intrapartum care Flashcards
should DVT prophylaxis be given post delivery?
if >35 yrs and >35 BMI and any other risk factors
or 2 risk factors
risk factors include:
- parity >/= 4, previous VTE
- varicose veins, paraplegia
- sickle cell, nephrotic syndrome, cardiac disease, pre-eclampsia, thrombophilia, IBD, myeloproliferative disease, infection
- use of foreceps, manual evacuation of products, excess blood loss
- post partum sterilisation.
what does DVT prophylaxis post delivery involve?
LMWH as soon as delivered
- first confirm no PPH
- wait >4 hours post epidural insertion/ removal
continue for 3-5 days (even at home)
TED stockingswhen assessing maternal urine during labour, what should be done if ketones are found
give IV 10% dextrose
what drug is given routinely in stage 3 of labour and why? when is this contraindicated?
syntometrine (oxytocin) given to reduce length of 3rd stage to reduce risk of PPH (oxytocin is uterotonic)
contraindicated in pre-eclampsia, HTN, renal disease, severe heart disease, hypercholesterolaemia and liver impairment
what antenatal information should be given about labour?
what to expect
pain management
what is normal and what isn’t - when to get help
what care is received throughout labour?
- ask about:
- fetal movements in last 24 hours
- options of pain relief
- strength, length and frequency of contractions - encourage women to adopt the most comfortable position
- vaginal examination
- obstetric examination
- measure pulse, BP, urinalysis and temperature
- measure fetal heart for atleast 1 min after every contraction and offer CTG (but every 15 mins in 1st stage and more regular in 2nd stage)
when should you refer intrapartum care to obstetrician (over midwife led care)?
pulse >120 on two separate occasions BP >160/110 protein in urine temperature >38 vaginal blood loss
rupture of membranes >24 hours before onset of labour
presence of meconium
transverse/oblique lie
fetal HR <110 or >160
abnormal CTG
reduced fetal movements in last 24 hours.
how can the first stage of labour be detected by clinician?
contractions are regular and painful
cervix is dilated >3cm
what should be recorded during first stage of labour?
1/2 hourly obs : record frequency of contractions, pulse BP and temperature
4 hourly urine frequency
auscultation of foetal HR atleast for 1 min every 15 mins
what pain relief can be offered in the first stage of labour?
Entanox
IV pethidine/ diamorphine and antiemetic
epidural
if an epidural is given what should be measured?
BP every 15 mins
assess effectiveness of epidural
assess level of sensory block hourly
how do we know the mother is in the second stage of labour?
cervix is fully dilated - can see babies head.
what should be recorded/offered in stage 2 of labour?
continue observation
still offer pain relief
consider oxytocin if contractions are inadequate
continue to monitor fetal HR
what should be done in the 3rd stage of labour?
record mothers appearance, resp rate, blood losss
what is the difference between the active and physiological management of 3rd stage of labour?
active - give oxytocin and clamping and cutting the cord
physiological - no drugs, no clamping, delivery of placenta by maternal effort
what is the role of cutting and clamping the cord in stage 3 of labour? can this be done straight away?
cant be done until atleast 1 min post delivery of fetus. but done before 5 mins.
(after oxytocin has been administered)
after cutting the cord can use traction to help deliver the placenta.
when is active management of stage 3 offered?
routinely offered to anyone to prevent PPH
but strongly advised if haemorrhage or in stage 3 for up to 1 hour
what advice is given to mother once baby is delivered?
skin to skin contact ASAP
wrap baby in warm blanket
start attempting breast feeding asap
how is the baby assessed once delivered?
APGAR score at 1 min post delivery and 5 min post delivery
record time from birth to regular respirations
record head circumference, length, temperature and birth weight within 1 hour
how is the mother assessed post delivery?
record temperature, BP, pulse
examine perineum
repair perineum by suturing
also appearance, respiratory rate and blood loss
describe the differences from first degree to 4th degree perineal tears.
1st degree = injury to skin only
2nd degree = injury to perineal muscles but not anal sphincter
3rd degree = anal sphincter damage
3a - <50% of external anal sphincter torn
3b - >50 % of external anal sphincter torn
3c - internal anal sphincter torn
4th degree = injury involving internal and external anal sphincter and anal epithelium.
what is CTG?
Cardiotocography - monitors foetal HR and uterine contractions.
what are the two sensors used in CTG?
Foetal HR transducer - place on mothers abdomen near fetal heart OR place on fetal head transcervically
uterine transducer - placed on uterine fundus and measures the strength, frequency, duration of contractions and the resting tone.
how is a CTG interpreted?
