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Obstetrics > intrapartum care > Flashcards

intrapartum care Flashcards

1
Q

should DVT prophylaxis be given post delivery?

A

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.
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2
Q

what does DVT prophylaxis post delivery involve?

A 
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 stockings
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3
Q

when assessing maternal urine during labour, what should be done if ketones are found

A

give IV 10% dextrose

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4
Q

what drug is given routinely in stage 3 of labour and why? when is this contraindicated?

A

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

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5
Q

what antenatal information should be given about labour?

A

what to expect
pain management
what is normal and what isn’t - when to get help

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6
Q

what care is received throughout labour?

A
  • 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)
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7
Q

when should you refer intrapartum care to obstetrician (over midwife led care)?

A 
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.

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8
Q

how can the first stage of labour be detected by clinician?

A

contractions are regular and painful

cervix is dilated >3cm

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9
Q

what should be recorded during first stage of labour?

A

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

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10
Q

what pain relief can be offered in the first stage of labour?

A

Entanox
IV pethidine/ diamorphine and antiemetic
epidural

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11
Q

if an epidural is given what should be measured?

A

BP every 15 mins
assess effectiveness of epidural
assess level of sensory block hourly

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12
Q

how do we know the mother is in the second stage of labour?

A

cervix is fully dilated - can see babies head.

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13
Q

what should be recorded/offered in stage 2 of labour?

A

continue observation
still offer pain relief
consider oxytocin if contractions are inadequate
continue to monitor fetal HR

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14
Q

what should be done in the 3rd stage of labour?

A

record mothers appearance, resp rate, blood losss

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15
Q

what is the difference between the active and physiological management of 3rd stage of labour?

A

active - give oxytocin and clamping and cutting the cord

physiological - no drugs, no clamping, delivery of placenta by maternal effort

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16
Q

what is the role of cutting and clamping the cord in stage 3 of labour? can this be done straight away?

A

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.

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17
Q

when is active management of stage 3 offered?

A

routinely offered to anyone to prevent PPH

but strongly advised if haemorrhage or in stage 3 for up to 1 hour

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18
Q

what advice is given to mother once baby is delivered?

A

skin to skin contact ASAP
wrap baby in warm blanket
start attempting breast feeding asap

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19
Q

how is the baby assessed once delivered?

A

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

20
Q

how is the mother assessed post delivery?

A

record temperature, BP, pulse
examine perineum
repair perineum by suturing

also appearance, respiratory rate and blood loss

21
Q

describe the differences from first degree to 4th degree perineal tears.

A

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.

22
Q

what is CTG?

A

Cardiotocography - monitors foetal HR and uterine contractions.

23
Q

what are the two sensors used in CTG?

A

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.

24
Q

how is a CTG interpreted?

A

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
25
Q

when using CTG..
what indicates abnormal variability?
what level of variability of foetal HR is good?

A

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
26
Q

What are accelerations (on CTG) and are these good?

A

increase in foetal HR for short periods of time

- healthy = >15bpm for atleast 15 seconds

27
Q

which decelerations (on CTG) are worrying and which are not?

A

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

28
Q

what defines fetal tachycardia and what are the causes of this? (CTG)

A

> 160 bpm

causes: fetal tachyarrhythmia, fetal hypoxia, maternal pyrexia, maternal/fetal anaemia, chorioamnionitis, hyperthyroid, prematurity

29
Q

what defines fetal bradycardia? when does this occur? (CTG)

A

<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

30
Q

what defines severe fetal bradycardia and what does this indicate? (CTG)

A

<80bpm for >3 mins

indicates severe fetal hypoxia

31
Q

severe hypoxia of fetus can result in severe fetal bradycardia. what are some possible causes of this? (CTG)

A 
cord compression
cord prolapse
rapid fetal descent 
maternal seizure 
epidural/ spinal anaesthesia
32
Q

how does the HR change with umbilical cord compression? why would this occur? (CTG)

A

umbilical vein occluded - acceleration in HR
umbilical artery occluded - deceleration
pressure relieved - acceleration and back to baseline

sometimes occurs when mother changes position

33
Q

what is meant by shoulders of deceleration? (CTG)

A

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

34
Q

what are the causes of reduced variability on CTG?

A 
sleeping fetus 
fetal acidosis (due to hypoxia)
fetal tachycardia 
drugs - opioids, benzo, MgSO4, methyldopa
CHD
35
Q

what are the causes of late decelerations on CTG?

A 
indicates insufficient blood flow to uterus and placenta
can occur due to:
  - maternal hypotension 
  - pre-eclampsia 
  - uterine hyperstimulation
36
Q

what is indicated in case of late decelerations on CTG?

A

fetal blood sampling for pH is indicated

if acidotic this indicates hypoxia and emergency C section indicated.

37
Q

what defines a prolonged deceleration on CTG? what action should be taken?

A

deceleration for 2-3 mins = non reassuring
deceleration for >3 mins = abnormal

fetal blood scalp sample indicated and C section if acidotic

38
Q

what is indicated by a sinusoidal pattern on CTG?

A

rare but very concerning
associated with mortality and morbidity

indicatessevere fetal hypoxia, severe fetal anaemia or fetal/maternal haemorrhage

39
Q

how are normal, suspicious and pathological defined on CTG?

A

normal - no abnormal or non reassuring features

suspicious - 1 non reassuring but 2 reassuring features

pathological - 1 abnormal feature or 2 non-reassuring features.

40
Q

list the reassuring CTG features

A 
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
41
Q

list the non-reassuring CTG features

A

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

42
Q

list the abnormal CTG featuress

A 
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 decelerations
43
Q

what should you do in the instance of acute bradycardia or prolonged deceleration on CTG ?

A

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

44
Q

when does NICE indicate continuous CTG monitoring?

A
  • 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

45
Q

When can corticosteroids be used if there is a growth restriction?

A

normally used from 24+0 weeks to 34 +6 weeks

but if growth restriction can give up to 35 +6 weeks.

Obstetrics (8 decks)

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