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Y4 - GOSH > stages of labour > Flashcards

stages of labour Flashcards

(64 cards)

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1
Q

what re the 7 steps of engagement and descent which allow a baby to be born

A

engagement and descent

flexion

internal rotation of the head

extension of the head

restitution

internal rotation of the shoulder

lateral flexion

delivery of the anterior then posterior shoulder

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2
Q

how do you differentiate between Braxton-Hicks contraction and labour

A

Labour is painful, progressive in frequency, amplitude and duration

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3
Q

what are the different stages of labour

A

1st stage - labour
2nd stage - delivery of the baby
3rd stage - delivery of placenta

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4
Q

what are the different phases of 1st stage of labour

A

1st stage of labour = from onset of labour to full dilatation of the cervix

latent phase - painful contraction which are not necessarily continuous along with some changes eg effacement and dilatation to 4 cm

active/established phase - regular painful contraction (5 mins apart and getting closer and short) and progressive dilation from 4 cm to full dilatation (10cm)

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5
Q

what is considered to be a failure to progress in a primigravid lady?

A

< 2cm per 4 hours of dilatation

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6
Q

what is considered to be a failure to progress in a multip lady?

A

< 2cm per 4 hour of dilatation or regression of dilatation

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7
Q

what are some causes of failure to progress?

A

Power - insufficient uterine activity
Passenger - malpositions, large baby
Passage - inadequate pelvis

or a combination of all those

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8
Q

what is the management of failure to progress?

A

if in the latent phase - manage conservatively

active phase

  • ARM and reassess in 2 hours
  • amniotomy + syntocinon infusion and reassess in 2 hours
  • LSCS
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9
Q

when is passive and active stages of 2nd stage of labour

A

passive 2nd stage - full dilatation of cervix prior to or in absence of involuntary expulsive contractions

active 2nd stage - when mother starts expulsive efforts using her abdo muscles

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10
Q

when is delayed of 2nd stage of labour diagnosed?

A

primi -
once actively pushing, delay of the second stage is diagnosed wif birth not imminent in 2 hours

multi-
once actively pushing, delay of the second stage is diagnosed if birth is not imminent in 1 hour

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11
Q

mx of delayed of 2nd stage of labour

A

instrumental delivery or C-section

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12
Q

what is active management of 3rd stage of labour

A

reduces risk of maternal haemorrhage, anaemia & need for transfusion and shorten 3rd stage

  • syntocinon
  • early clamping and cutting of the cord
  • controlled cord traction

prolonged active 3rd stage of labour - 30 minutes

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13
Q

what is physiological management of 3rd stage of labour

A

no routine use of uterotonic drugs
no clamping of cord until pulsation has ceased
delivery of placenta by maternal effort

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14
Q

when should a physiological management of 3rd stage of labour converted into active

A

when haemorrhage
failure to deliver the placenta in 1 hour
maternal desire to shorten 3rd stage

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15
Q

what are some maternal monitoring during labour

A 
BP
HR 
temp 
urineanalysis 
vaginal loss - colour 
contraction frequency, strength & length 
abdo palpatations 
VE to determien progress

all recorded on partogram

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16
Q

what are some foetal monitoring

A

low risk
- intermittent auscultation of fetal heart using sonicaid/doppler

high risk

  • continuous monitoring - CTG using foetal scalp electrode- DR C BRAVADO
  • foetal blood sampling
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17
Q

what are the management of worrying CTG

A

1) left lateral position
2) IV fluids
3) foetal scalp stimulation
4) foetal blood sample
- deliver if FBS is bad

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18
Q

how do you interpret FBS

A

pH > 7.25 = nomral
7.20-7.25 = bordeline
< 7.20 = deliver

must be 3 cm dilated to conduct FBS

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19
Q

what are the non-pharmacological methods of managing pain

A

education regarding what to expect
warm bath, acupuncture, hypnosis, aromatherapy and homeopathy
transcutaneous electricl nerver stimulation (TENS) - may not be adequate as labour advances

