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Y4 GOSH obs CCs > Abnormal labour > Flashcards

Abnormal labour Flashcards

1
Q

What is PPROM (as opposed to PROM) and how is it diagnosed?

A

-Premature pre-labour rupture of membranes ie <37 weeks
DIAGNOSIS
-Pooling of amniotic fluid seen on sterile speculum
–NB do not perform vaginal examination due to infection risk
-AMNISURE= placental alpha-microglobulin-1 test

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2
Q

What is the probability of spontaneous labour in PPROM vs SROM at term?

A

PPROM = 80% within 7 days
SROM at term = 90% within 48h

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3
Q

How should PPROM be managed?

A

Aim is to bide time to delay delivery
-Prophylactic steroids to help with foetal lung maturity (betamethasone 12mg IM, 2 doses 24h apart)
-Antibiotics (erythromycin 250mg QDS for 10 days)
-Intrapartum antibiotic prophylaxis (IAP) should be given during delivery (IM 1.5g Ben-pen)
-Induce labour:
–around 34w if signs of infection
–around 37w if no signs
unless maternal / foetal distress implied

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4
Q

What are the complications of a PPROM before foetal viability?

A

Absence of amniotic fluid causes the following problems:
-Pulmonary hypoplasie due to reduced ability to ‘practice’ breathing
-Infection risk
-Limb problems due to inability to move
-GI problems - normally foetus ingests fluid and excretes it to keep the oesophagus patent and kidneys functioning

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5
Q

How is breech presentation defined?

A

-Foetal position in utero oriented so the buttocks are delivered first
-Can be:
–Frank / extended (65%)
–Complete / flexed (10%)
–Incomplete / footling (25%) (pre-term + highest risk)

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6
Q

How should a breech presentation be managed?

A

1.External cephalic version (ECV)
2. C-section (reduced morbidity and mortality for breeched babies compared to VD)
3. Planned vaginal delivery
(Moxibustion = acupuncture alternative)

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7
Q

What risk factors are there for breech presentation?

A

-Uterine malformations
-Fibroids
-Placenta praevia
-Polyhydramnios / oligohydramnios
-Foetal abnormality
-Prematurity

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8
Q

What risks are associated with breech presentation?

A

-Cord prolapse (position creates a less effective ‘plug’ on cervix)
-Difficulty delivering head
-Foetal hypoxia
-Increased foetal morbidity and mortality

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9
Q

What does ECV involve?

A

-Applying gentle pressure to the abdomen to turn the foetus
-Done at 36-37 weeks (if <36 weeks most will turn spontaneously)
-Tocolytics given to relax uterine muscles, allowing movement
-CTG monitoring pre- and post-procedure
-Success rate = 50%, 5% chance of moving again once successfully rotated

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10
Q

What risks are associated with ECV?

A

-Foetal distress
-Cord entanglement
-Transient foetal bradycardia
-Pain
-Foeto-maternal haemorrhage (give Anti-D in Rh- patients)
-Placental abruption

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11
Q

What are some contra-indications for ECV in breech presentations?

A

ABSOLUTE
-Placenta praevia
-Uterine malformations
-Ruptured membranes
-Abnormal CTG
-Multiple pregnancies
RELATIVE
-Previous CS
-Active labour
-Pre-eclampsia
-Oligohydramnios
-Foetal abnormalities
-Hyperextension of foetal head
-Maternal cardiac disease

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12
Q

What is the main factor in determining pregnancy outcome in twins / higher order pregnancies?

A

-Chorionicity
= whether twins share a placenta or not

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13
Q

What are the 4 types of chorionicity / amnioticity and what do they mean?

A

Dichorionic / Diamniotic = 2 placentas + 2 sacs (DCDA)
Monochorionic / Diamniotic = 1 placenta + 2 sacs (MCDA)
Monochorionic / Monoamniotic = 1 placenta + 1 sac (MCMA)
Conjoined twins

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14
Q

When are the different cleavage times for pregnancies of different chorionicities?

A

DCDA = days 1-3
MCDA = days 4-8
MCMA = days 8-13
Conjoined = days 13-15
NB all dizygotic twins are DCDA, monozygotic twins can be any

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15
Q

What do T and lamda signs denote on USS of twin pregnancies?

A

-Lamda sign = DCDA
-T = MCDA

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16
Q

What maternal complications does a multiple pregnancy carry?

A

-Hyperemesis gravidarum
-Anaemia
-GDM + G-HTN
-Placenta praevia
-Miscarriage
-Preterm labour and delivery
-Pre-eclampsia
-Antepartum haemorrhage
-Postpartum haemorrhage
-Postnatal depression

17
Q

What foetal complications does a multiple pregnancy carry?

A

-Polyhydramnios
-Prematurity
-Malpresentation
-Cord prolapse
-Placental abruption
-Chromosomal / congenital abnormalities (2-3 times higher for monozygotic twins)
-IUGR
-Intrauterine death

18
Q

What is twin-twin transfusion syndrome?

