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Labour Flashcards

1
Q

What does lie of the baby refer to

A

The babies position in relation to the mothers
- longitudinal
- oblique
- transverse

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2
Q

What does presentation of baby refer to

A

The part of the fetus which leads

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3
Q

What does position of baby refer to

A

The way the back of the head is facing
- either right or left
- then part of baby which presenting
- then either anterior or posterior

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4
Q

What is desired position of a baby

A

Right or left occipito-anterior

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5
Q

Other than occiput what can presentation be

A

Mentum- face
Sacrum- bum

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6
Q

When does a foetal head become engaged

A

When LARGEST part of presenting part passes into the pelvic brim

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7
Q

What does station refer to in labour

A

Relation of presenting part to ischial spine

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8
Q

What are the 3 stages of labour

A

1st stage- cervical dilation up to 10cm
2nd stage- from 10cm onwards to birth of baby
3rd stage- delivery of placenta

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9
Q

How can first stage of labour be broken up

A

Latent- contractions prior to being 4cm dilated
Established- painful regular contractions leading to at least 4m dilation

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10
Q

When thinking about what could be wrong with a birth what consider

A

4 P’s
- passenger
- power
- passage
- position

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11
Q

How does engagement differ between women based on number of births

A

If first birth it will happen prior to labour typically
If had multiple births very often will only happen once labour has begun

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12
Q

When considering the Ps what are potential causes for error in abirth

A

Passenger- too big
Power- tired, regularity of contractions
Passage- previous surgeries, shape
Position- what position is baby in

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13
Q

What is normal number of contractions that happy with

A

3 in 10 mins

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14
Q

Why is occiptio transverse the desired engagement

A

Lateral width of pelvic inlet is the largest

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15
Q

What are the movements fetus undergoes during delivery

A

Engagement in occipito transverse with neck flexed to reduce the SA coming out
Then internally rotates so head becomes occipto anterior to fit through pelvic outlet
This when get crowning
For head to be delivered the neck extends
Once head through the shoulders internally rotate to be in an AP plane
Once through the head restitutes by externally rotating to correct alignment of head with shoulders
Anterior shoulder comes out first and then baby comes out in lateral flexion movement

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16
Q

What is restitution

A

When head externally roates outside the body to re-align head and shoulders

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17
Q

What is problem of breech delivery

A

Shoulder dystocia
DDH
Head getting stuck

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18
Q

What are different types of breech delivery

A

Frank- legs up to head
Complete- bum lying down
Footling where one or both feet come first

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19
Q

What is main complication of induction of labour

A

Uterine hyperstimulation (tachysystole)

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20
Q

What is wrong with uterine hyperstimulation

A

Uterine rupture
Fetal hypoxia

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21
Q

What are rfx for chord prolapse

A

Prematurity
Non-longitudinal lie
Mutliparity
Twin pregnancy

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22
Q

What is chord prolapse defined as

A

Descent of umbilical chord through cervix past or alongside the presenting part

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23
Q

What is the definition of chord presentation

A

Where chord is between fetus and cervix with or without rupture of membranes

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24
Q

When does chord prolapse most often occur

A

At artificial rupture of membranes

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25
Q

What is management of chord prolapse

A

Immediate C-section but in meantime
- on all 4s
- consider tocolytics
- retrofill the bladder from catheter
- do not touch chord at all as risk of vasospasm
- push presenting part back in
Consider forceps delivery if fully dilated and head is near

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26
Q

What is most common breech presentation

A

Frank breech where hips flexed and legs fully extended

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27
Q

What is management of breech pre 36 weeks

A

It is normal and high probability will return to normal

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28
Q

Rfx for breech and transverse presentation

A

Uterine malformations like fibroids
placenta praevia
Polyhydramnios or oligohydramnios
Fetal abnormalities
Prematurity

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29
Q

What is external cephalic version

A

Where doctor attempts to turn baby around to where head is presenting part
Successful in 60% of cases

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30
Q

Management of breech presentation

A

Before 36 weeks leave alone
Offer ECV at 36 weeks if nulliparous
Offer ECV at 37 weeks if multiparous

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31
Q

When can you not do ECV

A

Ruptured membranes
Major uterine abnormality
Abnormal CTG
Multiple pregnancy
Antepartum haemorrhage in last 7 days
When C-section required

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32
Q

What is alternative to ECV that can be offered at 33-35 weeks

A

Moxibustion

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33
Q

Management if severe pre-eclampsia and within 24 hours of giving birth

A

IV magnesium sulphate

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34
Q

Which breech presentation has very high mortality

A

Footling

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35
Q

What is pathophysiology of amniotic fluid embolism

A

Amniotic fluid enters the maternal circulation causing a systemic immune response

