Woman presenting to birth suite at term Flashcards Preview

Obstetrics and Gynaecology > Woman presenting to birth suite at term > Flashcards

Flashcards in Woman presenting to birth suite at term Deck (66):
1

First step

Initial assessment Indication for presentation: contractions, vaginal loss, spontaneous ROM, pain

2

Important history

Verbal Hand help record Model of care General health and well being Obstetric and gynaecological history Medical/surgical history Psychosocial, spiritual Investigations during pregnancy LMP, EDD by scan or period Presence of contractions Gush of fluid/blood Fetal movements

3

Investigations during pregnancy need to know

Blood and urine test results->blood group, resus, infection screens, Hb levels, urine, BP throughout pregnancy Measurements of fundus Results of CFTS, US morphology and growth scans Whooping cough vaccination

4

What examination is required

Vitals, BP, Temperature, General CTG for fetal monitoring Abdominal examination->privacy and consent. Fundal height, lie, presentation, position, engagement. Contractions, FHR, CTG, FM Vaginal Loss->nil. show, liquor, blood Vaginal examination->if indicated and no contraindications

5

What advice to give when baby is OP position and in established labour

OP presentations are common in primi, sometimes can make labour slower as baby has to rotate 135 degrees anterior.

6

Information recorded on partogram

Vagina Cervix-->effacement, consistency, dilitation, application of presenting part, membranes, liquor Presenting part--> Nature, level, sutures, fontanelles, position, caput, moulding Pelvic assessment Procedures and recommendations FHR Descent Oxytocin Contractions Drugs and fluids Temp BP Maternal HR Urine, bowels, vomit

7

When is a partogram started

When in established labour 4cm dilated

8

When are the warning and action lines drawn

2 hours for warning and 4 hours for action line to the right of the expected cervical dilation of 1cm per hour.

9

Expected cervical dilation rate/hour

1cm/hour

10

When to reassess uncomplicated established labour

4 hourly

11

Purpose of ARM

To bring the presenting part closer to the cervix, increase production of natural prostaglandins

12

Prior to administering an epidural, 3 things need to do

Consent and catheter, CTG

13

Indications for continuous CTG (10)

Preterm Prolonged Suspected fetal compromise Meconium stained liquor FHR abnormalities Oxitocin Epidural Previous CS Multiples Any condition that led to antenatal CTG monitoring

14

Risks of epidural (7)

Maternal motor blockade, reduced movement Xbladder sensation->need for catheter Hypotension Need for continous CTG Slight increase in overall length of labour Slight increase in operative vaginal delivery Small risk of postnatal headache

15

How to commence an oxytocin infusion

Establish indication Gain IV access Main-line infusion of Hartmanns/normal saline w/ T connector Oxytocin infusion in 500ml hartmanns containing 10IU hartmanns commenced via T piece

16

When to increase oxytocin infusion rate

Increased half hourly until desired labour pattern acheived

17

Oxytocin dose acheived with fluid load

ml/h, micro-units/min 10/3.25 20/6.5 40/13

18

10 units oxytocin in 500ml equals how many units of oxytocin/ml

0.02

19

Following intial VE on presentation what next?

Discomfort and pain-> assess response to contraction Review birth plan Discuss options Reassure, reinforce coping Note preference for pain relief

20

Documentation after presenting

Date time and reason Assessment Time regular contractions commences Time of SROM Communication, advice, management plan

21

Following initial assessment

Discuss/consult if risk factor identified Triage stage of labour and manage as indicated

22

Defining active first stage labour

Regular painful contractions Progressive dilation of cervix 4-5 cm

23

Overview of management in active first stage labour (5)

Supportive care Ongoing assessment Documentation Identify risks Diagnose delay in active first stage

24

Define delay in first stage

Cervical dilation

25

Supportive care in active first stage- aspects to consider (6)

Woman centred Review birth plan Environment Mobilisation and positioning One to one care Non-pharmacological comfort strategies

26

Ongoing assessment in active first stage labour (12)

Maternal and fetal condition Progress and descent of fetal head FHR- 1/4 to 1.2 hourly Temp and BP 4 hourly Maternal pulse 1/2 hourly Abdominal palpation 4 hourly Contractions 1/2 hourly for 10 minutes Vaginal loss hourly VE 4 hourly/indication Nutrition and hydration- offer fluids/food Bladder- monitor and encourage 2 hourly emptying Discomfort and pain

