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Obstetrics and Gynaecology > Labour and Delivery > Flashcards

Labour and Delivery Flashcards

1
Q

What is the lie of the fetus? What are the types?

A

Relationship of fetal long axis to uterus long axis

Longitudinal
Oblique
Transverse

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2
Q

What is the presentation of the fetus? What are the types?

A

Fetal part that enters the maternal pelvis

Cephalic is the safest
Face, Brow, Breech, Shoulder

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3
Q

What is the vertex/position of the fetus?

A

Position of the fetal head as it exits the birth canal

Occipito-anterior is safest

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4
Q

What are the stages of labour?

A

First stage - from onset - true contractions, until 10cm cervical dilatation
Second stage - from 10cm cervical dilatation until delivery of the baby
Third stage - from delivery of baby until delivery of placenta

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5
Q

What are the phases of first stage of labour?

A

Latent phase - onset involves cervical dilation and effacement. Show - mucus plug falls out and creates space for baby to pass through. Irregular contractions.
From 0-3cm; progresses at 0.5cm per hour.

Active phase - from 3cm to 7cm dilatation, progresses at around 1cm per hour, regular contractions.

Transition phase - from 7cm to 10cm, progresses around 1cm per hour, strong regular contractions.

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6
Q

What are Braxton-Hicks contractions?

A

Occasional irregular contractions of the uterus
Usually felt during the second and third trimester
Temporary and irregular tightening or mild cramping in the abdomen, do not indicate onset of labour.

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7
Q

What are the signs of the onset of labour?

A

Show - mucus plug from the cervix
Rupture of membranes
Regular, painful contractions
Dilating cervix on examination

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8
Q

What is ROM?

A

Rupture of membranes, the amniotic sac has ruptured

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9
Q

What is SROM?

A

Spontaneous rupture of membranes

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10
Q

What are the types of premature rupture of membranes?

A

Premature rupture of membranes - >1hr before onset of labour at >=37 weeks gestation

Pre-term premature rupture of membranes - rupture occur before 37 weeks gestation

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11
Q

How common is premature rupture of membranes?

A

10-15% of term pregnancies

Minimal risk to mother and fetus

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12
Q

How common is preterm premature rupture of membranes?

A

~2%

Higher rates of maternal and fetal complications

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13
Q

What are the risk factors associated with premature rupture of membranes?

A

Multiple pregnancy
Lower GU infection

Smoking
Vaginal bleeding during pregnancy
Polyhydramnios
Cervical insufficiency
Invasive procedures - amniocentesis
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14
Q

What are the differentials for premature rupture of membranes?

A

Urinary incontinence
Loss of mucus plug

Normal vaginal secretions
Secretions associated with infection

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15
Q

What is the pathophysiology of premature rupture of membranes?

A

Normal weakening occurs earlier than normal due to:
- Higher levels of apoptotic markers in amniotic fluid

  • Infection - cytokines weaken membrane
  • Genetic disposition
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16
Q

How is a premature rupture of membranes diagnosed?

A

Maternal history of rupture and positive examination findings

Sterile speculum examination - amniotic fluid draining from cervix and pooling in vagina when lying down for 30 mins

Reduced amniotic fluids suggestive

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17
Q

What is important to investigate if you suspect premature rupture of membranes and what should you avoid?

A

High vaginal swab done - look for group B strep

Avoid digital vaginal exam until in labour –> poss. intrauterine infection

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18
Q

What does premature rupture of membranes cause?

A

Amniotic fluid stimulate uterus and labour occur within 24-48 hours

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19
Q

If labour doesn’t occur following premature rupture of membranes, what should be done?

A

<34 weeks - aim for increased gestation

34 weeks + - induce labour

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20
Q

How should premature rupture of membranes before 36 weeks be managed?

A

Monitor for chorioamnionitis
Advise against sexual intercourse

Prophylactic erythromycin
Corticosteroids (dexamethasone) - fetal lung development

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21
Q

How should premature rupture of membranes >36 weeks be managed?

A

Monitor for chorioamnionitis

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22
Q

What are the complications of premature rupture of membranes?

A

Prematurity
Sepsis

Pulmonary hypoplasia

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23
Q

How can premature rupture of membranes be prevented?

A

Intravaginal progesterone and cervical cerclage - if history of Preterm-PROM

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24
Q

What is chorioamnionitis?

A

Result of ascending bacterial infection of amniotic fluid, membranes or placenta

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25
Q

What are the risk factors for chorioamnionitis?

A

Preterm premature rupture of membranes

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26
Q

How is chorioamnionitis managed?

A

Prompt delivery of foetus

IV antibiotics

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27
Q

What occurs in preterm labour with intact membranes?

A

Regular painful contractions and cervical dilatation without the rupture of the amniotic sac

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28
Q

How can preterm labour with intact membranes be diagnosed?

A

Speculum examination for cervical dilatation
Less than 30 weeks - clinical assessment enough
More than 30 weeks - TV USS, assess cervical length
If less than 15mm - management can be offered

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29
Q

What is fetal fibronectin?

A

An alternative test to vaginal ultrasound, found in the vagina during labour it is between the chorion and uterus
Result of less than 50mg/ml considered negative - indicates preterm labour unlikely

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30
Q

What are the management options for improving outcomes in preterm labour?

A

Fetal monitoring - CTG or intermittent auscultation
Tocolysis with nifedipine
Maternal corticosteroids offered before 35 weeks
IV magnesium sulphate given before 34 weeks
Delayed cord clamping or cord milking

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31
Q

What is tocolysis?

