Labour and Delivery Flashcards
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
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
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
4
Q
What are the stages of labour?
A
First stage - from onset - true contractions, until 10cm cervical dilatation
Second stage - from 10cm cervical dilatation until delivery of the baby
Third stage - from delivery of baby until delivery of placenta
5
Q
What are the phases of first stage of labour?
A
Latent phase - onset involves cervical dilation and effacement. Show - mucus plug falls out and creates space for baby to pass through. Irregular contractions.
From 0-3cm; progresses at 0.5cm per hour.
Active phase - from 3cm to 7cm dilatation, progresses at around 1cm per hour, regular contractions.
Transition phase - from 7cm to 10cm, progresses around 1cm per hour, strong regular contractions.
6
Q
What are Braxton-Hicks contractions?
A
Occasional irregular contractions of the uterus
Usually felt during the second and third trimester
Temporary and irregular tightening or mild cramping in the abdomen, do not indicate onset of labour.
7
Q
What are the signs of the onset of labour?
A
Show - mucus plug from the cervix
Rupture of membranes
Regular, painful contractions
Dilating cervix on examination
8
Q
What is ROM?
A
Rupture of membranes, the amniotic sac has ruptured
9
Q
What is SROM?
A
Spontaneous rupture of membranes
10
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
11
Q
How common is premature rupture of membranes?
A
10-15% of term pregnancies
Minimal risk to mother and fetus
12
Q
How common is preterm premature rupture of membranes?
A
~2%
Higher rates of maternal and fetal complications
13
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
14
Q
What are the differentials for premature rupture of membranes?
A
Urinary incontinence
Loss of mucus plug
Normal vaginal secretions
Secretions associated with infection
15
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
16
Q
How is a premature rupture of membranes diagnosed?
A
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
17
Q
What is important to investigate if you suspect premature rupture of membranes and what should you avoid?
A
High vaginal swab done - look for group B strep
Avoid digital vaginal exam until in labour –> poss. intrauterine infection
18
Q
What does premature rupture of membranes cause?
A
Amniotic fluid stimulate uterus and labour occur within 24-48 hours
19
Q
If labour doesn’t occur following premature rupture of membranes, what should be done?
A
<34 weeks - aim for increased gestation
34 weeks + - induce labour
20
Q
How should premature rupture of membranes before 36 weeks be managed?
A
Monitor for chorioamnionitis
Advise against sexual intercourse
Prophylactic erythromycin
Corticosteroids (dexamethasone) - fetal lung development
21
Q
How should premature rupture of membranes >36 weeks be managed?
A
Monitor for chorioamnionitis
22
Q
What are the complications of premature rupture of membranes?
A
Prematurity
Sepsis
Pulmonary hypoplasia
23
Q
How can premature rupture of membranes be prevented?
A
Intravaginal progesterone and cervical cerclage - if history of Preterm-PROM
24
Q
What is chorioamnionitis?
A
Result of ascending bacterial infection of amniotic fluid, membranes or placenta
25
What are the risk factors for chorioamnionitis?
Preterm premature rupture of membranes
26
How is chorioamnionitis managed?
Prompt delivery of foetus
| IV antibiotics
27
What occurs in preterm labour with intact membranes?
Regular painful contractions and cervical dilatation without the rupture of the amniotic sac
28
How can preterm labour with intact membranes be diagnosed?
Speculum examination for cervical dilatation
Less than 30 weeks - clinical assessment enough
More than 30 weeks - TV USS, assess cervical length
If less than 15mm - management can be offered
29
What is fetal fibronectin?
An alternative test to vaginal ultrasound, found in the vagina during labour it is between the chorion and uterus
Result of less than 50mg/ml considered negative - indicates preterm labour unlikely
30
What are the management options for improving outcomes in preterm labour?
Fetal monitoring - CTG or intermittent auscultation
Tocolysis with nifedipine
Maternal corticosteroids offered before 35 weeks
IV magnesium sulphate given before 34 weeks
Delayed cord clamping or cord milking
31
What is tocolysis?
Using medications to stop uterine contractions
Nifedipine - Ca channel blocker
Atosiban - oxytocin receptor antagonist
Can be used between 24 and 33 + 6 weeks in preterm labour
32
What corticosteroids are given in preterm labour?
