Labour Flashcards
Indications for cardiotocograph
Maternal: previous CS, pre-eclampsia, post term pregnancy, induced labour, DM, antepartum haemorrhage, prolonged rupture of membranes
Foetal: FGR, prematurity, oligohydramnios, multiple pregnancy, meconium stained liqour, breech
Note: only time it is not needed is during full term spontaneous uncomplicated labour
Define accelerations and decelerations on CTG
accelerations = increase >15bpm above baseline for >15s
decelerations = decrease >15bpm for >15s
Normal vs abnormal contractions
- duration, interval, frequency
normal: 3-5/10mins, lasts 60s, interval 60s
abnormal: >5/10min, >2mins duration, <60s interval
Interpreting CTG
documentation - name, date, calibration
"DR C BRAVADO" define risk - reason for CTG contractions baseline rate variability accelerations decelerations overall
Causes of foetal tachycardia and bradycardia
Bradycardia
- maternal - drugs, hypoxia, hypotension
- foetal - hypoxia, normal for post term
Tachycardia
- maternal - tachycardia, fever, infection, dehydration, drugs
- foetal - premature, tachyarrhythmia
Causes for reduced/absent variability
definition of reduced / absent variability
sleep
CNS depression - hypoxia, infection, drugs
reduced = 3-5bpm and absent = <3bpm
normal variability = 6-25bpm
Types of decelerations and cause of each
early - mirror contraction, small and symmetrical, return to baseline quickly, caused by head compression during contraction (good)
late - just after contraction, no return to baseline for 20s, caused by placental insufficiency
variable - V shaped and large, any time, sharp fall >40bpm, caused by cord compression
prolonged - >2mins
General management of abnormal CTG
Call for help - midwife and obstetrician
Reposition mum - left lateral position, encourage to mobilise
Check maternal vitals
IVF
if uterine contractions an issue - stop oxytocin and prostaglandins and consider tocolysis
Define ‘normal birth’
37-42 weeks
spontaneous onset vaginal birth
low risk at start of labour and throughout birth
vertex presentation at birth
Define ‘ true labour’
regular painful contractions of increasing intensity, duration and frequency
progressive dilation and effacement of cervix
descent of progressing part with progression of station
Define ‘false labour’
irregular painless contractions with unchanging intensity and long intervals
no cervical dilation or effacement or descent
What are the stages of labour?
- 0-10cm cervical dilation
latent: =3cm, irregular and infrequent contractions
active: 4-10cm, regular and painful contractions
2. 10cm to delivery of baby 2h nulliparous 1hr multiparous passive/pelvic: no urge active/perineal: urge to push
- delivery of placenta and membranes
<30mins - 2hrs post partum monitoring of mother and neonate
Foetal movements during delivery
- descent and engagement
- flexion of head
- internal rotation so occiput is towards midline near symphysis
- extension of head as it is delivered
- external rotation / restitution
- anterior should delivered
- posterior shoulder
Factors affecting course of labour (3Ps)
power of uterine contractions
passage - resistance of bony pelvis and soft tissues
passenger - lie, presentation, attitude, position
Types of cephalic presentation
vertex - neck flexed, AP diameter is suboccipito-bregmatic
occipitoposterior - baby anterior rather than posterior, head only partially flexed
brow - partial extension, occipitomental (largest diameter)
face - full extension, submento-bregmatic diameter
Engagement definition
when bipareital diameter has passed through pelvic inlet
abdominal palpation - 2/5 of head is palpable above symphysis and is fixed
occurs around 36 weeks
What is the modified bishop score and what are the components assessed for it
pre labour screening of whether induction is required and if cervical ripening is required - predicts likely outcome of IOL
Bishops score Iffacement Station Hard or soft - consistency Opening - dilatation Position
How to monitor progress of low risk labour
VE - on admission and every 4 hours for bishop score
Contractions
Partogram - FHR, cervical dilation, station, contractions, liquor, drugs and fluids, maternal vitals
How to monitor foetal condition during labour
Intermittent auscultation with hand held doppler - 15 mins in first stage, 5 mins in second
CTG
Foetal scalp and lactate sampling if abnormal FHR or CTG
liquor
moulding - suture lines meet, cross over, cross over but not reducible
IVFs during labour - what type and indications
Hartmann’s
>6hrs of labour foetal distress on CTG foetal or maternal tachycardia fever dehydration
Indications for episiotomy
perineum begins to tear breech macrosomia shoulder dystocia instrumental birth prolonged 2nd stage
active management for 3rd stage of labour
IV oxytocin shortly after delivery of baby
delayed cord clamping (>2mins) prolong foetal O2 supply
controlled cord traction
Non pharm options for pain relief
psychoprophylaxis - breathing techniques and coping mechanisms
posture - upright reduces labour time
TENS machine - early stage, 2 electrodes on back
water emersion
heat/cold packs
massage
Pharmacological options for pain relief
- benefits and disadvantages
paracetamol - early labour
morphine or pethidine - NOT if <2hrs before baby, okay if >4hrs until baby expected
- effective, easy, fast
- n&v, constipation, resp depression
nitrous oxide - early labour
- mother has control, rapid, low SE
- doesn’t completely relieve pain, confusion
epidural - excellent relief, minimal resp depression, mother has control
- hypotension, headache, prolonged 2nd stage, increased requirement for oxytocin and assisted delivery, reduces mobility, need catheter, neuro risks, infection
Degrees of perineal tears
1st - vagina and perineal skin
2nd - posterior vaginal wall, underlying perineal muscles, includes episiotomy - requires sutures
3rd - anal sphincter - repair in theatre
4th - anorectal mucosa - repair in theatre and IV Abx
indications for IOL
maternal - pre-eclampsia, GDM, APH, obstetric cholestasis
foetal - foetal distress, post dates (40+10), SGA/IUGR, macrosomia, infection, Rh disease of newborn
risks of IOL
failure
cervical ripening - uterine rupture, laceration (balloon), hyperstimulation, bronchospasm, glaucoma
ARM - infection, cord prolapse, abruption
oxytocin - uterine hyperstimulation, rupture, cord prolapse
methods for IOL (4)
cervical ripening - if MBS <7 and membranes intact; balloon catheter or dinoprostone (prostaglandin) if balloon fails
ARM - MBS >7 with favourable cervix
oxytocin - used after ROM (do not use within 6hrs of dinoprostone gel, can be used 30mins post removal of pessary)
Ddx of maternal collapse during labour
hypovolemia - septic shock, ruptured aneurysm
hypoxia - dissection, asthma, PE
hypothermia - rare
hyper/hypokalaemia - rare
tension PTX
tamponade
thromboembolism - AF embolism, PE, MI (dissectio)
toxins - MgSO4, insulin, local
Cause and mx of uterine inversion
over enthusiastic cord traction or placentation densely attached to uterus
relocate manually, if that doesn’t work go to theatre
Cord prolapse management
do not touch cord - causes spasm
put hand up and push presenting part of foetus up to prevent cord spasm and occlusion
cat 1 CS
shoulder dystocia presentation and complications
turtle sign - head presents and retracts
complication - hypoxia, Erb’s palsy
mx of shoulder dystocia
HELPERR
call for Help
consider Episiotomy
Legs on McRoberts manoeuvre (hug to chest)
suprapubic Pressure
above should work, if not:
Enter and manoeuvre baby
Remove posterior arm
Roll patient onto hands and knees and reattempt
definition of primary and secondary PPH
primary - >500ml vaginal >1000ml CS
secondary - >24 hours up to 6 weeks post partum
Causes of PPH
uterine atony
- over distension ie multiparty, multiple pregnancy, polyhydramnios, GDM, macrosomia
- prolonged labour >12 hours
trauma
- malpresentation
- perineal, vaginal, cervical tears
tissue
- retention of products
- praaevia or abruption
thrombin
- PET
- coagulopathy
- anticoagulants
- DIC
general Mx of PPH
IV access
remove retained products, uterine fundus massage, bimanual compression, uterotonics, TXA, uterine tamponade, uterine compression suture, embolisation, hysterectomy
types of uterotonics for PPH
IV oxytocin
IV ergometrine
IM carboprost
PR or sublingual misoprostol
