Abnormal Labour and Post Partum Care Flashcards by Annie Caldwell

Risks of induction of labour

less efficiency
more pain
need for foetal monitoring
uterine hyperstimulation with prostaglandin/oxytocin induction

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Induction of Labour definition

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

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Predispositions to labour not starting

High BMI

Previous labour where induction is needed

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Indications for induction of labour

Diabetes (big babies)
Post dates - term + 7 days
Maternal Health problem that necessitates planning of delivery e.g. treatment of DVT
Foetal reasons e.g. growth concerns, oligohydroamnios
Social reasons
Maternal request
Pelvic pain

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What score is used to clinically assess the cervix?

Bishops score

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What is used to induce labour when the cervix is not dilated and effaced and therefore has a lower bishops score?

Vaginal prostaglandin pessaries

Cook balloon

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What do vaginal prostaglandin pessaries and cook balloons do?

Ripen (open) the cervix

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How long can vaginal prostaglandins take to open the cervix?

2-3 days

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How long does mechanical cook balloon take to work?

Up to 24 hours

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What induction of labour is used when the cervix is dilated and effaced?

Amniotomy

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What Bishops score is considered favourable for amniotomy?

7 or more

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The bishops score includes…

Dilatation 
Length of cervix (effacement)
Position 
Consistency 
Station

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Definition of amniotomy

Artificial rupture of foetal membranes (“waters”) usually using a sharp device e.g. amniohook

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What is used in induction of labour after amniotomy is performed?

IV oxytocin to achieve adequate contractions

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What is IV oxytocin used for in induction of labour?

After amniotomy to achieve adequate contractions

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Overall process of induction of labour

Ripen/Soften cervix
Break waters/membranes
IV oxytocin for contractions

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Causes of inadequate process in labour

Cephalopelvic disproportion (CPD)
Malposition 
Malpresentation 
Inadequate uterine activity
Obstruction e.g. fibroid or ovarian cyst

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Problems in labour are due to the 3Ps….

Powers
Passenger
Passages

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Powers mean….

Contractions

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Passages mean….

Birth canal

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Passenger means….

Baby

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Station definition

How the baby is coming through the pelvis = a measurement of the descent of the babys head

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Definition of Cephalopelvic disproportion (CPD)

Foetal head is in the correct position for descent but it is too large for negotiating the maternal pelvis to be born

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What is presentation?

The bit of the baby presenting to the vagina

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Longitudinal lie meaning

The spine of the baby is parallel to the mothers spine

The result of a transverse lie is that....

A variety of different presentations can result

Malposition definition

Involves foetal head being in an incorrect position and 'relative' CPD occurs

Position that is normal for the presenting part of the baby

Occipito-anterior

The position of the baby is determined by

Vaginal exam

Management of foetal distress

``` Delivery the baby the quickest way - forceps - instrumental - vacuum If not fully dilated - C section ```

Feotal well being in labour is determined by

Intermittent auscultation of the foetal heart Cardiotography Foetal blood sampling (hypoxaemia) Feotal ECG

When is foetal blood sampling done?

When there is an abnormal CTG

Situations where labour is not advised

Obstruction to the birth canal (masses, major placenta praevia) Malpresentations Medical conditions where labour would not be safe for the women (rare) Specific previous labour complications e.g. previous uterine rupture Foetal conditions

Types of instrumental/assisted delivery

``` Forceps Vacuum extraction (cup) ```

C section is essential management for

obstructed labour failure to progress in labour fetal distress before the cervix is fully dilated

Risks of C section

infection bleeding visceral injury VTE

Retaine placenta definition

Complication of the 3rd stage of labour in which the placenta has not undergone placental expulsion within 30 mins when the 3rd stage of labour has been managed actively.

