The smart way to learn. The smart way to teach.
Find a course ...
BusySpR MRCOG PART II
MRCOG Part 2, MRCOG II

We have 2200 SBA, 1500 EMQs; 1200 based on 2015 - 2019 recalls. Fees: £49 =1 month, £59 =2 months, £69 = 3 months, £95 =4 months, £105 =5 months, £115 =6 months, £135 =9 months £155 =12 months.

(1) Register. (2) Log-in  (3) Click 'Join this Course' to get 1 day FREE TRIAL.

MRCOG 2 Past Questions Tutorial: GROUP 3: Sat 16/11 from 10:00 - Statistics. Sun 17/11 from 10:00 - Oncology 1. Group 2: Sat 16/11 from 19:00 - Contraception & STI. See DISCUSSIONS below for details.

 

 

roblox hack

Course PAID
notes317
EMQ1583
Best of 52247
 
 
 
Rate   
Do you realy want to delete this discussion?
Forum >> Essay 260 - Twin pregnancy
Essay 260 - Twin pregnancy Posted by PAUL A.
Tue Feb 5, 2008 10:57 pm
A healthy 20 year old primigravida with a dichorionic diamniotic twin pregnancy presents in spontaneous labour at 37 weeks gestation. Twin 1 is cephalic and twin 2 is transverse. (a) Justify your management of the first stage of labour [5 marks]. (b) She remains undelivered 3 hours after full dilatation with a direct occipito-anterior position 2cm below the ischial spines Evaluate the options to effect safe delivery of the first twin [6 marks]. (c) she experiences heavy blood loss from the uterus following normal delivery of both twins. Justify your initial management [9 marks].
Posted by S M.
Wed Feb 6, 2008 01:16 am
A healthy 20 year old primigravida with a dichorionic diamniotic twin pregnancy presents in spontaneous labour at 37 weeks gestation. Twin 1 is cephalic and twin 2 is transverse. (a) Justify your management of the first stage of labour [5 marks]. (b) She remains undelivered 3 hours after full dilatation with a direct occipito-anterior position 2cm below the ischial spines Evaluate the options to effect safe delivery of the first twin [6 marks]. (c) she experiences heavy blood loss from the uterus following normal delivery of both twins. Justify your initial management [9 marks].

a) A senior obstetrician and senior midwife should be involved in the management because this is a high risk pregnancy with an increased risk of maternal and fetal morbidity and mortality. There is a risk that complications may occur such as antepartum haemorrhage, fetal distress or postpartum haemorrhage and therefore intravenous access should be secured and bloods taken for full blood count, group and save. Continuous electronic fetal monitoring should be done since this will allow for early identification of fetal distress. Blood pressure should be monitored regularly because of the increased risk of pre eclampsia. Abdominal palpation should be done for frequency and strength of contractions. Vaginal examination should be done for cervical dilatation, position and descent of head. These findings should be plotted on the partogram to assess progress of labour. Vaginal examination should be perfomed every 4 hours to detect poor progress. If there is slow progress, to augment labour artificial rupture of memebranes should be done. If no progress after 2 hours, then syntocinon infusion should be commenced. In order to make the woman as comfortable as possible and reduce stress, analgesia should be offered in the form of inhalation anaesthesia with entonox, systemic opioids or epidural.

b) Delivery may have been delayed because of poor contractions. ARM and syntocinon should be started to improve the contractions. The mode of delivery is dependent on maternal and fetal wellbeing. If both are well, the first option is to give clear instructions or directions for her to give effective pushes. This is good because if successful it avoids intervention and the risks of operative delivery. The second option is an instrumental delivery with ventouse or forceps since the head is below the spines and in the occipito anterior position. This is beneficial because after 3 hours of full dilatation there is a risk of fetal distress. Also, the mother will be very tired. With the ventouse there is less maternal injury and less analgesia may be required. With the forceps, it can be succesful even if the mother is exhausted and can\'t push effectively. Also, it can lead to a faster delivery than ventouse in fetal distress. The final option is caesarean section and this is appropriate if there is a suspicious CTG. It allows for a fast but safe delivery.

c) This is an obstetric emergency and the first step in the management is to call for help from a senior obstetrician, anaesthesist, midwives and to alert the theatre team. The airway should be confirmed to be open and oxygen given 5 litres/ minute by face mask. There is a risk of hypovolaemia, shock and death and therefore two large bore cannulae should be sited and blood taken for full blood count, crossmatching of 6 units of blood. Intravenous fluids in the form of colloids should be started immediately to maintain the circulation. Blood pressure and pulse should be measured to assess the haemodynamic status. There is great chance of uterine atony in twin pregnancies, so uterine massage should be done to make the uterus contract. A syntocinon infusion of 40IU of syntocinon in 500mls of normal saline should be started to help contract the uterus and reduce the bleeding. If still in situ, the placenta should be expelled and confirmed complete. Further uterontonic agents should be given such as haemabate, misoprostol and ergometrine. Ergometrine should not be given if she is hypertensive. A vaginal examination should be done to identofy cerviacl or perineal tears that may have caused the bleeding and need to be sutured. A foley\'s catheter should be inserted into the bladder and the fluid input and output monitored closely.
Posted by Sarwat F.
Wed Feb 6, 2008 02:56 am
Twin pregnancy is a high risk pregnancy. Most senior obstetrician on duty should be present to manage her labour and delivery. Hospital protocol regardng management of twin pregnancy should be followed. As she has presented in spontaneous labour she should be admitted to delivery suite and history and examination is done. She will be asked about onset of contractions, frequency, any history of leaking and show. If she gives history of leaking then duration of ruptured membranes and colour of liqour is asked. Examination to check her blood pressure, pulse temprature is done. abdominal examination is done to confirm the lie and presentation of twins and if needed confirmed by scan. vaginal examination is done to check dilatation, length, position, consistency of cervix, station of presenting part and colour of liqour. Continuous ctg will be done as twin pregnancy is a high risk pregnancy. Partogram will be maintained to assess progress. She will be reexamined in four hours unless vertx is visible or any changes in CTG prompt examination. A progress of atleast 2 cm in four hours is expected. In case of slow progress patient will be reexamined to check the position of leading twin and in case of incordinate uterine contractions oxytocin infusion can be considered depending on hospital protocol after discussion with on call consultant.
In case she is undelivered 3 hours after full dilatation of cervix, options for safe delivery of first twin include encouraging her to push as delivery should be completed in four hours after full dilatation. In case she is exhausted instrumental delivery with ventouse cup or forceps can be considered. as this is a twin pregnancy it may be appropriate to conduct the delivery in theatre according to protocol of hospital. preparations for caesarean section like IV access, full blood picture, group and save and anaesthetist should be present. a scanner should be available in case it is needed for second twin.
Twin pregnancy is associated with a high risk for postpartum haemorrhage. initial management will include checking airway, breathing and circulation. If patient is awake and breating normally then two wide bore intravenous access will be maintained with 16 guage cannula and blood taken for full blood picture, group and crossmatch 4 units and coagulation studies. Massive obstetric haemorrahge bleep will be put out to notify anaesthetist, on call consultant, haematologist, porters and blood bank. patients blood pressure, pulse, resp. rate and oxygen saturation is monitored. pressure infusion will be started with colloids and crystalloids. O negative blood can be given intill crossmached blood arrives. Cause of PPh will be checked by examining the abdomen for relaxed uterus and vaginal examination for any vaginal or cervical tears. syntocinon infusion will be given and ergometrine and PGF2 alpha given in case uterus is relaxed. patient may need to go to theatre for laparotomy in case of intractable uterine atony for arterial ligation or as a last resort and life saving procedure hysterectomy. An incident report form will be filled. patient will be explained at each step of management and appointment made postnatally for debriefing.
Posted by S M.
Wed Feb 6, 2008 03:28 am
Twin pregnancy is a high risk pregnancy. The lady should receive multidisciplinary care involving senior midwife, senior obstetrician and anaesthetist. She should be seen by a senior obstetrician in early labour, rescanned to determine lie and mode of delivery, if not discussed earlier, should be discussed. She should be reassured that most of vaginal twin deliveries where the first twin is cephalic are uneventful however at times if the second twin does not become cephalic on its own, external cephalic version, internal podalic version or crash caesarean may be needed. She should be reviewed by the anaesthetist and offered epidural anasthesia if she opts for vaginal delivery as external cephalic version or internal podalic version might be needed for second twin. An IV line should be inserted and bloods should be taken for full blood count and group and save as there is a risk of PPH. The labour ward protocol for management of twins in labour should be followed. Continuous electronic fetal monitoring should be performed to ensure fetal wellbeing and fetal scalp electrode should be inserted if there is difficulty in differentiating between the twins. Progress in labour should be monitored carefully and synto started if there is slow progress. Patient should be transferred to theatre when she is fully dilated.

If the contractions have disappeared , a trickle of synto can be given for a short duration. However if contractions are appropriate, the options of delivery of the first twin are trial of instrument in theatre Vs emergency caesarean section. With the head OA and at +2 station the former seems to be a safer option if the baby is not too big and the pelvis is adequate and no head is palpable abdominally. Emergency caesarean at second stage can be challenging with difficulties in delivering the head. Neonatologists should be present during delivery.

PPH is an obstetric emergency and the patient can loose a lot of blood in minutes. Therefore the first thing to do is to call for help including senior obstetrician, sho, anaesthetist and midwife so that there are enough people to take care of the various aspects of resuscitation and management. Airway, breathing and circulation needs to be assessed while somebody tries to rub up a contraction as the most common cause of PPH is atony. 2 wide bore iv lines should be inserted to resuscitate the patient and bloods should be taken for FBC, G&S , cross match and clotting. Syntocinon bolus followed by synto infusion (40 units in 500mls of Normal Saline) should be started to help uterus contract. If that doesn?t help, ergometrine (1 amp im), hemabate 250 microgram every 15 minutes until a maximum of 8 doses) and misoprostol 800-1000 microgram PR should be given. Placenta should be checked to ensure its complete. Vaginal and cervix should be assesses for tears. Consultant should be called in if none of these help.
Posted by Shankaralingaia N.
Wed Feb 6, 2008 04:26 am
a)Initially I would review the notes and understand the management plan.We would put a venflon in,take bloods for FBC and group and save.Discuss about adequate pain relief and probably having an epidural would help in manouvering of the second twin in the second stage.Continous fetal monitoring is important as she is high risk.Assess the contractions and progress and start syntocinon infusion if needed.Start the partogram.
Set up two delivery packs and trollies,40 units of syntocinon for 3rd stage and ultrasound scan in the close proximity to determine the lie of the second twin after delivery of the first twin.
Inform counsultant and anaesthetist.

b)Options of delivery are based on the fetal condition,contractions,descent on pushing,caput,moulding,the duration of pushing and maternal choice.
If no fetal distress and good descent on pushing then we could encouage her to push,evaluating episiotomy.
If mother is exhausted or if for fetal distress then instrumental delivery in the form of ventouse or forceps is used after empting the bladder.Ventouse is used if the absence of caput so there is less failure.This is associated with less maternal trauma.It can cause cephalohaematoma and neonatal jaundice.
Neville barns forceps is used to delivery with episiotomy in case of caput after performing an episiotomy to reduce maternal trauma.There is risk of fetal and maternal injury,neonatal jaundice associated with it.

c)Call for help and ask SHO or anesthetist to put another grey venflon.Start some collids for fluid replacement.Check her vital signs like BP,Pulse and oxygen saturation.Start 40 units of syntocinon infusion straight away.Check her vitals every 5 minutes.
Assess the uterus for atony and if so give another dose of syntometrine.Uterine massage and bimanual compression will help in contralling the bleeding.If continued to bleed put a indwelling urinary catheter.
Do a vaginal examination and check for any tear and any other bleeding point and suture the tear/episiotmy quickly to control the bleeding.Check the placenta if it is complete if not she needs manual removal in theatre.Check her clotting profile and assess by checking if the blood is clotting.
If bleeding does not settle then inform the consultant and organise to take her to theatre,during the interim give her a dose of haemobate.
Debrief the mother and partner and document in the notes.
Posted by Srivas  P.
Wed Feb 6, 2008 10:31 am
(a) Management should be multidisciplinary with senior obstetrician, pediatrician, anesthetist and senior midwife. Local guidelines and protocol for twin deliveries should be followed.

She should be encouraged to labor in lat position to avoid compression on major vessels. I/V line should be started to administer oxytocin to augment labor or manage any PPH after delivery. Blood should be taken for grouping, CM and serum should be saved. Epidural anesthesia is indicated for pain relief; it minimizes push before full dilatation of cervix and allows quick application of manouvres like internal podalic version, doing operative deliveries or a C.Section. She should have continuous electronic fetal monitoring of both fetuses. She may need labor augmentation with oxytocin which should be given very carefully. If she has spontaneous rupture of membranes pelvic examination should be done to rule out cord prolapse. After ROM, first twin can then be better monitored with scalp electrode.

(b) Options depend on cause of the delay, maternal exhaustion, nature of uterine contractions, presence Fetal distress in both fetuses, and possibility of CPD.

If no CPD, FHR is normal but contractions are ineffective, I would do ARM if membranes are present and augment contractions with syntocinon and anticipate normal delivery of first twin, avoiding operative delivery. If she is exhausted and not pushing well I would prefer forceps to hasten delivery and I would conduct this in operation theatre as the second is in transverse lie and I would need to do ECV/IPV to effect delivery of second twin which is in transverse lie.

If FHR of first twin is suspicious with no CPD, I would consider operative delivery as the head is at +2 station and this will be quickest method and also avoid possibly traumatic second stage C.S. If FHR if second twin is suspicious I would take her for C.S even if first twin is alright as delay with delivery of first twin can further jeopardize the second twin. Marked caput or moulding suggesting CPD is an obvious case for emergency C.S which would need to be done by senior most obstetrician due to possibility of more complicated C.S.

c) Obstetric haemorrhage accounts for 28% of direct maternal deaths of which 80% show sub standard care. It is important to act fast, recruit help to manage this emergency. Team should be multidisciplinary involving senior obstetrician, midwife in charge, anesthetist, hematologist, porter and theatre staff. Insert two 14G I/V cannulae and immediately resuscitate with N-saline or haemaccel or colloids and give 100% oxygen by mask while simultaneously assessing amount of blood loss, pulse, B.P, level of conciousness and Pao2. Cross match 4-6 units blood and do coagulation profile. O negative blood can be given till crossmatched blood becomes available. With massive hemorrhage FFP, cryoprecipitate, platelets and packed cells may become necessary. So blood bank should be alerted and hematologists should be involved if needed. Insert Foley?s catheter as a full bladder can precipitate an atonic uterus and it is also useful to monitor urine output. Monitor all vitals closely.

