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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
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
26
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
27
Tranexamic acid use in labour
Anti-fibrinolytic medication that reduces bleeding Prevention and treatment of PPH
28
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)
29
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
30
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
31
Possible interventions during a delayed second stage
Changing positions Encouragement Analgesia Oxytocin Episiotomy Instrumental delivery Caesarean section
32
What is delay in the third stage of labour?
More than 30 minutes with active management More than 60 minutes with physiological management
33
Simple analgesia in labour
Paracetamol is frequently used in early labour Codeine may be added for additional effect Avoid NSAIDs
34
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
35
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
36
Epidural use in labour
Epidural space in the lower back Outside the dura mater, separate from the spinal cord and CSF
37
Adverse effects of epidural
Headache after insertion Hypotension Motor weakness in the legs Nerve damage Prolonged second stage Increased probability of instrumental delivery
38
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
39
Management of cord prolapse
Emergency Caesarean section While waiting, mother in left lateral position + tocolytic medication
40
What is shoulder dystocia?
Anterior shoulder of baby becomes stuck behind pubic symphysis of the pelvis, after the head has been delivered Obstetric emergency
41
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
42
Management of shoulder dystocia
Get help Episiotomy McRoberts manoeuvre Pressure to anterior shoulder Rubins manoeuvre Wood's crew manoeuvre Zavanelli manoeuvre
43
Shoulder dystocia risk factors
Macrosomia Secondary to GDM
44
Complications of shoulder dystocia
Foetal hypoxia (and subsequent cerebral palsy) Brachial plexus injury and Erb’s palsy Perineal tears Postpartum haemorrhage
45
Indications for instrumental delivery
Failure to progress Foetal distress Maternal exhaustion Control of the head in various fetal positions
46
What can increase risk of requiring an instrumental delivery?
Epidural
47
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)
48
Key risks to baby with instrumental delivery
Cephalohaematoma with ventouse Facial nerve palsy with forceps
49
What is a ventouse delivery?
Suction cup on cord Main complication is cephalohaematoma - collection of blood between skull and periosteum
50
Nerve injuries in instrumental delivery
Rare Usually resolves over 6-8 weeks Main nerves affected: femoral and obturator
51
When do perineal tears occur?
External vaginal opening is too narrow to accommodate the baby
52
Who are perineal tears most common in?
First births (nulliparity) Large babies (over 4kg) Shoulder dystocia Asian ethnicity Occipito-posterior position Instrumental deliveries
53
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
54
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
55
Reducing risk of perineal tears
Episiotomy Perineal massage
56
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
57
PPH blood loss volumes
500ml after a vaginal delivery 1000ml after a caesarean section
58
Minor vs major PPH
Minor PPH – under 1000ml blood loss Major PPH – over 1000ml blood loss
59
Causes of postpartum haemorrhage
Tone (uterine atony – the most common cause) Trauma (e.g. perineal tear) Tissue (retained placenta) Thrombin (bleeding disorder)
60
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
61
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
62
Mechanical treatment of PPH
Rubbing uterus through abdomen to stimulate a uterine contraction Catheterisation (bladder distention prevents uterus contractions)
63
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
64
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
65
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
66
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
67
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
68
Two key causes of maternal sepsis
Chorioamnionitis UTIs
69
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
70
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
71
Management of amniotic fluid embolus
Supportive Medical emergency ABCDE
72
What is uterine rupture?
Muscle layer of uterus (myometrium) ruptures
73
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
74
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
75
Presentation of uterine rupture
Acutely unwell mother + abnormal CTG Abdominal pain Vaginal bleeding Ceasing of uterine contractions Hypotension Tachycardia Collapse
76
Management of uterine rupture
Obstetric emergency Resuscitation and transfusion may be required Emergency caesarean section
77
What is uterine inversion?
Rare complication of birth Fundus of uterus drops down through uterine cavity and cervix, turning uterus inside out
78
Presentation of uterine inversion
PPH Maternal shock/collapse
79
Management of uterine inversion
Johnson manoeuvre Hydrostatic methods Surgery - laparotomy
80
What is a breech presentation?
Presenting part of the foetus is the legs and bottom
81
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
82
Management of breech presentation
External cephalic version Choice between vaginal and caesarean
83
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)

Obstetrics & Gynaecology (13 decks)

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