Abnormal Labour and Postpartum Care Flashcards
How many labours are induced?
About 1 in 5 fail to start and require induction
What are the disadvantages of induction?
- Less efficient
- More painful
- Need foetal monitroing
What is there risk of the prostaglandin/oxytocin induction?
Hyperstimulation
What are the indications for induction?
- 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
- Social, maternal request, pelvic pain or big babies
What are the 3 components of induction?
- Ripen cervix
- Artificially rupture membranes
- Oxytocin
What is induction of labour?
Induction of labour is 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)
What score is used to clinically assess the cervix?
Bishop’s score
-The higher the score, the more progressive change there is in the cervix and indicates that induction is likely to be successful.
What is a Bishop score of 0?
Dilatation:
0cm
Length of cervix (effacement):
3cm
Position:
Posterior
Consistency:
Firm
Station:
-3cm
What is a Bishop score of 1?
Dilatation:
1-2cm
Length of cervix :(effacement)
2cm
Position:
Mid
Consistency:
Medium
Station:
-2cm
What is a Bishop score of 2?
Dilatation:
3-4cm
Length of cervix(effacement):
1cm
Position:
Anterior
Consistency:
Soft
Station:
-1,0
What is a Bishop score of 3?
Dilatation:
5+cm
Length of cervix(effacement):
0cm
Station:
+1,+2cm
When is amniotomy considered favourably?
Bishop score of 7 or more (once cervix has dilated and effaced)
What is an amniotomy?
Amniotomy is the artificial rupture of the foetal membranes (“waters”) usually using a sharp device e.g. amniohook
How can the cervix be ripened when there is a low Bishop score (not dilated or effaced)?
- Vaginal prostaglandin pessaries
- Cook balloon
After an amniotomy is performed, how are contractions induced?
- IV oxytocin us used to achieve adequate contractions
- Aim for 4-5 contractions in 10 minutes
What can cause inadequate progress during labour?
- Cephalopelvic disproportion (CPD)
- Malposition
- Malpresentation
- Inadequate uterine activity
- Other reasons for obstruction (e.g. ovarian cyst or fibroid)
- Foetal distress
How is progress of labour assessed?
Combination of abdominal and vaginal examinations to determine:
- Cervical effacement
- Cervical dilatation
- Descent of the fetal head through the maternal pelvis
What is considered suboptimal progress in the active first stage of labour?
Cervical dilatation:
- Less than 0.5cm per hour for primigravid women
- Less than 1cm per hour for parous women
What happens if the uterine contractions are inadequate?
If contractions are inadequate the foetal head will not descend and exert force on the cervix and the cervix will not dilate.
How can the strength and duration of contractions be increased?
By giving synthetic IV oxytocin to the mother
What could stimulation of an obstructed labour lead to?
A rupture uterus
What problems may there be with the baby and the passage?
- Cephalopelvic disproportion
- Malpresentation
- Malposition
What is cephalopelvic disproportion?
- Genuinely rare
- It means that the foetal head is in the correct position for labour but is too large to negotiate the maternal pelvis and be born!
- Caput and moulding develop
Why is cord prolapse a medical emergency?
- Once the cord hits the air it spasms and stops pulsating
- Can result in death of the baby
Give examples of malpresentation.
- Longitudinal lie but breech presentation
- Transverse lie with shoulder presentation
What way can a baby lie?
- Longitudinal
- Oblique
- Transverse
What is malposition?
- Much more common
- Involves the fetal head being in an incorrect position for labour and ‘relative’ CPD occurs
- Occipito-posterior & Occipito-transverse
What positions can a baby be in?
- Occipito anterior
- Occipito posterior
- Left occipito transverse
- Right occipito transverse
- ROA
- LOA
- ROP
- LOP
Why is it important to avoid too many contractions?
Can result in foetal distress due to insufficient placental blood flow.
What is foetal wellbeing during labour determined by?
- Intermittent auscultation of the foetal heart
- Cardiotocography
- Foetal blood sampling
- Foetal ECG
When is foetal blood sampling carried out?
