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MRCOG PART 2 SBAs and EMQs

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ESSAY 190 - Prolonged second stage

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		Posted by Remi A. Mon Jan 28, 2002 05:17 pm
Duration of second stage may be allowed to extend to three hours in a primigravidal with an epidural,provided maternal and fetal conditions are optimal. In this case,the options are augmentation with oxytocin if there are inadequate contractions[<3/10],operative vaginal delivery or ceaserean section in case of failed operative vaginal delivery. Whichever option to be taken depends on maternal condition and wishes,fetal condition and availability of expertise. If augmentation with oxytocin does not result in delivery in half an hour or there is a change in fetal condition,then there is aclear indication for operative delivery. Forceps and Ventouse are both appropriate in this case.Forceps is more likely to succeed,but is associated with more risk of perineal trauma.Ventouse is associated with more risk of cephalhaematoma,retinal haemorrhages,maternal worries about the baby.Its also contrainicated in gestation<35/40 and bleeding disoders.There is no difference in C/s rate,Apgar score and need for phototherapy.Accocheur should use the instrument they are more comfortable with,although all obstetrician should be well trained in both. Its important to discuss the risk benefit with the patient and should be documented.Paediatric team should attend delivery,as the baby may be delivered with a low apgars score.Cord PH Should be taken after delivery-important for Good practice,audit and risk management. Post delivery,the woman should be observed for bleeding,and any perineal tear should be rapaired appropriately Its important to make sure she voids urine in the first six hours,otherwise she should be catheterised to prevent urinary retention.Early Breastfeeding should be encouraged.Adequate analgesia is vital. Contraception should be discussed. Thromboprophylaxis could be in form of Good hydration,early mobilisation or prophylactic heparin depending on the risk profile of the patient. Incident reporting is indicated in case of a failed operative vaginal delivery or adverse maternal/fetal outcome.
		Posted by Raja kumar S. Tue Jan 29, 2002 03:14 am
such an event would definitely be stressful for the mother and the attending staff. counsel the mother rEgarding the situation and the fetal condition(CTG BEING NORMAL).calm her and relief her of her anxiety. primary concern of maternal well being,ensure adequate hydration and sufficient analgesia.subsequently a repeat assessment should be done including a per abdominal palpation (level of fetal head felt per abdomen,rough guide if suspect macrosomia),look for a distended bladder(catheteraisaton might be all that is required to facilitate delivery).review the partogram ,asses the frequency and amplitude of uterine contractions,and identify any poor progress in the first stages.(might indicate some form of dystocia).since she is on epidural ,there might be incordination between her effort and those of uterine contraction.consider temporarily reducing or stopping the epidural if suggestive. subsequently asses for descent of presenting part with her pushing effort and uterine contraction,no descent or minimal decent with any retraction might indicate dystocia and should consider recourse to emergency CS. AT this stage ,baring any contraindications and if vaginal delivery is thought to be appropriate then a consideration for operative vaginal delivery should be given and such an option should be presented to the mother. it would be prudent to discuss with the labour unit consultantand a decision be made jointly. in such clinical situations a trial of forceps delivery would be a sensible approach and as such it should be conducted in a fully equiped operation theatre where in the event of failure an emergency CS can be carried out. as a safety measure ,counsel regarding the benefit and risks of the forceps delivery and CS.Group and cross- match blood and at least two large bore IV ACCESS ready. have the anesthetic colleague review her epidural and possibly top it up and the nenatologist in stand by to resuscitate the baby if required. follow the departmental protocol for instrumental delivery and do not attempt with excessive traction. provide pro phylactic antibiotic and the third stage should be managed actively(risk of uterine atony and pph).post delivery inspection and repair of any perineal injury (3rd and 4th degree tears should be done by experienced personnel. Post natally might require catheteraisation for bladder atony(36-48 hrs).consider oxytocic drip to guard against uterine atony. in the event of any excessive bleeding assess for requirement for blood tranfusion.and correction of anemia.since there is risk of fever /endometritis consider iv antibiotics. inform the mother regarding any adverse outcome eg injuries to the neonate ,perineal injury ,pain. in The event of abdominal delivery , a senior collegue should be called in to perform the surgery (as theremay be difficulties in disengaging a deeply impacted head ).post pArtum thromboprophylaxis .should be provided.
