Abnormal Labour Flashcards
What is antepartum haemorrhage?
Haemorrhage from the genital tract after the 24th week of pregnancy but before the delivery of the baby
Give causes of antepartum haemorrhage
Placenta praevia
Vasa praevia
Placental abruption
What is vasa praevia?
Abnormally unprotected fetal blood vessels, in which they travel through the membrane and run near the internal opening of the uterus, exposing them to rupture
Give risk factors for vasa praevia
IVF
Multiple pregnancy
Low lying placenta (placenta within 20mm of cervical os, wheras praevia is covering)
How does vasa praevia present?
Painless vaginal bleeding following membrane rupture
Pulsating fetal vessels on examination
Fetal heart rate abnormalities/bradycardia
How is vasa praevia managed?
Elective c section 34-36 weeks with glucocorticoids
Emergency c section if antepartum haemorrhage
What is placenta praevia?
Implantation of the placenta within the lower uterine segment, below the presenting part of the fetus
Describe grade 1 placenta praevia
Placenta on the lower segment of uterus but does not reach cervical os, also known as low lying
Describe grade 2 placenta praevia
Placenta reaches the cervical os but still does not cover it, also known as low lying
Describe grade 3 placenta praevia
Placenta partially covers the cervical os
Describe grade 4 placenta praevia
Placenta completely covers cervical os
What are risk factors for placenta praevia?
Multiparity
Multiparous
Increased maternal age (>35)
Intrauterine fibroids
Maternal smoking
Previous C-Section, as in future pregnancies placenta attaches to scar
Previous placenta praevia
IVF
How does placenta praevia present?
May be asymptomatic and often incental as stable maternal and fetal condition
Painless bright red bleeding
Malpresentation of the fetus, usually transverse
Soft, non tender uterus
Why can placenta praevia only be officially diagnosed in the third trimester?
Although can be seen on original booking scan, a significant number will migrate up, so can only be diagnosed officially in third trimester
What US is used in placenta praevia diagnosis?
Transvaginal
What is the management of placenta praevia?
Planned c section at 36-37 gestation
What is the management of placental praevia haemorrhage?
Emergency c section
Blood transfusion
Intrauterine balloon tamponade
Uterine artery occlusion
Emergency hysterectomy
What is placental abruption?
Premature separation of the placenta from the uterine wall during pregnancy
What are the categories of placental abruption?
Revealed, haemorrhage is apparent externally as the blood escapes through the cervical os
Concealed, haemorrhage occurs between the placenta and uterine wall and so does not escape through os
Mixed
Give risk factors for placental abruption
PET/HTN
Multiple pregnancy
Polyhydramnios
Smoking
>Age
Multiparity
Previous abruption
Cocaine
Trauma
How does placental abruption present?
Severe sudden continous abdominal pain in 3rd trimester
Dark red vaginal bleeding, although absence does not rule out diagnosis as in the case of concealed
Increased uterine activity/tone/contractions
Couvelaire uterus/bruising
‘Woody’ hard uterus
Cold to touch
Longitudinal fetus
How is placental abruption managed?
Urgent involvement of a senior obstetrician, midwife and anaesthetist
2 x grey cannula
Crossmatch 4 units of blood
Fluid and blood resuscitation as required
CTG monitoring of the fetus and monitoring of the mother
Attempt vaginal delivery or emergency aesarean section
What is amniotic fluid embolism?
Anaphylactic reaction to the presence of amniotic fluid and fetal matter into the maternal lungs, leading to HTN and hypoxia
Give the prognosis of amniotic fluid embolism
80% mortality
How does amniotic fluid embolism present?
Occurs shortly after labour
Hypoxia, including cyanosis
Hypotention
Coagulopathy, showing increased PT
How is amniotic fluid embolism managed?
Oxygen and fluid resucitation
Treat coagulopathy
Immediate delivery
Supportive management thereafter
What is preterm labour?
