Intra-partum care + its complications Flashcards
What are the early preparatory phases of labour? (d-w before delivery)
- Uterine contractions without cervix dilatation - Braxton Hicks (usually shorter + less intense, in groin/lower abdo)
- Lightening + dropping feeling - head descends in pelvis
- Urinary frequency - bladder compression
- Less SOB - less pressure on diaphragm
- Bloody show - cervical mucus plug falls out as cervix starts to dilate
What happens in the first stage of labour?
Longest phase, shorter in multiparous women, is is from the onset of painful contractions with cervical changes up to full cervical dilatation
- Early latent phase - cervix effaces (thins), shortens and dilates up to 3cm
- Active phase - dilates up to 10cm (roughly 0.5cm/hr)
- Spontaneous rupture of membranes should occur at this point
What happens in the second stage of labour?
Lasts 2-3h, from full dilation to delivery of fetus
- Pelvic/passive phase without pushing
- Active phase - strong urge to push to help the uterine contractions deliver the fetus
- Baby goes through various movements to leave the birth canal
What happens in the third stage of labor?
Within 30 mins the placenta is delivered: uterus contracts to separate the placenta from the wall, contractions help push it + the fetal membranes out
What movements does the baby go through to exit the mother?
- Engagement: biparietal diameter of the head below the plane of the pelvic inlet
- Descent
- Flexion: chin to chest to make presenting part smaller
- Internal rotation as it reaches the pelvic floor
- Extension of head until delivered, crowning is where head is at the intraoitus and doesn’t go back in
- Expulsion: deliver the anterior shoulder, posterior shoulder then the rest comes out
What does labour depend on? (3Ps)
- Power - uterine contractions
- Passenger - lie, presentation, size, attitude
- Passage - pelvic shape, softening of ligaments
What are the clinical signs of labour?
- Regular painful contractions of increasing freq + duraion
- ROM (chorion + amnion)
- Bloody show (associated but not alone)
- Leopold manoeuvres (palpation of abdomen to establish fetal position)
- Cervix changes: effacement (0-100%, thinning shortening + drawing up of cervix), dilation (from 0-10cm)
How do you monitor the progress of labour?
- Rate of dilatation - VE on admission and every 3-4h in the first stage
- Descent - palpable portion of the head that is above the pelvic brim, in fifths. Engaged when no more than 1/5 is palpable abdominally + the vertex is at the level of the ischial spines
How do you monitor the fetus during labour?
- Partograms: a paper chart where you plot the FHR, cervical dilation, liquor, station, maternal HR/BP/temp. Its started at time 0 when they are admitted to labour ward
- Fetal heart rate: look at the bpm and the decelerations, every 15m in stage 1 and every 5m in stage 2
- CTG: done if high risk labour, continuously monitor the FHR and contractions
- Fetal ECG via the abdo/fetal scalp to see hypoxia
- Fetal blood sampling - acid base balance + lactate (if FHR abnormal)
What advice is given to women in the early stages of labour?
Empty bowels + bladder, shower
What methods of pain control are available for labour?
- Non-pharm: preparation, breathing + relaxation, TENS, water birth
- Pharm: nitrous oxide (50/50 mix, good for short term relief, inhale as contraction starts), narcotics (pethidine, morphine or remifentanil, risk of respiratory depression in neonate)
- Regional anaesthesia: epidural (can be done at any time, given into lumbar epidural space with local, spares motor fibres of the lower limb), spinal (for CS), pudendal nerve block (not really used nowadays), local for episiotomy repair
What are the complications of epidural anaesthetic?
- Reduces sensation so can reduce bearing down and lose ‘Ferguson reflex’
- Hypotension - so preload with Hartmann’s
- Dural puncture leading to CSF leak
- Post-dural headache
CI in infection, coagulopathy or hypovolaemia
In what circumstances would you monitor the fetus with CTG during labour?
Previous CS, PET, post-dates, prolonged ROM, IOL, DM, APH, IUGR, premature, oligohydramnios, abnormal Dopplers, multiple pregnancy, meconium-stained liquor, breech presentation
How do you interpret fetal heart rate?
- Normal rate 110-160 with some baseline variability
- Baseline variability reduces in sleep, infection and hypoxia
- Accelerations - abrupt increase >15bpm for >15s, a/w fetal movements, they’re normal
- Decelerations - reduction >15bpm for >15s, early decels are related to contractions and usually normal (head compression), late decels indicate placental insufficiency
What is preterm labour?
Labour from 24 to 36+6w, then there’s regular contractions + progressive cervical effacement + dilatation
What are the RF for preterm birth?
