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Slow Progress
We've talked about the 3Ps for labour and the partogram is going to provide a lot of information about how they are doing.
Passage. You have just learnt that the space in the pelvis is fairly tight for the baby to negotiate so of course if a woman has a small pelvis this may make progress more difficult and can lead to cephalopelvic disproportion (CPD). No amount of contractions from oxytocin is going to help true CPD.
Now let's look at Power. Ideally contractions should be strong, lasting 60 seconds and come about 3-4 times every 10 minutes.
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Reasons for poor contractions
- Dehydration
- Exhaustion
- Infection
- Pain and fear
- Idiopathic (Primiparous 25%)
The management will include
- IV fluids
- Adequate pain relief which can include heat, entonox, TENS, pethidine and epidural
- Support
- Amniotomy - Artificial Rupture of Membranes (ARM) with amnihook
- Oxytocin - Syntocinon (caution if multiparous as power is unlikely to be a problem here and you need to consider other causes particularly obstructed labour. A senior clinician needs to be involved in the decision making here.)
What about the passenger then?
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- Macrosomia- big baby
- Fetal anomaly eg hydrocephalus
- Malposition/presentation
Occipitoposterior (OP) - most common
Brow
Face
You have already looked at some baby and pelvic measurements-here they are again
OA suboccipitobregmatic = 9.5cm
OP occipitofrontal = 11cm
Brow supraoccipitomental = 13.5cm
Face submentobregmatic MA = 9.2cm
Transverse BPD = 9.5cm
One main part of the management here is the same as for poor contractions ie giving syntocinon. With OP presentation the head usually deflexed. Stronger contractions can flex and rotate head to OA giving a smaller diameter and therefore less likely to get stuck.
Oxytocin (Syntocinon)
Before augmentation of labour we need to think about the strength, duration and frequency of contractions, the pelvic capacity and the fetal size and position.
As we said caution is require with multiparous women as failure to progress is unlikely to be due to inadequate uterine activity alone. When using oxytocin ensure membranes are ruptured, give continuous monitoring and perform regular review.
The risks are - hyperstimulation, fetal distress, hyponatraemia, uterine rupture and amniotic fluid embolus.
