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Obstetrics and Gynaecology > Labour and Delivery > Flashcards

Labour and Delivery Flashcards

1
Q

What does ‘foetal lie’ denote?

A

Orientation of the long axis of the foetus with respect to the long axis of the uterus (longitudinal, transverse, oblique)

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2
Q

What does ‘foetal presentation’ denote?

A

Foetal part presenting at pelvic outlet

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3
Q

What are the four possible foetal presentations? Which of these is considered normal?

A
  1. Breech (complete, frank, footling)
  2. Cephalic (vertex, face, asynclitic)
  3. Transverse (shoulder)
  4. Compound (foetal extremity comes along with presenting part)

Vertex normal, everything else = malpresentation

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4
Q

What does ‘foetal position’ denote?

A

Position of presenting part of the foetus relative to the maternal pelvis.

Normally, foetal head enters maternal pelvis and engages in occiput transverse presentation, subsequently rotates to occiput anterior position (or occiput posterior in small percentage)

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5
Q

What does foetal ‘attitude’ mean?

A

Flexion/extension of foetal head relative to shoulders

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6
Q

What does foetal ‘station’ mean? (3)

A

Position of presenting part relative to ischial spines - determined by vaginal exam

At ischial spines = station 0 = engaged

Can be meaure by cm above (-5 –> -1) or below (+1 –> +5)
or station above (-3 –> -1) or below (+1 –> +3)

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7
Q

What is the definition of true labour?

A

Regular, painful contractions of increasing intensity associated with progressive dilatation and effacement of cervix and descent of presenting part, or progression of station

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8
Q

Define preterm, term and post-term

A

Preterm: less than 37 weeks GA
Term: 37-42 weeks GA
Post-term: more than 42 weeks GA

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9
Q

What is the definition of false labour?

A

aka Braxton Hicks contractions - irregular contractions with unchanged intensity and long intervals, occur throughout pregnancy and not associated with any dilatation, effacement or descent.

Often relieved by rest or sedation

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10
Q

What is the first stage of labour? (3)

A

Cervical effacement and dilatation, ending at full dilatation 10cm

Composed of two phases - latent and active

6-18h in nulliparous women, and 2-10h in multiparous

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11
Q

What occurs in the latent phase of the first stage of labour? (2)

A
  1. Uterine contractions typically infrequent and irregular

2. Slow cervical dilatation and effacement

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12
Q

What occurs in the active phase of the first stage of labour? (2)

A
  1. Rapid cervical dilatation to full dilatation (nulliparous ~1.2cm/h, multiparous ~1.5cm/h)
  2. Painful, regular contractions q2-3min, lasting 45-60 s
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13
Q

What occurs in the second stage of labour?(4)

A
  1. Period from full dilatation to delivery of baby
  2. Mother feels a desire to bear down and push with each contraction
  3. Progress measured by descent
  4. Nulliparous 30min - 3h, multiparous 5-30 min
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14
Q

What occurs in the third stage of labour? (3)

A
  1. Separation and expulsion of placenta
  2. Start prophylactic oxytocin in anticipation of placental delivery - can reduce risk of PPH
  3. Nulliparous 5-30 min, multiparous 5-30 min
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15
Q

What are the four signs of placental separation?

A
  1. Gush of blood
  2. Lengthening of cord
  3. Uterus becomes globular
  4. Fundus rises
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16
Q

What are the cardinal movements of the foetus during a normal delivery? (9)

A
  1. Descent
  2. Flexion (so that smallest diameter -suboccipitobregmatic - presents)
  3. ‘Hit the gutter’ (levator ani)
  4. Internal rotation (to OA)
  5. Extension (once under the pubic arch)
  6. Restitution (correct alignment with body)
  7. External rotation
  8. Delivery of anterior shoulder
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17
Q

What is engagement? (during delivery) How can this be checked? (2)

A

when the widest diameter of the head has passed the pelvic inlet, usually the narrowest part of the pelvis

Examined:

  1. abdomen - less than 1/5 of head can be felt above mother’s pubic bone
  2. vaginally - when vertex of baby’s head has reached ischial spines
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18
Q

Describe the shape of the three parts of the pelvic passage.

A
  1. Pelvic inlet - typically oval, longer diameter - transverse
  2. Mid-pelvis - typically circular
  3. Outlet - typically oval, longer diameter in front to back
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19
Q

How often should a vaginal exam during labour be done?

A

4 hourly

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20
Q

What is the normal range for a baseline foetal heart rate?

A

110-160bpm

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21
Q

Describe the rationale behind looking for variability in a CTG.

A

Physiologic variability is a normal characteristic of FHR - effect of vagus nerve on foetal heart

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22
Q

Define normal variability.

A

5-25 bpm in a representative minute

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23
Q

Define reduced variability.

A

Between 3-5 bpm in a representative minute

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24
Q

Define absent variability.

A

Less than 3bpm in a representative minute

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25
Q

Describe what an accleration looks like on a CTG.

A

Increase of greater than or equal to 15bpm lasting at least 15 seconds in response to foetal movement or uterine contractions

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26
Q

What are the three types of decelerations?