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20
Q

what are the pharmacological methods of managing pain

A

Entonox - works on the NMDA receptor, short half life so can not overdose on it

paracetamol

opioids - Daimorphine is 1st line in labour

opioids - pethidine - can cause neonatal respiratory distress and so will need naloxone

regional anesthesia

  • pudendal nerve block for operative vaginal delivery
  • local anesthetics - before performing an episiotomy

epidural or combined spinal analgesia

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21
Q

disadvantage of epidural

A 
inc supervision 
maternal fever 
reduced mobility - inc PE risk 
inc instrumental delivery rate 
hypotension 
urinary retentions
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22
Q

advantage of epidural

A

most effective analgesia in labour

can be topped up

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23
Q

what are some general indication for induction of labour

A

when it is agreed that the foetus or mother will benefit from a higher probability of a healthy outcome that if birth is delayed

prolonged pregnancy

IUGR

HTN and pre-eclampsia

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24
Q

obstetric indications for induction of labour?

A 
uteroplacental insufficiency 
prolonged pregnancy 
IUGR 
oligo or anhydramnios - twins 
non-reassuring CTG 
PROM 
pre-elcampsia/eclampsia 
DM - induce at 38 weeks 
IUD 
antepartum haemorrhage 
chorioamnionitis
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25
maternal indications for induction of labour?
``` HTN DM renal disease malignancies cardiac abnor > 40 - induce @ term ```
26
what are some C/I to induction of labour
absolute - acute foetal compromise - placental praevia - unstable lie - pelvic obstruction relative - previous C-section - still inc risk of uterine rupture - breech - prematurity - high parity
27
when will you consider induction of labour according to Bishop score?
if Bishop score < 5 - labour unlikely to start on its own
28
when will you not consider induction of labour according to Bishop score?
if Bishop score > 9, most likely to commence labour spontaneously
29
what is the first thing to do before offering a formal induction of labour?
stretch and sweep if nuiparious - 40-41 weeks if miltiparious - 41 weeks onward cervical ripening with prostaglandin in tablet, gel or tape form
30
what is the general pathway of induction of labour
stretch and sweep cervical ripening - prostaglandin, can try twice 6 hours after the other and allow 6 hours to work oxytocin or amniotomy/ARM if no uterine contraction after 2 hours from ARM - oxytocin infusion
31
how would you use oxytocin to induce or agment a labour
start off with low dose inc every 30 mints to achieve optimal contractions (3-4 every 10 mins, each lasting 30-60 sec) continuous CTG should be use
32
complications for oxytocin use for induction or agmentation?
hyperstimulation - reduce rate if using oxytocin, can use terbutalien (tocolytic) ``` operative delivery amniotic fluid embolus prematurity cord prolapse SE of oxytocin - inc pain or discomfort - foetal distress uterine rupture ``` prostaglandin - N+V diarrhoea bronchorestriction - caution in asthmatic C/S should induction fails
33
when will you augment a labour
when failure to progress - muti - 2cm per 2 hours - pri - 1cm per 2 hours
34
how would you augment the labour in 2nd stage of labour?
if after 2 hours of passive descent, push for 1 hour - then no progress - is the baby above or below the ischial spines? - is above C-S if below - instrumental delivery
35
what is the most common malposition?
occipito-posterior - often result in longer labour
36
mx of occipito-posterior position?
close monitoring of both foetus and mother epidural recommended adequate fluids be given to mother discourage any urge to push before full dilatation forceps or C-Section maybe required
37
mx of occipito transverse position
the head must be rotated using the Kielland's focreps or delivered using vacuum extraction in theatre so can quickly transition into C-section if fails --> C-section
38
mx of face-presentation
if mento-anterior position - mento = chin, results in longer labour but should be fine if mento-posterior - C-section
39
mx of brwo's position
C-section as vaginal delivery is not possible since the diameter of head is too big
40
what are the different types of breech presentation
extended flexed footling - requires C-section
41
what is breech position associated with
congenital abnor - pre-term baby and so contribute to congenital abnor also associate with placenta praevia, abnor of the uteres eg fibroids
42
mx of breech position
external cephalic version - from 36 weeks in nulliparous - from 37 weeks in multi - anti-D should be given if mother is Rh -ve common practice for breech position is C-section although vaginal delivery is possible, emergency C-section risk is high
