King Khalid University Hospital

Department of Obstetrics & Gynecology

Course 482

Management of labour &

fetal assessment
 Management of labour & fetal
assessment
:Objectives
Managements of the stages of labour
Pain relief in labour
Fetal assessment (antenatal & intra-partum)
Management of labour
:Definition of labour
Progressive cervical effacement and dilatation
resulting from regular uterine contractions that
occur at least every 5 minutes and last 30-60
seconds
Braxton Hicks: contractions Not associated with
cervical changes
Lightening: Descent of the fetal head into the
pelvis
There are 4 stages of labour
First stage of labour
Start from onset of true labour pain----full dilatation of cervix
In primigravida------ 12 hour duration
In multigravida-----6 hours duration

Chiefly concerned with preparation of the birth canal as to facilitate expulsion of

the fetus in the second stage

It has 2 phases
A latent phase up to 3 cm dilatation of cervix
is variable: up to 8 hours in primi •
hours in multi 4 •
An active phase from 3 cm to full dilatation of cervix
Rate of dilatation 1 cm/hour in primigravida
cm/ hour in multigravida 1.5 •
 Dilatation of the cervix
Dilatation usually measured by fingers but
recorded in cm

Dilatation relates with dilatation of internal os

 Effacement or taking up of cervix
Muscle fibers of cervix are pulled upward and merges
with the fibers of the lower uterine segment

Cervix becomes thin during first stage

In primi----- effacement precedes dilatation of the cervix
In multi-----both occur simultaneously

Effacement is determined by the length of the cervical

canal in the vagina
Effacement is expressed in terms of percentage
Effacement or taking up of cervix
 First stage of labour
Maternal system
General condition remains-
unaffected
Pulse rate increases by 10-15-
bpm during contraction
with the settle down to its
previous rate in between
contractions
Systolic BP increase by 10 mm-
Hg during contraction
Temperature remains -
unaffected
Fetal system
As so long as the membranes-
are intact, usually there is
no adverse effect on the
fetus BUT
However, during contraction
there may be slowing of
FHR by 10-20 bpm which
soon returns to its normal
as the intensity of
contraction diminishes
 Management of labour
:Initial assessment
History: Onset, strength, frequency of contractions
Leakage of fluid
Vaginal bleeding
Fetal movement
Medications
Last oral intake
Review of past obstetric history, prenatal lab tests,
gestational age, parity, size of previous infants, any
antenatal complications
 Management of the first stage of
labour
Informed consent on management of labour & delivery- -
Maternal position---lateral recumbent position -
Avoid supine hypotension -
:Partogram -
Iv fluids & avoid oral intake-
Maternal vital signs every 1-2 hours-
Input-output monitoring-
Analgesia-
Fetal heart rate monitoring (CTG)-
Uterine contractions monitoring-
Vaginal examination for cervical dilatation & poistion in-
active phase every 2 hours
Amniotic membranes status & amniotic fluid colour- -
Monitoring progress of labour
(Partogram)
 Mechanics of labour
The Power: force generated by uterine
contraction
 Second Stage of labour
From full dilatation of cervix till delivery of the
neonate
The mother has a desire to bear down with each
contraction
Last from 30 minutes to 3 hours in primigravida
minutes in multigravida 5-30
Mechanism of labour
 Management of the second stage of
labour
Molding (alteration of the relationship of the
fetal cranial bones to each other as a result of
compression forces by the bony pelvis)
Caput (localized edematous swelling of the scalp
caused by pressure of the cervix on the
presenting portion of the fetal head)--- gives
false impression of fetal descent
 Management of the second stage of
labour
Crowning ( when the largest diameter of the fetal head is
encircled by the vulvar ring)
Vaginal examination every 30 minutes-
Maternal position– any comfortable position for bearing-
down
Bearing down---with each contraction-
Delivery of the fetal head---manual perineal support-
Fetal airway clearance-
Umbilical cord clamping-
Place the infant under warmer-
 Episiotomy
Incision in the perineum after crowning to aid
delivery and avoid laceration of perinium
Types: Right mediolateral
Left mediolateral
Central
 PERINEAL LACERATION
:TYPES 4
First degree: laceration involving the vaginal-
epithelium or perineal skin
Second degree: laceration extending into the sub--
epithelial tissues of the vagina or perineum with
or without involving the perineal body
Third degree: laceration involving anal sphincter
Fourth degree: laceration involving rectal mucosa
 Third stage of labour
The interval between the delivery of the infant and
complete delivery of the placenta & membranes
Duration is 5-30 minutes
:Signs of placental separation
Fresh blood show from vagina -1
The umbilical cord lengthens outside the vagina -2
The fundus of the uterus rises up -3
The uterus becomes firm & globular -4
The placenta should be examined to ensure that it is
complete
The blood loss should be estimated
 Forth stage of labour
The hour immediately after the delivery

