Shoulder dystocia should be managed systemically and the manoeuvres should be attempted in order as per the algorithm suggested by the RCOG.

Green Top guideline no 42, March 2012, Shoulder dystocia. http://​www.​rcog.​org.​uk/​files/​rcog-corp/​GTG42_​25112013.​pdf

Shoulder dystocia is difficult to predict or prevent. Conventional risk factors predicted only 16 % of shoulder dystocia that resulted in infant morbidity.

PPROM is not a known risk factor for shoulder dystocia.

Previous shoulder dystocia cases can be offered either vaginal delivery or elective LSCS based on discussions with the woman although it is known that women with previous shoulder dystocia have a higher risk of the same in future pregnancies. There is no requirement to recommend elective caesarean birth routinely, but factors such as the severity of any previous neonatal or maternal injury, predicted fetal size and maternal choice should all be considered and discussed with the woman and her family when making plans for the next delivery.

There is no recommendation for elective LSCS in nondiabetic women with suspected macrosomia to prevent shoulder dystocia or morbidity thereof. Infants of diabetic mothers have a two- to fourfold increased risk of shoulder dystocia compared with infants of the same birth weight born to nondiabetic mothers. Elective caesarean section should be considered to reduce the potential morbidity for pregnancies complicated by pre-existing or gestational diabetes, regardless of treatment, with estimated fetal weight of greater than 4.5 kg.

Having two previous caesarean births is not known to be a risk factor for shoulder dystocia and neither is it an absolute indication for elective caesarean section.

Green Top guideline No. 42, March 2012, Shoulder dystocia. http://​www.​rcog.​org.​uk/​files/​rcog-corp/​GTG42_​25112013.​pdf

Offer women with uncomplicated monochorionic twin pregnancies elective birth from 36 weeks 0 days, after a course of antenatal corticosteroids has been offered. Offer women with uncomplicated triplet pregnancies elective birth from 35 weeks 0 days, after a course of antenatal corticosteroids has been offered.

Offer women with uncomplicated dichorionic twin pregnancies elective birth from 37 weeks 0 days. It is appropriate to aim for vaginal birth of monochorionic twins unless there are accepted, specific clinical indications for caesarean section, such as twin one lying breech or previous caesarean section.

Most monochorionic, monoamniotic twins have cord entanglement and are best delivered at 32 weeks, by caesarean section, after corticosteroids.

1. NICE clinical guideline 129, Multiple pregnancy: the management of twin and triplet pregnancies in the antenatal period issued: September 2011 guidance.nice.org.uk/cg129. http://​www.​nice.​org.​uk/​nicemedia/​live/​13571/​56422/​56422.​pdf

2. Green-Top guideline no. 51, December 2008, Management of monochorionic twin pregnancy. http://​www.​rcog.​org.​uk/​files/​rcog-corp/​uploadedfiles/​T51ManagementMon​ochorionicTwinPr​egnancy2008a.​pdf

Conventional risk factors predicted only 16 % of shoulder dystocia that resulted in infant morbidity:

Shoulder dystocia – RCOG Green Top guideline No. 42. Mar 2012. http://​www.​rcog.​org.​uk/​files/​rcog-corp/​GTG42_​25112013.​pdf

Evidence reports mediolateral episiotomy (favoured in UK and European practice) to have a significantly lower risk of sphincter injury compared with a midline episiotomy (favoured in the USA) at 2 versus 12 %. Published evidence on the role of episiotomy is contradictory. Traditional teaching is that episiotomy protects the perineum from uncontrolled trauma during delivery.

Although several authors have demonstrated a protective effect against sphincter injury with mediolateral episiotomy, others have reported the converse. The differences between medical and midwifery staff in conducting a mediolateral episiotomy have been studied, with doctors performing episiotomies that are longer and at a wider angle compared with midwives. An important learning point is that current evidence is unable to support the routine use of episiotomy to prevent anal sphincter injury. The type of episiotomy is important.

Fowler G. Risk factors & management of obstetric anal sphincter injury. Obstet Gynaecol Reprod Med. 2013;23(5): 131–6.

There should be a clear local protocol for massive obstetric haemorrhage. Massive blood loss is defined as a loss of one blood volume in 24 h or loss of 50 % of blood volume within three hours. Another definition is blood loss at a rate of 150 ml/min. Normal blood volume in the adult is defined as 7 % of ideal body weight. Major haemorrhage should involve a consultant obstetrician, anaesthetist and haematologist and the blood bank with training drills and regular practice. Women should have group and save or crossmatch sample taken according to local protocol, if a major haemorrhage is anticipated as in placenta previa/accreta.

RCOG Green Top guideline No. 47 – Blood transfusion in obstetrics.

