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
What are the benefits of a c-section (think consenting for surgery)?
- As appropriate to individual
- Quickest and safest route of delivery
What risks to mother do you need to explain for consenting a pt for c-section?
- Thromboembolic disease
- Bladder injury
- Ureter injury
- Emergency hysterectomy
- very rarely death
- Wound and scarring
- haemorrhage
- infection
What risks to foetus do you need to explain for consenting a pt for c-section?
-Cuts to baby - common
What risks to future pregnancies do you need to explain for consenting a pt for c-section?
- Uterine rupture
- Need for further c-sections
- placenta praevia
How does the risk of HIV transmission differ between vaginal delivery and c-section?
It is the same if they are on anti-retrovirals with low viral load.
How do we prepare a pregnant woman for a planned c-section?
- Low-residue diet to reduce anaesthetic risk
- Isotonic drinks
- G&S if at risk of haemorrhage
What is the aim of active management oflabour?
To reduce the number of prolonged labours.
What tool is used to monitor a mother throughout labour?
The partogram
Why are partograms good?
They show the progressover time, allowing the rate of progress to be assessed so if it slows or stops, it isn’t missed.
What information is included on a partogram?
- Foetal HR
- Contractions
- Maternal BP, HR, Temperature, and urine output (as appropriate)
How does induction of labour differ from augmentation?
Augmentation is enhancing contractions once labour has started.
Induction is starting labour by uterine stimulation.
Which 3 groups of women should be routinely offered induction of labour?
- Women with health pregnancy after 41 weeks
- Women with diabetes, HTN, or pre-eclampsia before term
- Pre-labour rupture of membranes after 37 weeks (immediate to 4 days post-rupture)
What 4 things need to be checked before induction of labour?
- Lie and position of foetus
- Amniotic fluid volume
- Uterine tone
- Cervical ripeness
What are the 4 absolute contra-indications for IOL?
- Severe placenta praevia
- Transverse lie
- Severe cephalopelvic disproportion
- Bishop’s score less than 4
What 3 methods can be employed to induce labour?
- Membrane sweep
- Prostaglandin gel/pessary
- Oxytocin +/- ARM
What are the potential complications for induction of labour?
- Failure
- Uterine hyperstimulation -> foetal distress
- Uterine rupture
- Infection
- Prolpased cord
- Amniotic fluid embolism
At what rate of dilation should we give syntocinon for augmentation?
If cervical dilation is slower than 1cm per hour.
How many stages are there in a normal labour?
3
What does the first stage of labour begin with?
Regular contractions
What does the first stage of labour end with?
Cervix fully dilated to 10cm.
What are the 2 parts of the first stage of labour?
- Latent/quiet phase
- Active phase
What is the latent phase of the first stage of labour?
The first phase - contractions are at 5-10 minute intervals, not too painful, and gradually become stronger and over shorter intervals.
Cervix dilates to 3-4 cm.
What is the active phase of the first stage of labour?
Starts at 3-4 cm dilation.
Dilation occurs more rapidly.
During this time, the foetal head descends into the maternal pelvis.
How do we manage the first stage of labour?
- Reassure and keep pt in the loop
- Measure pulse hourly and Temp/BP 4 hourly.
- Monitor contraction rate half-hourly
- Offer vaginal examination 4 hourly
- Discuss pain relief
What is the second stage of labour?
It starts with the cervix fully dilated and ends with the birth of the baby.
How frequently do contractions occur in the second stage of labour?
Every 2-5 minutes and last 60-90 seconds.
How does the foetus move during the second stage of labour?
Head descends into pelvis, rotates anteriorly.
Once the head has been born, head rotates to allow shoulders to pass.
How is the second stage of labour managed?
- Pain relief as required
- Encourage pushing during contractions
- Monitor contractions and FHR
How long should the second stage of labour last in a:
a) nulliparous woman?
b) multiparous woman?
a) under 2 hours
b) under 1 hour
What is the third stage of labour?
Starts with birth of baby and ends with delivery of placenta and membranes.
How long does the 3rd stage of labour typically take?
Around 5 minutes
How should the 3rd stage of labour be managed?
- Expectantly or actively
- Clamp the cord once it has stopped pulsating
- Give IM oxytocin if active Mx is prefered
- Cut the cord and check the placenta is whole
What are the benefits of water births?
- May shorten first stage of labour
- Reduce episiotomy rates
- Reduce need for analgesia
How common are operative vaginal deliveries?
Fairly, around 10-15% of deliveries.
How can an assisted delivery be avoided?
- Good support during childbirth
- Mother labours in an upright or left lateral position
- Avoid epidural anaesthesia
What are the types of instrumental delivery?
Forceps delivery
Ventouse delivery
What can prevent a woman having to have an assisted delivery?
- Presence of someone supporting her though childbirth
- Labouring in upright or left lateral position
- Avoiding using epidural
What are the classifications of forceps deliveries?
- Outlet
- Low
- Mid-cavity
- High
Based on position and station of baby
Why are assisted deliveries used?
To shorten second stage of labour e.g. if foetus is compromised, there is maternal compromise or disease, or inadequate prgression.
When are assisted deliveries contraindicated?
- Predisposition to fractures in foetus
- Bleeding tendancy in foetus
- Face presentation with vacuum extraction
- Vacuum extraction in under 34 weeks (although dicey up to 36 weeks)
What acronym can be used to assess requirements for instrumental delivery?
FORCEPS
What are the aspects of the FORCEPS tool?
