Labour And Delivery Flashcards
What are signs of labour?
Show, rupture of membranes, regular+painful contractions, dilating cervix
What is meant by rupture of membranes?
The amniotic sac has ruptured
What is meant by SROM?
Spontaneous rupture of membranes- the amniotic sac has ruptured spontaneously
What is meant by PROM?
Premature rupture of membranes- amniotic sac has ruptured before the onset of labour
OR
Prolonged rupture of membranes- the amniotic sac ruptures more than 18 hours before delivery
What is meant by P-PROM?
Preterm premature rupture of membranes- the amniotic sac has ruptured before the onset of labour and before 37 weeks gestation
Who is offered progesterone for prophylaxis of preterm birth?
Women with a cervical length of less than 25mm on vaginal ultrasound between 16-24 weeks gestation
What is cervical cerclage?
Putting a stitch in the cervix to keep it closed and add support for women at risk of preterm labour, this is removed when women reach term or go into labour
What are the causes of postpartum haemorrhage? remembered by the 4 T’s
Tone- Atony of uterus
Trauma- injury to birth canal or tear
Tissue- retained placenta or foetal tissue
Thrombin- coagulopathies
What interventions can improve outcomes in preterm labour?
Fetal monitoring (CTG or intermittent auscultation), tocolysis with nifedipine, maternal corticosteroids (reduce RDS risk in neonates), IV magnesium sulphate (protects baby’s brain), delayed cord clamping
What is tocolysis?
Stopping uterine contractions using medications
What is nifedipine and what is atosiban?
Nifedipine- calcium channel blocker
Atosiban- oxytocin receptor antagonist
What would be an example corticosteroid routine given to women with suspected preterm labour of babies <36 weeks?
Two doses of IM betamethasone 24 hours apart
What are key signs of magnesium toxicity?
Reduced resp rate, reduced blood pressure, absent reflexes
What is a bishop score?
A score used to determine whether to induce labour
What is maximum bishops score?
13
What does a score above 8 and a score below 8 on the bishops score mean?
A score of 8 or more predicts a successful induction of labour
Less than 8 suggests cervical ripening may be required to prepare the cervix
What are some options for induction of labour?
Membrane sweep, vaginal prostaglandin E2, cervical ripening balloon, artificial rupture of membranes with an oxytocin infusion
What can be used to induce labour where intrauterine fetal death has occurred?
Oral mifepristone plus misoprostol
What does failure to progress mean?
When labour is not developing at a satisfactory rate which increases risk to foetus and mother
Is failure to progress more common in women who’ve had multiple previous pregnancies or those in labour for the first time?
Those who have not had previous births
Progress in labour is influenced by what three Ps?
Power: uterine contractions
passenger: size, presentation and position
passage: shape and size of pelvis and soft tissues
When is there considered to be a delay in the first stage of labour?
Less than 2cm dilatation in 4 hours, slowing of progression in a multifarious woman
What is recorded on a partogram?
Cervical dilatation, descent of fetal head, maternal obs (pulse, HR, BP, temp, urine output), fetal HR, frequency of contractions, status of membranes, drugs given
How are uterine contractions measured?
Number of contractions per 10 minutes
What is amniotomy?
Articulacy rupturing the membranes
When plotting the cervical dilatation on a partogram what needs to be done if the points cross the alert and action lines?
Alert: indicates amniotomy
Action: care is escalated to obstetric led care ad senior decision makers
When is there considered to be a delay in the second stage of labour?
When active second stage (pushing) lasts over 2 hours in nulliparous women or more than 1 hour in multifarious women
What can be used if there are weak uterine contractions delaying delivery of the baby?
Oxytocin infusion
When talking about ‘passenger’, what are the four descriptive qualities?
Size, attitude, lie and presentation
What defines a delay in the third stage of labour (delivery of baby to delivery of placenta)?
More than 30 minutes with active management
More than 60 minutes with physiological management
What are things that can improve symptoms of labour without medications?
Information about what to expect, having good support relaxed environment, changing position to stay comfortable, controlled breathing, TENS machine in early stages of labour
What simple analgesia is used in labour, which are not used?
Paracetamol is used, so is codeine
NSAIDs are avoided
What is involved in an epidural?
Insertion of a small tube into epidural space in the lower spine, this outside the duramater, and local anaesthetic is infused into this space
What anaesthetics are used in an epidural commonly?
Bupivacaine or levobupivacaine, usually mixed with fentanyl
What are some adverse effects of an epidural?
Increased probability of instrumental delivery, headache, hypotension, motor weakness in legs, nerve damage, prolonged second stage
What needs to be in place when a woman in labour is using patient controlled anaesthesia?
Anaesthetic input, naloxone in case of resp depression, atropine in case of bradycardia
What ar the sides effects of IM pethidine or diamorphine used as pain relief in labour?
Can make mother nauseous or drowsy, if given too close to birth neonate may have respiratory depression
What is the most significant risk factor for cord prolapse?
Foetus in abnormal lie after 37 weeks gestation
When should cord prolapse be suspected?
When there are signs of fetal distress on CTG
How is cord prolapse diagnosed?
