10/11) Labour & Delivery - NICE Intrapartum Care Flashcards
Increased risk in perinatal outcome in low risk primp delivering at home
4 per 1000 (9 per 1000 from 5 per 1000)
Rates of transfer to CLC from MLU/home
Approx 10% multips, 40% nullips
Most common recent for transfer into hospital
Delay in first/second stage
When is maternal pulse an indication to transfer to CLC?
- HR >120 on 2 occasions >30 minutes apart
When is maternal blood pressure an indication to transfer to CLC?
> 160/110
OR >140/90 on 2 occasions >30 minutes apart consecutively
OR ++ protein and single BP >140/90
When is maternal temperature an indication to transfer to CLC
?Temp >38 or >37.5 on 2 readings 1 hour apart
When is vaginal loss an indication to transfer to CLC?
Vaginal blood loss other than show
Significant meconium
PROM >24h
When is fetal presentation/size an indication for transfer to CLC?
Abnormal presentation/lie
High (4/5-5/5 palpable) or free-floating head in null
Suspected FGR/macrosomia
Suspected anhydramnios/polyhydramnios
When is fetal movements an indication for transfer to CLC?
Reduced in last 24 hours
When is maternal pain an indication for transfer to CLC?
Pain different from contractions
What to do if I/A indicates possible FHR abnormalities?
Offer CTG and if normal after 20 minutes return to I/A
Temperature of water in pool
37.5
How long to stay out of pool after opiates?
2 hours
When to measure BP during epidural?
Every 5 minutes for 15 minutes during epidural establishment or boluses
When to recall anaesthetist if not pain free?
30 minutes
When to assess level of sensory block?
Hourly
CTG monitoring during epidural
30 minutes during establishment and after administration of each further 10mL bolus
Medication in epidural
10-15mL 0.0625-0.1% bupivicaine with 1-2microgram/mL fentanyl.
When to auscultate FH during labour?
Every 15 minutes in first stage (for 1 minute after contraction)
When should contraction frequency suggest CTG required?
lasting >60s or >5:10
FBS results
Normal: >7.25 or lactate <4.1
Borderline: 7.20-7.25 and lactate 4.2-4.8
Abnormal: <7.20 or lactate >4.9
When to repeat FBS?
1 hour after normal result or 30 minutes after borderline result
What to do if you can’t obtain FBS?
- If accelerations in response to stimulation then decide re: continuing labour v expediting
- If no accelerations in response to stimulation then expedite
Average length of labour
P0: Average 8 hours, unlikely >18h
Multiple: Average 5 hours, unlikely >12h
How frequent ops in first stage of labour?
30 minutes: Contractions
Hourly: Pulse
4 hourly: Temp and BP
VE: 4 hourly
When to diagnose delay in first stage?
<2cm in 4 hours in either primps or multis.
In multips, slowing in progress.
Descent and rotation of baby’s head.
Changes in strength, duration and frequency of contractions.
How to manage delay?
- Offer ARM if suspecting delay
- Whether ARM accepted or not allow a further 2 hours and if <1cm dilated then consider that diagnostic.
- Once diagnosed transfer to CLC and offer synt
How to titrate synt?
Every 30 minutes until 4-5:10 contractions
When to reassess after starting sync for delay in first stage?
4 hours - if <2cm then consider CS, if >2cm then VE again in 4 hours
How often to do VE in 2nd stage?
Hourly
When to diagnose delay in second stage?
Primip: Active 2nd stage >2h (suspect if progress inadequate after 1h)
Multip: Active 2nd stage >1h (suspect if progress inadequate after 30 minutes)
How frequent to have obstetric review for delay in second stage?
Every 15-30 minutes
Comparison of active v physiological 3rd stage
N&V: 10% v 5%
PPH 1.3% v 2.9%
Blood transfusion 1.4% v 4%
What is an abnormal neonatal RR suggesting review required?
> 60
Abnormal neonatal sats?
<95%
When to do neonatal obs?
Sig mec: 1h, 2h and then 2h to 12h
Non-sig mec: 1h, 2h
PROM: 1h, 2h, 6h, 12h
