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Intrapartum Flashcards

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1
Q

Definitions of each stage of labour

A

1- Onset of regular painful contractions to Fill dilatation via effacement
2- Full dilatation to delivery
3- Infant delivery to placenta/membrane delivery

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2
Q

What is active vs latent stage 1 of labour?

A

Latent- up to 4cm dilation with irregular contractions/involuntary contractions
Active- 4-10cm dilation with regular contractions

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3
Q

What is active stage 2 of labour?

A

Passive- Full dilatation, expulsive contractions or active maternal effort

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4
Q

Average length of each stage of labour in a primiparous?

A

1- ~8 hours 0.5-1cm/hr
2- 1-2 hours… > 4 is abnormal
3- Up to 30 mins

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5
Q

Average length of each stage of labour in a multiparous?

A

1- ~5 hours 1-2cm/hr
2- Up to 1 hour
3- Up to 30 mins

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6
Q

During labour, which point has the highest risk of low oxygenation?

A

Stage 2, limit this stage of active pushing

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7
Q

How can you limit peritoneal damage during labour?

A

Pant and little pushes when baby is crowning

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8
Q

When is normal labour during pregnancy

A

37+ weeks (until 42)

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9
Q

How do you actively manage stage 3

A

Uterotonic drugs

Controlled cord traction whilst applying suprapubic pressure

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10
Q

Optimum position of baby for labour

A

Occipitoanterior

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11
Q

How do you assess the descent of the head into the pelvis

A

Assessing in stage 1 in reference to the ischial spines (Station 0)
+ if below
- if above

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12
Q

Describe how the baby is born

A

Head floating before engagement
Engagement- Flexion and descent
Further descent and internal rotation
Complete rotation and beginning extension
Complete extension as the head is delivered
Restitution (external rotation)
Delivery of anterior then posterior shoulder

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13
Q

What are the features of a false labour?

A

Last 4 weeks of pregnancy
Irregular contractions
No progressive cervical changes

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14
Q

Under what circumstances would you consider continuous CTG monitoring?

A 
Oxytocin induced labour
Meconium stained liquor 
Fresh Bleeding
Multiple pregnancy
IUGR
Abn Ausc 
Severe HTN >160/110
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15
Q

DR C BRAVADO

A

Determine Risk
Contractions (4-5/10mins)- Frequency and duration
Baseline rate- 110-160
Accelerations- 15BPM Rise for >15s
Variability- 5-25BPM
Decelerations- >15bpm drop for >15s, Early, Late, Variable (?>60bpm for >60s)
Overall Impression

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16
Q

When would you use a fetal scalp electrode?

A

Poor contact with abdominal transducer
High BMI
Twins
Abd scarring

CI: Praevia, BBV, Preterm, Bleeding disorders

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17
Q

What would you do after classifying a CTG as worrying?

A 
Left lateral position 
Fluids
Foetal scalp stimulation
Foetal blood sampling
?Delivery
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18
Q

When can you do a Foetal blood sample?

What do the results mean?

A

> 3cm dilated, delivery not imminent

PH inducates hypoxaemia
PH>7.25 NORMAL
PH 7.2-7.25 Repeat in 30 mins
PH<7.2 Deliver

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19
Q

Absolute CI to an Epidural

A

Anticoagulants
Local or systemic infection
Anaphylaxis to LA
Bleeding disorders

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20
Q

Relative CI to an epidural

A

Spinal surgery

Massive haemorrhage

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21
Q

Complications of an epidural

A 
Hypotension
Failure
Post-dural puncture headache
Low RR
Infection
LA toxicity
Damage
Haematoma (Look for leg weakness, need MRI)
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22
Q

Absolute CI to IoL

A

Non-cephalic lie
Placenta Praevia
Pelvic obstruction
Acute fetal compromise

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23
Q

Relative CI to IoL

A

Previous CS as VBAC risks scar dehiscence

Breech, Prematurity, High parity

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24
Q

Commonest reason to IoL

A

post maturity

Still birth rate significantly increases after 42 weeks so consider IoL at 41-42 weeks

