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0Finals Revision > Labour and Delivery > Flashcards

Labour and Delivery Flashcards

1
Q

Risk factors for PPH

A
  • previous PPH
  • multiple pregnancy
  • obesity
  • macrosomic baby
  • failure to progress in the second stage
  • prolonged third stage
  • pre-eclampsia
  • placenta accreta
  • retained placenta
  • instrumental delivery
  • GA
  • episiotomy or perineal tear
  • maternal bleeding disorder
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2
Q

Causes of PPH

A 
4 T's
Tone
Trauma
Tissue
Thrombin
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3
Q

How can you reduce the risk of PPH?

A
  • labour with an empty bladder (full bladder reduced uterine contraction)
  • active management of the third stage (IM oxytocin)
  • IV TXA for high risk c-sections
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4
Q

How can you reduce the consequences of PPH?

A

treat anaemia during the antenatal period

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5
Q

How is PPH defined?

A
  • bleeding after delivery of the pregnancy and the placenta which is >500ml in a vaginal delivery or >1000ml in a section
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6
Q

How can PPH be classified?

A

By volume:

  • minor <1000ml
  • major 1000ml-2000ml
  • severe >2000ml

By time:

  • primary if within 24hr of birth
  • secondary if between 24hrs and 12 weeks postpartum
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7
Q

What is the initial management of PPH?

A
  • resuscitation with an ABCDE approach
  • lie the lady flat and keep her warm
  • communicate well with mum and her birthing partner
  • insert 2 large-bore cannulas (grey/orange)
  • take bloods: FBC, U&E, clotting screen, crossmatch 4 units
  • warmed fluids / blood product resus as required
  • O2 regardless of sats
  • FFP if clotting abnormal or after 4 units transfused
  • activate major haemorrhage protocol if severe
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8
Q

What are the mechanical interventions available for PPH?

A
  • rubbing the uterus through the abdomen
  • bimanual uterine compression
  • catheterisation
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9
Q

What are the medical interventions available for PPH?

A
  • oxytocin infusion
  • ergometrine IV or IM
  • carboprost IM (caution in asthma)
  • misoprostol sublingual
  • TXA IV
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10
Q

What are the surgical interventions available for PPH?

A
  • intrauterine balloon tamponade
  • B-Lynch suture
  • uterine artery ligation
  • hysterectomy
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11
Q

What are the most likely causes of secondary PPH and their management?

A
  • RPOC: evacuation

- infection: antibiotics

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12
Q

What initial investigations are indicated for secondary PPH?

A
  • USS to look for RPOC

- endocervical and high vaginal swabs for infection screen

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13
Q

What system is used to predict the success of an induction of labour?

A

Bishop Score

PC DES BISHOP 238

position (2)
consistency (2)
dilatation (3)
effacement (3)
station (3)

score of 8+ predicts successful IOL, lower scores suggest cervical ripening needed

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14
Q

What are the indications for induction of labour?

A
  • post-maturity
  • maternal health: obstetric cholestasis, GDM, hypertension
  • foetal growth: IUGR, large for gestational age
  • pre-labour rupture of membranes: >37 weeks expectant management up to 24hrs, <37 weeks give abx and delay ROM to 37 weeks if poss
  • intrauterine foetal death
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15
Q

What are the potential complications of induction of labour?

A
  • failure of induction
  • uterine hyperstimulation (can be managed with tocolytics)
  • cord prolapse (risk of hypoxia due to vasospasm (due to change in temp) or mechanical compression of the cord)
  • infection (reduce risk by minimising VEs)
  • pain (epidural often required)
  • increased rate of assisted delivery compared to spontaneous labour
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16
Q

What is uterine hyperstimulation?

A

prolonged and frequent uterine contractions which can cause:

  • foetal distress and compromise (hypoxia, acidosis)
  • uterine rupture
  • need for section
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17
Q

How is uterine hyperstimulation managed?

