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4th Year GOSH > Abnormal Labour > Flashcards

Abnormal Labour Flashcards

1
Q

Consequences and management of OP position?

A

Larger diameter to negotiate pelvic outlet –> longer labour, more painful and earlier desire to push.

If progress is normal - no action needed. Some rotate to OA spontaneously or deliver OP.

If slow, augmentation. If no full dilation, c-section.

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2
Q

Consequences and management of OT position?

A

Occiput lies on left or right - position head normally enters the pelvis in first stage.

Rotation with traction - usually achieved with ventouse.

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3
Q

Consequences and management of brow position?

A

Extension of foetal head on neck –> large diameter (13cm) that will not deliver vaginally.
Anterior fontanelle, supraorbital ridges and nose palpable.

C-section.

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4
Q

Consequences and management of face presentation?

A

Complete extension of head –> face is presenting part (mouth eyes, nose palpable)

Can deliver if chin anterior (mento-anterior) - can be flexed over perineum. If chin posterior (MP) - c-section.

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5
Q

What is longitudinal lie? Two types?

A

Foetus lying longitudinally within the uterus

Cephalic or breech

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6
Q

Transverse and oblique lie?

A

Transverse = lying across uterus with head in flank

Oblique = lying across uterus with head in iliac fossa

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7
Q

Causes of abnormal lie?

A

Preterm labour (complicated more by abnormal lie)

More room to turn (polyhydramnios, high parity = lax uterus –> unstable lie)

Prevention of turning (foetal/uterine abnormalities, twin pregnancies)

Prevention of engagement (placenta praevia, pelvic tumours/uterine deformities)

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8
Q

In whom is unstable lie rare?

A

Nulliparous women

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9
Q

Potential complications of abnormal lie?

A

Head/breech cannot enter pelvis –> labour cannot deliver foetus

Uterine rupture as a result of prolapse of an arm or the cord when membranes rupture

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10
Q

Management of abnormal lie? (before 37 weeks)

A

No management before 37 weeks unless woman in labour

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11
Q

Management of abnormal lie? (after 37 weeks)

A

Admit to hospital in case membranes rupture - USS to exclude identifiable causes

ECV not justified - if spontaneous version occurs and persists for more than 48 hours woman can be discharged.

Abnormal lie usually stabilises before 41 weeks in absence of obstruction.

PERSISTENT ABNORMAL LIE –> c-section

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12
Q

What is breech presentation?

A

Presentation of the buttocks (3% of term pregnancies)

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13
Q

What are the 3 types of breech presentation and their incidences?

A

Extended (Frank) Breech (70%) – both legs extended at the knee.

Flexed (Complete) Breech (15%) – both legs flexed at knee.

Footling (Incomplete) Breech (15%) - more common if preterm – one or both feet present below buttocks.

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14
Q

Types of footling breech?

A

Single footling
Double footling
Footling-frank
Kneeling

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15
Q

Diagnosis of breech presentation?

A

Only important from 37 weeks or if in labour.

  • Upper abdominal discomfort common
  • Hard head normally palpable and ballotable at the fundus
  • USS – confirms diagnosis, helps detection of foetal abnormality, pelvic tumour or placenta praevia and ensures prerequisites for ECV are met.
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16
Q

Complications of breech presentation?

A

Perinatal and long-term morbidity/mortality increased.

Labour has potential hazards
Cord prolapse, trapping of after-coming head

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17
Q

What is ECV?

A

After 37 weeks – attempt made to turn baby to cephalic position –> hopefully reduction in breech presentation at term –> no caesarean or vaginal breech delivery.

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18
Q

When is ECV not recommended?

A

Before 37 weeks!

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19
Q

What is the success rate of ECV? Who has lower success rates?

A

50% –> 3% of successfully turned breeches will turn back

Lower success in nulliparous women, Caucasians, obese women and liquor volume reduced.

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20
Q

Process of ECV?

A

Breech mobilised, manual forward rotation using both hands (one to push breech and other to guide vertex) - completion of forward roll, then backward roll.

