the UK). It may be used in preference to rotational forceps. As traction is applied, with the cup over the posterior fontanelle, rotation during delivery occurs. It should not be us ed if the head is above the ischial spines. It is contraindicated for face presentations an d for babies <34+0 wks; caution if 34+1 \200\22336+0 wks. A cup is applied with a suction f orce of 0.8kg/cm2. The baby \200\231s scalp is sucked up to form a \200\230chi- gnon \200 \231, which resolves in 2 days. There is increased rate of fetal cephalhaema- toma (p90), f ailed delivery, fetal retinal hemorrhages compared to forceps. After delivery Give vitamin K (p120). Give regular analgesia. Document time and volume of 1st void urine (catheterize f or 12h if epidural). Pass catheter if re- sidual suspected. Is thromboprophylaxis needed (p 16)? Arrange physiotherapy to reduce incontinence. Discuss future delivery; >80% will be va ginal but indi- vidual plan if 3rd or 4th degree tear with this delivery. 76 \200 s c i r t e t s b O 77 Indications for operative delivery Relative indications (cesarean an alternative) \200 De lay or maternal exhaustion in second stage. \200 Dense epidural block with diminished urg e to push. \200 Rotational instrumental delivery needed for malposition of head. \200 S uspected fetal distress. Speci \201 c indications for forceps (forceps delivery is usually superior to ventouse or cesarean in these circumstances) \200 Assisted breech delivery, forceps to deliver head. \200 Assisted delivery of preterm infant <34 weeks \200\231 gest ation. \200 Controlled delivery of head at cesarean section. \200 Assisted delivery wit h face presentation. \200 Assisted delivery with suspected coagulopathy or thrombocytopen ia in s c i r t e t s b O fetus (but note coagulopathy is a relative CI to forceps). Instrumental delivery where maternal condition precludes pushing (eg cardiac disease, respiratory disease). \200 Cord prolapse in second stage of labor. \200 Instrumental delivery under GA. Operative delivery likely to fail (Consider delivery in t heater) \200 Maternal BMI >30 \200 Big baby (estimated weight >4kg) \200 OP presentat ion (p71) \200 Midcavity if >1/5 head palpable per abdomen \200\207Abandon operative vag inal delivery if no progression with each pull and delivery not imminent with 3 pulls by ex perienced operator. Obstetric brachial plexus injury (OBPI) OBPI complicates <0.5% of live births. factors: Lar ge birthweight; Risk shoulder dystocia with prolonged 2nd stage of labor; forceps delivery; vacuum extraction; diabetes mellitus; breech presentation. Formerly, the cause of OBPI was excessive lateral traction applied to the fetal head at delivery, in association with ante rior shoulder dystocia. Instrumental-associated OBPI may arise because of nerve stretch injuries after rotations of >90 or from direct compression of the forceps blade in the fetal neck. 168 Not all cases of bra- chial plexus palsy are attributable to traction. Intrauterine factors may play som e role. 169 Management: 10 \200\22320% need surgical intervention for optimal results. 170 Some injuries will be permanent. 171 See p764 for orthopedic insights. Fig 1. Brachial plexus injury. Cesarean section (CS) 78 \200 \200\207If previous section, localize placenta by ultrasound to see if praevia. If color \202 ow Doppler suggests accreta/percreta (p14), off er MRI to clarify invasion. \200 37. 2 Incidence WHO says to aim for <15%. It is \200\20624% of UK labors (30% in the USA) 9 \200\22316% are pre-labor. 172 Maternal mortality: 1 per 100,000. Morbidity is high- er \200\224eg infection, ileus, and thromboembolism. For 1st operations 25% are due to failure to progress, 28% for fetal distress, 14% for breech; of 2nd cesareans 44% have had previou s section. Use of support in labor, induction at 41 weeks, consultant involvement in decisi on to section, fetal blood sampling when fetal monitoring is used, and use of a 4 hour part ogram with action line all help re- duce incidence of cesarean sections. 9 : 1000 will requ ire ITU care. Lower uterine segment incision Joel Cohen incision (straight incision 3cm abo ve symphysis pubis) with blunt dissection thereafter is recommended (re- duces blood loss). Fetal laceration rate is 2%. Classical cesarean section (vertical incision) Rarely used. I ndications: \200 Very premature fetus, lower segment poorly formed \200 Fetus lies tran sverse, with ruptured membranes and liquor draining \200 Structural abnormality makes low er segment use impossible \200 Constriction ring present \200 Fibroids (some) \200 So me anterior placenta praevia when lower segment abnormally vascular \200 Mother dead and rapid birth desired. Before an emergency section \200\207Explain to the mother what is to happen. \200 Activate the anesthetist, theater staff , porters, and pediatrician. \200 Have the mother breathe 100% O2 if