labour and delivery Flashcards
define labour
progressive effacement ( and dilatation of the cervix in the presence of regular uterine contractions
can have open cervix without contractions but thats not labour
define delivery
expulsion of fetus and placenta
define show in labour and delivery
cervical mucus plug ppl will present with bleeding basically like snot with blood in it
define SRM in labour
spontaneous rupture of membranes, can preced labour
bag membranes around baby breaks can happen prematurely
define ARM in labour
artificial rupture of membranes
colour of fluid can present concerns
miscarriage
before 24 weeks or less than 500g
at what cm does full effacement happen
3-4 cm of dilaltation
what is latent first stage
what is establishes/active 1st stage of labour is
latent
- painful contractions
- upto 4cm cervical change
Active
regular contractions 3/4x every 10 minutes
3-4cm dilated
progressive cervical dilatation from 4 cm
cervix fully dialted 10cm
fully dilated til when baby comes out
BABY comes out of palcenta
factors affecting labour
passage
- pelvis and symbodian passage anf muscular passage
powers
- contraction
passenger
- baby
the passage in labour
pelvic inlet - baby faces towards hips
mid cavity -rotates
pelvic outlet - look down at floor
Soft tissues
Lower uterine segment
- issues arise if they had FGM
Cervix
- if they had cervical cancer Tx then it will weaken the cervical wall, stop dilating
Vagina
Vulva
Pelvic floor
Perineum
- if they look like they gonna tear do episiotomy clinicians judgement
powers in labour
There is fundal dominance of contractions
Contraction are rhythmic and occur every 3-4 minutes in early labour, and every 2-3 minutes in advanced labour
3/4x every 10 minutes - start at fundus and work down
passenger in labour
Lie relationship of fetal long axis of the baby to that of the mother (long, oblique, transverse)
Presentation the part of the fetus lowermost in the uterus HEAD FIRST (cephalic: vertex, brow, face; breech; shoulder)
Denominator part of fetus used as reference point to describe position in maternal pelvis (occiput, mentum - chin, sacrum - breech, acromion)
Position relation of the fetal denominator to the maternal pelvis (occipitoanterior, occipitotransverse, occipitoposterior)
define each term occipitoanterior, occipitotransverse, occipitoposterior)
occipitoanterior - head at the top chin on chest
occipitotransverse - ladies right
occipitoposterior - baby looking at ceiling - prolonged labour in first and second stage
how is passenger position assessed
vaginal examination
look for 2 fontanelles
posterior fontanelles is where occiput is look at position triangle shape
anterior is diamond shape
why do we worry about position of head
degree of flexion/extension of head makes a big difference to the circumference
grading of moulding of fetal cranium
bones not moved - 0
bones not touching 1+
bones overriding but can be pushed apart 2+
bones overriding but cannot be pushed apart 3+
caput - swelling of head
mechanism of labour
- engagement - baby fixed in pelvis 1/5ths? 2/5th is in pelvis unlikely to move
imp - flexion - chin on chest
- descent
- internal rotation - occipitoanterior, pelvic floor helps with this
- extension
- external rotation
why is engagement importnat in assessing assisted vaginal delivery
important in assisted vaginal delivery as you should not feel any of the head
what is monitored in the mother during labour
Observations BP, P, T
Hydration
Analgesia
Antacids - high risk rinatidine every 6 hours
Bladder care - voiding regularly, if epidural give indwelling catheter
Position - lie on back uterus presses in BVs in turn causing hypo then bradycardia
Progress contractions
cervical dilatation
descent of presenting part
3rd stage active management
- give injection or oral infusion of oxytocin reduces bleeding and second stage and controlled cord traction
Perineum - check for trauma
why is monitoring bladder important
can obstruct
can give bladder dysfunction post delivery
fetal wellbeing how is it checked
Fetal Heart Monitoring
high risk continuous monitoring on CTGs
Colour of Liquor clear pinky blood stained meconium- fetal distress
what is station in terms of descent
station how far down has the baby head descended into the pelvis
locating where the lowest part of your baby is in relation to your pelvis
how far the widest part of baby head (biparietal) diameter in conjunction with the narrowest part of the pelvis ischial spine
-1 cm above
+2 baby head is about to come out
what is normal progress in labour
1cm every hour
1/2 cm every hour
common problems in labour
failure to progress (delay in 1st or 2nd stage)
malpresentation/malposition
suspected fetal compromise (fetal distress)
vaginal birth after c section
operative delivery
shoulder dystocia
what is failure to progress
Can occur in first or second stage
Causes: Powers Passenger Passage
POWER
Inadequate contractions
Maternal Exhaustion
PASSENGER
Fetal malposition/malpresentation
Cephalopelvic disproportion (relative, absolute - baby cant come thru pelvis)
PASSAGE
Obstructed Labour - kaput and moulding, haematuria, vulval swelling, cervix becomes oedematous
qs to ask when the labour is failing to progress
Parous or nulliparous? First or Second Stage? Frequency Duration Strength of Contractions? Malpresentation/Malposition? Evidence of fetal compromise? Evidence of Obstructed Labour?
