HANDBOOK OF OBSTETRICS AND GYNAECOLOGY by Thomas J. Borody M.B. BS., B.Sc. (Med.) Roderick D. Peek M.B. B.S. B.Sc. (Med.) Clifford O. Rosendahl M.B. B.s. Edited By Barry G. Wren, M.D. M.B. B.S., M.R.C.O.G., F.A.G.0. Senior Lecturer in Obstetrics & Gynaecology, Uni. of N.S.W. With Illustrations by Susan Casey First Edition 1975 PRINTED IN HONG KONG BY DAI NIPPON PRINTING CO (H.K.) LTD.FOREWORD In 1972 the School of Obstetrics and Gynaecology at the University of New South Wales introduced a new curriculum and assessment scheme based on modern educational principles. The basic concept was to develop many workable Units of Instruction containing relevant material which could be learnt in about 10-20 hours of structured student activity. Each Unit of Instruction had an overall aim stating the fundamental concept to be learnt, the reason for learning the material and the level of competence to be achieved. The aim is called the General Instructional Objective for the Unit of Instruction. A series of Learning Strategies was then developed for each Unit of Instruction, stating clearly where the student was most likely to learn the relevant material to achieve the competence required for the General Instructional Objective. Finally, a sample of the behaviours a student should exhibit, to show he has understood, and can achieve, the General Instructional Ob- jective, are listed. The samples of the Specific Behaviours which the student must exhibit at the completion of the course contain re- presentative material from the three domains of knowing (cognitive), doing (psychomotor) and careing (affective). When assessing whether the student has achieved the required standard of competence in the course, only the Specific Behaviours are examined, and because a large number of the behaviours are not examinable by conventional means a new type of assessment was devised based on student/patient interaction and problem-solving devices (Patient Management Pro- blems). When the students first entered the course, they were given a copy of the new curriculum and a comprehensive program was drawn up to allow greater student/patient contact. A series of introductory lectures was given at the beginning of the term followed by multiple small group tutorials based on provocative cases. Notes and reference books were provided but the students felt that a large amount of material was not adequately explained regarding its relevance, and where differing opinions occurred, confusion among students became ‘a source of frustration.During the fist term of 1974, three students (Tom Borody, Clit Rosendul and Rod Peek) suggested that they write a handbook to explain, in reasonable deal, the vatious points which required cari fication. They were eventually persuaded. to write this handbook covering all te Units of Instruction so that stadents coming late to the term could easily read and organise their thoughts on any of the Units of Instruction. On completion of the text the illustrations were Kindly prepared by Susan Casey, another medial student. ‘This handbook is not intended to replace the notes or the reference ‘books but isto act as a means of quickly identifying the itereation- ship of the content material in each Unit of Instruction ‘Although it was prepared with the course in obstetrics and gynaeco- logy at the University of New South Wales ia ming, it may be of value ‘over students. Each chapter begins with the curiculum plan clearly se out for a speciic Unit of Instruction and the bandbook summarises the basie Cognitive knowledge required in that field of instruction. However, ‘8 previously sated this handbook does aot replace the notes ot refereace books, not does it replace the practical application, of the skills and knowledge tobe learat, to reabfe situations. I hope students ‘will find this handbook useful Barry G. Wrea MD, MBBS, MRCOG, FAGO, Seniot Lecturer, School of Obstericg & Gynaecology, Uni. of NS.W. ACKNOWLEDGEMENTS We are grateful to Smith Kline and Fresch Laboratories Ltd, Roche Products Lid. and Searle Australia Pry. Lid. for the fnancil support of this work We wish also to thank Mrs. J. Crossland, Mrs. J.R, Peek, and Mise Irene Roschepkin for typing the manuscript, and Miss Susan Casey for preparing the line drawings16, 1. “18. 1. 20, CONTENTS History Taking and Examination P [Normal Pregnancy and Normal Puerperiam Labour . oe : Disproportion, Prolonged Labour, Occipito-Posteriot and ‘Teal of Labour 3 ‘Hypertension in Pregnancy Bleeding in Easy Pregnancy Bleeding in Late Pregnancy Foetal Well: Being a ‘Complications of The Puerperium ‘Abnormal Presetation and Multiple Pregnancy Maternal Diseat in Pregnancy ‘Anaesthesia in Obstetrics and Gynaecology LLeucorthoea and Pelvic Infection Prolapse and Uterine Displacemeat Dysmenorchoea, Dyspareunia, Endometriosis, Adenomyosis Inerility, Amenorchoen and Contraception [Abnormal Bleeding ia Non-pregnant Females Benign Tumours of The Genital Tract Gynaecological Malignancy Product Information ® 99 m BL ur m 189 219 m9 27 07 ms 36 30 395 23 CHAPTER 1 HISTORY TAKING AND PHYSICAL EXAMINATION General Instructional Objective ‘Develops competence in history taking and physical examination so that normality and abnormality ean be recognised in the obstetrical ‘or gynaecological patient. ‘Specific Behaviours 1, Demonstrates an ability to elicit all the relevant history 2 Demonstrates an ability to competently examine a patient 3. Demonstrates empathy in taking a history and conducting. physical examination 4. Desertes observations made during. physical examination of patent. a ‘History Taking and Physical Examination Otstette History ‘Name and matial satus Age Parity (ex. Para. L+1 means one delivery of more than 20 weeks gestation plus one delivery of an aborfus ‘of less than 20 weeks gestation).2 LHANDROOK OF OBSTETRICS AND GYNAECOLOGY Last menstrual Record first day of last meastrual period, and period (LIMP) ask about its duration, volume of flow and pain. Did it appear normal, or was it merely spotting. If the latter is the case then the second last men strual period should also be recorded in case last ‘menstrual period was really an implantation bleed. oyele (g. $72838) Ask whether patient was on the “Pill” shorly before falling pregnant and, if $0, ‘whether regular periods had been reestablished Since cestation of “Pll” Expected date of Method of calculation in a 28 day cycle: delivery (EDD) eg LMP. 38.73 add 10 days and 9 months EDD. 13574 If jee is longer than 28 days, the E:D.D. is brought forward by the extra number of days in the period. The converse is done if the cycle “is shorter. Number of weeks As calelated from L.M.P, amenorthoea| ‘Nationality Important in eg. Thalasstemia Anticipated Patent will need to be advised re contraindicated foverseas rip immunistions, Past History Obstetrical: Wauriy abo] Resch Tanat Menstrual history Age at menarche. ‘Menstruation since thea. Contraceptive History. Details of all contraceptives used, Was any contraceptive used when the present pregnancy began? "RERG?] comncaon ex] we —e ‘Gynaecological [HISTORY TAKING AND PHYSICAL EXAMINATION 3 Medical: ‘Any heart disease, eheumatic fever, hypertension. ‘Any TB. asthma, bronchitis ‘Any Urinary Tract Infetion or Pyslonephritis, Surgical: Any operations or accidents ‘Any D & C's (often not regarded by the patient tobe an operation), Any transfusions. ‘NB, “With respect to D & C's or other operations of significance, record the date, place snd mame of the H.M.O- involved. Family Heath Any serous illnesses in close relatives. ‘Any TB, diabetes in the family. ‘Any history of twin. Social If patient is singe, ask what her plans are for the infant, Do you think the patient needs to see a Social Worker. Is shea mower of a Medical Benefits Fund? History of Present Pregnancy ‘Ask about the common symptoms of pregnancy [Nausea and vomiting. Breast swelling and tenderness. there any scalding. ‘Ask about foetal movements ‘These are first felt at 1618/92, amenorthoes in imultgravidas and at 18-20/52 amenorthoea in primi gravida ‘The exact day that they are frst felt should be recorded if possible. Movements are. fist felt as faint sensations of “bubbles” or “buter- fis in the abdomen.” Abnormal symptoms and influences: ‘Ask about pain, P.V. bleeding, and abnormal discharge4 [HANDBOOK OF OBSTETRICS AND GYNAECOLOGY ‘Ask about abnormal urinary tract and bladder symptoms, ef. urine retention, ‘Ask about any infection at al, e~, respiratory {race infection. ‘During the 2nd and 3rd trimesters, ask about headache, visual disturbance, and finger oedema (Goes her wedding ring fee tighter ‘Ask about any drugs or medications 1s she taking iron and folate tablets and, if s0, does she have enough ‘to ase unt the next Visit ‘System Review ‘Ask about: Now investigate Medications or drugs at preient. Allergies. Smoking. Alcohol intake. ‘Weight; normal and any change. [Last Pap. smear stems in detail as indicated by previous findings Obstetrical Examination General impression Hands and nails ‘Radial pube Feet Teeth and oral hygiene Thyroid Thorax Breasts [Note anything obvio ight; weight. Blood measure ‘Sweling: varicosities ‘Any enlargement Tnspect and auscuate the heart and lung fields Tnspect — Any datkening‘of the arcota ‘Any enlargement of Montgomery's tubercle. ‘Any increase in venous engorgement. Palpate — Any fluid’ expressable from the nip- les ‘Any tumps [HISTORY TAKING AND PHYSICAL EXAMINATION 5 Abdomen Funda height Foxal lie Presentation Position Attitude Engagement Inspect striae, sears, anything obvious. Plpate liver, spleen, Kidneys, uterus. the uterus is palpable, then estimate as much ofthe following as possible: Gone of these observations will be relevant tnt close to term) Just above the symph. pubis (12/52); Midway From symph. to umblics (16/52); Just above umbilicus (24/2). Divide area from umbilicus to xiphistermum into thirds. Fundal tights at the upper level fof each third are consistent with 28, 32 and 36 ‘weeks amenotrhoea respectively “After 36/52 the fundus may descend to a variable egrce depending on whether the head engages so that at 38/52, for example, the fundal Height ‘may also be consistent with 34/52. ‘State your overall impression as to uterine size Longitudinal, oblique or teansverse (elationship of long axis of foctus to long axis of uterus), Cephalic, Breech oF otherwise Relationship of denominator of the presenting foetal part to the mother's pelvis. As tsual pre- senting partis the head, then the occiput is the ‘sual denominator (face — mentum, breech — sacrum) ‘The denominators used to describe positions are: Occipital ~ in a vertex presentation, Mental in a face presentation. Sacral in a breech presentation ‘Normally universal flexion Engagement is said to have occurred when the widest diameter of the presenting part has pasted ‘rough the pelvic brim. This may be determined by palpation6 HANDBOOK OF OBSTETRICS AND GYNAECOLOGY HISTORY TAKING AND PHYSICAL EXAMINATION 7 ‘icant as haat, semis toling te ibe spr wh te thom nd Set ee te eat se oe er tae a a ‘Sects he ou tong Se ase ae py gen to ging Fowl hat 1s sand if 6, whe th pit of ieee peetias beckon mene eer [Notes on determining the foetal postion ifn vertex presentation Observe the following features of the cervi: ing the foetal postion ne 1. Site ‘Midiine or otherwise. se ' bee ‘Side of occiput 3. Contour : Irregularities, tumours. Ce re cipal pation wed bow to Sor SSR Eis) in Stats sis prem. pete 08 Ors Sa OF Ss s Is there any ectopic columnar 04 Back on ah of mie ‘stim he ook Say Anterior shoulder within 5 cm. of either side covered with flat pink squamous ‘of the midline. This corresponds with the point epithelium)? eee cee ee so Rapa vom) o pase rare 6. Dichrges\tee tcomig rom th ad Bek on ight ie furs tas he ns en a een awk Sak ae ‘of the midline ~ corresponds with the point of of the cervix. Seen Wen scl daw gent tom he agin. Dore he Boa Seo no? ck el oot nto Hank on Hat ie, sour tan 1 Plat Ask Se eee am Sen Dos oe Ett et eh a 9 Mek lee Be ee ohm Pai eal a levine he etemen ft ow wb, Now lize th Tet hand ju above she pai ™ and bimanually palpate the cervix, uterus and Pele ‘Aways done atthe fis vist and later if indicated. Sateal forces, Ect ee ‘ (Oren note Oe mentee, pec le firs, sec ese eee Eerie Fi Se Tee ‘a saath Os on otmcney alg os se ora ec omen, Get etal tas gett eine ad ee ea — aa ; PEs muck of he rim posible, working Holing satay sued speci (och you ee hhave Iubicated) in your gloved right hand and [Next assess the eavty by palpating the sacrum,Vagina Cervix Uterus Fognices and Adnexae RANDBOOK OF OWSTETRICS AND GYNAECOLOGY The lower two or three segments may be palpable. Is the sacrum flat oF concave? Palpate the ischial spines and note whether they are prominent To asses the outlet first estimate the subpubic ‘ange. Te should normaly beat Teast 85°. Eutimate the bituberous diameter. It should be at leat 105 em, Init is reduoed or the sub-pelvic ‘anges natrow, estimate the pos sapptal diameter. ‘This is measured from the midpoint of the btu ‘erous diameter to the tip of the coceyx, and should be at feast 7.5 em. Withdeaw the examining fingers, and examine ‘them for blood or discharge which has adhered. Normal, hypertrophic of atrophic epithelium. ‘Any eystocle,revtocele, uretheocee, ee. ‘site Contour: Keregularves, tumours, etc Consistency : Is it softened as in pregnancy? Mobily “Tenderness os £ Parous of aul Site + Midline or otherwise Dirsstion Size "Lemon" 1/52 amenorshoea. “Orange” 10/52 amenorthoca. “Grapeuit” 12/52 amenorthoe Shape: Contour, irregularity, fibroids Contisteney : Firm, hard oF soft Mobility ‘Tenderness IF there is nothing obvious to be found then there are probably no adnormalitis. Palpation fof the ovaries is dificult unless the patient is under anaesthe Gynaecological History [Name and m status ital LISTORY TAKING AND PHYSICAL EXAMINATION 9 Ae Parity Last menstrual Period and second lat ‘menstrual period Menstrual ele, Presenting ‘Symptoms History of Present Condition Post Health Family Health ‘Try to ascertain what is worrying the patient most Pursue this in a Jopial sequence, but finish up bby_an enquiry into the mejor gynaecological symptoms: 1. Pain, bleeding (elation to imercourse), dise charge of pruritus 2. Sensation of prolapse, aay urinary tract or bowel symptoms. 3. Inferility, sexual function, marriage. ‘Ones you will not uncover any problems in these aras unless you ask about them specifically. 1. Menstrual history: a. Age at menarche 1b. Regularity and duration of period. ©. Nature of period how heavy (how many pads, etc.) what isthe colour, are there any clots, Obstetrical history. Contraceptive history. “Medical and sugical histor ask about D & C's specfealy cee ae ‘Ask about close relatives, and any specific con- ditions that are indicated (eg. thyroid disorders It menorrbagic or amenortbagic, diabetes if infertile), ‘Social History Occupation. Is V.D. a possibilty in her ease. Financial security Social adequacy, ete.10 [HANDBOOK OF ONSTETRICS AND GYNAECOLOGY ‘Systers Review ‘Ask about: Medications and. drugs. at_ present or recently Ge. during present ines). Allergies Smoking ‘Alcohol intake, Weight Last Pap. smear ‘Then investigate systems in detail a indicated by findings. Gynaecological Examination General [Note anything obvious impression [Note degree of sexual development Hands and nails Radial pube, Blood pessure Feetand legs Swelling, varicosities. Face and oral cavity Neck IVP, thyroid. ‘Thorax Inspect ‘Aascultae the heart and lung flds Breasts Inspect Palpate for lamps ‘Abdomen Inspect Palpate Vagina Speculum examination Digital examination NB. Ireysolele, ectocde or stress incontinence is suspected, ask the patient to cough before Withdrawing your fingers and determine whether fan impulse is felt Describe findings systematically as set out under ‘obstetric examination. Rectal examination if indicated, Aneliary Investigations Routine Pap. smear Others a indicated CHAPTER 2 NORMAL PREGNANCY AND NORMAL PUERPERIUM General Instructional Objective Understands the changes ia normal pregnancy and puerperium so ‘that he can manage « normal pregnaney and puerperium. ‘Speci Bebaviours 1, Explains the significant signs of pregnancy Explains changes in the puerperal patient. ions performed in normal pregnancy. Explains the changes due to pregnancy Demonstrates ability to manage normal pregnancy and normal puerperium, 6, Discusses the pharmacology of and indications for drugs used in normal pregnancy and puerperium. 7. Demoastcates empathy and emotional support to patent during pregnancy and puerperium, 2 3 Discusses invest 4 s aoe em [Normal Pregnancy and Poerperom ‘A. The Symptoms And Signs Of Pregnancy ‘The significant signs of pregnancy form in Table 21 re expressed in a summarised2 [HANDBOOK OF OASTETRICS AND GYNAECOLOGY 1. The basal body temperature chart (se Fig. 16:7). If 2 patient had been keeping a temperature char, the persistence of the ralsed temperature after ovulation, together with absence of menstruation, js the earliest sign of prepnancy. This is due to the pessistence of progesterone secretion from the corpus luteum. 2 Pregnancy test All tests depend on the production of chorionic sonadoteophio, a. Biological tests i, Ascheim-Zondek Test ~ This is positive if haemorrhagic follicles oF corpora lutea develop in a female mouse 5 days ater injection of the patient’ urine. ii, Friedman tet As above, but here a female rabbit is wed and results are obtained in 2 days. ‘ii, Hogben tet ~ Injection of the pregnant patients urine fnto a female toad cause eauses ovulation with visible release of ova within 12 to 14 hous. 1. Immnological tests: Several agglutination inhibition tests exist which are based fon the principle illstated in Figure 2.1, The tests differ in their agutinating particles which may be latex particles (Gravindes), oF ted Blood cell (Prognosticon; Prepuern) ‘The test using red blood cells is more accurate (9874) than that using latex (92%), but the former takes some 2 hours to read while the latter only 2 minute. Performed early (eg. 8 days after a “missed period”) the fest may not react and a confirmatory testis usally required ft 6 weeks amenorthoes. Fale positives may be obtained ‘uring a mid-ycle LLH. peak (H.C.G. and LH. cross-react), ‘0 premenopausally when LH. rises ‘3, Amenorthoes - In a previously menstruating woman the presence of amenorehoca suggest thtt-a patient is pregnant until proven Stherwise, Pregnancy may, however, be resent inspite of menstrual= like Dieeding whose mechanism isnot known, or due to implantation (placental ign). i 24, Pence of te aenatin ton tpn, poser BBSRERRSERESoenoveene [NORMAL PREGNANCY AND NORMAL PUERPERIUM. B he ib Sianesth oars =, ie Basal body temperature chart Pregnancy ext ‘Amenorthoea ‘Morning sickness Breast changes Bladder changes ‘Cervical changes Palpable uerie changes Vaginal and valval changes Hlgar's sign Uterus palpable abdominally Uliasound echoscopy Ballotement Xray signs Quickening (ultgravida) ‘Abdominal enlargement ‘Quickening (primigravida) Palpable uterine contraction Palpable foetal movements ‘Audible foetal heart sounds alpable foetal pas. TABLE 21 (Modified fom Garsey etal, 172)“4 ‘uawoRook OF OBSTETRICS AND GYNAECOLOGY 4. Moming sickness. "This occurs in $0 to 60% of pregnant women ‘Detween the fourth and ninth wecks of pregnancy, although ft may persist longer. Suggested causes include raised levels of circulating Fruman chorionic gonadotrophin and oestrogens. Morning sickness 1s Usually adequately relieved by Debendox, but where antimetic and tranguilier effect are required Stelazine is prescribed. (See page 29) ‘S. Breast changes. Increased vascularity, a sensation of heaviness fad almost of pin is de to the raised Oestrogen and progesterone Ievels. There is alo en increse io the pigmentation of the nipple and areola, together with enlargement of the areola. Montgomery’ tubercles (otermediates between sweat and true mammary glands) become prominent, By week 16 colostrum may be expressed from the breast 6, Bladder symptoms. Frequency will occur between the 6th and Th weeks amenorrhoes inigaly, ts eauses inclide an ineeased renal slomerular fitration rate, bladder hyperaemia, and pressure of the bterus on the bladder Frequency at in pregnancy (36 to 40 weeks) i caused by the compres- son of the bladder by the uterus aginst the pelvic brim. 71, Cervical changes consist of softening and a deep blue discoloration Of the cervin, due to increased vascularity and water content, and reduced collagen 8 Palpable uterine enlargement is best compared with everyday objects golf ball size ~ 6 weeks Small lemon ~ 6 10 8 weeks ‘orange ~ 80 10 weeks srapefruit — 12 to 14 weeks 9. Vaginal and vara changes include pulsation in the lateral for ‘ies, darkening ofthe vaginal mucosa, and vulval varicosities (Kluge's sian). 10, Hegar’s sign is elicited on bimanual examination when, due to the softening of the lower segment by ‘esizogens the examiner's fingers appear to almost meet (Fig. 22) and is usually felt between ‘Sand 10 weeks, 11, The uterus spapable abdomiaally at about 12 wecks amenorrhea, Its fleas dette mass above aad deep tothe symphysis pubis. 12, Usrasonie echoscopy can be used to visualise the uterine contents 13 Internal ballttement is illustrated in Figure 2.3. and it depends on a ficely floating forts within the membranes [NORMAL PREGNANCY AND NORMAL PUERPERUM 15 PPRLS {Fe.22, Hepicsign. The eamines ges apptr amos! tomes. 14, X-ray signs. With good techniques eakification of foetal bones may be seen at 16 weeks. 1S, Quickening in the multigravida it probably felt earlier than ia ‘the primigravide because of previous experience. 16, Abdominal elargement i first noticeable at about 16 weeks. 