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Obstetrics > Labour 2 > Flashcards

Labour 2 Flashcards

1
Q

What is the benefit of waterbirth

A

Has been shown to reduce the need for regional anaesthesia

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2
Q

What do you need to monitor with waterbirth

A

Temperature needs to be checked hourly to kept below 37.5 degrees to prevent maternal pyrexia

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3
Q

What pain relief is used in waterbirth

A

Narcotic injections eg. pethidine 50-150mg IM

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4
Q

When can’t you use pethidine in waterbirth and how long do you have to wait before you can get in water after injection

A

Can’t use if due in

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5
Q

How long till anaesthesia with pethidine and how long does it last

A

Within 20min and lasts 3hours

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6
Q

What is CI for nitrous oxide - what are side effects

A

CI in pneumothorax

Can make women feel light-headed and nauseated

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7
Q

What is anaesthetised with epidural

A

Pain fibres carried by T11-S5

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8
Q

What is given in epidural

A

IV ephedrine

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9
Q

When do you start epidural and how often do you need top ups?

A

Started in latent 1st phase of labour
Top ups 2-hourly
Continued until placenta is delivered and any repairs done

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10
Q

Problems with epidural x5

A

Doesn’t work
Postural hypotension
Paralysis of muscles - reduces voluntary effort
Afterwards - urinary retention and headache

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11
Q

How does being on heparin affect epidural

A

Have to wait 12hr before doing a block after heparin
Have to wait 4hr after block before next heparin dose
Must be vigilant to detect any neurological problem and

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12
Q

What is combined spinal epidural anaesthesia?

A

Large bore needle into epidural space - fine bore needle through that to puncture subdural space
Small dose of opiate and anaesthetic inserted for 1st stage
Catheter remains in place for top up in 2nd stage with more profound anaesthesia

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13
Q

Benefits of combined spinal epidural

A

Quicker pain relief and because controlled by mother - dose reduction by 35% and reduced motor blockade

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14
Q

Incidence of twins and triplets

A

Twins 3:200 pregnancies

Triplets 1: 10,000

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15
Q

Predisposing risk factors to twins

A 
Previous twins
FH of twins 
Older maternal age
Induced ovulation and IVF 
Race origin 1:150 for Japanese 1:23 for Nigerian
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16
Q

Features of twins pregnancy

A

Uterus large for dates
Hyperemesis
Later may be polyhydramnios
Two poles, multiciplicity of fetal parts, 2 fetal heart rates

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17
Q

Complications of twin pregnancy

A

Polyhydramnios
Pre-eclampsia 30% vs 10%
Anaemia
APH increased incidence 6% vs 4.7% (due to abruption or placenta praevia)

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18
Q

Incidence of perinatal mortality, singletons vs twins etc

A

8/1000 singletons, 36.7/1000 twins, 73/1000 triplets and 204/1000 for high multiples

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19
Q

Fetal complications of twin pregnancies

A

Main problem is prematurity
Growth restriction common
Malformation rates increased x2/4
FFT - fetal fetal transfusion, one fetus plethoric and one anaemic

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20
Q

Labour complications of twin pregnancies

A

Malpresentation common - Ce/Ce is only 40%

Ce/Breech 40%

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21
Q

Monitoring of twin pregnancy

A

Monthly from 20weeks or 2-weekly if monochorionic
Name twins (eg. left and right) and discordant growth of >25% indicates growth restriction
Weekly antenatal visits from 30 weeks

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22
Q

When to offer elective birth with twins

A

37+0 for uncomplicated dichorionic
36+0 for uncomplicated monochorionic
35+0 for uncomplicated triplets

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23
Q

Number of multiple births in IVF pregnancies

A

1 in 4 IVF pregnancies

monozygotic are also more common

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24
Q

Problems if donor egg with IVF pregnancies

A

Pregnancy induced hypertension is 7.1times more common in nulliparous women who received donated eggs than for standard IVF

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25
Q

Genetic defects with IVF pregnancies

A

Beckwith-Weidermann syndrome is 6x more common in IVF babies

Concern that ICSI could encourage chromosomal abnormalities or cystic fibrosis in men with azoospermia or oligospermia

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26
Q

Other pregnancy problems in IVF pregnancies

A

Vasa praevia more common
Low birthweight more common
Prematurity is 2x as common in IVF singleton and 3x more common for prematurity

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27
Q

Most common malpresentation and its incidence at various weeks gestations?

