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MID2010 > WK1: Prolonged pregnancy, IOL, precip labour > Flashcards

WK1: Prolonged pregnancy, IOL, precip labour Flashcards

1
Q

Define IOL

A

Induction of labour is the intervention to initiate the process of labour by any or all artificial means.
- it usually involved more than one agent.

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2
Q

What are some maternal and fetal indications for IOL?

A

Generally when it it believed that maternal or fetal condition suggests a better outcome if the pregnancy is not continued.

Maternal indications include
- prolonged pregnancy
- PROM (infection risk for baby )
- mat condition e.g. renal, resp or cardiac that are exacerbated by pregnancy
- hypertension, PE, GDM on insulin
- Previous obstric hsiotry e.g. still birth at term, IVF
- social/psychological reasons, antenatal depression, family/violet situation (may have support at a specific time * consider the whole picture)

Fetal indications include
- FGR and/or potential compromise (if straight compromised= C/S)
- non-reassuring fetal surveillance e.g. doplers show blood flow is impacted
- Rhesus isoimmunisation with heamolysis
- Fetal death in utero (FDIU) to birth baby
- seven congenital abnormlaities

Joint indications
- Preeclampsia
- Unstable lie= baby continually moving (risk of cord prolapse when ROM)= OB and RM will AROM and both externally and internally guide baby into pelvis is correct position (DIFFERENT TO MALPRESENTATION)
- APH- antepartum heamorrhange e.g. if placenta starts to seperate of uterine wall or from babys cord attachment

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3
Q

Explain the cascade of intervention and give an example

A

Cascade of intervention= when one intervention increases the likelihood of anther being used.

e.g. synt + CSL
= CTG indicated= immoblaised, prevents water/shower use
= more uncomfortable and longer labour as baby turns
= may require epidural
= increased risk of
- instrumental birth
- C/S
- episiotomy
- PPH
- Separation of mother and baby
- Extended hospital stay
- Neonatal resus
- engorgement / BF issues

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4
Q

What is the impact of intervention on oxytocin production?

A

= intervention reduces the production of natural oxytocin therefore the women misses the psychological benefits.
- less endorphins are produced so increased pain percieved= less able to cope= increased incidence of epidural and therefore instrumental.

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5
Q

Define augmentation of labour

A

labour began spontaneously and intervention occurred later in response to either failure to progress, suspected low fetal reserves

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6
Q

What are some contraindications for IOL?

A

Anything that is contraindicative of a vaginal birth
e.g. active genital herpes, placenta previa, vaso previa, mal presentation
- CTG where birth is required immediately
- Previous major uterine surgery - classice C/S or myomectomty e.g. of she is going for an VBAC and has to have an IOL then this is dangerous as syntocin for example caussing increased likleyhood for the uterine scar to rupture, absolute cephalo/celvic disproportion/previous pelvic injury e.g. screws in her pevis from previous surgery

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7
Q

Define mal presentation

A

oblique or transverse lie, footing breech, brow presentation

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8
Q

Complications of IOL? and who is more at risk?

A

Iatrogenic prematuirty= babys born prematurely by utalising medical intervention/IOL

Uterine hyperstimulation= artificial oxytocin cause to much contraction of the uterine muscle (tachysystole + hypertonous)

Non-reassuring FHR tracing/fetal disresees= due to quick succession of progression of labour

Process ‘fails’ to bring on labour

Increased risk of;
- operative delivery
- shoulder dystocia
- PPH (due to uterus fatigue and inability to contact after birth)

More risk= nulliparous women

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9
Q

Outline the process of IOL

A
  • Give information (risks + benifits + any questions she may have) and time for decision making
  • gain informed consent
  • document indication for IOL
    Ensure no contraindications
    *once confirmed EDB + gestational age + parity
  • perform documentation and cervical assessment (Bishops score) + abdo assessment + FHR
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10
Q

Explain a Bishops score + its features

A
  • Indicated the degree of cervical ripening and therefore level of induction/agents needed.
  • done via VE

<6 Bishops score= cervix is unfavourable or indication
0 1 2 3
Dilation: <1cm 1-2cm 2-4cm >4cm
Cervix length: >4cm 2-4cm 1-2cm <1cm
Station: -3 -2 -1/0 +1/+2
Consistency: Firm Average Soft -
Position: Posterior Mid Anterior -

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11
Q

List some alternative and natural methods of induction

A

These are anecdotal (not scientific) and hot harmful.
Intercourse
- women releases oxytocin= relaxes and initiates contraction
- Male sperm is prostaglandin rish= ripens cervix* (*may contribute, only about 1% of when we use in medical procedure)

Nipple and clitoral stimulation (oxytocin production)

laxatives/castor oil/spicy foods= laxitives which cause bowels crams which can stimulate initiation of labour

Acupuncture or acupressure (blood flow to uterus/oxytocin due to relaxation)

Raspberry leaf tea (herbal uterotonic agent)

*still consider the risks + benefits
*no need to discuss/reccomended before 40 weeks
*suggest she refers to someone in that area e.g. natropath

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12
Q

What are the 3 types of IOL + cervical ripening?

