Perinatal/intrapartum care Flashcards

Question

What is the examination of the placenta during 3rd stage of labor?

Answer 1

 Placenta acreta = Placenta reaches the myometrium  Placenta increta = Placenta invades into > 50% of myometrium  Placenta percreta = Placenta reaches serosa of uterus and may even perforate the uterus

Answer 2

o Post-partum hemorrhage (PPH) o Uterine perforation o Introduction of infection into uterine cavity

Answer 3

Modified Bishops score B-ishop I-ffacement S-tation H-ard or soft (consistency) O-pening (dilatation) P-resenting part (position)

Answer 4

Restricted to following situations o Singleton pregnancy o Cephalic presentation o Term fetus o Fetus with normal NST o Nulliparous with Bishop score ≤ 6 or multiparous with Bishop score ≤ 4 Rule out contraindications * Asthma * Glaucoma * Cardiac diseases or allergy

Answer 5

Prostin vaginal tablet (3mg): 3mg prostin vaginal tablet inserted into the posterior fornix of the vagina 1 day before the planned induction * Fetal monitoring following admin of prostin: 2 hour continuous tracingo fetal heart is undertaken. In the absence of regular uterine contractions, a normal tracing can be discontinued and the women is allowed to mobilize. * Cervical assessment performed 6 hours later and repeat 3mg dose can be used if cervix is still not favorable. No more than 2 doses should be used within 24 hours. If labor is still not established, senior staff should be consulted to decide on subsequent management Propess vaginal pecessary (10mg): sustained release system with 10mg of dinoprostone. 10mg propoess vaginal pessary is inserted into the posterior fornix of the vagina 1 day before the planned induction. Should be removed 24 hours after insertion or in the next morning or if any of the below indications are present * Regular pain contractions every 3 mins irrespective of cervical change * Spontaneous rupture of membrnaes * Antepartum hemorrhage (APH) * Any suggestion of uterine hyperstimulation or hypertonic uterine contractions * Fetal distress or suspicious CTG * Maternal systemic AE of dinoprostone: nausea/ vomiting, hypotension, tachycardia Do not replace pessary back to vagina if accidentally dislodged and upon dislodgeemnt or removal, the doctor or midwife should check and document if propoess is intact in hte medicla record progress

Answer 6

* Continous electrical fetal monitoring should be carried out for 2 hours after insertion * If patients report painful contractions every 3 mins, CTG should be performed and medical officer should be performed for review * Bishop score should be reassesed after 24 hours or the next morning * If cervix favorable: artifical rupture of membranes (amniotomy), syntocinon induction: commneced 30 mins after removal of propess if contraction not regular * If cervix unfavorable: review with specialist to consider prostaglandin priming of PGE2 induction

Answer 7

Nitrous oxide (entonox) * Non opioid analgeic which is a gas mixture of oxygen and nitrous oxide with 50% each * Effect is peak at 20-30s and offset in 1 min. Patient instructed to inhale when uterus is starting to contract and continue inhalation until contraction begins to subside for maximal analgesic effect * Adv: self administered, fast acting and has minimal maternal and fetal side effects. Quickly eliminated via lungs and does not accumulate to cause respiratory depression * Disadv: nausea, vomiting, dizziness, tetany, hypocapnia and fetal hypoxia after prolonged use. Difficult in second stage of labor when patient has to be alert to push during the contraction Pethidine: opioid analgesic * Administerd IV or IM (contraindicated in patients with thrombocytopenia or coagulopathy) * Adv: offerred when neuraxial analgesia is not an option. Less invasive than neuraxial tecnique. * Disadv: less pain relief compared to neuraxial technique. Placental transfer of opioids to fetus may cause neonatal respiratory depression which is readily reversible with naloxone.

