Abnormal Labour And Post Partum Care Flashcards
Induction of labour
- Approx 1 in 5 pregnancies induced
- Less efficient, more painful
- Need foetal monitoring
- Risk of uterine “hyperstimulation” with prostaglandin/oxytocin induction
Indications for induction (IOL)
- Diabetes (usually before due date)
- Post dates – Term + 7 days
- Maternal health problem that necessitates planning of delivery e.g. on treatment for DVT
- Foetal reasons e.g. growth concerns, oligohydramnios
- You may also see IOL for - social / maternal request / pelvic pain / “big” babies
Process of induction of labour
- If cervix not dilated and effaced (lower Bishop’s score), then vaginal prostaglandin pessaries / Cook Balloon can be used to ripen the cervix
- Once cervix has dilated and effaced, an amniotomy can be performed
- Once amniotomy performed, IV oxytocin can be used to achieve adequate contractions – aim for 4-5 contractions in 10 minutes
What ‘Bishop score’ is considered favourable for amniotomy?
7
What is an amniotomy?
Amniotomy is the artificial rupture of the foetal membranes usually using a sharp device e.g. amniohook
Reasons for inadequate progress of labour
- Cephalopelvic disproportion (CPD)
- Malposition
- Malpresentation
- Inadequate uterine activity
- Other reasons for obstruction (e.g. ovarian cyst or fibroid)
How is progression in labour evaluated?
A combination or abdominal and vaginal examinations to determine:
- Cervical effacement
- Cervical dilatation
- Descent of the foetal head through the maternal pelvis
In the active first stage of labour suboptimal progress is defined as cervical dilatation:
- less than 0.5cm per hour for primigravid women
- less than 1cm per hour for parous women
Consequences of inadequate uterine activity
If contractions are inadequate the fetal head will not descend and exert force on the cervix and the cervix will not dilate.
How is inadequate uterine activity managed?
- It is possible to increase the strength and duration of the contractions by giving a synthetic IV oxytocin to the mother
- It is important to exclude an obstructed labour in these circumstances as stimulation of an obstructed labour could result in a ruptured uterus
Cephalopelvic disproportion (CPD)
- Genuine CPD is relatively rare
- It means that the fetal head is in the correct position for labour but is too large to negotiate the maternal pelvis and be born - caput and moulding develop
Malposition
- Much more common than cephalopelvic disproportion
- Involves the foetal head being in an incorrect position for labour and ‘relative’ CPD occurs
- Occipito-posterior & Occipito-transverse
Foetal blood sampling
- Used when abnormal CTG
- Provides a direct measurement from baby
- We can measure pH and base excess
- pH gives a measure of likely hypoxaemia
Situations advise not to labour
- Obstruction to birth canal
- Major placenta praevia, masses
- Malpresentations
- Transverse, shoulder, hand, breech
- Medical conditions where labour would not be safe for woman
- Specific previous labour complications
- Previous uterine rupture
- Foetal conditions
Instrumental delivery
- Accounts for around 15% of births
- Forceps and vacuum extraction
Caesarean section
- Essential procedure for the management of obstructed labour or fetal distress before the cervix is fully dilated
- Average rate in the UK is around 25%
Caesarean section risks and benefits
- Carries increased risks of infection, bleeding, visceral injury and VTE compared with vaginal birth
- Reduced risk of perineal injury compared with vaginal birth
3rd stage complications
- Retained placenta
- Post partum haemorrhage
- Tears
Postnatal Problems
- Post partum haemorrhage
- Venous thromboembolism
- Sepsis
- Psychiatric disorders of the puerperium
- Pre-eclampsia
Primary postpartum haemorrhage
Primary = blood loss of >500ml within 24 hrs of delivery Tone, Trauma, Tissue, Thrombin (4 T’s)
Secondary postpartum haemorrhage
Secondary = blood loss > 500ml from 24 hrs post partum to 6 weeks
Retained tissue, Endometritis (infection), Tears / trauma
Lochia
Lochia is normal for 3-4 weeks postnatal “should be like a period or less”
Thromboembolic disease symptoms
- Suspicious = women with unilateral leg swelling and/or pain and women complaining of SOB or chest pain
- Sometimes the only sign of a PE will be an unexplained tachycardia
- May present atypically in pregnancy / postnatally
What further increases risk of thromboembolic disease in pregnancy?
Immobilisation following spinal anaesthetic / Caesarean section
Thromboembolic disease investigations
- D-dimer unreliable in pregnancy
- ECG
- Leg Dopplers
- CXR +/- VQ scan or CTPA (NB: radiation exposure during pregnancy /breast feeding)
Thromboembolic disease treatment
- Treat with low molecular weight heparin
- Warfarin is teratogenic, can be used when breast feeding
What to do when you suspect maternal sepsis?
- prompt IV antibiotic administration
- perform full septic screen - blood cultures, LVS, MSSU, wound swabs
- antipyretic measures, IV fluids and referral to hospital
Baby blues
- Affects most women due to hormonal changes around the time of birth - usually 1-3 days PN
- Does not affect functioning and requires no specific treatment
Postnatal Depression
- Can continue on from baby blues or start sometime later
- Has classical ‘depressive’ symptoms
- Affects functioning, bonding and often requires treatment
- Increased risk in women with personal or family history of affective disorder
Puerperal psychosis
- Rare but serious psychotic illness of the postnatal period
- Women can be a danger to themselves and their babies
- Requires inpatient psychiatric care
- Much more common in women with personal or family history of affective disorder, bipolar disorder or psychosis
