Non-progressive labour Management Steps in managing non-progressive 1st stage are similar to induction of labour, but skipping cervical ripening: First: analgesia, empty bladder, and ensure membranes ruptured. Artificial rupture if required. If dilating Non-progressive 2nd stage: If fetal malposition (OP or OT): rotate manually, rotation ventouse, or Kielland's forceps. If position correct(ed) (OA): oxytocin → if unsuccessful, traction ventouse or forceps. C-section if above steps fail. Complications Postpartum hemorrhage. Uterine rupture. Fistula Shoulder dystocia. Hypoxia

1. LABOUR
COMPLICATIONS
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2. NON-PROGRESSIVE LABOUR
• MANAGEMENT
• STEPS IN MANAGING NON-PROGRESSIVE 1ST STAGE ARE SIMILAR
TO INDUCTION OF LABOUR, BUT SKIPPING CERVICAL RIPENING:
• FIRST: ANALGESIA, EMPTY BLADDER, AND ENSURE MEMBRANES RUPTURED.
ARTIFICIAL RUPTURE IF REQUIRED.
• IF DILATING
• NON-PROGRESSIVE 2ND STAGE:
• IF FETAL MALPOSITION (OP OR OT): ROTATE MANUALLY, ROTATION VENTOUSE, OR
KIELLAND'S FORCEPS.
• IF POSITION CORRECT(ED) (OA): OXYTOCIN → IF UNSUCCESSFUL, TRACTION
VENTOUSE OR FORCEPS.
• C-SECTION IF ABOVE STEPS FAIL.

3. COMPLICATIONS
• POSTPARTUM HEMORRHAGE.
• UTERINE RUPTURE.
• FISTULA
• SHOULDER DYSTOCIA.
• HYPOXIA

4. CAESAREAN SECTION
• PROCEDURE AND TIMING
• USUALLY A LOWER-SEGMENT CS (LSCS) VIA A TRANSVERSE INCISION, EITHER
PFANNENSTIEL (CURVILINEAR, 2 CM ABOVE SYMPHYSIS PUBIS) OR JOEL COHEN
(STRAIGHT, 1 CM HIGHER, FEWER COMPLICATIONS).
• IF THERE ARE STRUCTURAL ABNORMALITIES OR A VERY PRETERM BABY, A
CLASSICAL CS USING VERTICAL INCISION MIGHT BE NEEDED.
• IDEALLY CARRY OUT AFTER 39 WEEKS TO REDUCE NEONATAL RESPIRATORY
PROBLEMS.
• USUALLY DONE UNDER SPINAL ANAESTHESIA, THOUGH EPIDURAL AND GENERAL
ARE ALSO OPTIONS.
• THERE ARE FEW CONTRAINDICATIONS.

5. INDICATIONS
• PREVIOUS CS.
• NON-PROGRESSIVE LABOUR.
• BREECH PRESENTATION, INCLUDING OF 1ST TWIN IN MULTIPLE PREGNANCY.
• FETAL DISTRESS.
• MATERNAL DISEASE E.G. PRE-ECLAMPSIA, ACUTE FATTY LIVER.
• INFECTION PREVENTION: UNCONTROLLED HIV, GENITAL HERPES WITH ONSET IN 3RD
TRIMESTER.
• PLACENTAL MALPOSITION: PLACENTA PRAEVIA MAJOR, MORBIDLY ADHERENT PLACENTA.
• EMERGENCY CS

6. SHORT TERM COMPLICATIONS AND THEIR
MANGEMENT
• STANDARD SURGICAL RISKS: BLEEDING, TRAUMA (BABY OR ORGANS), AND
ABDOMINAL PAIN (BUT LESS PERINEAL PAIN THAN VAGINAL DELIVERY). 1/500
WILL REQUIRE A HYSTERECTOMY.
• ACID ASPIRATION PNEUMONITIS, SO GIVE RANITIDINE BEFORE.
• DVT, SO GIVE STOCKINGS BEFORE AND LMWH AFTER.
• INFECTION – INCLUDING ENDOMETRITIS OR WOUND INFECTION – SO GIVE
CO-AMOXICLAV DURING OPERATION.
• NEONATAL RESPIRATORY DISTRESS SYNDROME, SO GIVE MATERNAL IM
STEROIDS UP TO ≤38+6 WEEKS AS OPPOSED TO THE USUAL ≤36+6 WEEKS.
• MANAGEMENT MNEMONIC,
SSRI: STEROIDS, STOCKINGS, RANITIDINE, INFECTION PROPHYLAXIS.

