Normal and abnormal labor Part 2 :abnormal labor - PowerPoint PPT Presentation

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Normal and abnormal labor Part 2 :abnormal labor

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Undergraduate course lectures in Obstetrics&Gynecology .Faculty of Medicine,Zagazig University .Prepared by DR Manal Behery – PowerPoint PPT presentation

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Title: Normal and abnormal labor Part 2 :abnormal labor


1
NORMAL ABNORMAL LABOUR PART 2 Abnormal labor
Dr Manal Behery Assistant Professor , Zagazig
University 2013
2
1-labor Dystocia2- Fetal lie and fetal
presentation that impair delivery
3-Cephalopelvic disproportion4- Operative
vaginal delivery5- induction of labor
  • Part 2 ABNORMAL LABOUR

3
All of the following cause labor dystocia except
  • A-Hydroceplus
  • B- Occipto anterior
  • C-Face presenation
  • D- Occipto Posterior
  • E-Ovarian mass
  • F- Shoulder dystocia
  • Answer B

4
what is labor dystocia?
  • Difficult labor, but refers to abnormally slow
    progress of labor

5
Failure to progress in labor
6
what are protraction disorders and arrest
disorders?
  • Things are moving slower than expected
  • No change occurs

7
Normal vs.Prolonged latent phase
8
How is protraction disorder dx?
  • Nulliparous dilation lt1.2cm/hr, descent
    lt1.0cm/hr
  • Multiparous dilation lt1.5cm/hr, descent
    lt2.0cm/hr

9
How is arrest disorder dx?
  • -Nulliparous NOdilation gt2hr, no descent gt1hr
  • -Multiparous NO dilation gt2hr, no descent gt1hr

10
How long do you let woman push for?
  • 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

11
Effects of labor dystocia includes all except
  • A-Chorioamnionitis
  • B-Uterine rupture
  • C-Reassuring FHR trace
  • D-Pelvic floor injury
  • ANSWER C

12
The three P's of labor
  • A-Power uterine contractions
  • B-Passenger the baby
  • C-Passage the patient's pelvis, pelvic floor

13
Power and stages of labor
  • 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 patient's pushing
    efforts

14
How do you measure uterine activity?
  • -External tocodynamometry or an intrauterine
    pressure catheter (IUPC)
  • For IUPC, patient must be ruptured and increased
    the risk of infection

15
What are considered adequate contractions?
  • 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

16
What can you do about inadequate power of
uterus?
  • -If contraction pattern is irregular or less than
    3 in 10 minutes or if MVU's are less than 200,
    use Pitocin to increase intensity and frequency
    of contractions.

17
What can you do about inadequate power of
pushing?
  • Allow patient to rest through a few contractions
    to catch her breath.
  • Try different positions for more effective
    pushing
  • If everything fails, operative vaginal delivery
    or Cesarean section

18
Characteristics of the passenger
  • Lie
  • Presentation
  • Size
  • Anomalies

19
Fetal lie and fetal presentation that impair
delivery
  • -Fetal lie non-longitudinal presentation-transver
    se, 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

20
Types of breech presentation
  • 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

21
Correct manouver of breech delivery is
  • 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

22
Which is wrong in breech delivery mechanism?
  • A-ant hip has a more rapid decent than post hip
  • B- ant hip is beneath the symphysis pubis and
    intertrochanteric diameter rotates around a 45
    degree axis
  • C- if post hip is beneath the symphysis pubis it
    has to go through 225 degree axis rotation
  • D-for sacrum ant or post position, the axis of
    rotation is around 45 degrees
  • Ans C

23
Under what condition is external cephalic
version allowed in breech or transverse
position,?
  • A- multiparity
  • B-placenta previa
  • C- presenting part engagement
  • D- CPD
  • Ans A

24
Which is wrong about face presentation?
  • A- This is a rare presentation above inlet
  • B-brow presentation most of the time changes to
    face presentation
  • C- decent mechanism is completely different from
    vertex presentation
  • D-delivery is possible if mentum appears beneath
    the symphysis.
  • AnsC

25
A woman 35 years old- P2 GA of 38 wks -EFW of 2
kg presents face and posterior shoulder
presentation.How do you manage her delivery?
  • A-induction of labor
  • B- internal rotation to make mentum ant position
  • C- observation to allow spontaneous rotation
  • D- C/S
  • AnsC

26
4-Which is wrong about persistent occiput
posterior?
  • A-Forceps can be applied
  • B-manual rotation of the head can be done
  • C- manual rotation of the head cant be done
  • D-there is no place for observation
  • AnsD

27
Fetal weight impairing delivery
  • -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

28
Fetal anomalies impairing delivery
  • -Hydrocephalus
  • large fetal abdomen from tumor
  • Ascites
  • distended bladder
  • Conjoined twins

29
How do you solve passenger problems?
  • -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

30
Cephalopelvic disproportion
  • -The size of the maternal pelvis is inadequate to
    the size of the presenting part of the fetus

31
Clinical pelvimetry definition
  • -manual evaluation of the diameters of the pelvis

32
Clinical pelvimetry possible contracted pelvis
signs ALL except
  • 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
  • diameterE -Narrow suprapubic arch
  • ANSWER B

33
Obstetric conjugate and diagonal conjugate
  • 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)

34
Gynecoid pelvis vs Android pelvis
  • -normal female type male
    type- inlet
    triangular or heart-shaped

35
Anthropoid pelvis
  • -Ape-like type-Anteroposterior
  • diameters long,
  • Transverse short,
  • Sacrum long and narrow,
  • Subpubic angle narrow

