GP Life is a study guide written by a GP Registrar in NSW. As such, the focus is largely on NSW and central Australian communities for the purpose of studying for the ACRRM CGT StAMPS exam. The below is not to be taken as medical advice or relied upon for the diagnosis or management of real-life patients.

Normal Birth

Assessing a pregnant woman with signs of labour should involve:

Review of reason for presentation and obstetric + medical history (if time permits).
- Time of onset of contraction.
- Duration, frequency, and strength (and trajectory thereof).
Maternal vitals + abdominal assessment: fundal height, lie, presentation etc.
FHR + CTG
Vaginal examination -> cervical dilation + length.

Preparation in the Rural Setting

We have two patients to consider in our rural hospital. Of course this will depend a little bit on the clinical vignette, however we should think about:

People: get at least the GPA in to assist. If complications appear likely, also call in the registrar or non-procedural GP to assist. If any of the midwifery-trained RNs are available, have them present to assist. Notify retrieval and the obstetrician at the regional centre that we may need support imminently.
Equipment: Ensuring we have the adult resuscitation trolley present, the Resuscitaire set up, and neonatal resuscitation equipment including airway management equipment and an appropriate size BVM. May want to prep nitrous for analgesia also.
Drugs: Again, assuming a normal birth, we will need oxytocin 10 IU (IM) for after delivery. In preparing for complications, we can consider further oxytocin, TXA, and ergometrine. Once we have control, an oxytocin infusion and carboprost or misoprostol would be useful for maintenance. We should also have neonatal resuscitation equipment and adrenaline, and be ready to release our units of blood if required.
Location: This patient will be managed in the resuscitation area of StAMPSville ED. We will need to move other patients out of the acute area if possible and have admin notify other patients that reviews will be delayed.

First Stage

First stage can be divided into latent and active. Active is regular contractions and cervical effacement and dilatation of 4+ cm. If the pregnancy is low risk and the woman is at term, I’d probably keep an active first stage and just manage with the obstetrician on the phone. Consider transfer if early/latent first stage.

During first stage the focus is on supportive care and monitoring. This will include:

Analgesia: nitrous, morphine. Epidural if GPA confident and skilled.
Monitoring:
- FHR: Queensland guidelines say every 15-30 min intermittent auscultation however CTG would also be reasonable in the rural setting.
- Maternal pulse 30 minutely.
- Contractions: every 30 mins for 10 minds.

The biggest concern is delay in active first stage. This is defined by <2 cm of dilatation in 4 hours (or slowing of progress in multips). You would of course be keeping the obstetrician abreast of this situation.

Second Stage

Second stage is split into active and passive second stage. Passive is defined as full cervical dilatation without the urge to push. This should last no longer than an hour. Here we increase FHR monitoring to 15 minutely.

Active second stage begins when there are involuntary expulsive contractions. FHR should be reviewed at least every 5 mins or at the end of each contraction.

Third Stage

From the birth of the baby to delivery of the placenta. All births are recommended to have oxytocin 10 IU IM after the birth of the baby. Clamp cord >1 min after birth then controlled cord traction with uterine guarding can be used. Should last <30 mins. Have someone experienced check the placental membrane to ensure it is intact.

Assessment of the Neonate

Initial assessment should include breathing, HR, colour, reflex irritability (crying), tone. Apgars should be done at 1 and 5 minutes. Maintain warmth, and continue to assess 15 minutely for the first 2 hours. Non-urgently, Hep B and vit K 1 mg IM should be given, as well as an initial weight, length, and head circumference.

Complications

Shoulder Dystocia

HELPER:

Help: Send for help.
Evaluate for episotomy.
Legs: McRobert’s
Pressure: suprapubic (not fundal)
Enter: enter the vagina and perform rotational manoeuvres.
Remove: remove the posterior arm.

In the worst case scenario, would need to prepare for breaking the clavicle.

