WK2: Prolonger labour and augmentation. Operative vaginal birth

Question 1

Define labour

Answer 1

A series of continuous, regular and painful contractions that result in the descent and expulsion of the fetus, membranes and placenta through the birth canal. It is spontaneous in onset at term, with the fetus presenting by vertex.

Question 2

Define prolonged labour? (first and second stage)

Answer 2

A labour the progresses past
- 18hrs for primips (last on average 8 hours and are unlikely to last over 18 hours)
- 12hrs for multis (last on average 5 hours and are unlikely to last over 12 hours) (NICE, 2014)

This is equivalent to a rate of cervical dilation of 0.5 cm – 1 cm/hr during the active phase (established labour)

Duration of the second stage;
Primip= <3hrs
Multi= <2hrs

Question 3

On what basis can delay of first stage be diagnosed?

Answer 3

• primip cervical dilation of <2cm in 4hrs
• Multi cervical dilation of <2cm in 4hrs or slowing the progress of labour
• no descent and rotation of fetal head detected on abdo palp or VE
• changes in the strength, duration and frequency of uterine contractions (slowing down, spacing out, less intense)

Question 4

What are some points of consideration that must be made before diagnosing as a prolonged first stage?

Answer 4

• parity (primip or multi?)
• cervical dilatation and rate of change
• uterine contractions
• station and position of presenting part (brow= may take longer as fetal skull is pressuring cervix in a uniform manner)
• the woman’s emotional state (comfortable with people in the room?)
• the environment/people around the woman (warm?)
• bladder (full?)
• hydration/energy intake

Ultimately consider the 5 P’s
1. Passage
2. Passenger
3. Power
4. Psyche
5. Problems

Question 5

How can we manage the suspected slow progress of labour?

Answer 5

Change something!!

• position changes
• empty bladder
• change environment
• encourage movement
• consider intervention
• Assess overall condition of woman and fetus
• Consult with the team

Repeat VE in 2hrs

Question 6

What are the risks of prolonged labour?

Answer 6

Prolonged labour can increase the risks of;
- fetal distress (fetal stores running out)
- PPH (due to the uterus being to fatigued to adequately contract after birth of the placenta)
- Shoulder dystocia
- Instrumental birth (due to the uterus being to fatigued to adequately contract after birth of the placenta)
- C/S

Question 7

What is the role of the midwife in the care of a women who is suspected to have a prolonged labour?

Answer 7

• change something (position, bladder, activity, environment)
• assess all aspects of labour to ensure your suspicions are accurate
• monitor maternal and fetal measures of wellbeing
• referral to an interprofessional team

Question 8

Define dysfunction of labour and name some other terms used to refer to it.

Answer 8

= one that is ‘protracted or arrested progress in cervical dilation during the active phase….or during the second stage’
*prolonged labour is an indication of dysfunction

Other terms used to describe dysfunction labour=
- Failure to progress
- Labour dystocia (slow, difficult labour)
- Persistent malposition
- Cephalopelvic disproportion (fetal head disproportionate to maternal pelvis)
- Protracted labour
- Uterine inertia

Question 9

Define augmentation of labour

Answer 9

The intervention to promote or improve labour once it has spontaneously begun.

Question 10

What are 3 common methods of augmentation of labour?

Answer 10

1. oxytocin infusion
2. ARM
3. Streach and sweep (earl one, ar 3-4cm/latent pahse)

Question 11

What are the risks and benefits of the augmentation method of ARM?

Answer 11

Benifits=
- Allows descent
- Allows for equal pressure on the cervix to help with positive feedback oxytocin system
- promotes uterine contractions
- controls frequency and strength

Risks=
- Cord prolapse
- Infection
- psych = disturbing natural oxytocin production by performing a VE
- Increased pain and discomfort
- Removing the waters which are a cushioning for baby
- Baby less ability to rotate when not in the waters and bag
- uterine hyperstimulation

Question 12

When is augmentation of labour indicated?

Answer 12

• prolonged first or second stage as a prophylactic for fetal distress.
• anticipated low fetal reserves.

