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GOSH > Intrapartum > Flashcards

Intrapartum Flashcards

1
Q

Definitions of each stage of labour

A

1- Onset of regular painful contractions to Fill dilatation via effacement
2- Full dilatation to delivery
3- Infant delivery to placenta/membrane delivery

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2
Q

What is active vs latent stage 1 of labour?

A

Latent- up to 4cm dilation with irregular contractions/involuntary contractions
Active- 4-10cm dilation with regular contractions

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3
Q

What is active stage 2 of labour?

A

Passive- Full dilatation, expulsive contractions or active maternal effort

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4
Q

Average length of each stage of labour in a primiparous?

A

1- ~8 hours 0.5-1cm/hr
2- 1-2 hours… > 4 is abnormal
3- Up to 30 mins

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5
Q

Average length of each stage of labour in a multiparous?

A

1- ~5 hours 1-2cm/hr
2- Up to 1 hour
3- Up to 30 mins

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6
Q

During labour, which point has the highest risk of low oxygenation?

A

Stage 2, limit this stage of active pushing

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7
Q

How can you limit peritoneal damage during labour?

A

Pant and little pushes when baby is crowning

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8
Q

When is normal labour during pregnancy

A

37+ weeks (until 42)

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9
Q

How do you actively manage stage 3

A

Uterotonic drugs

Controlled cord traction whilst applying suprapubic pressure

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10
Q

Optimum position of baby for labour

A

Occipitoanterior

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11
Q

How do you assess the descent of the head into the pelvis

A

Assessing in stage 1 in reference to the ischial spines (Station 0)
+ if below
- if above

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12
Q

Describe how the baby is born

A

Head floating before engagement
Engagement- Flexion and descent
Further descent and internal rotation
Complete rotation and beginning extension
Complete extension as the head is delivered
Restitution (external rotation)
Delivery of anterior then posterior shoulder

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13
Q

What are the features of a false labour?

A

Last 4 weeks of pregnancy
Irregular contractions
No progressive cervical changes

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14
Q

Under what circumstances would you consider continuous CTG monitoring?

A 
Oxytocin induced labour
Meconium stained liquor 
Fresh Bleeding
Multiple pregnancy
IUGR
Abn Ausc 
Severe HTN >160/110
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15
Q

DR C BRAVADO

A

Determine Risk
Contractions (4-5/10mins)- Frequency and duration
Baseline rate- 110-160
Accelerations- 15BPM Rise for >15s
Variability- 5-25BPM
Decelerations- >15bpm drop for >15s, Early, Late, Variable (?>60bpm for >60s)
Overall Impression

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16
Q

When would you use a fetal scalp electrode?

A

Poor contact with abdominal transducer
High BMI
Twins
Abd scarring

CI: Praevia, BBV, Preterm, Bleeding disorders

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17
Q

What would you do after classifying a CTG as worrying?

A 
Left lateral position 
Fluids
Foetal scalp stimulation
Foetal blood sampling
?Delivery
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18
Q

When can you do a Foetal blood sample?

What do the results mean?

A

> 3cm dilated, delivery not imminent

PH inducates hypoxaemia
PH>7.25 NORMAL
PH 7.2-7.25 Repeat in 30 mins
PH<7.2 Deliver

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19
Q

Absolute CI to an Epidural

A

Anticoagulants
Local or systemic infection
Anaphylaxis to LA
Bleeding disorders

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20
Q

Relative CI to an epidural

A

Spinal surgery

Massive haemorrhage

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21
Q

Complications of an epidural

A 
Hypotension
Failure
Post-dural puncture headache
Low RR
Infection
LA toxicity
Damage
Haematoma (Look for leg weakness, need MRI)
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22
Q

Absolute CI to IoL

A

Non-cephalic lie
Placenta Praevia
Pelvic obstruction
Acute fetal compromise

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23
Q

Relative CI to IoL

A

Previous CS as VBAC risks scar dehiscence

Breech, Prematurity, High parity

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24
Q

Commonest reason to IoL

A

post maturity

Still birth rate significantly increases after 42 weeks so consider IoL at 41-42 weeks

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25
Q

What is PROM

A

Pre-labour Rupture of Membranes
Labour likely within 24 hours
If not then this is prolonged so offer IoL at 24 hours (Max wait time is 4 days)

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26
Q

What Bishops score would indicate labour is unlikely without induction

A

5 or less

>8 likely to have VD

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27
Q

What does the Bishops score consider?

