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Delivery Suite Guidelines St George’s Healthcare NHS Trust

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Section 11: Ante/Intra partum Complications

Management of Dysfunctional Labour 11: 2 Vaginal Birth with uterine scar 11: 2 Uterine Rupture 11: 3 Instrumental delivery 11: 5 Trial of instrumental delivery 11: 8 Thromboprophylaxis following Operative Delivery 11: 10 Caesarean Section 11: 11 Type of Caesarean Section 11: 12 Category One Section Protocol 11: 15 Responsibility of Midwife in theatre 11: 15 Prophylaxis against haemorrhage 11: 16 Prophylaxis against infection 11: 16 Pre-term Labour 11: 17 Tocolysis 11: 19 Rescue/Emergency cervical cerclage 11: 19 Treatment of recurrent preterm labour 11: 20 Conduct of labour and delivery 11: 20 Post delivery 11: 20 Extremes of viability 11: 21 Guidelines for the management of preterm prelabour rupture of membranes 11: 21 VBAC Sticker 11: 23 Emergency Caesarean Section log book 11: 24


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MANAGEMENT OF DYSFUNCTIONAL LABOUR Always complete the partogram Definition of slow labour Cervical dilatation less than 0.5cm per hour since the previous examination. Causes of slow labour � Inefficient uterine activity. � Fetal malposition and malpresentation. � Cephalopelvic disproportion. � A combination of the above. Exclude a full bladder. Management of slow labour Inform Midwife-in-Charge and summon the SpR to assess the clinical situation. See Section 6 on Augmentation. In nulliparous women at term with intact membranes

o Perform ARM and reassess in 4 hours if there are strong and regular contractions

In nulliparous women at term with membranes that have already ruptured o oxytocin per protocol

In multiparous women it is extremely important to e xclude mechanical causes of delay before considering oxytocin . The Registrar should carefully assess such cases and involve the Senior Registrar. Strong contractions > 3 in 10, fetal malposition, moulding and poor pelvis assessment are suggestive of obstructed labour. Discuss reasons for augmentation with the patient and her partner. Reassess progress in 1-2 hours. • VAGINAL BIRTH WITH UTERINE SCAR Women should be offered a vaginal birth after a single previous lower segment caesarean section (LSCS) after:

1. Reviewing the previous maternity notes, including operative notes 2. Excluding any intra-operative/post-operative complications that may be a

contra-indication for vaginal birth 3. Reviewing index pregnancy to exclude any factors that may be a contra-

indication (e.g. fetal malpresentation, major degree placenta praevia) 4. Counsel the woman regarding pros and cons of elective caesarean section vs

Trial of scar (vaginal birth after caesarean section). This discussion should include

a. Scar dehiscence (rarely uterine rupture) occurs in approximately 5/1000 women who have previously had a caesarean section in spontaneous

SECTION 11 ANTE/INTRA PARTUM COMPLICATIONS


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labour and 8/1000 with augmentation with oxytocin infusion and 24/1000 when induced with prostaglandins

5. Need for continuous electronic fetal monitoring in labour A woman should be helped to make an informed choice and her decision should be supported. Antenatal In women with a uterine scar, the Senior Registrar or a Consultant must make a plan for fetal monitoring and delivery and this should be documented in the Antenatal Care Plan. IOL (induction of labour) should only be planned after discussion with Consultant and if more than 1 dose of Prostin (3 mg) is needed, this should be discussed with the Consultant. Following the diagnosis of labour � Insert IV cannula. � Take blood for G & S. � Review by Specialist Trainee (ST) to confirm that trial of scar is still appropriate. � Commence continuous CTG. � All methods of analgesia are available including epidural. � If there is failure to progress in labour, the patient is examined by the Registrar.

Syntocinon may be commenced only after prior discussion with Senior Registrar / Consultant. Prolonged use of oxytocin (>10 hours from the estab lishment of labour in trial of scar) is contraindicated . (Please refer to the guideline on the Use of Oxytocin in labour).

� There is no value in examining the uterine scar after delivery. UTERINE RUPTURE Symptoms/signs of scar dehiscence / rupture � Vaginal bleeding. � Abnormal CTG. � Severe lower abdominal pain. � Cardiovascular instability (eg tachycardia, hypotension). � Diminishing uterine activity. � Haematuria. � Slow progress. If uterine rupture suspected : Manage as per an Obs tetric Emergency (ABC) • Check Airway (A), Breathing (B), Circulation (C)

� Call for immediate assistance: Obstetrician and Anaesthetist on call � Resuscitate with intravenous fluid. � Give oxygen. � Cross-match 6 units of blood. � Prepare for Immediate Laparotomy (activate Obstetric emergency Call) � Inform Consultant obstetrician and anaesthetist on call

The following should be clearly documented in the Care Plan, preferably by the use of ‘VBAC Stickers’ (see appendix). a. Documentation of antenatal discussion on the mode of delivery b. Documentation of plan for the place of labour c. Documentation of individual management plan for lab our


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d. Documentation of plan for labour should this commence early – this should be done when a woman is admitted in preterm labour (in the labour ward)

e. Documentation of plan for labour should this not commence as planned (i.e. Induction of labour Vs Elective caesarean section), that has been discussed with the consultant obstetrician

f. Documentation of plan for the monitoring of the fe tal heart in labour Audit and monitoring The documentation of individual management plan for labour and plan for monitoring fetal heart rate in labour will be audited once in every 18 months. This audit will be conducted by Ms. Carolyn Romer/ Edwin Chandraharan and the audit findings will be discussed in the Risk Management Meeting Action Plan will be monitored by the Risk management team References • Arulkumaran S, Ingermansson I, Ratmann SS (1989). Oxytocin augmentation in dysfunctional labour

after previous Caesarian Section. BJOG 96 939-41. • Goetz L, Shipp TD, Cohen A et al., (2001). Oxytocin dose and the risk of uterine rupture in trial of

labour after caesarian section. Obstet Gynaecol 97 381-4. • Peaceman AM, Sciora JJ, (1996). Encouraging trials of labour for patients with previous Caesarian

Section birth. Lancet 347 278. • Rosen MG, Dickenson JC, Welhoff CL, (1991). Vaginal birth after Caesarean Section. A Meta-

analysis of morbidity and mortality. Obstet Gynecol 77 465-70. • Arulkumaran S, Chua TM, et al. (1991). Uterine activity in dysfunctional labour and target uterine

activity to be aimed with oxytocin titration. Asia Oceania J of Obstet Gynacol 7 101-6 • Camm H, Van Eeckhout E (1996). A randomised controlled trial of early versus delayed use of

amniotomy and oxytocin infusion in multiparous labours. BJOG 10 313-318 • Chua S, Arurlkumaran S, Kurup A, Tay D, Ratnam SS, (1991). Oxytocin titration for induction of

labour: a prospective randomised study of 15 vs 30 mins dose increment schedules. Aus NZ J Obstet Gynaecol, 31 134-137.