Question 13

What are 5 things we need to consider before augmenting labour to change the labour?

Answer 13

Position
Passenger
Psyche
Powers
Passage

Question 14

What are some prerequisite considerations for an instrument/operative birth?

Answer 14

• Informed consent
• Fully dilated and effaced
• OB present
• Membrane ruptured
• Right indication
• Head down

Question 15

What are the contraindications for an operative/instrumental vaginal birth?

Answer 15

• Breech
• Less than 34 weeks
• Face presentation
• Coagulation issues
• Not an experienced doc
• Inadequate pain relief (if time)
• If there is any question that it won’t work

Question 16

What are risk factors for an operative/instrumental vaginal birth?

Answer 16

• Tearing
• Heammorhage
• Brising for baby
• Hypoxia (fetal hypoxia)

Question 17

What are possible adverse outcomes for an operative/instrumental vaginal birth that you should prepare for?

Answer 17

• Hypoxia
• PPH
• Fetal resus
• Shoulder dystocia (head is pulled the shoulder doesnt rotate and is stuck behind the symphisis)

Question 18

What are some maternal-related factors that can contribute to a prolonged second stage?

Answer 18

Well-being mother
- fatigue
- fear (prevents natural oxytocin)
- environment

The efficiency of pushing/lack of Ferguson’s Reflex
- epidural
- position

Efficiency uterine contractions- first stage may have been prolonged

Full bladder/rectum: impending on descent of presenting part
*very normal to open bowels in second stage as usually head is right behind it.

Question 19

What are some fetal related factors that can contribute to a prolonged second stage?

Answer 19

• Cephalo-pelvic disproportion: Large fetus/vertex
• Malposition e.g. posterior
• Malpresentation e.g. brow presentation
• Fetal abnormality
• Deep transvers arrest (DTA): head hasnt rotated

*look for reassuring factors

Question 19

What are some fetal related factors that can contribute to a prolonged second stage?

Answer 19

• Cephalo-pelvic disproportion: Large fetus/vertex
• Malposition e.g. posterior
• Malpresentation e.g. brow presentation
• Fetal abnormality
• Deep transvers arrest (DTA): head hasnt rotated

*look for reassuring factors

Question 20

What is the midwifes role in preventing or rectifying prolonged labour?

Answer 20

• Support woman
• Encourage upright positions and discourage supine position.
• If pushing is ineffective
  - change position
  - Upright
  - Mobile
  - empty bladder (pushing on toilet = effective +++)
  - Teach that pushing is the same as pooing
• Fluids, potentially tell her to drink
• Bladder
• Encourage woman to follow instincts, undirected pushing (unless woman has lack of sensation due to epidural)
  - Directed pushing= when women has epidural and doesnt know when to push.
  - You palpate for contractions and tell comen when to push
  - Some RMs do VE and put slight pressure on rectum to alert women to where to push.
• Observe wellbeing of mother & baby (Maternal HR and Temp, fetal HR)
  - Signs of a labour being ocstructed= mother becomes febrile
• Collaborate with midwifery and obstetric staff if no progress is observed

*if prolonged labour has been diagnosed and obstetric team has been involved

Question 21

What are indications for assisted/instrumental vaginal birth?

Answer 21

• Abnormal CTG= presumed fetal compromise: CTG is abnormal but not enough to have CS
• To shorten and reduce the effects of the second stage of labour on medical conditions (e.g. if mother has Epilepsy/Cardio conditions where specialist has provided a letter saying she should not be actively pushing for a certain time etc)
• Nulliparous women – lack of continuing progress for 3 hours (total of active and passive second-stage labour) with regional anaesthesia/epidural, or 2 hours without regional anaesthesia
• Multiparous women – lack of continuing progress for 2 hours (total of active and passive second-stage labour) with regional anaesthesia/epidural, or 1 hour without regional anaesthesia
• Maternal fatigue/exhaustion

Forceps can be used for the after-coming head of the breech and in situations where maternal effort is impossible or contraindicated

Question 22

What factors should be considered before the decision to expedite birth is made?

Answer 22

1. the risks of the procedure to mother and baby vs the risk of not carrying it out.

