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CONTENTS Page

Foreword to the Third Edition vii

Foreword to the Second Edition ix
Preface to the First Edition X

Chapter 1 Antenatal Care 1

B . B a ss aw
Chapter 2 The Bony Pelvis 22
S. R o o p n a rin e sin g h
Chapter 3 Anaemia in Pregnancy 38
B . B a ss aw

Chapter 4 Diabetes in Pregnancy 52

B. B assaw
Chapter 5 Hypertensive Disorders in Pregnancy 66
B . B a ssa w

Chapter 6 Cardiac Disease in Pregnancy 82

B . B a ssa w a n d M . B lo tt

Chapter 7 Vomiting, Jaundice and Abdominal Pain

in Pregnancy 91
S. R o o p n a rin e sin g h a n d A ka sh R o o p n a r in e s in g h
Chapter 8 Adolescent Pregnancy 109
Advanced Maternal Age
Grand Multiparity
Obesity
S. R o o p n a rin e sin g h
Chapter 9 Factors affecting Birthweight
Intra-Uterine Growth Restriction
Fetal Macrosomia 129
S. R a m sew a k
Chapter 10 Fetal Malpresentation 140
A m rit R o o p n a rin e sin g h a n d R. R o o p n a rin e sin g h

Chapter 1 1 Twin Pregnancy 153

S. R o o p n a rin e sin g h a n d R . R o o p n a r in e s in g h
Chapter 12 Antepartum Haemorrhage 164
H . P er sa d a n d V. S a k h a rk a r
Chapter 13 Rhesus Iso-immunisation in Pregnancy 177
S. R a m se w a k a n d A . S irju sin g h
Chapter 14 Ultrasonography 186
S. S a id a n d M . G eary
Chapter 15 The Umbilical Cord and Placenta 205
S. R o o p n a rin e sin g h a n d R . R o o p n a rin e sin g h
Chapter 16 Amniotic Fluid 216
S. R o o p n a rin e sin g h a n d R. R o o p n a rin e sin g h
Chapter 17 Antepartum Fetal Surveillance 227
A k a sh R o o p n a rin e sin g h
Chapter 18 Normal Labour 237
B . B a ssa w
Chapter 19 Intrapartum Fetal Monitoring 253
P. R e id , N . M o h a m m e d a n d B. B assaw
Chapter 20 Postpartum Haemorrhage 263
A kash R o o p n a rin e sin g h a n d J . S u ra tsin g h

Chapter 21 Preterm Labour PPROM 277

S. R oopnarinesingh a n d A kash R oopnarinesingh

Chapter 22 Post-Term Pregnancy 291

S. R o o p n a rin e sin g h a n d A . S irju sin g h
Chapter 23 Induction of Labour 298
S. R o o p n a rin e sin g h a n d A . S irju sin g h

Chapter 24 Operative Delivery 307

A . S irju sin g h a n d A ka sh R o o p n a rin e sin g h
Chapter 25 Obstetric Analgesia and Anaesthesia 331
C. D in d ia l
Chapter 26 Infections in Pregnancy 345
H . F letcher
Chapter 27 The Puerperium Lactation 364
H. Persad and S. Kulkarni
Index 381

V
 ANTENATAL CARE

CHAPTER ONE

ANTENATAL CARE

INTRO DUCTIO N
Many surveys have revealed that women who receive no antenatal care
have very high perinatal mortality rates. In general, perinatal mortality
shows an inverse relationship to the num ber of antenatal visits. These
findings suggest that antenatal care is beneficial and that more frequent
attendance is associated with better outcom e. This may be considered
simplistic since women who book early for antenatal care are often
healthier, better educated, more likely to be in a higher socio-econom ic
group and they tend to be more compliant with medical advice and
intervention. These confounding variables certainly play a major role in
improved perinatal and maternal outcome. The contribution which
adequate antenatal care makes to better pregnancy outcom e can only be
tested by large random ized controlled trials which are difficult to
conduct for many reasons, especially on ethical grounds.

This uncertainty about the value of antenatal care together with a

long waiting time in the clinic, lack of continuity, lack of inform ation
and depersonalized care cause consum er groups and women activists to
mount a great deal of criticism o f the manner in which antenatal care is
being practiced. These problems have led to the introduction o f the
concept of antenatal care based on risk-assessment. Other im portant
aspects considered were gestational age at booking and care throughout
pregnancy, including routine investigations.

Aims and Objectives of Antenatal Care

• To assess the health and well being o f the m other and the fetus,
and to make appropriate arrangem ents for care during pregnancy
and labour.

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 ANTENATAL CARE

• To predict and, if possible, prevent or detect early and manage

effectively maternal and /or fetal complications developing
during pregnancy.
• To ameliorate the discomforts and minor complaints of
pregnancy.
• To prepare the couple for childbirth.
• To provide appropriate health screening and health education

THE BOOKING VISIT

This represents the first consultation between the midwife, general
practitioner or specialist and the pregnant woman. Ideally this should
occur between 8 - 1 4 weeks.

Advantages of early booking:

• It represents an opportunity for health education. She should be
advised of the harmful effects of smoking, alcohol and other
addictive drugs. Normal physical exercise should be
recommended but the extreme exertion required for some
occupations may affect the pregnancy adversely. She should be
offered dietary advice and specifically instructed to avoid soft
cheeses that may contain listeria monocytogenes and liver or liver
products, which may result in the development of Vitamin A
toxicity.
• Clarification of gestation by a careful menstrual history,
abdominal and pelvic examination, and if required, an ultrasound
scan to measure crown-rump length in the first trimester. An
early booking ultrasound scan allows for the accurate dating of
the pregnancy, early identification of multiple gestations and
determination of chorionicity. Accurate dating is essential for the
planning of routine follow up, screening tests and ultimately the
time of delivery.
• Screening for pre-existing maternal medical conditions. For
example, diabetes mellitus, cardiac disease, seizure disorders and
hypertension. Medication can be changed to a preparation that is
appropriate for pregnancy. For example, anti coagulant therapy
can be converted from warfarin, which can cause an embryopathy
(chondrodysplasia punctata), to heparin, which does not cross the
placenta and is safe in pregnancy.

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 ANTENATAL CARE

• Screening for potential medical complications in pregnancy. For

example, the obese parturient is at increased risk o f developing
gestational diabetes and pre-eclampsia in pregnancy.
• Screening for fetal chrom osom al abnormalities. Patients may be
offered tests, which can be perform ed in either the first or second
trimester. For example, if we consider D ow n’s syndrom e, the tests
available for first trimester screening are nuchal translucency on
ultrasound and the measurement of the beta subunit o f human
chorionic gonadotrophin and pregnancy-associated plasma
protein-A (PAPP-A) in the maternal serum. In the second
trimester human chorionic gonadotrophin (hCG), alpha-
fetoprotein (AFP), oestriol and inhibin can be measured in the
maternal serum, usually between 16 to 18 weeks gestation. It
should be emphasized that these serum tests are not universally
available; that they are only screening tests that quantify the risk
and that they are only applicable to singleton gestations. The
confirm atory or diagnostic tests are chorionic villus sampling and
amniocentesis.
• Screening for fetal structural anomalies. A detailed anom aly scan
for structural defects can be perform ed at 18-22 weeks gestation.
Detailed cardiac scans are best perform ed at 24 weeks gestation.
A high AFP in the maternal serum may suggest an open neural
tube defect.
• Allows the timely insertion of a cervical cerclage.

History taking
• The menstrual history. The date o f the beginning of the normal
menstrual period (LMP) is carefully ascertained. The expected
date of delivery (EDD) is calculated by adding 7 days and 9
months to the LMP (N aegele’s rule). M enstrual irregularity,
recent horm onal contraception and ovulation induction may all
affect the timing of ovulation.
• Previous pregnancies with details o f any unusual events.
a) Dates of previous pregnancies.
b) Number of pregnancies- A viable pregnancy is one, which
has crossed 28 weeks (live or stillborn) and is calculated
towards the patient’s parity. Those before 28 weeks are
termed “ m iscarriages” . A patient who is currently pregnant
and has had 3 previous viable pregnancies and 2 miscarriages
is a gravida 6, para 3+2.

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 ANTENATAL CARE

c) Duration of pregnancies- A pregnancy may end in the first

trimester (up to 14 weeks), the second trim ester (12-28
weeks) or the third trimester (after 28 weeks). L abour may
have been spontaneous or induced.
d) Medical complications o f pregnancy.
e) Type of delivery- this may be spontaneous vaginal, assisted
vaginal (forceps or vacuum), or abdom inal.
f) Complications o f labour such as prolonged labour, shoulder
dystocia, third and fourth degree perineal tears and
postpartum haem orrhage.
g) Features of the baby - weight, condition at birth and any
neonatal complications.
h) A thorough history of the present and past pregnancies is
taken, including problem s which are recurrent such as
gestational diabetes, pre-eclampsia, and certain fetal
abnormalities, significant past medical history e.g. cardiac
disease, haem oglobinopathies or previous uterine surgery e.g.
myomectomy or Caesarean section.
i) A family history of diabetes, hypertension, sickle-cell disease
and multiple pregnancy.

Physical examination
• The patient’s height and weight are measured and the body mass
index calculated.
• Examination o f her general physical condition, especially the
mucous membranes, state of hydration, pulse rate and blood
pressure. The thyroid gland, breasts, cardio-respiratory system
and lower limbs are examined.
• A speculum examination to note the condition o f the cervix and
the presence of any vaginal discharge.
• A bimanual examination to assess the adequacy o f the pelvis, to
search for any ovarian tum ours or uterine fibroids and to
determine whether the uterine size corresponds with the
gestational age. The estimate of uterine size at this time is perhaps
more accurate than at any further occasion in pregnancy.

Investigations
• Full blood count.
• Sickle cell test and haem oglobin electrophoresis, if necessary.

4
 ANTENATAL CARE

• ABO blood group and Rhesus type.

• VDRL.
• Other haematological tests include Rubella antibodies, HIV and
Hepatitis screening, antibodies against the D-antigen in Rhesus
negative women and glucose screen.
• Urinalysis for proteinuria, glycosuria and ketonuria.
• Mid-stream urine collection for microscopy, culture and
sensitivity if indicated.

Risk Assessment
Risk assessment should be conducted by a senior officer employing a
predetermined checklist. The list should include maternal age (teenage
or advanced maternal age), parity (primigravida or grandmultiparity),
and uncertain gestation, previous obstetric problems such as medical
disorders of pregnancy, preterm deliveries, intrauterine growth
restriction, fetal anomalies, caesarean section and perinatal loss. This will
allow for the categorization of the pregnancy as high or low risk.

Further antenatal care for the low-risk category can be obtained

primarily from the midwife and general practitioner. High risk patients
should be seen in specialist obstetric clinics though there is scope for
shared care with the midwife and general practitioner. Although risk
assessment has definite merits, it is certainly not perfect since women who
are normal at booking can develop serious complications later in
pregnancy.

Antenatal visits should be individualized. The use of a rigid

system of 4 weekly visits up to 28 weeks gestation, fortnightly between
28 and 36 weeks, and weekly until delivery is counterproductive. A more
flexible system allows for greater patient compliance. Finally, a small
group of pregnant women may benefit from joint care with the
obstetrician and a specialist internist. This may include patients with
cardiac disease, seizure disorders, diabetes mellitus, hypertension and
sickle cell disease.

FURTHER A N TENATAL VISITS

• Inquire about the general state of health and minor complaints,
and about abdominal pain and vaginal bleeding.

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 ANTENATAL CARE

• M onitor blood pressure, urinalysis and weight-gain. The

average patient will gain about 12 kg throughout pregnancy.
If weight-gain exceeds 1 kg in any one week, this might indicate
the onset of pre-eclampsia. However, weight-gain is variable
from patient to patient. For example, an obese m other may have
little weight-gain in pregnancy. Failure to gain weight or
weight-loss may be due to excessive vomiting in the first trimester
or to intra-uterine growth restriction or fetal demise in the third
trimester. Excessive weight-gain may be due to pre- eclampsia,
twins or polyhydram nios. The practice of measuring weights at
each visit seems obsolete in to d a y ’s obstetrics.
• Assess uterine size. Record serial measurements of symphysio-
fundal height.
• Haematinics can be prescribed from 16 weeks gestation.
• Fetal monitoring with daily fetal kick charts and when indicated,
biophysical methods such as the non-stress test.
• Repeat full blood count and antibody screen at 28 weeks.
• Rhesus negative mothers can receive routine antenatal anti-D
prophylaxis at 28 and 34 weeks gestation.
• In the third trimester, determine the presentation and lie o f the
fetus, and assess the liquor volume.
• Assess if the head is engaged or even better, the num ber of fifths
palpable above the symphysis pubis in the late third trimester.
• Plan the mode and time o f delivery.

THE OBSTETRIC EXAM INATION

Inspection
This can be perform ed in the clinic standing at the foot of the bed. A
systematic inspection can commence from the patient’s head and
proceed all the way to inspection o f the chest, abdom en and extremities.
The important points to note on inspection o f the abdomen are:
• It is distended in an anteroposterior diam eter and moves with
respiration.
• The umbilicus may be inverted, flat or everted depending on the
gestation.
• There may be a prom inent linea nigra.

6
 ANTENATAL CARE

• There may be demonstrable striae gravidarum.

• One can com m ent on the hair distribution and the presence of
surgical scars.
• Fetal movement may be observed.

Abdominal palpation
By means of palpation, one can determine the lie, presentation, attitude
and position of the fetus. Understanding these terms is crucial and they
are defined later in this chapter. The abdom en should also be palpated
for tenderness, which may be a sign of a placental abruption whilst a
tense abdomen may be indicative o f polyhydram nios.

The following four manoeuvres, as described by Leopold, are

used in the sequence mentioned, in the third trimester:

First manoeuvre: Facing the patient, both hands are placed laterally on
the abdomen towards the fundus of the uterus to determine its height in
relation to the umbilicus and the xiphoid, and in relation to gestational
age as calculated from the last period.
By using the fingertips, one can determine whether the breech or
the head is occupying the upper part o f the uterus. The breech is felt as
a large irregularly shaped mass, while the head is felt as a hard, round
mass which can be balloted between the hands.

Second manoeuvre: The hands are lowered on the sides o f the abdom en
and one hand is held firmly against one side while the finger-tips o f the
other hand are used to feel for small irregularly-shaped parts
(extremities) or to feel for a smooth persistent regular surface which is
interpreted as the back. When an impression is gained as to whether an
extremity or the back of the fetus is one side, this may be confirm ed by
using the finger-tips of the other hand to feel the other side o f the
abdomen.

Third manoeuvre: The thumb and first two fingers of the right hand are
placed over the lower abdomen just above the symphysis (Pawlik’s grip)
to determine what pole of the fetus is presenting, and whether engaged or
not. The other is placed at the fundus o f the uterus to stabilize it.

Fourth manoeuvre: The obstetrician faces the feet of the patient and the
four fingers o f each hand are placed over the lower abdom en just above

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 ANTENATAL CARE

the symphysis pubis and deep pressure is made downwards to feel the
features of the presenting part.

Figure 1. Leopold manoeuvres

The height o f the fundus is an important observation at every

antenatal visit since it can indicate if the fetus is growing as expected.
From about 20 weeks gestation the measuring tape is used to measure the
sym physio-fundal height. The measurement is taken from the fundus to
the m idpoint of the superior border of the sym physis pubis. The error
with the measuring tape is plus or minus 2 weeks. The greatest value of
the measuring tape is seen when the same observer takes the
measurement serially.

8
 ANTENATAL CARE

With normal growth of the fetus the fundus of the uterus reaches
certain levels on the abdominal wall in “ clim bing” from the level of the
symphysis pubis at 12 weeks gestation to just beneath the xiphisternum
at 38 weeks gestation. If the level of the fundus is higher than expected
for the gestational age, multiple pregnancy should be suspected, as well
as other reasons for a large-for-dates uterus; if lower than expected there
could be intra-uterine growth restriction (IUGR) or fetal abnorm ality.
Disparity on clinical examination warrants re-assessment o f the gestation
based on her LMP and recourse to fetal biometric studies.

Percussion
This is done in order to detect the presence of a fluid thrill, which is a
common finding with polyhydram nios. In such a case the abdominal
girth should be measured.

Auscultation
The fetal heart sounds are heard loudest over the area at which the fetal
left scapula comes in contact with the uterus. They should be listened
for at every visit after the 24th week of gestation, using the Pinard’s
stethoscope; a rate of 110-160 beats per minute is norm al. The Sonicaid
or the Doptone (ultrasonic fetal heart detectors) will pick up fetal heart
sounds as early as the 10,h week.

DEFINITIONS

• Lie of the fetus. The lie of the fetus is the relation o f the long
axis of the fetus to the long axis of the uterus. It may be
longitudinal, transverse or oblique. When the lie is longitudinal,
either the head or the breech is directly above the brim o f the
pelvis. When the lie is transverse, the shoulder occupies the lower
pole of the uterus and the long axis o f the fetus lies across the
long axis of the uterus. It occurs when there is a lax uterine wall,
or polyhydram nios or a major placenta praevia.

• Attitude is the relation of the fetal head and limbs to its trunk.
Normally this should be one of flexion, when the trunk is bent,
the head is flexed so that the chin touches the chest, the thighs are
flexed on the abdomen and the legs are flexed on the thighs.

_
 ANTENATAL CARE

• Presentation refers to the part o f the fetus, which lies above or in

the pelvic brim. The vertex presents in 96 percent o f cases, and
the breech in 3 percent. Shoulder, face and brow presentations
are much less com m on.

• Position is defined as the relationship o f the denom inator to the

pelvic axis. The denom inator is a landm ark on the presenting part
that is used to indicate the position o f the fetus in relation to the
pelvis. It may be the occiput in vertex presentations, the sacrum in
breech, the mentum in face, and the acrom ion process in shoulder
presentations. In the left occipito-anterior (LOA) position, the
occiput points to the left ilio-pectineal em inence on the left
anterior area of the pelvic brim. In this situation, the sagittal
suture is in the right oblique diameter of the brim . In the left
occipito-posterior (LOP) position the occiput points to the left
sacro-iliac joint while the sagittal suture is in the left oblique
diam eter of the brim.

• Engagement of the head. An engaged head is one in which the

biparietal diam eter has passed through the pelvic brim . The head
should be engaged in a primigravida by the 38th to 39th week o f
gestation, and if not, the cause should be investigated. When the
head is engaged, it will not move in the pelvis and the greater
bulk of the head is not palpable over the brim . In fact, the
leading edge of the head is at the plane o f the ischial spines and
the head is then said to be at station zero. When engagem ent
occurs, no more than two fifths of the head would be palpable
abdom inally.

On rare occasions, the head is not palpable abdom inally

because it is deep down in the pelvis. In this situation, the
anterior shoulder will be immediately above the sym physis pubis
and may be mistaken for the breech. When doubt exists, a
vaginal examination will resolve the issue.

The causes of a "hig h head" at term are:

o Placenta praevia.
o M ultiple pregnancy,
o Polyhydram nios,
o Uterine fibroids or ovarian cysts,
o Pelvic brim -inclination o f 80° or more.

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 ANTENATAL CARE

o Faulty assessment o f the period o f gestation,

o M alpresentation or deflexed head.

Cephalo-pelvic disproportion. This means that the head is too large for
the particular pelvis through which it must pass; it is a relative term. The
disproportion may be pelvic or cephalic in origin, due to a contracted
pelvis, a large fetus or a com bination of both. It is a matter o f concern
when the patient is of short stature; a maternal height of less than 5 feet
is considered critical.

LOP

Posterior
fontanel

11
 ANTENATAL CARE

Urine examination
Urine is routinely tested for glycosuria, album inuria and ketonuria.
Proteinuria is the presence of protein in the urine in concentrations
greater than 300 mg/1 in a random urine collection, by dipstick
exam ination. The urine must be a voided clean catch specimen or one
obtained by catheterization. Proteinuria is an ominous sign of pre­
eclampsia.

It is not uncom m on to find a trace o f album inuria in women who

are otherwise quite normal. However, persistent albuminuria should be
investigated, the common causes of which are pyelonephritis, pre­
eclampsia, kidney lesions, certain collagen diseases, orthostatic
proteinuria and contamination from vaginal discharge.

Glycosuria should be investigated bearing in mind the fact that

pregnancy is often the event, which brings a diabetic disorder to light.
The obstetrician should have a high index o f suspicion o f diabetes in
women who have:
• A strong family history o f diabetes.
• Previously given birth to macrosomic infants.
• Persistent glycosuria.
• A history o f unexplained fetal losses.
• Obesity and polycystic ovarian syndrom e.

Blood Pressure
Ideally, when blood pressure is being taken, the patient should be sitting
on a couch, at rest. The left lateral position is also acceptable. The
sphygm om anom eter cuff should be approxim ately level with the heart.
In a norm al pregnancy, the blood pressure rarely rises above 120/80
mmHg and as a rule shows a drop in the second trimester o f pregnancy,
at which time pressures as low as 85/50 mmHg may be recorded. A B.P.
of 140/90 mmHg or more is abnormal.

Weight-gain in pregnancy
The am ount of weight gained in normal pregnancy depends on a
num ber of factors and tends to vary widely around an average o f 12 kg.
As a general rule, if the weight gained in a week is more than one kg,
there is a likelihood of the patient developing pre-eclampsia.

12
 ANTENATAL CARE

Oedema
The development of oedema, especially where this involves the fingers,
may be a sign that pre-eclampsia is either present or imminent. Oedema
should be looked for, at every visit. It is usually associated with an
excess of weight-gain.
Approximately 85% of patients who develop generalized oedema
have normal pregnancies and only about 15% develop pre-eclampsia.
Hence, oedema in pregnancy may reflect changes that are physiological.
The previously held concept of treating oedema with diuretics is now
discarded. In fact, the use of diuretics in pre-eclampsia may be harm ful
as they decrease plasma volume and reduce uteroplacental perfusion.

Nutrition in Pregnancy
Pregnancy is an anabolic state and women store large quantities of
energy above the immediate needs of the growing fetus. M uch of this
storage is in the growth of tissue: the fetus, the breasts, the uterus and the
expanding blood volume.
The placenta acquires nutrients effectively for the fetus so that
plasma levels of nutrients, which are low in the mother, are much higher
in the fetus. Thus, the fetus becomes protected from the vagaries of the
maternal diet.

Special problems
Research studies in animals and observations during famine and war
show that grossly inadequate diets during pregnancy may lead to fetal
malformation, low birthweight and prematurity; in the m other it may
lead to abortion, anaemia, pre-eclampsia and inadequate lactation.

The pregnant woman of average weight requires about 2400 Kcal

per day during pregnancy. This is about 300 Kcal/day more than her
non-pregnant counterpart. Significantly inadequate caloric intake is
often associated with low birthweight and neonatal problems.

Cell growth requires protein. Inadequate protein intake during

pregnancy can lead to suboptimal growth of the fetus, decrease in the
size of various fetal organs and an increase in perinatal morbidity and
mortality. Most o f the protein should come from animal sources such as
meat, milk, eggs, cheese, poultry and fish.

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 ANTENATAL CARE

M inerals are also im portant. Many women have inadequate iron

stores because of blood loss during menses. Iron stores may be further
depleted by the dem ands of the fetus during pregnancy. For this reason,
supplemental iron is needed for both the fetus and the expanding
maternal blood volume. Elemental iron (30-60 mg) should be given
daily to supplem ent the diet, starting from about 16 weeks.. Iron is
found in liver, red meat, beans, green leafy vegetables, whole grain, cereal
and dried fruits. The average daily diet contains about 12 mg o f iron,
and usually 10-20% of this is absorbed. Iron is best absorbed when
presented to the duodenum and upper jejunum in the ferrous state.
Humans do not absorb iron from non-haem sources well.

The recom m endation fo r calcium o f 1200 mg/day can be met by

drinking a quart o f milk a day. However, many women find milk
“ u p settin g '’. Alternative sources o f calcium are cheese and beans.
Calcium has been shown to reduce the incidence o f pre-eclam psia in the
Caribbean and in South America if started about 14 weeks gestation. It is
custom ary in the developing world to prescribe iron and vitamin
supplements routinely.

Folic acid is required in the form ation o f haem, the iron-

containing protein of haem oglobin. Deficiencies in folic acid can cause
megaloblastic anaemia. Studies in Jamaica have shown that the average
diet provides adequate am ounts of folic acid and that folic acid
deficiency is not a problem in the Caribbean area. A pproxim ately 800-
meg folic acid daily are required during pregnancy. An adequate daily
supplem ent is 1 mg daily. Periconceptional folic acid supplem entation
reduces open neural tube defects and cleft palate. In the United
Kingdom , the recom m ended dose is 400m cg.

During pregnancy 80 mg daily o f vitamin C is recom m ended and

this is contained in leafy vegetables and citrus fruits. Body stores o f
vitamin B12 are usually low in vegetarians and its supplem entation
should be provided in these women.

High doses of Vitamin A are harm ful, and therefore should be

avoided. Recently, there have been recom m endations to increase the
intake of Omega-3 fatty acids in a pregnant w om an's diet.

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 ANTENATAL CARE

Groups at special risk for nutritional deficiency

The following patients are at special risk:
• Those of low socio-economic status.
• Patients with pre-existing anaemia or sickle-cell disease.
• Patients of high parity.
• Patients with intestinal parasites - round worm, hookworm.
• Those with poor weight-gain during pregnancy.
• Obese women and those who are underweight.
• Vegetarians.

FIRST TRIM ESTER COM PLICATIONS

Nausea and vomiting
The psychological factors of early pregnancy, the sharp rise of human
chorionic gonadotrophin and the hypotonic gastrointestinal tract all
contribute to constipation, poor appetite and varying degrees o f nausea
and vomiting. When nausea and vomiting become excessive, the
condition is called hyperemesis gravidarum.

Hyperemesis gravidarum
The patient shows signs of dehydration, tachycardia and a low urine
output with ketonuria. She is unable to retain any liquids or solids. This
is discussed further in chapter seven.

Threatened miscarriage
The symptoms and signs are mild cramp-like pain in the lower abdom en,
backache and small loss of blood per vaginam. In a num ber o f cases the
cause is not known and no specific treatment is given. “ Rest in b e d ” is
the most practical therapy but there is no supportive evidence that this is
of benefit. Since some cases can be caused by progesterone deficiency
from ineffective corpus luteum function, some obstetricians will
empirically prescribe a progesterone supplem ent. Whereas many
patients can be treated at home, with appropriate advice and instructions,
some patients will be better off in hospital.

Habitual miscarriage
Habitual or recurrent miscarriage refers to three or more consecutive
miscarriages. It constitutes about 5 percent of all spontaneous
miscarriages. The aetiology is unknown in the majority of cases.
However, in 15% there is demonstrable maternal and fetal pathology.

15

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 ANTENATAL CARE

While first trimester miscarriages are usually related to problem s of

conception and em bryogenesis, in the second trimester they are usually
related to uterine anomalies and cervical incompetence.

Couples with repeated early loss should be assessed for

chromosomal disorders: studies should be done on both fetus and
placenta and the parents should be checked for balanced translocations.
Some habitual miscarriages may be due to im m unological rejection and
anti-phospholipid syndrome.

Diagnostic investigations may cover the range of endocrine

disorders, nutritional status, psychogenic influence and luteal phase
deficiency. A hysterosalpingogram may reveal uterine abnormalities
including bicornuate uterus, septate uterus, subm ucous fibroids or
incom petent cervix.

Exposure to rubella
The pregnant woman exposed to rubella in the first trimester has a 15 to
20 percent chance of having an abnormal baby. The risk of abnorm ality
is significantly less after 16 weeks gestation. Steps to be taken are:
• Measure rubella antibodies. If immunity is dem onstrated, the
patient can be reassured and nothing further need be done. If
titres are greater than 1:10, they indicate im m unity.
• The patient should be observed for a serologic response. A
repeat rubella titre should be done 2 to 3 weeks after the initial
one. A rising titre is indicative o f infection.
Many patients may elect to terminate the pregnancy. The
administration of gamma globulins should be considered for the infected
patient who decides to continue with the pregnancy.

Although 70-90% of pregnant women are im m une, it is

recom m ended that routine testing for rubella antibodies be carried out at
the first antenatal visit. This enables appropriate advice to be given to the
patient, i.e. if immune, they can be reassured; if not, they should avoid
contact with rubella sufferers, be given immune globulin if such contact
has occurred and vaccinated in the puerperium , if still susceptible.
Rubella vaccine should not be administered in pregnancy. However, if a
woman inadvertently receives the rubella vaccine in pregnancy, she
should be advised that this is not an indication for termination.

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 ANTENATAL CARE

SECOND TRIM ESTER COM PLICATIONS

Urinary tract infection
Frequency o f micturition is a common symptom o f pregnancy. An
increased glom erular filtration rate and the pressure of the uterus on the
trigone o f the bladder contribute to this. However, UTIs are more
common in pregnancy because of the stasis and incomplete bladder
emptying that occurs. Hence, an ascending infection may arise from the
bladder to cause a pyelonephritis. A midstream specimen o f urine
should be cultured and sensitivity of organisms detected.

Cervical incompetence
The typical account is one of spontaneous rupture of the membranes
during the mid-trimester, followed by rapid expulsion of the fetus. The
miscarriage is described as painless, complete and almost bloodless. The
cervix prematurely dilates in the course o f early pregnancy, due to some
cervical weakness that may be due to a congenital condition or to prior
trauma from delivery or from overzealous dilatation.

One of the procedures found effective in overcoming cervical

incompetence is the Shirodkar operation. The optimal time o f insertion
of the cervical suture is between the 14th and 18th week of gestation.

The patient is anaesthetised and the cervix is gently grasped by

applying Allis forceps to the anterior and posterior lips. A transverse
incision about 2 cm long is made in the vaginal mucosa just where it
turns upon the anterior part of the cervix. A pair o f artery forceps is
used to deepen this incision to reach the cervical tissue. The bladder is
then displaced upwards by sharp dissection to a level just above the
internal os. A similar transverse incision is made posteriorly at the same
level.

A suture specially designed for this operation is pre-packaged

with two aneurysm needles threaded on a broad nylon tape. One
aneurysm needle is passed through the anterior incision, under the
vaginal mucosa and around the cervix and out through the posterior
incision. Similarly, the other aneurysm needle carries the Mersilene
ligature around the other half of the cervix. The suture is then tied
posteriorly, a length of the tape being left beyond the knot to facilitate its
removal later. The anterior and posterior mucosal incisions are sutured.
The McDonald suture is an alternative to S hirodkhar’s: it is a
purse string type of suture applied around the cervix near enough to the

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 ANTENATAL CARE

internal os, without reflecting the bladder off the cervix. This m ethod is
much simpler than the Shirodkar.

The suture may be removed in the antenatal clinic, without

anaesthesia, at 38 weeks, at the time of caesarean section or earlier if
preterm labour or rupture of the membranes occurs.

THIRD TRIM ESTER COM PLICATIONS

Bad obstetric history
Not infrequently, a patient gives a “ bad obstetric history’ reporting
successive pregnancy losses. Invariably, no medical disorder emerges as
the cause for the mishaps and the chances for a repetition o f the tragedy
are high. There is a saying “what the uterus does once, it can do ag ain ” .
These patients should be managed in a high-risk antenatal clinic by a
senior obstetrician.

Antepartum haemorrhage
This topic is dealt with elsewhere. In most cases the signs and symptoms
are dramatic resulting in emergency admission.

Intra-uterine growth restriction

Careful examination in the antenatal clinic will alert the obstetrician to
the fetus that is not growing. Once this is suspected, the patient should be
admitted to the hospital for a range of investigations. These infants have
a significantly increased risk of neonatal mortality and m orbidity and
may have long-term sequelae. A ppropriate timing of delivery is of
param ount importance. This condition is dealt with in detail, in chapter
nine.

Pre-eclampsia
Pre-eclampsia is associated with the following risk factors:
• Teenage pregnancies and advanced maternal age.
• Nulliparity.
• Past history of pre-eclampsia.
• Family history (m other or twin sister).
• Obesity.
• Lower socio-economic group.
• Inadequate prenatal care.

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 ANTENATAL CARE

• Medical conditions e.g. diabetes, sickle cell anaemia, chronic

renal disease.
• Current pregnancy with hydatidiform mole, multiple
gestation and triploidy.

Patients who have the above predisposing factors require regular

blood pressure assessments and urinalysis from about 24 weeks
gestation. Supplementation with calcium or low dose aspirin may
provide a certain degree of protection against pre-eclampsia.

Gestational diabetes
This is discussed in detail in chapter four. Screening is normally
performed at 28 weeks unless an indication exists to do so prior to this.
Risk factors include:
• Pregnancy itself since it is a diabetogenic state.
• Obesity and polycystic ovarian syndrom e. r
• First degree family history.
• Ethnic group (more com m on am ongst East Indians and
Asians).
• Advanced maternal age and high parity.
• Past obstetric history - recurrent miscarriages, unexplained
stillbirths, macrosomia, traumatic vaginal deliveries (e.g.
shoulder dystocia), and certain congenital abnormalities.
• Current pregnancy - persistent glycosuria, uterus is “ large-
for-dates” suggestive o f polyhydram nios or macrosomia,
recurrent vaginal candidiasis, and early- onset pre-eclampsia.

Preterm labour
Predisposing factors are:
• Teenage pregnancies.
• Low socio- economic conditions.
• Poor prenatal care.
• Drug addiction and sexually transmitted diseases.
• Past history of preterm labour, congenital uterine
abnormalities including cervical incom petence.
• Multiple pregnancy.
• Polyhydram nios and preterm rupture o f the m embranes.
• Subclinical infections in the genital tract e.g. Chlamydia,
M ycoplasma hominis and G roup B beta haemolytic
streptococci.

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 ANTENATAL CARE

• Maternal illness e.g. pyelonephritis.

Educate these women on the early signs of preterm labour. These

include:
• Changes in Braxton Hicks contractions, which become more
regular.
• Abdominal cramping.
• Low backache.
• Pelvic pressure or heaviness.
• Increase in vaginal discharge especially blood-tinged or
mucoid.

CONCLUSION
Antenatal care is all about management and planning. One of its, crucial
roles is risk assessment. It is important to rem em ber that the actual
pattern of care may be less significant to the woman than the attitudes
and efficiency of those providing it. Delegation of responsibility must be
backed up by trust and support as well as a high standard of
perform ance as demonstrated by clinical audit.

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 ANTENATAL CARE

KEY POINTS

• Risk assessment is a crucial element of antenatal care.

• The ideal time for the booking visit is 8 to 14 weeks.
• The EDD can be calculated from the LMP using Naegele’s rule.
• Accurate dating is essential as it allows for the planning of routine
follow up, screening tests and ultimately the time of delivery.
• Routine booking blood tests include a full blood count,
haemoglobin electrophoresis, group and rhesus, antibody screen
and screening for some infections such as syphilis.
• Antenatal care should be individualized to the requirements of the
mother and fetus.
• High-risk patients should be under the care of an obstetrician.
• A small group of pregnant woman may benefit from joint care
with the obstetrician and a specialist internist. This may include
patients with cardiac disease, seizure disorders, diabetes mellitus,
hypertension and sickle cell disease.

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 BONY PELVIS

CHAPTER TWO

THE BONY PELVIS

INTR O D U C TIO N
It is of great importance for the student in Obstetrics to know the
m orphology of the pelvis in detail. It is the platform from which a more
detailed understanding of female pelvic anatom y can be developed and it
is fundam ental to the com prehension of the mechanics o f labour.

No diagrams, however clear, can replace the actual specimen to

facilitate a thorough understanding o f the structural arrangem ent o f the
pelvis. It is recom m ended that an articulated specimen o f the pelvic
bones be used when reading this chapter.

THE PELVIC BONES

The four bones of the pelvis are the two hip bones (innom inate bones or
os coxae), the sacrum and the coccyx. The hip bone is form ed from the
fusion of three bones: the ilium, the ischium and the pubic bone (Figure
1 ).

The Ilium
The parts of the ilium are the wings or alae and the body. The body
forms the superior two-fifths of the acetabulum. The following
landm arks should be identified on the ilium:
• iliac crest: it can be palpated beneath the skin throughout its entire
length.
• anterior end: anterior superior iliac spine
• posterior end: posterior superior iliac spine
• iliac tubercle
• iliac fossa

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 BONY PELVIS

• anterior inferior iliac spine

• arcuate line (part of the linea terminalis)
• iliopectineal eminence
• posterior inferior iliac spine
• greater sciatic notch
• auricular surface
• iliac tuberosity

The Ischium
It is subdivided into the body and the ramus. The superior extremity of
the body form s the postero-inferior part of the acetabulum . The
following landmarks should be located:
• ischial tuberosity with its falciform line
• lesser sciatic notch
• ischial spine
• greater sciatic notch
• obturator foramen

Figure 1. Medial View of the right hip bone

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 BONY PELVIS

The Pubis
The parts o f the pubis are the body and two rami (superior and inferior).
The following landm arks should be located:
• symphyseal surface
• pubic crest
• pubic tubercle
• pecten pubis
• iliopectineal eminence
• obturator crest
• obturator groove
• acetabulum: lunate surface
fossa acetabuli
acetabular notch

The Sacrum
The sacrum form s the base o f the vertebral colum n and is located
between, and firmly connected with, the two hip bones. In the adult, it is
form ed from fusion of the five sacral vertebrae.

The following landmarks should be identified on the pelvic surface:

• sacral prom ontory
• four transverse lines
• four paired pelvic sacral foram ina
• pars lateralis

The following landmarks should be identified on the dorsal surface:

• median sacral crest with spinous process
• sacral hiatus bounded by sacral cornua
• interm ediate sacral crest
• lateral sacral crest
• sacral canal

The C occyx
It is form ed from the fusion o f four coccygeal vertebrae.

TH E PELVIC JOINTS

The sacro-iliac joints

These are synovial joints that are form ed by the articulation between the
irregular auricular surfaces of the sacrum and ilium, which are covered

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 BONY PELVIS

by cartilage. Slight movements are possible which increase in range

during pregnancy due to the ligaments becom ing softened under
horm onal influences.
The ligaments of these joints are:
• The ventral sacro-iliac ligament.
• The dorsal sacro-iliac ligament is thick and strong and transmits
the weight of the trunk to the lower limbs.
• The interosseous sacro-iliac ligament is the strongest of the three
ligaments.

In addition, there are three other strong ligaments that connect the hip
bones with the vertebral colum n. These are:
• Sacro-tuberous ligament. This passes from the posterior end of
the iliac crest, the sacrum and the coccyx to the ischial tuberosity
and sends a thin extension along the ramus o f the ischium
(falciform process), which forms the medial boundary o f the
pudendal canal.
• Sacro-spinous ligament. This passes from the sacrum and coccyx
to the ischial spine and separates the greater from the lesser sciatic
foram en. The weight of the trunk applies a downward force on
the upper part of the sacrum. This is resisted by both the sacro-
tuberous and sacro-spinous ligaments.
• Ilio-lumbar ligament. This is a strong triangular ligam ent
between the fourth and fifth lum bar vertebrae and the iliac crest.
It is an im portant structure as it prevents the fifth lum bar vertebra
from falling into the pelvic cavity under the weight o f the trunk.

Symphysis pubis
This is a secondary cartilaginous joint that is form ed by the articulation
between the symphyseal surfaces of the left and right pubic bones. The
pubic symphysis is shorter and broader in the female than in the male.
The interpubic disc is a fibro-cartilaginous plate, which is thicker in
the female than in the male. It is adherent to the hyaline cartilage
covering the symphyseal surfaces of the pubic bones. In its postero-
superior part a slit-like cavity develops near puberty. This cavity is not
lined by synovial membrane and is usually larger in the female than in
the male.
The ligaments of the pubis are (a) the superior pubic ligament
which extends laterally along the pubic crest as far as the pubic tubercle,
medially blending with the interpubic disc and (b) the arcuate pubic
ligament, which is a thick band o f fibres between the inferior pubic rami,

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 BONY PELVIS

also inseparably connected with the interpubic disc. No appreciable

movement normally takes place. During pregnancy the cartilage
becomes softer and the pelvis can be tem porarily enlarged.
The obturator m embrane o f the hip bone is not connected with any
joint. A notch on its supero-posterior border form s with the obturator
groove of the pubic bone, the obturator canal, through which pass the
obturator vessels and nerve from the pelvis into the thigh. From its
pelvic surface originates the internal obturator muscle and from its outer
surface, the external obturator muscle.
The lumbo-sacral joint
This is a secondary cartilaginous joint with a massive intervertebral disc
found between the bodies o f L5 and S I . Its ventral m argin is just above
the sacral prom ontory. There are synovial plane joints between the
inferior articular processes o f L5 and the superior articular processes of
S I.

The sacro-coccygeal joint

This is a secondary cartilaginous joint. It is an articulation between the
body and cornua of S5 and those o f the first coccygeal vertebra. The
intervertebral disc is small. Backward and forward movements o f the
coccyx on the lower end o f the sacrum are possible. The backward
movement is increased during labour at the time o f the passage o f the
fetal head.

THE PELVIC PARTS

The pelvis is subdivided by the terminal line into the false pelvis and the
true pelvis. The false pelvis consists mainly o f the iliac fossae and is of
m inor clinical im portance.
The true pelvis, which is o f great im portance in Obstetrics, is
bounded above by the pelvic inlet and below by the pelvic outlet. In
between the inlet and the outlet, is the pelvic cavity.

Pelvic inlet
The pelvic inlet or pelvic brim is demarcated by a line from the superior
border o f symphysis pubis, the pubic crest and tubercle, the pecten pubis,
the arcuate line, the superior border of the ala o f the sacrum and the
sacral prom ontory.

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Pelvic cavity
This is a curved canal with a shallow anterior wall (about 5 cm) form ed
by the symphysis pubis and bodies of the pubic bones and a deep
concave posterior wall (about 10 cm) formed by the sacrum and coccyx.
Its lateral walls are formed by the pelvic surfaces o f the lower part of the
ilium, the ischium and rami of the pubic bones.

Pelvic outlet
This is rhom boid in shape and can be considered as being com posed of
two triangles with a common base: the line connecting the two ischial
tuberosities. The anterior triangle has as its apex the lower-most point of
the symphysis pubis, and the sides are form ed by the bones form ing the
pubic arch. The posterior triangle has as its apex the tip o f the coccyx
and its sides are form ed by the sacro-tuberous ligaments.

It is important to note the following points when the subject is in the

erect (anatomical) position:
• the anterior superior iliac spine is in the same frontal plane as the
pubic tubercle.
• the anterior superior iliac spine, the posterior superior iliac spine
and the spine of the second sacral vertebra are in the same
horizontal plane.
• the pubic crest, the head of the femur, the tips o f the greater
trochanters and the coccyx are in the same horizontal plane.
• the plane of the pelvic inlet forms an angle of 55°-60° with the
horizontal plane. Depending on the degree o f lum bar lordosis
this angle of inclination is either increased or decreased. When
the inclination is high, the presenting part of the fetus does not
readily engage despite normal size and shape of the pelvic inlet
and the absence of disproportion between the size of the fetal
head and that of the pelvic inlet.

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 BONY PELVIS

PELVIC D IA M ETER S

Pelvic inlet
(Figure 2)
• The true conjugate is the distance between the m idpoint o f the
sacral prom ontory and the center o f the upper border of the
symphysis pubis (11.5 cm).
• The obstetric conjugate is the distance between the m idpoint of
the sacral prom ontory and the posterior surface o f the sym physis
pubis. The diam eter is of practical im portance, since it is the
smallest sagittal diam eter o f the pelvic canal. It is about 5m m less
than the true conjugate.
• The oblique diam eter is the distance between the upper border o f
the sacro-iliac joint and the ilio-pectineal em inence o f the
opposite side (12.5 cm). The right oblique diam eter starts from
the right sacro-iliac joint and the left from the left joint.
• The diagonal conjugate is the distance between the lower border
o f the sym physis and the sacral prom ontory (13 cm). It is not
exactly a m easurem ent o f the pelvic inlet, but it is m easurable per
vaginam and it gives an indication o f the size o f the true
conjugate, which is 1.5 - 2.0 cm less than the diagonal conjugate.
• The transverse diam eter is the greatest transverse m easurem ent o f
the pelvic inlet (13 cm). It divides the pelvic inlet into a fore­
pelvis and hind-pelvis.

Figure 2. Diameters of the pelvic inlet

1. Obstetric Conjugate
2. Right Oblique
3. Transverse

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 BONY PELVIS

Pelvic cavity
• The antero-posterior diam eter is the distance between the junction
o f the second and third sacral vertebrae and the centre o f the
posterior surface of the sym physis pubis (12.5 cm ).
• The transverse diam eter is the greatest transverse m easurem ent o f
the pelvic cavity (12.5 cm).
• The oblique diam eter is the distance between the lower margin o f
the sacro-iliac joint and the centre of the opposite obturator
m em brane (13.0 cm).

Pelvic outlet

Figure 3. Diameters of the pelvic outlet

1. Antero-posterior
2. Transverse
3. Ischial tuberosity
4. Sacro-tuberous ligament

• The antero-posterior diam eter is the distance between the lower

border of the symphysis pubis and the tip o f the coccyx. It can
be enlarged during parturition from 10 cm to 12.5 cm by the
backward movement of the coccyx at the sacro-coccygeal joint.
• The transverse diam eter is the distance between the inner surfaces
of the ischial tuberosities (11.5 cm). The transverse diam eter

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 BONY PELVIS

between the ischial spines (10.5 cm ) is sm aller than the transverse

diam eter between the ischial tuberosities and is th erefo re o f more
practical im portance.
• The oblique diam eter is the distance between the m iddle o f the
sacro-tuberous ligam ents and the junction o f the ram i o f the
ischial and pubic bones o f the opposite side (1 2 .0 cm ).

The greatest diam eter o f the pelvic inlet is transverse (1 3 .0 cm );

in the mid-cavity it is oblique (13.0 cm ), and in the pelvic outlet it is
antero-posterior (12.5 cm ).

This arrangem ent explains the m echanism o f internal rotation o f

the fetal head during its passage th ro u g h the pelvic cavity (the fetal head
tends to occupy the widest diam eter o f the pelvis).

O ther dim ensions o f im portance in O bstetrics are:

• The plane o f the greatest pelvic dim ensions is the plane that
passes through the m iddle o f the sym physis pubis and the
junction between the second and third sacral vertebrae. It is the
widest part o f the pelvic cavity.
• The plane o f the least pelvic dim ensions is the plane that passes
through the lower border o f the sym physis pubis, both ischial
spines and the lower b o rd er o f the sacrum . It is the narrow est
part o f the pelvic cavity.
• The subpubic angle can be assessed vaginally and is the distance
between the points o f the inferior pubic rami at 2 cm fro m the
lower border o f the sym physis pubis. From an O bstetrical point
o f view, a satisfactory subpubic angle should be about 8 5 -9 0 °. A
narrow angle is a com m on cause o f difficult lab o u r at the pelvic
outlet. D ifficulty in the extension o f the fetal head u n d er the
pubic arch forces it to move backw ard toward the coccyx, in this
way exerting more pressure on the perineum and increasing the
chance of perineal laceration.

The five critical m easurem ents o f the pelvis which can influence the
progress o f labour are the:
• true conjugate.
• transverse diam eter o f the pelvic inlet.
• diam eter between the ischial spines.
• plane o f the least pelvic dim ensions.
• subpubic angle.

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 BONY PELVIS

PELVIC AX IS V E R SU S T H E A X IS OF TH E BIR TH C A N A L
Many authors consider these two terms as synonym ous. However, by
definition, they should be different.

The pelvic axis is constructed through the centres o f the pelvic

inlet and outlet and any interm ediate plane o f the pelvic cavity and it is
represented by an im aginary curved line corresponding to the curve o f
the sacrum.

The axis of the birth canal is o f m ore practical im portance, since

it indicates the course taken by the fetal head in its passage th ro u g h the
pelvic cavity. It is a straight line perpendicular to the plane o f the pelvic
inlet until it reaches the level o f the ischial spines, where it m akes a right-
angled turn forward at the utero-vaginal angle. It therefore changes
from a dorso-inferior into a ventro-inferior direction, bringing the
descending fetal head into the axis o f the pelvic outlet, which roughly
corresponds to the centre o f the vagina. This change o f direction is
caused by the sloping pelvic diaphragm , attached to the lateral wall o f the
pelvis at the level of the ischial spines, and by the forw ardly-directed
vagina.

PELVIC - TYPES

The four parent types o f pelvis (Figure 4), as described by Caldwell in

1940, are:
• G ynaecoid (true fem ale type)
• A ndroid (male type)
• A nthropoid type
• Platypelloid type (flat pelvis)

Gynaecoid type:
• The pelvic inlet is slightly oval transversely and alm ost round.

Android type:
• The pelvic inlet is heart-shaped. The anterior segm ent is rather
triangular.
• The pelvic cavity is conical: “ fu n n el-p elv is.”

Anthropoid type:
• The transverse diam eter o f the pelvic inlet is less than the antero­
posterior one.

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 BONY PELVIS

• It is oval antero-posteriorly.
• The lateral walls of the pelvis are straight.
• The subpubic arch is narrow.

Platypelloid type:
• The antero posterior diam eter of the pelvic inlet is narrow while
the transverse diameter.
• subpubic arch is wide
• sacral prom ontory can be felt per vaginam .
•

Figure 4. The four parent types of the pelvic inlet.

Anthropoid Platypelloid

PELVIMETRY
Pelvimetry refers to the assessment of the adequacy o f the pelvis by the
m easurem ent of various param eters for the purpose o f predicting the
course of labour. It is an essential aspect of antepartum care and its aims
are:
• To prevent a prolonged and difficult labour.
• To select patients for trial of labour.

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 BONY PELVIS

• To assure the patient o f the likelihood o f a vaginal delivery.

The findings obtained by pelvimetry should always be considered in
conjunction with:
• an estimate of the fetal size.
• the presence of m alpresentation e.g. breech
• the presence of m alposition e.g. occipito-posterior
• the presence of congenital anom alies e.g. hydrocephalus
• the patient’s Obstetric history
• the presence o f a uterine scar.

Methods
Pelvimetry can be achieved by clinical exam ination or im agery such as
X-ray, CT or MRI.

Clinical pelvimetry is done routinely on all prim igravidae in the

antenatal clinic at the patien t's first visit (booking) during the first
trimester o f pregnancy. There is little evidence to support this practice
however.

If the patient first presents beyond the 14lh week or if assessment at

booking was unsatisfactory, clinical pelvimetry is deferred until 38
weeks. At this time, the procedure is easier to perform because o f the
relaxation o f the pelvic ligam ents and muscles.
A vaginal exam ination is perform ed to determine:
• W hether or not the sacral prom ontory can be tipped. The
distance between the lower border o f the sym physis pubis and the
sacral prom ontory is called the diagonal conjugate diam eter and
it normally measures 12.0 - 13.0 cm. In a norm al pelvis
therefore, the sacral prom ontory cannot be reached (Figure5).
• The transverse diam eter o f the inlet. The norm al value is 13 cm
and one should not be able to abut the lateral extrem ities
simultaneously on digital exam ination.
• The concavity of the sacrum. Normally there will be a wide sacral
bay. If the sacral bay is flat, rotation of the head in the mid-cavity
is prevented and deep transverse arrest occurs.
• The slope o f the side walls o f the pelvis.
• The prom inence o f the ischial spines. If unduly prom inent, arrest
of labour may occur at this level (station zero).
• The width o f the sacro-spinous ligam ents. These should
norm ally accom m odate 2 fingers. Provided there are two sacral
alae this gives an indirect assessment of the interspinous diam eter.

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 BONY PELVIS

• The angle of the subpubic arch. This should almost be a right

angle (90°). If the subpubic arch is narrow (< 80°), the head is
displaced posteriorly during delivery at the outlet of the pelvis,
and may cause perineal lacerations.
• The bituberal diameter. The knuckles of the fist are pressed
against the perineum between the two ischial tuberosities. If the
fist is accommodated, then the outlet is considered room y. The
bituberal diameter measures about 11.0 to 11.5 cm.

X-ray or CT pelvimetry may be perform ed when there is doubt about

the adequacy of the pelvis from clinical examination and in those
patients where it is necessary to measure the dimensions of the pelvis
accurately. The procedure is best done during the latter weeks of
pregnancy.
Indications include:
• Previous prolonged or obstructed labour ending in an
instrumental or abdominal delivery.
• Unexplained death of the fetus occurring during the intrapartum
or early neonatal period, in a previous confinem ent.
• Primigravidae with a breech presentation (almost always the mode
of delivery would be abdominal).
• Contracted pelvis suspected clinically.
• High head at term.
• Previous Caesarean section in a patient who has never had a
vaginal delivery. For example, a Para 1+0 who was delivered
abdominally, say for placenta praevia, can have a radiological
pelvimetry to assist in determining the mode of delivery on this
occasion.

Figure 5. Diameters at the

inlet
T.C. = True conjugate
O.C. = Obstetric conjugate
D.C. = Diagonal conjugate

34
 BONY PELVIS

Views taken:
• An erect lateral view is the most useful. An isometric scale is
placed between the buttocks and is included in the film. It
provides the following information:
■ The obstetric conjugate.
■ The inclination of the brim.
■ The shape of the sacrum.
■ The width and shape o f the sacro-sciatic notch.
• An antero-posterior view of the brim to determine:
■ The shape of the inlet.
■ The A-P and transverse diameter of the pelvic brim.
■ The inter-ischial diameter.
■ Convergence of the lateral pelvic walls.

TRIAL OF LABOUR

Definition
A trial of labour is one in which labour is allowed to proceed in a
primigravida with suspected cephalopelvic disproportion at the pelvic
brim, with the head not engaged, with readiness for Caesarean section,
and with careful frequent assessment to determine the signs o f progress
of labour, maternal distress and fetal distress.

Progress of labour is determined by the descent of the presenting part

and dilation and effacement of the cervix. It is ascertained by periodic
vaginal examinations done under sterile conditions.

Advantages
The advantages of a trial of labour are twofold. Firstly, the Caesarean
section rate is reduced. Secondly, a successful trial guarantees that the
patient may have a vaginal delivery on the next occasion, providing that
other factors remain the same. In contrast, a failed trial implies future
abdominal deliveries for the patient.

Disadvantages
In an attempt to secure a vaginal delivery in the woman with a borderline
pelvis, one may be subjecting the fetus and the m other to unnecessary

35
 BONY PELVIS

stress. Hypoxia may adversely affect the fetus* and intracranial

haem orrhage may occur. Furthermore, compared to elective Caesarean
section, trial of labour is associated with a higher perinatal and maternal
morbidity rate.

The conduct of a trial of labour

A trial of labour ought to be conducted in a tertiary health-care
institution, where facilities for blood transfusion and operative delivery
are available.
The patient should be starved and intravenous access established
with a wide bore cannula. A full blood count is perform ed and two units
of crossed-matched blood are requested. There should be continuous
CTG monitoring with an abdominal transducer or if possible, a scalp
electrode. The patient’s blood pressure, pulse rate and respiratory rate
are taken at half-hourly intervals and the urine is tested for ketonuria.
Once in established labour, progress may be determined by sterile
vaginal examination every 4-6 hours (earlier if any CTG abnorm ality).

As soon as the head becomes engaged (less than two fifths of the
head are palpable abdom inally), the trial is considered to be over but it is
useful to continue electronic monitoring o f the fetus.

The trial should cease if fetal distress occurs or if the mother

becomes dehydrated, ketotic and uncooperative (maternal distress) or if
there is little or no progress o f labour after 8-12 hours o f uterine
contractions.

It is important to avoid prolongation o f the first stage after the

membranes have ruptured because o f the risk o f chorioam nionitis and
should the patient require a Caesarean section, this will aggravate the
postoperative course. Persistence in aiming for a vaginal delivery at the
expense of securing a flat baby is bad Obstetric practice. Timely
intervention is called for and the senior Obstetric team must supervise
mothers undergoing a trial.

Contra-indications
• Elderly primigravidae (> 35 years).
• Malpresentation e.g. breech.
• Midcavity and outlet contraction.
• Pregnancy-induced hypertension.
• Diabetes mellitus.

36
 BONY PELVIS

• Cardiac and respiratory diseases o f the m other.

• Absolute cephalopelvic disproportion e.g. when the true
conjugate diam eter is less than 9 cm.
• Previous failed trial of labour.
• Presence o f a uterine scar.
• Fetal m acrosom ia.
• Bad obstetric history or a history of infertility.

KEY POINTS
• The true pelvis is bounded above by the pelvic inlet and
below by the pelvic outlet. In between the inlet and the
outlet, is the pelvic cavity.
• The majority of cases of disproportion occur at the
pelvic inlet.
• Rotation of the head occurs in the pelvic cavity. A flat
sacrum would imply a high risk of deep transverse
arrest.
• Pelvimetry refers to the assessment of the adequacy of
the pelvis by the measurement of various param eters for
the purpose of predicting the course of labour.
• Pelvimetry can be achieved by clinical exam ination or
imagery such as X -ray, CT or MRI.
• A trial of labour is one in which labour is allowed to
proceed in a primigravida with suspected cephalopelvic
disproportion at the pelvic brim, with the head not
engaged, with readiness for Caesarean section.

37
 ANAEMIA

CHAPTER THREE

ANAEMIA IN PREGNANCY

INTRODUCTION
Anaemia is probably the most frequently encountered medical
complication in pregnancy in developing countries. This condition is
still a major contributor to maternal mortality. In the West Indies, one
must be particularly vigilant, because the following conditions may exist:

• Pre-existing iron-deficiency anaemia or depleted iron stores at

the start of a pregnancy because o f nutritional deficiency,
parasitic infestation or m enorrhagia due to fibroids.
• Grandmultiparity with short interpregnancy intervals.
• H aemoglobinopathies, especially sickle-cell disease.

The com m on types o f anaemia seen in pregnancy are preventable com m o n typ e s of anaemia usually
v i • . i- . . , . , , , .. are treated with appropriate diet
with appropriate dietary manipulation and supplem entation. Ir anaemia
is diagnosed, then further testing to determine the cause is warranted. iSmln^mlSivepostpartum
Prompt correction o f the cause and treatment are m andatory. Anaemic “jSSidnsk ofinfection
patients are at a marked disadvantage in being unable to withstand 3. increased risk of dvt
significant blood loss such as postpartum haem orrhage. They are also at
an increased risk o f developing puerperal infection and deep venous
thrombosis. Puerperal: of, relating to, or occurring
during childbirth or the period immediately
DEFINITION following

The World Health Organisation (1972) defines anaemia in pregnancy as

a haem oglobin concentration of less than 11.0 g/dl. However, in
Trinidad as in some other Caribbean territories, a cut-off value o f 10.0
g/dl is used to define anaemia.

38
 ANAEMIA

HAEM ATOLOGICAL CH ANG ES IN PR EG NANCY

Pregnancy is a hyperdynam ic and hypervolaemic state. The plasma changeinpiasmavolume
volume increases from early in the second trimester and peaks at about
32-34 weeks gestation, with a tendency to plateau in the last 8 weeks. An
expansion of 1250-1500 ml is usually noted but in multiple gestations
an increase of 2000 ml is not unusual.

The red cell mass increases by about 400-500 ml (30 per cent) in Change in RBC

pregnancy as a result of accelerated erythropoiesis. The reticulocyte

count is noted to rise from about 16 weeks gestation and peak at 35
weeks.

A physiological anaemia results from this discrepancy in com bine effect of change (Physiological Anaemia)

increments of plasma volume and red cell mass. It occurs most

commonly at 28-32 weeks gestation. The haem oglobin may fall to
9.0g/dl. Oxygen delivery to the feto-placental unit is not com prom ised at
these levels of haem oglobin, as there is a concurrent rise in maternal red
cell 2, 3-diphospho-glycerate. This facilitates oxygen transfer to the
fetus.

CLINICAL FEATURES
Symptoms would include:
• lethargy
• shortness of breath
• palpitations
• chest pain
• headaches
• dizziness and fainting

Signs would include:

• pallor
• tachycardia
• soft ejection systolic m urm ur
•

AETIOLOGY
• Nutritional deficiencies:
S Iron deficiency
S Folic acid deficiency

39
 ANAEMIA

S Vitamin B ]2 deficiency

• Physiological anaemia
• Haemoglobinopathies:
S Sickle cell anaemia
S Thalassaemia syndromes
• Chronic disease such as renal failure
• Aplastic anaemia
• Haemolytic anaemia:
S Auto-im mune haemolytic anaemia
S Systemic lupus erythematosus
• Leukemia/lymphoma

IRON DEFICIENCY ANAEM IA

Most common haematological issue

The commonest haematological problem in pregnancy is anaemia
is pregnancy is iron deficiency resulting from iron deficiency. The bulk of iron in the body is
10% of iron is absorbed from daily contained in the haem oglobin of circulating and developing red cells
intake
and iron exchange is both extremely limited and precisely regulated.
Absorption takes place at the
duodenum and proximal jejunum (DJ)
The iron content of the body is controlled largely by a limited variation
Ferric iron is converted to Ferrous iron
in absorption and not by excretion. The average diet contains 10 to 15
mg iron of which 10 per cent is absorbed. Most o f the absorption occurs
in the duodenum and proxim al jejunum and is aided by gastric acid,
which converts the ingested ferric iron to the more soluble ferrous form.

When iron storage is low or depleted Iron absorption is increased when iron stores are depleted, e.g.
there is a increase in transferrin
(iron transporter) to aid in uptake o f iron
when there is a low ferritin level and a high concentration of unsaturated
Erythroid hyperplasia occurs to try
transferrin and also when there is erythroid hyperplasia with a rapid iron
and maintain RBC levels turnover.

There are 2 distinct pathways for iron absorption, viz one for
inorganic and the other for haem iron. In most foods inorganic iron is
in the ferric form and it has to be converted to the ferrous form before
2 Pathways fo r iron absorption:
absorption can take place.
1. Haem (meat) - easy uptake
2. Inorganic (plants) - need converting
In grains, iron forms a stable complex with phytates and only
Phytates prevent iron absorption
limited amounts of iron are absorbed. Similarly poor absorption o f iron
in eggs occurs because the iron is bound to phosphates. Milk is poor in
iron content. Haem iron derived from haem oglobin and m yoglobin o f
animal origin is more effectively absorbed than non-haem iron. Haem

40
 ANAEMIA

iron also prom otes the absorption of inorganic iron. Populations from
the underdeveloped parts of the world subsist largely on non-haem iron
and its poor availability explains the prevalence of iron deficiency.

The increased demand for iron in pregnancy is about 1000 mg.

This is shown by a simple accounting exercise below. During pregnancy
there is an average requirem ent of 4 mg per day, rising from 2.5 mg in
early pregnancy to 6.6 mg per day in the last trimester. This dem and
arises from the increase in red cell mass and the requirem ents o f the fetus
and placenta. The fetus receives its iron from the maternal serum by
active transport across the placenta, mainly in the last 6 weeks of
pregnancy.

D ebit C redit

F etus and p la c e n ta = 500 m g B lo o d sa v ed fro m

Red c e ll m a s s = 500 mg 4 0 w e e k s p erio d
B lo o d lo s s at d e liv e r y = 180 m g o f am enorrhoea =
L actation= 180 m e 360 mg
1360 m e 360 m e

Investigation of patients with iron-deficiency anaemia requires a Thing to take note of:
Gynae Hx
detailed history. In the past gynaecological history, fibroids may be the 1. Fibroids - Menorrhagia & depleted stores
cause of m enorrhagia and depleted iron stores. In the obstetric history, O bsH x
high parity especially with little spacing of births or haem orrhage 1. Little spacing of children
2. Hemontiage with child bearing
complicating those pregnancies and multiple pregnancy may decrease 3. Haemorrhoids
4. Parasitic infestation
serum ferritin and thus predispose to anaemia. Chronic blood loss e.g. 5. Celiac disease
haemorrhoids or parasitic infestation (hookworm s) and past history of 6. Taking supplements as advice

gastric surgery or coeliac disease arc significant. It is also im portant to

ascertain whether there has been good compliance with iron supplements
and dietary advice.

Diagnosis
The haemoglobin, all the blood indices (MCV, MCH, MCHC), serum CBC
ferritin and serum iron will be low while the total iron binding capacity 1. Decrease in Hb indices

(TIBC) will be high. Serum ferritin assesses iron stores. Ferritin is stable Iron Investigations
1. Decrease in serum ferritin
and not affected by recent ingestion o f iron and in the developm ent of 2. Decrease in serum iron
3. Increase in TIBC
iron deficiency a low serum ferritin is the first abnorm al laboratory test.
Serum iron even in combination with TIBC is not a reliable indication o f Stool
1. Occult stool
iron stores because it fluctuates widely and is affected by recent ingestion 2. Ova
3. Cyst

Urine
1.Urine microscopy

Blood Film
1. Microcytic
2. Hypochromic
41 Remember serum ferritin is an
acute phase reactant and will
elevate in cases of inflammation
 ANAEMIA

of iron and other factors such as infection. With iron deficiency

anaemia, urine for microscopy and stools for occult blood and ova, cyst
and parasite should be included in the battery o f tests required.
Sometimes a bone marrow aspirate for iron is perform ed. The aspirate is
stained with Prussian blue. This is a rapid and reliable but invasive
method of assessing iron stores in pregnancy.

Iron deficiency results in a microcytic, hypochrom ic picture on a

blood film whereas folic acid and Vitamin B 12 deficiency give rise to a
macrocytic, megaloblastic anaemia.

Prevention of Iron deficiency

It is more economical to prevent iron deficiency than to treat anaemia.
Since, even in developed countries, many women have depleted iron
stores, iron supplem entation should be considered for all pregnant
women. Prophylaxis with oral supplementation of 60-120 mg per day of
elemental iron should commence at 16 weeks gestation when the nausea
and vomiting of early pregnancy have subsided.

Side effects with oral iron are rare, mainly mild gastric upsets and
constipation, which can be alleviated by, increased fluid intake and a
high fibre-diet.

Management
• The underlying cause must be treated.
• The treatment depends o f the severity o f the anaemia, whether
symptomatic (easy fatiguability. headache, palpitation, dyspnoea,
dizziness and syncopy) or not. It also depends on the period o f
gestation.
• All patients with severe anaemia (Hb 4 g/dl) require urgent
admission to hospital. These women are at high risk o f
developing cardiac failure. They require transfusion with packed
cells.
• The aim of treatment is to achieve a haem oglobin o f at least 10.0
g/dl at 40 weeks gestation. During the first week of treatment,
there is no rise in haem oglobin; only a reticulocytosis is
observed. From the end o f week 2, the haem oglobin increases by
approximately 1 g/dl per week. Thus, if the patient is at 30 weeks
gestation and the haem oglobin is 7.0 g/dl, iron supplem entation
would suffice. It is to be expected that the haem oglobin would
rise to 10.0 g/dl by 34 weeks. On the other hand, if the
haem oglobin is 7.0 g/dl at 38 weeks, transfusion with packed cells
would be required to raise the haem oglobin to 10.0 g/dl.

42
 ANAEMIA

• Parenteral iron (e.g. Venofer®) is reserved for patients who

cannot tolerate oral iron because o f the gastro-intestinal side
effects or for those who are not compliant with oral medication.
The rate of rise of haem oglobin is slightly faster than that seen
with oral iron. The amount o f parenteral iron required to correct
the anaemia can be calculated by subtracting the patient’s Hb
level from a '‘n o rm a l” level of 13 g/dl and multiplying this result
by 0.25 to obtain the dose o f iron required. For exam ple, a
m other with an Hb of 7.0 g/dl will require (13-7) x 0.25 which
equals 1.5 g of Iron.

FOLIC ACID DEFICIENCY

At a cellular level folic acid is reduced to dihydrofolic acid and then to
tetrahydrofolic acid, which forms the cornerstone of cellular folate
metabolism. It is required for cell growth and cell division. The more
active a tissue is in reproduction and growth, the greater is the
requirement for folate co-enzymes. Thus it is not surprising that there is
a greater need for folic acid in pregnancy, to meet the requirem ents of
the fetus, placenta, uterus and maternal red cell mass. The placenta
transports folate actively to the fetus.

Foods that are very rich in folate include leafy vegetables such as
spinach, but up to 90 per cent of their folate is lost with boiling and
steaming. Other rich sources are avocados and bananas.

Dietary inadequacy com pounded by frequent childbirth and

multiple pregnancy explains the high incidence of megaloblastic
anaemia from folic acid deficiency seen in many Third World countries.
Anticonvulsant therapy, in particular phenytoin and phenobarbitone,
interferes with folic acid absorption. Haemolytic anaemia such as
haemoglobinopathies (sickle cell disease and thalassaemia) also increases
the demand for folic acid.

Peri-conceptional folic acid supplements decrease the incidence

of neural tube defects and possibly harelip and cleft palate as well.

Diagnosis
Macrocytosis as evident in a raised MCV is one of the hallmarks o f folic
acid deficiency. The blood film may show hypersegm entation of
polymorph neutrophils. Red blood cell folate is superior to plasma

43
 ANAEMIA

folate levels as a confirm atory test. A stained bone marrow aspirate will
reveal megaloblastic changes.

Treatment
Prophylaxis of 200-300 meg folic acid daily should be administered to
all pregnant women. It is mandatory in grand multiparas, patients with
previous abruptio placentae and with multiple pregnancy.

Once megaloblastic haematopoiesis is established treatment with

folic acid (5 mg daily) should be com m enced immediately and
continued for several weeks after delivery.

VITAM IN B 12 DEFICIENCY IN PR EG N A N C Y
Vitamin B12 deficiency is uncommon in pregnancy except in strict
vegans who will not eat any animal-derived foods. Addisonian
pernicious anaemia does not usually occur during the reproductive
years. Vitamin B I2 deficiency is associated with infertility. A low serum
vitamin B12 level confirm s the diagnosis. The recom m ended intake of
vitamin B12 is 3.0 meg per day. Treatment o f Vitamin B12 deficiency is
with weekly intramuscular injections of cyanocobalam in.

HAEMOGLOBINOPATHIES
The haem oglobinopathies are inherited genetic defects of haem oglobin,
resulting from impaired globin synthesis (thalassaemia syndrom es) or
from structural abnormality of globin (haem oglobin variants such as
sickle cell disease).

The haem oglobin molecule consists of four globin chains each o f

which is associated with a haem com plex. There are three normal
haem oglobins in man, Hb A ( a 2 P2), Hb A2 ( a 2 62) and Hb F ( a 2 y2)-
The synthesis of the a - chains is under control o f 4 genes (2 derived
from each parent) situated on chromosome 16 while the developm ent of
the a , 5 and y chains are controlled by 2 genes (1 derived from each
parent), which are located on chrom osom e 1 1.
In thalassaemia, the synthesis of one o f these globin chains is
defective whereas in sickle cell disease, valine replaces glutamic acid at
position 6 on the (3-chain. In the form er condition, the red blood cells
have inadequate haem oglobin, whereas in the latter (i.e. sickle cell
disease) these red blood cells may undergo sickling in response to
hypoxia.

44
 ANAEMIA

Thalassemia
The only com m on thalassaemic syndrom es seen in pregnant women in
the Caribbean are a - and (3-thalassaemia m inor. Individuals with
Southeast Asian ancestry are at an increased risk for offspring with Hb
Bart's or Hb H disease. H aemoglobin H disease is usually associated with
mild or moderate anaem ia. Alpha-thalassaemia m ajor (Hb Bart) results in
the absence o f a -globin; this is associated with hydrops fetalis,
intrauterine death, and pre-eclampsia.

The diagnosis of |3-thalassaemia, which is caused by a mutation in

the p-chain production, is suspected because of the low haem oglobin and
low MCV and MCH and a relatively normal MCHC. Target cells are
seen in a blood film. The confirm atory test is haem oglobin
electrophoresis, which shows a raised Hb A2 concentration with or
without a raised Hb F.

Women with beta thalassaemia m inor require the usual oral iron
and folate supplem ents in the antenatal period. Oral iron for a limited
period will not result in significant iron overload, but parenteral iron
should never be used. If the serum ferritin is high in early pregnancy,
then iron supplem ents should be withheld.

Genetic screening can identify couples at risk for offspring with

haemoglobinopathies and allow them to make inform ed decisions
regarding reproduction and prenatal diagnosis. If both parents are
determined to be carriers, genetic counselling is recom m ended. Some o f
the investigations that should be considered in the w ork-up o f
thalassaemia include complete blood count, blood indices, haem oglobin
electrophoresis and sometimes DNA-based tests.

The course of pregnancy in women with a -thalassaemia trait is

not significantly different from that o f women with norm al
haemoglobin. Pregnancy outcom e is favourable in women with |3-
thalassaemia minor. There is a possible risk o f oligohydram nios and
IUGR. Pregnancy in women with P-thalassaemia major is recom m ended
only with those with normal cardiac function who have had prolonged
hypertransfusion therapy to maintain normal haem oglobin levels.
During pregnancy, haem oglobin levels are kept at or near lOg/dl with
blood transfusion. Desferroxamine is usually discontinued because the
safety of iron chelation in pregnancy has not been established. The

45
 ANAEMIA

mode of delivery should be individualized, with Caesarean section

usually reserved for obstetric indications.

Sickle cell disease

The term sickle cell disease covers a group o f conditions in which the
pathology may be attributed to the presence o f sickle haem oglobin. The
four principal genotypes of sickle cell disease are:
• SS disease
• SC disease
• S-thalassaemia
• Sickle cell trait

H om ozygous sickle cell disease (SS disease) is the most severe form
while sickle cell trait is relatively innocuous except under hypoxic
conditions. Sickle cell trait (Hb-AS) occurs in about 10 per cent o f the
West Indian population. In these patients, approximately 30% o f the red
cells have the capacity to sickle.

The haem oglobin level in an SS patient is usually between 6.0

and 8.0 g/dl. The increase in 2, 3 diphosphoglycerate ensures adequate
off-loading of oxygen to the tissues despite the low haem oglobin. These
patients require folic acid supplementation to meet the dem ands o f
erythroid hyperplasia. If there is folic acid deficiency, the typical case
would demonstrate a haem oglobin markedly below steady state values
(usually, 4 g/dl) associated with a low reticulocyte count (2-6% ),
macrocytosis and a megaloblastic marrow. Peripheral blood films reveal
anisocytosis, poikilocytosis, macrocytes, large num bers o f nucleated red
cells and hypersegmented neutrophils. There may also be changes
consistent with iron deficiency.

The sickle cell trait (Hb-AS) causes few com plications in

pregnancy. Asymptomatic bacteriuria, haematuria, pyelonephritis and
chronic renal disease do occur. Patients with SC disease are at risk o f
painful crises and fulm inant pre-eclampsia.

Tests for Sickle Haemoglobin

A blood test for sickle cell anaemia is a routine procedure in the
antenatal clinic at booking. This test may be by an assessment of
sickling “in vitro” or more accurately by gel electrophoresis, which also
has the advantage of identifying the particular structural haem oglobin
variant present.

46
 ANAEMIA

• The sickle test. This depends on the m orphological change of

HbS containing red cells when deoxygenated. The standard
technique involves adding one drop o f a 2% sodium
metabisulphite solution to one drop of blood on a m icroscope
slide, which is then covered with a coverslip, and this is sealed with
paraffin wax to exclude air and prevent drying. M icroscopic
exam ination is done after 24 hours and the classical finding is
sickling.
• Gel electrophoresis. The principles of haem oglobin
electrophoresis at an alkaline pH are based on the change o f the
charge in a haem oglobin m olecule, which follows certain am ino
acid substitutions. The replacem ent by the neutral valine for the
negatively charged glutam ic acid in HbS results in one net
positive charge per chain. HbS therefore moves more slowly than
HbA. HbC moves even more slowly than Hb S.
%

Complications of SS Disease in Pregnancy

• A decreased fertility potential, attributed to a late m enarche, less
sexual exposure, anaem ia and chronic ill health.
• An increased risk o f spontaneous miscarriage.
• An increased incidence o f infections, notably pyelonephritis,
pneum ococcal pneum onia and possibly salm onella osteom yelitis,
and puerperal sepsis.
• An increased risk of throm bo-em bolism .
• An increased incidence o f pre-eclam psia.
• An increased risk of abruptio placentae.
• Preterm labour and intra-uterine growth restriction are more
com m on.
• Acute and chronic fetal distress.
• An increased risk o f stillbirth and thus, a higher perinatal
mortality rate.
• Maternal mortality rate, although increased, is less com m on
nowadays because o f im proved obstetric care.
• Crises are more com m on. These are discussed in m ore detail
below.

Painful Crisis
The painful crisis is one o f the most characteristic m anifestations of
sickle cell disease and the pain is felt in the extrem ities, back, abdom en,
or chest usually associated with fever and the passage o f dark or red

47
 ANAEMIA

urine. It is im p o r ta n t to k e e p in m in d th a t o n e o f th e d iffe r e n tia l

d ia g n o s e s o f a b d o m in a l p a in in p r e g n a n c y is a p a i n fu l c risis.

Precipitating factors for painful crises include:

• Infection, especially in the urinary tract and respiratory tract
• Pyrexia
• Hypothermia
• Acidosis and hypoxia
• Dehydration
• Emotional stress
• High altitude
• Smoking
• Excessive exercise
• Labour.

