Normal and abnormal labor part 2


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Undergraduate course lectures in Obstetrics&Gynecology .Faculty of medicine,Zagazig University Prepared by DR Manal Behery

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Normal and abnormal labor part 2

  1. 1.  Part 2: ABNORMAL LABOUR
  2. 2. A-HydroceplusB- Occipto –anteriorC-Face presenationD- Occipto –PosteriorE-Ovarian massF- Shoulder dystocia Answer B
  3. 3.  Difficult labor, but refers to abnormally slow progress of labor
  4. 4.  Things are moving slower than expected No change occurs
  5. 5.  Nulliparous: dilation <1.2cm/hr, descent <1.0cm/hr Multiparous: dilation <1.5cm/hr, descent <2.0cm/hr
  6. 6.  -Nulliparous: NOdilation >2hr, no descent >1hr -Multiparous: NO dilation >2hr, no descent >1hr
  7. 7.  A-1 hr if multi,2hrs if nulli ,add 1hrs if epidural B-2 hrs if mulli,3 hrs if nulli ,add 1hrs if epidural C-1.5 hr if multi ,2.5 hrs, add 1 hr if epidural ANSWER A
  8. 8.  A-Chorioamnionitis B-Uterine rupture C-Reassuring FHR trace D-Pelvic floor injury ANSWER C
  9. 9.  A-Power: uterine contractions B-Passenger: the baby C-Passage: the patients pelvis, pelvic floor
  10. 10.  During first stage of labor, you are concerned with the power of the uterine contractions During the second stage of labor, you are concerned with the power of the patients pushing efforts
  11. 11.  -External tocodynamometry or an intrauterine pressure catheter (IUPC) For IUPC, patient must be ruptured and increased the risk of infection
  12. 12.  Strong enough to cause cervical change Optimal frequency is a minimum of three contractions in a 10 min period (ideal is every 2 min) Greater than or equal to 200 Montevideo units
  13. 13.  -If contraction pattern is irregular or less than 3 in 10 minutes or if MVUs are less than 200, use Pitocin to increase intensity and frequency of contractions.
  14. 14. 1) Allow patient to rest through a few contractions to catch her breath.2) Try different positions for more effective pushing3) If everything fails, operative vaginal delivery or Cesarean section•
  15. 15.  Lie Presentation Size Anomalies
  16. 16. -Fetal lie: non-longitudinal presentation- transverse, oblique or shoulder-Fetal presentation: breech, face (1 in 600), or brow (1 in 3000), compound presentation (1 in 700)-hand or arm prolapses along fetal headAsynclitism-lateral deflection of the head to a more anterior or posterior position in pelvis•
  17. 17.  frank breech: legs are piked -complete breech: indian style or curled legs -footling breech: one leg down, monitor for if umbilical cord falls through pelvis
  18. 18.  A- Pinard manouverto deliver leg,rotate sacrum anterior,wrap trunk in tawel,deliver arm when scapula visible,downward pr on maxilla to deliver the head B- Pinard manouverto deliver leg,rotate sacrum anterior,wrap trunk in tawel,deliver arm when scapula visible,downward pr on mandible to deliver the head C- Pinard manouverto deliver leg,rotate sacrum posterior,wrap trunk in tawel,deliver arm when scapula visible,downward pr on mandible to deliver the head ANSWER B
  19. 19. A-ant hip has a more rapid decent than post hipB- ant hip is beneath the symphysis pubis and intertrochanteric diameter rotates around a 45 degree axisC- if post hip is beneath the symphysis pubis it has to go through 225 degree axis rotationD-for sacrum ant or post position, the axis of rotation is around 45 degreesAns: C
  20. 20. A- multiparityB-placenta previaC- presenting part engagementD- CPDAns: A
  21. 21. A- This is a rare presentation above inletB-brow presentation most of the time changes to face presentationC- decent mechanism is completely different from vertex presentationD-delivery is possible if mentum appears beneath the symphysis.Ans:C
  22. 22. A-induction of laborB- internal rotation to make mentum ant positionC- observation to allow spontaneous rotationD- C/SAns:C
  23. 23. A-Forceps can be appliedB-manual rotation of the head can be doneC- manual rotation of the head can’t be doneD-there is no place for observationAns:D
  24. 24.  -Macrosomia is defined as an infant weighing greater than 4,000-4,500 g Risk factors include maternal obesity, diabetes, multiparity, excessive maternal weight gain, prolonged gestation and a history of a macrosomic infant•
  25. 25.  -Hydrocephalus large fetal abdomen from tumor Ascites distended bladder Conjoined twins
  26. 26. • -not much we can do about fetal weight or anomalies -external cephalic version prior to labor can be performed to convert breech or transverse to vertex -rotation of fetal head to direct OA presentation manually or with forceps•
