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MRCOG PART 2 SBAs and EMQs

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ESSAY 202 - Labour

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		Posted by Balakrishnan V. Thu Jul 27, 2006 08:04 pm
The active first stage of labour in a patient is identified by progressive diltation and effacement of the cervix. Slow progress of first stage means cervix is not dilating 1cm/hr as is the standard in primigravida. First stage is approximately ten to twelve hours in primigravida and six to eight hours in multigravida. The progress of first stage of labour depends upon uterine, pelvic and fetal factors so I will evaluate the patient in detail to see what is the cause of slow progress. I will see her labour notes whether she is in spontaneous labour or was induced as induced uterine contractions are more likely to be incoordinate. I will review her partogram for frequency and intensity of contractions, progression of dilatation and descend of the head. But these can be inaccurate as depend upon manual palpation. I will do abdominal palpation to confirm lie, presentation and assess fetal size. Is head palpable suprapubically and strength and regularity of uterine contractions. Then I will do vaginal examination to see the dilatation and effacement of the cervix, presence of membranes.The position and station of vertex whether its occipitoanterior or occipitoposterior, fully flexed or not. I will review her CTG if its reassuring then we have time and there are some options which can be tried. If membranes are intact, artificial rupture of membranes (ARM) will release prostaglandins which stimulate myometrium and give rise to strong contractions. If this is not successful or membranes already have ruptures spontaneously oxytocin infusion 10IU in 500 mls of normal saline can be started per unit protocol. It is titrated according to frequency and intensity of uterine contraction. She will need continuous fetal monitoring with Oxytocin infusion as there is risk of uterine hyperstimulation and fetal distress. Good analgesia in labour also help in dilatation of cervix. Pethidine or epidural analgesia can be used. If vertex is occipitoposterior, usually labour is slow but head rotate to occipitoanterior position and vaginal delivery can occur. I will document all the details and plan to reassess the patient in three hours, if she is not progressing despite all the interventions I will seek my seniors advice for caesarean section. I will counsel the patient regarding risk of fetal hypoxia if progress remains slow and risks of caesarean section and will proceed according to her wish. After delivery there is risk of PPH due to prolonged labour and proper thromboprophylaxis should be given.
		Posted by Ebeinheizer S. Thu Jul 27, 2006 10:28 pm
Slow progress in active phase of first stage can be caused by either one or combination of ?Power?,?Person?,?Passage? and ?Passenger? (4P). Determining the cause would be the first step of management. Uterine contraction may fade after going into established labour. Determining adequate contraction, at least 3 strong contractions in 10 minutes is important to achieve adequate progress of at least 1 cm cervical dilatation per hour in active phase for primigravida. This can be achieved by syntocinon augmentation. However, there is a risk of hyperstimulation and tetanic uterine contraction with syntocinon. Uterine rupture in primigravida has also been reported with syntocinon.. These may lead to fetal distress and eventually Caesarean section; the rates of which are higher in labour where syntocinon augmentation is used. There is also a small risk of fluid overload, hyponatremia, water intoxication and fitting due to syntocinon. Syntocinon usage is also associated with increased neonatal jaundice. Incoordinate uterine contraction can also contribute to slow progress and correctable with syntocinon augmentation. Some women have slow progress due to inadequate pain relief and involuntary pushing causing cervical oedema. Even though there are no strong evidence, adequate pain relief especially with epidural anaesthesia are known to improve slow progress. However,usage of epidural anaesthesia carries its own risks such as neural injury and dural tap. Usage of excess opioid analgesia can cause neonatal respiratory depression. The woman herself could be exhausted causing lactic acid build-up in myometrium which in turn hinders effective contraction. Light drink during labour is permitted and aids against dehydration. Urine ketone levels can give a picture of dehydration. If present, intravenous fluid infusion can be given. Blood for FBC and group&save can be taken while setting IV cannula. Even though the patient is healthy,fluid input/output should be monitored to avoid fluid overload and its consequences such as pulmonary oedema. Assesssment of adequacy of pelvic outlet is not satisfactory antenatally or in labour. However, if there were obvious pelvic contraction such as very acute sub-pubic arch and no adequate descend of fetal head, Caesarean Section should be considered. Fetal position, presentation and size plays an important factor in labour progress. Malposition and malpresentation are obvious causes of slow progress. Some of them are self-correcting with adequate contraction but frequently they persist needing Caesarean Section. Macrosomic babies frequently cause slow progress. Clinical assessment of fetal size is not satisfactory and ultrasound in labour should be considered. If suspected, caesarean section should be considered. Upon correction of the ?4P?,slow progress may persist. In this situation caesarean Section need to be performed as slow progress can cause prolonged labour . Prolonged labour can cause maternal exhaustion, fetal distress, uterine atonia and postpartum haemorrhage. The patient should be informed with diagrams for clarity. She should be allowed to make an informed decision.
