Management of labour

Slow Progress

Slow labour is a rate of <1cm/h after the latent phase. Prolonged labour is >12h after the latent phase.

Powers

Ineffective uterine action is the most common cause of slow progress in labour and happen almost exclusively in nulliparous women. In multiparous women, malpositions and malpresentations must be checked for carefully. It is managed using augmentation i.e. amniotomy with oxytocin.

Hyperactive uterine action is excessive, prolonged and frequent contractions. This can cause fetal distress and this distress indicates Caesarean section.

Passenger

If you don't know the nomenclature for the different presentations, go here.

Malpositions

Breech presentations (where the baby's bum is the presenting part) is usually discovered before labour. It can be delivered vaginally or by Caesarean and about 50% are successfully delivered vaginally. It is more common in premature labour.

Transverse lie (where neither bum nor face but arms or back are the presenting part i.e. the foetus is lying transversely) is impossible to deliver vaginally. Elective Caesaerean is indicated

External cephalic version (ECV) is an attempt to turn the baby from breech to cephalic presentation. Terbutaline is given to relax the uterine muscles and the obstetrician attempts to turn the baby. Fetal heart monitoring is done before, during and after the procedure and an ultrasound scan is done beforehand.

Malpresentations

Occipito-posterior (OP) presentation occurs in 5% of deliveries and generally results in longer and more painful labour. Delivery is by flexion of the head the head, rather than extension, over the perineum and towards the abdomen. Instrumental delivery can turn the head round to face the right way.

Occipito-transverse (OT)" needs to be manually rotated by instrumental delivery, either forceps or a Ventouse if the labour has already reached the second stage.. Brow and Face presentations must be delivered by Caesarean section.

Pain Relief

There are basically three main areas: non-medical, drugs and anaesthaesia.

Non-drug

Transcutaneous electrical nerve stimulations (TENS) applies a mild electrical current to the skin via electrodes. Theoretically, it stops pain pathways working effectively but the evidence is pretty rubbish. Complementary therapies can also be used along with a water or birthing pool (not necessarily the same as a water birth). These are offered as they are cheap and can be helpful to some women, even if only psychologically.

Drugs

Nitrous oxide and oxygen (Entonox) affectionately and colloquially known as gas and air is as 50:50 mixture which is used during the first two stages of labour. It is under the mother's control and works quickly and lasts for a short period of time. Half of women achieve satisfactory relief. It is also very safe.

Pethidine is an opioid analgesic given intramusclarly which takes around 15 mins to work and lasts 2-3 hours. It's efficacy is debated. Remifentanil is patient-controlled analgesic which has been proven effective in small, intermittent boluses.

(It is important to note that with opiate analgesia, babies may develop respiratory distress after delivery which is treated with naloxone.)