Tutorial - Normal & abnormal labour

1
Tutorial - Normal abnormal labour
2
Obstetric History

• Age
• Gravidity
• Parity- (Preggt24 wks)(Preglt 24wks)
• LMP menst.cycle conceived on pill EDD
• Prev. preg- Gestation mode of delivery ,
  - length of labour
  complication - third stage
  complications - postnatal
  problems
• Medical,surgical,drug family history

3
Examination

• Consent, explanation beware of supine
  hypotension
• General examination
• -Colour
• -Hand,eyes mouth
• -Presence of oedema (where)
• -BP Urine
• -CVS Resp. examination

4
Abdominal Examination

• Inspection- abdominal scars, striae
  gravidarum,linea nigra oedema
• Palpation- Symphysio-fundal height
• -lie relationship of long. axis of fetus to
  long.axis of uterus i.e longitudinal,transverse,ob
  lique
• -presentationpresenting part of fetus occupying
  the lower pole of uterus i.e ceph,breech
• -PositionRelation of denominator(occiput/sacrum)
  of presenting part to the quadrants of pelvis i.e
  ROA,LSP
• -EngagementWidest diameter of head below the
  pelvic brim. No. of 5th head palpable above the
  pelvic brim
• -Amniotic fluid AND FETAL HEART

5
Vaginal examination

• Vulva
• Vagina
• Cervix-dilatation ,effacement, position
  consistency
• Presenting part i.e Vertex
• Station-cm above the ischial spine
• Caput-swelling on the scalp superficial to
  periosteum of cranium ,as a result of venous
  congestion, on the part of head most in advance
• Moulding- Overriding of the bones of skull
• Membranes Liquor

6
Scenario1

• Mrs M, is G1P0. She presents at 38 weeks
  gestation with a five hour history of regular
  painful contractions. The contractions are
  moderate in strength, every 5 minutes lasting
  about 20 minutes. She has had an uncomplicated
  antenatal course. On vaginal examination (VE),
  the cervix is 2cm dilated, soft in consistency,
  midposition and partially effaced. The presenting
  part is cephalic, and is at station -2 (2cm above
  the ischial spines).

7
Issues

• What is labour?
• -Regular uterine contractions
• -Rupture of membranes
• -Show
• How is the diagnosis of labour confirmed?
• - Regular uterine contraction and /or decent of
  presenting part
• - Cervical dilatation shortening

8
stages of labour

• First stage-Onset of regular contraction to full
  dilatation.
• Second stage- Full dilatation of cervix until
  delivery of baby. (progressive decent of
  vertex)
• Mechanism of labour Decent, flexion,internal
  rotation, restitution external rotation
  (demo)

9
Stages of labour

• Third stage-delivery of baby until delivery of
  placenta.
• Syntometrine IM
• 5U syntocinon( regular cont. in 2 min), 500µg
  ergometrine(sustained cont.in 7 min)
• Signs of placental separation
• -Firming rising of the fundus
• -Lengthening of the cord
• -Gush of blood at introitus
• Delivery of placenta(active management)

10
Scenario - cont

• She is allowed to mobilise but is transferred
  back to the Labour Ward six hours later as she is
  requiring some pain relief. She is examined. Her
  pulse is 100bpm, BP 135/85, Temp 37C. Urine
  dipstick reveals ketones. Fetal heart rate 130
  bpm. Her contractions are 3 every 10 minutes. VE
  Cervix 3cm dilated, effaced, the head is at
  station -2 (2cm above the ischial spines). A
  partogram is commenced.

11

• What is a partogram ?
• -Graphical record of course of labour
• -Maternal P,BP,urine,temp,strength of
  contractions, dilatation of cervix,decent of
  head,colour of liquor,drugs epidural
• -Fetal heart rate
• How would you monitor maternal wellbeing?
• What options are there for monitoring fetal
  wellbeing in labour? Which option would be the
  choice, for this patient at this time?
• - Intermittent (i) Pinard (ii) doppler USS
• - Continuous (i) abd. pulsed USS (ii) Fetal
  scalp electrode
• - FBS
• - Colour of liquor

12

• What options would you consider for pain relief
  in this patient? Consider the advantages and
  disadvantages of each.
• Entonox(N2OO2)
• Opiates- vomitting, resp.depression
• Epidural-hypotension
• -respiratory paralysis(intrathecal
  injection) - neurological
  (weakness/paralysis of legs)
• Others TENS,soak in bath, birthing balls,
  slings, aromatherapy, hynotherapy
• SUPPORTIVE BIRTHING PARTNER

13
Scenario - cont

• Mrs M is re examined 4 hours later. Her BP
  135/90, Pulse 85 bpm, Temp 37C, Urine dipstick
  ketones. FH138 bpm. VE 5cm dilated, effaced.
  Cephalic presentation with station -2. The
  position is occipito posterior (OP). Membranes
  felt intact.

