Abnormal Labour Flashcards
what is malpresentation of a baby
non vertex:
- breech (frank, footling, complete)
- transverse
- shoulder/ arm
- face
- brow
what is malposition of a baby
abnormal position of the head- OP/ OT
what is pre term
<37 weeks
what is post term
> 42 weeks
when is malposition more likely
if baby too early/ late
what are the types of breech
complete- hip and knee flexed (cross legged)
footling - one/both feet coming first
frank (most common) - hips flexed, knees extended (legs up, bottom comes first)
what can happen if a very small baby starts to be delivered through a cervix that is not fully dilated
body goes through but head can get stuck
what does it mean if a babies arm is delivered first
baby in transverse lie, cannot be delivered need CS
can face/ brow presentations be delivered
brow means head at widest diameter- wont deliver
face will if chin at front
what classifies as abnormal labour
Too early (<27wks( - preterm birth Too late (>42wks)– induction of labour Too painful - requires anaesthetic input Too long - failure to progress Too quick- hyperstimulation Fetal distress - hypoxia/sepsis Wrong part presenting
what pain relief options for mothers in childbirth
support (better usually if not men) massage/ relaxation techniques inhalational agents- entonox TENS machine water immersion IM opiate analgesia (morphine) IV remifentanil PCA regional anaesthesia
what causes labour pain
compression of para cervical nerves
myometrial hypoxia
does an epidural impair uterine activity
no
what might an epidural inhibit
progress during stage 2
what is given in epidural anaesthesia
levobupivacaine +/- opiate
what are the possible complications of an epidural
hypotension (20%) due to vasodilation
dural puncture (1%)
headache
high block (blockage goes too high, can make it hard to breath)
is an epidural more effective than opiods
yes
do you always need IV access when given an epidural
yes
what are the risks in obstructed labour
sepsis (increased by vaginal exams)
uterine rupture (uterus thins, more common in women who have had previous section and if given syntocinon)
obstructed AKI (impaired renal drainage)
PPH
fistula formation
fetal asphyxia
neonatal sepsis
how do you assess progress in labour
dilation
descent of presenting part
signs of obstruction: moulding, caput, anuria, haematuria, vulval oedema
what dilation progressions indicate a suspected delay in 1st stage
nulliparous <2cm in 4 hours
parous <2cm in 4 pours or slowing in progress
should parous or nulliparous women usually progress faster in birth
parous
what is station measured in
fifths (where head is in relation to the ischial spines)
what are the three P’s of failure to progress
power:
- inadequate contractions (frequency and/ or strength)
passage:
- short stature (under 5 ft)
- trauma
- shape
passenger:
- big baby
- malposition (relative cephalo-pelvic disproportion)
how many contractions are you aiming to have in 10 mins
3-4
what are the widest parts of the pelvis
inlet- transverse diameter
mid cavity- AP = transverse
outlet= AP diameter
what is the widest presentation of the babies head
brow- occipito-mental = 13 cm
what is the narrowest presentation of the babies head
vertex (suboccipito-bregmatic = 9cm) and face (submento-bregmatic = 9cm)
what does a partogram measure
fetal heart amniotic fluid cervical dilation descent contractions obstruction (moulding) maternal obs- BP, HR, urinalysis
what is the minimum expected dilation on a partogram
1cm every 2 hours
what can be give to speed up a labour that is failing to progress
syntocinon
what can be used to identify fetal distress
doppler ausculatation
electronic fetal monitoring- cardiotocograph
colour of amniotic fluid
when is doppler auscultation of fetal heart done in stage 1 of labour
During and after a contraction
Every 15 minutes
when is doppler auscultation of fetal heart done in stage 2 of labour
At least every 5 minutes
during & after a contraction for 1 whole minute
check Mat pulse at least every 15 mins
what are the risk factors for fetal hypoxia
