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3A > Obstetrics - Labour > Flashcards

Obstetrics - Labour Flashcards

1
Q

Normal labour definition and characteristics

A

Onset of painful and regular contractions

  1. Contractions
  2. Cervical show - Shedding of mucus plug
  3. ROM
  4. Shortening and dilation of cervix
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2
Q

Hormones in labour

A

Prostaglandins

  • Decrease cervical resistance
  • Stimulate release of oxytocin from posterior pituitary

Oxytocin - Stimulates uterine contraction

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3
Q

Monitoring in labour

A
  1. Foetal HR - Continuously
  2. Uterine contractions - 30 minutes
  3. Maternal HR - 1 hour
  4. Maternal BP - 4 hours
  5. Maternal temperature - 4 hours
  6. Urine - 4 hours
  7. PV - 4 hours
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4
Q

Diagnosis of labour

A

Regular painful contractions

Cervical dilation and effacement

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5
Q

Stage 1 labour

A

Onset of true labour to full dilation of cervix

10-16 hours

Latent - 0-3cm - 6 hours

Active - 3-10cm

  • 2cm / hour if multiparous
  • 1cm / hour if nulliparous
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6
Q

Abnormal stage 1 causes

A

Inefficient uterine contractions - Most common in nulliparous

Cephalopelvic disproportion - Most common in multiparous

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7
Q

Management of inefficient uterine contractions

A

Augment labour

  • Amniotomy
  • Syntocinon
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8
Q

Cephalopelvic disproportion causes, presentation and management

A

Causes

  • Malposition
  • Malpresentation
  • Inadequate pelvis
  • May lead to secondary arrest

Signs - Caput and moulding

Management - CS

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9
Q

Stage 2 labour

A

Full dilation of cervix to delivery of baby

Passive - No pushing

Active - Pushing

  • 20 minutes if multiparous
  • 40 minutes if nulliparous

Transient foetal bradycardia!

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10
Q

Abnormal stage 2 diagnosis and management

A

Multiparous > 1 hour
Nulliparous > 2 hours

Management

  • Ventouse
  • Forceps
  • CS
  • Episiotomy
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11
Q

Stage 3 labour

A

Delivery of foetus to delivery of placenta

15 minutes

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12
Q

Stage 3 labour management

A

Physiological - Maternal effort alone

  • No synometrine or syntocinon
  • Cord allowed to stop pulsating before clamping and cutting

Active - Decreases risk of PPH

  • IM synometrine or syntocinon
  • Clamping and cutting of cord
  • Controlled cord traction - Push down suprapubically to prevent uterine inversion
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13
Q

Presentation

A

Part of the foetus occupying the lower segment

90% vertex

Breech
Cephalic

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14
Q

Presenting part

A

Lowest palpable part of foetus

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15
Q

Position

A

Where the head is in the outlet

Occiput

OA
OP
OT

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16
Q

Attitude

A

Degree of head flexion

Brow
Vertex
Face

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17
Q

Lie

A

Longitudinal axis of foetus

Longitudinal
Oblique
Transverse

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18
Q

Engagement

A

Widest part of the presenting part (usually head) has passed through the widest part of the pelvic inlet

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19
Q

Station

A

How far in the pelvis the baby’s head is

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20
Q

Movements in stage 2 labour

A
  1. Engage in OT
  2. Descent in flexion
  3. Internal rotation to OA
  4. Descent in OA
  5. Crowning
  6. Extension to deliver
  7. Internal rotation of shoulders to AP
  8. Restitution of head - In line with shoulders
  9. Lateral flexion of shoulder to deliver
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21
Q

Induction of labour indications

A

BISHOP SCORE < 5

Maternal

  • Post-date > 12 days
  • Diabetes > 38 weeks
  • Pre-eclampsia

Foetal

  • IUGR
  • Pre-labour preterm ROM

Rhesus incompatibility

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22
Q

Bishop score

A

Spontaneous > 9
Requires induction < 5

Cervical position 
Cervical consistency 
Cervical effacement 
Cervical dilation 
Foetal station
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23
Q

Induction of labour methods

A

Prostaglandins - E2

  • Best for nulliparous
  • Inserted into post-vaginal fornix

Amniotomy + Oxytocin

  • Amniotic hook - Risk of chorioamnitis
  • No response on 2 hours - Oxytocin

Cervical sweep - Painful!
- Finger inserted through cervix between membranes and uterus

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24
Q

Induction of labour contraindications

A

Maternal - Something in the way?

  • Vasa previa
  • Cord prolapse
  • Placenta previa
  • Obstruction - Pelvic mass
  • Premature
  • Previous CS

Foetal - Distress!

