Management of labour

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Management of labour fetal assessment

• King Khalid University Hospital
• Department of Obstetrics Gynecology
• Course 481

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Management of labour fetal assessment

• Objectives
• Managements of the stages of labour
• Pain relief in labour
• Fetal assessment (antenatal intra-partum)

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Management of labour

• Definition of labour
• Progressive cervical effacement and dilatation
  resulting from regular uterine contractions that
  occur at least every 5 minutes and last 30-60
  seconds
• Braxton Hicks contractions Not associated with
  cervical changes
• Lightening Descent of the fetal head into the
  pelvis
• There are 4 stages of labour

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First stage of labour

• Start from onset of true labour pain----full
  dilatation of cervix
• In primigravida------ 12 hour duration
• In multigravida-----6 hours duration
• Chiefly concerned with preparation of the birth
  canal as to facilitate expulsion of the fetus in
  the second stage
• It has 2 phases
• A latent phase up to 3 cm dilatation of cervix
• is
  variable up to 8 hours in primi
• 
  4 hours in multi
• An active phase from 3 cm to full dilatation of
  cervix
• Rate of dilatation 1 cm/hour in primigravida
• 1.5 cm/ hour
  in multigravida

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Dilatation of the cervix

• Dilatation usually measured by fingers but
  recorded in cm
• Dilatation relates with dilatation of internal os

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Effacement or taking up of cervix

• Muscle fibers of cervix are pulled upward and
  merges with the fibers of the lower uterine
  segment
• Cervix becomes thin during first stage
• In primi----- effacement precedes dilatation of
  the cervix
• In multi-----both occur simultaneously
• Effacement is determined by the length of the
  cervical canal in the vagina
• Effacement is expressed in terms of percentage

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Effacement or taking up of cervix
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First stage of labour

• Maternal system

• Fetal system

• -General condition remains unaffected
• -Pulse rate increases by 10-15 bpm during
  contraction with the settle down to its previous
  rate in between contractions
• -Systolic BP increase by 10 mm Hg during
  contraction
• - Temperature remains unaffected

• -As so long as the membranes are intact, usually
  there is no adverse effect on the fetus BUT
• However, during contraction there may be slowing
  of FHR by 10-20 bpm which soon returns to its
  normal as the intensity of contraction diminishes

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Management of labour

• Initial assessment
• History Onset, strength, frequency of
  contractions
• Leakage of fluid
• Vaginal bleeding
• Fetal movement
• Medications
• Last oral intake
• Review of past obstetric history, prenatal lab
  tests, gestational age, parity, size of previous
  infants, any antenatal complications

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Management of the first stage of labour

• -Informed consent on management of labour
  delivery
• Maternal position---lateral recumbent position
• Avoid supine
  hypotension
• Partogram
• -Iv fluids avoid oral intake
• -Maternal vital signs every 1-2 hours
• -Input-output monitoring
• -Analgesia
• -Fetal heart rate monitoring (CTG)
• -Uterine contractions monitoring
• -Vaginal examination for cervical dilatation
  poistion in
• active phase every 2 hours
• -Amniotic membranes status amniotic fluid
  colour

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Monitoring progress of labour (Partogram)
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Mechanics of labour

• The Power force generated by uterine
  contraction

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Second Stage of labour

• From full dilatation of cervix till delivery of
  the neonate
• The mother has a desire to bear down with each
  contraction
• Last from 30 minutes to 3 hours in primigravida
• 5-30 minutes in multigravida

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Mechanism of labour
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Management of the second stage of labour

• Molding (alteration of the relationship of the
  fetal cranial bones to each other as a result of
  compression forces by the bony pelvis)
• Caput (localized edematous swelling of the scalp
  caused by pressure of the cervix on the
  presenting portion of the fetal head)--- gives
• false impression of fetal descent

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Management of the second stage of labour

• Crowning ( when the largest diameter of the fetal
  head is encircled by the vulvar ring)
• -Vaginal examination every 30 minutes
• -Maternal position any comfortable position for
  bearing down
• -Bearing down---with each contraction
• -Delivery of the fetal head---manual perineal
  support
• -Fetal airway clearance
• -Umbilical cord clamping
• -Place the infant under warmer

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Episiotomy

• Incision in the perineum after crowning to aid
  delivery and avoid laceration of perinium
• Types Right mediolateral
• Left mediolateral
• Central

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PERINEAL LACERATION

• 4 TYPES
• -First degree laceration involving the vaginal
  epithelium or perineal skin
• -Second degree laceration extending into the
  sub-epithelial tissues of the vagina or perineum
  with or without involving the perineal body
• Third degree laceration involving anal
  sphincter
• Fourth degree laceration involving rectal mucosa

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Third stage of labour

• The interval between the delivery of the infant
  and complete delivery of the placenta membranes
• Duration is 5-30 minutes
• Signs of placental separation
• 1- Fresh blood show from vagina
• 2- The umbilical cord lengthens outside the
  vagina
• 3- The fundus of the uterus rises up
• 4- The uterus becomes firm globular
• The placenta should be examined to ensure that it
  is complete
• The blood loss should be estimated