A

Dilatation, Length, Station of presenting part, Consistency, Position

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28
Q

Stage one IoL

A

Ripening of the cervix with vaginal Prostaglandin E2 ideally a propess pessary

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29
Q

Stage 2 IoL

A

Amniotomy to artificially rupture membranes

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30
Q

Risks of an amniotomy

A

Amniotic fluid embolism

Cord prolapse

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31
Q

Stage 3 IoL

A

IV syntocinon to induce uterine contractions

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32
Q

Risks of Cervical ripening and Cervical dilatation during IoL

A

Hyperstimulation of the foetus
Therefore monitor on CTG
Give tocolytic and titrate IV syntocinon down if this occurs

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33
Q

Complications of IoL to explain to patient

A 
Cord prolapse 
Foetal distress
Failure- Operative delivery or C-section 
Uterine hypertonia and rupture
Amniotic fluid embolus
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34
Q

Managing cord prolapse

A

Tocolytics
Elevate
Knee to chest or left lateral position Immediate c-section and on all fours whilst waiting
Never push it back into uterus

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35
Q

What is the difference between augemtation and IoL

A

Augmentation is then the membranes have ruptured spontaneously
No RoM= IoL

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36
Q

What type of breech is highest risk?

A

Footling

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37
Q

RF for Breech presentation

A

Prematurity, Uterine malformation including fibroids, Praevia, Poly/Oligohydramnios, Foetal Abn

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38
Q

When would you consider an EVC for Breech presentation?

A

> 36 wks if nullips, >37 if multips

39
Q

What is ECV?

A

Manual procedure to turn baby.
Give tocolytic to relax uterus +/- Anti-D
CTG essential pre- and Post-
Success in 60%

40
Q

When is an ECV CI?

A

Active labour when the membranes have ruptured

41
Q

Risks of an ECV?

A

Cord entanglement, Foetal distress, Transient Brady, Pain, Failure

42
Q

How useful is C-section for Breech babies?

A

Vs VD: Decreased perinatal and early neonatal mortality especially if slow progress during VD

43
Q

What prophylaxis should be given in twin delivery?

A

Oxytocin/Ergometrine as increased PPH risk

Continuous CTG monitoring

44
Q

What 3 P’s influence labour

A

Power
Passenger- (position and size)
Passage- (Parity)

45
Q

How do you diagnose stage 1 delay

A

<2cm dilatation in 4 hours if Primi

46
Q

How can you help counteract stage 1 delay

A

Artificial rupture of membranes
Syntocinon infusion
C-section

47
Q

What must be the conditions be for assisted vaginal delivery to be done?

A

Fully dilated, Ruptured mems, Cephalic, engaged part not palpable abdominally

48
Q

Process of operative delivery

A

Consent- Analgesia- Ad contractions- Empty bladder- Know position- Ruptured mems

49
Q

Indications for operative delivery

A

Slow S2 progress
Exhaustion
Avoid raising ICP/BP
Fetal compromise

50
Q

Different methods of operative delivery

A 
Vacuum extraction/Ventouse delivery
Traction forceps (ONLY IF OA) curved to fit pelvis
Rotational forceps
51
Q

What does FORCEPS stand for?

A 
What you need for operative delivery...
Fully dilated
OA/OP
Ruptured mems
Cephalic
Engaged
Pain relief
Sphincter empty
52
Q

Complications of vacuum extraction

A

Cephalohaematoma, Retinal haemorrhage

53
Q

Complications of forceps delivery

A

Facial brusing and CN7 palsy

54
Q

Maternal risks of operative delivery

A 
Failure!
Inc blood loss
Post-partum pain
Perineal trauma Pelvic floor weakness 
Psychological sequela
55
Q

What does the colour of the liquor tell you about the pathology?

A 
Green/Yellow= Meconium
Pink= Full dilatation 
Red= Rupture
56
Q

Definition of fetal macrosomia

A

> 4kg

57
Q

What does shoulder dystocia increase the risk of?

A

Brachial plexus injury

PPH, Perineal tear, Hypoxia, C-spine injury, Intracranial haemorrhage, Death

58
Q

3 simple manoeuvres for shoulder dystocia

A

McRobert’s
Suprapubic pressure
Woodscrew (roate 180 degres) post-episiotomy

59
Q

What is McRobert’s Manoeuvre?

A

Flex and externally rotate hips to stretch symphysis and open pelvic outlet

60
Q

Advanced manoeuvres for shoulder dystocia

A

Rotate anterior shoulder
Deliver posterior arm
Break clavicle
Emergency C-section

61
Q

What are the risks of a LSCS

A 
ABCI
Adjacent organ damage 1/1000
Bleeding 
Clot 1/1000
Infection 1/20

+ Laceration to baby which is mild and rare
+Anaesthetic risks
+VBAC risks
+ May need extra procedures like hysterectomy, transfusion
+VTE risk
+? ICU admission

+ Increases praevia/Accreta risk in the future

62
Q

Who should you screen for pre-term labour?

A

Hx preterm delivery
Late miscarriage
Cervical treatment
Multiple pregnancy also increases your risk as does IUGR

63
Q

Key principles in managing preterm delivery

A

Has it reached threshold of viability- YES

  • Antenatal steroids 26-24+6 weeks
  • Nifedipine tocolysis
  • Teritary neonatal unit
  • ?Prophylactic MGSO4 and Benzyl penicillin

RoM= Infection likely so do not use tocolysis

64
Q

If poor history of preterm delivery what can be done?

