stages of labour Flashcards
what re the 7 steps of engagement and descent which allow a baby to be born
engagement and descent
flexion
internal rotation of the head
extension of the head
restitution
internal rotation of the shoulder
lateral flexion
delivery of the anterior then posterior shoulder
how do you differentiate between Braxton-Hicks contraction and labour
Labour is painful, progressive in frequency, amplitude and duration
what are the different stages of labour
1st stage - labour
2nd stage - delivery of the baby
3rd stage - delivery of placenta
what are the different phases of 1st stage of labour
1st stage of labour = from onset of labour to full dilatation of the cervix
latent phase - painful contraction which are not necessarily continuous along with some changes eg effacement and dilatation to 4 cm
active/established phase - regular painful contraction (5 mins apart and getting closer and short) and progressive dilation from 4 cm to full dilatation (10cm)
what is considered to be a failure to progress in a primigravid lady?
< 2cm per 4 hours of dilatation
what is considered to be a failure to progress in a multip lady?
< 2cm per 4 hour of dilatation or regression of dilatation
what are some causes of failure to progress?
Power - insufficient uterine activity
Passenger - malpositions, large baby
Passage - inadequate pelvis
or a combination of all those
what is the management of failure to progress?
if in the latent phase - manage conservatively
active phase
- ARM and reassess in 2 hours
- amniotomy + syntocinon infusion and reassess in 2 hours
- LSCS
when is passive and active stages of 2nd stage of labour
passive 2nd stage - full dilatation of cervix prior to or in absence of involuntary expulsive contractions
active 2nd stage - when mother starts expulsive efforts using her abdo muscles
when is delayed of 2nd stage of labour diagnosed?
primi -
once actively pushing, delay of the second stage is diagnosed wif birth not imminent in 2 hours
multi-
once actively pushing, delay of the second stage is diagnosed if birth is not imminent in 1 hour
mx of delayed of 2nd stage of labour
instrumental delivery or C-section
what is active management of 3rd stage of labour
reduces risk of maternal haemorrhage, anaemia & need for transfusion and shorten 3rd stage
- syntocinon
- early clamping and cutting of the cord
- controlled cord traction
prolonged active 3rd stage of labour - 30 minutes
what is physiological management of 3rd stage of labour
no routine use of uterotonic drugs
no clamping of cord until pulsation has ceased
delivery of placenta by maternal effort
when should a physiological management of 3rd stage of labour converted into active
when haemorrhage
failure to deliver the placenta in 1 hour
maternal desire to shorten 3rd stage
what are some maternal monitoring during labour
BP HR temp urineanalysis vaginal loss - colour contraction frequency, strength & length abdo palpatations VE to determien progress
all recorded on partogram
what are some foetal monitoring
low risk
- intermittent auscultation of fetal heart using sonicaid/doppler
high risk
- continuous monitoring - CTG using foetal scalp electrode- DR C BRAVADO
- foetal blood sampling
what are the management of worrying CTG
1) left lateral position
2) IV fluids
3) foetal scalp stimulation
4) foetal blood sample
- deliver if FBS is bad
how do you interpret FBS
pH > 7.25 = nomral
7.20-7.25 = bordeline
< 7.20 = deliver
must be 3 cm dilated to conduct FBS
what are the non-pharmacological methods of managing pain
education regarding what to expect
warm bath, acupuncture, hypnosis, aromatherapy and homeopathy
transcutaneous electricl nerver stimulation (TENS) - may not be adequate as labour advances
what are the pharmacological methods of managing pain
Entonox - works on the NMDA receptor, short half life so can not overdose on it
paracetamol
opioids - Daimorphine is 1st line in labour
opioids - pethidine - can cause neonatal respiratory distress and so will need naloxone
regional anesthesia
- pudendal nerve block for operative vaginal delivery
- local anesthetics - before performing an episiotomy
epidural or combined spinal analgesia
disadvantage of epidural
inc supervision maternal fever reduced mobility - inc PE risk inc instrumental delivery rate hypotension urinary retentions
advantage of epidural
most effective analgesia in labour
can be topped up
what are some general indication for induction of labour
when it is agreed that the foetus or mother will benefit from a higher probability of a healthy outcome that if birth is delayed
prolonged pregnancy
IUGR
HTN and pre-eclampsia
obstetric indications for induction of labour?
uteroplacental insufficiency prolonged pregnancy IUGR oligo or anhydramnios - twins non-reassuring CTG PROM pre-elcampsia/eclampsia DM - induce at 38 weeks IUD antepartum haemorrhage chorioamnionitis
maternal indications for induction of labour?
