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Year 4 OBGYN > Labour > Flashcards

Labour Flashcards

(104 cards)

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1
Q

What is a Breech presentation?

A

Where the foetus presents buttocks/feet first

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2
Q

What are the three types of Breech Presentation?

A

Complete flexed: Both legs flexed at hips and knees (cross legged)
Frank (Extended): Most Common, Flexed at hip straight at knee, buttocks at pelvic inlet
Footing: One or both legs extended at hip so foot is presenting part

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3
Q

Give two Uterine and two Foetal risk factors for Breech Presentation

A

Uterine: Malformations (Septate), Fibroids

Foetal: Macrosomia, Polyhydramnios

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4
Q

How is Breech presentation diagnosed?

A

Clinical examination reveals head in upper uterus and irregular mass in pelvis
Foetal Heart auscultated higher OE
USS

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5
Q

How is Breech presentation managed?

A

May spontaneously resolve

ECV (External Cephalic Version)

Caesarean

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6
Q

Describe the method of ECV

A

Forward Roll Technique

Breech elevated from pelvis
Pushed to side where back is
Head is pushed and forward roll is completed

Afterwards CTG and give Anti D to Rhesus Neg mothers

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7
Q

Give two contraindications and two complications of ECV

A

Contraindications: Recent Antepartum Haemorrhage, Ruptured Membranes

Complications: Transient foetal Heart abnormalities, Placental Abruption

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8
Q

The Woman may choose a vaginal birth despite Breech (contraindicated completely in footing), describe two specific manoeuvres used

A

Lovsetts (if arms are above chest) - place hands around baby, rotate 180 degrees clockwise then anti-clockwise with downward traction (allows anterior, then posterior shoulder to be delivered)

Mauriceau Smellie Veit - place two fingers over maxilla and two over back of head to flex it, mum should be encouraged to push

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9
Q

Define Foetal Lie and how you would determine it

A

Relationship between the long axis of the foetus and the mother

Can be longitudinal/transverse/oblique

Place hands either side of the abdomen, gently apply pressure with one hand and feel with the other (one side firm- back, other side knobbly - foetal limbs)

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10
Q

Define Foetal Presentation and how you would determine it

A

The part that first enters the maternal pelvis

Safest is cephalic, but others include Breech/Shoulder/Face/Brow

Palpate lower uterus with fingers of both hands

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11
Q

Describe foetal position and how you would determine it

A

Position of foetal head as it exits birth canal

Usually occipitoanterior but can be occipitoposterior or occipitotransverse

Use vaginal examination and fontanelles as landmarks

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12
Q

Give five indications for Induction of Labour

A

Prolonged Gestation
Premature Rupture of Membranes
Foetal Growth Restriction
Maternal Health Problems (such as Pre-Eclampsia)

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13
Q

Give two absolute and two relative contraindications to IOL

A

Absolute: Cephalopelvic Disproportion, Major Placenta Praevia

Relative: Breech, Triplet or higher order pregnancy

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14
Q

Describe the Vaginal Prostaglandin method of IOL

A

Prostaglandins increase cervical ripening and cause uterine contractions

Can be given as Tablet/Gel (one every 24 hours) or Pessary

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15
Q

Describe the Amniotomy method of IOL

A

Membranes are ruptured artificially using Amnihook, causing release of Prostaglandins

Only done when cervix is determined as ‘Ripe’ by Bishops Score

Syntocinon given alongside

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16
Q

Describe the Membrane Sweep Adjunct of IOL

A

Insert gloved finger through cervix and rotate against foetal membrane

Aims to separate Chorionic Membrane from Decidual Membrane and cause PG Release

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17
Q

What is Bishops Score and when is it measured?

A

Measure of Cervical Ripeness via Vaginal Exams

Checked prior to induction, and during induction (6 hours post tablet/gel or 24 hours post pessary)

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18
Q

State the five parameters of the Bishops Score

A 
Cervical Dilation (cm)
Cervical Length (cm)
Cervical Station
Cervical Consistency
Cervical Positon
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19
Q

Describe the results of the Bishops Score

A

> 7 the cervix is ripe/favourable and there is a high chance of response to IOL
<5 the labour is unlikely to progress naturally so IOL required

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20
Q

Give four complications of IOL

A

Failure of Induction (15%)
Uterine Hyperstimulation (Contractions too long or too frequent, manage with tocolytics)
Cord Prolapse
Infection

