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9. Female Genito-urinary System > 9.11 Abnormal Labour > Flashcards

9.11 Abnormal Labour Flashcards

1
Q

Maternal & fetal risk factors for malpresentation or poor progress in labour

A

Maternal
- Abnormalities of the pelvic size or shape
- Pelvic tumours
- Placenta praevia
- Abnormalities of the uterus
- Pendulous abdomen
- Ineffective contractions

Fetal
- Very large baby
- Multiple pregnancy
- Congenital anomalies (tumours)
- Polyhydramnios (⬆️ amniotic fluid)
- Preterm labour
- Intra-uterine death

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2
Q

Etiology of prolonged first stage
Poor progress in labour

A
  • Malpresentations (especially occipito-posterior)
  • Cephalo-pelvic disproportion (CPD)
  • Excessive sedation
  • Overextension of the uterus (polyhydramnios, multiple pregnancy, very large fetus)
  • Pelvic tumours (e.g. large myomas)
  • Ineffective contractions (contractions in the wrong way)
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3
Q

Etiology of prolonged second stage
Poor progress in second stage (dilations)

A
  • CPD
  • Ineffective contractions
  • Malpresentation
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4
Q

Define occiput posterior position

A

A vertex presentation with the occiput in one of the posterior quadrants of the pelvis

Vaginal examination
- Posterior fontanelle is in the posterior half of the pelvis
- Anterior fontanelle is in the anterior half of the pelvis
- Occipital bone is posterior

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5
Q

What is the normal position of presentation of a baby at labour?

A

Usually spine in on the left side
- “left occiput-anterior”

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6
Q

Cardinal stages of labour

A
  1. Engagement
  2. Decent
  3. Flexion
  4. Internal rotation
  5. Extension
  6. External rotation
  7. Expulsion
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7
Q

Define face presentation

A
  • Longitudinal lie
  • head presenting
  • attitude of complete extension
  • presenting part is the face between the orbital ridges
  • denominator is the chin (look at the chin)
  • not ideal for vaginal birth but can
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8
Q

Define brow presentation

A
  • Longitudinal lie
  • head presenting
  • attitude of partial extension
  • presenting part is the area between the orbital ridges and the bregma
  • The anterior fontanelle and orbital ridges can be palpated but not the mouth or chin
  • cannot deliver (should be full flexion / full extension)
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9
Q

Define compound presentation

A
  • When a limb engages with the baby’s head
  • spontaneous correction is common
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10
Q

Define abnormal labour in the first stage of labour

A
  • There is poor progress if the cervix dilates at a rate of <1 cm/hour in the active phase (crosses the partogram alert line)
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11
Q

Define abnormal labour in the second stage of labour

A
  • If delivery has not occurred after 45 minutes of pushing in a nullipara, or after 30 minutes in a multipara

Second stage - Woman starts to push

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12
Q

The rule of the 4 “P’s”
Patient
Powers
Passage
Passenger

A

Patient (mother)
- Psychological condition
- Support from partner
- Pain (morphine, epidural, gasses)
- Hydration
- Bladder empty?
- Position (best position is the position that the mother picks)

Power
- Uterine contractions (at least 3-4 per 10 minutes, lasting about a minute).
- Oxitosin (very dangerous, so use very carefully)

Passage
- Cervix (dilation, effacement)
- Membranes
- Application (how well the baby {head or buttocks} is pressing on the cervix)
- Presenting part
- Pelvic size and shape

Passenger (baby)
- Fetal size
- Fetal lie
- Fetal presentation and position
- Level of presenting part

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13
Q

Define and discuss RF for umbilical cord presentation and prolapse

A

EMERGENCY

  • Cord presentation is when the presenting part is the umbilical cord, but with the membranes still intact.

In cord prolapse, the umbilical cord comes out of the cervix in front of the fetal presenting part, with the membranes ruptured. Frequently, the cord may appear at the vulva.

Risk factors:
- Preterm rupture of the membranes
- Polyhydramnios
- Multiple pregnancy
- Compound presentation
- Breech presentation
- High head (big baby)
- Malpresentations

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14
Q

Define and describe associating factors of shoulder dystocia

A

EMERGENCY

  • In shoulder dystocia delivery of the baby’s head is not followed by delivery of the rest of the body because one or occasional both shoulders are stuck above the pelvic brim.
  • More common with babies of diabetic mothers and other large babies but is unpredictable.

