scar recommended  and  active  management  ot third  stage    due  to increased  risk  of  uterine  PPH.If  there  are  signs  of  scar dehiscence or  rupture,fetal  distress, non progression  of  labour  emergency LSCS  is  performed.In  case  of  rupture  incident  report is  filled  with  debriefing .Thromboprophylaxis  and  prophylactic  antibiotics  given  if  emergency  cesarean section.

Doaa Posted by PAUL A.

 

a)Detailed past obstetric history in regards previous LSCS ,including indication and weather or not the cause persisted in the current preg like what and why will the question say vaginal birth is planned?.,and it's order (e.i wether or not it's followed by normal delivery)as this will give better chance of success of VBAC ,interval between deliveries.As this patient had SROM timing since she starts leaking should be obtained,colour of liquor if meconium stained and any foul smelling loss.

Examination should include set of observation BP,Pulse (1),temperature, pain status of the patient should be assessed how do you do this on examination? and assured  it's controlled by epidural analgesia or nitrous gas+opioid. Abdominal examination for symphsio-fundal hight to assess foetal size,presentaion ,if presenting part was engaged or not (1), as well as pelvic examination to  assess the status of the cervix(bishop score) do you assess Bishop score for a woman in labour???,dilatation,effacement ,consistency,confirm presentation vertex,position  and the station of presenting part.Avoidance of repeated vaginal examination should be practised to avoid ascending infection .As the patient has slow progress consultant obstetician should be informed and alerted .

CTG monitoring (1) should be observed  and continued for the foetal heart  status and wellbeing as well as uterine contractions if she is getting regular strong and frequent contractions.

Ensure that the patient has an Iv access and blood is taken for FBC and group and save in case she goes for emergency LSCS

b)This is high risk patient,Provided CTG monitoring is normal and there's  no indication to intervene so allowing vaginal delivery should be the aim is this the standard management or an option? .Re assessment in an hour there is almost no point repeating a VE after 1h at 6 cm time and if its same finding

Augmentation may be carefully what does this mean? practised to avoid uterine rupture will careful augmentation avoid rupture? and scar dehiscence,Consultant obstetrician should be informed (1) and oxytocin dose/titration should be decreased to what? Is it the dose that you use or the frequency & strength of contractions? as patient is multipara+ had previous LSCS to avoid uterine rupture and scar dehiscence.it should be adjusted against uterine contractions so where does dose come in? You either increase until 3-4/10 or you leave it at x mu/min when she is contracting 1-2/10 because you have reached your max dose.

 if  it's  still same finding .Threshold for em LSCS should be lowered, if  any sign of foetal distress or failure to progress occured to dectease maternal morbidity and mortality.pt should give informed consent and explaination should be gived about the reason to have LSCS and  it's benifits in this situation outweigh the risks.Theatre nurses should be informed as well as paediatrician to attend the delivery.

care should be taken to record the finding with it's partcular timing in patient's note.

Shivamalar Posted by PAUL A.

 

(a)I would ask the patient if she feels any contractionand the frequency of her contraction better asking the midwife. I would ask if she feels continuos abdominal pain in between her contraction which may suggest scar dehiscence. I will  then examine her to check her vital signs include blood pressure, pulse, (1) and temperature. Then I will examine her abdomen to feel for presentation, the fundal height to assess if baby clinically appears 'big baby', I will feel for the engagement of the presenting part (1). I will also perd=form vaginal examination to assess for cervical dilatation, the effacement of the cervix, the position of fetal head if its is occiput posteriro which may explain the porolonged stage of labour, the station of the presenting part in relation to the ishial spine and assess for the presence of moulding and caput which may indicate obstructed labour (1). I will aso assess the CTG (1) to see if any fetal distress and check on the contraction, the strngth and it's frequency.

 

(b) I will discuss with the patient the option to continue the trial of vaginal delivery if there are no sign of scar dehiscence or obstructed labour or fetal distress (1). But I will reassess her sooner - within an hour's too short time to check on her progress. This is because she had 2 previous vaginal delivery which is single predictor for successful subsequent vaginal delivery. I will also take into consideration her future fertility plan so if she says she does not want any more children you will let her rupture her uterus? What will most women say if asked this question during labour or shortly after delivery? as vaginal delivery allows higher number of subsequent deliveries.This as well will alleviate the risk of caesarean section for both mother and baby what are the risks of CS to the baby?. I will take careful consideration of not augmenting her ? meaning because it increases the risk of scar rupture. Whereas, if clinical assessment shows big baby with obstructed labour how do you diagnose this? and fetal distress, I will counsel patient for urgent caesarean section (1) to expedite delivery as it reduces risk of perinatal mortality.. caesarean section does not carry risk of scar rupture (1). But other risk in caesarean section includes bleeding, visceral organ injury, wound dehiscence and infetion, venousthromboembolism and fetal laceration (1). Repear caesarean section also reduces number of future fertility and carries risk to future pregnancy including p;acenta praevia and accreta. Increase number of caesarean section also carries higher risk of scar rupture with future pregnancy and trial of vaginal birth. And I will take maternal request and patient's decision into consideration (1) for my management option.

Posted by Ravi B.

A)

I would first ask about the frequency of contraction, any constant abdominal pain, or decreased or absent fetal movements.

The last time this patient passed urine and opened her bowel is also important since a distended bladder is a cause for failure to progress.

