Abnormal Labour Flashcards
(36 cards)
What is abnormal labour?
Too early - preterm birth
Too late - IOL
Too painful - requires anaesthetic input
Too long - failure to progress
Fetal distress:
• Hypoxia
• Sepsis
If it requires intervention -
operative birth
Types of analgesia available during labour?
Support
Paracetamol
Massage / relaxation techniques
Inhalational gas (entonox), AKA laughing gas
TENS
Water immersion
IM opiate analgesia, e.g: morphine
IV Remifentanil PCA - this is a very short-acting but powerful opiate that can be given in bursts whenever the woman has a contraction; they must be monitored, as it is an opiate
Regional anaesthesia
NOTE - these can be used in a stepwise fashion
Efficacy of epidural anaesthesia?
Complete pain relief in 95% of people
It does not impair uterine activity
Drugs delivered in epidural anaesthesia?
Levobupivacaine +/- opiate
Issues assoc. with epidural analgesia?
May inhibit progress during stage 2
May increase risk of requiring instrumental delivery
Complications of epidural analgesia?
Hypotension (20%)
Dural puncture (1%) - patients have a headache and back pain
Atonic bladder (40%) - if the patient is not spontaneously urinating, place a urinary catheter to prevent urinary retention
Methods of assessing progress in labour, to determine if their is a failure to progress?
- Cervical dilatation
2, Descent of presenting part
NOTE - for the head, this is in relation to the ischial spines
- Signs of obstruction
When is their a failure to progress?
Suspected delay (stage 1):
• Nulliparous - <2cm dilation in 4 hours
• Parous - <2cm dilation in 4 hours OR slowing in progress
NOTE - very concerning if multiparous woman fails to progress
3 Ps for causes of failure to progress?
Power - inadequate contractions, in either frequency or strength
Passage:
• Short stature - this is not a barrier in itself, as the pelvis may be satisfactory; an FH of normal births from a short mother is reassuring
• Trauma - pelvis must be very deformed to interfere
• Shape
Passenger:
• Big baby
• Malposition - results in relative cephalo-pelvic disproportion
What are the various attitudes of the passenger?
Well flexed (9.5cm) - this is the NORMAL attitude
Less well-flexed (11.5cm)
Extended, i.e: brow presentation (13cm)
Hyperextended, i.e: face presentation (9.5cm)
What is a partogram?
Graphic representation of the progress of labour; it is commenced as soon as the female enters the labour ward
It can be used to ID and manage failure to progress
Recordings made on the partogram?
Foetal heart
Amniotic fluid
Cervical dilatation
Descent
Contractions
Obstruction (moulding)
Maternal observations
What should be done in the following case where there is failure to progress?
ADD IMAGE
Attempt to mobilise her (movement helps to change pelvic positions)
If this does not help, an oxytocic drug could be added to her drip
What should be done in the following case where there is failure to progress?
ADD IMAGE
This patient has had oxytocin but it has not helped.
Concerned about this patient failing to progress, as she has had children before and the midwife has expressed concerns of the baby being too large
She requires a c/s, otherwise she may suffer uterine rupture
Methods of identifying foetal distress?
Intrapartum foetal assessment which can involve the following
Doppler auscultation of the foetal heart (used for normal pregnancies):
• Stage 1 - during and after a contraction, as well as every 15 minutes
• Stage 2 - at least every 5 minutes, during and after a contraction, for 1 whole minute; check the maternal pulse at least every 15 minutes
Electronic foetal monitoring with a cardiotocograph (CTG)
Colour of the amniotic fluid:
• Clear - normal
• Meconium-stained - indicates either a mature baby that has opened its bowel, e.g: 40 weeks, OR foetal distress
• No liquor - concerned as this can indicate a small baby
Risk factors for foetal hypoxia?
- Small foetus
- Preterm / post-dates
- Antepartum haemorrhage
- Hypertension / pre-eclampsia
- Diabetes
- Meconium
- Epidural analgesia
- VBAC (vaginal birth after caesarian)
- PROM >24 hrs)
- Sepsis (temperature >38 degrees C)
- Induction / augmentation of labour
If any of these risk factors are present, continuous monitoring of the foetal heart is required
Aetiology of acute foetal distress?
Placental abruption
Vasa praevia - babies’ blood vessels run near the internal opening of the uterus; these vessels are at risk of rupture when the supporting membranes rupture
Cord prolapse
Uterine rupture
Feto-maternal haemorrhage
Uterine hyperstimulation
Regional anaesthesia
Aetiology of subacute foetal distress?
Hypoxia
What is assessed on a CTG?
Duration and quality of the recording
Baseline HR
Variability - normal if between 5-25 bpm; this indicates normal oxygenation
Accelerations - normal
Decelerations - abnormal; the contractions must be timed alongside these:
• Early - caused by foetal head compression; they are normal, as they occur during a contraction
• Late - dip in HR after a contraction; these can be a sign of hypoxia
Recording of contractions
ADD IMAGE
4 features of a CTG?
- Baseline foetal HR
- Baseline variability
- Presence or absence of decelerations
- Presence of accelerations
Classifications of CTG?
Normal
Suspicious
Pathological
NOTE - it is not always possible to categorise or interpret every CTG trace
Features of a normal / reassuring CTG?
Baseline HR of 100-160 bpm
Baseline variability of 5 or more
None OR early decelerations
Features of a non-reassuring CTG?
Baseline HR of 161-180 bpm
Baseline variability of <5 for 30-90 minutes
Variable deceleration:
• Dropping from baseline by 60 bpm or less AND taking 60 seconds or longer to recover
• Present for over 90 mins
• Occurring with over 1/2 of the contractions
OR
Variable decelerations:
• Dropping from baseline by >60 bpm OR taking >60 secs to recover
• Present for up to 30 mins
• Occurring with over 1/2 of the contractions
OR
Late decelerations:
• Present for up to 30 mins
• Occurring with over 1/2 of the contractions
Features of an abnormal CTG?
Baseline HR of >180 or <100 bpm
Baseline variability of <5 for over 90 mins
Non-reassuring variable decelerations:
• Still observed 30 mins after starting conservative measures
• Occurring with >50% of contractions
OR
Late decelerations:
• Present for >30 minutes
• Do not improve with conservative measures
• Occurring with >50% of contractions
OR
Bradycardia or a single prolonged deceleration lasting 3 minutes or more