Speculum examination
What is the management of cord prolapse?
Emergency C section
Do not push cord back in, handling can result in vasospasm
Get women to lie in left lateral position or knee-chest position, tocolytic meds can be given while waiting for C section
What is shoulder dystocia?
When the anterior shoulder of the baby gets stuck behind the pubic symphysis after head is delivered
What is failure of restitution seen in shoulder dystocia?
Head of baby remains downwards and does not turn sideways as expected after delivery of the head
What is the turtle neck sign seen in shoulder dystocia?
Where the head is delivered but retracts back into the vagina
What is McRoberts manoeuvre?
Get the woman to flex their hips (bringing knees to abdomen) which causes a posterior pelvic tilt moving the pubic symphysis
What are the key complications of shoulder dystocia?
Fetal hypoxia, brachial plexus injury + Erb’s palsy, perineal tears, postpartum haemorrhage
What does having an instrumental delivery increase the risk of for mothers?
Postpartum haemorrhage, episiotomy, perineal tears, nerve injury (obturator or femoral)
What is the key risk to baby with ventouse and forceps delivery?
Cephalohaematoma with ventouse
Facial nerve palsy with forceps
If a baby has hardened lumps of fat on their face following forceps delivery, what is this likely to be? What will happen to these lumps?
Fat necrosis, this will resolve itself over time
What symptoms can a woman have if her obturator nerve is damaged during an instrumental delivery or by fetal head during normal delivery?
Weakness of hip adduction and rotation, numbness of medial thigh
What symptoms can a woman have if her femoral nerve is damaged during an instrumental delivery?
Weakness of knee extension, loss of patellar reflex and numbness over anterior thigh and medial lower leg
What does para refer to in an obstetric patient?
The number of times a woman had given birth after 24 weeks gestation, regardless of wether foetus was alive or not
What does nulliparous, primiparous and multiparous mean?
Nulliparous= not given birth to a baby after 24 weeks before
Primiparous= has given birth to a baby after 24 weeks once before
Multiparous= has given birth to a baby after 24 weeks more than once before
How often would we expect contractions in early labour?
Every 3-4 minutes
How often would we expect contractions in advanced labour?
Every 2-3 minutes
What shapes do the different font Allen’s tend to be?
Posterior tends to be more V shaped whereas anterior is more like a diamond
What are the the 6 parts of the mechanism of labour?
Engagement, flexion, descent, internal rotation, extension, external rotation
What are risks of an abnormal lie at delivery?
Significant risk of cord prolapse or uterine rupture
What are some complications of breech delivery?
Trapped head, cord prolapse, intracranial haemorrhage, internal injuries
If during CTG monitoring of a baby during labour there appears to be suspected fetal compromised, what could be causing this?
Uterine hyper stimulation, hypotension (from epidural or positioning during labour), poor fetal tolerance of labour (e.g IUGR), cord compression, infection
If a woman in labour has hypotension, how can we get them to move to relieve this?
Left lateral position (get them to turn on their left side)
What are indications for instrumental delivery?
Fetal distress or/and failure to progress in second stage, maternal exhaustion
How often do roberts manouevre and suprapubic pressure help overcome shoulder dystocia?
90-95% of cases
What are two key causes of sepsis in pregnancy?
Chorioamnionitis, UTIs
What are the two parts of the second stage of labour?
Passive (non-voluntary pushing) and active where mum is pushing voluntarily
What are the five features of a bishops score?
Dilatation, effacement, station, consistence and position
What rate or cervical dilatation would we expect in the active phase of the first stage of labour?
2cm every 4 hours
What is a non-pharmacological option for pain relief in labour? When can this be used?
TENS machine, only used in early labour
What inhalation method can be given for pain relief in labour?
ENOX (50:50 oxygen and nitrogen)
What IV and IM opioids are commonly given for pain relief in labour?
Pethidine or diamorphine
What are the risks of opioids for pain relief in labour?
Woman can become drowsy, nauseous or sick
Baby can have short term respiratory depression and drowsiness when born
What is an epidural?
An injection of local anaesthetic in to the space outside the dura mater which acts to numb the spinal nerves and block pain signalling in them
What are the risks with an epidural?
Hypotension, temporary loss of bladder control, nausea, headache, nerve damage, procedure failure
What is the gold standard investigation for preterm labour?
Transvaginal ultrasound for cervical length
At what cervical length would we determine preterm labour and offer treatment?
Less than 15mm
What swab can be used to see if a woman is at risk of preterm labour?
Actim-partus, this measures phosphorylated IGFBP-1 and is an endocervical swab
How is uterine tamponade applied in an major obstetric haemorrhage?
Through bakri balloon
What is postpartum thyroiditis?
A condition where there are changes to thyroid function seen within 12 months of giving birth in women without previous thyroid disease
What is the prognosis of postpartum thyroiditis?
Generally resolves over time (by 1 year) returning to normal levels, a small portion of women will need long term thryoid management
What is the management for postpartum thyroiditis?
Hyperthyroidism- symptomatic treatment with propanolol
Hypothyroidism- levothyroxine