I would also review her chart and assess her fluid balance to ensure the patient is not dehydrated.

I would review her antenatal records to identify any factors that would indicate a macrosomic baby like large symphysio-fundal height (SFH). Indication for the previous caesarean section and any complications that developed is also important.

Examination would entail measurement of pulse, blood pressure (BP) using an appropriately sized cuff, temperature and respiratory rate.

Subsequent examination of the abdomen, assessing for tenderness is also important in a patient with previous caesarean section. Vaginal examination assessing the station and position of the presenting part, effacement and dilatation of the cervix and presence of vaginal bleeding is important in assessing a patient with failure to progress.

I would then review the cardiotocographic trace, as she should be on continuous monitoring in labour along with a review of her partogram.

Initial investigations in this patient should entail complete blood count, group and save. This patient should also have an intravenous access.

 

b)

Management of this patient would entail achieving delivery either vaginally or via caesarean section after appropriate informed consent.

The patient should be informed that the chance of successful vaginal birth after caesarean section (VBAC) is 72 to 76% and expectant management with review in 2hrs is an option. This however carries additional risk. Additional risks with VBAC are, increased risk of uterine rupture (22 – 74/10000), increased risk of endometritis and blood transfusion (additional risk of 1% when compared to elective repeat caesarean section (ERCS)), and increased risks or perinatal birth related death (2-3/10000 additional risk).

This patient should be informed that there is an increased risk of rupture (2-3 fold) and emergency caesarean section (1.5 fold) if augmentation is used with oxytocin. If augmentation is being considered, then this should be a consultant led decision with the timing intervals should be discussed with the woman by the consultant. Oxytocin regime should not exceed a maximum rate, which produces contractions of 4 in 10minutes. The senior midwife should attend to this patient and the senior anaesthetist alerted. The lab should also be alerted and informed of the possible need for blood products if patient should require. Obstetric theatre should be informed with facilities on labour ward for resuscitation if necessary.

This patient should also be informed that ERCS carries increased risk of current and future complications of bowel and bladder injury, with increased risk of adherent placenta and blood transfusions. There is also a risk of fetal lacerations with ERCS. There is also increased risk of respiratory distress with ERCS (3-4%) when compared to VBAC (2-3%).

This woman should be consented with documentation of maternal wishes along with risks and complication involved. An incident form should be filled out for any adverse outcomes.

Essay 365 vbac. Posted by MONA V.
a)    Initial assessment would involve review of previous operative record regarding indication for cesarean any macrosmia ,failure to progress which would effect the success of vbac now. Any complications previously, type of uterine incision if known, whether previous vaginal delivery were vbac as that would increase the chance of success of present vbac to 80-90%. Antenatal record of present pregnancy checked for any recent growth scan indicating estimated fetal weight to look for macrosomia causing delay in progress. Pulse blood pressure temp are monitored to note any early sign of impending scar rupture like tachycardia hypotension. Abdominal examination is done for uterine contractions intensity,duration, clinical fetal weight estimation and fifths papable to rule out possible cephalopelvic disproportion (cpd). Vaginal examination to look for any malpresentarion like brow causing delay in progress. High Station of presenting part, excess caput , grade 3 moulding would point to cpd. CTG is assessed for fetal wellbeing as50-80% uterine rupture have abnormal ctg findings b)    Further management would involve consultant based decision regarding further continuation ,need for oxytocin augmentation if contractions are inadequate. The options should be discussed with the woman ,appropriate written information given. She should be told that oxytocin augmentation is associated with two to three fold increase in risk of uterine rupture and is a consultant based decision. The woman's wishes are respected and cesarean done if she wishes so. She is told of the advantages of vbac regarding avoidance of cesarean, impact on future pregnancies ,less morbidity,early return to normal functions ,avoidance of surgery and shorter hospital stay, less pain. she should also be made aware of the small risk of uterine rupture 0.2-0.7% with previous transverse uterine incision, need for emergency laparotomy if rupture associated perinatal mortality. Epidural is not contraindicated and should be offered for pain relief. Serial cervical assessment should be done every 2 to 3 hours preferably bybthe same person to assess adequate cervical dilatation and progress. In case of non progress and delay early resort to emergency cesarean is better option and decision to discontinue vbac should be by a consultant. The woman must be made aware of the risk of cesarean like injury to bladder , would infection thromboembolism need for blood transfusion and fetal laceration. But if it is the safest mode then it has to be resorted to for safety of mother and baby.
Essay vbac. Posted by MONA V.
a)    Initial assessment would involve review of previous operative record regarding indication for cesarean any macrosmia ,failure to progress which would effect the success of vbac now. Any complications previously, type of uterine incision if known, whether previous vaginal delivery were vbac as that would increase the chance of success of present vbac to 80-90%. Antenatal record of present pregnancy checked for any recent growth scan indicating estimated fetal weight to look for macrosomia causing delay in progress. Pulse blood pressure temp are monitored to note any early sign of impending scar rupture like tachycardia hypotension. Abdominal examination is done for uterine contractions intensity,duration, clinical fetal weight estimation and fifths papable to rule out possible cephalopelvic disproportion (cpd). Vaginal examination to look for any malpresentarion like brow causing delay in progress. High Station of presenting part, excess caput , grade 3 moulding would point to cpd. CTG is assessed for fetal wellbeing as50-80% uterine rupture have abnormal ctg findings b)    Further management would involve consultant based decision regarding further continuation ,need for oxytocin augmentation if contractions are inadequate. The options should be discussed with the woman ,appropriate written information given. She should be told that oxytocin augmentation is associated with two to three fold increase in risk of uterine rupture and is a consultant based decision. The woman's wishes are respected and cesarean done if she wishes so. She is told of the advantages of vbac regarding avoidance of cesarean, impact on future pregnancies ,less morbidity,early return to normal functions ,avoidance of surgery and shorter hospital stay, less pain. she should also be made aware of the small risk of uterine rupture 0.2-0.7% with previous transverse uterine incision, need for emergency laparotomy if rupture associated perinatal mortality. Epidural is not contraindicated and should be offered for pain relief. Serial cervical assessment should be done every 2 to 3 hours preferably bybthe same person to assess adequate cervical dilatation and progress. In case of non progress and delay early resort to emergency cesarean is better option and decision to discontinue vbac should be by a consultant. The woman must be made aware of the risk of cesarean like injury to bladder , would infection thromboembolism need for blood transfusion and fetal laceration. But if it is the safest mode then it has to be resorted to for safety of mother and baby.
Posted by shazard S.