A

Medical/pharmacological
- Oxytocin drip
- Dinoprostone preparations (prostaglandin E2, PGE2, PG gel, Prostin E2, Cervidil)
* Prostaglandin E2 vaginal gel (Prostin)
* Standardised regimen (CPG)

Prostaglandin E2 continuous release pessary (Cervadil)
Standardised regimen (CPG)
Inserted into the posterior side of the cervix
Inserted for 12hrs

Surgical
- ARM (helps apply head on cervix better to streach it)

Mechanical
- stretch and sweep
- transcervical catheter (e.g. foley= 1 ballon or cooks= 2 ballons)

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13
Q

What are some key practice points for prostaglandins

A

*different is every hospital
30mins FHP monitoring
the give prostaglandin
Stay with mother for 30 mins
Ensure no adverse reactions
Closely monitor for 12hrs

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14
Q

What are the risks/complications and benefits of prostaglandins?

A

Risks/complications
- uterine hypertonous
- uterine tachysystole
- FHR abnormalities
- Placenta abruption
- uterine rupture
- GI effects, back pain, pyrexia, warm feeling in the vagina

Benefits
- ripening of the cervix
- can go home after insertion (unless high risk)
- pessary can be removed if complication occurs
- can be used again if cervix is not yet favourable

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15
Q

What are some contraindications for prostaglandins?

A
  • a bishops score <6
  • abnormal CTG
  • persistent increased maternal temp
  • vaginal bleeding
  • known hypersensitivity
  • spont labour already occured
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16
Q

Explain the insertion of a prostaglandin?

A
  • Get a normal CTG
  • do abdominal palpation
  • VE
  • endure indication and no contraindications
  • insert syringe or yel
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17
Q

Explain the action/benefits and complications of a ballon catheter.

A

Ballon catheter= foleys (one ballon) or cooks (two ballons)

Action/benifit
Strips the membranes form the lower uterine segment inducing prostaglandin formation.
- the pressure is also applied to the cervix to shorten and stretch it.

Complications
- Pre labour ROM
- infection
- APH
- Presenting part displaced from pelvis

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18
Q

Explain the procedure of a ballon inserting

A
  • a speculum is used to place the catheter
  • Catheter introduced into endocervix by direct visualisation or blindly by sliding it over finger through the endocervix into potential space between amniotic membrane and lower uterine segment
  • Balloon inflated with 50mL (Foley) or 80mL per balloon (Cooks) of sterile water
  • retract so that it rests on the internal os
  • Catheter removed at time of membrane rupture or may be expelled spontaneously indicating cervical dilatation
  • Usually left in for around 12 hours *depending on where you are
  • Can fall out its self when women dilate
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19
Q

What is the theory behind a membrane sweep and how is it performed?

A

Goal: to facilitate the production of natural prostaglandins in the womens body

*Despite it being non medicated- it is still an intervention and non a may not always be considered natural
*still can initiate a casacde on intervention

  • involves the midwife inserting one to two fingers into the cervix
  • putting pressure onto the cervix in a circular sweeping motion
  • with the intention to separate the chorioamniotic membranes from the decidua and thus encourage prostaglandin release to increase cervical ripening.
  • This requires the cervix to be open enough to fit one to two fingers of course, so if the cervix is completely closed or too posterior to be reached, a S&S cannot be performed.
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20
Q

Explain an ARM or amniotomy and some key practice points.

A

Use= used to stimulate or augment labour
- accelerates progress by increasing the frequency and strength of contractions
- allows viewing of liquor (colour and amount)

Key practice points
- birth should occur in 24hrs or PROM can increase infection
- ARM (augmentation) should only be used in cases of abnormal labour progress

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21
Q

What are the benefits of membranes staying intact? (therefore for risks of ARM)

A
  • reduced pain as there is cushioning on cervix
  • reduced risk of infection
  • facilitates fetal movement/positioning better
  • facilitated descent of baby
  • protects from cord compression
  • prevents cord prolapse
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22
Q

Direct complications of ARM?

A
  • Cord prolapse
  • Chorioamnionitis (infection of the membranes)
  • Sepsis
  • Umbilical cord compression (head may have been kept of the cord by fluid)
  • rupture of vasa praevia (vessels in membranes)
  • Malpresentation
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23
Q

What is the use of oxytocin and what is its function?

