Abnormal labour Flashcards
What is pPROM?
Pre-term premature rupture of the membranes
How common is pPROM?
3% singleton
10% twins
What are some risk factors for pPROM
- Polyhydramnios
- Cervical insufficiency (Dilatation ocurring early)
- Infection
- Trauma (Including amniocentesis)
- Bleeding (Haematomas)
Management of pPROM
- Antibiotic prophylaxis
- Steroids (Depending on gestation) - Allows rapid lung maturation
- Admission for minimum 48 hours
- Close monitoring for infection
- Delivery by 37 weeks
What is induction of labour (IOL)?
The use of medications to stimulate the onset of labour
Indications for IOL
- 41 and 42 weeks gestation
- Prelabour rupture of membranes
- Fetal growth restriction
- Pre-eclampsia
- Obstetric cholestasis
- Existing diabetes
- Intrauterine fetal death
What scoring system is used to assess cervical readiness for induction of labour?
Bishop’s score (0-13)
What are the factors of Bishop’s score
- Fetal station (scored 0 – 3)
- Cervical position (scored 0 – 2)
- Cervical dilatation (scored 0 – 3)
- Cervical effacement (scored 0 – 3)
- Cervical consistency (scored 0 – 2)
What Bishop’s score predicts a successful induction of labour?
≥8
What are some methods of inducing labour?
Membrane sweeping
Vaginal prostaglandin E2
Cervical ripening balloon (CRB)
Artificial rupture of membranes
Oral mifepristone (Anti-progesterone) + misoprostol
What is involved in membrane sweep?
Insert a finger into the cervix to stimulate it
This should produce onset of labour within 48 hours (Used from 40 weeks)
What are some forms of vaginal prostaglandin E2 (Dinoprostone)
Gel
Tablet (Prostin)
Pessary (Propess)
How does vaginal prostaglandin E2 work?
It stimulates the cervix and uterus to cause the onset of labour
What is involved in cervical ripening balloon?
A silicon balloon is inserted into the cervix and gently inflated to dilate the cervix
Used in previous C-sections or multiparous women (≥3)
What is involved in artificial rupture of the membranes?
A small hook like instrument is used to rupture the membranes whilst an oxytocin infusion is also given
When may mifepristone plus misoprostol be used to induce labour?
In cases of intrauterine death
What monitoring is required during induction of labour
CTG
Bishops score
What is the main complication of induction of labour via prostaglandins?
Uterine hyperstimulation
What is uterine hyperstimulation?
A condition in which contraction of the uterus is prolonged and frequent, causing foetal distress and compromise
What are the main criteria for uterine hyper stimulation?
- Individual uterine contractions lasting more than 2 minutes in duration
- More than five uterine contractions every 10 minutes
What are some risks of uterine hyperstimulation?
- Fetal compromise, with hypoxia and acidosis
- Emergency caesarean section
- Uterine rupture
Management of uterine hyperstimulation
- Removing the vaginal prostaglandins, or stopping the oxytocin infusion
- Tocolysiswithterbutaline
What is failure to progress?
When labour is not developing at a satisfactory rate
In who is failure to progress most common?
Primigravida women
What are the 3Ps of labour?
P - Power
P - Passenger
P - Passage
Example of a power problem that can cause failure to progress?
Insufficient uterine activity
Example of a passenger problem that can cause failure to progress?
Foetal macrosomia
Malpresentation
Example of a passage problem that can cause failure to progress?
Small pelvis
Cephalo-pelvic distortion (Pelvic shape)
Definition of failure to progress in 1st stage - Nulliparous woman
<2cm dilatation in 4 hours
Definition of failure to progress in 1st stage - Multiparous woman
<4cm dilatation in 4 hours
Definition of failure to progress in 2nd stage - Nulliparous woman
2nd stage lasting >2 hours or >3 with epidural
Definition of failure to progress in 2nd stage - Multiparous woman
2nd stage lasting >1 hour (2 with epidural)
Definition of failure to progress in 3rd stage
> 30 minutes with active management
60 minutes with physiological management
Active management of 3rd stage
Intramuscular oxytocin and controlled cord traction
What is obstructive labour?
Labour that is not progressing despite good contractions
What are some signs of failure to progress?
- Slow/no cervical dilatation
- No descent or high presenting part
- Caput/moulding of presenting part (Excessive)
- Haematuria or anuria
- CTG “too good” with no stress on the baby despite regular contractions
- Ascites at C-section
- Bandl’s ring at C-section
- Vulval oedema
Risks of failure to progress?
- Sepsis
- Uterine rupture
- Kidney injury
- PPH
- Fistula formation
- Foetal asphyxia
Maternal investigations in failure to progress?
Obs
Urine output
Abdominal exam
Vaginal exam
Foetal investigations in failure to progress?
Heart rate monitoring
Colour of liquor
How is progression of labour monitored
Partogram
What measurements are recorded on partogram?
