Labour and Delivery part 2

Question 1

What are the non-pharmacological methods for pain relief in labour?

Answer 1

Maternal support,
Environment,
Birthing pools,
Education

Question 2

What are the pharmacological methods for pain relief in labour?

Answer 2

Inhaled analgesics (entonox) - may cause N+V and lightheadedness.
Systemic opioid analgeis - IM diamorphine but must avoid if delivery in the next 4 hours.
Pudendal analgesia
Regional - epidural or spinal.
General anesthesia - risks greater than non-pregnant. Increased risk of aspiration and intubation more difficult

Question 3

Explain the differences between an epidural and spinal

Answer 3

Epidural - general use for labour and can be topped up for intrumental delivery. Analgesic effect may be patchy. Does prolong second stage of labour and there is high rate of instrumental delivery.

Spinal - Used for operative delivery/management of postpartum complications. One off Sucharach injection which lasts for 2-4 hours. Dense and reliable block.

Question 4

What are the complications of regional analgesia?

Answer 4

Dural puncture headache (CSF leakage).
Hypotension (due to blockage of sympathetic tone),
Local anesthetic toxicity,
Accidental total spinal block (may lead to loss of consciousness, resp arrest and hypotension. Requires intubation).
Neurological complications.
Bladder dysfunction (can be lifelong)

Question 5

What are the indications and requirements(prerequisites) for instrumental delivery?

Answer 5

Indications - failure to progress, fetal distress, maternal exhaustion, control of head in various fetal positions.
Must be fully dilated, membranes ruptured, vertex at spines/below, position known, analgesia, consent, bladder emptied

Question 6

What are the contra-indications for instrumental delivery

Answer 6

If prerequisites not met,
Risk of significant fetal bleeding disorder.
Gestation < 34 weeks for ventouse,

Question 7

What are the maternal risks of an instrumental delivery?

Answer 7

PPH
Episiotomy,
Perineal tears,
Injury to anal sphincter,
Incontinence of urine/faeces,
Nerve injury - femoral or obturator nerve damage

Question 8

What are the fetal risks with an instrumental delivery?

Answer 8

Cephalohaematoma (collection of blood between skull and periosteum) with ventouse.
Facial nerve palsy with forceps
Others: Subgaleal haemorrhage, intracranial haemorrhage, skull fracture, jaundice, retinal haemorrhages, chignon and spinal cord injury.

Question 9

What are the risks of a C-section?

Answer 9

Bleeding,
Hysterectomy,
VTE,
Infection,
Bowel/bladder/ureteric injury,
Cut to baby,
Return to theater,
ITU admission,
Pain,
Increased risk of stillbirth, placenta praevia and accreata spectrum in next pregnancy.

Question 10

What are the indications for continuous CTG monitoring?

Answer 10

Sepsis,
Maternal tachycardia,
significant meconium,
Pre-eclampsia,
Fresh antepartum haemorrhage,
Delay in labour
Use of oxytocin,
Disproportionate maternal pain

Question 11

What are the key features to look for on a CTG?

Answer 11

Contractions - No. per 10mins.
Baseline rate - fetal baseline rate,
Variability - How the fetal heart rate varies up and down around baseline,(5-25)
Accelerations - fetal heart rate spikes,
Decelerations - where fetal heart rate drops

Question 12

What is the normal baseline rate and variability on CTGs

Answer 12

Baseline rate - 110 to 160.
Variability - 5 to 25.
Concerning baseline rate is 100-109 or >161 to 180.
Abnormal baseline rate is below 100 or above 180

Question 13

Describe features of CTG accelerations

Answer 13

These are good signs that the foetus is healthy, particularly when occurring alongside contractions of the uterus.

Question 14

Describe features of decelerations

Answer 14

More concerning as fetal heart rate drops in response to hypoxia. The four types are:
Early decelerations,
Late decelerations,
Variable decelerations,
Prolonged decelerations

Question 15

Describe features of early decelerations

Answer 15

Gradual dops and recoveries in heart rate which corresponds to uterine contractions.
These are normal and are caused by the uterus compressing the head of the fetus which stimulates the vagus nerve.

Question 16

Describe features of late decerlerations

Answer 16

Gradual fall in heart rate AFTER uterine contraction has already begun. The lowest point of the deceleration occurs after the peak of contraction.
Late decelerations are caused by hypoxia in the fetus.

