COURSE AND MANAGEMENT OF LABOUR – Deep Transverse Arrest (DTA)
COURSE OF LABOUR:
- Avg duration of both 1st& 2nd stage of labour is increased.
FIRST STAGE-
- Engagement is delayed
- Persistence of deflexion of head
- Driving force transmitted through the fetal axis is not alignment with axis of inlet.
- Early rupture of membrane occur.
- Abnormal uterine contraction
SECOND STAGE:
- Delayed due to long internal rotation or malrotation , with at times, arrest of head
THIRD STAGE:
- Increased incidence of postpartum hemorrhage & trauma to genital tract
MODE OF DELIVERY :
- Long anterior rotation of occiput -spontaneous or assisted vaginal delivery occurs.(90%)
- Short posterior rotation-spontaneous or assisted vaginal delivery may occur as face to pubis but there is more chance of perineal tear
- Non-rotation or short anterior rotation-spontaneous vaginal delivery highly unlikely .
- May progress to prolonged or obstructed labour.
MANAGEMENT OF LABOUR:
FIRST STAGE-
Partogram is done to monitor the :
- Uterine contraction (frequency, duration and strength )
- Fetal heart.
- Dilatation of the cervix.
- If progressive cervical dilatation does not occur augmentation with an oxytocin drip may be tried.
- If still no progress obtained in a few hours caesarian section (C/S) is performed.
- Also if there is fetal distress C/S is done
SECOND STAGE:
- 70% cases provided that the uterine contractions are strong occiput rotated forward and normal delivery
- 10% the baby may be delivered face-to pubic but there is a great risk of a perineal tear.
- 20% of cases with failure of the presenting part to rotate and descend C/S or rotation can be enhanced by assistance
Arrest In occipito-transverse or oblique position
- Ventouse- It is suitable in cases where the pelvis is adequete & non-rotation of the occiput due to weak contraction or lack of tone of pelvic floor
Alternative methods-
- Manual rotation followed by forceps extraction
- Forceps rotation & extraction
- Caesarean section
- Craniotomy
- Full hand method
Manual rotation & forcep extraction
- First head is rotated manually till the occiput is placed behind symphysis .
- It is done with either by whole hand method or half hand method.
- Then forceps blades are applied.
- The pelvis should be adequate,
- Baby is of average size
- There is good amount of liquor
- The shoulder girdle of the fetus should be rotated at the same time as the head by pressure through the abdominal wall by external hand.
- After rotation completed an obstetric forceps are applied to complete the delivery.
Forceps rotation&extraction:
- It is done by experts
- Kielland’s forceps used
- Advantage over manual rotation
- No chance of displacement of head
- No accidental cord prolapse
- Rotation can be done above or below the level of obstruction
- Caeserean section-if there is midpelvic contraction
- Craniotomy- it is done in case of dead baby
Occipito sacral arrest:
Station of head:
- Above the level of ischial spine: Caeserean section
- Below the spine:Ventouse or forceps with deep episiotomy
Deep transverse arrest:
- Means arrest of labour when the fetal head has descended to the level of the ischial spines and the sagittal suture lies in the transverse diameter of the pelvis.
- The occiput lies on one side of the pelvis and the sinciput on the other side and the head is badly flexed.
- It is only diagnosed during the 2nd stage of labour.
- If the head is firmly fixed in the transverse position obstructed labour will occur
Etiology
- Android pelvis
- Epidural analgesia
- Uterine inertia
Management:Assisted delivery:
Pelvis adequate
- Manual rotation of occiput to anterior position followed by forceps extraction
- vacuum delivery
- forceps rotation
Inadequate pelvis
- Caeserean section
Dead baby:
- Craniotomy
Exam Important
- For Patient with occipito posterior position Wait and watch for progress of labour
- Deep transverse arrest is most commonly seen in Android pelvis,Epidural analgesia & Uterine inertia
- In deep transverse arrest the delivery of baby is conducted by Cesarean section, Vacuum extraction, Keilland forcep and Manual rotation and forcep delivery
- In a case of direct occipitoposterior position (Face to pubis delivery) most commonly encountered problem is Complete perineal tears
- In deep transverse arrest with adequate pelvis, best mode of delivery will be Ventouse
- Best management in Mento-posterior presentation Caesarean section
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