Management of painful crises:

• Admit to the Antenatal ward.
• Bed rest.
• Oxygen via nasal cannulae if the saturation is less than 95%.
• Reassurance.
• Investigations for infection: sputum for culture and sensitivity,
and midstream urine for microscopy and culture and sensitivity.
• Rehydration: increased fluid intake is recom m ended both orally
and with intravenous fluids of normal saline or H artm ann's
solution.
• Analgesics should be sufficient to control or alleviate the pain
and should not be excessive. Caution must be exercised with the
use of addictive drugs such as m orphine and pethidine. Mild
pain often responds to acetam inophen, and severe pain to
pentazocine.
• Limited exchange transfusion to reduce the concentration of HbS
to less than 30 per cent may be of use in severe or recurrent
crises.
• Broad spectrum antibiotics should be administered.
• If the period of gestation is beyond 30 weeks, a non-stress test is
indicated to determine fetal well-being.

48
 ANAEMIA

Acute Anaemia
This may arise from an aplastic crisis and less com m only from acute
splenic sequestration (seen mainly in the third trimester). Aplastic crisis
is a self-limited state but total arrest of erythropoietic maturation results
in an absence of reticulocytes and a rapidly falling haem oglobin level. It
may result from infection with parvovirus B19. The main clinical
features are listlessness, pale mucous membranes and an upper
respiratory tract infection. The treatment involves blood transfusion.
Spontaneous recovery of the marrow within 5 to 10 days is the norm.

Acute Chest Syndrome

The sudden onset of pleuritic chest pain, fever, dyspnoea and tachypnoea
consistent with either pneum onia or pulm onary embolism occurs
commonly in pregnancy. During a painful crisis, necrotic bone marrow,
fat, and even spicules of bone may embolise to the small vessels in the
lungs. Treatment is supportive therapy with blood transfusion, oxygen
and heparin.

Management of SS Disease in Pregnancy.

Antenatal management
• Early booking to the antenatal clinic.
• Joint care by Obstetrician and Haematologist.
• Folic acid and iron supplements.
• Repeated haem oglobin and renal function assessments, as well as
determination of HbS concentration.
• Consider partial exchange transfusion with HbA blood to keep
the level of HbS below 30 per cent.
• Antenatal diagnosis such as chorionic villus sampling,
amniocentesis or fetal blood assessment (i.e. cordocentesis).
• Fortnightly midstream urine for microscopy and culture and
sensitivity.
• Early ultrasound scan for accurate dating o f the pregnancy.
• Antenatal visits every 2 weeks up to 28 weeks gestation and then
weekly until delivery.
• Regular monitoring o f blood pressure and urinalysis for
proteinuria, which ensures early diagnosis of pre-eclampsia.
• In some places, a pneum ococcal vaccine or penicillin V
(penicillin prophylaxis) is administered in pregnancy.
• Assessment of fetal well-being with fetal kick charts, and
biophysical methods (such as non-stress test, Doppler studies and
biophysical profile) in the third trimester.

49
 ANAEMIA

• M onitoring o f fetal growth with maternal weight, serial

sym physio-fundal height, and if IUGR is suspected, ultrasound
measurements of biparietal diameter, abdom inal circum ference
and fem ur length.

• Admission to the antenatal ward for:

(a) Crises
(b) Pre-eclampsia
(c) IUGR
(d) Preterm labour
(e) Abruptio placentae
(f) Fetal distress
(g) Pyelonephritis
(h) Throm bo-em bolism .

Time and mode of delivery

Sickle cell disease is considered to be an indication for induction of
labour at 38-40 weeks gestation. Earlier delivery may be indicated with
some of the problems mentioned above. Caesarean section is required
for obstetric indications and sometimes for pelvic deform ity.

Intrapartum management includes oxygen, intravenous fluids,

adequate pain relief, active management of first stage o f labour,
continuous cardiotocographic m onitoring, and in the second stage, an
episiotomy and possible assisted delivery with outlet forceps.

Antibiotics may be warranted for postpartum pyrexia, which

com m only results from endometritis. Breast-feeding should be
encouraged. Neonatal diagnosis of sickle cell disease can be made with
agar electrophoresis of cord blood.

Contraception
Sterilization should be considered as a perm anent form o f contraception
for the patient with sickle cell disease, especially when no further
pregnancies are required. It is felt that the progestogen-only pill or
depot m edroxyprogesterone acetate offer effective alternative methods
of contraception. These do not increase the risk o f throm bo-em bolism .
The new low-dose combined oral contraceptive is a convenient,
acceptable and reliable method and it can be recom m ended to some of
these sicklers. The intra-uterine device is considered contraindicated
because of an increased susceptibility to infection but this is debatable.

50
 ANAEMIA

KEY POINTS

• Anaemia is the most frequently encountered medical

complication in pregnancy in developing countries.
• It is defined as a haemoglobin concentration of less
than 10.0 g/dl.
• Iron deficiency is the most common cause. Oral iron
therapy results in an increase in the haemoglobin of
approximately 1 g/dl per week after the second week.
• Patients with sickle cell disease should be prescribed
5mg of folic acid daily.
• Crises are more common in pregnancy and are
precipitated by infection, hypoxia, hypothermia and
dehydration.
• Intrapartum management includes oxygen,
intravenous fluids, adequate pain relief and
continuous cardiotocographic monitoring. An
instrumental delivery can be performed to shorten
the second stage of labour.

51
 DIABETES

CHAPTER FOUR

DIABETES IN PREGNANCY

INTRODUCTION
During the second half of the twentieth century great strides have been
made in the understanding o f the pathophysiology, diagnosis and
treatment of diabetes in pregnancy. Better control o f diabetes resulted
with the availability of insulin, which was discovered by Banting and Best
in 1921 in Toronto.

The greater awareness of the fetal com plications and the need for
immaculate control of blood glucose levels throughout pregnancy have
resulted in a significant fall in the perinatal mortality rate from 25% in
the 1950’s to less than 5% two decades later (Abell et al, 1976). The
increased requirem ent for insulin as pregnancy advances, the problems
of pyelonephritis, polyhydram nios, pre-eclampsia, preterm labour,
congenital abnormalities, sudden unexplained late stillbirths, fetal
macrosomia and hence the risks of shoulder dystocia and birth asphyxia
form the classic picture o f a diabetic pregnancy.

CLASSIFICATION
There are three types of diabetes seen in pregnancy:
• Type 1- Insulin Dependent Diabetes Mellitus.
• Type 1 1-Non-Insulin Dependent Diabetes Mellitus.
• Gestational Diabetes Mellitus.

Type 1
This usually occurs in the young patient (under 20 years) but no age
group is exempt. Most often the diagnosis of insulin-dependent diabetes

52
 DIABETES

will have been made before pregnancy, the patient presenting with weight
loss, polydypsia, and polyuria with glycosuria, hyperglycaem ia and a
tendency to ketoacidosis. Circulating insulin is usually absent, and thus
insulin therapy is necessary for m aintenance of well-being.

Type 11
This disease has an insidious onset. It usually occurs in older obese
patients who may have norm al fasting insulin levels. The insulin
secretion is inadequate to deal with hyperglycaem ia. This is largely due
to insulin resistance.

Gestational diabetes
Pregnancy is a diabetogenic state due to the presence of anti-insulin
factors (Table 1). These include hum an placental lactogen,
progesterone, prolactin and cortisol.

Table 1. Factors which oppose the action of insulin during

pregnancy
1. Human placental lactogen (Hum an chorionic
somatomammotrophin)
2. Prolactin
3. Cortisol
4. Glucagon
5. Progesterone
6. Placental insulinase

There is a tendency for elevation o f maternal blood glucose levels in Pregnancy is diabetogenic (increases the
probability to getting diabetes)
pregnancy. This effect is counterbalanced by an increase in insulin 1. Increase in material glucose
2. Body doubles insulin to deal with increasec
concentrations reaching almost twice non-pregnant levels (K uhl, 1975). maternal glucose
This rise is itself offset by increasing insulin resistance. The vast 3. Body increases resistance to increased
insulin to prevent hypoglycemia
majority of pregnant women m anage to maintain norm oglycaem ia, but •Occurs @ =>13 weeks or =>24 weeks
about 3-5% cannot do so, and they develop gestational diabetes (Abell *50% of individuals who get DM in pregnancy
will develop DM after 25 years
and Beischer, 1975). This abnorm ality o f interm ediary m etabolism of
carbohydrate (CHO) usually starts during the 2nd or 3rd trim ester and
disappears after delivery. The major change in CHO m etabolism during
pregnancy is a decreased sensitivity to insulin and this decreased
sensitivity increases as pregnancy advances. Pregnancy is therefore
diabetogenic. It is now recognised that as much as 50% o f gestational

53
 DIABETES

diabetics will develop overt diabetes after about 25 years (O 'Sullivan,

1984).

Table 2 shows the W hite's classification of carbohydrate intolerance in

pregnancy.
White’s Classification distinguishes between
pre-gestational diabetes and gestational
Table 2. White’s classification of carbohydrate intolerance in diabetes (Type A1 and A2) and state the
risks
pregnancy_____________ ____________________________
there has been modifications to the
Group Characteristics_______________________________________ classification:

Type A1: abnormal oral glucose tolerance

test (OGTT) BUT normal glucose after
A Asymptomatic diabetes by glucose tolerance tests fasting & 2hr meals
Type A2: abnormal oral glucose tolerance
test (OGTT) BUT abnormal glucose after
B Diabetes with onset after age 20, duration 0-9 years fasting & 2hr meals
Type E: overt diabetes m ellituswith calcified
pelvic vessels.
C Diabetes with onset ages 10-19, duration 10-19 years Type F: diabetic nephropathy.
Type R: proliferative retinopathy.
D Diabetes with onset before age 10, and duration 20 years Type RF: retinopathy and nephropathy.
Type H: ischemic heart disease.
or more Type T: prior kidney transplant.

E Diabetes with nephropathy

F Diabetes with retinopathy ______

SC R E E N IN G FO R G E ST A T IO N A L D IA BETES
The justification for screening for gestational diabetes is based on the
assumption that there is an increased m orbidity and mortality with this
condition. Early diagnosis and appropriate treatm ent o f gestational
diabetes can im prove the outcom e of the pregnancy.

Table 3. Screening tests_______________________________

1. Glycosuria
2. 50 g glucose screen (O ’Sullivan et al, 1973)
3. Random blood glucose (Lind, 1985)
4. Glycosylated haemoglobin
5. Serum fructosamine
6. Amniotic fluid and/or cord blood insulin levels
7. Formal Glucose Tolerance Test - gold standard.

54
 DIABETES

Glycosuria
Testing for glycosuria is universally perform ed in pregnancy. This test The proximal tubule can only reabsorb a limited
amount of glucose. When the blood glucose level
is simple, inexpensive and easy to perform but glycosuria may be present exceeds about 1 6 0 -1 8 0 mg/dl, the proximal
tubule becomes overwhelmed and begins to
despite normal blood glucose levels since the renal threshold for glucose excrete glucose in the urine. This point is called the
renal threshold of glucose (RTG).
may fall in pregnancy. In many centres, urinalysis for glycosuria is no
longer perform ed.

50 g glucose screen
The patient is given a 50 £ glucose load irrespective of the time of the Giveaptsogglucose.if plasmaglucoseis>7.8
. , i i i . i i i i - 1 1 1 r mmol/L is abnormal after 1hr
a
day or last meal and a blood glucose level is measured 1 hour after. A
venous plasma glucose o f > 7.8 mmol/L (> 140 mg/dl) is abnorm al and
the patient should have a form al glucose tolerance test. The false
positive rate with the 50g glucose screening test is 10-15 per cent.

Random blood sugar (RBS)

A plasma sample is taken on arrival at the antenatal clinic. If this is Plasma glucose taken at antenatal clinic
Abnormal if:
within 2 hours of the last meal the upper limit o f norm al is taken as 4.7 1. >4.7 mmol/L & w/i 2hrs taking meal
mmol/L (85 mg/dl) or if more than 2 hours from the last meal the upper 2. >4.1 mmol/L & after 2hrs taking meal
FOR 1 & 2 c o n firm w ith fu ll OGTT
limit is 4.1 mmol/L (74 mg/dl). A lthough this test is simple, it may carry 3. >11 mmol/L = diabetes

a high false negative rate. An abnorm al test warrants a full oral glucose
tolerance test. If the result of the RBS is more than 11 mmol/1 (198
mg/dl), this is already indicative o f diabetes.

Glycosylated haemoglobin Hb A le
This has proved to be a useful indicator of average long-term blood
glucose levels in clinical diabetes but is not an adequate screening test for pregnancy
gestational diabetes.

If diabetes is diagnosed in late pregnancy, an abnorm al

glycosylated haemoglobin (>8%) may be indicative of hyperglycaem ia
during the previous 2 to 3 months. High levels o f Hb A le in early
pregnancy may point to poor control during the time o f organogenesis
and this carries an increased risk o f congenital abnorm alities. Glycaemic
control during pregnancy should aim for a H b A lc o f less than 7%. MmforHbAictobelessthan6.5%

Serum fructosamine
Serum fructosamine concentrations are a measure of glycosylated correlates closely to fasting glucose.
, , , 1 , . , .. No level to state normal from abnormal
protein and correlate closely with fasting plasma glucose. The limitation
with this test is the unavailability o f a clear cut-off point that can
differentiate between normal and abnorm al glucose tolerance (Shah et al,
1982).
 DIABETES

Am niotic fluid and/or cord blood insulin levels

It has been reported that high levels o f am niotic fluid insulin levels are
found when the fetus is m acrosom ic and in patients destined to develop
overt diabetes (Weiss et al, 1984).

Form al Oral Glucose Tolerance Test (OG TT)

This is the diagnostic test for diabetes. It would be ideal if all pregnant
women could be subjected to a form al OGTT but this is im practical. The Pt eat normally 3 days before
OGTT is tim e-consum ing, expensive and entails significant laboratory Fast on the day of test

work. The patient should have a high carbohydrate diet for the VALUES TAKEN after

preceding 3 days. On the m orning o f the test, a fasting blood glucose is Administered 75g glucose within
5 mins
done and this is followed immediately by the adm inistration o f a 75g
VLAUES TAKEN 1 & 2 hrs after
oral glucose drink. The patient should drink this within 5 m inutes.
Then further blood glucose levels are taken at 1, and 2 hours. We no
longer do the 3 hour testing since it does not affect the m anagem ent.

W .H .O . classification of abnorm al glucose tolerance

Fasting ^ 7.0 mmol/L 126 mg/dl)
2-hour ^ 11.0 mmol/L 198 mg/dl)
Impaired Fasting > 6.1 mmol/L (> 110 to 125m g/dl)
Impaired 2-hour >7.8 m m ol/L(> 140 to 197 mg/dl)
(Im paired levels are also used to indicate gestational diabetes)

In Trinidad a positive test is indicated by -

Fasting ^ 5.6 mmol/L (s> 105 mg/dl)
1-hour ^ 8.9 mmol/L 160 mg/dl)
2-hour ^ 7.8 mmol/L 140 mg/dl)
3-hour ^ 6.7 mmol/L 120 mg/dl)

The intravenous glucose tolerance test is reserved for women who cannot Cant tolerate OGTT then given
IGTT
tolerate the oral glucose. Im paired glucose tolerance is not discussed
separately since the m anagem ent o f this condition is similar to that o f
gestational diabetes.

56
 DIABETES

Table 4. Risk factors for gestational diabetes Good

Fat
Glycosuria in current preg
First degree relative with DM
Pregnant Polycystic Ovarian Syndrome
Mothers Maternal age >30
1. First degree relative with diabetes Only Obesity
Eat Ethnic Group (East Indian)
2. M aternal age (> 30 years) High
Protein
High parity
Previous babies with birth weight over 9lbs
Burgers Bad obstetric hx
3. Obesity
Created by Anggelos
4. Ethnic group (East Indian)
5. High parity
6. Previous babies with birthweights of 9 lbs or
more
7. Bad obstetric history - recurrent m iscarriages,
congenital malformation, unexplained stillbirths
8. Glycosuria in current pregnancy
9. Polycystic ovarian syndrome

Screening for diabetes should also be considered if the following indicationsfor Diabetes screening
conditions are detected in the antecedent pregnancy: early onset pre­
eclampsia, polyhydram nios, macrosom ia and multiple pregnancy.

EFFECTS OF PREGNANCY ON DIABETES k n o w f o r c o u n c il s t a t io n

I Insulin requirement increase

Increased insulin requirem ents as pregnancy advances. KjU Ketoacidosis and coma
Dogs Det. nephropathy
Risks of ketoacidosis and com a. Dragons Det. retinopathy
Insects Infections
Deterioration o f nephropathy.
Created by Anggelos
Deterioration o f proliferative retinopathy, which can result in
blindness.
Infections especially vaginal candidiasis and urinary tract
infections including pyelonephritis.

EFFECTS OF D IABETES ON PR E G N A N C Y KNOW FOR COUNCIL STATION

• Recurrent miscarriages.
• Congenital abnormalities involving the central nervous system. Normallythereis a2%riskoffetal
. . . . . . . . abn orm alities, w ith diabetes it is 4 tim es
cardiovascular system, renal system, gastrointestinal system, and thenormal risk
the musculo-skeletal system (see Table 5).

57
 DIABETES

• Pre-eclampsia.
• Preterm labour and prem ature rupture of m em branes.
• Polyhydram nios: the cause is obscure but may be related to fetal
polyuria resulting from fetal hyperglycaem ia.
• Fetal macrosomia: this is due to poor m etabolic control o f the
m other. An increased transport of nutrients to the fetus as a
result of increased maternal substrate stimulated fetal
hyperinsulinaem ia which leads to increased anabolic activity.
M aternal insulin does not cross the placenta.
• Visceromegaly - heart, liver, lungs.
• Traum atic births particularly from shoulder dystocia.
• Late unexplained stillbirths: this may be due to a com bination o f
hyperglycaem ia, hypoglycaem ia and acidosis in the fetus.
• Neonatal metabolic problem s -
(a) hypoglycaem ia
(b) hypocalcaem ia
(c) hypom agnesaem ia
(d) hyperbilirubinaem ia - neonatal jaundice.
• Polycythaem ia may be related to fetal hypoxia and
increased erythropoietin production.
• Respiratory distress syndrom e: it has been postulated that fetal
hyperinsulinism may im pair phospholipid synthesis and this
affects the quality o f the surfactant. The surface tension in the
alveoli remains high and these neonates suffer from hyaline
membrane disease. If a diabetic woman must be delivered
before term , amniotic fluid lecithin to sphingom yelin (L/S) ratio
should be measured or the presence o f phosphatidyl choline and
phosphatidyl glycerol confirm ed. A L/S ratio o f greater than 3: 1
ensures adequate fetal m aturation in a diabetic.
• Prematurity - may be iatrogenic, for instance, with worsening
nephropathy, retinopathy or severe pre-eclam psia.
• Intra-uterine growth restriction: this is a problem with long
standing diabetes (Type 1) where there is an arteriopathy which
also impairs utero-placental perfusion.
• Increased perinatal and neonatal m orbidity and m ortality.
• M aternal mortality is unlikely.

58
 DIABETES

Table 5. Congenital anomalies in infants of diabetic mothers

CNS Open neural tube defects e.g. anencephaly
M acrocephaly

Cardiac Cardiomyopathy
Transposition of great vessels
Ventricular and atrial septal defects
Co-arctation of the aorta

Renal Hydronephrosis
Renal agenesis

Gastro-intestinal Duodenal atresia

Small left colon syndrome

Musculo-skeletal Sacral agenesis P athonm onic presentation o f diabetes

Caudal regression syndrome

Chromosomal abnormalities

MANAGEMENT
The diabetic pregnant woman should receive her care jointly from the
obstetrician and the diabetologist. Early diagnosis in the case of
gestational diabetes, and pre-conceptional counselling in the clinical
diabetic would improve the outcom e o f the pregnancy.

Medical management
• Pre-conceptional care, which starts 3 m onths prior to conception,
allows for good control o f the metabolic state at the time of
organogenesis. This is best achieved by discontinuation of oral
hypoglycaemic drugs and the adm inistration o f insulin. The
obese patient is also advised on a weight restrictive diet. Folic acid
supplementation is com m enced then.

• Control of diabetes
a. Dietary intake-The diabetic patient is usually com m enced
on a 1600-1800 kilocalorie diet daily. The assistance o f the
dietitian is crucial since factors such as pre-pregnancy weight and

59
 DIABETES

the level o f physical activity should be taken into account in

order to tailor the caloric needs to an individual. The diabetic
diet usually contains high protein, high unrefined carbohydrate,
high residue and low fat (Nolan, 1984). The patient receives 5
meals daily, 3 main meals and a m id-m orning and a late-night
snack.
b. Insulin - Insulin therapy is warranted if diet alone is If insulin is being given for the
first time
insufficient, in patients with Type I diabetes who were on insulin 1. Use boo king w e ig h t as
base weight
prior to conception, and to replace oral hypoglycaem ic therapy 2. Give:
a. 0.7 units 1st trimester per kg
in patients with Type II diabetes. The requirements for insulin b. 0.8 units 2nd trimester per kg
c. 0.9 units 3rd trimester per kg
increase with advancing gestation. Soluble insulin, three times
[Dr. Meadly]
daily, is administered to achieve euglycaem ia. Very rarely,
control may still not be tight, and insulin may have to be
administered four times daily or an insulin pum p inserted. When
control is satisfactory, insulin in the form o f a twice daily split
regime can be recom m ended. The patient is taught to self-
adm inister her insulin.

Split-dose regime - Suppose the total daily requirem ent

for soluble insulin is 60 units. The m orning insulin - 40 units (i.e.
2/3 of total daily requirem ents) is given as follows: Short-acting
insulin: 26 units (i.e. 2/3 of m orning requirem ents) and
Interm ediate-acting insulin: 14 units.

The evening insulin - 20 units (i.e. 1/3 o f total daily

requirem ents) is given as follows: Short-acting insulin - 10 units
(50% of total requirem ents) and Interm ediate-acting insulin: 10
units.

Long-acting (lente) insulin does not provide Long acting insulin NOT used
in pregnancy:
norm oglycaem ia throughout the 24-hour period, and thus lente 1. Teratogen
2. Hard to control
insulin should not be used in pregnancy. Oral hypoglycaem ic 3. > chance o f fetal
hypoglycemia
drugs are not used in pregnancy because of their teratogenic
effects (since they cross the placenta), difficulty in achieving tight
control, and the risk of severe neonatal hypoglycaem ia.

• M onitoring the level o f control

This is done by regular blood glucose m easurem ents. In the
well-motivated woman, this is best achieved with home blood
glucose m onitoring using a simple reflectance m eter (e.g.
Diascan). The patient checks her capillary glucose levels about

60
 DIABETES

2-3 times weekly and via the telephone she is advised how to
adjust the insulin regime if this is necessary. In most developing
countries, home blood glucose m onitoring is not the routine.
Hence the diabetic pregnant women must be adm itted to hospital
on a regular basis for a blood glucose profile.
KNOW THIS
Dawn phenom enon
Blood glucose profile Normal values The dawn phe nom enon is a norm al rise In blood
sugar as a p e rso n 's bod y prepares to wake up.

- Fasting blood glucose (FBS) < 1 1 0 mg/dl 61 mmol/L S om ogyi effect

If the blo o d sugar level drops to o lo w in the early
- Pre-lunch/pre-supper < 120 mg/dl 6-6mmol/L m orn ing hours, horm ones (such as grow th
horm one, c o rtiso l, and catecholam ines) are
-2hr Post prandial < 1 4 0 mg/dl 7-7mmol/L released. These help reverse the lo w b lood sugar
level b u t m ay lead to b lood sugar le vels that are
h igher than norm al in the m orning.

Random blood glucose estimations are not precise for assessment Naegele's Rule is used to estimate the due date
of the fetus. Rule uses 28 day cycle as normal
of control in the pregnant diabetic. H aem oglobin A le 1. I.d. date of LMP
2. G o back 3 months from that date
measurements provide some idea o f the control o f the diabetic 3. Add 1 year 7 days to that date

state during the preceding 8-12 weeks. SHORT CUT = Just go back 3 months add
0 days if 21 day cycle
7 days if 28 day cycle
Every v is it
1. Fundoscopy- Eyes
• Assessment o f renal and retinal status is essential in the Type I 4 days if 32 day cycle

2. ECG - Heart (if cardio issues) diabetic. Therefore these patients should have regular renal
3. Renal - Renal Function
function tests and fundoscopy perform ed during pregnancy.

Antepartum obstetric management

• Accurate dating o f the pregnancy in the first trim ester using
Naegele’s rule and ultrasound m easurem ent o f crow n-rum p
length.
• At 18-20 weeks, an anom aly scan is perform ed to exclude
congenital abnorm alities e.g. anencephaly or cardiac defects.
• Antenatal visits should be provided at 2-weekly intervals, with a
view to detecting maternal com plications such as pre-eclam psia
and urinary tract infections. Close attention is paid to the blood
pressure levels and the presence o f album inuria, and frequent
midstream urine samples for culture and sensitivity are integral in
the m anagem ent. In the third trimester, antenatal visits should be
weekly.
• Assessment o f fetal well-being by daily fetal m ovem ent counts NST=Fetai Non-stressTest
and antepartum cardiotocography (NST) from about 30-32
weeks. If fetal com prom ise is suspected, a biophysical profile
should be perform ed.

61
 DIABETES

• M onitoring fetal growth with m onthly ultrasound m easurem ents

o f biparietal and trunk diam eter from 24 weeks to detect fetal
overgrowth and thus macrosomia.
Testing for fetal lung maturity • If delivery is considered before term, amniotic fluid lecithin to
Biochemial
A. Lecithin/sphingomyelin (L/S) ratio sphingom yelin ratio greater than 3 to 1, or the presence of
B. Phosphatidylglycerol measurements. phosphatidyl glycerol may be considered with am niocentesis.
Biophysical • Ultrasound may also be necessary to exclude or confirm
polyhydram nios.
• If preterm labour or prem ature rupture o f m em branes occurs,
ofethefetus^ungsSter°'d)'s ^ivent0aic*inthedevei°Pmentj^etamethasone administration should be considered. However, as
steroids can cause hyperglycaem ia an insulin sliding scale may be
Antibiotics is given to prevent infection o f the fetus since . .
itsprotection(amnioticfluid)has beenremoved required to ensure norm oglycaem ia. Antibiotics should be
Beta-sympathomimetics are in pre- adm inistered.
c o n t r a in d i c a t e d Beta-sym pathom im etic drugs (e.g. Salbutam ol )
^^saib^amo^1^W l^ c*ia*3etes=causeshyperglycemia have m ild glucogenic effects and thus other tocolytic agents may
be preferable in the diabetic.

Indications for hospitalisation

• Investigation for diabetes i.e. GTT to be perform ed.
• Stabilization o f the diabetic state. Polyhydram nios and
m acrosom ia may be indicative of poor glycaem ic control.
• Developm ent of keto-acidosis.
• Pre-eclampsia.
• Polyhydram nios.
• Preterm labour/prem ature rupture o f m em branes.
• Pyelonephritis.
• Suspected m acrosom ia.
• Electively at 36 weeks in preparation for delivery.
• Fetal distress for biophysical assessment e.g. NST.

Intrapartum management
Time of delivery
40 weeks is allowed if no signs and symptoms The tim ing o f delivery is not as rigid as heretofore, and much depends
Induction of labour ideally at 38 weeks to avoid
sudden still birth
upon the p atient’s cooperation regarding control o f her diabetes and the
Delivery before 38 weeks:
A. Proliferate retinopathy
absence of pregnancy com plications. In some countries if pregnancy is
B. Renal failure norm al, it may be allowed to continue to 40 weeks thereby awaiting
C. Severe pre-eclampsia
spontaneous labour. It is still our practice, to perform an induction o f
labour at 38 weeks, and this is mainly to avoid the risk o f sudden late
stillbirths. M aternal indications for delivery prior to 38 weeks include
severe pre-eclam psia, progressive proliferative retinopathy and renal
failure.

62
 DIABETES

For those who have been in poor control or have had a previous
stillborn fetus, delivery should be accom plished as soon as pulm onary
maturity has been confirm ed. The Neonatologist should be involved in
this decision.

Mode of delivery
If the pelvis is adequate and the fetus is not m acrosom ic, the aim should
be for a vaginal delivery. Diabetes by itself is not an indication for
Caesarean section.

Indications for abdom inal delivery in diabetics are cephalo-pelvic

disproportion, another obstetric com plication such as breech presentation
or severe pre-eclam psia, previous traum atic vaginal delivery and a past
history o f a Caesarean section.

Induction of labour
Cervical assessment is determ ined the day before the planned induction.
If the cervix is unfavourable, a prostin pessary or another ripening agent
is used to prime the cervix. On the m orning o f the induction, a fasting
blood glucose level is measured and half the usual m orning insulin dose
is given. The appropriate dose of Syntocinon is added to a litre of
Hartmann’s solution and usual titration rate is followed. Every 2 hours,
blood glucose estimations are perform ed and insulin, if needed, is given
at a dose of 1-2 units per hour. If hypoglycaem ia ensues, a 5 % dextrose
infusion is com m enced and insulin is withheld. A partogram should be
started to monitor the progress o f labour since the diabetic must not be
allowed to have a prolonged labour.

Augmentation of labour with am niotom y is perform ed once the

cervix is 2cm dilated. Antibiotics such as Ampicillin are com m enced in
some centres once the m em branes rupture. C ontinuous fetal heart rate
monitoring is done with the cardiotocographic machine. Once labour is
established, the aim is to achieve delivery within 12 hours as plasma
glucose control becomes increasingly difficult thereafter and the patient
runs the risk o f keto-acidosis. A timely episiotom y is invaluable in
shortening the second stage. The N eonatologist should be present for
resuscitation of the newborn. Third stage o f labour is m anaged with the
administration of Syntom etrine (if not contra-indicated) with the delivery
of the anterior should and controlled cord traction for the delivery o f the
placenta.

If failure to progress exists, an em ergency Caesarean section is

warranted. If elective abdom inal delivery is chosen, it should be

63
 DIABETES

perform ed early in the m orning with the patient fasted overnight and the
m orning insulin dose withheld. A fasting blood glucose is done and a
5 % dextrose infusion is com m enced. D epending on the level o f the
blood glucose, insulin may be given.

Postpartum management
As soon as delivery has been achieved, the maternal requirem ents for
insulin decrease precipitously. Glucose levels are m onitored at 4, 8, 12
and 24 hours, and insulin is given, if indicated. Breastfeeding is not
contra-indicated for the diabetic m other. The mild diabetic can be
advised the new low-dose oral contraceptive pill but in the severe diabetic
com plicated by retinopathy and/or nephropathy, it is best to advise
sterilization.
Hyaline Membrane Disease
condition in newborn babies in which the lungs
The neonate should be admitted to the intensive care unit and
are deficient in surfactant, which prevents their
proper expansion and causes the formation of
frequent evaluation o f his metabolic state perform ed. Assisted
hyaline material in the lung spaces ventilation may be necessary if hyaline m em brane disease exists.

A rrangem ents must be put in place for the diabetic women to

receive long-term medical care from the diabetologist. If gestational
diabetes is suspected, a repeat glucose tolerance test is done 6 weeks post­
delivery. If this is abnorm al, then a diagnosis o f clinical diabetes is a
predisposing factor for the developm ent o f diabetes in later life. The
only m ethod of intervention which seems to reduce this risk is
maintenance o f the appropriate weight for height, and thus the dietitian
should be consulted to advise a weight reduction diet for the obese
woman.

In conclusion, m odern m ethods o f identifying and m anaging

gestational diabetes have reduced the perinatal mortality rate. M orbidity,
however, remains a concern, and it occurs from birth traum a, respiratory
distress and biochem ical disturbances such as hypoglycaem ia and
hypocalcaem ia.

64
 DIABETES

KEY POINTS

• Pregnancies complicated by diabetes mellitus are

associated with high perinatal morbidity and
mortality.
• Glycaem ic control may be achieved by diet only
or diet and insulin therapy. A void oral
hypoglycaem ic agents.
• Aim to keep fasting blood glucose levels less than
5.6m m ol/l (105m g/dl), postprandial glucose levels
less than 7.8mm ol/l (140m g/dl) and H b A lc levels
less than 7 %.
• Aim to deliver at 38 weeks gestation.
• The mode of delivery is vaginal unless an obstetric
indication exists for abdominal delivery.
• Maternal complications include nephropathy,
retinopathy, pre-eclam psia, recurrent infections
and obstructed labour.
• Fetal complications include congenital
abnormalities, miscarriage, unexplained stillbirth,
organom egaly, m acrosom ia, birth trauma
(shoulder dystocia), polyhydram nios and preterm
labour.
• Neonatal complications include respiratory
distress syndrom e, hypoglycaem ia,
hypocalcaem ia, hypom agnesaem ia, hypothermia
and hyperbilirubinemia (neonatal jaundice).

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CHAPTER FIVE

HYPERTENSIVE DISORDERS IN PREGNANCY

IN T R O D U C T IO N
The hypertensive disorders o f pregnancy constitute an im portant area for
all providers of Obstetric care. H ypertension, with or without proteinuria,
is one o f the com m onest com plications o f pregnancy. This medical
disorder of pregnancy is a leading cause of mortality and m orbidity to
both the m other and newborn. In Trinidad, the hypertensive diseases of
pregnancy account for 70 per cent o f all maternal deaths
(R oopnarinesingh et al, 1991) and in the United K ingdom , these
disorders rival throm boem bolism as the leading cause o f direct deaths of
pregnant women.

C LASSIFIC A TIO N
• Pre-eclampsia
• Pregnancy-induced hypertension (gestational hypertension)
• Chronic hypertension.
• Chronic hypertension with superim posed pre-eclam psia.

Pre-eclampsia
Women who have norm al blood pressures at the start of pregnancy and
develop hypertension with significant proteinuria usually in the second
half of pregnancy are said to have pre-eclam psia.

H ypertension is defined as a systolic blood pressure of 140 mm

Hg or above, and a diastolic blood pressure o f at least 90 mm Hg. These
readings are taken on two occasions, at least six hours apart. In the past,
hypertension was also defined as a rise in systolic blood pressure o f 15
mm Hg and a rise in diastolic blood pressure o f 15 mm Hg over the

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booking blood pressure in the first trimester. This latter definition is no

longer used.

Significant proteinuria refers to at least 300 mg o f proteinuria in

a 24-hour urine sam ple. This is equivalent to 1+ or greater on semi-
quantitative assessment with the dipstick. A trace o f proteinuria is
ignored since this is almost always due to contam ination by vaginal
discharge or antiseptic solution. In the presence o f hypertension, a 24-
hour urine collection is done to measure the urinary volum e, protein
excretion and creatinine clearance. M ore than 3 g of proteinuria daily is
considered as severe proteinuria. The woman who persistently loses in
excess of 5 g o f protein daily is at risk for the developm ent o f the
nephrotic syndrom e.

In the past, pre-eclam psia was believed to com prise a triad

including hypertension, proteinuria and oedem a. In 80% o f pregnant
women, it is common to find oedem a, and this has been shown to be o f
no diagnostic or prognostic significance. No longer is it therefore
necessary to have oedem a for the diagnosis o f pre-eclam psia to be made.
Excessive weight gain due to generalised oedem a is an im portant feature
of imminent pre-eclam psia. Pathological oedem a may be found in the
face, hands, abdom inal wall, sacrum, vulva and lower limbs.

Severe pre-eclampsia is diagnosed if any o f the following exists:

• Systolic blood pressure o f 160 mm Hg or above on two occasions
at least 6 hours apart (in practice, however, one should not wait 6
hours between blood pressure m easurem ents before diagnosing
severe disease and starting anti-hypertensive therapy).
• Proteinuria o f at least 3 g in a 24-hour urine collection (or 3+ or
4+ based on semi-quantitative assay).
• Oliguria as a result of renal failure.
• Cyanosis as a result of pulm onary oedem a.
• Symptoms o f im pending eclam psia (such as headache or visual
disturbances or epigastric pain).
• Features of HELLP syndrom e. HELLP syndrom e includes
Haemolysis, Elevated Liver enzym es (transam inases greater than
10% of the upper limit of norm al), and a Low Platelet count (less
than 100 000///L).

Causes of proteinuria in pregnancy

• Pre-eclampsia/eclampsia
• Urinary tract infection

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 HYPERTENSION

• Vaginal discharge, blood, mucus and m econium

• Renal disease e.g. glom erulonephritis/pyelonephritis
• Collagen vascular disorders
• Sickle cell disease
• Orthostatic proteinuria in pregnancy

A clean-catch specimen should be used when testing for proteinuria.

This is done by first swabbing the vulva, and then a vaginal plug is
inserted to prevent contam ination o f the urine. The urine is then
collected in a clean container.

Eclampsia
Eclampsia is the developm ent of epileptiform convulsions in the
pregnant patient. These seizures are of the grand-m al tonic clonic type.
A bout 20% of eclam ptic convulsions occur with no prodrom al
sym ptom s, but the rem ainder present with the sym ptom s and signs of
im pending eclampsia. The incidence of eclam psia is about 1 to 3 per
thousand pregnancies. D uring the 11 years between 1981 and 1991,
there were 103 eclamptics out o f 63,574 parturients at the M ount Hope
M aternity Hospital, an incidence o f 0.16 per cent (Bassaw et al, 1994).

Eclamptic convulsions usually start with facial twitchings; then the

entire body becom es rigid in a generalised m uscular contraction. The
face is distorted, the eyes protrude, the arms are flexed, the hands are
clenched, and the legs are inverted. This phase may persist for 15 to 20
seconds. Suddenly the jaws begin to open and close violently and this is
followed by all the muscles of the body alternately contracting and
relaxing.

After about 1 minute, the m uscular movements subside and the

patient suddenly takes a long, deep, stertorous inhalation, and breathing
is resumed. She then enters a post-ictal phase.

Pregnancy induced hypertension

This is characterised by the developm ent of hypertension (but not
proteinuria) in women who are apparently norm otensive at the beginning
o f the pregnancy. There is usually a strong family history of
hypertension. This condition occurs in both prim igravidae and
multigravidae but is more com m on in m ultigravidae. It is more com m on
with advancing maternal age and it can be considered a forerunner to the
developm ent o f essential hypertension in later life.

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Chronic hypertension
Some of the causes are chronic renal disease, phaeochrom ocytom a, renal
artery stenosis and coarctation o f the aorta. H ypertension will be present
before and persist after the pregnancy. There may also be associated
proteinuria with chronic disease. Some o f these patients may develop
superimposed pre-eclam psia.

Measurement of blood pressure in pregnancy

• Patient should be sitting com fortably at 45 degrees with a slight
tilt to the right.
• The appropriate size cuff should be placed on the right arm
evenly and firm ly, but not tightly.
• Systolic blood pressure is taken with the appearance o f the first
sound i.e. 1st K orotkoff sound.
• Diastolic blood pressure is more reproducible if the K orotkoff
phase V sound (disappearance o f the sound) is taken. Note that
there may not be any 5th sound since pregnancy is a
hyperdynam ic state. Thus sometimes the 4th sound i.e. onset of
m uffling is taken to represent the diastolic blood pressure.
• Readings are recorded to nearest 2 or 5 mm Hg.
• At the first visit the blood pressure should also be taken in the left
arm. If the blood pressure in the left arm is 10 mm Hg or more
than in the right arm, this must be docum ented. Coarctation o f
the aorta must be excluded.

PRE-ECLAMPSIA
Predisposing factors for pre-eclampsia
• Nulliparity
• Extremes o f reproductive age; it is more com m on in patients
below 16 and over 35 years o f age
• Past history of pre-eclam psia (esp. if same male partner)
• Family history of eclam psia
• Lower socio-econom ic group
• Poor prenatal care
• Chronic hypertension or renal disease
• Hyperplacentosis i.e. hydatidiform mole, diabetes mellitus and
gestational diabetes, multiple pregnancy, triploidy, and rhesus
isoimmunization
• Sickle cell anaemia (SS disease and SC disease)
• Obesity

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 HYPERTENSION

• Sm oking actually lowers the incidence of pre-eclam psia but when

a sm oker develops pre-eclam psia, it is more likely to becom e
fulm inant.
H ydatidiform mole is the only condition where a diagnosis o f pre­
eclampsia can be made before the 20th week o f pregnancy.

Pathophysiology of pre-eclampsia

Kidney
The most consistent renal lesion in pre-eclam psia is glom erulo-capillary
endotheliosis. The endothelial cells are so swollen as to block, partially
or even com pletely, the capillary lumen. It is believed that the renal
lesion in the true pre-eclam ptic patient is reversible and that the
occurrence o f the disease in pregnancy does not predispose to
hypertension in later years. The renal blood flow is reduced in pre­
eclampsia. G lom erular function is im paired, and this is reflected by a
decrease in creatinine clearance. Proteinuria and in severe cases,
oliguria exists. Acute renal failure, usually due to acute tubular necrosis
and rarely due to cortical necrosis, is a possible com plication.

Brain
Cerebrovascular haem orrhage, vasospasm and oedem a are the
underlying pathological changes seen in patients with pre-eclam psia and
eclampsia. Convulsions are thought to be due to cerebral vasospasm and
oedem a which lead to increased neuronal activity. H eadache, visual
disturbances, nausea, vomiting and hyperreflexia seen in patients with
im pending eclam psia are due to a central cause.

Liver
Periportal haem orrhages and hepatocellular necrosis are reported with
pre-eclam psia. The epigastric or right hypochondrial pain is believed to
be a consequence o f swelling o f the G lisson’s capsule. Elevated
transaminases (10% above the norm al range) are a feature of the HELLP
syndrom e. Rarely, hepatic rupture can com plicate pre-eclam psia.

Cardio-respiratory systems
The hypertension is mainly a result o f increased peripheral resistance
from generalised vasospasm. Increased cardiac output may play a m inor
role. Cardiac failure and pulm onary oedem a are serious com plications
and it is thus prudent to restrict intravenous fluids to avoid these risks to
the m other. H aem odynam ic measurements with a Swan-Ganz catheter
are essential in the m anagem ent of a pre-eclam ptic with pulm onary

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oedema. Adult respiratory distress syndrom e is a m ajor contributor to

maternal deaths.

Haem atological changes

The most frequent haem otological consequence is the constriction o f
plasma volume, which can result in decreased regional perfusion and
could subject the woman to hypovolem ic shock if antepartum or
postpartum haem orrhage occurs. The haem atocrit rises as the severity
and duration o f the disease increases.

T hrom bocytopenia is the most frequent coagulation abnorm ality

and this may be a m anifestation o f the m icroangiopathic haem olytic
anaemia. This entity is characterised by haem olytic anaem ia
accompanied by bizarre red blood cell m orphology and consum ption o f
platelets and other coagulation factors. There is platelet aggregation, a
phenom enon o f altered throm boxane/prostacyclin ratio in pre-eclam psia.
Other changes in the coagulation cascade are seen but the full picture of
disseminated intravascular coagulation is usually not observed.

Uterus and Placenta

In general, utero-placental perfusion is decreased by 50-65% about 3 to
4 weeks before the onset of hypertension. The decreased blood flow
results in intra-uterine growth retardation and increased perinatal
morbidity and m ortality. There is also the possibility o f abruptio
placentae, as well as dissemination o f trophoblastic tissue into the
maternal circulation which can be a trigger for DIC. The placenta in
pre-eclampsia is characterised by a failure o f the trophoblast to invade
the spiral arteries of the inner-third of the m yom etrium . Some o f the
spiral arteries in pre-eclam ptics dem onstrate lesions o f acute atherosis,
consisting o f fibrinoid deposition in the vessel wall and foam cell
accumulation in the intima, leading to total or partial vessel occlusion.

Aetiology
The aetiology o f pre-eclam psia is still unclear but many theories have
been proposed to explain this multi-system disorder.
• Genetic - a family history o f eclam psia in the m other increased
the risk about seven times in daughters. This seems to be due to a
single recessive gene.
• Im m unological - this disease is mainly seen in first pregnancies
but the protective effect o f nulliparity may be lost with a new
partner. The disorder is also recurrent if the partner is the same.
This altered im m une mechanism seems to operate locally (i.e. the
placenta) and not in the entire body.

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• A bnorm alities in renin-angiotensin-aldosterone pathway - the

refractoriness to angiotensin 1 1 seen in norm al pregnancies is lost
in women with pre-eclam psia.
• Altered prostacyclin-throm boxane ratio - there is a relative
prostacyclin deficiency which leads to vasoconstriction and
platelet aggregation.
• Endothelial dysfunction - the endothelium secretes
vasoconstrictors (e.g. endothelin) and vasorelaxants (e.g. nitric
oxide, prostacyclin); and the increased sensitivity to vasopressors
seen in pre-eclam psia could be explained by a decreased
production o f nitric oxide. Endothelial injury and activation are
new concepts used to explain the m orphological changes in the
renal glom eruli and vasoconstriction of pre-eclam psia.

Clinical course of pre-eclampsia

The course o f pre-eclam psia is usually unpredictable; the main threat
being the developm ent of convulsions with a consequent increased
maternal mortality. The disorder may be mild in some women, in others
it gradually progresses in severity, and occasionally it may be severe
from its clinical onset. Once the diagnosis has been established, because
o f the possibility o f progression o f the disorder and the associated
maternal m orbidity and m ortality, all patients should be m onitored
carefully.

It is well known that rapid gain in weight from retention o f fluid

is an im portant clinical sign. Oedema of the hands or face is also
regarded as an early sign preceding the developm ent o f pre-eclam psia.
This is evident as an abnorm al increase in weight.

In 1984, Gant et al noted that patients who were angiotensin-

sensitive, and later developed pre-eclam psia, also dem onstrated supine
hypertension. The supine hypertensive response is the basis of the “ ro ll­
o v er” test described by Gant. In this test, done between the 28th and 3 2 nd
week o f gestation, blood pressure is measured in the left lateral position
until stable. The patient is then rolled to the supine position, and the
blood pressure is measured immediately and again 5 minutes later. A
positive supine pressor test is characterised by a rise of 20 mm Hg or
more in the diastolic blood pressure. The so-called roll test or roll over
test or supine pressor test in G an t’s study was o f great clinical
significance in predicting pre-eclam psia. Hypertensive disorders of
pregnancy developed in 94% of patients with a positive test, while in 91%
o f cases with a negative test rem ained normotensive.

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Management of Pre-eclampsia
The m anagem ent depends upon the severity o f the condition, the
presence of any m aternal com plications and the assessment o f the fetal
well-being and m aturity.

Aims of treatment include:

• To control the blood pressure and prevent the developm ent o f
any com plications, such as cerebrovascular accidents, renal or
liver failure and eclam ptic seizures.
• To detect IUGR and any im pairm ent o f fetal well-being and to
prevent intrauterine death.
• To deliver the fetus by the safest and most expeditious means
when it is judged that the risk to the m other and/or fetus if
pregnancy is continued outweighs the risks of delivery and
prem aturity.

Antenatal Management
All patients found to have hypertension and/or proteinuria should be
referred to a tertiary centre im m ediately. The patients, irrespective o f the
severity of the disease, should be admitted to hospital or a day unit for
detailed assessment and m onitoring.

Bed rest may im prove utero-placental perfusion and increases the

delivery of oxygen and nutrients to the fetus. The patient is encouraged
to lie in a lateral position to eliminate supine hypotension. A nti­
hypertensive therapy is warranted if there is severe hypertension (i.e.
blood pressure > 160/110 mm Hg, or if the diastolic blood pressure
exceeds 100 mm Hg on 2 occasions taken 4-6 hours apart with the
patient on bed rest). Treatm ent may be started at lower levels depending
on the clinical situation however it can cause a reduction in the placental
perfusion.

Anti-hypertensive therapy
Emergency or rapid-acting anti-hypertensive drugs used in severe pre­
eclampsia include hydralazine, calcium -channel blockers, and labetalol
and to a lesser extent diazoxide and sodium nitroprusside. The chronic
management of hypertension in mild pre-eclam psia may involve the use
of drugs such as m ethyldopa, labetalol and hydralazine.

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Hydralazine
With severe hypertension, the blood pressure should be m onitored
continuously with a Dinamap m onitor. Hydralazine in 5 mg boluses are
administered intravenously until the diastolic blood pressure stabilises in
the range 90 to 100 mm Hg. Then a Hydralazine infusion consisting of
10 mg in 100 ml of norm al saline is titrated against the blood pressure
readings. H ydralazine is believed to increase renal blood flow and
cardiac output. Side effects include reflex tachycardia, headache and
palpitations.

Calcium -channel blockers

These include nifedipine (Zenusin), nicardipine and verapam il. They
have a rapid onset of action when administered sublingually. However,
there is the potential for a precipitous fall in blood pressure when
administered by this route. Several reports o f ischemic events and deaths
have prom pted the discontinuation o f this use and therefore oral
administration is recom m ended.

Labetalol
This is an a 2 and |3-adrenergic blocker which is given as an intravenous
infusion o f 200 mg in 200 ml norm al saline starting at 20 mg/h and
doubling every 30 minutes until the diastolic pressure is below 110 mm
Hg or a m axim um dose of 160 mg/h is reached. Labetalol is claimed to
produce a smooth fall in blood pressure without hypotensive episodes.
Labetalol can also be given orally in the chronic m anagem ent of
hypertension though its use is often restricted to the third trimester.

M ethyldopa
This is primarily a central a-adrenergic stimulant which produces
peripheral vasodilatation by reducing sym pathetic nervous system
outflow. It may produce side-effects such as depression, postural
hypotension, nightm ares, and less com m only cholestatic jaundice and a
positive C o o m b 's test. There may also be a mild elevation in serum uric
acid levels. M ethyl-dopa remains the anti-hypertensive agent o f choice
for the chronic m anagem ent of hypertension.

Propranolol
The mechanism o f action involves a central adrenergic effect, blockage
o f renin secretion and in some cases decreased cardiac output. B-
adrenergic blockers such as propranolol may cause fetal and neonatal
apnea. There is also an association between high doses of propranolol
and intra-uterine growth retardation. This drug is also relatively contra­
indicated in diabetes in pregnancy.

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Diuretics
Thiazide diuretics should not be used in pre-eclam psia since the drug
can further decrease the already depleted plasma volum e. Other
complications associated with thiazide diuretics include electrolyte
disturbance, cardiac arrhythm ias, pancreatitis, abnorm al glucose
tolerance, and throm bocytopenia. M annitol may be used with cerebral
oedema, and frusem ide (Lasix) is valuable in the treatm ent of pulm onary
oedema.

Important aspects of the antepartum managem ent include:

• Regular blood pressure readings, every 4 hours and urinalysis at
least twice daily.
• M onitoring for sym ptom s and signs o f im pending eclampsia.
• Assessment o f fetal well-being with daily non-stress tests,
contraction stress tests if needed, weekly biophysical profile
especially for the detection o f oligohydram nios. Adm inistration
of steroids if less than 34 weeks.
• M onitoring o f fetal growth, clinically with serial sym physio-
fundal height m easurem ents, and with ultrasound scans to
determine head circum ference, biparietal diam eter, trunk area,
abdominal circum ference and fem ur length.
• Transfer to a unit experienced in the m anagem ent o f p re­
eclampsia with facilities for neonatal resuscitation.
• The following investigations should be perform ed on admission
and repeated serially:
1. H aem oglobin- There is the risk o f m icroangiopathic
haem olytic anaem ia, abruptio placentae and DIC. In
addition these patients may require a Caesarean
section.
2. Platelet - possible platelet consum ption and thus,
throm bocytopenia, DIC.
3. Renal function tests - Creatinine to assess glom erular
function since the possibility o f kidney failure exists.
Uric acid gives an indication o f fetal prognosis (a
rising trend or an elevated uric acid indicates
worsening fetal prognosis).
4. Liver function test - especially elevated transam inases
(HELLP syndrom e).
5. Clotting profile. These patients are at risk o f clotting
abnorm alities as a result of throm boctopaenia, DIC
and the HELLP syndrom e.

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6. M idstream urine for m icroscopy, culture and

sensitivity to exclude other causes o f proteinuria.
7. 2 4 -h o u r urine collection. The param eters evaluated
are: (i) volum e (less than 400 m illitres is abnorm al)
(ii) protein excretion (>3g is severe p roteinuria) and
(iii) creatinine clearance (< 125 ml/min is abnorm al).
• Diet. Pregnancy is a salt-losing state and hence, to prevent
hyponatraem ia, a low salt diet should be avoided.
• Sedative e.g. Phenobarbitone may be recom m ended to the
woman who is anxious and who has difficulty while sleeping in
hospital.

Delivery
The time and m ode o f delivery require an evaluation o f the m aternal and
fetal status. With mild pre-eclam psia, it is preferable to delay delivery
until 38 weeks gestation. However, with severe pre-eclam psia delivery
may be required several weeks before term because o f a m aternal or fetal
indication.

C onsultation with the N eonatologist is beneficial in the prevention

o f birth o f a very prem ature baby which has a slim chance o f survival in
the Intensive Care U nit. One must also be ever aware o f the risks to the
m other o f w orsening hypertension and the developm ent o f
com plications such as eclam psia, and to the fetus o f acute fetal distress
and intra-uterine dem ise if the pregnancy is allowed to continue. If a
w ell-equipped N eonatal Unit is available, a com prom ise is to deliver the
severe pre-eclam ptic at about 30 to 32 weeks gestation.

Once the decision to deliver the patient with severe pre-eclam psia
has been m ade they should be started on m agnesium sulphate (M A G PIE
study).

The preferred m ode o f delivery is vaginal and cervical ripening

can be achieved with prostaglandin gel or pessaries. However caesarean
section may be w arranted for:
• Fetal distress
• Im pending eclam psia
• M alpresentation/abnorm al lie
• Very unfavorable cervix
• C ontra-indications for vaginal delivery (e.g. placenta praevia).

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Intrapartum m anagem ent includes induction of labour medically

and surgically, close m onitoring for sym ptom s and signs o f im pending
eclampsia, the adm inistration of m agnesium sulphate prophylactically to
prevent convulsions.
Dinamap m onitoring o f blood pressure and the use o f rapid
acting anti-hypertensive therapy e.g. H ydralazine if required, continuous
electronic fetal heart rate m onitoring, adequate pain relief (consider an
epidural analgesia), and a partogram to m onitor the progress o f labour.
The input o f the Senior Obstetrician, Anaesthetist and
Paediatrician is vital. In the second stage o f labour, an episiotom y and
forceps should be considered. Syntom etrine must not be given. Instead,
Syntocinon is used and is given with the delivery o f the anterior
shoulder. The episiotomy should be repaired soon after the delivery of
the placenta. Close m onitoring o f the m other must continue for at least
12 to 24 hours post-delivery since eclampsia may occur for the first time
after delivery.

Breastfeeding and contraception should be encouraged.

MANAGEMENT OF EC LA M PSIA
Resuscitation
Call for help. The initial step should be to place the patient in the left
lateral position and ensure that there is a patent airway. Attempts may be
made to insert an oropharyngeal airway though this may difficult.
Oxygen can be adm inistered by nasal prongs and intravenous access
established with two wide bore cannulae.

Anticonvulsant therapy
The Collaborative Eclampsia Trial dem onstrated that M agnesium
sulphate is the drug of choice and in general there is no need for
polypharmacy. It is a simple salt that is excreted by the kidneys and acts
both centrally and peripherally. Peripherally, it inhibits pre-synaptic
transmission at the neurom uscular junction and catecholam ine release
from the adrenal medulla. Centrally, it inhibits excitatory receptors in the
central nervous system such as the NMDA receptors and produces a
vasodilatation, which has a beneficial effect in cerebral oedem a. In
addition, it has a mild hypotensive effect, does not produce sedation and
obtunds the hypertensive response to endotracheal intubation. The
loading dose of M agnesium sulphate is 4g (20 ml o f a 20% solution)
administered intravenously over 3 to 5 minutes.

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To prevent further convulsions M agnesium sulphate can be given

either intravenously or intram uscularly. The intravenous regim e is
titrated to deliver 1 to 2 grams per hour. With the intram uscular route,
immediately following the bolus intravenous dose of 4 g, 5g of
M agnesium sulphate (10 ml o f a 50% solution) are adm inistered in each
buttock, and then 5g are injected in alternating buttocks every 4 hours.
Before each successive dose is given, signs o f m agnesium toxicity must
be excluded. The pulse rate, respiratory rate, deep tendon reflexes,
hourly and the urine output are m onitored. Serial m agnesium levels are
not routinely needed at this dosage. Ensure:

• Pulse > 60 beats per minute.

• Respiratory rate > 12 per minute.
• Deep tendon reflexes are present.
• Urine output > 30 ml per hour.
• Serum m agnesium 4-7 mg/dl.

M agnesium sulphate has a narrow therapeutic index i.e. the

therapeutic and toxic ranges are close (Table 2). If the therapeutic range
is exceeded, the next dose of M agnesium sulphate is om itted. The
antidote for M agnesium toxicity is 1 g Calcium gluconate (10 ml o f a
10% solution given over 10 m inutes).
As an alternative, a bolus o f Diazepam (10 m g) may be given
intravenously to stop the convulsion. If the fit continues, then the
Diazepam is repeated in 10 mg bolus up to a m axim um o f 40 m g. To
prevent further convulsions an infusion o f 40 mg o f Diazepam in 500 ml
o f 5% Dextrose is adm inistered at a rate to keep the patient sedated but
arousable. If the seizure still continues, then the patient is treated like one
with status epilepticus. She is given muscle relaxation, intubated, and
ventilated.

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Table 2. Magnesium toxicity

Serum concentration Manifestation

(mg/dl)
1.5-3 Normal
4 -7 Therapeutic levels
5 - 10 ECG changes
8-12 Loss of patellar reflex. Flushing
10 - 12 Som nolence. Slurred speech
15-17 Muscle paralysis. Respiratory difficulty
a 30 Cardiac arrest

Stabilization
The blood pressure is m onitored continuously with a D inam ap. The
desired diastolic blood pressure is in the range o f 90-100 m m Hg and this
can be achieved with one o f the em ergency antihypertensive drugs
(Hydralazine, Nifedipine or Labetalol) m entioned earlier. There should
be strict input/output charting. A F o ley ’s catheter is inserted with an
hourly urom eter and fluid restricted to 85 millilitres per hour (1 ml/
kg/hr).

Baseline investigations include a full blood count, renal function

tests, liver function tests, clotting profile, and cross-m atch o f at least 2
units of blood. Assessment of fetal well-being with a non stress test is
important to exclude fetal distress.

Delivery
Once the patient has been stabilised, a decision must be made to deliver
the fetus. Ideally this should occur within 12 hours o f adm ission. If the
patient is already in labour, then augm entation o f labour with an
amniotomy and a Syntocinon infusion should be perform ed. For the
patient who is not in labour, the anticipated induction-delivery interval
must be determined. If this interval is considered to be short, induction
of labour should be done. On the other hand, if the induction-delivery

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interval is likely to be prolonged, an em ergency Caesarean section is

preferable. Other indications for abdom inal delivery are:

• Contra-indications to a vaginal delivery.

• Fetal distress.
• M alpresentation.

In the absence of a clotting abnorm ality regional anaesthesia is

the anaesthesia o f choice. An added benefit is that it will aid with the
control o f the blood pressure. G eneral anaesthesia can be a hazardous
undertaking in pre-eclam psia for a num ber of reasons. Firstly, laryngeal
oedem a may make intubation a difficult prospect and secondly there is a
hypertensive response to intubation. In addition, magnesium sulphate
prolongs the action of muscle relaxants and this may delay the return o f
spontaneous ventilation.

In the presence o f a clotting abnorm ality there is a significant risk

o f a spinal haem atom a and hence general anaesthesia is preferred. It is
extrem ely im portant that senior anaesthetic staff is present because of the
potential difficulties.

With a vaginal delivery, the second stage of labour can be

shortened with an episiotom y and forceps. Avoid Syntom etrine. If an
oxytocic agent is required, there should be judicious use o f a Syntocinon
infusion. The N eonatologist should be available to resuscitate the
newborn.

Postpartum
Postpartum, close m onitoring of the m other is imperative. Forty percent
o f all eclamptic episodes occur during this period and anticonvulsant
therapy should continue for at least 24 hours after the delivery or 24
hours after the last seizure, whichever is later. A nti-hypertensive
treatm ent may also be required post-delivery.

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KEY POINTS

• The hypertensive disorders of pregnancy are one o f the

leading causes of direct maternal deaths.
• Pre-eclam psia is a multisystem disorder with implications
for both mother and fetus. The definitive managem ent is
DELIVERY.
• Eclampsia may occur de novo or as a consequence of
severe pre-eclampsia.
• The indications for Magnesium sulphate therapy are
severe pre-eclam psia, impending eclam psia and
eclampsia.
• The symptoms of impending eclampsia are nausea,
vomiting, headaches, blurring of vision and epigastric
pain. The latter is due to stretching o f Glisson’s capsule.
• The signs of impending eclampsia are hyper-reflexia, 2 or
more beats of clonus, epigastric tenderness and
papilloedema.

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CHAPTER SIX

CARDIAC DISEASE IN PREGNANCY

IN T R O D U C T IO N
The incidence of heart disease in pregnancy is 1-2%. The maternal
mortality rate with cardiac disease in association with pregnancy is about
0.2% . Although there has been an absolute decrease in m aternal
mortality attributed to heart disease, recent Confidential Enquiries into
M aternal Deaths in England and Wales illustrated the relative im portance
o f this medical disorder as a contributor to maternal deaths.

Between 1985 and 1987, there were 23 maternal deaths due to

cardiac disease in England and Wales and this ranked third after
pulm onary em bolism and hypertensive disease. Interestingly for the
triennium 2000-2002, there were 44 deaths from cardiac disease (80%
from acquired heart disease especially cardiom yopathy and 20% from
congenital heart disease especially pulm onary hypertension).
Substandard care was mainly due to the patients who proceeded with a
pregnancy against strong medical advice. On the medical side, lack of
team consultation, late involvement of specialist colleagues, and delivery
in circumstances inadequate to cope with m ajor com plications, all
contributed to substandard care.

AETIOLOGY
In developing countries, rheumatic heart disease accounts for up to 90%
o f cases seen in pregnancy. It is associated with mitral and aortic valve
stenosis and is on the decline because of the use of antibiotics in the
treatm ent o f streptococcal infection.

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On the other hand, the num ber o f females with congenital heart
disease reaching childbearing age has increased. This is due to
improvements in the m anagem ent of children with these anomalies,
particularly when am enable to surgery. In many British hospitals,
congenital heart disease is as com m on in pregnancy as rheum atic heart
disease.

Other less com m on causes o f cardiac disease in pregnancy are

coronary artery disease, cardiom yopathy, hypertensive disease, collagen
vascular disorders and syphilis.

CARDIOVASCULAR C H A N G E S IN PR E G N A N C Y
The work done by the heart is considerably increased during pregnancy
and this is primarily due to a com bination o f increased blood volume
and decreased peripheral resistance.

Plasma volume increases progressively throughout pregnancy.

This change begins early in the first trimester, peaks at about 32 weeks,
after which it tends to plateau. At delivery, plasma volume decreases and
by 6-8 weeks postpartum , levels return to norm al. O f interest, is the
association between plasma volum e and the size o f the fetus: large
plasma volumes are associated with large babies, and vice versa.
Red cell volume increases, but to a lesser extent than plasma
volume. Consequently, there is a haem odilution and this causes a
decrease in haematocrit and haem oglobin values.

Cardiac output increases 40% from about 4.5 to 6.5

litres/minute. This increase follows closely the increase in plasm a volume.
Cardiac output falls as a result o f significant blood loss, supine
hypotension (also referred to as aortocaval com pression), and epidural
analgesia if adequate pre-loading was not done. In labour, cardiac output
increases with each contraction and in the immediate post-delivery
period. It drops considerably by 2 weeks. The increase in cardiac output
is as a result of vasoactive substances such as nitric oxide, prostaglandins
and oestrogen.

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 CARDIAC DISEASE

Cardiac output = Heart rate x Stroke volume

The heart rate increases by about 10-15 beats per m inute. The
stroke volume rises from 64 to 80 ml. Blood pressure falls in the second
trimester and then it returns to pre-pregnancy levels in the third
trimester.

Blood pressure = Cardiac output x Total peripheral resistance

The increase in cardiac output is mainly due to the increase in

stroke volume.

The heart is displaced upwards and laterally in pregnancy and

this is thought to be due to elevation of the left hem i-diaphragm . It is
thus not uncom m on to find the apex beat in the fourth left intercostal
space and in the anterior axillary line. A soft ejection systolic m urm ur
may be heard at the apex or in the pulm onary area and this is due to the
fact that pregnancy is a hyperdynam ic state. All diastolic and loud
systolic m urm urs are pathological and must be investigated.

DIA G N O SIS
The following sym ptom s and signs are indicative o f heart disease:
• Dyspnoea
• O rthopnoea
• Paroxysmal nocturnal dyspnoea
• Haemoptysis
• Cough
• Chest pain
• Cyanosis
• Elevated jugular venous pressure
• Thrill
• Parasternal heave
• Loud ejection systolic m urm urs (grade 1 1 1-1V) which vary with
respiration
• Pansystolic m urm ur
• Diastolic m urm ur
• Cardiac arrhythm ias
• Diastolic gallop rhythm or pulsas alternans
• Click
• Pericardial friction rub suggests pericarditis.

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 CARDIAC DISEASE

• Radio-fem oral delay occurs with coarctation o f the aorta.

There is a diagnostic dilem m a since many o f the clinical features of
organic heart disease occur in a normal pregnancy. Some of these are
hyperventilation, oedem a of the lower extrem ities, a palpable left sternal
border systolic thrill and a soft ejection systolic (flow) m urm ur.

INVESTIGATIONS
• Haemoglobin
• Electrocardiogram
• Chest X-ray (with shielding o f the abdom en)
• Echocardiogram is the technique o f choice. It detects the
majority of structural abnorm alities.

FUNCTIONAL C A PA C ITY OF THE H EART

It is customary to place patients with heart disease in pregnancy into one
of four categories according to the New York Heart Association
Classification (1965).

Class I No limitation of physical activity. No

fatigue, palpitation, dyspnoea or angina.

Class 11 Shortness of breath with moderate degree

of physical activity.

Class 111 Marked limitation with minimal activity.

Class IV Shortness of breath even at rest.

The above classification gives a good indication as to whether or not the

patient is incapacitated by her sym ptom s and to what extent. In our view,
it is still the best means o f assessing cardio-pulm onary status. It should
be remembered that women who have a functional Class o f 1 or 11 in
early pregnancy may deteriorate to Class 111 or IV later on. It is
therefore important that the functional capacity o f the patient be assessed
on each visit.

Predisposing factors for cardiac failure

• Pregnancy

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 CARDIAC DISEASE

• Obesity
• Infection (e.g. cystitis)
• Anaemia
• Hypertension
• M ultiple pregnancy
• Blood loss
• H yperthyroidism .

M ED IC A L M A N A G E M E N T
The basic principle in the m anagem ent o f a patient with cardiac disease
in pregnancy is to limit the burden on the heart. This can be achieved
by:
• Bed rest and limitation o f strenuous physical activity. Mild
exercise is encouraged to improve physical fitness and to reduce
the risks o f venous throm bo-em bolism .
• Avoiding em otional upsets.
• Careful diet and weight control.
• Prevention and early treatm ent o f anaemia.
• Prevention and treatment of infection especially urinary and
respiratory infections.
• Prom pt treatm ent o f hypertension.
• Avoid supine position. The sem i-recum bent position is
preferable.

IND IC A TIO N S FO R H O SPITALISATIO N

• All patients with Class 111 or IV disease for the entire duration
o f the pregnancy.
• Hypertensive disorders of pregnancy.
• Cardiac failure.
• Infection such as pyelonephritis.
• Anaemia.
• Routine admission for bed rest between 28 and 32 weeks
gestation and again at 38-39 weeks in preparation for delivery.
• Some workers advocate term ination o f pregnancy for Class 111
and IV disease. It is im portant that the patient who has cardiac
disease be assessed early in pregnancy. The m anagem ent should
be jointly between the obstetrician and the cardiologist.

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• Other indications for term ination of pregnancy include

E isenm enger s syndrom e, prim ary pulm onary hypertension, and
pulm onary veno-occlusive disease.

OBSTETRIC M A N A G E M E N T
Ideally, delivery o f these patients should be planned with senior
anaesthetic and obstetric staff available. The patient should be allowed to
go into spontaneous labour. By itself, cardiac disease is not an indication
for induction of labour. It is also not an indication for Caesarean section.
Caesarean section is perform ed only for an obstetric indication. A
Syntocinon infusion may cause circulatory overload and artificial
rupture of m em branes may lead to chorioam nionitis and subacute
bacterial endocarditis. Vaginal delivery is therefore the preferred route
of delivery.

First Stage of Labour

• The patient is placed on bed rest in a sem i-recum bent position.
• Avoid supine position.
• Intravenous infusions should be avoided.
• Ensure a recent H aem oglobin value and 2 units o f cross-m atched
blood should be available.
• Intermittent oxygenation via face mask or nasal cannula.
• Administer broad-spectrum antibiotics e.g. Ampicillin and
Gentamicin every 8 hours as soon as labour starts or when the
membranes rupture in order to reduce the incidence o f subacute
bacterial endocarditis. There is little evidence to support this
practice however.
• Close m onitoring o f pulse, tem perature, blood pressure,
respiratory rate, and for the developm ent of cyanosis.
• Adequate pain relief with narcotic analgesics e.g. M orphine or
Pethidine. In carefully selected cases, a lum bar epidural analgesic
would provide almost pain-free labour.
• Early amniotomy is best avoided and vaginal exam inations
should be restricted.

Second Stage of Labour

When the cervix is fully dilated, the patient is encouraged to bear down
with each contraction. If there is maternal distress, the second stage is
shortened with the aid of forceps and a generous episiotom y ought to be
performed.

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With the birth o f the anterior shoulder, Syntom etrine is withheld.

All oxytocic agents may be reserved for those with significant bleeding
after the end of the third stage o f labour. A Syntocinon infusion may
then be cautiously com m enced. Syntom etrine is contra-indicated
because it causes intense uterine contraction and thus a marked increase
in venous return which aggravates the work on the heart. Syntom etrine
may also lead to transient hypertension.

Third Stage of Labour

The placenta is removed using the Brandt Andrews m ethod. Im m ediately
after the third stage, the episiotomy must be repaired. The patient must
be closely m onitored for cardiac failure.

Puerperium
The patient is encouraged to breast-feed. She should be advised to have
more bed rest. For patients with Class 111 or IV disease, sterilization
should be recom m ended. If this is not acceptable, then barrier
contraception is advisable.

The intra-uterine contraceptive device is relatively contra­

indicated in patients with cardiac disease because o f an endom etritis and
bacteraem ia, which can cause subacute bacterial endocarditis.

The oral contraceptive pill should be used with caution because

those containing oestrogens may predispose the patient to th ro m b o ­
embolic phenom ena. Rheumatic heart disease, pulm onary hypertension
and cardiom yopathies are predisposing factors to throm bus form ation.
The new low-dose com bined contraceptive pill may be used in carefully
chosen cases. This ensures effective contraception with minimal risks.

Before discharge from the postnatal ward, follow-up by a

cardiologist must be arranged.

COM PLICATIONS
• Congestive cardiac failure.
Treatm ent should be administered by a cardiologist. The patient
must be admitted to the antenatal ward or a high-dependency
area. She must be nursed in a sem i-recum bent position. O xygen
is administered and fluid restriction instituted. Her vital signs are
m onitored. Frusemide (Lasix) is given to create a diuresis.
M orphine is useful since it decreases venous return by causing
peripheral vasodilatation. Furtherm ore, M orphine is an anxiolytic

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agent. The patient may require D igoxin. An electrocardiogram is

perform ed to exclude arrhythm ias.
• Pulm onary hypertension.
The maternal mortality rate is about 50% in patients with severe
pulm onary hypertension. Deaths tend to occur when there is a
sudden decrease in venous return due to a), supine hypotension
or b). volume losses. The critical time for these patients is
immediately after delivery because of the sudden return o f blood
from the uterus and placental bed to the systemic circulation.
• T hrom bo-em bolic phenom ena.
Patients with prosthetic heart valves may develop arterial
embolism. These women are usually on prophylactic W arfarin. At
36 weeks gestation. W arfarin must be discontinued and either
conventional Heparin or low m olecular weight Heparin
com m enced.
• Subacute bacterial endocarditis.
The use of antibiotics in labour has resulted in a sharp fall in the
risk o f infective endocarditis. The increased incidence o f
pyelonephritis during pregnancy and bacteraem ia during
parturition, particularly in women with prolonged rupture o f the
membranes, predispose to subacute bacterial endocarditis.
• M yocardial infarction.
• Aortic dissection.
• Puerperal cardiom yopathy.

CARDIAC SURGERY
Cardiac surgery is not perform ed in pregnancy unless it is absolutely
necessary. By-pass operation is contra-indicated in pregnancy since the
use of the heart-lung m achine carries a high risk o f fetal wastage. A
mitral valvotomy may be perform ed between 16-20 weeks if there is a
tight mitral valve, which is causing cardiac failure that is unresponsive to
medical therapy.
 CARDIAC DISEASE

KEY POINTS

• The incidence of cardiac disease in pregnancy is

1 to 2%.
• Rheumatic heart disease accounts for 90% of
cases of cardiac disease in pregnancy in
developing countries.
• Echocardiography is the investigation of choice.
• These patients should be m anaged jointly by an
obstetrician and a cardiologist.
• Patients with Class III and IV disease should be
admitted to hospital for the duration of the
pregnancy.
• V aginal delivery is the preferred route of
delivery. This is a high risk delivery and there
should be a multidisciplinary approach.
• A void early artificial rupture of the membranes
and restrict vaginal examinations.
• A void Syntometrine in the third stage of labour.
• Monitor closely postpartum.

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 JAUNDICE

CHAPTER SEVEN

VOMITING
JAUNDICE
ABDOMINAL PAIN IN PREGNANCY

VOMITING IN PR E G N A N C Y

INTRODUCTION
Nausea and vomiting are com m on sym ptom s of pregnancy affecting 50
to 75% of all conceptions. Usually, it is a self-limiting process beginning
in early pregnancy and resolving spontaneously after 16 weeks.

Vomiting occurs m ore frequently in prim igravidae, teenagers,

non-smokers, obese women and those with multiple pregnancies. On the
whole, patients respond to simple measures such as reassurance and
dietary advice. The use o f ginger extracts and pyridoxine may be
helpful in some patients whilst others may require pharm acotherapeutic
intervention in the form o f antiemetics such as cyclizine.

Persistent, excessive vomiting refractory to these simple measures

is known as hyperemesis gravidarum . This may result in dehydration,
electrolyte disturbances and nutritional deficiencies, which have
implications for maternal and fetal well-being. Fortunately, this
condition is rare occurring in less than 1% o f all pregnancies.

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 JAUNDICE

AETIOLOGY
The precise cause o f nausea and vomiting is not known. Several theories
have been put forward and both endocrine and psychogenic factors have
been postulated. Em otional stress and fear o f m otherhood have been
cited as significant factors.

Some authorities believe that it is due to the effect o f high

oestrogen levels on the chem oreceptor trigger zone. A similar role has
been ascribed to hum an chorionic gonadotrophin. Elevated levels are
found in gestational trophoblastic disease and multiple pregnancies and
are probably the cause o f vomiting in these conditions.

DIFFER ENTIA L DIA G N O SIS

It is essential that other causes of vomiting are considered in the initial
assessment o f these patients. This requires a detailed history and
exam ination and recourse to appropriate investigations. A thorough
approach at this stage will ensure that a potentially lethal condition is
unlikely to be overlooked.

After 20 weeks gestation, vomiting may be as a result o f pre­

eclampsia. This is an om inous sym ptom and indicative o f an elem ent o f
cerebral irritation. It is im portant to make this distinction early as the
fluid resuscitation that is part o f the initial m anagem ent of hyperem esis
can have a deleterious effect in severe pre-eclam psia. Peripartum , other
pregnancy related conditions that may present with vomiting are the
HELLP syndrom e and acute fatty liver o f pregnancy. M aternal
deterioration can be swift.
A ppendicitis, acute intestinal obstruction, cholecystitis and a
torted ovarian cyst can occur throughout pregnancy. They may present
with vomiting though this is usually associated with a significant elem ent
o f abdom inal pain. Urinary tract infections, such as pyelonephritis,
should also be considered. Fever, rigors and loin pain usually lend
themselves to this diagnosis. Rare causes would include diabetic
ketoacidosis, cerebral tum ours and cerebral throm bosis.

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COM PLICATIONS
Vomiting in pregnancy usually runs a benign course. Hyperem esis
gravidarum on the other hand represents the extrem e o f the process and
can result in a wide spectrum o f com plications. These include:-
• Weight loss.
• D ehydration.
• Throm boem bolism
• Electrolyte disturbance. Namely, hyponatraem ia,
hypokalaem ia and hypochloraem ia.
• M endelson’s syndrom e. M aternal deaths have been reported
in the literature secondary to this aspiration pneum onitis.
• M allory Weiss syndrom e. O esophageal m ucosal tears can
occur secondary to protracted retching.
• Vitamin deficiencies. Thiam ine ( Bl ) deficiency can lead to
W ernicke’s encephalopathy. While deficiency o f Pyridoxine
(B6) and Cyanocobalam in (B 12)may result in a
megaloblastic anaem ia and peripheral neuropathy.
• Fetal growth restriction.