		Posted by Kishor S. Thu Jun 15, 2006 09:06 pm
The normal limit of duration of second stage of labour in a primi under epidural anaesthesia is 3 hours after which maternal morbidity increases. Since she has been already in second stage for 2.5 h and exhausted, it is unlikely that she will deliver in the remaining half hour without any intervention. The aim is a safe vaginal delivery and it is anticipated since CTG is normal and presenting part, vertex is in fully rotated anterior position without any moulding at +2 station. The interventional options are augmentation with oxytocin culminating into a safe vaginal delivery or instrumental (operative) vaginal delivery. A quick history will be taken in regard to period of gestation, any associated medical conditions such as cardiac disease and PIH, antenatal heparin, whether labour has been induced or augmented with oxytocin. Clinical assessment will include BMI, pulse, BP, other signs of exhaustion (ketone bodies in urinalysis), quality of uterine contractions (intensity, frequency and duration), estimated fetal weight and assessment of pelvis. If the contractions are mild and coming less frequent than 2 ? 3 minutes, oxytocin augmentation (or increase in rate if it has been already on flow) upto 16 milli units per minute will be initiated. An additional intravenous dextrose saline drip will be started in order to take care of exhaustion. With this if there is no appreciable progress such as descent of head in 15 minutes or so, then instrumental delivery will be performed. Since all the prerequisites of forceps application have been fulfilled and station is +2, I will do a low (low cavity) forceps delivery. Use of ventouse will not be considered as it is more likely to fail and more likely to be associated with cephalohaematoma and retinal haemorrhage An informed consent will be taken for forceps delivery with a possible C/S in case of failure. Rare complications such as complete perineal tear, cephal haematoma and urinary incontinence will be informed. If BMI >30 or EFW > 4Kg, risk of failure is to be anticipated and the procedure will be done in operation theatre with the woman prepared provisionally for C/S. Long curved obstetric forceps (e.g. Simpson?s forceps) will be used with aseptic technique after emptying the bladder with a catheter. Even though there is currently insufficient evidence to support the routine use of episiotomy, if the perineum is very rigid and likely to have perineal tear, a right medio-lateral episiotomy will be given. She will be closely observed for any PPH and oxytocin drip, if on flow, will be continued for one hour. Paediatrician will attend the baby since there is chance low apgar in such delivery. In case of unsuccessful forceps delivery, C/S will be done and an incident form will be completed as part of risk management Routine use of prophylactic antibiotics is not currently recommended unless there is PROM or any other indication. Indwelling urinary catheter will be kept for 12 hours to prevent asymptomatic overfilling. She will be made ambulatory and kept well hydrated with oral drinks. If she has been on antenatal heparin, it will be continued for 6 weeks. In case of extreme obesity (BMI >39), heparin thromboprophylaxis will be given until discharge (3- 5 days). In case of heparin prophylaxis, epidural cannula will not be removed before 12 hours of the last dose. For relief of pain after removal or epidural regular paracetamol + diclofenac will be recommended for 4 to 5 days. She will be explained the indications for forceps delivery, recommendations for subsequent pregnancies, which have 80% likelihood of vaginal delivery. There is no effective way of preventing of post-natal depression following operative delivery. Lastly, use of contraceptive will be discussed and pelvic floor physiotherapy will be offered to prevent urinary incontinence.