A

Using medications to stop uterine contractions
Nifedipine - Ca channel blocker
Atosiban - oxytocin receptor antagonist

Can be used between 24 and 33 + 6 weeks in preterm labour

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32
Q

What corticosteroids are given in preterm labour?

A

Two doses of intramuscular betamethasone, 24 hours apart

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33
Q

Why is magnesium sulfate given in preterm labour?

A

Helps protect the fetal brain
Reduces risk and severity of cerebral palsy
Given within 24 hours of delivery in preterm babies less than 34 weeks
Given as bolus and then infusion for 24 hours in lead up to birth

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34
Q

What are the signs of magnesium sulfate toxicity?

A

Reduced respiratory rate
Reduced blood pressure
Absent reflexes - check patella reflex

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35
Q

What are the methods of induction?

A

Vaginal prostaglandins - gel, tablet (Prostin) or pessary (propess)
Membrane sweep

Cervical ripening balloon - silicone balloon gently inflated to dilate cervix

Amniotomy +- oxytocin
Only be used if not to use vaginal prostaglands

Oral mifepristone (anti progesterone) plus misoprostol used to induce labour where intrauterine death occurred

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36
Q

How do vaginal prostaglandins induce labour?

A

Ripen cervix and role in contractions

Taken as tablet, gel or pessary

Induction can take days

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37
Q

How does a membrane sweep induce labour?

A

Adjunct to induction

Gloved finger rotate against fetal membrane - aim to separate from decidua and release prostaglandins

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38
Q

Explain the use of an amniotomy to induce labour

A

Used if vaginal prostaglandins CI

Membranes ruptures using hook - release prostaglandins to stimulate labour

Oxytocin given to increase strength and freq. of contractions

Only performed once cervix is ripe

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39
Q

What are the absolute contraindications for induction of labour?

A

Cephalopelvic disproportion
Major placenta praevia

Transverse lie
Vasa praevia
Cord prolapse
Active primary genital herpes

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40
Q

What are the relative contraindications for induction of labour?

A

Breech
Triplet or higher order pregnancy

2 or more previous low transverse C sections

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41
Q

What is the bishop’s score?

A

Scoring system used to assess cervical ripeness

Score >9 - labour likely commence spontaneously
Score <5 - labour unlikely to start without induction

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42
Q

Describe the factors in bishop’s score

A

Cervix: 0 points, 1 point, 2 point, 3 point

Position - posterior, midline, anterior, NA
Consistency - firm, medium, soft, NA
Effacement - 0-30%, 40-50%, 60-70%, >80%
Dilation - closed, 1-2cm, 3-4cm, >5cm
Station - -3, -2, -1 and 0, +1 and +2
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43
Q

What complications are associated with induction of labour?

A

Uterine hyperstimulation
Failure of induction - req. C Section

Uterine rupture
Cord prolapse - occur in amniotomy with rush of fluid
Intrauterine infection - prolonged membrane rupture and repeated vaginal examinations

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44
Q

What is uterine hyperstimulation associated with and how is it managed?

A

Fetal distress

Contraction of the uterus is prolonged and frequent

Terbutaline - anti-contraction agent
Removing the vaginal prostaglandin or stopping the oxytocin infusion

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45
Q

When is IOL offered?

A

Between 41 and 42 weeks

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46
Q

When might induction of labour be offered early?

A 
Prelabour rupture of membranes
Fetal growth restriction
Pre-eclampsia
Obstetric cholestasis
Existing diabetes
Intrauterine fetal death
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47
Q

What monitoring is required during the induction of labour?

A

CTG to assess the fetal heart rate and uterine contractions

Bishops score before and during to monitor progress

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48
Q

What can be the consequences of uterine hyperstimulation?

A

Fetal compromise with hypoxia and acidosis
Emergency c-section
Uterine rupture

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49
Q

What do the following abbreviations stand for in CTG monitoring?

DR
C
BRa
V
A
D
O
A

Define Risk
Contractions

Baseline Rate
Variability
Accelerations
Decelerations
Overall impression
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50
Q

What is define risk on CTG?

A

Defining whether a pregnancy is high or low risk. It gives you context to the CTG and may change your threshold for intervention

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51
Q

What do you need to record about contractions?

A

Number in a 10 minute period (seen as peaks of uterine activity on CTG)

Strength and duration

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52
Q

What is a normal fetal heart rate?

A

110-160

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53
Q

How is a baseline fetal heart rate calculated?

A

Average in 10 minute window

Ignore accelerations and decelerations

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54
Q

How is prolonged severe bradycardia in a fetus defined?

A

<80bpm for >3 mins

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55
Q

What conditions are associated with fetal tachycardia?

A

Fetal hypoxia
Chorioamnionitis

Maternal or fetal anaemia
Hyperthyroidism

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56
Q

What conditions are associated with fetal bradycardia?

A

Prolonged gestation
Transverse or posterior occiput presentation

(100-120 bpm)

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57
Q

What conditions are associated with prolonged severe fetal bradycardia?

A

Prolonged cord compression
Cord prolapse

Epidural
Rapid fetal descent

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58
Q

What does baseline variability on a CTG tell you? What is a normal variability?

A

How a fetus’ HR varies from one beat to the next

Indicate fetus is adapting to environment due to input from nervous system, baroreceptors and chemoreceptors

Normal is 5-25

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59
Q

What could cause reduced fetal variability?

A

Fetus sleeping
Fetal acidosis - hypoxia

Fetal tachycardia
Congenital heart defect
Prematurity
Maternal medication - opiates, benzo, methyldopa, magnesium sulphate

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60
Q

What is a fetal acceleration?

A

Abrupt increase in baseline fetal HR

> 15bpm for >15s

They are reassuring

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61
Q

What is a fetal deceleration?