A

Breech
40% at 20weeks
20% at 28 weeks
3% at term

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28
Q

Conditions predisposing to breech position x7

A

Contracted pelvis, Bicornuate uterus, fibroid uterus, placenta praevia, oligohydramnios, spina bifida, hydrocephalic fetus

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29
Q

What is extended breech? (frank breech)

A

Flexed at hips but extended at knees - most common

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30
Q

What is flexed breech? (complete breech)

A

Knees and hips both flexed therefore presenting part is mixture of buttocks, genitalia and feet

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31
Q

What is footling breech?

A

Least common
Feet are presenting part
Greatest risk of cord prolapse

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32
Q

Diagnosis of breech presentation

A

Mother may complain of pain under ribs

Smooth round mass which can be ballotted (head) in the fundus

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33
Q

What is external cephalic version?

A

Moving of fetus into cephalic presentation
Usually doing a forward somersault
Only done if PVD planned

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34
Q

When is external cephalic version done for primips and multips?

A

Primips at 36 weeks and multips at 37 weeks

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35
Q

Success rate of external cephalic version

A

40% in primips and 60% in multips

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36
Q

What is used to deliver head in assisted breech delivery

A

Forceps after body hangs there for 1-2mins until nape of neck is seen. Body then lifted above vulva for head to be delivered

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37
Q

What is prolapsed cord?

A

When cord descends through the cervix before the presenting part of the fetus in the presence of ruptured membranes

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38
Q

What are the two types of prolapsed cord?

A

Occulta - Alongside the presenting part

Overt - In front of the presenting part

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39
Q

Why is prolapsed cord an emergency?

A

Because of fetal asphyxia

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40
Q

Incidence of prolapsed cord

A

0.1-0.6%

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41
Q

Risk factors for prolapsed cord x7

A 
2nd twin 
Male
Footling breech 
Transverse or unstable lie
Shoulder presentation 
Polyhydramnios
Unengaged head
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42
Q

What should you do if prolapsed cord is noted prior to membrane rupture

A

Emergency c-section

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43
Q

What should you do if membrane rupture and prolapsed cord? x4

A

Try and displace the presenting part - push it back up towards mothers head during contraction
Not recommended to try and replace the cord
Infuse 500ml saline into bladder
Tocolytics can help reduce contractions and therefore fetal bradycardia

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44
Q

What are best maternal positions for prolapsed cord

A

Head down in left lateral position or knee-elbow position so that bum is higher than head

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45
Q

General best response if fetus alive and prolapsed cord and other situations?

A

Emergency c-section
If fully dilated and presenting part is low in pelvis can do forceps delivery or breech extraction — if leads to birth in

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46
Q

What is shoulder dystocia? and other name

A

Impacted shoulders

Shoulders not delivering after delivery of fetus head

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47
Q

Incidence of shoulder dystocia

A

0.6% of deliveries

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48
Q

Risks associated with shoulder dystocia x4

A

Fetal mortality and morbidity high
Brachial plexus injuries in 4-16% (10% left with serious disability)
PPH high - 11%
4th degree perineal tears - 3.8%

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49
Q

Associations of shoulder dystocia

A 
Large fetus
Maternal BMI 
Induced or oxytocin augmented labours 
Prolonged 1st or 2nd stages 
Assisted vaginal delivery 
Previous shoulder dystocia 
MOST occur in women with no risk factors
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50
Q

Danger with shoulder dystocia

A

Death from asphyxia - speed is vital because cord is usually squashed at pelvic inlet

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51
Q

What should you do if shoulder dystocia

A

Use McRoberts (hyperflexed lithotomy) position - successful in 90% (femurs ext rotated, abducted and flexed to bring thigh up to abdomen)
Pressure on lower pelvis to push in direction baby is facing
Steady traction of fetal head
Aims to displace anterior shoulder bringing it into pelvis

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52
Q

If first steps of managing shoulder dystocia fail?

A

If ant.shoulder is not under pubic symphysis then rotate it so that it is - repeat 1st steps
If this fails rotate 180degrees so posterior shoulder is forward and try again

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53
Q

If second steps of managing shoulder dystocia fail?

