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Obstetrics > Labour > Flashcards

Labour Flashcards

1
Q

List 4 ways in which the fetal health / distress can be assessed during labour

A
  • Observation of the colour of liquor
  • Intermittent auscultation of the fetal heart by Pinard stethescope or hand-held Doppler
  • Cardiotocograph (CTG) i.e. continuous external monitoring
  • Fetal scalp blood sampling
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2
Q

In a normal labour, how frequently should the fetal HR be checked?

A

1st stage = every 15 minutes

2nd stage = every 5 minutes

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3
Q

What does CTG stand for?

A

Cardiotocograph

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4
Q

What is a normal fetal HR on CTG?

A

110-160bpm

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5
Q

List some maternal factors which might indicate the need for CTG rather than intermittent fetal HR auscultation.

A 
PROM
Obesity
Previous C-section
Pre-eclampsia
Induction of labour
Diabetes
Other maternal medical condition
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6
Q

List some fetal factors which might indicate the need for CTG rather than intermittent fetal HR auscultation.

A 
Multiple pregnancy
Breech presentation
Meconium stained liquor
IUGR
Abnormal Doppler artery velocities
Oligohydramnios
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7
Q

List some intrapartum factors which might indicate the need for CTG rather than intermittent fetal HR auscultation.

A 
Maternal pyrexia
Oxytocin augmentation
Epidural analgesia
Intrapartum haemorrhage
Abnormal HR on intermittent FHR auscultation
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8
Q

What is meant by a ‘reactive’ CTG trace?

A

2 or more ‘accelerations’ in 20 minutes of CTG trace

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9
Q

What is the normal range of baseline variability for fetal HR on CTG?

A

5 - 25bpm variability

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10
Q

What gestation is described as ‘term’?

A

37 - 42 weeks

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11
Q

What is the definition of labour?

A

The process by which the foetus, placenta and membranes are expelled through the birth canal

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12
Q

What is the first stage of labour?

A

Initiation of contractions until full dilatation. Divided into latent phase (up to 4cm) and active phase (from 4cm to full dilatation)

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13
Q

What is the second stage of labour?

A

Full dilatation to delivery of the baby

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14
Q

What is the third stage of labour?

A

Delivery of the placenta

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15
Q

For primiparous women, how quickly would you expect cervical dilatation to occur in the active part of the first stage of labour?

A

0.5cm per hour

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16
Q

What are the 3 ‘P’s which define progress of labour?

A

Power
Passenger
Passage

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17
Q

What is meant by the ‘presentation’ of the baby?

A

May be cephalic or breech i.e. which end of the baby is coming down first

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18
Q

What is meant by the ‘lie’ of the baby?

A

The orientation of the long axis of the baby relative to the long axis of the mother’s uterus…Ideally this is longitudinal, but may be oblique or transverse

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19
Q

What is meant by the ‘station’ of the baby?

A

The level of the baby’s head relative to the ischial spines. ‘0’ is when the head is at the level of the spines, while -3 means it is still in the pelvis and +3 means it has descended further than the level of the spines

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20
Q

What is meant by the ‘position’ of the baby, and what is the best position for it to be in for labour?

A

The orientation of the baby’s head relative to the mother. The best is the ‘left occiput anterior’ so that the baby’s occiput is facing forwards (towards pubic symphysis) and towards the mother’s left thigh

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21
Q

What is aorto-caval compression?

A

Lying flat (supine) during labour can cause compression of major blood vessels by the uterus which reduces cardiac output and causes hypotension and fetal distress

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22
Q

What is meant by ‘augmentation’ of contractions?

A

Artificially strengthening the contractions to make them more effective

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23
Q

Give some ways in which contractions may be augmented (naturally and artificially)

A 
Encouraging the mother to mobilise
Changing position e.g. left lateral
Ensure adequate analgesia
Rupturing the membranes
Administering Syntocin
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24
Q

What is meant by induction of labour?

A

Initiation of labour before spontaneous onset

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25
Q

What is the Bishop’s Score?

A

A score based on several conditions of the cervix which helps to make the decision whether an induction of labour would be successful.

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26
Q

Which 5 factors is the Bishop’s Score based on?