A

Abrupt decrease in baseline fetal HR of >15bpm for >15s

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62
Q

Why do fetuses reduce their heart rate?

A

In response to hypoxia to reduce myocardial demand and preserve myocardial oxygenation and perfusion

Fetus can’t change respiratory depth or rate

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63
Q

What is an early deceleration?

A

Start when uterus contract and recover when contraction stop

Due to fetal RICP and increasing vagal tone

Physiological deceleration

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64
Q

What is a variable deceleration?

A

Rapid fall in heart rate with variable recovery phase

May not have any relationship to contractions

Seen in labour and with oligohydramnios patients

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65
Q

What are “shoulders of decelerations”?

A

Accelerations occur before and after deceleration

Indicate fetus still able to adapt and not yet hypoxic

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66
Q

What causes the acceleration, deceleration, acceleration in shoulders of decelerations?

A

Umbilical vein occluded - acceleration

Umbilical artery occluded - deceleration

Pressure off cord - acceleration

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67
Q

What is a late deceleration?

A

Begin at peak of contraction and recover after it has ended

Indicate lack of blood supply to uterus and placenta - hypoxia and acidosis

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68
Q

What causes late decelerations?

A

Maternal hypotension
Pre-eclampsia

Uterine hyperstimulation

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69
Q

What must you do if you see a late deceleration?

A

Fetal blood sampling for pH

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70
Q

What is a prolonged deceleration?

A

Deceleration lasting >3mins

Fetal blood sampling or emergency C section needs to be arranged

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71
Q

What is a sinusoidal pattern on a CTG?

A

Smooth regular wave like pattern with no beat to beat variability

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72
Q

What can cause a sinusoidal CTG pattern?

A

Severe fetal hypoxia
Severe fetal anaemia

Haemorrhage

Very concerning and associated with high levels of morbidity and mortality

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73
Q

What would be seen on a reassuring CTG?

A

110-160bpm
5-25 variability

No or early decelerations
Variable decelerations with no concerning characteristics <90 mins

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74
Q

What characteristics of variable decelerations are concerning?

A

> 60s
Reduced baseline variability within deceleration

Fail to return to baseline
Biphasic (W) shape
No Shouldering

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75
Q

What features of a CTG would be considered non-reassuring?

A

100-109bpm OR 160-181bpm
Variability <5 for 30-50mins or >25 for 15-25mins

Variable decelerations with no concerns >90mins
Variable decelerations with concerns in <50% of contractions >30mins
Variable decelerations with concerns in >50% of contractions <30mins
Late in >50% of contractions for <30 mins with no clinical risk factors (bleeding or meconium)

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76
Q

What features of a CTG would be considered abnormal?

A

<100 or >180 bpm
Variability <5 for >50 mins OR >25 for >25mins OR sinusoidal pattern

Variable decelerations with concerns >50% of contractions for >30 mins
Late decelerations >30mins
Acute bradycardia
Single prolonged deceleration >3mins

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77
Q

What is a normal CTG and what is the management?

A

All features reassuring

Continue CTG and usual care

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78
Q

What is a suspicious CTG and how is it managed?

A

1 non-reassuring AND 2 reassuring features

Seek advice from obstetrician or senior midwife, correct underlying causes, full set of maternal obs

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79
Q

What is a pathological CTG?

A

1 abnormal feature OR 2 non reassuring features

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80
Q

How is a pathological CTG managed?

A

Seek advice - obstetrician or senior midwife
Correct underlying cause

Exclude acute events - cord prolapse, placental abruption, uterine rupture
Offer digital fetal scalp stimulation

If still pathological after scalp stimulation, consider fetal blood sample and expediting birth

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81
Q

What CTG requires urgent intervention?

A

Acute bradycardia

Single prolonged deceleration >3mins

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82
Q

What is done if a CTG requires urgent intervention

A

Urgently seek obstetrician help
Correct underlying causes

Expedite birth if acute event
Prepare for urgent birth
Expedite birth if bradycardia >9mins
Discuss expedited birth if bradycardia recover

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83
Q

What are the CI’s for fetal blood sampling?

A

Risk of maternal-fatal infection

Fetal bleeding disorders

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84
Q

What results are in a normal fetal blood sample? What is the next step?

A

Lactate <=4.1mmol/L
pH >= 7.25

Repeat in an hour

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85
Q

What results are in a Borderline fetal blood sample? What is the next step?

A

Lactate 4.2-4.8mmol/L
pH 7.21-7.24

Repeat in 30 mins

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86
Q

What results are in an abnormal fetal blood sample? What is the next step?

A

Lactate >=4.9 mmol/L
pH <=7.20

Expedite birth

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87
Q

What are the indications for continuous CTG monitoring in labour?

A 
Sepsis
Maternal tachycardia >120
Significant meconium
Pre-eclampsia - particularly blood pressure >160/110
Fresh antepartum haemorrhage
Delay in labour
Use of oxytocin
Disproportionate maternal pain
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88
Q

What is the rule of three for fetal bradycardia?

A 
For prolonged fetal bradycardia
3 mins - call for help
6 mins - move to theatre
9 mins - prepare for delivery
12 mins - deliver baby, by 15 mins
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89
Q

What are late decelerations?

A

Gradual falls in heart rate after the uterine contraction has already begun.
Delay between uterine contraction and deceleration, lowest point of deceleration occurs after peak of contraction.
Due to hypoxia in the fetus.
May be caused by excessive uterine contractions, maternal hypotension or maternal hypoxia.

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90
Q

What are prolonged decelerations?

A

Last between 2 and 10 minutes
With a drop of more than 15 bpm from baseline
Often indicates compression of umbilical cord, causing fetal hypoxia.

