Labour Flashcards
What is a Breech presentation?
Where the foetus presents buttocks/feet first
What are the three types of Breech Presentation?
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
Give two Uterine and two Foetal risk factors for Breech Presentation
Uterine: Malformations (Septate), Fibroids
Foetal: Macrosomia, Polyhydramnios
How is Breech presentation diagnosed?
Clinical examination reveals head in upper uterus and irregular mass in pelvis
Foetal Heart auscultated higher OE
USS
How is Breech presentation managed?
May spontaneously resolve
ECV (External Cephalic Version)
Caesarean
Describe the method of ECV
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
Give two contraindications and two complications of ECV
Contraindications: Recent Antepartum Haemorrhage, Ruptured Membranes
Complications: Transient foetal Heart abnormalities, Placental Abruption
The Woman may choose a vaginal birth despite Breech (contraindicated completely in footing), describe two specific manoeuvres used
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
Define Foetal Lie and how you would determine it
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)
Define Foetal Presentation and how you would determine it
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
Describe foetal position and how you would determine it
Position of foetal head as it exits birth canal
Usually occipitoanterior but can be occipitoposterior or occipitotransverse
Use vaginal examination and fontanelles as landmarks
Give five indications for Induction of Labour
Prolonged Gestation
Premature Rupture of Membranes
Foetal Growth Restriction
Maternal Health Problems (such as Pre-Eclampsia)
Give two absolute and two relative contraindications to IOL
Absolute: Cephalopelvic Disproportion, Major Placenta Praevia
Relative: Breech, Triplet or higher order pregnancy
Describe the Vaginal Prostaglandin method of IOL
Prostaglandins increase cervical ripening and cause uterine contractions
Can be given as Tablet/Gel (one every 24 hours) or Pessary
Describe the Amniotomy method of IOL
Membranes are ruptured artificially using Amnihook, causing release of Prostaglandins
Only done when cervix is determined as ‘Ripe’ by Bishops Score
Syntocinon given alongside
Describe the Membrane Sweep Adjunct of IOL
Insert gloved finger through cervix and rotate against foetal membrane
Aims to separate Chorionic Membrane from Decidual Membrane and cause PG Release
What is Bishops Score and when is it measured?
Measure of Cervical Ripeness via Vaginal Exams
Checked prior to induction, and during induction (6 hours post tablet/gel or 24 hours post pessary)
State the five parameters of the Bishops Score
Cervical Dilation (cm) Cervical Length (cm) Cervical Station Cervical Consistency Cervical Positon
Describe the results of the Bishops Score
> 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
Give four complications of IOL
Failure of Induction (15%)
Uterine Hyperstimulation (Contractions too long or too frequent, manage with tocolytics)
Cord Prolapse
Infection
Describe the Ventouse method of Operative Vaginal Delivery
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
Give two advantages and two disadvantages of Ventouse Delivery
Advantages: Less Pain, Less Perineal Injuries
Disadvantages: Cephalohaematoma, Subgaleal Haematoma
Describe the Forceps method of Operative Vaginal Delivery
Different specific forceps depending on position
Blades around foetal head with blades then locked together and gentle traction with contractions
Give an advantage and disadvantage of Forceps Delivery
Advantages: Doesn’t require maternal efforts
Disadvantages: Higher rate of perineal tears
How many attempts should you have at Operative Vaginal Delivery?
3
Give three indications for Operative Vaginal Delivery
Inadequate Progression
Maternal Exhaustion
Suspected foetal compromise
Give three absolute contraindications to Operative Vaginal Delivery
Unengaged Foetal Head
Incompletely dilated cervix
Breech/Face/Brow Presentation
Describe the classifications of foetal descent
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
Describe the different between PROM and PPROM
PROM - Rupture of foetal membranes at least one hour before onset of labour
PPROM- when the above occurs before 37 weeks gestation
Describe the pathophysiology of PROM
Chorion and Amnion strengthened by collagen that physiologically becomes weaker closer to term
May occur earlier due to infection, or genetic predisposition
Give three risk factors for PROM
Smoking
Lower GTI
Invasive Procedures
How does PROM present?
Normally the classical description of Waters Breaking (pop followed by gush of water)
May be more subtle (gradual leaking, damp underwear)
State 5 investigations for PROM
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)
Describe the management of PROM
<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
Describe the classification of an Caesarean Section
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
Why are Prokinetics such as Ranitidine given Pre-Caesarean?
