A lady presents at 37 weeks of gestation with uterine contraction and pain suggestive of labor for 10 hours. On examination, cervix is persistently 1 cm dilated and uneffaced. What should be the next line of treatment? [AI 11]
B) Sedation and wait
Presence of pain suggestive of labor without progressive dilatation and effacement of cervix suggests a diagnosis of false labor pains.
False labor pains at 37 weeks of gestation are best managed by sedation and watchful waiting to prevent prematurity.
What are the various stages of labor?
First stage - starts from the onset of true labour pain and ends with full dilatation of cervix. [JIPMER 98]
Second stage - starts from full dilatation of cervix and ends with expulsion of fetus from the birth canal.
Third stage - starts after expulsion of fetus and ends with expulsion of placenta and membranes. [IOM 11]
Fourth stage - stage of observation for at least one hour after expulsion of the after-births.
What are the substages of stage 1 of labor?
Latent phase – Effacement of cervix
Active phase – Dilatation of cervix
How do you diagnose Prolonged latent phase of labor?
Cervical dilatation <3cm, and duration >20hrs in primigravida and >14hrs in multigravida.
What is the cause of prolonged latent phase? How do you manage?
Injudicious analgesia, Hypotonic (contraction frequency decreased) or hypertonic ( contractions are intense, lasts for less duration) uterine contractions.
Management is therapeutic rest and sedation - when she wakes up, cervix may be dilated. Not C/S.
How do you diagnose prolonged/arrested active phase?
What are the causes of prolonged /arrested active phase?
Passenger- fetal size or orientation
Pelvis – mothers bony pelvis
Powers - Uterine contractions
(these are the causes of Prolonged second stage of labor also)
How can you manage prolonged/arrested active phase?
Among 3 P – the thing that we can change is Power. First we ascess the quality of contraction (frequency, duration, and intensity).
It should be at least a contraction every 3 minutes, lasting 45-60 seconds, cannot indent the contracted uterus.
If the contraction is adequate, the management is C/S, and if the contractions are not adequate, give Oxytocin.
How do you diagnose Prolonged second stage of labor?
≥ 2hrs without Epidural
≥ 3hrs with Epidural
When can the mother push the baby?
Only in second stage of labor
How can you manage Prolonged second stage of labor?
Ascess Uterine contractions.
Oxytocin if no adequate contractions.
If head engaged, forcep or Vacuum extraction.
If not, C/S.
What is the most common cause of prolonged third stage of labor?
Inadequete uterine contractions.
What is the weight of mature placenta? [AI 96]
about 450 gms
What are the components of active management of third stage of labor? [IOM 11,13,AI 10,12]
Administration of uterotonic soon after birth of baby. Oxytocin is the uterotonic of choice. If oxytocin not available, ergometrine may be used.
Delayed cord clamping and cutting. [AI 10]
Controlled cord traction for delivery of placenta followed by uterine massage.
Active management of third stage of labor reduces the PPH incidence by 30-60%. [IOM 11]
What should be the timing of cord clamping?
Current evidence shows that delayed cord clamping is beneficial for the baby.
Immediate cord clamping has been shown to increase the incidence of iron deficiency anemia.
For premature and low birth weight babies, immediate cord clamping can also increase the risk of intraventricular hemorrhage and late onset sepsis.
What are the contraindications of Ergometrine?
Suspected multiple pregnancy
Organic cardiac diseases
Severe preeclampsia and eclampsia
Rh- negative mother [IOM 09] - more chance of feto-maternal micro-transfusion
A 22 yrs old woman at term has been 2 cm for 3 hrs with no change, Normal fetus on sono, cephalic presentation, normal EFM tracing, Management?
Observation, therapeutic rest and sedation.
A 22yr G1 P0 at term has gonne from 4 to 7 cm over the past 2 hrs, with no change in station, Fetus is normal on sono, cephalic presentation, and normal EFM tracing, Management?
She is in active phase of first stage of labor, so, we do not expect descent of fetus, and she is dilating 1.3cm/hr, which is normal, so management is observation.
A 22 yrs woman at term has been 6cm for 3 hrs with no cervical change, Normal fetus on sono, cephalic presentation, and normal EFM tracing, management?
Cervix has not been dilated for >2hrs, so there is problem in 3P, but we can only change the Power, so if there are inadequate contractions, use Oxytocin, if not, C/S.
A 22 yr woman at term presents with regular Uterine contractions at 7cm dilatation , No presenting part can be palpated, through the bulging membranes, Management?
Sonogram to identify the lie, presentation and fetal normality.
A 22yr woman at term has 10cm and pushing for 3 hrs, with no change in station, normal fetus on sonogram, cephalic presentation and normal EFM tracing, Management?
