The smart way to learn. The smart way to teach.

MRCOG PART 2 SBAs and EMQs

Course PAID
notes	336
EMQ	1502
SBA	2115

Do you realy want to delete this discussion?

Forum >>

ESSAY 224 - failure to progress

Page 1 of 1 [1]
		Posted by Srivas P. Fri Feb 2, 2007 03:23 pm
a)Even though 2nd stage of labor is not prolonged there is requirement for intervention in this woman with exhaustion due to pushing as she is unlikely to cooperate.She should be reassessed to decide about operative vaginal delivery or C.S. Partogram should be studied to see any delay in 1st stage suggesting possible CPD and CTG for any evidence of fetal compromise and liquor on pads for signs of meconium. These along with clinical examination will help decide mode of delivery which is best for her. Per abdominal examination should be done to clinically estimate fetal size, if fetal poles are palpable. Vaginal examination to look for caput, moulding and station of presenting part. Color of liquor should be noted. If there are no clinical signs of disproportion and baby is of average size she should be considered for trial of operative vaginal delivery. Choice is between vacuum extractor and mid cavity forceps delivery. Forceps would be preferred if there is a large caput. Both instruments have different risk profile and this should be explained to the woman and her partner. More risks of retinal hemorrhage and cephal haematoma with vacuum while there is more risk of perineal and vaginal lacerations with forceps. But vacuum is more likely to fail. Choice of instrument also depends on expertise of the surgeon. Informed consent should be taken. She should be told about need for C.S if procedure fails which is likely as head is still at +1 station. Bladder should be empty. Oxytocin drip should be started if contractions are not adequate. Procedure should be done under regional anesthesia preferably in the operation theatre with recourse to C.S if instrument delivery fails. She would need a top up of regional anesthesia. There should be descent with each pull and the procedure should be abandoned if delivery is not imminent after 3 pulls and she should be taken up for C.S. Serial use of instrument delivery should be avoided. Cord Ph should be taken for risk management. Incident report should be written if there is failure of operative delivery, apgar less than 7 at 5mins or if cord PH is less than 7.1. If the initial assessment shows disproportion clinically, based on slow 1st stage of labor coupled with caput /moulding or if the baby size is big she should be taken for C.S. The C.S should done by a senior obstetrician as there is likelihood of extensions with deeply engaged head. b)The third degree tear should be sutured by senior obstetrician or done under her supervision, inside the operation theatre under good lighting, with regional or general anesthesia. Full extent of the tear should be reevaluated after vaginal and rectal examination under anesthesia and graded. External anal sphincter should be stitched with delayed absorbable sutures such as 3-0 PDS, using over-lapping or end-to-end approximation. Internal anal sphincters if involved should be stitched separately with 3-0 PDS by end to end approximation, using figure of eight stitches. Vaginal epithelium is closed continuously with 3-0 vicryl and perineal muscles in 2 layers by interrupted sutures with 2-0 vicryl. Perineal skin is closed with Vicryl 3-0 subcuticular stitches as it is associated with less gaping, and short term pain. Rectal exam to be repeated to ensure proper suturing and rule out any deep rectal sutures. Incident report should be written as risk management and case notes written meticulously regarding mode of suturing, suture material with diagrams if possible. She may need post op Catheterisation. Post op fluid chart and urine void should be observed for 24 hrs. She should be given I/V antibiotics and metronidazole pre operatively, later both continued orally. Post operatively should get stool softeners like lactulose and bulking agents like fibogel for 2 weeks to prevent hard stools and rupture of sutures. Early mobilization should be encouraged and thromboprophylaxis should be considered based on risk assessment. Follow up is very crucial. She should follow up at multidisciplinary perineal clinic at 12 weeks with colorectal surgeon and senior obstetricain and should have endoanal ultrasound and anal manometry. She should be enquired about fecal/ flatal incontinence and dyspareunia. Defect in anal sphincter on ultrasound may need secondary suturing and all subsequent deliveries should the be by C.S. Even woman with no obvious sphincter defect at 12 weeks, may remain symptomatic at 12 months. They should be reviewed again by colorectal surgeon. Asymptomatic woman can be allowed vaginal delivery. No role for prophylactic episiotomy in next delivery. Her risks of getting repeat 3rd degree tear are same as rest of population.
		Posted by neera B. Fri Feb 2, 2007 10:08 pm
Since the women is exhausted she needs to be reviewed . I will review her partogram and CTG and assess hydration. On abdominal examination , I shall inspect for Bandl\'s ring which is an indicator for obstructed labour. I will palpate to assess how many fifths of fetal head is palpable per abdomen. The three Ps of labour that is passage, passenger and power should be assessed . Vaginal examination will be done to assess caput , moulding , colour of liquor, station and deflexion of head. Evidence does not show pelvimetry to be useful. I shall give her Ringer Lactate infusion if she is dehydrated . Adequate analgesia will be ensured because she is exhausted. I will start continuous CTG monitoring because the fetus may be compromised. I will arrange 1:1 support for the woman as it is associated with decreased ceasarian rate . If there are signs of obstructed labour , I shall offer her emergency Caesarian or else the uterus could rupture. If CTG is pathological and vertex is at +1 station I shall deliver her by forceps because this is the quickest way to deliver the baby. If uterine contractions are inadequate , CTG is normal and there are no signs of obstructed labour , I shall augment with oxytocin infusion with meticulous monitoring and carry out forceps delivery during contractions. Although forceps is associated with more perineal and pelvic floor injury , I prefer forceps because it has lesser chances of failure, less chance of retinal hemorrhage and cephalhematoma compared to ventouse. I shall keep the woman fully informed and involve her in decision making.Not more vthan 3 pulls will be tried with forceps. If this fails , I shall try ventouse because the morbidity with sequential instruments is less than caesarian. If ventouse also fails, I shall offer a ceasarian. Consultant obstetrician will be called for ceasarian due to risk of extension of the thinned out lower segment and bleeding. An assistant will be asked to push the fetal head from the vagina as this helps to disimpact the deepely engaged head . Active management of 3rd stage will be done due to high risk of atonic PPH. I will ensure presence of neonatologist because fetus may be hypoxic. Paired cord samples for the Ph will be taken . After the procedure, clear explanaion would be given to the women , antibiotic and thromboprophylaxis will be offered and the discussion will be clearly documented. In case of failed forceps incident report will be made . b) I shall inform the consultant obstetrician , on duty anaesthetist, operation theatre staff, and senior midwife. I shall keep the women fully informed and involve her in decision making. The tear will be repaired in operation theatre , under general or regional anaesthesia with good light . Experienced obstetrician , at least yr 4 or 5 specialist registrar or a colorectal surgeon should repair it because the first repair gives the best results. Rectal examination is done to ensure that the rectal mucosa is intact , current evidence shows end to end anastomosis to be as good as overlap technique and monofilament polydiaxone to be as effective as braided polyglactin suture. I shall ensure hemostasis and a correct instrument and swab count. Post operatively, I shall give antibiotics and stool softner like lactulose because they improve outcome. The broadspectrum antibiotics should include metronidazole for anaerobic cover. i shall explain the events to the lady and document the discussion . Incident report will be filed. Follow up visit is arranged after 6-12 wks. for review by obstetrician with interest in anorectal problems or colorectal surgeon. If symptomatic , endoanal ultrasound and rectal manometry are advised. If repeat repair is needed, it should be performed by a colorectal surgeon. In next pregnancy , if she is symptomatic then elective caesarian is offered but the optimal mode of delivery for asymptomatic patients is uncertain.
