Labour Flashcards
1
Q
What does lie of the baby refer to
A
The babies position in relation to the mothers
- longitudinal
- oblique
- transverse
2
Q
What does presentation of baby refer to
A
The part of the fetus which leads
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
4
Q
What is desired position of a baby
A
Right or left occipito-anterior
5
Q
Other than occiput what can presentation be
A
Mentum- face
Sacrum- bum
6
Q
When does a foetal head become engaged
A
When LARGEST part of presenting part passes into the pelvic brim
7
Q
What does station refer to in labour
A
Relation of presenting part to ischial spine
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
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
10
Q
When thinking about what could be wrong with a birth what consider
A
4 P’s
- passenger
- power
- passage
- position
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
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
13
Q
What is normal number of contractions that happy with
A
3 in 10 mins
14
Q
Why is occiptio transverse the desired engagement
A
Lateral width of pelvic inlet is the largest
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
16
Q
What is restitution
A
When head externally roates outside the body to re-align head and shoulders
17
Q
What is problem of breech delivery
A
Shoulder dystocia
DDH
Head getting stuck
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
19
Q
What is main complication of induction of labour
A
Uterine hyperstimulation (tachysystole)
20
Q
What is wrong with uterine hyperstimulation
A
Uterine rupture
Fetal hypoxia
21
Q
What are rfx for chord prolapse
A
Prematurity
Non-longitudinal lie
Mutliparity
Twin pregnancy
22
Q
What is chord prolapse defined as
A
Descent of umbilical chord through cervix past or alongside the presenting part
23
Q
What is the definition of chord presentation
A
Where chord is between fetus and cervix with or without rupture of membranes
24
Q
When does chord prolapse most often occur
A
At artificial rupture of membranes
25
What is management of chord prolapse
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
26
What is most common breech presentation
Frank breech where hips flexed and legs fully extended
27
What is management of breech pre 36 weeks
It is normal and high probability will return to normal
28
Rfx for breech and transverse presentation
Uterine malformations like fibroids
placenta praevia
Polyhydramnios or oligohydramnios
Fetal abnormalities
Prematurity
29
What is external cephalic version
Where doctor attempts to turn baby around to where head is presenting part
Successful in 60% of cases
30
Management of breech presentation
Before 36 weeks leave alone
Offer ECV at 36 weeks if nulliparous
Offer ECV at 37 weeks if multiparous
31
When can you not do ECV
Ruptured membranes
Major uterine abnormality
Abnormal CTG
Multiple pregnancy
Antepartum haemorrhage in last 7 days
When C-section required
32
What is alternative to ECV that can be offered at 33-35 weeks
Moxibustion
33
Management if severe pre-eclampsia and within 24 hours of giving birth
IV magnesium sulphate
34
Which breech presentation has very high mortality
Footling
35
What is pathophysiology of amniotic fluid embolism
Amniotic fluid enters the maternal circulation causing a systemic immune response
36
Management of amniotic fluid embolism
Very supportive
37
Presentation of amniotic fluid embolism
Similar to sepsis or anaphylaxis
38
What is done if in breech position but in advanced station and labour
C- section
39
What is definition of shoulder dystocia
Vaginal cephalic delivery that requires additional obstetric manoeuvres to deliver the foetus after gentle traction has failed
40
Rfx for shoulder dystocia
Macrosomia
GDM
Prolonged labour
High BMI
41
Management of shoulder dystocia
Call for additional help
McRoberts manoeuvre with suprapubic pressure
42
What is McRoberts manoeuvre
Flexion and abduction of the maternal hips bringing thighs up to abdomen which increases the AP angle of the pelvis
43
Second line options for shoulder dystocia
Internal manipulation or all 4's position (ideal if slim and no epidural)
44
Third line options for shoulder dystocia
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
45
What is a cleidotomy
Cutting 1 or both clavicles to reduce daimeter of baby in shoulder dystocia
46
What is a symphisiotomy
Where divide the anterior fibres of the symphyseal ligament
47
What is the zavanelli method