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Forth stage of labour

• The hour immediately after the delivery
• Needs close observation of blood pressure,
• pulse rate, uterine blood loss
• Watch for post partum hemorrhage

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Pain relief in labour

• Goal effective pain relief to the mother that is
  safe for her the fetus with minimal side
  effects on the progress outcome of labour

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Pain relief in labour

• Non pharmacological method
• Back massage
• Acupuncture
• Hypnosis
• Breathing exercises

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Pain relief in labour

• Pharmacological methods
• Narcotic analgesics cross the placenta cause
  fetal respiratory depression (Nitrous oxide,
  pethidine)
• Epidural analgesia The most effective
• Contra indicated if-coagulo-pathy, infection at
  needle site, severe hypo-volemia
• Side effects Hypotension, headache, impaired
  ability to push, prolonged second stage (15
  Minutes)
• Pudendal block for S2-S4
• for the second
  stage of labour
• for instrumental
  delivery

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Fetal assessment

• Aim Ensure fetal wellbeing ( Identify patients
  at risk of fetal asphyxia)
• To prevent prenatal mortality morbidity

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Screening for high risk pregnancy

• History
• Age
• Social burden
• Smoking
• Past medical conditions e.g D.M, HTN
• Past Obstetric history

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FETAL AND NEONATAL COMPLICATIONS OF ANTEPARTUM
ASPHYXIA Stillbirth (Mortality) Metabolic
acidosis at birth Hypoxic renal
damage Necrotizing enterocolitis Intracranial
haemorrhage Seizures Cerebral palsy
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CONDITIONS ASSOCIATED WITH INCREASEDPERINATAL
MORBIDITY/MORTALITY

• Small for gestational age fetus
• Decreased fetal movement
• Postdates pregnancy (gt294 days)
• Pre-eclampsia/chronic hypertension
• Pre-pregnancy diabetes
• Insulin requiring gestational diabetes
• Preterm premature rupture of membranes
• Chronic (stable) abruption

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When to start fetal Assessment antenatally

• Risk assessed individually
• For D.M. fetal assessment should start from 32
  weeks onward if uncomplicated
• If complicated D.M. start at 24 weeks onward
• For Post date pregnancy start at 40 weeks
• For any patient with decrease fetal movement
  start immediately
• Fetal assessment is done once or twice weekly

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Antenatal Fetal Assessment

• Fetal movement counting
• Non stress test
• Contraction stress test
• Ultrasound fetal assessment
• Umbilical Doppler Velocimetry

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Fetal movement counting

• Cardiff technique
• Done in the morning, patient should
• calculate how long it takes to have 10 fetal
  movement
• 10 movements should be appreciated in 12 hours

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Fetal movement counting

• Sadovsky technique
• -For one hour after meal the woman should lie
  down and concentrate on fetal movement
• -4 movement should be felt in one hour
• -If not , she should count for another hour
• -If after 2 hours four movements are not felt,
  she should have fetal monitoring

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Non stress test

• Done using the cardiotocometry with the patient
  in left lateral position
• Record for 20 minutes

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Non stress test

• The base line 120-160 beats/minute
• Reactive
• At least two accelerations from base line of 15
  bpm for at least 15 sec within 20 minutes
• Non reactive
• No acceleration after 20 minutes- proceed for
  another 20 minutes

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Non stress test

• If non reactive in 40 minutes---proceed for
  contraction stress test or biophysical profile
• The positive predictive value of NST to predict
  fetal acidosis at birth is 44

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NST
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NST
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Contraction stress test

• Fetal response to induced stress of uterine
  contraction and relative placental insufficiency
• Should not be used in patients at risk of preterm
  labor or placenta previa
• Should be proceeded by NST

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Contraction stress test

• Contraction is initiated by nipple stimulation or
  by oxytocin I.V.
• The objective is 3 contractions in 10 minutes
• If late deceleration occur-----positive CST

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Interpretation of CTG

• Normal Baseline FHR 110160 bpm
• Moderate bradycardia 100109 bpm
• Moderate tachycardia 161180 bpm
• Abnormal bradycardia lt 100 bpm
• Abnormal tachycardia gt 180 bpm

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CTG
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Acceleration
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Deceleration

• EARLY Head compression
• LATE U-P Insufficiency
• VARIABLE Cord compression
• Primary CNS
  dysfunction

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Early deceleration
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Late deceleration
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Variable Deceleration
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Reduced Variability
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TachycardiaHypoxia ChorioamnionitisMate
rnal fever B-Mimetic drugsFetal
anaemia,sepsis,ht failure,arrhythmias
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Ultrasound fetal assessment

• Assessment of growth
• Biophysical profile (BPP)

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Assessment of fetal growth by ultrasound

