MANAGEMENT OF LABOUR AND DELIVERY Flashcards
(251 cards)
1
Q
Choices for place of birth
A
Home
Midwifery unit/birthing centre
Hospital
2
Q
Advanatges of home birth
A
being in familiar surroundings, where you may feel more relaxed and better able to cope - more relaxed = more oxytocin released = easier birth
not having to interrupt your labour to go into hospital
not needing to leave your other children, if you have any
not having to be separated from your partner after the birth
increased likelihood of being looked after by a midwife you have got to know during your pregnancy
lower likelihood of having an intervention, such as assisted births or episiotomy
Associated with higher rates of spontaneous vaginal births
3
Q
Considerations for a home birth
A
You may need to transfer to hospital if there are complications. For nulliparous women 45% will go to hopsital, for multiparous only 12%
Epidurals are not available at home
Doctor or midwife may recomemend giving birth in hospital e.g. if twins or breech
4
Q
Advanatges of a birth centre or midwifery unit?
A
Being in surroundings where you may feel more relaxed than at jppsital and better able to cope with labour
More likely to be looked after by a midwife you got to know during your preganncy
The unit might be much closer to your home than the hopsital
Lower likelihood of having an intervention such as forceps or ventouse than giving birth in hospital
5
Q
Considerations for choosing to deliver in a birthing unit?
A
You may need to be transferred to a hospital if there are any complications
No access to epidural
Your doctor or midwife may recommend you give birth in a hospital
6
Q
Advanatges to hospital birth?
A
Direct access to obstetricians if labour becomes complicated
Direct access to anaesthetists who can give epidurals and GA
Access to neonataologistss and SCBU if any problems with baby
7
Q
Cosiderations for choosing to deliver at hospital?
A
You may go home directly from labour ward or you may be moved to postanatal ward
In hospital you may be looked after by a different midwife from the one who looked after you during your pregnancy
More likely to have an epidural, episiotomy or a forceps or ventouse delivery in hospital
8
Q
Risk factors for preterm labour?
A
Previous premature birth
Multiple gestations
Women with certain anomalies of reproductive organs e.g. cervical incompetence
Med conditions: UTI, STI, hypertension, PV bleeding after 24/40, development anomalies in foetus, IVF preganncy, being underweight or obese before pregnancy, <6 months between birth and starting another pregnancy, placenta pre via, diabetes, blood clotting problems, PPROM
Women<18 or women >35
Having no prenatal care
Smoking, alcohol, drugs
Stress
Domestic violence
Long working hours with long periods of standing
9
Q
Impact of BMI on the choice of place of birth
A
In general the higher the BMI at booking, the greater the likelihood of complications e.g. unplanned C-section, PPH, transfer to an obestetric unit, stilllbirth, neonatal death
This may be something for the pt to think about when planning their place of birth
10
Q
To which women would you offer prophylactic vaginal progesterone and cervical cerclage?
A
women who have both:
Hx of spontaneous preterm birth (up to 34+0 weeks of pregnancy) or loss (from 16+0 weeks of pregnancy onwards)… and…
results from a transvaginal ultrasound scan carried out between 16+0-24+0 weeks of pregnancy that show a cervical length of 25 mm or less.
Consider in women who only have 1 of the above.
11
Q
What is cervical cerclage?
A
This involves putting 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
12
Q
What is “rescue” cervical cerclage?
A
16+0-27+6
When there is cervical dilatation without rupture of membranes - aims to prolong pregnancy to a viable gestation in a woman who was not previously identified as at risk for cervical insufficiency but later develops sign suggesting cervical weaknesss that may lead to preterm birth
13
Q
What is vaginal progesterones moa for preventing preterm labour?
A
Given vaginally via a gel or pessary as prophylaxis for preterm labour
It decreases the activity of the myometrium and prevents the cervix remodelling in preparation for delivery
14
Q
Classification of prematurity by WHO
A
Under 28 weeks: extreme preterm
28 – 32 weeks: very preterm
32 – 37 weeks: moderate to late preterm
15
Q
What is PROM and P-PROM?
A
Prelabour ruptre of membranes - amniotic sac has ruptured before the onset of labour OR prolonged rupture of membranes where amniotic sac ruptures >18hrs before delivery
Preterm prelabour rupture of membranes - amniotic sap ruptured before onset of labour and before 37/40
16
Q
How common is preterm prelabour rupture of membranes?
A
Happens in 2% of pregnancies but is associated with around 40% of preterm deliveries
17
Q
Complications of P-PROM?
A
Foetus - Prematurity, infection or pulmonary hypoplasia, oligohydramnios, neonatal death, umbilical cord prolapse
Maternal - chorioamnionitis
18
Q
How to confirm P-PROM?
A
Sterile speculum examination - look for pooling of amniotic fluid in posterior vaginal vault. If positive no other tests required.
If pooling of fluid is not observed… test vaginal fluid for placental alpha microglobulin-1 protein (PAMG-1) or Insulin-like growth factor binding protein-1 - If these are negative and no amniotic fluid is observed unlikely P-PROM
Ultrasound is not used routinely, but may facilitate diagnosis in cases where it remains unclear. Reduced levels of amniotic fluid within the uterus are more suggestive of membrane rupture.
19
Q
Why will vaginal fluid contain insulin-like growth factor-binding protein-1 and placental alpha-microglobulin-1 in P-PROM?
A
They’re both present in amniotic fluid so will only be present in vaginal discharge if rupture of membranes has occured
(IGFBP-1 is produced by foetal membranes (amnion) and PAMG-1 is produced by the placenta)
20
Q
Management of P-PROM?
A
admission
regular observations to ensure chorioamnionitis is not developing
As prophylaxis for chorioamnionitis - oral erythromycin 250mg 4 times a day for 10 days or until woman is in established labour
antenatal corticosteroids and magnesium sulfate should be considered
delivery should be considered at 34 weeks of gestation (although RCOG suggests offer expectant management until 37+0)
21
Q
What is choriomanitis? What causes it? Whats the biggest risk factor?
Whats the Tx?
A
Infection of the amniotic fluid, membranes and placenta
Its a potentially life-threatening condition to both mother and foetus and is therefore considered a medical emergency
Usually as a result of an ascending bacterial infection
Biggest risk factor is PPROM which exposes the normally sterile environment of the uterus to potential pathogens
Prompt delivery of foetus and IV antibiotics is initial Tx
22
Q
How to diagnose chorioamnionitis in a woman with P-PROM?
A
Fever, uterine fundal tenderness and maternal tachycardia
CRP, WBC
CTG for foetal heart rate - usually >160/min
23
Q
What can cause PROM?
A
Physiologic weak ending of membranes combined with forces caused by uterine contractions
Infections
Genetic predisposition
24
Q
Risk factors for PROM and P-PROM?
A
Smoking - especially <28/40
Previous PROM or preterm delivery
Vaginal bleeding during pregnancy
Lower genital tract infection
Invasive procedures e.g. amniocentesis
Polyhydramnios
Multiple pregnancy
Cervical insufficiency
25
Clinical features of PROM?
Painless pop-> gush of watery fluid leaking from vagina
Gradual leakage of watery fluid from vagina, damp underwear or a change in colour/consistency of vaginal discharge
26
Why is it important to avoid performing a digital vaginal exam in women with suspected PROM or P-PROM?
It has been shown to reduce the time between rupture of membranes and onset of labour
It is also more likely to introduce an ascending intrauterine infection
27
How do we diagnose preterm labour with intact membranes?