Push head back into the vagina readt for a c-section in the case of shoulder dystocia
48
Maternal and foetal complications of shoulder dystocia
PPH from perineal tears
Brachial plexus injury and neonatal death
49
When are forceps indicated
Fetal distress in second stage
Maternal distress in second stage
Failure to progress in second stage of labour
Control of head in breech delivery
50
What are requirements for forceps delivery
Remembered using FORCEPS mnemonic
Fully dilated cervix
OA position ideal
Ruptured membranes
Cephalic presentation
Engaged presenting part
Pain relief
Sphincter (bladder empty)
51
Where should head be for forceps delivery
Engaged below ischial spines
In occipito anterior position
52
What is management if presenting part in vagina during chord prolapse
Push it back into uterus
53
What are anaesthetic options for labour
Regional- epidural
Non-regional- inhaled NO or systemic analgesic like pethidine
54
What are two surgical types of C-section
Classical- midline incision
Lower segment- pfannenstiel scar
55
What are the 4 categories of C-section
Cat 1- within 30 minutes
Cat 2- within 75 minutes
Cat 3- delivery required
Cat 4- elective
56
What is difference between indication for cat 1 and 2 c-section
Cat 1- immediate risk to mother or baby
Cat 2- maternal or foetal compromise but not life-threatening
57
What does active management involve
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
58
What are internal manipulation techniques used for shoulder dystocia
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
59
Order of tissues cut through in C-section
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
60
Complications of transverse lie
PROM
Cord prolapse
61
Management of transverse lie
At 36 weeks antenatal appointment
If want vaginal
- ECV, if unsuccessful then c-section
If want c-section
- elective c-section
62
What are risks of births going on past 41+0 weeks
Progression to C-section
Neonatal death
Neonatal stillbirth
Admitting to neonatal ICU
63
What offer if preterm prelabour rupture of membranes before 34 weeks with regards to birth
If before 34 weeks only induce if obstetric complications like fetal compromise or infection
Expectant management until 37+0
64
What offer if preterm prelabour rupture of membranes between 34 and 37 weeks
Options induction of labour or expectant management until 37 weeks
Base it off risks to mother, risks to baby and circumstances
65
What do if preterm labour between 34 and 37 weeks but GBS swab been positive
Immediate induction
66
What do if prelabour rupture of membranes at term
Offer induction of labour or expectant management for 24 hours
67
What do if prelabour rupture of membranes at term but positive swab for GBS
Immediate induction or C-section
68
What is dinoprostone
Prostaglandin E2
69
What defines macrosomia
Baby over 95% percentile at 36 weeks or later
70
What defines uterine hyperstimulation
6 contractions in 10 minutes for at least 20 minutes
OR
Less than 60s between contractions
71
What is precipitate labour
Very fast labour which happens less than 3 hours after start of contractions
72
If is failed induction what do
Monitor baby with CTG
Offer
- rest and then reassess
- expectant
- further attempts to induce
- C-section
73
Is outpatient induction possible
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
Problems with induction if previous C-section
Increased risk of c-section
Can lead to uterine rupture
75
Techniques used for induction if history of c-section
Avoid any pharmacological inducers
Use surgical options like balloon catheter
76
When only do induction of labour if breech position
Birth needs to be expedited
Declines C-section
ECV unsuccessful, declined or CI
77
If is foetal growth restriction what do with regards to labour
DO NOT INDUCE IF COMPROMISE
Offer C-section
78
If history of precipitate labour can you induce labour
No as risk of unattended birth
79
If intrauterine fetal death but ruptured membranes, infection or bleeding what offer
Induction or c-section
80
If has chosen an induction of labour with intrauterine death what does management depend on
If uterine scar or not
No scar
- oral mifepristone followed by vaginal dinoprostone or vaginal misoprostol
Scar
- mechanical
81
If intrauterine death what do with regards to birth
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
If bishop score 6 or less what are options
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
If bishop score more than 6 what are options