7. LONG TERM COMPLICATIONS
• 1/200 RISK OF UTERINE RUPTURE DURING ANY FUTURE VAGINAL BIRTH
AFTER CAESAREAN (VBAC). HIGHER RISK IF LABOUR IS INDUCED. IF VBAC
IS ATTEMPTED, USE CONTINUOUS CTG AND MAKE SURE C-SECTION
FACILITIES ARE AVAILABLE. VBAC CANNOT BE ATTEMPTED AFTER
CLASSICAL CS.
• PLACENTA PRAEVIA.
• STILLBIRTH
• ADHESIONS

8. INSTRUMENTAL VAGINAL DELIVERY
• BACKGROUND
• VACUUM (VENTOUSE) OR FORCEPS (KIELLAND'S).
• FORCEPS HAS HIGHER SUCCESS RATE BUT MAY REQUIRE MORE SKILL.
• USED TO SHORTEN THE SECOND STAGE OF LABOUR.
• INDICATIONS
• FETAL DISTRESS.
• MATERNAL EXHAUSTION, OFTEN SEEN AFTER 2 HOURS WITHOUT PROGRESS IN 2ND
STAGE (OR 3 HOURS IN NULLIP).
• CAN BE ELECTIVE IN PATIENTS WITH UNDERLYING DISEASE E.G. CARDIAC,
NEUROMUSCULAR.

9. PRE-REQUISITES
• CEPHALIC PRESENTATION WITH HEAD ≤1/5TH PALPABLE. IF MORE IS
PALPABLE, CONSIDER C-SECTION.
• FULLY DILATED CERVIX AND EMPTY BLADDER.
• PUDENDAL OR SPINAL BLOCK FOR MID-CAVITY ROTATION.
• VACUUM: BABY MUST BE OCCIPITO-ANTERIOR, AND ≥34 WEEKS (AND
IDEALLY ≥36 WEEKS). FORCEPS, HOWEVER, CAN ROTATE BABIES INTO
POSITION AND BE USED BEFORE 34 WEEKS.

10. PROCESS
• LITHOTOMY POSITION (STIRRUPS).
• EPISIOTOMY MAY BE REQUIRED TO AID PASSAGE OF INSTRUMENTS.
• ENSURE MATERNAL PUSHES ARE IN SYNC WITH PULLS. USE OXYTOCIN IF
NEEDED.
• AFTER 3 FAILED ATTEMPTS, SWITCH TO C-SECTION. FOR THIS REASON,
THEATRE SHOULD BE READY IF NEEDED OR THE PROCEDURE SHOULD BE
PERFORMED IN THEATRE.

11. COMPLICATIONS
• MATERNAL PERINEAL OR VAGINAL TRAUMA, ESPECIALLY WITH FORCEPS. DEGREE OF TEARS:
1ST DEGREE IS PERINEAL AND VAGINAL SKIN, 2ND DEGREE IS PERINEAL AND VAGINAL
MUSCLES AND FASCIA, 3RD DEGREE IS TO ANAL SPHINCTER, AND 4TH DEGREE IS TO RECTAL
MUCOSA. MOST REQUIRE SUTURING.
• FORCEPS CAN CAUSE MINOR MARKS WHICH FADE QUICKLY.
• VACUUM CAN CAUSE CHIGNON (SMALL BUMP WHICH FADES QUICKLY), CEPHALOHEMATOMA,
OR MUCH MORE SERIOUSLY, SUBGALEAL HAEMORRHAGE, WHICH CROSSES SUTURE LINES.
• FACIAL NERVE PALSY, ESPECIALLY WITH FORCEPS.
• RETINAL HAEMORRHAGE, ESPECIALLY WITH VACUUM.
• NEONATAL INTRACRANIAL HAEMORRHAGE OR SKULL FRACTURE.
• SHOULDER DYSTOCIA: NOT SO MUCH A COMPLICATION, BUT THE NEED TO USE INSTRUMENTS
MAY SUGGEST A HIGH RISK, MACROSOMIC BABY.

