Complicated Labour

Question 1

Diagnosis of shoulder dystocia

Answer 1

Turtle sign: foetal head retraction into perineum after expulsion (due to reverse traction of the shoulders being impacted at the pelvic inlet)
With routine practice of gentle downward traction failing to accomplish delivery of the anterior shoulder

Question 2

Management of shoulder dystocia

Answer 2

Document time of delivery of head (have 5 minutes to delver shoulder as pH drops by 0.04/min until resorption is established after head is delivered)
HELPERR
H- call for help
E - Episiotomy
L - legs (McRoberts) + move bum to end of bed
P - Suprapubic pressure (Rubin I)
E - Enter (Rubin II, Woodscrew, reverse woodscrew)
R - remove posterior shoulder
R - roll onto all 4s (Gaskin all 4s)
Last resorts:
Cleidotomy (surgical fracture of foetal clavicle
Symphysiotomy (incision through symphysis pubis)
Zavanelli (push back in - csection)

Question 3

Complications of shoulder dystocia

Answer 3

Maternal
 - post partum haemorrhage
 - vaginal and perineal lacerations (3rd & 4th deg tears)
 - uterine rupture
Foetal
 - cerebral hypoxia
 - Cerebral palsy
 - fractured clavicle and/or humerus
 - brachial plexus injuries

Question 4

McRoberts manoeuvre

Answer 4

Hyper flexion of mothers legs to increase mobility if sacroiliac joint

Question 5

Rubin I manoeuvre

Answer 5

Supra pubic reassure, downward traction to foetal head aiming to deliver anterior shoulder in a CPR or rocking motion

Question 6

Rubin II manoeuvre

Answer 6

Two fingers behind foetal anterior shoulder trying to displace ant shoulder forward towards foetal chest

Question 7

Woods screw manoeuvre

Answer 7

Two fingers behind ant shoulder, two fingers in front of post shoulder, rotate ant shoulder across foetal chest

Question 8

Reverse woods screw manoeuvre

Answer 8

Pressure behind posterior shoulder to rotate post shoulder across foetal chest wall

Question 9

Zavanelli manoeuvre

Answer 9

Replacement of foetal head into pelvis followed by caesarean section

Question 10

Risk factors for shoulder dystocia (10)

Answer 10

High birth weight (>4000g)
Maternal obesity
Diabetes mellitus
Advanced maternal age
Previous shoulder dystocia
Multiparity
Prolonged late active phase
Prolonged second stage of labour
Post term pregnancy
Male foetal gender

Question 11

Definition of breech presentation

Answer 11

Presentation of buttocks, foot or feet in birth canal, instead of head

Question 12

Types of breech presentation

Answer 12

Frank breech: hips flexed, legs extended at the knee

Complete breech: hips and knees flexed and feet not below the foetal buttocks

Incomplete/Footling breech: one or both feet presenting due to one or both hips and knees being extended

Question 13

Likelihood of spontaneous version of breech to cephalic after 36 weeks

Answer 13

May occur in up to 25%

Question 14

Maternal risk factors for breech presentation at labour (8)

Answer 14

Nulliparity
Previous breech birth
Abnormal anatomy of uterus
Placental abnormalities (praevia, cornual)
Oligohydramnios
Polyhydramnios
Multiple gestation
Grand multiparity

Question 15

Foetal risk factors for breech presentation at labour

Answer 15

Extended legs
Short umbilical cord
Early gestation
Foetal abnormality
Poor foetal growth

Question 16

Signs suggestive of breech presentation

Answer 16

• Presenting part on abdo examination irregular and not ballotable
• hard round bllotable head in fundus on abdo exam
• FHR heard high in abdo
• head not felt in pelvis on pelvic exam (may feel buttocks and/or feet)
• thick, formed meconium present once membranes ruptured

Question 17

Antenatal management if suspect breech presentation beyond 37 weeks

Answer 17

USS
-Confirm type of breech presentation
- estimate foetal weight
- exclude hyperextension of foetal head
- exclude placenta praevia
- asses foetal morphology
External cephalic version
Elective C-section at 38.5 weeks or vaginal delivery

Question 18

Success rate of external cephalic version in trained operator

Answer 18

40% nulliparous

60% multiparous

Question 19

Contraindications to external cephalic version (12)

Answer 19

• Antepartum haemorrhage in current pregnancy
• Ruptured membranes
• Multiple pregnancy
• Severe foetal abnormality
• C-section necessary for other indications
• Previous C-section (relative)
• Poor foetal growth
• Significant HTN or PET
• Uterine anomaly
• Cord around foetal neck (nuchal cord)
• Abnormal CTG
• Hyperextension of head

Question 20

Management post external cephalic version attempt

Answer 20

CTG for 30 minutes
USS to confirm success and exclude cord presentation
Dose of 625IU RhD if Rh -ve
IF UNSUCCESSFUL
- consider salbutamol tocolysis if due to uterine tone
- book elective LSCS

Question 21

Cases in which vaginal delivery of breech presentation may occur

Answer 21

• Undiagnosed breech presentation
• Precipitate labour that does not allow time for C-section
• Delivery of the second twin in breech position
• woman chooses to deliver vaginally and has agreed management plan including conditions for abandonment of vaginal birth, with a specialist

Question 22

Considerations before vaginal breech birth

Answer 22

• Exclude IUGR
• Confirm foetal weight 2.5-4kg
• confirm presentation either complete or frank (not footling)
• Exclude hyperextended head
• No previous C-section

Question 23

Complications during vaginal breech birth

Answer 23

Head entrapment (obstetric emergency)
Nuchal arms (arms extended above head, may lead to head entrapment)

Question 24

Types of malpresentation

Answer 24

Breech (Complete, incomplete, frank)
Shoulder
Transverse
Compound (e.g. head and hand)
Face
Brow
Funic (cord presentation)