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GOSH > Labour > Flashcards

Labour Flashcards

1
Q

What are the four characteristics of labour?

A 
Uterine contractions 
Cervical dilatation and engagement 
Rupture or membrane 
Descent of presenting part 
Birth of baby 
Delivery of baby
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2
Q

What dilation is the cervix in stage 1 of labour?
What position is baby’s head?
How quickly does the head progress?

A

4-10cm
Occipitotransverse with increasing flexsion
0.5 cm per hour

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3
Q

How can head position be described in stage one

A
  1. In relation to Ischial spine

2. Palpable above public bone

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4
Q

What are the 3 stages of stage 2 of labour?

A

Passive: full dilation of cervix prior to urge to bear down. Rotation and flexion complete. Only a few mins.

Active: explosive contractions with active maternal pressure. As head is visible only encourage small pushes.

Delivery:
Head extendeds and restitutes to transverse position. Delivery of shoulder (anterior first). If slow can cause feral distress.

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5
Q

What pneumonic can be used to remember the descent of the baby in labour?

A

Don’t forget I eat rhubarb in labour

Descent 
Flexion
Internal rotation
Extension of the head 
Restitution 
Internal rotation of shoulders
Lateral flexion
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6
Q

What are the 3 mechanical factors of labour? Think the 3 ps

A

The powers: the uterus contracts, effacement of cervix

The passage: shape of bony pelvis and cervical dilation

The passenger: size of head, rotation of head, extension/flexion

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7
Q

How often does the uterus contract in labour?

A

45-60 seconds every 2-3 mins

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8
Q

What is effacement?

Difference between primos and multiple

A

When the cervix effaces, a mucus plug passes out of the vagina “bloody show”

Primips: external os remains closed until effacement is complete
Multiple: occur simultaneously

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9
Q

What is the longest diameter of the bony pelvis at the inlet and at the outlet?

A

Inlet: transverse
Outlet: AP

Hence why the head rotates during the descent

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10
Q

Cervical dilatation is dependant on what?

A

Contractions
Fetal head pressure on cervix
Ability of cervix to soften

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11
Q

With maximum flexion how long is the presentation?
What is it a brow presentation (90 degrees)
What if it’s face presentation (30 degrees)

A

Norma: 9.5 cm
Brows: 13cm
Face: may be too big to deliver

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12
Q

How much should the head rotates during labour?

What percent are OA? What happens if the baby’s head doesn’t rotate OT?

A

90 degrees .
90% OA (5% OP - more difficult birth)
Occipitotransverse- require forceps

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13
Q

What can you say under each of these headings when describing the fetal head

A 
Presentation: 
Part in Lower pelvis, cephalic or breech 
Presenting part: 
Lowest part palpable on vaginal examination
Cephalopod: vertex, brow, face 
Position:
OA, OP, OT
Attitude 
Describes degree of flexion
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14
Q

What can be the causes of damage to the fetus?

A 
Fetal hypoxia 
Infection/inflammation in labour
Meconium aspiration 
Trauma 
Fetal blood loss
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15
Q

If the amniotic fluid is brown, what does this suggest?
What affects could this have?
What precautions would you take?

A

Meconium in a. Fluid.

Increases perinatal mortality by 4 X as baby may aspirate it (chemical pneumonitis) and become hypoxia

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16
Q

In low risk pregnancies, not requiring CTG, how often and how do you monitor FHR?

A

Pinards stethoscope or hand held Doppler

  • every 15 mins in stage 1
  • every 5 in 2nd
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17
Q

What are the normal and abnormal values for fetal blood sampling? What is pH indicative of?

A

pH above 7.25 is normal
7.2-7.25 is borderline
Below 7.2 is v bad deliver baby

Sign of hypoxaemia

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18
Q

What is the pneumonic for CTG interpretation?

A

DR C Bravado

Determine risk
Contractions 
baseline rate 
Accelerations
Variability
Decelerations 
Overall impression
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19
Q

What are high risk pregnancies that require CTG?

A 
Meconium stained liquor 
Multiple pregnancies
IUGR
Oxytocin infusion 
Abnormality on intermittent auscultation
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20
Q

If there were over 5 contractions in 10 mins?

