TEALE FENNING

Nick Raine-Fenning

This was originally posted by wolverine

mridulaben · Posted: Sun Jan 21, 2007 10:53 am Post subject:

Here is another hot topic I think:

You are the registrar on call in labour ward and the midwife ask you to review a primiparous woman at term in spontaneous labour. Her cervical dilatation was 7 cms 4 hours ago and now is 8.

1. How would you assess the situation?

2. What are the risks of this situation?

3. How can you correct it?

This is obviously secondary arrest of dilatation. Review the AN notes for any high risk factors, infertility, or suspicion of big baby on USG as these if present will give us low threshhold for conservative treatment.Then review the partogram, so that we can get idea about previous progress,
was it satisfactory or delayed progress from the start. Assess maternal condition with vital signs, hydration Per abdomen exam to feel if both poles of fetal head felt or not.per vag. exam to soo for dilatation , application of cervix to the head, caput, moulding, station as will tell us if CPD. Her pain relief measure to be reviewed.CTG to be reviewed for any suspicious changes. Uterine contractions to be checked.

Risks, always remember, Power, passenger, passage
Maternal distress
Fetal distress
Obstructed labour, rupture uterus if not timely intervention

Correct Hydration, pain relief
If CPD suspected LSCS
IF malposition& CTG O.K, no maternal distress- Expectant versus Active m/g in form of oxytocin aug if contractions not adequate, Amniotomy if not performed.
Both equally effective, Active m/g reduces the labour duration by 0.6 to 2.3 hrs though not significant but increases anaelgesia req.. No evidence as to which is better, though dublin trial prefers active m/g.
No evidence as to lower instrumental or LSCS with either m/g
Take maternal wishes into account after detailed discussion with her regarding the situation

wolverine · Century Club Joined: 16 Jan 2007 Posts: 394

My answer would be like:
introduction:
Dysfunctional labour is a common problem that an obstetrician faces in his everyday practice, can be difficult to manage and may lead to increase maternal and fetal morbidity and mortality. It is also an area of inconsistency of practices resulting in miscommunication among midwives and doctors which can be detrimental to how mothers experience labour.
How would you assess?
Hx: Partogram review, membranes intact/ruptured, syntocinon used or not, what type of analgesia in labour is used
Powers: Frequency, duration and amplitude of contractions
Passanger: CTG, presentation, position, station, caput, moulding (I don't think there is any point looking in the notes if the baby is big as a) USS can be inacurate +/-20% of EFW b) is not going to change much to your management (like asking a woman with prolapse how many deliveries she had and how big were the babies) c) most women will not have a recent growth scan)
Passage: Cervical dilatation, application to the head, assesment of pelvis, clinical pelvimetry of controversial value
Risks
Should be divided to risks to the mother:
Increased risk of intervention (instrumental caesareans) and therefore maternal trauma
Risk of infection
Metabolic derangement (dehydration)
PPH
Shoulder dystocia
Uterine rupture and fistula formation in extreme and neglected cases
Risks for the fetus, Fetal distress, infection, traumatic delivery
What treatment options are there
Conservative: Support and one to one care significantly reduses operative deliveries, dysfanctional labour and need for painrelief. Amniotomy if the membranes are still intact is seen to accelarate labour by 50' but can cause CTG abnormalities. Also woman should be encourage to adopt whatever position she finds comfortable although avoiding the supine position. Upright and lateral positions may reduce the duration of second stage, instrumental deliveries, perineal tears and fetal distress
Medical: Correction of dehydration
Oxytocin infusion to increase the frequency duration and amplitude of contractions if felt that they are not enough with caution to avoid injudicious use which can lead to hyperstimulation and fetal distress.
Adequate painrelief (epidural can remove the urge to push before the cervix is fully dilated)
Surgical: Caesarean section if signs of fetal distress and abnormal FBS, or signs of true CPD although this is usually a retrospective diagnosis
Woman should be fully informed about the treatment options and involved in the descision process

bronwyn · Posted: Mon Jan 22, 2007 9:05 am Post subject:

Good answer Very Happy

Good to see the old bubbling Teale-Fenning approach still works despite the change in question format!
_________________
Bronwyn Bell
SpR
Portsmouth

Abik · Posted: Mon Jan 22, 2007 3:24 pm Post subject:

Great question!