12. PRETERM LABOUR
• DEFINITION
• LABOUR BEFORE 37 WEEKS.
• THREATENED PRETERM LABOUR (TPTL) IS CONTRACTIONS WITHOUT CERVICAL
EFFACEMENT OR DILATION.
• SIGNS AND SYMPTOMS
• PRETERM UTERINE CONTRACTIONS, BECOMING REGULAR AND WITH INTERVALS
DECREASING.
• PRETERM PRELABOUR RUPTURES OF MEMBRANES (P-PROM).

13. RISK FACTORS
• PREVIOUS PRETERM LABOUR.
• MULTIPLE PREGNANCY: 50% OF TWIN PREGNANCIES ARE PREMATURE.
• OBSTETRIC COMPLICATIONS: PRE-ECLAMPSIA, APH.
• MATERNAL CO-MORBIDITIES: DIABETES, HYPERTENSION.
• ANATOMICAL: ABNORMAL UTERINE ANATOMY, PREVIOUS ABORTIONS.
• INFECTIONS: UTI OR BV.

14. PREVENTION
• RISK OF PRETERM LABOUR CAN BE REDUCED WITH VAGINAL
PROGESTERONE OR CERVICAL CERCLAGE. THE LATTER INVOLVES
SUTURING THE CERVIX TO TIGHTEN IT, WITH THE SUTURE REMOVED
BEFORE BIRTH.
• INDICATED IF TRANSVAGINAL US AT 16-24 WEEKS SHOWS CERVICAL
LENGTH AND WOMAN HAD PREVIOUS PRETERM BIRTH OR PREVIOUS
PREGNANCY LOSS BETWEEN 16-34 WEEKS.

15. INVESTIGATIONS
• FOR WOMEN WITH INTACT MEMBRANES:
• SPECULUM EXAM ± PV EXAM, LOOKING FOR CERVICAL DILATION.
• IF >30 WEEKS, CONFIRM WITH TRANSVAGINAL US (CERVICAL LENGTH ≤15 MM =
PRETERM LABOUR) OR FETAL FIBRONECTIN IN VAGINAL SECRETIONS (>50 NG/ML =
PRETERM LABOUR).
• FOR WOMEN WITH SUSPECTED P-PROM:
• SPECULUM EXAM TO LOOK FOR POOLING OF AMNIOTIC FLUID.
• NO PV EXAM UNLESS THOUGHT TO BE IN LABOUR, AS THIS MAY DELAY SUBSEQUENT
ONSET OF LABOUR AND INCREASE INTRAUTERINE INFECTION RISK.
• LOOK FOR INTRAUTERINE INFECTION: FBC, CRP, FETAL HR ON CTG, URINE DIPSTICK
AND MC+S, HIGH VAGINAL SWAB FOR GROUP B STREP.
• IN ESTABLISHED PRETERM LABOUR, MONITOR FETAL WELLBEING:
• CTG
• INTERMITTENT AUSCULTATION IF OTHERWISE LOW RISK.

16. MANAGEMENT
• STEROIDS TO MUM IF ≤35+6 WEEKS, THOUGH EFFECT IS STRONGEST FOR
≤33+6 WEEKS. BETAMETHASONE IM, 2 DOSES 24H APART.
• TOCOLYSIS WITH NIFEDIPINE IF ≤33+6 WEEKS AND MEMBRANES INTACT.
• MAGNESIUM SULFATE IV FOR FETAL NEUROPROTECTION IF ≤29+6 WEEKS.
• ERYTHROMYCIN PO UNTIL ESTABLISHED LABOUR IF THERE IS P-PROM.
• BENZYLPENICILLIN IV INTRAPARTUM FOR GROUP B STREP PROPHYLAXIS IN
ALL VAGINAL PRETERM LABOURS.

