Problems encountered in labour Flashcards by Kofi Antwi

What are some problems encountered in labour?

Failure to progress
Malpresentation/Malposition
Suspected Foetal Compromise (foetal distress)
Vaginal birth after Caesarean Section
Operative delivery
Shoulder dystocia

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What causes in ‘Failure to Progress’?

Can occur in first and second stage. Causes are:

Inadequate contractions (augment with oxytocin)
Foetal malposition/ malpresentation
Cephalopelvic disproportion
Obstructed labour
Maternal Exhaustion

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What are types of Malrotation?

Occipito-posterior
Deep transverse arrest

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What are types of Malpresentation?

Face: baby lying on tummy coming out
Brow: can feel tops of the eye
Breech: Sucking toe, Baby flexed

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What are complications of Breech?

Trapper aftercoming head
Cord prolapse
Intracranial haemorrhage
Internal injuries

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What are types of Abnormal Lie?

Oblique lie
Transverse lie

needs Caesarean Section

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What are causes of Suspected Foetal Compromise during labour?

Uterine Hyperstimulation (can be iatrogenic oxy): Terbutaline used to control
Hypotension
Poor foetal tolerance of labour (IUGR?)
Cord compression
Infection
Maternal Disease

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How is suspected foetal compromise generally managed?

Rectify reversible causes. Deliver by speediest route if unable to correct or if significant acidosis
Left lateral position
Stop oxytocics
Confirm compromise by blood sampling where possible

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What are risks of attempting Vaginal birth after Caesarean Section?

Complication

Uterine scar dehiscence/rupture 0.5%
Emergency C-section in labour

Contraindications:

Previous uterine rupture
Classical caesarean scar

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What are precautions for VBAC?

IV access and Group &Save
Continuous electronic foetal monitoring
Avoid prolonged labour
Augmentation/induction decision made by specialist only

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What is required for Ventouse/Forceps delivery?

Indications: maternal reasons, failure to progress in 2^nd stage,
Pre-requisites: trained operator, full dilation, absent membrane, cephalic presentation, clearly defined position, presenting part engaged, no evidence of CPD, adequate analgesia, empty bladder

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What is required for a Caesarean Section?

Indications

Maternal reasons
Absolute cephalopelvic disproportion
Placenta praevia grades ¾
Pre-eclampsia
Post-maturity
IUGR
Foetal distress in labour/prolapsed cord
Failure of labour to progress
Malpresentations: brow
Placental abruption: only if foetal distress; if dead deliver vaginally
Vaginal infection e.g. active herpes
Cervical cancer (disseminates cancer cells)

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What are complications of Ventouse/Forceps delivery?

Failure
Foetal trauma (cephalohaematoma, sub-glial haemorrhage)
Maternal trauma
Postpartum Haemorrhage
Urine retention

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What are immediate complications of a Caesarean Section?

Haemorrhage
Infection
Bladder/bowel injury
Thromboembolic disease
Requirement of blood transfusion
TTN
Foetal trauma

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What is Shoulder Dystocia?

Complication of vaginal cephalic delivery. Entails inability to deliver body of the foetus using gentle traction after the head has already been delivered.
Occurs due to impaction of the anterior foetal shoulder on maternal pubic symphysis preventing entry into pelvic inlet
Causes both maternal and foetal morbidity. Associated with PPH, perineal tears and brachial plexus injury e.t.c.
Neonatal death occasionally occurs from shoulder dystocia

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What are risk factors of Shoulder Dystocia?

Foetal macrosomia
High maternal body mass index
Diabetes mellitus
Prolonged labour.

What are complications of Shoulder Dystocia?

Foetal death
Asphyxia with resulting hypoxic damage
Birth trauma (Erb’s palsy, fractured bone
Maternal trauma (soft tissue trauma, psychological)

What is the management for Shoulder Dystocia?

1^st Line: McRoberts manoeuvre performed (after help is called) + suprapubic manoeuvre.

Woodscrew manoeuvre can also be tried
Symphysiotomy and the Zavanelli manoeuvre can cause significant maternal morbidity and are not first-line options.
Episiotomy does not relieve the bony obstruction but sometimes used to allow better access for internal manoeuvres.

What is the McRoberts manoeuvre?

Entails flexion and abduction of maternal hips bring mother’s thigh towards her abdomen.
This rotation increases anterior-posterior angle of the pelvis and often facilitate successful delivery

What is Symphysis pubis dysfunction?