 

Essay 365

(a) Firstly, review her clinical notes and birth plan. Important operative details of her caesarean section include its indication. Recurrent indications like failed progress in labour reduce the chance of successful vaginal birth after caesarean section(VBAC). Uterine incisions other than an uncomplicated transverse lower segment incision are associated with an increased risk of uterine rupture. Documentation of large symphysio-fundal height measurements or a large estimated fetal weight by ultrasound are associated with a large fetus. A large fetus will reduce the chance of successful VBAC. Note her BMI. A BMI>30 kg/m2 is asscociated with reduced VBAC success. Ascertain and respect her wishes regarding mode of delivery. Determine the frequency of contractions by asking the midwife in charge. Incoordinate contractions is a cause of slow progress that may be corrected by augmentation with oxytocin. Illicit symptoms associated with scar dehiscence. These include abdominal pain that persists between contractions and shoulder tip pain (seen with a haemoperitoneum). Assess the adequacy of analgesia. If inadequate offer an epidural if not already sited. No epidural anaesthesia increases the incidence of  failed VBAC. On examination note her blood pressure and pulse rate. Note her height. Short stature is associated with failed VBAC. On abdominal examination measure her symphysio-fundal height (SFH) and estimate fetal size by palpation. Assess the number of fifths of the fetal head palpable per abdomen. More than 1/5 palpable indicates failure of the fetal head to engage. This is a sign of cephalo-pelvic disproportion. Significant scar tenderness and easily palpable fetal parts per abdomen are signs suggestive of scar dehiscence. Suspicion of scar dehiscence precludes VBAC. By vaginal examination confirm cephalic presentation. Findings such as a high station, malposition, grade 3 caput and moulding and no descent with contractions indicate cephalo-pelvic disproportion (CPD). CPD precludes VBAC. Assess the colour of the liquor. Meconium staining suggests fetal compromise. Heavily blood stained liquor is seen with scar dehiscence. Review the Cardio-tocograph (CTG). CTG abnormalities suggests fetal compromise and may also be seen in scar dehiscence. Ask her to empty her bladder and examine the urine. Blood stained urine may be seen with uterine rupture. Relevant blood investigations include a complete blood count and group and save.

(b)Options include expectant management, augmentation of labour and delivery by caesarean section. Regarding vaginal delivery, it is associated with 5 fold less maternal mortality compared to caesarean secton. Continue labour only if there are no signs of cephalo-pelvic disproportion or of fetal compromise. Achieving vaginal delivery is important because it avoids the potential surgical and anaesthetic risks of caesarean section. Vaginal delivery also reduces the incidence of transient tachypnoeia of the newborn (TTN). Incidence is 2-3 % with vaginal delivery and 3-4% with elective caesarean section. Vaginal delivery avoids the increased risk of placenta praevia/accreta associated with multiple caesarean sections. Demerits include risks of birth related perinatal mortality. There is an increased risk of hypoxic ischaemic encephalopathy and consequent neonatal and childhood developmental pathology. Associated with VBAC is an increased incidence of endometritis and blood transfusion requirement. Additional risks associated with prolonged first stage include prolonged second stage, operative vaginal delivery, vaginal and perineal injury and shoulder dystocia. Note that caesarean section performed at a later stage in labour is associated with increased maternal morbidity. Regarding expectant management, this requires re-assessment of progress in 2 hours preferably by the same person. Note that expectant management is associated with prolonged labour with a consequent increased risk of uterine rupture. Regarding augmentation of labour with oxytocin, this option is associated with a 2-3 fold increase in uterine rupture and a 1.5 fold increase in caesarean section. Therefore this decision must be consultant led. Discussion should be undertaken with the patient regarding parameters used to assess progress of labour and indications for caesarean section. The oxytocin infusion should be titrated to the frequency of contractions. Aim for 3-4 contractions in 10 minutes. The value of caesarean section is that it avoids the risks of VBAC. These include uterine rupture, birth related perinatal mortality, hypoxic ischaemic encephalopathy, vaginal and perineal injury. Caesarean section also allows for simultaneous sterilization after appropriate counseling. Demerits include the risks of visceral injury ( bladder and bowel). Fetal injuries at caesarean section include lacerarations, bruises and fractures. Caesarean section entails the risk of intra-operative haemorrhage with consequent blood transfusions and hysterectomy. Post-operative risks include post partum haemorrhage, infections ( respiratory, wound site and urinary tract infections) and venous thrombo-embolism. Regarding the medico-legal implication of uterine rupture occurring with VBAC and slow progress, this may be avoided by opting for caesarean section.    