Two doses of intramuscular betamethasone, 24 hours apart
33
Why is magnesium sulfate given in preterm labour?
Helps protect the fetal brain
Reduces risk and severity of cerebral palsy
Given within 24 hours of delivery in preterm babies less than 34 weeks
Given as bolus and then infusion for 24 hours in lead up to birth
34
What are the signs of magnesium sulfate toxicity?
Reduced respiratory rate
Reduced blood pressure
Absent reflexes - check patella reflex
35
What are the methods of induction?
Vaginal prostaglandins - gel, tablet (Prostin) or pessary (propess)
Membrane sweep
Cervical ripening balloon - silicone balloon gently inflated to dilate cervix
Amniotomy +- oxytocin
Only be used if not to use vaginal prostaglands
Oral mifepristone (anti progesterone) plus misoprostol used to induce labour where intrauterine death occurred
36
How do vaginal prostaglandins induce labour?
Ripen cervix and role in contractions
Taken as tablet, gel or pessary
Induction can take days
37
How does a membrane sweep induce labour?
Adjunct to induction
| Gloved finger rotate against fetal membrane - aim to separate from decidua and release prostaglandins
38
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
39
What are the absolute contraindications for induction of labour?
Cephalopelvic disproportion
Major placenta praevia
Transverse lie
Vasa praevia
Cord prolapse
Active primary genital herpes
40
What are the relative contraindications for induction of labour?
Breech
Triplet or higher order pregnancy
2 or more previous low transverse C sections
41
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
42
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
```
43
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
44
What is uterine hyperstimulation associated with and how is it managed?
Fetal distress
Contraction of the uterus is prolonged and frequent
Terbutaline - anti-contraction agent
Removing the vaginal prostaglandin or stopping the oxytocin infusion
45
When is IOL offered?
Between 41 and 42 weeks
46
When might induction of labour be offered early?
```
Prelabour rupture of membranes
Fetal growth restriction
Pre-eclampsia
Obstetric cholestasis
Existing diabetes
Intrauterine fetal death
```
47
What monitoring is required during the induction of labour?
CTG to assess the fetal heart rate and uterine contractions
| Bishops score before and during to monitor progress
48
What can be the consequences of uterine hyperstimulation?
Fetal compromise with hypoxia and acidosis
Emergency c-section
Uterine rupture
49
What do the following abbreviations stand for in CTG monitoring?
```
DR
C
BRa
V
A
D
O
```
Define Risk
Contractions
```
Baseline Rate
Variability
Accelerations
Decelerations
Overall impression
```
50
What is define risk on CTG?
Defining whether a pregnancy is high or low risk. It gives you context to the CTG and may change your threshold for intervention
51
What do you need to record about contractions?
Number in a 10 minute period (seen as peaks of uterine activity on CTG)
Strength and duration
52
What is a normal fetal heart rate?
110-160
53
How is a baseline fetal heart rate calculated?
Average in 10 minute window
Ignore accelerations and decelerations
54
How is prolonged severe bradycardia in a fetus defined?
<80bpm for >3 mins
55
What conditions are associated with fetal tachycardia?
Fetal hypoxia
Chorioamnionitis
Maternal or fetal anaemia
Hyperthyroidism
56
What conditions are associated with fetal bradycardia?
Prolonged gestation
Transverse or posterior occiput presentation
(100-120 bpm)
57
What conditions are associated with prolonged severe fetal bradycardia?
Prolonged cord compression
Cord prolapse
Epidural
Rapid fetal descent
58
What does baseline variability on a CTG tell you? What is a normal variability?
How a fetus' HR varies from one beat to the next
Indicate fetus is adapting to environment due to input from nervous system, baroreceptors and chemoreceptors
Normal is 5-25
59
What could cause reduced fetal variability?
Fetus sleeping
Fetal acidosis - hypoxia
Fetal tachycardia
Congenital heart defect
Prematurity
Maternal medication - opiates, benzo, methyldopa, magnesium sulphate
60
What is a fetal acceleration?
Abrupt increase in baseline fetal HR
>15bpm for >15s
They are reassuring
61
What is a fetal deceleration?
