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Obstetrics and Gynaecology > Labour and Birth > Flashcards

Labour and Birth Flashcards

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1
Q

What is the lie of the fetus? What are the types?

A

Relationship of fetal long axis to uterus long axis

Longitudinal
Oblique
Transverse

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2
Q

What is the presentation of the fetus? What are the types?

A

Fetal part that enters the maternal pelvis

Cephalic is the safest
Face, Brow, Breech, Shoulder

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3
Q

What is the vertex/position of the fetus?

A

Position of the fetal head as it exits the birth canal

Occipito-anterior is safest

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4
Q

How are malpresentation of the fetus managed?

A

Brow - C Section
Shoulder - C-section
Face - if chin anterior then normal labour possible, chin posterior then C Section

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5
Q

What happens in most malpositions?

A

90% spontaneously rotate to occipito-anterior as labour progress

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6
Q

What is the management if a malposition doesn’t rotate?

A

Rotation and operative vaginal delivery attempted

C Section can be performed

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7
Q

How common is breech presentation?

A

20% at 28 weeks

3-4% at term - majority spontaneously turn

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8
Q

What are the risk factors associated with breech presentation?

A

85% spontaneous

Uterine abnormality
Lax uterus - multiparty
Placenta praevia
Abnormal amniotic fluid

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9
Q

How is breech presentation identified?

A

Palpation of abdomen
Fetal heart auscultated higher in abdomen
USS

20% not diagnosed until labour - fetal distress or foot felt

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10
Q

What should happen if a breech is identified at 35/36 week scan?

A

Refer for scan and specialist opinion

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11
Q

What are the types of breech delivery?

A

Complete breech
Frank breech
Footling breech

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12
Q

How are breech babies delivered?

A

Try ECV first

C Section or Vaginal depending on woman and specific presentation
Footling breach - vaginal contraindicated

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13
Q

How is a breech baby delivered vaginally?

A

Hand off baby - traction can lead to neck hyperextension and head getting trapped

Flex fetal knees - deliver legs
Lovsetts - rotate body to deliver shoulders
MSV - flex head

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14
Q

What complications are associated with breech delivery?

A

Cord prolapse
Fetal head entrapment
Premature rupture of membranes
Birth asphyxia

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15
Q

When is external cephalic version carried out?

A

36 weeks if nulliparous - 40% success

37 weeks if multiparous - 60% success

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16
Q

What is the result of external cephalic version?

A

Reduce risk of non-cephalic birth or need for caesarian
Still higher risk of complications than spontaneous cephalic
Safe with no risk of intra-uterine death
<5% revert to breech

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17
Q

What are the CI’s for external cephalic version?

A 
APH within last week
Ruptured membranes
Major uterine abnormalities
Abnormal CTG
Multiple pregnancy
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18
Q

What are the complications associated with external cephalic version?

A

Placental abruption
Uterine rupture
Fetal-maternal haemorrhage
Fetal distress

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19
Q

What are the types of premature rupture of membranes?

A

Premature rupture of membranes - >1hr before onset of labour at >=37 weeks gestation

Pre-term premature rupture of membranes - rupture occur before 37 weeks gestation

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20
Q

How common is premature rupture of membranes?

A

10-15% of term pregnancies

Minimal risk to mother and fetus

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21
Q

How common is preterm premature rupture of membranes?

A

~2%

Higher rates of maternal and fetal complications

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22
Q

What are the risk factors associated with premature rupture of membranes?

A 
Multiple pregnancy
Lower GU infection
Smoking
Vaginal bleeding during pregnancy
Polyhydramnios
Cervical insufficiency
Invasive procedures - amniocentesis
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23
Q

What are the differentials for premature rupture of membranes?

A

Urinary incontinence
Loss of mucus plug
Normal vaginal secretions
Secretions associated with infection

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24
Q

What is the pathophysiology of premature rupture of membranes?