		Posted by Zaharuddin R. Fri Feb 2, 2007 10:57 pm
a) The patient has a prolonged second stage of labour with maternal exhaustion. The aim of management is to assist delivery to ensure safe delivery to the mother and the fetus. Antenatal notes should be reviewed and physical examination should be done to exclude big baby or relative cephalopelvic disproportion such as palpable fetal head per abdomen. Partogram should be reviewed for labour progress. Maternal well being should be assessed with vital signs such as BP, PR and temperature and cardiotocogram should be done to assess fetal well being. Contraction should be reviewed and to aim for good contraction 3-4 in 10 minutes to titrate with IV oxytocin infusion. The patient should be explained regarding assisted delivery. Consent from the patient is needed before the procedure. The patient should have adequate analgesia preferably by epidural analgesia. Anaesthesist should be informed and epidural analgesia should be topped up. Paediatrician should be stand by and operation theater staff should be alerted in case of failed procedure. The patient should be explained regarding steps of procedure to gain her cooperation. Urine should be drained in/out. Vaginal examination should be done to ensure position of fetal head and membrane should be ruptured earlier. Instrumental delivery with forcep is preferable as it is associated with less subarachnoid haemorrhage (SAH) of the baby. However forcep delivery is associated with increased risk of maternal perineal tissue trauma and post primary post partum haemorrhage. The patient should be reassured that forcep marks on baby?s face is temporary and it will be disappear after a few days. Choice of instrumental delivery is depending on the surgeon familiarity with the instrument. Another option is ventouse delivery. The procedure is relatively associated with less maternal perineal tissue trauma compared to forcep delivery. However ventouse delivery is associated with increased risk of SAH and increased maternal worry. b) The patient and her spouse should be informed regarding the complication. Consent should be taken for perineal repair in the operation theater (OT). Two large bore venous access should be inserted and blood should be sent for full blood count and group crossed match for 2-4 pints whole blood. The consultant obstetrician, anaesthesist and OT staff should be informed. Third degree tear of perineum include tear of anal sphincter but rectal mucosa is intact. Procedure should be done by an experience surgeon with interest in perineal repair. The operation should be done in OT because of good lighting, appropriate instruments available and a number of assistants. Anal sphincter is smooth muscle and should be repaired with monofilament suture such as PDS 2/0 as less infection rate. Repair could be done either end to end or overlapping method of sutures as the outcome is not significantly different. Perineal muscle should be repaired with rapid absorbable sutures such as rapid Vicryl 2/0. Vaginal musosa should be repaired with continuous unlocked method with rapid absorbable sutures as it is associated with less perineal pain compared to interrupted locked sutures. Skin should be closed subcuticularly with rapid absorbable sutures as it is associated with less less perieal pain and dyspareunia compared to interrupted method. Blood loss should be estimated. Urinary catheter should be inserted for at least 24hours. Broad spectrum antibiotics should be given such as third generation of cephalosporin and metronidazole intravenously for at least a day then continue with oral medication till a week. Adequate analgesia in form of epidural or NSAIDs should be prescribed. Adequate hydration, TED stocking and subcutaneous heparin should be prescribed to prevent VTE. Debulking and stool softening agent such as lactulose should be given. Blood transfusion or iron tablets should be given depending on estimated blood loss and Hb level. The patient and her spouse should be explained regarding sequence of events. Detail of events and procedures should be clearly documented in the patient?s notes. Incidence form should be filled up for future audit. The patient should be followed up after 6 months delivery with a gynaecologist with interest in urogynaecology or perineal study. Indication of caesarean section in future pregnancy is persistent incontinence or documentation of more than 25% disruption of anal sphincter by endoanal scan.
		Posted by Fahima A. Sun Feb 4, 2007 12:03 am
a)First of all I will review her partogram to see the progress of labor from the beginning to get a clue about cephalopelvic disproportion(CPD). As the lady is pushing for 1 hour I will asses maternal condition check pulse, BP, temperature and dehydration. If she is dehydrated I will start normal saline. If there is pain I will start epidural analgesia or give top up if already started Then I will look for power, passage & passenger. If uterine contraction is insufficient I will start syntocinon drip. An abdominal exam is also necessary for the assessment of fetal size & to check how many 5th palpable for exclusion of CPD. For fetal well being I will check the tracing of Cardiotocography & do a pelvic examination for any caput, moulding or meconium stained liquor. If maternal & fetal condition is satisfactory I will give support to the woman encourage her to push effectively and wait for spontaneous vaginal delivery. If still she can not push properly or if there is maternal/ fetal distress I will go for a trial of instrumental delivery. In this case I will prefer ventouse as it is associated with less perineal trauma than forceps. However ventouse is associated with more failure rate, cephalhaematoma & retinal haemorrhage. But as in this case there is direct occipitoanterior position, 1 cm below ischial spine, with skilled hand the failure is low. If instrumental delivery fails even after 3 pulls the choice of delivery will be either forceps or caesarean section depending upon station of presenting part. In both the cases there is high neonatal morbidity. Paired cord blood should be taken for umbilical pH . Neonatologist should be present at delivery. If CPD is suspected I will do C/S not instrumental delivery. b)Third degree perineal tear means tear of vaginal mucosa, perineal muscle & anal sphincter. It should be managed appropriately otherwise the lady may have future anal symptoms like fecal urgeny, incontinence . First of all I will explain about the tear to the lady and take informed consent for repair under anaesthesia in theatre as this will give better repair. In theatre with proper asepsis I will try to identify the structure.. In any doubt I will take help from colorectal surgeon. During repair I will strict to the hospital protocol & RCOG guideline. The internal anal sphincter should be sutured with interrupted suture with 3/0 PDS as this will cause less infection than braided suture .The external anal sphincter with 3/0 PDS, I will suture like figure of 8. There is no benefit of end to end or overlapping technique with one another. Vaginal mucosa & perineal muscle should be repaired with 3/0 vicryl with continuous suture. Skin should be closed with vicryl in a subcuticular stitch as this will cause less perineal pain than interrupted suture. After completion of suture I will do a per rectal examination to detect any accidental knot in anal canal which may give rise to fistula formation. Prophylactic antibiotics with cephalosporin and metronidazole should given intravenously during repair and further one week orally. A catheter should be kept for 24 hours because of pain & adequate analgesia provided. Fybogel & lactulose should be prescribed for softening of stool as hard stool may interrupt the stitches. Proper documentation & incidental report is vital. A follow up should be given after 6 weeks to check any anal symptoms and to discuss about future mode of delivery.
		Posted by Freha Z. Sun Feb 4, 2007 12:12 am
Review of fetomaternal condition is required. Her progress of first stage should be reviewed with help of partogram. Abdominal examination should be done for lie, presentation and for uterine contractions. Her pulse, blood pressure and temperature should be noted. I/v fluids should be given to rehydrate the patient. More analgesia should be given if required. Contractions should be 3-4/10 minutes titrated accordingly with syntocinon. Continuous CTG should be attached if not done previously. Reassurance should be provided to the mother. If both fetomaternal condition is stable women can be offered expectant delivery with analgesia and support. If she doesnt want further expectant management or fetal/maternal compromise is there instrumental delivery should be considered. Experienced obstetrician and anaesthetist should be involved. Bladder should be empty and informed consent should be taken. Delivery should be undertaken with help of forceps under good analgesia in theatre. Forceps delivery is associated with vaginel lacerations, more need of analgesics, fetal trauma and suboccipital haematoma. Vaccum extraction is another option which is associated with less maternal genital tract injuries but higher fetal scalp injuries and higher failure rate. Neonatologist should be present at time of delivery. (b) In event of third degree evaluation should be done in theatre with good lighting, appropriate analgesia and by experienced operator. Full extent of injury should be ascertaied by careful vaginal and rectal examination. External anal sphincter should be repaired using uninterrupted or matteress 3-0 polydioxanone. Then vaginal epitheliam closed using loose continuous non-locking stitch with absorbable 2-0 polygalactin. The perineal body should be re-constructed to support the sphincter repair using interrupted 2-0 polygalactin. A careful vaginal and rectal examination should be unndertaken to ascertain completeness of repair and oral antibiotics continued after one week of repair for one week. An indwelling cathetor should be left for 12 hours to prevent retention. Adequate analgesia should be prescribed. Opiates should be avoided to prevent constipation. Laxatives such as lactulose prescribed to avoid constipation. Ensure women has opened bowel before discharge. Physiotherapy referral should be made. The women should be given adequate information on the extent of injury, perineal care and contacts if symptoms of infection or incontinence develop. A follow up appointment should be made12 week postpartum. Detailed bladder, bowel and sexual history by a structured questionaire may be used. Perineal, vaginal and rectal examination should be done to assess healing, scar tende rness and tone. Advice should be given regarding next delivery.
