Normal and abnormal labour+ctg.pptx obst

obg

1. Normal and abnormal labour Presenter : Yap Pea Wen, Teh Zhen Wei Supervised by Dr Janisha, Dr Adilah

2. Definition of labour Labour is a process whereby, there is a presence of regular uterine contractions of increasing intensity and frequency that is associated with progressive dilatation and effacement of the cervix and descent of the presenting part . It may or may not be associated with rupture of membranes and leaking liquor. (MOH 2013)

3. Power- myometrium Myometrial cells contain filament of actin and myosin Actin and myosin interacts and cause progressive shortening of uterine smooth muscle cells (retraction of upper segment) Lower segment becomes thinner and more stretched Cervix being taken up into the lower segment of uterus (effaced) Prostaglandin and oxytocin increase intracellular free calcium ions increase smooth muscle contraction

4. Passage – pelvic inlet and outlet Normal transverse diameter- Inlet: 13.5cm , outlet: 11cm Normal AP diameter- Inlet: 11-12cm , outlet: 13.5cm (Transverse is the widest diameter at the inlet while AP is the widest at the outlet) Angle of inlet normally 60°to the horizontal in the erect position Increased angle may delay entering and descending of fetal head During 3 rd trimester, these become loosen Pelvic ligament at pubic symphysis Sacroiliac joint

5. Caldwell Moloy classification of female pelvis

6. Passage - pelvic floor Formed by levator ani muscles, which with their fascia, for a musculofascial gutter during second stage of labour Encouraged fetal head to flex and rotates as it descends through the midpelvis towards the outlet

7. Passage – perineum Perineal body Condensation of fibrous and muscular tissue Between vagina and anus Always involved in a 2 nd degree perineal tear

8. Passenger - Fetal skull bones, sutures and fontanelles Sutures allow bones to move together and even to overlap Parietal bones usually slides over the frontal and the occipital bones These allowing moulding to occur- reducing the diameter of fetal skull and ease the labor process without harming brain

9. passenger Presentation Attitude Presenting diameter Length (cm) Vertex (occipito-anterior position) Flexed Suboccipitobregmatic 9.5 Vertex Semi-deflexed Suboccipitofrontal 10.5 Vertex (occipitoposterior position) Deflexed Occipitofrontal 11.5 Brow Semi-extended Mentovertical 13 Face Extended Submentobregmatic 9.5

10. • • • • • • • En g a g e m e n t Descent Flexion Internal rotation Extension Restitution and external rotation Expulsion(delivery of shoulder and body) Mechanism of labour

11. Stages of labour

12. First stage of labour Duration of labour: first labours last on average 8 hours and are unlikely to last over 18 hours second and subsequent labours last on average 5 hours and are unlikely to last over 12 hours Latent first stage of labour - a period of time, not necessarily continuous, when: there are painful contractions and there is some cervical change, including cervical effacement and dilatation up to 4cm Established first stage of labour - when: there are regular painful contraction and there is progressive cervical dilatation from 4cm

13. Second stage of labour Passive second stage of labour : - the finding of full dilatation of the cervix before or in the absence of involuntary expulsive contractions. Onset of the active second stage of labour : - the baby is visible - expulsive contractions with finding of full dilatation of the cervix or other signs of full dilatation of the cervix - active maternal effort following confirmation of full dilatation of the cervix in the absence of expulsive contractions. Duration of the second stage and definition of delay : - For a nulliparous woman: birth would be expected to take place within 3 hours of the start of the active second stage in most women diagnose delay in the active second stage when it has lasted 2 hours - For a multiparous woman: birth would be expected to take place within 2 hours of the start of the active second stage in most women diagnose delay in the active second stage when it has lasted 1 hour

14. Third stage of labour The third stage of labour is the time from the birth of the baby to the expulsion of the placenta and membranes. Prolonged third stage if not completed within 30 minutes with active management.

