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Intrapartum and post partum care Flashcards

1
Q

What is the natural rate of twinning?

A

1:90

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2
Q

What is the incidence of monozygotic twins?

A

4:1000

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3
Q

What increases the incidence of dizygotic twins?

A 
Age
Parity
Weight
Height
Higher in some families
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4
Q

When would multiple pregnancy be suspected?

A

Large for date uterine size
Multiple fetal heart rates are detected
Multiple fetal parts are felt
Human chorionic gonadotrophin and and maternal serum alphafetoprotein elevated for gestational age
Pregnancy with assisted reproduction technique

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5
Q

How is multiple pregnancy diagnosed?

A

Ultrasound

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6
Q

What causes monozygotic pregnancy?

A

Fertiliation of a single egg which splits into two

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7
Q

What causes dizygotic pregnancy?

A

Ovulation of 2 egg cells which are both fertilised

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8
Q

What are monochorionic twins?

A

When twins within the uterus are within the same chorion, and share a placenta

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9
Q

Within how many days of fertilisation does cleavage of the egg result in dichorionic/diamniotic twins?

A

3 days

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10
Q

What are monochorionic/monoamniotic twins?

A

Twins sharing the same chorion/placenta and are within the same amniotic sac - much higher fetal mortality rate

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11
Q

Within how many days of fertilisation does cleavage of the egg result in monochorionic/diamniotic twins?

A

4-8 days

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12
Q

Within how many days of fertilisation does cleavage of the egg result in monochorionic/monoamniotic twins?

A

9-12 days

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13
Q

What happens if the fertilised egg is cleaved after 12 days?

A

Conjoined twins

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14
Q

What are the different types of placentation of monozygotic twins?

A

Dichorionic/diamniotic
Monochorionic/diamniotic
Monochorionic/monoamniotic

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15
Q

What are complications of multiple pregnancy?

A 
High perinatal mortality and morbidity
Abortion
Nausea and vomiting
Preterm labour
Intrauterine growth restriction
Preeclamptic toxaemia
Polyhydramnios
Congenital anomalies
Postpartum haemorrhage
Placental abruption/placenta previa
Discordant twin growth
Cord prolapse
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16
Q

What are cause of perinatal mortality and morbidity?

A 
Prematurity- Respiratory distress syndrome
Birth trauma
Cerebral haemorrhage
Birth asphyxia
Congenital anomalies
Still birth
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17
Q

What is twin-twin transfusion?

A

Occurs in monochorionic twins - 20-25% incidence

One fetus donates blood to the other due to a vascular anastamosis

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18
Q

What happens as a result of twin-twin transfusion?

A

Recipient fetus will have heart failure, polyhydramnios, and hydrops
Donor fetus will have intrauterine growth restriction and oligohydramnios

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19
Q

How is twin-twin transfusion managed?

A

Amnio-reduction of recipient twin
Intra-uterine blood transfusion for donor twin
Selective fetal reduction
Fetoscopic laser ablation of placental anastamosis

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20
Q

What is hydrops?

A

Large amounts of fluid builds up in fetal tissues and organs causing extreme swelling

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21
Q

What is amnioreduction?

A

Removal of amniotic fluid - used for polyhydramnios

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22
Q

What is antenatal management in multiple pregnancy?

A

Adequate nutrition - 300 additional calories per fetus
Prevent anaemia
More frequent antenatal visits
USS checks
Multifetal reduction for high order multiple gestation in first trimester
Preterm labour risk - serial cervical length assessment, steroids for fetal lung maturation

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23
Q

What ultrasound checks are done in multiple pregnancy?

A

Chorionicity at 9-10 weeks
Nuchal translucency at 12-13 weeks
Assessment of fetal growth and wellbeing every 3-4 weeks from 23 weeks onward

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24
Q

How is labour managed in multiple pregnancy?

