Labour and delivery Flashcards by Hania Azraa

Stages of labour

Stage 1: From onset of labour until 10 cm cervical dilation
Stage 2: from 10cm cervical dilatation until the delivery of the baby
Stage 3: from delivery of the baby until delivery of the placenta

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Stages of first stage of labour

Latent - 0-3cm, irregular contractions
Active - 3-7 cm dilation, regular contractions
Transition - 7-10 cm, strong regular contractions

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What are Braxton-hick’s contractions

Occasional irregular contractions of the uterus - felt during the second and third trimester. They are not true contractions and do not indicate onset of labour

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Signs of onset of labour

Rupture of membranes
Regular, painful contractions
Dilating cervix on examination

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What does PROM mean?

Amniotic sac has ruptured before onset of labour

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What does P-PROM mean?

The amniotic sac has ruptured before onset of labour and before 37 weeks gestation

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What does prolonged rupture of membranes mean?

The amniotic sac ruptures more than 18 hours before delivery

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How do you classify pre-term?

Under 28 weeks - extreme preterm
28-31 - very preterm
32-37 - moderate to late preterm

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Prophylaxis of pre-term labour

Vaginal progesterone - decreases activity of the myometrium and prevents cervix remodelling in preparation for delivery

Cervical cerclage - involves putting in a stitch in the cervix to add support and keep it closed. The stitch is removed when the woman goes into labour or reaches term.

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Preterm Prelabour Rupture of Membranes - Diagnosis and management

Diagnosis - on speculum examination - pooling of amniotic fluid in the vagina

Management - prophylactic antibiotics to prevent chorioamnionitis.

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Preterm labour with intact membranes - diagnosis and management

speculum examination to diagnose.

Management - foetal monitoring (CTG), tocolysis with nifedipine to suppress labour
Maternal corticosteroids - to reduce neonatal morbidity and mortality
IV Magnesium sulphate - can be given before 34 weeks and helps protect baby’s brain
Delayed cord clamping

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What is the bishops score?

Used to determine whether to induce labour.

A score of 8 or more predicts a successful induction of labour

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Options for induction of labour

Membrane sweep

Vaginal prostaglandins to stimulate the cervix and cause onset of labour

Cervical ripening balloon

Artificial rupture of membranes with oxytocin infusion

Oral mifepristone and misoprostol

NICE:
if the Bishop score is ≤ 6
vaginal prostaglandins or oral misoprostol
mechanical methods such as a balloon catheter can be considered if the woman is at higher risk of hyperstimulation or has had a previous caesarean
if the Bishop score is > 6
amniotomy and an intravenous oxytocin infusion

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Five key features on a CTG

Contractions
Baseline rate
Variability
Accelerations
Decelerations

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What do decelerations indicate?

Drop in foetal HR in response to hypoxia.

Causes of decelerations: VEAL CHOP

Variable decelerations –> Cord compression
Early decelerations –> Head compression
Accelerations –> Okay!
Late decelerations –> Placental Insufficiency

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What are early decelerations?

Gradual dips and recoveries in HR that correspond to uterine contractions. These are normal and not pathological.

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What are late decelerations?

Gradual fall in HR after uterine contractions. Caused by hypoxia

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What are variable decelerations?

Abrupt decelerations unrelated to uterine contractions. Falls of more than 15 bpm of baseline

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What are prolonged decelerations?

Last between 2-10 minutes with a drop of more than 15bpm of baseline. Often indicates umbilical compression causing foetal hypoxia.

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Management of foetal hypoxia

Rule of 3s

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

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Oxytocin - functions and uses

Function - ripen the cervix and contractions of the uterus
Uses - induce labour, progress labour, improve frequency and strength of uterine contractions, preventing or treat PPH

Ergometrine - function and uses

Function - stimulates smooth muscle contraction - uterus and blood vessels.

