Delivery Flashcards
what are the three stages of labour?
First stage – from the onset of labour (true contractions) until 10cm cervical dilatation
Second stage – from 10cm cervical dilatation until delivery of the baby
Third stage – from delivery of the baby until delivery of the placenta
what does first stage involve
cervical dilation and effacement. the show (mucus plug in cervix, preventing bacteria from entering uterus) falls out, creating space for baby to pass through
the stages of the first stage
Latent phase – from 0 to 3cm dilation of the cervix. This progresses at around 0.5cm per hour. There are irregular contractions.
Active phase – from 3cm to 7cm dilation of the cervix. This progresses at around 1cm per hour, and there are regular contractions.
Transition phase – from 7cm to 10cm dilation of the cervix. This progresses at around 1cm per hour, and there are strong and regular contractions.
what are braxton hicks contractions
NOT indicate labour
clinical fx of braxton hicks
occasional irregular contractions - mild cramping
in second or third trimester
do not progress or become regular
improve with hydration and relaxing
O/E onset of labour
Show (mucus plug from the cervix)
Rupture of membranes
Regular, painful contractions
Dilating cervix on examination
latent first stage NICE guildelines
Painful contractions
Changes to the cervix, with effacement and dilation up to 4cm
established first stage of labour NICE guidelines
Regular, painful contractions
Dilatation of the cervix from 4cm onwards
rupture of membranes definition
amniotic sac ruptured
spontaneous rupture of memrbanes definition
amniotic sac ruptures spontaneously
prelabour rupture of memrbanes definition
amniotic sac ruptured before onset of labour
preterm prelabour rupture of membrnaes def
amniotic sac has ruptured before the onset of labour and before 37 weeks gestation (preterm).
prolonged rupture of membranes def
The amniotic sac ruptures more than 18 hours before delivery.
prematurity def
<37 weeks gestation
when non viable
<23 weeks
WHO classification of prematurity
Under 28 weeks: extreme preterm
28 – 32 weeks: very preterm
32 – 37 weeks: moderate to late preterm
prophylaxis of preterm labour options
vaginal progesterone - decrease activity of myometrium and prevent cervix remodeeling
cervical cerclage - stitch in cervix to add support/keep closed, removed when enter labour, used in prev issues. ‘rescue’ version offered when cervical dilation with rupture of membranes
diagnosis of preterm prelabour rupture of membranes
examination - pooling of amniotic fluid in vagina
IGFBP-1 - protein in amniotic fluid, test of vaginal fluid
PAMG-1 - similar
mx of preterm prelabour rupture of membranes
prophylactic abx to prevent chorioamnionitis - erythromycin 250mg x4 a day for 10 days or until labour established, if within 10 days
induction of labour if >34 weeks offered
preterm labour with intact membranes diagnosis
<30 weeks - clinical assessment
>30 weeks - transvaginal USS to assess cervical length (<15mm)
fetal fibronectin - 50ng/ml
mx of preterm labour with intact membranes
Fetal monitoring (CTG or intermittent auscultation)
Tocolysis with nifedipine: nifedipine is a calcium channel blocker that suppresses labour
Maternal corticosteroids: can be offered before 35 weeks gestation to reduce neonatal morbidity and mortality
IV magnesium sulphate: can be given before 34 weeks gestation and helps protect the baby’s brain
Delayed cord clamping or cord milking: can increase the circulating blood volume and haemoglobin in the baby at birth
tocolysis definition
using meds to stop uterine contractions
can be used between 24 and 33+6
tocolysis examples of meds
nifedipine - CCB
atosiban - oxytocin receptor antagonist (if nifedipine is c/i)
when give antenatal steroids
prevent ARDS
used in women with suspected preterm labour of babies less than 36 weeks gestation.