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21
Q

Describe the Ventouse method of Operative Vaginal Delivery

A

Cup attached to foetal head via vacuum (can be electrical, only suitable for OA, or handheld ‘Kiwi’)
Attached with centre over flexion point over foetal skull
Traction applied during contractions

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22
Q

Give two advantages and two disadvantages of Ventouse Delivery

A

Advantages: Less Pain, Less Perineal Injuries
Disadvantages: Cephalohaematoma, Subgaleal Haematoma

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23
Q

Describe the Forceps method of Operative Vaginal Delivery

A

Different specific forceps depending on position

Blades around foetal head with blades then locked together and gentle traction with contractions

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24
Q

Give an advantage and disadvantage of Forceps Delivery

A

Advantages: Doesn’t require maternal efforts
Disadvantages: Higher rate of perineal tears

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25
How many attempts should you have at Operative Vaginal Delivery?
3
26
Give three indications for Operative Vaginal Delivery
Inadequate Progression Maternal Exhaustion Suspected foetal compromise
27
Give three absolute contraindications to Operative Vaginal Delivery
Unengaged Foetal Head Incompletely dilated cervix Breech/Face/Brow Presentation
28
Describe the classifications of foetal descent
Outlet: Foetal scalp visible with parted labia Low: Lowest presenting part is at least +2 below ischial spine Midline: Lowest presenting part is below ischial spine but above +2 Subdivided into rotation needed or not needed
29
Describe the different between PROM and PPROM
PROM - Rupture of foetal membranes at least one hour before onset of labour PPROM- when the above occurs before 37 weeks gestation
30
Describe the pathophysiology of PROM
Chorion and Amnion strengthened by collagen that physiologically becomes weaker closer to term May occur earlier due to infection, or genetic predisposition
31
Give three risk factors for PROM
Smoking Lower GTI Invasive Procedures
32
How does PROM present?
Normally the classical description of Waters Breaking (pop followed by gush of water) May be more subtle (gradual leaking, damp underwear)
33
State 5 investigations for PROM
Vaginal exam (after lying for 30 mins to allow fluid to pool) High Vaginal Swab for GBS Ferning Test (Cervical Secretions on Slide allowed to dry, fern shaped pattern) Actim Prom (IGFBP-1 conc in Vagina) Nitrazine Testing (pH of fluid in Vagina as Amniotic is more alkaline)
34
Describe the management of PROM
<34 weeks: aim to increase gestation, give prophylactic steroids and erythromycin 34-36 weeks: IOL and steroids >36 weeks: IOL if not commenced in 48h, prophylactic Erythro
35
Describe the classification of an Caesarean Section
1 - Immediate threat to maternal/foetal life so baby should be born within 30 mins 2 - Maternal/Foetal compromise that’s not immediately threatening (born within 75 mins) 3 - No compromise but needs delivery 4 - Elective
36
Why are Prokinetics such as Ranitidine given Pre-Caesarean?
Due to risk of Mendelson’s Syndrome (Aspiration of gastric contents into lung causing chemical pneumonitis from pressure of Gravid Uterus)
37
How should the patient be positioned in a Caesarean Section?
15 degrees left lateral tilt (reduces risk of hypotension due to aortocaval compression)
38
Outline the stages of a Caesarean Section
1) Skin Incision 2) Sharp Blunt Dissection 3) Visceral Dissection to reveal bladder (retracted by Doyen) 4) Uterine Incision and Fundal Pressure 5) Oxytocin and aided placental delivery
39
Give three immediate complications of Caesarean Section
PPH Bladder Trauma Foetal Lacerations
40
Give two late complications of Caesarean Section
Fistula | Uterine Rupture
41
What is the main risk with VBAC?
Uterine Rupture | Results in foetal hypoxia and large maternal haemorrhage
42
How should VBACs be managed?
In hospital setting Continual CTG monitoring Avoid induction where possible
43
Give three contraindications to VBAC
Upper Caesarean Previous Rupture Complex Scars
44
Give two side effects Syntocinon
Arrhythmias | Headache
45
When is Mifepristone used?
Antiprogesterone ripening cervix and increasing prostaglandin sensitivity Used in ToP or foetal death
46
Give two side effects of Mifepristone
Cramps | Infection
47
Give two non pharmacological methods of Pain Control
