labour dystocia.pptx

Labour dystocia

1. Definition of labour presence of strong regular painful contractions resulting in progressive cervical change . Diagnosis of labour suspected when awoman presents with contraction-like pains vaginal examination that reveals effacement and dilatation of the cervix. Loss of a ‘show’ (a blood-stained plug of mucus passed from the cervix

2. Stages of labour First stage  Latent first stage of labour when there are painful contractions, and some cervical change, including cervical effacement and dilatation up to 4 cm. Active first stage of labour : when there are regular painful contractions, and there is progressive cervical dilatation from 4 cm •also New definition : 6 cm of dilation

3. Duration of the first stage Primi 1cm/h last on average 8-10 hours and considered delay if less than 2/4h. unlikely to last over 18 hours. Multi 2cm/h last on average 5 hours and considered delay if less than2/4h. unlikely to last over 12 hours.

4. Management of normal labour history Previous births and size of previous babies . Previous caesarean section. Onset, frequency, duration and perception of strength of the contractions. Whether membranes have ruptured and, if so, colour and amount of amniotic fluid lost. Presence of abnormal vaginal discharge or bleeding. Recent activity of the fetus (fetal movement). Medical or obstetric issues of note (e.g. diabetes, hypertension, fetal growth restriction [FGR]). Any special requirements (e.g. an interpreter or particular emotional/psychological needs). Maternal expectations of labour and delivery?

5. General examina The temperature, pulse and blood pressure Abdominal examination it is important to determen fundal height, lie, presentation, position and station , liquor, engagement also includes an assessment of the contractions ; Vaginal examination for position, length and effacement, consistency, dilatation of the cervix and position station of the presenting part . The condition of the membranes

6. Fetal assessment options in labour Inspection of amniotic fluid – fresh meconium staining, absence of fluid, and heavy blood-stained fluid or bleeding are markers of potential fetal compromise . Intermittent auscultation of the fetal heart using a Pinard stethoscope or a handheld Doppler ultrasound. Continuous external electronic fetal monitoring (EFM) using CTG. Continuous internal electronic fetal monitoring using a fetal scalp electrode (FSE ) and CTG. Fetal scalp blood sampling (FBS).

7.  women having pain without cervical change are not in labour Offer them support and occasionally analgesia, and encouraged to return home .

8. Observations during the active first stage  Use partogram with 4-hour action line once labour is established.  Observations during the first stage of labour include:  4-hourly temperature and blood pressure  hourly pulse  half-hourly documentation of frequency of contractions frequency of emptying the bladder  vaginal examination 4-hourly, or where there is concern about progress and after vaginal loss.  Intermittent auscultation of the fetal heart every 15 minutes.  Encourage women to communicate their need for analgesia at any point during labour .

9. Possible routine interventions in the first stage  active management of labour (one-to-one continuous support; early routine amniotomy ; routine 2-hourly vaginal examination; oxytocin if labour becomes slow) should not be offered routinely.  In normally progressing labour , amniotomy should not be performed routinely.  Combined early amniotomy and oxytocin should not be used routinely.

10. Fetal heart assessment and reasons for transfer to continuous EFM Intermittent auscultation of the FHR is recommended for low-risk women in established labour Indications for continuous EFM Significant meconium staining of the amniotic fluid. Abnormal FHR detected by intermittent auscultation. Maternal pyrexia (temperature ≥38.0°C or ≥37.5°C on two occasions). Fresh vaginal bleeding. Augmentation of contractions with an oxytocin infusion. Maternal request.

11. Management during first stage . One-to-one midwifery care should be provided. Additional emotional support from a birth partner should be encouraged. Obstetric and anaesthetic care should be available as required. Maternal and fetal wellbeing should be monitored. Vaginal examinations are performed 4 hourly or as clinically indicated. Progress of labour is monitored using a partogram with timely intervention if abnormal . Appropriate pain relief should be provided consistent with the woman’s wishes . Ensure adequate hydration and light diet to prevent ketosis. .

12. First-Stage Arrest Six centimeters or greater dilation with membrane rupture and no cervical change for 4 hours or more of adequate contractions ( eg , >200 Montevideo units) or 6 hours or more of oxytocin administration if contractions are inadequate

13. Risk Factors for Labor Dystocia • Induction of labor • Chorioamnionitis • Maternal obesity • Epidural anesthesia • Fetal malposition • Fetal malpresentation • Cephalopelvic disproportion  Contracted pelvis  Fetal macrosomia

14. To diagnosis , the clinician needs to address the following questions, using the Six Ps mnemonic as a guide: • Passenger: Is there a malposition or malpresentation or suspected macrosomia ? • Power: Are contractions adequate in frequency, duration, and strength? • Pelvis: Is there cephalopelvic disproportion because of a contracted pelvis? • Patient: Are there other coexisting clinical issues such as chorioamnionitis or nonreassuring fetal monitoring that affect the treatment choices? • Psyche: How are the woman and her support individuals coping with the labor?