43
contra-indication for ECV
absolute - when C-section already indicated - APH - foetal compromise - oligohydramnios - rhesus status - pre-eclampsia relative - previous C-S - foetal abnor - maternal hypertension
44
what are some risks associated with transverse and unstable lie
obstructed labour and potential uterine rupture cord prolapse - 20%
45
mx for transverse or unstablie lie
unstable lie - admit to hospital from 37 weeks, CS can be carried out if labour stars or membrane rupture inc gestation will help to revert the lie to longituitonal is lie is still unstable -- >C/s at 41 weeks
46
when should twins be delivered?
induced at 38 weeks
47
management of twins delivery
continuous CTG monitoring monitor leading twin with foetal scalp electrode deliver twins in theatre the 1st twin can be delivered vaginally, after the 1st twin is delivered, the lie of twin 2 should be check and stabilise with abdominal palpitation 2nd twin is usually delivered within 20 minutes of the 1st oxytocin may help with diminishing contraction if any distress with twin 2 - forceps or ventouse C-section if failed
48
what are some of the risk of labour of twins
``` malpresentation foetal hypoxia in second twin after delivery of 1st cord prolapse operative delivery post-partum haemorrhage ``` rare cord entanglement - MCMA twins only head entrapment with each other - locked twins
49
what are some maternal indication for instrumental delivery
``` exhaustion to avoid inc ICP to avoid inc BP prolonged 2nd stage > 1 hour of active pushing in multi, > 2 hours of active pushing in premip ```
50
what are some foetal indication for instrumental delivery
foetal compromise | to control the after coming head of breech
51
when should you not use a ventouse
when foetus < 34 weeks
52
what is the requirement for instrutmental delivery
FORCEPS ``` Fully dilated cervix OA position preferable Ruptured membranes cephalic presentation Engaged presenting part pain relief is adequate - vacuum or low forceps - perineal nerve block - mid - forceps - epidural or pudeneal nerve block or general anaesthetic sphincter bladder - empty ```
53
what are some side effect of C-section
abdo pain VTE bladder or uretric injury hysterectomy
54
what are the main indication for C-S
``` breech presentation foetal compromise repeated C-S failure to progress maternal request ```
55
what are the different categories of C-Section
Cat 1 - immediate threat to life of the women or foetus Cat 2 - maternal or foetus compromise which is not immediate threat to life Cat 3 - no maternal or foetal compromise but needs early delivery Cat 4 - elective
56
what requires Cat 1 C-section
crash C-section should be done within 30 minutes - placental abruption with abnor FHR or uterine irritability - cord prolapse - uterine scar rupture - prolonged bradycardia - scalp pH < 7.2
57
what requires a Cat 2 C-section
failure to progress with pathological CTG
58
what requires a Cat 3 C-section
severe pre-eclampsia IUGR with poor foetal function tests failed induction of labour
59
what requires a Cat 4 C-section
elective - delivery timed to suit woman and staff - twin pregnancy with no-cephalic 1st twin - maternal HIV - primary genital herpes in 3rd trimester - placenta praevia - prev hysterotomy or classical C-S usually carried out at around 39 weeks
60
what are some complications for C-section
intra-op - bladder laceration - bowel laceration - uterine or uterocervical laceration - inc blood loss - hysterectomy post-op - endometritis - wound infections - pulmonary atelectasis +/- infection - VTE - UTI longterm - urinary and bowel incontinence - uterine rupture - placenta praevia & plaenta accreta - antepartum stillbirth
61
What does shoulder dystocia
Usually the anterior shoulder is impacted against the synthesis pubis due to failure of internal rotation of the shoulder Posterior shoulder can also be impacted leading to bilateral impaction which greatly increase mortality
62
What are the complications of shoulder dystocia
foetal ``` cerebral palsy brachial plexus palsy - Erbs & Klumpkes fracture of the clavicle or humerus intracranial haemorrhage cervical spine injury rarely foetal death ``` maternal PPH genital tract trauma - 3rd and 4th-degree tear
63
RF for shoulder dystocia
Antenatal ``` Previous history of shoulder dystocia foetal macrosomia BMI > 30 & excessive weight gain in pregancny Diabetes post-term ``` intrapartum ``` lack of Progress in late first stage of labour Induction of labour Prolong second stage Instrumental vagina delivery Oxytocin augmentation of labor ```
64
management of shoulder dystocia
MCroberts suprapubic pressure episotomy - only if advanced intervention is required ``` advance intervention - rotate shoulder - woodscrew - deliver posterior arm - woodscrew - break clavicle emergency C-section ```

Y4 - GOSH (12 decks)

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