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Reproductive Medicine > Abnormal labour and Induction of labour > Flashcards

Abnormal labour and Induction of labour Flashcards

1
Q

What percentage of pregnancies are induced?

A

10-20%

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2
Q

What are obstetric indications for induction of labour?

A
  • Uteroplacental insufficiency
  • Prolonged pregnancy - 41-42 weeks
  • IUGR
  • Oligo/anhydramnios
  • Abnormal uterine/umbilical dopplers
  • Abnormal CTG
  • Severe pre-eclampsia/Eclampsia
  • Unexplained antepartum haemorrhage
  • Chorioamnionitis
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3
Q

What are medical indications for induction of labour?

A
  • Severe hypertension
  • Uncontrolled DM
  • Renal disease with deteriorating renal function
  • Malignancies
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4
Q

What is induction of labour?

A

An attempt to artificially instigate labour using medications +/- artificial rupture of the amniotic membranes (performing amniotomy)

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5
Q

How is cervical ripening assessed?

A

Bishops Scoring

  • Dilatation
  • Effacement
  • Position
  • Consistency
  • Station
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6
Q

What are absolute contraindications to induction of labour?

A
  • Abnormal lie
  • Known pelvic obstruction
  • Placenta praevia
  • Foetal distress
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7
Q

What is the Bishop’s score used to determine?

A

Gives a score on cervical change - higher the score the more progressive change there is, indicating that induction of pregnancy is likely to be successful and when an amniotomy is likely to be possible

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8
Q

What are the relative contraindications to induction of labour?

A
  • Previous C-section
  • Asthma
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9
Q

Why is previous C-section a relative contraindication to induction of labour?

A

Uterus has a scar which increases risk of dehiscence/rupture if labour is artificially induced. The risk of rupture is increased with the use of prostaglandins

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10
Q

Why is asthma a relative contraindication of induction of labour?

A

Prostaglandins can cause respiratory smooth muscle contraction

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11
Q

What medications are used in the induction of labour?

A
  • Prostaglandin analogues - Dinoprostone, Misoprostol
  • Oxytocin
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12
Q

What type of prostaglandin analogue is Dinoprostone?

A

Prostaglandin E2 analogue

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13
Q

What type of prostaglandin analogue is Misoprostol?

A

Prostaglandin E1 analgogue

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14
Q

What is the mechanism of action of prostaglandin analogues in induction of pregnancy?

A

Encourage cervical dilatation and effacement - ripening

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15
Q

What are adverse effects of prostaglandin analogues used for induction of labour?

A
  • Severe/hypertonic contractions
  • Nausea and vomiting
  • Bowel upset
  • Pyrexia
  • Hypotension
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16
Q

What needs to be regularly monitored when using prostaglandin analogues?

A

Foetal heart - CTG

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17
Q

What is the mechanism of action of oxytocin in the induction of labour?

A

Initiates uterine contraction by attaching to uterine oxytocin receptors, increasing the frequency and force of contractions

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18
Q

What type of drug is oxytocin?

A

Cyclic nonapeptide

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19
Q

How are prostaglandin anaolgues administered?

A

PV

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20
Q

How is oxytocin administed for induction of labour?

A

IV

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21
Q

When is amniotomy performed in induction of labour?

A

Once cervix has effaced an dilated - Bishops > 7

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22
Q

When is oxytocin given in induction of labour?

A

Often used following prostaglandin treatment, once amniotomy has been performed

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23
Q

What monitoring needs to be done whilst giving a women an oxytocin infusion for induction of labour?

A

CTG monitoring

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24
Q

What are risks of oxytocin use in induction of labour?

A
  • Uterine hypertonicity
  • Hypotension
  • Hyponatraemia
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25
Q

What does amniotomy cause release of?

A

Local prostaglandins - causes cervical ripening and myometrial contractions

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26
Q

Why is oxytocin often given at the time of amniotomy in induction of labour?

A

Decreases induction-delivery time, thereby decreasing both the foetal and maternal risk of sepsis

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27
Q

What are risks of trying to induce labour?

A
  • Prematurity
  • Drug side effects
  • C-section due to failed induction
  • Atonic PPH
  • Intrauterine infection with prolonged induction
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28
Q

Why should you monitor U+Es in someone being given oxytocin?

A

Has similar effects to ADH - look for dilutional hyponatraemia

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29
Q

How would you induce for intrauterine death at term?