A

Depends on presentation, gestational age, presence of fetal complications, experience of obstetrician
Usually if first fetus is cephalic normal delivery
If not cephalic - cesarean
If locked twins - cesarean
Active management of third stage of labour to prevent post partum haemorrhage

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25
What are locked twins?
One is cephalic | One is breech
26
What are the three main categories of pain relief in labour?
Drug free techniques Simple drug therapies Advanced drug therapies
27
What are non drug techniques for labour anagesia?
``` Use of a birthing ball Birthing pool TENS machines Hypnobirth Aromatherapy ```
28
What is a TENS machine?
Transcutaneous electrical nerve stimulation
29
What are simple drug therapies for labour pain relief?
Entonox | Diamorphine
30
What are advanced drug therapies for pain relief in labour?
Remifentanil PCA | Epidural
31
What is another name for entonox?
Gas and air
32
How long does entonox take to work?
30 seconds
33
What are advantages of entonox?
``` Widely used Safe Under the patient's control Acts quickly Wears off quickly Can be used with other therapies ```
34
What are negative effects of entonox?
``` Dizziness Dry mouth Nausea Helps you cope but does not take all pain away Take practice ```
35
How is diamorphine administered?
Injection at top of leg
36
What are benefits of diamorphine?
Works in 30 mins Lasts 4 hours Relaxes you Helps to cope with labour
37
What are negative effects of diamorphine?
Nausea/vomiting Drowsiness Bradypnoea Similar effects on baby - especially if received several times
38
What is remifentanil PCA?
Remifentanil patient controlled analgesia pump
39
How long does remifentanil take to reach full effect?
1 minute
40
How long does a patient have to wait before receiving another dose of remifentanil?
2 minutes since last dose
41
What are benefits of remifentanil PCA?
Patient is in control Works quickly and wears off quickly Strong pain relief
42
How is labour defined?
The process through which the fetus, placenta, and membranes are expelled via the birth canal
43
What is normal term for labour?
37-42 weeks
44
What are key physiological changes that happen to allow initiation of labour naturally?
Cervix softens Myometrial tone changes to allow for coordinated contractions Progesterone decreases Oxytocin and prostaglandins increase to allow labour to initiate
45
What is stage I labour?
Process of dilatation of cervix - complete when cervix is fully dilated - lasts 8 hours on average
46
What is the latent first stage of labour?
Period during which there are intermittent often irregular painful contractions - bring cervical effacement and dilatation up to 4 cm
47
What is established first stage of labour?
Regular painful contractions that that result in progressive effacement and cervical dilatation from 4cm
48
What rate is the cervix expected to dilate at?
0.5-1cm per hour
49
What is stage II of labour?
From full cervical dilatation to the birth of the baby
50
How long is stage II of labour expected to take in primagravida and multigravida patients?
Primagravida - 2 hours | Multigravida - 1 hour
51
What is stage III of labour?
Time from the birth of the baby to the expulsion of the placenta and membranes
52
What is active management of stage III of labour?
Routine use of uterotonic drugs Deffered clamping and cutting of cord Controlled cord traction after signs of seperation from placenta
53
What is physiological management of the third stage of labour?
No routine use of uterotonic drugs No clamping of cord until pulsation has stopped Delivery of the placenta by maternal effort
54
When should prolonged third stage of labour be diagnosed?
If stage III is not completed within: 30 minutes of birth with active management 60 minutes of birth with physiological management
55
What must be monitored throughout labour?
Blood pressure, pulse, temp, resp rate, oxygen sats, urine output and urinalysis Abdominal palpation - fetal lie, engagement Vaginal examination - cervical effacement and dilatation Monitoring of liquor once spontaneous or artifical rupture of membranes occurs (colour, smell, volume) Auscultation of fetal heart Palpation of uterine muscle contractions
56
How is fetal heart auscultated?
Doppler | Cardiotocograph
57
What is the target for frequency and length of uterine muscle contractions?
3-4 per 10 minutes | Lasting 40-60 seconds moderate to strong in strength
