Essay 284 - Intra-partum care

a)I will try to obtain HISTORY informations that would help me in appropriaate manamement,when was the laast delivery and if this pregnancy spontaaanous or induced;confirm GA;to review her antenatal care notes:any difficult or instrumental delivery;delivery of big baby;history of medical problems and drug history.on examining this patient I will check her hydrtion status,pallor,BP and Temp,then in abd exaaminaation,I will evaluate for CPD;??big baby and if there is tenderness apart from contractions,Then:the patient should have IV line,BG and sample for cross match,rehydration and tilting the patient to left  lateral position can improve the bradycaardia.to perform ARM;if clear liquor then continue fetal monitoring plus syntocinone augmentation,fetal scalp sampling can help confirming fetal compromise,and if so an emergency C/S is indictated.                                                  b)This is an emergency C/S so I will explain the condition to patient and her relative and consent;quick delivery is required so senior anaaesthatist and Nursery docror to be there;I will bear in mind the following:to check FHR to last moment,low down head and stritched lower segment so I will open in upper of lower segment smiling incision to avoid bladder injury and incision extention respectively.keep supporting the mother.

I would assess the woman by taking a detailed history , examination and review of her antenatal records. any risk factors for fetal compromise in labour like iugr,checked. h/oy oxytocin augmentation,  spontaneous rupture of membs or arm ,time of rupture ,whether fetal heart deceleration noted immediately after arm ,should be asked.any h/o severe abdominal pain, bleeding enquired. . examination should include checking for temp, abd examination for uterine contractions,whether uterus is tense or tender.per vaginal exam to note any cord prolapse , meconium stained liquor,bleeding, position& station of fetal head.further assessment would be by continuous electronic monitoring. reversible causes like maternal position especially supine corrected & adequate hydration ensured,.if hypercontractions noticed oxytocin should be stopped .cont efm should be started .if ctg is showingcont prolonged deceleration.immediate steps should be arranged for category 1 caesarian.if ctg shows normal trace ,continue observations . if any suspicious ctg and if cs not warranted immediately, fbs should be done.depending on fbs value ,rate of progress,and ctg reading further decisions regarding route of delivery, time of delivery decided.all changes,concerns should be explained to woman and partner in each stage.

b, the complications of emergency caesarian are infection, bleeding, injury to bladder, urinary tract infection, blood transfusion and thromboembolism.so adequate steps should be taken inorder to reduce or prevent these complications. consent should be taken and possible complications should be explained in a sensitive way .discuss about anaethesia, post operative pain need for catherisation.all these will help to cope up with the sequences of surgery.the indication of c.s , what will happen if not done ,alternative option available  should be explained. to prevent anasthetic complications epidural anaesthesia is preferred. this has less morbidity compared to general anaesthesia.to prevent aspiration if general anaesthesia needed antacids & h2 receptor antagonists should be given.to avoid infection, prophylactic antibiotics administered before skin incision.all aseptic techniques should be followed. since it is like fully dilated cx senior obstetrician should do surgery. bladder should be catheterised withepidural anaethesia . this will help to avoid bladder injury. uterovesical fold of peritonium identified and incision put just 2cm below.this will avoid incision putting in vagina.uterotonics given immediately after delivery of baby to prevent pph.

post operatively thromboprophylaxis should be started to avoid  thromboembolism.close monitoring of vitals in the immediate post op period.adequate pain relief,fluid maintainance needed .

regarding baby a paediatrician should be present during c.s to resuscitate the baby. close monitoring of baby with frequent assessment of the well being of the baby atleast for the initial 12 hours needed.

A)    I would reposition the woman to the left lateral position to prevent aortocaval hypotension. I would also start IV fluids as dehydration can affect the fetus. I check the patient’s vital signs. I would look for hyperstimulation in the CTG and stop oxytocin if she was started on an infusion. I would palpate the abdomen to check fetal descent and abdominal tenderness in between contractions (a high head when compared to previous findings or palpable fetal parts on palpation and abdominal pain with abnormalities in a CTG can be an indication of uterine rupture).A woody abdomen on palpation with pv bleeding is a sign of placental abruption. Then perform a vaginal examination to assess dilation, fetal descent and to see if an instrumental delivery would be possible or if a section would more appropriate. During the vaginal examination I would assess for cord prolapse (a sudden gush of liquor with high head can indicate cord prolapse), any bleeding (a sign of vasa previa or placental abruption) and colour of liquor.

B)    First the reason for the section should be explained to the patient and her partner and consent obtained. The emergency bleep should be sent out to inform all necessary staff. The consultant-oncall should be informed and the paediatric team on standby. If the patient has an epidural insitu this should be topped up, if not the procedure is to be performed under a general anaesthetic. The anaesthist gives a once only dose of Co- Amoxiclav to prevent infection. During surgery care should be taken while opening the abdomen to avoid injury to the bladder and also while opening the uterus, the incision should high up in the lower segment to avoid extension of the incision to the cervix. After delivery, the baby should be handed to the paediatrician for resuscitation. Cord blood gases must be taken. Bleeding must be minimised with uterus closed as soon as the placenta is delivered and Oxytocin infusion started (40 IU). Post-op vitals and bleeding should be monitored. If bleeding was excessive during surgery a FBC should be performed to assess if a blood transfusion is needed. A FBC should also be performed on Day 2 after the section. Prophylactic dose of low molecular weight Heparin is given and the patient is encouraged to wear the thromboembolic deterrent stockings.  She is also encouraged to mobilise.

A) Bradycardia occurs in the baby for more than 3 minutes is considered to be pathological and  urgent medical aid should be sought and preparations should be made to urgently expedite the birth of the baby,

Help is summoned from senior midwife, neonatologist and anaesthetist.

She should be enquired regarding adequacy of pain relief.  Pulse, blood pressure are noted. Maternal notes is reviewed for the possibility of IUGR or  clinical or sonological evidence of big baby. 

Abdominal examination is performed to identify clinically big baby, to assess palpable fifths of fetal head. 

Vaginal examination to assess the cervical dilatation, application on the fetal head and station of the head. Colour of the liquor is noted if meconium stained.  

If the delivery is imminent , vaginal delivery or operative vaginal delivery is conducted depending upon the station of the fetal head to expedite the birth of the baby.

If vaginal delivery is not imminent, and if the fetal heart recovers within 9 minutes,  the decision to deliver should be reconsidered in conjunction with the woman if reasonable. 

If vaginal delivery is not imminent and the bradycardia persists, arrangements are made to move her to the theatre to perform urgent category 1 caesarean section . Theatre staff should be informed about the possibility of urgent grade 1 caesarean section. Woman and her family are informed regarding the fetal compromise and the need of urgent CS.  This should be performed as soon as possible . Decision to delivery interval should not exceed 30 minutes. 

 Foley's catheter is inserted to facilitate the drainage of urine and reduces the risk of bladder injury.

Emergency caesarean section during active labour is associated with increased risk of blood loss, blood is sent for grouping and saving. 

