Labour and Delivery 4 Flashcards
What is preterm labour?
between 24 and 37 weeks gestation
What are the causes of preterm labour?
subclinical infection cervical 'incompetence' multiple pregnancy antepartum haemorrhage diabetes polyhydramnios fetal compromise uterine abnormalities idiopathic iatrogenic
How can preterm labour be prevented?
abs if bacterial vaginosis, UTI, STD or Hx of infection in prev preterm labour
cervical suture if cervical component likely (at 12 weeks if cervix shortens)
progesterone pessaries (at 12 weeks if cervix shortens)
fetal reduction/amnioreduction
What are the features of preterm labour?
abdo pain
antepartum haemorrhage
ruptured membranes
cervical incompetence silent
How is preterm labour managed?
steroids if <34 weeks, tocolysis for max 24 hours
abs if in confirmed labour
C-section for normal indications
inform neonatologists
What are the indications for instrumental delivery?
prolonged second stage
fetal distress in second stage
when maternal pushing is contraindicated
What are the different method of instrumental delivery?
ventouse attaches by suction. allowing traction with rotation
non rotational forceps grip and allow traction
rotational forceps, allow rotation and then traction
How often is the perineum left intact after vaginal delivery?
in 1/3 of nulliparous women and 1/2 of multiparous women
How are perineal tears classified?
1st degree - minor damage to fourchette
2nd degree - perineal muscle
3rd degree - anal sphincter
4th degree - anal mucosa
What are the indication for episiotomy?
1) delay due to rigid perineum, and cutting will expedite delivery + prevent tear
2) tear seems imminent + episiotomy deemed preferable
3) if instrumental delivery inc breech delivery with forceps
How is the perineum repaired?
adequate analgesia (top up epidural or LA)
place pad high in vagina to prevent blood from uterus obscuring view
Check extent of cuts and lacerations
Repair mucosa
Repair muscle layers
Put finger in rectum to ensure rectal mucosa intact
What are the different types of C section?
emergency section
maternal or fetal compromise which isn’t immediately life threatening
no maternal or fatal compromise but needs early delivery
delivery times to suit woman or staff
What are the indications for an emergency c-section?
cord prolapse
fetal distress in first stage
antepartum haemorrhage
What are the indications for a c-section?
cephalopelvic disproportion breech or transverse lie at term multiple pregnancy severe hypertensive disease in pregnancy fetal distress, VLBW failed induction of labour prev c-section pelvic cyst or fibroid maternal infection (herpes/HIV)
What are the benefits of having a c-section?
reduced perineal and abdominal pain during birth and 3 days post partum
reduced injury to vagina
reduced early PPH
reduced obstetric shock
What are the risks of C-section?
increased risk of NICU admission longer hospital stay increased risk of hysterectomy risk of infection increased risk of cardiac arrest affects future pregnancies as risk of uterine rupture
How many women successful have a vaginal birth after c-section (VBAC)?
2/3
How is maternal collapse managed in pregnancy?
resuscitation - clear airway, oxygen, CPR if necessary, IV access
What is placenta praevia managed if patient is in shock/heavy bleeding and is >37 weeks?
lower segment C-section, give blood
What is placenta praevia managed if blood loss has stopped or they are <37 weeks?
give steroids if <34 weeks, anti-D rhesus -ve, keep in hospital +c-section at 39 weeks
How is placental abruption managed if the CTG is abnormal?
emergency c section
give blood
How is placental abruptions managed when the fetes is dead?
anticipate anticoagulopathy + transfuse blood +/- fresh frozen plasma, induce labour with intense monitoring
How is placental abruption managed when the CTG is normal >37 weeks?
induce unless small painless bleed
How is placental abruption managed when the CTG is normal <37 weeks?
steroids if <34 weeks anti D if rhesus -ve
serial US
What are the causes of massive PPH?
perineal/vaginal trauma –> suture
Uterus poorly contracted –> ergometrine and oxytocin infusion
bleeding persistent –> examine under anaesthetic
Uterine atony –> intra-myometrial prostaglandin if oxytocin fails
Uterine bleeding persists - laparotomy, consider brace suture/tamponade with ballon/embolization/hysterectomy/vacular ligation
How else should a massive PPH be managed?
as per protocol
replace blood with fresh frozen plasma if >4 units given at same time as treating cause
check clotting, FBC, watch fluids and oxygen
How should cardiac problems be managed when there is maternal collapse?
e.g. MI
control pain with IV diamorphine + LVF with iv furosemide
correct arythmies as determined by ECG
100% oxygen
if complete heart block, maintain ventricular rate with IV atropine until able to keep pace
tilt mu to left
CPR
Intubate early
C section if adequate circulation is not established
How is a pulmonary embolism managed in labour and delivery?
treat with LMWH
does adjusted to factor Xa level
more in needed than for non-preganant women
stop treatment shortly before labour
What is an amniotic embolism?
Liquor enters maternal circulation
presents with anaphylaxis, with sudden dyspnoea, hypoxia and hypotension, accopanyied by seizures and cardiac arrest
if survive –> DIC, pulmonary oedema
How is amniotic embolism managed?
blood for clotting, FBC, electrolytes and cross match taken
blood and fresh frozen plasma required
transfer to ITU