17, Quickening inthe primigravida should be enquited for. The fel of early foctal movements may be described as a faint “butery ‘movemeat within, or that of “bubbles” inthe abdomen 18, Palpable uterine contractions, Soon after implantation the uterus exhibits intermittent, painless, iregular contractions. These become ‘palpable st about 20'weeks, and are called Braxton Hicks’ contractions 19, Palpable foetal movements. Detection of these is irregular and may depend on the thickness of the abdominal wall 20, Audible focta heart sounds. This refers to the foetal heart founds that are picked up in the antenatal clinic with a foetoscope. ‘These appear at about 24 weeks amenorthoea. With electronic means the heartbeat can be picked up mach earlier 21, Palpable fstl parts. This sign is used more for finding. the6 RANDROOK OF OBSTETRICS AND GYNAECOLOGY ‘Pe, 23, Inealblotenent of fet in aly pean. lie and presentation than to confirm the presence of a pregnancy. B. Physiological Changes In Pregnancy ‘In the pregnant woman not only does the genital tact show changes ‘but physiological alteration take place throughout the body ‘Three generalisations may be made with respect to central nervous stom. Toe. patient may exhibit easy faigabilty and somnolence, ‘euphoria and wellbeing, and. sometimes depression and chronic Fatigue probably due tovexcesive weight carrying Inthe cardonascular system the cardiac output increases by a maximum 0f 20% due to both rate and stroke volume incense. The caus ofthis is obscure but may be due to the placenta acting as a shunt, The [peripheral vessels reduce ther resistance 50 that peripheral blood flow increases 6-fold near term. Progesterone reduces vascular muscle tone, and oestrogen reduces the acid mucopolysaccharides in the walls ofthe larger vessels. Varicose in the legs are more common dae, in pare, tothe higher venous pressure distal to the uterine obe- traction of the inferior vena cava. Haematological changes include a blood volume inerease of some 50% [NORMAL PREGNANCY AND NORMAL PUIRFERIUM. "7 by the end of the second trimester, mainly due to an increase in the plasma volume as a revult of aldosterone antagonism by progesterone And water retention by oestrogens (Fig. 24.) The haemoglobin falls {5 a consequence of the plasma volume increase, to some 12 g.% at 432 werks, even though te toll red blood cell mass does show some increase (Fig. 2.4) The leucocyte count increases from @ mean 4500 to 7500 cells/mm’, and plateles rise from some 200,000 to 300,000 ‘near term, and 606,000 in the puerperium. The erythrocyte sedimenta- tion rate (ESR) rises fourfold with the increased levels of fibrinogen. ‘Hacmodilution masks the increase in the total plasma proteins. The ‘more imporiant changes are shown in Table 22. Blood lipid levels also vse significantly, being highest sear term. Fa. 24, Boo! yume and haemoglobin chang lathe nomal pregaty ica rom Hen aS) ‘Changesin the respiratory systeminclud an increas in the tidal volume (minute volume rss from 7.25 to 105 lites) due to a 20% rise in the oxygen consumption. Near term the lower ribs tend to flare out, Rising oestrogens are responsible forthe gum hypertrophy sometimes found in pregnancy. Progesterone, by reducing muscle excitability ‘ecreases intestinal motility leading to constipation. The musculature ‘of the caufiae sphincter is relaxed and may allow regurgitation and heartburn. Renal blood flow increases by 25 to 50% and the glomerular filtration rate by some 50%, However, since tubular reabsorption is unaltered the clearance of many solutes for example, urea uric acd, and glucese, is increased ‘Metabolic changes in pregnancy are complex and under much investi-1B LHANDAOOK OF OBSTETRICS AND GYNAECOLOGY sation, There is general increase in the metabolic rate, largely due {fo foctal demands, Oxygen consumption rises by 20% and the thyroid sland hypertrophies in perhaps 707 of patents ‘The carbohydrate metabolim is afected by human placental lactogen during pregnancy. This hormone aatagonize the action of insulin, breaks down body fat, and thus acts towards the elevation of blood shicose levels. Asa result insulin ies to even higher levels increasing glucose utilisation but restricting any abnormal blood level. (Fig. 25). The increased demand on the pancreas may at ths tage uncover a laient diabetic. Protein metabolism shows an overall positive nitrogen balance, some 500 grams of protein being retained by term. This fac calls for high protein dit during pregnancy e-25, Pasa nul sponte te suo test meal Pancreat stinuation {lta s maui! dase t i reser de to steal nang ves non nhs, acm ctogen. Mode ‘rom Hyena, 151 Fat isthe main form of maternal stored energy during pregnancy and most oft sin the form of depot fat. Blood lipid also increases signi= icantly. The importance of this lies in the fact that since geo stores are low any major tree will draw quickly on fat for energy thus predisposing to ketosis. ‘The average total weight gain should be some 12.5 kg (28 Ibs.) the main increase being in the second half of the pregnancy. It should not exceed. S00gm) week Endocrine changes in pregnancy are sumerous and important. Sophis- cated immunoassay techniques ae revealed an unexpecied versatility fof the placenta as a source of pititay-ike hormones. ‘8. Hunan Chorionic Gonadotrophin (HCG). HCG is & glycoprotein with a molecular weight of about [NORMAL PREGNANCY AND NORMAL PUERPERIUM. 9 30,00, and is produced by the trophoblast It is tempting to ‘conclude that Langhans calls of the eytotrophoblast are the ultimate source since ther decline in the placenta parallels the production of HCG (Fig. 2.6, Hytten ef af, 1971). Rade foimmuncassay techniques can detect HCG in the serum 10 days after ovulation of 2 to 3 days after implantation, but ‘standard pregnancy tests become reliable some 26 days after conception, or about 40 days after the last menstrual period (CMP) ina woman with 28 days cycles. The action of TCG. isto maintain the corpus hiteal secretion of oestrogen and progresterone until the placenta has developed suBiciently fo take over all steroid production High levels of H.C.G. may be associated with: Hydatidiform mole * Choriccarcinoma { (Choriocarcinoma of the testis) Twins Severe precclamsia (Leraine et a, 1971) ‘Pi.26, Serum hr goadotophin ad wrnary pregame and onl atin in onal pecs. Med tom Hyena 193 Human Placental Lactogren (H.P.L) This hormone was previously called human chorionic somatomammotrophin (H.C.S). Produced by the trophoblast[HANDROOK OF OBSTETRICS AKD GYNAECOLOGY itrises steadily throughout the pregnancy (Fig. 27). Levels of HPL. can therefore be used to detecmine the state of the plaeata, although this testis not generally wsd as yet, being fn an experimental stage. HPL. has a mammotrophic ‘effect on the growth of the breast, and may influence also ‘carbohydrate end lipid metabolism. fe, 27, ern pnt hctowen in ool eeany. Mode fom ‘St ay Oestrogen and Progesterone Dring the frst 12 weeks of gestation ovarian (corpus luteum) production of oestrogen and. progesterone is important in ‘maintaining the pregnancy. After this time placental pro- ‘duction of both hormones makes the foetus more slf-suicient. In the production of oestrogen the foetus and placenta work together a8 a unit, in which the placenta can earry out certain synthetic steps, and the foetal adrenal and liver the remaining steps. Measurement of the urinary levels of oestriol, a d= tradation product of the potent 17 oestradiol ean therefore ive an index of the wellbeing of the foctoplacental meta bolic unit. The syncytial eal of the tcophoblast is probably the ultimate source of the hormone (Deane ef al 1953). ‘Actions of Oestrogens During Pregnancy i. Protea aynthesiis stimulated atthe clllar lve fi, tera ~ oestrogen stimulates growth of the myometrium, fil Breast ~ growth of the duct system is stinulated. 1. Connective tse ~ alternation of polymerization of acid ‘mucopolysaccarides increases the stretch properties of collagen (Hytten er al 1971), and increases hygroscopic, (quilts producing water retention. vy. Serum protein changes ~ there isan increase in hepatic protein production (see Table 22) [NORMAL PREGNANCY AND NORMAL FUERPERIUM, a ‘Plasma Protein Alterations Daring Pregnancy Protein Change Total protein Rises ‘Tota protein concentration - Falls (due to haemodiution) Albuania Globulin ratio” — Falls. ‘Albumin alpha, alpha and beta Fells Globulins '2,22,and 8 ~ Rise (ransport globulins) Gamma globulins Gamma globatins ~ No change Fibrinogen = _ Rises (25 to 507% increase, Clotting factors 79,1012 Rise aati? ‘Actions of Progesterone During Pregnancy 4. Reduction of smooth muscle excitability especially in the Uterus, protets the foetus from expulsion, To a lesser depree this same effect is seen in the ureter, stomach, and large bowel, predisposing these to dilatation and reduced motility. Hyperthermia progesterone causes the raised basal ten perature ater Ovulation Ii, Far metabolism ~ progesterone promotes fat storage. jv, Breast ~ growth of alveolar structures is stimulated. ‘One ought to keep in mind that many of the abovementioned changes are to some extent dependent on more than one hormone 4. Other Hormones Adrenal cortieal homones, thyroid hor ‘mones, and numerous other hormones ‘undergo vasious changes during a pregnancy, but these will not be discussed here For detailed descriptions refer to Hytten ef al, 197L ©. Tavestgations Performed la The Normal Pregaancy 1, Pregnancy test: This is performed on an early morning mid stream urine specimen (see page 21) (only if there is doubt re- ‘arding the fact of the pregnancy). 2 Blood tests: Performed at the frst visit 18. Blood group. Tae ABO and Rh groupings are performed. 1. Anibody sereening. All patients whether Rhye of —ve, tested. Besides D-antbodies occasional antic, anti-Kell, find immune ant-A and anti-B antibodies will be detected,2 [RANDBOOK OF OBSTETRIC AND GYRAECOLOGY ‘The purpose here is to forewarn any cross-matching diffcultes, and to alere the doctor to seh Babies ac may need exchange {ransfusions. In Rh —ve women screening should be caried ‘out again at 28 weeks and if Deantibedies are found appeo- priste management is undertaken (se Chapter 8). At any Stage, the mere presence of Deanibodies 1s significant no ratter what the ‘it, &. Hacmoglobin~At about 12 weeks the lower timit is 120em2% ‘At no time during the pregnancy should the haemoglobin {alt below 10Spm 7. A second haemoglobin estimation is made at 32 to 36 weeks, d, Rubella antibody tre. "A titre of 1/20 or more is positive evidence of rubella infection. The test provides baseline For ny future comparison if infection is suspected. ce. Wasserman (complement fixation) and Kahn (Boccultion) tests for syphilis are routinely carried out 3. Urinalysis: A midstream specimen is tested after a vaginal toilet fo remove contaminating seretions 12. Side-room analysis including specie gravity, protein and ‘sugar content ate performed 1, Baca sereen text (B.S.T) is routine in some centres, and shouldbe carried out when urinary tract infection i suspected, 4. Papanicolaou smear. A cervical smear for cancer is routine on the fis vst in antenatal linc. 5. Chest X-ray is ordered if @ year has clapsed from a previous chest Xray. D. Management of « Normal Pregnancy ‘After confirmation of the pregnaney, enrol the patient in an antenatal linc (whether private of hospital) and explain the importance of attending regulany (Gee Chapter 8). For an accurate asessment of the early uterine size is esenial to have the patient attend an an tenatal cling before 12 weeks amenorthoea. During the dst vis 1. Full History Resord the date of the last normal menstrual period, and cal- culate the expected delivery date (EDD). ‘Take a full medical history enquiring especially about past rubella [NORMAL PREGNANCY AND NORMAL PUERPERIUM 2 infection, diabetes, renal disease, cardiac function, respiratory function, and any past lines, ‘Take a Tull surg! history including any previous blood trans- fusions, surgery on the genital teact (previous Casesarian section), ‘and abdominal surgery. Record in detail any previous obstetric and gynaecologic history (Gee Chapter 1) emphasizing any previous abnormal conditions 2. Examination {A general and pelvic examination i carted out (ce Chapter 1) Daring the speculum examination a cervical smear is. taken. (On bimanual palpation the size of the werus is estimated. 3. Laboratory Investigations Routine tess described above are performed. Subsequent Vis th weekly until 32 weeks 1D. Fortnightly until 36 weeks Weekly until delivery During the “subsequent visits" a routine is followed which will include: General engi pain, ot bleeding. Any questions ere answered. ‘Weight, blood pressure, Tundal eight, presence of foetal heart sounds of of movemeats. = Oodema of the bands. ‘Avurine sample is tested for protein and sugar. [At 32 to 34 weeks the foetal postion js checked and external ‘version may be undertaken in case of a breech presentation, [At this vist the second aeroglobin estimation is made. [At 360 38 weeks a pelvic examination should ideally be carried fut to assess pelvi adequacy. 5 as to health, especially any discharges, Comsetiag It is the obstetriian’s duty 10 volunteer information to the pregnant patient concerning intercourse, clothing, exereise, immunization, Emoking and traveling. Various misconceptions ‘concerning, form4 HANDBOOK OF OBSTETRICS AND GYNAECOLOGY example, diet, should be cleared up. Unmarried mothers may obtain ‘2 government allowance and this information should be supplied E, Changes In The Puerperal Patient ‘The puerperium may be defined as that period following childbirth in which the genital organs retura to their pre-pregnant condition. is usually regarded as being 6 weeks following deliver |. The Uterus, At the end of the third stage of labour the size of the uterus is that of «20 weck pregnancy. Over the next sx weeks its weight reduces from 1000g to some 40g, and remains slighty rger than in the pre-pegnant condition, ‘This involution takes place by cytoplasmic autolysis secondary 10 oestrogen withdrawl Giinically the uterus regresses by about one fingr-breadth per day, sinking behind the symphysis by day 10 to 12 postpartum. 2. xdometrium cegenerates by day 10 postpartum in all areas except fat the placental site. Here regeneration takes some 6 weeks, 3. Loch is the puerperal vaginal discharge. Initially, for about 44 days, a ced vaginal discharge (loca rubra) i preset, but this is soon replaced by a more serous one (lochia serosa) for the next 6 days of so. Finally, for the next 4 weeks a yellowish (0 White discharge lochia alba) is produced which diminishes in ‘volume and disappears. 4. Cerve. The cervix is at fist Mabby, bruised, purple, and will ‘admit 2-3 fingers. Within 7 days dic 10 water los and muscle ‘growth the os wil admit one finger only. The permanent change {the cervical os is illustrated in Figure 28. Pe, 28, The ceva ota the A. muliparous, and B, pais woman R ‘The management will be discussed under [NORMAL PREGNANCY AND NORMAL PUERPERIUM. 2s Vagina and Vulva rapidly regain thei tonicity and by week 3 after parturition the vaginal size bas returned to normal “The Blood changes include a reduction in the volume and cardine ‘utp, which teach normal levels by day 5. The haemoglobin falls, Thre isa lecocytosis at parturition which slowly resolves. ‘The tlrinogen Tevels increase in week one ater parturition and then fall to-normal levels ‘Weight loss on the average is 2S kg (St Ibs.) during the fist week after delivery. Urinary tract. cate retention of urine may follow parturition ddue to reflex suppression of micturition, sphincter spasm, aod ‘oedema and typersemi of the bladdet. This may last for up to 24 hours and catheterization will ned to be performed. During the days following a diuresis takes place, By two wecks afer parturition the diated ureters and pelves are nearing their normal Sie Breast changes ee described later under “lactation Re-establishment of Menstruation is variable but usualy takes ome 10-12 weeks in the non-breast feeding mother, and 14 or more weeks in the breastfeeding mother. ‘Management of The Normal Puerperiam number of headings Rest and sleep is the most important need after a labour. Often fan analgesic will be required. Meanwhile a 4-hourly temperature chart is commenced to detect Any infection or other complications Early ambulation helps to strengthen the pelvic floor muscles and to drain the lochia. Advice on post-naal exercises is aso given ‘Pile of mala. A stetle pad is worn as long as lochia discharges, and a shower is taken after each motion Rooming-in with the baby during the day is the ideal situation where the facies allow. This procedure is psychologically good Since it reduces anxiety, and allows demand:-feeding to be practised as well as giving mother the opportunity to leara baby care early under supervision. "Third day bles”. Temporary depression coinciding with breast,6 "HANDBOOK OF ORSTETRICS AND GYNAECOLOGY agorgment may sen, when the excitement ofthe bith has {GeI down and problems of really re returning, Sympathy and ‘Sumsclng are reauired 6 After pans occa especially in he mukipara alter betting, IEE ee to warns Involason contactons ab simulted BY tenn (ie 29) ap emer in en ete fener rem ee Sere ete mers ae eaicumeearetenae eee eaeaniarmane Pe 17. Discharge from hospital is effected when: the baby is feeding well, and is not jaundiced, the uterus is involuting, normally, all tears and incisions are healing, 1 thee if n0 suspicion of deep venous thrombosis, ‘inary fonction is normal ‘A postnatal visit is arranged for 6 wecks after parturition, mean- ‘ehile the patient it warned to report any fever, bleeding, of breast tenderness. [NORMAL PREGNANCY AND NORMAL PUERPERIUM 2 Daring the postnatal visit attention is directed at the return ‘of the genital tract to normal, at lactation, and at any problems that the patient may have, such as stress incontinence. A cervical ‘smear is albo taken. Discuss contraceptive advice and offer the various alternatives. G, Lactation and Breast Changes Dring pregnancy the effect of oestrogens and progesterone on the breast isto increase the growth of alveoli and terminal ducts, ierease the weight ofthe breast, and cause pigmentation, enous engorgement and prominence of Montgomery's tubercle. The stage is set for mile ‘production but none is produced, excepe small amounts of coloseum, Until the oestrogens and progesterone production falls at parturition. Milk "comes in at about the third day post-partum. The mechanisra of lactation is illustrated in Figure 2.9. The baby's stimulation of the nipple sends neural stimuli to the hypothalamus which releases oxy- tocin and mediates the release of prolactin. The prolactin mobilizes the raw materials required for milk production. The oxytocin causes the myo-epithell cells in the breast {0 contact forcing milk out into the dict system of the breast. It also speeds up uterine involtions. ‘The amount of nipple stimulation therefore determines the amount of milk produced. ‘The baby does not suek the milk out but eather compresses the lactferous ducts with its gums so forcing the mile Jnto its mouth. The maximom time io minute, spent by the baby at each breast, should be no greater than the baby’s age in days, reach- ing a limit of 10 mainte, Advantages of Breast Milk and Breast Feeding When comparing breast milk with cow's milk the following advantages may be observed: Protein: Even when diluted 1: 1 cows milk has mote protein asin) ‘than has breast milk. The difference however, lis in the quality, the human protein being more easly digestible. Moreover, human eascin promotes greater Ca* and Fe? * absorption aswellasgreater sulphur fetention. Maternal antibodies (IgA) are also passively transferred in the milk, Carbohydrates: There is more carbohydrate in human milk Quality of far: Although the quantity is not diferent, human milk has the advantage of containing the ei-cs form of the esental fatty acid, linoleic acid. Cow's milk contain this acid but in the cistransB HANDBOOK OF OBSTETRICS AND GYNAECOLOGY form which canmot act as an essential fatty acid. Humen milk also contains higher proportion of unsaturated fatty acids. tecroyte load is important inthe neonate since the immature kidney ‘anaot produce concentrated urine. Even when diluted 1:1 cows ml caties a higher elcrolyte Joad than human milk, and because nore water is required to clear this load the infant would be more Sceplile 10 dehydration Vitamins: Cow's milk contains less vitamin A, C, and E. ‘Susceptibility to infection is lower in the breast-fed child, in part due to the vigorous growth of lactobacllas inthe lower gut, so preventing puthogens from gaining a foothold. Human milk i rich in oligosac- {arides which encourage growth of lactobacilli bides, Other advantages: From the maternal point of view the following advaniages are probably the most important. ‘An emotional bond and maternal satisfaction develops. This ob- ously is dificult to measure but is a zeality to those who have experienced the feling Uterine involution speeds up (Fig. 29) Menstruation is inbibited for a longer petiod of time probably as a result of prolactirs inhibition of FSH. and LH. release [Breast milk is always atthe eight temperature, its fee, and there {sno need fr sterilizing, mixing, heating, botle washing, oF special arrangements When travelling. Complications of Lactation 1, Inadequate lactation is uewally dve to inadequate prolactin pro- duction through lack of nipple stimulation (Fig. 2.9, and here Interval Between feds should be reduced to 3 hours. 2 Breast engorgement results ftom a failure of the “et-down” efit. Tr may be improved by sub-ngual or intranasal oxytocin, together with manual expression, if the baby cannot suckle 3. Infection is predisposed to by lack of hygiene, obstruction and stasis, and cracked nipples, Since the bosptal staphylococci fae ually penicilin resistant streptomycin by injection is the . Ina motipara ~ about 3 hour 4. “Bearing Down” This is due to descent of foetus compressing the rectum. ‘Results in a great increase in intra-abdominal pressure which js wansmitted to the uerus and reinforces uterine contractions (Fig. 34). ‘¢. Materially assists in expulsion of the foetus. 4. Should be discouraged until the cervix is fully dilated and 2 contraction is occurring, otherwise, stretching of the lateral ‘cervical ligaments occurs, predisposing to prolapse at a later stage. 160; mm Hg 120 A 80) 40) B Minutes 34, tof tig down, a ‘8 “nse mirautcine prose dt i Concton anour 3 5. Balglg of the Perineam — 8. Occurs when the foetal ead reaches the vaginal opening, 'b, Increases with each contraction May result in perineal teasing unless an episiotomy is earred cout 6 “Crowning” the term applied when the preseating partis visible, ‘between the labia minora, 1. Mechanism — see seston 9, ‘The Third Stage of Labour Onset ~ following delivery of the baby. Completion — with delivery of the placenta. ‘Duration ~ should be no more than 30 minutes, ‘Separation of Placenta results from — ‘8. Retraction of uterine musculature (after birth of the Baby), which also compresses the maternal blood. vessel Continuing contractions ©. Spread of extravasted blood throveh the decidua 5. Sings of Placental Separation A permanent lengthening of the umbilical cord, ouside the vue. '. The fundus ofthe uterus ives and becomes firm and globular. © A gush of Blood occurs, rom the vagina 4. Upward displacement of the fundus fils to shorten the umbilical cord outside the vulva. “The Physiology of Normal Labour I : The Passages = the bony pelvis and the fi 1, The Bony Pebisis conveniently thought of as having a brim (nk), cavity and an cult The pelvic brim ~ i. Boundaries sot sues,cy Table 3.1 Brim Casity Outlet [HANDBOOK OF OBSTETRICS AND GYNAECOLOGY «upper surface of back of symphysis pubis, 1 the pubie erst, the pectveal eminence, the ilo-pectineal line (lac portion), the sacroiliac joint, the sacral promontory. ‘Summary of Pelvic Diameters A-P (ems) Oblique (em) Transverse (ems.) W 2 1B 2 2 2 B 2 1 Biischial diameter ~ 10.5 ems. Posterior sagtal jameter ~ 75 ems Diameters ~(@wv. Table 3.1). Anteroposterior diameter (ive conjugate) ~ {rom the posterior supetior margin of the pubic sym- ‘hyis tothe eente ofthe steal promontory (11 em) «Two Oblique diameters, e4, the right oblique extends {rom right scrolliae joint to the left pectineal eminence (dem) Transverse diameter ~ the widest part of the inlet (Bem) Nota teve diameter as Me does not pass ‘through the centre of the inlet. 