Intrapartum Care Flashcards
What is placenta accreta?
Placenta implants deeper, through and past the endometrium, making it difficult to separate the placenta after delivery of the baby
Management of placenta accreta
Hysterectomy with the placenta remaining in the uterus (recommended)
Uterus preserving surgery, with resection of part of the myometrium along with the placenta
Expectant management, leaving the placenta in place to be reabsorbed over time
Outline the 3 stages of labour
Stage 1 - onset of labour (true contractions) until 10cm cervical dilation
Stage 2 - 10cm cervical dilation until delivery of baby
Stage 3 - delivery of baby until delivery of placenta
What happens during the first stage of labour?
Cervical dilation and effacement (thinning)
“Show” - mucus plug falls out
What are the 3 phases of the first stage?
Latent phase - from 0 to 3cm dilation of the cervix, progresses at around 0.5cm per hour (irregular contractions)
Active phase - from 3cm to 7cm dilation of the cervix, progresses at around 1cm per hour (regular contractions)
Transition phase - from 7cm to 10cm dilation of the cervix, progresses at around 1cm per hour (strong and regular contractions)
What are Braxton-Hicks contractions?
Occasional irregular contractions of the uterus
2nd and 3rd trimester
Do not indicate onset of labour
Signs of onset of labour
Show (mucus plug from the cervix)
Rupture of membranes
Regular, painful contractions
Dilating cervix on examination
Prophylaxis of preterm labour
Vaginal progesterone
Cervical cerclage
What is preterm prelabour rupture of membranes?
Amniotic sac ruptures, releasing amniotic fluid, before the onset of labour and before 37 weeks
Diagnosis of preterm prelabour rupture of membranes
Speculum exam reveals pooling of amniotic fluid in vagina
Management of preterm prelabour rupture of membranes
Prophylactic antibiotics to prevent development of chorioamnionitis (erythromycin 250mg 4x daily for ten days, or until labour is established)
Induction of labour may be offered from 34 weeks
What is preterm labour with intact membranes?
Regular painful contraction and cervical dilatation, without rupture of the amniotic sac
What is tocolysis?
Medications to stop uterine contractions
Nifedipine (CCB) first line
Atosiban (oxytocin receptor antagonist) is alternative
Can be used between 24 and 33+6 weeks gestation in preterm labour to delay delivery and buy time for further foetal development, administration of maternal steroids or transfer to a more specialist unit (e.g. with a neonatal ICU)
Short term measure (i.e. less than 48 hours)
When is induction indicated?
41-42 weeks gestation
Prelabour rupture of membranes
Foetal growth restriction
Pre-eclampsia
Obstetric cholestasis
Existing diabetes
Intrauterine fetal death
What is the Bishop score?
Scoring system used to determine whether to induce labour
Five things are assessed and given a score based on different criteria:
Fetal station (scored 0 – 3) Cervical position (scored 0 – 2) Cervical dilatation (scored 0 – 3) Cervical effacement (scored 0 – 3) Cervical consistency (scored 0 – 2)
Score of 8 or more predicts successful induction
Below 8 may require cervical ripening
What are the options for inducing labour?
Membrane sweep
Vaginal prostaglandin E2
Cervical ripening balloon
Artificial rupture of membranes
Complication of vaginal prostaglandins used for induction of labour
Uterine hyperstimulation
Contraction of uterus is prolonged and frequent, causing foetal distress and compromise
Indications for CTG
Sepsis
Maternal tachycardia (>120)
Significant meconium
Pre-eclampsia (particularly blood pressure >160/110)
Fresh antepartum haemorrhage
Delay in labour
Use of oxytocin
Disproportionate maternal pain
Key features on CTG
Contractions – the number of uterine contractions per 10 minutes
Baseline rate – the baseline foetal heart rate
Variability – how the foetal heart rate varies up and down around the baseline
Accelerations – periods where the foetal heart rate spikes
Decelerations – periods where the foetal heart rate drops
How to assess features of a CTG?