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91
Q

What is a normal baseline variability in CTG?

A

5-25 bpm

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92
Q

What is a suspicious CTG?

A

Lacking at least one feature of normality, but with no pathological features
Low probability of having hypoxia/acidosis

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93
Q

What is a pathological CTG?

A

Two non-reassuring features or a single abnormal feature

Above 180bpm or below 100bpm
Baseline less than 5 >50 mins, more than 25 >30 mins or sinusoidal for >30 mins

Repetitive, late or prolonged decelerations with any concerning characteristics >30 mins or >20 mins if reduced variability

Single prolonged deceleration below 100bpm lasting 3 mins or more

Fetus with high probability of having hypoxia or acidosis

94
Q

what is the management following a suspicious CTG?

A 
Full set of maternal observations
Consider risk factors
Immediate conservative measures - change maternal position, reduce or stop oxytoxin, remove propess, consider tocolysis, paracetamol if sepsis, oral fluids/IV
Escalate to coordinator, document
Correct hypotension
Communicate with women regards to plan
Review in 30 mins or before
95
Q

What is the management following a pathological CTG?

A

Full set of maternal observations
Consider risk factors
Immediate conservative measures
Escalate immediately to obstetric team
Consider FSE and FBS - fetal blood sampling and scalp electrode.
Correct hypotension
If pushing - stop to see if improvement made
VE - offer digital stimulation
Consider expediting delivery if indicated

96
Q

Describe the MOA, side effects and CI’s for syntocinon

A

Synthetic oxytocin - stimulate myometrium contraction

Stimulates ripening of cervix, also plays role in lactation during breastfeeding.

Used to induce labour, progress labour, improve freq and strength of uterine contractions, prevent or treat PPH.

SE - N&V, headache, hypertension

CI - hypertonic uterus, severe CVS disease

97
Q

Describe the MOA, side effects and CI’s for ergometrine

A

Alpha adrenergic, dopamine and serotonin receptor action to stimulate contraction of uterus

May be used during third stage and post partum to treat PPH. Only used after delivery of baby.

SE - Hypertension, nausea, bradycardia

CI - Hypertension, eclampsia, vascular disease

98
Q

Describe the MOA, side effects and CI’s for carboprost

A

Prostaglandin analogue

SE - bronchospasm, pulmonary oedema, HTN, cardiovascular collapse

CI - Cardiac/pulmonary disease

99
Q

Describe the MOA, side effects and CI’s for misoprostol

A

Prostaglandin analogue
Binds to prostaglandin receptors and activates them
Used alongside mifepristone for abortions, and IOL after intrauterine fetal death.

SE - diarrhoea

100
Q

What is mifepristone?

A

Anti-progestogen that blocks the action of progesterone, halting pregnancy and ripening cervix
Not used during pregnancy with healthy living fetus

101
Q

What is nifedipine?

A

Calcium channel blocker acts to reduce smooth muscle contraction in blood vessels and the uterus
Reduces blood pressure in hypertension and pre-eclampsia
Tocolysis in premature labour

102
Q

What is progress in labour influenced by?

A

Power - uterine contractions
Passenger - size, presentation and position of baby
Passage - shape and size of pelvis and soft tissue

103
Q

When is there considered to be a delay in the first stage of labour?

A

Less than 2cm of cervical dilatation in 4 hours

Slowing of progress in multiparous women

104
Q

What is the importance of a partogram?

A

Measures cervical dilatation, descent of fetal head, maternal and fetal obs, status of membranes

Crossing alert line indicates need for amniotomy

Crossing action line means need for obstetric led care

105
Q

When is there considered to be a delay in the second stage of labour?

A

If active second stage pushing lasts over 2 hours in a nulliparous woman or 1 hour in multiparous woman

106
Q

What are the causes of a delayed second stage of labour?

A

Power - poor contractions

Passenger
Size - macrosomia, should dystocia

Attitude - how rounded back is, limbs and head flexed

Lie - longitudinal, transverse or oblique and presentation.

107
Q

What can be some interventions if there is a delayed second stage of labour?

A 
Changing positions
Encouragement
Analgesia
Oxytocin
Episiotomy
Instrumental delivery
C-section
108
Q

When is it defined that there is a delay in the third stage of labour?

A

More than 30 mins with active management

More than 60 mins with physiological management

109
Q

What are management options in failure to progress?

A

Amniotomy
Oxytocin infusion
Instrumental delivery
C-section

110
Q

What pain relief is available in labour?

A

Simple analgesia - paracetamol, codeine, avoid NSAIDs

Gas and air - nitrous oxide and oxygen

IM pethidine or diamorphine
Can cause drowsiness or nausea in the mother, and respiratory depression in the neonate if given too close to birth, may make first feed more difficult.

Patient controlled analgesia - remifentanil, bolus of short acting opiate medication.
Need naloxone for resp depression and atropine for bradycardia if adverse events occur.

Epidural - placed in epidural space, outside dura mater infused into catheter
Bupivacane, mixed with fentanyl

111
Q

What can be the adverse effects of an epidural?

A 
Headache after insertion
Hypotension
Motor weakness in legs
Nerve damage
Prolonged second stage
Increased probability of instrumental delivery
112
Q

What are the types of cord prolapse?

A

Occult - cord drop alongside baby but may not be seen in advance

Overt - cord come before baby’s head can come out

113
Q

How does fetal hypoxia occur in cord prolapse?

A

Occlusion - fetus press on umbilical cord occluding blood flow

Arterial vasospasm - exposure of cord to cold atmosphere results in umbilical arterial vasospasm

114
Q

What are the risk factors for cord prolapse?