1. The cavity ~ between the pelvic inlet and outer. ‘The plane of greatest mensions almost circular, bounded. by-anteriorly, the midpoint ofthe back of the symphysis pubis and posteriorly, the junction of the second And third sacral vertebrae. (Fig. 3.5) The plane of least dimensions — the most important plone of the pelvis. Ie extends from the lower border (Of the symphysis pubis to the ischial spines and the lower border of the last sacral vertsbrae (Fig. 3.5, ‘The pelvic eanal turns sharply forward at this level |. The bi-‘schial dlameter ~ the distance between the two ischial spines 4a “The planes of ete and est pve dimensions ha 1 peas pe nen val Ress ©. The Outer extends from the plane of last pelvic dimensions {o the anatomical outlet. i, The anatomical oulet ~ consists of two planes joining at the Ftohial tberoniies (Fig. 36). Its boundaries are — the lower border ofthe syanphysis pubis, the ischial tuberosites, and the cooeyx. ii. Diameters ~ Anteroposterior diameter ~ fom the mile of the lower ‘border of the symphysis pubis to the tip of the last saceal vertebra (13 ems)‘TABLE 32 eanove 8 COMPARISON OF THE SHAPE. SIZE AND CAPACITY TABLE 32, Gomis) owe Bumetor Gitkeou) Pubic Ach formal io Very wide fer Iroagant seine Se lone od, Bib hans bis nd hore a fe Bancer Jadeaunte, fone ‘capay fadegente —_|Adonnte Ae Ae Piad ‘Antopid | Pac Polen donate ot Hse losin (Eas Diameter listeopos- tance tes” acer Gee aad Pn St atone ie and Deyo fencaret Rbourl™ Once nt ‘Stone, uly eay. Iepased ‘tite’ tea iting Strention ommon—leyhawoid aey ftv erHANDBOOK OF OBSTETRICS AND GYXAECOLOGY «Transverse diameter — between the inner aspects ofthe two “aohialtuberostes (11 ems), Posterior sagittal diameter ~ fom the midpoint of the ‘raneverse diameter to the up of the sacrum. 216 The ott of he pat ram ba bata ston (Cassification of the Pebis: ‘There is a complete spectrum of shapes, planes and diameters of the female pelvis, There are four basie types — gynaecoid, ‘android, anthropoid, and platypelloid ~ based on the shape of the inlet. These characteristics are described in Table 3.2. (ano- iiled. from the classiiation of Caldwell and Malloy), and Figs. 37 A, B ‘The Soft Passages “The ple oor compris the soft tus ling the pie oe I's pat ty toe nals ~ the uel apna and real cont ‘The major stucture of the pelvic floor isthe levator ani musce. It arses from back of the body ofthe pubis, the tendinovs arch of pelvic fascia and the pelvic aspect of the ischial spine, and fers into the vaginal wall, the tendinous centre of the perineum, the anal canal and lateral border of the cooz}x. Lavator ani is ‘comprised of pubovaginalie, puborectali, pudscoccygeus and Hiceooeygeus (Fig. 38). Distention of the birth canal during the second stage of labour stretches (and sometimes tars) the muscle fibres. f marked, this damage predisposes to prolapse. ‘The Physiology of Labour IK: The Passenger 1, The Foetal Skull (Figs 319, 3.10) Subdivisions ~ 4, Base large, Semly united bones. They are incompressible and serve to protect the vital centres of the brain ste, 4 Face ~ fem, but incompletely ossied bones. li, Vout — thin, poorly ossted bones including the occiput, two parietal Bones, two temporal and two frontal bones.[HANDBOOK OF OBSTETRICS AND GYNAECOLOGY Wea le (Bregma) - diamond shape area formed "ty: the junction of the sagittal, coronal, and frontal sutures. Measures about 3 ems. x 2 ems. |. Posterior fontanele - a triangula shaped area formed by the junction of ‘the sagital and lambdoid. sutures thas only three sutures running ints it. i. The vertex — point lying midway between anterior and posterior fontanelles The occiput - from the posterior fontanell tothe foramen ‘magnum, ‘LanouR a ¥. The sineput ~ from the bregma to the root of the nose (glabelay bounded by the coronal sutures and the orbital edges, i. The glabella ~ the elevated repion between the two oF bita ridges. miniroRmis: ae cocevorus—7 onturaton 7 INTERNS. ey! suevator ‘38. The pve Baoe Com above ~ note contous Diameters ~ (qv. Table 3.3 and Figs. 3.10, 11). L Suboccipto-Bregmarc ~ from centre of bregma to the rape of the neck. e218, The foal ll ~ Sowing Indah (ide view),8 HANDBOOK OF OBSTETRICS AND GYRABCOLOGY li, Occipto frontal ~ from glabela to the occipital pro- truberance 310. Toe forall om stow) shoving anda and ve i fi, Mentorertical - from the of chin to 1” in front of the posterior fontanlla ‘Fe. 311, Major mete ofthe feta kl Diamar Prescation I, Supcsioeeenic ced ee E Sitwectto oral Paply dfeed verten & Girona! at een 5 Sib begmatc Far anour ° iv., Submento-Bregmatc ~ from the junction of neck and chin to the centre of the bregma. 1 Biparietal ~ between the two parctal eminences (the ‘widest transverse diameter). Foote pelvic relationships Lie ~ the relationship of the long axis of the foetus to the long axis of the mother. These axes ace usually parallel i longitudinale . Presentaion ~ the part of the foetus occupying the lower pole of the uterus ~ hence “presents”. Normally itis vertex resentation. ‘& Potion — relationship of the denominator (a particular part of the presenting part) to the pelvic brim. In & normal Fexed vertex presentation the occiput is the denominator, ‘AC the onset Of labour the most frequent position is the lateral (Fig. 312) 4. Attitude - the teatve postion of foetal pats to one another [Normally thece is universal flexion. © Engagement ~ when the biparietal diameter of the foctal skull enters the pelvic brim Fy. 312. Pequncy of pstions ofthe ost a the onset of bow.2 |MaND9OOK OF ORSTETRICS AND GYNAECOLOGY 3. Asyncitsm ~ refers tothe situation where the parietal emminence prevents at the pelvic inlet atthe onset of labour. Posterior asynlition occurs particularly in the primiparae as ‘there is beter tone in the abdominal wall and the Uerus is held ‘upright. Under these conditions the posterior parietal bone is lower than the anterior one and the sagittal suture is closer to the symphysis pubis. This is the most common mechanism of engagement (Fg. 3.138). Anterior asyneltiom occu in women with lax abdominal muscles. ‘The uterus fill forwards 0 that when the Torta head enters the pelvis the anterior parietal bone is lowermost and the sagittal suture les closer to the steral promontory (Fg. 3.132). Table 33 ‘Summary of Focal Diameters Diameter Length (ems.) Presentation 1. Suboceipto-Bregmatic 95 Texed vertex 2. Oscipito-Frontal ns defloxed vertex 3. Oscipito-Mental 1s 4. Meato-Vertical BS brow 5. Submento-Bregmatic 95 face 6 Bipaseta 9s 7. Bitemporal 80 8. Bisacromial 110 9. Bitochanteric 100 ‘The Physiology of Labour III: The Powers 1. The Myomettiam 12. Is derived from the Mullerian ducts . Is composed of 3 layers — an interdigitating spiral layer, an outer longitudinal layer, and fn Inner cireuar layer (the two later ones are unimportant) tavour a The spiral layer is more marked in the body of the uterus, where the fibres intersect at an angle of 60", than in the Tower segment where the fibres imerse:t at ‘almost 180" ‘The spirals uncoll during pregnancy. 4. Thereisa resting tone uterine muscle of about 612 mmHg. Reds Anais: 8 Rotor sett 2. Contractions ~ | Originate at a pacemaker at the junction of the fallopian ‘ube and body of the utr 7 mits ad 30 INTENSITY 20) " }ronus 0 365 = 10 Minutes Fig 2.1 Usin contractions —intensiy and regen.2 [HANDBOOK OF OBSTETRICS AND GYNAECOLOGY Cause an increase in intrauterine pressure (amplitude) (Fig. 319). © Produce, inthe lower segment, an upward pull on the fibres of the cervix, ‘4. Produce cieular narrowing in the upper segment and pre- dominantly centrally directed presture, hence the amniotic ‘uid flows into the lower segment causing a bulging of the forewaters with each contraction; and, direct transmission of the pressure tthe Foetus. ‘& Cause the uterus to become more rigid and to move forwards Strighten out the foctal spine, forcing the preseting part towards the pelvis. ‘Mechanism of Normal Labour ‘The mechanism of labour refers to the way the foetus adapts to and passes through the maternal pelvis. Tt involves — Descent Flexion Taternal Rotation Extension Restitution External Rotation anaes 1, Descent Descent is continuous throughout labour and on it the other movements are superimposed. It includes engagement. which ‘ceurs often several weeks before labour in the primipara and as Tate asthe second stage of labour in multiparous patients 2. Flexion [At the commencement of labour the foetus is normally in an attitude of flexion. With descent, and resistence encountered at the pelvic inlet or pelvic oor there is increased flexion ~ the chin approaches the chest and the occiput of the foetal skull bbecomer lowermost (Fig 315) ‘The increased flexion results in the engagement of the smaller suboceipito-bregmatic diameter (9S ems) rather than the oeipito- frontal ameter (11'S em). 1avour 3 3. Internal Rotation [As descent through the birth canal proceeds, the foetal head lates so that its long axis occupies the largest diameters of the pelvis. Henee, the anteroposterior diameter of the head must ‘occupy the transverse (or oblique) diameter of the pelvic inlet fad the antero-posterior diameter of the outlet. This Occurs with anterior rotation of the occiput during descent ~ the head per- forming a spiral movement. i.e Resta at pu he sty of he and dt = cae 1 foramen nagaum. BS neoiace ap Bah grater Mon Ra TM: results lin. ‘The shoulders do not rotate with the head. When the occiput is anterior the shoulders remain in the oblique diameter of the pelvic brim ~ the neck thus being twisted at 45° (Fig. 3.16). This Felationship continues as long as the head isin the pelvis. The ‘cause of anterior rotation is unknown Theories suggested include = a. Harts Law: “The part ofthe foetus which fist encounters the resistence ofHANDBOOK OF OBSTETRICS AND GYNAECOLOGY the lateral portion of the posterior segment of the pelvic ‘oor willbe rotated to the front” This depends on the Tact that the pelvic foor slopes forwards, dowawards and inwards, especially i its posterior par. In most cases the occiput i fist to come in contact with the pelvie floor as the head is usually well exe. OQ e216. ermal rotation ofthe out produces 34 et ia he nek, » Law of Unequal Flexibilities: ‘The strongest bands of muscle connecting the head and the trunk will occupy the postion where they are subjected (9 the least strain. The posterior muscles of the neck come 19 Tie anteriorly ~ the weaker muscles of anterior part of the neck then lie in the curved posterior part of the birth canal The Properties ofthe Birth Canal: Factors such a8 the bony pelvis, the clastic properties of the walls of the birth eaaaland the ossillatory movements produced by the uterine contractions. may combine to en- Courage anterior rotation of the occiput. The Shope of the Foetal Head may also be important. ‘The head is asymmetrical with the greater proportion ting savour 5s anterior to the mento-vertical diameter (Le. longest diameter OF the foetal skull), Fig. 3.17) Larger segment 27, Tempe part of he foal ad es attiort he enter ic ne At the lve of the ical spines the birth canal curves forward providing a great deal more room posteriorly (inthe hollow Of the sacrum) than aatriorly. Thus, the larger segment of the foetal head is encouraged to rotate to the back. Extension In birth of the bead the sinciput must travel much further than the occiput. This occurs with the oseiput pivoting around the symphysis pubis and the head extending ~ the forehead, nose, ‘mouth and chin being born in succession, AC this tage, the should cers are in the oblique diameter ofthe mid pels. Restitution Dring internal rotation the neck became twisted on the shoulders, When the head is born itis no longer restrained by the bith canal and it rotates (stitutes) back 48° ~ the normal head-to- fhoulder relationship.56 HANDWOOK OF OBSTETUCS AND GYNAECOLOGY 6, External Rotation [External rotation of the head merely reflests the internal rotation ff the shoulders. After the shoulders enter the pelvis, in either ‘the oblique or transverse diameter, they rolate back to the sntero- [posterior diameter ~ the largest diameter of the outlet. As the head is ot restricted by the birth canal it rotates frely withthe shoulders. ‘Moulding: During labour the bones of the vault overside one another, thus reducing the diameter engaging in the pelvis. Moulding refers to this ablty to adapt to the maternal pelvis. The engaging diameter is reduced and the diameter perpendicular to itis increased in length ‘The occipital bone andthe two frontal bones are driven slightly under the pata bons. The posterior prea bone dive unr the anterior one Mectansn of he Soules, Trunk gd Extremities: ‘The anterior shoulder reaches the pvc Noor stand rotates anteriorly Nhat in the opposte deston tothe ateror rotation of the decipt Te anterior shosiger i born by Intalio (poten), (Fie 318) The posterior shoulder follows again by Ir Beton, Sutin an anterior decton (Fig. 319), Once the shoulers re bor the trunk end extremes fellow with 9 special mechani ‘ig318, Tresnteir shoulders bom by teal xin ina poser ection. ‘Mechanism ofthe Third Stage of Labour: The placenta separates from the uterine wall when retraction has reduced the placental site by about 5°% Separation occurs through the compact decidua basalls~ the myometcium acting a8 a barrier fon one side and Nitabuch’s layer on the other protects the placenta from fragmenting ieregulary ‘asour 7 Haemorshage is controlled by compression of the thin walled uterine vessels by strongly retracting mosele fibres arranged in a figure-of- fight fashion. Anything which interferes with muscle retraction, ‘2 incomplete placental separation, of retained placental ragments, ‘wll result in baemorehage ‘ig 3u8. The pots shes brn by aera! Bn, in an anior ‘The signs of placental separation have already been discussed on puge 34 ‘The Management of Normal Labour (On Admission to Labour Ward | The History is recorded ~ thi comprises the antenatal record (@wv. Chapter 1) and the time of onset of contractions, the frequency” and strength of contractions, and whether the membranes have ruptured. 2 Examination — temperature, pulse, blood pressure. « The character and frequency of the uterine contractions sare observed, ._Absominal palpation - qyv. Chapter 1, and note is made ‘of the Jevel of the anterior shoulder! ‘The foetal heart Fate is recorded, The degree of cervieal dilatation is noted. . Avmigsteam urine specimen is tested for pH, protein, reducing sugar and acetone. 3. A pubic toilet and enema ae given, 4 The patient has a shower “Management ofthe Fist Stage of Labour 1. Ambulation — is allowed early, if the membranes are intactse HANDBOOK OF OBSTETRICS AND GYNAECOLOGY One the membranes ruptre, the pata shoul patent sould stay in bed in order to minimise the vk of cord rolapar” wen ‘head is well engaged, pole net Obserations If labour is peomesing spontaneously ther eno indeaion of fost sess, ech as meron sine quot ora stoning ofthe focal heat fay bee, ons are cared ot every 2 hours, naing |, maternal pulse rate, blood pressure and temperature, ii frequency, duration and stength of contractions, ii abdominal palpation especialy regarding engagement of the head eel of th anterior shoulder and fal eet me Note: a. The foetal heart rate is awculated every 15 minutes i the liquor i meconium ssncd. or ‘if oxytocin is used (q.v. Ghapter 8). ven more fequet nfording of fot rate is indicated os een 1 the qr i stained with fh meconium (Le. & light elowepeea cleus), cr fi any slowing or iregulaiy of rate is detected, ‘he patents encouraged to ass rine every couple of hours ‘The urine is sted for pH, poten, glucose snd Ketones Ceve atatin- Once te cei i lf inte, ue Feovos tt moe sap and anchand e e Se of fm: Deeriaton oe ont of te ton geass anion ors fk ‘egal eamnaton enor arase soar ees inormaton than foal smoaton apa eh ee Ta wep chee dos ees sak Staton es comptes ih al ea acs this precaution is taken. yw ‘Vaginal examination yields information regarding — Lhe cervix The condition of the cervix ~ soft or hard + The degre of effacement and dilatation. 5 anor ° The peseaton | Copal or tbr) capt exe, + Te on of he presenting parte level ofthe Pits aon mr had variation rom lll in Wc Sabor te chalet eae claw min (owl othe) Ser eine pos The poston |The diction of sgt sate in the ater ose De shia o anee dame of te pe. | Ths potion te anterior o posterior ontzei "arte sail suture cant be palpated ~ he ateo- posterior diameter of the headean be determined by Beg ene Te pins por fo the opt angois (x, Caper 12) ~ a asl eqied by the iMeaPen f the tat sige, cater bal iatation of te sev Aalesce ou eget ed te ~ 1 Pete 30g 1M + Sptie 25 g.— maybe repeated 3h some penta more potet aap 8 Tguted and morpine16-me is sometimes used, If TE eby bore wn shou of the ton, Li vos 03 mgs inetd it he mb vein ime par dey and before the cord ops pub Intalotonl eae 7O%, nitous oxide and 3% Shen The ptt should be naracted how to se he oe {When she fs « contraction egoning she should Treat tough tea Go appld tote fre) 4 Se should ot wat he contacton becomes pa If se arts ole conscious, she wil allow te tsk tol avay fom be ae ie Between conrcton ke soul rete i © Continuous epidural anaesthesia@ HANDBOOK OF ONSTETRICS AND GYNAECOLOGY 6. Nutrition In early fist stage, where inhalation anaesthesia is not to be usod at delivery the patient may have a light mea. 'b. Fluids may be taken by mouth, € Atalater stage nutrition and hydration are often achieved by intravenous infusion of $7 dextrose. Other advan- tages of having a drip set up include ~ iA route for rapid administration of anaesthetics, ‘blood or plasma expanders (Gf necessary during the third or fourth stage), i Route to administer syntocinon if uterine action is inadequate. 7. Reassurance Empathy, support and encouragement for the patient are important. Relaxation accelerates labour. Bearing down too 7 carly delays cervical dilatation (the cervin. becomes large land” oedematous), the patient becomes exhausted. and it predisposes to prolaee at a lntr date, In addition there is only a limited amount of analgesics that can be given to 2 patient ~ although the introduetion of ontinuous epidural anaesthetic has markedly reduced this ‘Sieuty “Management ofthe Second Stage of Labour: 1. Aseptic Technique Washing technique ‘A brash may be used to clean under and around the nails If washing with soap, the hands and arms should be thorough ly washed several times with the soap and the exces lather \wathed off several times: The whole process should take not less than five minutes. A scrubbing brush should not be ued fom hands and-arms as it tends to traumatise the skin and, Increase the surface biterial count If washing with a sueface antiseptic preparation thea two) minutes should elapse during which time the preparation Jn use remain in contact with the skin and i not washed olf Ail the end of the “scrub.ap" anu o 'b. Gowns and ploves must be used from sterile packs. An ecient ‘mask will Feduce the droplet spread of infection, but when worn for much more than half an hou it becomes inefficient. 2, Delivery Postion Patients will be delivered in the dorsal or lithotomy position, ‘The lithotomy position is the method of choice for it enables easier access fo\the perineal area by one or more accoucheurs. ‘There is more space to allow delivery of the head, particularly when manipulation is required to deliver the anterior shoulder. Finally, because all liquor and meconium drop immediately into the Tinen tub thee iso risk thatthe foetus wil inhale these aids ‘sth head is pushed backwards to dsiver the anterior shoulder Tf using the dosal position a small pillow should be placed under the buttocks to elevate and make delivery ear If inthe lithotomy poston, the buttocks should come down to the end. of the bed. 3. Swabbing Using, sponge-olding forceps the mons pubis and inner sides of both thighs, for a distance of six inches away from the vagina, tare swabbed with an antiseptic solution, making sure the swab passes from in front backwards and is discarded on reaching the pevianal region, [Next the labia are separated and the vaginal intritus, peri- ‘wethral and foutchette areas are swabbed. 