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36
Q

Management of amniotic fluid embolism

A

Very supportive

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37
Q

Presentation of amniotic fluid embolism

A

Similar to sepsis or anaphylaxis

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38
Q

What is done if in breech position but in advanced station and labour

A

C- section

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39
Q

What is definition of shoulder dystocia

A

Vaginal cephalic delivery that requires additional obstetric manoeuvres to deliver the foetus after gentle traction has failed

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40
Q

Rfx for shoulder dystocia

A

Macrosomia
GDM
Prolonged labour
High BMI

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41
Q

Management of shoulder dystocia

A

Call for additional help
McRoberts manoeuvre with suprapubic pressure

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42
Q

What is McRoberts manoeuvre

A

Flexion and abduction of the maternal hips bringing thighs up to abdomen which increases the AP angle of the pelvis

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43
Q

Second line options for shoulder dystocia

A

Internal manipulation or all 4’s position (ideal if slim and no epidural)

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44
Q

Third line options for shoulder dystocia

A

Only consider after 5 minutes as then is when slight risk of HIE
Cleidotomy
Symphiosotomy
Zavanelli manoeuvre
USE WITH CAUTION AS ASSOCIATED WITH HIGH RISK OF MATERNAL MORBIDITY AND NEONATAL COMPLICATIONS

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45
Q

What is a cleidotomy

A

Cutting 1 or both clavicles to reduce daimeter of baby in shoulder dystocia

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46
Q

What is a symphisiotomy

A

Where divide the anterior fibres of the symphyseal ligament

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47
Q

What is the zavanelli method

A

Push head back into the vagina readt for a c-section in the case of shoulder dystocia

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48
Q

Maternal and foetal complications of shoulder dystocia

A

PPH from perineal tears

Brachial plexus injury and neonatal death

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49
Q

When are forceps indicated

A

Fetal distress in second stage
Maternal distress in second stage
Failure to progress in second stage of labour
Control of head in breech delivery

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50
Q

What are requirements for forceps delivery

A

Remembered using FORCEPS mnemonic
Fully dilated cervix
OA position ideal
Ruptured membranes
Cephalic presentation
Engaged presenting part
Pain relief
Sphincter (bladder empty)

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51
Q

Where should head be for forceps delivery

A

Engaged below ischial spines
In occipito anterior position

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52
Q

What is management if presenting part in vagina during chord prolapse

A

Push it back into uterus

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53
Q

What are anaesthetic options for labour

A

Regional- epidural
Non-regional- inhaled NO or systemic analgesic like pethidine

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54
Q

What are two surgical types of C-section

A

Classical- midline incision
Lower segment- pfannenstiel scar

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55
Q

What are the 4 categories of C-section

A

Cat 1- within 30 minutes
Cat 2- within 75 minutes
Cat 3- delivery required
Cat 4- elective

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56
Q

What is difference between indication for cat 1 and 2 c-section

A

Cat 1- immediate risk to mother or baby
Cat 2- maternal or foetal compromise but not life-threatening

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57
Q

What does active management involve

A

Synctocinon
EARLY clamping and cutting of cord, over 1 minute after delivery but less then 5 minutes
Controlled cord traction after signs of placental separation
DONE TO REDUCE PPH RISK

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58
Q

What are internal manipulation techniques used for shoulder dystocia

A

Wood’s screw- put hand in and rotate baby 180 degrees
Rubin manoeuvre- press on posterior shoulder to allowing lifting up of anterior shoulder from pubic symphysis

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59
Q

Order of tissues cut through in C-section

A

Superficial fascia
Deep fascia
Anterior rectus sheath
Rectus abdominis muscle (not cut, rather pushed laterally following incision of the linea alba)
Transversalis fascia
Extraperitoneal connective tissue
Peritoneum
Uterus

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60
Q

Complications of transverse lie

A

PROM
Cord prolapse

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61
Q

Management of transverse lie

A

At 36 weeks antenatal appointment
If want vaginal
- ECV, if unsuccessful then c-section
If want c-section
- elective c-section

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62
Q

What are risks of births going on past 41+0 weeks

A

Progression to C-section
Neonatal death
Neonatal stillbirth
Admitting to neonatal ICU

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63
Q

What offer if preterm prelabour rupture of membranes before 34 weeks with regards to birth

A

If before 34 weeks only induce if obstetric complications like fetal compromise or infection
Expectant management until 37+0