DR C BRaVADO
DR – Define Risk (define the risk based on the individual woman and pregnancy before assessing the CTG)
C – Contractions
BRa – Baseline Rate
V – Variability
A – Accelerations
D – Decelerations
O – Overall impression (given an overall impression of the
CTG and clinical picture)
Oxytocin use in labour
Induce labour
Progress labour
Improve the frequency and strength of uterine contractions
Prevent or treat postpartum haemorrhage
Ergometrine use in labour
Stimulates smooth muscle contraction in uterus and blood vessels
Used in THIRD stage and POSTPARTUM
Prevent and treat PPH
Prostaglandin use in labour
Prostaglandin E2 (dinoprostone)
Used for induction of labour
Terbutaline use in labour
Beta-2 agonist
Stimulates beta-2 adrenergic receptors
Acts on smooth muscle of uterus to suppress uterine contractions
Used for tocolysis in uterine hyperstimulation, notably when the uterine contractions become excessive during induction of labour
Nifedipine use in labour
Calcium channel blocker
Reduces smooth muscle contraction in blood vessels and the uterus
Reduces BP in hypertension and pre-eclampsia
Tocolysis in premature labour, where it suppresses uterine activity and delays the onset of labour
Carboprost use in labour
Synthetic prostaglandin analogue (binds to prostaglandin receptors)
Stimulates uterine contraction
Given as a deep IM injection in PPH
CONTRAINDICATED IN ASTHMA
Tranexamic acid use in labour
Anti-fibrinolytic medication that reduces bleeding
Prevention and treatment of PPH
How is progress in labour influenced?
3 Ps
Power (uterine contractions)
Passenger (size, presentation and position of the baby)
Passage (the shape and size of the pelvis and soft tissues)
What is delay in the first stage of labour considered?
EITHER
Less than 2cm of cervical dilatation in 4 hours
Slowing of progress in a multiparous women
What is delay in the second stage of labour?
Active second stage (pushing) lasts over:
2 hours in a nulliparous woman
1 hour in a multiparous woman
Possible interventions during a delayed second stage
Changing positions
Encouragement
Analgesia
Oxytocin
Episiotomy
Instrumental delivery
Caesarean section
What is delay in the third stage of labour?
More than 30 minutes with active management
More than 60 minutes with physiological management
Simple analgesia in labour
Paracetamol is frequently used in early labour
Codeine may be added for additional effect
Avoid NSAIDs
Gas and air use in labour
Mixture of 50% nitrous oxide and 50% oxygen
Used during contractions for short term pain relief
Can cause lightheadedness, nausea or sleepiness
IM pethidine or diamorphine use in labour
Opioid medications, usually given by IM injection
May help with anxiety and distress
May cause drowsiness or nausea in mother
Can cause respiratory depression in neonate if given too close to birth
Epidural use in labour
Epidural space in the lower back
Outside the dura mater, separate from the spinal cord and CSF
Adverse effects of epidural
Headache after insertion
Hypotension
Motor weakness in the legs
Nerve damage
Prolonged second stage
Increased probability of instrumental delivery
What is umbilical cord prolapse?
Umbilical cord descends below presenting part of the foetus and through the cervix into the vagina, after rupture of the foetal membranes
Resulting in foetal hypoxia
Management of cord prolapse
Emergency Caesarean section
While waiting, mother in left lateral position + tocolytic medication
What is shoulder dystocia?