there is fetal distress. \200 Neutralize gastric conte nts with 20mL of 0.3 molar sodium citrate, and pro- mote gastric emptying with metocloprami de 10mg IV. (NB: there is no time for H2 agonists to work; ranitidine is kept for elective sections, eg 150mg Po 2h before surgery.) Consider pre-operative emptying of stomach (eg if prolonged labor or opiate given). The stomach should be routinely emptied prior to extubat ion to minimize risk of post-operative aspiration. See Men- delson \200\231s syndrome, p80. s c i r t e t s b O Take to theater (awake); set up IVI. Take blood for crossmatch, eg 2U; if for abrup- tion ( 6U and 2 IVIs if previous section and anterior placenta praevia \200\224see below). Catheterize the bladder. Tilt 15 to her left side on operating table. \200 Use pulse ox imetry peri/post-operatively if dark skinned. \200 Tell the pediatrician if the mother ha s had opiates in the last 4h. \200 Off er prophylactic antibiotics given before skin inci sion. \200 48 \200 Remember thromboprophylaxis (see OPPOSITE). Avoid halothane for obste tric procedures because uterine muscle relaxation increases bleeding. Other anesthetic prob lems include vomiting on induction (use rapid sequence induction, p626), and light anesthes ia (out of consideration for the baby) causing paralyzed awareness. \200\207In reducing ma ternal mortality, the importance of having an experienced anesthetist is vital. When appro- priate, off er regional anesthesia. Document indication for and urgency of operation. Note : in 2002 \200\2233 only 8% of cesarean sections were under GA. Indications for elective ce sarean sections \200 Known cephalo \200\223pelvic dispro- portion \200 Placenta praevia \200 Morbid adherent placenta (accreta/percreta p14) \200 Breech presentation (off er version at 37 weeks) \200 Twins where 1st twin not cephalic \200 Some malpresentations (p71) \200 After vaginal surgery (suburethral repair; vesico \200\223vaginal \201 stula repair) \200 Some maternal infections, eg herpes (p36), hepatitis c+HIV (p26), some with HIV (p23) \200 Maternal request (NICE). \200 48 10% go into labor before expected date of operation at 39 weeks, so plan for this. Plan elective cesarean section after 39 complet ed weeks gestation (to reduce incidence of neonatal respiratory problems). 173 Give antenat al corticos- teroids (p51) for all elective cesareans up to 38+6 weeks. \200\225119 Emergency section may be needed because of antenatal complications, eg severe pre-eclampsia , abruptio placentae (baby still alive). In others, the need becomes apparent during labor: fetal distress; prolapsed cord (if fetus alive); after failed induction; or failure to pro gress. Trial of scar in labor: See p80. Beware oxytocin. Antibiotic prophylaxis is recommen ded. Infection (wound, endometritis, and UTI) is reduced by IV anti- biotics (eg 2g cefradi ne at induction, 1g at 6h and 12h post-op) for both emer- gency and elective sections. Long er courses do not appear to be superior, nor do more expensive second-generation cephalospo rins. Abdominally placed cervical cerclage if cerclage in place and delivery by cesarean th e suture can be left for future pregnancy. \200\225174 Management of women already on thro mboprophylaxis \200\22552 If on high dose or 75% of weight adjusted therapeutic dose proph ylaxis (see p16) halve to same dose/24h as was previously being given/12h, on the day befor e planned cesarean. For all on prophylaxis omit dose on morning of cesarean and give 3h pos t-op unless epidural used: see p66. 2% of women will get a wound hae- matoma. At cesarean s ection Remove placenta by controlled cord traction (less en- dometritis than manual removal ). In Rh \200\223ve mothers, remove all excess blood from peritoneal cavity. Use a Kleihaue r test (p9) to determine dose of anti-D. After cesarean section \200 175 Give one-to-one s upport in recovery unit. Aim for baby/mother skin to skin contact (beware chilling baby). C heck pulse, res- piration rate (RR), BP, and sedation levels at least half hourly for 1st 2 h, then hourly for 24h and until 2h after epidural or patient-controlled opiate analge- sia discontinued). Use MEOWS (Modi \201 ed Early Obstetric Warning Score chart). After epidur al, remove urinary catheters when mobile or 12h after last top- up dose (whichever is later ). After GA, give extra midwife support to help establish breastfeeding. Mobilize early. Re move wound dressing at 24h. Give analgesia (ibuprofen + co-codamol if pain severe, co-codam ol if moderate, paracetamol if mild). Average hospital stay is 3 \200\2234 days but mothers can be discharged after 24h if they wish and are well. Discuss reason for cesarean section and birth options in future. Prophylaxis against thromboembolism \200 Women with no risk factors undergoing elective cesarean section in an un- complicated pregnancy require only early mobilization and good hydration. \200 All women having elective cesarean who have 1 or more risk factors for thromboembolism (MINIBOX p16) should be considered for low molecu lar weight heparin for 7 days postnatally. 