Answer 8

* Spinal anesthesia (for C section) * Epidural anesthesia (EA top up) for vaginal delivery/caesarean section * Combined spinal epidural (CSE) — Spinal component = rapid onset of a predictable block — Epidural = long lasting analgesia + titrate dose given to the desired effect Neuraxial technique is the most effective and commonly used therapy for pain relief during labor and delivery

Answer 9

T4 = Caesarean delivery, T10 = vaginal delivery Level required for surgery depends on dermatome level of skin incision and by level required for surgical manipulation. Low abd incision for C-section is made at T11-12 dermatome but a T4 spinal level is required to prevent pain with peritoneal manipulation since the innervation of peritoneum is up to T4 level.

Answer 10

* Absolute contraindications o Increased intracranial pressure (ICP)-->Cerebral herniation o Uncontrolled bleeding diathesis-->Epidural or subdural hematoma o Severe hypovolemia o Patient’s refusal * Relative contraindications o Spinal or soft tissue infection Meningitis/ Osteomyelitis/ Epidural abscess

Answer 11

Elective C/S is usually performed at 38 – 39 weeks of gestation

Answer 12

* Maternal distress or complications o Preeclampsia/ Eclampsia * Failure to progress during labor * Failed induction of labour * Failed instrumental delivery * Abnormal placentation o Placental previa (< 2 cm from os) o Placental abruption (unstable) o Placenta accreta o Vasa previa * Chorioamnionitis * Previous uterine scar or rupture o High risk in classical scar, myomectomy that enters uterine cavity or previous history of uterine tear

Answer 13

* Non-reassuring fetal status o Cord prolapse o Prolonged bradycardia * Fetal malpresentation o Breech presentation particular footling breech o Transverse fetal lie * IUGR o Fetus may be in distress when undergoing the stress of labour * Macrosomia o > 4500 g in women with DM o > 5000 g in women without DM

Answer 14

Administered to patients underoing both elective and emergency C-section. Standard regimen = cefazolin 1g IV given 15-60 mins prior to skin incision Alternative regimen for patient with penicillin allergy: clindamycin 600-900mg IV, erythromycin 500mg IV Additional dose of prophylactic antibiotics may be given 3-4 hours after initial dose if the procedure is lengthy >3 hours or estimated blood loss >1500ml

Answer 15

VBAC (vaginal birth after Cesarean section) is the attempt for vaginal birth in pregnancies after previous C/S: also known as trial of scar. Healed scarred uterus may still not be as strong as the normal unscarred uterus during pregnancy and thus patients are at relatively higher risk of scar rupture. Majority of women with 1 previous C/S can have a normal udelivery and therefore given a choice of either VBAC or ERCS (elective repeat Caesarean section). Patient without previous C/S or uterine tear or surgery will not be offered elective C-section in public hospital unless deemed necesary for obstretic indications

Answer 16

* More than 1 previous C/S * Previous classical C/S * Previous myomectomy with entry into uterine cavity * Previous hysterotomy * Previous uterine tear * Other obstretic indications for C/S

Answer 17

Rate of successful vaginal delivery after spontaneous onset of labor following C-section = 72-76% Chance will be higher and up to 90% in women who have given birth vaginally before. Chance will be lower in women who require induction or augmentation of labor Failure of VBAC --> emergency C section will be performed

Answer 18

Benefits of VBAC * Shorter recovery period * Shorter hospital stay * Less bleeding/blood loss * Less infection/fever * Less injury to surrounding organs such as bladder, ureter and bowel Risk and complications * Scar rupture: after 1 C/S = 0.5-.7%. Risk after 2 C/S = 2.5% * Rare complication but its chance increases in women having VBAC compared with virtually zero risk in women having ERCS

Answer 19

* Accelerations associated with fetal movement possibly resultng from stimuilation of peripheral proprioceptors, increased catecholamines release and autonomic stimulation of heart * Presence of acceleration predicts absence of ongoing hypoxic injury and metabolic acidosis * Absence of accleration alone is a poor predictor of hypoxic injury and metabolic acidosis Conditions associated with absence of acceleration * Fetal sleep cycle * Prematurity * Fetal hypoxia * Fetal arrhythmia * Fetal anemia * Congenital CVS or CNS anomalies

