What are the key components of parturitional management, including induction of labor, amniotomy, management of normal labor, detection of abnormalities, management of postpartum hemorrhage, repair of perineal tears, assistance in forceps delivery, and cesarean section, as well as postoperative care?

Parturitional Management: A Comprehensive Approach

Induction of Labor

For labor induction with a favorable cervix (high Bishop score), use oxytocin infusion with artificial rupture of membranes; for an unfavorable cervix, use oral misoprostol solution 20-25 µg every 2-6 hours, or mechanical methods (Foley catheter) in high-risk cardiac or cyanotic patients. 1

Cervical Assessment and Method Selection

• Assess the Bishop score before selecting an induction method to determine cervical favorability 1
• A favorable cervix indicates readiness for oxytocin and membrane rupture 1
• An unfavorable cervix requires cervical ripening first 1

Primary Induction Methods by Clinical Scenario

For favorable cervix:

• Oxytocin infusion with artificial rupture of membranes is the standard approach 1, 2
• Consider adding membrane stripping at the beginning of induction 3

For unfavorable cervix:

• Oral misoprostol solution 20-25 µg every 2-6 hours is the preferred pharmacological method, resulting in fewer cesarean sections and lower uterine hyperstimulation rates 1
• Alternative: 50 µg every 4-6 hours if no more than 3 contractions per 10 minutes and no previous uterine surgery 3
• Combination approach: 60-80 mL single-balloon Foley catheter for 12 hours plus misoprostol or oxytocin 3

For high-risk patients:

• Mechanical methods (Foley catheter) are preferable to pharmacological agents in patients with cyanosis, active cardiovascular disease, or conditions where drops in systemic vascular resistance would be detrimental 1
• Dinoprostone is contraindicated in active cardiovascular disease due to profound blood pressure effects, theoretical risk of coronary vasospasm, and low risk of arrhythmias 4

Critical Contraindications

Misoprostol is absolutely contraindicated in women with previous cesarean delivery due to 13% uterine rupture risk, substantially higher than oxytocin (1.1%) or prostaglandin E2 (2%). 1

• Oxytocin in prior cesarean: 1.1% rupture risk 1
• Prostaglandin E2 in prior cesarean: 2% rupture risk 1
• Misoprostol in prior cesarean: 13% rupture risk 1

Timing Considerations

• For term prelabor rupture of membranes, induction with oxytocin should occur immediately (as soon as feasible) or up to 12 hours if labor is not evident 3
• Cesarean delivery should not be performed before 15 hours of oxytocin infusion and amniotomy if feasible, and ideally after 18-24 hours of oxytocin infusion 3
• Wait at least 30 minutes after removing dinoprostone before starting oxytocin 4

Monitoring Requirements

• Continuous fetal heart rate monitoring is mandatory during all pharmacological induction methods 1, 4
• Continuous uterine activity monitoring is required throughout dinoprostone administration 4

Amniotomy

Amniotomy alone results in spontaneous labor within 24 hours in 90.1% of women with favorable cervix, making it a simple, safe, and effective method when membranes are accessible. 5

Indications and Technique

• Amniotomy is indicated when membranes are accessible and cervix is favorable 6
• Can be used alone or in combination with oxytocin for labor induction 1, 3
• When used with oxytocin for favorable cervix, this combination is the standard approach 1

Outcomes

• Spontaneous labor occurs in 90.1% within 24 hours 5
• Oxytocin augmentation required in 9.8% of cases when amniotomy used alone 5
• Overall vaginal delivery rate of 92.1% (80.5% spontaneous, 7.3% ventouse, 4.3% forceps) 5
• 90.5% of multiparous women and 63.4% of primiparous women achieve spontaneous vaginal delivery 5

Timing of Secondary Intervention

• When amniotomy is used alone, consider secondary intervention (oxytocin) if labor does not establish within an appropriate timeframe 6
• Once 5-6 cm cervical dilation is achieved during induction, consider discontinuing oxytocin if adequate contractions are present 3

Management of Normal Labor

Labor should be conducted in a high-care area with continuous invasive hemodynamic monitoring for high-risk patients, maintaining left lateral or sitting-up position, with epidural analgesia preferred for pain control and ability to extend for emergency cesarean if needed. 7, 1

Labor Positioning and Monitoring

• Left lateral position ensures adequate venous return from inferior vena cava 7
• Sitting-up position may be needed for women in cardiac failure 7
• Continuous cardiotocography for fetal monitoring 7
• Continuous urinary catheter drainage for high-risk patients 7

Analgesia and Anesthesia

• Epidural analgesia is preferred during labor as it stabilizes cardiac output 7, 1
• Early epidural analgesia can be extended for emergency cesarean if needed 1
• For cesarean section, continuous spinal anesthesia and combined spinal-epidural anesthesia are recommended 7

