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Competence and Skills Training

‘I look forward to the great advances in knowledge that lie around the corner, but I do sometimes wonder whether the vast sums of money now being spent on research might not produce more rapid and spectacular improvement in health if devoted to the application of what is already known’. Max Rosenheim, President, Royal College of Physicians, 1968 Introduction and Historical Context Improving maternal and perinatal…

Perinatal Audit in Labour and Delivery: Safety, Quality and Consistency

‘You only know what you measure and what you cannot measure must be made measurable’. Galileo Introduction From the available literature, it is clear that intrapartum care is provided in many different ways and with variable outcomes, for which there will be many reasons. The intention of this chapter is not to suggest one way of providing care but rather to embrace different ways of providing…

Destructive Operations on the Fetus

These are a group of operations aimed at reducing the size of the head, shoulder or trunk of a dead fetus or a fetus with a lethal anomaly in order to facilitate its passage through the birth canal. Other than cases of drainage of the hydrocephalic fetal head, these procedures have no place in modern obstetrics, particularly in regions with developed health services. However, there may…

Symphysiotomy

‘I believe the operation fills a most useful place in practice, and that is the opinion of many others, and if everyone would deliberately struggle against taking up an extensive extreme position with regard to the operation, that place could be more exactly determined’. Munro Kerr, 1908 The operation of symphysiotomy has had a rather chequered history. It was originally performed upon the dead as an…

Acute Uterine Inversion

‘The child was born about an hour before I came, and the midwife in attempting to bring away the placenta, had inverted the uterus; for upon examination, I found the whole body of the uterus with the placenta, adhering to the fundus, hanging out beyond the labia; there was a great profusion of blood, and the woman was dead before I came … This case should…

Lower Genital Tract Trauma

Perineal trauma after childbirth affects millions of women worldwide. Approximately 85% of women sustain some form of perineal trauma following vaginal delivery. Short- and long-term morbidity associated with perineal repair can lead to major physical, psychological and social problems affecting the woman’s ability to care for her newborn baby and other members of the family. Perineal trauma may occur spontaneously during vaginal birth or when a…

Pelvic Vessel Ligation and Embolization: Obstetric and Radiological Perspective

Measures to deal with life-threatening obstetric haemorrhage have been outlined previously, including the use of oxytocic agents, uterine tamponade, uterine compression sutures and hysterectomy. The aim of this chapter is to describe the role of major pelvic vessel ligation or embolization when other methods to control bleeding have failed. The main indications for pelvic vessel ligation or embolization are bleeding of uterine origin in which preservation…

Uterine Compression Sutures

Uterine compression sutures of an improvised type have been used for decades: for example, figure-of-eight sutures in the lower uterine segment in cases of placenta praevia. In recent years, more specific techniques for the application of compression sutures have been developed. In most cases, haemostatic sutures are used at the time of caesarean section, although they are occasionally used when all other methods of haemostasis have…

Uterine and Vaginal Tamponade

When the cause of a postpartum haemorrhage (PPH) is not immediately obvious and oxytocic agents have failed, examination under anaesthesia (EUA) is warranted. In the event of continued uterine bleeding after EUA, many clinicians used to resort to laparotomy and hysterectomy. In modern care, however, the availability of uterine tamponade as well as the means to diagnose and treat clotting abnormalities has made laparotomy for PPH…

Retained Placenta

Introduction ‘I find it both amongst the ancients and moderns there have been different opinions and directions about delivering the placenta; some alleging that it should be delivered slowly, or left to come, of itself; others, that the hand should be immediately introduced into the uterus, to separate and bring it away … So in my opinion we ought to go the middle way, never to…

Postpartum Haemorrhage

Introduction ‘The dangerous efflux is occasioned by everything that hinders the emptied uterus from contracting … in these cases such things must be used as will assist the contractile power of the uterus and hinder the blood from flowing so fast into it and the neighboring vessels.’ William Smellie Treatise on the Theory and Practice of Midwifery. London: D. Wilson; 1752:402–404 ( Fig 34.1 ). Although…

Labour and Delivery in Women With a High Body Mass Index

Introduction Obesity has become a new epidemic, affecting all ethnic and racial groups. In the developed world, its incidence is persistently increasing, resulting in higher rates of overweight and obesity than normal body mass index (BMI) in some countries. In developing countries, obesity exists alongside malnourishment. More than 20 years ago, the World Health Organization (WHO) formally recognized obesity as a global epidemic. Despite increasing efforts…

Analgesia and Anaesthesia in Labour and Delivery

‘No greater boon has ever come to mankind than the power thus granted to induce a temporary but complete insensibility to pain’. Howard Wilcox Haggard Devils, Drugs, and Doctors. The story of the science of healing from medicine-man to doctor. London: William Heinemann (Medical Books) Ltd; 1929. Introduction Pain is defined as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or…

Amniotic Fluid Embolism

‘Pulmonary embolism by the particulate matter contained in amniotic fluid which gained entrance to the maternal circulation has been demonstrated by us at autopsy in 8 cases in which it seemed to be the cause of death…Having gained entrance to the maternal venous system, the emboli would be carried to the first filter bed, in these instances the lungs, and would lodge in vessels corresponding to…