9.11 Abnormal Labour Flashcards
(37 cards)
Maternal & fetal risk factors for malpresentation or poor progress in labour
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
Etiology of prolonged first stage
Poor progress in labour
- 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)
Etiology of prolonged second stage
Poor progress in second stage (dilations)
- CPD
- Ineffective contractions
- Malpresentation
Define occiput posterior position
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
What is the normal position of presentation of a baby at labour?
Usually spine in on the left side
- “left occiput-anterior”
Cardinal stages of labour
- Engagement
- Decent
- Flexion
- Internal rotation
- Extension
- External rotation
- Expulsion
Define face presentation
- 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
Define brow presentation
- 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)
Define compound presentation
- When a limb engages with the baby’s head
- spontaneous correction is common
Define abnormal labour in the first stage of labour
- There is poor progress if the cervix dilates at a rate of <1 cm/hour in the active phase (crosses the partogram alert line)
Define abnormal labour in the second stage of labour
- 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
The rule of the 4 “P’s”
Patient
Powers
Passage
Passenger
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
Define and discuss RF for umbilical cord presentation and prolapse
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
Define and describe associating factors of shoulder dystocia
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
Causes of antepartum hemorrhage
Bleeding during pregnancy
- Abruptio placentae
- Placenta praevia
- Local lesions
- APH of unknown cause
- Dilatational bleeding (labour)
Grades of placenta praevia
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’
Signs and symptoms of placenta praevia
- 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
Causes and RF of abruptio placentae
Placenta ruptures
- Pre-eclampsia (hypertension)
- Prelabour ROM
- Chorioamnionitis
- Blunt abdominal trauma
- Cigarette smoking
- Cocaine/methamphetamine use
- Previous abruptio
Signs & symptoms of abruptio placentae
- 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)
Define antepartum haemorrhage of unknown origin
After excluding all other causes
- 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
Post-partum haemorrhage
Define
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
Post-partum haemorrhage
Classification
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
Post-partum haemorrhage
Consequences
- Severe anaemia requiring blood transfusion
- Disseminated intravascular coagulation
- Hysterectomy
- Multiorgan system failure
- Death
Post-partum haemorrhage
Causes NB
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
