Maternal
- Contractions
- strength and frequency, palpated and on the toco
- Cervix
- dilatation, effacement, station, position, caput and moulding
- Hydration, pain, bladder, exhaustion
- Hydration, pain, bladder, exhaustion
- Oxytocin titrated to contractions, not to the clock
- Oxytocin titrated to contractions, not to the clock
Fetal
- Heart rate and its response to the augmented contractions
- Heart rate and its response to the augmented contractions
- Position of the occiput by sutures and fontanelles
- Position of the occiput by sutures and fontanelles
- Descent by station and by abdominal fifths
- Descent by station and by abdominal fifths
- Caput and moulding as the record of the fit
- Caput and moulding as the record of the fit
Arrest, defined (ACOG/SMFM 2014)
| Situation | Definition |
|---|---|
| Latent phase | Prolonged latent phase (over 20 hours nulliparous, 14 multiparous) is not an indication for caesarean. |
| First-stage arrest | At 6 cm or more with ruptured membranes: no cervical change for 4 hours of adequate contractions, or 6 hours of inadequate contractions with oxytocin. |
| Second-stage arrest | No descent or rotation after 3 hours of pushing (nulliparous) or 2 hours (multiparous), longer with an epidural, provided the fetus is well. |
The three Ps
| Power | Passenger | Passage |
|---|---|---|
| Contractions inadequate in frequency, duration or strength (Montevideo units under 200 on an intrauterine catheter) | Occiput posterior or transverse, deflexed head, macrosomia, brow or face presentation | Cephalopelvic disproportion, rarely a contracted pelvis; a full bladder |
| Oxytocin augmentation; amniotomy | Position changes; manual rotation; time; operative delivery if the criteria are met | Empty the bladder; the diagnosis of true disproportion is made by failure to progress despite adequate contractions |
Operative vaginal delivery and caesarean
- Vacuum or forceps: full dilatation, ruptured membranes, engaged head at station plus 2 or lower, known position, adequate analgesia, empty bladder, an operator who can abandon and proceed to caesarean. Indications: prolonged second stage, fetal compromise, maternal exhaustion or a condition where pushing is unwise.
- Caesarean for arrest is a diagnosis made after time and augmentation, not at the first slow hour. Category (urgency) is communicated clearly: immediate threat to life, maternal or fetal compromise that is not immediately life-threatening, no compromise but early delivery needed, at a time to suit.
- Trial of labour after caesarean: appropriate for most with one prior low transverse incision; success around 60 to 80 percent; uterine rupture risk about 0.5 to 1 percent, higher with induction. Continuous monitoring; a sudden fetal bradycardia is rupture until proven otherwise.
Spinal for caesarean: the anaesthesia simulation in SurgSpace
Check
G1, 7 cm for 3 hours with membranes ruptured and contractions every 5 minutes lasting 40 seconds. Fetal heart rate Category I. What is the next step?
Watch it done
Association of Professors of Gynecology and Obstetrics teaching topic on reading the strip in labour.
Layer by layer from skin to uterus and back, the sequence the operation note follows.
On the modelCervixBony pelvisIsthmus and lower segment