Abnormal Labour and Postpartum Care Flashcards
Between 2004 and 2005, how many labours were induced?
1 in 3
What are the disadvantages of inducing labour?
Less efficient
More painful
Carries higher chance of instrumental delivery or Caesarean section
What are the indications for inducing labour?
Diabetes Post-dates, term + 7 days Maternal health problems that necessitate the planning of the delivery to make changes to medications Foetal reasons Social reasons
Why might labour be induced in women with diabetes?
Usually induced before due date because of risk of bigger babies and stillbirth
Why is labour induced post-term?
After a certain point of full-term babies become more at risk of death
What foetal reasons might necessitate induction of labour?
Growth concerns
Oligohydramnios
What is induction of labour?
When an attempt is made to instigate labour artificially using medications and/or by artificial rupture of membranes (amniotomy)
What is the Bishop’s score?
Scoring system used to clinically assess the cervix - the higher the score, the more progressive change there is in the cervix which indicates that induction is likely to be successful
Lower score indicates that induction may be more likely to fail but can still be attempted
When can an amniotomy be performed?
Once the cervix has dilated and effaced - cervix needs to be dilated enough to break the waters
What can be used if the cervix is not dilated enough and effaced, but labour needs to be induced?
Vaginal prostaglandin pessaries can be used to artificially open the cervix
What Bishop’s score is considered favourable for amniotomy to be performed?
7 or more
What is an amniotomy?
Artificial rupture of the foetal membranes (waters), usually using a sharp device e.g. amniohook
After an amniotomy is performed, what can be used to achieve adequate contractions?
IV oxytocin
What should you aim to achieve in terms of contractions when using IV oxytocin to induce labour?
4-5 contractions in 10 minutes
In labour, what are the powers, passages and passenger?
Power - contraction
Passages - pelvic tract
Passenger - baby
What might cause inadequate progress in labour?
Cephalopelvic disproportion Malposition Malpresentation Inadequate uterine activity Other reasons for obstruction e.g. ovarian cyst or fibroid
How is progress in labour evaluated?
By a combination of abdominal and vaginal examinations to determine; cervical effacement, cervical dilatation and descent of the foetal head through the maternal pelvis
In the active first stage of labor, what is suboptimal progress defined as?
Cervical dilatation of less than 0.5cm per hour for primigravid women and less than 1cm per hour for parous women
What will happen if contractions are inadequate?
The foetal head will not descend and exert force on the cervix, and the cervix will not dilate
What effect will giving synthetic IV oxytocin to the mother have?
Increase the strength and duration of the contractions
If there is inadequate uterine activity and you are considering giving the mother IV oxytocin, what is it important to exclude first?
Obstructed labour - stimulation of an obstructed labour could result in a ruptured uterus which can result in severe foetal and maternal morbidity and mortality e.g. large baby, abnormal position, uterus struggling
What is cephalopelvic disproportion (CPD)?
Genuine CPD is relatively rare
It is where the foetal head is in the correct position for labour but is too large to negotiate the maternal pelvis and be born
In these circumstances, the baby’s head becomes compressed and caput and moulding develop
What should the baby’s spine be in line with?
Baby’s spine should be running in line with the mother’s spine, with head down
What do you need to be aware of in transverse lie?
Placental position
Umbilical cord filling space
What positions can a baby lie in in the uterus?
Longitudinal
Oblique
Transverse
What positions carry risks of cord or placenta filling space?
Oblique and transverse
What is malposition?
Involves the foetal head being in an incorrect position for labour and a relative CPD occurs
What is the normal position for delivery?
Occipito-anterior
Occipito-posterior and occipito-transverse are abnormal
Why is it important to avoid causing too many contractions?
This can result in foetal distress due to insufficient placental blood flow
How is foetal wellbeing in labour determined?
Intermittent auscultation of the foetal heart
Cardiotocography (CTG) - more high risk labour, monitors baby’s heart and contractions
Foetal blood sampling
Foetal ECG
When is foetal blood sampling used?
When persistently suspicious or pathological CTG
What does foetal blood sampling measure?
Provides a direct measurement from the baby
Can measure pH and base excess
pH gives measure of likely hypoxaemia
In what situations is labour not advised?
Obstruction to birth canal e.g. major placenta praevia, masses
Malpresentation - transverse, shoulder, hand, breech
Medical conditions where labour wouldn’t be safe for the mother e.g. CVS conditions
Specific previous labour complications e.g. previous uterine rupture
Foetal conditions
What percentage of first births involve assisted/instrumental delivery?
Around 15%
What is used in assisted/instrumental delivery?
