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Obstetrics > Labour > Flashcards

Labour Flashcards

1
Q

What are the 3 stages of labour

A

1st stage – initiation so full cervical dilation

2nd stage – full dilation to foetal delivery

3rd stage – foetal delivery to delivery of placenta

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2
Q

what forces determine progress during labour

A

Power - degree of expulsion of the foetus

passage - dimensions of pelvis + soft tissue resistance

passenger - diamters of the foetal head

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3
Q

what is associated with poor uterine contraction during labour

A

nulliparity

induction of labour

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4
Q

why are the ischial spines an important landmark in labour

A

used to determine the level of descent or ‘station’ of the head of the baby

station 0 = level of spines
-2 = 2cm above

+2 = 2 cm below

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5
Q

what is the ideal ‘attitude’ of the foetal head for the easiest labour

A

maximum flexion (head tucked) giving the minimum diameter of the head

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6
Q

what are some mal-attitudes of the baby during labour and what are the implications of these

A

90 degree extension - brow presentation

120 degree extension - face presentation

these have a higher chance for birth failure

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7
Q

what is the ideal position of the baby for optimal labour conditions

A

OA - face to floor

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8
Q

what are some positions associated with increased birth complications

A

OT (face to side) - may be transient as baby rotates 90 degrees in the birth canal but if it persists natural delivery is impossible

OP (face up)- 5% of births, highly difficult to deliver

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9
Q

how do you diagnose labour

A

effacement, dilation of the cervix

usually associated with rupture of the membranes but PPROM exists so not diagnostic

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10
Q

what are the substages of stage 1 of labour

A

latent stage - first 4cm of dilation, takes hours

active stage - 4-10cm, 1cm/hr nulliparous women, 2cm/hr multiparous women

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11
Q

how long is the active part of stage 1 of labour meant to be

A

<16 hours

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12
Q

what are the substages of stage 2 of labour

A

passive - no desire to push, full dilation of cervix-head hitting pelvic floor

active- when mother is pushing active pushing phase

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13
Q

how long does the active phase of stage 2 of labour usually take

A

40 mins nulliparous women

20 mins multiparous women

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14
Q

at what point do you begin to consider assistive options for birth during the active part of labour

A

> 1 hour

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15
Q

in what order should the baby come out of the vagina

A

head first, anterior shoulder, posterior shoulder, rest of baby

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16
Q

how long on average does it take the placenta to deliver

A

15 mins

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17
Q

what is a normal amount of blood lost post-partum

A

<500ml

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18
Q

what physiological response should occur that stops most of the post-partum bleeding

A

oxytocin release leads to uterine contraction which should constrict any bleeding vessels

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19
Q

what % of women get perineal trauma during labour

A

2/3 of nulliparous women, 1/2 of multiparous women

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20
Q

how are perineal tears graded

A

1st Degree - minor (pelvic floor muscles not involved)

2nd Degree - episiotomy grade, minor muscle involvement

3rd degree - anal sphincter involved (1%)

4th degree - anal mucosa torn

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21
Q

what are the general management principles of a woman in labour

A

temp and BP every 4 hours
Pulse every 1 hour in 1st stage, 15 mins in 2nd
contraction frequency should be every 30 mins
position - semi-recumbant
eating is ok unless anaethetics likely to be required
catheterisation if epidural, otherwise important to encourage urination

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22
Q

what should be done if a woman in labour’s temperature rises to >38

A

IV Abx and constant CTG monitoring required

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23
Q

what is associated with causing hyperactive labour

A

placental praevia

too much oxytocin/prostaglandin

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24
Q

how should you manage hyperactive labour

A

check for abruption

if you’re happy there is no abruption IV salbutamol as a tocolytic

generally most patients end up with a C section however

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25
Q

what augmentation of labour is available for nulliparous women

A

IV oxytocin

artificial rupture of membranes

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26
Q

what time period does oxytocin tend to work in for delayed labour

A

4 hours

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27
Q

what is the general advice in regards to pushing in labour

A

do not push until you feel an urge

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28
Q

when is instrumental delivery indicated for labor

A

stage 2 lasting for 1-2 hours

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29
Q

what is the difference between the use of augmentation of labour in multiparous and nulliparous women

A

you must exclude malpresentation in multiparous women before augmenting labour in any way

