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Labour and delivery Flashcards

1
Q

What are the 3 stages of delivery

A

-1st : true contractions until 10cm cervical dilation
-2nd : 10cm cervical dilation until delivery
-3rd : from delivery until delivery of placenta

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2
Q

What are the 3 stages of the 1st stage of pregnancy ?

A

-latent : 0 to 3cm dilation. Irregular contractions
-Active : 3cm to 7cm dilation. Regular contractions
-Transition : 7cm to 10cm. Strong, regular contractions

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3
Q

What are braxton-hicks contractions

A

Occasional irregular contractions of the uterus during the second and third trimester

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4
Q

What are 4 signs of the onset of labour

A

Show (mucus plug from cervix)
Rupture of membranes
Regular, painful contractions
Dilating cervix on examination

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5
Q

give the 5 definitions referring to the rupture of membranes in pregnancy

A

-> ROM : amniotic sac rupture
-> SROM : rupture spontaneously
-> PROM - prelabour rupture: rupture before onset of labour
-> P-PROM (preterm, prelabour) : ruptured before onset of labour & before 37 weeks gestation (preterm)
-PROM - prolonged rupture : ruptures >18 hrs before delivery

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6
Q

what 2 things can be done if a woman has a cervical length of <25mm between 16 and 24 wks for prohpylaxis of preterm labour

A

-Vaginal progesterone
-Cervical cerclage : putting a stitch in the cervix

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7
Q

What is done in preterm prelabour rupture of membranes

A

-AMniotic sac ruptures before onset of labour and before 37 wks
-Diagnosed : if not with speculum, check IFBP-a on vaginal fluid
- Prophylactic erythromycin 250mg 4x daily for 10 days to prevent chorioamnionitis
- Induction of labour may be offered from 34 wks to initiate onset of labour

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8
Q

What are 5 options for managing preterm labour with intact membranes to improve outcomes

A

-Fetal monitoring
-Tocolysis with nifedipine : CCB that suppresses labour.
-Maternal corticosteroids : before 35 wks, reduce neonatal morbidity
-IV magnesium sulphate : before 34wks to protect brain
-Delayed cord clamping or cord milking : increases circulating blood volume and Hb in the baby

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9
Q

What is tocolysis

A

-Medications to stop uterine contractions in labour with intact membranes
-CCB : nifedipine
Can be used between 24 and 33+6 wks gestation in preterm to delay delivery

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10
Q

What maternal steroids are used in suspected preterm labour of babies <36 wks

A

2 doses of IM betamethasone 24 hrs apart

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11
Q

When is IV magnesium sulphate given in preterm babies

A

within 24 hrs of delivery of babies <34 wks gestation
reduces risk and severity of cerebral palsy

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12
Q

what are 3 key signs of magnesium toxicity in the mother?

A

reduced resp rate
reduced blood pressure
absent reflexes

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13
Q

What scoring is used to determine whether to induce labour?

A

Bishop

Fetal station
Cervical position, dilation, effecement and consistency

8 or more = successful induction of labour

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14
Q

what are the 4 options for inducing labour

A
  • membrane sweep
  • vaginal prostaglandin E2
  • cervical ripening balloon
  • artificial rupture of membranes with oxytocin infusion
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15
Q

What 2 ways are women monitored in the induction of labour

A

-cardiotocography (CTG) : fetal HR and uterine contractions
-Bishop score

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16
Q

what is the main complication of labour induction with vaginal prostaglandins

A

uterine hyperstimulation

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17
Q

What are the risks of uterine hyperstimulation

A

fetal hypoxia and acidosis
emergency c section
uterine rupture

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18
Q

how is uterine hyperstimulation managed

A

remove vaginal prostaglandins
tocolysis with terbutaline

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19
Q

what is CTG used for

A

to measure fetal heart rate and uterine contraction

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20
Q

what are accelerations, decelerations and variability on a CTG?