A

Mother into all 4’s position
Maternal symphiostomy
Replace fetal head and do c-section

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54
Q

What is risk with meconium-stained liquor? Management

A

Aspiration can cause severe pneumonitis
Routine suction of naso and oropharynx not recommended
Suction if thick/tenacious meconium in oropharynx

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55
Q

What is definition of dystocia?

A

Difficulty in labour

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56
Q

3 main causes of dystocia

A

Passages
Passenger
Propulsion

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57
Q

Which presentations always need c-section

A

Transverse lie and brow presentations

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58
Q

Which presentations may be delivered PVD but are more likely to face problems

A

Face and OP presentations

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59
Q

Which type of cephalic presentations are less favourable?

A

Less flexed the head is - less favourable it is

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60
Q

When is breech presentation most unfavourable?

A

If baby >3.5kg

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61
Q

What is ideal contraction pressure peak?

A

30-60mmHg

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62
Q

When can propulsion be a problem? x3

A

Not strong enough
Not often enough
Occur too close to each other

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63
Q

What can help with propulsion causes of dystocia?

A

Oxytocin (but be careful in multips)

Pain relief - pain can induce catecholamines which inhibit uterine activity

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64
Q

Incidence of operative delivery in UK

A

10-13%

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65
Q

Conditions for use of operative delivery x8

A 
Head must be engaged
Membranes must be ruptured
Cervix must be dilated
Position of head must be known and presentation suitable
Cephalo-pelvic disproportion must not be present 
Uterus must be contracting
Analgesia must be adequate
Bladder must be empty
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66
Q

What are forceps shaped like?

A

Have cephalic curve which fits baby’s head and pelvic curve which fits pelvis

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67
Q

3 types of forceps

A

Short-shanked - used for lift out deliveries when head is on perineum
Long-shanked - used for higher deliveries
Keillands - have reduced pelvic curve and used for rotation

68
Q

When are forceps used x4

A

Delay in second stage of labour
If fetal distress, prolapsed cord or eclampsia
If need to avoid maternal stress (respiratory disease, cardiac disease, pre-eclampsia)
For after-coming of head with breech deliveries

69
Q

Technique for using forceps

A

Insert left blade, then right blade then fix together
Pull head downwards to begin with
Then when occipit clears the pubic symphysis pull up and out

70
Q

What is ventouse

A

Less maternal injury that forceps

Suction pad on baby’s head - over posterior fontanelle

71
Q

When is ventouse contraindicated x2

A

Babies under 34 weeks
Use with caution 34-36 weeks
Face presentation

72
Q

What is there increased risk of with ventouse delivery compared to forceps?

A

Fetal cephalhaematoma
Failed delivery
Fetal retinal haemorrahges

73
Q

WHO aim for % of c-sections

A

Aim for

74
Q

Current rate of c-sections in UK

A

> 24% of all UK labours

75
Q

What incision is used for c-sections?

Rate of fetal lacerations

A

Joel Cohen incision - straight incision 3cm above pubic symphysis
Blunt dissection afterwards
Fetal laceration rate 2%

76
Q

When is classical c-section used x6 and what is it?

A

Vertical incision
V.premature fetus, lower segment poorly formed
Fetus transverse, ruptured membranes and liquor draining
Structural abnormality means can’t use lower segment
Fibroids
Anterior placenta praevia and lower segment especially vascular
Mother dead - rapid birth desired

77
Q

What anaesthetic should be avoided for obstetric procedures and why?

A

Halothane

Uterine muscle relaxation and therefore more bleeding

78
Q

When do you do elective c-sections? x8

A 
Known disproportion 
Placenta praevia 
Morbid adherent placenta 
Breech 
Twins if 1st not cephalic 
Vaginal surgery 
Some maternal infections
Maternal request
79
Q

When should elective c-section be planned for?

A

after 39 weeks completed gestation

80
Q

Elective c-section and thromboprophylaxis?

A

If high dose - then halve to same dose over 24hr as normally given in 12hr - on day before planned c-section
For all - omit on morning of c-section and give 3hr post-op unless epidural

81
Q

How common is uterine rupture in UK?

