Sudan international university

Handouts part one

Subject obstetrics

Contents

1-obstetric history + some definitions

2- obstetric examinations

3- Hypertensive disorders

4- Normal Labour

5- Abnormal Labour

6-Miscarriage

7-Ectopic pregnancy

8-Molar Pregnancy

9-Hyperemesis gravidarum

10-Antepartum haemorrhage

11- postpartum haemorrhage

13-Preterm labour & premature rupture of membranes

14- Obstetric procedures

15-Venous thrombo-embolism in pregnancy

16- Puerperal pyrexia

17-Anaemia in pregnancy

18-Malaria in pregnancy

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Chapter-1

Introduction to obstetric patients/Obstetric History

& some defintions

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Introduction to obstetric patiants

Pregnant women require routine prenatal care to help ensure their health and the health of the fetus.

Also, evaluation is often required for symptoms and signs of illness. Common symptoms that are often pregnancy-related include vaginal bleeding, pelvic pain, vomiting, and lower-extremity edema .

Before pregnancy & timing of first visit:

Ideally, women who are planning to become pregnant should see a physician before conception, so that they can be counseled about pregnancy risks and ways to reduce them. The initial routine prenatal visit should occur between 6 and 8 wk gestation.

Subsequent visits

Follow-up visits should occur at about 4-wk intervals until 28 wk, at 2-wk intervals from 28 to 36 wk, and weekly thereafter until delivery. Prenatal care includes screening for disorders, taking measures to reduce fetal and maternal risks, and counseling.

Initial visit

During the initial visit, clinicians should obtain a full medical history, including previous and current disorders.

Drug use (therapeutic, social, and illicit)

Risk factors for complications of pregnancy

Obstetric history, with the outcome of all previous pregnancies, including maternal and fetal complications (eg, gestational diabetes, preeclampsia, congenital malformations, stillbirth)

Family history should include all chronic disorders in family members to identify possible hereditary disorders.

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Defintions• Gravidity number of all pregnancies including ongoing

pregnancy Irrespective of outcome or its fate , or nature.

• Parity delivery after 24 weeks (In some countries 20 weeks )

• Abortion or Miscarriage Termination of pregnancy before viability (24 weeks) or conceptus wieghing 500 g or less.

Other important definitions

Term 37 weeks-42 weeks of gestation

Preterm labour onset of labour between 24 weeks-↓37 weeks of gestation.

Stillbirth: A stillborn baby is a baby who is born dead after 24 completed weeks of pregnancy.

Neonatal deaths Number of deaths during the first 28 completed days of life per 1,000 live births in a given year or period.

Neonatal deaths may be subdivided into early neonatal deaths, occurring during the first seven days of life, and late neonatal deaths, occurring after the seventh day but before the 28 completed days of life.

Posterm Pregnancy When pregnancy extends beyond 42 weeks of gestation

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Postdate pregnancy When pregnancy exceeds 40 weeks but still below 42 weeks.

Post-maturity when the new-born shows signs postmaturity such as retarded growth long nails, loss of S/C fat, old man look ect.

Other definitions

Lie

Relationship between longitudinal axis of the mother and longitudinal axis of the fetus.

Presentation

Lowermost part of the fetus adjacent (near) to pelvis or cervix (e.g. if head it is called cephalic presentation & if bottock it is called breech presentation

Denominator

A Point in the presenting part which denotes postion

e.g. In cephalic vertex presentation the denominator is the occipt & in breech presentation it is the sacrum.

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Position

The relationship of the denominator of the presenting part to the 4 quadrants of the pelvis.

e.g. in cephalic vertex presentations positions are left & right occipto-lateral-occipto-aterior & occipto-posterior (mention others)

Attitude

relationship of different fetal parts to each other. Normal attitude is flexed attitude.

Labour

regular periodic painful contraction resulting in cervical dilatation & effacement.

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Skeleton of obstetric history

1-Introduction (greeting/introduce self/ explain to patient what is you are going to do)

2-Personal History

3-Why patient is here /

4-Gyaecological history

5-Obstetric history

6-Current pregnancy in trimesters

7-Details of her current complaints if any

8-Systemic review

9- Past medical & surgical history

10-Family history

11-Social history

12-Drugs & hypersenstivity

13-Summary

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Personal History• Name (4 names)

• Age (Importance, some will not till real age)

• Occupation

• Educational- level

• Residency (How far from hospital by time or distance)

• Tribe??