Risk factors:
- Maternal obesity
- Diabetes in pregnancy
- Large baby

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15
Q

Causes of antepartum hemorrhage

A

Bleeding during pregnancy
- Abruptio placentae
- Placenta praevia
- Local lesions
- APH of unknown cause
- Dilatational bleeding (labour)

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16
Q

Grades of placenta praevia

A

Major or minor P Praevia
- Major- covers the os
- Minor- within 2cm of the os (inferior placental edge located at 1–20 mm from the internal cervical os) Also called ‘low lying’

17
Q

Signs and symptoms of placenta praevia

A
  • Painless bleed (mother is bleeding, not fetus)
  • Bright red blood (maternal blood)
  • No fetal distress initially (fetus not bleeding)
  • Uterus normal size for expected gestation (no blood clots in the uterus)
  • Fetus can have abnormal lie (breech, transverse or oblique) or high presenting part due to placenta in lower segment
  • Soft, non-tender uterus
18
Q

Causes and RF of abruptio placentae

A

Placenta ruptures
- Pre-eclampsia (hypertension)
- Prelabour ROM
- Chorioamnionitis
- Blunt abdominal trauma
- Cigarette smoking
- Cocaine/methamphetamine use
- Previous abruptio

19
Q

Signs & symptoms of abruptio placentae

A
  • Can have risk factors (trauma, pre-eclampsia etc)
  • Painful bleed
  • Dark red blood with clots (fetal bleeding as well) {dark blood because of haemoglobin}
  • Fetal distress, absent movement or IUD
  • Hard, tender uterus (filled with blood clots and contracting)
  • Uterus larger than expected (due to blood clots)
20
Q

Define antepartum haemorrhage of unknown origin
After excluding all other causes

A
  • No Abruptio clinically
  • No placenta praevia on ultrasound
  • Normal speculum exam (no cervicitis, cervical carcinoma, tears or ulcers)
  • Not in labour

Most likely a small, undetectable abruptio
- may progress to a full abruptio within next few hours

21
Q

Post-partum haemorrhage
Define

A

Definition
Traditional definition:
- Blood loss of ≥ 500 ml after a vaginal delivery
-Blood loss of ≥ 1000 ml after a caesarean delivery

Some have changed definitions:
- ACOG: Cumulative blood loss of ≥ 1000 ml or blood loss associated with signs and symptoms of hypovolaemia (hypotension and
tachycardia), irrespective of the route of delivery
- Bleeding associated with a drop of haematocrit ≥10% or necessitating blood transfusion

22
Q

Post-partum haemorrhage
Classification

A

Primary
- if within first 24 hours after the delivery

Secondary
- when it occurs between 24 hours and 42 days after delivery
- Most commonly due to:
= Retained products of conception (usually with infection; endometritis)
= Haematoma in the vagina or perineum draining spontaneously
- Trophoblastic neoplasia

23
Q

Post-partum haemorrhage
Consequences

A
  • Severe anaemia requiring blood transfusion
  • Disseminated intravascular coagulation
  • Hysterectomy
  • Multiorgan system failure
  • Death
24
Q

Post-partum haemorrhage
Causes NB

A

Tone (uterine atony)
Trauma (lacerations or uterine rupture)
Tissue (retained placenta or clots)
Thrombin (clotting-factor deficiency)

*PPH is a description of an event and not a
diagnosis in itself… FIND THE CAUSE

1. Uterine causes
- uterine atony
- contracted uterus (cervical laceration, uterine rupture)
- uterine inversion

2. Non-uterine causes
- lower genital tract lacerations
- coagulopathy
- haemotoma

25
Q

Uterine atony (Tone)
General
Risk factors

A
  • Most likely to occur shortly after delivery
  • Normal uterus contracts after delivery – can be felt just below the umbilicus
  • If the uterus relaxes again uterine atony occurs leading to profuse bleeding at the site of placental separation

Risk factors
- A full bladder
- Blood clots or retained products of conception (pieces of placenta and membranes), which prevent effective contraction of the myometrium
- Overdistention of the uterus due to multiple gestation, polyhydramnios or an abnormal foetus
- Augmentation of labour with oxytocin
- Halothane used for general anaesthesia
- Obesity
- Prolonged or precipitous labour
- Chorioamnionitis
- Grand multiparity
- Administration of magnesium sulphate
- Uterine tumours, such as fibroids
- Congenital abnormalities of the uterus
- Previous episodes of uterine atony
- Abnormal placentation, such as placenta praevia, placenta accreta, increta and percreta.
- Uterine atony can also develop with no identifiable risk factor (idiopathic)

26
Q

Post-partum haemorrhage
Risk factors

A

Obstetrical lacerations
- Operative vaginal delivery
- Precipitous labour
- Episiotomy

Retained placenta
- Placenta accrete spectrum
- Previous uterine surgery
- Incomplete delivery of placental tissue or membranes

Maternal coagulopathy
- Severe preeclampsia and eclampsia
- HELLP (haemolysis, elevated liver-enzyme level, and low platelet count) syndrome
- Intrauterine foetal death
- Placental abruption
- Coagulation disorder that is acquired (amniotic fluid embolism) or inherited

27
Q

NB define retained placenta

A
  • Definition: Failure to deliver the placenta within 20 minutes of delivery of the baby
  • However if the patient has no significant bleeding administration of oxytocin infusion and waiting for separation for 1 hour is appropriate (prior to manual removal)
28
Q

Morbidly adherent placenta

A
  • Failure of normal decidual formation with partially or totally absent decidua basalis, and subsequent abnormal trophoblast invasion resulting in chorionic villi penetrating into the myometrium
  • Placenta Acreta: villi attached to myometrium without intervening decidua
  • Placenta Increta: villi penetrate into but not through myometrium
  • Placenta Percreta: Villi penetrate through the myometrium (even into the bladder)
29
Q

Uterine rupture
Define
Classification

A
  • Rupture of the uterus is a life-threatening complication of pregnancy and labour.