Amniotomy with or without IV oxytocin
84
What does bishop score indicate
Less than 5 suggests labour unlikely to start without induction
8 or more suggests cervix is ripe and high chance of spontaneous labour
85
What does bishop score incorporate
Cervical position
Cervical consitency
Cervical effacement
Cervical dilation
Foetal station
86
Causes of thickened nuchal translucency
Downs
Cardiac defects
Abdominal wall defects
87
Causes of hyperechogenic bowel
CF
Downs
CMV
88
What do if bishop score over 8
No interventions needed however can consider amniotomy
89
What is a membrane sweep
Finger inserted vaginally into the cervix which separates the chorionic membrane from the decidua
90
What is an amniotomy
Artificial rupture of membranes
Can be done with glove with hook on end or an amnihook
91
What are risks of amniotomy
Cord prolapse
Infection
Beech position
92
Is membrane sweep a induction method
No is seen as an adjunct
93
What prompts constant CTG usage
New onset bleeding
Temp above 38 or suspected infection
Oxytocin use
Presence of meconium
94
Problems of occipital posterior presentation
Longer labour
Augmentation or c-section may be required
95
When do you consider ventouse or forceps delivery
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
What is monitoring in typical uncomplicated labour
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
If have given vaginal prostaglandin what do next
Reassess in 6 hours
If bishops score under 7 give again
98
Where is incision for c-section
Transverse suprapubic
99
What do if placenta not delivered after 1 hour
Surgical removal
100
If placenta is still not being delivered what can do to expedite
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
Management if placenta not delivered and significant bleeding
Resus and take to theatre
102
What is normal rate of cervical dilation in a primigravida versus multiparous in first stage of labour
0.5-1cm/ hour in primip
1.5-2cm/hour in multip
103
What is proceeding management if carry out amniotomy
Reassess in 2 hours and consider synctocinon
104
What consider before synctocinon
Analgesia
Potentially anaesthetist will identify epidural site
105
Management of vasa praevia in labour
Emergency c-section
106
What is uterine inversion
When the fundus collapses in on the uterine cavity
107
Causes of uterine inversion
Pulling on unseparated placenta
Fundal placenta
Manual removal of placenta
108
Patient in shock and difficult to outline the uterine fundus after delivering placenta
Uterine inversion
109
First line dinoprostone delivery method
Pessary
110
When are C-sections indicated
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
Delivery if co-infection with HIV and Hep C
C-section
112
Platelet requirement for epidural
Needs to be above 70
113
What is most common antenatal steroid regime
2x12mg IM betamethasone
114
What is fetal fibronectin used for
If in preterm labour predicts what likelihood of giving birth in next 48 hours is
115
When are episiotomies indicated
Forceps
Macrosomia
Shoulder dystocia
116
Where are episiotomy cuts made and with what
60 degrees from midline- mediolateral
Angled scissors
117
Causes of prolonged second stage of labour
OP position
Macrosomia
Tired mother
118
Causes of preterm
Idiopathic majority of time
Infection
Smoking in pregnancy
Extremes of weight
Maternal illness
119
Indications for pudendal nerve block
Epiosotomy
Instrumental delivery
Offered for second stage of labour
120
What is palpated for on insertion of pudendal nerve block
Ischial spine- it runs infero medially to it
121
What causes reduction in SFH from 36 weeks onwards
Increased foetal staion
122
When is fetal fibronectin contraindicated
If rupture of membranes
123
Where is fetal fibronectin taken from
A swab from inside of the vagina
124
What does fetal fibronectin measure
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
What type of drug is carboprost
Oxytocin analogue
126
What type of drug is ergometrine
Alpha-blocker
127
Can you give steroids before 24 weeks
NO
128
If membranes rupture at 18 weeks how manage
Admit
USS
Infection markers
129
Contraindications to epidurals
Hypotension
Bleeding disorder
Infection over administration site
Platelets under 70
130
What analgesia used if epidural contraindicated
Remifentanil
131
When are epidurals indicated in labour
Uncontrolled pain relief
Foreseen long labour
Synctocinon infusion
132
In episiotomy what muscle are you trying to avoid
