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Finals > Labour and delivery > Flashcards

Labour and delivery Flashcards

1
Q

how is postpartum haemorrhage defined and classified

A

-500ml after vaginal delivery
-1000ml after c section
-Minor PPH : <1000ml
-Major : >1000ml
-Moderate PPH : 1000-2000ml
-Severe : >2000ml

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2
Q

what are 4 causes of postpartum haemorrhage (4 T’s)

A

T : Tone : uterine atony (most common)
T : Trauma (e.g. perianal tear)
T : Tissue (retained placenta)
T : Thrombin (bleeding disorder)

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3
Q

what are the mechanical management options of PPH

A
  • Fundal massage to stimulate uterine contractions.
  • Catheterisation
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4
Q

what are the medical management options of PPH

A
  • IV oxytocin : slow injection then continuous infusion.
  • Ergometrine (IV or IM)
  • Carboprost IM
  • Misoprostol (sublingual)
  • Tranexamic acid (IV)
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5
Q

what are the surgical management options of PPH

A
  • Intrauterine balloon tamponade
  • B-lynch suture around uterus
  • Uterine artery ligation
  • Hysterectomy
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6
Q

what is secondary postpartum haemorrhage and what investigations and management is involved

A

Bleeding from 24 hrs to 12 wks
Usually caused by RPOC or infection
Ix : USS + endocervical and high vaginal swabs
Mx : surgical evaluation of retained products of conception, Abx for infection.

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7
Q

when is ergometrine CI in management of PPH

A

-> HTN

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8
Q

when is carboprost CI in the management of PPH

A

-> Asthma

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9
Q

What are the 3 stages of delivery

A

-1st : true contractions until 10cm cervical dilation
-2nd : 10cm cervical dilation until delivery
-3rd : from delivery until delivery of placenta

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10
Q

What are the 3 stages of the 1st stage of pregnancy ?

A

-latent : 0 to 3cm dilation. Irregular contractions
-Active : 3cm to 7cm dilation. Regular contractions
-Transition : 7cm to 10cm. Strong, regular contractions

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11
Q

What are braxton-hicks contractions

A

Occasional irregular contractions of the uterus during the second and third trimester

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12
Q

What are 4 signs of the onset of labour

A

Show (mucus plug from cervix)
Rupture of membranes
Regular, painful contractions
Dilating cervix on examination

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13
Q

give the 5 definitions referring to the rupture of membranes in pregnancy

A

-> ROM : amniotic sac rupture
-> SROM : rupture spontaneously
-> PROM - prelabour rupture: rupture before onset of labour
-> P-PROM (preterm, prelabour) : ruptured before onset of labour & before 37 weeks gestation (preterm)
-PROM - prolonged rupture : ruptures >18 hrs before delivery

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14
Q

what 2 things can be done if a woman has a cervical length of <25mm between 16 and 24 wks for prohpylaxis of preterm labour

A
  • Vaginal progesterone (oral or pessary)
    -Cervical cerclage : putting a stitch in the cervix (done if previous premature birth or cervical trauma)
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15
Q

What is done in preterm prelabour rupture of membranes

A
  • Amniotic sac ruptures before onset of labour and before 37 wks
  • Diagnosed : if not with speculum, check IGFBP-a on vaginal fluid
  • Prophylactic erythromycin 250mg 4x daily for 10 days to prevent chorioamnionitis
  • Induction of labour may be offered from 34 wks to initiate onset of labour
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16
Q

What are 5 options for managing preterm labour with intact membranes to improve outcomes

A

-Fetal monitoring
-Tocolysis with nifedipine : CCB that suppresses labour.
-Maternal corticosteroids : before 35 wks, reduce neonatal morbidity
-IV magnesium sulphate : before 34wks to protect brain
-Delayed cord clamping or cord milking : increases circulating blood volume and Hb in the baby

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17
Q

What is tocolysis

A

-Medications to stop uterine contractions in labour with intact membranes
-CCB : nifedipine
Can be used between 24 and 33+6 wks gestation in preterm to delay delivery

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18
Q

What maternal steroids are used in suspected preterm labour of babies <36 wks

A

2 doses of IM betamethasone 24 hrs apart

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19
Q

When is IV magnesium sulphate given in preterm babies

A

within 24 hrs of delivery of babies <34 wks gestation
reduces risk and severity of cerebral palsy

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20
Q

what are 3 key signs of magnesium toxicity in the mother?