17. MEDICAL SLIDES

18. PRELABOUR RUPTURE OF MEMBRANES
(PROM)
• DEFINITION AND EPIDEMIOLOGY
• RUPTURE OF MEMBRANES BEFORE LABOUR.
• OCCURS IN 40% OF PRETERM LABOURS, WHERE IT IS KNOWN AS PRETERM
PRELABOUR RUPTURE OF MEMBRANES (P-PROM).
• 60% OF PROMS PROGRESS TO LABOUR WITHIN 24 HOURS. FAILURE TO
PROGRESS CARRIES RISK OF CHORIOAMNIONITIS AND NEONATAL SEPSIS.
• SIGNS AND SYMPTOMS
• WATERY PV FLUID AND WET UNDERWEAR/PADS.

19. INVESTIGATIONS
• SPECULUM EXAM ONLY IF THERE IS ANY UNCERTAINTY FROM THE HISTORY:
LIQUOR IN THE POSTERIOR FORNIX SUGGESTS RUPTURE. ALTERNATIVELY,
GIVE PADS AND CHECK REGULARLY.
• DIGITAL EXAM SHOULD ONLY BE PERFORMED IF THERE IS STRONG
SUSPICION OF LABOUR E.G. REGULAR CONTRACTIONS. OTHERWISE IT
RISKS DELAYING LABOUR.
• IF PREMATURE, CHECK FETAL FIBRONECTIN AND HVS.

20. MANAGEMENT
• FETAL MONITORING:
• CTG IF ≥26 WEEKS, THEN EVERY 24 HOURS IF NOT GONE INTO LABOUR. FETAL
HEART AUSCULTATION IF YOUNGER.
• ADVISE MUM TO MONITOR MOVEMENTS.
• IF WELL AND AT TERM:
• OFFER INDUCTION OR SEND HOME AND ARRANGE TO RETURN IN 24 HOURS, BY
WHICH TIME 60% WILL HAVE GONE INTO LABOUR.
• ADVISE TO MONITOR TEMPERATURE, AVOID SEX DUE TO INFECTION RISK, BUT
BATHING OK.
• ANTIBIOTICS ONLY IF THERE ARE SIGNS OF INFECTION.
• INDUCTION IF THERE IS NO PROGRESS TO LABOUR WITHIN 24 HOURS AND ≥34
WEEKS.
• IF PRETERM (P-PROM), ADMIT AND GIVE:
• STEROIDS IM.
• ERYTHROMYCIN PO FOR UP TO 10 DAYS OR UNTIL ESTABLISHED LABOUR.

21. CHORIOAMNIONITIS AND INTRAPARTUM
ANTIBIOTICS
• BACKGROUND
• CHORIOAMNIONITIS (AKA INTRAAMNIOTIC INFECTION) IS INFECTION OF THE
AMNIOTIC FLUID, PLACENTA, AND/OR FETUS, OCCURRING BEFORE OR DURING
LABOUR.
• ANTIBIOTICS MAY ALSO BE GIVEN INTRAPARTUM TO TREAT GROUP B STREP
AND THUS PREVENT TRANSMISSION TO NEONATE.
• CHORIOAMNIONITIS PRESENTATION
• FEVER. IF <39°C AND NO OTHER SIGNS, DOES NOT NECESSARILY REQUIRE
TREATMENT (BUT CONSIDER BLOODS AND URINE DIP).
• MATERNAL OR FETAL ↑HR.
• TENDER UTERUS.
• MALODOUROUS AMNIOTIC FLUID.

22. INTRAPARTUM ANTIBIOTICS:
INDICATIONS AND DRUGS
• INDICATIONS:
• CHORIOAMNIONITIS
• PRE-TERM LABOUR.
• POSITIVE GROUP B STREP TEST DURING CURRENT PREGNANCY (COLONIZATION
OR INFECTION E.G. UTI).
• NO GBS TEST BUT HISTORY OF GBS IN PRIOR PREGNANCY.
• PREVIOUS BABY WITH GBS REGARDLESS OF GBS TEST RESULT.
• BENZYLPENICILLIN IV FOR MOST, BUT ADD GENTAMICIN IV AND
METRONIDAZOLE IV IF CHORIOAMNIONITIS.

