Labour and delivery Flashcards
what is the first stage of labour
onset of labour true contractions until cervix is fully dilated to 10cm.
latent,active and transition
Braxton hicks contractions -durign 2nd and 3rd stage of labour - false contraction
2nd stage of labour
10cm cervical dilation until delivery of baby
3rd stage of labor
from delivery of baby to delivery of the placenta
PROM means
the amintioc sac has ruptures before the onset of labour
extreme preterm
under 28 weeks
very is 28 -32
moderate to late 32-37
prophylaxis of preterm labour what can you do too prolong labour
vaginal progesterone - maintaining pregnancy and preventing labour by decreasing action of myometrium and prevent cervical moderation
cervical cerclage - stitch in cervix to add support to keep closed involving anaesthetic removed when in labour
doubt of amintioc fluid rupture what tests
Insulin-like growth factor-binding protein-1 (IGFBP-1) is a protein present in high concentrations in amniotic fluid, which can be tested on vaginal fluid if there is doubt about rupture of membranes
Placental alpha-microglobin-1 (PAMG-1) is a similar alternative to IGFBP-1
prophalcic antiobitcs given to prevent chorioamnionitis
when do you give antenatal steroids
Giving the mother corticosteroids helps to develop the fetal lungs and reduce respiratory distress syndrome after delivery. They are used in women with suspected preterm labour of babies less than 36 weeks gestation.
An example regime would be two doses of intramuscular betamethasone, 24 hours apart.
what can you give to protect the brain during fatal delivery if premature.
This reduces the risk of cerebral palsy and severity. given within 24hr of delivery
IV magnesium sulfate
what magnesium toxicity
signs of magnesium toxicity
Reduced respiratory rate
Reduced blood pressure
Absent reflexes
Prelabour rupture of membranes Fetal growth restriction Pre-eclampsia Obstetric cholestasis Existing diabetes Intrauterine fetal death
indications of when to start labour
what is the bishops score
The Bishop score is a scoring system used to determine whether to induce labour.]
A score of 8 or more predicts a successful induction of labour. A score below this suggests cervical ripening may be required to prepare the cervix.
used to monitor along with CTG
how do you induce labour
membrane sweep
vagianl PGE2
cervical ripening balloon
oral mifepristone ) anti-progesterone plus misprostol induced labour where fatal death intrauterine has occurred
CTG accelerations and deceerlaerations
Accelerations are generally a good sign that the fetus is healthy, particularly when occurring alongside contractions of the uterus.
Decelerations are a more concerning finding. The fetal heart rate drops in response to hypoxia. The fetal heart rate is slowing to conserve oxygen for the vital organs.
DR – Define Risk (define the risk based on the individual woman and pregnancy before assessing the CTG)
C – Contractions
BRa – Baseline Rate
V – Variability
A – Accelerations
D – Decelerations
O – Overall impression (given an overall impression of the CTG and clinical picture)
Progress in labour is influenced by the three P’s:
Power (uterine contractions)
Passenger (size, presentation and position of the baby)
Passage (the shape and size of the pelvis and soft tissues)
are NSAIDS avoided in pregnancy
yes
simple analgesia in preg
paracetamol
other methods include entonox( nitrous oxide and oxygen) , diamorphen (opiod) , remifentanil patietn given , epidural
what is cord prolapse
Cord prolapse is when the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after rupture of the fetal membranes. There is a significant danger of the presenting part compressing the cord, resulting in fetal hypoxia.
transverse or oblique lie past 37 weeks
mangamnt of cord prolapse
emergency c section
women lie in left lateral position, knee chest position , tocolytic medication such as terbutaline used to minimise contractions whilst waiting fro c section
what is shoulder dystocia
Shoulder dystocia is when the anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis, after the head has been delivered. This requires additional obstetric manoeuvres to enable delivery of the rest of the body. Shoulder dystocia is an obstetric emergency.
main cause of shoulder dystocia
common presentation of head and signs
macrosomia secondary to gestational diabetes.
face downwards (occipito-anterior
turtle neck sign
what is mcroberts manoeuvre
hyeprflexion of mother at the hip knees to abdomen provides psotieor pelvic tilt lifting the PS out the way in shoulder dystocia
Rubins manoeuvre involves reaching into the vagina to put pressure on the posterior aspect of the baby’s anterior shoulder to help it move under the pubic symphysis.
Wood’s screw manoeuvre is performed during a Rubins manoeuvre. The other hand is used to reach in the vagina and put pressure on the anterior aspect of the posterior shoulder. The top shoulder is pushed forwards, and the bottom shoulder is pushed backwards, rotating the baby and helping delivery. If this does not work, the reverse motion can be tried, pushing the top shoulder backwards and the bottom shoulder forwards.
Zavanelli manoeuver involves pushing the baby’s head back into the vagina so that the baby can be delivered by emergency caesarean section.
4 main complications of shoulder dystocia
Fetal hypoxia (and subsequent cerebral palsy)
Brachial plexus injury and Erb’s palsy
Perineal tears
Postpartum haemorrhage
a single dose of what is recommended after instrumental delivery to reduce the risk of maternal infection
co-amoxiclav
indications for instrumental delivery
Failure to progress
Fetal distress
Maternal exhaustion
Control of the head in various fetal positions
main complication of ventouse
cephalohaematoma.
nerves injured in instrumental delivery
femoral and obturator nerve
lateral cuanoeus nerve
lumbosarcal plexus
common perineal nerve
when does a perineal tear occur
A perineal tear occurs where the external vaginal opening is too narrow to accommodate the baby. This leads to the skin and tissues in that area tearing as the baby’s head passes.
