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Labour Flashcards

1
Q

Define Labour.

A

Products of conception expelled from uterus >24 weeks gestation.

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2
Q

Before how many weeks gestation is labour considered pre-term?

A

Before 37 weeks

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3
Q

What is the average length of labour for primiparous and parous women?

A

primiparous - 10 hours (unlikely to exceed 18 hours)

parous - 5.5 hours (unlikely to exceed 12 hours)

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4
Q

Describe the 1st stage of labour.

A

Onset of regular contractions
Cervical changes
Lasts until full dilatation of cervix and no longer palpable

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5
Q

The 1st stage of labour is split into the early latent phase and the active phase. Describe the cervical changes that occur in each.

A

Early latent phase - cervix becomes effaced, shortens in length and dilates to 4cm

Active phase - cervix fully dilates to 10cm

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6
Q

Describe the 2nd stage of labour.

A

From full cervical dilatation to delivery of foetus

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7
Q

The 2nd stage of labour is split into passive and active stages. Describe each.

A

Passive - full dilatation of cervix prior to or in absence of involuntary expulsive contractions

Active - baby is visible/ persistent involuntary expulsive contractions/ other signs of full cervical dilatation/ active maternal effort in absence of involuntary expulsive contractions

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8
Q

When is prolonged 2nd stage abour diagnosed in nulliparious women?

A

At 2 hours

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9
Q

When is prolonged 2nd stage labour diagnosed in multiparious women?

A

At 1 hour

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10
Q

What is the first-line management of prolonged labour?

A

Refer to obstetric reg unless birth is imminent

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11
Q

List 4 complications of prolonged labour.

A

Foetal distress
PPH
Pelvic floor dysfunction
Fistulae

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12
Q

Describe the 3rd stage of labour.

A

Time between delivery of foetus and delivery of placenta and membranes
Occurs 10-15 mins post foetal delivery and can last up to 30 mins

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13
Q

Describe physiological management of the 3rd stage of labour.

A

No drugs, cord not clamped until pulsations ceased

Placenta delivered by maternal effort

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14
Q

Describe active management of the 3rd stage of labour.

A

Use of uterotonic drugs (oxytocin or syntometrine) with delivery of anterior shoulder or immediately after birth or before cord stops pulsating
Bladder catheterisation
Deferred cord clamping and cutting
Controlled cord traction after sings of placental separation

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15
Q

Outline the signs of placental separation from membranes.

A

The uterus contracts, hardens and rises
Umbilical cord lengthens permanently
There’s a gush of blood variable in amount
Placenta and membranes appears at introitus.

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16
Q

Outline the pros and cons of active management of the 3rd stage of labour.

A

Pro - shortens length of 3rd stage

cons - increase risk of N&V, haemorrhage and blood transfusion

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17
Q

When is a change from physiological management of 3rd stage labour to active management indicated?

A

Excessive bleeding of haemorrhage occurs
Failure to deliver the placenta within one hour
The patient’s desire to shorten the third stage.

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18
Q

Describe 3 clinical signs of the onset of labour.

A

Regular, painful contractions that increase in duration and frequency
Passage of blood stained mucous from cervix
Rupture of membranes

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19
Q

What is the definition of prelabour rupture of membranes?

A

If the period between rupture of membranes to painful contractions is >4hours.
Called premature rupture of membranes if occurs before full-term gestation.

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20
Q

Describe hormonal changes that occur to initiate labour.

A

progesterone decreases
oestrogen and oxytocin increase thus increasing prostaglandin production
CRH is also thought to be involved - increases oestrogen and prostaglandin synthesis and reduces progesterone

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21
Q

How does oxytocin act to initiate labour?

A

released from posterior pituitary
acts on decidual tissue to promote prostagladin release
Initiates and sustains contractions
Also synthesised directly in decidual and extraembryonic tissue and placental tissue
oxytocin receptors in myometrial and decidual tissues increases towards end of pregnancy to increase uterine contractility

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22
Q

State another 2 hormones that influence uterine myocytes.

A

relaxin
activin A

(influence cAMP production causing relaxation of myometrial cells. Relaxin also helps soften pelvic ligaments and the pubic symphysis so allow room for baby to exit)

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23
Q

Describe 3 changes in the cervix towards term gestation/in labour.

