Labour and Delivery Flashcards
premature labour
birth before 37 weeks gestation.
Considered viable from 24 weeks
Extreme preterm: <28 weeks
Very preterm: 28-32 weeks
moderate/late preterm: 32-37 weeks
prophylaxis of preterm labour
vaginal progesterone
- decreases activity of myometrium and preventing cervix remodelling
Cervical cerclage
-stitch in cervix to add support and keep it closed
preterm prelabour rupture of membranes
amniotic sac rupture, releasing amniotic fluid, before the onset of labour and in a preterm pregnancy
management; prophylactic Abx (erythromycin)
preterm labour with intact membranes
regular painful contraction and cervical dilatation without rupture of amniotic sac.
management of preterm labour with intact membranes
Fetal monitoring (CTG)
Tocolysis with Nifedipine
Maternal corticosteroids (<36 weeks gestation)
IV magnesium sulphate (<34 week gestation)
Delayed cord clamping
Tcolysis
Using medications to stop uterine contractions.
Nifedipine
-CCB: medication of choice for tocolysis
Atosiban if Nifedipine contraindicated
breech presentation (+types)
presenting part of foetus is legs and bottom
Complete
-legs fully flexed at hips and knees
Incomplete
- one leg flexed at hip and extended at knee
Extended breech
- Frank breech
- Both legs flexed at hip and extended at knee
Footling breech
- foot presenting through cervix with leg extended
management of breech
before 36 weeks
- often turn spontaneously: no breech required
External Cephalic Version
active management of third stage
physiological management
Active management
- dose of intramuscular oxytocin to help uterus contract & careful traction to umbilical cord to guide placenta out of uterus & vagina
amniotic fluid embolism
Rare
Amniotic fluid passes into mother’s blood.
usually occurs around labour and delivery.
Amniotic fluid contains foetal tissue, causing immune reaction from the mother.
presentation of amniotic fluid embolism
SOB hypoxia hypotension coagulopathy haemorrhage tachycardia confusion seizures cardiac arrest
management of amniotic fluid embolism
supportive
ABCDE approach
c-section most common skin incision
transverse lower uterine segment incision
Blunt dissection is used after initial incision with scalpel.
cord prolapse
umbilical cord descends below presenting part of the fetus and through the cervix into the vagina, after rupture of the fetal membranes.
significant danger of presenting part compressing cord, resulting in fetal hypoxia.
cord prolapse risk factor
Abnormal lie after 37 weeks gestation
cord prolapse management
Emergency c-section
Tocolytic medication to minimise contractions whilst waiting for delivery by c-section
oxytocin in labour
stimulate ripening of cervix and contractions of uterus.
Infusions are used to 0induce labour -progress labour -imrpove frequency and strength of uterine contractions -prevent/ treat postpartum haemorrhage
ergometrine in labour
stimulates smooth muscle contraction.
Useful for delivery of the placenta and to reduce postpartum bleeding.
Only used after delivery of baby
prostaglandins in labour
stimulate contraction of uterine muscles
Example: Dinoprostone
Used for induction of labour
nifedipine in labour q
CCB that reduces smooth muscle contraction in blood vessels and the uterus
reduces BP in hypertension and pre-eclampsia
-tocolysis in premature labour
terbutaline in labour
beta-2 agonist
acts on smooth muscle of uterus to suppress uterine contractions
used for tocolysis in uterine hyperstimulation
carboprost in labour
synthetic prostaglandin analogue
Stimulate uterine contractions
AVOID in patients with asthma
given as deep IM injection in postpartum haemorrhage if ergometrine and oxytocin have been inadequate
tranexamic acid in labour
antifibrinolytic
Reduces bleeding
Prevention and treatment of postpartum haemorrhage.
delay in first stage of labour
<2cm of cervical dilatation in 4hrs
delay in 2nd stage of labour
Active (pushing phase) lasts
>2 hours in nulliparous women
>1 hour in multiparous wome
delay in third stage
> 30 minutes with active management (IM oxytocin and controlled cord traction)
60 minutes with physiological management
management of failure to progress
amniotomy (artificial rupture of membranes)
oxytocin infusion
instrumental delivery
c-section
options for induction of labour
Membrane sweet
Vaginal prostaglandins E2 (dinoprostone)
Cervical ripening balloon (CRB)
Artificial rupture of membranes+ oxytocin infusion
monitoring during induction of labour
CTG
- assess fetal heart rate and uterine contractions before and during induction of labour
Bishop score
-before and during induction of labour to monitor progress
pain relief in labour
Simple analgesia
Gas & air (entonox)
IM pethidine/ diamorphine
Epidural
perineal tears
Occurs where the external vaginal opening is too narrow to accommodate the baby.
leads to skin and tissues in that area tearing as the baby’s head passes.