She is stage 2, there should be change in station and baby should be delivered baby in 2hrs. So, it is prolonged stage 2. The defect is on 3 P. We can only change power. So, if the contraction is not adequate, use Oxtocin or forceps. If adequate, do C/S.
22 yrs old woman presents at 6 cm dilatation with no presenting fetal part. Sono shows transverse lie. Risks if membranes are ruptured?
Prolapsed Umbilical cord - donot rupture the membrane unless the presenting part is well against the fetal membranes.
A lady G3P1A1 is admitted to the labour room at term. Cervix is 4 cm dilated, membrane are intact and head is palpable 3/5 per abdomen. After 4 hours, repeated examination is done and cervix is 5 cm dilated, station is unchanged and the cervicograph remains on the right side of alert lens. Which of the following statements about the progress of labor is true? [AI 12]
B) The cervicograph status suggest that intervention is likely to be required
The patients cercix has dilated only 1 cm in 4 hours after entering the active phase (4 cm dilatation) indicating a very slow rate of progress of labor. The cervicograph line if plotted will be seen to lie to the right of 'alert line'closely approaching the action line indicating a high likelihood that an intervention will be required.
Head is likely to be engaged when the portion above the brim is represented by less than 2 finger or less (<2/5 per abdomen). Since the head is palpable 3/5 per abdomen on admission, it is not engaged at the time of admission.
What are the signs of third stage of labor?
Gush of blood, lengething of cord, Balling up of uterus.
What are the factors that cause the internal rotation of fetal head?
Resistance of levator ani muscle
Passage of biparietal diameter through the pelvic inlet.
What change do you find in Umbilical cord prolapse?
What is the most common cause of Prolapsed Cord?
Membrane ruptured with head unengaged.
What is the management of prolapsed cord?
Elevate fetal head take to operating room and Emergency C/S.
What are the steps in management of shoulder dystocia? [AI 10,11]
Steps include HELPERR algorithm:
H: Call for Help; Shoulder dystocia is called if shoulders cannot be delivered with gentle traction
E: Evaluate for Episiotomy: Not routinely indicated; maybe needed when attempting intra-vaginal maneuver
L: Legs (McRoberts): Hyperflexion and abduction of hips—initial maneuver
- causes tilting of pelvis, and increases pelvic space
P: (Suprapubic Pressure):
No fundal pressure; combination of McRoberts and suprapubic pressure resolves most shoulder dystocias
E: Enter (Internal Maneuvers):
i. Woods maneuver: Insert hand into posterior vagina and rotate posterior shoulder clockwise or counterclockwise
ii. Rubin: Push posterior or anterior
shoulder toward fetal chest to adduct shoulders
R: Remove/delivery posterior arm
R: Roll the patient to her hands and knees
[Note: if none of the above succeeds, we go for SALVAGE METHODS, which include
1. Posterior axillary sling
2. Zavanelli maneuver
3. Fracture clavicles
What is Zavanelli maneuver?
It is a salvage method for shoulder dystocia. It includes:
- tocolytics is used to relax the uterus,
- pushing back the delivered head into the birth canal
- performing emergency CS
What are the degrees of Obstetrical lacerations?
First degree – Only perineal mucosa.
Second degree – perineal body muscles.
Third degree – Rectal sphincter involved, rectal mucosa not involved.
Fourth degree - Rectal mucosa involved.
[@ mucosa, muscle, muscle, mucosa]
A woman presented on 7th day after 3rd degree of perineal tear. When do you repair it?
Recent tear should be repaired immediately following the delivery of the placenta. This reduces the chance of infection and minimizes the blood loss.
In case of delay beyond 24 hrs, the repair is to be withheld. Antiseptic dressing is prescribed and the wound is allowed to heal by granulation tissue or repaired after the infection is controlled.
The complete tear (3rd degree tear) should be repaired after 3 months if delayed beyond 24 hours.
What are the indications of Episiotomy?
What are the structures cut in medio-lateral episiotomy? [SGPGI 03]
Posterior vaginal wall
Superficial and deep transverse perineal muscles, bulbospongiosus and part of levator ani
Fascia covering those muscles
Transverse perineal branches of pudendal vessels and nerves
Subcutaneous tissue and skin
In which condition do you find Bandl ring? [MP 01]
What is Mauriceau Smellie Veit Maneuver?
Mauriceau Smellie Veit maneuver:
With fetus resting on hand and forearm, the operator's index and middle fingers lift up the fetal maxillary prominences and an assistant applies suprapubic pressure.
It is used to deliver the aftercoming head in a breech delivery.
[Note: Other methods for delivery of aftercoming head of breech include: Burns-Marshall maneuver and Forceps application]