A

Decreased collagen
Increased hyaluronic acid (softens and stretches the cervix by decreasing affinity for fibronectin and collagen and increasing affinity for water)
Progressive uterine contractions causes effacement and dilatation of cervix

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24
Q

State the 7 stages of labour.

A 
Engagement
Descent 
Flexion 
Internal rotation 
Extension 
External rotation (restitution)
Expulsion
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25
Q

How is engagement assessed in the 1st stage of labour.

A

Assessing how much of the foetal head can be felt in the abdomen, this is done in 5ths. i.e. if all of the head can be felt in the abdomen - it is 5/5 parts palpable. If no head can be felt it is 0/5 parts palpable.

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26
Q

List 8 possible causes of abnormal labour.

A

Malpresentation (non-vertex)
Malposition (occipitoposterior, occipitotrasnverse)
Preterm labour <37 weeks
Post-term labour >42 weeks
Too painful - requires anaesthestic input
Too quick (<2 hours) - hyperstimulation, precipitate labour
Too long - failure to progress
Foetal distress (hypoxia, sepsis)

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27
Q

Use the 3 Ps of labour to suggest reasons for failure to progress.

A

Powers - inadequate contractions
Passage - trauma, shape, cephalopelvic disproportion
Passenger - big baby, malposition

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28
Q

What are the possible complications of obstructed labour?

A

Sepsis - ascending genitourinary tract infection
PPH
fistula formation
Foetal asphyxia
Neonatal sepsis
Uterine rupture - increased risk if previous scar
Obstructed AKI

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29
Q

How is progression of labour assessed?

A

Vaginal examination every 4 hours to assess cervical dilatation, descent of presenting part and signs of obstruction (moulding, caput, anuria, haematuria, vulval oedema)

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30
Q

How is failure to progress defined?

A

<2cm cervical dilatation in 4 hours

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31
Q

State the 3 types of forceps that can be used for operative vaginal delivery and give an example of each.

A

Outlet forceps - Wrigley’s
Mid-cavity/ low-cavity forceps - Neville barnes, Andersons, Simpsons
Rotational forceps - Kielland’s forceps (should be performed with appropriate anaesthesia in theatre)

32
Q

What is required for a forceps delivery?

HINT - use the pneumonic FORCEPS

A

Fully dilated cervix (10cm)
Occipitoanterior position (possible with Keilland forcepts and ventouse)
Ruptured membranes
Cephalic presentation
Engaged presenting part
Pain relief
Sphincter (bladder) empty - may require catheterisation

33
Q

Give some indications for operative vaginal delivery.

A

Failure to progress in 2nd stage
Foetal distress
Maternal exhaustion
Special indication (i.e. if 2nd stage needs to shortened) include maternal cardiac disease, severe pre-eclampsia/ eclampsia, intra-partum haemorrhage, umbilical cord prolapse

34
Q

List some disadvantages to operative vaginal delivery.

A 
neonatal trauma; 
marks on babies face 
brachial plexus injury 
Facial nerve palsy 
Shoulder dystocia 
Perineal trauma incl. 3rd and 4th degree tears 
Psychological trauma 
Bowel symptoms 
Urinary symptoms 
PPH
35
Q

List some disadvantages to c-section.

A 
Haemorrhage 
Infection 
VTE 
Visceral injury (bladder and ureters)
Longer hospital stay 
Risk of uterine rupture in future labours
x4 greater risk of maternal mortality 
Transient tachypnoea of the newborn
36
Q

What are the advantages and disadvantages to ventouse delivery vs forceps?

A

less perineal trauma

more likely to fail
can cause cephalohaematoma and retinal haemorrhage

37
Q

What are the contraindications to ventouse?

A 
Prematurity (<34 weeks)
Face presentation 
Suspected foetal bleeding disorder 
Foetal predisposition to fracture e.g. osteogenesis imperfecta 
Maternal HIV or hep C
38
Q

Give 4 indications for the induction of labour.

