Abnormal Labour Flashcards
What is the vertex?
Part of the baby’s head bounded by the anterior and posterior fontanelles and the parietal eminences
What percentage of babies are breech?
25% at 28 weeks
3-4% at term
Name the three types of breech
- Frank (legs up around head)
- Footling (one or both feet point down)
- Complete (legs folded at baby’s bottom)
Other than breech what other types of malpresentation are there
Transverse
Shoulder/arm
Face (hyperextension)
Brow (forehead first)
State the risk factors for breech presentation
Preterm Praevia Twins Polyhydramios Oligohydramios
Name three management options for a breech baby
- external cephalic version
- planned vaginal birth
- c-section
What are the risk of a planned vaginal birth in a breech baby?
Hypoxia/death
Head entrapment
Cord Prolapse
Describe the external cephalic version
Use gas and air, monitor foetal heart with CTG
Lift the baby’s bum and encourage the head to move
50% success rate, risk of 1 in 800 of causing distress
After 37 weeks it is much harder
What are the side effects of an epidural?
Hypotension (fluid given beforehand) Dural puncture and CSF leak Headache High block Atonic bladder - may require catheterisation
State the risk of obstructed labour
Sepsis - ascending infection
Uterine rupture - previous c-section, multiparous
AKI - obstruction of ureters
PPH - long labour can cause atonic PPH
Fistual formation - local necrosis and disintegration
Fetal asphyxia
neonatal sepsis
What is classed as failure to progress?
<2cm/4 hours or slowing progress
In terms of the 3Ps what can cause failure of progress?
Power - inadequate contractions
Passage - short stature, trauma, shape (rickets)
Passenger - big baby and malposition
What is a partogram?
Graphic representation of the progress of labour
- foetal heart
- amniotic fluid
- cervical dilatation
- descent
- contractions
- obstruction
- maternal observations
State the signs of obstruction
Moulding Caput Anuria Haematuria Vulval oedema
Describe the largest diameter of the pelvic inlet and outlet
Inlet - transverse bigger
Mid-cavity - equal
Outlet - AP bigger
What is the commonest cause of slow progression?
Occipito-posterior presentation
When should a doppler auscultation be used in labour?
Stage 1 - during and after contraction, every 15 minutes
Stage 2 - at least every 5 minutes during and after for 1 minute and check maternal pulse every 15 minutes
State the risk factors for fetal hypoxia
- Small
- Preterm (sepsis)
- Post dates
- Antepartum haemorrhage
- Hypertension
- Diabetes
- Meconium (signs of distress)
- Epidural (placenta blood supply may be compromised)
- VBAC
- PROM >24 hours
- Sepsis
- IOL
State the acute causes of fetal hypoxia
Uterine hyperstimulation Abruption Cord prolapse Uterine rupture Haemorrhage Anaesthesia Vasa praevia
State the chronic causes of fetal hypoxia
Placental insufficiency Fetal anaemia (rhesus or haemorrhage)
What features can be seen on a CTG?
Contractions Baseline heart rate Decelerations (dips) Accelerations (peaks) Variability (5-25 bpm)
What is the normal baseline heart rate?
110-150bpm
Define accelerations
15 beats above baseline for at least 15 seconds - normal, associated with activity
Define decelerations and name the three types
15 beats below the baseline for at least 15 seconds
- early
- variable
- late
What are early decelerations?
Increased vagal tone, common during labour and are physiological with contractions
What are late decelerations?
Onset is after the peak of contraction, suggests reduced placental perfusion and hypoxia
What are variable decelerations?
Common and are associated with cord compression, represents compensatory change due to baroreceptors
How does hypoxia look on CTG?
- loss of accelerations
- repetitive deeper and wider decelerations
- rising baseline
- loss of variability
What is the pneumonic for assessing CTG?
DR BRAVADO Determine Risks Baseline R Ate Variability Accelerations Decelerations Overall impression
How can suspected fetal hypoxia be managed?
Change maternal position IV Fluids Stop snytocin Scalp stimulation should cause an acceleration Terbulaine - slows contractions Maternal assessment Surgical/instrumental delivery
How is fetal blood sampled?
Capillary sample from baby’s scalp
What do specific pH’s mean on fetal blood sampling?
> 7.25 - normal
7.2-7.25 - borderline, repeat in 30 mins
<7.2 metabolic acidosis - deliver
Name two standard indications for instrumental delivery
Delay (failure to progress stage 2)
Fetal monitoring concern
What are the ‘special’ indications for instrumental delivery?
Maternal cardiac disease
Severe PET/eclampsia
Intra-partum haemorrhage
Umbilical cord prolapse
How long should stage 2 last?
Prims - 2 hours, 3 hours with epidural
Multi - 1 hour, 2 hours with epidural
What percentage of women have a C section?
30%
At what gestational age should a C-section be carried out?
39 weeks - lower risk of ADHD and autism
What are the indications for c-section?
- previous c section
- fetal distress
- failure to progress in labour
- breech presentation
- maternal request
What are the morbidities associated with C section?
4 times greater than SVD
Sepsis, haemorrhage, VTE, trauma, TTN, sub fertility, complications in future, cut to baby
What is given to all women before a c-section and why?
PPI - ranitidine to reduce risk of aspiration
What blood tests are done prior to a c-section?
Hb, G and S, ABO, clotting factors (low platelets/PET)