27

Documentation during first stage

Intrapartum record Date and time labour commenced Assessment Effectiveness of supportive care Time of SROM- color, odour, amount, consistency Communication, advice and management plan

28

Define latent first stage

Some cervical change with cervical dilation and effacement up to 4-5 cm 1 contraction/5 mins 30-60s regular

29

Management of latent first stage if not admitted/discharge

Encourage to remain at home Reassure normality Discuss comfort strategies Advise mobilisation may establish contractions Provide support information and instructions on when to return Document

30

Support strategies for latent stage labour

If tired- rest Hydration and nutrition Warm showers/baths Massage/back rubs TENS Paracetamol 1 g 6 hourly or 1 g hourly orally

31

What is the bishop score and measurements

Rates the readiness of the cervix for labour Dilation Effacement Station Consistency Position if cervix

32

What bishop score says cervix is favourable and unfavourable

Favourable when >6 Unfavourable when

33

What is the defining feature of second stage labour

Urge to push or active maternal effort of pushing

34

Overview of care in second stage

Onset when full cervical dilation, maternal pushing Supportive case-->environment, positioning, emotional support Assessment Documentation Identify delay in active second stage

35

Assessment requirements in second stage

Maternal and fetal condition FHR

36

Define delay in second stage

In nulliparous- after 2 hours or when total length of second stage >3 hours Multiparous > 1 hour

37

Management of passive second stage

Full dilation w/o involuntary expulsive contractions FHR 1/4 hourly Delay pushing if no urge Other care as per second stage

38

When is diagnosis of delay in passive second stage made

Nulliparous and multiparous- after 1 hour

39

Definition of third stage labour

From birth of baby to expulsion of placenta

40

Management overview of third stage

Supportive care: environment, skin to skin, minimal interruption of maternal/newborn bonding Physiological/Active or Modified active management Care and assessment Documentation

41

Physiological management of third stage

Birth of placenta by maternal effort only Clamp cord after cessation of pulsation No routine use of uterotonics

42

Active management of third stage labour

Routine administration of uterotonics CCT Uterine massage

43

Modified active management of third stage labour

Active management with uterotonics after cord pulsation has ceased

44

Care and assessment in third stage labour

Observe breastfeeding Encourage upright Ensure empty bladder Observe general physical condition- color, resp, vaginal losses, womans self report

45

Following birth of placenta, assess

Temperature, pulse, BP Blood loss Fundus Placenta and membranes Perineum

46

Documentation in third stage

Time of birth of placenta Management, care and assessment Estimated blood loss Communication, advice and management plan

47

Define prolonged third stage

Active >30 mins Physiological >60 mins

48

Fourth stage new born care- immediate

Initial assess- skin to skin Tone, breathing, HR, colour, reflex Apgar Newborn examination Ensure not separated from mother STS for minimum 1 hour Initiate breastfeeding Keep warm Ensure clear visibility of newborn and optimal airway positioning Lighting adequate to observe for colour

49

Care of newborn following breastfeeding

Weight, length, HC Administer Vitamin K and hepatitis V RR, colour, position 1/4 hourly for 2 hours Temp and HR 1 hour from brith Document- date, time, apgar, assessment, ID, commence neonatal clinical pathway and health record.

50

Care of mother in fourth stage

STS contact Keep with baby Allow bonding Eat, drink and rest Pain relief offer Personal hygeine needs If negative blood group- cord blood test to determine Anti-D requirements Temperature w/i first hour Pulse, respiration, lochia after birth of placenta and 1/4 and 1/2 hourly Perineum Pain Urine output Document

51

Mechanism of changes to cervix in first stage

1. Uterus contracts and retracts->heaping of upper uterus, cervix thins and stretches.

52

Methods of induction of labour

1. Artificial rupture of membrane +/ dinoprostone 2. Oxytocin infusion

53

Mechanism of labour

1. Estrogen +myometrium activity, progesterone suppresses 2. Late pregnancy: fetal adrenals +DHEAS->Estrogen and contractions 3. Decidua produces PG->contractions->hypoxia->+PG 4. Final pathway in cytosol free calcium->actin + myosin

