Intrapartum Care 2 Flashcards
What is the lie of the baby?
The way the long axis of the fetus is facing
What four terms can be used to describe a baby’s lie?
1) Cephalic - head down and bum towards the fundus of the uterus
2) Breech - bum of feet down with the head towards the fundus
3) Transverse - the baby is lying horizontally in the uterus
4) Oblique - the baby is on the diagonal
What is the presentation of the baby?
Which part of the fetus is at the pelvic brim
What three terms can be used to describe a baby’s presentation?
1) Face
2) Brow
3) Breech
What is the position of the baby? What is normal?
The way in which the presenting part is position in relation to the maternal pelvis
Normal = occipito-transverse at the pelvic brim rotating to the occipito-anterior at the pelvic floor
What is a malposition?
When the head coming first does not rotate from the occipito-transverse position to the occipito-anterior
Or it might rotate incorrectly and present occipito-posterior
What is the cause of breech presentation?
1) High ratio of amniotic fluid to fetal size allowing freer movement - eg <32 weeks or polyhydramnios
2) Extended legs prevent flexion and stop further turning
3) Multiple pregnancy
4) Something filling lower segment eg placenta praevia or fibroids
5) Fetal malformations preventing cephalic presentation eg hydrocephaly
What are the 3 types of breech presentation?
A - frank / extended breech
B - Complete / flexed breech, both knees flexed
C - Footling breech, either single or double with both hips extended. Occurs in very small babies
Which type of breech is most common?
A - frank / extended breech
What is face presentation associated with?
Anencephaly
What is a brow presentation?
Presenting with the supra-orbital ridges and the bridge of the nose
Usually palpable on VE
Which is the least favourable of the malpresentations?
Brow presentation
What is the management of breech presentation?
External cephalic version (ECV)
- Offered from 36wks in nulliparous women and 37wks in multiparous women (do not bother in placenta praevia as they will require CS anyway)
What is the method of ECV?
Listen to the fetal HR immediately before and after the procedure
Administer SC salbutamol or ritodrine as a tocolytic (uterine relaxant)
Disengage the breech from the pelvis, and pushing the head and breech in opposite directions, slowly rotate the baby through 180 degrees
Which breeches are more likely to turn in ECV?
Flexed breech (B) more likely to turn than extended breech (A)
What are the success rates of ECV?
30% for nulliparous
50% for multiparous
What are some risks of ECV? (6)
Pain Transient bradycardia Prolonged bradycardia Abruption (<1%) Emergency LSCS Materno-foetal haemorrhage (give anti-D if Rh-ve mother)
What factors are unfavourable for a vaginal breech delivery?
1) Inadequate pelvic diameters - requires >11cm AP and transverse
2) Foetal weight >3.5kg
3) Footling breech (C)
4) Other CI to vaginal birth eg placenta praevia, compromised foetus
5) Prev CS
6) Hyperextended fetal neck
What are some risks of vaginal breech delivery?
1) 3x inc risk of fetal hypoxia
2) Risk of head entrapment
3) Risk of intracranial damage
4) May lead to emergency CS
What is the management of a transverse lie?
<36 weeks = presentation is usually self correcting
> 37 weeks (multiparous) or >38wk (nulliparous) = admission to hospital for ECV attempts daily
If still transverse lie at term
- Stabilising induction
- Elective CS (usually safer, reduced risk of cord prolapse)
What is a stabilising induction?
ECV done in labour ward
Foetus’s head held over brim of pelvis and high membrane rupture performed
Amniotic fluid escapes and the head often sinks into the pelvis
How may a baby be malpositioned?
Occipito-posterior or occipito-transverse
What is the management of an occipito-transverse position?
Will not deliver spontaneously
Give epidural
Instrumental delivery with rotational forceps - Kielland’s straight forceps
- CI in foetal distress
IV symptometrine with head crowning as risk of PPH is inc
- Deliver placenta promptly after foetus born
Inc risk of perineal tears and injury to anal sphincter and rectal mucosa
Inc risk of foetal mortality (hypoxia and birth trauma) and morbidity (intracranial haemorrhage)
What are some complications of twin delivery?
PPH more common
Prolapse of umbilical cord more common
Mechanical collision of lead parts as they both enter pelvis (rare)
Delay in delivery of 2nd twin leads to higher mortality
What is the management of labour of twin delivery?
Plan for hospital delivery
Ensure first twin is longitudinal - both twins lie longitudinally 90% time, and the first twin is cephalic 90% time
Check for cord prolapse when membranes rupture - often early in labour
Progress is often uneventful
CTG
Epidural useful - allows any necessary manoeuvring of 2nd twin
When can syntometrine be given in twin delivery?
Ensure it is not given inadvertently after 1st twin delivery - would compromise blood supply of 2nd twin
Can give with delivery of 2nd twin and continue oxytocin IV for another hour
How soon after twin 1 should twin 2 be born? Would should happening following 1st twin delivery?
Ideally within 60 minutes of the first
If uterus does not restart spontaneous contractions after 5 mins, use IV oxytocin
Rupture membranes of 2nd sac
Deliver placenta promptly - retained placenta and PPH are common
What 5 conditions must be met for an instrumental vaginal delivery?
1) Adequate analgesia
- Epidural or pudendal + field block
2) The fetal head should not be more than 1/5 palpable in the abdo
3) Full cervical dilatation
4) Presenting part at the ischial spines of below with accurate knowledge of the fetal head position (OA / OT / OP)
5) Empty bladder via catheter
What is a ventouse extraction?
aka vacuum extraction
Suction cup used to get purchase of fetal head, allowing traction to be applied
What are some indications for a ventouse extraction? (4)
1) Delay in 2nd stage - often with OP or OT presentation
2) Maternal exhaustion
3) Compound presentations (hand or foot lies alongside the head)
4) High head of twin 2
What are some contraindications for a ventous extraction? (3)
1) Malpositions - esp face presentation / breech
2) Prematurity (<36wks)
3) Maternal HIV / hep B
What are two types of forceps?
1) Non-rotational
2) Rotational
Describe non-rotational forceps and when they are used
Grip the head in whatever position it is in and allow traction
Only suitable when head is in OA position
Have a cephalic curvature for the head and a pelvic curve which follows the sacrum
Describe rotational forceps and when they are used
Have no pelvic curve and are straight handled to allow a malpositioned head (OT / OP) to be rotated to the OA position before applying traction
What biophysical signs may indicate fetal hypoxia?
Tachy / bradycardia
Loss of baseline variability
Late decels
What biochemical signs may indicate fetal hypoxia?
pH <7.15 on FBS
How is the risk of a perineal tear minimised during a forceps delivery?
Episiotomy (mediolateral recommended)
However it may extend