79 s c i r t e t s b O All women having an emergency cesarean section should be considered for low molecular weight heparin for 7 days postnatally. Women who have had a thromboembolism in pregnancy should receive thromboprophylaxis for 6 weeks postpartum. All women having thromboprophylaxis antenatally should have it for 6 weeks postpartum. See p16. \200 Uterine rupture 80 \200 Ruptured uterus is rare in the UK (0.5 \200\2232 : 10 000 deliveries in an unscarred uter- us but 1 : 100 deliveries in parts of Africa). Associated maternal mortality is 5%, and the fetal mortality 30%. 70% of UK ruptures are due to dehiscence of cesarean section scars. Lower-segment scars are far less likely to rupture (<0.74%) than the classical scars (2 \200\2239%) \200\224see p78. Other risk factors: \200 Ob- structed labor in the multiparo us, especially if oxytocin is used \200 Previous cervical surgery \200 High forceps del ivery \200 Internal version \200 Breech extraction. Rupture is usually during the third trimester or in labor. Vaginal birth after cesarean (trial of scar): Vaginal birth will be success- ful in 72 \200\22376%. Endometritis, need for blood transfusion, uterine rupture and perinatal death ( \200\200 by 2 \200\2233 : 10,000 births \200\224mainly due to increas ed stillbirth at around 39 weeks: this increases mortality to that of a \201 rstborn) are com- moner than with elective repeat cesarean. \200\225176 Neonatal respiratory problems are, however, reduced. 24 \200\22328% undergo repeat emergency section. Of 9 rup- tures in 4021 women undergoing trial of scar; there were no maternal or fetal deaths. 177 Use fetal monitoring. \200 48 Signs and symptoms Rupture is usually in labor. In a few (usually a ca e- sarean scar dehiscence) rupture precedes labor. Pain is variable, some only having sligh t pain and tenderness over the uterus. In others pain is severe. Vaginal bleeding is variab le and may be slight (bleeding is intraperitoneal). Un- explained maternal tachycardia, sud den maternal shock, cessation of contrac- tions, disappearance of the presenting part from the pelvis, and fetal distress are other presentations. Postpartum indicators of rupture: c ontinuous PPH with a well-contracted uterus; if bleeding continues postpartum after cervica l repair; and whenever shock is present. Management If suspected in labor, perform laparoto my, deliver the baby by cesarean section, and explore the uterus. \200 \200 Give O2 at 15L/min via a tight- \201 tting mask with reservoir \200 Set up IVI \200 Crossmatch 6 U of blood and correct shock by fast transfusion. \200 Arrange laparotomy. The type of op eration per- formed should be decided by a senior obstetrician; if the rupture is small, re - pair may be carried out (possibly with tubal ligation); if the cervix or vagina are invol ved in the tear, hysterectomy may be necessary. Care is needed to identify the ureters and exclude them from sutures. Give post-operative anti- biotic cover, eg ampicillin 500mg/6h I V and gentamicin 3 \200\2235mg/kg/8h IV over 3min (unless there is renal impairment). 85% o f spontaneous ruptures require hysterectomy, but >66% of ruptured scars are repairable. \200 Mendelson \200\231s syndrome This is the name given to the cyanosis, bronchospasm, pul monary oedema, and tachycardia that develop due to inhalation of gastric acid during genera l anesthesia. Clinically it may be diffi cult to distinguish from cardiac failure or amniot ic \202 uid embolism. Pre-operative H2 antagonists, sodium citrate, gastric emptying, cri coid pressure (p626), the use of cuff ed endotracheal tubes during anesthesia, and pre-extu bation emptying of stomach aim to prevent it (p78). Management \200 Tilt the patient head down. Turn her to one side and aspirate the pharynx. Give 100% oxygen. Give aminophylline 5 mg/kg by slow IVI and hydrocortisone 200mg IV stat. 178 The bronchial tree should be sucked out us- ing a bronchoscope under general anesthesia. Antibiotics, eg ampicillin and gentam icin (as above), should be given to prevent secondary pneumonia. Ven- tilation conducted on intensive care may be needed. Physiotherapy should be given during convalescence. s c i r t e t s b O This page intentionally left blank Stillbirth (intrauterine fetal death, IUFD) 82 \200 Stillbirths are those babies born dead after (but that were alive at \200\224see BOX) 24 we eks \200\231 completed gestation. Rate: 1 : 200 total births. Death in utero can occur at a ny stage of pregnancy or labor. Delivery is an emotional strain for mother and attendant st aff : labor may seem futile, mothers may feel guilty \200\224or punished. Some hours after a fetus has died in utero