Labour Flashcards by Shaili Kadambande

What is failure to progress?

Labour not developing at a satisfactory rate

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Ps of progress in labour

Power: uterine contractions

Passenger: size, presentation and position of the baby

Passage: the shape and size of the pelvis and soft tissues

Psyche

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Phases of first stage of labour

Latent
Active
Transitional

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Latent phase

0-3cm dilation of cervix
0.5cm/hr
irregular contractions

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Active phase

3-7cm dilation of cervix
1cm/hr
Regular contractions

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Transitional phase

7cm-10cm dilation of cervix
1cm/hr progression
strong and regular contractions

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Delay in labour:
First stage
Second stage
Third stage

1st stage:
Less than 2cm of cervical dilatation in 4 hours
Slowing of progress in a multiparous women

2nd stage:
Pushing more than 2 hours in nulliparous
Pushing more than 1 hour in multiparous

3rd stage:
>30 mins active management
> 60 mins physiological management

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Passenger

Size: shoulder dystocia
Attitude: posture
Lie: position of fetus in relation to mother’s body
Presentation: part of fetus closest to cervix

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Risk factors for uterine rupture in VBAC

Previous c section
Previous uterine surgery 
Obstruction or induction of labour
Multiparity
Multiple pregnancies

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Absolute contraindications to VBAC

Classical c section scar
Previous uterine scar
Contraindications to vaginal birth

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Active management of the third stage of labour

im oxytocin

controlled cord traction

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management of failure to progress

amniotomy: ARM
oxytocin infusion
instrumental delivery
c section

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Relative contraindications to VBAC

Complex uterine scars

>2 prior lower segment c sections

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Management of VBAC delivery

These women should deliver in a hospital setting with facilities for emergency caesarean and advanced neonatal resuscitation.

There should be continuous CTG monitoring.

Beware of additional analgesic requirements during the labour as may indicate impeding uterine rupture.

Avoid induction where possible.

If induction is required, the risk of uterine rupture is less using mechanical techniques (e.g. amniotomy) than induction with prostaglandins.

Be cautious with augmentation (increased risk of uterine scar rupture)

Any decisions about both induction and augmentation require input from a senior obstetrician.

After 39 weeks an elective repeat caesarean is recommended delivery method.

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when does normal labour and delivery usually occur?

37-42weeks

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definition of labour

progressive dilatation and effacement of cervix in presence of regular uterine contractions

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delivery definition

expulsion of feotus and placenta

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show defintiino

cervical mucus plus

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gravidity

total number of pregnancuies

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parity

the state of having given birth
>24 weeks
>500g

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three stages of labour

First stage – from the onset of labour (true contractions) until 10cm cervical dilatation

Second stage – from 10cm cervical dilatation until delivery of the baby

Third stage – from delivery of the baby until delivery of the placenta

braxton-hicks contractions

Braxton-Hicks contractions are occasional irregular contractions of the uterus. They are usually felt during the second and third trimester. Women can experience temporary and irregular tightening or mild cramping in the abdomen. These are not true contractions, and they do not indicate the onset of labour. They do not progress or become regular. Staying hydrated and relaxing can help reduce Braxton-Hicks contractions.

signs of labour

Show (mucus plug from the cervix)

Rupture of membranes

Regular, painful contractions

Dilating cervix on examination

indications for continuous CTG monitoring in labour

Sepsis

Maternal tachycardia (> 120)

Significant meconium

Pre-eclampsia (particularly blood pressure > 160 / 110)

Fresh antepartum haemorrhage

Delay in labour

Use of oxytocin

Disproportionate maternal pain

CTG features to look for

Dr C BRAVADO Contractions – the number of uterine contractions per 10 minutes Baseline rate – the baseline fetal heart rate Variability – how the fetal heart rate varies up and down around the baseline Accelerations – periods where the fetal heart rate spikes Decelerations – periods where the fetal heart rate drops Overall impression

Contractions on CTG

Number of contractions present in 10 squares | Duration and intensity

Too many contractions

uterine hyperstimulation, fetal compromise

too few contractions

labour not progressing

fetal tachycardia causes

``` >160 fetal hypoxia chorioamnionitis hyperthyroidism fetal/ maternal anaemia fetal tachyarrhythmia ```

fetal bradycardia causes | 100-200

postdate gestation | occiput posterior or transverse presentations

causes of prolonged, severe bradycardia in ctg

``` prolonged cord compression cord prolapse epidural and spinal anaesthesia maternal seizures rapid fetal descent ```

normal variability CTG

5-25

causes of reduced variability

``` fetal sleeping fetal acidosis fetal tachycardia drugs: opiates, benzodiazepines prematurity congenital heart abnormalities ```

early decelerations

start when uterine contraction begins and recover when uterine contraction stops normal

causes of early decelerations

uterus compressing the head of the fetus stimulating vagus nerve slowing heart rate

late decelerations causes

maternal hypotension pre-eclampsia uterine hyperstimulation

variable decelerations causes

umbilical cord compression | if shoulders are there not worrying

fetal bradycardia rule of 3s

3 minutes – call for help 6 minutes – move to theatre 9 minutes – prepare for delivery 12 minutes – deliver the baby (by 15 minutes)

sinusoidal CTG causes

severe fetal hypoxia severe fetal anaemia fetal/maternal haemorrhage

oxytocin indication | syntocinon

induction of labour progressiob of labour increase strength of contracetions PPH

atosiban indication

oxytocin receptor antagonist | alternative to nifedipine in premature labour

ergometrine indication

PPH | third stage of labour

prostaglandins indication | dinoprostone

induction of labour

misoprostol

prostaglandin analogues | medical management of miscarriage

mifepristone

anti-progestogen blocks progesterone and ehnances prostaglandins used in induction of labour after intrauterine fetal death and alongside misoprostol for abortions

nifedipine

CCB that acts to reduce smooth muscle contraction in blood vessels and uterus reduces BP tocolysis in premature labour, delay onset

terbulatline

B2 agonist | tocolysis in premature labour

carboprost

prostaglandin analogue stimulates uterine contraction PPH caution in asthma

Gas and Air (Entonox)

Gas and air contains a mixture of 50% nitrous oxide and 50% oxygen. This is used during contractions for short term pain relief.

Intramuscular Pethidine or Diamorphine

IM opioid They may cause drowsiness or nausea in the mother, and can cause respiratory depression in the neonate if given too close to birth. The effect on the baby may make the first feed more difficult.

PCA

remifentanil

epidural side effects

Headache after insertion Hypotension Motor weakness in the legs Nerve damage Prolonged second stage Increased probability of instrumental delivery