 

assay364 -365- Posted by huaida A.

Hi paul

my answer to assay 364 not marked , may be  because am posted it  late  ? but  assay 365posted early.

thanks

Posted by MONA V.
Hi my answer to essay 365 not marked Thank you
Posted by PAUL A.

 

assay364 -365- Posted by huaida A.
Fri Jul 13, 2012 06:59 am

Hi paul

my answer to assay 364 not marked , may be  because am posted it  late  ? but  assay 365posted early.

thanks

  Posted by MONA V.
Fri Jul 13, 2012 08:56 am

Hi my answer to essay 365 not marked Thank you

 

YOUR ANSWERS MUST BE POSTED AS A REPLY TO THE QUESTION LIKE ALL THE OTHERS ABOVE. FREE-STANDING ANSWERS WILL NOT BE MARKED AND WILL BE DELETED.

 

Posted by PAUL A.

 

   
  Posted by MONA V.
Fri Jul 13, 2012 08:56 am

Hi my answer to essay 365 not marked Thank you

 

SEE MESSAGE HERE REGARDING MARKING OF ANSWERS

 

https://www.busyspr.com/discussion/15/1534/busyspr_mrcog_part_ii.html

 

Yingjian Posted by PAUL A.

 

a)

I would review patient’s case notes and take further history. I would ask the indication of her previous caesarean section (1) , if classical caesarean incision was used would vaginal birth have been planned?, any complications during delivery or labour. I would ask the birthweights of her 3 children at delivery, any antenatal problems such as gestational diabetes or abnormal placentation. I would ask if she has any other previous operations or medical problems healthy woman – such general statements do not earn marks. Regarding this current pregnancy, I would check her antenatal scan reports regarding fetal growth and estimated fetal weight (1), fetal anomalies, presentation at last scan and placental position and if she had antenatal problems such as gestational diabetes mellitus, pregnancy induced hypertension, antepartum haemorrhage healthy woman.I would check how long have her membranes ruptured, if she has any group B streptococcal infection ? relevance to the question – will you write this for every question on a woman in labour? and any antibiotics started. I would ask patient if her pain relief is adequate (1), frequency of contractions, any caesarean section scar tenderness sign- you do not ask about tenderness. I will check her the type of analgesia she was given and when was it started, if any oxytocin was started why should it have?.

 

I would check patient’s vital parameters such as blood pressure, heart rate, temperature (1). I would do an abdominal palpation to assess presenting part and how many fifths palpable it is, any caesarean section scar tenderness, estimated fetal weight (1). I would check if her urine is bloodstained, any brisk vaginal bleeding and do a vaginal examination to reassess cervical dilation, cervical effacement, any caput or moulding, station and postion of presenting part, colour of liquor (any meconium staining) (1). I would check fetal heart rate CTG for any fetal distress such as decelerations.

 

b) The patient has poor progress in first stage of labor and opting for vaginal birth after caesarean section with risks of scar rupture.

I would catheterise patient why???. I would explain patient’s progress of labor to her and provide supportive care what does this involve?. I would provide adequate analgesia such as epidural: epidural will not prolong 1st stage of labor but may mask signs of scar tenderness does not.  I would monitor her vital parameters (blood pressure, pulse rate)continuously and ensure she has adequate midwifery support. I would put her on continuous external fetal monitoring if not on. I would set 2 large bore IV cannulas not necessary she is not bleeding on her and take blood for group cross match do not need to crossmatch blood. I would ensure she is on intravenous iv crystalloids for hydration. I would monitor her for risks of scar rupture such as scar pain, bloodstained urine, fetal distress on CTG. If her contractions are suboptimal how do you know if they are sub-optimal?, I would discuss with consultant regarding judicious use of oxytocin (1). I would insert a STAN for monitoring any fetal ST events.Did NICE intra-partum care guidelines recommend this? I would review patient in 2 hours (1), if cervix  is<1cm further dilated, I would consider a cesarean section delivery would you consider or recommend? for poor progress in first stage of labor. If I suspect scar dehiscence at any point, patient would be delivered by emergency caesarean section. I would explain this to patient and keep her nil by mouth if needed how will you decide if this is needed?. I would inform the anesthetist and neonatologist if she needs a caesarean section and ensure there are facilities for blood transfusion, caesarean section and neonatal special care. I would start her on iv antibiotics if she has ruptured membranes for >12hours or has group B streptococcal infection.   

Huaida Posted by PAUL A.

 

A healthy 34 year old woman presents with spontaneous rupture of the membranes and uterine contractions at 39 weeks gestation. She has two previous vaginal deliveries and one previous caesarean section. She has been counseled and vaginal birth is planned. At 00:20, her cervix was 5cm dilated. You are asked to review her at 04:40 because the cervix is 6cm dilated. (a) Discuss your assessment of this patient [8 marks]. (b) Critically evaluate your management options [12 marks] 

a/ I would    revise review her note  looking for the last estimated foetal wt as cephalopelvic disproportion what does estimated fetal weight tell you about CPD? If it was that simple, why was she allowed to labour? may be a cause of her delayed progress.