Preterm Labour

Risk factors: previous preterm birth, cervical surgery, multiple D&Cs, <17 yrs or >35 yrs, psychosocial stressors, low BMI, short cervical length, IVF pregnancy, substance use, short cervical length.

Defined as contractions with cervical changes <37 weeks. Typically presents with a prodrome of menstrual-like cramping, irregular contractions, low back ache, a pressure sensation in the vagina/pelvis, and PV discharge or spotting.

These are obviously deeply vague symptoms and a fFN can be used to help guide risk at 22-34 weeks. Differentials include Braxton-Hicks (more likely if irregular, less severe) and pre-eclampsia (if upper abdomen or atypical features).

Physical examination should include vitals, abdominal palpation, application of fetal monitoring (CTG), sterile speculum examination to identify if ROM, visualising the cervix/membranes. Do not do a digital vaginal exam if there is ROM or known placenta praevia.

Should have HVS for MCS, a low vaginal/anorectal swab for GBS, and a urine MCS.

Admission (and therefore transfer to the regional centre) should be considered if:

Cervical dilatation or changes.
Positive fFN.
Rupture of membranes has occurred.
Contractions are regular and painful.
It is a high-risk pregnancy.

These patients should be transferred out of rural sites in utero. Queensland guidelines advice if <28/40, accept a high level of risk for birth en route unless it puts mum’s life at risk.

Management while awaiting retrieval/transfer includes:

Antenatal corticosteroids: (if 22-34+6/40).
Tocolysis: nifedipine 20 mg PO. Repeat after 30 mins if contractions continue and then QID for 48 hours.
Antibiotics: give GBS prophylaxis (benpen) regardless of status or membranes if labour is established. If chorioamnionitis is present, given amp + gent + metro.
Magnesium sulfate: if <30+0/40 if labour established.
Prepare for birth: consider neonatal and maternal complications.

Chorioamnionitis

Intraamniotic infections present nonspecifically. Consider in a pregnant woman with fever with ruptured membranes or during labour, uterine tenderness, or with purulent amniotic fluid.

Chorioamnionitis can lead to preterm labour, PPH, endometritis, and neonatal mortality. Treatment is with amp/gent/metro.

Post-Partum Haemorrhage

Notify retrieval and obstetrician. Consider activation of retrieval transfusion protocol.
Assess degree of blood loss and stability of patient (A->E approach with simultaneous fundus massage).
Resuscitation:
- Apply monitoring (HR/SpO2/BP), oxygen.
- Ensure adequate IV access. If required crystalloid bolus to maintain BP. Otherwise consider starting to replace with your units of blood.
- TXA 1g IV over 10 min.
Tissue: If placenta isn’t out, attempt delivery. Check for completeness.
Tone: massage fundus. Give
- oxytocin 5 IU IV
- ergometrine 250 microg IV
- oxytocin 5-10 IU/hr IV infusion
- misoprostol 800-1000 microg PR
- Consider carboprost
Trauma: inspect genital tract, clamp obvious arterial bleeders, rapid primary repair.
Thrombin: Consider giving fibrinogen concentrate if clotting problem suspected under specialist guidance.

Failing the above, an intrauterine balloon tamponade if available or bimanual compression and urgent transfer to higher level facility.

Ensure that follow-up is arranged on discharge and consider debrief with staff after this event.

Practice Question

Sally, a 24-year-old Indigenous woman from StAMPSville, presents to your ED at 9pm on a Friday. She is 37+5/40, G4P3. Sally is getting lower abdominal cramps.

What is your differential and your approach to reviewing Sally today?
Sally’s pregnancy has been uncomplicated and she has received appropriate antenatal care. She has been getting increasingly regular low abdominal cramps, and just prior to coming in her Sally is 7 cm dilated and having regular contractions. What are your next steps?
Sally undergoes a normal delivery of a healthy neonate with Apgars of 8 and 9. About 5 minutes after delivering the placenta, Sally develops profuse vaginal bleeding and starts feeling faint. How would you manage this situation?

Birth and Complications