Labour problems Flashcards
Problems with power and failure to progress in labour
Inefficient uterine action
Normal uterine contraction rate
45-60 second long contractions every 2-3 minutes in active labour. During delivery can slow to 60-90sec duration every 3-5mins
Mums likely to have Inefficient uterine action
Nulliparous
Management of Inefficient uterine action at different labour stages
1st stage = Augmentation via artificial rupture of membranes/amniotomy or oxytocin infusion. Exclude malpresentation!
2nd stage passive = nulliparous women given oxytocin infusion if delayed by 2hrs.
2nd stage active = if delay over 1hr consider episiotomy or instrumental delivery depending on fetal position.
Adverse effects of augmentation of labour
Hyperactive uterine action, fetal distress, increase risk of uterine rupture of previous C/S
Contraindications for augmentation in prolonged labour
Placenta or vasa previa Umbilical cord presentation Prior classical uterine incision Active genital herpes infection Pelvic structural deformities Invasive cervical cancer
Problems with passage and failure to progress in labour
Obstruction from abnomral pelvic architecture, pelvic mass (fibroid or tumour), cephalo-pelvic disproportion.
Causes of an abnormal pelvic architecture
Rickets, osteomalacia, spinal abnormality (scoliosis), polio
Problems with passenger and failure to progress in labour
Macrosomia
Poor presentation (breech, occiput-posterior, brow, occiput-transverse, face)
Fetal hydrocephalus.
Bishops Score
Less than 5 = labour unlikely to happen without intervention.
Over 5= labour will occur spontaneously.
Comprised of = Cervical dilation, length of cervix, station of head above ischial spines, cervical consistency, position of cervix.
Methods for inducing labour
Membrane sweep - releases prostaglandins and separates the amniotic membranes from the walls of the cervix.
Vaginal PGE2
Amniotomy plus/minus oxytocin.
Use of prostaglandin gel
Tablet or gel - Can give 2nd dose after 6hrs but subsequent ones not useful.
Pessary release - one over 24hrs.
Assess Bishop score after 6hrs.
Surgical methods for inducing labour
Amniotomy, add oxytocin infusion if no progress after 2hrs.
Examples of indications for inducing labour
Prolonged pregnancy (over42weeks), IUGR, antepartum haemorrrhage, preterm rupture of membranes, pre-eclampsia, gestational diabetes, in-utero death.
Cord prolapse definition
umbilical cord descends before fetus.
Complications of cord prolapse
Compression of cord and cord spasms
Fetal hypoxia
Cerebral palsy and irreversible fetal damage - death.
Risk factors for cord prolapse
Premature, breech presentation, abnormal lie, polyhydramnios, multiple pregnancy esp not the first baby delivered, placenta praevia, artificial rupture of membranes.
Clinical features of cord prolapse
No features in mum, unless see or feel prolapsed cord.
Fetus will have bradycardia.
Investigations and management of cord prolapse
Vaginal examination
DELIVER THE BABY - c-section ASAP, try not to handle cord too much but could push back to avoid compression.
Shoulder dystocia definition
Failure for the anterior shoulder to pass under the symphysis pubis after delivery of the fetal head that requires specific manoeuvres to facilitate delivery
Risk factors for shoulder dystocia
Previous history Macrosomia DM High maternal BMI Induction of labour Prolonged 1st or 2nd phase of labour Use of oxytocin
Signs of shoulder dystocia in birth
Difficulty delivery face and chin, failure of restitution of head, failure of shoulders to descend, retracting head = turtle neck sign.
Management of shoulder dystocia
Call for help! McRobert's Manoeuvre (thighs to abdo) Suprapubic pressure Consider episiotomy or internal manouevers e.g. rotation. Discourage maternal pushing.
Complications of shoulder dystocia
Maternal = PPH, perineal tears, bladder injury. Baby = brachial plexus injury (Erb's palsy), hypoxia, clavicle or humerus fracture.
