Adjuncts in Labour Flashcards by Anneliese Brady

What non-medical methods reduce early labour pain?

Back rubbing
TENS
Immersion in water at body temperature

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What medical methods can be used in labour to reduce pain?

Entonox - NO and oxygen
- causes light headedness, nausea and hyperventilation

Systemic opiates - pethidine or Meptid

IM injection
patient controlled
SE sedation, confusion, respiratory depression in newborn (need nalaxone)

Epidural analgesia

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What anaesthesia is used for obstetric procedures?

Spinal anaesthesia - local anaesthetic injected into CSF

short lasting but effective method for C-section or mid cavity instrumental
SE: hypotension

Pudendal nerve block - local anaesthetic injected bilaterally around pudendal nerve
- suitable for low-cavity instrumental

Epidural - injection of local anaesthetic +/- opiates via catheter into space between L3 and L4

infused continuously or topped up intermittently
complete sensory and partial motor blockage is normal

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What are the advantages to an epidural?

Only pain free method

Used in long labour, hypertensive women

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What are disadvantages to an epidural?

Increased midwifery supervision needed
Bed-bound
Urinary retention
Transient fetal bradycardia

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What are contraindications to epidural?

Sepsis
Coagulopathy or anticoagulant therapy - unless low dose heparin
Active neurological disease
Spianl abnormalities
Hypovolaemia

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What are complications of an epidural?

Spinal tap - puncture of dura mater causing leakage of CSF and severe headache
Total spinal analgesia -> respiratory paralysis

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What is the difference between induction and augmentation of labour?

Induction - labour that is artificially started

Augmentation - contractions of established labour are strengthened

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What methods are there for induction of labour?

Prostaglandins
Amniotomy
Oxytocin (only after membrane rupture)
Cervical sweeping

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How is prostaglandin used in induction of labour?

Gel inserted into posterior vaginal fornix

best for nulliparous women and multips unless cervix is very favourable
starts labour or allows amniotomy to be performed
can give another dose 6hr later but no more than 2 total

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How is oxytocin used in induction of labour?

Amniotomy - forewaters ruptured with amnihook

Start oxytocin infusion within 2hrs

Can be used alone if SROM has already occured

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What natural inductions are used?

Cervical sweeping - finger through cervix and stripping between membrane and lower segment of uterus

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What are indications for induction?

Fetal

prolonged pregnancy
IUGR
compromise
APH
PROM

Maternal

pre-eclampsia
diabetes
in utero death

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What are contraindications for induction?

Acute fetal compromise
Abnormal lie
Placenta praevia
Pelvic obstruction
2+ C-sections (increased scar rupture rate)

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How is induced labour managed?

CTG used

May prolong early labour

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What are complications of induction?

May fail to start or be slow due to uterine inefficiency

Higher risk of C-section and instruments

Hyperstimulation syndrome of the uterus -> rupture

PPH

Infection

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What are contraindications for VBAC?

Usual for C-section
Vertical uterine scar
2+ previous C-sections

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What are good prognostic features for VBAC?

Spontaneous labour
Interpregnancy interval less than 2 years
Low age and BMI
Previous vaginal delivery

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How is prelabour term rupture of the membranes diagnosed?

Gush of clear fluid followed by uncontrollable trickle

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What are risks of prelabour term ROM?

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Cord prolapse - usually complication of transverse lie or breech presentation

Neonatal infection - increased by VE, GBS, increased duration of rupture

How is prelabour term ROM managed?

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Only do VE in sterile manner if risk of cord prolapse

CTG, high vaginal swab
Give antibiotics if lasts more than 18hrs

Either await spontaneous onset of labour or induce labour - 80% start labour within 24hrs

When are ventouse/forceps indicated?

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Expedition of second stage

Adds power and rotation

What are ventouse?

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Vacuum extractor - delivers head in OA position and allows shape of pelvis to rotate head to OA position

What are forceps and when are they used?