Really got me thinking.
A likely scenerio would be a woman in the pool with intermittent monitoring who was requesting further pain relief (in Poole she would be on the Haven - our MW led unit down the corridor)

My initial thoughts to assessment if I was sat on Del suite would include;
History;
SRM/ ARM ? - meconium?
Any prior VE's - was it the same MW or a student!!
When did she come in? when did she get in the pool and when did she ask for the epidural (as you just know she has by now!!) - these all point towards adequacy of contractions and length of labour so far.
The FH is vital but there may not be much to say if intermittent monitoring used.
I would then look in her notes at her birth plan! Fair warning of tricky punters (and scoring for likelihood of LSCS!!!!!!)
History from the woman has to include her wishes and plans as this needs to guide our practice.
Exam;
I think you've covered it all - bearing in mind the most likely cause is power, assessment of contractions is important and I think a good midwife will tell you this (also the fact that she has made it to 8cm!)
Investigations;
Might want to ask for a CTG before suggesting management?

Risks?
PPH is at the front of my mind, and their poor pelvic floors - risk of prolapse later??
Risk of rupture must be small isn't it?
Risk of maternal dissatisfaction ith long labour and subsequent request for LSCS must be quite high!

Treatment options are pretty well covered - could only think of nipple stimulation to add!!!

Abik · Posted: Mon Jan 22, 2007 6:15 pm Post subject:

What do people think about correction of malposition? If contractions seem adequate and position is OP or OT with a low station, manual rotation could be helpful?

wolverine · Century Club Joined: 16 Jan 2007 Posts: 394

before full dilatation? It's worthless as it's gonna go back to where it was i think. At full dilatation and just before delivery it's acceptable during a contraction to try and correct it manually. Risk of cord prolapse. Personally I have 66% success rate in this! (2 out of three... Very Happy

)

Abik · Posted: Tue Jan 23, 2007 1:43 pm Post subject:

Actually if the presenting part is low enough it can work quite well - true there is a risk of cord prolapse.

Nick Raine-Fenning · Posted: Sat Jan 27, 2007 4:24 pm Post subject:

Not a big fan of manual rotation to be honest ... slap a vacuum on or get the Kjelland's out Wink

If is going to turn, turn it properly. Always thought manual rotation was for the inexperienced obstetrician who could not apply an OP cup (most still do not know what this is) or dribbled nervously and wnet quiet when the beautiful word Kjelland was mentioned Razz

Pre-full dilatation, indeed pre-instrumental delivery, manual rotation has no role. I will allow you to rotate a bit and apply forceps but you get 1 mark at most Wink

The best management of a malposition is mobilise the mother, ensure adequate uterine activity through the use of oxytocics, and most important of all, delay active pushing for 1-2 hours if there is an epidual in situ.
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"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

hansolo · Joined: 10 Nov 2006 Posts: 3

'primiparous' = a woman who has given birth once before?

if this is true, should exercise caution in managing such 'slow to progress' labor.

at full dilatation malposition whatever chosen, manual rotation, metal cup and kielland's (specially kielland's) this is a discussion in itself which oft colored by emotion, personal experience and prejudices. most residents would revert to what they know best (whether it was the right option or not) i.e. performing LUSCS.

for MRCOG II purposes though, do have a look at the GreenTop guidelines for operative vaginal delivery.

good luck!

Nick Raine-Fenning · Posted: Mon Jan 29, 2007 11:51 am Post subject:

Nick Raine-Fenning · Posted: Mon Jan 29, 2007 11:53 am Post subject:

Xerxes I · Posted: Tue Jul 29, 2008 4:01 pm Post subject: