Labour Flashcards
What is the epidemiology of labour?
o 600,000 babies born per year
o 30% by C-section (elective and emergency), 10% instrumental, 60% by natural means (inc. induction)
What is labour?
Painful uterine contractions leading to effacement and dilation of the cervix (normal length = 4cm)
o N.B. 2/5th palpable or below is defined as engagement
o If someone is just dilating due to cervical insufficiency, you can perform cervical cerclage
What are braxton hicks contractions?
PAINLESS and NO CERVICAL CHANGE
Describe the 3 stages of labour?
o 1st stage – painful uterine contractions -> full (10cm) cervical dilatation
§ Latent phase = begins with painful, irregular contractions; dilation up to 4cm
§ Established stage 1 = regular painful contractions; ≥4cm dilation
o 2nd stage – starts with the urge to push and ends with delivery of the foetus
§ Passive stage (not pushing) -> Active stage (pushing)
§ Analgesia (‘1, 2, 3’ and analgesia = +1 hour):
· In nulliparous women -> 3 hours (epidural) or 2 hours (no epidural)
· In multiparous women -> 2 hours (epidural) and 1 hour (no epidural)
o 3rd stage – delivery of placenta and foetal membranes
§ Can last as long as 30 mins
What are the mechanisms of labour?
o N.B. pelvic inlet widest TRANSVERSE, but pelvic outlet widest ANTERIOR-POSTERIOR
o Progress of labour determined by:
§ Power – contractions
§ Passage – dimensions of pelvis
§ Passenger – diameter of foetal head
o Restitution = brining head in line with the shoulders
What are the risk factors of shoulder dystocia?
macrosomia, high maternal BMI, DM, prolonged labour
What are the S/S of shoulder dystocia?
difficult face/chin delivery, ‘turtling’ head (retracting), failure of restitution, failure of shoulder descent
What is the management of shoulder dystocia?
§ 1) Call for senior help + discourage pushing
§ 2) McRobert’s manoeuvre (legs up to abdomen) and suprapubic pressure – 90% success
§ 3) Evaluate for episiotomy
§ 4) Either (depends on user experience / clinical indication):
· 1) Rubin’s manoeuvre (push anterior shoulder towards baby’s chest)
· 2) Woods’ Screw (Rubin’s + push posterior shoulder towards baby’s back -> rotation)
· 3) Deliver posterior arm (then, rotate 180 and deliver the other arm)
§ 5) Change position to all fours and repeat the above manoeuvres
§ 6) Symphysiotomy, cleidotomy (divide clavicles) or Zavanelli (reversal of normal delivery movements)
What is the complication of shoulder dystocia?
Erb’s Palsy
What is Bishop’s score?
a score used to see how likely one is to go into labour soon
Define effacement, position and station.
o Effacement = (also called shortening or thinning) is reported as a percentage from 0% (normal length cervix) to 100% or complete (paper thin cervix)
o Position = the position of the foetal head relative to the maternal head and maternal pelvis
o Station = position of the baby’s head relative to the ischial spines of the maternal pelvis. If the head is level with the spines, the score is 0; however, above or below them can modify the score
How do you use Bishops score?
§ <3 IOL unlikely to be successful
§ ≤5 IOL with PV prostaglandin gel (should start labour or ripen cervix)
§ 6-8 ARM (amniotomy ± oxytocin infusion if labour does not begin)
§ ≥9 labour likely to occur spontaneously
Offer x2 PGE2 and then ARM
Offer x2 PGE2 and then ARM
Summarise the management of the first stage of labour
§ One-to-one midwifery care
§ Vaginal examinations performed 4-hourly or as clinically indicated
§ Progress of labour is monitored using a partogram with timely intervention if abnormal
§ Ensure adequate:
· Analgesia ± antacids
· Hydration and light diet to prevent ketosis (which can impair uterine contractility)
§ Normal Progress: ~1 cm every hour (a well flexed head will speed this up)
§ Delay: <1cm over 2 hours (a well flexed head will speed this up)
What do you do in latent first phase?
mobilise and managed away from the labour suite
§ This stage is generally silent as the cervix gradually effaces over a period of days/weeks
§ Intervention should be avoided where possible
§ Standing upright may encourage progress of labour (so mobility should be encouraged)
How do you manage delay in the first stage of labour?
