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3a Women's health > Labour and delivery > Flashcards

Labour and delivery Flashcards

1
Q

When do labour and delivery normally occur during pregnancy?

A

Between 37 and 42 weeks gestation

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2
Q

When is labour diagnosed

A

when painful uterine contractions accompany dilatation and effacement (thinning/shortening) of the cervix

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3
Q

What is the 1st stage of labour

A

From the onset of true labour to when the cervix is fully dilated

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4
Q

What is the 2nd Stage of labour?

A

From full dilation of the cervix to the delivery of the baby

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5
Q

What is 3rd stage of labour?

A

From the delivery of the baby to delivery of the placenta and membranes

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6
Q

Give 4 signs of labour

A
  • regular and painful uterine contractions
  • a show (shedding of mucous plug)
  • spontaneous rupture of the membranes (not always)
  • shortening and dilation of the cervix
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7
Q

What are the phases of Stage 1 of labour and their characteristics?

A
  • Latent phase: 0-3/4cm cervical dilation. Irregular contractions, effacement of cervix
  • active (established first stage) phase: 3/4-10 cm cervical dilation, regular, painful contractions
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8
Q

What are Braxton-Hicks contractions, and how do they differ from true contractions?

A

Braxton-Hicks contractions are occasional irregular contractions of the uterus that are not true contractions. They do not indicate the onset of labour and do not progress or become regular.

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9
Q

Describe the two stages within stage 2 labour

A
  • passive - full dilatation until the head reaches pelvic floor
  • active - when the mother is pushing
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10
Q

What are the three factors that influence progress in labour?

A
  • Power - uterine contractions
  • Passenger - size, presentation, lie and attitude
  • Passage - shape and size of the pelvis and soft tissues
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11
Q

What is the average cervical dilation rate during the active first stage of labour for nulliparous and multiparous women?

A
  • nulliparous women - 1 cm/hr
  • multiparous women - around 2 cm/hr
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12
Q

What constitutes a delay in the first stage of labour?

A

either:
* less than 2 cm of cervical dilation in 4 hours
* slowing of progress in a multiparous woman.

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13
Q

What tool is used to monitor the progress of women during the first stage of labour?

A

partogram

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14
Q

What key information is recorded on a partogram during labour?

A
  • Cervical dilation (measured by a 4-hourly vaginal examination)
  • Descent of the fetal head (in relation to the ischial spines)
  • Maternal pulse (1hr), bp, temp and urine output (4hr)
  • Fetal HR (every 15 mins)
  • Frequency of contractions (half-hourly)
  • Status of the membranes, and whether it is stained by blood or meconium
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15
Q

How is failure to progress in labour defined for nulliparous and multiparous women

A
  • nulliparous - labour >20hr
  • multiparous - labour >14hr
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16
Q

How long does the second stage of labour typically last?

A

approximately 1hr multiparous women and 2 hrs in nulliparous women

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17
Q

What interventions may be required when there are problems in the second stage of labour?

A
  • Changing positions
  • Encouragement
  • Analgesia
  • Oxytocin
  • Episiotomy
  • Instrumental delivery
  • Caesarean section
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18
Q

How is the third stage of labour managed actively

A
  • uterotonic drugs - IM oxytocin
  • cord clamping and cutting
  • controlled cord traction
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19
Q

Why is active management routinely offered to all women during labour?

A

To reduce the risk of postpartum haemorrhage

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20
Q

How is a delay in the third stage of labour defined?

A
  • > 30 minutes with active management
  • > 60 minutes with physiological management
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21
Q

How is failure to progress in labour managed

A
  • Amniotomy - artificial rupture of membranes for women with intact membranes
  • Oxytocin infusion - stimulate uterine contractions
  • Instrumental delivery
  • Caesarean section
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22
Q

What is the target contraction frequency when administering an oxytocin infusion during labour?

A

aim is for 4–5 contractions per 10 minutes

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23
Q

What are the typical positions of the fetal head during entry into the pelvis and delivery?

A

The fetal head normally enters the pelvis in the occipito-transverse position and delivers in the occipito-anterior position.

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24
Q

What should be considered if the fetal head remains in the occipito-transverse position after one hour of pushing in the second stage of labour?

A

Rotation with traction - ventouse

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25
Q

Give 4 RFs for perineal tears

A
  • nulliparity
  • large babies
  • forceps delivery
  • shoulder dystocia
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26
Q

What are the four degrees of perineal tear?

A
  • First-degree: Superficial damage with no muscle involvement
  • Second-degree: Involves the perineal muscles, but not the anal sphincter
  • Third-degree: Involves the ext and int anal sphincter, but not the rectal mucosa
  • Fourth-degree: injury to perineum involving the anal sphincter complex and rectal mucosa
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27
Q

How can third-degree perineal tears be subcategorized?

A
  • 3A: <50% of the external anal sphincter torn
  • 3B: >50% of the external anal sphincter torn
  • 3C: Both external and internal anal sphincter torn
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28
Q

How are first and second degree perineal tears repaired

A
  • first - usually do not require any sutures
  • second - suturing on the ward by a suitably experienced midwife or clinician
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29
Q

How are third and fourth degree perineal tears repaired

A

require repair in theatre by a suitably trained clinician

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30
Q

What additional measures are taken to reduce the risk of complications after perineal tears?