Forceps
Vacuum extraction
What is the essential procedure for the management of obstructed labour or foetal distress before the cervix is fully dilated?
Caesarean section
What are the risks of Caesarean sections?
Increased risks of infection, bleeding, visceral injury and VTE compared with vaginal birth
What is there a reduced risk of in Caesarean section compared to vaginal birth?
Reduced risk of perineal injury with C-section
What is the average rate of C-section in the UK?
25%
What are the third stage complications?
Retained placenta
Post-partum haemorrhage
Tears
What are the degrees of tears?
First degree - vaginal mucosa
Second degree - perineal muscle
Third degree - anal sphincter muscles
Fourth degree - into rectal mucosa
What is the normal puerperium period?
6 weeks after birth
What are the normal procedures for the postpartum period?
See midwife for 9-10 days then referred to health visitor
Continue to observe for signs of abnormal bleeding
Observe for evidence of infection
Debrief events around birth, especially if emergency CS
6 week postnatal check at GP
What are some common problems in the postpartum period?
Problems with infant feeding
Problems with bonding
Social issues e.g. with partner, other children, financial
What is the immediate postnatal care for high risk women?
Care in recovery
15-60 minute observations
Ensure uterus remains contracted and there is no evidence of abnormal bleeding
Prophylactic antibiotics given if appropriate
Appropriate thromboprophylaxis
Recovery from spinal/epidural/general anaesthetic
Fit for transfer to postnatal ward
What are some serious postnatal problems?
Postpartum haemorrhage Venous thromboembolism Sepsis Psychiatric disorders of the puerperium Pre-eclampsia
What is primary postpartum haemorrhage?
Blood loss of > 500ml within 24 hours of delivery
What is secondary postpartum haemorrhage?
Blood loss of > 500ml from 24 hours postpartum up to 6 weeks after birth
What are the 4 Ts in postpartum haemorrhage?
Tissue - retained
Tone - more acute/primary, uterus not contracted back to normal
Thrombin
Trauma
What are the causes of primary postpartum haemorrhage?
Uterine atony Local causes e.g. traumatic tears to perineum/vagina/cervix Retained tissue/placenta Coagulopathy Tone, trauma, tissue, thrombin
What are the causes of secondary postpartum haemorrhage?
Retained tissue
Endometritis
Tears/trauma
All women will have bleeding for 2-4 weeks after delivery, but this should be “like a period or less”
Why is there an increased risk of thromboembolic disease in pregnancy and the postpartum period?
Pregnancy and the immediate postpartum period is a hypercoagulable state
What is the increased risk of developing thromboembolism (DVT or PE) in pregnant women?
Pregnant women are 6-10 times more likely to develop thromboembolism for up to 6 weeks after delivery
What is required to reduce thromboembolism risk?
High quality risk assessment and appropriate thromboprophylaxis
When should you be suspicious of DVT/PE in a pregnant woman?
May be relatively asymptomatic compared to non-pregnant counterparts
Suspicious in;
- women with unilateral leg swelling and/or pain
- SOB or chest pain
Unexplained tachycardia may be the only sign of a PE
May also present atypically in pregnancy/postnatally
Always have high index of suspicion
What will further increase the risk of thromboembolism in pregnancy/postpartum?
Immobilisation following spinal anaesthetic/Caesarean section
What is the investigation for suspected thromboembolism in pregnancy?
ECG
Doppler scan of legs
CXR and/or V/Q scan or CTPA
V/Q generally done first due to risk from radiation exposure
How do you treat thromboembolism in pregnancy?
Low molecular weight heparin
What is the treatment for sepsis in pregnancy?
Prompt IV antibiotic administration
Antipyretic measures
IV fluids
Referral to hospital if you are concerned a pregnant or postnatal woman is septic
What is the investigation for sepsis in pregnancy?
Full septic screen
- blood cultures
- LVS
- MSSU
- wound swabs
What number of women who died between 6 weeks and one year after pregnancy died from mental health-related causes (MMBRACE report 2015)?
Almost a quarter
1 in 7 of these died from suicide
Who should manage any concerns about a pregnant/postpartum woman’s mental health?
Dedicated perinatal mental health team
What are the ‘baby blues’?
Affects most women due to hormonal changes around the time of birth, usually occurs 1-3 days postnatally for a few days only, does not affect functioning and requires no specific treatment
What are the features of postnatal depression?
Can continue from baby blues or can start some time later
Classic depressive symptoms
Affects functioning and bonding
Often requires treatment
Increased risk in women with personal or family history of affective disorder
What are the features of 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 a personal or family history of affective disorder, bipolar disorder or psychosis
When do most eclamptic seizures occur?
In the postnatal period