Abrupt decrease in baseline fetal HR of >15bpm for >15s
62
Why do fetuses reduce their heart rate?
In response to hypoxia to reduce myocardial demand and preserve myocardial oxygenation and perfusion
Fetus can't change respiratory depth or rate
63
What is an early deceleration?
Start when uterus contract and recover when contraction stop
Due to fetal RICP and increasing vagal tone
Physiological deceleration
64
What is a variable deceleration?
Rapid fall in heart rate with variable recovery phase
May not have any relationship to contractions
Seen in labour and with oligohydramnios patients
65
What are "shoulders of decelerations"?
Accelerations occur before and after deceleration
Indicate fetus still able to adapt and not yet hypoxic
66
What causes the acceleration, deceleration, acceleration in shoulders of decelerations?
Umbilical vein occluded - acceleration
Umbilical artery occluded - deceleration
Pressure off cord - acceleration
67
What is a late deceleration?
Begin at peak of contraction and recover after it has ended
Indicate lack of blood supply to uterus and placenta - hypoxia and acidosis
68
What causes late decelerations?
Maternal hypotension
Pre-eclampsia
Uterine hyperstimulation
69
What must you do if you see a late deceleration?
Fetal blood sampling for pH
70
What is a prolonged deceleration?
Deceleration lasting >3mins
Fetal blood sampling or emergency C section needs to be arranged
71
What is a sinusoidal pattern on a CTG?
Smooth regular wave like pattern with no beat to beat variability
72
What can cause a sinusoidal CTG pattern?
Severe fetal hypoxia
Severe fetal anaemia
Haemorrhage
Very concerning and associated with high levels of morbidity and mortality
73
What would be seen on a reassuring CTG?
110-160bpm
5-25 variability
No or early decelerations
Variable decelerations with no concerning characteristics <90 mins
74
What characteristics of variable decelerations are concerning?
>60s
Reduced baseline variability within deceleration
Fail to return to baseline
Biphasic (W) shape
No Shouldering
75
What features of a CTG would be considered non-reassuring?
100-109bpm OR 160-181bpm
Variability <5 for 30-50mins or >25 for 15-25mins
Variable decelerations with no concerns >90mins
Variable decelerations with concerns in <50% of contractions >30mins
Variable decelerations with concerns in >50% of contractions <30mins
Late in >50% of contractions for <30 mins with no clinical risk factors (bleeding or meconium)
76
What features of a CTG would be considered abnormal?
<100 or >180 bpm
Variability <5 for >50 mins OR >25 for >25mins OR sinusoidal pattern
Variable decelerations with concerns >50% of contractions for >30 mins
Late decelerations >30mins
Acute bradycardia
Single prolonged deceleration >3mins
77
What is a normal CTG and what is the management?
All features reassuring
Continue CTG and usual care
78
What is a suspicious CTG and how is it managed?
1 non-reassuring AND 2 reassuring features
Seek advice from obstetrician or senior midwife, correct underlying causes, full set of maternal obs
79
What is a pathological CTG?
1 abnormal feature OR 2 non reassuring features
80
How is a pathological CTG managed?
Seek advice - obstetrician or senior midwife
Correct underlying cause
Exclude acute events - cord prolapse, placental abruption, uterine rupture
Offer digital fetal scalp stimulation
If still pathological after scalp stimulation, consider fetal blood sample and expediting birth
81
What CTG requires urgent intervention?
Acute bradycardia
| Single prolonged deceleration >3mins
82
What is done if a CTG requires urgent intervention
Urgently seek obstetrician help
Correct underlying causes
Expedite birth if acute event
Prepare for urgent birth
Expedite birth if bradycardia >9mins
Discuss expedited birth if bradycardia recover
83
What are the CI's for fetal blood sampling?
Risk of maternal-fatal infection
| Fetal bleeding disorders
84
What results are in a normal fetal blood sample? What is the next step?
Lactate <=4.1mmol/L
pH >= 7.25
Repeat in an hour
85
What results are in a Borderline fetal blood sample? What is the next step?
Lactate 4.2-4.8mmol/L
pH 7.21-7.24
Repeat in 30 mins
86
What results are in an abnormal fetal blood sample? What is the next step?