A

25 mcg misoprostol every 2-4 hrs

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30
Q

When is labour augmentation required?

A

When contractions reduce frequency or strength in active labour even after spontaneous onset of labour

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31
Q

What needs to be determined before using medications to augment labour?

A

Woman needs to be assessed for signs of causes of lack of progress of labour e.g. obstruction due to malposition, which contractions could result in harm to foetus

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32
Q

What is used to augment labour?

A

IV oxytocin infusion

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33
Q

What are reasons for slow progress at stage 1 of labour?

A
  • Power - Inefficient uterine contraction
  • Passenger - Malposition/malpresentation, Large Baby
  • Passages - Inadequate pelvis
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34
Q

When is failure to progress in labour suspected?

A

If there is:

  • <2cm dilation in 4 h
  • Slowing progress in parous woman
35
Q

What is the term used to describe labour slow from onset?

A

1o dysfunctional labour

36
Q

What is the term used to describe previously adequate progress which has slowed in the first stage of labour?

A

2o arrest

37
Q

When would delay in 2nd stage of labour be suspected in a nulliparous woman?

A

If delivery is not imminent after 1 hr of active pushing

38
Q

When would delay in 2nd stage of labour be suspected in a multiparous woman?

A

If delivery is not imminent after 1 hr of activ pushing - requires obstetrician review and consideration for CS

39
Q

What would delay in the 2nd stage of labour always raise suspicion of in a multiparous woman?

A
  • Malposition
  • Disproportion
40
Q

What are the main reasons for failure of labour?

A

Powers, passages and passenger:

  • Powers - uterine inactivity
  • Passages - inadequate pelvies
  • Passanger - Large baby, malpresentation, malposition
41
Q

What is the difference between malposition and malpresentation?

A

Malpresentation referes to foetal position in the uterus, whereas malposition refers to the orientation of the foetal head (e.g. OA, LOA etc.)

42
Q

How would you monitor for foetal distress in labour?

A
  • Intermittent auscultation
  • CTG
  • Foetal blood sampling
43
Q

When would you consider advising against labour?

A
  • Obstruction to birth canal - Major placenta praevia, masses
  • Malpresentations - Transverse, shoulder, hand, ??breech
  • Medical conditions where labour would not be safe for woman
  • Specific previous labour complications - Previous uterine rupture
  • Fetal conditions
44
Q

What are the main complications that can occur in the 3rd stage of labour

A
  • Retained placenta
  • PPH
  • Obstetric shock
  • Inversion of the uterus
45
Q

What is a first degree perineal tear?

A

Injury to skin only

46
Q

What is a 2nd degree perineal tear?

A

Injury to the perineum involving perineal muscles

47
Q

What is a 3rd degree perineal tear?

A

Injury to perineum involving anal sphincter complex

48
Q

What is a grade 3a perineal tear?

A

Injury to perineum + <50% EAS thickness torn

49
Q

What is a grade 3b perineal tear?

A

Injury to perineum and >50% EAS torn

50
Q

What is a grade 3c perineal tear?

A

Injury to perineum and tear to IAS

51
Q

What is a 4th degree perineal tear?

A

Injury to perineum involving anal sphincter complex (EAS + IAS) and the anal/rectal epithelium

52
Q

What grade of tear is the following?

A

Grade 1

53
Q

What grade of perineal tear is the following?

A

Grade 2 - injury to perineal muscles

54
Q

What grade of perineal tear is the following?

A

Grade 3

55
Q

What grade of perineal tear is the following?

A

Grade 4

56
Q

What factors increase the risk of tears that involve the anal sphincters?

A
  • Forceps delivery
  • Nulliparity
  • Shoulder dystocia
  • 2nd stage > 1hr
  • Persistent OP postion
  • Midline episiotomy
  • Birth weight > 4kg
  • Epidural anaesthesia
  • Induction of labour
57
Q

When should episiotomy be considered?

A
  • Complicated vaginal delivery - breech, shoulder dystocia, forceps, ventouse
  • Extensive lower GI tract scarring - FGM, poorly healed 3rd/4th degree tears
  • Foetal distress
58
Q

What are the different types of episiotomy procedures?

A
  • Mediolateral episiotomy - most commonly used in UK
  • Midline episiotomy
59
Q

How is an episiotomy performed?

A
  • Epidural or regional block
  • 2 fingers between babies head and perineum
  • Scissors used to make sharp cut - 3-4cm long
60
Q

What are general complications of perineal trauma (including episiotomy)?