		Posted by neera B. Fri Jul 28, 2006 02:46 am
Slow progress is assessed by the rate of cervical dilatation less than 1 cm/hour and descent of presenting part.Review notes to see if labour is spontaneous or induced. The 3 P\'s of labour should be assessed 1.power by palpating duration,intensity & interval between contractions 2.presentation & position of passenger 3.passage,pelvimetry is not reliable. Continuous presence of a support person , other than /in addition to partner and maintaining a partogram are associated with reduced caesarian rates and should be encouraged. Hydration should be maintained by oral or intrvenous fluids but fluid overload should not be done due to risk of fluid retention,especially if oxytocin is also being given.Analgesia helps to prevent premature pushing,but epidural can cause hypotension, fetal bradycardia,headache,dural tap while neonatal depression may occur with opioids.If membranes are intact,ARM should be done.However fetal heart must be checked after ARM due ta risk of cord prolapse.If contractions are poor, oxytocin infusion shold be started with continuous CTG,infusion pump, careful monitoring with 1:1 patient:midwife ratio and half hourly increment in doses.Despite this hypertonic contractions can occur, causing fetal hypoxia.neonatal jaudice and fluid retention may occur with high doses. These interventions shorten the duration of labour but do not decrease caesarian rate or perinatal mortality.So their beneficial effect is in doubt. Periodic assessments should be done.The patient should be kept informed and involved in decision making,informed consent should be taken.If CTG is pathological,scalp ph is recommended.scalp ph<7.2,brow and persistent mentoposterior face are indications for caesarian.If macrosomia is suspected, seniormost obstetrician on duty with an experienced midwife should attend the delivery due to risk of shoulder dystocia. In labour,continuous CTG,neonatologist,active management of third stage,risk assessment for thromboprophylaxis are essential due to prolonged labour.clear documentation and explanation of events is essential.postnatal visit is arranged and possibility of recurrence in next pregnancy discussed.
		Posted by Sarwat F. Fri Jul 28, 2006 06:38 am
Slow progress in the active phase of first stage of labour is less than 1 cm per hour. This can be due to fault in passage, power and passenger. With regard to passage, there can be cephalopelvic disproportion due to shape of pelvis, there may be slow progress because of passenger for example big baby or deflexed head or due to power that is inadequate uterine contractions. Slow progress during labour is managed by vigilant monitoring, recording all events on partogram and taking appropriate steps. These include for example in case of inadequate uterine contractions, artificial rupture of membranes can be done and syntocinon infusion can be started. Added benefits of ARM include assessment of colour of liquor and hence some indication of fetal well being. Also in women with raised body mass index where abdominal transducer to assess fetal heart rate is difficult to apply, fetal scalp electrode can be applied after ARM. On the other hand with ARM there is a risk of cord prolapse with unengaged ballot able head. There is also a risk of introducing infection which is minimal. Syntocinon infusion can be started to augment uterine contractions however adequate titration of dose is needed. However with syntocinon infusion woman will require intravenous line and freedom is restricted as continuous CTG monitoring is needed. Risks of syntocinon infusion include hyperstimulation of uterus and fetal distress which may neccitate caesarean section. Other risks include dilutional hyponatremia and neonatal jaundice. Cases of cephalopelvic disproportion can be identified by combination of various factors. These include antenatal assessment of size of baby, this is however not always accurate and labour is the best pelvimeter. It has been advocated by some to assess the size of pelvis by radiological techniques like X-ray or MRI however it is not recommended not only because of harmful effects of X-rays but also because of the fact that various soft tissue changes during labour cannot be predicted by antenatal investigations. Other factors to consider for CPD include nonengagement of fetal head, presence of caput or moulding during labour. In these cases individual assessment is required and caesarean section may be needed. Woman is fully counseled and involved in decision. Various short term and longterm risks of caesarean section are discussed like hemorrhage damage to adjacent structures, infection, risk of VTE and long term reproductive outcome. Slow progress in first stage is also related in some cases to slow second stage as well as other complications like increased risk of operative delivery, shoulder dystocia and postpartum hemorrhage. Proper protocol should be in place to manage first stage to prevent complications.