What is not measured by contractions

A

Hyperstimulation

Not intensity

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21
Q

What is the normal baseline rate?
High is associated with …
Low is associated with….

A

110-160
High: fever, infection
Low: hypoxia

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22
Q

What is variability a flexion of? After how long would you be worried the baby is not sleeping?

A

Reflection of autonomic NS, often first thing to become abnormal on CTG.

After 45 mins below 5bpm

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23
Q

What type of decelerations are worrying?

A

Late: fetal hypoxia - have to have morphology

Variable
Atypical: over 60s and over 60bmp

Sign of mechanical or hypoxia stress

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24
Q

Is CTG was non-reassuring or abnormal what could you do?

A 
Change maternal position: L lateral
Give fluids & oxygen 
Stop oxytocin infusion 
Fetal blood sample 
Delivery
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25
Q

How many women are asymptomatic with group b strep infection.

What effect can this have if mother is infected during labour?

A

Early onset group B streptococcus (GBS) infection.

At term = 6% mortality

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26
Q

What is Tx for group B strep? Is here screening in UK? Who is treated?

A

No screening in U.K.

TX high risk
- precious affected neonate 
/ +ve urinary culture
Preterm labour 
Rupee of membrane over 18 hr
Maternal fever in labour
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27
Q

What form is used to making monitor maternal progress? What factors does it record?

A 
The partogram 
Patient demographics and risk 
Maternal observations (every 30min)
Contractions 
Cervical dilation (PV every 4 hours)- look at trend and response to oxytocinin 
Head descent 
Liquor 
Final birth details
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28
Q

What is the apgar score? What does it measure? When would you require paediatric support?

A

Babe score 1-5 mins after birth to determine well being.

Records:
Appearance, pulse, grimacing, activity and respiration from score 0, score 1 or score 3

If total score is under 7 need paed support and oxygen

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29
Q

Side effects of Entnox

A

Feeling faint, N&V, hyperventilation

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30
Q

What mild analgesic can you not give? Why?

A

NSAIDS- premature closure of ductus arteriosis

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31
Q

What opioids are given in labour? Ads and dials?

A

Pethidine, meptid IM or IV

Ads: easily administered PCS
Disads: sedation, confusion, antiemetic needed, can cause respiratory distress of new born. Not complete analgesia

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32
Q

What are the side effects of spinal anaesthetic?

A

Hypotension, total spinal analgesia and RA

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33
Q

When & where can you insert a epidural?

A

Once labour is established between L3 & L4.

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34
Q

What are the advantages of epidural?

A 
Pain free
Advised in 
prolonged labour 
↓ BP in hypertensive women
Abolish premature urge to push
Analgesia for instrumental delivery or CS
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35
Q

Disadvantages for epidural?

A 
Hypotension 
Local anaesthetic toxicity 
↑ instrumental delivery rate 
Bed bound: pressure sores
Urinary retention require catheter 
maternal fever 
spinal tap 'headache'
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36
Q

Contraindications for epidural?

A

Patient refusal
Anti-anticoagulation & bleeding disorders
Local or severe infection
anaphylaxis to LA

37
Q

Complications of epidural?

A

Immediate: Failure, hypotension, LA toxicity, total spinal

Delayed: postpartum puncture headache, infection, haematoma, neurological damage

38
Q

What are the indications for induction of labour?

A

Risk of continuing pregnancy > achieving a vaginal birth.

Obstetric Indications:
Uteroplacental insufficiency 
IUGR
Prolonged pregnancy (41-42 weeks)
Oligo- or anhydraminos
Abnormal CTG
PROM
Severe PET
IUD
Antepartum haemorrhage

Medical Indications:
With underlying medical conditions, planned induction of labour may limit the maternal risks associated with pregnancy.
Severe hypertension + PTE
Uncontrolled hypertension
Renal disease with deteriorating renal function
Malignancies

39
Q

What are the absolute and relative contraindications for induction of labour?

A 
Absolute:
Acute fetal compromise 
Abnormal lie 
Placenta praaevia 
Pelvic obstruction (pelvic mass, deformity)

Relative:
1 previous LSCS (↑scar rupture rate)
Prematurity
High parity

40
Q

What is the bishop score?

