The smart way to learn. The smart way to teach.

MRCOG PART 2 SBAs and EMQs

Course PAID
notes336
EMQ1502
SBA2115
Do you realy want to delete this discussion?
Forum >>

Essay 324 - Non-progressive labour

Posted by MR R.
MR

a. I will gather history regarding her previous deliveries including the type of vaginal deliveries and duration since her last delivery.I will ask about the course of her antenatal period and identify any history of diabetes predisposing to big baby.I will review her ultrasound scan to recognise any macrosomia or polyhydramnios.I will ask her regarding the type of pain releif she is using and the effectiveness on uterine contractions.I will enquire about the support ( one to one ) from midwifery staff and her partner her.I will assess her oral and intravenous fluid input and the amount and colour of urine.I will also ask the patient about her birth plan and her views regarding medical intervention.
I will review her partogram for temperature, pulse rate(tachycardia can signify dehydration or obstructed labour) and blood pressure.I will estabish the wellbeing of the fetus from the monitoring.I will identify the colour of the amniotic fluid.I will assess the frequency, strength and duration of her uterine contractions.I will do an abdominal examination to identify the lie,presentaion,clinical size and the number of the fifths of the fetal head palpable.I will obtain a verbal consent and ensure adequate pain releif to carry out a vaginal examinatio.On vaginal assessment I will assess for cervical dilation,presenting part and its relation to ischial spines,effacement of the cervix,any malpositon, moulding and caput.
b. I will explain to the patient about her very slow progress in labour.The common causes for slow progress in labour are dehydration,malpostion and inadequate contractions.However signs of obstructed labour should be recognised to reduce maternal and perinatal mortality.I will arrange one to one midwifery support for this patient.I will ensure she she is adequately hydrated.If patient willing will establish an intravenous access to suffice hydration and also to obtain bloods for full blood count and group and save.The treatment options are conservative management where no intervention is done and the patient is reassessed after 2 hours preferably by the same person.She can be started on oxytocin infusion according to unit policy.However in parous women this should be used judiciously because of the risk of uterine rupture.A satisfactory level is the one where we can achieve 3 -4 contraction lasting 40- 50 seconds in 10 minutes.The patient is reassessed in 3 hours.Continious electronic fetal monitoring is offered.Adequate pain releif in the form of epidural should be offered as oxytocin produces painful contactions.If the patient has not progressed despite adequate contractions and if signs of obstruction are identified on examination then delivery should be caesarean section.A less than 1cm progress after conservative approach or oxytocin infusion should prompt delivery ny caesarean section.
Posted by Kiran  J.
I will first establish her risk status.As she is a multiparous it is imperative to find out her past obstetric history,mode of deliveries and birth wieghts of her children.Her currant pregnancy history of any concerns regarding fetal size or macrosomia.
I will find out regarding decent and rotation of the fetal head and if there has been progress with regards to that.Also important information regarding caput and moulding and if compoud presentation has been ruled out as all these could be a cause of delay.I will assess clinically if the baby is macrosomic although it is not a validated way to confirm fetal size.
I will ascertain the presentation of fetus and rule out face and brow presentation as this can inadverently cause a delay.
It is essential to confirm the uterine contractions as well becuase there should be at least 4 uterine contractions in 10 minutes for labour to progress.
It is impotant to know the fetal status and good practise to check fetal heart and liqour colour to rule out fetal hypoxia.
Additional factors that can cause a delay in labour are inadequate hydration, inadequate analgesia and emotional support hence I would check if she has analgesia on board and rectify the need for emotional supprt from her birth attendants(relatives and midwife)
(b) My available options are in the face of ruling out dysfunctional labour due to reasons of inefficient uterine contractions,dehydration,inadequate analgesia,malposition and malpresentation.If all the above are discounted and the fetal status is reassuring with clinically an adeqaute pelvis and average size baby augmentation with oxytocine can be considered.Analgesia in the form of epidural can be offered if still not instituted and good emotional support.Her wishes and concerns are discussed and councelled.She should be re-examined in 2 hours after commencing oxytocine infusion and if there is progress of 1 cm in 2 hours with reassuring fetal heart on CTG and haemodynamically stable mother labour can be allowed to continue with vigilant monitoring of fetal heart and maternal pulse and blood pressure and to avoid hyperstimulation.If the progress is less than 1cm in 2 hours LSCS is to be performed.
Posted by H H.
hhhh
I will ask the woman permission to conduct clinical examination. I will ask if she is comfortable with her labour pain and she need more analgesia and if she wish will supply her with regional analgesia provided there is no evidence of fetal or maternal compromise. I will look at her notes regarding her previous vaginal deliveries,the course of labour,any delay, instrumental deliveries and neonatal weights. I will see in the notes regarding the follow up of present pregnancy and wether the baby is macrosomic on ultrasound. I will check her partogram and ask the accompanying midwife of any complaints by the patient during labour till I arrived( vaginal bleeding, constant abdominal pain, abnormalities in fetal hearts).
I will check her pulse , if tachycardic(dehydration, pyrexia), BP and temperature(pyrexia).I will do abdominal examination for uterine contractions( frequency,duration), will check how much of fetal head felt per abdomen and look at the CTG for abnormal or non reassuring signs which may warrant fetal blood sampling( at least one abnormal or two non reassurring signs).
I will ask permission to perform a local vaginal examination for cervical dilatation, knowing that 4 hrs ago it was 5cm, cervical effacement, station of head, position (occipito posterior, malpositio), other cephalic presentation as brow, caput (cervical caput) or moulding.
After assessment will inform the patient and her partner of my findings and the proposed line of management. The findings are documented in her notes in addition to her wishes.