A

Normal weakening occurs earlier than normal due to:

  • Higher levels of apoptotic markers in amniotic fluid
  • Infection - cytokines weaken membrane
  • Genetic disposition
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25
How is a premature rupture of membranes diagnosed?
Maternal history of rupture and positive examination findings Sterile speculum examination - amniotic fluid draining from cervix and pooling in vagina when lying down for 30 mins Reduced amniotic fluids suggestive
26
What is important to investigate if you suspect premature rupture of membranes and what should you avoid?
High vaginal swab done - look for group B strep Avoid digital vaginal exam until in labour --> poss. intrauterine infection
27
What should be given if a woman has isolated group B strep?
Clindamycin or Penicillin
28
What does premature rupture of membranes cause?
Amniotic fluid stimulate uterus and labour occur within 24-48 hours
29
If labour doesn't occur following premature rupture of membranes, what should be done?
<34 weeks - aim for increased gestation 34 weeks + - induce labour
30
How should premature rupture of membranes before 36 weeks be managed?
Monitor for chorioamnionitis Advise against sexual intercourse Prophylactic erythromycin Corticosteroids (dexamethasone) - fetal lung development
31
How should premature rupture of membranes >36 weeks be managed?
Monitor for chorioamnionitis
32
What are the complications of premature rupture of membranes?
Prematurity Sepsis Pulmonary hypoplasia
33
How can premature rupture of membranes be prevented?
Intravaginal progesterone and cervical cerclage - if history of Preterm-PROM
34
What is chorioamnionitis?
Result of ascending bacterial infection of amniotic fluid, membranes or placenta
35
What are the risk factors for chorioamnionitis?
Preterm premature rupture of membranes
36
How is chorioamnionitis managed?
Prompt delivery of foetus | IV antibiotics
37
How commonly is labour induced?
20% of pregnancies
38
What are the indications for induction of labour?
``` Prolonged pregnancy Premature rupture of membranes Fetal growth restriction Intrauterine fetal death Maternal health problems - diabetes, hypertension, obstetric cholestasis ```
39
What are the methods of induction?
Vaginal prostaglandins Membrane sweep Amniotomy +- oxytocin
40
How do vaginal prostaglandins induce labour?
Ripen cervix and role in contractions Taken as tablet, gel or pessary Induction can take days
41
How does a membrane sweep induce labour?
Adjunct to induction | Gloved finger rotate against fetal membrane - aim to separate from decidua and release prostaglandins
42
Explain the use of an amniotomy to induce labour
Used if vaginal prostaglandins CI Membranes ruptures using hook - release prostaglandins to stimulate labour Oxytocin given to increase strength and freq. of contractions Only performed once cervix is ripe
43
What are the absolute contraindications for induction of labour?
``` Cephalopelvic disproportion Major placenta praevia Transverse lie Vasa praevia Cord prolapse Active primary genital herpes ```
44
What are the relative contraindications for induction of labour?
Breech Triplet or higher order pregnancy 2 or more previous low transverse C sections
45
What is the bishop's score?
Scoring system used to assess cervical ripeness Score >9 - labour likely commence spontaneously Score <5 - labour unlikely to start without induction
46
Describe the factors in bishop's score
Cervix: 0 points, 1 point, 2 point, 3 point ``` Position - posterior, midline, anterior, NA Consistency - firm, medium, soft, NA Effacement - 0-30%, 40-50%, 60-70%, >80% Dilation - closed, 1-2cm, 3-4cm, >5cm Station - -3, -2, -1 and 0, +1 and +2 ```
47
What complications are associated with induction of labour?
Uterine hyperstimulation Failure of induction - req. C Section Uterine rupture Cord prolapse - occur in amniotomy with rush of fluid Intrauterine infection - prolonged membrane rupture and repeated vaginal examinations
48
What is uterine hyperstimulation associated with and how is it managed?
Fetal distress Terbutaline - anti-contraction agent
49
What instruments can be used to aid delivery?
``` Forceps Vacuum extraction (Ventouse) ```
50
How can instrumental deliveries be categorised?
Classified by degree of fetal descent - lower they are, lower risk of complications Outlet Low Midcavity
