It’s Monday morning and you are the physician on-call at a rural 1A obstetrics site staffed by you (on-call for obstetrics), one other physician (on-call to ER), two RNs, and an RPN. The other physician, an RN, and the RPN are currently busy in the ER. The second RN is available to help with labour and delivery.

You get called into the delivery room where you find a young woman entering in visible distress accompanied by her aunt. She appears to be full-term and has been having abdominal pain for the past five hours. She has no known allergies, her family history and past medical history are insignificant, and her general physical exam is otherwise normal.

27 y/o woman presents to the ED in labour with her aunt as a support person. The other physician, an RN, and an RPN are currently busy in the ER. Assess the woman and fetus.

Modifiers (in red): Actions by the learner (which will have a consequence) OR actions to prompt learner. Extra information, audio clips, etc. are provided below.

Three hours have passed and Leah is now 10cm dilated. She is feeling lots of pressure and requesting pain management.

The patient is almost ready to deliver the fetus. Prepare for delivery by gathering the necessary equipment and discussing the management plan with Leah.

Modifiers (in red): Actions by the learner (which will have a consequence) OR actions to prompt learner. Extra information, audio clips, etc. are provided below.

30 minutes have passed and the woman exclaims, “I’m feeling a lot of pressure now. I think I need to push!”

Practice coaching the patient through pushing and managing a vaginal delivery.

Modifiers (in red): Actions by the learner (which will have a consequence) OR actions to prompt learner. Extra information, audio clips, etc. are provided below.

The baby has been safely delivered. The nurse takes the baby from you, and with minimal drying, the baby begins to cry and is placed on the mother’s abdomen for skin-to-skin contact. Manage the third stage of labour.

Modifiers (in red): Actions by the learner (which will have a consequence) OR actions to prompt learner. Extra information, audio clips, etc. are provided below.

The neonate and placenta have been successfully delivered. APGAR score is normal and neonate continues skin-to-skin contact with the mother. The mother’s fundus is firm and a handbreadth beneath the umbilicus. Vaginal and perineal tears have been repaired. Bleeding is minimal. The case is complete.

Go to Debrief

Leopold Maneuvers: Systematic abdominal palpation maneuvers performed after 30-32 weeks gestation. They are used to determine the presentation, position, and engagement of the fetus in utero.

• First: to determine which fetal part is lying furthest away from pelvic inlet 
• Second: to determine the location of the fetal back 
• Third: to determine which fetal part is lying above the pelvic inlet 
• Fourth:  to locate the fetal brow 

from Toronto Notes 2022 

Fetal Orientation:

1. Fetal Lie
2. Fetal Presentation 
3. Fetal Position 
4. Fetal Attitude 
5. Station 
6. Synclitism

1. Fetal Lie: Relation of fetal long axis to long maternal uterus

Longitudinal (0 degrees) - most common  Transverse (45 degrees)  Oblique (90 degrees)

2. Presentation: The part of the fetus that overlies pelvic inlet (separation between abdominal & pelvic organs - borders include sacral promontory & pubic symphysis)

Cephalic (head down in pelvic inlet) - most common  Breech (bum of feet)  - Frank breech - bum presenting, knees extended (pike position)   - Complete - cannon ball position  - Single footling breech  - Double footling breech  Compound (more than one part presenting - e.g., cephalic or breech + extremity   Shoulder: Shoulder is presenting combined with a transverse or oblique lie

3. Fetal Position: Relationship to maternal pelvis

Occiput Anterior (OA) - fetal occiput (posterior head) towards pubic symphysis (face down) - Left OA - fetal back faces left, anterior fontanelle faces right (most common position) - Right OA - fetal back faces right, anterior fontanelle faces left   Occiput Posterior (OP) - fetal occiput towards sacral promontory  Sacrum - direction of fetal sacrum in breech presentation  Mentum - (chin) in extended cephalic (aka face) presentation