Anterior shoulder of baby becomes stuck behind pubic symphysis of the pelvis, after the head has been delivered
Obstetric emergency
Presentation of shoulder dystocia
Difficulty delivering face and head
Obstruction in delivering the shoulders after delivery of the head
May be failure of restitution, where head remains face downwards (occipito-anterior) and does not turn sideways as expected after delivery of the head
Turtle-neck sign - head is delivered but then retracts back into the vagina
Management of shoulder dystocia
Get help
Episiotomy
McRoberts manoeuvre
Pressure to anterior shoulder
Rubins manoeuvre
Wood’s crew manoeuvre
Zavanelli manoeuvre
Shoulder dystocia risk factors
Macrosomia
Secondary to GDM
Complications of shoulder dystocia
Foetal hypoxia (and subsequent cerebral palsy)
Brachial plexus injury and Erb’s palsy
Perineal tears
Postpartum haemorrhage
Indications for instrumental delivery
Failure to progress
Foetal distress
Maternal exhaustion
Control of the head in various fetal positions
What can increase risk of requiring an instrumental delivery?
Epidural
Risks to the mother in instrumental delivery
Postpartum haemorrhage
Episiotomy
Perineal tears
Injury to the anal sphincter
Incontinence of the bladder or bowel
Nerve injury (obturator or femoral nerve)
Key risks to baby with instrumental delivery
Cephalohaematoma with ventouse
Facial nerve palsy with forceps
What is a ventouse delivery?
Suction cup on cord
Main complication is cephalohaematoma - collection of blood between skull and periosteum
Nerve injuries in instrumental delivery
Rare
Usually resolves over 6-8 weeks
Main nerves affected: femoral and obturator
When do perineal tears occur?
External vaginal opening is too narrow to accommodate the baby
Who are perineal tears most common in?
First births (nulliparity)
Large babies (over 4kg)
Shoulder dystocia
Asian ethnicity
Occipito-posterior position
Instrumental deliveries
Outline the varying degrees of perineal tear
First-degree – injury limited to the frenulum of the labia minora (where they meet posteriorly) and superficial skin
Second-degree – including the perineal muscles, but not affecting the anal sphincter
Third-degree – including the anal sphincter, but not affecting the rectal mucosa
Fourth-degree – including the rectal mucosa
Management of perineal tears
First-degree usually do not require sutures
Third- and fourth-degree likely needs theatre
Broad-spectrum antibiotics to reduce the risk of infection
Laxatives to reduce the risk of constipation and wound dehiscence
Physiotherapy to reduce the risk and severity of incontinence
Follow-up to monitor for longstanding complications
Reducing risk of perineal tears
Episiotomy
Perineal massage
What is “active management” of the third stage?
Midwife or doctor assists in delivering of the placenta
IM oxytocin (10U) after delivery of baby
Careful traction to the umbilical cord to guide the placenta out
PPH blood loss volumes
500ml after a vaginal delivery
1000ml after a caesarean section
Minor vs major PPH
Minor PPH – under 1000ml blood loss
Major PPH – over 1000ml blood loss
Causes of postpartum haemorrhage
Tone (uterine atony – the most common cause)
Trauma (e.g. perineal tear)
Tissue (retained placenta)
Thrombin (bleeding disorder)
PPH preventative measures
Treating anaemia during the antenatal period
Giving birth with an empty bladder (a full bladder reduces uterine contraction)
Active management of the third stage (with intramuscular oxytocin in the third stage)
IV tranexamic acid can be used during caesarean section (in the third stage) in higher-risk patients
Management of PPH
Resuscitation with an ABCDE approach
Lie the woman flat, keep her warm and communicate with her and the partner
Insert two large-bore cannulas
Bloods for FBC, U&E and clotting screen
Group and save + cross match 4 units
Warmed IV fluid and blood resuscitation as required
Oxygen (regardless of saturations)
FFP is used where clotting abnormalities or after 4 units of blood transfusion
Mechanical treatment of PPH
Rubbing uterus through abdomen to stimulate a uterine contraction
Catheterisation (bladder distention prevents uterus contractions)
