Intrapartum Flashcards
Definitions of each stage of labour
1- Onset of regular painful contractions to Fill dilatation via effacement
2- Full dilatation to delivery
3- Infant delivery to placenta/membrane delivery
What is active vs latent stage 1 of labour?
Latent- up to 4cm dilation with irregular contractions/involuntary contractions
Active- 4-10cm dilation with regular contractions
What is active stage 2 of labour?
Passive- Full dilatation, expulsive contractions or active maternal effort
Average length of each stage of labour in a primiparous?
1- ~8 hours 0.5-1cm/hr
2- 1-2 hours… > 4 is abnormal
3- Up to 30 mins
Average length of each stage of labour in a multiparous?
1- ~5 hours 1-2cm/hr
2- Up to 1 hour
3- Up to 30 mins
During labour, which point has the highest risk of low oxygenation?
Stage 2, limit this stage of active pushing
How can you limit peritoneal damage during labour?
Pant and little pushes when baby is crowning
When is normal labour during pregnancy
37+ weeks (until 42)
How do you actively manage stage 3
Uterotonic drugs
Controlled cord traction whilst applying suprapubic pressure
Optimum position of baby for labour
Occipitoanterior
How do you assess the descent of the head into the pelvis
Assessing in stage 1 in reference to the ischial spines (Station 0)
+ if below
- if above
Describe how the baby is born
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
What are the features of a false labour?
Last 4 weeks of pregnancy
Irregular contractions
No progressive cervical changes
Under what circumstances would you consider continuous CTG monitoring?
Oxytocin induced labour Meconium stained liquor Fresh Bleeding Multiple pregnancy IUGR Abn Ausc Severe HTN >160/110
DR C BRAVADO
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
When would you use a fetal scalp electrode?
Poor contact with abdominal transducer
High BMI
Twins
Abd scarring
CI: Praevia, BBV, Preterm, Bleeding disorders
What would you do after classifying a CTG as worrying?
Left lateral position Fluids Foetal scalp stimulation Foetal blood sampling ?Delivery
When can you do a Foetal blood sample?
What do the results mean?
> 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
Absolute CI to an Epidural
Anticoagulants
Local or systemic infection
Anaphylaxis to LA
Bleeding disorders
Relative CI to an epidural
Spinal surgery
Massive haemorrhage
Complications of an epidural
Hypotension Failure Post-dural puncture headache Low RR Infection LA toxicity Damage Haematoma (Look for leg weakness, need MRI)
Absolute CI to IoL
Non-cephalic lie
Placenta Praevia
Pelvic obstruction
Acute fetal compromise
Relative CI to IoL
Previous CS as VBAC risks scar dehiscence
Breech, Prematurity, High parity
Commonest reason to IoL
post maturity
Still birth rate significantly increases after 42 weeks so consider IoL at 41-42 weeks
What is PROM
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)
What Bishops score would indicate labour is unlikely without induction
5 or less
>8 likely to have VD
What does the Bishops score consider?
Dilatation, Length, Station of presenting part, Consistency, Position
Stage one IoL
Ripening of the cervix with vaginal Prostaglandin E2 ideally a propess pessary
Stage 2 IoL
Amniotomy to artificially rupture membranes
Risks of an amniotomy
Amniotic fluid embolism
Cord prolapse
Stage 3 IoL
IV syntocinon to induce uterine contractions
Risks of Cervical ripening and Cervical dilatation during IoL
Hyperstimulation of the foetus
Therefore monitor on CTG
Give tocolytic and titrate IV syntocinon down if this occurs
Complications of IoL to explain to patient
Cord prolapse Foetal distress Failure- Operative delivery or C-section Uterine hypertonia and rupture Amniotic fluid embolus
Managing cord prolapse
Tocolytics
Elevate
Knee to chest or left lateral position Immediate c-section and on all fours whilst waiting
Never push it back into uterus
What is the difference between augemtation and IoL
Augmentation is then the membranes have ruptured spontaneously
No RoM= IoL
What type of breech is highest risk?
Footling
RF for Breech presentation
Prematurity, Uterine malformation including fibroids, Praevia, Poly/Oligohydramnios, Foetal Abn
When would you consider an EVC for Breech presentation?
> 36 wks if nullips, >37 if multips
What is ECV?
Manual procedure to turn baby.
Give tocolytic to relax uterus +/- Anti-D
CTG essential pre- and Post-
Success in 60%
When is an ECV CI?
Active labour when the membranes have ruptured
Risks of an ECV?
Cord entanglement, Foetal distress, Transient Brady, Pain, Failure
How useful is C-section for Breech babies?
Vs VD: Decreased perinatal and early neonatal mortality especially if slow progress during VD
What prophylaxis should be given in twin delivery?
Oxytocin/Ergometrine as increased PPH risk
Continuous CTG monitoring
What 3 P’s influence labour
Power
Passenger- (position and size)
Passage- (Parity)
How do you diagnose stage 1 delay
<2cm dilatation in 4 hours if Primi
How can you help counteract stage 1 delay
Artificial rupture of membranes
Syntocinon infusion
C-section
What must be the conditions be for assisted vaginal delivery to be done?