A
  • Broad-spectrum antibiotics to reduce the risk of infection
  • Laxatives to reduce the risk of constipation and wound dehiscence
  • Physiotherapy to reduce the risk and severity of incontinence
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31
Q

How is damage to the anal sphincter during an episiotomy avoided?

A

performing a mediolateral episiotomy.

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32
Q

Define prolonged rupture of membranes

A

When the amniotic sac ruptures more than 18 hours before delivery

33
Q

Define prelabour rupture of membranes

A

The amniotic sac has ruptured before the onset of labour

34
Q

What is preterm prelabour rupture of membranes

A

the amniotic sac has ruptured before the onset of labour and before 37 weeks gestation (preterm).

35
Q

How is preterm prelabour ROM diagnosed

A
  • 1st: sterile speculum exam to look for pooling of amniotic fluid in the posterior vaginal vault
  • if no pooling of fluid, test fluid for Placental alpha-microglobin-1 (PAMG-1) or Insulin-like growth factor-binding protein-1 (IGFBP-1)
36
Q

How is preterm prelabour ROM managed

A
  • admission
  • oral erythromycin QDS for 10 days or until in labour
  • antenatal corticosteroids to reduce risk of resp distress syndrome
  • induction of labour from 37w
37
Q

why are prophylactic antibiotics given to women with preterm prelabour ROM

A

Prevent development of chorioamnionitis

38
Q

Give 2 features of preterm labour with intact membranes

A
  • regular painful contractions
  • cervical dilatation
39
Q

What is the recommended clinical assessment process for preterm labour based on gestational age?

A

Clinical assessment includes a speculum exam to assess for cervical dilatation
* <30w (29+6) - speculum alone is sufficient for management
* >30w - transvaginal ultrasound to measure cervical length
* >30w - if TVUS unavailable, consider fetal fibronectin. +ve = >50ng/ml

40
Q

What are the implications of cervical length measurements on ultrasound for preterm labour management?

A

A cervical length of less than 15 mm suggests that management of preterm labour can be offered; more than 15 mm indicates that preterm labour is unlikely

41
Q

How is preterm labour managed

A
  • fetal monitoring (CTG and intermittent auscultation)
  • tocolysis with nifedipine
  • maternal corticosteroids before 35w to reduce neonatal morbidity/ mortality - betamethasone
  • IV Mg sulphate before 34w for neuroprotection of the baby
  • delayed cord clamping - wait 60 seconds
42
Q

What is the prophylactic treatment of preterm birth and when is it offered

A
  • Vaginal progesterone and Cervical cerclage
  • offered to women with a cervical length <25mm on TVUS between 16 and 24 weeks gestation
43
Q

What is cervical cerclage

A
  • putting a stitch in the cervix to add support and keep it closed
  • stitch is removed when the woman goes into labour or reaches term.
44
Q

How does progesterone prevent preterm labour

A

Progesterone has a role in maintaining pregnancy and preventing labour by decreasing activity of the myometrium and preventing the cervix remodelling in preparation for delivery

45
Q

What are 5 indications for induction of labour?

A
  • Prolonged pregnancy (1-2w after the est due date)
  • Preterm prelabour rupture of membranes
  • Diabetic mother > 38 weeks
  • Pre-eclampsia
  • intrauterine growth restriction
  • Obstetric cholestasis
  • Intrauterine fetal death
46
Q

What score is used to determine whether to induce labour

A

Bishop score

47
Q

What are the 5 components of the bishop score

A
  • fetal station (scored 0 - 3)
  • Cervical position (scored 0 – 2)
  • Cervical dilatation (scored 0 – 3)
  • Cervical effacement (scored 0 – 3)
  • Cervical consistency (scored 0 – 2)
48
Q

How are bishop scores interpretated

A
  • A score of <5 indicates that labour is unlikely to start without induction
  • A score of ≥ 8 indicates that the cervix is ripe = high chance of spontaneous labour or a positive response to induction interventions.
49
Q

What are the possible methods for inducing labour?

A
  • Membrane Sweep - examining finger passing through the cervix to rotate against the wall of the uterus, to separate the chorionic membrane from the decidua. adjunct to full induction
  • Vaginal Prostaglandin E2 (PGE2): dinoprostone.
  • Oral Prostaglandin E1: Also known as misoprostol.
  • Amniotomy with maternal oxytocin infusion
  • Cervical Ripening Balloon: Passed through the endocervical canal and gently inflated to dilate the cervix.
50
Q

When is a membrane sweep typically offered to women during their pregnancy?

A

offered at 40-42w gestation for nulliparous women and at 41 weeks for multiparous women.

51
Q

In what situations is a cervical ripening balloon (CRB) used as an alternative method for inducing labour?

