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Thromboprophylaxis in Labour and Delivery

Introduction Pregnancy is a significant risk factor for venous thromboembolism (VTE), which remains a leading direct cause of maternal death in developed countries. There is good evidence that thromboprophylaxis reduces the incidence of VTE in at-risk groups. Heparin, a naturally occurring anticoagulant produced by basophils and mast cells, and its low molecular weight derivatives are the most commonly used anticoagulants and are effective in preventing deep…

Haemorrhagic Shock, Disseminated Intravascular Coagulation and Obstetric Resuscitation

‘After floodings, women sometimes die in a moment, but more frequently in a gradual manner; and over the victim, death shakes his dart, and to you she stretches out her helpless hands for the assistance which you cannot give, unless by transfusion. I have seen a woman dying for two or three hours together, convinced in my own mind that no known remedy could save her:…

Placenta Praevia and the Placenta Accreta Spectrum

Placenta Praevia The term placenta praevia refers to implantation of the placenta in the lower uterine segment that overlies or abuts the internal os ( Fig. 28.1 ). The incidence of placenta praevia is 4 per 1000 deliveries, with evidence of geographical variation. The aetiology of placenta praevia is poorly understood but risk factors include advancing maternal age, smoking, multiple pregnancies, assisted reproduction technologies and any…

Additional Procedures at Caesarean Section − Salpingectomy, Myomectomy, Ovarian Surgery and Hysterectomy

Salpingectomy Sterilization is a common procedure performed at caesarean section. An increasing awareness of the tubal origin of serous carcinoma has led to an increased focus on opportunistic salpingectomy as a risk-reducing measure for ovarian cancer. The incidence of salpingectomy at caesarean section has increased over the last 10 years. A number of studies have demonstrated that salpingectomy is safe, does not compromise ovarian function and…

Clinical Challenges at Caesarean Section : Uterine Rotation, Transverse Lie and Caesarean at Full Dilatation

Introduction Caesarean section (CS) is a common operation of which the majority are straightforward. This risks a relaxed attitude to the procedure, and its occasional complexities can catch out the unwary. This chapter highlights important anatomical and surgical principles relevant to all CS but of particular importance in three challenging situations: an exaggerated or malrotated uterus, a transverse fetal lie, and in the second stage of…

Caesarean Section: Procedure

Caesarean section represents the most significant operative intervention in all of obstetrics. Its development and application has saved the lives of countless mothers and infants. However, its inappropriate use can be a direct and avoidable cause of maternal mortality and morbidity. For these reasons, caesarean section probably represents the largest source of controversy and debate in modern obstetrics. The frequency with which it is carried out…

Caesarean Section: Controversies, Audit, Classification and Indications

Women will always choose the type of delivery that seems safest for them and their babies. If women choose a type of delivery that we disagree with then either they may be right and we may be wrong, the care that is being provided is not what we think it is or appropriate information is not available. Controversies The caesarean section (CS) debate continues to be…

Uterine Rupture

Introduction Uterine rupture is an infrequent, life-threatening obstetric complication for the mother and the fetus, which is often related to a previous caesarean delivery. Although it has been described in nulliparous women, uterine rupture is generally a complication of multiparous women, often related to prior caesarean delivery in the developed world, but it may be a consequence of prolonged obstructed labour in the developing world. A…

Labour and Delivery After Previous Caesarean

Once a Caesarean Always a Caesarean ‘One thing must always be borne in mind, viz., that no matter how carefully a uterine incision is sutured, we can never be certain that the cicatrized uterine wall will stand a subsequent pregnancy and labor without rupture. This means that the usual rule is, once a Caesarean always a Caesarean. Many exceptions occur … The general rule holds, however,…

Twin and Triplet Delivery

On Twins: ‘It is a constant rule, to keep patients, who have born one child, ignorant of there being another, as long as it can possibly be done’. Thomas Denman An Introduction to the Practice of Midwifery. London: J. Johnston, 1795 In recent years the incidence of fraternal twins and triplets has doubled and increased 10-fold, respectively. These increases are attributable to the improving success rates…