What is retaine placenta a common cause of

PPH

Causes of PPH (THE 4TS)

Tone Trauma (Tears) Tissue Thrombus

Another name for the post partum period

Puerperium

Post natal problems

``` PPH VTE sepsis psychiatric disorders of the puerperium Pre-eclampsia ```

Types of PPH

Primary | Secondary

Primary PPH definition

Blood loss >500ml within 24 hours (the 4Ts)

Secondary PPH definition

Blood loss >500ml from 24 hours post partum to 6 weeks (due to e.g. endometritis, retained tissue, tears/trauma etc)

Normal bleeding post partum

Should be like a period or less for 3-4 weeks

Symptoms that increase suspicion of thromboembolic disease in post partum women

Women with unilateral leg swelling and/or pain and women complaining of SOB or chest pain

What investigation can you NOT use to investigate thromboembolic disease in pregnancy/post partum?

D dimer

Investigations for thromboembolic disease in pregnancy/post partum

ECG Leg dopplers CXR +/- VQ scan or CTPA

Treatment of thromboembolic disease in pregnancy

LWMH

Warfarin in pregnancy/post partum

SHOULD NOT BE USED IN PREGNANCY = teratogenic | Can be used in breastfeeding

Psychiatric problems post natally

Baby blues Post natal depression Puerperal psychosis

Labour problems are most common in what type of women?

Primigravid

Vaginal birth after a previous C section is contraindicated in who?

Previous vertical (classical) Caesarean scars Previous episodes of uterine rupture Patients with other contraindications to vaginal birth (e.g. placenta praevia)

Definition of lochia

Vaginal discharge after giving birth, containing blood, mucus and uterine tissue

How long does lochia last for?

4 - 6 weeks after childbirth

What Bishops score indicates that labour is unlikely to start without induction?

< 5

What Bishops score indicates that labour is likely to happen spontaneously?

> 9

Risk factors for breech presentation

``` Uterine malformations, fibroids Placenta praevia Polyhydramnios or oligohydramnios Foetal abnormality (e.g. CNS malformation, chromosomal problem) Prematurity ```

What is more common in breech presentations?

Cord prolapse

Management of breech presentation

If < 36 weeks foetus still may turn spontaneously If breech at 36 weeks = external cephalic version (ECV) Breech in delivery = planned C section or vaginal

Contraindications to external cephalic version

``` Where C section is required APH in last 7 days Abnormal CTG Major uterine abnormality Ruptured membranes Multiple pregnancy ```

What can be used to improve the effectiveness of Macroberts manouvre?

Suprapubic pressure

What is the Macroberts manouvre done for?

Shoulder dystocia

What does the macroberts manouvre involve?

Mother moving onto her back and hypeflexing and abducting the hips, bringing her thighs towards the abdomen

Management of PPH

1. Group and save vs cross match 2. Syntometrin 3. Give 2nd syntometrin if > 500ml 4. Fluids and call senior 5. Carboprost 6. Theatre 7. Balloon inserted that puts pressure on spinal arteries 8. B lynch suture 9. Tie of uterine or iliac arteries 10. Subtotal/total hysterectomy (last resort)

When is a B lynch suture more common?

C section

What should be done if the macroberts manoeuvre doesn’t work for shoulder dystocia?

Wood screw manoeuvre

What does the wood screw manoeuvre involve?

Hand in vagina and rotate foetus 180 degrees to dislodge the anterior shoulder from the symphysis pubis

Only contraindication to epidural

Coagulopathy

What is given to all women with premature prerupture of membranes? (PPROM)

10 Days erythromycin

What is puerperal pyrexia?

Temp >38C in 1st 14 days following delivery

Causes of puerperal pyrexia

``` Endometriosis UTI Wound infection (perineal tears / C section) Mastitis VTE ```

Most common cause of peurperal pyrexia

Endometriosis

What is the treatment if endometriosis causes peurperal pyrexia?

IV Ax

Can trimethoprim be used in breastfeeding?

Yes

What food should be especially avoided in pregnancy and why?

Liver - as contains high levels of vitamin A which is a teratogen

In induced labour, what can an epidural help with?

Lowering high BP

Abnormal Labour and Post Partum Care Flashcards

(77 cards)