• Kurup A, Chua S, Arulkumaran S, et al., (1991). Induction of labour in multiparous women with poor cervical score: oxytocin and PG vaginal Pessaries. Aus NZ J of Obstet Gynecol 31 223-226.

• WHO (1994) Maternal Health and Safe Motherhood Programme. WHO Partograph in management of labour. Lancet 343 1399-1404.

• Olah KSJ, Neilson JP, (1994). Failure to progress in the management of labour. BJOG 101 1-3.


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INSTRUMENTAL DELIVERY

Operative vaginal delivery using ventouse and forceps delivery are indicated in the second stage of labour to facilitate vaginal birth. Both these instruments are complementary and the choice of a specific instrument should be based on the clinical circumstances and the knowledge, skills as well as the familiarity/competency of the attending clinician. The scope of this guideline will include indications for operative vaginal delivery, choice of instrument, aspects of safe clinical practice, risk of physical and psychological complications and a brief review of special circumstances. Operative vaginal delivery rates have remained stable at between 10% and 15%. There has been an increasing awareness of the potential for morbidity for both the mother and the baby. The risk of traumatic delivery in relation to forceps, particularly rotational procedures, has been long established, although with careful practice overall rates of morbidity are low. All women should be encouraged to have continuous support during labour. Use of a partogram, use of upright or lateral positions and avoiding epidural analgesia, will reduce the need for operative vaginal delivery. Oxytocin in primiparous women with epidurals will decrease the need for operative vaginal delivery. Delayed pushing in primiparous women with an epidural will reduce the risk of rotational and mid-cavity deliveries

Who should perform the procedure: Instrumental vaginal delivery should be undertaken by an obstetrician who has the necessary skills and familiarity with the chosen instrument. Obstetric trainees should receive appropriate training in operative vaginal delivery prior to independent practice and competency should be confirmed prior to conducting unsupervised deliveries. In the delivery room, the procedure can be performed by the registrar (ST3-5) unsupervised, if he/she has assessed the clinical situation and has the skills and expertise to perform the procedure. If the trainee is not competent, operative vaginal delivery should be performed under direct supervision. The senior registrar (ST6/7) or a consultant must be present in the theatre for ‘trial of instrumental’ delivery and directly supervise junior obstetric trainees (ST 3-5). In clinical situations that require urgency (such as prolonged deceleration), the procedure should be carried out by the senior most member of the team to expedite delivery. INDICATIONS Planned : when pushing not allowed / possible (but after descent and rotation), eg:

� Severe pre-eclampsia / eclampsia. � Some cases of cardiac, cerebrovascular and respiratory disease � Cerebral haemorrhage / previous neurosurgery � Detached retina / previous pneumothorax � Spinal injury � Myasthenia gravis � Unconscious patient (e.g., diabetic coma) � Existing hernia.


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Emergency: to shorten second stage in maternal or fetal interests: � Compromised fetus � Evidence of fetal hypoxia (pH <7.20, severe deterioration in

CTG). � Maternal exhaustion or unwillingness (e.g., pain or anxiety). � Prolonged delay in second stage. � Trial of scar. � Bradycardia (<100 bpm). � Dural tap (prolonged pushing is not advised).

Prerequisites for operative vaginal delivery:

Safe operative vaginal delivery requires a careful assessment of the clinical situation, clear communication with the mother and healthcare personnel and expertise in the chosen procedure. Full abdominal and vaginal examination

o Head is less than 1/5 palpable per abdomen o Vertex presentation o Cervix is fully dilated and the membranes ruptured o Exact position of the head can be determined so proper placement of the

instrument can be achieved o Pelvis is deemed adequate

Mother o Informed consent must be obtained and clear explanation given o Appropriate analgesia is in place, for mid-cavity rotational deliveries this will

usually be a regional block o A pudendal block may be appropriate, particularly in the context of urgent

delivery o Maternal bladder has been emptied recently o Indwelling catheter should be removed or balloon deflated o Aseptic techniques

Staff o Operator must have the knowledge, experience and skills necessary to use the

instruments o Adequate facilities and back-up personnel are available o Willingness to abandon the procedure if vaginal delivery not possible o Back-up plan in place in case of failure to deliver o Anticipation of complications that may arise (e.g. shoulder dystocia, postpartum

haemorrhage) o Personnel present who are trained in neonatal resuscitation

What instruments should be used for operative vagin al delivery?

The operator should choose the instrument most appropriate to the clinical circumstances and their level of skill. Forceps and vacuum extraction are associated with different benefits and risks. The options available for rotational delivery include Kielland forceps, manual rotation followed by direct traction forceps or rotational vacuum extraction. Rotational deliveries should be performed by experienced operators under the supervision of a consultant, the choice depending upon the expertise of the individual operator. All trials of instrumental delivery in theatre must be attended by the Senior Registrar/Consultant.


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Informed Consent: A clear explanation of the procedure and a verbal consent must be obtained prior to attempting an instrumental delivery in the room. The discussion should also include a clear plan to stop the procedure in absence of progress. The indication for the procedure and the verbal consent should be documented in the medical records.

If there is no progress of labour (descent or rotation) despite of 3 tractions, the procedure should be abandoned. Opinion of the senior most obstetrician available should be sought or an abdominal delivery should be considered For the ‘trial of instrumental delivery’ a written consent must be signed specifying the possibility for a Caesarean delivery if the instrumental delivery was unsuccessful.

Where the procedure should take place: Delivery Room

• True maternal exhaustion (progressed at a normal rate to full dilatation and head is crowning).