After a normal twin delivery, an atonic PPH is the most likely cause. Bimanual massage should be done while intravenous ergometrine and oxytocin should be given. If bleeding gets controlled continue oxytocin infusion for 3-4 hrs. If bleeding does not stop, and uterus remains flaccid give carbotrast .25mg which can be repeated every 15 mins upto 8 doses. Rectal misoprostol can be given if carboprost is not available and is equally effective. If bleeding still uncontrolled examine the placenta to see if there are missing cotyledons and a bedside USG should be done to look for placental bits inside uterus as this maybe the cause of continuing bleeding. Patient should be shifted to theatre to look for any cervical trauma, uterine inversion. Uterine packing should be done and in 85% cases, this maybe effective in controlling atonic PPH non-surgically.
Posted by Anna A.
Wed Feb 6, 2008 11:20 am
a)Reexamine the abdomen to ensure that the leading twin is in cephalic presentation. Ensure intravenous access and withdraw blood for cross match as twin pregnancy is associated with higher risk of PPH (post partum haemorrhage). There is higher risk of fetal distress especially to the second twin therefore continues CTG should be ensured and fetal scalp CTG for first twin is recommended. There is higher risk of operative delivery in twin pregnancy thus adequate analgesia in the form of epidural is prudent. Adequate hydration is important for the first stage to progress well. Presence of doulas may increase the chances of vaginal delivery. Adherent to partogram is important to enable early detection of poor progress, thus augmentation with oxytocine can be initiated. Oxytocine should be used with cautious as over distention of uterus is a risk factor to develop uterine rupture. Evidence of cephalo-pelvic disproportion should be looked out for during vaginal examination.
b)Intervention to deliver the babies is indicated as this patient is having prolonged second stage. Reassessment for evidence of macrocosmic baby or evidence of cephalo-pelvic disproportion like severe molding and huge caput should be carried out. Presence of fetal distress in the second twin makes emergency caesarean section (CS) is more appropriate. Presence of senior obstetrician, neonatologist and experienced midwife are important. If instrumental delivery is anticipated, ensure the couple are inform about the reason of intervention and complications are explained. Consent should be obtained. Bladder should be emptied and adequate analgesia should be ensured. Forceps would be the best option if there is presence of caput and poor maternal effort. However, maternal wishes should be taken into consideration. Instrumental delivery should be abandoned if no evidence of decent on each pull (maximum after 3 pulls). Trial of instrumental delivery can be undertaken in Operation Theater if there is suspicion of macrosomic baby in the first twin. Detail documentation of indication, time and type of instrumental delivery is important. Perineum should be inspected and sutured.
c)Involvement of senior obstetrician, anesthetist, haematologist and experienced midwife are important aspect as this patient shows sign of PPH. Vital sign should be obtained and resuscitation should be initiated in a form of crystalloid or colloid to restore intravascular depletion if she is hypotension and tachycardic. Oxygen should be administered if she appears drowsy. Blood should be sent for full blood count, coagulation profile and cross matched. The degree of blood loss should be asses quickly and underlying caused of PPH should be determined. Evidence of uterine atony should be looked out for. Oxytocic agent should be initiated if there is evidence of uterine atony. Timely surgical intervention (B Lynch or hysterectomy) if medical treatment fails to contact the uterus are important to avoid DIVC. Possibility of genital tract trauma should be bare in mind if she had instrumental delivery. Examination under anesthesia would help the surgeon to locate and secure the bleeder. Post partum monitoring in high dependency unit should be ensured. Assistance from community midwife would help the patient to cope with her twin babies. Long term contraception advice should be ensured before discharge.
Posted by Sahathevan S.
Thu Feb 7, 2008 04:55 am
(a) Justify your management of the first stage of labour [5 marks].
Patient should be admitted under Consultant care as twin pregnancy is high risk. Patient need venous access and blood should be taken for FBC and Group and serum save as twin pregnancy is associated with increase risk of operative delivery and PPH. Continues fetal mentoring of twin required for early identification of fetal hypoxia , preferably FSE to monitor the first twin as soon as possible. Regional anaesthesia is recommended as potential risk of having ECV, internal podalic version and Emergency LSCS to deliver the second twin. Optimal mode of delivery should be discussed with the woman and she should be kept informed any potential intervention.Deliveery should be by Caesarean section if unable monitor the second twin adequately. Ultrasound scan may be helpful to locate the Fetal heart beat if any difficulty in abdomional monitoring . Vaginal delivery is accepted if first twin is cephalic though optimal mode of delivery if second twin is non cephalic is remain contravesial therefore senior obstetrican should invoved in descion making and woman?s wishes should taken into consideration.

(b) She remains undelivered 3 hours after full dilatation with a direct occipito-anterior position 2cm below the ischial spines Evaluate the options to effect safe delivery of the first twin [6 marks].
Prolonged second stage is associated with maternal morbidity, increased perineal trauma, fecal and urinary incontinence and neonatal morbidity and more rapid deveplment of hypoxia and acidosis. Delivery should be conducted in thetre, lithotomy position and receive appropriate analgesia. Both twin should be monitored continuously Options for delivery of the first twin, Ventouse, non rotaional forceps delivery and Episiotomy with active pushing.
An abdominal and VE should be carried out to assess to decide for choice of instrument or mode of delivery. Head should not be palpated on abdominal examination as vertex +2 cm on VE if not VE must be incorrect. Contraction should be palpated and oxytocin infusion may be needed. rupture of the membrane should be confirmed and colour of liquor should be noted.Presence of meconium associated with fetal hypoxia and requires delivery without delay.Moulding is associated with obstructed labour and presence of caput increases the likelihood of ventouse failing. .Choice of the instrument depend on the oprater experience.Presence of caput and poor maternal effort more likely to associate with failed ventouse therefore Neville barnes foceps should be considered. However ventouse associated with less risk of perineal trauma but increase risk of cephalhematoma, scalp laceration and retinal haemorrhages. In case if first instrument fail using of second instrument is associated with increase risk of fetal mortality and morbidity and maternal mortality.in this circumstance emergency LSCS may be considered. If the mother is actively pushing with good contractions (may be after oxytocin infusion) there is possibility of having NVD with episiotomy.

(c) she experiences heavy blood loss from the uterus following normal delivery of both twins. Justify your initial management [9 marks].
Postpartum haemorrhage is an Obstetric emergency.Obsterician , Anaesthetist and experience midwife should be called immediately for help,. Patient need assessment of airway, breathing and circulation and may need basic life support .Uterus should be rub-up for contractions to stop the bleeding as most common cause for PPH is uterine agony. Venous should be obtained and blood should be taken for FB C, blood Group and 6utits blood cross match,LFT,U&E and clotting screen.Haematogist should be discussed for urgent request of blood and blood products. IV fluids should be commencing crystalloids, colloids negative blood should be considered if any delay in cross matching bloods. Facial Oxygen. should be given Ureterotonic agents which are ergometrine IM /IV , oxytocin bolus IV , Oxytocin IV infusion 40 units in 500ml N Saline ( 125ml/hr) should be administeted to contract the uterus and stop the bleeding.Misoprostol PR , Carboprost IM can be given if haemorrhage continues. Carboprost can be repeated (maximum 8 doses -250 microgram x8) .Women and family members should be informed of events and reason for the intervention. Futher management depend on the progress with initial management and cause for PPH.
Posted by Elizabeth  V.
Thu Feb 7, 2008 04:59 am
Twin pregnancy is a high risk pregnancy and the first step when a twin pregnancy presents in labour is to confirm suitability for vaginal delivery.This can be done by checking the antenatal record for the plan for delivery which would have been derived at after a detailed discussion with the patient.Ensure there are no complications which would make vaginal delivery unsuitable,such as pre-eclampsia,DM,dischordancy,intrauterine therapy,placental location.
Explain the plan to the couple and the anticipated risk if the second twin remains transverse ,such as cord prolapse,ECV, internal podalic version,CS.
Once the mode of delivery is decided on a vaginal examination should be done to ceck for the state of the cervix.Continuos CTG monitoring is important and a CS would be indicated if the second twin cannot be adequately monitored.FSE can applied when the memranes are ruptured.Intravenous access and blood should be sent for full blood count and group and save,in view of the high risk for labour dystocia and PPH.One to one midwifery care ,partogram and early involvement of senoir obstetrician are important.Adequate pain relief and hydration are important in the management of first stage.
Options for delivery include a vaginal delivery .However 3 hrs at full dialatation is an indicator of failure of the powers ,passenger,passage.As a prerequisite to spontaneous vaginal delivery there shoud not be any evidence of fetal distress. Encourage pushing if contractions are adequate.
Assisted vaginal delivery would be an option if there is evidence of fetal distress,maternal exhaustion,Epidural analgesia etc. The choice of instrument here would depend on the skill of the obstetrician.Both instruments are associated with similar neonatal outcome although the ventouse is associated with scalp bruising and increased maternal worries.Forceps is associated with increased risk of maternal injuries.Cs would be an option in the event of fetal distress and anticipated difficulty with delivery of the baby.
Postpartum heamorrhage is an anticipated complication of twin delivery.The initial step would consist of calling for help and checking the vitals of the mother.Insert two large bore IV cannulas and take blood for full blood count, crossmatching,and coagulation screen.Start IV fluids. Feel for the fundus and the check if bladder is palpable.Deliver the placenta and check that it is complete.Ask the assistant to rub up a contraction and insert an in dwelling cathter into the bladder.Start Syntocin infusion and check for cervical ,vaginal,perineal trauma. Manage PPH with syntometrine ,misoprostol and hemabate in a step wise manner..If hemostasis is not attained involve senior help and transfer to OT after explaining and consenting the patient.In OT a deep vaginal tear may be visualised,or may have to proceed to uterine tamponade, uterine artery ligation, internal iliac artery ligation,uterine artery embolisation or a hysterectomy as the situation warrants.Blood transfusion and blood products may be necessary. Transfer the patient to HDU care and initiate clinical risk management.
Posted by Reiaz M.
Thu Feb 7, 2008 08:33 am
a) Management of this patient should include a risk assessment fot venous thromboembolism. A full blood count and group and save are done as this patieny is at risk of anemia and postpartum haemorrhage. A large bore venous access should be placed.
Multiple pregnancy is associted with an increased perinatal morbidity and mortality rate. Continuous electronic fetal monitoring of both twins is thus indicated. Twin 1 should be monitored by Fetal scalp electrode once the fetal memebreanes have ruptured.
An epidural is allowed if the patient is desirous of one. A partogram should be used to assess progress in the first stage of labour as poor progress may be an indication for cesarean section.

b) This patient has a prolonged second stage of labour.
One option is to encourage the patient to push. This may not be appropriate in cases of maternal exhaustion and in cases of suspected fetal compromise.
A low forceps can be applied. Use of a forceps is associated with a greater success rate when compared to the vauum extractor. Forceps are associated with a greater risk of maternal morbidity secondary to perineal trauma. As a result the vauum should be attempted first.
Use of the vacuum is associted with an increased risk of fetal retinal haemorrhages and cephalhaematoma. It is also associated with increased maternal worry about the baby.
There is no difference in need for phototherapy, Apgar scores or Caesarean section rates with the vacuum or forceps.
Cesarean section can be difficult with the fetal head deeply engaged as it may be associated with uterine tears extending into the cervix.
The patient should be informed of her choices and her wishes met.

c) Post partum haemorrhage is an obstetric emergency and the first step is to call for help. The senior midwife, senior obstetrician, hematologist and anesthesist should all be informed.
It is ensured that the patients airway is patent and she is breathing. Two large bore (14 or 16G) venous cannula are sited. Blood is taken for FBC to assess the haemoglobin and platelet count. Blood is sent for cross match and a coagulation screen is done as she is at risk of disseminated intravascular coagulation.
The uterus is examined. Twin pregnancy may predispose to uterine atony. If the uterus is atonic it is massaged to help it contract. A syntocinon infusion is commenced to help keep the uterus contracted. Misoprostol administered rectally can also be used. This has the advantage of being cheap, easily stored and easily administered.
The cervix and perineum are examined for lacerations which may be causing the bleeding. If present these are repaired. Inspection of the placenta and memebranes should be done as retained products of conception can result in PPH necessitating removal. The patients pulse and BP should be continuously monitored. Packed cell may need to be transfused. The p[atient should be monitored for development of DIC.
If bleeding persists, uterine artery embolisation, B Lych suture or even hysterectomy may need to be done.
An incident form is completed.

c) Post partum
Posted by Sahaja G.
Thu Feb 7, 2008 03:35 pm
I will take brief history and check notes to rule any antenatal risk factors, plan documented for delivery and growth monitoring if both twins. I will secure IV line and take bloods for FBC, group & save , as she may require interventions to deliver 2nd twin. I will the check presentation of 1st twin by per abdominal examination and confirm with scan. Continuous fetal monitoring by CTG is essential to ensure fetal well being and rule out any episodes of fetal distress. I will then perform VE to check cervical dilatation,position and station of 1st twin and record on partogram . Progress should be monitored with partogram. I will ensure that she had adequate analgesia and advice for epidural once she is in active labour as this will provide pain relief if she requires any manuevres like External cephalic version or internal podalic version to deliver 2nd twin.
I will review her partogram to check for progress in first stage,CTG for fetal well being.If the frequency and strength of her contractions are not adequate I will start her on oxytocin infusion if there are no signs of fetal distress and review her in 30min for further management. If she is actively pushing and as twin 1 is direct OA at +2 I will consider trial of instrumental delivery in theatre. Although it is safer to perform instrumental delivery,forceps or ventouse ,on 1st twin, she may need interventions to stabilise lie of 2nd twin by external cephalic or internal podalic version hence delivery in theatre is more appropriate.I will inform consultant on call and ensure that paediatrician present at delivery.
Postpartum hemorhage is an obstetric emergency , so I will call for help- senior midwife, anaesthetist,senior or junior colleagues,inform consultant on call, haematologist,porters and ODPs. After ensuring that airway and breathing are patent She needs o2 inhalation , 2nd large bore IV line and bloods for clotting studies,cross match 4-6units and start IV fluids preferably colloids.I will give her 2nd dose of syntometrine after ensuring no history of hypertension of PET and oxytocin infusion at 10units /hr.I will then do bimanual compression and ask a midwife to check if placenta is complete. If the uterus is contracted I will check perineum and cervix for any tears.If the uterus is not well contracted then I will give IV ergometrine,250microgms of hemobate deep IM or inramyometrial.hemobate can continued for further 3 doses at 15 min interval but I will consider transfer to theatre for EUA and further management. I will request the presence of consultanton call for EUA.
Posted by hoping ..
Thu Feb 7, 2008 03:37 pm
This is high risk pregnancy and should receive Obstetrician led care.She should receive one to one midwifery care in labour. Patient should be offered adequate analgesia, preferably epidural to aid manipulation of second twin.If she receives epidural then bladder should be catheterised. She should be seen by anaesthetist colleague as twin pregnancy carries high risk of operative delivery. Bloods should be checked for FBC and group and save done as there is increased risk of operative delivery and postpartum haemorrhage. She should have iv access established.Both twin heart rates should be monitored throughout labour. It is best to get fetal scalp electrode on first twin at earliest opportunity.This helps in distinguishing traces. Patients progress and efficacy of contractions should be confirmed at regular intervals. IF contractions inadequate in absence of other complications syntocinon augmentation is justified.If she has been shown to be group b strep carrier then antibiotic prophylaxis should be given.