54

Process of CCT

1. Uterotonic drugs given following delivery of anterior shoulder 2. Left hand above symphysis pubis guards front wall of uterus preventing inversion. Empty bladder, relax 3. Umbilical cord grasped in right hand, steady traction until delivered 4. Membrane follows placenta->may need gentle rotation of placenta to help peel off. Check for completeness

55

Pin relief options

1. Non-drug Warm bath Relaxation Hypnosis TENS 2. Drug Nitrous oxide: inhale before each contraction Morphine: no antispasmodic, for OP, long labours. AVoid 2 hours before delivery, can cause depression to baby. Give metoclopramide. Pethidine Diamorphine 3. Anaesthesia Local Regional: epiD at T11-S4 General: when emergency C-section and need speed

56

Movements of fetus during labour

1. Flexion Head engages when head through pelvic brim 2. Descent Brim to mid cavity 3. Internal rotation One parietal lower than the other 4. Further flexion Chin tightly up against fetal chest Occiput behind pubis 5. Extension'Head forward, gradual extension, distending perineum Widest part passes through introitus= crowning 6. Restitution and internal rotation Shoulders enter maximum diameter One shoulder leads->rotates and head rotates 90 degrees Shoulders in AO behind pubic symphysis 7. Delivery of the body Assist lateral flexion of fetal head, ant shoulder slips under Posterior shoulder follows

57

Potential changes in fetal heart

1. Fetal tachyC 2. Baseline bradyC 3. Baseline variability Increased Loss of variability 4. Intermittent changes Deccelerations Accelerations

58

Normal fetal heart rate and baseline variability

1. Normal FHR 110-160 2. Normal variability 6-25 beats/ minute

59

Define fetal tachyC and causes

1. FHR >170 2. Maternal tachyC->pyrexia, pain, deH, blood loss 3. Fetal hypoxia->prolonged, intense contractions, por placental flow etc

60

Baseline bradyC significance

1. If baseline 110-120 usually of no significance

2. Mild bradycardia of between 100-120bpm is common in the following situations:

Post-date gestation

Occiput posterior or transverse presentations

3. Severe prolonged bradycardia (< 80 bpm for > 3 minutes) indicates severe hypoxia

Prolonged cord compression

Cord prolapse

Epidural & Spinal Anaesthesia

Maternal seizures

Rapid foetal descent

61

Define increased variability and causes

1. Increased = 25 variability

2. Fetal hypoxia

3. Fetal anemia

62

Define loss of variability and causes

1. Reassuring – ≥ 5 bpm

2. Non-reassuring – < 5bpm for between 40-90 minutes

3. Abnormal – < 5bpm for >90 minutes

Causes

1. Foetus sleeping – this should last no longer than 40 minutes – most common cause

2. Foetal acidosis (due to hypoxia) – more likely if late decelerations also present

3. Foetal tachycardia

4. Drugs – opiates, benzodiazipine’s, methyldopa, magnesium sulphate

5. Prematurity – variability is reduced at earlier gestation (<28 weeks)

6. Congenital heart abnormalities

63

Early deccelerations

1. Vagal response as head compression during descent

2. Usually no significance- physiological

3. Early decelerations start when uterine contraction begins & recover when uterine contraction stops. 

4. Quickly resolves once the uterine contraction ends & intracranial pressure reduces

64

Late decceleration

1. U shaped, >30 s after contraction and continue following the contraction

2. This type of deceleration indicates there is insufficient blood flow through the uterus & placenta

3. As a result blood flow to the foetus is significantly reduced causing foetal hypoxia & acidosis

Reduced utero-placental blood flow can be caused by: ¹

1. Maternal hypotension

2. Pre-eclampsia

3. Uterine hyper-stimulation

Needs to be taken seriously, fetal pH monitoring

65

Variable deccelerations

1. Isolated variable, Common

Umbilical cord compressed

As long as returns to normal, baby no aphyxiated and fetal blood sampling not required

2. Recurrent variable deccellerations

Vary in shape and relationship to contraction

Most commonly caused by cord compression between presenting part and pelvic side walls

66

Accelerations

1. Intermittent FHR ++above baseline 2. Sign of fetal health