After assessing the patient and in absence of fetal or maternal compromise, should the patient is uncomfortable and feel much pain I would ask for an epidural to be sited after discussion with anesthasist. If patient is dehydrated I would correct it with IV fluids.
On my local examination should I find that the cervix is still 5 cm and contractions are infrequent and weak, I would start an oxytocin drip according to local guidelines and protocols , but if contractions were already frequent and strong(3 per 10 minutes each lastiong 45second) ,I would recognise that the cervix failed to dilate and failure to progress diagnosed. Some of these ladies improve after application of epidural, rehydration and support. If I diagnose faiure of progress despite good uterine contractions ,I would explain this to the woman and lower segment cesarean section would be a safe line of delivery.
If I find evidence of fetal compromise on CTG while I am allowing the patient to progress in labour ,fetal blood sampling is done if one abnormal or two non reassuring signs found on CTG. If fetal PH <7.21 ,urgent delivery is needed, but between 7.24 and 7.21 ,repeat FBS in 30 min.
If patient progressed well and in absence of fetal compromise, would allow her for vaginal delivery , taking care of possibility of shoulder dystocia, post partum hemorrhage, perineal tear and should alert the neonatologist of possibility of macrosomia for early neonatal feeding.




Posted by zara A.
A multiparous lady with delayed progress should be assessed in asupportive manner considering her emotional status,as she will anxious.Her antenatal record should be reviewed ,weight of previous babies ,any complication in previous deliveries.In current pregnancy macrosomia detected,any fetal abnormality like hydrocephelous as these problems can be acause of delayed progress.partogram should be reviewed to look for progress of labour.her need for analgesia assessed if not already given . Physical examination done pulse and Bp should be recorded.temp should be noted.hydration status assessed as prolonged labour causes dehydration .abdominal examination should carried out for fundal height.lie .presentation,and size of baby assessed as could be a cause delayed progressdue to cpd.strength of uterinecontractions noted as hypotonic uterine activity could be a cause of delayed progress.ctg should be done to look for foetal compromise.vaginal examination should be done to look for colour of liqour[meconium ] as prolonged labour can cause fetal distress.presentation,Position .station of presenting part noted.Any evidenceof moulding,and caput should be noted as there presence indicate cephelopelvic disproportion.her wishes and expectation should be assessed.[b]Management dependson maternal wishes ,foetal status,examinationfindings.If everything fine then continution of labour allowed.Explanation and ressurence offeredAccording to her wishes partener support given and analgesia provided.hydration should be mantained .Augmentation with syntocinon started to correct hypotonic contractions titrated according to uterine contractions with aim of 3 to4 contractions 40 sec duration .Syntocinon should be given carefully with monitering as in muti parous lady there is risk of uterine rupture .one to one monitering provided.contious ctg monitring offered.vaginalexamination repeated after 2 hours to look for cervical dilatation .descent of presenting part,To determine progress of labour .change in frequency of contractions noted.hourly pulse,and 4 hourly Bp and temp recordedbladder emptying done frequently.all observations recorded on partogram.if progress is well contiue labour with fetomaternal monitring with aim of vaginal delivery.Csection is other option should be considered if on repeat examination labour not progressing ,if fetal distress, if mother wishes.
Posted by Chitra.s M.
a)The woman\'s antenatal records are reviewed for presence of risk factors in current pregnancy like fetal macrosomia,unstable lie/malpresentation which can affect labour progress.She is enquired about any intrapartum problems & outcome of previous pregnancies including the birth weight of the babies.She is enquired about her pain relief requirement.
Partogram is reviewed for labour progress and previous CTG for any fetal heart rate abnormality.Her BMI is assessed as obesity can predispose to slow labour progress.Her hydration status, pulse ,BP and temperature are noted. Abdominal examination is done for uterine size,lie,presentation .fifths of presenting part palpable per abdomen and FHS. The frequency,strength & duration of uterine contactions is noted. Vaginal examination is performed to assess cervical dilatation,presentation,station,presence of caput/moulding and colour of liquor .
b) The woman is informed about the diagnosis of slow progress of labour and her emotional needs are assessed. One to one support is offered and support from partner encouraged. Dehydration is corrected if present.Intravenous access is obtained and blood sent for group and save.Effective pain relief like regional analgesia is offered. Voiding is ensured. Partogram with an action line (WHO partogram)is used to monitor labour progress .If uterine contractions are inadequate ,oxytocin infusion is started on consultant advice. (as there is increased risk of uterine rupture in a multiparous woman with oxytocin use).The woman is infomed that use of oxytocin brings forward the time of birth but does not influence the mode of birth.Oxytocin infusion is incremented every 30 mins according to unit protocol to achieve 4-5 contractions/10mins.Continuous electronic fetal monitoring is done.vaginal examination is performed after 2hours /according to unit protocol to note labour progress.If the progress in dilatation is <1cm in 2 hours ,caeserean section is considered for failure to progress.
If there is >1cm dilatation in 2hours labour is allowed to progress as long as the maternal & fetal condition is satisfactory.The consultant obstetrician,anaesthetist,theatre are alerted for possibility of Caeserean section ,in case of further delay/arrest in labour .CTG abnormalities if present are managed according to unit protocol. If the woman progresses to full dilatation, the team is alert for possibilty of instrumental deliveryand shoulder dystocia. Active management of 3rd stage of labour is done as she is at a risk of post partum haemorrhage.
Posted by Arun D.


