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Obs & Gynae > Abnormal labour > Flashcards

Abnormal labour Flashcards

1
Q

What do the top and bottom lines on this tracing indicate?

A

Top line - fetal heart rate

Bottom line - uterine contractions

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2
Q

How many contractions in ten minutes is this lady having?

A

3

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3
Q

How is the strength of contractions measured during labour?

A

Placement of an intrauterine pressure catheter

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4
Q

How is the strength of uterine contractions measured on the tracing?

A

Strength of contraction = amplitude of each wave

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5
Q

What pain relief options are avaliable in labour?

A

Support

Massage / relaxation techniques

Inhalational agents - Entonox

TENS (T10-L1, S2-S4)

Water immersion

IM opiate analgesia e.g. Morphine

IV Remifentanil PCA

Regional anaesthesia

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6
Q

What is TENS?

A

Transcutaneous electrical nerve stimulation that can provide pain relief in labour

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7
Q

What is the ‘attitude’ of the passenger/baby?

A

Flexion/extension of the baby

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8
Q

What observations are recorded in the partogram?

A
  • Fetal Heart
  • Amniotic Fluid
  • Cervical Dilatation
  • Descent
  • Contractions
  • Obstruction - Moulding
  • Maternal Observations
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9
Q

Why is this labour failing to progress?

A

Contractions are weak, incoordinated and infrequent (only just reached 3 every ten mins)

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10
Q

Why is this labour failing to progress?

A

Cervix won’t dilate past 6cm

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11
Q

How often during stage one and stage two of labour should doppler auscultation of the fetal heart be performed?

A

•Stage 1:

During and after a contraction

Every 15 minutes

•Stage 2:

Every 5-10 minutes

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12
Q

What are the risk factors for fetal hypoxia?

A

Small fetus

Preterm / Post Dates

Antepartum haemorrhage

Hypertension / Pre-eclampsia

Diabetes

Meconium

Epidural analgesia

VBAC

PROM >24h

Sepsis (Temp > 38C)

Induction / Augmentation of labour

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13
Q

What are some of the acute causes for fetal distress?

A
  • Abruption
  • Vasa Praevia
  • Cord Prolapse
  • Uterine Rupture
  • Feto-maternal Haemorrhage
  • Uterine Hyperstimulation
  • Regional Anaesthesia
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14
Q

What should be assessed on cardiotogograph (CTG)??

A
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15
Q

What is the normal fetal heartrate? What are normal and pathological variations seen on CTG?

A
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16
Q

What feature is being pointed out on this CTG?

A

Accelerations

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17
Q

What is the difference between early and late decelerations?

A

Early decelerations are normal and occur with contractions: this is due to increased foetal intracranial pressure causing increased vagal tone, and so resolves quickly after contraction

Late decelerations begin at the peak of uterine contraction & recover after the contraction ends: this type of deceleration indicates there is insufficient blood flow through the uterus & placenta, as a result blood flow to the foetus is significantly reduced causing foetal hypoxia & acidosis

.

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18
Q

What are variable decelerations?

A

Variable decelerations are seen as a rapid fall in baseline rate with a variable recovery phase

They are variable in their duration & may not have any relationship to uterine contractions

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19
Q

When are variable decelerations most often seen?

A

In labour and in patients with reduced amniotic fluid volume

20
Q

What is the usual cause of variable decelerations?

A

Variable decelerations are usually caused by umbilical cord compression:

  • the umbilical vein is often occluded first causing an acceleration in response
  • then the umbilical artery is occluded causing a subsequent rapid deceleration
  • when pressure on the cord is reduced another acceleration occurs & then the baseline rate returns
  • accelerations before & after a variable deceleration are known as the “shoulders of deceleration”
  • their presence indicates the foetus is not yet hypoxic & is adapting to the reduced blood flow
21
Q

What does DR C BRAVADO stand for?

A

D ETERMINE

R ISK

C ONTRACTIONS

B ASELINE

R

A TE

V ARIABILITY

A CCELERATIONS

D ECELERATIONS

O VERALL IMPRESSION

22
Q

What factors must be taken into consideration when ‘definining risk’ during a CTG reading?

A

Maternal medical illness e.g. asthma, diabetes, hypertension

Obstetric complications e.g. multiple gestation, post-date gestation, previous cesarean section, IUGR, PROM, congenital malformations, induction of labour, pre-eclampsia

Other risk factors e.g. no prenatal care, smoking, drugs

23
Q

What should be recorded in the ‘contractions’ part of the CTG assessment?