Classification:
- Spontaneous rupture (antenatally or during labour)
=In a scarred uterus
=In an unscarred uterus
- Traumatic rupture
=Associated with obstetric interventions
=Following blunt or penetrating trauma to theuterus

30
Q

Spontaneous rupture in a scared uterus

A
  • A scar in the uterine musculature is thought to represent a weak area where rupture may occur.

Classical caesarean section:
- High risk for rupture (12% during a subsequent pregnancy)
- Weak fibrotic healing of the uterine musculature after transection of the muscle bundles.
- 2/3 during labour with contractions
- 1/3 occurs antenatally (gestational distension)

Lower segment transverse caesarean section:
- Low risk for rupture (<1%)

Uterine scarring after a previous myomectomy, perforation, repairs of congenital uterine abnormalities, or after a previous pregnancy complicated by a morbidly adherent placenta, may similarly predispose a patient to uterine rupture.

31
Q

Traumatic obstetric rupture

A
  • Such rupture may follow obstetric interventions and manoeuvres that are all rare in current obstetrical practice.
  • This list includes
    = Internal podalic version
    = Breech extraction
    = Destructive procedures for the delivery of a dead, impacted fetus.
32
Q

Traumatic non-obstetric rupture

A
  • Blunt trauma to the pregnant uterus sustained during motor vehicle accidents and blows or kicks to the abdomen may cause explosive rupture of the uterus.
  • Penetrating wounds to the uterus caused by bullet or stab wounds are associated with variable degrees of destruction of uterine musculature, and present as such with rupture of the uterus.
33
Q

Uterine inversion
General
Aetiology
Associated with

A

Abnormal turning of the uterus inside out:
- Incomplete inversion: the uterine fundus does not invert beyond the cervix
- Complete inversion: the entire uterus turns inside out, the fundus extends through the cervix and protrudes into the vagina or externally

  • Rare but potentially catastrophic, delay in reduction may result in increasing uterine congestion, oedema and formation of a constriction ring, further impeding replacement
  • Patients may become profoundly shocked due to a combination of haemorrhage and neurogenic shock due to traction of pelvic peritoneum

Combination of:
- Adherent fundal placenta
- Uterine atony during placental delivery
- Excessive cord traction or fundal pressure during placental delivery

Associated with:
- Foetal macrosomia
- Vaginal birth after caesarean section
- Precipitous labour

34
Q

Trauma to lower GT
Perineal lacerations
Risk factors

A

**Perineal lacerations: **
- Occurs during delivery of the foetal head and shoulders
- Usually involves the perineum, but may also involve the lateral tissues
- Any laceration involving more than the skin and subcutaneous tissue should be regarded as an obstetric complication
- Final step in normal labour involves extension of the foetal head, it is important to protect the perineum and assist with extension during this process of gradual perineal stretching

Risk factors:
Maternal factors:
- Precipitous labour
- Very narrow subpubic angle of the pelvis
Foetal factors
- Large Foetus
- Persisting occiput-posterior position
- Face, breech or other abnormal presentation that can be delivered vaginally
Obstetric care factors
- Uncontrolled delivery
- Macerated episiotomy: incision of the anal muscles and epithelium
- Extended episiotomy by tearing

35
Q

Classification of perineal tears

A

1 - laceration of skin and subcutaneous tissue; no muscular damage

2 - lacerations of skin, subcutaneous tissue, perineal body and muscles

3 - lacerations involving the skin, subcutaneous tissue , perineal body and muscle and the anal sphincter
A - <50% of external anal sphincter torn
B - >50% of external anal sphincter torn
C - internal anal sphincter torn

4 - grade 3 + anal epithelium

36
Q

Trauma of lower GT
Haematomas

A
  • Rupture of subcutaneous blood vessels, with ensuing rapid dissection of blood into tissue planes
  • Small vulvar haematomas are not uncommon, are usually asymptomatic and will resolve without specific treatment
  • Large haematomas occur less frequently and are associated with normal or instrumental delivery
37
Q

Trauma of lower GT
Fistula

A
  • May develop after direct perineal injury (grade 4 tear)
    =Missed injury
    =Inadequate repair
    =Breakdown of repair
  • In cases of neglected, prolonged labour with fetal head impaction, leading to ischaemia and necrosis of the vaginal walls leading to delayed presentation of vesicovaginal and rectovaginal fistula

9. Female Genito-urinary System (14 decks)

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