LABOUR AND DELIVERY
Malpresentation in pregnancy:
• Vertex ‘normal’ presentation è cephalic-presenting foetus in the occipito-anterior position ® foetal head diameter
Definitions minimise to fit through pelvic brim
• Malpresentation: any position other than the vertex presentation
BREECH PRESENTATION SHOULDER FACE/BROW COMPOUND PRESENTATION
(< 5% of pregnancies by 37 wks) PRESENTATION PRESENTATION
• When presenting part of fetus to pelvis Result of an oblique and • Face - when foetal neck is • foetal extremity precedes or is
is feet or buttocks transverse lie extended and face from adjacent to the presenting part
• Often rotates from cephalic to breech forehead to chin is (i.e. hand/arm next to head
before 28 wks gA presenting
Cause • Frank/extended – hip flexed, • Brow = presenting part
knees extended extending from the anterior
fontanelle to the orbital
• Complete – hips, knees flexed ridge WORST POSITION
• Footling (one or both feet flexed
or extending out)
• Small fetus (preterm, IUGR, SGA, LBW, ancephaly)
• Big fetus (GDM baby) (cephalopelvic disproportion, macrosomia, hydrocephaly,)
RF • Compliant uterus (multiparity, oligo/polyhydramnios),
• Obstructions (pelvic tumours, placenta previa, prior breech delivery)
• black race/ethnicity,
• Abdo palpation with Leopold maneuvers at 36wks GA (feel head superiorly)
® mother may feel subcostal discomfort
• If suspected non-cephalic presentation ® confirm on TVUS
Ix • Vag examination in 2nd stage of labour:
o Face only (cannot palpate anterior fontanelle) ® brow
o buttocks and/or feet ® breech
o ribs / shoulder / prolapsed arm ® shoulder
• Cord prolapse + prolonged cord compression ® fetal hypoxia ® infection risk, fetal resp. distress (anoxia), meconium aspiration
• Head/shoulder entrapment and birth trauma ® clavicle #, DDH, erb’s palsy, cerebral haemorrhage
Comp.
• Foetal trauma = to a prolapsed arm, bruising and oedema at the presenting part
• Maternal trauma = uterine rupture. Perineal tears
1) NVD (see below for technique) - if no • ECV before rupture of • Most deliver spontaneously, • Expectant mx because foetal
footling + head small enough to fit membranes • early consideration for LSCS extremity often retract as head
through pelvis • LSCS is indicated if for prolonged labour descends
2) ECV – if expertise available > 36% success active labor or rupture • LSCS for obstructed labour
Mx rate if near term) of membranes is
3) LSCS – if all else fails or elected by present
patient
4) 6 wk USS outpatients
External Cephalic Version in pregnancy:
• Breech presentation or incorrect lie after 36 weeks
Indication
• 50% success rate
• Abnormal CTG
Mx of breech babies:
• ROM 1. Hands OFF
Abs. CI • Contracted pelvis
2. Bring legs out
• Fetal death
• Placental abruption 3. Place Breech towel around hip
1) Consent needed 4. For upper limbs ® Lovset’s manoeuvre (Hold
2) Vitals + USS assessment for 40 mins® check for absolute CI hips and rotate foetus to either 10 or 2 o’clock
3) If CTG reactive ® give tocolytics (TERBUTALINE) to relax uterus position and bring down each anterior shoulder)
4) Perform ECV 30mins after tocolytics OR when maternal pulse > 100
5. Let go and led baby dangle
5) Arrange Kleihauer
Process o Anti-D for Rh-ve women (prevent fetalis hydrops in 2nd child) 6. For obstructed head ® Mauriceau manoeuvre
6) If successful ECV: (extend baby’s head upwards towards mum in
o Routine antenatal care w/ referring team/clinic in 1 week “J” shape position to deliver)
7) If unsuccessful ECV:
Additional help
o Refer to Obstetrics Registrar to discuss mode of delivery
(e.g. NVD vs elective LSCS) Ø Suprapubic pressure
• Placental abruption Ø Use forceps
• Uterine rupture
• ROM with umbilical cord prolapse
Comp.