I would assess her analgesia (1)as pain may adversely affect labour.

I would assess the general condition of the pt ??? PR ? rectal examination?, bp  and mucous membranes for evidence of dehydration.

Iwould examine the abdomen  for the lie and presentation of the foetus,estimated foetal wt,and how many fifth of the head is palpable per abdomen (1) ? contractions.

 

Would assess the foetalwellbeing and the contractions with CTG (1).

Then would perform per vaginal examination for the cx dilatation liquor colour,presence of caput  or 

moulding,and the head station,whether membrane ruptured or not did the questions say membranes were ruptured?.

B/

Management options depend on the underlying cause of the slow progress.

emergent c/s will be the  option of choice in some conditions.

If there is any evidence of obstruction (1) such oedematous cx, caput and moulding  c/s will be the option.

Foetal compromise  shown by CTG and confirmed by foetal blood sample how would you exclude uterine rupture when the CTG is pathological to allow you to do FBS? is another cause for em c/s.

If no foetal compromise or evidence of obstruction, the pt ?? should  kept  well dehydrated.Analgesia should be topped up if not sufficient or should provided if not given before as pain  may delay labour progress.

.Accelaration by ARM read the question _+ Synticinon will be the management  if  the CTG showed inefficient uterine contractions how do you measure efficiency of contractions on CTG?.

Then pt should be re-assessed after 4 hours. If you use oxytocin, you should re-assess sooner

Ravi Posted by PAUL A.

 

A)

I would first ask about the frequency of contraction ask the woman?, any constant abdominal pain, or decreased or absent fetal movements ? relevance of fetal movements during labour.

The last time this patient passed urine and opened her bowel is also important since a distended bladder is a cause for failure to progress.

I would also review her chart and assess her fluid balance to ensure the patient is not dehydrated.

I would review her antenatal records to identify any factors that would indicate a macrosomic baby like large symphysio-fundal height (SFH). Indication for the previous caesarean section (1)and any complications that developed is also important.

Examination would entail measurement of pulse, blood pressure (BP) using an appropriately sized cuff, temperature and respiratory rate why is this necessary?.

Subsequent examination of the abdomen, assessing for tenderness is also important in a patient with previous caesarean section lie, presentation, engagement. Vaginal examination assessing the station and position of the presenting part, effacement and dilatation of the cervix and presence of vaginal bleeding is important in assessing a patient with failure to progress caput / moulding.

I would then review the cardiotocographic trace (1), as she should be on continuous monitoring in labour along with a review of her partogram.

Initial investigations in this patient should entail complete blood count, group and save. This patient should also have an intravenous access.

 

b)

Management of this patient would entail achieving delivery either vaginally or via caesarean section after appropriate informed consent.

The patient should be informed that the chance of successful vaginal birth after caesarean section (VBAC) is 72 to 76% even though she has not progressed? and expectant management with review in 2hrs is an option in which circumstances would this option be appropriate. This however carries additional risk. Additional risks with VBAC are, increased risk of uterine rupture (22 – 74/10000) is this woman’s risk unchanges given that she has not progressed?, increased risk of endometritis and blood transfusion (additional risk of 1% when compared to elective how do you discuss ELECTIVE CS during labour??? repeat caesarean section (ERCS)), and increased risks or perinatal birth related death (2-3/10000 additional risk). This is not an antenatal woman being counseled about VBAC – her risks much be much higher at this point

This patient should be informed that there is an increased risk of rupture (2-3 fold) and emergency caesarean section (1.5 fold) if augmentation is used with oxytocin (1). If augmentation is being considered, then this should be a consultant led decision with the timing intervals what should the interval be? should be discussed with the woman by the consultant. Oxytocin regime should not exceed a maximum rate what is the maximum rate?, which produces contractions of 4 in 10minutes. The senior midwife should attend to this patient and the senior anaesthetist alerted. The lab should also be alerted and informed of the possible need for blood products if patient should require. Obstetric theatre should be informed with facilities on labour ward for resuscitation if necessary.

This patient should also be informed that ERCS what does ERCS stand for and how could this woman possibly have ERCS?? carries increased risk of current and future complications of bowel and bladder injury, with increased risk of adherent placenta and blood transfusions you said VBAC had increased risk of blood transfusion above and ERCS also has increased risk of blood transfusion??? Which is right?. There is also a risk of fetal lacerations with ERCS. There is also increased risk of respiratory distress with ERCS (3-4%) when compared to VBAC (2-3%).

This woman should be consented with documentation of maternal wishes along with risks and complication involved. An incident form should be filled out for any adverse outcomes. You have simply reproduced information from the guidelines without thinking about what you are writing and how it applies to the question.