B) 

Maternal complications include visceral injury and bladder injury is more common. Insertion of foleys catheter reduces the risk of bladder injury. Anticipation of the presence of  oedematous bladder  and   opening of the peritoneum at a higher level  may reduce the possibility of injury. In case of injury to urinary bladder, surgical assistance is sought to accomplish the repair. 

Difficulty is expected during the delivery of the fetal head as it is deeply engaged. Caesarean section performed or supervised by experienced obstetrician will help to overcome this difficulty .  Assistant is asked to push the fetal head from below through the vagina to aid the delivery of deeply engaged fetal head. 

Extension of the uterine incision should be anticipated during the delivery of the fetal head and the presence of senior obstetrician is required to deal with the difficult tear.

Caesarean section during second stage is associated with  the  risk of intra operative haemorrhage as well as PPH. Meticulouls repair of the uterine incision and lower segment tears  is necessary to achieve haemostasis. PPH is managed according to the unit protocol. If haemorrhage is due to atony of the uterus , uterine massage along with pharmacological measures ( syntometrine, Carboprost ) help to control the bleeding. Surgical interventions like uterine artery ligation, B-Lynch sutures or hysterectomy should be undertaken if PPH is not controlled with preliminary measures. 

The risk of endometritis is more in case of emergency caesarean section. Prophylactic antibiotic before skin incision reduces this risk. 

The  risk factors for  thromboembolism are assessed after CS and in the absence of additional risk factors LMWH is given for 7 days post operatively. Good hydration and early mobilisation are ensured to reduce the risk.

Communication among different specialities and organising the team is important in achieving decision to delivery interval of 30 minutes which reduces the perinatal mortality.  

 The presence of neonatologist who is experienced in neonatal resuscitation also helps to reduce perinatal morbidity. 

She  is a HEALTHY  lady  and P2. The  CTG  showing  deep deceleration  for  3  minutes  is  pathological  and  quick  action is  mandatory.I will turn  her to left  lateral   ,maintain intravenous  line  (if  not previously  maintained), start  I/V  hydration  ,and  O2  inhalation ( for short period only) .I will quickly  assess  antepartum  and  intrapartum notes  for  any  risk  factors like  IUGR   , good size  fetus  or  GDM    W as    deceleration  associated  with   any  event  like  SROM,ARM, sudden  change in position ,sitation of  epidural (although  at  this  dilatation but  possible),emptying  of  bowel  or bladder .I will  examine  vital signs  of  mother( tachycardia  and  hypotension may represent  bleeding).I  will  enquire  about  nature of  pain  sudden  and  constant  pain( non contractile)  may represent  abruption. On  abdominal  examination  I will assess tenderness for  abruption . I will  reconfirm  for  lie,  presentation,  position ,estimated fetal  size  and   clinical assessment  of CPD. I will  perform  vaginal examination  to reconfirm position  and  exclude  cord  prolapse or  compression .if  ARM  not  yet  done  I will do  ARM    and  see  colour  of  liquor . I will start  continous electronic  monitoring .I will inform  senior  obstetrition  , midwife , anesthetist and  neonatologist. I will advise  arrangements  for possible  C/section . X match  and hold  blood .I will explain  condition  to  couple .

B  . C/section  has been  decided  it  is  almost  like  second  stage  C/section.i will inform anesthetist . OR  staff , neonatologist , senior  obstretition .I will  inform  couple  about  situation  and take  informed conscent  for  C/section .patient  will be  shifted  to OR  in left  lateral  position .Choice  of  anesthesia  is that of  anesthetist  in case of  severe  disress  general  anesthesia may be quicker and  quick delivery of  fetus  may  be  possible .I will  reassess  her vaginally   to assess  possible  instrumental delivery .For  C/section  I will  use  phenenstiel  inscision   as  it is  more  cosmetically  acceptable, associated  with less bleeding  and better healing,. Bladder  may  be higher  and   and  I will perform  carefull dissection  to avoid  injury. The  head  may be deeply  engaged  and  may be  needed  to push  vaginally .uterine  inscision may  need  extention .she  is  high  risk  for intrapartum  and  post partum bleeding ;.Meticulous  hemostasis  will be  needed  during  closing prophylactic  measures  will  be  taken for PPH         .Postoperatively   careful  monitoring  for PPH   will be  done  .early  mobilization  and  hydration will be  started   as prophylaxes  for  thromboprophylaxes.     IF  no  other risk  factor   present  LMWH   is  given  for  7  days   but  can be  modified  according  to  protocol  if  risk  factors  present.     I  will  explain  condition  to  patient  post operatively  . I  will councell  her  about  contraception .and  implications  on  next pregnancy

Intrapartum care

 A.    As she is having fetal heart rate of <100bpm which is pathological CTG finding  she is urgently assessed for risk factors in antenatal and intraparum period for fetal compromise.I will ask about her time of onset of labour whether it was spontaneous or iduced and ruptured or intact membranes.I will ask about history of diabetes mellitus, hypertensive disorders ,fetal growth restriction.she is asked about previous instrumental deliveries and birth weight of babies.I will  check  her blood pressure ,pulse, temperature,hydration status,urine for proteins and ketones. I will see which analgesia being given and any recent dose of epidural analgesia and any oxytocin being given.I will do abdominal examination to see lie, presentation,position and engagement of presenting part,tenderness. Frequency and severity of uterine contraction is noted.Vaginal examination is done to see dilatation,lengthof cervix;presentation and position of presenting part;membranenes ruptured or intact. Any bleeding or meconium noted.I will change position of patient with left lateral tilt; hydrate patient  if required and subcutaneous terbutaline if its uterine hyperstimulation.I will start continuous electronic fetal heart rate monitoring and finding are clearly documented with date and time adjusted on mechine.I will perform fetal scalp blood sampling for pH which will tell about fetal acidosis after excluding the contraindications like HIV and fetal bleeding disorders.

Depending upon assessment decision is made about immediate instrumental delivery or emergency caesarean delivery.   

B.  For type1 emergency caesarean section senior obstetrician ,anaethtist,theatre staff ,neonatologist should be informed. Time from decion to delivery interval shold be 30 minutes.Blood gp ,save and cross match done,Hb is checked as there is risk of postpartum haemorrhage.Antacids are given to reduce the risk of aspiration pneumonia ,antibiotic prophylaxis given to reduce risk of postoperative wound infection,thrombprophylaxis given depending upon risk to reduce thromboembolism postoperatively.Abdomen opened by pfanenstiel incision,uterus by transverse incision on lower segment.an assistant may be needed to push head up from vagina. Baby head is delivered by gentle flexion of the neck.placenta is delivered by controlled cord traction and IV syntocinon 5u given.Uterus  closed in two layers. Visceral and parietal peritoneum is not closed.

 Umblical arterial blood sent for pH,which will confirm fetal hypoxia and acidosis.Intravenous oxytocin infusion 40iu in 1 litre of saline  considered as there is risk of PPH.Patient is monitored carefully for PPH in postpartum period.