• Amniotic fluid embolism
• Fetal distress
• Fetomaternal haemorrhage
, Stages of labour (37-42 weeks GA – term labour)
Stage Define Key event Clinical Issues
Alvarez- Physiological; Low intensity, high frequency contractions • Reassurance
waves after 20 GA • Assess bishop score to indicate whether labour will begin spontaneously
Braxton Physiological; • Irregular, uncoordinated uterine contractions of moderate (score 8 = yes)
Hicks 2nd or 3rd intensity + NO PAIN Red flags:
contractions trimester • Typically stop with rest, walking, and/or a change in position. • Vaginal discharge (fluid, blood)
Irregular contractions of high intensity ® every 5–10 min to • Strong regular contraction unable to “walk through”
correctly position fetal head in pelvis • Reduced foetal movement
3–4 days before 1. Baby descent = Increased cortisol = increased estriol = If pre-term ® delay labour
Prelabor
birth stimulate contraction Ø Tocolytics = nifedipine
2. Prostaglandin release = initiate labour (breakdown
collagen in cervix)
0 to 3cm cervix
• Irregular Painful contractions
• Analgesia – GAS (NO) or opioids
1st stage • The show – (eject protective cervical mucus plug)
dilation • Fetal HR
(latent) (0.5cm/hr) • CERVICAL DILITATION AND EFFACEMENT (MUST know)
• Check fetal position (abdo/pelvic exam or USS)
• Rupture of membranes
• Regular assessment of cervical dilation and descent of fetal head
1st stage 3 to 7cm cervix BOTH (cm, + 0 – )
dilation Ø Regular Painful contractions
(active) (1.0cm/hr) Ø Changes to cervix effacement and dilatation
7 to 10cm
1st stage
cervix dilation
(transition)
(1.0cm/hr)
Things to do
Ø Analgesia – EPIDURAL (bupivacaine)
Ø Check descent or foetla station (-5 to +5) = (+2 = time to push)
Ø Warm compresses and perineal massage
Ø Consider episiotomy? ® mediolateral incision to enlarge vaginal
opening (cuts through bulbospongiosus muscle)
o C-section = foetal distress (CTG, scalp pH)
o McRoberts’s = shoulder dystocia
o Oxytocin = contractions
Foetal station (+2 = time to push) Success depends on three P’s
10cm to Power Strength of contractions
delivery of • Size = esp. head (CPD)
2nd stage baby o ED LSCS ® if CPD or IoL w/ gel pessary
• Posture = flexed head/limbs?
• Lie = longitudinal (up/down) vs transverse (side/side)
or oblique
Passenger
BENEFITS OF NVD • Presentation = cephalic (head), shoulder, breech (legs)
Ø Sense of accomplishment o Complete breech – hips and knees flexed
Ø Natural – shorter labour time (cannonball)
Ø Skin-skin contact immediate o Frank – bottom 1st, hips flexed, knees extended
® encourages breastfeeding o Footling - foot hanging through cervix
and increase oxytocin and Immediate things to do ® paeditrics:
Size / shape of passageway
decreases cortisol (↓stress) 1. Hepatitis + Vit K inject. Ø Pelvic inlet diameter
Ø Impart natural immunity (IgA) Passage
2. Skin-skin è Begin 1st BF. Ø Cervical stenosis
Ø Shorter recovery
3. Measure Wt, Length, HC Ø Masses
Physiological Placenta delivered by maternal effort • Uterus fundal massage: induce contractions and stop
Mx without medications or cord traction bleeding + minimise tearing
From birth to Need assistance of midwife or doctor to o PPH = check maternal BP
delivery placenta (e.g. prolonged 3rd stage)
placenta Active Mx • Asses perineal tears
delivery Ø IM 10IU oxytocin injection to help
shorten 3rd uterus contract and expel placenta o 1st deg = fourchette skin
1) Blood gush stage to:
(50-100mL)
Ø Controlled cord traction to guide o 2nd deg = “ + perineum + perineal body
3rd stage 1) reduce risk placenta out while uterus pushed
2) Cord of PPH o 3rd deg -= “ + anal sphincter
lengthens upwards to prevent uterine prolapse
Ø Massage uterus until firm/contracted
o 4th deg = “ + rectal mucosa
3) Uterus rise
4) Placental Minimise by:
removed *For 3rd + 4th deg tear è needs sterile OR to re-stitch (to minimise
Ø Hydrate, verbal guidance,
Perineal Tears risk of faecal/anal incontinence)
Ø Perineal massage or epino (dilating
balloon to help expand the perineum)
• Irregular contractions Monitor BP, HR + temp to rule out:
