Cephalopelvic Disproportion is anatomical disproportion between fetal head and maternal pelvis. It may be as a result of big head, small pelvis or combination of both. It occurs when the head of the fetus does not fit in to the mother’s pelvis or a delivery condition in which the mother’s pelvis is too small or too misshapen to allow the fetal head to pass through. It can be classified as mild, moderate or severe. Causes of CPD These may be divided into maternal and fetal causes. Maternal causes Fetal Causes Contracted Pelvis This is when the one or more pelvic diameters are reduced by1 centimeter or more centimeters. Signs of contracted pelvis Degrees of contracted pelvis Signs of CPD Methods of Determining Cephalopelvic Disproportion Management of CPD

Malpresentations & Malpositions are among the causes of poor progress of labour. Good progress of labour is enhanced when the presenting part is well applied to the cervix. In malpresentation like face presenting part is not well applied resulting to poor progress. Also, in face presentation the face is not compressible for a lesser diameter to pass through the pelvis, like moulding in the vault.  Through vaginal delivery is possible but takes longer. Brow presentation is larger than diameters of pelvis, except hypertension of the neck occurs and face presentation result in.  Shoulder presentation cannot be delivered vaginally. What are risk factors/causes of Malpresentations & Malpositions? How abnormalities of Birth Canal (the Passage) cause Malpresentations & Malpositions The bony pelvis may be the reason for the delay during labour. Abnormalities of uterus and cervix can also delay the progress of labour e.g., fibroid.  Unsuspected fibroid in the lower uterine segment can impede descent of labour. The fetal head cervical dystocia can also cause delay in progress of labour.  Cervical dystocia can also cause delay in progress of labour. Cervical dystocia means non-compliant cervix which effaces but fail to dilate. Poor progress in the Second Stage of Labour Delay in second stage of labour can occur during the latent or active phase of labour i.e., (pelvic or perineal phase). The causes are: The midwife should not encourage the woman to bear down during the latent phase of 2nd stage as this can lead to maternal exhaustion. The second stage may range from 30 minutes to 2 hours for multiparae and 1-3 hours in primiparae. This will not make the midwife to hurry the woman provided both the mother and fetus are in good condition. During the active phase of labour intervention is not needed if the woman and baby are in good condition. If active phase becomes unduely prolonged, obstetrician should be invited to assess the woman instrumental delivery using forceps or vacuum extraction may be used to deliver the baby if risk of prolonging the labour further outweighs this intervention. Operative delivery may also be taken. The Role of the Midwife in caring for a woman in poor progress of labour Thanks for reading.  See you next time.

Trial of labour is conducted in the presence of a minor or moderate degree of cephalopelvic disproportion in an attempt to achieve a vaginal delivery. The factors supporting the achievement of vaginal delivery in trial of labour are: What is trial of labour? Trial of labour is defined as a test given to a woman with mild or moderate cephalopelvic disproportion (CPD) to see if she can deliver her baby vaginally  with least or no harm damage to herself and baby. Factors that influence the prognosis in trial of labour Advantages of trial of labour Trial of labour prevents unnecessary elective caesarean section in cases of minor degree of disproportion. This is particularly vital in developing countries where facilities for maternity service are poorly equipped and patients may not return for antenatal supervision after delivery by Caeserean section. These patients run the great risk of uterine rupture in subsequent pregnancies. Another advantage is the avoidance of premature induction of labour (with its attendant risk) which is used to popularly practised in cases of suspected disproportion. Premature induction of labour refers to the delivery of a baby which may be too big for the maternal pelvis if delivered at term. It’s, however, not without risks. The patient may fail to go into labour and intrauterine infection may result in. if the patient goes into labour, a grossly premature baby may be delivered. Wherever possible, vaginal delivery is to be preferred to an abdominal delivery. If, hence, trial of labour ensures a safe vaginal delivery, so much the better for all concerned. Disadvantages of trial of labour Trial of labour may fail and when it fails, the patient is naturally disappointed; she may have gone via a great deal of psychological trauma. Her failure to deliver per vias naturates (by the natural route) may affect her adversely. She may have consider herself or her baby abnormal and she would think of many reasons why she is unable to do what others women seem to do without much mental or physical trauma. Apart from psychological agony the patient and her attendants go through, if trial of labour has gone on too long, the risk of intrauterine infection with its consequences on both the mother and baby cannot be underestimated. Conditions in which trial of scar is considered These are: Contraindications of trial of labour Trial of labour should not be attempted in the following situations: A trial of scar When a woman has had a scar of Caeserean section or hysterotomy is given chance to deliver vaginally. This trial is given to see if the scar is strong enough to withstand the labour. Like trial of labour it has to be conducted in hospital. A failure of trial scar is indicated by (a) pain and tenderness over the scar (b) slight vaginal bleeding and (c) slight raise in pulse. Vacuum is usually applied in 2nd stage if there is no sign of rupture. Outcome of trial labour When does a trial of labour fails? Trial of labour is said to be successful if the delivery of the baby is accomplished per vagina spontaneously or by forceps or vaccum extractor.  It is only when unfavourable conditions such as fetal or maternal distress or failure to advance after 6-8hours of good contraction make the delivery of the baby by Caeserean section necessary that trial of labour can be said to have failed. The midwife’s duties during a trial of labour Since there is a chance of obstruction during trial of labour, it should only be done in a hospital with facilities for emergency Caeserean section. The midwife should on no account undertake the conduct of trial of labour on her own responsibility without due arrangement for emergency. The following are the roles of midwife during a trial of labour: 1. Duties to the patient:  It is advisable to explain the situation to the patient and forewarn her of possible operative interferences.  The patient should be carefully assessed on admission to determine the following: The physical and the emotional states of the patient are very essential factors in trial of labour so the midwife should endeavour to improve the morale of the patient.  The patient is confined to bed to prevent early rupture of membranes, sedation is administered liberally to promote rest and avoid exhaustion and undue anxiety.  Stay   with   patient,   talk   to   her   have   the   labour   is progressing, and help her to be relaxed. Adequate hydration of the patient is ensured by giving intravenous infusion of 5% glucose. Nothing per oral is allowed since operative interference may be at short notice. The danger of inhalation of vomitus during anaesthesia is hence prevented. However, she may be allowed sips of water. The bladder and rectum should be emptied to facilitate descent of the fetal head. Encouragement of the patient and a friendly attitude on the part of the midwife will go a long way to boost the patient’s morale. Keep her as comfortable and as dry as possible. Strict asepsis is maintained to avoid infection. 2. Assessment of progress of labour:  the progress of labour is monitored by vigilant observations made by the midwife in the constant attendance of the patient. The observations are made on: a. The uterine contractions: They type of uterine contractions (i.e. their frequency, strength and duration) are noted and recorded hourly and half-hourly towards the end of the labour.  The effects of these contractions on the patient and the fetus are also noted. b. The descent of the presentation: The uterine contractions should facilitate the flexion and descent of the head into the pelvis. The descent of the head is determined abdominally hourly. c. The maternal condition:  A half-hourly observation and record are made of the maternal pulse, blood pressure and respiration.  The temperature is recorded hourly and every specimen of urine the patient passes is tested to rule out albuminuria and acetonuria. Fluid chart is also kept and the midwife should inform the doctor at once if the patient can no longer endure the ordeal. d. The

