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Theo's Obs And Gynae > Labour > Flashcards

Labour Flashcards

0
Q

What are braxton-hicks contractions?

A

Intermittent contractions of the uterus from early pregnancy onwards

These increase in frequency and amplitude as labour approaches

These are irregular, low frequency, and high amplitude in character, and only occasionally painful

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1
Q

What are the differences between primigravid and multigravid labour?

A

Primigravid:
Unique psychological experience
Inefficient uterine action common, so labour lasts longer
Functional capacity of pelvis not known
Serious injury to child more common
Incidence of instrumental delivery is higher
Uterus virtually immune to rupture

Multigravid:
Uterine action efficient and genital tract stretches more easily, therefore labour usually shorter
Cephalopelvic disproportion is rare
Serious injury to child is rare
Small risk of uterine rupture
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2
Q

What are the pro pregnancy factors promoting pregnancy continuation?

A

Progesterone
Nitric oxide
Catecholamines
Relaxin

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3
Q

What are the pro labour factors stimulating the onset of labour?

A 
Oestrogens
Oxytocin
Prostaglandins
Prostaglandin dehydrogenase
Inflammatory mediators
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4
Q

When can labour be diagnosed?

A

When painful uterine contractions accompany dilatation and effacement of the cervix

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5
Q

What are the foetal manoeuvres in labour?

A

Descent- head into pelvis
Flexion
Internal rotation of head - so faces sacrum
Head extension
Restitution - head turned to be back in line weigh shoulders after head delivered
Internal rotation of shoulders
Lateral Flexion - manually delivered

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6
Q

What is the normal position of the baby in labour?

A

Lie is longitudinal
Presentation is cephalic
Position is left or right occipitoanterior
Attitude is one of good Flexion
Presenting part - posterior part of anterior parietal bone

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7
Q

What is the attitude of the foetus?

A

The degree to which the head is flexed on the neck

The ideal attitude is maximum Flexion (vertex presentation)

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8
Q

What is a well flexed (vertex) attitude?

A

The head is maximally flexed so the vertex of the skull is presented

The presenting diameter is the 9.5cm and the smallest diameter of the skull, from the anterior fontanelle to below the occipit

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9
Q

What is deflexed attitude?

A

The head is not flexed so the sinciput-occipit diameter presents

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10
Q

What is a brow presentation?

A

The head is slightly extended, so the diameter from the chin to the vertex presents

Watch and wait- if does not change, then cs is indicated

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11
Q

What is a face presentation?

A

The head is hyperextended so the face presents

Can deliver vaginally if chin is anterior. If chin is posterior, may require CS

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12
Q

What is the position if the head during labour?

A

Initially occipitotransverse as the head enters the pelvis in the transverse position

Later, the head undergoes internal rotation to face the sacrum, and the position is occipitoanterior

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13
Q

What is a show and how often does it occur?

A

A blood stained mucous discharge

Occurs in two-thirds of women by the time of presentation and supports diagnosis of labour in women with regular contractions

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14
Q

What is pre labour rupture of membranes?

A

Rupture of the membranes prior to the onset of uterine contractions, after 37 weeks gestation

Occurs in 6-12% of cases

Can be managed conservatively, and 70% begin labour within 24 hours, although there is a small risk of ascending infection

Induce after 24 hours!

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15
Q

What is the first stage of labour?

A

From the onset of labour until the cervix is 10cm dilated

Latent phase - from onset of contractions until cervix is fully effaced and 4cm dilated

Active phase- 4cm to 10cm cervix dilation

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16
Q

What is the second stage of labour?

A

From full cervical dilation til the head is completely delivered

Propulsive - from full dilatation until head has descended onto pelvic floor

Expulsive - from time the mother has an irreversible desire to bear down and push until the baby is delivered

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17
Q

What is the third stage of labour?

A

From delivery of the baby until expulsion of the placenta and membranes

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18
Q

How is slow progress in the first stage of labour defined in primip and multips?