14

• How is progress in labour assessed?
• (i) Frequency, duration strength of
  contraction
• (ii) Dilatation effacement of cervix
• (iii) Decent of presenting part in relation to
  IS
• What do you think are the likely factors
  influencing the apparent lack of progress in Mrs
  M?
• -dehydration, fetal position, anxiety,?
  contractions
• What options might you consider to correct
  failure to progress in the first stage of labour
  in Mrs M?
• - IV fluids, ARM pain relief

15
Scenario - cont

• Mrs M is reassessed 4 hours later. She is 7 cm
  dilated, position OP with no caput or moulding of
  the fetal head. The station is now -1 (1cm above
  the ischial spines). She requests further
  analgesia.
• Her observations at this stage
• BP 145/90, Pulse 90bpm, Urine NAD, FHR 140
  bpm. Contractions 310. Liquor clear.

16
Causes of prologed labour

• Fetal Malposition
• macrosomia
• malformation(hydrocephaly,anencephaly
  )
• Maternalcontracted pelvis(CPD)
• pelvic shape
  (android/anthropoid)
• pelvic disease/injury
• Combination
• -malpresentation i.e brow,face,shoulder
• -maternal abnormality -pelvic tumour
• -cx
  stenosis
• -uterine
  inertia

17

• what factors may be influencing her lack of
  progress?
• -Contractions
• -Malposition
• What are your options of management at this
  stage?
• - Syntocinon infusion
• - Epidural

18
Scenario - cont

• She is commenced on syntocinon IV. She also
  has an epidural sited for pain relief. When she
  is reassessed (4 hours later), she is fully
  dilated (10 cm), the position is occiptio
  anterior (OA), there is no significant moulding
  but some caput (caput 1). She commences active
  pushing after an hour (allowing passive descent
  of the presenting part). Mrs M pushes for 1hr and
  45 minutes and the midwife is concerned that the
  CTG shows some decelerations with her
  contractions. Mrs M is also now exhausted and
  requests that the delivery is expedited.

19

• a) What is a CTG ? How you would describe the
  important features of a CTG?
• Cardiotocograph
• Fetal heart trace
• Uterine contraction ?strength
• FH
• - Baseline Rate-110-160bpm
• - Baseline variability ( FH controlled by
  auto. Sys,adrenal
• - Acceleration-gt15bpmgt15sec
• - Decelaration-gt15bpm gt15sec Early,variable
  or late
• Which features would be reassuring of fetal
  wellbeing?
• normal heart rate ,variability,
  acceleration when?
• What features would correlate with evidence of
  fetal hypoxia
• Reduced variability deceleration (
  variable, late)

20

• What are operative delivery options?
• Ventouse, forceps casarean section
• What are the main indications for an operative
  /assisted delivery?
• Failure to progress in 2nd stage
• Suspected fetal compromise(distress)
• What must be fulfilled/ considered prior to
  performing an instrumental delivery?
• Consent
• Adequate pain relief
• Bladder empty
• Abd-adequate contractions, head 0/5
• Cx- fully dilated
• Station- 0 or below
• Position of head defined
• Membranes ruptured

21

• What are the advantages and disadvantages of each
  type of operative delivery? What are the
  complications of each type of operative delivery
• Forceps
• Adv used for vertex or face presentation
• Quick delivery
• Effective with poor maternal effort
• Disadv complications Perineal tears, cx
  tears
• Facial
  palsy,Intracranial hemorrhage
• Ventouse
• Adv Minimal perineal trauma
• Disadv complication used only for vertex
• Requires
  good maternal effort
• Takes too
  long for urgent cases
• fetal scalp
  trauma
• 
  Cephalohematoma

22

• She has a ventouse delivery and a live male
  infant is delivered in good condition (apgars 9
  at one minute and 9 at 5 minutes), with the aid
  of an episiotomy. While awaiting the delivery of
  the placenta and membranes, you notice that she
  starts to bleed profusely. She has primary post
  partum haemorrhage
• What is post partum haemorrhage
• -Excessive bleeding from genital tract after
  birth of the child.
• - Blood loss gt500ml.
• - Primary- upto 24 hr following delivery
• - Secondary- 24hrs to 6wks following delivery
• What risk factors does she have for PPH
• Prolonged labour
• Uterine inertia( incoordinate uterine
  contraction)
• Perineal trauma

23
Postpartum hemorrhage management

• O2 IV access 2 large bore cannulae
• Bloods (FBC,cross match 4 u, clotting UEs)
• IV fluids
• Regular Observations
• Repeat syntometrine
• Think 4 Ts(tone,trauma,tissue,thrombin)
• ? Placenta complete
• Oxyctocin infusion
• Prostaglandins- carboprost,misoprostol
• Blood products
• Surgical- MROP,B lynch, Rusch balloon,uterine
  artery embolization, ligation of arteries,
  hysterectomy
• DONT FORGET - antibiotics Thromboprophylaxis

24

• Scenario 2. Mrs P, G3P1 (previously normal
  vaginal delivery ) presents at T12 in an
  uncomplicated pregnancy. She is fed up.
• What are the fetal and maternal risks of
  prolonged pregnancy
• - Fetal distress Fetal death
• - IOL with its risk
• - Inefficient labour
• What does formal induction of labour requires?
• - Cervical ripening- membrane sweep,
  prostaglandin E2
• - Amniotomy
• - Augmentation of contractions- oxytocin infusion
• Risks/side effects of the drugs.
• - uterine hyperstimulation fetal distress
• Management of woman declining IOL?
• - Twice weekly doppler liquor volume
• - CTG monitoring