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Obs & Gynae > Adjuncts in Labour > Flashcards

Adjuncts in Labour Flashcards

1
Q

What non-medical methods reduce early labour pain?

A

Back rubbing
TENS
Immersion in water at body temperature

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2
Q

What medical methods can be used in labour to reduce pain?

A

Entonox - NO and oxygen
- causes light headedness, nausea and hyperventilation

Systemic opiates - pethidine or Meptid

  • IM injection
  • patient controlled
  • SE sedation, confusion, respiratory depression in newborn (need nalaxone)

Epidural analgesia

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3
Q

What anaesthesia is used for obstetric procedures?

A

Spinal anaesthesia - local anaesthetic injected into CSF

  • short lasting but effective method for C-section or mid cavity instrumental
  • SE: hypotension

Pudendal nerve block - local anaesthetic injected bilaterally around pudendal nerve
- suitable for low-cavity instrumental

Epidural - injection of local anaesthetic +/- opiates via catheter into space between L3 and L4

  • infused continuously or topped up intermittently
  • complete sensory and partial motor blockage is normal
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4
Q

What are the advantages to an epidural?

A

Only pain free method

Used in long labour, hypertensive women

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5
Q

What are disadvantages to an epidural?

A

Increased midwifery supervision needed
Bed-bound
Urinary retention
Transient fetal bradycardia

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6
Q

What are contraindications to epidural?

A 
Sepsis
Coagulopathy or anticoagulant therapy - unless low dose heparin
Active neurological disease
Spianl abnormalities
Hypovolaemia
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7
Q

What are complications of an epidural?

A

Spinal tap - puncture of dura mater causing leakage of CSF and severe headache
Total spinal analgesia -> respiratory paralysis

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8
Q

What is the difference between induction and augmentation of labour?

A

Induction - labour that is artificially started

Augmentation - contractions of established labour are strengthened

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9
Q

What methods are there for induction of labour?

A

Prostaglandins
Amniotomy
Oxytocin (only after membrane rupture)
Cervical sweeping

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10
Q

How is prostaglandin used in induction of labour?

A

Gel inserted into posterior vaginal fornix

  • best for nulliparous women and multips unless cervix is very favourable
  • starts labour or allows amniotomy to be performed
  • can give another dose 6hr later but no more than 2 total
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11
Q

How is oxytocin used in induction of labour?

A

Amniotomy - forewaters ruptured with amnihook

Start oxytocin infusion within 2hrs

Can be used alone if SROM has already occured

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12
Q

What natural inductions are used?

A

Cervical sweeping - finger through cervix and stripping between membrane and lower segment of uterus

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13
Q

What are indications for induction?

A

Fetal

  • prolonged pregnancy
  • IUGR
  • compromise
  • APH
  • PROM

Maternal

  • pre-eclampsia
  • diabetes
  • in utero death
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14
Q

What are contraindications for induction?

A 
Acute fetal compromise
Abnormal lie
Placenta praevia
Pelvic obstruction
2+ C-sections (increased scar rupture rate)
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15
Q

How is induced labour managed?

A

CTG used

May prolong early labour

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16
Q

What are complications of induction?

A

May fail to start or be slow due to uterine inefficiency

Higher risk of C-section and instruments

Hyperstimulation syndrome of the uterus -> rupture

PPH

Infection

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17
Q

What are contraindications for VBAC?

A

Usual for C-section
Vertical uterine scar
2+ previous C-sections

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18
Q

What are good prognostic features for VBAC?

A

Spontaneous labour
Interpregnancy interval less than 2 years
Low age and BMI
Previous vaginal delivery

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19
Q

How is prelabour term rupture of the membranes diagnosed?

A

Gush of clear fluid followed by uncontrollable trickle

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20
Q

What are risks of prelabour term ROM?

A

Cord prolapse - usually complication of transverse lie or breech presentation

Neonatal infection - increased by VE, GBS, increased duration of rupture

21
Q

How is prelabour term ROM managed?

A

Only do VE in sterile manner if risk of cord prolapse

CTG, high vaginal swab
Give antibiotics if lasts more than 18hrs

Either await spontaneous onset of labour or induce labour - 80% start labour within 24hrs

22
Q

When are ventouse/forceps indicated?

A

Expedition of second stage

Adds power and rotation

23
Q

What are ventouse?

A

Vacuum extractor - delivers head in OA position and allows shape of pelvis to rotate head to OA position

24
Q

What are forceps and when are they used?