the skin begins to peel. At delivery such fetuse s are described as macerated, as opposed to fresh stillbirths. If left, spontaneous labor u sually occurs (80% within 2 weeks, 90% within 3 weeks). Coagulopathy (p88) occurs in 10% wi thin 4 weeks of late IUFD: 30% thereafter. Causes of stillbirth Antepartum: Malformation (6 % have chromosomal anomalies); congenital infection (TORCH p35), pre-eclampsia; APH (p56); maternal disease (hypertension, renal, diabetes), hyperpyrexia (T >39.4 C), post-ma- tur ity. Intrapartum: Abruption; maternal and fetal infection; cord prolapse/ knots; uterine ru pture. In 50% no cause is found. Multiple pregnancy \200\200 risk (16.6 : 1000).Increasing maternal age, smoking and obesity increase incidence. Diagnosis The mother usually reports absent fetal movements. No heart sounds (unreliable). Diagnose by absent fetal movement (e g heart beat) on ultrasound. It may help the mother to see lack of heart beat. Mothers some - times feel passive movements after death. Repeat ultrasound, if mother re- quests. If mot her alone at diagnosis; off er to call a companion. Management \200\207If mother Rh -ve gi ve anti-D (p9). Do Kleihauer on all women to diagnose fetomaternal hemorrhage (FMH) \200 \224a cause of stillbirth; and to deter- mine anti-D dose. If large FMH diagnosed; repeat K leihauer at 48h to check fetal cells cleared. Check maternal T , BP, urine for protein, an d blood clotting screen if fetus not thought recently demised. Advise delivery if pre-eclam psia, abruption, sepsis, coagulopathy or membrane rupture. If safe, the mother may want to go home after diagnosis to re \202 ect, collect things, and make arrangements. If not indu ced in 48h check for coagulopathy twice weekly. Labor is induced using mifepristone orally, adding prostaglandin (or misoprostol) vaginally. Amniotomy is traditionally contraindicate d as it risks ascending infection. Oxytocin augmen- tation may be needed later. If vaginal scar seek consultant advice re induction/ augmentation. Deliver away from sounds of babies, if possible. s c i r t e t s b O Ensure good pain relief in labor (if epidural, check clotting tests all normal and no sepsi s). Do not leave the mother unattended. When the baby is born wrap it (as with any other ba by) and off er to the mother to see and to hold \200\224if she wishes. A photograph may be taken for her to take home, a lock of the baby \200\231s hair and palm-print given (keep in notes for later if not wanted then). Unseen babies can be diffi cult to grieve for. Naming the baby and holding a funeral service may help with grief. Remember thromboprophylaxis if needed (p16). Discuss lactation suppression and contraception. Labor ward procedure (to tr y to establish cause) Maternal tests: Kleihauer (above); FBC, CRP, LFT, TFT, HbA1c, glucose , blood culture, viral screen (TORCHEtc* screen p35), thrombophilia screen, antibodies (ant i-red cell, anti-Ro, anti-La, alloimmune antiplatelet, if indicated \200\225179), MSU, uri ne for cocaine (if indi- cated and permission given), cervical swabs, parental chromosomes, if indi- cated. \200\225179 Fetal tests Fetal and placental swabs. Cord blood in lithium heparin tube for infection. Thorough examination of the stillbirth. Take time to talk to pa rents about how helpful a post-mortem may be to them, in understanding what happened, and p lanning further pregnancies. If post-mortem is refused, MRI (may miss signi \201 cant path ology and is not routinely available), cytoge- netics (use fetal skin, cartilage and placen ta, this can also be used for sexing babies which may be diffi cult in macerated and very p remature stillbirths) small volumes of tissue for metabolic studies, and placental histo logy may be acceptable but are less informative and still need written parental consent. \200\230TORCH \200\231 infections: Toxoplasmosis, Other (eg syphilis), Rubella, CMV, Herpe s (and hepatitis)et al \201\201 Helping parents after stillbirth \200 Give parents a follow-up appointment to d iscuss causes found by the above tests. Consider a domiciliary visit if parents prefer. Ref er for genetic counseling if appropriate. 