Low/high age, heavy work, smoking, drugs, APH, multiple pregnancy, uterine anomalies, cervical incompetence, PROM (often a/w infection), prev preterm, complicated pregnancies
How are preterm births managed?
- Prevention: Abx for bacteraemia, cervical cerclage (putting stitch in), reducing physical activity if at risk
- If >5cm + ROM have happened then allow labour progression
- If <5cm and membranes intact + <34w - give steroids + Adv bed rest
- If >34w usually deliver, gentle + controlled as skull is softer
- Tocolysis: drug management to suppress premature labour
What is PROM and PPROM and how do they present?
- PPROM-preterm PROM
- PROM - pre-labour ROM. Occurs at term, >4h between ROM and onset of contractions
- Occur because the membranes are weakened, by early activation of normal processes or infections. May lead to early labour (but may also not)
- CF: broken waters (painless pop then gush of fluid)/discharge changes/gradual fluid leakage, fluid pools in posterior fornix
- Don’t do DVE until in labour in case ROM hasn’t actually happened
Differentials for PROM
Incontinence, normal discharge, cervical discharge from infection, vesicovaginal fistula, loss of mucus plug
GBS is a common cause so take a HVS from all and sometimes sample the fluid to see if it is AF or not
How is PROM managed and what are the potential issues?
- Comps: chorioamnionitis (infection of membranes), oligohydramnios (causes lung hypoplasia if <24w), neonatal death from prematurity complications, abruption, cord prolapse
- Management: before 34w aim to increase gestation and give prophylactic Abx + steroids; 34-36w usually give steroids + IOL; >36w IOL if labour doesn’t start within 24-48h cos of infection risk
- If GBS is found give benpen or clarithromycin to mother during labour
- Avoid coitus + monitor for chorioamnionitis
Prolonged labour
Labor lasting >24h in a primip or >16h in a multip
- Inadequate progress indicated after >2h of active pushing in a primip or >1h in a multip
- If exceed this then need assisted delivery
Prolonged pregnancy
Pregnancy that lasts 42w or more
- RF: nulliparity, >40y, previous post-dates pregnancy, obesity, FH
- CF: oligohydramnios, static growth, reduced FM, meconium presence, dry/flaky skin as reduced vernix
- Comps: stillbirth, placental insufficiency, meconium aspiration, higher intervention risk in delivery, neonatal hypoglycaemia (as placental degradation depletes the glycogen)
- M: delivery before 42w is recommended by NICE + RCOG, encourage it with membrane sweeps, may need IOL, monitor fetus with CTG+US for amniotic fluid+distress, if signs of distress do EMCS
What are the indications for induction of labour?
- Prolonged pregnancy
- PET
- Placental insufficiency/IUGR - deliver before fetus compromised
- APH (usually abruption)
- Rhesus isoimmunisation
- Medical issues
- PROM
- IUD (if mother otherwise well)
- Bishop score <5
What are the contraindications to induction of labour?
- Absolute: cephalopelvic disproportion, major placenta praaevia, vasa praevia, cord prolapse, transverse lie, primary genital herpes
- Relative: breech presentation, triplets, 2+ previous low transverse CS
How is labour induced?
- Vaginal prostaglandin gel/pessary to ripen cervix
- Amniotomy - rupture membranes with amniohook which causes prostaglandin release
- Syntocinon infusion (artificial oxytocin) to increase strength + frequency of contractions
- Membrane sweep: an adjunct to help spontaneous IOL, aims to separate the chorionic membrane from the decidua for natural prostaglandin release
What monitoring is done for IOL?
- Bishop score: 7+ for IOL to work, if <4 unlikely but can try before CS
- CTG
What is the Bishop score?
Used to assess whether labour is likely to progress spontaneously (score >9) or not (score <5); need a score of 7 or more to indicate that IOL could work
Scores (what it should be for labour to progress): cervical position (anterior), cervical consistency (soft), cervical effacement (80%), cervical dilation (>5cm), fetal station (+1, +2)
What are the possible complications of IOL?
Failure, uterine hyperstimulation, cord prolapse (amniotomy), infection (pessary is best way to prevent), pain, higher risk of further intervention, uterine rupture (rare)
Management of spontaneous vaginal delivery?
- Short pushing spells with periods of panting to allow tissues to stretch
- With each contraction gently pull head downwards until anterior shoulder delivered, then pull anteriorly to deliver posterior shoulder + rest f baby
- 3rd stage active management with IM oxytocin, clamp + cut cord after 2mins, if signs of placental separation use controlled cord traction to deliver it
What is the Apgar score?