Answer 20

* Nifedipine, atosiban, terbutaline, salbutamol * Toco =labor, lysis =dissolve

Answer 21

* Preterm labor: delay delivery in the absence of signs or fetal distress for at least 48 hours to enable the effect of corticosteroids to enhance fetal lung maturation. Delay delivery until fetus has reached a gestation when perinatal survival is reasonable such as after 30 completed weeks of gestation * External cephalic version: relax the uterus to increase chance of success of ECV * Uterine hyperstimulation: relax the uterus rapidly and relieve fetal stress during uterine hyperstimulation

Answer 22

* Preeclampsia * Placental abruption * Chorioamnionitis * Gestation >34 weeks * Fetal death in utero * Fetal malformation where palliative care is plannewd * Suspected fetal compromise as deteremined by USG or CTG warranting delivery Relative contraindications * Maternal cardiac disease, DM, thyrotoxicosis, ruptured membrane and abnormal fetus

Answer 23

Nifedipine: half life (2-3 hours), maximum dose = 160mg daily **Protocal for acute tocolysis** = adalt 20mg PO Q30 min x up to 2 doses, then adalt retard 20mg PO Q8H for up to 48 hours 20mg orally stat followed by 20mg orally after 30 mins if contractions persist, followed by slow release form 20mg orally 30 mins later at every 8 hours for 48 hours as indicated **Protocal for maintenance tocolysis** = adalat retard 20mg BD to TDS. Long acting nifedipine 40-60mg orally per day MoA * Myometrial relaxation * Block the influx of Ca2+ through cell membrane --> decrease intracellular free 2+

Answer 24

* Baseline BP, pulse, RR, temp and FHR * Blood tests for CBC and LFT * Continuous CTG monitoring * Temperature Q4H * BP/P Q15min for the 1st hour, then Q30 min for the second hour, than Q1H in the first 24 hours, then q4h when on maintenance dose

Answer 25

Termination of treatment * Severe hypotension (stop treatment and IV rehydration with NS or Hartmanns solution) * Tachycardia >120bpm * Cannot tolerate side effects of nifedipine Contraindications * Significant maternal cardiac disease * Hypotension * Liver dysfunction * Concurrent use of IV betamimetics * Concurrent use of transdermal nitrates or antihypertensive medications * Concurrent use of MgSO4 Side effects * Hypotension (effect on BP is minimal on normotensive patients) * Reflex tachycardia and palpitations * Flushing/headache/dizziness * Nausea * Dyspnea

Answer 26

Atosiban: oxytocin and vasopressin antagonist Indications * Failed tocolysis with nifedipine (CCB) * Intolerable side effects of other tocolytics * In utero transfer of patients having preterm labor who has already started on atosiban at other hospitals

Answer 27

Initial bolus IV injection: 0.9ml (7.5mg/ml) solution for injection over 1 min High dose loading infusion: 5ml per vial concentrate for injection x 2 vials, added to 90ml normal saline or 5% dextrose or Hartmann solution Low dose subsequent infusion: 5ml per vial concentrate for injeection x 2 vials, added to 90ml normal saline or 5% dextrose or Hartmann solution Up to 3 further re-treatment are permitted MOA: oytocin receptor antagonist compete with oxytocin for binding to oxytocin receptors in the myometrium and decidua Prevents the increase in intracellular free Ca2+ that occurs when oxytocin binds to its receptors

Answer 28

Monitoring * Continous CTG monitoring * Temperature q4h * BP/P q15 min for first hour, than q30min Side effects * Chest pain * Pulmonary edema * Hypotension * Tachycardia and palpitation * Dyspnea * Headache * Nausea and vomiting

Answer 29

3rd line tocolytic agent, 1st line for external cephalic version (ECV) due to faster onset) Indicated when nifedipine or atosiban failed or cannot be tolerated Dosage * 8mg in 500ml of 5% dextrose solution * The starting dose is 5ug.min increasing the rate at 10-min interval by 20ml/hour until there is evidence of patient response shown by diminution in strength, frequency and duration of contractions. The maximum dose should not exceed 25ug/min or 100ml/hour * Apart from terbutaline, fluid replacement with Hartmanns solution should be given. Total infusion rate should be maintained 100ml/hour. Individualized adjustment can be made if clinically indicated. * Drug should be used with caution in diabetics because of its hyeprglycemic effect.