If suspected preterm labour and…
- 29+6 weeks of less advise Tx
- 30+0 weeks pregnant or more, consider transvaginal USS measurement of cervical length as a diagnostic test to determine the likelihood of birth within 48 hrs. If cervical length is 15mm or less then view the woman as being in diagnosed preterm labour and offer Tx
Foetal fibronectin can be used instead for women 30+0 weeks pregnant or more if transvaginal USS measurement is indicated but is not available or acceptable. If positive view woman as being in diagnosed preterm labour and offer Tx
28
Why can foetal fibronectin testing be used as a diagnostic test to determine the likelihood of birth within 48 hours in women who are 30+0 weeks pregnant or more?
Foetal fibronectin is a protein produced by foetal membrane and the placenta. Its role is in adhesion of the foetalk sac to the uterine lining
If its found in vaginal fluid it can suggest preterm labour is likely
29
Management for improving outcomes in preterm labour?
Foetal monitoring with CTG or intermittent auscultation
Tocolysis with nifedipine
Maternal corticosteroids
IV magnesium sulphate
Delayed cord clamping
30
What is tocolysis?
Medications to delay the delivery of a foetus to suppress premature labour
31
What drug is most often given for tocolysis? how does it work?
Nifedipine
It’s a calcium channel blocker that relaxes uterine wall muscle decreasing contractions and prolonging time to delivery. Allows more time to administer corticosteroids for foetal lung maturity - not its only used for short time i..e ~48 hours
32
Who do you give nifedipine for tocolysis in women with intact membranes and suspected preterm labour?
Women between 24+0 - 33+6 weeks
33
What can you use for tocolysis if nifedipine is contraindicated?
An oxytocin receptor antagonist such as atosiban
34
Purpose of giving maternal corticosteroids to women in suspected or established preterm labour?
Reduces the severity of lung disease of prematurity by accelerating lung maturation
35
What corticosteroids are used in suspect premature labour to mature foetal lungs?
Betamethasone and dexamethasone
36
Which women in preterm labour should be offered maternal corticosteroids?
Women between 24+0 - 35+6 weeks
Note women less than 34+0 should have a single repeat course if they haven’t given birth within 7 days and they are at very high risk of giving birth in the next 48 hours
But be aware in women <30+0 weeks or in babies with suspected growth restriction, of the possible impact on foetal growth of a repeat course of maternal corticosteroids
37
Purpose of giving magnesium sulphate to women in preterm labour?
For neuroprotection of the baby - reduces risk and severity of cerebral palsy
38
Who should be offered magnesium sulphate in preterm labour?
Women between 24+0-33+6
In established preterm labour OR having a planned preterm birth within 24 hours
39
How do you give magnesium sulphate in preterm labour?
Give a 4 g intravenous bolus of magnesium sulfate over 15 minutes, followed by an intravenous infusion of 1 g per hour until the birth or for 24 hours (whichever is sooner).
40
What should you monitor whilst giving a woman in preterm labour magnesium sulphate?
Monitor at least every 4 hours for clinical signs of magnesium toxicity
Pulse, BP, RR, deep tendon reflexes
(signs of magnesium toxicity is reduced RR, hypotension and absent reflexes)
Look out for reduced urine output or other evidence of renal failure
41
Foetal monitoring options in preterm labour?
Cardiotocoography or intermittent auscultation
In some scenarios… foetal scalp electrodes and foetal blood sampling
42
From which week can the sonicaid be used for foetal monitoring?
From 16 weeks
43
From which week can the pinnard stethoscope be used for foetal monitoring?
From 16 weeks
44
From which week can the CTG be used for foetal monitoring?
From 26 weeks onwards
45
When can foetal scalp electrode be used for foetal monitoring?
Only in labour and when waters have broken!
Note this is a version of CTG. used instead of the abdominal transducer
46
What is Dawes Redman?
A software that analyses the CTG
Gives an objective value as CTG is otherwise highly subjective
Must not be used for intrapartum CTG analysis as it can’t be used in the presence of uterine contractions
47
What is cardiotocography?
Electronic foetal monitoring to measure foetal heart rate and the contractions of the uterus
48
How do you set up CTG?
Place 1 transducers above the foetal heart to monitor foetal heartbeat - it uses Doppler US
Place the other transducer near the fundus of the uterus to monitor the uterine contractions - it assesses the tension in the uterine wall
49
Mneumonic for CTG reading?
DR C BRAVDO
DR - Define RIsk
C - Contractions
BR- Baseline rate
A - Accelerations
V - Variability
D - Decelerations
O - overall impression
50
What are the 5 key features to look for on a CTG?
Contractions – the number of uterine contractions per 10 minutes
Baseline rate – the baseline fetal heart rate
Variability – how the fetal heart rate varies up and down around the baseline
Accelerations – periods where the fetal heart rate spikes
Decelerations – periods where the fetal heart rate drops
51
What does too little or too many contractions on CTG indicate?
How many should there be?
Too little - labour not progressing
Too many - uterine hyperstimulation which can lead to foetal compromise
Should be 3-5 contractions in 10 min window lasting 40-60 seconds each
52
What is normal baseline foetal HR on CTG? What is abnormal?
110-160
Non-reassruaing is 100-109 and abnormal is <100 or >180
53
What is normal variability and what is abnormal?
Normal variability is 5-25
Non-reassuring is <5 for 30-50 mins or >25 for 15-25 mins
Abnormal is <5 for over 50 mins or >25 for over 25 mins
54
What can cause reduced baseline variability on CTG?
Foetus sleeping - this shouldn’t last >40 mins though
Foetal acidosis due to hypoxia
Foetal tachycardia
Drugs: opiates, benzos, methyldopa, MgSO4
Prematurity
Congenital heart abnormalities
55
What can cause foetal tachycardia?
Fetal hypoxia
Chorioamnionitis
Hyperthyroidism
Fetal or maternal anaemia
Fetal tachyarrhythmia
56
What can cause foetal bradycardia?
Prolonged cord compression
Cord prolapse
Epidural and spinal anaesthesia
Maternal seizures
Rapid fetal descent
Note prolonged bradycardia (<80 for >3 mins) indicates severe hypoxia
Note its common to have baseline HR 100-130 in post date gestation and occiput posterior or transverse positions
57
What are accelerations on a CTG?
Abrupt increases in the baseline foetal HR of >15 bpm for >15 seconds
58
What do accelerations on CTG tell us?
They are reassuring - a sign of a healthy foetus
The absence of accelerations with an otherwise normal CTG is of uncertain significance
59
What are decelerations on a CTG?
abrupt decrease in the baseline fetal heart rate of greater than 15 bpm for greater than 15 seconds
60
What does a deceleration on CTG represent?
Foetus reduces its HR in response to hypoxic stress. This is to preserve myocardial oxygenation and perfusion
61
What is an early deceleration on CTG?
What causes it?
These are decelrations that start when the uterine contraction begins and recovers when uterine contractions stop
Due to increased foetal ICP causing increased fatal tone during contractions. Physiological not pathological!
62
What is variable deceleration on CTG?
What causes it?
Decelerations with variable recovery phase. No relationship to uterine contractions.
Usually caused by umbilical cord compression. Often see shoulders of decelrations where acceleration of the foetal heart rate before and after the deceleration occurs. Their presence indicates the foetus is not yet hypoxic and is adapting to the reduced blood flow.
Variable decelrations without the shoulders are more worrying as it suggests the foetus is becoming hypoxic!
63
What is a late deceleration on CTG?
What causes it?
These decelrations begin at the peak of uterine contraction and recover after the contraction ends
It indicates insufficiency blood flow to the uterus and placenta, so blood flow to foetus is significantly reduces causing foetal hypoxia and acidosis
Causes:
Maternal hypotension
Pre-eclampsia
Uterine hyperstimualtion
64
What is prolonged deceleration on CTG?
