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Year 4 OBGYN > Labour > Flashcards

Labour Flashcards

1
Q

What is a Breech presentation?

A

Where the foetus presents buttocks/feet first

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2
Q

What are the three types of Breech Presentation?

A

Complete flexed: Both legs flexed at hips and knees (cross legged)
Frank (Extended): Most Common, Flexed at hip straight at knee, buttocks at pelvic inlet
Footing: One or both legs extended at hip so foot is presenting part

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3
Q

Give two Uterine and two Foetal risk factors for Breech Presentation

A

Uterine: Malformations (Septate), Fibroids

Foetal: Macrosomia, Polyhydramnios

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4
Q

How is Breech presentation diagnosed?

A

Clinical examination reveals head in upper uterus and irregular mass in pelvis
Foetal Heart auscultated higher OE
USS

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5
Q

How is Breech presentation managed?

A

May spontaneously resolve

ECV (External Cephalic Version)

Caesarean

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6
Q

Describe the method of ECV

A

Forward Roll Technique

Breech elevated from pelvis
Pushed to side where back is
Head is pushed and forward roll is completed

Afterwards CTG and give Anti D to Rhesus Neg mothers

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7
Q

Give two contraindications and two complications of ECV

A

Contraindications: Recent Antepartum Haemorrhage, Ruptured Membranes

Complications: Transient foetal Heart abnormalities, Placental Abruption

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8
Q

The Woman may choose a vaginal birth despite Breech (contraindicated completely in footing), describe two specific manoeuvres used

A

Lovsetts (if arms are above chest) - place hands around baby, rotate 180 degrees clockwise then anti-clockwise with downward traction (allows anterior, then posterior shoulder to be delivered)

Mauriceau Smellie Veit - place two fingers over maxilla and two over back of head to flex it, mum should be encouraged to push

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9
Q

Define Foetal Lie and how you would determine it

A

Relationship between the long axis of the foetus and the mother

Can be longitudinal/transverse/oblique

Place hands either side of the abdomen, gently apply pressure with one hand and feel with the other (one side firm- back, other side knobbly - foetal limbs)

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10
Q

Define Foetal Presentation and how you would determine it

A

The part that first enters the maternal pelvis

Safest is cephalic, but others include Breech/Shoulder/Face/Brow

Palpate lower uterus with fingers of both hands

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11
Q

Describe foetal position and how you would determine it

A

Position of foetal head as it exits birth canal

Usually occipitoanterior but can be occipitoposterior or occipitotransverse

Use vaginal examination and fontanelles as landmarks

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12
Q

Give five indications for Induction of Labour

A

Prolonged Gestation
Premature Rupture of Membranes
Foetal Growth Restriction
Maternal Health Problems (such as Pre-Eclampsia)

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13
Q

Give two absolute and two relative contraindications to IOL

A

Absolute: Cephalopelvic Disproportion, Major Placenta Praevia

Relative: Breech, Triplet or higher order pregnancy

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14
Q

Describe the Vaginal Prostaglandin method of IOL

A

Prostaglandins increase cervical ripening and cause uterine contractions

Can be given as Tablet/Gel (one every 24 hours) or Pessary

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15
Q

Describe the Amniotomy method of IOL

A

Membranes are ruptured artificially using Amnihook, causing release of Prostaglandins

Only done when cervix is determined as ‘Ripe’ by Bishops Score

Syntocinon given alongside

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16
Q

Describe the Membrane Sweep Adjunct of IOL

A

Insert gloved finger through cervix and rotate against foetal membrane

Aims to separate Chorionic Membrane from Decidual Membrane and cause PG Release

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17
Q

What is Bishops Score and when is it measured?

A

Measure of Cervical Ripeness via Vaginal Exams

Checked prior to induction, and during induction (6 hours post tablet/gel or 24 hours post pessary)

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18
Q

State the five parameters of the Bishops Score

A 
Cervical Dilation (cm)
Cervical Length (cm)
Cervical Station
Cervical Consistency
Cervical Positon
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19
Q

Describe the results of the Bishops Score

A

> 7 the cervix is ripe/favourable and there is a high chance of response to IOL
<5 the labour is unlikely to progress naturally so IOL required

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20
Q

Give four complications of IOL

A

Failure of Induction (15%)
Uterine Hyperstimulation (Contractions too long or too frequent, manage with tocolytics)
Cord Prolapse
Infection

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21
Q

Describe the Ventouse method of Operative Vaginal Delivery

A

Cup attached to foetal head via vacuum (can be electrical, only suitable for OA, or handheld ‘Kiwi’)
Attached with centre over flexion point over foetal skull
Traction applied during contractions

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22
Q

Give two advantages and two disadvantages of Ventouse Delivery

A

Advantages: Less Pain, Less Perineal Injuries
Disadvantages: Cephalohaematoma, Subgaleal Haematoma

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23
Q

Describe the Forceps method of Operative Vaginal Delivery

A

Different specific forceps depending on position

Blades around foetal head with blades then locked together and gentle traction with contractions

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24
Q

Give an advantage and disadvantage of Forceps Delivery

A

Advantages: Doesn’t require maternal efforts
Disadvantages: Higher rate of perineal tears

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25
Q

How many attempts should you have at Operative Vaginal Delivery?