A

A scoring system to predict the likelihood off successful induction.

A higher score indicates the cervix is more favourable

41
Q

What does it measure?

A

Position, consistency, effacement, dilation and station.

42
Q

What modifiers add one point?

A

PTE and previous VD

43
Q

What modifiers subtract a point?

A

Postdate pregnancy, nulliparity, PPROM (premature rupture of membrane)

44
Q

After ARM using amniohook induction, what percentage of women will go straight into labour?

A

80%

45
Q

For how long do you wait in primps and multis before starting the oxytocin infusion

A

Primip: 2 hours
Multip: 4 hours

46
Q

What are the complications of ARM

A
  • inefficient uterine activity
  • instrumental delivery/LSCC
  • Hyperstimulation of uterus
  • PPH
  • Infection
47
Q

Methods for cervical ripening

A

stretch & sweep
Prostgladins
Oxytocin infusion

48
Q

What bishops score would indicate the need for cervical ripening?

A

< 5

49
Q

How long after prostaglandins should you wait before giving oxytocin? why

A

6 hours, hyper stimulation

50
Q

What is augmentation

A

using prostaglandins or oxytocin once labour is established

51
Q

What is malposition? What are the 3 categories

A

Lie of foetus not parallel to axis of uterus

  • longitudinal
  • Oblique
  • Transverse
52
Q

How common

A

1 in 200

53
Q

What are the causes

A

Preterm labour
Circumstances that allow more room to turn:
Polyhdramnios
Multiparity

Conditions that prevent turning:
Placenta praaevia
Pelvic mass

Conditions that prevent turning:
Fetal or uterine abnormality
Twins

NB: ‘unstable’ or continually changing lie in nulliparous women is rare.

54
Q

Management

A

< 37 nothing

CS is almost always indicated do USS to identify cause.

55
Q

Malpresentation (breech)- what is it? classifications?

A

Part of fetes that occupies lower segment

  • extended (70%)
  • flexed
  • footling
56
Q

what is the most common cause?

A

Preterm labour (25%)

57
Q

management plan for breech

A

ECV @ 36 week (primi), 37 (multip)

Vaginal delivery or Elective LSCS.

Vaginal birth more dangerous

58
Q

What factors increase the risk of vaginal birth?

A

baby >4kg, extended head, footling leg

59
Q

Clinical features of multiple pregnancies

A

Hyperemesis gravidarum
Uterus larger than for expected dates
3+ poles felt by >24 weeks
2 fetal heart sounds on auscultation

Many diagnosed by USS in 1st trimester; dating or nuchal translucency scan.

Determine chronicity: 1st/2nd trimester USS
Dichorionic: widely separates, ‘Lamda’ sign, dividing membrane, different sex
- Monochorionic: T sign, dividing < 2mm

60
Q

Which twins are at risk of twin to twin transfusion syndrome?

A

Monochorionicity twins

61
Q

How many times more likely is a multiple pregnancy to have pre-eclampsia than a singleton?

A

5 times

62
Q

Discuss the management of labour in a multiple pregnancy.

A

Vaginal delivery can occur if the first fetus is cephalic (regardless of second twin). CS is preferred, as is indicated for triplets +.

Induction or CS occurs ar
37-38 weeks for DC twins
34-37 weeks for MC twins

Labour:

  • Conintous CTG
  • 2 paeds staff, anaesthetic and 2 midwives
  • Oxytocin after 1st baby
  • ECV if second baby has abnormal lie
  • If any distress -> forceps/ventouse.
63
Q

What are the 3 types of forceps - when are they used

A
  • ventouse: most deliveries
  • Non-rotational forceps (simpsons & neville barnes): only if OA: has pelvic and cephalic curve
  • Rotational: Keillands: allow rotation by operator no pelvic curse

Can be used if second stage of labour need to be expedited.