		Posted by Abi T. Sun Feb 4, 2007 02:29 am
a) This is prolonged second stage and maternal exhaustion may be one of the causes. Assisted delivery is an option. There should be clear communication with the patient and her informed consent obtained prior to any intervention. Maternal hydration should be optimized.Contraction efficacy improved with an oxytocin drip provided there are no signs of obstruction. The antenatal notes and partogram should be reviewed to identify risk factors for potentially difficult instrumental delivery and high failure rate such as high BMI, fetal weight more than 4kg and slow progress in late first stage, and perhaps assisted delivery should be done in theatre with quick recourse to C/Section if it fails. Continuous CTG monitoring is indicated to detect fetal distress and delivery expedited if present. The patient should be placed in lithotomy position and aseptic techniques employed. Maternal bladder should be emptied as a full bladder may pose as an obstruction to head descent.The balloon should be deflated if she has an indwelling catheter to avoid urethral injury. The head should be 0/5th palpable abdominally if it is in OA postion. Vaginal examination should ensure membranes are ruptured and exact position ascertained to ensure correct instrument placement. Presence of caput and moulding would influence choice of instrument. Adequate analgesia should be provided, either regional block or pudendal block with perineal infiltration. The choice of instrument depends on the skill and experience of the operator. .Midcavity forceps are more successful especially if there is poor maternal effort, lots of caput and moulding, but has a higher rate of maternal genital tract trauma and fetal facial injuries. The operator should ensure a matching pair is available and the blades lock with ease when applied. Ventouse deliveries have less risk of significant maternal genital tract trauma but higher risk of failure and associated with fetal cephlahematoma , retinal hemorrhage and maternal worry about the baby. There should be progressive descent with each pull otherwise procedure should be abandoned and delivery completed by C/section. Sequential instrument use is not recommended but may be considered balancing this against risk of second stage C/section. Episiotomy is not a routine recommendation but can be considered in this nulliparous woman to prevent multiple lacerations. There is an increased risk of shoulder dystocia and ensuing PPH with difficult instrumental deliveries hence, midwifery staff should be alerted and extra staff present to effect prompt manoeuvres. IV access, FBC and group and save should be obtained prior to embarking on delivery and active third stage management instituted to reduce blood loss. Neonatologist should be present at delivery. b) I would explain to the patient the nature of injury, need for repair in theatre and subsequent risks of infection, residual anal incontinence and possible repeat repair and obtain written consent. Repair is best done in theatre as it offers the best outcome and allows for adequate lighting, appropriate instruments, provision of an assistant and an aseptic environment. Regional or general anaesthesia should be used as it allows for repair of the sohincter ends without tension. The tear should be repaired by an adequately trained obstetrician or at least be supervised by one as inexperienced repair attempts increase maternal morbidity. There is no reliable evidence to support use of end to end technique repair over overlap and the surgeon should use the technique he is most experienced with. The use of PDS sutures has less infection rates and provides better long term sphincter function compared to monofilament sutures. Finer sutures also cause less irritation. Broad spectrum antibiotics prophylaxis should be provided intraoperatively and postoperatively to reduce infection rates and wound dehiscence and laxatives should be prescribed to also reduce wound dehiscence. There should be contemporaneous documentation of the classification of tear, repair technique, suture material used, swab and instrument count for audit and legal purposes. An incident form should be filled as part of risk management strategy. The patient should be debriefed and counselling offered regarding risk of developing anal incontinence or worsening symptoms in subsequent pregnancies. A follow-up appointment must be offered in 6-12 months with a gynaecologist with interest in anorectal dysfunction or a colorectal surgeon to detect residual incontinence symptoms and the appropriate investigations and management can be done.
		Posted by GBENGA O. Sun Feb 4, 2007 11:20 pm
Though,maternal exhaustion is the obvious cause of prolongation here,the general progress of the labour and intrapartum fetal well-being should be assessed.The course of labour is important because a slow 1st stage is a pointer to CPD and shoulder dystocia.The pathogram should therefore be reviewed.The CTG is also reviewed for uterine contactions and fetal well-being.Abdominal examination is performed to roughly assess the size of the baby and specifically the engagement.If any part of the fetal haed is palpable per abdomen,then intrumental delivery is not recomended.A vaginal examination is then performed to assess suitability for vaginal delivery.Important things to look for are caput and moulding.Exessive moulding is an indication of CPD and may make vaginal delivery very difficult if not impossible.If vaginal delivery is feasible,then a selection of either vacuum or forceps is then made .This largely depends on the experience and to a great extent degree of caput.Too much caput may make vacuum delivery difficult.Oxytocin should be commenced if the contractions are ineffective,bladder is emptied and patient is put in littotomy position.Instrument is applied and episiotomy given as necessary.If there is no descent with the 2nd pull,then this should be abandoned and caesrian section perfomed.An incident form should also be completed for a failed instrumental delivery .When there is any doubt of vaginal delivery, a trial of intrumental delivery is attempted and caesarian section is resorted to if there is failure.The third option is caesarian section especailly if any part of the head is palpable by abdomen.The findings and plans are discussed with the woman and her views taken and docummented in the notes.She is also properly counselled on the mode of delivery and written consent taken where appropriate.For the trial of intrumental delivery and or caesarian section,an in-dwelling catheter is inserted,ranitidine administered and the anaesthetist and theatre contacted. Third degree tear is associated with instrumental delivery especially forceps.It is important that a proper vaginal examination is perfomed after vaginal delivery to diagnose it.When missed,it is a source of litigation.The patient is informed of the finding and the plan for its repair.THe repair should be done by a senior obstetrician or under his suppervision.The repair could be done in the labour ward if the patient has effective regional anaesthesia and there is adequate lighting,otherwise it is done in theartre under regional or general anaethesia. THe sphincteric complex are repaired in end-to-end or overlap fashion with PDS which is associated with less infection compared with vicyrl nad catgut ( not in use again in the UK).There is however a risk of knot migration.THe muscles and the vaginal walls are then repaired in layers.Subcutaneous closure of the skin is recomended because of less requirement for nanalgesia. Antibiotics is administered intra-op and continued for 5 days.Stool softner is also administered.The patient is brought back for review in about 6wks and counselling regarding future preganncies and mode of delivery undertaken.Symptoms of faecal incotinence is sought.An endoanal ultrasound scan is arranged to outrule any sphincteric defects.A referal to a colorectal surgeon may also be arranged.If there is any symptoms or defects of syphincter,caesarian section may be advised in subsequent deliveries.Contraception is advised and cervical smear taken if one is due.
		Posted by Parveen Q. Mon Feb 5, 2007 01:07 am
The most likely diagnosis in this case is failure to progress, and further management depends on the maternal and fetal condition. I will see the CTG for any evidence of fetal distress, this will allow me to expediate the delivery by the safest means either by instrumental or caesarean section delivery. I wil check her vital signs, and due to her exhaustion, she might be dehydrated , so i will hydrate her.I will review the partogram, to assess the progress of labour. I will do abdominal examination to see if head is palpable, and also palpate for uterine contractions. vaginal examination done next, and if membranes are intact , it will be ruptured and note down the colour of liquor.Any caput or moulding will be palpated for , as caput will interfere with the application of cup and leads to failure by slipping. Any evidence of macrosomia will be noted from the patient\'s record . The consultant obstetrician informed and the patient should be involved in the decision making process. The choice of instrumental delivery depends on the availability of the instrument and the experience of the operator. Both ventouse and forceps has different risks and bnefits. Ventouse is more likely to fail, cause more anxiety in the mother about her baby, and more fetal cephal hematoma and retinal hemorrhages. It causes less perineal pain in 24hours, less perineal trauma and less regional anaesthesia. The low 5minute APGA, casarean section rate, is same for both ventouse and forceps. I will consider ventouse as my first choice, and i will take consent from the mother, for ventouse and if it fails for LSCS. I will allow her to take an informed choice, and inform the consultant obstetrician, paediatrician and anasthetist and the theatre satff. I will see 4-6 units of blood is available before proceeding . I will see there is an IV line and oxytocin drip in an optimal dose.I will check the ventouse cup and check for all connections, and the pressure built up is smooth. Patient will be placed in lithotomy positon ,under aseptic conditions ,bladder will be catheterised . Foetal scalp electrode will be removed, patient will be informed at each step, to gain her support. Ventouse cup will be applied, and after adequate pressure, with 1 or 2 pulls, descent of fetal head takes place and effective delivery happens. If there is no descent or if cup slips, casarean section should be performed. There is no role of propyhlactic episitomy, but can be undertaken in a primi, on a selective basis. Active management of second stage to avoid PPH, as prolonged labour and instrumental delivery is associated with PPH. Baby will be seen by the paediatrician at delivery. Perineum will explored for any injuries and effective and immediate suturing done. (b)Third degree perineal tear involves the anal sphinecter complex. Examination of the injury under adequate lighting to know the extent , is paramount importance. It will be undertaken in operation theatre , under general or regional anaesthesia to improve the outcome.I will take patient\'s consent , and inform the consultant obstetrician for expert advise if need arises. Prophylactic antibiotics given peroperativly and continud postoperatively. Asepsis will be maintained and hemostasis will be secured. A loose, continuous non locking suturing of each layer will be undertaken, as this is associated with less short term pain. I will use rapid acting polyglactin sutures, as it is associated with less perineal pain, analgesic use, dehiscence and resuturing. Swabs and instrument count done before and after procedure. all the details will be documentd and patient will be informed early to avoid litigation. Postopeartively, i will advise her about her diet, pelvic floor exerciexs, and give her adequate pain relief, and laxatives, and stool softeners to avoid constipation. She will be given a planned followup by experienced gynaecologist with an interest in anorectal dysfunction or by a colrectal surgeon . She will need an endoanal ultrasound or anorectal manometry if she has symptoms of anal incontinence. Susequent vaginal delivery will worsen the symptom . If asympatamatic, there is no evidence to the best mode of delivery.There is no evidence to the role of prophylactic episiotomy . In a sympatamatic woman or if there is abnormal endoanal or anorectal manmetry finding, the option of elective casarean section is discussed . Documentation done in the notes, during her booking visit.