A)i will enquire about the previous 3 vaginal deliveries regarding duration of labour,duration of active and latent phase of labbour,which should give me a rough idea about the time she takes to deliver a baby.
I will also enquire about the previous baby weights which will help me to make a comparison with the estimated fetal weight in this time and make a rough idea od her progress in present labour.
History of any cervical surgery after 3rd delivery may lead to cervical dystocia and poor cervical dilatation.
BMI should be noted as high BMI women might have slow progress in labour.
Hydration status should be noted as dehydration delays progress in labour.
Urine ketone should be examined as ketosis also prolongs labour.
Bladder emtying should be enquired as full bladder might delay head descent and labour as well.
Fetal weight should be assessed and compared to her previous birth weights, which could give us a rough idea about her progress in labour.
How much head felt per abdomen should be noted, which could guide us about the descent of head, to be confirmed by vaginal examination as well.
Attitude of head, ie, flexed or deflexed should be identified, which gives us a rough idea about progress of labour.finding needs to be confirmed by vaginal examination.
Duration of contraction needs to be noted and need for pain relief as wwell, which will give us an idea about intensity of contraction.
In vaginal examination, station of head should be identified which will tell us that descent is adequate or not.
Position of head should be noted as occipito-posterior positions are associated with slow progress in labor.
Any evidence of caput or moulding is present or not should be checked, which can tell us about some problem of possible cephalo-pelvic disproportion.
CTG should be interpreted properly as this might modify plan of further management.reassuring CTG can help us to decide about augmentation of labor.
B)adequate hydration should be maintained.
Mother should be mobile.
Frequent emtying of bladder is wrequired.
Partogram should be maintained adequately.
Augmentation of labour should be started with oxytocin infusion.
To be reassessed after 4 hours of good contraction or earlier if any concern.
Good pain relief should be achieved.
1:1 midwifery care should be ensured.
Close eye should be kept on CTG.
If CTG abnormality is noted in the first stage, fetal blood sampling is to be done and to proceed accordingly as per pH value.
If CTG is abnormal in 2nd stage and head is below the spine, she should be takn for trial of instrumental delivery in theater or caesarean , depending on finding.
If there is no progress in first stage in spite of good contraction, needs caesarean.
If halts in 2nd stage, depending on descent of head, trial of delivery in theater or room should be taken as per expertise.
If malposition is identified in 2nd stage, may need rotational forceps or ventouse delivery, which might need the presence of senior experienced surgeons who has adequate experience in that field.
In 2nd stage caesarean, proper method of head delivery should be followed to prevent uterine extensions.
Blood to be sent for grouping and cross matching.
Whatever be the mode of delivery, proper explanation to couple and adequate consent and documentation is essential of good practice.
After the delivery, proper debriefing is essential to the couple.

Posted by Bee N.
A healthy 34 year old woman with three previous vaginal deliveries presents in spontaneous labour at 38 weeks gestation. At 08:00h, the cervix was 4cm dilated with intact membranes. At 12:00h, the cervix was 5cm dilated and amniotomy was performed. There are 3 uterine contractions every 10 minutes. You are asked to review her at 16:00h because the cervix is still 5cm dilated. (a) Discuss and justify your clinical assessment [10 marks]. (b) Discuss the available options to achieve safe delivery [10 marks].

(BEE).
A) After introducing myself to the patient and explaining the reason I have been called to assess her, I will access her case not to see if she has had previous scans in this pregnancy to estimate fetal weight. I will also look out for any other information or abnormality which may have been missed out in her case note such as hydrocephalus of fibroids especially at the lower uterine segment. I will try to find out the birth weight in previous pregnancies and when her last delivery was as this will give an idea of how big the baby in this pregnancy is likely to be.
I will assess patient generally for dehydration by checking for dry lips and tongue. I will the check for Blood pressure and pulse to rule out shock which has been associated with obstructed labour.
I will then examine her abdomen, palpating the uterus to estimate fetal size. I will examine to find out the lie and presentation of the baby and if cephalic, the descent into the pelvis. I will then palpate for contractions for 10 minutes to assess the intensity, duration and frequency. Vaginal examination will then be done to check for colour of liqour which will indicate the possibility of fetal distress. I will examine her vulve which can be seen to swollen as a sign of obstructed labour. I will the do a digital vaginal examination with consent from the patient to confirm the dilatation, find out the position of the fetal head with relation to the pelvis and station. I will then check for the presence of caput and moulding. These will give indication to the presence of malpositioning as the cause of cephalopelvic disproportion if present. I will palpate her bladder while doing the examination and offer to empty her bladder both to assess urine output and to relieve a full bladder which may contribute to obstruction. Urine input and output will be assessed to rule out dehydration.
I will assecc the cadiotocograph if one has been started otherwise i will arrange for one to be started immediately to assess fetal wellbeing.I will then take some blood for full blood count and group and save if this hasnt been done. I will insert an intravenous cannula in preparation for either an emergency ceasarean section or augumentation of labour. I will explain my finding to the patient and her partner.

B)Depending on my findings, emergency ceasarean section or augumentation of labour will be the options of management. The patients wishes will be taken on board in decision making. Unit protocol will be used to guide management. A senior obstetrician should be involved in decision making.If obstructed labour has been ruled out and patient found not to be contracting adequately, augumentation of labour can be done with syntocinon very cautiously. A contraction of 3-5 in 10 lasting 45-60 second and moderate to strong in intensity will be the aim. Continuos fetal monitoring with CTG will be done and patient assessed 2 hours after adequate contraction in the presence of a normal CTG has been established. If still no progress has been made, emergency ceasarean section will be offered.If syntocinon will be used, epidural analgesia will be offered and good support in labour will be ensured with one on one care.
Alternatively, if the patient does not wisg to be augumented or their are establish signs of obstructed labour in the presence of adequate contractions, then emergency ceasarean section will be carried out with patient consent.
Whatever the mode of delivery, there will be active management of third stage of labour and pediatricians will be called in to attend delivery. Cord blood will be taken to document PH even in the absence of fetal distress on CTG monitoring. A clinic incident form should be filled for every prolonged labour and all patient in prolonged labour should be reassess in labour for thromboprophylaxis. The patient will be debriefed adequately as to the events thats occured and approprite advice given for breats feeding and subsequent deliveries.
Posted by sonu P.
I would like to undertake a thorough clinical assessment in the form of reviewing the antenatal and intrapartum events till now, including the previous obstetric history. The diagnosis is secondary protracted/dysfunctional labour and failure to progress. I will assess the general condition of the women in terms of dehydration and take her views regarding the slow progress in formulating a plan. An abdominal examination will be done to assess the presentation, position, engagement of presenting part; frequency, duration and strength of contractions.; Followed by vaginal examination to confirm the cervical dilatation, effacement, consistency, station of presenting part in relation to the ischial spines, how well the presenting part is applied to the cervix, position and any evidence of caput, moulding, deflexion or asynclitism. I will also note the colour of liquor. I will assess the fetal well being by continuous monitoring if she was having intermittent auscultation. The commonest reason for poor progress in multiparous patient is malpresentaion or malposition.

