What is High Risk Pregnancy?

High risk pregnancy is defined as a pregnancy that has an increased risk of mortality (Death) and/ or morbidity (illness) in the mother and/or fetus (unborn baby), compared to the average mortality/ morbidity of pregnant women in the same environment.

What is Bad Obstetric History?

A woman is said to have a “Bad Obstetric History” if there are disastrous factors related to her previous pregnancies and deliveries.

These factors should be considered in taking decisions about her future management.

What is the difference between high risk pregnancies and bad obstetric history?

In “Bad Obstetric History” there are disastrous factors related to her previous pregnancy/ pregnancy’s and deliveries such as intrauterine death of the fetus, stillbirth, operations etc.

Even a first pregnancy can be a “high risk pregnancy” eg. If there are medical complications such as hypertension and diabetes mellitus in pregnancy.

Therefore it must be emphasized that all patients with “Bad Obstetric History” are high risk patients (but the reverse is not true for all patients).

Factors related to bad obstetric pregnancy

i) Stillbirth:

A detailed history of stillbirth in a previous pregnancy, if present should be taken . Is the stillbirth fresh or marcerated? (Macerated fetus is due to long time spent by the dead fetus in the uterus).

If it is a fresh stillbirth it is important to inquire about the duration of labour, the type of the labour and the mode of delivery.

Proper evaluation should be done of all women who are suspected to have prolonged labour/stillbirth during a previous pregnancy.

Caeserean section should be planned for future pregnancies if there is evidence of contracted pelvis.

Detailed history of the mode of delivery should be taken eg History of difficult forceps may warrant elective caesarian section in future pregnancies.

If the fetus is macerated ,the causes of stillbirth are similar to those described below (Under intrauterine death of the fetus ).

ii) Intrauterine death of the fetus:

Some of the common causes of intrauterine death are essential hypertension, pre eclampsia, chronic nephritis, diabetes mellitus, fetal anomalies,rhesus isoimmunization (Rh- incompatibility), antepartum haemorrhage (Vaginal bleeding during the 2nd and third trimesters of pregnancy) especially accidental haemorrhage, placental insufficiency, maternal syphilis and severe anaemia.

The causes of intrauterine death can be divided into recurrent and non recurrent causes. The recurrent causes will require antenetal supervision and timely delivery.

Placental function tests are also mandatory if there is a previous history of intrauterine death due to recurrent causes, this will enabel better fetal monitoring and determine the optimal time for delivery.

Blood be be transfused promptly if there is recurrent antepartum haemorrhage.

Prevention and treatment of anaemia is also essential in preventing intrauterine death.Recurrent anaemia should be fully investigated.

Maternal syphilis should also be detected early.

ultrasound scanning and measurement of amniotic fluid/serum alpha fetoprotein are very useful in determining abnormal fetuses. They should be carried out especially in women aged 35 years and above.

iii) Operations:

Women who have had two previous cesarean sections should subsequently be delivered by elective cesarean section. This is to avoid the risk of uterine rupture during labour.

A woman who has had a single cesarean section section due to recurrent factor should also be delivered by elective cesarean section.

It is also important to note that women who have had successful repair of vesico-vaginal fistula due to obstetric reasons should be delivered by cesarean section to avoid recurrence.

iv) Neonatal Factors:

Common causes of neonatal death are jaundice and infection. The cause of the neonatal death should be thoroughly investigated and necessary precautions taken.

v) Postpartum factors:

Postpartum haemorrhage(Vaginal bleeding after delivery of the baby) is one of recurrent post partum factors. Morbidly adherent placenta is a cause of recurrent postpartum haemorrhage.

Therefore postpartum haemorrhage should be anticipated in a woman with a previous history of postpartum haemorrhage and adequate precautions taken. This includes getting at least 2 units of blood that is grouped and crossmatched and the administration of 0.5mg of ergometrine intravenously with the delivery of the anterior shoulder.

vi) Puerperium:

Important complications of the puerperium are puerperal psychosis and puerperal sepsis.

Puerperal psychosis in a previous pregnancy can recur in a subsequent pregnancy, therefore a psychiatrist should be consulted.

It is important to know that puerperal sepsis can affect the integrity of a cesarean section scar, which will in turn affect the mode of delivery in subsequent pregnancies.

References:

Textbook of Obstetrics and Gynaecology for Medical Students, Volume II by Akin Agboola et al

This is a situation where the placenta is not expelled 30 minutes after the birth of the baby.

The incidence of retained placenta is about 2% of deliveries. The risk of having a retained placenta is markedly increased (20-fold) if the gestation is< or = 26 weeks gestation. From 26 to 37 weeks it is increased three times than at term. There is a 10-fold increase risk of haemorrhage in a patient with a retained placenta. The haemorrhage peaks at 40 minutes after delivery.