• Adequate maternal analgesia: regional or local • Vertex at +1 or below the ischial spines • Normal progress in first and second stage • No evidence of fetal compromise • Suspected fetal compromise or confirmed acute fetal compromise and if

delivery is deemed safer and faster in attending clinician’s judgement as compared to transferring the patient to the theatre.

• Malpositions, where in clinican’s judgement, there is an increased likelihood of vaginal delivery.

Procedure for Vacuum extraction A Adequate anaesthesia B B ladder empty C Cervix fully dilated D Determine position E Equipment check F Fontanelle, cup near posterior G Gentle traction H Halt procedure (see below) I Incision (i.e. episiotomy) Indications to abandon vacuum extraction � Failure to achieve extraction within 20 minutes of initiation of procedure and if

delivery is not imminent. � Disengagement of extractor cup two times. � No significant progress in three consecutive pulls of a correctly applied instrument

by an experienced operator � Unless fetal head is at the perineum or if progress of labour (rotation and

descent) has been observed, Do NOT use forceps afte r failed vacuum procedure.

Do not apply ventouse if less than 34 weeks.


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PROCEDURE FOR FORCEPS DELIVERY A Adequate anaesthesia B B ladder empty C Cervix fully dilated D Determine position, consider dystocia E Equipment check F Forceps application and check (see below) G Gentle traction (Pajot’s manoeuvre) H Handles elevated to follow J curve of pelvis I Incision (i.e. episiotomy). Document forceps procedure on standard form. Check the forceps applied correctly

• Posterior fontanelle should be midway between shanks and 1cm above plane of shanks.

• Fenestration in forceps’ blades admits no more than 1 fingertip. • Lambdoidal sutures should be above and equidistant from upper surface of

each blade. Special points

• A bimanual VE is very helpful to assess moulding and the true amount of head palpable abdominally.

• Instrumental delivery should not be carried out prior to full dilatation. • Rotational forceps should only be performed with spinal or epidural analgesia in

theatre. • Patients must be continually monitored during transfer to theatre and during trial

of instrumental delivery. • If delivery after augmentation with oxytocin, use IV oxytocic for 3rd stage and

continue with oxytocin 40 IU in Normal Saline 500ml over 4-6 hours • After delivery take cord arterial and venous samples for pH and base excess.

Ensure the results are recorded in the maternal and neonatal notes. • A neonatologist should be present at all instrumental vaginal deliveries. • With epidural anaesthesia for forceps delivery, an indwelling Foley catheter

should be inserted, and only removed when full sensation has returned (within 24 hours).

• Women should have regular observations taken following delivery and any wounds should be inspected for correct healing. Any problems should be escalated.

TRIAL OF INSTRUMENTAL DELIVERY Operative vaginal births that are deemed to have a higher rate of failure based on clinician’s judgement or clinical circumstances should be considered as a trial and conducted in the theatre, where immediate recourse to caesarean section can be undertaken. Higher rates of failure are associated with:

• Maternal body mass index greater than 30 • Estimated fetal weight greater than 4000 g or clinically big baby • Occipito-posterior/ Malposition position fetal head


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• Mid-cavity delivery or when 1/5 head is palpable per abdomen • Protracted second stage, when there is increased likelihood of caesarean

section (diabetic mother or a suspected ‘large for dates’ baby) • Have a low threshold for carrying out instrumental delivery in theatre. Rotational

forceps deliveries must be performed in theatre. � Beware:

a.) Clinically large baby especially in a woman of small stature. b.) Slow progress in the late first and second stages. c.) Significant caput and moulding.

d.) Previous difficult instrumental delivery. � All trials of instrumental delivery in theatre must be attended by the Senior Registrar

/ Consultant. � Take blood for G&S, consent for proceed to caesarean section, before the

procedure is started. � Give: 1) 50 mg ranitidine IV as soon as decision to operate made. 2) 30mls of 0.3 Molar Sodium Citrate immediately before anaesthesia. 3) If opiates in labour - add 10mg Metoclopramide IM immediately after

delivery. � If the CTG is suspicious, carry out a fetal blood sample before proceeding to

rotational forceps delivery. If pH is <7.20 or trace is abnormal, Kiellands forceps should NOT be used.

� If the presenting part is 0/5 or 1/5 abdominally, at the spines and not moulded, then a trial may be undertaken.

� If there is difficulty applying ventouse or forceps, achieving descent or rotation, or great force required then STOP and proceed to caesarean section.

� If there is uncertainty about the fetal position, an ultrasound scan to locate position of fetal spine may help.

When should operative vaginal delivery be abandoned ?

• Operative vaginal delivery should not be attempted unless the criteria for safe delivery have been met.

• Operative vaginal delivery should be abandoned where there is no evidence of progressive descent with each pull or where delivery is not imminent following three pulls of a correctly applied instrument by an experienced operator.

• Adverse outcomes, including unsuccessful forceps or vacuum delivery, should trigger an incident report as part of effective risk management processes.

• Paired cord blood samples should be processed and recorded following all attempts at operative vaginal delivery.

What precautions should be taken for care of the bl adder after delivery? The timing and volume of the first void urine should be monitored. All women undergoing an operative vaginal delivery should have monitoring, such as a fluid balance chart, for at least 24 hours, to detect postpartum urinary retention. A post-void residual should be measured if retention is suspected. Women who have had spinal anaesthesia or epidural a naesthesia that has been topped up for a trial of labour may be at increased risk of retention and should be offered an indwelling catheter, to be kept in pl ace for at least 12 hours following delivery to prevent asymptomatic bladder overfilling (Please refer to Bladder Care Guideline). Women should be offered ph ysiotherapy-directed strategies to prevent urinary incontinence.


