Abnormal Labor

Epico educational topic number 22

00:02

abnormal labor you may remember our

00:04

patient labora deliver it from our app

00:06

go video number eleven intrapartum care

00:09

we follow libera through a normal labor

00:11

and delivery course in that video in

00:13

this video labora will experience

00:15

abnormal labor we will discuss how best

00:18

to provide care for labora and her fetus

00:20

to optimize outcomes the objectives of

00:22

this video are to list and describe the

00:24

causes and methods of evaluation of

00:26

abnormal labor patterns discuss fetal

00:28

and maternal complications of abnormal

00:30

labor list indications and

00:32

contraindications for oxytocin

00:34

administration describe risks and

00:36

benefits of trials of labor after

00:38

caesarean delivery and lastly discuss

00:40

strategies for emergency management of

00:42

breech presentation

00:43

shoulder dystocia and cord prolapse here

00:46

is labora entering labor and delivery

00:48

and active labor

00:48

she is dilated to 5 centimeters let’s

00:51

start by talking about the 3 p’s that

00:53

contribute to a normal labor the power

00:55

the passenger and the passage the power

00:58

refers to uterine contractions the

01:00

uterus must produce strong frequent

01:02

contractions that will dilate the cervix

01:04

and cause the fetus to descend down

01:06

ideally the uterus should contract three

01:08

times in a 10-minute period here is a

01:10

fetal heart rate tracing and remember

01:12

that the top line is the fetal heart

01:14

rate and the bottom line are the uterine

01:16

contractions this tracing shows ten

01:18

minutes of laborious labor and she has

01:20

three contractions marked by the white

01:22

arrows the uterine contractions are

01:25

usually monitored by an external tool

01:26

commoner which does not give information

01:28

about the strength of the contractions

01:29

just the timing let’s check back on

01:32

labora she was admitted to labor and

01:33

delivery in active labor at five

01:35

centimeters dilated and she’s been

01:37

having regular painful contractions for

01:39

two hours since she is a gravity’ one

01:42

pair zero and active labor her cervix is

01:44

expected to dilate at approximately one

01:46

point two centimeters per hour a

01:48

multi-purpose patient and active labour

01:50

should have progression of approximately

01:52

1.5 centimeters per hour after 2 hours

01:55

when we recheck labora cervix it is

01:57

unchanged and it is still 5 centimeters

01:59

dilated

02:00

in order to assess the strength of the

02:02

contractions we place an intrauterine

02:03

pressure catheter or IUP see this

02:06

tracing is from an IUP see the strength

02:09

of the contraction is the amplitude of

02:11

each wave a Montevideo unit

02:13

can be simply calculated by measuring

02:15

the amplitude above the baseline for a

02:17

10-minute period and adding them

02:19

together

02:19

normal labor progress is usually

02:21

associated with a Montevideo unit of

02:23

greater than 200 next let’s move on to

02:26

the passenger ideally the foetus is not

02:28

too big and is in a good position for

02:30

delivery if the fetus has an estimated

02:32

weight greater than 4,500 grams the risk

02:35

of shoulder dystocia and labour dystocia

02:37

are greater the fetal position is

02:39

important as well for ideally you want

02:41

the fetus positioned in the optimal way

02:43

to be able to fit through the pelvis

02:45

let’s review the bony landmarks of the

02:47

fetal vertex on vaginal examination the

02:50

diamond-shaped anterior fontanelle and

02:52

the triangular shape posterior

02:54

fontanelle can be palpated as well as

02:56

the sagittal suture this photo has a

02:58

better view of the triangular shaped

03:00

posterior fontanelle we describe the

03:02

fetal position in relationship to the

03:04

fetal occiput and the maternal body here

03:08

is a fetus in the occiput anterior

03:10

position here is the posterior

03:11

fontanelle and the occupant is on the

03:13

anterior part of the maternal body this

03:16

is the optimal position for delivery for

03:18

this as the smallest diameter that has

03:19

to pass through the pelvis this fetus is

03:22

in the occiput posterior position note

03:24

the posterior occiput and the anterior

03:26

fontanelle this fetus is in the occiput

03:29

transverse position both the occiput

03:33

posterior and occiput transverse

03:35

positions have bigger diameters that

03:37

need to fit through the pelvis there are

03:39

other possible presentations such as a

03:40

compound presentation or face

03:42

presentation which could all contribute

03:44

to labor dystocia labor can be stalled

03:47