A

Breech
Artificial rupture of membranes

High fetal station
Polyhydramnios
Prematurity
Long umbilical cord

115
Q

How may cord prolapse present?

A

Fetal heart rate abnormal - subtle decelerations on contraction and bradycardia

Cord felt vaginally

Presence of blood suggest alternate diagnosis

116
Q

How is cord prolapse managed?

A

Avoid handling cord - avoid vasospasm
Knee-chest position for mother

Manually lift presenting part by digital vaginal exam
Tocolysis - terbutaline - relax uterus and stop contractions
Delivery - usually emergency c-section
If fully dilated - can encourage vaginal/instrumental delivery

117
Q

What is shoulder dystocia?

A

Anterior shoulder of baby becomes stuck behind the pubic symphysis of the pelvis after the head has been delivered

118
Q

What are the types of shoulder dystocia?

A

Anterior shoulder impacted on maternal pubic symphysis

Posterior shoulder impacted on sacral promontory (less common)

119
Q

What are the risk factors associated with shoulder dystocia?

A

Macrosomia
Maternal diabetes

Maternal BMI >30
Previous Hx of shoulder dystocia
Induction of labour
Prolonged labour

120
Q

What are the risks of shoulder dystocia?

A

Fetus
- Delay in delivery - hypoxia

  • Brachial plexus injury - traction to head
  • Humerus/clavicle fracture

Mum

  • Perineal tears
  • PPH
  • Pelvic floor weakness
121
Q

What should be immediately done if the shoulders get stuck in delivery?

A

Call for help
Stop pushing

Avoid downward traction - only apply axial traction
Consider episiotomy

122
Q

What is the first line management for shoulder dystocia?

A

McRoberts manoeuvre - hyperflex maternal hips (knees to chest)
+ suprapubic pressure - apply pressure behind anterior shoulder

123
Q

What is the second line management for shoulder dystocia?

A

Insert hand into sacral hollow and grasp posterior arm

Internal rotation - corkscrew manoeuvre - turn shoulders 180 degrees

124
Q

What is the last resort for shoulder dystocia?

A

Cleidotomy - fracture fetal clavicle

Symphysiotomy - cut pubic symphysis

Zavenelli - return fetal head to pelvis for C-Section

125
Q

What is the presentation of shoulder dystocia?

A

Failure of restitution where the head remains facing downwards - occipito-anterior and does not turn sideways as expected after the delivery of the head.

Turtle neck sign - head is delivered but then retracts back into the vagina.

126
Q

How can instrumental deliveries be categorised?

A

Classified by degree of fetal descent - lower they are, lower risk of complications

Outlet
Low
Midcavity

127
Q

What does it mean if a instrumental delivery is classified as outlet?

A

Fetal scalp visible with labia parted
Fetal skull reached pelvic floor

Fetal head on perineum

128
Q

What does it mean if a instrumental delivery is classified as Low?

A

Leading point at +2 station or lower

Subdivided depending on rotation - more or less than 45 degrees

129
Q

What does it mean if a instrumental delivery is classified as midcavity?

A

Head 1/5 palpable abdominally
Leading point between 0 and +2

Subdivided depending on rotation - more or less than 45 degrees

130
Q

What are the indications for instrumental delivery?

A

Maternal
- Inadequate progress of 2nd stage of labour

  • Exhaustion
  • Hypertensive crisis
  • CVS disease
  • Myasthenia gravis and spinal cord injury
    Fetal
  • Compromise
  • Protect head during breech
131
Q

When should instrumental delivery be abandoned for C Section?

A

No descent seen in 3 pulls

132
Q

What are the contraindications for instrumental delivery?

A

Bleeding or fracture predisposition of fetus
Face delivery

<34 weeks if ventouse

133
Q

What are the requirements for instrumental delivery?

A

Fully dilated cervix
Occipito-anterior position

Ruptured membranes
Cephalic presentation
Engaged presenting part
Pain relief adequate
Sphinter (bladder) empty
134
Q

What maternal complications are associated with instrumental delivery?

A

Maternal mental health - can develop tocophobia
Urinary and faecal incontinence

3rd/4th degree tears
Pelvic organ prolapse

135
Q

What fetal complications are associated with instrumental delivery?

A

Cephalhaematoma
Facial bruising

Retinal haemorrhage

136
Q

What is the difference between caput seccedaneum and cephalhaematoma?

A

Caput secumdum
- Soft puffy swelling due to oedema

  • Present at birth, cross the midline and resolve within days

Cephalhaematoma

  • Bleeding between periosteum and skull
  • Present within hours, doesn’t cross midline and resolve within months
137
Q

What nerve injuries can occur during instrumental delivery?

A

Femoral nerve - compressed against inguinal canal, leads to weakness of knee extension, loss of patella reflex, numbness of anterior thigh and medial lower leg.

Obturator nerve - compressed by forceps or fetal head, causes weakness of hip adduction and rotation, numbness of medial thigh.

Lateral cutaneous nerve of the thigh, lumbosacral plexus, common peroneal - foot drop.

138
Q

How is perineal injury classified?

A

1st degree - injury to skin
2nd degree - injury to perineal muscles but not anal sphincter

3a - <50% of external anal spincter
3b - >50% external anal sphincter
3c - internal anal sphincter
4 - injury to perineum inc. anal sphincter and epithelium

139
Q

What are the risk factors for perineal injury?

A

Primigravida
Large babies

Precipitant labour
Shoulder dystocia
Forceps delivery

140
Q

What is the relative risk of perineal trauma to women with a history of severe perineal trauma?

A

Risk not increased

141
Q

When/how is an episiotomy done?