		Posted by sandra B. Mon Feb 5, 2007 02:59 am
(a) Prolonged second stage is associated with increased neonatal and perinatal morbidity. This patient needs to be delivered. I would first assess the CTG to determine the well-being of the baby, this determines the urgency of the delivery. I would then assess the patient\'s labour notes especially the partogram to see whether there was good progress or slow progress durng the labour. Slow progress could indicate cephalo-pelvic disproportion.Abdominal palpation is performed to assess fetal size and to determine the fifths palpable per abdomen. An EPV is also performed specifically assessing for signs of obstruction including caput and moulding. A third trimester scan may be available and this woild provide an estimated fetal weight. An instrumental delivery is warranted.This can either be done in the delivery room or operating theatre. The station is at +1 with an OA position and providing there is no significant caput or moulding there is a high chance of success; I would therefore perform the instrumental in the room. However if there were signs of obstruction as outlined above, I would perform the instrumental delivery in theatre where early recourse to a cesaren section is available. Verbal consent should be sought from the patient after describing the procedure. I would ensure that the patient has adequate analgesia:epidural or a pudendal block, ensure adequate contractions 3-4/10, if not second stage syntocinon should be started provided the CTG is reactive. The bladder is then emptied. In view of maternal exhaustion I would choose forceps as opposed to a ventouse. The success of the forceps is less reliant on maternal effort. Also forceps is less likely to fail and it causes less worry about the baby. However forceps when compared to a ventouse is more likely to cause significant perineal injury Assistants should be available to place the place the patient\'s legs in the MacRoberts position should there be any shoulder dystocia. Postpartum haemorrhage should also be anticipated and third stage syntocinon should be available. (b) I would explain that a third degree tear involves the anal sphincter. I would then obtain written consent for the procedure. I would do the repair in theatre to ensure I have adequate light and assistants are available. The patient needs to have adequate analgesia, ideally a spinal or an epidural as the retracted edges of the anal sphincter become more visibla. My choice of sutres would be PDS because of its longer half life. I would repair the tear using the overlap technique as opposed to the end-to-end technique; even though studies have shown no difference in outcome between the two, there is a greater surface area of the sphincter brought together with the overlap technique. Antibiotics are given intraoperatively and for one week afterwards. This is to decrease the risk of infection leading to wound breakdown and subsequent fistula formation. Laxatives such as lactulose and fybogel are given to soften the stool; this ensures that the repair is not compromised by the passage of hard faeces, On discharge, the possible sequelae of a third degree tear are discussed such as faecal incontinence and she is asked to report any symptoms to her GP. She is seen at six weeks postpartum in the perineal clinic. where any symptoms are discussed and the mode of subsequent deliveries discussed.
		Posted by Dr Saibal S. Mon Feb 5, 2007 10:52 am
As there is no obvious anomaly regarding prolonged labour or malposition, maternal exhaustion in primigravida suggests early pushing in the pelvic phase of 2nd stage.I would enquire about hydration and analgesia as pain and dehydration increase maternal exhaustion and cause incoordinate uterine action. If epidural analgesia has been sited this would prolong second stage due to loss of ferguson reflex. The partogram will help to exclude prolonged labour in 1st stage and CTG analysis wiill reveal fetal condition I would do a general examination to exclude signs of dehydration on lips and tongue and increased pulse rate showing tachycardia.I would also enquire the time of last pass of urine as a distended bladder can lead to dysfunctinal labour. An abdominal exam to check for descent and palpable fetal parts,frequency and intensity of contraction to exclude incoordinate contraction. I would undertake a pelvic assessment to check dilatation and descent,position, caput and moulding of fetal head as well as liquor colour. If all is well with a reassuring CTG,clear liquor and no caput or moulding,then hydration by IV fluids ,pain relief, one to one midwifery care and allowance of more time may prevent an instrumental delivery.The woman and partner have to be reassured that everything is going fine and to expect a vaginal delivery. If the contractions are weak then syntocinon should be started according to hospital protocol with continuous fetal monitoring to achieve a vaginal delivery. If the CTG is nonreassuring and woman is unable to push then she has to be made aware that instrumental delivery would be best for safe delivery as there is full dilatation and head is low down.Ideally forceps delivery would be more successful as the head is just below spines. The woman should be explained about forceps delivery including the benefits of safe delivery, chances of trauma to the perineum , bleeding,and the small chance of failure in which case emergency caesarean would need to be done and her consent documented. Delivery should be by a trial of forceps in theatre, adequate analgesia and in the presence of pediatrician.Pelvic examination is again done to confirm position and descent of head,bladder should be catheterised and episiotomy performed. If there is no descent in three pulls then lscs is a safer option to deliver. Multiple instruments should not be used due to increased maternal and fetal morbidity and low apgars. All events should be documented and incident form filled for failed instrumental delivery. The parents will be debriefed about the outcome as well as answer questions and concerns After taking patients consent,3rd degree perineal tear should be repaired in theatre, with good light and an assistant to check the extent of trauma and bleeding. Adequate analgesia is essential to ensure full relaxation and assessment of the tear. First the internal sphincter if torn should be repaired with 3-0 PDS checking that there are no button hole tears of the mucosa. External sphincter should be repaired with 3-0 long acting PDS with either end to end or overlapping technique to prevent future sphinteric dysfunction Perineal muscles can be repaired with vicryl rapide by continuous or interrupted sutures and vaginal mucosa by continuous non locking sutures. Skin approximation will be by subcuticular suture as healing is better and post op pain is reduced in short term. Rectal examination to asses tone of sphincter should be done. Anti biotics and analgesia are required to reduce chances of infection, pain , and allow mobility.Stool softeners are prescibed to prevent wound dehiscence. The woman is explained about the proceduore and follow up arrranged in 3-6months time to assess rectal and anal funtion. If symptomatic then appoinment with colorectal experts wnd endoanal ultrasound should be made available. Contraception and future pregnancy should be discussed .
