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Y5 OG Conditions > Labour > Flashcards

Labour Flashcards

1
Q

What is the epidemiology of labour?

A

o 600,000 babies born per year

o 30% by C-section (elective and emergency), 10% instrumental, 60% by natural means (inc. induction)

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2
Q

What is labour?

A

Painful uterine contractions leading to effacement and dilation of the cervix (normal length = 4cm)

o N.B. 2/5th palpable or below is defined as engagement

o If someone is just dilating due to cervical insufficiency, you can perform cervical cerclage

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3
Q

What are braxton hicks contractions?

A

PAINLESS and NO CERVICAL CHANGE

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4
Q

Describe the 3 stages of labour?

A

o 1st stage – painful uterine contractions -> full (10cm) cervical dilatation
§ Latent phase = begins with painful, irregular contractions; dilation up to 4cm
§ Established stage 1 = regular painful contractions; ≥4cm dilation

o 2nd stage – starts with the urge to push and ends with delivery of the foetus
§ Passive stage (not pushing) -> Active stage (pushing)
§ Analgesia (‘1, 2, 3’ and analgesia = +1 hour):
· In nulliparous women -> 3 hours (epidural) or 2 hours (no epidural)
· In multiparous women -> 2 hours (epidural) and 1 hour (no epidural)

o 3rd stage – delivery of placenta and foetal membranes
§ Can last as long as 30 mins

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5
Q

What are the mechanisms of labour?

A

o N.B. pelvic inlet widest TRANSVERSE, but pelvic outlet widest ANTERIOR-POSTERIOR

o Progress of labour determined by:

§ Power – contractions

§ Passage – dimensions of pelvis

§ Passenger – diameter of foetal head

o Restitution = brining head in line with the shoulders

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6
Q

What are the risk factors of shoulder dystocia?

A

macrosomia, high maternal BMI, DM, prolonged labour

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7
Q

What are the S/S of shoulder dystocia?

A

difficult face/chin delivery, ‘turtling’ head (retracting), failure of restitution, failure of shoulder descent

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8
Q

What is the management of shoulder dystocia?

A

§ 1) Call for senior help + discourage pushing

§ 2) McRobert’s manoeuvre (legs up to abdomen) and suprapubic pressure – 90% success

§ 3) Evaluate for episiotomy

§ 4) Either (depends on user experience / clinical indication):

· 1) Rubin’s manoeuvre (push anterior shoulder towards baby’s chest)

· 2) Woods’ Screw (Rubin’s + push posterior shoulder towards baby’s back -> rotation)

· 3) Deliver posterior arm (then, rotate 180 and deliver the other arm)

§ 5) Change position to all fours and repeat the above manoeuvres

§ 6) Symphysiotomy, cleidotomy (divide clavicles) or Zavanelli (reversal of normal delivery movements)

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9
Q

What is the complication of shoulder dystocia?

A

Erb’s Palsy

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10
Q

What is Bishop’s score?

A

a score used to see how likely one is to go into labour soon

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11
Q

Define effacement, position and station.

A

o Effacement = (also called shortening or thinning) is reported as a percentage from 0% (normal length cervix) to 100% or complete (paper thin cervix)

o Position = the position of the foetal head relative to the maternal head and maternal pelvis

o Station = position of the baby’s head relative to the ischial spines of the maternal pelvis. If the head is level with the spines, the score is 0; however, above or below them can modify the score

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12
Q

How do you use Bishops score?

A

§ <3 IOL unlikely to be successful

§ ≤5 IOL with PV prostaglandin gel (should start labour or ripen cervix)

§ 6-8 ARM (amniotomy ± oxytocin infusion if labour does not begin)

§ ≥9 labour likely to occur spontaneously

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13
Q

Offer x2 PGE2 and then ARM

A

Offer x2 PGE2 and then ARM

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14
Q

Summarise the management of the first stage of labour

A

§ One-to-one midwifery care

§ Vaginal examinations performed 4-hourly or as clinically indicated

§ Progress of labour is monitored using a partogram with timely intervention if abnormal

§ Ensure adequate:

· Analgesia ± antacids

· Hydration and light diet to prevent ketosis (which can impair uterine contractility)

§ Normal Progress: ~1 cm every hour (a well flexed head will speed this up)

§ Delay: <1cm over 2 hours (a well flexed head will speed this up)

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15
Q

What do you do in latent first phase?