Assesses condition of neonate at 1 and 5 mins - looks at colour, tone, pulse, respiration and reflex irritability
Perineal injury
- 1st degree: vaginal + perineal skin, can leave if edges apposed
- 2nd degree: to posterior vaginal wall + perineal muscles. Episiotomy + suturing to minimise bleeding
- 3rd degree: involves anal sphincter. Repair under epidural/spinal/GA
- 4th degree: involves anorectal mucosa. As 3rd degree
RF for anal sphincter damage: macrosomia, 1st PV delivery, instrumental delivery, O-P position, prolonged 2nd stage, IOL, shoulder dystocia
What does malpresentation mean and what are the different forms?
That the baby is not in the normal vertex presentation (where head is flexed) so is harder to get through the birth canal
- Cord presentation: usually causes cord prolapse so deliver ASAP
- Face presentation
- Brow presentation: most unfavourable, need CS
- Breech: buttocks/feet first, at 28w 1/5 are breech but most revert by term. May be flexed (H+K flexed), extended (H flex, K extended-commonest) or footling (one/both hip extended so foot presenting part, rare but risky as cord prolapse higher chance)
- Oblique/transverse/unstable lie (e.g. transverse lie a/w cord prolapse and PROM) [longitudinal lie is normal]
- Malposition of head: usually occipitoanterior, malposition makes delivery harder
Causes and complications of breech presentation
- RF: uterine factors (multiparous/malformed/fibroids/placenta praevia) + fetal factors (premature, macrocosmic, polyhydramnios, twins)
- Comps: cord prolapse, fetal head entrapment, PROM, birth asphyxia, brain bleeds
How is breech presentation managed?
- <36w most turn spontaneously
- External cephalic version - risk of abruption + transient FHR abnormalities but works in 60%. Offer at 36w to nulliparous or 37w to multip. CI if CS needed, APH in past week, abnormal CTG, uterine abnormality, ruptured membranes, multiple pregnancy
- Vaginal breech birth - possible except in footling breech, keep hands off as can make the head extend and become trapped
- Caesarean section - adv lowest risk to baby for early neonatal morbidity
What are the types of instrumental delivery?
- Ventouse - suction cup attached to head to provide traction during contractions, less maternal injury but more cephalhaematoma/retinal haemorrhage risk to neonate. Must be 34w
- Forceps - put into pelvis around head, gentle traction during contractions, a/w more 3rd/4th degree tears
Requirements, indications and contraindications for instrumental delivery?
- Requirements: full dilation, ROM, cephalic presentation, head no more than 1/5 palpable, empty bladder, adequate maternal pelvis
- Indications: poor progress, exhaustion, medical comps in mother, fetal suspected 2nd stage compromise, significant APH, malposition
- Contraindications: non-engaged head, incompletely dilated, for ventouse if likely coagulation disorder
Complications of instrumental delivery
- Fetal: jaundice, scalp lacerations, cephalhaematoma, subageal haematoma, facial bruising, CN VII injury, skull#, retinal haemorrhage
- Maternal: perineal injury, VTE, incontinence, postpartum haemorrhage infection
Elective Caesarean section
Category 4 - planned, usually after 39w or planned for earlier if medical reason (give steroids)
Indications: term breech/other malpresentation, twins, medical conditions making labour dangerous, transmissible diseases, placenta praevia/abruption, previous shoulder dystocia, macrosomia, previous 3rd/4th degree perineal tear, previous CS (esp if >1), cord prolapse, maternal choice
Emergency Caesarean section
Cat 1 - immediate threat to mother/fetus life, do within 30 mins
Cat 2 - compromised M/F, do within 1h
Cat 3 - no compromise but needs early delivery
What are the benefits of C-sections
Less perineal trauma, less prolapses, reduce late stillbirth, less neonatal infection
What are the possible complications of C-sections
- Immediate: PPH, wound haematoma, intra-abdominal haemorrhage, neonate (transient tachypnoea of the newborn, lacerations)
- Intermediate: UTI, endometritis, resp infection, VTE
- Late: urinary tract fistula, sub fertility, psychological (like if cat 1), rupture of scar at future labours, higher risk of placenta praevia and accrete in future
What are the pros and cons of VBAC?
- Pros: shorter hosp stay than CS, less chance of TTN, if successful better chance of future VBAC, maternal preference
- Cons: 0.5% risk of uterine rupture, 5% risk of anal sphincter injury, 0.8% risk HIE, stillbirth risk whilst awaiting spontaneous labour
Would do more monitoring continuous CTG, do in a hospital with CS facilities, avoid induction with prostaglandins, caution with augmentation (syntocinon), if >39w then do ELCS
When is VBAC contraindicated?