A

3

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26
Q

Give three indications for Operative Vaginal Delivery

A

Inadequate Progression
Maternal Exhaustion
Suspected foetal compromise

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27
Q

Give three absolute contraindications to Operative Vaginal Delivery

A

Unengaged Foetal Head
Incompletely dilated cervix
Breech/Face/Brow Presentation

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28
Q

Describe the classifications of foetal descent

A

Outlet: Foetal scalp visible with parted labia
Low: Lowest presenting part is at least +2 below ischial spine
Midline: Lowest presenting part is below ischial spine but above +2

Subdivided into rotation needed or not needed

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29
Q

Describe the different between PROM and PPROM

A

PROM - Rupture of foetal membranes at least one hour before onset of labour
PPROM- when the above occurs before 37 weeks gestation

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30
Q

Describe the pathophysiology of PROM

A

Chorion and Amnion strengthened by collagen that physiologically becomes weaker closer to term
May occur earlier due to infection, or genetic predisposition

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31
Q

Give three risk factors for PROM

A

Smoking
Lower GTI
Invasive Procedures

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32
Q

How does PROM present?

A

Normally the classical description of Waters Breaking (pop followed by gush of water)
May be more subtle (gradual leaking, damp underwear)

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33
Q

State 5 investigations for PROM

A

Vaginal exam (after lying for 30 mins to allow fluid to pool)

High Vaginal Swab for GBS

Ferning Test (Cervical Secretions on Slide allowed to dry, fern shaped pattern)

Actim Prom (IGFBP-1 conc in Vagina)

Nitrazine Testing (pH of fluid in Vagina as Amniotic is more alkaline)

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34
Q

Describe the management of PROM

A

<34 weeks: aim to increase gestation, give prophylactic steroids and erythromycin

34-36 weeks: IOL and steroids

> 36 weeks: IOL if not commenced in 48h, prophylactic Erythro

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35
Q

Describe the classification of an Caesarean Section

A

1 - Immediate threat to maternal/foetal life so baby should be born within 30 mins
2 - Maternal/Foetal compromise that’s not immediately threatening (born within 75 mins)
3 - No compromise but needs delivery
4 - Elective

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36
Q

Why are Prokinetics such as Ranitidine given Pre-Caesarean?

A

Due to risk of Mendelson’s Syndrome (Aspiration of gastric contents into lung causing chemical pneumonitis from pressure of Gravid Uterus)

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37
Q

How should the patient be positioned in a Caesarean Section?

A

15 degrees left lateral tilt (reduces risk of hypotension due to aortocaval compression)

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38
Q

Outline the stages of a Caesarean Section

A

1) Skin Incision
2) Sharp Blunt Dissection
3) Visceral Dissection to reveal bladder (retracted by Doyen)
4) Uterine Incision and Fundal Pressure
5) Oxytocin and aided placental delivery

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39
Q

Give three immediate complications of Caesarean Section

A

PPH
Bladder Trauma
Foetal Lacerations

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40
Q

Give two late complications of Caesarean Section

A

Fistula

Uterine Rupture

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41
Q

What is the main risk with VBAC?

A

Uterine Rupture

Results in foetal hypoxia and large maternal haemorrhage

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42
Q

How should VBACs be managed?

A

In hospital setting
Continual CTG monitoring
Avoid induction where possible

43
Q

Give three contraindications to VBAC

A

Upper Caesarean
Previous Rupture
Complex Scars

44
Q

Give two side effects Syntocinon

A

Arrhythmias

Headache

45
Q

When is Mifepristone used?

A

Antiprogesterone ripening cervix and increasing prostaglandin sensitivity
Used in ToP or foetal death

46
Q

Give two side effects of Mifepristone

A

Cramps

Infection

47
Q

Give two non pharmacological methods of Pain Control

A

TENS (as long as not in established labour)

Entonox (50/50 O2 and NO)

48
Q

Give three considerations to IV/IM Opioids in labour

A

Side effects include drowsiness and nausea for mother, and resp depression for baby
May interfere with breast feeding
Shouldn’t enter birthing pool within two hours

49
Q

Epidural (Bupivicaine, Fentanyl) is the most effective pain relief in labour, how should patients be monitored?