The options in this situation are either to augment the labour with judicious use of oxytocin, if the contractions are not of satisfactory strength or duration with a defined time to reassess preferably by the same person. Optimising analgesia is an important factor to consider as augmented labour is more painful. I will keep the oral intake to small amout of fluids only and no solid food. At this stage I will make sure that we have some basic blood test like FBC and group & save sample available. The rate and dose of oxytocin used should be guided by the unit protocol If the contractions have been of good intensity and have been present for whole of the 4 hours duration, then the option of delivery by caesarean section should also be offered. The women’s views must be taken into account in the decision making process. It might be difficult to convince the women for caesarean section as she had 3 previous normal deliveries.


Posted by SYAMALRANJAN S.
A healthy 34 year old woman with three previous vaginal deliveries presents in spontaneous labour at 38 weeks gestation. At 08:00h, the cervix was 4cm dilated with intact membranes. At 12:00h, the cervix was 5cm dilated and amniotomy was performed. There are 3 uterine contractions every 10 minutes. You are asked to review her at 16:00h because the cervix is still 5cm dilated.
(a) Discuss and justify your clinical assessment [10 marks].

I will introduce myself with the attitude of helping problem and gaining confidence of woman .
All clinical records, past obstetrics incidents, ultrasonographic reports of current pregnany are to be reviewed again for management plan.
Maternal temperture , pulse, blood pressure, dehydration are to be checked because of their relation with progress of labour.
Frequency and strength of uterine cotractions are checked because inefficient uterine contractions needs proper and judicious management.
Fetal wellbeing by Doppler( continuous CTG monitoring is recommended here) and fetal size , presentations, descent(by fifths assessment) are assessed for delivery planning. Vaginal loss
( blood, liquor, offensive smell) are assessed.
Vaginal examinations and assessment of cervical dilatation, fetal head descent, rotation, caput, moulding, possible disproportion are very important parameters for further planning.
Psychological aspect and emotional needs, adequate supports, coping labour pain are very important points to note, without optimisations of those good progress of labour is not possible.
Attitude and woman\'s wishes are observed and respected.

(b) Discuss the available options to achieve safe delivery [10 marks].

Judicious augmentations by oxytocin is an option but being multipara senior advice is needed in this case because of risk of uterine rupture. After one hour if progress is satisfactory, vaginal delivery is possible because of three previous vaginal delivery.
Contionuos CTG monitoring is recommended in this case to diagnose fetal hypoxia and timely interference.
If vaginal delivery is not assumed then CS is advisable but discussing and explaining risks of second stage CS operations to woman and partners.
Adequate support from partner , MW are to be ensured for progress of labour.
Adequate pain relief( epidural analgesia) is needed for progress of labour or if needed for operative interventions( operatve vaginal or abdominal delivery) .
Dehyration, temperature must be treated adequately to achieve safe delivery.
Continuous psychological, emotional support, one-to-one MW support are proved to be helpful.

Posted by L S.
LS:
(a) Discuss and justify your clinical assessment [10 marks].
Her clinical notes should be reviewed especially details on her previous deliveries and the difficulties encountered. I will assess her emotional state and ask her if she has adequate pain relief as anxiety and pain can inhibit uterine contractions and prolong labour. Her hydration status should be checked as ketosis will lead to prolonged labour. I will carry out an abdominal examination to assess uterine contractions, presentation and engagement to note if there are any signs of cephalopelvic disproportion (CPD). Subsequently I will carry out a vaginal examination to assess position of fetal head, station and for evidence of excessive caput and moulding which will make suspicion of CPD more likely. Clinical pelvimetry can be carried out if suspicion of CPD but is subjective and should be interpreted with caution. I will assess her fetal wellbeing by checking to confirm the fetal heart rate is reassuring. Finally I will assess her partogram on all parameters especially on the pattern of her uterine contractions in terms of frequency, intensity and duration since onset of labour to see if it is the cause of her delay.

(b) Discuss the available options to achieve safe delivery [10 marks]
She should be reviewed by a senior obstetrician who will carry out a full assessment to rule out cephalopelvic disproportion before deciding on oxytocin augmentation to increase uterine contraction as multiparous women has an increased risk of uterine rupture with oxytocin and should be used with caution. She should be advised on continuous fetal monitoring once on oxytocin. She should be offered adequate support and pain relief. Epidural can be offered before oxytocin is commenced. She should be counselled that once oxytocin has been started she will reviewed in 4 hours and if she has progressed less than 2cm from current dilatation she will be counselled for a caesarian section. If she has progressed more than 2cm in 4 hours, she will be reviewed every 4 hour and decision will be made on subsequent management at every review provided both maternal and fetal wellbeing are reassuring.
Posted by Aruna R.
ARUNA, U.K