- Fully dilated cervix
- Occipito-anterior position
- Ruptured membranes
- Cephalic presentation
- Engaged
- Pain relief is adequate
- Sphincter (bladder is empty)
What maternal factors are associated with failure of instrumental delivery?
Maternal BMI over 30
What foetal factors are associated with failure of instrumental delivery?
Weight over 4kg
OP position
Mid-cavity
When should an instrumental delivery be abandoned?
After 3 pulls with no descent seen
What aftercare needs to be done following an instrumental delivery?
- Perineal examination
- Analgesia (paracetamol and diclofenac)
- Assess need for thromboprophylaxis
- Bladder care
- Reassure about future deliveries.
What should be done if an instrumental delivery fails?
C-section
What are the complications seen with the baby following instrumental delivery?
- Cephalohaematomas
- Retinal haemorrhages
These are not associated with long term adverse effects.
What maternal complications can arise from instrumental delivery?
- Perineal tear esp. 3rd and 4th degree
- Urinary/faecal incontinence
- ?increased risk of pelvic organ prolapse
What is foetal distress?
Compromise of the foetus due to inadequate oxygen or nutrient supply.
What factors can contribute to foetal distress?
Maternal, foetal, or placental.
What is the main cause of antepartum foetal distress?
Uretoplacental insufficiency
What factors may cause uretoplacental insufficiency?
Uretoplacental vasculoar disease
Reduced uterine perfusion
Intrauterine sepsis
Cord compression
What are the risk factors for foetal distress?
Maternal hx of: -Stillbirth -IUGR -Oligo/polyhydramnios -Multiple pregnancy -Rhesus sensitisation -HTN -Obesity -Smoking -Diabetes and other chronic disease -Pre-eclampsia/pregnancy induced HTN -Recurrent antepartum haemorrhage -Post-term pregnancy Maternal age over 35
What symptoms/signs would raise suspicion of foetal distress?
- Reduced foetal movements
- Slowing/stopping of growth from serial measurements
- Abnormal sonogram
- Changes on uterine artery/venous Doppler
- Non-reassuring CTG
- Abnormal amniotic fluid volume
- Foetal scalp blood sample non-reassuring
What are the steps to managing foetal distress?
- Monitor
- View to induce if not in labour or planned c-section
- Expedite delivery if continuing foetal distress
How quickly do the guidelines say that delivery should occur if there is immediate threat to the mother or foetus?
Quickly and safely within 30 minutes if possible.
What might complicate the birth of a foetus who experienced distress in-utero?
Meconium-strained liquor.
Why is meconium-stained liquor detrimental?
If it is inhaled it can cause chemical pneumonitis and be detrimental to foetal lungs.
How might ofetal distress be detected? (in simple terms)
- Foetal hypoxia
- Acidosis on blood sampling
What are the risk factors for birth trauma?
- Large infant (esp. over 4.5kg)
- Cephalopelvic Disproportion
- Instrumental delivery
- Breech delivery
- Prematurity
- Shoulder dystocia
What skull injuries can occur during birth?
- Cephalohaematoma
- Subgaleal haematoma
- Caput succedaneum
- Cuts and abrasions
- Subcut fat necrosis
What categories of injury can occur during birth?
- Skull injury
- Brachial plexus injury
- Cranial nerve injury
- Laryngeal nerve injury
- Spinal cord injury
- Fractures
- Abdominal bleeding
- Hypoxia
What is cephalohaematoma?
Bleeding between the periosteum and skull.
What can cephalohaematoma lead to?
- Blood loss can cause anaemia and even hypotension
- Hyperbilirubinaemia from breakdown of haemoglobin
What is a subgaleal haematoma?
Bleeding between the periosteum and the scalp, usually following instrumental delivery.
How are cephalohaematomas different to subgaleal haematomas?
A subgaleal haematoma is not confined by suture lines as it is between periosteum and the scalp and not the skull.
What is caput succedaneum?
Poorly defined subcut collection of fluids, common after a prolonged labour.
What can cause cuts and abrasions in delivery?
C-section cutting into the uterus.
Instrumental delivery
How common are brachial plexus injuries?
2 per 1000 births
What brachial plexus injuries can occur during birth?
Erb’s palsy
Klumpke’s paralysis
Which brachial plexus injury is most common durng birth?
Erb’s palsy
What is Erb’s palsy?
Damage to C5 C6 segments of brachial plexus causing the arm to become limp, adducted, and internally rotated. The elbow is pronated and wrist is flexed.
What is the classic sign of Erb’s palsy?
Waiter’s tip deformity
What is Klumpke’s paralysis?
Damage of the nerves in C7 C8 T1 segment causing weakness of the hand and loss of grasp reflex.
How should a birth related brachial plexus injury be managed?
Most cases resolve spontaneously, although it can take up to 2 years in some cases.
Exclude any fractures with x-rays
Examine phrenic nerve for damage
What can cause cranial nerve damage during birth?
Hyperextension, traction, overstretching with simultaneous rotation.
How can birth injury to laryngeal nerve present?
Hoarse cry or stridor, swallowing may also be affected.
Bilateral damage causes severe respiratory problems.
Why does spinal cord injury during birth often lead to stillbirth or neonatal death?
Inability to breath - ventilation may be life-saving.
Which bones are most commonly fractured during birth?
Clavicle, or arm/leg bone fractures.
How does abdominal bleeding from birth injury present?
Shock
Pallor
Distended abdomen
Anaemia
How can abdominal bleeding due to birth injury occur?
Hepatic laceration or rupture of spleen.