		Posted by Zaharuddin R. Thu Jun 15, 2006 09:08 pm
The patient has a prolonged second stage of labour. Clinically cephalopelvic disporpotion could be excluded as fetal head at +2cm below ischial spine without moulding. No evidence of fetal distress as CTG is reactive. Contraction should be monitored and augmented with oxytocin infusion if contraction is weak. Labour should be allowed for another an hour as long as CTG is reassuaring. If contraction is strong, options are either instrumental delivery or emergency LSCS. Instrumental delivery is either vacuum or forcep. Vacuum could be either silicon cup or metal cup as fetal cephalic in direct OA position. Silicon cup less traumatic to the fetus and the patient but higher failure rate. Metal cup however associated with more incidence of cephalohaematoma, scalp injury and vaginal laceration. Forcep delivery is associated with less traumatic to the fetus but more vaginal injury to the patient compared to vacuum delivery. Emergency LSCS for prolonged second stage of labour need skill surgeon as it is difficult procedure due to impacted fetal head into the pelvis. It is associated with extended tear, massive bleeding requiring blood transfusion and injury to adjacent organ mainly urinary bladder. The patient should make an informed choice after benefits and effects of options has been discussed. Most of the time, instrumental delivery is an appropiate option. Either vacuum or forcep delivery is depending on the surgeon familiarity of the instrument. Anesthesist should be informed as pain relieve could be augmented for instrumental delivery or possibility of failed instrumentation. Paediatrician should be stand by during the procedure and examined the baby upon delivery. After delivery, the patient should be examined to ensure haemodinamically stable. Blood loss should be estimated and haemoglobin level should be check. Mild anaemia will be treated with oral haematinics but severe anaemia may require blood transfusion. Vital signs such as pulse rate, blood pressure, temperature, contracting uterus and vaginal loss should be monitored at regular interval. The patient should be well hydrated either by good oral intake or infusion of saline, encouraged for ambulation to reduce risk of venous thromboembolism. Subcutanous heparin should be given if the patient had emergency LSCS. Pain relieve such as suppository NSAIDs is appropiate for post instrumental delivery and LSCS. Breast feeding on demand should be encouraged. Contraception option should be discussed before discharge. Written information and follow up date should be given after 6 weeks and the baby should received scheduled vaccination.
		Posted by Srivas P. Thu Jun 15, 2006 11:02 pm
It is important to find out the reason for the delayed second stage?this involves a review of her general condition, hydration, assessing possibility of ketosis, excess sedation and study of the partogram to assess uterine contractions- frequency and duration of contractions and the strength of contractions clinically. Since there is no evidence of CPD or fetal compromise there is a case for trying to continue with vaginal mode of delivery after quick review of the woman. She may need to be hydrated with Ringer lactate and if contractions are not adequate she should be augmented with syntocinon so as to get atleast 3 good contractions per 10 mins and she should be put on continuous electronic fetal monitoring. She may respond to oxytocin and this may obviate the need for any operative vaginal delivery. Should she not progress inspite of adequate uterine contractions due to maternal exhaustion or subsequent fetal distress she should be considered for operative vaginal delivery. It is important to have senior input at all stages of decision making and also explain the plan to the woman and her relatives who are likely to be very apprehensive and concerned at this stage and involve them in the decision making and informed consent should be taken. Both vacuum and forceps delivery have similar risk benefit profile and the choice depends on on the expertise of the operator in the chosen method. The vacuum is more likely to fail in achieving vaginal delivery and is associated with higher cephal haematoma and retinal haemorhage in the baby but the risk of severe maternal vaginal and perineal injuries are lesser than forceps delivery. The symptoms of fecal incontinence are more following forceps. The woman should be reexamined to confirm she fulfills the prerequisites for a safe vaginal operative delivery. The cephalic should not be palpable more than 1/5th per abdomen, membrane should be absent, position of cephalic should be reconfirmed and pelvis should be adequate. Back up plan should be made for quick C.S should the procedure fail. If risks of failure appear high due to big baby or maternal obesity it is better that operative delivery is planned inside the theatre. The bladder should be drained and indwelling catheter removed. Neonatal resuscitation team and the anaesthetist should be alerted. Since the late second stage C.S has increased risk of Obstetric haemorrhage and neonatal complications consultant should be available during the procedures. Sequential use of instruments should be avoided unless carefully done by senior colleague. She is high risk for post partum haemorrhage and shoulder dystocia and arrangements to meet such eventualities should be in place. Prophylactic synthometrine should be given. The episiotomy should be reviewed to rule out 3rd and 4th degree perineal tears which are missed sometimes leading to fecal incontinence and subsequent litigations. This woman with prolonged 2nd stage, epidural aneathesia, operative delivery and possible prolonged immobilization should be assessed for thromboprophylaxis and put on post partum 3-5 days of S/C LMWH injection if assessed to be high risk. Her first void urine should be measured and if she seems likely to have urinary retension, an indwelling catheter should be left in for 12 hours. The woman is likely to suffer psychological morbidity following a difficult operative vaginal delivery. Senior consultant should explain the chsain of events, indications of operative delivery etc. She should be told that she has 80% chance of subsequent vaginal delivery and encouraged to have normal vaginal delivery. She should be assessed for postpartum depression and apprehensions and social worker should help her cope psychologically following a difficult delivery. Incident report should be done in case of failed instrument delivery or with any other adverse events.
