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Reproductive and Neonatal Health (RNH) > Labour and Delivery > Flashcards

Labour and Delivery Flashcards

1
Q

Define ACTIVE LABOUR.

A

Active labour is defined as 3 to 4 contractions per 10 mins, lasting 60 to 90 seconds each, with cervical dilatation > 3cm +/- ROM.

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2
Q

What are the three stages of labour?

A
  1. Cervical ripening
  2. Expulsion of foetus
  3. Delivery of the placenta
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3
Q 
STAGE ONE - CERVICAL DILATATION
✔️ mechanism 
✔️ duration
✔️ monitoring
✔️ other considerations
A

MECHANISM
Prostaglandins promote cervical dilatation.
Cervical dilatation is widening of the cervical os; cervical effacement is shortening of the cervix.

DURATION
✔️ first pregnancy: 12 to 15 hours
✔️ subsequent pregnancies: 7 to 8 hours

MONITORING
✔️ MHR and FHR every 30 mins
✔️ Maternal BP every 30 to 60 mins
✔️ Maternal temperature every 2 hours
✔️ contractions (duration, length, frequency, strength) every 60 mins
✔️ PV examination every 4 hours

OTHER CONSIDERATIONS:
✔️ give IV penicillin during stage one of labour if GBS positive
✔️ give penicillin if GBS status unknown

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4
Q 
STAGE TWO - EXPULSION OF THE FOETUS
✔️ mechanism 
✔️ duration
✔️ monitoring
✔️ other considerations
A

MECHANISM
Combination of prostaglandins, oxytocin and downward pressure from the foetal head.

DURATION
First pregnancy: 45 o 120 minutes
Subsequent pregnancies: 15 to 45 minutes

MONITORING
✔️ FHR every 5 mins
✔️ encourage active pushing every 2 to 3 minutes
✔️ controlled descent of the head

OTHER CONSIDERATIONS
✔️ give IM oxytocin to facilitate delivery of the placenta
✔️ immediate skin to skin contact after delivery
✔️ Vitamin K and Hepatitis B injection to be given (with parental consent) after delivery

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5
Q

What are the positions of the foetus as it is delivered?

A
  1. descent and engagement
  2. head flexion
  3. internal rotation
  4. head extension
  5. external rotation
  6. delivery of anterior shoulder
  7. delivery of posterior shoulder
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6
Q 
STAGE THREE - DELIVERY OF THE PLACENTA
✔️ mechanism 
✔️ duration
✔️ monitoring
✔️ other considerations
A

MECHANISM
Oxytocin facilitates delivery of the placenta within 5 to 10 minutes of second stage of labour (this can take up to 30 minutes if oxytocin is not given).

DURATION
5 to 10 minutes

MONITORING
✔️ apply gentle traction to the cord
✔️ ensure placenta is in tact
✔️ collect blood in petri dish
✔️ fix perineal trauma

OTHER CONSIDERATIONS
✔️ nil

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7
Q

Define BISHOP’S SCORE. When is this used?

A

The Bishop’s Score is a clinical stratification tool used to predict the likelihood of induction of labour being successful.

It is based on FIVE components:

  1. cervical dilatation
  2. cervical effacement
  3. cervical consistency
  4. foetal lie / position
  5. foetal station (0 is when the head is at the ischial spine)

A Bishop’s Score > 7 to 8 means that induction of labour is likely to be successful.

A Bishop’s Score < 6 means that induction of labour is unlikely to be successful.

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8
Q

Define INDUCTION OF LABOUR. What are the indications for induction of labour?

A

Induction of labour is an attempt to bring on labour in a non-labouring woman. This is not to be confused with augmentation of labour, which is the act of progressing labour in an already contracting woman.

Indications for induction of labour:
✔️ pre-eclampsia > 37 weeks (or where the risks of pregnancy outweigh the benefits)
✔️ gestational diabetes mellitus > 38 to 39 weeks
✔️ post-term pregnancy (40 + 10)
✔️ IUGR
✔️ non-reassuring foetal trace

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9
Q

Describe mechanisms for induction of labour.

A

MECHANICAL MECHANISMS
✔️ stretch and sweep
✔️ artificial rupture of membranes –> not to be performed if the foetal head is not properly engaged, to prevent cord prolapse

HORMONAL MECHANISMS
✔️ intracervical balloon catheter
✔️ prostaglandin gel
✔️ oxytocin drip –> requires one-on-one midwife monitoring

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10
Q

What are the benefits and risks of NATURAL VAGINAL DELIVERY.