Answer 30

Myometrial relaxation: B2 agonists bind with receptors and increase intracellular adenyl cyclase Increase in intracellular cyclic adenosine monophosphate activates protein kinase and results in phosphorylation of intracellular proteins, Resultant drop in intracellular free Ca2+ interferes with the activity of myosin

Answer 31

Monitoring * Continuous CTG monitoring * Temperature Q4h * BP/P q15 min for first hour then q30min * Check serum Na+, K+, urea, glucose before commencing terbutaline infusion as baseline but infusion can be commenced before results are available. Serum electrolytes and glucose level should be determined at regular intervals q12h. Termination of treatment * Severe hypotension * Tachycardia >120bpm * Cannot tolerate side effects of terbutaline Contraindications (specific to B adrenergic agonists) * Hypotension * Severe cardiac diseases * Thyrotoxicosis or taking B blocker for palpitation * Poorly controlled DM Side effects * Hypotension * Tachycardia and palpitation * Dyspnea

Answer 32

Considered if patient is allergic to terbutaline or if patients has been on salbutamol infusion when before transferral to our unit Dosage: 20mg in 500ml 5% dextrose starting at 10ug/min, increasing by 15ml/hour every 10 min to a maximum of 45ug/min. MoA * Myometrial relaxation: B2 agonist bind with receptors and decrease in intracellular Ca2+ --> interferes with activity of mysoin light hcain kinase Monitoring * Continous CTG monitoring * Temperature Q4h * BP/P q15 min for first hour, then q30min * Check serum Na+, K+, urea, glucose before commencing terbutaline infusion as baseline but infusion can be commenced before results are available: serum electrolytes and glucose level should be determined at regular intervals q12h. In between regular blood taking serum glucose should be further monitored by Hstix Q4h Contraindications * Hypotension * Severe cardiac diseases * Thyrotoxicosis or taking B blocker for palpitation * Poorly controlled DM Side effects * Hypotension * Tachycardia and palpitation * Dypsnoea

Answer 33

* Patients with preterm labor or at risk of emergency or elective deliveries between 26-34 weeks, corticosteroids should be given to the mother for fetal lung maturation Lower limit for admin of antenatal corticosteroids is 23 weeks of gestation since only a few primitive alveoli are present below this gestation age Lungs need to have reached a stage of development that is biologically responsive to corticosteroids for it function

Answer 34

* Accelerates the development of tyep 1 and 2 pnuemocytes leading to structural and biochemical changes that improve lung mechanics (maximal lung volume, compliance) and gas exchange * Induction of type 2 pneumocytes increases surfactant production by incuding production of surfactant proteins and enzymes necessary for phospholipid synthesis Effectiveness * 65% reduction in respiratory distress syndrome for babies delivered >24 hours and <7 days: maximal neonatal benefits are achieved when preterm birth occurs between 24 hours adn 7 days after corticosteroid administration. Efficacy appears to be incomplete <24 hours and appears to decline >7 days * 20% reduction in RDS for babies delivered <24 hours: tocolysis is therefore indicated to delay delivery in the absence of signs of maternal or fetal distress for at least 48 hours to enable to effect of corticosteroids to enhance fetal lung maturation Other beneficial effeects: reduce incidence of intraventricular hemorrhage (IVH), necrotizing entercolitis (NEC), sepsis and neonatal mortality

