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Management of labour Flashcards

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1
Q

What risks are associated with VBAC?

A

perinatal death
hypoxic ischaemic encephalopathy
uterine rupture
Blood transfusion or endometritis

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2
Q

How would you repair an anorectal mucosal tear?

A

3-0 vicryl continuous/interrupted sutures (polyglactin)

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3
Q

What is the recommended dose of oxytocin for vaginal delivery?

A

10iu IM

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4
Q

What is the recommended dose of oxytocin for caesarean section?

A

5iu by slow IV injection

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5
Q

By how much do prophylactic oxytocics reduce the risk of PPH?

A

60%

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6
Q

What are the indications for fetal blood sampling in labour?

A

cervix >3cm dilated and
1) pathological ctg
or
2)Suspected acidosis in labour

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7
Q

What are the contraindications to FBS?

A

Fetal compromise
Active maternal infection
prematurity <34weeks
Fetal coagulopathy

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8
Q

What is a normal, borderline and abnormal pH for an FBS?

A 
Normal = pH >7.25
Bordeline = pH 7.21 - 7.24
Abnormal = pH <7.20
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9
Q

Risk of perinatal death with VBAC

A

2-3 in 10,000

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10
Q

Risk of hypoxic ischaemic encephalopathy with VBAC

A

8 in 10,000

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11
Q

Risk of uterine rupture with VBAC

A

24-72 in 10,000

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12
Q

Risk of blood transfusion and endometritis with VBAC

A

1%

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13
Q

Benefit of VBAC for neonate

A

Reduces risk of neonatal respiratory problems from 3-4% to 2-3%

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14
Q

What is the frequency of obstetric anal sphincter injuries in nulliparous women?

A

6%

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15
Q

What is the frequency of obstetric anal sphincter injuries in multiparous women?

A

1.7%

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16
Q

What is the frequency of obstetric anal sphincter injuries overall?

A

2.9%

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17
Q

What blood pressure reading would prompt transfer to obstetric led care?

A

1 reading of diastolic >110 or systolic >160
2 readings over 30 mins diastolic >90 or systolic >140
Or protein++ on urinalysis and either diastolic >90 or systolic >140

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18
Q

What are the main causes of meconium stained liquour?

A

Maturity - late gestation >40 weeks
Fetal distress
Fetal hypoxia

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19
Q

When would a H2 receptor antagonist be offered?

A

Never routinely
If risk factors suggest GA is a possibility
If woman receives opioids

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20
Q

If you give iv or im opioid, what else should you give?

A

An antiemetic

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21
Q

What stage of labour is an epidural likely to prolong?

A

Second stage

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22
Q

What are the risks of an epidural?

A

longer second stage, more likely to require vaginal instrumentation, more likely to be less mobile, will need IV access and additional monitoring

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23
Q

How do you manage a women with regional anaesthesia who is fully dilated?

A

If urge to push or head visible - continue to second stage
if no urge to push or head not visible - wait one hour or longer
Second stage should be initiated within 4 hours

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24
Q

what regional analgesia is used when rapid analgesia is required?