  • Abnormal lie
  • Malpresentation
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25
Q

Induction of labour complications

A

Slow labour
Fast labour
PPH
Infection

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26
Q

Preterm pre-labour ROM

A

2% pregnancies
Associated with 40% preterm deliveries

ROM < 37 weeks
No contractions

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27
Q

PPROM complications

A

Foetal

  • Prematurity
  • Infection
  • RDS

Maternal - Chorioamnitis

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28
Q

PPROM investigations and management

A

Admit and monitor!

Sterile speculum exam
USS - Assess foetal presentation
CTG - Assess foetal state

Infection swab
Oral erythromycin - 10 days

Dexamethasone - Reduce risk of RDS

Delivery at 34-36 weeks

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29
Q

Prolonger labour causes

A

The Ps!

Power - Nulliparous ladies?

  • Insufficient uterine contraction
  • Augmentation - Amniotomy + Oxytocin

Passenger

  • Malpresentation
  • Abnormal lie

Passage - CPD

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30
Q

Prolonged labour diagnosis

A

1st stage
< 2cm / 4 hours

2nd stage
Nulliparous > 2 hours
Multiparous > 1 hour

31
Q

Premature labour definition and RFs

A

24-37 weeks

RFs

  • Smoking
  • Previous prem
  • Maternal disease
  • Maternal age
32
Q

Premature labour aetiology

A

THE CASTLE!

Too much inside the castle

  • Polyhydramnios
  • Multiple pregnancy

Defendants flee

  • IUGR
  • Pre-eclampsia
  • Maternal disease

Wall breach

  • Cervix - CIN
  • Uterine abnormality

Enemy invasion - Infection

33
Q

Premature labour prevention

A

Cervical cerclage - Sutures
Progesterone - From early pregnancy
Foetal reduction @ 10-14 weeks
Manage maternal disease

34
Q

Premature labour investigations

A

Assess likelihood of delivery

  • Foetal fibronectin
  • Transvaginal sonography

Assess foetal state - CTG

Swab for infection

35
Q

Premature labour management

A

Steroids - Allow lung maturity - Reduce risk of RDS

Tocolytics - Nifedipine - Give the steroids time to work

Magnesium sulphate - Neuroprotection @ 24-34 weeks

36
Q

Premature labour delivery

A

Vaginal if possible
May require CS - Abnormal lie

Delayed cord clamping - 45 seconds

37
Q

Premature ROM

A

Term baby
ROM
No contractions

38
Q

Premature ROM aetiology

A

“I-I-I… Me waters have broken but I’m not having contractions!”

Idiopathic
Infection
Incompetency - Cervical

39
Q

Premature ROM management

A

Antibiotics

Wait 24 hours

Induce labour

40
Q

Forceps delivery indications

A

Prolonged 2nd stage
Foetal distress
Abnormal lie
Malpresentation

Prophylactic

  • Reduce maternal exhaustion
  • Cardiac disease
41
Q

Forceps delivery prerequisites

A

FORCEPS!

Fully dilated 
OA 
Ruptured membranes 
Cephalic 
Empty bladder 
Pain relief 
Size - Baby/pelvis ratio
42
Q

CTG monitoring

A

Baseline HR
Variability
Accelerations
Decelerations

43
Q

CTG findings and management

A

1 non-reassuring = Non-reassuring

  • Left lateral position
  • Fluids
  • Observe

2 non-reassuring or 1 abnormal = Abnormal and test
- Foetal blood sample

> 2 abnormal or brady < 100 for 3 minutes = Abnormal and treat
- Category 1 CS

44
Q

CTG reporting

A

DR C BraVADO

DR - Define Risk 
C - Contractions / 10 minutes 
Bra - Baseline rate / 10 minutes 
V - Variability
A - Accelerations - Abrupt increase for > 15 seconds 
D - Decelerations 
O - Overall impression
45
Q

CTG variability

A

Variation from one beat to the next
Normal > 5
Non-reassuring < 5 for 40-90 minutes
Abnormal < 5 for 90 minutes

Causes

  • Foetal sleeping
  • Foetal acidosis - With late decelerations
  • Foetal tachycardia
  • Drugs
  • Prematurity
  • CHD
46
Q

CTG decelerations

A

Normal - Early
- In line with uterine contractions

Non-reassuring - Variable

  • No relationship to uterine contractions
  • Cord compression

Abnormal - Late

  • Begin at peak of uterine contraction
  • Caused by insufficient blood flow to uterus and placenta
  • Maternal hypotension
  • Pre-eclampsia
  • Uterine hyperstimulation
47
Q

CTG baseline rate

A

Normal - 110-160

Non-reassuring

  • 100-110
  • 160-180

Abnormal < 100 or > 180

Bradycardia causes

  • Increased foetal vagal tone
  • Maternal BB use

Tachycardia causes

  • Maternal pyrexia
  • Chorioamnitis
  • Hypoxia
  • Prematurity
48
Q

Foetal distress aetiology

A

Hypoxia of the foetus

Prolonged labour
APH
Cord prolapse
Oxytocin use - Too many contractions - Hypoxia