Mona Posted by PAUL A.

a)    Initial assessment would involve review of previous operative record regarding indication for cesarean (1) any macrosmia ,failure to progress which would effect the success of vbac now. Any complications previously, type of uterine incision if known, whether previous vaginal delivery were vbac as that would increase the chance of success of present vbac to 80-90%. Antenatal record of present pregnancy checked for any recent growth scan indicating estimated fetal weight to look for macrosomia causing delay in progress (1). Pulse blood pressure temp are monitored to note any early sign of impending scar rupture like tachycardia hypotension. Do these tell you about impending rupture? Abdominal examination is done for uterine contractions intensity,duration frequency, clinical fetal weight estimation and fifths papable (1) to rule out possible cephalopelvic disproportion (cpd). Vaginal examination to look for any malpresentarion like brow causing delay in progress. High Station of presenting part, excess caput , grade 3 moulding (1) would point to cpd. CTG (1) is assessed for fetal wellbeing as50-80% uterine rupture have abnormal ctg findings b)    Further management would involve consultant based decision regarding further continuation ,need for oxytocin augmentation if contractions are inadequate. The options should be discussed with the woman ,appropriate written information given you expecting her to read written information in labour?. She should be told that oxytocin augmentation is associated with two to three fold increase in risk of uterine rupture (1)and is a consultant based decision. The woman's wishes are respected and cesarean done if she wishes so (1). She is told of the advantages of vbac regarding avoidance of cesarean does persisting with VBAC avoid CS? , impact on future pregnancies ,less morbidity do RCOG guidelines say planned VBAC has lower morbidity? How do you know she is going to have successful VBAC?,early return to normal functions ,avoidance of surgery and shorter hospital stay, less pain. she should also be made aware of the small risk of uterine rupture 0.2-0.7% is this unchanged even when she has not progressed? with previous transverse uterine incision, need for emergency laparotomy if rupture associated perinatal mortality. Epidural is not contraindicated and should be offered for pain relief. Serial cervical assessment should be done every 2 to 3 hours (1) preferably bybthe same person to assess adequate cervical dilatation and progress. In case of non progress and delay early resort to emergency cesarean is better option and decision to discontinue vbac should be by a consultant surely you are able to make this decision. The woman must be made aware of the risk of cesarean (1) like injury to bladder , would infection thromboembolism need for blood transfusion and fetal laceration. But if it is the safest mode then it has to be resorted to for safety of mother and baby.

Shazard Posted by PAUL A.

 

Essay 365

(a) Firstly, review her clinical notes and birth plan. Important operative details of her caesarean section include its indication (1). Recurrent indications is this a recurrent indication? like failed progress in labour reduce the chance of successful vaginal birth after caesarean section(VBAC). Uterine incisions other than an uncomplicated transverse lower segment incision are associated with an increased risk of uterine rupture. Documentation of large symphysio-fundal height measurements or a large estimated fetal weight by ultrasound (1)are associated with a large fetus. A large fetus will reduce the chance of successful VBAC. Note her BMI. A BMI>30 kg/m2 is asscociated with reduced VBAC success. Ascertain and respect her wishes regarding mode of delivery. Determine the frequency of contractions by asking the midwife in charge. Incoordinate contractions is a cause of slow progress that may be corrected by augmentation with oxytocin.Illicit ?? symptoms associated with scar dehiscence. These include abdominal pain that persists between contractions and shoulder tip pain (seen with a haemoperitoneum). Assess the adequacy of analgesia (1). If inadequate offer an epidural if not already sited. No epidural anaesthesia increases the incidence of  failed VBAC. On examination note her blood pressure and pulse rate. Note her height. Short stature is associated with failed VBAC so how did she manage previous vaginal births?. On abdominal examination measure her symphysio-fundal height (SFH) and estimate fetal size by palpation. Assess the number of fifths of the fetal head palpable per abdomen. More than 1/5 palpable indicates failure of the fetal head to engage (1). This is a sign of cephalo-pelvic disproportion. Significant scar tenderness and easily palpable fetal parts per abdomen are signs suggestive of scar dehiscence. Suspicion of scar dehiscence precludes VBAC. By vaginal examination confirm cephalic presentation. Findings such as a high station, malposition, grade 3 caput and moulding (1) and no descent with contractions indicate cephalo-pelvic disproportion (CPD). CPD precludes VBAC. Assess the colour of the liquor. Meconium staining suggests fetal compromise. Heavily blood stained liquor is seen with scar dehiscence. Review the Cardio-tocograph (CTG) (1). CTG abnormalities suggests fetal compromise and may also be seen in scar dehiscence. Ask her to empty her bladder and examine the urine. Blood stained urine may be seen with uterine rupture. Relevant blood investigations include a complete blood count and group and save.