A

BENEFITS
✔️ improved recovery time (within 24 hours)
✔️ reduced risk of major blood loss
✔️ no need for anaesthetic
✔️ improves prospects for more children
✔️ encourages breast feeding
✔️ improved outcomes for baby in terms of respiratory function and immune function

RISKS
✔️ fear and pain
✔️ cephalopelvic disproportion (CPD)
✔️ shoulder dystocia
✔️ cord prolapse
✔️ conversion to emergency C/S
✔️ post-partum haemorrhage
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11
Q

What are some indications for EPISIOTOMY?

What are the two types of episiotomies performed?

A

✔️ shoulder dystocia
✔️ need to hasten delivery
✔️ reduces risk of Grade III and IV perineal tears

There are two types of episiotomy:

  1. midline incision (preferred)
  2. mediolateral incision
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12
Q

What are the requirements for INSTRUMENTAL delivery?

A

Instrumental delivery is indicated in the case of:
✔️ maternal exhaustion (e.g. prolonged second stage labour)
✔️ need to hasten delivery

In order for instrumental delivery to be successful: 
✔️ no CPD
✔️ baby station at 2+
✔️ stable lie
✔️ position absolutely known
✔️ complete dilatation of the cervix 
✔️ rupture of membranes
✔️ skilled operator
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13
Q

What are some indications for ELECTIVE and EMERGENCY C/S?

A

ELECTIVE C/S
✔️ breech position
✔️ previous C/S
✔️ LGA baby (>4.5kg in GDM, >5.5kg no GDM)
✔️ diagnosed placenta previa
✔️ cephalopelvic disproportionate (CPD)
✔️ active HSV lesions (reduces risk of vertical transmission)
✔️ maternal HIV (reduces risk of vertical transmission)

EMEGENCY C/S
✔️ undiagnosed placenta previa
✔️ failure to progress
✔️ obstructed labour
✔️ undiagnosed breech
✔️ foetal distress
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14
Q

Discuss risks associated with C/S.

A

ANASTHETIC RISKS
✔️ cardiovascular and respiratory risks (hypotension)
✔️ allergy / anaphylaxis
✔️ able to feel procedure
✔️ pain with insertion of spinal / epidural

INTRA-OPERATIVE RISKS
✔️ bleeding –> significant blood loss in a C/S
✔️ damage to surrounding structures (e.g. bladder, bowel)
✔️ infection (e.g. endometritis, sepsis)

EARLY POST-OP RISKS
✔️ DVT / PE
✔️ actelectasis (lung collapse)
✔️ urinary tract infection
✔️ immobility 
✔️ pain
✔️ wound discoherence 
✔️ infection (of surgical site OR systemic)

PROLONGED RISKS
✔️ 6 week recovery time
✔️ increased risk of uterine rupture (future pregnancies)
✔️ increased risk of ectopic pregnancy (future pregnancies)
✔️ implications for future fertility
✔️ bowel obstruction (fever, abdominal pain)

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15
Q

What are the options available for pain relief during labour?

A 
NON-PHARMACOLOGICAL
✔️ mindfullness / hyponosis 
✔️ warm showers / baths / heat packs
✔️ TENS
✔️ massage

PHARMACOLOGICAL (NON-INVASIVE)
✔️ nitrous oxide gas
✔️ morphine

PHARMACOLOGICAL (INVASIVE)
✔️ pudendal nerve block
✔️ spinal anaesthetic
✔️ epidural anaesthetic

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16
Q

What are the benefits and risks of EPIDURAL ANAESTHETIC?

A

BENEFITS
✔️ high level of pain relief
✔️ women are often unable to feel contractions
✔️ “top up” doses via PCA
✔️ can be used for C/S if necessary
✔️ minimal effects of the foetus
✔️ usually women can mobilise throughout labour

RISKS
✔️ takes 15 mins to become effective
✔️ failed attempts --> multiple attempts required
✔️ anaesthetic is not effective
✔️ allergy / anaphylaxis to anaesthetic
✔️ nausea and vomiting
✔️ pain with insertion 
✔️ cardiovascular / respiratory complications of anaesthetic (e.g. hypotension)
✔️ temporary spinal damage (very rare)
✔️ bowel and bladder incontinence 
✔️ unable to mobilise throughout labour (rare)
✔️ infection at injection site
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17
Q

What are the benefits and risks of SPINAL ANAESTHETIC?

A 
BENEFITS
✔️ high level of pain relief 
✔️ indicated for use during C/S
✔️ given as a one-time dose
✔️ more efficient onset of action
RISKS
✔️ maternal hypotension
✔️ respiratory depression
✔️ ineffective block (mother able to feel)
✔️ infection at the site of insertion
18
Q

Describe how an epidural is given.

A

An epidural is a procedure commonly used during labour for highly effective pain relief.

This procedure involves inserting a catheter at the level of L3/L4 through a needle. The catheter is used to feed medication into the space surrounding the spinal cord (called the epidural space).

N.B. The procedure is sterile and must be performed via an anaesthetist.