A 
Dilatation (cm)
Effacement (%)
Station
Cervical consistency
Cervical position
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27
Q

A Bishop’s score of ?? would indicate that induction of labour is likely to be successful?

A

Bishop’s Score 6 or more indicates favourable conditions for induction

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28
Q

List 3 methods of induction of labour

A

Natural induction i.e. ‘sweeping’
Prostaglandin gel
Amniotomy (breaking waters) ± oxytocin infusion

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29
Q

What is amniotic fluid embolism?

A

Amniotic fluid enters the maternal circulation and causes anaphylaxis, with acute onset SOB, hypotension, hypoxia and DIC. It is rare, but an important cause of maternal mortality. Treatment is supportive - admission to ITU is required.

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30
Q

What is cord prolapse?

A

An obstetric emergency where the umbilical cord moves below the presenting part of the baby usually during the rupture of membranes. Over 50% of cases occur when membranes are artificially ruptured.

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31
Q

What are the 2 key findings which lead to a diagnosis of cord prolapse?

A

Fetal bradycardia

Palpation of the cord on vaginal examination

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32
Q

There are different types of breech presentation…which is the most common?

A

‘Frank’ (or extended) breech i.e. where both legs are fully extended at the knees

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33
Q

What is the key management for a breech presentation?

A

External cephalic version (ECV) i.e. attempt to rotate the baby by abdominal palpation. Success rate about 50%.

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34
Q

What is the definition of preterm birth?

A

Happens after 24 but before 37 weeks gestation

35
Q

What are the 4 major mechanisms of preterm birth?

A

Maternal / fetal stress
Uterine infection / inflammation
Over-distension
Haemorrhage

36
Q

What are the two definitive investigations which can be used to assess a woman in preterm labour to predict her likelihood of having a preterm birth?

A

Measure cervical length (by transvaginal ultrasound scan)

Fetal fibronectin

37
Q

How can we manage a woman in preterm labour?

A 
Steroids
Tocolytic agents
Antibiotics
Cervical cerclage
In utero transfer
Delivery
38
Q

How do tocolytics help for a woman in preterm labour?

A

They buy time - They halt uterine contractions and can allow time e.g. for steroids to work, or for the woman to be transferred to a higher care centre. They give about an extra 48 hour window.

39
Q

Give 2 contraindications to tocolytics in preterm labour

A

Haemorrhage

Chorioamnionitis

40
Q

What does the mneumonic ‘Dr C Bravado’ mean and when is it used?

A

Used to assess a CTG:

Dr = Defined risk
C = Contractions
Br = Baseline rate
A = Accelerations
Va = Variability
D = Decellerations
O = Overall impression
41
Q

What is primary post partum haemorrhage?

A

Loss of >500mL of blood within 24 hours of delivery

42
Q

What is secondary post partum haemorrhage?

A

Loss of >500mL of blood after 24 hours but within 6 weeks of delivery

43
Q

What are the 4 ‘T’s of post partum haemorrhage causes?

A

Tone i.e. uterine atone
Trauma i.e. tears
Tissue i.e. retained placenta etc.
Thrombin i.e. clotting disorders

44
Q

What can cause secondary post partum haemorrhage?

A

Endometritis
Other gynaecological pathology
Gestational trophoblastic disease

45
Q

How might a uterine rupture present?

A
  • During labour
  • Constant abdominal pain
  • Vaginal bleeding
  • Ceasing of contractions
  • Fetal decellerations on CTG
46
Q

What orientation is the baby’s head in when it first becomes engaged? Why?

A

At this point it is in the transverse position as the transverse direction is the widest part of the pelvis at the pelvic inlet (about 13cm), so it allows the head to enter the inlet

47
Q

Describe the mechanisms of labour

A

1) Head engages with the pelvis, at which point it is in transverse position
2) Flexion of the head and descent through the pelvis
3) Once the head reaches the pelvis floor, it internally rotates 90 degrees so the head is now in antero-posterior position as this is the widest diameter of the pelvic outlet, and is no longer in line with the rest of the body
4) Crowning of the head occurs when extension starts and the head becomes visible. It no longer recedes back in between contractions.
5) Extension of the head for delivery
6) Restitution - the head externally rotates back again so it is once again in a transverse position and aligned with the rest of the body
7) Internal rotation of the shoulders so that they are lying in AP position (widest diameter of pelvic outlet)
8) Delivery of the anterior shoulder
9) Delivery of the posterior shoulder by lateral flexion

48
Q

What is a ‘show’?