The patient is counselled postoperatively and effects of caesarean section on future pregnancies. 

A) I would elicite a quick history likely to cause acute bradycardia like-  IUGR, any ARM done, H/O bleeding per vaginum ,whether epidural was started or topped up.Review her notes of any present or previous risk factors IUGR, Macrosomia, difficult deliveries.  Clinical examination pulse , BP, hydration to detect hypo or hypertension. Abdominal Examination to determine the frequency of contractions , duration & intensity  to rule out hypersystole >6/10min , hard nonrelaxing uterus S/o abruption. Estimated fetal weight clinically , ? /5Th palpable . Commence continuous EFM.  pervaginal examination : to note membrane status , cervical dilataion, progress, caput moulding,position of fetal head and descent, colour of liquor , any meconium or bleeding.

Simultaneously  would ask the MW to start an IV line , ringer lactate solution, place woman in left lateral position. any reversible cause like stop synto if tachysystole,consider tocolytic, infusion if brady was following epidural topup with hypotension.ARM done if membranes intact and colour noted.  If initial resuscitation measures fail FBS indicated as brady present for 3min pathological  .PH < 7.2 indicates acidosis hence fetus needs immediate delivery by most expiditious route , inthis case by emergency cat I Caeserean if cx not fully dilated otherwise by operative vag delivery if fully dilated. Any unfavourable circumstances like macrosomia , obesity, OP ,> 2/5th palpable necitates instrumental delivery in theatre. If PH >7.2 or borderline continue close monitoring and repeat FBS if new CTG changes occur or consider delivery.

B) I would inform the consultant on call , alert the neonatologist, senior anaesthetist   . Senior obstetrician sholud do, or  be immediately available in theatre as the risks of CS with head deeply engaged in almost full dilatation is higher than elective or 1st stage  CS. The risks of 2nd stage CS breifed to the woman and partner and consent obtained. Risks of infection - wound, UTI, need for blood transfusion , any refusals noted, r/o thromboembolism, visceral injury ,future pregnancy risks explained.

regional anaesthesia preferable &could be sited very quicky in an emergency situation also ,by an senior anaesthetist as would reduce the risk of full stomach and aspiration pneumonia. Antacids & H2 blockers given to reduce acidity and aspiration risks.

Intraop measures : Bladder catherised , as it could be drawn up.  IV antibiotics Cefuroxime at skin incision to reduce r/o infection. Suprapubic transverse incision preferred even in emergency situation to ruduce futyre risks of hernia & for cosmesis and less pain. UV fold opened and bladder reflected to prvent bladder injuries. Uterine incision made highon lower segment  to avoid enetering into vagina.angeles extended bluntly either with fingers or scissors curved upwards to avoid damage to uterine vessels.Assistance may be neede to gently push the fetal head from below by anothe r person - careful not to give undue pressure to avoid fetal skull injuries. Prophylatic syntocinon 5IU slow iv after delivery of placenta to rduce r/o PPH. Additional measures like syntometrine, prostaglandin or misoprostol rectally if bleeding continues. Consider Blynch sutures if atonic PPH.  Angle extension need careful suturing of Uterine arteries. Avoid inadvertent suturing of ureters or bladder inclusion in stitches while trryong to control bleed. Hemostasis and counts verification.

Post op hydration , ambulation, pain relief, VTE Prophylaxis LMWH for 7 days.Contarception discussed.

Cord blood analysis for hypoxia done. Senior neonatolgist presence at delivery.Resuscitation depending on babies condition .   Well baby needs breast feeding & no need to separate from mother but observation for 12 hours . depressed baby has to be resuscitated by trained personel & monitored in NICU for cry, activity, colour, neurological status. Risk of Meconium aspiration, hypoxia ,siezures needs monitoring & treatmen.tParents counselled about baby condition & updated regularly .

Decicion to delivry interval noted. accurate documentaion.preservation of CTG & all events noted clearly in CTG in case records and prserved. Incident reporting of term babies to NICU admission noted as is any ontoward event.   

a.) Initial management aims to expedite delivery as fetal bradycardia persisting for >3mts is pathological. Commence continuous EFM [electronic fetal monitoring] if not already in progress, change her to the left lateral position, insert intravenous access to ensure proper hydration [if not already present] and start Oxygen inhalation. A quick history taken regarding preceding events like rupture of membranes with a gush of liquor may suggest cord prolapse, bleeding per vaginum and continuous severe abdominal pain may point uterine rupture, abruptio placenta. Note if epidural insertion or topping dose given, any oxytocin augmentation started. Review her past obstetric record for instrumental delivery, recent Ultrasound scan for fetal  growth restriction and macrosomia.Examine her vital signs,pulse,blood pressure for tachycardia and hypotension, note  temperature, hydration status, do urinalysis for proteins,ketones. Abdominal examination for frequency and strength of contractions, [rules out hyper systole].Note position, lie and presentation. A woody, tense feel of uterus suggests placental abruption.Vaginal examination to note cervical dilatation and length, station of presenting part. Look for bleeding or meconium, caput or moulding and rule out cord prolapse.Review the CTG, note absent variability, accelerations or variable decelerations. If the delivery is imminent, and the bradycardia recovers, a vaginal or operative vaginal delivery can be conducted after taking an informed consent from patient. If bradycardia persists, FBS done to assess fetal hypoxia, if pH is <7.2, plan for an emergency Caesarian Section [C.S]. The consultant obstetrician, anaesthetist, paediatrician, senior midwife and OT staff will be informed of the decision. The woman and her partner will be informed about the fetal compromise and the risks associated with emergency C.S [in almost second stage of labor], consent will be taken.                    b.) The intraoperative maternal complications are prevented by the senior obstetrician performing or supervising the Cae sarian section. Though regional anesthesia preferred, general anesthesia can be given.Pre incision antibiotic dose is given, Joel Cohen’s incision allows quick entry with blunt dissection. Visceral injury especially bladder is minimized by entering the peritoneal cavity as high as possible and Foley’s catheterization. Risk of bleeding prevented by proper homeostasis and ensuring blood is grouped and saved. A curvilinear incision high on lower segment prevents extension of uterine incision with care taken to avoid digital injury to broad ligament. If the head is deeply engaged, an assistant may disimpact by pressure through vagina and delivery is facilitated by flexing the head.Paediatrician presence for neonatal resuscitation reduces perinatal morbidity Cord blood [arterial and venous] sent to confirm acidosis. Prophylactic oxytocin infusion takes care of PPH which is continued in the postoperative period, adequate thromboprophylaxis as recommended by guidelines. Monitor vitals and bleeding. Early mobilization, good hydration, adequate pain relief, TED stockings and antibiotics complete the care. Encourage breastfeeding. Debriefing and Counseling regarding future pregnancies is documented. Incident reporting if NICU admission of  baby.  Contraception advice given.

