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Complex care 1 > Module 6: Malpositions, malpresentations, disordered uterine action and pain in labour > Flashcards

Module 6: Malpositions, malpresentations, disordered uterine action and pain in labour Flashcards

1
Q

Labour dystocia: Definition and incidence

A

Definition: an abnormal or difficult labour.
Incidence: 8-11% of deliveries and the lead cause of LSCS

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2
Q

Labour dystocia: cause

A

Three P
Powers: ineffective pattern of contractions
Passage: pelvis eg CPD
Passenger: malposition/malpresentation of the fetus
Other causes: dehydration and ketosis, psychologic state - anxiety and fear

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3
Q

When is labour dystocia suspected

A

Lack of progress in the rate of cervical dilation
Lack of progress in fetal descent and expulsion
An alteration in the characteristics of uterine contractions
Most common cause of labour dystocia will be “abnormal uterine action”

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4
Q

What is inefficient uterine action

A

Contractions do not effectively dilate the cervix
Progress in labour is slow
Length of labour is prolonged
Contractions may be too weak or not working in harmony.

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5
Q

What is hypotonic uterine action

A

Contractions are weak, short and inefficient
Slow or no cervical dilation
Woman and fetus not distressed

Either:
Primary - occurring in early labour
Secondary - after a normal contraction pattern has established

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6
Q

Management of inefficient uterine action

A

Labour progression is currently measured against the Friedman curve, based on 100 women in 1954.
Wide variation in duration for multips and primips

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7
Q

Incoordinate uterine action

A

Polarity of uterus is reversed
Cervix dilates slowly despite frequent painful contractions
Linked to malposition of the occiput.

Two types:
Colicky uterus
Hypertonic lower uterine segment

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8
Q

Management of incoordinate uterine action

A

Identify cause and correct it if possible
Emotional support
Avoid dehydration and ketosis
Ensure bladder care
Incoordinate uterine activity may be aggravated by the supine position, encourage ambulating, positions using gravity or warm bath
Augmentation with synto?

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9
Q

Hypertonic uterine action

A

Rarely occurs without the use of oxytocic’s
Pain out of proportion to contractions and cervical dilation
Seen in multiparous women with precipitate labour <2 hours.
May result in uterine rupture, perineal trauma and PPH
Outcome: dependent on risks

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10
Q

Management of hypertonic uterine action

A

Determine the cause
Early recognition
Timely preparation for birth under controlled conditions
Properly administered analgesia

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11
Q

Cervical dystocia

A

Oedematous anterior lip of cervix
Rigid cervix: uterus contracts normally but the cervix fails to dilate. Women may have a history of cervical stenosis from previous cervical surgery or congenital abnormality of the cervix
Important to exclude this prior to the use of syntocinon because of the associated risk of uterine rupture.

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12
Q

Pelvic dystocia

A

Contractures of the pelvic diameters reducing capacity of the inlet, cavity and the outlet.

Most common cause of obstructed labour leading to LSCS

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13
Q

Soft tissue dystocia

A

Obstruction of the birth passage by an anatomic abnormality other than the bony pelvis

Causes
Pelvic mass - fibroids
Ovarian tumours or rare tumours of the bony pelvis

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14
Q

Fetal cause of labour dystocia

A

Anomalies eg hydrocephalus, conjoined twins
Disproportion
Malposition
Malpresentation

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15
Q

Define malpositions

A

Refers to a position of the fetus in the uterus which will not aid normal progress in labour

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16
Q

Define malpresentations

A

When the fetal head is not over the cervix, the breech brown, shoulder or face may be found instead.

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17
Q

Brow presentation: Definition and incidence

A

Head is partly extended with the brow presenting. The forehead (glabella) is the presenting part.

Incidence 1:1500

Presenting diameter: 13.5cm - requires LSCS

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18
Q

Brow presentation causes

A

Multiparity, placenta previa, uterine anomaly, polyhydramnios, prematurity, multiple births and macrosomia.

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19
Q

Face presentation

A

Attitude of head is complete extension, glabella to under surface of chin lies over os.

Incidence 1:5-600 births

Considerations: Prolonged labour, escalate, avoid FSE, monitor progress

20
Q

Shoulder presentation: Cause and management

A

Associated with transverse or oblique lie. Rare

Causes: lax multiparous uterus, placenta previa, fetal anomaly, polyhydramnios and uterine malformation

Management: usually LSCS, occasionally cephalic version is attempted but not in labour and need to exclude placenta previa.

21
Q

Breech presentation: Definition and incidence

A

A breech presentation occurs when the buttocks lie lowermost in the maternal uterus and the fetal head occupies the fundus

Incidence: 3-4% at term and the most common malpresentation. Proportion decreases with advanced gestational age

22
Q

Breech presentation diagnosis

A

Palpation in late pregnancy or during labour.
Auscultation of the FHR is usually heard above the umbilicus when the breech has not engaged
U/S
Fetal abnormalities in 9% of term breech births

23
Q

Types of breech presentation

A

Complete (flexed)
Extended (frank)
Knee
Footling

24
Q

Causes of breech presentation

A

Restricted space: primip, bicornuate uterus, fibroids, placenta previa, contracted pelvic, multiple pregnancy
Excessive uterine space: grand multiparity, polyhydramnios
Fetal causes: hydrocephaly, preterm labour, congenital anomalies.