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30
Q

what is the initial management of an OP presentation in labour

A

rotation via keilland forceps/ventouse/manual rotation

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31
Q

what is the initial management of an OT presentation in labour

A

only relevant if delivery has not occured within an hour of the pushing stage

ventouse rotation

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32
Q

what is the management of a brow presentation in labour

A

C-section

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33
Q

what is the management of a face presentation in labour

A

flex head over perineum

if the chin is posterior c-section indicated

34
Q

what is the highest permanent neonatal complication

A

cerebral palsy - 10% of all cerebral palsy patients

35
Q

what are causes of foetal damage during labour

A

Foetal hypoxia/distress

Infection – mainly worried about GBS

Meconium aspiration leading to chemical pneuomitis

Trauma – usually due to instrumentation

Foetal blood loss

36
Q

what test is done to check for neonatal hypoxia and what is a concerning score

A

foetal scalp pH

<7.2 = significant hypoxia

<7 = neurological damage likely

37
Q

what are common causes of foetal hypoxia in birth

A

Placental abruption

Hypertonic uterine state

Use of oxytocin

Prolapse of umbilical cord

Maternal hypotension

38
Q

what are labour related risk factors that are associated with foetal hypoxia

A

Prolonged labour

Meconium

Epidurals

Oxytocin

39
Q

what are antepartum risk factors associated with foetal hypoxia at birth

A

IUGR

Pre-eclampsia

40
Q

what are the signs of foetal distress/hypoxia

A

Meconium stained liquor – only if undiluted and <41 weeks

Abnormal foetal heart rate and ausciltation

Abnormal CTG  
<110 bpm, >160bpm  
Prolonged reduced variability (<5bpm) (>45mins-1 hour, to account for foetal sleeping) 
Decelerations  
Variable or late  
Early are usually benign

<7.2pH on foetal blood sampling

41
Q

what are the indications for a CTG, prelabour and during labour

A

Pre-labour

Pre-eclampsia
IUGR
Previous c section
Previous Induction

Labour

Presence of meconium
Use of oxytocin
Maternal temp >38
Epidural

42
Q

what is some non medical pain relief used in labour

A 
preparation - antenatal classes
presence of a birth attendant
maintenance of mobility 
immersion in body temp water 
TENS
hypnotherapy 
acupuncture 
massage
aromatherapy
43
Q

what are medical pain reliefs used in labour

A

inhalation - entonox

systemic opioids (IM) - pethidine/meptid

epidural - fentanyl + LA

spinal anaethesia

pudendal nerve blockade

44
Q

what are systemic opioids associated with during labour

A

maternal confusion/drowsiness

foetal bradypnoea

45
Q

when is a higher dose of epidural required

A

intrumental delivery

C-section

46
Q

what is spinal anaethesia reccomended for during labour

A

C-sections

midsection delivery

47
Q

what is a complication of spinal anaethesia during labour

A

hypotension

48
Q

why is lying supine bad in pregnancy

A

IVC compression

49
Q

what is pudendal nerve blockade appropriate for during labour

A

low-cavity instrumental deliveries

50
Q

what is the general management of labour in stage 1

A

Mobility is encouraged

Supine avoided

If analegisia requested - entonox or epidural is given

Foetal heart rate monitored every 15 mins – abnormal means C-section

Progress measured every 4 hours

51
Q

what is the general management of labour in stage 2

A

Pushing encouraged in women without an epidural if the head is visible or if the woman has the urge

If an epidural is in place pushing is nor encouraged for at least an hour

Oxytocin is given to nulliparous women or women with poor descent

Women with epidurals are encouraged to push 3 times for about 10 seconds during each contraction

If stage 2 is prolonged (2 hours nulliparous, 1 hour multiparous), or if there is foetal distress instrumental delivery is required

Episiotomy should be reserved for foetal distress or if the head is not passing over the perineum despite maternal effort

When the head starts to deliver the mother is asked to stop pushing and start panting, the birther will press on the perineum and head to prevent a too rapid delivery

On the next contraction, maternal pushing and gentle downwards contraction on the head should deliver the baby

52
Q

what should be done immediately post delivery if the baby has a normal APGAR score

A

baby should be dried, wrapped and placed on the mothers chest

53
Q

when should the cord be clamped post-delivery

A

should be left on for at least 1 minute unless resus is urgently required

54
Q

what is the general management of stage 3 of labour

A

Once shoulders are delivered oxytocin IM is delivered

Active management of 3rd stage unpopular but it reduces PPH and the need for a blood transfusion