15. Partogam

16. Management of labour First stage Start partogram (active stage) Hydration Left lateral and ambulation IV Pitocin Second stage Empty bladder Support and encouragement Episiotomy

17. Abnormal labour

18. DEFINITION Failure of uterine contractions that results in progressive dilatation and effacement of the cervix which suggest an increased risk of an unfavourable outcome Obstetrician to consider alternative methods for a successful delivery that minimize risks to both mother and infant

19. ETIOLOGY (3Ps) Power : Poor uterine contraction, poor maternal effort Passenger : Macrosomic baby, malpresentation Passage : Contracted pelvis, soft tissue abnormalities (myoma, tumors, perineal edema)

20. Risk factors Older maternal age Macrosomic baby Pelvic contraction Nulliparity Short stature Chorioamnionitis High station at full dilatation Occiput posterior posterior

21. Labour patterns Normal labour divided into : 1. Latent phase 2. Active phase Abnormal labour : 1. Prolonged latent phase (Nullipara >20H, Multipara >14H) 2. Protraction and arrest disorders of active phase

22. Prolonged latent phase Factors that affect the duration of the latent phase include : 1. Excessive sedation 2. Poor cervical conduction : thick, unaffected or undilated cervix 3. False labour Management: 1. Simple analgesics 2. Oxytocin 3. Amniotomy 4. Mobilization

23. Protraction or arrest disorders of active phase Protraction is defined as a slow rate of cervical dilatation or head descent Arrest of dilatation defined as 2 hours with no cervical change or arrest of descent as 1 hour without fetal descent Factors contributing to both conditions: 1. Excessive sedation 2. Fetal malposition 3. Cephalopelvic disproportion (CPD)

24. Classification of abnormalities of pelvis Contracted pelvis : shape and size are sufficiently abnormal to cause difficulty in vaginal delivery of normal baby 3 classifications: 1. Contracted Inlet plane 2. Contracted mid-pelvis 3. Contraction outlet plane Pelvic malformations : 1. Congenital (Naegel’s pelvis, Robert’s pelvis, split pelvis) 2. Acquired (Metabolic diseases, Vertebral column diseases)

25. Uterine dysfunction Most common cause of poor progress in labour Assessment done by clinical examination and tocography. A frequency of 4-5 contractions is considered ideal There are 3 types of uterine dysfunction: Hypotonic uterine dysfunction Hypertonic uterine dysfunction Incoordinated uterine dysfunction

26. Hypotonic uterine dysfunction No basal hypertonous and uterine contraction have a normal gradient pattern (synchronous) but the slight rise in pressure during contraction is insufficient to dilate the cervix Treatments: 1. Maternal hydration 2. ARM 3. IV Oxytocin

27. Hypertonic uterine dysfunction Either basal tone is elevated appreciably or pressure gradient is distorted, perhaps by contraction of the mid-segment of the uterus with more force than the fundus Incoordinate uterine dysfunction Complete asynchronism of the impulses originating in each cornue Treatments: 1. Oxytocin 2. Caesarean section

28. Abnormalities of the fetus F e t o pelvic r el a ti o nshi p s: 1 . Lie ( T r an s v e r se, o blique o r l o ngitudinal) 2 . Presentation (cephalic, Breech, shoulder or cord presentation) Positions : 4 common classical positions : ( LOA, ROA, ROP, LOP) Macrosomic

29. CARDIOTOCOGRAHY Normal & Abnormal CTG

30. INTRODUCTION Cardiotocography is a combination of: Cardiography – continuous electronic record of the FHR obtained via ultrasound transducer either externally or internally Tocography – electronic record of uterine activity via tranducer placed on mother’s abdomen over the uterine fundus Not a diagnostic test but a screening test for identification of babies with acute or chronic fetal hypoxia or at risk of developing such hypoxia High degree of sensitivity but low level of specificity

31. Approach to ctg ( dr c bravado) D efine R isk C ontraction B aseline Ra te V ariabilities A ccelerations D ecelerations O verall

32. D eFINE R ISK Firstly, you have to assess either the pregnancy is low/high risk Some pregnancy may consider as high risk MATERNAL MEDICAL ILLNESSES Hypertension Gestational diabetes Asthma OBSTETRIC COMPLICATIONS Multiple gestation Post-date gestation Previous caesarean section Intrauterine growth restriction PROM Congenital malformation Pre- eclampsia Induction of labor OTHER RISK FACTORS Smoking Drug abuse Absence of prenatal care

33. Control Factor (MOTHER) Meconium Oxytocin Temperature Hyperstimulation, hemorrhage Epidural, environment (maternal, fetal and organizational) Rate of progress of labor Scar, sepsis and size (both maternal and fetal)

