Malpresentation -ILA Flashcards
What are risk factors for failure to progress in labour?
Starting labor with medicine or other methods Epidural Problems with amniotic sac Water breaks before labor starts—PROM A large baby/ small pelvis Wrong position Weak contractions uterus Prior FTP nulliparous woman Diabetes Fertility treatments
How is labour induced?
1st- membrane sweep -> oxytocin and PG release
2nd- syntocin (analogue of oxytocin) if nulliparous; prostins; cervical balloon catheter
What are indications for labour induction?
Induction – indications: gestational DM, multiple pregnancy, PROM, FGR, pre-eclampsia
BISHOP score
Waht drug stops the effects of oxytocin?
atosiban- used against premature labour
Describe the first stage of labour
First stage –
Latent is first 4cm cervical effacement with irregular contractions and active is until full 10cm dilation with regular contractions
Head descends flexed to remain small diameter
90 degree rotation from occipito transverse to occpito anterior/posterior happens
SROM
Describe the second stage of labour
Passive stage: Head descends and flexes further a rotation usually complete - reaches pelvic floor
Active stage (pushing):
Head extends as reaches perineum (crowning – often tears at this part)
Head restitutes, rotating back to transverse before shoulders deliver
Describe the third stage of labour?
placental delivery - afterbirth
What is defined as adaquate progress of labour?
Should progress at 1cm an hour for multiparous and 1/2cm per hour for multiparous
Latent phase should take up to 24 hours in nulliparous women and 12 hours in multiparous
What are the 3 main causes of failure to
progress in labour?
Power (force of contractions)
passenger
passage
What is the most common cause of failure to progress in labour?
Poor uterine contractions (power) - common in nulliparous
What are the problems with the passenger in labour?
malpresentation
malposition of large fetal head
What problems with the passage in labour?
Disparity between size of mother and baby - cephalopelvic disproportion
How do you assess failure to progress in labour?
Palpate abdomen for lie, head and contractions
CTG
colour amniotic fluid
PV exam
What are fetal and maternal consequences of failure to progress in labour?
low oxygen levels for the baby and therefore fetal distress
abnormal heart rhythm in the baby
abnormal substances in the amniotic fluid
maternal - haemorrhage, tears, PTSD, UTI
What is monitored on a partogram?
Fetal heart rate (FHR) State membranes Uterine contractions (/10 mins) Vitals mother Dilatation of mother Station of head (every hour in second stage) Drugs given Engagement urine Position of baby (is it cephalic, longitudinal or transverse)
What is an action line on a partogram?
Indicates slow progression
At action line need to take ACTION
What are the risks of of PG and oxytocin? (remember they can be v dangerous)
If someone is multigravida be concerned about oxytocin rupturing uterus – as there will be fibrous tissue from hyperplasia of uterus from previous pregnancy or c-section scar
PG and syntocin all cause uterine contractions –> can reduce fetal blood flow – if hyperstimulation occurs then try to resolve by removing PG if possible
–> tocolsis and emergency c-section if bad
What are SE of PG?
N+V+D
What is malpresentation?
the foetus is not presenting by the vertex (maximal flexion -head down- meaning the presenting part is the anterior fontanelle ) eg presenting with brow, breech or face
What is breech presentation?
When the presenting part of the foetus is not the head
The foetus is in longitudinal lie with the buttocks or feet closest to the cervix
What is the most common type of malpresentation?
Extended breech- presenting part is fetus’ bottom
How may breech presentation be diagnosed?
USS
PV or abdo exam
Mother may complain of pain under the ribs
Mx of breech presentation?
if still present at 36 weeks - External cephalic version (ECV) – manoeuvring the baby to correct
LCSC if doesnt wor/ CI
CI to ECV?
pre-eclampsia; placenta praevia; APH last 7 days; multiple birth; ROM; GR; CTG abnormal
What are brow and face presentations?
Brow presentation = extension of 90 degrees
Face presentation = further extension of 30 degrees - 120 total
What should the correct position of the baby be when presenting?
Occipito-anterior- so can flex head and then extend out of vagina ie face and head down
What is a malposition?
Presenting part in right place but in wrong position (how head is in relation to pelvis) with occipito-posteriorly or occipito-transverse
When should the baby be occipitotransverse and occiitoposterior/ ant?
The head is normally occipitotransverse as eneters the pelvis (engagement) and becomes occipitoposterior/ anterior at the pelvic floor during internal rotation.
Then goes back to occipital-transverse positioning at external rotation
mx of malposition?
may be fine if occipitoposterior, may need forceps or LSCS
Describe the movements of the baby in labour
Engagement in occipito transverse —-> descent and flexion —> rotation by 90 degrees to occipito anterior —> descent –> extension to deliver –. Restitution and delivery shoulders
What is the lie of the baby?
Lie – the relationship between the long axis of the fetus and the mother.
Longitudinal, transverse or oblique
Want it to be longitudinal
What is sometimes the significance of meconium liquor ?
fetal distress
Which breech presentation is associated with highest-risk of cord prolapse?
footling breech
How is the baby optiminally delivered?
Occipital-anterior position vertex presentaion
What is brow presentation also known as?
attitude = deflexed ++; presentation = brow; mean presenting diameter = mento-vertical (13.5 cm)
What is face presentation also known as?
attitude = deflexed +++; presentation = face; mean presenting diameter = submento-bregmatic (9.5 cm)
mx of a face presentation?
If the chin is anterior (mento-anterior) a normal labour is possible; however, it is likely to be prolonged and there is an increased risk of a C-section being required
If the chin is posterior (mento-posterior) then a C-section is necessary
mx of a brow presentation?
a C-section is necessary
mx of occipito-posterior birth?
- epidural
- forceps
- if VD not working use c-section
mx of occipito-transverse birth?
Rotate fetus with forceps/ use ventouse
