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Labour Flashcards

1
Q

How many labours are induced and what do they require?

A

Approx 1 in 5 pregnancies are induced (artificially starting labour)

  • Need fetal monitoring
  • Need for cervical ripening=Prostaglandins (pharmacological) or Balloon (mechanical)
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2
Q

What is induction of labour?

A

When an attempt is made to instigate labour artificially using medications and/or devices to “ripen cervix” followed usually by artificial rupture of membranes (performing an amniotomy)

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3
Q

What is the BISHOP’S SCORE used for?

A

To clinically assess the cervix

The higher the score the more progressive change there is in the cervix & indicates that induction is likely to be successful

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4
Q

When can an amniotomy be performed?

A

Once cervix has dilated and effaced

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5
Q

What Bishop score is considered favourable for amniotomy?

A

7 or more

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6
Q

What is an amniotomy?

A

Artificial rupture of the fetal membranes usually using a sharp device (e.g. amniohook)

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7
Q

Once an amniotomy is performed what is IV OXYTOCIN used for?

A

Can be used to achieve adequate contractions (unless contractions spontaneously start) - aim for 4-5 contractions in 10 minutes

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8
Q

What are the indications for the induction (IOL)?

A

Diabetes

Post dates – Term + 7 days (Especially as increase over 41 weeks gestation-increasing risk of still birth)

Maternal need for planning of delivery e.g. on treatment for DVT

Foetal reasons e.g. growth concerns, oligohydramnios

Social / maternal request

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9
Q

What may cause inadequate progress in labour?

A

Inadequate uterine activity (powers)
Cephalopelvic disproportion (CPD) (passages)
Other reasons for obstruction e.g. fibroid (passages)
Malposition (passenger)
Malpresentation (passenger)

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10
Q

What is labour defined by?

A

Regular uterine contractions, progressive effacement & dilation of the cervix & descent of presenting part (baby)

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11
Q

Progress in labour is evaluated by a combination of abdominal & vaginal examinations to determine what?

A

-Cervical effacement
-Cervical dilation
-Descent of the fetal head through the maternal pelvis

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12
Q

For 1) Primigravid women & 2) Parous woman in the active 1st stage of labour suboptimal progress is defined as cervical dilation of less than what?

A

1) <0.5cm per hr
2) <1cm per hr

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13
Q

What happens if contractions are inadequate?

A

Fetal head will not descend & exert force on the cervix & the cervix will not dilate

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14
Q

How can the strength and duration of the contractions be increased?

A

Giving a synthetic IV oxytocin to the mother

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15
Q

Why is it important to exclude an obstructed labour in circumstances of inadequate uterine activity?

A

As stimulation of an obstructed labour could result in a ruptured uterus

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16
Q

What is cephalopelvic disproportion (CPD)?

A

Fetal head is in the correct position for labour but is too large to negotiate the maternal pelvis to be born

Caput (soft tissue swelling on head) &
Moulding (foetal skull bones start to cross over each other) develop

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17
Q

Is a degree of caput & moulding normal in labour?

A

Yes

Caput (soft tissue swelling on head) &
Moulding (foetal skull bones start to cross over each other)

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18
Q

What is malposition in labour and what occurs?

A

Involves the fetal head being in a suboptimal position for labour and ‘relative’ CPD occurs

Occipito-posterior (OP) & Occipito-transverse (OT)

Occipito-anterior position=optimal position
OT-babys not typically born in this position

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19
Q

How can tell of position of babies head?

A

Vaginal exam to feel for babies head-use fontanelles to guide

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20
Q

What is Vasa praevia?

A

Bleeding from foetal vessels that are abnormally placed in the amniotic sac

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21
Q

Why is it important to avoid causing too many contractions (Uterine Hyper-stimulation)?

A

Can result in fetal distress due to insufficient placental blood flow

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22
Q

What are the main causes of foetal distress?

A

Hypoxia, infection & also rare occurrences such as cord prolapse, placental abruption & vasa praevia

In many cases of suspected fetal distress no cause is found

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23
Q

There are 4 ways that foetal monitoring can be carried out. What are they?

