A TERM PAPER ON TRIAL LABOUR

BY

GROUP FOUR MEMBERS:

KAZEEM OMOLARA 198641

OLANIYAN OLAJUMOKE 198648

OLORO HANNAH 198649

TADE-MAKINDE BOLADE 198659

TO

DEPARTMENT OF NURSING,

UNIVERSITY OF IBADAN,

IBADAN.

COURSE CODE: NSG 519

COURSE TITLE: MIDWIFERY IV

LECTURER-IN-CHARGE: DR. CHIZOMA NDIKOM

DR. MARGARET AKINWAARE

SUBMITTED ON: 14TH OF NOVEMBER 2022.

 Table of Content

Introduction and definition of trial labour

Indication of trial labour

Contraindication of trial labour

Conduction of trial labour

Duration of trial labour

Successful trial labour

Failure of trial labour

Complications of trial labour

Advantages of trial labour

Disadvantages of trial labour

Nursing management of trial labour

Summary and conclusion

References
Introduction

Trial of labour is the conduction of spontaneous labor in a moderate degree of disproportion, in

an institution under supervision with watchful expectancy hoping for a vaginal delivery. It is a
test of labour allowing the patient to enter active labour putting all variable (power, passage, and
passenger) into test and determine whether vaginal delivery is possible or not.

The health provider may allow labour to continue against contraindications during birth or even
stimulate labour with oxytocin with pelvic measurements to see if the fetal head will descend
making vaginal delivery possible. However, if the progressive changes in dilation and station do
not occur, a caesarian delivery is performed.

Trial of Labour after caesarian section (TOLAC) this is referred to as a planned attempt to labour
and delivery vaginally by a woman who has had a caesarian section in the past. It differs from
Vaginal birth after caesarian (VBAC) delivery in that not all trial of labor may result in vaginal
delivery.

Trial of labour after caesarian (TOLAC) is a planned or attempted vaginal birth after caesarian
(UBAC).Sometimes, there is a need to change the plan, and a TOLAC results in caesarian birth
after caesarian (CBAC). A birth is officially considered a VBAC ok once the TOLAC results in a
vaginal deficiency.

Indication for Trial of labour

Trial of labor should be considered putting all the variable into test and this would determine
when vaginal delivery is possible or not. Expertise and experience are also important in
attempting trial of labour.

 Previous elective caesarian section with no prior complication: If the previous caesarian
section was as a result of the choice of the mother, and not a complication, labour can be
tried.

 Previous lower segment transverse caesarian and no complications after caesarian

section: If the previous caesarian delivery was a lower segment caesarian section and
 there was no complication such as infection, uterine rupture etc., trial of labour can be
perfomed.

 Single pregnancy with vertex presentation: In patients pregnancy with single pregnancy
whose presentation is vertex, trial of labor can be done. When trying labour,
malpresentation and obvious disproportion must be excluded.

 Multiple pregnancy with vertex-vertex presentation: In patients with multiple vertex-

vertex presented pregnancy, labour can be tried given that there's a professional on
ground to perform caesarian delivery should trial of labour fail.

 No history of myomectomy: History of myomectomy might indicated the presence of

scar tissue in the uterus. No history of myomectomy is an indication for Trial of labour.

 Other favourable factors influencing labour (power, passage, passenger) I. cases of

moderate disproportion: A trial of labour in patients with a previous Caesarean scar is
safe, and can be allowed even in patients who had the previous Caesarean for
cephalopelvic disproportion, although malpresentation and obvious disproportion must
be excluded

 The availability of anaesthesia and personnel for emergency caesarian delivery: this is to
ensure that preparation for other option of caesarian delivery is ready should trial of
labour fail.

 Full understanding of risks of Trial of labour after caesarian when necessary: Patient
should be educated that if any obvious disproportion should occur in the process of
labour, caesarian delivery will be performed. Consent should also be taken.

 Presence of physician immediately available throughout active labour who is capable of

monitoring labour and performing an emergency caesarian delivery.

Contraindications For Trial of Labour

The contraindications for trial of labour can be factors associated with the mother or the fetus

Factors associated with the mother

  Previous uterine rupture; Uterine rupture is a rare, but serious childbirth complication
that can occur during vaginal birth. It causes the mother's uterus to tear so the baby slips
into the mother's abdomen. This can cause severe bleeding in the mother and can
suffocate the baby.This condition affects less than 1 percent of pregnant women. It occurs
in women with uterine scars from previous cesarean deliveries or other uterine surgeries.
A woman’s risk of uterine rupture increases with every cesarean section.

 Cephalopelvic disproportion; Cephalopelvic disproportion exists when the capacity of the

pelvis is inadequate to allow the fetus to negotiate the birth canal.

