Abnormal Labour & Delivery Flashcards
What is shoulder dystocia?
It is impaction of the anterior shoulder of the foetus behind the pubic symphysis.
What are the risk factors for a foetus developing shoulder dystocia?
Maternal factors: ineffective uterine contractions, maternal illness (DM, pre-ecalmpsia), placenta previa
Fetal factors: MACROSOMIA, fetal malpresentation
Mechanical factors: Cephalopelvic disproportion
How should you manage shoulder dystocia?
Obstetric emergency.
Call for help immediately and note time ~ 5mins to deliver baby.
Create space (empty bladder, episiotomy)
Perform McRobert manoeuvre (hyperflexing the mother’s legs tightly to her abdomen.) + suprapubic pressure.
Further manoeuvres (ruben/wood screw)
HELPERR Help Episiotomy + empty bladder Lift legs (McRobert manoeuvre) Pressure (suprapubic) Enter (vagina for internal manoeuvre ruben/woodscrew) Release posterior arm by flexing elbow Roll patient on to front (Gaskin manoeuvre)
What are the complications of shoulder dystocia?
Fetal: Hypoxia Brachial plexus injury (erbs palsy damage C5-7) Fracture of clavicle Inter cranial haemorrhage Fetal death
Maternal:
PPH
Perennial tear (3rd/4th degree)
What is brow presentation and how is it managed?
The fetal head is extended creating a large diameter.
Requires C-section.
Note this is rare.
What is face presentation and how is it managed?
When the fetal head is fully extended.
Usually vaginal delivery by flexion (instead of extension) is possible.
However is the chin is posterior will require a C-section.
What is a funic presentation?
When the umbilical cord is below the head.
C-section may be indicted as there is a risk of prolapse.
What is cord prolapse and why is it important?
It is an obstetric emergency and is when the cord protrudes below the presenting part after rupture of membranes.
It is important as when there are contractions there may be cord compression leading to hypoxia to the foetus and potentially fetal death.
What are the risk factors for having a cord prolapse?
Malpresentation Multiple pregnancies Polyhdraminos Prematurity High presenting part Long cord AROM
How should cord prolapse be managed?
Delivery of foetus immediately.
If close to delivery instrumentally or alternatively be emergency c-section.
How can you prevent compression to the cord during a prolapse?
Knee to chest position
Hand in the vagina
Bladder filling can also be used to buy time before c-section.
Tocolysis can be used to abolish uterine contractions and improve fetal oxygenation
What are the causes of labour dystocia?
Also known as obstructed labour aka prolonged labour.
- Power (inadequate contractions)
- Passage (bony pelvis aka CPD)
- Passenger (malpresentation, macrosomia head extension)
What is Cephalopelvic disproprtion?
It is when the head is disproportionately large for the pelvis.
It can be absolute (when the head will be too large for the pelvis even when in optimal position)
Relative: where it is only too large when there is fetal malposition, head extension etc.
Absolute CPD is contraindication for vaginal delivery
What are the general principles of managing a poorly progressing labour?
Exclude absolute CPD
Confirm adequate uterine contractions. If not adequate consider syntocin drip.
If contractions are adequate then one of the following will happen:
- dilation and effacement of the cervix with descent of the head
- worsening caput and moulding
Consider c-section.
Always consider hydration status and antibiotics if there is prolonged rupture.
What are the different types of intra-cranial bleeds which may occur during pregnancy in the foetus?
Can occur at several sites but most common is:
-Intra-ventricular haemorrhage 45% have a poor prognosis with long term neurological sequelae
Other bleeds include subdural and parenchymal. 90% have poor prognosis due to heavy bleeding.