Causes of retained placenta:

a) Uterine Atony; This could be due to grand multiparity, prolonged labour , uterine malformation or large placental area (Diabetes mellitus and multiple pregnancy).

b) Morbid adherent placenta ( Placenta Increta, placenta acreta and placenta percreta).

c) Seperated but retained due to poor voluntary effort. This could be due to maternal exhaustion or prolonged labour.

d) Incarcerated placenta due to constrictive ring. This could be due to ergometrine given too early or attempts to deliver the placenta before it has separated.

Complications of retained placenta.

i) Post partum haemorrhage.

ii) Post partum shock

iii)Puerperal sepsis.

iv) Risk of recurrence in subsequent pregnancies.

Management of retained placenta.

The first step is to find out if the placenta is separated or not. One should look out for features of placental separation such as lengthening of the cord, gush of blood coming out of the vagina and the uterus becomes round and firm with the level of the fundus rising. If the placenta is separated it has to be delivered by controlled cord traction.

After delivery of the placenta ,it should be inspected for completeness. This is important because certain segments of the placenta could be retained. In such cases manual exploration of the uterine cavity is required . This should be done under anaesthesia.

Manual removal of the placenta

If there is retained placenta with post-partum haemorrhage, one should manually remove the placenta without delay. For manual removal of the placenta general anaesthesia is preferable. However if the facilities are not available the following steps can be undertaken:

a) Sedate the mother with 50mg of pethidine(25mg iv and 25mg im) and diazepam 10mg iv slowly.

b) The patient should be placed in the dorsal position.

c) Insert an iv canula (14G)  and send blood for grouping and DT (direct test).

d) Manual removal of the placenta must be undertaken under full aseptic conditions.

e) The bladder should be emptied.

f) Steady the uterus with the left hand placed on the abdomen.

g) Make your hand as narrow as possible and trace the course of the umbilical cord into the uterus, feel the edge of the placenta.

h) Having reached the lower edge of the placenta gently detach it with a sweeping action using the edge of the hand while keeping the fingers together to avoid perforating the uterus.

When the placenta has been completely separated from the uterus, it should be grasped and pulled out from the uterus.

i) After delivery of the placenta both the maternal and fetal sides should be inspected to ensure that it is removed completely.

j)After removal of the placenta the fundus and abdomen must be examined carefully for evidence of perforation.

k) If there is any evidence of incomplete separation the uterus should be re-explored.

l) Syntocinon drip is necessary to cause a firm contraction and cease bleeding.

m) Continuous monitoring of pulse rate, blood pressure, respiratory rate and vaginal bleeding is important for the first 24 hours (Mainly to detect perforation of the uterus  and infection).

n) Antibiotics must be given (Cefuroxime, Amoxycillin, Metronidazole) should be given orally for 3-5 days. This is to prevent infection (puerperal sepsis).

References:

Chapter 26 p 319, Dewhurst’s Textbook of Obstetrics and Gynaecology for Postgraduates -sixth edition -blackwell science publication.

Clinical Obstetrics for Undergraduates, compiled by Dr WDN De Alwis, Dr R Gnanasekeram, Dr N. Gunawansa. Edited by Professor Randeniya MB;BS. MS, FRCOG, National Hospital of Sri Lanka.

Textbook of Obstetrics and Gynaecology for Medical Students by Akin Agbola et al Volume 2 second edition.

Labour Ward Manual- A guide for the trainee by Deepal  S Weerasekera MS(O$G), MRCOG, FRCS (Ed), Kapila K Gunawardene MS (O$G), MRCOG, Jayatissa Nalin Rodrigo FRCOG, FCS (SL), Dobst (Cey).

]]> http://www.askdrshihaan.org/pregnancy/2008/10/retained-placenta-a-complication-of-labour/feed/ 0 http://www.askdrshihaan.org/pregnancy/2008/10/inversion-of-the-uterus-rare-complication-of-labour/ http://www.askdrshihaan.org/pregnancy/2008/10/inversion-of-the-uterus-rare-complication-of-labour/#comments Wed, 29 Oct 2008 10:28:44 +0000 Dr Shihaan http://www.askdrshihaan.org/pregnancy/?p=156

It is also known as acute inversion of the uterus. It is a rare complication of the third stage of delivery. The incidence is about 1 in 2000 deliveries. It could be partially or completely turned inside out after delivery.

There is no evidence to suggest that acute uterine inversion is caused by the mismanagement of the third stage of labour.

Clinical features and diagnosis.

There is profound shock( Reduced perfusion to the peripheral areas of the body-ie a reduction in the flow of blood to the limbs and organs etc) which is out of proportion to the amount of blood loss. The vaginal tone is increased, a physiological response to acute inversion of the uterus.

The uterus may or may not protrude through the vagina. In over 90% of cases uterine inversion is associated with haemorrhage.

Degrees of Uterine Inversion

a) Inverted fundus reaches the cervical os.

b) The whole body of the uterus is inverted up to the vulva.

c) The uterus, vagina and cervix are completely inverted.