A

accelerations : periods where fetal heart spikes & is generally normal
decelerations : where fetal heart drops in response to hypoxia
variability : how the fetal HR goes up and down around the baseline

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21
Q

what baseline fetal HR is reassuring on a CTG

A

110-160

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22
Q

what baseline fetal HR on a CTG is abnormal

A

below 100 or above 180

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23
Q

what variability in fetal HR on CTG is reassuring

A

5-25

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24
Q

what variability in fetal HR on CTG is abnormal

A

<5 for over 50 mins
or >25 for over 25 mins

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25
what are the 4 types of decelerations on a CTG
Early Late Variable Prolonged
26
what are early decelerations on CTG
gradual dips and recoveries in HR corresponding with uterine contractions normal ! lowest point of deceleration = peak of contraction uterus compresses fetal head -> vagus stimulation -> slowing of HR
27
what are late decelerations on a CTG
falls in HR that start ATFER the uterine contraction has began lowest point of deceleration = after the peak of contraction more concerning as caused by hypoxia in the fetus
28
what are variable decelerations
fall in the HR of >15bpm from the baseline last <2 mins caused my intermittent compression of umbilical cord causing hypoxia Brief accelerations before and after these decelerations = shoulders = reassuring
29
what are prolonged decelerations
last between 2 and 10 mins drop of 15bpm from the baseline indicates compression on umbilical cord causing fetal hypoxia abnormal and concerning
30
what would a reassuring CTG be
no decelerations early decelerations or less than 90 mins variable decelerations with no concerning featues
31
what are the rules for fetal bradycardia
rule of 3's 3 min - call for help 6 min - move to theatre 9 min - prepare for delivery 12 min - delivery (by 15 min)
32
what CTG would suggest severe fetal compromise
sinusoidal CTG
33
what is oxytocin and why are infusions given in pregnancy
-Hormone that stimulates cervical ripening and uterine contractions -Role in lactation in breastfeeding -Given to induce or progress labour, improve/frequency & strength of uterine contractions and prevent or treate postpartum haemorrhage
34
where is oxytocin produced
Hypothalamus Secreted by the posterior pituitary gland
35
what is ergometrine and when is it used
-AFTER delivery in the third stage of labour -Helps with delivery of the placenta and to prevent and treat postpartum haemorrhage -Stimulates smooth muscle contraction
36
why are prostaglandins given in pregnancy ?
stimulate uterine contractions example : dinoprostone (prostaglandin E2)
37
what 2 medications are used in abortion and induction of labour in intrauterine fetal death
misoprostol mifepristone
38
what is used to reduced BP in HTN and pre-eclampsia and for tocolysis in prem labour
nifedipine CCB -> reduces smooth muscle contraction in blood vessels and terus
39
what is used for tocolysis in uterine hyperstimulation
terbutaline beta-2-agonist
40
what can be given if ergometrine or oxytocin are inadequate in postpartum haemorrhage
carboprost (deep IM injection) synthetic prostaglandin analogue
41
what else can be used in prevention and treatment of postpartum haemorrhage
tranexamic acid antfibrinolytic - prevents conversion of plasminogen to plasmin therefore reduces plasmin required to dissolve fibrin in clots = reduces bleeding
42
what is failure to progress in labour and what can it be influenced by
- Labour not developing at satisfactory rate. - Influence by 3P's - Power (uterine contractions) - Passenger (size, presentation and position of baby) - Passage (shape, size of pelvis and soft tissue) Psyche can be added (support and antenatal prep for labour and delivery)
43
what is considered as delay in 1st stage of labour
less than 2cm cervical dilation in 4 hrs slowing of progress in multiparous women
44
how are women monitored for progress in the 1st stage of labour
Partogram. Records : - cervical dilation (measured every 4 hrs) - descent of fetal head - maternal pulse BP temp & urine output, -fetal HR - uterine contractions (contractions per 10 mins) - status of membranes - drugs and fluids given