A
  • Bleeding
  • Haemorrhage
  • Pain
  • Infection
  • Scarring +/- potential disruption to anatomy
  • Dyspareunia
  • Fistula formation - very rare
61
Q

What should be done before repairing a perineal tear?

A

PR examination - ensure no trauma to anal sphincter

62
Q

What are the main indications for caesarian section?

A
  • Foetal compromise
  • Failure to progress in labour
  • Breech presentation
  • Repeat Caesarian section
63
Q

What are indications for category 1 (immediate) C-section?

A
  • Placental abruption with abnormal FHR/uterine irritability
  • Cord prolapse
  • Scar rupture
  • Prolonged bradycardia
  • Scalp pH < 7.2
64
Q

What are indications for category 2 (urgent) C-section?

A

Failure to progress with pathological CTG

65
Q

What are indications for category 3 (scheduled) C-section?

A
  • Severe pre-eclampsia
  • IUGR with poor foetal function tests
  • Failed induction of labour
66
Q

What are indications for a category 4 (elective) C-section?

A
  • Term singlton breech
  • Twin pregnancy with non-cephalic first twin
  • Maternal HIV
  • Primary genital herpes in 3rd trimester
  • Placenta praevia
67
Q

What intraoperative complications can occur in C-section procedures?

A
  • Uterine/uterocervical lacerations
  • Blood loss - Blood transfusion
  • Bladder laceration
  • Hysterectomy required
  • Bowel laceration
  • Ureteral injury
68
Q

What postoperative complications can occur following C-section?

A
  • Endometritis
  • Wound infection
  • Pulmonary atelectasis
  • VTE
  • UTI
69
Q

What risk factors can increase with risk of infection developing post C-section?

A
  • Preoperative remote infection
  • Chorioamionitis
  • Maternal severe systemic disease
  • Pre-eclampsia
  • High BMI
  • Nulliparity
  • Increased surgical blood loss
70
Q

What can C-section increase the risk of in subsequent pregnancies?

A
  • Uterine ruptue
  • Pleacenta praevia
  • Placenta accreta
  • Antepartum still birth
71
Q

What is preterm rupture of membranes?

A

DEfined as leakage of amniotic fluid in the abscence of uterine activity after 37 completed weeks of gestation

72
Q

What can cause prelabour rupture of membranes at term?

A
  • Unkown
  • Clinical/subclinical infection
  • Polyhydramnios
  • Multiple pregnancy
  • Malpresentations
73
Q

What might be symptoms of prelabour rupture of membranes at term?

A
  • Sudden gush of fluid leaking from the vagina
  • Recurrent dampness
  • Constant leaking
74
Q

What might you see on examination in someone with prelabour rupture of membranes at term?

A

May need speculum exam:

  • Fluid leaking from cervix on valsalva
  • Liquor pooling in upper vagina
75
Q

What are clinical features of chorioamionitis?

A
  • Foetal tachycardia
  • Maternal tachycardia
  • Maternal pyrexia
  • Raised leucocytes
  • Rising CRP
  • Irritable/tender uterus
76
Q

How would you manage prelabout rupture of membranes at term?

A

Immediate induction (recommended after 24 hrs of rupture) or expectant managment

77
Q

What are maternal causes of malpresentation?

A
  • Multiparity
  • Pelvic tumours
  • Congenital uterine abnormalities
  • Contracted pelvis
78
Q

What are foetal causes of malpresentation?

A
  • Prematurity
  • Multiple pregnancy
  • Intrauterine death
  • Macrosomia
  • Foetal abnormality
79
Q

What placental problems can cause malpresentation?

A
  • Placenta praevia
  • Polyhydramnios
  • Amniotic bands
80
Q

When should retained placenta be suspected?

A

If it is not delivered within 30 minutes of the baby in actively managed 3rd stage and in 1h in physiologically managed 3rd stage

81
Q

How would you manage retained placenta?

A
  • IV access, FBC and crossmatch
  • Give Syntometrine or oxytocin
  • Transfer to theatre if oxytocin not effective
82
Q

What is regarded as delay in the 1st stage of labour?

A

<2cm/hr dilatation in 4hrs in any woman OR slowing progress

83
Q

What Bishops score would indicate that a womans cervix is “ripe”?

A

>5

Reproductive Medicine (43 decks)

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