Intrapartum Care

Question 1

Initial management in the first stage of labour?

Answer 1

Hx:

• general
• pregnancy

Exam:

• general
• abdominal palpation
  
  • size
  • lie
  • presenting part
• vaginal examination
  
  • cervical dilatation and effacement
  • presenting part
• Ix
  
  • CTG

Question 2

What are the ongoing things you do for a mother in the first stage of labour?

Answer 2

• assess mother
• fetal surveillance
  
  • CTG (increased fetal risk, or all labours)
  • intermittent auscultation if no RFs
• Assessment of progress
  
  • abdominal palpation hourly check presenting
  • vaginal exam (progressive dilatation of cervix)
• food and fluid
  
  • IV line, nil oral
  • clear fluids late
• antibiotics
• Pain relief
  

Question 3

What are the Stages of Labour?

Answer 3

Stage 1 = cervical effacement + dilation - ends at full dilation (10cm)

• latent = slow progression full effacement and 3cm dilatation
• active - faster rate of dilation (usually 2-4cm) usually approx 1cm per hr

Stage 2 = delivery of baby - begins at full dilatation

Stage 3 = delivery of placenta begins at delivery of the baby

Question 4

What are the indications for antibiotics during delivery?

Answer 4

• GBS
  
  • 20% women carry, 1 in 200 serous infection, 1 in 5 infection permanent disability (1 in 5000).
  • Intrapartum Penicillin IV during labour - note if penicillin allergic and get clinda/erythro
  • lower vaginal and anal swab at 36 weeks gestation
• prolonged rupture of membranes (>18hrs)
• suspected choreoamnionitis
• endocarditis prophylaxis

Question 5

What are some of the principles for Pain relief in Labour?

Answer 5

non-pharmacological

• support person
• TENS (works in 1/3) - low voltage skin impulses, electric stimulation to pads on nerve segments to uterus
• other stuff doesn’t work too well
  
  • massage
  • relaxation
  • position changes
  • hot + cold packs

pharmacological

• Nitrous oxide - small number effective (breath on mask)
• narcotic - don’t work well - in order to give enough to cause pain relief they don’t breath. Respiratory arrest between contractions.
• heroin - no longer, criminality (staff/external)
• morphine - 5mg im 4 hourly
• pethidine - 100mg im 4 hrly
• fentanyl - IV infusion
• side effects:
  
  • nausea, vomiting,
  • resp depression
  • narcan (weak agonist, make it worse in absence of narcotic)
  • respiratory support (can wear out of kids - admit in nursery)
• regional
  
  • epidural
  • spinal (in CSF - very effective, low volume)
  • spinal segments (T10-S4)
    
    • C3,C4, C5 keep diaphragm alive
    • T10-L1 - uterus and pelvic viscera
    • S2-S4 - perineum
  • sepsis - abscess
  • agents:
    
    • lignocaine

Question 6

What does Labour success depend on?

Answer 6

Power:

• Strong enough
• Long enough
• Frequent: 3-5 every 10 mins cyclic

Passenger:

• size,
• lie - babies position in relation to mother (longnitudinal, transverse, oblique)
• presentation (in relation to uterus, breech, transverse, cephalic)
• attitude - degree of extension/flexion
• position - babies rotation in relation to maternal pelvis (denominator in clockface) - cephalic use occipitus

Passage:

• regular observations for infection (chorioamnionitis)
  
  • pulse
  • temperature
  • vaginal loss
• Pre-eclampsia
  
  • BP
  • urinalysis
• Intrapartum hemorrhage
  
  • pulse
  • blood loss
  • vaginal loss
• emotional wellbeing + pain

Question 7

What are some side effects of pain relief within labour?