A

-Occurs in monochorionic pregnancies
-One foetus dominates over the other, creating an imbalance in placental blood flow to each foetus
-Donor = smaller, fails to thrive, higher risk of intrauterine death
-Recipient = fluid overload, heart failure, more risks postnatally, polyhydramnios, cardiac hypertrophy
-Trocar procedure divides blood vessels to manage this

19
Q

What additional antenatal care is needed for multiple pregnancies?

A

-Higher dose folic acid (5mg)
-Aspirin 75mg
-Detailed anatomy and cardiac scans
-Regular growth scans (4-weekly if DCDA, 2-weekly if MC)
-Regular BP and urine checks (pre-eclampsia)
-OGTT at 28 weeks

20
Q

When and how should twins be delivered?

A

-DCDA = 37-38 weeks
-MCDA = 36 weeks
-MCMA = 32-34 weeks by CS
-If presenting twin is cephalic –> vaginal delivery
-If presenting twin is breech / transverse –> CS

21
Q

How is delayed labour diagnosed (1st stage)?

A

Primigravida = dilatation of <2cm in 4h
Multigravida = dilatation of <2cm in 4h or slowing of progress

22
Q

What are the 3Ps that influence progress in labour?

A

POWER - uterine contraction
PASSENGER - foetal position, foetal size
PASSAGE - parity, pelvis

23
Q

How is slow progress managed in the 1st stage of labour?

A

-ARM
-Syntocinon infusion
-C-section if all else fails

24
Q

What does the partogram show?

A

A pictorial record of labour, showing:
-Cervical dilatation and descent of head
-Frequency of contractions
-Foetal HR
-Colour of liquor
-Maternal obs
-Any drugs / fluids given

25
Q

When is instrumental delivery indicated?

A

-Slow progress in 2nd stage of labour
-Maternal exhaustion
-To avoid raising ICP
-To avoid raising BP
-Presumed foetal compromise

26
Q

When can instrumental delivery be considered?

A

-Once fully dilated
-Membranes must be ruptured
-Cephalic presentation
-Engaged part must not be abdominally palpable

27
Q

What are the different methods of instruments used in assisted vaginal delivery?

A

-Vacuum extraction / Ventouse
–Baby must be in correct position, takes 3-4 contractions, difficult to get a good seal
–Risk of cephalohaematoma
-Traction forceps
–Baby must be in correct position, takes 1-2 contractions
–Risk of facial nerve palsy, facial paralysis, bruising
-Rotational forceps
–Risks as above

28
Q

What maternal risks are associated with instrumental delivery?

A

-Postpartum haemorrhage
-Pain
-Perineal trauma / need for episiotomy
–Anal sphincter tears
-Incontinence
-Psychological distress
-Obturator or femoral nerve injury

29
Q

What is shoulder dystocia and what risks are associated with it?

A

-Occurs when anterior shoulder becomes stuck behind the pubic bone during vaginal delivery (once head is out)
RISKS
-Postpartum haemorrhage
-Perineal tears
Foetus:
-Hypoxia
-Brachial plexus injury
-Intracranial haemorrhage
-Cervical spine injury
-Death

30
Q

What risk factors make shoulder dystocia more likely?

A

-Hx of shoulder dystocia
-Lack of progress in 1st/2nd stage of labour
-Foetal macrosomia
-High maternal BMI
-Diabetes
-Prolonged labour

31
Q

What management options are there to correct shoulder dystocia?

A

PALE SISTER (order of interventions)
Prepare
Assistance
Legs (McRoberts)
Episiotomy

Suprapubic pressure
Internal Rotation
Screw (reverse Wood’s)
Try recovering posterior arm first
Extreme measures eg break pubic bone, CS
Repair + record

-McRobert’s manoeuvre = flex and externally rotate hips to stretch symphysis and open pelvic outlet

32
Q

What are the 2 types of C-section?

A

-Lower segment (99%)
-Classic (longitudinal incision in upper segment of uterus)

33
Q

What indications are there for a CS?

A

-Cephalopelvic disproportion (CPD)
-Placenta praevia grades 3-4
-Pre-eclampsia
-Post-maturity
-IUGR
-Foetal distress in labour / prolapsed cord
-Failure to progress in labour
-Malpresentations
-Placental abruption (but if IUD then deliver vaginally)
-Vaginal infection eg active herpes
-Cervical cancer

34
Q

What risks does CS pose to the mother?

A

SERIOUS
-Emergency hysterectomy
-Need for further surgery / ICU admission
-VTE
-Bladder / ureteric injury
-Death (v rare)
FREQUENT
-Persistent wound / abdominal discomfort
-Increased risk of future CSs when VBAC admitted
-Haemorrhage
-Infection

35
Q

What risks does CS pose for future pregnancies?

A

-Increased risk of uterine rupture
-Increased risk of antepartum stillbirth
-Increased risk of placenta praevia and accreta

36
Q

What is a transverse lie?

A

-Back of foetus is across the opening of the cervix

37
Q

How long do you have before hypoxic injury occurs in shoulder dystocia?

A

-5 mins

Y4 GOSH obs CCs (18 decks)

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