a)The patient is probably a low risk patient as she has been allowed to go into spontaneous labour at 41 weeks.She should be initially assessed for adequate pain relief and hydration.An iv line shold be in place and she should be turned to the left lateral position as this can help in recovery of bradycardia.A quick abdominal examination should be done to assess frequency and intnsityof uterine contraction ,if there is hyperstimulation tocolysis with terbutaline should be done as this can cause recovery of bradycardia.Fundal height,fifths palpable ,presentation of fetus should be noted.A vaginal examination to detrmine dilation ,station and rotation and status of membranes shold be done as this will give an idea whether delivery is imminent and also rule out acute obstetrical emergencies like cord prolapse.Amniotomy should be done if membranes arei ntact and colour of liquor should be noted.All this while patient must be on continuous fetal monitoring.If bradycardia persists but vaginal delivery is imminent patient should be offered operative vaginal delivery after explaining the benefits and risks associated.Adequate analgesia should be in place and a right mediolateral episiotomy should be given as there is fetal bradycardia.If vaginal delivery is not iminent and fetal bradycardia persists patient should be shifted to the operation theatre.In the operation theatre a final vaginal examination should be done.If fetal bradycardia recovers within 9 minutes the decision to deliver her urgently should be reconsidered.A fetal blood sampling should be done to check for acidosis.b)Category 1 casearean section at 8 cm dilation with station at+1 can pose certain problems for both mother and baby.The first step is to ensure that adequately skilled persons are involved in the procedure.A senor obstetrician should perform the CS.Patient should be catheterised with indwelling catheter as this reduces the chance of bladder injury.Uterus should be opened by curvilinear incision by sharp dissection rather than splitting with fingers. This reduces the incidence  of extension into the vagina.As the head is deeply engaged there may be difficulty in delivering the head.To overcome this an assistant should be present to push the head vaginally and disengage it.As this patient is at increased risk of postpartum hemorrhage uterotonics should be given as soon as the baby is delivered.She should also get prophylactic antibiotics before skin incision to reduce the risk of post operative infection.A pediatrician should attend the caesarean section in case neonatal resuscitation is required.Since the patient has undergone category1 caesarean section her risk for thromboembolism should be assessed in the postpartum period and thromboprophylaxis given accordingly.Debriefing of the patient by one of the senior obstetricians present in her case should be done at the earliest .

Aim of initial management is to identify the cause of this pathological CTG.Woman should be in left lateral position .Histroy taken from women or/and midwife of any recent histroy of epidural analgesia or other narcotics ,as these drugs cause bradycardia.histroy of  per vaginal bleeding for abruptionand uterine dehisence. Any change in frequency duration  and strength of contraction with suspicion of utrinerupture.sudden loss of watery vaginal discharge point towards membrane rupture and suspected cord prolapse.Review antenatal notes and partogram to find related abnormality that leads to fetal hypoxia.GPE for general wellbeing ,maternal hypotnsion, hypovolemia and assessment of hydration,take BP,pulse, temperture and signs of dehydrationFreqency of bladder emptying should be checked.assess pain and painrelief.Abdominal examination include fetal position, lie,liqure volume and head engagment.Assess frequency of contractions strength and duration for uterine hypercontractility.pelvic examination to rule out cord prolase, for color of liquor whether meconium stained, if membranes ruptured and if not rupture and check colour and volume of liquor.Cervical effacement and dilatation position ,station and positionof presenting part to make decision of mode of delivery.As CTG showed abnormal feature ,fetal blood sampling should be taken unless there is clear evidence of acute compromise.After abnormal FBS consultant obtetetric advise should be sought.Shortterm oxygenation may be considered .Correct any dehydration and hypovolemia by IV fluids.Adequate pain analgesia should be offered.Woman should be informed and appropriate consent should be taken before each intervention.

b]Csection should be as ealy as possible. preop,give antacid and antiemetics IV.Cathetrized the patient.BLood grouped and saved.Crossmatched as increased risk of haemorrage.perform by experienced sugeon preferably under regional anesthesia.Prophylactic antibiotics preincision.

Intraoperatively Joel cohen incision. Enter peritoneal cacity relativly high to prevent bladder damage.Give high incision on lower uterine segment.Assisstance may be required to deimpact the head.Deliver the head by flexion and try to minimise any fetal head injury.Oxytocin should be given slow IV 5 IUand placenta delivered by controlled cord traction.Umblical artery PH should be done.Uterus stitched in double layers. No need to close viseral and perital peritoneum, it reduces I/O time and postop pain.start syntocinon infusion.

Post op,adequate analgesia. mobilization and adequate hydration.LMWH for 7 days .neonatal assessment by a neonatologist. baby should be warmed and early maternal contact should be ensured if possible.breast feeding should be encouraged.Debreifing is very important for woman and her family.

I will check general condition of the mother to exclude serious complications i-e shocked mother,vaginal bleeding, heamaturia, cessation of contractios & use of oxytocin augmentation may point to possible rupture uterus in this multigravida woman.I will check vaginal loss, recent rupture of membrane with bleeding may be due to vasa previa. Also bleeding may point to placental abruption. I will change position of mother to left lateral position,give facial oxygen & observe CTG as supine hypotensive syndrome may be the cause. I will do PV examination to check whether delivery is eminent & notice colour of liquore. If CTG improved with good variability, base line 110-160 & this prolonged deceleration ends up to 3 minutes, so this is a suspicious CTG & I will keep observation of CTG.

If prolonged deceleration continues, immediate delivery is indicated. In case of fully dilated cervix, ruptured membrane engaged head, pelvis is deemed adequate & vaginal delivery is likely I can use operative vaginal delivery either obstetric forceps or ventouse. Should the cervix is not fully dilated or other  prerequisites are not fulfilled, Caesarean section class 1 is indicated.                                                                                                                                                                                             B) I will call for help, ask senior obstetrician to attend the operation. A blood sample for cross matching should be sent. I will insert urinary catheter & fix it. I will give prophylactic dose of antibiotic intravenous. I will ask for neonatologist to attend delivery for resuscitation of the baby & inform him about CTG findings & gestational age.

During the operation: I will incise the uterus by curvilinear incision at the level of loose peritoneal attachment which may be little higher due to 8 cm cervical dilatation. Avoid widening of incision by fingers as this may lead to lower segment extension, use scissor instead. Iwill disimpact the fetal head & this may be helped by one of my assistant who wear sterile gloves & push fetal head upward through vagina. I will direct occiput towards surgical wound to deliver the baby. Should this fail due to deep impaction of fetal head, breech delivery can be tried. Proper heamostasis is essential with suturing any lower segment laceration. I will insert drain if needed, observe colour of urin& if heamaturia check for bladder injury.

I will write incidental report as part of risk manegment. Iwill write full operative detailes. Following operation, psychological support is offered to the woman.