A

Expulsion of the mucous plug from the cervix, and is often an early sign of labour

49
Q

What is effacement?

A

Shortening of the cervix and drawing up so that it is at the level of the uterus

50
Q

What is the risk of a physiological 3rd stage of labour?

A

Increased risk of PPH

51
Q

What is an ‘active’ 3rd stage?

A

An IM injection of syntometrin is given to encourage uterine contractions (Syntocinon only if the woman has high BP)

52
Q

What is the widest diameter of the pelvic outlet?

A

The anterio-posterior diameter

53
Q

Why does flexion of the head occur in labour?

A

It’s required because the smallest diameter of the head needs to be the presenting part. It occurs because the head meets resistance from the pelvic floor and so, with the downward pressure from the rest of the body, it flexes

54
Q

What orientation is the baby’s head in when it internally rotates? Why?

A

It becomes antero-posterior at this point because this aligns it with the widest diameter of the pelvic outlet (about 13cm)

55
Q

What are the 3 signs that the placenta has separated from the uterine wall?

A
  • Uterus moves up and becomes hard (like a cricket ball
  • Slight blood loss
  • Elongation of the cord
56
Q

Describe how you would manage the 3rd stage of labour (active management)

A
  • Check mother’s intentions for placenta
  • Give IM Syntometrin on delivery of the anterior shoulder
  • Observe for signs of separation
  • ‘Guard uterus’ but putting hand over pubic symphysis
  • Controlled cord traction to deliver the placenta, cord and membranes
  • Note the time of delivery
  • Estimate blood loss
  • Check perineal trauma / tears
57
Q

What is the ideal shape of a woman’s pelvis for labour?

A

Gynaecoid

58
Q

What are the 4 possible shapes for a female pelvis

A

Gynaecoid
Android
Platypelloid
Anthropoid

59
Q

How many vessels should be found on the placenta when inspecting it?

A

3 vessels (2 arteries, 1 vein)

60
Q

Describe how you would check the placenta following delivery

A
  • Check insertion of the cord
  • Check vessels (there should be 2 arteries and 1 vein)
  • Check there are 2 membranes and that they are intact
  • Observe the cotyledons and ensure they are complete
  • Observe for any signs of infection
  • Take cord gases if indicated
  • Safely dispose of human tissue
61
Q

Approximately what diameter is the suboccipitobregmatic diameter of the baby’s head?

A

9.5cm

62
Q

True / False: It is not possible for a brow presentation to deliver vaginally

A

True - The mental-vertical diameter is the presenting part in a brow presentation and this is 13.5cm which is too large to engage in the pelvis and so cannot deliver vaginally

63
Q

What features on a CTG are classified as normal (or ‘reassuring’)?

A

Fetal HR 100-160
Variability 5-25bpm
Decelerations: None or early decelerations only

64
Q

How might you classify a CTG?

A

Normal (or ‘reassuring’)
Non-reassuring
Abnormal

65
Q

What features on a CTG are classified as non-reassuring?

A

Fetal HR 161-180bpm
Variability less than 5bpm for 30-90mins
Decelerations (present on at least 50% of contractions):
- Late decelerations for up to 30mins
- Variable decelerations of under 60bpm which recover within 60secs, lasting for over 90mins
- Variable decelerations of over 60bpm or which don’t recover within 60sec, lasting for over 30mins

66
Q

What features on a CTG are classified as abnormal?

A

Fetal HR above 180bpm or below 100bpm
Variability less than 5bpm for over 90mins
Decelerations (present on at least 50% of contractions):
- Any bradycardia or prolonged deceleration lasting over 3mins
- Variable decelerations (as defined by ‘non-reassuring trace’) still present 30mins after conservative measures
- Late decelerations for over 30mins which don’t improve with conservative measures

67
Q

List some causes of foetal tachycardia as seen on CTG during labour

A 
Chorioamnionitis
Maternal pyrexia
Hypoxia
Prematurity
Maternal or fetal anaemia
68
Q

List some causes of reduced variability as seen on CTG

A

Baby is sleeping (up to 40 minutes only)
Drugs e.g. opiates
Prematurity
Hypoxia

69
Q

What is an ‘early deceleration’ as seen on CTG?

