Labour Flashcards
Types of delivery
vaginal - SVD / induced ± instrumental
Caesarean section - emergency / elective
Talk about instrumental delivery
Forceps and vontouse
only be done if needed in dystocic labour and abiding by certain rules including
- cervix is fully dilated, head at or below the spines, no maternal bleeding disorder and also it needs to be done with the woman’s permission
Reasons for instrumental delivery:
Fetal indications - concern of fetal distress based on CTG or FBS
Maternal - fatigue, failure to progress
Forceps poses less risk to the baby, can only be used if there is direct presentation of the baby
Vontouse - better for mother (less risk of perineal injury)
- can be used for rotational delivery. - risk of cephalohaematoma
How do you know a woman is in labour?
Symptoms include Spontanous ROM, painful regular contractions
Signs - confirmation of ROM based on speculum examination
- can test the fluid to confirm liquor vs vaginal secretions - amnisure, pH, ferning
What is the Bishop’s score?
Score based on examination of the cervix used to assess if induction of labour would be favourable. A higher Bishop score suggests a woman is more likely to progress in labour.
Description of cervix when not in labour
Posterior, not effaced, firm, not dilated
Description of cervix when labour begins
Anterior, soft, full effaced, starting to dilate, feta head should be at the ischial spines.
What is a dystocic labour?
Dystocia refers to abnormal progression in labour
Ideally should progress with cervical dilation at 1cm/hr.
Can have primary or secondary arrest of labour.
Primary - labour is confirmed but fails to progress. Secondary - labour progresses a bit before stopping
What are the causes of dystocia?
Powers - contractions
Passenger - position of the baby
Passage - Think cephalopelvic disproportion if pains are strong, regular, frequent and the baby is in an OA position.
What can be done to help progress if the contractions aren’t regular?
Artificial ROM with woman’s permission if not already R
Oxytocin
When should oxytocin not be used?
Used with caution in multiparous women and in women with previous C section due to risk of scar causing uterine rupture
Maternal indications for induction of labour
Pre-eclampsia Intra-hepatic cholestasis of pregnancy Diabetes - macrosomia Post dates Choice Ruptured membrane at term but not in labour ( allow 24hrs for spontaneous labour before inducing)
Most likely cause of dystocia in a multiparous woman?
Passenger - position of baby
passage - cephalopelvic disproportion
In what circumstances would you not wait 24hrs between SPROM and inducing labour?
If meconium in liquor -> fetal distress.
GBS, HIV, Hep B -> minimise time of exposure for the baby
Fetal indications for induction of labour
Oligohydramnios
Reduced fetal movements
Macrosomia - hx of big babies, may induce before EDD
Growth restricted baby if could tolerate labour
Fetal anomaly that requires treatment at birth and need to plan for neonatal care e.g. cardiac abnormality, gastroschesis.
Difference between induction and augmentation of labour?
Induction is when there are no s&s of labour and a decision is made to start the labour
Augmentation is intervention to help progress in a dystocic labour
What are the stages of labour?
1st - from onset of labour to full dilatation
2nd - full cervical dilatation to delivery of fetus
3rd - from delivery of fetes to delivery of placenta
How are contractions classified?
Based on their duration
mild - less than 30s
moderate 30-60s
severe 60s+
Complications of CS
VTE Bleeding Infection Trauma - fetus, bladder, bowel. Scar on uterus for subsequent pregnancies
What are the indications for a CS?
Fetal- distress -> emergency
Maternal
- Dystocia
- Condition requiring delivery that is not suitable for IOL e.g. chorioamnionitis
- Primary active herpes infection
- Choice
- Placenta praevia
- Previous classic CS
- 2 previous CS
What are the pain relief options available for women in labour?
Complementary
Conventional - Entenox, opioids, epidural, pudendal block, spinal anaesthetic, GA
What complementary pain relief methods are available?
There are lot of options and a combination of different methods using ‘labour hopscotch’ can work well.
one to one midwife care has been shown to help manage pain in labour
TENS machine Aromatherapy Hypnotherapy Acupuncture Acupressure Heat pack Water pool/ shower
Conventional pain relief
Entenox and opioids
Entenox - mix of O2 and NO, inhale, peak efficacy at 20-30s, no harm to baby
Opioids - Pethidine IM ( can cause euphoria, cautious of resp depression, N&V). Morphine. - Remifentanyl (PCA, ultra short acting, may be used if epidural is contraindicated, requires constant supervision because risk of resp depression and arrest)
Epidurals
Combination of local + opioid
Placed at the level of T10 for labour
Can be topped up and used if need to change to CS.
Onset of action 15-20mins
Who can’t have an epidural?
§ Thrombocytopenia (less than 80)
§ Heparin prophy in last 12hrs or therapeutic dose in last 24hrs
§ Inherited bleeding disorder
§ Septic
§ Scoliosis
§ Caution with some cardiac issues e.g. aortic stenosis ( the epidural will drop their BP)
Haemodynamically unstable - can’t drop the BP further
Possible complications of an epidural
Haematoma
Abscess
Dural puncture headache
Nerve damage
Pudendal block
Spinal
Pudendal block - injection of local into the pudendal nerve (roots S2,3,4). Short lived, may be used in instrumental deliveries where an epidural hasn’t been given.
Spinal benefits - single shot, patient is awake
Why is GA not generally used anymore?
- Only used if contraindication to spinal or if anaesthetic team choose GA as the fastest method in an emergency (category 1 CS)
- Mother won’t be awake for birth, can’t bond with baby immediately at birth
- inhaled anaesthesia can cross placenta to affect baby
- laryngeal oedema makes the intubation technically difficult.
What’s the significance for labour of a woman being primiparous?
She is more likely to have a primary arrest
- Usually due to insufficient uterine contraction
- May require oxytocin to augment her labour
What is the risk of uterine rupture in a woman having a VBAC?
<1%
Risk of C section with induction?
Risk of having a c section if a woman comes in spontaneous labour is about 6%, if she’s a 2nd time mum that risk drops to 2%
If a women is induced her risk goes up to about 38%, a multiple induced goes up to 4%
How is induction carried out?
First decide if woman is suitable for ARM - based on bishop score (anterior, soft, short cervix, open/ dilated os and fetal head at ischial spines).
If suitable ARM, followed by oxytocin ( care in primp and prep CS)
If not suitable for ARM, use PG gel to ripen the cervix first.
Other option to PG is dilapam to physically dilate the cervix
