Labour Flashcards
Maternal Causes of preterm labour
PPROM, uterine stretch, cervical insufficiency, APH, infection, trauma, IOL
Fetal causes of preterm labour
IUGR, aneuploidy, structural malformations
Risks of giving oxytocin to induce labour
Uterine hyper stimulation, amniotic fluid embolism, water intoxication
When to do fetal fibronectin?
When cervix <3cm dilated, not in active labour, not ROM
How to diagnose preterm labour?
If regular, powerful contractions
Cervix is dilated to 4 or more cm
Or cervical dilation
Causes of OP position
- Android/anthropoid type pelvis
2. Use of intrapartum epidural analgesia due to relaxation of the pelvic floor muscles - it can’t rotate anteriorly
How to manage OP position in labour?
- Closely monitor progress and fetus (CTG)
- Use oxytocin to maintain 3-4 contractions every 10 minutes, will help rotation to OA
- Can use instrumental delivery
- If failure to progress/CTG abnormality, C section needed
What to do when you diagnose TAPS?
Follow up for MCA PSV within 24 hours
Maternal risks in multiple pregnancy (antenatal)
IDA, backache, GERD, hyperemesis gravidarum
APH, preeclampsia, GDM, GHTN, miscarriage
PPROM, preterm labour
Maternal risks multiple pregnancy (intra and postpartum)
Operative delivery, cord prolapse, PPH, postpartum depression
What are the antibiotics given for PPROM?
- Erythromycin 250MG PO QID for 10 days/till labour starts
2. Ampicillin 2g IV 6hrly for 2 days, then amoxicillin 250mg PO TDS for 5 days + erythromycin as above
When to do active management for PROM?
GBS +ve, SROM > 96 hours, meconium staining, chorioamnionitis, abnormal CTG, breech/malpresentation, multiple pregnancy
Definition of macrosomia
Above 90th percentile/4.5kg (Aussie)
When can you use low/mid cavity forceps
Fetal head 1/5th palpable per abdomen
Leading point of skull is above station + 2cm but NOT above ischial spines
Rotation of 45 or less
Postnatal care for instrumental delivery
Prophylactic antibiotics Thromboprophylaxis Analgesia Indwelling catheter for 12 hours Pelvic floor exercises
Early and intermediate risks for C-section
Maternal - PPH - damage to bowel, bladder, ureters - anesthesia - wound hematoma Fetal - TTN - laceration
Intermediate
- infection
- VTE
Late risks for C-section
Urogenital fistula Adhesion Uterine rupture with subsequent prev Placental malpositioning Ectopic pregnancy Repeat C-section for subsequent pregnancy
How to diagnose PPROM/PROM
Sterile speculum
- pooling of amniotic fluid
- if not, do ActimProm
Investigations for PPROM/PROM
Vital signs
FBC, CRP
First-void urine for chlamydia and gonorrhea PCR
MSU for MC&S
Low vaginal and perianal swab if GBS unknown
Ongoing maternal and fetal surveillance PPROM
Maternal
- 4-6 hourly temperature and pulse
- vaginal loss and uterine activity
- WCC 2x a week
- blood culture if chorio suspected, expedite birth
- woman must notify staff if feeling unwell, foul discharge, abdominal pain, change in fetal movements
Fetal
- CTG if more than 28 weeks, daily for 3 days then twice weekly
- BPP if less than 28 weeks, same
Birth timing in PPROM
All women expedite at 37 weeks, expectant if less.