83 In England, a Certi \201 cate of Stillbirth is required (issued by obstetrician or midwife attending birth), that the mother (or father, if married at time of birth) is required to take to the Registrar of Births and Deaths within 42 days (21 days in Scotland, 5 days in N orthern Ireland) of birth for fe- tuses born after 24 weeks \200\231 completed gestation. I f there is developmental or ultrasound evidence that the fetus was not alive at 24 complete d weeks \200\231 gestation (eg in cases of fetus papyraceous, or after selective fetal redu c- tion before 24 weeks), then such a certi \201 cate is not issued, \200\225180 but evid ence for the fact why the fetus is not believed to have been alive at 24 completed weeks sh ould be written in the woman \200\231s notes. The father \200\231s name only ap- pears in t he register if the parents are married, or if both parents make the registration, or the fa ther signs a Form of Declaration (available from Registrar). Registration can be delegated to a health care professional or hospital bereavement offi cer. s c i r t e t s b O The Registrar then issues a Certi \201 cate of Burial or Cremation which the parents then give to the undertaker (if they have chosen a private funer- al \200\224in which case they bear the cost of the funeral), or to the hospital ad- ministrators if they have chosen a ho spital funeral \200\224for which the hospital bears the cost. Parents are issued with a Cer ti \201 cate of Registration to keep which has the name of the stillborn baby (if named), the name of the in- formant who made the registration, and the date of stillbirth. UK hospitals are directed by the Department of Social Security to off er \200\230hospital \200\231 funerals for stillborn babies (arranged through an undertaker). If the parents off er to pay for this, the hospital may accept. The hospital should notify the parents of the time of the funeral so that they may at- tend, if they wish. With hospital funerals a coff i n is provided and burial is often in a multiple-occupancy grave in a part of the graveyar d set aside for babies. The hospital should inform parents of the site of the grave. Graves are unmarked, so should the parents not attend the funeral and wish to visit later it is r ecommended that they contact the graveyard at- tendants for the grave to be temporarily mar ked. Parents may buy a single occupancy grave, if they wish, on which they can later erect a headstone. Hospitals can arrange cremations, but the parents pay for this. Tell parents t hat there may not be any ashes after cremation. Arrange a follow-up appointment with the obstetrician to discuss im- plications for future pregnancy, and the cause (if known) of the still- birth. Give parents the address of a loca l branch of an organization for bereavement counseling, eg SANDS. 181 Grief may take a long time to resolve (p498) and parents may \201 nd it diffi cult to contact ordinary medical staff without the \200\230excuse \200\231 provided by asking about the baby \200\231s ail ments. Each maternity unit should have a bereavement counselor to support the mother and father, a nd help guide them through the formalities. In the UK statutory maternity pay and the maternity allowance and social fund maternity payments are payable after stillbirth. After stillbirth Be vigilant to possi ble depression. In next pregnancy after un- explained stillbirth recommend obstetrician ant enatal care and delivery, and screen for diabetes. If there was evidence of growth restrict ion assess growth by serial ultrasound biometry in subsequent pregnancies. \200\225179 \200 Postpartum hemorrhage (PPH) 84 \200 Primary PPH is the loss of greater than 500mL (de \201 nitions vary) in the \201 rst 24h after delivery. This occurs after 6% of deliveries; major PPH (>1 liter) in 1.3%. Causes: uterine atony (90%), genital tract trauma (7%), clotting disor- ders \200\224p88 (3%). Dea th rate: 2/yr in the UK; 125,000/yr worldwide. Risk factors for PPH: Antenatal \200 Previ ous PPH or retained placenta \200 BMI>35kg/m2 \200 Maternal Hb<8.5g/dl at onset of labo r \200 Antepartum haemor- rhage \200 Multiparity 4+ \200 Maternal age 35y+ \200 Ute rine malformation or \201 broids \200 A large placental site (twins, severe rhesus dise ase, large baby) \200 Low pla- centa, \200 Overdistended uterus (polyhydramnios, twins) \200 Extravasated blood in the myometrium (abruption). In labor \200 Prolonged labor ( 1st, 2nd or 3rd stage) \200 Induction or oxytocin use \200 Precipitant labor \200 Ope rative birth or cesarean section. \200\207Book mothers with risk factors for obstetric uni t delivery. Management \200 Give oxytocin 5U slowly IV. \200 Call emergency ambulance u nit (p4) \200\224if not in hospital. Give high- \202 ow O2 as soon as available. \200 Se t up IVI (2 large-bore cannulae). \200 Call anesthetist (a CVP line may help guide \202 uid re- placement, but not if it causes delay). \200 If shocked give Gelofusine or fre sh blood of the patient \200\231s ABO and Rh group (uncrossmatched group O Rh \200\223ve i n emergency) fast until systolic BP >100mmHg and urine \202 ows at >30mL/h (cath- eterize the bladder). \200 Is the placenta delivered? If it is, is it complete? If not, explore the uterus. \200 If the placenta is complete, put the patient in the lithoto- my position with adequate analgesia and good lighting. Check for and repair trauma. \200 If the plac enta has not been delivered but has separated, attempt to deliver it by controlled cord tra ction after rubbing up a uterine contraction. If this fails, ask an experienced obstetricia n