Labour and delivery Flashcards
CTG
i) what does it measure? (2) how many transducers are placed on? how is each measured?
ii) name five indications for CTG monitor? what are five key features to look at?
iii) what can too many contractions be a sign of? what are accelerations?
iv) what is normal baseline HR? what is non reassure? what is abnormal? what is normal variability? what is abnormal?
v) what are decellerations? what causes them? what type are concerning? (2)
i) measures fetal HR and contraction of the uterus
two transducers - one for fetal heart monitor and one near fundus to monitor uterine contractions
measure HR with doppler US and measure tension in uterine wall for contractions
ii) indic - sepsis, mat tachy, meconium, pre ec, fresh antepartum haemm, delay in labour, oxytocin use
look at contractions, baseline fetal HR, variability, accel (spikes in HR), decell (drops in fetal HR)
iii) too many contrac > uterine hyperstim
accelerstions are a good sign that fetus is healthy
iv) baseline HR is 110-160, non reassure is 100-109 or 161-180, abnormal below 100 or above 180
variability 5-25 is normal, non reassure < 5 for 30 mins or more than 25 for 15 mins
abnormal less than 5 for 50 mins+ or more than 25 for > 25 mins
v) decelerations are when fetaL HR drops in relation to hypoxia
early are normal
late - fall after contract > hypoxia = concerning
prolonged decel - due to compress of umbilical cord
MX BASED ON CTG
i) what three features can be used to guide tx? what are the four categories of CTG?
ii) what is the rule of 3s for fetal bradycardia? what is a sinusoidal CTG?
iii) what is DR C Bravado?
i) mx on baseline rate, variability, decellerations
normal, suspicious (one non reassure feature), pathol (two non reassure features or single abnormal) uregent interven = acute brady or prolonged decel for 3 mins
ii) 3 mins call for help, 6 mins move to theature, 9 mins prep for deliver, 12 mins deliver baby (within 15)
sinus - severe fetal compromise usually assoc with anaemia from vasa praevia
iii) Define Risk, Contractions, Baseline Rate, Variability, Accel, Decelm Overall impression
DRUGS IN LABOUR
i) where is oxytocin made and secreted from? how does it impact cervix and uterus? what does it also play a role inn? name four things oxytocin infusions are used for? what is the brand name?
ii) what does ergometrine do? what is it useful for? when must it not be used? name three side effects? what is syntometrine? what is it used for?
iii) what can PGs do before delivery? what is the key PG in labour? name the three forms it comes in? how do PGs affect BP?
iv) what is misoprostol? what is it used for alone? what is it used for combined with mifepristone? (3)
v) what is mifepristone? what does it do? (2)
i) oxytocin made by hypothal and secreted by post pit
ripens cervix and causes contraction of uterus - also plays a role in lactation in bf
infusions used for induction of labour, progress labour, improve freq and strength of contract, prevent/treat post part haem
synoticinon is brand name
ii) ergometrine stim sm muscle contraction > delivery of placenta to reduce pp bleeding
only used in third stage after delivery of baby
SE - hypertension, vom, diarr, angina - avoid in pre ec
syntometrine is combo of oxytocin and ergometrine > prevent/tx post part haem
iii) PG can stim contrac of uterine muscles and ripening the cervix
key PG is dinoprostone = PG E2 - used for induction as pessary/tablet/gel
PGs lower BP
iv) misoprostol - PG analog used in medical mx of miscarriage
use with mifepristone for abortion, induc of labour and IU fetal death
v) mifepristone is a anti progestogen that blocks progresterone so halts preg and ripening of cervix
enhances effects of PGs to stim contractions
not used in pregnancy with a healthy fetus
DRUGS IN LABOUR 2
i) what is nifedipine used for in preg? (2)
ii) what is terbutaline? what does it do? what is it used for?
iii) what is carboprost? what effect does it have on the uterus? when is it given? how is it given? which patients must it be avoided in?
iv) what is tranexamic acid? when may it be used?
i) nifedipine is a CCB - reduces smooth muscle contraction in uterus
in preg.- reduces BP in pre ec or tocolysis in premat labour (supresses uterine activity)
ii) beta 2 agonist > stim beta 2 adrenergic to suppress uterine contractions = used in tocolysis for uterine hyperstim (stop contrac) after excess induction
iii) carboprost = PG analog > stim uterine contrac given by deep IM inject in PP haem if ergomet/oxy are inadrwquate
avoid in asthma
iv) TX is an anti fibrinolytic (binds plasminogen and stops conversion to plasmin) used to tx PP haem
SHOULDER DYSTOCIA
i) what is it? how quick does it need to be tx? whats it usually caused by?
ii) how can it px? what is the turtle neck sign?
iii) which two teams should be called? what can be done to reduce risk of perineal tears?
iv) which three manoeuvre may be done? what is done in each? where may pressure be applied
v) name four key complications?
i) when anterior shoulder gets stuck behind the pubic symphysis after the head has been delivered
obstet emergency > usually caused by macrosomia
ii) px with fail of restitution - head remains face down and doesnt turn sideways
turtle neck sign - head delivered by retracts back into the vagina
iii) call paeds and anaesthetics
episiotomy can be done to enlarge vaginal opening
iv) mcroberts - bring mums knees to abdo to provide a post pelvic tilt lifting pubic symph out the way
rubins - reach into vagina and put pressure on post aspect of shoulder to move it under symph
wood screw - during rubins put pressure on ant aspect of post shoulder and post aspect of anti shoulder to twist out
zavanellie - push head back into vagina to deliver by emegerncy CS
v) complics - fetal hypoxia (CP), brachial plex injury/erbs palsy, perineal tears, post partum haem
POST PARTUM HAEMORRHAGE
i) how much blood needs to be lost after vaginal delivery? after CS? what classifies as major? what is minor?