23. STILLBIRTH
• DEFINITION AND EPIDEMIOLOGY
• DEATH OF FETUS AFTER 24 WEEKS GESTATION, BEFORE OR DURING BIRTH.
• AFFECTS 1/200 BIRTHS.
• PRESENTATION
• MAY PRESENT WITH REDUCED FETAL MOVEMENTS, PV BLEEDING, SYMPTOMS OF
THE UNDERLYING CAUSE, OR BE DISCOVERED DURING FETAL MONITORING OR
LABOUR.

24. CAUSES AND RISK FACTORS
• FETAL FACTORS:
• IUGR: COMMONEST CAUSE.
• PREMATURE LABOUR OR RUPTURE OF MEMBRANES.
• CONGENITAL ABNORMALITY.
• PLACENTAL INSUFFICIENCY.
• MULTIPLE PREGNANCY.

25. CAUSES AND RISK FACTORS
• NON-OBSTETRIC MATERNAL FACTORS:
• DEMOGRAPHIC: ↑MATERNAL AGE, LOW SES, AFRO-CARIBBEAN RACE.
• LIFESTYLE: OBESITY, SMOKING.
• PRE-EXISTING DIABETES, BUT NOT GESTATIONAL DM.

26. CAUSES AND RISK FACTORS
• OBSTETRIC MATERNAL FACTORS:
• PRE-ECLAMPSIA.
• APH
• OBSTETRIC CHOLESTASIS.
• NULLIPARITY
• INFECTION: ERYTHEMA INFECTIOSUM (PARVOVIRUS), MEASLES.
• AROUND 30% ARE UNEXPLAINED.

27. MANAGEMENT
• DELIVERY:
• MAY BE DIAGNOSED INTRAPARTUM, IN WHICH CASE DELIVER AS PLANNED.
• IF DIAGNOSED ANTENATALLY, INDUCE LABOUR USING MISOPROSTOL PV.
• COUNSELLING:
• GIVE TIME WITH THE BABY, INCLUDING TO DRESS AND TAKE PHOTOS IF WANTED.
• HELP TO MAKE FUNERAL ARRANGEMENTS IF WANTED.
• DISCUSS POST-MORTEM EXAMINATION.
• PARENTS ARE ENTITLED TO USUAL PARENTAL LEAVE.
• REGISTRATION:
• ALL STILLBIRTHS MUST BE REGISTERED WITHIN 6 WEEKS.

28. BREECH PRESENTATION
• BACKGROUND
• FETUS IS BUM FIRST AS OPPOSED TO THE USUAL CEPHALIC (AKA VERTEX)
PRESENTATION.
• POSITION IN LABOUR THUS DESCRIBED AS 'SACRO-TRANSVERSE' NOT 'OCCIPITO-
TRANSVERSE' ETC.
• BABY AT RISK OF TRAUMA OR HYPOXIA DURING BIRTH.
• OTHER NON-CEPHALIC PRESENTATIONS (RARE): TRANSVERSE, OBLIQUE.
• TYPES
• EXTENDED (70%, AKA FRANK BREECH): HIPS FLEXED, KNEES EXTENDED.
• FLEXED (AKA COMPLETE BREECH): HIPS AND KNEES FLEXED.
• FOOTLING (AKA INCOMPLETE BREECH): ONE/BOTH HIPS EXTENDED, WITH
FOOT/FEET DANGLING DOWN.