A
  • Intermittent auscultation of the foetal heart
  • Cardiotocography (CTG)
  • Fetal blood sampling
  • Fetal ECG
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24
Q

How is fetal blood sampling carried out and when is it used?

A

Speculum used to take fetal scalp blood sample

Used when abnormal CTG

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25
Q

Foetal blood sampling provides a direct measurement from baby of what?

A
  • pH & base excess
  • Lactic acid

pH gives a measure of likely hypoxaemia

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26
Q

What forms of assisted or operative delivery are available?

A
  • Instrumental deliveries (forceps/ventouse)
  • Planned (elective) CS
  • Emergency CS
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27
Q

When can CS be performed in labour?

A

Can be performed at any time in labour-risk of PPH increases when performed at full dilatation

28
Q

What are 3rd stage complication examples?

A
  • Retained placenta (If after 60 mins placenta not out-would offer manual removal of placenta)
  • PPH (4 Ts)
  • Tears
    Graze
    1st degree
    2nd degree
    3rd degree – involving anal sphincter complex
    4th degree – involving rectal mucosa
29
Q

What are the 4 Ts associated with PPH?

A

TRAUMA
TONE
THROMBIN (clotting abnormal)
TISSUE (retained preg tissue)

30
Q

Labour problems are common especially in ..?..

A

Primigravid women

31
Q

What in its simplest terms are labour problems due to

A

’ The Passage, The Powers or The Passenger’

32
Q

When may operative vaginal birth or CS be necessary?

A

When problems occur in labour to prevent fetal & maternal morbidity & mortality

33
Q

Labour complications can be context specific: Give examples of this?

A

Place of birth, Skilled birth attendance
Fetal & Maternal monitoring in labour (e.g. labour progress, observations)

Access to; medical care in labour (e.g. long transfer in extremis), CS (e.g. in a tertiary hospital only), assisted vaginal birth (e.g. where medical staff work), medical care in context of birth after CS

Prevalence and severity of female genital mutilation

34
Q

What are the key labour complications that occur where healthcare resource is limited?

A
  • Prolonged labour leading to: uterine rupture, obstetric fistula, PPH
  • Untreated HT disorders of pregnancy (may or may not be labour-related)
  • Infection (may be intrapartum or post-partum)
  • Intrauterine death, preterm birth, neonatal death
35
Q

What are the top maternal mortality causes in low income settings?

A
  • PPH
  • Infection post-birth
  • High BP complications
36
Q

What are some context specific risk factors for adverse outcomes?

A

Education level & Socioeconomic status
Intimate partner violence
Cultural practices e.g. FGM
Long-distance travel to facility
Antenatal care attendance/follow-up
Multiparity
Twin pregnancy
Lack of women’s involvement in decision-making

37
Q

When can uterine rupture occur & what can it lead to?

A

Can happen after a very prolonged labour

Can lead to abrupt maternal haemorrhage & foetal hypoxia

38
Q

What are the risk factors for uterine rupture?

A
  • Prolonged labour
  • Previous uterine surgery (could be previous CS or myomectomy)

(Can happen particularly in women of high parity when labour has been long)

39
Q

How is an obstetric fistula formed?

A

During prolonged labour, compression of soft tissues between the babys head & womans pelvis cuts off blood flow to the bladder or rectum. As a result, tissue dies, leaving a hole/fistula

40
Q

How are fistulas managed?

A

Repair- complex & may only be provided by charity organisations

Requires extensive experience & surgical skills

41
Q

When does morbidly adherent placenta arise?

A

Arises when placenta does not attach normally in development but attaches firmly or even invades through uterine wall- life threatening haemorrhage may occur at births- many such births require hysterectomy to stop bleeding

This condition is more common after repeated caesarean births

42
Q

Normal placenta is separated form uterine wall by a what?

A

Fine fibrinous layer

43
Q

What can be used in the prevention of labour complications?