Question 17

What are some potential causes of late decelerations?

Answer 17

Excessive uterine contractions, maternal hypotension or maternal hypoxia

Question 18

Describe features of variable decelerations

Answer 18

Abrupt decelerations which may be unrelated to uterine activity. These often indicate intermittent compression of the umbilical cord causing brief hypoxia.

Question 19

What is shouldering on a CTG

Answer 19

Breif accelerations before and after decelerations. These are a reassuring sign that the fetus is coping.

Question 20

What are prolonged decelerations

Answer 20

These last between 2-10 mins with a drop of more tha 15bpm from the baseline. Indicates compression of umbilical cord causing fetal hypoxia.

Question 21

What are the four categories for a CTG

Answer 21

Normal,
Suspicious - single, non reassuring feature.
Pathological - Two non-reassuring features or a single abnormal feature.
Need for intervention - acute bradycardia or prolonged deceleration for more than 3 mins.

Question 22

What are the rules of 3’s for fetal bradycardia?

Answer 22

3 mins of bradycardia - Call for help.
6 mins of bradycardia - Move to theater.
9 mins of bradycardia - prepare for delivery.
12 mins of bradycardia - Deliver the baby by 15mins

Question 23

What CTG pattern is associated with severe fetal anaemia?

Answer 23

Sinusoidal CTG - Pattern similar to sine wave with smooth, regular ups and downs

Question 24

What is a structured way of interpreting CTG’s

Answer 24

DR C BRaVado
DR - Define risk (base on women and pregnancy before CTG use).
C - contractions.
BRa - Baseline RAte
V - Variability
A - Accelerations
D - Decelerations
O - overall impression

Question 25

What is the immediate post birth care generally?

Answer 25

Skin-to-skin contact if no neonatal resus required - It improves neonatal thermoregulation, resp regulation and successful breastfeeding.
Maternal oxytocin.
Rhesus bloods and Anti-D if required.
Assessment of risk for postpartum psychosis/depression/child protection.
6 hour discharge if mum and baby are well.

Question 26

What is the immediate post birth care for the baby?

Answer 26

Apgar score at 1, 5 and 10 mins.
Clamp and cut cord after one minuet.
Record weight and temperature.
Physical exam of baby.
Record first micturition and feed.
Consent and administer Vit K.

Question 27

What is the immediate post-birth care for mum?

Answer 27

Observation of vaginal blood loss and palpate fundus to assess uterine contraction.
Examine for trauma.
Support skin to skin and offer breast if wishes.
Record patient colour, BP, HR, resp rate and temp.
Offer something to eat.
Record first micturition after birth.
VTE risk

Question 28

What are the benefits of breastfeeding?

Answer 28

For baby - reduces risk of infections, vomiting and diarrhoea, childhood leukaemia, obesity, CV disease in adulthood. Also encourages strong emotional bond.
For mum - Lowers risk of breast and ovarian cancer, osteoporosis, CV disease and obesity

Question 29

What occurs later on post birth?

Answer 29

In first 10 days there is up to 3 midwife visits. Aim is to assess risk of PTSD, postnatal depression, discuss contriception and examine both mum and baby.
6 weeks postnatal - review birth, discuss physical symptoms, do a FBC and cervical smear and discuss contracetion

Question 30

What are some potential post birth complications?

Answer 30

Anaemia - give oral iron if asymptomatic.

Bowel (constipation) and breast problems (pain, cracks, bleeding, mastitis, abscess),

Perineal breakdown,

Incontinence (commonly resolves spontaneously and is due to impaired pudendal nerve function

Peurperal pyrexia,
Secondary PPH,
VTE (give LMWH if at rifk)
Mental health problems

Question 31

Describe features of puerperal pyrexia

Answer 31

It is defined as temp > 38 degrees on any occasion in first 14 days after birth.
Most commonly genital tract (endometritis) or UTI.
Consider DVT/PE and other sources of infection. Start sepsis 6 if sepsis is suspected.

Question 32

Describe features of secondary PPH

Answer 32

Significant bleeding > 24 hours post delivery.
Usually due to infection of uterine cavity or retained products.
Measure HR, BP and temp, palpate uterus and send vaginal swabs for culture.
Give antibiotics and remove retained products