This patient needs delivery.Maternal and wellbeing of both twins should be ascertained to determine urgency of delivery, example if second twin shows pathological CTG then performing Caesarean will enable quiker delivery for both twins and also reduce maternal morbidity after different modes of delivery. Maternal wishes should be taken into account . Maternal abdominal examination to check for engagement and cephalic palpation for fifths should be done along with vaginal assesment for presence of caput, moulding to help in decision for appropriate mode of delivery and choice of instrument. Use of epidural, duration of active pushing and progress in first stage should be checked.Bladder should be emptied . Expectant mode of delivery can be considered if delivery is imminent. Syntocinon should be used to augment contractions if contractions are inefficient and no sign of obstructed labour. Instrumental delivery with forceps or ventouse should be considered if per abdomen cephalic is less than one finger palpable, choice of instument will depend upon maternal effort, caput.If instrumental delivery is anticipated to be difficult then patient should be delivered in theatre. Other option is to do caesarean section, it carries higher risk of complications to mother and if fetus is very low in birth canal can increase fetal morbidity. Pediatrician should be present at delivery.

Her initial management efforts should be directed towards resuscitaion- airway, breathing and circulation management. help should be summoned and senior obstetric , midwifery and anaesthetic staff should be involved . Bloods should be sent for FBC, CLOTTING and crossmatch at least 4 units.Haematologist should be informed. Two large bore iv access should be in place and iv fluids given. Both Placentae should be removed if still undelivered and if delivered checked for integrity. Bimanual compression of uterus, syntocinon infusion of 50iu in 50 ml NSaline @ 10ml per hour should be given. Syntometrine 5U can be given twice. INdwelling urinary catheter should be inserted. If bleeding continues, patient should be shifted to theatre (if not delivered there )and haemabate 250 u should be given. this can be repeated to maximum of four doses. During initial management someone should provide support and explanation of events to birth partner.
Posted by Farina A.
Thu Feb 7, 2008 10:22 pm
Cephalic twin one is an indication to deliver the twins vaginaly. Twin pregnancy is regarded as high risk pregnancy so careful first stage monitoring is essential. As she is at risk of PPH, two IV lines with wide bore canulae are maintained. Blood is grouped and cross matched and a request for Hb should be sent. Her antenatal record is reviewed to search for a complication of twin pregnancy like PIH, placenta previa, polyhydraminious, congenital anomalies and discordant growth. Continuous electronic fetal heart rate monitoring is recommended for both the twins simultaneously during labour. Progress of labour should be monitored vigilantly. Labour can be augmented with ARM and judicious use of syntocinon if required. Early resort to CS is advised in case of failure to progress and suspicious CTG. Epidural analgesia can be administered.

Direct OP position is one of the commonest malposition encountered. About 6% of which can deliver face to pubes with strong uterine contraction. Provided the baby is not macrosomic, efficient uterine contraction can be established with judicious use of syntocinon. If efficient uterine contractions are already there manual rotation of head can be tried. If it fails rotational vacuum extractor is used with OP cup. Ventouse is associated with increase incidence of fetal cephalhematoma and retinal haemorrhage, but has an advantage of less maternal trauma. Forceps delivery is another option with less failure rate and minimal trauma to the baby at the expense of grater incidence of maternal trauma. However expert hand minimizes the risk of maternal trauma. Second stage CS is the last option with the advantage of minimal trauma to the baby but with the risk of uterine incision extension and per operative haemorrhage. Presence of a senior obstetrician is vital before the delivery, whatever the mode of delivery is.

Ensure two wide bore IV access, maintain airways with oxygen, collect blood for grouping and cross matching, atleast 5 units of blood and fresh frozen plasma are asked for. Call for senior help. Presence of a senior midwife is essential, monitor vital signs maintaining a CVP line, catherize the patient to monitor the input and output. Volume replacement with crystalloids and colloids is vital until blood is available. Close collaboration with anesthetist and haematologist is essential. Meanwhile detect the cause of PPH. If there is uterine atony, which is most likely after a twin delivery, uterine massage, IV syntocinon 40 units in 500 cc drip and 5 units direct IV plus IV methergine are given. Resistant cases can be treated by PGF 2 alpha, misoprostol per vaginal or per rectum and hemabat. Examine the lower genital tract for any injury and quick repair under anesthesia if required. Ruptured uterus is rare in primigravidas however should be looked for. Laprotomy is the last resort with consent for total or sub-total hysterectomy. However per operatively uterine conservation is a priority with β-lynch suture or internal artery ligation. Life saving hysterectomy is the last resort.
Posted by Azza S.
Thu Feb 7, 2008 10:40 pm
An I.V. line should be secured and blood sample collected for full blood count and group& cross-match. Her vital signs, and the examination finding should be blotted in the partogram as it is proved to reduce the risk of operative delivery. Continuous support is of proven value in labour. Continuous monitoring of both twins [CTG] as the second twin is at high risk, when it is possible the first twin should be monitor by scalp electrode. Epidural anaesthesia -if no contraindication- should be advised as there is increased risk of operative delivery especially for the second twin so the anaesthetist should be informed. A senior obstetrician input is required especially in the second stage of labour. The progress of labour and the traces of both twins CTG as well as maternal wellbeing should be noticed. Her risk of VTE should be calculated on admission to the labour room.
Second stage of labour in primigravidae in the presence of epidural analgesia often reach 3 hours. In the presence of normal CTG the woman should encourage to push. Another option is to advise instrumental delivery. Ventouse is associated with less maternal perineal injuries compared to the low cavity Forceps but more failure and more minor trauma to the neonate. Caesarean section is an option but emergency procedure with fetal position at +2 it carry more risk, however it may be needed for the second twin in case of persistent transverse lie.
I should call for help . Crystalloid as normal saline should be started while waiting for the blood and another large IV canula should be inserted. The patient should be examined . Pulse, blood pressure level of consciousness, fundal level consistency of the uterus, retained placentae or injuries to genital tract. With twins pregnancy post partum haemorrhage should be anticipated. The commonest cause is usually a hypotonic uterus. Administration of oxitoxic as- Ergometrine or synticinon- drugs and manual compression is effective in most of the cases. Carboprost 250 micrograms intra-muscular may be needed. Blood should be started. In case of failure to stop the bleeding or if the bleeding exist while the uterus is well contracting, an exploration in theater with possible intervention should be advise.
t
Posted by Idris O.
Thu Feb 7, 2008 11:51 pm
a)I would ask her the duration of labour pains and if had rupture of membranes the colour of the liquor if blood stained or meconium to determine additional risk factors . I would review her antenatal note and the growth scan of the fetus to see no growth discordancy in the twins.
I would examine her to assess fetal wellbeing with CTG and vaginal examination to determine cervical dilatation, presentation and position and confirm labour. If there is fetal distress in first stage of labour, this would be an indication for c-section except she?s fully dilated.
I would explain the findings to her and that there might be need for manipulation of the second twin if the lie is not longitudinal after the delivery of twin 1.
I would inform her the preparation for this delivery include, siting an intravenous line because may require syntocinon for the delivery of twin 2 if develop uterine inertia and to prevent bleeding after delivery. I would obtain her blood for FBC, to check for anaemia and her platelet count because of risk of bleeding. I would send her blood for grouping and save. I would discuss pain relief in labour with her. She would be seen by the anaesthetist early in labour. I would commence fetal monitoring if no contraindication to vaginal delivery with scalp electrode for twin 1 and abdominal transducer for twin 2. My senior colleague would be aware about this impending delivery.

b)The safest option would be a delivery conducted in theatre due to increased risk of caesarean section for twin 2 if malpresentation persists. I would review her pain relief in labour as epidural is associated with prolongation of second stage. If there is no fetal distress and she has not being pushing for up to 90minutes she can anticipate spontaneous vaginal delivery. This is very save and associated with good outcome to the fetus. As she?s being fully dilated for 3h, there is more likely to be maternal exhaustion and instrumental vaginal delivery with ventouse offers good chance of safety to the baby. There is risk of cephalhaematoma and NNJ developing in the baby. There is also increased maternal worries about the baby after delivery.
Forceps delivery provide more quicker delivery if there is fetal distress . It is however associated with increased risk of perinaeal tears and bleeding. C-section would be inappropriate at this stage as increases risk of injury to the first twin. There is increased risk of bleeding and lateral extension of caesarean incision.
c)This is more likely to be due to uterine atony with increased risk of DIC from massive PPH.
Initial management would be calling for help from the consultant obstetrician and anaesthetist and the midwife. I would ensure the airway is patent. I would ask the midwife to examine that the placenta is complete. I would check she?s breathing and the anaesthetist would administer oxygen by face mask . I would check FBC, and clotting factors to determine the degree of anaemia and the need for FFP. I would maintain her circulation with crystalloids and transfuse FFP early. I would rub off uterine contractions. I would administer ergometrine intravenously. I would continue with syntocinon infusion. If bleeding continues, I would administer carboprost intamyometrially 250mcg and this would be repeated every 15minutes up to maximum of 8doses. I would give misoprostol 800mcg PR. If bleeding still continues will replace with packed cells and FFP. If bleeding still continues she would need to be transferred to theatre for insertion of Bakri balloon to tamponade bleeding from the placenta bed. The last option to would be laparotomy and compression test and if positive may benefit from B-Lynch suture or she may require hysterectomy. Her partner would be debriefed during all this treatment.

Posted by Hala T.
Fri Feb 8, 2008 12:30 am
a)Multidisciplinary team such as senior mid-wife, anaesthetist , neonatologist and hematologist should be involved in the management as it is high-risk pregnancy. Local agreed protocol and guidelines should be followed.
The maternal vital signs including BP should be measured and monitored for risk of pre-eclampsia . Abdominal examination then vaginal examination is performed for cervical dilatation ,effacement and descent of fetal head of the first twin. Using a partogram improves the maternal and fetal outcome .
Venous access should be in place ,and blood for FBC , group and cross-match for saving blood for any suspected complications ; such as fetal distress and PPH . Continuous electronic fetal monitoring , and FSE should be used for first twin( if membrane is already ruptured. )
Hydration should be maintained through IV fluids. Analgesia should be initiated through regional anaesthesia which has value in operative delivery and also, provides higher rates of maternal satisfaction. The progress of labour should be monitored through assessment of uterine contractions , their frequency , strength ,cervical dilatation and descent of presenting part. Augmentation should be initiated via oxytocin I V infusion according to unit protocol if there is slow progress. The patient should be transferred to the operating theatre if the cervix is fully dilated. The patient should be provided written information and twin support group .
b) She should be encouraged to have continuous support during childbirth in presence of partner , ratherthan , starting oxytocin with epidural will decrease the need for operative vaginal delivery. Pushing should be delayed until she has a strong urge to push. This option enables the avoiding of operative vaginal delivery which can be associated with maternal and neonatal morbidity.
Operative vaginal delivery is an another option, especially indicated for maternal fatigue,
exhaustion or presumed fetal compromise . The mother should give informed consent after explanation to her the need of intervention including possibility of episiotomy. Maternal bladder must be empty, and indwelling catheter should be removed . Vacum extractor is associated with less maternal laceration and less analgesia requirement , but an increased risk of neonatal cephalhematoma and retinal haemorrhages. The non-rotational forceps is preferable if she is exhausted and unlikely to be pushing properly. It also,expedites the delivery in the presence of fetal distress , but may be associated with maternal perineal injury ,pain and fetal scalp or facial injury.
Failure of operative vaginal delivery or presence of fetal distress , caesarean section should be undertaken as a last option. Senior neonatologist should be available at operating theatre.
c) I have to call for help from senior anaesthetist , senior obstetrician , haematologist, mid-wifery staff and theatre team . The general status of the patient should be assessed , pulse, BP, and facial oxygen is given and CPR is commenced if required.
Venous access at least two wide bore cannulae should be secured. Blood should be sent for FBC,
LFT ,U&E, Clotting study ,Group and Cross-match 6 units of blood .The need of blood products and their urgency should be discussed with the haematologist.
IV Fluids , crystalloid , colloid , or O Rh negative blood should be given. Blood transfusion and any objections that woman have should be discussed with haematologist.
Uterine atony is the most likely common cause , so , uterine tone must be assessed and rub-up a contraction to stop bleeding. If placentae should be expelled and any RPOC to be removed.
Uterotonic agents should be administered. Oxytocin 40 IU in 500 ml over 4h infusion., ergometrine ,carboprost 25 mg IM or intramometrial maximum 2 doses. Vaginal or rectal prostaglandins. Bimanual compression is life-saving but painful. Uterine inversion , uterine rupture can not be excluded except after laparotomy. Laparotomy with internal iliac artery ligation , uterine compression with B-lynch brace sutures or hysterectomy is the ultimate intervention. Blood results should be obtained for coagulopathy to treated with haematologist. Complication of massive blood loss or transfusion including thrombocytopenia, hypocalcaemia, hyperkalaemia should be detected . Platelet ,FFP should be administered. Monitoring of pulse,BP,SpO2 every 15 min and urine output hourly for 24 hrs. Detailed documentation and incident form should be filled.
The patient should be reassured and her family kept informed at all stages.

Posted by Lekshmi B.
Fri Feb 8, 2008 12:52 pm
1) Assessment of general condition of the patient will be done including temperature, pulse rate and Blood pressure .Abdominal examination will be done to assess the presentation of the 1st baby and the descent of head .This will be followed by vaginal examination .This will confirm the presentation, and give information about the nature of cervix, favourability and the station of presenting part. Major abnormalities of the pelvis precluding vaginal delivery can be noted. She will be advised to remain nil per orally and I/V fluids started keeping in mind the increased risk of caesarean section and anaesthesia requirement. Blood will be sent for complete blood count and grouping typing and save serum also due to the same reasons.Continuous CTG monitoring of the fetus will be done since it is a high risk pregnancy. The neonatologist, Theatre staff and anaesthetist will be informed of this patient admitted in labour.

2) Vaginal examination will be repeated to look for large caput or major degree molding suggestive of cephalo pelvic disproportion (CPD) and if present caesarean delivery will be decided. If facilities are available intra partum USS will be done to assess the presentation of second twin now and if found to be breech the possibility of inter locking will be looked for. Any suspicion will be an indication for caesarean section, provided the fetal hearts are reassuring. If contractions are found to be inadequate oxytocin augmentation will be done and dehydration corrected if any. After explaining the situation to the woman informed consent for operative delivery will be obtained. Vacuum extraction of the fetus will be done after emptying bladder and providing adequate analgesia. This is associated with reduced risk of maternal genital tract trauma compared to forceps delivery , but increased risk of neonatal morbidity like cephalhematoma and retinal haemorrhage.The other alternative is low forceps delivery which will be attempted under supervision. If no progressive descent with each pull or if no signs of imminent delivery after 3 pulls of properly placed instrument caesarean delivery will be decided.