degrees of perineal tears
first degree
- injury limited to frenulum of labia minor and superficial skin
2nd degree
- includes perineal muscles, but doesn’t affect anal sphincter
3rd degree
- Includes anal sphincter but not rectal mucosa
- 3A: <50% external anal sphincter affected
- 3B >50% external anal sphincter affected
- 3c: external and internal anal sphincter affected
4th degree
-includes rectal mucosa
management of perineal tears
First degree; do not require sutures
Sutures to correct the injury
Reduce risk of complications
- Broad-spectrum AB
- Laxative
- physio
- follow-up
complications of perineal tear
Short-term
- pain
- infection
- bleeding
- wound dehiscence or wound breakdown
Long-term
- urinary incontinence
- anal incontinence and altered bowel habit
- dyspareunia
- psychological consequences
Epiosiotomy
Cuts perineum before delivery
perineal massage
reduce risk of perineal tears
massaging skin and tissues between vagina and anus
postpartum haemorrhage
Loss of
>500ml after vaginal delivery
>1000ml after c-section
Cause of postpartum haemorrhage
tone (uterine atony)
trauma (perineal tear)
Tissue (retained placenta)
thrombin (bleeding disorder)
management of postpartum haemorrhage (stabling patient)
obstetric emergency
ABCDE approach
insert two large-bore IV cannulas
Bloods: FBC, U&E, clotting screen
Group and cross match 4 units of blood
Warmed IV fluid and blood resuscitation as required
Oxygen
FFP (clotting abnormalities or after 4 units of blood transfused)
Severe:activate major haemorrhage protocol
management of postpartum haemorrhage (stop bleeding)
Mechanical
- rubbing uterus to stimulate uterus contraction
- catheterisation
Medical
- oxytocin
- ergometrine
- carboprost
- tranexamic acid
Surgical
- intrauterine balloon tamponade
- B-lynch suture
- uterine artery ligation
- last resort: hysterectomy
Secondary postpartum haemorrhage
bleeding occurs from 24 hours to 12 weeks postpartum
Likely cause
- retained products of conception or infection
Investigation
- US
- Endocervical and high vaginal swabs
Management
- surgical evacuation of retained products of conception
- antibiotics for infection
shoulder dystocia
anterior shoulder of baby becomes stuck behind pubic symphysis of the pelvic, after head has been delivered
Management of shoulder dystocia
1st: McRobert’s manoeuvre
Rubin’s manoeuvre
Wood’s screw manoeuvre
Zavanelli manoeuvre
uterine inversion
funds of uterus drops down through uterine cavity nd cervix, turning the uterus inside out.
Very rare occurence
Life-threatening obstetric emergency
Incomplete vs complete uterine inversion
Incomplete
-fundus descends inside uterus or vagina, but not as far as introitus
Complete uterine inversion
-involves uterus descending through vagina to introitus
management of uterus inversion
Johnson manoeuvre
Hydrostatis methods
Surgery
-laparotomy
uterine rupture
complication of labour.
Muscle layer of uterus (myometrium) ruptures
Obstetric emergency
very rare to occur in nulliparous
incomplete vs complete uterine rupture
incomplete/ uterine dehiscence
-uterine serosa (perimetrium) surrounding uterus remains intact
Complete rupture
-serosa ruptures along with myometrium, and the contents of the uterus are released into peritoneal cavity
uterine rupture presentation
abdo pain vaginal bleeding ceasing of uterine contraction hypotension tachycardia
collapse
uterine rupture management
resuscitation and transfusion
Emergency c-section
maternal sepsis main aetiology
chorioamnionitis
UTI
chorioamnionitis
infection of chorioamniotic membranes and amniotic fluid
Leading cause of maternal sepsis and notable cause of maternal death
Presentation
fever, tachycardia, raised RR, reduced O2 sats, low BP, altered consciousness, reduced urine output, raised WCC
Evidence of foetal compromise on CTG
Chorioaminonitis
- abdo pain
- uterine tenderness
- vaginal discharge
UTI
- dysuria
- urinary frequency
- suprapubic pain or discomfort
- renal angle pain (pyelonephritis)
- vomiting (pyelonephritis)
investigations of maternal sepsis
Blood test
- FBC
- U&E
- LFTs
- CRP
- Clotting
- Blood cultures
- Blood gas (lactate, pH and glucose)
Additional
- urine dipstick and culture
- high vaginal swab
- throat swab
- sputum culture
- wound swab
- lumbar puncture for meningitis or encephalitis
Sepsis 6
three tests
- blood lactate level
- blood cultures
- urine output
three treatments
- O2
- empirical broad spectrum ABx
- IV fluids
antibiotics for maternal sepsis
Co-amoxiclav + metronidazole
Severe: Piperacillin/ Tazobactam + Clindamycin
Shock: Piperacillin/ Tazobactam + Clindamycin + Gentamicin
Penicillin allergic: Clindamycin + Gentamicin