- Classical Caesarean scar - a midline scar rather than the usual lower segment scar, usually for a v preterm infant/rapid delivery
- Previous uterine rupture
- Any other contraindication for SVD
What is primary postpartum haemorrhage?
Bleeding >500ml within 24h post-delivery
What are the causes of primary postpartum haemorrhage?
the 4 Ts:
- Tone - uterine atony [90%!], cos of obesity/uterine overdistension like polyhydramnios/IOL/prolonged labour/placental issues
- Trauma during delivery
- Tissue - retained placenta
- Thrombin - coagulopathies (vWD, ITP, HELLP, DIC), vascular issues (placental abruption, PET)
How are primary postpartum haemorrhages managed?
Prevention is by actively managing the 3rd stage with oxytocin
- ABC, 2 14G cannulae
- XM 4-6 units
- Give unto 2L of warmed crystalloid and O-neg until XM blood arrives, may need major haemorrhage protocol
- Atony - bimanual compression + drugs to stimulate contraction (syntocinon, ergometrine, carboprost, misoprostol)
- Trauma - repair
- Tissue - attempt to deliver manually or surgically, IV syntocinon, Abx
- Thrombin - blood products
What is secondary PPH?
Abnormal bleeding from 24h to 6w post-delivery
Causes and CF of secondary PPH?
- Causes: endometritis, retained fragments of placenta, abnormal involution of placental site, trophoblastic disease
- CF: PV bleeding but not as severe as primary (may just be spotting but can b a major bleed), endometritis causes fever/rigors/lower abdo pain/foul lochia
How are secondary PPH managed?
ABx, uterotonics like syntocinon etc, may need surgery
What are the main third stage complications?
- Primary PPH
- Secondary PPH
- Vaginal wall haematoma - superficial or deep
- Uterine inversion - rare, fundus inverts through cervix
- Perineal wound breakdown due to infection or haematoma
What is cord prolapse and why is it an issue?
When the cord drops below the presenting part and get compressed - rare but high mortality as the cord becomes occluded and/or is exposed to the cold causing vasospasm thus fetal hypoxia results
Who is more at risk of cord prolapse?
Breech presentation, unstable lie, artificial ROM, polyhydramnios, prematurity, twins, cephalopelvic disproportion, placenta praevia, long umbilical cord, high status
CF of cord prolapse
- Non-Reassuring FHR e.g. late decelerations
- Blood liquor
- Cord palpable or visible below the intraoitus
Management of cord prolapse
- DO NOT HANDLE CORD –> vasospasm
- Put woman in left lateral position, if cord already past the intraoitus keep it warm + moist and ask woman to go on all fours
- Tocolysis if delivery isn’t imminent
- Usually need EMCS
RF for shoulder dystocia
Previous baby with SD, macrosomia, DM, BMI >30, IOL, long 1st/2nd stage, secondary arrest of labour, oxytocin augmentation, instrumental delivery
CF and complications of shoulder dystocia
- CF: failure of restitution (doesn’t ‘turn to look to side’ to let shoulders out one at a time), hard to deliver head, turtle neck sign (fetal head emerges and retracts against the perineum)
- Comps: maternal perineal tears or PPH, fetal # (humerus, clavicle), brachial plexus injury, HIE from delay in delivery
How is shoulder dystocia managed?
- Stop pushing
- Avoid downward traction on head and avoid fundal pressure
- Consider episiotomy
- O+G do manoeuvres - McRoberts’ to flex + abduct maternal hips bringing thighs to abdomen which increases A-P angle of pelvis
- Active 3rd stage management cos of PPH risk
- Paeds r/v + debrief the mother
What is eclampsia and when does it usually occur?
When at least 1 seizure occurs in a pre-eclamptic woman, without any other cause. Occurs after 20w in women with RF for PET, but most commonly postpartum
What are the CF of eclampsia and what else may cause this presentation?
- CF: new onset tonic seizure, fetal distress if baby still inside, signs of end organ dysfunction (frontal headache, hyperreflexia, N_V, oedema, RUQ pain, visual disturbance, altered mental state)
- DDx: hypoglycaemia, pre-existing epilepsy, head trauma, stroke, meningitis, medications, SOL, aneurysm, sepsis
What are the fetal + maternal complications of eclampsia?
- Maternal: DIC, HELLP, AKI, ARDS, brain haemorrhage, CNS damage, death
- Fetal: IUGR, prematurity, RDS, IUD
How is eclampsia managed?
- Left lateral position
- Stop seizure with magnesium sulfate + control BP with IV labetalol + hydralazine
- Continuous CTG
- CS once mother stable
What is uterine rupture?