C) Resuscitation of the patient will be given top priority. This includes rapid infusion of crystalloid or colloid solutions based on the degree of estimated blood loss. Full blood count will be repeated and instructions for crossmatching of blood given. If the uterus is found to be relaxed massaging will be done to promote uterine contraction. Urinary bladder will be cathetrised as residual urine is found to interfere with uterine contractions. Bimanual compression of uterus will be attempted which will cause stretching of uterine arteries leading to reduced blood flow. Meanwhile senior obstetrician, midwife and more experienced staff will be called for help.Oxytocin bolus 10 units I/M or I/V will be given Along with that an oxytocin infusion containing 40 units in 500 ml crystalloid will be started. This will promote uterine contraction in majority of cases of atonic uterus. If not, injection ergometrine will be given I/M provided her blood pressure is normal and in the absence of a history of PIH.Intra muscular injection of Prostaglandin F 2 alpha will be given in a dose of 250 micro gram if the bleeding persists. History of bronchial asthma has to be ruled out prior to this. Per rectal administration of 4- 5 tablets of PG E1 is also seen to promote uterine contraction. If uterus is found to be contracted well and bleeding persisting, proper examination under adequate lighting and analgesia will be done to rule out genital tract trauma. Any local injury noted will be sutured. I f any suspicion of retained bits of placenta gentle curetting will be attempted to remove them. In case of falling blood pressure and Tachycardia blood will be transfused and if not responding to the medical measures immediate laparotomy will be decided after informing consultant and senior anaesthetist.
Posted by PAUL A.
Fri Feb 8, 2008 11:59 pm
a) A senior obstetrician and senior midwife should be involved in the management because this is a high risk pregnancy labour with an increased risk of maternal and fetal morbidity and mortality. There is a risk that complications may occur such as antepartum haemorrhage, fetal distress or postpartum haemorrhage and therefore intravenous access should be secured and bloods taken for full blood count, group and save (1) . Continuous electronic fetal monitoring (1) should be done since this will allow for early identification of fetal distress. Blood pressure should be monitored regularly because of the increased risk of pre eclampsia. Abdominal palpation should be done for frequency and strength of contractions. Vaginal examination should be done how often? for cervical dilatation, position and descent of head. These findings should be plotted on the partogram to assess progress of labour. Vaginal examination should be perfomed every 4 hours to detect poor progress. If there is slow progress, to augment labour artificial rupture of memebranes should be done. If no progress after 2 hours, then syntocinon infusion should be commenced (1) . In order to make the woman as comfortable as possible and reduce stress, analgesia should be offered in the form of inhalation anaesthesia with entonox ? anaesthetic?? , systemic opioids or epidural would any of these be more appropriate? .

b) Delivery may have been delayed because of poor contractions. ARM and syntocinon should be started to improve the contractions would this be appropriate 3h after full dilatation? . The mode of delivery is dependent on maternal and fetal wellbeing presence of regional analgesia, maternal wishes . If both are well, the first option is to give clear instructions or directions for her to give effective pushes this would be pointless if she has been pushing well with no progress . This is good because if successful it avoids intervention and the risks of operative delivery. The second option is an instrumental delivery with ventouse or forceps since the head is below the spines and in the occipito anterior position. This is beneficial because after 3 hours of full dilatation there is a risk of fetal distress. Also, the mother will be very tired. With the ventouse there is less maternal injury and less analgesia may be required (1) . With the forceps, it can be succesful even if the mother is exhausted and can\'t push effectively will the ventouse not be effective if the woman is exhausted? . Also, it can lead to a faster delivery than ventouse in fetal distress. The final option is caesarean section and this is appropriate if there is a suspicious CTG NO ? A SUSPICIOUS CTG is not an indication for delivery and certainly not an indication for C/S with a direct OA position at +2 (-1) . It allows for a fast can you deliver this baby faster by C/S compared to forceps? but safe delivery you are likely to undertake a difficult delivery with extensions at the uterine angles + difficulties delivering the head. How could this be safe??? (-1) .

c) This is an obstetric emergency and the first step in the management is to call for help from a senior obstetrician, anaesthesist, midwives (1) and to alert the theatre team. The airway should be confirmed to be open and oxygen given 5 litres/ minute by face mask. There is a risk of hypovolaemia, shock and death and therefore two large bore cannulae should be sited and blood taken for full blood count, crossmatching of 6 units of blood (1) . Intravenous fluids in the form of colloids should be started immediately to maintain the circulation ? O Rh neg blood . Blood pressure and pulse should be measured to assess the haemodynamic status. There is great chance of uterine atony in twin pregnancies, so uterine massage should be done to make the uterus contract ? bimanual compression . A syntocinon oxytocin infusion of 40IU of syntocinon in 500mls of normal saline given over how long? should be started to help contract the uterus and reduce the bleeding. If still in situ, the placenta should be expelled and confirmed complete. Further uterontonic agents should be given such as haemabate, misoprostol and ergometrine what will you give and in what order? You must demonstrate that you will know which of these to use . Ergometrine should not be given if she is hypertensive. A vaginal examination should be done to identofy cerviacl or perineal tears that may have caused the bleeding the question clearly states that she is bleeding from the uterus and need to be sutured. A foley\'s catheter should be inserted into the bladder and the fluid input and output monitored closely.
You have not provided sufficient detail to demonstrate that you can manage PPH from an atonic uterus successfully
Posted by PAUL A.
Sat Feb 9, 2008 12:00 am
Twin pregnancy is a high risk pregnancy. Most senior obstetrician on duty should be present to manage her labour and delivery. Hospital protocol regardng management of twin pregnancy should be followed. As she has presented in spontaneous labour she should be admitted to delivery suite and history and examination is done. She will be asked about onset of contractions, frequency, any history of leaking and show. If she gives history of leaking then duration of ruptured membranes and colour of liqour is asked. Examination to check her blood pressure, pulse temprature is done. abdominal examination is done to confirm the lie and presentation of twins and if needed confirmed by scan you are given this in the question . vaginal examination is done to check dilatation, length, position, consistency of cervix, station of presenting part and colour of liqour. Continuous ctg (1) will be done as twin pregnancy is a high risk pregnancy. Partogram will be maintained to assess progress. She will be reexamined in four hours unless vertx is visible or any changes in CTG prompt examination. A progress of atleast 2 cm in four hours is expected. In case of slow progress patient will be reexamined to check the position of leading twin and in case of incordinate uterine contractions oxytocin infusion can be considered (1) depending on hospital protocol after discussion with on call consultant.
In case she is undelivered 3 hours after full dilatation of cervix, options for safe delivery of first twin include encouraging her to push as delivery should be completed in four hours depends on maternal / fetal condition and progressive descent after full dilatation. In case she is exhausted instrumental delivery with ventouse cup or forceps which will you use and why? can be considered. as this is a twin pregnancy it may be appropriate to conduct the delivery in theatre (1) according to protocol of hospital. preparations for caesarean section like IV access, full blood picture, group and save and anaesthetist should be present. a scanner should be available in case it is needed for second twin.
Twin pregnancy is associated with a high risk for postpartum haemorrhage. initial management will include checking airway, breathing and circulation (1) . If patient is awake and breating normally then two wide bore intravenous access will be maintained with 16 guage cannula and blood taken for full blood picture, group and crossmatch 4 units and coagulation studies (1) . Massive obstetric haemorrahge bleep will be put out to notify anaesthetist, on call consultant, haematologist, porters and blood bank (1) . patients blood pressure, pulse, resp. rate and oxygen saturation is monitored. pressure infusion will be started with colloids and crystalloids why use both? . O negative blood can be given intill crossmached blood arrives. Cause of PPh will be checked by examining the abdomen for relaxed uterus and vaginal examination for any vaginal or cervical tears READ THE QUESTION ? she is bleeding from the UTERUS ? the examiner did not make a mistake . syntocinon oxytocin; ? dose / duration infusion will be given and ergometrine and PGF2 alpha which will you use first? given in case uterus is relaxed. patient may need to go to theatre for laparotomy in case of intractable uterine atony for arterial ligation or as a last resort and life saving procedure hysterectomy. An incident report form will be filled. patient will be explained at each step of management and appointment made postnatally for debriefing . you were asked about INITIAL management

Posted by PAUL A.
Sat Feb 9, 2008 12:03 am
Twin pregnancy is a high risk pregnancy. The lady should receive multidisciplinary care involving senior midwife, senior obstetrician and anaesthetist. She should be seen by a senior obstetrician in early labour, rescanned to determine lie and mode of delivery take the question at face value - twin 1 is cephalic , if not discussed earlier, should be discussed you were asked about the management of the first stage of labour and you only have 5 marks . She should be reassured that most of vaginal twin deliveries where the first twin is cephalic are uneventful however at times if the second twin does not become cephalic on its own, external cephalic version, internal podalic version or crash ? meaning caesarean may be needed. She should be reviewed by the anaesthetist and offered epidural anasthesia if she opts for vaginal delivery take the question at face value ? the examiner is asking you to manage the first stage of labour in a twin pregnancy as external cephalic version or internal podalic version might be needed for second twin. An IV line should be inserted and bloods should be taken for full blood count and group and save as there is a risk of PPH (1) . The labour ward protocol for management of twins in labour should be followed. Continuous electronic fetal monitoring (1) should be performed to ensure fetal wellbeing and fetal scalp electrode should be inserted if there is difficulty in differentiating between the twins. Progress in labour should be monitored carefully how? and synto what is this? started if there is slow progress. Patient should be transferred to theatre when she is fully dilated.

If the contractions have disappeared , a trickle of synto YOU ARE WRITING AN EXAM ? what dose is a trickle? How would the midwife know what dose to administer? (-1) can be given for a short duration 5 minutes??? . However if contractions are appropriate, the options of delivery of the first twin are trial of instrument in theatre Vs emergency caesarean section. With the head OA and at +2 station the former seems to be a safer option if the baby is not too big and the pelvis is adequate how would you make this assessment and how reliable are you? and no head is palpable abdominally. Emergency caesarean at second stage can be challenging with difficulties in delivering the head. Neonatologists should be present during delivery.

PPH is an obstetric emergency and the patient can loose a lot of blood in minutes. Therefore the first thing to do is to call for help including senior obstetrician, sho, anaesthetist and midwife (1) so that there are enough people to take care of the various aspects of resuscitation and management. Airway, breathing and circulation needs to be assessed (1) while somebody tries to rub up a contraction as the most common cause of PPH is atony (1) . 2 wide bore iv lines should be inserted to resuscitate the patient and bloods should be taken for FBC, G&S , cross match and clotting (1) . Syntocinon oxytocin bolus followed by synto ?? infusion (40 units in 500mls of Normal Saline) given over how long? should be started to help uterus contract. If that doesn?t help, ergometrine (1 amp is this a recognised dose???? im), hemabate 250 microgram every 15 minutes until a maximum of 8 doses) and misoprostol 800-1000 microgram PR should be given (1) . Placenta should be checked to ensure its complete. Vaginal and cervix should be assesses for tears. Consultant should be called in if none of these help.

This is a competitive exam. If you come across as being careless, you will lose marks
Posted by PAUL A.
Sat Feb 9, 2008 12:05 am
a)Initially I would review the notes and understand the management plan.We would put a venflon in,take bloods for FBC and group and save (1) .Discuss about adequate pain relief and probably having an epidural (1) would help in manouvering of the second twin in the second stage.Continous fetal monitoring (1) is important as she is high risk.Assess the contractions and progress and start syntocinon infusion if needed.Start the partogram.
Set up two delivery packs and trollies,40 units of syntocinon for 3rd stage and ultrasound scan in the close proximity to determine the lie of the second twin after delivery of the first twin you were asked about the first stage .
Inform counsultant and anaesthetist.

b)Options of delivery are based on the fetal condition,contractions,descent on pushing,caput,moulding,the duration of pushing and maternal choice (1) .
If no fetal distress and good descent on pushing then we could encouage her to push (1) ,evaluating episiotomy.
If mother is exhausted or if for fetal distress then instrumental delivery in the form of ventouse or forceps is used after empting the bladder.Ventouse is used if the absence of caput so there is less failure.This is associated with less maternal trauma (1) .It can cause cephalohaematoma and neonatal jaundice.
Neville barns forceps is used to delivery less likely to fail with episiotomy in case of caput after performing an episiotomy to reduce maternal trauma.There is risk of fetal and maternal injury,neonatal jaundice associated with it.

c)Call for help from who? and ask SHO or anesthetist to put another grey venflon ? any blood tests? .Start some collids for fluid replacement.Check her vital signs like BP,Pulse and oxygen saturation (1) .Start 40 units of syntocinon infusion given over what time? straight away.Check her vitals every 5 minutes.
Assess the uterus for atony and if so give another dose of syntometrine.Uterine massage and bimanual compression (1) will help in contralling the bleeding.If continued to bleed put a indwelling urinary catheter.
Do a vaginal examination and check for any tear and any other bleeding point and suture the tear/episiotmy quickly to control the bleeding read the question ? she is bleeding from the UTERUS .Check the placenta if it is complete if not she needs manual removal in theatre (1) .Check her clotting profile and assess by checking if the blood is clotting.
If bleeding does not settle then inform the consultant and organise to take her to theatre,during the interim give her a dose of haemobate.
Debrief the mother and partner and document in the notes.
If you had read the question, you would have focused your answer on the management of uterine atony

Posted by PAUL A.
Sat Feb 9, 2008 12:06 am
(a) Management should be multidisciplinary with senior obstetrician, pediatrician, anesthetist and senior midwife. Local guidelines and protocol for twin deliveries should be followed.

She should be encouraged to labor in lat position to avoid compression on major vessels. I/V line should be started to administer oxytocin to augment labor or manage any PPH after delivery. Blood should be taken for grouping, CM and serum should be saved what is CM? Cross match? Why cross match and group & save at the same time? . Epidural anesthesia is indicated it is not INDICATED for pain relief; it minimizes push before full dilatation of cervix and allows quick it may take 15 minutes to top-up an epidural application of manouvres like internal podalic version, doing operative deliveries or a C.Section. She should have continuous electronic fetal monitoring of both fetuses (1) . She may need labor augmentation with oxytocin (1) which should be given very carefully. If she has spontaneous rupture of membranes pelvic examination should be done to rule out cord prolapse. After ROM, first twin can then be better monitored with scalp electrode ? vaginal examinations to assess progress .

(b) Options depend on cause of the delay, maternal exhaustion, nature of uterine contractions, presence Fetal distress in both fetuses, and possibility of CPD how will you diagnose CPD with a station of +2? .

If no CPD, FHR is normal but contractions are ineffective, I would do ARM if membranes are present and augment contractions with syntocinon and anticipate normal delivery of first twin is it possible for her to deliver normally without oxytocin? , avoiding operative delivery. If she is exhausted and not pushing well I would prefer forceps why? to hasten delivery and I would conduct this in operation theatre (1) as the second is in transverse lie and I would need to do ECV/IPV to effect delivery of second twin which is in transverse lie.