49
Q

Foetal distress diagnosis

A

CTG anomaly - Decelerations / bradycardia

Foetal blood pH < 7.2

Meconium stained liquor

50
Q

Foetal distress management

A

Conservative

  • Stop contractions - Terbutaline
  • Left lateral position
  • Oxygen
  • Fluids

Foetal blood sample - Scalp?
pH < 7.2 - Emergency CS
pH > 7.2 - Observe

Brady > 3 minutes - Emergency CS

51
Q

Cord prolapse aetiology

A

Artificial ROM
Premature labour

Multiparity
Multiple pregnancy
Polyhydramnios

Abnormal presentation - Breech?
Placenta previa

52
Q

Cord prolapse presentation

A

Cord descends ahead of presenting part

Palpable or visible O/E
Foetal distress on CTG - Variable decelerations

53
Q

Cord prolapse management

A

Trendelenburg - All fours
Push foetus back up and hold
Tocolytics - Nifedipine
Emergency CS

54
Q

Cord prolapse complications

A

Cord spasm
Foetal asphyxiation
Brain damage - Death

55
Q

Uterine rupture aetiology

A

High pressure - Multiple pregnancy

Low resistance

  • VBACS
  • Previous uterine surgery
56
Q

Uterine rupture presentation

A

Cessation of contractions

PV bleeding
Abdo pain
Maternal shock

57
Q

Uterine rupture management

A

ABC
Fluids

CS then…

  • Surgical repair
  • Hysterectomy
58
Q

Uterine rupture complications

A

Maternal death

Foetal hypoxia

59
Q

Post-partum haemorrhage definition

A

Vaginal blood loss > 500ml
CS blood loss > 1L

Primary < 24 hours
- Uterine atony

Secondary - 24 hours - 2 weeks
- Retained placental tissue

60
Q

PPH causes

A

TTTTTTTTTTT

Tone

  • Large uterus
  • Prolonged labour
  • Multiparous
  • Fibroids

Tissue - Retained placenta

Trauma

  • Shoulder dystocia
  • Macrosomia
  • CPD
  • Ventouse

Thrombin - Blood disorders

61
Q

PPH management

A 
ABC
Fluids 
IV access 
FBC
Cross match

IV syntocinon
IV ergometrine - CI in HTN
IM carboprost into myometrium - CI in asthma
Abx if caused by endometriosis

Remove retained placenta

Balloon tamponade
B-lynch suture
Uterine artery ligation 
Hysterectomy 
ERCP
62
Q

Shoulder dystocia

A

Impaction of anterior foetal shoulder on maternal pubic symphysis

RFs

  • Macrosomia
  • Maternal DM
  • Maternal obesity
  • Prolonged labour
  • Previous
  • CPD
63
Q

Shoulder dystocia complications

A

Maternal

  • PPH
  • Tear
  • Psychological

Foetal

  • Hypoxia
  • Clavicle fracture
  • Death
64
Q

Breech presentation types

A

Frank - Buttocks first

Footling - Feet first

65
Q

Breech RFs

A 
Premature
Foetal anomaly 
Multipregnancy 
Polyhydramnios 
Uterine abnormalities
66
Q

Breech management

A

< 36 weeks - Leave

> 36 weeks

  • ECV - Sensitising event
  • Tocolytics - Nifedipine
  • CS @ 39 weeks
  • Can deliver vaginally - On all fours
67
Q

Breech complications

A

Cord prolapse
PPH

Foetal

  • Clavicle fracture
  • Brachial plexus palsy
  • DDH
68
Q

ECV contraindications

A

Abnormal CTG
Multiple pregnancy

APH in last 7 days
Major uterine anomaly
Ruptured membranes

CS required

69
Q

Caesarean section indications

A

Indications

Maternal

  • Eclampsia or severe pre-eclampsia
  • APH - Previa, accreta, abruption, previa
  • Previous CS - Classical scar
  • Infection

Foetal

  • Distress
  • Cord prolapse
  • Malpresentation
  • IUGR
  • Twin
70
Q

CS risks

A

Maternal

  • Bladder damage
  • Ureter damage
  • Haemorrhage
  • Infection
  • Death

Later pregnancies

  • Need CS
  • Accreta
  • Uterine rupture

Foetal

  • RDS
  • Injury
71
Q

Vaginal birth after CS contraindications

A

Classical CS scar
> 2 CS
Previous uterine rupture

72
Q

VBAC risks

A

Uterine rupture

Need for emergency CS

73
Q

VBAC positive predictors

A

< 2 years since last pregnancy
Low age
Low BMI
Previous successful vaginal delivery

3A (31 decks)

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