		Posted by adnan S. Sat Jun 17, 2006 08:33 am
Second stage of labour in primigravida with an epidural aneasthesia up to 3 hours is considerd normal.Premature bearing down effort in the pelvic phase ,as descent of the head is expected with uterine contractions may lead to maternal exhaustion &distress. As the CTG is normal there is no need to rush for immediate delivery.Antenatal notes to be checked for any risk factors for dystocia like diabetes malitus,obesity which may indicate macrosomia may be the cause. .Abdominal examination is done to note the frequency and intensity of uterine contractions,fetal head may not be palpable as it is 2cm below ischial spines .Vaginal examination is done to note the colour of the liquor . If the uterine contractions felt to be inadequate and contributing factor in the prolong second stage an oxytocin drip should be started ,if she is already on oxytocin drip dose and infusion rate to be checked.Maternal dehydration should be corrected with ringer lactate.The option of management lie between expectant and instrumental vaginal delivery.Due to maternal exhaustion instrumental vaginal delivery is prefferd.The woman /partner should be involved in the decision making with regard to the mode of delivery.If woman opted for instrumental vaginal delivery informed consent must be obtained with clear explanation .The goal of operative vaginal delivery is to mimic spontaneous vaginal birth ,thereby expediting delivery with a minimum of maternal or neonatal morbidity.The instrument of choice will be vacuum extraction or low cavity forcep delivery depends upon skill of operator and are associated with different benefits and risks.The relative risks and benefits of vacuum extraction compared with forcep are more likely to fail in achieving vaginal delivery,associated with cephalhaematoma,retinal heamorrhage and maternal worries about baby but lesslikely to be associated with significant maternal perineal and vaginal trauma,no more likely to be associated with delivery by c section ,low 5-minute apgar score and need for phototherapy.In view of reduction of maternal pelvic floor injuries ,the vacuum extraction has been advocated as the instrument of first choice.Paired cord blood samples should bo processed and recorded.Neonatologist should be presnt at the time of delivery for neonatal resuscitation if required,There is isk of postpartum haemrrhage active management of third stage is done.Prophylactic antibiotics are given along with good standerds of hygiene and aseptic technique. Post-natal care include reassessment for risk factors for VTE and thromboprophulaxis is considerd , if two current or persisting risk factors LMWH should be considerd,other wise early mobilization and hydration is adequate. Analgesics like paracetamol and diclofenac should be given.Indwelling catheter should kept in place for at least 12hours following delivery to prevent asymptomatic bladder overfilling,this should be followed by complition of fluid balance charts to ensure good voiding volumes.Physiotherapy should be offered to prevent urinary incontinence.Prior to hospital discharge indications for operative delivery management of any complications and the prognosis for future deliveries should be discussed and high probability of successful spontaneous vaginal delivery in future.