Answer 35

* Standard regimen = betamethasone 12mg IMI q24h for 2 doses * Alternative regimen = dexamethasone 6mg IMI 16h for 4 doses: to be used if patient has been given dexamethasone before transferral to our unit or when betamethasone is not available Betamethasone vs dexamethasone Dexamethasone is associated with lower incidence of neonatal intracranial hemorrhage but is associated with a higher NICU admission rate --> betamethasone thus remains the standard of choice

Answer 36

* Multiple course of steroid in PPROM may be associated with increase early onset neonatal sepsis * Used in caution with combination with tocolytics because of the risk of maternal pulmonary edema

Answer 37

Bishop score is below Modified Bishop score (position, station, cervical length, cervical dilatation, consistency)

Answer 38

* Lengthening of the umbilical cord * Gush of blood from the vagina signifying separation of the placenta from the uterine wall * Change in shape of the uterine fundus from discoid to globular with elevation of the fundal height.

Answer 39

Ask mother to bear down and gently tug on the umbilical cord to deliver it. Place a hand on the abd to secure the uterine fundus to prevent uterine inversion. After placental expulsion, massage the uterine fundus to help it contract into a firm globular mass. A flabby fundus suggests atony, which is the most common cause of postpartum hemorrhage. (administer oxytocin 20 units in 500ml saline over 1 hour or 10 units IM)

Answer 40

* Umbilical cord: 2 arteries and 1 vein (thicker) * Insertion point of the umbilical cord (smooth side of placenta): central, eccentric, marginal * 2 membranes layer: chorion is the outer, opaque, friable membrane that lines the uterus and extends to the edfge of the placenta. The amnion is the smooth, stronger, inner, translucent membrane that covers the umbilical cord. * Look for blood vessels leading into the membranes that may suggest a succenturiate lobe is retained in the membranes. * Examine maternal surface, ensure all the cotyledons are present, fit together without gaps and with a uniform edge. Take cord blood samples for BG analysis if baby is born by C section or low Apgar score. Samples for blood group and Rhesus factor will be taken if mother has a Rh-ve blood group. Where maternal sepsis is suspected or confirmed eg. chorioamnionitis or prolonged membrane rupture, cord samples will be taken for blood culture. Swabs from the fetal and maternal surfaces are also required.

Answer 41

Spontaneous rupture of membrane when in labor (regular, usually painful, contractions that bring about progressive cervical changes) Premature ROM: ROM before onset of labor Preterm PROM: PROM occurring when preterm

Answer 42

Dont pull too hard during CCT --> risk of uterine inversion Dont pull on placenta and membran directly --> risk of placenta and membrane breaking apart --> RPOG

Answer 43

Late and variable decelerations are pathological and must be managed immediately Late deceleration: uterine contraction compresses maternal blood vessels which decreases maternal perfusion of intervillous space of placenta. pO2 decreases initiating an autonomic sympathetic reflx to cause peripheral vasoconstriction. Increase in BP stimulates baroreceptors to slow the HR, reduce the CO and return BP to normal Variable deceleration: compression of umbilical cord --> decreases fetal venous return causing a baroreceptor mediated reflex rise in FHR. Further compression occludes the umbilical arteries causing an abrupt increase in fetal resistance and BP.

Answer 44

Reassuring: 5-25bpm Non reassuring: less than 5bpm for between 30-50 mins, more than 25bpm for 15-25 mins Abnormal: less than 5bpm for more than 50 mins, more ethan 25bpm for more than 25 mins Causes of reduced variability * Fetal sleeping: should lsat no longer than 40 mins (most common cause) * Fetal acidosis (due to hypoxia): more likely if late decelerations also present * Fetal tachycardia * Drugs: opiates, BDZ, methyldopa * Prematurity * Congenital heart abnormalities

Answer 45

Reassuring, suspicious or abnormal Factors incuded: * baseline HR: 110-160bpm * Baseline variability: 5-25bpm * None or early, varaible decelerations with no concerning characteristics for <90 mins

Perinatal/intrapartum care Flashcards

(103 cards)