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Yr4 - O&G > Delivery > Flashcards

Delivery Flashcards

1
Q

Define IOL

A

Artificial Induction of labour

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2
Q

Indications for induction of labour

A 
Prolonged gestation
- 40+0 to 40+14 weeks gestation 
Premature rupture of membranes 
- > 37 weeks
Maternal health problems
- hypertension, pre-eclampsia, diabetes and obstetric complications 
Intrauterine foetal death
- mother physically well and membranes intact
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3
Q

Contraindications for IOL

A 
Absolute
- cephalopelvic disproportionation
- major placenta praevia
- vasa praevia
- cord prolapse
- transverse lie
- active primary genital herpes
- previos classical caesarean section
Relative
- breech presentation 
- triplet or higher
- two or more low transverse caesarean sections
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4
Q

Methods of induction of labour

A

Vaginal prostaglandins
- ripen cervix and contraction of smooth muscle
- either tablet, gel or pessary
- max one cycle in 24 hours
Amniotomy
- membranes artificially ruptured using amnihook
- releases prostaglandins
- only performed in cervix ripe
Membrane sweep
- offered at 40 and 41 weeks gestation to nulliparous women and 41 weeks for multiparous
- adjunct of IOL
- increases likelihood of spontaneous delivery reducing need for formal induction
- separate chorionic membrane from decidua -> releases prostaglandins

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5
Q

What is the Bishop score

A

Assessment of cervical ripeness

  • > 7 = cervix ripe/favourable - high chance of success of IOL
  • < 4 = labour unlikely to progress naturally and prostaglandin required
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6
Q

Features of the Bishop score

A 
Cervical dilation (cm)
< 1 = 0
1-2 = 1
2-4 = 2
> = 4
Cervical length (cm)
> 4 = 0
2-4 = 1
1-2 = 2
<1 = 3
Station - relative to ischial spine
-3 = 0
-2 = 1
-1/0 = 2
\+1/+2 = 3
Consistency
firm = 0
average = 1
soft = 2
Position
posterior = 0
mid/anterior = 1
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7
Q

CTG monitoring during labour

A

Prior to IOL reassuring foetal heart rate must be confirmed by cardiotocography
Intermittent auscultation
If oxytocin infusion started monitor using continuous CTG

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8
Q

Complications of induction of labour

A 
Failure of indcution (15%)
- offer further cycle of prostaglandins or caesarean section
Uterine hyperstimulation
- contractions last too long or are too frequent -> foetal distress
- managed with tocolytic agents such as terbutaline
Cord prolapse
- can occur at time of amniotomy
Infection
- risk is reduced by using pessary vs tablet/gel as fewer vaginal examinations required to check progress
Pain
- IOL more painful than spontaneous
- epidural often required
Increased rate of further intervention 
- 22% require emergency sections
- 15% require instrumental deliveries
Uterine rupture
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9
Q

Define caesarean section

A

Delivery of a baby through surgical incision in abdomen and uterus
Either elective or emergency

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10
Q

Classification of emergency caesarean

A

Category 1 - must be born within 30 minutes
- immediate threat to life of women or foetus
Category 2 - within 75 mins
- maternal or foetal compromise that is not immediately life-threatening
Category 3 - scheduled
- no maternal or foetal compromise
- booked elective LSCS but admitted earlier
Category 4 - elective
- time to suit women/staff

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11
Q

Indications for planned C-section

A

Breech presentation at term
Other malpresentations
Twin pregnancy
Maternal medical conditions - cardiomyopathy
Foetal compromise - early onset growth restriction
Transmissible disease - poorly controlled HIV
Primary genital herpes
Placenta praevia
Maternal diabetes - foetal weight over 4.5kg
Previous 3rd/4th degree perineal tear - where patient symptomatic
Maternal request

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12
Q

Indications for emergency C-section

A

Failure of labour to progress

Suspected/confirmed foetal compromise

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13
Q

When are elective c-sections planned

A

After 39 weeks

  • reduce respiratory distress in the neonate
  • if needed before administer corticosteriods to stimulate development of surfactant in foetal lungs
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14
Q

Pre-operative procedure for C-section

A 
FBC and G+S
- average blood loss 500-1000ml
H2-receptor antagonist
- Ranitidine
- risk of aspiration of gastric contents into lung
- due to pressure applied by gravid uterus on stomach
Risk score for VTE
- anti-thromboembolic stockings +/- LMWH
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15
Q

Anaesthesia procedure for C-section

A 
Usually regional 
- topped up epidural or spinal
Sometimes GA required
- contraindication to regional
- failure of regional
- concerns about foetal wellbeing and need to expedite delivery
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16
Q

Spinal vs epidural anaesthesia

A 
Spinal - directly into subarachnoid space
- 1 time using needle
- shorter length
Epidural - epidural space
- catheter so continuous
- longer length
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17
Q