Types of uterine rupture
Incomplete/occult = at previous surgical scar, visceral peritoneum is intact, asymptomatic.
Complete = EMERGENCY!
Traumatic - RTA, oxytocin infusion, poorly conducted vaginal delivery.
Spontaneous - patients with Hx of c-section, multiparity.
Clinical features of uterine rupture
Abdo pain in 3rd trimester! May refer to shoulder. Constant between contractions. Vaginal bleeding. Maternal shock! Sudden shortness of breath. Scar tenderness. CTG abnormalities. Haematuria
Investigations and management of uterine rupture
TransVag USS.
ABCDE - resuscitate mum.
URGENT C-SECTION, contraindicate future vaginal births.
Diagnosis of prolonged 3rd stage of labour
Not completed within 30mins if active management or within 1hr if no management.
Main causes of retained placenta
Uterine atony, trapped placenta (closed os), placenta accreta or percreta
Management of retained placenta
Analgesia for mum
IV oxytocin
Vaginal examination and manual removal - PAINFUL
Complications of retained placenta
PPH
Genital tract infection
Uterine inversion - emergency!
Definition of preterm labour
between 24 and 37weeks gestation labour.
Prophylaxis for preterm
Vaginal progesterone or cervical cerclage - women with history of preterm babies or USS scan reveals cervical length shortening.
Diagnosing preterm labour with intact membranes
Transvaginal USS - cervical length is less than 15mm.
or Fetal Fibronectin test -conc more than 50ng/ml
Diagnosing preterm premature rupture of membranes
P-PROM
Speculum exam - pooling of amniotic fluid
Managing P-PROM
Prophylactic Abx - erythromycin.
If over 34weeks gestation baby can be cared for in specialist unit.
If under 34weeks gestations consider:
Tocolysis (prevent labour) with nifedipine
Consider corticosteroids for mum (help with fetal pulmonary immaturity)
IV magnesium sulphate
Risks with c-sections
bladder injury uterus injury hysterectomy VTE future placenta praaevia Uterine rupture Neonatal respiratory morbidity.
Analgesia steps
1 = simple paracetamol, ibuprofen. 2 = opioids (single shot IM, morphine) 3 = PCA opioids IV (fentanyl) 4 = regional (epidural/spinal) Also gas + air = Entonox
Indications for an epidural
Multiple pregnancy,
instrumental delivery likely, maternal request, augmented labour.
Contra-indications for an epidural
Maternal refusal Local infection Septicaemia Abnormal anatomy Coagulopathy.
Level of an epidural and spinal
L3/4, Tuffiers line
Difference between epidural and spinal
Epidural goes between spinal dura and vertebral canal.
Spinal goes into subarachnoid space (mostly used for c-section)
Diagnosis of delay in 2nd stage of labour active phase
Nulliparous = longer than 2hrs Multiparous = longer than 1hr
meaning of early decelerations
deceleration of fetal heart rate on onset of contraction. mostly due to head compressions - non-reassuring
late decelerations
utero-placenta insufficiency. ABNORMAL - fetal distress
Variable decelerations
cord compression, independent of contractions.
Action Line
On partogram, indicates need for intervention when measurements are worrying.
Measurements on a partogram
FHR, Descent of head, cervical dilation, liquor, contractions, oxytocin infusion, drugs or fluids given, maternal HR, BP and temp, urine output, ketones and protein
Meconium liquor causes
Fetal distress
Fetal maturity
Breech/malpresentation
Another name for brow presentation
Mento-vertical
Another name for face presentation
Submento-bragmatic
Maternal fever, maternal tachycardia, and fetal tachycardia
Chorioamnionitis
Drugs which encourage uterine quinescence (stop contractions if premature labour)
Nifedipine
Salbutamol
(tocolytic drugs)
Serum marker indicating early labour
fetal fibrinonectin
Antidote for oxytocin
Atosiban
Side effects of epidural analegsia
Hypotension Haematoma at injection site Anaphylaxis to medication Post-dural headache Spinal cord damage