Uses - to prevent and treat of PPH

Prostaglandins - function

Function - stimulates uterine muscles

Misoprostol - uses

Medical management of miscarriage. Used alongside mifepristone for abortions, induction of labour after intrauterine foetal death

Mifepristone - function and uses

Function - stimulation of the uterus. Uses - used alongside misoprostol for abortions, induction of labour after intrauterine foetal death

Nifedipine - function and uses

Function - reduce smooth muscle contraction in blood vessel and the uterus Uses - reduces blood pressure in hypertension and pre-eclampsia, tocolysis (delaying onset of labour)

Carboprost - MOA and uses

Synthetic prostaglandin analogue. IM injection for PPH

Adverse effects of epidural

Heachache after insertion Hypotension Motor weakness in the legs Nerve damage Increased probability of instrumental delivery

Uterine cord prolapse diagnosis

Foetal distress on the CTG Speculum examination can be used to confirm the diagnosis

Management of uterine cord prolapse

Emergency c section Pushing the cord back in is not recommended. The cord should be kept warm and wet and have minimal handling whilst waiting for delivery (handling causes vasospasm). Tell woman to go on all fours OR left lateral position with the pelvis higher than the head - using gravity to draw the fetus away from the pelvis and reduce compression on the cord

Indications for instrumental delivery

Failure to progress Fetal distress Maternal exhaustion Control of the head in various position

Risks of instrumental delivery increases the risk to the mother of:

PPH Episiotomy Perineal tears Injury to the anal sphincter Incontinence of the bladder or bowel

Serious risk to the baby as a result of instrumental delivery

Subgleal haemorrhage (most dangerous)

Risk to remember to the baby with ventouse

Cephalohaematoma

Risk to remember to the baby with forceps

Facial nerve palsy

Classification of perineal tears

First- degree - injury limited to the frenulum of the labia minor and superficial skin Second-degree - includes perineal muscles but not affecting the anal sphincter Third-degree A -less than 50% of the external anal sphincter 3B - more than 50% of the external anal sphincter affected 3C - external and internal anal sphincter affected Fourth - degree - including the rectal mucosa

Management of perineal tears

First degree - do not repair Second degree - require suturing on the ward by a suitably experienced midwife or clinician Third degree - requires repair by clinician in theatre Fourth degree - require repair in theatre by a suitably trained clinician

Complications of perineal tears

Urinary incontinence Anal incontinence Fistula between the vagina and bowel Sexual dysfunction and dyspareunia

PPH classification

500 ml after vaginal delivery 1000 ml after c section

Major vs minor PPH

Minor - under 1000ml blood loss Major - over 1000 ml blood loss

Primary vs secondary PPH

Primary PPH - within 24 hours of birth Secondary PPH - from 24 hours to 12 weeks after birth

Causes of PPH

Four Ts: Tone - uterine atony Trauma - perineal tear Tissue - retained placenta Thrombin - bleeding disorder

PPH management - mechanical

Rubbing the uterus Catheterisation

PPH management - medical treatment

Oxytocin Ergometrine Carboprost Misoprostol Tranexamic acid

PPH management - surgical treatment

Intrauterine balloon tamponade B-lynch suture - putting a suture around the uterus to compress it Uterine artery ligation Hysterectomy

What layers do you have to go through for a C-Section?

SS RR PUA Skin Subcutaneous tissue Rectus sheath Rectus abdominis Peritoneum Uterus Amniotic sac

Risks of spinal anaesthetics during C-Sections

Allergic reaction/anaphylaxis Hypotension Headache Urinary retention Nerve damage Haematoma

Causes of sepsis in pregnancy

Chorioamnionitis UTIs

Risk factors for uterine rupture

Main risk factor - previous c-section Vaginal birth after caesarean Previous uterine surgery Increased BMI High parity Increased age

Signs and symptoms of uterine rupture

Abnormal CTG Abdominal pain Vaginal bleeding Ceasing of uterine contractions Hypotension Tachycardia Collapse

Management of uterine rupture

Immediate delivery of baby via emergency c-section Stop any bleeding and repair or remove the uterus (hysterectomy)