34. C ONTRACTION Record the number of contraction present within 10 minutes Assess the contraction based on Duration – How long do the contraction last? Intensity – How strong are the contractions? Hyperstimulation >5:10

35. B aseline ra te Baseline rate is the average heart rate of the fetus within a 10 minute excluding the accelerations and decelerations

36. Baseline rate ( bpm ) NICE 2017 Reassuring 110 – 160 Non-reassuring 100 – 109 OR 161 – 180 Abnormal < 100 OR > 180

37. 100 200 180 160 140 120 60 80 180 100 110 160 REASSURING NON REASSURING ABNORMAL 40 60 80 100 20

38. V ariabilities Variations of fetal heart rate from one beat to the next To determine variabilities , you measure how much peaks and troughs of the heart rate deviate from the baseline

39. Baseline variability ( bpm ) NICE 2017 Reassuring 5 - 25 Non-reassuring < 5 for 30 – 50 minutes OR > 25 for 15 – 25 minutes Abnormal < 5 for > 50 minutes OR > 25 for > 25 minutes OR Sinusoidal

40. 100 200 180 160 140 120 60 80 40 60 80 100 20 10 20 60 40 70 100 90 80 110 REASSURING ABNORMAL > 50 MINUTES <5 BPM NON REASSURING 30 50

41. 100 200 180 160 140 120 60 80 40 60 80 100 20 10 20 60 40 70 100 90 80 110 REASSURING NON REASSURING ABNORMAL > 25 MINUTES > 25 BPM 30 50

42. A ccelerations Transient increases in FHR of ≥ 15 bpm and lasting ≥ 15 s

43. Acceleration NICE 2017 Reassuring No specific classification Presence of accelerations even with reduced baseline variability generally a sign that the baby is healthy Absence of accelerations on otherwise normal CTG trace does not indicate fetal acidosis Non-reassuring Abnormal

44. D ECELERATIONS Transient episodes of slowing of FHR below the baseline level of >15 bpm and lasting ≥ 15 s or more Early D ecelerations Starts when the contraction begin and recover once the contraction stop Caused by vagal nerve stimulation secondary to head compression

45. Late decelerations Decelerations that occur at peak of uterine contraction and recover after contractions end. It is seen decreased transplacental exchange, as in placenta insufficiency maternal hypotention, supranormal uterine activity. ‎.

46. Variable decelerations Variable decelerations defined as rapid fall in baseline fetal heart rate with variable recovery phase Commonly caused by umbilical cord compression and may be abolished by changing position of the mother so as to relieve cord compression.

47. Prolonged decelerations Decelerations that last more than 3 minutes If it is last between 2-3 minutes – non reassuring If it is last more than 3 minutes - abnormal If it is last more than 3 minutes with FHR maintained below 80 bpm and associated with reduced variability, are frequently associated with asevere fetal hypoxia and require urgent intervention

48. Changes during fetal hypoxemia (ABCDE) A – Absence of accelerations B – Baseline rise – catecholamine surge following decelerations becoming deeper and wider to redistribute blood and to perfuse vital organs C – Compensated stress response – the fetus maintains a stable baseline and a reassuring variability despite ongoing deceleration and an increase in the baseline FHR D – Decompensation characterized by loss of baseline variability and/or cycling, which may be followed by an unstable baseline FHR E – End stage characterized by a progressive decline in the baseline FHR – the “stepladder pattern to death”

49. The “end stage” of hypoxia: The “stepladder pattern to death”.

50. Sinusoidal pattern Smooth, regular wave like pattern , 2-5 cycles in a minute with stable baseline rate 120-160 bpm and no beat to beat variability

51. Decelerations NICE Guideline 2017

52. NO CONCERNING CHARACTERISTICS CONCERNING CHARACTERISTICS LASTING < 60 SECONDS LASTING > 60 SECONDS

53. NO CONCERNING CHARACTERISTICS CONCERNING CHARACTERISTICS VARIABILITY WITHIN DECELERATION REDUCED VARIABILITY WITHIN DECELERATION

