Abnormal Labour Flashcards
(52 cards)
1
Q
Is it common to induce Labour
A
Yes, ~1/5 of labours are induced
2
Q
Any risks/disadvantages associated with an induced labour
A
- Less efficient and more Painlful
- Higher chance of instrumental delivery (15%)
- Higher chance of CS (22%, though new evidence does suggests it may not increase CS rates)
- Higher risk of requiring an epidural
- Higher risk of foetal distress
- Risk of hyperstimulation of uterus (“Hypertonic”)
3
Q
During an induced labour what is recommended in regards to the foetus
A
Due to higher risk of foetal distress continuous foetal monitoring is recommended
4
Q
4 indications for inducing labour
A
- Diabetes (usually before due date)
- Post dates (term + 7days or 42weeks)
- Maternal health problems that necessitates planning of delivery e.g. receiving treatment for DVT
- Foetal reasons e.g. growth concerns, “big babies”, oligohydramnios (deficiency of amniotic fluid, opposite of poluhydramnios)
5
Q
2 ways of inducing labour
A
- Amniotomy (artificial rupture of membranes)
- Medically, Prostaglandin suppository, IV Oxytocin
6
Q
What is the Bishop’s score
A
- Used to clinically asses the cervix for “cervical ripening”
- The higher the score the more progressive the change in the cervix is and the more likely an induced labour will be successful
- Also been used to assess the odds of spontaneous preterm delivery
7
Q
When can an amniotomy be performed
A
When the cervix had dilated and effaced
8
Q
5 criteria assessed in the Bishop’s score
A
- Dilatation (0-5+ cm)
- Length of cervix (Effacement)(3-0cm)
- Position (post. -> mid -> ant.)
- Consistency (firm -> medium -> soft)
- Station (-3 - +2cm)
9
Q
If the cervix is not dilated and effaced what bishops score would be awarded
A
A low score
10
Q
If the cervix is not dilated and effaced how would you “ripen” the cervix
A
Vaginal Prostaglandin Pessary
11
Q
What Bishop’s score is considered favourable for an amniotomy
A
7 or higher
12
Q
What is used to perform an amniotomy
A
Amniohook or Amnicot
13
Q
Once an amniotomy has been performed what is the next step to induce labour
A
IV oxytocin, to achieve adequate contractions
14
Q
What rate of contraction should be aimed for when inducing labour
A
4-5 in 10 minutes, when using IV oxytocin
15
Q
Describe the full process of inducing labour
A
- Vaginal Prostaglandin Pessary, if cervix is not dilated and effaced (low bishop’s score)
- Amniotomy, if cervix has dilated and effaced (Bishop score of 7 or higher)
- IV Oxytocin to achieve adequate contractions, aiming for 4-5 in 10 minutes
16
Q
What can cause inadequate progression
A
- Cephalopelvic disproportion (CPD) (due to large head or small pelvis or both)
- Malposition
- Malpresentation
- Inadequate uterine activity
[?ovarian cysts or fibroids?]
17
Q
Definition of suboptimal progress in the first stage of labour
A
- Cervical dilation of less than 0.5cm per hr for primigravid women (first pregnancy)
- Cervical dilatation of less that 1cm per hr for parous women (not first pregnancy)
18
Q
What’s the result of inadequate contractions and how is it corrected
A
- Foetal head will not descend and exert force on the cervix therefore the cervix will not dilate
- IV Oxytocin will increase strength and duration of contractions
19
Q
When inadequate uterine activity is suspected, e.g. inadequate contractions, what MUST be excluded and why
A
- MUST EXCLUDE AN OBSTRUCTED LABOUR
- Stimulation of an obstructed labour can lead to a ruptured uterus, resulting in severe maternal and foetal morbidity and mortality
20
Q
Describe Cephalopelvic disproportion (CPD)
A
- Genuine CPD is relatively rare
- Foetal head is in correct position but is too large to negotiate maternal pelvis to be born
21
Q
What can happen due to Cephalopelvic disproportion (CPD)
A
Head becomes compressed and caput succedaneum and head moulding (abnormal shape) develop
22
Q
Describe Caput Succedaneum
A
- Presents as a scalp swelling that extends across the midline and over suture lines
- Does not usually cause complications and usually resolves over the first few days
- The baby will often be irritable so may require analgesia for its headache and handling should be kept to a minimum for the first few days.
