Chapter ii

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1. ABNORMAL LABOR AND DELIVERY BY GEBREMARYAM T BSc MW Chapter two

2. Induction and Augmentation of Labor

3. Cont … Induction: - Induction is the initiation of labour by artificial means for medical or obstetric reasons. Labour is induced when it is considered that the health or well being of the mother and or fetus would be adversely affected if the pregnancy continued. Augmentation : - Is to increase or to speed it up when the progress of labour is slow. Also known as acceleration of labour.

4. Cont … 1. Induction of labour Labour is induced by the following three methods 1. Medica l By giving intravenous oxytocin infusion (syntocinon) By administering prostaglandin orally and vaginaly 2. Surgical (ARM) – also known as amniotomy. Rupture of the membranes is performed to stimulate uterine contraction. Usually ruptured using an amnihook (Kocher’s) 3. Combination of the two methods above

5. Indications for induction 1. Prolonged pregnancy After 42 weeks of gestation the rate of placental deterioration is increase and the well being of the fetus is in danger due to placental insufficiency. 2. Pre – eclampsia Done that maternal health is at risk due to pre – eclampsia Fetus from placental insufficiency. Due to fear of placental insufficiency induction is done after 37 wks completed in pre eclampsia . If the pre – eclampsia is serious for the fetus and mother it is done before 30 wks If persistent protein urea is presentation induction is done at after 34 wks completed.

6. [ 3. Evidence of diminished fetal well – being. Placental insufficiency severe enough to affect fetal well – being is characterized by intra uterine growth retardation. Reduced fetal movements and movements and abnormal fetal heart sound is the diagnostic measure. 4. The older primigravida Placental insufficiency is more common in primigravida aged over 35 years. For this reason induction is recommended at term to avoid additional risk to the fetus.

7. 5. Poor obstetric history Still birth or IUGR in a previous pregnancy tends to recur so induction is done at term. 6. Spontaneous rupture of membranes. If the membranes rupture spontaneously after 34 weeks gestation and labour does not commence with in 12 – 24 hours it should be induced due to fear of intra – uterine infection. 7. Previous large baby A previous baby whose birth weight was over 4 kg may indicate the need for induction between 38 – 40 weeks of gestation.

8. 8. Diabetes mellitus Necessary to induce labour between 36 and 38 weeks of gestation for fear of IUFD and fetal macrosomia . If good control is not achieved during pregnancy. 9. Rhesus – Iso – immunization When rhesus antibodies are present it is then necessary to induce labour to arrest haemolysis .

9. 10. Unstable – lie – after correction If placenta praevia and pelvic abnormalities have been excluded as causes of unstable lie labour may induced after the lie has been corrected and made longitudinal and cephalic presentation. 11. Genital herpes In a woman with a history of genital herpes labour is frequently induced if the disease in remission after 38 wks. This avoids c/s for active herpes at the onset of spontaneous labour.

10. 12. Previous precipitate labour As precipitate labour tends to recur induction is sometimes performed at 38 weeks. 13. Placental abruption Once maternal shock has been treated by intravenous fluid replacement it is usual to induce labour by ARM. This relieves increased intra – uterine pressure caused by retro placental hemorrhage and controls bleeding by allowing the uterus to contract and empty

11. 14.Social reasons. Some times a woman may wish the baby to be born for family reasons or simply because she is fed up. 15. Intra – uterine death Labour may be induced once IUFD has been confirmed due to fear of coagulation defects.

12. Contra indications of induction In general any condition that is contraindication for spontaneous labor and vaginal delivery should be contra indication for induction of labor. Contra indications may include but are not limited to the following.

13. Absolute contra indications Gross CPD Transverse and oblique lie Footling breech Upper segment uterine scar Active genital herpes Extensive genital wart Pelvic tumor obstructing the birth canal Placenta praevia Acute fetal distress Two or more previous lower uterine segment cesarean scar

14. Relative contra indications Grande multiparity Bad obstetric history Twin pregnancy Prematurity Macrosomia One previous lower segment c/s

15. Favorable factors for induction The successful induction of labour depend up on The period of gestation. When gestation is more than 38 weeks induction of labour is more likely successful as the nearer to term of pregnancy. Level of presenting part When three – fifths of the head or less is palpable above the pelvic brim Sensitivity of the uterus Condition of the cervix -If cervix is well effaced induction is successful

16. Bishop Score Def n - A method of assessing the favorability of the cervix prior to induction of labour. Five different features are considered and each is a warded a score of between 0 and 3.

