Epico educational topic number 22

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abnormal labor you may remember our

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patient labora deliver it from our app

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go video number eleven intrapartum care

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we follow libera through a normal labor

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and delivery course in that video in

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this video labora will experience

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abnormal labor we will discuss how best

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to provide care for labora and her fetus

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to optimize outcomes the objectives of

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this video are to list and describe the

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causes and methods of evaluation of

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abnormal labor patterns discuss fetal

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and maternal complications of abnormal

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labor list indications and

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contraindications for oxytocin

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administration describe risks and

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benefits of trials of labor after

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caesarean delivery and lastly discuss

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strategies for emergency management of

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breech presentation

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shoulder dystocia and cord prolapse here

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is labora entering labor and delivery

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and active labor

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she is dilated to 5 centimeters let’s

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start by talking about the 3 p’s that

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contribute to a normal labor the power

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the passenger and the passage the power

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refers to uterine contractions the

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uterus must produce strong frequent

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contractions that will dilate the cervix

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and cause the fetus to descend down

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ideally the uterus should contract three

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times in a 10-minute period here is a

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fetal heart rate tracing and remember

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that the top line is the fetal heart

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rate and the bottom line are the uterine

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contractions this tracing shows ten

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minutes of laborious labor and she has

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three contractions marked by the white

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arrows the uterine contractions are

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usually monitored by an external tool

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commoner which does not give information

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about the strength of the contractions

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just the timing let’s check back on

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labora she was admitted to labor and

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delivery in active labor at five

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centimeters dilated and she’s been

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having regular painful contractions for

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two hours since she is a gravity’ one

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pair zero and active labor her cervix is

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expected to dilate at approximately one

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point two centimeters per hour a

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multi-purpose patient and active labour

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should have progression of approximately

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1.5 centimeters per hour after 2 hours

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when we recheck labora cervix it is

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unchanged and it is still 5 centimeters

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dilated

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in order to assess the strength of the

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contractions we place an intrauterine

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pressure catheter or IUP see this

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tracing is from an IUP see the strength

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of the contraction is the amplitude of

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each wave a Montevideo unit

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can be simply calculated by measuring

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the amplitude above the baseline for a

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10-minute period and adding them

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together

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normal labor progress is usually

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associated with a Montevideo unit of

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greater than 200 next let’s move on to

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the passenger ideally the foetus is not

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too big and is in a good position for

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delivery if the fetus has an estimated

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weight greater than 4,500 grams the risk

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of shoulder dystocia and labour dystocia

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are greater the fetal position is

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important as well for ideally you want

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the fetus positioned in the optimal way

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to be able to fit through the pelvis

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let’s review the bony landmarks of the

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fetal vertex on vaginal examination the

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diamond-shaped anterior fontanelle and

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the triangular shape posterior

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fontanelle can be palpated as well as

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the sagittal suture this photo has a

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better view of the triangular shaped

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posterior fontanelle we describe the

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fetal position in relationship to the

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fetal occiput and the maternal body here

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is a fetus in the occiput anterior

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position here is the posterior

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fontanelle and the occupant is on the

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anterior part of the maternal body this

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is the optimal position for delivery for

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this as the smallest diameter that has

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to pass through the pelvis this fetus is

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in the occiput posterior position note

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the posterior occiput and the anterior

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fontanelle this fetus is in the occiput

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transverse position both the occiput

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posterior and occiput transverse

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positions have bigger diameters that

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need to fit through the pelvis there are

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other possible presentations such as a

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compound presentation or face

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presentation which could all contribute

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to labor dystocia labor can be stalled

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before she reaches ten centimeters

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dilated known as failure to progress or

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arrest and dilation where the patient

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can reach ten centimeters and the fetus

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does not descend for delivery known as a

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rest of descent the last of the three

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P’s to discuss is passage maternal

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skeletal or soft tissue issues can

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obstruct the birth canal

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cephalo pelvic disproportion refers to

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the conflict between the fetal head and

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the pelvic size the pelvic bone shape or

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maternal soft tissue most commonly

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excess adipose tissue can contribute to

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labor dystocia let’s get back to labora

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remember that she was admitted at five

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centimeters dilated in active labor at

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the time of a repeat sterile vaginal

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examination she was still 5 centimeters

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and replaced an intrauterine pressure

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catheter and this demonstrated that her

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contractions were not strong enough

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augmentation refers to stimulation of

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uterine contractions amniotic or

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rupturing of her amniotic membranes can

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enhance progress in the active phase it

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may stimulate release of prostaglandins

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which aid in augmenting the force of

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contractions and also allows for the

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fetal head to be the dilating force

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oxytocin can also be given intravenously

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to strengthen contractions the goal is

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to titrate the oxytocin so that the

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contractions are strong and frequent

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enough to produce cervical change in

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fetal descent but not too strong to

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cause uterine tachy systole uterine

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tachy systole is defined as more than

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five contractions in 10 minutes over a

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30 minute period you perform an an Reata

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me and oxytocin has started for labora

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three hours later you check on her and

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she is happily 10 centimeters dilated

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and she starts pushing her second stage

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is slow but she continues to make

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progress and after 2.5 hours of pushing

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she delivers the fetal head and you

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realize that the anterior shoulder is

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stuck this is a shoulder dystocia let’s

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now switch gears to discuss shoulder

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dystocia

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shoulder dystocia can be a true

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obstetric ‘el emergency the baby’s

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anterior shoulder is effectively caught

