labour and birth Flashcards
Risk factors for shoulder dystocia
Risk factors
- generally no strong predictive tool
Prelabour
Macrosomia - baby of 4.5kgs
Half of shoulder dystocia’s weigh less then 4 kgs Diabetic
2-4 increased risk compared to infants with the same birth weight born to non diabetic mothers
Previous shoulder dystocia – 10% risk recurrence
BMI over 30
Labour Slow progress in first stage Slow progress in second stage Second stage arrest Instrumental delivery Syntocinon augmentation
What is the incidence of shoulder dystocia
What is the recurrence risk
0.58-0.7%
Recurrence 10%
What is the definition of shoulder dystocia
Vaginal cephalic delivery that requires additional obstetric manoeuvers to deliver the fetus after the head and gentle traction has failed
It is the anterior shoulder impacting on the pubic symphysis or the posterior on the sacral promontory
More then 60 seconds head to shoulders
Can we prevent shoulder dystocias?
Prevention
IOL does not prevent shoulder dystoicia in non diabetic woman with an LGA baby
IOL at term can reduce the risk for shoulder dystocia in diabetic woman at term
Caesarean
Diabetic woman with a baby over 4.5 kg should be offered ELLSCS to reduce morbidity
2-4 increases shoulder dystocia
443 LSCS to prevent one BPI
ACOG says any baby over 5 kg should be considered for LSCS
NICE says USS for EFW should not be routinely done in a low risk woman palping large for dates
Previous shoulder dystocia
Joint decision making – VB or LSCS
10X increased risk if previous shoulder dystocia 1-25% however this may be inderestimated as after a bad shoulder dystocia then ELLSCS likely followed
Make the decision considering fetal size, the womans wishes, family planning
What is the incidene of BPI with shoulder dystocia?
How many have permanent compromise?
Brachial plexus injury 2.3-16%
Most cases resolve
Fewer then 10% permanent function
Larger infants are more likely to have a permanent BPI
46% BPI are related to substandard care
12% BPI from uncomplicated caesarean (just happens not from birth trauma)
Can also occur from delivery and not manipulation
Must document which shoulder was anterior or posterior – as if the BPI is the posterior soulder unlikely to be related to manoeuvres
What are the maternal risks of shoulder dystocia ?
Maternal
OASIS injury 3.8%
PTSD
PPH 11%
What are the 4 signs to look out for for managing shoulder dystocia
Difficultly with the delivery of the face and chin
The head remains tightly applied to the vulva or even retracting
Failure of restitution of the head
Failure of the shoulders to descend
PG for IOL
What is the risk of hyperstimulation
What is the risk of misoprostol ?
Risk Hyperstimulation 4.8% (no treatment risk is 1%) FHR changes Rupture if prev LSCS 1.4-2.5% Misoprostol More effective 3X increased risk hyperstimulation Rupture 0.3% if scarred uterus Off label use
Routine epis?
When indicated for a normal birth
No evidence for routine
Should be considered when A high likelihood of severe laceration;
- Soft tissue dystocia;
- A requirement to accelerate the birth birth of a compromised fetus;
- A need to facilitate operative vaginal birth;
- A history of Female Genital Mutilation (FGM)
In spont labour when are the thresholds for normal cx dilatation/ what is the 10th centile for primips and multips ?
Latent –phase
No time limit
Active labour Primip 10th centile is 0.9 cm / hour Commonly 1 cm / hour May be 1 cm / 2 hours for woman prioritising low intervention
Multip
10th centile is 1.2 cm per hour
Augmentation only with absolute care
Indications for ARM?
Relative contraindications
IOL
Augmentation
Cochrane 2009 routine ARM does not shorten labour
Risk of ascending infection increases once membranes are ruptured
ARM gives information on fetal wellbeing eg liquor volume and colour
Relative contraindications
Hep C.B.HVS, HIV
High mobile presenting part
how does activity affect first stage?
Activity
First stage 1.5 hours shorter if woman are up and walking around
Woman should be encouraged to use upright or mobile positions in the first stage
Woman should be encouraged to freely mobilise
Preterm delayed cor clamping benefits
Term delayed cord clamping
less transfusion, reduced necrotising enterocolitis, less IVH
Term:
Increased hct and reduced iron deficiency at 3-6 months
Increased polycythemia and jaundice
Currently no guidance
most likely to benefit are if mum is iron deficient or if exclusively breastfed
75% of possible blood to transfuse occurs in the first 1 minute
If baby is held between 10 cm below and above then the transfusion occurs in 3 minutes – if 40 cm below then occurs in 1 minute
Serious fetal compromise
SPLIT pneumonic
Synto off
position left lateral (or R or hand and knees) immediately on transfer and on table
IV F stat 1L
Low BP - consider pressors
tocolysis - terbutamine 0.25 mg
or GTN 2 puffs repeat at 1 minute if still contracting - max 3 doses