A

Rare

82
Q

Maternal and fetal mortality with rupture uterus

A

Maternal 5% and fetal 30%

83
Q

Which scars are more likely to rupture

A

Classic more likely (2-9%) than lower segment

84
Q

Other risk factors for ruptured uterus other than previous c-section? x5

A 
High forceps delivery 
Previous cervical surgery 
Obstructed labour in multiparous especially if oxytocin used
Internal version 
Breech extraction
85
Q

What is trial of scar and how successful?

A

PVD after c-section

PVD successful in 72-76%

86
Q

What is increased and what is reduced with trial of scar?

A

Increased endometritis, blood transfusion, uterine rupture and perinatal death
Decreased neonatal respiratory problems

87
Q

Signs or symptoms of ruptured uterus

A 
Usually during labour
May be pain - may just be tender
May have vaginal bleeding
Loss of presenting part from pelvis
Decreased contractions 
Unexplained maternal tachycardia or shock
88
Q

Management of ruptured uterus

A

Laparotomy, remove baby and assess uterus
May be able to mend tear (>66% ruptured scars)
But if cervix or vagina involved may need hysterectomy

89
Q

% of spontaneous uterine ruptures that need hysterectomy

A

85%

90
Q

What is Mendelson’s syndrome?

A

Cyanosis, bronchospasm, pulmonary oedema and tachycardia due to inhalation of gastric acid with general anaesthesia

91
Q

Management of Mendelson’s syndrome

A

Tilt patient head down
Turn to one side and aspirate pharynx
Give o2 100%
Anitbiotics and steroids

92
Q

What is the definition of a still birth?

A

Babies born dead after 24 weeks gestation (but were alive at 24 weeks)

93
Q

Rate of still birth

A

1 in 200 of births

94
Q

What happens after several hours IUFD?

A

Skin begins to peel and fetus becomes macerated

95
Q

How many IUFD will go into spontaneous labour (within 2 and within 3 weeks)

A

80% within 2 weeks and 90% within 3 weeks

96
Q

What can happen 4 weeks after late IUFD? (incidence at 4 weeks and incidence after)

A

10% at 4 weeks - coagulopathy

30% after 4 weeks

97
Q

Antepartum causes of IUFD? x7

A 
Malformation 
Congenital infection (TORCH)
Pre-eclampsia 
APH
Maternal illness (HTN, DM, renal disease) 
Hyperpyrexia >39.4
Post-maturity
98
Q

What are the TORCH infections?

A 
Toxoplasmosis
Other (syphilis)
Rubella
CMV 
Herpes (hepatitis)
99
Q

Intrapartum causes of IUFD? x4

A

Placental abruption
Maternal and fetal infection
Cord prolapse/knot
Uterine rupture

100
Q

What % of intrapartum IUFD are no cause found for?

A

50%

101
Q

What increases the risk of IUFD? x4

A

Maternal age
Multiple pregnancies
Smoking
Obesity

102
Q

What test do you need to do after IUFD and what is it?

A

Kleihauer - to diagnose fetomaternal haemorrhage (fetal blood cells going into the maternal circulation)
To determine anti-d dose in rh- mothers

103
Q

When do you advise delivery with IUFD? x4

A

Abruption
Pre-eclampsia
Coagulopathy
Membrane rupture

104
Q

What do you use to induce labour with IUFD? - what is CI

A

Mifepristine
+ vaginal prostaglandins (misoprostol)
Amniotomy is CI because increased risk of infection

105
Q

What formality needs to be done after stillbirth?

A

Certificate of stillbirth within 42 hours to registry by mother (or father if married)

106
Q

What is definition of primary PPH?

A

Loss of >500ml in first 24 hour after delivery

107
Q

What is major PPH?

A

Loss of >1l

108
Q

What % of deliveries have primary PPH and what % have major PPH?

A

Primary 6%

Major 1.3%

109
Q

Death rate from PPH in Uk

A

2/year

110
Q

Antenatal risk factors for PPH x11

A

Previous PPH or retained placenta
BMI >35
Maternal Hb

111
Q

Labour risk factors for PPH x4

A 
Prolonged labour
Induction or oxytocin use 
Preciptate labour (very quick)
Instrumental delivery or c-section
112
Q

Management of PPH x3

A

Give oxytocin and high flow O2
If shocked give Gelufusine or blood
Check if placenta is delivered and if not then explore uterus

113
Q

What is gelufusine?

