Abnormal Labour and Postpartum Care Flashcards
Characteristics of failure to start labour
- 1 in 5 pregnancies induced
- Less efficient, more painful
- Need foetal monitoring
- Risk of uterine ‘hyperstimulation’ with prostaglandin/oxytocin induction
Indications for induction of labour
- Diabetes (usually before due date)
- Post date - term + 7 days
- maternal health problems that necessitate planning of delivery e.g. treatment of DVT
- Foetal reasons - growth concerns, oligohydramnios
- Other
- Social/maternal request/pelvic pain/’big’ babies
What is induction of labour
- 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 assess the cervix in labour
- Bishop’s - the higher the score the more progressive change there is in the cervix and indicates that induction is likely to be successful
- Cervix Assessment
0
1
2
3
Dilation (cm)
0
1-2
3-4
5+
Length if cervix (effacement) (cm)
3
2
1
0
Position
Posterior
Mid
Anterior
Consistency
Firm
Medium
Soft
Station (cm)
- 3
- 2
- 1,0
+1, +2
How is labour induced if low Bishop’s score
- Cervix not dilated and effaced
- Vaginal prostaglandin pessaries/Cook Balloon can be used to ripen (open) cervix
What can be performed once the cervix is dilated and effaced
- Amniotomy
What Bishop’s score is considered favourable for amniotomy
- 7 or more
What is an amniotomy
- Artificial ruptire of foetal membranes (‘waters’)
- Usually a sharp device e.g. amniohook
In induction of labour what happens once the amniotomy has been performed
- IV oxytocin can be used to achieve adequate contractions - aim for 4-5 in 10 mins
What are the stages of labour
*
What progress problems can occur during labour
- Cephalopelvic disproportion (CPD)
- Malposition - head in wrong position (occipito-posterior, occipito-transverse)
- Malrepresentation (lie)
- Inadequate uterine activity
- Other reasons for obstruction (e.g. ovarian cyst of fibroid)
- Foetal disease
How is progress of labour evaluated
- Combination of abdominal and vaginal examinations to determine
- Cervical effacement
- Cervical dilatation
- Descent of the foetal head through the maternal pelvis
What is considered suboptimal progress in the first stage of labour
- defined by cervical dilation
- <0.5cm per hour in primigravid
- <1cm per hour for parous women
what happens if contractions are not adequate
- The foetal head will not descend and exert force on the cervix and the cervix will not dilate
- Important to check no obstruction as stimulation can result in ruptured uterus
What is cephalopelvic disproportion
- Foetal head is in the correct position but is too large to negotiate the maternal pelvis
- Caput and moulding develop
What can cause foetal distress
- too many contractions (uterine hyper-stimulation) due to lack of blood flow to the placenta
How is foetal well-being monitored during labour
- Intermittent auscultation of the foetal heart
- Cardiotocography (CTG)
- Foetal blood sampling
- Used when abnormal CTG
- Provides direct measurements
- pH and base excess - measure hypoxia
- Foetal ECG
When would advise not to labour be given
- Obstruction of birth canal
- Major placenta praevia, masses
- Misrepresentations
- Transverse, should, hand, breech
- Medical conditions where labour would not be safe
- Specific previous labour complications
- Previous uterine rupture
- Foetal conditions
Types of assisted/instrumental delivery
- 15% of all births
- Forceps
- Vacuum extraction
When is C-section essential
- Obstructed labour or foetal distress before cervix is fully dilated
- UK rate 25%
Risks of C-section
- Infections
- Bleeding
- Visceral injury
- VTE
Benefits of C-section
- Reduced risk of perineal injury
3rd stage labour complications
- Retained placenta
- Post-partum haemorrhage
- Tears
What are the causes of post-partum haemorrhage
- 4Ts
- Trauma
- Tissue
- Tone
- Thrombin
Types of tears in labour
- Graze
- 1st degree
- 2nd degree
- 3rd degree
- 4th degree
What is the postpartum period of time called
- puerperium
Why is the midwife/health visitor seen for 9-10 days after birth
- Observe for signs of abnormal bleeding
- Observe for evidence of infection
- Wound/endometritis/breast
- Debrief events around birth (especially if emergency C-section)
When do all women have a postnatal check up
- 6 weeks at GP
What are the common postnatal problems picked up on checkup (non-medical)
- Problems with feeding
- Problems with bonding
- Social issues (partner, other children, financial)
What are some postnatal problems (medical)
- Post-partum haemorrhage
- VTE
- Sepsis
- Psychiatric disorders of the puerperium
- Pre-eclampsia
Types of post partum haemorrhage
- Primary - blood loss of >500ml within 24hrs of delivery
- Secondary - blood loss of >500mls from 24hrs postpartum to 6 weeks
- Lochia is normal for 3-4 weeks (normal period or less)
Why is thromboembolic disease more of a risk when pregnant
- Pregnancy and the postpartum period is a hypercoagulable state
- 6-10x more likely to develop TE
What is suspicious of thromboembolic disease
- Unilateral leg swelling and/or pain
- SOB
- Chest pain
- Tachycardia
- May present atypically
What further increases the risk of VTE in pregnancy
- Immobilisation - spinal anaesthetic, C-section
How should VTE be investigated in pregnancy
- D-dimer unreliable
- ECG
- Leg doppler
- CXR +/- VQ scan (radiation exposure during pregnancy/breast feeding)
How should VTE be treated in pregnancy
- Low molecular weight heparin
- Warfarin is teratogenic, can be used in breastfeeding
What is the leading cause of maternal death in the UK
- Sepsis
- May present atypically
What is the treatment for maternal sepsis
- Prompt IV antibiotics
- Antipyretic measure
- IV fluids
How is maternal sepsis investigated
- Full septic screen - blood cultures, LVS, MSSU, wound swabs
What are the baby blues
- Affect most women due to hormonal changes around the time of birth - after 1-3 days
What is postnatal depression
- Can continue from baby blues or start sometime later
- Has classical depressive symptoms
- Affects functioning, bonding and often requires treatment
- Increased risk if personal or family history of affective disorder
What is puerperal psychosis
- rare but serious illness
- Can be a danger to themselves and their baby
- Inpatient psychiatric care
- More common in women with personal/family history of affective disorder, bipolar, psychosis
What occurs in postpartum hypertensive disorders
- Most eclamptic seizures occur in the post-natal period
- Pre-eclampsia can develop postnatally or may worsen several days following delivery