(b)Options include expectant management, augmentation of labour and delivery by caesarean section. Regarding vaginal delivery, it is associated with 5 fold less maternal mortality compared to caesarean secton absolutely not true – the majority of women who die during CS die from CS performed because of failed vaginal birth. This is a complication of PLANNED vaginal birth not CS. Continue labour only if there are no signs of cephalo-pelvic disproportion or of fetal compromise. Achieving vaginal delivery is important because it avoids the potential surgical and anaesthetic risks of caesarean section.Not if it is at the expense of a ruptured uterus or a CS at full dilatation Vaginal delivery also reduces the incidence of transient tachypnoeia of the newborn (TTN). Incidence is 2-3 % with vaginal delivery and 3-4% is this difference statistically significant?with elective caesarean section. Vaginal delivery avoids the increased risk of placenta praevia/accreta associated with multiple caesarean sections. Please see RCOG guidelines – you coulsel women by comparing PLANNED vaginal birth with PLANNED CS, not by comparing successful vaginal birth with all caesarean sections Demerits include risks of birth related perinatal mortality. There is an increased risk of hypoxic ischaemic encephalopathy and consequent neonatal and childhood developmental pathology. Associated with VBAC is an increased incidence of endometritis and blood transfusion requirement YOU ARE NOT COULSELLING AN ANTEPARTUM WOMAN. Additional risks associated with prolonged first stage include prolonged second stage, operative vaginal delivery, vaginal and perineal injury and shoulder dystocia. Note that caesarean section performed at a later stage in labour is associated with increased maternal morbidity. Regarding expectant management, this requires re-assessment of progress in 2 hours in which circumstances is expectant management appropriate? preferably by the same person. Note that expectant management is associated with prolonged labour with a consequent increased risk of uterine rupture (1). Regarding augmentation of labour with oxytocin, this option is associated with a 2-3 fold increase in uterine rupture (1) and a 1.5 fold increase in caesarean section. Therefore this decision must be consultant led (1). Discussion should be undertaken with the patient regarding parameters used to assess progress of labour and indications for caesarean section. The oxytocin infusion should be titrated to the frequency of contractions. Aim for 3-4 contractions in 10 minutes. The value of caesarean section is that it avoids the risks of VBAC. This is not an elective ante-partum CS – how can a woman in labour avoid the risks of VBAC? These include uterine rupture, birth related perinatal mortality, hypoxic ischaemic encephalopathy, vaginal and perineal injury. Caesarean section also allows for simultaneous sterilization after appropriate counseling this is not an advantage of CS. Demerits include the risks of visceral injury ( bladder and bowel). Fetal injuries at caesarean section include lacerarations, bruises and fractures. Caesarean section entails the risk of intra-operative haemorrhage with consequent blood transfusions and hysterectomy. Post-operative risks include post partum haemorrhage, infections ( respiratory, wound site and urinary tract infections) and venous thrombo-embolism. Regarding the medico-legal implication of uterine rupture occurring with VBAC and slow progress, this may be avoided by opting for caesarean section.    You have not recognized that the woman is in labour and have therefore provided inappropriate information.

VBAC Posted by shraddha G.

 

A)     Detailed history has to be taken regarding the indication of previous LSCS, duration of LSCS, whether it was before the vaginal delivery or after, so as to predict the success of Trial of labour after caesarean section (TOLAC). Review the records of LSCS if available, so as to find out the adverse factor such as extension of incision, which demands the deferment of TOLAC. Examine the general status of patient, if she is ill looking, dehydrated,  raised temperature, tachycardia, hypotension, these features are suggestive of exhaustion , deep transverse arrest, obstructed labour. Inspect the abdomen for presence of any pathological  ring. Palpate for the frequency and strength of contractions.3 contractions in 10 min , each lasting for 35-40 sec ,so one cannot dent the abdomen,  with good relaxation in between are the good contactions. Do NST to assess the fetal heart. Assess the baby size and look for the scar tenderness. Do per-vaginal examination to assess the cervical dilatation, effacement, position of saggittal suture in relation to the maternal pelvis ,station of head, presence of membranes, colour of liquor,caput, moulding. Assess the pelvis if it is adequate for the vaginal birth of baby. Do fetal blood sampling and if facility of USG, scar thickness should be assessed. Scar < 3 cm is considered as thin and demands LSCS.

B)      Our management options may include augmentation with oxytocin and VBAC. But this may involve risks of scar dehiscence, uterine rupture, prolonged labour, uterine atony, PPH ,and neonate may be jeopardized due to this. There are risks of fetal distress, perinatal asphyxia, HIE, cerebral palsy, sepsis, caput, moulding and admission in NICU. Repeated vaginal examination may lead to postpartum endometritis. The benefits associated with VBAC are avoidance of major surgery, risks of surgery and anaesthesia; such as mendelson syndrome i.e, aspiration pneumonitis, early convalescence to work,less post-op pain,respiratory discomfort,ease in feeding the child.

Instrumental delivery with vacuum is another option, provided the rotation of head is < 45 degree from the pubic symphysis. But it needs expertise,and may lead to sub-galeal hemmorhage, IVH, retinal hemorrhage . Still is a good option when fetal distress is there and immediate delivery is required and thus avoid major surgery which may increase maternal and neonatal morbidity.

Emergency LSCS is required in case of arrest of labour, obstructed labour, severe fetal distress, meconium stained liquor. It eliminates the risk of perinatal asphyxia, HIE,RDS,IVH  as immediate delivery is accomplished . Mother is also benefitted as the risk of scar dehiscence , uterine rupture are decreased .Since LSCS is a major surgery, may require blood transfusion and its hazards. Uterine atony due to prolonged, obstructed labour may occur and may demand B-lynch, uterine artery ligation, which may add up to the morbidity of patient. Further spinal headache, post-op pain, respiratory difficulty due to incision may limit the activities of mother and affect the mother-child bonding. There are chances of DVT, so one should be vigilant in prevention and use TED stockings if required.

QUIERY Posted by H H.

 

In the old forum there were 2 essay questions sent every week. With changes in the exam ,we used to get one essay question and two EMQs. When I joined for one year in the forum I expected this ,as EMQ  questions are important and keep you thinking. Will not sending EMQ questions reduce the fee of the forum, much obliged, Dr Shaaban

Shraddha Posted by PAUL A.