• Husband name (4 names)

• Husband age

• Husband Occupation

• Duration of marriage {&periods of sub-fertility if suitable}

• Consanguinity

• Patient blood group (Importance)

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Why patient is here

EXAMPLES• VAGINAL BLEEDING

• LABOUR LIKE PAIN

• WATERY DISCHARGE PER VAGINUM

• HEADACHE, EPIGASTERIC PAIN ,BLURRING OF VISION, DIPLOPIA, RIGHT HYPOCHONDRIAL PAIN/

• NO COMPLAINT COMING FOR ANC IN OUTPATIENTCLINIC

• She is coming for final MBBS examination

• G3p2+0 with 2 previous LSCS at 38 weeks of gestation,Coming for third repeat elective caesarean section.

• Primigravida at 38 weeks of gestation admitted today for elective LSCS tomorrow because of breech presentation.

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Gynaecological History• Menarche

• Kata

• Regularity/amount/Dysmenorrhea/Intermenstural Bleeding(IMB)/post-coital bleeding PCB

• Vaginal discharge/ amount//any itching/ador/color

• Dysparunia

• Contraceptive

• Gynaecological Operations/ Myomectomy/successful repair of VVF./anterior or posterior repair

• Last cervical smear

• LNMP

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Obstetric historyEDD (how to calculate)

GA (How to calculate)

Details of each pregnancy: start from first how pregnancy occurred (spontaneous or induced)//Any incident during pregnancy (Eventful or uneventful)

Delivery term or preterm /spontaneous or induced or augmented/ vaginal/instrumental/ caesarean section & if C/S mention indication /Duration/home or hospital/any complications

Outcome of delivery alife/dead/ Weight/ school performance.

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Pregnancy in trimesters;

First trimesterFirst 13 weeks

• Ask about

• When Pregancy was diagnosed

• Morning sickness

• Early ultrasound when & was it is consistent with date or not

• Booking?? // Vaginal bleeding //drugs // febrile illness specially with skin rash //exposure to radiation // UTI

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Pregnancy in trimesters; Second trimester 13-28 weeks

Quickening

First fetal movements perceived by mother timing in Multiparous 16-18 weeks//Primigravida 18-20 weeks (why)

Tetaus toxiod vacciation & number of doses taken

UTI

Vaginal bleeding.

Third Trimester-(28 weeks till delivery)

• Still appreciating fetal movements

• Epigastric pain, headache blurring of vision, vomiting & right hypochondrial pain

• UTI

• Vaginal bleeding

History of present illness or details of woman complaint

• You elaborate more according to mother complaint

Systematic review

• If relevant

Past medical (PH) & Surgical History

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• PH of DM

• PH of hypertension

• H/O bronchial Asthma

• H/O Cardiac disease

• PH of any other chronic illness

• PH of hosptilization

• PH of surgical operations (other than those mentioned in obstetric & gynaecological history)

• PH of blood transfusion

Family History

• FH of D.M

• FH of Hypertension

• FH of Bronchial Asthma

• FH of inherited diseases (rather than congenital)-e.g. haemoglobinpathies

• FH OF MULTIPLE PREGNANCY

• FH of anaesthetic complications

• FH of thrombo-embolic diseases or familial thrombophilias

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Social History

• Describe socio-economic status

• Housing house own or rented, consists of how many rooms, water & electrical supply

• Bad habits like smoking, Alcohol, & Illicit drugs

• Animals specially cats

Drugs & Hypersensitivities

• Any long term Medication

• Iron & folic acid

• Hypersensitivity to penicillins or any other medications

Summary

Include First name/ age/parity/GA in weeks/why she is here/any other important point in history e.g. previous caesarean sections & its indication, chronic illness, H/O PPH RH –ve blood groups allergy to penicillin ect. , ect.

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Chapter-2

Obstetric examinations1-Before Examination 1.1 -Communication skills:

Smile to your patient

Greeting

Introduce your self

Explain what you are going to do

Take permission

1.2-Others

Wash hands

Warm hands

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Obstetric examinations include

General examination

Systemic examination mainly CVS, Chest & breast.