antenatal steroids dose
x2 doses IM betamethason, 24 hours apart
when give mag sulfate
protect foetal brain in prematurity
to reduce risk of cerebral palsy
mag sulfate dosing
given within 24 hours of delivery of preterm babies of less than 34 weeks gestation. It is given as a bolus, followed by an infusion for up to 24 hours or until birth
close monitor for mg toxicity - obs and tendon reflexes
signs of mg toxicity
Reduced respiratory rate
Reduced blood pressure
Absent reflexes
when induction of labour offered
41-42 weeks gestation
or when beneficial to start labour early ->
Prelabour rupture of membranes
Fetal growth restriction
Pre-eclampsia
Obstetric cholestasis
Existing diabetes
Intrauterine fetal death
scoring system used to determine whether to induce labour
Bishop score
bishop score
Fetal station (scored 0 – 3)
Cervical position (scored 0 – 2)
Cervical dilatation (scored 0 – 3)
Cervical effacement (scored 0 – 3)
Cervical consistency (scored 0 – 2)
8 or more - successful induction of labour, otherwise ripening required
options for inducing labour
membrane sweep - insert finger into cervix to stimulate, if >40 weeks
vaginal prostaglandin E2 (dinoprostone) - gel/tablet/pessary
cervical ripening balloon - alternative to vaginal prostaglandins, or in prev caesarean or para>3
oxytocin infusion - artificial rupture of membranes, after vaginal prostagladins or alternative
oral mifepristone (anti-progesterone) plus misoprostol - where IUFD has occured
monitors used during induction of labour
Cardiotocography (CTG) to assess the fetal heart rate and uterine contractions before and during induction of labour
Bishop score before and during induction of labour to monitor the progress
when slow progression (>24 hours) of labour options
Further vaginal prostaglandins
Artificial rupture of membranes and oxytocin infusion
Cervical ripening balloon (CRB)
Elective caesarean section
main complication of using vaginal prostaglandins
UTERINE HYPERSTIMULATION - contraction of uterus if prolonged and frequent…
Fetal compromise, with hypoxia and acidosis
Emergency caesarean section
Uterine rupture
criteria for uterine hyperstimulation
Individual uterine contractions lasting more than 2 minutes in duration
More than five uterine contractions every 10 minutes
mx of uterine hyperstimulation
Removing the vaginal prostaglandins, or stopping the oxytocin infusion
Tocolysis with terbutaline
cardiotocography use
to measure the fetal heart rate and the contractions of the uterus
how get CTG readout
One above the fetal heart to monitor the fetal heartbeat using doppler
One near the fundus of the uterus to monitor the uterine contractions by assessing tension in wall
indications for continuous CTG monitoring
Sepsis
Maternal tachycardia (> 120)
Significant meconium
Pre-eclampsia (particularly blood pressure > 160 / 110)
Fresh antepartum haemorrhage
Delay in labour
Use of oxytocin
Disproportionate maternal pain
key fx of CTG monitoring
Contractions – the number of uterine contractions per 10 minutes
Baseline rate – the baseline fetal heart rate
Variability – how the fetal heart rate varies up and down around the baseline
Accelerations – periods where the fetal heart rate spikes(good sign, esp with uterine contractions)
Decelerations – periods where the fetal heart rate drops (concerning)
baseline heart rate NICE guidelines interpretation
reassuring - 110-160, with 5-25 variability
non reassuring - 100-109 or 161-180, with <5 for 30-50mins or >25 for 15-25mins
abnormal - <100 or >180, with <5 for >50 mins, >25 for >25 mins variability
why does foetal HR drop
in response to hypoxia
4 types of decelerations
Early decelerations
Late decelerations
Variable decelerations
Prolonged decelerations
early decelerations
gradual dips and recoveries
correspond with uterine contractions
not pathological
caused by uterus compressing head of fetus, stimulating vagus nerve
late decelerations
gradual falls in HR start after uterine contractions had already begun
The lowest point of the declaration occurs after the peak of the contraction. Late decelerations are caused by hypoxia in the fetus, and are more concerning
causes include excessive uterine contractions, maternal hypotension or maternal hypoxia
variable decelerations
abrupt decelerations that may be unrelated to uterine contractions. There is a fall of more than 15 bpm from the baseline. The lowest point of the declaration occurs within 30 seconds, and the deceleration lasts less than 2 minutes in total. Variable decelerations often indicate intermittent compression of the umbilical cord, causing fetal hypoxia. Brief accelerations before and after the deceleration are known as shoulders, and are a reassuring sign that the fetus is coping.