A

reduced resp rate
reduced blood pressure
absent reflexes

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21
Q

What scoring is used to determine whether to induce labour?

A

Bishop

Fetal station
Cervical position, dilation, effecement and consistency

8 or more = successful induction of labour

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22
Q

what are the 4 options for inducing labour and when is it offered

A
  • membrane sweep
  • vaginal prostaglandin E2
  • cervical ripening balloon
  • artificial rupture of membranes with oxytocin infusion

Offered between 41 and 42 wks gestation

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23
Q

What 2 ways are women monitored in the induction of labour

A

-cardiotocography (CTG) : fetal HR and uterine contractions
-Bishop score

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24
Q

what is the main complication of labour induction with vaginal prostaglandins

A

uterine hyperstimulation -> prolonged and frequent uterine contractions causing fetal distress and compromise

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25
Q

What are the risks of uterine hyperstimulation

A

fetal hypoxia and acidosis
emergency c section
uterine rupture

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26
Q

how is uterine hyperstimulation managed

A

remove vaginal prostaglandins
tocolysis with terbutaline

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27
Q

what is CTG used for

A

to measure fetal heart rate and uterine contraction

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28
Q

what are accelerations, decelerations and variability on a CTG?

A
  • > accelerations : periods where fetal heart spikes & is generally normal
    -> decelerations : where fetal heart drops in response to hypoxia
    -> variability : how the fetal HR goes up and down around the baseline
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29
Q

what baseline fetal HR is reassuring on a CTG

A

110-160

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30
Q

what baseline fetal HR on a CTG is non-reassuring and abnormal

A
  • Non reassuring : 100-109 or 161-180
  • Abnormal : below 100 or above 180
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31
Q

what variability in fetal HR on CTG is reassuring

A

5-25

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32
Q

what variability in fetal HR on CTG is non reassuring and abnormal

A
  • Non reassuring : <5 for 30-50 mins or >25 for 15-25 mins
  • Abnormal : <5 for over 50 mins
    or >25 for over 25 mins
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33
Q

what are the 4 types of decelerations on a CTG

A

Early
Late
Variable
Prolonged

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34
Q

what are early decelerations on CTG

A
  • Gradual dips and recoveries in HR corresponding with uterine contractions
  • Normal !
  • Lowest point of deceleration = peak of contraction
  • Uterus compresses fetal head -> vagus stimulation -> slowing of HR
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35
Q

what are late decelerations on a CTG

A
  • Falls in HR that start ATFER the uterine contraction has began
  • Lowest point of deceleration = after the peak of contraction
  • More concerning as caused by hypoxia in the fetus
  • Can be caused by : excessive uterine contractions, maternal hypotension or maternal hypoxia
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36
Q

what are variable decelerations

A
  • Fall in the HR of >15bpm from the baseline
  • Last <2 mins
  • Caused my intermittent compression of umbilical cord causing hypoxia
  • Brief accelerations before and after these decelerations = shoulders = reassuring
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37
Q

what are prolonged decelerations

A
  • Last between 2 and 10 mins
  • Drop of 15bpm from the baseline
  • Indicates compression on umbilical cord causing fetal hypoxia
    abnormal and concerning
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38
Q

what would a reassuring CTG be

A

no decelerations
early decelerations
or less than 90 mins variable decelerations with no concerning featues

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39
Q

what are the rules for fetal bradycardia

A

rule of 3’s

3 min - call for help
6 min - move to theatre
9 min - prepare for delivery
12 min - delivery (by 15 min)

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40
Q

what CTG would suggest severe fetal compromise

A

sinusoidal CTG

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41
Q

what is oxytocin and why are infusions given in pregnancy

A

-Hormone that stimulates cervical ripening and uterine contractions
-Role in lactation in breastfeeding
-Given to induce or progress labour, improve/frequency & strength of uterine contractions and prevent or treate postpartum haemorrhage

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42
Q

where is oxytocin produced

A

Hypothalamus
Secreted by the posterior pituitary gland

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43
Q

what is ergometrine and when is it used

A

-AFTER delivery in the third stage of labour
-Helps with delivery of the placenta and to prevent and treat postpartum haemorrhage
-Stimulates smooth muscle contraction

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44
Q

why are prostaglandins given in pregnancy ?