Assessments should include:
- the degree of urgency
- clinical findings on abdominal and vaginal examination
- choice of mode of birth (and whether to use forceps or ventouse if an instrumental birth is indicated)
- anticipated degree of difficulty, including the likelihood of success if instrumental birth is attempted
- location (birth suite or operating theatre?)
- the need for additional analgesia or anaesthesia?
- the woman’s preferences. Which instrument would she prefer? Would she prefer C/S?
- relevant staff present (paediatrics, consultant OB, multiple midwives)

Question 23

What are the prerequisites for an instrumental/operative birth?

Answer 23

• Informed consent
• Abdominal palpation
  - no head above pelvic brim (by practitioner doing the instrumental birth)
  - If any presing part is above pelvic brim, should fo for C/S
  - head <1/5th palpable per abdomen
• VE
  - vertex presentation
  cervix fully dilated
  - membranes ruptured
  - exact position determined so proper placement of instruments can occur
  - assess caput and molding
  - pelvic is deemed adequate. Irreducible moulding may indicate cephalo-pelvc disproportion.
• Appropriate analgesia
• Assistance for care of baby
  - midwife/paediatrician
• Bladder emptied- may need in/out catheter
• Cervix fully dilated, vertex presenting and ROM
• Determine position of baby is appropriate for type of birth so when pulled, it can floor the natural mechanics of birth

Question 24

What is the role of the midwife in an operaive/instrumental birth?

Answer 24

• Record the time at which the decision to expedite the birth is made
• Be aware of the indication and ensure the woman understands and consents
• Support woman & partner informed and thoroughly counselled
• Get assistance 2nd midwife
• Help prepare equipment/know what is required
• Assist Obstetric team
• Position the woman in lithotomy
• If the woman has epidural palpate contractions
• Document maternal observations, contractions, fetal wellbeing, and timeline of events of operative birth
• Page/call paediatrician to attend (depends on hospital policy) – Prepare for resuscitation
• Receive baby and manage baby condition
• Active third stage is recommended - Give oxytocin (= due to intervention= increased risk of PPH, instrument is a massive risk of PPH)

Question 25

What equipment is necessary for an instrumental/operative birth?

Answer 25

• Forceps / vacuum or vontuse
• Birth pack / gown / sterile gloves
• Episiotomy scissors / suture pack
• Catheter
• Pudendal needle / syringe 21g needle
  - Local anaesthetic – 1% lignocaine
  - Epidural top up (most likely PCEA)
• Oxytocic
• Lithotomy supports
• Neonatal resuscitation equip.

Question 26

What documentation is necessary for an instrumental/operative birth?

Answer 26

Each blade has a different curve- one for FH and one for maternal pelvis
- Note time each blade gets inserted
- Note when they are connected
- Note when contraction is and pull is applied (+ maternal contraction)
- Blades off when crowing occurs

Question 27

What are he three classifications of a operative/instrumental vaginal birth?

Answer 27

1. Outlet (use forceps or vacuum)
2. Low cavity
3. Mid-cavity
4. High cavity

Question 28

Explain what an outlet classification of an operative/instrumental vaginal birth is.

Answer 28

• Fetal scalp visible without separating the labia (naturally sitting there, an see presetnting part)
• Fetal skull has reached the pelvic floor
• The sagittal suture is in the anterio-posterior (AP) diameter or right or left occiput anterior or posterior position (rotation does not exceed 45º)
• Fetal head is at or on the perineum

Question 29

Explain what an low cavity classification of an operative/instrumental vaginal birth is.

Answer 29

• Leading point of the skull (not caput) is at or below +2 station and not on the pelvic floor.
• Two subdivisions
  - rotation of 45º or less from the occipito-anterior position
  - rotation of more than 45º including the occipito-posterior position

Question 30

Explain what an mid cavity classification of an operative/instrumental vaginal birth is.

Answer 30

• Fetal head is no more than 1/5th palpable per abdomen
• Leading point of the skull is above station + 2 cm but not above the ischial spines

Two subdivisions:
- rotation of 45º or less from the occipito-anterior position
- rotation of more than 45º including the occipito-posterior position

Question 31

Explain what an high cavity classification of an operative/instrumental vaginal birth is.

