Pain in labour, disordered uterine action, malpositions and malpresentations Flashcards
labour dystocia
- An abnormal or difficult labour
- 8-11% of all deliveries and leading cause of LSCS
- Classical causes include
- Powers – ineffective pattern of contractions
- Passage – pelvis e.g CPD
- Passenger – malposition/malpresentation of the fetus
- Other causes – dehydration, ketosis, anxiety
when is dystocia suspected
a lack of progress in rate of dliatation
lack of progress in fetal descent and expulsion
alteration in characteristics of uterine activity
hypotonic uterine action
contractions are
weak
short
inefficient
slow or no cervical dilatation
woman and fetus not distressed
types of hypotonic uterine action
primary occurs in early labour
secondary after normal contraction pattern is established
–> friedman curve (management) for labour progress
incoordinate uterine action
- Polarity of uterus is reversed
- Cervix dilates slowly despite frequent painful contractions
- Linked to malposition of the occiput and minor CPD (cephalopelvic disproportion)
- 2 types – colicky uterus and hypertonic lower uterine segment
incoordinate uterine action management
- Identify cause
- Avoid dehydration and ketosis
- Bladder care
- Incoordinate uterine activity may be aggravated by the supine position
hypertonic uterine action
- Pain out of proportion to contractions and cervical dilation
- Seen in multips with precipitate labour and CPD
- Uterine rupture, perineal trauma, PPH
management hypertonic uterine action
determine cause
early recognition
timely preparation for birth
analgesia
cervical dystocia
- Oedematous anterior lip of cervix
- Rigid cervix: uterus contracts normally but the cervix fails to dilate, woman 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 syntoconin because of the associated risk of uterine rupture
pelvic dystocia
- Contractures of the pelvic diameters reducing the capacity of the inlet, cavity and outlet
- Labour outcomes – most common cause of obstructed labour , fetal complications
soft tissue dystocia
- Obstruction of the birth passage by an anatomic abnormality other than the bony pelvis
- Pelvic mass – fibroids located in the LUS or on the cervix can prevent fetal head descent
- Ovarian tumours or rare tumours of the bony pelvis may also prevent the head from entering the pelvis
fetal cause of labour dystocia
- Anomalies – hydrocephalus, conjoined twins
- Disproportion
- Malposition
- Malpresentation
malpositions
position of the fetus in the uterus which will not aid normal progress in labour
malpresentations
when the fetal head is not over the cervix, breech, brow, shoulder or face may be found instead
face presentation
- Attitude of head is complete extension, glabella to under surface of chin lies over os
- 1:5-600 births
- Mechanism – anterior or posterior
- Labour – prolonged, avoid fetal electrode, VE, progress
brow presentation
- Head is partly extended with the brow presenting, forehead is presenting part
- 1:1500
- Causes – multip, placenta previa, uterine anomaly, polyhydramnios, prematurity, multiple births, macrosomia
- Findings on palpation: may reveal a high head that does not descend despite strong contractions
- VE: may detect sagittal suture in the transverse or oblique position, anterior fontanelle feels very large and the orbital ridges are palpable
shoulder presentation
- Rare
- Transverse or oblique lie
- Lax multip uterus, placenta previa, fetal anomaly, polyhydramnios and uterine malformation
- Usually LSCS
breech
- Fetal buttcks lie lowermost in the maternal uterus and the fetal head occupies the fundus
- 3-4% at term and most common
- Longitudinal
- Denominator is sacrum
- Presenting diameter in a complete breech presentation is the bitrochanteric = 10cm
- Palpation
causes malpresentation
- Restricted space e.g primip, bicornuate uterus, fibroids, placenta previa, contracted pelvis, multiple pregnancy
- Excessive space e.g grand multip
- Fetal causes e.g hydrocephaly, preterm labour, congenital anomalies
antenatal management malpresentation
- External cephalic version (ECV):
- Involves turning of the breech by abdominal or intrauterine manipulation.
- It is recommended that all women with an uncomplicated breech presentation be offered an ECV between 37 and 42 weeks of pregnancy
- Procedure: Uses ultrasound guidance, tocolysis and CTG monitoring pre and post procedure. NB: Rh-negative women
- Risks: placental abruption, failed version, cord entanglement, ruptured uterus
contraindications of ECV
uterine scar
hypertension
oligohydramnios
h/o prem labour
multiple pregnancy
hydrocephalic fetus
ECV mechanisms
The lie is longitudinal
The attitude 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 (left) 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
Lateral flexion of the body
Restitution of the buttocks
Internal rotation of the shoulders
Internal rotation of the head
External rotation of the body
Birth of the head
breech risks
- Impacted breech
- Cord prolapse
- Birth injury (fractures, dislocation, erbs palsy, trauma to internal organs, spinal cord damage or fractures spine, intra-cranial haemorrhage, soft tissue damage)
- Fetal hypoxia
- Premature separation of the placenta
- Maternal trauma
