Failure to Progress Flashcards
What is meant by failure to progress?
- occurs when labour is not developing at a satisfactory rate
- more likely to occur in women who are in labour for the first time
What are the 4 P’s that can influence progression in labour?
Power:
- strength of uterine contractions
Passenger:
- position, size + presentation of the fetus
Passage:
- size / shape of the pelvis
Psyche:
- support / antenatal preparation for delivery
What are the 3 phases of the first stage of labour?
What is normal progression during these stages?
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
When is delay in the first stage of labour considered?
- less than 2cm cervical dilatation in 4 hours
- slowing of progress in a multiparous woman
What is used to monitor progress in the first stage of labour?
partogram
What is recorded on a partogram?
- 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
How are uterine contractions measured?
- the number of contractions in 10 minutes
- “2 in 10” means 2 contractions occurring in 10 mins
How can you use the partogram to assess whether labour is progressing adequately?
- 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
What is done when the “alert” and “action” lines are crossed?
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
What is meant by the second stage of labour?
from 10cm cervical dilatation to delivery of the baby
this stage is influenced by the 3Ps
What is considered to be delay in the second stage of labour?
- > 2 hours in a nulliparous woman
- > 1 hour in a multiparous woman
What is meant by “power” during the 2nd stage and how can it be influenced?
- power is the strength of uterine contractions
- if contractions are weak, oxytocin infusion can be given
What are the 4 descriptive qualities of the fetus considered in “passenger”?
- P - presentation
- A - attitude
- L - lie
- S - size
remember as “PALS”
How can the size of the fetus influence progress in labour?
- larger babies (macrosomia) can be more difficult to deliver
- there may be issues such as shoulder dystocia
What is meant by the attitude of the fetus?
- the posture of the fetus
- i.e. how the back is rounded and head / limbs are flexed
What is meant by the lie of the fetus?
- 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
What is meant by presentation of the fetus?
the part of the fetus that is closest to the cervix
What interventions may be required during the second stage of labour?
- changing of positions
- analgesia
- oxytocin
- episiotomy
- instrumental delivery
- C - section
What is the third stage of labour?
from delivery of the baby to delivery of the placenta
What is classed as failure to progress in the third stage of labour?
- > 60 mins with physiological management
- > 30 mins with active management
What are the 4 main options for managing failure to progress?
- amniotomy (if the membranes are intact)
- oxytocin infusion
- instrumental delivery
- C-section
What is meant by instrumental delivery?
vaginal delivery assisted by:
- ventouse suction cup
- rotational forceps
- traction forceps
What additional medication is required for instrumental delivery?
- a single dose of co-amoxiclav is given after delivery
- this reduces the risk of maternal infection
What are the indications for instrumental delivery?
- failure to progress
- fetal distress
- maternal exhaustion
- control of the head in various fetal positions
- to avoid raising ICP / BP
What must be in place prior to instrumental delivery?
- ruptured membranes
- adequate contractions
- empty bladder
- adequate analgesia
- knowledge of where the baby is positioned
What procedure can increase the risk of requiring an instrumental delivery?
presence of an epidural
What are the increased risks for the mother related to instrumental delivery?
- postpartum haemorrhage
- episiotomy
- perineal tears
- injury to the anal sphincter
- incontinence of the bladder or bowel
- nerve injury (obturator / femoral)
What are the increased risks to the fetus related to instrumental delivery?
- cephalhaematoma (ventouse)
- facial bruising
- facial nerve palsy (forceps)
- retinal haemorrhage
What is a ventouse and how does it work?
- a suction cup on a cord
- the suction cup goes on the baby’s head and careful traction is applied to the cord
What is the main complication associated with use of a ventouse?
cephalohaematoma
- small blood vessels are ruptured due to pressure on the fetal head
- this results in a collection of blood between the skull / periosteum
What are the main complications associated with forceps delivery?
- 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
What are the most common nerve injuries associated with instrumental delivery?
- femoral nerve
- obturator nerve
- these injuries usually resolve over 6-8 weeks
How may the femoral nerve be injured?
What does this result in?
- 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
What does compression of the obturator nerve result in?
- 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