A

These are decelerations which start with a contraction and recover when the contraction ends. Due to compression of the fetal head during uterine contraction. Not concerning providing they recover at the end of the contraction.

70
Q

What is meant by ‘variable decelerations’ on CTG? What might this indicate?

A

Variable i.e. can occur at any time, not specifically with contractions. There is a sudden drop in foetal HR and a variable recovery time. Generally reflect cord compression.

71
Q

What is meant by ‘accelerations’ on a CTG?

A

Increase of foetal HR by 15bpm or more for 15 seconds or more. Accelerations are good.

72
Q

What is meant by ‘decelerations’ on a CTG?

A

Decrease of foetal HR by 15bpm or more for 15 seconds or more. Generally pathological.

73
Q

What do variable decelerations generally indicate?

A

Cord compression

74
Q

What is meant by ‘late decelerations’ on CTG? What might this indicate?

A

Drops in HR which do not recover after the end of a contraction. Late decelerations indicate foetal hypoxia.

75
Q

Define the different severities of perineal tears

A

1st degree = Minor damage to skin or vaginal epithelium
2nd degree = Involving perineal muscle
3rd degree = Involving anal sphincter
4th degree = Involving anal mucosa

76
Q

What are the steps in the management of shoulder dystocia?

A 
McRobert's manoeuvre
Suprapubic pressure
Episiotomy
Reposition onto all 4's
Woodscrew manoeuvre
Break clavicle
Zavanelli manoeuvre (emergency C-section)
77
Q

What is the McRobert’s manoeuvre?

A

First step in the management of shoulder dystocia. Mother’s legs are fully flexed and externally rotated so that the pubic symphysis is stretched and pelvic outlet widened.

78
Q

What is the Woodscrew manoeuvre?

A

Performed in shoulder dystocia if McRobert’s and episiotomy fails to deliver the baby. The anterior shoulder is rotated and the posterior shoulder delivered, with the aim of reducing the diameter of the stuck body.

79
Q

What is the Zavanelli manoeuvre?

A

Last resort in the management of shoulder dystocia. It’s an emergency C-section where the head is pushed back inside vaginal cavity and the baby is delivered via C-section.

80
Q

What is the management for PPH?

A

DRABCDE approach:

  • High flow oxygen
  • Position the woman flat
  • Monitor observations closely
  • Identify cause (likely to be uterine atony)
  • IV access with 2x wide bore cannula
  • Bloods: FBC, U+E, clotting, crossmatch 6 units
  • IV fluids with crystalloid
  • Blood transfusion to replace lost blood
  • Uterine massage
  • Bimanual compression
  • Syntometrine IV (or syntocinon if raised BP)
  • Syntocinon infusion over 4 hrs
  • IM carboprost
  • Misoprostol PR
  • Surgical intervention might be required to stop bleeding
81
Q

What drug can be given to oppose the action of oxytocin e.g. if uterine hyper stimulation occurs following induction?

A

Terbutaline - a beta agonist which relaxes the uterine muscle

82
Q

What is the management of placental abruption?

A

Depends on foetal and maternal compromise, plus gestation:

  • Manage maternal haemodynamic status and pain
  • If foetal distress, emergency Caesarian section
  • No fetal distress and baby at term, induction of labour (amniotomy)
  • No fetal distress and baby preterm, give mother steroids and monitor (may be discharged)
83
Q

What is fetal fibronectin and how is it used in detection of preterm birth?

A

It is a protein which binds to the fetal membranes. It is not normally present in vaginal secretions. Any disruption of the membrane interface will cause release of fibronectin and cause it to be present in secretions, so it is useful to detect premature labour. Good negative predictive value, but not diagnostic.

84
Q

What is PPROM?

A

Preterm pre-labour rupture of membranes

Obstetrics (5 decks)

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