Lactate >=4.9 mmol/L
pH <=7.20
Expedite birth
87
What are the 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
```
88
What is the rule of three for fetal bradycardia?
```
For prolonged fetal bradycardia
3 mins - call for help
6 mins - move to theatre
9 mins - prepare for delivery
12 mins - deliver baby, by 15 mins
```
89
What are late decelerations?
Gradual falls in heart rate after the uterine contraction has already begun.
Delay between uterine contraction and deceleration, lowest point of deceleration occurs after peak of contraction.
Due to hypoxia in the fetus.
May be caused by excessive uterine contractions, maternal hypotension or maternal hypoxia.
90
What are prolonged decelerations?
Last between 2 and 10 minutes
With a drop of more than 15 bpm from baseline
Often indicates compression of umbilical cord, causing fetal hypoxia.
91
What is a normal baseline variability in CTG?
5-25 bpm
92
What is a suspicious CTG?
Lacking at least one feature of normality, but with no pathological features
Low probability of having hypoxia/acidosis
93
What is a pathological CTG?
Two non-reassuring features or a single abnormal feature
Above 180bpm or below 100bpm
Baseline less than 5 >50 mins, more than 25 >30 mins or sinusoidal for >30 mins
Repetitive, late or prolonged decelerations with any concerning characteristics >30 mins or >20 mins if reduced variability
Single prolonged deceleration below 100bpm lasting 3 mins or more
Fetus with high probability of having hypoxia or acidosis
94
what is the management following a suspicious CTG?
```
Full set of maternal observations
Consider risk factors
Immediate conservative measures - change maternal position, reduce or stop oxytoxin, remove propess, consider tocolysis, paracetamol if sepsis, oral fluids/IV
Escalate to coordinator, document
Correct hypotension
Communicate with women regards to plan
Review in 30 mins or before
```
95
What is the management following a pathological CTG?
Full set of maternal observations
Consider risk factors
Immediate conservative measures
Escalate immediately to obstetric team
Consider FSE and FBS - fetal blood sampling and scalp electrode.
Correct hypotension
If pushing - stop to see if improvement made
VE - offer digital stimulation
Consider expediting delivery if indicated
96
Describe the MOA, side effects and CI's for syntocinon
Synthetic oxytocin - stimulate myometrium contraction
Stimulates ripening of cervix, also plays role in lactation during breastfeeding.
Used to induce labour, progress labour, improve freq and strength of uterine contractions, prevent or treat PPH.
SE - N&V, headache, hypertension
CI - hypertonic uterus, severe CVS disease
97
Describe the MOA, side effects and CI's for ergometrine
Alpha adrenergic, dopamine and serotonin receptor action to stimulate contraction of uterus
May be used during third stage and post partum to treat PPH. Only used after delivery of baby.
SE - Hypertension, nausea, bradycardia
CI - Hypertension, eclampsia, vascular disease
98
Describe the MOA, side effects and CI's for carboprost
Prostaglandin analogue
SE - bronchospasm, pulmonary oedema, HTN, cardiovascular collapse
CI - Cardiac/pulmonary disease
99
Describe the MOA, side effects and CI's for misoprostol
Prostaglandin analogue
Binds to prostaglandin receptors and activates them
Used alongside mifepristone for abortions, and IOL after intrauterine fetal death.
SE - diarrhoea
100
What is mifepristone?
Anti-progestogen that blocks the action of progesterone, halting pregnancy and ripening cervix
Not used during pregnancy with healthy living fetus
101
What is nifedipine?
Calcium channel blocker acts to reduce smooth muscle contraction in blood vessels and the uterus
Reduces blood pressure in hypertension and pre-eclampsia
Tocolysis in premature labour
102
What is progress in labour influenced by?
Power - uterine contractions
Passenger - size, presentation and position of baby
Passage - shape and size of pelvis and soft tissue
103
When is there considered to be a delay in the first stage of labour?
Less than 2cm of cervical dilatation in 4 hours
| Slowing of progress in multiparous women
104
What is the importance of a partogram?
Measures cervical dilatation, descent of fetal head, maternal and fetal obs, status of membranes
Crossing alert line indicates need for amniotomy
Crossing action line means need for obstetric led care
105
When is there considered to be a delay in the second stage of labour?