45
How is a partogram read?
It has 2 lines : alert and action Dilation of cervix is plotted against time When it takes too long to dilate, the readings cross to the right of the alert and action lines
46
What does crossing of the alert line indicate
amniotomy & repeat exam in 2 hrs
47
What does crossing the action line mean
obstertric led care and senior decision makers
48
What does success in the second stage depend on and what would suggest delay
Success : the 3 P's delay : pushing lasts 2hrs in nulliparous woman or 1 hr in multiparous women
49
What is defined as delay in the third stage of labour ?
>30 mins with active management (IM oxytocin and controlled cord traction) OR >60 mins with physiological management
50
What are the 4 main options for management of failure to progress
-Amniotomy of intact membranes -Oxytocin infusion - 1st line (aim for 4-5 contractions per 10min) -Instrumental delivery -C section.
51
Give 5 pain relief options for labour
-Simple analgeis (avoiding NSAIDs) -Gas and air (entonox) during contractions -IM Pethidine or Diamorphine (opiodi) -Patient controlled IV remifetanil Epidural
52
What is used in an epidural and where is it injected into
epidural space levobupivacaine / bupivacaine (usually mixed with fantanyl
53
Give 6 SE of epidural
Increased probability of instrumental delivery Headache Hypotension Motor weakness in legs Nerve damage Prolonged second stage
54
What is an umbilical cord prolapse and the problem with it
-Umbilical cord descends below the presenting part of the fetus -Risk of presenting part compressing the cord = fetal hypoxia
55
what is the biggest RF for a cord prolapse and how is it diagnsed
RF : baby in abnormal lie Diagnosis : fetal distress on CTG, diagnosed by vaginal exam and speculum to confirm
56
how is cord prolapse managed
emergency c section keep cord warm and wet with minimal handling
57
what is shoulder dystocia and what is it often caused by
-Anterior shoulder of baby gets stuck behind pubic symphysis after head is delivered -Often caused by macrosomia secondary to gestational DM
58
what are the different ways shoulder dystocia can be managed
-Episiotomy : enlarge vaginal opening -McRoberts manoeuvre -Pressure to anterior shoulder -Rubins manoeuvre : hand in vagina, pressure on anterior shoulder -Wood's screw manoeuvre : hand in vagina, pressure om ppsterior shoulder -Zavanelli manoeuvre : push baby back in, c section
59
A single dose of what is recommended after instrumental delivery to reduce the risk of maternal infection
co-amoxiclav
60
what is a ventouse and what is the risk to the baby when used
-Suction cup on a cord -Complication : cephalohaematoma
61
what is the main complication to the baby with forcep use in delivery
-Facial nerve palsy w/ facial paralysis on one side
62
what 2 nerve injuries are a risk to the mother in instrumental delivery
-> Femoral nerve compression against inguinal canal -> Obturator nerve compression
63
How does femoral nerve compression present
weakness of knee extension, loss of patella reflex and numbness of anterior thigh
64
how does obturator nerve compression present
weakness of hip adduction and rotation numbness of medial thigh
65
what are 3 common nerve injuries during birth
-Lateral cutaneous nerve of the thigh : numbness of anterolateral thigh -Lumbosacral plexus : foot drop, numbness of anterolateral thigh, lower leg and foot -Common peroneal nerve : foot drop and numbness in lateral lower leg
66
what are the 4 classifications of perianal tears
-1st : injury to frenulum of labia minora -2nd : injury to perineal muscles -3rd : includes anal sphincter 3a : <50% external anal sphincter 3b : >50% external anal sphincter 3c : external and internal sphincters -4th : includes recal mucosa
67
how are perianal tears managed
-Greater than 1st degree = sutures -Abx -Laxatives -Physio to avoid incontinence risk
68
How can the risk of perianal tear be reduced ?
Perineal massage
69
what are 2 options for the 3rd stage of delivery
-Physiological : placenta delivered by maternal effort -Active management
70
what is active management of the third stage of labour
-IM dose of oxytocin (10 IU) for uterus contraction -Cord clamp & cut within 5 mins -Controlled cord traction -Uterus is pressed upwards -Massage uterus until contracted and firm
71
how is postpartum haemorrhage defined and classified