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behind the pubic symphysis which is

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illustrated in white it is important to

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remain calm and to know the steps to

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help deliver the shoulder in general

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there is about 5 minutes to deliver a

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well oxygenated term infant first and

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foremost take steps to make sure that

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you have adequate nursing and obstetric

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‘el staff support start with McRoberts

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maneuver which is hyper flexion and

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abduction of the hips this can open up

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space that will enable the shoulder to

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be reduced the next step is suprapubic

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pressure which is pressure directed

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downward on the anterior shoulder if

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these first two steps do not lead to

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delivery then next try to deliver the

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posterior arm of the fetus an episiotomy

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can be helpful at this point to open up

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space posteriorly additional steps for

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shoulder dystocia include the wood screw

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and Reuben maneuver which are rotation

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of the fetus to reduce the shoulder it

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can also be helpful to move the patient

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onto her hands and knees in severe cases

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intentional clavicular fracture can be

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performed and the last option is to

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perform as a Vannelli

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procedure which requires reversing the

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Cardinal movements to labor and to flex

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the head back into the uterus and to

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perform a cesarean delivery brachial

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plexus injury rates with a shoulder

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dystocia range from four to forty

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percent regardless of the maneuvers used

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to deliver the fetus the second

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obstetrical emergency that we will now

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discuss is cord prolapse this is when

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the umbilical cord descends in advance

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of the fetal presenting part here is the

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fetus and the blue umbilical cord that

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has prolapsed through the cervix cord

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prolapse occurs when one the fetus is

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not vertex or two there are spontaneous

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rupture of membranes before the vertex

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is well engaged or three there is

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iatrogenic artificial rupture of

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membranes before the vertex is well

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engaged cord prolapse is an emergency

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for the blood vessels in the umbilical

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cord are compressed when this is

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recognized the providers hand must push

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the fetal head up so it does not further

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compress the cord and the cord needs to

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be manually reduced back into the

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uterine cavity and the patient needs to

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be brought back to the operating room

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for an immediate caesarean section the

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hand needs to stay in place throughout

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this time until the baby is safely

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delivered the last emergency that we

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will discuss is breech delivery it is

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important to note that singleton breech

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presentations should be delivered by

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cesarean section there may be situations

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however when cesarean section is not

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possible because of precipitous delivery

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or lack of operative resources if this

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situation were to arise the first thing

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is to call for assistance next it’s

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important to avoid any traction on the

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fetus for the goal is to avoid a fetal

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head extension which can make the

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delivery more difficult wait until the

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maternal efforts have resulted in the

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fetus being delivered to the level of

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the umbilicus suprapubic pressure can

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then be applied to promote flexion and

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descent of the fetal head we will

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conclude laborious journey into the

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world of abnormal labor with a

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discussion about women who have had a

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previous cesarean section what if labore

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had a history with cesarean section with

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their first pregnancy there are three

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primary possible outcomes she could have

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a successful trial of labor after

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cesarean which is a vaginal birth after

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cesarean or VBAC this is the ideal

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option for labora will have decreased

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maternal morbidity and decreased risk of

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complications with future pregnancies at

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a population level more vivax mean there

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is a decreased overall cesarean delivery

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rate

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our next preferred option would be a

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scheduled repeat low transverses Aryan

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section at 39 weeks

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our third preferred option is a failed

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trial of labor after cesarean and she

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still ultimately needs a caesarean

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delivery this option has the highest

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rates of maternal morbidity with higher

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rates of bleeding and infection it is

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important to weigh the risks and

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benefits when making these decisions

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with our patients the benefits of a

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successful trial of labor after

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caesarean delivery are that you avoid

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surgery which needs to lower rates of

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hemorrhage infection and you’ll have

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shorter recovery periods in addition

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there are decreased future abnormal

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placentation risks such as placenta

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previa or placenta accreta uterine

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rupture is the most feared complication

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of a trial and labor after cesarean with

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a history of one low transverse cesarean

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section the risk of uterine rupture is

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0.7 20.9% with a history of too low

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trans vs. Aaron sections the risk of

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rupture is 0.9 to 1.8% with a history of

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a classical cesarean section the risk of

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uterine rupture is 10% this high rupture

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risk is why these women should have a

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repeat cesarean delivery and not try to

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labor when counseling patients who’ve

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had a load trans versus Aaron section

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different clinical factors have to be

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taken into account that either increase

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or decrease your probability of a

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successful VBAC having a history of a

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prior vaginal birth or if she presents

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some spontaneous labor both increase

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your probability of a successful VBAC

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factors that increase her chance of a

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failed trailer labor after caesarean

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include increased maternal age non-white

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ethnicity obesity a recurrent indication

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for the initial cesarean delivery such

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as labor dystocia increased neonatal

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birth weight at gestational age greater

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than 40 weeks preeclampsia and a short

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enterprise-e interval ultimately labora

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and her healthcare provider should

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discuss and decide on a delivery plan

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that factors in her individual clinical

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factors as well as the availability of a

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24 hour blood bank continuous electronic

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fetal monitoring and other Hospital

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factors such as in-house anesthesia that

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will enable an expedient cesarean

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delivery to be performed if necessary

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this concludes the Africa video an

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abnormal labor we have discussed the

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three P’s to consider in evaluating

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labor discuss fetal and maternal

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complications of abnormal labor

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discussed oxytocin and risks and

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benefits of trial of labor after

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caesarean

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disgust management of emergent of

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technical situations