When there is an abnormal CTG
What can a foetal blood sample tells us?
Direct measurement from baby
- Measure pH and base excess
- pH gives a measure of likely hypoxaemia
When should a mother be advised 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 such as previous uterine rupture
- Foetal conditions
How many births are assisted by instrumental delivery?
About 15%
What types of instrumental deliveries are there?
- Forceps
- Vacuum
In what cases is caesarean section an essential procedure?
For the management of obstructed labour or foetal distress before the cervix is fully dilated
What are the risks associated with C section?
- Infection
- Bleeding
- Visceral injury
- VTE
What is there reduced risk of with C section?
Perineal injury
How many babies are born via C section?
About 25%
What are some 3rd stage complications?
- Retained placenta
- Post partum haemorrhage
- Tears
What are the 4Ts of post partum haemorrhage?
- Tone
- Thrombosis
- Tissue
- Thrombin
What is the puerperium?
The first 6 weeks of the post partum period
What happens to the mother during the puerperium?
Sees midwife after 9-10 days and the HV
- Continue to observe for signs of abnormal bleeding
- Observe for evidence of infection (Wound / Endometritis / Breast)
- Debrief events around birth (especially if emergency CS)
Postnatal check at GP (6 weeks)
Consider contaception
What common problems are there during the puerperium?
- Problems with infant feeding
- Problems with bonding
- Social issues
What post-natal problems may occur?
- Post partum haemorrhage
- Venous thromboembolism
- Sepsis
- Psychiatric disorders of the puerperium
- Don’t forget pre-eclampsia
What is primary postpartum haemorrhage?
Blood loss of >500ml within 24 hours of delivery
What causes primary postpartum haemorrhage?
- Tone
- Tissue
- Thrombin
- Trauma
What is secondary postpartum haemorrhage?
Blood loss of >500ml from 24 hours post partum to 6 weeks
What causes secondary post partum haemorrhage?
- Retained tissue
- Endometriosis (infection)
- Tears/ trauma
When is lochia (mixed vaginal discharge) normal?
Normal for 3-4 weeks post-natal
What is the association between pregnancy and postpartum period and VTE?
- Pregnancy and the immediate post partum period is a hypercoagulable state
- Pregnant women 6-10 times more likely to develop thromboembolism (DVT or PE)
- High quality risk assessment and appropriate thromboprophylaxis is required to reduce this risk
When should you be suspicious of VTE?
- Women with unilateral leg swelling and/ or pain
- Women with SOB or chest pain
- May present atypically
What can sometimes be the only sign of PE?
Unexplained tachycardia
What test is unreliable in pregnancy?
D-dimer
How should thromboembolic disease be investigated in pregnancy?
- ECG
- Leg Dopplers
- CXR +/- VQ scan or CTPA (NB: radiation exposure during pregnancy /breast feeding)
How should thromboembolic disease be treated in pregnancy?
- Low molecular weight heparin
- WARFARIN IS TERATOGENIC
What increases risk of VTE following birth?
Immobilisation following spinal anaesthetic or C section
What is the leading cause of maternal death in the UK?
Sepsis
What should you do in any women you suspect sepsis?
- Prompt IV antibiotics administration
- Antipyretic measures
- Refer to hospital if not already there
What should bed
one if sepsis is suspected?
Perform full septic screen
- Blood cultures
- LVS
- MSSU
- Wound swabs
How can maternal sepsis present?
Atypically
What is the prevalence of postpartum psychiatric problems?
- 1/4 of women who died between 6 weeks and 1 year after pregnancy died form mental-health related causes
- 1 in 7 by suicide
What is the prevalence of the 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
How does post natal depression present?
- Can continue on from baby blues or start sometime later
- Has classical ‘depressive’ symptoms
- Affects functioning, bonding and often requires treatment
Who is at increased risk of postnatal depression?
Women with a personal of family history of affective disorder
What is puerpal 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
When do most eclamptic seizures occur?
Postnatal period
When can pre-eclampsia develop?
- During pregnancy
- Can develop postnatally or may worsen several days following delivery
Who are labour problems particularly common in?
Primigravid women