After the cord starts to lengthen, indicating placental separation, the cord is gently tugged whilst the suprapubic area is palpated to prevent uterine inversion

Placenta is checked for missing lobes and perineum for tears

Tears are sutured

Blood loss recorded

(<500ml normal)

Mother can be cleaned, made comfortable and encouraged to breast feed

Maternal observation should continue for at least 2 hours

55
Q

what is the criteria for a retained placenta

A

stage 3 >30 mins

56
Q

how many pregnancies have a retained placenta

A

2.5%

57
Q

how should you manage a retained placenta

A

Partial separation may lead to considerable blood loss into the uterus and hypovolaemia

In the absence of bleeding 1 hour is left for natural separation, after which the placenta is manually removed

Blood is cross matched and IVAbx given

58
Q

how are 1st and 2nd degree perineal repairs performed

A

Done under local anaethetic

Absorbable synthetic material is used with a continuous suture

Rectal and vaginal exam must be done to exclude sutures that are too deep and retained swabs

59
Q

how are 3rd and 4th degree perineal tears repaired

A

Under spinal or epidural in a theatre

Antibiotics, analgesia and laxatives given

Follow up physio required

60
Q

what % of pregnancies get 3rd-4th degree tears

A

1-3%

61
Q

what % of women get long term sequale of labour

A

30% of women have long term sequalae – incontinence/urgency

62
Q

when considering induction of labour, what does Bishop’s score measure and what are its components

A

Success of induction

consistency of the cervix (soft =higher)
Degree of effacement/early dilation
Station of the baby
Cervical position (OA/OP)

63
Q

what Bishops score is the threshold for induction

A

8

64
Q

what are common labour inducing agents

A

prostaglandin gels

amniiotomy +/- oxytocin

Oxytocin (used if membranes have already been ruptured)

Natural induction - cervical sweep

65
Q

what is the effectiveness of a cervical sweep

A

50%

66
Q

what are the indications for induction

A 
Foetal  
Prolonged pregnancy  
IUGR 
Antepartum haemorrhage  
Poor obstetric history  
Premature rupture of membranes

Materno-foetal
Pre-eclampsia
Diabetes

Maternal
Social reasons
In utero death

67
Q

if induction is medically indicated, what gestation is used

A

38 weeks

68
Q

what are the absoloute contraindications for induction of labour

A

Acute foetal compromise

Abnormal lie

Placental praevia

Pelvic obstruction >1 c-section

69
Q

what is the relative contraindication for induction of labour

A

> 1 c section + prematurity

70
Q

how do you manage a labour once induction has been decided

A

Foetus is at risk due to drugs used – at least 1 hour CTG monitoring required

Increases the time spent in early labour – warn the mother

71
Q

what are the complications of induction of labour

A

PPH

Intraprtum/postpartum infection

Prematurity

Instrumental deliver or C-section

72
Q

what is a VBAC

A

vaginal birth after c-section

73
Q

what are the contraindications for a VBAC

A

All absoloute indications for C-section

Vertical uterine scar

Previous uterine rupture

Multiple previous C-sections

74
Q

what are factors associated with increased success for a VBAC

A

Spontaneous labour

Interpregnancy interval <2 years

Low age and BMI

Caucasian

Previous vaginal delivery

Previous elective C section

75
Q

what is the risk of uterine rupture with a VBAC, and how does this change with successive C-sections

A

0.5% with 1, 1.3% with 2

76
Q

what is recommended for labour day in a VBAC patient

A

hospital delivery + continuous CTG monitoring

77
Q

how does a VBAC scar rupture present

A

Foetal distress

Scar pain

Cessasion of contractions

Vaginal bleeding

Maternal collapse

78
Q

what % of women experience prelabour term rupture of membranes

A

10%

79
Q

what % of prelabour, term rupture of membranes patients start labour within 24 hours

A

60%

80
Q

what are risks of a prelabour rupture of membranes

A

cord prolapse

neonatal infection

81
Q

management of prelabour rupture of membranes

A

Lie/presentation checking
Vaginal exam avoided
Foetal auscilatation
CTG

If spontaneous labour
Wait <24 hours
If meconium is present or there is materna infection, immediately induce
After 18-24 hours give prophylatic antibiotics to prevent GBS and to induce labour

If induced
No increased risk of c-section
Reduced risk of maternal infection

Obstetrics (16 decks)

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