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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
what augmentation of labour is available for nulliparous women
IV oxytocin artificial rupture of membranes
26
what time period does oxytocin tend to work in for delayed labour
4 hours
27
what is the general advice in regards to pushing in labour
do not push until you feel an urge
28
when is instrumental delivery indicated for labor
stage 2 lasting for 1-2 hours
29
what is the difference between the use of augmentation of labour in multiparous and nulliparous women
you must exclude malpresentation in multiparous women before augmenting labour in any way
30
what is the initial management of an OP presentation in labour
rotation via keilland forceps/ventouse/manual rotation
31
what is the initial management of an OT presentation in labour
only relevant if delivery has not occured within an hour of the pushing stage ventouse rotation
32
what is the management of a brow presentation in labour
C-section
33
what is the management of a face presentation in labour
flex head over perineum | if the chin is posterior c-section indicated
34
what is the highest permanent neonatal complication
cerebral palsy - 10% of all cerebral palsy patients
35
what are causes of foetal damage during labour
Foetal hypoxia/distress Infection – mainly worried about GBS Meconium aspiration leading to chemical pneuomitis Trauma – usually due to instrumentation Foetal blood loss
36
what test is done to check for neonatal hypoxia and what is a concerning score
foetal scalp pH <7.2 = significant hypoxia <7 = neurological damage likely
37
what are common causes of foetal hypoxia in birth
Placental abruption Hypertonic uterine state Use of oxytocin Prolapse of umbilical cord Maternal hypotension
38
what are labour related risk factors that are associated with foetal hypoxia
Prolonged labour Meconium Epidurals Oxytocin
39
what are antepartum risk factors associated with foetal hypoxia at birth
IUGR Pre-eclampsia
40
what are the signs of foetal distress/hypoxia
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
what are the indications for a CTG, prelabour and during labour
Pre-labour Pre-eclampsia IUGR Previous c section Previous Induction Labour Presence of meconium Use of oxytocin Maternal temp >38 Epidural
42
what is some non medical pain relief used in labour
``` preparation - antenatal classes presence of a birth attendant maintenance of mobility immersion in body temp water TENS hypnotherapy acupuncture massage aromatherapy ```
43
what are medical pain reliefs used in labour
inhalation - entonox systemic opioids (IM) - pethidine/meptid epidural - fentanyl + LA spinal anaethesia pudendal nerve blockade
44
what are systemic opioids associated with during labour
maternal confusion/drowsiness foetal bradypnoea
45
when is a higher dose of epidural required
intrumental delivery C-section
46
what is spinal anaethesia reccomended for during labour
C-sections midsection delivery
47
what is a complication of spinal anaethesia during labour
hypotension
48
why is lying supine bad in pregnancy
IVC compression
49
what is pudendal nerve blockade appropriate for during labour
low-cavity instrumental deliveries
50
what is the general management of labour in stage 1
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
what is the general management of labour in stage 2
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
what should be done immediately post delivery if the baby has a normal APGAR score
baby should be dried, wrapped and placed on the mothers chest
53
when should the cord be clamped post-delivery
should be left on for at least 1 minute unless resus is urgently required
54
what is the general management of stage 3 of labour
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
what is the criteria for a retained placenta
stage 3 >30 mins
56
how many pregnancies have a retained placenta
2.5%
57
how should you manage a retained placenta
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
how are 1st and 2nd degree perineal repairs performed
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
how are 3rd and 4th degree perineal tears repaired
Under spinal or epidural in a theatre Antibiotics, analgesia and laxatives given Follow up physio required
60
what % of pregnancies get 3rd-4th degree tears
1-3%
61
what % of women get long term sequale of labour
30% of women have long term sequalae – incontinence/urgency
62
when considering induction of labour, what does Bishop's score measure and what are its components
Success of induction consistency of the cervix (soft =higher) Degree of effacement/early dilation Station of the baby Cervical position (OA/OP)
63
what Bishops score is the threshold for induction
8
64
what are common labour inducing agents
prostaglandin gels amniiotomy +/- oxytocin Oxytocin (used if membranes have already been ruptured) Natural induction - cervical sweep
65
what is the effectiveness of a cervical sweep
50%
66
what are the indications for induction
``` 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
if induction is medically indicated, what gestation is used
38 weeks
68
what are the absoloute contraindications for induction of labour
Acute foetal compromise Abnormal lie Placental praevia Pelvic obstruction >1 c-section
69
what is the relative contraindication for induction of labour
>1 c section + prematurity
70
how do you manage a labour once induction has been decided
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
what are the complications of induction of labour
PPH Intraprtum/postpartum infection Prematurity Instrumental deliver or C-section
72
what is a VBAC
vaginal birth after c-section
73
what are the contraindications for a VBAC
All absoloute indications for C-section Vertical uterine scar Previous uterine rupture Multiple previous C-sections
74
what are factors associated with increased success for a VBAC
Spontaneous labour Interpregnancy interval <2 years Low age and BMI Caucasian Previous vaginal delivery Previous elective C section
75
what is the risk of uterine rupture with a VBAC, and how does this change with successive C-sections
0.5% with 1, 1.3% with 2
76
what is recommended for labour day in a VBAC patient
hospital delivery + continuous CTG monitoring
77
how does a VBAC scar rupture present
Foetal distress Scar pain Cessasion of contractions Vaginal bleeding Maternal collapse
78
what % of women experience prelabour term rupture of membranes
10%
79
what % of prelabour, term rupture of membranes patients start labour within 24 hours
60%
80
what are risks of a prelabour rupture of membranes
cord prolapse | neonatal infection
81
management of prelabour rupture of membranes
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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