		Posted by SWATI M. Mon Feb 5, 2007 08:58 pm
a)Since woman is exhausted and undelivered after 1 hour of active pushing may need intervention to effect delivery. Assess maternal pulse,dehydration, analgesia.Review partogram to see her progress during first stage as suboptimal progress suggest possibility of CPD. Assess uterine contractions-frequency,strength and duration. Assess fetal size by abdominal palpation, FHR and if fetal head is palpable abdominally .Pervaginal examination should be done to confirm the findings. After the examination decide if vaginal delivery is feasible. If CPD is suspected then cesaerean section should be recommended and counsel woman . Hydrate woman if dehydrated , provide adequate analgesia if not given already as pain adversely affects labour.If fetal condition is good ,allow some more time to effect vaginal delivery after reassurance and adequate analgesia. If she has adequate analgesia, instrumental delivery would be safer option.Forcep would be preferred in her case as head is at +1 station.If fetus has excessive caput, delivery should be best undertaken in theatre as a trial of forceps. Woman should be counseled about forceps delivery, explain procedure,benefits, risks and obtain a verbal consent. Neonatologist should be informed as baby may need resuscitation. Ensure adequate analgesia before procedure,may need top up of epidural.Bladder should be catheterized and perform episiotomy if required. If there is no descent with 3 pulls ,forceps should be abandoned and cesarean section should be undertaken as a safer option. Paired cord blood sample should be collected for pH assessment and documentation should be done appropriately as a part of clinical risk management and has medicolegal significance. Shoulder dystocia, PPH, perineal tear can occur after forcep delivery. Anticipate,prepare and manage accordingly. b)Maternal morbidity due to third degree perineal tear is risk of PPH, infection, wound break down, late complication such as fecal / flatus incontinence and need for secondary repair.Repair should be undertaken early by appropriately trained person/under supervision, in operating theatre with good lightening and appropriate assistance to minimize these complications. Assess amount of pervaginal bleeding ,if excess start resuscitation with 2 wide bore IV lines, call for help and cross match 2-4 units according to blood loss. Counsel woman about the tear, repair and obtain consent. Inform operating theatre , anaesthesist and senior obstetrician. Adequate analgesia is needed to retrieve the torn edges of sphincter. Prophylactic antibiotics such as ampicillin/ cephalosporin with metronidazole should be given IV to minimise infection. Internal and external anal sphincter should be repaired with PDS as less likely to cause infection than braided suture , after retriving ends by end to end or overlapping sutures without tension to maintain repair. Vagina and perineal muscles sutured with polyglactin continuose loose stitches as less painful and minimises risk of vaginal contracture. Skin sutured with polyglactin subcutaneouse stitches as less painful.Indwelling urinary catheter done to avoid urinary rentension due to pain and kept for 24 hrs. Documentation should be done in details as it has medicolegal significance. Counsel woman postop about layers involved, repair undertaken and postop care. Maintain perineal hygiene and continue oral antibiotics. Bulk laxatives should be given to maintain repair. Analgesia other than opiods should be given to minimize pain. Keep in hospital until bowel is opened up. At discharge counsel about contraception, follow up arrangement made to see her after 6 ? 12 weeks to know about the success of repair &discuss implications for future pregnancy and mode of delivery.
		Posted by Shyamaly S. Tue Feb 6, 2007 01:25 am
A) Intervention at this stage is justified- the woman is exhausted-she is unlikely to deliver given more time. Prolonged active second stage is associated with maternal morbidity- increased perineal trauma, faecal and urinary incontinence, and neonatal morbidity- more rapid development of hypoxia and acidosis. Progress in labour should be assessed; slowing at the end of the first stage is associated with a higher risk of shoulder dystocia and failed vaginal delivery. The fetal heart should be assessed with a CTG. If there are concerns, the most expedient mode of delivery with the highest chance of success should be chosen. On examination,high maternal BMI and fetal size are associated with a higher risk of shoulder dystocia and failed vaginal delivery. This is also true when head is palpable abdominally. At vaginal examination, rupture of the membranes should be confirmed; instrumental delivery is otherwise not possible. The colour of liquor also indicates fetal wellbeing- meconium is associated with poorer outcomes and requires delivery by the most expedient means. The presence of caput or moulding will help determine choice of instrument. Moulding is associated with obstructed labour and may suggest that vaginal delivery is likely to fail, and the presence of caput increases the likelihood of the ventouse failing. If there are concerns that vaginal delivery may fail, this delivery should be conducted under a spinal anaesthetic in theatre with recourse to Caesarean. It should be performed or supervised by a senior obstetrician. The mother should give informed consent for a trial of instrumental delivery with Caesarean Section, considering the risks of fetal facial/scalp lacerations, maternal lacerations, bleeding, infection, visceral damage and thromboembolic disease. She should receive appropriate analgesia: pudendal/perineal block or epidural/spinal anaesthesia. The choice of instrumental is dependent on operator experience, presence of caput and maternal effort (ventouse more likely to fail with poor maternal effort). The aim should be to chose the correct instrument and avoid the use of sequential instruments. The options for delivery are: rotational ventouse, which is associated with neonatal cephalhematoma; direct OP delivery with Neville Barnes Forceps, which is associated with a significant risk of anal sphincter injuries; manual rotation to OA and delivery with Forceps, which is associated with less sphincter injuries; or Kiellands forceps delivery, a skilled procedure which is associated with more lacerations. Instrumental delivery is associated with postpartum haemorrhage, perineal trauma and shoulder dystocia. A caesarean Section may be needed. At full dilatation, the risk of bleeding and bladder/ureteric injury is increased. A second stage Caesarean should trigger risk management incident reporting. B) A third degree tear necessitates repair- otherwise there will be infection, fistula formation and faecal incontinence. Repair should be undertaken as soon as possible to minimise blood loss and infection. A trained experienced obstetrician should perform it. The patient should be consented for repair, including awareness that 40% of women may still suffer with faecal or flatal incontinence; there is a significant risk of bleeding requiring blood transfusion and infection. The repair should be performed with good lighting, under good anaesthesia and with an assistant to ensure the extent of damage is adequately assessed with rectal and vaginal assessment, the sphincter edges are dissected and repaired properly. The internal sphincter should be identified and repaired with interrupted sutures. The external sphincter repaired using either end-to-end or overlapping technique using a monofilamentous suture such as PDS to reduce the risk of infection. The vaginal mucosa, perineal muscles and skin should be closed routinely. Aseptic technique should be used, intravenous antibiotics should be given during the procedure and these should be continued for 10 days post op to minimise infection, fistula formation and wound breakdown. Rectal examination should be performed at the end to ensure no stitches are palpable, good anal tone and no defects. The repair should be documented accurately as this is an important area of litigation, and risk management trigger forms should be completed. Postnatal physiotherapy should be organised to improve pelvic muscle tone, laxatives should be prescribed to avoid constipation because straining may impede wound healing. She should be followed up in clinic after 10 weeks- if she had any symptoms of incontinence, anal USS and manometry should be organised with a view to secondary repair.
		Posted by Shyamaly S. Tue Feb 6, 2007 01:50 am
please can you ignore my last entry....got the wrong question. i was talking ops [:rolleyes:] A) Intervention at this stage is justified- the woman is exhausted-she is unlikely to deliver given more time. Prolonged active second stage is associated with maternal morbidity- increased perineal trauma, faecal and urinary incontinence, and neonatal morbidity- more rapid development of hypoxia and acidosis. Progress in labour should be assessed; slowing at the end of the first stage is associated with a higher risk of shoulder dystocia. On examination, high maternal BMI and fetal size are associated with a higher risk of shoulder dystocia. The abdomen should be carefully palpated, if head is palpable then it is likely that the VE is incorrect or that there is caput extending to +1. At vaginal examination, rupture of the membranes should be confirmed; instrumental delivery is otherwise not possible. The colour of liquor also indicates fetal wellbeing- meconium is associated with poorer outcomes and requires delivery by the most expedient means. The presence of caput or moulding will help determine choice of instrument. Moulding is associated with obstructed labour and may suggest that vaginal delivery is likely to fail, and the presence of caput increases the likelihood of the ventouse failing. The mother should give informed consent for an instrumental delivery, considering the risks of fetal facial/scalp lacerations, maternal lacerations, bleeding, perineal trauma including anal sphincter injury. She should be delivered in lithotomy position, receive appropriate analgesia: pudendal/perineal block or epidural/spinal anaesthesia. The bladder should be emptied to minimise the risk of vesico vaginal fistula and obstruction. The choice of instrumental: ventouse or forceps, is dependent on operator experience, presence of caput and maternal effort (ventouse more likely to fail with poor maternal effort). The aim should be to chose the correct instrument and avoid the use of sequential instruments. Ventouse is associated with less maternal lacerations, but an increased risk of neonatal cephalhematoma, scalp laceration and retinal hemorrhages. Forceps may be associated with a higher incidence of maternal perineal injury, and pain and maybe associated with scalp or facial injury. Given that the woman is exhausted, I would opt for Neville Barnes Forceps delivery because she exhausted and unlikely to be pushing properly. Instrumental delivery is associated with postpartum haemorrhage, perineal trauma and shoulder dystocia. B) A third degree tear necessitates repair- otherwise there will be infection, fistula formation and faecal incontinence. Repair should be undertaken as soon as possible to minimise blood loss and infection. A trained experienced obstetrician should perform it. The patient should be consented for repair, including awareness that 40% of women may still suffer with faecal or flatal incontinence; there is a significant risk of bleeding requiring blood transfusion and infection. The repair should be performed in theatre with good lighting, under good anaesthesia and with an assistant to ensure the extent of damage is adequately assessed with rectal and vaginal assessment, the sphincter edges are dissected and repaired properly. The internal sphincter should be identified and repaired with interrupted sutures. The external sphincter repaired using either end-to-end or overlapping technique using a monofilamentous suture such as 3.0 PDS to reduce the risk of infection. The vaginal mucosa, perineal muscles and skin should be closed routinely with continuous sutures of 2.0vicryl rapide to minimise post op pain. Aseptic technique should be used, intravenous antibiotics should be given during the procedure and these should be continued for 10 days post op to minimise infection, fistula formation and wound breakdown. Rectal examination should be performed at the end to ensure no stitches are palpable, good anal tone and no defects. An indwelling catheter should be left in situ to prevent bladder over distension post operatively. The repair should be documented accurately as this is an important area of litigation, and risk management trigger forms should be completed. Postnatal physiotherapy should be organised to improve pelvic muscle tone, laxatives should be prescribed to avoid constipation because straining may impede wound healing. Opiate analgesia should be avoided as these increase constipation, instead non steroidals should be prescribed. She should be followed up in clinic after 10 weeks- if she had any symptoms of incontinence, anal USS and manometry should be organised with a view to secondary repair.