A

Primip- >12 hours duration (1cm per hour)

Multip - >7 hours duration (2cm per hour)

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19
Q

How is slow progress in the second stage of labour defined for the primip and Multip?

A

Primip- after one hour of active labour, recommend amniotomy
- after two hours, consider instrumental delivery or cs

Multip - after one hour, consider instrumental delivery or cs

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20
Q

What are the options for foetal intrapartum surveillance?

A

Intermittent auscultation

Continuous CTG

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21
Q

When should intermittent auscultation be used, and how often?

A

In a woman with no risk factors, performed for a full minute after contractions

At least every 15 mins in the first stage

Every five mins or after every other contraction in the second stage

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22
Q

What are the risk factors which suggest a need for CTG? Maternal and foetal

A 
Maternal:
Previous CS
Cardiac problems
Pre-eclampsia
>42 weeks
Prom
Induced labour
Diabetes
APH
Foetal:
IUGR
Prematurity
Oligohydramnios
Multiple pregnancy
Meconium stained liquor
Breech presentation
23
Q

What intrapartum risks require CTG?

A 
Oxytocin augmentation
Epidural analgesia
Intrapartum vaginal bleeding
Pyrexial
Meconium staining of liquor
Abnormal foetal heart rate on IA
Prolonged labour
24
Q

What is Meconium stained liquor and how is it managed?

A

Detection of the first bowel movement in the amniotic fluid- assoc with perinatal morbidity and mortality and may be aspirated by the foetus

Management:
Induction of labour if PROM
Advise CTG
If baby born with depressed vital signs, requires laryngoscopy

25
Q

What are the indications for instrumental delivery?

A

Maternal:
Exhaustion
Prolonged second stage
Pushing not possible - paraplegia or tetraplegia
Medical indications for avoiding pushing - severe cardiac disease, hypertensive crisis, brain aneurysm

Foetal:
Foetal compromise
To control head in breech

26
Q

What are the complications of operative vaginal delivery?

A

Forceps - maternal trauma - especially to anal sphincter

Rotational forceps - may cause spiral tears of vagina

Foetal injuries - VII palsy, skull fractures, orbital injury, intracranial haemorrhage

Ventouse - scalp lacerations and avulsions, cephalhaematoma, retinal haemorrhage

27
Q

What are the differences between forceps and ventouse?

A

Ventouse is more likely to fail

Ventouse is more likely to cause foetal trauma

Forceps are more likely to cause maternal genital tract trauma

28
Q

When should instrumental delivery be abandoned and deliver by emergency c section instead?

A

No evidence of progressive descent with each pull

Where delivery is not imminent following three pulls of a correctly applied instrument by an experienced operator

29
Q

What are the two main types of episiotomy?

A

Mediolateral episiotomy - extends from the fourchette laterally to reduce the risk of anal sphincter injury

Midline episiotomy - extends from the fourchette towards the anus

30
Q

What are the potential complications of episiotomy?

A 
Bleeding
Haematoma
Pain
Infection
Scarring
Dyspareunia 
Rarely, fistula formation
31
Q

When is episiotomy recommended?

A

Complicated vaginal delivery - breech, shoulder dystocia, forceps, ventouse

Foetal distress

If extensive lower genital tract scarring

32
Q

How are perineal tears classified?

A

1st degree - injury to the skin only

2nd degree - injury to the perineum involving perineum

3rd degree - injury to the perineum including the anal sphincter

4th degree - injury to perineum involving anal/rectal epithelium

33
Q

What are the main indications for Caesarean section?

A

Repeat Caesarean section
Foetal compromise
Failure to progress in labour
Breech presentation

Maternal request is not an indication in itself but may be taken in to account

34
Q

What categories determine the timing of Caesarean section?

A

Crash - immediate threat to the life of the woman or foetus - category 1

Urgent - maternal or foetal compromise which is not immediately life threatening - category 2

Scheduled - no maternal or foetal compromise but needs early delivery - category 3

Elective - delivery times to suit woman and staff - category 4

35
Q

What are the two types of Caesarean section?

