child birth Flashcards
different types of breech presentation
complete breech - legs folded with feet at level of babys bottom
footling breech - one or both feet point down so the legs would emerge first
frank breech - legs point uo with feet by babys head so bum emerges first
brow bresentation
head extented instead of flexed (can see brows)
step before face presentation
epidural anaethesia + complications
effective - complete pain relief in 95%
does not impair uterine activity
levobupivacaine +/- opiate
complications
- hypotension
- dural puncture
- headache
- high block
- atonic bladder
epidural facts
- Only available in obstetric units
- More effective than opioids
- Not assoc with long term backache
- Not assoc with longer first stage of labour
- Does not increase C-section chance
- Assoc with longer 2nd stage of labour**
- Slightly increased chance of operative birth
- Accompanied by a more intensive level of monitoring
- Requires IV access
- Mobility may be reduced
who is failure to progress in labour more likely in
nulliparous
signs of obstruction
moulding of skull
caput - swelling/lump on heaf
anuria
haematuria
vulval oedema
obstructed labour risks
sepsis
uterine rupture
obstructed AKI
PPH
fistula formation
fetal asphyxia
neonatal sepsis
suspected delay in stage 1
Nulliparous - <2cm dilation in 4hrs
multiParous - <2cm dilation in 4hrs or slowing in progress
intra-partum fetal assessment
Stage 1
- During and after a contraction
- Every 15mins
Stage 2
- At least every 5 mins during + after a contraction for 1 whole minute + check Mat pulse at least every 15mins
- Electronic fetal monitoring – cardiotocograph (CTG)
- Colour of amniotic fluid
causes of fetal hypoxia
acute
- uterine hyperstimulation
- abruption
- cord prolapse
- uterin rupture
- feto-maternal haemorrhage
- regional anaesthesia
- vasa praevia
chronic
- placental insufficienct
- fetal anaemia
fetal hypoxia on CTG
loss of acceleration
repetitive deeper + wider deceleration
rising fetal baseline heart rate
loss of variability
management of abnormal CTG
change maternal position
IV fluids
stop syntocinon
scalp stimulation
consider tocolysis - terbutaline
maternal assessment
consider fetal blood sampling - from skull
operative delivery
fetal scalp blood pH
> 7.25 - normal
7.20-7.25 - borderline -> repeat 30min
<7.20 - abnormal ->deliver
operative delivery, what prophylactic antibiotic is required after?
vaginal delivery assisted by either a ventouse suction cup or foreceps
single dose of co-amoxiclav is recommended after to reduce risk of maternal infection
indications for operative deliveries
“standard” indications
o Delay – failure to progress stage 2
o Fetal monitoring concern
“special” indications
o Maternal cardiac disease
o Severe PET/eclampsia
o Intra-partum haemorrhage
o Umbilical cord prolapse stage 2
(each case considered individually)
(ZTF)
failure to progress
fetal distress
maternal exhaustion
control of head in various positions
** increased risk of requiring an instrumental delivery with epideural is in place
complications of operative deliveries to mum
PPH
episiotomy
perianal tears
injury to anal sphincter
incontinence of bladder or bowel
nerve injury - obturator, femoral
complications of operative deliveries to baby
cephalohaematoma ->ventouse (suction cup)
forceps
- facial nerve palsy
- bruises
- fat necrosis - hardened lumps of fat on cheeks, resolves over time
others
- subgaleal haemorrhage - most dangerous
- intracranial haemorrhage
- skull fracture
- spinal cord injury
nerves at risk of injury in operative delivery
femoral
obturator
usually resolves over 6-8wks
what effects would damge to the femoral nerve cause
(may be compressed against inguinal canal during forceps delivery)
- weakness of knee extension
- loss of patella reflex
- numbness of anterior thigh + medial lower leg
what effects would damge to the obturator nerve cause
(may be compressed by forceps during instrumental delivery or fetal head during normal)
- wekness of hip abduction + rotation
- numbness of medial thigh
duration of stage 2 in prims vs multips
prim - no epidural 2hr, epidural 3hr
multips - no epidural 1hr, epidural 2hr
pain relief in labour
non-medical - changing position, water births, tens machines in early stages
simple analgesia - paracetamol, codeine (NO NSAIDS)
gas+air (entonox)
IM pethidine or diamorphine (see complications)
epidural
IM pethidine or diamorphine during labour
opioid medications given via IM injection
mother -> drowsiness, nausea
neonate -> respiratory distress if given too close to birth, may make first feed more difficult
epidural
Local anaesthetic into epidural space
- Diffuse to surrounding tissue + into spinal cord
Anaesthetic options – levobupivacaine, bupivacaine usually mixed with fentanyl
indwelling catheter required
Contraindicated in coagulopathies
adverse affects of epidural anaesthetic
headache after insertion
hypotension
motor weakness
nerve damage
prolonged 2nd stage
increased probability of instrumental delivery
epidural haematoma
what is recorded on a partogram
(used to monitor progress in first stage of labour)
- cervical dilatation - measure by 4hrly vaginal exam
- descent of fetal head - in relation to ischial spines
- maternal pulse, BP, temp + urine output
- fetal heart rate
- frequency of contractions
- status of membranes, presence of liquor + whether liquor is stained by blood or meconium
- drugs + fluids that have been given
measuring uterine contractions
measure in contractions per 10mins
“she is contracting 2 in 10” = 2 contractions in 10mins
what are the lines on partograms and what do they mean?
2 lines that indicate when labour may not be progressing adequately - labelled “alert” + “action”
- the dilation of cervix is plotted against duration of labour (time)
-* when it takes too long for cervix to dilate, the reading will cross to the right of the laert + action lines
crossing alert line -> indication for amniotomy (artifically rupturing membranes) + repeat exam in 2hrs
crossing action line -> care needs to be escalated to obstetric-led care
tocolysis
drugs used during pregnancy which supress contractions + thus labour
- can only used for a few days + should not be used long term
indicated in pre-term labour to delay delivery by a few days - buy time for steroids to work/allow time to move mother to appropriate care unit
examples of tocolysis
nifedipine (CCB) –> 1st line UK
atosiban (oxytocin receptor antagonist)
indomethacin (NSAID)
terbutaline (beta2agonist)
–> magnesium sulphate may be administered for its foetal neuroprotective effects
contraindications to tocolysis
- Greater than 34wks
- Non-reassuring cardiotocograph, fatal foetal anomaly or intrauterine death
- Intrauterine growth restriction or placental insufficiency
- Cervical dilation <4cm
- Chorioamnionitis
- Maternal factors – pre-eclampsia, ante-partum haemorrhage, haemodynamic instability
Drug specific contraindications
- Eg nifedipine -> cardiac disease – severe hypotension, heart failure