		Posted by Vinayak B. Fri Jul 28, 2006 07:26 am
Slow progress of labour in active phase in primigravida may be due to changes in 3 ps power (Uterine contraction)passenger (fetal weight, position),passage(contracted pelvis or cephalopelvic dispraportion), leading to poor progress in labour crossing the alert line of partogram (1cm/hr). I would like to take the history and asses the record whether patient is in spontaneous labour or induced , presence or absence of membranes , duration of labour pains , like to review partogram . As this will give clue towards possible aetiology of slow progress as uterine infection may lead to incordinate action ,fetal distress. Maternal pulse , temperature taken , signs of dehydration( Dry toungue )looked for . tachycardia , dehydration may be present in prolonged labour due to infection or cephalopelvic disproportion or poor fluid intake during labour. Per abdominal examination done to assess fundal height, clinical estimation of fetal weight, l,engagement of head in 5ths ,fetal heart rate. Frequency , intensity, duration of uterine contraction(mild/mod/strong) noted . Lowersegment streching or tenderness assessed signs of obstructed labour excluded .vaginal examination done to assess dilatation , effacement ,station of fetal head, presence of caput . moulding. Suggestive of feto pelvic disproportion., fetal postion( occipito posterior ) and brow/ face presentation excluded as occipito posterior position do progress slowly in labour..colour of liquor noticed.pelvic size and shape assessed . Fetal CTG taken to know the fetal wellbeing and uterine contraction .ultrasound examination done to assess fetal weight to exclude macrosomia but this may not be accurate in labour decision to section should not be based on usg fetal wt assessment in labour. . Urine tested for ketonuria , and fbc and Blood for grouping and cross matching send . Management options are based on clinical examination and investigations Correction of maternal factors to treat dehydration with iv fluids as it causes myometrium relaxation giving poor contraction . Expectant management if no abnormal factor detected clinically & Partogram shows delayed progress is not more than four hours passed action line. ( as per Rcog guidelines) as this will reduce section rates. Require close watch on progress of labour and fetal condition . . , For poor or incordiante contraction ,Pitocin augmentation is preferred with infusion pump .Dosage to be given as per unit protocol .This will require continuous electronic monitoring of fetal heart and close watch on uterine contraction and progress of labour. patient should be informed about management options and its consequences. .1/1 staff to patient ratio is needed .Hyperstimulation may occur . Excessive pitocin may lead to hypernatraemia and convulsion, it has antidiuretic effect also. Lowersegment cesarean section done for fetal distress, mal position(brow, mento posterior),cephalopelvic disproportion , or no response with maximum dose of pitocin. Requires prophylactic antibiotics, and thromboprophylaxis . increased hospital stay.and post operative follow up. Hence decision of lscs should not be taken hastly. Slow progress may be associated with postpartum hemorrhage third stage managed actively. Findings should be documented clearly.
		Posted by Zaharuddin R. Fri Jul 28, 2006 09:06 am
Management of slow progress of labour for healthy primigravida should be started by history taking. Antenatal records should be reviewed to exclude other risk factors for cephalo-pelvic disproportion (CPD), suspected big baby, modified glucose tolerance test or history of pelvic bone trauma. Maternal obesity may associated with big baby and there is difficulty in estimating fetal weight either by physical examination or ultrasound. Latest ultrasound result should be reviewed either singleton or multiple pregnancies, placenta localization and estimated fetus weight. Physical examination and ultrasound test intrapartum are not accurate in estimating fetal weight. Presentation of fetus should be examined to exclude breech or non engaged head. If it is breech presentation, emergency caesarean section should be done to reduce perinatal morbidity & mortality. If the fetal head is non engaged, CPD should be suspected. Contraction should be palpated & timed. Weak contraction (without CPD) augmented with oxytocin titration to aimed for good contraction for 30-45 sec for 3-4 in 10 minutes. Labour progress should be monitored by partogram. Labour progress should be reviewed at least every 2-4 hours by abdominal examination to assess progression of head engagement and vaginal examination to assess progression of cevical dilatation and descending of the fetal head. Position of fetal head should be determined as malposition such as occipito-posterior or occipito-transverse position associated with poor progress of labour. In early part of first stage of labour, augmentation of labour may correct the position. Progression of labour should be plotted in the partogram. Fetal well being should be monitored with continuous cadiotocograph (CTG) as oxytocin augmentation may associated with abnormal CTG tracing. Adequate analgesia should be given either by epidural analgesia or im pethidine. Blood should be taken for haemoglobin level and group screened and hold as the patient may need caesarean section if labour progress if poor. After reviewing the partogram, poor progress of labour will be noted if labour progress is beyond the action line in spite of good contractions. Emergency caesarean section should be done. Proper documentation during labour is essential for future referrance as it will affect management of future pregnancy. Relative CPD will allow vaginal birth after delivery and absolute CPD is indication for repeat caesarean section. The patient sholud be informed about the labour and a discharge summary with future plan in future pregnancy should be given to the patient and her GP.
