Labour and delivery Flashcards
Stages of labour
Stage 1: From onset of labour until 10 cm cervical dilation
Stage 2: from 10cm cervical dilatation until the delivery of the baby
Stage 3: from delivery of the baby until delivery of the placenta
Stages of first stage of labour
Latent - 0-3cm, irregular contractions
Active - 3-7 cm dilation, regular contractions
Transition - 7-10 cm, strong regular contractions
What are Braxton-hick’s contractions
Occasional irregular contractions of the uterus - felt during the second and third trimester. They are not true contractions and do not indicate onset of labour
Signs of onset of labour
Rupture of membranes
Regular, painful contractions
Dilating cervix on examination
What does PROM mean?
Amniotic sac has ruptured before onset of labour
What does P-PROM mean?
The amniotic sac has ruptured before onset of labour and before 37 weeks gestation
What does prolonged rupture of membranes mean?
The amniotic sac ruptures more than 18 hours before delivery
How do you classify pre-term?
Under 28 weeks - extreme preterm
28-31 - very preterm
32-37 - moderate to late preterm
Prophylaxis of pre-term labour
Vaginal progesterone - decreases activity of the myometrium and prevents cervix remodelling in preparation for delivery
Cervical cerclage - involves putting in a stitch in the cervix to add support and keep it closed. The stitch is removed when the woman goes into labour or reaches term.
Preterm Prelabour Rupture of Membranes - Diagnosis and management
Diagnosis - on speculum examination - pooling of amniotic fluid in the vagina
Management - prophylactic antibiotics to prevent chorioamnionitis.
Preterm labour with intact membranes - diagnosis and management
speculum examination to diagnose.
Management - foetal monitoring (CTG), tocolysis with nifedipine to suppress labour
Maternal corticosteroids - to reduce neonatal morbidity and mortality
IV Magnesium sulphate - can be given before 34 weeks and helps protect baby’s brain
Delayed cord clamping
What is the bishops score?
Used to determine whether to induce labour.
A score of 8 or more predicts a successful induction of labour
Options for induction of labour
Membrane sweep
Vaginal prostaglandins to stimulate the cervix and cause onset of labour
Cervical ripening balloon
Artificial rupture of membranes with oxytocin infusion
Oral mifepristone and misoprostol
NICE:
if the Bishop score is ≤ 6
vaginal prostaglandins or oral misoprostol
mechanical methods such as a balloon catheter can be considered if the woman is at higher risk of hyperstimulation or has had a previous caesarean
if the Bishop score is > 6
amniotomy and an intravenous oxytocin infusion
Five key features on a CTG
Contractions
Baseline rate
Variability
Accelerations
Decelerations
What do decelerations indicate?
Drop in foetal HR in response to hypoxia.
Causes of decelerations: VEAL CHOP
Variable decelerations –> Cord compression
Early decelerations –> Head compression
Accelerations –> Okay!
Late decelerations –> Placental Insufficiency
What are early decelerations?
Gradual dips and recoveries in HR that correspond to uterine contractions. These are normal and not pathological.
What are late decelerations?
Gradual fall in HR after uterine contractions. Caused by hypoxia
What are variable decelerations?
Abrupt decelerations unrelated to uterine contractions. Falls of more than 15 bpm of baseline
What are prolonged decelerations?
Last between 2-10 minutes with a drop of more than 15bpm of baseline. Often indicates umbilical compression causing foetal hypoxia.
Management of foetal hypoxia
Rule of 3s
3 minutes - call for help
6 minutes - move to theatre
9 minutes - prepare for delivery
12 minutes - delivery the baby (delivery by 15 minutes)
Oxytocin - functions and uses
Function - ripen the cervix and contractions of the uterus
Uses - induce labour, progress labour, improve frequency and strength of uterine contractions, preventing or treat PPH
Ergometrine - function and uses
Function - stimulates smooth muscle contraction - uterus and blood vessels.
Uses - to prevent and treat of PPH
Prostaglandins - function
Function - stimulates uterine muscles
Misoprostol - uses
Medical management of miscarriage. Used alongside mifepristone for abortions, induction of labour after intrauterine foetal death
Mifepristone - function and uses
Function - stimulation of the uterus.