A

Cervical stitch pre-conception

65
Q

Management of preterm delivery

A

Steroids- Takes 2-3 days for impact
Nifedipine if 26-33+6 IF NO INFECTION
Admit and inform neonatal team
-Prophylactic MGSO4 and Benzyl penicillin if delivery within 24 hours

66
Q

What is a Fibronectin assay

A

-ve= Unlikely to Labour

67
Q

What Cervical length would indicate that a ?preterm labour is unlikely to deliver

A

> 15mm

68
Q

What is a major Antepartum Haemorrhage

A

> 50ml blood loss >24weeks gestation

69
Q

Causes of antepartum haemorrhage

A

Uterine: Praevia, Abruption, Vasa praevia, Marginal bled,

Cervical: Cancer, Polyps, Ectropion

Show= Loss of mucus plug

70
Q

Signs of a placental abruption (Uterus and placenta prematurely separate)

A 
Vaginal bleed ?Dark red
Pain and contractions 
Woody tense very tender uterus 
shock and foetal distress
(in praevia foetal distress is rarer)
71
Q

Risk factors for placental abruption

A

Pre-eclampsia, PROM, IUGR, Multiple preg, polyhydramnios, Inc maternal age, smoker, drugs use, HTN, Hx abruption, Thrombophilias
Trauma

72
Q

When is a placental abruption most common

A

25 weeks

73
Q

What are the 4 stages of placenta praevia

A

1- Reaches lower segment but not OS
2- Reaches int.OS but does not cover it
3- Covers int OS before dilation but not when dilated
4- Completely covers OS

74
Q

RF for placenta Praevia

A

Multiparity, c-section, Multiplem pregnancy,

75
Q

When is placenta praevia most often picked up? What is best for detecting this?

A

20 weeks TV USS most accurate

76
Q

What happens to most praevias after 16 weeks?

A

Most rise
16-20=5%
0.5% at delivery

77
Q

What do you do if a placenta praevia is diagnosed in the 2nd trimester?

A

Repeat scan at 34 weeks

78
Q

Presentation of a APH B/C placenta praevia

A

Bright red vaginal bleeding +/- Hypovolaemic shock
NO PAIN
Foetus relatively unaffected unless massive
Always ask about anatomy scan and where the placenta was

79
Q

How do you manage a Placenta praevia?

A

Remain inpatient until delivery
?Steroids
If major then C-section at 39 weeks or before a significant bleed

80
Q

Can you perform an internal examination if there is a placenta praevia?

A

Avoid until location known as may precipitate bled

81
Q

Management of an APH

A

Maternal resus> Foetal wellbeing (CTG once mother stable)
Blood products needed
A to E, 2 large bore grey cannulae in ACF
Left lateral position, Tilt bed down
FBC, Clotting, Crossmatch 6U, G+S
Steroids as there is a risk of preterm labour
Anti-D and Kleihauer test

82
Q

What is the Kleihauer test

A

Blood test for the amount of fetal Hb transferred from a fetus to a mothers blood stream. Helps guide whether Anti-D is needed

83
Q

What cause of APH comes with a very big DIC risk?

A

Placental abruption

84
Q

What does a triad of Rom, Fetal brady and painless bleeding suggest

A

Vasa Praevia

85
Q

How do you define the 4 degrees of perineal tears

A

1- Skin only
2- Perineum injury involving muscle (Episiotomy)
3- Perineum, EAS involved
a- EAS<50% b- EAS>50% torn c- IAS involved
4- Above + Anal/rectal epithelium

86
Q

Basic principles of managing a perineal tear

A

Suture ASAP to reduce infection and bleeding
Lithotomy position and analgesia
Rectal exam both before and after!
Broad spec Abx esp if 3/4
Stool softener & 6 week review if 3/4

87
Q

How does uterine inversion present?

A

Vasovagal shock- Pale, clammy, hypotensive, Bradycardia, mass in the introitus, haemorrhage, clotting problems, renal dysfunction

88
Q

How can you manage uterine inversion?

A

O’Sullivan method- Reduce inversion by hydrostatic technique
Shock will correct itself when the uterus is replaced

89
Q

Different categories of C-Section

A

1) ASAP Life threatened
2) 1 hr Compromise
3) 24 hr No immediate risk
4) Elective

90
Q

What is augmentation of labour?l

A

Used if slow progress in Stage 1 (<1cm/hr dilation)
?Syntocinon and early amniotomy
‘stimulating the uterus during labour to increase the frequency, duration and strength of contractions.’

91
Q

Augmentation vs induction of labour

A

Induction of labour: stimulating the uterus to begin labour.
Augmentation of labour: stimulating the uterus during labour to increase the frequency, duration and strength of contractions.
DIFFERENT INDICATIONS BUT METHODS SAME

92
Q

What are Braxton Hicks contractions?

A

Front only, Irregular, Not getting closer/stronger, Stop with position change
NOT TRUE LABOUR

93
Q

CI to IoL

A

Praevia, Transverse lie, Cephalopelvic disproportion, Cervix <4 on Bishops

94
Q

When are Kielland’s forceps good?

A

If you need to rotate baby

GOSH (5 decks)

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