Answer 7

Side effects:

• hypotension (block sympathetic so less PR, block venules - reduce VR). Prevention with adrenergic agonists (ephedrine, metaraminol) or volume (crystalloid - worried about anaphylaxis with colloid).
• total spinal block (variation with epidural) - big dose into subarachnoid. Intubate, blocked every vessel. Circulatory support (adrenaline).
• local toxicity (not major issue)
• don’t push as well (lift head over perineum).

Postpartum:

• pruritis
• lower backache
• urinary retention
• dural puncture headache
• abscess or haematoma

Late:

• paralysis (1 case in 10,000,000 - 8 years ago in sydney).

Question 8

Monitoring the Fetus during Labour?

Answer 8

• auscultation of fetal heart
  
  • intermittent auscultation (less accurate)
    
    • every 15mins in active phase S1
    • after every contraction in S2 - up it, in it for lot longer.
  • continous electronic fetal monitoring
    
    • indicated in all pregnancies
• amount and colour of amniotic fluid
  
  • indicates placental sufficiency
  • volume (renal perfusion) - oligohydraminos
  • colour - meconium (aspiration risk?)

Question 9

Evaluation on admission?

Answer 9

• Timing:
  
  • latent - 6-18hrs in nullipara, 2-10hrs multipara
  • active 1cm/hr
• evaluation:
  
  • med Hx, past Obs Hx, complications during pregnancy
  • GBS status, double check Hep C, HIV
  • blood group
• Labour history:
  
  • duration labour, show (mucus plug), ROM, bleeding, FM
• antenatal education, birth plan/analgesia
• examination
  
  • pre-eclampsia, infection, bleeding
  • how low presenting part in relation to ischial spine

Question 10

Progress of labour evaluation?

Answer 10

• Uterine contractions
• vaginal exam
  
  • effacement
  • dilatation
  • presenting part (in relation to ischial spine)
• documentation of partogram
  
  • dilatation of cervix and fetal HR. With interventions.

Question 11

Normal routine care in normal labour?

Answer 11

• Obs
• activity (ambulate)
• fluids and diet
• IV access not routine (PPH/c-section, dehydration)
• antibiotic prophylaxis - postive swab

Question 12

Timing of second stage of labour? What are the mechanics?

Answer 12

• Timing
  
  • arrested descent (epidural)
    
    • N >3hrs
    • M >2 hrs
  • arrested descent (no epidural)
    
    • N >2 hrs
    • M >1 hr
• head negotiating pelvis
  
  • moulding - not fully ossified (compressible)
  • altitude - flexion makes head smaller, favourable diameter. occiput to bregma (9.5cm average),
  • rotation - after delivery encourage head to rotate transverse
  • maternal bony pelvis - 11.5cm all the way, but transverse is broad then go in. 13.5 to 10.5 and broadens to tuberosities. Bispinous in the issue - ‘at spine’
    
    • engagement - widest part of head past brim
    • station - low station well down, high station sitting in abdomen. zero is ‘at spines’

1. descent
2. flexion
3. internal rotation
4. extension - start to extend once out. spine lateral so rotate to be in line
5. rotation of head - restitution

Question 13

Third stage of delivery, what do you look for?

Answer 13

• seperation of placenta, average 5-10mins, can go up to an hour
• 3 signs:
  
  • fresh show of blood
  • lengthening of umbilical cord
  • uterus becomes firm
• gentle traction on the cord
• active management:
  
  1. prophylactic oxytocic
     
     • syntocin
     • syntometrine
     • ergometrine
  2. controlled cord traction
  3. early cord traction (not that important - delay to protect Fe deficiency at 2-6months without jaundice)
• PPH
  
  • atony - uterus forgotten to contract
  • genital tract lacerations (vulva and perineum) - check
  • coagulopathy (abruption, uterine inversion)

Question 14

Talk through the types of perineal lacerations.

Answer 14

• 1st degree = perineal skin/vaginal mucosa
• 2nd degree = perineal structures
• 3rd degree - external anal sphincter
• 4th degree = communicates with rectum

+/- episiotomy (80% of first deliveries)