Abdominal obstetric examinations including obstetric maneuvers

Lower limb edema & varicose veins

Here I will concentrate on breast & abdominal examinations

General examination include

upper limb

Pulse/B.P/clubbing/kolinychia/pallor of fingers and palm

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Head and neck

For pallor/jaundice/cyanosis/angular stomatitis/oral hygiene/ smooth tongue/gum/missed or loose teeth/artificial denture/dental caries.

Examine neck

for thyroid swelling, raised JVP, Tracheal deviation and lymph nodes.

Chest & CVS

symmetry and any deformity/Air entry//Heart sounds &thrills and murmurs.

Breast examinations

The Purpose of breast examination in pregnancy is to exclude any tumors (commonest tumor is fibro-adenoma but most important to screen for is CA Breast)-secondly breast examination is important in assessment and preparation for lactation. Colostrums is expressed in antenatal period.

If milk is expressed before delivery, this may occur in cases of intrauterine fetal death or in cases of women lactating during pregnany.

Breast examinations consist of

Inspection for symmetry/primary areola, secondary areola, Montgomery tubercles ,nipples (flat ,everted or inverted) scars,cracks and discharge.

Superficial palpation for tenderness and superficial masses. Look for patient face during this part of the examination.

Deep palpation areas to be examined are 4 quadrants of both breasts, nipple area & axillary tail. The quadrants are upper medial ,lower medial ,lower lateral and upper lateral.

You should support 2 quadrants while examining the other 2 i.e. when you are examining the medial or inner 2 quadrants support the lateral or outer 2 quadrants,& when you are examining the lateral or outer 2 quadrants.

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support the medial or inner 2 quadrants . Go in a circular method clockwise or anti-clock wise.

Abdominal obstetric examinations

Expose abdomen after permission and cover other areas.

Inspection

inspect abdomen for and comment about distension e.g. (Abdomen is distended consistent with pregnancy) /other things in inspection include, Linea Nigera, striae gravidarum//umbilicus position (inverted ,everted or flat )-scars ( most common is pfannenstiel incision for caesarean section, the other alternative which is rare nowadays is mid-line infra-umbilical incision).you should also comment about fetal movements ( absent or present). Ask patient to cough and comment about hernia orifices (e.g. hernia orifices are intact)

Superficial palpation (for superficial masses, tenderness and amount of Liquor). Before you start as mother wither she feels pain at any area.

Let the area of pain to be examined at last. If you encounter a mass and you like to check that wither it is deep or superficial ask patient to sit from lying position to put anterior abdominal wall muscle in action. If the mass is superficial it will be more prominent and vice versa.

Deep palpation

Deep palpations are for liver, spleen and both kidneys. Ask woman to take deep breath while you are palpating any of these organs. When you examine either liver or spleen ask patient to lie on the side opposite to the organ being examined i.e. left side for liver palpation an right side for spleen.

Obstetric maneuvers include 1-fundal level 2-fundal grip (which part occupies the fundus) 3-Lateral grips (where is the back & where are the limbs)4-first pelvic grip (for presentation)5-second pelvic

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grip (for engagement)6-check fetal heart rate sound after determining its position according to finding in lateral grips. (see later)

1-fundal level

Bear in your mine the gestational age as per history to compare it with the finding in your examinations.

Determine the xiphoid process.

Correct position of uterus by pushing it gently to left (to correct right obliquity of uterus occurring as the result of presence of sigmoid colon in left side) use the left hand ulnar or radial side to palpate the fundus by sliding gently from xiphisterum till the first area of resistance which is the fundus. Keep your left hand on fundus, release you right hand put it at the fundus instead of left hand. Check how many fingers between fundus & and xiphistrenum. Every one finger = 2 weeks. Substract the result out of 40 for example /one finger 40-2= 38 weeks/2 fingers 40-4=36 weeks/3 fingers 40-6=34 weeks. Now having determined the fundal level in weeks compare it to gestational age as per history( e.g. if gestational age in history was 36 weeks and fundal level was 36 weeks you can report that as follows:

The fundal level is 36 weeks corresponding to date (or consistent with date). If you find in another case the fundal level=36 weeks and gestational age as per history is 32 weeks you can report it as follows; the fundal level is 36 weeks which is more than date {causes (see later)}. In another patient the fundal level =32 weeks and gestational age by history is 36 weeks you can report as follows; fundal level is 32 weeks which is less than date {causes (see later)}.

