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Physiology of labour And what could go wrong Dr Yovisha Vijayakumar Stages of labour Stage 1: Effacement & Dilation of cervix to 10cm – Latent, Active Stage 2: Delivery of the fetus Stage 3: Delivery of placentaStage 1: Cervical effacement & dilation Labour can start naturally or with induction Labour starts when contractions are 3-5 minutes apart Cervical effacement is thinning of the cervix Latent Phase Active phase ● (SLOW) • (FASTER) ● Cervical dilation from 0-6cm • Cervical dilation from 6cm to 10cm ● Nullip 20 hours • Dilates 1.5cm per hour ● Multips 14 hours Delay in 2ndstage st • if <1cm per hour ● Delay in 1 stage ○ cervical dilation is <2cm in 4 hours ○ Amniotomy if membranes not Secondary arrest • Cessation of cervical dilation for 2 hours – after ruptured previous normal dilation • Related to fetal malposition Obstructed labour • Fetal malposition (Can’t fit through the pelvis! Can’t get engaged! ) • Cervical dilation stops, cervix dilated, hematuria due to compression of bladderInduction of Labour ● Why ? ○ 41 weeks – stillbirth risk ○ Rupture of membranes before labour, for >24 hours, Group B Strep positive ○ Fetal growth restriction - stillbirth ○ Macrosomia (reduce risk of shoulder dystocia) ○ Severe obstetric cholestasis - stillbirth ○ Intrauterine fetal death ● With: (aim to release prostaglandins) ○ Stretch and sweep ○ Prostaglandin gel, ○ balloon, ○ Amniotomy (Artificial rupture of membranes) ○ IV oxytocinStage 2: Delivery of the baby ● Commences with complete cervical dilation to 10cm ● Ends with the delivery of the baby Prolonged second stage: ● Previous deliveries ● Fetal size and position ● Pelvis shape ● Contraction strength ● Maternal tiredness ● Co-morbiditiesPelvic anatomy 2.Engagement 3.Neck flexion 4.Internal rotation Mechanism 5.Crowning 6.Extension of of labour presenting part 7.Restitution 8.External rotation 9.Lateral flexion 1. Head descent Helped by ● Braxton hicks contractions ● Fundal dominance during contractions ● Increased frequency and strength of contractions The Occiput will either be facing the Left or Right2. Head engagement Largest part of fetal head fits into Largest diameter of maternal pelvis3. Neck flexion As the fetus descends into the pelvis, The occiput comes into contact with the pelvic floor The fetal neck flexes (chin to chest) Allowing the circumference to be sub-occipitobregmatic (9.5cm) Smallest diameter for the fetal skull to allow passage4. Internal rotation The pelvic floor acts like a gutter (forward & downward slope) With each contraction, the fetal head pushes on the pelvic floor This causes a small degree of rotation – until the head reaches a 90-degree rotation Best position WHAT COULD GO WRONG? FETAL MALPOSITION With the other positions: We take the patient to theatre Spinal anaesthesia Use our hands to manually rotate the fetal head Then use forceps / ventouse to deliver Can still deliver vaginally5. Crowning When the widest part of the fetal head successfully goes through the narrowest part of the pelvis Head is visible at vulva6. Extension of presenting part The occiput slips below the suprapubic arch The head extends The head is delivered !7. External rotation and restitution Restitution: The head externally rotates To face mother’s R / L thigh The shoulders then also rotate from transverse to anterior-posterior position This allows the shoulders to be delivered next8. Delivery of the shoulders & body 1. The Midwife gives 2. Then upward traction to 3. The shoulders are delivered downward traction to deliver deliver the posterior the anterior shoulder shoulder And Body after WHAT COULD GO WRONG? SHOULDER DYSTOCIA Shoulder gets stuck behind the pubic bone Risk factors: Diabetes & macrosomia, high BMI Which is why we monitor growth ! Estimated fetal weight (EFW) >95 – we Induce at 38 weeks / C-section Consequences: - Brachial plexus injury / Erb’s palsy - If the body is not delivered, the baby can’t get enough oxygen - Can lead to irreversible brain injuryMcRoberts maneuverStage 2: Delivery of the baby Prolonged second stage: ● Previous deliveries ○ Primiparous usually take a longer time ○ Multiparous ladies delivery quickly ● Fetal size and position ● Pelvis shape ● Contraction strength & frequency ○ 4 contractions in 10 minutes ○ Contractions can be felt – uterus hard ● Maternal tiredness ○ If mum is too tired to push we can help with instrumental ● Co-morbidities ○ Severe pre-eclampsia – If BP unstable we need to deliver asapStage 3: Delivery of the placenta Spontaneous delivery of placenta takes between 5 – 30 minutes If >30 minutes it is a risk for Post partum haemorrhage Active 3 stage: - Controlled cord traction - Uterotonic drug early – Oxytocin, ergometrine, carboprost, Misoprostol - Early cord clamping If >30 minutes without delivery of placenta, we may need to take the patient to theatre for : Manual removal of placenta Risks: PPH, retained placenta, infection – sepsis Post-partum haemorrhage Loss of blood after birthClassification Post-Partum Haemorrhage = Losing > 500 ml of blood after delivery ● Minor: 500 – 1000 ml ● Moderate: >1000 ml ● Severe: > 2000 ml ● Primary: Within 24 hours ● Secondary: More than 24 hoursCauses – 4 T’s ● Tone – Uterine Atony ● Trauma – Laceration, C-section, Episiotomy ● Tissue – Retained placenta ● Thrombin – Coagulopathies Multiple pregnancy Risk factors Previous PPH Large baby ● Tone – Uterine Atony General anaesthetic ● Trauma – Laceration, C-section, Episiotomy ● Tissue – Retained placenta ● Thrombin – Coagulopathies Pre-eclampsiaManagement ● Resuscitate as needed ! ● A-E assessment ● Large cannula ● Bloods (FBC, Group and save, Coagulation) ● IV fluids / blood transfusion ● Tranexamic Acid ● ?Major haemorrhage protocol ○ Red cells, FFP, Cryoprecipitate platelets TREAT THE CAUSEUterine Atony ● Uterine Massage ● Uterotonics – Oxytocin, Ergometrine ● Intra-uterine Balloon Tamponade ● B-Lynch suture ● Uterine Artery Ligation ● Emergency Hysterectomy● Trauma Make sure there are no bleeding vessels after C-section Or after a Tear – repair the tear ● Tissue Placental not removed -> Manual Removal of Placenta in theatre ● Thrombin Women with coagulopathies go through strict antenatal haematology clinics and will have a plan in place of what to administer at what time