Uses - used alongside misoprostol for abortions, induction of labour after intrauterine foetal death
Nifedipine - function and uses
Function - reduce smooth muscle contraction in blood vessel and the uterus
Uses - reduces blood pressure in hypertension and pre-eclampsia, tocolysis (delaying onset of labour)
Carboprost - MOA and uses
Synthetic prostaglandin analogue.
IM injection for PPH
Adverse effects of epidural
Heachache after insertion
Hypotension
Motor weakness in the legs
Nerve damage
Increased probability of instrumental delivery
Uterine cord prolapse diagnosis
Foetal distress on the CTG
Speculum examination can be used to confirm the diagnosis
Management of uterine cord prolapse
Emergency c section
Pushing the cord back in is not recommended. The cord should be kept warm and wet and have minimal handling whilst waiting for delivery (handling causes vasospasm).
Tell woman to go on all fours OR left lateral position with the pelvis higher than the head - using gravity to draw the fetus away from the pelvis and reduce compression on the cord
Indications for instrumental delivery
Failure to progress
Fetal distress
Maternal exhaustion
Control of the head in various position
Risks of instrumental delivery increases the risk to the mother of:
PPH
Episiotomy
Perineal tears
Injury to the anal sphincter
Incontinence of the bladder or bowel
Serious risk to the baby as a result of instrumental delivery
Subgleal haemorrhage (most dangerous)
Risk to remember to the baby with ventouse
Cephalohaematoma
Risk to remember to the baby with forceps
Facial nerve palsy
Classification of perineal tears
First- degree - injury limited to the frenulum of the labia minor and superficial skin
Second-degree - includes perineal muscles but not affecting the anal sphincter
Third-degree A -less than 50% of the external anal sphincter
3B - more than 50% of the external anal sphincter affected
3C - external and internal anal sphincter affected
Fourth - degree - including the rectal mucosa
Management of perineal tears
First degree - do not repair
Second degree - require suturing on the ward by a suitably experienced midwife or clinician
Third degree - requires repair by clinician in theatre
Fourth degree - require repair in theatre by a suitably trained clinician
Complications of perineal tears
Urinary incontinence
Anal incontinence
Fistula between the vagina and bowel
Sexual dysfunction and dyspareunia
PPH classification
500 ml after vaginal delivery
1000 ml after c section
Major vs minor PPH
Minor - under 1000ml blood loss
Major - over 1000 ml blood loss
Primary vs secondary PPH
Primary PPH - within 24 hours of birth
Secondary PPH - from 24 hours to 12 weeks after birth
Causes of PPH
Four Ts:
Tone - uterine atony
Trauma - perineal tear
Tissue - retained placenta
Thrombin - bleeding disorder
PPH management - mechanical
Rubbing the uterus
Catheterisation
PPH management - medical treatment
Oxytocin
Ergometrine
Carboprost
Misoprostol
Tranexamic acid
PPH management - surgical treatment
Intrauterine balloon tamponade
B-lynch suture - putting a suture around the uterus to compress it
Uterine artery ligation
Hysterectomy
What layers do you have to go through for a C-Section?
SS RR PUA
Skin
Subcutaneous tissue
Rectus sheath
Rectus abdominis
Peritoneum
Uterus
Amniotic sac
Risks of spinal anaesthetics during C-Sections
Allergic reaction/anaphylaxis
Hypotension
Headache
Urinary retention
Nerve damage
Haematoma
Causes of sepsis in pregnancy
Chorioamnionitis
UTIs
Risk factors for uterine rupture
Main risk factor - previous c-section
Vaginal birth after caesarean
Previous uterine surgery
Increased BMI
High parity
Increased age
Signs and symptoms of uterine rupture
Abnormal CTG
Abdominal pain
Vaginal bleeding
Ceasing of uterine contractions
Hypotension
Tachycardia
Collapse
Management of uterine rupture
Immediate delivery of baby via emergency c-section
Stop any bleeding and repair or remove the uterus (hysterectomy)