A

If clinical need - instrumental delivery or fetal compromise

Mediolateral approach originating at vaginal fourchette directed to right

142
Q

Why should a perineal tear be repaired as soon as possible?

A

Minimise risk of infection and blood loss

143
Q

What is the management of perineal tears?

A

First degree usually no sutures
Third or fourth likely need repairing in theatre

Broad spectrum antibiotics to reduce risk of infection
Laxatives to reduce risk of constipation and wound dehiscence
Physio to reduce risk and severity of incontinence
Follow up

Women symptomatic after third or fourth degree tears offered elective c-section in subsequent pregnancies.

144
Q

What are the short term complications after perineal injury repair?

A

Pain
Infection
Bleeding
Wound dehiscence or wound breakdown

145
Q

What are the lasting complications of perineal tears?

A

Urinary incontinence
Anal incontinence and altered bowel habit in third and fourth degree tears
Fistula between vagina and bowel
Sexual dysfunction and dyspareunia
Psychological and mental health consequences

146
Q

What is a perineal massage?

A

Massaging skin and tissues between vagina and anus - perineum, done in a structured way from 34 weeks onwards to stretch and prepare the tissues for delivery.

147
Q

What is the third stage of labour and the management options?

A

From the completed birth of the baby to delivery of the placenta.

Physiological management - placenta delivered by maternal effort

Active management
Dose of IM oxytocin to help uterus to contract, and traction to the umbilical cord
Shortens third stage, reduces risk of bleeding, increased chance of n+v

148
Q

When is active management offered?

A

Offered routinely to all women to reduce the risk of PPH
Initiated if haemorrhage
More than 60 min delay in delivery of the placenta

149
Q

What are the steps in active management of third stage of labour?

A

IM dose of oxytocin after delivery
Cord clamped and cut within 5 minutes; there should be a delay of 1-3 mins between delivery and clamping
Abdomen palpated to assess for a uterine contraction before delivery of the placenta
Controlled cord traction, stopping if resistance
One hand presses uterus upwards to prevent uterine prolapse
Uterus massaged until contracted and firm

150
Q

What is a minor PPH?

A

Under 1000ml blood loss

151
Q

What is a major PPH?

A

Over 1000ml blood loss

152
Q

What is a moderate and severe PPH?

A

Further subdivision of major PPH, moderate is 1000ml-2000ml

Severe - over 2000ml

153
Q

What is a primary and secondary PPH?

A

Primary - within 24 hours of birth

Secondary from 24 hours to 12 weeks after birth

154
Q

What are the causes of PPH?

A

Tone - uterine atony
Trauma - perineal tear
Tissue - retained placenta
Thrombin - bleeding disorder

155
Q

What are the risk factors of PPH?

A 
Previous PPH
Multiple pregnancy
Obesity
Large baby
Failure to progress during second stage of labour
Prolonged third stage
Pre-eclampsia
Placenta accreta
Retained placenta
Instrumental delivery
General anaesthesia
Episiotomy or perineal tear
156
Q

What measures can be taken to reduce the risks and consequences of PPH?

A

Treating anaemia during antenatal period
Giving birth with an empty bladder, as full bladder reduces uterine contraction
Active management of third stage, with oxytocin
Intravenous tranexamic acid during c-section in third stage in higher risk patients

157
Q

What is the management of PPH?

A 
Major haemorrhage protocol, gives rapid access to 4 units of crossmatched or O neg blood.
Resus, A-E approach
Two large bore cannulas
Bloods for FBC, UE, clotting
G&S, cross match 4 units
Warmed IV fluid and blood
Oxygen
FFP

Mechanical, medical or surgical treatment to stop the bleeding

158
Q

What treatment is needed to stop the bleeding in PPH?

A

Mechanical - rubbing the uterus to stimulate contraction
catheterisation to prevent bladder distention

Medical
Oxytocin IV or IM - 40 units in 500mls
Carboprost - caution in asthma
Misoprostol sublingual
Tranexamic acid IB
Surgical
Intrauterine balloon tamponade
B-lynch suture - put suture around uterus to compress it
Uterine artery ligation
Hysterectomy
159
Q

What are the likely causes of a secondary PPH?

A

Retained products of conception

Infection i.e. endometritis

160
Q

What are the investigations for secondary post partum haemorrhage?

A

Ultrasound for retained products of conception

Endocervical and high vaginal swabs for infection

161
Q

What is the management of secondary post partum haemorrhage?

A

Surgical evaluation of retained products of conception

Antibiotics for infection

162
Q

How may secondary post partum haemorrhages present?

A

Usually spotting
Gush of blood or major haemorrhage possible

Endometritis - fever, lower abdomen pain, foul smelling lochia
Retained products - fundus felt on examination

163
Q

How are malpresentation of the fetus managed?

A

Brow - C Section
Shoulder - C-section

Face - if chin anterior then normal labour possible, chin posterior then C Section

164
Q

What happens in most malpositions?

A

90% spontaneously rotate to occipito-anterior as labour progress

165
Q

What is the management if a malposition doesn’t rotate?

A

Rotation and operative vaginal delivery attempted

C Section can be performed

166
Q

How common is breech presentation?

A

20% at 28 weeks

3-4% at term - majority spontaneously turn

167
Q

What are the risk factors associated with breech presentation?

A

85% spontaneous

Uterine abnormality
Lax uterus - multiparty
Placenta praevia
Abnormal amniotic fluid

168
Q

How is breech presentation identified?

A

Palpation of abdomen
Fetal heart auscultated higher in abdomen

USS

20% not diagnosed until labour - fetal distress or foot felt

169
Q

What should happen if a breech is identified at 35/36 week scan?

A

Refer for scan and specialist opinion

170
Q

What are the types of breech delivery?