A

stimulate uterine contractions
example : dinoprostone (prostaglandin E2)

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45
Q

what 2 medications are used in abortion and induction of labour in intrauterine fetal death

A

misoprostol
mifepristone

46
Q

what is used to reduced BP in HTN and pre-eclampsia and for tocolysis in prem labour

A

nifedipine
CCB -> reduces smooth muscle contraction in blood vessels and terus

47
Q

what is used for tocolysis in uterine hyperstimulation

A

terbutaline
beta-2-agonist

48
Q

what can be given if ergometrine or oxytocin are inadequate in postpartum haemorrhage

A

carboprost (deep IM injection)
synthetic prostaglandin analogue

49
Q

what else can be used in prevention and treatment of postpartum haemorrhage

A

tranexamic acid
antfibrinolytic - prevents conversion of plasminogen to plasmin
therefore reduces plasmin required to dissolve fibrin in clots = reduces bleeding

50
Q

what is failure to progress in labour and what can it be influenced by

A
  • Labour not developing at satisfactory rate.
  • Influence by 3P’s
    • Power (uterine contractions)
    • Passenger (size, presentation and position of baby)
    • Passage (shape, size of pelvis and soft tissue)

Psyche can be added (support and antenatal prep for labour and delivery)

51
Q

what is considered as delay in 1st stage of labour

A

less than 2cm cervical dilation in 4 hrs
slowing of progress in multiparous women

52
Q

how are women monitored for progress in the 1st stage of labour

A

Partogram.
Records :
- cervical dilation (measured every 4 hrs)
- descent of fetal head
- maternal pulse BP temp & urine output,
-fetal HR
- uterine contractions (contractions per 10 mins)
- status of membranes
- drugs and fluids given

53
Q

How is a partogram read?

A
  • It has 2 lines : alert and action
  • Dilation of cervix is plotted against time
  • When it takes too long to dilate, the readings cross to the right of the alert and action lines
54
Q

What does crossing of the alert line indicate

A

amniotomy & repeat exam in 2 hrs

55
Q

What does crossing the action line mean

A

obstertric led care and senior decision makers

56
Q

What does success in the second stage depend on and what would suggest delay

A

Success : the 3 P’s
delay : pushing lasts 2hrs in nulliparous woman or 1 hr in multiparous women

57
Q

What is defined as delay in the third stage of labour ?

A

> 30 mins with active management (IM oxytocin and controlled cord traction)
OR
60 mins with physiological management

58
Q

What are the 4 main options for management of failure to progress

A

-Amniotomy of intact membranes
-Oxytocin infusion - 1st line (aim for 4-5 contractions per 10min)
-Instrumental delivery
-C section.

59
Q

Give 5 pain relief options for labour

A

-Simple analgeis (Paracetamol +/- codeine)
-Gas and air (entonox) during contractions (50% nitrous oxide, 50% O2)
-IM Pethidine or Diamorphine (opiod)
-Patient controlled IV remifetanil
- Epidural

60
Q

What is used in an epidural and where is it injected into

A
  • Epidural space : outside the dura mater
  • levobupivacaine / bupivacaine (usually mixed with fantanyl)
61
Q

Give 6 SE of epidural

A

Increased probability of instrumental delivery
Headache
Hypotension
Motor weakness in legs
Nerve damage
Prolonged second stage

62
Q

What is an umbilical cord prolapse and the problem with it

A
  • Umbilical cord descends below the presenting part of the fetus
  • Risk of presenting part compressing the cord = fetal hypoxia
63
Q

what is the biggest RF for a cord prolapse and how is it diagnsed

A
  • RF : baby in abnormal lie after 37 wks gestation
  • Diagnosis : suspected when fetal distress on CTG, diagnosed by vaginal exam and speculum to confirm
64
Q

how is cord prolapse managed

A
  • Emergency c section
  • Keep cord warm and wet with minimal handling
65
Q

what is shoulder dystocia and what is it often caused by

A

-Anterior shoulder of baby gets stuck behind pubic symphysis after head is delivered
-Often caused by macrosomia secondary to gestational DM