Operative procedure for C-section

A

Woman positioned with left lateral tilt of 15 degrees - reduce risk of supine hypotension
Indwelling Foley’s catheter catheter inserted - drains bladder and reduce risk of bladder injury
Anaesthesia
Skin prepared with antiseptic solution and antibiotics
Skin incisions - Pfannenstiel
Sharp/blunt dissection through abdomen
- skin
- Camper’s fascia - superficial fatty layer of subcut tissues
- Scarpa’s fascia - deep membranous layer of subcut tissue
- Rectus sheath
- Rectus muscle
- Abdominal peritoneum
- Visceral peritoneum
- Uterine incision
- Baby delivered with fundal pressure from assistant
- Placenta delivered
Oxytocin 5iu given IV to aid delivery of placenta
Everything closed

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18
Q

Post-op management of C-section

A

Ob and lochia monitored
Early mobilisation, eating and drinking and removal of catheter
Aim to discharge 1 day later

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19
Q

Complications of C-section

A 
Immediate
- postpartum haemorrhage
- wound haematoma
- intra-abdominal haemorrhage
- bladder/bowel trauma
- neonatal
     - transient tachypnoea of the newborn
     - foetal lacerations
Intermediate
- infection
     - UTI
     - endometritis
     - resp
- VTE
Late
- urinary tract trauma (fistula)
- subfertility
- regret and other negative psychological sequelae
- rupture/dehiscence of scar at next labour (VBAC)
- placenta praevia/accrete
- caesarean scar ectopic pregnancy
20
Q

Define operative vaginal delivery

A

Use of an instrument to aid delivery of foetus

  • Ventouse or forceps - choice is operator dependent
  • if after 3 contractions and pulls no reasonable progress attempt abandoned
21
Q

Features of ventouse

A

Attaches to foetal head by vacuum
- electrical pump attached to a silastic cup - only suitable if foetus in occipital-anterior position
- hand-held disposable Kiwi - used for all positions
Cup applied to centre over flexion point on the foetal skull - traction applied during contractions

22
Q

Associations of ventouse delivery

A 
Lower success rate
Less maternal perineal injuries
Less pain
More cephalhaematoma
More subgaleal haematoma
More foetal retinal haemorrhage
23
Q

Features of forceps delivery

A

Double bladed instruments
- Rhodes, Neville-Barnes or Simpsons - used for OA positions
- Wrigley’s - used in C-section
- Kielland’s - used for rotational deliveries
Blades introduced into pelvis and applied to side of foetal head
- blades locked together
- gentle traction applied during uterine contractions following J shape of maternal pelvis

24
Q

Associations of forcep delivery

A

Higher rate of 3rd/4th degree tears
Less often used to rotate
Doesn’t require maternal effort

25
Q

Indications for operative vaginal delivery

A

Maternal
- inadequate progress
- nulliparous women - expect delivery in 2 hours
- multiparous women - expect delivery in 1 hour
- maternal exhaustion
- maternal medical conditions meaning active pushing or prolonged exertion should be limited
- intracranial pathologies
- maternal congenital heart diseases
- severe hypertension
Foetal
- suspected foetal compromise in second stage of labour - diagnosed by CTG monitoring or foetal blood sample
- clinical concerns
- significant antepartum haemorrhage

26
Q

Contraindications for operative vaginal delivery

A

Absolute
- unengaged foetal head in singleton pregnancies
- incompletely dilated cervix in singleton pregnancies
- true cephalo-pelvic disproportion
- breech or face presentation
- preterm gestation for ventouse < 34
- high likelihood of any foetal coagulation disorder for ventouse
Relative
- severe non-reassuring foetal status with station of head above level of pelvic floor
- delivery of second twin when head has not engaged or cervix reformed
- prolapse of umbilical cord with foetal compromise when cervix completely dilated and station is mid cavity

27
Q

Pre-requisites for instrumental delivery

A 
Fully dilated
Ruptured membranes
Cephalic presentation
Defined foetal position
Foetal head at least level of ischial spines and no more than 1/5 palpable per abdomen
Empty bladder
 Adequate pain relief
Adequate maternal pelvis
28
Q

Classification of operative vaginal deliveries

A 
Outlet
- foetal scalp visible with labia parted
- foetal skull reached pelvic floor
- foetal head on perineum
Low
- lowest presenting part is +2 or further below ischial spines
     - > 45 degrees - rotation needed
     - < 45 degrees - no rotation needed
Midline
- 1/5 palpable abdominally
- lowest part is above +2 but lower than ischial spines
     - > 45 degrees - rotation needed
     - < 45 degrees - no rotation needed
29
Q

Complications of operative vaginal delivery

A 
Foetal
- neonatal jaundice
- scalp lacerations
- cephalhaematoma
- subgaleal haematoma
- facial bruising
- facial nerve damage
- skull fractures
- retinal haemorrhage
Maternal
- vaginal tears - 3rd/4th degree
     - 1:100 in normal delivery 
     - 4:100 in ventouse
     - 10:100 in forceps
- VTE
- incontinence
- PPH
- shoulder dystocia
- infection
30
Q