to remove it under general anaes- thesia. Beware renal shut down. s c i r t e t s b O If bleeding continues despite all the above, give 10 units of oxytocin in 500mL dextrose sa line, eg at a rate of 15 drops/min. Bimanual pressure on the uterus may decrease immediate loss. Inform consultant. Check that blood is clotting (5mL should clot in a plain round-bot tomed glass tube in <6min); formal tests: platelets, prothrombin ratio, kaolin \200\223ceph alin clotting time, \201 brin degrada- tion products. Involve consultant hematologist if coagulopathy. Intravenous tranexamic acid eg 1g may also reduce bleeding. Explore the uteru s for pos- sible rupture. If uterine atony is the cause, and the circulation is still compr o- mised, give carboprost 250 g (15-methyl prostaglandin F2 \200 ) eg as Hemabate 1mL de ep IM. If no response to 2 doses, >15min apart consider other method eg hysterectomy. SE: n ausea, vomiting, diarrhea, T \200\200; (less commonly \200\224asth- ma, BP \200\200, pu lmonary oedema). It controls bleeding in 88%. If atony persists despite drugs a B-Lynch br ace uterine suture 182 may well stop bleeding (can be used in conjunction with vessel ligat ions). Rarely, uterine packing, internal iliac artery or uterine vessel ligation or emboliz ation, or hysterectomy is needed to stop bleeding. Ask a hematologist \200\231s advice on c lotting factor replacement (fresh frozen plasma contains all of them; the cryoprecipitate h as more \201 brin- ogen, but lacks antithrombin III). Secondary PPH This is excessive blo od loss from the genital tract after 24h from delivery. It usually occurs between 5 and 12 days and is due to retained placental tissue or clot. Secondary infection is common. Uterin e involution may be incomplete. If bleeding is slight and there is no sign of infection it may be managed conservatively \200\224but heavier loss, the suggestion of retained products on ultrasound, or a tender uterus with an open os requires explo- ration. Crossmatch 2 uni ts of blood pre-operatively. Give antibiotics (eg am- picillin 500mg/6h IV, metronidazole 1 g/12h PR) if there are signs of infection. Carefully curette the uterus (it is easily perfo rated at this stage). Send curet- tings for histology (excludes choriocarcinoma). 85 Managing those refusing blood transfusion in pregnancy \200 Know maternal attitude to tra nsfusion at booking. \200 Give oral iron and folate to mother to maximize hemoglobin stor es (par- enteral iron if does not respond \200\224p22 (not if thalassaemia)). Book for delivery where there are good facilities to deal with hemorrhage promptly (includi ng facilities for hysterectomy, balloon angioplasty to sta- bilize loss, and interventional radiology techniques such as uterine artery embolization), and with critical care faciliti es and cell salvage if the mother is high risk, eg if placenta praevia. Ensure consultant obstetrician and anesthetist assess antenatally to make plans for labor. Arrange ultrasound to know placental site. \200 Inform consultant when admitted in labor. Ensure experienced staff conduct labor. Give oxytocin as soon as the baby is delivered. Do not leave the mother alone for \201 rst hour post-delivery. s c i r t e t s b O Consultant obstetrician and anesthetist should perform cesarean sec- tion if required. Cell savers which wash the woman \200\231s own blood so that it may be returned may be acce ptable to some women (suitable for intra-abdominal blood not contaminated by amniotic \202 uid). 172 \200 Hemorrhage should be dealed with promptly, and clotting disorders ex- cluded early. Involve a consultant obstetrician early (to decide if interven- tion may be needed eg embolization of uterine arteries, B-Lynch suture, internal iliac ligation or hyst erectomy), and a consultant anesthetist (for help with \202 uid replacement and for use o f intensive care facilities). Liaise with a consultant hematologist. Avoid dextran (adverse ly aff ects haemo- stasis), but Gelofusine is useful. Erythropoeitin is not an eff ective alterna- tive to transfusion as it takes 10 \200\22314 days to work. Ensure the woman does not want to change her mind and receive a trans- fusion. Should the woman die of exsanguination both bereaved relatives and distressed staff should be off ered support. Retained placenta (RP) Third stage of labor (p58) is considered delayed if not complete by 30 min- utes with active management, by 60 minutes with physiological 3rd stage. A placenta not delivered by then will probably not be expelled spontaneously. The danger with retaine d placenta is hemorrhage. Associations: \200 Previous RP or uterine surgery \200 Preter m delivery \200 Maternal age >35y \200 Placental weight <600g \200 Parity >5 \200 I nduced labor \200 Pethidine used in labor. Management If the placenta does not separate r eadily, avoid excessive cord traction \200\224the cord may