Epidural may take 15 minutes to become effective. An initial bolus dose is given. The patient can then control how much medication is given via a PCA.

Epidural promotes “numbness” from the abdomen, down.

If required for a C/S, the woman will be able to feel pressure but no pain.

19
Q

What are the benefits and risks of MORPHINE in labour?

A

BENEFITS
✔️ non-invasive technique
✔️ moderate pain relief
✔️ doses can be delivered IV or PO every 4 hours

RISKS
✔️ cannot be delivered within 4 hours of delivery due to risk of foetal distress

20
Q

Define SHOULDER DYSTOCIA.

A

Shoulder dystocia is an obstetric emergency in which there is difficulty delivery the anterior and posterior shoulders following delivery of the foetal head, despite gentle traction and downward pressure.

21
Q

What are some risk factors for shoulder dystocia?

A 
✔️ macrosomnia (>4,000g)
✔️ gestational diabetes
✔️ previous shoulder dystocia
✔️ CPD
✔️ prolonged 2nd stage of labour
✔️ maternal obesity
22
Q

What is the classical clinical presentation of shoulder dystocia?

A

✔️ failure to deliver the shoulders after delivery of the head
✔️ turtle neck sign
✔️ foetal distress

23
Q

Outline some complications of SHOULDER DYSTOCIA for mother and foetus.

A

MATERNAL
✔️ increased risk of perineal tears (third and fourth degree)
✔️ increased risk of PPH
✔️ increased risk of uterine rupture
✔️ increased risk of retrovaginal fistular

FOETAL
✔️ cleidotomy
✔️ brachial plexus injury
✔️ Erb's palsy
✔️ foetal distress
✔️ hypoxia --> cerebral palsy
✔️ death
24
Q

Describe the appropriate clinical management of SHOULDER DYSTOCIA.

A
  1. Identify impending shoulder dystocia, notify a senior and discourage pushing.
  2. McRobert’s Manœuvre (flexion of the hips and knees).
  3. Apply downward pressure (Robin’s I Manouevre) and / or roll onto side.
  4. Consider episiotomy.
  5. Internal manoeuvres
    ✔️ Robin’s II –> downward pressure on the posterior shoulder and delivery of the anterior shoulder
    ✔️ Corkscrew Manœuvre –> delivery of the posterior shoulder
  6. Cleidotomy or symphysiotomy
25
Q

Define CORD PROLAPSE.

A

Cord prolapse occurs when the umbilical cord either:

  1. presents against the cervix
  2. falls in front of the presenting part
  3. presents alongside the presenting part (e.g. occult presentation)
26
Q

Identify some risk factors for cord prolapse.

A 
✔️ artificial rupture of membranes (induction of labour prior to full head engagement)
✔️ IUGR
✔️ small for gestational age
✔️ pre-term labour
✔️ EVC
✔️ malpresentation
✔️pre-term delivery
27
Q

What can cause a false positive FETAL FIBRONECTIN (fFN)?

A

✔️ sexual intercourse in the last 24 house
✔️ bimanual examination prior to speculum
✔️ recent trauma
✔️ PV bleeding
✔️ amniotic fluid (PPROM)
✔️ lubricant on speculum

28
Q

When is FETAL FIBRONECTIN indicated?

A

fFN is a test used to predict the likelihood of a women experiencing preterm labor (PTL). It is NOT indicated if there has been rupture of membranes in a woman < 34 weeks pregnant.

fFn is positive if > 50 and negative if < 50. If negative, there is a 95% likelihood that the woman will NOT experience labour within the next two weeks.

29
Q

Define PRETERM LABOUR.

A

Preterm labour is the onset of labour < 37 weeks gestation.

Whilst uterine contractions are experienced by many women, preterm labour must include all components of ACTIVE LABOUR: > 3cm cervical dilatation PLUS 3 to 4 uterine contractions per 10 mins lasting 60 to 90 seconds duration.

30
Q

What are some risk factors for pre-term labour?

A 
✔️ PPROM
✔️ previous pre-term labour
✔️ twin pregnancy / multi-gestation pregnancy
✔️ pre-eclampsia
✔️ uncontrolled gestational diabetes
✔️ obesity
✔️ maternal weight < 50kg
✔️ chorioamnitis 
✔️ systemic maternal infection
✔️ placental abruption 
✔️ poor antenatal care
✔️ low SES
31
Q

How may pre-term labour present?

A

✔️ PPROM –> PV bleeding or abnormal discharge
✔️ crampy abdominal pain
✔️ lower back pain

32
Q

What are appropriate investigations for PRETERM LABOUR?

A 
✔️ foetal HR monitoring with CTG
✔️ maternal HR monitoring 
✔️ maternal BP monitoring 
✔️ fFN (if < 34 weeks GA and no PPROM)
✔️ GBS screening (if not done)
✔️ transabdominal USS for foetal lie
33
Q

Outline the appropriate management of PRETERM LABOUR.

