Problems encountered in labour Flashcards
What are some problems encountered in labour?
- Failure to progress
- Malpresentation/Malposition
- Suspected Foetal Compromise (foetal distress)
- Vaginal birth after Caesarean Section
- Operative delivery
- Shoulder dystocia
What causes in ‘Failure to Progress’?
Can occur in first and second stage. Causes are:
- Inadequate contractions (augment with oxytocin)
- Foetal malposition/ malpresentation
- Cephalopelvic disproportion
- Obstructed labour
- Maternal Exhaustion
What are types of Malrotation?
- Occipito-posterior
- Deep transverse arrest
What are types of Malpresentation?
- Face: baby lying on tummy coming out
- Brow: can feel tops of the eye
- Breech: Sucking toe, Baby flexed
What are complications of Breech?
- Trapper aftercoming head
- Cord prolapse
- Intracranial haemorrhage
- Internal injuries
What are types of Abnormal Lie?
- Oblique lie
- Transverse lie
needs Caesarean Section
What are causes of Suspected Foetal Compromise during labour?
- Uterine Hyperstimulation (can be iatrogenic oxy): Terbutaline used to control
- Hypotension
- Poor foetal tolerance of labour (IUGR?)
- Cord compression
- Infection
- Maternal Disease
How is suspected foetal compromise generally managed?
- Rectify reversible causes. Deliver by speediest route if unable to correct or if significant acidosis
- Left lateral position
- Stop oxytocics
- Confirm compromise by blood sampling where possible
What are risks of attempting Vaginal birth after Caesarean Section?
Complication
- Uterine scar dehiscence/rupture 0.5%
- Emergency C-section in labour
Contraindications:
- Previous uterine rupture
- Classical caesarean scar
What are precautions for VBAC?
- IV access and Group &Save
- Continuous electronic foetal monitoring
- Avoid prolonged labour
- Augmentation/induction decision made by specialist only
What is required for Ventouse/Forceps delivery?
- Indications: maternal reasons, failure to progress in 2nd stage,
- Pre-requisites: trained operator, full dilation, absent membrane, cephalic presentation, clearly defined position, presenting part engaged, no evidence of CPD, adequate analgesia, empty bladder
What is required for a Caesarean Section?
Indications
- Maternal reasons
- Absolute cephalopelvic disproportion
- Placenta praevia grades ¾
- Pre-eclampsia
- Post-maturity
- IUGR
- Foetal distress in labour/prolapsed cord
- Failure of labour to progress
- Malpresentations: brow
- Placental abruption: only if foetal distress; if dead deliver vaginally
- Vaginal infection e.g. active herpes
- Cervical cancer (disseminates cancer cells)
What are complications of Ventouse/Forceps delivery?
- Failure
- Foetal trauma (cephalohaematoma, sub-glial haemorrhage)
- Maternal trauma
- Postpartum Haemorrhage
- Urine retention
What are immediate complications of a Caesarean Section?
- Haemorrhage
- Infection
- Bladder/bowel injury
- Thromboembolic disease
- Requirement of blood transfusion
- TTN
- Foetal trauma
What is Shoulder Dystocia?
- Complication of vaginal cephalic delivery. Entails inability to deliver body of the foetus using gentle traction after the head has already been delivered.
- Occurs due to impaction of the anterior foetal shoulder on maternal pubic symphysis preventing entry into pelvic inlet
- Causes both maternal and foetal morbidity. Associated with PPH, perineal tears and brachial plexus injury e.t.c.
- Neonatal death occasionally occurs from shoulder dystocia
What are risk factors of Shoulder Dystocia?
- Foetal macrosomia
- High maternal body mass index
- Diabetes mellitus
- Prolonged labour.
What are complications of Shoulder Dystocia?
- Foetal death
- Asphyxia with resulting hypoxic damage
- Birth trauma (Erb’s palsy, fractured bone
- Maternal trauma (soft tissue trauma, psychological)
What is the management for Shoulder Dystocia?
1st Line: McRoberts manoeuvre performed (after help is called) + suprapubic manoeuvre.
- Woodscrew manoeuvre can also be tried
- Symphysiotomy and the Zavanelli manoeuvre can cause significant maternal morbidity and are not first-line options.
- Episiotomy does not relieve the bony obstruction but sometimes used to allow better access for internal manoeuvres.
What is the McRoberts manoeuvre?
- Entails flexion and abduction of maternal hips bring mother’s thigh towards her abdomen.