A deceleration that lasts>2 mins
If it lasts between 2-3 mins its classified as non-reassuring
If it lasts >3 minutes its immediately classed as abnormal
65
What is a sinusoidal pattern on CTG?
What does it indicated?
A smooth, regular, wave-like pattern with a frequency of around 2-5 cycles in 1 minute. Stable baseline rate and no beat to beat variability
Indicates either:
- severe foetal hypoxia
- severe foetal anaemia
- foetal/maternal haemorrhage
66
What are the 3 ways a CTG can be described in the “overall Impression”?
Reassuring
Suspicious
Abnormal
67
Reassuring signs on CTG?
Baseline rate 110-160
Baseline variability 5-25bpm
No/only early decelerations. Or variable decelerations with no concerning characteristics for <90 minutes
68
Non-reassuring signs on CTG?
Baseline HR 100-109 or 161-180bpm
Baseline variability of <5 for 30-50 mins, or >25 for 15-25 mins
Variable decelerations with no concerning characteristics for 90 minutes or more.
Variable decelerations with any concerning characteristics in up to 50% of contractions for 30 minutes or more.
Variable decelerations with any concerning characteristics in over 50% of contractions for less than 30 minutes.
Late decelerations in over 50% of contractions for less than 30 minutes, with no maternal or fetal clinical risk factors such as vaginal bleeding or significant meconium
69
Abnormal features on CTG?
Baseline rate <100 or >180bpm
Baseline variability <5 for >50 mins, or >25 for >25 mins, or sinusoidal
Variable decelerations with any concerning characteristics in over 50% of contractions for 30 minutes (or less if any maternal or fetal clinical risk factors).
Late decelerations for 30 minutes (or less if any maternal or fetal clinical risk factors).
Acute bradycardia, or a single prolonged deceleration lasting 3 minutes or more.
70
What is the rule of 3s for foetal bradycardia on CTG?
If foetal bradycardia occurs for…
3 minutes – call for help
6 minutes – move to theatre
9 minutes – prepare for delivery
12 minutes – deliver the baby (by 15 minutes)
71
What is foetal blood sampling?
Taking a blood sample from the foetal scalp. Used alongside CTG during labour to assess the wellbeing of the foetus
It provides info on pH and lactate levels of foetal blood which can be used to assess if baby is recieving enough oxygen
72
Signs of labour?
Regular and painful uterine contractions
a show (shedding of mucous plug from cervix)
rupture of the membranes (not always)
shortening and dilation of the cervix on examination
73
3 stages of labour:
stage 1: from the onset of true labour to when the cervix is fully dilated to 10cm
stage 2: from full dilation to delivery of the fetus
stage 3: from delivery of fetus to when the placenta and membranes have been completely delivered
74
Monitoring in labour?
Foetal HR monitored every 15min or continuously via CTG
Contractions assessed every 30min
Maternal pulse rate assessed every 60min
Maternal BP and temp should be checked every 4 hours
Vaginal exam should be offered every 4 hours to check progression of labour
Maternal urine should be checked for ketones and protein every 4 hours
75
How long does stage 1 of labour usually last?
Primigravida - 8-18 hours
Multigravida - 5-12 hours
76
What are the 2 phases of stage 1 of labour?
Latent phase = 0-4cm dilation - uusally progressed at 0.5cm per hour. Irregular contractions with some cervical changes e..g. effacement
Active phase = 4-10cm - 1cm/hour. Regular contractions
77
What are Braxton-Hicks contractions?
Occasional irregular contractions of the uterus usually felt during the second and third trimester where women experience temporary and irregular tightening or mild cramping in the abdomen
They do not indicate the onset of labour and they do not progress or become regular
Staying hydrated and relaxed can help reduce them
78
What is vertex positioning of the foetus and how common is it for babies to be in this position at the point of established labour?
Cephalic position with neck tucked in
90%
79
What are the 2 phases of second stage of labour?
Passive second stage - 2nd stage i.e. cervix fully dilated in absence of pushing
Active stage - 2nd stage with active maternal pushing
80
What is cervical ripening?
Also known as cervical effacement
The softening, thinning and shortening of the cervix that occurs before labour and allows the cervix to dilate
Oestrogen, relaxin and prostaglandins break down cervical connective tissue
81
Outline the role of oxytocin in initiating labour?
Throughout pregnancy oxytocin has limited action as there are low numbers of oxytocin receptrs and its inhibited by relaxin and progesterone
At around 36/40, under the influence of oestrogen there is an increase in the number of oxytocin receptors present within the myometrium so the uterine begins to respond to the pulsation release of oxytocin from the posterior pituitary gland by contracting = pushes baby towards cervix and its head pushes against the cervix
Oxytocin production is increased by afferent impulses from the cervix and vagina = positive feedback loop to release more oxytocin leading to stronger contractions
This is the Ferguson reflex
82
What happens in the passive phase of the second stage of labour?
The head of the foetus descends to the pelvic floor when the woman will then experience the desire to push
83
Outline foetal station?
This refers to where the presenting part is in the pelvis
Stations range from -5 to +5
0 means head is aligned with ischial spines
-5 means baby’s head is not yet engaged in the birth canal
+5 is when the head is crowning i.e. 5cm below ischial spines
84
Outline how the myometrium is specially adapted to drive the process of labour?
The fibres of the myometrium dont fully relax following each contraction
This steadily reduces the uterine capacity so the pressure inside becomes stronger as labour progresses and this helps with the expulsion of the foetus
85
Which hormones help make contractions more forceful and frequent during the active stage of labour?
Prostaglandins - more intracellular calcium is released per action potential, increasing the force of contractions
Oxytocin - lowers the threshold for action potentials, increasing the frequency of contractions
86
How long does the active phase of the second stage of labour typically take?
<1 hour in nulliparous women
About 20 mins in multiparous women
87
If active phase of second stage of labour lasts >1 hour what should be considered?
Ventouse extraction, forceps delivery of caesarean section
88
Outline delivery of the foetus?
Once the head of the foetus reaches the perineum, it extends in order to come up and out of the pelvis. Following delivery of the head, it rotates by 90 degrees to assist with delivery of the shoulders.
The anterior shoulder delivers first, coming under the symphysis pubis while the body flexes laterally and posteriorly to aid passage. Following this the body flexes laterally and anteriorly to help deliver the posterior shoulder.
Once the shoulders have been delivered the rest of the body follows.
89
Describe pelvic dimensions?
Transverse diameter - pelvic inlet is largest 13cm
Anterior-posterior diameter - pelvic outlet is largest 13cm
Since transverse diameter is > AP diameter in pelvic inlet, the widest circumference of the foetal head descends in a transverse position. However when it gets closer to the pelvic outlet, the nature of the pelvic floor muscles encourages the foetal head to rotate from a transverse to AP position as this is greater
90
Explain how fetal head diameter varies depending upon the degree of neck flexion
Suboccipitobregmatic (vertex, flexed) is 9.5cm
Occipitofrontal (vertex, neutral flexion) is 11.0cm
Submentobregmatic (face) is 9.5cm
Verticomental (brow) is 13.5cm - largest and most challenging
91
Outline foetal cardinal movements
Descent - foetus descends into pelvis from 38 weeks in primigravida women or may not occur until labour in multigravida women
Engagement - when the largest diameter of the foetal head descends deep into the maternal pelvis. Defines on abdominal palpation where foetal head is 3/5th palpable or less
Flexion - occiput comes into contact with pelvic floor which causes flexion of the foetal neck. This allows circumference of foetal head to reduce to sub-occpitobregmatic 9.5cm which is the smallest diameter
Internal rotation - foetal head completes 90 degree turn
Crowning - when the widest diameter of the foetal head successfully negotiates through the narrowest part of the maternal bony pelvis. Clinically evidence when the head visible at the vulva, no longer retreats between contractions. Pushing must now be controlled so head is born with control so that skin and muscles in perineum have time to stretch.