INVESTIGATIONS
The following should be considered baseline investigations for all
patients who present to hospital with vomiting in pregnancy:
• Urinalysis. Two pluses or m ore o f ketonuria denotes
significant metabolic disturbance.
• Midstream urine (MSU) for m icroscopy culture and
sensitivity. The presence o f protein, blood, leucocytes or
nitrites on urinalysis warrants this investigation.
• Full Blood Count. A raised haem atocrit will be seen in the
dehydrated patient whilst throm bocytopenia will be seen in
conditions such as the HELLP syndrom e.
• Urea and Electrolytes. May reveal hyponatraem ia,
hypokalaem ia and hypochloraem ia.
• Liver Function Tests. May reveal elevated transam inases.
• Thyroid Function Tests. May be abnorm al because o f the
thyroid stimulating effect of the alpha sub-unit o f hum an
chorionic gonadotrophin. It does not usually require
treatment.
• An ultrasound scan can be perform ed to rule out multiple
pregnancy and gestational trophoblastic disease. There is no
need to repeat the scan on admission if a previous scan has

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 JA UN DICE

confirmed a viable singleton intrauterine pregnancy.

However, serial scans may be performed later in pregnancy if
fetal growth restriction is suspected.

MANAGEMENT
Simple measures
The vast majority of patients with vomiting in pregnancy respond to
simple measures. This may include reassurance and dietary advice. A
bland diet bereft of oil (for example dry crackers) and regular, small
aliquots o f simple fluids (such as water/electrolytes) may be all that is
required. A supportive family network is often helpful and it may be
that her partner can be encouraged to assume tasks that would allow her
to avoid noxious stimuli. Ginger extracts and pyridoxine are simple
remedies with antiemetic properties. Oral antiemetics can also be
prescribed. If absorption is an issue buccal, sublingual and rectal
preparations are available.

Advanced measures
The patient with hyperemesis gravidarum needs admission to hospital.
Oral intake should initially be restricted and there should be strict input
and output charting.
• Intravenous fluid therapy - is the mainstay of management.
Isotonic solutions such as H artm ann's and normal saline are
the fluid of choice.
• Biochemistry should be repeated daily and fluid therapy and
potassium chloride supplementation tailored depending on
these results. Dextrose containing fluids should be avoided as
they may precipitate W ernicke's encephalopathy.
• Antiemetic therapy - is safe in pregnancy. The drugs used
include:-
(1) The neuroleptic phenothiazines, such as
Prochlorperazine (Stemetil) and Chlorpromazine
(Largactil), are dopamine antagonists that act at the
chemoreceptor trigger zone. They may be
administered intravenously, intramuscularly, bucally
or rectally. Rarely, extrapyramidal side effects such as
tardive dyskinesia are seen. The antidote is
Benzatropine (Cogentin).
(2) Antihistamines such as Dimenhydrinate (Gravol) and
Promethazine (Phenergan). These drugs have a

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 JAUNDICE

sedative effect which tends to disappear after a day or

two.
(3) Piperazine derivatives such as Cyclizine, Meclozine
and Buclizine. Cyclizine is especially useful and may
be administered intravenously, intramuscularly or
orally. They have a milder sedative effect than the
antihistamines.
(4) Dopamine antagonists such as Domperidone and
Metoclopramide. Domperidone does not readily cross
the blood-brain barrier and is less likely to cause
extrapyramidal side effects when compared with
metoclopramide and the phenothiazines.
(5) Serotonin antagonists such as Ondansetron. These
are useful in instances where none of the above drugs
have proved effective.
(6) Corticosteroids have been used to good effect in
patients with intractable vomiting resistant to other
treatment modalities.
• Antacid Therapy. Persistent vomiting stimulates gastric acid
production. This can cause symptoms such as dyspepsia.
Antacids such as magnesium trisilicate can be administered to
raise the luminal pH of the stomach. Histamine H2 receptor
antagonists (Ranitidine) and protein pump inhibitors
(Omeprazole) can be given to reduce the production of
gastric acid.
• Vitamin Therapy.
(1) Thiamine ( Bl ) should be prescribed to all patients with
hyperemesis gravidarum. This may be
administered orally or intravenously. The usual oral
dose is 25 mg three times daily.
(2) Pyridoxine (B6) and Cyanocobalamin (B12)
supplementation should be instituted if there is evidence
o f deficiency.
• Nutritional Support - may be required in severe cases of
hyperemesis. This may take the form o f total parenteral
nutrition or enteral feeding whereby nutrition is administered
via a feeding tube.
• Thromboprophylaxis - Due consideration should be given to
the use of compression stockings and low molecular weight
heparin. Factors which should influence this decision include
severe dehydration, morbid obesity, multiple pregnancy and
where prolonged immobilization is anticipated.

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 JA UN DICE

• Termination of P regnancy- A deterioration of maternal status

may warrant termination of pregnancy. The removal of all
trophoblastic tissue can be considered the definitive
management of vomiting in pregnancy.

KEY POINTS
• Nausea and vomiting are common symptoms of
pregnancy.
• Most patients respond to simple measures.
• Persistent, excessive vomiting that may result in
dehydration, electrolyte disturbances and
nutritional deficiencies is known as hyperemesis
gravidarum .
• Isotonic solutions are the mainstay of
intravenous fluid therapy.
• A void dextrose infusions as they may precipitate
W ernicke’s encephalopathy. Thiamine should be
prescribed to all patients with hyperemesis
gravidarum .
• Antiemetic therapy is safe in pregnancy.
• Termination of pregnancy can be considered in
the event of deterioration o f maternal status.

.JAUNDICE IN P R E G N A N CY
Maternal jaundice is a relatively rare complication encountered in
pregnancy. It occurs in approximately 1:3000 gestations and in the
developing world it makes a significant contribution to maternal
mortality. In Ibadan, Nigeria, for example, 15.3% of all maternal deaths
were associated with acute liver failure. This propensity for adverse
maternal outcome should prompt thorough investigation o f this sign of
hepatic dysfunction.

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 JAUNDICE

AETIOLOGY
Jaundice can result from conditions unique to pregnancy (such as acute
fatty liver) or it may arise de novo in pregnancy from conditions that
also affect the non-pregnant patient (such as viral hepatitis). Rarely, it
may occur in patients who had liver disease prior to conception (such as
cirrhosis). The list of potential cause o f jaundice in pregnancy is
exhaustive. In this section we have confined discussion to the following
important factors:-
• Viral hepatitis
• Obstetric cholestasis
• Acute fatty liver o f pregnancy
• HELLP syndrome
• Hepatotoxic drugs
• Cirrhosis
In the Caribbean the haemolytic anaemias (especially SCD and G6PD
deficiency) and cholelithiasis are other significant causes.

Viral hepatitis
Viral hepatitis accounts for 40% of all cases o f jaundice in pregnancy.
This can be due to the hepatotrophic viruses:-
• Hepatitis viruses - A,B,CX) or E
• Cytomegalovirus (CMV)
• Epstein Barr virus (EBV)
• Herpes simplex virus (HSV)

Hepatitis A
This is a RNA virus that is transmitted by faecal contamination. There is
usually a brief attack of hepatitis followed by rapid recovery and
permanent immunity. Vertical transmission is rare but may occur if
maternal inoculation occurs around the time o f delivery. The neonate
should be given immune globulin at birth.

Hepatitis B
This is a highly infectious DNA virus that is transmitted parenterally and
through sexual contact. The major antigenic determinants of the virion
are the surface antigen (HBs Ag), the core antigen (HBc Ag) and the e
antigen (HBe Ag). These can be identified in the maternal serum.
Vertical transmission usually occurs at the time o f delivery and the risk is
greatest in mothers who are HBs Ag and HBe Ag positive. When infected,
more than 90% of newborns will become chronic carriers of the virus,
which can lead to hepatocellular carcinoma and cirrhosis. All neonates

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therefore should receive both active and passive immunisation in the

form of the hepatitis B vaccine and the immunoglobulin within 24 hours
o f delivery.

Delivery should be vaginal unless an obstetric indication exists

for abdominal delivery. Intrapartum, invasive procedures such as fetal
scalp electrodes and fetal blood sampling should be avoided as these
have the potential for inoculating the fetus. Breastfeeding is not
contraindicated although it should not be initiated prior to immunisation.

Hepatitis C
This is a single stranded RNA virus that is transmitted parenterally.
Vertical transmission may occur but there are no available vaccines.
Breastfeeding is not contraindicated.

Obstetric Cholestasis
This is principally a disease of late pregnancy. Although the precise
aetiology is unknown it is probably due to a multitude o f factors,
including a genetic predisposition, which result in an increased sensitivity
of the hepatocyte membrane to oestrogens.
The hallmark of the disease is that, in the absence of a rash, there
is a generalised pruritus, which characteristically affects the palms of the
hands and soles of the feet. There may be hepatomegaly though
jaundice is not a common feature. The biochemical picture is that of an
obstructive process and the most common abnormalities are elevated
transaminases and bile acids. Alanine transaminase, which is primarily a
cytosolic enzyme, is thought to be a more sensitive marker of the mild
hepatocellular damage that is seen in obstetric cholestasis. The diagnosis
is one of exclusion and the differential diagnosis would include
cholelithiasis, viral hepatitis and primary biliary cirrhosis. A liver
ultrasound and serology for hepatitis A, B and C, Epstein-Barr virus,
cytomegalovirus and liver autoantibodies should therefore be performed.

The principal risks are premature labour, fetal distress,

intrauterine demise and postpartum haemorrhage. Postpartum
haemorrhage is as a result of a bleeding diathesis secondary to a
deficiency of vitamin K dependent clotting factors. Vitamin K is a fat-
soluble vitamin that is dependent on bile acid secretion and micelle
formation for absorption from the gastrointestinal tract. To prevent this
deficiency and counteract the malabsorption attendant with this disease
entity all patients should be prescribed a prophylactic water-soluble
preparation of vitamin K such as phytomenandione.

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Symptom control can be achieved with the use o f simple

emollients such as calamine lotion and aqueous cream. Antihistamines
such as chlorpheniramine are effective and their sedative properties can
be particularly useful in patients who are sleep deprived.
Ursodeoxycholic acid has been used to good effect and improves the
biochemical profile but not necessarily the outcome. Severe pruritus
refractory to treatment may respond to steroids.

The timing and frequency of antepartum surveillance is

controversial. This is because the insult to the fetus is acute anoxia for
which there is currently no reliable investigation. Most departments
would employ monitoring to include a combination of fetal biometry,
cardiotocography, liquor volume assessment and umbilical artery
dopplers. Maternal serology should be repeated weekly and delivery
should be aimed for 38 weeks unless surveillance is abnormal, the
clotting profile is abnormal or maternal symptomatology is severe. The
mode of delivery is vaginal, usually an induction of labour unless there is
an obstetric indication for an abdominal delivery. This is a high risk
pregnancy and there should be continuous cardiotocographic
monitoring throughout labour.

The natural history o f the disease process is for spontaneous

resolution following delivery. However, all patients should have liver
function tests performed at six weeks postpartum and those with a
persistent abnormality should be referred for further investigation.
Patients should be advised o f the risk of recurrence in subsequent
pregnancies (40%) and offered advice on contraception.

The principle behind counselling with regards to contraception

should be the avoidance of oestrogen containing preparations. Thus
barrier methods of contraception and progesterone only preparations
such as the mini pill or the levonorgestrel intrauterine system may be
most suitable for these patients.

Acute fatty liver of pregnancy

Acute fatty liver of pregnancy (AFLP) is rare occurring in 1:10,000
pregnancies. The aetiology is unknown and it classically presents
peripartum. Maternal mortality is 20%. However, if the patient survives
the first 48-72 hours the prognosis is good.

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Associated factors:
• young primigravidae
• multiple pregnancy
• male offspring

Clinical features include:

• nausea and vomiting.
• severe jaundice.
• anuria or oliguria secondary to acute renal failure.
• bleeding, secondary to clotting abnormalities such as
disseminated intravascular coagulation.
• seizure episodes or impaired consciousness secondary to hepatic
encephalopathy.
• abdominal pain and bleeding secondary to placental abruption.
• upper abdominal pain secondary to intracapsular liver
haematomas or liver rupture.

Investigations:
• Haematology - full blood count and clotting profile. May reveal
thrombocytopenia, anaemia, leucocytosis and an abnormal
clotting profile.
• Biochemistry - urea and electrolytes and liver function tests.
These may reveal the following biochemical abnormalities:
hypoglycaemia, elevated transaminases, hyperbilirubinemia,
hyperuricaemia, elevated urea and creatinine and
hypoalbuminaemia.
• Liver ultrasound scan - may be normal.
• Liver biopsy - may reveal centrilobular distribution of fat within
hepatocytes with preservation of the liver architecture. Biopsy is
not safe in the presence of clotting abnormality.

Management:
An early consideration in the management of these patients should be to
expedite delivery. If a long induction to delivery is anticipated the mode
of delivery should be caesarean section. There should be a multi­
disciplinary ethos to management in a high dependency or intensive care
setting. Early involvement of senior obstetricians, anaesthetists, renal
physicians, hepatologists and haematologists is mandatory.
Haematological abnormalities may need correcting with blood
component therapy such as packed cells, fresh frozen plasma or
cryoprecipitate. Hypoglycaemia can be profound and should be
corrected with dextrose infusions. There should be strict input/output

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charting with due attention to fluid and electrolyte replacement. Central

venous pressure monitoring can help in this regard.

Renal therapy (dialysis or haemofiltration) may be required in

some patients with renal failure. Rarely, in the event o f fulminant liver
failure, transplant may represent a life saving option.

HELLP syndrome
This is a complication of pre-eclampsia and is associated with increased
maternal morbidity and poor perinatal outcome. The hallmarks are
intravascular haemolysis (H), elevated liver enzymes (EL) and low
platelets (LP).

The clinical features are similar to those o f AFLP and it tends to

occur peripartum. Evidence of haemolysis can be demonstrated by the
presence of Burr cells or fragmentocytes on a blood film, or as an
elevated serum lactate dehydrogenase. The management principles are
similar to those for AFLP. I n tr a v e n o u s s te r o id s m a y im p r o v e la b o r a to r y
in d ices b u t it is s till im p e r a tiv e to e x p e d ite d e liv e r y . Maternal
complications include acute renal failure, abruptio placentae and liver
rupture. Finally, unlike obstetric cholestasis, the risk o f recurrence of
HELLP syndrome in subsequent pregnancies is low.

Hepatotoxic Drugs
Drugs are an important cause o f hepatic injury. The liver is the
predominant site of drug clearance, biotransformation and excretion. A
wide spectrum o f abnormalities is seen from minor derangement to
fulminant hepatic necrosis. The following drugs may cause hepatic
dysfunction and jaundice: acetaminophen, isoniazid, methyldopa,
chlorpromazine and methotrexate.

Cirrhosis
Cirrhosis is usually associated with infertility. Occasionally these patients
conceive. One o f the main problems in pregnancy is bleeding from
oesophageal varices.

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KEY POINTS

• Maternal jaundice is a rare complication encountered

in pregnancy.
• It makes a significant contribution to maternal
mortality.
• Viral hepatitis accounts for 40% of all cases of
jaundice in pregnancy.
• Obstetric cholestasis is a diagnosis o f exclusion.
An early consideration in the treatment of AFLP and HELLP
should be to expedite delivery

A B D O M IN A L PAIN IN PR E G N A N C Y

IN T R O D U C T IO N
Abdominal pain during pregnancy may be due to a condition either in a
pelvic structure or in an abdominal organ. In many instances the pain
has a benign origin but in a few patients, it is of a more sinister nature as
in the case of abruptio placentae or uterine rupture. Pain is a subjective
experience and it cannot be precisely measured. About 90% of women
complain of this symptom during the course of pregnancy and the
incidence rises as term is approached. When pain awakens a patient or is
severe enough to require analgesia, a definite cause must be sought. This
is done chiefly by means of a careful history, physical examination and
recourse to appropriate investigations.

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HISTORY, EX A M IN A TIO N A N D IN V ESTIG A TIO N S

Clinical Features
To establish the cause of pain, an accurate history is essential. One
should elicit the site and nature of the pain and its mode o f onset. This
may point towards the definitive diagnosis at the outset. For example,
intermittent pain may suggest uterine contractions or ureteric colic. If
the pain is constant, consider abruptio placentae. If the pain is of sudden
onset and of a severe degree, entertain the possibility of perforation of a
viscus. Shoulder-tip pain is suggestive of diaphragmatic irritation and
when present with abdominal pain in the early weeks of gestation, an
ectopic pregnancy must be excluded. Enquire whether or not there is
associated vomiting or vaginal bleeding or fainting spells. It is obvious
that there will be diagnostic difficulties because pain and vomiting occur
sufficiently often in an otherwise normal pregnancy to delay recognition
of certain disorders such as intestinal obstruction.

On examination, one routinely records the vital signs of

temperature, pulse rate and blood pressure. If pain occurs with pyrexia,
consider an infective cause such as pyelonephritis or appendicitis. If
there is tachycardia and hypotension, associated with cold sweats and
fainting spells, think of haemorrhage as in ectopic pregnancy and
abruptio placentae.

Abdominal examination in women complaining of pain in

advanced pregnancy is a difficult proposition because some signs are
obscured by the pregnant uterus and by displacement of the viscera. It is
difficult to palpate a mass separately from the pregnant uterus beyond
16 weeks gestation.

Ultrasound examination of the abdomen is safe in pregnancy and

may be useful in evaluation of the fetus, examination o f the adnexae and
evaluating the renal and biliary tracts. Conventional X-rays, on the other
hand, expose the fetus to ionising radiation. However, a single exposure
does not increase the risk of congenital malformations and this
investigation may be useful in suspected cases of intestinal obstruction or
perforation, renal colic and gall stones. There should be a sound
indication for recourse to this investigation and all attempts should be
made to minimise fetal exposure. Multiple X-rays should be avoided at
all costs as they increase the risk of development of childhood
malignancies.

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C L A SSIFIC A TIO N
It is useful to divide ‘p a in ’ into the discomforts o f pregnancy and true
pain. It is our experience that almost all patients attending antenatal
clinic complain of some type of abdominal pain. In the vast majority, it
is of no consequence and should be considered as a discomfort. All that
is needed is reassurance, tact and sympathy.

Table 1. Causes of the discomforts of pregnancy

Condition Examples
Increasing abdominal Multiple pregnancy
distension and over­ Hydramnios
distension
Epigastric pain Pre-eclampsia
Breech presentation
Stretching o f round Primigravidae
ligaments
Lower costal margin pain Primigravidae
(R>L) Large babies
Pendulous abdomen Grand multiparae

Table 2. Causes of true pain in pregnancy

Uterine Miscarriage
Red degeneration of a fibroid
Concealed abruptio placentae
Ruptured uterus
Ruptured cornual pregnancy
Labour
Adnexal Ruptured tubal pregnancy
Tubal miscarriage
Torsion of an ovarian cyst e.g.
dermoid
Rupture of an ovarian cyst
Extra-uterine Urinary tract problems
Gastro-intestinal disturbances
Sickle-cell crisis
Extra-uterine pregnancy

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MANAGEMENT
Uterine and adnexal origin
A vaginal examination is mandatory in early pregnancy to rule out
fibroids and ovarian cysts. An ultrasound scan is indicated if these
tumours are felt. The management o f red degeneration of a fibroid is
conservative, though these patients may require high dose opioid
analgesia. Complex ovarian masses suspicious o f malignancy require
further investigation. This may include MRI scanning or laparotomy. If
diagnosed in early pregnancy and the index o f suspicion is high, the
optimum time for surgical intervention is the second trimester. On the
other hand, torsion o f an ovarian cyst warrants immediate laparotomy
irrespective o f gestation.

Vaginal and speculum examinations are essential when patients

present with intermittent pain suggestive o f uterine contractions. The
management is as outlined in the chapter on Preterm Labour.

Extra-uterine origin
Urinary tract problems
• Acute retention of urine may be caused by compression o f the
urethral sphincter by a retroverted gravid uterus. It typically
occurs prior to 14 weeks in patients with a generous pelvis and a
prominent sacral prom ontory. They may require catheterisation
until the uterus has migrated out o f the pelvis.
• Acute pyelonephritis occurs more com m only on the right side
and during the second trimester o f pregnancy. These patients
require admission to hospital for parenteral antibiotics.
• Renal colic from calculi is rare but occurs more com m only on
the right side and is an important cause of haematuria. The pain
is usually severe and they are best managed in hospital. The
management is initially conservative with adequate analgesia
though these patients should be promptly referred to the
urologists.

Gastro-intestinal disturbances
• Epigastric pain may be due to recurrent vomiting. It is an
ominous sign in pre-eclampsia because it suggests hepatic
involvement and distension o f G lisson’s capsule.
• Reflux oesophagitis may cause heartburn. This is due to the
pressure effect of the gravid uterus and relaxation o f the cardiac

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sphincter of the oesophagus. Antacids are the mainstay of

treatment.
• Ulcers are rare in pregnancy. Epigastric pain and haematemesis
may occur. The management is similar to that for the n o n ­
pregnant patient.
• Acute appendicitis is the most com m on surgical condition
encountered in pregnancy. In late pregnancy the gravid uterus
may shift the appendix upwards and laterally and hence this may
present with right upper quadrant pain. The treatment is surgical;
appendicectomy achieved either laparoscopically or via a midline
laparotomy incision depending on the gestation.
• Cholecystitis is the second most common surgical condition
encountered in pregnancy. The diagnosis is similar to that in the
non-pregnant patient with right upper quadrant pain and a
positive M u rp h y ’s sign. The management is either conservative
or surgical.
• Pancreatitis is a rare complication of pregnancy. These patients
classically present with epigastric pain that radiates to the back
and is associated with nausea and vomiting. The mainstay of
management is intravenous fluids, a nasogastric tube and
adequate analgesia. There should be a low threshold for
multidisciplinary input and management of these patients in an
intensive care setting.
• Acute intestinal obstruction is a surgical emergency. The initial
management involves a nasogastric tube and intravenous fluids.
An abdominal X ray may be helpful in this circumstance.
• Constipation is a common occurrence in pregnancy. This is
primarily due to the inhibitory effect o f progesterone on the
smooth muscle of the bowel. The management revolves around a
high fibre, increased fluid intake and the use o f laxatives. Motility
stimulants are safe in pregnancy but not usually required. Stool
softeners such as lactulose and bulking agents such as fybogel are
usually sufficient.

Sickle-cell crisis
• Vaso-occlusive crises in patients with sickle-cell disease in
pregnancy are extremely painful. Musculo-skeletal pain is the
most common complaint. Pain over costo-chondral junctions,
spleen and liver is seen more frequently in the older patient.

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• An abdominal crisis associated with acute abdominal pain and

marked elevation in liver enzymes and serum bilirubin, occurs in
about 10% of patients with sickle-cell disease. Furthermore, there
is a high frequency o f pigmented gall stones which may give rise
to pain in the right hypochondrium .
• These patients should be well hydrated and well oxygenated.
They usually require high dose opioid analgesia.

Extra-uterine pregnancy
• This is a rare occurrence but should be suspected in patients with
chronic pain that is worse on movement o f the fetus, and in whom
fetal parts are easily felt. An ultrasound scan should clinch the
diagnosis.

PAIN AFTER V A G IN A L D E LIV E R Y

Postpartum uterine pain occurs frequently and is due to efficient
contraction and retraction of the myometrium following the
administration of syntometrine. Oral analgesia is all that is required. The
combination of paracetamol with an antispasmodic such as buscopan is
particularly useful. Abdominal pain persisting after delivery and
associated with postpartum haemorrhage and hypotension, should lead
one to suspect rupture o f the uterus, particularly if the patient had a
difficult vaginal delivery or one following a previous caesarean section.

Pain in the perineal area may be due to lacerations or an

episiotomy. It may cause acute retention of urine, and defaecation may
be almost intolerable. Sitting may be agonising, particularly when there
is perineal oedema, bruising and a haematoma. The treatment options for
postnatal perineal discomfort include:
• Cold sitz baths and advice about perineal hygiene
• Pulsatile electromagnetic irradiation (PEMI)
• Adequate analgesia - oral, topical or rectal
• Antibiotics if infection is suspected
• Stool softeners.

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KEY POINTS

• Abdominal pain is common in pregnancy.

• Epigastric pain is an ominous sign in pre­
eclam psia. It may be indicative of hepatic
involvement.
• Constant abdominal pain in the late second and
third trimester may be due to placental abruption.
• Acute appendicitis is the most common surgical
condition in pregnancy. It may present with right
upper quadrant pain.
• Acute cholecystitis is the second most common
surgical condition in pregnancy. It may present
with right upper quadrant pain.

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CHAPTER EIGHT

ADOLESCENT PREGNANCY
ADVANCED MATERNAL AGE
GRAND MULTIPARITY
OBESITY

ADOLESCENT PREGNANCY

INTRODUCTION
With the exception of Australia, teenage pregnancy is occurring with an
alarming frequency throughout the world, in developed as well as
developing countries. In the USA, the haunting tale o f unintended
pregnancies is rewritten every 2 minutes, when another adolescent
conceives. O f every 100 American girls, one will give birth by the age of
15 years and 33 will give birth by the age of 19 years. Each year, 1 out
of 10 adolescent girls aged 15-19 becomes pregnant. This represents
25% of those who are sexually active.
In many Caribbean countries, almost 60 percent of all first births
occur to teenagers, and one-half of these are to women 17 years and
under. Table 1 shows the num ber of births per 1000 women aged 15-19
in some countries in the region.

Table 1. Births per 1000 women aged 15-19 years.

Brazil 58.0 Antigua 90.0

Cuba 95.2 Barbados 91.7
Mexico 103.5 Guyana 120.0
Venezuela 105.4 Jam aica 113.0
St. Vincent 162.0

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In Trinidad and Jamaica, 1 in 5 o f all births is for a teenager, but

most teenage pregnancies occur in patients between the ages o f 17 and
19 years (Table 2).

Table 2. A ge and parity distribution in Trinidad teenagers

(Suratsingh et al., 1981)
A ge (years) Parity Total
0 1 2 3

13-15 16 2 0 0 18
16 22 6 0 0 28
17 41 10 1 0 52
18 34 14 3 0 51
19 40 28 5 3 76

Total 153 60 9 3 225

Black teenage pregnancy rates in the USA are even more

disturbing: almost twice that for whites. Nearly half o f U.S. black females
are pregnant before they are 20, and 4 out o f 5 black teen m others are
unm arried. In England and Canada, however, pregnancy in adolescents is
not exclusively a problem o f y oung black women.

The USA leads nearly all other industrialized nations in teenage

pregnancy, abortion and childbearing and is the only country where
teenage pregnancy is increasing. For exam ple, the study conducted by
the Alan G uttm acher Institute found that the U.S. pregnancy rate for 15
to 19 years olds (9.6% ) is twice that of Canada, E ngland or France
(4.4% ) and seven times that o f the N etherlands and Japan (1.4% ).

In 1994, an estimated 910,600 teenagers 15-19 years old became

pregnant in the USA, resulting in 505,500 live births, 276,380
terminations o f pregnancy and 128,730 fetal losses. The same year,
about 29,000 girls u n d er the age o f 15 also became pregnant.

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M ultiple factors c o n trib u te to these a larm in g statistics. The

progressively earlier onset o f m e n arch e and fertility, increasing sexual
activity in y o u n g e r individuals, often w ithout c o n tra ce p tio n , and a trend
toward a m ore u rb a n iz ed society with fewer constraints have been
postulated as significant factors.

T he upw ard trend in early sexual activity in all g e o g ra p h ic areas

has led to a g reater likelihood o f p re g n a n c y . In o th er w ords, in any
society with a large percen tag e o f sexually active y o u n g u n m a rrie d girls,
the risk o f c o n ce p tio n escalates and this leads to behavioral and
sociologic p ro b lem s.

The social and e co n o m ic co n se q u e n ce s o f teenage p re g n a n c y are

numerous: children raised in fatherless h o m es with little e c o n o m ic
opportunity, unw ed m others tra p p e d in a cycle o f poverty create what
leaders have term ed “ a national catastrophe in o u r m id s t” .

Lacking jo b skills and u n ab le to return to sch o o l, teen m o th ers

are much m ore likely to live below the poverty line. T h e y them selves
were daughters o f teenage m o th ers. T h e y suffer fro m neglect and abuse
because o f frustration and im m atu rity , and c o u p le d with m isin fo rm atio n
they becom e m others them selves.

Teenage child b irth is associated with increased health h azard s.

Many adolescents do not attend antenatal clinics and if th ey do, they
seek care only in the latter m o n th s o f p re g n a n c y . In m an y cases, p re ­
maturity and low birthweight babies are the e n d result. ,

A 1985 poll c o n d u c te d fo r Plan n ed P a re n th o o d by the H arris

organization revealed that 85% o f A m erican adults see teen ag e
pregnancy as a serious national p ro b le m . In co u n tries with the most
liberal attitudes toward sex, the m ost easily accessible co ntraceptive
services for teenagers and the most effective p ro g ra m m e s fo r sex
education have the lowest rates o f teenage p re g n a n c y . T he converse is
true: countries with the least o p en attitudes toward sex are those with the
highest teenage p re g n a n cy rates. The G u ttm a c h er study has fo u n d that
increasing the legitimacy and availability o f co n tra ce p tio n and sex
education in schools has resulted in lower teenage p re g n a n c y rates.

Clearly, schools are not the only m eans o f c o m m u n ic a tin g

messages about sexual responsibility to teens. T h ere m ust be a c o n ce rte d
effort on the part o f the h o m e , the c h u rc h and the state. A n a tio n ’s

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children are its greatest assets and no effort should be spared to bring
them up in a morally healthy environment.

ANTENATAL CARE
Pregnant adolescents require special management because of their age
and social circumstances such as marital status and educational
achievement. They should be seen early in gestation and examined once
every 4 weeks until 28 weeks, every 2 weeks until 36 weeks and weekly
thereafter.

They experience a number of emotional reactions but guilt

feelings are uncommon. A sympathetic attitude is required and the help
of a social worker is advisable.

A careful history should be taken in a relaxed way with time to

establish good rapport. Specific questions should include exposure to
drugs in the first trimester as a test for pregnancy (oestrogen /
progesterone), narcotics, heroin and marijuana. This is a relevant point as
far as fetal malformations are concerned, as well as carcinogenic and
behavioural consequences.

A good examination with the utmost sensitivity is of paramount

importance. The procedure should be carefully explained; teens tend to
be frightened or emotionally upset. Important too, is that the
examination must not be traumatic. Clinical pelvimetry is best deferred
until 36-38 weeks. Apart from routine haematinics, she should be
advised to follow a balanced diet, bathe regularly and obtain sufficient
rest and exercise. Antenatal exercise classes are recom m ended and she
should be allowed to visit the labour ward some time during the third
trimester.

A N T E N A T A L C O U R SE
• Nausea and vomiting (see Chapter seven).
• Hypertensive disorders of pregnancy. Essential hypertension is
rare in this age group. Pre-eclampsia has been noted to be the
commonest complication in teenage patients. The incidence
varies from 6.6% to 29.0%. In a Nigerian study, 17% of girls
aged 14 or less developed eclampsia compared with 7% of those
aged 16 years and 3% aged 20-24 years.

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• Anaemia. Suratsingh et al (1981) recorded that only 5.5% of

adolescent pregnant girls in Trinidad were anaemic (Hb < 10
g/dl). This low incidence was attributed to nutritional
supplementation to their patients. Osofsky et al (1968) and
Perkins et al (1978) found anaemia to be a frequent occurrence.
Along with the high growth rate around the time o f puberty, the
beginning o f menses, and poor nutrition, pregnancy can deplete
the b o d y ’s iron reserves.
• Preterm labour. About 12-15% o f teenage mothers go into p re­
term labour.

IN T R A P A R T U M C O U R SE
The majority o f patients deliver vaginally with minimal problems.
Analgesics should be administered liberally. O f importance is that
teenage girls should never be left to labour alone. The doctor or mid­
wife should be in constant attendance.

Since adolescents often become pregnant before full skeletal

growth has been achieved, it is not surprising that spatial problem s arise.
Caesarean section is required in a small percentage o f adolescents in
whom the primary indication is usually cephalopelvic disproportion. For
example, small pelvic architecture with a relatively large baby or a
malposition (occipito-posterior) is not an u n co m m o n finding.

PO STPA R TU M C O U R SE
There is no evidence that they are more prone to postpartum
haemorrhage. Several workers have found an increased incidence of
puerperal fever from pyelonephritis and mastitis. Apart from teaching
the teenager how to breastfeed her infant, she should be strongly advised
to use contraceptives, and should be referred to a family planning clinic
in 6 weeks time.

FETAL O U TC O M E
The end result of adolescent pregnancy depends on the type o f care
administered. Prematurity and low birthweight are the chief problem s.

Jekel et al (1972) com pared the outcome in mothers over 20 with

those under 20 years and found no significant difference in perinatal
loss. The perinatal mortality rate in the Trinidad study was only 8.9 per
1000 total births. In other words, with conscientious antenatal care and

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intrapartum monitoring, there appears to be uniformly good fetal

outcome in adolescent gestation. In contrast, statistics collected in the
USA and UK show relatively high perinatal mortality rates for mothers
younger than 15 years of age.

PR EV EN TIO N OF T EE N A G E PR E G N A N C Y
• Provide adolescents with general information about sex and birth
control, and give them an opportunity to share their own
experiences related to dating, sex and contraception.
• Modulation of teenage behaviour. Teenagers should be
encouraged to discuss with their friends and classmates the
realities of pregnancy, delivery and childcare. Negative peer
pressure for adolescent pregnancy has been found to be an
effective approach.
• Oral contraception.

SU M M A R Y
The medical consequences of teenage pregnancy are less serious than the
social and psychological ones. The emotional immaturity and lack of
preparation for the adult responsibilities o f motherhood frequently
results in psychological crises, which may be perpetuated in marital
maladjustment. The subsequent social handicaps for the teenage mother
are greatly increased in countries with relatively high rates o f out-of-
wedlock pregnancies. The reduced life expectancy of infants born to
these unmarried teenagers is well documented.

In the West Indies, it has been found that teenage pregnancy rates
are inversely related to the degree of stability within the family where the
parents themselves are unmarried, where the fathers are multiple or
absent and where the locus of moral authority is ill defined, the incidence
of adolescent pregnancy is highest.

Each year, about 14 million young women aged 15-19 give birth
worldwide. Teenage childbearing is most com m on in the developing
world, where the proportion of women who have their first child by age
18 is often between 25 to 50 per cent. By contrast, in the developed
world, fewer than one in ten have an early first birth.

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Although early marriage is less com m on now than it was a generation

ago, considerable variation exists am ong and within regions. For
example, the proportion o f women who had married by age 18 has
changed little in Ghana (39% of 40-44-year-olds versus 38% of 20-24-
year-olds), but has declined markedly in Kenya (47% versus 28%). By
contrast, substantial declines have taken place th ro u g h o u t Latin America
and the Caribbean, where the incidence of adolescent births to unmarried
women is now 12-25%.

Delaying childbearing benefits young women by giving them

more time to acquire education and develop skills that will enhance their
ability to care for their families and compete in the job market. It can
also have a dramatic impact on the rate of population growth. In many
developing countries, a woman who has her first child by age 18 will
have an average o f seven children. Postponing the first birth until her
early 2 0 ’s reduces the average num ber o f births to four.

The future rests heavily on the welfare o f adolescent women - on

how well they fulfill their roles as mothers, as contributors to the
economy, as teachers of the next generation and as sources o f strength
for their communities. They need to be informed about the importance
of antenatal care; they need social support during pregnancy; they
require assistance with breast-feeding, advice about nutrition, information
about immunization and they need contraceptive counselling in order to
delay the next pregnancy.

A D V ANCED M A T E R N A L A G E

INTRODUCTION
There is ample evidence to suggest that the num ber o f deliveries am ong
women in the latter part of their childbearing years is steadily increasing.
One reason for this trend is that some women intentionally delay their
plans for having children either in pursuit o f a career or, with their
husbands, they may wish first to establish themselves financially.
Furthermore, the post-war baby boom has resulted in an unprecedented
number of pregnant patients, aged 35 years or more, in the present
decade. In our setting, the low acceptance o f family planning methods
also plays a major role.

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Table 3. Antenatal complications with advanced maternal age.

Hypertensive disorders
Fibroids
Anaem ia
Pyelonephritis
Preterm rupture of membranes
Antepartum haemorrhage
Diabetes mellitus

Patients who become pregnant at age 35 years or more are

generally considered as ‘‘older gravidae” . The risks to primigravid
patients become significant at age 35 (elderly primigravida) and those to
the multiparous woman assume major significance at the age of 40 years.

Motherhood has been likened to a typical athletic performance,

and the capacity to undertake it in an efficient manner, falls off rapidly
with advancing age (Horger and Smythe, 1977). It is not surprising,
therefore, that numerous reports have appeared in the literature citing the
dangers of pregnancy in the elderly mother.

Since a wide spectrum of complications increases in frequency

with increasing maternal age, both Obstetricians and patients should be
aware of the many risks associated with delayed pregnancy.

Nortman (1974), for example, noted increased maternal and

perinatal mortality rates, as well as increased incidence of Dow ns’
syndrome and other congenital malformations in the offspring.

Mulcahy and Knaggs (1968) reported increased risks of

abortions, perinatal mortality and congenital defects with advancing
maternal age, especially after the age of 40.

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ANTENATAL COMPLICATIONS
Hypertension and pre-eclampsia
The hypertensive disorders of pregnancy are the commonest antepartum
complications, occurring in about one-third of elderly women.
Hypertensive vascular disease is a function o f age because as Nelson
(1955) pointed out “ after the age of 30, the blood pressure begins to
rise appreciably in the population as a whole” . Superimposed pre­
eclampsia may occur in many of these patients.

Uterine fibroids
Compared to a group o f younger patients, fibroids occurred more
frequently in a group o f elderly primigravidae in a Trinidad population
(6.0% versus 0.0%). The significance of this is that multiple fibroids
predispose to abnormal fetal lie and to obstructed labour. The elective
Caesarean section rate, therefore, is increased. Other complications which
fibroids may cause are:
• Spontaneous miscarriage.
• Abdominal pain due to red degeneration or torsion.
• Postpartum haemorrhage.

Pyelonephritis
Although some authorities have reported that chronic bacteriuria or
acute pyelonephritis occurs in 7-10% of pregnancies in women over 35
years of age, this is comparable to that usually seen in any antenatal
population.

Antepartum haem orrhage

This complication occurs in about 7% of elderly gravidae and is chiefly
due to abruptio placentae. Placental abruption bears a direct relationship
to hypertension and in older multigravidae possibly to folic acid
deficiency. Placenta praevia is not more com m on in older patients.

Diabetes mellitus
Diabetes may act in a manner similar to hypertension: there is an
increasing frequency by virtue of advancing age. Diabetes itself may be
associated with a higher perinatal mortality rate for older com pared to
younger pregnant women.

Premature rupture of the membranes (PRO M )

Kessler et al (1980) found an increased incidence of 13% for PROM
among elderly primigravidae compared to a 4% incidence among
primigravidae aged 20 to 25.

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Onset of labour
The need for induction of labour arises more frequently among older
mothers. From what we have stated before, this is not surprising. The
common indications for induction are premature rupture of the
membranes, hypertension, and pre-eclampsia and postdate pregnancies.

INTRAPARTUM COMPLICATIONS
Prolonged labour
Prolonged labour is defined as labour lasting for more than 24 hours.
On review of the literature, there is a suggestion of increasing duration of
labour with advancing age among primigravidae but little evidence of an
association with age among multigravidae. Prolonged labour is
associated with maternal distress when the patient develops dehydration,
tachycardia, ketosis and fever. She is unlikely to compensate as well as
her younger counterpart.

Intrapartum fetal distress

Fetal distress during labour in the elderly primigravid patient develops
far more often than is generally realized. Two major factors operate at
this time to put the fetus at risk from hypoxia: hypertension and
prolonged labour. For this reason, these patients should have artificial
rupture of membranes in early labour in order to ascertain whether or
not the liquor is meconium-stained. Continuous fetal heart rate
monitoring is advised throughout labour.

Caesarean section
Caesarean section rates vary proportionally with maternal age. In a study
in Trinidad we found that the rate among primigravidae aged 30 years or
more was 30.8% compared to 6.7% in a group of young primigravidae,
aged 20 to 22 years. Blum (1979) reported Caesarean section rates for
primigravidae as follows: age 20 to 29 - 2.3%; age 30 to 34 - 21.6%;
and above 35 years - 49.1%. Morrison (1975) cited a rate o f 31%
compared to a rate of only 3% among primigravidae less than 35. The
chief factors accounting for this trend are uterine fibroids, prolonged
labour and intrapartum fetal distress.

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MATERNAL OUTCOME
In present day Obstetrics there is little evidence to suggest that maternal
mortality for patients aged 35 years and older in developed countries is
any greater than their younger counterparts. However, in contrast. Figure
1 shows the increasing risk to the mother, from data obtained in Thailand
in 1970. It appears that there was a gradual increase in maternal
mortality from age 30.

Figure 1. Maternal mortality in relation to age o f mother.

Thailand, 1970.

FETAL OUTCOME
Spontaneous miscarriage
There is some association between maternal age and increased risk for a
first trimester spontaneous miscarriage. However, the magnitude of the
risk is not clear.

Birthweight
The Trinidad study revealed that maternal age has no bearing on
birthweight, either low birthweight (< 2500 g) or macrosomia (> 4000
g). There appears to be universal agreement on these findings.

Perinatal mortality
There is a consistent pattern of higher perinatal mortality rates among
the elderly, in the United States (Hansen, 1980) and in Scotland
(MacDonald and MacLennan, 1960). We obtained good perinatal results
in a study of elderly primigravidae in Trinidad, and this was related to a

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more liberal policy of Caesarean section particularly for protracted

labour.
Hansen (1980) states that the evidence in the USA appears very
strong that the stillbirth rate increases significantly with maternal age to
an approximate 2-fold risk for women in their mid-to upper thirties and
to a 3-to-4-fold risk for women in their early forties.

Chrom osom al abnormalities

There is a definite association between maternal age and chrom osom al
abnormalities, with a dramatic increase after age 40. The evidence for
this has been derived from:
• analysis of abortuses
• mid-trimester amniocentesis
• analysis of congenital abnormalities in live births.

Examination of karyotyped abortuses has revealed a definite trend

with the following rates o f chromosomal abnormalities by age
category: 35-39 (1.6%); 40-44 (6.0%); 45 and older (25.0% ). The
effect is greater for autosomal trisomies.

Analysis o f fetal cells obtained by amniocentesis in the mid­

trimester indicates that the risk o f having a live fetus with a
chromosomal abnormality increases from 1.3% at age 35 to 2.0% at
age 40, and to 8.0% at age 45.

The incidence o f Downs’ syndrom e is increased in older women

from 1.0% at age 30, to 2.5% at age 35 and 11.0% at age 40. The
implications o f these findings should be clear. The doctor needs to
be aware of them in order to advise and counsel older mothers.
However, one should heed the words of M acDonald and MacLennan
written over a quarter o f a century ago: “ A lthough it is apparent
that 1 in 25 elderly primigravid mothers will have a congenitally
abnormal baby, the joy o f a healthy, though Hate’ baby to a
comparatively aged mother must far outweigh this ris k ” .
Morrison (1974) refers to the elderly primigravida as having a
“ prem iu m p reg n an cy ” and as the due date is approached, careful
assessment with a view to delivery at term is essential. Although he is
in favour of liberal intervention and elective abdominal delivery,
particularly in cases unfavourable for induction o f labour, one
should aim for a vaginal delivery in the absence o f any Obstetrical
or Medical complication. However, there should be a low
‘threshold' for intervention and delivery by Caesarean section.

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GRAND MULTIPARITY

DEFINITION
The term grand multiparity applies to a pregnant patient who has had 5
or more deliveries bey o n d the 28th week o f p regnancy.

INCIDENCE
The problem o f grand multiparity occurs chiefly in countries o f the third
world. The World Health Organization has estimated that 40% o f women
in developing countries have more than 4 children. The total fertility rate
ranges from 2.4 to 6.5 in Latin A m erica and the Caribbean and from 5.3
to 8.3 in sub-Saharan Africa.
The main factors contributing to excessive childbearing are
poverty, lack o f education and unstable sexual relationships. The
converse o f this is also true: better educational opportunities and living
standards and a more realistic approach to contraception have been
responsible for the dramatic reduction in the incidence o f grand
multiparas in industrialized nations.

The several factors that contribute to the high incidence o f grand

multiparity are shown in Table 5.

Table 5. Contributory factors.

(1) Early start to a reproductive career.

(2) Late finish to a reproductive career.
(3) Illegitim acy.
(4) Religious beliefs.
(5) Opposition to contraceptive technology.
(6) Psychosocial circum stances.

In many countries, grand multiparity is c o m m o n because of

cultural, traditional and religious reasons. For exam ple in Israel, the
Government’s policy actually encourages large families, morally and
 ADVANCED MATERNAL AGE

economically. In several African countries, it is traditional that women

marry at an early age and bear children while they are still quite young.
Many African women are therefore, grand multiparous at a relatively
young age. In Trinidad, one o f every five pregnancies occurs in a grand
multipara, and the incidence is higher am ong East Indians than Negroes.

Whatever the reasons for frequent childbearing, there is consensus

that the risks to the mother and fetus increase markedly. While careful
Obstetric surveillance is required to minimize these risks, contraception
or sterilization should be an integral com ponent in the overall
m anagement o f these women.

A N T E P A R T U M C O M PLIC A TIO N S
Table 6 lists the various complications, which may be encountered in the
grand multipara, during the course o f pregnancy. There is little doubt
that the induced abortion rate am ong women o f high parity is increased.
This is most likely due to the high percentage o f unwanted pregnancies.

Table 6. Antepartum problems.

Increased rate of miscarriage/term ination

Anaem ia
Hypertensive disorders
Gestational diabetes
Antepartum haem orrhage
Multiple pregnancies
M alpresentation
Fetal m acrosom ia
Rhesus iso-immunization
Varicosities and haem orrhoids

Anaemia, defined as a haem oglobin o f less than 10 g/dl, is one o f the

com m onest complications. Frequent childbearing allows little time for
the mother to replenish her iron stores. It is not surprising; therefore, that

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many grand multiparous mothers enter pregnancy with an iron

deficiency. A similar state of affairs occurs with respect to vitamins, and
folic acid deficiency is also a major problem. These women should,
therefore, receive prophylactic iron and folic acid for the entire
pregnancy.

By virtue of their advancing age and life-stress situation, grand

multiparae tend to develop hypertension. Both hypertension and folate
deficiency are believed to cause abruptio placentae.

It is important to watch for malpresentation and unstable lie near

term in the high parity group o f patients. Early recognition and
appropriate management may avoid the possible deleterious effects of
these conditions.

Many of the minor discomforts of pregnancy are increased.

Haemorrhoids and varicose veins of the legs and vulva are com m on.
Pelvic discomfort and low backache may cause disturbance of sleep.

INTRAPARTUM COMPLICATIONS

Table 7. Complications of labour.

Preterm labour
Precipitate labour
Unstable lie
Cephalo-pelvic disproportion
Prolapse of the cord
Postpartum haemorrhage
Uterine rupture

As stated above, unstable lie and malpresentation are worrying

problems in the case of women o f high parity. If she goes into labour
with a malpresentation or if the head is high, the membranes may rupture
spontaneously and the cord may prolapse. It is our view that the best

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managem ent for the grand multipara with an unstable lie near term is
Caesarean section.

Occasionally, one encounters prolonged labour due to cephalo-

pelvic disproportion. This may be due either to deflexion o f the head
during labour or to a large infant. It should be rem em bered that,
generally speaking, there is increasing birthweight with increasing birth
rank and it is not entirely surprising for a mother to give birth to a
macrosomic infant in a later pregnancy.

Postpartum haem orrhage is perhaps the greatest hazard a

multiparous woman faces. It is due to uterine atony because in each
pregnancy muscle tissue is replaced by fibrous tissue and therefore,
retraction is interfered with. Donald stresses that it is not the contractility
o f the muscle that is at fault because often an atonic postpartum
haem orrhage may follow a precipitate labour. It is for this reason, that we
set up a 5% Dextrose-water drip at the onset o f labour and administer
Syntometrine intravenously into the rubber bung o f the G iving’s set,
with the delivery o f the anterior shoulder, in order to prevent postpartum
haemorrhage. If the uterus continues to relax, it is advisable to add 20
units o f Syntocinon into the infusion. An additional cautionary measure
is to have two units o f blood readily available for all grand multiparous
mothers in the birth department.

The Course of Labour

The dynamics of labour have been studied in grand multiparae and a two
com ponent curve for cervical dilatation and for descent o f the presenting
part has been described. Labour on the whole tends to be rapid. Figure 2
shows the pattern of cervical dilatation. One com ponent is linear with a
minor upward slope while the second has a rapid upward slope. It would
appear that the onset o f labour in the grand multipara begins at a
dilatation o f about 3 cm. The exponential increase of the rate o f cervical
dilatation which signals the beginning of a distinctive active phase of
labour occurs at 5 to 6 cm. Full dilatation occurs in an explosively rapid
fashion.

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Figure 2. C ervical dilatation

TIME (HRS)

Figure 3 shows the curve for descent o f the head. Descent tends to be
minimal until the cervical dilatation is > 7 cm after which descent is
abrupt.

In other words, a seemingly prolonged first stage o f labour in the

grand multipara is not a cause for concern until the onset o f the active
phase of labour, i.e. at 5-6 cm.
Similarly, failure of the fetal head
to descend is not a cause for
concern until the cervix is > 7 cm
dilated.

Figure 3. Descent.

PERINATAL OUTCOME

Several authors have reported increased perinatal mortality and morbidity

rates in the high parity group o f women. W e agree with an Australian
study by Chang and colleagues (1977) that close supervision during
labour and frequent Obstetric intervention will result in improved status o f
the newborn.

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C O N T R A C E PT IO N
It is disconcerting that despite econom ic stagnation in most third world
countries, more than half of the grand multiparae refuse or are not
interested in sterilization. Male opposition to contraception is a
significant problem in the Caribbean and large families result in a short
time span. Should the woman decide to take a unilateral decision, there is
a risk o f disruption o f family life and marital disharm ony. While religion
and superstition are some o f the other reasons advanced for a large
family, we agree with Goldheizer (1979) that no com m unity can rise
from destitution to dignity without the contribution o f family planning.

OBESITY

DEFINITION
A rbitrarily, some workers have considered pregnant patients to be obese
if their weight is > 80 kg. The best criterion for determ ining obesity is a
body mass index (BMI) > 30.

BMI = weight (kg)

height2 ( n r )

A N T E N A T A L C O U R SE
• Pregnancy-induced hypertension. The incidence o f this
com plication is significantly increased am ong obese patients. In a
recent study in Trinidad, we found that this risk was 4-5 times
greater than am ong non-obese m others. However, there is
nothing we are currently able to do to prevent the developm ent of
this disease. Im position o f caloric restrictions is not
recom m ended. There is an increased incidence o f placental
abruption, which may be related to the increased incidence of
pre-eclam psia among this group.
• Diabetes mellitus. The obese m other is at an increased risk of
diabetes. Our analysis has revealed that 1 in 9 obese m others will
develop gestational diabetes. M aternal obesity is therefore an
indication for screening for diabetes.
• Difficulty in palpation is experienced because o f the presence of
abdom inal fat. This gives rise to problem s in determ ining the
presenting part and estimating fetal size. There is also difficulty
in hearing the fetal heart sound with the P in ard 's stethoscope.

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• Large-for-dates. This is due to fetal m acrosom ia (> 4000 g).

• W eight-gain. Obese women have a greater tendency toward poor
weight-gain and a lower mean gestational weight-gain com pared
with norm al-weight women.

IN TR A PA R TU M C O U R SE
• Traum atic vaginal delivery. If the birthweight exceeds 4000
grams, labour might be prolonged requiring assistance in the
second stage with forceps. Shoulder dystocia is a distinct
possibility with fetal m acrosom ia. Correct identification o f a large
baby has its limitations either by ultrasound or clinically. It is
better to err on the side o f caution and avoid the vaginal route if
macrosom ia is suspected.
• Increased rate o f Caesarean section.
• Fetal m acrosom ia. Obese m others are delivered o f m ore
m acrosomic and fewer low-birth-weight babies than are non-
obese mothers.

PERINATAL O U T C O M E
Several authors have reported that maternal obesity is associated with
poor perinatal and neonatal outcom es. The increase in perinatal
mortality rate has been attributed to the pregnancy risk factors o f
hypertension and diabetes. Fetal birth injuries from difficult vaginal
deliveries account for significant m orbidity.

We have recently reported a low incidence o f preterm delivery

and intra-uterine growth retardation, as well as a low perinatal mortality
rate in obese gravidae. These encouraging findings were due to:
• Careful antenatal surveillance for pregnancy-induced
hypertension.
• Routine screening fo r diabetes in all obese m others.
• Aggressive approach in favour of Caesarean section, particularly
in cases of suspected fetal macrosom ia and failure to progress in
labour.
• Intensive neonatal care o f these infants.

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M A T E R N A L O U TC O M E
• M aternal injuries to the genital tract are more com m on.
• Because o f overdistension o f the uterus, postpartum uterine atony
may occur. Furtherm ore, the placental site is larger with a large
baby. These two factors predispose to postpartum haem orrhage.
• Haematoma and infection o f the abdom inal wound are com m on.
• Deep vein throm bosis is more likely, because o f a sluggish
circulation.
• Increased maternal mortality.

KEY POINTS

• A dolescence, advanced maternal age, grandmultiparity

and obesity are associated with high risk conceptions
with implications for both mother and fetus.
• Pre-eclam psia is more common at the extremes of
reproductive age.
• Postpartum haem orrhage is a potential complication of
grand multiparity. There should be a low threshold for
a prophylactic postpartum Syntocinon infusion.
• The obese parturient is at particular risk of developing
pregnancy induced hypertension and diabetes mellitus.
All obese patients should be offered glucose screening at
28 weeks gestation.
• Due consideration should be given to the use of
compression stockings and low m olecular weight
heparin in the obese parturient in the postpartum
period.

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CHAPTER NINE

FACTORS AFFECTING BIRTHWEIGHT

INTRA UTERINE GROWTH RESTRICTION
FETAL MACROSOMIA

INTRODUCTION
During its intra-uterine existence in the m other for approxim ately 266
days, the fetus may be considered as another body com partm ent,
deriving nutrients and elim inating waste products across the placenta via
the maternal circulation.

The fetus grows from a single fertilized cell, which first

undergoes m ultiplication millions o f times. This is essentially under
genetic control so that an abnorm al genetic influence may lead to poor
fetal growth from the early stages o f developm ent. Subsequent to cell
multiplication, the phase o f active growth takes place and the welfare o f
the fetus now becom es dependent upon placental function. Should there
be an inability of the placenta to handle the exchange o f gases (oxygen
and carbon dioxide) or nutrients such as glucose, then there will be a
decrease in the supply to the fetus, and this “ placental in su ffic ie n cy ”
may lead to dim inished fetal growth, resulting in a sm all-for-dates (SFD)
infant.
On the other hand, some babies are fast growing and becom e
large-for-dates (LFD). Obstetrical concern for these babies lies in their
association with the diabetic state in the m other and with increased
maternal and fetal com plications at the time of delivery.

DEFINITIONS
Small-for-dates (SFD) or Sm all-for-gestational age (S G A ) indicates
that a fetus or neonate is below a defined reference range o f weight for a

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particular gestational age. This is usually taken to be below the tenth

centile for estim ated fetal w eight. These fetuses are either constitutionally
small or they are grow th restricted. T he latter g ro u p has failed to achieve
their grow th potential and is deem ed to have intra-uterine grow th
restriction (IU G R ).

L arge-for-dates (L FD ) or L arge-for gestational age (L G A ) refers to a

fetus whose estim ated w eight is above the 9 0 th centile fo r a particular
gestation. Sim ilarly it can be applied to infants whose birthw eights are
two standard deviations above the mean fo r the period o f gestation. By
convention, fetal m acrosom ia indicates a birthw eight o f m ore than 4 000
gram s in a term infant.

Low birthweight (L B W ) infants are those w eighing 2 500 gram s o r less

at birth. T his w eight-lim it co n cep t applies regardless o f the perio d o f
gestation. It m ay be due to prem ature delivery o f a fetus w hose grow th is
ap p ro p riate fo r gestational age, or a fetus w hose grow th is inap p ro p riate
fo r the period o f gestation (IU G R ).

W hen the fetus is delivered spontaneously o r electively at a

gestational age o f less than 37 com pleted weeks (2 5 9 days), it is regarded
as “ p re -te rm ” ; betw een 37 and < 42 w eeks, it is a " te rm in fa n t” and at
42 weeks or m ore, it is " p o s t-te rm ” .

F A C T O R S A F F E C T IN G B IR T H W E IG H T
T he factors affecting fetal grow th and birthw eight are m yriad and it is
som etim es difficult to separate the effect o f one fro m the other. For
exam ple, socio-econom ic status, u n d er-n u tritio n , m aternal stature, parity
and sm oking m ay each influence fetal grow th but to som e ex ten t are all
inter-related. The con d itio n s affecting fetal grow th may be general,
m aternal o r fetal.

G eneral
• E thnic g ro u p s. In the West Indies, the sm allest babies are those o f
Indian o r C hinese ancestry and the largest are o f E u ro p ean and
A frican orig in .
• A ltitude. E xposu re to high altitude causes slowing o f grow th
particularly d u rin g the third trim ester.
• Socio-econom ic factors. An association exists between p o o r
living conditions and depressed m edian birthw eight, but it is

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difficult to separate this factor from under-nutrition and short

m aternal stature.

Maternal
• Size. There is a positive association between m aternal stature and
birthweight. Paternal stature makes only a slight contribution.
• Parity. First babies tend to weigh less than later born babies. In
other words, there is a tendency to increasing average birthw eight
with advance in birth rank.
• Age. M others over the age o f 40 years are more likely to have
smaller babies than their younger counterparts.
• N utrition. In states o f acute or chronic nutritional deficiency,
there is a fall in average birthweight. In the Caribbean area,
however, such extrem e level o f nutritional deprivation is not
com m only encountered.
• Medical disorders. SFD babies occur in certain conditions mainly
because of placental insufficiency. Exam ples are the hypertensive
disorders o f pregnancy, severe diabetes mellitus, sickle cell
disease, pyelonephritis, malaria, tuberculosis, upper respiratory
tract infection, cyanotic congenital heart disease and recurrent
antepartum haem orrhage.
• Sm oking. Sm oking slows fetal growth possibly because o f
placental vascular pathology, and this results in a reduction in
average birthweight fo r gestation. If sm oking is stopped before
the third trim ester, the chance o f IUGR falls.
• Drugs. Intake o f certain drugs may be associated with dim inished
fetal weight e.g. steroids, warfarin and certain hypotensive agents.
Growth restriction observed in chronic alcoholism is probably
due to the direct effects o f alcohol or its m etabolite
(acetaldehyde) or to deficiencies in essential nutrients. There is
good evidence to suggest that maternal heroin addiction can
impair fetal growth.

Fetal
• Genetic variation. A small percentage o f all babies may be small-
for-dates but otherwise norm al.
• Infant sex. Males tend to grow faster than females in-utero and
they have a higher average weight at birth.
• Congenital abnorm alities. C hrom osom al aberrations are
associated with poor fetal growth from early in pregnancy and
cause symmetrical growth restriction, such as D ow n's syndrom e

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(trisomy 21), T u rn e r’s syndrom e (45, XO), E dw ard's syndrom e

(trisomy 18) and Patau’s syndrom e (trisom y 13). A reduction of
somatic growth may also occur in babies who have congenital
anomalies of the cardiovascular system e.g. one um bilical artery;
or the nervous system e.g. anencephaly; or the renal system e.g.
Potter’s syndrom e (renal agenesis).
• Multifetal pregnancy. There is evidence to suggest that
deceleration in growth rate occurs with twin gestation, especially
in the third trimester. The larger the num ber o f fetuses, the earlier
the onset o f growth restriction.
• Intra-uterine infection. Organism s, such as toxoplasm a gondii,
rubella virus, cytom egalovirus (CM V), herpes simplex virus and
the syphilitic spirochaete, can severely limit growth potential in
the fetus. The ultimate effect is worse if infection occurs in the
first trimester, during the period o f organogenesis. However, it
should be noted that the spirochaete can only cross the placenta
after about 20 weeks' gestation so that infection after this time is
associated with the m axim um chance of fetal dam age.

IN TR A U TER IN E G R O W TH R E ST R IC T IO N (IU G R )
Outcome
Babies who are growth-restricted have an increased risk o f stillbirth and
neonatal death com pared with those appropriately grown for the period
o f gestation. The main causes o f death are intrapartum asphyxia,
pneum onia, pulm onary haem orrhage, hypoglycaem ia and m econium -
aspiration.

Birth asphyxia is also com m on. Inadequate liver glycogen stores

may predispose to hypoglycaem ia and this may lead to fits, cyanotic
attacks and associated pulm onary haem orrhage. The increased risk of
developing pneum onia may be associated with lower circulating levels of
IgG im m unoglobulin.

Because of the difficulties which these babies face, it is important

to detect the condition before severe fetal com prom ise occurs. It will
then be necessary to balance the extent o f fetal com prom ise with
pulm onary m aturity, which is usually adequate by 34 weeks gestation,
and to effect delivery of the fetus from the “ h o stile ” intra-uterine
environm ent. This may become m andatory to prevent intra-uterine death
and in some cases, survival is bought at the price o f prem aturity.

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Antenatal diagnosis and assessment are usually made by a

combination of clinical exam ination, ultrasound scrutiny and
biochemical tests.

Diagnosis
It is estimated that less than 50% o f SFD babies are detected on routine
clinical exam ination. The diagnosis is enhanced by:
• Accurate assessment o f gestational age. A pproxim ately 20-30%
o f women in our setting are unsure o f their last m enstrual period
(LM P). In those who are sure, the expected date of delivery is
calculated by N aegele’s rule (adding 7 days and subtracting 3
months) or more correctly, by adding 280 days. This assumes a
28-day cycle length so that adjustments will have to be made for
varying lengths o f the cycle. For exam ple, if the cycle is 35 days,
then a further 7 days should be added to the calculated expected
date. Usage o f horm onal contraception must also be determ ined
since this may be followed by an ovulation o f indefinite tim ing.
The " L M P ” would therefore only equate to a withdrawal bleed.
• Assessment of m aternal w eight-gain. This is not a precise
indicator o f fetal growth, but a static or falling maternal weight
should raise o n e ’s suspicion o f IUGR. W eight-gain in norm al
pregnancy is approxim ately 4 kg in the first 20 weeks and 8kg in
the following 20 weeks, the latter rate being about 0.5 kg per
week. After 30 weeks, growth of the fetus accounts for a large
part of the total maternal gain in weight so that a poor increase in
the latter is likely to reflect inadequate fetal growth.
• Accurate estimation o f uterine and fetal size by bim anual
examination, estimation of fundal height and fetal biom etry
(ultrasound).

Bimanual examination o f the uterus in the first trim ester by an

experienced observer provides inform ation that correlates well with
gestational age. Ultrasound at this stage is very accurate to measure the
biparietal diameter (BPD) or the crow n-rum p length (CRL) o f the fetus.
This is so because up to about 20 weeks, the variation about the mean for
growth of BPD and CRL is small, as shown in the chart of BPD versus
gestational age (Figure 1). Later on in pregnancy, the variation about
the mean is much more m arked, so that the error in maturity estimation
is high.

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 FETAL BIRTHWEIGHT

Figure 1. G raph to show increasing variation of BPD about the m ean,

with advancing gestational age.

Estim ation o f fundal height either by palpation or by tape m easurem ent

is not as accurate as the other m ethods since m aternal abdom ens are not
all o f standard length and size. The fundal height also varies with the
volume o f liquor. O f these two m ethods, however, serial m easurem ents
from the sym physis pubis to the fundus provide a m ore objective and
reliable assessment o f fetal grow th. These m easurem ents may be plotted
on custom ised growth charts.
U ltrasonography . The assessment o f fetal size and well being by
ultrasound is dealt with in C hapter fourteen. Since the abdom inal
circum ference is reduced in both sym m etrical and asym m etrical IUGR, it
is the single most reliable param eter for predicting fetal w eight. Liquor
volume and doppler studies are also im portant ultrasound param eters in
the evaluation o f the growth restricted fetus.

M anagement
When IUGR is suspected on clinical gro u n d s the patient should be
adm itted to the ward for fu rth er m anagem ent in ord er to:
• m onitor any associated disease process e.g. pre-eclam psia,
diabetes, sickle-cell anaem ia.
• encourage bed rest in the left lateral position because it
prom otes increased utero-placental blood flow.
• assess fetal w ell-being.

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 FETAL BIRTHWEIGHT

Fetal well-being may be assessed by:

• the “ k ic k ” chart or daily fetal m ovement chatr (DFMC)
• antenatal cardiotocography
• ultrasonography
• biochem ical tests

“ K ick c h a rt” . G enerally speaking, an active baby is a healthy baby.

Also, it has been shown that in cases o f placental insufficiency where the
fetus died, fetal movements decreased and stopped 12-48 hours before
demise occurred. Therefore, lack o f fetal activity can be a warning sign.
The approach is subjective but if 10 or more m ovements occur within
12 hours, this is considered satisfactory. Starting at a fixed hour in the
m orning, the time after which 10 movements have taken place, is noted
on the chart (Figure 2). A progressively increasing time between kicks
or less than 10 movements in 12 hours is an indication for further
investigation.

Figure 2. Fetal ‘Kick-Chart'

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9am M,J j Ittl T F S s T YY T F ft s M T YY T F s s M T YY T F FI ft M X YY x F ft ft X YY x F ft ft
30

30
11
30
12
30
1pm
30

30
3
30
4
30

30
6
30
7
30

30
- ®
I I 9
o> 8
* !7
e !«

ii :
s! 3
1
0

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 FETAL BIRTHWEIGHT

A ntenatal C ardiotocography (CTG ). In cases o f dim inished fetal

m ovem ent and in high risk pregnancies, antenatal c ard io to co g rap h y may
be em ployed as an objective guide to fetal w ell-being. T here are two
main types o f testing:
• non-stress card io to co g rap h y (NST)
• oxytocin challenge (stress) test (OCT)

U ltrasonography. This is useful in the:

• assessment o f fetal grow th velocity.
• distinction between asym m etrical and sym m etrical growth
restriction.
• assessment o f liq u o r volum e.
• assessment o f placental m aturity.
Fetal growth velocity is determ ined indirectly by serial
m easurem ent o f the fetal biparietal diam eter and fem u r length. In respect
o f fetal biparietal diam eter, various patterns have been described such as
“ low p ro file ” and “ late fla tte n in g ” . A dditional data such as
head/abdom en or head/chest circum ference ratio may be utilized to
define further types and onset o f the restriction in fetal grow th.

A sym m etrical or disp ro p o rtio n ate grow th restriction occurs

because o f placental insufficiency. The fetus is “ s ta rv e d ” but there is
preferential blood supply to the head, resulting in a baby w hose head
circum ference significantly exceeds the abdom inal circum ference, the
storage sites in the liver and spleen being m arkedly depleted.

In sym m etrical or pro p o rtio n ate grow th restriction, the head/

abdom en circum ference ratio is 1:1 as for a norm al baby but the actual
sizes fall below the 5th centile for the period o f gestation. This occurs
m ainly in cases o f fetal abnorm ality or when a teratogenic event has
taken place in the first trim ester. It is often the expression o f defective
growth potential.

L iquor volum e, m easured by the nu m b er o f pockets o f fluid seen,

gives additional inform ation. O ligohydram nios is an om inous sign
when sm all-for-dates has been diagnosed. It may also signify fetal
abnorm ality, such as renal agenesis.

Biochem ical tests. Substances p ro duced by the placenta or the feto­

placental unit have been m easured and used as a guide to fetal well­
being. The com m onest are hum an placental lactogen (hPL) in serum and
oestriol levels in serum or urine. Enthusiasm fo r these is now decreasing

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 FETAL BIRTHWEIGHT

because they provide only an indirect m easure o f well-being and the test
results are not im m ediately available. H um an placental lactogen is a
polypeptide horm one produced by the placenta. M aternal serum levels
correlate well with placental weight and size, so that rising or stable high
levels suggest good placental growth and this inform ation is indirectly
related to fetal w ell-being.

Oestriol is a steroid m etabolite produced by a com bination o f

fetal and m aternal processes. It, therefore, bears some correlation to feto­
placental integrity and serial levels are m onitored to indicate a change in
function o f the feto-placental unit. If serial levels keep falling, then this is
taken as evidence of fetal com prom ise.

The lack of im m ediate results delays interpretation and decision­

making so that tests with rapid results, such as antenatal CTG and
ultrasonography, are em ployed m ore frequently.

Additional inform ation on antenatal surveillance m ethods can be

found in C hapter seventeen

Definitive m anagem ent

Definitive m anagem ent of the sm all-for-dates baby entails delivery when
the risks of prem aturity are assessed to be sm aller than the risks o f
continued intra-uterine existence. C om prom ised babies tend to tolerate
the stresses of labour poorly so that elective Caesarean section is the
usual mode of delivery.

FETAL M A CR O SO M IA
Fetal macrosomia (large-for-dates, birthweight m ore than 2 S.D. above
the mean or birthweight more than 4000 gram s). The large baby as a
cause for obstetric concern has, over the years, been overshadow ed by
the small-for-dates infant. However, it is also quite clear that fetal
macrosomia contributes significantly to m aternal and fetal injuries and,
to some extent, to neonatal m orbidity and m ortality.

Maternal factors associated with large babies are:

• Postmaturity. The incidence o f m acrosom ia is 10 times m ore
frequent at 42 weeks than at 36 weeks.
• Obesity and pre-pregnancy weight o f m ore than 80 kg.
• Excessive w eight-gain in pregnancy.
• A family history o f diabetes mellitus.

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 FETAL BIRTHWEIGHT

• Gestational or clinical diabetes.

• A previous m acrosom ic infant.

D uring the antenatal period, or on admission to the delivery suite,

one should attempt to predict the presence of a m acrosom ic infant by
considering the various risk factors outlined above. If a m acrosom ic
infant had been delivered per vaginam previously, the ease or difficulty
o f labour and delivery should be ascertained by perusal o f the previous
labour record, if available, or by close questioning o f the patient.

D uring labour, the factors which may forewarn a large baby are:
• In the first stage - a slow active phase i.e. after cervical
effacem ent, cervical dilatation takes place at a rate slower
than 1 cm/hour.
• In the second stage - little descent o f the head on full
dilatation o f the cervix, after 1 h o u r o f m aternal expulsive
efforts.
The im portance o f identifying the m acrosom ic infant lies in the m aternal
and fetal risks chiefly during the birthing process.

Maternal risks
• Prolonged labour resulting in m aternal distress and ketosis -
this may be associated with fetal distress and also leaves the
m other in an unfavourable physical state for undergoing
operative delivery, especially if general anaesthesia is
required.
• Obstructed labour and uterine rupture, especially in grand
m ultiparous m others.
• M aternal soft tissue injury. There is an increased incidence of
second and third degree lacerations, large episiotom ies and
postpartum haem orrhage.

Fetal risks
The gravest em ergency for these babies is the occurrence o f shoulder
dystocia and associated perinatal asphyxia. This occurs when the bis­
acromial diam eter (across the shoulders) exceeds the A-P diam eter of the
pelvic inlet. The posterior shoulder, therefore, enters the hollow of the
sacrum but the anterior shoulder abuts against the sym physis pubis.
Delivery entails release o f the anterior shoulder after the posterior
shoulder has been delivered. This is a tim e-consum ing procedure which
is usually traum atic to the m other and baby, and is therefore associated
with significant perinatal asphyxia and m econium aspiration. The latter is
a dangerous com plication with high m orbidity and m ortality rates. Other

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 FETAL BIRTHWEIGHT

dangers to the baby include clavicular fracture and brachial plexus

injury.
From what has been stated, it is clear that vaginal delivery o f a
large fetus presents one o f the most desperate situations to the
obstetrician. It is also a principal cause for concern to the neonatologist
because these babies have a high incidence o f m econium -aspiration,
asphyxia and low A pgar scores.
G ood obstetric practice, therefore, dem ands the antenatal
identification o f the m acrosom ic baby and the prediction o f shoulder
dystocia. In em ploying ultrasonography to determ ine an thropom etric
disproportion between the shoulders and the head, it has been fo u n d that
a chest/head circum ference difference o f 1.6 cm o r m ore is indicative o f
the possibility o f shoulder im paction. However, biom etric prediction o f
shoulder dystocia is notoriously poor and the clinician m ust interpret the
results o f investigations in conjunction with individual risk factors. The
antenatal risk factors for shoulder dystocia are diabetes, obesity and
postdate pregnancies.
It is expected that 10% o f m acrosom ic babies will develop
shoulder dystocia and a liberal policy o f elective C aesarean section is
advocated for all m acrosom ic babies. That is to say, for large babies, it is
more prudent to anticipate and thus avoid the com plications o f vaginal
delivery.

KEY POINTS

• Small-for-dates (SFD ) or Sm all-for-gestational age (S G A )

indicates that a fetus or neonate is below a defined reference
range o f weight for a particular gestational age. This is usually
taken to be below the tenth centile fo r estimated fetal weight.
These fetuses are either constitutionally small or they are
growth restricted. The latter group has failed to achieve their
growth potential and is deem ed to have intra-uterine grow th
restriction (IU G R ). T here is an increased risk o f stillbirth and
intrapartum hypoxia.
• Large-for-dates (LFD ) or L arge-for gestational age (L G A )
refers to a fetus whose estim ated weight is above the 90th centile
for a particular gestation. Sim ilarly it can be applied to infants
whose birthweights are two standard deviations above the m ean
for the period o f gestation. Shoulder dystocia is a potentially
catastrophic risk but it is difficult to predict.

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 MALPRESENTATION

CHAPTER TEN

FETAL MALPRESENTATION

BR EE C H PR E SE N T A TIO N

“ But I do nothing upon myself, and yet I am mine own executioner” -

John Donne .

IN T R O D U C T IO N
The m ammalian dolphin always delivers by the breech and is assisted by
‘m idw ife' dolphins. By ‘masterly inactivity’, they wait for delivery of
the after-com ing head before pushing the infant upward to the surface
for its first breath. The aquatic surroundings in addition to the d o lp h in ’s
pelvic girdle seem ideal for this presentation.

B y'contrast, breech is a m alpresentation in the hum an species. It

is very com m on (about 25%) at 28 weeks o f gestation, however,
spontaneous version is the norm and as such the incidence falls to 3-4%
at term . This appears to be an active process whereby the fetus adopts
the position o f ‘best fit.’

The perinatal mortality rate in breech presentations is three times

higher than that for singleton vertex presentations. In addition the
perinatal m orbidity rate is twelve times higher. This difference is
prim arily due to prem aturity, congenital m alform ations and birth
asphyxia or traum a. This data should serve to em phasise that this
malpresentation represents a potential hazard for the fetus ante, intra and
postpartum .

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 MALPRESENTATION

AETIOLOGY
In many cases there is no obvious explanation for this m alpresentation.
However, potential causes include:

• Prematurity. This is the com m onest cause

• High parity
• Congenital anom alies of the uterus (uni- and bicornuate, and
subseptate)
• Uterine fibroids (distortion o f the uterine cavity)
• O ligohydram nios as may occur in Potter's syndrom e and
IUGR
• Polyhydram nios as may occur in poorly controlled diabetes
• Fetal abnorm alities such as m yotonic dystrophy,
hydrocephalus, anencephaly and the trisomies 13, 18 and 21
• Hydrops fetalis
• Intra-uterine death
• Short umbilical cord
• Placenta praevia
• Multiple pregnancies
• Hyperplacentosis secondary to infections such as syphilis
• Ovarian cysts or other large extra-uterine tum ours.

TYPES
There are three types of breech presentations (Figure 1):
• Frank
• Complete or flexed
• Incomplete or footling

Frank Breech
In this type, the thighs are flexed at the hips and the knees are extended
so that the fetus is literally looking straight ahead at its own feet. It is the
most favourable type of breech presentation if vaginal delivery is
anticipated as it fills the pelvis fairly well and presents a good dilating
wedge to the cervix. It accounts for 60-70% o f all breech presentations.

Complete Breech
The thighs are flexed at the hips and the knees are also flexed. The feet
and the buttock form the presenting part which now is irregular and does
not make a good fit with the lower segm ent. Descent and engagem ent
 MALPRESENTATION

are less likely and the possibility o f cord prolapse after rupture o f the
m em branes may be up to four times m ore com m on than in the frank
breech.

Footling Breech
One or both hips are partially or fully extended. This results in one or
both lower extrem ities o f the fetus being extended below the level o f the
buttocks. The risk o f cord prolapse is real and as such an elective
caesarean section should be perform ed at term .

Figure 1: Types of breech

D IA G N O SIS
One may suspect a breech presentation when the patient com plains of
pain or discom fort in the fundal area. On exam ination the fetal head,
which is hard, round and ballotable, can be outlined in the fu n d u s and
the presenting part at the pelvic inlet feels irregular and soft. At term , the
fetal heart sounds are best heard above the um bilicus. An ultrasound
should be perform ed to confirm the diagnosis, give an estim ation o f the
fetal weight and also to rule out hyperextension o f the neck or any
predisposing factors.