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Non-rotational forceps (Simpson’s, Neville-Barnes) - grip head in whatever position it is in and allow traction
Only suitable when occiput is anterior

Rotational forceps (Kieland’s) - no pelvic curve and allowed malpositioned head to be rotated to OA position before traction is applied

What are complications or forceps/ventouse delivery?

Failure Analgesia needed -> laceration, blood loss or third-degree tears Chignon - swelling on head of baby Occasionally - facial bruising, facial nerve damage, skull or neck fractures

What are indications for instrumental vaginal delivery?

Prolonged second stage - if active stage >1hr Fetal distress Prophylactic use to prevent pushing in severe cardiac disease or hypertension Breech delivery

How are instrumental deliveries avoided?

Continuous support and comfortable maternal position With epidural - delay maternal pushing for 1 hour after diagnosis of 2nd stage Oxytocin if head descent poor

What are prerequisites for instrumental delivery?

Head mustn't be palpable abdominally - at or below ischial spines Cervix must be fully dilated Known position of head - can be fatal Adequate analgesia Empty bladder

What are indications for emergency C-section?

``` During labour Prolonged first stage - full dilation >12hrs Inefficient uterine action Malposition Fetal distress ```

What are indications for an elective C-section?

Performed at 39 weeks Placenta praevia Severe fetal compromise Uncorrectable abnormal lie Previous vertical C-section

What are complications of C-section?

``` Haemorrhage Infection - give prophylkactic Abx Bladder/bowel damage VTE Future placenta praevia ```

What is shoulder dystocia?

Additional manouevres required after normal downwards traction to deliver shoulders

What are consequences of shoulder dystocia?

Excessive traction on neck damages brachial plexus resulting in Erb's palsy which is permanent in 50% of cases Can be lethal in as little as 5 mins

What are risk factors for shoulder dystocia?

Larege baby Previous shoulder dystocia Increased BMI

How is shoulder dystocia managed?

Gentle downwards traction McRoberts' manouvere - maternal legs onto abdomen Suprapubic pressure Episotomy for internal manouevres - Wood's screw manouevre

What is cord prolapse?

Membranes have ruptured and umbilical cord descends below presenting part Cord will be compressed or go into spasm -> hypoxia

What are risk factors for cord prolapse?

``` Preterm labour Breech presentation Polyhydramnios Abnormal lie Twin pregnancy Artifical amniotomy ```

How is cord prolapse managed?

``` Presenting part pushed up to avoid compression Give tocolytics (terbutaline) Patient goes on all fours while C-section is prepared ```

What is amniotic fluid embolism?

Liquor enters maternal circulation -> anaphylaxis Sudden dysponeoa, hypoxia and hypotension If woman survives for 30 mins she will develop DIC, pulmonary oedema and adult respiratory distress syndrome

What are risk factors for amniotic fluid embolism?

Occurs when membranes rupture, during labour , C-section or termination of pregnancy

How is an amniotic fluid embolism managed?

``` Oxygen and IV fluid Central venous monitoring Cross-match, FBC, clotting Blood and fresh frozen plasma Transfer to ITU ```

What is uterine rupture?

Can tear de novo or along old scar Fetus is extruded, uterus contracts down and bleeds -> acute fetal hypoxia and internal maternal haemorrhage Rupture from lower transverse C-section sar is less traumatic as reduced blood suplly

What are risk factors for uterine rupture?

Labours with scarred uterus | Congenital uterine abnormalities

How is uterine rupture managed?

IV fluid Blood Laparotomy to deliver fetus and stop bleeding

What is uterine inversion?

Fundus inverts into uterine cavity during traction on placenta Causes haemorrhage, pain and profound shock Push up from vagina otherwise GA and hydrostatic pressure of saline into uterus

What are other obstetric emergencies?

Epileptiform seizures - rule ot eclampsia Local anaesthetic toxicity Massie APH or PPH PE

What is active management of third stage?

Ergometrine + oxytocin = syntometrine

What is retained placenta?

Third stage >30 mins

Adjuncts in Labour Flashcards

(48 cards)