A
  • remove/stop IOL drugs
  • tocolysis with terbutaline
  • deliver by section if refractory to treatment
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18
Q

How is uterine hyperstimulation generally defined?

A
  • contractions >2 mins duration

- contractions >5:10

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19
Q

What are the requirements for an operative vaginal delivery (instrumental delivery)?

A
  • cervix fully dilated
  • head engaged (no more than 1/5 palpable)
  • rupture of membranes
  • known presentation, station and position (from VE)
  • intermittent catheter / empty bladder
  • mother consented
  • adequate pain relief e.g. spinal, epidural, pudendal block
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20
Q

What are the indications for an elective c-section?

A
  • placenta praveia
  • breech at term
  • multiple previous LSCS
  • multiple pregnancy
  • EFW >4.5kg
  • previous 3rd / 4th degree tear
  • maternal request persisting following discussion with two consultant obstetricians
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21
Q

What are the risk factors for pre-term delivery?

A
  • previous pre-term delivery
  • infection: UTi, chorioamnionitis
  • maternal conditions: preeclampsia, DM, inflammatory conditions, BV
  • multiple pregancy
  • polyhydramnios
  • social factors: smoking, alcohol, low BMI, drugs
  • interval <1 year since previous delivery
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22
Q

What are the management options for term breech presentation?

A
  • external cephalic version
  • elective caesarean section
  • vaginal breech delivery
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23
Q

What is shoulder dystocia?

A

impaction of the anterior shoulder on maternal pubic symphysis after delivery of the head

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24
Q

What are the risk factors for shoulder dystocia?

A
  • previous shoulder dystocia

- macrosomia

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25
Q

What is the initial management of shoulder dystocia?

A

HELPERRZ

  • call for help
  • assess for episiotomy
  • legs in mcroberts
  • suprapubic pressure
  • enter to rotate the shoulders
  • remove the posterior arm
  • roll over on all fours
  • zavanelli manoeuvre if nothing else is working
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26
Q

What are the potential complications of shoulder dystocia?

A
  • maternal tears
  • PPH
  • psychological trauma
  • foetal fractures (clavicle or humerus)
  • brachial plexus injury
  • hypoxic brain injury
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27
Q

What is the Zavanelli manoeuvre?

A

pushing the baby’s head back into the birth canal in anticipation of delivery by section, in cases of extreme shoulder dystocia that cannot otherwise be delivered

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28
Q

What are the risk factors for pre-eclampsia?

A 
Aged 40 years or older
Nulliparity
Pregnancy interval of more than 10 years
Family history of pre-eclampsia
Previous history of pre-eclampsia
Body mass index of 30kg/m^2 or above
Pre-existing vascular disease such as hypertension
Pre-existing renal disease
Multiple pregnancy
29
Q

What is the most significant risk factor for umbilical cord prolapse?

A

abnormal foetal lie after 37 weeks gestation

30
Q

When should you suspect umbilical cord prolapse?

A

signs of foetal distress on CTG

31
Q

How can you diagnose umbilical cord prolapse?

A
  • VE

- speculum if needed

32
Q

How do you manage umbilical cord prolapse?

A
  • arrange emergency caesarean section
  • keep the cord warm and wet while waiting for delivery
  • try to handle the cord as little as possible to avoid vasospasm
  • use tocolytics to minimise contractions while waiting for delivery
  • encourage mum to position herself so that gravity draws baby away from compressing the cord if appropriate
  • manually push presenting part of baby up and off the cord if appropriate
33
Q

It is recommended to push a prolapsed umbilical cord back into the birth canal while waiting for caesarean section. True or false?

A

False - keep the cord warm and wet while waiting for delivery and try to handle the cord as little as possible to avoid vasospasm

34
Q

It is recommended to proceed to instrumental vaginal delivery at the first sign of umbilical cord compression. True or false?

A

False - delivery should be by emergency caesarean section

35
Q

In a cephalic lie, baby’s head descends into the pelvis and leaves little room for the umbilical cord to prolapse. True or false?