51
What does it mean if a instrumental delivery is classified as outlet?
Fetal scalp visible with labia parted Fetal skull reached pelvic floor Fetal head on perineum
52
What does it mean if a instrumental delivery is classified as Low?
Leading point at +2 station or lower | Subdivided depending on rotation - more or less than 45 degrees
53
What does it mean if a instrumental delivery is classified as midcavity?
Head 1/5 palpable abdominally Leading point between 0 and +2 Subdivided depending on rotation - more or less than 45 degrees
54
What are the indications for instrumental delivery?
``` Maternal - Inadequate progress of 2nd stage of labour - Exhaustion - Hypertensive crisis - CVS disease - Myasthenia gravis and spinal cord injury Fetal - Compromise - Protect head during breech ```
55
What is considered inadequate progress of 2nd stage of labour?
Nulliparous - 2 hours of active pushing | Multiparous - 1 hour of active pushing
56
When should instrumental delivery be abandoned for C Section?
No descent seen in 3 pulls
57
What are the contraindications for instrumental delivery?
Bleeding or fracture predisposition of fetus Face delivery <34 weeks if ventouse
58
What are the requirements for instrumental delivery?
``` Fully dilated cervix Occipito-anterior position Ruptured membranes Cephalic presentation Engaged presenting part Pain relief adequate Sphinter (bladder) empty ```
59
What maternal complications are associated with instrumental delivery?
Maternal mental health - can develop tocophobia Urinary and faecal incontinence 3rd/4th degree tears Pelvic organ prolapse
60
What fetal complications are associated with instrumental delivery?
Cephalhaematoma Facial bruising Retinal haemorrhage
61
What is the difference between caput seccedaneum and cephalhaematoma?
Caput secumdum - Soft puffy swelling due to oedema - Present at birth, cross the midline and resolve within days Cephalhaematoma - Bleeding between periosteum and skull - Present within hours, doesn't cross midline and resolve within months
62
What are the complications of a prolonged second stage of labour?
Chorioamnionitis 3rd and 4th degree tears Uterine atony
63
What are the conditions where the placenta is retained?
Placenta adherens Trapped placenta Partial accreta
64
What happens in placenta adherens?
Myometrium fair to contract behind placenta
65
What happens in trapped placenta?
Detached placenta trapped behind closed cervix
66
What happens in partial accreta?
Part of placenta adhered to myometrium
67
What are the complications associated with retained placenta?
PPH | Infection
68
What are the signs the placenta has separated?
Sudden rush of blood Fundus move higher and become more rounded Increase length of visible umbilical cord Raising fundus doesn't cause cord to decrease in length
69
What should be done if a placenta has separated?
Deliver placenta by rubbing up uterus | Push towards vagina with expulsion of placenta and membranes
70
What should be done if the placenta can't be removed?
Vaginal exam - assess if detached
71
What should be done if the placenta hasn't detached?
IV access - oxytocin if excess bleeding | Manual removal under general anaesthesia
72
Define a post partum haemorrhage
Loss of >=500ml blood per vagina within 24 hours of delivery
73
What is the difference between a major and a minor post partum haemorrhage?
Minor - 500-1000ml | Major - >1000ml
74
Broadly, what causes a post partum haemorrhage?
Tone - failure of uterus to contract Thrombin - coagulopathies and vascular abnormalities Trauma Tissue - retention of placenta
75
What are the risk factors for the uterus failing to contract post delivery?
``` Age >40 BMI >35 Asian Uterine over-distention - multiple pregnancy, macrosomia, polyhydramnios Prolonged labour Placenta praevia or abruption ```
76
What are the risk factors for thrombin/trauma related post partum haemorrhage?
``` Placental abruption Hypertension Pre-eclampsia Coagulopathies Instrumental vaginal delivery Epsiotomy C-Section ```
77
How should a post partum haemorrhage be managed?
Simulataneous: Teamwork - range of specialists Resus - 2L warmed colloids, O-ve blood until X-matched blood available Investigations and monitoring - FBC, X match, Coag, U&E, vitals Medication
78
What medication can be given in a post partum haemorrhage?