66
Q

what are the different ways shoulder dystocia can be managed

A
  • Episiotomy : enlarge vaginal opening
  • McRoberts manoeuvre : hyperflexion of mother at the hip -> provides posterio pelvic tilt
  • Pressure to anterior shoulder by pressing on suprapubic region
  • Rubins manoeuvre : hand in vagina, pressure on anterior shoulder
  • Wood’s screw manoeuvre : hand in vagina, pressure on ppsterior shoulder
  • Zavanelli manoeuvre : push baby back in, c section
67
Q

A single dose of what is recommended after instrumental delivery to reduce the risk of maternal infection

A

co-amoxiclav

68
Q

what is a ventouse and what is the risk to the baby when used

A

-Suction cup on a cord
-Complication : cephalohaematoma : collection of blood between skull and periosteum

69
Q

what is the main complication to the baby with forcep use in delivery

A

-Facial nerve palsy w/ facial paralysis on one side

70
Q

what 2 nerve injuries are a risk to the mother in instrumental delivery

A

-> Femoral nerve compression against inguinal canal
-> Obturator nerve compression

71
Q

How does femoral nerve compression present

A

weakness of knee extension, loss of patella reflex and numbness of anterior thigh

72
Q

how does obturator nerve compression present

A

weakness of hip adduction and rotation
numbness of medial thigh

73
Q

what are 3 common nerve injuries during birth

A

-Lateral cutaneous nerve of the thigh : numbness of anterolateral thigh
-Lumbosacral plexus : foot drop, numbness of anterolateral thigh, lower leg and foot
-Common peroneal nerve : foot drop and numbness in lateral lower leg

74
Q

what are the 4 classifications of perianal tears

A

-1st : injury to frenulum of labia minora
-2nd : injury to perineal muscles but NOT anal sphincter
-3rd : includes anal sphincter but NOT rectal mucosa
3a : <50% external anal sphincter
3b : >50% external anal sphincter
3c : external and internal sphincters
-4th : includes recal mucosa

75
Q

how are perianal tears managed

A

-Greater than 1st degree = sutures
-Abx
-Laxatives
-Physio to avoid incontinence risk

76
Q

How can the risk of perianal tear be reduced ?

A

Perineal massage

77
Q

what are 2 options for the 3rd stage of delivery

A

-Physiological : placenta delivered by maternal effort
-Active management

78
Q

what is active management of the third stage of labour

A

-IM dose of oxytocin (10 IU) for uterus contraction
-Cord clamp & cut within 5 mins
-Controlled cord traction
-Uterus is pressed upwards
-Massage uterus until contracted and firm

79
Q

what are indications for an elective c section

A

Previous c section
Sx after previous sig perineal tear
Placenta praevia
Vasa praevia
Breech
Multiple preg
Unctrolled HIV infection
Cervical cancer

80
Q

what are the 4 categories of emergency c sectiom

A

1 : immediate threat to life. Decision to delivery is 30 min
2 : No imminent threat but c section is required urgently due to compromise of mother or baby. Decision to delivery is 75 mins
3 : Delivery required but mother and baby are stable
4 : elective caesarean

81
Q

What are the 2 kinds of incision in a c section

A

-Transverse : pfannenstiel (curved), Joel-cohen (straight)
-Vertical

82
Q

What 4 measures can be taken to reduce c section risks

A

-H2/PPIs due to risk of aspiration peumonitis
-Prophylactic Abx
-Oxytocin to reduce PPH risk
-VTE prophylaxis with LMWH

83
Q

Give 2 causes of sepsis during pregnancy

A

Chorioamnionitis : infection in chorioamniotic membranes and amniotic fluid
UTI

84
Q

what is used to measure signs of sepsis in pregnancy

A

MEOWS charts : maternal early obstetric warning system

85
Q

what is the sepsis 6

A

IN : oxygen, Abx and IV fluids
OUT : lactate level, cultures and urine output

86
Q

what is amniotic fluid embolism and 4 RF

A

-Amniotic fluid passes into mothers blood and causes immune reaction
-Increased maternal age, labour induction, C section and multiple pregnancy