A

Record the number of contractions present in a 10 minute period – e.g. 3 in 10

Each big square is equal to 1 minute, so you look how many contractions occurred in 10 squares

Individual contractions are seen as peaks on the part of the CTG monitoring uterine activity

You should assess contractions for the following:

  • Duration: how long do the contractions last?
  • Intensity: how strong are the contractions? (assessed using palpation)
24
Q

How is the baseline fetal heartrate assessed?

A

Ignore accelerations or decelerations, just assess the average heart rate over the last 10 minutes

25
Q

What is the definition of foetal tachycardia?

A

Foetal heart rate >160bpm

26
Q

What are some of the causes of foetal tachycardia?

A

Foetal hypoxia

Chorioamnionitis – if maternal fever also present

Hyperthyroidism

Foetal or Maternal Anaemia

Foetal tachyarrhythmi

27
Q

What is the definition of foetal bradycardia?

A

Baseline heart rate <120 bpm

28
Q

In what situations is mild foetal bradycardia 100-120 bpm common?

A

Post-date gestation

Occiput posterior or transverse presentations

29
Q

What are causes of prolonged severe foetal bradycardia?

A

Prolonged cord compression

Cord prolapse

Epidural & Spinal Anaesthesia

Maternal seizures

Rapid foetal descent

30
Q

What is the course of action that should be taken if the cause of severe, prologned foetal bradycardia cannot be identified and corrected?

A

Immediate delivery

31
Q

How can variability in the foetal heart rate be classified?

A

Reassuring ≥ 5 bpm

Non-reassuring < 5bpm for between 40-90 minutes

Abnormal < 5bpm for >90 minutes

32
Q

What are some of the causes of reduced variability on CTG?

A

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

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

Foetal tachycardia

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

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

Congenital heart abnormalities

33
Q

What are accelerations?

A

Accelerations are an abrupt increase in baseline heart rate of >15 bpm for >15 seconds

34
Q

How many accelerations should be present antenatally?

A

At least 2 every 15 minutes

However absence of accelerations in an otherwise normal CTG is not concerning

35
Q

What action should be taken if late decelerations seen on CTG?

A

Foetal blood pH sampling should be performed

If foetal blood found to be acidotic, this indicates significant hypoxia and urgent C-section is required

36
Q

Why might utero-placental blood flow become reduced?

A

Maternal hypotension

Pre-eclampsia

Uterine hyper-stimulation

37
Q

How might the overall impression of a CTG be described?

A

Reassuring

Suspicious

Pathological

38
Q

How can foetal distress be managed?

A

Change maternal position

IV Fluids

Stop syntocinon

Scalp stimulation

Consider tocolysis - Terbutaline 250 micrograms s/c

Maternal assessment - Pulse / BP / Abdomen / VE

Fetal blood sampling

Operative Delivery

39
Q

What is shoulder dystocia?

A

Bony impaction of the anterior shoulder behind the pubic symphisis (or occassionally posterior shoulder behind the sacral promontory)

40
Q

What are some of the antepartum risk factors for shoulder dystocia?

A

Diabetes

Macrosomnia

High BMI

Induced labour

Previous shoulder dystocia

41
Q

What are the intrapartum risk factors for shoulder dystocia?

A

Prolonged labour (first or second stage)

Instrumental delivery

Induction/augmentation of labour

42
Q

What are the signs of shoulder dystocia?

A

Turtle neck sign - head remains attached tightly to vulva

Difficulty delivering the head

Failure of the anterior shoulder to deliver

Failure of the restitution of the head

43
Q

How is shoulder dystocia managed?

A

H - call for Help

E - consider Episiotomy

L - legs: McRobert’s position

P - apply suprapubic Pressure to the pelvis

(Majority of shoulder dystocia is delivered at this point)

E - enter (the vagina): manouevers

R - Remove the posterior arm

R - Rollover on all fours and try all manoeuvres again

44
Q

What is McRobert’s position?

A

Patient laid flat and thighs hyperflexed to the abdomen

45
Q

What are some of the complications of shoulder dystocia?

A

Foetal hypoxia

Erb’s palsy

Klumpke’s palsy

Fractured clavicle

Uterine rupture

Perineal tears

Obs & Gynae (20 decks)

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