,Needs close observation of: blood pressure -

pulse rate, uterine blood loss

Watch for post partum hemorrhage

 Pain relief in labour
Goal: effective pain relief to the mother that is
safe for her & the fetus with minimal side
effects on the progress & outcome of labour
 Pain relief in labour
:Non pharmacological method
Back massage
Acupuncture
Hypnosis
Breathing exercises
 Pain relief in labour
:Pharmacological methods
Narcotic analgesics– cross the placenta – cause fetal
respiratory depression (Nitrous oxide, pethidine)
Epidural analgesia: The most effective
Contra indicated if-coagulo-pathy, infection at needle
site, severe hypo-volemia
Side effects: Hypotension, headache, impaired ability to
push, prolonged second stage (15 Minutes)
Pudendal block: for S2-S4
for the second stage of labour
for instrumental delivery
 Fetal assessment
Aim: Ensure fetal wellbeing ( Identify patients at
risk of fetal asphyxia)

To prevent prenatal mortality & morbidity

 Screening for high risk pregnancy
History
Age *
Social burden*
Smoking*
Past medical conditions e.g D.M, HTN*
Past Obstetric history*
 FETAL AND NEONATAL COMPLICATIONS OF
ANTEPARTUM ASPHYXIA

Stillbirth (Mortality)
Metabolic acidosis at birth
Hypoxic renal damage
Necrotizing enterocolitis
Intracranial haemorrhage
Seizures
Cerebral palsy
 CONDITIONS ASSOCIATED WITH INCREASED
PERINATAL MORBIDITY/MORTALITY

Small for gestational age fetus

Decreased fetal movement
Postdates pregnancy (>294 days)
Pre-eclampsia/chronic hypertension
Pre-pregnancy diabetes
Insulin requiring gestational diabetes
Preterm premature rupture of membranes
Chronic (stable) abruption
 When to start fetal Assessment
antenatally
Risk assessed individually **
For D.M. fetal assessment should start from 32**
weeks onward if uncomplicated
If complicated D.M. start at 24 weeks onward ***
For Post date pregnancy start at 40 weeks**
For any patient with decrease fetal movement**
start immediately
Fetal assessment is done once or twice weekly **
 Antenatal Fetal Assessment
Fetal movement counting
Non stress test

Contraction stress test

Ultrasound fetal assessment

Umbilical Doppler Velocimetry

 Fetal movement counting
:Cardiff technique
: Done in the morning, patient should*
calculate how long it takes to have 10 fetal
movement
movements should be appreciated in 12 10**
hours
 Fetal movement counting
:Sadovsky technique
For one hour after meal the woman should lie-
down and concentrate on fetal movement
movement should be felt in one hour 4-
If not , she should count for another hour-
If after 2 hours four movements are not felt,-
she should have fetal monitoring
 Non stress test
Done using the cardiotocometry with the*
patient in left lateral position
Record for 20 minutes**
 Non stress test
The base line 120-160 beats/minute*
:Reactive*
At least two accelerations from base line of 15
bpm for at least 15 sec within 20 minutes
:Non reactive
No acceleration after 20 minutes- proceed for
another 20 minutes
 Non stress test
If non reactive in 40 minutes---proceed for
contraction stress test or biophysical profile

The positive predictive value of NST to predict

fetal acidosis at birth is 44%
NST
NST
 Contraction stress test
Fetal response to induced stress of uterine
contraction and relative placental insufficiency

Should not be used in patients at risk of preterm

labor or placenta previa

Should be proceeded by NST

 Contraction stress test
Contraction is initiated by nipple stimulation or
.by oxytocin I.V

The objective is 3 contractions in 10 minutes

If late deceleration occur-----positive CST

 Interpretation of CTG
Normal Baseline FHR 110–160 bpm
Moderate bradycardia 100–109 bpm –
Moderate tachycardia 161–180 bpm –
Abnormal bradycardia < 100 bpm –
Abnormal tachycardia > 180 bpm –
CTG
Acceleration
 Deceleration
EARLY : Head compression

LATE : U-P Insufficiency

VARIABLE : Cord compression

Primary CNS dysfunction
Early deceleration
Late deceleration
Variable Deceleration
Reduced Variability
 Tachycardia
Hypoxia
Chorioamnionitis
Maternal fever B-Mimetic drugs
Fetal anaemia,sepsis,ht failure,arrhythmias
 Ultrasound fetal assessment
Assessment of growth

Biophysical profile (BPP)

 Assessment of fetal growth by
ultrasound
:Biometry
Biparietal diameter (BPD)
Abdominal Circumference (AC)
Femur Length (FL)
Head Circumference (HC)
Amniotic fluid
Placental localization
 Assessment of fetal growth by
ultrasound
BPD
AC

