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Obs and gynae > Labour > Flashcards

Labour Flashcards

1
Q

What are the 3 stages of labour

A

1 - start of contractions to full cervical dilation
2 - cervical dilation to birth of baby
3 - birth of baby to delivery of placenta

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2
Q

What are the 3 Ps of labour

A

Power, passengers, passage

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3
Q

Why are ischial spines important in delivery

A

2 things:

  1. station zero is when baby’s head is at ischial spine, can only do instrumental if baby’s head has reached this
  2. important for delivery PUDENDAL NERVE BLOCK
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4
Q

Why does foetal head rotate on its way down

A

Pelvic outlet is widest transversely and then AP. Therefore head rotates from transverse to AP on its way down. (this occurs in midpelvis)§

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5
Q

What are the four types of pelvis

A

Gynaecoid
Android (predisposes to failure of rotation)
Platypelloid (kid prefers occipito posterior)
Anthropoid (predisposes to failure of rotation)

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6
Q

What is the vertex

A

Usually presenting part

It’s the part in between ant and post fontanelles and where the parietal bones fuse

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7
Q

How do you describe descent

A

Position of posterior fontanelle in relation to pubic symphysis

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8
Q

Which position has the greatest presenting diameter

A

mento-vertical - 13cm

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9
Q

What are the actions of progesterone on the uterus

A

Prevent prostaglandin production
Inhibit gap junction formation
Prevent oxytocine release
PROMOTES QUIESCENT UTERUS

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10
Q

What two molecules are needed for labour

A

Oxytocin

Prostaglandin

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11
Q

What is the ferguson reflex

A

Pressure of foetal head on cervix makes maternal pit. secrete more oxytocin which causes contractions and further increases pressure

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12
Q

How is progesterone dethroned at the end of pregnancy

A

Oestrogen opposes prog actions
chorion starts making PG. - (increase calcium)
CRH conc. (from placenta) increases at the end of term which potentiates action of PG + Ox
Production of cortisol from foetus stimulates conversion of prog to oestrogen

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13
Q

What is the definition of labour

A

presence of painful contractions which lead to progressive cervical changes

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14
Q

What is the diagnosis of 1st stage

A

cervix 10cm

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15
Q

What are the 2 phases of 1st stage

A

latent (effacement of cervix to 3-4 cm dilation w/ contractions)
Active ( 3/4cm –> 10cm dilation)

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16
Q

What are the two phases of 2nd stage

A

Passive - time between mx cervical dilation and involuntary expulsive contractions (1-2 hours) head is high in pelvis
Acitve - urge to bear down (no longer than 2 hours)

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17
Q

What is a long 3rd stage

A

should take 5-10 mins

anything more than 60 mins is abnormal

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18
Q

How to gauge engagement

A

Palpate foetal head in abdomen (if >2/5 then not engaged)

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19
Q

Mechanism of labour

A 
engagement
descent
flexion of head
internal rotation
extension
restitution
external rotation
delivery of shoulders and foetal body
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20
Q

What are indications for increased foetal monitoring during labour

A 
Significant meconium 
Abnormal FHR
PV bleeding
If they're being augmented
Maternal pyrexia
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21
Q

What to look at in CTG

A

Baseline
variability
acceleration
deceleration

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22
Q

How to read CTG

A

All normal - reassuring
1 abnormal - suspiscious
2 abnormal - pathological CTG

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23
Q

How long after reaching full dilation (second stage) should baby be delivered?

A

Baby should be delivered 4 hours after start of stage 2

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24
Q

What is the management of 3rd stage

A

Active management - controlled cord traction to pull placenta out
Physiological - let mum do it (recommence active if >60 minutes or haemorrhage occurs)
If placenta retained go to theatre for manual removal of placenta under anaesthesia

25
Q

What is primary arrest

A

Where woman doesn’t progress into active phase of 1st stage - characterised by cervical dilation of less than 1cm per 2 hours. caused by poor contractions and cephalopelvic disorders

26
Q

What is secondary arrest

A

Where progress in active first stage is good but then it stops (cervix doesn’t dilate past 7 cm)
-malposition
malpresentation
- cephalopelvic disorders

27
Q

Definition of poor progress in 1st stage

A

dilation of less than 2cm in 4 hours
Should be 1cm every 2 hours
(can be down to any of 3 ps)

28
Q

Mx of dysfunctional uterine activity

A

Aim for 4-5 contractions per 10 mins (if it’s less than this)
If not happening do ARM (examine every 2 not 4 hours in this case)
If after 4 hours nothing has changed then give oxytocin (remember to give epidural before this)
On oxytocin need constant foetal monitoring
If no progress on oxy for 4-6 hours ECS§

29
Q

What are you concerned about in poor progress of 1st stage in multip

A

malposition and risk of rupture

30
Q

What suggest cephalopelvic disproportion

A

foetal head not engaged
slow progress in presence of good contractions
head poorly applied to cervix
haematuria

