Abnormal Labour Flashcards
Reasons for abnormal labour
- Malpresentation: most commonly breech
- Malposition: OP or OT
- Pre term: <37wks
- Post term: >42wks
- Obstruction
- Fetal distress - hypoxia/sepsis
- Too painful - anaesthetic needed
- Too quick - hyperstimulation
- Too long - failure to progress
What complications commonly occurs with breech presentation?
Cord prolapse (esp. if preterm) Head entrapment - baby might be delivered through a cervix that is not completely dilated causing the head to be trapped (esp if preterm and baby is small) Foetal injury at term
Types of malpresentation
Breech (3 types - complete, footling, frank)
Transverse
Shoulder/arm
Face
Brow - brow is leading, widest diameter, baby’s head won’t fit in pelvis
Aetiology of labour pain
Compression of para-cervical nerves
Myometrial hypoxia
Types of analgesia during labour
Support Massage / relaxation techniques Inhalational agents - Entonox TENS (T10-L1, S2-S4) Water immersion IM opiate analgesia e.g. Morphine IV Remifentanil PCA - infusion driven by a pump controlled by mother, given at peak of contraction during fast labour Regional anaesthesia
Benefits of epidural anaethesia
Effective - complete pain relief in 95%
Does not impair uterine activity
Can be topped up during long periods
is not associated with a longer first stage of labour
does not increased the chance of a caesarean birth
Drawbacks of epidural anaesthesia
May inhibit progress during stage 2 Requires IV access Reduced mobility More intensive level of monitoring Increased chance of operative birth
Examples of epidural anaesthetic
Levobupivacaine +/- Opiate
Complications of epidural anaesthesia
Hypotension (20%) Dural puncture (1%) Headache High block - excess of anaesthetic, if it rises to high (ex. up to chest) mother will have difficulty breathing Atonic bladder (40%)
What are the obstructed labour risks due to failure to progress?
sepsis uterine rupture obstructed AKI postpartum haemorrhage fistula formation fetal asphyxia neonatal sepsis
Features used to asses progress in labour
Cervical dilatation Descent of presenting part Signs of obstruction- - moulding -caput - anuria - haematuria - vulval oedema
Suspected delay during Stage I of nulliparous women?
<2cm dilation in 4 hrs
Suspected delay during Stage I of parous women?
<2cm dilation in 4 hour or slowing in progress
Failure to progress in relation to the 3P’s
Power: inadequacy of contractions (frequency and/or strength, <3 to 4 contraction in 10 minutes)
Passages: Short stature/ Trauma/ Shape
Passenger: Big baby, malposition (cephalo-pelvic disproportion)
Position of baby’s head at pelvic inlet
transverse
Position of baby’s head within pelvis
Left/ Right OA
Position of baby’s head at pelvic outlet
OA
What information is given by a partogram?
Fetal Heart Amniotic Fluid Cervical Dilatation Descent Contractions Obstruction - Moulding Maternal Observations
What is given during labour to speed up progression?
Oxytocin infusion
What is the most common form of Intra-partum Fetal Assesment?
Doppler auscultation of the heart:
Stage I:
every 15 min, during and after a contraction
Stage II:
At least every 5 mins during after a contraction for 1 full minute.
Check maternal pulse at least every 15 mins
Other methods of intrapartum foetal assesment
Electronic Fetal Monitoring -Cardiotocograph (CTG)
Colour of amniotic fluid
Risk factors for foetal hypoxia
Small fetus Preterm / Post Dates Antepartum haemorrhage Hypertension / Pre-eclampsia Diabetes Meconium Epidural analgesia VBAC PROM >24h Sepsis (Temp > 38C) Induction / Augmentation of labour
Aetiology of acute foetal distress
Abruption Vasa Praaevia Cord Prolapse Uterine Rupture Feto-maternal Haemorrhage Uterine Hyperstimulation Regional Anaesthesia
Aetiology of chronic foetal distress
Placental insufficiency
Fetal anaemia
CTG assessment - what to monitor?
Baseline foetal heart rate (110-150bpm)
Baseline variability
Presence or absence of decelerations
Presence of accelerations
Commonest kind of deceleration? Associated with?
Variable - quick to recover
Associated with cord compression
Classifications of CTG
Normal
Suspicious
Pathological
How does hypoxia appear on a CTG?
Loss of accelerations
Repetitive deeper and wider decelerations
Rising fetal baeline heart rate
Loss of variability
How to interpret a CTG (pneumonic) - DR.C BRAVADO
D ETERMINE R ISK C ONTRACTIONS B ASELINE R A TE V ARIABILITY A CCELERATIONS D ECELERATIONS O VERALL IMPRESSION
Management of foetal distress
Change maternal position
IV Fluids
Stop syntocinon
Scalp stimulation
Consider tocolysis -
Terbutaline 250 micrograms s/c
Maternal assessment - Pulse / BP / Abdomen / VE
Fetal blood sampling
Operative Delivery (Category 1 delivery)
What is foetal blood sampling?
Speculum/ scope with a light to look at foetal scalp during vaginal exam
Pin prick of foetal blood is taken from foetal scalp
“standard” indications for operative vaginal delivery (only at full dilatation of cervix)
Delay (failure to progress to Stage II)
Foetal distress
“special” indications or operative vaginal delivery (only at full dilatation of cervix)
Maternal cardiac disease Severe PET / Eclampsia
Intra-partum haemorrhage
Umbilical cord prolapse Stage 2
Ventouse is associated with ____?
Increased: failure cephalohaematoma retinal haemorrhage maternal worry
Reduced:
Anaesthesia
Vaginal trauma
Perineal Pain
Ventouse is associated with ____?
Increased: failure cephalohaematoma retinal haemorrhage maternal worry
Reduced:
Anaesthesia
Vaginal trauma
Perineal Pain
Main indications for C-sec
Previous CS Foetal distress Failure to progress Breech Maternal request
Complications of CS
4 X greater maternal mortality associated with CS
Morbidity - sepsis, haemorrhage, VTE, trauma, TTN, sub fertility, regret, complications in future pregnancy