A

True - abnormal lie after 37 weeks gestation is a risk factor for umbilical cord compression, cephalic lie is not

36
Q

What are the potential complications of umbilical cord prolapse?

A
  • cord compression
  • foetal hypoxia
  • foetal death
37
Q

Terbutaline may be indicated in cases of umbilical cord prolapse. True or false?

A

True - tocolytics may be used to minimise contractions while waiting for an emergency caesarean section

38
Q

Umbilical cord prolapse is diagnosed by signs of foetal distress on the CTG. True or false?

A

False - cord prolapse is diagnosed on VE +/- speculum, but should be suspected when there are signs of foetal distress on the CTG

39
Q

What is umbilical cord prolapse?

A
  • when the cord descends below the presenting part of the foetus
  • through the cervix and into the vagina
  • after the rupture of membranes
40
Q

What positions could help to draw baby away from compressing a prolapsed cause, while mum waits for emergency delivery?

A
  • left lateral

- all fours (knee-chest)

41
Q

What is the mnemonic for CTG interpretation?

A 
DR: Define risk
C: Contractions
BRa: Baseline rate
V: Variability
A: Accelerations
D: Decelerations
O: Overall impression
42
Q

Why might a pregnancy be considered high risk?

A

Maternal medical illness:

  • Gestational diabetes
  • Hypertension
  • Asthma
  • Fever
  • Cholestasis

Obstetric complications:

  • Multiple gestation
  • Post-date gestation
  • Previous cesarean section
  • Intrauterine growth restriction
  • Premature rupture of membranes
  • Congenital malformations
  • Oxytocin induction/augmentation of labour
  • Pre-eclampsia

Other risk factors:

  • Absence of prenatal care
  • Smoking
  • Drug abuse
43
Q

What features of contraction do you need to assess using the CTG?

A

Duration: How long do the contractions last?
Intensity: How strong are the contractions (assessed using palpation)?

44
Q

What is a normal foetal heart rate?

A

110-160bpm

45
Q

What is foetal tachycardia and what might cause it?

A 
HR >160bpm
Causes:
-Fetal hypoxia
-Chorioamnionitis
-Hyperthyroidism
-Fetal or maternal anaemia
-Fetal tachyarrhythmia
46
Q

What is foetal bradycardia and what normal variants might cause it?

A

HR <100bpm
Normal variant causes:
-Postdate gestation
-OP and transverse presentations

47
Q

What is prolonged severe bradycardia and what might cause it?

A

HR <80 bpm for more than 3 minutes - indicates severe hypoxia

Potential causes:

  • Prolonged cord compression
  • Cord prolapse
  • Epidural and spinal anaesthesia
  • Maternal seizures
  • Rapid fetal descent
48
Q

What is normal CTG variability and what does it indicate?

A

Normal variability is between 5-25 bpm and it indicates an intact neurological system in the foetus

49
Q

How is CTG variability categorised?

A

Reassuring: 5 – 25 bpm

Non-reassuring:

  • less than 5 bpm for between 30-50 minutes
  • more than 25 bpm for 15-25 minutes

Abnormal:

  • less than 5 bpm for more than 50 minutes
  • more than 25 bpm for more than 25 minutes
  • sinusoidal
50
Q

What might cause reduced variability on a CTG?

A
  • Fetal sleeping: this should last no longer than 40 minutes (this is the most common cause)
  • Fetal acidosis (due to hypoxia): more likely if late decelerations are also present
  • Fetal tachycardia
  • Drugs: opiates, benzodiazepines, methyldopa and magnesium sulphate
  • Prematurity: variability is reduced at earlier gestation (<28 weeks)
  • Congenital heart abnormalities
51
Q

What are accelerations (in relation to a CTG)? Are they reassuring or non-reassuring?

