Oxford Handbook of Midwifery (75 page)

but it could mask severe pain or may have side-effects that could make vaginal birth less likely.

to the mother if a caesarean is required.

1. National Institute for Health and Clinical Excellence (2004). Caesarean section. Clinical guideline
   

   13. London: NICE. Available at: M
   www.nice.org.uk/cg13.
   

2. Enkin M (2000). Labour and birth after previous caesarean. In: Enkin M, Keirse M, Neilson J,
   et al
   . (eds).
   A Guide to Effective Care in Pregnancy and Childbirth
   , 3rd edn. Oxford: Oxford University Press, p. 267.
   
3. Johnson C, Keirse M, Enkin M,
   et al
   . (2000). Hospital practices—nutrition and hydration in labor. In: Enkin M, Keirse M, Neilson J,
   et al
   . (eds).
   A Guide to Effective Care in Pregnancy and Childbirth
   , 3rd edn. Oxford: Oxford University Press, pp. 255–66.
   

   CHAPTER 18
   High-risk labour
   

   326‌‌
   

   Obstructed labour
   

   If progress in labour is limited in the first stage (i.e. no increase in cervical dilatation in 3–4h) consider the following:
   

   • The woman is not in established labour: proceed as for normal labour
     
   • Labour may be prolonged by psychological stress, support is
     paramount
     
   • The uterine contractions are not effective: the woman may benefit
     

     from oxytocin augmentation (b see Intravenous oxytocin, p. 368). Never arrange to use oxytocin to augment labour without gaining the consent of the woman and the obstetric registrar
     

   • The labour is obstructed: there is no advance of the presenting part in the presence of strong contractions.
     

     Causes
     

   • Obstruction at the pelvic brim may be apparent if the fetus is large in relation to maternal size. Contracted pelvis or previous pelvic injury could be a factor.
     
   • Obstruction at the outlet may occur, for example, when deep transverse arrest complicates the second stage. A fetus in the occipito- posterior position may occasionally be unable to rotate and becomes wedged at the level of the ischial spines.
     
   • Obstruction may occasionally occur as a result of:
     
     • Fetal abnormalities, e.g. the hydrocephalic fetus
       
     • Fetal malposition
       
     • Fetal malpresentation—shoulder or brow presentation
       
     • Persistent mentoposterior position
       
     • Rarely, locked twins
       
     • Rarely, fibroids or tumour.
       

       Prevention
       

   • Refer to the consultant obstetrician:
     
     • All women with suspected malpresentation
       
     • Some units require referral of primigravidae with non-engagement of the fetal head at term.
       
   • Be alert to a history of previous prolonged labour or difficult delivery.
     
   • Monitor labour carefully to detect a slow/no descent of the presenting head.
     

     Signs of obstructed labour
     

     In the first stage:
     

   • On abdominal palpation, assess for failure of the presenting part to engage
     
   • The cervix dilates slowly
     
   • The presenting part remains loosely applied to the cervix
     
   • The forewaters may rupture early or form a loose bag before the presenting part.
     

     In later first or second stage (late signs of obstruction):
     

   • Maternal pyrexia and rapid pulse
     
   • Maternal pain and anxiety
     

OBSTRUCTED LABOUR

327

fetal skull.

Management

• There is no progress in the first stage of labour despite the administration of intravenous oxytocin
  
• There is no progress in descent in the second stage of labour.
  

Complications

Maternal

Fetal

All of the above may lead to morbidity, stillbirth, neonatal death.

CHAPTER 18
High-risk labour

328‌‌

Delivery care for twins and other multiple births

Twin and multiple pregnancies carry a higher risk of antenatal complica- tions. This is especially true of monochorionic twins, due to:

• Unequal growth
  • Polyhydramnios
  
• Fetal abnormalities
  
• Intrauterine death of one or both twins
  
• Spontaneous abortion
  
• Pre-eclampsia
  
• Preterm labour.
  
  • There is a higher risk of complications during labour, due to:
    
    • Malpresentation of either twin
      
    • Asphyxia
      
    • PPH.
      
  • As a result, the following intervention may be necessary:
    
    • Intrauterine manipulation
      
    • Episiotomy and instrumental delivery
      
    • Caesarean section for one or both twins.
      

      These factors will affect the mode of delivery. Caesarean section is usual:
      

  • If there is only one amniotic sac
    
  • For multiple births (triplets and more).
    

    A plan for delivery will be made antenatally in discussion with the parents and obstetric consultant.
    

    Management of labour
    

  • When the first twin is cephalic and no other complications are present, expect to deliver the babies vaginally.
    
  • If a vaginal delivery is anticipated, encourage the woman to telephone and attend the delivery suite as soon as possible after the onset of labour, especially if she is multiparous, since labour may progress rapidly.
    
  • On admission, inform the senior obstetrician.
    
  • Consider the progress of the pregnancy, review the hospital records and assess maternal blood pressure, urinalysis, pulse, and temperature, ensuring general maternal well-being. Obtain IV access and send blood samples to the laboratory for FBC and G&S.
    
  • Confirm the growth and presentation of the fetuses by abdominal palpation and ultrasound scan.
    
  • If the woman is in early labour and the membranes are intact, continuous monitoring of the fetal hearts, movements, and uterine contractions for a short period may provide some assurance of fetal well-being.
    
  • During early labour the woman may find comfort from being able to change her position and walk around, and from the use of TENS or water.
    

  DELIVERY CARE FOR TWINS AND OTHER MULTIPLE BIRTHS
  

  329