		Posted by Kishor S. Fri Jul 28, 2006 10:54 am
Slow progress in active phase in a primi implies that the cervical dilatation is less than 1 cm/h. Management is directed towards identifying and treating the cause. Cause can be identified from history and clinical examination. Duration of active phase of labour and type of analgesic used should be enquired. She is likely to be dehydrated if duration is long and will require IV fluid to correct dehydration. Opiate analgesics do not affect the rate of progress of labour in active phase but use of epidural analgesia at an early stage may influence the progress, even though it is not shown to be true by RCTs. Examination will include determination of the presenting part and position, fetal weight estimation and assessment of the uterine contractions. Ineffective uterine contractions can be secondary to maternal dehydration or feto-pelvic disproportion. Another factor which is likely to slow the progress is mal position of presenting part e.g. occipito posterior. Clinical assessment of pelvis is shown to be unreliable but there are features which will suggest pelvic factor. Station of the presenting part is one of them and according to Freidman, at 5 cm dilated cervix in a primi the station should be at least 0 in a normally progressing labour without disproportion. It is also necessary to know the exact dilatation of cervix so that at what stage of active phase, the progress has slowed down. Though rate is collectively taken 1 cm /h cervical dilation during active phase, it differs at different stages e.g. stage of acceleration, maximum slope and deceleration. The progress may be slowed at these different stages and even protracted. Slow progress during the later stage of active phase is likely due to feto-pelvic disproportion which will be indicated by presence of moulding along with caput with / without fetal heart problem. In the absence of pelvic factor and fetal heart abnormality, active management will be started in the form of rupturing the membrane, if it were intact. This will provide an additional opportunity to see the colour of liquor. Following this procedure, uterine contractions are expected to improve culminating in normalizing the rate of progress of labour. If this does not happen in 1h, or membrane was already ruptured, oxytocin augmentation will be started at a titration dose till we get 3 contractions in 10 min. However, one should guard against increasing the dose beyond physiological dose which is considered to be 32 mIU/min at term uterus. Higher dose is associated with hyperstimulation, fetal distress and neonatal jaundice. Subsequent monitoring should include continuous CTG and assessment of cervical dilatation and descent of head every 2 ? 4 hours. In the event of unreassuring CTG or the cause for slow progress is disproportion, caesarean delivery will be done taking standard pre and post operative care and thromboprophylaxis. Proper documentation and informing all the events to the patient are necessary.
		Posted by Srivas P. Fri Jul 28, 2006 07:13 pm
In the acute phase of 1st stage of labor cervix normally dilates at minimum 1cm/hr upto 8-9 cm when it slows down towards full dilatation. Poor progress of labor is a leading cause of maternal exhaustion, primary C.S, instrumental vaginal delivery and poor perinatal outcome and should be diagnosed early and optimally managed. A detailed examination should be done to assess the cause of slow progress in this otherwise healthy woman. Her age, BMI, general condition like- her pulse, hydration, and temperature should be noted. Older and obese woman are prone to dysfunctional uterine contractions and slow progress. Abdominal Examination: for lie, presentation, position of presenting part and how many fifths above pubic symphysis, clinical assessment for size of the baby, any stretching of lower uterine segment, nature of contractions-duration, frequency and intensity, and color of liquor if membranes have ruptured should be noted. Partogram should be studied and CTG done to assess condition of the baby. Pelvic Examination: will reveal cervical dilatation, presence or absence of membranes, if cervix edematous and hanging loose or thin stretchable and well applied to presenting part, station of presenting part, any abnormal presentation like breech, brow or mento posterior can be noted and these cases should be taken for C.S. If vertex presentation, position of head, presence of caput or moulding should be noted. Failure of head to descend on abdominal push and if associated with fetal tracing abnormalities like early or variable decelerations are indicators of CPD and she should be taken for C.S. after reviewing with the consultant. If the examination shows no signs of disproportion or fetal compromise she should be managed conservatively. Active