TENS (as long as not in established labour) | Entonox (50/50 O2 and NO)
48
Give three considerations to IV/IM Opioids in labour
Side effects include drowsiness and nausea for mother, and resp depression for baby May interfere with breast feeding Shouldn’t enter birthing pool within two hours
49
Epidural (Bupivicaine, Fentanyl) is the most effective pain relief in labour, how should patients be monitored?
CTG for 30 mins after establishment, and after each bolus of more than 10ml If not pain free after 30 mins call anaesthetist
50
What should be plotted on a Partogram in the first stage of labour?
Hourly Pulse Four hourly temp and BP Frequency of passing urine Four hourly vaginal exam
51
How can you assess progression of labour during the first stage?
Cervical Dilation Descent and rotation of foetal head Changes in strength/duration/frequency
52
How should you titre Oxytocin?
Increase until there are 4-5 contractions every 10 minutes
53
During the second stage of labour the foetus should be monitored via intermittent auscultation and potentially continuous CTG. Give four indications for continuous CTG.
Maternal Pulse >120bpm on two separate occasions Oxytocin Use Presence of Meconium Temp above 38 degrees
54
Describe the method of reading a CTG
``` DR: Define Risk C: Contractions BR: Baseline Rate A: Accelerations Va: Variation D: Decelerations O: Overall Impression ```
55
How do you measure Contractions using a CTG?
Number in 10 minutes (ie 10 big squares)
56
What should the Baseline HR be, and what could deviations of this be caused by?
Should be 110-160bpm >160 could be hypoxia, anaemia <110 could be Cord Prolapse, Post Date Gestation
57
What are Accelerations?
Abrupt increase in baseline HR of >15bpm for >15 seconds Normal and reassuring
58
What is Variability on a CTG?
Normally between 5 and 25bpm Anything outside of these parameters is abnormal/non reassuring Causes of reduced variability: foetus sleeping, acidosis, opiates
59
What are Decelerations on a CTG?
Abrupt decrease in baseline HR of >15bpm for >15 seconds
60
What are early decelerations?
Physiological During uterine contractions only due to increased foetal intracranial pressure, increasing vagal tone
61
What are variable decelerations?
May or may not have relationship with uterine contractions Usually due to umbilical cord compression (vein occluded first causing acceleration then artery causing deceleration)
62
What are Late Decelerations?
Begin at the peak of contraction and recover after they end Indicates insufficient blood flow and foetal hypoxia Anything over 2 minutes is non reassuring
63
What are causes of Sinusoidal Decelerations?
Severe foetal hypoxia, severe foetal anaemia, haemorrhage
64
How could you classify overall impressions?
Reassuring Suspicious Abnormal
65
What is the normal range for Scalp pH?
>7.25
66
Define Shoulder Dystocia
After the delivery of the head, the anterior foetal shoulder becomes impacted on maternal pubic symphysis (most commonly) Leads to hypoxia of foetus, and any traction can cause brachial plexus injury
67
Give two pre labour and two intrapartum risk factors of Shoulder Dystocia
Prelabour: Macrosomia, Maternal BMI>30 Intrapartum: Prolonged first stage of labour, Oxytocin
68
Give two potential clinical features of Shoulder Dystocia
Failure of Restitution (remains occipitoanterior after head delivery) Turtle Neck (foetal head retracts slightly so neck is no longer visible)
69
What is the immediate management of suspected Shoulder Dystocia?
Call for help Advise mother to stop pushing Consider Episiotomy
70
Describe the first line manoeuvre for Shoulder Dystocia
McRoberts Manouvre Hyper flex maternal hips, tell patient to stop pushing and apply Suprapubic pressure This widens pelvic outlet
71
Give the two second line manoeuvres for Shoulder Dystocia
Posterior Arm: Insert hand posteriorly into sacral hollow and grasp post arm to deliver Corkscrew: Apply pressure to front of one shoulder and behind other to move baby 180 degrees
72
Give two maternal and two foetal complications of Shoulder Dystocia
Maternal: Perineal Tears, PPH Foetal: Humerus or Clavicular Fracture, Brachial Plexus Injury
73
Define Cord Prolapse and the three types
Where the umbilical cord descends through the cervix before the presenting part of the foetus Occult/Incomplete: Descends alongside presenting part but not beyond it Overt/Complete: Descends below presenting part Cord Presentation: Between presenting part and cervix
74
