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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
Foetal blood sampling provides a direct measurement from baby of what?
- pH & base excess - Lactic acid pH gives a measure of likely hypoxaemia
26
What forms of assisted or operative delivery are available?
- Instrumental deliveries (forceps/ventouse) - Planned (elective) CS - Emergency CS
27
When can CS be performed in labour?
Can be performed at any time in labour-risk of PPH increases when performed at full dilatation
28
What are 3rd stage complication examples?
- 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
What are the 4 Ts associated with PPH?
TRAUMA TONE THROMBIN (clotting abnormal) TISSUE (retained preg tissue)
30
Labour problems are common especially in ..?..
Primigravid women
31
What in its simplest terms are labour problems due to
' The Passage, The Powers or The Passenger'
32
When may operative vaginal birth or CS be necessary?
When problems occur in labour to prevent fetal & maternal morbidity & mortality
33
Labour complications can be context specific: Give examples of this?
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
What are the key labour complications that occur where healthcare resource is limited?
- 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
What are the top maternal mortality causes in low income settings?
- PPH - Infection post-birth - High BP complications
36
What are some context specific risk factors for adverse outcomes?
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
When can uterine rupture occur & what can it lead to?
Can happen after a very prolonged labour Can lead to abrupt maternal haemorrhage & foetal hypoxia
38
What are the risk factors for uterine rupture?
- 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
How is an obstetric fistula formed?
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
How are fistulas managed?
Repair- complex & may only be provided by charity organisations Requires extensive experience & surgical skills
41
When does morbidly adherent placenta arise?
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
Normal placenta is separated form uterine wall by a what?
Fine fibrinous layer
43
What can be used in the prevention of labour complications?
- 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
What is the process of normal labour?
Foetus, placenta & membranes are expelled via birth canal and is spontaneous
45
When does labour normally occur and what does it result in?
37-42 weeks gestation Spontaneous vaginal birth (SVD)
46
How does the foetus present in normal labour?
By the vertex (head down)
47
What triggers labour to start?
Triggered by paracrine & autocrine signals generated by maternal, foetal & placental factors which interplay
48
What key physiological changes must occur to allow for expulsion of the foetus?
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
What are the 3 stages of labour?
1st= Early/latent phase, active first stage & transition 2nd= Passive, active 3rd= Active or physiological
50
What can be the longest part of labour?
Latent phase - Irregular contractions Cervical changes & dilation up to 4cm
51
Length of active labour is what and what does it involve?
Can vary from 8-12 hrs - Regular, painful contractions - Cervix is 4-10 cm
52
What may be experienced in transition part of the first stage of labour?
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
What is the second stage of labour and what elements can it have?
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
What is the length of the second stage of labour?
Varies between 2-3hrs depending on if woman is nulliparous or multiparous
55
What is the 3rd stage of labour?
From birth of the baby to the expulsion of the placenta and membranes
56
What is involved in the physiological management of the third stage of labour?
No uterotonics used or cord clamping until pulsation has stopped- placenta is delivered by maternal effort
57
What is the active management of the third stage of labour?
Uterotonic drugs, optimal cord clamping & deliver by controlled cord traction
58
What are the mechanisms of labour?
-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
Is there always stress exerted on the foetus in labour?
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
Monitoring whether it is intermittent auscultation or continuous monitoring is dependant on what?
Woman's risk assesment
61
How can intermittent auscultation be carried out?
Can be done using a Pinards stethoscope or a handheld doppler
62
How is continuous monitoring carried out?
Cardiotocograph (CTG)
63
What is the description of a normal foetal HR?
~100-160 bpm with good variability (>5bpm) & accelerations (15bpm)
64
How can a woman be monitored in labour?
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
All women will experience labour differently, and there are many non-pharmacological and pharmacological options that they can utilise: What are they?
 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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