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25
What is PROM
Pre-labour Rupture of Membranes Labour likely within 24 hours If not then this is prolonged so offer IoL at 24 hours (Max wait time is 4 days)
26
What Bishops score would indicate labour is unlikely without induction
5 or less | >8 likely to have VD
27
What does the Bishops score consider?
Dilatation, Length, Station of presenting part, Consistency, Position
28
Stage one IoL
Ripening of the cervix with vaginal Prostaglandin E2 ideally a propess pessary
29
Stage 2 IoL
Amniotomy to artificially rupture membranes
30
Risks of an amniotomy
Amniotic fluid embolism | Cord prolapse
31
Stage 3 IoL
IV syntocinon to induce uterine contractions
32
Risks of Cervical ripening and Cervical dilatation during IoL
Hyperstimulation of the foetus Therefore monitor on CTG Give tocolytic and titrate IV syntocinon down if this occurs
33
Complications of IoL to explain to patient
``` Cord prolapse Foetal distress Failure- Operative delivery or C-section Uterine hypertonia and rupture Amniotic fluid embolus ```
34
Managing cord prolapse
Tocolytics Elevate Knee to chest or left lateral position Immediate c-section and on all fours whilst waiting Never push it back into uterus
35
What is the difference between augemtation and IoL
Augmentation is then the membranes have ruptured spontaneously No RoM= IoL
36
What type of breech is highest risk?
Footling
37
RF for Breech presentation
Prematurity, Uterine malformation including fibroids, Praevia, Poly/Oligohydramnios, Foetal Abn
38
When would you consider an EVC for Breech presentation?
>36 wks if nullips, >37 if multips
39
What is ECV?
Manual procedure to turn baby. Give tocolytic to relax uterus +/- Anti-D CTG essential pre- and Post- Success in 60%
40
When is an ECV CI?
Active labour when the membranes have ruptured
41
Risks of an ECV?
Cord entanglement, Foetal distress, Transient Brady, Pain, Failure
42
How useful is C-section for Breech babies?
Vs VD: Decreased perinatal and early neonatal mortality especially if slow progress during VD
43
What prophylaxis should be given in twin delivery?
Oxytocin/Ergometrine as increased PPH risk | Continuous CTG monitoring
44
What 3 P's influence labour
Power Passenger- (position and size) Passage- (Parity)
45
How do you diagnose stage 1 delay
<2cm dilatation in 4 hours if Primi
46
How can you help counteract stage 1 delay
Artificial rupture of membranes Syntocinon infusion C-section
47
What must be the conditions be for assisted vaginal delivery to be done?
Fully dilated, Ruptured mems, Cephalic, engaged part not palpable abdominally
48
Process of operative delivery
Consent- Analgesia- Ad contractions- Empty bladder- Know position- Ruptured mems
49
Indications for operative delivery
Slow S2 progress Exhaustion Avoid raising ICP/BP Fetal compromise
50
Different methods of operative delivery
``` Vacuum extraction/Ventouse delivery Traction forceps (ONLY IF OA) curved to fit pelvis Rotational forceps ```
51
What does FORCEPS stand for?
``` What you need for operative delivery... Fully dilated OA/OP Ruptured mems Cephalic Engaged Pain relief Sphincter empty ```
52
Complications of vacuum extraction
Cephalohaematoma, Retinal haemorrhage
53
Complications of forceps delivery
Facial brusing and CN7 palsy
54
Maternal risks of operative delivery
``` Failure! Inc blood loss Post-partum pain Perineal trauma Pelvic floor weakness Psychological sequela ```
55
What does the colour of the liquor tell you about the pathology?
``` Green/Yellow= Meconium Pink= Full dilatation Red= Rupture ```
56
Definition of fetal macrosomia
>4kg
57
What does shoulder dystocia increase the risk of?
Brachial plexus injury | PPH, Perineal tear, Hypoxia, C-spine injury, Intracranial haemorrhage, Death
58
3 simple manoeuvres for shoulder dystocia
McRobert's Suprapubic pressure Woodscrew (roate 180 degres) post-episiotomy
59
What is McRobert's Manoeuvre?
Flex and externally rotate hips to stretch symphysis and open pelvic outlet
60
Advanced manoeuvres for shoulder dystocia
Rotate anterior shoulder Deliver posterior arm Break clavicle Emergency C-section
61
What are the risks of a LSCS
``` ABCI Adjacent organ damage 1/1000 Bleeding Clot 1/1000 Infection 1/20 ``` + Laceration to baby which is mild and rare +Anaesthetic risks +VBAC risks + May need extra procedures like hysterectomy, transfusion +VTE risk +? ICU admission + Increases praevia/Accreta risk in the future
62
Who should you screen for pre-term labour?
Hx preterm delivery Late miscarriage Cervical treatment Multiple pregnancy also increases your risk as does IUGR
63
Key principles in managing preterm delivery