If active second stage pushing lasts over 2 hours in a nulliparous woman or 1 hour in multiparous woman
106
What are the causes of a delayed second stage of labour?
Power - poor contractions
Passenger
Size - macrosomia, should dystocia
Attitude - how rounded back is, limbs and head flexed
Lie - longitudinal, transverse or oblique and presentation.
107
What can be some interventions if there is a delayed second stage of labour?
```
Changing positions
Encouragement
Analgesia
Oxytocin
Episiotomy
Instrumental delivery
C-section
```
108
When is it defined that there is a delay in the third stage of labour?
More than 30 mins with active management
| More than 60 mins with physiological management
109
What are management options in failure to progress?
Amniotomy
Oxytocin infusion
Instrumental delivery
C-section
110
What pain relief is available in labour?
Simple analgesia - paracetamol, codeine, avoid NSAIDs
Gas and air - nitrous oxide and oxygen
IM pethidine or diamorphine
Can cause drowsiness or nausea in the mother, and respiratory depression in the neonate if given too close to birth, may make first feed more difficult.
Patient controlled analgesia - remifentanil, bolus of short acting opiate medication.
Need naloxone for resp depression and atropine for bradycardia if adverse events occur.
Epidural - placed in epidural space, outside dura mater infused into catheter
Bupivacane, mixed with fentanyl
111
What can be the adverse effects of an epidural?
```
Headache after insertion
Hypotension
Motor weakness in legs
Nerve damage
Prolonged second stage
Increased probability of instrumental delivery
```
112
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
113
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
114
What are the risk factors for cord prolapse?
Breech
Artificial rupture of membranes
High fetal station
Polyhydramnios
Prematurity
Long umbilical cord
115
How may cord prolapse present?
Fetal heart rate abnormal - subtle decelerations on contraction and bradycardia
Cord felt vaginally
Presence of blood suggest alternate diagnosis
116
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
117
What is shoulder dystocia?
Anterior shoulder of baby becomes stuck behind the pubic symphysis of the pelvis after the head has been delivered
118
What are the types of shoulder dystocia?
Anterior shoulder impacted on maternal pubic symphysis
Posterior shoulder impacted on sacral promontory (less common)
119
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
120
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
121
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
122
What is the first line management for shoulder dystocia?
McRoberts manoeuvre - hyperflex maternal hips (knees to chest)
+ suprapubic pressure - apply pressure behind anterior shoulder
123
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
124
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
125
What is the presentation of shoulder dystocia?
Failure of restitution where the head remains facing downwards - occipito-anterior and does not turn sideways as expected after the delivery of the head.
Turtle neck sign - head is delivered but then retracts back into the vagina.
126
How can instrumental deliveries be categorised?
Classified by degree of fetal descent - lower they are, lower risk of complications
Outlet
Low
Midcavity
127
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
128
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
129
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
130
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
131
When should instrumental delivery be abandoned for C Section?
No descent seen in 3 pulls
132
What are the contraindications for instrumental delivery?
Bleeding or fracture predisposition of fetus
Face delivery
<34 weeks if ventouse
133
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
```
134
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
135
What fetal complications are associated with instrumental delivery?
Cephalhaematoma
Facial bruising
Retinal haemorrhage
136
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
137
What nerve injuries can occur during instrumental delivery?
Femoral nerve - compressed against inguinal canal, leads to weakness of knee extension, loss of patella reflex, numbness of anterior thigh and medial lower leg.
Obturator nerve - compressed by forceps or fetal head, causes weakness of hip adduction and rotation, numbness of medial thigh.
Lateral cutaneous nerve of the thigh, lumbosacral plexus, common peroneal - foot drop.
138
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
139
What are the risk factors for perineal injury?
Primigravida
Large babies
Precipitant labour
Shoulder dystocia
Forceps delivery
140
What is the relative risk of perineal trauma to women with a history of severe perineal trauma?
Risk not increased
141
When/how is an episiotomy done?
If clinical need - instrumental delivery or fetal compromise
Mediolateral approach originating at vaginal fourchette directed to right
142
Why should a perineal tear be repaired as soon as possible?
Minimise risk of infection and blood loss
143
What is the management of perineal tears?