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64
Q

What offer if preterm prelabour rupture of membranes between 34 and 37 weeks

A

Options induction of labour or expectant management until 37 weeks
Base it off risks to mother, risks to baby and circumstances

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65
Q

What do if preterm labour between 34 and 37 weeks but GBS swab been positive

A

Immediate induction

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66
Q

What do if prelabour rupture of membranes at term

A

Offer induction of labour or expectant management for 24 hours

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67
Q

What do if prelabour rupture of membranes at term but positive swab for GBS

A

Immediate induction or C-section

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68
Q

What is dinoprostone

A

Prostaglandin E2

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69
Q

What defines macrosomia

A

Baby over 95% percentile at 36 weeks or later

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70
Q

What defines uterine hyperstimulation

A

6 contractions in 10 minutes for at least 20 minutes
OR
Less than 60s between contractions

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71
Q

What is precipitate labour

A

Very fast labour which happens less than 3 hours after start of contractions

72
Q

If is failed induction what do

A

Monitor baby with CTG
Offer
- rest and then reassess
- expectant
- further attempts to induce
- C-section

73
Q

Is outpatient induction possible

A

Yes provided no obstetric complications or pre-existing conditions
Discuss coming back if
- uterine contractions begin
- no contractions in an agreed time
- membranes rupture
- bleeding

74
Q

Problems with induction if previous C-section

A

Increased risk of c-section
Can lead to uterine rupture

75
Q

Techniques used for induction if history of c-section

A

Avoid any pharmacological inducers
Use surgical options like balloon catheter

76
Q

When only do induction of labour if breech position

A

Birth needs to be expedited
Declines C-section
ECV unsuccessful, declined or CI

77
Q

If is foetal growth restriction what do with regards to labour

A

DO NOT INDUCE IF COMPROMISE
Offer C-section

78
Q

If history of precipitate labour can you induce labour

A

No as risk of unattended birth

79
Q

If intrauterine fetal death but ruptured membranes, infection or bleeding what offer

A

Induction or c-section

80
Q

If has chosen an induction of labour with intrauterine death what does management depend on

A

If uterine scar or not
No scar
- oral mifepristone followed by vaginal dinoprostone or vaginal misoprostol
Scar
- mechanical

81
Q

If intrauterine death what do with regards to birth

A

If any bleeding, infection or ruptured membranes then c-section or induction
For all other women offer induction, expectant or C-section
If uterine scar with induction then must use mechanical options

82
Q

If bishop score 6 or less what are options

A

Dinoprostone as vaginal tablet, gel or delivery system (pessary)
OR Misoprostol tablets
Use mechanical options like balloon catheter or osmotic cervical dilator if
- risk of hyperstimulation
- preferrance
REASSESS AFTER 6 HOURS

83
Q

If bishop score more than 6 what are options

A

Amniotomy with or without IV oxytocin

84
Q

What does bishop score indicate

A

Less than 5 suggests labour unlikely to start without induction
8 or more suggests cervix is ripe and high chance of spontaneous labour

85
Q

What does bishop score incorporate

A

Cervical position
Cervical consitency
Cervical effacement
Cervical dilation
Foetal station

86
Q

Causes of thickened nuchal translucency

A

Downs
Cardiac defects
Abdominal wall defects

87
Q

Causes of hyperechogenic bowel

A

CF
Downs
CMV

88
Q

What do if bishop score over 8

A

No interventions needed however can consider amniotomy

89
Q

What is a membrane sweep

A

Finger inserted vaginally into the cervix which separates the chorionic membrane from the decidua

90
Q

What is an amniotomy

A

Artificial rupture of membranes
Can be done with glove with hook on end or an amnihook

91
Q

What are risks of amniotomy

A

Cord prolapse
Infection
Beech position

92
Q

Is membrane sweep a induction method

A

No is seen as an adjunct

93
Q

What prompts constant CTG usage

A

New onset bleeding
Temp above 38 or suspected infection
Oxytocin use
Presence of meconium

94
Q

Problems of occipital posterior presentation

A

Longer labour
Augmentation or c-section may be required

95
Q

When do you consider ventouse or forceps delivery

A

Second stage of labour over
- 1 hour in parous women
- 2 hours if nulliparous
Maternal tiredness
Foetal compromise
Requiring to reduce maternal effort like in CVD

96
Q

What is monitoring in typical uncomplicated labour

A

FHR every 15 mins
Contractions assessed every 30 mins
Maternal pulse every 60 mins
BP and temp every 4 hours
Vaginal exam every 4 hours
Urine for proteinuria every 4 hours