A

mobilise and managed away from the labour suite

§ This stage is generally silent as the cervix gradually effaces over a period of days/weeks

§ Intervention should be avoided where possible

§ Standing upright may encourage progress of labour (so mobility should be encouraged)

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16
Q

How do you manage delay in the first stage of labour?

A

<1cm per 2 hours is defined as delay (this is so intervention isn’t started too early)

1st -> Membranes intact -> ARM (Artificial Rupture of the Membranes) -> review in 2 hours

2nd -> Membranes ruptured -> oxytocin:
· Increase every 15-30 mins until regular contractions
· Once regular contractions, review in 4 hours

o During this phase, the membranes may be intact or may have ruptured

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17
Q

What are the types of delay in the first stage labour?

A

Primary dysfunctional labour <2cm dilation in 2 hours, never progressed properly
Most commonly due to ineffective uterine action

Secondary arrest of labour progressed well and then stopped
Prolonged latent phase
Cervical dystocia rare; cervix doesn’t dilate properly

18
Q

What is the management of the second stage of labour?

A

o First sign of the 2nd stage = urge to push (with 10cm dilation)

o Full dilatation of the cervix confirmed by a vaginal examination (if the head is not visible)

o Women should be discouraged from lying supine or semi-supine

o Use of regional anaesthesia (epidural or spinal) may interfere with the normal urge to push – meaning that the second stage is more often diagnosed on routine scheduled vaginal examination

19
Q

How do you manage a delayed second stage of labour?

A

o Delay / Prolonged Second Stage (from start of active 2nd stage):
In nulliparous women -> 3 hours (epidural) or 2 hours (no epidural)
In multiparous women -> 2 hours (epidural) and 1 hour (no epidural)

· 1st -> Membranes intact -> ARM (Artificial Rupture of the Membranes) -> review in 2 hours

· 2nd -> Membranes ruptured -> oxytocin:
o Increase every 15-30 mins until regular contractions
o Once regular contractions, review in 4 hours

20
Q

What happens in delivery?

A

§ Watch the perineum -> between contractions, elastic tone of the perineal muscles will push the head back into the pelvic cavity -> when head no longer recedes between contractions = crowning

· This indicates that delivery is imminent

§ As crowning occurs, the hands of the midwife are used to flex the foetal head and guard the perineum

§ Once the head has crowned, the woman should be discouraged from bearing down by telling her to take rapid, shallow breaths

21
Q

What is the immediate care of the neonate?

A

o The baby will usually take its first breath within seconds

o There is no need for immediate clamping

o After clamping/cutting umbilical cord, baby should have an Apgar score calculated at 1 minute and at 5 minutes

o The baby’s head should be kept dependent to allow mucus in the respiratory tract to drain

o Immediate skin-to-skin contact between mother and baby will help bonding and promote release of oxytocin

22
Q

When is the APGAR score used?

A

Apgar score is used at 1 minute and 5 minutes after delivery (and every 5 minutes after if condition remains poor)

o >7 is considered normal APGAR = Appearance, Pulse, Grimace, Activity, Respiration

23
Q

What should happen in the first hour of life?

A

§ The baby should be dried and covered with a warm blanket or towel

§ Initiation of breastfeeding should be encouraged within the first hour of life

§ Routine measurements of HC, birthweight and temperature should be measured soon after this hour

§ The first dose of baby’s vitamin K should be given in the delivery room (in first 24 hours

24
Q

What are the causes of PPH?

A

“Tow-Truck is most common”
Tone (uterine atony; 70%)
Trauma (laceration; 20%)

Tissue (retained products; 10%)
Thrombin (coagulopathy; 1%)

25
Q

What is the 3rd stage of labour?

A

o This normally takes 5-10 minutes (expulsion of placenta and foetal membranes)

o Management of the third stage can be described as active or physiologica

26
Q

What is the active management of the 3rd stage?

A

recommended to ALL women

§ 10 IU oxytocin (IM) / ergometrine (only oxytocin if hypertensive)

· After birth of the anterior shoulder

· Immediately after delivery (and before the cord is clamped and cut)

§ Clamp the cord between 1-5 mins

§ Use controlled cord traction to remove the placenta -> signs of placental separation:

· Gush of blood Cord lengthening

· Uterus rises Uterus becomes round

§ Uterine inversion is a rare complication

§ In 2% of cases, the placenta will not be expelled by this method

§ If no bleeding occurs, another attempt should be made after 10 mins

27
Q

What is the physiological management of the 3rd stage?