• Expel remaining contents • PPH (tone ® trauma ® tissue ® thrombin)
4 stage
th
12 hr recovery • preeclampsia
• uterine involution and bleeding cessation
(After pain) stage Inspect perineum
• Delayed Cord clamping for 1min (esp. if pre-term)
• Vulva haematoma vs PPH
o Reduce IVH, NEC, Anaemia, infections
Note: Multiparous women will have shorten time during each stage
Malpresentation in pregnancy:
• Vertex ‘normal’ presentation è cephalic-presenting foetus in the occipito-anterior position ® foetal head diameter
Definitions minimise to fit through pelvic brim
• Malpresentation: any position other than the vertex presentation
BREECH PRESENTATION SHOULDER FACE/BROW COMPOUND PRESENTATION
(< 5% of pregnancies by 37 wks) PRESENTATION PRESENTATION
• When presenting part of fetus to pelvis Result of an oblique and • Face - when foetal neck is • foetal extremity precedes or is
is feet or buttocks transverse lie extended and face from adjacent to the presenting part
• Often rotates from cephalic to breech forehead to chin is (i.e. hand/arm next to head
before 28 wks gA presenting
Cause • Frank/extended – hip flexed, • Brow = presenting part
knees extended extending from the anterior
fontanelle to the orbital
• Complete – hips, knees flexed ridge WORST POSITION
• Footling (one or both feet flexed
or extending out)
• Small fetus (preterm, IUGR, SGA, LBW, ancephaly)
• Big fetus (GDM baby) (cephalopelvic disproportion, macrosomia, hydrocephaly,)
RF • Compliant uterus (multiparity, oligo/polyhydramnios),
• Obstructions (pelvic tumours, placenta previa, prior breech delivery)
• black race/ethnicity,
• Abdo palpation with Leopold maneuvers at 36wks GA (feel head superiorly)
® mother may feel subcostal discomfort
• If suspected non-cephalic presentation ® confirm on TVUS
Ix • Vag examination in 2nd stage of labour:
o Face only (cannot palpate anterior fontanelle) ® brow
o buttocks and/or feet ® breech
o ribs / shoulder / prolapsed arm ® shoulder
• Cord prolapse + prolonged cord compression ® fetal hypoxia ® infection risk, fetal resp. distress (anoxia), meconium aspiration
• Head/shoulder entrapment and birth trauma ® clavicle #, DDH, erb’s palsy, cerebral haemorrhage
Comp.
• Foetal trauma = to a prolapsed arm, bruising and oedema at the presenting part
• Maternal trauma = uterine rupture. Perineal tears
1) NVD (see below for technique) - if no • ECV before rupture of • Most deliver spontaneously, • Expectant mx because foetal
footling + head small enough to fit membranes • early consideration for LSCS extremity often retract as head
through pelvis • LSCS is indicated if for prolonged labour descends
2) ECV – if expertise available > 36% success active labor or rupture • LSCS for obstructed labour
Mx rate if near term) of membranes is
3) LSCS – if all else fails or elected by present
patient
4) 6 wk USS outpatients
External Cephalic Version in pregnancy:
• Breech presentation or incorrect lie after 36 weeks
Indication
• 50% success rate
• Abnormal CTG
Mx of breech babies:
• ROM 1. Hands OFF
Abs. CI • Contracted pelvis
2. Bring legs out
• Fetal death
• Placental abruption 3. Place Breech towel around hip
1) Consent needed 4. For upper limbs ® Lovset’s manoeuvre (Hold
2) Vitals + USS assessment for 40 mins® check for absolute CI hips and rotate foetus to either 10 or 2 o’clock
3) If CTG reactive ® give tocolytics (TERBUTALINE) to relax uterus position and bring down each anterior shoulder)
4) Perform ECV 30mins after tocolytics OR when maternal pulse > 100
5. Let go and led baby dangle
5) Arrange Kleihauer
Process o Anti-D for Rh-ve women (prevent fetalis hydrops in 2nd child) 6. For obstructed head ® Mauriceau manoeuvre
6) If successful ECV: (extend baby’s head upwards towards mum in
o Routine antenatal care w/ referring team/clinic in 1 week “J” shape position to deliver)
7) If unsuccessful ECV:
Additional help
o Refer to Obstetrics Registrar to discuss mode of delivery
(e.g. NVD vs elective LSCS) Ø Suprapubic pressure
• Placental abruption Ø Use forceps
• Uterine rupture
• ROM with umbilical cord prolapse
Comp.