Answer 31

• Contrainidcation of operative vaginal birith
• Not included in the classification as operative vaginal delivery is not recommended in this situation where the head is 2/5th or more palpable abdominally and the presenting part is above the level of the ischial spines
• This should result in a Caesarean Birth

Question 32

What is a vaccum/ventous and how are they used?

Answer 32

Disposable cup (Kiwi)
- Single operator
- Attcked not on fontenell
- Squeeze to create pressure

Vacuum pump (rarely used)
- Soft silicone cup attached to an external source for suction
- Requires two operators

Question 33

What some contraindications of a vacuum or ventouse?

Answer 33

• A vacuum extractor should not be used at gestations of less than 34 weeks. Due to skin and skull integrity
• The safety of vacuum extraction between 34 weeks and 36 weeks of gestation is uncertain and therefore be used with caution because of the risk of subgaleal and intracranial haemorrhage
• Vacuum extractors are contraindicated with a face presentation
• Forceps and vacuum extractor deliveries before full dilatation of the cervix are contraindicated.
• Suspected fetal coagulopathy issues
• Inexperienced operator
• Unengaged head

Question 34

Explain the midwifery after care for a mother who had an instrumental/operative birth.

Answer 34

• Debrief woman & her partner/support person
• Care as per “1st hour post-birth”
• Anticipate complications such as:
  - increased bleeding – Postpartum haemorrhage > 500 mls blood loss)
  - Perineal tear
• Encourage skin-to-skin if baby does not require resuscitation
• The baby will require more frequent observation and may require admission to a special care nursery following major resuscitation

Question 35

How does the mother need to be prepared for n opertaive/instrumental birth?

Answer 35

Prep the mother
- clear explanation and informed consent
- appropriate analgesia is in place for mid cavity rotational deliveries. e.g. usually a regional block. Pudendal block may be appropriate, particularly int he content of urgent delivery.
- maternal bladder has been emptied. IDC should be removed or ballon deflated.

Question 36

How does staff need to be prepared for an operative/instrumental birth?

Answer 36

Preop of staff
- operator must have knowledge, experience and skill necessary.
- adequate facilities are available
- back up plan in place if failure to deliver. e.g. theatre stadd would be immediately available if CS is needed.
- anticipate complications that may arise
- personnel present that are trained in neonatal resus

Question 37

What are the 5 Ps that impact prolonged labour?

Answer 37

Passage
Passenger
Powers
Psyche
Problems

Question 38

Define the ‘passage’ impacts on prolonged labour and how we can over come its impact.

Answer 38

Passage - Pelvis & other soft tissue

The shape of the pelvis determines the diameters that the fetus needs to negotiate. i.e. gynaecoid, android, anthropoid or playtypelloid

There can also be resistance caused by the soft tissue including:
- pelvic floor and perineum
- the birth passage e.g. uterus, vagina, cervix

Midwife Actions:
Suggest positional changes, the goal is to change the relationship of the presenting part to the pelvis. - Upright positions, movement (rocking, squatting), and uneven positions (such as a standing position with one leg elevated or walking up stairs), can all help the fetus to move through the pelvis.

If soft tissue is not stretching increases blood flow by;
- getting in the bath
- applying a warm compress to the perineum can assist (this applies to second stage).
- position in a place where the peri is not as stretched. e.g. squatting very low compared to resting up right

Question 39

Define the ‘passenger’ impacts on prolonged labour and how we can over come its impact.

Answer 39

Passenger - Fetus (Baby)

The following can influence the progress of labour due to the presenting diameters:
position: Relationship of the denominator to six points of the pelvic brim. Vertex presentation - LOA LOP LOT, ROA, ROP or ROT
lie: Relationship of the long axis of the fetus to the long axis of the uterus: Longitudinal, transverse or oblique
attitude: the relationship of the baby’s head to its body e.g. flexed, deflexed, or extended
presenting part: The part of the fetus that lies at the pelvic brim. i.e. Presenting part is cephalic, breech
size of the baby: particularly the head

Midwife Actions:
Position changes will also impact this P, it is important to know what position the fetus is in, in order to make appropriate suggestions for the woman. For example, a posterior position can be assisted by encourage forward inversions or forward leaning positions. A great resource is the Spinning Babies website or additional Spinning Babies training.