ii) what are the two types of major? what are the four causes of PPH (4 Ts)
iii) name five RFs? name three ways it can be prevented?
iv) when should oxygen be given? name two mech tx to stop bleeding? name four medical tx? name four surgical tx?
v) what is secondary PPH? what is it due to? (2) how can it be mx?
i) 500ml after vaginal or 1000ml after CS
major is over 1000ml and minor is under 1000ml
ii) major > moderate 1000-2000ml or severe 2000ml and over
tone, trauma, tissue, thrombin
iii) RF are previous PPH, multiple preg, obesity, large baby, failure to progress in 2nd stage, prolonged 3rd stage, pre eclamp, place accreta, instrumentation, GA, episiotomy/tear
prevent with tx of anaemia in antenatal period, give birth with empty bladder, active mx of third stage with IM oxytocin, IV TXA
iv) always give oxygen regardless of sats
mech - rub uterus to stim contractions and catheterisation (bladder disten prevents uterine contracs)
medical - oxytocin, ergometrine, carboprost, misoprost, TXA
oxytocin is given as 40 units in 500ml
surgical - IU balloon tamponade, B lynch suture in uterus, uterine artery ligation, hysterectomy
v) secondary is 24hrs to 12 weeks post partum
usually due to retained products of conception or infection (endometritis)
ix are US or high cervical swab
mx dep on cause - sx eval of retained products or abx for the infection
MATERNAL SEPSIS
i) what are they two key causes of sepsis in pregnancy?
ii) what is chorioamnioitis? when does it usually occur? (2) what is it caused by? name three specific signs of chorio?
iii) name three signs that may be seen if there is UTI?
iv) what is mainstay mx? what type of monitoring is req? what is usually required in CS?
v) name three abx that may be used to tx?
i) chorioamnioitis and UTI
ii) chorio - infection of chrioamniotics membranes and am fluid > leading cause of mat sepsis and mat death
occ later in preg and during labour
caused by a large variety of bac
abdo pain, uterine tender, vaginal discharge
iii) UTI - dysuria, suprapubic pain, renal angle pain, vomiting
iv) sepsis six = give O2, abx and fluid - take cultures, urine output and lactate
maternal and fetal monitoring
GA if CS
v) piperacillin and taz plus gent, amox, clindamycin
UTERINE RUPTURE
i) what happens? what does it lead to? what is the main RF? name four other RF
ii) how does it usually px? (2) name three symptoms
iii) how is it mx? what is required
i) myometrium of uterus ruptures - can be complete or incomplete
incomp = perimetrium remains in tact
complete - seros ruptures too and contents are rel into peritoneal cavity
main RF is previous CS
other risks - VBAC, prev uterine sx, inc BMI, high parity, inc age, induction of labour, use of oxytocin
ii) px with acute unwell mother and abnormal CTG
abdo pain, vaginal bleeding, hypoten, tachycardia, collapse
iii) mx as an emergency, may need resus and transfusion
emergency CS to remove baby and stop bleeding and repair/remove uterus
CORD PROLAPSE
i) what happens? what is the danger? what is the most signif RF? when should it be suspected?
ii) how is it dx? (2) what is indicated once dx?
iii) what is there high risk of? what should be done to the cord?
iv) what can be done to the bbay? name two positions the woman should lay in?
v) what medication can be given whilst waiting for CS
i) cord descends before the presenting part into the vagina
danger is compression and fetal hypoxia
signif RF is abnormal lie after 37 weeks eg unstable, TV, oblique
suspect when fetal distress on CTG
ii) dx with vaginal exam and then confirmed by speculum
iii) high risk of cord compression and hypoxia - keep cord warm and wet with minimal handling to prevent vasospasm
iv) push baby head back in to prevent compressing cord
lay in left lat position or on all fours
tocolytic meds eg terbutamine to minimise contracs while waiting for CS
TRANSVERSE LIE
i) what is it? what are the three types of lie?
ii) when is this common? when do most move by?
iii) name four risk factors? how will it be detected? what will bef ound on exam
iv) name two complications? who needs to be involved to discuss mx? up to how many weeks is no mx req
v) what active mx can be done? name a CI to this? what delivery method is needed if the baby doesnt move?
i) fetal longitudinal axis is perp to long axis of uterus (head is on lat side of pelvis and bum is opposite) types are longitud, transverse, oblique
ii) common early in gestation and most move to longitud by 32 weeks
iii) RF are prev pregnancy, fibroids, twins/triplets, premature, polyhydramnios, fetal abnorm
det on rountine antenatal appt with abdo exam
abdo exxam - head and bum not palp ay each end of uterus
US - visualise TV lie
iv) complicats = premat rupture of mem and cord prolapse
before 36 no mx req
v) after 36 weeks - discuss with obs
perform ECV late in preg/early labour if membranes have not ruptures
CI to ECV is rupture of mem in last 8 days, multiple preg and uterine abnorm
need elective CS if ECV doesnt work
PRETERM PRELABOUR RUPTURE OF MEM
i) what % of preg does it occur in? name two fetal complicats and one maternal?
ii) how is it confirmed? what is seen? what should be avoided?
iii) when should PAMG-1 test be done? what other test can be done
iv) what abx should be given? how long for? what other drug should be given?
v) when should delivery be considered from?
i) 2%
fetal - premature, infect, pulm hypoplas
materal - chorioamnioitis
ii) confirm with sterile speculum to look for pooling of amniotic fluid in post vaginal vault
avoid digital exam
iii) test for PAMG1 if no pooling of fluid or IGF1
US may show oligohydramnios
iv) give oral erythro for 10 days
give corticosteroids to reduce RDS
v) consider delivery from 34 weeks
