Women's Health : Problems in Labour Flashcards by Duha Mahmood

First Stage Delay in Labour Definition

cervical dilatation of less than 2cm in 4 hours.

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Nulliparous Second Stage Delay

> 2 hour duration of second stage of labour.

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Multiparous Second Stage Delay

> 1 hour duration of second stage of labour.

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Actively Managed (oxytocin injection) Third Stage Delay

> 30 minutes without delivery of placenta

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Physiological Third Stage Delay

> 60 minutes without delivery of placenta.

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Three Ps’ of Delayed Labour

Power, Passenger, Passage

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What is “Power” in relation to delayed labour?

Uterine contractions - deviation from normal (i.e. 3-5 contractions of 30 seconds duration per 10 minutes).

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What is considered a deviation from normal uterine contractions?

3-5 contractions/30 sec/10 min

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What are important factors related to the ‘Passenger’ in labor?

Size, presentation, position of the foetus

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How is size of foetus monitored?

head diameter, shoulder diameter etc

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How is foetal presentation monitored?

Cephalic:vertex, brow, face vs breech

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How is foetal position monitored?

occipito-anterior (normal), occipito-posterior, occipito-transverse

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What is the normal fetal position?

Occipito-anterior

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What is “Passage” in relation to delayed labour?

Cephalopelvic disproporion

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How are delays in labour investigated?

● Diagnosed by regular foetal monitoring in labour. ● Aberrant foetal position can be diagnosed on vaginal examination.

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How is aberrant foetal position diagnosed?

Vaginal examination

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What is the first stage in the management of delayed labour?

Membranes intact - consider amniotomy. ○ Consider oxytocin infusion - requires continuous foetal monitoring (CTG).

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What is the second stage in the management of delayed labour?

Consider oxytocin infusion. ○ Offer expedited delivery i.e. instrumental delivery or caesarean section if vaginal delivery is improbable.

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What is the third stage in the management of delayed labour?

Controlled cord traction, IM oxytocin / ergometrine.

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What to consider if membranes are intact in the first stage?

Amniotomy

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What is shoulder dystocia?

(RCOG) Vaginal cephalic delivery that requires additional obstetric manoeuvres to deliver the foetus after the head has delivered and gentle traction has failed.

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What causes shoulder dystocia?

Discrepancy between size of foetal shoulders and maternal pelvic inlet leads to impaction: ○ Anterior shoulder behind maternal pubic symphysis (commonest). ○ Posterior shoulder behind maternal sacral promontory (more rare). ● Delay in delivery can result in hypoxic ischaemic encephalopathy (HIE) due to compression of the umbilical cord against the maternal pelvis. ● Another notable complication is brachial plexus injury resulting in Erb’s palsy (C5-6) or less commonly Klumpke’s palsy (C8-T1).

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Where does the anterior shoulder get impacted?

Behind maternal pubic symphysis (commonest)

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Where does the posterior shoulder get impacted?

Behind maternal sacral promontory (more rare)

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What is Erb’s palsy?

C5-6 brachial plexus injury

Risk Factors for Shoulder Dystocia

1. Previous shoulder dystocia 2. Macrosomia (foetal weight > 4500g) 3. Maternal diabetes mellitus 4. High maternal BMI 5. Induction of labour 6. Prolonged labour.

Signs of Shoulder Dystocia (which can lead to diagnosis)

○ Difficulty delivering face / chin ○ Turtle-neck sign (head retracts into birth canal) ○ Failure of restitution ○ Failure of shoulder descent

When can a definitive diagnosis of Shoulder Dystocia be made?

Definitive diagnosis is made when normal axial traction cannot deliver the baby’s body after the head has been delivered.

First Line Management for Shoulder Dystocia

1. McRoberts’ manoeuvre (mother hyperflexes hips, bringing her thighs to her abdomen) plus 2. Suprabupic pressure (to disimpact anterior shoulder) plus 3. Discourage pushing (to prevent further impaction.