15. Treatment for Labor Dystocia • Hydration • Position changes • Amniotomy • Oxytocin

16. Oxytocin Augmentation: Sample Protocols • Routine  Start at 1 to 2 mU /min  Increase by 1 to 2 mU /min every 30 min  Maximum dose: 36 mU /min • High‐dose  Start at 2 to 4 mU /min  Increase by 2 to 4 mU /min every 15 min  Maximum dose: 36 mU /min  May shorten length of labor, but caution with uterine tachysystole

17. Assessing Uterine Contractions • When expected cervical change is not occurring  Palpate abdomen for strength of contractions  Place intrauterine pressure catheter (IUPC)

18. If no cervical change deaspite adequate contractios for at least 4 hours consider c/s if inadequate contractions and no cervical change for at least 6 hours cosider c/s

19. Benefit of Watchful Waiting • 80% percent of those not progressing after 2 hours of adequate contractions had a vaginal delivery when allowed to labor for 4 hours with adequate contractions • Recommend waiting at least 4 hours after adequate contractions with no progress (instead of 2 hours) before making the decision for cesarean delivery, as long as FHR tracing remains normal.

20. Definition of the second stage Passive 2nd stage of labour : at full dilatation of the cervix with absence of involuntary expulsive contractions. active 2nd stage of labour : at full dilatation of the cervix with involuntary expulsive contractions

21. Duration and definition of delay in the second stage  Nulliparous women: Birth expected within (2hrs, 3hrs with epidural) of the start of the active 2nd stage.  Parous women: Birth expected within (1hrs, 2hrs with epidural) of the start of the active 2nd stage.

22. Observations during the second stage  All observations should be documented on the partogram :  half-hourly frequency of contractions frequency of emptying the bladder  assessment of woman's emotional and psychological needs.  maternal behaviour , effectiveness of pushing and fetal wellbeing,.  Intermittent auscultation of the fetal heart should occur after a contraction for at least 1 minute, at least every 5 minutes.  hourly BP and pulse, temperature and vaginal examination  consideration should be given to the woman's position, hydration, coping strategies and pain relief throughout the second stage

23. Women's position and pushing in the second stage  discouraged lying supine or semi-supine in the second stage of labour .  Inform Women that in the 2nd stage they should be guided by their urge to push.  If pushing is ineffective strategies to assist birth can be used: support, change of position, emptying of the bladder and encouragement

24. Second Stage Labor Dystocia New definitions for second stage arrest of labor: • No progress (descent or rotation) with epidural  Four hours or more for a nulliparous woman  Three hours or more for multiparous woman • No progress (descent or rotation) without epidural  Three hours or more for a nulliparous woman  Two hours or more for a multiparous woman

25. Second stage labor dystocia may occur secondary , inadequate contractions , maternal exhaustion , or cephalopelvic disproportion . Each of these etiologies has potential management options

26. • For fetal malposition  Consider manual rotation  Maternal position change and movement • For inadequate contractions in the second stage  Consider augmenting with oxytocin • Allow pushing in an upright, lateral, or hands‐knees position • Pushing in an upright position increases the risk of:  Second degree perineal tears  Postpartum hemorrhage

27. Passive Second Stage Management • If epidural, may delay active pushing after complete dilation (60 to 90 minute delay) • Allow patient to labor down to a lower station or until she develops the urge to push  Less time pushing may decrease maternal exhaustion  No decrease in cesarean or assisted vaginal delivery rates  No effect on neonatal outcomes

28. Second Stage Labor Dystocia : Cautions • In prolonged second stage  Assess fetal tolerance of ongoing labor and active pushing  Avoid prolonged dorsal lithotomy position  Allow rest between pushing • Expedite delivery for concerning fetal monitoring  Assisted vaginal delivery if station +2 or greater  Perform cesarean delivery

29. Prevention Maternity care providers can attempt to decrease the risk of dystocia with the following antepartum and intrapartum strategies: undertaking prenatal interventions to decrease the incidence of fetal macrosomia , providing labor support and hydration , avoiding elective labor induction with an unripe cervix, using epidural analgesia judiciously, and preventing chorioamnionitis .

30. Active management of the third stage  Active management of the third stage involves 3 components: 1. uterotonic drugs(oxytocin10 IU by intramuscular injection) 2. early clamping and cutting of the cord 3. controlled cord traction

31. Physiological management of the third stage  Physiological management involves 3 components: 1. no uterotonic drugs 2. no clamping of the cord until pulsation has ceased 3. delivery of the placenta by maternal effort.

32. Prolonged third stage  if not completed within 30 minutes of the birth of the baby with active management and 60 minutes with physiological management

33. Observations in the third stage 4. general physical condition, 1. report of how she feels 2. vaginal blood loss. 3. in the presence of haemorrhage , retained placenta or maternal collapse, frequent observations to assess the need for resuscitation are required

34.  Changing from physiological management to active management of the third stage is indicated in the case of:  haemorrhage  failure to deliver the placenta within 1 hour  the woman's desire to shorten the third stage.  Pulling the cord or palpating the uterus should only be carried after oxytocin .  Don‟t use routinely umbilical oxytocin infusion nor prostaglandin