Labour with an overdistended uterus

PROBLEM

• A woman in labour has an overdistended uterus or symphysis-fundal height more than expected for the period of gestation. 

GENERAL MANAGEMENT

• Prop up the woman.

• Confirm accuracy of calculated gestational age, if possible.

DIAGNOSIS

• If only one fetus is felt on abdominal examination, consider wrong dates, a single large fetus  or an excess of amniotic fluid.

• If multiple fetal poles and parts are felt on abdominal examination, suspect multiple pregnancy. Other signs of multiple pregnancy include:

- fetal head small in relation to the uterus;

- uterus larger than expected for gestation;

- more than one fetal heart heard with Doppler fetal stethoscope. 

Note: An acoustic fetal stethoscope cannot be used to confirm the diagnosis, as one heart may be heard in different areas. 

• Use ultrasound examination, if available, to:

- identify the number, presentations and sizes of fetuses;

- assess the volume of amniotic fluid.

• If ultrasound service is not available, perform radiological examination (anterio-posterior view) for number of fetuses and presentations.

MANAGEMENT 

SINGLE LARGE FETUS

• Manage as for normal labour. 

• Anticipate and prepare for prolonged and obstructed labour, shoulder dystocia and postpartum haemorrhage.

EXCESS AMNIOTIC FLUID

• Allow labour to progress and monitor progress using a partograph.

• If the woman is uncomfortable because of uterine distension, aspirate excess amniotic fluid:

- Palpate for location of fetus;

- Prepare the skin with an antiseptic;

- Under aseptic conditions, insert a 20-gauge spinal needle through the abdominal and uterine walls and withdraw the stylet;

- Aspirate the fluid using a large syringe. Alternatively, attach an infusion set to the needle and allow the fluid to slowly drain into a container;

- When the woman is no longer distressed because of overdistension, replace the stylet and remove the needle.

• If rupture of membranes is indicated for other reasons, rupture the membranes with an amniotic hook or a Kocher clamp.

• Check for cord prolapse when membranes rupture. If the cord prolapses and delivery is not imminent, deliver by caesarean section.

MULTIPLE PREGNANCY

FIRST BABY

• Start an IV infusion and slowly infuse IV fluids.

• Monitor fetuses by intermittent auscultation of the fetal heart rates. If there are fetal heart rate abnormalities (less than 100 or more than 180 beats per minute), suspect fetal distress.

• Check presentation:

- If a vertex presentation, allow labour to progress as for a single vertex presentation and monitor progress in labour using a partograph;

- If a breech presentation, apply the same guidelines as for a singleton breech presentation and monitor progress in labour using a partograph;

- If a transverse lie, deliver by caesarean section.

Leave a clamp on the maternal end of the umbilical cord and do not attempt to deliver the placenta until the last baby is delivered. 

SECOND OR ADDITIONAL BABY(S) 

• Immediately after the first baby is delivered:

- Palpate the abdomen to determine lie of additional baby;

- Correct to longitudinal lie by external version;

- Check fetal heart rate(s).

• Perform a vaginal examination to determine if:

- cord has prolapsed;

- the membranes are intact or ruptured.

VERTEX PRESENTATION

• If the head is not engaged, manoeuvre the head into the pelvis manually (hands on abdomen), if possible.

• If the membranes are intact, rupture the membranes with an amniotic hook or a Kocher clamp.

• Check fetal heart rate between contractions.

• If contractions are inadequate after birth of first baby, augment labour with oxytocin using rapid escalation (Table P-8, page P-23) to produce good contractions (three contractions in 10 minutes, each lasting more than 40 seconds).

• If spontaneous delivery does not occur within 2 hours of good contractions or if there are fetal heart rate abnormalities (less than 100 or more than 180 beats per minute), deliver by caesarean section.

BREECH PRESENTATION

• If the baby is estimated to be no larger than the first baby, and if the cervix has not contracted, consider vaginal delivery:

- If there are inadequate or no contractions after birth of first baby, escalate oxytocin infusion at a rapid rate (Table P-8) to produce good contractions (three contractions in 10 minutes, each lasting more than 40 seconds);

- If the membranes are intact and the breech has descended, rupture the membranes with an amniotic hook or a Kocher clamp;

- Check fetal heart rate between contractions. If there are fetal heart rate abnormalities (less than 100 or more than 180 beats per minute), deliver by breech extraction;

• If vaginal delivery is not possible, deliver by caesarean section.

TRANSVERSE LIE

• If the membranes are intact, attempt external version;

• If external version fails and the cervix is fully dilated and membranes are still intact, attempt internal podalic version:

Note: Do not attempt internal podalic version if the provider is untrained, the membranes have ruptured and the amniotic fluid has drained, or if the uterus is scarred. Do not persist if the baby does not turn easily.

- Wearing high-level disinfected gloves, insert a hand into the uterus and grasp the baby’s foot;

- Gently rotate the baby down;

- Proceed with breech extraction.

• Check fetal heart rate between contractions;

• If external version fails and internal podalic version is not advisable or fails, deliver by caesarean section.

• Give oxytocin 10 units IM or give ergometrine 0.2 mg IM within 1 minute after delivery of the last baby and continue active management of the third stage to reduce postpartum blood loss. 

COMPLICATIONS

• Maternal complications of multiple pregnancy include:

- anaemia;

- abortion;

- pregnancy-induced hypertension and pre-eclampsia;

- excess amniotic fluid;

- poor contractions during labour;

- retained placenta;

- postpartum haemorrhage.

• Placental/fetal complications include:

- placenta praevia;

- abruptio placentae;

- placental insufficiency;- preterm delivery;

- low birth weight;

- malpresentations;

- cord prolapse;

- congenital anomalies.

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