A

§ Placenta is delivered by maternal effort with no uterotonic drugs

§ Associated with more bleeding and a greater need for blood transfusions -> if haemorrhage occurs OR the placenta is undelivered after 60 mins, active management should be recommended

28
Q

What happens post delivery?

A

§ 1) Inspect placenta for: If retained -> EUA + MROP (manual removal of placental tissue)

· Missing cotyledons

· Succenturiate lobe

§ 2) Vulva inspected for tears

29
Q

What is the management of a prolonged 3rd stage?

A

§ Active management: >30 minutes

§ Physiological management: >60 mins -> move to active management

30
Q

How do you induce labour?

A

o 1st: Membrane Sweeping

§ Offered prior to formal induction (not part of induction of labour) -> repeat if labour not starting

§ Nulliparous women -> offer at 40-41 weeks

§ Multiparous women -> offer at 41 weeks

o 2nd: Prepare the cervix -> prostaglandins (Prostin or Propress; Vaginal Prostaglandin E2)

§ Preferred formal method of induction

§ Can be administered as a tablet, gel or pessary

· Pessary: 1 dose over 24 hours

· Tablet or Gel: 1 dose, followed by a second dose after 6 hours (MAX: 2 doses)

§ RISK -> uterine hyperstimulation

§ In cases of intrauterine foetal death, misoprostol and mifepristone may be used instead

o 3rd: Artificial Rupture of Membranes (ARM)

§ ARM = amniohook

§ Should not be used first line

o 4th: Syntocinon

o 5th: CS

Propess (24 hours) -> Prostin (if propess was insufficient – max 2x; 6 hourly) -> ARM -> Syntocinon -> C-sectio

31
Q

When is induction indicated?

A

Prevention of prolonged pregnancy (at 41wks, If declined -> twice weekly USS and CTG)

Maternal request (on or after 40 weeks, exceptional circumstances such as armed services partner leaving)

Intrauterine foetal death (If membranes intact -> offer induction If rupture of membranes, infection or bleeding -> immediate induction Induction regimen: oral mifepristone, followed by prostin or misoprostol)

32
Q

When should you be cautious for inducing labour?

A

Previous C section (use prostin/ propress)

Increased risk of uteriine rupture and need for 2nd C section

33
Q

When should you not induce?

A

PPROM before 34 weeks

Breech/ trasnverse lie (consider Csection/ ECV)

IUGR if severe (CSection)

Suspected foetal macrosomia

34
Q

What non pharmacological analgesia can be used?

A

§ TENS

§ Breathing techniques

§ Massag

35
Q

What pharmacological analgesia can be used?

A

§ Entonox (50% NO in O2) -> nausea, light-headed, dry mouth

§ Meperidine (pethidine, IM 1mg/kg) -> ‘sleepy baby’, low baby RR, constipation

§ Morphine (0.1-0.15mg/kg) or Diamorphine (IM 5-7.5mg) -> ‘sleepy baby’, low baby RR, constipation

§ Fentanyl PCA 20μG bolus with 5 min lockout -> ‘sleepy baby’, low baby RR, constipation

36
Q

What surgical analgesia can be used?

A

slow labour, increased instrumental risk

§ Lumbar epidural – bupivacaine, ropivacaine, levobupivacaine, chloroprocaine

§ Combined lumbar spinal-epidural – fentanyl 10-25mcg ± bupivacaine 2.5mg

37
Q

What is a partogram?

A

o Records condition of mother, condition of foetus, progress of labour

o Can be used to calculate a Bishop’s score (collects all necessary pieces of data)

38
Q

What are the obstetric emergencies?

A

o Sepsis
Antepartum haemorrhage or PPH
Placenta praevia

o Placenta accreta
Vasa praevia
Prolonged 3rd stage

o Eclampsia
Amniotic fluid embolism
Cord prolapse

o Shoulder dystocia
DVT PE
Uterine inversion

o Uterine rupture
Puerperal pyrexia

39
Q

What is puerperal pyrexia?

A

> 38C in the first 14 days following delivery

40
Q

What is the biggest cause of puerperal pyrexia?

A

Endometritis

41
Q

What are causes of puerperal pyrexia?

A 
Endometritis
UTI 
VTE
Wound infection (tear, CS) 
Mastitis
42
Q

What is the management of puerperal pyrexia?

A

IV Clindamycin AND IV Gentamicin until >24 hrs apyrexial

Y5 OG Conditions (76 decks)

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