Syntocinon (1st line) Ergometrine (1st line) Carboprost Misoprostol
79
Describe the MOA, side effects and CI's for syntocinon
Synthetic oxytocin - stimulate myometrium contraction SE - N&V, headache, hypertension CI - hypertonic uterus, severe CVS disease
80
Describe the MOA, side effects and CI's for ergometrine
Alpha adrenergic, dopamine and serotonin receptor action to stimulate contraction of uterus SE - Hypertension, nausea, bradycardia CI - Hypertension, eclampsia, vascular disease
81
Describe the MOA, side effects and CI's for carboprost
Prostaglandin analogue SE - bronchospasm, pulmonary oedema, HTN, cardiovascular collapse CI - Cardiac/pulmonary disease
82
Describe the MOA, side effects and CI's for misoprostol
Prostaglandin analogue SE - diarrhoea
83
What is the definitive management for a post partum haemorrhage due to failure of the uterus to contract?
Pharmacological measures and bimanual compression Intrauterine balloon tamponade Surgical measures - uterine or internal iliac ligation, hysterectomy
84
What is the definitive management for a post partum haemorrhage due to retained placenta?
IV oxytocin | Manual removal of placenta
85
What is the definitive management for a post partum haemorrhage due to trauma?
Repair lacerations | If uterine rupture - repair or hysterectomy
86
How can a post partum haemorrhage be prevented?
Active management of 3rd stage of labour reduce risk by 60% Vaginal - prophylactic 5-10 units IM oxytocin C-Section - 5 units IV oxytocin
87
What is a secondary post partum haemorrhage?
Excessive bleeding in period between 12hr post delivery and 12 weeks post partum
88
How may secondary post partum haemorrhages present?
Usually spotting Gush of blood or major haemorrhage possible Endometritis - fever, lower abdomen pain, foul smelling lochia Retained products - fundus felt on examination
89
What is lochia?
Discharge from childbirth
90
What can cause a secondary post partum haemorrhage?
Uterine infection - RF inc. C-Section, PROM, long labour Retained placental fragments or tissue Abnormal involution of placental site
91
How would you investigate a secondary post partum haemorrhage?
Speculum exam High vaginal swab Blood cultures Pelvic USS - retained products
92
How is a secondary post partum haemorrhage managed?
If major then same as primary Abx - clindamycin and metronidazole +gentamicin in endomyometritis or sepsis Uterotonics - syntocinon, ergometrine, carboprost etc.
93
What should you be aware of if surgical evacuation of retained products is required for a secondary post partum haemorrhage?
Higher risk of uterine perforation due to uterus being softer and thinner
94
Generally when is an emergency c-section carried out?
Failure to progress through labour | Fetal compromise
95
How can emergency c-sections be characterised?
1 - immediate threat to life of mother or fetus, 20-30 mins 2 - maternal or foetal compromise that isn't immediately life threatening 60-75mins 3 - No maternal or foetal compromise but need early delivery 4 - elective
96
Why may an elective c-section be planned?
Usually after 39 weeks - malpresentation - twins or higher order pregnancy - placenta praevia - uterine abnormality - cephalo-pelvic disproportion - maternal condition - can't cope with pregnancy - herpes simplex in trimester 3 - HIV - fetal weight estimated >4.5kg
97
What should be done before a C-Section is carried out?
G&S - usually 500-1000ml blood loss Prescribe ranitidine - lying flat with gravid uterus increase risk of gastric content aspiration VTE assessment - stockings and LMWH
98
What anaesthesia is used for a c-section?
Epidural or Spinal General if CI to regional or category 1 emergency
99
How is the woman position in a c-section?
Left lateral tilt of 15 degrees - reduce risk of supine hypotension due to aortocaval compression
100
What is done in the operating theatre prior to incision in a c-section?
Catheter - drain bladder so less likely to be injured | Abx administered
101
What incision is used for a c-section?
Pfannenstiel - transverse lower abdominal
102
What layers must you dissect through in a C-section?
Skin Camper's fascia - superficial subcutaneous fat Scarpa's fascia - deep membranous layer of subcutaneous tissue Rectus sheath and muscle Abdominal peritoneum - parietal
103
What happens to the visceral peritoneum in a c-section?
Incised | Pushed down to reflect bladder