4. Fetal Attitude: How much the fetal head flexes/extends during cephalic presentation

Vertex - maximum flexion (most common)  Forehead/Military - partial flexion  Brow - partial extension  Face - maximum extension  - Mentum anterior - chin to pubic symphysis  - Mentum posterior - chin to coccyx *spontaneous vaginal delivery possible in all attitudes

5. Fetal Station: Measurement (in cm) of where the presenting part of the fetus is located in the pelvis, in relation to ischial spine

Negative (-) = above ischial spine  Positive (+) = below ischial spine  0 = at level of ischial spine  Rule of fifths: when ⅖ or less of the fetal head are felt above the pubic symphysis through the maternal abdomen, the head is engaged

6. Synclitism: Parallelism between pelvic plane and plane of fetal head

Synclitism - posture in which the 2 parietal bones are at the same level Asynclitism - posture in which one parietal bone is at a lower level than the other due to lateral inclination of the head - Anterior / Naegele obliquity - sagittal suture towards sacral promontory → spontaneous vaginal delivery possible - Posterior / Litxmann obliquity - sagittal suture towards pubic symphysis, vaginal delivery NOT possible - indication for C-section

Retrieved July 2, 2023 from: https://www.parents.com/pregnancy/giving-birth/labor-and-delivery/cervix-dilation-chart-pictures-that-explain-the-stages-of-labor/

Retrieved July 27, 2023 from: https://www.instagram.com/p/CHJCbAhgdIu/?utm_source=ig_web_button_share_sheet

Retrieved July 27, 2023 from: https://www.youtube.com/watch?v=x17vY7_3M2M

Adapted September 12, 2023 from https://www.medicalnewstoday.com/articles/326380

Important Notes Regarding Pharmacological use in Labour: 

• Sedative and hypnotic drugs do not provide pain relief and may increase respiratory depression when given with opioids.
• No pharmacological method is devoid of maternal or fetal side effects - with almost all pharmaceutical therapies, some amount of the drug gets access to the fetus. 
• Anticholinergic side effects may occur with opioids and care should be directed at recognizing and addressing these discomforts.
• A pregnant person can receive opioids just before birth without significant respiratory depression in the newborn.
• When any opioid is used, opioid antagonists (e.g., naloxone) and resuscitation capabilities should be available. Before a pregnant person is sent home following opioid administration, she needs to be assessed to determine the effects and side effects of the medication.
• Action should be taken to prevent toxicity with all local anesthetics.
• Epidural analgesia provides the most efficacious pharmacological analgesia, with limited side effects to the mother and fetus.

Options for Pharmacological Pain Management in Labour (see dosing information below):

• Opioids 
  • Fentanyl preferred as it has a shorter half-life (use of meperidine, which has a longer half-life, is discouraged) 
  • Remifentanil patient controlled analgesia (PCA) may offer some benefits over traditional intramuscular (IM) opioids for labour analgesia 
    • Limitation: remifentanil requires constant nursing presence and oxygen saturation monitoring due to the narrow therapeutic window, as well as the increased risk of respiratory complications 
  • Opioids may be combined with an antiemetic as side effects of opioids include nausea and vomiting

Suggested Opioid use in labour:

• Nitrous Oxide 
  • Has been shown to provide mild analgesia, but high patient satisfaction.
    • Often useful for the pregnant person who has coped well until transition and then requires pain relief for a short time. 
  • Deep inhalation should begin as soon as the pregnant person is aware of the onset of a contraction to allow for maximal benefit. 
  • Non-analgesic benefits include relaxation, distraction from pain, anxiolysis, and an improved sense of being able to cope with the pain. 
  • Common side-effects: dizziness, nausea, altered cognition, dysphoria, and a feeling of claustrophobia.
  • It must be self-administered for safety reasons via a demand-valve.
  • Should be used in a well-ventilated room for workplace safety.
    • Nitrous oxide is destructive to the ozone layer - shorter use decreases environmental exposure. 
  • May also be used as an adjunct during other procedures such as the placement of a pudendal block or perineal repair. 
• Peripheral Nerve Blocks 
  • A pudendal block can be used for analgesia of the perineum in the second stage of labour. 
  • Useful for the sacral nerves and should be considered when other regional analgesia is not available or provides insufficient sacral spread. 
  • Important to recognize that local anaesthetic toxicity is additive. Toxic limits of each local anaesthetic should be known to ensure maximum cumulative dosing is not exceeded.
• Neuraxial Anesthesia 
  • Catheter in the epidural space (i.e., labour epidural analgesia (LEA))
  • Quite common in Canada and remains the most effective form of labour analgesia
  • Epidural analgesia can provide effective pain relief throughout all stages of labour and delivery, with limited side effects to the mother and fetus 
  • This option is often not available in rural 1A labour and delivery units, therefore will not be discussed in detail in this resource.