17. Bishop’s Score Parameters) 1 2 3 1 Dilatation of Cx Closed 1 – 2 3 – 4 5 – 6 2 Consistency of Cx Firm Medium Soft 3 Effacement of Cx 0 – 30% 40 – 50% 60 – 70% Above 80% 4 Position of the Cx Posterior Midline Anterior 5 Station of the presenting part - 3 -2 -1 , 0 +1, +2

18. If the score is 6 and above the condition of the cervix favorable for induction . If the score is 5 and below the condition of the cervix is unfavorable for induction.

19. Preparation for induction of labour Psychological preparation Liaison with other department - Involve specialist such as pediatrician and diabetic team Bowel preparation - Enema if the woman is constipated Admit pt 2 hrs before handle Empty bladder

20. Induction of labour by oxytocin infusion A. For multi para mother 1. Add 2 unit of oxytocin in 1000 ml of D/W running at 10 drops/min if no contraction double the drop every 20 min until it reaches 80 drops. 2. If no contraction add 2 unit of oxytocin in the same bag and start with 40 drops and double the drop after 20 min if no contraction and stop at 80drops. 3. If no contraction add again another 2 unit in the same bag and start with 40 drops and double the drop after 20 min if no contraction and stop at 80drops. The maximum dose for multi gravida mother is 6 units.

21. B. For primigravida mother 1. Add 5 unit oxytocin in 1000ml of D/W running 10 drops/min if no contraction doubles the drop every 20 min always stop at 80drops. 2. If no contraction add 5 unit oxytocin in the same bag and start with 40drops and double the drop after 20 min if no contraction. Always stop at 80drops 3. If no contraction add again another 5 unit oxytocin in the same bag and start with 40 drops and double the drop after 20 min if no contraction. Always stop at 80drops. The maximum dose for primigravida mother is 15 units

22. The aim to increase oxytocin drop is to achieve 3 – 5 contraction per 10 min lasting up to 40 – 60 seconds. Indication to stop the oxytocin drip Fetal distress Deterioration in maternal condition Strong and frequent contraction with no relaxation Strong contractions lasting over 60 seconds

23. Indications for oxytocin drip To induce labour (start) To accelerate (quicken) = augmentation of labour To prevent or treat PPH

24. Nursing care and observation Set up drip as instructed by the doctor and control the rate of flow Label and attach the following on the bag. Oxytocin unit, dose, time, started Check FHB every 15 min B/P and pulse every 30 min Temperature every 4 hrs Check contraction every 30 min Empty bladder Urine test for ketones Anti pain Watch the progress of labour on the partograph Control input and out put

25. Complications of induction 1. Over stimulation of the uterus Results in strong contractions which last more than 60 seconds and occur more frequently. Relaxation between contractions is inadequate. 2. Ruptured uterus - May result from over stimulation if any CPD is present 3. Amniotic fluid embolism – rare Which may be caused by strong contraction

26. Fetal distress Cord prolapse Premature separation of placenta Infection Prematurity Unforeseen CPD leading to obstructed labor

27. Surgical induction methods 1. Sweep membrane Is when the chorion is separated the cervix by the finger. This is a simple and often successful procedure. When Cx ripe 2. Amniotomy Usually done in conjunction with synotocinon drip. Problem is that once the membranes are ruptured if labour doesn’t start c/s will have to be done usually after 24 hours of ARM

28. Contra indications High head Unripe cervix Malpresentaiton IUFD (danger of infection)

29. Preparation for amniotomy Make sure bladder is empty Check FHB Careful abdominal palpation Explain the procedure Place in lithotomic position After rupture avoid frequent vaginal examination because danger of infection . Procedure Finger in inserted in to the cervix by holding amniotomy forceps or kocher’s and then ruptures the fore waters.

30. 2. Augmentation of labor Def n - correction of dystocia due to inefficient uterine contraction (power) by the use of oxytocin Indication Poor progress of labor due to inefficient uterine contractions .

31. Contra indications Breech presentation CPD Malpositions Invasive cervical Ca Active genital herpes infection Outlet and mid pelvis contracture None – reassuring FHB pattern and fetal macrosomia

32. Conditions to be fulfilled Proper evaluation of the fetus and mother to rule out contra indications Maternal dehydration, positioning The capacity to do emergency c/s Get an informed consent

33. Procedure Do ARM aseptically if membrane is intact Start oxytocin infusion Add 1 IU of oxytocin to 1000 ml of RL Start with 0.5 mu/min for multipara and 1 mu/min for primigravida The rate of increment should be 1 mu/min every 30min up to maximum dose of 20 mu/min NB : Dose of oxytocin is half of the dose for induction otherwise similar procedure

34. P rolonged labor

35. Prolonged Labour Defn Traditionally labour is prolonged if it exceeds 24 hours. When labour is actively managed it is termed prolonged if delivery is not imminent after 12 hours of established labour. NB - Transfer a patient to hospital from health center Primigravida at 18 hours Multigravida at 12 hours Or transfer the woman to hospital when the progress crosses alert line on the pantograph.

