Abnormal Labour Flashcards by Joanna Mitchell

What binds the vertex?

Anterior and posterior fontanelles

Parietal eminences

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What can cause an abnormal labour?

Malpresentation; non-vertex 
Malposition; OP or OT
Preterm <37 weeks 
Post-term >42 weeks 
Obstruction 
Foetal distress

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What are the 3 forms of breech?

Complete; legs folded with feet at the level of baby’s bottom
Footling breech; one or both feet point downwards so legs emerge first
Frank; legs point up with feet by babys head to bottom emerges first

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What is the commonest variant of breech?

Frank

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What are complications of breech?

Cord prolapse
Head entrapment
5% overall risk of foetal injury when breech delivered vaginally

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What percentage of term babies are breech?

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What are the 3 forms of malpresentation?

Breech; 3 types
Transverse
Shoulder/arm

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How can the head present if non-vertex?

Face presentation; if mental anterior can be delivered vaginally
Brow presentation; c/s

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When is a birth termed preterm?

<37 weeks

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Why can hyperstimulation resulting in a quick labour result in foetal distress?

If there is no gap between contractions, the placental vascular tree won’t have time to refill and therefore foetal hypoxia/ distress can occur

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What forms of analgesia are available for labouring women?

Support 
Massage/ relaxation 
Inhalation; entonox 
TENS (T10-L1, S2-4) 
Water immersion 
IM opiate analgesia; diamorph 
IV remifentanil PCA
Regional

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When is IV remifentanil PCA utilised?

Gives short lasting bolus at peak of contraction

Good for women whose labours are progressing too quickly for a regional anaesthesia

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Why is labour painful?

Compression of para-cervical nerves

Myometrial hypoxia

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What issues can an epidural have on labour progression?

May inhibit progress during stage 2

Does NOT impair uterine activity

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Complications of epidural anaesthesia?

Hypotension 
Dural puncture
Headache
High block; resp depression 
Atonic bladder

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What is injected in through an epidural?

Low conc LA with opioid; 10-15ml bupivacaine with fentanyl

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What is the purpose of the 1st test dose?

To endure that inadvertent intrathecal injection has not occured

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What are the risks of an obstructed labour?

Sepsis; lots of vaginal exams 
Uterine rupture; multiparous women 
Obstructed AKI
PPH
Fistula formation 
Foetal asphyxia
Neonatal sepsis

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How is progress assessed in labour?

Cervical dilation

Descent of presenting part

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What are signs of an obstructed labour?

Excessive moulding 
Caput 
Anuria
Haematuria
Vulval oedema

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What is considered failure to progress in stage 1 of active labour?

Nulliparous and parous; <2cm in 4 hours

Parous women really should be a little quicker than this

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When can you perform an instrumental delivery?

0 or + station

10cm dilated

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What are the 3 Ps of failure to progress?

Power
Passage
Passenger

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What can result in reduced power causing failure to progress?

Inadequate contractions; frequency +/- strength

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What can result in an inadequate passage for a baby resulting in failure to progress?

Short stature of mother Trauma Shape; not gynaecoid (anthropoid or android)

What problems with the baby can result in failure to progress?

Macrosomia | Malposition

How many contractions are expected per 10 mins?

3 to 4 | Duration of 40-50 seconds

What is the smallest diameter of the foetal head?

Suboccipito-bregmatic = 9.5cm | Submentobregmatic; 9.5cm

What is the biggest diameter at the pelvic inlet and outlet respectively?

Inlet; transverse diameter = 13.5cm | Outlet; AP diameter; 13.5cm

What are the different measurements for a vertex, OP, deflexed OP, brow and face presentation?

``` Vertex; suboccipito-bregmatic = 9.5 cm OP; suboccipito-frontal = 10 cm Deflexed OP; occipitofrontal = 11.5cm Brow = occipitomental 13cm Face; submentobregmatic = 9.5cm ```

What is the commonest reason why babies don't progress?

Suboptimal flexion of the head

What does the partogram measure?

``` Foetal HR Amniotic fluid Cervical dilatation Descent Contractions Obstruction = moulding Maternal observations ```

What can be given in the 1st stage of labour to assist with failure to progress?

IVI syntocinon

When is the foetal heart measured in stage 1 of labour?

During and after a contraction | Every 15 mins

When is the foetal heart rate measured in stage 2 of labour?