4. Draping If in the lithotomy position the patient is draped by passing a large towel over each leg from inside the thigh. One side of the drape hangs down over the leg and inner thigh whilst the other fide hangs down outside the lithotomy pole. The drape which fs folded over near the Toot is doubled back and clipped behind the Iithotomy pole in envelope postin, After both gs are covered, third laige towel is laid on the abdomen and the lower edge ‘adjusted to come down to the mons pubis. Finally a perineal towel i placed in position. ‘The patient is now ready for delivery Deaping in the dorsal posion. A towel is Inid over each flexed thigh to cover the exposed areas leaving the vulva uncovered. ‘A third towel is placed over the abdomen and the perineal towelHANDBOOK OF OBSTETRICS AND GYNAECOLOGY placed in potion. A fourth towel is placed on the bed between {he thighs and the upper edge pushed under the buttocks. Cathetersaion If there is any indication thatthe bladder has not been emptied it will be necessary to catheterse the patient. Chlorhexidine (hbitane cream should be used Co cover the urethral orifice and the catheter pased into the bladder through layer of this cream. “There is 10% risk of introducing infection into the urinary tact during this procedure. Analgesia ‘There are many ways of achicving adequate analgesia during delivery. These include ‘4, Pudendal block either transvaginal or transpernea '. Epidural anaesthesia ~ either continuous or single shot. Oxygen and nitrous oxide (inhalation). (Refer to Chapter 12). Epsiotomny In up to 50% of primiparae the perineum either delays birth cof the head or tends to fear rather than stretch. In these cases, {tis preferable to carry out an episiotomy. Dalivery “The accovcheur may stand on whichever side e finds convenient, bbut most people will stand on the patient's right side. ‘With the right hand covered by a towel to protect the gloved hand from contamination by the anus, an altempt is made to “catch the foetal chin as the head is being born. The chin can tasualy frst be palpated and held about the region of the anus and is then eased. across the perineum. The patient is told to stop ‘bearing down at this stage. Whilst the right hand is being used to ease the head out of the vaginal introltus, the let hand is used to steady the head as it "crowns" and is delivered unde the syraphysis pubis. This steady- ing of the head prevents too rapid a delivery and consequent damage to foetal and materoal taeue, Excessive guarding of the perineum, however, may delay delivery, stretch the pubo-ervical ap0uR 8 fascia and predispose to cystocele and stress incontinence at @ later date. ‘Once the brow and face are delivered across the perineum the towel is dropped and the index finger run round the introitus to'make certain tht the mouth and chin ae fee Restitution and external rotation will now take place (with the ‘occiput turning to the left in'a baby who had been inthe LOA, postion). [At this stage when using the lthotomy poston it is often more ‘convenient for the accoucheur to readjust his stance. He should take up a position so tat he faces the fetal occiput. By so doing, the foetal’ mouth and nose are away from accoucheur and are covenient for naso-pharyngeal aspiration by the assistant. With the right hand over the right parietal bone of the infant the head is pressed downwards to ascertain if there is any cord laragfnd the neck. Ifa loop of cord is sen this may be pulled down ‘lipped over the focal skull If there are several loops of cord use two artery forceps to clamp ‘and then cut the cord, When iti certain the neck is fee of ord, (he anterior shoulder is delivered, In the LO.A, position the right hand js placed on the right side of the baby’s skull with maximum effort over the parietal bone, ‘and the let hand over the let parcial bone. Making sure that thefinger tis arenot around the neck of the baby traction is exerted downwards and away from the vagina. The anterior shoulder will now slip from under the symphysis pubs. Placing the right middle finger in the axilla from behind the head is now lifted ‘upwards and away so that the posterior shoulder is feed With middle finger in each axilla from behind the baby is delivered across the accoucheur’s body till the leps are visible With the lft hand supporting the shoulders and head the right hand is patted along the back of the baby to the legs and the ankles are grasped with the Index finger Between the ankles, ‘The baby is then held along the left arm in 2 head dowa position with the mouth diteced towards the sister for naso-pharyngeal ction. ‘When the accoucheut i satisfied thatthe airway is clear the baby6 -RANDBOOK OF ONSHETICS AND GyaaEcOLOGY is placed diagonally on the mother's lower abdomen with the head directed towards the mother’s head. ‘The cord i then clamped (at about 3 ems. from the umbilicus), divided, and he baby passed to the care ofthe sister. Ito 2} ems. ‘Should be let beyond the clamp. 9, Naso-pharyageal suction - to remove mucus, liquor oF meconium Wipe away secretions from mouth 'b. Suck out pharynx — remove secretions or these will be inhaled. fc, Nasal suction — remember that the masal cavity projects ireetly backwards (not upwards). ‘Note: The suction tube is not an instrument for stimulation ‘bat only for the removal of secretions “Management ofthe Third Stage of Labour: 1. a Im Rh positive women oxytocin (5 units) it injected intra ‘muscultly withthe delivery of the anterior shoulder of the baby. b. In Rh negative women the injection is delayed until the clamp iS taken off the segment of cord attached to the placenta in order to reduce the possibility of foetal Rh postive cells reaching. the maternal’ circulation ‘Note: ‘The blood in the placenta is foetal blood and if the pressure builds up at the placental sie escape of foetal cells may be facilitated. 2. Separation ofthe placenta This often occurs within § minutes of delivery of the infant but ‘may take as long a8 1530 minutes, The signs of separation have been described (Gee page 56). 3. Delivery ofthe placenta ‘When the uterus is felt to be fmly contacted the placenta can bbe deliver by the Brandt-Andress technigue. This involves ~ stabilising the eras by pressure trough the anterior abdo- ‘minal wall, " = and anu 6 b, traction on the eon. I the uteres is not firmly contacted before traction is exerted ‘there isthe risk of causing inversion ofthe wierus (qv. Chapter 9), 4. Following dalvery of he placenta ergomerine (0-5 mg, int Iranian) i piven provided the bloodpressure 1s not sivted (Greater than 14/90 tig) 5 nection ofthe placenta to ensure — the placenta is complete membranes are comple, there are ther cord ves, 20 placental vexels extn past the edge — suggesting & Succeatriat Ibe which may have remalned inthe wet, wei 6 Repair of piimy 2. Vaginal wall~ with 0 eats, Trot suture above aper of the inion, care fly "easring anatomical apposition down ‘Sura the ernant of the yen. ~ deep sutures to obliterate dead space, = fubeutiulae suture to approximate che skin 1b Povineum Note: If pudendal block was cattied out prior to delivery this should provide sufficient analgesia. Management ofthe Fourth Stage of Labour ‘The patient is observed carefully in the delivery room for an hour following delivery ~ blood pressure, pulse rate and signs of haemorr- ‘age being checked, ‘The uterus should be palpated abdominally co ste that its firm, not bogey” due to retained placental fragments and haemorchage (Care and Assesment of the Neonate Following naso-pharyngeal suction the baby achieves spontaneous sustained respiration within a minute. Konakion 1 mg. is injected intramuscularly. Before being placed in the cot the baby is given to the mother to hold. I the baby is slow to breathe it may be stimulated by slapning on66 HANDAOOK OF OBSTETRICS AND GYNAECOLOGY ‘the sole ofthe foot. Those infants who have not cred witha one minute require further treatment. ‘The vital signs are assessed at 1 minute and $ minutes and a score given out of 10, by the Apgar system (Table 3.4). The most important Signs are heact rate and respiratory effort. A score of 7-10 indicates 10 depression; of 46 some depression, and of les than 4 severe Aepreston Table 342 Apeae Scoring method for Evaluating the Infant Respiratory | Absent Weak ery; | Good, strong effort ypoventi: ory lation Muscle tone | Limp Some fxion Active motion; cof extremities | extremities | ‘voll flexed Reflex | ieritabity (esponse to | Noresponse | Grimace | Cry Stimulation | of sole of foot | | Heart rate | Absent Slow Fast (over | Gelw 100) | 100 a es en Before the baby is removed from the delivery room its surname ie painted om its chest with gentian vilet and latee a name band is Placed around its wes ‘The baby is washed and examined in a heated room as it has poor temperature regulation. The umbilical stump is painted with iodine. vamination incl = mops 1, Assessment of gestational age. 2 Noting any congenital defect especially ~ apo o ridlne spinal defects, baie ip or lett palate, ‘obvious cataracts, congenital dislocation ofthe hips, ', undesoended tests, Wi imperforate anus, ii deformities ofthe extremities, 3. Recording weight, length and head circumstance. 4 Any marks or deformities received during delivery, eg. caput succedancum or cephalhaematoma. ‘These must be explained to the mother who is reassured that they will disappear. The baby is then dresed, briefly given to the mother again, before pled nthe bgt oom. References 1. CAREY, HLM. (1968). “Normal Labour". Notes in Obstetrics and. Gynaccology, Royal Hospital for Women, University of ‘New South Wales. 2. “Delivery Techniques”. Notes in Obstetrics and Gynaecology, Royal Hospital for Women, University of New South Wales. DXORN, H. and FOOTE, W.R. (1964), “Human Labour and Birth”. Appleion-Century-Crofts, Meredith Publishing Co., New York. 4, LLEWELLYN-JONES, D. (1969). “Fundamentals of Obstetrics ‘and Gynaccology”, Volume 1 - Obstetric, Faber and Faber, London, 5. MILLER, NF. EVANS, T.N. and HASS ,R,L, (1963) “Human Parturition - Normal and Abnormal Labout”, Wiliams & Wilkins Co, Baltimore. 6, TURNBULL, A.C. FLINT, APE, JEREMY, JY., PATTEN, PLT, KEIRSE, MJ.N.C., ANDERSON, Anne. (1974). Lance 10}. “Signiicant fall in progesterone ‘and rise in oestradiol Jevels in bumaa peripheral plasma before onset of labour”CHAPTER 4 DISPROPORTION, PROLONGED LABOUR, OCCIPITO-POSTERIOR AND TRIAL OF LABOUR General Instructional Objective t Recognises dystocia and its causes and implications so that manage- meat ean be indicated, Speciic Behaviours 1. Distingushes between normal labour and dystocia by history and observation Describes the causes of dystocia Deserbes consequences of untreated dystoci Describes the management of complications of dystoia ‘Specie the principles of management of the causes of dystocia, Recognises malpositions causing dystocia Expline the causes of delay in the second stage of labour. Anticipates the development of dystocia whilst participating in management Disproportion, Prolonged Labour, Occipto-Posterior ‘Teal of Labourvruppeer a HANDBOOK OF OBSTETRICS AND G¥NARCOLOGY Causes of dystocia. Ginza! recognition of dystocia, ‘Management of dystocia. ‘Abnormal uterine activity. ccipito-posterior position. Sequolae of untreated dystocia ‘Management of sequelae of dystocia (Causes of delay in second stage of labour and their management. a . 1 2 Dystocia—a dificult labour. (Other commonly used terms associated with dystocia: 1. Prolonged labour ~ labour longer than 30 hours. (Labour lasting longer than 24 houre oceare in 2% of multigravidae and 107% of primigravidae). . Disproportion - disparity between the sizeof the presenting part ofthe foetus and the maternal birth canal © Cephalopelvic disproportion — disproportion, where the pre- senting part isthe focal skull. 4. Contracted pebis ~ a pelvis ia which one of the major di: meters is reduced by more than 14 cms. ©. Inertia ~ slow dilatation of the cervix; primary inertia ~ abnormal uterine action from outset; secondary inet that following a period of normal action, F. Inadequate uterine action ~ decreased amplitude and frequency ‘of ‘uterine contractions, & Inco ordinate uterine action ~ asynchronous contractions of diferent pats of the uterus. 1h. Rigid cervix — aire of the cervix to dilate in spite of normal sctvty ofthe uterus. Causes of Dystocta 1 Disproportion doe to - Foetal factors (present in up to 50% of cates): 8. Large foetus (larger tan 34 Ke) DISPROPORTION, PROLONGED LABOUR, COCIPTO-POSTIRIOR 71 hereditary, grand multipara abetc or prediabetic mother, post maturity 1. Abnormal postion ofthe ociput: |. occipito-posteror. Abnormal presentation of fetus: i. hydrocephalus + spina bifida, fi, anencephaly, ii swellings of the neck, iv. swellings of the abdomen (iver, kidney, spleen, bladder), ¥. "moasten”. ‘Maternal factors (the only abnormal factor in dystocia in up to 25% of cases): 4. Small pelvis 1b. Abnormal shapes of maternal pelvis android, plarypetiid, fil, Congenital malformation. fect of disease or nur (ear: traumatic, infective (T-B., osteomyelitis), metabolic (rickets, osteomalacia), kyphosis, scoliosis, spondylalisthesis of lumbosacral joint, ‘congenital dislocation of hip, vii diseases ofthe hip or extremities. Prolonged labour due to power fulure (asually associated with mechanical eauses of diproportion): 1 Inertia due to poot uterine contractions.n [MANDBOOK OF OBSTETRICS AND GYNAECOLOGY b.Rigid cervix. . Inco-rdinate wterne activity: 1. colicky werine action, hyperactive lower segment, i. constrction-ing dystocia, iv. dystophia dystocia syndrome, 4. Mechanical factors: {. congenital abnormalities of the uterus, fi, previous operation, eg. myomectomy, li, extensive fibrosis, 5v._muiple fbromyomata, 7. over distention (aydramnioss, multiple pregnancy). 3. Excesive pain may make labour difficult due to 2 docreased pain tolerance, 1b. prolonged labour and disproportion. ‘mast be recognised that commonly more than one factor to cause dystocia. lineal Recognition of Dystocin 1, Before onset of labour: a. Hisory ~ previous obsietic history, maternal disease or malformations. b. General Assessment ~ eight, general stature, gait. Some women have small plves whic, although adeqiate in shape, tre 40 reduoed in overall dimensions that delivery becomes ‘dificult. This seems to be particularly so in women who tare under $f 1 ins. In about 25% of these eases dificult labours are encountered, whereas ia women taller than Sf ‘ins. approximately only 5% experience problems. © Careful abdominal polpation ~ large head, lie, presentation, attitude, postion, 4. Clinica assessment of pelvis ~ may be carted out at 34.36 wesks aod repeated at the onset of labour if disproportion is suspected. I placenta praevia i suspected (high free head or antepartum operating DISPROFORTION, PROLONGED LABOUR, OCCIPTO-POSTERIOR 73. Ihaemorrhage) then a vaginal examination should NOT be done see Chapter 7. In a vaginal assesment () the brim, (i) the cavity, and (Gi) the atl: are examined. |. Pelvic brim ~ normally only the anterior thir can be palpated and it usually fels well rounded. However, |m small Women the pelvic brim can easily be Tet in almost its entirety and in those with android shapes it ean be felt to ave straight margins in the anterior ‘seston of the brim. (On examination, the finger passes slong the iliopctineal fine towards the sacroiliac joint. If this can be reached ‘the sizeof the pelvis is small Tt wil vary with the length of the examining finger. An attempt can then be made to fel the saceal promontory. The diagonal conjugate is measure ftom the symphysis pubis tothe sacral pro ‘montory and is usually 11.5 ems. greater than the trae conjugate ‘The shape of the pelvis, whether gynaccoid,anthropoid, android’ or platypelloid, ean also be assessed at is li, The cavity ~ is assessed by feeling — the sacral curse, normally palpable over the lower three pieces of the serum, the width of the sacrospinous igament, the prominence of the ischial spines. ‘The ischial spines are usually not prominent but in some caies may project backwards into the pelvic cavity. Often in tis pe of case the sacrosiatic notch is reduced in Sap and the sacrospinous ligament is fet to be reduced below threesinger breadths in length. Ii The outlet is assessed by measuring — the subpubic ange, the transverse diameter ofthe outlet, in cases where this is reduced, the posterior sagital ameter. ‘The subpubic angle may be considerably reduced from the normal 85° angle.” RAxDBOOK OF OBSTETRICS AND GYNARCOLOGY nally the ischial tuberosites shouldbe at last 9.5 ems. (about four knuckles of clenched hand) apart. Munro-Kerr Manoeuvre: This manoeuvre is of special value. in. determining disproportion, for apart from tssesring the pelvic sae, the examiner also pushes the head into the brn with his left hand. In this manner the vaginal band can be used {0 asses engagement and escent (Fig. 4). 1 should be noted that many obsteticans do not eacry tout such an assessment during pregnancy as their ine tention is to proceed to a trial of labour. During this procedure clinical evaluation ofthe pelvis may be neces- ary Their reason is thatthe moulding foetal head isthe best “assessor” ofthe maternal peli Pe 4. Te Munro kere manonse X-Ray Examination ~ may be of immense value in managing “but consideration of the time for important. In some cases where ‘on clinical examination a degree of moderate to major dis proportion is thought to exist, or the foetal head is thought 2 DIseROPORTION, PROLONGED LABOUR, CcrPITO-POsTEROR 75, to be abnormal, or thee is malpositon, one is justified in ordering an X-ray of the foetus or pelvis between the 38th ‘and 40th weeks. ‘Some clinicians prefer to leave X-raying the pelvis till early bour on the premise that only after labour has progressed can the degree of skall moulding, the attitude, the position ff the bead and the engagement of the head be accurately ‘assessed in relationship to the maternal pelvis. Such a pro- ‘cedure, however, is sresaful for & patient having moderate ‘contractions, and thus becomes technically more compli ‘ated, offen needing an assistant to help steady the patient during a standing lateral view. ‘Types of X-ray Examination: Standing lateral view of the peli ‘This view gives most information if only one-X-ray is to be taken at any time prior to or during labour and shows the true conjugate diamoter, inclination of the pelvic brim, shape of the sacral eure, the general shape Of the pevie canal and the stcro-catic notch. During Tabour it wil also chow the moulding and engagement of the foetal skull. ii. Inlet of the pedis: Brim or Thoms view allows one to determine accuratcly the shape ofthe brim. If an android shaped pelvic brim fs suspected from clinial assessment, it may be of valve te have an accurate view of the shape and measurements ofthe beim, but in the majority of cases a brim view of the pelvis gives very lite extra informatio, and over Irradiates the footal gonads, However, im a breech pre- sentation it i of immense value and litle iradiation of the gonads results Bil, Outlet vew of the pels: ‘This view may be of valve when there is oveallreduction in pelvie messurements and doubt also exists regarding the size of the subspubic angle. It is rately necessary ‘eeause the outlet i readily accesible clinically. Dering Inbour dystocia may be recognised, by delay in progress, as determined by —[HANDBOOK OF ORSTETRICS AND GYNAECOLOGY 14, Descent ofthe head ~ if there bas been no descent of the pre Seating part over a period of 2 hours. 1b. Cervical dilatation ~ if there is no cervical dilatation ducing 2 hours, despite good contractions ‘&. Uterine contractions ~ if contractions remain irregular, weak snd ineffective Management of Dystocia “The management of dystocia involves either ~ 1 2 ‘Trial of labour, oF Lower segment caesarean se ‘rial of Labour “The best assessor of cephalopelovic disproportion is the Foetal head. Trial of labour is a clinical attempt to evaluate the extent of any disproportion, where there is a good prospect of vaginal ‘elivery. This is the prime course of management in any case of suspected disproportion ‘Asa degree of dificulty may be expected a tral of labour should ‘only be cartied out in a flly equipped hospital where an emergency TISC'S. can be done if necessary ‘Trial of labour may be induced of spontancous and is usually the later, unless there is some specie reason, e 8. postmaturity ‘or diabetes. The steps involved in the conduct ofa tal of labout a. Empty lower bowel ~ 4, ensures_no Soft tissue obstruction tothe descent of the presenting part, fi, enables better application of head to lower uterine Segment and cervix stimulating the release of oxytocin from the pituitary 'b. Ambulaton may be allowed carly if ~ 4. the patient is healthy; and li, the foetus is presenting normally an isin good condition Regular observations ~ every 2 hours, regarding ~ DISPROFORTION, PROLONGED LABOUR, OCCIPTO-POSTERIOR 77 ‘AND TRIAL OF LABOUR, i. the patien’s general condition - pulse, blood pressure and temperature Ti, contractions ~ frequency, duration and intensity. fin fn — shoal eatin, (is, penton, ion, descent of anterior shoulder and’ engagement ‘Of the head), and octal ear at ‘These observations should be carried out more frequently ITrequited, 8. when syntocinon dripisoperatingor following aifcial rupture of membranes, especially if liquor is meconi= ‘um stained ‘The patient is urged to pass urine every couple of hours ~ i, as a full Bladder impedes progress. fi, to ust for pH, proteinuria, Ketones. it orally ~ i. except water, once labour is established, Hi electrolytes and hydration are maintained by LY. fluids. Rupture of membranes — note time, i, note colour of iquor, ii, 2 vaginal examination is required if the head is not ‘well engaged in the pelvis ~ to exclude the possibilty of cond prolapse. Vaginal examinations — 4. as infrequently as possible, Hi to determine ~ ‘effacement and dilatation of cervix, progressive descent of head, application of head tothe cervix. [Induction ~ (0 augment aspontancous labour i itis considered Ineicient, or if preterm delivery is necessary — i. Surgically -by ether high or low rupture of membranes,HANDBOOK OF OBSTETRICS AND GYNAECOLOGY Ji, Medically - with a syntocinon dep. hh. Analgesia ~ refer also to Chapter 12 i. nitrous oxide, ii, pethidine $0 mg + spatine 25 mg, fi, continuous epidueal anaesthesia - provided the cervix is more than half diated, iv, singleshot epidural anaesthetic. i. Trial of labour is abandoned f— i, ‘There is no cervical dilatation during 2 houts, despite 004 contractions. ii, After ful dilatation, the head is not engaged within ‘one hour, of the baby not delivered in IY hours Foetal diseess develops. fv, Maternat condition deteriorates significantly. vv. No significant progress has been made after 24 hours! labour, Vi. Following rupture of membranes the contractions do not improve in quality and frequency in the next 4 ours. Judgment of progress and the final decision to terminate a ‘wil of labour is made in the light of the whole clinical im- pression gained by the obstetrician, Prognosis f teal of labour — 50% deliver spontaneously, 30% require forceps, 20% require LS.CS, 2 Hlective LS.CS. at term —is carted out — 42. when atrial of labour is contraindicated, Te with = 5, absolute disproportion, 4i, previous LS.CS. fr disproportion, ii, breech presentation whon disproportion is suspected. DISEROPORTION, PROLONGED LABOUR, OCCITO-FOSTENIOR 79 iv. malprsentation of foetal parts (except normal breech), 1. when the patient has other medical or obstetric com Plications such as severe pre-eclampsia, or diabetes, i placenta praevia ~ (ype II (post); type IIL; and type TV). b. when there is less marked pelvic disproportion, plus other ‘obstetric complications (eg, “postmaturty", preeslamp- {3a}, which increase the risk to the foetas, of a long Petlod of infertility Abnormal Uterine Activity 90% of cases of dystocia associated with an abnormality oft powers are due to hypoactive or inco-ordinate uterine” activi (Fig. 42). Incovrdinate uterine activity is usually seen in prime sravidee. The patient experiences coickyhypogastric pain and fften marked backache. With inadequate activiy slight (or no) pain is fet in the normal distribution and contractions appear less intense to palpation, also less frequent, less regular and lest sustained Management involves: 4 Making sure theres no other cause for the dystocia. General measures include care in noting occurence of dehy- ration and acidosis; review of abdominal and vaginal ndings nd ensuring the bladder and bowels ate empty. Sedation and analgesia must be adequate. © For inadequate uterine actsity: 4. Rupture membranes, Ji, Oxgtoccs fi, In second stage, forces (or vacuum extractor) way be used. With these measures 95% of babies deliver. iv. Antibiotics may be needed. 