• Biometry
• Biparietal diameter (BPD)
• Abdominal Circumference (AC)
• Femur Length (FL)
• Head Circumference (HC)
• Amniotic fluid
• Placental localization

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Assessment of fetal growth by ultrasound

• BPD

• AC
• FL

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Growth chart
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Placental localization
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Amniotic fluid
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Fetal Biophysical profile
Abnormal (score 0) Normal (score2) Biophysical Variable
Absent FBM or no episode gt30 s in 30 min 1 episode FBM of at least 30 s duration in 30 min Fetal breathing movements
2 or fewer body/limb movements in 30 min 3 discrete body/limb movements in 30 min Fetal movements
Either slow extension with return to partial flexion or movement of limb in full extension Absent fetal movement 1 episode of active extension with return to flexion of fetal limb(s) or trunk. Opening and closing of the hand considered normal tone Fetal tone
Either no AF pockets or a pocketlt2 cm in 2 perpendicular planes 1 pocket of AF that measures at least 2 cm in 2 perpendicular planes Amniotic fluid volume
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Management Interpretation Test Score Result
Intervention for obstetric and maternal factors Risk of fetal asphyxia extremely rare 10 of 10 8 of 10 (normal fluid) 8 of 8 (NST not done)
Determine that there is functioning renal tissue and intact membranes. If so, delivery of the term fetus is indicated. In the preterm fetus less than 34 weeks, intensive surveillance may be preferred to maximize fetal maturity. Probable chronic fetal compromise 8 of 10 (abnormal fluid)
Repeat test within 24 hr Equivocal test, possible fetal asphyxia 6 of 10 (normal fluid)
Delivery of the term fetus. In the preterm fetus less than 34 weeks, intensive surveillance may be preferred to maximize fetal maturity Probable fetal asphyxia 6 of 10 (abnormal fluid)
Deliver for fetal indications High probability of fetal asphyxia 4 of 10
Deliver for fetal indications Fetal asphyxia almost certain 2 of 10
Deliver for fetal indications Fetal asphyxia certain 0 of 10
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Umbilical Doppler Velocimetry

• Indication
• IUGR
• PET
• D.M.
• Any high risk pregnancy
• Use a free loop of umbilical cord to measure
  blood flow in it

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Umbilical cord
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Umbilical Artery Doppler
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Umbilical Artery Doppler
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Umbilical cord doppler
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Reverse flow in umbilical artery
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Management of Abnormal Doppler

• Depends on
• Fetal maturity
• Gestational age
• Obstetric history

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Management of Doppler results

• Reverse flow or absent end diastolic flow---
  Immediate delivery
• High resistance index---- repeat in few days or
  delivery
• Normal flow---- repeat in 2 week if indicated

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Assessment for Chromosomal Abnormality

• Ultrasound ----- nuchal translucency (N.T)
• Biochemical markers---
• 1st trimester---PAPPAßHCG
• Amniocentesis
• Chorionic villus sampling

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Assessment for Chromosomal Abnormality

• General Facts
• The general incidence of Down is 11000
• The risk by maternal age
• at the age of 35 -----------1365
• at the age of 40-----------1109
• at the age of 45-----------132
• Risk of recurrence is 1 ( 0.75 higher than
  maternal age related risk
• In case of parental aneuploidy---- 30 risk of
  Trisomy in offspring

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Methods available for screening for chromosomal
abnormality

• Maternal age
• Biochemical---1st trimester---PAPPAß HCG,
• 2nd trimester---Triple
  quadruple Test
• Ultrasound NT Other markers
• Fetal DNA

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Ultrasound screening for chromosomal abnormality

• Nuchal translucency?(N.T)
• Skin fold thickness behind the fetal cervical
  spine
• Timing 11-13 6days weeks of pregnancy
• 75-80 of trisomy 21
• 5-10 normal karyotype ( but could be associated
  with cardiac defects, diaphragmatic hernia,
  Exomphalos)

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Nuchal translucency
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Amniocentesis

• Obtaining a sample of amniotic fluid surrounding
  the fetus during pregnancy.
• Indications
• Diagnostic (at 11- 20 weeks)
• Therapeutic( at any time)

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Indications of amniocentesis

• Genetic amniocentesis
• Chromosomal analysis (Down syndrome)
• Spina bifida (Alpha fetoprotein)
• Inherited diseases (muscular dystrophy)
• Bilirubin level in isoimmunization
• Fetal lung maturation (L/S ratio)
• Therapeutic amniocentesis
• Reduce maternal stress in polyhydramnios
• Mainly in twin-twin transfusion or if abnormality
  associated

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Amniocentesis
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Chorionic villus sampling

• Sampling is done to the cyto-trophoblasts
• done between 10-14 weeks of pregnancy

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CVS
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Recommended books

• Essential of obstetrics gynecology (p 91- 119)
• Current diagnosis treatment Obstetrics
  gynecology (p 203-211 p249-258 p 441-460)