If inefficient uterine contractions are the cause, augment labour with Oxytocin.
Remember that a parous uterus can rupture
what is secondary arrest
no change in cervical dilation for at least 2 hours.
- what sort of analgesia
- hey may get an overwhelming feeling if pushing
leave them an hour WO pushing
types of breech
frank
complete
footling
breech complications
trapped aftercoming head
cord prolapse
intracranial haemorrhages - head is squeezed kaput compression and decompression rapidly
internal injuries - shouldnt pull baby as there is moral reflex
delivery options for breech presentation
External Cephalic Version
Elective Caesarean Section
Vaginal breech delivery
suspected fetal compromise on CTG signs
- Absence of acceleration (non-reactive) - HR goes up 15 beats for more than 15s
- Presence of decelerations
- Reduced baseline variability (flat) - 5-10 BPM
- Baseline tachycardia or bradycardia
Passage of Meconium - have babies opened up bowels
causes of suspected fetal compromise
uterine hyperstimulation ( ? iatrogenic)
hypotension - women lying on her back causing fetal distress
another cause is epidural
poor fetal tolerance of labour (e.g. IUGR)
cord compression - normal CTG short sharp deeleration w contractions u get fetal hypotension
infection - fetal pyrexia
maternal disease -
management of suspected fetal compromise
bradycardia - less than 100 BPM
3 mins call for help
6 mins theatre
6 mins baby out
rectify reversible causes, e.g. maternal hypotension
left lateral position - do not lie flat
stop oxytocics
confirm compromise by blood sampling where possible
deliver by speediest route if unable to correct or if significant acidosis
risks of vaginal birth after caesarean
Emergency Caesarean section in labour
Uterine scar dehiscence/rupture 0.5%
precautions of VBAC
iv access and G&S
continuous electronic fetal monitoring
avoid prolonged labour
augmentation/induction should be senior decision only
indications for operative delivery
failure to progress in 2nd stage, maternal exhaustion, maternal problems
fetal distress in 2nd stage
maternal reasons - maternal exhaustion, cardiac issues LESS COMMON THAN FIRST TWO
pre requisites for operative delivery
- trained operator
- full dilatation
absent membranes
cephalic presentation
clearly defined position
presenting part engaged
no evidence of Cephalic Pelvo Disproportion
adequate analgesia - epidural, pudendal nerve blocks
empty bladder
complications of operative delivery
failure
fetal trauma - cephalohaematomas - blood between skin and bone
lacerations from ventouse
maternal trauma - common with forceps
postpartum haemorrhage
urinary retention - common esp with a full bladder
indications for caesarean section
failure to progress
fetal distress maternal reasons - previous C section malpresentation/malposition failed instrumental delivery
pre-requisites for caesarean section
trained operator
adequate facilities adequate analgesia consultation with senior member of staff
complications of C-section
haemorrhage
infection bladder/bowel injury thromboembolic disease requirement for blood transfusion
TTN - Transient tachypnea of the newborn - thue dont scream go to special care unit
fetal trauma
define shoulder dystocia
Inability to deliver shoulders after delivery of head
Anterior shoulder does not enter pelvic inlet
risks of shoulder dystocia
- Fetal Death
- Asphyxia with resulting hypoxic damage
- Birth trauma (Erb’s palsy, fractured bones)
- physio
- surgery
- Maternal trauma (soft tissue trauma, psychological)
- PPH
- perineal tears
who is at risk of shoulder dystocia
- Macrosomic fetus
- Fetus of diabetic mother indication for C section
- Rotational instrumental delivery
- prolonged labour
- high BMI
management of shoulder dystocia
McRoberts position suprapubic pressure other obstetric manoeuvres zavanelli cut pubic symphysis - baby would not survive
what is the mcroberts position
The McRoberts’ manoeuvre is flexion and abduction of the maternal hips, positioning the maternal thighs on her abdomen.
why do we worry about shoulder dystocia
when baby gasp cant expand lungs chest is still in canal so not getting oxygen anywhere so gets hypoxic
what is latent first stage of labour
a period of time, not necessarily continuous, when:
there are painful contractions and
there is some cervical change, including cervical effacement and dilatation up to 4 cm.
what adivse can be given to the woman during laternt first stage of labour to reduce pain
breathing exercises
immersion in water
massage may reduce pain
what is the bishop score
predict the success of induction.