29. RISK FACTORS
• PAST HISTORY OF BREECH.
• PREMATURITY
• MULTIPLE PREGNANCY.
• OBSTETRIC COMPLICATIONS: PLACENTA PRAEVIA, POLY OR OLIGOHYDRAMNIOS.
• MATERNAL HEALTH: DIABETES, SMOKING, FIBROIDS.
• MANAGEMENT
• EXTERNAL CEPHALIC VERSION (ECV) AT 37 WEEKS. 50% SUCCESSFUL.
CONTRAINDICATED IF THERE IS APH, PRE-ECLAMPSIA, OLIGOHYDRAMNIOS,
FETAL DISTRESS, OR RHESUS DISEASE.
• IF ECV UNSUCCESSFUL, C-SECTION AT 39 WEEKS, THOUGH EXTENDED AND
FLEXED CAN BE DELIVERED VAGINALLY BY SKILLED TEAM.

30. SHOULDER DYSTOCIA
• DEFINITION AND RISK FACTORS
• AFTER DELIVERY OF HEAD, ANTERIOR SHOULDER CANNOT BE DELIVERED.
DEFINED AS SHOULDER DYSTOCIA WHEN TWO ATTEMPTS AT DELIVERING THE
SHOULDER WITH NORMAL TRACTION HAVE FAILED.
• EMERGENCY AS CORD MAY BE SQUASHED SO ↓O2 RISK: YOU HAVE AROUND 7
MINUTES TO DELIVER.
• RISK FACTORS: MACROSOMIA, SMALL WOMAN, PMH OF SHOULDER DYSTOCIA.
• OFTEN FOLLOWS PROTRACTED LABOUR.

31. MANAGEMENT
• HELPERR:
• HELP: GET OBSTETRICIAN, ANAESTHETIST, PAEDIATRICIAN, AND MIDWIFE.
• EPISIOTOMY: CONSIDER IT AS IT MAY EASE ACCESS FOR HANDS TO HELP MOVE
BABY.
• LEGS: THE KEY THING. HAVE MUM FLEX HIPS SO KNEES GO UP TO FACE INTO THE
MCROBERT'S POSITION. 90% SUCCESS RATE.
• PRESSURE: APPLY SUPRAPUBIC PRESSURE.
• ENTER, PUSH FINGERS IN ALONG BABY'S BACK, PUSH SHOULDER DOWN. TRY
PUSHING THE OTHER SHOULDER UP IF UNSUCCESSFUL, OR ROTATION.
• REMOVE BABY'S POSTERIOR ARM, PULLING IT DOWN AND OUT.
• ROLL MUM OVER ONTO ALL FOURS AND TRY PROCEDURES AGAIN.
• COMPLICATIONS
• PERINEAL TRAUMA: EPISIOTOMY, TEAR, PPH.
• FETAL: ERB'S PALSY, CLAVICLE FRACTURE, HYPOXIA, DEATH.

32. ERB'S PALSY
• INJURY TO UPPER BRACHIAL PLEXUS TRUNK (C5-6).
• WEAKNESS OF DELTOID, SUPRASPINATUS, TERES MAJOR, BICEPS, AND
BRACHIALIS. IMPAIRED SHOULDER EXTERNAL ROTATION AND FOREARM
FLEXION AND SUPINATION CAUSES 'WAITER'S TIP' POSTURE.
• ALTERED SENSATION OVER DELTOID, LATERAL FOREARM, AND HAND.

33. POSTPARTUM HAEMORRHAGE (PPH)
• DEFINITION AND CAUSES
• >500 ML BLOOD LOSS IN THE 24 HOURS POSTPARTUM (>1000 ML IF
CAESAREAN). MAJOR PPH IF >1000 ML OR SHOCK.
• CAUSED BY THE 4TS: REDUCED UTERINE TONE (80%), TISSUE (RETAINED
PLACENTA OR CLOTS), TRAUMA SUCH AS TEARS, AND THROMBIN I.E. CLOTTING
PROBLEMS OR THROMBOPROPHYLAXIS.
• ACTIVE MANAGEMENT OF 3RD STAGE OF LABOUR USING OXYTOCIN (OR
OXYTOCIN + ERGOMETRINE IF HIGH RISK) HELPS PREVENT PPH, THOUGH
OXYTOCIN DURING THE 1ST OR 2ND STAGE (E.G. AUGMENTATION)
MAY INCREASE PPH.

