Abnormal labour Flashcards
What are 6 types of abnormal labour?
- Too early – preterm birth (36+6 – before 37 weeks)
- Too late – Induction of labour (this is offered after 41 weeks)
- Too painful – requires anaesthetic input
- Too long – failure to progress
- Fetal distress – hypoxia/sepsis
- Requires intervention – operative delivery
What anaesthetic options are offered in labour?
ν Support
ν Massage / relaxation techniques
ν Inhalational agents – Entonox (gas and air)
ν TENS (T10-L1, S2-S4)
ν Water immersion
ν IM opiate analgesia e.g. Morphine
ν IV Remifentanil paient controlled anaesthesia system (PCA)
ν Regional anaesthesia
(patients are in pain due to the compression of para-cervical nerves and myometrial hypoxia)
Epidural anaesthesia:
- effective?
- does this impair uterine activity?
- does it inhibit progress of labour?
- what does it require?
- What may be reduced?
¥ Effective - complete pain relief in 95% (more effective relief than opioids)
¥ Does not impair uterine activity
¥ May inhibit progress during stage 2 – not associated with a longer 1st stage (due to inhibiting pelvic floor)
¥ requires intravenous access
¥ mobility may be reduced
What is used for an epidural?
¥ Levobupivacaine +/- Opiate
¥ Low-concentration anaesthetic with opioid solution
¥ The initial dose of anaesthetic is essentially a test dose – so administer cautiously to ensure that inadvertent intrathecal injection has not occurred
What are the complications for an epidural?
Hypotension (20%) – slows baby’s HR = fetal bradycardia/distress
Dural puncture (1%) Headache – due to dural puncture causing CSF leak and decrease in fluid pressure in the brain
Back pain (not long term backache)
Atonic bladder (40%) – a full bladder may prevent delivery
Increased chance of operative birth (not increasing chance of a C-section)
What is defined as failure to progress in labour?
Nulliparous (woman who has never given birth)
• <2cm dilation in 4 hours
Parous (woman who has given birth)
• <2cm dilation in 4 hours or slowing in progress
What can causes failure to progress:
- powers
- passages
- passenger
ν Powers:
¥ Inadequate contractions: frequency and/or strength
ν Passages:
¥ Short stature / Trauma / Shape
ν Passenger:
¥ Big Baby
¥ Malposition - relative cephalo-pelvic disproportion
What can indicate/assess fetal distress in labour?
Doppler auscultation of fetal heart - this is for low-risk women
¥ Stage 1: During and after a contraction / Every 15 minutes
¥ Stage 2: Every 5-10 minutes
ν Cardiotocograph (CTG) (+/- STAN st-analysis) – this is for high-risk
• Frequency of contractions and fetal heart monitoring
• Midwife assesses strength of contractions
ν Colour of amniotic fluid – meconium due to fetal distress/late delivery
How is fetal distress managed?
ν Change maternal position
ν IV Fluids
ν Stop syntocinon
ν Scalp stimulation
ν Consider tocolysis - Terbutaline 250 micrograms s/c
ν Maternal assessment - Pulse / BP / Abdomen / VE
ν Fetal blood sampling – is it acidic?
ν Operative Delivery
ν Vaginal – ventouse cup/forceps
What to do if scalp pH is:
->7.25
7.2-7.25
<7.2
- > 7.25
- normal
- no action
- 2-7.25
- borderline
- repeat in 30mins
<7.2
- abnormal
- deliver
What are the indications for surgical vaginal delivery?
Standard” Indications:
- Delay (failure to progress stage 2)
- Fetal distress
“Special” Indications:
- Maternal cardiac disease
- Severe PET / Eclampsia
- Intra-partum haemorrhage
- Umbilical cord prolapse Stage 2
No indication is absolute. Each case should be considered individually
What are the main indications for C section?
previous CS
fetal distress
failure to progress in labour
breech presentation
maternal request
Is this assoc with greater or less maternal mortality?
¥ 4 X greater maternal mortality associated with CS
What are the complications of c section?
sepsis, haemorrhage, VTE, trauma, TTN, subfertility, regret, complications in future pregnancy
TTN – transient tachypnea of the newborn: self limiting disease, babys lungs aren’t matured enough due to lack of mechanical motion of labour squeezing fluid out and encouraging lung maturation