a). Before reviewing this multiparous lady, I would like to review her notes to assess the previous delivery details, birth weight of those babies and associated co-morbidities like obesity and diabetes. I would look in the antenatal notes in this prgnancy to review any identified problems like bigbaby,malpresentation and associated cevical fibroids.These are some of the risk factors for delay in first stage of labour.
Assessing her partogram for maternal tachycardia,pyrexia,frequency and strength of contractions.Maternal dehydration, inadequate pain relief and inadequate uterine contractions can delay labour.
I would like to see the vaginal examination findings when she came in. Ther bisop score at that time will help to findout whether she was in established labour or in latent phase when amniotomy was performed, because augmentation at latent phase may cause delay.
I will do a detailed clinical examination to assess her pain,hydration and abdominal palpation to find out the quality of uterine contractions, size of the baby, presentation and lie of the baby.I will make sure that the bladder is empty before vaginal examination and do this examination to confirm the fetal presentation, rule out malposition, cervical dilatation ,position of fetal head including caput and moulding.These are important because inadequate uterine contractions,big baby,malpresentation and malposition can cause delay in progress.
cardiotocogram(CTG), and colour of the liquor will reveal the fetal status and the urgency to take action(Fetal blood sampling, delivery).

Options : This depend upon the cause for delay. If the examination revealed cephalopelvic disproportion or malpresentation (mentoposterior) ,the safest option is caesarean section.
If it is due to simple reasons like maternal anxiety,inadequate pain releif and dehydration , correction of the underlying cause(analgesic, Intravenous fluid and supportive care ) will help.
If the cotractions are inadequate oxytocin infusion as per unit protocol is an option. Epidural analgesia and oxytocin infusion to get adequate contractions and review after 2 hours to assess the progress. If progressing it is safer to let her continue to achieve vaginal delivery.
Generally mobilisation and one to one supportive care give good results.


Posted by A A.
a)This indicates delay in the established first stage of labour. I will the explain the patient the reason I have been called. I will review her antenatal record particularly if any Ultrasound performed in third trimester, Congenital malformation like hydrocephalous or suspected fetal macrosomia might be reason for this delay in progress. I will ask the midwife about colour of liqor, analgesic given to patient & review the partogram .
I will assess her emotional status, her BMI, Blood pressure, Pulse & hydration. Inadequate analgesia ,maternal exhaustion due to prolong labour & lack of one to one support could be reason of delay in progress .
I will do abdominal examination to check the fundal height , lie & presentation of fetus. Non cephalic presentation like breech or abnormal lie should be excluded.i If cephalic, the descent into the pelvis. I will then palpate for contractions for 10 minutes to assess the intensity, duration and frequency. EFM if already started for any abnormal or suspicious finding, if not I will arrange for one to be started immediately to assess fetal wellbeing
I will examine her vulve which if swollen could be a sign of obstructed labour. Digital examination to confirm presentation, station & position of presenting part. ,degree of caput or moulding if present .Cervical dilatation & effacement. Poorly applied oedematous cervix with severe caput or moulding may indicate obstructed labour. I will check colour of liqor, meconium if present possibility of fetal distress & Adequacy of pelvis clinically. I will explain my finding to patient & further discuss plan with her.
b) Depending on my findings, emergency ceasarean section or augumentation of labour will be the options of management, after taking patient, choice into consideration. In case of abnormal CTG, abnormal lie or non vertex presentation Caesarean section will be safe option I will inform senior Obstetrician .
If delay is due to inadequate uterine contraction , in the absence of fetal or maternal compromise augumentation with oxytocin is also safe. oxytocin will increase the frequency and strength of uterine contractions I will follow the departmental protocol. I will offer an epidural before starting oxytocin & continous EFM. For Oxytocin increments the dose should be no more frequent than every 30 minutes ,increase until 4-5 contraction per 10 minutes, repeat vaginal examination( VE) after 4hours,if < 2cm progress consider caesarean section. If 2 cm or more progress she will be reviewed every 4 hour and decision will be made on subsequent management at every review provided both maternal and fetal wellbeing are reassuring. There is risk of hyper tonic contraction, with risk of rupture uterus & fetal distress. So careful monitoring & councilling of patient is essential.
Posted by Syamala H.
the possible reasons for a mutiparous women with no progress in cervical dialatation in last 4 hr could be inadequate contractions,macrosomia, fetal malposition cephalopelvic disproportion ,inadequate support. i would review the antenatal record to identify any risk factor for macrosomia like gestational diabetes,obesity. also would like to know about the birth weight of prev babies, duration of labour and duration since last child birth and any usg performed during third trimester.i will be informing the patient of her present condition, reassure her and adress her emotional and psychological needs.asses her need for analgesia and provibe adequte analgesia as per need. general examination of the pt would include checking for hydration,ketone breath,pulse , BP, input and output and the color of urine. abdominal palpation to acertain the lie and position of the baby and number of fifths of head palpable. review ctg for any abnormal pattern. assess for strength and duration of each contaction. after obtaining consent i will perform vaginal exam to confirm the finding,see for station of head, rotaion of head and assess pelvic adequacy.
ans B: further mamagment will depend for finding of examination. if the cause is inadequate contraction and pt is having no signs of dehydation or obstructed labour can be started on oxytocin to obtain 4 contactions every 10 mins lasting for 40-50 secs. should be reasses again b/w 2-3 hrs for progress anf if progressing satisfactorily allow to deliver.slow or protacted progress may alert for possible shoulder dystocia and perineal trauma. pt to be kept on continous EFM with one to one midwifery care.. if any signs of obstructed labour ,macosomia with gross cpd or no progress despite adequate contaction recourse to lscs. inform theatre and anesthetist.debrief the partner or attendent.
Posted by Mohamed D.
Mohamed
a) Review her notes for any problem in the current pregnancy with regard to screening, growth scans to role out any fetal problems. Any past history of uterine anomaly, perforation during previous ERPC or previous myomectomy, needs to be taken in consideration during councelling for augmentation of labour. Review her previous deliveries and any long labours or induced labours and babies\' weights.A previous small babies and in comparison the current pregnancy is suspected to be a large one would suggest caution in augmentation of labour and increased risk of rupture uterus.
Review her CTG if she had one and assess her pain management status. She can be offered epiduaral before starting augmentation as contraction could be more painfull. Ask about liquor colour and amount at ARM ealier, meconeum could be a sign of fetal distress. Check her general condition, hydration, and urine output. Dehydration is a factor for poor progress. Abdominal palpation to role out large sized baby, malpresentation, high presenting part, or contration ring which all signs of obstruced labour.Palpate for contrations frequency and duration. Contractions could be insuffiecnt and short in duration. Vaginal examination to insure rupture of membranes, liquor colour, cervical dilatation, presentation, position and station of presenting part. Occipto-posterior usaully associated with poor progress. Oedematous cervix and high presenting part are signs of onstructed labour.