At least every 5 mins during and after a contraction for 1 whole minute Check mat pulse at least every 15 mins

What is included within the intrapartum foetal assessment?

Foetal HR - either pinnards, doppler or CTG | Colour of amniotic fluid

What are risk factors for foetal hypoxia?

``` Small foetus Pre-term/ post dates Antepartum haemorrhage Hypertension/ PET Diabetes Meconium Epidural analgesia VBAC PROM >24 hrs Sepsis (temp >38) Induction/ augmentation of labour ```

What is required if there are risk factors for foetal hypoxia?

CTG throughout labour

What can cause acute foetal distress?

``` Abruption Vasa praevia Cord prolapse Uterine rupture Foeto-maternal haemorrhage Uterine hyperstimulation Regional analgesia ```

What is vasa praevia?

A condition in which fetal blood vessels cross or run near the internal opening of the uterus. These vessels are at risk of rupture when the supporting membranes rupture, as they are unsupported by the umbilical cord or placental tissue

What can cause chronic foetal distress?

Placental insufficiency | Foetal anaemia

Can a CTG monitor the strength of contractions?

NO; only the frequency

What should be assessed when reviewing the CTG?

Baseline foetal heart rate Baseline variability Presence or absence of decelerations Presence of accelerations

What is a normal baseline foetal HR?

110-150 Tachy >150 Brady <110 (although only really worried when below 90)

What is normal variability?

5-25 bmp Reduced; <5 Saltatory >25 Complete loss = BAD

What are normal foetal accelerations?

Really reassuring to see accelerations Rise of 15 beats above baseline for at least 15 seconds In a 40 min period; want to see 2 accelerations

What is a normal deceleration?

Early with contractions but rise very quickly to baseline

What is a worrying deceleration?

Late; after peak of contraction Broad Slow to recover to baseline HR

How is a CTG classified?

Normal Suspicious Pathological

What is hypoxia characterised by on a CTG?

Loss of accelerations Repetitive deeper and wider decelerations Rising foetal baseline HR Loss of variability

What is an acronym to CTG interpretation?

``` Dr C Bravado Determine Risk Contractions Baseline R Ate Variability Accelerations Decelerations Overall impression ```

What makes a CTG pathological?

More than 2 abnormal features

How is foetal distress managed?

``` Change maternal position; left lateral IV fluids Stop syntocinon Scalp stimulation Consider tocolysis; terbutaline 250 mcg s/c Maternal assessment; pulse, BP, abdo, VE Foetal blood sampling Operative delivery; category 1 ```

How quickly must a category 1 delivery be performed in?

30 mins

What is foetal blood sampling?

Prick from foetal scalp | Look at pH to determine if foetus is hypoxic and acidotic = BAD

What is a normal foetal scalp pH?

>7.25

What is a borderline scalp pH?

7.20 - 7.25; repeat in 30 mins

What is an abnormal foetal scalp pH?

<7.20; DELIVER

What are the methods for an operative/ instrumental vaginal delivery?

Forceps | Vontouse

What are the "standard" indications for an instrumental delivery?

Delay; failure to progress at stage 2 | Foetal distress

What are the "special" indications for an instrumental delivery?

Maternal cardiac disease; pushing may be dangerous Severe PET/ eclampsia Intra-partum haemorrhage Umbilical cord prolapse at stage 2

What is the max time limit on the duration of stage 2 in a primigravida woman?

No epidural; 2hrs | Epidural; 3hrs

What is the max time limit on the duration of stage 2 in a multip woman?

No epidural; 1hr | Epidural; 2hr

What are the advantages of ventouse?

No anaesthesia needed Reduced vaginal trauma Reduced perineal pain

What are the disadvantages of a ventouse?

Increased rates of failure Increased risk of cephalohematoma Increased risk of retinal haemorrhage Increased maternal worry

Difference between forceps and ventouse?

Forceps; more damage to mother Ventouse; more damage to baby BUT No difference in c/s rates, apgar score or long term outcomes

What are the main indications for a c/s?

``` Previous c/s Foetal distress Failure to progress Breech Maternal request ```

Risks assoc with c/s?

``` Sepsis Haemorrhage VTE Trauma TTN Subfertility Regret Complications in future pregnancy ```

Abnormal Labour Flashcards

(68 cards)