If chorio or compromise, hasten
Intrapartum management of PPROM
If GBS, treat accordingly
Continuous CTG
Neonataology/paeds attend birth
Sent placenta and swabs for HPE
PPROM management flow
History Diagnosis Investigations Antibiotics CS/MGSO4 Ongoing surveillance Outpatient Birth timing Intrapartum mx Postnatal observation
When can discharge PPROM and indications
After admitted for 3 days, if got access to hospital, support at home, no signs of labour, no infection, no risk factors, no fetal compromise, gestational age
Expectant management for PROM
Book IOL within 96 hours after SROM or earlier if woman chooses
LVS and perianal swab for GBS if required
Review as outpatient every 48 hours
- CTG
- maternal vitals
- vaginal loss, abdominal pain and tenderness
If spontaneous labour, CTG at 24 hours after SROM
Bishop’s score cervical dilation and length scoring
0: 0cm/3
1: 1-2cm/2
2: 3-4cm/1
3: 5+/0
Bishop’s score cervical length scoring
0: 3cm
1: 2cm
2: 1cm
3: 0cm
Bishop’s score station scoring
0: -3
1: -2
2: -1,0
3: +1 onwards
Bishop’s score cervical consistency scoring
0: firm
1: medium
2: soft
Bishop’s score cervical position
0: posterior
1: mid
2; anterior
Contraindications to using vaginal pessary or vaginal gel to IOL
Multiparity > 3, unexplained vaginas bleeding, fetal compromise, previous c-section, major uterus surgery, asthma, hypersensitivity to PGE
Risks of using PGE2 for IOL
Uterine hyperstimulation, GI upset, uterine rupture, placenta abruptio
Which is the recommended episiotomy
Mediolateral at 60 angle to midline
Which sphincter injury causes fecal urgency and which causes fecal incontinence
External
Internal
Antenatal management of multiple pregnancy
High dose folate supplement and iron!
11-13 weeks: dating scan to determine chorionicity and assign nomenclature to fetus, as usual with others
20-22 week: anatomy scan
MCDA: fortnightly ultrasound from 16 weeks to monitor for TTTS and sFGR
DCDA: monthly scan from 24 weeks
Visits
- monthly till 30 weeks
- fortnightly till 34
- weekly after 34
Delivery timing and mode
DCDA: 37-38 weeks
MCDA: 36-37 (need betamethasone)
MCMA: 32-34
DCDA and MCDA: - vaginal of presenting twin cephalic, no complications, no size difference - epidural in case need IPV for breech - mom can choose c section MCMA: always c section Triplets and above: always c section
Monochorionic twins risk
- Twin-twin transfusion syndrome (TTTS)
- placenta laser ablation to disrupt anastomosis
- serial amnioreduction every 1-2 weeks - Twin reversed arterial perfusion sequence (TRAPS)
- cord ligation - Selective FGR
- Twin anemia-polycythemia sequence (TAPS)
- need to follow up with u/s for MCA PSV within 24 hours once detected
MCMA: cord entanglement (need to deliver early by c-section)
Maternal risks of multiple pregnancy
Antenatal:
IDA, GERD, backache, hyperemesis gravidarum
APH, GHTN, preeclampsia, GDM, miscarriage
Intrapartum and postpartum:
PROM, preterm labour, operative delivery, cord prolapse
PPH, breastfeeding, postpartum depression
Contraindications to vacuum delivery
Relative
- fetal bleeding disorders
- predisposition to fracture
Absolute
- <34 weeks due to risk of ICH
- face presentation
Outlet forceps (Wrigley’s) indications
fetal scalp visible without separating labia
fetal skull reached pelvic floor
rotation does not exceed 45
fetal head at or on perineum
Low/mid cavity forceps aka Neville Barnes, Anderson, Simpson
fetal head one-fifth palpable per abdomen
leading point of skill is above station + 2cm but not above ischial spines
rotation 45 or less
When to admit for preterm labour
Admit if:
fFn 50ng/ml or more
Cervical dilation/change after 2-4 hours, cervix length <15 mm
ROM/regular painful contraction/other concern
When is tocolysis needed for preterm labour and what are they
If risk of birth within 7 days, to allow for CS administration or if need transfer
Nifedipine, salbutamol, indomethacin
When to discharge if threatened preterm labour and when to follow-up
Normal maternal vitals No chorioamnionitis Infrequent contractions No cervical change Normal CTG FFN negative
must follow-up in one week and tell signs of PTL, risk reduction, how and when to seek clinical advice
Contraindications for ECV
Maternal: previous scar, high-risk mom Placenta: previa Fetal: IUGR, malformation, multiple preg, footling breech Fetomaternal: Rh incompatibility ROM Abnormal CTG
Procedure for breech
Admit mother and perform examination and investigations
Maternal: FBC, ECG, blood group, rhesus
Fetal: CTG, USG, amniotic fluid vol
NBM
Don’t empty bladder
Administer tocolytics
- SC terbutaline 250microgram or nifedipine 20mg oral
During:
- feel slight discomfort
- monitor FHR a intermittently
After
- Kleihauer
- give anti-D IgG
- perform CTG: if abnormal, PV bleed, unexplained pain, expedite birth
- if successful, monitor for a day
- come back for abdominal USG after a week
What maneuver is performed in breech delivery
Lovset’s