97
Q

If have given vaginal prostaglandin what do next

A

Reassess in 6 hours
If bishops score under 7 give again

98
Q

Where is incision for c-section

A

Transverse suprapubic

99
Q

What do if placenta not delivered after 1 hour

A

Surgical removal

100
Q

If placenta is still not being delivered what can do to expedite

A

If no significant bleeding can wait for up to 1 hour
In meantime IM synctocinon and breastfeeding
Also gain IV access and cross match blood

101
Q

Management if placenta not delivered and significant bleeding

A

Resus and take to theatre

102
Q

What is normal rate of cervical dilation in a primigravida versus multiparous in first stage of labour

A

0.5-1cm/ hour in primip
1.5-2cm/hour in multip

103
Q

What is proceeding management if carry out amniotomy

A

Reassess in 2 hours and consider synctocinon

104
Q

What consider before synctocinon

A

Analgesia
Potentially anaesthetist will identify epidural site

105
Q

Management of vasa praevia in labour

A

Emergency c-section

106
Q

What is uterine inversion

A

When the fundus collapses in on the uterine cavity

107
Q

Causes of uterine inversion

A

Pulling on unseparated placenta
Fundal placenta
Manual removal of placenta

108
Q

Patient in shock and difficult to outline the uterine fundus after delivering placenta

A

Uterine inversion

109
Q

First line dinoprostone delivery method

A

Pessary

110
Q

When are C-sections indicated

A

Placenta accreta
Placenta praevia
ECV failed in breech
In twins the first is not cephalic
Herpes in third trimester
HIV low viral load
Co-infection with HIV and Hep C
Previous classical c-section scar

111
Q

Delivery if co-infection with HIV and Hep C

A

C-section

112
Q

Platelet requirement for epidural

A

Needs to be above 70

113
Q

What is most common antenatal steroid regime

A

2x12mg IM betamethasone

114
Q

What is fetal fibronectin used for

A

If in preterm labour predicts what likelihood of giving birth in next 48 hours is

115
Q

When are episiotomies indicated

A

Forceps
Macrosomia
Shoulder dystocia

116
Q

Where are episiotomy cuts made and with what

A

60 degrees from midline- mediolateral
Angled scissors

117
Q

Causes of prolonged second stage of labour

A

OP position
Macrosomia
Tired mother

118
Q

Causes of preterm

A

Idiopathic majority of time
Infection
Smoking in pregnancy
Extremes of weight
Maternal illness

119
Q

Indications for pudendal nerve block

A

Epiosotomy
Instrumental delivery
Offered for second stage of labour

120
Q

What is palpated for on insertion of pudendal nerve block

A

Ischial spine- it runs infero medially to it

121
Q

What causes reduction in SFH from 36 weeks onwards

A

Increased foetal staion

122
Q

When is fetal fibronectin contraindicated

A

If rupture of membranes

123
Q

Where is fetal fibronectin taken from

A

A swab from inside of the vagina

124
Q

What does fetal fibronectin measure

A

It is high prior to 20 weeks from development of amniotic sac and after 36 weeks as shows labour amniotic sac is readying to burst
Therefore between 20 and 35 weeks is a good sign of how likely membranes are to burst

125
Q

What type of drug is carboprost

A

Oxytocin analogue

126
Q

What type of drug is ergometrine

A

Alpha-blocker

127
Q

Can you give steroids before 24 weeks

A

NO

128
Q

If membranes rupture at 18 weeks how manage

A

Admit
USS
Infection markers

129
Q

Contraindications to epidurals

A

Hypotension
Bleeding disorder
Infection over administration site
Platelets under 70

130
Q

What analgesia used if epidural contraindicated

A

Remifentanil

131
Q

When are epidurals indicated in labour

A

Uncontrolled pain relief
Foreseen long labour
Synctocinon infusion

132
Q

In episiotomy what muscle are you trying to avoid

A

Ischiocavernous as involved in sexual function

133
Q

When consider vaginal delivery in chord prolapse

A

Cervix fully dilated and head engaged

134
Q

If do vaginal delivery in chord prolapse what use

A

Forceps

135
Q

What must do if give synctocinon infusion

A

CTG monitoring
Epidural

136
Q

Describe the sensitivty and specificty of a CTG

A

Very sensitive but very low specificty

137
Q

If intrauterine death but trasnverse lie how manage

A

C-section

138
Q

What is turtleneck sign

A

When head delivers but then retracts

139
Q

If mother is in trauma situation, what is management

A

Resus and place mother in left tilt position
If mother no pulse then c-section
If mother ok then need to assess foetus to detemrine how manage them