before she reaches ten centimeters

03:48

dilated known as failure to progress or

03:51

arrest and dilation where the patient

03:53

can reach ten centimeters and the fetus

03:55

does not descend for delivery known as a

03:56

rest of descent the last of the three

03:59

P’s to discuss is passage maternal

04:02

skeletal or soft tissue issues can

04:03

obstruct the birth canal

04:05

cephalo pelvic disproportion refers to

04:07

the conflict between the fetal head and

04:09

the pelvic size the pelvic bone shape or

04:12

maternal soft tissue most commonly

04:14

excess adipose tissue can contribute to

04:16

labor dystocia let’s get back to labora

04:19

remember that she was admitted at five

04:21

centimeters dilated in active labor at

04:23

the time of a repeat sterile vaginal

04:25

examination she was still 5 centimeters

04:27

and replaced an intrauterine pressure

04:29

catheter and this demonstrated that her

04:31

contractions were not strong enough

04:33

augmentation refers to stimulation of

04:36

uterine contractions amniotic or

04:38

rupturing of her amniotic membranes can

04:40

enhance progress in the active phase it

04:42

may stimulate release of prostaglandins

04:44

which aid in augmenting the force of

04:46

contractions and also allows for the

04:48

fetal head to be the dilating force

04:51

oxytocin can also be given intravenously

04:53

to strengthen contractions the goal is

04:55

to titrate the oxytocin so that the

04:57

contractions are strong and frequent

04:59

enough to produce cervical change in

05:00

fetal descent but not too strong to

05:03

cause uterine tachy systole uterine

05:05

tachy systole is defined as more than

05:07

five contractions in 10 minutes over a

05:09

30 minute period you perform an an Reata

05:12

me and oxytocin has started for labora

05:14

three hours later you check on her and

05:16

she is happily 10 centimeters dilated

05:17

and she starts pushing her second stage

05:20

is slow but she continues to make

05:22

progress and after 2.5 hours of pushing

05:24

she delivers the fetal head and you

05:26

realize that the anterior shoulder is

05:28

stuck this is a shoulder dystocia let’s

05:30

now switch gears to discuss shoulder

05:32

dystocia

05:33

shoulder dystocia can be a true

05:35

obstetric ‘el emergency the baby’s

05:38

anterior shoulder is effectively caught

05:40

behind the pubic symphysis which is

05:42

illustrated in white it is important to

05:46

remain calm and to know the steps to

05:48

help deliver the shoulder in general

05:50

there is about 5 minutes to deliver a

05:52

well oxygenated term infant first and

05:54

foremost take steps to make sure that

05:56

you have adequate nursing and obstetric

05:58

‘el staff support start with McRoberts

06:00

maneuver which is hyper flexion and

06:02

abduction of the hips this can open up

06:04

space that will enable the shoulder to

06:06

be reduced the next step is suprapubic

06:09

pressure which is pressure directed

06:10

downward on the anterior shoulder if

06:12

these first two steps do not lead to

06:15

delivery then next try to deliver the

06:17

posterior arm of the fetus an episiotomy

06:20

can be helpful at this point to open up

06:22

space posteriorly additional steps for

06:25

shoulder dystocia include the wood screw

06:26

and Reuben maneuver which are rotation

06:28

of the fetus to reduce the shoulder it

06:30

can also be helpful to move the patient

06:32

onto her hands and knees in severe cases

06:35

intentional clavicular fracture can be

06:37

performed and the last option is to

06:39

perform as a Vannelli

06:40

procedure which requires reversing the

06:42

Cardinal movements to labor and to flex

06:44

the head back into the uterus and to

06:45

perform a cesarean delivery brachial

06:48

plexus injury rates with a shoulder

06:50

dystocia range from four to forty

06:51

percent regardless of the maneuvers used

06:53

to deliver the fetus the second

06:56

obstetrical emergency that we will now

06:57

discuss is cord prolapse this is when

06:59

the umbilical cord descends in advance

07:01

of the fetal presenting part here is the

07:04

fetus and the blue umbilical cord that

07:10

has prolapsed through the cervix cord

07:12

prolapse occurs when one the fetus is

07:14

not vertex or two there are spontaneous

07:16

rupture of membranes before the vertex

07:18

is well engaged or three there is

07:20

iatrogenic artificial rupture of

07:22

membranes before the vertex is well

07:23

engaged cord prolapse is an emergency

07:26

for the blood vessels in the umbilical

07:27

cord are compressed when this is

07:29

recognized the providers hand must push

07:31

the fetal head up so it does not further

07:33

compress the cord and the cord needs to