A

Non-rotational forceps (Simpson’s, Neville-Barnes) - grip head in whatever position it is in and allow traction
Only suitable when occiput is anterior

Rotational forceps (Kieland’s) - no pelvic curve and allowed malpositioned head to be rotated to OA position before traction is applied

25
Q

What are complications or forceps/ventouse delivery?

A

Failure
Analgesia needed -> laceration, blood loss or third-degree tears
Chignon - swelling on head of baby
Occasionally - facial bruising, facial nerve damage, skull or neck fractures

26
Q

What are indications for instrumental vaginal delivery?

A

Prolonged second stage - if active stage >1hr

Fetal distress

Prophylactic use to prevent pushing in severe cardiac disease or hypertension

Breech delivery

27
Q

How are instrumental deliveries avoided?

A

Continuous support and comfortable maternal position

With epidural - delay maternal pushing for 1 hour after diagnosis of 2nd stage
Oxytocin if head descent poor

28
Q

What are prerequisites for instrumental delivery?

A

Head mustn’t be palpable abdominally - at or below ischial spines

Cervix must be fully dilated

Known position of head - can be fatal

Adequate analgesia

Empty bladder

29
Q

What are indications for emergency C-section?

A 
During labour
Prolonged first stage - full dilation >12hrs
Inefficient uterine action
Malposition
Fetal distress
30
Q

What are indications for an elective C-section?

A

Performed at 39 weeks

Placenta praevia

Severe fetal compromise

Uncorrectable abnormal lie

Previous vertical C-section

31
Q

What are complications of C-section?

A 
Haemorrhage
Infection - give prophylkactic Abx
Bladder/bowel damage
VTE
Future placenta praevia
32
Q

What is shoulder dystocia?

A

Additional manouevres required after normal downwards traction to deliver shoulders

33
Q

What are consequences of shoulder dystocia?

A

Excessive traction on neck damages brachial plexus resulting in Erb’s palsy which is permanent in 50% of cases

Can be lethal in as little as 5 mins

34
Q

What are risk factors for shoulder dystocia?

A

Larege baby
Previous shoulder dystocia
Increased BMI

35
Q

How is shoulder dystocia managed?

A

Gentle downwards traction
McRoberts’ manouvere - maternal legs onto abdomen
Suprapubic pressure

Episotomy for internal manouevres - Wood’s screw manouevre

36
Q

What is cord prolapse?

A

Membranes have ruptured and umbilical cord descends below presenting part

Cord will be compressed or go into spasm -> hypoxia

37
Q

What are risk factors for cord prolapse?

A 
Preterm labour
Breech presentation
Polyhydramnios
Abnormal lie
Twin pregnancy
Artifical amniotomy
38
Q

How is cord prolapse managed?

A 
Presenting part pushed up to avoid compression
Give tocolytics (terbutaline)
Patient goes on all fours while C-section is prepared
39
Q

What is amniotic fluid embolism?

A

Liquor enters maternal circulation -> anaphylaxis
Sudden dysponeoa, hypoxia and hypotension

If woman survives for 30 mins she will develop DIC, pulmonary oedema and adult respiratory distress syndrome

40
Q

What are risk factors for amniotic fluid embolism?

A

Occurs when membranes rupture, during labour , C-section or termination of pregnancy

41
Q

How is an amniotic fluid embolism managed?

A 
Oxygen and IV fluid
Central venous monitoring
Cross-match, FBC, clotting
Blood and fresh frozen plasma
Transfer to ITU
42
Q

What is uterine rupture?

A

Can tear de novo or along old scar

Fetus is extruded, uterus contracts down and bleeds -> acute fetal hypoxia and internal maternal haemorrhage

Rupture from lower transverse C-section sar is less traumatic as reduced blood suplly

43
Q

What are risk factors for uterine rupture?

A

Labours with scarred uterus

Congenital uterine abnormalities

44
Q

How is uterine rupture managed?

A

IV fluid
Blood
Laparotomy to deliver fetus and stop bleeding

45
Q

What is uterine inversion?

A

Fundus inverts into uterine cavity during traction on placenta

Causes haemorrhage, pain and profound shock

Push up from vagina otherwise GA and hydrostatic pressure of saline into uterus

46
Q

What are other obstetric emergencies?

A

Epileptiform seizures - rule ot eclampsia

Local anaesthetic toxicity

Massie APH or PPH
PE

47
Q

What is active management of third stage?

A

Ergometrine + oxytocin = syntometrine

48
Q

What is retained placenta?

A

Third stage >30 mins

Obs & Gynae (20 decks)

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