A

spinal-epidural with bupivicane and fentanyl

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25
What dose solution do you usually use for an epidural?
0.0625–0.1% bupivicane or equivalent | 2 micrograms fentanyl
26
What rate of contractions would prompt CTG use?
contractions longer than 60 seconds or more than 5 per minute
27
What does NICE recommend as a tocolytic?
terbutaline 0.25mg subcut
28
What kind of drug is terbutaline?
A B2 agonist
29
What are the potential side effects of terbutaline?
tachycardia, hyperglycaemia, hypokalaemia, hypotension, pulmonary oedema, anxiety, headache fetal - hypoglycaemia and tachycardia
30
What is the half life of tebutaline?
6h
31
when might a FBS be falsely reasurring?
if there is significant meconium or maternal sepsis
32
When is FBS contraindicated?
Risk of materno-fetal transmission of infection fetal coagulopathy delivery needs to be expedited or acute cause of fetal distress identified i.e. cord prolapse
33
Maternal position for FBS
left lateral
34
normal pH on FBS
7.25 or above
35
Borderline pH on FBS
7.21-7.24
36
abnormal pH on FBS
7.20 or less
37
normal lactate on FBS
4.1 or less
38
Borderline lactate on FBS
4.2-4.8
39
abnormal lactate on FBS
4.9 or above
40
Management of a normal FBS with no acceleration to stimulation
(7.25 or more) Consider taking repeat FBS in 1 hour
41
Management of borderline FBS with no acceleration to stimulation
(7.21-7.24) Consider taking repeat FBS in 30 mins
42
what is the risk of infection with prelabour rupture of membranes at term?
1% vs. 0.5% in non PROM
43
What proportion of women who PROM go on to start labour within 24 hours?
60%
44
When should women who PROM be offered induction?
After 24 hours without onset of labour
45
Recommended site of an episotomy
mediolateral at the vaginal fourchette at 60 degrees
46
Definition of delayed third stage of labour
>30mins if active labour (with uterotonics) | >60mins if physiological
47
Dose of oxytocin for active third stage of labour
10iu IM oxytocin given with delivery of first shoulder or after delivery before cord clamped and cut
48
When should the cord be clamped?
After 1 minute of delivery and before 5 minutes (unless mother would prefer otherwise)
49
First line medical treatment for PPH
10iu oxytocin IV or 0.5mg ergometrine or 5iu/0.5mg IM syntometrine
50
Second line medical treatment for PPH
repeat bolus of first line med or add misprostol, oxytocin infusion or carboprost (IM) May consider tranexamic acid
51
Degrees of perineal tear
``` first - skin injury + vaginal muscle second - perineal muscles third - perineal and anal sphincter 3a <50% external anal sphincter 3b>50% external anal sphincter 3c internal anal spincter Fourth - anal canal ```
52
Dose of local anaesthesia for perineal repair
up to 20ml 1% lidocaine
53
Repair of skin of perineum
continuous subcuticular
54
Repair of perineal muscle and vaginal wall
continuous non-locking -absorbable synthetic suture
55
Acidotic threshold for neurologic injury
7.1
56
Suture material for anal mucosa repair
3-0 polyglactin interrupted or continuous | NOT PDS!
57
Repair of the internal anal sphincter
interrupted or mattress | 3-0 PDS (monofilament) or 2-0 polyglactin (modern braided)
58
Repair of the external anal spincter
overlapping or end to end if 3c end to end if 3a/3b 3-0 PDS (monofilament) or 2-0 polyglactin (modern braided)
59
post OASIS repair care
analgesia laxatives follow up in 6-12 weeks physio
60
Prognosis post EAS repair
60% asymptomatic at 12 months
61
FBS not obtained and CTG still abnormal
Expedite birth
62
When do you tend to perform an FBS?
If pathological CTG not improving with conservative measures
63
What is polyglactin and what is it used for?
Synthetic braided suture, absorbable - used for uterine closure in C-section and can be used in anal sphincter and perineal muscle repair
64
What is the correct placement of a ventouse?
sagittal suture line anterior to posterior fontanelle
65
Management of delay in first stage of labour
amniotomy for all women with intact membranes Transfer to obstetric led care oxytocin Infusion VE in 2 hours
66
If oxytocin started in first stage of labour - what would you expect?
>2cm cervical dilation over 4 hours If yes - 4 hourly VEs If no - obstetric review ?c-section
67
Diagnosis of delay in established first stage of labour
painful contractions + cervix dilated 4cm but progress less than 2cm per 4 hours in nullips and mulitps or slowing in multips Mgt - obstetric led care/amniotomy/oxytocin infusion
68
VE timing in delayed first stage
VE 2 hours post amniotomy VE 4 hours post oxytocin infusion If less than 2cm progression with oxytocin after 4 hours - review for c-section If more than 2cm progression - continue 4 hour exams
69
Diagnosis of delay in second stage of labour
>2 hours in nullips | >1 hour in mulitps
70
At onset of second stage if contractions are weak in a nullip
consider oxytocin
71
PDS suture
synthetic absorbable monofilament - may be used for sphincter repair but not recto-anal mucosa!
72
What is the vertex?
Presentation of the fetal head in cephalic presentation where the occiput is the leading part
73
In a vertex presentation where do you want the occiput?
occiput anterior (back of the head facing the anterior of the pelvis)
74
Most common presentation at birth?
left ocipitoanterior

Labour (4 decks)

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