Due to risk of Mendelson’s Syndrome (Aspiration of gastric contents into lung causing chemical pneumonitis from pressure of Gravid Uterus)
How should the patient be positioned in a Caesarean Section?
15 degrees left lateral tilt (reduces risk of hypotension due to aortocaval compression)
Outline the stages of a Caesarean Section
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
Give three immediate complications of Caesarean Section
PPH
Bladder Trauma
Foetal Lacerations
Give two late complications of Caesarean Section
Fistula
Uterine Rupture
What is the main risk with VBAC?
Uterine Rupture
Results in foetal hypoxia and large maternal haemorrhage
How should VBACs be managed?
In hospital setting
Continual CTG monitoring
Avoid induction where possible
Give three contraindications to VBAC
Upper Caesarean
Previous Rupture
Complex Scars
Give two side effects Syntocinon
Arrhythmias
Headache
When is Mifepristone used?
Antiprogesterone ripening cervix and increasing prostaglandin sensitivity
Used in ToP or foetal death
Give two side effects of Mifepristone
Cramps
Infection
Give two non pharmacological methods of Pain Control
TENS (as long as not in established labour)
Entonox (50/50 O2 and NO)
Give three considerations to IV/IM Opioids in labour
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
Epidural (Bupivicaine, Fentanyl) is the most effective pain relief in labour, how should patients be monitored?
CTG for 30 mins after establishment, and after each bolus of more than 10ml
If not pain free after 30 mins call anaesthetist
What should be plotted on a Partogram in the first stage of labour?
Hourly Pulse
Four hourly temp and BP
Frequency of passing urine
Four hourly vaginal exam
How can you assess progression of labour during the first stage?
Cervical Dilation
Descent and rotation of foetal head
Changes in strength/duration/frequency
How should you titre Oxytocin?
Increase until there are 4-5 contractions every 10 minutes
During the second stage of labour the foetus should be monitored via intermittent auscultation and potentially continuous CTG. Give four indications for continuous CTG.
Maternal Pulse >120bpm on two separate occasions
Oxytocin Use
Presence of Meconium
Temp above 38 degrees
Describe the method of reading a CTG
DR: Define Risk C: Contractions BR: Baseline Rate A: Accelerations Va: Variation D: Decelerations O: Overall Impression
How do you measure Contractions using a CTG?
Number in 10 minutes (ie 10 big squares)
What should the Baseline HR be, and what could deviations of this be caused by?
Should be 110-160bpm
> 160 could be hypoxia, anaemia
<110 could be Cord Prolapse, Post Date Gestation
What are Accelerations?
Abrupt increase in baseline HR of >15bpm for >15 seconds
Normal and reassuring
What is Variability on a CTG?
Normally between 5 and 25bpm
Anything outside of these parameters is abnormal/non reassuring
Causes of reduced variability: foetus sleeping, acidosis, opiates
What are Decelerations on a CTG?
Abrupt decrease in baseline HR of >15bpm for >15 seconds
What are early decelerations?
Physiological
During uterine contractions only due to increased foetal intracranial pressure, increasing vagal tone
What are variable decelerations?
May or may not have relationship with uterine contractions
Usually due to umbilical cord compression (vein occluded first causing acceleration then artery causing deceleration)
What are Late Decelerations?
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
What are causes of Sinusoidal Decelerations?
Severe foetal hypoxia, severe foetal anaemia, haemorrhage
How could you classify overall impressions?
Reassuring
Suspicious
Abnormal
What is the normal range for Scalp pH?
> 7.25
Define Shoulder Dystocia
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
Give two pre labour and two intrapartum risk factors of Shoulder Dystocia
Prelabour: Macrosomia, Maternal BMI>30
Intrapartum: Prolonged first stage of labour, Oxytocin
Give two potential clinical features of Shoulder Dystocia
Failure of Restitution (remains occipitoanterior after head delivery)
Turtle Neck (foetal head retracts slightly so neck is no longer visible)
What is the immediate management of suspected Shoulder Dystocia?