What is Antepartum haemorrhage? Antepartum refers to existing or occurring before birth. Hence, antepartum haemorrhage (APH) is defined as vaginal or genital  bleeding during pregnancy after the 28th week’s gestation. Another name  for antepartum haemorrhage (APH)  is called pre-partum haemorrhage.  How common is antepartum haemorrhage? APH as one of obstetric haemorrhages affects 3-5% of all pregnancies and accounts for 27% of all maternal deaths.  Antepartum bleeding is associated with increased perinatal morbidity and mortality and can occur at any time until completion of the second stage of labour . Antepartum haemorrhage causes The aetiology of APH are multifaceted and may include: Risk factors of antepartum haemorrhage The predisposing factors for APH are: Types of Antepartum haemorrhage APH can be divided into two based on duration or period of its occurrences. These are: Bleeding in early pregnancy This occurs when a pregnant woman experiences vaginal bleeding or bleeding from genital tract before the 20th week of gestation. Its causes are cervical erosion, cancer of cervix, abortion/miscarriage and ectopic pregnancy.  However, major causes of bleeding in early pregnancy are ectopic pregnancy and abortion —whether spontaneous or induced.  Bleeding before 24 weeks of pregnancy denotes miscarriage. Bleeding in late pregnancy This is the vaginal blood loss  that occurs during 24th or 28th weeks of pregnancy. This type of antepartum haemorrhage  is associated with increased maternal and perinatal morbidity and mortality. Placenta praevia and placental abruption are major causes of vaginal bleeding in late pregnancy.   Vaginal bleeding often dark in colour and accompanied by pain during pregnancy indicates  abruptio placenta. While bright vaginal bleeding during  pregnancy which is painless denotes placenta praevia. What are the signs and symptoms of antepartum haemorrhage? Antepartum haemorrhage symptoms are: Diagnosis of antepartum haemorrhage Apart from detailed history from the woman and examining her vaginally with aid of speculum, antepartum ultrasound helps to diagnose and confirm the actual cause of bleeding in pregnancy. Prenatal ultrasound is a safe and painless test which can be performed during the first, second, or third trimester based on what the health care provider is looking for. Note: Experienced midwife knows that bright vaginal blood loss which is painless is associated with placenta praevia while that which is dark in colour and accompanied with pain suggests placental abruption. Complications of antepartum haemorrhage These complications can be grouped into: Maternal complications Fetal complications Antepartum haemorrhage management Management for bleeding in pregnancy depends on the causative factor (s), stage of pregnancy, degree of haemorrhage and maternal and fetal conditions. What is the prevention of antepartum haemorrhage? No specific ways you prevent antepartum haemorrhage. However, encouraging early booking, regular antenatal care, early detection of high risk cases and early referral to a higher center help in preventing bleeding in pregnancy. The patient is encouraged to get adequate bed rest, avoid intercourse and limit physical activity. Those at higher risk of APH are advised on the use of contraceptives in order to prevent subsequent pregnancy. Aspirin  at doses of 75-100mg can be used before 16 weeks of pregnancy to prevent pre-eclampsia which is also effective at preventing antepartum bleeding. While pregnant women who have suffered bleeding during should be referred to higher facilities where there are good facilities for cesarean section and availability of blood banks so as to improve maternal and perinatal outcomes.