Instrumental vaginal delivery--back to basics.

Assisted vaginal delivery using forceps or a vacuum extractor is an essential part of obstetric practice. Operative vaginal delivery rates in the UK have remained stable between 10% and 15%, yielding safe and satisfactory outcomes for the majority of mothers and their babies. However, there has been an increase in medico-legal cases due to an increasing awareness of the potential morbidity for both the mother and the baby. There are many factors that can play a part in both the maternal and fetal complications resulting from instrumental deliveries. The aim of this educational review is to address these factors and identify measures to reduce them by adherence to the basics and relevant evidence.

Renal angiomyolipoma and lymphangioleiomyomatosis in pregnancy.

This is a literature review for management of angiomyolipoma (AML), lymphangioleiomyomatosis (LAM) and tuberous sclerosis (TS) during pregnancy, prompted by a case of a 23-year-old woman who presented with generalised itching at 31 weeks' gestation and was found to have a large vascular retroperitoneal mass in the lower pole of the left kidney. Magnetic resonance imaging (MRI) was suggestive of angiomyolipoma with multiple large aneurysms and haemorrhage within the tumour. She was delivered at 38 weeks by elective caesarean section, to avoid the risk of rupture and bleeding from the aneurysms during labour. Further imaging, with MR angiogram, computed tomography (CT) of the abdomen and pelvis and high resolution CT (HRCT) of the chest, confirmed lymphangioleiomyomatosis with left AML. She had embolisation of the AML performed twice, 8 weeks apart after delivery and subsequently had a left nephrectomy.

Pregnancy management following bariatric surgery.

Bariatric surgery is gaining in popularity, due to globally increasing rates of obesity. In the UK, this has manifested as a 14-fold increase in bariatric surgery between 2004 and 2010, making it necessary to develop strategies to manage women who become pregnant following bariatric surgery. This review paper has explored all the current evidence in the literature and provided a comprehensive management strategy for pregnant women following bariatric surgery. The emphasis is on a multidisciplinary team approach to all aspects of care. Adequate pre-conception and antenatal and postnatal care is essential to good pregnancy outcomes with emphasis on appropriate nutritional supplementation. This is especially important following malabsorptive procedures. There is no evidence to suggest that pregnancy outcome is worse after bariatric surgery, though women who remain obese are prone to obesity-related risks in pregnancy. Neonatal outcome post-bariatric surgery is no different from the general population.

Operative interventions in the management of major postpartum haemorrhage.

In many recent studies in the developed world, the incidence of postpartum haemorrhage (PPH) has been rising, though the mortality has come down, suggesting improvement in the management of this condition. Since the publication of the RCOG guidelines in 2009 for management of PPH and the Sheffield guidelines for the use of Rusch balloon along with the initial small case series (Keriakos and Mukhopadhyay 2006), many units have introduced the guidelines into clinical practice. This has led to the reduction of surgical intervention in our unit. Major PPH accounted for 1.6% of the total deliveries in our hospital. Surgical interventions accounted for 7.8% of these cases and only 0.1% of the total deliveries. Risk factors for PPH were identified in 83%. In this paper, we reviewed the management of all patients who had major PPH and failed medical management over a period of about 4 years. All surgical interventions including Rusch balloon, B-Lynch suture, radiological interventions and hysterectomy were described. An update to Rusch balloon guidelines and Sheffield guidelines for management of major PPH are appended.

Pelvic girdle pain during pregnancy and puerperium.

Pelvic girdle pain (PGP) is a term used specifically to pregnancy-related pain in the lumbosacral, sacroiliac and symphysis pubis joints. Pregnancy-induced hormonal and physical changes increase the risk of musculoskeletal problems in pregnancy. The severity of these conditions varies from mild self-limiting pain to a severe disabling condition. PGP is common in pregnancy and while most can be managed as outpatients, a few patients require inpatient admission for further investigations and management. Prompt identification of these conditions is essential to avoid serious disability. Lack of awareness and failure of recognition not only results in women feeling isolated, but may also result in long-term morbidity. In this review, we explore the aetiology, presentation, risk factors, risk of recurrence, differential diagnosis and multidisciplinary management of these conditions. We also enclose obstetric guidelines to increase the awareness of the health professionals.