58
How is fetal position determined?
Relation to the occiput
59
What is the normal mechanism of labour? ie what steps does the fetus go through
``` Descent Flexion Internal rotation of the head Crowning and extension of the head Restitution Internal rotation of shoulders External rotation of head Lateral flexion ```
60
What score is used to assess the cervix for induction of labour?
Bishop's score
61
What are the 5 components of Bishop's score?
``` Dilation (cm) Length of cervix/effacement (cm) Position Consistency Station (cm) ```
62
How is dilation scored in Bishop's score?
``` 0cm = 0 1-2cm = 1 3-4cm = 2 5+cm = 3 ```
63
How is effacement of the cervix scored in bishops score?
``` 3cm = 0 2cm = 1 1cm = 2 0cm = 3 ```
64
How is position scored in Bishop's score?
``` Posterior = 0 Mid = 1 Anterior = 2 ```
65
How is consistency scored in Bishop's score?
``` Firm = 0 Medium = 1 Soft = 2 ```
66
How is station scored in Bishop's score?
-3cm = 0 -2cm = 1 -1, 0cm = 2 +1, +2cm = 3
67
What are absolute contraindications to induction of labour?
Abnormal lie Known pelvic obstruction such as tumour or large ovarian cyst Placenta praevia Fetal distress
68
What are relative contraindications for induction of labour?
Previous cesarean | Asthma
69
What is used to induce labour?
Prostaglandin analogues - per vagina | Oxytocin - IV
70
What are examples of prostaglandin analogues?
Misoprostol
71
What i augmentation of labour?
Increasing frequency, duration, and intensity of contractions in labour
72
What is used to augment labour?
IV oxytocin
73
When is augmentation of labour required?
When contractions reduce in frequency or strength in active labour
74
What medications are used in active management of stage III labour?
Syntometrine | Oxytocin
75
How is primary post partum haemorrhage defined?
>500ml blood loss from the genital tract witihn 24 hours of delivery
76
What medication is given for post partum haemorrhage?
Oxytocin Syntometrine Prostaglandins Tranexamic acid
77
Why are steroids used in preterm labour?
To improve neonatal outcomes
78
What gestation will steroids be given at if there is risk of preterm?
24-35 weeks
79
What are toclytic drugs?
Drugs which reduce contractions - used to try to delay labour
80
What medications are used for hypertension in pregnancy?
Labetolol Nifedipine Methyldopa Hydralazine
81
What is the first line antihypertensive in labour?
Labetolol
82
What medication is used in women with symptomatic preeclampsia or at risk of eclampsia?
IV magnesium sulphate
83
What are components of breast milk?
``` Water Protein Carbohydrates Fats Vitamins and mineral Transfer factors Anti-inflammatories Hormones Oligosaccharides Enzymes White cells Viral fragments Immunoglobulins ```
84
What are features of colostrum?
``` Packed with protective factors Concentrated nutrition Strong anti-inflammatory factors Stimulates gut growth Small volumes Laxative effect to clear meconium ```
85
What are babies at risk of without breastfeeding?
``` Gastroenteritis Resp infections Allergies Obesity Type I and II diabetes Sudden infant death syndrome Necrotising enterocolitis ```
86
How do babies develop a microbiome in their gut?
Exposure to maternal microbes in womb and in vagina during birth Skin to skin contact Breastfeeding Breast milk oligosaccharides develop microbiome
87
What are the 3 stages of lactogenesis?
Lactogenesis I - Breast development and colostrum production - 16 weeks gestation Lactogenesis II - Onset of copious milk secretion - 32 -96 hours after birth Lactogenesis III - maintenance of milk production
88
What causes mothering behaviours?
Oestrogen and progesterone levels drop | Prolactin and oxytocin levels rise in response to touch, smell, and sight of baby
89
What hormones are involved in breast milk?
Prolactin - production, responsive to touch and stimulation | Oxytocin - responsible for milk delivery - Acts on muscle cells in pulsatile action, levels higher when baby is near
90
What are general benefits of oxytocin?
Lowers blood pressure and improves sleep Reduce cortisol Reduce pain sensitivity Boost immune system
91
What are benefits to skin contact between mother and baby?
Triggers lactation and mothering hormones Regulates temperature, heart rate, and breathing in baby Colonises baby with microbes Stimulates feeding behaviour Reduce stress hormones in mother and baby

Reproductive system (26 decks)

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