Intrapartum Care

Question 1

What are the differentials for abdominal pain around term?

Answer 1

• Placental abruption
• Pre-eclampsia
• UTI
• Active/latent labour
• Braxton-Hicks - not usually painful
• Appendicitis/gastroenteritis

Question 2

What signs indicate active labour?

Answer 2

• Cervical effacement
• Regular painful contractions
• Cervical dilation >3/4cm

Question 3

What do you look for when examining a baby during labour?

Answer 3

• Station: where the baby is - 1-3 above/below ischial spines, 0 is at the ischial spines
• Membranes felt or not

Question 4

Where can women give birth?

Answer 4

• If low risk can choose where to give birth
• Home
• Midwifery led unit - alongside or free standing (means can have different positions to give birth instead of on the bed)
• Obstetric unit

Question 5

What is intermittent auscultation?

Answer 5

Used at home birth etc. - hand held doppler, every 15 mins

Question 6

What is meconium?

Answer 6

• Can be a sign of fetal distress
• More common in post-term ladies
• Significant > high risk > obstetric unit > continuous CTG monitoring

Question 7

How do you interpret CTGs?

Answer 7

1. Reason for CTG
2. Contractions - x:10 (x contractions in 10 mins), strong/weak (hx, exam), regular/irregular
3. Baseline rate (baby’s HR): what is the rate if there is a line all the way through (normal = 110-160) - premature babies tend to have a higher rate, stable/unstable line
4. Variability and cycling: how wiggly is the line (normal is 5-25 beats of variation), decreased variability so the line is very flat can mean the baby is asleep, cycling (the baby sleeps then wakes, repeat)
5. Accelerations: up by 15 beats and lasts for >15 secs (reassuring, occur alongside uterine contractions which is a sign of a healthy foetus)
6. Decelerations: drop in baseline by 15 beats and lasts for >15 secs (more worrying if >30 mins), types are early, late and variable (late is usually most pathological)
7. 1 abnormal finding = suspicious CTG, 2 abnormal findings = pathological CTG

Question 8

Describe early and late decelerations

Answer 8

• Early: start when uterine contraction begins and recover when uterine contraction stops - increased fetal intracranial pressure> increased vagal tone > physiological (usually innocuous and indicate head compression)
• Late: begin at peak of uterine contraction and recover after contraction ends, indicates insufficient blood flow to uterus and placenta > can lead to fetal hypoxia and acidosis (asphyxia or placental insufficiency)
• Causes of reduced uteroplacental blood flow include: maternal hypotension, pre-eclampsia, uterine hyperstimulation

Question 9

Describe variable decelerations

Answer 9

• Rapid fall in baseline fetal HR with variable recovery phase (all different shapes) - variable in duration and may not have any relationship to uterine contractions
• Most often seen during labour and in patients with reduced amniotic fluid volume, can indicate cord compression
• Accelerations before and after a variable deceleration are known as shoulders of deceleration - presence indicates fetus is not hypoxic and is adapting to reduced blood flow
• Variable decelerations can sometimes resolve if the mother changes position
• Variable decelerations without the shoulders are more worrying - fetus becoming hypoxic

Question 10

What is the management of a mother during labour?

Answer 10

• In labour repeat examination every 4hrs
• Primigravid women are expected to make progress at 0.5cm/hr
• 2nd time mum > 1cm/hr
• Earlier intervention is not needed unless there is: CTG becomes suspicious/pathological or there are no other signs of 2nd stage of labour
• Fetal blood sample (FBS): tiny blood sample from baby’s head for blood gas analysis
• Fetal Scalp Electrode (FSE): if not getting good recording of baby
• Labour distress: acidotic, hypoxic
• Caput: oedema on baby’s head (wedged in birth canal)
• Moulding: skull bones can overlap to get through birth canal, can be permanent which is worrying (can be a sign of obstructed labour)

Question 11

What are the timings for women in labour?

Answer 11

• 1hr passive descent, commence pushing for 1hr

- Epidural: 2hrs passive, 1hr pushing

Question 12

What is the management if there are worrying signs in active labour?

Answer 12

• Fully dilated = instrumental (CS high risk)

- Not fully dilated = C-section

Question 13

What are the risks of ventouse instrumental delivery?

Answer 13

• Injury to perineum
• Bleeding
• Infection
• Cephalohaematoma

Question 14

What is the consent process for ventouse instrumental delivery?

Answer 14

• Suction cup on baby’s head
• Baby may have bruising/swelling on head for 24hrs
• Important: mum still needs to push
• May need episotomy to make room and prevent tears
• Will need to empty bladder prior to procedure with catheter
• Local anaesthetic to perineum
• If baby does not deliver with 3 pulls or cup pops off may need forceps or CS.

Question 15

What are uterotonic drugs?

Answer 15

• Syntocinon infusion - 40iu in 500ml NaCl IV
• Ergometrine 500mcg IM
• Carboprost 250mcg IM
• Misoprostol 1g PR
• Tranexamic acid 1g IV