Perineal tears are more common with:
First births (nulliparity) Large babies (over 4kg) Shoulder dystocia Asian ethnicity Occipito-posterior position Instrumental deliveries
third stage of labour wither physiological management mother does it or achieve managemten with what
IM oxytocin and cord clamped and cut within 5 minutes of birth
classification of post part haemorrhage
t can be classified as:
Minor PPH – under 1000ml blood loss
Major PPH – over 1000ml blood loss
Major PPH can be further sub-classified as:
Moderate PPH – 1000 – 2000ml blood loss
Severe PPH – over 2000ml blood loss
It can also be categorised as:
Primary PPH: bleeding within 24 hours of birth
Secondary PPH: from 24 hours to 12 weeks after birth
causes of PPH
T – Tone (uterine atony – the most common cause)
T – Trauma (e.g. perineal tear)
T – Tissue (retained placenta)
T – Thrombin (bleeding disorder)
preventative measure ofPPH
Treating anaemia during the antenatal period
Giving birth with an empty bladder (a full bladder reduces uterine contraction)
Active management of the third stage (with intramuscular oxytocin in the third stage)
Intravenous tranexamic acid can be used during caesarean section (in the third stage) in higher-risk patients
The most commonly used skin incision for c section. is a transverse lower uterine segment incision. There are two possible incisions:
Pfannenstiel incision is a curved incision two fingers width above the pubic symphysis
Joel-cohen incision is a straight incision that is slightly higher (this is the recommended incision)
what are the layers that need to be dissected
Skin
Subcutaneous tissue
Fascia / rectus sheath (the aponeurosis of the transversus abdominis and external and internal oblique muscles)
Rectus abdominis muscles (separated vertically)
Peritoneum
Vesicouterine peritoneum (and bladder) – the bladder is separated from the uterus with a bladder flap
Uterus (perimetrium, myometrium and endometrium)
amntioci sac
There is a risk of aspiration pneumonitis during caesarean section, caused by acid reflux and aspiration during the prolonged period lying flat. H2 receptor antagonists (e.g. ranitidine) or proton pump inhibitors (e.g. omeprazole) are given before the procedure to reduce the risk of this happening.
Venous Thromboembolism
Having a caesarean section is likely to lead to a period of reduced mobility. Women should have a VTE risk assessment performed to determine the type and duration of VTE prophylaxis (follow local guidelines). Prophylaxis for VTE involves:
Early mobilisation
Anti-embolism stockings or intermittent pneumatic compression of the legs
Low molecular weight heparin (e.g. enoxaparin)
contradinidcatd for c section
Two key causes of sepsis in pregnancy are:
Chorioamnionitis
Urinary tract infections
All patients admitted to maternity inpatient units, such as at the antenatal ward and labour ward, will have monitoring on a MEOWS chart. MEOWS stands for
maternity early obstetric warning system
The non-specific signs of sepsis include:
Fever Tachycardia Raised respiratory rate (often an early sign) Reduced oxygen saturations Low blood pressure Altered consciousness Reduced urine output Raised white blood cells on a full blood count Evidence of fetal compromise on a CTG
Additional signs and symptoms related to chorioamnionitis include:
Abdominal pain
Uterine tenderness
Vaginal discharge
Additional signs and symptoms related to a urinary tract infection include:
Dysuria Urinary frequency Suprapubic pain or discomfort Renal angle pain (with pyelonephritis) Vomiting (with pyelonephritis)
amniotic fluid embolism
amniotic fluid passes into the mother’s blood.
The amniotic fluid contains fetal tissue, causing an immune reaction from the mother. This immune reaction to cells from the foetus leads to a systemic illne
risk factors for amniotic fluid embolism
Increasing maternal age
Induction of labour
Caesarean section
Multiple pregnancy
symptoms of amniotic fluid syndrome
Shortness of breath Hypoxia Hypotension Coagulopathy Haemorrhage Tachycardia Confusion Seizures Cardiac arrest
A – Airway: Secure the airway
B – Breathing: Provide oxygen for hypoxia
C – Circulation: IV fluids to treat hypotension and blood transfusion in haemorrhage
D – Disability: Treat seizures and consider other neurological deficits
E – Exposure
uterine rupture is what layer
myometrium
Uterine rupture leads to significant bleeding. The baby may be released from the uterus into the peritoneal cavity. It has a high morbidity and mortality for both the baby and mother.
The main risk factor for uterine rupture is a
previous c section
symptoms of uterine rupture
Abdominal pain Vaginal bleeding Ceasing of uterine contractions Hypotension Tachycardia Collapse
main one Is cease of uterine contractions
mamagement for uterien rutprue
emergency c section
uterine inversion
fundus of the uterus drops down through the uterine cavity and cervix, turning the uterus inside out.
Uterine inversion typically presents with a large postpartum haemorrhage. There may be maternal shock or collapse.
management of uterine inversion
There are three options for treating uterine inversion:
Johnson manoeuvre
Hydrostatic methods
Surgery
Initial management of an inverted uterus is with the Johnson manoeuvre, which involves using a hand to push the fundus back up into the abdomen and the correct position. It is held in place for several minutes, and medications are used to create a uterine contraction (i.e. oxytocin). The ligaments and uterus need to generate enough tension to remain in place.
Where the Johnson manoeuvre fails, hydrostatic methods can be used. This involves filling the vagina with fluid to “inflate” the uterus back to the normal position. It requires a tight seal
Where both non-surgical methods fail, surgery is required. A laparotomy is performed (opening the abdomen) and the uterus is returned to the normal position.
For example, they may require resuscitation, treatment of postpartum haemorrhage and blood transfusion.