  27. 27.  -The size of the maternal pelvis is inadequate to the size of the presenting part of the fetus
  28. 28.  -manual evaluation of the diameters of the pelvis
  29. 29. • A-Ability to touch sacral promontory with index finger• B-Significant divergence of the pelvic side wall• C-Forward inclination of a straight sacrum• D-Sharp ischial spines with a narrow interspinous• diameter E -Narrow suprapubic arch ANSWER B•
  30. 30.  Obstetric: shortest anteroposterior diameter of pelvis Diagonal: distance from the lower margin of the symphysis to the promontory of the sacrum and subtracting 1.5cm (you want diagonal conjugate to be greater than 11.5cm)
  31. 31.  -normal female type male type - inlet triangular or heart-shaped
  32. 32.  -Ape-like type -Anteroposteriordiameters long, Transverse short, Sacrum long and narrow, Subpubic angle narrow
  33. 33.  All anteroposterior diameters are short, Transverse are long, subpubic angle is wide
  34. 34. A-Prolonged latent phase: question if false labor, treat with observation and sedation if neededB-Protraction disorder of active phase: augment with amniotomy or oxytocinC-Arrest disorder with adequate contractions: C- sectionD- All of the above Answer D
  35. 35.  -Rotate fetal head if necessary Change positions Operative delivery
  36. 36.  -If placenta not delivered w/in 30 min: manual sweep should be performed
  37. 37.  -Fetal head delivers but the shoulder is impacted behind the pubic symphysis Risk factors: fetal macrosomia, diabetes, operative delivery
  38. 38. • A-McRoberts Maneuver:sharply flex maternal thigh• B-Cut episiotomy if needed for more room C. Fundal pressure D-woods screw maneuver E. Delivery of the posterior arm ANSWER C
  39. 39. A-rotation of post. shoulder to deliver ant. shoulderB- abduction of shouldersC- flex of mother’s knees and suprapubic pressureD- rotation and extraction of ant. shoulderAns:BWoods screw=AMcRoberts m.=CZavanelli m.= repositioning of fetal head back into the uterus and C/S
  40. 40. 1. get help2. be sure bladder is drained3. cut episiotomy if needed for more room4. suprapubic pressure5. McRoberts Maneuver:sharply flexmaternal thigh6. woods screw maneuver:turn shoulders to amore direct AP position7. delivery of the posterior arm8. fracture clavicle or humerus9. zavanelli maneuver: flex and reinsert fetalhead and do C-section
  41. 41. A-Maternal heart disease, pulmonary compromiseB- prolonged first stage of labor,C-maternal exhaustionD- non-reassuring fetal heart rate pattern ANSWER B•
  42. 42. • A-inability to definitely determine position of fetal vertex B-fetus with presentation other than vertex or face with chin anterior C-fetus not engaged or above +2 station D-CPD: inadequate pelvis, estimated fetal weight >4000g E-membranes ruptured or cervix fully dilated F-fetus <34 weeks for vacuum delivery • ANSWER C
  43. 43. • -maternal complications *perineal trauma *hematoma *pelvic floor injury -fetal complications *facial nerve injury *skull fracture *intracranial hemorrhage *corneal abrasion if misplaced•
  44. 44. EPISIOTOMY – midline vs mediolateralPERINEAL TEAR – first to fourth degree
  45. 45. A-1st degree: involve the forchette, perineal skin and vaginal mucous membraneB-2nd degree: the fascia and muscles of the perineal bodyC-3rd degree: involve the anal CANALD-4th degree: extends through the rectal mucosa to expose the lumen of the rectum • ANSWER C•
  46. 46. Fourth-degree Perineal tear
  47. 47. A- immediatelyB-3 months laterC- 6 months laterD- 9 months laterAns:A
  48. 48. Which of the following is appropriate deviceA- LOW FORCEPSB-MID FORCEPSC- SOFT CUP VACCUMD- PIPER FORCEPS ANSWER A
  49. 49. -less maternal trauma -neonatal risks*intracranial hemorrhage *subgaleal hematoma *scalp laceration *hyperbilirubinemia *retinal hemorrhage *cephalohematoma•
  50. 50. • -Caput succedaneum: subcutaneous bleeding and swelling -Cephalohematoma: bleeding beneath the periosteum and therefore does not cross suture lines unless there is a skull fracture•
  51. 51. This patient has a bishop score ofA- 4B-5C-6D-8 ANSWER B
  52. 52. The most like explanation of deccleration isA- Maternal position on left lateral sideB- Uterine hyperstimulation from cervical ripening agentC- Compression of the fetal head mediated by vagusD- Umbilical cord compression ANSWER B
  53. 53. A- prior C-section or uterine scarB- Face mento anteriorC- labor dystociaD- Breech presentation<35 WKSE- fetal distressF- persistent mento posterior • ANSWER B•
  54. 54. THANK YOU