A

Oxytocin= stimulates the strength and frequency of uterine contraction.
- a positive feed back system based on the pressure on the cervix.

24
Q

What are key practice points of IOL with oxytocin?

A
  • Should not be used within 1-6 hours of prostaglandins (depends on type) = can cause hyperstimulatoin
  • Titrated according to maternal / fetal response – aim to use the lowest possible dose (BUT must actually get a woman into labour and don’t want to take it to slow and fatigue her and baby)
  • aim 4 contractions in 10 mins coordinated, strong, regular contractions
  • The dose can be changed every 30 mins
  • Continuous CTG monitoring
  • Uterine activity should be manually palpated every 15 – 30 minutes unless an internal pressure manometer is used
  • 10 IU of sintocinon dilute in 500ml or 1L of isotonic solution such as normal saline or Hartman’s solution
25
Q

What are some potential complications of oxytocin?

A
  • Uterine hypertonus, tachysystole, hyperstimulation (abnormal uterine contractions)
  • Uterine rupture
  • Severe hypotension with rapid bolus doses – must be diluted in an isotonic solution and administered via a pump
  • Antidiuretic effect may cause water retention – water intoxication if severe – use of Dextrose is not recommended
  • Fetal hypoxia (due to hypertonus, tachysystole, hyperstimulation as they lack oxygen supply)
  • Increased risk of PPH
  • Associated with frequent use of epidural (think cascade of interventions) * due to body not being able to produce natural pain killers like adrenaline and the mothers psych not being able to work up to the pain.
  • Increased rate of operative delivery
26
Q

Define tachysystole.

A

Tachysystole= more than 5 active labour contractions in 10 minutes without fetal heart rate abnormalities

27
Q

Define uterine hypertonous.

A

Uterine Hypertonus: contractions lasting more than two minutes in duration or contractions occurring within 60 seconds of each other, without fetal heart rate abnormalities

28
Q

Define uterine hyperstimulation.

A

Uterine hyperstimulation= either tachysystole to uterine hypertonus occurring with fetal heart rate abnormalities.

29
Q

What are some actions to management hyperstimulation?

A
  • turn of synt if IOL/augmenting
  • position change (not to stop the uterus but to try and decrease cord compression so baby can be less impacted)
  • CTG
  • remain with women
  • consider tocolysis (terbutaline)
  • consider urgent delivery
  • excessive uterine activity in the absence of fetal compromise is not an indication of tocolysis
30
Q

What are some tocolytics and what are their doeses?

A

Terbutaline
- 250 micrograms IV or SC

Salbutamol
- 100 micrograms IV

GTN spray
- 400 micrograms sudlingually

31
Q

Define prolonged pregnancy

A

Prolonged pregnancy= a pregnancy that continues past 42 completed weeks.

32
Q

Define post dates/post term

A

Post dates/term= after 40 weeks

33
Q

What is considered term?

A

37-42 weeks gestation

34
Q

Define post maturity and what are some of the features?

A

Post maturity= refers to a neonate and describes a baby born after 42 weeks.

Features include
- dry peeling skin (often mec stained)
- long nails
- alert face with wide eyes
- loose skin suggestive of malnourishment in recent days (can often be related to the increased nutritional requirements of the aging fetus which can not be met inutero)

35
Q

What are some risk factors for a prolonged pregnancy?

A

*this is not well understood.
- obesity
- nulliparity
- family history
- male fetus
- fetal anomaly (such as anencephaly)
*these women tend to still be pregnancy after 42 weeks

36
Q

How do we determine an EDC?

A
  • 8-12 week scan via the crown-rump length (CRL)
  • EDB based on LNMP or CRL before 8 weeks
    *After 12 weeks US measurements are not as reliable as genetics play a role in growth
37
Q

What are the maternal risks that are created from prolonged pregnancy?

A

Fetal macrosomia can lead to:
- Genital tract trauma e.g. tear, episomity
- Operative birth e.g. forceps, C/S
- Post partum haemorrhage= >500ml in the immediate post partum period

38
Q

What are the fetal risk factors of prolonged pregnant?

A
  • Perinatal mortality increases after 41 weeks
    Heimstad et al (2008) reported perinatal death rate of 0.018% at day 287 and 0.51% at day 302+
  • Meconium Aspiration Syndrome (MAS): open bowels onces they reach maturity around 41 weeks. Risk of meconium liquor aspiration that is think and can lead to sepsis
  • Shoulder Dystocia= sholder impacted on symphisis pubis (impacts woman and baby)
  • Bony injury (macrosomia)
  • Soft tissue trauma (macrosomia)
  • Hypoxia; asphyxia
  • Cerebral haemorrhage= usually result of hypoxia
  • oligohydramnios
  • still births
  • IUGR
39
Q

What are some risks of IOL?