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The other method to determine fundal level is by measuring tape.

One side of the measuring tape is in centimeter the opposite is in inches. Let inches side faces you measure in centimeters from fundus to upper edge of symphysis pubis. It is called symphysis-fundal height.

1cm = 1week e.g. if symphysis-fundal height=34 cm this means fundal level= 34 weeks.

2-fundal grip

Search what occupying the fundus area. It may be breech (soft, irregular, broad & non ballottable part) or Head (round, firm and ballottable part).

3-Lateral grips

Determine where is the back and where are the limbs.

One hand showed be fixed and supporting the uterus and the other hand is palpating the parts concerned. Then fix the mobile hand and palpate the other side by the hand which was fixed. Lateral grips determine back. If back was in the right side this means the lie is longitudinal, position is right occipto-lateral if the presentation is cephalic & right sacro-lateral in breech presentation. Fetal heart in cephalic presentation is detected on the side of the back between umbilicus and anterior superior iliac spine but in cases of breech presentation it is detected above the umbilicus.

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4-first pelvic grip

Be gentle and look for patient face.

palpate presenting part gently from side to side to recognize its nature (either head or breech (or rarely shoulder in transverse lie)

5-second pelvic grip

Slide your hands gently below presenting part.

If you can go below it, this means it is not engaged.

If you cannot this means it is engaged.

6-check fetal heart rate (see above in lateral grips)—normal fetal heart rate is 120-160 beat/minute.

After this final step cover patient abdomen & examine lower limbs for edema and varicose veins. Edema is elicited by pressure one inch above medial malleolus for one minute by one finger (Thumb) (role of one).

Lower limb edema is usually physiological in the majority of pregnant mothers. Edema of face and sacrum is more important.

Varicose veins are examined while patient is standing. The significance of varicose veins is that it may be associated with varicose veins in the vulva & if cut during episiotomy it may cause severe bleeding. So avoid the side of varicose veins and do episiotomy on other side if necessary. After you finish thank the patient.

Causes of fundus more than date

1-wrong date

2-mutiple pregnancy

3-sizable baby

4-pelvic mass (e.g. fibroid or ovarian mass)

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Causes of fundus less than date

1-wrong date

2-oligyhydramnios

3-constitutional small baby

4-IUGR

5-IUFD

6-Transverse lie.

Signs of iron deffiency anaemia in examination

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Chapter 3

Hypertensive disorders in pregnancy

Hypertensive disorders in pregnancy differ in many aspects like severity classifications. They range from mild PIH without hypertension to the most serious one which is Eclampsia. Hypertension can be pregnancy

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induced if it occurred for the first time after the first half of pregnancy (after 20 weeks of gestation) or it can be pre-existing (chronic hypertension) if it is known before pregnancy or occurred before 20 weeks (with rare exception {mention them?}).

In this handout I am not going to discuss definition, pathophysiology, classification or severity. I will only discuss the management of each category. For further details please refer to soft copy provided to you.

Mild PIH without Albuminuria (gestional hypertension

Most of the patient can be managed as out patient.

Close observation with more frequent antenatal visit

Check CBC including platelet count, KFT and RFT.

Close fetal monitoring for growth, liquor amount, and biophysical profile

If the mother and fetal condition stayed stable let her till 39-40 weeks so that she may go for spontaneous labour.

Never go beyond 40 weeks. At 40 weeks terminate pregnancy by suitable way (induction of labor in most cases).

Pre-eclampsia

Here the process became potentially or actually multi-systemic. Again pre-eclampsia differs in severity from mild to severe. Management depends mainly on gestational age, severity (assessed by symptoms, signs and biochemical measures). If it is mild and gestational is preterm admit patient close monitoring of mother and fetus as mentioned above.

Give corticosteroids to enhance maturity if gestational age is below 34 weeks. At 38 weeks pregnancy should be terminated preferably by induction of labour or sometimes by caesarean section (every case should be individualized. In severe pre-eclampsia pregnancy should be terminated irrespective of gestational age after stabilization of maternal condition.

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Severe uncontrolled hypertension

In cases of persistently severe hypertension (Systolic B.P ≥160 or diastolic B.P≥ 110) with the use of maximum doses of combined drugs pregnancy should be terminated because there is increased risk of CVA.