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 MALPRESENTATION

M A N A G EM EN T OPTIONS FO R THE TER M B R EE C H

The Term Breech Trial dem onstrated that there is a significant reduction
in perinatal m orbidity and mortality when elective abdom inal delivery is
compared with elective vaginal breech delivery. These findings have
resulted in a surge in caesarean section rates for breech presentations in
metropolitan countries. We recom m end a balanced approach whereby
patients are counselled about the available options, the risks and benefits
and the implications for future pregnancies. The options for the patient
with a breech at term include:

• External cephalic version (ECV).

• Vaginal breech delivery.
• Caesarean section.

EXTERNAL C EPH A LIC VERSIO N

This is a manoeuvre which converts the polarity of the fetus from breech
to cephalic. It is undertaken in late pregnancy (37-39 weeks) in an
attempt to lower the incidence o f breech presentations in labour.

Technique
ECV should be undertaken in a hospital that has facilities for perform ing
an emergency caesarean section as it may be necessary to perform this
procedure in approxim ately 0.5% o f cases. Ideally, ECV should be done
with ultrasound guidance which allows confirm ation o f successful
version and direct visualisation of fetal cardiac activity. Tocolysis may
also be helpful (e.g. terbutaline 250 /<g subcutaneously 15 m inutes prior
to ECV).

• Patient empties bladder

• Powder is liberally applied to the abdom en
• The breech is held in one hand which pushes it gently away
from the pelvic inlet. At the same time, the other hand, flexes
the fetal head.
• The fetus is then encouraged through a ‘forward ro ll’
(Figure 2). Alternatively, the fetus may be taken through a
‘back flip '; however this is not as widely practiced as the
forward roll.
• The mechanical goal is to encourage the fetal head gently out
of the fundal area to the transverse and finally into the lower
segment of the uterus.

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 MALPRESENTATION

• The fetal heart is auscultated or directly observed with

ultrasound.
• The introitus is inspected fo r blood or liquor.
• A non-stress test (NST) should follow fo r at least 20 m inutes.
• Rhesus negative m others should be given anti-D prophylaxis.

Figure 2: ‘Forw ard roll’ during ECV

Reported success rates vary significantly. However in units with a

dedicated ECV service overall success rates vary from 40% in nulliparas
to 60% in m ultiparous women. Spontaneous version to breech after
successful ECV occurs in less than 5 percent o f cases. Factors associated
with failure o f version include obesity, being prim igravid, anterior
placental location, frank breech, posterior positioning o f the fetal back,
engagem ent o f the breech and oligohydram nios.

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 MALPRESENTATION

A bsolute contraindications to ECV:

• A ntepartum haem orrhage within the last 7 days.
• A bnorm al cardiotocography
• M ajor uterine anom aly
• R uptured m em branes
• M ultiple pregnancy (except delivery o f the second twin)
• W here caesarean delivery is required

Relative contraindications to ECV:

• S m all-for-gestational-age fetus with abnorm al D oppler
param eters
• Pre-eclam psia
• O ligohydram nios
• M ajor fetal anom alies
• Scarred uterus
• U nstable lie

Complications o f ECV:
• Fetal distress
• Feto-m aternal transfusion
• R upture o f m em branes
• A bruptio placentae
• Uterine rupture
• A m niotic fluid em bolism (rare)

VAGINAL B R E E C H D E L IV E R Y
Some women with a breech presentation may choose to deliver vaginally.
They should be assessed carefully and advised specifically o f the
increased peril to them and their babies o f attem pting vaginal breech
birth. However, the im plication o f a successful delivery is that subsequent
pregnancies will be deem ed low risk.

Technique:
This is a high risk delivery and should take place in an institution with
facilities for em ergency caesarean section should the need arise. D uring
labour, early artificial rupture o f the m em branes should be avoided. If
they spontaneously rupture, a speculum exam ination should be done to
rule out prolapse of the um bilical cord.
 MALPRESENTATION

C ontinuous electronic fetal m onitoring should be considered for

all women with a breech presentation in labour. As in a cephalic
presentation, abnorm al cardiotocography warrants fetal blood sam pling.
This can be perform ed from the fetal buttock. A ugm entation o f labour
is not recom m ended and instead recourse to caesarean section should be
done for poor progress in labour. In the second stage o f labour failure
o f the presenting part to descend may be a sign o f relative feto-pelvic
disproportion.

In the active second stage o f labour, when the anterior buttock

becom es visible at the introitus, the patient is placed in the lithotom y
position and the perineum is cleaned and draped. An episiotom y is
perform ed as the posterior buttock distends the perineum . As the
buttocks are delivered, one ensures that the fetal back faces upwards; with
norm al descent this often occurs spontaneously. O perator intervention is
otherwise not yet required other than to encourage m aternal expulsive
effort. Safe delivery depends predom inantly on m aternal expulsive
forces and patience, not from traction below.

A fter the um bilicus appears over the m aternal perineum , a short

loop o f cord may be loosened and drawn dow n. In the frank breech, the
operator may align a finger medial to one thigh then, the other, pressing
laterally as the fetal pelvis is rotated away from that side. This results in
external rotation o f the thigh at the hip, flexion o f the knee, and delivery
o f one and then the other leg (Figure 3).

Figure 3: D elivery o f the legs in breech presentation

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 MALPRESENTATION

The fetal trunk is then wrapped with a towel, while further descent
results from expulsive forces from the m other during uterine
contractions. When the scapulae appear, the shoulders are ready for
delivery. In many cases, the arms flop out but if they are extended, they
can be delivered by Lovset’s manoeuvre. With the fetal back facing
upwards, the shoulders are in the transverse plane o f the maternal pelvis.
Grasping the bony pelvis o f the baby, it is rotated through 90 degrees to
bring one shoulder under the symphysis pubis. A finger is now placed
over the fetal shoulder from the back and the hum erus is followed to the
cubital fossa. The fetal arm can now be swept across the chest and
delivered. The posterior shoulder is then rotated through 180 degrees to
bring it under the pubis and the arm is delivered in a similar fashion.
Alternatively, the posterior shoulder is delivered posteriorly by some in
an attempt to minimise potential traum a and excessive twisting o f the
back.

After delivery o f the arms, the baby is allowed to hang at the

vulva so that the effect of gravity encourages further descent o f the fetal
head. Suprapubic pressure by an assistant may also be used to assist
flexion of the head. As the fetal hairline becom es visible, the head is now
ready for delivery.

Controlled delivery of the after-com ing head is imperative as

failure to do so may result in intracranial haem orrhage. The after­
coming head may be delivered with forceps (e.g. P ip e r’s forceps), the
Mauriceau-Smellie-Veit manoeuvre or the Burns-M arshall m ethod. The
first two methods are probably the most popular and concern has been
expressed about the risks of the Burns-M arshall m ethod if used
incorrectly, leading to over-extension o f the b a b y ’s neck.

Burns-Marshall method: the accoucheur, standing on one side

of the mother, holds the b a b y ’s feet, exerts traction outwards and takes
the baby through an arc towards the m o th er’s abdom en. There is no
control of the delivery o f the head, unlike the other two m ethods, thus
potentially increasing the possibility o f cerebral com plications.

Mauriceau-Smellie-Veit manoeuvre, this involves shoulder

traction and jaw flexion. For jaw flexion, the baby is placed astride the
accoucheur's left forearm ; the left middle finger is placed inside the
mouth while the index and ring fingers are placed on each maxilla.
Shoulder traction is achieved with the accoucheur's right middle finger
exerting pressure on the occiput while the index and ring fingers exert
gentle downward traction at the side o f the neck. As the face sweeps the

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 MALPRESENTATION

perineum , the nostrils are suctioned by the neonatologist. This

com bination of flexion and traction, along with m aternal effort and at
times suprapubic pressure by an assistant, results in delivery o f the head.

An anaesthetist should be available for the delivery, for two reasons:

• A caesarean section may be necessary at any time until delivery
o f the fetal um bilicus.
• General anaesthesia may be required if difficulty is encountered
with the after-com ing head

Contraindications to vaginal breech delivery include:

• Clinically inadequate pelvis.
• Footling breech
• Large baby (> 3500 g)
• Previous caesarean section.
• Growth-restriction
• Other contraindications to vaginal birth (e.g. placenta praevia,
fetal com prom ise)
• H yper-extended fetal neck in labour
• Absence of a clinician trained in vaginal breech delivery

Complications of vaginal breech delivery include:

• Cord prolapse and com pression.
• Fractures to the upper and lower limbs, ribs and pelvis.
• Dislocation o f the hip joint.
• Visceral traum a e.g. liver, spleen and adrenals.
• Brachial plexus injury.
• Intra-cranial haem orrhage.
• Sternom astoid injury: e.g. torticollis.
• Occipital diastasis from excessive pressure on the occiput.
• Stretching and spasm o f the vertebral arteries.

C A E S A R E A N SE C T IO N
In general, an elective caesarean is recom m ended in the following
circumstances:
• Large baby where the estimated fetal weight is greater than 3500
grams.
• Footling breech. This is prim arily to circum vent the risk o f cord
prolapse and head entrapm ent.

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 MALPRESENTATION

• Where an absolute indication exists for abdom inal delivery such

as a m ajor placenta praevia.
• The prim igravid breech. T hough this is not an absolute
indication, there are concerns about allowing vaginal delivery
through an untried pelvis.
• In addition, caesarean section is recom m ended in instances of
failure to progress in labour and where a contraindication exists
to vaginal breech delivery (see above).

M ANAGEMENT O PTIO NS FO R TH E PR E T E R M B R EE C H
Overall, routine caesarean section is safer for the preterm or the low
birthweight breech (less than 2500 g) though the evidence is not
conclusive. Vaginal delivery may result in head entrapm ent as the
discrepancy between the size of the head and buttocks is most m arked at
these early gestations. However, the m anagem ent should be tailored on
an individual basis since caesarean delivery can be difficult, as the lower
segment may not be well form ed.

At the extrem es o f viability (less than 26-28 weeks in Trinidad)

the survival prospects are poor no matter what the route o f delivery. In
this circumstance it would be appropriate to allow vaginal birth. It is
advisable that delivery occurs with the m em branes intact as this may
cushion the passage of the fetus through the birth canal (En caul).

External cephalic version for the breech in preterm labour is

controversial and not routine practice.

ABNORMAL LIE

Definitions
When the long axis of the fetus lies at right angles to the long axis o f the
uterus, the fetus is said to be in transverse lie and the presenting part is
frequently a shoulder. An oblique lie is another exam ple o f an abnorm al
lie where the presenting part lies in the iliac fossa.

Predisposing Factors
The several conditions which predispose to a breech presentation also
cause a transverse or oblique lie. O f im portance, are deficient tone to the

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 MALPRESENTATION

abdom inal wall muscles and a lax uterus from increasing parity, and
placenta praevia.

M anagement
In the absence of placenta praevia, ovarian cysts and uterine fibroids, an
induction-stabilization procedure at term may be attem pted to achieve a
vaginal delivery. This procedure involves
perform ing external version to make the lie longitudinal and

Figure 4: Shoulder presentation in transverse lie

setting up an intravenous Syntocinon infusion. The presenting part is

stabilized at the pelvic brim by an assistant. W hen the uterine
contractions are occurring every 3-5 m inutes, an am niotom y should be
perform ed. The procedure is not risk free. There is the hazard of cord
prolapse and also extreme caution must be exercised with the use of
Syntocinon in a highly parous woman. The preferred m ode o f delivery

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in a patient with a transverse or oblique lie is an elective Caesarean

section. If the feet o f the fetus occupy the upper segm ent, as in a dorso-
inferior transverse lie, consideration should be given to perform ing a
classical caesarean section, as it may otherwise be difficult to grasp the
feet and perform a breech extraction.
If transverse lie is recognised fo r the first time in labour, there is a
real risk o f uterine rupture. A rrangem ents should be made for an
immediate caesarean section.

FACE P R E SE N T A T IO N
Face presentation is a rare occurrence in labour. It may arise as a result
of fetal abnorm ality such as anencephaly and is m ost com m on in
multiparous patients. T he aetiology is otherwise sim ilar to that for breech
presentations and transverse lie.

In labour, caesarean section is usually perform ed to circum vent

the inevitable facial oedem a and perineal traum a that results from this
malpresentation. However, in m ento-anterior positions the fetal chin
abuts the sym physis pubis during parturition resulting in flexion o f the
head thereby perm itting vaginal delivery. In m ento-posterior positions
the head presents a progressively larger diam eter to the m aternal pelvis as
it hyperextends through the birth canal. This would norm ally preclude
vaginal delivery.

BROW PR E SE N T A TIO N
The incidence and aetiology are sim ilar to that for face presentation. The
mentovertical diam eter presents and it is the largest diam eter o f the fetal
head. The fate o f a brow presentation in lab o u r is that it may convert to
either a vertex or a face presentation. A bdom inal delivery is advised for
the latter.

OCC1PITO-POSTERIOR PO SITIO N
Approximately 10 percent o f cephalic presentations are in the occipito-
posterior (OP) position at the onset o f lab o u r, but in only 2 percent is
intervention required. The predisposing factors fo r this m alposition are;
an anterior placenta, a pendulous abdom en and a long oval pelvis
(anthropoid pelvis). A bdom inal exam ination reveals small fetal parts on
either side of the m id-line, a depression in the infra-um bilical region, a
high head and the fetal heart sounds are distant. V aginal exam ination in

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early labour reveals a high deflexed head, the anterior fontanelle

occupying the centre o f the pelvis whilst the posterior fontanelle lies at a
higher level and may be difficult to reach. The sagittal suture may
occupy an oblique diam eter or may run an tero-posteriorly.

Descent of the head is slow and prolonged labour is com m on.

By ensuring efficient uterine contractions with the use o f a Syntocinon
infusion the pattern o f labour and indeed the m alposition may be
corrected. On the whole, occipito-posterior position is associated with
higher rates of vacuum extraction, forceps delivery and caesarean
section.

KEY POINTS

• The incidence of breech presentation at term is 3-4% .

• Frank, complete and footling are the three types of
breech presentation.
• ECV is performed in late pregnancy in an effort to
reduce the incidence of breech presentation in labour.
• The Term Breech Trial demonstrated that there is a
significant reduction in fetal morbidity and mortality
when elective abdominal delivery is com pared with
elective vaginal breech delivery.
• The preterm breech runs the risk of head entrapment at
the time of vaginal delivery. Abdominal delivery is
recommended though this decision should be
individualised.
• Face presentation in the mento-anterior position may
deliver vaginally.
• All malpresentations should prompt a search for fetal
abnorm ality.

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CHAPTER ELEVEN

TWIN PREGNANCY

INTR O D U C TIO N
The incidence o f twins has generally been quoted as 1 in 100
pregnancies, but there is consensus that the condition occurs m ore
commonly in tropical clim ates. For exam ple, in Jam aica, the incidence is
1 in 66, in Trinidad, it is 1 in 72 and in N igeria, it is 1 in 20. Since
twinning is m ore com m on with ascending birth rank, the higher
incidence o f m ultiple pregnancies in A frica and the West Indies is
probably due to the fact that the average fam ily size is bigger than in
metropolitan countries. M ultifetal pregnancies also occur m ore often in
women with a fam ily history o f twins.

Furtherm ore, the use o f ovulation induction agents such as

clomiphene citrate result in a m ultiple pregnancy rate o f 10 percent;
while, in-vitro fertilisation (IV F) increases the rate to 22 percent. The
devastating consequences o f m ultiple pregnancy has encouraged some
regulatory bodies fo r assisted reproduction to insist on a two em b ry o
transfer rather than the previously recom m ended three em bryo transfer,
in an attempt to reduce the num ber o f m ultiple pregnancies.

TYPES
• Monozygotic twins, result from the division o f the fertilised ovum
(zygote) at a very early stage o f developm ent. This zygote has
resulted from the fertilization o f one ovum by one sperm . If it
divides before day 3, it becom es dichorionic, diam niotic; between
days 3 and 8, m onochorionic, diam niotic; and after day 8,
monochorionic, m onoam niotic (Figure 1).

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Figure 1: Types of Twins

Di-chorionic
Di-amniotic

Mono-chorionic
Mono-amniotic

Mono-chorionic
Di-amniotic

M onozygotic twins account for 20% o f all twins and their

incidence is constant throughout the world. They are the same
gender and often o f low birth weight. There is a 50% increased
risk o f structural abnorm alities and double the risk o f congenital
heart defects when com pared with singleton pregnancies. In
addition there are a num ber o f com plications unique to
m onozygotic twinning such as C onjoined Twins, the Twin-to-
Twin Transfusion Syndrom e (TTS) and Twin Reversed Arterial
Perfusion (TRAP) sequence which will be discussed later in the
chapter.
The perinatal mortality rate among m onozygotic twins tends to
be higher than in dizygotic twins.

• Dizygotic twins, result when two separate ova are fertilised by two
separate sperms. They are always dichorionic and diamniotic.
They may be o f the same or opposite sex and the risk o f trisomy
21 is twice the age related risk. There is a heritable com ponent to
dizygotic twinning and the incidence varies with age, race,
nutritional status and geographical location. Superfecundation is
the fertilisation o f two or more ova in the same m enstrual cycle
by separate sperm from separate episodes of coitus. This is a rare
occurrence and may result in a pregnancy with heteropaternal
fetuses. Superfetation is the fertilisation o f ova in different
menstrual cycles by separate sperm. It results in a pregnancy with

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fetuses of different gestational age. This is a phenom enon known

to occur in some anim al species but is extrem ely rare in hum ans.

• H ig h e r o rd e r m ultiples, usually result from the fertilisation o f a

num ber of ova by separate sperm as in dizygotic twins, though
m onozygotic division can also occur.

CLINICAL F E A T U R E S
Symptoms
• Hyperem esis gravidarum
• A bdom inal discom fort and backache
• Increased fetal movem ents
• H aem orrhoids and varicose veins o f the legs and vulva
• Dyspnoea; exacerbated by the splinting effect o f an enlarged uterus
on the diaphragm .

Signs
• Sym physio-fundal height, being large-for-dates
• Several small fetal parts are palpable
• There may be a dem onstrable fluid thrill indicating the presence o f
polyhydram nios.

Differential Diagnosis for Large-for-D ates

• Wrong dates
• Large baby
• Fibroids and/or ovarian cysts
• Polyhydramnios from other causes
• Hydatidiform mole

DIAGNOSIS
As soon as a multiple pregnancy is clinically suspected or if pregnancy
has resulted from assisted reproduction, the diagnosis must be confirm ed
by ultrasound scan. Early diagnosis and establishm ent o f zygosity and
chorionicity allows for the quantification o f risk, the establishm ent o f an
appropriate plan for the pregnancy and the institution o f m easures to
minimize potential com plications.

This is best achieved by an early first trim ester ultrasound

examination (between 6 and 9 w eeks’ gestation), when in dichorionic

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twins there is a thick septum between the sacs. A fter 9 weeks, this septum
becom es progressively thinner to becom e the chorionic co m p o n en t o f
the intertwin m em brane, but it rem ains thick and easy to identify at the
base o f the m em brane as a triangular projection, the lam bda o r twin peak
sign. At 11 to 14 w eeks’ gestation, presence o f the lam bda sign provides
reliable identification o f a dichorionic twin pregnancy. In the second
trim ester discordant genitalia im ply dizygosity and thus dichorionicty
while a thin septum in concordant sex twins suggests m o n o ch o rio n icity .

M A T E R N A L C O M PL IC A T IO N S
• Spontaneous m iscarriage
• H yperem esis G ravidarum
• A naem ia. Iron and folate deficiencies occur because o f the increased
dem ands of the fetuses. The increased blood volum e along with the
increased iron and folate requirem ents, predispose the patient to
anaem ia.
• Pregnancy-induced hypertension.
• A ntepartum haem orrhage. Placenta praevia and abruptio placentae
occur more com m only. The form er is due to the larger size o f the
placenta encroaching on the lower segm ent. The latter may be
associated with the increased incidence o f hypertension.
• Polyhydram nios. It occurs m ore often in m onochorionic
pregnancies and is som etim es o f acute onset.
• Supine hypotension. The increased weight o f the uterus predisposes
to aortocaval com pression.
• Postpartum haem orrhage occurs because o f uterine atony secondary
to over-distension o f the m yom etrial fibres.
• Increased operative intervention, particularly fo r the second twin.
The need for anaesthesia is likewise increased.

FE T A L C O M PL IC A T IO N S
• C ongenital abnorm alities. There is an increased incidence of
structural abnorm alities such as open neural tube and cardiac defects.
In dizygotic pregnancies the risk o f trisom y 21 is twice the age
related risk when com pared to singleton pregnancies. In
m onozygotic pregnancies division o f the zygote after day 12 may
result in conjoined twins. These are twins that are anatom ically fused

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at different levels, for exam ple the head (craniopagus), the thorax
(thoracopagus) or the abdom en (abdom inopagus). They may share
vital organs such as the heart and liver and have com plex
interconnecting circulatory systems. Delivery is by caesarean section
and the long term prognosis is usually poor.
Preterm labour is more com m on in m ultiple gestations. Over­
distension of the uterus predisposes to this. The m edian gestational
age at delivery is 39 weeks for singletons, 37 weeks for twins, 33
weeks for triplets and 31 weeks for quadruplets. The risks o f
prem aturity therefore increase as the num ber o f fetuses increases.
The resultant fetal com plications are a direct consequence o f
prem aturity and include respiratory distress syndrom e,
intraventricular haem orrhage and necrotising enterocolitis.
Intrauterine growth restriction. A pproxim ately one third o f fetuses
are growth restricted. This growth restriction may be concordant or
discordant. The growth restricted fetus tolerates hypoxic insult
poorly and there should be a low threshold for abdom inal delivery in
the presence o f growth restriction.
Abnormal lie and presentation. Table 1 shows the incidence o f fetal
presentation in twin pregnancies in Trinidad
Prolapse of the um bilical cord. This may occur due to a
combination of m alpresentation and polyhydram nios.
Cord entanglem ent. This is a potential com plication o f all
monoamniotic pregnancies.
Premature separation o f the placenta after delivery o f the first twin is
possible and the accoucheur must expedite the delivery o f the second
twin if this com plication arises.
Cervical contraction after delivery o f the first twin.
Interlocking of twins is rare and is a theoretical com plication o f
vaginal delivery when Twin A is breech and Twin B cephalic.
Twin to Twin Transfusion syndrom e (TTS) is a com plication o f
monochorial pregnancies. It is characterized by a deficiency o f
superficial vascular anastamoses and one fetus develops at the
expense of the other. The recipient fetus becom es hypervolaem ic and
plethoric and produces more am niotic fluid and as such there is
associated polyhydram nios. The d o n o r fetus becom es anaem ic,
hypovolemic and m alnourished. There is an associated
oligohydramnios. In extrem e cases, the latter may perish and becom e
a fetus papyraceous. Patients with pregnancies com plicated by TTS
are best managed by an obstetrician with a special interest in fetal

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medicine. Treatment options include laser ablation of the

communicating placental vessels, serial amnioreduction, selective
feticide and amniotic septostomy. Delivery should be expedited by
caesarean section once the benefits of delivery outweigh the risks of
prematurity.

• Twin reversed arterial perfusion (TRAP) sequence is another

potential complication of monochorial pregnancies. It is
characterised by an acardiac twin which parasitizes its blood supply
from its co-twin. The acardiac twin jeopardises the survival of the co­
twin and fetal wastage is high. Treatment options include ablation of
the communicating blood vessels (usually a large arterio-arterial
anastamosis). Delivery should be expedited by caesarean section
once the benefits of delivery outweigh the risks o f prematurity.

Table Is Incidence of fetal presentation in twin pregnancies

Presentation Percent
Vertex/Vertex 48.2
Vertex/Breech 32.7
Vertex/Shoulder 2.7
Breech/Vertex 13.2
Breech/Breech 2.8

ANTENATAL M ANAGEM ENT

• All patients should receive prophylactic iron and folic acid
supplementation.
• Serum screening for chromosomal abnormalities is not applicable
in multiple gestations and there is a high false positive rate with
nuchal translucency studies. Chorionic villus sampling and
amniocentesis are both available as diagnostic tests though
amniocentesis is preferable.
• Glucose screening should be considered at 28 weeks gestation or
earlier if clinically indicated.
• Fetal surveillance: Multiple pregnancies can be visualised by
trans-vaginal ultrasound as early as 6 weeks amenorrhoea.
Abdominal ultrasound examination should be repeated later in

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pregnancy for the following reasons: a) to define the

chorionicity, b) to exclude congenital anomalies, c) to diagnose
placenta praevia, d) to monitor the growth of the fetuses and e) to
confirm the presentation of twin A in order to decide the mode of
delivery. Fetal medicine departments will often perform fetal
biometry monthly from 24 weeks in dichorionic pregnancies and
fortnightly from 20 weeks in monochorionic pregnancies. A
detailed cardiac scan at 24 weeks and fetal echocardiography
should be performed in monochorionic pregnancies given the
risk of cardiac defects. Umbilical artery Doppler studies should
be performed when there is evidence of growth restriction.
• Antenatal follow up should be tailored to the requirements of the
individual pregnancy but in general, patients should be seen
every 2-3 weeks until 32 weeks gestation, fortnightly until 36
weeks and then weekly until delivery. A vigilant watch is kept for
the development of preeclampsia and anaemia. Women with
monochorionic twins require increased antenatal surveillance.
• Approximately 40% of women with twins will go into preterm
labour or require preterm delivery. There is no evidence of a role
for either prophylactic cervical cerclage or prophylactic tocolytic
therapy and the precise value of transvaginal ultrasound
evaluation of the cervix in multiple pregnancies is yet to be
established. However, in the event of preterm labour, tocolytic
therapy and antenatal corticosteroids (Betamethasone) are
recommended.
• In higher order multiple pregnancies (four or more) selective
feticide may be considered to improve the survival prospects for
the remaining fetuses. This is preferably performed at the end of
the first trimester.

INTRAPARTUM M A N A G EM EN T
Time of delivery
The time of delivery is dictated by the overall clinical scenario though
delivery is preferably delayed until fetal maturity is assured. In the
uncomplicated Dichorionic twin pregnancy we recommend elective
delivery at 38 weeks. Other units may recommend elective delivery by
40 weeks.

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In the uncomplicated M onochorionic twin pregnancy we

recom m end elective delivery at 38 weeks. However, in recognition o f the
high risk nature of this pregnancy, some units recom m end delivery as
early as 36 weeks to reduce the risk o f late stillbirth and late-onset TTS.

Mode of delivery
In the absence of growth restriction or fetal distress, the prime
determinant o f the mode o f delivery is the presentation o f Twin A. If the
presentation is cephalic, we advocate a vaginal delivery. If cephalic and
undelivered by 38 weeks gestation we recom m end an induction o f
labour with or without cervical ripening.
If the presentation o f Twin A is anything other than cephalic
(breech, shoulder etc) we recommend an elective caesarean section. In
addition, we recommend an elective caesarean section for higher order
multiple pregnancies and for the M onoam niotic twin pregnancy,
regardless of the presentation of Twin A, to circumvent the problem of
cord entanglement.

The conduct of a norm al vaginal delivery

Labour should be conducted in a hospital setting under the supervision
o f an experienced midwife and obstetrician. The neonatal and
anaesthetic teams should be informed o f the presence o f a patient with
twins on the unit and an ultrasound scan should be perform ed to confirm
that the presentation of Twin A is cephalic. In early labour, intravenous
access is established and blood samples taken for a full blood count and
‘group and save’ . Once in established labour there should be continuous
cardiotocographic monitoring of both fetuses. A fetal scalp electrode can
be applied to Twin A once the mem branes have ruptured (either
spontaneously or following amniotomy) and Twin B can be monitored
with an abdominal transducer. Early consideration should be given to
epidural analgesia as this may be useful to facilitate manipulation of the
second fetus or abdominal delivery if necessary.

The first twin - Labour can be augm ented with a Syntocinon

infusion if progress is slow in the first stage of labour. In the second
stage, the indications for episiotomy and/or instrumental delivery are the
same as with singleton labours. After delivery o f twin A, the umbilical
cord is divided between clamps and labelled.
The second twin - Once Twin A has delivered, cardiotocography
is continued and the maternal abdom en is palpated in order to establish
the lie and presentation o f twin B. This can be confirm ed by ultrasound.

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With twin B in a longitudinal lie and cephalic presentation, a vaginal

examination is perform ed, the forewaters are ruptured and the liquor is
released in a controlled manner. Uterine contractions norm ally ensue
within 5 minutes. If contractions have not resumed, a Syntocinon
infusion is com m enced. Maternal effort is encouraged with each
contraction and a normal delivery is perform ed. If breech, an assisted
breech delivery is executed as described in the chapter on breech
presentation.

Figure 2: Breech extraction o f Twin B

The presentation o f the second twin at delivery is not always

predictable and is non-vertex in about 40% of cases. The chance o f
cephalic delivery may be improved by routinely guiding the head o f the
second twin towards the pelvis (external version) immediately after
delivery of the first twin. Alternatively, some Obstetricians, routinely
expedite delivery o f the second twin by internal version, with the
membranes intact for as long as possible, followed by breech extraction
(Figure 2), irrespective of the presentation. This latter m anoeuvre is
particularly useful in cases where there is fetal distress in the second twin.
Epidural analgesia facilitates such manoeuvres. The chief reasons for
acute fetal distress of the second twin after delivery of the first are,
premature separation o f the placenta, cord entanglem ent and cord
prolapse.

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Abdominal delivery o f Twin B after Twin A has been delivered

vaginally is sometimes necessary. The incidence in Trinidad is 1 in 24
twin pregnancies. Indications for this procedure include:
• shoulder presentation after a prolonged period o f rupture o f the
membranes
• cervical contraction
• co m pound presentation
• cord prolapse with a high presenting part

P O ST P A R T U M M A N A G E M E N T
Postpartum haem orrhage is a potentially catastrophic consequence of
multifetal pregnancy. In the absence of placental abruption, this is
primarily due to uterine atony secondary to overdistension o f the
myometrial fibres. To reduce this risk, the third stage o f labour should
be actively managed. After the second twin is delivered, Syntometrine®
(one ampoule) is given intramuscularly and 40 units of Syntocinon® are
added to one litre o f an intravenous infusion. This infusion is titrated to
ensure that the uterus remains well contracted in the immediate
postpartum period.
The placenta should be carefully inspected and sent for
histological analysis if there is evidence o f TTS or uncertainty about the
chorionicity.

P E R IN A T A L O U T C O M E
Twin pregnancies are associated with a perinatal mortality rate up to
seven times higher than that associated with singleton pregnancies.
Higher order multiples are associated with even more alarming perinatal
mortality rates. Complications of prematurity such as respiratory distress
syndrome, intraventricular haem orrhage and necrotizing enterocolitis are
the leading causes o f morbidity and mortality. Other factors include
intrauterine growth restriction, congenital anomalies, placenta praevia.
abruptio placentae, preeclampsia, cord accidents and malpresentations.

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KEY POINTS
• The patient carrying more than one fetus
presents a formidable challenge.
• Twin pregnancies are associated with a
perinatal mortality rate up to seven times
higher than that associated with singleton
pregnancies.
• The perinatal mortality rate am ong
m onozygotic twins tends to be higher than in
dizygotic twins.
• Early diagnosis and establishment of zygosity
and chorionicity allows for the quantification of
risk, the establishment of an appropriate plan
for the pregnancy and the institution of
measures to minimize potential complications.
This is best achieved by an early first trimester
ultrasound exam ination.
• Serial ultrasound scrutiny should be performed
in all multiple pregnancies.
• Preterm delivery is, by far, the most important
complication and the predom inant reason for
the high perinatal loss. Improved prediction
and prevention of preterm labour would be an
important advance.
• Labour and delivery should be conducted in a
tertiary referral centre with appropriately
experienced staff available.

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CHAPTER TWELVE

ANTEPARTUM HAEMORRHAGE

IN T R O D U C T IO N
Antepartum haem orrhage constitutes a grave Obstetric em ergency which
until recently accounted for considerable perinatal loss and maternal
mortality. With improved Obstetric care, the maternal mortality rate has
fallen to less than 1 per cent but the perinatal mortality rate is 20-25 per
cent, mainly in cases of placental abruption.

Antepartum haem orrhage (APH) may be defined as bleeding

from the genital tract occurring after the period o f fetal viability, (which
is 28lh w'eek of pregnancy in most of the developing countries but 24
weeks in developed countries) but before the birth o f the baby. Its
overall incidence is about 3-5 per cent.

A ETIO LO G Y
The causes of antepartum haem orrhage may be divided as follows:
• Placenta praevia.
• Placental abruption (abruptio placentae).
• Indeterminate:
a) haemorrhage from the edge of a normally-situated placenta
or a marginal (sinus) haemorrhage
b) lower genital tract causes e.g. vulval varicose veins, vaginal
lacerations, cervical polyp and erosion, cervicitis or rarely
cervical carcinoma
c) ‘heavy show ’
d ) vasa praevia.

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PLACENTA PRAEVIA
Placenta praevia is defined as the implantation o f the placenta in the
lower uterine segment. Its aetiology is unknown but it occurs more
commonly in multigravidae. Several clinical associations have been
established. They often involve some type o f prior uterine trauma or
disturbance to the uterine vasculature. They are: increased maternal age
and parity, previous Caesarean section, previous induced abortion,
previous dilatation and curettage, multiple pregnancy, uterine structural
anomalies and maternal smoking.

Types of placenta praevia (Figure 1)

• Type 1 - the placenta lies mainly in the upper segment but
encroaches onto the lower segment.
• Type 2 - the edge o f the placenta extends to the margin of the
internal cervical os.
• Type 3 - the placenta partially covers the internal os.
• Type 4 - the placenta completely covers the internal os and is
usually centrally placed. This type presents the most serious
maternal risk.

Type 1 Type2 Type3

Figure 1. Types of placenta praevia.

Type 1 placenta praevia is also referred to as ‘Lateral’ placental

praevia, Type 2 as ‘M arginal’ and Type 3 and 4 are called as “C entral'
placenta praevia.

Placenta praevia is sometimes classified as ‘m in o r’ and ‘m a jo r’ .

Types 1, 2 anterior and Type 1 posterior placenta praevias are

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considered as minor placenta praevia while Type 2 posterior and Types 3

and 4 are considered major placenta praevia. Type 2 posterior placenta
praevia is considered as major because o f the fact that the posterior
placenta praevia reduces the antero-posterior diam eter o f obstetric inlet
and may be compressed between the fetal head and the maternal sacral
prom ontory during labour. This reduces fetal blood flow as well as
hinders the decent o f the head into the pelvis. However, because almost
all patients with placenta praevia have Caesarean section nowadays, this
classification has lost its importance.

Clinical features
The clinical picture of placenta praevia is seen during the third trimester
when the lower uterine segment begins to develop. Placental attachment
is disturbed as this area gradually thins during the latter weeks of
pregnancy. The history is one o f usually painless bright-red vaginal
bleeding, which often occurs spontaneously but may be precipitated by
coitus. In a num ber o f instances, the onset o f heavy bleeding is preceded
by small painless bleeds which occur a few weeks earlier. These are
referred to as ‘"‘w arning haem orrhages” . The blood that is lost is
maternal in origin. The mean gestational age at the onset of bleeding is
30-32 weeks.

On examination, the vital signs reflect the degree of

haem orrhage. The abdom en is non-tender and the lie o f the fetus may
be abnormal or unstable. This is because the placenta occupies the lower
pole o f the uterus. The presenting part is usually high above the pelvic
brim and may be deviated from the midline dep en d in g on the type and
position o f the placenta. In an anteriorly-situated placenta praevia, fetal
parts are difficult to palpate and the fetal heart appears faint with a
P in ard 's stethoscope.

Diagnosis
Clinically, the diagnosis could be confirm ed by feeling placental tissue
through the fornices or through the cervical os. Typically, one
appreciates a boggy feeling on digital exam ination, but clots in the upper
vagina may convey the same impression. V aginal exam ination,
how ever, is extrem ely dangerous as heavy bleeding m ay be
precipitated. Such exam ination should never be performed unless the
patient is in the operating theatre with readiness for an immediate
C aesarean delivery. Such “double set u p ’ is rarely necessary as
placental localization is done by ultrasound with much more accuracy. It
should be borne in mind that rectal exam ination carries a similar risk.
Speculum examination is advocated by some Obstetricians in order to

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rule out a local cause o f bleeding. It is the a u th o r ’s o p in io n that a

speculum can be traum atic and should be avoided until the diagnosis o f
placenta praevia is excluded by im aging techniques.

Placental localization
There are several m ethods available to co n firm the diagnosis o f placenta
praevia:
• Soft-tissue rad io g rap h y - in this m ethod, one looks at the
relationship between the presenting part to the sym physis pubis
and the sacral p ro m o n to ry . It is not useful b efo re 34 weeks o f
gestation and if the presentation is not cephalic.
• Radio-isotopic localization - this is a very accurate m ethod and
involves the use o f technetium 99 or indium 1 13. The area over
the lower segm ent is scanned using a scintillation c o u n ter and the
area with a high co u n t indicates the pro b ab le location o f the
placenta. This m ethod carries the hazard o f radiation e x p o su re.
• Pelvic arteriography.
With the advent and easy availability o f u ltrason ograp h y, these
methods are now obsolete.
• Transabdom inal u ltrasonography - most widely and effectively
used m ethod.
• Exam ination un d er anaesthesia (EU A) “ D o u b le set u p ” o r at
caesarean section.

Of these m ethods, only the last two are used in present-day

practice. U ltrasonography is an extrem ely accurate w ay o f visualising
the position of the placenta and is the method o f choice for diagn osin g
placenta praevia. It has a diagnostic accuracy o f 9 5% . T echnical
difficulties are encountered with a posterior placenta, maternal obesity
and when an over distended blad d er causes lower uterine segm ent
compression. It is advisable to p erform the ultrasound scrutiny for
placenta praevia first with a full bladder and then an em pty bladder.
Transvaginal and trans-labial ultrasound has also been e m p lo y e d to
increase the diagnostic accuracy especially where there are d o u b ts using
a transabdominal probe.

• Magnetic R esonance Im aging (MR1) - It can be used to diagnose

various placental abnorm alities including placenta praevia but is
unlikely to replace ultraso n o g rap h y .

If the first ultrasound in m id -p reg n a n c y revealed a low-lying

placenta, a repeat ultrasound is indicated after 34 weeks in the
asymptomatic patient. With the differential growth o f both the u p p er and

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lower uterine segments, a relative upward “m igration” of the placenta

takes place, away from the internal os, and in many cases, no placenta
praevia is found at this time. The term migration is clearly a misnomer as
the placenta does not move from its original place. The possibility of
this apparent “ m o v em en t” o f the placenta diminishes as the gestational
age at first detection increases. That is to say, the earlier in pregnancy
sonography is performed, the more frequently the internal os is seen to
be covered by the placenta but in the vast majority of such cases, a
praevia is not present in the late third trimester.

M anagement
All cases of antepartum haemorrhage should be managed in a hospital
with a blood bank and with facilities for performing ultrasonography
and Caesarean section. That is to say, they should be admitted to a
tertiary health-care unit.

Emergency management
The aim here is to stabilize the patient by resuscitation if needed. An
intravenous line with a wide-bore cannula is set up and blood is taken for
haemoglobin and 2 units o f cross-matched blood are reserved. Isotonic
fluids e.g. crystalloids or plasma, are used until blood is available.

During the process of placental separation, fetal cells may cross

into the maternal circulation. If the mother is Rhesus negative, a
Kleihauer-Betke test of maternal blood should be performed; to quantify
feto-maternal haemorrhage and anti D immune globulin should be
administered if she is not already sensitized as indicated by a negative
Indirect C o o m b ’s test, (see Chapter thirteen)

Further action depends on the diagnosis, severity o f the condition

and gestational age.

Obstetric management
All patients with placenta praevia with bleeding episode after 34 weeks of
pregnancy should be admitted to the Antenatal ward for the rest of the
pregnancy. The aim of management is to prolong the pregnancy to 38
weeks. The patients who never present with bleeding episodes need not
be admitted in the hospital. However, they should be warned and
educated about sudden massive haemorrhage and preferably should live
close to the hospital. Patients with bleeding episodes far from term are
likely to be delivered preterm either because o f massive haemorrhage or
because of fetal distress.

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The inpatient management is termed “expectant treatment”

which was popularized by Macafee and it depends on the balance o f the
patient’s clinical condition on the one hand and the maturity o f the fetus
on the other. Procrastination o f delivery to 38 weeks will benefit the fetus
but this must be done without jeopardizing maternal well-being. This
conservative approach was advocated by Macafee in 1945 and still is
being practiced. The patient is kept under constant supervision in
hospital where immediate active measures can be adopted, if and when
necessary. Cross-matched blood should be available should the need
arise. Maternal anaemia must be corrected since there is a likelihood of
further heavier bleeding. Blood loss must be monitored by means of a
sanitary pad count.

The optimal time of delivery is at 38 weeks and the mode is by

elective Caesarean section performed by a senior officer. In the case of
a Type I anterior placenta praevia, some Obstetricians allow a vaginal
delivery provided that the head engages in the pelvis but there is the risk
of intrapartum haemorrhage and we do not subscribe to it.

Caesarean section for placenta praevia is a daunting proposition

and should be performed by an experienced m ember o f the Obstetric
team. The blood loss is often considerable and there are usually massive
vessels over the lower segment making that approach frightening.
Formerly, placenta praevia was an indication for a classical Caesarean
section so as to avoid cutting into the large vessels present in the lower
segment. This however does not reduce the haemorrhage after placental
separation therefore a lower segment approach is preferable. The fetal as
well as maternal outcome is rarely compromised even if the incision is
through the placenta. Poor contractility o f lower segment sometimes can
make the hemorrhage uncontrollable. Various techniques such as
haemostatic sutures at placental bed, oversewing the placental
implantation site, uterine artery ligation, anterior iliac artery ligation, or
uterine artery embolization can be used. Tight packing of the lower
segment with long gauze and removing it vaginally after 12-24 hrs has
also proven useful in some cases. Hysterectomy may be required in some
cases especially with an abnormally adherent placenta and massive
uncontrolled haemorrhage.

On occasion, a patient may present for the first time with bleeding
after the 38th week of pregnancy. In such cases, after resuscitation, the
patient is taken into the operating theatre and with the Anaesthetist
present with drugs already prepared, and the scrub-nurse and an assistant
gowned, the patient is subjected to a gentle vaginal examination. The

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fornices are first palpated and if no placenta is felt, a finger is inserted

into the internal os. If placenta praevia is found, the patient is then
anaesthetised and a Caesarean section perform ed. Alternatively, if no
placenta is felt, amniotomy is perform ed and a Syntocinon drip is set up
in order to induce labour. This procedure has been termed the double set
up examination but with the advent of rapid and reliable ultrasound
availability and interpretation, this technique is unlikely to be practiced
in modern-day obstetrics.

Complications
• Fetal distress from prolonged separation o f the placenta however
this is not as common as with placental abruption.
• Increased perinatal mortality rate from prematurity and anoxia.
• Shock due to haemorrhage: occasionally, maternal demise.
• Postpartum haem orrhage. This is due either to a morbidly
adherent placenta or to the lack of contraction and retraction of
the lower uterine segment.

The frequency of morbidly-adherent placenta (accreta, incrcta and

percreta) is higher in cases o f placenta praevia. This should be suspected
in anterior placenta praevia with previous lower segment Caesarean
section.

A B R U PT IO PL A C E N T A E
This is defined as the separation before delivery, of a normally sited
placenta i.e. one in the upper uterine segment. O f the major causes of
antepartum haemorrhage, placental abruption is associated with the
highest fetal morbidity and mortality.

A e t io lo g y
The aetiology of abruptio placentae is uncertain. The risk factors are as
follows:
• Sudden uterine decompression which can occur at the time of
spontaneous or artificial rupture of the membranes, especially
when there is polyhydram nios.
• External physical trauma or following external cephalic version.
• Advanced maternal age and increasing parity.
• Hypertensive disorders in pregnancy.
• Cigarette smoking and cocaine use: the risk of fetal death from
abruption is six times greater among smokers than am ong non-
smokers.

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• Preterm premature rupture of membranes

• Short umbilical cord.
• Unexplained elevation of maternal serum alpha-fetoprotein. This
is used as a screening test for open neural tube defects.
• Thrombophilias
• Retroplacental leiomyoma
• Uterine abnormalities: this is still under debate.

Of all these factors, cigarette smoking and maternal hypertension

are the most important risk factors. In many cases placental abruption
recurs in subsequent pregnancies.

Pathophysiology
The first feature of abruptio placentae is vasospasm of the uterine vessels
followed by rupture of the arterioles into the decidua basalis. The blood
beneath the decidua can dissect under the placenta, thereby extending
the degree of separation, eventually appearing through the cervix in the
vagina, or it may enter the amniotic cavity through the membranes, or
infiltrate the myometrial muscle fibers towards the serosa causing the
uterus to contract and appear bruised, purplish and mottled (Couvelaire
uterus).

Clinical features
The clinical presentation depends on the degree o f placental separation
which often is not in keeping with the external blood loss through the
vagina. In the majority of cases, the onset o f symptoms occurs before
labour. The patient presents with a sudden onset o f abdominal pain and
this progressively becomes worse in intensity and spreads. The pain is
constant in nature rather than contractile. She may feel weak and may
collapse. Vaginal bleeding may or may not be present and the condition
may therefore be revealed or concealed or both (Figure 2).

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Figure 2. Varieties o f abruptio placentae.

On examination, there is tachycardia with a low-volume pulse. In

cases o f mild separation, the blood pressure may be normal or even
slightly elevated. In severe separation the patient may present with shock.
The uterus is extremely tender and hard (typically described as woody
hard consistency) Fetal parts are difficult to palpate and the fetal heart,
even if present, may not be audible with a P in ard ’s stethoscope. In
addition, the patient may present with signs o f disseminated intravascular
coagulation (DIC).

Diagnosis
In cases o f moderate or severe placental abruption, the diagnosis is
evident. In cases o f mild separation, however, it might be difficult to
differentiate between placenta praevia and abruptio placentae.
Essentially, the diagnosis o f placental abruption is a clinical one, but in
mild cases, ultrasonography may be useful. Here, one looks for the
presence of retroplacental clots. It should be stressed that a great deal of
operator skill is required to make this diagnosis.

Speculum examination is useful in mild cases in that local causes

can be excluded.

If the ultrasound fails to show a placenta praevia and if local

causes have been ruled out. a diagnosis of placental abruption should be
considered.

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Complications
The main m a te rn al complications are: DIC, renal failure, postpartum
haemorrhage and occasionally hypertension. Generally., DIC only occurs
in cases o f severe placental abruption, but on occasion can result in less
severe cases. It is thought to be initiated by the release o f large quantities
of thromboplastin from the decidua at the site o f separation. The
sequence o f events that follows is not completely clear and happens over
minutes. The initial coagulative state when clotting factors are rapidly
used is replaced by a fibrinolytic state when serum fibrinogen level falls
(< 150 mg/dl) and fibrin degradation products increase. Apart from
afibrinogenaemia, the platelet and other clotting factors are depleted.

The most com m on cause of consumptive co ag u lo p a th y in

pregnancy is a b ru p tio placentae.

Renal failure is a major cause o f maternal death in abruptio

placentae. The underlying pathology is renal cortical necrosis resulting
from prolonged hypovolaemia. Early blood transfusion and adequate
fluid replacement can prevent the onset o f renal failure.
Postpartum haemorrhage results from the inability o f the
myometrium to control bleeding effectively at the arteriolar level and is
exacerbated by an increase in fibrin degradation products (a result o f
DIC), and by maternal anaemia. Uterine atony and DIC are therefore the
chief causes of postpartum haem orrhage in patients with placental
abruption.
Hypertension can occur in spite o f severe blood loss because o f
the severe degree of vasospasm at the arteriolar and capillary bed level.
This can lead to inappropriate fluid replacement, thereby increasing the
risk of the other complications.
The chief fetal complication is fetal anoxia because placental
separation interferes with the transfer o f oxygen to the fetus. Electronic
monitoring may reveal a non-reassuring fetal status. The perinatal
mortality rate due to placental abruption is 40-509?’.

Management
In very mild cases, if the pregnancy is less than 38 weeks, the patient
may be managed conservatively provided that there is no deterioration of
her clinical condition and her symptoms o f pain and vaginal bleeding
are resolving. Once the pregnancy has gone to 38 weeks or if the patient
presents thereafter, delivery should be expedited. The preferred route is
vaginal, and labour is induced by am niotom y and Syntocinon infusion.

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Amniotomy must always precede a Syntocinon infusion in order to

reduce the risk of amniotic fluid embolism. Fetal heart rate should be
monitored by cardiotocography.

In moderate or severe cases, the aims in m anagement are:

• maintaining the blood volume.
• expediting the delivery o f the fetus by immediate amniotomy and
a Syntocinon infusion when necessary.
• prevention o f DIC.

Correcting the blood loss and maintaining the intra-vascular volume

are extremely important if one is to prevent renal failure from occurring.
In the majority of cases, the patient is under-transfused. The patient may
require two peripheral lines. The bladder is catheterised to monitor urine
output using a F o ley ’s catheter.

Blood investigations
Full blood count, in particular the platelet count
Prothrombin time and partial thromboplastin time
Reserve 4 units of fresh whole blood
Fibrinogen, urea and electrolytes.

A vaginal examination is done and amniotomy is performed a)

to induce or accelerate labour, b) reduce the uterine tension by
decreasing intra-uterine pressure, and c) to allow internal fetal heart rate
monitoring. One should aim for a vaginal delivery which is often rapid,
especially when fetal demise has already occurred. A Syntocinon
infusion may be required.

The role of Caesarean section is crucial in fetal distress. There is a

close association between the duration of labour and the perinatal
mortality. Absence of remarkable decelerations does not guarantee fetal
well being as fetal death can occur suddenly with increase in the severity
of placental separation which occurs almost in half the cases of expectant
management. However, in the presence o f a coagulation disorder,
surgery is extremely risky. In the event that the cervix is unripe and
amniotomy is not possible or haemorrhage is severe and delivery is not
anticipated soon, or fetal distress ensues, then Caesarean section is the
method of choice of delivery.

With adequate transfusion of fresh whole blood, DIC can be

prevented. Should it occur, then in addition to blood, cryoprecipitate and
fresh frozen plasma are given. The current trend is to avoid giving

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fibrinogen even if the serum level is low. W hole blood im p ro v es volum e

rep lacem en t, o x y g e n -c a rry in g c ap acity a n d some clotting facto rs, such
as fibrinogen. Alternatively, one may use packed red cells, platelets and
fresh frozen plasma instead o f whole blood.

The most critical time for the patient is during the third stage o f labour.
Intravenous Syntocinon should be given with the birth o f the anterior
shoulder. In addition, it is prudent to continue a high-dose Syntocinon
infusion to reduce postpartum haem orrhage, because the Couvelaire
uterus contracts and retracts poorly during the postpartum period.

In all cases of a b ru p tio placentae, a Kleihauer-Betke test should be

performed and if indicated, 300 ug (1500 IU) A nti-im m unoglobulin
given especially in cases o f traumatic abruption where feto-maternal
haemorrhage is greater as com pared to abruption from other etiological
factors.

INDETERM INATE A PH
This group encompasses all o f the other causes o f antepartum
haemorrhage that are not due to placenta praevia or placental abruption.
As in the previous two conditions, the immediate m anagem ent is aimed at
resuscitation and a haem oglobin estimation is done and cross-m atched
blood requested. The patient's clinical state and the duration o f her
pregnancy will indicate further m anagem ent. T h u s if she is 38 weeks or
more, delivery should be effected as there is little or no risk of
prematurity.

The patient should be admitted to the ward if the maturity is less

than 37 weeks and m anaged conservatively. Anaemia is corrected. An
emergency ultrasound scan is done to exclude placenta praevia.
Retroplacental clots may be detected. A speculum exam ination is then
done to look for a local cause of bleeding. Should the bleeding stop for
3-4 days, she may be allowed home and seen at frequent intervals to
ascertain continued fetal well-being. Provided everything remains
satisfactory, the pregnancy can be allowed to continue until 38 weeks
when labour is induced.

Marginal haem orrhage accounts for most of the cases in this

group and is often found in association with a circumvallate placenta.
Antepartum, it is often difficult to differentiate this condition from a
mild abruption, but the diagnosis can be made in retrospect after

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delivery, when the placenta is exam ined. Almost always, maternal and
fetal prognosis is good.
An uncom m on cause o f antepartum h aem orrhage is that from a
ruptured fetal vessel or vasa praevia. This usually presents following
rupture of the m embranes. Bleeding is usually painless and bright-red in
colour. The diagnosis can be confirm ed by Apt test (alkali denaturation
test) or Kleihauer-Betke test (acid elution test) which detects fetal
haem oglobin. The perinatal loss from this condition is high unless
delivery is immediate and the baby transfused. This is because the blood
loss is fetal in origin and small volumes result in exsanguination.

KEY POINTS

• Antepartum haem orrhage is defined as bleeding from

the genital tract in the third trimester of pregnancy.
• The most com m on causes are placenta praevia and
placental abruption.
• Placenta praevia occurs when the placenta occupies
partially or totally the low er uterine segm ent.
• Placental abruption is defined as prem ature separation
of a norm ally sited placenta.
• Expectant m anagem ent of placenta praevia includes
admission to the Antenatal ward for bed rest, pad chart,
correction of anaem ia, antenatal corticosteroids,
ensuring availability of cross-m atched blood with
readiness for an abdom inal delivery in the event of
heavy bleeding. If the bleeding settles aim to deliver
abdom inally at 38 weeks.
• Ultrasound is the mainstay o f diagnosis for placenta
praevia.
• Severe placental abruption is a m ajor em ergency and
requires rapid resuscitation and delivery.
• Prostaglandins (such as Prostin) increase the risk of
uterine rupture in patients with a history o f previous
uterine surgery such as C aesarean section or
m yom ectom y.
• The Kleihauer-Betke test detects fetal haem oglobin.

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CHAPTER THIRTEEN

RHESUS ISO IMMUNIZATION IN PREGNANCY

INTRO DUCTIO N
Isoimmunization is defined as the process whereby im m une antibodies
are produced in one individual in response to the injection o f antigens
from another individual o f the same species.

The severe effects of Rhesus iso-immunization (neonatal jaundice,

kernicterus and fetal hydrops) had been recognized for many years.
However, it was not until 1938 that there emerged the concept o f a
maternal antibody directed against fetal red blood cells (RBC), which
crossed the placenta and caused their destruction. The historical
sequence of this interesting facet o f Obstetrics is as follows:

1940- Discovery of the rhesus antigen by Landsteiner and Weiner.

Injection o f red cells from the Rhesus m onkey into rabbits
produced an antibody, which agglutinated 85% o f hum an cells
(Rh positive).

1953- Bevis showed that in this type of haemolytic disease the

amniotic fluid contained bilirubin, which provided a useful
index of fetal status. The amniotic fluid was obtained by
amniocentesis.

1963- Liley suggested that in the face o f fetal red blood cell
destruction, transfusion of rhesus negative blood to the fetus
could be undertaken during the antenatal period. This was the
procedure of intra-uterine transfusion.

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Early
1960'S- Postpartum prophylaxis was identified as a means of protecting
unsentisitized Rh negative mothers for future pregnancies. The
agent used was Rh immune globulin (Rhogam®)

Late
1 960’s- Antepartum prophylaxis was suggested. This would protect the
small percentage of women who may have had unrecognized
feto-maternal haemorrhage in the current pregnancy.

Thus, in the space of three decades, the following have been

accomplished:

• The patho-physiology of the condition has been explained.

• A means o f assessing severity has been developed.
• An effective therapeutic manoeuvre has been discovered.
• Preventive measures have been adopted.

In developed countries, the impact of this disorder on perinatal

morbidity and mortality has reduced significantly except in migrant
populations. Other blood group antigens are however becom ing more
of an issue.

PATHOPHYSIOLOGY
Blood production in the fetus begins at about 3 weeks' and Rh antigen
has been identified in the red cell membrane as early as 38 days after
conception. The initial maternal immune response to the D antigen is
slow, sometimes taking as long as 6 months to develop.

• Re-exposure to the antigen produces a rapid immunological

response usually measured in days.
• The sensitized mother produces IgG anti-D (antibody) that
crosses the placenta and coats D-positive fetal red cells which
are then destroyed in the fetal spleen.
• Mild to moderate haemolysis (red cell destruction) manifests as
increased indirect bilirubin (red cell pigment).
• Severe haemolysis leads to red blood cell production by the
spleen and liver.
o Subsequently, hepatic circulatory obstruction (portal
hypertension) with placental oedema interferes with
placental perfusion and ascites develops.

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o H epatom egaly, increased placental thickness, and

polyhydram nios often precede the development of
hydrops (fetal heart failure).
o As liver damage progresses decreased albumin production
results in the development of anasarca, and effusions.
• O v e r a ll, a b o u t 16% o f R h -n e g a tiv e w o m e n w ill b e c o m e
sen sitized a fter th e ir first p r e g n a n c y if n o t g iv e n a n ti D -Ig
o ABO incompatibility reduces this risk to 4-5%.
The reduced risk of Rh sensitization with ABO
incompatibility may result from the rapid clearance of
incompatible red cells thus reducing the overall exposure
to D antigen.

ANTENATAL C A R E
A blood sample taken for ABO and Rhesus grouping is a routine
procedure in the antenatal clinic. Rhesus negative individuals require
special care so that these women should all be seen in hospital clinics.

The history-taking should identify situations such as:

• Previous blood transfusions

• Previous early pregnancy bleeding or termination (including
miscarriages, ectopic pregnancies) as well as delivery o f a viable
fetus. The patient is questioned whether prior sensitization may
have occurred and if not, whether Rh-immune globulin was
administered post-delivery.

It is then necessary to determine whether the patient has circulating

antibodies in her serum directed against fetal red blood cells. This forms
the basis of the In d ir e c t C o o m b s ’ test (IDCT). The titre of the antibody
is determined using an antiglobulin technique and is recorded as 1:8,
1:32, 1:128 etc. A value of 1:32 or greater is a useful stage at which to
consider clinical intervention. The actual amount of antibody may also
be determined.

Generally speaking, clinical intervention, such as intra-uterine

transfusion, is not feasible before 22-24 weeks so that after the booking
blood test, subsequent testing for antiglobulin should restart at 20 weeks
and be repeated at 4-weekly intervals, until 38 weeks gestation, if the
result remains negative. If the C o o m b s’ test is positive, then the

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frequency of testing must increase to fortnightly or weekly assessments,

and plans made for intervention if a titre o f 1:32 or greater is obtained.

In modern day high-risk centres that manage these cases, often early
delivery is possible rather than risk continued intrauterine existence with
the possibility of the complications described above.

Amniocentesis
An ultrasound study is performed in order to locate a pool of liquor and
to identify the placental site. A local anaesthetic is infiltrated into the
abdominal wall. A sterile 22 gauge needle is inserted into the liquor pool
and a sample obtained. At the same time, in severe conditions, evidence
of fetal ascites and hydrops fetalis may be obtained. The complications
of amniocentesis include amnionitis and preterm labour. Injury to the
fetus is very unlikely.

Testing o f liquor (Spectrophotometry)

This is a technique whereby the absorption o f light passing through the
amniotic fluid at a particular wavelength (450 nm) is noted. The higher
the bilirubin pigment level, the less light will pass through so that the
absorption or optical density (OD 450) is said to be higher.

It is important to remember that contamination may occur with

blood or other pigments.

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 R H E S U S ISO IM M U N IZ A T IO N

The L iley C hart

The optical density is plotted against the period of gestation on the Liley
chart. The absolute value, plotted on the chart as well as the trend of
values, gives a prognostic indication and therefore allows form ulation of
a plan of management.

Values in Zone I indicate an Rh negative or mildly affected fetus,

so that the pregnancy may be continued until 38 weeks gestation.
Amniocentesis may be repeated every 3-4 weeks.

In Zone II, the fetus is moderately affected so that amniocentesis

should be repeated every 1-2 weeks to see the trend. Delivery by 34
weeks gestation is usually indicated.

Fetuses in Zone III are severely affected so that intra-uterine

transfusions are usually indicated. Delivery should be undertaken once
fetal pulmonary maturity is assured, on lecithin/sphingomyelin testing.

Invasive procedures are not com m onplace in m odern-day

practice however.

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Non-invasive fetal monitoring

Ultrasound and D oppler imaging o f middle cerebral artery peak systolic
velocity, intrahepatic umbilical venous maximum velocity, liver length,
and spleen perimeter are some of the measurements that are useful.
These methods have superseded invasive methods in high-risk centres
that manage these cases.

Intra-uterine transfusion
The procedure is feasible from 22-24 weeks gestation. Under ultrasound
guidance, a needle and cannula are inserted via the maternal abdominal
wall into the fetal peritoneal cavity. Ascitic fluid is withdrawn if present.
Between 60-120 ml of Rh negative packed red blood cells are
introduced.

Intra-uterine transfusions usually need to be repeated every 1-2

weeks with the aim of keeping the fetal haematocrit above 30%. The
fetus should be delivered at 34-35 weeks.

A tocolytic agent, may be used to quieten the uterus. Fetal

morbidity from the procedure is less than 10%.

Rh immune globulin (Rhogam /Partoglobulin®)

Antibody against the rhesus factor is prepared from pools of human
venous plasma of sensitized human volunteers. In view of the theoretical
risk of variant CJD posed by UK plasma anti-D produced by UK
companies is now manufactured from US plasma.

There is therefore, a limited supply and the product is expensive.

Each vial contains 1500 IU (300 m eg) Rh immune globulin, which is
sufficient to effectively suppress the immunizing potential of 12 ml Rh-
positive red blood cells. Before 20 weeks it is recom m ended that 250 IU
be administered.

There is a wide variation in the dose that is administered

worldwide however. There is no universal policy regarding the postnatal
dose which varies in different countries; 1500 IU (300 meg) is the
standard dose in the USA, 500-600 IU (100-120 meg) in Canada and
1000-1250 IU (200-250m cg) in many European countries except the
UK, Ireland and France.

Indications for Rh immune globulin

By far, the majority of instances for use of Rhogam occur in the
immediate postpartum period. However, the importance of antenatal

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administration in special instances must be emphasized if a diminution of

rhesus iso-immunization is to be achieved.

• Antenatal period: In cases o f threatened m iscarriage,

spontaneous or induced m iscarriage and ectopic pregnancy,
treatment with D im m unoglobulin is recom m ended. Before 12
weeks, it is not recom m ended unless a therapeutic medical or
surgical evacuation is perform ed. The Rh antigen does not cause
a significant immune response in early pregnancy. It is usual to
confirm that the indirect C o o m b s’ test is negative before
administration.

A Kleihauer-Betke test can be done to identify the extent o f feto-

maternal haemorrhage. This is an acid-elution technique which
identifies fetal red blood cells against a background o f “ g h o s t ”
maternal cells. One may adjust the dosage o f Rh immune
globulin depending on the num ber of fetal cells identified per
high-powered field. It is not considered necessary to administer
Rh immune globulin after delivery o f a hydatidiform mole.

Flow cytometry offers an alternative technique for quantifying

the size of FMH. It has a num ber of advantages in that results are
more accurate and more reproducible than those from the
Kleihauer test and that it detects RhD positive cells, making it
particularly helpful in patients with high HbF levels.

• Amniocentesis: Because of the chance o f placental trauma, it is

usual to administer prophylactic therapy.

• Abruptio placentae: The Kleihauer test is useful in these cases.

100 ug Rh immune globulin will neutralize up to 4.0 ml fetal
blood (corresponding to 80 fetal RBC per 50 low power field).

• Placenta praevia.

• External cephalic version. This procedure is contra-indicated in

Rh negative mothers (see Chapter 10).

• Routine antenatal prophylaxis: There are few patients who

become sensitized in the first pregnancy. This is preventable by
the prophylactic administration o f 500 IU Rh im m une globulin at
28 weeks and 34 weeks gestation. Large-scale clinical trials have
 R H E S U S ISO IM M U N IZ A T IO N

shown the efficacy o f this approach, but the cost-effectiveness has

been questioned.

Some women who have received anti-D Ig during pregnancy

may have detectable anti-D in their blood at delivery. Because it
may be difficult or impossible to distinguish between such passive
anti-D Ig and weak anti-D resulting from early immunization,
anti-D Ig should be given to any eligible woman with weak anti-D
antibody at delivery unless it has been clearly confirm ed that she
is already sensitized

• Postpartum period: At the time o f delivery o f all Rhesus negative

mothers, cord blood should be taken for: (1) establishing the
b a b y ’s blood group, (2) perform ing a direct C o o m b s ’ test and
(3) determining the bilirubin level.
In the case o f an Rh positive, direct C o o m b s ’ - negative baby, it
is usual to prescribe 300 ug Rh immune globulin. This should
ideally be given to the mother within 72 hours o f delivery. It is
worthwhile to rem em ber that Rh im m une globulin may be
effective even after 72 hours of delivery so administration should
not be withheld if this time-limit has passed.

The following clinical circumstances are more likely to be

associated with large FMH:
■ traumatic deliveries including caesarean section
■ manual removal o f the placenta
■ stillbirths and intrauterine deaths
■ abdominal trauma during the third trimester
■ twin pregnancies (at delivery)
■ unexplained hydrops fetalis

• Chorionic villus sampling.

• Percutaneous umbilical cord sampling.

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KEY POINTS

• Rhesus isoimmunization is becoming an

uncommon disorder in developed countries
• Routine prophylaxis with anti D immune
globulin both in the antepartum and the
postpartum period is advocated.
• Higher doses are required in certain
circumstances. Quantitative methods of
assessing the amount of feto-maternal
haem orrhage are needed in these cases.
• If isoimmunisation occurs, both non-invasive
and invasive methods of fetal surveillance are
available.
• Early delivery versus intra-uterine
monitoring is to be considered especially
where there are advanced special-baby care
units.

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CHAPTER FOURTEEN

ULTRASONOGRAPHY

INTRODUCTION
Obstetric ultrasound was pioneered in the late 1 9 5 0 ’s by Professor Ian
Donald of Glasgow University. It was subsequently introduced into
clinical practice in the 1 970’s. The ultrasonic waves used to image the
fetus or other organs cannot be heard and produce no sensation to the
person (e.g. fetus) being imaged. Ultrasound is painless, safe and
reliable and is now an integral part of modern obstetric care.

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BIOPHYSICS OF ULTRASOUND
Ultrasound is very high frequency sound. H um an ears can detect sound
with frequencies lying between 20 Hz and 20 kH z. Medical im aging
uses frequencies that are m uch h igher and typically fro m 3 to 15 M Hz.
These frequencies do not occur in nature and it is only within the last 50
years that the technology has existed to both generate and detect this
type of ultrasound wave in a practical way.

The device that both generates the ultrasound and detects the
returning echoes is called the transducer. Transducers are made fro m a
synthetic ceramic material, which can be m oulded into almost any shape.

The probe refers to the piece o f e q u ip m e n t in which the

transducer is m ounted. The probe can either be a conventional type used
externally (e.g. trans-abdom inal) or an intra-cavity type (e.g. trans-
vaginal). Trans-abdom inal probes used in obstetrics typically have
frequencies o f 3.5 M Hz or 5 M Hz, whereas trans-vaginal p robes can
utilise higher frequencies o f 7.0 MHz.

An important principle is that frequency is related to image

resolution but inversely related to the penetration o f the sound beam into
the tissue. Therefore, the higher the freq u en cy o f the p ro b e, the better
the resolution o f the image but only a shallower depth o f tissue can be
examined.

Current equipm ent provides two-dim ensional (2D ) or three -

dimensional (3D) inform ation. T hree-dim ensional im aging in real time,
known as four-dimensional (4D) im aging, is now available. However, 2D
imaging is most c o m m o n ly utilised in obstetrics and g y n aeco lo g y .

To obtain m axim um inform ation from any obstetric ultrasound

examination, the ultrasound e q u ip m en t should be suited to the required
examination and should be functioning correctly. Also, wom en should
be properly prepared and the operator should be confident in the ability
to perform the examination.

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 ULTRASONOGRAPHY

FIRST TRIMESTER ULTRASOUND

The gestational sac

Figure Is Early gestational sac surrounded by a thick bright ring

Demonstration o f a gestational sac within the uterus is the earliest

ultrasonic conformation o f an intrauterine pregnancy. It is usually
visualized from 31 days or 4 weeks + 3 days gestation using the trans-
vaginal method. It can be identified about a week later at 5 weeks + 3
days gestation, using the abdom inal route. The early gestation sac
appears as a circular transonic area surrounded by a thick bright ring
(Figure 1). It usually lies at the uterine fundus and is eccentrically
placed. The thick, bright ring o f the early gestation sac corresponds to a
rim o f invading chorionic villi and the underlying decidual reaction.
The gestational sac grows approximately one millimetre in diameter per
day. The normal sac loses its circular shape and becomes more elliptical
when its diameter exceeds 1 cm.

Use of gestational sac measurements

• C o n fir m a tio n o f a n in tr a u te r in e p r e g n a n c y
• C a lc u la tio n o f g e s ta t io n a l a g e b e fo r e th e e m b r y o is v is ib le
• D ia g n o s is o f m is c a r r ia g e

The yolk sac

The yolk sac appears as a circular transonic mass within the gestation sac
and can first be identified trans-vaginally at about 35 days, when it

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 ULTRASONOGRAPHY

measures 3-4 mm in diameter. At this stage it is significantly larger than

the embryo. It is a prominent landmark to search for within the early
gestation sac and, because of its close association with the embryo at this
stage, identifying it will automatically lead to the embryo. This becomes
less likely with the progressive elongation o f the yolk stalk with
increasing gestation.

The embryo
The embryo can be visualised from about 37 days using the trans-
vaginal route and is first seen as a bright linear echo, adjacent to the yolk
sac (Figure 2). At this stage, the crown-rump length (CRL) measures
around 2 mm and cardiac activity can be identified. Using trans­
abdominal ultrasound, the sequence of events is one week later.
The embryo grows at around 1 mm per day. All embryos of CRL >7
mm in length should demonstrate visible cardiac activity. Once an
embryo with visible heart action is seen, the pregnancy is unlikely to end
in miscarriage.

Figure 2: The embryo adjacent to the yolk sac

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 ULTRASONOGRAPHY

Measurement of crown-rump length

Fetal growth can be m onitored accurately later in pregnancy only if the
exact inform ation about gestational age is available. Less than 50% of
women are certain about their menstrual dates and as such this
calculation is not always accurate. Every effort should be made to
estimate fetal age early in pregnancy when biological variability is
m inim al. As soon as the em bryo can be seen the gestational age can be
estimated by m easuring the crow n-rum p length. The biological
variability of the crow n-rum p length is small and growth is very rapid.
However, there are still a num ber of factors that can affect the size of an
early em bryo, such as m easurem ent errors, differences in growth rates
between individuals, fetal sex and maternal conditions such as diabetes
mellitus. A correctly perform ed m easurem ent o f CRL is the most
accurate means o f estimating the gestational age (Figure 3).
M easurem ents are taken from the
top o f the head (crown) to the end of
the trunk (rum p). The gestation
deduced from m easuring the CRL
should be com pared with that from
the menstrual dates. The
m easurem ent has an accuracy
equivalent to + or -4 days so that the
p atient’s expected date o f delivery
(EDD) should not be changed if the
difference equates
to a week or less. Figure 3: The accurate
measurement of CRL
• C a lc u la te g e s ta tio n f r o m L M P
• I d e n tify th e u te r u s a n d g e s ta tio n s a c
• L o o k f o r F H p u l s a t i o n to c o n fir m v ia b ility
• M easure C R L
• V e rify E D D

M iscarriage
The patient may be asym ptom atic or experience brown vaginal staining
or frank bleeding. Pain may or may not be a prom inent sym ptom .

If there is no visible em bryo, this is termed an anembryonic

gestation. When the fetus can be measured but there is no cardiac
activity, the diagnosis is that o f silent (delayed or missed) miscarriage.

If cervical dilatation has allowed products o f conception to be

expelled from the uterus, ultrasound exam ination may assist in

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 ULTRASONOGRAPHY

diagnosing if the miscarriage has been com plete or incom plete.

Irregular echo-bright areas within the uterine cavity suggest an
incomplete miscarriage. In contrast, when all the products o f conception
have been expelled and the cavity o f the uterus is empty with a clear
midline echo, then the miscarriage is com plete.

If there is difficulty visualising a fetal pole or cardiac pulsations

on a trans-abdom inal scan, then a trans-vaginal scan should be
undertaken.

Identify the gestational sac. It may appear irregular and

collapsing or there may be evidence o f haem atom a form ation. Be aware
of the possibility o f m ore than one sac being present.
If the mean sac diam eter is more than 20 mm and there is no evidence o f
an embryo or yolk sac, the appearance is highly suggestive of an
anembryonic pregnancy. It is wise to obtain a second opinion to
confirm the findings.

If the mean sac diam eter is less than 20 mm or CRL is less than 6
mm, a repeat scan should be undertaken to assess viability after at least 7
days.

It must be remembered that a scan is an investigation requested by a

clinician who then considers all of the clinical features of a particular
case and then makes a final diagnosis.

Ectopic pregnancy
An ectopic pregnancy is defined as im plantation o f the fertilized ovum
outside the uterine cavity. Therefore if the uterine cavity appears em pty
and the patient has a definite positive pregnancy test, an ectopic
pregnancy is highly likely unless the history is suggestive o f a com plete
miscarriage. However, the intrauterine appearance may be less clear
because of the horm onal influences o f pregnancy causing the
endometrium to decidualise such that a pseudo-decidual or pseudo-
gestational sac becomes evident. This may be present in the endom etrial
cavity in up to 15% of ectopic pregnancies. A pseudo-sac contains
endometrial fluid, is usually less than 10 mm and is centrally located
within the uterine cavity. In contrast, the normal chorionic sac is
eccentrically placed within the uterine cavity and has a definite hyper-
echoic perimeter. The adenxa should always be exam ined to assess for
any associated mass. Adnexal abnorm alities are seen in 70% of ectopic
pregnancies but the appearances are variable and frequently suggestive
and not diagnostic of an ectopic pregnancy. A corpus luteum , pelvic

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 ULTRASONOGRAPHY

inflam m atory disease, endom etriosis and hydrosalpinges can all give
similar ultrasonic appearances. Evaluate the Pouch of D ouglas for free
fluid, suggestive of a haem operitoneum . If the patient has had significant
haem orrhage, an echo-free area is seen around the uterus.

The ultrasound findings will be interpreted in association with the

serum hum an chorionic gonadotropin (hCG) levels which greatly
improve the diagnostic accuracy. When the serum levels are m ore than
1000 IU/1, an intrauterine sac should be seen using the trans-vaginal
ultrasound. This discrim inatory cut o ff is higher for trans-abdom inal
scan when the threshold is 5000 IU/1. In a viable pregnancy, serum hCG
levels range from 100 IU/1 at the first missed period to 50-100 000 IU/1
at 10 weeks, falling to 10-20 000 at 20 weeks and rem ain around that
level until term . The levels double every 2 days at values below 1200
IU/1 and every 3 days below 6000 IU/1. In an ectopic or non-viable
pregnancy this predicted increase tends not to occur.

Multiple pregnancy
A first trimester scan is essential for the reliable identification of
chorionicity and am nionicity in multiple pregnancies. Twins arise from
the ovulation and fertilization o f two eggs (dizygotic twins) or a single
egg (m onozygotic twins). The fertilized egg is term ed the zygote. All
dizygotic twin pairs have separate placentas and therefore separate
chorionic sacs and separate amniotic sacs. The assessment o f chorionicity
and am nionicity is im portant as the m anagem ent o f m onochorionic twin
pregnancies presents greater challenges to the obstetrician com pared with
dichorionic twins. Later in pregnancy the assessment of chorionicity is
much more difficult, thus em phasizing the im portance o f achieving a
correct diagnosis in the first trim ester. Perinatal mortality is higher in
m onochorionic twin pregnancies because o f the sharing o f a common
circulation and in m onoam niotic ones because o f sharing one sac. An
understanding o f the em bryological form ation o f a twin pregnancy is
required to aid interpretation o f the scan findings.

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 ULTRASONOGRAPHY

Figure 4: The “T ” sign in a m onochorionic twin to the left and the

“lam bda” sign in dichorionic twin on the right side.

The chorionicity can be established as early as 5 weeks gestation

by simply seeing the num ber o f sacs. U ndercounting may occur at this
time and a repeat scan should be booked at 9 weeks gestation. The
amnionicity can be established at 8 weeks when the am nion is seen
separate from the em bryo. In a dichorionic, diam niotic twin pregnancy,
the chorionic sacs approxim ate and the dividing m em brane appears
thick, while the junction with the uterine wall appears wedge shaped. This
is termed the “ twin p e a k '’ or “ la m b d a ” sign (Figure 4). In a
monochorionic diam niotic twin pregnancy, the am niotic m em branes
from each sac come together to form a thin m em brane and when the
extra-amniotic space is obliterated, they appear to “ take o f f ” from the
uterine wall at 90 degrees. This is known as the “ T ” sign (Figure 4 ). In
a m onochorionic m onoam niotic twin pregnancy, there is no dividing
membrane and only one yolk sac with two em bryos.

