3.2. Labour - Abnormal Labour and Post-Partum Care Flashcards
What happens if there is a Failure to start Labour?
Induction of Labour will occur
Note - 1 in 5 pregnancies are induced, it is common
What are the disadvantages of Induction of Labour?
- Less Efficient - Higher Risk of Foetal Distress / Hyperstimulation of the Uterus
- More Painful - Higher chance of requiring Anaesthetic (Epidural)
- Higher chance of Instrumental Delivery (15%) / Caesarean Section (22%)
What are the indications for the Induction of Labour?
- Diabetes (usually before Due Date)
- Post-dates - Term + 7 days
- Maternal Health Problems (e.g. DVT)
- Foetal Reasons - Growth Concerns / Oligohydramnios
- Rare - Social / Maternal Request / Pelvic Pain / “Big” Babies
What is involved in Induction of Labour?
An attempt is made to instigate Labour, using Medications and / or Artificial Rupture of Membranes (Amniotomy)
What Score is used to Clinically assess the Cervix, for Cervical Ripening?
Bishop’s Score:
The Higher the score, the more progressive change there is in the Cervix - indicates induction is likely to be successful
When can an Amniotomy be performed, in Induction of Labour?
Once the Cervix has Dilated and Effaced
What does Bishops Score take into account?
- Dilation (cm) - 0 / 1-2 / 3-4 / 5+
- Length of Cervix (cm) (Effacement) - 3 / 2 / 1 / 0
- Position - Posterior / Middle / Anterior
- Consistency - Firm / Medium / Soft
- Station (cm) - -3 / -2 / -1, 0 / +1, +2
What is the Process of Induction of Labour?
- If Cervix not Dilated / Effaced (Low Bishop’s Score), Vaginal Prostaglandin Pessaries used to “Ripen” the Cervix
- Once Cervix is Dilated and Effaced, Amniotomy is Performed (Bishop’s Score > 7)
- I.V. Oxytocin used to achieve adequate contractions
Note - Aim for 4-5 contractions in 10 minutes
How is progress of Labour Evaluated?
Combination of Abdominal and Vaginal Examinations to determine:
- Cervical Effacement
- Cervical Dilation
- Descent of the Foetal Head through the Maternal Pelvis
What is Suboptimal Progress, during the first stage of Labour?
Cervical Dilation of less than:
- O.5cm / hour for a Primigravid (1st Pregnancy) Woman
- 1cm / hour for a Parous (Previous Pregnancy) Woman
How are the Strength and Duration of Contractions increased?
By giving I.V. Synthetic Oxytocin
Note - it is important to exclude obstructed labour first - could lead to ruptured Uterus
What can cause Inadequate Progress of Labour?
- Cephalopelvic Disproportion (CPD)
- Malpostion
- Malpresentation
- Inadequate Uterine Activity
- Other reasons for Obstruction (Cyst / Fibroid)
Note - This leads to Foetal Distress
What is Cephalopelvic Disproportion?
The Foetal Head is in the Correct Position for Labour but is too Large to negotiate the Maternal Pelvis and be Born
What happen to the baby in Cephalopelvic Disproportion?
The Babies head becomes compressed and Caput and Moulding develop
What is Malpresentation?
The Foetal Head is in an incorrect position for Labour (and so Relative Cephalopelvic Disproportion occurs)
What are the forms of Malpresentation?
- Longitudinal Lie - Vertex Position (Baby’s Back to the Side of the Uterus)
- Lonitudinal Lie - Breech Position (Baby’s Head is Superior-most)
- Transverse Lie - Shoulder Presentation
Note - The baby should be in the Longitudinal Lie, with its Back to the Anterior Uterus, and its Head Inferior-most to be delivered first
What can happen as a Result of Inadequate Uterine Activity?
Foetal Head will not Descend and Exert Force onto the Cervix - so the Cervix will not Dilate
How can Uterine Hyper-Stimulation cause Foetal Distress?
This can lead to insufficient placental blood flow
What is Foetal Well-Being, in Labour, determined by?
- Intermittent Auscultation of the Foetal Heart
- Cardiotocography (CTG)
- Foetal Blood Sampling
- Foetal ECG
When is Foetal Blood Sampling used?
- Persistently Suspicious
2. Pathological Cardiotocography
What does Foetal Blood Sampling provide?