Examples of condition where pregnancy should be terminated pre-maturely (after stabilizing mother)

1-eclampsia

2-hellp syndrome

3- oliguria or renal compromise

4- impending eclampsia (headache, blurring of vision, vomiting, epigasteric pain and right hypochondrial pain)

5-fetal compromise.

6-pulmonary oedema

7- DIC

Management of Eclampsia

Call for helpLateral positionPut airway to prevent tongue bitingSuction of secretions if anyi.v acess (2 wide bore canulae)Monitor maternal vital signsAnticonvulsant to abort fit (Magnesium sulphate or diazepam )Magnesium sulphate hourly to prevent recurrence of fits Monitor for Magnesium sulphate toxicity

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Respiratory rate/patellar reflex/Magnesium sulphate level in blood. Hydralazine or Labetalol/or Nifidipine to control blood pressureBlood sample for RFT,CBC,LFT, URIC ACID and coagulation profileInsert cathter to monitor urinary outputBalanced iv fluid intake (85 ml/hour or 65 ml/hour + previous 1 hour urinary output )Assess fetal conditionInform paediatrician & nursery teamAssess cervical favorability & pelvic adequacy to decide mode of deliveryTerminate pregnancy after stabilizationPost-natal monitoring in ICUContinue Magnesium sulphate 24 hours after last fit

Chapter-4

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Normal labour

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Definition of labour

Condition characterized by onset of regular or periodic uterine contractions resulting in cervical dilatation and effacement plus descend of the fetal presenting part.

Some important definitions

1-Effacement & dilatation:

Effacement is thinning & shortening of cervix as the cervix is stretched in the late weeks of pregnancy. The process continue during labour till cervix is taken up & disappears or merges in lower uterine segment so that the uterine & cervical canal become one canal. Please see the following images in internet

1- http://www.webmd.com/baby/cervical-effacement 2- http://www.families.com/wp-content/uploads/media/

effacement.jpg

Dilatation is the opening of cervix it is measured in centimeters or fingers. One finger = 2 centimeters.

The minimum accepted rate of cervical dilatation is 1 cm/ hour.

The average cervical dilatation is

Effacement and dilatation vary from woman to another.

In multiparous woman effacement & dilatation go together but in primigravida effacement precedes dilatation.

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2-Show

Is passage of mucus mixed with blood per vaginum. It is a sign of early labour. It is due to passage of mucus pulg when cervix starts to dilate. Blood is due to tear of small cervical vessels.

Show is not sure sign of labour & labour can occur hours or days after show.

3- Station of the presenting part Distance of lowest part of presenting part from ischial spines. But do not be confused by caput which can give false impression that head is lower than its original station.When lowest part reaches ischial spines the station is zero.1cm below ischial spines is +1 station & 2 cm is +2 station and so on.1cm above ischial spines is -1 station & 2 cm is -2 station and so on. At -3 station the head is high and at -4 station it is floating in abdomen. Below zero station the head is low & at +3 & + 4 it starches the perineum and vulva respectively.

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Below an image showing Stations of presenting part

Stages of Labour

First stage

From onset of uterine contraction to full dilatation of the cervix u(=10 cm or 5 fingers)

Duration of first stage

12-14 hours.

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For a primigravid woman

The average rate of cervical dilation is three centimeters per hour.The minimum acceptable rate is 1 cm per hour. Rates less than 1 centimeters per hour is abnormal and considered as slow labour. The process underlining first stage is cervical dilatation.

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For multigravid women

The average rate of cervical dilation is 3.7 centimeters per hour. Rates less than 1.5 centimeters per hour are considered prolonged.

The first stage is divided into latent phase & active phase

Latent phase or early labour from onset of labour to cervical dilation of 3-4 cm with effacement.

The latent phase begins with mild, irregular uterine contractions that soften and shorten the cervix. Contractions become progressively more rhythmic and stronger. Cervical change involves thinning, or effacement. The latent phase is the most variable from woman to woman, and from labor to labor. It may take a few days, or be as short as a few hours.Latent phase may be confused with Braxton Hicks contractions (false labour pains).

The duration of latent phase is 8-20 hours in primigravida & 5-14 hours in multiparous woman.

The diagnosis of labour in latent phase may be uncertain. Re-assessment after 3-4 hours can help in diagnosis by checking cervical effacement and dilation.