Learning points
• D ic h o r io n ic , d i a m n io tic p r e g n a n c i e s h a v e th e lo w e s t p e r in a t a l
m o r ta lity
• T h e la m b d a s ig n is s e e n in d i c h o r i o n ic tw in p r e g n a n c i e s
• T h e d iv id in g m e m b r a n e is th in a n d a t r ig h t a n g l e s to th e u te r in e
w a ll in m o n o c h o r i o n ic d i a m n io tic tw in p r e g n a n c i e s

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M OLAR PR EG N A N C Y (TR O PH O BLA STIC DISEASE)

Trophoblastic disease covers the spectrum from benign hydatidiform
m ole to m alignant choriocarcinom a. Early diagnosis enables
appropriate m anagem ent and counselling to be planned.

Complete hydatidiform mole

C om plete hydatidiform m oles are characterized by generalised swelling
o f the villous tissue and diffuse trophoblastic hyperplasia in the absence
o f em bryonic or fetal tissue. The typical second trim ester sonographic
appearance used to be described as a “ snow storm ” (F igure 5).

Partial hydatidiform mole

Partial m oles are characterized by focal swelling o f the villous tissue and
focal trophoblastic hyperplasia in the presence o f fetal tissue.
Sonolucent areas found within the placenta m ight represent either a
partial mole or a twin pregnancy in which one conceptus is norm al and
the other a com plete m ole. In the case o f a com plete mole coexisting
with a fetus, the m olar placenta will be clearly separated from the norm al
placenta, whereas in partial moles the m olar structures are dispersed
inside the placental mass.

C horiocarcinom a
C horiocarcinom a develops in approxim ately 1:40,000 term pregnancies
and this represents a quarter o f all cases. The other cases follow molar
disease, an abortion (spontaneous or therapeutic) or ectopic pregnancy.
The prim ary tum or is often very small and an extensive search o f the
placenta is frequently required to find the lesion.

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Figure 5: The “snowstorm appearance'” in complete

hydatidiform mole

SECOND A N D TH IRD T R IM E ST ER U L T R A SO U N D
All ultrasound exam inations benefit from a m ethodical approach.
Information regarding the gestational age, fetal anatom y, placental
morphology and the am niotic fluid volume can all be obtained. M any
obstetric units offer a routine ultrasound assessment at 1 8 - 2 2 weeks
gestation as a screening investigation to detect fetal anomalies.

Figure 6: Measurement of the BPD and HC

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 ULTRASONOGRAPHY

Measuring the biparietal diameter (BPD)

The BPD has traditionally been the most widely used ultrasound
param eter in the estimation o f gestational age. A single optim al
m easurem ent of the BPD, in the early second trim ester will predict the
gestational age to within ± 7 days. The BPD is the m axim um diameter
of a transverse section of the fetal skull at the level of the parietal
eminences (Figure 6). To measure the BPD, begin by acquiring an oval
transverse plane o f the head at the level o f the thalam us and cavum
septum pellucidum . M easure the BPD from the outer surface o f the
proxim al parietal bone to the inner surface o f the distal one. Gestational
age (independent variable) is plotted on the x-axis and the BPD
(dependant variable) is plotted on the y-axis. A grow th chart should be
used to determ ine if the param eter m easured is within the norm al range
for the gestational age as calculated from a reliable m enstrual history
and/or a first trim ester dating scan.

Measuring the head circumference (H C )

This is measured from the same view as that used for BPD. HC can be
measured by the ellipse m ethod: the first onscreen cursor is placed on
the outer table o f the skull at the occiput. The second cursor is then
placed on the outer table o f the skull at the synciput. Using the
appropriate control, a ready-form ed ellipse o f dots is moved out from
between the two cursors until it matches the outline o f the fetal skull.
The literature now contains a num ber o f datasets indicating the
superiority of the HC over the BPD for pregnancy dating.

M easuring the abdominal circumference (A C )

This is measured by obtaining an im age o f the u p p er abdom en in the
coronal plane. The outline should be circular and not ovoid and a short
length o f the um bilical vein should be visible. In this section the
stomach is also usually visible as an echolucent area in the left side of the
abdom en. The circum ference o f the abdom en is m easured in the same
way as the head circum ference. The AC is an im portant measurement
for assisting in the detection of intrauterine grow th restriction (IUGR).

Measuring the femur length (FL)

The fem ur length is a relatively easy and accurate measurement to
obtain. Its accuracy in predicting the gestational approxim ates that of
the BPD. The fem ur length can be m easured from 12 weeks onwards. It
is im portant to ensure that the entire length o f the fem ur is visualised.
The correct section should have soft tissue visible beyond both ends of
the fem ur and the bone should not appear to m erge with the skin of the

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thigh. One calliper m arker should be placed in the centre of the

proximal end and the other in the centre o f the distal end o f the fem ur.
This length should be recorded on an appropriate growth chart. If the
femur bone is small com pared with the m easurements for BPD and HC, a
careful survey of all the long bones should be perform ed to exclude
dwarfism.

Ultrasound and the “late booker”

Predicting gestational age by ultrasound is most accurate when
performed before 24 weeks o f gestation. Pregnant women who attend
the hospital for the first time after 24 weeks fall into the following
categories:
• All ultrasound m easurem ents correspond with the menstrual age.
These women do not need further ultrasound exam inations unless
clinically indicated.
> An unreliable m enstrual history or the fetal size is less than that
predicted by m enstrual dates. In these women an accurate EDD
cannot be predicted. They should have serial ultrasound
examinations to m onitor fetal growth and an approxim ate EDD
assigned.
• Fetal size is greater than that predicted from the menstrual
history. These women should be rescanned 2-4 weeks later to
observe the growth velocity and an approxim ate EDD can then be
assigned. The obstetrician should be vigilant for the possibility
of maternal diabetes in these cases.

Measurements and clinical interpretation

The measurements should be plotted on centile charts, which are based
on cross-sectional population data and now widely used (graph 1). O f
all the measurements, AC is the most sensitive predictor o f fetal weight
and this is to be expected because it reflects the glycogen stores o f the
liver. It is also an easier m easurem ent to obtain com pared to those o f the
head, as size, shape and accessibility will be altered according to where
the head is positioned. For exam ple, the head fixed in the pelvis is
difficult to measure or if the presentation is breech, the BPD is reduced
owing to elongation in the transverse plane (dolicocephaly).

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99
97
95
90

75

50

25

10
5
3
1

Graph 1: Fetal growth centile chart

In high risk patients, serial growth scans may be required. These will
com m ence at a gestation dictated by the clinical scenario and serial
biom etry should be undertaken at no less than 2- weekly intervals. A
shorter interval between scan m easurem ents may lead to a higher false
positive rate. An increase in AC of approxim ately 20 mm in 2 weeks is
expected for the average fetus.

A nother confounding variable is inter-observer difference, which

can make interpretation difficult. Various m odels have been used to
estimate fetal weight and the one described by Hadlock (1985), utilising
BPD, HC, and FL, appears to be the most accurate. Perfect accuracy of
fetal weight prediction is understandably im possible and up to 15%
difference in the actual and the estimated fetal weight is not uncom m on.
The estimation o f fetal weight is helpful to the obstetrician when

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considering preterm delivery or suspecting growth restriction or

macrosomia in the third trimester but its limitations must be realised.
Assessing fetal anatom y, and excluding anom alies.
An ultrasound exam ination has the benefit of being both a screening test
and a diagnostic test for fetal anomalies. Its clinical value is directly
dependant on the skills o f the sonographer. The fetal anatom y scan
should be undertaken between 18-22 weeks gestation, when the
structures can be visualised most clearly.

A routine and systematic approach is necessary and it is good

practice to com plem ent the fetal survey by a detailed report confirm ing
the structures exam ined. Some structures may not be clearly seen owing
to maternal obesity or fetal position. The details of fetal anatom y
scanning and description of different fetal anom alies are beyond the
scope of this chapter.

THE PLACENTA AND AMNIOTIC FLUID

Placental morphology
The placenta appears as a thick layer o f hom ogenous echoes attached to
the uterine wall and covered on its internal surface by a well-defined
bright line of echoes known as the chorionic plate. As the placenta ages,
it may undergo very noticeable changes. Echogenic areas (calcification)
may appear within the previously hom ogenous mass and indentations
may occur on the previously smooth chorionic plate. M ultiple cystic or
hypoechoic spaces are also often seen with mature placentas. Some
ultrasonographers may report on the G rannum grading (nam ed after its
author) of the placenta. This is a classification o f the norm al changes
that occur in the placenta during the course of a pregnancy and is scored
from grade 0 - III depending on the presence and extent o f placental
inclusions and indentations.

Placental localisation
Accurate assessment of placental location is im portant and can be
attempted after 18 weeks gestation.

The placenta is best identified by scanning the uterus

longitudinally and is easily recognised by its more echogenic pattern
compared with that o f the underlying m yom etrium . The actual internal
os might be difficult to identify transabdom inally but its position can be
assumed by visualizing the slight dimple at the upper end o f the cervical
canal. The placenta can be fundal, anterior, posterior or lateral, in which
cases it will be visualized on both the anterior and posterior walls o f the

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uterus. It m ight lie com pletely within the up p er part o f the uterus, with
its lower edge > 5 cm from the internal os. Such a position is usually
described as “ u p p e r ” or “ not lo w ” . A lternatively, if the leading edge
o f the placenta lies within 5 cm o f the internal os and/or appears to cover
the internal os then its position should be described as “ lo w ” and/or
“ covering the o s ” . The term “ placenta praevia” sh o u ld only be used
after 28 weeks.

Placenta praevia is divided into fo u r grades (I, II, III and IV).
Grades I and II are considered to be minor cases while grades III and IV
are m ajor. V aginal ultrasound has added a fu rth er dim ension to the
classification o f placenta praevia by enabling the distance between the
lower m argin of the placenta and the internal os to be m easured more
accurately. If the distance is less than 3 cm , this should be regarded .as in
keeping with a m ajor praevia while, distances o f 3 -5 cm are in keeping
with a m inor praevia.

Antepartum haem orrhage

A ntepartum haem orrhage refers to bleeding from the genital tract after
24 weeks gestation and is a com m on obstetric problem .

If the blood loss has been excessive, it is likely that the

m anagem ent will be dictated on the labour ward during and after
appropriate resuscitative m easures. The most im portant differential
diagnoses are placenta praevia and placental abruption. Ultrasound is
very helpful in the diagnosis of placenta praevia but less so for
abruption. Placental abruption is considered a clinical diagnosis and in
only a few cases will ultrasound be useful in confirm ing the diagnosis.

The ultrasonic assessment may reveal haem atom a formation

suggesting that an abruption has occurred. However, its ultrasonic
appearance may be very similar to that o f the placenta making
differentiation of the tissues difficult. The sonographic appearance also
changes with time as a haem atom a becom es organised and a mixed
echogenic pattern may be seen.

Assessment of amniotic fluid

In the first trim ester, the main contribution to am niotic fluid is maternal
in origin and thereafter, the fetus becom es progressively more
responsible for its regulation. A fter 20 weeks, the main source of
am niotic fluid is fetal urine and it is mainly cleared by fetal swallowing.
Any disruption to these m echanism s will result in m ajor changes in
volum e. The norm al range is wide but approxim ate volum es are 500 ml

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at 18 weeks, rising to a m axim um o f 800 ml at 34 weeks, and falling to

600 ml at term.

There are a num ber of m ethods o f assessing amniotic fluid volum e.

Subjective terms may be used to describe am niotic fluid volume such as:
virtually none (oligohydram nios), reduced, average, more than average,
and excess (polyhydram nios). Sonographic experience o f the average
amniotic fluid volume is necessary before these descriptive findings can
be used.

Objective measurements give a numerical value for the obstetrician and

there is less inter-observer variation compared to subjective assessment.
These measurements include:

Maximum vertical pool of liquor (MVPL)

The entire uterine cavity is scanned, looking in particular between the
fetal arms and legs, and around the neck for the deepest pool o f am niotic
fluid. The vertical depth of the largest pool o f amniotic fluid is located
and measured without the presence o f limbs or umbilical cord.
MVPL
• <2 cm = O ligohydram nios
• 2-3 cm = Reduced
• 3-8 cm = Normal
• >8-12 cm = M ore than average
• >12 cm = Polyhydram nios

Amniotic fluid index (AFI)

The largest vertical pool o f am niotic fluid without limbs or cord in each
quadrant of the uterus is located and the m easurem ents from each
quadrant are added.
AFI
• < 7 cm = O ligohydram nios
• 7-10 cm = Reduced
• 10-17 cm = Normal
• 17-25 cm = M ore than average
• > 25 cm = Polyhydram nios

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ABNORMAL FETAL GROWTH

Ultrasound is particularly useful for diagnosing and m onitoring
abnorm al fetal growth patterns. Some exam ples are; m acrosom ia, IUGR.
Twin to Twin Transfusion Syndrom e and hydrops fetalis.

M acrosomia - is most com m on in diabetic patients and in obese patients

with gestational diabetes. A large-for-dates fetus may be suspected
clinically and is frequently associated with excess am niotic fluid.
M easurem ents of the AC above the 90th centile are of concern because
fetal m acrosom ia may be associated with shoulder dystocia. The AC may
be disproportionately larger than the other param eters but there is no
accurate m ethod available to predict shoulder dystocia and it depends
more on the mechanics o f labour and the relative physique of mother
and fetus.

IUGR - although the World Health Organisation has defined small for
gestational age at a cut-off below the 10th centile, this does not always
equate with growth restriction because some fetuses will be normally
small and have reached their m axim um biological potential; while others
may be above the 10th centile but with growth restriction as their
potential was even greater but they had stopped grow ing. It is useful to
consider two mechanism s which result in growth restriction:

Low growth potential - this means that the fetus from conception is
destined not to grow well. M easurem ents o f the fetus are typically
reduced from m id-pregnancy. The fetus tends to be short and light with
all ultrasound m easurem ents being reduced. This is term ed symmetrical
growth restriction and may be due to the m other being biologically
small (< 45 kg) or there may be a pathological cause such as a
chrom osom al abnorm ality or viral infection.

Loss of growth support - this is usually found after 30 weeks and is due
to restriction o f oxygen and nutrients owing to vascular disease affecting
the utero-placental circulation, such as pre-eclam psia. The fetus tends to
be long and light with a reduced abdom inal girth. This is termed
asymmetrical growth restriction. With starvation the glycogen stores in
the fetus becom e depleted and, because the liver stores most of the fetal
glycogen, the abdom inal circum ference m easurem ent is reduced while
the BPD, HC and FL, remain unaffected. A lthough symmetrical and
asymm etrical growth restrictions classically are described as separate
entities, in clinical practice the differentiation is less clear.

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Doppler
Doppler ultrasound has been used to m easure the blood flow velocity in
vessels during the cardiac cycle in the feto-placental and utero-placental
circulations. Resistance to blood flow in the uterine arteries falls with
advancing gestation due to trophoblastic invasion o f the uterine spiral
arteries. V arious indices can be used to assess um bilical artery resistance
and, if raised, may indicate a problem . M ore clinically useful is the
observation o f absent end-diastolic flow or reversed end-diastolic flow
which indicates a progressive com prom ise in the blood flow through the
umbilical arteries.

FETAL BIOPHYSICAL PROFILE SCORE (BPS)

Biophysical profile scoring is a form alization o f fetal behavioural
assessment. Healthy fetuses dem onstrate g ood tone, general m ovem ents,
breathing m ovem ents and a norm al am niotic fluid volum e and heart rate
pattern (determ ined on C TG ). The BPS is affected by factors, which
suppress the fetal nervous system such as h y p o x ia, infection, and
maternal m edication.

Biophysical N orm al A bnorm al

Variable (S c o r e = 2 ) (S c o r e = 0 )
FBMs Present Absent

Gross FMs 2 or more discrete body/ <2 episodes o f body/limb

limb movements movements

Fetal tone 1 or more episodes of Slow extension with return to

active extension with partial flexion, movement of
return to flexion of fetal limb in full extension, absent
limb(s) or trunk fetal movement

Reactive FHR 2 or more accelerations < 2 accelerations within 20

(On CTG) associated with fetal min
movement within 20
min

Qualitative AFV 1 or more pockets of Either no pockets or largest

fluid measuring >2 cm pocket <2 cm
Fetal breathing m o v e m e n t s ( F B M ) , F e ta l m o v e m e n t s ( F M ) , F e ta l h ea rt rate ( F H R )

Table 1: The components of the Biophysical Profile Scoring

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A score o f 2 is given for each com ponent if the criteria are met
and zero if not. The m axim um score is 10, and scores o f 6 or below are
considered abnorm al. The purpose of the BPS is to assist in identifying
a fetus that may require delivery before becom ing seriously
com prom ised. The com ponents are illustrated in Table 1.

The fetus has a sleep-wake cycle of 20-40 minutes and hence the
observation period may take up to 30 minutes. In a com prom ised fetus
affected by hypoxia or infection, the first m arkers to go are breathing
and fetal heart rate reactivity and the last are m ovem ent and tone.

KEY POINTS
• Ultrasound is painless, safe and reliable and is
now an integral part of modern obstetric care
• Demonstration of a gestational sac within the
uterus is the earliest ultrasonic conform ation of
an intrauterine pregnancy. It is usually
visualized from 4 weeks + 3 days gestation
trans-vaginally or 5 weeks + 3 days gestation,
transabdominally.
• It is operator-dependant and appropriate
training in its use is crucial.
• The M aximum Vertical Pool o f Liquor
(M VPL) and the Amniotic Fluid Index (AFI)
are objective, reproducible measurements of
the liquor volum e.
• Biophysical profile scoring is a form alization of
fetal behavioural assessment.

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CHAPTER FIFTEEN

THE UMBILICAL CORD AND PLACENTA

INTRODUCTION
Far too little attention has been paid to the exam ination o f the umbilical
cord and placenta following delivery. The practice, in most delivery
units, is to discard the placenta after perform ing a cursory exam ination
and measuring its weight, despite the fact that placental weight is seldom
an important consideration in establishing the cause o f fetal distress or
demise. This is indeed a casual m anner in which to treat an organ, which
so vital in its function to the developing fetus, may yield valuable data
and provide clues to account for some o f the “ u n e x p lain ed ” causes o f
perinatal deaths we encounter from time to time.

Any approach to the gross exam ination o f the placenta has to be

brief, practical and systematic so that it can be perform ed as a routine for
all deliveries.

THE UMBILICAL CORD

Blood vessels - on section o f the um bilical cord, there are two arteries
and one vein (Figure 1). The other constituents o f the cord are a) the
inconstant relic o f the duct o f the yolk sac (the vitelline duct) which may
be seen as a tiny yellow speck near the insertion o f the cord into the
placenta, and b) the rem ains of the allantois. The vessels are em bedded
in a mass of connective tissue, called W harton’s jelly.

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Figure 1: Vessels of the umbilical cord

A ppearance - the cord is grey in colour and shows a spiral twist.

Pathological twisting (hyper-coiling) o f the cord is often thought of as a
sequel o f fetal demise, but it may indeed be a cause o f fetal death. The
surface may be nodular due to localised distension of the umbilical vein.
These ‘nodules’ are regarded as false knots and are essentially
varicosities with no clinical significance. True knots are caused when the
fetus passes through a loop of the cord, either spontaneously or as a
com plication of external version. In many instances, the knot is loose.
If tight, it may predispose to fetal distress.

Insertion - the cord inserts within 2 centimetres o f its centre in

approxim ately 10% of cases and eccentrically in 90%. It is normally
attached directly on the surface. O ccasionally, the um bilical vessels
becom e distinct and partially separated several centim etres from the
surface; this is called pedicle insertion. After insertion, the umbilical
vessels ramify along the surface o f the placenta and when they cross,
arteries pass over the branches o f the vein. Apart from pedicle insertion,
there are two other abnorm al insertions which should be looked for:
• Velamentous - when the vessels are inserted into the
chorioam nion beyond the placental disc surface. In this situation,
the vessels and more frequently the vein can be seen wandering
across the mem branes and com e to the placenta at a variety of

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points. V elam entous or m em branous insertion, as it is sometimes

called, may be seen m ore com m only with m ultiple pregnancies.
If these “ f r e e '’ vessels traverse the lower segm ent o f the uterus, it
is term ed vasa praevia. Vasa praevia has been defined as a
condition in which the blood vessels, unsupported by either
um bilical cord or placental tissue, traverse the fetal m em branes in
relation to the lower uterine segm ent in front o f the presenting
part. There are two m ajor com plications o f vasa praevia: i)
rupture o f the blood vessel causes antepartum haem orrhage and
may result in fetal exsanguination and ii) com pression o f the
velam entous blood vessel by the presenting part may cause fetal
distress.
• M arginal - is one in which the cord vessels are inserted onto the
edge o f the placental disc and the condition is also referred to as
“ battledore” . The clinical significance o f this anom aly is
doubtful.

Length - the length o f the cord varies greatly from about 10 - 200
centimetres. It is not m easured routinely but a very short cord may give
rise to com plications with delivery such as a delay in the descent o f the
presenting part or it may even rupture. Alternatively an excessively long
one may be m ore likely to becom e entangled around the fetal body or
limbs or may predispose to cord prolapse.

THE PLACENTA
Placental anatomy
The mature placenta is typically round or ovoid with a sm ooth outer
border. Its colour may be reddish-grey or deep purple-red and it has a
spongy character. The average weight o f a term placenta is 450 - 550
grams. It measures about 15 cm in diam eter and 2 cm in thickness when
laid flat. The placental: fetal weight ratio is usually l:6 .T h e placenta has
two surfaces: fetal and m aternal (Figure 2).

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feud capillarte*
maternal blood pools

— maternal
venule

m aternal
arteriole

um bilical
arteries

fetal p o rtio n v
o f placenta m atern al portion
(chorion) placenta

Figure 2: Fetal and maternal portions o f the placenta

The fetal surface is covered by a layer o f am nion over which the

umbilical vessels course and divide. The am nion can be stripped from
the chorion on the fetal surface. The follow ing observations should be
made:
• D iscolouration e.g. with m econium
• White infarcts. These denote fibrin deposition and are a sign of
m aturity.
• A m nion nodosum . M ultiple nodules on the fetal surface are
sometimes associated with renal agenesis.
• C horio-angiom a. This is a tu m our o f the blood vessels in a villus.
It is usually associated with hydram nios.
• Cysts. Unless large in size or num ber, these are of little
significance.

The maternal surface should be exam ined fo r the degree o f separation

o f the cotyledons. The spaces between the cotyledons are filled with
decidual septum , the apices o f which meet with the chorion. There are

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norm ally 15-30 cotyledons. The following observations should be made

on the m aternal surface:
• C otyledons. Are there any missing cotyledons? Consider this
possibility if sharp lines of cleavage are seen and if confirm ed,
evacuation o f the missing cotyledons is m andatory because o f the
possibility of postpartum haem orrhage and infection.
• Clots. Small elastic clots are norm ally present in the fissures. If
there are large retroplacental clots, the affected area of the
placenta appears depressed and infracted. This confirm s
clinically that there was some degree o f placental separation
(abruptio placentae).
• Fissures. The m aternal surface o f the placenta norm ally has
grooves or fissures. When these are noted to be absent, the reason
is that they are filled with fibrin. This is a sign o f placental
senility.
• Colour. The colour of the cotyledons depends on the fetal
haem oglobin. It is norm ally dark-red. Several grey speckled
areas may indicate placental aging and are seen m ore com m only
in postm ature pregnancies.
• Lobes. If the main lobe of the placenta is attached to a smaller
accessory portion by an artery and a vein, the diagnosis is a
succenturiate placenta. The smaller lobe has also been referred
to as a “ satellite” . Its clinical im portance lies in the fact that it
can be retained and cause a postpartum haem orrhage.
• Infarcts. An infarct is degenerated placental tissue and has a
glandular m ake-up. Recent infarcts have a rusty-brow n
appearance with a firm consistency, while older ones appear
yellowish-white and are m ore thinned out. M ultiple infarcts may
be a cause of fetal com prom ise.

Examination of the membranes

One abnormality in the insertion o f the m em branes with the placenta
needs mention: circum vallate placenta (Figure 3). In this condition, a
portion of the decidua separates the margin o f the placenta from its
chorionic plate and a thick round white opaque ring form s around the
periphery of the placenta. The rem ainder o f the chorionic surface is
normal in appearance but the fetal vessels are limited in their course
across the placenta by the white ring. The white ring is made up o f a
double reflection of the m em branes and an intervening layer o f deciduas
and fibrin. The fibrous ring may retract so that circum vallate placentae
are associated with abruptio placentae and are therefore an im portant
cause of antepartum haem orrhage.
 CORD AND PLACENTA

Figure 3: Circum vallate placenta

PLACENTAL FUNCTION
The main functions o f the placenta are as follows:
• nutritional
• respiratory
• excretory
• endocrine
• as a transient fetal liver
• as a storage organ

The functions o f the trophoblast do not take place independently of each

other: the placenta functions as a whole and a decline in one activity
often reflects a decline in all activities. However, two exam ples may
explain the com plexity o f placental function, intra-uterine growth
restriction (IUGR) and m aternal diabetes. In IUGR, the placenta is
usually m orphologically mature and fetal nutrition is adversely affected
more than is the exchange of oxygen and carbon dioxide. In contrast, in
poorly controlled diabetes the placenta appears morphologically
im m ature. Despite this, the fetus is well nourished but may die from
hypoxaem ia.

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The first three functions above are chiefly concerned with the
transfer o f nutrients and oxygen to the fetus, along with carbon dioxide
and waste products o f fetal metabolism to the m aternal com partm ent.
They are vital to fetal growth and survival.

The significant structural factors responsible for optim um

placental function are:
a) the total placental area: at term, this is approxim ately 11-14
square metres
b) the utero-placental blood flow in the intervillous space (norm ally
500-700 ml/min)
c) the capillary area of the villi and hence the volume o f fetal blood
flow (about 400 ml/min)

In placental insufficiency, these m orphologic param eters are all

decreased, but for obvious reasons they cannot be used in clinical
practice to identify the fetus at risk. In other words, the use of
radioactive substances, such as sodium and chrom ium to determ ine the
rate of placental blood flow, and placental biopsy to determ ine the fetal
vasculature are not routine clinical tests o f placental function.

PLACENTAL INSUFFICIENCY
The term ‘‘placental insufficiency” is a useful description o f the
condition associated with a reduction in placental transfer of nutrients
and waste products between the fetal and maternal com partm ents which
leads to fetal com prom ise.

Aetiology
Placental insufficiency can occur either during the antepartum period or
during labour and delivery.
a) A ntepartum - insufficiency during the latter weeks o f pregnancy
adversely affects the nutrition and developm ent o f the fetus resulting in
chronic hypoxia and intra-uterine growth restriction. Causes of this type
of placental dysfunction are:
• The hypertensive disorders o f pregnancy e.g. preeclam psia
• Sickle cell disease
• Prolonged pregnancy
• Chronic renal disease
• Smoking
• Diabetes mellitus

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b) Intrapartum - during the intrapartum period, uterine contractions

may cause a reduction in the rate o f transfer o f oxygen to the fetus
across the placenta. This transient decrease in oxygen is physiological
and an uncom prom ised fetus copes very well during norm al labour.
However, fetal hypoxia and fetal distress may occur in instances where
there is prem ature placental aging or if the uterine contractions are
occurring too frequently. Tetanic uterine contractions are said to occur
when there is no resting interval between contractions.

PLACENTAL FUNCTION TESTS

Placental insufficiency during the antepartum period takes place over a
prolonged period o f tim e. It is this chronic deterioration o f placental
function that leads to the dysm ature fetus o r intra-uterine growth
restriction and in severe cases, to intra-uterine dem ise. O ne o f the
greatest challenges to the Obstetrician is to identify such a fetus at risk
and to decide on the appropriate m anagem ent. U ltimately, a decision on
the time and m ode o f delivery has to be made that would give the fetus
its m axim um chance o f survival.

A ccurate evaluation o f fetal well-being during the antenatal period is

therefore essential in the m anagem ent o f high-risk pregnancies. Tests
em ployed to determ ine the integrity o f the feto-placental unit are
generally referred to as placental function tests. These param eters are
either biochem ical or biophysical and are listed below; the first three are
now obsolete and listed for historical interest only.
• Oestriol levels in m aternal urine or serum
• Human placental lactogen (hPL) in m aternal serum
• Heat-stable alkaline phosphatase levels in m aternal serum
• Stress test
• Non-stress test
• U ltrasound

The Oxytocin Challenge or Contraction Stress Test

The placenta should be capable o f supplying the fetus with the necessary
substrates for growth and developm ent and its functional reserve should
also be adequate to m eet the dem ands im posed by the stress o f labour.
The contraction stress test (CST) evaluates the fetal heart rate response
to induced uterine contractions. This test is rarely used nowadays, as
fetal wellbeing can largely be assessed using a com bination o f the non­
stress test (NST) and ultrasound param eters. However, one o f its main
indications in the past would have been in a pregnancy where a non­

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reactive NST was obtained. Perform ing a CST would be contra-indicated

in the following circumstances: antepartum haem orrhage, ruptured
membranes, previous Caesarean section, previous preterm delivery and
cervical incom petence.
Technique - the patient is placed in the sem i-Fowler’s position and a
fetal m onitor is applied. A baseline record o f the fetal heart rate is
obtained for 10-20 minutes, following which an intravenous infusion
containing Syntocinon® is com m enced. Uterine activity is observed
over a 10 minute period, during which time there should be 3
contractions each lasting 40-60 seconds. A negative test is obtained if no
late decelerations occur on the fetal cardiograph. The test is positive if
late decelerations occur and in that circumstance the patient should be
delivered immediately.

Non-Stress Test
This is a simple test used for assessing fetal health during the antenatal
period. It correlates fetal heart rate with fetal movements. It is a means
of screening high-risk pregnancies, such as those listed in Table 1, in an
attempt to identify those babies dem onstrating signs of a com prom ised
intra-uterine environm ent while at the same time identifying those that
provide reassuring signs o f fetal well-being.

Table 1. Indications for NST

I Postdate pregnancy
Hypertensive disorders
Haemoglobinopathies
Intra-uterine growth restriction
Decreased fetal activity
Antepartum haem orrhage

The NST is perform ed with a fetal heart m onitor, in patients

suspected of having placental insufficiency. The patient should be
placed in the left lateral position in order to exclude false non-reactive
NSTs resulting from com pression o f the maternal great vessels by the
pregnant uterus.

A NST is termed reactive if there have been at least two heart rate
accelerations in association with fetal movement. An acceleration is a
change in the fetal heart rate by at least 15 beats per minute above the
baseline, lasting at least 15 seconds and occurring within a 20-m inute
period. The reactive NST or the presence of fetal heart rate accelerations

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in association with fetal activity is a reliable indication of fetal well-being

and is highly predictive o f perinatal survival. It suggests a co-ordinated
control o f heart rate and m ovem ent, with the stim ulus for both
originating in the brain. In other words, it verifies the integrity of the
fetal heart rate control by reflex m echanism and indicates adequate
central nervous system control. Chronic hypoxia may blunt this control
and result in a non-reactive NST.

D epending on the original indication for perform ing a NST;

following a reactive NST, the patient may require evaluation twice
weekly, provided that there is no significant change in the maternal
status.

If the criteria for a reactive NST are not met after 40 m inutes, the
test is classified as a non-reactive NST. In such a situation there are no
accelerations with movements or there are no m ovem ents o f the fetus
during the period of observation.

It should be emphasized that a single non-reactive NST does not

necessarily imply fetal jeopardy. However, further tests of fetal well­
being should be perform ed such as an ultrasound evaluation (discussed
below). In some maternity units where contraction stress test is still used,
this may be indicated.

Ultrasound
This allows visualisation o f the fetus, placenta, um bilical cord and liquor.
Growth param eters such as the biparietal diam eter (BPD), head
circum ference (HC), abdom inal circum ference (AC) and fem ur length
can be m easured and an estimation o f the fetal weight can be acquired.
These m easurem ents allow the confirm ation o f suspected IUGR and
enable the obstetrician to differentiate between the symmetrical and
asym m etrical types.

The Biophysical Profile refers to five param eters; a) gross fetal

movements (FMs), b) fetal tone (FT), c) fetal breathing movements
(FBMs), d) liquor volume (LV) and e) NST. Each param eter is given a
score of 2 or 0 depending on if it is norm al or not, respectively.

The NST, if reactive scores 2 and if non-reactive a score of 0 is

given. The individual scores are added and given out o f a maximum of
10.

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Umbilical Artery Doppler flow velocity is a useful m easurem ent when

assessing intra-uterine growth restriction. There is usually forward flow
of blood in the umbilical artery during both systole and diastole which
give rise to typical waveforms. Values of norm al um bilical artery flow
velocity waveforms during pregnancy at various gestations are well
established. The most extrem e abnorm alities in waveforms are those in
which the velocities are absent or reversed. A bsence of end-diastolic
velocities is associated with an increase in perinatal m orbidity and
mortality. Even m ore predictive of a poor prognosis is a reversed flow
pattern.

Placental m orphology can be assessed using ultrasound. One

classification, named after its author, G rannum has been described. The
Grannum grading system describes four grades, O, I, II and III. The
correlation o f these grades with the m aturity o f the fetal lungs and with
fetal outcom e is quite variable and because o f this, m any obstetricians no
longer report on this feature.

KEY POINTS
• The umbilical cord contains two arteries, one vein,
the vitelline duct and remnants of the allantois
embedded in W harton's jelly.
• The length of the umbilical cord varies from about
10 to 200 cm.
• The average weight of a term placenta is 450 -
550g. The placental: fetal weight ratio is usuallv
1:6 .
• The term “placental insufficiency” is a useful
description of the condition associated with a
reduction in placental transfer of nutrients and
waste products between the fetal and maternal
compartments which leads to fetal com prom ise.
• Biophysical tests are the most com m only
performed placental function tests.

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CHAPTER SIXTEEN

AMNIOTIC FLUID

INTRODUCTION
The origin and com position o f amniotic fluid was first described by
Hippocrates who postulated that it was a product of the fetal kidneys.
The Greek, Soranus o f Ephesus, described it in the year 100 A.D., and
further observations were made by the Italian artist, Leonardo da Vinci
and the great French Obstetrician, Francois M auriceau. Prochownick
(1877) described the major solutes and Schroeder (1891) reported the
presence o f album in. In 1919, Uyeno produced a unique paper on the
biochem ical com position o f am niotic fluid, but it is only within the last
five decades that a considerable am ount of data has been obtained from
analysis of amniotic fluid and made applicable in clinical practice. It is
now possible, for exam ple, to determ ine the severity o f rhesus iso­
im m unisation, the degree o f fetal m aturation and the presence of
chrom osom al abnorm alities in the fetus.

In this chapter, we shall consider this subject under the following

headings:
• E m bryology o f the fetal m em branes
• Origin and circulation o f the amniotic fluid
• Volume
• Composition
• Clinical application
• Amniocentesis
• A m nioinfusion.

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EMBRYOLOGY OF THE FETAL MEMBRANES

Shortly after nidation, the chorionic vesicle grows rapidly and a cell
ridge in its interior differentiates into what later becom es the em bryo. A
constriction develops on the m argins o f this em bryonic disc and this
represents the border between the am nion and the yolk sac.

Growing slowly at first, the amniotic sac later exceeds the size of
the yolk sac and fills the extra-em bryonic coelom . The em bryonic disc
also enlarges and as it does so, it folds to a tubular form in cross-section
and the attachment o f the am nion is carried round to its ventral surface.
That portion o f the am nion near the umbilicus surrounds the cord as an
external layer and thus form s a sheath for the umbilical cord.

By week eight, the chorionic cavity (extra-em bryonic coelom ) is

completely obliterated by the growth o f the amniotic sac and the amnion
comes into direct contact with the chorionic layer. This relationship is
maintained until the end o f gestation.

Arm ii

Bod/stdk
Allantois

Yolksoc
Fused
and 01

Figure 1: Growth of the amniotic cavity

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 A M N IO T IC F LU ID

The amnion in late pregnancy consists o f five distinct histological

layers, the first o f which is the epithelial layer in contact with amniotic
fluid. The chorion has four layers, including the trophoblastic layer.
The am nion and chorion do not have a blood supply.

ORIGIN AND CIRCULATION OF AMNIOTIC FLUID

Origin
There is good evidence that both the m other and the fetus make
individual contributions to amniotic fluid. Its maternal origin is primarily
as an ultra-filtrate across the m em branes in the early weeks of
pregnancy. On the other hand, the fluid could arise as a secretion from
the placenta and m em branes, or from the fetus through the skin,
gastrointestinal tract, tracheo-bronchial tree or kidneys. O f these routes,
the fetal kidneys are the most im portant.

There is overwhelming clinical evidence for intra-uterine fetal

urine production starting as early as the 12th week o f pregnancy :
• Bladder aspirations at the time o f hysterotom y at 12-22 weeks.
• M icturition often accom panies birth.
• R adio-opaque dye injected intravenously to the m other for placental
localization results in an intra-uterine fetal pyelogram !
• Biochemically, amniotic fluid resembles fetal urine, with respect to
urea, uric acid, creatinine, sodium , glucose and osm olarity.
• M aternal globulin and fetal alpha-fetoprotein reach the amniotic
fluid through the renal tract.
• Bladder activity may be visualised in utero during a fetal ultrasound.
• Fetal renal agenesis tends to be associated with oligohydram nios.

Similarly, there is evidence of a contribution by the tracheo-bronchial

tree o f the fetus:
• Pulm onary surfactant is present in liquor.
• The presence o f a high chloride ion content and o f album in has been
attributed to a pulm onary route.
• Intra-uterine fetal breathing movements do occur and they cause a
small tidal flow o f liquor, thus allowing for pulm onary secretions to
reach the am niotic fluid.

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Circulation
In early pregnancy, there is an active exchange o f liquor through the
fetal skin and across the m em branes, to the maternal com partm ent. In
the second half of pregnancy, however, the exchange is principally at the
placental site and if there is any at all across the chorio-am nion, it must
do so by passive diffusion. In other words, the relative im portance o f the
different routes of liquor form ation and removal varies with fetal
maturity.

Fetal swallowing and micturition are important events in the

circulation of amniotic fluid. The evidence for fetal urine production
has already been cited. That for fetal swallowing is as follows:
• The presence o f lanugo hair and other epithelial debris in m econium
could hardly be explained by any other process.
• Injection o f radio-opaque chrom ium into am niotic fluid resulted in
its recovery in the “ diaper co n ten ts” if the fetuses were norm al, and
none if the fetuses were anencephalic and therefore could not
swallow.

VOLUME OF AMNIOTIC FLUID

Methods o f estimating amniotic fluid volume:
• Hysterotomy. Direct aspiration o f the intact sac removed at
hysterotomy has been perform ed in pregnancies from 10 to 16
weeks.
• Dye-dilution technique. A known am ount o f Coomassie blue is
injected by am niocentesis, time is allowed for adequate m ixing and
spectro-photometric analysis is perform ed on an aspirated specimen.
• Clinical estimation. This is not accurate.
• Ultrasound m ethods. The two most com m on m easurem ents are: a)
the maximum vertical pool of liquor (MVPL) or the deepest vertical
pool (DVP) and b) the amniotic fluid index (A F I). The AFI is a
more reproducible and quantitative technique o f measuring liquor
volume.

MVPL - O ligohydram nios is diagnosed when the largest pocket o f

amniotic fluid measured in two perpendicular planes is less than 2 cm.
Polyhydramnios is diagnosed when the largest pocket of am niotic fluid
exceeds 8 cm in two perpendicular planes.

AFI - The maternal abdom en is divided into quadrants. The level o f the
umbilicus is used to divide the uterus into upper and lower halves and the

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linea nigra is used as the midline to divide the uterus into right and left
halves. The largest vertical m easurem ent of am niotic fluid in each
quadrant is recorded. The values are added together to obtain the AFI in
centim etres. Patients at term with an AFI less than 5 cm are considered
to have oligohydram nios, while an AFI greater than 25 cm signifies
polyhydram nios.

Figure 2 shows liquor volumes at different periods o f gestation,

dem onstrating that the mean volume rises until about 34 to 36 weeks
after which it gradually decreases.

By 22 weeks the volume is about 400 ml and reaches one litre at

its m axim um .
Apart from gestational age, there are several other factors which
influence the volume of amniotic fluid:
• Fetal weight
• Placental weight
• Fetal swallowing. Swallowing is im paired in anencephaly,
iniencephaly, hyper-extension o f the fetal neck and fetal goitre.
These conditions are usually associated with hydram nios.
• Fetal well-being. In cases of placental insufficiency and in the case
o f intra-uterine demise, the amniotic fluid volume falls. This can be
interpreted as an excess o f absorption over production or as a failure
o f the fetal contribution o f amniotic fluid.

Figure 2: Range of liquor volume throughout pregnancy

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 A M N IO T IC FLU ID

• Fetal voiding. There is an association between oligohydram nios and

m alform ations of the fetal urinary system, such as agenesis or absent
urethra.
• Multiple pregnancy: hydram nios.
• Diabetes mellitus: hydram nios.

COMPOSITION OF LIQUOR
From a physio-chem ical point o f view, amniotic fluid is a heterogeneous
system com posed of a solution in which undissolved material is
suspended. It consists of 98% water and 2% solids. The solids are
organic and inorganic.

Organic constituents-:
• Proteins - the following proteins and break-dow n products o f protein
metabolism are found in liquor: album in, globulins, a-fetoprotein,
amino-acids, urea, uric acid and creatinine. There is no fibrinogen in
amniotic fluid.
• Carbohydrates - glucose, fructose, lactic acid, pyruvic acid, keto-
glutamic acid and citric acid. Glucose concentration varies from 25-
40%.
• Lipids - prostaglandins (unsaturated fatty acids) and phospholipids
(lipids containing a phosphate residue).
• Enzymes - alkaline phosphatase, acetylcholinesterase, glutamic-
oxalo-acetic transaminase, and histaminase are a few exam ples which
have been identified in cell-free amniotic fluid. M econium contains
large quantities o f alkaline phosphatase.
• Hormones - oestriol, oestrone, and oestradiol, ACTH and cortisone,
HCG, pregnanediol and insulin. Erythropoietin is present in low
concentrations but rises spectacularly in erythroblastosis fetalis.
• Pigments: bilirubin
• Vitamins.

Inorganic constituents-:
Sodium, potassium, calcium, m agnesium , chloride, iron, copper,
bicarbonate and phosphate.

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CLINICAL APPLICATION
The status o f the fetus can be evaluated to a large extent by exam ination
o f the am niotic fluid. Apart from quantitative analysis, the application of
biochem ical, biophysical and im m unological m ethods to the analysis of
am niotic fluid has allowed determ ination o f the severity o f rhesus iso­
im m unisation, the degree o f fetal lung m aturation, the presence of
chrom osom al abnorm alities and the detection o f neural tube defects.

The following inform ation is obtainable by exam ination o f liquor:

• Volume: polyhydram nios and o lig o h y d ram n io s. Causes of
polyhydram nios include; anencephaly, h y drocephaly with spina
bifida, uni-ovular twins, diabetes mellitus, h y d ro p s fetalis and villus
chorioangiom a. Causes o f o ligohydram nios include; placental
insufficiency, P o tter’s syndrom e, renal agenesis, postdates
pregnancies, abdom inal pregnancy and intra-uterine dem ise.
• Colour: am niotic fluid is colourless in m ore than 90% of
am niocentesis specim ens in the last trim ester. D iscolouration can be
due to the presence o f blood, m econium o r bilirubin.
a) Blood tinged fluid may result from transplacental aspiration
during am niocentesis, contam ination with m aternal blood or
recent intra-am niotic haem orrhage.
b) G reen-stained fluid is due to the presence o f m econium .
T raditionally, m econium has been considered a prim e indicator
o f fetal distress.
c) Brown-stained fluid is due to ‘" o ld ” intra-amniotic
haem orrhage and can be fo u n d in cases o f intra-uterine death.
d) Yellow discolouration. In norm al pregnancies before 32
weeks, the am niotic fluid is straw -coloured and this is due to the
presence o f bilirubin. A lthough yellow discolouration after this
time strongly suggests rhesus iso-im m unisation, other pigments
can also do so e.g. oxyhaem o g lo b in , m ethaem album in and
biliverdin.

• Optical density: direct spectrophotom etry o f the am niotic fluid was

introduced by Bevis in 1956. Optical density is plotted on a
logarithm ic scale against wavelength on a linear scale over a range of
360-550 mu. A straight line is obtained in norm al colourless fluid,
but in pigm ented fluid, a deviation occurs at 450 mu. The
significance o f this result can then be read fro m prognostic charts
(see chapter on rhesus disease).

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• Fetal maturity: determ ination of gestational age can be established

by cytological exam ination of amniotic fluid, creatinine
concentration and surfactant measurem ent, either by em ploying the
bubble test and/or the Lecithin/Sphingom yelin (L/S) ratio. These tests
are rarely em ployed nowadays in developed countries as neonatal
intensive care has made great advances over the last 15 years.
■ Cytology - a drop o f liquor is mixed with a drop o f 0.1% aqueous
solution of Nile Blue Sulphate on a warm slide. The slide is covered
with a cover-glass and exam ined under lower power. Fetal epiderm al
cells appear orange because they are covered with vernix caseosa.
The percentage o f these cells is zero before 32 weeks, 5-10% at 34-
38 weeks, 10-50% at 38-40 weeks and 50% postdates.
■ Creatinine - the creatinine concentration o f liquor increases pari
passu with advancing gestational age and a value o f 2 mg/dl or more
implies a fetal maturity o f 37 weeks or more.
■ Surfactant - the determ ination of the L/S ratio is the major technique
employed for the m easurem ent of surfactant in am niotic fluid.
Lecithin is the major com ponent of surfactant and is also the major
component o f amniotic fluid phospholipids. The phospholipids
modify the surface tension o f amniotic fluid. The principal
phospholipids which lower surface tension are phosphatidyl-choline
(PC or Lecithin), phosphatidyl-inositol (PI), phosphotidyl-glycerol
(PG) and sphingom yelin (S). Surfactant is a surface-active material
lining the alveolus. During expiration, the area of the alveolar film is
reduced but alveolar collapse is prevented by a corresponding fall in
the surface tension of the film. The increase in lecithin in the fetal
lung at the end o f pregnancy is closely reflected in its rising
concentration in liquor. Estimation o f the am ount o f surface-active
lecithin in the amniotic fluid provides an index of the functional
maturation and distensibility o f the alveoli and therefore also o f the
risk of Respiratory Distress Syndrom e (RDS) of the newborn.
Sphingomyelin remains unchanged. RDS rarely develops when the
L/S ratio is 2.0 or more in uncom plicated pregnancies. In diabetic
gestations and erythroblastosis fetalis, the critical ratio is 2.5. PG does
not appear until 36 weeks gestation and at term , it is the second most
abundant phospholipid.

• Gender determination: a m ethod o f prenatal sex determ ination by

means of amniotic fluid cytology was described in 1951, but it has no
practical significance. Fetal gender can be determ ined by direct
examination o f fetal cells or more routinely using ultrasound.

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• Diagnosis of neural tube defects: high concentrations o f ex-

fetoprotein in amniotic fluid are found in open neural tube
abnorm alities e.g. anencephaly and spina bifida.

• Detection of inherited disorders: genetic am niocentesis is usually

perform ed at 16-18 weeks for advanced m aternal age and trisom y 21,
a family history o f a chrom osom ally abnorm al fetus, sex
chrom osom e-linked disease, severe growth restriction and parental
chrom osom al abnorm ality. H aem oglobinopathies, haem ophilia and
D uchenne m uscular dystrophy are exam ples of disorders that may be
detected. Also, chrom osom al analysis and karyotyping can be
perform ed and some enzym e deficiencies can be detected.

AMNIOCENTESIS
Amniocentesis is the insertion o f a needle into the am niotic cavity for the
purpose of aspirating am niotic fluid or for injecting dyes and
m edications or introducing catheters. The trans-abdom inal approach is
preferred to the vaginal route.

Precautions before amniocentesis:

• The procedure should be explained thoroughly.
• Sterile precautions must be taken.
• M aternal blood group and rhesus status must be known.
• It should be perform ed under ultrasound guidance. This allows for
localization o f the placenta and identification o f a pool o f liquor.
Twin pregnancy can be excluded and gestational age can be
confirm ed. Gross fetal abnorm alities may be detected.
• Avoid area o f abdom inal scar.

Procedure:
The chosen puncture site is cleaned with an antiseptic solution and sterile
drapes are applied. Local anaesthetic is injected at the site and a 20-
gauge needle is directed under ultrasound guidance into a pool of
liquor. The stylette is removed and liquor is aspirated with a syringe.
The volume aspirated will vary on the tests being perform ed. The needle
is removed and a gauze swab is applied to the puncture site. Unsensitised
rhesus negative m others should be adm inistered anti-D immunoglobulin.

After the procedure, the patient should be observed for 15-30

minutes and the fetal heart rate checked.

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Complications:
• Traum a to the fetus.
• Chorioam nionitis
• Premature rupture of the mem branes
• M iscarriage (1-2% )
• Traum a to the uterus: intra-peritoneal bleeding
• M aternal sensitisation in rhesus negative m others.

AMNIOINFUSION
Amnioinfusion was first perform ed by Gabbe et al in 1979, using
experimental animals. These researchers established that variable
decelerations related to oligohydram nios and cord com pression could be
corrected by this procedure. In 1983, M iyazaki and Taylor successfully
employed saline am nioinfusion in 42 women for the relief o f variable or
prolonged decelerations.
The indications for am nioinfusion have since expanded and are as
follows:
• To eliminate variable decelerations in labour, particularly in
primigravidae whose labour is slow enough to undergo treatm ent.
• To deliver antibiotics to the chorioam nion (rare).
• To restore norm al amniotic fluid volume after prem ature rupture o f
membranes (not very effective as the fluid readily leaks out again).
• To correct oligohydram nios. A m nioinfused patients have been
found to have less operative deliveries for fetal distress and had good
umbilical artery pHs at birth (however does not address the actual
aetiology fo r the oligohydram nios and many o f these fetuses just
require delivery).
• To decrease the chance o f intrapartum m econium aspiration. A bolus
of 7 0 0 -1000ml of norm al saline at room tem perature is infused
through an intra-uterine pressure catheter over 30 m inutes and this is
followed by 200 ml every 2 hours. With this protocol there has been:
a) significantly less depressed babies at birth, b) less m econium below
the vocal cords and c) fewer cases o f m econium aspiration syndrom e.
Amnioinfusion is considered a relatively safe procedure however some
isolated complications reported in the literature include:
• Hydramnios.
• Umbilical cord prolapse.
• Uterine hypertonus.
• Severe maternal cardiopulm onary com prom ise.
• Maternal demise from am niotic fluid em bolism .

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KEY POINTS

• Fetal urine production contributes to amniotic

fluid from as early as 12 weeks.
• Fetal swallowing and micturition are important
events in the circulation of amniotic fluid.
• Amniotic fluid volume can be assessed by
ultrasound.
• The analysis of amniotic fluid allows for the
determination of the severity of rhesus iso­
immunisation, the degree of fetal lung maturation,
the presence of chromosomal abnormalities and
the detection of neural tube defects.
• High concentrations of AFP in the amniotic fluid
are found in open neural tube defects.
• A creatinine concentration of 2mg/dl or more in
the amniotic fluid implies a fetal maturity of 37
weeks or more.
• An L/S ratio of greater than 2 ensures fetal lung
maturity in uncomplicated singleton pregnancies.
• Amniocentesis may be performed to obtain fluid
for karyotyping. This would normally be
performed at 16 to 18 weeks gestation.
• Amnioinfusion: a) restores amniotic fluid volum e,
b) cushions the umbilical cord to reduce cord
compression, and c) dilutes the meconium to
minimise the toxic effects of aspiration.

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CHAPTER SEVENTEEN

ANTEPARTUM FETAL SURVEILLANCE

INTRODUCTION
The objective of antepartum fetal surveillance is to reduce perinatal
morbidity and m ortality. This can be achieved by the developm ent o f
surveillance strategies that identify the high risk population, institute the
appropriate tests in a timely fashion and em ploy interventions that
recognise the limitations of testing procedures.

Fetal anom aly, drugs and infection all make significant contributions to
adverse perinatal outcom e. However, it is fetal hypoxia that is responsible
for the lions share accounting for 70 % o f all perinatal m orbidity and
mortality. The growth-restricted fetus is particularly prone to hypoxic
insult and, for the purpose o f this chapter, antepartum fetal surveillance is
largely designed to predict and diagnose fetal hypoxia and growth
restriction so that appropriate interventions can be instituted.

INDICATIONS
Antepartum fetal surveillance should be offered to all m others with
pregnancies deemed high risk. This would include pregnancies
complicated by the following:
• Previous unexplained stillbirth.
• Decreased fetal movements or an abnorm al pattern o f
movement.
• Postdate pregnancy.
• Intrauterine growth restriction.
• Aberrant liquor volum e (Poly or oligohydram nios).
• Hypertensive disorders of pregnancy.
• Diabetes mellitus.

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• Rhesus isoim m unization.

• M ultiple gestations especially m onochorionic twin gestations
and multiples greater than two.
• Sm oking and drug abuse.
• M aternal medical conditions such as hyperthyroidism , cardiac
disease and haem oglobinopathies.

M ETHODS OF ANTEPARTUM SURVEILLANCE

The available tests can be classified as biophysical or biochem ical.
Biophysical testing constitutes the vast m ajority o f routine antepartum
surveillance. However, biochem ical tests have a role to play though they
are not widely available.

None o f these tests, in isolation, can be relied upon to establish

fetal well-being unequivocally. For exam ple, an abnorm al non-stress test
is predictive of poor perinatal outcom e on less than 40% o f occassions. It
is obvious, therefore that non-stress testing is not a particularly sensitve
m ethod o f assessment o f fetal well-being. This applies to the other tests
and in general, multimodality testing im proves the reliability of the
testing process.
In addition, local protocols need to be developed to make use of
the available resources. Most units in the United K ingdom would offer a
non-stress test, ultrasound assessment o f liquor volume and umbilical
artery D oppler studies to the m other who attends antenatal clinic
indicating a reduction o f fetal movements in the third trim ester. This
may not be appropriate in all units and non-stress testing may be the sole
ancillary investigation that resources allow.

Biophysical tests
The biophysical tests detailed in this chapter are:
• Assessment of fetal movement
• Assessment of sym physiofundal height
• C ardiotocography
• The biophysical profile
• Fetal biom etry
• L iquor volum e assessment
• D oppler ultrasound.

Assessment of fetal movement

The fetus dem onstrates patterns o f activity from early pregnancy. In
general, prim igravidae appreciate movem ent (quickening) from 18 to 20

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weeks and m ultigravidae two weeks earlier. M others may also recognise a
unique pattern o f activity with a large proportion of fetuses being most
active in the evening.

The fetal response to hypoxic insult is a reduction in these

movements or an abnorm al pattern o f m ovem ent with redistribution o f
blood to essential organs such as the brain, heart and adrenals. In
recognition o f this physiological response form al assessment o f fetal
movement was espoused. The daily fetal movement chart (DFMC) or
Pearson-Weaver chart involves the patient docum enting fetal movements
over a pre-defined period, usually 12 hours. The attainment o f 10 or
more movements over this period is deem ed satisfactory. Less than 10
movements warrants ancillary testing, that is, cardiotocography or
ultrasonography or both.

Though the evidence for benefit is not incontrovertible it is

recommended that form al assessment o f fetal m ovem ent constitute part
of routine antepartum surveillance.

Assessment of symphysiofundal height

The sym physiofundal height (SFH) is the distance in centim etres from
the superior border o f the sym physis pubis to the uterine fundus. This
measurement is affected by a m yriad of factors including the size and
number of fetuses, the liquor volume, the presence o f uterine tum ours
such as fibroids and maternal habitus.

The SFH m easurem ent can be plotted on a growth chart that has
been customized to cater for variations such as race and m aternal body
mass index. Serial measurements plotted in these customized growth
charts allow for the identification of growth abnormalities.

Standard custom ized growth charts in current use are m ore

effective in identifying the small for gestational age fetus than the large
for gestational age fetus. A bnorm alities warrant further investigative
scrutiny such as fetal biom etry and liquor volume assessment.

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Cardiotocography
The term cardiotocography (CTG) refers to the record o f the fetal heart
(cardio) and the strength (toco) and frequency o f uterine contractions.
Application o f the term in an antepartum context would imply a
quiescent uterus, as in non-stress testing, where there is a record o f the
fetal heart response to fetal movement.

The physiology o f cardiotocography relies on the criterion that

intact brain stem centres and the autonom ic nervous system control the
fetal heart. As in the adult, the baseline heart rate results from
equilibrium between sympathetic and para-sym pathetic outflow. D uring
fetal developm ent the sym pathetic system develops prior to the para­
sympathetic and equilibrium is not achieved until 32 to 34 weeks
gestation. Hence, the baseline heart rate is gestation dependent being
lower at term than it would be at say 24 weeks. The norm al baseline
heart rate is 110 to 160 beats per m inute.

The baseline variability also reflects the functionality o f the

autonom ic nervous system. The ascending limb o f the variation is due to
sympathetic outflow and the descending limb is due to para-sym pathetic
outflow. The norm al baseline variability is 10 to 15 beats per m inute.

An acceleration is an increase in the heart rate o f at least 15 beats

above the baseline lasting for at least 15 seconds. Heart rate
accelerations in response to m ovement are a reassuring feature and
indicative o f fetal well-being.

All decelerations on cardiotocographic m onitoring in the

antepartum period are abnorm al. U nprovoked decelerations may
indicate that the fetus has exhausted its ability to cope with further
hypoxic stimuli. This fetus may not tolerate the stresses o f labour and an
abdom inal delivery may be indicated. Early, late and variable
decelerations occur in the late first and second stage o f labour and are
discussed in the chapter on intrapartum surveillance.
The methods o f antenatal cardiotocography discussed are:
• The Non-Stress Test.
• The Contraction Stress Test.
• Com puterised cardiotocography.

a) Non-Stress Test
The non-stress test (NST) is the most com m only perform ed test of fetal
well-being. It involves an assessment and record o f the fetal heart and
the response to fetal movement. The test is perform ed with the patient in

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the left lateral position. This elim inates aorto- caval com pression and
ensures optim al placental perfusion th ro u g h o u t the testing procedure.
The fetal heart is located with an abdom inal transducer and the m other is
instructed to indicate when m ovem ents have occurred with the aid o f a
hand held device.

Figure 1. N orm al NST

The presence o f two accelerations (in response to fetal

movements) o f m ore than 15 beats for m ore than 15 seconds in a 20
minute period is indicative o f a norm al trace (Figure 1). This result can
be considered valid fo r 12 hours.

If no accelerations have occurred in a 20 m inute period the trace

should be continued for a further 20 m inutes. Absence o f accelerations
can occur during periods o f fetal sleep and therefore efforts can be m ade
to arouse the fetus. This can be achieved by either vibro-acoustic or cold
water stim ulation.

The absence o f accelerations after this 40 m inute period is

abnorm al. This warrants further testing such as fetal biom etry, liquor
volume assessment or D oppler ultrasound studies.

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b) Contraction Stress Test

Though it is not used in routine practice the contraction stress test (CST)
can be a useful adjunct to surveillance. The test is based on the response
o f the fetal heart to uterine contractions. D uring uterine systole placental
perfusion is decreased as blood is expunged from the retroplacental
pool. The transient hypoxaem ia that ensues is poorly tolerated by the
hypoxic fetus and this is manifest by decelerations o f the fetal heart.
Contractions may be induced by either a reduced regim e oxytocin
infusion or endogenous oxytocin production by means o f nipple
stimulation.
The test may be:
• Negative-if there are no late decelerations following
contractions.
• Positive-if late decelerations occur following m ore than 50%
o f contractions.
• Suspicious-if there are interm ittent late or significant variable
decelerations.
• Unsatisfactory - if there are less than 3 contractions in 10
minutes.

A negative result is indicative of fetal wellbeing and can be considered

valid for 48 hours.

Contraindications to testing include:

• Patients at high risk o f preterm labour including those with
preterm prem ature rupture of m em branes.
• In the presence o f a classical scar on the uterus where uterine
rupture is a potential risk.
• In cases of known major placenta praevia where contractions
may provoke a catastrophic haem orrhage.

c) Computerised cardiotocography
The main limitation of conventional cardiotocography is that the
interpretation is subjective. C om puter program m es have been developed
to evaluate specific param eters on the trace and provide an objective
assessment. Most o f these program m es measure the short term variability
and rely on the premise that variability is a more sensitive predictor of
fetal com prom ise than the absence o f accelerations or the presence of
decelerations.

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 A N T E P A R T U M FET A L SU R V E IL L A N C E

Biophysical Profile
The biophysical profile (BPP) utilizes cardiotocography and ultrasound
assessment of the fetus. The com ponents of the test are:
• Non-stress test.
• Fetal breathing m ovements - more than one episode o f 30
seconds duration or m ore within a 30 m inute period.
• Fetal body movements - four or more discrete body
movements.
• Fetal tone and posture - active extension and return to
flexion.
• Q uantification of liquor volume - one pocket greater than 2
cm is considered norm al.

The last four param eters are evaluated by sonography and each
parameter is afforded a score o f 2 for norm al and 0 for abnorm al. The
maximum cumulative score is 10. Scores o f 6 to 8 are abnorm al and the
test should be repeated in 12 to 24 hours. Scores o f 4 or less are
indications for expediting delivery. In an effort to improve the sensitivity
of the testing procedure placental grading can be incorporated into the
biophysical profile. This ‘m o d ified ’ BPP has an overall score o f 12 as
opposed to 10.

The main drawback of the BPP is that it is time consum ing and
requires considerable resources. However, it has a high negative
predictive value and norm al results can be considered valid fo r one week.

Fetal Biometry
This is considered in more detail in chapter fourteen. Biom etry is an
important intervention as it allows for the identification o f the growth
restricted fetus which is most at risk o f hypoxic insult and its sequelae.

Many different param eters may be m easured. Fetal abdom inal

circumference (AC) and head circum ference (HC) are the most com m on
measurements perform ed in the third trimester. Com parison o f AC and
HC allows for differentiation between symmetric and asym m etric growth
restriction while AC provides the most accurate estimate o f fetal weight.
This can be plotted on custom ised growth charts. Serial m easurem ents
allow for assessment o f growth. The recom m ended interval between
scans is fortnightly.

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Liquor Volume Assessment

In the latter half o f pregnancy liquor volum e reflects fetal urine
production. This is dependant on fetal renal perfusion and by extension
utero-placental perfusion. L iquor volum e therefo re represents an
indirect m ethod o f assessment o f placental function.

O ligohydram nios or reduced liquor volum e m ay be seen in

instances o f placental insufficiency. It may be suspected clinically in
that exam ination may reveal a uterus that is small fo r dates and fetal parts
may be easily felt. L iquor volum e can be estim ated on ultrasound scan
by either m easuring the deepest vertical pool or p erfo rm in g a four
quadrant analysis, the am niotic fluid index. Both m ethods have their
lim itations but provide an objective assessment o f liq u o r volum e. The
recom m ended interval between scans is one week.

D oppler Ultrasound
D oppler ultrasound may be used to evaluate b lood flow patterns in
m aternal and fetal blood vessels. It can identify abnorm alities o f flow
that can occur in certain conditions. T he m ore co m m o n ly perform ed
D oppler studies are:
• Um bilical A rtery D opplers:
Rely on the fact that in the norm al fetus there is flow o f blood
from the fetus to the placenta th ro u g h o u t systole and diastole. It
is a useful test in the grow th restricted fetus where increased
vascular resistance may cause abnorm alities in this flow.
N orm al um bilical artery D oppler waveform s are dem onstrated in
figure 2.
Absent end diastolic flow (EDF) and reversed ED F are abnormal
and good predictors o f fetal hyp o x ia (see fig 3 and 4).

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Figure 2-Norm al

Figure 3- Absent EDF

Figure 3-Reversed EDF

• Middle Cerebral Artery Dopplers:

Rely on the fact that in fetal growth restriction there is
preferential flow o f blood to essential organs such as the brain.
This increased flow o f blood in the middle cerebral arteries is also
seen in conditions such as fetal anaemia.

• Uterine Artery Dopplers:

Uterine artery D oppler studies can be perform ed at 20 to 24
weeks gestation on the maternal uterine arteries. This test is a
good predictor of subsequent fetal growth restriction. The
abnormality can be either reduced end diastolic flow or notching
of the waveform.

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Biochemical Tests
On the whole, biochem ical testing is used with less frequency than
previously. This is primarily because o f im provem ents in biophysical
technologies and their increased availability. A num ber of m aternal
serological m arkers have been shown to be associated with reduced fetal
growth in the third trimester. These include alpha feto protein (AFP),
hum an chorionic gonadotrophin (hCG) and hum an placental lactogen
(hPL).

The role of AFP is most apparent. Elevated levels may predict

poor pregnancy outcom e. It has been significantly associated with an
increased risk of pre-eclam psia, pre-term delivery, intrauterine growth
restriction and still birth.

CONCLUSION
No test in isolation is particularly sensitive and em ploying more than one
test should improve the process. Bearing this in mind, local protocols
should be developed that encourage m ultim odality testing and m ake use
o f the available resources.

KEY POINTS
• The objective of antepartum fetal surveillance is to
reduce perinatal morbidity and mortality.
• Local protocols should be developed.
• The non-stress test is the most commonly performed test
of fetal well-being. The presence of two accelerations of
more than 15 beats for more than 15 seconds in a 20
minute period is indicative of a normal trace.
• Baseline variability is a more sensitive predictor of fetal
compromise than the absence of accelerations or the
presence of decelerations.
• Liquor volume represents an indirect assessment of
placental function.
• Umbilical artery Doppler ultrasound is a useful test in
the growth restricted fetus.
• An elevated level of AFP is associated with an increased
risk of pre-eclampsia, pre-term delivery, intrauterine
growth restriction, placental abruption and still birth.

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CHAPTER EIGHTEEN

NORMAL LABOUR

EXPLANATION OF TERMS
The term labour represents the process whereby uterine contractions are
accompanied by effacem ent and dilatation of the cervix, resulting in the
expulsion o f the fetus and placenta through the birth canal.

Effacement is the process of “ taking u p ” o f the cervix, which

becomes progressively shorter until it becom es flush with the uterine
isthmus. This takes place before there is any appreciable dilatation of
the cervix, especially in prim igravidae and is a result of increased water
content and collagen lysis in the cervix. When effacem ent occurs, the
mucus plug within the cervical canal is released giving rise to a “ bloody
show” . The course o f events is dem onstrated in Figure 1.

Dilatation is the widening of the internal os to a m axim um o f 10

centimetres.

Uterine muscle contraction and retraction. Following each

uterine contraction, the relaxation of muscle fibres of the upper uterine
segment is accom panied by shortening. This gradual but progressive
shortening of the m yom etrial fibres causes a decrease in the length o f the
upper segment and an increase in the length of the lower segm ent. This
is called retraction, the consequence of which is a decrease in the volume
of the uterine fundus. The muscle fibres o f the uterus have the unique
ability to become progressively shorter and thicker while they retain their
power to contract forcibly. This therefore assists in achieving an
expulsive system. In norm al labour there is no abnorm ality o f fetal
presentation or lie and uterine muscle activity is efficient.

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AIMS OF INTRAPARTUM CARE

• To deliver a norm al, healthy, w ell-oxygenated baby.
• To assist a mentally prepared m other to enjoy the experience of
childbirth, avoid unnecessary delay, pain or traum a and prevent
the developm ent o f dehydration and infection.
• To provide the m other (and her spouse) with a relaxed, pleasant
environm ent in a site staffed by com petent midwives and
obstetricians.
• To ensure that full technical back-up facilities are available, if
required.

PREPARATIO N FOR LABOUR

This must be both physical and psychological. Thus, an anaemic patient
or one with disease o f the respiratory or cardiovascular systems is
unlikely to tolerate labour as well as the fit healthy wom an. Special
attention must be paid during the antenatal period to patients with
diabetes, hypertension, renal disease and anaem ia. The latter may be due
to m alnutrition, parasitic infestation or a haem oglobinopathy, com m only
sickle cell anaem ia in the West Indies. Psychological adjustment,
especially inform ing the patient what to expect during labour, is an
advantage and this is provided at antenatal classes.

A bout two weeks before labour, the fetal head in most

prim igravidae becom es fixed in the pelvic brim . This is called lightening
and the patient observes that the upper abdom en becom es flat. She
should be re-assured that this is a favourable sign.
D uring the last 4 to 6 weeks, mild sporadic contractions of the
uterus occur and as term is approached, they increase in frequency and
intensity. These are called Braxton-Hicks contractions. They are painless
and rhythm ic and are not associated with progressive dilatation or
effacem ent o f the cervix.

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T H E D IA G N O S IS O F L A B O U R
Labour com m ences when uterine contractions o f sufficient frequency,
intensity, and duration result in cervical dilatation and effacem ent.

Figure 1. The shape of the

cervix changes during labour. It
becomes increasingly effaced,
and the cervical canal
disappears entirely as delivery
approaches.

A history of regular contractions i.e. contractions occurring at

least once in every ten m inutes for one hour together with a history o f
passage of the ‘show ’ or ruptured m em branes is necessary for the
diagnosis of labour to be made. Exam ination of the abdom en may allow
palpation of a contraction. At the same time, engagem ent or num ber of
fifths palpable above the sym physis pubis can de determ ined. In the
primigravida, the head is usually engaged at this time. Engagement
occurs when the widest transverse diam eter (the biparietal) o f the fetal
skull has passed the pelvic inlet. Cervical dilatation of at least 2 cm and
effacement of the cervix are pre-requisites for the diagnosis o f labour.
 NORM AL LABOUR

TH E STA G ES O F LA BO U R
• First stage: from the start o f reg u lar uterine contractions to full
cervical dilatation. The first stage o f lab o u r has been subdivided
into a latent and an active phase. D uring the latent phase, uterine
contractions typically are in freq u en t and irreg u lar and gradual
cervical effacem ent and dilatation o f the cervix o ccu r (Figure 1).
The active phase o f labour begins when the cervix reaches 3-4 cm
o f dilatation. D uring the active phase, there is m ore rapid cervical
dilatation, and this is dem onstrated by a sharp gradient on a
partogram . The duration o f the first stage is variable. In the
prim igravida, it is 12-16 hours. In the m ultigravida, it is usually
shorter (6-12 hours).

• Second stage: from full dilatation o f the cervix to the delivery of

the fetus. Active pushing should not exceed one hour.

• Third stage: from the delivery o f the fetus to the com plete
separation and expulsion o f the placenta and the m em branes.
This stage norm ally lasts 15 to 30 m inutes.

THE MECHANISM OF LABOUR

The m echanism o f labour concerns alterations in the attitude and
position of the fetus, especially its presenting part, during passage
through the birth canal. With a cephalic presentation, the partially flexed
fetal head usually enters the pelvic brim in the right occipito-lateral
(ROL) or left occipito-lateral (LOL) position. In these positions, the
longest diam eter o f the head (anteroposterior) enters the pelvis in the
longest diam eter o f the inlet (transverse).

Descent with further flexion

D uring the first stage o f labour, uterine activity prom otes descent o f the
presenting part, and at the same time increased flexion o f the fetal head
occurs. The head descends th ro u g h the inlet with its biparietal diameter
approxim ately parallel to the plane o f the inlet (Figure 2).

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 NORM AL LABOUR

Figure 2. Descent through the inlet. The sagittal suture is equidistant

from pubis and sacrum.

Some degree o f m oulding o f the fetal head norm ally takes place.
This permits it to adapt itself to the size and shape o f the maternal pelvis
through which it must pass. M oulding is the overlapping of the fetal
cranial bones which occurs as a result of the compressive forces exerted
by the maternal pelvis. The occipital bone and the two frontal bones are
driven slightly under the parietals. The parietal bone, which is posterior,
is driven under the anterior. These changes are more pronounced if there
is cephalo-pelvic disproportion.

Caput succedaneum is an oedem atous swelling caused by pressure o f

the cervix on the presenting portion of the fetal scalp. It usually occurs
in primigravidae and becom es more and more pronounced as labour
progresses. It obscures the landm arks on the fetal skull used for
diagnosing its position by vaginal exam ination. It usually disappears
completely within 24 hours o f birth and in this respect, it differs from
cephalhaematoma - an effusion o f blood under the periosteum - which
takes 2-3 weeks to resolve.

Internal rotation
Once the cervix is fully dilated, the fetus rapidly descends to the level of
the ischial spines (station zero), where internal rotation begins as the head
meets the grooved gutter o f the levator muscles which form the floor o f
the pelvis. Further flexion o f the head takes place and anterior rotation
of the occiput takes place through 90° in the occipito-lateral, 45° in the
occipito-anterior and 135° in the occipito-posterior position o f the
vertex. This enables the occiput to become anterior, and lie behind the
symphysis pubis (Figure 3).

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 NORM AL LABOUR

Extension
Under the influence of maternal bearing-dow n expulsive efforts, the
head descends further thereby stretching the vulval orifice. This is
termed crowning. That is to say, crowning occurs when the largest
diam eter of the fetal head is encircled by the vulvar ring. With further
contractions, extension o f the head occurs, and the perineum sweeps over
the forehead, base o f nose, mouth and chin to release the head.

Figure 3. The mechanism of labour drawn from radiographs taken in

labour. Left occipito-transverse (or lateral) position o f the vertex.

A. Descent with further flexion

B. Internal rotation beginning
C. Internal rotation almost completed, head in the lower straight
D. Birth of the head by extension

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Restitution
The fetal shoulders, which have by now entered the pelvic cavity undergo
similar movements to those recently undertaken by the fetal head. The
bis-acromial diam eter becom es antero-posterior in relation to the pelvis.

The fetal head undergoes external rotation i.e. restitution, through

the same num ber o f degrees but in the opposite direction to that which
had occurred at the level o f the pelvic floor.

Delivery of the shoulders and rest of the fetus

The delivery o f the shoulders takes place by lateral flexion, first
posteriorly, to disengage the anterior shoulder which appears from
behind the symphysis pubis, and then anteriorly, to disengage the
posterior shoulder over the perineal body.

Further lateral flexion o f the fetal body over the m aternal

abdomen perm its the delivery o f the rest o f the fetus to take place.

MANAGEMENT OF LABOUR
Once the diagnosis o f labour is made, the patient should be adm itted to
the labour suite. A gentle enem a may be given. Vulval shaving is not
essential but, if perform ed only in the region o f an intended episiotom y,
it facilitates a satisfactory repair.
• Posture: C om fort of the patient is im portant because it makes her
feel less vulnerable and dictated to. The sitting position is useful
because it encourages descent o f the presenting part. At no time
must the patient remain supine because of the risk o f aorto-caval
compression by the uterus. The left-lateral position or a 15-30°
lateral tilt should be encouraged to ensure adequate utero­
placental perfusion.
• Intake: Once in labour, food is inadvisable. Stom ach em ptying is
greatly delayed and the need for operative intervention requiring
general anaesthesia results in a high risk of reflux and aspiration
of stomach contents. The aspiration o f acidic contents of pH 2.5
or less is universally associated with the developm ent o f the
“ acid-aspiration (M endelson’s) sy n d ro m e” which has an almost
100% mortality. It is useful therefore to adm inister alkalinising
agents such as Mist Mag Trisil Co. BPC or Sodium citrate 15 ml
every two hours. Oral fluids in strictly limited quantity may be
administered because o f the high ambient tem perature in tropical
countries. Intravenous fluids containing glucose are valuable
especially if a short labour is not expected.

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• Analgesia: The various m odes o f Obstetric analgesia are

discussed elsewhere. Certain principles are worth m entioning.
Prenatal relaxation and inform ation classes are useful so that the
patient can make an intelligent and guided effort to achieve as
pain-free a labour as possible. Epidural analgesia is very popular
in developed countries. It however must be perform ed by expert
Anaesthetists and probably m ore im portantly, with the assistance
o f properly trained midwives. It is essential that hypotension, due
to sympathetic blockage, does not occur because this will result in
poor placental perfusion and therefore fetal jeopardy. Narcotic
agents such as Pethidine are better adm inistered together with an
anti-emetic. They should not be given if delivery is anticipated
within 2 - 3 hours, because o f the risk o f respiratory depression
in the newborn baby. If this has inadvertently occurred, then the
attention o f the Paediatrician is sought at delivery. Usually all
that is needed is the adm inistration o f oxygen, possibly intubation
and a narcotic antagonist, e.g. N aloxone.
• Blood pressure, pulse, temperature and urinalysis: The general
condition o f the patient is m onitored at half-hourly intervals.
• The fetal heart rate. The options in labour include intermittent
auscultation with the P in ard ’s stethoscope or cardiotocographic
m onitoring. The latter yields a continuous record o f fetal well
being in labour, though its interpretation rem ains subjective, and
a fetal scalp electrode can be applied (following spontaneous or
artificial rupture o f the m em branes) in instances where
m onitoring proves difficult (eg. the obese patient). Suspicious or
abnorm al cardiotocography warrants fetal blood sampling and
appropriate senior input. Interm ittent auscultation is appropriate
for the low risk pregnancy and it is a cost effective method of
intrapartum fetal surveillance.
• A m anagem ent plan should be form ulated at the outset. Special
precautions must be taken in pregnancies com plicated by cardiac
disease, diabetes, hypertension including pre-eclam psia, sickle cell
disease, seizure disorders, antepartum haem orrhage and previous
operative delivery. Other potential high-risk labours include
m alpresentation, multiple gestation, intra-uterine growth
restriction o r suspected fetal m acrosom ia. Early senior input is
recom m ended to ensure that an appropriate plan of care is
devised for the individual patient.