A
  • Oxytocin injections
  • Good hygiene
  • Early treatment of infection
  • BP control & Magnesium Sulphate in severe pre-eclampsia

(Education, Access to health facilities,
Tackling poverty, cultural practices, low quality health services)

44
Q

What is the process of normal labour?

A

Foetus, placenta & membranes are expelled via birth canal and is spontaneous

45
Q

When does labour normally occur and what does it result in?

A

37-42 weeks gestation

Spontaneous vaginal birth (SVD)

46
Q

How does the foetus present in normal labour?

A

By the vertex (head down)

47
Q

What triggers labour to start?

A

Triggered by paracrine & autocrine signals generated by maternal, foetal & placental factors which interplay

48
Q

What key physiological changes must occur to allow for expulsion of the foetus?

A

o Cervix softens
o Myometrial tone changes to allow for coordinated contractions
o Progesterone decreases whilst oxytocin & prostaglandins increase to allow for labour to initiate

49
Q

What are the 3 stages of labour?

A

1st= Early/latent phase, active first stage & transition

2nd= Passive, active

3rd= Active or physiological

50
Q

What can be the longest part of labour?

A

Latent phase - Irregular contractions

Cervical changes & dilation up to 4cm

51
Q

Length of active labour is what and what does it involve?

A

Can vary from 8-12 hrs

  • Regular, painful contractions
  • Cervix is 4-10 cm
52
Q

What may be experienced in transition part of the first stage of labour?

A

May experience physical changes such as shaking, vomiting or the need to empty bowels

May express that they can no longer cope/in need of more pain relied

Cervix is 8-10cm

53
Q

What is the second stage of labour and what elements can it have?

A

Full dilation to birth

*Passive second stage of labour-no involuntary expulsive contractions
*Active second stage of labour-see presenting part visible or there are expulsive contractions or there is encouraged maternal effort

54
Q

What is the length of the second stage of labour?

A

Varies between 2-3hrs depending on if woman is nulliparous or multiparous

55
Q

What is the 3rd stage of labour?

A

From birth of the baby to the expulsion of the placenta and membranes

56
Q

What is involved in the physiological management of the third stage of labour?

A

No uterotonics used or cord clamping until pulsation has stopped- placenta is delivered by maternal effort

57
Q

What is the active management of the third stage of labour?

A

Uterotonic drugs, optimal cord clamping & deliver by controlled cord traction

58
Q

What are the mechanisms of labour?

A

-Engagement & descent
-Flexion
-Internal rotation of head
-Crowning & extension of head
-Restitution (twist of the neck to correct internal position)
-Internal rotation of the head & external rotation of the head
-Lateral flexion of shoulders (aid birth of baby by giving gentle axial traction)

59
Q

Is there always stress exerted on the foetus in labour?

A

Yes, stress is exerted onto the fetus regardless of it being a spontaneous or augmented labour therefore it is important to monitor the foetal heart

60
Q

Monitoring whether it is intermittent auscultation or continuous monitoring is dependant on what?

A

Woman’s risk assesment

61
Q

How can intermittent auscultation be carried out?

A

Can be done using a Pinards stethoscope or a handheld doppler

62
Q

How is continuous monitoring carried out?

A

Cardiotocograph (CTG)

63
Q

What is the description of a normal foetal HR?

A

~100-160 bpm with good variability (>5bpm) & accelerations (15bpm)

64
Q

How can a woman be monitored in labour?

A

o Maternal observations
o Abdominal palpation
o Vaginal examination
o Monitoring of liquor (colour, meconium, blood stained)
o Palpation of contractions
o External signs e.g Rhomboid of Michaelis and anal cleft line

65
Q

All women will experience labour differently, and there are many non-pharmacological and pharmacological options that they can utilise: What are they?

A

 Maternal position and mobility
 Breathing and hypnobirthing techniques
 Massage
 Aromatherapy
 TENS
 Oral analgesia
 Water
 Entonox
 Opioids
 Remifentanil PCA
 Epidural

Reproduction (17 decks)

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