Obs - Presentation + intrapartum complications Flashcards
At what gestation would you offer ECV for a breech presentation?
From 36/40 in nulliparous and 37/40 in multiparous women.
What medication can you offer to increase success of ECV?
Tocolysis with TERBUTALINE (IV/SC) or SALBUTAMOL (B2 agonists)
What are the risks + benefits of ECV?
Benefits:
- 50% decreased incidence of non-cephalic presentation
- decreased risk of having a C section
- few complications
Risks:
- discomfort/pain
- 50% failure rate
- spontaneous reversion to breech (<5%)
- high rate of obstetric intervention in labour with cephalic presentation following ECV
- abruption/foetal compromise
What are the absolute contraindications for ECV?
- CS required
- APH within last 7/7
- abnormal CTG
- major uterine anomaly
- ruptured membranes
- multiple pregnancy (exc. after delivery of 1st twin)
A G4P3 woman is urgently referred to obstetrician at 38/40 due to unstable foetal lie.
What are the risk factors for this?
- high parity
- uterine abnormalities
- poly/oligohydramnios
- multiple pregnancy
- foetal macrosomia/abnormality
- placenta praevia
A G4P3 woman is urgently referred to obstetrician at 38/40 due to unstable foetal lie.
What are the Mx options?
- consider elective admission from 38-39/40
- expectant Mx: if no contraindications, await onset of labour OR
- active Mx: ECV + IOL OR
- elective CS at 39/40 (higher maternal risk but lower foetal risk)
A 32yo G1P0 is in 2nd stage of labour. The foetal head has been delivered but the midwife notices that with the next contraction, the head retracts slightly back into the pelvis so that neck is not visible.
What is the diagnosis and how should the labour be managed?
Shoulder dystocia
- call for help - senior obstetrician, senior midwife + paediatrician
- advise mother to stop pushing
- McRobets’ manoeuvre (90% success rate): hyperflex maternal hips to widen pelvic outlet
- apply suprapubic pressure: to disimpact anterior shoulder
- active Mx of 3rd stage due to increased risk of PPH
2nd line manoeuvres:
- insert hand and grasp posterior arm to deliver
- internal rotation: apply pressure simultaneously in front of 1 shoulder and behind the other to move baby 180° or into an oblique position
What are the risk factors for shoulder dystocia?
Pre-labour
- prev. shoulder dystocia (x10 risk)
- macrosomia (>4.5kg)
- diabetes (x2.4 risk)
- maternal BMI >30
- IOL
Intrapartum
- prolonged 1st or 2nd stage
- oxytocin augmentation
- assisted vaginal delivery e.g. forceps or ventouse
How does cord prolapse lead to foetal hypoxia?
- occlusion of blood flow due to presenting part pressing onto umbilical cord
- exposure of cord to cold atmosphere causing umbilical artery vasospasm
Suggest risk factors for cord prolapse.
- breech presentation, esp. footling breach
- unstable lie
- artificial ROM
- polyhydramnios
- prematurity
How would you manage a labour with cord prolapse?
- call for senior help + paeds
- avoid handling of cord to decrease vasospasm + manually elevate presenting part by lifting it off cord
- encourage into knee-chest position or left lateral position with head down + pillow under left hip
- consider TERBUTALINE tocolysis if delivery not imminent to allow time to transfer to theatre
- emergency CS
When would you suspect delay in 1st stage of labour?
- <2cm dilation after 4hrs in labour
2. slowing of progress in parous women
What are the common causes of delayed 1st stage labour?
3 Ps:
- power (most common): inefficient uterine contractions
- passenger: malposition, malpresentation or LGA
- passage: inadequate pelvis
A G1P0 has been in labour for 5hrs and has only dilated 1cm. Membranes have not yet ruptured. How would you manage and when would you confirm delayed 1st stage?
- amniotomy: shortens labour by about 1hr but increases strength + pain of contractions
- reassess after 2hrs
- diagnose delay if <1cm progress
How would you manage a woman with confirmed delayed 1st stage of labour?
- Transfer to obstetrics-led care.
- Start OXYTOCIN infusion (with CTG monitoring) - titrate dose until there are 4-5 contractions/10 mins (max. dose change every 30mins).
- If <2cm dilation after 4hrs on oxytocin OR foetal distress: emergency CS