First degree usually no sutures
Third or fourth likely need repairing in theatre
Broad spectrum antibiotics to reduce risk of infection
Laxatives to reduce risk of constipation and wound dehiscence
Physio to reduce risk and severity of incontinence
Follow up
Women symptomatic after third or fourth degree tears offered elective c-section in subsequent pregnancies.
144
What are the short term complications after perineal injury repair?
Pain
Infection
Bleeding
Wound dehiscence or wound breakdown
145
What are the lasting complications of perineal tears?
Urinary incontinence
Anal incontinence and altered bowel habit in third and fourth degree tears
Fistula between vagina and bowel
Sexual dysfunction and dyspareunia
Psychological and mental health consequences
146
What is a perineal massage?
Massaging skin and tissues between vagina and anus - perineum, done in a structured way from 34 weeks onwards to stretch and prepare the tissues for delivery.
147
What is the third stage of labour and the management options?
From the completed birth of the baby to delivery of the placenta.
Physiological management - placenta delivered by maternal effort
Active management
Dose of IM oxytocin to help uterus to contract, and traction to the umbilical cord
Shortens third stage, reduces risk of bleeding, increased chance of n+v
148
When is active management offered?
Offered routinely to all women to reduce the risk of PPH
Initiated if haemorrhage
More than 60 min delay in delivery of the placenta
149
What are the steps in active management of third stage of labour?
IM dose of oxytocin after delivery
Cord clamped and cut within 5 minutes; there should be a delay of 1-3 mins between delivery and clamping
Abdomen palpated to assess for a uterine contraction before delivery of the placenta
Controlled cord traction, stopping if resistance
One hand presses uterus upwards to prevent uterine prolapse
Uterus massaged until contracted and firm
150
What is a minor PPH?
Under 1000ml blood loss
151
What is a major PPH?
Over 1000ml blood loss
152
What is a moderate and severe PPH?
Further subdivision of major PPH, moderate is 1000ml-2000ml
| Severe - over 2000ml
153
What is a primary and secondary PPH?
Primary - within 24 hours of birth
| Secondary from 24 hours to 12 weeks after birth
154
What are the causes of PPH?
Tone - uterine atony
Trauma - perineal tear
Tissue - retained placenta
Thrombin - bleeding disorder
155
What are the risk factors of PPH?
```
Previous PPH
Multiple pregnancy
Obesity
Large baby
Failure to progress during second stage of labour
Prolonged third stage
Pre-eclampsia
Placenta accreta
Retained placenta
Instrumental delivery
General anaesthesia
Episiotomy or perineal tear
```
156
What measures can be taken to reduce the risks and consequences of PPH?
Treating anaemia during antenatal period
Giving birth with an empty bladder, as full bladder reduces uterine contraction
Active management of third stage, with oxytocin
Intravenous tranexamic acid during c-section in third stage in higher risk patients
157
What is the management of PPH?
```
Major haemorrhage protocol, gives rapid access to 4 units of crossmatched or O neg blood.
Resus, A-E approach
Two large bore cannulas
Bloods for FBC, UE, clotting
G&S, cross match 4 units
Warmed IV fluid and blood
Oxygen
FFP
```
Mechanical, medical or surgical treatment to stop the bleeding
158
What treatment is needed to stop the bleeding in PPH?
Mechanical - rubbing the uterus to stimulate contraction
catheterisation to prevent bladder distention
```
Medical
Oxytocin IV or IM - 40 units in 500mls
Carboprost - caution in asthma
Misoprostol sublingual
Tranexamic acid IB
```
```
Surgical
Intrauterine balloon tamponade
B-lynch suture - put suture around uterus to compress it
Uterine artery ligation
Hysterectomy
```
159
What are the likely causes of a secondary PPH?
Retained products of conception
| Infection i.e. endometritis
160
What are the investigations for secondary post partum haemorrhage?
Ultrasound for retained products of conception
| Endocervical and high vaginal swabs for infection
161
What is the management of secondary post partum haemorrhage?
Surgical evaluation of retained products of conception
| Antibiotics for infection
162
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
163
How are malpresentation of the fetus managed?