• Amniotic fluid embolism
• Fetal distress
• Fetomaternal haemorrhage
, Stages of labour (37-42 weeks GA – term labour)
Stage Define Key event Clinical Issues
Alvarez- Physiological; Low intensity, high frequency contractions • Reassurance
waves after 20 GA • Assess bishop score to indicate whether labour will begin spontaneously
Braxton Physiological; • Irregular, uncoordinated uterine contractions of moderate (score 8 = yes)
Hicks 2nd or 3rd intensity + NO PAIN Red flags:
contractions trimester • Typically stop with rest, walking, and/or a change in position. • Vaginal discharge (fluid, blood)
Irregular contractions of high intensity ® every 5–10 min to • Strong regular contraction unable to “walk through”
correctly position fetal head in pelvis • Reduced foetal movement
3–4 days before 1. Baby descent = Increased cortisol = increased estriol = If pre-term ® delay labour
Prelabor
birth stimulate contraction Ø Tocolytics = nifedipine
2. Prostaglandin release = initiate labour (breakdown
collagen in cervix)
0 to 3cm cervix
• Irregular Painful contractions
• Analgesia – GAS (NO) or opioids
1st stage • The show – (eject protective cervical mucus plug)
dilation • Fetal HR
(latent) (0.5cm/hr) • CERVICAL DILITATION AND EFFACEMENT (MUST know)
• Check fetal position (abdo/pelvic exam or USS)
• Rupture of membranes
• Regular assessment of cervical dilation and descent of fetal head
1st stage 3 to 7cm cervix BOTH (cm, + 0 – )
dilation Ø Regular Painful contractions
(active) (1.0cm/hr) Ø Changes to cervix effacement and dilatation
7 to 10cm
1st stage
cervix dilation
(transition)
(1.0cm/hr)
Things to do
Ø Analgesia – EPIDURAL (bupivacaine)
Ø Check descent or foetla station (-5 to +5) = (+2 = time to push)
Ø Warm compresses and perineal massage
Ø Consider episiotomy? ® mediolateral incision to enlarge vaginal
opening (cuts through bulbospongiosus muscle)
o C-section = foetal distress (CTG, scalp pH)
o McRoberts’s = shoulder dystocia
o Oxytocin = contractions
Foetal station (+2 = time to push) Success depends on three P’s
10cm to Power Strength of contractions
delivery of • Size = esp. head (CPD)
2nd stage baby o ED LSCS ® if CPD or IoL w/ gel pessary
• Posture = flexed head/limbs?
• Lie = longitudinal (up/down) vs transverse (side/side)
or oblique
Passenger
BENEFITS OF NVD • Presentation = cephalic (head), shoulder, breech (legs)
Ø Sense of accomplishment o Complete breech – hips and knees flexed
Ø Natural – shorter labour time (cannonball)
Ø Skin-skin contact immediate o Frank – bottom 1st, hips flexed, knees extended
® encourages breastfeeding o Footling - foot hanging through cervix
and increase oxytocin and Immediate things to do ® paeditrics:
Size / shape of passageway
decreases cortisol (↓stress) 1. Hepatitis + Vit K inject. Ø Pelvic inlet diameter
Ø Impart natural immunity (IgA) Passage
2. Skin-skin è Begin 1st BF. Ø Cervical stenosis
Ø Shorter recovery
3. Measure Wt, Length, HC Ø Masses
Physiological Placenta delivered by maternal effort • Uterus fundal massage: induce contractions and stop
Mx without medications or cord traction bleeding + minimise tearing
From birth to Need assistance of midwife or doctor to o PPH = check maternal BP
delivery placenta (e.g. prolonged 3rd stage)
placenta Active Mx • Asses perineal tears
delivery Ø IM 10IU oxytocin injection to help
shorten 3rd uterus contract and expel placenta o 1st deg = fourchette skin
1) Blood gush stage to:
(50-100mL)
Ø Controlled cord traction to guide o 2nd deg = “ + perineum + perineal body
3rd stage 1) reduce risk placenta out while uterus pushed
2) Cord of PPH o 3rd deg -= “ + anal sphincter
lengthens upwards to prevent uterine prolapse
Ø Massage uterus until firm/contracted
o 4th deg = “ + rectal mucosa
3) Uterus rise
4) Placental Minimise by:
removed *For 3rd + 4th deg tear è needs sterile OR to re-stitch (to minimise
Ø Hydrate, verbal guidance,
Perineal Tears risk of faecal/anal incontinence)
Ø Perineal massage or epino (dilating
balloon to help expand the perineum)
• Irregular contractions Monitor BP, HR + temp to rule out:
• Expel remaining contents • PPH (tone ® trauma ® tissue ® thrombin)
4 stage
th
12 hr recovery • preeclampsia
• uterine involution and bleeding cessation
(After pain) stage Inspect perineum
• Delayed Cord clamping for 1min (esp. if pre-term)
• Vulva haematoma vs PPH
o Reduce IVH, NEC, Anaemia, infections
Note: Multiparous women will have shorten time during each stage