- This rotation increases anterior-posterior angle of the pelvis and often facilitate successful delivery
What is Symphysis pubis dysfunction?
- Ligament laxity increases in response to hormonal changes of pregnancy
- Pain over the pubic symphysis with radiation to the groins and the medial aspects of the thighs.
- A waddling gait may be seen
What is the definition of Cord Prolapse?
- Involves umbilical cord descending ahead of presenting part of the foetus. If left untreated it can lead to compression of the cord or cord spasm leading to foetal hypoxia and eventually irreversible damage or death*
- Majority of cord prolapses occur at artificial rupture of membrane.
What are risk factors for Cord Prolapse?
- Prematurity
- Multiparity
- Polyhydramnios
- Twin pregnancy
- Cephalopelvic disproportion
- Abnormal presentations e.g., Breech, transverse lie
- Placenta praevia
- Long umbilical cord
- High foetal station
What are types of Breech Presentation?
- Frank breech: Most common presentation with hips flexed and knees fully extended.
- Footling breech: Where one or both feet come first with the bottom at higher position. This is rare but carries a higher perinatal morbidity
What investigation results indicate Cord Prolapse?
- Foetal heart rate abnormal
- Cord is palpable vaginally or cord is visible beyond level of introitus
Wha is the immediate management of a Cord Prolapse?
- Presenting part of foetus may be pushed back into uterus to avoid compression
- If cord is past level of introitus, it should be kept warm and moist but should not be pushed back inside
- Tocolytics may be used
What is the defintive management options for Cord Prolapse?
- 1st line: Patient is asked to go on all fours until preparation for an immediate caesarean section has been carried.
- 2nd line: instrumental vaginal delivery is possible if cervix is fully dilated and head is low.
If treatment is early foetal mortality in cord prolapse is low. Incidence has been reduced by increase in C-section being used in breech presentation
What are risk factors for Breech Presentation?
- Uterine malformations
- Fibroids
- Placenta praevia
- Polyhydramnios or Oligohydramnios
- Fetal abnormality (e.g. CNS malformation, chromosomal disorders)
- Prematurity (due to increased incidence earlier in gestation)
What is the management for Breech Presentation?
- If <36 weeks: many foetuses will turn spontaneously
-
If still at 36 weeks: External Cephalic Version (ECV). Has success rate of 60%. Offered from:
- 36 weeks in nulliparous women and
- 37 weeks in multiparous women
- If baby is still breech after this then delivery options include planned caesarean section or vaginal delivery
What are absolute contraindications to ECV?
- Where caesarean delivery is required
- Antepartum haemorrhage within the last 7 days
- Abnormal cardiotocography
- Major uterine anomaly
- Ruptured membranes
- Multiple pregnancy
How should women with Breech Presentation be counselled?
- ‘Women should be informed that planned caesarean section carries a reduced perinatal mortality and early neonatal morbidity for babies with a breech presentation at term compared with planned vaginal birth.’
- ‘Women should be informed that there is no evidence that the long-term health of babies with a breech presentation delivered at term is influenced by how the baby is born.’
What are immediate complications of Caesarean Section?
- Emergency hysterectomy
- Need for further surgery at a later date, including curettage (retained placental tissue)
- Admission to intensive care unit
- Thromboembolic disease
- Bladder injury
- Ureteric injury
- Death (1 in 12,000)
- Prolonged ileus
- Persistent wound and abdominal discomfort in the first few months after surgery
- Increased risk of repeat caesarean section when vaginal delivery attempted in subsequent pregnancies
- Readmission to hospital
- Haemorrhage
- Infection (wound, endometritis, UTI)
What are complications of a Caesarean Section for Future pregnancies?
- Increased risk of uterine rupture during subsequent pregnancies/deliveries
- Increased risk of antepartum stillbirth
- Increased risk in subsequent pregnancies of placenta praevia and placenta accreta)
- Subfertility
What are indications for forceps delivery?
- Fetal distress in the second stage of labour
- Maternal distress in the second stage of labour
- Failure to progress in the second stage of labour
- Control of head in breech deliver
What are clinical features of Uterine Rupture?
Occurs during labour but can also occur in 3rd trimester. Risk factors are previous caesarean section. Presents:
- Maternal shock
- Abdominal pain
- Vaginal bleeding
What is False Labour?
Occurs in the last 4 weeks of pregnancy. Presents with:
- Contractions felt in the lower abdomen which are irregular and occur every 20 minutes.
- Progressive cervical changes are absent.