Brow - C Section
Shoulder - C-section
Face - if chin anterior then normal labour possible, chin posterior then C Section
164
What happens in most malpositions?
90% spontaneously rotate to occipito-anterior as labour progress
165
What is the management if a malposition doesn't rotate?
Rotation and operative vaginal delivery attempted
C Section can be performed
166
How common is breech presentation?
20% at 28 weeks
3-4% at term - majority spontaneously turn
167
What are the risk factors associated with breech presentation?
85% spontaneous
Uterine abnormality
Lax uterus - multiparty
Placenta praevia
Abnormal amniotic fluid
168
How is breech presentation identified?
Palpation of abdomen
Fetal heart auscultated higher in abdomen
USS
20% not diagnosed until labour - fetal distress or foot felt
169
What should happen if a breech is identified at 35/36 week scan?
Refer for scan and specialist opinion
170
What are the types of breech delivery?
Complete breech
Frank breech
Footling breech
171
How are breech babies delivered?
Try ECV first
C Section or Vaginal depending on woman and specific presentation
Footling breach - vaginal contraindicated
172
How is a breech baby delivered vaginally?
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
173
What complications are associated with breech delivery?
Cord prolapse
Fetal head entrapment
Premature rupture of membranes
Birth asphyxia
174
When is external cephalic version carried out?
36 weeks if nulliparous - 40% success
| 37 weeks if multiparous - 60% success
175
What is the result of external cephalic version?
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
176
What are the CI's for external cephalic version?
APH within last week
Ruptured membranes
Major uterine abnormalities
Abnormal CTG
Multiple pregnancy
177
What are the complications associated with external cephalic version?
Placental abruption
Uterine rupture
Fetal-maternal haemorrhage
Fetal distress
178
What are the conditions where the placenta is retained?
Placenta adherens
Trapped placenta
Partial accreta
179
What happens in placenta adherens?
Myometrium fair to contract behind placenta
180
What happens in trapped placenta?
Detached placenta trapped behind closed cervix
181
What happens in partial accreta?
Part of placenta adhered to myometrium
182
What are the complications associated with retained placenta?
PPH
| Infection
183
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
184
What should be done if a placenta has separated?
Deliver placenta by rubbing up uterus
| Push towards vagina with expulsion of placenta and membranes
185
What should be done if the placenta can't be removed?
Vaginal exam - assess if detached
186
What should be done if the placenta hasn't detached?
IV access - oxytocin if excess bleeding
| Manual removal under general anaesthesia
187
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
188
What are the risk factors for thrombin/trauma related post partum haemorrhage?
Placental abruption
Hypertension
```
Pre-eclampsia
Coagulopathies
Instrumental vaginal delivery
Epsiotomy
C-Section
```
189
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
190
Generally when is an emergency c-section carried out?
Failure to progress through labour
| Fetal compromise
191
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
192
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
193
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
194
What anaesthesia is used for a c-section?
Epidural or Spinal
General if CI to regional or category 1 emergency
195
How is the woman position in a c-section?
Left lateral tilt of 15 degrees - reduce risk of supine hypotension due to aortocaval compression
196
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
197
What incision is used for a c-section?
Pfannenstiel - transverse lower abdominal
198
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
199
What happens to the visceral peritoneum in a c-section?
Incised
| Pushed down to reflect bladder
200
Where is the uterine incision in a c-section?
Lower uterine segment beneath line of peritoneal reflection
201
How is the baby delivered in a c-section?
Fundal pressure
| De Lee's incision (lower vertical) if lower uterine incision poorly formed
202
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
203
What are the main benefits of a c-section?
Lower risk of:
Perineal trauma
Incontinence
Uterovaginal prolapse
Late stillbirth
204
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
205
What are the intermediate complications associated with c-sections?
VTE
UTI - catheter
Endometritis
206
What are the late complications associated with c-sections?
Subfertility
Dehiscence of scar in next labour
Regret/psychological
Placenta praevia
Ectopic pregnancy on scar
207
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
208
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
209
What are the advantages of vaginal birth after c-section?
Shorter hospital stay
Lower risk of maternal death
Lower risk of neonatal respiratory difficulties
210
What are the risks to vaginal birth after a c-section?
Uterine rupture
Anal sphincter injury
Risks of waiting for spontaneous labour
211
What are the risks associated with having an anaesthetic?