If FHR of first twin is suspicious with no CPD, I would consider operative delivery as the head is at +2 station and this will be quickest method and also avoid possibly traumatic second stage C.S. If FHR if second twin is suspicious see NICE classification of CTGs. A suspicious CTG is NOT an indication for delivery I would take her for C.S even if first twin is alright as delay with delivery of first twin can further jeopardize the second twin you have been presented with a simple situation and you are making it very complex. The examiner wants to know how you will deliver the FIRST twin. . Marked caput or moulding suggesting CPD is an obvious case for emergency how did the head get to +2? There is no indication for C/S unless operative vaginal delivery fails, which should be very unlikely in this situation (-1) C.S which would need to be done by senior most obstetrician due to possibility of more complicated C.S.
the options are: continued pushing if mother + fetus well with good progress, forceps (give reason) or ventouse (giver reason) in theatre (give reason)
c) Obstetric haemorrhage accounts for 28% of direct maternal deaths of which 80% show sub standard care if you get any of these % wrong, you will lose marks. They are not necessary . It is important to act fast, recruit help to manage this emergency. Team should be multidisciplinary the examiner wants to know what you will do. Your style is suggestive of someone writing a textbook involving senior obstetrician, midwife in charge, anesthetist, hematologist, porter and theatre staff (1) . Insert two 14G I/V cannulae and immediately resuscitate with N-saline or haemaccel or colloids this suggests you do not know what colloids are and give 100% oxygen by mask while simultaneously assessing amount of blood loss, pulse, B.P, level of conciousness (1) and Pao2. Cross match 4-6 units blood and do coagulation profile. O negative blood can be given till crossmatched blood becomes available. With massive hemorrhage FFP, cryoprecipitate, platelets and packed cells may become necessary. So blood bank should be alerted and hematologists should be involved if needed. Insert Foley?s catheter as a full bladder can precipitate an atonic uterus and it is also useful to monitor urine output. Monitor all vitals closely.

After a normal twin delivery, an atonic PPH is the most likely cause. Bimanual massage ? bimanual compression? This is different from massage should be done while intravenous ergometrine and oxytocin should be given. If bleeding gets controlled continue oxytocin infusion for 3-4 hrs (1) . If bleeding does not stop, and uterus remains flaccid give carbotrast .25mg which can be repeated every 15 mins upto 8 doses. Rectal misoprostol can be given if carboprost is not available and is equally effective (1) . If bleeding still uncontrolled examine the placenta to see if there are missing cotyledons and a bedsidee USG what is the evidence that this is useful? should be done to look for placental bits inside uterus as this maybe the cause of continuing bleeding. Patient should be shifted use appropriate language to theatre to look for any cervical trauma, uterine inversion. Uterine packing should be done and in 85% cases, this maybe effective in controlling atonic PPH non-surgically.
Posted by PAUL A.
Sat Feb 9, 2008 12:08 am
a)Reexamine the abdomen to ensure that the leading twin is in cephalic presentation. Ensure intravenous access and withdraw blood for cross match as twin pregnancy is associated with higher risk of PPH (1) (post partum haemorrhage). There is higher risk of fetal distress especially to the second twin therefore continues CTG should be ensured and fetal scalp CTG for first twin is recommended (1) . There is higher risk of operative delivery in twin pregnancy thus adequate analgesia in the form of epidural is pruden (1) t. Adequate hydration is important for the first stage to progress well. Presence of doulas ? evidence may increase the chances of vaginal delivery. Adherent to partogram is important to enable early detection of poor progress how? , thus augmentation with oxytocine (1) can be initiated. Oxytocine should be used with cautious as over distention of uterus is a risk factor to develop uterine rupture. Evidence of cephalo-pelvic disproportion should be looked out for during vaginal examination.
b)Intervention to deliver the babies is indicated as this patient is having prolonged second stage. Reassessment for evidence of macrocosmic baby or evidence of cephalo-pelvic disproportion like severe molding and huge caput should be carried out will you diagnose CPD with the head at +2? . Presence of fetal distress in the second twin makes emergency caesarean section (CS) is more appropriate why? You will encounter a very difficult C/S with high risk of morbidity for both mother and babies . Presence of senior obstetrician, neonatologist and experienced midwife are important. If instrumental delivery is anticipated, ensure the couple are inform about the reason of intervention and complications are explained. Consent should be obtained. Bladder should be emptied and adequate analgesia should be ensured you were not asked about what you would do. You were asked to EVALUATE THE OPTONS. Your answer should take the form: these are the options and these are their value . Forceps would be the best option if there is presence of caput and poor maternal effort (1) . However, maternal wishes should be taken into consideration. Instrumental delivery should be abandoned if no evidence of decent on each pull (maximum after 3 pulls). Trial of instrumental delivery can be undertaken in Operation Theater if there is suspicion of macrosomic baby in the first twin delivery should be in theatre irrespective of fetal size, especially given that twin 2 is transverse . Detail documentation of indication, time and type of instrumental delivery is important. Perineum should be inspected and sutured the options are: expectant management, ventouse or forceps. You then need to explain the value of each of these options. .
c)Involvement of senior obstetrician, anesthetist, haematologist and experienced midwife are important aspect as this patient shows sign of PPH (1) . Vital sign should be obtained and resuscitation should be initiated in a form of crystalloid or colloid to restore intravascular depletion if she is hypotension and tachycardic will you wait until these have developed? . Oxygen should be administered if she appears drowsy. Blood should be sent for full blood count, coagulation profile and cross matched (1) . The degree of blood loss should be asses quickly carefully and underlying caused of PPH should be determined. Evidence of uterine atony should be looked out for. Oxytocic agent which drug? should be initiated if there is evidence of uterine atony. Timely surgical intervention (B Lynch or hysterectomy) if medical treatment fails to contact the uterus are important to avoid DIVC you give the impression that you will give the woman an oxytocic agent then do a laparotomy 5 minutes later . Possibility of genital tract trauma should be bare in mind if she had instrumental delivery READ THE QUESTION ? she is bleeding from the UTERUS after a NORMAL DELIVERY. Examination under anesthesia would help the surgeon to locate and secure the bleeder. Post partum monitoring in high dependency unit should be ensured. Assistance from community midwife would help the patient to cope with her twin babies. Long term contraception advice should be ensured before discharge you were not asked about this. INITIAL management of PPH ? you will not get any marks and would have wasted time which could have been spent answering another question .

Posted by PAUL A.
Sat Feb 9, 2008 12:09 am
(a) Justify your management of the first stage of labour [5 marks].
Patient should be admitted under Consultant care as twin pregnancy is high risk. Patient need venous access and blood should be taken for FBC and Group and serum save as twin pregnancy is associated with increase risk of operative delivery and PPH (1) . Continues fetal mentoring of twin required for early identification of fetal hypoxia , preferably FSE to monitor the first twin as soon as possible (1) . Regional anaesthesia is recommended as potential risk of having ECV, internal podalic version and Emergency LSCS to deliver the second twin (1) . Optimal mode of delivery should be discussed with the woman and she should be kept informed any potential intervention.Deliveery should be by Caesarean section if unable monitor the second twin adequately. Ultrasound scan may be helpful to locate the Fetal heart beat if any difficulty in abdomional monitoring . Vaginal delivery is accepted if first twin is cephalic though optimal mode of delivery if second twin is non cephalic is remain contravesial this is not controversial. The presentation of the second twin is irrelevant as it can change once the first twin is delivered therefore senior obstetrican should invoved in descion making and woman?s wishes should taken into consideration.

(b) She remains undelivered 3 hours after full dilatation with a direct occipito-anterior position 2cm below the ischial spines Evaluate the options to effect safe delivery of the first twin [6 marks].
Prolonged second stage is associated with maternal morbidity, increased perineal trauma, fecal and urinary incontinence and neonatal morbidity and more rapid deveplment of hypoxia and acidosis. Delivery should be conducted in thetre, lithotomy position and receive appropriate analgesia. Both twin should be monitored continuously Options for delivery of the first twin, Ventouse, non rotaional forceps delivery and Episiotomy with active pushing.
An abdominal and VE should be carried out to assess to decide for choice of instrument or mode of delivery. Head should not be palpated on abdominal examination as vertex +2 cm on VE if not VE must be incorrect what is the point? The question states that the station is +2 and you are suggesting that this could be wrong?? . Contraction should be palpated and oxytocin infusion may be needed. rupture of the membrane should be confirmed and colour of liquor should be noted you were not asked about what should be done ? you were asked to evaluate the options. Your answer should be: these are the options and these are their value .Presence of meconium associated with fetal hypoxia and requires delivery without delay.Moulding is associated with obstructed labour and presence of caput increases the likelihood of ventouse failing. .Choice of the instrument depend on the oprater experience.Presence of caput and poor maternal effort more likely to associate with failed ventouse therefore Neville barnes foceps should be considered. However ventouse associated with less risk of perineal trauma but increase risk of cephalhematoma, scalp laceration and retinal haemorrhages. In case if first instrument fail using of second instrument is associated with increase risk of fetal mortality and morbidity and maternal mortality.in this circumstance emergency LSCS may be considered. If the mother is actively pushing with good contractions (may be after oxytocin infusion) there is possibility of having NVD with episiotomy (1) .

options are: expectant management (value = lower risk of morbidity), ventouse (less perineal trauma and less analgesia needed), forceps (less likely to fail)
(c) she experiences heavy blood loss from the uterus following normal delivery of both twins. Justify your initial management [9 marks].
Postpartum haemorrhage is an Obstetric emergency.Obsterician , Anaesthetist and experience midwife should be called immediately for help (1) ,. Patient need assessment of airway, breathing and circulation (1) and may need basic life support .Uterus should be rub-up for contractions to stop the bleeding as most common cause for PPH is uterine agony. Venous should be obtained and blood should be taken for FB C, blood Group and 6utits blood cross match (1) ,LFT,U&E and clotting screen.Haematogist should be discussed for urgent request of blood and blood products. IV fluids should be commencing crystalloids, colloids O Rh negative blood should be considered if any delay in cross matching bloods (1) . Facial Oxygen. should be given Ureterotonic agents which are ergometrine IM /IV , oxytocin bolus IV , Oxytocin IV infusion 40 units in 500ml N Saline ( 125ml/hr) should be administeted to contract the uterus and stop the bleeding (1) .Misoprostol PR , Carboprost IM can be given if haemorrhage continues. Carboprost can be repeated (maximum 8 doses -250 microgram x8) (1) .Women and family members should be informed of events and reason for the intervention. Futher management depend on the progress with initial management and cause for PPH.

Posted by PAUL A.
Sat Feb 9, 2008 12:11 am
Twin pregnancy is a high risk pregnancy and the first step when a twin pregnancy presents in labour is to confirm suitability for vaginal delivery.This can be done by checking the antenatal record for the plan for delivery which would have been derived at after a detailed discussion with the patient.Ensure there are no complications which would make vaginal delivery unsuitable,such as pre-eclampsia,DM,dischordancy,intrauterine therapy do these make vaginal delivery inappropriate??? Do women with twins + pre-eclampsia at 37 weeks not deliver vaginally??,placental location.
Explain the plan to the couple and the anticipated risk if the second twin remains transverse ,such as cord prolapse,ECV, internal podalic version,CS.
Once the mode of delivery is decided on a vaginal examination should be done to ceck for the state of the cervix.Continuos CTG monitoring (1) is important and a CS would be indicated if the second twin cannot be adequately monitored.FSE can applied when the memranes are ruptured.Intravenous access and blood should be sent for full blood count and group and save (1) ,in view of the high risk for labour dystocia and PPH.One to one midwifery care ,partogram and early involvement of senoir obstetrician are important.Adequate pain relief what would you recommend? and hydration are important in the management of first stage.
Options for delivery include a vaginal delivery .However 3 hrs at full dialatation is an indicator of failure of the powers ,passenger,passage.As a prerequisite to spontaneous vaginal delivery there shoud not be any evidence of fetal distress. Encourage pushing if contractions are adequate ?VALUE. you were asked to evaluate .
Assisted vaginal delivery would be an option if there is evidence of fetal distress,maternal exhaustion, Epidural analgesia is normal delivery not possible with epidural? etc do not write this . The choice of instrument here would depend on the skill of the obstetrician you are expected to be able to use both forceps and ventouse .Both instruments are associated with similar neonatal outcome although the ventouse is associated with scalp bruising and increased maternal worries contradictory. The disadvantages are not their VALUE ? you were asked to evaluate: attach a sense of value to .Forceps is associated with increased risk of maternal injuries. Cs would be an option in the event of fetal distress and anticipated difficulty with delivery of the baby which difficulty do you anticipate with the head at +2 to justify a second stage C/S? .
Postpartum heamorrhage is an anticipated complication of twin delivery.The initial step would consist of calling for help from who? and checking the vitals what are vitals??? of the mother.Insert two large bore IV cannulas and take blood for full blood count, crossmatching (1) ,and coagulation screen.Start IV fluids. Feel for the fundus and the check if bladder is palpable.Deliver the placenta and check that it is complete.Ask the assistant to rub up a contraction and insert an in dwelling cathter into the bladder (1) .Start Syntocin ?? do you mean syntocinon? Do not use trade names infusion and check for cervical ,vaginal,perineal trauma read the question ? she is bleeding from the UTERUS . Manage PPH with syntometrine ,misoprostol and hemabate in a step wise manner how does the examiner know that you know the steps??? ..If hemostasis is not attained involve senior help and transfer to OT after explaining and consenting the patient.In OT a deep vaginal tear may be visualised,or may have to proceed to uterine tamponade, uterine artery ligation, internal iliac artery ligation,uterine artery embolisation or a hysterectomy as the situation warrants.Blood transfusion and blood products may be necessary. Transfer the patient to HDU care and initiate clinical risk management.