- Foetal pH
- Liquor colour
- Moulding
- Foetal heart rate
- Cervical dilatation
- Foetal station (Compared to ischial spines)
- Contractions per 10 minutes
- Maternal pulse
- Maternal blood pressure
Management options for insufficiency uterine activity?
Artificial rupture of membranes
Synto
Assisted delivery
What is cephalic presentation
Head first presentation of the baby
What is breech presentation
Feet and bottom first presentation of the baby
What are some abnormal forms of cephalic presentation
Occipital-posterior or occipito-transverse
Brow presentation
Face presentation
Management of occipito-posterior or occipito-transverse presentation
Rotation if fully dilated
LUSCS
Management of brow presentation
LUSCS
Management of face presentation
Vaginal birth if mento-anterior (Chin anteriorly)
LUSCS if mento-posterior
What is transverse/oblique lie?
The baby is lying horizontally
Management of transverse/oblique lie?
LUSCS due to risk of cord presentation
How common is breech presentation?
<5% of pregnancies by 37 weeks
What are some types of breech presentation
Complete breech
Incomplete breech
Extended breech
Footling breech
What is complete breech?
Where the legs are fully flexed at the hips and knees
What is incomplete breech
Where one leg is flexed at the hip and extended at the knee
What is extended breech (Frank breech)?
Both legs flexed at the hip and extended at the knee
What is footling breech
Foot presenting through the cervix with one leg extended
Management of breech presentation
Before 36 weeks, babies usually turn on their own
After 37 weeks, external cephalic version can be used to attempt to turn the foetus
What is the chance of requiring emergency C-section in vaginal birth of breech presentation?
40%
What is the success rate of external cephalic version
50%
What is needed to perform external cephalic version?
Tocolysis with terbutaline
Anti-D prophylaxis (D-neg)
What test is required to find the dose of anti-D required?
Kleihauer test
IN whom is external cephalic version used?
After 36 weeks for nulliparous women
After 37 weeks in multiparous women
What is chorioamnionitis?
An infection of the placenta and amniotic fluid
How does chorioamnionitis usually occur?
Usually occurs when the amniotic sac is broken for a long time prior to birth
What are some risks of chorioamnionitis
Creates a hostile environment for the baby and so can lead to foetal or maternal death
Presentation of chorioamnionitis
- Maternal signs of sepsis/abnormal bloods
- Increase MHR, RR, Temp, White Cell Count, CRP, Lactate
- Can be difficult to separate from “normal” labour stressors but best to treat if suspicious particularly if PROM
- Fetal tachycardia/abnormal CTG
- Offensive/blood stained liquor
- Abdominal pain
- Intrauterine pus at section
Management of pre-term, premature rupture of the membranes to prevent chorioamnionitis
Erythromycin prophylaxis
Steroids (Gestation dependant)
Admit for observations
Delivery earlier if S/S infection
How is chorioamnionitis managed?
Golden hour of prompt recognition and initiation of antibiotics
Management of prolonged rupture of membranes
- At term expectant management for first 24 hours after SRM
- Offer induction after 24 hours to reduce risk of infection
- Offer immediate induction of labour if GBS positive
What is umbilical cord prolapse
when the umbiical cord comes out of the uterus with or before the presenting part of the baby
Risk factors for umbilical cord prolapse
Malpresentation
Pre-term labour
2nd twin
Artificial membrane rupture
How does umbilical cord prolapse cause problems?
Direct cord compression as well as cord spasm
This causes decreased blood flow, leading to foetal hypoxia and possibly death
Presentation of umbilical cord prolapse
- May be asymptomatic
- Non-engaged presenting part on abdominal exam
- Cord examined on vagional exam
Investigations for umbilical cord prolapse
Scanning for foetal cardiac activity
Management of umbilical cord prolapse
Immediate delivery (CS or forceps)
Tocoltic and maternal positions to relieve pressure
What is uterine inversion
where thefundus of the uterusdrops down through the uterine cavity and cervix, turning the uterus inside out.
What is incomplete uterine inversion
where the fundus descends inside the uterus or vagina, but not as far as theintroitus(opening of the vagina)
What usually causes uterine inversion
pulling too hard on the umbilical cord during active management of the third stage of labour.
How does uterine inversion usually present
Large PPH
Maternal shock or collapse
Visible uterus
Management options for uterine inversion
- Johnson manoeuvre
- Hydrostatic methods
- Surgery
What is Johnson manoeuvre
Using a hand to push the fundus back up into the abdomen and the correct position. The whole hand and most of the forearm will be inserted into the vagina to return the fundus to the correct position. It is held in place for several minutes, and medications are used to create a uterine contraction (i.e. oxytocin). The ligaments and uterus need to generate enough tension to remain in place.
What is involved in hydrostatic methods of reversing uterine inversion
filling the vagina with fluid to “inflate” the uterus back to the normal position. It requires a tight seal at the entrance of the vagina, which can be challenging to achieve.