A
  1. Early
  2. Variable - uncomplicated vs complicated
  3. Late
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27
Q

Describe the nature of early decelerations (3)

A
  1. Uniform shape (“V”) with onset early in contraction, returns to baseline by end of contraction, mirrors contraction
  2. Gradual deceleration
  3. Benign, due to vagal response to head compression
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28
Q

Describe the nature of uncomplicated variable decelerations. (4)

A
  1. Most common type seen during labour
  2. Variable in shape, onset and duration
  3. Due to cord compression or in second stage, forceful pushing with contractions
  4. Often with abrupt drop in FHR; usually no effect on baseline FHR or variability
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29
Q

Describe the nature of complicated variable decelerations. (4)

A
  1. To less than 70bpm for more than 60s
  2. Loss of variability or decrease in bseline after deceleration
  3. Slow return to baseline
  4. Baseline tachycardia or bradycardia
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30
Q

Describe the nature of late decelerations (3)

A
    1. Uniform shape with onset late in contraction, nadir after peak of contraction an slow return to baseline
  2. May cause decreased variability and change in baseline FHR
  3. Due to foetal hypoxia and acidaemia, maternal hypotension or uterine hypertonus - uteroplacental insufficiency
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31
Q

Name three maternal factors that can cause foetal tachycardia

A
  1. Fever
  2. Hyperthyroidism
  3. Anaemia
32
Q

Name two foetal factors that can cause foetal tachycardia

A
  1. Arrhythmia

2. Anaemia

33
Q

What kind of drugs can cause foetal tachycardia?

A

Sympathomimetics

34
Q

Name two uterplacental factors that can cause foetal tachycardia

A
  1. Early hypoxia

2. Chorioamnionitis

35
Q

Name three maternal factors that can cause foetal bradycardia

A
  1. Hypothermia
  2. Hypotension
  3. Hypoglycaemia
36
Q

Name three foetal factors that can cause foetal bradycardia

A
  1. Rapid descent
  2. Dysrhythmia
  3. Heart block
37
Q

Name two drugs that can cause foetal bradycardia

A
  1. Beta-blockers

2. Anaesthetics

38
Q

Name three uteroplacental factors that can cause foetal bradycardia

A
  1. Late hypoxia
  2. Acute cord prolapse
  3. Hypercontractility
39
Q

What is a more accurate way of investigating acid-base status of foetus?

A

Foetal scalp blood sampling

40
Q

List two contraindications against foetal scalp blood sampling.

A
  1. Known or suspected foetal blood dyscrasia (haemophilia, von Willebrand disease)
  2. Active maternal infection (HIV, genital herpes)
41
Q

What is the link between hypoxia and acidosis in the foetus?

A

Hypoxia –> reduces aerobic metabolism –> foetus gets energy by increasing anaerobic metabolism –> increased production of lactic and uric acid –> elimination of acids across placenta slow –> build-up to give metabolic acidosis in foetus

42
Q

In a breech presentation, what anatomical landmark is used to determine position?

A

Sacrum

43
Q

In a face presentation, what anatomical landmark is used to determine position?

A

Mentum

44
Q

In a brow presentation, what is the most common attitude of a foetus? What does this mean?

A

Head partially extended - largest diameter (occipitofrontal diameter - 12 cm) coming down - therefore requires C/S

45
Q

In a face presentation, what is the most common attitude of a foetus?

A

Head fully extended

46
Q

What is the difference between induction and augmentation of labour?

A

Induction: artificial initiation of labour

Augmentation: promotes contractions when spontaneous contractions are inadequate

47
Q

What are the 5 characteristics that is looked at in the Bishop scoring system?

A
  1. Position - posterior, mild, anterior
  2. Consistency - firm, medium, soft
  3. Effacement (%) - 0-30, 40-50, 60-70, more than 80
  4. Dilatation (cm) - 0, 1-2, 3-4, more than 5
    5 Station of foetal head - -3, -2, -1-0, +1-+3
48
Q

Which Bishop score is indicative of a ‘favourable cervix’?

A

more than 6

49
Q

When is induction indicated? (4)

A

When the risk of continuing the pregnancy outweighs the risk of inducing labour and delivery

  1. Post-dates pregnancy
  2. Maternal factors - significant APH, gestation HTN, other medical problems
  3. Maternal-foetal factors - PROM, chorioamnionitis
  4. Foetal factors - foetal compromise
50
Q

When is induction contraindicated? (3)

A

If vaginal delivery not possible!

  1. Maternal - unstable maternal condition, gross CPD, active maternal genital herpes, invasive cervical carcinoma
  2. Maternal -foetal - placenta previa or vasa previa
  3. Foetal - malpresentation
51
Q

List 5 methods in which labour can be inducted

A
  1. Stretch and sweep
  2. Amniotomy
  3. Intravaginal Prostaglandin (dinoprostone - PGE2) gel - cervical ripening
  4. Mechanical dilation - balloon catheter and laminaria tent
  5. Oxytocin
52
Q

What is a stretch and sweep?