A

Complete breech
Frank breech

Footling breech

171
Q

How are breech babies delivered?

A

Try ECV first

C Section or Vaginal depending on woman and specific presentation
Footling breach - vaginal contraindicated

172
Q

How is a breech baby delivered vaginally?

A

Hand off baby - traction can lead to neck hyperextension and head getting trapped

Flex fetal knees - deliver legs
Lovsetts - rotate body to deliver shoulders
MSV - flex head

173
Q

What complications are associated with breech delivery?

A

Cord prolapse
Fetal head entrapment

Premature rupture of membranes
Birth asphyxia

174
Q

When is external cephalic version carried out?

A

36 weeks if nulliparous - 40% success

37 weeks if multiparous - 60% success

175
Q

What is the result of external cephalic version?

A

Reduce risk of non-cephalic birth or need for caesarian
Still higher risk of complications than spontaneous cephalic

Safe with no risk of intra-uterine death
<5% revert to breech

176
Q

What are the CI’s for external cephalic version?

A

APH within last week
Ruptured membranes

Major uterine abnormalities
Abnormal CTG
Multiple pregnancy

177
Q

What are the complications associated with external cephalic version?

A

Placental abruption
Uterine rupture

Fetal-maternal haemorrhage
Fetal distress

178
Q

What are the conditions where the placenta is retained?

A

Placenta adherens
Trapped placenta

Partial accreta

179
Q

What happens in placenta adherens?

A

Myometrium fair to contract behind placenta

180
Q

What happens in trapped placenta?

A

Detached placenta trapped behind closed cervix

181
Q

What happens in partial accreta?

A

Part of placenta adhered to myometrium

182
Q

What are the complications associated with retained placenta?

A

PPH

Infection

183
Q

What are the signs the placenta has separated?

A

Sudden rush of blood
Fundus move higher and become more rounded

Increase length of visible umbilical cord
Raising fundus doesn’t cause cord to decrease in length

184
Q

What should be done if a placenta has separated?

A

Deliver placenta by rubbing up uterus

Push towards vagina with expulsion of placenta and membranes

185
Q

What should be done if the placenta can’t be removed?

A

Vaginal exam - assess if detached

186
Q

What should be done if the placenta hasn’t detached?

A

IV access - oxytocin if excess bleeding

Manual removal under general anaesthesia

187
Q

What are the risk factors for the uterus failing to contract post delivery?

A

Age >40
BMI >35

Asian
Uterine over-distention - multiple pregnancy, macrosomia, polyhydramnios
Prolonged labour
Placenta praevia or abruption

188
Q

What are the risk factors for thrombin/trauma related post partum haemorrhage?

A

Placental abruption
Hypertension

Pre-eclampsia
Coagulopathies
Instrumental vaginal delivery
Epsiotomy
C-Section
189
Q

What should you be aware of if surgical evacuation of retained products is required for a secondary post partum haemorrhage?

A

Higher risk of uterine perforation due to uterus being softer and thinner

190
Q

Generally when is an emergency c-section carried out?

A

Failure to progress through labour

Fetal compromise

191
Q

How can emergency c-sections be characterised?

A

1 - immediate threat to life of mother or fetus, 20-30 mins
2 - maternal or foetal compromise that isn’t immediately life threatening 60-75mins

3 - No maternal or foetal compromise but need early delivery
4 - elective

192
Q

Why may an elective c-section be planned?

A

Usually after 39 weeks
- malpresentation

  • twins or higher order pregnancy
  • placenta praevia
  • uterine abnormality
  • cephalo-pelvic disproportion
  • maternal condition - can’t cope with pregnancy
  • herpes simplex in trimester 3
  • HIV
  • fetal weight estimated >4.5kg
193
Q

What should be done before a C-Section is carried out?

A

G&S - usually 500-1000ml blood loss
Prescribe ranitidine - lying flat with gravid uterus increase risk of gastric content aspiration

VTE assessment - stockings and LMWH

194
Q

What anaesthesia is used for a c-section?

A

Epidural or Spinal

General if CI to regional or category 1 emergency

195
Q

How is the woman position in a c-section?

A

Left lateral tilt of 15 degrees - reduce risk of supine hypotension due to aortocaval compression

196
Q

What is done in the operating theatre prior to incision in a c-section?

A

Catheter - drain bladder so less likely to be injured

Abx administered

197
Q

What incision is used for a c-section?

A

Pfannenstiel - transverse lower abdominal

198
Q

What layers must you dissect through in a C-section?

A

Skin
Camper’s fascia - superficial subcutaneous fat

Scarpa’s fascia - deep membranous layer of subcutaneous tissue
Rectus sheath and muscle
Abdominal peritoneum - parietal

199
Q

What happens to the visceral peritoneum in a c-section?

A

Incised

Pushed down to reflect bladder

200
Q

Where is the uterine incision in a c-section?

A

Lower uterine segment beneath line of peritoneal reflection

201
Q

How is the baby delivered in a c-section?

A

Fundal pressure

De Lee’s incision (lower vertical) if lower uterine incision poorly formed

202
Q

What are the final steps of a c-section after delivery?

A

IV oxytocin - aid delivery of placenta
Placental delivery by controlled cord traction

Uterine cavity emptied
Closure

203
Q

What are the main benefits of a c-section?

A

Lower risk of:
Perineal trauma

Incontinence
Uterovaginal prolapse
Late stillbirth

204
Q

What are the immediate complications associated with a c-section?

A

PPH
Bladder/bowel trauma

Wound haematoma
Transient tachypnoea of newborn
Laceration of fetus
Need for hysterectomy

205
Q

What are the intermediate complications associated with c-sections?

