Intrapartum and post partum care Flashcards
What is the natural rate of twinning?
1:90
What is the incidence of monozygotic twins?
4:1000
What increases the incidence of dizygotic twins?
Age Parity Weight Height Higher in some families
When would multiple pregnancy be suspected?
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
How is multiple pregnancy diagnosed?
Ultrasound
What causes monozygotic pregnancy?
Fertiliation of a single egg which splits into two
What causes dizygotic pregnancy?
Ovulation of 2 egg cells which are both fertilised
What are monochorionic twins?
When twins within the uterus are within the same chorion, and share a placenta
Within how many days of fertilisation does cleavage of the egg result in dichorionic/diamniotic twins?
3 days
What are monochorionic/monoamniotic twins?
Twins sharing the same chorion/placenta and are within the same amniotic sac - much higher fetal mortality rate
Within how many days of fertilisation does cleavage of the egg result in monochorionic/diamniotic twins?
4-8 days
Within how many days of fertilisation does cleavage of the egg result in monochorionic/monoamniotic twins?
9-12 days
What happens if the fertilised egg is cleaved after 12 days?
Conjoined twins
What are the different types of placentation of monozygotic twins?
Dichorionic/diamniotic
Monochorionic/diamniotic
Monochorionic/monoamniotic
What are complications of multiple pregnancy?
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
What are cause of perinatal mortality and morbidity?
Prematurity- Respiratory distress syndrome Birth trauma Cerebral haemorrhage Birth asphyxia Congenital anomalies Still birth
What is twin-twin transfusion?
Occurs in monochorionic twins - 20-25% incidence
One fetus donates blood to the other due to a vascular anastamosis
What happens as a result of twin-twin transfusion?
Recipient fetus will have heart failure, polyhydramnios, and hydrops
Donor fetus will have intrauterine growth restriction and oligohydramnios
How is twin-twin transfusion managed?
Amnio-reduction of recipient twin
Intra-uterine blood transfusion for donor twin
Selective fetal reduction
Fetoscopic laser ablation of placental anastamosis
What is hydrops?
Large amounts of fluid builds up in fetal tissues and organs causing extreme swelling
What is amnioreduction?
Removal of amniotic fluid - used for polyhydramnios
What is antenatal management in multiple pregnancy?
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
What ultrasound checks are done in multiple pregnancy?
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
How is labour managed in multiple pregnancy?
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
What are locked twins?
One is cephalic
One is breech
What are the three main categories of pain relief in labour?
Drug free techniques
Simple drug therapies
Advanced drug therapies
What are non drug techniques for labour anagesia?
Use of a birthing ball Birthing pool TENS machines Hypnobirth Aromatherapy
What is a TENS machine?
Transcutaneous electrical nerve stimulation
What are simple drug therapies for labour pain relief?
Entonox
Diamorphine
What are advanced drug therapies for pain relief in labour?
Remifentanil PCA
Epidural
What is another name for entonox?
Gas and air
How long does entonox take to work?
30 seconds
What are advantages of entonox?
Widely used Safe Under the patient's control Acts quickly Wears off quickly Can be used with other therapies
What are negative effects of entonox?
Dizziness Dry mouth Nausea Helps you cope but does not take all pain away Take practice
How is diamorphine administered?
Injection at top of leg
What are benefits of diamorphine?
Works in 30 mins
Lasts 4 hours
Relaxes you
Helps to cope with labour
What are negative effects of diamorphine?
Nausea/vomiting
Drowsiness
Bradypnoea
Similar effects on baby - especially if received several times
What is remifentanil PCA?
Remifentanil patient controlled analgesia pump
How long does remifentanil take to reach full effect?
1 minute
How long does a patient have to wait before receiving another dose of remifentanil?
2 minutes since last dose
What are benefits of remifentanil PCA?
Patient is in control
Works quickly and wears off quickly
Strong pain relief
How is labour defined?
The process through which the fetus, placenta, and membranes are expelled via the birth canal
What is normal term for labour?
37-42 weeks
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
What is stage I labour?
Process of dilatation of cervix - complete when cervix is fully dilated - lasts 8 hours on average
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
What is established first stage of labour?
Regular painful contractions that that result in progressive effacement and cervical dilatation from 4cm
What rate is the cervix expected to dilate at?
0.5-1cm per hour
What is stage II of labour?
From full cervical dilatation to the birth of the baby
How long is stage II of labour expected to take in primagravida and multigravida patients?
Primagravida - 2 hours
Multigravida - 1 hour
What is stage III of labour?
Time from the birth of the baby to the expulsion of the placenta and membranes
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
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
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
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
How is fetal heart auscultated?
Doppler
Cardiotocograph
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
How is fetal position determined?
Relation to the occiput
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
What score is used to assess the cervix for induction of labour?
Bishop’s score
What are the 5 components of Bishop’s score?
Dilation (cm) Length of cervix/effacement (cm) Position Consistency Station (cm)
How is dilation scored in Bishop’s score?
0cm = 0 1-2cm = 1 3-4cm = 2 5+cm = 3
How is effacement of the cervix scored in bishops score?
3cm = 0 2cm = 1 1cm = 2 0cm = 3
How is position scored in Bishop’s score?
Posterior = 0 Mid = 1 Anterior = 2
How is consistency scored in Bishop’s score?
Firm = 0 Medium = 1 Soft = 2
How is station scored in Bishop’s score?
-3cm = 0
-2cm = 1
-1, 0cm = 2
+1, +2cm = 3
What are absolute contraindications to induction of labour?
Abnormal lie
Known pelvic obstruction such as tumour or large ovarian cyst
Placenta praevia
Fetal distress
What are relative contraindications for induction of labour?
Previous cesarean
Asthma
What is used to induce labour?
Prostaglandin analogues - per vagina
Oxytocin - IV
What are examples of prostaglandin analogues?
Misoprostol
What i augmentation of labour?
Increasing frequency, duration, and intensity of contractions in labour
What is used to augment labour?
IV oxytocin
When is augmentation of labour required?
When contractions reduce in frequency or strength in active labour
What medications are used in active management of stage III labour?
Syntometrine
Oxytocin
How is primary post partum haemorrhage defined?
> 500ml blood loss from the genital tract witihn 24 hours of delivery
What medication is given for post partum haemorrhage?
Oxytocin
Syntometrine
Prostaglandins
Tranexamic acid
Why are steroids used in preterm labour?
To improve neonatal outcomes
What gestation will steroids be given at if there is risk of preterm?
24-35 weeks
What are toclytic drugs?
Drugs which reduce contractions - used to try to delay labour
What medications are used for hypertension in pregnancy?
Labetolol
Nifedipine
Methyldopa
Hydralazine
What is the first line antihypertensive in labour?
Labetolol
What medication is used in women with symptomatic preeclampsia or at risk of eclampsia?
IV magnesium sulphate
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
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
What are babies at risk of without breastfeeding?
Gastroenteritis Resp infections Allergies Obesity Type I and II diabetes Sudden infant death syndrome Necrotising enterocolitis
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
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
What causes mothering behaviours?
Oestrogen and progesterone levels drop
Prolactin and oxytocin levels rise in response to touch, smell, and sight of baby
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
What are general benefits of oxytocin?
Lowers blood pressure and improves sleep
Reduce cortisol
Reduce pain sensitivity
Boost immune system
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