Full thickness rupture of the uterine muscle + serosa that may extend to the bladder or broad ligament, can result in uterine contents entering the peritoneal cavity
Usually happens during labour but can happen in T3
Who is more at risk of uterine rupture?
Previous CS/surgeries, IOL, syntocinon, obstructed labour, multiple pregnancy, multiparous
What are the features of uterine rupture?
Sudden severe abdo pain that persists between contractions, shoulder tip pain, PV bleeding, regression of the presenting part, palpable v parts, hypovolaemic shock, fetal distress
How is uterine rupture managed?
- ABCDE, protect airway, 15L O2 via nonrebreathe if hypoxic, 2 large bore cannulae, up to 2L warmed crystalloid + 1-2L warmed colloid, O neg, XM blood
- Check for other bleeding sources
- Surgery - CS and repair/hysterectomy
What is amniotic fluid embolism and what are the RF?
A rare and unpredictable complication where fetal cells/AF enter mother’s circulation and cause reactions
RF: higher maternal age + IOL most consistent RF but cause not fully understood, other stuff include multiple pregnancy, uterine rupture, eclampsia
M: supportive, if about to pass away do a CS so can then give the mother CPR, critical care, FFP for DIC
How does amniotic fluid embolism present?
Usually occurs during labour but can occur during a CS or immediately postpartum
CF: sudden onset hypoxia or respiratory arrest, hypotension, fetal distress, bronchospasms, tachycardia, seizures, shock, confusion, DIC, cardiac arrest
Which drugs are used for tocolysis?
- IV salbutamol - inhibits actin-myosin interaction to reduce uterine activity
- Prostaglandin synthesise inhibitors e.g. indomethacin - also an NSAID, reduces contractions by inhibiting prostaglandin synthesis but also a/w closure of the ductus arteriosus - oligohydramnios
- Magnesium sulphate - neuroprotective
- Slow calcium channel blockers e.g. nifedipine - oral
- Steroids to increase surfactant production to help alveoli expand
What is fetal attitude?
The fetal posture during labour
Syntocinon?
Synthetic oxytocin acts on myometrium to contract
- S/e: N+V, headache, hypotension from rapid infusion
- CI: hypertonic uterus, severe heart disease
Ergometrine
Multiple receptor sites for uterine compression
- S/e are HTN, nausea, bradycardia
- CI in HTN, PET
Carboprost
A prostaglandin E2 analogue for uterine compression
- SE bronchospasm, HTN, CVS collapse
- CI in asthma, severe heart/resp disease
Misoprostol
A prostaglandin E1 analogue for uterine compression
*Se diarrhoea
What are the risk factors for primary PPH?
Previous PPH, prolonged labour, pre-eclampsia, increased maternal age, polyhydramnios, EMCS, placenta praaevia or accreta, macrosomia, ritodrine (used for tocolysis)
How is PPH caused by uterine atony managed?
- IV syntocinon or IV ergometrine
- IM carboprost
- Surgical - intrauterine balloon tamponade, B-lynch suture, ligation of uterine arteries/IIAs
- If severe uncontrolled - hysterectomy
What does CTG record?
Pressure changes in the uterus
What is the normal FHR?
110-160/min
What abnormalities may be seen on CTG and what are the causes?
- Baseline bradycardia <100 - increased fetal vagal tone, beta blockers
- Baseline tachycardia >160 - maternal fever, chorioamnionitis, hypoxia, prematurity
- Loss of baseline variability <5 bpm - sleeping fetus (<40mins), drugs (BZD, opioids, methyldopa), prematurity, hypoxia/acidosis, tachycardia
- Early deceleration of HR with contractions - usually normal and indicates head temporarily compressed
- Late decelerations (ie lags with start of contracts and takes >30s after end of contraction to go) - fetal distress
- Variable decels (independent of contractions) - may mean cord compression
What antibiotics are given in PPROM?
10d erythromycin
Consider delivery at 34w - risks of neonate RDS vs maternal chorioamnionitis
What prophylaxis is offered for GBS?
- Maternal IV Abx during labour if have had a previous baby with early or late onset GBS
- IV Abx during labour for any woman in preterm labour, regardless of GBS status
- IV Abx if pyrexia during labour
What is the usual head position of the fetus?
Enters pelvic in occipito-lateral position and delivers in occipito-anterior position
What are the causes of decreased variability on CTG?
- Short <40 mins - usually foetus asleep
- > 40min more concerning: maternal drugs e.g. BZD/opioids, foetal acidosis (usually hypoxia), prematurity <28w, foetal tachycardia, congenital heart disease
