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Obstetrics and Gynaecology > Labour and puerperium > Flashcards

Labour and puerperium Flashcards

1
Q

what is pre-labour rupture of the membranes (PROM)?

A

this refers to membrane rupture before onset of labour (at least 1 hour before) occurring at 37 or greater weeks of gestation (at term).

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2
Q

what is preterm prelabour rupture of the membranes (PPROM)?

A

membrane rupture before labour onset before 37 weeks of gestation

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3
Q

causes of premature rupturing of the fetal membranes (comprising chorion and amnion)?

A

early activation of normal physiological processes-higher than normal levels of MMPs and apoptotic markers in the amniotic fluid
infection-cytokines assoc with inflammtory response known to contribute to weakening of fetal membranes
genetic predisposition

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4
Q

RFs associated with prelabour rupture of the membranes?

A 
smoking (especially less than 28wks gestation)
PROM in previous pregnancy/pre-term delivery
multiple gestation
vaginal bleeding during pregnancy
lower genital tract infection
invasive procedures e.g. amniocentesis
polyhydramnios
cervical insufficiency
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5
Q

how can premature rupture of the membranes be diagnosed clinically?

A

-usually from maternal history and
speculum examination-look for fluid pooling in the vagina or leakage from the cervix, may see pooling in posterior vaginal fornix. should be laid on examination couch for at least 30min for accurate examination.
-lack of normal vaginal discharge (‘washed clean’) may also be indicative of rupture
-US-lack of fluid in uterine cavity
-nitrazine test-detects pH change-amniotic fluid is more alkaline than normal vaginal fluids.
-ferning test-dried amniotic fluid examined under microscope-has fern like crystalline appearance

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6
Q

why should digital vaginal examination NOT be performed in women suspected of having premature rupture of the membranes?

A

as this increases risk of introducing ascending infection, and subsequently if PPROM, increases the risk of premature labour.

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7
Q

what 3 causes of neonatal death are associated with pre-term prelabour rupture of membranes (PPROM)?

A

prematurity
sepsis
pulmonary hypoplasia

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8
Q

differentials for premature membrane rupture?

A 
urinary incontinence
normal vaginal secretions of pregnancy
loss of mucus plug
increased sweat/moisture around perineum
increased cervical discharge e.g. due to infection
vesicovaginal fistula
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9
Q

why should a high vaginal swab be taken in all cases of premature membrane rupture?

A

look for group B streptococcus-would mean mother requires antibiotics during labour, plus may be the cause of PROM

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10
Q

what infection is commonly implicated in PPROM?

A

bacterial vaginosis

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11
Q

what is the ferning test?

A

ferning test can be used in the diagnosis of PROM/PPROM

cervical secretion placed on glass slide and allowed to dry, forms fern-patterned crystals if premature membrane rupture

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12
Q

management of mothers at 37 or greater weeks of gestation with premature membrane rupture?

A

can offer them choice between expectant management and induction of labour-majority will go into normal labour within 24hr, after this may decide to induce labour but mother can decide to wait for up to 96hr
monitor for signs of clincial chorioamnionitis
clindamycin/penicillin during labour if group B strep isolated

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13
Q

management of mothers between 34 and 36 weeks gestation with premature rupture of membranes?

A
  • due to poorer outcomes in babies as result of maternal infection, induction of labour is recommended (deliver baby!)
  • corticosteroids if between 34 and 34+6 weeks
  • prophylactic erythromycin 250mg QDS for 10 days
  • clindamycin/penicillin during labour if group B strep isolated
  • monitor for signs of clinical chorioamnionitis and advise pt to avoid sex as increases risk of ascending infection
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14
Q

management of mothers between 24 and 34 weeks gestation with premature rupture of membranes?

A

aim expectant management until 34 weeks due to risks of prematurity
corticosteroids
prophylactic erythromycin 250mg QDS for 10 days
montior for signs of clinical chorioamnionitis and advise pt to avoid sex

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15
Q

how does time between premature membrane rupture and spontaneous labour differ depending on wks gestation?

A

younger gestational age associated with increased latency between rupture and spontaneous labour, predisposing to a greater risk of maternal and fetal complications

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16
Q

complications of premature rupture of membranes?

A

chorioamnionitis-inflammation of fetal membranes due to infection
oligohydramnios-part significant if less than 24wks gestation as greatly increases risk of lung hypoplasia
neonatal death-problems assoc. with prematurity, lung hypoplasia and sepsis
placental abruption
umbilical cord prolapse

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17
Q

what is a membrane sweep?

A

this is offered before induction of labour
it involves an internal examination with a sweep around the cervix to try and separate the membranes from the cervix (separate chorion from the decidua) to release PGs and start labour
this can be done in the community

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18
Q

what score is used to assess favourability of the cervix, hence likelihood of spontaneous labour or response to interventions made to induce labour?