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PRO G RESS O F LABOUR

Progress in labour depends on a num ber o f factors:
• The Powers: The intensity, duration and frequency of the
contractions and the auxiliary forces.
• The Passenger: The size o f the fetus and the attitude (degree of
flexion) o f the presenting part.
• The Passage: The size o f the pelvis and its ability to increase its
diam eters by sacroiliac and pubic sym physeal m ovem ent, and
also the distensibility, thickness and softness of the cervix.

The best indicators o f progress are the rate o f cervical dilatation and the
descent o f the presenting part into the pelvis. This may be docum ented
on a partogram which provides is a graphical depiction o f the progress
of labour. Descent o f the presenting part is best determ ined by the
number of fifths palpable above the sym physis pubis. This m ethod is
superior to that using station.

The first stage

Abnormalities of the first stage o f labour com plicate about 10% o f all
cephalic deliveries. Delay in the second stage may be just as com m on.
Identification o f an abnorm al labour requires assessment of the powers,
the passenger, and the pelvis. Any reversible or correctable causes o f
dystocia (difficult labour) must be identified and rem edied. If the powers
are deemed inefficient, active m anagem ent o f labour involving
amniotomy followed by an oxytocin infusion should be im plem ented. It
is important to prevent m aternal dehydration and acidosis since these are
also associated with ineffective contractions. Epidural anaesthesia may
lead to a tem porary reduction in the strength o f uterine contractions. An
enlarged bladder is not only associated with suprapubic abdom inal
discomfort, but also with a dim inution in the frequency and strength o f
uterine contractions.

If failure to progress in labour, as determ ined by the partogram ,

is a result of cephalo-pelvic disproportion, then the im m ediate solution is
an emergency Caesarean section. A prim igravida who fails to progress
because of cephalo-pelvic disproportion usually goes out o f labour.
This is not true with a m ultigravida since the uterus continues to contract
despite the obstruction and thus she has a significant risk o f uterine
rupture. Other signs o f disproportion include no further descent o f the
presenting part, significant caput succedaneum and pathological
moulding (3+).

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 NORM AL LABOUR

The second stage

This is the time d u rin g w hich delivery o f the fetus o ccu rs. It is im p o rtan t
to appreciate that on discovering that the cervix is fully dilated, this is not
the tim e to ask the patient to com m ence p u sh in g . It is advisable to allow
the b a b y 's head to descend spontaneously until the m o th er feels rectal
pressure or the urge to push. This prevents the m o th er push in g too soon
and therefore becom in g exhausted and ultim ately req u irin g an operative
delivery.

C urrent evidence suggests that a second stage o f up to two h o u rs is not

associated with d etrim en t to the baby provided that the fetal h eart trace is
n orm al. The m echanism o f delivery is best un d ersto o d using a pelvis
and fetal m odel, and the diagram s in O bstetrics Illustrated are
reco m m en d ed . B riefly, the o ccip u t (d en o m in ato r) enters the pelvic brim
in the lateral position and rotates anteriorly in the m id-cavity o f the
pelvis. The fetal body does not u n d erg o the sam e rotation so that, at
delivery, the head appears o ccip ito -an terio r with the fetal sh o u ld ers at
right angles. The fetal head then u n d erg o es restitution i.e. it rotates
laterally to becom e aligned with the b o d y . D elivery o f the an terio r and
then posterior should ers and the b o d y are then acco m p lish ed .
Syntom etrine (E rg o m etrin e 0.5 mg and S y n to cin o n 5 I.U .) is routinely
given intra-m uscularly with the delivery o f the anterior shoulder. This
p ro ced u re significantly dim inishes the risk o f retained p lacen ta and
postpartum h aem o rrh ag e.

The third stage

Follow ing delivery o f the baby, the placenta and m em b ran es begin to
separate spontaneously within 5 to 10 m inutes o f the end o f the second
stage. Signs o f this event are:
• A gush o f b lo o d per vaginam .
• L en g th en in g o f the um bilical cord.
• The uterus becom es firm and g lo b u lar and the fu n d u s rises.

Placental separation m ay be co n firm ed by placing the left hand

suprapubically and p u shing upw ards: if the co rd does not m ove up , the
placenta is separated; if it does move up , it m eans that the placenta is not
separated.

Separation o f the placenta occurs in the sp o n g y p o rtion o f the

decidua basalis. This process starts d u ring ex p u lsio n o f the baby but the
placenta is in the u p p e r uterine cavity. F u rth er co n tractio n s com plete the
placental separation and force it into the distended low er segm ent.

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 NORM AL LABOUR

T he uterus is gently palpated while the cord is held taut but

without exerting undue traction. The uterus should not be squeezed to
hasten placental separation because it increases the likelihood o f
passage o f fetal cells into the m aternal circulation. G entle dow nw ard
pressure is applied to the fu n d u s o f the uterus. O nce p lacental descen t is
observed, the h an d is tran sferred fro m the fu n d u s to the su p rap u b ic area
and active delivery o f the afterbirth is acco m p lish ed by controlled cord
traction.

Figure 4. F ou r steps in the m anagem ent of the third

stage of labour.

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 NORM AL LABOUR

Steady traction is applied to the cord with the right hand (Figure
4). The left hand is placed on the abdom en with the radial border or the
fingertips just above the sym physis pubis to prevent inversion o f the
uterus. The placenta and m em branes are collected, together with blood,
in a basin. The uterus is then palpated to ensure that it is firmly
contracted. The fundus is now at the level of the um bilicus and the uterus
is broad and discoid.

Attention should now be paid to any uterine bleeding that may

originate from the placental site. The use of uterine massage and
oxytocin or prostaglandin will hasten uterine contractions which will
reduce the bleeding. The introitus and vulvar areas are now inspected for
lacerations and accurately repaired. The perineal area is wiped clean and
dried. A sterile pad is placed over the vulva, the legs are lowered and the
patient is covered.

Before she is taken to the postnatal ward, a final check is made to

ensure that a) the uterus is well contracted b) her pulse rate is below 100
bpm and c) there is no undue bleeding.

PERINEAL LACERATIONS
There are four degrees o f perineal lacerations:
First degree: involves the vaginal m ucosa or perineal skin,
Second degree: involves the subepithelial tissues but not the anal
sphincter or rectal mucosa,
Third degree: extends through the anal sphincter but does not
involve the anal mucosa. This can be further
classified by the extent o f sphincteric involvement
into 3a, 3b or 3c.
Fourth degree: involves the anal m ucosa.

EPISIOTOMY
Definition
An episiotom y is a deliberate incision in the perineum to enlarge the
introitus in order to facilitate delivery. The word episiotom y is derived
from the G reek words E p is e io n (external genitalia) and te m n ie n (to cut).

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Indications
• Tight perineum . This usually occurs in the prim igravida. The
skin o f the perineum appears tense, smooth and glistening. A few
drops o f blood appearing at this time may be from a vaginal tear.
If an episiotom y is not done, laceration o f the introitus may
occur.
• Delay o f the presenting part at the perineum may be due to
contraction o f the pelvic outlet, especially due to a narrow
subpubic arch. In this case, the head will be displaced backwards
and the anal sphincter may be dam aged.
• O ccipito-posterior position of the head because a large diam eter
is presenting.
• Breech delivery, particularly in the prim igravida.
• Forceps delivery.
• Fetal distress in the second stage o f labour.
• Prolapse of the cord in the second stage.
• Preterm delivery: “ the smaller the baby, the bigger the
episiotom y” .
• M ultiple births. The episiotomy is done when Twin A is being
delivered.
• Cardiac disease in pregnancy in order to shorten the second stage
and prevent m aternal exhaustion.
• Previous vaginal repair. Dense perineal scar tissue from a
previous repair may be unyielding.

Figure 5. The perineal muscles

24 9
 NORM AL LABOUR

Technique
M aking an episiotom y without analgesia is antiquated. Load a 20-ml
syringe with 1.0% X ylocaine. Insert two fingers o f the left hand into the
fourchette between the presenting part and the vulva and infiltrate widely
as far as the anal sphincter. Gently massage the soft tissue to disperse the
analgesic agent.
Using a blunt-tipped pair o f scissors, incise the skin and
underlying perineal muscles when the presenting part is distending the
perineum and when it is anticipated that its delivery is possible with the
next one or two contractions (Figure 5).
A m edio-lateral episiotom y is preferable to the m edian incision,
in Trinidad. However, the midline cut is less vascular and less painful as it
heals; the muscles retract sym m etrically and are easier to suture, allowing
better healing and less dyspareunia. The greatest disadvantage of the
median cut is the fear that it may extend into the anal sphincter.

The m edio-lateral incision is made at the 5 or 7 o ’clock position

and is directed about 3 cm lateral to the anus (Figure 6). The J-shaped
episiotom y is a median cut which is extended by curving the incision to
one side so as to avoid the anal sphincter.

Mediolateral
episiotomy

Figure 6. Types of episiotomy

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 NORM AL LABOUR

Repair
Repair of the episiotom y must be undertaken imm ediately after the
placenta has been expelled. A tam pon is inserted into the vagina above
the apex. Using 2/0 Vicryl Rapide® or chrom ic catgut, the vaginal
mucosa is reapproxim ated, starting just above the apex, with a continuous
suture that is tight enough to ensure haemostasis. At the m uco-cutaneous
junction this suture is locked or tied and kept for stitching the perineal
skin. The deep tissues are rebuilt with interrupted No. 1 sutures and tied
without much tension. The perineal skin m argins are then closed with a
subcuticular continuous stitch or interrupted mattress sutures. O f
importance are adequate haemostasis and obliteration o f dead space with
a minimum o f tissue injury. At the conclusion o f the suturing, remove
the tam pon, and perform a rectal exam ination since the inadvertent
incorporation o f the rectum with a suture is likely.

After-care
This consists of daily cold sitz-baths, oral analgesics such as paracetam ol,
infra-red lamp to reduce oedem a, a low-residue diet and a mild laxative
on Day 3. N upercaine ointm ent may be applied for pain.

Complications
• Haem orrhage.
• Infection especially if contam inated with faeces.
• Pain and superficial dyspareunia
• Haematoma.
• B artholin’s cyst.
• Injury to anal sphincter.
• Recto-vaginal fistula - rare.
• Injury to the fetus.
• Cardiac arrhythm ia and anaphylactic shock from the anaesthetic.

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KEY POINTS

• Labour is the process whereby painful regular

contractions produce effacem ent and dilatation
o f the cervix. It is divided into three stages
• The mechanism o f labour concerns alterations
in the attitude and position o f the fetus during
passage through the birth canal.
• A partogram is a graphical representation of
the progress o f labour.
• Three factors are involved: the Powers, the
Passenger and the Passage.
• Episiotom y is a deliberate incision in the
perineum in order to enlarge the introitus
during delivery.
• There are fo u r degrees o f perineal lacerations.

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CHAPTER NINETEEN

INTRAPARTUM FETAL MONITORING

INTRODUCTION
Intrapartum fetal m onitoring is used to identify fetal hypoxia before the
development o f perm anent cerebral dam age and so allow timely
intervention. At present, the established techniques o f intrapartum fetal
monitoring include interm ittent auscultation o f the fetal heart rate and
continuous electronic fetal m onitoring (or continuous cardiotocographic
monitoring).

The placenta acts as the respiratory organ o f the fetus in utero for
gas exchange. D uring a uterine contraction there is cessation of blood
flow in the intram ural vessels such that replenishm ent o f blood in the
placental bed ceases. However the fetus continues to receive oxygen
from the intervillous spaces. When the uterus relaxes there is a reactive
hyperemia and the system has time to recover between contractions. If
there is uterine hypercontractility, which can occur with injudicious use
of oxytocin, this lack o f recovery will eventually lead to fetal hypoxia.
Umbilical cord com pression is another im portant cause o f fetal hypoxia.
The fetus is able to adapt to the stresses o f labour and delivery
through changes in its cardiovascular and autonom ic nervous system.
When both m other and fetus are healthy and labour is norm al, the
decrease in placental exchange of gases is usually well tolerated.
However, in the presence o f maternal disease or placental insufficiency,
the reduction in intervillous flow may com prom ise the ability o f even a
normal fetus to tolerate the stresses o f labour. Chronically com prom ised
fetuses, such as those with intrauterine growth restriction, may not be able

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to tolerate the extra stresses o f labour and thus these fetuses may show
evidence o f fetal stress early in labour.

METHODS OF M ONITORING
Intrapartum fetal heart rate m onitoring includes: interm ittent auscultation
o f the fetal heart with a P in a rd ’s stethoscope (or a D oppler) or
continuous electronic m onitoring with the cardiotocographic m achine
(CTG).

Intermittent monitoring vs electronic fetal monitoring

Systematic reviews com paring interm ittent auscultation to EFM has
shown that continuous EFM was associated with:

• An increase in both caesarean section and instrum ental vaginal

delivery.
• A reduction in neonatal seizures.
• No difference in A pgar scores or neonatal intensive care unit
adm ission.
• No dem onstrable reduction in perinatal m ortality.

A lthough the value o f intrapartum fetal heart rate m onitoring has

been questioned it is currently the only m ethod by which the fetal
condition is regularly assessed. The heart rate itself is a crude indicator
o f fetal status but the changes o f the baseline heart rate may provide an
im portant insight to the fetal condition and its rate o f deterioration.
Decelerations in heart rate indicate a response to stress be it produced as
a result of cord com pression or because o f developing hypoxia.

Intermittent monitoring
Interm ittent m onitoring involves auscultation o f the fetal heart for one
m inute through a uterine contraction every 15 m inutes during the first
stage of labour, or every five minutes, in the second stage o f labour. The
maternal pulse should be palpated to differentiate between m aternal and
fetal heart rates. If there are abnorm alities in the baseline heart rate,
decelerations, irregular heart rate or if there is difficulty with auscultation
then continuous electronic fetal heart rate m onitoring should be
undertaken.

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Some o f the limitations o f intermittent auscultation include:

• It requires one to one midwifery care.
• Should only be used by experienced practitioners, with the
experience o f the technique, ability to palpate contractions and
able to recognize fetal heart rate changes.
• There is no printed recording for independent subsequent review.
• It may be difficult to auscultate the fetal heart rate in the obese
parturient.
• It is not suitable in m onitoring multiple pregnancies. With the
EFM, twin 1 may be m onitored via a fetal scalp electrode and
twin-2 with the external transducer on the maternal abdom en.
• Baseline variability, reactivity, and shallow decelerations are not
detectable with interm ittent auscultation

Continuous fetal heart monitoring (CTG)

This is especially useful in high-risk pregnancies where there is an
increased risk o f perinatal death, cerebral palsy or neonatal
encephalopathy (Table 9.1). There is no conclusive evidence that CTG
monitoring is beneficial for all women in labour. Fetal heart rate is
studied in relation to uterine contractions. The heart rate can be
monitored via a transducer on the maternal abdom en or internally by the
application of a spiral electrode on the fetal scalp (or buttocks if the
presentation is breech). For the latter, the m em branes must be ruptured.

Continuous EFM has sensitivity o f 85% with a corresponding

high negative predictive value in predicting the absence o f fetal hypoxia
and acidosis. Therefore, reassuring FHR patterns are reliable predictors
of fetal well being in labour. With a specificity o f only 40-50% and a
poor positive predictive value (PPV), continuous FHR m onitoring has not
been found to accurately identify fetal hypoxia and acidosis. The most
significant result of poor specificity and PPV is that continuous FHR
monitoring has led to an increase in operative delivery rate without a
reduction in perinatal m orbidity and mortality when com pared with a
protocol of intermittent auscultation.
There is also inter-observer variability in the interpretation o f FHR
patterns and num erous studies have shown clinicians agreeing in only
20-30% o f the tracings.

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Fetal heart rate changes in labour

Baseline rate and variability
The baseline fetal heart rate (FHR) in the term fetus is norm ally between
110 and 160 beats per m inute (bpm ). It is calculated by draw ing a line
through the trace where there are no accelerations or decelerations.
Bradycardia (< 110 bpm ) and tachycardia (> 160 bpm ) may be
indicative of fetal hypoxia.

Variability in the baseline FHR should be regarded as a reliable sign o f

fetal well being in labour, particularly when the direct fetal ECG is being
used as the signal source. Variability is the bandw idth o f the up and
down excursions or “ w ig g lin g ” o f the trace. N orm al long-term
variability, which is usually all that can be obtained from a standard FHR
tracing, com prises changes in rates o f between 5 to 25 bpm , which occur
three to five times a m inute. Prolonged decreased variability and
m arkedly increased variability may indicate fetal hypoxia.

The com bination o f an increasing baseline fetal heart rate and

reduced variability should raise the suspicion o f fetal h y poxia especially
if this occurs with other FHR changes and m econium -staining o f the
am niotic fluid.

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Table 9.1 Indications for continuous CTG (R C O G 20 0 1 )

Indication Risk factor
A n te p a r tu m P r e v io u s c a e sa r e a n s e c t io n
P r e -e c la m p s ia , d ia b e t e s o r o th e r m a tern a l d is e a s e
P o s t- te r m p r e g n a n c y ( > 4 2 w e e k s )
P r o lo n g e d m e m b r a n e ru p tu re ( > 2 4 h o u r s )
In d u c tio n o f la b o u r
A n te p a r tu m h a e m o r r h a g e

F etal G r o w th r e s tr ic tio n
P r e m a tu r ity
O lig o h y d r a m n io s
A b n o r m a l D o p p le r artery v e lo c im e t r y
M u lt ip le p r e g n a n c ie s
M e c o n iu m - s t a in e d liq u o r
B reech p r e s e n ta tio n
Intrapartum O x y t o c in a u g m e n t a tio n
E p id u ra l a n a lg e s ia
V a g in a l b le e d in g in la b o u r
M a te r n a l p y r e x ia
F r e sh m e c o n iu m sta in e d liq u o r

Decelerations
This is the drop in baseline o f m ore than 15 beats lasting fo r lo n g er than
15 seconds from onset to end. There are different types o f decelerations:

• Early decelerations. These decelerations occur concom itantly

with the uterine contraction and they are ascribed to fetal head
com pression. There is a rapid return to the baseline heart rate.
Deep early decelerations may be pathological.

• Variable decelerations. The underlying cause o f these

decelerations is considered to be cord com pression. These
decelerations are variable in appearance, am plitude and tim e o f
onset with respect to the contractions. Repeated variable
decelerations can lead to hypoxia.

• Late decelerations. These decelerations start after the onset o f the

contractions and there is a slow return to the baseline after then

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end o f the contraction. These decelerations are associated with

fetal hypoxia.

Table 9.2 Categorization of fetal heart rate traces

C a te g o r y D e fin itio n
Normal A CTG where a l l f o u r features fall into reassuring
category
Suspicious A C T G w hose features fall into o n e o f the non­
reassuring categories and the rem ainder o f the
features are reassuring
Pathological A CTG w hose features fall into t w o o r m o r e non­
reassuring categories or one o r more abnormal
categories
Table 9.3 Categorization of fetal heart rate features
F e a tu r e B a s e lin e V a r ia b ility D e c e le r a tio n s A c c e le r a tio n s
(b p m ) (b p m )

R e a s s u r in g 1 1 0 -1 6 0 >5 N one P resen t

N on­ 1 0 0 -1 0 9 <;5 f o r £ 4 0 E a rly d e c e le r a tio n

r e a ss u r in g 1 6 1 -1 8 0 b u t le s s V a r ia b le
th an 9 0 d e c e le r a tio n
m in u t e s S i n g l e p r o lo n g e d T he ab sen ce
d e c e le r a tio n u p t o 3 of
m in u t e s a c c e le r a tio n
A bnorm al <100 < 5 fo r > 9 0 A t y p ic a l v a r ia b le s w ith an
>180 m in u t e s d e c e le r a tio n s o th e r w is e
S in u s o id a l L a te d e c e le r a tio n s n orm al C TG
is o f
pattern S i n g l e p r o lo n g e d
un certain
>10 d e c e le r a tio n > 3
s ig n if ic a n c e
m in u te s m in u t e s

Fetal blood sampling (FBS)

When abnorm alities o f FHR patterns appear on the CTG, particularly
when progress of labour is satisfactory, FBS and determ ination o f the
fetal pH will help to confirm or deny fetal well being whether to continue
labour or expedite delivery.

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Interm ittent blood sam pling for pH is usually reliable enough to

permit clinical judgem ents to be m ade. Interm ittent p 0 2 and p C 0 2
values are less reliable because of the wide range in values that are found
in the dynam ic fetal milieu and also because o f the potential for aerobic
contam ination of the sample.

Fetal lactate m easurem ents are possible at earlier cervical

dilatation and use a smaller sample volum e. However one random ized
controlled trial showed there were no significant differences in caesarean
section rates, A pgar scores of less than seven at five m inutes or um bilical
artery pH in the lactate or pH groups. So as yet its role is unclear. Fetal
scalp pHs above 7.25 are considered norm al, whereas values below 7.20
represent signs o f acidosis and immediate delivery is indicated.

C ontraindications to FBS are fetal bleeding disorders

(haem ophilia), prem aturity (<34 weeks of gestation) and m aternal
infections such as HIV, hepatitis and herpes. Acute events such as
suspected uterine scar dehiscence or rupture, placental abruption or cord
prolapse are also contraindications to FBS.

Table 9.4 Fetal pH and Intervention

p H r e su lt S u b s e q u e n t a c tio n
>7.25 F B S s h o u ld b e rep eated i f F H R
a b n o r m a lity p e r s is t s .
7 .2 1 - 7 .2 4 R e p e a t F B S w it h in 3 0 m i n u t e s o r
c o n s id e r d e liv e r y i f rap id fa ll s i n c e
la st s a m p le .
<n .20 D e liv e r y in d ic a te d .

Meconium
Although the passage of m econium by the fetus is not always due to fetal
hypoxia, m econium -stained liquor must be considered seriously and
there should be continuous m onitoring o f the FHR by CTG in labour.
Because of the risk of m econium aspiration a Paediatrician should be
present at delivery.

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Fetal electrocardiogram in labour

In the search for m ore specific form s o f intrapartum m onitoring, the
fetal electrocardiogram (ECG) is being investigated to determ ine if m ore
useful inform ation can be obtained to detect m yocardial hypoxia and by
extension, cerebral hypoxia. At present evaluation o f the fetal ECG
waveform has been com prom ised by difficulties in signal acquisition and
m ethods of signal processing. Particular attention is being paid to the
T/QRS ratio, ST segm ent and the duration o f the P wave and the P-R
interval. A bnorm al fetal pH and base excess have been associated with a
prolonged R-R interval and a shortened P-R interval. It must be
em phasized that fetal ECG waveform analysis in labour is still at an early
stage.

Near infrared spectroscopy in fetal monitoring

Fetal near infrared spectroscopy (NIRS) was first recognized by Jobsis
(1977). It exploits the different optical absorption characteristics o f the
haem oglobin m olecule when in its oxygenated or reduced form . The
technique uses NIR light (750-1000 nm wavelength), which is
transmitted through the fetal scalp, skull and brain.

In labour, the laser diodes contained in an optrode are inserted

into the uterus via the cervical canal. At the same tim e, a fetal scalp
electrode can be attached to record the fetal ECG. Changes in cerebral
blood flow and oxygenation are identified im m ediately with the NIRS by
observing the various patterns on the m onitor. In the future NIRS may
provide a continuous method for intrapartum fetal m onitoring that will
directly measure fetal cerebral oxygenation and cerebral blood flow.

M ANAGEM ENT O F THE ABNORM AL CTG

• Note the time and date and ensure patient details are on the CTG
• Review the clinical details (parity, progress o f labour, presence of
m econium , oxytocin adm inistration, recent placem ent or topping-
up o f epidural) and m aternal observations such as pulse, blood
pressure, tem perature and dehydration status.
• Check maternal position (left lateral) to ensure there is no
aortocaval com pression.
• Ensure speed o f tracing is lcm /m in.
• Define the baseline, variability, presence o f accelerations.
• Define the type o f decelerations.

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• Note the frequency, duration and intensity o f the contractions, as

injudicious use of oxytocin can cause fetal hypoxia.
• Determine if fetal blood sample is needed or if delivery is
indicated.
• Ensure proper docum entation and at delivery paired venous and
arterial cord blood samples.

TREATMENT OF SPECIFIC CAUSES OF FETAL DISTRESS

• Cord prolapse. Ensure that cord com pression is prevented. It
has been suggested that rapid instillation o f 500-700 ml o f sterile
saline into the bladder via a Foley catheter will also prevent cord
com pression. U rgent delivery usually by Caesarean section must
be done.

• Antepartum or intrapartum haem orrhage. Significant maternal

and fetal bleeding can occur with abruptio placentae. If fetal
distress occurs with abruptio placentae, an em ergency Caesarean
section is indicated except if vaginal delivery is im m inent.

• Uterine Scar rupture. Uterine rupture is a m ajor cause of

maternal and perinatal m ortality. The diagnosis is clinical.
Suspected uterine rupture is an urgent indication for a
laparotom y by a senior obstetrician.

• Vasa Praevia. Vasa praevia presents similar to placenta praevia

and the mode of delivery is abdom inal. The diagnosis o f vasa
praevia can be confirm ed on exam ination o f the placenta at the
end o f the third stage.

• Chorioamnionitis. Intravenous broad spectrum antibiotics must

be administered and delivery expedited.

• Failure to progress or prolonged labour. Careful review of the

labour record and the partogram may direct attention to some
degree of disproportion and thus a Caesarean section should be
perform ed.

• Twin B with fetal distress. This may occur, for exam ple,
following the inadvertent administration of Syntom etrine with the

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anterior shoulder o f Twin A. There should be a low threshold for

an em ergency Caesarean section.

KEY POINTS

• The aim of monitoring is for the early

identification of fetal hypoxia to allow timely
intervention, before permanent cerebral
insult can occur.
• Continuous CTG monitoring is reserved for
high-risk women in labour.
• Several parameters are monitored including
the baseline heart rate, variability,
accelerations and decelerations.
• Deep early decelerations, especially early in
labour can be pathological.
• FBS is used to complement the use o f CTG
• There are newer methods of monitoring, but
they are not widely available.
• Because of the number of m edico-legal events
associated with this issue, it is wise to be
thorough in counseling and documentation of
events.

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CHAPTER TWENTY

POSTPARTUM HAEMORRHAGE

INTRODUCTION
Postpartum haem orrhage (PPH) is one o f the principal causes o f
maternal mortality worldwide. It occurs in 4 to 9% o f all pregnancies
and is associated with significant m orbidity including loss o f fertility and
end organ dam age such as renal failure. The problem is particularly
alarming in the developing world where it is co m p ounded by
grandmultiparity, short interpregnancy intervals, p o o r nutritional status
and a lack o f access to centres with appropriate facilities to m anage this
obstetric em ergency.

DEFINITION
By convention, this has been defined as blood loss from the genital tract
in excess of 500 millitres occurring after delivery o f the baby.

It can be classified as primary if this loss has occurred within 24

hours of delivery and secondary if after the first 24 hours but within the
puerperium.
Given that a num ber o f studies have fo u n d that 500 millitres is
the usual loss following a norm al vaginal delivery and that m ost patients
tolerate this loss well, a m ore constructive definition may be that o f
massive postpartum haem orrhage. This is defined as blood loss greater
than 1000 millitres or 1500 millitres occurring after delivery o f the
baby. The risk of ensuing com plications is significantly greater above
this threshold.

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AETIOLOGY
The m nem onic, the 4 T 's (Tone, Traum a, Tissue and T hrom bogenic)
allows for the categorization o f the causes o f postpartum haem orrhage:
• Tone refers to uterine atony. This is the most com m on cause
o f postpartum haem orrhage. It may be due to uterine
overdistension as occurs in m ultiple gestations,
polyhydram nios and fetal m acrosom ia. The efficiency of
m yom etrial contractility may also be com prom ised in
chorioam nionitis, grandm ultiparity, precipitate labour,
prolonged labour and following tocolytic therapy.
A ntepartum , placental abruption may result in suffusion of
blood between the m yom etrial fibres. This is known as the
C ouvelarie’s uterus and represents an im pedim ent to
effective uterine contraction.

• Trauma refers to genital tract lacerations. It tends to be more

com m on following instrum ental deliveries. Bleeding may
occur from episiotom ies, vaginal and cervical lacerations and
uterine rupture.

• Tissue refers to retained placental fragm ents such as a

succenturiate lobe. This may interfere with contraction and
provide a nidus for bleeding and infection.
• Thrombogenic causes. Patients with Von W illebrand’s
disease. Haem ophilia A or H aem ophilia B have an intrinsic
bleeding tendency that predisposes to postpartum
haem orrhage. In addition, coagulation abnorm alities can
occur in pregnancy as a sequel to the following:-
■ severe infections
■ severe pre-eclam psia
■ amniotic fluid em bolus
■ abruptio placentae
■ intrauterine demise
■ anticoagulant therapy

An alternative m nem onic is "C U T '- C oagulation disorders. Uterine

atony and Traum a.

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MANAGEMENT
This is an obstetric em ergency and merits the involvement o f senior
obstetricians, anaesthetists, haem atologists and midwifery staff.
M anagem ent can be thought o f broadly under the headings,
Resuscitation and Treatm ent of the causes. In practice these occur
simultaneously.

Resuscitation
Resuscitation follows a structured approach relating to the airway,
breathing and circulation. The initial step should be to call for help,
establish an airway and ensure that the patient is breathing. The
minimum requirem ent is an oropharyngeal airway though this is not
always necessary. However, massive haem orrhage may be associated with
unconsciousness and this patient is at particular risk o f an aspiration
pneumonitis. T herefore, airway protection may be required in the form
of a cuffed endotracheal tube. O xygen should be adm inistered at the rate
of 12-15 litres per minute as this will optimise oxygen delivery to
essential organs.

The patient should be placed in the left lateral and T rendelenburg

positions in order to limit aortocaval com pression and encourage venous
return, respectively. Intravenous access should be established with two
wide bore cannulae and blood taken for a full blood count, urea and
electrolytes, clotting profile, fibrinogen and fibrinogen degradation
products. At least 6 units o f blood should be cross-m atched. The
haematologist should be inform ed and the laboratory w arned that
additional blood and blood com ponents may be required urgently.

Fluid resuscitation should be com m enced with isotonic solutions

such as normal saline or H artm an’s until blood is available. Colloids may
also be used. Ideally, group specific cross-m atched blood should be
transfused but uncross-m atched O negative blood can be used in an
emergency.

The patient should be catheterised with strict input/output charting. An

hourly urom eter catheter bag can be used and one should aim to keep
the urine output greater than 30 ml/hour. M ost patients tolerate blood
loss well and require m onitoring in the form o f D inam ap m onitoring and
oxygen saturation only. More invasive m onitoring may be considered in
the event of massive haem orrhage. This may include an arterial line and
a central venous pressure line. A Swan-Ganz catheter or pulm onary
wedge catheter is not usually required though it may prove useful in
severe pre-eclampsia and cardiac or pulm onary disease.

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SPECIFIC M ANAGEM ENT

Uterine Atony
Uterine atony may respond to uterine massage (the Crede m anoeuvre).
This stimulates the uterus to contract and aides in the expulsion o f clots.
A vaginal exam ination can be perform ed and clots may be extricated
digitally. A significant proportion o f patients respond to these simple
measures only and they should be part of the initial assessment o f all
patients.

Brisk haem orrhage may respond to bim anual com pression. This
can be achieved by com pression o f the uterus between a hand on the
fundus and a fist in the vagina. Alternatively the fundus can be brought
forward with two hands and compressed against the pubic bone. These
m anoeuvres may be helpful in the short term but it is difficult to
maintain this effort for a protracted period.

Pharm acotherapy involving the use o f uterotonic agents is the

mainstay of the m anagem ent o f uterine atony. The use o f drugs with
different mechanisms o f action may have a cum ulative effect and
polypharm acy should be considered. This is discussed in more detail
later in the chapter.

Failure to respond to the above measures warrants surgical

m anagem ent. This may take the form o f an exam ination under
anaesthesia with gentle curettage of the uterine cavity. Genital tract
lacerations can be evaluated and treated at this time. A Rusch balloon
catheter or Sengstaken-Blakem ore tube can be inserted into the uterine
cavity and the balloon inflated to provide tam ponade o f blood vessels at
the placental bed. It is used in conjunction with an uterotonic infusion
and remains in-situ for 12 to 24 hours.
Persistent bleeding not responsive to these advanced measures
warrants laparotom y. This allows for interventions such as:
• Uterine artery ligation.
• Internal iliac artery ligation.
• Insertion of haemostatic sutures such as the B -lynch suture.
• H ysterectom y.

Finally, interventional radiology may have a role to play. X-ray

or MRI guided uterine artery em bolisation can be perform ed in the
stable patient.

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Genital Tract Trauma

Traum a should be suspected if haem orrhage continues in the presence o f
a well contracted uterus. An exam ination u nder anaesthesia with the
patient in the lithotom y position allows for a system atic assessm ent o f the
lower genital tract, that is, the vulva, vagina and cervix. Cervical
assessment can be perform ed with the aid o f two sponge holding forceps.
These are placed on the cervix at 12 o ’clock and 3 o ’clock and the
intervening tissue exam ined for bleeding vessels. The clam p at 12
o ’clock is then repositioned at 6 o ’clock and the process repeated until
the whole cervix has been evaluated fully. This is the ‘walk a ro u n d '
technique. If bleeding vessels are identified haem ostasis can be achieved
with interrupted sutures.

Bleeding that is com ing from the cervical canal may be

suggestive o f uterine rupture. Fortunately this condition is rare. It may
occur following an internal podalic version, the injudicious use o f an
oxytocic infusion or through a previous uterine scar. It may occur as a
catastrophic event with hypovolem ic shock and intrauterine dem ise.
However, it may also be silent or be preceded by signs o f im m inent
rupture. These include an area o f constriction between the u p p er and
lower segments (B andl’s ring), secondary arrest o f labour, small am ounts
of vaginal bleeding, haem aturia and abnorm al card io to co g rap h y .

The definitive m anagem ent is a hysterectom y. However, in an

effort to m aintain fertility m ore conservative m easures may be
considered. Tears that extend into the broad ligam ent pose a particular
challenge. Blood vessels tend to retract laterally and haem ostatic sutures
may occlude the ureters which run in the base o f the broad ligam ent.

Retained Placenta
A retained placenta may be defined as a placenta that rem ains
undelivered 30 m inutes following the end o f the second stage o f labour.
It occurs in 2 % o f all deliveries and is associated with a significant risk
of haemorrhage from the placental bed. The main causes o f a retained
placenta include:
• Delayed adm inistration o f syntom etrine. It is usually given with
the birth o f the anterior shoulder.
• Inappropriate cord traction prior to placental separation. This
may sever the cord leaving the placenta in-utero.
• A m orbidly adherent placenta. This condition typically results
from faulty decidualisation at the site o f previous insult to the
endom etrium . This can occur follow ing m anual rem oval o f the
placenta, caesarean section, previous m yom ectom y (cavity

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entered), endom etrial curettage and rarely, following endom etrial

ablation.

The diagnosis o f a m orbidly-adherent placenta is usually made

during the third stage o f labour at the time o f a m anual removal.
However, magnetic resonance im aging or colour D oppler ultrasound
may assist the diagnosis antepartum in patients know n to be high risk.
Three grades o f adherent placenta are recognized (they are in
alphabetical order):
• Placenta accreta - the villi are attached to the m yom etrium .
• Placenta increta - there is invasion o f the m yom etrium .
• Placenta percreta - the villi have invaded the full thickness of the
m yom etrium and may have breached the serosa.

As m entioned previously, the presence o f the placenta is an

im pedim ent to effective uterine contraction and there is a high risk of
haem orrhage from the placental bed. These patients should therefore be
dealt with in a prom pt fashion. The m anagem ent may be conservative or
surgical depending on the m aternal status and the degree of
haem orrhage.

Conservative measures may be pursued, provided the bleeding is

not heavy, with readiness for surgical intervention in the event o f failure.
The options include:
• A dequate analgesia, a postpartum syntocinon infusion (40 units
in 1 litre of norm al saline) and controlled cord traction following
placental separation.
• The umbilical vein can be catheterised and a syntocinon infusion
(50 units in 25 millilitres o f saline) injected. This is thought to
cause preferential contraction o f the m yom etrium at the placental
bed and result in shearing of the placenta. It is a safe alternative
to surgical m anagem ent.

M anual removal of the placenta is the mainstay o f management.

This should be conducted in the operating theatre under anaesthesia. In
exceptional circum stances, this can be perform ed on the delivery suite
using a com bination o f ketam ine and diazepam . Ketamine induces
dissociative anaesthesia. A dose of lm g/kg should provide sufficient
analgesia to allow the procedure without the need for airway protection
or ventilatory support. It is especially useful in the asthmatic but is
contraindicated in patients with pregnancy induced hypertension and
cardiac disease. N ightm ares, hallucinations and irrational behaviour may

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accom pany the recovery phase. Diazepam helps to prevent these

em ergence phenom ena.

The patient is placed in the lithotom y position, cleaned and

draped and the bladder em ptied. Elbow length sterile gloves or gauntlets
are worn and one hand, with fingers and thum b apposed, is introduced
into the vagina. The placenta is located by following the cord. The other
hand must perform the im portant function o f steadying the fundus
through the abdom inal wall. Having located the placenta, the periphery is
sought and a plane o f cleavage is established with the ulnar border o f the
hand. The placenta is steadily separated from the uterine wall, and
cupped in the hand which is then withdrawn. Patience and firm resolve
are required and one must resist the tem ptation to claw at the placenta, as
this may result in perforation o f the uterus or incom plete rem oval o f the
placenta.

If the placenta is m orbidly-adherent in any part, it is almost

impossible to rem ove it without leaving shreds o f tissue behind. U nder
these circum stances, an effort is made to remove as much placental tissue
as possible, digitally, and to control haem orrhage with an oxytoxic
infusion. Intrauterine tam ponade with either a pack o r Rusch balloon
catheter may also be required. Blood transfusion and prophylactic
antibiotics are usually necessary. In severe cases, a hysterectom y may be
required, but this must be undertaken only as a last resort. Rarely, in
cases of placenta percreta not com plicated by haem orrhage intravenous
methotrexate may have a role to play

Uterine inversion
This is a rare condition thou g h t to occur following inappropriate cord
traction. Conditions such as a m orbidly adherent fundal placenta may
increase this risk. There is a neurogenic elem ent to the shock seen in
these patients. This may be com pounded by hypovolem ia and these
patients should be resuscitated aggressively.
Uterine restitution may be achieved bv:-
• Manual reinsertion. A m ilking technique is em ployed with the
circum ferential reinsertion o f tissue from lateral to m edial.
Manual removal o f the placenta should only be attem pted after
reinsertion.
• O ’Sullivan's technique whereby hydrostatic pressure is used to
restore norm al uterine anatom y. A wide bore hose, attached to a
reservoir, is inserted into the vagina and a seal is achieved by

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apposing the labia with both hands. This is an effective and

atraumatic m ethod of restitution.
• H aultain's procedure. At laparotom y an incision is made on the
posterior wall of the uterus. Pressure from below allows
replacem ent o f the fundus and the incision is closed.
Following successful reinsertion an oxytocic infusion is used to keep the
uterus well contracted.

Placental Abruption
Antepartum haem orrhage secondary to abruption is a significant risk
factor for postpartum haem orrhage. This is because:
• There is a depletion o f clotting factors secondary to blood loss.
• Throm boplastins are released into the m aternal circulation.
• There is a risk of uterine atony secondary to a Couvelaire's
uterus.
These factors conspire to make PPH in this context a potential
nightm are. Strategies to counteract this are:
• There should be a low threshold fo r blood transfusion in
abruption to reduce the risk o f clotting abnorm alities and
disseminated intravascular coagulation.
• There should be active m anagem ent o f the third stage o f labour
with a low threshold for a prophylactic syntocinon infusion.

Amniotic fluid embolism

This is a rare condition with a high maternal mortality rate. It tends to
occur peripartum and is thought to be due to an anaphylactoid reaction
to the presence o f am niotic fluid and fetal cells in the maternal
circulation. The diagnosis should be entertained in any patient who
presents with central cyanosis, respiratory distress, bleeding and shock.
The prognosis is improved when there is aggressive resuscitation and a
low threshold fo r m anagem ent of these patients in an intensive care
setting. Postmortem may reveal the presence o f fetal squam ous cells and
lanugo hair in the maternal pulm onary circulation.

Anticoagulation therapy
Patients may be on anticoagulant therapy in pregnancy for a number of
reasons including artificial heart valves, throm boem bolic disease and
atrial fibrillation. Bleeding is a potential com plication and these patients
should be m anaged in conjunction with a haem atologist. If the bleeding
is severe, reversal o f the anticoagulation may be warranted. This can be
achieved by the adm inistration of:
• Vitamin K to patients on warfarin.
• Protamine sulphate to patients on heparin.

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BLOOD COMPONENT THERAPY

This is essential in the m anagem ent o f postpartum haem orrhage. It is
life-saving in the presence of disseminated intravascular coagulation. The
following blood com ponents may be used:-
• Packed cells are ideal for fluid resuscitation prim arily because
they increase the intravascular colloid oncotic pressure as well as
increasing the oxygen carrying capacity o f the blood.
• Fresh frozen plasma (FFP) contains clotting factors and
fibrinogen. Generally, 4 units o f FFP should be transfused for
every 6 units o f packed cells.
• Cryoprecipitate contains a higher concentration o f fibrinogen
than FFP.
• Platelets have a short half life which limits their effectiveness.
However, they may be transfused prior to surgical intervention.

Additional considerations include:-

• Cell salvage - if the technology is available.
• A utologous blood transfusion.

PHARMACOTHERAPY
This section is confined to a discussion of the uterotonic agents that are
currently in use.

Oxytocin
This is a naturally occurring nonapeptide that is synthesized in the
paraventricular nuclei of the hypothalam us and stored in the posterior
pituitary gland. Synthetic oxytocin is known as Syntocinon.

Syntocinon may be adm inistered intravenously or

intramuscularly. It exerts its effect via the oxytocin receptors present on
the myometrial cell m em brane. The num ber o f receptors increases
throughout pregnancy and therefore Syntocinon is m ore effective on the
gravid uterus at term than it is on the non-gravid uterus. Following
intravenous adm inistration it exerts its uterotonic effect after 30 seconds
with a duration o f action o f 30 minutes.

It may be adm inistered as an intravenous infusion in established

postpartum haem orrhage. For exam ple, 40 units o f Syntocinon are
added to 1 litre o f norm al saline and the infusion titrated to ensure the
uterus is well contracted. In high doses, Syntocinon exerts an
antidiuretic effect. This is because o f its structural similarity to

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vasopressin. Potential side effects w ould include fluid overload,

pulm onary oedem a, hypotension and reflex tachycardia.

Ergom etrine
This is an am ine ergot alkaloid that stim ulates contraction o f uterine and
vascular sm ooth m uscle. It may be adm inistered intravenously or
intram uscularly and is m etabolised and excreted by the liver. Follow ing
intravenous adm inistration it exerts its uterotonic effect after 30-60
seconds with duration o f action o f 30 m inutes. Intram uscular
adm inistration may im prove its side effect profile. The usual dose is 0.2-
0.5 m g.

It works equally well on the gravid and non-gravid uterus. It is

particularly useful in the m anagem ent o f postpartum h aem o rrh ag e as it
causes vasospasm o f blood vessels in the placental bed as well as
m yom etrial contraction. This vasoconstriction can increase peripheral
vascular resistance and blood pressure and therefore its use should be
cautioned in patients with preg n an cy induced h y pertension, cardiac
disease and peripheral vascular disease. O ther side effects include
nausea, vom iting, diarrhoea, dizziness, hallucinations, vertigo and
tinnitus.

Syntometrine
This is form ulated as a com bination o f 5 units o f Syntocinon and 0.5 mg
o f E rgom etrine in a 1 ml am poule. This preparation benefits from the
dual action o f both drugs. It may be adm inistered intravenously or
intram uscularly. Follow ing intram uscular adm inistration it exerts its
uterotonic effect after 2-3 m inutes with a duration o f action o f 180
m inutes.
Indications fo r use:
• Active m anagem ent o f the third stage o f lab o u r. It is
adm inistered routinely, intram uscularly with the birth o f the
anterior shoulder.
• In the treatm ent o f established postpartum haem orrhage due to
uterine atony.
• Following delivery o f a retained placenta.
• Following delivery o f the fetus at the time o f a caesarean section.
• Prophylactically for all potential cases o f postpartum
haem orrhage.

C ontra-indications:
• H ypertensive disorders o f pregnancy.
• Cardiac disease in pregnancy.

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• Twin pregnancy, after delivery o f twin A.

• Vaso-occlusive disease.

C om plications:
• Increased incidence o f retained placenta.
• Postpartum pain.
• Tetanic contractions resulting in fetal distress in undiagnosed
twins.

Misoprostol
This is a synthetic analogue o f prostaglandin E l . It is used to treat
uterine atony in patients unresponsive to ergom etrine and oxytocin. It is
rapidly absorbed from the gastrointestinal tract and may be adm inistered
sublingually, orally, vaginally, rectally or intrauterine. It is hydrolyzed
to active com ponents, m etabolized in the liver and excreted in the urine.
The dose is 200-800 meg.

It stimulates m yom etrial activity in both the gravid and non-

gravid uterus. It binds to EP-1 receptors resulting in an increase in
intracellular cyclic AMP. In addition it causes disaggregation o f
collagen fibres in the cervix.

Indications for use:

• In the treatm ent o f established postpartum haem orrhage due to
uterine atony.
• As an abortifacient.
• Prevention and treatm ent o f NSAID induced gastric ulceration.

As with all prostaglandins, gastrointestinal disturbance is the most

prevalent side effect. This includes nausea, vom iting, diarrhoea,
abdominal pain, dyspepsia and flatulence.

Carboprost
This is a prostaglandin F2-alpha analogue, also know n as H aem abate,
which potentiates the uterotonic effect o f oxytocin. It is used to treat
uterine atony in patients unresponsive to ergom etrine and oxytocin.

The route o f adm inistration is intram uscular or intram yom etrial

in a dose of 250 meg. This may be repeated every 15 m inutes to a
maximum total of 8 doses or 2 m gs. The side effect profile is sim ilar to
that for M isoprostol.

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PROPHYLAXIS
The most im portant preventive step is to identify the patient at risk of
developing postpartum haem orrhage. The risk factors for postpartum
haem orrhage are:
• Previous history o f postpartum haem orrhage.
• A ntepartum haem orrhage
• Previous caesarean section
• Intra-uterine death
• M ultiple pregnancies
• G rand multiparity
• Fibroid uterus
• H ydram nios.

Once a patient has been identified as being at risk of developing

postpartum haem orrhage, the im portant aspects in her m anagem ent are:
• Antenatal correction o f anaem ia - either haem atinics or
transfusion.
• Availability o f crossm atched blood at delivery.
• Active m anagem ent of the third stage o f labour.

D uring labour, intravenous access should be established.

Syntom etrine may be given intravenously with the birth of the anterior
shoulder, and the placenta delivered by controlled cord traction. These
patients may also benefit from an oxytocic infusion.

SECONDARY POSTPARTUM HAEMORRHAGE

In this condition, bleeding occurs after the first tw enty-four hours
following the birth o f the baby. The most com m on cause is retention of
products of conception with infection. D ehiscence and infection of
sutured sites are also causes. Rare causes w ould include gestational
trophoblastic disease such as choriocarcinom a.

The definitive m anagem ent o f retained products o f conception is

an evacuation (ERPOC) under anaesthesia. C rossm atched blood should
be available, because severe haem orrhage may attend the procedure as
the retained tissue tends to becom e organised and adherent to the uterine
wall. Antibiotics should be prescribed and the specim en should be sent
for histological analysis prim arily to ensure that there is no evidence of
gestational trophoblastic disease. Histological analysis is also good
practice from a m edico-legal perspective.

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COMPLICATIONS O F POSTPARTUM H A EM O RR H A G E
A num ber of com plications can arise as a result o f PPH, these include:
• M aternal demise.
• Puerperal sepsis.
• Renal failure. These patients may require renal therapy (dialysis
or haem ofiltration).
• Chronic iron deficiency.
• Necrosis o f the anterior pituitary gland (S heehan’s syndrom e).
This may present with the failure o f lactation.
• Disseminated intravascular coagulation. This is a life threatening
com plication o f massive haem orrhage. The m anagem ent
involves m aintaining the intravascular volum e, arresting the
haem orrhage and administering blood and blood products as
required. A low threshold for transfusion, especially when
postpartum haem orrhage is preceded by antepartum
haem orrhage may prevent the developm ent o f DIC in the first
instance.

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KEY POINTS

• Postpartum haem orrhage is one of the

principal causes of maternal mortality. This
is an obstetric emergency and senior staff1
should be involved at an early juncture.
• In practice, resuscitation and treatment of the
cause occur simultaneously.
• Uterine atony is the most common cause of
postpartum haem orrhage and uterine
massage is an important early m anoeuvre in
the managem ent of this condition.
• The signs of imminent rupture of the uterus
are a BandPs ring, secondary arrest of
labour, small amounts of vaginal bleeding,
hematuria and abnorm al cardiotocography.
• Blood component therapy can be life saving
in the presence of DIC.
• There should be a low threshold for
transfusion especiallv when PPH is preceded
by A PH .

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CHAPTER TWENTY-ONE

PRETERM LABOUR
PPROM

PRETERM_L_AB Q U R

INTRODUCTION
Preterm labour may be defined as labour occurring in pregnancies o f
less than 37 com pleted weeks o f am enorrhoea. A prerequisite fo r
diagnosis is that uterine contractions should last fo r at least 30 seconds,
occur every 10 m inutes or less, for at least 60 m inutes and should be
accom panied by dilatation and effacem ent o f the cervix and descent o f
the presenting part.

The incidence is 8 to 10 % o f pregnancies and the com bination

of prem ature birth and low birthweight (less than 1500 gram s) accounts
for 75% of all perinatal m orbidity and m ortality. In general, in the
uncomplicated singleton gestation, fetal lung m aturity is achieved by 34
weeks. Prior to this ex-utero pulm onary function is an issue and
respiratory distress syndrom e is the m ajor cause o f perinatal death.
Intraventricular haem orrhage, periventricular leukom alacia and
necrotising enterocolitis all ensue from preterm birth and im pact
negatively on perinatal outcom e. As neonatal services have im proved
great strides have been made in the salvage of these preterm infants.
However, the Epicure study dem onstrated that fo r extrem e prem aturity
the outcome rem ains poor.

Long term neurodevelopm ental delay, visual and hearing

impairment, chronic lung disease and cerebral palsy plague a significant
proportion of the survivors. This places an extrem e burden on health
service provision and for this reason, preterm labour rem ains one o f the
most im portant problem s in m odern-day Obstetrics. Its prevention would

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therefore theoretically lead to an im provem ent in overall perinatal

salvage.

Preterm prelabour rupture o f m em branes (PPROM) is considered

at the end of this chapter. It precedes 30% o f all preterm deliveries. The
aetiology and m anagem ent are similar to that fo r preterm labour though
there are some caveats that are best dealt with separately.

ASSOCIATED FACTORS
There are a num ber o f socioeconom ic factors that increase the risk of
preterm labour. These include:
• U nderw eight m others (<55 kg)
• Chronic m alnutrition
• Sm oking
• High parity
• A m bulant occupation
• Extrem es o f m aternal age.

AETIOLOGY
There are m any factors that have been im plicated in the aetiology of
preterm labour. These may occur in isolation o r in com bination. On
occasion no specific cause is fo und. This is know n as idiopathic preterm
labour. The identifiable causes o f preterm labour include:
• M aternal febrile illness - m aternal infections such as appendicitis,
cholecystitis and b ro n ch o p n eu m o n ia are associated with preterm
labour. H aem atogenous spread o f bacteria to the uterine cavity
can occur and stimulate a cascade o f events that ultim ately leads
to prostaglandin production by the fetal m em branes.
• U rinary tract infections - These are m ore com m on in pregnancy
prim arily because of the short length o f the fem ale urethra and
the muscle relaxant properties o f progesterone. These lend
themselves to colonisation o f the urinary tract. Asymptomatic
bacteriuria, urethritis, cystitis and acute pyelonephritis can ensue.
The m echanism whereby these stim ulate preterm labour is likely
to involve an elem ent o f haem atogenous spread and
prostaglandin production.
• Genital tract infections - The most com m on infection is bacterial
vaginosis. This represents an alteration in the vaginal flora
characterised by a preponderance o f anaerobic bacteria such as

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g ard n erella vaginalis, bacteroides an d m y co p lasm a h o m in is.

O ther organism s that can infect the g en ital tract an d cause
preterm lab o u r are trep o n em a pallid u m , neisseria g o n o rrh o e a ,
ch lam ydia tracho m atis and g ro u p B strep to co ccu s. The
m echanism is likely direct spread th ro u g h the cervical canal
which stim ulates the p ro d u ctio n o f p ro stag lan d in s by the fetal
m em branes.
• M ultifetal p regnan cies. T here is likely a m echanical e ffect o f
overdistension w hich stim ulates the la b o u r process.
• P o ly h y d ram n io s. T his can o ccu r as a result o f p o o rly c o n tro lled
diabetes, twin to twin transfusion sy n d ro m e o r fetal ab n o rm ality
that affects swallowing such as a n en cep h aly . As in m ultiple
gestations, the resultant overdistension stim ulates the lab o u r
process.
• M ullerian duct abn o rm alities such as a b ic o rn u a te u teru s.
• T u m o u rs o f the uterus such as su b m u co u s fib ro id s. T hese are
essentially space o ccu p y in g lesions that in co m b in atio n with the
developing co n cep tu s result in a relative ‘‘o v erd isten sio n
• Cervical in co m p eten ce is rare o c cu rrin g in less than 1% o f all
p regnancies. It m ay be due to either previous trau m a to the cervix
o r developm ental ab n o rm ality . It can lead to p ainless dilatation o f
the cervix and prem atu re loss. T his classically o ccu rs in the
second trim ester.
• Sexual intercourse m ay precipitate p reterm la b o u r bu t the
evidence is ten u o u s. Sem inal p ro stag lan d in s are th o u g h t to be the
culprit.
• Iatrogenic causes. F o r exam ple, m iscalculation o f the ex p ected
date o f delivery in patients req u irin g in d u ctio n o f la b o u r m ay
result in the delivery o f a preterm in fan t. T his situation is
c o m p o u n d ed in diabetes in p reg n an cy w here fetal lung m aturity
lags behind that o f a norm al singleton p re g n a n cy .
• Prem ature intentional delivery because o f clinical necessity such
as antepartum h aem o rrh ag e and p re-eclam p sia.

PREDICTION
Patients at risk o f developing preterm la b o u r sh o u ld have their
pregnancy accurately dated, p referab ly with an early b o o k in g u ltraso u n d
scan. They should be screened fo r asym ptom atic b acteriu ria and vaginal
infections and they should attend the antenatal clinic reg u larly fo r a
review o f sym ptom s and fo r serial cervical ex am in atio n s. C ervical

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exam inations in the presence of intact m em branes have not been found
to be associated with an increase in the rate o f prem ature labour or
infection, but there is controversy as to w hether they are a useful
screening technique for preterm birth in women at average risk. Serial
ultrasound evaluation o f the cervix may be helpful. Cervical shortening
and funnelling on ultrasound scan may be indicative o f pre-term labour.
Fibronectin is a protein that is present in the fetal m em branes. It
may be found in the vaginal secretions o f patients at risk of preterm
labour. U nfortunately a high false positive rate means this is not a good
diagnostic test for preterm labour. However, a negative value means it is
unlikely she will labour.

DIAGNOSIS
A prerequisite for diagnosing preterm labour is that uterine contractions
should last for at least 30 seconds and occur every 10 m inutes or less, for
at least 60 m inutes. By this criterion, the majority o f patients will stop
labour without specific treatm ent apart from bed rest. However, about 25
-50% o f patients with persistent, regular, painful contractions actually
proceed to preterm delivery. Pharm acological inhibition o f labour is
indicated in this latter group o f wom en, but is not justified in all
instances. Other diagnostic criteria include:
• The passage o f a show or operculum .
• A change in cervical findings on serial vaginal
exam inations.
• A change in cervical findings on serial transvaginal
ultrasound evaluations o f the cervix.
• Rupture of the m em branes. This may herald the onset of
labour.
• A positive fetal fibronectin test in the presence o f intact
m em branes. However, as m entioned above this is not a
particularly sensitive test.

M ANAGEM ENT
The patient in preterm labour should be adm itted to hospital for bed rest
preferably in the left-lateral position. Bed rest may have a mechanical
effect by reducing the pressure o f the presenting part on the lower
segment o f the uterus. There is the additional bonus o f an improvement
in uterine perfusion. This is known to allay the intensity and frequency
o f uterine contractions. These measures in conjunction with simple

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analgesia have been found to be effective in m any instances. If uterine

contractions continue, tocolytic therapy is indicated.

On adm ission, the following measures should be instituted:

intravenous access, vital signs, continuous cardiotocographic m onitoring,
full blood count, serum electrolytes, blood glucose and urinalysis. An
ultrasound exam ination is necessary to assess fetal num ber and
presentation, and the volum e o f am niotic fluid. Gestational age should
be ascertained and a speculum exam ination should be perform ed to
assess cervical dilatation and effacem ent. A high vaginal swab and the
fetal fibronectin test can be done at this time.

Most clinicians will treat preterm labour prior to 34 w eeks’

gestation, but approach the m anagem ent between 34 to 37 weeks on an
individual basis. M anagem ent can be considered under the following
headings:
• A ntenatal corticosteroid therapy.
• Tocolysis.
• A ntibiotic therapy.
• Cervical cerclage.

Antenatal corticosteroid therapy

The beneficial effect o f corticosteroids on fetal lung m aturity was first
reported in 1972. Data have since accum ulated that docum ent their
benefit in reducing the frequency o f intraventricular haem orrhage and
neonatal m ortality. C orticosteroids exert their effect on pulm onary
function by stim ulating the Type II pneum ocytes in the lung to produce
surfactant. Like all steroids, they are m em brane stabilizers and it is this
function that is responsible for reducing the incidence o f intraventricular
haemorrhage.
Long-acting parenteral corticosteroids such as B etam ethasone
and Dexam ethasone are used. They cross the placenta in biologically
active forms and have a half life o f up to 72 hours. The optim al
benefits begin 24 hours after initiation o f therapy and last fo r 7 days.
There is no scientific evidence to suggest that corticosteroid therapy
increases the risk o f either neonatal infection or adrenal suppression.
However, their use should be cautioned in the presence o f
chorioamnionitis.

The current UK recom m endations are fo r the adm inistration o f

corticosteroids to all women in preterm labour between 24 to 34 w eek s’
gestation. Betam ethasone may be given intram uscularly as two doses o f

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12 mg each, 24 hours apart. D exam ethasone may be given

intram uscularly as four doses o f 6 mg each, 12 hours apart.

Tocolysis
At present there is no evidence to suggest that long term tocolysis
im proves neonatal survival. In current practice the role o f tocolysis is to
allow for the adm inistration o f corticosteroids and in-utero transfer to a
unit with neonatal facilities.

U ndiagnosed bleeding from the genital tract is an absolute

contraindication to tocolytic therapy. This is because uterine relaxation
in the presence o f placental abruption may provoke catastrophic
haem orrhage with dire consequences for both m other and fetus. Relative
contraindications to tocolysis include:
• A cervical dilation o f greater than 4 cm . M ost drugs are
ineffective beyond this point.
• Intrauterine infection (chorioam nionitis) especially in the
presence o f ruptured m em branes.
• Fetal com prom ise. For exam ple, intrauterine grow th restriction,
fetal anom aly or intrauterine demise.
• M aternal m edical conditions that w arrant prom pt delivery such as
severe pre-eclam psia or eclam psia.
• R uptured m em branes. There is an increased risk of
chorioam nionitis when delivery is delayed and this im portant fact
should be considered against the advantage o f increasing
pulm onary m aturation.

A num ber o f pharm acotherapeutic agents have been used. They are
considered in alphabetic order.

Anti-prostaglandins
It is now well established that prostaglandins play an im portant role in
m ediating uterine contractions. They therefore may also be involved in
triggering prem ature labour. It is not surprising then that inhibition of
prostaglandin synthesis has been fo und to be effective in preventing the
onset and progression o f prem ature uterine contractions.

A nti-prostaglandins, such as Indom ethacin, interfere with the

m icrosom al enzym es collectively know n as prostaglandin synthetase.
Their efficacy in abolishing uterine contractions has been reported in
uncontrolled studies (Z uckerm an et al, 1974: Wiqvist et al, 1975) as well as

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in controlled studies (N iebyl et al, 1979) The dose o f Indom ethacin is 100
mg rectally follow ed by 25 m g orally every 6 hours. Despite prom ising
results, the use o f prostaglandin inhibitors d u ring p regnancy has been
questioned because o f their association with prem ature closure o f the
ductus arteriosus, pulm onary hypertension and h aem orrhagic diathesis in
the neonate.

Atosiban
Atosiban is an oxytocin receptor antagonist. It inhibits uterine activity
and is well tolerated. It is currently the drug o f choice in the U nited
K ingdom and this is largely due to its favourable side effect profile. It
has a short h alf life, is adm inistered intravenously and requires no
specific m onitoring. The main draw back is that the cost o f the d ru g can
be prohibitive.

Beta-adrenergic drugs
B eta-adrenergic receptors are situated on the o u ter surface o f the cell
m em brane in the m yom etrium . W hen they are stim ulated, for exam ple,
by a beta-adrenergic agonist, relaxation o f the uterus ensues. This
occurs because o f the release o f the enzym e adenylcyclase which
catalyses the conversion o f ATP to AM P. AM P then stim ulates the
activity o f a group o f enzym es which are responsible fo r protein
phosphorylation in the cell m em brane, the uptake and sequestration o f
intracellular calcium is increased, intracellular calcium levels fall and the
contractile state o f the m yom etrium is interfered with, resulting in
relaxation.

Isoxuprine (V asodilan) has been shown to be effective in

inhibiting prem ature labour. M ajor disadvantages are m aternal and fetal
tachycardia (due to beta 1 receptor stim ulation) and m aternal
hypotension (due to beta 2 receptor stim ulation). The drug is given as
an intravenous infusion o f 0.25 to 0.50 mg per m inutes for 12 hours,
followed by intram uscular injection o f 10 m g 4 to 6 hourly fo r 12 hours,
then orally, 10 m g 4 to 6 hourly until cessation o f uterine contractions,
or until the 37th week o f pregnancy.

Salbutam ol (V entolin) has a selective action on beta 2 receptors

on uterine m uscle and a success rate o f 90 percent has been achieved. It
is given as an intravenous infusion o f 5 m g in 500 ml D extrose-w ater at
first and once contractions have ceased, treatm ent is continued orally, 4
mg three times daily.

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Ritodrine hydrochloride, until recently, was the beta-adrenergic

receptor agonist o f choice in the U nited K ingdom . An intravenous
infusion o f 300 meg in 500 ml 5% D extrose-w ater is set up at a rate of
50 meg/min for 15 m inutes and titrated to the desired clinical response o f
uterine quiescence. If tocolysis is successful (less than 1 contraction
every 15 m inutes) the infusion is continued fo r 12-24 hours and then,
oral therapy is substituted. Its effectiveness is limited by a pernicious
side effect profile. O ther beta-m im etic agents used are O rciprenaline,
Terbutaline and Fenoterol.

Side effects of beta-adrenergic agonists include:

• M aternal and fetal tachycardia.
• M aternal hypotension.
• Pulm onary oedem a.
• Cardiac arrhythm ias and rarely, m yocardial ischaem ia.
• G lycogenolysis, hyperglycaem ia and increased plasm a insulin
levels.
• There is an intracellular shift o f potassium ions and a transient
hypokalaem ia.

C ontra-indications to the use o f beta-adrenergic agonists include:

• Severe pre-eclam psia
• Cardiac disease
• H yperthyroidism
• Diabetes mellitus
• A ntepartum haem orrhage
• M ultiple pregnancy

Calcium Channel Antagonists

Csapo and associates (1982) studied the action o f N icardipine on the
m yom etrium in rats. They reported a suppression o f myometrial
function which was not restored with oxytocin or prostaglandin F2 alpha.
A nother agent. N itrendipine, has been shown to have a sim ilar effect.

The calcium -channel blocker N ifedipine has been found to be a

potent uterine relaxant with a favourable side effect profile. It is
adm inistered orally. Sublingual adm inistration should be cautioned as
this may cause a profound hypotension which has im plications for
uteroplacental perfusion. A num ber o f studies indicate a m ajor role for
calcium blockers as tocolytic agents. N ifedipine is cost effective and has
an efficacy com parable to that o f Atosiban and R itodrine. Side-effects
are m aternal tachycardia and concom itant hypotension.

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Magnesium Sulphate
M agnesium sulphate exerts its tocolytic effect by interfering with
intracellular calcium form ation. The recom m ended regim e is an
infusion of 20 g M agnesium sulphate in 1 litre 5% D extrose-w ater at a
rate of 7 ml per minute for 1 hour, then 4 ml per m inute for 1 hour,
followed by 2 ml per m inute as a m aintenance dose for approxim ately 12
hours after cessation of uterine contractions. M agnesium sulphate has a
narrow therapeutic index and potential side-effects are m aternal
respiratory depression and cardiac arrest. It is also associated with fetal
academia and significant increases in neonatal m ortality when used in
preterm labour.

Progesterone
Progesterone depresses uterine contractility. It prom otes calcium uptake
by the sarcoplasmic reticulum . C onsequently, intracellular calcium levels
diminish. However, its use in the treatm ent of prem ature labour has been
found to be disappointing. Recently, 17 alpha-hydroxy-progesterone
caproate has been com bined with cortisol, and favourable results have
been reported.

Antibiotic therapy
Routine prophylactic antibiotics are not required in idiopathic preterm
labour in the absence o f m em brane rupture. However, if given after
membrane rupture, prophylactic antibiotics significantly increase the
number of women undelivered after seven days and reduces neonatal
and maternal infection and m orbidity. The Oracle Trial dem onstrated
that:
• E rythrom ycin is the drug o f choice prescribed at 250 mg orally
four times daily for 10 days.
• Co-am oxiclav (A ugm entin) should not be prescribed as it is
associated with an increased incidence of necrotising enterocolitis
in the newborn.

The presence o f chorioam nionitis or sepsis warrants delivery.

These patients should receive broad spectrum parenteral antibiotics such
as cefuroxime 750 mg and m etronidazole 500m g three tim es daily.
Treatment should be com m enced after a high vaginal swab and blood
cultures have been perform ed.

Screening for and treatm ent o f bacterial vaginosis and

asymptomatic bacteriuria does reduce the incidence o f preterm labour.

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Other organism s isolated on HVS or MSU may also need treating with
appropriate antibiotics.

G roup B streptococcus merits special attention. In m others who

are known to be carriers o f the organism , treatm ent intrapartum has been
shown to reduce the risk of early onset N eonatal G roup B Streptococcal
Disease. B enzylpenicillin or clarithrom ycin is given intravenously once
in established preterm labour. In PPROM , the recom m endation is the
same though the organism is sensitive to the routine prophylactic
erythrom ycin that is prescribed to all patients following m em brane
rupture.

C erclage
A small proportion o f patients benefit from elective cerclage perform ed
at the end o f the first trim ester. These are patients with cervical
incom petence which as m entioned previously accounts fo r less than 1%
o f all cases o f preterm labour. It m ay be p erform ed vaginally
(S hirodkhar or M cD o n ald ’s techniques) o r transabdom inally (Benson
and D urfee). Cerclage is not beneficial in cases o f preterm lab o u r due to
other causes such as infection, m ultiple pregnancy and polyhydram nios.

‘R escu e’ cerclage perfo rm ed after the onset o f lab o u r may

prolong intrauterine existence to the benefit o f the fetus. However, the
procedure itself may stimulate the process o f labour. Strict bed rest, the
deep T rendelenburg position and tocolysis may all be useful in the
im m ediate postoperative period.

Ruptured m em branes are an absolute contraindication to

cerclage.

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PRETERM PRELABPj JR RUPTURE OF MEMBRANES

INTRODUCTION
Prelabour rupture o f m em branes (PROM) may be defined as the rupture
o f m em branes prior to the onset o f uterine contractions, regardless o f the
gestation. On the other hand, preterm prelabour rupture o f m em branes
(PPROM) may be defined as the rupture o f m em branes prior to the onset
o f uterine contractions before 37 weeks gestation. It com plicates 30 % o f
all cases o f preterm labour.

The time from PROM to delivery is called the latent period. At

term, 8 out o f 10 patients labour spontaneously within the first 24 hours
of rupture o f m em branes. The more preterm the pregnancy the longer is
this latent period. This represents a window o f opportunity for
therapeutic intervention to improve the outcom e for the fetus. However,
it also represents an opportunity for maternal and fetal infection.

AETIOLOGY
The aetiology is similar to that for preterm labour and includes:
• Polyhydram nios.
• Cervical incom petence.
• M ultiple pregnancy.
• Sm oking.
• A deficiency o f copper and ascorbic acid.
• Epidem iological data suggest that sub-clinical infection may
cause an inflam m atory weakening o f the m em branes. There is a
link between recent coitus, histological chorioam nionitis and
PROM. This association becom es impressive when one considers
that the use o f a condom reduces this risk.
• It has been reported that the collagen content o f the am nion
norm ally decreases late in pregnancy. This change occurs at an
earlier gestation in patients with PPROM.

DIAGNOSIS
The patient may com plain of a gush of fluid from the vagina or a small
leak o f fluid or perineal dam pness. Vaginal exam inations should be
avoided. A sterile speculum exam ination can be perform ed to:
• Confirm that liquor is escaping from the cervical canal. A pool of
liquor may be seen in the posterior fornix.

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• Exclude cord prolapse or prolapse o f a fetal lim b.

• Take a swab for m icroscopy, culture and sensitivity.
• Take a sample to perform a fern test. A positive test is indicative
o f liquor.
• Take a sample and test the pH using N itrazine paper. The pH of
the vaginal secretions is 4 .5-6.0; whilst that o f am niotic fluid is
7.1-7.3.
The differential diagnosis would include:
• A vaginal discharge - either physiological or pathological.
• The operculum .
• Urine.
• Semen.

MANAGEMENT
The main principle of m anagem ent is to balance the m orbidity and
m ortality associated with a preterm birth against the risk o f m aternal and
fetal infection. The dilem m a o f leaving the fetus in utero to attain
additional m aturity m ust be balanced against prophylactic induction of
labour to avoid the danger o f fetal sepsis and chorioam nionitis
com pounding the com plications o f prem aturity.

The greatest risk to the fetus is respiratory distress syndrom e.

This is am plified at the extrem es o f viability (less than 24 weeks) by the
pulm onary hypoplasia that results from o lig ohydram nios.

In our setting, we aim for delivery at 35 w eeks’ gestation.

Provided the lie is longitudinal and there are no contraindications to a
vaginal delivery labour is induced with a syntocinon infusion. Caesarean
section is perform ed if an obstetric indication exists. The lower segment
o f the uterus is not form ed until 32 w eeks’ gestation and a lower
segm ent caesarean section can be a challenging affair. In some instances
a low vertical or a classical section is perform ed in preference to a lower
segm ent section as this allows fo r an atraum atic delivery.
Prior to 35 weeks the m anagem ent is conservative and includes:
• Adm ission to hospital.
• Bed rest.
• Pad chart to m onitor loss.
• Daily record o f tem perature and pulse.
• Full blood count and C-reactive protein. R epeated weekly.
• High vaginal swab. R epeated weekly.

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• U ltrasound scan to quantify the liquor volum e, evaluate fetal

growth and perform umbilical artery D oppler studies. W eekly
scans to evaluate liquor volum e and D opplers. Fortnightly scans
for growth.
• Daily or twice daily cardiotocography.
• Antenatal corticosteroids.
• Em pirical antibiotics. E rythrom ycin is the drug o f choice.
• The use of tocolytics is debatable and the decision should be
made by a senior obstetrician. The role o f tocolysis is to allow for
the adm inistration o f corticosteroids and in utero transfer. Once
this has occurred tocolysis is generally not necessary
• Consultation with neonatologist.

CONCLUSION
Preterm birth is the prim ary cause o f perinatal m orbidity and m ortality.
Complications such as respiratory distress syndrom e, intraventricular
haem orrhage and necrotizing enterocolitis are com m on in preterm
babies. The picture is further com plicated by PPROM. At present our
understanding of the pathogenesis o f preterm labour is deficient and this
has affected the developm ent o f specific therapeutic approaches. For
example, tocolytic therapy is usually initiated after the chain o f events in
uterine contractility is under way. Further research is required to predict
the onset o f preterm labour so that therapy can be instituted at an earlier
juncture.

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KEY POINTS
• Preterm labour may be defined as labour
occurring in pregnancies of less than 37 completed
weeks of am enorrhoea.
• The combination of preterm and low birthweight
(less than 1500 gram s) accounts for 75% of all
perinatal morbidity and mortality.
• A negative fetal fibronectin test means it is unlikely
that labour will ensue.
• The mainstay of management is admission to
hospital, bed rest, antenatal corticosteroids
±tocolysis.
• The main function of tocolytics is to allow for the
administration of antenatal corticosteroids and in-
utero transfer.
• Corticosteroids stimulate the production of
surfactant by the Type II pneumocytes in the lungs.
They reduce the incidence of respiratory distress
syndrom e.
• Cerclage may be beneficial in selected patients with
cervical incompetence.
• Prophylactic erythrom ycin, if given after
membrane rupture, improves outcom e.
• PPROM precedes 30% of all cases of preterm
labour. Aim to deliver patients with PPROM at 35
weeks following conservative m anagem ent,
provided there is no indication to deliver prior to
this.

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CHAPTER TWENTY-TWO

POST-TERM PREGNANCY

DEFINITION
A post-term pregnancy is defined as one that has reached o r gone
beyond 42 com pleted weeks o f gestation i.e. 294 days o r m ore from the
first day of the last m enstrual period. The term “ p o std ates” is confusing
and not well defined; it should be avoided. It can define a pregnancy that
has gone beyond the expected date o f delivery.

The term “ p o stm atu rity ” should be used to describe the

condition of the fetus at birth when delivery occurs at 42 weeks or later,
and the term “ postm ature sy n d ro m e ” describes a neonate who has
suffered the effects o f post-term .

INCIDENCE AND RISK FA C TO R S

The exact incidence is unknow n due to a high p ro p o rtio n o f o u r
population being unaware of the date o f their last m enstrual period as
well as horm onal abnorm alities that cause inconsistent ovulation. It is
estimated that about 10% o f pregnancies are post-term .
Associated risk factors include an error in dating, prim iparity,
previous post-term delivery, male fetus and rarely, fetal anencephaly.

EFFECTS OF POST-TERM PREG NANCY

Perinatal mortality
Perinatal m ortality is defined as the num ber o f neonatal deaths that occur
in the first week o f life, added to the num ber o f stillbirths. At 41 weeks,
there is no m ajor increase in perinatal m ortality. However, the perinatal
mortality rate at > 42 weeks is twice that at 40 weeks. In developed
countries, there are 4-7 deaths per 1000 births for post-term babies

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com pared to 2-3 deaths per 1000 births, for term babies. If the
pregnancy goes beyond 43 weeks, there is a six-fold increase in
m ortality.

Fetal morbidity
The incidence of fetal m acrosom ia is greater in the post-term
pregnancy. This translates to an increased risk o f the com plications o f
shoulder dystocia such as traum atic injuries to the viscera, skeletal
system, nerve palsies and hypoxem ic ischemic encephalopathy. Despite
this, there is no evidence to support routine induction o f labour as a
preventative measure.

The post-term infant often however exhibits physical signs of

intra-uterine m alnutrition, similar to that seen in chronic intra-uterine
growth restriction. These infants are labelled as “ p o stm a tu re ” or
“ d y sm a tu re ” . It is believed that this is because o f placental aging and
dysfunction. The infant may show tem perature instability, metabolic
instability and later, neurological dam age.

O ligohydram nios is a feature o f post-term pregnancies. The

liquor volume peaks at 37 weeks and reduces after this. There is a 33%
reduction in liquor volum e per week after the EDD.

The passage o f m econium in utero may result in m econium

aspiration. As the innervation o f the fetal gastrointestinal tract matures,
anoxia can result in hyperperistalsis and relaxation o f the anal sphincter.
M econium is rarely present in the am niotic fluid prior to 32 weeks. It
occurs in 10-15% o f term pregnancy but rises to 30% o f post-term
pregnancies. This com bined with a reduction in liquor volum e, results in
thick and viscous liquor. As the fetus breathes in utero, this can then plug
the smaller bronchioles resulting in the m econium aspiration syndrom e.
It is for this reason that the presence o f m econium in a post-term
pregnancy may be an indication for caesarean section, if vaginal delivery
is not im m inent.

M aternal effects of post-term pregnancy

The rates of induction o f labour and o f caesarean section are increased.
This results in an increased m aternal m orbidity especially if the
caesarean sections are perform ed as em ergencies.

Caesarean section rates are doubled if induction o f labour is

perform ed after 42 weeks, but is the same if induction o f labour is
undertaken at 41 weeks. O ther effects on the m other include a higher

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degree o f perineal traum a if the fetus is m acrosom ic and an increase in

anxiety and psychological stress. M ore intensive m onitoring and
hospitalisation are usually required for the post-term m other.