Describe the pathophysiology of Umbilical Cord Prolapse
Causes foetal hypoxia due to: Occlusion (presenting part presses on umbilical cord occluding flow) Arterial Vasospasm (due to cold exposure)
75
Give two risk factors for Cord Prolapse
``` Breech Presentation (especially footling) Unstable Lie ```
76
How does Cord Prolapse present?
Non reassuring foetal heart rate (bradycardia) and absent membranes
77
How should you manage Cord Prolapse?
Avoid handling the cord and elevate the presenting part vaginally In community - fill bladder with 500ml saline Consider tocolysis or emergency caesarean
78
Define Eclampsia
One or more convulsions superimposed on Pre- Eclampsia | Convulsions being Tonic Clonic and lasting 60-75s
79
How should Eclampsia be managed?
Consider Intubation Stabilise in Left Lateral Position MgSO4 for Anti Convulsant IV Labetolol/Hydralazine Deliver once stabilised
80
Name three things you should do/monitor after delivery of an Eclamptic baby
BP CT head Proteinuria
81
Describe the two types of Uterine Rupture
Incomplete: Peritoneum remains intact, Uterine contents remain within Complete: Peritoneum is also torn and uterine contents can escape into cavity
82
Give three risk factors for Uterine Rupture
Previous C Section Previous Uterine Surgery Obstruction of Labour (FGM)
83
Give four clinical features of Uterine Rupture
Severe Abdominal Pain (Persisting between contractions) Shoulder Tip Pain Vaginal Bleeding Palpable foetal parts
84
If Uterine Rupture is suspected, CTG monitoring of foetus should be commenced. What would an USS show?
Abnormal foetal lie/presentation Haemoperitoneum Absent Uterine Wall
85
How is a Uterine Rupture managed?
A to E rescucitation Up to 2L of warmed crystalloid Caesarean and subsequent uterine repair or hysterectomy
86
Give three contributing factors for an Amniotic Fluid Embolism
Strong Uterine Contractions Excess Amniotic Fluid Disruption of Vessels
87
What do Amniotic Fluid Embolism patients normally go on to develop?
DIC
88
What is the only way to definitely diagnose an Amniotic Fluid Embolism?
Post Mortem Foetal Squamous Cells in Pulmonary Vasculature
89
How should an Amniotic Fluid Embolism be managed?
A to E approach and rescucitation | Perimortem section if required to facilitate maternal CPR
90
Define Primary PPH
Loss of >500ml blood PV within 24 hours of delivery
91
Describe the four Ts of Primary PPH
Tone: Uterine Atony Tissue: Retention of tissue preventing it from contracting Trauma Thrombin: VWF, HELLP, Haemophilia
92
Describe the management of Primary PPH (TRIM)
Teamwork Rescucitation Investigation and Monitoring (every 15 mins) Measures to arrest bleed
93
If the cause of Primary PPH was Uterine Atony, what is the definitive management?
Bimanual Compression Pharmacological: Syntocinon, Ergometrine, Carboprost Surgical: Ballon Tamponade, Haemostatic Suture, Hysterectomy
94
If the cause of Primary PPH was retained Tissue, how would you manage?
IV Oxytocin and manual removal | Prophylactic Abx
95
How can you prevent Primary PPH?
Give at least 5 units Oxytocin IM if vaginal delivery or IV if C Section
96
Describe the three levels of Placental Overinvasion
Placenta Accreta- Placental villi attached to myometrium Placenta Increta - Placental villi invade through >50% myometrium Placenta Percreta - Pass through whole myometrium, potentially involving other organs
97
Define Secondary PPH
PV bleeding from 24hrs to 12 weeks post partum
98
Give three causes of Secondary PPH
Uterine Infection (Endometritis) Retained Placental fragments Abnormal involution of placental sites
99
Describe the clinical features of Secondary PPH
PV bleeding (normally not as severe as primary) If Endometritis: Fever, Lower Abdo Pain, Foul Smelling Lochia
100
What is Lochia?
Normal Uterine Discharge following childbirth
101
How is Secondary PPH managed?
Antibiotics (Ampicillin, Metronidazole +/- Gentamicin) | Uterotonics
102
Define Post Natal Depression
Depressive episode within first 12 months of Post Partum (negative cognitions about motherhood and coping skills) Not ‘Baby Blues’ : low mood and irritability within the first week
103
Give three risk factors for Post Partum Psychosis
Previous Mental Illness History in Mother or Sister Previous Psychosis
104
How is Post Partum Psychosis managed?
Often require treatment as inpatient under mental health act Antipsychotic and mood stabiliser Takes 6-12 months for full recovery

Year 4 OBGYN (15 decks)

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