A

bishop score-score of 8 or more indicates a favourable/ripe cervix

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19
Q

how is the bishop score calculated?

A

on vaginal examination-assessment made of station, effacement, dilation, position and consistency of the cervix.

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20
Q

how can labour be induced?

A

before formal induction, can do a membrane sweep
formal induction: if cervix unfavourable then give vaginal PGE2-can give a 1 dose pessary (propess) that can be left for 24hours (only 12 hrs if previous C section), once experiencing regular strong contractions vaginal examination performed again, if not dilated then pessary re-inserted, if 3cm or more then pessary can be removed
can also use vaginal PGE2 tablet or gel-this is given then repeated after 6hrs if labour not established
if cervix is favourable, can break waters using an amnihook (ARM)-will then need a sanitary pad until birth.
if waters are broken by midwife but still not having frequent regular contractions then oxytocin infusion required-will need continuous CTG monitoring until birth.

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21
Q

reasons for induction of labour?

A 
reduce risk of stillbirth!
specific indications:
pre-eclampsia
diabetes
postmaturity (40+12)
obstetric cholestasis
40yrs or older, nulliparous
previous stillbirth or poor pregnancy outcome
IVF
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22
Q

features assessed for in occiput-posterior fetal malposition?

A 
intense back pain
poor cervix dilatation and descent
depression in lower maternal abdomen
fetal HR heard laterally
anterior fontanelle in anterior
perineal laceration or episiotomy extension
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23
Q

how is the 1st stage of labour defined?

A 
regular contractions (3-4 in 10 mins), each lasting around 60s
up to full dilatation

latent and established phases

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24
Q

what is the latent 1st stage of labour?

A

painful contractions and some cervical change, including cervical effacement and dilatation up to 4cm

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25
Q

what is the established 1st stage of labour?

A

regular painful contractions and cervical dilatation from 4cm

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26
Q

duration of 1st stage of labour in women in their 1st pregnancy?

A

average=8 hours

may be up to 18

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27
Q

duration of 1st stage of labour in women in subsequent pregnancies?

A

on average 5 hours

unlikely to last over 12 hours

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28
Q

considerations for subsequent management if suspected delay in established first stage of labour?**

A

amniotomy if intact membranes
vaginal examination 2hrs later-diagnose delay if progress less than 1cm

if confirmed:
consider oxytocin
offer support and effective pain relief

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29
Q

what is passive management in the 2nd stage of labour?

A

mother pushes when she feels need without active encouragement

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30
Q

what is syntometrine?

A

a combination of ergometrine and oxytocin

more effective in reducing blood loss than oxytocin alone in delivery of placenta, but has more side effects!

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31
Q

most common cut for an episiotomy?

A

right posterolateral (mediolateral episiotomy)

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32
Q

problems associated with maternal obesity during labour and delivery?

A

slow progression of labour
shoulder dystocia
emergency C section
primary PPH (occurs within 1st 24hr after delivery)

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33
Q

what maneuver can be employed to assist in childbirth in the case of shoulder dystocia?

A

McRoberts maneuver:

hyperflexion of mother’s leg to her abdomen.

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34
Q

RFs for premature labour?

A 
young or old age
low SE status
polyhydramnios
multiple gestation
uterine abnormality, cervical insufficiency e.g. post LLETZ or cone biopsy
infection
previous premature baby
antepartum haemorrhage
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35
Q

what is a LSCS?

A

lower segment C section= most common type of C section.

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36
Q

causes of primary PPH?

A
  • uterine atony
  • retained placenta
  • genital tract trauma e.g. cervix, vagina
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37
Q

cause of secondary PPH (from 24 hrs to 12 weeks post delivery)?

A
  • infection

- retained products

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38
Q

define primary PPH?

A

500ml or more of vaginal blood loss within 24hrs of delivery.

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39
Q

complications of induction of labour?*

A

more likely to need interventions-drip, an epidural
need for instrumental delivery
need for a C section
increased risk of PPH
if previous C section, risk of uterine scar rupture is increased from 1/200 to 1/100

contractions not necessarily more painful then in spontaneous labour, but do come on more suddenly.

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40
Q

best time for labour to be induced?

A

if no concern for mum or baby, then induction advised at 40+12 weeks of pregnancy.
good to wait to give better chance of starting labour naturally in the meantime.

41
Q

role of a membrane sweep?

A

to separate membranes of the amniotic sac from the cervix to try and bring on labour

42
Q

management of a pt post term who refuses labour induction?

A

ensure given pt all the relevant information and respect her wishes
advise her to have frequent monitoring, both of her health and her baby’s condition.