07:36

be manually reduced back into the

07:37

uterine cavity and the patient needs to

07:39

be brought back to the operating room

07:41

for an immediate caesarean section the

07:43

hand needs to stay in place throughout

07:45

this time until the baby is safely

07:46

delivered the last emergency that we

07:49

will discuss is breech delivery it is

07:51

important to note that singleton breech

07:52

presentations should be delivered by

07:54

cesarean section there may be situations

07:56

however when cesarean section is not

07:57

possible because of precipitous delivery

07:59

or lack of operative resources if this

08:02

situation were to arise the first thing

08:04

is to call for assistance next it’s

08:07

important to avoid any traction on the

08:09

fetus for the goal is to avoid a fetal

08:11

head extension which can make the

08:12

delivery more difficult wait until the

08:14

maternal efforts have resulted in the

08:16

fetus being delivered to the level of

08:17

the umbilicus suprapubic pressure can

08:20

then be applied to promote flexion and

08:21

descent of the fetal head we will

08:24

conclude laborious journey into the

08:26

world of abnormal labor with a

08:27

discussion about women who have had a

08:28

previous cesarean section what if labore

08:31

had a history with cesarean section with

08:32

their first pregnancy there are three

08:34

primary possible outcomes she could have

08:36

a successful trial of labor after

08:38

cesarean which is a vaginal birth after

08:40

cesarean or VBAC this is the ideal

08:43

option for labora will have decreased

08:44

maternal morbidity and decreased risk of

08:46

complications with future pregnancies at

08:48

a population level more vivax mean there

08:51

is a decreased overall cesarean delivery

08:53

rate

08:53

our next preferred option would be a

08:55

scheduled repeat low transverses Aryan

08:57

section at 39 weeks

08:59

our third preferred option is a failed

09:01

trial of labor after cesarean and she

09:03

still ultimately needs a caesarean

09:04

delivery this option has the highest

09:06

rates of maternal morbidity with higher

09:08

rates of bleeding and infection it is

09:10

important to weigh the risks and

09:12

benefits when making these decisions

09:13

with our patients the benefits of a

09:15

successful trial of labor after

09:17

caesarean delivery are that you avoid

09:18

surgery which needs to lower rates of

09:20

hemorrhage infection and you’ll have

09:22

shorter recovery periods in addition

09:24

there are decreased future abnormal

09:26

placentation risks such as placenta

09:28

previa or placenta accreta uterine

09:30

rupture is the most feared complication

09:32

of a trial and labor after cesarean with

09:35

a history of one low transverse cesarean

09:37

section the risk of uterine rupture is

09:38

0.7 20.9% with a history of too low

09:42

trans vs. Aaron sections the risk of

09:44

rupture is 0.9 to 1.8% with a history of

09:48

a classical cesarean section the risk of

09:50

uterine rupture is 10% this high rupture

09:53

risk is why these women should have a

09:55

repeat cesarean delivery and not try to

09:57

labor when counseling patients who’ve

09:59

had a load trans versus Aaron section

10:00

different clinical factors have to be

10:02

taken into account that either increase

10:04

or decrease your probability of a

10:06

successful VBAC having a history of a

10:08

prior vaginal birth or if she presents

10:10

some spontaneous labor both increase

10:12

your probability of a successful VBAC

10:14

factors that increase her chance of a

10:17

failed trailer labor after caesarean

10:18

include increased maternal age non-white

10:20

ethnicity obesity a recurrent indication

10:24

for the initial cesarean delivery such

10:25

as labor dystocia increased neonatal

10:28

birth weight at gestational age greater

10:30

than 40 weeks preeclampsia and a short

10:32

enterprise-e interval ultimately labora

10:35

and her healthcare provider should

10:36

discuss and decide on a delivery plan

10:38

that factors in her individual clinical

10:40

factors as well as the availability of a

10:42

24 hour blood bank continuous electronic

10:44

fetal monitoring and other Hospital

10:46

factors such as in-house anesthesia that

10:48

will enable an expedient cesarean

10:50

delivery to be performed if necessary

10:52

this concludes the Africa video an

10:54

abnormal labor we have discussed the

10:56

three P’s to consider in evaluating

10:58

labor discuss fetal and maternal

10:59

complications of abnormal labor

11:01

discussed oxytocin and risks and

11:04

benefits of trial of labor after

11:05

caesarean

11:06

disgust management of emergent of

11:08

technical situations