Onset of labour before 37 completed weeks gestation
Describe mildly preterm
32-36
Describe very preterm
28-32
Describe extremely preterm
24-28
Give risk factors for preterm labour
Idiopathic
Multiple pregnancy
Extremes of maternal age
Heavy stressful work
Smoking
Substance of misuse
Cervical Incompetence
Uterine anomalies
Polyhydramnios
Previous pre-term delivery
Group B Streptococci
APH
Pre-eclampsia
Infection/UTI
Premature rupture of membranes associated with infection
What is the main cause of preterm labour?
Idiopathic
What investigations are used in PPROM?
Fetal fibronectin
- Protein released from gestational sac, associated with early labour
Speculum examination
- Pooling of amniotic fluid in the posterior vaginal vault
- Avoid digital examination to reduce the risk of introducing infection to the uterus
US
- Used if still expected but no pooling of amniotic fluid in posterior vaginal vault
- Oligohydramnios
What is fetal fibronectin?
Protein released from gestational sac, associated with early labour
How is PPROM managed?
Admission and observation for chorioamnionitis
Oral Erythromicin for 10 days
2 doses IM steroids for neonate lung maturity
Delivery at 34 weeks
What steroid is given in PPROM?
Dexamethasone
Give neonatal complications of pre-term labour
Respiratory distress syndrome
Intraventricular haemorrhage
Cerebral palsy
Nutrition
Temperature control
Jaundice
Infection
Visual impairment
Hearing loss
What is induction of labour?
When an attempt is made to instigate labour artificially using medications and/or devices to “ripen cervix”, followed usually by artificial rupture of membranes (performing an amniotomy)
How many pregnancies are induced?
Approx 1/5
Give indictations for induced labour
Gestational diabetes
Post dates, term + 7 days
Maternal health problem that necessitates planning of delivery, such as DVT, PET
Fetal reasons
- Suspected IUGR
- Oligohydramnios
- IUD
Social reasons
Maternal request
Pelvic pain
Big babies
Pre-labour rupture of membranes
Give disadvantages of induced labour
Less efficient and more painful
Requires fetal monitoring
Risk of uterine hyperstimulation with prostaglandin/oxytocin induction
Give contraindications for induced labour
Obstruction to birth canal
- Major placenta praevia
- Masses
Malpresentation
- Transverse
- Shoulder
- Breech
Medical conditions where labour would not be safe for women
Specific previous labour complications: Previous uterine rupture
Fetal conditions
Give complications of induced labour
>Risk of instrumental and operative delivery
Uterine hyperstimulation
Failed induction
Cord prolapse
Uterine rupture
What score is used to clinically assess the cervix
Bishop score
What does the Bishop score assess?
Used to clinically assess the cervix
The higher the score, the more progressive change there is in the cervix and indicates that induction is likely to be successful
What Bishop score suggests labour is unlikely to start without induction?
Less than 5
Describe the induction process
Membrane sweep
Vaginal prostaglandin pessaries or a Cook balloon is used to ripen/open the cervix
Once cervix has dilated and effaced, an amniotomy can be performed
Once amniotomy is performed, IV oxytocin is used to achieve adequate contractions, although misoprostol can also be used
What are the properties of a Cook balloon?
Inflates os
No hyperstimulation
Works within 12-24 hours
What are the properties of vaginal pessaries
Initiates contractions
Takes 2-3 days
Risk of hyperstimulation
What is an amniotomy?
Artificial rupture of membranes/amniotic fluid
What Bishop score is favourable of amniotomy?
7 or more
What Bishop score suggests labour is likely to commence spontaneously?
Over 9
Why can oxytocin only be given if no obstruction?
Can cause uterine rupture
How many contractions should be aimed for in induced labour with oxytocin?
4/5 in 10 minutes
What is the most common malpresentation?
Breech
What can cause malpresentation?
Often no cause identified
Multiple pregnancy
Polyhydramnios
Uterine abnormalities
Placenta praevia
Congenital abnormalities
What is the management of breech malpresentation?
External cephalic version at 36 weeks, as baby may move spontaneously before this
If remains breech, caesarean delivery is recommended due to risk of head entrapment
What is the management of face malpresentation?