management of labor advocated by Driscoll involving ARM, 2 hrly pelvic examination, judicious use of oxytocin, Daula support, adequate hydration and pain relief have many voters. Though it reduces duration of labor and has not shown any increase in neonatal and maternal morbidity, it has not shown any reduction in C.S. either. Improving hydration if the woman is dehydrated does improve her contractions and so intravenous line should be started. Amniotomy is indicated if FHR tracings look suspicious. Early routine amniotomy without oxytocin augmentation is not indicated. Though it gives earlier indication of color of liquor, gives access for FBS and scalp electrode and can augment labor, it is not beneficial if FHR tracings are good because adverse effects of early amniotomy include possible infections, cord compression and cord prolapse and rarely rupture of vasa praevia. If her contractions are not good and there are no indicators of disproportion, oxytocin augmentation should be done following ARM. It should be given at 1-2 mIU/min, increasing it every 30 mins according to unit protocol and should not increase beyond 32MIU/min to achieve target uterine activity of 3-4 contractions /10min and such trial should be given for 6-8hrs of effective contractions. She should have continuous CTG during oxytocin augmentation.If she fails to progress after this she should be taken for C.S. During this period of observation and augmentation she should have adequate analgesia or epidural anesthesia and good emotional and psychological support from mid wife, daula and her partner for better response to augmentation. Her partogram, CTG should be preserved for record keeping and all discussions and informed decisions including her willingness for oxytocin/C.S should be documented. Senior input should be taken at all stages.
		Posted by OJO AJIBADE . Fri Jul 28, 2006 11:00 pm
Slow progress in the active phase of a first stage of labour in a primigravida could be identified when the cervical dilatation of 1cm/hr is not achieved. The possible causes are:- problem with the passage (pelvis): due to cephalopelvic disproportion which could be absolute as in contrated pelvis or relative as in fetal malpositioning or malpresentation;problem with the person as in maternal severe pain or dehydration; problem with the passenger(fetus) as in macrosomia or fetal malpresentation or malpositioning or problem with the power(strenght of uterine contraction) as in uterine inertia or dystocia. The approach to management include appropriate assessment of the patient to determine the cause of the slow progress.This will include review of the notes to determine if estimated fetal weight from recent ultrasound(USS) was documented;USS will also exclude any adnexal masses or uterine fibriods which may cause uterine inertia;whether the labour was induced or spontaneous as induced labour often needs augmentation.Partogram will be reviewed and will help in determining when action need to be taken.She will be assessed for dehydration(dry tongue).Symphysio-fundal height will be assessed with the lie and presentation noted.The extent of fetal head palpable per abdomen will be noted and strenght of the contraction will be noted though palpatoion is not a reliable way of assessing strenght of contraction During vaginal examination;cervical dilation;descent;positioning of the head will be noted.The prescence of moulding;caput will support a degree of obstruction in which case augmentation is contraindicated and delivery by caeserian section carried out after due explanation to patient and consent taken.Further management depend on the findings of assessment and she needs to be fully informed about the different plans as her wish should be taken into consideration in decision making:IF patient is in pain adequate pain relieve (eg epidural) will be offered ;if dehydrated oral sips of water will be provided or she may be given intravenous drip if not tolerating water orally;support from dedicated midwife or family members is encouraged and will reduce anxiety and prevent prolonged labour.If the membrane is intact/ bulging,artificial rupture of membrane(ARM) will be carried out and this may augment the labour;If ARM has been done or membrane not intact;then augmentation with syntocinon as per unit protocol(via delivery pump) will be commenced.One should watch out for uterine hyperstimulation and fluid overload.Augmentation makes the labour fast but does not improve outcome.If malpostioning is noted eg occipito-postrior ,position in labour might be changed eg from supine to left lateral;labour will be allowed to progress and spontaneous change to OA may occur.However if there is any signs of obstruction eg caput; moulding or non reassuring CTG;patient will be infomed; consent taken and ceaserian section performed.