A 
>42 weeks gestation 
Pre-eclampsia 
Placental insufficiency and IUGR
Antepartum haemorrhage 
Rhesus isoimmunisation 
Diabetes mellitus 
Chronic renal disease
39
Q

What is used to assess the outcome of induction of labour?

A

Bishop’s score using cervical examination

40
Q

What 5 measurements does Bishop’s score use?

A 
Cervical dilatation (cm)
Effacement (%)
Station 
Cervical consistency 
Cervix position

score of 6 = labour likely after induction
score <5 = cervical ripening required

41
Q

What determines the method of induction?

A

Whether membranes are ruptured

Bishop’s score

42
Q

List the 5 methods of induction and give a caution for each.

A

Stripping of membranes/ sweep (involves finger inserted into cervix) - NNT high

Amniotomy to rupture membranes - requires soft cervix and engagement of head - risk of cord prolapse and placenta praevia

Synthetic oxytocin infusion (following amniotomy) - can cause uterine hyperstimulation leading to foetal asphyxia, may also cause uterine rupture

Cervical ripening and prostaglandin E2 (pessaries or gel applied to posterior fornix, or oral) - contraindicated if uterine scar due to risk of hyperstimluation or rupture

Mechanical cervical ripening - balloon catheter into cervix for 12 hours then removed to allow amniotomy

43
Q

What measurements are involved in a partogram?

A 
Foetal heart rate
Cervical dilation
Duration of labour
Colour of liquor
Frequency and duration of contractions
Caput and moulding
Station or descent of the head
Maternal heart rate, BP and temperature
44
Q

What is the common side effect of entonox gas?

A

nausea

45
Q

What are the contraindications to regional anaesthesia during labour?

A 
maternal refusal 
coagulopathy 
local or systemic infection 
uncorrected hypovolaemia 
inadequate staff experience or facilities
46
Q

What are the 3 methods of regional anaesthesia during labour?

A

Epidural
Spinal
Pudendal nerve block

47
Q

Give 3 advantages to epidural analgesia.

A

Complete pain relief in most women
Doesn’t increase risk of c-section
Can be controlled by patient
Can be topped up to allow operative deliveries

48
Q

Give 3 disadvantages to epidural analgesia.

A

Lack of pressure sensation may reduce desire to push during active second stage
Reduced uterine contraction due to loss of Ferguson reflex
Increased risk of assisted vaginal delivery
Causes abnormal foetal heart rate
Hypotension
Accidental dural puncture
Postural headache dependent on gauge of cannula
High block may cause maternal respiratory depression
Atonic bladder

49
Q

What does an epidural consist of?

A

Local anaesthetic agent (e.g. bupivacaine) injected into a fine catheter in the epidural space between L3-4
Addition of an opioid reduces dose requirement of bupivacaine and spares motor fibres to lower limbs and reduces complications i.e. hypotension and abnormal foetal heart rate

50
Q

What is mechanism of action of a pudendal nerve block?

A

local anaesthesia injected around the pudendal nerve at the level of the ischial spine
often used for operative vaginal delivery

51
Q

What are the disadvantages of pudendal nerve block?

A

can be ineffective
risk of haemorrhage from pudendal artery
risk of lignocaine toxicity if inadvertent muscular injection

52
Q

How is spinal anaesthesia used?

A

catheter inserted into subarachnoid space between L3-4 and anaesthetic agent injected
commonly used for operative delivery

53
Q

Why is spinal anaesthesia not used for pain control in labour?

A

because of the superior safety of an epidural and its ability to top up with suitable doses or use as a continuous infusion

54
Q

Give some examples of narcotic analgesia that can be used in labour.

A

pethidine
morphine
remifentanil

55
Q

What are the disadvatages to narcotic analgesia?

A

nausea and vomiting

foetal respiratory depression

56
Q

What is the mechanism of action of remifentanil?

A

ultra-short acting opioid that offers superior pain relief to pethidine with less desirable SE on foetus

57
Q

Give 3 maternal indications for CTG monitoring during labour.

