Tutorial - Normal & abnormal labour

Obstetric History Age Gravidity Parity- (Preg>24 wks)+(Preg< 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

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

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,oblique -presentation:presenting part of fetus occupying the lower pole of uterus i.e ceph,breech -Position:Relation of denominator(occiput/sacrum) of presenting part to the quadrants of pelvis i.e ROA,LSP -Engagement:Widest diameter of head below the pelvic brim. No. of 5th head palpable above the pelvic brim -Amniotic fluid AND FETAL HEART

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

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).

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

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)

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) Ion after 7 min

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.

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

What options would you consider for pain relief in this patient What options would you consider for pain relief in this patient? Consider the advantages and disadvantages of each. Entonox(N2O+O2) 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

Scenario - cont Mrs M is re examined 4 hours later. Her BP 135/90, Pulse 85 bpm, Temp 37C, Urine dipstick – ketones. FH~138 bpm. VE= 5cm dilated, effaced. Cephalic presentation with station -2. The position is occipito posterior (OP). Membranes felt intact.

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

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 3:10. Liquor clear.

Causes of prologed labour Fetal: Malposition macrosomia malformation(hydrocephaly,anencephaly) Maternal:contracted pelvis(CPD) pelvic shape (android/anthropoid) pelvic disease/injury Combination: -malpresentation i.e brow,face,shoulder -maternal abnormality -pelvic tumour -cx stenosis -uterine inertia

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

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.

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->15bpm>15sec - Decelaration->15bpm >15sec; 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)

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

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

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 >500ml. - 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

Postpartum hemorrhage management O2 & IV access 2 large bore cannulae Bloods (FBC,cross match 4 u, clotting & U&E’s) IV fluids Regular Observations Repeat syntometrine Think 4 T’s(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 DON’T FORGET - antibiotics & Thromboprophylaxis

Scenario 2. Mrs P, G3P1 (previously normal vaginal delivery ) presents at T+12 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