<1cm per 2 hours is defined as delay (this is so intervention isn’t started too early)
1st -> Membranes intact -> ARM (Artificial Rupture of the Membranes) -> review in 2 hours
2nd -> Membranes ruptured -> oxytocin:
· Increase every 15-30 mins until regular contractions
· Once regular contractions, review in 4 hours
o During this phase, the membranes may be intact or may have ruptured
What are the types of delay in the first stage labour?
Primary dysfunctional labour <2cm dilation in 2 hours, never progressed properly
Most commonly due to ineffective uterine action
Secondary arrest of labour progressed well and then stopped
Prolonged latent phase
Cervical dystocia rare; cervix doesn’t dilate properly
What is the management of the second stage of labour?
o First sign of the 2nd stage = urge to push (with 10cm dilation)
o Full dilatation of the cervix confirmed by a vaginal examination (if the head is not visible)
o Women should be discouraged from lying supine or semi-supine
o Use of regional anaesthesia (epidural or spinal) may interfere with the normal urge to push – meaning that the second stage is more often diagnosed on routine scheduled vaginal examination
How do you manage a delayed second stage of labour?
o Delay / Prolonged Second Stage (from start of active 2nd stage):
In nulliparous women -> 3 hours (epidural) or 2 hours (no epidural)
In multiparous women -> 2 hours (epidural) and 1 hour (no epidural)
· 1st -> Membranes intact -> ARM (Artificial Rupture of the Membranes) -> review in 2 hours
· 2nd -> Membranes ruptured -> oxytocin:
o Increase every 15-30 mins until regular contractions
o Once regular contractions, review in 4 hours
What happens in delivery?
§ Watch the perineum -> between contractions, elastic tone of the perineal muscles will push the head back into the pelvic cavity -> when head no longer recedes between contractions = crowning
· This indicates that delivery is imminent
§ As crowning occurs, the hands of the midwife are used to flex the foetal head and guard the perineum
§ Once the head has crowned, the woman should be discouraged from bearing down by telling her to take rapid, shallow breaths
What is the immediate care of the neonate?
o The baby will usually take its first breath within seconds
o There is no need for immediate clamping
o After clamping/cutting umbilical cord, baby should have an Apgar score calculated at 1 minute and at 5 minutes
o The baby’s head should be kept dependent to allow mucus in the respiratory tract to drain
o Immediate skin-to-skin contact between mother and baby will help bonding and promote release of oxytocin
When is the APGAR score used?
Apgar score is used at 1 minute and 5 minutes after delivery (and every 5 minutes after if condition remains poor)
o >7 is considered normal APGAR = Appearance, Pulse, Grimace, Activity, Respiration
What should happen in the first hour of life?
§ The baby should be dried and covered with a warm blanket or towel
§ Initiation of breastfeeding should be encouraged within the first hour of life
§ Routine measurements of HC, birthweight and temperature should be measured soon after this hour
§ The first dose of baby’s vitamin K should be given in the delivery room (in first 24 hours
What are the causes of PPH?
“Tow-Truck is most common”
Tone (uterine atony; 70%)
Trauma (laceration; 20%)
Tissue (retained products; 10%)
Thrombin (coagulopathy; 1%)
What is the 3rd stage of labour?
o This normally takes 5-10 minutes (expulsion of placenta and foetal membranes)
o Management of the third stage can be described as active or physiologica
What is the active management of the 3rd stage?
recommended to ALL women
§ 10 IU oxytocin (IM) / ergometrine (only oxytocin if hypertensive)
· After birth of the anterior shoulder
· Immediately after delivery (and before the cord is clamped and cut)
§ Clamp the cord between 1-5 mins
§ Use controlled cord traction to remove the placenta -> signs of placental separation:
· Gush of blood Cord lengthening
· Uterus rises Uterus becomes round
§ Uterine inversion is a rare complication
§ In 2% of cases, the placenta will not be expelled by this method
§ If no bleeding occurs, another attempt should be made after 10 mins
What is the physiological management of the 3rd stage?
