Failure to Progress Flashcards

1
Q

What is meant by failure to progress?

A
  • occurs when labour is not developing at a satisfactory rate
  • more likely to occur in women who are in labour for the first time
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2
Q

What are the 4 P’s that can influence progression in labour?

A

Power:

  • strength of uterine contractions

Passenger:

  • position, size + presentation of the fetus

Passage:

  • size / shape of the pelvis

Psyche:

  • support / antenatal preparation for delivery
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3
Q

What are the 3 phases of the first stage of labour?

What is normal progression during these stages?

A

latent phase:

  • from 0 - 3cm dilation of cervix
  • there are irregular contractions
  • progresses at 0.5cm per hour

active phase:

  • from 3 to 7cm dilation of cervix
  • there are regular contractions
  • progresses at 1cm per hour

transitional phase:

  • from 7 to 10cm dilation of cervix
  • there are strong, regular contractions
  • progresses at 1cm per hour
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4
Q

When is delay in the first stage of labour considered?

A
  • less than 2cm cervical dilatation in 4 hours
  • slowing of progress in a multiparous woman
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5
Q

What is used to monitor progress in the first stage of labour?

A

partogram

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6
Q

What is recorded on a partogram?

A
  • cervical dilatation (measured by 4-hourly vaginal exams)
  • descent of fetal head (in relation to ischial spines)
  • maternal obs (HR, BP, temp, urine output)
  • fetal HR
  • frequency of contractions
  • status of membranes + presence / colour of liquor
  • drugs / fluids given
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7
Q

How are uterine contractions measured?

A
  • the number of contractions in 10 minutes
  • “2 in 10” means 2 contractions occurring in 10 mins
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8
Q

How can you use the partogram to assess whether labour is progressing adequately?

A
  • there are 2 lines labelled “alert” and “action”
  • the dilation of the cervix is plotted against the duration of labour
  • when it takes too long for the cervix to dilate, the readings will cross over the “alert” or “action” line
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9
Q

What is done when the “alert” and “action” lines are crossed?

A

crossing the alert line:

  • amniotomy is performed
  • followed by a repeat examination in 2 hours

crossing the action line:

  • escalation to obstetric-led care and senior decision makers

amniotomy = artificial rupture of the membranes

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10
Q

What is meant by the second stage of labour?

A

from 10cm cervical dilatation to delivery of the baby

this stage is influenced by the 3Ps

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11
Q

What is considered to be delay in the second stage of labour?

A
  • > 2 hours in a nulliparous woman
  • > 1 hour in a multiparous woman
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12
Q

What is meant by “power” during the 2nd stage and how can it be influenced?

A
  • power is the strength of uterine contractions
  • if contractions are weak, oxytocin infusion can be given
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13
Q

What are the 4 descriptive qualities of the fetus considered in “passenger”?

A
  • P - presentation
  • A - attitude
  • L - lie
  • S - size

remember as “PALS”

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14
Q

How can the size of the fetus influence progress in labour?

A
  • larger babies (macrosomia) can be more difficult to deliver
  • there may be issues such as shoulder dystocia
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15
Q

What is meant by the attitude of the fetus?

A
  • the posture of the fetus
  • i.e. how the back is rounded and head / limbs are flexed
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16
Q

What is meant by the lie of the fetus?

A
  • the position of the fetus in relation to the mother’s body
  • transverse lie - fetus is straight side-to-side
  • oblique lie - the fetus is at an angle
  • longitudinal lie - the fetus is straight up and down
17
Q

What is meant by presentation of the fetus?

A

the part of the fetus that is closest to the cervix

18
Q

What interventions may be required during the second stage of labour?

A
  • changing of positions
  • analgesia
  • oxytocin
  • episiotomy
  • instrumental delivery
  • C - section
19
Q

What is the third stage of labour?

A

from delivery of the baby to delivery of the placenta

20
Q

What is classed as failure to progress in the third stage of labour?

A
  • > 60 mins with physiological management
  • > 30 mins with active management
21
Q

What are the 4 main options for managing failure to progress?

A
  • amniotomy (if the membranes are intact)
  • oxytocin infusion
  • instrumental delivery
  • C-section
22
Q

What is meant by instrumental delivery?

A

vaginal delivery assisted by:

  • ventouse suction cup
  • rotational forceps
  • traction forceps
23
Q

What additional medication is required for instrumental delivery?

A
  • a single dose of co-amoxiclav is given after delivery
  • this reduces the risk of maternal infection
24
Q

What are the indications for instrumental delivery?

A
  • failure to progress
  • fetal distress
  • maternal exhaustion
  • control of the head in various fetal positions
  • to avoid raising ICP / BP
25
Q

What must be in place prior to instrumental delivery?

A
  • ruptured membranes
  • adequate contractions
  • empty bladder
  • adequate analgesia
  • knowledge of where the baby is positioned
26
Q

What procedure can increase the risk of requiring an instrumental delivery?

A

presence of an epidural

27
Q

What are the increased risks for the mother related to instrumental delivery?

A
  • postpartum haemorrhage
  • episiotomy
  • perineal tears
  • injury to the anal sphincter
  • incontinence of the bladder or bowel
  • nerve injury (obturator / femoral)
28
Q

What are the increased risks to the fetus related to instrumental delivery?

A
  • cephalhaematoma (ventouse)
  • facial bruising
  • facial nerve palsy (forceps)
  • retinal haemorrhage
29
Q

What is a ventouse and how does it work?

A
  • a suction cup on a cord
  • the suction cup goes on the baby’s head and careful traction is applied to the cord
30
Q

What is the main complication associated with use of a ventouse?

A

cephalohaematoma

  • small blood vessels are ruptured due to pressure on the fetal head
  • this results in a collection of blood between the skull / periosteum
31
Q

What are the main complications associated with forceps delivery?

A
  • facial nerve palsy presenting with facial paralysis on one side
  • bruising on the face
  • fat necrosis (hardened lumps of fat on the cheeks)

fat necrosis resolves spontaneously over time

32
Q

What are the most common nerve injuries associated with instrumental delivery?

A
  • femoral nerve
  • obturator nerve
  • these injuries usually resolve over 6-8 weeks
33
Q

How may the femoral nerve be injured?

What does this result in?

A
  • the femoral nerve is compressed against the inguinal canal
  • this causes weakness of knee extension + loss of patella reflex
  • there is numbness of the anterior thigh + medial lower leg

this tends to only occur during a forceps delivery and not during normal birth

34
Q

What does compression of the obturator nerve result in?

A
  • weakness of hip adduction + rotation
  • numbness of the medial thigh

this can be compressed during forceps delivery or by the fetal head during a normal delivery