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Obstetrics & Gynaecology > Intrapartum Care > Flashcards

Intrapartum Care Flashcards

1
Q

What is placenta accreta?

A

Placenta implants deeper, through and past the endometrium, making it difficult to separate the placenta after delivery of the baby

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2
Q

Management of placenta accreta

A

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

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3
Q

Outline the 3 stages of labour

A

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

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4
Q

What happens during the first stage of labour?

A

Cervical dilation and effacement (thinning)

“Show” - mucus plug falls out

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5
Q

What are the 3 phases of the first stage?

A

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)

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6
Q

What are Braxton-Hicks contractions?

A

Occasional irregular contractions of the uterus

2nd and 3rd trimester

Do not indicate onset of labour

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7
Q

Signs of onset of labour

A

Show (mucus plug from the cervix)

Rupture of membranes

Regular, painful contractions

Dilating cervix on examination

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8
Q

Prophylaxis of preterm labour

A

Vaginal progesterone

Cervical cerclage

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9
Q

What is preterm prelabour rupture of membranes?

A

Amniotic sac ruptures, releasing amniotic fluid, before the onset of labour and before 37 weeks

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10
Q

Diagnosis of preterm prelabour rupture of membranes

A

Speculum exam reveals pooling of amniotic fluid in vagina

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11
Q

Management of preterm prelabour rupture of membranes

A

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

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12
Q

What is preterm labour with intact membranes?

A

Regular painful contraction and cervical dilatation, without rupture of the amniotic sac

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13
Q

What is tocolysis?

A

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)

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14
Q

When is induction indicated?

A

41-42 weeks gestation

Prelabour rupture of membranes

Foetal growth restriction

Pre-eclampsia

Obstetric cholestasis

Existing diabetes

Intrauterine fetal death

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15
Q

What is the Bishop score?

A

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

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16
Q

What are the options for inducing labour?

A

Membrane sweep

Vaginal prostaglandin E2

Cervical ripening balloon

Artificial rupture of membranes

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17
Q

Complication of vaginal prostaglandins used for induction of labour

A

Uterine hyperstimulation

Contraction of uterus is prolonged and frequent, causing foetal distress and compromise

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18
Q

Indications for CTG

A

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

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19
Q

Key features on CTG

A

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

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20
Q

How to assess features of a CTG?

A

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)

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21
Q

Oxytocin use in labour

A

Induce labour

Progress labour

Improve the frequency and strength of uterine contractions

Prevent or treat postpartum haemorrhage

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22
Q

Ergometrine use in labour

A

Stimulates smooth muscle contraction in uterus and blood vessels

Used in THIRD stage and POSTPARTUM

Prevent and treat PPH

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23
Q

Prostaglandin use in labour

A

Prostaglandin E2 (dinoprostone)

Used for induction of labour

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24
Q

Terbutaline use in labour

A

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

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25
Q

Nifedipine use in labour

A

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

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26
Q

Carboprost use in labour

A

Synthetic prostaglandin analogue (binds to prostaglandin receptors)

Stimulates uterine contraction

Given as a deep IM injection in PPH

CONTRAINDICATED IN ASTHMA

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27
Q

Tranexamic acid use in labour

A

Anti-fibrinolytic medication that reduces bleeding

Prevention and treatment of PPH

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28
Q

How is progress in labour influenced?

A

3 Ps

Power (uterine contractions)

Passenger (size, presentation and position of the baby)

Passage (the shape and size of the pelvis and soft tissues)

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29
Q

What is delay in the first stage of labour considered?

A

EITHER

Less than 2cm of cervical dilatation in 4 hours

Slowing of progress in a multiparous women

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30
Q

What is delay in the second stage of labour?

A

Active second stage (pushing) lasts over:

2 hours in a nulliparous woman

1 hour in a multiparous woman

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31
Q

Possible interventions during a delayed second stage

A

Changing positions

Encouragement

Analgesia

Oxytocin

Episiotomy

Instrumental delivery

Caesarean section

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32
Q

What is delay in the third stage of labour?

A

More than 30 minutes with active management

More than 60 minutes with physiological management

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33
Q

Simple analgesia in labour

A

Paracetamol is frequently used in early labour

Codeine may be added for additional effect

Avoid NSAIDs

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34
Q

Gas and air use in labour

A

Mixture of 50% nitrous oxide and 50% oxygen

Used during contractions for short term pain relief

Can cause lightheadedness, nausea or sleepiness

35
Q

IM pethidine or diamorphine use in labour

A

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

36
Q

Epidural use in labour

A

Epidural space in the lower back

Outside the dura mater, separate from the spinal cord and CSF

37
Q

Adverse effects of epidural

A

Headache after insertion

Hypotension

Motor weakness in the legs

Nerve damage

Prolonged second stage

Increased probability of instrumental delivery

38
Q

What is umbilical cord prolapse?

A

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

39
Q

Management of cord prolapse

A

Emergency Caesarean section

While waiting, mother in left lateral position + tocolytic medication

40
Q

What is shoulder dystocia?