A

VTE
UTI - catheter

Endometritis

206
Q

What are the late complications associated with c-sections?

A

Subfertility
Dehiscence of scar in next labour

Regret/psychological
Placenta praevia
Ectopic pregnancy on scar

207
Q

How successful/safe is vaginal birth after a C-Section?

A

Clinically safe for majority of women with 1 lower segment c-section

75% success rate
90% success rate if previous vaginal birth after c-section

208
Q

What are the contraindications for vaginal birth after a c-section?

A

Previous uterine rupture
Classical caesarian scar

Relative CI - >2 lower segment caesarians or complex uterine scars

209
Q

What are the advantages of vaginal birth after c-section?

A

Shorter hospital stay
Lower risk of maternal death

Lower risk of neonatal respiratory difficulties

210
Q

What are the risks to vaginal birth after a c-section?

A

Uterine rupture
Anal sphincter injury

Risks of waiting for spontaneous labour

211
Q

What are the risks associated with having an anaesthetic?

A 
Allergic reactions or anaphylaxis
Hypotension
Headache
Urinary retention
Nerve damage (spinal anaesthetic)
Haematoma (spinal anaesthetic)
Sore throat (general anaesthetic)
Damage to the teeth or mouth (general anaesthetic)
212
Q

What are the key causes of maternal sepsis?

A

Chorioamnionitis - abdominal pain, uterine tenderness, vaginal discharge
UTIs - UTI symptoms

213
Q

What is the aetiology of chorioamnionitis?

A

Ascending migration of cervicovaginal flora
Haemtogenous spread to intervillous space
Direct infection after invasive procedures e.g. amniocentesis
Descending infection from the peritoneum via fallopian tubes

214
Q

What are the risk factors for chorioamnionitis?

A 
Prolonged rupture of membranes
Prolonged labour
Preterm PROM
Multiple digital exams
Use of internal uterine fetal monitors
Genital tract pathogens
Tobacco and alcohol use
215
Q

What is the clinical presentation of chorioamnionitis?

A 
Fever
Uterine fundal tenderness
Purulent or foul smelling fluid from the cervical os
Maternal tachycardia, fetal tachycardia
Reduced fetal heart rate variability
216
Q

What is. thecriteria for a confirmed intraamniotic infection?

A 
Positive amniotic fluid test
Positive culture
Positive gram stain
Decrease in glucose
Raised WCC
Histopathology after delivery shows inflammatory iniltrates in membranes
217
Q

What is the management of chorioamnionitis?

A 
Antimicrobial agents
Antipyretics
Expedition of delivery
Management of symptoms
Ampicillin and gentamicin
Vaginal delivery preferable
218
Q

What are the complications of chorioamnionitis?

A 
Dysfunctional labour as infected uterus does not contract well
Operative delivery
PPH
Maternal sepsis
Postpartum endometritis
Adult RDS

Neonatal complications e.g. pneumonia, cerebral palsy, sepsis, premature birth complications

219
Q

What is an amniotic fluid embolism?

A

Amniotic fluid passes into the mother’s blood, occurs around labour and delivery.
Contains fetal tissue causing immune reaction

220
Q

What are the risk factors for amniotic fluid embolism?

A

Increasing maternal age
Induction
C-section
Multiple pregnancy

221
Q

What is the presentation of amniotic fluid embolism?

A 
Shortness of breath
Hypoxia
Hypotension
Coagulopathy
Haemorrhage
Tachycardia
Confusion
Seizures
Cardiac arrest
222
Q

What is the management of amniotic fluid embolism?

A

Supportive
A-E approach
Provide oxygen for hypoxia, IV fluids, treat seizures

Cardiopulmonary resuscitation and immediate c-section required if cardiac arrest occurs

223
Q

How should stillbirth’s be managed?

A

Allow parents time and space for reflection away from normal ward
Allow to dress and spend time with child

Hospital protocols - wrap baby, offer to hold, photos, hair and palm prints
Funeral arrangements
Hospital counsellors and chaplains - comfort to families
Bereavement midwives
Consent for post mortem
Inform GP practice

224
Q

What is uterine rupture?

A

Incomplete or complete rupture where the muscle layer of the uterus ruptures
Contents in complete can be released into the peritoneal cavity

225
Q

What are the risks of uterine rupture?

A

Anything causing the uterus to be weaker
Main RF is previous c-section

VBAC
Previous uterine surgery
High BMI
High parity
Increased age
IOL
Use of oxytocin
226
Q

What is the presentation of uterine rupture?

A 
Acutely unwell mother
Abnormal CTG
Abdominal pain
Vaginal bleeding
Ceasing of uterine contractions
Hypotension
Tachycardia
Collapse
227
Q

What is the management of uterine rupture?

A

Resuscitation
Transfusion
Emergency c-section
Repair or remove uterus

228
Q

What is uterine inversion?

A

Rare complication of birth

Fundus of uterus drops down through uterine cavity and cervix, turning the uterus inside out

229
Q

What are the two types of uterine inversion?

A

Incomplete - partial inversion where fundus descends inside uterus or vagina but not as far as the introitus (opening of vagina)

Complete - descends through the vagina, into the introitus

230
Q

What is the presentation of uterine inversion?

A

PPH
Maternal shock
Collapse

May be felt on vaginal examination if incomplete

231
Q

What is the management of uterine inversion?

A

Johnson manoevre - use hand to push fundus back up, whole hand and forearm inserted and held in place for several minutes with oxytocin given for a contraction

If this fails; hydrostatic manoeuvre, vagina filled with fluid to inflate back into normal place

If this fails, surgery with laparotomy

Obstetrics and Gynaecology (11 decks)

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