31
Q

Mx cephalopelvic disproportion

A

Can give oxy in primigravida with suspected CPD

NEVER in multip

32
Q

Which presentaiton can you deliver

A

Face - should be ok
Brow. - NO
Shoulder - questionable

33
Q

Who is at higher risk of malpresenation

A

HIGH PARITY

uterine rupture

34
Q

Causes of abnormalities of birth canal

A

Undiagnosed fibroids

Cervical dystocia - cervix effaces but doesn’t dilate cause of surgeries or something

35
Q

Causes of poor progress of 1st stage

A

Dysfunctional uterine activity (MOST COMMON)
CPD
Malpresentation
Abnormalities of birth canal

36
Q

How long should it take to give birth from active second stage

A

Nullip - 3 hours
Multip - 2 hours
W

37
Q

When to diagnose delay of second stage

A

If birth isn’t imminent after
1 hour in multio
2 hours in nullip

38
Q

Causes of poor progress in second stage

A

Secondary dysfunctional uterine activity
Android pelvis
Resitant perineum
Persistent OP position

39
Q

What is a RF for secondary delay

A

Epidural analgesia

Sometimes associated with maternal dehydration

40
Q

Mx of secondary delay

A

In nullip - if no mechanical obstruction can give oxytocin IV
In multip - full obstetrician review to assess whether you want to give oxytocin
NB- by time delay of second stage has been diagnosed you should not be giving oxytocin, should diagnose and correct this at the start of second stage

41
Q

When is meconium concerning

A

If it’s bright green or black

if it’s tenacious (thick and clingy)

42
Q

What to do if pathological CTG

A

Immediate vaginal exam to exclude cord prolapse and malpresentation
If cervix fully dilated can do instrumental
If not then do foetal blood sampling
If normal carry on for 30-60 mins
If abnormal emergency CS

43
Q

What are you looking for in foetal blood sampling

A

Level of acidosis
If less than 7.2 it’s foetal compromise
7.2-7.25 borderline
7.25 normal

44
Q

Side effects of opiatae analgesia

A

Vomiting and nausea - give w/ antiemetic
Delayed gastric emptying - interfere with GA
Resp distress in foetus
Can interfere with breastfeeding

45
Q

Whis is NO not good in long term

A

Leads to hyperventilation, hypocapnia and potentially foetal hypoxia

46
Q

What are indications of epidural

A 
High risk of operative delivery
maternal hypertension
select maternal conditions
multiple pregnancy
prolonged labour and oxytocin use
47
Q

Contraindications for epidural

A

Coagulopathy
sepsis
hypovolaemia

48
Q

Complications of dural

A

Dural puncture
Spinal haematoma
Leakage of CSF into subarachnoid space - spinal headache
Complete spinal anaesthesia - spinal headache
Bladder dysfunction - CATHETERISE
Hypotension - give IV fluids and vasopressors

49
Q

When is rupture most likely to happen

A

In late first stage when being augmented or induced

50
Q

Contraindications for VBAC

A

Relative (no more than 2):
Need for induction
2 or more c sections
Hx of CPD

Absolute contraindications:
Classical caesarean
pervious uterine rupture

51
Q

When to induce in PROM

A

> 37 induce roughly 24 hours after PROM
<34 need another reason to induce
34-37 case by case basis

52
Q

What are the absolute contraindications for IOL

A

Placenta praevia

Foetal compromise

53
Q

what is the bishop score

A

For induction

Looks at cervical changes (high score = more favourable cervix)

54
Q

How to induce labour

A

PGE2 - most common (first line)
ARM - only possible if cervix is beginning to dilate and efface. Don’t do if presenting part is mobile and high
IV syntocinon - offer if 2 hours after membranes rupture labour hasn’t started (to increase til 3-4 contractions per 10 mins)

Special circumstances:
Mifepristone and misoprostol (often used following intrauterine foetal death
Cervical sweep to break membrane and release prostaglandin. offered prior to formal measures especially from 40 weeks

55
Q

Complications of induction

A

increased risk of uterine atony

foetal compromise due to uterine hyperstiulation as s/e of prostaglandin

56
Q

Risk of ARM

A

cord prolapse

57
Q

Monitoring during normal labour

A 
1st stage - 
every 15 mins foetal HR
every 30 mins frequency of contractions
every hour maternal HR
every 4 hours - vaginal examination

2nd stage -
every 5 mins foetal HR
every 30 mins frequency of contractions
every hour - vaginal exam

58
Q

counselling for VBAV

A

VBAC -
positive predictors: hx of successful VBAC, normal size baby, reduce need for C section in further pregnancies
Risks of VBAC - uterine rupture 1in 200, success ratea 70-75%

Elective repeat c-section-
risk of another CS, risk of placenta praevia/accreta in future pregnancies
avoids risk of future emergency C section and uterine rupture

Obs and gynae (23 decks)

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