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Monitoring Competence The competence for conducting an operative vaginal delivery should be assessed for all the doctors using the assessment tools approved by the RCOG These include: OSATS (Objective Assessment of Technical Skills), CbD (Case-based Discussion) and Mini-CEX (Mini Clinical Evaluation eXercise) 4

Auditable standards • Rate of operative vaginal delivery - Every month through the Maternity Dashboard • Rate of failed operative vaginal delivery - Every month through the Maternity

Dashboard • Rate of sequential instrument use - Every month through the Maternity Dashboard • Rate of third- and fourth-degree perineal tears - Every month through the

Maternity Dashboard • Rate of neonatal morbidity to composite trauma (cephalhaematoma, brachial

plexus injury, fracture, facial nerve palsy, cerebral haemorrhage), low Apgar (less than 7 at 5 minutes) and cord arterial pH less than 7.1. – every year

• Standard of documentation –every year Monitoring The following will be monitored through a continuous audit on a daily basis through the ‘Continuous Audit book’:

• who can perform the procedure • whether informed consent has been obtained • when the procedure should be abandoned • Care of the bladder

The book will be reviewed by the lead for clinical governance or his designate every week and where deficiencies have been identified in the above, immediate feed back will be offered to clinicians and this will be documented in the Book The Audit results will be presented at the Labour Ward Forum once in every 18 months and its action plan will be monitored by the Obstetric Risk Management Committee Thromboprophylaxis following Operative Delivery Please refer to Thrombosis and Thrombophylaxis guidelines References:

Johanson RB. Instrumental vaginal delivery. London: Royal College of Obstetricians and Gynaecologists, 2000 Murphy DJ, Pope C, Frost J, Liebling RE. Women’s views onthe impact of operative delivery in the second stage of labour: qualitative interview study. BMJ 2003;327:1132 Peter EA, Janssen PA, Grange CS, Douglas MJ. Ibuprofen versus acetaminophen with codeine for the relief of perineal pain after childbirth: a randomized controlled trial. CMAJ 2001;165:1203–9.) www.rcog.org.uk/ourprofession/ Trainees' Frequently Asked Questions (FAQs) Johanson RB, Rice C, Doyle M et al., (1993). A Randomised prospective study comparing the vacuum extractor policy with forceps delivery. Par J Obstet Gynecol 100 524-30. Johanson R., (1999). Obstetric Proceedures. In: Dewhursts Textbook of Obstetrics and Gynaecology for postgraduates. D. Keith-Edmonds (ed), 6th Edition. Blackwell Sciences. Operative vaginal delivery. RCOG Green Top Guidelines 26(.revised 2005) RCOG . Press, London Thrombosis Prophylaxis In Pregnancy: RCOG guidelines for prophylaxis against thromboembolism in pregnancy. Griffen C & Barley C. Feb 2002 Thromboprophylaxis with low molecular weight heparin (dalteparin) in pregnancy. Pettila V et al. Thrombosis Research 1999; 96: 275-282Thrombosis in Pregnancy. Greer I. Lancet 353;1258 Chandraharan E, Arulkumaran S. Female pelvis and details of operative delivery; shoulder dystocia and episiotomy. Chapter In: Management of Labour. S. Arulkumaran, LK Penna, Basker Rao (eds). Orient Longman (India). January 2005. RCOG Green Top Guideline No 26. Operative vaginal delivery. www.rcog.org.uk. RCOG Press, 2005.


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CAESAREAN SECTION Make sure all the following have been considered and documented prior to proceeding to caesarean section: Decision The decision for caesarean section should be made by a

Specialist Trainee (ST) 6-7 / Consultant. The Consultant must always be informed except in life threatening circumstances.

Indication The indication must be documented and written on the operation

note by the person making the decision. Consent Written consent is essential, except in life threatening

circumstances. Preparation Tape wedding band and give all other jewellery to partner for

safekeeping. Anaesthesia Regional anaesthesia is safer than general anaesthesia for

caesarean section. In emergencies, the Obstetrician must inform the Anaesthetist of the degree of urgency and indication.

Blood Blood for FBC and G&S is sent after siting an IVI (16G or 14G

cannula). Must have recent antibody screen if not x-matched. Inform LAB in an emergency when sending sample.

Antacid therapy Elective: Ranitidine 150mgs and Metoclopramide 10 mgs at 22:00, night

prior to surgery and Ranitidine 150mgs at 06:00 morning of surgery.

Nil by mouth from midnight. Emergency: 1.) If Ranitidine has not been administered give 50mg ranitidine

IV as soon as decision to operate made. 2.) 30mls of 0.3 Molar Sodium citrate immediately before anaesthesia. 3.) If opiates in labour - add 10mg Metoclopramide IM

immediately after delivery. Theatre Prepared If Elective caesarean section book on the trust intranet, If Emergency, inform midwife in charge and discuss the degree

of urgency; midwife in charge to inform theatre. Catheterisation In theatre, immediately before caesarean section if GA, or once

spinal / epidural effective. Neonatologist Should be present at all emergency caesarean sections and

elective procedures where there is a risk of neonatal respiratory depression (e.g., under GA, severe IUGR). Inform neonatologist of estimated time of delivery and give further call if not already present when scrubbing up.

Position If being transferred on a bed, place woman in left lateral position.

All caesarean sections should be performed with table tilted


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laterally (left) 15 degrees. If fetal distress, administer oxygen by mask.

Document caesarean section procedure on standard form in the medical records. TYPE OF CAESAREAN SECTION There are 4 (four) different categories of caesarean section and category 1 to 3 are reserved for emergencies based on NICE/ RCOG guidance. Elective caesarean section (Category 4) Women should normally be given a date for delivery at 39 weeks (unless very high-risk for anaesthetic or complications in labour, in which casebook at 38 weeks). The midwife in ANC should book an appointment for the woman to attend the pre-admission clinic on DAU the day prior to surgery or a Friday if the surgery is booked for the following Monday. At the preadmission clinic the woman will be seen by the anaesthetist, bloods will be taken and premedication of Ranitidine 150mgs given. This is to be taken at 22.00 hrs the night before surgery and 06.00hrs the morning of surgery. Metoclopramide 10mgs will be taken on the morning of the surgery. Women are to come onto Gwillim ward on the day of operation at the time requested by the DAU midwives. Emergency caesarean section The urgency of the caesarean section must be clearly stated following these guidelines so that the theatre staff, anaesthetists and surgeons involved will know that is expected of them: Wherever possible regional anaesthesia (spinal / epidural top-up) should be used as there is no doubt that GA increases maternal morbidity and mortality. Where the need for rapid delivery is high, e.g. category 1 LSCS, clear communication of the time scale for delivery is vital to ensure that delivery is not delayed by inappropriate anaesthesia, wherever possible. The time of decision to deliver should be clearly documented as well as the category of LSCS and time to delivery. The situation may change after delivery decision e.g. recovery of bradycardia, improvement of CTG. Reasons for change of priority or decision should equally be documented contemporaneously Overall guiding principle: Maternal survival is paramount and LSCS may not always be in the interests of the mother or her baby especially <26 weeks gestation or in the presence of severe maternal illness – these cases should be discussed with the on call consultant as a matter of urgency. Category 1 - Immediate Caesarean section Where it is deemed that there is an immediate risk to the life of mother +/or her