§ Placenta is delivered by maternal effort with no uterotonic drugs
§ Associated with more bleeding and a greater need for blood transfusions -> if haemorrhage occurs OR the placenta is undelivered after 60 mins, active management should be recommended
What happens post delivery?
§ 1) Inspect placenta for: If retained -> EUA + MROP (manual removal of placental tissue)
· Missing cotyledons
· Succenturiate lobe
§ 2) Vulva inspected for tears
What is the management of a prolonged 3rd stage?
§ Active management: >30 minutes
§ Physiological management: >60 mins -> move to active management
How do you induce labour?
o 1st: Membrane Sweeping
§ Offered prior to formal induction (not part of induction of labour) -> repeat if labour not starting
§ Nulliparous women -> offer at 40-41 weeks
§ Multiparous women -> offer at 41 weeks
o 2nd: Prepare the cervix -> prostaglandins (Prostin or Propress; Vaginal Prostaglandin E2)
§ Preferred formal method of induction
§ Can be administered as a tablet, gel or pessary
· Pessary: 1 dose over 24 hours
· Tablet or Gel: 1 dose, followed by a second dose after 6 hours (MAX: 2 doses)
§ RISK -> uterine hyperstimulation
§ In cases of intrauterine foetal death, misoprostol and mifepristone may be used instead
o 3rd: Artificial Rupture of Membranes (ARM)
§ ARM = amniohook
§ Should not be used first line
o 4th: Syntocinon
o 5th: CS
Propess (24 hours) -> Prostin (if propess was insufficient – max 2x; 6 hourly) -> ARM -> Syntocinon -> C-sectio
When is induction indicated?
Prevention of prolonged pregnancy (at 41wks, If declined -> twice weekly USS and CTG)
Maternal request (on or after 40 weeks, exceptional circumstances such as armed services partner leaving)
Intrauterine foetal death (If membranes intact -> offer induction If rupture of membranes, infection or bleeding -> immediate induction Induction regimen: oral mifepristone, followed by prostin or misoprostol)
When should you be cautious for inducing labour?
Previous C section (use prostin/ propress)
Increased risk of uteriine rupture and need for 2nd C section
When should you not induce?
PPROM before 34 weeks
Breech/ trasnverse lie (consider Csection/ ECV)
IUGR if severe (CSection)
Suspected foetal macrosomia
What non pharmacological analgesia can be used?
§ TENS
§ Breathing techniques
§ Massag
What pharmacological analgesia can be used?
§ Entonox (50% NO in O2) -> nausea, light-headed, dry mouth
§ Meperidine (pethidine, IM 1mg/kg) -> ‘sleepy baby’, low baby RR, constipation
§ Morphine (0.1-0.15mg/kg) or Diamorphine (IM 5-7.5mg) -> ‘sleepy baby’, low baby RR, constipation
§ Fentanyl PCA 20μG bolus with 5 min lockout -> ‘sleepy baby’, low baby RR, constipation
What surgical analgesia can be used?
slow labour, increased instrumental risk
§ Lumbar epidural – bupivacaine, ropivacaine, levobupivacaine, chloroprocaine
§ Combined lumbar spinal-epidural – fentanyl 10-25mcg ± bupivacaine 2.5mg
What is a partogram?
o Records condition of mother, condition of foetus, progress of labour
o Can be used to calculate a Bishop’s score (collects all necessary pieces of data)
What are the obstetric emergencies?
o Sepsis
Antepartum haemorrhage or PPH
Placenta praevia
o Placenta accreta
Vasa praevia
Prolonged 3rd stage
o Eclampsia
Amniotic fluid embolism
Cord prolapse
o Shoulder dystocia
DVT PE
Uterine inversion
o Uterine rupture
Puerperal pyrexia
What is puerperal pyrexia?
> 38C in the first 14 days following delivery
What is the biggest cause of puerperal pyrexia?
Endometritis
What are causes of puerperal pyrexia?
Endometritis UTI VTE Wound infection (tear, CS) Mastitis
What is the management of puerperal pyrexia?
IV Clindamycin AND IV Gentamicin until >24 hrs apyrexial
