Labour Management - Western University · Third Stage of Labour • Signs of separation 1. New...
Transcript of Labour Management - Western University · Third Stage of Labour • Signs of separation 1. New...
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Labour Management
Clerkship Seminar Week 1University of Western Ontario
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Labour and Birth
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First Stage of Labour
• Definition:• Onset of labour
full dilatation• Latent phase: 0-4 cm• Active phase: 4-10 cm
• True Labour: regular uterine contractions causing progressive cervical dilation
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Describe FHR Patterns Heart rate
• Baseline• Normal 120-160 beats per minute (bpm)• Tachycardia >160 bpm • Bradycardia <120 bpm
• Accelerations• > 10 bpm from baseline
• Decelerations• > 10 bpm from baseline
• Type of decelerations • Early, late, variable or mixed-pattern decelerations
• Baseline variability • + or – 5 bpm
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First Stage of Labour
• Fetal Heart Rate (FHR) Monitoring• Intermittent:
• q 15 min 1st stage / q 5 min 2nd stage
• Continuous (CEFM) :• Meconium staining of amniotic fluid (MSAF)• High risk – Preeclampsia, bleeding, abN FHR• Induction / Augmentation – Syntocinon• VBAC (Vaginal Birth After Caesarean)• *Maternal, fetal or placental risk factors for adverse
pregnancy outcomes ?
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Fetal Wellbeing in Labour
• Baseline FHR• Accelerations• Decelerations• Type of
decelerations • Baseline
variability
• Contractions• Frequency • Amplitude• Duration • Baseline tone
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Cause ?
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Cord prolapse
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Fetal tachycardia
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What FHR pattern would you expect in this fetus ?
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Sinusoidal patternRegular amplitude and frequency
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Fetal anemia Hemolytic disease of fetus(Rh)
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Variable decel
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Variable deceleration
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Late decel
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Late decel
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Fetal acidemia, hypoxia….
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Fetal acidemia !!!
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Early decel(mirror contraction)
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Early decel
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Mixed pattern…
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Assessment of Uterine activity
• Contractions• yes/no
• Frequency of contractions• Optimally every 2-3 min
• Amplitude• 40-60 mmHg
• Duration • 60-90 seconds
• Baseline tone • <15 mmHg
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Progress in First Stage of Labour:Monitoring
• Contractions:• by palpation – q 30 min early• Tocometer – in high risk or slow progress• IUPC (intra-uterine pressure catheter)
• Cervical change:• Q 2 hours in early labour• Sooner based on patient symptoms, FHR • Assess dilation, effacement, station
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IUPC Intrauterine pressure catheter
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Friedman Curve
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Friedman Curve (1967)
• Normal curves of progress of labour • Not strict rules, but guidelines
• First stage• 6 - 18 hrs primip / active phase 1.2 cm/hr• 2 – 10 hrs multip / active phase 1.5 cm/hr
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Friedman
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Labour Dystocia(Failure to progress)
• Most common cited reason for C/S
1. Passage – Abnormal pelvis2. Passenger – LGA fetus3. Powers
poor contraction patternpoor pushing
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Labour and BirthSecond stage
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Second Stage of Labour• Definition:
• Full dilatation delivery of fetus
• Friedman: 30 min – 3 hrs primip5 min – 30 min multips
• Progress monitored by station• 0 = ischial spines• 1-5 cm (or thirds) of total distance
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Fetal Position
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Left occiput transverse (LOT)
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Labour and Birth
• Engagement• Descent• Flexion• Internal rotation
Mechanism of Normal Labour(Cardinal movements)
• Extension • External rotation• Expulsion
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Cardinal Movements
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Cardinal Movements
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Cardinal Movements
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Cardinal Movements
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Vaginal Delivery
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Second Stage of Labour
• Pelvic architecture issues:• Best outcomes with gynecoid & android
pelvis• Cardinal movements may be inhibited by
narrow or flat pelvis• Trial of labour is only true test of pelvic
adequacy
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Labour and BirthThird stage
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Third Stage of Labour• Definition:
• delivery of fetus expulsion of placenta
• Timeline – 2 – 30 min• Active management – WHO / SOGC
• Uterotonic agents (Syntocinon / Misoprostol )• Gentle traction on cord• Fundal massage
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Third Stage of Labour• Signs of separation
1. New onset bright bleed2. Lengthening of umbilical cord3. Globular and firmer uterus
• Uterine involution – oxytocin mediated
• Inspection and repair of lacerations• (including visualization of cervix)
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Labour and BirthSummary
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Analgesia• Natural supported labour
• Narcotics
• Nitrous/Oxygen inhalation
• Regional analgesia (Epidural)
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Induction• Indications:
• Post dates• Preeclampsia• Diabetes Mellitus• Maternal disease (cardiac)• PROM / IUGR
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Induction
• Methods • Syntocinon – synthetic oxytocin
• Prostagalndins – Cervidil, Prostin gel, Misoprostol
• ARM – artificial rupture of membranes, may be enough to initiate labour
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Augmentation
• Failure to progress• Oxytocin infusion• Titrate to good contraction pattern and
cervical change• Intrauterine pressure catheter (IUPC)
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Caesarean Section
• Indications1. Failure to progress2. Non-reassuring FHR status3. Previous caesarean section4. Fetal malpresentation – breech,
transverse
• Responsible for 70% of sections
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Labour Dystocia(Failure to Progress)
• Most common cited reason for C/S
1. Passage – Abnormal pelvis2. Passenger – LGA fetus3. Powers – poor contraction pattern
- poor pushing
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C/S Technique
• Standard Uterine Incision– Lower uterine segment– Transverse– Low risk of rupture in subsequent labour
(0.5%)• Vertical (Classical), or “T” Incision
– High risk of rupture in subsequent labour (5%)
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