A

Succinalyted gelatine - is colloid and behaves like blood filled with albumins

114
Q

If bleeding continues with PPH

A

Give oyxtocin 10 units in 500ml

Bimanual pressure on uterus to stop bleeding

115
Q

Main cause of PPH

A

Uterine atony 90%

116
Q

What to do if uterine atony is cause of PPH

A

Give carboprost - controls bleeding in 88%

117
Q

What is secondary PPH

A

Excessive blood loss from genital tract >24hrs after delivery

118
Q

When does secondary PPH usually occur

A

Between 5-12 days

119
Q

What is secondary PPH usually due to

A

Retained placenta or clots

120
Q

What is common with secondary PPH

A

Secondary infection

121
Q

When is a placenta considered retained?

A

3rd stage of labour is delayed if not completed by 30mins with active management or by 60mins in physiological 3rd stage
Placenta not expulsed by this time probably won’t ever be

122
Q

What is danger with retained placenta?

A

Haemorrhage

123
Q

Associations of retained placenta? x7

A 
Maternal age >35 
Parity >5 
Preterm delivery 
Previous RP or uterine surgery
Induced labour
Placental weight
124
Q

Management of retained placenta

A

Avoid excessive cord traction
Check placenta is not in vagina
Palpate abdomen - if uterus is well contracted - placenta is probably separated but trapped by cervix - wait for cervix to relax and release it
If uterus is bulky - probably not separated - rub up contraction and give oxytocin (empty bladder as full bladder causes atony)

125
Q

How do you do manual removal of placenta

A 
IVI and cross match 
Anaesthesia - maybe epidural 
One hand on abdomen to stabilise uterus 
Other hand up through cervix and separate it will ulnar border of hand 
Then remove with cord traction 
Give antibiotics
126
Q

What is uterine inversion

A

Uterus inverts - can be completely revealed or partial (remains in vagina)

127
Q

How is it to undo uterine inversion

A

Depends on how long since inversion - if not long then may be able to revert by hand
If its been long, tight ring forms around neck of inversion = needs more complex procedure

128
Q

What do you do if uterine has been inverted for a while

A

Halothane anaesthesia to relax uterus
Hold uterus in vagina with one hand
Close labia to seal vagina shut
Infuse 2l of warm saline into vagina through tubing
Hydrostatic pressure of water should reduce uterus and inversion can be corrected

129
Q

After uterus inversion has been reversed

A

Give ergometrine to contract uterus and prevent recurrence

Prophylactic antibiotics

130
Q

What should you give all babies with signs of trauma at birth

A

Vitamin K 1mg IM

131
Q

When can moulding be bad?

A

If too extreme - bones overlap so much that they can’t be reduced - can cause intracranial damage

132
Q

What is cephalhaematoma?

A

Subperiostial swelling on fetal head - boundaries are therefore limited by individual bone margins
Fluctuant
Spontaneous absorption occurs but may take weeks and therefore cause or contribute to anaemia

133
Q

Caput succedaneum

A

Oedematous swelling of scalp - above cranial periosteum - therefore does not limit it’s extent
As a result of venous congestion and exuded serum due to pressure on cervix and lower segment during labour
Presenting part therefore has swelling over it

134
Q

What is a common birth injury to the mother? - incidence in PVD

A

Anal sphincter injury - 1%

135
Q

What is consequence of anal sphincter injury?

A

30% flatus incontinence
8% liquid stool incontinence
4% solid stool incontinence

136
Q

Risk factors for anal sphincter injury x7

A 
Baby >4kg
Persistent OP position 
Induced labour 
Epidural 
2nd stage >1hr 
Midline epiostomy 
Forceps
137
Q

Where are fistulas common

A

Developing countries, malnourished girls whose pelvis not developed and pressure causes necrosis fetal death and fistula formation

138
Q

Consequences of labial tear

A

Common
Heal quickly
Suturing rarely helpful

139
Q

First degree perineal tear

A

Superficial and do not damage muscle

Suture skin unless skin edges are well apposed to aid healing

140
Q

Second degree perineal tear

A

Lacerations involve perineal muscle - suture in same way as epiostomy

141
Q

Third degree perineal tear - three classifications

A

Damage involves anal sphincter muscle
3a - only external anal sphincter fibres 50% thickness
3c - both internal and external torn