		Posted by Samir A. Sat Jul 29, 2006 12:57 am
Sloe progress in the active phase of 1st stage of labour is defined approximately as cervical dilatation of less than 1 cm/hr.This slow progress commonly caused by PDL (primary dysfunctional labour) as a result of hypotonic uterinr avtivity or inco-ordinate uterine contractions, SA (secondary arrest) due to CPD(cephalo-pelvic disproportion), malpresentation (breech,brow,mento-anterior face presentatiom), malposition(occipitp-posterior,head deflexion), multiple pregnancy, polyhydramnios and maternal conditions (dehydration, exhausion leading to lactic acid accumulation in myometrium and inadequate pain relief ). PDL affects 30% of primigravida and 10% of multiparae, 80-90% of them improve on oxytocin augmentation. SA affects 5% of primigravida and 2% of multiparae.60% present of primi and 20% of multi improve on oxytocin. I\'ll take history wheather spontaneous or induce labour,onset of labour pains, condition of membranes and analgesia. I\'ll review the old notes looking for single or multiple pregnancy, estimated fetal weight, liquor assessment, fetal lie and presentation. I\'ll examine the patient looking for BMI, temp., pulse, BP and state of hydration. I\'ll do abdominal exam for assessment of fetal lie, presentation, engagement and fetal size, however the later is not accurate during labour, as well as ultrasound assessment of fetal weight is not accurate during labour.Then I\'ll auscultate FHR, I\'ll assess uterine activity by CTG ( should be 3-4/10 minutes each lasting 45-70seconds to be effective) since manual estimation is inaccurate and unreliable. I\'ll do pelvic exam looking for cervical dilatation, membranes, pelvic assessment (acut sub-pubic angle, jutting sacral promontary or ischial spines), occiput position, station, skull moulding and caput.there is no evidence that Pelvimetry improves the outcome. I\'ll review the partogram for the progress and presenting part descent. If breech, brow or mento-posterior or severe CPD I\'ll organise for emergency CS. If DPL is the diagnosis I\'ll do ARM then start oxytocin titrated as per unit protocol with contineuous CTGand keep the patient in left lateral position. If fetal distress develops (late deceleration, siusoid pattern) I\'ll do FBS and do CS if<7.2. 80-90% of cases respond to augmentation, with ultimate vaginal delivery. If SA ia the diagnosis and no excessive moulding nor caput and maternal condition is satisfactory and not dehydrated I\'ll start augmentation under contineuous CTG after ARM if was not ruptured,60% respond. If OP is the diagnosis and the Patient condition is satisfactory I\'ll give 3-4 hours and re-evaluate. If ther are maternal dehydration ( dry mucous memb.,tachycardia) I\'ll rehydrate with normal saline + light oral fluid inake, with fluid chart to avoid overload.It has prooven that rehydration improves the outcome. If she in pain ,I\'ll give pethidine or epidural analgesia. However no strong evidence that adequate analgesia improve the oucome.Epidural analgesia in addition has its own risk of hypotension,dural tap,headache,total spinal,fetal bradycardia or infection.Pethidine might depress neonatal respiratory center.However adequate analgesia should be provided. Instrumental and abdominal delivery rate increase with PDL and SA in comparison to cases with no dely. I\'ll manage 3rd stage actively because of the increased risk of PPH.I\'ll give enough hydration, early ambulation, and stocking. There are risks of hyperstimulation with augmentayion, uterine rupture was recorded and hyponatraemia as aresult of fluid overload.I\'ll observe all of these risk specifically during augmentation. I\'ll keep the patient alawys informed with the whole situarion and allow her to have informed choice. I\'ll inform the paediatrician early .I\'ll persue the partener to give his support
		Posted by Ismatara B. Sat Jul 29, 2006 09:07 pm
In a primigravida slow progress in active first stage of labour is diagnosed by poor rate of cervical dilatation, i.e. < 1cm/h. Usually duration of first stage of labour for primi is 10-12 hrs. Management is directed towards identifying and treating the cause. It may be due to 3 P\'s: passage, power, and passenger. Cause can be identified from history and clinical examination. At first her partogramm should be reviewed with all its events. Assessment of the records should be done whether she is in spontaneous labour or induced, duration of labour pain, uterine contraction (duration, strength, any abnormality), any analgesia and oxytocic drugs given. Her age and BMI should also be assessed, as elder and obese are prone to slow progress due to macrosomia or other causes. Her pulse, temperature, signs of dehydration should be recorded as dehydration and tachycardia may present in prolonged labour and patient may need rehydration. Abdominal examination for lie, presentation, position of the presenting part, SFH, clinical estimation of head in fifths, frequency, duration intensity of uterine contraction, fetal heart rate, size of the baby, any stretching of lower segment should be noted. Pelvic examination to assess dilation, effacement, station of the presenting part, any abnormal presentation. If vertex, position of the vertex (occipitoanterior or posterior), presence of caput, moulding, colour of the liquor, if membrane ruptured. Pelvic assessment should also be done at the same time, though labour is the best pelvimeter. Regarding management labour can be allowed to continue if the condition of the mother and the fetus is satisfactory. Presence of supportive partner and ambulation during labour has shown in shorter labour, less use of analgesic and oxytocics and also cost-effective. If poor progress and she is