Pain in labour, disordered uterine action, malpositions and malpresentations

Question 1

labour dystocia

Answer 1

• 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

Question 2

when is dystocia suspected

Answer 2

a lack of progress in rate of dliatation
lack of progress in fetal descent and expulsion
alteration in characteristics of uterine activity

Question 3

hypotonic uterine action

Answer 3

contractions are
weak
short
inefficient
slow or no cervical dilatation
woman and fetus not distressed

Question 4

types of hypotonic uterine action

Answer 4

primary occurs in early labour
secondary after normal contraction pattern is established
–> friedman curve (management) for labour progress

Question 5

incoordinate uterine action

Answer 5

• 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

Question 6

incoordinate uterine action management

Answer 6

• Identify cause
• Avoid dehydration and ketosis
• Bladder care
• Incoordinate uterine activity may be aggravated by the supine position

Question 7

hypertonic uterine action

Answer 7

• Pain out of proportion to contractions and cervical dilation
• Seen in multips with precipitate labour and CPD
• Uterine rupture, perineal trauma, PPH

Question 8

management hypertonic uterine action

Answer 8

determine cause
early recognition
timely preparation for birth
analgesia

Question 9

cervical dystocia

Answer 9

• 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

Question 10

pelvic dystocia

Answer 10

• Contractures of the pelvic diameters reducing the capacity of the inlet, cavity and outlet
• Labour outcomes – most common cause of obstructed labour , fetal complications

Question 11

soft tissue dystocia

Answer 11

• 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

Question 12

fetal cause of labour dystocia

Answer 12

• Anomalies – hydrocephalus, conjoined twins
• Disproportion
• Malposition
• Malpresentation

Question 13

malpositions

Answer 13

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

Question 14

malpresentations

Answer 14

when the fetal head is not over the cervix, breech, brow, shoulder or face may be found instead

Question 15

face presentation

Answer 15

• 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

Question 16

brow presentation

Answer 16

• 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

Question 17

shoulder presentation

Answer 17

• Rare
• Transverse or oblique lie
• Lax multip uterus, placenta previa, fetal anomaly, polyhydramnios and uterine malformation
• Usually LSCS

Question 18

breech

Answer 18

• 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

Question 19

causes malpresentation

Answer 19

• 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

Question 20

antenatal management malpresentation

Answer 20

• 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

Question 21

contraindications of ECV

Answer 21

uterine scar
hypertension
oligohydramnios
h/o prem labour
multiple pregnancy
hydrocephalic fetus

Question 22

ECV mechanisms

Answer 22

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

Question 23

breech risks

Answer 23

• 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