Abnormal Labour Flashcards
What are indications for induction of labour?
Maternal DM (macrosomia as glucose crosses placenta –> more fat)
Maternal health, e.g. needs Rx for DVT
Foetal health (e.g. IUGR, oligohydramnios)
Late for due date (>42 weeks increases risk of still birth) - offer induction 7-12d past due date
Social/maternal/pelvic pain/big babies
Define induction of labour
Using medications/devices to ripen cervix and then artificially rupturing the membranes (amniotomy)
What score is used to determine how ripe the cervix is and how favourable amniotomy would be? Mention the factors looked at in the score
Bishop's score Don't ever peel cucumbers silly Dilatation Effacement Position Consistency Station
Score 7 or more favourable for amniotomy
What is the process of induction of labour?
Vaginal Ex to assess cervical ripeness
To ripen cervix - cook’s balloon or prostaglandin pessary
Amniotomy
IV oxytocin to stimulate contraction/contractions may begin themselves after amniotomy
Which method is best for ripening cervix?
Cook balloon inflates at Os to open cervix, no risk of hyperstimulation and works within 12-24h
Prostaglandins - initiate contractions, takes 2-3 days and can cause hyperstimulation
If cook balloon and prostaglandins fail to ripen the cervix what can you do?
C-section
How do you perform an amniotomy?
Amniohook
When giving IV oxytocin to stimulate contractions what are you aiming for?
4-5 strong contractions every 10 minutes
What are the 3Ps in abnormal labour?
Power - uterine contractions
Passenger - baby
Passage - birth canal
What things may cause inadequate progress through labour?
CPD Malpresentation Malposition Obstruction, e.g. fibroids/ovarian cysts Inadequate uterine activity
Define suboptimal progress in labour?
Cervical dilatation of
<0.5cm/h in PG
<1cm/h in MG
How often are woman examined during labour?
Every 4 hours
Obstructed labour can result in what two things?
Maternal exhaustion and dehydration
Uterine rupture, leading to death of mother and baby
How does inadequate uterine contractions –> no cervical dilatation?
As foetal head is not exerting pressure on cervix to dilate/efface it
What is treatment for inadequate uterine contractions?
IV oxytocin if you are certain of no obstructions (as if you give it and there are obstructions –> uterine rupture)
IV oxytocin increases strength and rate of contractions
In normal labour how many contractions would be expect?
3-4 in 10 mins of strong strength
How do we monitor progression of labour?
Descent/station (0 = ischial spines, after that its +1)
Cervical dilatation and effacement (VE)
What is cephalopelvic disproportion?
Foetal head in correct position but is too large for delivery in relation to size of maternal pelvis
What may cause CPD?
Abnormal maternal pelvis shape, shapes don’t match up as opposed to size, macrosomnia, multigravidity, late term pregnancy
What is caput?
Swelling around foetal scalp as a result of the pressure of pushing down on the dilating cervix
What is moulding?
Foetal skull bones can move over one another to aid birth without damaging the foetal brain
What is presentation?
Part of baby presenting to the vagina, e.g. vertex, breech
What is the worst malpresentation and why?
Transverse/oblique lie may lead to cord prolapse
What occurs in cord prolapse and how do you treat it?
As soon as cord hits cold air –> vasospasm –> baby can’t breath
Emergency c-section
What positions are suitable for vaginal delivery?
Occiput anterior - baby born facing floor
Occiput posterior - baby born facing roof (this often req. forceps/vacuum)
What positions aren’t suitable for vaginal delivery?
Occiput traverse/lateral
Require C-section
How can you feel for the baby’s position?
Feel posterior fontanelle
What things may cause foetal distress?
Hyperstimulation (too many uterine contractions –> less blood going to placenta)
IUGR
Infection
How can you monitor foetal stress?
Intermittent auscultation of foetal heart in low risk of foetal stress
Cardiotocography if high risk of foetal stress (continuous)
How do you interpret CTGs?
Accelerations - good
Decelerations may be bad
Flat lines - stress
What should you do if you see an abnormal CTG?
Foetal blood sample from skull (pH, lactic acid) - acidity may indicate hypoxia
Foetal ECG
How do you manage foetal distress?
If fully dilated - forceps/vacuum delivery
If <6cm - C-section
In which situations would you advise against labour?
Obstruction to birth canal, e.g. placenta previa Malpresentations Medical conditions where labour not safe Prev. labour complications Foetal conditions
What are woman who go through C-sections at increased risk of?
Infections, bleeding, visceral damage and VTE
What is involved in active manage of 3rd stage of labour?
IV oxytocin and CCT
How do you manage retained placenta?
Take to theatre and remove
What are the four cases of PPH?
4 Ts
Tone - inability of uterus to clamp down and stop bleeding from placental bed
Trauma - 1st to 4th degree tears
Tissue - retained tissue preventing clamping down of uterus
Thrombin - clotting problems
How do you manage tone problems in PPH?
IV oxytocin
How do you manage trauma problems in PPH?
Stiching
What is the pueriperium?
First 6 weeks after birth
When is the switch over between the midwife and health visitor?
9-10 days
When is the first check by the GP?
6-8 weeks
What should we be observing from in the puerperium?
Bleeding, infection
What are the commonest/biggest post-natal complications?
Sepsis Pre-eclampsia Thromboembolic events PPH Psychiatric dx
Define primary PPH
> 500ml blood loss within 24h
due to 4Ts
Define secondary PPH
> 500ml blood loss 24h-6wks
Mostly due to infection (endometritis), retained tissue, trauma
What is lochia?
Vaginal discharge with blood for 3-4weeks after birth (normal as long as it is the same/less than a normal period)
Why is TE events more common in post-partum period?
In hypercoagulable state
6-10x more likely to get PE/DVT
How do we prevent VTE?
Prophylaxis
How do we investigate VTE in pregnancy/postpartum?
NOT D-Dimer (unreliable)
CXR, CTPA, doppler, ECG, V/Q
How do we treat VTE in pregnancy/post-partum?
LMWH
What does VTE tend to present like in pregnancy/post-partum?
May be atypical, e.g. just tachycardia
Be aware of woman with unilateral leg swelling/breathless/chest pain
Which new mothers are at increased risk of VTE?
Epidurals/immobilisation after C section
How should you treat maternal sepsis?
IV antibiotics, antipyretics, IV fluids
How should you investigate maternal sepsis?
Blood cultures, MMSU, LVS (lower vaginal swab), wound swab
What is the most common psychiatric problem in the puerperium?
Baby blues
Usually req no Rx
Due to hormonal changes
What symptoms and RF are assoc with PND?
Depressive symptoms
May affect bonding
PPH/FH of affective disorder
Usually req. Rx
What is puerperal psychosis?
Rare but serious, danger to baby and themselves
Increased risk in those with PPH/FH of psychosis, bipolar disorder, affective disorder
Req. inpatient care
When is the highest risk of eclamptic seizures?
In post-natal period
What is eclampsia?
Pre-eclampsia + mal grand seizures/coma
What is pre-eclampsia?
Gestational HTN and proteinuria