-500ml after vaginal delivery -1000ml after c section -Minor PPH : <1000ml -Major : >1000ml -Moderate PPH : 1000-2000ml -Severe : >2000ml
72
what are 4 causes of postpartum haemorrhage (4 T's)
T : Tone : uterine atony (most common) T : Trauma (e.g. perianal tear) T : Tissue (retained placenta) T : Thrombin (bleeding disorder)
73
what are the mechanical management options of PPH
- Fundal massage to stimulate uterine contractions. - Catheterisation
74
what are the medical management options of PPH
- IV oxytocin : slow injection then continuous infusion. - Ergometrine (IV or IM) - Carboprost IM - Misoprostol (sublingual) - Tranexamic acid (IV)
75
what are the surgical management options of PPH
- Intrauterine balloon tamponade - B-lynch suture around uterus - Uterine artery ligation - Hysterectomy
76
what is secondary postpartum haemorrhage and what investigations and management is involved
Bleeding from 24 hrs to 12 wks Usually caused by RPOC or infection Ix : USS + endocervical and high vaginal swabs Mx : surgical evaluation of retained products of conception, Abx for infection.
77
what are indications for an elective c section
Previous c section Sx after previous sig perineal tear Placenta praevia Vasa praevia Breech Multiple preg Unctrolled HIV infection Cervical cancer
78
what are the 4 categories of emergency c sectiom
1 : immediate threat to life. Decision to delivery is 30 min 2 : No imminent threat but c section is required urgently due to compromise of mother or baby. Decision to delivery is 75 mins 3 : Delivery required but mother and baby are stable 4 : elective caesarean
79
What are the 2 kinds of incision in a c section
-Transverse : pfannenstiel (curved), Joel-cohen (straight) -Vertical
80
What 4 measures can be taken to reduce c section risks
-H2/PPIs due to risk of aspiration peumonitis -Prophylactic Abx -Oxytocin to reduce PPH risk -VTE prophylaxis with LMWH
81
Give 2 causes of sepsis during pregnancy
Chorioamnionitis : infection in chorioamniotic membranes and amniotic fluid UTI
82
what is used to measure signs of sepsis in pregnancy
MEOWS charts : maternal early obstetric warning system
83
what is the sepsis 6
IN : oxygen, Abx and IV fluids OUT : lactate level, cultures and urine output
84
what is amniotic fluid embolism and 4 RF
-Amniotic fluid passes into mothers blood and causes immune reaction -Increased maternal age, labour induction, C section and multiple pregnancy
85
What is uterine rupture
-Incomplete : myometrium ruptures but perimetrium remains in tact -Complete : serosa and myometrium ruptures and contents of uterus are released into peritoneal cavity
86
How does uterine rupture present
-Acute unwell mother and abnormal CTG -Abdo pain -Vaginal bleeding -Ceasing of uterine contractions -Hypotension -Tachycardia -Collpase
87
What is uterine inversion
-Incomplete uterine inversion : fundus of uterus descends inside uterus or vagina -Complete : uterus descends through vagina to the introitus (opening of vagina)
88
what are the 3 management options of uterine inversion
-Johnson manoeuvre : pushing fundus back into abdomen -Hydrostatic methods : filling vagina with fluid to 'inflate' uterus back to normal position -Surgery
89
Give 2 CI to vaginal birth after c section
Previous uterine rupture Classical C section (vertical incision)
90
Sudden history of collapse following artificial rupture of membranes
Amniotic fluid embolism
91
what is preterm labour with intact membranes
- Regular painful contractions + cervical dilation without rupture of amniotic sac
92
when would management of preterm labour with intact membranes be offered
- <30 wks : based on clinical assessment - > 30 wks : transvaginal USS to assess cervical length. Cervical length of <15mm = management
93
what is done to confirm P-PROM
- If speculum doesn't confirm fluid on posterior vaginal fault - USS to look for oligohydramnios
94
what causes 50% of umbilical cord prolapse
Artifical rupture of membranes
95
Before carrying out mechanical, medical or surgical management of PPH, what should be done ?
ABC approach - 2 large, 14 gauge cannula - lie woman flat - Bloods including group and save - Commence warmed crystalloid infusion
96
when is ergometrine CI in management of PPH
-> HTN
97
when is carboprost CI in the management of PPH
-> Asthma

3a (45 decks)

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