I will assess the need for thromboprophylaxis as category 1 CS is one of the risk factors for thromboembolism

Fetal bradycardia persisting for 3 min comes under non reassuring pattern so immediately I will look upon other parameters of the CTG trace to see whether they are reassuring or not. According to other parameters I have to classify the CTG trace as suspicious or pathological. if only bradycardia persisting upto 3 min with a normal variability and accelerations it will be a suspicious CTG and if it is having any other non reassuring parameter It will be a pathological CTG. immediate management in any case will be to make the women in the left lateral position, oxygen inhalation, hydration and stop oxytocin if it is there. Sideways assessment of her previous and current obstetrical records should be done to rule out any risk factors. On examination her vital signs should be checked to see if there is acute hypotension or tachycardia (supine position, regional analgesia, uterine rupture). Abdominal examination should be done to see Frequency and strength of uterine contractions, how many parts of fetal head palpable per abdominally, clinical size of the baby, assessment of signs of uterine rupture like tenderness, persisting  fetal bradycardia, cessation of uterine contractions etc. Vaginal examination should also be under taken to assess cervical dilatation, station and position of the presenting part, color of liquor, presence of caput or molding and presence of any fresh vaginal bleeding. If bradycardia does not persists beyond three minutes and CTG becomes reassuring and history examination shows that she is an otherwise low risk patient then we will continue the management of labour with continuous fetal heart rate monitoring, can restart the oxytocin if needed, and maintain the partogram. if fetal compromise is obvious and bradycardia persists then we will immediately plan for delivery according to stage of labour. If imminent delivery by spontaneous or instrumental route is not possible we will go for cesarean section. If fetal compromise is not so obvious like bradycardia settles but CTG remain pathological and delivery is also not imminent then we can go for fetal scalp blood sampling provided that there is no contraindication to it. Fetal blood sampling can act as an adjunct to make further decision about delivery. If FBS results are abnormal consultant should be sought if its borderline should be repeated within 30 min if CTG is pathological and if FBS is normal but CTG is still pathological it can be repeated after 1 hr or earlier in case of further abnormality. On delivery presence of pediatrician should be ensured and umbilical artery PH should be performed to guide state of fetal academia and management accordingly.

B: to optimize maternal and perinatal outcome we should follow certain steps which can be divided into preoperative ,intra operative and post operative.pre operative steps will include counseling of patient and relatives and take an informed consent. To make sure that documentation of reasons for section should be done. Patient’s investigations should be reviewed particularly hemoglobin levels and blood should be sent for cross match. operation theater staff, anesthetist, pediatrician should be immediately informed choice of anesthesia is important, regional anesthesia is more safe and having less mortality and morbidity so it should be offered for cesarean. if regional anesthesia has been decided she should be having indwelling catheter to reduce overdistension of bladder. She should be given antibiotic prophylaxis before skin incision in the form of one shot of ampiclline or cephalosporin. H2 receptor blockers and antiemetic should also be given to reduce the risk of vomiting and gastric aspiration. Volume preloading should also be done before regional anesthesia to reduce hypotension. OT table should have a tilt of 15 degree to reduce aortocaval compression. risk of thrombosis should be assessed and prophylaxis used accordingly. Considering the patient is in advance labour and head is at +1 station, one assistant should be prepared in theater to assist delivery of the baby which might be difficult. Make sure that decision to delivery interval should not be more than 30 minutes.

Intraoperatively we should follow safe surgical practices like steps to reduce the transmission of infection to the baby and staff, incision on the abdominal wall should be straight line incision 3cm above the symphysis preferably (joel cohen) because it has good healing and cosmetically better results, other layers of abdomen should preferably be separated bluntly and if dissection needed should be preferred with scissors and not with knife. Uterine incision should also be extended with blunt dissection. It should be explained to the mother that risk of fetal laceration is 2 %. in this case cesarean delivery of the baby can be difficult and we should be prepared for that. after delivery baby should be handed over to paediatrecian.5 iu oxytocin should be administered intravenously to reduce the risk of post partum hemorrhage. Umbilical artery PH should be performed for suspected fetal compromise. after delivery baby should be kept warm and skin to skin contact with the mother should be done immediately.

Post operatively she should be in an intensive care unit for continuous one to one monitoring uptill when she is aware and communicable. Then routine observations of vitals should be done ½ hrly for 2 hrs and then if stable1 hrly. Post operative pain relief is very important usually with diamorphine, if no contraindication NSAIDs can also be offered as an adjunct. Early breast feeding is difficult sometimes after cesarean section but it should be tried as early as possible. Oral intake can be started whenever she feels hungry or thirsty. Urinary catheter should be removed as woman is mobilized. Early mobilization, graduated stockings, good hydration and prophylactic low molecular wt heparin should be offered for at least 7 days to reduce the risk of thromboembolism. Be aware of signs and symptoms of thromboembolism like cough painful swollen leg etc in post operative period. This patient can be at more risk of post partum hemorrhage due to endometritis so we have to be vigilant. Wound care should be done postoperatively by removing dressing after 24 hrs and daily examination and cleaning of wound. In post operative period women should be explained about the reason for cesarean section if she want to know or otherwise if she does not want can be given this information later on. on third post operative day if everything is fine she can be discharged with follow up advise of regular analgesia and antibiotics to reduce pain and risk of endometritis. She can resume her normal activities when she will be no more bothered by pain. On follow up visit she should be explained all the details of cesarean section any concerns about next pregnancy and need for contraception should also be explained.

a)      I would like to ask the woman to lie in left lateral position to improve blood supply to the fetus . Where there is clear evidence of acute fetal compromise, quickly I would take obstetric history from her old notes regarding:birth weight, mode of delivery,complications like shoulder dystocia. Previous macrosomia or shoulder dystocia would reduce threshold for CS.        

 I would like toreview antenatal notes for fundal height measurements. All these should be as quick as possible for the fetal condition.Clinical evidence of macrosomia would reduce threshold for CS. 

 Abdominal examination should be done for assessment of fetal size and engagement of head.Also, I would examine abdomen for assessment of strength of contractions.Any Clinical evidence of macrosomia and high head would be highly suggestive of obstructed labour.

I would perform vaginal examination for cervical dilatation and application, position, station, presence of caput and moulding.    My vaginal examination should exclude mal-presentation such as brow. Marked caput and moulding indicates obstructed labour.

I would assess fetal well-being: colour of amniotic fluid and cord prolapse.

b)   Where the decision for performing the emergency caesarean section level 1 has been made, all members of the team should be made informed immediately. Moving the woman to theatre after consent had been taken. Pre-operative prophylactic antibiotics should be given.  
Pre-incision I would to confirm bladder emptied and in-dwelling catheter to reduce risk of bladder injury and any urinary retention.

I would performlow transverse abdominal incision with blunt dissection to reducepost-op pain and lower risk of dehiscence compared to mid-line incision.
Abdomen opened in layers to minimize visceral injury. 
Appropriate management of bladder by reflection of utero-vesical fold and use of retractor. I have to keep tissue handling to a minimum.