Active phase of first stage

from cervical dilatation of 4 cm to full dilatation.Duration of active of first stage is about 5 hours in multigravida & 8 hours in primigravida.

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Second stage of Labour

Starts with full dilatation of cervix & ends with delivery of baby.

Duration of second stage of labour.

In Primigravida it takes about 1 hour in average & maximum time is about 2 hours after which the second stage is called prolonged or delayed. Woman under epidural analgaesia have longer second stage due to loss of sense or urge to push & second stage is considered prolonged after 3 hours.

In multigravida it takes about 15 minutes in average & maximum time is about 1 hour after which the second stage is called prolonged or delayed. Woman under epidural analgaesia have longer second stage due to loss of sense or urge to push & second stage is considered prolonged after 2 hours.

The urge to push (bear down) also marks the second stage & attendants should advise mother to push during contractions to help descend of the presenting part.

The process underlining second stage is descend of presenting part.

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Criteria of normal labour:

Spontaneous (i.e no intervention pharmacological or instrumental)

Singleton foetus

Viable

Mature  

Presented by vertex presentation & occipto-anterior position  

Vaginal Route 

Within A reasonable duration (not less than 3 hours or more than 18 hours) [more than 18 hours it is called prolonged labour & less than 3 hours is called precipitate labour.]

Without complications to the mother, or the foetus

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Mechanism of normal labour

Passive movements of the fetus through birth canal

(EDFIERE)

E-Engagement

D-Descend

F-Flexion

I-Internal rotation at level of ischial spines (station zero)

E-Extension

R-Restitution

E-External rotation

Baby is in flexed attitude in the uterus

Baby is engaged in pelvic inlet at transverse position ( left or right occipto-lateral{also called occipto-transverse) & left occiptolateral is more common. Then descend of head and flexion of neck occur. At mid-pelvis at level of ischial spines the head rotate to occipto-anterior position by 2/8th of a circle and shoulders rotate by 1/8th of a circle to minimize twist. If head failed to rotate at level of ischial spines & persisted at transverse position this is called deep transverse arrest (mention options of management?).

After internal rotation there is crowning where head distends the vulva & become visible externally. Extension then occur & when head distends vulva it is called crowning. The baby rotates 1/8th of a circle to untwist the neck. Then external

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rotation occur to transverse position but shoulders will be in antero-posterior position.

(a soft copy is available as video film showing simulation of cardinal movements of mechanism of labour)

Partograph and cervicograph

Definition:

It is graphical record of key data of labor progress with both maternal and fetal data entered against

time.

Cervicgraph or cervicogram is cervical dilatation plotted in a graph against time. It is main part of the partogram.

Other components include

▪ uterine contraction

▪descent of fetal presenting part

▪states of membranes [intact=I/if ruptured is it clear=c or meconium stained=M

▪maternal vital signs

▪medications e.g. oxytocin

▪fetal heart rate

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Recording cevical dilataion

At addmision Then after 4h

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Multi & nuli

Recording uterine contraction

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Recording fetal heart rate

Recording of liqour &molding

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Cuases of abnormal partogarm

• ‘3Ps’ –

1. passenger (excessive fetal size , malpositions ,congenital anomalies , multiple gestation,

2.passages,(pelvic contraction , soft tissue abnormalities of the birth canal , masses or neoplasia , placental previa location &CPD ?

3- powers

• Less than three contractions in 10 minutes, each lasting less than 40 seconds

• Inco-ordanated

Prolonged Latent Phase

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Recording of maternal condition

• Cevix not full effaced and not dialated beyond 4cm after 8h of regular contraction

• Most common in primi delay in the chemical process which soften the cervix and allow effacement

• Management

– Simple analgesia

– Encourage mobilization

– Reassurance

– ARM and oxytocin will cuase poor progress later

Next image showing prolonged latent phase (see arrow direction)

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Primary Dysfunctional Labour

• Poor progress in the active phase <1cm/h

• Primi dysfunctional uterine contraction

• Multi mal-presentation, CPD

• Management

– ARM +oxcytocin in primigravida (in multi ,CPD may be the cause,but with caution you may start 2.5 u in 500ml dexterose

– Caesarean Section (multigravida,CPD,fetal distress, VBAC, breech)

– Next image showing abnormal partogram of primary dysfunctional labour i.e. rate of cervical dilatation is less than 1 cm/hour. {look for arrow direction}

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Secondary arrest

• Secondary arrest of cervical dilatation and descent of presenting part typically after 7 cm dilatation

• Most common cause is CPD

• Management

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– ARM +oxcytocin primigravida (in multi ,CPD may be but with cution 2.5 u in 500ml dexterose

– Caesrean section multi gravida,CPD,fetal distress, VBAC, breech.