104
Where is the uterine incision in a c-section?
Lower uterine segment beneath line of peritoneal reflection
105
How is the baby delivered in a c-section?
Fundal pressure | De Lee's incision (lower vertical) if lower uterine incision poorly formed
106
What are the final steps of a c-section after delivery?
IV oxytocin - aid delivery of placenta Placental delivery by controlled cord traction Uterine cavity emptied Closure
107
What are the main benefits of a c-section?
``` Lower risk of: Perineal trauma Incontinence Uterovaginal prolapse Late stillbirth ```
108
What are the immediate complications associated with a c-section?
``` PPH Bladder/bowel trauma Wound haematoma Transient tachypnoea of newborn Laceration of fetus Need for hysterectomy ```
109
What are the intermediate complications associated with c-sections?
VTE UTI - catheter Endometritis
110
What are the late complications associated with c-sections?
``` Subferility Dehiscence of scar in next labour Regret/psychological Placenta praevia Ectopic pregnancy on scar ```
111
How successful/safe is vaginal birth after a C-Section?
Clinically safe for majority of women with 1 lower segment c-section 75% success rate 90% success rate if previous vaginal birth after c-section
112
What are the contraindications for vaginal birth after a c-section?
Previous uterine rupture Classical caesarian scar Relative CI - >2 lower segment caesarians or complex uterine scars
113
What are the advantages of vaginal birth after caesarian?
Shorter hospital stay Lower risk of maternal death Lower risk of neonatal respiratory difficulties
114
What are the risks to vaginal birth after a c-section?
Uterine rupture Anal sphincter injury Risks of waiting for spontaneous labour
115
How is perineal injury classified?
1st degree - injury to skin 2nd degree - injury to perineal muscles but not anal sphincter 3a - <50% of external anal spincter 3b - >50% external anal sphincter 3c - internal anal sphincter 4 - injury to perineum inc. anal sphincter and epithelium
116
What are the risk factors for perineal injury?
``` Primigravida Large babies Precipitant labour Shoulder dystocia Forceps delivery ```
117
What is the relative risk of perineal trauma to women with a history of severe perineal trauma?
Risk not increased
118
When/how is an episiotomy done?
If clinical need - instrumental delivery or fetal compromise Mediolateral approach originating at vaginal fourchette directed to right
119
Why should a perineal tear be repaired as soon as possible?
Minimise risk of infection and blood loss
120
What is shoulder dystocia?
Shoulders stuck following delivery of the head
121
What are the types of shoulder dystocia?
Anterior shoulder impacted on maternal pubic symphysis Posterior shoulder impacted on sacral promontory (less common)
122
What are the risk factors associated with shoulder dystocia?
``` Macrosomia Maternal diabetes Maternal BMI >30 Previous Hx of shoulder dystocia Induction of labour Prolonged labour ```
123
What are the risks of shoulder dystocia?
Fetus - Delay in delivery - hypoxia - Brachial plexus injury - traction to head - Humerus/clavicle fracture Mum - Perineal tears - PPH - Pelvic floor weakness
124
What should be immediately done if the shoulders get stuck in delivery?
Call for help Stop pushing Avoid downward traction - only apply axial traction Consider episiotomy
125
What is the first line management for shoulder dystocia?
McRoberts manoeuvre - hyperflex maternal hips (knees to chest) + suprapubic pressure - apply pressure behind anterior shoulder
126
What is the second line management for shoulder dystocia?
Insert hand into sacral hollow and grasp posterior arm Internal rotation - corkscrew manoeuvre - turn shoulders 180 degrees
127
What is the last resort for shoulder dystocia?
Cleidotomy - fracture fetal clavicle Symphysiotomy - cut pubic symphysis Zavenelli - return fetal head to pelvis for C-Section
128
What are the types of cord prolapse?
Occult - cord drop alongside baby but may not be seen in advance Overt - cord come before baby's head can come out
129
How does fetal hypoxia occur in cord prolapse?
Occlusion - fetus press on umbilical cord occluding blood flow Arterial vasospasm - exposure of cord to cold atmosphere results in umbilical arterial vasospasm
130
What are the risk factors for cord prolapse?