36. Causes of prolonged labour (4 P’s are the main causes) 1. P assenger (The fetus) like Big baby Mal position (OPP) Mal presentation Congenital abnormalities (Hydrocephaly) CPD

37. 2. P assages (The pelvic) Abnormality of size, shape, of pelvis (Android) Disease or injury of pelvis (Rickets) Congenital abnormality pelvis CPD

38. 3. P owers (uterine contractions) Inefficient uterine contractions (Hypotonic uterine action). This is the most common causes of prolonged labour. 4. P sychological causes Abnormally tense or apprehensive women tend to have prolonged labour. This phenomenon affects primigravida more often than multigravida.

39. Causes of a prolonged second stage of labour 1. Hypotonic contraction - Secondary hypotonic contraction may cause delay 2. In effective maternal effort Fear exhaustion or lack of sensation may inhibit a woman’s ability to push and cause delay especially in a primigravida. 3. A rigid perineum May prevent the advance of the fetus during the perineal phase. If this is evident an episiotomy is performed

40. 4. Reduced pelvic outlet Android pelvis is the most likely cause of obstruction at the outlet due to it’s prominent ischial spines and narrow sub pubic arch. A forceps delivery is performed. 5. A large fetus 6. OPP

41. Management of prolonged labor With the principle of ” The sun should not set twice in woman in labor” 1. Acceleration of labour Doctor may order oxytocic drug in Iv drip and rupture membranes provided there is no disproportion. 2. C/S may be decided on depending the finding like if Any disproportion Condition of the mother and fetus The history of the pt will play a part in the decision 3. Enema may be repeated provided head descending 4. Instrumental delivery

42. Nursing care during labour is prolonged 1. Be kind to mother, reassure her, encourage here and explain to her what is happening if you do this the mother will be co – operative with you 2. Keep her as clean and dry as possible 3. Keep her bladder empty. Test urine for albumin and ketones 4. Don’t allow the woman to become dehydrated or prevent ketoacidosis

43. 5. Observe the following Dilatation of Cx Descent of the head Contractions General condition of the pt B/p every 4 hrs FHB and maternal pulse every 15 min

44. Complications of prolonged labour 1. Materna l Intera – uterine infection Acidosis and dehydration Vesico vaginal fistula Ruptured uterus PPH Cystocele, rectocele, and prolapse of uterus ( comes due to over stretching of uterus)

45. 2. Fetal Intera – uterine hypoxia IUFD Intra – uterine infection Intra cranial hemorrhage

46. Prolonged 1 st stage labour classified in to two 1. Prolonged latent phase The cervix effaces and dilatation occurs The average duration of the latent phase in nulliparous women was 8.6 hours and if it lasted 20 hours or more it should be considered as prolonged. The latent phase of labor is still poorly understood and it’s duration difficult to define.

47. 2. Prolonged active phase A rate of 1cm per hour is most commonly used. A prolonged active phase is caused by a combination of factors including the Cx , uterus, fetus and the mother’s pelvis.

48. Obstructed Labor

49. Obstructed Labor Defn - Where there is no advance of the presenting part in spite of good uterine contractions. It is the fault of the passages or passenger but not the power. Obstructed labour should not occur and does not occur when competent obstetric supervision and service is available

50. Causes of obstructed labour Contracted pelvis Big baby Major CPD OPP (Deep transverse arrest) Malpresentation (Brow, face, shoulder ) Malformation (Hydrocephalus) Pelvic tumors Locked and conjoined twins

51. Signs and symptoms of obstructed labour 1. Early signs The presenting part does not enter the brim in spite of good uterine contractions (about 6 – 8 hrs) The cervix dilates slowly and is edematous (thick) and hangs loosely like an empty sleeve. Cervix is badly applied to the presenting part Membranes rupture early

52. NB - The midwife must be able to recognize at this stage. And she should sedate her and transfer her as soon as possible.

