Abnormal Labour and Post Partum Care Flashcards
Risks of induction of labour
less efficiency
more pain
need for foetal monitoring
uterine hyperstimulation with prostaglandin/oxytocin induction
Induction of Labour definition
An attempt is made to instigate labour artificially using medications and/or devices to “ripen cervix” followed usually by artificial rupture of membranes (amniotomy)
Predispositions to labour not starting
High BMI
Previous labour where induction is needed
Indications for induction of labour
Diabetes (big babies)
Post dates - term + 7 days
Maternal Health problem that necessitates planning of delivery e.g. treatment of DVT
Foetal reasons e.g. growth concerns, oligohydroamnios
Social reasons
Maternal request
Pelvic pain
What score is used to clinically assess the cervix?
Bishops score
What is used to induce labour when the cervix is not dilated and effaced and therefore has a lower bishops score?
Vaginal prostaglandin pessaries
Cook balloon
What do vaginal prostaglandin pessaries and cook balloons do?
Ripen (open) the cervix
How long can vaginal prostaglandins take to open the cervix?
2-3 days
How long does mechanical cook balloon take to work?
Up to 24 hours
What induction of labour is used when the cervix is dilated and effaced?
Amniotomy
What Bishops score is considered favourable for amniotomy?
7 or more
The bishops score includes…
Dilatation Length of cervix (effacement) Position Consistency Station
Definition of amniotomy
Artificial rupture of foetal membranes (“waters”) usually using a sharp device e.g. amniohook
What is used in induction of labour after amniotomy is performed?
IV oxytocin to achieve adequate contractions
What is IV oxytocin used for in induction of labour?
After amniotomy to achieve adequate contractions
Overall process of induction of labour
- Ripen/Soften cervix
- Break waters/membranes
- IV oxytocin for contractions
Causes of inadequate process in labour
Cephalopelvic disproportion (CPD) Malposition Malpresentation Inadequate uterine activity Obstruction e.g. fibroid or ovarian cyst
Problems in labour are due to the 3Ps….
Powers
Passenger
Passages
Powers mean….
Contractions
Passages mean….
Birth canal
Passenger means….
Baby
Station definition
How the baby is coming through the pelvis = a measurement of the descent of the babys head
Definition of Cephalopelvic disproportion (CPD)
Foetal head is in the correct position for descent but it is too large for negotiating the maternal pelvis to be born
What is presentation?
The bit of the baby presenting to the vagina
Longitudinal lie meaning
The spine of the baby is parallel to the mothers spine
The result of a transverse lie is that….
A variety of different presentations can result
Malposition definition
Involves foetal head being in an incorrect position and ‘relative’ CPD occurs
Position that is normal for the presenting part of the baby
Occipito-anterior
The position of the baby is determined by
Vaginal exam
Management of foetal distress
Delivery the baby the quickest way - forceps - instrumental - vacuum If not fully dilated - C section
Feotal well being in labour is determined by
Intermittent auscultation of the foetal heart
Cardiotography
Foetal blood sampling (hypoxaemia)
Feotal ECG
When is foetal blood sampling done?
When there is an abnormal CTG
Situations where labour is not advised
Obstruction to the birth canal (masses, major placenta praevia)
Malpresentations
Medical conditions where labour would not be safe for the women (rare)
Specific previous labour complications e.g. previous uterine rupture
Foetal conditions
Types of instrumental/assisted delivery
Forceps Vacuum extraction (cup)
C section is essential management for
obstructed labour
failure to progress in labour
fetal distress before the cervix is fully dilated
Risks of C section
infection
bleeding
visceral injury
VTE
Retaine placenta definition
Complication of the 3rd stage of labour in which the placenta has not undergone placental expulsion within 30 mins when the 3rd stage of labour has been managed actively.