DR C BRaVADO
- DR - define risks e.g. gestational diabetes, HTN, multiple pregnancy etc
- C - contractions - look at frequency, duration, strength and resting tension
- BRa - baseline rate - should be between 110 and 160bpm
- V - variability of baseline HR
- A - accelarations
- D - Decelarations
- O - overall impression - reassuring, suspicious or pathological
when using CTG..
what indicates abnormal variability?
what level of variability of foetal HR is good?
baseline rate can fluctuate between 10-15 bpm = good variability (reassuring if between 5-25bpm)
reduced variability for prolonged period, should prompt investigation.
not reassuring:
- if <5bpm for 30-50 mins
- also excessive variability e.g. >25bm for 15 -25 mins is not reassuring
abnormal:
- <5bpm for >50 mins
- > 25 bpm for >25 mins
- sinusoidal
What are accelerations (on CTG) and are these good?
increase in foetal HR for short periods of time
- healthy = >15bpm for atleast 15 seconds
which decelerations (on CTG) are worrying and which are not?
the fetal HR can decelerate for short periods of time
- this normally occurs at the beginning of a contraction but resolves by the end of the contraction= normal = early deceleration
late deceleration = fetal HR decreases at some point within the contraction and has not resolved by the end - sign of fetal hypoxia
variable deceleration - fetal HR reduces at any time, not associated with contraction. Thought to be due to cord compression or reduced amniotic fluid
what defines fetal tachycardia and what are the causes of this? (CTG)
> 160 bpm
causes: fetal tachyarrhythmia, fetal hypoxia, maternal pyrexia, maternal/fetal anaemia, chorioamnionitis, hyperthyroid, prematurity
what defines fetal bradycardia? when does this occur? (CTG)
<100 bpm for >/= 3 mins
occurs if fetus is in transverse or occiput posterior lie. Also occurs if past gestational date. maternal B blocker use
what defines severe fetal bradycardia and what does this indicate? (CTG)
<80bpm for >3 mins
indicates severe fetal hypoxia
severe hypoxia of fetus can result in severe fetal bradycardia. what are some possible causes of this? (CTG)
cord compression cord prolapse rapid fetal descent maternal seizure epidural/ spinal anaesthesia
how does the HR change with umbilical cord compression? why would this occur? (CTG)
umbilical vein occluded - acceleration in HR
umbilical artery occluded - deceleration
pressure relieved - acceleration and back to baseline
sometimes occurs when mother changes position
what is meant by shoulders of deceleration? (CTG)
The acceleration is either side of a deceleration (e.g. as in cord compression) - this is less dangerous that deceleration alone which is very worrying and suggests severe hypoxia
what are the causes of reduced variability on CTG?
sleeping fetus fetal acidosis (due to hypoxia) fetal tachycardia drugs - opioids, benzo, MgSO4, methyldopa CHD
what are the causes of late decelerations on CTG?
indicates insufficient blood flow to uterus and placenta can occur due to: - maternal hypotension - pre-eclampsia - uterine hyperstimulation
what is indicated in case of late decelerations on CTG?
fetal blood sampling for pH is indicated
if acidotic this indicates hypoxia and emergency C section indicated.
what defines a prolonged deceleration on CTG? what action should be taken?
deceleration for 2-3 mins = non reassuring
deceleration for >3 mins = abnormal
fetal blood scalp sample indicated and C section if acidotic
what is indicated by a sinusoidal pattern on CTG?
rare but very concerning
associated with mortality and morbidity
indicatessevere fetal hypoxia, severe fetal anaemia or fetal/maternal haemorrhage
how are normal, suspicious and pathological defined on CTG?
normal - no abnormal or non reassuring features
suspicious - 1 non reassuring but 2 reassuring features
pathological - 1 abnormal feature or 2 non-reassuring features.
list the reassuring CTG features
HR between 110 and 160 bpm accelerations present variability - between 5 and 25 bpm decelarations: - early decelerations - variable decelerations with no concerning features for <90mins - no decelerations
list the non-reassuring CTG features
HR 100-109 bpm or 161 to 180 bpm
variability:
- <5 for 30-50 mins
- >25 for for 15 to 25 mins
decelerations:
- variable with no concerning features >90mins
- variable with concerning features for <30mins or <50% of contractions
list the abnormal CTG featuress
HR <100 or >180
variability:
- <5bpm for >50 mins
- >25 for >25 mins
- sinusoidal
decelerations:
- variable decelerations with concerning features for >30 mins or >50% of uterine contractions
- acute fetal bradycardia = single deceleration for >3mins
- late decelerationswhat should you do in the instance of acute bradycardia or prolonged deceleration on CTG ?
get urgent help
try correct cause
- e.g. fluids for mum if hypotensive
- e.g. reduce oxytocin if excessive contraction or can offer tacolytic drug
make preparations for urgent birth
when does NICE indicate continuous CTG monitoring?
- suspected sepsis, chorioamnionitis or >38 degrees
- HTN >160/80
- oxytocin use
- vaginal bleed during labour (could be due to placental rupture or placenta praevia)
- presence of meconium
considered if excessive contractions, delay in 1st/2nd stage, proteinuria, maternal pulse >120
When can corticosteroids be used if there is a growth restriction?
normally used from 24+0 weeks to 34 +6 weeks
but if growth restriction can give up to 35 +6 weeks.