		Posted by TAIWO NURENI Y. Tue Feb 6, 2007 04:51 am
a) The trend of events from Ist stage need to be review through the partogram.Having being pushing for an hour there is definite need for intervention.However,she has to be examined per abdomen to see if head still palpable and also vaginally to assess for caput or excessive moulding which are signs of cephalopelvic disproportion.If this is the case the instrumental delivery trial should take place in the theatre.Failure of descent or delivey after three pulls should be indication to proceed to ceasarian section.The possibility of this has to be discussed with the woman prior to going to theatre.In absence of signs of CPD,Vagina delivery should be feasible with assistance.The choice of assisted delivery could be by forceps or vacuum.There is more likelihood of vagina delivery with forceps owever it skills and causes more perineal trauma with risks of 3rd/4th degree tear compare to vacuum.Vaccum need less skills but increase risk of retinal haemorrhage,cephalohaematoma and maternal worries about baby.Prior to the procedure details of it is discussed and consent taken,bladder is emptied and bloods saved for group and hold. b)3rd degree tear need to be repaired in the theatre where there will be good lighting and adequate instruments.Regional or general anaesthesia should be available to ensure good repair and optimum outcome.Experience in the repair of this type of tears or supervision by experienced personnel contribute to better outcome.Method of either end to end or overlaping is employed with 3/0 vicryl or PDS suture for the external and internal sphincter.She is given broad spectrum antibiotics prophylactically and continue after for a week.She is put on laxative to soften her stool for 10 days as constipation and infection might cause breakdown of repair.Post natally, the whole events have to be discussed with mother and questions answered.Documentation and incident report is also vital.She is going to be reviewed in the clinic at 6months where implication for subsequent delivery is highlighted and if symptomatic referral to colorectal surgeon is made.
		Posted by M M A. Tue Feb 6, 2007 10:18 am
A] We should do careful assessment of the clinical situation, an abdominal examination is done to assess duration and frequency of uterine contractions and also to ascertain that there is no uterine ring. CTG is done to rule out fetal distress. We do vaginal examination to exclude meconium staining liquor and excessive moulding. If the contraction is efficient and CTG is normal with no sign of obstructed labour, we offer her encouragement and support and she can be nursed in upright or lateral position. If there is inadequate uterine activity, oxytocin drip should be started with close monitoring. If after 2 hours and still there is no evidence of progress, an instrumental vaginal delivery is indicated and discussed with the patient and her partner to obtain an informed consent. Both forceps and vacuum extractor have benefits and risks, we should select the instrument according to our experience and skills, if we have experience in both, vacuum will be the first line because of less incidence of maternal pelvic floor injury. It is preferable to be done in theatre with good standard of hygiene and aseptic technique; a staff should be standby for cesarean section in case of failure. Adequate analgesia ; regional or pudendal block should be ensured and the bladder is evacuated. If there is no evidence of progressive decent with each pull of correctly applied vacuum or delivery still not imminent after 3 pulls, the procedure should be abandoned. Forceps can be used sequentially but it has increased incidence of fetal trauma, however, we should balanced it against the risk of CS after failed vacuum. Episiotomy is not used routinely, also there is no evidence that antibiotic is recommended. If the instrumental delivery fail, we should progress for CS, an informed consent is taken with blood grouping and cross matching. A neonatologist should be present for resuscitation and cord blood is sent for PH and blood gases analysis. Catheter is inserted for 12 hour to avoid retention. She should be offered psychological support; we tell her that 80% of patients can deliver by spontaneous vaginal delivery in the future. B] Third degree tear means injury to anal sphincter, it should be sutured as soon as possible to reduce bleeding and risk of infection. A clear explanation is given to the woman to make an informed consent. Good lighting is required for inspection of genital tract to exclude cervical or other vaginal wall injury with help of an experienced assistance, the swaps should be calculated and the equipments should be checked carefully. Regional or general anaeshesia can be used so the sphincter will be relaxed and suturing will be more successful. Suturing by overlapping technique or end ?to- end anastomosis has similar outcomes. An appropriate anatomical approximation will minimize future morbidity like incontinence , perineal pain and dyspareunia. Anal sphincter is better to be sutured by synthetic long absorbable suture like polydiaxonone (PDS), it carries less incidence of infection and better long term function. Vaginal wall is sutured by synthetic absorbable sutures like polyglycolic acid or polygalactine; continuously locked or unlocked, these measures are associated with fewer incidences of perineal pain and analgesic requirement, also less incidence of dehiscence and re-suturing but the sutures require removal after 7 days. The muscles are approximated by continuous suture which has less short term pain than interrupted sutures. Suturing perineal skin by continuous subcuticular technique carries less short term pain. Rectal examination is done to check that sutures have not been inserted accidentally through it. Broad spectrum antibiotic is given intraoperatively to minimize postoperative infection, wound dehiscence and fistula formation. Appropriate documentation is required about the extent of the wound with a diagram if possible and the technique used for suturing and the sutures used. Post operative laxative is advised for 10 days to reduce wound dehiscence, with NSAIDs analgesia and indwelling catheter is fixed for 12-24 hour to avoid retention. The woman informed regarding extent of trauma and advices about diet, hygiene and pelvic floor exercise. Planned follow up appointments for 6-12 months is required, better with Gynecologist interested in anorectal dysfunction or with anorectal surgeon to detect and treat any dysfunction. Planned elective cesarean section is advised for future deliveries.
		Posted by M M A. Tue Feb 6, 2007 10:23 am
Please Dr Paul: When we say {Justify}...it means mentioning the causes or the dvantages that will be gained from doing a procedure or a treatment, but do we have to mention the disadvantages or negative implications also?? Thanks and regards.