D IAGNOSIS
The key to diagnosis obviously lies with an accurate recall o f the last
menstrual period and early diagnosis o f pregnancy. Far too often in o u r
setting, this inform ation is not available.

If the patient attends the antenatal clinic in the first trim ester, an
ultrasound can be perform ed to determ ine the crow n-rum p length. In the
second trim ester, the biparietal diam eter and the fem ur length are used
(Table 1).

Table 1. Clinical parameters used in assessing the gestational

age.

Calculate the EDD by adding 7 days and 9 months to the first

day of the last menstrual period (N a eg ele’s rule). Adjust for
variations in cycle length.
Fetal movements are first felt (quickening)
At 18-20 weeks in the prim igravida
At 16-18 weeks in the m ultigravida.
Pelvic exam ination in the first trimester.
The fetal heart tones can be first detected by Doppler at 12-14
weeks.
The fetal heart tones are heard by stethoscope at 18-20 weeks.
At 20 weeks, the symphisio-fundal height is at the level o f the
umbilicus.
Ultrasound in the first trimester, to measure the crown-rum p
length, has a m argin of error o f ± 5 days.
Ultrasound in the later trimesters to m easure the biparietal
diameter and femur length. In the second trimester, the accuracy
is ± 7 to 10 days. In the third trimester, this error increases to ±
21 days.

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MANAGEMENT
At 41 weeks, as previously stated, induction o f labour should be
considered. There is evidence that there will be a reduction in fetal
m ortality and m aternal m orbidity, when com pared to induction o f labour
at 42 weeks. This is especially so if the cervix is favourable.

If the cervix is unfavourable, the options include cervical ripening

or continued fetal surveillance. V arious tests are used, but there is a wide
range of sensitivity and specificity in determ ining fetal well being. These
tests are covered in m ore detail in chapter 17.
• Fetal m ovem ent m onitoring.
• N on-stress test.
• O xytocin stress test (rarely used).
• A m niotic fluid index (A FI).
• A biophysical profile.
• Placental grading.
• Umbilical and m iddle cerebral artery D oppler studies.

N on-stress testing and ultrasound fo r o ligohydram nios are

prim arily recom m ended. G enerally, tests are repeated 2-3 times per
week. The fetus should be delivered if the tests are abnorm al. Expectant
m anagem ent usually occurs until the cervix is favourable or the patients
reach 42 weeks. If there is a significant degree o f uncertainty o f the
gestational age, one may opt to go beyond this time provided the fetal
tests are norm al.

All patients with post-term pregnancies should have continuous fetal

m onitoring in labour. The fetus is at higher risk o f developing fetal
distress either from placental insufficiency o r from cord com pression.

Some o f the disadvantages o f em ploying routine induction o f labour for

all post-term pregnancies are:
• M iscalculation o f dates resulting in a preterm delivery.
• Failure of induction.
• Prolonged labour.
• Increased m aternal and fetal m orbidity.

The postmature fetus

This is a condition o f the fetus characterized by a long and lean body,
fragile and withered, alert facial expression, abundant hair growth, long
fingernails and parchm ent-like skin. The skin o f some fetuses is loose

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and stained with m econium . Others may have a peeling, icteric and dry
skin (Figure 1).

Figure 1. The post-term b a b y ________________________ _

After a few days, there may be extensive peeling and cracking.

The baby is wakeful and his primitive responses are lively. If however
there is neurological disturbance, the baby may be jittery and overactive.
The infant with m econium aspiration syndrom e has marked
respiratory difficulty with an increased respiratory rate and appears pale.
Aspiration o f m econium produces m echanical obstruction o f the airways
and a chemical inflam m atory response. M econium also, has been shown
to inactivate surfactant. Complete obstruction causes atelectasis, whereas
ball-valve obstruction may produce a pneum othorax. N eonatal death can
occur because o f respiratory em barrassm ent.

If the liquor is m econium stained, treatm ent will begin during

delivery. As soon as the baby's head comes out, the midwife or doctor
will suction out any m econium from the nose and m outh before the
baby takes a first breath. This however has not been conclusively shown
to reduce aspiration as the event may occur in utero. The neonatologist
may also pass a laryngoscope and undertake suctioning o f the trachea in
selected cases. This may help prevent the baby from inhaling any more
meconium. Positive pressure ventilation is avoided until after suctioning
has occurred.

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 PO S T -T E R M

Babies with MAS may be sent to the neonatal intensive care unit
to be closely m onitored. Treatm ents may include:
• oxygen therapy by oxygen hood or ventilation
• antibiotics
• use of surfactant
• nitric oxide blood gases

Figure 2. Radiograph showing diffuse chemical pneumonitis.

Babies who have severe aspiration and require mechanical

ventilation are at increased risk for bronchopulm onary dysplasia, a lung
condition that can be treated with m edication or oxygen. A
pneumothorax is treated by reinflating the lung (inserting a chest tube,
and allowing the lung to gradually re-expand).

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 PO ST -T E R M

K E Y P O IN T S

• Postterm and postdates are not

synonym ous.
• Postterm refers to a pregnancy that has
gone beyond 42 weeks.
• There are maternal and fetal
complications associated with the
postterm pregnancy.
• Induction of labour should be
considered after 41 weeks.

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CHAPTER TWENTY-THREE

INDUCTION OF LABOUR

DEFINITION
Labour is the process whereby the products o f conception are expelled
after the 28th week of pregnancy through the vaginal route by rhythmic
contractions of the uterus. In the United K ingdom , 24 weeks is used to
define a viable pregnancy. The goal o f induction o f labour is therefore
to achieve a vaginal delivery by stimulating uterine contractions before
the spontaneous onset o f labour.

A ugm entation o f labour differs from induction. It is the process

o f accelerating the progress o f labour.

INDICATIONS
In m odern obstetric practice, induction o f labour is generally undertaken
if the fetal in utero environm ent is deemed to be “ h o s tile ” and there is
no contra-indication to vaginal delivery. One must rem em ber that there
are three options at this time: allow the pregnancy to continue, induce
labour or perform a caesarean section.
The most com m on indications for induction o f labour are:

• Post-term pregnancy. This is probably the com m onest reason for

induction o f labour. There are increases in both maternal and fetal
com plications if the pregnancy goes beyond 41 weeks.
• Hypertensive disorders o f pregnancy. Frequently induction of labour
is necessary for worsening of hypertension and in order to prevent
maternal and fetal com plications.
• Diabetes Mellitus. Induction is usually perform ed at 38 weeks in
order to reduce stillbirths.
 IN D U C T IO N O F L A B O U R

• Prelabour rupture o f m em branes (PROM) and preterm prelabour

rupture o f m em branes (PPROM). Induction o f labour is undertaken
to reduce the risk o f ascending infection.
• Fetal m acrosom ia. Induction o f labour may reduce the risks
associated with fetal m acrosom ia especially in diabetic pregnancies.
• Placental abruption. Induction can be perform ed if there is no fetal
distress and there is no m ajor haem orrhage.
• Rhesus isoim m unization. C ontinued intrauterine haem olysis o f fetal
red blood cells may require early delivery.
• Sickle-cell disease. Intra-uterine growth restriction and stillbirths can
occur.
• Social reasons. Inductions are sometimes perform ed in patients with a
previous precipitate delivery or for psychological concerns.
• Intra-uterine demise and gross fetal anom alies e.g. anencephalus.
• Intra-uterine growth restriction. Caesarean section may be preferred
if there is severe grow th restriction or abnorm al fetal heart tracings.

CONTRAINDICATIONS
Generally, these are contraindications to vaginal delivery and include:
• A m ajor placenta praevia or a vasa praevia
• A bnorm al fetal lie
• Umbilical cord prolapse
• Previous transfundal uterine surgery
• Cephalo-pelvic disproportion

Other clinical situations are not contraindications but necessitate special

attention, these include:
• Previous lower segm ent caesarean section. There is a two­
threefold increased risk of uterine rupture when cervical prim ing
agents are used as well as when Syntocinon is adm inistered,
com pared to when labour occurs spontaneously in this group.
• G rand m ultiparity. The uterus in these patients may respond
erratically to stim ulation by prostaglandins and Syntocinon.
• Previous surgery on the cervix or m ajor perineal laceration
repair.
• Polyhydram nios.
• A high presenting part. There is an increased risk o f cord
prolapse.
• M ultifetal pregnancy.

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 IN D U C T IO N O F L A B O U R

• M aternal cardiac disease. There is a risk o f fluid overload and

infection.
• Breech presentation. C urrent data supports the use o f caesarean
section as the preferred m ode o f delivery.

PREPARING THE PATIENT

Before induction o f labour is em barked upon, there must be an
indication present. The obstetrician must be convinced that the time o f
delivery is optim al, to the extent that if the induction o f labour fails, a
caesarean section will be the result.

A ccurate dating is im portant to avoid iatrogenic prem aturity.

M ethods to confirm a term gestation have already been described, but
the following are useful to rem em ber:
• Fetal heart tones have been docum ented fo r 20 weeks by non
electronic fetal stethoscope or fo r 30 weeks by D oppler.
• >36 weeks since a positive serum or urine BhCG.
• An ultrasound was perform ed prior to 20 weeks and agrees with the
gestational age.

The patient should be counselled on the reasons fo r induction of

labour and the m ethods to be em ployed to achieve the delivery.

Care during induction of labour

For uncom plicated cases, the induction can com m ence on the antenatal
ward. For women with recognized concerns such as a previous caesarean
section, high parity and fetal growth restriction, it is recom m ended that
early transfer to the labour ward be perform ed.

It is good practice to perform a non stress test just prior to use of

a prim ing agent and to continue fetal m onitoring when contractions
com m ence. Once the fetal heart tracing is norm al, intermittent
m onitoring can be undertaken. If an oxytocin infusion is also used, then
continuous m onitoring is recom m ended.

CERVICAL RIPENING
The m odified Bishop scoring system is generally used to determ ine the
cervix that is unprepared and requires a prim ing agent, as well as the
cervix in which this process has already occurred (Table 1).

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 IN D U C T IO N O F L A B O U R

There is a direct correlation between the success or failure o f

induction of labour and the cervical score. A score o f less than 6 is
regarded as being unfavourable. Cervical prim ing is therefore indicated
in these cases.

Table 1. Modified ‘Bishop' score

Score 0 1 2 3
Cervical 0 1-2 3-4 >5
Dilatation
(cm)

Cervical 3 2 1 <1
Length
(cm)

Station -3 -2 -1 ,0 +1

Consistency firm medium soft

Position posterior mid anterior

Membrane sweeping
If the internal os can adm it a finger, the separation of the fetal
m em branes from the lower uterus has been shown to reduce the num ber
of women that will need form al induction o f labour. Prostaglandins are
released by this process.

The m other m ust be advised that the process could be painful and
cause the release o f the operculum (show) resulting in a bloodstained
vaginal loss. There is no increased risk of infection.
Priming agents
An ideal prim ing agent should fulfill the following criteria:
• It must be safe and practical.
• It should not cause m ajor fetal or m aternal effects.
• It must be econom ical.
A variety of m ethods has been used but prostaglandins are the mainstay
of induction o f labour with an unfavourable cervix.

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Prostaglandins
Prostaglandin E2 (PGE2) and synthetic prostaglandin E, (PGE,)
preparations are available. Two PGE2 dinoprostone preparations are
com m only available. A gel containing 1-2 mg and a vaginal pessary
containing 3mg (Prostin® ), or Cervidil®, a slow-release 10 mg
preparation (Figure 1).

M isoprostol, a synthetic PGE, analogue can be administered

intravaginally, sublingually or orally (25 m icrogram 4-6 hourly). It is
not licensed for this use but is associated with fewer undelivered patients
after 24 h versus dinoprostone. Areas o f concern relate to a higher
incidence of uterine hyperstim ulation, m econium -stained liquor,
precipitate labour, uterine rupture and postpartum haem orrhage. It is not
recom m ended in patients with previous uterine surgery. Potential
advantages over dinoprostone include that it does not need refrigeration
and it is far less expensive.

Figure 1. Cervidil® 10 mg pessary

The vaginal route is preferred

over the intracervical route when
adm inistering dinoprostone. We use a 3
mg pessary that can be repeated 6-8
hours later (m axim um o f 6 mg). The
pessary is inserted in the posterior fornix
and the patient is asked to remain supine
for 30 m inutes.

O xytocin is only com m enced if m ore than six hours have passed
since the insertion of dinoprostone to reduce the risk of
hyperstim ulation.

Possible side effects include uterine hyperstim ulation, uterine

rupture, vomiting, diarrhoea and mild pyrexia. If hyperstimulation
occurs, the pessary must be rem oved and a tocolytic agent is
administered.

M echanical
These are rarely em ployed in our setting. Exam ples include hygroscopic
dilators, osmotic dilators ( L a m i n a r i a j a p o n i c u m ) (Figure 2), the 24-
French Foley Balloon and the double balloon device (Atad Ripener
Device).

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 IN D U C T IO N O F L A B O U R

Figure 2. Lam inaria, before and after expansion

Other M ethods
These include continuous intravenous oxytocin, extra-am niotic saline,
vaginal recom binant hum an relaxin and intracervical purified porcine
relaxin. These are rarely used except for intravenous oxytocin, which is
sometimes used in cases of prelabour rupture o f m em branes with an
unfavourable cervix.
Sexual intercourse, breast stimulation, oestrogens, enemas, warm
baths, steroids, hyaluronidase, acupuncture, m ifepristone and
homeopathic m ethods have not been shown to be as effective as
prostaglandins.

A M N IO T O M Y
Artificial rupture of m em branes may be used as a m ethod o f labour
induction or may be perform ed after the cervix has becom e favourable,
following adm inistration of the prim ing agent. The tim ing of
contractions following am niotom y is very variable and it is
recommended that an oxytocic infusion be com m enced at the same time.

We perform am niotom y with an A m nihook® or a K ocher

forceps (Figure 3). Potential com plications of am niotom y include
prolapse of the cord or a lim b, chorioam niotis, umbilical cord
compression, and rupture o f vasa praevia. A m niotom y is not
recommended in cases with HIV or active Herpes Simplex Virus
infection. It is good practice to assess the fetal heart tones pre-and post-
amniotomy.

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Figure 3. Amnihook and Kocher Forceps

OXYTOCIN INFUSION
Following preparation o f the cervix and am niotom y, the next phase in
the induction of labour process is the use o f a
Syntocinon® infusion. In general, the myometrium
o f the m ultiparous patient is more sensitive to the
effects of oxytocin than in prim igravidae.

The safest way to infuse Syntocinon is by

either an infusion pum p or a syringe-driver pump.
The traditional gravity-infusions are unsafe as there
are num erous problem s with the infusion rates and
hence safety.

To reduce error, a standard dilution should

always be used in the infusion pum p. Suggested
standardized dilutions and dose regim ens include:

• 30 iu in 500 ml o f norm al saline; hence lm l/hr =

1miu/min
• 10 iu in 500 ml o f norm al saline; hence 3ml/hr =
1miu/min

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When induction of labour is undertaken with oxytocin, the

recom m ended regim en is:

• a starting dose o f 1 -2 miu/min

• increased at intervals of 30 m inutes or more.

The m inim um dose possible of oxytocin should be used and this should
be titrated against uterine contractions aiming for a m axim um of three to
four contractions every ten minutes. A dequate contractions may be
established at 12 milliunits per m inute. If higher doses are used the
m axim um dose used should not exceed 32 m illiunits per m inute.

HAZARDS
1. Iatrogenic preterm delivery. This can occur if there is an erro r in
the calculation o f the expected date o f delivery.
2. Fetal distress. U tero-placental insufficiency may occur due to
frequent and intense contractions not allowing time for recovery
o f blood flow.
3. C horioam nionitis. The duration o f rupture of m em branes is
related to the incidence o f ascending infection.
4. U nusual uterine activity:
• H ypertonicity- contractions>90 seconds
• Tachysystole- >5 contractions per 10 minutes
• H yperstim ulation- exaggerated uterine response with late
decelerations.
The oxytocic infusion must be stopped if this occurs.
5. Uterine rupture. Caution should be exercised especially when
used in parous women and those with previous uterine surgery.
6. Precipitate labour.
7. Fluid overload. This can occur especially if doses of more than
40 iu are used per day in isotonic intravenous solutions.
8. Failure of induction and increase in caesarean section rates.
9. Neonatal hyperbilirubinem ia. The m echanism is by oedem a o f
fetal red blood cells that are easily destroyed in the neonatal
period.

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KEY POINTS

• Induction o f labour is the artificial

stimulation o f contractions in order to
achieve a vaginal delivery
• There are m aternal and fetal indications
for induction o f labour
• Priming o f an unfavourable cervix can
be done with m echanical and chem ical
methods but prostaglandins are the
com m onest used.
• Syntocinon is best administered via a
controlled infusion
• There are risks associated with
hyperstimulation o f labour

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CHAPTER TWENTY FOUR

OPERATIVE DELIVERY

INTRODUCTION
For the purpose of this chapter the term ‘Operative D elivery' is used to
encompass caesarean section, forceps delivery and vacuum extraction. A
significant proportion o f all deliveries involve operative intervention. In
general, countries with higher operative delivery rates have better
perinatal and maternal m orbidity and m ortality. However, a m ultitude of
factors impact directly on these measures and a favourable outcom e
cannot be solely attributed to intervention.

The World Health Organisation in their search for an optim um

level of intervention recom m ends a rate o f 10-15% for caesarean section.
This in itself is an arbitrary figure and not applicable globally. The
more im portant issue is to ensure that the appropriate intervention is
offered to the parturient at the appropriate time. In other words, the
prime objective remains the welfare o f m other and baby and all decisions
for intervention should be tailored to the individual circum stance.

CAESAREAN SECTION
HISTORICAL BACK GROUND
The origin o f the term ‘caesarean' is obscure, but three main
explanations have been suggested. Firstly, according to legend, Julius
Caesar was delivered in this m anner. This is unlikely because as late as
the 17th century, this operation was invariably fatal. Secondly, in Roman
law, Numa Pompilius (8th century BC) ordered that the procedure be
undertaken in dying women so that the m other and infant could be
buried separately. This law, Tex reg ia’, was eventually renam ed Tex
caesarea’ and the operation itself may have later becom e known as the
caesarean operation. Thirdly, sometime in the M iddle Ages, the word

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caesarean was derived from the Latin verb ‘cae d e re ’ (to cut).
Interestingly, the word section is derived from the word ‘s e c o ’ which
also means to cut.
Caesarean delivery was first recom m ended in the living in the
celebrated work o f Francois Rouseet (1581) entitled kTraite N ouveau de
l ’H ysterotom otokie ou L ’Enfantem ent C esarien’ when he reported on 14
successful caesarean deliveries. O f interest, he had never him self
witnessed such a delivery, but his inform ation was collated from
correspondence with friends. A turning point in the alm ost universal
mortality from this operation was achieved by Max Sanger in 1882, when
he recom m ended the suturing o f the uterine incision. This had long
been neglected because o f the false belief that sutures in the uterine
muscle would be harm ful.
Over the years, the operative technique has been refined to reduce
the attendant m orbidity and m ortality. Im portant contributions to the
safety of the procedure have been made by:
• Antibiotic prophylaxis
• Blood transfusion.
• General and regional anaesthesia.
• Lower segm ent deliveries.
• T hrom boprophylaxis.

INCIDENCE
There has been a worldwide trend o f increasing caesarean section rates
over the past few decades. This surge in rates is even m ore alarm ing in
m etropolitan countries where in the United States for exam ple, the rates
have risen from 5.5% in 1970 to 22% in 1994. In the U nited K ingdom ,
the figure rose from 3.1 to 7.5% from 1963 to 1978 and from 11.3% in
1990 to 15.5% in 1995. The incidence currently hovers around 25%.
Figures reported from Trinidad were 2.2% in 1976, 6.6% in 1985 and
9.3% in 1996. Possible explanations for this trend include:-

• M edical m alpractice litigation.

• Reduced family size and at a later m aternal age - the so-called
‘precious p re g n a n cy ’
• Electronic fetal m onitoring.
• A reduction in the use o f rotational forceps fo r mid-cavity
vaginal deliveries, and the consequent lack o f O bstetricians with
the necessary skill to perform these types o f deliveries.
• Socio-econom ic and dem ographic factors, e.g., short stature.
• Reluctance to allow vaginal breech delivery.

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The health implications and econom ic costs associated with burgeoning

caesarean section rates make it crucial that policies are im plem ented to
address this trend. The following represent potential strategies:-

• A policy of vaginal birth after one caesarean section should be

actively encouraged.
• Consideration should be given to vaginal birth after two caesarean
sections in carefully selected cases.
• Intrapartum , recourse should be made to fetal blood sam pling in
the presence o f abnorm al cardiotocographic m onitoring. This
has been shown to reduce caesarean section rates.
• There should be involvement o f senior obstetric staff in the
decision making process, especially in the prim igravidae.
• External cephalic version should be offered to m others with a
breech presentation after 36 weeks.
• Routine induction o f labour should be offered after 41 weeks and
not prior to this unless a sound indication exists.

URGENCY
A num ber of classifications exist that define abdom inal delivery
further based on the urgency with which delivery is required. Below is
the one in current use in the United K ingdom .

Classification of urgency of Caesarean section.

GRADE DEFINITION
1) Emergency Immediate threat to life of woman or fetus

2) Urgent M aternal or fetal com prom ise, not immediately life

threatening.
3) Scheduled Needing early delivery but no maternal or fetal
com prom ise.
4) Elective At a time to suit the woman and maternity
team.

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INDICATIONS
There are num erous indications for caesarean section delivery but very
few can be considered absolute. The majority o f those listed are relative
indications and it is often a com bination o f factors that guide the
ultimate decision. In this chapter, for sim plicity, we have adopted an
anatomical classification that describes the indications as either maternal
or fetoplacental. We have then discussed failure to progress in labour or
cephalopelvic disproportion separately as this is one of the more
frequent indications and warrants special consideration.

Maternal indications
• Pelvic tum ours. Fibroids in the lower segment and large ovarian
cysts may obstruct labour.
• After m yom ectom y, if the uterine cavity had been entered or
multiple incisions were em ployed.
• Previous caesarean section for a recurrent indication.
• Previous classical caesarean section.
• After vaginal repair operations for bladder descent or stress
incontinence.
• Gross pelvic contraction. This is uncom m on, but can be a result
of nutritional deficiency, trauma and rare inherited disorders.
The patient with sickle cell disease can develop pelvic contracture
as a result of multiple bony infarcts.
• Significant maternal illness where an unfavourable cervix would
imply a long induction to delivery interval. This would include
eclampsia, im pending eclampsia and severe cardiac or respiratory
disease.
• Previous traumatic vaginal delivery which resulted in birth trauma
to the infant, third and fourth degree perineal tears or vaginal
fistula form ation.
• To reduce the vertical transmission o f infections such as human
im m unodeficiency virus in m others with a high viral load, and
prim ary genital herpes that is active in the third trimester.
• M aternal request. Caesarean section is not routinely offered for
maternal request but it can be justified in exceptional
circumstances. It is imperative to explore and discuss the specific
reasons for the request and ensure that the patient is fully
inform ed of the benefits and the risks associated with abdominal
delivery including the implications for subsequent pregnancies.
Consideration should be given to referral for a second opinion
and counselling.

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Fetoplacental indications
• Presumed fetal distress:
a) In certain cases, m econium -stained liquor may suggest
fetal distress.
b) C ardiotocographic abnorm alities.
c) A bnorm al scalp blood pH.
d) Severe intra-uterine growth restriction.
• A bnorm al presentation/lie:
a) Oblique lie.
b) Transverse lie.
c) C om pound presentation.
d) Brow/face presentation.
e) Breech (large, prem ature, footling, extended head)
• Fetal m acrosom ia.
• M ultiple pregnancy. When the first twin is non-vertex; if the
first twin has delivered and there is fetal distress in the second
with the cervix not fully dilated; triplets and higher order
multiple gestation.
• Gross fetal anom aly such as hydrocephaly.
• Placenta praevia.
• A bruptio placentae, especially if the cervix is unfavourable,
the bleeding is heavy or there is fetal distress.
• Cord prolapse o r cord presentation.
• Vasa praevia.

Failure to progress in labour

Failure to progress in labour or cephalo-pelvic disproportion (CPD) is
probably the most com m only cited reason for caesarean section delivery.
However, true pelvic disproportion is uncom m on. A lthough X-ray
pelvimetry has been used to predict obstetric outcom e, there is
considerable variation in practice and its use has been criticised. In
addition, the use o f com puterised tom ography and m agnetic resonance
imaging has been advocated as there is a reduction in exposure to
ionising radiation with a significant im provem ent in image quality. On
the whole pelvimetry has a poor predictive value when it com es to
assessing the likelihood o f a vaginal delivery after a caesarean section
and should only be used in selected cases.
A caesarean section for failure to progress in a prim igravida
should only be considered after an am niotom y has been perform ed and
there are adequate contractions (+/- a Syntocinon infusion). This is
provided there are no other indications as previously stated, there is

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appropriate intrapartum fetal m aternal surveillance and all facilities are in

place if a caesarean delivery is needed.

PRO CEDURE
Preparation o f the patient
For elective procedures, the m other is adm itted the day prior to surgery.
Inform ed written consent is obtained and she is reviewed by the
anaesthetist who discusses the planned anaesthesia (general, spinal or
epidural). If she has requested sterilisation at the time o f surgery she
should be advised that:
• There is a small failure rate o f 1:250. The failure rate is higher if
the procedure is perform ed at the time o f caesarean section as
opposed to as an interval procedure.
• There is a risk o f ectopic gestation in the event o f failure.
• That the procedure should be considered irreversible.
• There are alternatives such as the L evonorgestrel intrauterine
system and vasectomy which have significantly sm aller failure
rates (1:500 and 1:1000 respectively).

Blood is taken for a full blood count and 2 units o f whole blood are
cross-m atched. Oral ranitidine can be adm inistered on the evening prior
to surgery and oral intake restricted from m idnight. On the m orning of
surgery, she receives a gentle non-abrasive shave o f the pubic hair and an
indwelling Foley catheter is inserted for continuous bladder drainage. If
a neonatal problem is anticipated, the case is discussed with the
neonatologist whose presence may be required at delivery.

Pre-m edication on call to theatre

• Ranitidine hydrochloride 50 mg IM/IV.
• An oral antacid e.g.. Sodium Citrate 30 ml.
O pioid analgesics, such as Pethidine, are contra-indicated as pre­
m edication as they cross the placenta and can cause p ro fo u n d neonatal
respiratory depression at delivery. A tropine was given previously as an
anti-sialogogue but it is no longer routinely adm inistered.

O perative procedure
The skin incision
There are two types o f incision that may be em ployed:
• The vertical incision:
The advantages o f this approach are that it allows very rapid entry
into the abdom inal cavity: the incision is easy to extend to allow

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greater exposure o f the abdom inal contents if required; easier to

perform a classical section; easier to perform a caesarean
hysterectom y if necessary. The main disadvantages are a greater
incidence of dehiscence and a less cosmetically acceptable scar.

• The suprapubic incision (Pfannenstiel, Cohen):

The advantages are that it is more cosmetically acceptable and
there is less risk o f an incisional hernia. The main disadvantages
are that it takes more time to perform ; surgical exposure can be
difficult in certain women and it is not as easy to extend if greater
access is required; there is an increased incidence o f wound
haem atom a form ation.

The uterine incision

Several uterine incisions have been perform ed, such as the vertical upper
segment (classical), the vertical lower segment (De Lee), the transverse
lower segment (LSCS) and a variety of m odified lower segment extended
incisions which are named for the shape on the uterus (J, Inverted T, C,
etc). The two com m onest types, the classical and the lower segm ent, will
be discussed.

The Classical Caesarean section

After the abdom en is opened in layers, a vertical incision is made in the
anterior upper uterine segm ent. There are disadvantages to this type o f
incision:
• Increased haem orrhage.
• Weaker uterine scar and greater risk o f rupture in a subsequent
pregnancy, which can occur during the antenatal period. The
risk of rupture is 12%.
• Difficult surgical re-approxim ation of the uterine incision.
• Increased m orbidity e.g., puerperal infections, longer
hospitalisation, greater need for blood transfusion.

There are only a few indications for this type o f incision in present
day practice. These include:
• Lack o f access to the lower segment which may occur as a result
o f fibroids, dense adhesions from previous pelvic surgery, and the
lower segment of the preterm uterus may not be wide enough to
allow atraumatic delivery.
• Postmortem, to save a live fetus.
• Transverse lie (dorso-inferior).
• At an elective caesarean-hysterectom y.

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• In major placenta praevia (relative indication).

The Lower Segment Caesarean section

After the abdom en is opened in layers, a large m oistened abdom inal
pack is placed in each para-colic gutter to prevent soiling o f the
abdom inal contents by amniotic fluid, blood or m econium . The lower
segm ent is identified by the loose fold o f the peritoneum superior to the
bladder (the utero-vesical fold). This is grasped with a non-toothed
dissecting forceps and a transverse incision is m ade. The b lad d er is then
reflected o ff the lower segm ent in a caudal direction. A D oyen bladder
retractor is inserted to protect the bladder and expose the lower segm ent.
A transverse incision is made with the scalpel and the am niotic
m em branes are exposed. The m em branes are then ru p tu red and the
fetus is delivered with the aid o f uterine fundal pressure and som etim es
obstetric forceps.

To aid in placental separation and to reduce blood loss, the

anaesthetist usually adm inisters an am poule o f Syntom etrine or
Syntocinon intravenously as soon as the cord is clam ped. An infusion
can also be com m enced containing 40 units o f Syntocinon in 1 litre of
5% norm al saline and titrated to keep the uterus contracted. The placenta
is delivered by controlled cord traction and the uterine cavity is explored
with a large swab to remove any additional m em branes. The presence of
any subm ucosal fibroids or M ullerian duct abnorm alities can also be
detected at this time.

G reen-A rm ytage clamps are then applied to the lateral angles and
the edges o f the lower segm ent incision. These clam ps are particularly
suited for this purpose because they are atraum atic and have a broad
base providing a wide surface area for haem ostasis. The incision is closed
in two layers. The first is the haemostatic layer while the second layer
covers the raw edges o f the first adding tensile strength to the incision.
The visceral and abdom inal peritoneum are repaired after the pelvic
structures are inspected and the abdom inal incision is closed in layers.

The vagina is then swabbed to rem ove any clots. This is an

im portant step as any subsequent post-operative bleeding can be quickly
identified. The urine in the collecting tubing is inspected to ensure that
it is clear.

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Postoperative care
First 24 hours
• Vital signs every 15 minutes for the first hour, every ho u r for the
next four hours and then every fo u r hours for the next 24 hours.
• 3 litres o f intravenous fluids such as norm al saline or
H artm ann’s.
• Input-output charting. The Foley catheter is left on continuous
drainage for 24 hours.
• Analgesia such as Pethidine, 100 mg i.m. every 4 hours for 6
doses.
• Anti-emetics such as D im enhydrinate 50 mg i.m. for 2-3 doses.
• Intravenous broad-spectrum antibiotics are recom m ended as a
single dose as soon as the cord is clam ped to reduce sepsis.

Days 1-3
The operative findings and procedure are explained to the patient. The
records are checked for the vital signs and the input-output chart. A
general exam ination is perform ed with particular em phasis on the
presence o f bowel sounds and signs o f throm boem bolic disease.

Sips o f clear fluids are started and if tolerated, the intravenous

line can be discontinued. Physiotherapy and gentle am bulation are
com m enced. The Foley catheter is removed on Day 1. Oral analgesia is
started and oral antibiotics can be prescribed if necessary. Breastfeeding
is encouraged and the indirect C oom bs test is perform ed if she is rhesus
negative.

The haem oglobin is checked on Day 2 and a soft diet

com m enced. A norm al diet is started on the third day. The passage o f
flatus is indicative of peristaltic activity and may herald an im m inent
bowel m otion. M otility stimulants such as Dulcolax rectal suppositories
can be adm inistered to aid the process. The dressing is changed and
once she has sufficient family support at hom e she is discharged. N o n ­
absorbable skin sutures and staples are rem oved on day seven. An
appointm ent is made for postnatal follow up. This is an ideal opportunity
to review the indications and procedure, offer advice on contraception
and advise early antenatal care in a subsequent pregnancy.

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COMPLICATIONS
C om plications occur more com m only when the procedure is done as an
em ergency rather than as an elective.
• Anaesthetic com plications will be discussed in m ore detail in the
following chapter. They are increased when general anaesthesia
is used in preference to regional anaesthesia. With general
anaesthesia, M endelson’s syndrom e is the m ost im portant
com plication. This can be reduced by the use o f cricoid pressure
at induction and reducing the pH o f the stomach contents. If it
occurs there is a high m aternal m ortality. Com plications
associated with regional anaesthesia include hypotension,
hypotherm ia, tem porary peripheral nerve dam age and headaches.
• H aem orrhage is the m ost com m on com plication. The gravid
uterus is a vascular organ with a blood flow through the uterine
vessels at term o f 400 to 800 ml/min. Hence the need to ensure
that pre-operatively, the m other is not anaem ic and crossm atched
blood is available. R eactionary haem orrhage can o ccur as a
result of slipped ligatures or oozing from the edges o f the uterine
incision when the blood pressure rises. Secondary haem orrhage
may present 1-2 weeks following the surgery as a result o f post­
operative endom etritis.
• Traum a. The bowel, bladder and the uterus are particularly at
risk. Occasionally the fetus may be at risk o f scalpel injury on
m aking the uterine incision.
• Sepsis. Peritonitis can occur, especially in the presence of
chorioam nionitis. Superficial infections occur frequently,
especially with the Pfannenstiel incision which is prone to
haem atom a collection.
• T hrom boem bolism is responsible fo r a significant contribution to
m aternal m ortality. The use o f intra-operative pneum atic calf
com pression devices, early post-operative am bulation, calf
com pression stockings and low m olecular weight heparin is
advocated.
• Paralytic ileus is uncom m on but can occur following
contam ination o f the abdom inal cavity by infected blood and
liquor.
• Respiratory m orbidity in babies born by caesarean section before
labour. The risk decreases after 39 weeks.

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VAGINAL BIRTH AFTER C A ESAREAN SECTION

Vaginal birth after caesarean section is a term that was coined in North
America. It should replace the old term inology o f ‘trial o f scar' which
implies that the Obstetrician is testing the integrity of the scar with the
endpoint being rupture o f the uterus instead o f a vaginal delivery.
Success rates of 80% have been reported and the outcom e is improved in
patients who labour spontaneously. It is im portant before em barking on
a VBAC that:-
• There is no gross cephalopelvic disproportion. This is difficult
to establish antepartum as pelvimetry is now o f limited value in
clinical practice and ultrasound estimation of the fetal weight is
associated with an error o f plus or minus 20% at term .
• There was no endom etritis following the previous caesarean
which can result in a weaker scar.
• The scar was in the lower segment and the presentation is
cephalic.
• All facilities are in place if a repeat caesarean is necessary. When
in labour, the m other should be labelled as ‘high risk ’ . There
must be close maternal and fetal surveillance. Oral intake should
be restricted, an intravenous access line sited and blood cross-
matched.
• There should be early recourse to caesarean, especially if she has
been in established labour for more than 6 hours and vaginal
delivery is not im m inent.

Complications of VBAC
Uterine rupture or scar dehiscence can occur. The risk is 0.4% in those
patients with one previous lower segm ent caesarean section who have
laboured spontaneously. Loss o f uterine activity, signs of hypovolaem ic
shock, bright red vaginal bleeding, ascent o f the presenting part out o f
the pelvis, fetal parts easily palpated through the abdom inal wall and an
abnormal cardiotocography are all indicative of uterine rupture. ‘Scar
tenderness’ is a rather loose term , but tenderness in the suprapubic
region should be viewed with suspicion.

CONCLUSION
Caesarean section is a deliberate operative intervention that has
implications for both m other and baby. Patients should be adequately
counselled and advised of all the available options as well as the benefits
and risks. The following is a checklist that can be used to appraise the
patient fully on the benefits and risks o f abdom inal delivery.

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Benefits include:
• Reduced incidence o f uterovaginal prolapse.
• Reduced incidence o f urinary incontinence.
• Reduced incidence o f perineal pain.
There is an increased incidence of the following risks after caesarean
section when com pared with a norm al spontaneous vaginal delivery:
• A bdom inal pain
• Bladder injury
• Ureteric injury
• Bowel injury
• Throm boem bolism
• Hysterectomy
• Blood transfusion
• ITU admission
• M aternal death
• Placenta praevia and placenta accreta in subsequent pregnancies
• Uterine rupture in subsequent pregnancies
• Neonatal respiratory m orbidity

KEY POINTS
• The World Health Organisation recommends an
abdominal delivery rate of 10 to 15% . This is not
applicable globally.
• Failure to progress in labour is the most
commonly cited indication.
• The lower segment caesarean section is the most
commonly performed procedure. The risk of
rupture of the uterus in a subsequent pregnancy is
0.4% .
• The classical caesarean section is associated with
significant haemorrhage and is performed for a
few select indications such as a transverse lie with
the fetal back inferior. The risk of rupture of the
uterus in a subsequent pregnancy is 12%.
• The success rate of VB AC is 80% .
• Neonatal respiratory morbidity is a potential
complication if abdominal delivery takes place
prior to the onset of labour. The risk decreases
after 39 weeks.

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 FORCEPS

OBSTETRIC FORCEPS

INTRODUCTION
Peter C ham berlen, a French H uguenot and “ b arber su rg e o n ” , designed
the precursor to the m odern forceps in the late 16th century. There have
since been a num ber of m odifications resulting in the instrum ents used
in contem porary clinical practice. Despite these m odifications the most
im portant factor for a successful outcom e rem ains the o p e ra to r’s skill
and familiarity with the instrum ent of choice. With this in m ind a
profound appreciation o f this topic is imperative.
The subject is considered under the following headings:-
• Incidence.
• Types o f forceps.
• Indications.
• Conditions which must apply prior to application.
• M ethod of delivery.
• Com plications.

INCIDENCE
There is wide international variation in the recourse to instrum ental
delivery. In general, the incidence has been found to be higher in centres
with higher epidural rates. The instrum ental delivery rate in the United
K ingdom is 10% of which 40% are forceps deliveries. The failure rate is
in the region o f 2-10% .

TYPES OF FORCEPS
The basic instrum ent consists o f three parts:-
• the blade.
• the shank
• the handle

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The blades are curved to fit the fetal head, the cephalic curve. Some
instruments are curved to fit the curve o f the birth canal, the pelvic
curve. The short W rigley's forceps, used to deliver the head at the time
o f a Caesarean section, has no pelvic curve. Forceps can be classified into
two broad subgroups:-
• Midcavity forceps.
• Outlet forceps.

M idcavity forceps
These are applied when the head is at the level of the ischial spines or
below. There are many different types:
• Simpsons forceps
These are midcavity traction forceps with a sturdy fram e, a long
shank and a m arked pelvic curvature. See Figure 1.
• Neville B arnes' forceps
These are midcavity traction forceps, which may also be used for
delivery o f the aftercom ing head o f the breech.
• K ielland's forceps
These forceps are designed for both traction and rotation o f the
fetal head and
are especially
useful in
instances of
deep transverse

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arrest. It requires considerable skill and should be perform ed in

the operating theatre with readiness for a caesarean delivery
should any difficulties arise. Usually a generous episiotom y is
em ployed as the absence o f a significant pelvic curvature means
that perineal dam age is almost inevitable. The hallm arks o f this
instrum ent are:-
a) A long shank.
b) Absence of a significant pelvic curve.
c) A sliding lock which allows correction o f asynclitism
d) A knob on the shoulder o f the instrum ent which allows for
identification of the occiput during rotation.

Outlet forceps
• Pipers forceps
• These instrum ents are now practically obsolete. They were
designed specifically to control the delivery and m aintain the
flexion o f the aftercom ing head o f the breech. This provides
protection for the head during its descent and minimises the
effects of the sudden pressure change. The distinguishing feature
o f the P ip e r’s forceps is the m arked curvature o f the shank.
• Wriglev ’s forceps
W rigley’s forceps perm it delivery when the fetal head is below
the level of the ischial spines. It can be applied easily and
painlessly. A m odicum o f traction is required and it is
distinguished by its light fram e and short shank.

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INDICATIONS
Instrum ental vaginal delivery should be em barked upon only when a
valid indication exists for expediting delivery o f the baby. There are few
absolute indications and the decision is usually based on several factors.
M aternal indications include the following:-
• M aternal illness requiring a short second stage, for exam ple,
cardiac disease which may limit m aternal effort, pre-eclam psia
and eclampsia.
• M aternal distress.
• Prolonged second stage or failure to progress in the second stage
o f labour. That is, the second stage o f labour has exceeded one
hour in the prim igravida or 30 minutes in the m ultigravida. This
may be due to a m yriad of factors such as persistent occipito-
posterior, deep transverse arrest or ineffective uterine
contractions.
Fetal indications include:-
• Fetal distress.
• Prem aturity.
• The aftercom ing head o f the breech.

CONDITIONS PRIOR TO APPLICATION

In order to ensure a successful outcom e, the following conditions should
be fulfilled prior to application of the forceps:
• There must be no cephalopelvic disproportion. The
biparietal diam eter must have passed through the pelvic brim
and the head should be at station 0 or below. T hat is to say,
the head must be engaged on abdom inal exam ination.
• The position o f the head must be known. This is ascertained
by vaginal exam ination.
• The cervix must be fully dilated.
• The m em branes must have ruptured.
• Both the bladder and the rectum should be em pty.
Catheterise if necessary.
• The patient should be in the lithotom y position with adequate
anaesthesia or analgesia. G eneral anaesthesia may be required
with midcavity forceps, though this is rare. Recourse can be
made to an epidural, spinal or a pudendal block. The low
risk deliveries can be perform ed in the delivery room though
all preparations should be in place for a Caesarean section

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should the procedure fail. High risk deliveries such as those

in which the progress of labour has been slow from a
dilatation o f 7 cm should be conducted in the operating
theatre.
• A Syntocinon infusion may be com m enced to ensure
efficient uterine contraction.
• The patient should have a generous episiotomy with
lignocaine infiltration.
The neonatologist should be in attendance at the delivery with
facilities for resuscitation. The following is a useful
m nem onic:-
F - Full dilatation of cervix
O - Outlet adequate
R - Ruptured membranes/rectum empty
C - Contractions good/catheterise bladder
E - Engaged head/episiotomy
P - Position known/ paediatrician in attendance
S - Suitable presentation

METHOD OF DELIVERY
Traction Forceps
The instrument should be assembled and checked to ensure that the
blades are com plem entary. Traction forceps are designed to fit laterally
on the fetal head. The left hand blade is usually inserted first and the
process of insertion com m ences with the instrum ent parallel to the
inguinal ligament on the contralateral side. It is slid to its position,
following the pelvic curvature; along the palm and fingers o f the right
hand which are protecting the vaginal mucosa. The process is then
repeated for the right hand blade. Once inserted the blades should lock
easily. Never force them into position. Instead, extract the blades,
recheck the position and repeat the process of application.

Gentle traction is com m enced during a contraction and the

mother is encouraged to bear down. The direction of traction is initially
downwards, then horizontal and upwards once the head is on the
perineum . Delivery should be anticipated after three traction efforts.
Failure of descent following one traction effort requires re-assessment.
The procedure should be abandoned if delivery has not been achieved
following five traction efforts.

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Rotational forceps
The K iellan d ’s forceps is typically used when the saggital suture is in the
transverse plane. The blades are designed to be inserted anterior and
posterior to the fetal head. The right hand is inserted into the vagina with
the fingers anterior to the fetal head. T he an terio r blade is grasped with
the left hand and application com m ences with the instrum ent below the
perineum in the vertical plane. It is slid along the palm and fingers of
the right hand to nestle above the fetal head. T his is the direct technique
o f insertion. O ccasionally insertion by this m eans is not possible and
one can attem pt the ‘w a n d erin g ' tech n iq u e. The anterior blade is
inserted laterally as described fo r the left blade o f the traction forceps. It
is then gently encouraged into position by w andering over the fetal face.
Due care needs to be taken to avoid injury to the pelvic structures.

The insertion o f the posterior blade is m ore straightforw ard. This

can usually be achieved by the direct tech n iq u e. The left hand is
inserted into the vagina with the fingers posterior to the fetal head, and
the blade is slid along the palm and fin g ers o f the left h an d . The blades
should lock easily and the direction k n o b s should point to the occiput.
The sliding lock allows for correction o f asynclytism and gentle finger
pressure can be applied to effect rotation. These m ovem ents are
perform ed during uterine diastole. Delivery is then achieved by traction
as previously described.

C O M PLIC A TIO NS
M uch controversy has surrounded forceps since their inception, yet they
have continued to com m and an im portant role in O bstetrics. This is
m ainly due to the significant reduction in m aternal m orbidity and
neonatal asphyxia associated with ap p ro p riate forceps delivery.
Caesarean section, as an alternative, is associated with a h ig h er maternal
m orbidity and m ortality.
M aternal:
• Perineal tears. These are alm ost inevitable with the K ielland’s
forceps. There may be co m prom ise o f the anal sphincter and
extension into the anal canal and rectum .
• V aginal tears. Lateral vaginal wall tears can bleed profusely and
need careful attention. Posterior vaginal wall tears m ay extend
into the rectum , which is in direct relation to its m iddle one-third
o f the vagina.
• Cervical tears. May extend into the uterus. It must be em phasised
that forceps m ust never be used if the cervix is not fully dilated.
To do so, even with a rim o f cervix, is to invite disaster.

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• Uterine rupture. May occur in instances o f unrecognised

disproportion. The consequences o f this are especially grave and
recourse to internal iliac artery ligation or hysterectom y may be
life-saving.
• There may be direct injury to surrounding viscera such as the
urinary bladder or rectum . A late com plication o f genital tract
injury w ould be fistula form ation. In an attem pt to m inim ise
injury, it has been recom m ended that the head should be
delivered in the occipito-anterior position and that the n um ber o f
traction efforts should be restricted to three or less.

Fetal:
• Facial nerve palsies.
• Scalp injuries - including lacerations and crush injuries.
• C ephalhaem atom a
• Intracranial haem orrhage

In addition, it should be rem em bered that there is the potential for

shoulder dystocia with all instrum ental deliveries. Senior m idwifery staff
should be in attendance and prepared for this com plication. In the vast
m ajority o f instances, simple m anoeuvres such as the M cRoberts position
and suprapubic pressure are sufficient to achieve delivery. Despite the
aforem entioned com plications, the forceps rem ain an essential elem ent in
the arm am entarium of the Obstetrician provided their use is indicated
and that there is adherence to the recom m endations and conditions for
application.

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KEY POINTS

• The blade, the shank and the handles are the three parts
of the forceps. The blade has both a pelvic and a
cephalic curvature.
• The Neville Barnes forceps is a m idcavity traction
forceps which may also be used for delivery of the
aftercoming head of the breech.
• The K ielland’s forceps can correct asynclytism , effect
rotation and provide traction.
• High risk deliveries such as those in which the progress
of labour has been slow from a dilatation o f 7 cm
should be conducted in the operating theatre.
• There is the potential for shoulder dystocia with all
instrumental deliveries. Senior staff should therefore be
present and prepared to deal with this obstetric
em ergency.

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VACUUM EXTRACTION

INTRODUCTION
The vacuum extractor or ventouse is a w onderfully simple device that has
been touted by many authors as a superior alternative to the forceps.
This is a m oot point and both instruments deserve equal consideration.
The ventouse provides traction and allows rotation o f the fetal head
in conjunction with maternal effort and can be perform ed with relatively
simple analgesia, such as perineal infiltration with local anaesthetic or a
pudendal block. Failure rates are decidedly higher than with the forceps
and are in the region o f 10-20%.

INCIDENCE
As m entioned previously, there is wide international variation in the
recourse to instrum ental delivery as a whole. The choice of ventouse as
opposed to forceps is operator dependent and varies from centre to
centre.

TYPES
The basic instrum ent is dem onstrated below. Many different types exist
with subtle variations on a com m on theme.

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• Silc cup
This is a silastic device best applied when easy delivery is
expected and the following conditions apply; the head is in the
occipito-anterior position, well flexed vertex presentation, no
caput and an average sized baby is expected.
• Bird anterior cup
This is a metal cup that is applied when a more difficult delivery
is anticipated. There may be caput. The head is well flexed and
in the occipito-anterior position.
• Bird posterior cup
This is a metal cup that may be used when the head is deflexed
and in the occipito-posterior position
• The Kiwi cup
This is a hand-held device. The vacuum is established by a pum p
that is built into the handle.

METHOD OF DELIVERY
As with forceps, ventouse delivery is conducted with the patient in the
lithotom y position. The m em branes should be ruptured and the position
o f the occiput known.
• Always apply the largest cup possible.
• This should be positioned over the vertex.
• The vacuum is initially built up to 0.2 kg/cm2 and a digital
exam ination perform ed to exclude entrapm ent o f vaginal and
cervical tissue.
• The vacuum is then built up to 0.8 kg/cm2 over 1-2 m inutes.

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• Traction is com m enced with uterine contractions and m aternal

effort.
• Apply countertraction with the index finger and thum b o f the left
hand and ensure that the direction o f pull is perpendicular to the
cup.
• The direction of traction is similar to that for forceps, that is,
downwards, horizontal and finally upwards.

INDICATIONS
These are basically the same as for forceps delivery. However, ventouse
extraction may be perform ed before full dilatation o f the cervix (> 8 cm)
in an em ergency and is safer for delivery o f the second twin. Fetal
distress in the late second stage o f labour is a classic indication fo r the
ventouse.

Forceps, on the other hand, is the only alternative in delivery o f the

aftercom ing head o f the breech or in a face presentation (m ento­
anterior). The ventouse should also be avoided in the preterm infant o f
less than 36 weeks because of the softness o f the calvaria.

AD V A NTA G ES
• Reduced maternal m orbidity. Usually there are fewer birth canal
injuries with the ventouse. This is mainly due to the fact that the
ventouse occupies less space. However, cervical lacerations are a
distinct possibility.
• Recourse to general and regional anaesthesia is less likely to be
used with ventouse delivery.
• Can be used to facilitate rotation o f the head which means
avoidance of more pernicious instrum ents such as the K iellan d 's
forceps.

DISADVANTAG ES
• The application-to-delivery interval tends to be lo n g er with the
ventouse than with the forceps.
• High failure rate - 10-20% com pared with 2-10% for forceps.
The m ethod is considered a failure when the cup has slipped on
three occasions, there is no descent following three traction
efforts or delivery has not occurred after five traction efforts.

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• The artificial caput or chignon usually disappears within a few

hours. O ccasionally, however, superficial necrosis may occur.
This is especially likely in instances o f prolonged traction.
• 5-20% may develop a cephalhaem atom a. These are more likely
to develop in deliveries where the traction times exceed twenty
minutes.

CONCLUSION
In sum m ary, instrum ental delivery is an essential elem ent of Obstetric
care. Familiarity with the options is m andatory and the trainee should
acquire the necessary skill in order to achieve an appropriate
instrum ental delivery.

KEY POINTS

• The ventouse provides traction and allows

rotation of the fetal head.
• It can be performed with relatively simple
analgesia.
• A lw ays apply the largest cup.
• Build the vacuum up to 0.8 kg/cm2 over 1-
2 minutes.
• The ventouse should be avoided in the
preterm infant.
• The method is considered a failure when
the cup has slipped off more than three
times, there is no descent following three
traction efforts or delivery has not
occurred after five traction efforts.

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CHAPTER TWENTY FIVE

OBSTETRIC ANALGESIA AND ANAESTHESIA

INTRODUCTION
There is no doubt that the field o f obstetric anaesthesia has grown in the
past 30 years and is likely to expand even further as m ore high risk
patients becom e pregnant and caesarean section rates increase. This has
led to dedicated 24-hour obstetric anaesthetic input for provision of
epidural analgesia fo r labour and anaesthesia for operative delivery.

Obstetric a n a lg e s ia is defined as pain relief in labour without loss

of consciousness.

Obstetric a n a e s th e s ia may involve a regional or general

anaesthetic technique. Regional anaesthesia is the loss o f sensation,
motor function and reflex activity over a specific region of the body,
whereas general anaesthesia results in a loss o f consciousness.

OBSTETRIC ANALGESIA
Analgesia improves the morale o f the patient but it is not solely
important for maternal satisfaction, since this may be influenced by other
factors such as outcom e o f labour, support from a partner or midwife,
interaction with staff and having control over pain rather than its
amelioration.

Preparation usually begins six weeks before delivery and includes

instruction in norm al anatom y and physiology of pregnancy, labour and
delivery. This in itself reduces the fear and anxiety arising from the
unknown. Preparation o f events o f childbirth is probably of benefit to
almost all women and regardless of the mode o f analgesia used, can
make the experience more pleasant. Nevertheless, it is essential that any
system o f preparation for childbirth include:-

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• An acknow ledgem ent that pain can be an unavoidable feature o f

labour in many women.
• An assurance that if and when the need arises, relief will be
provided.
• Explanation and dem onstration of the range o f techniques of
analgesia available in the obstetric unit.

Methods of analgesia used are:

• Relaxation therapy/arom atherapy/hypnotherapy
• Im m ersion in warm water
• LAM AZE
• Transcutaneous electrical nerve stimulation (TENS)
• Nitrous O xide/oxygen inhalation (ENTONOX) ®
• Parental opioid
• Regional analgesia

LAM AZE
The psychoprophylactic method of Lamaze relies on positive
conditioning and patient education regarding the process o f childbirth
based on the belief that pain o f labour and delivery can be suppressed by
re-organisation of the cerebro-cortical activity. C onditioned pain
reflexes associated with uterine contraction and perineal distension can
be replaced by a ‘positive’ conditioned reflex. For exam ple, the patient
is thought to respond to the beginning o f a contraction by immediately
taking a deep ‘cleansing b reath ’ gently exhaling and breathing in a
specific shallow pattern until the contraction ends. She also focuses her
eyes on a specific object or location away from herself. She concentrates
on the release o f muscle tension, maintains the proper breathing rhythm
and listens to the reassuring words o f her instructor. The increased
concentration required by these activities distracts from or inhibits the
painful sensation associated with uterine contractions.

TENS
Electrical impulses applied to the skin o f the back via electrodes from a
battery powered stim ulator known as an ‘obstetric p u lsar’, m odulate the
transmission o f pain by closing a ‘g a te ’ in the dorsal horn o f the spinal
cord. The effect is similar to massage of the lower back, stimulating the
body to produce its own natural pain killers, endorphins. It lessens the
pain for m any, but not all, women.

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ENTONOX®
The gas mixture o f 50% oxygen and 50% nitrous oxide is stored in blue
cylinders under pressure and delivered to the patient via a dem and valve,
a tubing and a face mask or m outh piece.

Inhalation should start just as a contraction begins, in order that

maximum effect is achieved at its peak. The drug does not affect the
fetus, may cause sedation and is non-cum ulative.

OPIOIDS
Pethidine is the most widely used opioid in labour and can be given by
midwives in a dose of 1mg/kg (m axim um 150mg IM ). It lasts about 3
hours. It causes sedation and induces a feeling o f disorientation which
may make pain tolerable. M aternal gastric em ptying is reduced and it
may induce nausea and vomiting. An anti-emetic should be
administered as well. M aternal and neonatal respiratory depression are
recognized side effects. N aloxone 10 microgram s/kg reverses neonatal
respiratory depression. The lack o f efficacy o f pethidine as an analgesic
has prom pted investigation into the use o f other opioids. O f interest,
patient controlled analgesia, PCA, using rem ifentanil, an ultrashort acting
opioid which does not accum ulate, has the benefit o f giving the
parturient some degree of control. It is also advantageous in patients
where epidural analgesia is contraindicated e.g. coagulopathy. However,
it still may not give com plete pain relief and requires close m aternal and
fetal supervision as large studies are needed to ascertain the ideal dose.

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REG IO N A L A N A LG ESIA

Ovarian plexus

F ig u r e 1

D uring the first stage o f labour, pain is due to uterine contractions and
dilatation o f the cervix. Pain originating from the uterus is transm itted
via visceral afferent fibres accom panying the sym pathetic nerves and
enters the spinal cord at T10, T i l , T12 and L I . Some fibres travel via
the ovarian plexus from where they are distributed m ainly to the fundus
(fig 1). The pain resulting from the distension o f the birth canal and
perineum during the second stage o f labour is conveyed by the afferent
fibres o f the posterior roots o f S2, S3, and S4.

The spinal cord usually ends at the level o f L I in adults while the dural
sac ends at S2 (fig 2). The epidural space extends from the foram en
m agnum superiorly to the sacral hiatus caudally. It is a cylindrical space
bounded internally by the dura m ater and externally by the periosteum
o f the vertebral bodes anteriorly, ligam entum flavum posteriorly and the
intervertebral foram ina laterally.

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Posterior
longitudinal Dura
ligament
Spinal cord
Ligamentum flavum

— Interspinous ligament

Supraspirous ligament

Epidural space
Vertebral bodies

Subcutaneous tissue

F ig u r e 2

Regional analgesia involves blockade o f the sensory nerves as they enter

the spinal cord. The techniques include:-

• Central neuro-axial blocks, e.g. lum bar epidural, spinal, or

com bined spinal epidural (CSE) blocks.
• Pudendal nerve block.
• Paracervical nerve block.

CENTRAL N EUR O -A X IA L BLOCK

Local anaesthetic drugs are introduced into the epidural or subarachnoid
space or both. Regional blockade by this m ethod is far superior to other
analgesic m odalities.
The average epidural rate in the UK is 24% . The prim ary indication is
analgesia, by m aternal request.

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Other indications may be:

• Medical - Systemic diseases in pregnancy, e.g.

pulm onary and cardiovascular problem s.
Anticipated difficult intubation.
A history o f m alignant hypertherm ia.
• Obstetric - Breech presentation.
M ultiple gestation.
An increased risk o f Caesarean section.
Pre-eclampsia.

Absolute contraindications include:

• Patient refusal.
• U ncorrected anticoagulation or coagulopathy.
• Local or systemic sepsis (pyrexia >38°C not treated with
antibiotics).
• H ypovolem ia or active haem orrhage.
• Lack o f sufficient num bers o f trained midwives for continuous
care and m onitoring o f m other and fetus for the duration of
regional blockade.

Relative contraindications include:

• Low m olecular weight heparin adm inistration within previous 8
hours.
• Previous spinal surgery may make the technique difficult and
spread o f local anaesthetic solution may be variable.

TECHNIQUE
Resuscitation equipm ent and an oxygen source should be available and
the blood pressure m onitored. A 16G intravenous cannula is inserted
and 1 litre R inger’s lactate solution attached for easy bolus
administration if hypotension should occur by sym pathetic blockade.
The patient may be sitting or in the lateral position with the back flexed
and in line with the edge of the trolley. An aseptic technique is used and
the L3 - L4 interspace is infiltrated with 1 ml local anaesthetic.

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Ligamentum flavum

Figure 3

Fig. 3 shows that the epidural needle - 16G Tuohy -passes through the
skin, subcutaneous tissue, supraspinous ligam ent, interspinous ligam ent
and ligam entum flavum in to the epidural space. The anatom ical
landm ark is the space above the line between the left and right iliac crest
which crosses the L4 vertebra.

The epidural space is identified by the Toss o f resistance to air or saline’

to depression of a syringe plunger as the Tuohy needle is advanced
through the ligam entum flavum. An epidural cannula is then inserted
through the needle into the epidural space.
The subarachnoid space, which contains the CSF, is a few
millimetres deeper, inside the meninges and spinal needles can be used
for deliberate spinal injection through the Tuohy needle before insertion
of the epidural catheter (Com bined Spinal Epidural, CSE). The
advantage is rapid onset o f analgesia, even though being more invasive.

Interm ittent epidural boluses, continuous infusions and patient

controlled epidural analgesia all provide com parable pain relief.

M ixtures of local anaesthetics and opioids (Bupivacaine 0.1% and

Fentanyl 2 micrograms/ml) act synergistically to reduce the am ount o f
local anaesthetic used (low dose top up). The low dose regim en, e.g. 10
- 15 ml in the epidural space and 2.5 ml in the subarachnoid space of
the above mixture provides effective, rapid onset o f analgesia and high
maternal satisfaction rates com pared with traditional top ups, e.g.
Bupivacaine 0.25% . It also decreases the likelihood of local anaesthetic

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toxicity and results in a decreased intensity of m otor block. However,

they do not last as long as traditional 'top ups' and may be inadequate for
instrum ental delivery. Side effects of opioids are respiratory depression
and pruritus.

PROBLEMS
• Inability to site the epidural.
• ‘Patchy B lock’ or missed segm ent. Re-siting and avoidance o f
inserting more than 4 cm o f catheter into the epidural space may
be helpful.
• Bloody tap with needle and cannula. The needle should be re­
sited.
• Dural tap. 85% of women will develop a severe postural
headache caused by leakage of CSF. Each unit should have a
plan of action for inadvertent dural tap. The occurrence of a
dural tap must be docum ented and the anaesthetist must decide
whether to use the catheter for a continuous spinal technique or
whether to resite the epidural. It is no longer advocated that the
parturient should have an elective assisted delivery. But the
second stage should not be prolonged as the chances o f CSF
leakage are increased thereby making post-dural puncture
headache more likely. The definitive treatment is a ‘blood
p atch ’ - an epidural injection of 20 ml o f autologous blood -
best undertaken at 24 - 48 hours post delivery.

COM PLICATIONS
• H ypotension M anagem ent follows the ‘A B C ’ o f resuscitation
approach with relief of aorto-caval com pression.
• Local anaesthetic toxicity. Unintentional injection of local
anaesthetic into the epidural vein may cause sym ptom s and signs
o f toxicity due to high concentrations of local anaesthetic in the
CNS (table 1). The m axim um recom m ended dose of Lignocaine
is 3 mg/kg and Bupivacaine is 2 mg/kg.

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Table 1: Symptoms and Signs of local anaesthetic toxicity.

SYMPTOMS SIGNS
numbness of tongue or lips slurring of speech
tinnitus drowsiness
light-headed convulsions
Anxiety cardio-respiratory
arrest

• Total spinal: usually due to unintentional adm inistration o f large

doses of local anaesthetic into the subarachnoid space. Loss of
sensation and muscle power is very rapid. The signs are
hypotension and respiratory arrest, treated with em ergency
tracheal intubation and support o f the blood pressure with fluid
and vasopressors.

PARACERVICAL NERVE BLOCK

This method o f providing pain relief in the first stage o f labour has
several advantages including simplicity, suitability for use of obstetricians
and the avoidance o f hypotension. U nfortunately, because o f fetal
bradycardia and occasionally, fetal death, the continued use of
paracervical block in labour is difficult to justify.

Paracervical block satisfactorily relieves the pain o f uterine

contraction in 55 - 90% of patients. A successful bilateral paracervical
block affects only the uterus. The vaginal, the perineum and the vulva
remain sensitive to pain.

Bupivacaine is the drug o f choice, but it has the disadvantage o f

causing substantial reductions in uteroplacental blood flow.

TEC H N IQ U E
The patient is placed in the supine position and aseptic routine is
followed. A needle with a blunt outer guard is used. The guard is
pressed into the lateral fornix, the needle is advanced to 1 cm , and after
ensuring that no blood is aspirated, an injection o f 5 - 10 ml o f 0.25%
Bupivacaine is given. The procedure is repeated on the other side.
Injections are usually made at 3 and 9 o ’clock positions, but they may
be made at 4 and 8 o ’clock positions to reduce the risk o f injection in to
the uterine artery (uterosacral block).

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COM PLICATIO NS
• Fetal bradycardia
• Injection into the uterine artery
• Injection into the fetus
• Overdosage
• Infection
• Laceration o f the vagina

PUDENDAL NERVE BLOCK

The pudendal nerve is derived from the anterior roots o f S2, S3, and S4,
and is a m ixed m otor and sensory nerve. It supplies the p erineum , vulva
and lower portion o f the vagina and is the m otor nerve to the perineal
muscles and to the external anal sphincter.

A pudendal nerve block does not relieve the pain o f uterine

contraction. It can be used for m id-forceps delivery. The nerve is best
blocked as it crosses the sacrospinous ligam ent close to its attachm ent to
the ischial spine.

TECHNIQUE
The transvaginal approach
The patient is placed in the lithotom y position and an aseptic procedure
is observed. A guarded needle o f the type used in paracervical block is
placed along the second and third fingers o f one hand and introduced
carefully into the vagina. The ischial spine is palpated with the tip o f the
fingers and the needle is advanced th ro u g h the vaginal wall, im m ediately
behind the ischial spine to a depth o f about 1.25 cm.

The needle is now advanced continuously until its tip is felt to

em erge from the ligam ent. A loss o f resistance is usually appreciated.
A spiration for blood is carried out. A bout 5 - 10 ml o f local anaesthetic
is then injected and the procedure repeated on the other side.
The perineal approach
The ischial tuberosity is palpated through the buttock and the needle
introduced along the m edial side o f the tuberosity into the pudendal
canal. The canal lies about 2.5cm deep to the free surface o f the
tuberosity. A bout 5 - 10ml o f local anaesthetic is then injected after
aspiration fo r blo o d . The procedure is repeated on the o th er side.

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ANAESTHESIA FOR C A ESA R EA N SECTION

Anaesthesia for Caesarean section may be a general or regional
technique. A UK wide survey o f more than 60,000 Caesarean sections in
1997 revealed that 78% were perform ed under regional anaesthesia.
Even though the proportion of general anaesthetics has fallen, the
increasing num ber o f Caesarean sections has kept the overall num ber o f
general anaesthetics broadly the same. The Royal College of
Anaesthetists, UK, in 2007, recom m ended that 85% o f em ergency and
95% o f elective Caesarean sections be perform ed under regional
anaesthesia.

A four point classification of urgency of Caesarean section

similar to that used by the National Confidential Enquiry into
Perioperative Deaths, UK, should aid decisions as to which mode o f
anaesthesia is appropriate in non-elective cases (Chapter 24)).

Women must receive an explanation of the proposed anaesthetic

technique and limitations. Written consent is not essential in difficult
situations but at least oral consent should be docum ented.

Generally, maternal mortality attributed to anaesthesia has fallen

steadily in the last 30 years. In the Confidential Enquiry in M aternal
Death 2000 - 2002 Report, UK, there were 6 direct deaths. All had
general anaesthesia - 2 had oesophageal intubations, 2 had delay in
getting help, 1 aspirated and 1 suffered an anaphylactic reaction. It was
recommended that:

• Training in airway m anagem ent be em phasised.

• Seek assistance from other anaesthetic subspecialties.
• The anaesthetist should be inform ed of high risk patients early,
e.g., obesity and needle phobia.

For elective Caesarean section, fasting intervals of 6 hours for food and 2
hours for fluids (tea/coffee with semi-skimmed milk or fruit squash) are
appropriate. Ranitidine 150 mg should be prescribed 2 hours before an
elective operation and adm inistered 8 hourly to women in labour with
risk factors for Caesarean section to reduce gastric acid secretion. The
administration of a non-particulate antacid, e.g. 30m l sodium citrate,
immediately before every Caesarean section is necessary. The risk of
aspiration not only is possible during general anaesthesia but also if
protective airway reflexes are obtunded in the event o f a very high
regional block.

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Before any anaesthetic, all equipm ent must be checked including suction,
laryngoscopes and endotracheal tubes as well as drugs for induction o f
anaesthesia and em ergency drugs. A 16G intravenous cannula must be
inserted with a litre o f R in g er's lactate attached.

REGIONAL ANAESTHESIA
Single-shot spinal anaesthesia
With the advent of pencil-point tip needles, 24G Sprotte and 25G
Whitacre, the incidence o f post dural puncture headache (PDPH) has
been lowered due to loss o f leakage o f CSF, making single-shot spinal
anaesthesia the most popular technique for operative delivery.

The injection site is at the L3/L4 interspinous space which is the

space at or immediately above the line joining the highest points o f the
iliac crests.

A solution of hyperbaric Bupivacaine with or without intrathecal

Fentanyl (which reduce the incidence o f intra-operative visceral pain) is
injected slowly into the subarachnoid space.

The patient is placed in the supine position with a wedge to

prevent supine hypotension. The vital signs are m onitored every 5
minutes and the level of the block ascertained. Loss o f light touch
sensation to T5 is a good predictor of pain free Caesarean section with
opioid-free spinal Bupivacaine.

H ypotension due to sym pathetic blockade is treated by:

• strict avoidance o f aorto-caval com pression.

• prom pt boluses o f vasopressor.
• infusion o f crystalloid imm ediately after intrathecal injection.

Epidural Anaesthesia
The quality of an epidural anaesthetic is generally poorer than a spinal
anaesthetic, though it still may be desirable when gradual establishm ent
o f a block is necessary to minimize hypotension.

Bupivacaine 0.5% solution 10 - 20 ml is the drug o f choice, with

or without 50 - 100 m icrogram s o f Fentanyl.

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Combined Spinal-Epidural (CSE)

A CSE technique is useful when the surgery may outlast a single-shot
spinal block, e.g., Caesarean hysterectom y in a woman with placenta
praevia, where the epidural will allow extension o f the block.

GENERAL ANAESTHESIA
General anaesthesia is preferable to a regional technique in the following
circumstances:

• ‘E m erg en cy ' Caesarean sections.

• Patients objection to regional anaesthesia.
• Coagulopathy.

The major risks of general anaesthetic are:

• Airway problem s, e.g., failed tracheal intubation.

• Aspiration o f gastric contents.
• A naphylaxis (typically to Succinylcholine).

If a difficult intubation is anticipated, then an awake fibre optic

intubation should be considered. It is therefore necessary for good
communication between the anaesthetist and obstetrician to ensure the
safety of the m other.

With the patient supine and a wedge in place, the ECG, non-
invasive blood pressure and pulse oxim eter m onitors are attached to the
patient.

The patient is pre-oxygenated through a mask for 3 m inutes. A

rapid sequence induction with T hiopentone, Suxam ethonium and
Cricoid pressure is universal. When the cuff o f the endotracheal tube is
inflated and proper placem ent confirm ed by return of carbon dioxide on
capnography and auscultation o f breath sounds over the anterior chest
and axilla, only then the cricoid pressure is released.

Anaesthesia is maintained with 50% oxygen, 50% nitrous oxide,

0.5 % H alothane, 1.0% Enflurane or 0.75% Isoflurane.

After delivery o f the baby, an opioid, e.g.. M orphine or Pethidine

and Oxytocin 5 IU bolus are adm inistered. The oxygen - nitrous oxide

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ratio is adjusted to 3:5. With inhalational agent m onitoring, the risk o f

awareness in obstetric anaesthesia is reduced.

The patient is extubated awake on the left lateral position to

prevent inhalation of stom ach contents.

KEY POINTS

• N on-regional analgesia remains the most

frequently used method during labour.
• Epidural analgesia is the most effective form of
analgesia in labour.
• The majority of caesarean sections are performed
under spinal or epidural anaesthesia.
• Major maternal risks of general anaesthesia are
failed intubation, failed ventilation and pulm onary
aspiration of gastric contents.

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CHAPTER TWENTY SIX

INFECTIONS IN PREGNANCY

INTRODUCTION
Infections occur quite often in pregnancy and in many cases pose a
serious threat to the m other and fetus. M aternal predilection to infection
is increased in pregnancy for a num ber o f reasons. Firstly, pregnancy is
a state of relative im m unocom prom ise due to the high levels o f steroids
(both corticosteroids and sex steroid horm ones), which are necessary to
obtund the maternal im m une response to fetal antigens and the invading
trophoblast. Secondly, a num ber o f anatom ical changes occur in
pregnancies that lend themselves to an increased susceptibility to
infection. For exam ple, urinary tract infections are m ore com m on in
pregnancy because o f the com bination of an inherently short urethra
and the stasis o f urine that results from the smooth muscle relaxation o f
the urinary tract by progesterone.

The fetus, on the other hand, is cocooned in the uterine

environm ent and enveloped by the m em branes of the chorion and
amnion. Transplacental passage of maternal antibodies also confers an
element o f protection. Fetal infection, however, may occur as a result o f
ascending infection following preterm prem ature ruptures o f the
m em branes, haem atogenous spread through the placental barrier or
during parturition (vertical transm ission). Vertical transmission may also
occur postpartum during breastfeeding. The implications for the fetus
include miscarriage, stillbirth or congenital infection. Congenital
infections may be associated with disease manifestation, major
abnormality especially if infection has occurred during the period of
organogenesis, or a self-limiting illness.

In this chapter we have dealt initially with individual pathogens

that have the potential to cause congenital infections. This is followed by
urinary tract infections, bacterial vaginosis and periodontal disease, which

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are all implicated in preterm labour. There is a section on sexually

transmitted infections and finally screening in pregnancy. The
constraints of space have meant that a num ber o f infections have
intentionally been excluded. The postgraduate student, in particular, is
encouraged to refer to the appropriate reference texts especially as it
applies to infections such as Varicella Zoster Virus (VZV) and Parvovirus
B19.

TOXOPLASM OSIS
This is caused by a unicellular protozoan, T o x o p la s m a g o n d i i. The
parasite can infect almost any living animal and is usually contracted by
hum ans from ingestion o f raw meat or contact with cat faeces. While
most infected persons have no sym ptom s, pregnant women and
im m unocom prom ised persons can develop serious problem s from this
parasite. In one study antibodies to toxoplasm a were found in 46% of
urban and 58% rural Jam aican youth (Rawlings et al 1989).
The sym ptom s o f toxoplasm osis are usually vague, often
presenting as a mild flu-like illness. O cular toxoplasm osis may present
with blurred vision and all pregnant women with abnorm al eye
com plaints should be referred to the ophthalm ologist for further
evaluation.
Diagnosis relies on the detection o f antibodies to T o x o p la s m a
g o n d i i in the m aternal serum. The most reliable o f these investigations is
the Sabin-Feldm an dye test. Other serologic tests including the indirect
haem agglutination test, the latex agglutination test, m odified
agglutination test, and the enzym e-linked im m unoadsorbent assay
(ELISA), offer some advantages. For exam ple, agglutination tests are
easy to perform . Serologic evidence of an acute acquired infection is
obtained when antibody titres rise by a factor o f 4 to 16 in serum taken 2
to 4 weeks after the initial serum collection, or when specific IgM
antibody is detected.

Pregnant women, who acquire the parasite for the first time just
prior to or in early pregnancy, can pass it to their neonate and this can
cause serious neonatal ocular or brain dam age. Intra-cerebral
calcifications on ultrasonography in the fetus or on com puterised
tom ography (CT) (caudate nucleus choroids plexus and sub-ependym al
region o f the brain) in a neonate is suggestive o f T. g o n d i i infection. The
hallmarks of congenital toxoplasm osis are intracerebral calcifications,
hydrocephalus and chorioretinitis.

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A ntiprotozoal treatm ent reduces the risk o f fetal infection. The

main treatm ent options are sulphadiazine + pyrim etham ine after 16
weeks or spiram ycin or clindam ycin + pyrim etham ine. In the presence
o f ultrasound evidence o f fetal infection term ination of pregnancy is an
option that may also be considered.

RUBELLA
This is a measles-like illness (also called G erm an measles) which is very
com m on and usually of a benign nature except in early pregnancy when
it can cause serious congenital m alform ations and even perinatal death.

Most people who develop rubella have slight flu-like sym ptom s
and a rash, which is not easy to distinguish from measles. Rubella is
caused by the rubella RNA virus ( R u b iv ir u s ). The first visible sign of
rubella is a fine red rash that begins on the face and rapidly moves
downward to cover the whole body within 24 hours. The rash lasts about
three days, which is why rubella is sometimes called the three-day
measles. A low fever and swollen lym ph nodes, especially pre-auricular
and neck (cervical), often accom pany the rash. Joint pain and swelling
can occur and this may linger for a week or two. It is quite com m on to
get rubella and not show any sym ptom s (subclinical infection). M ost
people recover fully with no com plications.

A lthough rubella causes only mild sym ptom s in most children

and adults, it can have severe com plications fo r women in the first
trimester o f pregnancy. Pregnancies may spontaneously miscarry or
result in a stillborn infant and high percentages are born with birth
defects.

Birth defects are reported to occur in 50% o f women who

contract the disease during the first m onth of pregnancy, 20% o f those
who contract it in the second m onth, and 10% of those who contract it in
the third m onth. The most common birth defects resulting from
congenital rubella infection are eye defects, such as cataracts,
glaucom a, and blindness, deafness, congenital heart defects, long bone
and teeth anom alies, hepato-splenom egaly and mental retardation.
Taken together, they constitute the congenital rubella syndrome
(CRS).

The risk o f birth defects falls after the first trimester, and is rare
by week 20. In a study done in Jamaica in 1988, 22% o f children with

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blindness were found to have CRS (M oriarity 1988). The diagnosis is

clinical but can be confirm ed by a four-fold rise in serum titre of
antibodies. Congenital rubella is diagnosed by detection o f specific
Rubella IgM in neonatal serum, which remains positive up to one year of
age.