4. For taco-ordinated werne activity: i. Nil by mouth as 35% progress to LS.CS. i, Rapture membranes. fi, Put the patient om her side — this simple measure may smarkedly reduce the pain of contractions,» ex $ é LHANDDOOK OF OBSTETRICS AND GYNAECOLOGY iv. Analgesia ~ morphine or pethidine is often required. IF the baby is delivered within Sve hours of administration ‘ofthese narcotics, then lvallorphan 0.1 mg. is given into ‘the umbilical vein or intramuscularly. Analgesia is best o mmHg 40) 20) ° 13 5 7 9 Minutes 42, Nansen 208 coordinate tern ac ea i mmHg ye 068 Inset. treats, DISFROPORTION, PROLONGED LABOUR, OCcIMTO-FOSTEROR — 81 atsined by continuous epidural anaesthesia when the ‘cervix is more than half dilsted~ earlier administration fs Tkely to prolong labour and necessitate catheter- sation to one, ‘Antibiotics may be required. Note: Onytocies augment uterine activity but do not alter "ene, unless inco-ordination is mild oxytecies following prerequisites are mot ~ ‘ill iattion. ‘ceipto anterior position (except for Kielland forcepts rotation) on apawred membranes, A 2° Nas 5 4° | fe containdlated. In mid ease some ceria! dilatation £ 20 an be achieved by their we ¢. With fll dilatation of the cerdx (and the patient in the ° lithotomy postion) frcepe delivery may be achieved if the 5.7 9 — C= good eonracrions E — empty bladder (bowel usualy already empty) P= pam reliefs adeqe S — head atthe level ofthe spines or below. £ Lower segment Caesarean section may be required if the ‘cervix falls dilate or if foetal or maternal distress supervene.. 2. False labour is labour in which the patient has contractions not unlike those of true labour, but there are no other signs which ‘ndicate thatthe patient is actually in labour and the contractions trentually pass of. In false labour the pans are iereglar, do not increase in duration and severity or become more frequent ~ as opposed to true labour. Again, the cervix does not become tliaced and there ino descent of the presenting part. ‘The patient is given analgesics and sedation. The situation is explained to her, she is reassured and may be sent home. 3. Contition Ring Dystodia~ see Delay in Second Stage 4. Colleky ters indicates a pattern of uterine activity characterised by frequent irregular contraction occuring all over the uterus. 1 may be termed werne fibration and isa result of spontaneous ‘ew pacemakers, There is no effective expulsive free. The patent may experience colicky abdominal cramps, backache or lower abdominal pain depending on the site of maximal contraction,2 [HANDBOOK OF OBSTETRICS AND GYNARCOLOGY 5. Hyperactive lower segment involves a loss of the normal gradient of intauterine activity. The lower segment contracts more strongly ‘than the upper ~ normal “fundal dominance” is lost. The patent suffers espacally from backache and contractions may be severe and distressing. ‘These are forms of inco-ordinate uterine activity and should be ‘managed as deseribed in section 1. above. (Oceipito Posterior Position Definition: 1. Denominator ~ occiput Iying in the posterior segment of the ‘maternal peli 2. Presenting diameter ~ variable, depending on the presenting pert, ‘but usualy ccepitontal (11-5 om). 3. Lie, longitu 4. Presentation = cephalic, (Gee Fig. 43) Fe 43. Osipae poster pation, DISFROPORTION, PROLONGED LABOUR, OCCLFTO-FOSTERIOR — 83 ‘The occiput may take up any of these positions: ight occipit-posterior (ROP) ~ where the long axis of the head isin the right oblque diameter of the pelvis, 2. let occipito-posterior (LOP) — where the long axis of the head is in the left oblique diameter ofthe pelvis, 3. ocipito-postrior (OP) -the long axis ofthe head isin the antero- posterior diameter of the peli. Al these mabpositons are likely to cause delay in the fist stage of labour. Tacidence: ‘There is great variation in the estimated incidence of the occipito- posterior position atthe onset of labour (from 8.30%) This is de to 1. dificaly in palpation to be sure of postion, 2, majority of postions are right or let lateral, and 3. most rotate anteriorly during labour. ~ the shape of thie inlet, especial with android or anthropoid pelves (a long AP and short transverse diameter) eocourages engagement ‘with the biparietal diameter Inthe transverse of the inlet 2. When the head is dflxed at the onset of labour larger diameter presents atthe pelvic brim. Diagnosis 1, History 4. Ossipito-posteior positions are often associate with severe backache Prolonged infective labour 2. Abdominal Examination ‘Flattened abdominal contour (may have depression, oF lack of fullness, supra-pubically or in the umbilicus). 'b. Back and shoulder well over in flank (not easily identified.i HANDBOOK OF OBSTETRICS AND GYNAECOLOGY Limbs are felt anteriorly. (Often the head is high; and the brow and occipat are at the same lve. ‘e. The finger placed atthe side of the oceipat sinks deeper than that over te sincipat. Foetal heart sounds are loudest fa out inthe lank or centrally 3. Vagiaal Examination ‘4, The anterior fontanelle inthe anterior segment ofthe pelvis and the posterior fontanelle in the posterior segment. 'b. The sagt suture indicates the postion of the ecciput (as Jett to righ). If in doubt about the poston, the car may be used as landmark ~ the pinna points 10 the occiput. “Mechanisms of Labo oF i occpito-postrior positions at the onset of labour ~ 80% rotate anteriorly through 138° to an occipito-anterior position, 10% rotate posteriorly through 45° to a persistent oesipito- posterior position ("face-to-pabes”), and ‘partial rotation of the occiput occurs to the lateral postion with fo further progress ~ (deep transverse arrest of the head). This ‘sual occurs inthe plane of least pelvic dimensions. Irrespective of the rotation involved, labour wil probably be protonged due to abnormal pelvic shape, abnormal uterine activity and a large presenting dameter (due to lack of flexion and moulding). These factors combine to produce slow dilatation ofthe cervix, slow descent of the head and maternal distress. Figs. 4.4 and 4.5) |, The Anterior Rotation ‘a. Descent and engagement ~ with descent of the head through the inlet there Ba tendency to deflesion resulting in engage- meat of the occiptorontal diameter (11S ems) Internal rotation ~ through 135° to the_occipito-anterior postion is followed by normal delivery of the infant. DISPROFORTION, PROLONGED LABOUR, OCCIFTO-FOSTERIOR 85 Fis.44_Aoteioeroaion SUNMARY OF LONG ARC ROTATION : ROP. TOO. "ROP. oot of tahoe Toteralromtoa RO to ROT. Insta oat ! BOLT. 9 OR Ben mmo Extral rotation “ROA. to ROT. 2. The Posterior Rotation ‘ ‘Descent and engagement ~ the head fails to flex and descends86 in the oblique diameter of the pelvis, the occpitorontal diameter (115 cms) caeasing ‘Internal rotation — occurs through 45* so that the occiput ‘occupies the hollow of the sacrum -The sagital suture fies in the AP diameter of the pelvis. &._Deivery of the head ~ occurs with further descent. There is litle flexion, resoling in bith of the bregma, vertex and ‘occiput, fllowed by extension ~ the face finally sweeping the perineum If there is good flexion the diameter pivoting under the symphysis pubis (the suboceipite-frontl (1.5 ems.) presents ft the perineum and increases the risk of trauma to the saternal passages. 4. Restitution of the occiput through 45° to either the right ‘or eft oblique in order to resume the normal head and shoulder ‘elatonshi. External rotation through a further 45° brings the ocsiput to the lateral position asthe shoulders occupy the AP meter of the pelvis. Delivery ofthe tran follows flexion of the trunk. Rotation and arrest in the transverse diameter is diseussed in Section 9 Management: Prior to labour no treatment is required or possible. ‘With the onset of labour ~ management is trial of labour with special attention to: 8. General i. watch for and treat dehydration and acidosis, ii ail by mouth (except water), li sdequate analgesia, Vaginal examination - to confirm position. ‘& Oxytocin nfesion ~ may be uted only ifthe contractions are weak and absolute disproportion has. been excluded. DISPROPORTION, PROLONOED LABOUR, OCCIFTO-POSTENOK 87 3. Delivery Persistent oscpito-posteior requires a generous episiotomy 50 ‘hat gross vaginal lacerations can be avoided. Re. 43. SUMMARY OF SHORT ARC ROTATION: ROP. TO OP. A Rn. ent of ahr Bee gator REF w on Restwlon 0. 0 ROP. Even eaten | ROP to ROT, mmpor:[HANDRODK OF OBSTETRICS AND GYNAECOLOGY Delivery may be — spontaneous, * forceps, LEses. a. Forceps delivery: If spontaneous delivery appears unlikely after about one tnd a half hours in the second stage, forceps delivery (by @ ‘Specialist obstetrician) may be performed, This may involve elther ~ ‘Simple, extraction following spontaneous anterior ro- otaton (either manually or with Kielland’s forceps) jad extraction ~ see management of deep transverse arrest, li, detvery asa persistent O. only ifthe hea is distending the perineum ~ ie. as an assistance to the maternal powers Ifthe head is higher the incidence of trauma fo moter and foetus is unacceptable. b, LSCS. is required if lnbour fails to progress or foetal dlisress occurs and forceps delvery is not possible. Ie may also be fequted if brow presentation develops (see Chapter 10) Sequelae of Dystocia |. Foetal ~ litle risk until membranes rupture, 1 Foetal death ~ siress asphyxia (excesive contractions cause decreased placental blood flow), greater trauma in delivery. (Cerebral damage. Increased risk of infection Increased risk of cord prolapse (increased twelve times), (Cephalhaematoma, Fracture of skull E's pay ~ roots of CS and C6 torn, following traumatic delivery of bead and shoulders. DISPROPORTION, PROLONGED LABOUR, OCcIFTO-rosTERIOR — 89 Increased foctl risk as oflen postmature Maternal — 4. Increased risk of infection ~ prolonged labour. b, Increase risk of severe birth canal injury ~ ruptured uterus, and with assisted deliveries (specially rotations), torn cervix, vagina, traumatic fistulae & Paychologicl fear of further dificult pregnancy and avoidance thereof Tncreased incidence of postpartum haemorrhage. Tncceased incidence of urinary tract infections. ‘Trauma to bladder neck, bladder neck necrosis with formation of vesicovaginl fistula (after about 2 hours in second stage), renee ‘Management of Sequelae oetal Death ~ deliver by eithes normal vaginal route, b, desiructive operation (embryotomy) ~ craniotomy, decapitation, eviseeration, ‘deidotomy. LSC. - if inexperienced in the above (b.) measures. Cerebral Damage ~ prophylaxis ~ careful forceps, judicious est- mation of progress of labour. Infection ~ amnionits, due to ascending infection may produce intra-natal pneumonia in the foetus without stimulating a rise in maternal temperature. Perinatal morality (in both primi- fravidas and muligravidae) increase signieatly 24 hours after the membranes rupture With the exception of crystalline penicillin G given by injection in doses of | tegauni the ordinary antibioies given by math for intramuscular injections do not reach the amniotic Mid in0 uanDD00K OF OBSTETRICS AND GYNAECOLOGY salfcient concentration in the time available to be fully effective jn controlling infection. ‘re, 46 Tosrgloction of stints ito the wtoe evicr wing Cara's Fitba of te Drew Sa he caihete DISPROFORTION, PROLONGED LABOUR, OCCIFTO-FOSTERIOR 91 Even with prophylactic antibiotics given orally or intramuscularly during labour, one third of mothers who have had prolonged labour ‘will show evidence of puerperal sepsis (see Chapter 8). ‘To be fully effective antibiotics must be given directly into the amniotic fuid in high concentration. A’ polyethylene catheter may be inserted above the presenting part, using Carey's modif- ‘ation of the Drew-Smythe catheter as an inserter. Streptomycin gm, (or ampiciin 1 gm. is added to $00 mls. of 3% dextrose and 100 mis. of this solution isan into the amniotic cavity every two oF thfce hours. Ths isthe only effective way of introducing fn. antibiotic (except cystallie.peniilin) into the smote fluid. Fig. 4.9) Cord Prolapse ~ requires delivery as soon as possible (unless the foetus is dead, when normal delivery is continued). ‘While preparations for delivery are carried out ~ arabe foot of bed, and 'b. get the patient int ether the Sim's or geau-poctorl position So prevent compression ofthe cord between the presenting part and the pelvis, administer oxygen (of doubifu value), digitally push the presenting part away from the cord - to relieve compresion. Note: ‘These is no risk to the mother in these procedures. If the pre-requisites for forceps delivery are fulfilled then this is the method of choice, IPnot, LS.C'S. must be undertaken ‘Spontancous rupture ofthe uterus - usually oocurs atthe junction ‘of the expanding lower segment and the retracting upper segment Fig. 47 Iemay also occur atthe site of previous Caesarean section ~ especially if classical section had been done. “The patient experiences severe abdominal pain and shock rapidly ‘ensues. Vaginal blood loss is variable in amount. On examination All the signs of en acute abdomen are present and vaginally there Is noted an absence of the presenting part “Management involves resuscitation and immediate laparotomy and hysterectomy. The baby does not survive. In cases where previous Ceesarean sections have been carted ‘out consideration should be given to elective LS.CS. at term.2 HANDBOOK OF OBSTETRICS AND GYNAECOLOGY After two previous Caesarean sections (LS.C.S)thisisthe method ‘of choice for delivery. Following classical Caesarean section 2.5% of uteri rapture in a following Pregnancy, but this figure rises 10 10% i the mother goes into labour Lower Uterine Segment Re. 42, Cepblopis apropotion wth threatened rate ofthe tens 6 Detydestion and Acidosis require the administration of $% and 10% dextrose respectively, by intravenous drip, Acidosis can be detected by urinalysis. Expeially in prolonged labour where operative interference may bbe expected, there should be no oral food given, but a dextrose tip shouldbe runaing from early in the labour. Note: Acidosis decreases the myometrical response to oxytocin 17. ‘Trauma to the badder — do not delay for too long in the second stage, and 1. ensure good obstetrical manipulations. DISPROPORTION, PROLONGED LABOUR, OCCIPCTO-POSTERIOR 93 ‘Causes of Delt in the Second Stage of Labour 1. Deep transverse arrest. 2 Shoulder dystocia. 3. Abnormal presentation 4. Consrcton ting. 5. Rigid perineum, 6 Hs 7 8 °. ‘uterine activity Slow normal labour. ‘Vaginal abnormality - septum, Short umbilical cord, 10, Abdominal oF thoracic enlargement of foetus. 11, Locked twins, Management: 1. Deep transverse arrest ‘A faulty condition in the mechanism of labour when a fat sacrum land android type of materual pelvis cause arrest of the foetal Ibe a the level of ischial spine, withthe sagital suture in the tranwverse diameter. The situation occurs most commonly wit the funnet-shaped android pelvis. Successful delivery depends upon rotation of the occiput to an anterior postion ~ such that the long axis of the head cccupics the largest diameter ofthe pelvis. This may be schieved by — forceps, sanvally, ©. the vacuum extractor. 8. Rotation with Kellands forceps 1 immediate rotation is dificult, sight traction may be applied and rotation once agtin attempted. Often rotation is easier ifthe head is elevated slightly so that an adequate transverse diameter is obtained. Note: Undue force must NOT be used. If unsuccessful proceed to LS.CS. Manual rotation involves grasping the head and elevating it above the point of arrest. Rotation is accomplished wile an assistant pushing. the anterior shoulder across the materalon HANDBOOK OF OBSTETRICS AND GYNAECOLOGY abdomen, Delivery is completed with forceps. (Fig. 48). ‘&Although the use of vaca extractor results in less vaginal rate (ae high as 20%) and i ie. 48, Manual rution in dep transverse set DISFROFORTION, PROLONGED LABOUR, OCCIITO-FOSTERIOR 95 2. Shoulder dystocia Following delivery of the head, impaction of the shoulders pre- vents further progress in an otherwise normal second stage. The baby will die if not delivered immediately. (Fig. 49) Tistead of rotating 10 negotiate the plvi brim in the transverse or oblique diameter, the shoulders become impacted inthe antero- posterior diameter ‘Management involves ~ a. Anaesthesia '. Lithetomy postion ©. Vaginal examination to exclude other causes, 4. Episitomy. © Altempt 10 deliver the anterior shoulder by downward and ‘ackiaed traction of the baby's bead, placing tension on the tissue and clavicle of the anterior shoulder, while an ausistant applies fm pressure on the point of the shoulder (above the symphysis pubis) so that it may be forced down Under the symphysis. (Fig. 4.1). Te this fails to work — Attempt 10 delve the posterior shoulder. The foetal head is fined forwards and one hand passed up into the curve of the sacrum and then the Fingers run up infront of the foetal thoulder to the antecubital fossa, Pressure over the flexor surface of the antecubital fossa will allow the arm to be Gelvered by Piaard manoeuvre down into the pelvis. By pulling on the arm the shoulder then slides down into the ‘urve ofthe sacrum and pelvic eavity and delivery is usually easy. (Fig. 411) If dificult is experienced in bringing down an arm ~ Attempt rotate shoulders i, Several fingers are introduced into the vag texeried behind the anterior shoulder to encourage Folat fo. an oblique diameter. Simultaneous suprapubic Dressure is exerted by an asistant to bring the antecior ‘Shoulder into the pelvis. fi. Several fingers of the left hand are passed up in front ofthe posterior shoulder and pressute is exerted 59 as to rotate i, resulting in is delivery into the pelvis. The96 HANDBOOK OF OBSTETRICS AND GYNABCOLOGY Fe 49, Sbouider deca, Ss Fe. 410, Devry of Antic Shoulder FeAl, Delivery of Postsior Soule. DDSFROFORTION, PROLONGED LABOUR, OCCIPTO-POSTEROR 97 anterior shoulder (ow postriot) is delivered by re- eating the procedure Finally, if no other measure has succeeded and usually when the baby is dead, the head may be pressed backwards and a lsidotomy performed using Mayo. sisors 3. Constrieton ring dystocia ‘A constriction ring isa rare condition involving annular spasm fof the myometrium usually at the level of the junction of the ‘upper and lower uterine segments, Constition may also oocur~ a. in the lover uterine segment, 1. atthe level of the internal os, ©. in the upper uterine segment. 1 may oocar spontancousy, follow the use of oxytocics in eases ‘of hypertonic werine action of follow obstetrical interference fand i associated with extreme thinning of the lower uterine fegment. Lack of recognition may lead to rupture of the uterus (Ga'a multpara) of uterine inerta (in a primiparous patient). Diagnosis: a. Obstrcted labour. Vaginal examination reveals a poorly applied presenting par Definitive diagnosis can only be made by intrauterine exe ploration when the contrition ring is palpated, 44, Theconstriction may be palpable, or even visible abdominal. Treatment: Surgical anaethesia to relax the ring and then subsequent forceps delivery. Caesarean section when the condition has been allowed to progress for too Tong, It may be necessary to incise the ring (Glacial Caesarean section) to deliver the infant 4. Malprsentation which may result in dystocia include: «= vertex ~ cospito-posterior position with extended head (10% ‘of presentation), brow face ~ mento-posterior,shoulder {breech "— with larger than average head, or flexed, knee oF Feotling breech, Management of these condtions are considered under specific References | “Indvetion of Labour”. (1971). Notes in Obstetrics and Gynae- cology. Royal Hospital for Women, University of New South Wales. WREN, B.G. (1973). “Management of Disproporton”. Notes in Obstetrics and Gynaecology. Royal Hospital for Women, University of New South Wales CAREY, H. M. (1972), “Abnormal Uterine Activity”, Notes ia Obstetrics and Gynaecology. Royal Hospital for Women, Univer- sity of New South Wales. “Oscipito-posterior Position”. (1970). Notes in Obstetrics and Gynaecology. Royal Hospital for Women, Univesity of New ‘South Wales. OXORN, H. and FOOTE, W. R, (1964). “Human Labour and Binth”. Appleton-Century-Crofts, New York. MeDONALD, LA. (1971). “A. Method of Obstetrics and. Gy- naccology” Pergamon Press Australia LLEWELLYNJONES, D. (1971). “Fundamentals of Obstetrics and Gynaecology”, Faber and Faber, London, DANFORTH, G.N. (ED). (1971). “Texthook of Obstetrics and Gynaecology”, 2nd Eaition. Harper and Row, New York CHAPTER 5 HYPERTENSION IN PREGNANCY General Instructional Objective Understands hypertension in pregnancy so that appropriate manage ‘ment can be instituted. ‘Spociic Behaviours 1. Discusses aetiology of hypertension in pregnancy. 2. Describes changes associated with hypertension in pregnancy. 3. Describes the complications which may result from hypertension in pregnancy. 4, Demonstrates an ability to assess a woman with hypertension in pregnancy. 5. Discusses pharmacology of drugs influencing hypertension in Pregnancy. 6. Discusses the managment of patients with hypertension in pre- ancy. 7. Displays an understanding of the significance of investigations for hypertension in pregnancy. 