small fetus (biggest risk) preterm/ post dates antepartum haemorrhage HPTx/ PET diabetes meconium epidural analgesia vaginal birth after caesatean premature rupture of membranes >24 hours sepsis (temp >38c) induction/ augmentation of labour
what do you need to do additionally when there are risk factors for fetal hypoxia
continuously monitor fetal heart
what are the acute causes of fetal distress
abruption vasa praevia cord prolapse uterine rupture feto-maternal haemorrhage uterine hyperstimulation regional anaesthesia
what are the symptoms of fetal abruption
severe pain
bleeding
very acute
abnormal fetal HR
what is vasa praevia
when the babies placental or umbilical blood vessels run across the entrance to the cervix
what are the chronic causes of fetal distress
placental insufficiency
fetal anaemia
how can CTG be done
abdominal tracing
fetal scalp electrode- needed sometimes if mother obese
what does CTG tell you about contractions
frequency (not strength)
what are normal fetal heart rates
110-150 bpm
tachycardia >150
bradycardia <110
what is variability of fetal HR on CTG
(how wiggly the line is)
normal= changes of 5-25 bmp
what are abnormally variabilities of fetal HR
saltatory: >25 bmp
reduced: <5 bmp
complete loss
all signs of hypoxia
what are acceleration in fetal HR
increases
due to baby moving
want to see 15 bmp above baseline rate 2x in 10 mins
what are decelerations of fetal HR and when are they normal/ abnormal
reduction in HR
early- occur with contractions- normal
late- follow the contraction- abnormal- sign of hypoxia
variable- most common type- can be complicated or uncomplicated (complicates associated with cord compression)
what should you document when revieing a CTG
baseline fetal HR
baseline variability
presence/ absence of decelerations
presence of accelerations
classify as normal, suspicious or pathological
hypoxia can evole gradually in labour- what is seen on a CTG
loss of accelerations
repetitive deeper and wider decelerations
rising fetal baseline HR
loss of variability
what mnemonic for CTG interpretation
DR C BRAVADO determine risk contractions baseline rate variability accelerations decelerations overall impression (normal, suspicious, pathological)
when is a CTG pathological
when more than 2 abnormal features
what is the management for fetal distress
change maternal position IV fluids stop syntocinon scalp stimulation consider tocolysis- terbutaline 250 micrograms s/c (stop/ reduce contractions) maternal assessment -pulse, BP, abdomen, VE fetal blood sampling operative delivery
how is fetal blood sampling done
pin prick of scalp via vaginal endoscopic tube
what is normal/ abnormal fetal scalp blood pH
>7.24= normal= no action needed 7.2-7.25= borderline= repeat in 30 mins <7.2= abnormal= deliver
a what point in labour must a women be at in order to have an instrumental delivery
babies head below/ at ischial spines
cervix must be fully dilated
what are the indications for an instrumental delivery
delay (failure to progress to stage 2)
fetal distress
special cases:
- maternal cardiac disease
- severe PET/ eclapmsia
- intra-partum haemorrhage
- umbilical cord prolapse in stage 2
how long should stage 2 of labour last
prims: 2hrs no epidural, 3hrs with epidural
multips: 1 hr no epidural, 2 hrs with epidural
what are the pros and cons of venoutous compared to forceps
ventouse (not used as mush in scotland, foceps used more):
- increased failure
- increased cephalohaematoma
- increased retinal haemrorhage
- increased maternal worry
- decreased anaesthesia
- decreased vaginal trauma
- decreased perineal pain
long term outcomes the same, ventouse more traumatic to baby, forceps more traumatic for mother
what are the main indications for a c section
previous CS fetal distress failure to progress in labour breech presentation maternal request
how many people in tayside get a cs
30%
what are the risks of a c sections
4 X greater maternal mortality
Morbidity - sepsis, haemorrhage, VTE, trauma, transient tachypnoea of newborn, subfertility, regret, complications in future pregnancy
how many women in tayside have a SVD
~60%