Fluid Management

• Care must be taken to prevent fluid overload and pulmonary oedema from IV infusions 7
• Continue antenatal oral medications during labor 7
• Heparin should not be given after contractions have started 7

Second Stage Management

• Prolonged bearing down efforts must be discouraged 7
• Where spontaneous delivery cannot be achieved rapidly, low forceps or vacuum-assisted delivery will reduce exertion and shorten the second stage 7

Third Stage Management

Active management of third stage with oxytocin is preferred; ergometrine is contraindicated in women with respiratory disease due to bronchospasm risk. 7

• Single dose of intramuscular oxytocin for active management 7
• Ergometrine is contraindicated as it may cause bronchospasm, particularly in association with general anesthetics 7
• Prostaglandin F2α should not be used in women with asthma as it may cause bronchoconstriction 7
• Single IV dose of furosemide commonly given after delivery to manage auto-transfusion from lower limbs and contracted uterus 7

Detection of Abnormalities of Labor

Immediate intrauterine resuscitation for fetal bradycardia includes discontinuing uterotonic agents, administering subcutaneous terbutaline, providing oxygen at 10 L/min by facemask, changing maternal position to left lateral, and assessing for cord prolapse, while simultaneously preparing for urgent cesarean section. 8

Fetal Heart Rate Abnormalities

Critical distinction: Potentially reversible causes (uterine hyperstimulation, hypotension after epidural, aortocaval compression) versus irreversible causes (umbilical cord prolapse, major placental abruption, ruptured uterine scar, fetal hemorrhage). 8

• Discontinue uterotonic agent immediately 8
• Administer subcutaneous terbutaline to stop uterine hyperstimulation 8
• Administer oxygen at 10 L/min by facemask, which significantly increases fetal oxygen in abnormal FHR patterns 8
• Change maternal position to left lateral to relieve potential aortocaval compression 8
• Assess for cord prolapse immediately 8

Decision for Expedited Delivery

• Expedited delivery via operative vaginal delivery or cesarean section is indicated if FHR tracing remains abnormal despite intrauterine resuscitation measures 8
• Fetal condition is likely maintained during delay in majority of cases with potentially reversible causes 8
• Significant decline in neonatal pH occurs with increasing bradycardia-delivery interval in irreversible causes 8

Management of Postpartum Hemorrhage

For postpartum hemorrhage management, establish infrastructure with strong nursing leadership, access to blood bank with massive transfusion protocols, and use oxytocin as first-line uterotonic; avoid ergometrine in women with respiratory disease and prostaglandin F2α in women with asthma. 7

Prevention and Preparation

• Established infrastructure and strong nursing leadership accustomed to managing high-level postpartum hemorrhage should be in place 7
• Access to blood bank capable of employing massive transfusion protocols 7
• Intraoperative availability of cell-saver, point of care testing, adequate surgical trays 7
• Coordination of blood bank with scheduling or timing of case 7

First-Line Management

• Oxytocin is indicated to produce uterine contractions during third stage and control postpartum bleeding or hemorrhage 2
• Methylergonovine is indicated for routine management of uterine atony, hemorrhage and subinvolution of uterus following placenta delivery 9

Special Considerations

• Prostaglandin F2α used for uterine atony may cause bronchoconstriction and is not recommended in women with asthma 7
• Ergometrine may cause bronchospasm particularly with general anesthetics 7
• Women on long-term systemic corticosteroids have increased risk of poor wound healing and infection 7

High-Risk Scenarios

• Delivery in highly experienced maternity centers with coordinated care team and ability to garner additional expertise improves outcomes in severe hemorrhage 7
• Multidisciplinary care team should include experienced obstetricians, maternal-fetal medicine subspecialists, pelvic surgeons, urologists, interventional radiologists, obstetric anesthesiologists, critical care experts, general surgeons, trauma surgeons 7

Repair of Perineal Tears

Warm compress on the perineum during second stage likely results in reduction of third- or fourth-degree tears (RR 0.46) and large reduction in perineal pain, making it the most evidence-based perineal protection technique. 10

Evidence-Based Perineal Techniques

Warm compress application:

• Likely results in reduction of third- or fourth-degree tears (RR 0.46,95% CI 0.27 to 0.79) 10
• Likely results in large reduction in perineal pain (MD -0.81,95% CI -1.18 to -0.44) 10
• May result in little to no difference in second-degree tears 10

Combined warm compress and massage:

• Likely results in reduction of second-degree tears (RR 0.63,95% CI 0.46 to 0.86) 10
• May result in reduction in PPH ≥ 500 mL but confidence intervals are wide (RR 0.43,95% CI 0.14 to 1.35) 10
• Likely results in increase in maternal satisfaction 10