Posted by PAUL A.
Sat Feb 9, 2008 12:12 am
a) Management of this patient should include a risk assessment fot venous thromboembolism. A full blood count and group and save are done as this patieny is at risk of anemia and postpartum haemorrhage. A large bore venous access should be placed (1) .
Multiple pregnancy is associted with an increased perinatal morbidity and mortality rate. Continuous electronic fetal monitoring of both twins is thus indicated. Twin 1 should be monitored by Fetal scalp electrode once the fetal memebreanes have ruptured (1) .
An epidural is allowed if the patient is desirous of one. A partogram should be used to assess progress in the first stage of labour as poor progress may be an indication for cesarean section.

b) This patient has a prolonged second stage of labour.
One option is to encourage the patient to push. This may not be appropriate in cases of maternal exhaustion and in cases of suspected fetal compromise ? value .
A low forceps can be applied. Use of a forceps is associated with a greater success rate when compared to the vauum extractor (1) . Forceps are associated with a greater risk of maternal morbidity secondary to perineal trauma. As a result the vauum should be attempted first.
Use of the vacuum is associted with an increased risk of fetal retinal haemorrhages and cephalhaematoma. It is also associated with increased maternal worry about the baby you were asked about its VALUE ? use / advantages, NOT the disadvantages / risks .
There is no difference in need for phototherapy, Apgar scores or Caesarean section rates with the vacuum or forceps.
Cesarean section can be difficult with the fetal head deeply engaged as it may be associated with uterine tears extending into the cervix.
The patient should be informed of her choices and her wishes met.

c) Post partum haemorrhage is an obstetric emergency and the first step is to call for help. The senior midwife, senior obstetrician, hematologist and anesthesist should all be informed (1) .
It is ensured that the patients airway is patent and she is breathing ? circulation?? . Two large bore (14 or 16G) venous cannula are sited. Blood is taken for FBC to assess the haemoglobin and platelet count. Blood is sent for cross match (1) and a coagulation screen is done as she is at risk of disseminated intravascular coagulation.
The uterus is examined. Twin pregnancy may predispose to uterine atony. If the uterus is atonic it is massaged to help it contract ? bimanual compression . A syntocinon oxytocin infusion is commenced to help keep the uterus contracted (1) . Misoprostol administered rectally can also be used. This has the advantage of being cheap, easily stored and easily administered.
The cervix and perineum are examined for lacerations which may be causing the bleeding. If present these are repaired read the question ? bleeding from the UTERUS . Inspection of the placenta and memebranes should be done as retained products of conception can result in PPH necessitating removal (1) . The patients pulse and BP should be continuously monitored. Packed cell may need to be transfused. The p[atient should be monitored for development of DIC.
If bleeding persists, uterine artery embolisation, B Lych suture or even hysterectomy may need to be done.
An incident form is completed.

c) Post partum

Posted by Dr seema jain J.
Sat Feb 9, 2008 05:48 pm
Since it is a twin pregnancy, blood will be sent for grouping, cross match & save and an intravenous access secured in view of risk of postpartum hemorrhage.. Continuous fetal monitoring for both the babies will be done. A senior obstetrician will be kept informed . Vaginal enamination will be done four hourly if the patient is not in active labour and two hourly if she is in active labour and charted on a partogram. If the contractions are poor, augmentation of labour with amniotomy may be done. Augmentation with oxytocin in 5% Dextrose starting at the rate of 1 mIU/ml will be done if contractions do not get well-established following amniotomy. If there is any sign of fetal distress of any of the twins then to opt for caesarean section. Ambulation should be maintained as much as possible and epidural analgesia should be offered.

The options to effect delivery include a normal vaginal delivery, forceps or a ventouse. Since it is a twin pregnancy, delivery should be attempted in a theatre and a senior obstetrician kept informed. If the contractions are poor, oxytocin augmentation can be done and a normal vaginal delivery may be attempted. If normal vaginal delivery is not possible and if there is no caput, ventouse extraction with a silastic cup can be attempted, since it causes less fetal and maternal trauma. A metallic cup for ventouse extraction has lesser chances of failure in comparison to a silastic cup. The other option is to apply outlet forceps, the risk of failure is less, though the risk of extension of episiotomy and laceration / tears is more. In case of no descent with a single pull of ventouse or a failed operative vaginal delivery, caesarean section should be opted for. The caesarean section in 2nd stage of labour can be a tough proposition and should be undertaken under the supervision of a senior obstetrician.

The most likely cause is uterine atony. I will check airway, breathing and circulation of the patient and resuscitate her if she is not stable. I will call for extra help and inform a senior obstetrician and also blood bank personnel and hematologist in case blood transfusion is required. I will take intravenous access with 18G angiocath at two sites and give her crystalloids. Bimanual compression of the uterus may help the uterus to contact. 10 units of oxytocin in 5% Dextrose will be given to the patient to cause uterine contractility. Injection ergometrine can be given intramuscularity if she has no PIH. Injection Carboprost(PGF2ALPHA) 50 mcg intramuscularly can be given. Rectal Misoprostol 200mcg is also an effective alternative. In case blood transfusion is required, O negative blood can be given After examination of the placenta if there is any evidence of retained cotyledons, an attempt to remove the cotyledons under general anesthesia can be done.
Posted by Dr seema jain J.
Sat Feb 9, 2008 05:49 pm
Since it is a twin pregnancy, blood will be sent for grouping, cross match & save and an intravenous access secured in view of risk of postpartum hemorrhage.. Continuous fetal monitoring for both the babies will be done. A senior obstetrician will be kept informed . Vaginal enamination will be done four hourly if the patient is not in active labour and two hourly if she is in active labour and charted on a partogram. If the contractions are poor, augmentation of labour with amniotomy may be done. Augmentation with oxytocin in 5% Dextrose starting at the rate of 1 mIU/ml will be done if contractions do not get well-established following amniotomy. If there is any sign of fetal distress of any of the twins then to opt for caesarean section. Ambulation should be maintained as much as possible and epidural analgesia should be offered.

The options to effect delivery include a normal vaginal delivery, forceps or a ventouse. Since it is a twin pregnancy, delivery should be attempted in a theatre and a senior obstetrician kept informed. If the contractions are poor, oxytocin augmentation can be done and a normal vaginal delivery may be attempted. If normal vaginal delivery is not possible and if there is no caput, ventouse extraction with a silastic cup can be attempted, since it causes less fetal and maternal trauma. A metallic cup for ventouse extraction has lesser chances of failure in comparison to a silastic cup. The other option is to apply outlet forceps, the risk of failure is less, though the risk of extension of episiotomy and laceration / tears is more. In case of no descent with a single pull of ventouse or a failed operative vaginal delivery, caesarean section should be opted for. The caesarean section in 2nd stage of labour can be a tough proposition and should be undertaken under the supervision of a senior obstetrician.

The most likely cause is uterine atony. I will check airway, breathing and circulation of the patient and resuscitate her if she is not stable. I will call for extra help and inform a senior obstetrician and also blood bank personnel and hematologist in case blood transfusion is required. I will take intravenous access with 18G angiocath at two sites and give her crystalloids. Bimanual compression of the uterus may help the uterus to contact. 10 units of oxytocin in 5% Dextrose will be given to the patient to cause uterine contractility. Injection ergometrine can be given intramuscularity if she has no PIH. Injection Carboprost(PGF2ALPHA) 50 mcg intramuscularly can be given. Rectal Misoprostol 200mcg is also an effective alternative. In case blood transfusion is required, O negative blood can be given After examination of the placenta if there is any evidence of retained cotyledons, an attempt to remove the cotyledons under general anesthesia can be done.
Posted by M M A.
Sun Feb 10, 2008 01:38 am
(a)
Rapid history is taken with reviewing of her antenatal notes to detect if there is any contraindication to vaginal delivery like major placenta previa.
General assessment is done including vital sign to ensure maternal wellbeing and stating a baseline measurements. Also abdominal assessment with electronic monitoring of both fetuses. Pelvic assessment is done also to detect if she has adequate pelvis, also to measure cervical dilatation and effacement , station of presenting part and its position to monitor progress of labour also to exclude malposition or cephalopelvic disproportion.
Adequate analgesia is required, preferable epidural anaesthesia which will help also if instrumental delivery or intrauterine manipulation is required later on.
Ensure good iv line access as she may need iv fluid and medications also send for blood grouping and saving.
Use partogram to assess progress of labour and this will allow early interference if there is delay.
Close monitoring of the mother and the fetuses are required.

(b)
Vaginal delivery can be achieved as the presenting part is at +2 station provided that no sign of obstructed labour like excessive molding or caput succedaneum, it is safer than emergency caesarean section done in the second stage of labour.
Instrumental delivery can be used, preferably ventose which carries less incidence of maternal genital tract injury than forceps, however, forceps carries more success rate and can lead to more rapid delivery especially if there is fetal compromise.
In case of failure of instrumental delivery or the labour is obstructed, emergency caesarean section is done although it is associated with high maternal and fetal morbidity and mortality.

(c)
We ensure that she has two iv line with wide pore canulae with aspiration of 10 cc of blood to be sent for blood grouping and cross matching. We prepare 4-6 units of blood initially. we call for help of senior obstetrician, anaesthetist and good nursing staff also we inform the blood bank staff.
We measure pulse and blood pressure to evaluate patient condition. We review if the placenta has been delivered or not and if delivered, was it complete or not. If there is retained placental piece or membrane , we do manual evacuation of uterus. If placenta is delivered completely, we look for uterine tone as she may has uterine atony. We do uterine massage and give uterotonic drugs like syntometrin im provided that she is not hypertensive and oxytocin infusion 40 iu/500 ml Normal saline or prostaglandin vaginal suppositories. Folly\'s catheter is inserted to evacuate bladder and measure urine output. Also we try to do bimanual compression of uterus for about 30 minutes as this gives time for drugs to act and time for replacement. Warm iv fluid is given , normal saline or colloid until blood is ready.
If the uterus is contracted, we look for genital tract injury and arrange for suturing under aseptic technique with good lighting. If there is suspicion of uterine rupture, we arrange for laparotomy and inform consultant obstetrician and consultant anaesthetist. We should exclude other causes of bleeding like coagulopathy. Clotting profile is done and a haematologist is involved in the management.
Monitoring chart of vital signs, oxygen saturation, fluid input and out put is started. CVP may be required to assess patient circulation provided that patient has no coagulopathy.
Clear documentation of the events and procedures is done with time reporting, also medication and names of the assistant personals.
Posted by PAUL A.
Mon Feb 11, 2008 12:46 am
I will take brief history and check notes to rule any antenatal risk factors, plan documented for delivery and growth monitoring if both twins. I will secure IV line and take bloods for FBC, group & save (1) , as she may require interventions to deliver 2nd twin. I will the check presentation of 1st twin by per abdominal examination and confirm with scan the question tells you it is cephalic . Continuous fetal monitoring by CTG is essential (1) to ensure fetal well being and rule out any episodes of fetal distress. I will then perform VE how often? to check cervical dilatation,position and station of 1st twin and record on partogram . Progress should be monitored with partogram. I will ensure that she had adequate analgesia (1) and advice for epidural once she is in active labour as this will provide pain relief if she requires any manuevres like External cephalic version or internal podalic version to deliver 2nd twin.
I will review her partogram to check for progress in first stage,CTG for fetal well being.If the frequency and strength of her contractions are not adequate I will start her on oxytocin infusion is it possible for her to deliver normally without oxytocin? if there are no signs of fetal distress and review her in 30min for further management. If she is actively pushing and as twin 1 is direct OA at +2 I will consider trial of instrumental delivery in theatre (1) . Although it is safer to perform instrumental delivery,forceps or ventouse ,on 1st twin, she may need interventions to stabilise lie of 2nd twin by external cephalic or internal podalic version hence delivery in theatre is more appropriate.I will inform consultant on call and ensure that paediatrician present at delivery you were asked to evaluate ? what is the value of starting oxytocin, using forceps or ventouse? .
Postpartum hemorhage is an obstetric emergency , so I will call for help (1) - senior midwife, anaesthetist,senior or junior colleagues,inform consultant on call, haematologist,porters and ODPs. After ensuring that airway and breathing are patent ? meaning?? She needs o2 inhalation , 2nd large bore IV line and bloods for clotting studies,cross match 4-6units (1) and start IV fluids preferably colloids ? O Rh neg blood .I will give her 2nd dose of syntometrine after ensuring no history of hypertension of PET and oxytocin infusion at 10units /hr (1) . I will then do bimanual compression ? rub up a contraction initially and ask a midwife to check if placenta is complete. If the uterus is contracted I will check perineum and cervix for any tears.If the uterus is not well contracted then I will give IV ergometrine,250microgms of hemobate deep IM or inramyometrial (1) ? misoprostol .hemobate can continued for further 3 doses at 15 min interval but I will consider transfer to theatre for EUA and further management. I will request the presence of consultanton call for EUA.
Posted by PAUL A.
Mon Feb 11, 2008 12:47 am
This is high risk pregnancy and should receive Obstetrician led care.She should receive one to one midwifery care in labour. Patient should be offered adequate analgesia (1) , preferably epidural to aid manipulation of second twin. If she receives epidural then bladder should be catheterised do you mean an in-dwelling catheter? . She should be seen by anaesthetist colleague as twin pregnancy carries high risk of operative delivery. Bloods should be checked for FBC and group and save done as there is increased risk of operative delivery and postpartum haemorrhage. She should have iv access established (1) . Both twin heart rates should be monitored throughout labour by intermittent auscultation?? Continuous electronic fetal monitoring . It is best to get fetal scalp electrode on first twin at earliest opportunity.This helps in distinguishing traces. Patients progress and efficacy of contractions should be confirmed at regular intervals how often? . IF contractions inadequate in absence of other complications syntocinon augmentation is justified (1) oxytocin . If she has been shown to be group b strep carrier then antibiotic prophylaxis should be given where did the question mention anything about GBS? .

This patient needs delivery.Maternal and wellbeing of both twins should be ascertained to determine urgency of delivery, example if second twin shows pathological CTG then performing Caesarean will enable quiker delivery for both twins you have been asked a simple question and you have decided to make it into a very difficult one. Delivering twin 1 by C/S with the head at +2 is unlikely to be an easy delivery. Your claim that delivery by C/S would be quicker is questionable and also reduce maternal morbidity after different modes of delivery this is questionable . Maternal wishes should be taken into account (1) . Maternal abdominal examination to check for engagement and cephalic palpation for fifths should be done you are not answering the question. You were not asked about what should be done. You were asked to evaluate the options? along with vaginal assesment for presence of caput, moulding to help in decision for appropriate mode of delivery and choice of instrument. Use of epidural, duration of active pushing and progress in first stage should be checked. Bladder should be emptied not answering the question . Expectant mode of delivery can be considered if delivery is imminent (1) . Syntocinon should be used to augment contractions if contractions are inefficient and no sign of obstructed labour. Instrumental delivery with forceps or ventouse should be considered if per abdomen cephalic is less than one finger palpable what will you expect with the head at +2 with a direct OA position? , choice of instument will depend upon maternal effort, caput.If instrumental delivery is anticipated to be difficult then patient should be delivered in theatre would you not do it in theatre otherwise? . Other option is to do caesarean section with a direct OA position at +2??? (-1) , it carries higher risk of complications to mother and if fetus is very low in birth canal can increase fetal morbidity. Pediatrician should be present at delivery.

you have not answered the question. What are the options? Expectant management, ventouse, forceps. What is the value of these options (evaluate)?
Her initial management efforts should be directed towards resuscitaion- airway, breathing and circulation management. help should be summoned (1) and senior obstetric , midwifery and anaesthetic staff should be involved . Bloods should be sent for FBC, CLOTTING and crossmatch at least 4 units (1) .Haematologist should be informed. Two large bore iv access should be in place and iv fluids given which fluids? . Both Placentae should be removed if still undelivered and if delivered checked for integrity. Bimanual compression of uterus (1) , syntocinon infusion of 50iu in 50 ml NSaline @ 10ml per hour should be given. Syntometrine 5U can be given twice (1) . INdwelling urinary catheter should be inserted. If bleeding continues, patient should be shifted transferred to theatre (if not delivered there )and haemabate 250 u ? dose units??? should be given. this can be repeated to maximum of four doses. During initial management someone should provide support and explanation of events to birth partner.
Posted by PAUL A.
Mon Feb 11, 2008 12:48 am
Cephalic twin one is an indication to deliver the twins vaginaly. Twin pregnancy is regarded as high risk pregnancy so careful first stage monitoring is essential. As she is at risk of PPH, two IV lines with wide bore canulae are maintained. Blood is grouped and cross matched and a request for Hb should be sent (1) . Her antenatal record is reviewed to search for a complication of twin pregnancy like PIH, placenta previa, polyhydraminious, congenital anomalies and discordant growth. Continuous electronic fetal heart rate monitoring is recommended (1) for both the twins simultaneously during labour. Progress of labour should be monitored vigilantly how? . Labour can be augmented with ARM and judicious use of syntocinon if required (1) . Early resort to CS is advised in case of failure to progress and suspicious CTG suspicious CTG is NOT an indication for delivery . Epidural analgesia can be administered (1) .