		Posted by sailaja devi K. Tue Feb 6, 2007 08:56 pm
Review the data concerning maternal signs ,fetal signs & progress of labour in partogram.Note the time of full cervical dilation ,note the duration of total of active & passive second stage of labour. Evaluate general condition of women.Monitor vital signs.Identify any signs of dehydration, if present correct with intravenous ringer lactate solution . Perabdomen examination to identify if head is palpable per abdomen, size of fetus.Ensure that the women is getting adequate uterine contractions 3 in 10 min each lasting for 40 sec. Check the fetal heart rate.Pervaginal examination to check colour of liquor,note the degree of moulding & caput formation, degree of deflexion of the head and assess the lower pelvis The options available are deliver spontaneously occipitoposterior position ,require an assisted delivery occipito posterior or rotated & delivered occipito anterior or may need to be delivered by caesarean section.This depend on the expertise available and on the clinical situation. If the progress of labour is adequate ,pelvis is adequate ,fetal heart rate is reassuring & getting adequate uterine contractions watch for progress of labour.If contractions are not adequate start Oxytocin agumentation. In nulliparous women lack of progress for 3 hours with regional anaesthesia,or 2 hours without anaesthesia indicate inadequate progress ,is an indication for operative vaginal delivery.Explain to the women that her chances to have normal delivery were less ,she would be better of with operative vaginal delivery .Choice of instrument depend on expertise of the operator. Experienced operator should be present for midcavity operative vaginal delivery.Make sure prerequisites for operative vaginal delivery as advised in RCOG guidelines were met.Informed consent must be obtained & explanation given. Ensure she gets good analgesia.Make sure maternal bladder is emptied .Maintain aseptic technique .Make sure adequate facilities & back up personnel were available.Anticipate complications as direct occipito position is associated with increased perineal trauma,increased incidence of Erb?s palsy ,facial palsy following forceps delivery in this group.The role of routine episiotomy for operative vaginal delivery is poorly evaluated,but in occipito posterior position episiotomy in needed to prevent tears. Make sure personnel who are trained in neonatal resuscitation were present.Good standard of hygiene & aseptic techniques are recommended.RCOG guide lines suggest paired cord samples should be processed & recorded following operative vaginal delivery. If obstruction is present abandon labour in favour of caesarean section. Explain to the women about third degree tear & need to repair , written consent to be taken.RCOG guidelines suggest third degree perineal tear shoud be repaired in an operation theatre,under regional or general anaesthesia for improved outcome. Repair in theatre will allow operation under aseptic conditions with appropriate instruments,adequate light & with an assistant.Regional anaesthesia will allow the women to be pain-free & the anal sphincter to relax.This helps to retrive the retracted torn ends of the anal sphincter & allows the ends of the sphincter to be brought together without any tension. Repair should be done by experienced obstetrician.Suture material should be monofilament sutures such as Polydioxanone .This is associated with less infection,less irritation & better long term function of anal sphincter complex.Method of repair should be over lap method or end to end method as evidence shows there is no advantage of one method over other..Intraoperative broad spectrum antibiotics are recommended because the development of infection will pose a high risk of anal incontinence & fistula formation following breakdown of the sphincter repair.Metronidazole to be included to cover the possible anaerobic contamination from fecal matter. Regarding risk management clear documentation & patient information are vital.Document clearly the anatomical structure involved ,the method of the repair & suture materials used.Make sure the instruments ,swabs & sharps are accounted for.Women should be informed the nature of the injury & the importance of subsequent follow up. The antibiotics to be continued in the post operative period.During postoperative period passage of hard stool can disrupt the repair so laxatives are recommended.Use of stool softener such as lactulose & a bulking agent such as Fybogel is recommended for about 10 days after the repair. Arrange for follow up at 6 -12 months by a gynaecologist with a interest in anorectal dysfunction or a colorectal surgeon.If symptoms of anal incontinence are present offer endoanal ultrasonography & anarectal manometry .If abnormality is present refer to colorectal surgeon for consideration of secondary sphincter repair . Women should be counselled regarding the risk of developing anal incontinence or worsening symptoms with subsequent vaginal delivery.If symptomatic or with abnormal endoanal ultrasonography or manometry ,the option of elective caesarean section should be discussed.If asmptomatic ,there is no clear evidence as to the best mode of delivery. Women should be counseled at booking visit in next pregnancy about mode of delivery & should be documented in the notes.
		Posted by kiria O. Tue Feb 6, 2007 10:28 pm
The main aim of intervention at this stage is to deliver her safely with minimal maternal morbidity. As she is exhausted, appropriate instrumental delivery is indicated. First of all i will assess her general condition, look for signs of dehydration and commence iv fluid. i will examine her abdomen assess duration,frequancy and strenght of uterine contraction, any fifth of head felt in abdominal examination my change mode of delivery , oxytocin infusion 5 unites can be started if no uterine contractions. Detailed vaginal examination to confrim the finding of full dilatation, position, station, presence and severity of moulding and to insure that the situation is fullifilled to apply forceps, such as ruptured membrance. empty bladder,adequate outlet and adequate analgesia. Continous fetal monitring and CTG must be assessed to ensure fetal wellbeing. If there is no contraindication such as none engagment of head, and all criteria are fullifilled ,i would chose mid cavity forceps as it has less risk of failure and less risk of retinal heamorrhage and cephalheamatoma compred to ventouse.However,forceps has high risk of perineal injuries and tears. If there is high suspecion of unsuccess, trial of foreceps must be carried out in theater and all staff(in theater, anasthateist peadiatrician must be ready for emergency Cesearian section. Application of forceps must be easy and performed or supervised by experienced obstetrician and three pulls is allowed, to reduce both fetal and maternal risks and morbidites associated with difficult instrumental delivery.peadiatrician must be informed. Patient with 3rd degree tear,need to be transfered to theater or a place with good lighthining to ensure adequate examination and repair. Consultant must be informed , anasthatest informed as repair traditionally performed under general anasthesia but now depend on maternal wishs and can be performed under local or regional analgesia. Carefull examination to exclude any other cervical or periurethral tears , per rectal examination to exclude involvment of anal mucosa. Good assistance and experienced obstetrician must perform the repair as this is associated with better outcome. External anal sphincter should be repaired with none absorbable monofilament suture(3-0 PDS) as it associated with less risk of dehiscence and pain. internal anal sphincter repair should be done by 2-0 PDS. perineal muscles and vaginal mucosa repaired by continous rapid vicral suture. skin is sutured subcuticular as it associated with less pain and lower rate of infection. intraoperative broad spectrum antibiotics and continued for10 days post delivery to reduce risk of infection and wound dehiscence. Laxatives or stool softenner with adequate fluids and avoidance of fiber as it increase bulk of stool which may lead to over distension of sphincter muscles and dehiscence. Patient must be explained the debrifened regarding whole situation and implication of 3rd degree tears such as a need for follow up and endo anal ultrasound and assessment by anorectal surgon if she has any symptoms of incontienance. Also the effect of 3rd degree tears on the mode of delivery on subsequent pregnancy as she should know that prophylactic episitomy cannot protect against tears and if she had no symptoms vaginal delivery is allowed but if she had any symptoms ,may be worsened after normal delivery.
		Posted by Randa E. Wed Feb 7, 2007 03:42 am
Active pushing for 1 hour with no delivery and maternal exhaustion is an indication for intervening in order to minimise maternal and fetal morbitidity. The partogram should be reviewed for the progress of labour and maternal well-being. Maternal records should be reviewed for any evidence of fetal macrosomia, bleeding disorders or susceptibility to fractures. Fetal size must be assessed subjectively by abdominal palpitation. Factors influencing the duration should be checked, such as strength of contraction and use of epidural. Fetal well being should be checked. If CTG monitering was undertaken then this can be reviewed for any signs of fetal distress, otherwise this should be assessed by a thorough clinical examination. Vaginal examination to asses caput, moulding and deflexion of the head and to confirm the findings of the abdominal examination should be done. Also colour of liquor and presence of meconium must be ascertained. If there were any signs of fetal distress then delivery should be undertaken by the fastest and safest route possible at the time. If fetal macrosomia is suspected, then instrumental delivery must be undertaken as a trial in theatre with everything ready for c/s in case of failure. Otherwise delivery can be undertaken in the delivery room with facilities available for assistance or abdominal delivery if vaginal delivery fails. The reasons for intervention should be explained very clearly to the mother. She should be made aware of potential complications that might arise, e.g. failure of the instrumental delivery and thus the need for an emergency c/s or complications and injuries that might affect the baby e.g. cephalohaematoma. The possibility of an episiotomy or perineal lacerations during the delivery and their implications must also be explained to the mother before the delivery is undertaken. An informed consent must be obtained.Before starting the instrumental delivery adequate analgesia must be insured. The bladder should be emptied. The procedure should be done by a suitably skilled operator under aseptic conditions. Continious CTG monitering should be undertaken. Neonatologist should be present at the delivery. Choice of instrument should be made by the operator and must be appropriate to the clinical situation and their level of skill and should take maternal wishes into consideration. If there is marked caput and poor descent with maternal effort then forceps might be more appropriate. However it is associated with increased perineal trauma and post partum haemorrhages. The vacuum is associated with less perineal trauma but has a higher rate of failure. It is also associated with increased cephalohaematomas and retinal haeommorhage. Good contractions must be present at a vacuum delivery. If there is no evidence of progressive descent with each pull or delivery is not eminent after 3 pulls then the vaginal operative delivery should be abandoned and help should be summoned immediately. The woman should be reassessed and emergency c/s considered. Cord blood samples should be obtained and recorded.The indications, timing of delivery and procedure used should be clearly documented. b)3rd degree repair should be undertaken in the operating theatre with good lighting and appropriate analgesia/anaethesia and by a trained operator or under supervision. Careful vaginal and rectal examination should be undertaken with the woman in the lithotomy position to ascertain the full extent of the injury. Anal epithelium should be repaired with 3-0 polygalactin sutures. The internal anal sphincter should be identified and repaired using interrupted or mattress 3-0 PDS. External anal sphincter repaired using 2-0 PDS using end to end or overlapping technique. Vaginal epithelium should be closed using a loose continuous non-locking stitch with rapid absorbable 2-0 polygalactin. The perineal body should be re-constructed to support the sphincter repair using interrupted 2-0 polygalactin. The perineal skin is then closed using sub-cuticular 2-0 rapide absorbable polygalactin. A careful vaginal and rectal exaomination should then be undertaken to ascertain completeness of repair and remove any swaps or tampons. Braod- spectrum iv antibiotics should be administered at the time of repair and oral treatment continued after the repair for 1 week. The bladder should be emptied and an in-dwelling catheter inserted. Alternatively spontaneous voiding must be insured to occur at least every 6 hours. Adequate analgesia must be prescribed avoiding opiates for it might lead to constipation. Rectal analgesia should also be avoided. The repair must be documented accurately and an incident form completed. Laxatives should be prescribed to prevent constipation and it is important to insure that the women has opened her bowels before discharge. Physiotherapy referral should be made and the situation explained fully to the woman. Information about perineal care and contacts if symptoms of infection or incontinence develop should also be provided. A follow-up appointment should be made at around 12 weeks post-partum.