Call for help
Advise mother to stop pushing
Consider Episiotomy
Describe the first line manoeuvre for Shoulder Dystocia
McRoberts Manouvre
Hyper flex maternal hips, tell patient to stop pushing and apply Suprapubic pressure
This widens pelvic outlet
Give the two second line manoeuvres for Shoulder Dystocia
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
Give two maternal and two foetal complications of Shoulder Dystocia
Maternal: Perineal Tears, PPH
Foetal: Humerus or Clavicular Fracture, Brachial Plexus Injury
Define Cord Prolapse and the three types
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
Describe the pathophysiology of Umbilical Cord Prolapse
Causes foetal hypoxia due to:
Occlusion (presenting part presses on umbilical cord occluding flow)
Arterial Vasospasm (due to cold exposure)
Give two risk factors for Cord Prolapse
Breech Presentation (especially footling) Unstable Lie
How does Cord Prolapse present?
Non reassuring foetal heart rate (bradycardia) and absent membranes
How should you manage Cord Prolapse?
Avoid handling the cord and elevate the presenting part vaginally
In community - fill bladder with 500ml saline
Consider tocolysis or emergency caesarean
Define Eclampsia
One or more convulsions superimposed on Pre- Eclampsia
Convulsions being Tonic Clonic and lasting 60-75s
How should Eclampsia be managed?
Consider Intubation
Stabilise in Left Lateral Position
MgSO4 for Anti Convulsant
IV Labetolol/Hydralazine
Deliver once stabilised
Name three things you should do/monitor after delivery of an Eclamptic baby
BP
CT head
Proteinuria
Describe the two types of Uterine Rupture
Incomplete: Peritoneum remains intact, Uterine contents remain within
Complete: Peritoneum is also torn and uterine contents can escape into cavity
Give three risk factors for Uterine Rupture
Previous C Section
Previous Uterine Surgery
Obstruction of Labour (FGM)
Give four clinical features of Uterine Rupture
Severe Abdominal Pain (Persisting between contractions)
Shoulder Tip Pain
Vaginal Bleeding
Palpable foetal parts
If Uterine Rupture is suspected, CTG monitoring of foetus should be commenced. What would an USS show?
Abnormal foetal lie/presentation
Haemoperitoneum
Absent Uterine Wall
How is a Uterine Rupture managed?
A to E rescucitation
Up to 2L of warmed crystalloid
Caesarean and subsequent uterine repair or hysterectomy
Give three contributing factors for an Amniotic Fluid Embolism
Strong Uterine Contractions
Excess Amniotic Fluid
Disruption of Vessels
What do Amniotic Fluid Embolism patients normally go on to develop?
DIC
What is the only way to definitely diagnose an Amniotic Fluid Embolism?
Post Mortem Foetal Squamous Cells in Pulmonary Vasculature
How should an Amniotic Fluid Embolism be managed?
A to E approach and rescucitation
Perimortem section if required to facilitate maternal CPR
Define Primary PPH
Loss of >500ml blood PV within 24 hours of delivery
Describe the four Ts of Primary PPH
Tone: Uterine Atony
Tissue: Retention of tissue preventing it from contracting
Trauma
Thrombin: VWF, HELLP, Haemophilia
Describe the management of Primary PPH (TRIM)
Teamwork
Rescucitation
Investigation and Monitoring (every 15 mins)
Measures to arrest bleed
If the cause of Primary PPH was Uterine Atony, what is the definitive management?
Bimanual Compression
Pharmacological: Syntocinon, Ergometrine, Carboprost
Surgical: Ballon Tamponade, Haemostatic Suture, Hysterectomy
If the cause of Primary PPH was retained Tissue, how would you manage?
IV Oxytocin and manual removal
Prophylactic Abx
How can you prevent Primary PPH?
Give at least 5 units Oxytocin IM if vaginal delivery or IV if C Section
Describe the three levels of Placental Overinvasion
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
Define Secondary PPH
PV bleeding from 24hrs to 12 weeks post partum
Give three causes of Secondary PPH
Uterine Infection (Endometritis)
Retained Placental fragments
Abnormal involution of placental sites
Describe the clinical features of Secondary PPH
PV bleeding (normally not as severe as primary)
If Endometritis: Fever, Lower Abdo Pain, Foul Smelling Lochia
What is Lochia?
Normal Uterine Discharge following childbirth
How is Secondary PPH managed?
Antibiotics (Ampicillin, Metronidazole +/- Gentamicin)
Uterotonics
Define Post Natal Depression
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
Give three risk factors for Post Partum Psychosis
Previous Mental Illness
History in Mother or Sister
Previous Psychosis
How is Post Partum Psychosis managed?
Often require treatment as inpatient under mental health act
Antipsychotic and mood stabiliser
Takes 6-12 months for full recovery