A
  • Uterine hyperstimulation
  • Failed IOL
  • Increased need for epidural analgesia (which increases risk of operative birth)
  • Operative birth
  • PPH
40
Q

What considerations must be done when continuing a prolonged pregnancy?

A
  • if the risks to the mother and baby of a post dates birth outweigh the risks of IOL.

Consider if induction is to just prophylactic avoid potential risks. Should we wait and let the pregnancy go on and manage risks/adverse events as they present?

41
Q

What weight is considered fetal macrosomia?

A

4500g birth weight

42
Q

Explain the management of prolonged pregnancy

A
  • IOL offered at 41 weeks + aim for baby to be born before 42 weeks
  • membrane sweep may be offered at 40-41

@ 41+3 fetal surveillance should begin.
- 2x weekly US and AFI
- 2x weekly CTG monitoring

  • IOL should be priorities if any obstetric or medical complications
43
Q

Describe expectant management

A

managing risks/complications as they arise.
e.g. fetal surveillance
- Awaiting events rather than IOL
- recommend closer monitoring

44
Q

Explain active management

A

refers to managing pregnancy with intervention to prevent an outcome.

45
Q

What should be considerations for expectant and active management? (acroynm)

A

B- benitifts
R- risksk
A- alternatives
I- intuition
N- nothing

Benefits – What are the potential benefits?
Risks – What are the potential risks?
Alternatives – Are there any alternatives?
Intuition – What does my gut tell? Do I fully understand all of the information I’ve received?
Nothing – What happens is we do nothing or wait a while and the review again?

46
Q

Describe when info and what information about IOL for prolonged pregnancy will be provided to women in the antenatal period?

A

@38 week antenatal visit, all women should be offered info on risks + benefits of pregnancy lasting longer than 42weeks.
+ risks of IOL

Options offered should include
- what a membrane sweep is
- that discomfort and vaginal bleeding from IOL are possible from the procedure
- induction of labour between 41+0 and 42+0 weeks
expectant management ‘what if we don’t induce’- fetal surveillance
- if monitoring deviates from normal, the plan will be reviewed.

47
Q

What is the role of the midwife in the expectant management of IOL?

A
  • Ensure you give clear, unbiased, evidence based information
  • Explain possible risks AND benefits
  • May need to act as the woman’s advocate
  • Women in this situation are particularly vulnerable and rely on experts to help guide them to make the right decision
  • Ensure you understand the guidelines for expectant management and IOL
48
Q

Define oligohydramnios

A

a decrease in amniotic fluid

49
Q

Define precipitate labour

A

precipitous or precip labour= abnormally rapid labour.
- completion on second stage is 3hrs after the commencement of labour.

=expulsion of the fetus within 3 hours of commencement of contractions

  • can be spont or induced
50
Q

What are some potential complications of precip labour?

A
  • Increased perinatal death rate
  • Soft tissue trauma due to sudden streachng and distension e.g. perineum tears
  • Maternal gentiourinary tract injury
  • Fetal hypoxia due to increased frequency and strength of contractions
  • Intecranial haemorrhage due to sudden compression and decompression of the fetal skull as it passes through the birth canal with speed.
  • Possible injury to the head and bosy as it emerges rapidly and can be uncontrolled and hit the floor.
  • hypothermia= the lack on control of birthing environment may mean it is significantly unfavorable and compromise baby by not allowing it to maintain temp
  • Over efficient uterus may relax after baby is born causing retained placenta or PPH
51
Q

Why can a precip labour be more difficult for the labouring women?

A
  • the body still has to complete the same processes to have the baby but just faster.
    e.g. cervical effacement, dilation, fetal descent and rotation.
52
Q

Define BBA and what they commonly result from?

A

Birth before arrival
= when a woman gives birth before arriving at hospital/location where she is giving birth
e.g.
- ambo
- home (if planned hospital)
- when in transit

Commonly result from precip labour

53
Q

If a woman births at home but planned to birth at the hospital is this considered a BBA?

A

Yes

54
Q

What are the risks of a BBA?

A
  • trauma and stress for the woman
  • PPH
55
Q

What are the risks of the mother when shes has a precipitate BBA?

A
  • Placenta abruption
  • Infection
  • Pre-eclampsia
  • Baby may not be term
  • Genitourinary trauma/tearing
  • Retained placenta/PPH due to uterus relaxing after baby is born
  • Stress and axniety
56
Q

What are the risks to the fetus of a precip labour?

A
  • It can mean they are BBA so they experience changing of environments and may find it hard to maintain their body temp, thus causing hypothermia
  • Hypoxia as contractions are more frequent and strong

MID2010 (8 decks)

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