Ischiocavernous as involved in sexual function
133
When consider vaginal delivery in chord prolapse
Cervix fully dilated and head engaged
134
If do vaginal delivery in chord prolapse what use
Forceps
135
What must do if give synctocinon infusion
CTG monitoring
Epidural
136
Describe the sensitivty and specificty of a CTG
Very sensitive but very low specificty
137
If intrauterine death but trasnverse lie how manage
C-section
138
What is turtleneck sign
When head delivers but then retracts
139
If mother is in trauma situation, what is management
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
How are the anterior and posterior fontanelles described
Anterior- diamond
Posterior- Y
141
Where is egg most often fertilised
Ampulla of fallopian tubes
142
What are the 2 types of forceps
Kiellands
Neville Barnes
143
Difference in use between kiellands forceps and neville barns
Kiellands- rotation needed to OA
Neville barnes- just used to guide out
144
How many contractions length should forceps be used for
3 contractions- if over do C-section
145
What is Mazzanti technique
When pressure applied on abdomen to help with McRoberts
146
With SROM what is management
Sterile speculum exam or obtain a sample of liquor to test
Offer IOL or expectant management until 24 hours
147
Uterine inversion on examination
Bluish grey mass in vagina
Unable to palpate fundus
148
Shock out of proportion to bleeding and pain postnatally
Uterine inversion due to pulling on the round ligament which can cause vagal stimulation
149
What does auscultating heart beat above umbilicus suggest
Breech presentation
150
First and second line tocolytics
Nifedipine
Then atosiban
151
MOA of atosiban
Competitive inhibitor of oxytocin
152
How does AFE normally come on
Chest pain and dyspnoea immediate onset
DIC proceeds
153
HOw check for rupture of membranes
Speculum to look for pooling of fluid
Rom plus test looking for insulin like growth factor binding protein 1
154
Severe sudden onset abdo pain during labour
Uterine rupture
155
Management of uterine inversion
Attempt to manually reduce uterus
If unsuccessful attempt surgical intervention
156
If suspect preterm labour what is first thing do
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
What cervical length suggests preterm labour imminent
Under 15mm
158
When do you fibronectin to assess preterm labour likelihood
TVUSS unacceptable or unavailable
159
When can TVUSS not be used to assess preterm labour likelihood
Under 30 weeks gestation
160
What is cutoff fibronectin to indicate imminent labour
Over 50 suggests labour likely within 48 hours
161
Generally at what point should women be admitted when theyve started contracting
When cervix reaches 4cm dilated or contraactions every 5 minutes
162
What determines whether lady admitted to labour ward or birth centre
Whether want epidural
High risk pregnancy which will need obstetric or neonatal involvement
163
Best analgesia pre admission for labour
Paracetamol or co-dydramol
164
What are the patient controlled analgesias available
Entonox
Remifentanil
165
What are risks of ventouse
Risk of facial trauma, lacerations, retinal and intracranial haemorrhages
This is why contraindicated pre 34 weeks
166
Pain ladder for pregnancy
Paracetamol
Co-dydramol
IM diamorphine
Epidural
Pudendal nerve block
167
What do if first baby in twins cephalic but second breech
Deliver first one vaginally then can offer ECV for second
168
In first stage what aiming for in terms of contractions
Moderate intesnsity
Lasting over 30 seconds
Greater than every 3 per 10 mins
169
How can vasa praevia present
Painless vaginal bleeding in third trimester or gush of blood at ROM
170
How is vasa praevia best diagnosed
Trans vaginal and abdominal USS with colour doppler imaging
171
What is management of vasa praevia when identified pre rupture of membranes
Consider permanent hospitalisation from 32 weeks
Give steroids from 32 weeks
Aim for elective C-section 34-36 weeks
172
What is vasa praevia
normally in pregnancy the fetal vessels from umbilical chord run directly into the placenta
In vasa praevia they are free unprotected
173
What are 2 types of vasa praevia
Type 1- when vessels run from valementous umbilical chord to placenta
Type 2- when vessels connect via a succenturiate or accessory placenta
174
What does velamentous chord mean
When umbilical chord doesn't attach directly to the placenta
175
What is given before every C-section
Omeprazole
176
How many attempts at vetnouse are you allowed
3