Extension - occiput slips beneath the suprapubic arch allowing head to extend. Foetus born with its occiput anterior
External rotation/restitution - head naturally aligns with the shoulders. Shoulders reach the pelvic floor and complete their rotation from a transverse to AP position
Delivery of shoulder and body = expulsion
92
What encourages foetal descent in the pelvis?
Increased abdominal muscle tone
Braxton hicks in the late stages of pregnancy
Fundal dominance of the uterine contractions during labour
Increased frequency and strength of contractions during labour
93
What is the third stage of labour?
This follows delivery and lasts until placenta is delivered
Uterine muscle fibres contract to compress blood vessels supplying the placenta which then shears away from the uterine wall. Contractions continue until placenta and membranes have been delivered.
This stage usually lasts about 15mins and up to 500ml blood loss is normal
94
What is a partogram?
Pre-printed paper form on which labour observations are recorded
It monitors the progress of labour and can identify cases of abnormal labour where intervention may be necessary
95
What are the 2 ways of managing the 3rd stage of labour?
Active - IM injection of oxytocin as soon as you give birth to make womb contract. The cord is clamped and cut within 5 minutes or birth and then controlled cord traction of the umbilical cord during uterine contraction occurs to help deliver the placenta. The other hand will press on the uterus upwards to prevent uterine prolapse. After the uterus is massaged until it is contracted and firm and the placenta will be examined to ensure it is complete and no tissue remains in the uterus.
Physiological - natural. Cord is not cut until it has stopped pulsing which takes 2-4 minutes. Placenta comes away from womb and you can push the placenta out in a few minutes
96
What are the benefits and problems with active management of the third stage of labour?
It shortens the third stage, reduces the risk of postpartum haemorrhage. Will be initiated if there is any haemorrhage or a prolonged third stage (>60 mins)
Associated with nausea, vomiting and abdominal cramping
97
How commonly is induction of labour required?
In 20% of pregnancies
98
Indications for induction of labour?
prolonged pregnancy, e.g. 1-2 weeks after the estimated date of delivery
prelabour premature rupture of the membranes
maternal medical problems e.g. diabetic mother > 38 weeks, pre-eclampsia, obstetric cholestasis
intrauterine fetal death
99
What is the Bishop score?
Outline it
A scoring system used to determine whether to induce labour
It scores the following from 0-3 (position and consistency score 0-2)
Cervical position
Cervical consistency
Cervical effacement
Cervical dilation
Foetal station
Score <5 means labour is unlikely to start without induction
Score >=8 indicates cervix is ripe and high change of spontaneous labour
100
Possible options for induction of labour
Membrane sweep
Vaginal prostaglandin E2
Oral prostaglandin E2
Maternal oxytocin infusion
Amniotomy
Cervical ripening balloon
101
What is a membrane sweep? When are women offered it?
The examining finger passes through the cervix to rotate against the wall of the uterus which separates the chorionic membrane from the decidua; this stimulates prostaglandin production. If successful it should produce onset of labour within 48 hours.
This can be done by a midwife at the antenatal clinic
Nulliparous women are typically offered this at the 40 and 41 week antenatal visits and parous women at the 41 week visit
(This is regarded as an adjunct to induction of labour rather than an actual method of induction)
102
Prostaglandins role in labour
Promotes cervical ripening and encourages the onset of labour by acting on cervical collagen to encourage it to soften and stretch
May also stimulate uterine contractions
103
Outline how vaginal prostaglandin E2 works to induce labour? Whats its medical name?
Dinoprostone
Involves inserting a gel, tablet (prostin) or pessary (propess) into the vagina. This slowly releases local prostaglandins over 24 hours which should stimulate the cervix and uterus to cause onset of labour
Usually done in the hospital setting so women can be monitored
104
Outline how oral prostaglandin E1 works to induce labour? Whats its medical name?
Misoprostol
Like prostaglandins, it acts on cervix and uterine smooth muscle
105
Examples of synthetic oxytocin?
Pitocin
Syntocinon
106
How does synthetic oxytocin help induce labour?
Stimulates uterine smooth muscle contractility
107
What is amniotomy?
This is artificial rupture of membranes using an amnihook
This may augment labour by allowing direct pressure from foetal scalp on uterine cervix and releases prostaglandins
108
What is a cervical ripening balloon?
a silicone balloon that is inserted into the cervix and gently inflated to dilate the cervix. This mechanical stretching stimulates the release of prostaglandins which help soften and open the cervix.
The only method used for outpatient induction of labour
109
NICE guidance for inducing labour when Bishop score is <=6?
Vaginal prostaglandins or oral misoprostol
Mechanical methods if women at higher risk of hyperstimualtion or has had a previous Caesarian - ballon catheter (less risk of uterine rupture)
110
NICE guidance for inducing labour when Bishop score is >6?
Amniotomy and IV oxytocin infusion
111
What is the main complication of induction of labour with prostaglandins?
Uterine hyperstimulation - prolonged and frequent uterine contractions which can cause foetal distress and compromise (>5 contractions in 10 or contractions lasting >2 mins)
(Sometimes called tachysystole)
112
Potential consequences of uterine hyperstimulation?
Intermittent interruption of blood flow to intervillous space over time may result in foetal hypoxamia and acidemia
Uterine rupture
113
How do we manage uterine hyperstimualtion secondary to induction of labour?
removing the vaginal prostaglandins if possible and stopping the oxytocin infusion if one has been started
consider tocolysis with terbutaline
114
Monitoring during induction of labour?
CTG
Bishop score before and during induction to monitor progress of labour
115
Options when there is slow or no progress after induction of labour?
Further vaginal prostaglandins
Artificial rupture of membranes and oxytocin infusion
Cervical ripening balloon (CRB)
Elective caesarean section
116
Oxytocin role? where is it released form?
Stimulates ripening of the cervix and contractions of the uterus during labour and delivery. Also plays a role in lactation during breastfeeding
Produced in hypothalamus. Secreted by posterior pituitary gland
117
Indications for oxytocin?
Induce labour
Progress labour
Improve the frequency and strength of uterine contractions
Prevent or treat postpartum haemorrhage
118
What is atosiban?
Oxytocin receptor antagonist
Used as an alternative to nifedipine for tocolysis in premature labour
119
Indications of ergometrine?
Used for active management in the 3rd stage of labour and postpartum to prevent and treat postpartum haemorrhage
(Only used AFTER delivery of baby!)
120
Moa of ergometrine?
SE?
Who can’t have it?
Constricts vascular smooth muscle of uterus, blood vessels, GIT by stimulating alpha-adrenergic, dopaminergic and serotonergic receptors
This makes it useful for delivery of placenta and to reduce postpartum bleeding
SE - D+V, angina, hypertension - due to effects on blood vessels (e.g. coronary artery spasm) and in GIT
Avoid in eclampsia
Only use with significant caution in pt with hypertension
121
What is syntometrine?
A combination drug containing oxytocin and ergometrine
Used for prevention and Tx of PPH
122
What forms can dinoprostone come in?
Vaginal pessaries (Propess)
Vaginal tablets (Prostin tablets)
Vaginal gel (Prostin gel)
123
How does terbutaline work for tocolysis?
It stimautes beta-2-adrenergic receptors on smooth muscle of uterus - suppresses contraction
124
What is failure to progress in labour?
When labour is not developing at a satisfactory rate
This can increase the risk to foetus and mother
More likely to occur in primigravida
125
What are the 3 Ps that influence the progression of labour?
Power - uterine contractions
Passenger - size, presentation and position of baby
Passage - shape and size of pelvis and soft tissues
126
When is it considered that delay in the first stage of labour has occurred?
