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Abnormal Labour Flashcards

1
Q

Is it common to induce Labour

A

Yes, ~1/5 of labours are induced

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2
Q

Any risks/disadvantages associated with an induced labour

A
  • Less efficient and more Painlful
  • Higher chance of instrumental delivery (15%)
  • Higher chance of CS (22%, though new evidence does suggests it may not increase CS rates)
  • Higher risk of requiring an epidural
  • Higher risk of foetal distress
  • Risk of hyperstimulation of uterus (“Hypertonic”)
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3
Q

During an induced labour what is recommended in regards to the foetus

A

Due to higher risk of foetal distress continuous foetal monitoring is recommended

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4
Q

4 indications for inducing labour

A
  • Diabetes (usually before due date)
  • Post dates (term + 7days or 42weeks)
  • Maternal health problems that necessitates planning of delivery e.g. receiving treatment for DVT
  • Foetal reasons e.g. growth concerns, “big babies”, oligohydramnios (deficiency of amniotic fluid, opposite of poluhydramnios)
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5
Q

2 ways of inducing labour

A
  • Amniotomy (artificial rupture of membranes)

- Medically, Prostaglandin suppository, IV Oxytocin

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6
Q

What is the Bishop’s score

A
  • Used to clinically asses the cervix for “cervical ripening”
  • The higher the score the more progressive the change in the cervix is and the more likely an induced labour will be successful
  • Also been used to assess the odds of spontaneous preterm delivery
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7
Q

When can an amniotomy be performed

A

When the cervix had dilated and effaced

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8
Q

5 criteria assessed in the Bishop’s score

A
  • Dilatation (0-5+ cm)
  • Length of cervix (Effacement)(3-0cm)
  • Position (post. -> mid -> ant.)
  • Consistency (firm -> medium -> soft)
  • Station (-3 - +2cm)
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9
Q

If the cervix is not dilated and effaced what bishops score would be awarded

A

A low score

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10
Q

If the cervix is not dilated and effaced how would you “ripen” the cervix

A

Vaginal Prostaglandin Pessary

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11
Q

What Bishop’s score is considered favourable for an amniotomy

A

7 or higher

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12
Q

What is used to perform an amniotomy

A

Amniohook or Amnicot

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13
Q

Once an amniotomy has been performed what is the next step to induce labour

A

IV oxytocin, to achieve adequate contractions

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14
Q

What rate of contraction should be aimed for when inducing labour

A

4-5 in 10 minutes, when using IV oxytocin

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15
Q

Describe the full process of inducing labour

A
  1. Vaginal Prostaglandin Pessary, if cervix is not dilated and effaced (low bishop’s score)
  2. Amniotomy, if cervix has dilated and effaced (Bishop score of 7 or higher)
  3. IV Oxytocin to achieve adequate contractions, aiming for 4-5 in 10 minutes
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16
Q

What can cause inadequate progression

A
  • Cephalopelvic disproportion (CPD) (due to large head or small pelvis or both)
  • Malposition
  • Malpresentation
  • Inadequate uterine activity

[?ovarian cysts or fibroids?]

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17
Q

Definition of suboptimal progress in the first stage of labour

A
  • Cervical dilation of less than 0.5cm per hr for primigravid women (first pregnancy)
  • Cervical dilatation of less that 1cm per hr for parous women (not first pregnancy)
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18
Q

What’s the result of inadequate contractions and how is it corrected

A
  • Foetal head will not descend and exert force on the cervix therefore the cervix will not dilate
  • IV Oxytocin will increase strength and duration of contractions
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19
Q

When inadequate uterine activity is suspected, e.g. inadequate contractions, what MUST be excluded and why

A
  • MUST EXCLUDE AN OBSTRUCTED LABOUR
  • Stimulation of an obstructed labour can lead to a ruptured uterus, resulting in severe maternal and foetal morbidity and mortality
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20
Q

Describe Cephalopelvic disproportion (CPD)

A
  • Genuine CPD is relatively rare

- Foetal head is in correct position but is too large to negotiate maternal pelvis to be born

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21
Q

What can happen due to Cephalopelvic disproportion (CPD)

A

Head becomes compressed and caput succedaneum and head moulding (abnormal shape) develop

22
Q

Describe Caput Succedaneum

A
  • Presents as a scalp swelling that extends across the midline and over suture lines
  • Does not usually cause complications and usually resolves over the first few days
  • The baby will often be irritable so may require analgesia for its headache and handling should be kept to a minimum for the first few days.
23
Q

3 types of lie

A
  • Longitudinal
  • Oblique
  • Transverse
24
Q

Describe malposition

A
  • Common

- Foetal head in an incorrect position for labour and relative CPD occurs

25
Q

How can too many contractions (uterine hyper-stimulation) cause foetal distress

A

Causes insufficient placental blood flow

26
Q

How is foetal well being monitored during labour

A
  • Intermittent auscultation of foetal heart
  • Cardiotocography (CTG) (monitors foetal heartbeat + uterine contractions)
  • Foetal blood sampling
  • Foetal ECG
27
Q

When do use Foetal blood sampling and what does it provide

A
  • Used when persistently suspicious or pathological CTG
  • pH and base excess
  • pH gives a measure of likely hypoxaemia
28
Q

