Intrapartum Management Flashcards
What are some of the factors that make need for epidural anaesthesia more likely during labour?
Obesity
Multiple gestation
Pre-eclampsia
Prolonged labour
What are some of the contraindications for using epidural aneasthesia during labour?
Coagulopathy
Patient refusal
Maternal haemorrhage
What is the most common cause of primary postpartum haemorrhage?
Uterine atony
What is the consequence of uterine atony in labour?
Failure of the uterus to contract fully after delivery of the placenta allowing massive blood loss
How should postpartum haemorrhage be managed?
ABCDE inc. 14 gauge cannulae
Bimanual uterine compression.
Start major PPH protocol.
IV syntocinon (synthetic oxytocin) 10 units or IV ergometrine
IM carboprost
IU balloontamponade if uterine atony is the only cause
What is a CTG?
Cardiotocography
Measurement of foetal heart and maternal uterine contractions
What is the second thing to assess on a CTG?
Variability - does the foetal HR vary around its baseline?
What is the first thing to look at on the CTG?
Foetal HR baseline
What should a foetal HR be on a CTG?
Between 110 and 160 BPM
What are accelerations on a CTG?
An abrupt increase in the baseline fetal heart rate of greater than 15 bpm for greater than 15 seconds
Describe an early deceleration on a CTG.
Early decelerations start when the uterine contraction begins and recover when uterine contraction stops
Describe a late deceleration on a CTG.
Late decelerations begin at the peak of the uterine contraction and recover after the contraction ends.
What mnemonic can help remind me how to read a CTG?
DR C BRaVADO
What does Dr C Bravado do?
DR - define risk C - contractions BRa - Baseline rate V - variability A - accelerations D - decelerations O - overall impression
How do we measure contractions for a CTG?
How many occur in a ten minute period?
Each contraction is a peak on the uterine part of the CTG.
How are contractions assessed on the CTG?
By duration and intensity (Ax by palpation)
What does the baseline rate of a CTG refer to?
Foetal HR i.e. average foetal HR within a ten minute window.
Why might a foetus be tachycardic?
- Hypoxia
- Chorioamnionitis
- Hyperthyroidism
- Anamia (F/M)
- Tachyarrythmia
Why might a foetus be bradycardic?
- Postdate gestation
- Occiput posterior or transverse presentation
- Cord compression/prolapse
- Anaesthesia
- Maternal seizure
- Rapid foetal descent
What is variation on a CTG?
Variation of the foetal HR from one beat to the next.
What is considered normal variability on a CTG?
between 5 and 25 bpm
What can cause reduced variability on a CTG?
Non-worrying:
- Foetal sleeping
- Prematurity
Worrying:
- Acidosis
- Tachycardia
- Drugs
- Congenital heart problems
Are accelerations reassuring or not?
Yes they are reassuring
What are decelerations on a CTG?
An abrupt decrease in the baseline fetal heart rate of greater than 15 bpm for greater than 15 seconds.
Why is an early deceleration considered physiological and not pathological?
It is due to fetal intracranial pressure increasing -> increased vagal tone - it is transient and depends upon the contraction.
What are variable decelerations?
a rapid fall in baseline fetal heart rate with a variable recovery phase, not related to uterine contractions.
What are variable decelerations usually caused by?
Umbilical cord compression
Why are late decelerations considered pathological?
They are caused by insufficient blood flow to the uterus and placenta, causing foetal hypoxia and acidosis.
What tests should we do if late decelerations are seen on a CTG?
Foetal blood sampling for pH.
If acidotic, go for emergency C-section
How long can a deceleration last before being classed as abnormal?
3 minutes
What is a rare but very worrying pattern on CTG?
Sinusoidal pattern i.e. smooth regular wave-like pattern
What do we do for sinusoidal CTG? Why?
Immediate C-section as it indicates severe foetal hypoxia or acidosis, or maternal/foetal haemorrhage.
Once pre-term labour is diagnosed, where is the best place for the mother?
Somewhere she can deliver safely with appropriate neonatal support available
What drugs can be given to suppress contractions in premature labour?
Tocolytic drugs e.g. nifedipine or oxytocin receptor antagonist
Why do we want to delay premature labour as much as possible?
To reduce neonatal mortality and morbidity, as well as maternal side-effects
What 2 drugs do we give to try and reduce neonate morbidity in premature labour?
Why do we give them?
- Corticosteroids to reduce IRDS and intraventricular haemorrhage
- Magnesium sulphate to reduce risk of cerebral palsy as a neuroprotective
If a mother is over 16 weeks with a dilated cervix but unruptured membranes, what procedure can be performed?
Emergency cervical cerclage i.e. use suture or tape to reinforce the cervix
What are the possible “passenger” indications for c section?
- Malpresentation
- Multiple pregnancy
- Foetal distress
- IUGR
What are the possible “passage”/maternal indications for c section?
- Cephalopelvic disproportion
- Severe HTN in pregnancy
- Failed induction
- Repeat c section
- Pelvic cyst/fibroid
- Maternal infection
What is a level 1 C-section?
an emergency section - needs to be done due to immediate threat to life of woman or foetus.
Usually under 30 minutes decision-to-delivery time.
What is a level 2 C-section?
Maternal or foetal compromise which isn’t immediately life-threatening. Usually about 75 minutes decision-to-delivery time.
What is a level 3 C-section?
Need early delivery but no compromise to mother or foetus.
Timing depends on indication.
What is a level 4 C-section?
C-section timed to suit mother or staff. Completely elective. Not booked before 39 weeks.
Where is a C-section performed on the mother?
Across the lower uterine segment
What anaesthesia is usually used for a C-section?
Either spinal or epidural block.
Why is a lower segment C-section best?
The risk of uterine rupture in subsequent pregnancies is much lower.
What do we need to make sure leaves the uterus?
The baby or babies.
The placenta - all of it :)
How is the placenta removed after C-section?
Controlled cord contraction
Why is the placenta removed by controlled cord contraction following a c-section?
It reduces the risk of endometritis.
What prophylaxis do we need to give a woman undergoing a C-section?
Thromboprophylaxis - it’s surgery and she’s preggo so it’s a double risk.
What is the rate of C-section delivery in the UK?
Around 25%
When should a planned C-section be performed routinely?
At or after 39 weeks
What are the indications for planned C-section?
Breech Multiple pregnancy Pre-term SGA Placenta praevia
What are the risk categories of performing a C-section (think consenting for surgery)?
Risk to mother
Risk to baby
Risk to future pregnancies