snap or the uterus invert. Check that the placenta is not in the vagina. Palpate the abdomen. If the uterus is well contrac ted, the placenta is probably separated but trapped by the cervix. Wait for the cervix to r elax and release it. If the uterus is bulky, the placenta may have failed to separate. Rub up a contraction, put the baby to the breast (stimulates oxytocin production). Give 20IU ox ytocin in 20mL saline into umbilical vein and proximally clamp cord. Empty the bladder (a f ull bladder causes atony). If the placenta still does not deliver within further 30mins, of f er examination to see if manual removal is needed (delay may precipitate a PPH). Examinat ion needs analgesia or anesthesia. Stop if examination is painful. \200 106 Manual removal Set up IVI and crossmatch blood (eg 2U). Call the anaes- thetist to arrange anesthesia. Th e procedure can be done under epidural if in situ. Obtain consent. With the mother in litho tomy position, using aseptic technique, place one hand on the abdomen to stabilize the uter us. Insert the other hand through the cervix into the uterus. Following the cord assists \201 nd- ing the placenta. Gently work round the placenta, separating it from the uter- us using the ulnar border of the hand. When separated it should be possible to remove it by co rd traction. Check that it is complete. Give oxytocic drugs and start antibiotics, eg doxyc ycline 200mg stat, 100mg/24h and metronidazole 500mg/8h IV. 86 \200 s c i r t e t s b O Rarely, the placenta will not separate (placenta accreta) and hysterectomy may be necessary \200\224by a senior obstetrician. \200 Uterine inversion Inversion of the uterus is rare. It may be due to mismanagement of the third stage, eg with cord traction in an atonic uterus (between contractions) and a fun dal insertion of the placenta. It may be completely revealed, or partial when the uterus re mains within the vagina. Even without hemorrhage the mother may become profoundly shocked. Management The ease with which the uterus is replaced depends on the amount of time elapsed since inversion, as a tight ring forms at the neck of the inversion. With an inversion not ed early before shock sets in, replacement by hand may be possible. If shock has ensued, se t up a fast IVI and infuse colloid or blood. Summon expert help. Under halothane anesthesia to relax the uterus, hold the uterus in the vagina with one hand. Run two litres of warm 0 .9% sa- line fast into the vagina through cystoscopy tubing (or with a funnel and tube) wit h an assistant holding the labia encircled tightly around the operator \200\231s arm to pre vent the \202 uid running away. Running the \202 uid through a silastic ventouse cap he ld in the vagina improves the \200\230vaginal seal \200\231. The hydrostatic pressure of t he water should reduce the uterus. Once the inversion has been corrected, give ergometrine to contract the uterus and prevent recurrence. Prophylactic antibiotics are advisable. \200 This page intentionally left blank \200 DIC and coagulation defects 88 \200 DIC in pregnancy is always secondary to stimulation of coagulation by pro- coagulant substa nce release in the maternal circulation. Known triggers are: retention of a dead fetus (of greater than 20 weeks \200\231 gestation which has been dead for >3 weeks); pre-eclampsia; placental abruption; endotoxic shock; am- niotic \202 uid embolism; placenta accreta; hyd atidiform mole; prolonged shock from any cause; acute fatty liver of pregnancy (p26). Patho genesis: Thrombo- plastins are released into the circulation, \201 brin and platelets are consumed as intravascular clotting occurs. Tests: Kaolin \200\223cephalin clotting time \200\200 ( \200\201 factors II, V, VII), \201 brinogen \200\201, \201 brin degradatio n products \200\200. In situations where DIC is a possibility send blood for crossmatch, p latelets, partial thromboplastin time or accelerated whole blood clotting time, prothrombin time, \201 brinogen estimation, and \201 brin degradation products. Preliminary result s should be available in 30min. Management: Presentation may be as heavy bleeding and shock , and the \201 rst measures must be the correction of shock. \200 Give O2 at 15 L/min vi a a tight \201 tting mask with reservoir. Set up at least 1, preferably 2, wide-gauge IVI s, take bloods as above, and give blood fast (group-compatible blood \200\224available in 5 \200\22310min or O Rh \200\223ve blood if desperate). Stored blood is de \201 cient in cl otting factors. Give fresh frozen plasma to normalize the kao- lin \200\223cephalin clottin g time and the prothrombin time. Platelets are indicated with prolonged bleeding and low pl atelet count. Calcium is sometimes needed to counteract citrate in stored blood (eg 10mL of 10% calcium gluconate IVI, eg after 6U of blood). Seek expert help from a hematologist. Th e condition is usually