Direct OP position READ THE QUESTION is one of the commonest malposition encountered. About 6% of which can deliver face to pubes with strong uterine contraction. Provided the baby is not macrosomic, efficient uterine contraction can be established with judicious use of syntocinon. If efficient uterine contractions are already there manual rotation of head can be tried. If it fails rotational vacuum extractor is used with OP cup. Ventouse is associated with increase incidence of fetal cephalhematoma and retinal haemorrhage, but has an advantage of less maternal trauma. Forceps delivery is another option with less failure rate and minimal trauma to the baby at the expense of grater incidence of maternal trauma. However expert hand minimizes the risk of maternal trauma. Second stage CS is the last option with the advantage of minimal trauma to the baby but with the risk of uterine incision extension and per operative haemorrhage. Presence of a senior obstetrician is vital before the delivery, whatever the mode of delivery is.

Ensure two wide bore IV access, maintain airways with oxygen, collect blood for grouping and cross matching (1) , atleast 5 units of blood and fresh frozen plasma do you normally ask for FFP at this stage? (-1) are asked for. Call for senior help. Presence of a senior midwife is essential, monitor vital signs maintaining a CVP line not indicated at this stage , catherize the patient to monitor the input and output. Volume replacement with crystalloids and colloids is vital until blood is available ? O Rh neg blood . Close collaboration with anesthetist and haematologist is essential. Meanwhile detect the cause of PPH. If there is uterine atony, which is most likely after a twin delivery, uterine massage, IV syntocinon 40 units in 500 cc ml. Over what time? drip and 5 units direct IV plus IV methergine what is this?? are given. Resistant cases can be treated by PGF 2 alpha, misoprostol per vaginal or per rectum and hemabat (1) . Examine the lower genital tract for any injury and quick repair under anesthesia if required. Ruptured uterus is rare in primigravidas however should be looked for. Laprotomy is the last resort with consent for total or sub-total hysterectomy. However per operatively uterine conservation is a priority with β-lynch suture or internal artery ligation. Life saving hysterectomy is the last resort.
Posted by PAUL A.
Mon Feb 11, 2008 12:49 am
An I.V. line should be secured and blood sample collected for full blood count and group& cross-match do you crossmatch blood? . Her vital signs, and the examination finding should be blotted in the partogram as it is proved to reduce the risk of operative delivery. Continuous support is of proven value in labour. Continuous monitoring of both twins (1) [CTG] as the second twin is at high risk, when it is possible the first twin should be monitor by scalp electrode. Epidural anaesthesia -if no contraindication- should be advised as there is increased risk of operative delivery (1) especially for the second twin so the anaesthetist should be informed. A senior obstetrician input is required especially in the second stage of labour you were asked about first stage . The progress of labour and the traces of both twins CTG as well as maternal wellbeing should be noticed what does NOTICED mean???? . Her risk of VTE should be calculated on admission to the labour room.
Second stage of labour in primigravidae in the presence of epidural analgesia often reach 3 hours ? meaning?? Does the question mention epidural? . In the presence of normal CTG the woman should encourage to push this depends on progress . Another option is to advise instrumental delivery. Ventouse is associated with less maternal perineal injuries (1) compared to the low cavity Forceps but more failure and more minor trauma to the neonate. Caesarean what is the value of forceps? The disadvantages of ventouse do not equal the value of forceps section is an option but emergency procedure with fetal position at +2 it carry more risk, however it may be needed for the second twin you were asked about the first twin in case of persistent transverse lie.
I should call for help from who? . Crystalloid as normal saline should be started while waiting for the blood and another large IV canula should be inserted. The patient should be examined . Pulse, blood pressure level of consciousness (1) , fundal level consistency of the uterus, retained placentae or injuries to genital tract. With twins pregnancy post partum haemorrhage should be anticipated. The commonest cause is usually a hypotonic uterus. Administration of oxitoxic as- Ergometrine or synticinon- drugs and manual compression (1) is effective in most of the cases. Carboprost 250 micrograms intra-muscular may be needed. Blood should be started. In case of failure to stop the bleeding or if the bleeding exist while the uterus is well contracting, an exploration in theater with possible intervention should be advise.

Posted by PAUL A.
Mon Feb 11, 2008 12:49 am
a) I would ask her the duration of labour pains and if had rupture of membranes the colour of the liquor if blood stained or meconium to determine additional risk factors . I would review her antenatal note and the growth scan of the fetus to see no growth discordancy in the twins.
I would examine her to assess fetal wellbeing with CTG and vaginal examination to determine cervical dilatation, presentation and position and confirm labour
you should take the question at face value ? you are given the presentation and told she is in spontaneous labour . If there is fetal distress in first stage of labour, this would be an indication for c-section except she?s fully dilated.
I would explain the findings to her and that there might be need for manipulation of the second twin if the lie is not longitudinal after the delivery of twin 1.
I would inform her the preparation for this delivery include, siting an intravenous line because may require syntocinon for the delivery of twin 2 if develop uterine inertia and to prevent bleeding after delivery. I would obtain her blood for FBC, to check for anaemia and her platelet count because of risk of bleeding. I would send her blood for grouping and save (1) . I would discuss pain relief in labour with her what would you recommend? . She would be seen by the anaesthetist early in labour. I would commence fetal monitoring if no contraindication to vaginal delivery with scalp electrode for twin 1 and abdominal transducer for twin 2 (1) . My senior colleague would be aware about this impending delivery.

b)The safest option would be a delivery conducted in theatre (1) due to increased risk of caesarean section for twin 2 if malpresentation persists. I would review her pain relief in labour as epidural is associated with prolongation of second stage. If there is no fetal distress and she has not being pushing for up to 90minutes she can anticipate spontaneous vaginal delivery (1) . This is very save and associated with good outcome to the fetus. As she?s being fully dilated for 3h, there is more likely to be maternal exhaustion and instrumental vaginal delivery with ventouse offers good chance of safety to the baby. There is risk of cephalhaematoma and NNJ developing in the baby you were asked about the value, not the risks ? less analgesia required and lower risk of perineal injury . There is also increased maternal worries about the baby after delivery.
Forceps delivery provide more quicker poor English delivery if there is fetal distress . It is however associated with increased risk of perinaeal tears and bleeding lower risk of failure . C-section would be inappropriate at this stage as increases risk of injury to the first twin. is it an option if it is inappropriate? There is increased risk of bleeding and lateral extension of caesarean incision. evaluate = attach value = present benefits / advantages. Critically evaluate = attach value & find faults = present benefits + disadvantages
c)This is more likely to be due to uterine atony with increased risk of DIC from massive PPH.
Initial management would be calling for help from the consultant obstetrician and anaesthetist the consultants are 20 mins away ? who else will you call? and the midwife. I would ensure the airway is patent. I would ask the midwife to examine that the placenta is complete why is this done between checking the airway is patent and checking she is breathing???? . I would check she?s breathing and the anaesthetist would administer oxygen by face mask . I would check FBC, and clotting factors you have not sent a cross-match / Gp & save to determine the degree of anaemia and the need for FFP. I would maintain her circulation with crystalloids and transfuse FFP early you have not given her a single unit of blood and you are giving FFP?? (-1) . I would rub off uterine contractions. I would administer ergometrine intravenously. I would continue with syntocinon infusion this is an important early intervention rather than a measure which is used only if bleeding continues . If bleeding continues, I would administer carboprost intamyometrially 250mcg and this would be repeated every 15minutes up to maximum of 8doses. I would give misoprostol 800mcg PR (1) . If bleeding still continues will replace with packed cells and FFP. If bleeding still continues she would need to be transferred to theatre for insertion of Bakri balloon to tamponade bleeding from the placenta bed. The last option to would be laparotomy and compression test and if positive may benefit from B-Lynch suture or she may require hysterectomy. Her partner would be debriefed during all this treatment. you have not demonstrated competent initial management of PPH. In particular, you have not administered blood promptly
Posted by PAUL A.
Mon Feb 11, 2008 12:50 am
a)Multidisciplinary team such as senior mid-wife, anaesthetist , neonatologist and haematologist why? Do you involve the haematologist when a woman with a twin pregnancy presents in labour?? should be involved in the management as it is high-risk pregnancy. Local agreed protocol and guidelines should be followed.
The maternal vital signs including BP should be measured and monitored for risk of pre-eclampsia . Abdominal examination then vaginal examination is performed for cervical dilatation ,effacement and descent of fetal head of the first twin. Using a partogram improves the maternal and fetal outcome .
Venous access should be in place ,and blood for FBC , group and cross-match for saving blood do you cross-match blood? for any suspected complications ; such as fetal distress and PPH . Continuous electronic fetal monitoring , and FSE should be used for first twin what about the second twin? ( if membrane is already ruptured. )
Hydration should be maintained through IV fluids. Analgesia should be initiated through regional anaesthesia (1) which has value in operative delivery and also, provides higher rates of maternal satisfaction. The progress of labour should be monitored through assessment of uterine contractions , their frequency , strength ,cervical dilatation and descent of presenting part. Augmentation should be initiated via oxytocin I V infusion according to unit protocol if there is slow progress (1) . The patient should be transferred to the operating theatre if the cervix is fully dilated. The patient should be provided written information and twin support group .
b) She should be encouraged to have continuous support you are not answering the question during childbirth in presence of partner , ratherthan , starting oxytocin with epidural will decrease the need for operative vaginal delivery ? meaning . Pushing should be delayed until she has a strong urge to push the question states that she is undelivered 3h after full dilatation . This option enables the avoiding of operative vaginal delivery which can be associated with maternal and neonatal morbidity.
Operative vaginal delivery is an another option, especially indicated for maternal fatigue,
exhaustion or presumed fetal compromise . The mother should give informed consent after explanation to her the need of intervention you are not answering the question. You were not asked about management or what should be done. You were asked to evaluate the options? including possibility of episiotomy. Maternal bladder must be empty, and indwelling catheter should be removed . Vacum extractor is associated with less maternal laceration and less analgesia requirement (1) , but an increased risk of neonatal cephalhematoma and retinal haemorrhages. The non-rotational forceps is preferable if she is exhausted and unlikely to be pushing properly. It also,expedites the delivery in the presence of fetal distress , but may be associated with maternal perineal injury ,pain and fetal scalp or facial injury.
Failure of operative vaginal delivery or presence of fetal distress , caesarean section should be undertaken as a last option. Senior neonatologist should be available at operating theatre.
c) I have to call for help from senior anaesthetist , senior obstetrician , haematologist, mid-wifery staff and theatre team (1) . The general status of the patient should be assessed , pulse, BP, and facial oxygen is given and CPR is commenced if required.
Venous access at least two wide bore cannulae should be secured. Blood should be sent for FBC,
LFT ,U&E, Clotting study ,Group and Cross-match 6 units of blood (1) .The need of blood products and their urgency should be discussed with the haematologist.
IV Fluids , crystalloid , colloid , or O Rh negative blood should be given (1) . Blood transfusion and any objections that woman have should be discussed with haematologist.
Uterine atony is the most likely common cause , so , uterine tone must be assessed and rub-up a contraction to stop bleeding. If placentae should be expelled and any RPOC to be removed (1) .
Uterotonic agents should be administered. Oxytocin 40 IU in 500 ml over 4h infusion (1) ., ergometrine ,carboprost 25 mg IM ? dose?? or intramometrial maximum 2 doses can you only give 2 doses?? . Vaginal or rectal prostaglandins. Bimanual compression (1) is life-saving but painful. Uterine inversion , uterine rupture can not be excluded except after laparotomy. Laparotomy with internal iliac artery ligation , uterine compression with B-lynch brace sutures or hysterectomy is the ultimate intervention. Blood results should be obtained for coagulopathy to treated with haematologist. Complication of massive blood loss or transfusion including thrombocytopenia, hypocalcaemia, hyperkalaemia should be detected . Platelet ,FFP should be administered. Monitoring of pulse,BP,SpO2 every 15 min and urine output hourly for 24 hrs. Detailed documentation and incident form should be filled you were asked about initial management .
The patient should be reassured and her family kept informed at all stages.

Posted by PAUL A.
Mon Feb 11, 2008 12:51 am
1) Assessment of general condition of the patient will be done including temperature, pulse rate and Blood pressure .Abdominal examination will be done to assess the presentation of the 1st baby and the descent of head .This will be followed by vaginal examination .This will confirm the presentation, and give information about the nature of cervix, favourability and the station of presenting part. Major abnormalities of the pelvis precluding vaginal delivery can be noted for example?? . She will be advised to remain nil per orally and I/V fluids started keeping in mind the increased risk of caesarean section and anaesthesia requirement. Blood will be sent for complete blood count and grouping typing and save serum also due to the same reasons (1) .Continuous CTG monitoring of the fetus (1) fetuses will be done since it is a high risk pregnancy. The neonatologist, Theatre staff and anaesthetist will be informed of this patient admitted in labour.

2) Vaginal examination will be repeated to look for large caput or major degree molding suggestive of cephalo pelvic disproportion (CPD) and if present caesarean delivery will be decided how reliable is your diagnosis of CPD given the head is at +2? (-1) . If facilities are available intra partum USS will be done to assess the presentation of second twin now and if found to be breech the possibility of inter locking will be looked for how do you get locking when the first twin is cephalic??? (-1) . Any suspicion will be an indication for caesarean section, provided the fetal hearts are reassuring. If contractions are found to be inadequate oxytocin augmentation will be done and dehydration corrected if any. After explaining the situation to the woman informed consent for operative delivery will be obtained you are not answering the question ? you were not asked about what should be done. You were asked to evaluate the options . Vacuum extraction of the fetus will be done after emptying bladder and providing adequate analgesia. This is associated with reduced risk of maternal genital tract trauma (1) compared to forceps delivery , but increased risk of neonatal morbidity like cephalhematoma and retinal haemorrhage.The other alternative is low forceps delivery which will be attempted under supervision how is it that you can undertake a ventouse delivery without supervision but need supervision for an outlet forceps delivery? Your answer indicates you are not confident with forceps . If no progressive descent with each pull or if no signs of imminent delivery after 3 pulls of properly placed instrument caesarean delivery will be decided.