b) If no contraindication to continue with labour and both mother and baby are well, rehydration and mobilization should be tried first. Observe for uterine activity and ensure she is having regular uterine contractions, then reevaluate after 4 houres. Progress of 1 cm every 2 houres is acceptable.
Augmentation of labour with oxytocin ifusion is another option but she should be councelled as she is at higher risk of rupture uterus (multipara). Continous fetal monitoring should be commenced before that. Epidural analgesia should be offered before augmentationa as contractions could be more painfull. Oxytocin infusion for a multipara should be discussed with senior as she is at risk of rupture uterus with obstructed labour. Caution in esclating oxytocin infusion and aim for 3-4 contactions in 10 minutes, not to increase the risk of rupture uterus. Reassessment in 4 houres and a dilataion of at least 6 cms is expected.
Caesarean section delivery if suspected maternal or fetal compromize or if she declines augmentation with oxytocin.
Posted by bandir G.
Bandir Ganob
(A)I would ask about past obstetric history including birth weight of her babies ; need for oxytocin infusion; or instrumental delivery . I would review the patient antenatal notes for ultrasound assessment of expected fetal weight . I would review the CTG for assessment of fetal condition . I would ask if oxytocin infusion given and if any form of analgesia given . I would review the partogram for descent of fetal presenting part .

I would check pulse , blood pressure , and tempratureand examine her lips as dry lips , tachycardia or fever may be an indication of dehydration .
Abdominal examination clinical assessment of fetal size , lie , presentation and number of fetal head fifth palpable per abdomen as well as palpation of uterine contractions.
Vaginal examination for assessment of presenting part : its station and position as well as presence of caput or moulding as they may indicate obstruction . inspection of amniotic fluid for meconium .