HTN DM renal disease malignancies cardiac abnor > 40 - induce @ term
what are some C/I to induction of labour
absolute
- acute foetal compromise
- placental praevia
- unstable lie
- pelvic obstruction
relative
- previous C-section - still inc risk of uterine rupture
- breech
- prematurity
- high parity
when will you consider induction of labour according to Bishop score?
if Bishop score < 5 - labour unlikely to start on its own
when will you not consider induction of labour according to Bishop score?
if Bishop score > 9, most likely to commence labour spontaneously
what is the first thing to do before offering a formal induction of labour?
stretch and sweep
if nuiparious - 40-41 weeks
if miltiparious - 41 weeks onward
cervical ripening with prostaglandin in tablet, gel or tape form
what is the general pathway of induction of labour
stretch and sweep
cervical ripening - prostaglandin, can try twice 6 hours after the other and allow 6 hours to work
oxytocin
or
amniotomy/ARM
if no uterine contraction after 2 hours from ARM - oxytocin infusion
how would you use oxytocin to induce or agment a labour
start off with low dose
inc every 30 mints to achieve optimal contractions (3-4 every 10 mins, each lasting 30-60 sec)
continuous CTG should be use
complications for oxytocin use for induction or agmentation?
hyperstimulation - reduce rate if using oxytocin, can use terbutalien (tocolytic)
operative delivery amniotic fluid embolus prematurity cord prolapse SE of oxytocin - inc pain or discomfort - foetal distress uterine rupture
prostaglandin
- N+V
diarrhoea
bronchorestriction - caution in asthmatic
C/S should induction fails
when will you augment a labour
when failure to progress
- muti - 2cm per 2 hours
- pri - 1cm per 2 hours
how would you augment the labour in 2nd stage of labour?
if after 2 hours of passive descent, push for 1 hour
- then no progress
- is the baby above or below the ischial spines?
- is above C-S
if below - instrumental delivery
what is the most common malposition?
occipito-posterior - often result in longer labour
mx of occipito-posterior position?
close monitoring of both foetus and mother
epidural recommended
adequate fluids be given to mother
discourage any urge to push before full dilatation
forceps or C-Section maybe required
mx of occipito transverse position
the head must be rotated using the Kielland’s focreps or delivered using vacuum extraction in theatre so can quickly transition into C-section
if fails –> C-section
mx of face-presentation
if mento-anterior position - mento = chin, results in longer labour but should be fine
if mento-posterior - C-section
mx of brwo’s position
C-section as vaginal delivery is not possible since the diameter of head is too big
what are the different types of breech presentation
extended
flexed
footling - requires C-section
what is breech position associated with
congenital abnor - pre-term baby and so contribute to congenital abnor
also associate with placenta praevia, abnor of the uteres eg fibroids
mx of breech position
external cephalic version
- from 36 weeks in nulliparous
- from 37 weeks in multi
- anti-D should be given if mother is Rh -ve
common practice for breech position is C-section although vaginal delivery is possible, emergency C-section risk is high
contra-indication for ECV
absolute
- when C-section already indicated
- APH
- foetal compromise
- oligohydramnios
- rhesus status
- pre-eclampsia
relative
- previous C-S
- foetal abnor
- maternal hypertension
what are some risks associated with transverse and unstable lie
obstructed labour and potential uterine rupture
cord prolapse - 20%
mx for transverse or unstablie lie
unstable lie - admit to hospital from 37 weeks, CS can be carried out if labour stars or membrane rupture
inc gestation will help to revert the lie to longituitonal
is lie is still unstable – >C/s at 41 weeks
when should twins be delivered?