A

CTG for 30 mins after establishment, and after each bolus of more than 10ml
If not pain free after 30 mins call anaesthetist

50
Q

What should be plotted on a Partogram in the first stage of labour?

A

Hourly Pulse
Four hourly temp and BP
Frequency of passing urine
Four hourly vaginal exam

51
Q

How can you assess progression of labour during the first stage?

A

Cervical Dilation
Descent and rotation of foetal head
Changes in strength/duration/frequency

52
Q

How should you titre Oxytocin?

A

Increase until there are 4-5 contractions every 10 minutes

53
Q

During the second stage of labour the foetus should be monitored via intermittent auscultation and potentially continuous CTG. Give four indications for continuous CTG.

A

Maternal Pulse >120bpm on two separate occasions
Oxytocin Use
Presence of Meconium
Temp above 38 degrees

54
Q

Describe the method of reading a CTG

A 
DR: Define Risk
C: Contractions
BR: Baseline Rate
A: Accelerations
Va: Variation
D: Decelerations
O: Overall Impression
55
Q

How do you measure Contractions using a CTG?

A

Number in 10 minutes (ie 10 big squares)

56
Q

What should the Baseline HR be, and what could deviations of this be caused by?

A

Should be 110-160bpm

> 160 could be hypoxia, anaemia

<110 could be Cord Prolapse, Post Date Gestation

57
Q

What are Accelerations?

A

Abrupt increase in baseline HR of >15bpm for >15 seconds

Normal and reassuring

58
Q

What is Variability on a CTG?

A

Normally between 5 and 25bpm
Anything outside of these parameters is abnormal/non reassuring

Causes of reduced variability: foetus sleeping, acidosis, opiates

59
Q

What are Decelerations on a CTG?

A

Abrupt decrease in baseline HR of >15bpm for >15 seconds

60
Q

What are early decelerations?

A

Physiological

During uterine contractions only due to increased foetal intracranial pressure, increasing vagal tone

61
Q

What are variable decelerations?

A

May or may not have relationship with uterine contractions

Usually due to umbilical cord compression (vein occluded first causing acceleration then artery causing deceleration)

62
Q

What are Late Decelerations?

A

Begin at the peak of contraction and recover after they end

Indicates insufficient blood flow and foetal hypoxia

Anything over 2 minutes is non reassuring

63
Q

What are causes of Sinusoidal Decelerations?

A

Severe foetal hypoxia, severe foetal anaemia, haemorrhage

64
Q

How could you classify overall impressions?

A

Reassuring
Suspicious
Abnormal

65
Q

What is the normal range for Scalp pH?

A

> 7.25

66
Q

Define Shoulder Dystocia

A

After the delivery of the head, the anterior foetal shoulder becomes impacted on maternal pubic symphysis (most commonly)

Leads to hypoxia of foetus, and any traction can cause brachial plexus injury

67
Q

Give two pre labour and two intrapartum risk factors of Shoulder Dystocia

A

Prelabour: Macrosomia, Maternal BMI>30

Intrapartum: Prolonged first stage of labour, Oxytocin

68
Q

Give two potential clinical features of Shoulder Dystocia

A

Failure of Restitution (remains occipitoanterior after head delivery)

Turtle Neck (foetal head retracts slightly so neck is no longer visible)

69
Q

What is the immediate management of suspected Shoulder Dystocia?

A

Call for help
Advise mother to stop pushing
Consider Episiotomy

70
Q

Describe the first line manoeuvre for Shoulder Dystocia

A

McRoberts Manouvre

Hyper flex maternal hips, tell patient to stop pushing and apply Suprapubic pressure

This widens pelvic outlet

71
Q

Give the two second line manoeuvres for Shoulder Dystocia

A

Posterior Arm: Insert hand posteriorly into sacral hollow and grasp post arm to deliver

Corkscrew: Apply pressure to front of one shoulder and behind other to move baby 180 degrees

72
Q

Give two maternal and two foetal complications of Shoulder Dystocia

A

Maternal: Perineal Tears, PPH
Foetal: Humerus or Clavicular Fracture, Brachial Plexus Injury

73
Q

Define Cord Prolapse and the three types

A

Where the umbilical cord descends through the cervix before the presenting part of the foetus

Occult/Incomplete: Descends alongside presenting part but not beyond it
Overt/Complete: Descends below presenting part
Cord Presentation: Between presenting part and cervix

74
Q

Describe the pathophysiology of Umbilical Cord Prolapse

A

Causes foetal hypoxia due to:
Occlusion (presenting part presses on umbilical cord occluding flow)
Arterial Vasospasm (due to cold exposure)

75
Q

Give two risk factors for Cord Prolapse

A 
Breech Presentation (especially footling)
Unstable Lie
76
Q

How does Cord Prolapse present?