CTG straigh after and anti-d given to resus -ve women

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21
Q

Risks of ECV?

A

Low complication rate

Pain
Transient bradycardia (resolves spontaneously)
Abruption (<1%)
Prolonged bradycardia 
Emergency LSCS (0.5%).
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22
Q

Contraindicaitons to ECV?

A

Absolute = placenta praevia (vaginal birth contraindicated anyway), uterine malformations, antepartum haemorrhage, rupture membranes, abnormal CTG, multiple pregnancy.

Relative = previous CS (1 is fine), active labour, preeclampsia, oligohydramnios, foetal abnormalities, hypertension of foetal heart, maternal cardiac disease.

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23
Q

C-section in breech presentation?

A

If ECV failed or contraindicated or breech presentation missed – safest method of delivery is elective C-section.

  • Reduces neonatal mortality and short-term morbidity – does not affect long-term outcomes. Maternal morbidity not increased.
  • 1/3 of attempts at breech delivery end in emergency caesarean anyway – greater risks than elective.
  • Decision is up to parents in the end.
24
Q

Process of vaginal breech delivery?

A

Buttocks distend perineum, perform episiotomy.

Finger behind knee delivers legs, finger hooks each arm down, forceps deliver head once arms out.

25
Q

What is most common method of delivery for twins and why?

A

Caesarean section increasingly used for all – even uncomplicated. Due to increased risk of death and hypoxia in second twin compared to the first.

26
Q

When is c-section absolutely indicated in twin delivery?

A

o If first foetus is breech or transverse lie (20%)
o Triplets (or other high order multiples)
o If there have been antepartum complications
o With monochorionic twins

27
Q

When would vaginal delivery be appropriate in twin delivery?

A

When first foetus is cephalic

28
Q

Timing of induction/caesarean in twin delivery?

A

38 weeks (DC twins)

36-37 weeks (MC twins)

After this point perinatal mortality is increased.

29
Q

Monitoring/epidural in twin delivery?

A

CTG advised

Epidural recommended as difficulty sometimes in delivering second twin

30
Q

Process of twin delivery?

A

First twin delivered normally –> contractions usually diminish after first twin then return after a few minutes (oxytocin if not).

Lie of second twin checked and ECV performed if not longitudinal –> head or breech enters pelvis –> membranes ruptured (amniotomy) and pushing begins again.

Delivery usually easy whether cephalic or breech – 20 minutes after first foetus. (Delay associated with increased morbidity for second twin)

31
Q

Problems in twin delivery? (2nd twin)

A

If head does not descend – malpresentation (usually brow) is likely –> C-section

If foetal distress/cord prolapse –> ventouse or breech extraction (GA/epidural/spinal).

32
Q

Indications for instrumental deliivery?

A

Prolonged 2nd stage (after 1 hour)
Foetal distress
Prophylactic (avoiding labour)
Breech delivery

33
Q

Pre-requisites for instrumental delivery?

A
  • Head not be palpable abdominally (deeply engaged)
  • Head at or lower than the level of ischial spines on vaginal examination
  • Cervix must be fully dilated
  • Position of head must be known
  • Adequate analgesia
  • Bladder should be empty
34
Q

What is ventouse?

A

Consists of rubber or metal cap, connected to handle. Cap fixed near foetal occiput by suction. Traction during maternal pushing will delvier OA head; also allows shape of pelvis to simultaneously rotate a malpositioned head to OA position.

35
Q

Examples of non-rotational forceps?

A

Simpson’s

Neville-Barnes

36
Q

When can non-rotational forceps be used? What is their shape?

A

Grip head in whatever position it is in to allow traction. Only suitable when occiput is anterior.

Have a ‘cephalic’ curve for the head and a ‘pelvic curve’ which follows the sacral curve.

37
Q

Example of rotational forceps?

A

Kielland’s

38
Q

Use for rotaional forceps? Shape?

