Maternal & Fetal Monitoring in Labour

Teaching With Dr Khaleed =) A very dedicated Obstetricians & lecturers~

Trying to recall what had been taught..lets see what I can remember..hehe
To dear groupmates, feel free to add...

1) What is normal labour?
Normal labour is from the onset of labour starts, strong regular contractions, effacement of cervix, full dilatation of cervix, expulsion of fetus until placenta delivery

2) What should be monitored during labour??
3 components - Maternal, fetal & labour progress

3)How many stages of labour? Three
Stage 1 - From onset of labour until full dilatation of cervix
subdivided into latent &active phase
Latent phase - Regular contractions to cervical effacement until 3cm dilatation of cervix
Active phase - from 3cm until full dilatation of cervix (10cm)
Stage 2 - From full dilatation until delivery of baby
Stage 3 - From delivery of baby until expulsion of placenta

4)What should be assessed for maternal while in labour??
Blood pressure - late onset of PE & also look for proteinuria
Pulse rate - infection (frequent VE introduce infection), maternal distress
Temperature - infection or maternal distress (if other causes has been excluded)
Urine - ketone (maternal dehydration), protein (especially in PE) & sugar (DM mother)

Ketones present when mother in exhaustion & distress. Body adapt produce energy by gluconeogenesis protein & later fat (cause the presence of ketones in urine)
Some maternal distress patient will have fruity odour of ketones

Monitor contraction pain.
The best is by using our own hands.
CTG can detect the presence of contraction but did not count the intensity.
So, practice to time contraction. Timing the duration of contraction in 10 minutes & intensity (mild <20secs,>40secs)
Adequate if it is 3:10 strong & 4:10 moderate
(Dr khaleed mentioned in his place, they said is adequate when contraction is 1:2. If the nurse report to him 1:1, he would ask the nurse to reduced it & achieve contraction in 1:2)

5)Fetus Monitoring??
Check for fetal heart rate using:-
CTG
Daptone
Pinnard (not suitable)

when is the best time to check baby's fetal heart rate?
Before & after uterine contraction, not while contraction. To look at the baseline heart rate.

Check descent of head via:-
VE - station of fetus head in relation to ischial spine
Per abdomen - check how many fifth palpable??

Check any caput or moulding (indicates difficult labour)
bear in mind, false station could be felt due to this. Initially the head is still high but due to severe caput/moulding, we said the station is 0

Look at the liquor.
Slight, moderate or thick meconeum. If thick need to deliver immediately.
Could be via SVD, assissted delivery or CS (depends on the progress of labour&mother&fetal condition)

PH scalp sampling or FBS (fetal blood sampling)
(done when suspicion of fetal distress. Only FBS can definitely diagnose fetal hypoxia & acidosis in labour. Other modes sometimes is inaccurate. If acidemia meaning fetus in distress. Not done in Malaysia. Doing this has no risk to the baby)

If suspicious CTG / abnormal, important to rule out malpresentation or cord prolapse
If cervix fully dilated, may be possible to deliver the baby vaginally using forceps or ventouse
If cervix not fully dilated, FBS can be considered. Normal results will permit labour to continue. repeat CTG every 45 -60minutes if CTG abnormalities persist or worsen.
If there is other indication of ceaer (failure to progress), cesaer will be done despite normal FBS result, but with less urgency.

6) How to monitor labour progress??
Chart on Partogram. Watchout for abnormal delivery pattern such as:-
- Prolonged Latent Phase
- Primary Dysfunctional Labour
- Secondary Arrest

Prolong Latent Phase -
- The latent phase is longer than the arbitrary time limits
- This phase should not be worried as patient still in latent phase
- Sent patient to antenatal ward, give simple analgesics, mobilization & reassurance

Primary Dysfunctional Labour -
- poor progress in the active phase of labour where the dilatation takes >1cm/hour
- common in primid
- might be due to inefficient uterine contractions, CPD & malposition of fetus
- tx of choice in this: ARM (if not ARM yet) + oxytocin infusion-for augmentation
- great care must be exercised in the use of oxytocin if CPD, malposition / malpresentation is suspected in multiparous labour as it can cause uterine rupture in this situation
- primid with uterine rupture is a very rare event
- if suspected malposition, give further time see if the problem correct itself. But depends on the type of malposition

Secondary Arrest -
- Progress in the active phase is initially good but then slows or stops altogether, typically after 7cm dilatation
- common cause: fetal malposition, malpresentation & CPD
- eventhough the above is the common cause, but still dont forget to check the contraction, maybe due to inefficient uterine contraction (eventhough less likely)
- treatment: depends on the cause. Could end up either SVD, assissted delivery(vaccum, forcep) Or Ceaser

When the above occurs, need to evaluate 3 components:
A) Power
B) Passenger
C) Passage

Power:
- Due to incoordinate uterine contractions
- Start patient on pitocin
- Monitor the contraction progress
- 3:10 strong or 4:10 moderate
- If hyperstimulation occurs, stop pitocin. the contraction will reduce as the half life is about 5minutes

Passenger:
Macrosomic baby, Malposition, Malpresentation & TRO CPD

Passage:
suspect contracted/small pelvis
ask about past obstetric history - any difficult labour before
assess height of mother (in old school teaching will ask about shoe size)
On VE -look any obstruction of the passage (soft tissue swelling-swelling vulva vagina & cervix)
at the same time assess pelvimetry

If you received a patient in active phase, on VE 4cm, cephalic, station -1, what should you do??
Admit patient to labour room
Do ARM -observe liquor color -slight, moderate or thick. If thick need to deliver immediately
4 hours time.
If primid, after 4 hours should at 8cm
If multip, cervix >8cm or usually will deliver within 4hours as the progress of dilatation of cervix was not necessary to be 1cm/hour
if primid/multip, after 4 hours not reaching 8cm, starts pitocin after assess the 3Ps

Do we give syntocinon in all delivery mother??yes in 2nd stage but not all in 1st stage

What else should we give&monitor during delivery??
1) Time contraction
2) BP, PR, T, urine, dextrostix (in DM mother)
3) Give analgesics
Entonox inhalation (mixture of 50% NO & 50% O2) if time of delivery is suspected to be less than 4hours (have quick onset, short duration of effect)
more effective then TENS(transcutaneous electrical nerve stimulation) or pethidine
SE - light headedness & nausea

Pethidine chosen if delivery is more than 4 hours. This drugs need 2 hours to be washed out from circulation. If given when patient was about to deliver, it will have prolong effect on the baby - cause the baby to come out flat, sleeping or with respiratory depression.
antidote - naloxone

Regional - epidural. Patient will feel very comfortable, can read news paper or watching television

4)Antibiotics
SBE prophylaxis for heart disease patient
IV ampicillin in patient positive for GBS

References:
Dr Khaleed's lectures
10 teachers Obs & Williams Obs