25
Q

Breech presentation ECV

A

External cephalic version involves turning of the breech by abdominal or intrauterine manipulation. It is recommended that all women with an uncomplicated breech bet offered an ECV between 37 and 42 weeks of pregnancy

26
Q

ECV risks

A

placental abruption
failed version
cord entanglement
ruptured uterus

27
Q

Contraindications for ECV

A

Uterine scar
Hypertension
Oligohydramnios
H/O premature labour
Multiple pregnancy
Hydrocephalic fetus

28
Q

Mechanism of left sacro-anterior breech position

A

The lie is longitudinal
The attidue is one of complete flexion
The presentation is breech
The position is left sacroanterior
The denominator is the sacrum
The presenting part is the anterior buttock
The bitrochanteric diameter, 10cm, enters the pelvis in the left oblique diameter of the brim
The sacrum points to the left of the iliopectineal eminence
Compaction
Internal rotation of the buttocks
Internal rotation of the shoulders
Internal rotation of the head
External rotation of the body
Birth of the head

29
Q

Breech presentation labour management

A

First stage: Normal labour cares, FHR assessment, membranes, liquor, pain relief. Often intrapartum monitoring and use of EDB to prevent premature pushing

Second stage: Confirm full dilatation. Notify obstetrician, pediatrician and anesthetist. No active pushing until the buttocks distends the vulva. Birth position

Third stage: timing of oxytocic

30
Q

Breech manoeuvres

A

Mauriceau-Smellie-Veit = for jaw flexion and shoulder traction
Lovet manoeuvre = for delivery of extended arms
Burns Marshall method for the after coming head

31
Q

Breech presentation risks

A

Impacted breech
Cord prolapse
Birth injury
Fetal hypoxia
Premature separation of the placenta
Maternal trauma

32
Q

Induction

A

Is any attempt to initiate uterine contractions before their spontaneous onset to facilitate a vaginal birth.

33
Q

Augmentation

A

Any attempt to stimulate uterine contractions during the course of labour to facilitate a vaginal birth.

34
Q

Incidence of induction/augmentation

A

35.6% of all NSW confinements were induced or augmented with ARM, oxytocin and/or prostaglandins in 2020

35
Q

Criteria to commence an induction

A

An engaged presenting part
No previous classic uterine incision
No fetopelvic disproportion
No non-reassuring fetal heart rate patterns
No major bleeding from an abruptio placenta
No placenta praevia or vasa praevia
No active herpes or primary herpes infection

36
Q

Methods of induction

A

Oxytocin
Prostaglandins
Amniotomy/ARM
Digital stretching of the cervix
Mechanical cervical dilators
Herbs, blue and black chosh tinctures, raspberry leaf tea
Cod liver oil
Acupuncture, homeopathy
Nipple stimulation, sexual intercourse

37
Q

Bishop’s score

A

A score is ascertained by performing a vaginal examination and assigning points to dilation, consistency, length, position and station. <6 requires cervical ripening. >9 indicates induction favourability

38
Q

Amniotomy/ARM

A

Artificial rupture of the membranes with an amnihook.

Advantages: Decreases the length of some labours, allows assessment of the colour of the amniotic fluid, allows for internal fetal and uterine monitoring.

Risks: Can increase pain and lead to further intervention, variable decelerations, cord prolapse, vasa previa, infection.

39
Q

Prostaglandins

A

Route: Intravaginal (posterior fornix)

Dosage: 1-2 mg can be repeated 6 hourly, max 3 doses

Care: check dates, note bishops score, explain procedure, manage anxiety, abdominal palpation, pre and post CTG, woman to remain supine for 30-60 min post administration, assess for hyperstimulation, observe other side effects

40
Q

Prostaglandins advantages and risks

A

Advantages:
Enhanced cervical ripening
Decreased use of oxytocin
Decreased oxytocin induction time
Reduced amount of oxytocin used
Decreased caesarean section rate

Risks:
Uterine hyperstimulation - uterine rupture
Non reassuring FHR pattern changes
Gastrointestinal side effects

41
Q

Mechanical cervical ripening

A

Various methods used; however, all stimulate the release of prostaglandins due to mechanical pressure

Mechanical methods include balloon catheters now back in practice, natural dilator, synthetic dilator

Risks: infection, PROM, hemorrhage

42
Q

Syntocinon

A

Oxytocin promotes the contraction of the uterine smooth muscle, synthetic form is syntocinon
Administered when cervix is favourable.

Route IV through a pump, piggy backed to the main line, prepared in an isotonic solution eg Harmann’s

Care: Explanation, relieve anxiety, prepare infusion, check dates, peform palp, ARM, baseline obs, maintain infusion, positions, continuous CTF, usual labour cares

43
Q

Syntocinon side effects

A

Uterine hyperstimulation
Antidiuretic effect
Prematurity
Fetal hypoxia
Hyperbilirubinemia

44
Q

Occipito-posterior position in labour incidence and cause

A

10-25% during the early stage, 10% during the active phase and 6% at birth. More common in nulliparas.

Causes pelvis type - android

45
Q

Issues with occipito-posterior position in labour

A

embranes: best if intact to facilitate the fetus to rotate
Contractions: often hypotonic, irregular, coupling, incoordinate
Progress: is slower, loss of fetal axis pressure, contractions are not effectively stimulated
Descent: is slow and requires flexion, fetal head is compressed in unfavourable diameters. Greater risk of tentorium cerebelli damage and the likelihood of intracranial haemorrhage.
Second stage and urge to push: is premature
Lots of back pain
Facilitating normal labour: active labour, upright positions, all fours, water.

46
Q

Labour care of women with posterior babies

A

Explanation, support
Discomfort management, positions, water
Nutrition
Observations
? Augmentation
Premature urge to push
Confirmation of second stage

Complex care 1 (9 decks)

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