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baby . Urgent delivery of the fetus is required as soon as possible and within 30minutes of the decision to deliver wherever possible. Examples of such situations are: • prolonged fetal bradycardia (move to theatre at 6 mins, decision at 9mins) • pre-terminal CTG • abnormal CTG with scalp pH <7.20 / STAN event • failed trial of forceps / ventouse in the presence of abnormal CTG • delivery of the second twin with acute fetal distress as above • uterine rupture • cord prolapse • large ongoing APH e.g. placenta praevia with maternal or fetal compromise • large placental abruption with fetal heart activity demonstrated • maternal acute cardiovascular compromise where continuing the pregnancy is

deemed harmful e.g. large PE, amniotic fluid embolism Occasionally delivery required within 20 minutes may be possible vaginally in theatre with a trial of instrumental delivery - such as with an abnormal CTG with scalp pH <7.20 / STAN event in the second stage – this is viewed as a Category 1 delivery and warrants the Obstetric Emergency Call. Implicit in the concept of a “trial” is that in the event of failure of operative delivery, there is rapid recourse to delivery by LSCS as soon as possible Category 2 – Urgent Caesarean section Where it is deemed that significant delay to delivery will lead to an adver se maternal or fetal outcome Urgent delivery of the fetus is required within 90 minutes of the decision to deliver wherever possible. Examples include: • non-profound fetal distress in 1st stage • failed forceps delivery without evidence of fetal distress • failure to progress in 2nd stage and unsuitable for instrumental delivery • delivery of the second twin with no apparent fetal distress • eclampsia after maternal stabilisation Category 3 - Emergency “non-urgent” Caesarean section Where it is deemed that there is NO immediate risk to the life of mother +/or her baby or that significant delay to delivery will NOT lead to an a dverse maternal or fetal outcome Delivery of the fetus is required as soon as is safely possible, practical and feasible when other labour ward risks have been considered. The timing of delivery is at the discretion of the Obstetrician and Anaesthetist, but should take place when the woman is deemed stable, usually within 24 hours. However, in some situations (e.g. worsening pre-eclampsia or abnormal uterine artery Dopplers when a fetus is preterm may necessitate administration of corticosteroids to mature the lungs and hence, caesarean section may be performed after 24 hours) Examples include: • failure to progress / obstructed labour in the 1st stage with a normal CTG • booked elective caesarean section in early labour • undiagnosed breech presentation in early labour


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• premature delivery for pre-eclampsia after stabilisation of BP NB: the above lists of examples for different categ ories of LSCS are not exhaustive and each individual case should be manag ed on an individual risk-based assessment. • It is unnecessary to suture the parietal peritoneum. • Always check and record examination of the fallopian tubes and ovaries. • All operators should wear goggles and double gloves when caesarean section is

being carried out. Blunt needles are used, particularly for closure of the uterus. • All caesarean section patients must be debriefed and discussion documented in

the patients notes. In addition to the above. a. the consultant obstetrician on call should be involved in the decision making

process in all elective caesarean sections and emergency caesarean sections (unless doing so would be life threatening to the women or the fetus). b. the reason(s), if any, for delay in undertaking the caesarean section should be

clearly documented. c. All women to be offered prophylactic antibiotics (Augmentin 1.2 g i.v. peri-

operatively unless there are specific contra-indications) d. All women should be managed according to our postnatal guidelines for the first 24

hours following delivery e. Obstetricians should debrief women after the surger y and this should include

a discussion with women the implications for future pregnancies before discharge.

Audit and Monitoring A continuous audit will be carried out to assess the documentation of the classification of caesarean section and the decision to delivery interval and documentation of the indication for caesarean section in the health records by the person making the decision interval on a daily basis using the ‘Caesarean Section Monitoring Book’. The Book will be reviewed by the Lead for Clinical Governance on a weekly basis and, if criteria for decision to delivery interval are not met, notes will be reviewed to identify any system failures. If the category of caesarean section, or indication for caesarean section, is not documented, feed back will be given to individual clinicians to improve practice in future. This will be documented in the Caesarean Section Monitoring Book Please see Appendix 2 and 3 for example of the book and the monitoring checklist


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Category One Section Protocol

Declaration of Category One Section should be by th e most senior Obstetrician available

Contact Category One Caesarean Team through Switchboard: Emergency

number 2222 - State ‘Obstetric Emergency' and give location

1. The team includes:

a) Obstetric Senior Registrar/Consultant (bleep XXXX) b) Obstetric Registrar (bleep XXXX) c) Two Anaesthetic Registrars (bleeps XXXX and XXXX) d) Midwife in charge of delivery unit (bleep XXXX) e) ODA (bleep XXXX) f) 1st assistant (bleep XXXX) g) Scrub nurse (bleep XXXX) h) Porter (bleep XXXX)

2. Actions to be taken by midwife and ST 3-5:

a) Explain and get consent b) IV access c) Blood for Hb and X match d) Switch off oxytocin if in use e) Consider tocolytic (IV or SC Terbutaline 0.25µg) f) Shave/Catheter g) Peri-operative ICP (Integrated Care Pathway) should be started

3. Responsibility to shift women to O.T.

a) Porter with assistance by Midwife and O&G registrar in charge of patient. b) Midwife in charge of the ward should allocate staff to help as required. THE RESPONSIBILITY AND ROLE OF THE MIDWIFE IN THEAT RE The Midwife is responsible for the provision of care to the mother and baby pre- and post-operatively, including the documentation. 1. Pre-operatively Once the woman is prepared, the Midwife should escort her to theatre. The fetal

heart is auscultated and CTG monitoring undertaken when appropriate. Ensure that resuscitation / cot / incubator equipment is ready for use. Ensure the Neonatologist is informed and also tell NNU if a transfer is likely. Once the regional block is effective or the woman anaesthetised, catheterise bladder.