When would labour not be recommended

A
  • Obstruction of birth canal (major placenta praevia, masses)
  • Malpresentation (transverse, hand, shoulder)
  • Specific previous labour complications (uterine rupture)
29
Q

3 3rd stage complications

A

-Retained placenta
-Post partum haemorrhage (4 T’s)
-Tears
Graze
1st degree
2nd degree
3rd degree
4th degree

30
Q

How long is the post partum period and are patients managed during it

A
  • Lasts ~6wks
  • Midwife manages for first 9-10 days then they’re referred to a health visitor
  • Observe for signs of abnormal bleeding, infection (wound/breast/endometritis)
  • 6 week check at GP
31
Q

Describe immediate postnatal care for high risk women

A

-15-60 minute observations
-Ensure;
Uterus remains contacted + no evidence of abnormal bleeding
Prophylactic antibiotics, where required
Appropriate thromboprophylaxis
Recovery from spinal/epidural/general anaesthetic

32
Q

5 postnatal problems

A
  • Post partum haemorrhage
  • Venous thromboembolism
  • Sepsis
  • Psychiatric disorders of the puerperium
  • Don’t forget Pre-eclampsia
33
Q

Describe pre-eclampsia

A

-Characterised by high BP and Proteinuria
-Begins after 20wks of pregnancy (can occur during postnatal period)
-If untreated can cause seizures (then called Eclampsia)
-In severe disease is causes;
RBC breakdown
Low blood platelet count
Impaired liver function
Kidney dysfunction
Oedema
SOB due to fluid in the lungs,
visual disturbances

34
Q

Risk factors of pre-eclampsia

A
  • Older maternal age
  • Diabetes mellitus
  • Obesity
  • Prior Hypertension
  • Primigravid women or twin pregnancies
35
Q

Management of Pre-eclampsia

A
  • Expedited delivery via induced labour/CS
  • Prevention and treatment of eclamptic seizures (magnesium sulphate)
  • Treatment of sever hypertension (160/110) with Labetolol, Hydralazine or Nifedipine
36
Q

What anti-hypertensive are contraindicated during pregnancy

A

ACE Inhibitors and Angiotensin receptor blockers as they affect foetal development

37
Q

2 types of Postpartum Haemorrhage (PPH)

A
  • Primary = blood loos >500ml within 24hrs of delivery

- Secondary = blood loss > 500ml from 24hrs post partum to 6wks

38
Q

Causes of primary PPH, think 4 T’s

A

4 T’s = Tone, Trauma, Tissue, Thrombin

  • Uterine atony (loss of tone in the uterine musculature)
  • Local cause e.g. traumatic tears of perineum/vagina/cervix
  • Retained tissue/placenta
  • Coagulopathy
39
Q

Causes of secondary PPH

A
  • Retained tissue
  • Endometritis (infection)
  • Tears/trauma
40
Q

Why is there an increased risk of Thromboembolic disease during and immediately after pregnancy and what is atypical about pregnant women experiencing a DVT or PE

A
  • Pregnancy and the immediate post partum period are hypercoagulable states
  • Pregnant women 6-10 times more likely to develop a thromboembolism
  • Pregnant women can be relatively asymptomatic compared to normal women
41
Q

How to reduce risk of thromboembolic disease in pregnant women

A
  • High quality risk assessment

- Appropriate thromboprophylaxis

42
Q

How to pregnant women present with a DVT/PE

A
  • UNILATERAL leg swelling and/or pain and complaining of SOB or chest pain
  • Sometimes the only sign of a PE will be an UNEXPLAINED TACHYCARDIA

Always have a high index of suspicion in pregnant or postnatal women

43
Q

What will increase the risk of thromboembolic disease in pregnant/postnatal women

A

Immobilisation following Spinal anaesthetic/CS

44
Q

Investigations to diagnose a DVT/PE

A
  • ECG
  • Leg Dopplers
  • CXR +/- VQ scan or CTPA(CT Pulmonary Angiogram) [risk of radiation during pregnancy and breast feeding]
45
Q

Treatment of DVT/PE in pregnancy

A
  • Low molecular weight heparin (LMWH)

[WARFARIN IS TERATOGENIC]

46
Q

What’s troubling about maternal sepsis

A

May present atypically

47
Q

Describe “baby blues”

A
  • Due to hormonal changes around time of birth
  • Usually occurs 1-3 days postnatally for only a few days
  • Doesn’t affect functioning and requires no specific treatment
48
Q

Describe Postnatal Depression

A
  • Can continue from “baby blues” or start sometime lateral
  • Has classical “depressive” symptoms
  • Affects functioning, bonding and often requires treatment
49
Q

Risk factor for Postnatal Depression

A

Personal or family Hx of affective disorder

50
Q

Describe Puerperal Psychosis

A
  • Rare but serious psychotic illness of the postnatal period
  • Women can be a danger to themselves and their babies
  • Requires INPATIENT psychiatric care
51
Q

Risk factors for Puerperal Psychosis

A

Personal or family Hx of;

  • Affective disorder
  • Bipolar disorder
  • Psychosis
52
Q

When do most Eclamptic seizures occur

A

In the postnatal period

Pre-eclampsia can develop postnatally or worsen several days following delivery

Reproduction (22 decks)

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