<2cm of cervical dilatation in 4 hours
Slowing of progress in multiparous women
127
What is recorded on a partogram?
Cervical dilatation (measured by a 4-hourly vaginal examination)
Descent of the fetal head (in relation to the ischial spines)
Maternal pulse, blood pressure, temperature and urine output
Fetal heart rate
Frequency of contractions
Status of the membranes, presence of liquor and whether the liquor is stained by blood or meconium
Drugs and fluids that have been given
128
What should you do if on the partogram the progression of cervical dilatation crosses to the right of the alert and acttion line?
Crossing the alert line is an indication for amniotomy and repeat examination in 2 hours
Crossing the action line means care needs to be escalated to obstetric-led care
129
How can we intervene in failure to progress in the second stage of labour?
Caused by issues with the 3 Ps so intervention will be focused on trying to fix the cause:
Changing positions
Encouragement
Analgesia
Oxytocin
Episiotomy
Instrumental delivery
Caesarean section
E.g. if power is the issue try oxytocin infusion
130
Whats the definition of failure to progress in the third stage of labour?
More than 30 minutes with active management
More than 60 minutes with physiological management
131
Options to improve pain without mediation in labour?
Understanding what to expect e.g. been to antenatal classes so they feel prepared
Having good support
Being in a relaxed environment. More relaxed=more oxytocin
Changing position to stay comfortable - kneeling, walking, rocking
Controlled breathing
Massage
Water births may help some women
TENS machines may be useful in the early stages of labour
132
Analgesia options in labour
Simple analgesia
Gas and air (entonox)
IM pethidine or diamorphine
Patient controlled analgesia
Epidural
133
What simple analgesia can you use during labour?
What should be avoided and why?
Paracetemol
Codeine may be added
Avoid NSAIDs as they can cause premature closure of the ductus arteriosus
134
What is entonox?
Side effects
50% nitrous oxide and 50% oxygen
“Gas and air”
The woman takes deep breaths using a mouthpiece at the start of a contraction, then stops using it as the contraction eases. Takes about 15 seconds to work. It can cause lightheadedness, nausea or sleepiness.
135
How does IM pethidine help manage pain in labour? How long does it take to work? How long do the effects last?
Side effects?
Acts as an agonist at u-opioid receptors
Takes 20 mins to work
Effects last 2-4 hours so not recmmended from the active second stage of labour
Makes you feel lightheaded, nauseous, forgetful. If given too close to time of delivery it can affect the baby’s breathing and can interfere with the baby’s first feed as it can make the baby drowsy
136
What patient-controlled analgesia can be offered during labour?
MOA?
Monitoring and SE?
IV remifentanil
Patient can press a button at the start of a contraction to administer a bolus of this. It works quickly and wears off after a few minutes
Mu-type-opioid receptor agonist
Requires pt to have oxygen saturations monitored
It can make you feel sleepy, nauseous, dizzy or itchy. It can also affect the baby’s breathing but typically wears off quickly
137
What is an epidural?
Inserting a catheter into the epidural space in the lower back where local anesthetic medications can be infused through the catheter and diffuse into surrounding tissues and through to the spinal cord where they have an analgesic effect
Anaesthetic options are levobupivacaine or bupivacaine, usually mixed with fentanyl.
In most cases it gives complete pain relief so is really helpful if labour is particuarly long or painful. Takes about 20-30 mins to take full effect
138
Recovery from an epidural?
Numbness usually lasts a few hours after epidural is stopped
Pt should be advise to rest in a lying or sitting position
May be a slight tingling sensation in the skin
Pt will not be able to drive, operate machinery or drink for 24 hours after having one
139
Side effects and risks of epidural?
Headache after insertion
Hypotension (although rare as IV fluids given)
Motor weakness in the legs - if significant they will need urgent anaesthetic review as catheter may be incorrectly sited in the subarachnoid space within the spinal cord
Nerve damage
Prolonged second stage of labour
Increased probability of instrumental delivery as you will no longer feel contractions
140
Advantages to using water in labour?
The water in a birthing pool supports 75% of a labouring woman’s weight, allowing a feeling of buoyancy and comfort. This makes mobility easier which conserves a woman’s energy during her labour.
• The baby adopts a better position for birth in the pelvis
• Reduction in the need for other strong pain relief. The relaxing effect of warm water helps produce endorphins, promoting the body’s natural pain relief mechanism.
• A feeling of being more in control of your body.
• Less need for drugs that accelerate labour such as oxytocin.
• A calm unhurried birth of the baby aided by the counterpressure of the water.
• A relaxed warm baby guided straight into the arms of the mother.
• The water can help lower your blood pressure.
141
What is umbilical cord prolapse? How common is it?
When the umbilical cord descends below the presenting part of the foetus and through the cervix into the vagina
Occurs in 1 in 500 deliveries
142
Whats the danger with umbilical cord prolapse?
Left untreated it can lead to compression of the cord or cord spasm which can cause foetal hypoxia and eventually irreversible damage or death
143
Risk factors for cord prolapse?
abnormal presentations e.g. Breech, transverse lie
prematurity
multiparity
polyhydramnios
twin pregnancy
cephalopelvic disproportion
Artificial rupture of membranes when baby is not far enough down into the pelvis
144
How is a diagnosis of umbilical cord prolapse made?
when the fetal heart rate becomes abnormal on CTG and the cord is palpable vaginally, or if the cord is visible beyond the level of the introitus.
145
Management of umbilical cord prolapse?
cord prolapse is an obstetric emergency
the presenting part of the fetus may be pushed back into the uterus to avoid compression
if the cord is past the level of the introitus, there should be minimal handling and it should be kept warm and moist to avoid vasospasm
the patient is asked to go on 'all fours' until preparations for an immediate caesarian section have been carried out - uses gravity to draw the foetus away from the pelvis and reduces compression on the cord
the left lateral position is an alternative
tocolytics may be used to reduce uterine contractions - terbutaline
retrofilling the bladder with 500-700ml of saline may be helpful as it gently elevates the presenting part
although caesarian section is the usual first-line method of delivery, an instrumental vaginal delivery is possible if the cervix is fully dilated and the head is low.
146
What is shoulder dystocia?
the inability to deliver the body of the fetus using gentle traction, the head having already been delivered. It usually occurs due to impaction of the anterior fetal shoulder on the maternal pubic symphysis.
It’s a cause of both maternal and fetal morbidity so its an obstetric emergency
147
Risk factors for shoulder dystocia?
fetal macrosomia (hence association with maternal diabetes mellitus)
high maternal body mass index
diabetes mellitus
prolonged labour
148
Signs of shoulder dystocia?
Difficult delivering the face and head, and obstruction in delivering the shoulders after delivery of the hea
Failure of restitution - head remains Occipito-anterior and does not turn sideways as expected
Turtle neck sign - head is delivered and then retracts back into the vagina
149
Management of shoulder dystocia?
HELPERR
Call for Help
Episiotomy - may be done to allow for better access for internal manoeuvres and reduce risk of perineal tears
Legs: McRoberts Maneuver
External Pressure - suprapubic
Enter: rotational maneuvers
Remove the posterior arm
Roll the patient to her hands and kness Call for senior help
Symphysiotomy and zavanelli manoeuvres can cause significant maternal morbidity and are not first-line options
150
What is McRoberts manoeuvre?
flexion and abduction of the maternal hips, bringing the mother's thighs towards her abdomen
This rotation increases the relative anterior-posterior angle of the pelvis and often facilitates a successful delivery.
151
What is Zavanelli manoeuvre?
Pushing the baby’s head back into the vagina so the baby can be delivered by emergency c-section
152
Complications of shoulder dystocia?