A

Anterior shoulder of baby becomes stuck behind pubic symphysis of the pelvis, after the head has been delivered

Obstetric emergency

41
Q

Presentation of shoulder dystocia

A

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

42
Q

Management of shoulder dystocia

A

Get help

Episiotomy

McRoberts manoeuvre

Pressure to anterior shoulder

Rubins manoeuvre

Wood’s crew manoeuvre

Zavanelli manoeuvre

43
Q

Shoulder dystocia risk factors

A

Macrosomia

Secondary to GDM

44
Q

Complications of shoulder dystocia

A

Foetal hypoxia (and subsequent cerebral palsy)

Brachial plexus injury and Erb’s palsy

Perineal tears

Postpartum haemorrhage

45
Q

Indications for instrumental delivery

A

Failure to progress

Foetal distress

Maternal exhaustion

Control of the head in various fetal positions

46
Q

What can increase risk of requiring an instrumental delivery?

A

Epidural

47
Q

Risks to the mother in instrumental delivery

A

Postpartum haemorrhage

Episiotomy

Perineal tears

Injury to the anal sphincter

Incontinence of the bladder or bowel

Nerve injury (obturator or femoral nerve)

48
Q

Key risks to baby with instrumental delivery

A

Cephalohaematoma with ventouse

Facial nerve palsy with forceps

49
Q

What is a ventouse delivery?

A

Suction cup on cord

Main complication is cephalohaematoma - collection of blood between skull and periosteum

50
Q

Nerve injuries in instrumental delivery

A

Rare

Usually resolves over 6-8 weeks

Main nerves affected: femoral and obturator

51
Q

When do perineal tears occur?

A

External vaginal opening is too narrow to accommodate the baby

52
Q

Who are perineal tears most common in?

A

First births (nulliparity)

Large babies (over 4kg)

Shoulder dystocia

Asian ethnicity

Occipito-posterior position

Instrumental deliveries

53
Q

Outline the varying degrees of perineal tear

A

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

54
Q

Management of perineal tears

A

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

55
Q

Reducing risk of perineal tears

A

Episiotomy

Perineal massage

56
Q

What is “active management” of the third stage?

A

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

57
Q

PPH blood loss volumes

A

500ml after a vaginal delivery

1000ml after a caesarean section

58
Q

Minor vs major PPH

A

Minor PPH – under 1000ml blood loss

Major PPH – over 1000ml blood loss

59
Q

Causes of postpartum haemorrhage

A

Tone (uterine atony – the most common cause)

Trauma (e.g. perineal tear)

Tissue (retained placenta)

Thrombin (bleeding disorder)

60
Q

PPH preventative measures

A

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

61
Q

Management of PPH

A

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

62
Q

Mechanical treatment of PPH

A

Rubbing uterus through abdomen to stimulate a uterine contraction

Catheterisation (bladder distention prevents uterus contractions)

63
Q

Medical treatment of PPH

A

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

64
Q

Surgical treatment of PPH

A

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

65
Q

Indications for elective caesarean

A

Previous caesarean

Symptomatic after a previous significant perineal tear

Placenta praevia

Vasa praevia

Breech presentation

Multiple pregnancy

Uncontrolled HIV infection

Cervical cancer

66
Q

Categories of emergency caesarean section

A

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

67
Q

Measures to reduce risk during caesarean

A

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

68
Q

Two key causes of maternal sepsis

A

Chorioamnionitis

UTIs

69
Q

What is amniotic fluid embolus?

A

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

70
Q

Presentation of amniotic fluid embolus

A

Similar to sepsis, PE or anaphylaxis, with acute onset of symptoms of:

Shortness of breath

Hypoxia

Hypotension

Coagulopathy

Haemorrhage

Tachycardia

Confusion

Seizures

Cardiac arrest

71
Q

Management of amniotic fluid embolus

A

Supportive

Medical emergency

ABCDE

72
Q

What is uterine rupture?

A

Muscle layer of uterus (myometrium) ruptures

73
Q

Incomplete vs. complete uterine rupture

A

Incomplete (uterine dehiscence):
Uterine serosa surrounding uterus remains intact

Complete:
Serosa ruptures along with the myometrium, releasing contents of uterus into peritoneal cavity

74
Q

Risk factors for uterine rupture

A

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

75
Q

Presentation of uterine rupture

A

Acutely unwell mother + abnormal CTG

Abdominal pain

Vaginal bleeding

Ceasing of uterine contractions

Hypotension

Tachycardia

Collapse

76
Q

Management of uterine rupture

A

Obstetric emergency

Resuscitation and transfusion may be required

Emergency caesarean section

77
Q

What is uterine inversion?

A

Rare complication of birth

Fundus of uterus drops down through uterine cavity and cervix, turning uterus inside out

78
Q

Presentation of uterine inversion

A

PPH

Maternal shock/collapse

79
Q

Management of uterine inversion

A

Johnson manoeuvre

Hydrostatic methods

Surgery - laparotomy

80
Q

What is a breech presentation?

A

Presenting part of the foetus is the legs and bottom

81
Q

Types of breech presentation

A

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

82
Q

Management of breech presentation

A

External cephalic version

Choice between vaginal and caesarean

83
Q

Management of stillbirth

A

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)

Obstetrics & Gynaecology (13 decks)

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