2. Baby Assist the neonatology trainee with resuscitation and do not leave alone with

the baby unless checked that assistance is no longer required. If regional block, give mother (and father) the opportunity to hold the baby. Examine and weigh baby, giving care as normal. The baby should stay wit the mother unless there


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is a clinical reason for them to be parted. 3. Post-operatively

• Check placenta and membranes, taking cord blood for cord pH and Coombes Test (if required). The cord pH is the responsibility of the Midwife receiving the baby unless arranged with surgeon (in which case double-clamp the cord). If baby is admitted to NNU or pregnancy complicated (e.g., prematurity / stillborn / abruption / chorioamnionitis), send placenta for histology.

• Clean and restock resuscitaire.

• During recovery the woman will be cared for by a Recovery staff nurse.

• Women who have had a caesarean section under general anaesthesia must be

recovered in Lanesborough Recovery Ward.

• The mother and baby may be moved to await transfer to the ward but they should always have a person with them. Inform postnatal ward prior to the transfer and accompany the woman and baby there.

Please also see SECTION 18 Care of Obstetric Patien ts in Recovery References Thomas J, Paranjothy S, and James D National cross sectional survey to determine whether the decision to delivery interval is critical in emergency caesarean section. BMJ 2004 328: 665. Tuffnell DJ, Wilkinson K, Beresford N Interval between decision and delivery by caesarean section-are current standards achievable? Observational case series. BMJ. 2001 Jun 2;322(7298):1330-3 NICE Clinical Guideline: Caesarean section. RCOG Press April, 2004 Decision to delivery interval in Caesarean Sections. College Statement No. C-Obs 14. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. July, 2007. Lurie S et al. The decision to delivery interval in emergency and non urgent cesarean sections. European J Obstet, Gynaecol & Reproductive Biology 2004; 113(2): 182-5. Mackenzie IZ, Cooke I: What is a reasonable time from decision-todelivery by caesarean section? Evidence from 415 deliveries. An International J Obstet and Gynaecol (BJOG) 2002; 109(5): 498-504.

PROPHYLAXIS AGAINST HAEMORRHAGE Use oxytocics liberally;

a) IV oxytocin 5 IU. b) IM ergometrine 0.5mg.. c) Oxytocin 40 IU in 500ml Normal Saline over 4-6 hours.

Estimate blood loss as accurately as possible. PROPHYLAXIS AGAINST INFECTION After the fetus is delivered and the umbilical cord clamped, give cephradine 1g IV. This is followed by metronidazole 1g PR at the end of the operation. References Depp R (1991). Cesarian delivery and other surgical proceedures. In: Gabb S, Niebye JR, Simpson JL, (eds). Normal and problem pregnancies. New York: Churchill Livingstone, pp643-5 Doyle PM, Alvi S, Johanson R (1992). The effectiveness of double goving. Br J Obstet Gynaecol 99 83.


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Johanson R (1999). Obstetric Proceedures. In: Dewhursts Text Book of Obstetrics and Gynaecology for Postgrads. DK Edwards (ed) 6th Ed. Blackwell Science. Migford M, Kinston J, Chalmers J., (1989). Reducing the incidence of infection after caesarean section: implications of prophylaxis with antibiotics for hospital resources. BMJ 229 1003-6.

PRETERM LABOUR The outcome for babies delivered between 34-37 weeks gestation is extremely good and for this reason labour is normally allowed to proceed at this gestation. These guidelines apply to a situation where labour occurs in a singleton pregnancy that is otherwise uncomplicated. If other complications exist a Senior Registrar / Consultant's opinion must always be sought before the management plan is finalised. The diagnosis of preterm labour remains clinical with a careful history and speculum examination being important components. Digital examination should be avoided if there is any suggestion of ruptured membranes as this increases the risk of ascending infection. Which patient should be judged at risk of preterm d elivery within 7 days? • PPROM. • Clinical suspicion of idiopathic preterm labour • Obstetric complications (eg. Pre-eclampsia, IUGR, placenta praevia) for which early

delivery is planned or which may necessitate early delivery. DIAGNOSTIC CRITERIA • Regular uterine activity, with a contraction frequency of at least 1 every 10 minutes AND at least one of the following: • Ruptured membranes. • Evidence of progressive cervical change on repeat vaginal examinations.

Any change if by the same examiner. A change in cervical length or dilatation of >1 cm if by different examiners. Level of presenting part.

In a nullip, findings acceptable for a diagnosis of preterm labour are: • Cervical dilatation of 2 cm or more OR • Partial cervical effacement (to a length of 1 cm or less). INVESTIGATIONS Check gestation. Perform the following investigations: • Urinalysis for proteinuria and Nephur test. • MSU for culture (treat as presumed infection if proteinuria / Nephur +ve and

symptoms). • HVS (for M, C&S). • Endocervical swab (for chlamydia). • Insert IV and take the following bloods: FBC U&E


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Glucose • Ultrasound assessment as soon as practicable for: presentation weight estimate (especially if <32 weeks) liquor volume (by amniotic fluid index) umbilical artery Doppler. Consider: • Kleihauer • Consider urine screen for 'drugs' • Blood for Listeria culture • C-reactive protein MANAGEMENT Discuss the management plan with the patient and document it in the notes. The use of betamimetics must be discussed with the Senior Registrar. Care must be taken in multiple pregnancies. • If less than 34 weeks gestation the use of betamimetics should be considered

short-term to allow dexamethasone to be given and to take effect. • If more than 34 weeks gestation and a neonatal intensive care cot is available in

the unit, monitor the fetal heart rate continuously and allow labour to proceed. • In-utero transfer after 32 weeks should only be considered after discussion with

the Consultant Neonatologist. • Early communication with the Neonatologists is essential. Which patient should receive antenatal steroid ther apy? • All women at 24 –34 weeks gestation judged to be at high risk of delivery within 7

days • Babies of women delivering at 34 – 36 weeks gestation may also benefit • Use clinical judgement in deciding to initiate steroids (eg. Planned caesarean

section at 34 – 36 weeks). Two doses of Betamethasone 12mg intramuscularly are given 24 hours apart. Optimal clinical effect is observed from 24 hours to 7 days. Betamethasone may be repeated after 28 days if gestational age is <32 weeks, although this is of uncertain benefit. Which patient should receive antibiotics? � Recommend intravenous benzylpenicillin (or clindamycin) to reduce risk of early

onset Group B Streptococcus infection in the neonate (See Group B Streptococcus Guideline ).