A
  1. Tocolysis if < 34 weeks AND no contraindications (absolute or relative)
    ✔️ prostaglandin inhibitor (e.g. indomethacin)
    ✔️ calcium channel blocker (e.g. nifidepine)
    ✔️ beta-2 agonist (e.g. salbutamol)
    ✔️ magnesium sulfate
  2. Magnesium sulfate if between 24 to 34 weeks
    ✔️ 4g IV, stat (loading dose)
    ✔️ 1g per hour, until birth
  3. Maternal corticosteroids (e.g. betamethasone, dexamethasone)
    ✔️ 48 hours MINIMUM
  4. Antibiotics
    ✔️ erythromycin to be given if PPROM for 7 to 10 days
    ✔️ IV penicillin to be given if GBS positive
34
Q

What are some ABSOLUTE and RELATIVE contraindications to tocolysis?

A 
ABSOLUTE CONTRAINDICATIONS
✔️ PTL > 34 weeks
✔️ PPROM with signs of infection
✔️ chorioamnitis 
✔️ intrauterine foetal demise
✔️ non-reassuring foetal status
✔️ severe pre-eclampsia
✔️ placental abruption
✔️ maternal bleeding with haemodynamic instability 
RELATIVE CONTRAINDICATIONS
✔️ severe GDM
✔️ cervical dilation > 5cm
✔️ maternal heart disease
✔️ hyperthyroidism 
✔️ IUGR
35
Q

What are the WHO RECOMMENDATIONS FOR IMPROVING BIRTH OUTCOMES?

A
  1. Tocolysis if PTL < 34 weeks and no contraindications
  2. Maternal corticosteroids (e.g. betamethasone, dexamethasone) for 24 to 34 weeks
  3. MgSO4 (for neuroprotection) for 24 to 30 weeks
    ✔️ 4g IV stat over 20 to 30 mins loading dose
    ✔️ 1g IV per hour until delivery
  4. No regular antibiotics
  5. Antibiotics if PROM
    ✔️ erythromycin PO for 7 to 10 days
  6. C/S not routinely recommended
  7. Kangaroo care
  8. Surfactant after delivery for prevention of RDS
  9. Oxygen at 30% (0.3) to prevent retinopathy of prematurity
  10. CPAP for all
36
Q

Define PREMATURE RUPTURE OF MEMBRANES.

A

Premature rupture of membranes (PROM) occurs in ~8% of pregnancies. This is when the membranes rupture prior to the onset of labour.

PROM increases risk of:
✔️ preterm labour
✔️ preterm delivery (and subsequent complications of prematurity)
✔️ chorioamnionitis

37
Q

What are some risk factors for PROM?

A 
✔️ previous PROM
✔️ twin pregnancies
✔️ antepartum haemorrhage
✔️ cervical insufficiency (< 25mm)
✔️ trauma
✔️ urogenital tract infection
✔️ < 6 months between pregnancies
✔️ smoking, drug and alcohol use
✔️ maternal age < 18 or > 45 
✔️ amniocentesis
✔️ polyhydroamniosis
38
Q

What is the management of PROM and PPROM?

A
  1. admit to hospital
    ✔️ 4 hourly CTG and temperature monitoring
  2. antibiotics
    ✔️ erythromycin 7 to 10 days to protect against chorioamniotis
    ✔️ IV penicillin during labour to protect against GBS (if positive or status unknown)
  3. tocolysis
    ✔️ indomethacin or nifidepine if no contraindications (e.g chorio, non-reassuring foetal signs)
  4. maternal corticosteroids (if 24 to 34 weeks)
  5. maternal MgSO4 (if 24 to 30 weeks) –> aim to give within 4 hours of delivery
  6. plan for delivery
    ✔️ 34 to 37 weeks –> NVD
    ✔️ < 34 weeks –> tococlysis, expectant management
    ✔️ < 32 weeks –> transfer
  7. notify NICU
39
Q

What are some indications where outpatient management of PROM / PPROM may be appropriate?

A

✔️ no signs of infection
✔️ no signs of PTL (e.g. contractions)
✔️ woman lives nearby to hospital
✔️ woman is well-informed about the situation and the risks

40
Q

What are the principles of outpatient management for PPROM / PROM?

A
  1. daily temperature monitoring (return to hospital if > 37°C)
  2. fortnightly USS
  3. weekly antenatal review
  4. arrange admission if signs of chorio develop
  5. avoid intercourse, tampon use and bathing
  6. induce if:
    ✔️ signs of infection
    ✔️ confirmed foetal demise
    ✔️ woman’s request

Reproductive and Neonatal Health (RNH) (8 decks)

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