C) Resuscitation of the patient will be given top priority. This includes rapid infusion of crystalloid or colloid solutions based on the degree of estimated blood loss call for help; assess airway, breathing, circulation ? . Full blood count will be repeated and instructions for crossmatching of blood given. If the uterus is found to be relaxed massaging will be done to promote uterine contraction. Urinary bladder will be cathetrised as residual urine is found to interfere with uterine contractions. Bimanual compression of uterus will be attempted (1) will you perform it or attempt it?? which will cause stretching of uterine arteries leading to reduced blood flow is this the mechanism?? . Meanwhile senior obstetrician, midwife and more experienced staff will be called for help.Oxytocin bolus 10 units I/M or I/V will be given Along with that an oxytocin infusion containing 40 units in 500 ml crystalloid will be started over how long? . This will promote uterine contraction in majority of cases of atonic uterus. If not, injection ergometrine will be given I/M provided her blood pressure is normal and in the absence of a history of PIH.Intra muscular injection of Prostaglandin F 2 alpha will be given in a dose of 250 micro gram if the bleeding persists (1) . History of bronchial asthma has to be ruled out prior to this. Per rectal administration of 4- 5 tablets of PG E1 is also seen to promote uterine contraction. If uterus is found to be contracted well and bleeding persisting, proper examination under adequate lighting and analgesia will be done to rule out genital tract trauma. Any local injury noted will be sutured. I f any suspicion of retained bits of placenta gentle curetting NO ? you will perforate the uterus. You should explore the cavity manually will be attempted to remove them. In case of falling blood pressure and Tachycardia will you wait until there is evidence of haemodynamic compromise to give blood? (-1) blood will be transfused and if not responding to the medical measures immediate laparotomy will be decided after informing consultant and senior anaesthetist. your repeated reference to ?attempting? rather than performing procedures indicates a lack of confidence which will be very obvious to the examiner
Posted by Dr.Anies S.
Mon Feb 11, 2008 08:29 pm
a. Twin pregnancy in labour is associated with high morbidity and mortality for the fetus and then the mother. I will quickly go through her antenetal records, looking for the plan of delivery. Labour is carried out in an unit where caeserean section facilities and neonatal resuscitation facilties are available. Senior obstetrician, anaesthetist and neonataligist are made aware of the mother of twins in labor. Abdominal examination is carried out to assess the presentation and to confirm the adequacy of uterine contraction. Vaginal examination confirms the presentation and excludes cephalo pelvic disproportion. I would ask a mid wife to site 2 large bore(16 -18g) I.V cannulae. Blood is obtained at the same time and sent for blood group and cross match. Partogram is maintained which is useful to identify the disfunctional labour, if the line falls on the right side. I would ensure that the woman is well hydrated at all times. Adequate analgesia is discussed by the anesthetist and provided.

b. The clinical picture suggests that the women is in prolonged second stage of labour. Immediate delivery is planned after assesing the maternal and fetal well being. The options available for the delivery are low forceps or vaccum extraction. Delivery should be conducted in theatre with facilities kept ready for ceasarean section. Both forceps and vaccum are equaly effective. Forceps is associated with maternal injuries and vaccum with fetal injuries. Neonatologist should be present at the time of delivery. There is no difference in low 5 minutes APGAR score in both methods.

c. I would call for help. Haemotologist and porters are alerted. Bladder is catheterised.Oxygen is given by face mask. Most likely PPH is due to uterine atonicity.Uterine massaging is done. One mid wife is asked to monitor her vitals and urine output. Intravenous crystalloids are initiated along with 40-50 units of oxytocin infused. I would check that the placenta is complete. If there is no contraindication methyl ergometrine is given. If still continous to bleed examination is carried in the theatre under anesthesia looking for any trauma to the genital tract. Blood is obtained and sent for coagulation profile. Injection carboprost or rectal mysoprostol is administered.
Posted by Dr seema jain J.
Thu Feb 14, 2008 12:44 pm
My answer on twin pregnancy has not been checked.
Posted by M M A.
Fri Feb 15, 2008 11:09 pm
Please Dr paul,

I know it is an extraordinary effort that you are doing to read and score all these answers, but if you have a time, can you please just give me your comment about my answer?

Thank you and sorry for disturbances.
Posted by M M A.
Fri Feb 15, 2008 11:16 pm
Please Dr paul,

I know it is an extraordinary effort that you are doing to read and score all these answers, but if you have a time, can you please just give me your comment about my answer?

Thank you and sorry for disturbances.
Posted by PAUL A.
Tue Feb 19, 2008 09:58 pm
sorry we missed your answer
Since it is a twin pregnancy, blood will be sent for grouping, cross match & save and an intravenous access (1) secured in view of risk of postpartum hemorrhage.. Continuous fetal monitoring (1) for both the babies will be done. A senior obstetrician will be kept informed . Vaginal enamination will be done four hourly if the patient is not in active labour and two hourly if she is in active labour why examine her every 4 hours when she is not in labour? Why should she be examined every 2h in labour? There is no indication for 2 hourly VE and charted on a partogram. If the contractions are poor, augmentation of labour with amniotomy may be done. Augmentation with oxytocin in 5% Dextrose do you administer oxytocin in 5% dextrose??? starting at the rate of 1 mIU/ml this is a concentration, not a rate (-1) will be done if contractions do not get well-established following amniotomy. If there is any sign of fetal distress of any of the twins then to opt for caesarean section. Ambulation should be maintained as much as possible and epidural analgesia should be offered (1) .

The options to effect delivery include a normal vaginal delivery, forceps or a ventouse. Since it is a twin pregnancy, delivery should be attempted in a theatre (1) and a senior obstetrician kept informed. If the contractions are poor, oxytocin augmentation can be done and a normal vaginal delivery may be attempted. If normal vaginal delivery is not possible and if there is no caput, ventouse extraction (1) with a silastic cup can be attempted, since it causes less fetal and maternal trauma. A metallic cup for ventouse extraction has lesser chances of failure in comparison to a silastic cup. The other option is to apply outlet forceps, the risk of failure is less, though the risk of extension of episiotomy and laceration / tears is more (1) . In case of no descent with a single pull of ventouse will you abandon after ONE pull and do a second stage C/S?? Is this an indication for abandoning the procedure? (-1) or a failed operative vaginal delivery, caesarean section should be opted for. The caesarean section in 2nd stage of labour can be a tough proposition and should be undertaken under the supervision of a senior obstetrician.

The most likely cause is uterine atony. I will check airway, breathing and circulation (1) of the patient and resuscitate her if she is not stable. I will call for extra help and inform a senior obstetrician ? anaesthetist?? and also blood bank personnel and hematologist in case blood transfusion is required. I will take intravenous access with 18G angiocath at two sites and give her crystalloids. Bimanual compression of the uterus may help the uterus to contact (1) stops bleeding . 10 units of oxytocin in 5% Dextrose ? in what volume?? will be given to the patient to cause uterine contractility. Injection ergometrine can be given intramuscularity if she has no PIH. Injection Carboprost(PGF2ALPHA) 50 mcg ? dose intramuscularly can be given. Rectal Misoprostol 200mcg ? dose is also an effective alternative. In case blood transfusion is required, O negative blood can be given After examination of the placenta if there is any evidence of retained cotyledons, an attempt to remove the cotyledons under general anesthesia can be done (1) .

your drug doses are incorrect and suggest you have not managed this situation before


Posted by PAUL A.
Tue Feb 19, 2008 09:58 pm
Sorry we missed your answer
(a)
Rapid why do you need to rush?? history is taken with reviewing of her antenatal notes to detect if there is any contraindication to vaginal delivery like major placenta previa.
General assessment is done including vital sign to ensure maternal wellbeing and stating a baseline measurements. Also abdominal assessment with electronic monitoring of both fetuses. Pelvic assessment is done also to detect if she has adequate pelvis what are your criteria? What will you do if you decided her pelvis was inadequate?? , also to measure cervical dilatation and effacement , station of presenting part and its position to monitor progress of labour also to exclude malposition or cephalopelvic disproportion HOW??? .
Adequate analgesia is required (1) , preferable epidural anaesthesia which will help also if instrumental delivery or intrauterine manipulation is required later on.
Ensure good iv line access as she may need iv fluid and medications also send for blood grouping and saving (1) .
Use partogram to assess progress of labour and this will allow early interference if there is delay.
Close monitoring of the mother and the fetuses are required.

(b)
Vaginal delivery can be achieved as the presenting part is at +2 station provided that no sign of obstructed labour like excessive molding or caput succedaneum, it is safer than emergency caesarean section done in the second stage of labour.
Instrumental delivery can be used, preferably ventose (1) which carries less incidence of maternal genital tract injury than forceps, however, forceps carries more success (1) higher success rate rate and can lead to more rapid delivery especially if there is fetal compromise.
In case of failure of instrumental delivery or the labour is obstructed, emergency caesarean section is done although it is associated with high maternal and fetal morbidity and mortality.

(c)
We ensure that she has two iv line with wide pore canulae with aspiration of 10 cc of blood to be sent for blood grouping and cross matching (1) will you request any other blood tests? . We prepare 4-6 units of blood initially. we call for help of senior obstetrician, anaesthetist and good nursing staff ?? do you have bad nursing staff in your hospital?? also we inform the blood bank staff.
We measure pulse and blood pressure to evaluate patient condition will you do this AFTER taking blood or before? . We review if the placenta has been delivered or not and if delivered, was it complete or not. If there is retained placental piece or membrane , we do manual evacuation of uterus in the delivery room? . If placenta is delivered completely, we look for uterine tone as she may has uterine atony. We do uterine massage (1) and give uterotonic drugs like syntometrin im provided that she is not hypertensive and oxytocin infusion 40 iu/500 ml Normal saline (1) over what period? or prostaglandin vaginal suppositories. Folly\'s catheter is inserted to evacuate bladder and measure urine output. Also we try to do bimanual compression of uterus for about 30 minutes as this gives time for drugs to act and time for replacement. Warm iv fluid is given , normal saline or colloid until blood is ready resuscitation should be your priority, not something that is considered after you have administered drugs ? .
If the uterus is contracted, we look for genital tract injury and arrange for suturing under aseptic technique with good lighting. If there is suspicion of uterine rupture, we arrange for laparotomy and inform consultant obstetrician and consultant anaesthetist. We should exclude other causes of bleeding like coagulopathy. Clotting profile is done and a haematologist is involved in the management.
Monitoring chart of vital signs, oxygen saturation, fluid input and out put is started. CVP may be required to assess patient circulation provided that patient has no coagulopathy.
Clear documentation of the events and procedures is done with time reporting, also medication and names of the assistant personals.

Posted by PAUL A.
Tue Feb 19, 2008 09:58 pm
Sorry we missed your answer

a. Twin pregnancy in labour is associated with high morbidity and mortality for the fetus and then the mother how many women die in the UK every year as a result of twin pregnancies??? . I will quickly why quickly?? Why not thoroughly?? go through her antenetal records, looking for the plan of delivery. Labour is carried out in an unit where caeserean section facilities and neonatal resuscitation facilties are available. Senior obstetrician, anaesthetist and neonataligist are made aware of the mother of twins in labor. Abdominal examination is carried out to assess the presentation and to confirm the adequacy of uterine contraction. Vaginal examination confirms the presentation and excludes cephalo pelvic disproportion how would you exclude cephalo-pelvic disproportion? Have you every seen anyone make a diagnosis of cephalo-pelvic disproportion in a twin pregnancy (OR ANY PREGNANCY) at 37 weeks in the first stage of labour??? . I would ask a mid wife to site 2 large bore(16 -18g) I.V cannulae. Blood is obtained at the same time and sent for blood group and cross match would you cross-match blood?? . Partogram is maintained which is useful to identify the disfunctional labour, if the line falls on the right side. I would ensure that the woman is well hydrated at all times. Adequate analgesia (1) is discussed by the anesthetist and provided.

b. The clinical picture suggests that the women is in prolonged second stage of labour. Immediate delivery is planned after assesing the maternal and fetal well being. The options available for the delivery are low forceps or vaccum extraction ? spontaneous delivery?? . Delivery should be conducted in theatre (1) with facilities kept ready for ceasarean section. Both forceps and vaccum are equaly effective. Forceps is associated with maternal injuries and vaccum with fetal injuries these are their disadvantages ? what is their value?? . Neonatologist should be present at the time of delivery. There is no difference in low 5 minutes APGAR score in both methods.

c. I would call for help from who . Haemotologist and porters are alerted. Bladder is catheterised is this the first thing you will do when you walk into a room to assess a woman who is bleeding heavily??? .Oxygen is given by face mask. Most likely PPH is due to uterine atonicity (1) .Uterine massaging is done. One mid wife is asked to monitor her vitals and urine output. Intravenous crystalloids are initiated along with 40-50 units of oxytocin infused over how long? . I would check that the placenta is complete. If there is no contraindication methyl ergometrine is given. If still continous to bleed examination is carried in the theatre under anesthesia looking for any trauma to the genital tract. Blood is obtained and sent for coagulation profile. Injection carboprost or rectal mysoprostol is administered (1) .
Posted by PAUL A.
Tue Feb 19, 2008 10:04 pm
A good candidate should

(a)
? Know that this is a high risk labour (1)

? Recommend continuous electronic fetal monitoring. Know the value of fetal scalp electrode in monitoring twin 1 (1)

? Discuss options for pain relief in labour. Know the value of regional analgesia (1)

? Obtain venous access, FBC and G&S as there is an increased risk of C/S and PPH (1)

? Recommend vaginal examinations every 3-4h to assess progress. Know that oxytocin may be used for primary dysfunctional labour (1)

(b)

? Know that the most appropriate intervention would depend on maternal wishes, maternal & fetal condition and the presence of regional analgesia (1)

? Anticipate spontaneous vaginal delivery if maternal and fetal condition satisfactory and there is progressive descent ? associated with low risk of maternal / perinatal morbidity (1)

? Justify need to perform operative vaginal delivery in the operating theatre (1)

? Vacuum extraction would be the procedure of choice in the absence of regional analgesia. Associated with lower risk of perineal laceration (1)

? Non-rotational forceps have higher likelihood of successful delivery ? can be undertaken with pudendal / regional analgesia (1)

(c )

? Know that uterine atony is the most likely cause. Prompt intervention is required to minimise the risk of morbidity / mortality (1)

? Call for assistance from anaesthetist, midwives, additional medical staff and porters. Know the importance of teamwork (1)

? Know the importance of following local guidelines / protocols (1)

? Assess volume of blood loss, airway, pulse, BP. Commence resuscitation as appropriate (1)

Obtain venous access, blood for FBC, crossmatch, clotting (1)
? Rub-up a contraction / use bi-manual compression and empty the bladder if uterine bleeding persists (1)

? Administer oxytocic agents ? ergometrine iv + oxytocin infusion (1)
.
? Commence iv fluids ? crystalloid / colloid and if bleeding is severe, O Rh negative blood (1)

? Exclude retained products (1)

? Consider additional uterotonics including carboprost and rectal misoprostol (1)
d Posted by PAUL A.
Mon May 7, 2012 01:39 am

asd