 Multiple pregnancy; This involves a pregnancy with more than one fetus

• Previous classical cesarean section; Classical cesarean section is a midline uterine incision
in the contractile portion of the uterus.
 • Maternal
Acquired Immune Deficiency Syndrome or active genital herpes

 Previous hysterotomy; Hysterotomy is a surgical procedure that involves making an

incision in the uterus to remove uterine contents. It can be performed for various reasons
including caesarian section, foetal surgery, delayed abortion, and a range of
gynaecological procedures.

 Cervical carcinoma; Cervical cancer is a type of cancer that occurs in the cells of the
cervix — the lower part of the uterus that connects to the vagina
 Pelvic tumor; Pelvic tumor/masses develop in the gynecologic or pelvic organs, such as
the bladder, kidneys, uterus, cervix or other nearby organ. There are many conditions that
can cause a mass to develop in the pelvic area, and many of these masses are not
cancerous.

 Preeclampsia; Preeclampsia is a serious blood pressure condition that develops during

pregnancy. People with preeclampsia often have high blood pressure (hypertension) and
high levels of protein in thei urine (proteinuria). Preeclampsia typically develops after the
20th week of pregnancy. It can also affect other organs in the body and be dangerous for
both the woman and her developing fetus, because of these risks, preeclampsia needs to
be treated by as early as possible.

 Uterotonic hypersensitivity.

 Three or more previous cesarean section.

 Increased maternal age.

 Obstetric/medical complications.

 Medical disorder e.g., heart disease, renal disease etc.

 Maternal obesity.

 Vaginal bleeding (Vasa previa and placenta previa).

 Patient refusal to undergo trial labour.

Factors associated with the fetus

 Malpresentation; Fetal malpresentation refers to a fetus with a fetal part other than the
head engaging the maternal pelvis.

 Macrosomia; This refers to a fetal weight more than 4.5kg at term.

  Fetal distress; distress is an uncommon complication of labor. It typically occurs when
the fetus has not been receiving enough oxygen.Fetal distress may occur when the
pregnancy lasts too long (postmaturity) or due oher complications of pregnancy or labor.

 Intrauterine fetal death; Intrauterine fetal death occurs when a fetus dies in utero (in the
mother's womb) after the second trimester (after 20 weeks of gestation).

 Prematurity.

 Gestational age greater than 40weeks.

Conduction of Trial Labour

The management of trial labour requires careful supervision and consideration;therefore, the
following guidelines are prescribed.

 The labour should ideally be spontaneous in onset butincase where labour fails to start
even on due date, induction of labour may be done.

 Oral feeding remains suspended, and hydration is maintained by intravenous drip,

adequate analgesic is administered.

 The progress of labour is marked with pathograph.

 To monitor the maternal health, routine check-up includes;

i. Observation of pulse, blood pressure and temperature 2hourly

ii. Observe the tongue periodically for hydration

iii. Note the urine output, urine for acetone and glucose

iv. Give Intravenous fluid and drugs

  If there is failure to progress due to inadequate uterine contractions, augmentation of
labour may be done by amniotomy along with oxygen infusion, on no account should the
procedure be employed before the cervix is at least 3cm.

 After the membrane rupture, pelvic examination is to be done to.

a. Exclude cord prolapse

b. Note the color of liquor

c. Assess the pelvic once more

d. Note the condition of cervix including pressure of presenting part on the cervix.

 In favorable cases, it ends spontaneously, low forceps and ventouse

 In unfavorable cases, caesarean section should be done

Duration of trial labour

Inspire of adequate uterinecontractions, if there is arrest ofdescent or dilatation of the cervix for a
reasonable period (3-4 hours) in the active phase,labour is terminated by caesareansection.

Successful trial labour

A trial is called successful, if a healthy baby is born vaginally, spontaneous or by forceps or

ventouse with the mother in good condition.

Successful outcome depends on

1. Shape of the pelvis: The shape of the pelvic cradle is an important component in
determining the outcome of birth experience. The size and shape of this bony canal
determines whether a baby of average size and shape and lying in a normal position would
be able to negotiate its way out into the world.

There are 4 basic types of female pelvises, and these are classified according to the shape of
the brim or inlet. Although the shape of the pelvis varies, it is not a rigid, fixed structure, but an
elastic system of bones that can widen and stretch, and which is very flexible at the joints so that
it can open wide during labour
  The Gynaecoid or genuine female pelvis

It has an almost round brim and will permit the passage of an average-sized baby with the least
amount of trauma to the mother and baby in normal circumstances. The pelvic cavity (the inside
of the pelvis) is usually shallow, with straight side walls and with the ischial spines not so
prominent as to cause a problem as the baby moves through. 