If there is concern with the size of the fetal head, remember that the smallest diameter should pass through the pelvis first, which is either fully flexed (chin to chest), or fully extended (face presentation). If the fetal head is in an optimal position it is very unlikely that it will not fit through the pelvis. Again, some body work or position changes can influence this. Sometimes this can also be impacted by the uterine contractions (see below).

Question 40

Define the ‘powers’ impacts on prolonged labour and how we can overcome its impact.

Answer 40

During labour contractions usually occur with rhythmic, regular waves.
The contraction builds in strength, frequency and duration.
After each contraction, the uterus retracts and maintains some shortening
Primary uterine contractions occur in first stage.
Secondary maternal effort or pushing occurs in second stage. As well as contractions, the maternal effort help the baby to birth.

Midwife Actions:
Think about what is causing the contractions in the first place; oxytocin hormone and positive feedback loop from pressure of presenting part (PP) onto cervix initiating release of prostaglandins. Therefore thinking about ways to increase natural oxytocin production (increase sense of calm and safety, if a loving, trusted support person present encourage them to hug or hold the woman, soft lighting, familiar calming music, space to be alone and unobserved). And think about the two previous points regarding optimal fetal positioning.

Question 41

Define the ‘psyche’ impacts on prolonged labour and how we can overcome its impact.

Answer 41

Psyche - maternal reaction

The woman’s attitude towards labour can impact upon the progress of labour e.g. fear, anxiety, previous experience.
She can also be influenced by her culture and expectations.
Any fears and anxieties a woman may have can be allayed by good preparation e.g. antenatal care and antenatal education.
Midwife Actions:
Speak to the woman, is she holding a lot of fear toward labour and birth? What is she particularly afraid of? Can we work with her to alleviate this by coming back to her breath and taking it one contraction at a time?
Think about who else is in the room, what is their mental/emotional state? If she has a partner or support person who is very stressed this will likely impact on her psyche. Speak to this person and work with them to alleviate their fears, or even at times suggest they leave the room in order to take a break and come back in a calmer state.

Remind the woman and her supports that birth is normal and that her body is capable.

Question 42

Define the ‘problems’ impacts on prolonged labour and how we can overcome its impact.

Answer 42

Problems - disruption to normal process

Includes any physical, emotional or psychological stress that can cause disruption to the normal process.
Midwife Actions:
Midwives are constantly observing and analysing everything happening in a labour. From an abdominal palpation to simply watching how the woman moves and sounds during a contraction, everything is a clue as to how this woman’s labour is progressing, and can help to predict how it might continue to progress.

Anticipating problems is a major role of the midwife. If you enter a birth space and there are bright lights, many strangers, lots of activity, little privacy and the woman is lying in the bed, you are already anticipating that there are many factors which have the potential to interfere with the progress of this labour. It is the role of the midwife to make suggestions, to dim the lights, to ask anyone who does not need to be in the room to leave, to ensure the woman feels undisturbed and unobserved, and to teach the woman about upright and active labour positions.

All of the above midwife actions can apply to this P

Question 43

What are some risk factors of an operative instrumental birth? and what are some adcerse outcomes we should prepare for?

Answer 43

Risk factors
- Tearing
- Haemorrhage
- Bruising for baby
- Hypoxia (fetal hypoxia)

Possible outcomes to prepare for?
- Hypoxia
- PPH
- Fetal resus
- Shoulder dystocia (head is pulled the shoulder doesnt rotate and is stuck behind the symphisis)

Question 44

What are some prerequisites for consideration of an operative instrumental birth? and what are some adverse outcomes we should prepare for?

Answer 44

Informed consent
Fully dilated and effaced
OB present
Membrane ruptured
Indicated
Head down