Direct Measurements of the Baby’s:
- pH and Base Excess
- Hypoxaemia (due to pH)
What situations would it be best to advise against Labour?
- Obstruction to the Birth Canal (Masses / Major Placenta Praevia)
- Malpresentations
- Medical conditions where Labour would not be safe for the Woman
- Specific Previous Labour Complications (Previous Uterine Rupture)
- Foetal Conditions
What is the options if Labour is ill-advised?
- Caesarian Section
2. Assisted / Instrumental Delivery (15% of Births)
What are the Risks associated with a Caesarian Section?
- Infection
- Bleeding
- Visceral Injury
- Venous Thromboembolism
What are regarded as “3rd Stage” Complications of Pregnancy?
- Retained Placenta
- Post-Partum Haemorrhage (4 T’s)
- Tears - Graze / 1st / 2nd / 3rd / 4th Degree
What check-ups normally happen in the Post-Partum (Puerperium) Period?
- See Midwife for the first 9-10 days, the the Health Visitor
- All women have a 6 week Post-Natal Check at the GP
What is the purpose of seeing the Midwife (and then the Health Visitor)?
- Continue to observe for signs of Abnormal Bleeding
- Observe for Evidence of Infection
- Debrief events around Birth
What are common problems which will present at the 6 week Post-Natal Check (with the GP)?
- Problems with Infant Feeding
- Problems with Bonding
- Social Issues (Partner / Other Children / Financial Issues)
- Contraception
What is involved in the immediate Post-Natal Care for High Risk Women?
15 - 60 minute observations to check for:
- Uterus remains contracted and no evidence of Abnormal Bleeding
- Prophylactic Antibiotics
- Appropriate Thromboprophylaxis
- Recovery from Spinal / Epidural / General Anaesthesia
- Fit for transfer to Post-Natal Ward
What are the major Post-Natal Problems?
- Post-Partum Haemorrhage
- Venous Thromboembolism
- Sepsis
- Psychiatric Disorders of the Post-Partum (Puerperium) Period
- Pre-Eclampsia
What are the 2 types of Post-Partum Haemorrhage?
- Primary - >500ml Blood Loss within 24 hours
2. Secondary - >500ml Blood Loss from 24 hours Post-Partum to 6 weeks
What are the causes of Primary Post-Partum Haemorrhage?
Note - 4T’s
- Tone - Uterine Atony
- Trauma - Tears to the Perineum / Vagina / Cervix
- Tissue - Retained Tissue / Placenta
- Thrombin - Coagulopathy
What are the causes of Secondary Post-Partum Haemorrhage?
- Retained Tissue
- Endometritis (Infection)
- Tears / Trauma
What are the major Thromboembolic Diseases to be concerned of during Pregnancy / immediate Post-Partum?
Pregnancy and the Immediate Post-Partum Period is a Hypercoaguable State, and you are worried for:
- Deep Vein Thrombosis Formation (Unilateral Leg Swelling / Pain)
- Pulmonary Embolism (Dyspnoea / Chest Pain / Tachycardia)
What is used to investigate the risk of Thromboembolic Disease?
- ECG
- Leg Dopplers
- Chest X-Ray +/- Ventilation-Perfusion Scan
How is Thromboembolic Disease treated?
- Thromboprophylaxis
- Low-Molecular Weight Heparin
Note - Do not treat with Warfarin as it is Teratogenic
How should any Maternal Woman be treated if Sepsis is Suspected?
- Prompt I.V. Antibiotics Administration
- Perofrm a Full Septic Screen
Note - Sepsis may present Atypically
Who deals with significant concerns about a Womans mental health around pregnancy?
Dedicated Peri-Natal Mental Health Team
What are the “Baby Blues”?
- Hormonal changes around the time of Birth - 1-3 days post-natally
- Does not affect functioning and requires no specific treatment
What is Post-Natal Depression?
- It can continue on from the “Baby Blues” or start some time later
- Classical Depressive Symptoms
- Increase risk in women with Personal / Family History of Affective Disorder
What is Pueperal Psychosis?
- Serious Psychotic Illness of the Post-Natal Period
- Women can be a danger to themselves and their baby
- Requires inpatient Psychiatric Care
- Much more common in women with personal or family history of affective disorder, bipolar disorder or psychosis
When do most Eclamptic Seizures occur?
In the Post-Natal Period
Note - Pre-eclampsia can develop post-natally or may worsen several days following delivery