Next image of abnormal partogram with secondary arrest of cervical dilatation (look for arrow direction)

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Delayed second

The second stage of labour is said to be delayed if there is no delivery of the baby even after 2 hours of full dilation of the cervix in primigravida & more than one our in multigravida. In cases of patient on epidural analgaesia the second stage is

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considered prolonged or delayed after 2 hours in multigravida & after 3 hours in primigravida.

Causes of delayed or prolonged second stage of labour

1-Secondary uterine inertia (weak contraction/ineffective contraction or faults of the power) may be due to dehydration or ketosis.

2- Occipto-Posterior position: long internal rotation , persistance Occipto-Posterior position.

3-Deep transverse arrest (faiure of internal rotation from occipto-transverse to occipto-lateral) associated with narrow mid-pelvis (android pelvis)

4- Epidural analgaesia.

Management of delayed or prolonged second stage• Oxytocin infusion if contraction is not stronge • In DEEP transverse arrest rotational forceps may use to

brings the head to OA position• C/S is best option• Manual rotation also an option

Management of prolonged labour

A/Prolonged latent phase

Rest & sedations for 6-8 hours then reassess 85 % will enter into true labour

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10 % are in false labour and can go home5 % will have ineffective uterine contraction & will respond to oxytocin augmentation.If there is reason to terminate pregnancy (e.g. severe pre-eclampsia or amnionitis) active management by accelerating labour should be done from the start.

B/Slow progress in active phase of first stage (protraction disorder) or also called failure to progress It is due to Slow cervical dilatation (cervical dilatation rate less than 1 cm/hour) or descent of presenting part less than 1 cm/hour. Causes Faults in power i.e. ineffective uterine contraction spe cially in primigravida.Faults in passages like CPD,Pelvic tumors,vaginal septumFaults in passanger like sizable foetus, fetal hydrocephalus, fetal ascitis, malpresentations & malpostions.ManagementTreatment of slow progress(or protraction disorders) depends on the presence or absence of fetopelvic disproportion, the adequacy of uterine contractions, and the fetal status. Cesarean section is indicated in the presence of confirmed fetopelvic disproportion. If uterine contractions are effective patients are unlikely to respond to augmentation of labour.Assess by abdominal palpation & vaginal examination.Assess fetal condition & employ continuous fetal monitoring. If no obstructive element and no contraindication to vaginal delivery ARM & Oxytocin can be started specially in primigravida.If there is obstructive element or a malpresentation/malposition non deliverable vaginally go for caesarean section.

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In multiparous lady one should be cautious about augmentation because faults of power are rare and there may be malpresentation/malposition or obstructive element.

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Arrest disorders(1) secondary arrest of dilatation, with no progressive cervical dilatation in the active phase of labor for 2 hours or more; and (2) arrest of descent, with descent failing to progress for 1 hour or more.Causes of arrest disorder1-fetopelvic disproportion2-inadequate uterine contraction.3-various fetal malpositions (eg, occiput posterior, occiput transverse, face, or brow)4-excessive sedation or prolonged anaesthesia.5-sizable baby.Treatment of arrest disordersAssess size of baby and pelvic adequacy by abdominal and vaginal examination. If no CPD or other obstacles to vaginal delivery & contractions are inadequate oxytocin stimulation is used to produce further progress. If there CPD or obstructive element go for emergency caesarean section. In multiparous lady caesarean section is preferred as faults of power are rare and oxytocin stimulation is dangerous if there is obstructive element (can lead to ruptured uterus) Precipitate Labor Disorders (rapid labour)

Precipitate labor has been defined as delivery in less than 3 hours from onset of contractions.

Precipitate labor may result from either extremely strong uterine contractions or low birth canal resistance.

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Complications are rare & include

1-rupture uterus.2-cervical tear.3-vaginal tear.4-PPH.5-Fetal complications intracranial haemorrge/increased perinatal mortality and complications of unattended delivery.

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