Abnormal Labour Flashcards
Is it common to induce Labour
Yes, ~1/5 of labours are induced
Any risks/disadvantages associated with an induced labour
- 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”)
During an induced labour what is recommended in regards to the foetus
Due to higher risk of foetal distress continuous foetal monitoring is recommended
4 indications for inducing labour
- 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)
2 ways of inducing labour
- Amniotomy (artificial rupture of membranes)
- Medically, Prostaglandin suppository, IV Oxytocin
What is the Bishop’s score
- 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
When can an amniotomy be performed
When the cervix had dilated and effaced
5 criteria assessed in the Bishop’s score
- Dilatation (0-5+ cm)
- Length of cervix (Effacement)(3-0cm)
- Position (post. -> mid -> ant.)
- Consistency (firm -> medium -> soft)
- Station (-3 - +2cm)
If the cervix is not dilated and effaced what bishops score would be awarded
A low score
If the cervix is not dilated and effaced how would you “ripen” the cervix
Vaginal Prostaglandin Pessary
What Bishop’s score is considered favourable for an amniotomy
7 or higher
What is used to perform an amniotomy
Amniohook or Amnicot
Once an amniotomy has been performed what is the next step to induce labour
IV oxytocin, to achieve adequate contractions
What rate of contraction should be aimed for when inducing labour
4-5 in 10 minutes, when using IV oxytocin
Describe the full process of inducing labour
- Vaginal Prostaglandin Pessary, if cervix is not dilated and effaced (low bishop’s score)
- Amniotomy, if cervix has dilated and effaced (Bishop score of 7 or higher)
- IV Oxytocin to achieve adequate contractions, aiming for 4-5 in 10 minutes
What can cause inadequate progression
- Cephalopelvic disproportion (CPD) (due to large head or small pelvis or both)
- Malposition
- Malpresentation
- Inadequate uterine activity
[?ovarian cysts or fibroids?]
Definition of suboptimal progress in the first stage of labour
- 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)
What’s the result of inadequate contractions and how is it corrected
- 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
When inadequate uterine activity is suspected, e.g. inadequate contractions, what MUST be excluded and why
- 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
Describe Cephalopelvic disproportion (CPD)
- Genuine CPD is relatively rare
- Foetal head is in correct position but is too large to negotiate maternal pelvis to be born
What can happen due to Cephalopelvic disproportion (CPD)
Head becomes compressed and caput succedaneum and head moulding (abnormal shape) develop
Describe Caput Succedaneum
- 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.
3 types of lie
- Longitudinal
- Oblique
- Transverse
Describe malposition
- Common
- Foetal head in an incorrect position for labour and relative CPD occurs
How can too many contractions (uterine hyper-stimulation) cause foetal distress
Causes insufficient placental blood flow
How is foetal well being monitored during labour
- Intermittent auscultation of foetal heart
- Cardiotocography (CTG) (monitors foetal heartbeat + uterine contractions)
- Foetal blood sampling
- Foetal ECG
When do use Foetal blood sampling and what does it provide
- Used when persistently suspicious or pathological CTG
- pH and base excess
- pH gives a measure of likely hypoxaemia
When would labour not be recommended
- Obstruction of birth canal (major placenta praevia, masses)
- Malpresentation (transverse, hand, shoulder)
- Specific previous labour complications (uterine rupture)
3 3rd stage complications
-Retained placenta
-Post partum haemorrhage (4 T’s)
-Tears
Graze
1st degree
2nd degree
3rd degree
4th degree
How long is the post partum period and are patients managed during it
- 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
Describe immediate postnatal care for high risk women
-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
5 postnatal problems
- Post partum haemorrhage
- Venous thromboembolism
- Sepsis
- Psychiatric disorders of the puerperium
- Don’t forget Pre-eclampsia
Describe pre-eclampsia
-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
Risk factors of pre-eclampsia
- Older maternal age
- Diabetes mellitus
- Obesity
- Prior Hypertension
- Primigravid women or twin pregnancies
Management of Pre-eclampsia
- 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
What anti-hypertensive are contraindicated during pregnancy
ACE Inhibitors and Angiotensin receptor blockers as they affect foetal development
2 types of Postpartum Haemorrhage (PPH)
- Primary = blood loos >500ml within 24hrs of delivery
- Secondary = blood loss > 500ml from 24hrs post partum to 6wks
Causes of primary PPH, think 4 T’s
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
Causes of secondary PPH
- Retained tissue
- Endometritis (infection)
- Tears/trauma
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
- 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
How to reduce risk of thromboembolic disease in pregnant women
- High quality risk assessment
- Appropriate thromboprophylaxis
How to pregnant women present with a DVT/PE
- 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
What will increase the risk of thromboembolic disease in pregnant/postnatal women
Immobilisation following Spinal anaesthetic/CS
Investigations to diagnose a DVT/PE
- ECG
- Leg Dopplers
- CXR +/- VQ scan or CTPA(CT Pulmonary Angiogram) [risk of radiation during pregnancy and breast feeding]
Treatment of DVT/PE in pregnancy
- Low molecular weight heparin (LMWH)
[WARFARIN IS TERATOGENIC]
What’s troubling about maternal sepsis
May present atypically
Describe “baby blues”
- 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
Describe Postnatal Depression
- Can continue from “baby blues” or start sometime lateral
- Has classical “depressive” symptoms
- Affects functioning, bonding and often requires treatment
Risk factor for Postnatal Depression
Personal or family Hx of affective disorder
Describe Puerperal Psychosis
- Rare but serious psychotic illness of the postnatal period
- Women can be a danger to themselves and their babies
- Requires INPATIENT psychiatric care
Risk factors for Puerperal Psychosis
Personal or family Hx of;
- Affective disorder
- Bipolar disorder
- Psychosis
When do most Eclamptic seizures occur
In the postnatal period
Pre-eclampsia can develop postnatally or worsen several days following delivery