64
Q

Indications for forceps

A 
Prolonged second stage
1hr of pushing (active 2nd stage)
Mother is exhausted 
Fetal distress in second stage
When maternal pushing is contraindicated 
Cardiac disease 
Hypertension
Breech delivery
65
Q

What indications should be met before using forceps

A
  • Cervix is dilated
  • Position of head is known
  • head must not be palpable abdominally
  • Head below ischial spines
  • Adequate analgesia
  • Bladder empty
  • valid indication
66
Q

Indications

A

Failure: more commonly ventouse (cup misplaced)

Maternal trauma: lacerations, haemorrhage, third-degree tears, ↑ analgesia

Fetal trauma: lacerations, bruising, facial nerve injury, hypoxia if prolonged delivery, ‘chignon’: swelling in scalp. Ventouse = worse.

67
Q

What are the rates OF CS

A

20-30%

68
Q

Elective reasons for CS. When is performed

A 
39 weeks 
Breech presentation 
Prv LSCS
Placenta praevia 
Realtive: severe IUGR, twins, DM + other medical disease, prv LSCS
<34 weeks: severe PTE, severe IUGR
69
Q

Emergency reasons for CS

A 
Emergency:
Failure to advance 
full dilatation not occurred by 12hr 
Indications for instrumental delivery not met 
Often due to inefficient uterine action
Fetal distress
FHR &amp; fetal blood sampling
70
Q

Complications

A

Material:

  • Haemorrhage
  • Blood transfusion
  • Uterine/wound sepsis
  • VTE
  • Risk of anaesthetic
  • Subsequent pregnancies (p. praevia & accreta)

Fetal:
Fetal resp morbidity
Bonding & breastfeeding

71
Q

How common is shoulder dystocia

A

1 in 200

72
Q

Complications of shoulder dystocia

A

Erb’s Palsy

Delay in delivery- can be lethal

73
Q

Risk factors for should dystocia

A 
Large baby
Previous shoulder dystocia 
↑ BMI
Labour induction
Low height 
Maternal DM
Instrumental delivery
74
Q

Management

A

Senior help

McRoebrt’s Maneovre + suprapubic pressure (works in 90%)

75
Q

Cord prolapse can cause what to the fetus?

A

Ischaemic enchepalopathy

76
Q

Diagnosis

A

increased FHR and cord palpated vaginally

77
Q

What can present with anaphylaxis, sudden dyspnoea, hypoxia Can lead to seizure & cardiac arrest or acute heart failure

A

Amniotic fluid embolism

78
Q

What are the consequences if the mother survives over 30 mins

A

DIC
Pulmonary oedema
ARDs

79
Q

When can amniotic fluid embolisms occur

A

Membrane rupture
Labour
CS
termination of pregnancy

80
Q

What the two main complications of uterine rupture?

A
  • acute fetal hypoxia

- massive internal haemorrhage

81
Q

Clinical features of uterine rupture

A 
Abnormal FHR
Constant lower abdominal pain
Tenderness over scar
Vaginal bleeding  
cessation of contractions 
maternal collapse
82
Q

Risk factors

A 
labours with a scarred uterus 
- classical CS
- deep myomectomy 
- LSCS (lowest)
Neglected obstructed labour 
Congenital uterine abnormality 
Previous rupture (high recurrence rates)
83
Q

Prevention

A

avoid induction

caution when using oxytocin in previous CS

84
Q

Management

A

Maternal resuscitation
Blood: clotting, Hb, X-match
Urgent laparotomy (deliver fetus & cessation of bleeding)

85
Q

If the liquor turns green or brown, what does this suggest?

A

The baby has passed meconium which is in response to vagal stimulation. Can be a sign of post dates to fetal distress.

86
Q

What are the aim for contracting in first and second stages of labour?

A

Stage 1: 3-4 in 10 minutes

Stage 2: regular contractions lasting for 1 minute with 1 minute gaps.

87
Q

What are the criteria for instrumental vaginal delivery?

A

Cervix is fully dilated & membrane ruptured
Position of head known (correct positioning of forceps/ventouse)
Head must not be palpable abdominally
Head at/below ischial spines on vaginal examination
Adequate analgesia
Bladder should be empty
Valid indication for delivery

88
Q

Describe how Neville Barnes and Keillands forceps differ?

A

Neville barns are non-rotational forceps for the mid-cavity. They are used in OA position. (sagittal suture felt OA). They are shorted and more curved blade/

Kiellands are for rotational delivery and are therefore more flat.

GOSH (13 decks)

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