Figure 1
Number of reported congenital rubella syndrom e (C R S) cases versus
percentage of women seropositive for rubella antibodies in Jam aica
1972 to 1998 (adapted from King 1972, B a x terl9 8 6 and W vnter et al
1999)

With the introduction of the routine vaccination o f all girls aged

10-11 in Jamaica in 1978, CRS is now very rare with a significant decline
since then, associated with a significant increase in individuals tested, with
positive antibodies from 52% in 1972 to over 80% in the 1990s (figure
1). The MMR (measles m um ps rubella) vaccine is given to young girls
and boys and also to young women who are im m unonegative and are
trying to get pregnant.

The Rubella vaccine is a live attenuated vaccine, which is not

usually given in pregnancy, however if this is done inadvertently, it is not

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an indication to term inate the pregnancy, since there is no risk of

congenital infection by this route. N on-im m une patients should be
vaccinated postpartum .

CYTOM EGALOVIRUS
Cytom egalovirus (CMV) is a m em ber o f the herpes virus fam ily (DNA
viruses). It is the virus most frequently passed on to babies during
pregnancy and can cause hearing loss and other problem s in children
who contract it in utero.

Between 50 and 100 % of women already have CMV before they

conceive. In Jamaica by age 25 more than 97% o f people tested were
positive for CMV antibodies (Prabhakar et al 1992). Like other herpes
viruses, it remains dorm ant in the body after an initial infection but can
becom e reactivated if the im m une system is com prom ised, resulting in
recurrent CMV infection. Fortunately, the risk of transm itting the virus to
the fetus during a recurrent infection is very low (less than 1 percent),
and the risk of serious com plications is even lower. So if the first CMV
infection occurs at least 6 m onths before conception, the risk to the baby
from CMV is very small.

A bout 1 to 3 percent o f women get CMV for the first time whilst
pregnant, and the chance o f passing the infection to the baby is much
higher (about 30%). These babies also have a m uch higher chance o f
developing serious com plications. A bout 80 to 90 percent o f babies who
get CMV this way develop problem s such as hearing or vision loss,
mental retardation, and coordination difficulties within their first few
years. Even infected babies who seem healthy at birth can develop
problem s later, most com m only hearing loss.

A new CMV infection is hard to recognize because most people

don't develop any sym ptom s. Those who do tend to have flu-like
symptoms such as fever, chills, swollen lym ph nodes, fatigue, and mild
pain. CMV can be spread by contact with an infected person's body
fluids, such as saliva, urine, faeces, semen, vaginal secretions, blood, tears,
and breast milk.

An infected woman can transm it the virus to her baby in several

ways: by lateral transmission through the placenta during pregnancy, or
by vertical transmission when her baby comes in contact with infected
fluids at birth or through infected breast milk after delivery. Fortunately,

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most babies who contract CMV during birth or from breast milk develop
few or no sym ptom s, so the benefits o f vaginal delivery and
breastfeeding outweigh any risks for women with CMV infection. CMV
may also cause intra-cerebral calcifications on CT scan o f the neonate or
infant.

M aternal infection may be confirm ed by enzym e linked

im m unosorbent assay (ELISA ) looking fo r specific IgM antibodies
denoting current infection. Fetal infection may be established by analysis
o f am niotic fluid, chorionic villus sam pling or fetal blood sam pling.
There is currently no available vaccine and no effective antim icrobial
treatm ent. Term ination o f pregnancy is an option in the presence of
dem onstrable fetal infection.

HERPES SIMPLEX VIRUS

Herpes is a contagious infection that is caused by H e r p e s s im p le x , a DNA
virus. One type of the virus - herpes simplex virus type 1 (HSV1) - can
lead to cold sores around the m outh. An infection o f herpes simplex
virus type 2 (H SV 2) can lead to genital herpes, a sexually transm itted
disease that causes blisters and pain in the genital area.

Both types o f the virus can be transm itted th ro u g h direct contact.

A person can get the cold sores o f HSV1 by kissing o r sharing eating
utensils with an infected person. A person can get genital herpes or
HSV2 by having sexual contact with an infected person. With the
changes in sexual practices, oral sexual contact has resulted in both types
now been found in the genital region.

In many cases the patient has recurrent outbreaks after the initial
infection. These recurrent attacks occur more com m only if the person is
im m unocom prom ised or if the individual has an intercurrent illness such
as a com m on cold or the flu (hence the term cold sore). Some women
tend to get outbreaks at the time o f m enstruation o r if they are under
stress. A fter the first herpes infection, the virus can lie dorm ant without
causing any sym ptom s for some time. The virus rem ains in the ganglion
o f a cutaneous nerve and m igrates down the nerve when the im m une
system of the individual is stressed. The infection results in tingling and
num bness, then a blister occurs which then form s a crust. The regional
nodes may becom e swollen tem porarily.

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In some cases, herpes is asym ptom atic, it is therefore possible for

a person to carry it and unknowingly pass it on to som eone else. In other
cases, herpes infections can lead to infections in other parts o f the body.

A m other who has active genital herpes can pass the infection on
to her newborn, if she delivers the baby vaginally. She should be
delivered by caesarean section. If the lesions are noted after the
m em branes have been ruptured for more than six hours, a caesarean
section may not prevent m other to child transmission o f the virus.
Prophylaxis with antiviral agents- acyclovir or valacyclovir in the last 4-6
weeks of pregnancy and during delivery may be valuable in preventing
neonatal infection.

To allow early identification o f infected babies HSV culture

and/or polym erase chain reaction (PCR) of surface swabs including
oropharynx, eyes, urine and cerebrospinal fluid (CSF) should be
perform ed. In addition EDTA blood for PCR should be taken.
Intravenous acyclovir 20mg/kg/tds for 14 days should be com m enced
and continued for 21 days if the CSF is abnorm al. If acyclovir is not
started im m ediately, the neonate should be closely m onitored for signs
o f lethargy, fever, poor feeding or lesions. A cyclovir should be
com m enced immediately should any cultures becom e positive.

Neonatal herpes is a very rare, but can be a serious infection with

high m orbidity and mortality. The incidence is 3.9/ 100,000 live births.
All women, not just those with a history of genital herpes, should
undergo careful vulval inspection at the onset o f labour to look for
clinical signs of herpes infection. Fetal scalp electrode, forceps and
vacuum delivery should be avoided.

SYPHILIS
Syphilis is a com m unicable disease caused by T r e p o n e m a p a l l i d u m ,
which belongs to the Spirochaetaceae fam ily. When untreated, syphilis is
a lifelong infection that progresses through three characteristic clinical
stages. After initial invasion through m ucous m em branes or skin, the
organism multiplies rapidly and disseminates widely. The organism
spreads through the perivascular lym phatics and then the systemic
circulation before clinical developm ent o f the prim ary lesion. The
prim ary lesion, containing infectious treponem es, occurs within hours
after infection and persists throughout prim ary and secondary disease.

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Secondary lesions develop when spirochetal invasion o f tissues of

ectoderm al origin (e.g., skin, m ucous m em branes, central nervous system
(CNS) precipitates an inflam m atory response. These lesions develop 6-
12 weeks after infection. This stage o f rapid spirochete m ultiplication
and dissem ination may bring invasion o f the entire body. T hus, tertiary
syphilis may involve any organ system, usually after a latent phase o f 5-
20 years.

N eurosyphilis, one form o f tertiary syphilis, can m anifest in

various ways. M eningeal syphilis rarely occurs and presents a few years
following the original infection. Late neurosyphilis may present with
focal ischem ia of the CNS or stroke as a result o f endarteritis o f small
blood vessels of the brain. M eningovascular syphilis can affect any part
o f the CNS. Actual destruction o f the nerve cells in the cerebral cortex
leads to a com bination o f psychiatric m anifestations and neurologic
findings. Cardiovascular syphilis may lead to destruction o f the aorta
causing an aneurysm , which can erode through the sternum and resulting
in death from exsanguination.

Congenital syphilis is caused by transplacental transm ission o f

spirochetes; the transm ission rate approaches 100%. Perinatal death may
result from congenital infection in m ore than 40% o f affected, untreated
pregnancies. A m ong survivors, m anifestations traditionally have been
divided into early and late stages. M anifestations are defined as early if
they appear in the first 2 years o f life and late if they develop after age 2
years.
Because inflam m atory changes do not occur in the fetus until
after the first trim ester o f pregnancy, organogenesis is unaffected.
Nevertheless, all organ systems may be involved. With early-onset
disease, m anifestations result from transplacental spirochetem ia and are
analogous to the secondary stage o f acquired syphilis. C ongenital
syphilis does not have a prim ary stage. Late-onset disease is seen in
patients older than 2 years and is not considered contagious.

Most affected infants are asym ptom atic at birth and are identified
only by routine prenatal screening. If untreated, sym ptom s develop
within weeks or m onths. The typical stillborn o r highly sym ptom atic
newborn is born prem aturely with an enlarged liver and spleen, skeletal
involvement, and often pneum onia and bullous skin lesions.

The earliest signs o f congenital syphilis may be p o o r feeding and

snuffles (syphilitic rhinitis). Early m anifestations o f congenital infection
are varied and involve m ultiple organ systems. The m ost striking lesions

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affect the m ucocutaneous tissues and bones. M ucous patches, rhinitis,

and condylom atous lesions are highly characteristic features o f m ucous
m em brane involvement in congenital syphilis.

Nasal fluid is highly infectious. Snuffles are followed quickly by

a diffuse m aculopapular desquamative rash that involves extensive
sloughing o f the epithelium , particularly on the palms and soles and
about the mouth and anus. In contrast to acquired syphilis, a vesicular
rash and bullae may develop. These lesions are highly infectious.
Hepatom egaly is reported in almost 100% o f cases, and biochem ical
evidence o f liver dysfunction is the norm .

Late-onset congenital syphilis occurs because o f scarring from

the early systemic disease. M anifestations include neurosyphilis and
involvement o f the teeth, bones, eyes, and the eighth cranial nerve
causing deafness.

The diagnosis is usually made by a serological test on cord

blood. The typical test is a VDRL (venereal disease research laboratory)
a non-treponem al test with a high false positive rate, or a more specific
test fluorescent treponem a antibody (FTA) or m icrohem agglutination
assay for antibodies to T p a l l i d u m (M HA-TP). An uncom m on m ethod to
achieve definitive diagnosis is to identify spirochetes by m icroscopic
darkfield exam ination or by direct fluorescent antibody tests on exudate
or tissue. Exam ination o f a serous transudate from moist lesions (e.g., the
prim ary chancre, condylom a latum, m ucous patch or placenta) is most
productive because these lesions have the largest num bers o f treponem es.
Darkfield microscopy is particularly helpful early in maternal disease,
prior to developm ent of seroreactivity. However the spirochaete o f
syphilis is indistinguishable from other spirochaetes such as those
causing Yaws or Pinta, diseases endemic in some countries. Specimens
from the oral cavity cannot be used because nonpathogenic treponem es
are part of the norm al oropharyngeal flora.

Penicillin remains the drug o f choice to treat all stages o f syphilis;

no evidence o f increasing penicillin resistance exists. Prim ary, secondary,
and early latent disease is treated with a single IM dose o f benzathine
penicillin G (50,000 U/kg; not to exceed 2.4 million U). Where there is
doubt of the stage or if Syphilis has been there for more than one y e a r’s
duration, this should be treated with weekly doses o f 2.4 MU IM for
three weeks. A lthough other regim ens can be considered for penicillin-
allergic patients, desensitization followed by penicillin is the preferred
m ethod.

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N on-pregnant, penicillin-allergic patients without neurosyphilis

may be treated with either doxycycline (100 mg PO bid for 2 wk) or
tetracycline (500 mg PO q.i.d. for 2 wk). Shorter-acting form s o f
penicillin must be used to treat neurosyphilis to produce reliably
therapeutic levels in the CSF.

LISTERIA M ONOCYTOGENES
L iste ria m o n o c y to g e n e s is a gram -positive non-spore form ing rod, which
has been known to cause hum an disease for many years. They are
ubiquitous in the environm ent and found worldwide. They are not
highly pathogenic to healthy adults, however, pregnant women, neonates,
the elderly and the im m unocom prom ised are at particular risk and
disease in these groups can be severe.
The bacterium has been isolated from a range o f raw foods
including vegetables and uncooked meats as well as processed foods. A
wide range of food products have been implicated in outbreaks
including soft cheeses and meat based pates. The bacterium is also
com m only carried in the human gut in about 1-10% o f people.
While m aternal infections can be asym ptom atic, it may cause a
flu-like illness or m eningo-encephalitis/septicaem ia and spontaneous
miscarriage or stillbirth. When listeria m eningitis occurs, the overall
mortality may be as high as 70%; mortality from septicemia is about
50% and from perinatal/neonatal infections greater than 80%.
The majority o f cases are believed to be food borne and its ability
to grow at a great range of tem peratures makes it particularly dangerous
as refrigeration and heating may not denature it. Some cases occur by
direct contact with animals. M other to fetus transfer in utero or during
birth, or via person-to-person spread between infants shortly after
delivery are possible routes of perinatal infection.
Diagnosis is made by culture o f the bacterium from blood or
cerebrospinal fluid. Successful treatm ent with parenteral penicillin or
ampicillin has been reported. T rim ethoprim -sulfam ethoxazole has been
shown effective in patients allergic to penicillin.

BRUCELLA ABORTUS
B r u c e lla are very small, gram -negative coccobacilli that cause a zoonosis
called brucellosis. Sym ptom s of brucellosis include fluctuating fever,
chills, sweating, headache, muscle pain, and weight loss. One species of
B r u c e lla , called B . a b o r tu s infects the placenta and fetus o f gestating

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cows and causes the fetus to m iscarry. When hum ans are infected by this
organism they develop a severe fever, but do not m iscarry.

A lthough brucellosis occurs worldwide, it is concentrated in

Europe, Africa, India, M exico, and South A m erica. Some cases have
been caused by consum ption o f raw milk and cheeses. However, the
majority o f cases occur in people who handle livestock, such as
slaughterhouse workers and veterinarians.

Preventative measures include the quarantine and testing o f

im ported animals and pasteurisation o f milk. Once a person becom es
infected though, they are prescribed a com bination o f tetracycline and
streptom ycin for 3-6 weeks. Also, there is a vaccine available fo r animals
but it is not effective in hum ans.

PRETERM L A BO UR AND GROW TH RESTRICTION

Some infections in pregnancy affect the neonate indirectly by
stimulating the production o f inflam m atory m ediators. This results in the
production o f large am ounts o f prostaglandins, which can cause uterine
contractions or uterine vessel constriction leading to preterm birth or
intra uterine growth restriction. Im plicated infections include urinary
tract infections, bacterial vaginosis and periodontal disease.

URINARY TRACT INFECTION (UTI)

Women are prone to urinary tract infections because o f the short urethra
and the close proxim ity o f the external urethral orifice to the vagina and
the anus. A pproxim ately 6% o f women have significant colony counts o f
bacteria in their urine (>106 cols /ml) without sym ptom s. In over 95% o f
cases the bacteria cultured are coliform s, most com m only E s c h e r ic h ia
c o li. In pregnancy the same num ber o f women start out pregnancy
asymptomatic but about 25% o f these will go on to develop sym ptom s
during the pregnancy.

Pregnancy causes sym ptom s to start because o f several reasons:

• Stasis of urine occurs because o f the m echanical obstruction o f
the ureters by the enlarging uterus.
• The presence o f progesterone causes sm ooth muscle relaxation
and this also causes stasis o f the pelvicalyceal system and ureters.

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• There is increased nutrient substrate for the bacteria because of

the decreased renal threshold fo r glucose.
• The pH of the urine changes; becom ing more alkaline, which
favours the growth o f some bacteria.
• The high levels of steroids in pregnancy (progesterone,
oestrogens and corticosteroids) cause the woman to be relatively
im m unocom prom ised.

Some of the symptoms typical o f a UTI are encountered in

norm al pregnancy. These include urinary frequency (first trim ester
uterus resting on the bladder and third trim ester the presenting part
resting on the bladder) and lower abdom inal discom fort and pain, which
may be due to pubic joint laxity. However, other sym ptom s such as
dysuria, urgency and haem aturia may be more diagnostic. Pyelonephritis
may result from ascending infection resulting in loin pain, fever and
rigors. If this goes untreated the patient may develop a gram -negative
septicaemia. M any patients with a urinary tract infection labour
prem aturely as a result o f prostaglandin production.

Exam ination o f the patient may also prove difficult in pregnancy.

Low abdom inal tenderness is com m on in most pregnant women and
supra pubic palpation invariably leads to discom fort. However the
presence o f renal angle tenderness and pyrexia are abnorm al signs. In
some patients the presence o f prem ature labour may be detectable on
palpation o f regular contractions o f the uterus. The presence o f a small
for dates uterus may indicate longstanding systemic infection. All
women with preterm labour should be tested for a UTI.

The diagnosis may be suspected on urinary dipstick testing. The

presence of protein, nitrites, blood or leucocytes supports this diagnosis.
The definitive diagnosis should be made by perform ing m icroscopy,
culture and sensitivity tests on a mid stream urine test (M SU). The
presence o f pus cells is im portant to confirm that this is not a
contam inated sample. Greater than 106 colonies per ml of a coliform
organism usually confirm the diagnosis.

In sym ptom atic patients treatm ent may com m ence em pirically
with antibiotics such as penicillins or cephalosporins depending on
regional sensitivity patterns. A dequate analgesia should be prescribed
and liberal fluid intake encouraged. Lower urinary tract infections can
be treated satisfactorily on an outpatient basis with oral m edication.
However, patients with pyelonephritis may be constitutionally unwell and
the attendant vomiting means these patients may require admission for

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parenteral antibiotics and intravenous fluids. Treatm ent can be tailored

pending the sensitivity report. Failure to respond to treatm ent, despite
appropriate sensitivities, may suggest urinary tract abnorm ality such as a
calculus, renal abscess, or bladder diverticulum . Urinary tract
abnorm alities are difficult to diagnose since the urinary tract is
abnorm ally dilated in all pregnancies and there is a thrust to limit fetal
exposure to X- rays. U ltrasonography is also made difficult by the
presence of the pregnant uterus. Definitive evaluation for abnorm alities
o f the urinary tract is best done three m onths after the end o f pregnancy.
Very rarely in severely ill patients, a single film intravenous pyelogram is
perform ed.
Pregnancy predisposes patients to recurrent urinary tract
infections and therefore some units recom m end that a repeat MSU be
perform ed ten days after treatm ent to ensure the absence o f bacteruria. If
present, a urinary antiseptic such as nitrofurantoin can be prescribed for
the duration o f the pregnancy.

PERIODONTAL DISEASE
There have been several studies, which have linked dental caries and
gingivitis to perinatal problem s. The offending organism is usually
P o r p h y r o m o n a s g in g iv a lis . These studies have linked periodontal disease
with preterm labour, growth restriction and even pre-eclam psia.
Im proving dental hygiene has been reported to reduce these problem s.

VAGINAL INFECTIONS
Bacterial vaginosis results from an im balance o f the norm al vaginal
flora with an overgrowth o f anaerobic bacteria and a lack o f the norm al
lactobacillary flora. D uring pregnancy it is associated with poor perinatal
outcom e and, in particular, preterm birth.

While studies have been conflicting as to whether or not BV causes

preterm labour most now agree that this is quite plausible. A m eta­
analysis was done of studies looking at random ized trials com paring
antibiotic treatm ent with placebo or no treatm ent, or com paring two or
more antibiotic regim ens in pregnant women with bacterial vaginosis or
intermediate vaginal flora. Treatm ent did not reduce the risk of PTL
before 37 weeks, or the risk o f preterm pre-labour rupture o f m em branes
(PPROM). However, treatment before 20 weeks' gestation did reduce the
risk o f preterm birth less than 37 weeks.

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The diagnosis o f BV is done by exam ination o f a smear from the

endocervix. The presence of Clue Cells is confirm atory. Treatm ent is
with either clindam ycin or m etronidazole.

Group B B Haemolytic streptococcocus (GBS) is a com m on cause o f

infection in women. A bout 30% will have asym ptom atic cervical
colonisation. This can cause serious infections in a neonate. Early onset
disease occurs in 2-3/1000 babies and manifests it self as septicaemia,
septic shock, pneum onia or m eningitis. This is much m ore likely in
preterm infants. Late onset infection occurs in 1/1000 infants and occurs
about 4 weeks after delivery and usually occurs as a m eningitis. Swabs
should be obtained from the lower vagina (not cervix) and rectum (not
anal orifice) and should be prom ptly placed into non-nutrient transport
m edia (e.g., Stuart’s). GBS can be treated with penicillin, erythrom ycin
or clindam ycin. There is no evidence that GBS causes preterm labour
and treatm ent is normally only given during labour to reduce the risk o f
neonatal infection.

Vaginal candidiasis is probably the most com m on clinical infection in

pregnancy. It tends to occur more frequently in pregnancy, presenting
with a thick m em brane-like cheesy discharge associated with itching and
redness of the vulva. These infections are more com m on in diabetic and
im m unocom prom ised patients and cause no serious risk to the m other or
child. Treatm ent is with vaginal pessaries such as mycostatin or
clotrim azole.

SEXUALLY TRANSMITTED INFECTIONS

These are im portant in pregnancy because they are usually transmitted to
the baby during delivery or in some cases breast-feeding. These include
G o n o c o c c u s , C h la m y d ia tr a c h o m a tis , Human papillom a virus. Human
im m unodeficiency virus, Human T cell lym photrophic virus and
Hepatitis B and C. Other STDs such as Herpes Simplex and Syphilis have
already been discussed earlier in the chapter.

GONOCOCCUS AND CHLAM YDIA TRACH O M ATIS

G onoccoccus (GC) and Chlam ydia are two o f the two most com m on
sexually transmitted infections. Both cause purulent inflam m ation of
m ucous m em branes. In women of reproductive age, they do not cause
vaginitis because the vaginal epithelium is too thick. They however will
cause urethritis, cervicitis, endom etritis and salpingitis. All these surfaces

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are lined by m ucous m em branes. In children and postm enopausal

women however, vaginitis is possible. Inadequately treated infection may
result in the Fitz-Hugh-Curtis syndrom e.

The specimen o f choice for establishing the diagnosis of GC and

Chlam ydia is an endocervical swab. M icroscopic exam ination will reveal
intracellular diplococci in the case o f GC while C hlam ydia requires an
ELISA, PCR or ligase chain reaction test to confirm the diagnosis.

In pregnancy the fetus is protected by the m em branes (chorion

and am nion) and only becomes infected if this is breached. Infections
therefore occur com m only during vaginal delivery. This can result in
serious eye infections ( O p h th a lm ia n e o n a t o r u m ) and if not treated
prom ptly blindness can result. This is prevented by routinely giving all
babies silver nitrate eye drops shortly after birth.

HUM AN PAPILLOM A VIRUS

Human papillom a virus is very com m on; a recent study in
Jamaican women, pregnant and non-pregnant, revealed that about 80%
o f them had been exposed to HPV. O f the over 200 serotypes about
thirty are serious (high risk). The high-risk types such as type 16, 18, 31,
45 can cause genital and head and neck cancers. Low risk types such as
6 and 11 cause genital warts (c o n d y lo m a ta a c u m i n a ta ) and laryngeal
papillom ata. The virus if present in an active lesion can be passed to the
fetus during delivery and result in neonatal and childhood HPV.
Treatm ent o f condylom ata includes local destruction with cryotherapy or
electrocautery or the use o f creams such as interferon alpha or
podophyllotoxin. These creams are however contraindicated in
pregnancy.

M any authors have shown that HPV infections tend to get worse
in pregnancy and regress after. This is as a result o f the relative
im m unocom prom ised state o f pregnant women. Thus multiple
pregnancies are believed to be a risk factor for persistent HPV infection
and the developm ent o f intra-epithelial neoplasia and cancer of the
vulval vagina and cervix.

The introduction o f vaccines against the most com m on types 16,

18, 6 and 11 has already occurred and has been shown to be almost
100% effective. Long-term data is awaited.

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H U M A N IM M UNODEFICIENCY VIRUS
Over 40 m illion people worldwide are infected with H IV . U nlike
m any sexually transm itted diseases the num bers continue to rise as this
disease is incurable and there is no vaccine. In the C aribbean some
countries have rates, which are very high second only to Sub Saharan
A frica. AIDS is now the leading cause o f death am ong y o ung adults 15-
44 years old in the C aribbean. Unlike sub Saharan A frica where rates are
uniform ly high in m ost countries because o f land borders, in the
C aribbean the rates are not hom ogenously high and we m ust be careful
not to stigmatise all countries when we quote this problem as a C aribbean
problem . The highest rates are 6.1% in Haiti, 3.5% in the B aham as, 2.7%
in G uyana, 2.5% in D om inican R epublic and T rinidad and T o b ag o ,
1.2% in B arbados and Jamaica and less than 1% fo r m ost Eastern
C aribbean countries and Cuba (Figueroa 2 0 03). A rate o f less than 1% is
similar to most developed countries in N orth A m erica and E urope and in
some o f these countries there are higher rates in pockets o f the
population especially in Eastern E urope.

This is an RNA virus that is transm itted by contact with body

fluids such as blood and semen. M ost people contract HIV during
unprotected sexual contact. The epidem ic is also fueled by the use o f
illicit drugs especially from exchange o f hypoderm ic needles and from
prostitution. While the disease was at first m ore com m on in hom osexual
m en, heterosexual contact is now the leading m ode o f transm ission
accounting for 65% o f disease in the C aribbean.

Once infected, an individual will develop antibodies (seroconvert)

within 3 weeks up to 12 m onths. D uring the time when they are
seronegative they may still be infectious (window period) and only
antigenic testing will determ ine this. The HIV ELISA usually becom es
positive at about 4 m onths. The W estern Blot confirm atory test is always
done if ELISA is positive, to ensure true seropositivity. A rapid test has
been introduced which gives results in a few hours and is o f great value
for unbooked patients who present in labour.

In pregnancy the virus can be transm itted from m other to child

through the placenta or in most cases (66-75% ) during childbirth. This
used to be a very com m on m ode o f transm ission and resulted in over
1000 children infected annually in the C aribbean. Howeve,r this is now
being reduced by the use o f universal screening o f all preg n an t wom en
and the introduction o f antiretroviral therapy during pregnancy and
delivery and by avoiding breast-feeding in positive w om en. This strategy
can reduce m other to child transm ission from about 25% to 1-2%.

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M onitoring o f pregnant women is done using their CD4 count

and viral load and this determines the type and dose o f antiretroviral
therapy given. Zidovudine m onotherapy only reduces perinatal
transmission to about 8%. Achieving better rates requires m ulti-drug
treatment (HAART-highly active antiretroviral therapy). However, some
o f these drugs are costly and not without toxicity. In a few Caribbean
islands, prevention o f m other-to-child transmission (MTCT) of HIV with
zidovudine prophylaxis has reduced transmission rates from 27 - 44% to
5.5 - 9 % (Steel-Duncan et al 2004).

Neonates who are at risk are also given anti retroviral therapy
nevirapine suspension soon after birth. Caesarean section is an option
especially in women with high viral loads and low CD4 counts. Providers
should practice universal safe practices when dealing with all patients
(regardless of known HIV status), as there have been reports o f health
care workers becom ing infected from needle stick injuries or contact
with infected body fluids in the eyes or cuts on the hand.

HUM AN T CELL LYM PHOTROPHIC VIRUS

Adult T-cell leukem ia/lym phom a (ATL) is the com m onest lym phoid
malignancy in adult Jamaicans, reflecting the role o f the causative agent,
human T-cell lym photrophic virus type I (HTLV-I). This virus causes
im m unocom prom ise o f the host and can result in other disorders such as
HTLV-I-associated m yelopathy/tropical spastic paraparesis (HAM TSP)
and infective dermatitis in children.

The major modes of transmission are through sexual contact,

blood transfusion, and m other to child via breast-feeding. Some bottle-
fed babies also seroconvert so some vertical transmission during
childbirth also does occur. Babies born to m others with HTLV-1 may be
antibody positive for a few months after birth because of the passive
transfer of m aternal antibodies. However, after this time seropositivity
usually means infection. The consequences to the infant are serious in
some cases, leading to infective dermatitis and possible later ATL or
HAMTSP. The majority o f infections are however asym ptom atic.

HEPATITIS
There are several viruses that can cause Hepatitis in hum ans. The most
im portant in pregnancy is Hepatitis B. Hepatitis C also has obstetric

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implications similar to Hepatitis B. However, the presence o f the antibody

to Hep C does not prevent vertical transmission, which occurs in about
5% o f cases. The risk o f fetal infection is related to the Hep C RNA viral
load. These viruses are dealt with in more detail in the Chapter on
Jaundice in Pregnancy.

SCREENING
The introduction o f screening for infections in pregnancy has now
becom e an im portant part o f obstetric m anagem ent. Serological tests for
Syphilis and HIV are standard in most obstetric units. Tests for
antibodies to rubella and antigenic testing for Hepatitis B are also highly
recom m ended. Screening for BV, GBS, G onoccoccus and C hlam ydia is
also done routinely in some units. A mid stream urine looking for
asymptomatic bacteruria is recom m ended by some as m andatory in all
pregnant women. The main limiting factor to these recom m endations is
cost and most countries cannot institute universal screening fo r all o f
these conditions. However, where they are used the providers are better
able to recom m end vaccination where applicable (for future
pregnancies) or prophylactic antim icrobials for the prevention o f
m orbidity and m ortality in the m other and her baby in the present
pregnancy. This approach results in significant long term saving with
reduced hospitaliation and in some cases prevention of rehabilitation and
institutionalisation of children with serious birth defects.

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KEY POINTS

• Pregnancy is a state of relative

immunocompromise.
• The hallmarks of congenital toxoplasm osis
are intracerebral calcifications,
hydrocephalus and chorioretinitis.
• The most common birth defects associated
with the congenital rubella syndrom e are
cataracts, glaucom a, blindness, deafness
and mental retardation.
• CMV is the virus most frequently
transmitted to the fetus and can cause
hearing loss and other problems.
• The mode of delivery in patients with active
genital herpes at term is by caesarean
section.
• The avoidance of breastfeeding and
antiretroviral therapy during pregnancy
and delivery can reduce mother to child
transmission rates of HIV from 25% to 1-
2 %.
• In HIV the mode of delivery is by caesarean
section if the maternal viral load is high.
• Screening for infections is an integral
component of antenatal care.

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CHAPTER TWENTY SEVEN

THE PUERPERIUM
LACTATION

THE PUERPERIUM
The puerperium refers to the period following childbirth during which
the various anatom ical and physiological changes that occurred during
pregnancy revert back to the pre-pregnancy state. The duration is
typically six weeks. The process o f involution occurs exponentially, the
rate is most rapid in the first two weeks and then m ore gradual in the
subsequent weeks. Some changes such as stretch m arks can be
perm anent.

A N A TO M IC A L CH A N G ES
U te r in e in v o lu tio n
This is the process w hereby the postpartum uterus, which weighs 1kg,
reverts to its pre-pregnancy state o f less than lOOg. Im m ediately
following delivery the fundus o f the uterus is just palpable above the
um bilicus but by two weeks postpartum it is at the level o f the sym physis
pubis. Involution occurs by a process o f autolysis. The b y-products are
absorbed through the bloodstream and excreted in the urine. This
process is more rapid in women who breastfeed.

L o c h ia
Following the expulsion o f the placenta the decidua sloughs as a result o f
necrosis. M ost o f it as part o f the lochia. Initially this is dull red in colour
and by the end o f the second week it becom es reddish-brow n and then
yellowish and disappears by the 4-6 weeks after delivery. Persistent red
lochia suggests delayed involution. This could be due to infection or
retained placental tissue. Occasionally red lochia may occur during
breastfeeding.

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Cervix
The cervix is very flaccid, oedem atous, irregular and bruised
im m ediately following delivery. Small cervical lacerations are frequent
and require little attention unless bleeding. The internal os rem ains
patent until the second week but the external os takes m uch longer and
may rem ain perm anently patulous.

Vagina and vulva

Following delivery the vaginal wall is sm ooth and oedem atous with a
bluish hue. W ithin a few days the rugae reappear. Lacerations o f the
vagina and perineum generally heal well. T hough this m ay be adversely
affected by haem atom as, infection and poor suturing technique.

Urinary Tract
Initially for 2-3 days the lower urinary tract is oedem atous and bruised
and m icturition may be difficult. M arked diuresis occurs within the first
few days. By week 3 the ureteric dilatation is reduced and m ainly
com plete by 6-8 weeks. However, it may persist in some patients fo r 12
weeks and interferes with the interpretation o f an intravenous urogram
(IVU).

Breasts
These changes are described in detail at the end o f the chapter.

PH YSIOLOGICAL C H A N G ES
Horm onal
After the third stage o f labour there is a decline in the levels o f the
following horm ones: hum an placental lactogen (H PL), progesterone,
oestrogens, aldosterone, cortisol, m elanocyte stim ulating horm one
(MSH) and insulin.

Prolactin levels in the m aternal blood increase during pregnancy and

remain elevated after delivery in the presence o f lactation. Episodic
peaks are superim posed by suckling. In m others who choose not to
breastfeed or if lactation is never established prolactin levels return to
normal in two weeks.

Cardiovascular and C oagulation changes

Both the heart rate and cardiac output fall in the early puerperium . There
is a rise in stoke volum e and peripheral resistance. The plasm a volum e
initially increases due to return o f blood from the placenta and then

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begins to decrease. It is traditional to check the hem oglobin level on day

3 post delivery but in the absence o f postpartum blood loss the level may
not fall. Plasma fibrinolytic activity is increased from days 1-4 and
returns to norm al by one week and the platelet count rises. These
changes contribute to an added risk for throm bo-em bolism .

O varian function and Menstruation

Women who breastfeed will not experience any return o f periods on
average for 3-4 m onths. N on-lactating women can ovulate as early as
day 27 and m enstruate by 8 weeks. This puts them at risk fo r pregnancy
even prior to the traditional postnatal visit. An elevated prolactin level in
breastfeeding m others suppresses ovarian activity and the resum ption o f
m enstruation. This is referred to as lactational am enorrhea and is an
im portant form o f contraception worldwide albeit not very effective.

W eight loss
There is an immediate loss of 4.5-6kg following birth due to the
placenta, amniotic fluid and blood loss. By 6 weeks postpartum about
30% of women have returned to their pre-pregnancy w eight. The
rem ainder should have done so by 6 m onths if they had not experienced
excess weight gain during pregnancy. W omen who gain in excess o f
15kg may have a net gain o f m ore than 5kg at 6 m onths and this may be
indefinite.

M ANAGEM ENT
G eneral measures
Im m ediately after delivery, the baby should be offered to the m other to
be cuddled and suckle. Most w omen after this are exhausted and fall
asleep. Repair of the episiotom y and any lacerations should be
com pleted expeditiously and the m o th e r's vital signs are observed every
15 m inutes for 30-60 m inutes. The uterus should be palpated to confirm
contraction and the vulval pads exam ined for any excessive blood loss.
The patient is tidied and transferred to an observation area. She is then
offered som ething to drink and encouraged to void. If there is difficulty,
catheterization may be required. Once the m o th e r's condition is stable
she is transferred to the postnatal ward.

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Postnatal ward care

D uring her confinem ent the patient’s pulse, tem perature, blood pressure,
fundal height and the lochia should be evaluated regularly. The breasts
may be exam ined and the legs checked for tenderness. The perineum
and any w ounds are checked for signs of infection. The urine output and
bladder em ptying are checked to ensure norm ality. Bladder em ptying
may be delayed following regional analgesia/anaesthesia and these
patients may benefit from an in-dwelling urinary catheter. Early
ambulation is encouraged alongside appropriate physiotherapy
including pelvic floor exercises.

Care of the perineum

The patient is advised on perineal hygiene and encouraged to adopt a
regim e as per unit protocol. Simple analgesics such as paracetam ol or
diclofenac suppositories, infrared irradiation and an ointm ent containing
a local anaesthetic will reduce discom fort. A low residue diet and stool
softeners can be prescribed for patients with extensive vaginal/perineal
lacerations,especially third and fourth degree perineal tears involving the
anal sphincter com plex.

Preparing for discharge

Most first time m others spend at least 24 hours in hospital following a
norm al vaginal delivery. M ultigravidas could be discharged between 6-
24 hours postpartum if there are no com plications.

The patient and her partner are taught proper infant feeding and
care practice. Observations are made to ensure successful m other/infant
bonding and help with em otional and physical support. Some maternity
units have a dom iciliary service available which can be helpful. G eneral
practitioners, com m unity midwives and public health nurses deal with
m other and infant issues in the com m unity with a low threshold for
hospital referral in the event of com plications following discharge.

THE PO STNATAL VISIT (6 WEEKS)

The purpose o f this visit is to ensure that m other and baby are in good
health and to address any concerns. Enquiries are made about lactation,
return o f m enstruation and sexual activity. A joint clinic with obstetric,
midwifery and paediatric personnel would be the ideal fram ework so that
m other and baby issues could be addressed sim ultaneously.

The exam ination includes an assessment o f her mental and physical state
and the progress of the baby. Weight, blood pressure and urinanalysis

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are docum ented and a general, abdom inal and pelvic exam ination
perform ed. A cervical sm ear can be taken at this time if not done
previously. Special attention is paid to urine, bowel and sexual function.
Advice is given about contraception and pelvic floor exercises.

CO NTRACEPTIO N
O f the m ethods of contraception available the most reliable are
sterilization, horm onal m ethods and the intra-uterine device. Sterilization
is an effective form o f contraception but it is essentially irreversible and
hence perm anent. It can be done im m ediately postpartum o r prior to
hospital discharge by m ini-laparotom y. A fter the postnatal visit it may be
perform ed in a num ber o f fashions, one o f which is laparoscopic clip
sterilisation.

H orm onal contraception available includes:

• the com bined pill
• progesterone only pill (m ini pill)
• injectable progesterone e.g. depot m edro x y -p ro g estero n e acetate
(D epo-provera)
• progesterone im plant e.g. Im planon
• levonorgestrel intrauterine system (M irena)

Traditionally the pill is started when menses resum e, however ovulation

precedes m enstruation in 75% o f cycles. It would make sense to start the
pill earlier but this is associated with an increased risk for th ro m b o ­
em bolism and inhibition o f lactation. It can be started after three m onths
o f delivery, even if still breastfeeding.

COM PLICATIO NS OF THE PUERPERIUM

Puerperal Pyrexia
Significant puerperal pyrexia is defined as a tem perature o f 38°C
(100.4°F) or higher on any two o f the first 10 days postpartum exclusive
o f the first 24 hours. C om m on sites associated with puerperal pyrexia
include chest, throat, breasts, urinary tract, pelvic organs, Caesarean or
perineal w ounds and the legs. The evaluation o f the sym ptom s, signs and
relevant investigations and treatm ent o f puerperal pyrexia are shown in
Table 1.

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Table 1: PrinciDles for manaeement of oueroeral Dvrexia

Symptoms Diagnosis Investigations

Manaeement

Cough Chest infection Sputum for C/S

Physiotherapy
Purulent sputum Pneumonia
Antibiotics
Dyspnoea

Sore throat Tonsillitis Throat swab

Antibiotics
Cervical adenopathy

Headaches Meningitis Lumbar puncture

Antibiotics
Neck stiffness

Dysuria Pyelonephritis Urine for C/S

Antibiotics
Loin pain

2° PPH Endometritis Pelvic ultrasound

Antibiotics
Tender bulky uterus
Curettage

Pelvic or Deep vein thrombosis Doppler of legs

Heparin
Calf vein tenderness

Chest pain Pulmonary embolism V/Q scan/Spiral

Heparin CT

Painful or Mastitis Milk for C/S

Antibiotics
Engorged breasts Abscess
Incision/drainage

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 P U E R P E R IU M

Genital tract infection

• Lower genital tract infection; the com m onest culprit is an infected
episiotom y or a vaginal laceration. T reatm ent consists o f
m eticulous hygiene, analgesics and antibiotics
• U pper genital tract infection: In most instances, the infection is
confined to the decidua. This occurs within the first week after
delivery and the clinical findings are pyrexia and an offensive
heavy lochia. The uterus is tender and there is cervical excitation
pain. O ccasionally the organism s are virulent and spread beyond
the m yom etruim to involve the param etrium , tubes and ovaries.
G eneralized peritonitis leading to septicaem ia and endotoxic
shock may follow. Treatm ent consists o f aggressive fluid and
electrolyte replacem ent and broad spectrum antibiotics whilst
awaiting culture reports. A ntibiotic regim es include either
Am oxiclav and M etronidazole or C ephalosporin and
M etronidazole. Clindam ycin and G entam icin have also been
used.

Urinary tract infection

This is one o f the main causes o f puerperal pyrexia. It may be recurrent
pyelonephritis or infection acquired after delivery. The latter is a
com m on com plication and results from traum a to the bladder during
delivery, urinary retention and catheterization. Sym ptom s are mild
pyrexia, dysuria and urinary frequency. A fter obtaining a MSU,
em pirical broad spectrum antibiotics are started pending the culture
report.

Mastitis
The incidence is low but may follow breast engorgem ent. The infective
organism is usually staphylococcus. Prophylaxis is by ensuring
em ptying o f the breasts after suckling. Treatm ent is with M ethicillin or
Cloxacillin. Cases of M ethicillin resistant staphylococcus are now being
reported (M RSA) in which C iprofloxacin or V ancom ycin is the drug o f
choice.

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 P U E R P E R IU M

Table 2: Com m on risk factors for puerperal genital infection

Antenatal intra-uterine infection

Prolonged rupture of membranes
Prolonged labour
Multiple vaginal exam inations
Instrumental delivery
C aesarean section
Retained products of conception
M edical factors e.g. obesity, diabetes, HIV

Table 3: Puerperal pelvic infection

M alaise, headache, fever, rigours
A bdom inal discom fort, vomiting and diarrhoea
Offensive lochia
Secondary postpartum haem orrhage

Signs of pelvic infection

P yrexia and tachycardia
Uterus enlarged, boggy and tender
Indurated adnexae
Bogginess in the pouch o f D ouglas
Abdom inal distension
Peritonism and paralytic ileus

Investigations for puerperal genital infection

Full blood count
Urea and electrolytes
High vaginal swabs and blood culture
Pelvic ultrasound
C oagulation screen e.g. suspected DIC
A rterial blood gas e.g. shock

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 P U E R P E R IU M

Prevention of puerperal sepsis

This can be achieved by applying the principles o f general hygiene,
good surgical techniques and scrupulous hand w ashing when exam ining
patients. The risk is higher following Caesarean section especially in an
em ergent setting. Use o f prophylactic antibiotics such as A m oxiclav or
C efuroxim e and M etronidazole adm inistered by a single or two doses
after clam ping o f the cord is recom m ended.

Thrombosis and Embolism

The main factors responsible for p u erp eral throm bosis are: stasis,
infection and alteration in the blood constituents. There is a shift in the
balance from fibrinolysis to hy p er coagulation in the p u erp eriu m . O ther
risk factors include obesity, advanced m aternal age, anaem ia, operative
delivery and traum a to the calf veins.

Superficial throm bophlebitis

The area around the vein is red and tender. The risk o f extension to the
deep veins is low. This condition responds well to non-steroidal anti­
inflam m atory analgesics.

Deep venous throm bosis

This condition ranks high as a cause o f m aternal m ortality. There are two
types: phlebo-throm bosis and ilio-fem oral throm bosis.
• Phlebothrom bosis: In this condition the patient com plains o f pain
in the calf and on exam ination there is evidence o f inflam m ation,
calf tenderness and a positive H o m an ’s sign. In some patients
these sym ptom s and signs may be vague and the initial
presentation m ay that o f pulm onary em bolism .
• Ilio-fem oral thom bosis: this type is associated with pelvic sepsis
and most com m only occurs in the second postpartum week. The
main finding is that o f a swollen tender leg with a bluish hue to a
very swollen cold leg white in co lo u r (phlegm asia alba dolens).

Both conditions can present as pulm onary em bolism . The initial

investigation o f choice is doppler scanning. M anagem ent is aim ed at
m inim izing the predisposing factors and consists of: early
am bulation, aggressive treatm ent o f pelvic sepsis, com pression
stockings and anticoagulation. Low m olecular weight heparin or
unfractionated heparin may be used. This can be converted to
warfarin therapy once fully anticoagulated. Breast feeding can
continue with warfarin therapy as less than 2% is excreted via breast
m ilk.
 P U E R P E R IU M

Secondary Postpartum H aem orrhage

This is defined as bleeding form the genital tract after 24 hours and up
to 6 weeks postpartum . This is covered in C hapter 20.

Puerperal psychological disorders

C hildbirth is usually a m uch longed for and happy event but m aternal
sadness and depressive sym ptom s can occur in up to 28% o f wom en.
M any cases are under diagnosed and under treated. The m ajority o f
women leave hospital within 48 hours o f delivery and may not be seen
until the postnatal visit at 6 weeks. At this time the focus may be on
physical ailments and m uch attention on the baby thus overlooking o f
the w o m an 's mental state. Three types o f postpartum m ental disorder are
recognized.
• Postpartum "b lu es” ; this is a transitory and relatively benign
condition affecting up to 70% o f w om en. It peaks at day 3 and is
resolved by day 10. E m otional and psychological support is
given but no pharm acotherapy is necessary.
• Postpartum psychosis; this may be seen in about 0.1% o f
postnatal women. It is characterized by anxiety, a com bination o f
m ania and depression, suicidal thoughts and a wish to self-harm
or the baby. This problem is a psychiatric em ergency as 5% o f
women are at risk for suicide or infanticide. Institutionalized care
under strict supervision may be needed initially.
• Postpartum depression: seen in up to 10-15% o f w om en.
C om m on sym ptom s are insom nia, loss o f self-esteem , m ood
swings and occasionally obsessive behavior. T reatm ent is by a
psychiatrist who will provide psychotherapy and anti-depressants.
Family support is extrem ely im portant.

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 PUERPERIU M

Table 4: Risk factors for postnatal depression

Single m other
A ge less than 20 years
U pbringing by a single parent
P oor parental support in childhood
P oor relationship with partner
Socially disadvantaged
P oor educational achievem ent
Low self-esteem
P revious em otional problem s
Previous depressive illness
Difficult or operative delivery
P rolonged hospitalization
Stillbirth

CO U N SELLIN G AFTER PE R IN A T A L D E A T H
W hen a w om an and her fam ily experience a loss associated with
p reg n an cy , special attention is req u ired . T rain ed senior perso n n el and
specialist bereavem ent coun selo rs best handle this task. It is essential that
a robust system is in place that allows all the issues that su rro u n d a
perinatal death to be dealt with in an efficient and com passionate
m anner.
Sym ptom s o f the norm al g rie f reaction include sleeplessness,
fatigue, poor eating habits, guilt, hostility, an g er and d isru p tio n in the
norm al pattern o f daily life. C ounselling can help to identify the g rie f
coping m echanism s most suitable to the individual circum stance.
It must be em phasised that these fam ilies require sym pathy and
an o p p o rtunity to express and discuss issues in an open m an n er. M edical
professionals should be readily available to facilitate this. A ttention will
need to be directed to the legal and adm inistrative obligations follow ing
a perinatal death. N ot least o f which is the post m o rtem . In som e
circum stances, this is a m andatory legal req u irem en t in others it is
optional. In the latter circum stance the couple should be in fo rm ed o f the
p rocedure, the benefits and risks and the im plications fo r future
pregnancies. In a small percentage o f instances this m ay identify possible
preventable causes. This know ledge has im plications fo r risk assessm ent
and counselling in subsequent pregnancies.

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 L A C T A T IO N

LACTATION

ANATOMICAL CHANGES
The breasts are m ade up of glandular, adipose and connective tissue.
D uring pregnancy the breasts increase in size from proliferation of the
glandular tissue and associated ducts and from an increase in fat
deposition between the lobules. These changes are in response to the
horm ones; oestrogens, progesterone and hum an placental lactogen. The
breasts become vascular and the veins becom e visible under the skin. The
nipples and areola becom e larger and more pigm ented with the
appearance o f M ontgom ery ’s tubercles.

The breast consists of 15-20 functional units arranged radially

from the nipple and each unit is made up of a lactiferous duct, a
m am m ary gland lobule and alveoli. The lactiferous ducts dilate to form
lactiferous sinuses. Contractile m yoepithelial cells surround the ducts and
alveoli. The nipple itself is m uscular and becom es erectile (see Figure 1)

Pectoral
m u scle s
co n n e ctive tissu e

M am m ary du cts

M am m ary glan d lo bules

Figure 1. The breast during lactation

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 L A C T A T IO N

PHYSIOLOGICAL CHANGES
The mechanism o f lactation is com plex involving the inter-relation of a
num ber of neuro-endocrine factors. Lactation consists of two phases:

• Prolactin reflex. In this phase, there is secretion o f milk by the

alveolar cells into the alveoli. This is under the control of
prolactin, but this mechanism only becom es active after birth.
Whilst there is a high level o f prolactin during pregnancy, the
simultaneous presence o f high level of oestrogens inhibits the
action of prolactin on the alveoli. Following delivery there is a
rapid fall in oestrogens.

Suckling produces a m arked increase in prolactin level, thereby

encouraging lactation. Continued lactation is dependent on
frequent suckling. Milk appears in the breast by the third to
fourth postpartum day, replacing colostrum s. After this, milk
secretion is a continuous process unless inhibited by other factors
e.g. lack o f suckling, em otional or physical stress.
Prolactin release

Neural
arc
Prolactin
(in blood)

Suckling

Figure 2. Prolactin reflex

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 L A C T A T IO N

• Milk ejection (let-down or draught reflex). In this phase alveolar

milk is ejected into the ducts and the lactiferous sinuses, from
where it is expelled. This is m ediated by a n eu ro-hum oral reflex
whereby oxytocin is released and stimulates the m yoepithelial
cells around the small and large ducts. This reflex is initiated by
suckling and by other factors, such as the awareness o f the
feeding time or the hunger cry o f the infant.

Suckling

Figure 3. Milk ejection reflex

Colostrum
This is a thin yellowish fluid secreted by the breast that can be
expressed as early as the 16th week o f pregnancy. It has high protein
content but less carbohydrate and fat than milk. In addition the
content of sodium , potassium and chloride is higher than milk. It is
replaced by milk by the third or fourth postpartum day. The daily

377
 L A C T A T IO N

volume is less than 50 cc. C olostrum contains IgA (im portant in

protection against gastroenteritis), lysozym e and lactoferrin. The
latter facilitates iron absorption. It is believed that Colostrum also has
a laxative effect which facilitates em ptying the b a b y ’s bowel o f
m econium .

BREASTFEEDING
B reastfeeding is a physiological process and breast milk is the only milk
suited for hum ans. Its com position varies slightly from feed to feed as
well as the gestational age at birth and postpartum . It is not affected by
the m o th e r’s dietary intake.

M easures to prom ote lactation

• A ntenatal preparation
• C orrect technique taught by supporting staff
• Early and frequent suckling
• M anual expression o f the breast after each feed
• Avoid supplem ental form ula
• E ncourage and ensure a calm environm ent.

Advantages o f breastfeeding
• Breast milk is at the right tem perature and ideal nutritional value.
• C heaper than form ula feed with no need for special preparation.
• Breast milk protects against gastroenteritis, m al-absorption, cow
milk allergy, infantile eczem a, neonatal tetany and dehydration.
• Breast milk has antim icrobial properties due to the presence o f
phagocytes, m acrophages, lym phocytes, im m unoglobulins,
interferon producing cells, lysozym e and lactoferrin that protect
against bacteria and viruses by altering the gut flora.
• B reastfeeding prom otes bonding which further prom otes
breastfeeding and attachm ent between m other and her baby.
• Lactation gives some m easure o f protection against conception.
• Reduced risk o f breast cancer.

Barriers to breast feeding

• It is m ore dem anding every 3-4 hours hence it may affect the
m o th e r’s ability to rest and participate in other social activities as
well as return to work. This can be overcom e by expressing breast
milk and suitable storage and given by another m em ber o f the
household.

378
 L A C T A T IO N

• Some women despite adequate measures may not produce

enough milk. Dopam ine receptor blockers e.g. m etoclopram ide
could be used on a tem porary basis.
• Cracked nipples may result which can lead to mastitis and breast
abscesses.

Contra-indications to breastfeeding
• Serious maternal infection e.g. HIV, HTLV-1, TB, septicaem ia or
breast abscess.
• Systemic disease e.g. cardiac failure or cancer
• M edications e.g. cytotoxic drugs or lithium
• Severe mental illness
The health authorities in the region are prom oting a UNICEF initiative to
make all maternity institutions “ b a b y -frien d ly ” .

Table5: Ten steps to successful breastfeeding (UNICEF 2004 )

1) Have a written breastfeeding policy
2) Train all staff
3) Inform all pregnant women of the advantages of breast
feeding
4) Help mothers initiate breastfeeding within 30 minutes of
birth
5) Show mothers how to breastfeed
6) Foster the establishment of breastfeeding support groups
7) Practice 24 hour room ing in
8) Encourage breastfeeding on demand
9) Give newborn infants no other food or drink unless
medically indicated
10) Use no artificial teats

Suppression of lactation
In the face of certain contra-indications to breastfeeding or following the
delivery o f a stillborn infant, inhibiting o f lactation becomes necessary.
Use of a tight brassiere, fluid restriction and liberal analgesics has been
shown to be just as effective as suppressive drugs. Oestogens are no
longer recom m ended due to the risk o f throm bo-em bolism . Dopam ine
receptor stimulants e.g. Brom ocriptine can be given at a dose o f 2.5m g
three times a day for 2 weeks. However concerns about massive

379
 L A C T A T IO N

m yocardial infarction and the cost may limit its use. A lternatively,
cabergoline lm g orally can be adm inistered as a one o ff dose.

KEY POINTS

• During the puerperium (which extends for 6 weeks

after the delivery) various anatom ical and
physiological changes occur.
• Venous throm ho-em bolism is a major complication
in pregnancy and the risk increases further in the
puerperium.
• Puerperal sepsis is a fairly com m on problem . There
are m any causes such as an infected episiotom y,
urinary tract infection, endometritis, mastitis and
chest infection.
• V igilance is recom m ended for the psychological or
psychiatric problems that can occur in the
puerperium. It has become a major cause of
maternal mortality in the UK.
• On the whole breastfeeding should be encouraged.

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 IN D E X

INDEX

Abdom en, V ita m in 12 d e fic ie n c y , 4 5

e xa m in a tio n of, 6-9 s ic k le ce ll,

A b d o m in a l, A n a e s t h e s ia , 3 4 2 -3 4 5
c irc u m fe re n c e , 1 96, 1 9 7 , 2 3 3 re g io n a l, 3 4 3
d e liv e ry, 1 4 8 -1 4 9 g e n e ra l, 3 4 4
pain, 102 -1 0 7 A n a lg e s ia a n d a n a e s t h e s ia , 3 3 1 -3 4 4
A B O in co m patib ility, 179 a n a lg e s ia o b ste tric, 3 3 1 -3 4 1
ce n tral n e u ro a x ia l b lo c k , 3 3 5 -3 3 9
A b ortion , 190,191
p a ra c e rv ic a l b lo c k , 3 3 9
th rea te n e d , 15
p u d e n d a l b lo c k , 3 4 0
habitual, 1 5 -1 6
re g io n a l, 3 3 5 -3 3 6
Abruptio placentae, 164,170-175,264 A n d ro id p e lv is , 31
a e tio lo g y of, 164 A n e n c e p h a ly , 1 3 2 , 2 2 0 , 2 2 2 , 2 2 4
a to n y o f u te ru s in, 173
A n te n a ta l
c o a g u la tio n p ro b le m s in, 173
a im s a n d o b je c tiv e s , 1-2
c o m p lic a tio n s, 173
c a r e , 1-21
A d o le s c e n t p re g n a n c y , 1 0 9 -1 1 5 e xa m in a tio n , 4
A fte rco m in g h e a d , A n te p artu m
d e liv e ry of, 1 4 7 -1 4 8 haemonbage, 18,117,122,164-176,284
A g e , a d v a n c e d , 115-121 fetal s u rv e illa n c e , 2 2 7 -2 3 6
m ate rn a l, 131 A n th ro p o id p e lv is, 32
A lb u m in u ria , 12 A n tib io tics,
A lc o h o l, 131 in c a r d ia c d is e a s e , 8 7 , 8 9
A lp h a feto protein, 3 in d ia b e tic p a tie n ts, 6 2
for p u e rp e ra l p y re x ia , 3 7 0
A m n io c e n te s is , 3, 2 2 4 -2 2 5
A n tib o d ie s s e e im m u n o g lo b u lin
A m n io in fu sio n , 2 2 5 -2 2 6
A n ti-e m e tics, 94
A m n io tic fluid, 2 1 6 -2 2 6
circu la tio n of, 2 1 9 A n tih ista m in e s, 9 4 -9 5
c o m p o sitio n of, 221 A n ti-p ro sta g la n d in s , 2 8 2 -2 8 3
cre a tin in e in, 2 2 3 A rte rio g ra p h y , 167
fetal sw a llo w in g of, 2 1 9 , 2 2 0
A s p h y x ia , 1 3 2 , 1 3 8 , 139
fetal u rinatio n in, 2 1 8
A s y m p to m a tic b a c te riu ria , 2 7 8
in d e x , 2 2 0
p h o s p h o lip id s in, 2 2 1 ,2 2 3 A to n y uterine, 2 6 4 , 2 6 6
v o lu m e of, 2 1 6 , 2 1 9 , 2 2 2 Attitude, 10
A m n io to m y, 3 0 3 A u sc u lta tio n , 9
Anaem ia, 3 8 -5 1 ,1 1 3 ,1 1 6 ,1 2 2 ,1 2 3
a e o tio lo g y , 3 9 -4 0
fo lic a c id d e fic ie n c y , 4 3
B a c te ria l v a g in o s is , 2 8 6 , 3 5 7 -3 5 8
iron d e fic ie n c y , 4 0 -4 3
p h y s io lo g ic a l, 40 B a n d l's ring, 2 6 7
B a ttle d o re p la c e n ta , 2 0 8

381
 IN D EX

B e ta -a d re n e rg ic d ru g s ,74, 2 8 3 -2 8 4 v a g in a l birth after, 31 7

B e ta m e th a so n e , 159, 2 8 1 ,2 8 2 C a lc iu m 14,
B io h y p ica l profile sco re , 2 0 3 C a lc iu m an tag o n ist, 73, 2 8 4 -2 8 5
Biparietal diameter, 1 34,136,195,196,293 C a p u t s u c c e d a n e u m , 241
Birthw eight, 129, 130, 139 C a rd ia c
facto rs affecting, 130 c o m p lica tio n s, 8 8 -8 9
low, 131 d is e a s e , 8 2 -9 0 , 2 4 9 , 30 0
B is h o p sc o re , 300-301 failure, 8 5 -8 6 , 88
output, 84
Blood,
su rg e ry , 89
p re ssu re , 12, 84
su g a r, 5 3-5 6 C a rd io to c o g ra p h y , 1 3 5 -1 3 7 , 2 5 5 -2 5 8
B o d y m a s s ind ex, 126 C a rd io -v a s c u la r c h a n g e s , 83, 84
B o o k in g visit, 2-5 C e p h a lh a e m a to m a , 330
B ra c h ia l n e rve p a lsy, 139 Cephab-pelvic disproportion, 12,245,311
B raxton H ic k s , 2 38, C e rv ix , dilatation, 125, 2 3 7 , 2 82
B re a st, C e rv ic a l
fe e d in g, 3 7 8 -3 7 9 c e rc la g e , 2 86
milk, 3 7 6 -3 7 7 in co m p e te n ce , 17-1 8,2 7 9 ,2 8 6 -2 8 7
laceration ,
B re e c h , 140-149
rip ening, 3 0 0 -3 0 3
c a e s a re a n se ctio n for, 14 8 -1 4 9
c a u s e s of, 141 C hart,
co m p lica tio n s of, 148 kick, 1 3 5 ,2 2 9
d e live ry of, 143, 145 -1 4 8 Lile y , 181
in cid e n ce of, 140 C h ig n o n , 33 0
presentation, 14 0 -1 4 9 C h la m y d ia tra ch o m a tis, 3 59
ty p e s of, 141-142 C h lo rp ro m a zin e , 94
Brom o criptin e, 380 C h o le lith ia sis, 97
B ru ce lla A b o rtu s, 355 C h o le s ta s is , 9 7 -9 9
B u p iv a c a in e , 337 Chono-amnbnitis, 225 ,2 6 1 ,2 6 4 ,2 8 7 ,3 0 3 ,
B u rn s-M a rsh a ll te ch n iq u e, 147 305
C h o rio ca rc in o m a , 194
C h o rio n ic v illu s sa m p lin g , 3
Caesarean section, 117,118,137,139,143, Chromosomal abnormality, 120,131,222,224
169,307-318
C ircu m v a lla te p la ce n ta , 2 09
a n a e sth e s ia for, 3 4 1 -3 4 2
c la s s ic a l, 313 C o a g u la tio n d iso rd e rs, 2 64
co m p lica tio n s of, 3 16 C o c c y x , 24
h ysterecto m y an d, 318 C o lo stru m , 3 7 7 -3 7 9
in d icatio n s for, 3 1 0 -3 1 2
low er se gm e n t, 314 C o n c e a le d h a e m o rrh a g e , 172
p o st o perative c a re , 3 15 C o n d y o m a ta a c u m in a ta , 3 59
rates, 3 0 8 -3 1 0 Congenital rubella syndrome (C R S ), 347-348
repeat,
C o n ju g a te ,

382
 IN D EX

diagon al, 28 Doppler flow assessment, 203,234,235

obstetric, 28 D ysto cia,
true, 28 sh ou lder, 138
Contraception, 368 E c la m p s ia , 68 , 7 7 -8 0
Contraction stre s s test, 2 1 2 -2 1 3 , 232 E c to p ic p re g n a n cy , 191-192
C o n vu lsio n s, 68, 70, 7 0-7 8 Efface m e n t, 138, 237
C o o m b s' test, 179-180 E m b o lism ,
Cord, S e e U m bilical cord, am niotic fluid, 270
Corticosteroid therapy, 2 8 1-282 pulm onary, 369
Cotyledon, 208 E n g a g e m e n t of h e ad , 239
C o u ve laire uterus, 1 7 1 ,2 6 4 E n to n o x, 333
Creatinine, 75, 223 Ep id u ra l block, 3 3 5-339
Crow ning, 242 E p isio to m y, 248-251
Crow n-rum p, Ergo m etrine, 272
length, 133, 189, 190,293 E xam in a tio n under a n a e sth e s ia , 166
C yto m e galo virus (C M V ), 3 4 9 -3 5 0 E xtern al c e p h a lic ve rsio n , 1 4 3-145

D eep vein throm bosis, 372 Fatty liver, 99-101

Delivery, Fem u r,
fo rcep s, 3 1 9 -3 2 6 fracture of, 148
in diabetes, 62 length, 196-197
of breech, 145-149 F e rro u s su lphate,
of tra n sv e rse lie, 150
Fetal
D esferroxam in e, 47 an o m a ly, 199
D exam e th aso n e , 2 8 1 -2 8 2 d e m ise , 132
Diabetes melittus, 52-65,117,134,137,139, d istre ss, 118, 138
227 heart rate, 230
classificatio n of, 52-54 m aturity, 2 1 9 , 2 2 2 , 2 2 6
effect on the fetus of, 5 7-5 9 m acro so m ia, 202
effect on the m other of, 57 m onitoring, 2 5 3 -2 6 0
m an age m e n t of, 5 9-6 4 presentation, 10
risk facto rs, 57 Fib ro id s, 117, 2 7 9
scre e n in g test for, 5 4-5 6
F itz H u g y -C u rtis S y n d ro m e , 359
D iago n al co n ju gate , 28
F o lic a cid , 4 3 -4 4
D iaze p am , 78
Footling b ree ch , 142, 143, 149
D igoxin, 89
F o rc e p s, 2 49, 3 1 9 -3 2 6
D issem inated in travascu lar for afterco m in g h e ad , 322
coagulation, 71, 173, 275 in tra n sv e rse arrest, 322
Diuretics, 75 in heart d is e a s e , 322
in ca rd ia c failure, 88 typ e s, 319-321
in pre-e clam p isia, 75 ind icatio ns, 322

383
 IN D EX

co m p licatio n s, 3 2 4 -3 2 5 Human T Cell Lymphotrophic Vims, 361,362

m ethod, 3 2 3 -3 2 4 H u m e ru s, fractu re of, 149
Fru cto sa m in e , 55, 56 H ydatidiform m ole, 70, 194, 195
F u n d a l height, 6, 133, 134 H y d ra lla zin e , 74
H y d ra m n io s, 2 2 1 ,2 2 5 , 2 7 9 , 287
H y d ro p s fetalis, 2 2 3
G a m m a -g lo b u lin , 182 H yp e rb iliru b in ae m ia , 3 0 5
G e n e ra l a n a e sth e s ia , 3 4 3 -3 4 4 H y p e re m e sis, 1 5 ,9 1 ,9 4 - 9 7
G e sta tio n al H yp e rte n sio n ,
a g e , 130, 133, 139, 293 c la ssific a tio n , 6 6 -6 7
d ia b e te s, 19, 52-6 5, 122, 127 p re g n a n c y -in d u c e d , 68
G lo m e ru lo -e n d o th e lio sis, 70 m a n a g e m e n t, 7 3 -7 7
G lu c o s e to leran ce test, 56 Hypertensive disorders, 112,116,117,122,
G ly c o sy la te d h ae m o glo b in , 55,56 131,227
G ly c o su ria , 1 2 ,5 4 -5 5 H y p o g ly c a e m ia , 132
G o n o c o c c u s , 359 H y p o xia ,
Grand multiparity, 121-126,263,264,299 fetal, 2 2 7
Group B Hemolytic streptococcus (G B S), 358 H yste re cto m y,
in postpartum
G y n a e c o id p e lvis, 31-3 2
h a e m o rrh a g e , 2 6 6 , 2 6 9
in uterine rupture, 2 6 7

H ab itual abortion, 15 Ilium , 22,

H a e m o glo b in , 39 Im m u no glob ulin, 132, 1 8 2 -1 8 4
H ae m o g lo b in o p a th ie s, 4 4 -5 0 Inco m p ete nt ce rv ix, s e e ce rv ica l
H a e m o rrh a ge , in co m p e te n ce In cisio n ,
antepartum , 164-176 P fa n n e n stie l, 313
indeterm inate, 1 7 5-176 su b -u m b ilica l m idline, 312
postpartum , 2 6 3 -2 7 6 Indeterm inate A P H , 1 7 5 -1 7 6
H e ad , In d u ctio n -stab liizatio n , 150
aftercom ing, 147-148
Inhibin, 3,
circu m fe re n ce , 196
e n g a g e m e n t of, 239 Insulin
requirem ents, 60-61
H e art d is e a s e , s e e C a rd ia c
Intracran ial h a e m o rrh a g e , 2 8 9
H epatitis, 97 -9 8 , 362
Intrapartum
H e rp e s S im p le x v iru s, 350-351
m a n a g e m e n t in twin, 1 6 0-162
H u m an ch o rio n ic go nad otrop hin, 3, p re g n a n c y , 1 5 9-162
Human Immunodeficiency Vim s (HIV), 360- Intra-uterine
361 death, 132
H u m an papillom a v iru s, 3 5 9 -3 6 0 d e m ise , 2 2 0 ,2 6 4
H u m an placen tal lacto ge n , 136, 137 grow th-restriction, 18, 1 3 2 -1 3 7
tra n sfu sio n , 182

384
 IN D EX

In ve stigatio n s, 5 L a n u g o ,219
Iron, L a rg e -fo r-d a te s, 129, 130, 137, 139
d e ficie n cy, 4 0 -4 3 Le o p o ld m an o e u vre , 7-8
p ro p h ylaxis, 42
Lie ,
requirem ents, 41
ab no rm al, 149-151
ven ofer, 43
longitudinal, 9
Isch iu m , 23 o bliqu e, 149
Iso -im m unization , 1 7 7-185 tra n ve rse , 149, 150
Iso xu p rin e, 283 u n stab le , 123
Lig h te n in g , 238
L ile y chart, 181-1 8 2
Ja u n d ic e , 9 7 -1 0 2 Liste ria m o n o c y to g e n e s, 354
Lo c h ia , 364
L o v s e t's m an o e u vre , 147
K ic k chart, 135
K id n e y,
function, 70 Macrosomia, fetal, 122,127,130,137-139,
failure, 70 292
K ie lla n d 's fo ce p s, 324 M alpresentation , 140
M a g n e siu m su lp h a te , 7 7 -7 9 , 2 8 5
Labo ur, M arginal insertion, 164
d ia g n o sis of, 239
M astitis, 370
fetal m onitoring in, 244
first sta g e of, 2 4 5 -2 4 6 M aternal m ortality, 82, 119, 164, 341
induction of, 2 9 2 , 2 9 4 , 2 9 8 -3 0 6 M a u rice a u -S m e llie -V e it, 147
m e ch a n ism of, 2 4 0 -2 4 3 Maximum vertical pool of liquor, 201,219
norm al, 2 3 7 -2 5 2
Me D o n a ld 's suture, 18
preparation for, 238
preterm , 19-20, 2 7 7 -2 8 6 M econium , 2 2 2 ,2 9 2
p ro g re ss of, 2 4 5 -2 4 6 aspiration of, 132,139,2 2 5 ,2 9 2 ,2 9 5 ,2 9 6
se c o n d sta g e of, 138, 246 M e m b ran e s,
third s ta g e of, 2 4 6 -2 4 7 ruptured, 303
trial of, 35-3 7 M e n d e lso n 's sy n d ro m e , 294
La ce ra tio n s, M enstrual history, 3 -4
ce rv ica l, 267
M ethyldopa, 74
perineal, 138, 248
uterine, 267 Mid stream urine test (M S U ), 7 6 , 356
Lactatio n, 3 7 5 -3 7 8 Milk ejection reflex, 377
su p p re ssio n , 379 M iscarriag e , 15-1 6, 190-191
Lactifero us Mitral
du cts, 375 in co m p e te n ce , 82
sin u s e s , 375 ste n o sis , 82
L a m a ze , 332 valvo to m y, 89
Lam inaria, 302, 303 M o n iliasis, 358

385
 IN D E X

M o u ld in g, 241 P a r a c e r v ic a l b lo c k , 3 3 9 -3 4 0
M ultiple p r e g n a n a c y , 1 5 3 -1 6 3 P a w lik 's g rip , 8
P e lv im e try , 3 2 -3 5
N a e g e le 's rule, 3 ,2 9 3 P e lv ic
N a lo x o n e , 3 3 3 a x is , 31
b o n e s , 2 2 -2 4
N a u s e a a n d vo m itin g, 15
c a v ity , 2 7 ,2 9
N e o n a ta l, d ia m e te rs, 28-31
h y p o c a lc a e m ia , 58 inlet, 2 6 -2 8 ,
h y p o g ly c a e m ia , 58 jo in ts, 2 4 -2 6
ja u n d ic e , 58 outlet, 2 7 , 29
N ica rd ip in e , 2 8 4 ty p e s, 3 1 -3 2
N ife d ip in e , 7 4 , 2 8 4 P e lv is ,
N itrofurantoin, 3 5 7 c o n tra c te d , 12
ty p e s of, 3 1 -3 2
N itro u s o xid e , 3 3 2 ,3 4 3
P e n ic illin , 3 5 3 -3 5 4 , 3 5 7 -3 5 8
N on-stress test, 136,2 1 3 -2 1 4 ,2 3 0 -2 3 1
P e rin e a l la c e ra tio n , 2 4 8
N u c h a l tra n s lu c e n c y , 3
P e rin e u m c a r e , 3 6 7
Nutrition, 13, 131
in h y p e re m e s is , 95 P e rin a ta l d e a th , 3 7 4
Perinatal mortality, 1 1 9 ,1 2 7 ,1 4 0 ,1 6 4 ,2 9 1
O b e s ity , 7 0 , 8 5 , 1 2 6 -1 2 8 , 1 3 7 , 139 rate,
O c c ip ito -a n te rio r p o sitio n , 1 5 2 -1 5 3 P e rio d o n ta l d is e a s e , 3 5 7
O cc ip ito -p o ste rio r p o sitio n , 1 5 1 , 241 P e th id in e , 3 3 3 , 3 4 3
O e d e m a , 13 P h le b o th ro m b o sis , s e e T h ro m b o s is
O e strio l, 3, 137 P h o sp h a tid y l,
c h o lin e , 2 2 3
Oligohydramnios, 136,141,201,218-222,
ino sito l, 2 2 3
2 2 5 ,2 2 7 ,2 3 4 ,2 8 8 ,2 9 2 g ly c e ro l, 2 2 3
O p th a lm ia n e o n a to ru m , 3 5 9 P h o s p h o lip id s , 2 2 1 ,2 2 3 , 3 2 3
O p tic a l d e n sity , 2 2 2
P itu itary n e c ro s is , 2 7 5
O utlet
P la c e n ta , 1 2 9 , 2 0 7 -2 1 5
fo rc e p s, 321 ab ru p tio , 1 7 0 -1 7 5 , 2 0 9 , 2 7 0
o f p e lv is, 2 7 a c c re ta , 2 6 8
O v a ria n c y st, 141 a g in g of, 2 0 9 , 2 1 0
O x y to c in , 3 0 4 -3 0 5 b a ttled ore, 2 0 8
c irc u m v a lla te , 2 0 9
O xytocin challenge test 1 3 6 ,2 3 2 ,2 7 1
e xa m in a tio n of, 2 1 0
in cre ta, 2 6 8
in s u ffic ie n c y of, 211
P a in , lo c a liza tio n of, 1 6 7 -1 6 8 , 199
a b d o m in a l, 1 0 2 -1 0 8 m a n u a l re m o v a l of, 2 6 8 -2 6 9
relief, 331 m orb id ly a d h e re n t,
p e rcre ta , 2 6 8
P a in fu l c ris is , 4 8 , 1 0 6 -1 0 7
p e rfu sio n , 71

386
 IN D E X

p ra e v ia , 1 6 5 -1 7 0 P ro lactin , 3 7 6
retain ed, 2 6 7 -2 6 9 P ro la p s e o f co rd, 123, 142, 2 9 9
se p a ra tio n of, 2 4 6 -2 4 7
su c c e n tu ria te , 2 0 9 P ro lo n g e d lab ou r, 118

M o rp ho logy, 199 P ro p ra n o lo l, 7 4 -7 5

P A P P -A , 3 P ro s ta g la n d in s , 3 0 2 , 3 0 3

P la c e n ta l, P ro te in u ria ,12, 68
function test, 2 1 2 -2 1 5 P u b is , 25
insufficiency, 1 2 9 ,1 3 5,136,211,212 P u d e n d a l n e rv e b lo ck, 340
P la s m a vo lu m e, 83 P u e rp e ra l infection, 3 6 8 -3 7 0
P la typ e llo id p e lv is, 32 P u e rp e riu m , 2 6 3 , 3 6 4 -3 7 4
Polyhydramnios, 141,201,219-220,222,227, infection, 3 6 8 -3 7 0
264 P y e lo n e p h ritis, 3 5 6
P o std a te , 139, 2 2 7 , 291
P o stm atu rity, 137, 2 9 1 ,2 9 4
P o stp a rtu m , R a n itid in e , 3 1 2
d e p re s sio n , 3 7 3 R e d -c e ll
haemorrhage, 123-124,128,138,162, m a s s , 39
173,263-276 v o lu m e , 83
P o st-te rm , 2 9 1 -2 9 7 R e g io n a l b lo ck, 3 4 2 -3 4 3
P re -e c la m p s ia , 18, 19, 6 6 -8 1 , 134 Renal
ae tio lo g y, 71 a g e n e s is , 132, 136, 2 2 2
clin ica l c o u rs e , 72 failu re , 70
P re g n a n c y Respiratory distress syndrom e, 288-289
a d o le sc e n t, 1 0 9 -1 1 5 R estitu tion , 2 4 3
e cto p ic, 1 9 1 -1 9 2
R e tra ctio n , 2 3 7
in d u ce d h yp erte n sio n , 68 , 126
m ultiple, 2 2 7 , 2 8 4 , 287 R h esu s
p ro lo n ge d , 2 9 1 -2 9 7 im m une glo b u lin , 182
p o std ate , 291 iso -im m u n iz a tio n ,122, 1 7 7 -1 8 4 ,
v ia b le , 3 222, 228
P re m a tu re R h e u m a tic heart d is e a s e , 82
rupture of membranes, 117,287,289, R h o g a m , 1 8 2 -1 8 4
345
R ito drine h y d ro ch lo rid e , 2 8 4
Prem aturity, 113 R u b e lla , 16, 132, 3 4 7 -3 4 9
P re se n ta tio n , 10
R u p tu re ,
Preterm uterine, 2 6 7 , 3 1 7
labour, 130, 2 7 7 -2 8 6 , 3 5 5 , 357 o xyto cin an d,
premature rupture of, membranes, 287- s c a r, 3 1 7
289
P rim ig ra vid a ,
elde rly, 116
S a c r o -s c ia t ic notch, 2 3
P ro g e ste ro n e , 2 8 5

387
 IN D EX

V e lam e n to u s insertion, 2 0 6 -2 0 7
Ventolin, 283
V ersion ,
external ce p h a lic, 143-145
internal podalic, 161
V ia b le , 3
V illu s,
ch o ra n gio m a , 222
Vom iting, 91-96

W eight-gain, 6, 127
W e igh t-lo ss, 6
W rigley's fo rce p s, 321

X -ra y pelvim etry, 34

Zid o vu d in e , 3