induced at 38 weeks
management of twins delivery
continuous CTG monitoring
monitor leading twin with foetal scalp electrode
deliver twins in theatre
the 1st twin can be delivered vaginally, after the 1st twin is delivered, the lie of twin 2 should be check and stabilise with abdominal palpitation
2nd twin is usually delivered within 20 minutes of the 1st
oxytocin may help with diminishing contraction
if any distress with twin 2 - forceps or ventouse
C-section if failed
what are some of the risk of labour of twins
malpresentation foetal hypoxia in second twin after delivery of 1st cord prolapse operative delivery post-partum haemorrhage
rare
cord entanglement - MCMA twins only
head entrapment with each other - locked twins
what are some maternal indication for instrumental delivery
exhaustion to avoid inc ICP to avoid inc BP prolonged 2nd stage > 1 hour of active pushing in multi, > 2 hours of active pushing in premip
what are some foetal indication for instrumental delivery
foetal compromise
to control the after coming head of breech
when should you not use a ventouse
when foetus < 34 weeks
what is the requirement for instrutmental delivery
FORCEPS
Fully dilated cervix OA position preferable Ruptured membranes cephalic presentation Engaged presenting part pain relief is adequate - vacuum or low forceps - perineal nerve block - mid - forceps - epidural or pudeneal nerve block or general anaesthetic sphincter bladder - empty
what are some side effect of C-section
abdo pain
VTE
bladder or uretric injury
hysterectomy
what are the main indication for C-S
breech presentation foetal compromise repeated C-S failure to progress maternal request
what are the different categories of C-Section
Cat 1 - immediate threat to life of the women or foetus
Cat 2 - maternal or foetus compromise which is not immediate threat to life
Cat 3 - no maternal or foetal compromise but needs early delivery
Cat 4 - elective
what requires Cat 1 C-section
crash C-section should be done within 30 minutes
- placental abruption with abnor FHR or uterine irritability
- cord prolapse
- uterine scar rupture
- prolonged bradycardia
- scalp pH < 7.2
what requires a Cat 2 C-section
failure to progress with pathological CTG
what requires a Cat 3 C-section
severe pre-eclampsia
IUGR with poor foetal function tests
failed induction of labour
what requires a Cat 4 C-section
elective - delivery timed to suit woman and staff
- twin pregnancy with no-cephalic 1st twin
- maternal HIV
- primary genital herpes in 3rd trimester
- placenta praevia
- prev hysterotomy or classical C-S
usually carried out at around 39 weeks
what are some complications for C-section
intra-op
- bladder laceration
- bowel laceration
- uterine or uterocervical laceration
- inc blood loss
- hysterectomy
post-op
- endometritis
- wound infections
- pulmonary atelectasis +/- infection
- VTE
- UTI
longterm
- urinary and bowel incontinence
- uterine rupture
- placenta praevia & plaenta accreta
- antepartum stillbirth
What does shoulder dystocia
Usually the anterior shoulder is impacted against the synthesis pubis due to failure of internal rotation of the shoulder
Posterior shoulder can also be impacted leading to bilateral impaction which greatly increase mortality
What are the complications of shoulder dystocia
foetal
cerebral palsy brachial plexus palsy - Erbs & Klumpkes fracture of the clavicle or humerus intracranial haemorrhage cervical spine injury rarely foetal death
maternal
PPH
genital tract trauma - 3rd and 4th-degree tear
RF for shoulder dystocia
Antenatal
Previous history of shoulder dystocia foetal macrosomia BMI > 30 & excessive weight gain in pregancny Diabetes post-term
intrapartum
lack of Progress in late first stage of labour Induction of labour Prolong second stage Instrumental vagina delivery Oxytocin augmentation of labor
management of shoulder dystocia
MCroberts
suprapubic pressure
episotomy - only if advanced intervention is required
advance intervention - rotate shoulder - woodscrew - deliver posterior arm - woodscrew - break clavicle emergency C-section