Lower segment uterine incision Joel-Cohen with blunt extension should be done to reduce intra-operative blood loss and to reduce risk of rupture in future pregnancies.

 A caesareansection performed while the head is +1 station, care must be taken that the incision is not too low. An assistant should place a hand through the vagina and apply gentle pressure on the fetal head.    
Placenta should be delivered by CCT with manual exploration of uterine cavity to minimize risk of endometritis and retained products. A cord blood sample should be taken for PH and base excess. Non-closure of the peritoneum would lead to less post-operative pain and lower risk of adhesions.I have to achieve good  haemeostasis and maintain sterile operating field.

       The rectus sheath should be closed by vicryl suture as it gives the main strength to the wound.

Closure of the skin by subcuticular stitches should be performed.
Prophylactic antibiotics should be given to reduce risk of infection,such as endometritis, urinary tract and wound infection. 

Neonatologist must attend before starting CS to resuscitate the newborn once delivered.

She should be offered post-operatively, thromboprophylaxis as LMWH for seven days with adequate hydration and early mobilization. Breast feeding should be encouraged and

The woman should be explained the whole events.

Incident report should be filled and documentation of the labour events should be done.

a.Initial management plan includes turning the patient to left lateral position,starting her on  bolus dose of IV fluids and giving her facial oxygen. Check maternal pulse to avoid error in the diagnosis  of bradycardia.If  bradycardia settles after 3 minutes,expectant management can be allowed with continuous fetal monitoring by CTG. Realise that she is now a high risk woman in labour. FBS after 15-20 minutes should be done and plan of action should be based on the results.A quick history should be taken to detect the causes for brady cardia such as opiate administartion prior to the event,epidural top ups if any ,vomiting ,change of maternal position,any vaginal bleeding.Abdominal examination to look for fetal size to rule out fetal macrosomia,fetal presentation and engaegement to rule out fetal malpresentation,uterine tenderness.Vaginal examination to check cervical effacement,dilatation,application,position,station,caput,moulding and colour of liquor.If fetal bradycardia doesn't settle by 3 minutes and vaginal operative delivery is not possible,call for Grade 1 emergency Caesarean section under GA and inform Consultant Obstetrician ,Anaesthetist ,Neonatologist ,Senior midwife and theatre staff.If vaginal instrumental delivery can be done as per examination findings,obtain verbal consent by explaining the procedure.Type of instrument,need for adequate pain relief ,emptying of bladder,need for episiotomy and risks of perineal laceratins should be discussed in detail.

B.Maternal risk of Caesarean section  include bleeding,pain,infection ,visceral injury,hysterectomy and VTE.

Fetal risks include hypoxia,asphyxia,trauma and death.Verbal consent should be obtained discussing the risks.Obtain IV access and blood should be crossmatched.Prophylactic antibiotics prior to skin incision,high entry of peritoneum to avoid bladder injury should be done.Higher incision on the lower uterine segment to avoid broad ligament injury and cervical trauma.Attention to hemostasis and senior assistance if blleding not under control/visceral injury.Postpartum analgesics and VTE prophylaxis .Debrief and document.Fill incident form and arrange followup.

First I would like to see other features of FHR trace as it will direct my management plan .like baseline,variability and acceleration..  Than I  will take a quick history to look for any antenatal feature like wheter iugr or abnormal artery doppeler is presen . factor which can affect FHR trace should be assesd like position , if she is in supine position advice her to adopt lateral positon. Any recent evidence of epidural placement or topup should be looked because that can also result in change  in fhr trace. Check maternal bp  because maternal hypotension can also lead to abnormal trace check maternal  hydration and startiv fluid if she looks dehydrated. Whenever there is abnormal trace in FHR, maternal pulse should be check. any recent episode of vomiting or valsava maeuar can also lead to abmnarmal trace. Ask for any recentepisode of blowel or bladerr emptying becaue that can also lead to abnormal trace. High conc of nasal oxygen should be avoided as this may be harmful to baby . there is  no sufficient evidence for lowdose oxygen. On abdominal examination I would like to asses for uterine contration frequency , and  m,aternal perception of strength because hypercontractility can also lead to abnormal FHR trace. If hypercontractlity is without oxytocin infusion .25mg terbutalin should be given. If there is continous pain and hard uterus and vaginal bleeding, abruption shoul be suspected and urgent delivery is required. Asses fetal lie, presentation and engament . A rare possibility of uterine rupture in multi gravid should also be kept in  mind which is mor commonly associated with oxytocin infusion. It is presented by detorian of maternal codition, pale look, cont abdominal pain in between the contration and vaginal bleeding. Urgent laprotomy  is required inthis condition. I will like to asses for vaginal loss to look fcolour of liuor like meconium strain, bleeing  for abruption and cord prolapsed which is mor  commen imultiigravida. Vaginal examination should be done to asses cx dilataion ans station as this will dicide mode of delivery also. If delivery is imminent condut the vaginal delivery. If FHR trace is abnormal and fetal condition is not acutly comprmised like recovery of deceleration within 9 min FBS should be taken . and any abnormal FBS should be discuseed with consultant obstetrician. Women should be informed throughout and her wishes should be consider.

2) In category 1 CS  delivery of the baby should be done as soon as possible . seior obtertician shoud be informed. Health care professional expert in neonatal resusctitation shoud be informed to be available at the time of delivery. written consent should be taken.FBC , Group and save should be sent . bladder should be catheterize. Preoperative medication like h1 antagonists ,  anti emetic should be given. General anesthesia is preferable . in GA preoxygenation , rapid sequence and cricode pressure application is advisable. In case of regional anesthesia preloading shoud be done to avoid hypotension. Women shouldlie with 15deg lateral tilt position . preincision antibiotic should be given. abdominal incision should be joel cohen incision . peritonieum should be open high to avoid injury to  bladder.uterine incision should transverse and high to avoid inadvertent incision on cervix due to stretching of lower segment. Assistant may be needed to disimpact the baby vaginally. Head should be delivere by flexion to avoid extension of incision.  Double clamping of cord should be done and umblicle  artery ph should be measured. Placeta should be removed by controlled cord traction. 5 iu oxytocin should be started. Uterus should be close in double layer. Parital and visceral peritoneum need nat to be close as it will reduce intraoperative time,postoperative pain and women’s satisfaction. Subcuticular space should be sutured in layer if it is more tha 2 cm. baby should be assed by neonatologist.baby should be kept warm. Breastfeeding should be encouraged. Good hydration early moblistion and postop thromboprophylaxis for 7 day should be offerd. Debriefing is imp to women and relatives

a)      I would like to ask the woman to lie in left lateral position to improve blood supply to the uterus. Where there is clear evidence of acute fetal compromise, quickly I would take obstetric history from her old notes regarding:birth weight, mode of delivery,complications like shoulder dystocia. Previous macrosomia or shoulder dystocia would reduce threshold for CS.        

I would like toreview antenatal notes for fundal height measurements. All these should be as quick as possible for the fetal condition.Clinical evidence of macrosomia would reduce threshold for CS. 