``` Breech Artificial rupture of membranes High fetal station Polyhydramnios Prematurity Long umbilical cord ```
131
How may cord prolapse present?
Fetal heart rate abnormal - subtle decelerations on contraction and bradycardia Cord felt vaginally Presence of blood suggest alternate diagnosis
132
How is cord prolapse managed?
Avoid handling cord - avoid vasospasm Knee-chest position for mother Manually lift presenting part by digital vaginal exam Tocolysis - terbutaline - relax uterus and stop contractions Delivery - usually emergency c-section If fully dilated - can encourage vaginal/instrumental delivery
133
What is uterine rupture?
Full thickness disruption to uterine muscle and overlying serosa
134
What are the risk factors for uterine rupture?
Anything that makes the uterus wall weaker: - previous c-section - previous uterine surgery - induction with prostaglandins - multiple pregnancy
135
How does uterine rupture present?
Sudden severe abdominal pain - persist between contractions Shoulder tip pain Vaginal bleeding Regression of presenting part Palpable fetal parts on abdominal examination Fetal distress Maternal hypovolaemic shock
136
What are the differentials for uterine rupture?
Placental abruption Placenta and vasa praevia - usually painless
137
How is uterine rupture managed?
Resuscitate Deliver fetus by c-section Repair uterus or hysterectomy
138
What is an amniotic fluid embolism?
Fetal cells/amniotic fluid enters maternal blood stream causing a reaction
139
How does an amniotic fluid embolus present?
Sudden onset ``` Hypoxia Hypotension Shock DIC Seizures ```
140
How is an amniotic fluid embolus diagnosed?
Focus on resus not diagnosis Definitive diagnosis made post mortem - fetal squamous cells and debris found in pulmonary vasculature
141
How is an amniotic fluid embolus managed?
ABCDE - high flow o2 - fluid resuscitation
142
How should stillbirth's be managed?
Allow parents time and space for reflection away from normal ward Allow to dress and spend time with child Hospital protocols - wrap baby, offer to hold, photos, hair and palm prints Funeral arrangements Hospital counsellors and chaplains - comfort to families Bereavement midwives Consent for post mortem Inform GP practice
143
What us puerperium?
6 week period following birth where body reverts to non-pregnant state
144
When do the CVS adaptations of pregnancy revert?
Within 2 weeks
145
What happens to the vagina in the puerperium?
Regain tone within 2 weeks Initially swollen and blue
146
What happens to the uterus in the puerperium?
Initial - drop to size at 20 weeks Day 12 - non-palpable Week 6 - only slightly larger than original
147
What changes occur to lochia in the puerperium?
First 3 days - mostly blood and trophoblastic tissue remnants 4-12 days - Colour change from reddish-brown to yellow
148
What are the common complaints in puerperium and how are they managed?
Painful perineum - analgesia and sit on rubber ring Urinary retention - catheter Stress incontinence - pelvic floor exercises Constipation - stool softeners Haemorrhoids - normally disappear in few weeks Dyspareunia - examine perineum and encourage lubricants Backache - analgesia Anaemia - iron
149
When do women require contraception after pregnancy?
After day 21
150
When can the progesterone only pill be taken after delivery?
Day 21 onwards with additional cover for first 2 days | Some progesterone enter breast milk but not harmful
151
What is the guidance on COCP after pregnancy?
Not for 6 weeks post partum if breastfeeding - unacceptable health risk If not breastfeeding, can start after 21 days but req. 7 days additional cover VTE risk
152
When can the IUD/IUS be inserted post delivery?
Within 48 hours or | After 4 weeks
153
What is the lactational amenorrhoea method of contraception?
98% effective contraception for fully breast-feeding women that are amenorrhoeic and <6 months post partum
154
What is puerperal pyrexia?
Temp >38 within first 14 days
155
What can cause puerperal pyrexia?
``` Endometritis - most common cause UTI Wound infections - perineal tear/c-section Mastitis VTE ```
156
How is puerperal pyrexia managed?
Endometritis suspected then pt. should be referred to hospital for IV Abx - clindamycin and gentamicin until afebrile for >24hrs

Obstetrics and Gynaecology (21 decks)

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