140
Q

How are the anterior and posterior fontanelles described

A

Anterior- diamond
Posterior- Y

141
Q

Where is egg most often fertilised

A

Ampulla of fallopian tubes

142
Q

What are the 2 types of forceps

A

Kiellands
Neville Barnes

143
Q

Difference in use between kiellands forceps and neville barns

A

Kiellands- rotation needed to OA
Neville barnes- just used to guide out

144
Q

How many contractions length should forceps be used for

A

3 contractions- if over do C-section

145
Q

What is Mazzanti technique

A

When pressure applied on abdomen to help with McRoberts

146
Q

With SROM what is management

A

Sterile speculum exam or obtain a sample of liquor to test
Offer IOL or expectant management until 24 hours

147
Q

Uterine inversion on examination

A

Bluish grey mass in vagina
Unable to palpate fundus

148
Q

Shock out of proportion to bleeding and pain postnatally

A

Uterine inversion due to pulling on the round ligament which can cause vagal stimulation

149
Q

What does auscultating heart beat above umbilicus suggest

A

Breech presentation

150
Q

First and second line tocolytics

A

Nifedipine
Then atosiban

151
Q

MOA of atosiban

A

Competitive inhibitor of oxytocin

152
Q

How does AFE normally come on

A

Chest pain and dyspnoea immediate onset
DIC proceeds

153
Q

HOw check for rupture of membranes

A

Speculum to look for pooling of fluid
Rom plus test looking for insulin like growth factor binding protein 1

154
Q

Severe sudden onset abdo pain during labour

A

Uterine rupture

155
Q

Management of uterine inversion

A

Attempt to manually reduce uterus
If unsuccessful attempt surgical intervention

156
Q

If suspect preterm labour what is first thing do

A

Speculum exam
If under 30 weeks and suspect preterm labour from exam give steroids and tocolysis
If over 30 weeks and suspect preterm labour do TVUSS to assess cervical length

157
Q

What cervical length suggests preterm labour imminent

A

Under 15mm

158
Q

When do you fibronectin to assess preterm labour likelihood

A

TVUSS unacceptable or unavailable

159
Q

When can TVUSS not be used to assess preterm labour likelihood

A

Under 30 weeks gestation

160
Q

What is cutoff fibronectin to indicate imminent labour

A

Over 50 suggests labour likely within 48 hours

161
Q

Generally at what point should women be admitted when theyve started contracting

A

When cervix reaches 4cm dilated or contraactions every 5 minutes

162
Q

What determines whether lady admitted to labour ward or birth centre

A

Whether want epidural
High risk pregnancy which will need obstetric or neonatal involvement

163
Q

Best analgesia pre admission for labour

A

Paracetamol or co-dydramol

164
Q

What are the patient controlled analgesias available

A

Entonox
Remifentanil

165
Q

What are risks of ventouse

A

Risk of facial trauma, lacerations, retinal and intracranial haemorrhages
This is why contraindicated pre 34 weeks

166
Q

Pain ladder for pregnancy

A

Paracetamol
Co-dydramol
IM diamorphine
Epidural
Pudendal nerve block

167
Q

What do if first baby in twins cephalic but second breech

A

Deliver first one vaginally then can offer ECV for second

168
Q

In first stage what aiming for in terms of contractions

A

Moderate intesnsity
Lasting over 30 seconds
Greater than every 3 per 10 mins

169
Q

How can vasa praevia present

A

Painless vaginal bleeding in third trimester or gush of blood at ROM

170
Q

How is vasa praevia best diagnosed

A

Trans vaginal and abdominal USS with colour doppler imaging

171
Q

What is management of vasa praevia when identified pre rupture of membranes

A

Consider permanent hospitalisation from 32 weeks
Give steroids from 32 weeks
Aim for elective C-section 34-36 weeks

172
Q

What is vasa praevia

A

normally in pregnancy the fetal vessels from umbilical chord run directly into the placenta
In vasa praevia they are free unprotected

173
Q

What are 2 types of vasa praevia

A

Type 1- when vessels run from valementous umbilical chord to placenta
Type 2- when vessels connect via a succenturiate or accessory placenta

174
Q

What does velamentous chord mean

A

When umbilical chord doesn’t attach directly to the placenta

175
Q

What is given before every C-section

A

Omeprazole

176
Q

How many attempts at vetnouse are you allowed

A

3

Obs (9 decks)

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