87
Q

What is uterine rupture

A

-Incomplete : myometrium ruptures but perimetrium remains in tact
-Complete : serosa and myometrium ruptures and contents of uterus are released into peritoneal cavity

88
Q

How does uterine rupture present

A

-Acute unwell mother and abnormal CTG
-Abdo pain
-Vaginal bleeding
-Ceasing of uterine contractions
-Hypotension
-Tachycardia
-Collpase

89
Q

What is uterine inversion

A

-Incomplete uterine inversion : fundus of uterus descends inside uterus or vagina
-Complete : uterus descends through vagina to the introitus (opening of vagina)

90
Q

what are the 3 management options of uterine inversion

A

-Johnson manoeuvre : pushing fundus back into abdomen
-Hydrostatic methods : filling vagina with fluid to ‘inflate’ uterus back to normal position
-Surgery

91
Q

Give 2 CI to vaginal birth after c section

A

Previous uterine rupture
Classical C section (vertical incision)

92
Q

Sudden history of collapse following artificial rupture of membranes

A
  • Amniotic fluid embolism
  • Will also present with SOB, hypoxisa, hypotension etc
93
Q

what is preterm labour with intact membranes

A
  • Regular painful contractions + cervical dilation without rupture of amniotic sac
94
Q

when would management of preterm labour with intact membranes be offered

A
  • <30 wks : based on clinical assessment
  • > 30 wks : transvaginal USS to assess cervical length. Cervical length of <15mm = management
95
Q

what is done to confirm P-PROM

A
  • If speculum doesn’t confirm fluid on posterior vaginal fault
  • USS to look for oligohydramnios
96
Q

what causes 50% of umbilical cord prolapse

A

Artifical rupture of membranes

97
Q

Before carrying out mechanical, medical or surgical management of PPH, what should be done ?

A

ABC approach

  • 2 large, 14 gauge cannula
  • lie woman flat
  • Bloods including group and save
  • Commence warmed crystalloid infusion
98
Q

when is ergometrine CI in management of PPH

A

-> HTN

99
Q

when is carboprost CI in the management of PPH

A

-> Asthma

100
Q

what is the criteria for uterine hyperstimulation

A
  • Individual uterine contractions lasting more than 2 minutes in duration
  • More than five uterine contractions every 10 minutes
101
Q

what are the indications for continuous CTG monitoring

A

Sepsis
Maternal tachycardia (> 120)
Significant meconium
Pre-eclampsia (particularly blood pressure > 160 / 110)
Fresh antepartum haemorrhage
Delay in labour
Use of oxytocin
Disproportionate maternal pain

102
Q

what are the 5 key features on a CTG ?

A
  1. Contractions : no. per 10 mins
  2. Baseline fetal HR
  3. Variability in HR
  4. Accelerations : spikes in fetal HR
  5. Decelerations : drop in fetal HR
103
Q

what are the 4 categories of fetal CTG ?

A
  • Normal
  • Suspicious: a single non-reassuring feature
  • Pathological: two non-reassuring features or a single abnormal feature
  • Need for urgent intervention: acute bradycardia or prolonged deceleration of more than 3 minutes
104
Q

what mneumonic is used to assess features of a CTG

A

DR C BRaVADO

  • 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
105
Q

Give 4 complications of shoulder dystocia

A
  • Fetal hypoxia (and subsequent cerebral palsy)
  • Brachial plexus injury and Erb’s palsy
  • Perineal tears
  • Postpartum haemorrhage
106
Q

what is the management if uterine rupture

A
  • Emergency C section
107
Q

what is offered for induction of labour based on bishop score ?

A
  • < = 6 = vaginal prostaglandins / misoprostol
    >6 : amniotomy and IV oxytocin
108
Q

Explain the stepwise management of shoulder dystocia

A

CALLING MY SUPERVISOR ENSURES SUCCESSFUL RESULTS (RAH)

  • C : Call for help
  • M : McRoberts manouver
  • S : Suprapubic pressure
  • E : Evaluate for episiotomy
  • S : Start manouvers (1st = rubin’s, 2nd = woodscrew)
  • R : Removal of posterior arm
  • R : Roll mum onto all 4’s
109
Q

Birth plan after previous vertical c section

A

planned caesarean at. 37 weeks gestation

110
Q
A

Finals (92 decks)

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