An abnormal cardiotocograph is the most consistent finding in uterine rupture and is present is 55–87 % of these events. Hence, continuous electronic fetal monitoring is generally used in women during planned VBAC. Other signs of uterine rupture include cessation of previously efficient uterine activity, maternal hypotension or shock and loss of station of the presenting part. None of these are pathognomic but the presence of any of the above should raise the concern of the possibility of this event. Early diagnosis of scar rupture followed by expeditious laparotomy and resuscitation is essential to reduce associated morbidity in mother and infant.

RCOG Green Top guideline No 45. Birth after previous caesarean birth.

A number of factors are associated with successful VBAC. Previous vaginal birth, particularly previous VBAC, is the single best predictor for successful VBAC. Risk factors for unsuccessful VBAC are induced labour, no previous vaginal birth, body mass index greater than 30 and previous section for dystocia. Other factors associated with a decreased likelihood of successful VBAC are VBAC at or after 41 weeks, birth weight greater than 4000 g, previous preterm caesarean birth, less than 2 years from previous caesarean birth, advanced maternal age, non-white ethnicity, short stature and a male infant. Counselling a woman should include appropriate risk assessment and counselling to ensure safe delivery and successful outcome.

RCOG Green Top guideline No. 45. Birth after previous caesarean birth.

Delay in the first stage is suspected if the cervix is dilated <2 cm in 4 h. If delay in the established first stage of labour is suspected, amniotomy should be considered for all women with intact membranes, after explanation of the procedure and advice that it will shorten her labour by about an hour and may increase the strength and pain of her contractions.

Whether or not a woman has agreed to an amniotomy, advise all women with suspected delay in the established first stage of labour to have a vaginal examination 2 h later, and diagnose delay if progress is less than 1 cm.

https://​www.​nice.​org.​uk/​guidance/​cg190/​chapter/​1-Recommendations

Planned VBAC carries a risk of uterine rupture of 22–74/10,000. There is virtually no risk of uterine rupture in women undergoing ERCS. Uterine rupture in an unscarred uterus is extremely rare at 0.5–2.0/10,000 deliveries; this risk is mainly confined to multiparous women in labour. If women with a previous scar undergo induced and/or augmented labours, this risk increases by two- to threefold. There is also a 1.5-fold increased risk of caesarean section in induced and/or augmented labours compared with spontaneous labours. There is higher risk of uterine rupture with induction of labour with prostaglandins.

Birth after previous Caesarean birth. RCOG Green Top guideline No. 45

NICE guidelines recommend delivery at 37–38 weeks for dichorionic twins and 36–37 weeks for monochorionic diamniotic twins, but marked variability in policy exists in practice. There is growing evidence that perinatal mortality rates increase after 38 weeks even in uncomplicated twin pregnancies. Additionally, intervention at 37 weeks does not appear to be associated with a significant difference in mode of delivery or maternal complications when compared to expectant management.

Regarding preterm birth, evidence suggests that progesterone supplementation does not prevent early preterm labour in twin pregnancies and the use of untargeted single or multiple courses of corticosteroids is not recommended. The Twin Birth Study suggests that there is no advantage to a policy of planned caesarean section for twins with respect to both maternal and neonatal morbidity. Current practice supports the policy of planned vaginal birth in uncomplicated pregnancies with a cephalic first twin, unless the mother prefers caesarean delivery.

Bonney E, Rathod M, Cohen K, Ferriman E. Twin pregnancy. Obstet Gynaecol Reprod Med. 23(6):165–70.

Steps in active management of the third stage of labour:

http://​www.​who.​int/​maternal_​child_​adolescent/​documents/​postpartum/​en/​

The 1996 guidelines from AAP and ACOG for HIE indicate that all of the following must be present for the designation of perinatal asphyxia severe enough to result in acute neurological injury:

[Guideline] Committee on fetus and newborn, American Academy of Pediatrics and Committee on obstetric practice, American College of Obstetrics and Gynecology. Use and abuse of the APGAR score. Pediatrics. 1996;98:141–2.

When negotiating the birth canal, the fetus undergoes a series of manoeuvres. As the fetus descends through the different planes of the pelvis, it needs to move into the position of best fit.

Pregnancy itself affects the immune system, and conditions such as anaemia, impaired glucose tolerance or diabetes mellitus reduce resistance to infection. Obesity, an increasing problem in the developed world, is a risk factor for sepsis, as is multiparity. Antibiotic prophylaxis plays an important role in preventing surgical-site infection. Therapy should be directed towards likely offending organisms endogenous in the lower genital tract including: Escherichia coli, other Gram-negative rods, Streptococcus species, Staphylococcus aureus, coagulase-negative staphylococci, Enterococcus faecalis, Gardnerella vaginalis and anaerobes including Bacteroides species and Peptostreptococcus species. To optimise intraoperative tissue concentration, prophylactic antibiotics should be given at the time of induction. Repeated doses confer no further benefit and increase the risk of adverse effects and antibiotic resistance. The antibiotic of choice should be well tolerated and safe to use and will be determined by local microbial population and their known sensitivities.