PPH
Perineal tears
Brachial plexus injury and Erb’s palsy
Neonatal death
153
How common are assisted vaginal briths?
1 in 8 women
1 in 3 for primigravida women
154
Indications for assisted vaginal birth?
Failure to progress
Fetal distress
Maternal exhaustion
Control of the head in various fetal positions
You’ve been advised not to try to push the baby out because of an underlying health condition e.g. severe hypertension
Increased risk when an epidural is in place
155
Risks of instrumental delivery?
PPH
Episiotomy
Perineal tears + higher chance of 3rd or 4th degree vaginal tear
Injury to anal sphincter
Incontinence of bladder or bowel
Obturator or femoral nerve injury
Cephaloaematoma with ventouse
Facial nerve palsy with forceps
Chignon with ventouse cup
Marks from forceps and small cuts on baby’s face and scalp
Fat necrosis that leads to hardened lumps of fat on their cheeks from forceps
Rarely:
Subgaleal haemorrhage
Intracranial haemorrhage
Skull fracture
Spinal cord injury
156
What is a ventouse
A suction cup that goes into the baby’s head and the doctor or midwife applies careful traction to the cord to help pull the baby out the vagina
Note if <36/40 and need an assisted birth, forceps may be recommended over ventouse as they are less likely to cause damage to baby’s head
157
Main complication for baby when using ventouse for delivery?
Cephalohaematoma
158
Main complications of forced-assisted delivery?
Facial nerve palsy
Bruises
Nerve injury for mother
159
How can forceps-assisted delivery cause femoral nerve injury in the mother?
How does it present?
The femoral nerve may be compressed against the inguinal canal during a forceps delivery.
Injury to this nerve causes weakness of knee extension, loss of the patella reflex and numbness of the anterior thigh and medial lower leg.
160
How can forceps-assisted delivery cause obturator nerve injury in the mother?
How does it present?
Obturator nerve may be compressed by forceps during instrumental delivery or by the fetal head during normal delivery.
Injury causes weakness of hip adduction and rotation, and numbness of the medial thigh.
161
Which nerves can be damaged during labour and delivery in the mother?
Femoral nerve
Obturator
Lateral cutaneous nerve of the thigh
Lumbosacral plexus
Common peroneal nerve
162
What causes lateral cutaneous nerve injury to the thigh during labour?
How does it present?
Prolonged flexion at the hip while in the lithotomy position
163
What causes lumbosacral plexus injury during labour?
How does it present?
Foetal head can compress the lumbosacral plexus during the second stage of labour
Foot drop and numbness of the anterior arterial thigh, lower leg and foot
164
What causes common peroneal nerve injury during labour?
How does it present?
This nerve can be compressed on the head of the fibula whilst in the lithotomy position
Foot drug and numbness in lateral lower leg
165
What is a chignon?
a temporary swelling left on an infant's head after a ventouse suction cap has been used to deliver him or her
166
Risk factors for perineal tears?
primigravida
large babies
precipitant labour
shoulder dystocia
Instrumental delivery
167
What is a first degree perineal tear?
Superficial damage with no muscle involvement
168
What is a second degree perineal tear?
Injury to the perineal muscle, but not involving the anal sphincter
169
What is a third degree perineal tear?
Injury to the perineum involving the anal sphincter complex - external and internal anal sphincter
170
What is a fourth degree perineal tear?
Injury to the perineum involving the anal sphincter complex (EAS + IAS) and rectal mucosa
171
Subtypes of third degree perineal tears?
3a: less than 50% of EAS thickness torn
3b: more than 50% of EAS thickness torn
3c: EAS and IAS torn
172
Management of perineal tears
First degree usually dont require any repair
Second degree requires suturing on the ward but a suitably experienced midwife or clinician
Third and fourth degree require repair in theatre by a suitably trained clinician
Broad-spectrum antibiotics to reduce the risk of infection
Laxatives to reduce the risk of constipation and wound dehiscence
Physiotherapy to reduce the risk and severity of incontinence
Followup to monitor for longstanding complications
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Complications of perineal tears
Pain
Infection
Bleeding
Wound dehiscence or wound breakdown
Urinary incontinence
Anal incontinence and altered bowel habit with third and fourth degree tears
Rectovaginal fistula
Sexual dysfunction and dyspareunia
Psychological
174
What is an episiotomy? how is it done?
where the obstetrician or midwife cuts the perineum before the baby is delivered.
This is done in anticipation of needing additional room for delivery of the baby (e.g. before forceps delivery).
It is performed under local anaesthetic.
A cut is made at around 45 degrees diagonally, from the opening of the vagina downwards and laterally, to avoid damaging the anal sphincter (mediolateral episiotomy)
Cut is sutured after deloiver
175
What is perineal massage? When should it be done?
Massaging the perineum to reduce the risk of perineal tears
From 35 weeks onwards every day until baby is born
176
Perineal protection at time of birth?
Birth position - kneeling, on all-fours, lying on side
HCP can place a warm compress on the perineum as the baby’s head stretches the perineal tissues
‘Hands-on’ birth - HCP supports perineum as baby is being born
177
What is a postpartum haemorrhage? What are the 2 types?
defined as blood loss of > 500 ml after a vaginal delivery
It can be primary or secondary
Primary - losing the blood within the first 24 hours after the birth of the baby
Secondary - abnormal of heavy vaginal bleeding between 24 hours and 12 weeks after the birth
178
What causes secondary PPH?
Typically due to retained placental tissue or endometritis
179
How commmon is primary PPH?
5-7% of deliveries
180
Causes of PPH?
Tone - uterine atony (when your uterine muscles don't contract enough to clamp the placental blood vessels shut after childbirth) - this is the vast majority of cases
Trauma e.g. perineal tear, episiotomy can cause hidden haematomas - woman likely shopped disproportionately to bleeding
Tissues e.g. retained placenta causing alteration of structure of the uterus which stops it from contracting properly
Thrombin e.g. clotting or bleeding disorder
181
Risk factors for PPH
prolonged labour - particularly 3rd stage
Multiple gestation - stretches uterus so much causes uterine atony
pre-eclampsia - can cause HELLP syndrome which causes thrombocytopenia which can increase risk of bleeding
increased maternal age
polyhydramnios
emergency Caesarean section
placenta praevia, placenta accreta - risk factors for placental retention
macrosomia
Nulliparity
Episiotomy and lacerations
Others:
Previous PPH
Asian ethnicity
Anaemia
Obesity BMI >35
182
Minor and major PPH?
Minor - <1000ml blood loss
Major >1000ml blood loss (moderate 100-2000 and severe is >2000ml loss)
183
Preventative measures for PPH?
Treating anaemia and any clotting disorders during the antenatal period
Giving birth with an empty bladder - a full bladder reduces uterine contraction
Active management of the third stage with syntocinon just after delivery of the anterior shoulder to increase uterine tone
Intravenous tranexamic acid can be used during caesarean section in higher-risk patients
Early cord clamping and cutting
184
Management of PPH
In absence of signs of shock - monitor closely (they may be ok these women have increased blood volume as a physiological response to pregnancy)
If sign sof shock…
Stabilise the pt:
Resuscitation with an ABCDE approach
Lie the woman flat, keep her warm and communicate with her and the partner
Insert two large-bore cannulas
Bloods for FBC, U&E and clotting screen
Group and cross match 4 units
Warmed Crystalloid infusion
Oxygen (regardless of saturations)
Catheterisation - prevent bladder distension which can prevent uterus contractions
Fresh frozen plasma is used where there are clotting abnormalities or after 4 units of blood transfusion
In severe cases activate the major haemorrhage protocol
Tx to stop bleeding:
Palpate uterine fundus and rub it to stimulate contractions
Bimanual compression - 1 hand over pelvis and 1 hand against body of uterus in vagina to compress it
IV oxytocin (syntocinon) slow injection followed by continuous infusion - issue with this is receptors can become saturated
Ergometrine slow IV or IM - stimulates smooth muscle contraction so causes uterine contraction (don’t give in pre-eclampsia/hypertension)
Carboprost IM - a prostaglandin that stimulates uterine contraction
Misoprostol sublingual - a prostaglandin that stimulates uterine contraction
Tranexamic acid IV - reduces bleeding
Surgical if medical options fail
185
Surgical treatment options for PPH?