A

Non reassuring foetal heart rate (bradycardia) and absent membranes

77
Q

How should you manage Cord Prolapse?

A

Avoid handling the cord and elevate the presenting part vaginally

In community - fill bladder with 500ml saline

Consider tocolysis or emergency caesarean

78
Q

Define Eclampsia

A

One or more convulsions superimposed on Pre- Eclampsia

Convulsions being Tonic Clonic and lasting 60-75s

79
Q

How should Eclampsia be managed?

A

Consider Intubation
Stabilise in Left Lateral Position

MgSO4 for Anti Convulsant
IV Labetolol/Hydralazine

Deliver once stabilised

80
Q

Name three things you should do/monitor after delivery of an Eclamptic baby

A

BP
CT head
Proteinuria

81
Q

Describe the two types of Uterine Rupture

A

Incomplete: Peritoneum remains intact, Uterine contents remain within

Complete: Peritoneum is also torn and uterine contents can escape into cavity

82
Q

Give three risk factors for Uterine Rupture

A

Previous C Section
Previous Uterine Surgery
Obstruction of Labour (FGM)

83
Q

Give four clinical features of Uterine Rupture

A

Severe Abdominal Pain (Persisting between contractions)
Shoulder Tip Pain
Vaginal Bleeding
Palpable foetal parts

84
Q

If Uterine Rupture is suspected, CTG monitoring of foetus should be commenced. What would an USS show?

A

Abnormal foetal lie/presentation
Haemoperitoneum
Absent Uterine Wall

85
Q

How is a Uterine Rupture managed?

A

A to E rescucitation
Up to 2L of warmed crystalloid
Caesarean and subsequent uterine repair or hysterectomy

86
Q

Give three contributing factors for an Amniotic Fluid Embolism

A

Strong Uterine Contractions
Excess Amniotic Fluid
Disruption of Vessels

87
Q

What do Amniotic Fluid Embolism patients normally go on to develop?

A

DIC

88
Q

What is the only way to definitely diagnose an Amniotic Fluid Embolism?

A

Post Mortem Foetal Squamous Cells in Pulmonary Vasculature

89
Q

How should an Amniotic Fluid Embolism be managed?

A

A to E approach and rescucitation

Perimortem section if required to facilitate maternal CPR

90
Q

Define Primary PPH

A

Loss of >500ml blood PV within 24 hours of delivery

91
Q

Describe the four Ts of Primary PPH

A

Tone: Uterine Atony
Tissue: Retention of tissue preventing it from contracting
Trauma
Thrombin: VWF, HELLP, Haemophilia

92
Q

Describe the management of Primary PPH (TRIM)

A

Teamwork
Rescucitation
Investigation and Monitoring (every 15 mins)
Measures to arrest bleed

93
Q

If the cause of Primary PPH was Uterine Atony, what is the definitive management?

A

Bimanual Compression
Pharmacological: Syntocinon, Ergometrine, Carboprost
Surgical: Ballon Tamponade, Haemostatic Suture, Hysterectomy

94
Q

If the cause of Primary PPH was retained Tissue, how would you manage?

A

IV Oxytocin and manual removal

Prophylactic Abx

95
Q

How can you prevent Primary PPH?

A

Give at least 5 units Oxytocin IM if vaginal delivery or IV if C Section

96
Q

Describe the three levels of Placental Overinvasion

A

Placenta Accreta- Placental villi attached to myometrium
Placenta Increta - Placental villi invade through >50% myometrium
Placenta Percreta - Pass through whole myometrium, potentially involving other organs

97
Q

Define Secondary PPH

A

PV bleeding from 24hrs to 12 weeks post partum

98
Q

Give three causes of Secondary PPH

A

Uterine Infection (Endometritis)
Retained Placental fragments
Abnormal involution of placental sites

99
Q

Describe the clinical features of Secondary PPH

A

PV bleeding (normally not as severe as primary)

If Endometritis: Fever, Lower Abdo Pain, Foul Smelling Lochia

100
Q

What is Lochia?

A

Normal Uterine Discharge following childbirth

101
Q

How is Secondary PPH managed?

A

Antibiotics (Ampicillin, Metronidazole +/- Gentamicin)

Uterotonics

102
Q

Define Post Natal Depression

A

Depressive episode within first 12 months of Post Partum (negative cognitions about motherhood and coping skills)

Not ‘Baby Blues’ : low mood and irritability within the first week

103
Q

Give three risk factors for Post Partum Psychosis

A

Previous Mental Illness
History in Mother or Sister
Previous Psychosis

104
Q

How is Post Partum Psychosis managed?

A

Often require treatment as inpatient under mental health act

Antipsychotic and mood stabiliser

Takes 6-12 months for full recovery

Year 4 OBGYN (15 decks)

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