```
Allergic reactions or anaphylaxis
Hypotension
Headache
Urinary retention
Nerve damage (spinal anaesthetic)
Haematoma (spinal anaesthetic)
Sore throat (general anaesthetic)
Damage to the teeth or mouth (general anaesthetic)
```
212
What are the key causes of maternal sepsis?
Chorioamnionitis - abdominal pain, uterine tenderness, vaginal discharge
UTIs - UTI symptoms
213
What is the aetiology of chorioamnionitis?
Ascending migration of cervicovaginal flora
Haemtogenous spread to intervillous space
Direct infection after invasive procedures e.g. amniocentesis
Descending infection from the peritoneum via fallopian tubes
214
What are the risk factors for chorioamnionitis?
```
Prolonged rupture of membranes
Prolonged labour
Preterm PROM
Multiple digital exams
Use of internal uterine fetal monitors
Genital tract pathogens
Tobacco and alcohol use
```
215
What is the clinical presentation of chorioamnionitis?
```
Fever
Uterine fundal tenderness
Purulent or foul smelling fluid from the cervical os
Maternal tachycardia, fetal tachycardia
Reduced fetal heart rate variability
```
216
What is. thecriteria for a confirmed intraamniotic infection?
```
Positive amniotic fluid test
Positive culture
Positive gram stain
Decrease in glucose
Raised WCC
Histopathology after delivery shows inflammatory iniltrates in membranes
```
217
What is the management of chorioamnionitis?
```
Antimicrobial agents
Antipyretics
Expedition of delivery
Management of symptoms
Ampicillin and gentamicin
Vaginal delivery preferable
```
218
What are the complications of chorioamnionitis?
```
Dysfunctional labour as infected uterus does not contract well
Operative delivery
PPH
Maternal sepsis
Postpartum endometritis
Adult RDS
```
Neonatal complications e.g. pneumonia, cerebral palsy, sepsis, premature birth complications
219
What is an amniotic fluid embolism?
Amniotic fluid passes into the mother's blood, occurs around labour and delivery.
Contains fetal tissue causing immune reaction
220
What are the risk factors for amniotic fluid embolism?
Increasing maternal age
Induction
C-section
Multiple pregnancy
221
What is the presentation of amniotic fluid embolism?
```
Shortness of breath
Hypoxia
Hypotension
Coagulopathy
Haemorrhage
Tachycardia
Confusion
Seizures
Cardiac arrest
```
222
What is the management of amniotic fluid embolism?
Supportive
A-E approach
Provide oxygen for hypoxia, IV fluids, treat seizures
Cardiopulmonary resuscitation and immediate c-section required if cardiac arrest occurs
223
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
224
What is uterine rupture?
Incomplete or complete rupture where the muscle layer of the uterus ruptures
Contents in complete can be released into the peritoneal cavity
225
What are the risks of uterine rupture?
Anything causing the uterus to be weaker
Main RF is previous c-section
```
VBAC
Previous uterine surgery
High BMI
High parity
Increased age
IOL
Use of oxytocin
```
226
What is the presentation of uterine rupture?
```
Acutely unwell mother
Abnormal CTG
Abdominal pain
Vaginal bleeding
Ceasing of uterine contractions
Hypotension
Tachycardia
Collapse
```
227
What is the management of uterine rupture?
Resuscitation
Transfusion
Emergency c-section
Repair or remove uterus
228
What is uterine inversion?
Rare complication of birth
| Fundus of uterus drops down through uterine cavity and cervix, turning the uterus inside out
229
What are the two types of uterine inversion?
Incomplete - partial inversion where fundus descends inside uterus or vagina but not as far as the introitus (opening of vagina)
Complete - descends through the vagina, into the introitus
230
What is the presentation of uterine inversion?
PPH
Maternal shock
Collapse
May be felt on vaginal examination if incomplete
231
What is the management of uterine inversion?
Johnson manoevre - use hand to push fundus back up, whole hand and forearm inserted and held in place for several minutes with oxytocin given for a contraction
If this fails; hydrostatic manoeuvre, vagina filled with fluid to inflate back into normal place
If this fails, surgery with laparotomy