54. NO CONCERNING CHARACTERISTICS CONCERNING CHARACTERISTICS RETURN TO BASELINE FAILURE RETURN TO BASELINE

55. NO CONCERNING CHARACTERISTICS CONCERNING CHARACTERISTICS NO BIPHASIC (W) WAVE BIPHASIC (W) WAVE

56. NO CONCERNING CHARACTERISTICS CONCERNING CHARACTERISTICS SHOULDERING NO SHOULDERING

57. 100 200 180 160 140 120 60 80 40 60 80 100 20 REASSURING NO DECELERATION

58. 100 200 180 160 140 120 60 80 40 60 80 100 20 10 30 20 VARIABLE DECELERATION WITHOUT CONCERNING CHARACTERISTICS < 90 MINUTES REASSURING SHOULDERING RETURN TO BASELINE RETURN TO BASELINE NO BIPHASIC (W) WAVE LASTING < 60 SECONDS VARIABILITY WITHIN DECELERATION NO CONCERNING CHARACTERISTIC < 90 MINUTES

59. 100 200 180 160 140 120 60 80 40 60 80 100 20 10 20 30 VARIABLE DECELERATIONS WITH ANY CONCERNING CHARACTERISTICS IN UP TO 50% OF CONTRACTIONS FOR ≥ 30 MINUTES NON REASSURING NO SHOULDERING FAILURE TO RETURN TO BASELINE LASTING > 60 SECONDS & NO VARIABILITY WITHIN DECELERATION BIPHASIC (W) WAVE 4 VARIABLE DECELERATION IN 10 CONTRACTION

60. 100 200 180 160 140 120 60 80 40 60 80 100 20 NON REASSURING LATE DECELERATION IN OVER 50% OF CONTRACTION FOR < 30 MINUTES 10 30 20

61. 100 200 180 160 140 120 60 80 40 60 80 100 20 ACUTE BRADYCARDIA OR SINGLE PROLONGED DECELERATION LASTING 3 MINUTES OR MORE 10 30 20 ABNORMAL

62. O VERALL Once you’ve assessed all aspects of the CTG, you’ve to provide overall impression. Based on NICE guidelines 2017, the overall impressions can be described as Normal Suspicious Pathological The overall impression is determine by how many reassuring, non-reassuring and abnormal features seen

63. I nterpretation NICE 2017 Normal All features are reassuring Suspicious 1 non-reassuring feature AND 2 reassuring features Pathological 1 abnormal feature OR 2 non-reassuring features

64. managament

65. Normal All features are reassuring Continue CTG (unless it was started because of concerns arising from intermittent auscultation and there are no ongoing risk factors) and usual care

66. Suspicious 1 non-reassuring feature and 2 reassuring features Maternal observation and assessment, correct any underlying causes, such as hypotension or uterine hyperstimulation Start 1 or more conservative measures Encourage woman to mobilise or adopt an alternative position (avoid being supine, i.e put patient on left lateral position) Offer intravenous fluids if the woman is hypotensive Reduced contraction frequency by reducing or stopping oxytocin Offering tololytic drug (s/c terbutaline 0.25mg) Catheterise patient and do vagina examnation for digital fetal scalp stimulation Inform an superior and document a plan for reviewing the whole clinical picture and CTG findings

67. Pathological 1 abnormal feature or 2 non-reassuring features Obtain a review by superior If the CTG trace is still pathological after implementing conservative measures: Obtain a further review by an obstetrician Offer digital fetal scalp stimulation and document the outcome If the CTG trace is still pathological after fetal scalp stimulation: Consider fetal blood sampling Consider expediting the birth Take the woman’s preferences into account

68. Urgent intervention Acute bradycardia or a single prolonged deceleration for 3 minutes or more Urgently seek obstetric help Make preparations for an urgent birth Talk to woman and her birth companion about what is happening Expedite the birth if the acute bradycardia persists for 9 minutes If the FHR recovers at any time up to 9 minutes, reassess any decision to expedite the birth, in discussion with the woman

69. REFERENCES Intrapartum care for healthy women and babies; NICE guideline; 2019 Intrapartum care: NICE Guildeline CG190 CTG (Feb 2017) Clinical Protocols in Obstetrics & Gynaecology For Malaysian Hospitals Rushdan Noor & Bavanandan Naidu; Normal Pregnancy Labour and Operative Delivery (Revised Edition); 2019 Diogo Ayres de-Campos; FIGO consensus guidelines on intrapartum fetal monitoring; FIGO; 2015q

70. THANK YOU