Vaginal delivery is possible in mento-anterior (chin lying behind symphysis pubis)
Ventouse delivery is contraindicated
What is the management of transverse malpresentation?
Stabilizing induction with external cephalic version
Followed by artificial rupture of membranes, otherwise caesarean section
When is external cephalic version contrainindicated?
Where caesarean delivery is required
Antepartum haemorrhage within the last 7 days
Abnormal cardiotocography
Major uterine anomaly
Ruptured membranes
Multiple pregnancy
Give absolute contraindications to external cephalic version
Caesarean section is already indicated for other reason
Ante-partum haemorrhage has occurred in the last 7 days
Non-reassuring cardiotocograph
Major uterine abnormality
Placental abruption or placenta praevia
Membranes have ruptured
Multiple pregnancy, but may be considered for delivery of the second twin
Give a complication of transverse malpresentation
Risk of cord prolapse if spontaneous rupture of membranes
What is cord prolapse?
Descent of the umbilical cord through the cervix alongside or past the presenting part of the fetus, increasing risk that fetus will compress the cord and cause hypoxia
Give risk factors for cord prolapse
Prematurity
Multiparity
Polyhydramnios
Multiple pregnancy
Cephalopelvic disproportion
Malpresentation
Placenta praevia
Long umbilical cord
High fetal station
What is the most common cause of cord prolapse?
Artificial amniotomy
How does cord prolapse present/how is it diagnosed?
Suspected in CTG fetal distress
Confirmed with speculum
What are the indications for continuous CTG monitoring during labour?
Ssuspected chorioamnionitis or sepsis, or a temperature of 38°C or above
Severe hypertension 160/110 mmHg or above
Oxytocin use
Presence of significant meconium
Fresh vaginal bleeding that develops in labour
How is cord prolapse managed?
Call for help
Elevate presenting part either manually or by filling the urinary bladder
Knees and elbows position while waiting for surgery
Tocolytic medication can be used to minimise contractions while waiting for surgery
Immediate delivery
- Forceps vaginal delivery if cephalic presentation and fully dilated
- Emergency caesarean section
Once delivered, neonatal resuscitation as appropriate
Give complications of cord prolapse
Infant death
Cerebral palsy and hypoxic encephalopathy, caused by cord compression and vasospasm
What is shoulder dystocia?
Anterior shoulder impacts on maternal symphysis pubis and so delivery requires additional obstetric manoeuvres to release
Give risk factors for shoulder dystocia
Previous shoulder dystocia
Macrosomia
Diabetes mellitus
BMI>30
Induction of labour
Prolonged first and second stage labour
Forceps/Ventouse delivery
Oxytocin
Give the management for shoulder dystocia
HELPERR
Call for help
Evaluate for episiotomy
McRobert’s manoeuvre
Suprapubic pressure
Internal rotation of anterior shoulder
Remove posterior arm
Roll the patient onto all fours and begin the cycle
What is McRobert’s manoeuvre?
Flexion and abduction of the maternal hips, bringing the mother’s thighs towards her abdomen
Give complications of shoulder dystocia
Fetal mortality
Hypoxic encephalopathy
Cerebral palsy
Brachial plexus injury
Erb’s palsy
PPH
Significant perineal trauma
What is Chorioamnionitis?
Preterm premature rupture of the membranes
- Exposes the normal sterile environment of the uterus to potential pathogens
- However can occur when membranes are still intact
How does chorioamnionitis present?
Abdominal pain
Uterine tenderness
Flu like symptoms
Pyrexia
Foul smelling discharge
How is chorioamnionitis managed?
Prompt delivery, C section if necessary
Administration of IV antibiotics
Give complications of chorioamnionitis
Maternal and fetal mortality, obstetric emergency
What is placenta accreta?
Describes the attachment of the placenta to the myometrium, due to a defective decidua basalis
As the placenta does not properly separate during labour there is a risk of post-partum haemorrhage
Give risk factors for placenta accreta
Previous C section
Placenta praevia
How is placenta accreta managed?
Hysterectomy
- Delayed placental delivery