Reference(s): 

Grant G. (2022). Pharmacologic management of pain during labor and delivery. In Crowley M (Ed.), UpToDate. Retrieved Jul 2, 2023, from https://www.uptodate.com/contents/pharmacologic-management-of-pain-during-labor-and-delivery

Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

1. Engagement, descent, and increased flexion (occur simultaneously)

• The head engages below the plane of the pelvic inlet.
• The presenting part begins to descend into the birth canal.
• The chin of the fetus moves towards its chest.

2. Internal rotation: The fetal head rotates by 90° (two 45° steps) in the midpelvis, from a transverse to anterior-posterior position.
3. Extension: The fetal head, lying behind the symphysis pubis bone and the pelvic floor, acts upwards and forwards.
4. Restitution: The fetal head rotates 45° in the opposite direction as it passes through the pelvic outlet.
5. External rotation: The anterior shoulder rotates 45° anteriorly as it meets the maternal pelvic floor. This action is transmitted to the head which also rotates 45°, placing the head in its original transverse position.
6. Expulsion: Delivery of the head, anterior shoulder followed by the posterior shoulder, and the body.

Funai, E. F., & Norwitz, E. R. (2022). Labor and delivery: Management of the normal second stage. In M. Prabhu (Ed.), UpToDate. Retrieved July 19, 2023, from https://www.uptodate.com/contents/labor-and-delivery-management-of-the-normal-second-stage

Proposed Methods:

• Application of warm compress to perineum during and between pushes when baby’s head distends perineum or with active descent
• Perineal massage: two fingers of the lubricated gloved hand moving from side to side just inside the patient's vagina and exerting mild, downward pressure on the perineum
  • Can be performed during antenatal period and/or during second stage, however limited evidence exists to recommend its use
• Finnish & Viennese Manual Perineal Protection methods (FMPP & VMPP) - proposed to reduce the extent of perineal trauma by reducing transverse perineal tension using thumb and index finger alongside vaginal opening, and dispersing the highest perineal tension over a wider surface area
  • Most effective when the thumb and index finger were applied 12 cm apart, 2 cm anterior to the posterior fourchette and approximated medially by 1 cm on either side

Kleprlikova, H, Kalis, V, Lucovnik, M, et al. Manual perineal protection: The know-how and the know-why. Acta Obstet Gynecol Scand. 2020; 99: 445– 450. https://doi.org/10.1111/aogs.13781

Delivery with Nuchal Cord

• Very common occurrence - up to a third of deliveries
• May be incidentally found on prenatal ultrasound, however it does not change prenatal or intrapartum management
• However, >3 loops may be a consideration in deciding between IA & EFM

Management

• Monitor fetal heart rate: Nuchal cord tightness can change with descent which may result in FHR decelerations → manage as in any labor with FHR decelerations
• In a cephalic delivery, if the cord is palpated on the posterior neck after expulsion of the head, the cord can often be slipped over the head from baby’s posterior to anterior

Retrieved Aug 1, 2023 from https://www.youtube.com/watch?v=6nZtMT4YhnA

• If the cord is too tight to slip over the head, it may be possible to slip it back over the shoulders and deliver the body through the loop
• Somersault Maneuver
  • Deliver the baby without removing the cord
  • Good technique if the cord is too tight to slip over the head or shoulders
  • Place palm on fetal occiput and push face towards mothers thigh in the direction the baby is facing (or pubic bone if OP)
  • Baby delivers, keeping head close to the mother’s body
  • Cord can then be unwrapped from the neck