Has it reached threshold of viability- YES - Antenatal steroids 26-24+6 weeks - Nifedipine tocolysis - Teritary neonatal unit - ?Prophylactic MGSO4 and Benzyl penicillin RoM= Infection likely so do not use tocolysis
64
If poor history of preterm delivery what can be done?
Cervical stitch pre-conception
65
Management of preterm delivery
Steroids- Takes 2-3 days for impact Nifedipine if 26-33+6 IF NO INFECTION Admit and inform neonatal team -Prophylactic MGSO4 and Benzyl penicillin if delivery within 24 hours
66
What is a Fibronectin assay
-ve= Unlikely to Labour
67
What Cervical length would indicate that a ?preterm labour is unlikely to deliver
>15mm
68
What is a major Antepartum Haemorrhage
>50ml blood loss >24weeks gestation
69
Causes of antepartum haemorrhage
Uterine: Praevia, Abruption, Vasa praevia, Marginal bled, Cervical: Cancer, Polyps, Ectropion Show= Loss of mucus plug
70
Signs of a placental abruption (Uterus and placenta prematurely separate)
``` Vaginal bleed ?Dark red Pain and contractions Woody tense very tender uterus shock and foetal distress (in praevia foetal distress is rarer) ```
71
Risk factors for placental abruption
Pre-eclampsia, PROM, IUGR, Multiple preg, polyhydramnios, Inc maternal age, smoker, drugs use, HTN, Hx abruption, Thrombophilias Trauma
72
When is a placental abruption most common
25 weeks
73
What are the 4 stages of placenta praevia
1- Reaches lower segment but not OS 2- Reaches int.OS but does not cover it 3- Covers int OS before dilation but not when dilated 4- Completely covers OS
74
RF for placenta Praevia
Multiparity, c-section, Multiplem pregnancy,
75
When is placenta praevia most often picked up? What is best for detecting this?
20 weeks TV USS most accurate
76
What happens to most praevias after 16 weeks?
Most rise 16-20=5% 0.5% at delivery
77
What do you do if a placenta praevia is diagnosed in the 2nd trimester?
Repeat scan at 34 weeks
78
Presentation of a APH B/C placenta praevia
Bright red vaginal bleeding +/- Hypovolaemic shock NO PAIN Foetus relatively unaffected unless massive Always ask about anatomy scan and where the placenta was
79
How do you manage a Placenta praevia?
Remain inpatient until delivery ?Steroids If major then C-section at 39 weeks or before a significant bleed
80
Can you perform an internal examination if there is a placenta praevia?
Avoid until location known as may precipitate bled
81
Management of an APH
Maternal resus> Foetal wellbeing (CTG once mother stable) Blood products needed A to E, 2 large bore grey cannulae in ACF Left lateral position, Tilt bed down FBC, Clotting, Crossmatch 6U, G+S Steroids as there is a risk of preterm labour Anti-D and Kleihauer test
82
What is the Kleihauer test
Blood test for the amount of fetal Hb transferred from a fetus to a mothers blood stream. Helps guide whether Anti-D is needed
83
What cause of APH comes with a very big DIC risk?
Placental abruption
84
What does a triad of Rom, Fetal brady and painless bleeding suggest
Vasa Praevia
85
How do you define the 4 degrees of perineal tears
1- Skin only 2- Perineum injury involving muscle (Episiotomy) 3- Perineum, EAS involved a- EAS<50% b- EAS>50% torn c- IAS involved 4- Above + Anal/rectal epithelium
86
Basic principles of managing a perineal tear
Suture ASAP to reduce infection and bleeding Lithotomy position and analgesia Rectal exam both before and after! Broad spec Abx esp if 3/4 Stool softener & 6 week review if 3/4
87
How does uterine inversion present?
Vasovagal shock- Pale, clammy, hypotensive, Bradycardia, mass in the introitus, haemorrhage, clotting problems, renal dysfunction
88
How can you manage uterine inversion?
O'Sullivan method- Reduce inversion by hydrostatic technique Shock will correct itself when the uterus is replaced
89
Different categories of C-Section
1) ASAP Life threatened 2) 1 hr Compromise 3) 24 hr No immediate risk 4) Elective
90
What is augmentation of labour?l
Used if slow progress in Stage 1 (<1cm/hr dilation) ?Syntocinon and early amniotomy 'stimulating the uterus during labour to increase the frequency, duration and strength of contractions.'
91
Augmentation vs induction of labour
Induction of labour: stimulating the uterus to begin labour. Augmentation of labour: stimulating the uterus during labour to increase the frequency, duration and strength of contractions. DIFFERENT INDICATIONS BUT METHODS SAME
92
What are Braxton Hicks contractions?
Front only, Irregular, Not getting closer/stronger, Stop with position change NOT TRUE LABOUR
93
CI to IoL
Praevia, Transverse lie, Cephalopelvic disproportion, Cervix <4 on Bishops
94
When are Kielland's forceps good?
If you need to rotate baby

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