		Posted by Farzana N. Wed Feb 7, 2007 06:21 pm
a)Maternal exhaustion in this case would be an indication for active intervention.Options include operative vaginal delivery by ventouse or forceps, or cs. Initial assessment of this pt should include review of partogram to note progress of labour ,presence of epidural anesthesia.Abdominal examination done to assess the fetal size and adequate uterine contraction.CTG seen for fetal condition.P/V exam to look for any caput or moulding and color of liquor.If big baby,with excessive caput or moulding ,or any signs of fetal compromise on CTG or meconium stained liqour ,CS would be the best option. In presense of average size baby,good uterine contractions ,head not more than 1/5 palpable and the given P/v findings AVD can be undertaken either by ventouse or forceps. Adequate analgesia should be given.Epidural should be placed if she does not have.Bladder should be emptied .Pediatrician should attend delivery,with facilities for neonatal resuscitation.In case of ventouse delivery,descent should occur with uterinecontractions and pt should deliver in not more than three pulls.In case of failure,procedure should be abandoned and pt should be taken for cs.Choice between the forceps and ventouse would depend upon operators choice and expertise.Compared to forceps,ventouse is more likely to fail; higher risk of fetal complications such as cephalhematoma and retinal hemorrhages.But the risk of perineal trauma is much less .Pt should be counseled about the available options and amount of risk involved .Informed consent should be taken. b)Third degree tear should be promptly repaired in an operating theatre with good lighting facilities.Full extent of injury should be ascertained by careful vaginal and rectal examination,with the woman in lithotomy position.The anal epithelium is repaired with 3-0 vicryl sutures. the internal anal sphincter is identified and sutured with 3-0 PDS,interrupted or mattress. External anal sphincter is repaired using 2-0 PDS by end to end /overlapping technique.Vaginal mucosa, perineal body and perineal skin repaired using 2-0 polygalactan.A careful P/V and P/R done to ensure completeness of procedure and remove swabs or tampons. Broad spectrum antibiotics should be given .Bladder should be emptied and an indwelling catheter inserted alternatively ensure spontaneous voiding every 6hrs.Adequate analgesia and laxatives should be given. Ensure that woman should open her bowel before discharge. The repair should be documented accurately and incidence form completed. The woman should be given adequate information on the extent of injury, perineal care and contacts if symptoms of infection or incontinence appear.Follow-up appointment is made 12wks postpartum.
		Posted by Yasser S. Thu Feb 8, 2007 01:22 am
Delivery is indicated because of maternal exhaustion. She is a primigravida and already exhausted so needs assistance to deliver. Partogram should be reviewed to see any delay in the first stage as it can indicate cephalopelvic disproportion. Abdominal examination should be performed to assess the size of the fetus, adequate contractions and palpable fetal head. Vaginal examination is done to rule out the presence of caput or moulding. When there?s no caput , the head is in direct occipito anterior position and 1 cm below the spine and the fetal size is average with no palpable part of fetal head per abdomen , then the mode of delivery of choice is by ventouse. If there?s caput then ventouse should be avoided as there?s increased chance of failure. In such case forceps delivery is safer option in the given scenario. Any instrument should be applied after ensuring adequate analgesia. Bladder should be catherized. Verbal consent should be taken from the ,mother. If however CPD is suspected, the safest option is C section. A trial for instrumental delivery can be given in the OR with double set up for abdominal delivery. The women should be informed about the choices, there risks and benefits and any procedure should be done after an informed consent. The patient should be examined in lithotomy postion with good light. Extent of the trauma is identified. Consent is obtained. Suturing should be done as soon as possible to reduce the risk of bleeding and infection. Repair should be undertaken by appropriately trained staff with good assistance and under adequate analgesia in the theatre. If there?s any doubt about the extent of trauma or the structures involved, then more experienced adivice should be seeked. An indwelling catherter should be inseted to prevent urinary retension and is left insitu for 24 hrs. Prophylatic antibiotics should be given to minimize the risk of infection. Proper tissue aligment is important and consideration should be given to cosmetic results. A loose, continous non locking suturing technique should be used to appose each layer using absorbable synthetic material. It is associated with less short term pain. Rectal examination should be performed by the end of the procedure to ensure that accidental suture ahs not been taken through the rectal mucosa. Following repair, the women should be informed about the extent of the trauma. Pain relief should be discussed. Diet, hygiene and the importance of pelvic floor excercises should be discussed. Follow up appointment should be given in 6 wks time.
		Posted by Shatha A. Thu Feb 8, 2007 06:25 am
(a) Maternal exhaustion is one of the indication for assisted vaginal delivery. Therefore a review of the partogram to check progress of labour, an abdominal examination to palpate frequency of uterine contraction and any fifth of the foetal head, a CTG review if she has continuous foetal monitoring for foetal wellbeing, if not then it should be started. Vaginal examination for detection of meconeum, caput or moulding. Assisted vaginal delivery should be offered to the woman, and a verbal concent with explanation of the procedure and possible risks should be taken and documented. The choice between instrument depends on the experience of the operator, the urgency of delivery and the presence of excessive caput or moulding. The use of forcepse is associated with higher risk of maternal tissue and anal sphincter injury, while ventouse is associated with higher risk of cephal haematoma and retinal haemorrhage. In this particular case, if there is no foetal compromise, and no excessive moulding or caput the use of ventouse is justified to minimise risk of maternal injury. Adequate analgesia is essential, if the patient has no epidural on board then a pudendal block and perineal infiltration is adequate. Bladder should be emptied, and the venouse cup should be applied on the flexion point, and maternal tissue should be checked prior the increasing the pressure. Gentle pull with contraction should be applied, with willingness to abandon the procedure if no descent of the foetal head with consecutive pulls, if the cup slips more than once. The use of double instrument should be avoided if at all possible specially if there has been no descent, other wise if head is on perineum then an outlet forceps can be used. In this scenario the need for an emergency caesarean section is very unlikely due to station and position of the head. The use of episiotomy with instrumental delivery is not mandatory and should be left to the operator judgment. The possibility of shoulder dystocia and post partum haemorrhage is higher in instrumental delivery and the appropriate protocol should be followed if it happens. Maternal tissue should be checked for injury and a per rectal examination is important to exclude anal sphincter injury. Accurate documentation of the procedure and timing of events is mandatory from the clinical risk management of view. The woman should be debriefed after the procedure. (b) The presence of 3rd degree tear is a major risk factor for the development of faecal incontinence later. Therefore early identification and proper repair is of at most importance. A full explanation to the woman about the extent of the injury with all the possible consequences of faecal incontinence and fistula formation and the importance of proper repair should be made. A written concent should be taken. The repair should be done in theatre, under a regional anaesthesia preferably, good lighting and assistance. The operator should be experienced in repairing such injury by attending the appropriate courses, other wise a senior help should be sought. The extent of the sphincter damage and and relevant classification should be made clear and documented. In respect to the method of repair, although overlap technique has been advocated as associated with better outcome, but there is inconclusive evidence about it?s superiority. I would choose the overlap technique in type 3c where the whole sphincter is torn, but the end to end in less severe injury. A delayed absorbable sutures like 000 PDS should be used for the sphincter while vicryl rapid 00 for the rest of the repair. Intra and post operative broad spectrum antibiotics should be given to minimise risk of infection, and possible wound breakdown. Stool softner with bulking agent (lactulose + fybogel) for 10 ? 14 days should be prescribed. Assessment of risk of thromboembolism with appropriate prophylaxis is important. Incident form should be completed. A follow up 6 weeks postnatal appointment in hospital should be made, and referral to colorectal surgeon should be considered if there is any problem.