34. RISK FACTORS
• BIG OLD LONG BLEED:
• BIG UTERUS: MULTIPLE PREGNANCY, MACROSOMIA, POLYHYDRAMNIOS.
• OLD: ↑MATERNAL AGE.
• LONG OR COMPLICATED (INDUCTION, INSTRUMENTATION, C-SECTION)
LABOUR.
• BLEED HISTORY: PREVIOUS PPH, APH (PLACENTA PRAEVIA OR ABRUPTION), OR
BLEEDING DISORDER.

35. MANAGEMENT
• 1. RESUSCITATE:
• HIGH FLOW O2.
• IV FLUID THOUGH LARGE BORE CANNULA. TRANSFUSE IF MAJOR BLEED.
• FBC, BLOOD GROUP, AND COAG.
• 2. IDENTIFY CAUSE:
• LITHOTOMY POSITION FOR EXAMINATION TO FIND AND TREAT ANY TRAUMA OR
RETAINED TISSUE.
• 3. TREAT AS UTERINE ATONY IF TISSUE, TRAUMA, AND THROMBIN ARE RULED
OUT. TRY EACH FOLLOWING STEP IN TURN, UNTIL BLEEDING STOPS:
• BIMANUAL UTERINE COMPRESSION.
• STEPWISE UTEROTONIC THERAPY, WITH CONCURRENT TRANEXAMIC ACID:
OXYTOCIN IV SLOW BOLUS → ERGOMETRINE IV → OXYTOCIN INFUSION →
CARBOPROST (PGF2Α) IM OR INTRAMYOMETRIAL → MISOPROSTOL SUBLINGUAL.
• SURGERY IF MEDICAL MANAGEMENT UNSUCCESSFUL E.G. BALLOON TAMPONADE,
UTERINE ARTERY LIGATION.

37. SECONDARY PPH
• BLOOD LOSS AFTER 24 HOURS AND UP TO 12 WEEKS, USUALLY AFTER 7-14
DAYS.
• USUALLY DUE TO RETAINED TISSUE OR CLOT, OFTEN WITH ASSOCIATED
ENDOMETRITIS.
• INVESTIGATIONS: FBC, BLOOD CULTURE, SWABS, URINALYSIS, AND CONSIDER
USS.
• SPECULUM EXAM TO VISUALISE TISSUE AND REMOVE WITH FORCEPS IF
POSSIBLE. IF HEAVY MANAGE SURGICALLY.
• IV ANTIBIOTICS IF ANY SIGNS OF ENDOMETRITIS.

38. POSTPARTUM INFECTION
• TYPES
• USUALLY ENDOMETRITIS.
• OTHER TYPES ARE: UTIS, WOUND INFECTIONS, PERINEAL CELLULITIS, MASTITIS,
AND INFECTIONS RELATING TO RETAINED PRODUCTS OF CONCEPTION.
• CAN PROGRESS TO SEPSIS, WHICH IS THE COMMONEST CAUSE OF MATERNAL
MORTALITY.
• RISK FACTORS
• C-SECTION
• PROM
• PRIOR CHORIOAMNIONITIS.
• LONG LABOUR.
• SECONDARY PPH.

39. ENDOMETRITIS SYMPTOMS
• LOWER ABDO PAIN.
• OFFENSIVE DISCHARGE.
• TENDER UTERUS.
• INVESTIGATIONS
• FBC
• MSU
• SWABS: HIGH VAGINAL, WOUND SITE.
• BLOOD AND SPUTUM CULTURE.

40. MANAGEMENT
• NTIBIOTICS. IV IF THERE ARE ANY SIGNS OF SEPSIS.
• FLUCLOXACILLIN PO FOR MASTITIS.
• POSTNATAL DEPRESSION
• AFFECTS 10-15% IN THE 3 MONTHS POSTPARTUM. CONSIDER CBT OR SSRI
(PAROXETINE OR SERTRALINE) IF SEVERE.
• DIFFERENT FROM 'BABY BLUES', WHICH AFFECTS 50% 3-5 DAYS POSTPARTUM.
PROVIDE REASSURANCE, WITH NO SPECIFIC TREATMENT NEEDED.

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