Principles of Management

The immediate resuscitation of the patient is of utmost importance, this is achieved by the treatment of hypovolemia (reduced amount of circulating blood volume).

If the inversion of the uterus occurs at the time of delivery one should try to replace the uterus back to the normal position manually with the hands immediately.

The earlier the restoration is done the more likely that it would succeed. One should not try to remove the adherent placenta without repositioning the uterus.

Once uterine inversion has occurred one should not attempt control cord traction and counter traction (Active management of labour).

The placenta should be removed manually (see the post on retained placenta and manual removal of the placenta.)

Procedure to replace immediately:

Immediate replacement of the inverted uterus via the vagina is recommended. The part which was inverted last should be replaced last, therefore the fundus must be replaced last.

Give atropine 0.6mg intravenously and diazepam 10mg iv.

After replacement of the uterus give ergometrine 0.5mg iv, then the placenta can be removed manually.

Procedure to replace the inverted uterus in the theatre:

The uterus of only about a third of patients can be repositioned without the use of uterine relaxants. This is best done under general anaesthesia using halothane (2% or higher).

Once the uterus is repositioned the attendants hand should remain in the uterine cavity until firm contraction occurs.

Once the procedure is completed, further bleeding and recurrence of inversion can be prevented by giving syntocinon infusion 20 units in 500ml of normal saline.

Procedure to replace the uterus if the inversion takes place sometimes after delivery:

O’ Sullivan’s hydration method of replacing the uterus should be tried.

In this method about 2 liters of normal saline in body temperature is instilled into the posterior fornix of the vagina (This can be done via a rubber tubing connected to a douche can or using an infusion set).

The douche can or the saline bag should be kept more than 1 meter above the patient. The escape of the fluids should be prevented by the operators hand blocking the introitus (opening of the Vagina) or by using several green armitage forceps. After the hydrostatic reduction is complete the fluid is allowed to flow out freely. The placenta can be manually removed if it is still attached.

0.5 mg of ergometrine or 10 units of oxytocin should be given after the procedure.

Reference:

O’ Sullivan JV (1945) Acute inversion of the uterus B med J 2 ,282.

Chapter 26: Obstetric Procedures by R Johanson. Dewhurst’s Textbook of Obstetrics and Gynaecology for Postgraduates. Sixth Edition Edited by Keith Edmonds.

The third stage of labour refers to the period from the birth of the baby to the complete delivery of the placenta and membranes. The third stage of labour is a crucial time in the management of labour.

Major complications such as retained placenta and primary postpartum haemorrhage could occur.

The third stage normally lasts between 5 and 10 minutes. The third stage is said to be prolonged if it is greater than 30 minutes.

The separation of the placenta from the uterus occurs in the third stage of labour . It occurs due to uterine contraction and retraction of the muscle fibers of the uterus, which leads to the formation of a cleavage plane within the deciduas basilis.

The Signs of Placental Separation are:

i) The fundus of the uterus rises up and also becomes hard and globular (rises up to the umbilicus).

ii) A gush of blood from the vagina.

iii) Lengthening of the cord.

The lengthening of the cord is the most convincing sign of placental separation. If a clamp is placed on the cord as close as possible to the vulva , the lengthening of the cord can be easily detected.

Management of the third stage of labour:

Active management of the third stage of labour is now recommended in modern obstetric practice. It reduces the incidence of post partum haemorrhage.

In active management there is no need to await signs of placental separation.

The active method of delivery is also known as Brandt Andrews method which is controlled cord traction (Traction and countertraction).

The active management of labour entails :

i) Intramuscular syntometrine (0.5 mg of ergometrine and 5iu of oxytocin) is given to the mother with the delivery of the anterior shoulder . Alternatively 10iu of synthetic oxytocin could be given. Syntometrine should not be given to hypertensive women.

ii) The cord should be clamped ( with two clamps) approximately 1 minute after the delivery of the baby. The lengthening of the cord is easily observed is a clamp is placed close to the vulva. The left hand of the delivery attendant (Midwife or Doctor) should feel the uterus for contraction while the right hand should grasp the cord. A steady traction should be exerted until the placenta is delivered.

Complications of the Third Stage of Labour

i) Primary postpartum haemorrhage.

ii) Retained placenta.

iii) Genital tract injuries.

iv) Acute inversion of the uterus.

v) Post partum shock and collapse.

Among the complications of the third stage of labour, primary post partum haemorrhage and retained placenta are the commonest complications.

The complications of the stage stage of labour will be dealt with extensively with posts dedicated to each complication.

References:

O’ Driscoll .K, Meagher D, Boylan P, Active Management of Labour, 3^rd Edition. Mosby 1993.

Russel .K.P (1982) The course and conduct of normal labour and delivery in current obstetric , gynaecologic diagnosis and treatment, 5t edition R.C. Benson. Lange Medical Publications, Los Altos , California.