53. 2. Late signs A. Maternal condition Signs of dehydration and ketosis develop Raised pulse and temperature Vomiting and restlessness Oligouria B. Fetal condition Change in the fetal heart rate and rhythm Meconium is passed in a vertex presentation Excessive fetal movement Excessive caput and moulding

54. C. Abdominal examination The abdomen is tense. Tender, and hard to palpate The contractions are long, strong with little or no relaxation between them. Some times the contraction stop as the uterus exhausted. Bandl’s ring is seen rising to the level of the umbilicus showing that the lower uterine segment is very thin and ready to rupture.

55. D. Vaginal examination The presenting part is wedged (stuck) usually in the pelvic brim and there will be excessive caput and Moulding felt Cervix is loose and edematous and hangs like an empty sleeve The vagina is hot and dry There will be meconium stained liquor and meconium on the finger Edematous vulva and cervix ( Kanula syndrome)

56. Dangers of Obstructed Labour A. Mather Rupture of the uterus Hemorrhage Shock Death Vesico vaginal fistula B. Fetal Meconium aspiration Still birth Neonatal death Asphyxia Infection (Ascending)

57. Management of obstructed labour Caesarean section if baby is a live Intra venous fluid Blood group and cross matching Pass a catheter Reassurance Antibiotics Craniotomy if fetus is dead Decapitation if shoulder presentation & dead

58. Prevention of obstructed labour A. During pregnancy Select high risk patient for hospital delivery Pelvic assessment at 36 wks for all primigravida Careful antenatal follow up

59. B. During labor Careful observations on all women in labor noting how the head is descending how the cervix is dilating and it’s state. Beware of any woman who has had a previous still birth or instrumental delivery if you get mother in such condition refer her as soon as possible after you do the following:

60. IV infusion must be commenced Start antibiotics Send blood donors Check uterus is not ruptured Bladder drainage (Folly catheter for about 10-14 days to prevent VVF) Antipain or sedative

61. BY GT BSc MW Obstetric Anesthesia

62. Obstetric anesthesia Obstetrical anesthesia presents unique challenges. Labor begins without warning, and anesthesia may be required within minutes of a full meal. Vomiting with aspiration of gastric contents is a constant threat. The usual physiological adaptations of pregnancy require special consideration, especially with disorders such as preeclampsia, placental abruption, or sepsis syndrome.

63. Cont… Anesthesia complications caused 1.6 percent of pregnancy-related maternal deaths in the United States from 1991 through 1997.

64. Role of obstetricians Every obstetrician should be proficient in local and pudendal analgesia that may be administered in appropriately selected circumstances. In general, however, it is preferable for an anesthesiologist or anesthetist to provide pain relief so that the obstetrician can focus attention on the laboring woman and her fetus. General anesthesia should be administered only by those with special training.

65. Principles of Pain Relief T he experience of labor pain is a highly individual reflection of variable stimuli that are uniquely received and interpreted by each woman. These stimuli are modified by emotional, motivational, cognitive, social, and cultural circumstances.

66. Cont… The complexity and individuality of the experience suggest that a woman and her caregivers may have a limited ability to anticipate her pain experience prior to labor. Thus, choice among a variety of methods of pain relief is desirable

67. NONPHARMACOLOGICAL METHODS OF PAIN CONTROL Fear and the unknown potentiate pain. A woman who is free from fear, and who has confidence in the obstetrical staff that cares for her, usually requires smaller amounts of analgesia. T he intensity of pain during labor is related in large measure to emotional tension.

68. Cont… The urged that women be well informed about the physiology of parturition and the various hospital procedures they may experience during labor and delivery. Pain often can be lessened by teaching pregnant women relaxed breathing and their labor partners psychological support techniques. These concepts have considerably reduced the use of potent analgesic, sedative, and amnesic drugs during labor and delivery.

69. cont … When motivated women have been prepared for childbirth, pain and anxiety during labor have been found to be diminished significantly, and labors are even shorter. In addition, the presence of a supportive spouse or other family member, of conscientious labor attendants, and of a considerate obstetrician who instills confidence have all been found to be of considerable benefit.

70. Pharmacological therapy Meperidine 25–50 mg (IV) every 2–4 hr 5 min onset of action (IV) or 50–100 mg (IM) every 1–2 hr have onset of action 30–45 min (IM) Fentanyl 50–100 g (IV) every 1 hr onset of action after 1 min Nalbuphine 10 mg (IV or IM) every 3 hr onset of action after 2–3 min (IV) or after 15 min (IM) Butorphano l 1–2 mg (IV or IM) every 4 hr

71. Obstetric Anesthesia Cont … 1. General Anesthesia Defn - When a state of unconsciousness is induced but which may also involve giving some analgesia. Agents used in general anesthesia A. In halation anesthesia Gas anesthetics (Nitrous oxide) may be used to provide pain relief during labor as well as at delivery. The agents produce analgesia and altered consciousness . The gases are connected to a breathing circuit through a valve that opens only when the patient inspires. Volatile anesthetics (halothane)

72. Cont … B. Intravenous drugs during anesthesia Thiopental:- given IV and widely used in conjunction with other agents for general anesthesia Ketamine :- given IV in low doses of 0.2 to 0.3 mg/kg this drug is used to produce analgesia and sedation just prior to delivery.