A

Have no pelvic curve and enable a malpositioned head to be rotated by the operator in the OA position, before traction is applied.

39
Q

Forceps vs Ventouse?

A

Ventouse causes…

  • Higher failure rate (but LSCS not more common if forceps then used)
  • More foetal trauma
  • No difference in Apgar scores
  • Less maternal trauma.
40
Q

What is the thing on the baby’s head called after ventouse?

A

Chignon

41
Q

What % of deliveries are C-sections?

A

20-30%

42
Q

What kind of incision in C-section?

A

Suprapubic transverse incision

43
Q

Indications for emergency c-section?

A

Failure to progress (prolonged first stage)

Foetal distress

44
Q

Indications for elective c-section

A

Absolute = placenta praevia, severe antenatal foetal compromise, uncorrectable abnormal lie, previous vertical C-section, gross pelvic deformity

Relative = breech, twins, DM/others, previous C-section, older nulliparous patients

When delivery needed before 34 weeks

45
Q

Maternal request for c-section?

A

Should try to understand and address the reasons for the request, and encourage normal birth. If not, most obstetricians now agree to procedure.

46
Q

Complications of c-section? (maternal)

A

Rare but greater than vaginal delivery (more common with emergency)

Haemorrhage
Infection
Bladder/bowel damage
Post-operative pain/immobility
VTE
47
Q

Foetal complications of c-section?

A

Elective c-section increases risk of respiratory mortality at any given gestational age. Should not be done before 39 weeks if uncomplicated.

48
Q

Complications for subsequent pregnancies with c-section?

A

Incidence of placenta praevia is more common in pregnancies after a caesarean.

Placenta accreta/percreta
 Placenta may implant more deeply than normal, into myometrium (accrete) or through into surrounding structures (percreta).
Can need hysterectomy and can be lethal.

49
Q

What is shoulder dystocia?

A

When additional manoeuvres required after normal downward traction has failed to deliver the shoulders after the head is delivered – 1 in 200 deliveries.

50
Q

Potential consequence of shoulder dystocia

A

Excessive traction on the neck damages the brachial plexus –> Erb’s (waiter’s tip) palsy.

Delay in delivery can be lethal

51
Q

Risk factors for shoulder dystocia?

A
  • Large baby – but only half of all cases occur in babies >4kg – also antenatal prediction of foetal size is poor.
  • Maternal BMI
  • Labour induction
  • Low height
  • Maternal DM
  • Instrumental delivery
52
Q

External manoeuvres in shoulder dystocia?

A

Gentle downward traction - Because obstruction is at pelvic inlet, excessive traction is useless –> Erb’s palsy

McRoberts’ manoeuvre - Legs are hyperextended onto the abdomen. Suprapubic pressure also applied. Facilitates disimpaction of anterior foetal shoulder.

53
Q

Internal manouvres in shoulder dystocia?

A

• Wood’s screw manoeuvre - Insert two fingers into the vagina posteriorly and apply pressure to the anterior surface of the posterior shoulder to rotate the infant 180°

Delivery of Posterior Arm - Posterior arm grasped and, by extension at elbow, hand is brought down and swept across foetal chest.

54
Q

What may result from delivery of posterior arm?

A

Fracture of clavicle and/or humerus may result

55
Q

Last resorts in shoulder dystocia?

A

Symphysiotomy - cartilage of the pubic symphysis is divided to widen the pelvis

Zanavelli Manoeuvre - Replacement of the head (rotated to OA position, flexed rotated and pushed back up to uterus) and caesarean section.

56
Q

Mnemonic for shoulder dystocia?

A

HELPER

  • Help: Obstetrics, neonatology, anesthesia
  • Episiotomy: Generous, possibly even episioproctotomy
  • Legs flexed: McRoberts’ maneuver
  • Pressure: Suprapubic pressure, shoulder pressure
  • Enter vagina: Rubin’s maneuver or Wood’s Maneuver
  • Remove posterior arm: Splint, sweep, grasp and pull to extension

4th Year GOSH (23 decks)

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