Sheffield modified technique for external cephalic version.

External cephalic version (ECV) is the manipulation of the fetus, through the maternal abdomen, to a cephalic presentation. The incidence of caesarean section for breech presentation has increased markedly in the last 20 years. External version has become more popular in the past 10 years because of the increasing evidence of risks from vaginal breech delivery, increasing demand on the reduction of caesarean sections, a strong safety record, and high success rate of ECV of up to 80%. The use of external cephalic version can produce considerable cost savings in the management of the breech presentation at term; however, there is a wide variation in the success rate, with a range between 30-80%. The ECV technique has remained unchanged for many generations without any modification. This paper provides the outcome of a small prospective study implementing a modified technique for ECV, which has a high success rate.

Obstetric management and perinatal outcome of extreme prematurity: a retrospective study.

The aim of this retrospective study is to evaluate the obstetric management and perinatal outcome of extreme prematurity (22-27 weeks) in a busy teaching hospital between April 2004 and March 2005. A total of 57 babies were delivered in 49 women representing 0.9% of total births. A total of 67% of babies were transferred to the NICU and the survival rate for those who were admitted to the NICU was 47%. The overall survival rate for all births at hospital discharge was 32%. Caesarean section was carried out in 32% of the 49 mothers. The overall survival at discharge in these babies was 50%. Only 12.5% of babies delivered by caesarean section at less than 27 weeks survived as compared with 70% survival rate at 27 weeks. There was no survival among babies delivered by caesarean section below 26 weeks. Gestational age of the neonate was the single most important parameter related to survival at 7 days, 30 days and 90 days/discharge, even after adjusting for other parameters like birth weight, sex of baby and maternal chorioamnionitis. Birth weight was an independent risk factor for survival, with a birth weight of 900 g; the survival rate was significantly higher. Hypertensive disorder was the most common maternal medical complication and responsible for 7/16 caesarean sections. The study highlighted the importance of the multidisciplinary team management and the involvement of parents in the decision regarding management of these very pre-term babies, during labour and after delivery.

The use of the Rusch balloon for management of severe postpartum haemorrhage.

Tamponade techniques using a uterine balloon in management of postpartum haemorrhage has been reported increasingly in recent years. The aim of this retrospective study is to evaluate the use of the Rusch hydrostatic balloon in the management of severe postpartum haemorrhage not controlled by medical measures. All women had risk factors for PPH. The Rusch balloon was used in all cases of PPH apart from traumatic PPH, which is considered as a contraindication for its use. The Rusch balloon was successful in seven out of the eight cases treated. We have introduced guidelines for using the Rusch balloon and they are provided in this paper.

The RUMI manipulator and Koh colpotomiser system for total laparoscopic hysterectomy.

The initial experience in 25 patients of using the Koh Colpotomiser System in conjunction with the RUMI Manipulator, a new modified technique for performing total laparoscopic hysterectomy, is presented. Of 25 operations, 23 (92%) were completed successfully. Complications were limited to minor pre-operative haemorrhage in two patients and post-operative bleeding in another. The Koh Colpotomiser System successfully maintained a pneumoperitoneum following colpotomy, giving the operator improved visibility and access to the pelvic organs. This resulted in greater efficiency, while eliminating the difficulties of vaginal access.

Screening for Down's syndrome: experience of two district general hospitals having different screening strategies.

The aim of this retrospective study is to determine the rate of reduction in the number of Down's syndrome babies delivered in two hospitals having different screening strategies. The total number of Down's syndrome babies during the study period was 0.6/1000 births at Birch Hill Hospital and 1.9/1000 births at Oldham Hospital. Antenatal diagnosis of Down's syndrome was made in 1/4 of women (25%) at Birch Hill and 7/19 of women (37%) in Oldham. The reduction rate of Down's syndrome was similar in both hospitals (25 and 26%). This retrospective analysis and comparison between two neighbouring units, highlights the fact that there is little standardisation of screening policies and screening programmes have not resulted in a substantial reduction in Down's syndrome babies.