A
  • women at higher risk of hyperstimulation
  • previous caesarean section
  • multiparous woman (para ≥ 3).
52
Q

What is the preferred method of induction of labor if the Bishop score is ≤ 6 ?

A

Vaginal prostaglandin or oral misoprostol

53
Q

What is the preferred method of induction of labor if the Bishop score is > 6 ?

A

amniotomy and an intravenous oxytocin infusion

54
Q

Give 3 contraindications for induction of labour

A
  • placenta praevia
  • breech, abnormal lie
  • abnormal cardiotocograph
55
Q

What is the main complication of induction of labour

A

uterine hyperstimulation

56
Q

What is uterine hyperstimulation

A

prolonged and frequent uterine contraction causing fetal distress

57
Q

What complications can arise from uterine hyperstimulation?

A
  • Fetal compromise, including hypoxia and acidosis (due to intermittent interruption of blood flow)
  • Emergency caesarean section
  • Uterine rupture
58
Q

How is uterine hyperstimulation managed

A
  • remove vaginal prostaglandins and stop oxytocin infusion
  • consider tocolysis
59
Q

What is instrumental delivery?

A

A vaginal delivery assisted by a ventouse suction cup or forceps.

60
Q

Give 3 indications for an instrumental delivery

A
  • Failure to progress in 2nd stage of labour
  • Fetal distress
  • Maternal exhaustion/ distress
  • Control of the head in various fetal positions
61
Q

What is the relationship between epidurals and instrumental delivery?

A

There is an increased risk of requiring an instrumental delivery when an epidural is in place for analgesia.

62
Q

What are some risks to the mother associated with an instrumental delivery?

A
  • Postpartum haemorrhage
  • Episiotomy
  • Perineal tears (3rd degree)
  • Incontinence of the bladder or bowel
  • Nerve injury (obturator or femoral nerve)
63
Q

Give 3 risks to the baby associated with instrumental delivery

A
  • facial nerve palsy (forceps)
  • cephalohematoma (ventouse)
  • lacerations/ bruising
64
Q

What is ventouse delivery

A
  • suction cup connected to a handle
  • cup goes on baby’s head which allows careful traction to be applied
65
Q

Describe forceps delivery

A
  • non-rotational or rotational forceps depending on
  • the blades go either side of the fetal head allowing traction +/- rotation
66
Q

What are the 2 main types of caesarean section

A
  • lower segment
  • classic - longitudinal incision in upper segment of uterus
67
Q

Give 5 indications for an elective C-section

A
  • placenta/ vasa praevia
  • malpresentations
  • pre-eclampsia
  • multiple pregnancies
  • uncontrolled HIV
  • cervical cancer
68
Q

Describe the 4 categories of caesarean section

A

Category 1:
* an immediate threat to the life of the mother or baby.
* Decision - delivery time is 30 minutes.
Category 2:
* maternal or fetal compromise which is not immediately life-threatening
* Decision - delivery time is 75 minutes.
Category 3: Delivery is required, but mother and baby are stable.
Category 4: elective caesarean

69
Q

Give 4 indications for a category 1 C-section

A
  • uterine rupture
  • major placental abruption
  • cord prolapse
  • fetal hypoxia or persistent fetal bradycardia
70
Q

What are the layers of the abdomen that need to be dissected during a caesarean section?

A
  • Skin
  • Subcutaneous tissue
  • Fascia / rectus sheath (the aponeurosis of the transversus abdominis and external and internal oblique muscles)
  • Rectus abdominis muscles
  • Peritoneum
  • Vesicouterine peritoneum (and bladder)
  • Uterus (perimetrium, myometrium and endometrium)
  • Amniotic sac
71
Q

What are the risks to future pregnancies after a caesarean section

A
  • increased risk of uterine rupture
  • increased risk of stillbirth
  • increased risk of placenta praevia and placenta accreta
72
Q

What are the maternal complications of having a caesarean section

A
  • ICU admission/ readmission to hospital
  • bladder/ ureter injury
  • VTE
  • haemorrhage
  • wound infections
  • endometritis
73
Q

What complication may occur to the fetus during a caesarean section?

A

increased risk of lacerations to the fetus

74
Q

What is the criteria for a planned vaginal birth after Caesarean (VBAC)?

A

Planned VBAC is appropriate for pregnant women at ≥ 37 weeks gestation with a single previous Caesarean delivery.
* exceptions after counselling by a senior obstetrician

75
Q

Give 2 contraindications to having a vaginal birth after caesarean

A
  • previous uterine rupture
  • classical caesarean scar
76
Q

What measures can be taken to reduce risks during a caesarean section?

A
  • Administer H2 receptor antagonists (e.g., ranitidine) or PPI before the procedure - for acid reflux and aspiration
  • prophylactic Abx to reduce infection risk.
  • Administer oxytocin to reduce the risk of PPH
  • Provide VTE prophylaxis with LMWH (e.g. enoxaparin)
77
Q

What anaesthetic is given to women undergoing a caesarean section

A
  • spinal anaesthetic - local anaesthetic (e.g lidocaine) into CSF at lower back
78
Q
A

3a Women's health (12 decks)

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