8, Demonstrates an ability to counsel women with hypertension in pregnancy. ee ee ow Hypertension in Pregnancy Definitions: 1 Hypertension in Pregnancy . ‘A pregnant woman is said to be suffering from hypertension|MANDROOK OF OBSTETRICS AND GYNAECOLOGY ‘when the diastolic blood pressure (BP. is raised 15 or more mm. Hg above pre-pregnancy levels, or when there i a sustained BP. ‘of 140/90 or greater. NB. The normal tendency i for BLP, to fall lightly during the sid trimester, PreEclampsia| ‘A condition associated only with the pregaant state in which at least two of the fllowing thre criteria are fullled, ‘Hypertension (as defined above) ~ Attributable to no other '. edema ~ Must be generalised and attributable to no other Albuminuria ~ Attibutable to no other cause (eg. contami ‘ation, infection, postural proteinuria) elampsia “Fitting” for the fist time, in pregnancy NB. 80% of cases follow pre-eclampsia, 20% have no antesedent pre-celampeia “Hyperteosion In Pregnancy Incidence «6% of all pregnancies wil be complicated by pre-clampsia, 13%; of Primigravidas will have pre-eclampsia. Wien causes of hypertension other thin pre-eclampsia are included the total ineidence is slightly higher than that of pre= tclampsia, the incidence of cases other than those associated ‘with pre-elampsia increasing with maternal age ‘The following conditions predispose to pre-eclampsia: a. Fitst pregnancy. b. Essential Hypertension. Mabie pregnancy (ncidence raised thre times). Renal disease © Hydatidiform mole (may cause preeclampsia in the frst haf of pregnancy) Hydramaios. . Rhisoimmunisation, 1h, Diabetes in pregnancy. HYPERTENSION IN PREGNANCY 101 Actiology: 1. Causes of hypertension In pregnancy other than pre-clampsia, Essential hypertension Renal disorders and occlusive renal ©. Endoctine disorders 4, Coarcation of the sorts. 2. Aetiology of Pre-eclamsia This remains unknown. Some of the theores attempting to ex- plain it are summarised below 8 The concept of circulating toxins producing pre-elamptic “toxzemia® has never been validated and is aow regarded b. Some have tried to relate pre-eclampsia to increased intra- terine tension using the increaed incidence asrocated with smuliple pregnancy, hydramnins, hydrops and diabetes to sup- port their argument Dietary deficiency has been proposed as an actiological factor ‘but this has not been proven, 4. Dixon ef al (1967), have revealed some interesting uterine changes occurring in pre-eclampsia by biopsying the sub- placental uterine wall n eases of pre-eclampsia ‘which have ‘gone to Caesarean section. They have shown that the normal vascular change (dlatation of the uterine radial arteries) does not oocur to the same extent or to-a® great a. depth in the sub-placental uterine wall of the preeslamptic as in nnon-preelamptic cases. Also, an increased amount of im- mature trophoblast and prominent degenerative changes in ‘ther trophoblastic cells have been found, They state thatthe resul of these changes may bea chronically reduced placental blood flow triggering the release of thrombolpastns from the placenta and thus leading to the characteristic. peripheral ‘aseular lesion of pre-eclampsia to be described below. Pathological changes associated with hypertension in pregnancy: ‘With hypertension in pregnancy not due to pre-eclampsia the patho- logical changes are the sume as those oowuring non-pregnant patients and will vary with the severity and stage of the proses. ery disease.102 HANDBOOK OF OBSTETRICS AND GY¥AECOLOGY Preeclampsia on the other hand is associated with a characteristic lesion in the peripheral vascular bed. This lesion ¥s thought fo be due to the deposition of fibrin and in effect results in a narrowing of the vessels involved. creasing peripheral resistance causes a direct rise in BLP, a loss of ud because of the inereated hydrostatic pressure, and thus seneralised oedema. ‘The peripheral vascular lesion may involve any organ of the body ‘but most commonly and significantly afleced are the placeta, Kid seys, liver and brain, Tavolvernent of the kidneys may lead to a decreased. glomerular ftation rate, activation of the teninangio- teosion pathway and thus a secondary increase in B.P. Tt may also lead to albuminuria with a consequent decrease ia the otmolality ofthe vascular compartment and an aggravation ofthe oedema. ‘The histological appearance of the peripheral vacsular lesion is as follows At frst there is a swelling of endothelial cell in capillaries and pre= capillary arterioles. As the condition progresses thee is a fibrinoid ‘deposition between the endothelial cell and the basement membrane, ‘This specifi lesion has been found only in pregnant patients, Complications of Pre-clampaia: ‘These will be clasifed according to organ involvement. a. Placenta Pre-eclampsia is associated with fibrinoid deposition on the vil and in the intervillous spaces, redicing blood flow and causing Stagnation of maternal oa Tait may abo or free reducing the placental function. Normally about $00-700 ml. Fates bloat passthrough the Pacenal"ike™ coche ‘This may be seriously reduced in preeclampsia so that only 300-400 ml. pass each minute, Theres is reduced foetal nutrition, failure of intrauterine growth and poor reserves of plycogen for the neonate. ‘Also, premature separation of the placenta is more common ja ‘patients with pre-eclampsia, the incidence of accidental bacmort hhage being 1015%, HYPERTENSION IN PREGNANCY 103 Kidneys Reduction in glomerular ftation rate with a secondary agera- vation of BLP. rise has already been mentioned. ‘Albuminuria in pre-eclampsia is de to a change in permeability of the glomerular capillaries. Tt is an unfavourable prognostic sign belng associated with an increased Torta wastage and a ‘worsened mater2al prognosis, Liver Periportal destruction and necrosis occur due to fibrinoid. de- position within the portal vessels. There is also occasional haemort= Fage within the liver but regeneration usually occurs over some days without serious residual damage, Occasionally liver rupture Rarely, liver involvment may lead to disorders in the clotting mechanism with a consequent haemorrhagic diathess. 1 Langs In advanced pre-eclampsia the lungs may show features of acute pulmonary cclems. This may bea part ofthe generalised oedema Of the condition or may be secondary to heart failure. ‘Hypostatic pneumonia may also occur especialy in those patents bedridden for considerable lengths of time Heart Microvascular cardiac lesions do occur but are considered to be san inadequate explanation of the acute congestive enrdie failure Which may cause maternal death in. pre-elampeia. It is more Tikely that cardiac failure is due to increased resistance in the peripheral cisculation, a reduced intravascular compartment land: decreased cardiac return, Brain Post mortem findings in patients who die following eclampsia vary from focal or extensive petechial haemorrhages to gross cerebral hemorrhage, and they may occur in the cerebral cortex, inthe parabasal ganglia, and occasionally in the pons. “These lesions are probably the result of severe elevation of blood. pressure and may contribute to the praduction of clampeia ‘The eclampsia alternatively may be caused by other factors and104 HANDBOOK OF OBSTETRICS AND GYNAECOLOGY ‘ay lead to cerebral heemorrhage via. the production of cerebral [hypoxia or by causing a sharp rise in blood pressure. ‘One explanation of eclampsia is that the metabolic or enzymatic block in the extra cellular Buid compartment of the brain, which normally protects the cortex from afferent stimuli capable of Inducing seizures, may be rendered inefective by the metabolic alterations and compartmentl shifts in fd and electrolytes, ‘The convulsions in eclampsia are identical to grand-mal epileptic fits, Usually there are ony one, oF maybe two fs, but occasionally condition resembling status epilepticus occurs. ‘The occurrence of eclampsia immediately worsens the progno- sis for the baby and the mother, being associated with a7, ‘maternal morality. ‘The dilferential diagnosis of eclampsia is 4. Epilepsy, ‘Toxic response to regional or local anaesthesia ‘Cans of Materal Death in Pre-eclampsia: Circulatory failure ‘6. Pulmonary oedema ©. Cerebrovascular acident 44. Renal failure, infection and other causes Intracranial haemorshage is the most common cause of death in ‘women dying from eclampula Assessment, Investigations and Diagnosis of Hypertension on Pregnancy: Daring the second half of pregnancy the routine history taken at cach antenatal visit should include enquiries into tightness of rings, pre= seace of headaches, drowsiness, blurred vision, or seotoma, Scotomas may occur in normal pregnancy but i they occur with pre-eclampsia they have serious implication, being due to cireulatory disturbances in the visual corte, optic nerve, of retina. Other symptoms of pe= eclampsia include epigastric pin (rom distension of the liver capsule), and rapid weight gain. If the patent is putting on excess weight then fan enquiry Into the diet should be made to exclude overeating as the HYPERTENSION IN PREGNANCY 105 Examination: Accurate weigh, blood presure recordings and urinalysis for protein are route antenatal proceedures. Blood pressure should be revorded. At the beginning of the visit before the patient has relaxed completely ‘this js a more accurate indication of the patients blood pressure tinder the stress of normal everyday activities, Another parameter in pre-eclampsia is weight gain with or without ‘demonstrable oedema. A weight gain of over one Kilogram per week is abnormal especially in the thid trimester. It should be noted that ‘swelling of hands and ankles does occur in about 60% of normal Pregnancies. Bven so, oedema of the fingers and face must be carefully ‘Sought for and itis present, pre-eclampsia must be excluded. ‘Other findings which arouse suspicion of pre-eclampsia are the pre- seace of byperreflexia and/or sustained ankle conus. At each antenatal examination the doctor must be alert to detect any of the factors predisposing 1 pre-eclampsia ‘An accurate estimation of gestation age in the fist twelve weeks by bimanual palpation of the werus is of paramount importanoe because if preterm indvetion is indicated this can be timed with accuracy and the rsk of prematurity anticipated. Ina case of diagnosed pre-eclampsia the clinica assessment of uterine size will provide a rough estimate of progress or retardation of foetal growth Tavestgation: 1. If the ward urinalysis indicates that protein is preset in a carefully collected mid-stream specimen of urine this should be evaluated ‘quantitatively by acidifying (with a drop of acetic acid) about 10 mils ofthe urine in a test tube and then rolling it. The protien inthe urine will be denatured and precipitate out of solution and ‘an be quantitated as percentage ofthe volume inthe urine sample, If there is any doubt ss 10 possible contamination of the sample, ‘a repeat specimen should ft be taken after the vulva and vagina have been swabbed with antiseptic solution, then the guantiative measurement of protein may be made. 2. Ina case of diagnosed oF suspecied pre-eclampsia, blood urea and serum creatinine estimations should be made to assess renal function. The upper limits of normal in pregnancy are blood ‘urea 28 mg/l00 ml; serum creatinine 2 mg/100 ml106 HANDBOOK OF OBSTETRICS AND GYNAECOLOGY 3. Ia patient has pre-eclampsia then serial urinary oestriol deter- ‘minations are 2 useful indication of placental adequency of ite adequacy at the 30th week of pregnancy. A fallin values over several days usually indicates placental ineufiency which may lead to foetal death, In such a case, induction of labour should De considered 4. The other investigations relevent to precclampsia are those simed at determing foetal maturity when preterm induction of labour is being considered [Echograms estimate the size of the foetal head and trunk when ‘compared to the average foetal size for that gestational age and are of immense value im detecting failure to grow. X-rays have limited value in investigating the effects of hypertension ‘on pregnancy for they can usually only detect foetal age when epiphysis are present. The distal femoral epiphysis becomes Visible at about the 36th week and the proximal bial epiphysis at about the 38th week. ‘Management: Hypertension not due to Pre-eclampsia “The effects of hypertension on the placenta and fostus are similar to the effects of pre-eclampsia so the management follows & similar pattern. However, whileanti-hypertenive drugs are avoided in managing preeclampsia, the patient with non-pre-eclamptic Ihypertension should usally stay on her pre-pregnancy deug re ‘ime, with the omission of any teratogenic drugs, She should be Closely observed for the development of concomitant pre-eclamp- b. Preeclampsia Because delivery ofthe placenta removes the major source of the iniatng cause of pre-eclampsia, and because deterioration of placental function may lead to Intrauterine death, early induction of labour is indicted in the management of pre-eclampsia, the ‘actual timing of induction depending on the severity of the disease However, in a number of cases, pre-eclampsia develops at such ‘an early stage that delivery ofthe foetus would severely jeopardise its chances of survivial Because of the hazards of prematurity ‘an altemptis always made to carry the pregnancy as fat as possible HYPERTENSION IN PREGNANCY 107 towards term to achieve foetal maturity without in any way jeopardising the foetus whilst remains in utero. Tn cases of pre-eclampsia in which immediate delivery is not indicated ed vest with toilet privileges onl i the basic treatment. ‘This shouldbe used even if only one of the parameters (e.g. hyper- tension or oedema) is preten to a significant degree. Sedation (Valium 2-5 mg tds. and Mogadon at night) will make bed rest more acceptable and may possibly remove the anxiety come pPnent ofthe hypertensive state. In most cases this form of manage- fen wil result in fall ofthe blood pressure with a diuresis and ‘decrease of cedeme Hiypotensive agents do not result in increased placental perfusion. ‘Moreover, they remove a valuable parameter ofthe severity of the ‘condition — elevated blood pressure ~ and so should only be wed if'a sharp rise in blood pressute leads to the danger of maternal ‘cerebral haemorrhage. Diuttis are not given as a definitive treatment for pre-eclampsia ‘but may be used to (eat the oedema symptomatically. Wore te a esr tl he ee ee a eee le Siler Cet reas we et HESS alt le a ia gy We, te hoes a sl les Se te oon ian ane ee gaat Heal Seam srr a ts fof Pia ao 3 38 25 ES & & 38 ‘Teeatmeat of Sharp Ris in Blood Pressare If the blood pressure does rise suddenly (eg. to 190/115) then the immediate risk is that the mother may progress to eclampsia and ‘possibly have a cerebral haemorrhage. In such a case a rapidly acting108 LHANDOOK OF OBSTETRICS AND GYNAECOLOGY antihypertesive Hiyperstat (Diazoxide) is used. The dose is 300 mg LL, in 30 seconds. This may be supplemented at 1-3 hourly iatervals ‘but the body rapidly becomes insensitive to its action so that itis rarely of use after 24 hours. Valium vp t0 100 mg LV. of Phenobarbital 30-60 mg. LV. may also ‘be given at this time to reduce the probability of aft. Such treatment should be followed as soon as possible by delivers. ‘Treatment of Eclampsa: ‘This isan emergency and initial treatment will probably be given by ‘ure. It consists of ~ Maintaining an airway. ’. Preventing tongue biting (padded spoon handle or Gvede!'s airway) ‘6 Administration of oxygen (va face mast). Definitive treatment consists of — Valium 100 mg. .V.or Phenobarbital 30-0 mg. LV. inan attempt to control the fit and prevent further iting , Delivery by the quickest and least traumatic method as soon as ‘ing is under control. Prognosis: For the mother ~ 8. Preveclampsa is the third leading cause of death in obstetric pat~ jents (ater abortion and haemorthage). This incidence can be ‘rently reduced ({0 almost zero) by proper management But at resect is rising in many countries due to increasing complacency land carelessness. Its @ reversible disease and docs not produce chronic hypertension, chronic renal disease or other sqeuclae . Eelampsia hiss wpy dangerous tthe mother bu if i not complied y a cerebral hasmorrhage or death inthe acute stage, recovery should be complete after delivery Pre-clampsia is not likely to recur in patient unless one of the major predisposing factors earlier mentioned is present. HYPERTENSION IN PREGNANCY 109 For the baby ~ Perinatal mortality is about $% in pre-eclampsia if pre-eclampsia is present fom the 86th week. It rises to over $0% if eclampsia occurs. [An inoreasd incidence of fetal abnormalities and epilepsy has been reported in babies from pregnancies complicated by pre-eclampsia. “The Majo Drag used in the Management of Pre-eclampsa: 1. Vall Diazepam) Mode of action and dosage “Antianxiely" of “Mental relaxation” effect when used in relatively low doses (eg, 25 mg. orally, LM. or LY). Some oasider that this may contribute to Towering ‘of the blood pressure by eliminating. the “anxiety component” of hypertension. Muscle relaxation is produced by large doses (€- 100 mg) LV. This is used in the teatment of eclampsia or in rinent eclampsia. Onset of Acton + Within seconds of intravenous injection Problems Potentiation by barbiturates and morphine ‘derivatives, 2. Hyperstat (Diazonide) Mode of Action + Relaxes constricted smooth muscle in the peripheral arterioles thus resulting in. Sizect decrease in. peripheral resistance Without interfering With plaetal Blood blood flow. Dose 300 mg. LV. in 30 seconds ‘Onset of Action: Blood pressure usually falls within 5 minutes of administration, ‘Duration of Action: There i @ gradual return of blood pressure to normal valve over 4-6 hours. may be repeated at this time but blood presure110 generally becomes refractory to its effect ‘within 24 hours, Special Advantages: Yt docs aot complicate anaesthesia. No Inarmful effects on the foctus have been demonstrated Tt is unusual to get hypotension asa result of its ws, Te may tansiently increase blood glucose levels. It may interrupt labour, Rarely it may ‘cause hypotension and shock Gastrointestinal upset Sodium and water retention (efter repetod injections). “Mogadon (benzodiazepine) 5-10 mgm at night Duration of ection: 6-8 hours of deep sleep. ‘Special Advantages. : Ut induces deep sleep and relieves anxiety states without producing depression. It bas no" apparent hem ees on the Disadvantages CHAPTER 6 BLEEDING IN EARLY PREGNANCY General Instructional Objective ‘Understands the significance, causes and treatment of vaginal bleeding in carly pregnancy so that he can manage this condition appropriately. Specific Behaviours 1. Describes the physiology of conception and pregnancy [with relation to implantation } 2. Describes the various symptoms and signs which may be asso- ated with vaginal bleeding in early pregnancy and their diagnostic significance. 3. Discusses the various causes of vaginal bleeding in early preg: nancy. 4, Braluates the physical condition of women with vaginal bleeding. in early pregnancy. 5. Makes and discusses his provisional diagnosis of the cause of ‘vaginal bleeding in women in early pregnancy. 6. Discusses the management of women with vaginal Bleeding in catly pregnancy. a es Bleeding in Early Pregeancy AL Physiology of Conception and Implanation Some 9 10 11 days ater ovulation, when the blastocyst has become completely buried within the endometrium, the trophoblast is actively12 [HANDROOK OF OBSTETRICS AND GYNAECOLOGY developing two layers ~ the synytiotrophoblast, and cytotrophoblast Gig. 61). The syncyliotrophoblast rapidly develops into the primitive placenta, in which primitive lcunae form later to be the intervillous paces The lacunse fill with blood under low pressure when a maternal blood veselis eroded (Fig. 6.1). At this stage the stromal cells of the ‘i, Baty stage in he dewtopmat of chai il. The wophaiast {BE detaoped tre fver= the trinropgbin and the eygropbolast [FE SESE contin’ Yow ot fed ond cas he menses core . Type? ~ NEES be placate es below the lower were segment {tthe teat dos aot cove he ifa on, ~ Te pense cal wen We ced ot ‘ype 4 — Te cal opel cover the internal o ven when dtd.1 [HANDBOOK OF OBSTETRICS AND GYNAECOLOGY ‘Unstable te ofthe foetus and abnormal presentation occur in about 30% of placenta praevas. Obviously ifthe placenta is well down in the iower segment. the presenting partis prevented from engaging and a breech, transverse le or high ‘non-engaged head results. Diagnosis: Definite diagnosis can only be made by seeing thatthe placenta isin the Lower segment at operation, o by feeling placental issue vaginally. Aclinial diagnosis, however, is made on history and examination. ‘A painless, apparently causcess, repeated bleed should make one suspscious of placenta praevia. Te absence of signs of preeclamptic {oxaemia (which may be seen if accidental baemorrahge has occurred) may be helpful. The uterus i usually relaxed and soft, and no areas of tenderness canbe found. Using a Sims speculum a. careful examination to determine the site of blood los is performed. The bleding may be seen (0 issue from the ‘os. If from a Tesion on the cervix, this can be treated as necesstry. Do NOT perform a digital vaginal examination, ‘An unstable lie or non-engaged presenting part may make the obstet- ‘cian suspect placenta praevia, especially if associated with abled, Als to Diagnosis. In expert hands soft tissue placenography may be of help. Dise placement of the head and an inequality of the thicknes of the ‘ierine wall in one place are suggestive. Pacentography is of value ‘only after the 35th week, and then is oaly 80% accurate 2. Isotope placental lcalsion (available at the Royal Hospital for ‘Womea) is about 97% accurate. and is based on increased radion activity counts over the placenta afer injection of material such 4 1 or Technesura 99 3. Ulrasonic Placentography is about as accurate as the isotope aethod, but is quicker and free of complications. Management: ‘The patient with a suspected placenta praevia should be transferred 04a fully emuipped hospital where bed rest is advised untl a diagnosis is made. Two unite of blood ate cross matched and stored for any ‘urgent transfusion, Occasionally, transfasion may need to be carried [IEEDING IW LATE ¥REONANCY 135 ‘out immediately if the bleding has been severe. Once in hospital, the farther management is either ative or expectant a. Active Management ‘This is generally only carried out after the 36th week, or when the patient continues to bleed profusely. Continuing haemorrhage neces- fitating interference is usually associated with the onset of labour. 