Massage alone:

• May have little to no effect on second-degree tears 10
• May reduce fourth-degree tears but confidence intervals are wide 10
• Likely results in little to no difference in perineal pain 10

Hands off (poised) versus hands on:

• May result in little to no difference in second-degree tears or third/fourth-degree tears 10
• Probably results in little to no difference in breastfeeding two days after birth or perineal pain 10

Assistance in Forceps Delivery

Low forceps or vacuum-assisted delivery should be used when spontaneous delivery cannot be achieved rapidly in the second stage to reduce maternal exertion and shorten the second stage, particularly important in women with cardiac disease or respiratory compromise. 7

Indications

• Prolonged second stage where spontaneous delivery cannot be achieved rapidly 7
• Need to reduce maternal exertion in high-risk patients 7
• Shorten second stage in women with cardiac or respiratory disease 7

Technique Considerations

• Low forceps application preferred to minimize trauma 7
• Vacuum-assisted delivery is alternative option 7
• Strong bearing down efforts must be discouraged in high-risk patients 7

Assistance in Caesarean Section and Postoperative Care

Caesarean section should be performed in highly experienced maternity centers with multidisciplinary team available, including experienced obstetricians, maternal-fetal medicine subspecialists, pelvic surgeons, anesthesiologists, and critical care experts, with assurance that critical care services are engaged for postoperative care. 7

Preoperative Considerations

• Maximization of preoperative hemoglobin values 7
• Verification of specific timing of planned delivery 7
• Identification of exact location of delivery (surgical suite and its associated capabilities) 7
• Verification that necessary preoperative consultations have occurred 7

Indications for Caesarean Section

• Obstetric indications 7
• Significant aortopathy (e.g., > 40 mm in Marfan syndrome; aortic diameter > 45 mm) 7
• Vascular Ehlers-Danlos syndrome 7
• Patients requiring ongoing anticoagulation 7
• Severe pulmonary hypertension 7
• Maternal or fetal instability, such as acute heart failure 7
• Life-threatening maternal complication (immediate delivery should be considered, primarily to improve maternal outcomes) 7
• Cardiac arrest (caesarean section delivery should occur within 5 minutes) 7

Intraoperative Management

• Verification of appropriate complement of surgical expertise involved or available 7
• Intraoperative availability of resources: cell-saver, point of care testing, adequate surgical trays, necessary urologic equipment 7
• Verification of availability of related services (interventional radiology) 7
• Coordination of blood bank with timing of case 7

Anesthesia Considerations

• Regional anesthesia preferred in breastfeeding women to limit impact on ability to care for infant 7
• Epidural analgesia can be extended for emergency cesarean 1
• Continuous spinal anesthesia and combined spinal-epidural recommended for planned cesarean 7

Postoperative Care

Critical care services must be engaged and available for postoperative care, with identification of primary service responsible for postoperative management. 7

• Assurance that critical care services are engaged and available 7
• Identification of primary service responsible for postoperative care 7
• Optimal post-partum analgesia allows early mobilization with minimal side-effects 7
• Pain should be assessed and managed in multimodal way 7
• Respiratory depressant effect of opioids and suppression of cough are particularly important in women with respiratory diseases 7

Specific Postoperative Risks

• Women on long-term systemic corticosteroids have increased risk of poor wound healing and infection, especially important after caesarean section in those with suppurative lung disease 7
• Risk of post-partum venous thromboembolic disease is increased with immobility; early mobilization or thromboprophylaxis with low-molecular-weight heparin should be considered 7
• Anticoagulants should be restarted in consultation with obstetrician and anesthesiologist when post-partum bleeding has stopped and epidural/spinal catheter removed 7

Breastfeeding Considerations

• Vast majority of anesthetics, sedatives, analgesics, neuromuscular blockers and anti-emetics pass in low levels into breast milk 7
• Women should be encouraged to breastfeed as normal without need to express or discard milk 7
• Codeine and aspirin at analgesic doses are contraindicated 7
• Tramadol and oxycodone should be used with caution, monitoring infants for drowsiness 7
• Several ACE-inhibitors (captopril, enalapril, quinapril) can be used in breastfeeding women 7
• Breastfeeding is not advised in patients with suspected peripartum cardiomyopathy due to postulated negative effects of prolactin subfragments 7

Common Pitfalls to Avoid

• Avoid prolonged induction time when cervix remains unfavorable; consider mechanical methods or cesarean delivery if cervical ripening fails 1, 4
• Do not use misoprostol in women with prior cesarean—the rupture risk is unacceptably high 1
• Avoid dinoprostone in active cardiovascular disease; choose mechanical methods instead 4
• Ensure adequately trained staff and equipment are easily available for emergency cesarean within 5 minutes in case of cardiac arrest 7