(B)If CTG is reassuring , maternal dehydration not present or corrected and there is no signs of obstruction , oxytocin infusion is an option with aim of acheiving 4-5 contractions per 10 minutes . Epidural analgesia should be offered before starting oxytocin infusion . continous electronic fetal monitoring should be maintained . vaginal examination after 4 hours of oxytocin infusion . If progress in cervical dilatation is > 2 cm , then oxytocin infusion is maintained with 4-hourly vaginal examinations . If progress in cervical dilatation is < 2 cm in 4 hours , then the alternative option to be considered is caesarean section ( CS)
Posted by football  C.
a) She is most likely to be distressed and anxious . She should be approached in a sympathetic manner. Reassured of appropriate management after evaluation of delayed progress. It is ensured that she is receiving adequate analgesia.
Clinical assessment includes recording temperature, pulse, blood pressure . and looking for dry tongue as raised temperature and tachycardia indicate infection or dehydration.
Maternal records are reviewed to identify suspected big baby.
Abdominal examination is undertaken to assess the size of the uterus( over distended), lie , presentation of the fetus and for the assessment of the palpable portion of the head per abdomen. Examination is continued to identify vulval edema which indicates prolonged labour. Under aseptic precautions, vaginal examination is performed to assess presentation of the fetus,( to exclude face or brow presentation), station of the presenting part, abnormal moulding or, caput formation Color of the liquour is noted. It is important to note if cervix is oedematous and well applied to the presenting part.which indicate CPD.
Partogram and CTG are evaluated to identify fetal wellbeing and for the assessment of strength, duration and intensity of uterine contractions.
b) The woman and the family are informed about the finding of evaluation and possible cause of delayed progress. Adequate hydration and analgesia is provided. Continuous electronic fetal monitoring is undertaken.
In case of inadequate uterine contractions and in the absence of CPD and fetal compromise, her labour is augmented with oxytocin.to aim normal vaginal delivery.Oxytocin augmentation is associated with risk of hypertonic uterine contractions, fetal distress and uterine rupture. With adequate uterine activity( 4 contactions every 10 mins lasting for 40-50 sec) next vaginal examination is performed after 2 or 3 hrs to assess the progress.
In the presence of CPD or fetal compromise, caesarean section is undertaken to avoid obstructed labour and risk of uterine rupture. Caesarean section after prolonged labour is associated with risk of sepsis, and hemorrhage
Maternal wishes are taken into consideration.
Posted by VINITA N.
I will first take a brief history od her previous vaginal deliveries, the duration of labour, whether she had an instrumental or spontaneous delivery and previous birth weight as this information would give an idea of previous prolonged labour, big baby, shoulder dystocia. Next I would assess if she is diabetic, if high BMI as it is associated with delay in progress of labour. I will then look at her partogram to assess progress, check for signs of dehydration, check if bladder is empty, confirm that her vitals are stable and she is not pyrexial as these factors can delay progress.I would then assess her abdominally to look for full bladder, presentation and how many fifth\'s palpable the presenting part is and if there was any signs of obstruction like bandl\'s ring. I would also time the frequency and duration of contractions. I would next do a vaginal examination with consent to assess dilatation of cervix, position and station of vertex as a deflexed head, brow presentation or mentoposterior could lead to obstructed labour. I would discuss my findings with mum and involve her in any plan.B) Further management would depend on clinical findings and patient\'s wishes. If there are signs of obstructed labour, the safest mode of delivery would be by caesarean section. I would discuss the case with my consultant and then consent her for LSCS. In theatre I would make the uterine incision high but below the bandl\'s ring. I would give post delivery syntocinon infusion to keep uterus contraced as more prone to PPH. If no signs of obstruction, then I would correct dehydration if present, check if she has adequate analgesia and then discuss option with patient, either to wait for another 2 hours and reassess to check for progress if contracting adequately, advantage being a safe option but disadvantage of prolonged 1st stage, the next option would be to start syntocinon cautiously, the advantage is if mild malposition, it gets corrected, disadvantage is the risk of uterine rupture in a mutiparous woman. If having syntocinon, I will ensure one to one care and continous monitoring aiming to achieve 4 contractions in 10 minutes lasting 30-40 seconds. I would inform the consultant regarding the plan and document discussion in her notes. I will examine her again after 4 hours to assess progress.
Posted by leelavathi C.
above clinical presentation indicates primary dysfunctional labour. initially i will explain to the patient why i called for and reassure her to ease her situation. i will ask about labour pains intensity,frequency and her tolerability. i will ask any symptoms of dehydration like dry lips, mouth,dizzines. maternal dehydration and inadequate pain relief is one cause of poor progress in labour. i will check antenatal records for recent ultrasound to check fetal weight, any pelvic masess like fibroids. fetal macrosomia, pelvic masess are reletive causes for CPD, that could cause poor progress in labour. i will check past obstetric history for previous babies weights ,any delivery complications to help in present management. i will enquire from midwife about liquor colour, volume, or any changes since ARM. on examination check maternal pulse, blood pressure, temperatur .maternal tachycardia,confusion, is possible indication for maternal exausion is one of indication for obstructed labour. on abdominal examination chek for syphisio fundal height ( >40 cm at this stage of labour indicates large baby) degree of engagement( fifths palpable per abdomen). i will place woman on contineous CTG monitering if she not on it, to asses fetal wellbeing. on vaginal examination check position of presenting part, to help in decision for intrvention. check for moulding , presence of pelvic masses on examination that helps to ruled out obstructed labour. asses the descent of the presenting part with contraction. and contraction frequency to ruled out incordinate utrine activity.
B)After initial clinical assesment if there is any fetal compromise or any absolute CPD immediat decision should be emregency c-section. once there is no fetal compromise maternal rehydration with normal saline, and adquate pain relief improve the sucess rate of vaginal delivery. the provision of one to one care by contineous presence of a care giver helps to reduce length of labour and decreases the likelihood of c-section, instrumental delivery. on clinical assessment if notice incordinate uterine activity augmentation of labour with oxytocin is considered. decision on augmentation should come from senior level. because in multi gravida ther is risk of uterine rupture with augmentation. oxytocin should be titrated to provide a contraction frequency of four in 10 min with each contraction lasting approximatly 40sec. frequency and duration of contractions should be assessed by either external or internal tocography.
if progerss of labour remain unsatisfactory despite of augmentation , mechanical factors such as deflexed head or malposition may be causes.desition of c-section should be made depends on maternal, and fetal condition. women should be councelled about extra risks involved in c-section performed in labour.
Posted by NIRMALA M.
Reply Author: Nirmala

I will enquire about previous obstetric history in detail to include spontaneous onset, duration of active phase of labour, mode of delivery, weight of previous babies and any post partum complications. As she is a multiparous lady, one should suspect some form of obstruction or the contractions may not be strong enough. I will enquire about antenatal history and ensure whether growth, liquor and estimated fetal weight has been normal and find out whether she is complicated by any medical disorders like diabetes mellitus as uncontrolled diabetes might lead on to macrosomia. I will proceed with abdominal examination to assess lie whether longitudinal, whether cephalic or breech, if cephalic how many fifths palpable, baby\'s size, contractions whether they are strong enough to effectively cause descent of the baby and look for any constriction ring (bandl\'s ring). The next important part of assessment is vaginal examination which is complementary to abdominal examination to assess cervical effacement, cervical dilatation, whether application of the cervix to fetal head if it is applied loose it may be suspective of cephalopelvic dysfunction or shoulder dystocia,any fetal malpositions like deflexed OA / OP, brow or face presentation, station of the fetal head, presence of caput and moulding as these are strong indicators of CPD, colour of liquor which is an indicator of fetal well being. I will assess the CTG in order to ascertain the fetal well being and to note the regularity of contractions.
Once ruling out cephalo pelvic disproportion, if the contractions are not strong enough though they may be 3 in 10, Syntocinon can be started as per the protocol and titrated according to the contraction till 3-4 contractions in 10 minutes, each contraction lasting from 45 seconds - 1 minute is reached. In cases of CPD, brow presentations, emergency Caesarean section should be offered to her. If it is an undiagnosed breech, options discussed for vaginal or Caeserean section. As she is a multiparous lady, if the baby is average sized and if the liquor is adequate she can be encouraged to have a vaginal delivery after discussing the risks in the presence of expertise in breech deliveries, with syntocinon augmentation. She should be continuously monitored by CTG. She should be vigilantly monitored for signs of impending rupture uterus/ rupture uterus and should do a crash section to save the baby. After starting syntocinon, I would assess her in 4 hours time after the onset of effective regular contractions to note any progress. If she is progressing well as per the partogram follow her till delivery and help her out in cases of II stage delay in progress by instrumental delivery in cases of malrotations. If no progress with syntocinon as well, I would prepare her for emergency LSCS.
Posted by KWASI RICHARD A.
Review her antenatal notes noting the birthweight of her previous delivereis and whether they were normal vaginal or instrumental deliveries.Assess her emotional state. Check her temperature, pulse, blood pressure, urinalysis to assess her state of hydration
Review the partogram to assess changes in strength, duration and frequency of contractions, state of liquor, any moulding or caput noted in previuos examinations which is suggestive of obstruction. Has syntocinon been started and what is she using for pain relief. Take into consideration the fetal well being. Is she having intermittent ausculation or continous CTG monitoring. Is the fetal heart rate monitoring reassuring, suspiciuos or pathological, and then act accordingly by performing fetal blood sampling or emergency caesarean section.