Medical treatment of PPH
Oxytocin (slow injection followed by continuous infusion)
Ergometrine (IV or IM) stimulates smooth muscle contraction (contraindicated in hypertension)
Carboprost (IM) prostaglandin analogue and stimulates uterine contraction (caution in asthma)
Misoprostol (sublingual) prostaglandin analogue and stimulates uterine contraction
TXA (IV) reduces bleeding
Surgical treatment of PPH
Intrauterine balloon tamponade – inserting an inflatable balloon into the uterus to press against the bleeding
B-Lynch suture – putting a suture around the uterus to compress it
Uterine artery ligation – ligation of one or more of the arteries supplying the uterus to reduce the blood flow
Hysterectomy is the “last resort” but will stop the bleeding and may save the woman’s life
Indications for elective caesarean
Previous caesarean
Symptomatic after a previous significant perineal tear
Placenta praevia
Vasa praevia
Breech presentation
Multiple pregnancy
Uncontrolled HIV infection
Cervical cancer
Categories of emergency caesarean section
Category 1: Immediate threat to the life of mother or baby (decision to delivery time 30 minutes)
Category 2: No imminent threat to life, but caesarean is required urgently due to compromise of the mother or baby (decision to delivery time 75 minutes)
Category 3: Delivery is required, but mother and baby are stable
Category 4: Elective
Measures to reduce risk during caesarean
H2 receptor antagonists (e.g. ranitidine) or proton pump inhibitors (e.g. omeprazole) before the procedure
Prophylactic antibiotics during the procedure to reduce the risk of infection
Oxytocin during the procedure to reduce the risk of postpartum haemorrhage
VTE prophylaxis with low molecular weight heparin
Two key causes of maternal sepsis
Chorioamnionitis
UTIs
What is amniotic fluid embolus?
Rare condition where amniotic fluid passes into mother’s blood
Usually occurs around labour and delivery
Contains foetal tissue, causing an immune reaction to the mother
Presentation of amniotic fluid embolus
Similar to sepsis, PE or anaphylaxis, with acute onset of symptoms of:
Shortness of breath
Hypoxia
Hypotension
Coagulopathy
Haemorrhage
Tachycardia
Confusion
Seizures
Cardiac arrest
Management of amniotic fluid embolus
Supportive
Medical emergency
ABCDE
What is uterine rupture?
Muscle layer of uterus (myometrium) ruptures
Incomplete vs. complete uterine rupture
Incomplete (uterine dehiscence):
Uterine serosa surrounding uterus remains intact
Complete:
Serosa ruptures along with the myometrium, releasing contents of uterus into peritoneal cavity
Risk factors for uterine rupture
Previous caesarean section - scar is weak point
Vaginal birth after caesarean (VBAC)
Previous uterine surgery
Increased BMI
High parity
Increased age
Induction of labour
Use of oxytocin to stimulate contractions
Presentation of uterine rupture
Acutely unwell mother + abnormal CTG
Abdominal pain
Vaginal bleeding
Ceasing of uterine contractions
Hypotension
Tachycardia
Collapse
Management of uterine rupture
Obstetric emergency
Resuscitation and transfusion may be required
Emergency caesarean section
What is uterine inversion?
Rare complication of birth
Fundus of uterus drops down through uterine cavity and cervix, turning uterus inside out
Presentation of uterine inversion
PPH
Maternal shock/collapse
Management of uterine inversion
Johnson manoeuvre
Hydrostatic methods
Surgery - laparotomy
What is a breech presentation?
Presenting part of the foetus is the legs and bottom
Types of breech presentation
Complete breech: legs fully flexed at hips and knees
Incomplete breech: one leg flexed at hip and extended at the knee
Extended (frank) breech: both legs flexed at hip and extended at knee
Footling breech: foot presenting through the cervix with leg extended
Management of breech presentation
External cephalic version
Choice between vaginal and caesarean
Management of stillbirth
USS for diagnosis
Anti-D prophylaxis if rhesus-D negative
Induction of labour with mifepristone or misoprostol
Dopamine agonists e.g. cabergoline to suppress lactation after birth
Genetic testing to determine cause (requires parental consent)