Fully dilated, Ruptured mems, Cephalic, engaged part not palpable abdominally
Process of operative delivery
Consent- Analgesia- Ad contractions- Empty bladder- Know position- Ruptured mems
Indications for operative delivery
Slow S2 progress
Exhaustion
Avoid raising ICP/BP
Fetal compromise
Different methods of operative delivery
Vacuum extraction/Ventouse delivery Traction forceps (ONLY IF OA) curved to fit pelvis Rotational forceps
What does FORCEPS stand for?
What you need for operative delivery... Fully dilated OA/OP Ruptured mems Cephalic Engaged Pain relief Sphincter empty
Complications of vacuum extraction
Cephalohaematoma, Retinal haemorrhage
Complications of forceps delivery
Facial brusing and CN7 palsy
Maternal risks of operative delivery
Failure! Inc blood loss Post-partum pain Perineal trauma Pelvic floor weakness Psychological sequela
What does the colour of the liquor tell you about the pathology?
Green/Yellow= Meconium Pink= Full dilatation Red= Rupture
Definition of fetal macrosomia
> 4kg
What does shoulder dystocia increase the risk of?
Brachial plexus injury
PPH, Perineal tear, Hypoxia, C-spine injury, Intracranial haemorrhage, Death
3 simple manoeuvres for shoulder dystocia
McRobert’s
Suprapubic pressure
Woodscrew (roate 180 degres) post-episiotomy
What is McRobert’s Manoeuvre?
Flex and externally rotate hips to stretch symphysis and open pelvic outlet
Advanced manoeuvres for shoulder dystocia
Rotate anterior shoulder
Deliver posterior arm
Break clavicle
Emergency C-section
What are the risks of a LSCS
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
Who should you screen for pre-term labour?
Hx preterm delivery
Late miscarriage
Cervical treatment
Multiple pregnancy also increases your risk as does IUGR
Key principles in managing preterm delivery
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
If poor history of preterm delivery what can be done?
Cervical stitch pre-conception
Management of preterm delivery
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
What is a Fibronectin assay
-ve= Unlikely to Labour
What Cervical length would indicate that a ?preterm labour is unlikely to deliver
> 15mm
What is a major Antepartum Haemorrhage
> 50ml blood loss >24weeks gestation
Causes of antepartum haemorrhage
Uterine: Praevia, Abruption, Vasa praevia, Marginal bled,
Cervical: Cancer, Polyps, Ectropion
Show= Loss of mucus plug
Signs of a placental abruption (Uterus and placenta prematurely separate)
Vaginal bleed ?Dark red Pain and contractions Woody tense very tender uterus shock and foetal distress (in praevia foetal distress is rarer)
Risk factors for placental abruption
Pre-eclampsia, PROM, IUGR, Multiple preg, polyhydramnios, Inc maternal age, smoker, drugs use, HTN, Hx abruption, Thrombophilias
Trauma
When is a placental abruption most common
25 weeks
What are the 4 stages of placenta praevia
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
RF for placenta Praevia
Multiparity, c-section, Multiplem pregnancy,
When is placenta praevia most often picked up? What is best for detecting this?
20 weeks TV USS most accurate
What happens to most praevias after 16 weeks?
Most rise
16-20=5%
0.5% at delivery
What do you do if a placenta praevia is diagnosed in the 2nd trimester?
Repeat scan at 34 weeks
Presentation of a APH B/C placenta praevia
Bright red vaginal bleeding +/- Hypovolaemic shock
NO PAIN
Foetus relatively unaffected unless massive
Always ask about anatomy scan and where the placenta was
How do you manage a Placenta praevia?
Remain inpatient until delivery
?Steroids
If major then C-section at 39 weeks or before a significant bleed
Can you perform an internal examination if there is a placenta praevia?
Avoid until location known as may precipitate bled
Management of an APH
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
What is the Kleihauer test
Blood test for the amount of fetal Hb transferred from a fetus to a mothers blood stream. Helps guide whether Anti-D is needed
What cause of APH comes with a very big DIC risk?
Placental abruption
What does a triad of Rom, Fetal brady and painless bleeding suggest
Vasa Praevia
How do you define the 4 degrees of perineal tears
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
Basic principles of managing a perineal tear
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
How does uterine inversion present?
Vasovagal shock- Pale, clammy, hypotensive, Bradycardia, mass in the introitus, haemorrhage, clotting problems, renal dysfunction
How can you manage uterine inversion?
O’Sullivan method- Reduce inversion by hydrostatic technique
Shock will correct itself when the uterus is replaced
Different categories of C-Section
1) ASAP Life threatened
2) 1 hr Compromise
3) 24 hr No immediate risk
4) Elective
What is augmentation of labour?l
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.’
Augmentation vs induction of labour
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
What are Braxton Hicks contractions?
Front only, Irregular, Not getting closer/stronger, Stop with position change
NOT TRUE LABOUR
CI to IoL
Praevia, Transverse lie, Cephalopelvic disproportion, Cervix <4 on Bishops
When are Kielland’s forceps good?
If you need to rotate baby