Breech Presentation

Epidemiology Breech presentation is a normal variant, occurring in up to 4% of term and 25% of preterm births. It is more common in nulliparous women (60%), where there are uterine or fetal abnormalities, placental praevia or another pelvic obstruction, and where there has been a previous breech baby (8% risk), but most are idiopathic. Both maternal and paternal genetic influences (family history) appear to be…

Shoulder Dystocia

‘… time passes. The child’s face becomes suffused. It endeavours unsuccessfully to breathe. Abdominal efforts by the mother or by her attendants produce no advance, gentle head traction is equally unavailing. Usually equanimity forsakes the attendants. They push, they pull. Alarm increases. Eventually “by greater strength of muscles or by some infernal juggle” the difficulty appears to be overcome, and the shoulders and trunk of a…

Assisted Vaginal Delivery – Rotational Forceps

Rotational Forceps – Historical Context The development of nonrotational forceps, manual rotation and vacuum as part of the obstetric armamentarium has been described in the previous three chapters. Obstetric forceps required adaptation in order to achieve rotation within the confines of the mid pelvis. The Norwegian obstetrician, Christian Kielland (1871–1941) originally designed his straight forceps to manage ‘deep transverse arrest’ associated with obstructed labour and cephalopelvic…

Assisted Vaginal Delivery – Vacuum

The Vacuum Extractor – Historical Context The use of the vacuum extractor in high-income countries has increased, so that a majority of assisted vaginal deliveries globally are now performed using this instrument as opposed to the obstetric forceps. The vacuum principle was probably first applied with use of a cupping-glass to treat depressed skull fractures in infants and adults. The first attempted obstetrical application was in…

Assisted Vaginal Delivery – Nonrotational Forceps and Manual Rotation

The Forceps – Historical Context The invention of the forceps by the Chamberlen family and how the instruments were initially used has been described in Chapter 15 . The addition of the pelvic curve to the design of the forceps ( Fig. 16.1 ) and the subsequent change in the direction of traction during delivery provided the foundation for the technique used in contemporary nonrotational forceps.…

Assisted Vaginal Delivery – an Overview

Introduction Assisted vaginal delivery (AVD) remains, in skilled hands, the most efficient method of expediting birth in the second stage of labour and is associated with fewer adverse maternal and neonatal outcomes than any alternative. This chapter will focus on the history and state of the art as it currently stands, examine important areas of practice and suggest a way forward that will keep AVD at…

Malpresentations and Malpositions

Malpresentations are all presentations of the fetus other than the vertex. Malpositions are abnormal positions of the normal presenting part (the vertex) of the fetal head with the occiput as the reference point relative to the maternal pelvis . Fetal malpresentation exists when the presenting part is other than the normal vertex of the fetal head. This includes two malpresentations that are covered in other chapters:…

The Use of Oxytocin to Accelerate or Induce Labour

Oxytocin Oxytocin is a mammalian neurohypophysial hormone and is produced in the supraoptic and paraventricular nuclei of the hypothalamus. It is a neuropeptide that physiologically is a potent uterotonic, stimulating the smooth muscles of the uterus. It also causes contraction of the myoepithelial cells surrounding the mammary alveoli, leading to milk ejection during lactation. The physiological effects of oxytocin are modified not only by circulating oxytocin,…

Cord Prolapse

‘Yet sometimes the navel string falls down and comes before it; for which cause the child is in much danger of death… As soon as ‘tis perceived, you must immediately endeavor to put it back, to prevent the cooling of it, behind the child’s head, lest it be bruised… But sometimes, not withstanding all these cautions, and the putting back of it, it will yet come…

Acute Tocolysis

Introduction The uterine myometrium is one of the most powerful muscles in the body, designed to ‘push out’ a 3.5–4.5-kg fetus during birth, and to expel the placenta after birth. However, any deviation from the normal uterine activity may adversely affect fetal and maternal health, because excessive uterine activity may result in repetitive and sustained compression of the umbilical cord and progressive reduction in uteroplacental circulation…