73. Cont … Mendelson’s syndrome This is when general anesthesia is induced silent regurgitation may easily occur unnoticed and if acid stomach contents are then aspirated in to the lungs a condition known as Mendelson’s syndrome. (When acid gastric juice is inhaled during general anesthesia).

74. Cont … Sign and symptoms of Mendelson’s Syndrome Patient become restless Dyspnoea Bronchospasm Cyanosis Tachycardia Hypotension Pulmonary edema Death

75. Cont … Prevention NPO if patient is high risk Give antacid if patient going for general anesthesia Empty a full stomach/ NG tube in place Cricoid pressure:- pressure on the one complete ring of tracheal cartilage to occlude the esophagus so preventing acid reflex

76. Cont …. Management 1 . Obstetric emergency Head down Aspirate secretion Artificial respiration Oxygen 2. Antibiotics For chemical pneumonia 3. Steroids To inhibit inflammatory reaction

77. Cont … B. Failed intubations This may occur when there may be some laryngeal edema, poor mouth opening and a fat or stiff neck or large breasts may also contribute to difficulty with intubations. Prevention Pre oxygenate every pregnant woman prior to induction of anesthesia

78. Cont … C. Supine hypertensive syndrome ( aortacaval occlusing ) This occur when the weight of the gravid uterus occluding the inferior vanacava with supine position. Prevention Ensure that she is tilted laterally either by means of a small rubber wedge under the mattress or by placing a folded blanket under one buttock.

79. Cont … Regional anesthesia Defn - When a group of nerve is anaesthetized, so giving an area of anesthesia . Various nerve blocks have been developed over the years to provide pain relief during labor and delivery. They are correctly referred to as regional analgesics. Types of regional anesthesia 1. Epidural anesthesia This is the commonest type of approach and there are different techniques when may be used. The anesthetic is introduced between lumbar vertebrae 3 and 4 or 2 and 3.

80. Cont … Indication Maternal request Malposition Malpresentation PIH Multiple pregnancy

81. Cont … Spinal anesthesia Is a technique by which local anesthetic solution is injected in to the subarachnoid space that is in to the CSF. Advantages include a short procedure time, rapid onset of blockade, and high success rate. Indication Caesarean section F orceps or vacuum delivery

82. Vaginal delivery Vaginal Delivery Low spinal block can be used for forceps or vacuum delivery. The level of analgesia should extend to the T10 dermatome, which corresponds to the level of the umbilicus. Blockade to this level provides excellent relief from the pain of uterine contractions

83. Cesarean Delivery A level of sensory blockade extending to the T4 dermatome is desired for cesarean delivery Depending on maternal size, 10 to 12 mg of bupivacaine in a hyperbaric solution or 50 to 75 mg of lidocaine hyperbaric solution are administered. The addition of 20 to 25 mg of fentanyl increases the rapidity of blockade onset and reduces shivering. The addition of 0.2 mg of morphine improves pain control during delivery and postoperatively.

84. Cont … 3 3 Pudendal block This is a technique used to anaesthetize the specific area served by the pudendal nerve. Local anesthetic solution is injected adjacent to the pudendal nerves as they pass close to the ischial spine. Within 3 to 4 minutes of injection, the successful pudendal block will allow pinching of the lower vagina and posterior vulva bilaterally without pain. 4

85. Cont… If delivery occurs before the pudendal block becomes effective and an episiotomy is indicated, then the fourchette , perineum, and adjacent vagina can be in- filtrated with 5 to 10 mL of 1-percent lidocaine solution directly at the site where the episiotomy is to be made. By the time of the repair, the pudendal block usually has become effective

86. cont… 4 Paracervical block In this technique the paracervical plexuses are blocked. This gives pain relief for the first stage of labor. The local anesthetic solution is injected to 3 or 9 a clock on the cervix. Because the pudendal nerves are not blocked, however, additional analgesia is required for delivery.

87. Cont … Local anesthesia Defn - When a small specific area is anaesthetized. This is the most common instance of use of local anesthesia for the midwife, who may undertake it herself prior to performing or repairing an episiotomy The drug in most common use is lignocaine / Lidocaine /.