1, after the 36th week, @ decision has been made for active iater- ference, what should be done? In an operating theatre fully equipped for Caesaran section, the patient fully anaesthetised, a careful vaginal examination is per- formed. First the fornices are carefully palpated to determine if possible, whether & placenta is Tying in the lower segment. If no placenta is felt, a finger is passed gently through the cervical os to feel the membrane, placenta or foetal presenting part. If no placenta is fe, the membranes are arifcally ruptured and the patient allowed to go into labour. Ifa type IK or IV (Fig. 7.1), placenta praevia is discovered, the mana _gement isto perform a Caesarean section. A type I placenta pracvia ‘of posterior position may necestate a Caesarean section, but if ying in front should not obstruct delivery. A type [placenta praevia should allow vaginal delivery unless bleeding continues. b. Expectant Management ‘As large majority of patients with suspected placenta pracvia are fist seen before they each 36 weeks gestation, active treatment would necessitate delivery of a large number of peemature infants if all patients were treated inthis manner. For ths reason, expectant mana- {Fement was intcoduced by Macafee of Belfast in the early 1940, Fe treated all his cases of placenta praevia who presented before the 36th week by bed rest. As a general rule these patents rarely suiered ‘lethal haemorrhage at the fest bled. By puting them to bed and keeping activity toa minimum, the chances of a further placental separation are very much reduced. Blood should be cross matched and kept stored at all times. ‘An attempt should be made (0 increase the haemoglobin level by irom thereapy (See Chapter 211). |At 38 wecks of amenorrhora, an examination under anaesthesia is performed to assess the stage of placenta praevia, and either the136 LHANDAOOK OF OBSTETRICS AND GYNAECOLOGY ‘membranes ruptured or a Caesarean section performed. It is impere= tive that these provedures be performed in an operating theatre with full Cassarean section set-up. 2. Accidental Haemorrbage (Abrupt placentae) Definition: ‘Accidental haemorrhage is etroplacental antepartum bleding which ‘ocurs from a normaly situated placental site after the 20th week of | Sotation. External Bleeding may occur from this site ifthe placenta { detached atthe edge Incidence: ‘Accidental haemorchage occurs in 0.7 -1% Pathogenesis: ‘The placenta separates through the desidus allowing blood to ake” Under the placenta. Ae the blood colets under the placenta it may Srp up more placeatal tissue of fore its way between the membran ‘ouschgrion and the decidua tilt reaches the cervix, and then appears a: revealed Blood loss (Fig. 72~A,C). Ifthe reroplacental haemorrhage rps up the placenta and doesnot escape externally, a concealed ac~ cidental haemorrhage results (Fig. 7.2 B). A small concealed bleed ‘may organise, Become fbrosed and calcified producing a correspond- ing area of infarction and boss in the placenta itself ‘With a recent bleed an area of depression with an attached clot may be seen om the surface of the placenta at delivery. If some time has lapsed, infarction at varying stages of organisation will be present. Grades of Accidental Haemorchage: ‘Accidental haemorrhage may be: ‘a. Mild ~ 60% cases ~ less than 3 separation of placenta 1. Moderate ~ 15% cases - 4-4 separation of placenta ©. Severe ~ 574 cases ~ more than § separation of placenta ‘This classification s based on the amount of placental involvement and the resulting shock which follows 1 the placental area involved is small and under a quarter of the placental site affected, the condition is generally of mild. degree, And foctal prognosis ix generally good. The blood strips the chorion ‘rom the decidua and trickles out through the os to appear asa revealed scidental haemorrhage. AB the area of placenta involved is small, of pregnancies. BLEEDING IN LATE FREGNANCY BT blood loss can be replaced. A foetus can exist with about one third ‘of the normal placenta affected, obtaining sufficient autriment and oxygen through the remaining placenta Fie.72. Depecs of deachmet of « normally Sopaned ntact tal deacon and eternal Nein 8 Ses aering ic tena mrp hs oredr eachnent and ex ‘Seoul ieoding: CRedrawn fom Danforth, 197 If over « quarter of the placenta is separated, the blood loss tends to be greater, more placental tissue is rendered hyporic andthe foetus138 HANDBOOK OF OBSTETRICS AND GYNAECOLOGY is at greater risk, There is generally some delay in seeing vaginal ‘blood toss after the inital onset of symptoms, and this may BE re- corded as concealedtevealed accidental haemorrhage In those cases where the blood first strips the whole of the placenta, from the decidus, there is a considerable collection of blood besind the fully separated placenta. Shock may be profound, foetal death always occurs and bleeding from the vagina may not be seen In the moderate to severe forms of acidental haemorthage, there may ‘be gradual filing ofthe uterus with blood, The Blood spreads through the decidua and myometrial tisue and separates muscle bundles, ‘This blood may track into the broad ligaments and to the serosal surface of the uterine wall. Because of the blood in the myometsium of the utecus and muscular ivtabiiy, thi organ usually becomes tense and tender and later goes into spontancous labour. Actiology and Associated Factors ‘The actual actiology of accidental haemorchage isnot enircly settled ‘bt there area number of conditions which are found to be associated ‘with its oeeucrence: Mulipary ~ There is a rising incidence of accidental ha ‘morthage with increasing. party, and a woman having 5 ‘or more children has a four-fold increase in the risk of sulle. ing from accidental haemorchage over the primipa, Age ~ There i a slightly greater risk with increasing age but ths appar oe clsly reed to increasing party i the majority of eases, © Mutton ~ People from lower income brackets who eat less protein and green vegeiables have a higher incidence of Accidental haemorthage than women in the upper socal classes. 4. Anaemia i. Some 2074 of women who had accidental haemorchage were found to have a haemoglobin below 11.0 gm oe before the onset of the haemorrhage. A majority ofthese women were suifering from iron deficient anaemia, fi, An interesting fact wikch has recently been observed by Hibbard in England is that 987 of patients who had accidental haemorrhage had a raised F-LG.LLU level in [BLEEDING IN LATE PREGNANCY 1 superman Sao forever oe Sota eee os ee a pak Sa cit ca ent res Sn eeae fe. Obstewic History ows pinta moti n patients wh sur fom [Stemal haemotage about four nes as high as Send eiher words thee mothers have aba be ar abstehioy, and about one Mth of motes Ter pees oo Sey ee us atasy in her pegancies ao tice High in tier who ave aceldenal hacmorshage &s in the ‘reall poplin. Teak repeated accidental baemorage i five times gjeatin patents who have Had an acienalMaemor age asi yin the ovral population “ Patare Labour over bal te cases of abruptio pasate oct be he 26 wn, ba he ak um er cre dtig the 36h ea iin cs fap ra aou hen stn dad thee maybe ein cause or the Spi in crn concactions I mah b that werine ceeetana cher of premature labour of Draxfon EIEgpe’ acing va a neurely anchored plceta, Hy inate separation oft minor or major degree Soke 300 of te nats bora to bes having se40 ental haemorrhage are smaller than the size expected for the petiod of gestation Preeclampsia and Hypertension Although about 30% of patients who have accidental haemorrhage are found (0 have a raised blood pressure and. protsinuria after haemorrhage, this is thought 10 be due to ‘Compensatory mechanism to the blood los, leading to vaso- ‘consriction and renal ischaemia. In large groups of pre- feclamptcs carefully observed. in antenatal and hospital ‘inie, there is a slight increase only in the number of aci- ‘dental haemorrhages occurring. Trauma ‘Trauma may very rarely beacause for accidental haemorrhage, bbut_generally there is no antecedent history of blows of knocks tothe abdomen. Hydramios ‘There appears to be a slightly higher risk of accidental hae- rmorrhage occurring with hydramnios than in the normal population but the majority of accidental haemorrhage cases have a0 evidence of excess liquor. Congenital Malformations ace 3 times as common in those cases having abruptio as in normal pregnancies. Severe Foetal Respiratory and Cardiovascular Disease was seen five times more often in cases of abruptio placentae ‘as in the overall population. ‘Renal infection may be related to deciduo-placental throm ‘boses and precipitation of ischaemic changes leading to socidental haemorrhage, ‘The clinical impression concerning the aetiology and patho- logy of accidental haemorrhage Is one_of inferior social Status, poor nutrition and prevalence of anaemia associated ‘with tauliparty, recurrent accidental haemorthage and pre- vious poor abitetrc history. The postive fact that folle acid deficiency is particularly common suggests that this may play an extremely important role in the actology of abruptio placentae, [BLEEDING IN LATE PREGNANCY 4 ‘Symptoms and Signs: ‘The severity of the symptoms and signs is related to the amount of, placental separation, so that clnially fue indiation may be pained Of the grade of hcmorrhage Mild Antepartum Haemorthage: 4. Poin - a vague lower abdominal discomfort may or may not be present. Here differentiation from a placenta prac it required. 1b. Tendemess ~ Tenderness may be very slight and should be carefully searched for. & Bleeding ~ Scant to moderate (less than SOOml) dark vagin bleeding is present. 4. Mother Vial signs remain unchanged fe Foetus ~ Footal heart sounds are srong and regula, Moderate Antepartum Haemorshage: ‘Mild separation may progress to a moderate separation, or, the onset of symptoms of moderate separation may be abrupt 8. Pain ~ There is a continuous abdominal (uterine) pain which ‘may be severe, Bleeding ~ Although only moderate vaginal bleeding may ‘ovat the total blood loss may be over I lite, &,Tendemess ~ Uterine tenderness i larly present, Sometimes the tenderness is generalised and there is muscle guarding with rebound tenderness. The tenderness is due to uterine Infiltration with blood. 4. Mother ~The patient may be shocked, with hypotension, tachycardia and a cold, moist skin, but often has hypecteason, fssocated. with reduced renal output and protenuria. ©. Foetus ~ The foetus may show sigos of focal distress and succumb. Preeclampsia ~ May oocat here but is more prominent with severe separation, ‘Severe Antepartum Hacmorshage: Here the onset i usually abrupt. ‘a. Pain ~ Uterine pan is agonizing. 1. Tenderness ~ The uterus is tender, tense, and “woody hard”, probably due to a reflex tetanic contraction, ©. Bleeding ~ External bleeding may be moderate or absentwe (concealed haemorrhage). At east 2 litres of blood have been lost from citculation, 4. Mother ~ The patient is usually hypertensive initially but quickly becomes shocked. (The degree of shock cannot be felated to the external blood loss) fe, Foetus ~ The foetus almost invariably dies. £ Preeclampsia ~ This is present in about one third of cases Biving Hse to proteinuria, and rising the blood pressure to flmost normal level in spite of shock. Complications: Hypofibrinogenaemia is an uncommon but extremely dangerous complication of acidental haemorrhage, and can occur after any ‘degree of abruption, but more commonly after the severe concealed variety. ‘The patient has an attack of abdominal pain, following placental Separation, and the typical tense, tender woody uterus occur. ‘After an interval of time bleding is sen, and despite adequat ‘therapy, blood transfusion and delivery ofthe infant, the bleeding continues. If a sample of blood is taken and examined, it is scen that either no clot forms or, fa clot does develop, it can be easly broken Uup by gentle shaking ofthe test cube. This condition is Known as Ihypofibrinogenaemia, and the patient may bleed to death unless adequate therapy is instituted to correct the abnormality How Does Hypofbrinogeaaemia Oscar? ‘There are thought t0 be two major mechanisms javolved which may act separately or together to deplete fibringogen levels, J. Following the haemorrhage there is a release of thrombo- plastins into the Blood sieeam from placental tissue. This ‘thromboplastin causes a generalised intravascular deposition ‘of fibrin which, although not sufiient to block the vessels, ‘auses laying down of a thin thrombus on the vesel wall ‘This fibrin deposition causes a reduction in fibrinogen levels to Below 0.1 gm 92. As the fibrinogen level fall, the blood ceases {0 coagulate, and uncontrollable haemorrhage may fi, Fibrinolytc system: Normal plasma contains a complicated fibrinolytic system which aids in the contol of the haemo- BLERDING IN LATE PREGNANCY 43 static mechanism, This system consists of pro-ctivators, fan inactive precursor (plasminogen), an active enzyme (plas: min), and various inhibitory substances. The pro-ecivators fare released rom placental tissues, Plasmin is abe to hydeo- lyse fibrinogen and other clotting factors and destroy their effectiveness. Fibrin degradation products then act to inhibit, thromboplasin conversion of prothrombin to thrombin “The effectiveness ofthe conversion of plasminogen to plasmin can be prevented by competition by a certain aminoacid known as epsilon amino caproic acid (EACA), These amino- acids act to inhibit the activators of the plasminogen Renal Failwe may occur due to the resultant renal schaers ‘which develops folowing hypovolaemia and arteriolar constriction. It is important in the prevention of renal failure to resuscitate the patieat adequately, preferably with whole blood, The werus may have multiple bruising or eyhmoses on its serosal surface due to the blood which tracks through muscle and para- ‘mettal tissue (Couvelare ters}. ‘Management of Accidental Haemorrhage: ‘The initial management can be divided into two types, depending on the severity of the condition a. Mild, Revealed Accidental Haemorrhage I this case there is often a small amount of bleding asso- ciated with minimal pain and tendernes. The condition may occur before the 36th week, s0 itis eseaial 10 gain foetal maturity whenever possible, Put the patient to bed in hospital, Analgesic ~ morphia 15 mg or pethidine 100 mg. ii Crose match blood. Estimate Hb and haematocrit |W. Have fibrinogen available if necessary. ‘¥. Observe patient for several days until bleeding and pain subside, then allow out of bed after excluding a placenta praevia, If no other contraindiations are present, the patient may be allowed home, These patients must not be allowed to go postmatur, because the placeotal Tunetion has already been reduced duc to the accidental haemorrhage. b. Moderate/Severe Accidental Haemorrhage4 HANDBOOK OF OBSTETRICS AND GYNAECOLOGY ‘These cases are sufering from severe pain, are bleeding, ‘and have lost more blood than i usually estimated. They may go into ireversible shock, sue cenal damage or hypofbrinogenaesia tnless treated adgeustely. i, Putt rst in bod in hospital. ii. Give morphia 15mg. Ti. Cross match and begin transfusing blood. The patent Jnvariably loses twice as mach asi estimated. To prevent the patient suffering shock a drip must be set up as cary as possible. iv, Check the blood from a vein to determine flrinogen levels. A quick test can be performed by placing blood in atest tube and inverting every 30 see. Normally the the blood will clot and remain a firm matrix within 1-2 minutes, Any delay in cloting necessitates a full fibrinogen estimation, but donot delay ‘treatmeat. Give fibrinogen 2, 4 of 6 gm. as required, oF fresh whole blood Tit is suspected that ibinolysins are responsible forthe ‘coagulation defest and these factors are demonstrated absent, then EACA can be given, 46 gm initially then 1 gmy/hour. When the patient is resuscitated, rapture the membranes to presipitate labour. Often, however, one will find the patient fs already in labour following the initial tetanic Contraction, but if not an oxytocin dip may be setup. Vi, Deliver the infant as quickly as necessary, but take special care that post-partum haemorthage does not take place. Ergometrine must be given following delivery to fin maximum amount of advantage from uterine contractions, Mortality: oe moray ets depend ently onthe degre of svriy of the condition ‘The maternal mortality isin the vicinity of 774 for severe types of| semorhag, manly from ascited hypoisnopensenit Foetal loss isin the vicinity of 95% for severe concealed accidental haemorrhage and drops to about $-10% for cases of mild degre, LABDING ny LATE PREGNANCY 4s ‘There isan overall foral loss of about 25% in all eases of accidental baemocehage. Differential Diagnosis: In mild cases differentiation from a placenta pracvia may be dificult. Recial and urinary bleding as a cause of haemorchage must always tb exchuded. ‘A diagnosis of acidental haemorrhage can only be made inthe pre- ‘sence of pain and tenderness of the uterus, whereas the other {pes Of ADA. are usualy painless, ‘A concealed accidental haemorrhage may be confused with appendi- cits inary tract infection, other causes of intraabdominal bleeding, torsion of a viscus, or rupture of the uterus. A careful history is ‘sential together with complete physical and laboratory examination. 3, Lesions of the Cervix, Vaglaa, and Valva “This i an uncommon cause of bleeding in late pregnancy. A detailed history and carefully examination with a Sim's speculum will help leate the ste of bleding. Treatment of these conditions is discussed in the appropriate chapters. The leiont may be cervical carcinoma, cervical erosion of polyps, varicosities, vaginitis, or trauma. 4. Vasa Pracvia In this rare condition there is a velamentous insertion of the cord in ‘sociation with a placenta praevia, 40 that foetal cord vessels pass ‘across the cervical opening. Bleeding here is of foetal origin. General Management of ‘The assessment of a patient who has been bleeding in late pregnancy begins with adequate history (f the condition permits). One must ‘exclude plicenta praevia and abruptio placentae, therefore relevant ‘Westions concerning the respective symptoms are asked. tient with Antepartum Hacmorvhag. In the examination such points ate looked for as blood pressure uterine tenderness, presence of the focial heart sound, and the source of bleeding om speculum examination. ‘The patient is admitted to the ward and rested in bed until special investigations bave made the diagnosis more clear. More definitive treatment may then be commence, iit is indicated.146 HANDBOOK OF OBSTETRICS AND GYNAECOLOGY References 1. WREN, B. G. (1969), “Antepartum Haemorchage", School of Obstetrics and Gynaccology, University of New South Wales 2 DONALD, 1. (196), “Practical Obstetric Problems", Lloyd Luke Lid, "London, 3. DANFORTH, DN. (1971), “Textbook of Obstetrics and Gynae- cology”, Harper and Row, New York. CHAPTER 8 FOETAL WELL BEING General Instructional Objective Recognises parameters, of and understands factors affecting foetal wel being s0 that appropriate management can be instituted, Specie Behaviours 1, Describes factors which may impair foetal well bein. 2. Distnguishes “at risk” from normal pregnancies. 3. Demonstrates ability 10 assess foetal well being. 4. Explains the importance of antenatal eae on foetal wel being 5 Evaluates sccening and diagnostic procedures wsed during preg saney to assess foetal wellbeing 6. Discusses the management of the “at risk” pregnancy. =e em Foetal Well Belag During a pregnancy the normal development and maturation of a foctus may be influenced by a variety of factors many of which are known and most of which are either preventable or treatable. During labour the survival of the foetus may be threatened by hypoxia or biochemical or nutetional failure and this may be manifest by signs of foetal distress. The obstetrcian’s task, therefore, is the erly re- cognition of the foetus at risk and the provson of the best possibleus [HANDBOOK OF OBSTETRICS AND GYNAECOLOGY management of the problem, both during the pregnancy and the labour. |A. Factors which may impair foctal well bsing during pregnancy. (Che high-risk prepnancis) “The known factors may be classed as being maternal, placental, oF foetal 1, Maternal Factors: “Hypertension (any causs) Placental vascular lesions such as acute Abinoid necrosis hnyalinisation, and possibly arteriolar spasm may lead to infarction and placental insuficiency. (Chapter 5). Urinary Tract Infection Bacterial toxins are thought to produce fibrinoid. changes within vessels reducing blood flow. This is followed by ine creased incidence of antepartum haemortbage, premature labour, intrauterine death, and neonatal death. (Chapter I), Diabetes Melis Several factors are important here, including an increased incidence of urinary tact infections and pre-eclampsia, maternal Keto, and intrauterine death of obscure origin. (Chapter 11. Anaemia Anaemia is associated with increased rate of prematurity tnd low birth weight (Chapter 11). Elerly Prinigravda In primigravidae over the age of 35 stillbirths are more com- ‘mon, predominantly due to placental insuficiency or ac- cident haemorthage (ste page 167 fr further discussion). Rh loimisaton Foetal red blood cell destruction by maternal antibodies may progress (0 anaemia, eardac failure, and_ generalised cate non oli Ge page 16 for fer di FOETAL WELL-BEING 49 Other Factors Include: i. Mulliple pregnancy ~ reduced placental area ‘Nuteitional factors — smaller babes. [Low socioconomic status ~ smaller babies. Smoking ~ smaller babies. %. Grand mallipara ~ more complications (Gee page 168 for further discussion) 5 vi. Poor obstetric history ~ increased risk ‘of problems. vi. Maternal syphilis ~ intrauterine death (Chapter 13) vi Uterine malformations and fibroids. 