A

Lower uterine segment incision - most common as reduced adhesion formation and blood loss

Classical - involves vertical incision into the upper uterine segment

36
Q

What are intraoperative complications of cs?

A 
Uterine lacerations
Blood loss
Hysterectomy
Bowel lacerations
Ureteral injury
37
Q

What are the post operative complications of CS?

A 
Endometritis
Wound infections
Pulmonary embolism
VTE 
UTI
38
Q

What are the long term effects of cs?

A

Higher risk of uterine rupture
Placenta previa - scar tissue means placenta may adhere in the wrong place
Placenta accreta - placenta won’t come off uterus
Antepartum stillbirth

39
Q

What can cause pre labour rupture of membranes?

A 
Idiopathic
Infection
Polyhydramnios
Multiple pregnancy
Mal presentations
40
Q

What are the clinical features of chorioamnionitis?

A 
Fetal tachycardia 
Maternal tachycardia
Maternal pyrexia
Rising leucocyte count
Rising CRP
Irritable or tender uterus
41
Q

How long does it take to deliver a placenta before it is considered retained?

A

A placenta is retained if it is not delivered within 30 mins of baby if third stage is actively managed

One hour if it is passively managed

May require manual removal of placenta in theatre

42
Q

What is active management of the third stage?

A

Syntometrine or oxytocin

Controlled cord traction

43
Q

What is placenta accreta, increta and percreta?

A

Placenta is not separated from the myometrium

Placenta accreta- placental villi attached to myometrium

Placenta increta - villi invade myometrium

Placenta percreta - villi pass through myometrium and involve other viscera

44
Q

What is primary post partum haemorrhage

A

Blood loss of 500ml or more from the genital tract occurring within 24 hours of delivery

45
Q

What is secondary post partum haemorrhage?

A

Excessive loss occurring between 24 hours and six weeks after delivery

46
Q

What are the causes of primary PPH?

A

Uterine atony - failure of uterus to contract after delivery - often due to twins, polyhydramnios, high parity, retained products

Genital tract trauma

Coagulation disorders

Abnormal placental site - placenta previa, accreta

47
Q

What are the antenatal risk factors for PPH?

A 
Previous PPH 
Previous retained placenta
Para four or more
APH
Over distension of the uterus
Maternal age and bmi
48
Q

What is a transverse or oblique lie?

A

When the axis of the foetus is across the axis of the uterus

Common before term, but occurs in 1% after 37 weeks

49
Q

What is unstable lie?

A

When the lie is changing, usually several times a day, and may be transverse or longitudinal, and cephalic or breech presentation

50
Q

What are the causes and associations of abnormal foetal lie?

A 
Multiparity (lax uterus)
Polyhydramnios
Uterine abnormalities eg. Fibroids
Placenta previa and obstructions to pelvis
Foetal abnormalities
Multiple pregnancy
51
Q

What are the risks of abnormal lie?

A

Obstructed labour and potential uterine rupture

Membrane rupture risks cord prolapse, as with normal longitudinal lie, the presenting part prevents descent if the cord through the cervix

52
Q

How is unstable lie managed?

A

Admit to hospital from 37 weeks so that CS can be carried out if labour starts

Lie may stabilise

If lie does not stabilise, a CS is performed at 41 weeks

If lie is stable but not longitudinal, a CS should be considered at 39 weeks

53
Q

What is the medical management of PPH due to atomic uterus?

A 
Empty bladder
Oxytocin - ergetrine
Massage uterus through abdominal wall
Carboprost for further bleeding
B- lunch suture - to compress uterus
Hysterectomy as last resort
54
Q

What are the indications for elective section?

A

Previous CLASSIC section
Failed ECV
Placenta previa
Multiple pregs if first twin is not cephalic
Reducing risk of transmission of infection - eg HIV and herpes outbreak

55
Q

Which forceps are rotational, and which have a fixed curve!

A

Kiellands - rotational

Neville Barnes - fixed cephalic curve

Theo's Obs And Gynae (22 decks)

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