A

An office procedure used to induce labour; in which a digital examination is performed to stretch the cervix and sweep membranes from lower segment - mechanical effects and release of prostaglandins induces labour

53
Q

What is amniotomy?

A

A labour ward procedure which involves digital examination and instrumental rupture of membranes to stimulate PG synthesis and secretion and which requires a dilated cervix. Not usually done on its own

54
Q

List three risks of amniotomy in the induction of labour

A

Cord prolapse
Infection
Foetal injury

55
Q

How does synthocinon work in the induction of labour?

A

Synthocinon = synthetic oxytocin that is given in a controlled IV infusion that stimulates myometrial receptors

56
Q

What is the half-life of oxytocin?

A

3-5 min

57
Q

List three risks in using oxytocin in the induction of labour

A

Hyperstimulation
Uterine muscle fatigue/atony - may result in PPH
Vasopressin-like action causing anti-diuresis –> hypotension, hypernatraemia, tachycardia

58
Q

What is used n the augmentation of labour?

A

syntocinon

59
Q

What is the preferred method of induction for a woman who has a favourable cervix?

A

Amniotomy + syntocinon

60
Q

List 5 contraindications to trial of scar

A
  1. Previous classical caesarean (inverted-T)
  2. Medical or obstetric complications that preclude vaginal birth e.g. placenta previa
  3. Inability to perform emergency Caesarean section - lack of access to adequate facilities or personnel
  4. 2 or more previous Caesareans
  5. Previous uterine rupture
61
Q

List 5 complications to trial of scar

A
  1. Uterine rupture
  2. Hysterectomy
  3. Thromboembolic disease
  4. Transfusion
  5. Endometritis
62
Q

List 5 clinical manifestations of a uterine rupture

A
  1. Foetal bradycardia, decelerations
  2. Constant abdo pain, signs of haemorrhage
  3. Maternal tachycardia, hypotension
  4. Uterine tenderness
  5. Cessation of uterine contractions
63
Q

What is the safest option in managing a uterine rupture in VBAC?

A

Immediate transfer to theatre to expedite delivery - hysterectomy is usually the safest option but may consider repair to retain fertility

64
Q

Define shoulder dystocia

A

A delivery where additional maneouvres are required to deliver shoulders after gentle traction has failed - occurs when breadth of shoulders is greater than biparietal diameter of head

65
Q

List 6 risk factors for shoulder dystocia

A

Maternal: obesity, diabetes, multiparity, previous shoulder dystocia baby
Foetal: prolonged gestation, macrosomia

66
Q

List 4 complications of shoulder dystocia

A
  1. Chest compression by vagina or cord compression by pelvis can lead to hypoxia
  2. Brachial plexus injury - usually Erb’s palsy, Klumpke’s palsy can also happen - 90% resolve within 6 months
  3. Foetal fractures - clavicle, humerus
  4. Maternal perineal injury, may result in PPH
67
Q

List 4 radical maneouvres that can be performed in shoulder dystocia

A
  1. Cleidotomy - deliberate fracture of neonatal clavicle
  2. Zavanelli maneouvre - replacement of foetus into uterine cavity and emergent C/S
  3. Symphysiotomy
  4. Abdominal incision and shoulder disimpaction via hysterotomy - subsequent vaginal delivery
    * only when they’re in REAL trouble*
68
Q

What should be included in the documentation of a shoulder dystocia delivery? (6)

A
  1. Time and birth of head
  2. Maneouvres performed, the timing and sequence
  3. Direction baby is facing, which shoulder is impacted
  4. Time of delivery of body
  5. Staff in attendance
  6. Condition of baby at birth
69
Q

Define frank breech

A

Where the hips are flexed and legs extended

70
Q

Define complete breech

A

Where the hips and knees are flexed and the feet are not below the level of the foetal buttocks

71
Q

Define footling breech

A

Where one or both feet are presenting as the lowest part of the foetus

72
Q

In a breech presentation, only in which instances should vaginal birth be undertaken in labour? (5)

A
  1. Birth is imminent
  2. Obstetrician skilled in vaginal breech birth is available
  3. Senior medical, anaesthetics, paediatric and midwifery staff have been called to attend
  4. There is no absolute contraindication to vaginal birth (e.g. placenta praevia)
  5. Frank or complete breech
73
Q

Which mode of delivery is better for a breech presentation?

A

Planned caesarean - reduced risk of perinatal mortality and early morbidity compared with planned vaginal birth

74
Q

How is a woman with GDM/T1/T2DM undergoing elective caesarean section managed? (4)

A
  1. Usual insulin the night before caesarean section
  2. Book first on the theatre list in the morning
  3. Morning of C-section - withhold usual insulin
  4. Avoid IV dextrose unless hypoglycaemic
75
Q

How is a woman with GDM managed postpartum? (2)

A
  1. Blood glucose monitoring BD for 48 hours - if blood gluose levels greater than 7 - continue to monitor until discharge
  2. Insulin ceased post-birth
76
Q

Define preterm labour

A

Labour occurring between 20 and 37 weeks gestation

Obstetrics and Gynaecology (10 decks)

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