dehydrated, improving hydration may improve her contraction so iv line should be started. Urine ketone level is to be done to assess dehydration, Blood for FBC, group and save serum. Active management by ARM, if membrane is intact, as it reduce the duration of labour and color of the liquor can be assessed at the same time, but there are risk of cord prolapse and negligible risk of infection. If this is not successful or the membrane is already ruptured, oxytocin augmentation should be given at 1-2 mIU/min, increasing it every 30 mins according to unit protocol and should not increase beyond 32mIU/min to achieve uterine contraction of 3-4/10 mins. Oxytocin infusion can lead to uterine hyper stimulation, fetal hypoxia, dilutional hyponatremia,neonatal jaundice. It is advisable to do continuous CTG. During augmentation she should have adequate analgesia (opiates) or epidural anaesthesia and good emotional and psychological support from midwife, partner for better responses. Epidural can improve progress of labour but risk of neural injury, headache and dural tap.Opiatew can cause neonatal respiratory depression. Reassessment should be done at a fixed interval (2-4hrly). Use of oxytocics and ARM reduces the duration of first stage labour (50-120) but does not confer any benefit to the mother or fetus and also does not reduce the rate of caesarean section or maternal satisfaction. Approximately half of these women perform equally well without active management. In occipitoposterior position, instruments is advisable if there is no CPD. If there is CPD or malpresentation or position, the fetus is compromised, macrosomic or if the progress is poor in spite of active intervention caesarean section should be performed. But C/S is associated with increased risk of haemorrhage, infection, injury, VTE, long-term reproductive outcome. Prophylactic antibiotics and thromboprophylaxis (according to risk factors) should be given. Active management of the third stage of labour should be considered, as there is chance of postpartum haemorrhage. It is appropriate to discuss with the patient and then manage according to her wishes, because patient choice is an important issue. All documents should be preserved for record keeping and all discussions and informed decisions should be documented clearly.
		Posted by Aroosha B. Sun Jul 30, 2006 07:35 am
Slow progress of labour in a primigravida is diagnosed when the cervical dilatation is slower than 1cm per hr in the active phase of labour (shown by a line to the right of the alert line on the partogram) .To confirm slow progress detailed assessment of the case will be needed , this involves careful review of her antenatal records for an ultrasound showing macrosomia and presentation or presence of a fibroid in the lower segment of the uterus although ultrasound assessment of fetal weight is not much superior clinical assessment . Her height is also noted although short stature does not necessarily mean that she will have a contracted pelvis. This is followed by a detailed examination of the patient looking for a cause in the passage,power or passenger . Her state of hydration is assessed and vital signs are noted . Abdominal examination is done for estimation of the size of baby , the presentation and the fifths of head palpable . Vaginal examination for pelvic assessment , presentation , position , station of head and any size of disproportion like caput or moulding is observed . CTG is noted . I/V access maintained if not already insitu and sample sent for cross-matching of blood . If there is no sign of disproportion , fetal distress and no malpresentation there are two options of management to be discussed with the patient . Active management where one anticipates and starts action rather than passive management where one acts only when the problems arise. She should be told that active management is not associated with maternal or neonatal morbidity but it does not show a decrease in C/S rates . Active management involves early amniotomy , oxytocin augmentation , two hourly vaginal examination , one to one support , hydration and pain relief , fetal surveillance with CTG and FBS if needed . Continous support in labour by an untrained person (dula) has been shown to be very effective in reducing the length of labour , operative delivery rates and analgesia requirements . Amniotomy has been shown to reduce the time of labour by 120 mins,helps to identify the color of liquor and provide access for FBS but increases the risk of cord compression , cord prolapse if head is high and rate of infection . Oxytocin infusion is used if contractions are not adequate one hour after amniotomy . Starting dose of 1-2 mU/min doubling at 30 minutes interval to achieve three contractions/10 mins of atleast 30-45 seconds duration however it needs continous monitoring as there is risk of fetal distress , hyper stimulation and sometimes hyponatremia . Efficient contractions increase flection of head thereby reducing the presenting diameter and therefore decrease length of labour . Epidurial anesthesia is best for pain relief but it does not effect the length of labour . Hydration improves the efficiency of skeletal muscles and has a positive effect on the progress of labour . Ambulation has not been shown to influence the progress of labour and also does not permit CTG monitoring . Poor progress is identified if there is no progressive cervical dilatation , failure of head to descend , increased caput and moulding , thickening of cervix and if cervix is not well applied to the head in which case C/S should be considered . Proper documentation of events to serve as a guide for next delivery should be done and a discharge letter to the GP is handed over .
