FAILURE TO PROGRESS AND SHOULDER DYSTOCIA Flashcards
What are the three factors that determine the rate of progression in labour?
Passages
Passenger
Power
What are the factors associated with the passages (bony pelvis and soft tissue) that might lead to labour failing to progress?
Abnormal shaped pelvis Cephalopelvic disproportion Uterine/cervical fibroids Cervical stenosis Circumcision
What are the factors associated the fetus (passenger) that might lead to labour failing to progress?
Fetal size - macrosomia
Fetal abnormality
Fetal malpresentation
Fetal malposition
What are the factors associated with power or push that might lead to labour failing to progress?
Lack of coordinated regular strong uterine contractions
What are the normal rates of progression in terms of cervical dilation?
Primip - 0.5 - 1 cm/h
Multip - 1 - 2 cm/h
What are the causes of a woman having abnormal shaped pelvis, which might lead to her labour failing to progress?
Conditions:
Osteogenesis imperfecta
Ectopia vesicae
Dislocation of the hip at birth
Acquired: Kyphosis of thoracic or lumbar spine Scoliosis of spine Spondylolisthesis Pelvic fractures Rickets/osteomalacia Poliomyelitis in childhood
What conditions lead to macrosomia?
Diabetes
Hydrops fetalis - rhesus isoimmunization or parvovirus infection
What vertex presentations might lead to failure to progress in labour?
Occipito-posterior position
Occipito-transverse position
What proportion of vertex presentations will be occipito-posterior?
20%
How do we manage a fetus presenting in the occipito-posterior position?
Most will rotate spontaneously
Those that don’t will either still deliver without problems, or can be turned manually or with an instrument.
What properties of contractions suggest inefficient uterine action?
Uncoordinated contractions
Fewer than 3-4 in 10 min
Lasting less than 60s
Delivering a pressure of less than 40 mmHg (recorded using a pressure catheter)
How do we manage a patient whose labour is failing to progress due to inefficient contractions?
Artificial rupture of membranes
Use of IV syntocinon - caution must be exercised in multiparous patient
How does artificial rupture of membrane help labour along?
Thought to release prostaglandins.
Why is it important to monitor fetus after administration of IV syntocinon?
If contractions become too frequent this can reduce oxygen exchange in the placental bed and lead to fetal hypoxia.
What might prompt a physician to consider delivery by caesarian section?
Presence of good contractions over several hours without significant progression in terms of cervical dilatation
What is shoulder dystocia?
This is when the head has been delivered but the shoulders (specifically the anterior shoulder) is unable to pass into the pelvic inlet.
What are the complications of shoulder dystocia?
Erb’s palsy
Hypoxia due to cord compression whilst in the vagina
What is Erb’s palsy?
Damage to nerve roots C4, C5 and C6 leading to paralysis of the arm
How is shoulder dystocia managed?
Do not pull on the head - leads to damage of brachial plexus
Lie patient flat and try following steps until they work:
Put them in McRoberts position, if this does not work then
Apply suprapubic pressure to dislodge and deliver anterior shoulder, if this does not work then
Use internal rotation techniques to try and rotate anterior shoulder from under pubic symphysis
Deliver posterior arm
What is McRoberts position?
Hyperflex the mother’s knees onto her abdomen with her hips apart and apply suprapubic pressure