FL
Growth chart
Placental localization
Amniotic fluid
 Fetal Biophysical profile
Biophysical Normal (score=2) Abnormal (score= 0)
Variable

Fetal episode FBM of at least 30 s 1 Absent FBM or no episode

breathing duration in 30 min >30 s in 30 min
movements

Fetal discrete body/limb movements in 3 or fewer body/limb 2

movements 30 min movements in 30 min

Fetal tone episode of active extension with 1
return to flexion of fetal limb(s) or
trunk. Opening and closing of the
hand considered normal tone
Either slow extension with
return to partial flexion or
movement of limb in full
extension Absent fetal
movement

Amniotic fluid pocket of AF that measures at 1 Either no AF pockets or a

volume least 2 cm in 2 perpendicular planes pocket<2 cm in 2
perpendicular planes
Test Score Result Interpretation Management

of 10 10 Risk of fetal asphyxia Intervention for obstetric and maternal factors

of 10 (normal fluid) 8 extremely rare
of 8 (NST not done) 8
of 10 (abnormal fluid) 8 Probable chronic fetal Determine that there is functioning renal
compromise tissue and intact membranes. If so, delivery of
the term fetus is indicated. In the preterm
fetus less than 34 weeks, intensive
surveillance may be
.preferred to maximize fetal maturity
of 10 (normal fluid) 6 Equivocal test, possible Repeat test within 24 hr
fetal asphyxia
of 10 (abnormal fluid) 6 Probable fetal asphyxia Delivery of the term fetus. In the preterm fetus
less than 34 weeks, intensive surveillance
may be preferred to maximize fetal maturity

of 10 4 High probability of fetal Deliver for fetal indications

asphyxia
of 10 2 Fetal asphyxia almost Deliver for fetal indications
certain
of 10 0 Fetal asphyxia certain Deliver for fetal indications
 Umbilical Doppler Velocimetry
:Indication
IUGR
PET
.D.M
Any high risk pregnancy
Use a free loop of umbilical cord to measure
blood flow in it
Umbilical cord
Umbilical Artery Doppler
Umbilical Artery Doppler
Umbilical cord doppler
Reverse flow in umbilical artery
 Management of Abnormal Doppler
:Depends on
Fetal maturity
Gestational age
Obstetric history
 Management of Doppler results
Reverse flow or absent end diastolic flow---
Immediate delivery

High resistance index---- repeat in few days or

delivery

Normal flow---- repeat in 2 week if indicated

 Assessment for Chromosomal
Abnormality
Ultrasound ----- nuchal translucency (N.T)
---Biochemical markers
1st trimester---PAPPA&βHCG

Amniocentesis
Chorionic villus sampling
 Assessment for Chromosomal
Abnormality
:General Facts
•The general incidence of Down is 1:1000
•The risk by maternal age:
at the age of 35 -----------1:365
at the age of 40-----------1:109
at the age of 45-----------1:32
•Risk of recurrence is 1% ( 0.75% higher than
maternal age related risk
•** In case of parental aneuploidy---- 30% risk of
Trisomy in offspring
 Methods available for screening for
chromosomal abnormality
• Maternal age
• Biochemical---1st trimester---PAPPA&β HCG,

• 2nd trimester---Triple &

quadruple Test

• Ultrasound NT + Other markers

• Fetal DNA
 Ultrasound screening for
chromosomal abnormality
Nuchal translucency(N.T) •
Skin fold thickness behind the fetal cervical spine •

• Timing: 11-13 +6days weeks of pregnancy

• 75-80% of trisomy 21

• 5-10% normal karyotype ( but could be associated

with cardiac defects, diaphragmatic hernia,
Exomphalos)
Nuchal translucency
 Amniocentesis
Obtaining a sample of amniotic fluid
”.surrounding the fetus during pregnancy

:Indications
Diagnostic (at 11- 20 weeks) •
Therapeutic( at any time) •
 :Indications of amniocentesis
:Genetic amniocentesis •
Chromosomal analysis (Down syndrome)
Spina bifida (Alpha fetoprotein)
Inherited diseases (muscular dystrophy)
Bilirubin level in isoimmunization
Fetal lung maturation (L/S ratio)
:Therapeutic amniocentesis
Reduce maternal stress in polyhydramnios •

Mainly in twin-twin transfusion or if abnormality •

associated
Amniocentesis
 Chorionic villus sampling
Sampling is done to the cyto-trophoblasts

done between 10-14 weeks of pregnancy

CVS
 Recommended books
Essential of obstetrics & gynecology (p 91- 119)

Current diagnosis & treatment Obstetrics &

gynecology (p 203-211 & p249-258 & p 441-
460)