		Posted by adnan S. Tue Aug 1, 2006 07:04 am
When progress of labour is slower than 1cm/hr in active phase attention needs to to be paid.It is managed by either active management where with anticipation action is started,in expectant management act only when the problem arise.Active management is associated with shortened labour and not associated with unfavourable maternal or neonatal outcomes but not associated with reduction in c-section deliveries. Emotional support by personal midwife or dulas associated with less likely to have analgesia,operative delivery and dissatisfaction with child birth experience.Posture like upright position may enhance placental perfusion compared to lying on her back ,but does not appear to shorten the labour. Adequate hydration by intra venous fluid has positive influence on progress of labour but limit the mobility of mother where as inadequate hydration may be a contributing factor to dysfunctional labour and possible increase in c-section delivery. Amniotomy allows observation of the colour of liquor particularly presence of meconium or blood.and potent labour augmenting effect especially in woman with poor progress of labour.A recent metaanalysis has shown that amniotomy is associated with a reduction in labour duration of 60-120mints,the likelihood of a 5mint apgar score of less than 7 was reduced,and decrease in the use of oxytocin.Amniotomy may be associated with increase infection due to repeated vaginal examinations ,reduces the liquor volume may result in cord compression during contractions and risk of cord prolapse if the presenting pare is high. Augmentation with oxytocin infusion ther are no particular regime ,low dose regime of 1-2mu/min titrated every 30mints against uterine contractions aiming for max 3-4 contractions every 10mints,each contractions lasting for more than 40sec.Oxytocin infusion is associated with risk of hyperstimulation which may lead to iatragenic fetal distressand operative delivery.Continues CTG monitoring is required along with 1:1midwifery care.Neonatal jaundice and water intoxication is rare can occur if high doses used for prolong period and large volume of intravenous fluid is administerd . Adequate analgesia ,there are many methods pain relief in labour ,epidural is the most efficient of these ,however there is concern that it may cause poor progress and increase the the incidence of instrumental deliveries. Re-assessment at pre determined time usually 2hrly vaginal examination .Despite adequate uterine contraction for optimal period ,if no progress in cervical dilatation poor progress of labour is identified ,there may be additional signs like failure of head to decent,caput formation,increase moulding and oedema of cervix not being well applied to head should be deliverd by c-section . Good communication with woman along with clear explanation of interventions are important and womans wishes should be respected .
		Posted by afroz S. Thu Aug 3, 2006 07:34 am
Dear Paul. It\'s the first time for me to post a reply. Please correct it. Slow progress is a cervical dilatation < 1cm per hour in primigravida in active phase of labour. Defect may be either in passage[CPD], passenger[fetus] or power[uterine contractions]. Maternal condition including temp,pulse,B.P,pain relief, dehydration should be assessed. Fetal condition is assessed by CTG monitoring. Management includes review of the obstetric notes,for e.g macrosomia by clinical examination & ultrasound determination of estimated fetal weight which may not be very much accurate.Examination includes vital signs. PA examination for fetal size,uterine contractions.PV examination for cervical dilatation & effacement,head station and position,ecessive caput or moulding,CPD. Partogram plays a very important role in detection and management of slow progress. Options include- 1] If maternal & fetal conditions are satisfactory,then observation or conservative management may be effective. 2]Active management- a] ARM leads to establishment of good uterine contractions and delivery in many pts. It is not associated with hyperstimulation.Early ARM may lead to CTG artifacts & increased rate of interventions. b] oxytocin infusion if the uterine contractions are not effective.Injudicious use of oxytocin leads to hyperstimulation and risk of uterine rupture and fetal distress.It may lead to neonatal jaundice.Continous CTG monitoring is required during it\'s use. c] Adequate analgesia relieves pain and maternal anxiety.IM analgesia may lead to neonatal respiratory depression.Epidural analgesia may lead to prolongation of 2nd stage of labour. d]re assessment at regular intervals to see the progress of labour. Support of the trained midwife during labour and ambulation is important. If no progress after above measures or signs of fetal compromise,C/S is required.There is a risk of PPH in prolonged labour.So active management of the 3rd stage of labour is required. Pt\'s choice and request is taken into consideration in the management.