Define PROM

A

Premature Rupture of Membranes

  • rupture of foetal membranes at least 1 hour prior to onset of labour at 37+ weeks gestation
  • occurs in 10-15%
  • associated with minimal risk to mother and foetus due to advanced gestation
31
Q

Define P-PROM

A

Pre-term Premature Rupture of Membranes

  • rupture of foetal membranes occurring before 37 weeks
  • complicates 2% of pregnancies - 40% of preterm deliveries
  • higher rates of foetal and maternal complications
32
Q

Pathophysiology of PROM/P-PROM

A

Foetal membranes weaken at term - apoptosis and collagen breakdown by enzymes
Earlier weakening of membranes
- earlier activation of normal physiological process - higher than normal levels of apoptotic markers and MMPs in amniotic fluid
- infection - inflammatory markers contribute to weakening
- gender predisposition

33
Q

Risk factors for PROM/P-PROM

A 
Smoking
 Previous PROM/pre-term delivery
Vaginal bleeding during pregnancy
Lower genital tract infection
Invasive procedures - amniocentesis
Polyhydramnios
Multiple pregnancy
Cervical insufficiency
34
Q

Clinical features of PROM/P-PROM

A

‘Broken waters’ - painless popping sensation followed by gush of watery fluid leaking from vagina or gradual leaking or change in colour/consistency of vaginal discharge
On speculum examination fluid draining from cervix and pooling in posterior vaginal fornix

35
Q

Differential diagnosis of PROM/P-PROM

A 
Urinary incontinence
Normal vaginal secretions of pregnancy
Increased sweat/moisture around perineum
Increased cervical discharge - infection
Vesicovaginal vaginal fistula
Loss of mucus plug
36
Q

Investigations for PROM/P-PROM

A

Maternal history
Positive examination findings
USS not routinely used unless unclear
High vaginal swab should be taken - may grow group B Streptococcus

37
Q

Management of PROM/P-PROM

A

Most will enter labour in 24-48 hours
If not
- < 34 weeks - aim for increased gestation till 34 weeks
- monitor for clinical chorioamnionitis and avoid sexual intercourse
- prophylactic erythromycin
- corticosteriods
- 34-36 weeks - IOL and delivery recommended
- monitor for clinical chorioamnionitis and avoid sexual intercourse
- prophylactic erythromycin
- corticosteriods
- clindamycin/penicillin during labour if GBS isolated
- > 36 weeks - IOL
- watch and wait for 24 hours or consider IOL and delivery

38
Q

Complications of PROM/P-PROM

A

Outcome of PROM generally correlates with gestational age
Greater latency period the lower the gestational age - increases risk of complications
- chorioamnionitis - inflammation of foetal membranes due to infection
- oligohydramnios - esp if less than 24 weeks increases risk of lung hypoplasia
- neonatal death - complications associated with prematurity, sepsis and pulmonary hypoplasia
- placental abruption
- umbilical cord prolapse

39
Q

Define VBAC

A

Vaginal birth after caesarean section

- planned vaginal birth after C-section is clinically safe for majority of women who have had one prior LSCS

40
Q

Risk factors for VBAC

A

Multiple pregnancy
Macrosomia
Maternal age > 40 years old - risk of uterine rupture

41
Q

Feature of VBAC

A

If successful shorter hospital stay and recovery
Risk of uterine rupture - 0.5%
5% risk of anal sphincter injury
Risk of maternal death - 4 in 100,000
If successful good chance of successful future VBACs
2-3% risk of transient resp difficulties for neonate
Risk of hypoxic ischaemic encephalopathy to neonate
Risk of stillbirth beyond 39 weeks whilst awaiting spontaneous labour

42
Q

Features of elective repeat caesarean section

A 
Longer recovery
Almost negates risk of uterine rupture
No risk of anal sphincter injury
Risk of maternal death - 13 in 100,000
Subsequent pregnancies likely to require C-section
4-5% risk of neonatal resp morbidity
< 0.01% risk of neonatal HIE
With each C-section delivery there is an increased risk of placental problems (accreta and praevia) and adhesion formation
43
Q

Define uterine rupture

A

Full-thickness disruption of the uterine muscle and overlying serosa
- foetus can be extruded from the uterus -> foetal hypoxia and larger internal maternal haemorrhage

44
Q

Risk factors for uterine rupture

A 
Previous C-section - esp classical incisions
Previous uterine surgery - myomectomy
Induction of labour
Obstruction of labour
Multiple pregnancy
Multiparity
45
Q

Management of VBAC delivery

A

Women should be in hospital setting with facilities for emergency caesarean and advanced neonatal resuscitation
Should be continuous CTG monitoring
Additional analgesic requirements may indicate uterine rupture
Cautious with augmentation - increased risk of uterine scar rupture
After 39 weeks an elective repeat section is recommended delivery method

46
Q

VBAC contraindications

A 
Absolute
- classical caesarean scar
- previous uterine rupture
- placenta praevia
Relative
- complex uterine scars
- > 2 lower segment C-sections

Yr4 - O&G (19 decks)

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