It assesses the favourability of the cervix and is based on; dilatation, effacement, station, position and consistency of the cervix.
Bishop score is inversely correlated with the labour duration; a patient with score > 8 is likely to achieve a successful vaginal birth without induction. A score of <6 indicates that cervical ripening may be required.
Interpretation
a score of < 5 indicates that labour is unlikely to start without induction
a score of > 9 indicates that labour will most likely commence spontaneously
RFs for breech
- uterine malformations, fibroids
- placenta praevia
- polyhydramnios or oligohydramnios
- fetal abnormality (e.g. CNS malformation, chromosomal disorders)
- prematurity (due to increased incidence earlier in gestation)
what is major placental praevia
when the placenta covers the internal os of the cervix
RFs for placental praevia
- previous history of placental praevia
- previos C section
- Advancing maternal age.
- Increasing parity.
- Smoking.
- Cocaine use during pregnancy.
- Previous spontaneous or induced abortion.
- Deficient endometrium due to past history of, for example, endometritis, manual removal of placenta, curettage.
- Assisted conception.
presentation of placental praevia
incidental finding
painless bleeding after the 28th week - spotting earlier
all babies at breech at term need to have what as a follow up
USS of hip 6 weeks following delivery
initial Mx of breech
external cephalic version
Risk of ECV to mum and foetus
MATERNAL RISKS
- pain
- rhesus sensation
- EMCS
FOETAL RISKS
- reversion
- Foetal Heart Rate changes
- unsuccessful
what is rhesus sensitisation
Sensitisation happens when a woman with RhD negative blood is exposed to RhD positive blood, usually during a previous pregnancy with an RhD positive baby. The woman’s body responds to the RhD positive blood by producing antibodies (infection-fighting molecules) that recognise the foreign blood cells and destroy them.
If sensitisation occurs, the next time the woman is exposed to RhD positive blood, her body produces antibodies immediately. If she’s pregnant with an RhD positive baby, the antibodies can cross the placenta, causing rhesus disease in the unborn baby. The antibodies can continue attacking the baby’s red blood cells for a few months after birth.
what are the delivery options if the baby is breech
c section
vaginal breech birth
issue with C section that affects the future
scarred uterus
what can scarred uterus cause
placental disease
uterine rupture
main risk of vaginal birth after C section
uterine rupture
what drug is administerd for active third stage labour
oxytocin
- Uterotonic drugs
- Deferred clamping and cutting of cord, over 1 minute after delivery but less then 5 minutes
- Controlled cord traction after signs of placental separation
if HTN do not give ERGOMETRINE
what is cord prolapse
umbilical cord descending ahead of the presenting part of the fetus.
this can lead to compression of the cord or cord spasm, which can cause fetal hypoxia and eventually irreversible damage or death.
RFs of cord prolapse
prematurity multiparity polyhydramnios twin pregnancy cephalopelvic disproportion abnormal presentations e.g. Breech, transverse lie placenta praevia long umbilical cord high fetal station
what conditions would warrant a CTG monitoring
- Abnormal fetal growth
- Maternal HR >120 on 2 occasions 30 mins apart
- Temp >38 (or >37.5 on 2 consecutive occasions 1 h apart); or suspected chorioamnionitis or sepsis
- Presence of significant meconium
- Fresh PV bleeding that develops in labour
- HTN +/- significant proteinuria
- Confirmed delay in 1st or 2nd stage
- Contractions >60s or >5/10
- Syntocinon
- Epidural analgesia
features of OP delviery
delivery is possible
- augmentation shoulf be used if progress is slow
- kiellan’s forceps are ass w most successful outcomes
- women have an earlier urge to push in OP than OA
give features that are assessed during a vaginal examination in labour
consistency, effacemtn, dilation of the cervix
- whether the membranes are intact
- colour of the amniotic fluid
- nature and presentation of the presenting part and its relationship tothe ischial spines
- size of pelvic outlet
when is placenta expelled
within 30 mins
if it fails -> oxytocin then surgery