Abdominal examination to get an impression of the size of the baby and the presenation - whether cephalic or breech and how many fifths palpable abdominally.

Vaginal examination to determine presenation, station and position of the presenting part. Is the presenation brow,face or a deflexed occipito-posterior position and exclude cephalo-pelvic disproportion. Exclude evidience of obstruction- is there caput or moulding?

Establish intravenous access and draw blood for full blood count and group and save in case she may be going to theatre or transfusion is required if post partum haemorrhage. Ultra sound scan may be requireed to confirm presentation.

Ensure supportive one-to-one care and effective pain releif. Start intravenous fluids in the form of Hartmanns solution to ensure adequate hydration.

Start syntocinon infusion if no contraindications to its use. Offer epidural for pain relief before starting syntocinon. Explain to the patient that syntocinon will bring forward time of birth but not influence the mode of delivery. it will increase the frequency and strength of contractionsand continuous cardiotocograph (CTG)monitoring will be neccessary.

Continue syntocinon infusion untill contractiosn 4-5 in 10 minutes. Reduce if more than 5 in 10 or if CTG is suspicious or pathological and consider fetal blood sampling or immeadiate delivery - whichever is appropriate at the time.

Vaginal examination will be performed 4 hours after starting syntocinon and if there is progress of more than 2cm in dilation of the cervix, labour will be allowed to continue and vaginal examination repeated again 4 hourly if the CTG remains normal. However if progress is less than 2 cm after starting syntocinon then caesarean section will be considered.

If she progresses to full dilation and the second stage is prolonged and the head is well below the spines and there is evidence of maternal exhaustion or fetal distress, intrumental delivery may be considered.
Posted by Ir A.
I would like to confirm the diagnosis of delay in first stage of labour as suggested by less than 2 cm progress in dilatation in 4 hours. I will do an abdominal palpation to assess the strength of contractions and to see how many fifths of fetal head is palapable above the pelvic brim. I will note her pulse, blood pressure and temperature and assess her for dehydration and pain relief. I will do a quick review of her antenatal records to see the estimated fetal weight. I will see the cardiotocograph to assess fetal well being and to note the frequency of uterine contractions. I will explain to her the possible diagnosis and offer her a vaginal examination. I will assess the effacement of the cervix, presentation, station of the fetal head, position of the sutures as positions like occipitoposterior are associated with delay in progress of labour. I will assess for caput and moulding as grade 2 and above moulding will suggest cephalopelvic disproprtion. I will see the colour of the liquor as freshly passed meconium will suggest fetal distress.
Once the diagnosis of delay in first stage is confirmed, I will explain the diagnosis to the patient and offer her the use of oxytocin. I will explain to her that oxytocin will increase the frequency and intensity of the uterine contractions and bring forward her time of birth but will but will not influence the mode of birth or other outcome. I will enquire about her pain and offer her epidural for adequate pain relief. If she agrees for augmentation of labour with oxytocin, I would offer her continuous electronic fetal monitoring. The oxytocin should be started at 2.5 mU in 500 ml of normal saline and titrated till the frequency of contractions is 4-5 in ten minutes. I will repeat the vaginal examination 4 hours after starting oxytocin. I fthe progress is more than 2 cm, she can be reviewed next after another 4 hours. However if the progress is still less than 2 cm, I would offer her delivery by cesarean section.
Posted by Bgk H.
bgk

a. This patient is currently having failure to progress. Correct assessment to identify the cause is important. Timely management and decision may prevent maternal and perinatal morbidity and mortality.

I will assesss her effectiveness of the contraction. Duration of each contraction should be determine. I will enquire any augmentation has been given to her. Her pain relief need to be reviewed. If inadequate pain relief, an effective analgesia should be offered. I will review her antenatal notes including latest ultrasound to detect any lower segment mass such as fibroid. Her currrent antenatal problem such as GDM and PIH should be reviewed.

On clinical assessment, height weight and BMI of the patient should be measured and calculated. Hydration of the patient should be assees clinically or by urine ketone. I will palapate the abdomen and estimate the fetal weight to rule out fetal macrosomia, although it might be inaccurate. I will then perform vaginal examination to determine the position of the fetal head, station caput and moulding. Pelvimetry can be done to assess the pelvic outlet. Fetal well being should be monitored continously.

b. To achive a safe delivery, the identified cause of failure to progress should be corrected. Adequate hydration should be given. Appropriate and effective analgesia should be offerred. Mobilisation should be encouraged. Judicious use of oxytocin augmentation should be commenced to achieve effective contractions.

If there is suspected fetal macrosomia and contracted pelvis and the dlivery is not imminent, caesaerean section is a safer way.

If all the causes corrected, she should be reviewed in targeted time in 2 to 4 hours to assess the progress and charted in partogram. If still no progress, then patient should be explained and option of caesarean section should be considered.

Giving more time is an option provided no fetal compromised and patient understand the consequences of prolonged labour like post partum haemorrahge and fistula formation.

Patient should be kept informed regrding her progress of labour and given an informed consent on each decision.