Abnormal Labour Flashcards
What can cause an abnormal labour?
- Malpresentation: Not the head coming first
- Malposition: Occipito-Posterior or Occipito-Transverse
- Pre-term <37wks
- Post-term >42 wks
- Obstruction
- Foetal distress
What are the different types of breech presentation?
Complete Breech - both legs under foetus, born first
Footling Breech - one foot presents
Frank Breech - feet up by baby’s head, bottom presents first
Other than breech, how can a baby present in the wrong way?
Transverse
Shoulder/arm
Face
Brow
What methods of analgesia are used in pregnancy?
- Supportive partner/ family member/ friend
- Massage / relaxation techniques
- Gas and Air (Entonox)
- TENS (Lower thoracic and sacral nerves stimulated)
- Water immersion
- IM Morphine
- IV Remifentanil
- Regional anaesthesia
How effective are epidurals in labour?
complete pain relief in 95%
Women can have an epidural and still experience contractions that allow them to push in pregnancy. TRUE/FALSE?
TRUE
- uterine muscle not affected by anaethesia
Why may an epidural inhibit progress during stage 2 of labour?
- Numbs and relaxes the pelvic floor
- Pelvic floor muscles are needed to provide resistance to baby’s head causing it to flex before birth
What else is usually injected alongside local anaesthetic in an epidural?
Opiate
What are the main complications of an epidural?
Hypotension (20%)
Dural puncture (1%)
Headache (due to dural puncture - worst day after birth)
High block (may cause resp. depression => SOB)
Atonic bladder (women don’t know when bladder is full)
What becomes a higher risk if a labour is obstructive?
- Maternal OR neonatal sepsis
- uterine rupture (especially if prev. C-section)
- obstructed AKI (if foetal head is compressing ureters)
- PPH (uterus works so hard in obstructed labour that it gives up and does not constrict blood vessels after)
- fistula formation (recto-vaginal)
- foetal asphyxia
How can progress during labour be assessed?
- Cervical dilatation
- Descent of presenting part
- Signs of obstruction: moulding, caput, vulval oedema
What measurements of cervical dilatation would make you consider delayed labour?
<2cm dilation in 4 hours
OR if labour is slowing in progress in a lady who has had children before
Station is measured in relation to what landmark in the mother?
Ischial spines
What are the 3 Ps considered when a labour shows Failure to Progress?
Powers: Inadequate contractions
Passages: Short stature / Pelvis Shape
Passenger: Big baby, Malposition/ malpresentation
What is assessed on a partogram?
- Foetal Heart Rate
- Amniotic Fluid
- Cervical Dilatation
- Descent
- Contractions
- Obstruction - Moulding/caput
- Maternal Observations (BP, pulse)
How often should a doppler be used to assess foetal heart rate in the 1st and 2nd stages of labour?
1st Stage
- Measure during and after a contraction (Every 15 mins)
2nd Stage:
- every 5 mins
- AND during and after a contraction for 1 whole minute
- check maternal pulse at least every 15 mins
How else can the foetus be assessed during labour?
- Electronic Fetal Monitoring -Cardiotocograph (CTG)
- Colour of amniotic fluid
What factors can increase the risk of foetal hypoxia?
- Small fetus
- Preterm / Post Dates
- Antepartum haemorrhage
- Hypertension / Pre-eclampsia
- Diabetes
- Meconium
- Epidural analgesia
- Sepsis
- IOL
What acute causes are there for foetal distress?
- Abruption
- Vasa Praevia
- Cord Prolapse
- Uterine Rupture
- Feto-maternal Haemorrhage
- Uterine Hyperstimulation
- Regional Anaesthesia
If a baby is presenting breech, what complication are they at increased risk of?
- Cord prolapse
- due to feet presenting first => space around feet for cord to prolapse
What are the chronic causes of foetal distress?
Placental insufficiency
Foetal anaemia
What features of a CTG should be assessed on review?
- baseline fetal heart rate
- variability
- presence/absence of decelerations
- presence of accelerations
How should a CTG be classified?
- normal
- suspicious
- pathological
What CTG changes may indicate foetal hypoxia has evolved in labour?
- loss of accelerations
- Repetitive deeper and wider decelerations
- Rising fetal baseline heart rate
- Loss of variability
What mneumonic is used to interpret a CTG?
“Dr C Bravado”
D ETERMINE R ISK C ONTRACTIONS B ASELINE R A TE V ARIABILITY A CCELERATIONS D ECELERATIONS O VERALL IMPRESSION
HOw should foetal distress be managed?
- Change maternal position
- IV Fluids
- Stop oxytocin
- Scalp stimulation
- Beta Agonist- Terbutaline
- Maternal assessment - Pulse / BP / Abdomen / VE
- Foetal blood sampling (check not too acidic => <7.2)
- Operative Delivery?
When is an instrumental delivery normally indicated?
If woman is at full dilatation
- Labour Delay (failure to progress stage 2)
- Foetal distress
What are the “special” indications for an instrumental delivery?
- Maternal cardiac disease (due to valsalva manoeuvres in obstructive labour)
- Severe PET / Eclampsia
- Intra-partum haemorrhage
- Umbilical cord prolapse Stage 2
How long would be considered a delay in labour?
first baby - 2hrs (3 if epidural)
subsequent baby - 1hr (2 if epidural)
What is ventouse delivery and what does this increase the risk of?
Ventouse = cup-shaped suction device (vacuum delivery)
Higher risk of:
- Failure
- cephalohaematoma
- retinal haemorrhage
- maternal worry
What are the main indications for a C-section?
previous CS foetal distress failure to progress in labour breech presentation maternal request
Maternal mortality is increased how much in C-section?
4 X greater maternal mortality
What complications of C-section increase morbidity in the mother?
- sepsis
- haemorrhage
- VTE
- trauma
- subfertility
- complications in future pregnancy