Abdominal examination should be done for assessment of fetal size and engagement of head.Also, I would examine abdomen for assessment of strength of contractions.Any Clinical evidence of macrosomia and high head would be highly suggestive of obstructed labour.

I would perform vaginal examination for cervical dilatation and application, position, station, presence of caput and moulding.    My vaginal examination should exclude mal-presentation such as brow. Marked caput and moulding indicates obstructed labour.

I would assess fetal well-being: colour of amniotic fluid and cord prolapse.

b)   Where the decision for performing the emergency caesarean section level 1 has been made, all members of the team should be made informed immediately. Moving the woman to theatre after consent had been taken. Pre-operative prophylactic antibiotics should be given.  
Pre-incision I would to confirm bladder emptied and in-dwelling catheter to reduce risk of bladder injury and any urinary retention.

I would performlow transverse abdominal incision Joel-Cohen , about 3 cm above the symphysis pubis . This is to reducepost-operative  pain and lower risk of dehiscence compared to mid-line incision.
Abdomen opened in layers to minimize visceral injury. 
Appropriate management of bladder by reflection of utero-vesical fold and use of retractor. I have to keep tissue handling to a minimum.

Lower segment uterine incision  with blunt extension should be done to reduce intra-operative blood loss and to reduce risk of rupture in future pregnancies.

A caesareansection performed while the head is +1 station, care must be taken that the incision is not too low. An assistant should place a hand through the vagina and apply gentle pressure on the fetal head.    
Placenta should be delivered by CCT with manual exploration of uterine cavity to minimize risk of endometritis and retained products. A cord blood sample should be taken for PH and base excess. Non-closure of the peritoneum would lead to less post-operative pain and lower risk of adhesions.I have to achieve good  haemeostasis and maintain sterile operating field.

       The rectus sheath should be closed by vicryl suture as it gives the main strength to the wound.

Closure of the skin by subcuticular stitches should be performed.
Prophylactic antibiotics should be given to reduce risk of infection,such as endometritis, urinary tract and wound infection. 

Neonatologist must attend before starting CS to resuscitate the newborn once delivered.

She should be offered post-operatively, thromboprophylaxis as LMWH for seven days with adequate hydration and early mobilization. Breast feeding should be encouraged and

The woman should be explained the whole events.

Incident report should be filled and documentation of the labour events should be done.

A

I would place her in the left lateral position to prevent aortocaval compression.  I would check her blood pressure and pulse because hypotension and tachycardia may suggest abruptio placenta or uterine rupture.  I would also check her oxygen saturation and if below 96% will administer oxygen by face mask at 7 – 10l/min.  I would establish an intravenous access if not already sited and start on intravenous fluids like hartmann’s to maintain volume and hydration if signs of dehydration like dry mucous membrane.  I would discontinue syntocinon if it has been administered to reduce uterine activity.  I would find out if she has just had an epidural or epidural has been topped up prior to the deceleration and call in the anaesthetist.  She may require ephedrine if hypotensive.  I would draw blood for full blood count and group and save if not already done in anticipation of delivery by caesarean section.  I would perform a vaginal examination to exclude cord prolapse and assess progress if labour for cervical dilatation and station of presenting part.  I would consider vaginal delivery or operative vaginal delivery if station of presenting part is low.  I would explain to the patient and partner what is happening and all that I am doing.

B

I would ensure the caesarean section is performed by a  senior obstetrician or a trainee under supervision because of the potential difficulty of delivery at station + 1.  I would ensure blood is grouped and saved because of the potential risk of intra-operative bleeding.  I would put in an indwelling foley catheter because of the risk of bladder injury.  I would perform the caesarean section under regional anaesthesia preferably general anaesthesia.  I would ensure the anaesthetic gives a pre-incision prophylactic antibiotics because of the risk of postoperative febrile conditions.  I would use the Joel-Cohen incision and enter the peritoneal cavity as high as possible to reduce the risk of bladder injury.  I would make my incision high on the lower segment to avoid entering the vagina and minimise injury to the broad ligament.  I would give syntocinon infusion 40 in in 500mls of normal saline because of the risk of uterine atony.   I would give her lower molecular weight heparin for 7 days with wearing ted stockings.  I would ensure the paediatrician is in attendance.  I would require an assistant to disimpact the head by pressure in the vagina.  I would facilitate delivery by flexing the head to reduce skull injury.  I would take paired cord blood for blood gas analysis.  I would debrief the patient and partner after surgery.

A

I would place her in the left lateral position to prevent aortocaval compression.  I would check her blood pressure and pulse because hypotension and tachycardia may suggest abruptio placenta or uterine rupture.  I would also check her oxygen saturation and if below 96% will administer oxygen by face mask at 7 – 10l/min.  I would establish an intravenous access if not already sited and start on intravenous fluids like hartmann’s to maintain volume and hydration if signs of dehydration like dry mucous membrane.  I would discontinue syntocinon if it has been administered to reduce uterine activity.  I would find out if she has just had an epidural or epidural has been topped up prior to the deceleration and call in the anaesthetist.  She may require ephedrine if hypotensive.  I would draw blood for full blood count and group and save if not already done in anticipation of delivery by caesarean section.  I would perform a vaginal examination to exclude cord prolapse and assess progress if labour for cervical dilatation and station of presenting part.  I would consider vaginal delivery or operative vaginal delivery if station of presenting part is low.  I would explain to the patient and partner what is happening and all that I am doing.

B

I would ensure the caesarean section is performed by a  senior obstetrician or a trainee under supervision because of the potential difficulty of delivery at station + 1.  I would ensure blood is grouped and saved because of the potential risk of intra-operative bleeding.  I would put in an indwelling foley catheter because of the risk of bladder injury.  I would perform the caesarean section under regional anaesthesia preferably general anaesthesia.  I would ensure the anaesthetic gives a pre-incision prophylactic antibiotics because of the risk of postoperative febrile conditions.  I would use the Joel-Cohen incision and enter the peritoneal cavity as high as possible to reduce the risk of bladder injury.  I would make my incision high on the lower segment to avoid entering the vagina and minimise injury to the broad ligament.  I would give syntocinon infusion 40 in in 500mls of normal saline because of the risk of uterine atony.   I would give her lower molecular weight heparin for 7 days with wearing ted stockings.  I would ensure the paediatrician is in attendance.  I would require an assistant to disimpact the head by pressure in the vagina.  I would facilitate delivery by flexing the head to reduce skull injury.  I would take paired cord blood for blood gas analysis.  I would debrief the patient and partner after surgery.