A
  • an abrupt increase in the baseline fetal heart rate of greater than 15 bpm for greater than 15 seconds
  • presence of accelerations is reassuring
  • accelerations occurring alongside uterine contractions is a sign of a healthy foetus
  • absence of accelerations with an otherwise normal CTG is of uncertain significance
52
Q

What are decelerations, in relation to a CTG?

A

an abrupt decrease in the baseline fetal heart rate of greater than 15 bpm for greater than 15 seconds

53
Q

How can decelerations be categorised?

A
  • early
  • late
  • variable
  • prolonged
  • sinusoidal
54
Q

What are early decelerations on a CTG and why might they happen? Should we worry about them?

A
  • deceleration starts when the uterine contraction begins and quickly recover when uterine contraction stops, due to increased foetal ICP causing increased vagal tone
  • they are physiological and not worrying
55
Q

What are variable decelerations on a CTG and why might they happen? Should we worry about them?

A
  • a rapid fall in baseline foetal heart rate with a variable duration before the recovery phase
  • they may not have any relationship to uterine contractions
  • they’re usually caused by cord compression
  • shouldering (accelerations before and after the deceleration) indicates the foetus is adapting to the changing blood flow
  • absence of shouldering is more worrying as it suggests the foetus may be becoming hypoxic
56
Q

What are late decelerations on a CTG and why might they happen? Should we worry about them?

A
  • decelerations that begin at the peak of the uterine contraction and recover after the contraction ends
  • they indicate insufficient blood flow to the uterus and placenta which results in foetal hypoxia and acidosis
  • this could be due to maternal hypotension, pre-eclampsia or uterine hyperstimulation
  • they are worrying
57
Q

What are prolonged decelerations on a CTG? Should we worry about them?

A
  • deceleration that lasts more than 3 minutes
  • if it lasts between 2-3 minutes it is classed as non-reassuring
  • if it lasts longer than 3 minutes it is immediately classed as abnormal
58
Q

What is a sinusoidal CTG pattern? Should we worry about them?

A
  • smooth, regular, wave-like pattern with a frequency of around 2-5 cycles a minute, stable baseline rate around 120-160bpm with no beat to beat variability
  • very concerning as it is associated with high rates of fetal morbidity and mortality
59
Q

How do you present your overall impression of a CTG?

A

describe risk and contractions
classify the combination of baseline rate, variability and decelerations as: reassuring, suspicious, abnormal or requiring urgent intervention

reassuring: all features are reassuring
suspicious: 1 non-reassuring and 2 reassuring features
abnormal: 1 abnormal feature OR 2 non-reassuring features
requires urgent intervention: acute bradycardia, or a single prolonged deceleration for 3 minutes or more

60
Q

What are the indications for continuous CTG monitoring in labour?

A
  • sepsis
  • maternal tachycardia >120bpm
  • significant meconium
  • pre-eclampsia
  • fresh antepartum haemorrhage
  • delay in labour
  • use of oxytocin
  • disproportionate maternal pain
61
Q

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

A
  • less then 2cm dilatation in 4 hours

- slowing progress in a multip

62
Q

How is the first stage of labour monitored and recorded?

A

partogram

63
Q

What does it mean to cross the alert line on a partogram?

A

indication for amniotomy and repeat examination in 2 hours

64
Q

What does it mean to cross the action line on a partogram?

A

care needs to be escalated to obstetric-led care

65
Q

What information is recorded on a partogram?

A
  • cervical dilatation (by 4 hourly VE)
  • station in relation to ischial spines
  • maternal obs
  • FHR
  • frequency of contractions
  • status of membranes and description of liquor
  • drugs and fluids that have been given
66
Q

What interventions may be used if there are problems with progression in the second stage of labour?

A
  • changing position
  • encouragement
  • analgesia
  • oxytocin
  • episiotomy
  • instrumental delivery
  • section
67
Q

How is delayed third stage of labour defined?

A
  • more than 30mins with active management

- more than 60 mins with physiological management

68
Q

What is active management of the third stage of labour?

A
  • IM oxytocin

- controlled cord traction

0Finals Revision (21 decks)

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