� The use of other antibiotics to prolong pregnancy, particularly after PPROM, has not been shown to be of benefit, indeed it may be harmful.

Plan for delivery � Mode of delivery. � Whether caesarean section will be performed if fetal distress. � Mode of monitoring (usually continuous CTG). � Discuss with Neonatologists. � Encourage breastfeeding


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TOCOLYSIS What is the role of tocolysis? • Use only rarely and for periods not exceeding 48 hours (discuss with Senior

Registrar). • May be used to admit in-utero transfers or delay delivery for 24 hours after initiating

steroids. The regimen is GTN 10mg patch applied to the skin daily. If contractions have not diminished after 1 hour, a second GTN 10mg patch may be added (no more may be added for 24 hours after this). Remember to give analgesia (e.g. paracetamol) to prevent headache, particularly if 2 GTN patches are being worn. Simultaneously indomethacin 100mg daily PR is given. Contraindications to tocolysis: � Pregnancy > 34 weeks gestation. � Maternal disease, (e.g. - CVS disease, thyroid disease, etc). � APH. � Chorioamnionitis. � Fetal compromise Tocolysis are contraindicated if delivery would be in the best interests of the mother and / or baby. Therapy should be discontinued if labour progresses. They should be used with particular caution in women with multiple pregnancy, as there is a higher risk of serious side effects from the therapy. This is even more likely when bethamethazone/dexamethasone has been given. Side effects of GTN Headache Hypotension Flushing Tachycardia RESCUE / EMERGENCY CERVICAL CERCLAGE Under 26 weeks (before the time the fetus has a good chance of survival and a few weeks makes a significant difference). ‘Rescue cerclage’ may be performed where: � Uterine activity can be suppressed. � There is a good history of relatively ‘silent’ dilatation. � Membranes are intact. � Mother informed about risk of failure (ruptured membranes, chorioamnionitis, NND

and handicap). � Routine scan confirms no anomaly. � Scan before operation shows fetal heart present. Discuss with Consultant and inform Neonatologist. Perform early in order to minimise length of time membranes bulging in the vagina. Consider IV antibiotics (e.g. co-amoxyclav) prophylactically before and orally for up to 10 days after. Technique: Head down tilt on operating table. Pass Foley catheter through cervix and inflate (up 30 ml) to reduce membranes. Minimal handling of membranes.


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MacDonald with Mersilene or Wurm nylon suture (4-6 sutures closing cervix). If membrane rupture occurs, abandon procedure and advise oxytocin. Aftercare If rupture of membranes or signs of chorioamnionitis occur, remove suture immediately. Occasionally before 28 weeks gestation, a cervical suture might not be removed straightaway. The risks of fetal / maternal infection have to be weighed against the risks of prematurity. Discuss with a Consultant . Otherwise suture should be removed on Delivery Suite at 37 weeks. TREATMENT OF RECURRENT PRETERM LABOUR Individual management must be discussed with Consul tant . Broadly, there may be a place for repeated or prolonged courses of tocolytic medication in extreme prematurity (e.g. 24-26 weeks). CONDUCT OF LABOUR AND DELIVERY PRETERM Discuss the conduct of delivery beforehand with Senior Registrar and Consultant and Senior Neonatologist. In general cephalic presentations will be delivered vaginally, whereas breeches and other malpresentations <34 weeks will be considered for caesarean section. Vaginal delivery should be carefully controlled and non-traumatic by an experienced Midwife or Obstetrician. Avoid ARM (leads to cervix closing down and compound presentation). Episiotomy reduces perineal resistance and bruising to the preterm infant. A Senior Registrar should be present for all caesarean sections <34 weeks as they can be technically difficult. Keep the Neonatologist informed about labour progress. A Neonatologist should be present at all deliveries <36 weeks. If <30 weeks, call Registrar in addition to SHO. A Resuscitaire must be available and equipment prepared. Leave a long length of umbilical cord at delivery in case umbilical catheterisation required. POST DELIVERY Parents should visit NNU as soon as possible. Any women who delivers <34 weeks should have the fo llowing investigations: � Arterial and venous cord pH at delivery. � Placenta, membranes and cord to histology requesting: ‘any evidence of

chorioamnionitis or abruption?’ � Placental swabs for microbiology (‘?Listeria or other causes, chorioamnionitis’). Whenever possible women should be seen afterwards to plan for future pregnancy treatment.


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EXTREMES OF VIABILITY All babies delivered at 23 weeks gestation or more should be considered potentially viable and resuscitation should be discussed and planned with the Neonatologists. With the Neonatologists, give information to parent s, and make recommendations on: � Estimates of risk to the mother of attempts to continue the pregnancy. � Risks to mother, immediate and long-term, of different routes of delivery (e.g.

classical Caesarean section). � Short-term and long-term fetal and neonatal outcomes. � At every gestation approximately 10-15% of survivors will have moderate to severe

mental or physical handicaps. � Survival may be lower if there is evidence of sepsis or IUGR. � Management plans discussed with parents should include flexibility for initiating,

withholding or withdrawing treatment and may require modification immediately at and following birth, depending on the status of the neonate.

Wherever possible, a decision to withhold or withdraw new-born treatment immediately after birth should be made jointly, after full discussion by the Neonatologist, with the parents or guardians, and appropriate members of the health care team. What will guide the decision for or against resuscitation must be discussed before delivery if possible, as there is no time at delivery. The decision is preferably made by the Neonatologists using information about size, gestational age, intrapartum events and condition at birth. Management decisions should be documented clearly in the medical record. The infant should always be given compassionate care, including warmth and pain relief as required.