		Posted by SANGEETA P. Sun Jun 18, 2006 08:37 am
Prolonged 2nd stage is a commonly seen scenarion in labourward. Primigravidas can be given 3 hours with epidural analgesia in 2nd stage but here because mother is already exhausted that warrants delivery.Causes of remaining undelivered despite of 1 hour pushing may be inadequate uterine contractions,poor maternal hydration, full bladder or maternal exhaustion itself. Since CTG is normal so situation can be handled calmly and with full explaination to the couple of all the options. Since it is favourable position, direct occipito anterior and 2+ station, she can be delivered in the room.Though couple should be councelled that there is a small chance of unsuccessful delivery despite of these favourable factors,in that case she will need to be taken to theatre for reassessment and possible cesarean section, so couple should be verbally consented for that.On call consultant,labour ward mid wife incharge, theatre staff should be made aware of it in advance. instrumental delivery should be done by the person who has the skill, knowledge and the experience of the instruments.Couple should be councelled for the risks and benefit of the instrumental delivery, advantage being to cut short the second stage in view of maternal exhaustion.Risks of vacuum delivery include cephalhematoma, retinal haemorrhage,failed delivery and risks with forceps include more vaginal and perineal tears and lacerations, more fetal trauma.Couple\'s wish, operator\'s choice of instrument should decide the type of instrument used.Parents should be warned of CHIGNON with vacuum delivery to avoid unnecessary worry of the parents.There should be progressive descent with the instrumental delivery, if not then instrumental delivery should be abondoned.Episiotomy should be given according to the need,there is no role of prophylactic episiotomy with instrumental delivery.Paediatrician should attend to the baby as there may be low apgar score and cord blood should be taken for cord ph. Prolonged labour, instrumental delivery are risk factors for post partum haemorrhage so if need patient may need syntocinon infusion drip.Perineum should be inspected and examined for vaginal and perineal tears specially 3rd degree tears with the forceps.If suspected 3rd degree tear,should be taken to theatre.With the epidural block and syntocinon drip she will require an catheter for 6-12 hours to avoid bladder overfilling.There is no evidence to suggest the prophylactic antibiotics with instrumental delivery. Post delivery she should be explained all the delivery events again and should be given the chance of asking any questions.Adequate analgesia in the form of paracetamol and diclofenac should be prescribed and if she had sustained 3rd degree tear should also be prescribed antibiotics, luxatives and 6weeks follow up with the consultant clinic or colo rectal clinic if need. She should be assessed for the risk factors for thrombo embolism and should be given thromboprophylaxis accordingly. Breast feeding should be encouraged and contraception should be discussed. Instrumental delivery is associated with suffecient degree of psychological distress and post natal depression and this factor should be discussed thoroughly before her discharge.Her future pregnancy should be discussed.She should be councelled that she has 80% of chances of normal delivery next time without instrument.
		Posted by Samir A. Sun Jun 18, 2006 10:03 am
The second stage of labour should not exceed 3 h if under epidural analgesia.Since the patient ia exhausted expedition of delivery is indicated.Firstly I\'ll check her Tep.,pulse,BP,RR and asses the degree of hydration and hydrate her using dextrose 5%.I\'ll review her notes for BMI,her basic vital signs and gestational age and estimated fetal weight.I\'ll do abdominal examination to asses fetal size,weight clinically to predict macrosomia and ascertain that the head is less than1/5 palpable abdominally should vaginal operative delivery will be contempelated. I\'ll review the partogram to asses the frequency of uterine contracions and cervical dilatation. The I\'ll do pelvic examination to asses the cervical dilatation,head station,codition of membranes and moulding. If cotractions are less than 3 in 10 minutes, I\'ll allow icrement of syntocinon under contineous CTG since there is no moulding(i.e no suspected CPD). If wthin half an hour there is no progressive descent of the head and delivery is not completed and no fetal compromise, I\'ll consider operative vaginal delivery after consenting the patient. If <35 weeks I\'ll opt low forceps rather than ventose,since the higher risk of cerebral haemrrhage with the latter. I\'ll inform the patient regarding ventose delivery complications( fetal cephalhaematoma,retinal haemrrhage) and the possiblity of perineal injuries,urinary and fecal incontinence in forcps delivery,taking herb wishes in decision making. I\'ll ask the anaesthist to top up the epidural,I\'llempty the bladder before contemplating vginal operative delivery.I\'ll inform paediatrician to attend the delivery since low apgar score is expected. I\'ll abandon vainal operative delivery if no progressive descent with each pull or delivery is not imminent following 3 pulls of correctly applied instrument.Sequential use of forceps after ventose is possible provided no fetal compromise and senior Obsetrician is attending. In failed operative vaginal delivery I\'ll recourse for CS. After instrumental delivery I\'ll examine the perineum,vulva and vagina for tears.If any I\'ll repair under adequate light.If 3rd/4th perineal tear I\'ll repair with assistance of senior Obstetrician. I\'ll give 40 U syntocinon in 500 ml dextrose IV over 6 h since there is a risk of PPH after instrumental delivery.I\'ll observe vital signs,time and volume of voided urine,vaginal bleeding and fluid chart since there are risks of urine retention and PPH. If epidural was topped up I\'ll keep a Foley catheter for 12 h since the risk of retention is higher. I\'ll hydrate, early mobilise to minimise the risk of thromboembloism. If she has high risk factors for VTE(e.g BMI>30, previous DVT,sickler,DM,thrombophilia) I\'ll give prophylactic LMW heparine3-5 days/6 weeks according to risk factor/s. I\'ll give paracetamol or diclfenac to control pain.I\'ll advise for pelvic floor physiotherapy as incontinece prophylaxis. I\'ll explain all the events to tha patient and partener after delivery and encourage her for spontaneous vaginal delivery in subsequent pregnancy as ther is a high possibility of success.
