Failure to Progress

Question 1

What is meant by failure to progress?

Answer 1

• occurs when labour is not developing at a satisfactory rate
• more likely to occur in women who are in labour for the first time

Question 2

What are the 4 P’s that can influence progression in labour?

Answer 2

Power:

• strength of uterine contractions

Passenger:

• position, size + presentation of the fetus

Passage:

• size / shape of the pelvis

Psyche:

• support / antenatal preparation for delivery

Question 3

What are the 3 phases of the first stage of labour?

What is normal progression during these stages?

Answer 3

latent phase:

• from 0 - 3cm dilation of cervix
• there are irregular contractions
• progresses at 0.5cm per hour

active phase:

• from 3 to 7cm dilation of cervix
• there are regular contractions
• progresses at 1cm per hour

transitional phase:

• from 7 to 10cm dilation of cervix
• there are strong, regular contractions
• progresses at 1cm per hour

Question 4

When is delay in the first stage of labour considered?

Answer 4

• less than 2cm cervical dilatation in 4 hours
• slowing of progress in a multiparous woman

Question 5

What is used to monitor progress in the first stage of labour?

Answer 5

partogram

Question 6

What is recorded on a partogram?

Answer 6

• cervical dilatation (measured by 4-hourly vaginal exams)
• descent of fetal head (in relation to ischial spines)
• maternal obs (HR, BP, temp, urine output)
• fetal HR
• frequency of contractions
• status of membranes + presence / colour of liquor
• drugs / fluids given

Question 7

How are uterine contractions measured?

Answer 7

• the number of contractions in 10 minutes
• “2 in 10” means 2 contractions occurring in 10 mins

Question 8

How can you use the partogram to assess whether labour is progressing adequately?

Answer 8

• there are 2 lines labelled “alert” and “action”
• the dilation of the cervix is plotted against the duration of labour
• when it takes too long for the cervix to dilate, the readings will cross over the “alert” or “action” line

Question 9

What is done when the “alert” and “action” lines are crossed?

Answer 9

crossing the alert line:

• amniotomy is performed
• followed by a repeat examination in 2 hours

crossing the action line:

• escalation to obstetric-led care and senior decision makers

amniotomy = artificial rupture of the membranes

Question 10

What is meant by the second stage of labour?

Answer 10

from 10cm cervical dilatation to delivery of the baby

this stage is influenced by the 3Ps

Question 11

What is considered to be delay in the second stage of labour?

Answer 11

• > 2 hours in a nulliparous woman
• > 1 hour in a multiparous woman

Question 12

What is meant by “power” during the 2nd stage and how can it be influenced?

Answer 12

• power is the strength of uterine contractions
• if contractions are weak, oxytocin infusion can be given

Question 13

What are the 4 descriptive qualities of the fetus considered in “passenger”?

Answer 13

• P - presentation
• A - attitude
• L - lie
• S - size

remember as “PALS”

Question 14

How can the size of the fetus influence progress in labour?

Answer 14

• larger babies (macrosomia) can be more difficult to deliver
• there may be issues such as shoulder dystocia

Question 15

What is meant by the attitude of the fetus?

Answer 15

• the posture of the fetus
• i.e. how the back is rounded and head / limbs are flexed

Question 16

What is meant by the lie of the fetus?

Answer 16

• the position of the fetus in relation to the mother’s body
• transverse lie - fetus is straight side-to-side
• oblique lie - the fetus is at an angle
• longitudinal lie - the fetus is straight up and down

Question 17

What is meant by presentation of the fetus?

Answer 17

the part of the fetus that is closest to the cervix

Question 18

What interventions may be required during the second stage of labour?

Answer 18

• changing of positions
• analgesia
• oxytocin
• episiotomy
• instrumental delivery
• C - section

Question 19

What is the third stage of labour?

Answer 19

from delivery of the baby to delivery of the placenta

Question 20

What is classed as failure to progress in the third stage of labour?

Answer 20

• > 60 mins with physiological management
• > 30 mins with active management

Question 21

What are the 4 main options for managing failure to progress?

Answer 21

• amniotomy (if the membranes are intact)
• oxytocin infusion
• instrumental delivery
• C-section

Question 22

What is meant by instrumental delivery?

Answer 22

vaginal delivery assisted by:

• ventouse suction cup
• rotational forceps
• traction forceps

Question 23

What additional medication is required for instrumental delivery?

Answer 23

• a single dose of co-amoxiclav is given after delivery
• this reduces the risk of maternal infection

Question 24

What are the indications for instrumental delivery?

Answer 24

• failure to progress
• fetal distress
• maternal exhaustion
• control of the head in various fetal positions
• to avoid raising ICP / BP

Question 25

What must be in place prior to instrumental delivery?

Answer 25

* ruptured membranes * adequate contractions * empty bladder * adequate analgesia * knowledge of where the baby is positioned

Question 26

What procedure can increase the risk of requiring an instrumental delivery?

Answer 26

presence of an epidural

Question 27

What are the increased risks for the mother related to instrumental delivery?

Answer 27

* postpartum haemorrhage * episiotomy * perineal tears * injury to the anal sphincter * incontinence of the bladder or bowel * nerve injury (obturator / femoral)

Question 28

What are the increased risks to the fetus related to instrumental delivery?

Answer 28

* cephalhaematoma (ventouse) * facial bruising * facial nerve palsy (forceps) * retinal haemorrhage

Question 29

What is a ventouse and how does it work?

Answer 29

* a **suction cup** on a cord * the suction cup goes on the baby's head and **careful traction** is applied to the cord

Question 30

What is the main complication associated with use of a ventouse?

Answer 30

**cephalohaematoma** * **small blood vessels are ruptured** due to pressure on the fetal head * this results in a **collection of blood** between the skull / periosteum

Question 31

What are the main complications associated with forceps delivery?

Answer 31

* **facial nerve palsy** presenting with facial paralysis on one side * **bruising** on the face * **fat necrosis** (hardened lumps of fat on the cheeks) ## Footnote fat necrosis resolves spontaneously over time

Question 32

What are the most common nerve injuries associated with instrumental delivery?

Answer 32

* **femoral nerve** * **obturator nerve** * these injuries usually resolve over **6-8 weeks**

Question 33

How may the femoral nerve be injured? What does this result in?

Answer 33

* the femoral nerve is compressed against the **inguinal canal** * this causes **weakness of knee extension** + **loss of patella reflex** * there is numbness of the **anterior thigh + medial lower leg** ## Footnote this tends to only occur during a forceps delivery and not during normal birth

Question 34

What does compression of the obturator nerve result in?

Answer 34

* weakness of **hip adduction + rotation** * numbness of the **medial thigh** ## Footnote this can be compressed during forceps delivery or by the fetal head during a normal delivery