2 Placental Factors: a. Antepartum Haemorrhage ‘The extent of placental separation determines foetal nutrition and future foetal growth capacity. (Chapler 7). b. Prolonged Pregnancy Placental efficiency declines after term with reduction of blood flow and, therefore, of transplacental nutrient transfer, ©. Other Placental Factors Infarct, haemangiomala, single artery ~ associated with reduced placental efficiency. Cord about foetal neck ~ may ‘cause reduced blood flo. 3. High-Risk Pregnancy Identifications: ‘Barly detection ofthe foetus at risk depends on the patient's catly and regular attendance, and the obstetrician’ clinical ‘Skil inthe antenatal clinic. ‘An accurate initial history will help detect many of the abovementioned factors such as urinary tact. infection, ‘iabetes, the elderly primigravids, smoking, poor obstetric history and others ‘The examination wll confirm some of the above and unmasi others such as hypertension. Routine and. special invest ‘ations wil elp diagnose anaemia, Rh status syphilis, rubella, for diabetes mellitus. Detection of some conditions can only be made during the various stages of pregnancy. In this respect regular maternal[HANDBOOK OF OBSTETRICS AND GYNAECOLOGY attendance at the antenatal eine is of paramount importance to the foetus, Preeclampsia, urinary tract infection, anaemia, Rh isoimmunization, and antepartum haemorrhage mist actively be searched for. Monitoring of Foetal Growth and Wellbeing may be caztied ‘out during the latter part of pregnaney by the use of the Following methods: 4, Ulrasonie Fchoscopy — accurate measurement of the Di-parctal diameter of the foetus can give a growth rate curve when performed every 7 to 10 days. Thie ‘may be started at 28 weeks to establish an early baseline. FETAL WELL-SaING 11 limits (Fig. 8.1) are not absolute bat may be taken as the 10th percentile of the distribution. ‘Osstil assays are exried out on 24 hour wrine samples land may be commenced, for an at-risk foetus, at about ‘week 20, since itl ean Be done forthe foetus ifs falling trend is seen prior to this time, iii, Lecithin Sphingomyelin Ratio ~ Since the alveolar suc- factant’ required for normal ventilation is made up largely of lecithin, the amniotic concentrations of the above phospholipids can be used to predict foctl res piratory maturity. Io normal pregnaney an increased production of lecithin in relation to the production of Sphingomyein at about week 34 (Fig. 8.2) is associated with lang maturation. Delivery of a foetus aller this time correclates closely with markedly reduced occur rence of respiratory distress syndrome, .3 _- LECITHIN a= fl ae i 7 k GG / BE ee HNC OMTELN B5 s t 2 20 28 36 ‘Fe. 41, Tweatyfou our wiry oestiol. (Ale Landy ta 1979). iL Urinary Oesiriol Levels ~ The integrity of the feto- placental unit may be asessed by urinary oestriol ex- retion, However, this method requires intelligent interpretation since daily variation can be of the order Weeks Gestation Pe. 82. Amaia and sohinganvelia concentations ix normal ‘gun he raon ¢ ty pean feces a vale 21 ore ACSRoat Se nets gran The iueased LS ron a at inde of focal ing mst om Chet of 97) ‘of 30-5074, making a single estimation vitally sels. Using day estimations a tend is established. The normal ‘wend is a rising one, a falling tend may indicate de- creasing foetal or placental function. Normal lower In the high-risk pregnancy maturation of the focal Tung is known tobe acelerated by maternal hypertension, antepartum haemorrhage, and. prolonged. rupture of ‘membranes. The foetuses of some diabetics have dlayed132. [HANDBOOK OF OBSTETRICS AND GYNAECOLOGY lung. maturation, (Gluck er el, 1973). Corticosteroids may be the mediators of the acelerated maturation and ‘hus their use may prove useful in the high-risk patents prior to delivery. iv, Anmiotie Bilirubin - Intrauterine foetal haemolysis leads {o'a spillover of bilirubin into the amaloti ft. Meas surement of its concentration is of prognostic value and is used as a guide in management (se page 160 Tor further discussion) of cass of rhesus incompatibility. ¥._ Radiology ~ Estimation of foetal maturity is by no means accurate and is of litle valve prior to the calcfeation of the distal femoral (36 weeks) ot the proximal tibia eiphyses (38 weeks), 4. Clinical Measurements ~ A crude clinical estimation of foetal growth can be made by measuring the maternal gcth fand fundal height. From wecks 28 to 36 the greatest abo- ‘inal circumstances is taken to increase ata rate of I"/veek being 36 inches at 36 weeks, Fundal height, measured rom the symphysis pubis, rises at a rate of lem/weck, reaching ‘36cm at 36 weeks. 1B Antenatal Care ‘The objects of antenatal care are: 1. To promote and maintain good physic the mother during pregnancy. 2 To ensure a mature, live, healthy cil 3. To prepare the mother for labour, cation and the subsequent care of her child, from the physical, psychological and domestic point of view. 4. To detect at an cary stage any medial or obstetrical abnormality which might endanger the life or impair the health of the mother fad baby’ and treat this abnormality appropriately When meticulous attention is paid to all aspects of antenatal care by the obstetrician maternal and foetal morbidity and.-morality is significantly redoced. Ths will not be possible, however, if maternal attendance is not regula, ‘The explanation ofthese fact 0 the patent isthe obstetrcian’s duty. With the “captive” population of women who attend the clini any FORTAL WELL-BEING 153 disease may be sereened for and detected carly. Such sereeing will remove focal wastage due to diseases such as rubella, venereal disease, ‘or isoimmunisation. Regular attendance allows also for the care of the mother and the foetus considered to be suering from those “high risk” matemnal conditions which may lead to foetal death Maternal education through counseling, lectures, discussion groups, and films concerning labour, the puerperium, and motherhood, wil prepare the patient psychologically Tor those future events. Mis- conceptions and problems can be aed atthe clinic, and this will help to revolve mich unnecesary anxiety. Foetal Distress ‘The term “octal distress’ is usually applied to the acute situation oc curing during labour when such signs as foetal tachycardia (greter than 160/minute), bradycardia (ess than 100/minute), or meconium ling of quot amni indicate the foctus may be deprived of clo mentary nutrition. This is usually precipitated by biochemical hypoxia and hypoglycaemia. Twenly per cent of babies showing signs of foetal distress will abo have a blood pH of less than 7.15, Some 107(-15% of patients who go into labour can be labelled as ‘high risk” pregnancies. Due to their chronic autrtional deprivation resulkng in reduced giycopen stores many of the foetuses in these Pregnancies wil be unable withstand the rigors of « dificult oF prolonged labour and thus will be mote prone to show signs of cal distress during labour Statistically, of 1000 mothers going into labour 140 of thei foetuses will have signs of foetal distress, either as susained bradycardia, meconiumstained liquor, or both. Of these, only 40 foetuses will have alow blood pH, and of ths 40,20 are at risk of death unless active measures are taken. This ony 2% ofthe original 1000 mothers. ‘To perform Caesarean section with it's Told increase in. matemal mortality on the original 14%, because signs of foetal distress were ‘resent, would result in greaer morbidity and morality than if only the 2% were to be considered for Caesarean section. Note that of the abovementioned 140 mothers, 80 will come from the “high-risk? pregnancy group previously mentioned, ‘There is, therefore, a need for a method of deciding which babies are at rsk, and consequently which babes will require to be delivered before the nora end ofthe labour. “Two groupe of babies can be dealt with fairly easily, In those cases1s HANDAOOK OF OBSTETRICS AND GYNAECOLOGY te te hh sts dates income eet Shae tieigares eoheraton ca ihe ees cram ere Leese eae chee fesGeeae tame Uterine contraction 8 recorded on tocograph Contraction Strength of Ur 5. Vari or cord ommesion bulk of cases manifesting signe of otal dnt i bo {even ie above to cut nde orgie nwa problems (On fnding focal disses during abou the catue and sty of the Shue mast be etcmine, Contouous focal ear’ moctodng ombined wth ontoring a eerie atny by toca may hom ‘tie tts of bradyntla 83). ‘These ae: 1. Early, or Head Compression characterized by ~ carly onset, bradycardia usually of not less than 100/min, bradyeardia usally shorter than 90 seconds duration, not affected by breathing oxygen 2. Late or Utero Placental Compression ‘comes on late in the uterine contraction, FoerAL WeLL-RENG 155 lasts a variable time after the end ofthe contraction 3. Variable or Cord Compression variable onset and foetal heart rate, bradycardia usually falls below 100/mia, baseline being normal, duration of bradycardia varies from 10 sc to miautens * markedly altered by maternal postion change In the high-risk pregnancy any sustained bradycardia of less than 100)min, should be followed by a determination of foetal blood pH, ‘A persistent pH of less than 715 is associated with Apgar scores of less than 6, ad in these cases, therefore, immediate delivery by Cases sarean section or forceps, i indicated. Since selection erteria are not yet accurate, many operative procedures are probably Unnecessary Management ofthe High-Risk Pregnancy: Each condition that creates a high-isk prepnacy has is spesific mana ‘ement and is discussed in deal elsewhere. The general management ‘of a high risk pregnancy, however, will involve the following major ‘components:= a. EarlyAlagnonis antenataly b. Alteration of the antenatal routine to suit the particular Condition, For example, te patient with diabetes melitys is admitfed to hosptal at the frst visit for stabilisation, and is then seen at least every 2 weeks and not the usual 4 weeks. The patent with @ muliple pregnancy will require extra iron and folate supplements and will be brought Into hospital for rest at 30 weeks to reduce the likelihood of premature labour. © Alteration of the delivery procedure. In some eases time of Uelivery will be dictated by the oestriol levels, echoscope findings, and leithin/sphingomyelia ratios, Most diabetic patients wil have labour induced at 37 weeks, The time of delivery, and the method, again depeads on the particular condition. D. Induction of Labour Induction of labour isan attempt to terminate a pregnancy arifally at any time afer 20 wecks gestation, aiming al a vaginal delivery ‘The incidence of induction varies between 3 and 25% depending on136 HANDBOOK OF OBSTETRICS AND GYNAECOLOGY the policy at various hospitals. At the Royal Hospital for Women itis approximately 20% In general terms, a pregnancy should be terminated if i's continua tion endangers the feof the mother, or if itis Fel thatthe foetus i fata grater rick in the uterus than if it were in crib, The indications for ndvetion wil be listed. ‘Maternal Indications for Induction of Labour Eclampsia Pre-eclampsia Hypertension CChronie pyelonephritis ‘Accidental haemorrhage Placenta praevia Intrauterine death Foetal Indications for Induction of Labour Rhesus io-immonisation Diabetes melitus ‘Recurrent intrauterine death Placental insuliciency Prolonged pregnancy ‘Methods of Induction: Labour may be induced medically or surgically. 8, Melia! Induction ‘il, enema, and shower ~ of doutstuleicieny. fi, Quinine suiphate~ not very effective and seldom used, Jil, ormones ~ a) Oestrogen ~ may be used in cases of fnrauteriae death ut is not regarded as being of any marked value. ‘b) Prostaglandins ~ may be used sucessfully to induce labour But inense nausea and cardio-vascular reactions have reduced {ts use and itis not generally advocated. ©) Osytocins = oxytocin stimulates. uterine contractility, but in larger amounts has an fantidiuretic action, A synthetic preparae tion, Syntocinon (Sandoz), is now com monly used, FOETAL WELL-BEING Isr Oxytocin may be administered as: Intravenous infusion 5 Buceal Ptocin (abit) [Nasal Pitocin (pray) ‘Nasal Syntocinon (pray) Intramuscular Syntocinion should never be used prior to delivery Because of the danger of uterine rupture ‘Oxytocin may be used as the only method of induction, oF (sociated with) artical rupture of the ‘membranes, in ‘hich eae the succes rate will be over 90%, Close supervision is required when using an oxytocin in- fusion because the patients sensitivity to the drug ie not known, She may espoad to it by a tetanic werine contraction causing foetal hypoxia, and occasionally rupture ofthe uterut say occur. Contrandiations to Oxytocin Infusion include: 1. Grand Muliparity~ This is not an absolute contre-indication| but great care is necessary, since risk of uterine rupture is high. 2 Previous Caesarean Section ~ This is another relative con- traindcation, since the chance of sear rupture is hig. Absolute Disproportion 4. Incoordnaie Uterine Activity ~ These cases are valikely 19 ‘profit from the oxytocin while the risk of erie rupture Increased ‘Surgical Indetion Anmiotomy is the usual and most efficient method for induction ‘oflabour. Either high or low artical rupture ofthe membranes (LAM) can be performed. Hindwater (high) rupture is less likely to be followed by cord proplapse or infection than forewatet (low) rupture. Is chiet place isin drainage of excess liquor if the presenting par is High (in cases of polyhyhramaios: when the head becomes well applied to the cervix, 2 L.A.R.M. should follow). The main factor ibfecting succes of amniotomy isthe state ofthe cervix. "Sucess™ ‘means that labour ensures within 24 hours of amniotomy. If the138, cervics “ripe” admitting two fingers, soft and effacing ~ induction will succeed in 95% of cases. With a long, frm cervix admitting ‘only one finger the success rae falls to 657 Risk of Induction of Labour: 4 Failure 1 the patient is not in Inbour 48 to 72 hours after induction, Caesarean section is almost inevitable. The main hazard (0 both smother and baby is sepsis, and antibiotics should be administered within 24 hours to reduce its inidence (se Chapter 4). Prematurity ‘This risk must always be borne in mind, especially when there is tome doubt as to the date ofthe L-MLP. and the time of eon ception Disordered Uterine Action may result when induction with oxytocin js attempted in a uterus whichis not ready (ee Chapter 4). Complications of Surgical Induction, 8. Sepsis ~ If the patient isnot delivered by 24 hours from the time the membranes were ruptured the incidence of infection tises rapidly. The incidence of uterine infection doubles for very 6 hours that elapses after 24 hours of ruptured me- branes. For this reason, penicilin and streptomycin are tsually ordered. when the ‘membranes have been ruptured for 24 hours. Cond Prolapse ~ with the engaged head the incidence is 0.1” but ries to 2-59 with high head, The risks not completly abolished with high rupture, asthe forewaters also may be inadvertently ruptured. © Accidental Haemorrhage may follow the sudden release of a inrge volume of liguot in cases of polyhdramnios, in which a slow release should be made er, alternatively, abdominal paracentesis carried out 4. Anionic Fuld Embolsm is raze but often lethal. Liquo ‘containing debris, meconium, and hai, may enter a mater Sinus, usually dating or after a heh rupture and Is often associated with maternal death or severe hypofibrinogenaemia, OETAL WeLL-ING 19 ‘Suggested Method of Induction: 4, Empty the lower bowel, This will remove obstruction to ‘the dosent of the preseting pat. 'b. Anmiotomy with strict aseptic precautions is carried out next, ‘provided thatthe foetal head i well applied to the cers, ‘Acarefl vaginal examination is made prior to the amniotomy, to check pelvic dimensions, state of the cervix, and postion and nature of the presenting part. The index or both index land middle fingers are then passed through the cervix and themembranes stripped widely fom the lower uterine segment. ‘Then the eft hand puides a pair of artery forceps along the fingers ofthe cht hand. The membranes are grasped, tented and ruptured by pulling. on the foreeps. The hole made in ‘the membranes in enlarged by the fingers of the right hand ‘which remain in the vagina, controlling the escape of liquor arn uni the presenting pact i firmly setled in the pelvic. ©. The patient is observed at regular intervals for the onset of uterine contractions and for evidence of foetal distress. 4. Oxytocin Drip. If the indication for induction is very ut- ‘ent an oxytocie dep canbe set up at the time the membranes fre rupted. But if this is not absolutely necessary it should bbe withheld as #0% or more of the patients who ave their rlembranes ruptured will proceed with a normal labour. Tf labour has not ensued 12 hours afer amniotomy an oxytecie. drip should be commenced, with soon after. At the Royal Hospital for Women 10 of women who are induced require an oxytocin drip. E, Intranterine Death Foctal death before 20 weeks results in an abortion. Infrequently foetal retention wil result in a missed abortion (ste Chapter 6) ‘After the 20th week intrauterine death may be diagnosed by the following signs nd symptoms ‘Maternal lack of ‘pregnant feling’ with regression of breast changes Prolonged absence of foetal movements Lack of fortal heert sounds on auscultation and with the Doptone Delector160 [HANDBOOK OF OBSTETRICS AND GYNAECOLOGY Cessation of wetine enlargement. Falling or very low oestriol levels in the urine. (Pregnancy test ‘yin pose wp fo # moa) ‘collapsed foetal skull on palpation, giving a “grating” feeling 45 the skull bones override eachother, ‘Xray changes includ’ i. Overlapping. of skull bones (Spalding's sign) wich take about $3-4days to develop, and is due to reduction of intracranial contents and softening of ligaments i, Increased flexion of the spine (Ball's sign) which takes at least 2 ‘weeks to develope. asin the great vessel, usually present about 36 hours afer death ‘Management ‘Daring the 2to 3 week period after foetal death in which the diagnosis is being made, 70 t0 907 of dead foetuses are expelled. At thi stage peychological support for the patient i of paramount importance, 1 delivery does not occur within 3 weeks, indaction of labour should be undertaken in anticipation of the development of hypoibrino- ‘Benaemia. A syntocinon infusion may be used for induction. If some able placenta stil produces progesterone which reduces uterine ruscle excitability however, oestrogens may be used to block this ‘ction, is wise not to rupture membranes in the presence of « dead foetus as labour may not follow and the risk of infection is high, , Tsoinmanisation 1, Rhesus (Rb) Factor ‘The “Rh factor" was fst detected in 1940 by Landstsinder and Wiener but it was not till 1944 that Fisher discovered the indi- idual antigens that made up the “Rh factor”. There are 6 main Rhesus antigens (three pairs) which are inherited by 6 separate ones, Cyc, D, d, Ee. Three genes (one fromeach pat) are located fon each of a pair of chromosomes, one choromarome being inberited from éach parent. Its the presence or absence of the D ‘antigen, which alone determines if a. person is Rh positive or Rh negative. In European races £3% of people are Rh positive, 50 of whom are heterozygous and 33 homozygous for the D antigen, FOETAL WELL-BEING 161 In pure Asian and Polynesian races there are no D negative ine dividuals, very few in Indians and only 0.3% in Japanese. Rhesus isoimmunisation may occur when a Rh-negative mother is pregnant with 2 Rh positive foetus. The foetal cells may Teak into the materoal circulation (foeto-materaal baemorchage) and 8 they contain blood group proteins (antigens) absent in the ‘mother, maternal antibody formation may be stimulated, ‘Maternal sensitization is more likely to oocur after such proce dures as induced abortion, exteroal version (especialy if performed ‘oder anaesthesia), dificult instrumental deliveries, manual removal ofthe placenta, acidental hemorthage and Caesarean Section, 1 may also occur at the time of placental separation in the 3rd stage of labour, during amaiccentesis, and after transfusion with Rh-tve blood. Maternal antibody formation depends on_the size of the foctosmatemnal haemorrhage, the time at which it cocurs, the individual sensitivity of the mother, and on the ‘ABO blood groups. Ifthe baby's ABO grouping is incompatible With the mother, then the mother's anti A andjor anti B antibodies rapidly: destroy'the foetal rod cells, and maternal sensitization isimoch less fequent. An Rh-ve woman may marry an. Rh-ve bhusbund and his children will all be Rh-ve. Wi a beterozygous D husband only Rh-+ve offspring are at risk. Is are fr the ist Rhesus postive pregnancy to sensitize a woman, but 1 in 10 women are sensitised by two such pregnancies. Tis risks doubled (i/5) if both Rh-=ve pregnancies are ABO compatible with the mother. At present about 6/1000 babies are affected in ths way, fone of which will evelop a suffcient degree of anaemia to pro- dace a stibirth, nthe frst pregnancy in which Rh antibodies ‘occur the risk of stilbith is about 10%. Foetal red blood cels ‘can be detected in the maternal blood by the Kleibauer count, Which is based on the fact that focal ells contain Hib in con- trast to the Hb-A of adult haemoglobin. When treated with a ‘DH 33 bulfer, focal cells stan in much the same way as"usul, ‘while maternal calls lose their haemoglobin and appear as “ghost” cells. Following sensitization two types of antibodies develop in the mother! ‘Complete (Saline) or IgM antibodies. These are detected first and do not cross the placental basier because of the size (about 890,000 mol. wt). 'b. Incomplete (Albumin) or IgG antibodies. Being much smaller12 HANDBOOK OF OBSTETRICS AND GYNAECOLOGY (mol. wt. 140,000) they readily cross the placenta resulting in vacying degrees of destruction of foetal red Blood cells. 2. Foetal Response Foetal haemopositic tissues attempt to compensate by increasing the rate of red cell formation, as evidenced by a retiulocyte count of over 6%. The liver, spleen and placenta are enlarged by areas of haemoporiss, ‘The foetal red blood cell destruction leads to an increase in bil rubin production, most of which Is removed into the maternal circulation bythe placenta. Some bilirubin enters the liquor ami and its concentration is used to determine the severly of the haemolysis, Kerncteres, therefore, will not develop in utero Following delivery jaundice may appear within 48 hours in mid cases and within 12 hours in sovere eases dve to the rapid rise in bilirubin, unless this is prevented by multiple exchange trens- fusions. Ifthe bilirubin level rises above 20 mg, there is an ‘creased risk of developing kernicterus, especialy ithe premature infant With severe intrauterine anaemia due to baemolyis, the foetus will develop cardiac failure with generalised oedems, known a hydrops fotalis, followed by intrauterine death, 3. Management Prevention of Sensiiat It is now possible to eradicate foetal wastage due to Rh immut sation, This requires expert care ofall Rheve women during all Sages of their reproducitve lives, Even before a pregnancy occurs all transfusions should be done using Rhve blood for the Rh-ve woman Early in the pregnancy blood grouping and antibody check is cauried out. In the unsensitized patient with such conditions {5 an abortion (after 8 weeks) of anterpatim haemorrhage, human ‘Aati-D gamma globulin is given intramuscularly in the dose of 200 mg (Im) unless itis known with certainty thatthe husband js Rivve and the child i his, Apart from the above conditions, the D antigen will not immunise 94% of women during the pi sgnancy ~ for an, as yt, unkaown reaton. FORTAL WELL-BEING 163 ‘The test for Rh antibodies is repeated at 26-28 weeks, and if found negative, the pregnancy is continued as a normal one, At 28 and 34 weeks anti D gamma globulins given to the unsensitized Rh-ve woman to mop up any cells that may Teak into the materal circulation before deivry, as oceurs in a small numberof paints In the management of the third stage of labour care should be taken to minimise the risk of footo-maternal transfusions. ‘The administration of oxytocies should be withheld until the

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