Schaffer, L. & Zimmermann, R. (2022). Nuchal Cord. In Chakrabarti A  (Ed.), UpToDate. Retrieved Aug 1, 2023, from https://www.uptodate.com/contents/nuchal-cord?search=nuchal%20cord&source=search_result&selectedTitle=1~14&usage_type=default&display_rank=1

Created using information from: Simon LV, Hashmi MF, Bragg BN. APGAR Score. StatPearls. 2022 Feb. https://www.ncbi.nlm.nih.gov/books/NBK470569/

Clinical Pearls:

• Royal Women’s Hospital Guidelines for Perineal Trauma Assessment, Repair and Safe Practice https://thewomens.r.worldssl.net/images/uploads/downloadable-records/clinical-guidelines/perineal-trauma-assessment-repair-and-safe-practice_280720.pdf
• 2nd Degree Vaginal Laceration Repair (13 min): https://www.youtube.com/watch?v=bUj_wpAMpq0
• Repairing Perineal Tear (Global Health) (13 min): https://www.youtube.com/watch?v=8LjLpeyqk8g

Preparation

• Good lighting and perineal visualization are important, however lithotomy position is not always necessary - “frog leg” position is often sufficient
• Assess extent of bleeding and injury to the perineum, vagina, and anorectum
  • Visual inspection & digital palpation, including routine rectal examination
• If feces are present, remove it and irrigate tissues thoroughly, and perform a gentle scrub with chlorhexidine
• Perineal shaving is unnecessary
• Single dose of a broad spectrum antibiotic is recommended for third- and fourth-degree tears (antibiotics necessary for first- and second-degree)

Anesthesia

• If epidural catheter in situ, it can be used for anesthesia for the repair
  • Redosing epidural prior to repair of third- and fourth-degree tears may help relax muscles, allowing repair without tension
• Bilateral pudendal block with or without a local field block, a saddle block, or general anesthesia are alternatives if there is no preexisting analgesia
  • Pudendal nerve block or local field block is generally adequate for first- and second-degree tears with no preexisting anesthesia
• Use of agent with epinephrine is helpful

Vidaeff, A. C. (2023). Pudendal and paracervical block. In Eckler K (Ed.), UpToDate. Retrieved August 2, 2023 From https://www.uptodate.com/contents/pudendal-and-paracervical-block?search=controlled%20cord%20traction%20&topicRef=5399&source=see_link#H3

Pudendal Block

• Use ischial spine as landmark for where to inject local anesthetic
• Insert the needle approximately 1 cm medially and inferiorly to the ischial spine

Vidaeff, A. C. (2023). Pudendal and paracervical block. In Eckler K (Ed.), UpToDate. Retrieved August 2, 2023 From https://www.uptodate.com/contents/pudendal-and-paracervical-block?search=controlled%20cord%20traction%20&topicRef=5399&source=see_link#H3

See https://www.youtube.com/watch?v=gWWXzJmT7cg for explanation of injection site.

Choice of Suture

• Recommendation: synthetic, rapidly absorbed suture material (e.g., Polyglactin 910) 
  • Associated with reduced short-term perineal pain, superficial dyspareunia at three months postpartum and the need for suture removal up to three months postpartum
• Use the smallest diameter suture that has adequate tensile and know strength for the task
  •  2/0 and 3/0 sutures are suitable for most routine repair of perineal and vaginal lacerations
• Balance the benefits and risks of suture type
  •  Monofilament: less tissue discomfort and infection risk but longer absorption time & quicker loss of tensile strength

Repair Technique
Third- & Fourth-degree tears can be difficult and should be repaired first. This type of  perineal trauma should ideally be repaired in the operating room with regional or general anesthetic and appropriate lighting. Transfer to appropriate medical centre.