Ligament laxity increases in response to hormonal changes of pregnancy
Pain over the pubic symphysis with radiation to the groins and the medial aspects of the thighs.
A waddling gait may be seen

What is the definition of Cord Prolapse?

Involves umbilical cord descending ahead of presenting part of the foetus. If left untreated it can lead to compression of the cord or cord spasm leading to foetal hypoxia and eventually irreversible damage or death*
Majority of cord prolapses occur at artificial rupture of membrane.

What are risk factors for Cord Prolapse?

Prematurity
Multiparity
Polyhydramnios
Twin pregnancy
Cephalopelvic disproportion
Abnormal presentations e.g., Breech, transverse lie
Placenta praevia
Long umbilical cord
High foetal station

What are types of Breech Presentation?

Frank breech: Most common presentation with hips flexed and knees fully extended.
Footling breech: Where one or both feet come first with the bottom at higher position. This is rare but carries a higher perinatal morbidity

What investigation results indicate Cord Prolapse?

Foetal heart rate abnormal
Cord is palpable vaginally or cord is visible beyond level of introitus

Wha is the immediate management of a Cord Prolapse?

* Presenting part of foetus may be pushed back into uterus to avoid compression * If cord is past level of introitus, it should be kept warm and moist but should not be pushed back inside * Tocolytics may be used

What is the defintive management options for Cord Prolapse?

* 1^st line: Patient is asked to go on all fours until preparation for an immediate caesarean section has been carried. * 2^nd line: instrumental vaginal delivery is possible if cervix is fully dilated and head is low. If treatment is early foetal mortality in cord prolapse is low. Incidence has been reduced by increase in C-section being used in breech presentation

What are risk factors for Breech Presentation?

* **Uterine malformations** * Fibroids * **Placenta praevia** * **Polyhydramnios** or **Oligohydramnios** * **Fetal abnormality** (e.g. CNS malformation, chromosomal disorders) * **Prematurity** (due to increased incidence earlier in gestation)

What is the management for Breech Presentation?

* **If \<36 weeks:** many foetuses will turn spontaneously * **If still at 36 weeks:** External Cephalic Version (ECV). Has success rate of 60%. Offered from: * 36 weeks in nulliparous women and * 37 weeks in multiparous women * **If baby is still breech** after this then delivery options include planned caesarean section or vaginal delivery

What are absolute contraindications to ECV?

* Where caesarean delivery is required * Antepartum haemorrhage within the last 7 days * Abnormal cardiotocography * Major uterine anomaly * Ruptured membranes * Multiple pregnancy

How should women with Breech Presentation be counselled?

* 'Women should be informed that planned caesarean section carries a reduced perinatal mortality and early neonatal morbidity for babies with a breech presentation at term compared with planned vaginal birth.' * 'Women should be informed that there is no evidence that the long-term health of babies with a breech presentation delivered at term is influenced by how the baby is born.'

What are immediate complications of Caesarean Section?

* Emergency hysterectomy * Need for further surgery at a later date, including curettage (retained placental tissue) * Admission to intensive care unit * Thromboembolic disease * Bladder injury * Ureteric injury * Death (1 in 12,000) * Prolonged ileus * Persistent wound and abdominal discomfort in the first few months after surgery * Increased risk of repeat caesarean section when vaginal delivery attempted in subsequent pregnancies * Readmission to hospital * Haemorrhage * Infection (wound, endometritis, UTI)

What are complications of a Caesarean Section for Future pregnancies?

* Increased risk of uterine rupture during subsequent pregnancies/deliveries * Increased risk of antepartum stillbirth * Increased risk in subsequent pregnancies of placenta praevia and placenta accreta) * Subfertility

What are indications for forceps delivery?

* Fetal distress in the second stage of labour * Maternal distress in the second stage of labour * Failure to progress in the second stage of labour * Control of head in breech deliver

What are clinical features of Uterine Rupture?

Occurs during labour but can also occur in 3^rd trimester. Risk factors are previous caesarean section. Presents: * Maternal shock * Abdominal pain * Vaginal bleeding

What is False Labour?

Occurs in the last 4 weeks of pregnancy. Presents with: * Contractions felt in the lower abdomen which are irregular and occur every 20 minutes. * Progressive cervical changes are absent.