ESSAYS

by **mandible** Mon Jul 05, 2010 2:29 am

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 [

by **mandible** Mon Jul 05, 2010 2:32 am

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

by **mandible** Mon Jul 05, 2010 2:35 am

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.

by **mandible** Mon Jul 05, 2010 2:38 am

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

by **mandible** Mon Jul 05, 2010 2:40 am

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.

by **mandible** Mon Jul 05, 2010 2:43 am

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

by **mandible** Mon Jul 05, 2010 2:44 am

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.

by **mandible** Mon Jul 05, 2010 2:48 am

[b]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.

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