Abnormal labour and post partum care

Question 1

what is uterine hyperstimulation and what is it caused by?

Answer 1

overcontractionn of the uterus, caused by prostaglandinn/oxytocinn inductionn

Question 2

what is usually needed if there is failure to start labour?

Answer 2

epidural, fetal monnitorinng, instrumental delivery, Csection

Question 3

what are some of the indications for induction of labour (IOL)?

Answer 3

Diabetes – before due date,
Post dates – term date + 7 days, Maternal health problem that necessitates planning of delivery e.g. treatment for DVT,
Fetal reasons – e.g. growth concerns, oligohydramnios, May also be seen for: social/maternal request/pelvic pain/’big’ babies.

Question 4

define IOL

Answer 4

Induction of labour is when an attempt is made to instigate labour artificially using medications and/or devices to “ripen cervix” followed usually by artificial rupture of membranes (performing an amniotomy)

Question 5

what is the Bishops score?

Answer 5

The Bishop’s score is used to clinically assess the cervix. The higher the score, the more progressive change there is in the cervix and indicates that induction is likely to be successful. (Dilation, Length of cervix (effacement), position, connsistency and station). Once the cervix is dilated and effaced, an amniotomy can be performed.

Question 6

what bishops score is considered favourable for amniotomy?

Answer 6

7 or more

Question 7

if the cervix is not dilated/effaced (low bishops score) then how is it helped to open?

Answer 7

giving prostaglandin pessaries and using a cook balloon

Question 8

what is an amniotomy?

Answer 8

artificial rupture of the fetal membranes (“waters”) usually using a sharp device e.g. amniohook

Question 9

onnce the amniotomy is performed what is given to help achieve adequate contractions? What is the aim time/number?

Answer 9

iv oxytocin, 4-5 contractions every 10 mins. (Also Ensure adequate pain relief amd hydration for the mother)

Question 10

what is the power, passages and passenger idea?

Answer 10

power = contraction, passage = cervix, passenger = baby, something could go wrong in each.

Question 11

what may cause innadequate progress?

Answer 11

Pelvic abnormality, Cephalopelvic disproportion (CPD), Malposition, Malpresentation, Inadequate uterine activity, Other reasons for obstruction (e.g. ovarian cyst or fibroid), causing fetal distress.

Question 12

how is progress in labour evaluated?

Answer 12

cervical effacement, cervical dilation, decent of the fetal head through the maternnal pelvic

Question 13

In the active first stage of labour suboptimal progress is defined as cervical dilatation:

Answer 13

less than 0.5cm per hour for primigravid women, less than 1cm per hour for parous women

Question 14

Power - Inadequate uterine activity, what is the basis behind this, what is used to help alleviate this?

Answer 14

If contractions are inadequate the fetal head will not descend and exert force on the cervix and the cervix will not dilate. It is possible to increase the strength and duration of the contractions by giving a synthetic IV oxytocin to the mother. It is important to exclude an obstructed labour in these circumstances as stimulation of an obstructed labour could result in a ruptured uterus.

Question 15

Passages and passenger - what issues may arise here?

Answer 15

CPD, Malpresentation and malposition

Question 16

what is CPD (Cephalopelvic disproportion)?

Answer 16

Genuine CPD is rare, Means the fetal head is in the correct position but is too large to negotiate the pelvis, In this case the babies head can become compressed which can cause caput and moulding.

Question 17

outline issues with malpresentation and malposition

Answer 17

Malpresentation: Women are advised not to deliver vaginally – especially not a first pregnancy.
Malposition: Common – causes ‘relative’ CPD because the head is in the wrong place, Ideally the occiput faces anteriorly = OA, BUT in this case it faces Occipito-posterior & Occipito-transverse.

Question 18

why can Uterine hyperstimulation be bad for the fetus?

Answer 18

fetal distress, due to innsufficient placental flow.

Question 19

how is fetal wellbeing in labour determined?

Answer 19

Intermittent auscultatoin of the fetal heart, cadriotocopraphy (CTG), fetal blood samplinng, fetal ECG.

Question 20

what features on CTG may show fetal distrss?

Answer 20

absence of accelerrations, presence of decellerations, decreased baseline activity, baseline tachy or bradycardia.

Question 21

when is fetal blood samplinng used?

Answer 21

when there is a suspicious or abnormal CTG

Question 22

what does fetal blood smapling do?

Answer 22

Provides a direct measurement from the baby: Measure pH and base excess, Blood pH can give a measure of likely hypoxia. pH > 7.25 = normal (Repeat in 60 mins unless CTG improves), pH 7.21 – 7.24 = borderline (Repeat in 30 mins), pH < 7.20 = abnormal – shows that the baby isn’t coping with the labour (Needs immediate delivery (within 30 mins))

Question 23

what does pH < 7.20 mean?

Answer 23

abnormal – shows that the baby isn’t coping with the labour (Needs immediate delivery (within 30 mins))

Question 24

Which situations should you advise not to labour?

Answer 24

Obstruction to birth canal: Major placenta praevia, masses, Malpresentations: Transverse, shoulder, hand, breech – usually advised against, Medical conditions where labour would not be safe for women, Specific previous labour complications e.g. previous uterine rupture, Fetal conditions

Question 25

postnatal problems - post partum haemorrhage

Answer 25

Primary = blood loss of >500ml within 24hrs of delivery. Causes: Uterine atony, Local causes such traumatic tear, Retained tissue/placenta, Coagulopathy, 4t's.
Secondary = blood loss >500ml from 24hrs port partum to 6 weeks

Question 26

what are the 4t’s of post-partum haemorrhage?

Answer 26

Tone, Trauma, Tissue, Thrombin

Question 27

postnatal problems - thromboembolic disease

Answer 27

Hypercoagulable state, Pregnant woman 6 x more likely to develop thromboembolism, Can be relatively asymptomatic compared to non-pregnant counterparts, Important to have a high index of suspicion, D-dimer unreliable. Suspicious = women with unilateral leg swelling and/or pain and women complaining of SOB or chest pain. Always have a high index of suspicion for VTE in pregnant or postnatal women. WARFARIN IS TERATOGENIC , so use low weight molecular heparin.

Question 28

postnatal problems - maternal sepsis

Answer 28

Post-partum sepsis can present atypically, Any suspect of sepsis – prompt IV antibiotic administration, Full septic screen – blood cultures, LVS, MSSU, wound swabs, Antipyretic measures, IV fluids.

Question 29

postnatal problems - psychiatric problems

Answer 29

Postnatal Depression

Puerperal Psychosis

Question 30

postnatal problems - preeclampsia

Answer 30

Most eclamptic seizures occur in the postnatal period, Pre-eclampsia can develop postnatally or may worsen several days following delivery