Adjuncts in Labour Flashcards
What non-medical methods reduce early labour pain?
Back rubbing
TENS
Immersion in water at body temperature
What medical methods can be used in labour to reduce pain?
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
What anaesthesia is used for obstetric procedures?
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
What are the advantages to an epidural?
Only pain free method
Used in long labour, hypertensive women
What are disadvantages to an epidural?
Increased midwifery supervision needed
Bed-bound
Urinary retention
Transient fetal bradycardia
What are contraindications to epidural?
Sepsis Coagulopathy or anticoagulant therapy - unless low dose heparin Active neurological disease Spianl abnormalities Hypovolaemia
What are complications of an epidural?
Spinal tap - puncture of dura mater causing leakage of CSF and severe headache
Total spinal analgesia -> respiratory paralysis
What is the difference between induction and augmentation of labour?
Induction - labour that is artificially started
Augmentation - contractions of established labour are strengthened
What methods are there for induction of labour?
Prostaglandins
Amniotomy
Oxytocin (only after membrane rupture)
Cervical sweeping
How is prostaglandin used in induction of labour?
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
How is oxytocin used in induction of labour?
Amniotomy - forewaters ruptured with amnihook
Start oxytocin infusion within 2hrs
Can be used alone if SROM has already occured
What natural inductions are used?
Cervical sweeping - finger through cervix and stripping between membrane and lower segment of uterus
What are indications for induction?
Fetal
- prolonged pregnancy
- IUGR
- compromise
- APH
- PROM
Maternal
- pre-eclampsia
- diabetes
- in utero death
What are contraindications for induction?
Acute fetal compromise Abnormal lie Placenta praevia Pelvic obstruction 2+ C-sections (increased scar rupture rate)
How is induced labour managed?
CTG used
May prolong early labour
What are complications of induction?
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
What are contraindications for VBAC?
Usual for C-section
Vertical uterine scar
2+ previous C-sections
What are good prognostic features for VBAC?
Spontaneous labour
Interpregnancy interval less than 2 years
Low age and BMI
Previous vaginal delivery
How is prelabour term rupture of the membranes diagnosed?
Gush of clear fluid followed by uncontrollable trickle
What are risks of prelabour term ROM?
Cord prolapse - usually complication of transverse lie or breech presentation
Neonatal infection - increased by VE, GBS, increased duration of rupture
How is prelabour term ROM managed?
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
When are ventouse/forceps indicated?
Expedition of second stage
Adds power and rotation
What are ventouse?
Vacuum extractor - delivers head in OA position and allows shape of pelvis to rotate head to OA position
What are forceps and when are they used?
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
What are complications or forceps/ventouse delivery?
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
What are indications for instrumental vaginal delivery?
Prolonged second stage - if active stage >1hr
Fetal distress
Prophylactic use to prevent pushing in severe cardiac disease or hypertension
Breech delivery
How are instrumental deliveries avoided?
Continuous support and comfortable maternal position
With epidural - delay maternal pushing for 1 hour after diagnosis of 2nd stage
Oxytocin if head descent poor
What are prerequisites for instrumental delivery?
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
What are indications for emergency C-section?
During labour Prolonged first stage - full dilation >12hrs Inefficient uterine action Malposition Fetal distress
What are indications for an elective C-section?
Performed at 39 weeks
Placenta praevia
Severe fetal compromise
Uncorrectable abnormal lie
Previous vertical C-section
What are complications of C-section?
Haemorrhage Infection - give prophylkactic Abx Bladder/bowel damage VTE Future placenta praevia
What is shoulder dystocia?
Additional manouevres required after normal downwards traction to deliver shoulders
What are consequences of shoulder dystocia?
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
What are risk factors for shoulder dystocia?
Larege baby
Previous shoulder dystocia
Increased BMI
How is shoulder dystocia managed?
Gentle downwards traction
McRoberts’ manouvere - maternal legs onto abdomen
Suprapubic pressure
Episotomy for internal manouevres - Wood’s screw manouevre
What is cord prolapse?
Membranes have ruptured and umbilical cord descends below presenting part
Cord will be compressed or go into spasm -> hypoxia
What are risk factors for cord prolapse?
Preterm labour Breech presentation Polyhydramnios Abnormal lie Twin pregnancy Artifical amniotomy
How is cord prolapse managed?
Presenting part pushed up to avoid compression Give tocolytics (terbutaline) Patient goes on all fours while C-section is prepared
What is amniotic fluid embolism?
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
What are risk factors for amniotic fluid embolism?
Occurs when membranes rupture, during labour , C-section or termination of pregnancy
How is an amniotic fluid embolism managed?
Oxygen and IV fluid Central venous monitoring Cross-match, FBC, clotting Blood and fresh frozen plasma Transfer to ITU
What is uterine rupture?
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
What are risk factors for uterine rupture?
Labours with scarred uterus
Congenital uterine abnormalities
How is uterine rupture managed?
IV fluid
Blood
Laparotomy to deliver fetus and stop bleeding
What is uterine inversion?
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
What are other obstetric emergencies?
Epileptiform seizures - rule ot eclampsia
Local anaesthetic toxicity
Massie APH or PPH
PE
What is active management of third stage?
Ergometrine + oxytocin = syntometrine
What is retained placenta?
Third stage >30 mins