self-limiting if the stimulus can be removed. In the case of intraut erine death and abruption (p56) removal of the uterine contents is the way to cor- rect the stimulus, and this should be done as promptly as possible. Mortality: <1% if placental abr uption; 50 \200\22380% if infection/shock. Autoimmune thrombocytopenic purpura (AiTP) Incid ence 1 \200\2232 : 10,000 pregnancies. IgG antibodies cause thrombocytopenia (associated wi th in- creased bone marrow megakaryocytes) in the mother and, being able to cross the place nta, they cause thrombocytopenia in 10% of fetuses. Exclude sys- temic lupus erythematosus in the mother (thrombocytopenia may be an early presentation; do DNA binding, OHCM p540). Consider maternal HIV. If maternal platelets fall below 20 \211\210 109/L or 50 \211\210 109/L near delivery, give steroids. Rarely, splenectomy is necessary during pregnancy (idea lly in the second trimester). Immunoglobulin IgG 0.4g/kg IV for 5 days is sometimes used ne ar expected date of delivery, inducing maternal and fetal remission for up to 3 weeks, but it is extremely expensive. Aim for non-traumatic delivery for both mother and baby. Neonata l platelet count may fall further in the \201 rst days of life, then gradually rise to no rmal over 4 \200\22316 weeks. Treatment is not needed unless sur- gery is contemplated. Mat ernal mortality due to AiTP is now negligible, but fetal mortality remains (due to intracra nial bleeding). Take cord blood at deliv- ery. If platelets <20 \211\210 109/L give baby I gG 1g/kg IVI at birth. If platelets low at birth observe baby for 2 \200\2235 days as furth er falls likely. Causes of thrombocytopenia in pregnancy s c i r t e t s b O 1 Spurious (try citrated bottle). 2 Pregnancy-associated thrombocytopenia (benign gestation al thrombocy- topenia) \200\224mild and self-limiting (platelets stay above 100 \211\210 109/L). 3 Autoimmune thrombocytopenia. 4 Pre-eclampsia (platelets may fall early, preceding clottin g abnormality). 5 DIC (above) and haemolytic uraemic syndrome (p176)/thrombotic throm- bocy topenic purpura (2 ends of a microangiopathic spectrum, OHCM p332). 6 Folate de \201 ciency. 7 Congenital (May \200\223Heggin anomaly, hereditary macrothrombo cytopenia). 8 Marrow disease; hypersplenism. 89 Amniotic \202 uid embolism This condition, with a mortality of up to 61% (20% in 2006 \200\2238 UK), presents with sudden dyspnoea and hypotension heralded in 20%, by seizures. 50% also develop DIC, and of those who survive the initial collapse 70% go on to develop pu lmonary oedema (acute respiratory distress syndrome, ARDS, OHCM p178). There may be premoni tory symptoms such as breathlessness, chest pain, feel- ing cold, light-headedness, restles sness, distress, panic, paraesthesiae in \201 n- gers, nausea and vomiting. 183 These may be from immediately before until up to 4h before collapse. An anaphylactic type of respons e occurs to (possibly abnormal) amniotic \202 uid in the maternal circulation. Presentati on is often at the end of the \201 rst stage of labor or shortly after delivery but can c omplicate amniocentesis, or termination of pregnancy, abruption, trauma, cesarean section, and has even occurred up to 48h postpartum. Medical induction does appear to double risk, a lthough absolute excess risk is low. 184 Management \200 The \201 rst priority is to pre vent death from respiratory failure. Give mask oxygen and call an anesthetist urgently. End otracheal intubation and ventila- tion may be necessary. Set up IVI in case DIC should supe rvene. Cardiovascular collapse is due to left ventricular failure. DIC and hemorrhage then usually fol- low. Treatment is essentially supportive \200\224important steps are detailed below. Diagnosis may be diffi cult: exclude other causes of obstetric shock (p55). s c i r t e t s b O \200 Cardiopulmonary resuscitation if indicated. \200 Give highest available O2 concentra tion. If unconscious, ventilate and use 100% inspired O2. \200 Monitor for fetal distress. \200 If hypotensive, give \202 uids rapidly IVI to inc rease preload. If still hypotensive consider inotropes: dobutamine (a better inotrope than dopamine), eg in a dose range of 2.5 \200\22310 g/kg/min IVI may help. \200 Pulmonary artery catheterization (Swan \200\223Ganz catheter if available) helps guide haemodynamic management. \200 After initial hypotension is corrected, give only maintenance requirements of \202 uid to avoid pulmonary oedema from acute respiratory distress syndrome. Transfer to intensi ve care unit as soon as possible. \200 Treat DIC with fresh whole blood or packed cells and fresh frozen plasma. Use of hepa rin is controversial; there are insuffi cient data to warrant routine heparinization. \200 If the mother dies it is recommended to deliver the baby abdominally. Peri- mortem ce sarean within 5 minutes can aid resuscitation of the mother.