What is retaine placenta a common cause of
PPH
Causes of PPH (THE 4TS)
Tone
Trauma (Tears)
Tissue
Thrombus
Another name for the post partum period
Puerperium
Post natal problems
PPH VTE sepsis psychiatric disorders of the puerperium Pre-eclampsia
Types of PPH
Primary
Secondary
Primary PPH definition
Blood loss >500ml within 24 hours (the 4Ts)
Secondary PPH definition
Blood loss >500ml from 24 hours post partum to 6 weeks (due to e.g. endometritis, retained tissue, tears/trauma etc)
Normal bleeding post partum
Should be like a period or less for 3-4 weeks
Symptoms that increase suspicion of thromboembolic disease in post partum women
Women with unilateral leg swelling and/or pain and women complaining of SOB or chest pain
What investigation can you NOT use to investigate thromboembolic disease in pregnancy/post partum?
D dimer
Investigations for thromboembolic disease in pregnancy/post partum
ECG
Leg dopplers
CXR +/- VQ scan or CTPA
Treatment of thromboembolic disease in pregnancy
LWMH
Warfarin in pregnancy/post partum
SHOULD NOT BE USED IN PREGNANCY = teratogenic
Can be used in breastfeeding
Psychiatric problems post natally
Baby blues
Post natal depression
Puerperal psychosis
Labour problems are most common in what type of women?
Primigravid
Vaginal birth after a previous C section is contraindicated in who?
Previous vertical (classical) Caesarean scars
Previous episodes of uterine rupture
Patients with other contraindications to vaginal birth (e.g. placenta praevia)
Definition of lochia
Vaginal discharge after giving birth, containing blood, mucus and uterine tissue
How long does lochia last for?
4 - 6 weeks after childbirth
What Bishops score indicates that labour is unlikely to start without induction?
< 5
What Bishops score indicates that labour is likely to happen spontaneously?
> 9
Risk factors for breech presentation
Uterine malformations, fibroids Placenta praevia Polyhydramnios or oligohydramnios Foetal abnormality (e.g. CNS malformation, chromosomal problem) Prematurity
What is more common in breech presentations?
Cord prolapse
Management of breech presentation
If < 36 weeks foetus still may turn spontaneously
If breech at 36 weeks = external cephalic version (ECV)
Breech in delivery = planned C section or vaginal
Contraindications to external cephalic version
Where C section is required APH in last 7 days Abnormal CTG Major uterine abnormality Ruptured membranes Multiple pregnancy
What can be used to improve the effectiveness of Macroberts manouvre?
Suprapubic pressure
What is the Macroberts manouvre done for?
Shoulder dystocia
What does the macroberts manouvre involve?
Mother moving onto her back and hypeflexing and abducting the hips, bringing her thighs towards the abdomen
Management of PPH
- Group and save vs cross match
- Syntometrin
- Give 2nd syntometrin if > 500ml
- Fluids and call senior
- Carboprost
- Theatre
- Balloon inserted that puts pressure on spinal arteries
- B lynch suture
- Tie of uterine or iliac arteries
- Subtotal/total hysterectomy (last resort)
When is a B lynch suture more common?
C section
What should be done if the macroberts manoeuvre doesn’t work for shoulder dystocia?
Wood screw manoeuvre
What does the wood screw manoeuvre involve?
Hand in vagina and rotate foetus 180 degrees to dislodge the anterior shoulder from the symphysis pubis
Only contraindication to epidural
Coagulopathy
What is given to all women with premature prerupture of membranes? (PPROM)
10 Days erythromycin
What is puerperal pyrexia?
Temp >38C in 1st 14 days following delivery
Causes of puerperal pyrexia
Endometriosis UTI Wound infection (perineal tears / C section) Mastitis VTE
Most common cause of peurperal pyrexia
Endometriosis
What is the treatment if endometriosis causes peurperal pyrexia?
IV Ax
Can trimethoprim be used in breastfeeding?
Yes
What food should be especially avoided in pregnancy and why?
Liver - as contains high levels of vitamin A which is a teratogen
In induced labour, what can an epidural help with?
Lowering high BP
