Intrapartum And Postpartum Care

Introduction

Intrapartum and postpartum care are high-yield topics for the MCCQE1. As a Canadian medical graduate, you are expected to demonstrate competency in the Medical Expert and Health Advocate CanMEDS roles by managing normal labour, recognizing obstetric emergencies, and ensuring safe transition to the puerperium.

This guide focuses on evidence-based practices aligned with the Society of Obstetricians and Gynaecologists of Canada (SOGC) guidelines, essential for MCCQE1 preparation.

Intrapartum Care: Management of Labour

Stages of Labour

Understanding the physiology and timeframes of labour is fundamental.

Fetal Health Surveillance (FHS)

According to SOGC Guidelines, the method of surveillance depends on risk status.

Pain Management

1. Non-Pharmacological: Breathing techniques, hydrotherapy, massage, position changes.
2. Pharmacological:
   • Nitrous Oxide: Self-administered.
   • Opioids: Morphine or Fentanyl (Caution: risk of neonatal respiratory depression if given close to delivery).
   • Regional Anesthesia (Epidural): Gold standard for pain relief.
     • Contraindications: Coagulopathy, infection at site, hypovolemia.
     • Common Side Effect: Maternal hypotension (manage with fluids, left lateral tilt).

Obstetric Emergencies

Postpartum Hemorrhage (PPH)

Defined as blood loss >1000 mL for C-section OR vaginal delivery (SOGC updated definition), or any amount causing hemodynamic instability.

The 4 Ts of PPH (Etiology)

• Tone (Uterine Atony - 70% of cases)
• Trauma (Lacerations, Rupture, Inversion)
• Tissue (Retained Placenta)
• Thrombin (Coagulopathy)

Management Steps

Shoulder Dystocia

An obstetrical emergency where the anterior shoulder impacts behind the pubic symphysis. Sign: “Turtle Sign” (head retracts against perineum).

Management Mnemonic: ALARMER

• Ask for help.
• Lift legs (McRoberts Maneuver: hyperflex hips).
• Anterior shoulder disimpaction (Suprapubic pressure - Never fundal pressure).
• Rotation (Wood’s screw maneuver).
• Manual removal of posterior arm.
• Episiotomy (only to make room for maneuvers, does not release bone impaction).
• Roll over onto all fours (Gaskin maneuver).

Postpartum Care (The Puerperium)

Immediate Assessment (BUBBLE-HE)

• Breasts (Lactation, cracks, mastitis)
• Uterus (Involution: should be at umbilicus post-delivery, descends 1 cm/day)
• Bladder (Voiding, retention)
• Bowels (Constipation, flatus)
• Lochia (Rubra $\rightarrow$ Serosa $\rightarrow$ Alba)
• Episiotomy/Laceration (Healing, infection)
• Homan’s Sign (DVT check - though low sensitivity/specificity, think VTE risk)
• Emotional State (Bonding, mood)

Rh Isoimmunization Prevention

Postpartum Mood Disorders

Differentiating between “Blues,” Depression, and Psychosis is a frequent MCCQE1 exam target.

Contraception

• Lactational Amenorrhea Method (LAM): Effective if exclusively breastfeeding, amenorrheic, and infant <6 months.
• Progestin-only pills (Mini-pill): Safe immediately postpartum.
• Combined OCP: Avoid in first 3-6 weeks due to VTE risk and potential impact on milk supply (estrogen).
• IUD: Can be inserted immediately post-placenta (higher expulsion rate) or at 6 weeks.

Canadian Guidelines (SOGC)

Key guidelines relevant to MCCQE1:

1. Induction of Labour (IOL): Recommended for post-term pregnancy (41+0 to 42+0 weeks).
2. Group B Streptococcus (GBS): Universal screening at 35-37 weeks.
   • Positive: IV Penicillin G in labour (at least 4 hours before delivery).
   • Unknown status + Risk Factors: Treat if <37 weeks, fever >38°C, or ROM >18 hours.
3. C-Section on Maternal Request: Physician is not obligated to perform but must provide a referral for a second opinion.

Key Points to Remember for MCCQE1

• Active Management of Third Stage: Reduces PPH risk by 60%. Always oxytocin with anterior shoulder.
• PPH Definition: Any blood loss causing hemodynamic instability is the most clinically relevant definition.
• Magnesium Sulfate: Neuroprotection for fetus <32 weeks and seizure prophylaxis in preeclampsia.
• Cord Prolapse: Elevate presenting part (hand in vagina), knee-chest position, immediate C-section.
• GBS Prophylaxis: Not required for planned C-section with intact membranes, even if GBS positive.

Sample Question

Clinical Scenario

A 28-year-old G2P2 woman has just delivered a healthy male infant weighing 4100 g following a vacuum-assisted vaginal delivery. The placenta was delivered spontaneously 10 minutes later. Thirty minutes after the delivery of the placenta, the nurse calls you because the patient has saturated two pads with bright red blood and appears pale. Her blood pressure is 90/50 mmHg, and her heart rate is 110 bpm. On abdominal examination, the uterus is soft and palpable 3 cm above the umbilicus.

Question

Which one of the following initial management steps is most appropriate for this patient?

• A. Administration of tranexamic acid IV
• B. Bimanual uterine massage and rapid infusion of oxytocin
• C. Inspection of the cervix and vagina for lacerations
• D. Immediate transfer to the operating room for laparotomy
• E. Administration of carboprost (Hemabate) intramyometrial injection

Explanation

The correct answer is:

• B. Bimanual uterine massage and rapid infusion of oxytocin

Detailed Explanation: This patient is presenting with Postpartum Hemorrhage (PPH). The most common cause of PPH is Uterine Atony (Tone), accounting for approximately 70% of cases. Risk factors in this scenario include a large infant (macrosomia) and instrumental delivery.

• B is correct: The physical finding of a “soft” (boggy) uterus above the umbilicus confirms uterine atony. The immediate first-line management for atony involves mechanical compression (bimanual massage) and pharmacological enhancement of uterine contraction (oxytocin). This aligns with SOGC guidelines and the “4 Ts” approach.
• A is incorrect: Tranexamic acid is an excellent adjunct (TRAAP trial), but it is not the first step before mechanical compression and oxytocin for atony.
• C is incorrect: While trauma (lacerations) is the second “T” and likely given the vacuum use, the boggy uterus points primarily to atony. You must address the atony first. If the uterus becomes firm but bleeding continues, then you suspect lacerations.
• D is incorrect: Laparotomy is a last resort after medical and conservative surgical measures (like balloon tamponade) fail.
• E is incorrect: Carboprost is a second/third-line agent used if oxytocin and massage fail. It is not the initial step.

References

1. Society of Obstetricians and Gynaecologists of Canada (SOGC). ALARM (Advances in Labour and Risk Management) Course Manual.
2. SOGC Clinical Practice Guideline. Active Management of the Third Stage of Labour: Prevention and Treatment of Postpartum Hemorrhage.
3. SOGC Clinical Practice Guideline. Fetal Health Surveillance: Intrapartum Consensus Guideline.
4. Public Health Agency of Canada. Family-Centred Maternity and Newborn Care: National Guidelines.
5. Medical Council of Canada. Objectives for the Qualifying Examination Part I.