 The Android pelvis

It has a heart-shaped brim and is quite narrow in front. This type of pelvis is likely to occur in
tall women with narrow hips and is also found in African women. The pelvic cavity and outlet
are often narrow, straight and long. The ischial spines are prominent. Women with this shape
pelvis may have babies that lie with their backs against their mothers’ backs and may experience
longer labours. It is important that these women take an active role during their labour and need
to squat and move around as much as possible. 

 The Anthropoid pelvis

It has an oval brim and a slightly narrow pelvic cavity. The outlet is large, although some of the
other diameters may be reduced. If the baby engages in the pelvis in an anterior position, labour
would be expected to be straightforward in most cases. 

 The Platypelloid pelvis

It has a kidney-shaped brim, and the pelvic cavity is usually shallow and may be narrow in the
antero-posterior (front to back) diameter. The outlet is usually roomy. During labour the baby
may have difficulty entering the pelvis, but once in, there should be no further difficulty.Many
women are concerned that their pelvic capacity may be limited and that they will therefore have
difficulty in giving birth. The true capacity of the pelvis will only be realised during labour. Only
the forces created by mother and baby during birth will allow the pelvis to open to its full
potential. This may take some time, but it is the only true way of exploring the “fit” between the
mother and baby during birth.
2. Favourable vertex presentation: In vertex presentations the head of the fetus most
commonly faces to the right and slightly to the rear. This position is said to be the most
usual one because the fetus is thus best accommodated to the shape of the uterus. In
breech presentation the buttocks or the legs are the first to pass through the pelvis. The
feet may be alongside the buttocks, or the legs may be extended against the face. Because
the head is the last part of the fetus to be delivered in breech birth, there is some danger
that the fetus will be asphyxiated; there is also danger that the umbilical cord will be
compressed during birth of the head. In face presentation it may be necessary to turn the
fetus before delivery if the chin is directed backward. Transverse presentation, which
occurs only once in several hundred labours, requires turning of the fetus before vaginal
delivery or else delivery by caesarean section. A favourable vertex presentation will result
to a successful trial labour while an unfavourable vertex presentation will result to a failed
trial labour leading to caesarean section.
3. Effective uterine contractions: Uterine contractions are part of the process of
natural childbirth (i.e., not by Caesarean section). During labour, uterine contractions
changes from episodic and uncoordinated to highly coordinated. There are several
endogenous compounds involved in coordinating uterine contractility in labour,
including oxytocin and prostaglandins. Very effective uterine contraction will lead to
successful trial labour while ineffective contraction can result in failed trial labour.
4. Intact membranes till full dilatation of cervix.
5. Tolerance of the patient: tolerance level of the patient determines if the trial labour will
be successful or not

Advantages of trial of labour

1. There is lower incidence of caesarean section

2. A successful trial of labour ensures the woman a good future obstetric history

Disadvantages of trial of labour

1. It may end before full cervical dilatation

 2. There is increased maternal mortality and morbidity.

3. There is increased psychological morbidity when trial of labour ends with traumatic
vaginal delivery or caesarean section.

Management of trial of labour

Trial of labour should be done in a hospital that has the resources to perform emergency
caesarean section.

1. Allay the woman's anxiety and explain the procedure to her

2. Obtain informed consent for trial of labour.

3. Use of Foley catheter to ripen the cervix in a woman planning trial of labour

4. Oxytocin should be used with caution for induction and augmentation of labour to avoid
uterine rupture.

5. Labour progress should be monitored carefully. Lack of progress with adequate

contractions for 2-3 hours warrants reassessment of the mode of delivery

6. Careful monitoring of the fetal condition using continuous electronic fetal monitor as
changes to the fetal heart rate tracing are key indicators to uterine rupture.

7. Careful observation of maternal well being

SUMMARY AND CONCLUSION

In conclusion, trial of labour is conducted under careful supervision and it should be done in a
hospital with resources for emergency caeserean section. It can either fail or be successful.
REFERENCES

David H. Chestnut MD, in Chestnut's Obstetric Anesthesia, 2020 ; Trial of Labor and Vaginal
Birth after Cesarean Delivery

Donna Murray, RN, BSN. Cephalopelvic Disproportion: How common it is, risks, diagnosis,
treatment, and complications. Updated on June 14, 2021

F L Videla et al. Am J Perinatol; Trial of labor: a disciplined approach to labor management

resulting in a high rate of vaginal delivery

https://www.uchicagomedicine.org/conditions-services/pregnancy-childbirth/labor-delivery/
tolac-vbac

Jessica D & Jon B. (2019). No 382- Trial of labour after caeserean section. Journal of Obstetrics
and Gynaecology, Canada: 41(7); 992-1011.