A

Gestation <37 weeks or >42 weeks
Induced labour
Administration of oxytocin
Ante/intrapartum haemorrhage
Maternal illness (e.g. diabetes, cardiac or renal disease, hyperthyroidism, maternal infection)
Pre-eclampsia
Previous uterine scar (c-section or myomectomy)
Contractions > 5 in 10 or lasting more than 90 seconds
During/ following insertion of epidural block.
Maternal request

58
Q

Give 3 foetal indications for CTG monitoring during labour.

A

Abnormal doppler artery velocimetry
Known or suspected IUGR
Oligohydramnios or polyhydramnios
Malpresentation
Meconium stained liquor
Multiple pregnancy (all babies need to be monitored)
Suspected small for gestational age or macrosomia
Reduced foetal movements in the last 24hours reported by the woman
Two vessel cord
Prolonged rupture of membranes >24hours unless delivery is imminent
A rise in baseline, repeated decelerations or slow to recover decelerations or overshoots.
Foetal structural abnormalities diagnosed during the antenatal period and planned for CEFM.

59
Q

What may meconium indicate?

A

foetal distress/ hypoxia/ obstructed labour
prolonged pregnancy in a term infant
breech presentation
may be normal

60
Q

What is the disadvantage to CTG monitoring during labour?

A

non-specific and increase medical intervention

61
Q

Describe how to interpret a CTG.

Hint - Dr BrVADO

A 
Define risks e.g. pre-eclampsia, diabetes
Baseline foetal heart rate 
Variation in foetal HR
Accelerations (>15bpm above baseline)
Decelerations (>15bpm below baseline)
Overall impression
62
Q

What CTG changes are non-reassuring/abnormal?

A 
Foetal bradycardia (HR<100) 
Foetal tachycardia (HR>160)
Sinusoidal HR pattern
<5 accelerations in 90 mins
Late decelerations 
Reduced variability
63
Q

What should be done if a CTG is non-reassuring?

A 
inform senior 
move to left lateral position 
encourage fluids (IV or oral)
Stop oxytocin 
Consider tocolysis
64
Q

What should be done if you suspect an abnormal or pathological CTG?

A

inform senior
start conservative measures
offer foetal blood sampling
exclude factors that indicate need for immediate delivery (cord prolapse, uterine rupture, hyperstimulation, abruption)
Treat dehydration, hyperstimulation, hypotension and change position

65
Q

What should be done if you suspect an abnormal or pathological CTG that requires urgent intervention?

A

Inform senior
start conservative measures
makes preparations for urgent birth (category 1 c-section)

66
Q

When is foetal blood sampling indicated and how is it performed?

A

when their are abnormalities in foetal HR during labour and foetal acidosis is suspected

an amnioscope is used to obtain blood from the foetal scalp, cervix must be >3cm dilated

67
Q

What is normal foetal pH?

A

7.25-7.35

68
Q

What is the management plan if foetal blood pH is <7.2 and high lactate?

A

deliver - forceps or c-section

69
Q

What are the 4Hs and 4Ts that can cause collapse that also need to be considered in pregnancy?

A

Hypovolaemia
Hypoxia
Hypo/hyperkalaemia
Hypothermia

Thromboembolism
Toxicity
Tension pneumothorax
Tamponade (cardiac)

70
Q

What are the causes of maternal collapse isolated to pregnancy?

A

pre-eclampsia/ eclampsia

intracranial haemorrhage

71
Q

What are the possible causes of maternal hypovolaemia in pregnancy?

A

bleeding
relative hypovolaemia of dense spinal block
septic or neurogenic shock

72
Q

What are the possible causes of maternal hypoxia in pregnancy?

A

peripartum cardiomyopathy
myocardial infarction
aortic dissection
large vessel aneurysms

73
Q

What are the possible causes for thromboembolism in pregnancy?

A

amniotic fluid embolism
pulmonary embolus
air embolus
myocardial infarction

74
Q

How does an amniotic fluid embolism present?

A 
acute respiratory distress and cardiovascular collapse in a patient during labour or in one who has recently delivered 
acute hypotension 
respiratory distress 
acute hypoxia  
seizures and cardiac arrest may occur
75
Q

What are the complications of amniotic fluid embolism if the woman survives?

A

left ventricular dysfunction or failure

disseminated intravascular coagulation resulting in massive PPH

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