 

A)     Detailed history has to be taken regarding the indication of previous LSCS (1) , duration of LSCS ? relevance, whether it was before the vaginal delivery or after, so as to predict the success of Trial of labour after caesarean section (TOLAC)This will not impress the examiner who might never have heard of this. Your patients will also not know what it means . Review the records of LSCS if available, so as to find out the adverse factor such as extension of incision, which demands the deferment of TOLAC how do you defer it? Can she come tomorrow and have it? Are you going to change the plan that was agreed antenatally?. Examine the general status of patient, if she is ill looking, dehydrated,  raised temperature, tachycardia, hypotension, these features are suggestive of exhaustion are they?, deep transverse arrest, obstructed labour. Inspect the abdomen for presence of any pathological  ring. Palpate for the frequency and strength of contractions.3 contractions in 10 min , each lasting for 35-40 sec ,so one cannot dent the abdomen,  with good relaxation in between are the good contactions. Do NST what is this? to assess the fetal heart. Assess the baby size how? and look for the scar where would you see this? Your approach is not logical – palpate contractions then NST (presume an investigation) then size of baby ? how then scar tenderness!! tenderness. Do per-vaginal examination to assess the cervical dilatation, effacement, position of saggittal suture in relation to the maternal pelvis what does this tell you? Is this all you need to know to determine position? ,station of head, presence of membranes,read question colour of liquor,caput, moulding (1). Assess the pelvis if it is adequate for the vaginal birth of baby.How would you do this and how can you possibly conclude that her pelvis is inadequate when she has 2 previous vaginal births Do fetal blood sampling why?? (-1) and if facility of USG, scar thickness should be assessed. Scar < 3 cm is considered as thin and demands LSCS this is unacceptable – how thick is the myometrium of the lower segment in a woman with no previous CS? What is the evidence for this? (-1).

B)      Our management options may include augmentation with oxytocin and VBAC what has been going on up to this point? How is VBAC different from TOLAC?. But this may involve risks of scar dehiscence, uterine rupture, prolonged labour, uterine atony, PPH ,and neonate may be jeopardized due to this. There are risks of fetal distress, perinatal asphyxia, HIE, cerebral palsy, sepsis, caput, moulding and admission in NICU. Repeated vaginal examination may lead to postpartum endometritis. The benefits associated with VBAC are avoidance of major surgery so when you embark on VBAC, can you guarantee you are going to avoid major surgery?, risks of surgery and anaesthesia; such as mendelson syndrome i.e, aspiration pneumonitis, early convalescence to work,less post-op pain,respiratory discomfort,ease in feeding the child.

Instrumental delivery with vacuum is another option at 6cm dilatation? (-2), provided the rotation of head is < 45 degree from the pubic symphysis. But it needs expertise,and may lead to sub-galeal hemmorhage, IVH, retinal hemorrhage . Still is a good option when fetal distress is there and immediate delivery is required and thus avoid major surgery which may increase maternal and neonatal morbidity.

Emergency LSCS is required in case of arrest of labour, obstructed labour, what is the difference between arrest of labour and obstructed labour? severe fetal distress, meconium stained liquor. It eliminates the risk of perinatal asphyxia does it? Have you never delivered an asphyxiated baby at emergency cs? , HIE,RDS,IVH  as immediate delivery is accomplished . Mother is also benefitted as the risk of scar dehiscence , uterine rupture are decreased .Since LSCS is a major surgery, may require blood transfusion and its hazards. Uterine atony due to prolonged, obstructed labour may occur and may demand B-lynch, uterine artery ligation, which may add up to the morbidity of patient. Further spinal headache, post-op pain, respiratory difficulty due to incision may limit the activities of mother and affect the mother-child bonding. There are chances of DVT, so one should be vigilant in prevention and use TED stockings if required.

Answer PLAN Posted by PAUL A.

 

A good answer should include

Assessment

History

  • Identify reason for previous caesarean section (1 mark)
  • Review birth weights of previous babies, assessment of fetal growth in this pregnancy and any growth scans (1 mark)
  • Assess woman’s pain and need for pain-relief (1 mark)

Examination

  • P, BP, dehydration; BMI (1 mark)
  • Abdominal examination – fundal height, presentation and engagement; uterine tenderness (1 mark)
  • Frequency and strength of uterine contrctions (1 mark)
  • Vaginal examination – cervical dilatation, effacement, application. Fetal presentation, position, station, caput and moulding. Colour of amniotic fluid (1 mark)

Investigations

  • Fetal wellbeing using CTG (1 mark)

 

Management options

  • Know the importance of shared decision making (1 mark)

(i) Delivery by emergency caesarean section

  • Should be recommended if there is evidence of obstructed labour or mal-presentation (breech, brow) (1 mark)
  • Features suggestive of obstructed labour include high presenting part, cervical oedema, marked caput / moulding (1 mark)
  • Associated with surgical risks (1 mark)
  • Minimizes risk of uterine rupture (1 mark)

(ii) Oxytocin augmentation of labour

  • Should only be used following discussion with the consultant obstetrician (1 mark)
  • Should only be used if uterine contractions < 3-4 in 10 or only mild-moderate and obstructed labour has been excluded (1 mark)
  • There should be a clear plan for re-assessment within 2-3 hours by senior medical staff (1 mark)
  • The woman should be informed of the increased risk of uterine rupture associated with oxytocin augmentation (1 mark)

(iii) Expectant management

  • Adequate analgesia and hydration with re-assessment within 2-3 hours (1 mark)
  • Obstructed labour should have been excluded (1 mark)
  • Also associated with increased risk of uterine rupture but lower than with oxytocin augmentation (1 mark)
Posted by fadi A.

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