		Posted by Samir A. Mon Jun 19, 2006 09:04 pm
Dear Paul, Thank you for correcting our answer for Q 190. Can you kindly post to us the model answer for that Q.?
		Posted by Aroosha B. Tue Jun 20, 2006 06:54 am
Dr Paul, I am sorry for postinf my answer at wrong place and being late. Plaese check my answer. I need your expert advice. Thanks. This woman needs assisted delivery most likely instrumental vaginal .(ventouse / forceps )and less likely abdominal delivery, the need of which may arise in case of contraindication , failure or woman refusal for instrumental delivery . Decision of above intervention will depend upon assessment of foetal and maternal well being ,ruling out any fetopelvic disproportion ,Skill and experience and facilities for instrumental delivery and informed consent of patient . So first step in management would be to assess fetal well being by CTG by which we can decide whether to have non interventional approach or urgent delivery .As regards to maternal well being ,it is assessed by ruling out medical conditionS Which contraindicate prolonged pushing and urine Ketone assessment is also indicated for urgent delivery. Next Step is to rule out feto pelvic disproportion which although is very unlikely in this case but is prerequisite for any intervention It is done by ruling out any H/O diabetes ,fetal macrosmia shown by recent. USG and by per abdomens and pervaginum examination. It is also important to assess effectiveness of uterine contraction. After assessment different option of delivery are discussed with the patient and informed consent is taken. Option of non interventional delivery for another half an hour with or without Syntocinon dependindg upon uterine activity is valid , if there?s no Contraindication and the women gives Consent for it as it is l as associated with less maternal and fetal risk But this option may not be acceptable in this woman as she is exhausted. Anyhow if she accepts, she is given psychological Support and asked to bear down only when the head is on the perineum without her being exhausted Other option are instrumental vaginal delivery . Risk and benefits are to be explained to patient .Ventouse is recommended as instrument of choice by RCOG as it is associated with less maternal risk but has risk of failure which can be decreased by use of Bird cup .Its associated fetal Complication LIKE subgaleal hematoma and retinal hemorrhage is to be explained . Other options?are of forceps delivery either by manual rotation followed by direct application of it or by low out let forceps or rotational forceps delivery but it need more skill and experience and associated with more maternal complication (like cervical ,Vaginal, perineal tear , hemorrhage and fistula) Its fetal complication include injury to nerve ,soft tissue and skull. If woman opts for instrumental delivery prerequisite of it is to be ensured that is it is preferably done in OR with all preparation for LSCS, experienced operator,neonatal facilities, backup plan in case of failure is to be ensured. Any OPERATIVE vaginal delivery is to be abandoned if there is no imminent delivery following three pulls of correctly applied instrument by experience operates If this fails option of Sequential instrument like application of forceps after VENTOUSE is there as it is associated with less maternal mortality and morbidity than LSCS in second Stage . Incase of woman refusal or failed instrumental delivery Lscs is an option which Should be done by an experienced person . Post-Natal care ?..Pts is advised to Keep good hygiene.,analgesic like paracetamol or dicloferac is given ,Antibiotics are prescribed. women Should be assessed for Risk of VTE and thrombo prophylaxis is accordingly considered. It is also important to Keep fluid balance Chart for first 24 hour to detect urinary retention. As this patient is with epidural,choice of indwelling Catheter is given for12 hours to avoid urinary retention. Pt is also advised physiotherapy to avoid incontinence which is common after instrumental delivery .Psychological support is also necessary. Pt is reviewed by Obstetricians before discharge to discuss indication ,and Complication of procedure and mode of delivery in future Which is likely vaginal in more than 80%, of cases. If there is associated with third or fourth degree perineal tear, patient is given antibiotic analgesic and Stool Softener and advised to followed by anal USG and manometry which will help in detection of degree of defect on which future mode of delivery will depend..