142
Q

Fourth degree tear

A

Rectal mucosa involved

143
Q

Repair of fourth degree tear

A

Rectal mucosa sutured first - from tears apex to mucocutaneous junction
Muscle then interposed
Vaginal mucosa sutured
Internal anal sphincter and then external anal sphincter repaired
Finally repair skin

144
Q

Actions after repairing 3rd and 4th degree tears

A

Prophylaxis antibiotics
High fibre diet and lactulose for 10 days to avoid constipation
Pelvic floor exercise physiotherapy for 6-12 weeks
Consultant obstetrician follow up for 6-12 weeks

145
Q

Which tissues are incised with episiotomy? x5

A

Vaginal epithelium, perineal skin, bulbocavernosus muscle, superficial and deep transverse perineal muscles

146
Q

How is episiotomy performed?

A

Hold perineal skin away from presenting part of fetus
Infiltrate area to be cut with local anaesthetic
Cut mediolaterally towards ischial tuberosity - starting at midline 6 o’clock

147
Q

Repair of episiotomy

A

Vaginal mucosa first
Then perineal muscle
Then skin

148
Q

Problems with episiotomy x7

A

Bleeding (increase HIV spread from mother to baby)
Infection and breakdown
Haematoma formation
Pain (rectal diclofenac)
Superficial dyspareunia
Labia minora can be sutured too small and introitus left too small
If deep layers not sutured properly - introitus too round exposing bladder to coitus thrusts

149
Q

When is the puerperium

A

6 weeks following delivery

150
Q

Uterus changes in puerperium

A

1kg to 100g at delivery
Umbilicus post-delivery
Pelvic organ after 10 days
Afterpains are common as it contracts

151
Q

Cervix changes in puerperium

A

Becomes firm over 3 days
Internal os closes by 3 days
External os by 3 weeks

152
Q

Discharge in puerperium

A

Lochia is passed PV
It is endometrial slough, white cells and red cells
Red lochia for 1st 3 days
Then yellow then white over next 10 days until 6 weeks

153
Q

Breast changes in puerperium

A

Milk (instead of colostrum) starts at 3 days

Swollen and tender at 3-4 days

154
Q

What is puerperal pyrexia?

A

T > 38 in 14 days post delivery or miscarriage

155
Q

Signs of endometritis

A

Pyrexia
Lower abdominal pain
Offensive lochia
Tender uterus on bimanual examination

156
Q

What is puerperal psychosis

A

High suicidal drive (not just mild depression following birth) severe depression, mania, more rare = schizophrenic symptoms - delusions child is malformed

157
Q

Incidence of puerperal psychosis

A

1 in 500 births

158
Q

Presentation of puerperal psychosis time wise

A

7 days pp in 50%, by 3 months in 90%

159
Q

What is lactational amenorrhoea

A

Natures contraception
If breastfeeding delays return of ovulation
If

160
Q

When is first average menstruation in breastfeeding mother

A

28.4 weeks postpartum (range = 15-48)

161
Q

When is breastfeeding contraceptive efficacy reduced? x6

A

After 6 months, if not breastfeeding at night, if decrease breastfeeding, if periods return, if separation from baby, baby or mother becomes ill/stressed

162
Q

When can POP be started post-partum

A

Any time but if after 21 days need to use extra contraception for 2 days
Does not affect breast milk

163
Q

When can COC be started post-partum

A

At 3 weeks if not breastfeeding
Not recommended if breastfeeding until 6 months
Can be used from 6 weeks if no other method acceptable

164
Q

When can emergency contraception be used postpartum and what?

A

Progesterone methods can be used by all

Not needed 21 days postpartum

165
Q

Depot injections post-partum

A

Not recommended until 6 weeks in those breastfeeding

If bottle feeding then can start medroxyprogesterone acetate 5 days postpartum

166
Q

Progesterone implants post-partum

A

Insertion not recommended until 6 weeks in those breastfeeding
Implant at 21-28 days in those bottle feeding

167
Q

IUCD post partum

A

Either in first 48hr or after 4 weeks
Because of risk with uterine perforation at insertion
Progesterone device also at 4 weeks

Obstetrics (5 decks)

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