36
platypelloid pelvis-flat female type
  • All anteroposterior diameters are short,
  • Transverse are long, subpubic angle is wide

37
Treatments of first stage disordersWhich Is
True ?
  • A-Prolonged latent phase question if false
    labor, treat with observation and sedation if
    needed
  • B-Protraction disorder of active phase augment
    with amniotomy or oxytocin
  • C-Arrest disorder with adequate contractions
    C-section
  • D- All of the above
  • Answer D

38
Treatments for second stage disorders
  • -Rotate fetal head if necessary
  • Change positions
  • Operative delivery

39
Treatment for third stage disorder
  • -If placenta not delivered w/in 30 min manual
    sweep should be performed

40
Shoulder dystocia definition and risk factors
  • -Fetal head delivers but the shoulder is impacted
    behind the pubic symphysis
  • Risk factors fetal macrosomia, diabetes,
    operative delivery

41
Management of shoulder dystocia include the
following except
  • A-McRobert's Maneuversharply flex maternal thigh
  • B-Cut episiotomy if needed for more roomC.
    Fundal pressure D-woods screw maneuverE.
    Delivery of the posterior arm
  • ANSWER C

42
Management of shoulder dystocia
43
1-What is Robin maneuver to release shoulder
dystocia?
  • A-rotation of post. shoulder to deliver ant.
    shoulder
  • B- abduction of shoulders
  • C- flex of mothers knees and suprapubic pressure
  • D- rotation and extraction of ant. shoulder
  • AnsB
  • Woods screwA
  • McRoberts m.C
  • Zavanelli m. repositioning of fetal head back
    into the uterus and C/S

44
Robin maneuver Suprapubic pressure
45
Management of shoulder dystocia
  • 1. get help2. be sure bladder is
    drained3. cut episiotomy if needed for more
    room4. suprapubic pressure5. McRobert's
    Maneuversharply flex maternal thigh6. woods
    screw maneuverturn shoulders to a more direct AP
    position7. delivery of the posterior arm8.
    fracture clavicle or humerus9. zavanelli
    maneuver flex and reinsert fetal head and do
    C-section

46
Indications for operative vaginal delivery all
except
  • A-Maternal heart disease, pulmonary compromise
  • B- prolonged first stage of labor,
  • C-maternal exhaustion
  • D- non-reassuring fetal heart rate pattern
  • ANSWER B

47
Contraindications to an operative vaginal
delivery all except
  • A-inability to definitely determine position of
    fetal vertexB-fetus with presentation other than
    vertex or face with chin anteriorC-fetus not
    engaged or above 2 stationD-CPD inadequate
    pelvis, estimated fetal weight gt4000gE-membranes
    ruptured or cervix fully dilatedF-fetus lt34
    weeks for vacuum delivery
  • ANSWER C

48
Risks of forceps delivery
  • -maternal complicationsperineal
    traumahematomapelvic floor injury-fetal
    complicationsfacial nerve injuryskull
    fractureintracranial hemorrhagecorneal
    abrasion if misplaced

49
EPISIOTOMY midline vs mediolateral PERINEAL
TEAR first to fourth degree
50
All are true about obstetrical lacerations
degrees except
  • A-1st degree involve the forchette, perineal
    skin and vaginal mucous membrane
  • B-2nd degree the fascia and muscles of the
    perineal body
  • C-3rd degree involve the anal CANAL
  • D-4th degree extends through the rectal mucosa
    to expose the lumen of the rectum
  • ANSWER C

51
Third degree perineal tear
Fourth-degree Perineal tear
52
A week after NVD episiotomy dehiscence occurs.
When the dehiscence should be repaired?
  • A- immediately
  • B-3 months later
  • C- 6 months later
  • D- 9 months later
  • AnsA

53
25 years old G3 P11 at 35 wks in second stage
of labor at 2 station Has been pushing for 2 hrs
,maternal exhaustion occurs and you concerned
about fetal distress
  • Which of the following is appropriate device
  • A- LOW FORCEPS
  • B-MID FORCEPS
  • C- SOFT CUP VACCUM
  • D- PIPER FORCEPS
  • ANSWER A

54
Risks of vacuum delivery
  • -less maternal trauma-neonatal risks
  • intracranial hemorrhagesubgaleal
    hematomascalp lacerationhyperbilirubinemiare
    tinal hemorrhagecephalohematoma

55
Types of scalp hemorrhages
  • -Caput succedaneum subcutaneous bleeding and
    swelling-Cephalohematoma bleeding beneath the
    periosteum and therefore does not cross suture
    lines unless there is a skull fracture

56
26 years old g2p10 at 41 weeks gestation comes
for induction of labor .Cx exam show 1cm dilated
CX,firm ,anterior,50 effaced -2 station
  • This patient has a bishop score of
  • A- 4
  • B-5
  • C-6
  • D-8
  • ANSWER B

57
Induction of labour
58
A few hours in labor induction CTC shows a late
deccleration after episodes of frequent
contraction
  • The most like explanation of deccleration is
  • A- Maternal position on left lateral side
  • B- Uterine hyperstimulation from cervical
    ripening agent
  • C- Compression of the fetal head mediated by
    vagus
  • D- Umbilical cord compression
  • ANSWER B

59
All are indications for C-section except
  • A- prior C-section or uterine scar
  • B- Face mento anterior
  • C- labor dystocia
  • D- Breech presentationlt35 WKS
  • E- fetal distress
  • F- persistent mento posterior
  • ANSWER B

60
THANK YOU
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