Repair of First- and Second-degree Perineal Trauma:
Step 1 – Suturing the vaginal wall 

• Identify the apex of the vaginal trauma
• Vagina can be packed with sterile gauze to prevent uterine bleeding from obscuring surgical field  
• Insert the first stitch (anchor) 5 – 10 mm above the apex to secure any bleeding points that may not be visible 
• Using the surgeon’s square knot secure that first stitch. Cut off the short end of the suture material, leaving about 1 - 2 cms.
• Suture should be placed 5 – 10 mm from the wound edges
• Each stitch should reach the trough of the wound to close any dead space 
• Match each stitch on either side of the wound for depth as well as width 
• Suture the posterior vaginal trauma using a loose continuous non-locking stitch (usually about 3 to 4 stitches) until the hymenal remnants are reached
  • Sutures should be taught, but loose enough to allow for post-delivery edema
• Insert one more stitch to close the hymenal ring.

Step 2 – Suturing the perineal muscle layer

• Insert the needle at the level of the fourchette (near to the hymenal ring) to emerge deep in the centre of the muscle layer
• Check the depth of the trauma 
• Using a continuous non-locking suture, place each stitch 5 – 10 mm below the wound skin edges and match each stitch for depth as well as width
• Close the perineal muscles in one layer, or if the trauma is very deep use two layers, ending with the needle at the inferior aspect of the trauma
• Ensure the muscle edges are apposed carefully leaving no dead space
  • It is critical to realign the muscles so that the skin edges can be reapproximated with minimal tension.

Step 3 – Suturing the skin layer 

• Reverse the stitching direction at the inferior aspect of the trauma 
• Close the perineal skin by inserting fairly deep sutures in the subcutaneous layer - not through the skin
• Each stitch should be placed opposite each other, not pulled too tight and approximately 5 – 10 mm apart 
• Complete the repair to the hymenal ring, swing the needle under the tissue into the vagina behind the hymenal remnants
• Complete the repair by using a loop or Aberdeen knot 
• Check and count all equipment used and document

(A) Second-degree median episiotomy
(B) The vaginal epithelium to just outside the hymenal ring is reapproximated first.
(C) The perineal body and bulbocavernosus muscle are then reapproximated with intermittent or continuous sutures. The perineal skin can be reapproximated with a continuous running subcuticular suture.
(D) Completed repair.

Toglia, M. R. (2022). Repair of perineal lacerations associated with childbirth. In Eckler K (Ed.), UpToDate. Retrieved August 2, 2023, from https://www.uptodate.com/contents/repair-of-perineal-lacerations-associated-with-childbirth?search=controlled%20cord%20traction%20&topicRef=134954&source=see_link#H1697103

Reference(s)

Maternity Services. (2019). Perineal Assessment and Repair Following childbirth: Guideline for Midwives, Aneurin Bevan University Health Board. Retrieved July 31, 2023, from https://wisdom.nhs.wales/health-board-guidelines/aneurin-bevan-file/perineal-assessment-and-repair-following-childbirth-guideline-for-midwives-aneurin-bevan-2016-pdf/

The Royal Women’s Hospital. (2020). Guideline: Perineal Trauma Assessment, Repair and Safe Practice. The Royal Women’s Hospital. Retrieved August 1, 2023 from https://thewomens.r.worldssl.net/images/uploads/downloadable-records/clinical-guidelines/perineal-trauma-assessment-repair-and-safe-practice_280720.pdf

Toglia, M. R. (2022). Repair of perineal lacerations associated with childbirth. In Eckler K (Ed.), UpToDate. Retrieved August 2, 2023, from https://www.uptodate.com/contents/repair-of-perineal-lacerations-associated-with-childbirth?search=controlled%20cord%20traction%20&topicRef=134954&source=see_link#H1697103

Vidaeff, A. C. (2023). Pudendal and paracervical block. In Eckler K (Ed.), UpToDate. Retrieved August 2, 2023 From https://www.uptodate.com/contents/pudendal-and-paracervical-block?search=controlled%20cord%20traction%20&topicRef=5399&source=see_link#H3