prolonged decelerations
last between 2 and 10 minutes with a drop of more than 15 bpm from baseline. This often indicates compression of the umbilical cord, causing fetal hypoxia. These are always abnormal and concerning.
mx based off what aspect of CTG
Baseline rate
Variability
Decelerations
4 catergories of outcomes from CTG
Normal
Suspicious: a single non-reassuring feature
Pathological: two non-reassuring features or a single abnormal feature
Need for urgent intervention: acute bradycardia or prolonged deceleration of more than 3 minutes
mx following outcome of CTG
Escalating to a senior midwife and obstetrician
Further assessment for possible causes, such as uterine hyperstimulation, maternal hypotension and cord prolapse
Conservative interventions such as repositioning the mother or giving IV fluids for hypotension
Fetal scalp stimulation (an acceleration in response to stimulation is a reassuring sign)
Fetal scalp blood sampling to test for fetal acidosis
Delivery of the baby
rule of 3’s for fetal bradycardia
3 minutes – call for help
6 minutes – move to theatre
9 minutes – prepare for delivery
12 minutes – deliver the baby (by 15 minutes)
what is a sinusoidal CTG
rare pattern
severe fetal compromise, eg: severe anaemia
sine wave- smooth regular waves up and down that have an amplitude of 5 – 15 bpm
mneumonic for fx of CTG
DR – Define Risk (define the risk based on the individual woman and pregnancy before assessing the CTG)
C – Contractions
BRa – Baseline Rate
V – Variability
A – Accelerations
D – Decelerations
O – Overall impression (given an overall impression of the CTG and clinical picture)
oxytocin mechanism and indications
ripening of the cervix and contractions of the uterus during labour and delivery. It also plays a role in lactation during breastfeeding.
infusions of oxytocin indications
Induce labour
Progress labour
Improve the frequency and strength of uterine contractions
Prevent or treat postpartum haemorrhage
oxytocin AKA
brand name - syntocinon
atosiban mechanism
oxytocin receptor antagonist
atosiban indication
alternative to nifedipine for tocolysis in premature labour (when nifedipine is contraindicated).
ergometrine mechanism
stimulates smooth muscle contraction in uterus and blood vessles
ergometrine indications
delivery of the placenta and to reduce postpartum bleeding. It may be used during the third stage of labour (delivery of the placenta) and postpartum to prevent and treat postpartum haemorrhage. It is only used after delivery of the baby, not in the first or second stage.
ergometrine s/e
HTN
N+V
diarrhoea
angina
ergometrine c/i
eclampsia
HTN patients
syntometrine what and use
a combination drug containing oxytocin (Syntocinon) and ergometrine. It can be used for prevention or treatment of postpartum haemorrhage.
prostaglandins mechanism
stimulating contraction of uterine muscles
ripening cervix
prostaglandins example
dinoprostone-
Vaginal pessaries (Propess)
Vaginal tablets (Prostin tablets)
Vaginal gel (Prostin gel)
dinoprostone use
induction of labour
what drug is generally avoided in pregnancy
NSAIDS- inhibit prostaglandins
increasing BP
misoprostol mechanism
prostaglandin analogue
misoprostol uses
medical mx in miscarriage
used alongside mifepristone for abortions, and induction of labour after intrauterine fetal death.
mifepristone mechanism
anti-progestogen…blocks action of progesterone…ripening cervix and enhances effects of prostaglandins to stimulate uterine contraction
mifepristone uses
used alongside misoprostol for abortions, and induction of labour after intrauterine fetal death. It is not used during pregnancy with a healthy living fetus.
nifedipine mechanism
CCB - reduce smooth muscle contraction in blood vessels and uterus
nifedipine uses
Reduce blood pressure in hypertension and pre-eclampsia
Tocolysis in premature labour, where it suppresses uterine activity and delays the onset of labour
terbutaline mechanism
beta-2 agonist - acts on smooth muscle of uterus to suppress uterine contractions
terbutaline uses
tocolysis in uterine hyperstimulation, notably when the uterine contractions become excessive during induction of labour