23
Q
3 types of lie
A
- Longitudinal
- Oblique
- Transverse
24
Q
Describe malposition
A
- Common
- Foetal head in an incorrect position for labour and relative CPD occurs
25
How can too many contractions (uterine hyper-stimulation) cause foetal distress
Causes insufficient placental blood flow
26
How is foetal well being monitored during labour
- Intermittent auscultation of foetal heart
- Cardiotocography (CTG) (monitors foetal heartbeat + uterine contractions)
- Foetal blood sampling
- Foetal ECG
27
When do use Foetal blood sampling and what does it provide
- Used when persistently suspicious or pathological CTG
- pH and base excess
- pH gives a measure of likely hypoxaemia
28
When would labour not be recommended
- Obstruction of birth canal (major placenta praevia, masses)
- Malpresentation (transverse, hand, shoulder)
- Specific previous labour complications (uterine rupture)
29
3 3rd stage complications
-Retained placenta
-Post partum haemorrhage (4 T's)
-Tears
Graze
1st degree
2nd degree
3rd degree
4th degree
30
How long is the post partum period and are patients managed during it
- Lasts ~6wks
- Midwife manages for first 9-10 days then they're referred to a health visitor
- Observe for signs of abnormal bleeding, infection (wound/breast/endometritis)
- 6 week check at GP
31
Describe immediate postnatal care for high risk women
-15-60 minute observations
-Ensure;
Uterus remains contacted + no evidence of abnormal bleeding
Prophylactic antibiotics, where required
Appropriate thromboprophylaxis
Recovery from spinal/epidural/general anaesthetic
32
5 postnatal problems
- Post partum haemorrhage
- Venous thromboembolism
- Sepsis
- Psychiatric disorders of the puerperium
- Don't forget Pre-eclampsia
33
Describe pre-eclampsia
-Characterised by high BP and Proteinuria
-Begins after 20wks of pregnancy (can occur during postnatal period)
-If untreated can cause seizures (then called Eclampsia)
-In severe disease is causes;
RBC breakdown
Low blood platelet count
Impaired liver function
Kidney dysfunction
Oedema
SOB due to fluid in the lungs,
visual disturbances
34
Risk factors of pre-eclampsia
- Older maternal age
- Diabetes mellitus
- Obesity
- Prior Hypertension
- Primigravid women or twin pregnancies
35
Management of Pre-eclampsia
- Expedited delivery via induced labour/CS
- Prevention and treatment of eclamptic seizures (magnesium sulphate)
- Treatment of sever hypertension (160/110) with Labetolol, Hydralazine or Nifedipine
36
What anti-hypertensive are contraindicated during pregnancy
ACE Inhibitors and Angiotensin receptor blockers as they affect foetal development
37
2 types of Postpartum Haemorrhage (PPH)
- Primary = blood loos >500ml within 24hrs of delivery
| - Secondary = blood loss > 500ml from 24hrs post partum to 6wks
38
Causes of primary PPH, think 4 T's
4 T's = Tone, Trauma, Tissue, Thrombin
- Uterine atony (loss of tone in the uterine musculature)
- Local cause e.g. traumatic tears of perineum/vagina/cervix
- Retained tissue/placenta
- Coagulopathy
39
Causes of secondary PPH
- Retained tissue
- Endometritis (infection)
- Tears/trauma
40
Why is there an increased risk of Thromboembolic disease during and immediately after pregnancy and what is atypical about pregnant women experiencing a DVT or PE
- Pregnancy and the immediate post partum period are hypercoagulable states
- Pregnant women 6-10 times more likely to develop a thromboembolism
- Pregnant women can be relatively asymptomatic compared to normal women
41
How to reduce risk of thromboembolic disease in pregnant women
- High quality risk assessment
| - Appropriate thromboprophylaxis
42
How to pregnant women present with a DVT/PE
- UNILATERAL leg swelling and/or pain and complaining of SOB or chest pain
- Sometimes the only sign of a PE will be an UNEXPLAINED TACHYCARDIA
Always have a high index of suspicion in pregnant or postnatal women
43
What will increase the risk of thromboembolic disease in pregnant/postnatal women
Immobilisation following Spinal anaesthetic/CS
44
Investigations to diagnose a DVT/PE
- ECG
- Leg Dopplers
- CXR +/- VQ scan or CTPA(CT Pulmonary Angiogram) [risk of radiation during pregnancy and breast feeding]
45
Treatment of DVT/PE in pregnancy
- Low molecular weight heparin (LMWH)
[WARFARIN IS TERATOGENIC]
46
What's troubling about maternal sepsis
May present atypically
47
Describe "baby blues"
- Due to hormonal changes around time of birth
- Usually occurs 1-3 days postnatally for only a few days
- Doesn't affect functioning and requires no specific treatment
48
Describe Postnatal Depression
- Can continue from "baby blues" or start sometime lateral
- Has classical "depressive" symptoms
- Affects functioning, bonding and often requires treatment
49
Risk factor for Postnatal Depression
Personal or family Hx of affective disorder
50
Describe Puerperal Psychosis
- Rare but serious psychotic illness of the postnatal period
- Women can be a danger to themselves and their babies
- Requires INPATIENT psychiatric care
51
Risk factors for Puerperal Psychosis
Personal or family Hx of;
- Affective disorder
- Bipolar disorder
- Psychosis
52
When do most Eclamptic seizures occur
In the postnatal period
Pre-eclampsia can develop postnatally or worsen several days following delivery
