Management of labour Flashcards
What is the general care of the woman in labour?
Temp and BP every 4 hrs- pulse every 1hr (1st stage), every 15 mins (2nd stage_
Position- semi-recumbent
Eating is appropriate- unless high risk
Pyrexia >37.5- more common with epidural and prolonged labour. Paracetemol given and IV antibiotics and CTG of fever reaches 38
Frequent micturition- catheterisation is required if an epidural is in situ
Adrenaline secretion slows labour- caregiver is reassuring
What are the consequences of hyperactive uterine contraction?
occurs with excessively strong, frequent or prolonged contractions
foetal distress occurs as placental blood flow is diminished and labour may be very rapid
associated with placental abruption, too much oxytocin or a side effect of PG administered to induce labour
if no abruption it can be treated with a tocolytic (eg. salbutamol IV), but C-section is often indicated because of foetal distress
What are the problems in labour in nulliparous women?
Inefficient uterine action- artificial rupture of membranes (ARM/amniotomy) or IV oxytocin with a gradually increasing dose- CTG is required
• Oxytocin usually increased cervical dilation within 4hrs if it is going to be effective- if full dilation not imminent within 12-16hrs then C-section is performed
• Pushing need not be directed unless ineffective or an epidural is present, if active 2nd stage lasts longer than 1-2hrs, then instrumental delivery is often required due to maternal exhaustion, foetal hypoxia and maternal trauma
What occurs with OP position?
often combined with varying degrees of extensions causing a larger diameter
labour is often longer and more painful with backache and an early desire to push
is position is persistent (5%) then delivery will be ‘face to pubis’ and completed by flexion rather than extension over the perineum
instrumental delivery is usually achievable with rotation to OA position using ventouse, manual rotation or Keilland’s forceps
What occurs with the OT position?
this occurs when normal rotation has been incomplete
only if vaginal delivery has not been achieved after 1hr of pushing in 2nd stage is the position significant, this is common and usually associated with poor powers rotation with traction is required for delivery to occur and is achieved with the ventouse
What occurs with brow position?
rare, occurring in 1 in 1000 labours
extension of the foetal head on the neck results in large presenting diameter that will not normally deliver vaginally
anterior fontanelle, supraorbital rides and nose are palpable vaginally
C-section is required
What occurs with face presentation?
rare, occurring in 1 in 400 labours
complete extension of the head resulting in the face being the presenting part
foetal compromise in labour is more common- presenting diameter is 9.5cm allowing vaginal delivery is most cases, as long as the chin is anterior
delivery is completed by flexion over the perineum
if the chin is posterior then a C-section is indicated
What is cephalic-pelvic disproportion?
• This is when the pelvis is too small to allow passage of the head, but can almost never be diagnosed with certainty
it is most commonly a retrospective diagnosis, defined as the inability to deliver a particular foetus despite:
o The presence of adequate uterine activity
o The absence of a malposition or presentation
More common with a large baby, with very short women or where the head in a nulliparous women remains high at term
What are the pelvic variants and deformities?
• The gynaecoid pelvis is found in 50-80% of Caucasian women
• The anthropoid pelvis if found in 20% of women- it has a narrower inlet, with a transverse diameter often less than the AP diameter
• The android pelvis is found in 5% of women- it has a heart-shaped inlet and a funnelling shape to the mid- pelvis
• The platypelloid pelvis is found in 10% of women- the oval shape of the inlet persists within the mid-pelvis
• Rarely, a pelvic mass blocks engagement and descent of the head eg. ovarian tumour or uterine fibroid-
palpable vaginally and C-section is indicated
What are the causes of damage to the foetus during labour?
o Foetal hypoxia- commonly described as ‘distress’
o Infection/inflammation in labour eg. GBS
o Meconium aspiration leading to chemical pneumonitis
o Trauma- commonly due to obstetric intervention (eg. forceps)
o Foetal blood loss
Which pH indicates hypoxia?
foetal scalp blood with pH of <7.2 indicates significant hypoxia
however, it is only pH <7 that neurological damage is considerably more common and even then most babies with neurological damage had a normal pH at birth
this suggests other influences, such as IUGR or maternal fever on neonatal outcome
What can acute hypoxia in labour be due to?
o Placental abruption o Hypertonic uterine states o Use of oxytocin o Prolapse of the umbilical cord o Maternal hypotension
What are the intrapartum risk factors for hypoxia?
o Long labour
o Meconium
o Epidurals
o Oxytocin
What are the antepartum risk factors for hypoxia?
o Pre-eclampsia
o IUGR
How is foetal distress diagnosed?
Colour of the liquor: rare in preterm foetuses, but common after 41 weeks
undiluted it shows a fourfold increase in perinatal mortality
undiluted it shows an fourfold increase in perinatal mortality
Foetal heart auscultation: the heart is ausculated every 15 minutes during the 1st stage and every 5 mins during the 2nd stage using a Pinard’s stethoscope or handheld Doppler
CTG
Foetal blood sampling: blood taken from the scalp- if pH <7.2 then delivery is expedited in the fastest way possible
