Labour Flashcards
What is failure to progress?
Labour not developing at a satisfactory rate
Ps of progress in labour
Power: uterine contractions
Passenger: size, presentation and position of the baby
Passage: the shape and size of the pelvis and soft tissues
Psyche
Phases of first stage of labour
Latent
Active
Transitional
Latent phase
0-3cm dilation of cervix
0.5cm/hr
irregular contractions
Active phase
3-7cm dilation of cervix
1cm/hr
Regular contractions
Transitional phase
7cm-10cm dilation of cervix
1cm/hr progression
strong and regular contractions
Delay in labour:
First stage
Second stage
Third stage
1st stage:
Less than 2cm of cervical dilatation in 4 hours
Slowing of progress in a multiparous women
2nd stage:
Pushing more than 2 hours in nulliparous
Pushing more than 1 hour in multiparous
3rd stage:
>30 mins active management
> 60 mins physiological management
Passenger
Size: shoulder dystocia
Attitude: posture
Lie: position of fetus in relation to mother’s body
Presentation: part of fetus closest to cervix
Risk factors for uterine rupture in VBAC
Previous c section Previous uterine surgery Obstruction or induction of labour Multiparity Multiple pregnancies
Absolute contraindications to VBAC
Classical c section scar
Previous uterine scar
Contraindications to vaginal birth
Active management of the third stage of labour
im oxytocin
controlled cord traction
management of failure to progress
amniotomy: ARM
oxytocin infusion
instrumental delivery
c section
Relative contraindications to VBAC
Complex uterine scars
>2 prior lower segment c sections
Management of VBAC delivery
These women should deliver in a hospital setting with facilities for emergency caesarean and advanced neonatal resuscitation.
There should be continuous CTG monitoring.
Beware of additional analgesic requirements during the labour as may indicate impeding uterine rupture.
Avoid induction where possible.
If induction is required, the risk of uterine rupture is less using mechanical techniques (e.g. amniotomy) than induction with prostaglandins.
Be cautious with augmentation (increased risk of uterine scar rupture)
Any decisions about both induction and augmentation require input from a senior obstetrician.
After 39 weeks an elective repeat caesarean is recommended delivery method.
when does normal labour and delivery usually occur?
37-42weeks
definition of labour
progressive dilatation and effacement of cervix in presence of regular uterine contractions
delivery definition
expulsion of feotus and placenta
show defintiino
cervical mucus plus
gravidity
total number of pregnancuies
parity
the state of having given birth
>24 weeks
>500g
three stages of labour
First stage – from the onset of labour (true contractions) until 10cm cervical dilatation
Second stage – from 10cm cervical dilatation until delivery of the baby
Third stage – from delivery of the baby until delivery of the placenta
braxton-hicks contractions
Braxton-Hicks contractions are occasional irregular contractions of the uterus. They are usually felt during the second and third trimester. Women can experience temporary and irregular tightening or mild cramping in the abdomen. These are not true contractions, and they do not indicate the onset of labour. They do not progress or become regular. Staying hydrated and relaxing can help reduce Braxton-Hicks contractions.
signs of labour
Show (mucus plug from the cervix)
Rupture of membranes
Regular, painful contractions
Dilating cervix on examination
indications for continuous CTG monitoring in labour
Sepsis
Maternal tachycardia (> 120)
Significant meconium
Pre-eclampsia (particularly blood pressure > 160 / 110)
Fresh antepartum haemorrhage
Delay in labour
Use of oxytocin
Disproportionate maternal pain
CTG features to look for
Dr C BRAVADO
Contractions – the number of uterine contractions per 10 minutes
Baseline rate – the baseline fetal heart rate
Variability – how the fetal heart rate varies up and down around the baseline
Accelerations – periods where the fetal heart rate spikes
Decelerations – periods where the fetal heart rate drops
Overall impression
Contractions on CTG
Number of contractions present in 10 squares
Duration and intensity
Too many contractions
uterine hyperstimulation, fetal compromise
too few contractions
labour not progressing
fetal tachycardia causes
>160 fetal hypoxia chorioamnionitis hyperthyroidism fetal/ maternal anaemia fetal tachyarrhythmia
fetal bradycardia causes
100-200
postdate gestation
occiput posterior or transverse presentations
causes of prolonged, severe bradycardia in ctg
prolonged cord compression cord prolapse epidural and spinal anaesthesia maternal seizures rapid fetal descent
normal variability CTG
5-25
causes of reduced variability
fetal sleeping fetal acidosis fetal tachycardia drugs: opiates, benzodiazepines prematurity congenital heart abnormalities
early decelerations
start when uterine contraction begins and recover when uterine contraction stops
normal
causes of early decelerations
uterus compressing the head of the fetus
stimulating vagus nerve
slowing heart rate
late decelerations causes
maternal hypotension
pre-eclampsia
uterine hyperstimulation
variable decelerations causes
umbilical cord compression
if shoulders are there not worrying
fetal bradycardia rule of 3s
3 minutes – call for help
6 minutes – move to theatre
9 minutes – prepare for delivery
12 minutes – deliver the baby (by 15 minutes)
sinusoidal CTG causes
severe fetal hypoxia
severe fetal anaemia
fetal/maternal haemorrhage
oxytocin indication
syntocinon
induction of labour
progressiob of labour
increase strength of contracetions
PPH
atosiban indication
oxytocin receptor antagonist
alternative to nifedipine in premature labour
ergometrine indication
PPH
third stage of labour
prostaglandins indication
dinoprostone
induction of labour
misoprostol
prostaglandin analogues
medical management of miscarriage
mifepristone
anti-progestogen
blocks progesterone and ehnances prostaglandins
used in induction of labour after intrauterine fetal death and alongside misoprostol for abortions
nifedipine
CCB that acts to reduce smooth muscle contraction in blood vessels and uterus
reduces BP
tocolysis in premature labour, delay onset
terbulatline
B2 agonist
tocolysis in premature labour
carboprost
prostaglandin analogue
stimulates uterine contraction
PPH
caution in asthma
Gas and Air (Entonox)
Gas and air contains a mixture of 50% nitrous oxide and 50% oxygen. This is used during contractions for short term pain relief.
Intramuscular Pethidine or Diamorphine
IM opioid
They may cause drowsiness or nausea in the mother, and can cause respiratory depression in the neonate if given too close to birth. The effect on the baby may make the first feed more difficult.
PCA
remifentanil
epidural side effects
Headache after insertion
Hypotension
Motor weakness in the legs
Nerve damage
Prolonged second stage
Increased probability of instrumental delivery