Second Line Management for Shoulder Dystocia

1. Deliver posterior arm 2. Attempt internal rotation manoeuvres. 3. If above fails - all fours position and repeat manoeuvres

Third Line Management (rare) for Shoulder Dystocia

○ Cleidotomy ○ Symphysiotomy ○ Zavanelli manoeuvre.

What does suprapubic pressure aim to do?

Disimpact anterior shoulder.

Why should pushing be discouraged during shoulder dystocia?

Prevent further impaction.

What to do if first line options fail?

All fours position, repeat manoeuvres

What is assisted vaginal birth (by forceps or vacuum) also known as?

Instrumental Delivery

How common are instrumental deliveries in the UK?

10-15% of deliveries ; ; ⅓ of first deliveries for nulliparous women.

What are the 2 types of instrumental delivery?

Forceps and Vacuum

What is typical for forceps delivery?

Interlocking blades fit around the baby's head and guide it down the birth canal, typically alongside medio-lateral episiotomy.

What is vacuum delivery?

Suction cup adheres to the baby's head to assist with delivery

What is an outlet classification in assisted vaginal birth?

The fetal scalp is visible, the skull has reached the perineum, and the required rotation is less than 45 degrees.

What is a low cavity classification in assisted vaginal birth?

The fetal station is at +2 cm, but the skull has not yet reached the perineum.

What is a mid cavity classification in assisted vaginal birth?

The fetal head is less than 1/5th palpable abdominally, and the station is between +1 cm and 0 cm.

What type of instruments are used for non-rotational assisted deliveries?

Neville Barnes forceps (low cavity) : Simpson’s forceps Wrigley forceps (outlet, also used in caesarean sections) Anterior cup

What type of instruments are used for rotational assisted deliveries?

Kjelland’s forceps ; Posterior cup (e.g., Kiwi)

When are rotational instruments used in assisted vaginal deliveries?

Rotational instruments are used when the fetal position is occipito-posterior or occipito-transverse.

When are Wrigley forceps typically used?

Wrigley forceps are used for outlet deliveries and during caesarean sections

What classifies an outlet-assisted vaginal birth?

Visible scalp, <45° rotation.

What classifies a low cavity-assisted vaginal birth?

Station +2cm, not perineum.

What classifies a mid cavity-assisted vaginal birth?

Station +1 to 0cm.

When are rotational instruments used in assisted deliveries?

Occipito-posterior/transverse position.

Non-rotational forceps examples

Neville Barnes, Simpson’s, Wrigley

Rotational forceps example

Kjelland’s

Use of Wrigley forceps

Outlet, caesarean sections

Indications for Instrumental Delivery

1. Suspected foetal compromise 2. Delayed second stage 3. Maternal exhaustion / distress 4. Medical contraindication to Valsalva

Risks of Forceps

1. Vaginal trauma 2. Postpartum haemorrhage 3. Obstetric anal sphincter injury (3rd degree tear) 4. Facial / scalp laceration

Risks of Vacuum

1. Vaginal trauma 2. Postpartum haemorrhage 3. OASI 4. Facial / scalp laceration 5. Retinal haemorrhage 6. Cephalohematoma 7. Subgaleal haemorrhage

How are obstectric injuries classified?

Degrees of Tears

1st Degree Tear

Skin only

2nd Degree Tear

Perineal muscle

3rd Degree Tear Types

Type A <50% external AS, Type B >50% external AS, Type C internal & external AS

4th Degree Tear

Anorectal epithelium

Caesarean Sections are categegorised by....

classifications of urgency

Category 1 Caesarean

within 30 minutes of decision - immediate threat to life of woman or foetus e.g. pathological CTG, placental abruption.

Category 2 Caesarean

within 75 minutes of decision - maternal / foetal compromise, not immediately life-threatening but birth must be expedited.

Category 3 Caesarean

no compromise, early birth indicated.

Category 4 Caesarean

elective

Indications for a Caesarean Section

-Breech presentation (resistant to external cephalic version).Placenta praevia - Placenta accreta spectrum - Maternal choice - Emergency: foetal bradycardia, abruption, uterine rupture, cord prolapse, foetal pH < 7.20, failure of instrumental delivery.