I will first let the woman lie down in the left lateral position .I will also check the maternal pulse to differentiate whether it is fetal bradycardia or maternal recording. continuous ctg monitoring should be started if she is not on it.moreover, take a quick history to know if the woman had a rupture of membrane to know the cause as bradycardia can be because of cord prolapse.Also to know if she had per vaginal bleeding to rule out abruption, i will also see if the woman is on syntocinon or not because uterine hyperstimulation can also cause bradycardia. If she is on syntocinon then the syntocinon ahouls be stopped

I will also assess her hydration status.p/a examination to assess her contractions and also to feel if the uterus is relaxing in between contractions or not to rule out placental abruption.per vaginal examination- to  know the position, dilatation of the cervix, caput and moulding. also also to note the colour of liquor if she had rupture of membrane, any per vaginal bleeding.I will also send blood for group and save and Iv cannulae should be inserted if the woman is not on it.If the bradycardia recovers within 3 min then I will do a fetal blood sampling to know the ph otherwise if the bradycardia continues then I will take her for caeserean section after informing the labour room consultant on call and notifying the theatre staff anf the midwife.

b- the mother should be informed first that we are taking her emergency caeserean section and her consent needs to be taken after telling the benefits and risks of emergency c/s. the consultant should be informed, the anesthetic and the paediatrician should be informed and emergency c/s to be done within 30 minutes.Blood should be group and save and her haemoglobin known. Iv antibiotic should be gievn before srating of the caeserean section and mother needs to be catheterised.Intraoperative there is a risk of uterine incision extension as the woman is 8 cm dilated and head is low. we may also need help to push the baby from vagina.after the baby is delivered , the baby should be handed to the paediatrician and cord blood ph should be taken.the mother is at risk of postpartum haemorrhage so active management should be done by giveing 5 units of syntocinon slow IV.placenta removed by controlled cord traction and to assess if the uterus contracted. The anaesthesia to be used will be general anaesthesia as this is an mergency situation. 

the mother should be debriefed later on, and the woman should be observed for the vitals.documentation should be done in the patient notes.

a. Place the woman in left lateral position to reduce aortacaval copression and improve uteroplacental blood flow. Commence continuous Electronic fetal monitoring with abdominal transducer or FSE and use a pulse oximeter to differentiate maternal and fetal pulse.  Elicit a history including events that precipitated the bradycardia such as SRM as there may be a cord prolapse or vaginal bleeding with or without constant abdominal pain as she may have had a placental abruption or ruptured vasa praevia.  Abdominal exmaination feeling for uterine tenderness suggestive of abruption or uterine rupture.  Vaginal examination to check for cord prolapse and assess cervical dilatation, position and station of the fetal head.  Whilst I was doing my examination I would ask another member of the team e.g. the midwife to obtain IV access and send bloods for FBC and G+S, anticipating operative delivery.   If vaginal examination indicated that delivery is imminent and the bradycardia was ongoing I would perform an operative vaginal delivery to expediate delivery.  If delivery is not imminent I would perform a category 1 ceasarean section.  I would explain to the patient what is happening.

b. Verbal consent should be taken for a category 1 LSCS to reduce the decision to delivery time.  Decision to delivery time should be within 30 minutes, but as quickly as possible to reduce the risk of neonatal morbidity and mortality.  I would inform members of the team including the anaesthetist, theatre team, co-ordinating midwife, neonatal team and consultant obstetrician on call.  

Administration of ranitidine, metoclopramide and sodium citrate to reduce the risk of aspiration.  Mode of anaeathesia should be whichever affords a quicker decision to delivery time, this is likely to be a general anaesthetic.  Rapid sequence induction with cricoid pressure should be used for GA to reduce risk of aspiration.  Catheter should be inserted to reduce risk of bladder injury.  Antibiotics should be given in accordance to local policy, ideally pre-incision to reduce risk of post-operative infection.  Neonatal team should be called to attend, however delivery should not be delayed if they are not present.  

Joel cohen incision should be used to allow rapid access to the pelvis.  A curvilinear incsion high on the lower segment with blunt extension should be used to reduced the risk of extension and entry into the vagina and broad ligaments.  An assistant may be used to disimpact the fetal head from the pelvis to aide delivery of the baby.   The cord should be double clamped so that paired cord samples can be obtained for pH and BE.  The baby should be transferred to the resuscitaire for evalutaion and reuscitation if needed.

Oxytocin 5iu IV should be administered to reduce risk of PPH.  Placenta delivered by CCT once there has been evidence of separation.  2 layer closure of the uterus, paying particular attention to the angles of incision to ensure haemostasis.  There is no evidence to support closure of the peritoneum.  the subcutaneous fat layer should be closed if it is greater than 2cm to reduce the risk of wound infection.  

Postoperatively the catheter should be in situ for at least 12 hours.  Thromboprophlaxis should include LMWH based on weight for 7 days post natal, early mobilisation, graduated compression stockings and adequate hydration.  Debrief of patient and relatived regarding the events.  Counsel regarding implications for future pregnancies and offer contracpetive advice.

Assessment the patient should be offered when there is a deceleration on CTG. Quick review of the patient s  notes should be seen for progress of labour, bleeding, time of rupture membranes, contractions frequency from CTG and if there was any induction of labour by Oxytocin , kind of regional analgesia and when it was inserted.

Abdominal examination is essential to identify the size of abdomen and fetal lie. Vaginal examination (PV) is useful to identify the presentation ,station, engagement, bleeding, meconium stained and cord presentation or cord prolapse.

Initial management should include measurement of BP and Pulse to check for any hypotension . Keep IV line opened and access tosupply adequate fluid after take G & S with cross matchin 2 blood unites. The position of the patient should be adjusted to left lateral sideto improve the perfusion of the placenta. Stop Oxytocin infusion if it was used to avoid the hypoxia to the fetus and O2 supply by mask is recommended. Continue observation by CTG to identify any repeat CTG abnormalities. Fetal Blood Sample ( FBS ) can be taken to measure the PH of fetal blood and if it is less than 7.20 ,the emergency Ceaserian Section ( CS ) should be arranged.

To optimize the mother outcomes, the senior level or consultant should do this Caesarean Section (CS) . Group & save with cross matching 2 blood units before operation should be ready because the risk of bleeding.

Pfannenstiel incision can be done which is better than midline incision to reduce the risk of midline hernia.

During operation the bladder should be dissected well to avoid bladder injuries . The lower segment (LS) incision should be low with pushing up the head of the fetus per vagina by another assistant to avoid LS lacerations. The shape of J incision or classical incision can be done if the head is very low and delivered the baby by Breech.

Forceps can be used for delivery of the baby with less risk of LS laceration. Utero tonic medications can be used during operation to reduce the risk of post partum bleeding fron uterine atony. Therefore, Oxytocin, Methergin and carpobrost can be used.

Thromboprophylaxis by LMWH can be used to reduce the risk of thromboembolism events.

To optimize the results of fetus , the LS incision should be wide enough with caution about the scaple to avoid  the fetus cut wound. Sometimes, the Breech extraction can be useful to avoid any fetal truma.

paul sir  plz check my answer

Hi Paul

Would you consider IV GTN to relax the uterus as well as an inverted T or J shaped incision to facilitate access as valid points for the essay? 

Cheers