Weeks (if appropriate for gestational age) 22 23 24 25 26 27 28

Survival rate (approx. ) 0 <5 10 20 40 60 >80 GUIDELINES FOR THE MANAGEMENT OF PRETERM PRELABOUR RUPTURE OF MEMBRANES DIAGNOSIS • History of sudden gush of watery fluid and continuing involuntary loss pv. • Speculum examination + note pool of amniotic fluid in the vagina. • If no fluid is seen, history is suggestive or findings equivocal, visualised the

external os and ask patient to cough. AF may be observed coming through. • Examine a sample of AF outside the vagina (AF is watery, cervical secretion is

viscid / mucoid) • If still in doubt, offer extended pad test. • Obtain a low vaginal / perineal / peri-anal swab for GBS • Avoid a digital examination if pPROM diagnosed or still probable Gestational age < 23 weeks Perinatal survival approx. 13% compared to 50% if pPROM 24 - 26 weeks1

Risk of pulmonary hypoplasia – approx 50% if pPROM @ 19 weeks falling to < 10% @ 25 weeks.2 Discuss further management with on call consultant and / or the FMU


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Gestational age ≥≥≥≥ 23 < 34 weeks (We await further evidence on eryth romycin and prevention of neonatal morbidity & we do not ad opt this intervention at present)

• Admit to Hospital for the first 5 – 7 days and inform neonatologists • Administer Betamethasone 12mg i.m. x 2 doses 24 hr apart • Tocolysis6 - 7 (GTN) patch for 24 hours if uterine activity is present and

negative clinical / biochemical signs of chorioamnionitis • Leave cervical cerclage (if present) in situ unless decision taken to deliver • Inform XXXXXXX / ANC sister if patient is HIV positive • Arrange FMU scan – presentation, growth, EFW, Doppler, residual AFV with /

without biophysical profile • Exclude clinical chorioamninitis - defined as any 2 or more of: maternal / fetal

tachycardia, pyrexia ≥ 380 C, leucocytosis > 15,000, CRP raised by ≥ 30% above baseline,8 tender/irritable uterus, purulent or offensive vaginal discharge

• Chase up microbiological samples • If known to be GBS positive and pPROM is to be managed conservatively –

give iv penicillin G 3g stat then 1.5g 6 hourly for 5 days: Repeat after 5 wk if still undelivered. If allergic to penicillin consider clindamycin

• CTG daily, HR, temperature 4 hourly, FBC, CRP twice weekly • IOL @ 34 weeks + intrapartum antibiotic prophylaxis, add gentamicin if CCA

suspected Gestational age ≥≥≥≥ 34 weeks 3 - 5

• Admit and inform Neonatologists • Confirm dates with early ultrasound scan • USS to confirm presentation if in doubt • Exclude clinical chorioamnionitis • IOL stat, Remove cervical cerclage if one is in place • IOL should be started with PGE2 • D/W consultant if previous Ceasarean section • Intrapartum antibiotic prophylaxis for GBS • See birth plan & inform Austin Ugwumadu/ANC sister if patient is HIV+ve

Out patient management 9 (after 5 days in hospital & still < 34 wk)

• Assess home / social / domestic situation, available adult accompany to hospital

• Fetus in cephalic presentation and no evidence of fetal compromise • Should live within a reasonable distance of the hospital + access to telephone • Could and willing to attend DAU twice a week, monitor own temperature, heart

rate and pv loss • Avoid sexual intercourse (protected or not)

References:

1. Moretti et al. Am J Obstet Gynecol 1988;159:390 – 396 2. Rotschild et al. Am J Obstet Gynecol 1990;162:46 – 52 3. Naef RW, et al Am J Obstet Gynecol 1998;178:126-30. 4. Gorti M, Ugwumadu A. Am J Obstet Gynecol 2003;189:305 5. Grable I et al Am J Obstet Gynecol. 2002;187:1153-8. 6. Hoe et al J Mat Fetal Med 1998;7:8 – 12. 7. Decovalas et al. Eur J Obstet Gynaecol Reprod Biol 1995;55:143 - 147 8. Romen et al Am J Obstet Gynecol 1984;150:546 – 550 9. Carlan et al Obstet Gynecol. 1993;81:61-64.


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Appendix 1

VBAC Sticker


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Appendix 2 Continuous Audit: Emergency Caesarean Section.

Date.

And

Patient: name / MRN

Reason for C.section:

documented by person making the decision?

C.section: category

And

Decision

to delivery interval

If there was a delay: is the reason for this delay

documented

Was a consultant involved in

decision making

process?

Was the

operation & Implications

for future pregnancy discussed

with Patient

Were

prophylactic antibiotics

offered (please circle)

Was care of the mother in first 24

hours post surgery in line with

local protocol?

If there are

any shortcomings has the Lead for Clinical

Governance been

informed?

Actions Taken

Y / N

Y / N / NA Y / N / NA Y / N Y / N Y / N Y / N / NA

Y / N

Y / N / NA

Y / N / NA

Y / N Y / N Y / N Y / N / NA

Y / N


Y / N


Y / N


Y / N


Y / N



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Appendix 3 Monitoring Checklist

Element to be monitored Lead Tool Frequency Reporting arrangement

Acting on recommendations

and Lead(s)

Change in practice and lessons to be

shared

a. classification of all caesarean sections as agreed by the maternity service*

b. timing for each classification of caesarean section as agreed by the maternity service

c. requirement to document the reason for performing Grade 1 caesarean sections in the health records by the person who makes the decision

d. need to include a consultant obstetrician in the decision making process unless doing so would be life threatening to the woman or the fetus

e. requirement to document any reasons for delay in undertaking the caesarean section

f. requirement for all women to be offered prophylactic antibiotics* and thromboprophylaxis

g. care of the mother in the first 24 hours following delivery*

h. requirement to discuss with women the implications for future pregnancies before discharge

Labour Ward Lead Consultant

Continuous monitoring using attached proforma

Audit once in 12 months to review continuous monitoring

To Labour Ward Forum and Obstetric Risk Management Committee

Labour Ward Lead and monitored by ORMC

Delivery Suite Coffee morning, Risky Business and Joint Clinical Governance Days


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Appendix 4 Monitoring Checklist

Element to be monitor Lead Tool Frequency Reporting arrangement

Acting on recommendations and Lead(s)

Change in practice and lessons to be shared

a. who can perform the procedure

b. assessment prior to performing the procedure

c. documentation of why the procedure is indicated

d. documentation of informed consent

e. ensuring effective analgesia

f. when to use sequential instruments

g. when the procedure should be abandoned

h. care following operative vaginal delivery

i. care of the bladder j. decision to delivery

interval

Labour Ward Lead Consultant

Continuous monitoring using attached proforma

Audit once in 12 months to review continuous monitoring

To Labour Ward Forum and Obstetric Risk Management Committee

Labour Ward Lead and monitored by ORMC

Delivery Suite Coffee morning, Risky Business and Joint Clinical Governance Days

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