Intrauterine balloon tamponade – inserting an inflatable balloon into the uterus to press against the bleeding. This is first line
B-Lynch suture – putting a suture around the uterus to compress it
Uterine artery ligation – ligation of one or more of the arteries supplying the uterus to reduce the blood flow
Hysterectomy is the “last resort” but will stop the bleeding and may save the woman’s life
186
How should you investigate secondary PPH?
Ultrasound for retained products of conception
Endocervical and high vaginal swabs for infection (endometritis can cause it)
187
What is MEOWS?
Maternity Early Obstetric Warning System - observations monitoring
188
How common is amniotic fluid embolisation?
Rare! 2 per 100,000 deliveries
189
What is amniotic fluid embolism?
When foetal cells/amniotic fluid enter the mother’s bloodstream and stimulates a reaction leasing to a systemic illness with >20% mortality rate
190
Aetiology of amniotic fluid embolism?
It is widely accepted that maternal circulation must be exposed to fetal cells/ amniotic fluid in order for an amniotic fluid embolism to occur. However the precise underlying pathology of this process which leads to the embolism is not well understood, though suggestions have been made about an immune mediated process.
191
Risk factors of amniotic fluid embolism?
Increasing maternal age
Induction of labour
192
Clinical presentation of amniotic fluid embolism?
The majority of cases occur in labour , though they can also occur during caesarean section and after delivery in the immediate postpartum.
Symptoms include: chills, shivering, sweating, SOB, anxiety and coughing.
Signs include: cyanosis, hypotension, bronchospasms, tachycardia. arrhythmia and myocardial infarction.
Amniotic Fluid Embolism Triad: Hypotension, Fetal distress and pulmonary oedema/ARDS
193
Diagnosis of amniotic fluid embolism?
Clinical diagnosis of exclusion, as there are not definitive diagnostic tests
194
Management of amniotic fluid embolism?
Critical care unit by a multidisciplinary team, management is predominantly supportive
Cardiopulmonary resuscitation and immediate caesarean section are required if cardiac arrest occurs.
195
Incomplete vs complete uterine rupture
Incomplete – where the peritoneum overlying the uterus (perimetrium) is intact. In this case, the uterine contents remain within the uterus. Also known as uterine dehiscence
Complete – the peritoneum is also torn, and the uterine contents can escape into the peritoneal cavity.
196
Risk factors for uterine rupture?
Previous C-section - particuarly vertical incisions
VBAC
Previous uterine surgery e.g. myomectomy
Increased BMI
Induction of labour - particularly with prostaglandins and use of oxytocin to stimulate contractions
Obstruction of labour
Multiple pregnancy
High parity
197
Clinical features of uterine rupture?
Sudden severe abdominal pain that persists between contractions
Should-tip pain from diaphragmatic irritation
Vaginal bleeding
Ceasing of uterine contractions
Regression of presenting part on examination
Scar tenderness and palpable;e foetal parts on abdominal examination
Signs of hypovolaemic shock if significant haemorrhage
Foetal monitoring may reveal foetal distress or absent heart sounds
198
Diagnosing uterine rupture?
USS
199
Management of uterine rupture?
Obstetric emergency so resuscitation - oxygen, insert 2 large bore cannulas and start circulatory resuscitation and transfusion
Deliver foetus by C-section
Repair uterus or hysterectomy
Decision-incision interval in operative intervention should be less than 30 minutes.
200
What is uterine inversion?
Uterine inversion is a rare complication of birth, where the fundus of the uterus drops down through the uterine cavity and cervix, turning the uterus inside out.
201
What is incomplete and complete uterine inversion?
Incomplete - fundus descends inside the uterus but not as far as the introitus
Complete - uterus descends through vagina to introitus
202
What can cause uterine inversion?
may be there result of pulling too hard on the umbilical cord during active management of the third stage of labour.
203
Presentation of uterine inversion?
Large postpartum haemorrhage
Maternal shock or collapse
Incomplete uterine inversion may be felt with manual vaginal examination. With a complete uterine inversion, the uterus may be seen at the introitus of the vagina.
204
Management options of uterine inversion?
Johnson manoeuvre - using hand to push fundus back up into abdomen, hold in place for several minutes and meds are used to create a uterine contraction - tension holds it in place
Hydrostatic methods - filling vagina with fluid to inflate the uterus back to the normal position. Requires a tight seal at the entrance of the vagina which can be challenging
When both the above fail…
Surgery - laparotomy to return uterus to normal position
205
2 main types of Caesarean sections
lower segment caesarean section: now comprises 99% of cases
classic caesarean section: longitudinal incision in the upper segment of the uterus
206
Indications for caesarean section?
absolute cephalopelvic disproportion
placenta praevia grades 3/4
pre-eclampsia
post-maturity
IUGR
fetal distress in labour/prolapsed cord
failure of labour to progress
malpresentations: brow + breech
placental abruption: only if fetal distress; if dead deliver vaginally
vaginal infection e.g. active herpes
cervical cancer (disseminates cancer cells)
Multiple previous C-sections
Multiple pregnancy
207
Categorisation of c-sections
Category 1 - immediate threat to life of mother or baby so delivery should occur within 30 mins of making decision e.g. suspected uterine rupture, cord prolapse, foetal hypoxia etc
Cetagroy 2 - maternal or foetal compromise which is not immediately life-threatening so delivery of baby should occur within 75 minutes
Category 3 - delivery is required but mother and baby are stable
Category 4 - elective caesarean
208
‘Frequent’ risks of c-section?
Maternal:
persistent wound and abdominal discomfort in the first few months after surgery
increased risk of repeat caesarean section when vaginal delivery attempted in subsequent pregnancies
readmission to hospital
haemorrhage
infection (wound, endometritis, UTI)
Fetal:
lacerations, one to two babies in every 100
209
‘Serious’ risks of c-section?
Maternal:
emergency hysterectomy
need for further surgery at a later date, including curettage (retained placental tissue)
admission to ICU
thromboembolic disease
bladder injury
ureteric injury
death (1 in 12,000)
Future pregnancies:
increased risk of uterine rupture during subsequent pregnancies/deliveries
increased risk of antepartum stillbirth
increased risk in subsequent pregnancies of placenta praevia and placenta accreta)
210
VBAC
planned VBAC is an appropriate method of delivery for pregnant women at >= 37 weeks gestation with a single previous Caesarean delivery
around 70-75% of women in this situation have a successful vaginal delivery
Uterine rupture risk in VBAC is about 0.5%.
Contraindications:
Previous uterine rupture
Classical caesarean scar (a vertical incision)
Other usual contraindications to vaginal delivery (e.g. placenta praevia)
211
2 possible skin incisions in transverse lower uterine segment incision C-section?
Pfannenstiel incision is a curved incision two fingers width above the pubic symphysis
Joel-cohen incision is a straight incision that is slightly higher (this is the recommended incision)
212
When might a vertical incision be used in c-section?
in cases in which it is difficult to access the lower uterine segment, such as that in preterm labor, dense adhesion, anterior placenta previa/accrete
213
Why is blunt dissection used for abdominal wall and uterus in c-section?
less bleeding, shorter operating times and less risk of injury to the baby than using sharp tools
214
Layers of abdomen that are dissected during a caesarean?
Skin
Subcutaneous tissue
Fascia / rectus sheath
Rectus abdominis muscles (separated vertically)
Peritoneum
Vesicouterine peritoneum (and bladder) – the bladder is separated from the uterus with a bladder flap
Uterus (perimetrium, myometrium and endometrium)
Amniotic sac
215
Why is a spinal anaesthetic used in a caesarean rather than a general?
safer and leads to fewer complications and a faster recovery than a general anaesthetic
Baby is exposed to lowest among of meds
Mother can actively participate in baby’s birth
216
Measures taken during a caesarean to reduce the risks of complications?
H2 receptor antagonists (e.g. ranitidine) or proton pump inhibitors (e.g. omeprazole) before the procedure. Reduces risk of aspiration pneumonia is caused by acid reflux and aspiration during prolonged period lying flat
Prophylactic antibiotics during the procedure to reduce the risk of infection
Oxytocin during the procedure to reduce the risk of postpartum haemorrhage
Venous thromboembolism (VTE) prophylaxis with low molecular weight heparin
217
Risks of c-sections
Generic surgical risks - bleeding, infection, pain, VTE
Complications in postpartum period - PPH, wound infection, wound dehiscence, endometritis
Damage to ureter, bladder, bowel or blood vessels
May affect the ileus, cause adhesions or hernias
Effects on future pregnancies - increased risk of repeat c-section, uterine rupture, placenta praevia and stillbirth
Effects on baby - risk of laceration and increased incidence of Transient tachypnoea of the newborn
218
VTE prophylaxis during/after C-section
Early mobilisation
Anti-embolism stockings or intermittent pneumatic compression of the legs
Low molecular weight heparin (e.g. enoxaparin)
219
delivery of monoamniotic twins
elective C-section between 32-33+6 weeks
220
delivery of diamniotic twins
Vaginal delivery is possible when the first baby has a cephalic presentation (note that >1/3rd of women who plan a vaginal birth go on to have a c-section)
Caesarean section may be required for the second baby after successful birth of the first baby
Elective caesarean is advised when the presenting twin is not cephalic presentation
at 37-37+6 weeks
221
mode of delivery of triplets
c-section at 35 weeks
222
when will a planned birth be offered for an uncomplicated monochorionic monoamniotic twin pregnancy?
32-33+6
223
when will a planned birth be offered for an uncomplicated dichorionic diamniotic twin pregnancy?
at 37 weeks
224
when will a planned birth be offered for an uncomplicated monochorionic diamniotic twin pregnancy?
at 36 weeks
225
when will a planned birth be offered for an uncomplicated monochorionic diamniotic twin pregnancy?
35 weeks -continuing pregnancy beyond 35+6 increases the risk of foetal death
226
managing third sage of labour in multiple pregnancy
only offer actuive management due to increased risk of PPH
consider using additional uterotonics
227
228
Discuss the measurement of outcomes in labour and delivery
Maternal mortality
Neonatal mortality
Stillbirth
Preterm birth
Birth injury
PROMs
Postpartum depression
Maternal confidence and success with breast feeding
Pelvic pains and dysfunction
Mother-infant attachment
Confidence with role as a mother
Hospital readmissions
229
What % of pregnancies are breech at 28 weeks and at 38 weeks?
25% at 28 weeks
Only 3% in last weeks
230
What is frank breech?
Most common presentation of breech with hips flexes and knees fully extended
Also known as extended breech
231
What is complete breech?
Legs fully flexed at the hips and knees
232
What is incomplete breech?
With 1 leg flexed at the hip and extended at the knee
233
What is footling breech?
With 1 foot presenting through the cervix with the leg extended
Rare - carries high perinatal morbidity
234
Risk factors for breech presentation?
uterine malformations e.g. fibroids
placenta praevia
polyhydramnios or oligohydramnios
fetal abnormality (e.g. CNS malformation, chromosomal disorders)
prematurity (due to increased incidence earlier in gestation)
235
Management of breech babies?
if < 36 weeks: many fetuses will turn spontaneously
if still breech at 36 weeks NICE recommend external cephalic version (ECV)- this has a success rate of around 60%. The RCOG recommend ECV should be offered from 36 weeks in nulliparous women and from 37 weeks in multiparous women
if the baby is still breech then delivery options include planned caesarean section or vaginal delivery
236
C-section vs vaginal birth for breech baby?
Planned c-section carries reduced perinatal mortality and early neonatal morbidity for babies compared with planned vaginal birth
No evidence that long term health of babies with a breech presentation delivered at term is influenced by how the baby is born
Overall, vaginal birth is safer for the mother, and caesarean section is safer for the baby. There is about a 40% chance of requiring an emergency caesarean section when vaginal birth is attempted.
237
RCOG absolute contraindications to ECV?
where caesarean delivery is required
antepartum haemorrhage within the last 7 days
abnormal CTG
major uterine anomaly
ruptured membranes
multiple pregnancy
238
How to do ECV?
Women are given tocolysis to relax the uterus before the procedure. (subcutaneous terbutaline.) A beta-agonist that reduces the contractility of the myometrium, making it easier for the baby to turn.
Apply pressure to pregnant abdomen
Rhesus-D negative women require anti-D prophylaxis when ECV is performed. A Kleihauer test is used to quantify how much fetal blood is mixed with the maternal blood, to determine the dose of anti-D that is required.
239
Comparing incidence of 3rd/4th degree perineal tears c-section vs vaginal birth
0 per 100,000 c-sec
560 per 100,000 which is 1 in 179 - vag - even higher in assisted vag birth
240
Comparing incidence of urinary incontinence lasting >1 year c-section vs vaginal birth
1 in 4 c-sec
1 in 2 vag
241
Comparing incidence of faecal incontinence lasting >1 year c-section vs vaginal birth
1 in 13 c-sec and unassisted vag
1 in 7 assisted vag
242
Comparing incidence of UTI c-section vs vaginal birth
1 in 1000 c-sec
0 in 1000 vag
243
Average amount of time spent in hopsital with c-section vs vaginal brith?
4 days c-sec
2.5 days vaginal birth
244
Comparing incidence of uterine rupture in future pregnancy: c-section vs vaginal birth
1 in 98 c-section
1 in 2500 vag
245
Comparing incidence of emergency hysterectomy: c-section vs vaginal birth
1 in 670 c-section
1 in 1250 vag
246
Comparing incidence of placenta accreta spectrum: c-section vs vaginal birth
1 in 1000 c-sec
1 in 2500 vag
247
Comparing incidence of maternal death within 6 weeks of childbirth: c-section vs vaginal birth
1 in 4200 c-sec
1 in 25,000 vag
248
Comparing incidence of neonatal mortality: c-section vs vaginal birth
1 in 2000 c-sec
1 in 3300 vag
249
How can you make sure the CTG is measuring foetal HR instead of maternal HR?
Simultaneous pulse oximetry recordings of maternal HR + intermittent auscultation of FHR throughout labour
250
What is the MOST accurate way to measure foetal heart rate?
Internal electronic foetal monitoring - using foetal scalp electrode
251
How to act if CTG detects foetal bradycardia
Check its definitely foetal HR and not maternal HR
Call for help at 3 mins of bradycardia. Stop oxytocin’s and prostaglandins. Turn to left lateral. Give IV fluids and oxygen. Give terbutaline.
If 6 mins still bradycardia move to theatre
At 9 mins Brady prepare for delivery
12 mins deliver - cat 1 C-sec
(Oxytocin and prostaglandins can cause uterine hyperstimulation which is the most common cause of this. We give terbutaline to stop these uterine contractions and restore foetal HR)