43
Q

risks of a planned C section?

A

risks to mother:

  • frequent risks-infection-wound, UTI-catheter post op, but antibiotics will be given in theatre to help prevent this (6 in 100 women have infection).
  • increased blood loss (5 in 1000), may be need for blood transfusion.
  • wound and abdo discomfort in 1st few mnths after surgery (9 in 1000 women)
  • increased risk of rpt C section when vaginal delivery attempted in future pregnancies (1 in 4)
  • readmission to hospital (5 in 100)

also, longer hosp. stay, and may not be able to bond with baby straight away.

-risks of anaesthetic

  • uncommon but serious risks-blood clots in leg or lungs (4-16 in every 10,000), can be life threatening
  • bladder, ureter or bowel damage (1 in 1000-10,000), risk increased with future C sections
  • emergency hysterectomy (7-8 in 1000)
  • need for another op at a later date, including scrape of the womb
  • ITU admission
  • death
  • baby-frequent risks-small cut to baby during the op (1-2/100)
  • also more likely baby will have breathing problems when born as still fluid in the lungs, so may need short stay on the neonatal ICU.
  • risks to mother in future-increased risk of tear in womb during future pregnancies/deliveries
  • increased risk of low-lying and abnormally adherent placenta (4-8/1000)
  • increased risk of baby’s death in womb (1-4/1000)
  • further gynae surgery may be more difficult and have higher complication rates.
44
Q

side effects and complications of regional anaesthesia used for a C section?

A
  • legs will be numb for a few hrs
  • BP can drop, but this can be treated
  • severe headache
  • may be difficult to get spinal/epidural line in, or may not work
  • you’ll be aware of pulling/tugging sensations which can feel uncomfortable during the op, occasionally may feel pain
  • need for GA if RA doens’t work
  • back tenderness for a few days
  • serious complications e.g. nerve damage, but these are rare.
45
Q

benefits of a vaginal birth after C section (VBAC)?

A
  • less pain
  • less chance of wound infection
  • less likely to need blood transfusion
  • shorter recovery time
  • shorter hospital stay
  • no driving restrictions
  • reduced chance of DVT
  • increased chance of an uncomplicated birth in future pregnancies

benefits for baby:
fewer breathing difficulties
easier bonding between mother and baby
easier to establish breastfeeding

75% of women who have had 1 previous C section will have a normal vaginal delivery.

46
Q

when is VBAC not recommended?

A

if had an ‘up and down’ incision on womb
if had 2 or more previous CS
if breech presentation
if low lying placenta

47
Q

management options for a breech delivery?

A

vaginal breech delivery
elective C section-after 39wks to minimise risk of breathing difficulties for newborn
ECV-external cephalic version-firm pressure applied to abdomen to turn baby, neither analgesia or anaesthesia are routinely given, US used for guidance.

48
Q

complications of ECV?

A
  • cord entanglement and fetal distress-all ECVs carried out on delivery suite, baby’s HR monitored for at least 30mins before and after ECV has been carried out
  • failure, need for C section
  • placental abruption
  • labour with a cephalic presentation following successful ECV is assoc. with a higher rate of obstetric intervention than when ECV has not been required.
  • uterine rupture
  • fetomaternal haemorrhage
49
Q

when is an ECV carried out?

A

ideally at 36-37wks (from 36 in nulliparous, 37 in multiparous), as only very small chance of spontanous version after this time, and not assoc. with increased rate of preterm labour.)
as after this time, amniotic fluid gradually decreases, reducing chance of success, and also it becomes increasingly common for the breech to descend into the pelvis or engage (1/5 of head felt on abdo palpation**)

50
Q

success of ECV?

A
  • about 50-60% of breech babies are successfully turned (lower % in nulliparous compared to multiparous).
  • ECV will reduce mother’s chance of needing a C section
  • success more likely with multiparous non-white women who have a relaxed uterus, non-engaged breech with head easily palpable.
51
Q

why might a woman experience palpitations during ECV?

A

if the drug terbutaline (beta 2 receptor agonist) (tocolytic/anti-contraction medication) is used to relax the muscles of the womb, as this increases the mother’s HR.
the success rate of ECV is increased with use of tocolysis-slow IV or SC bolus may be given routinely of if an initial ECV without it has failed.

52
Q

chance of baby turning back to breech after successful ECV?

A

less than 5%

ECV can be repeated if baby turns back to breech

53
Q

what must mum be told to report following an ECV?

A

any of the following symptoms:
abdo pain
PV bleeding
sudden reduction in fetal movements

54
Q

RFs for breech presentation?

A
  • previous breech presentation
  • polyhydramnios or oligohydramnios
  • multiple gestation
  • premature delivery
  • placenta praevia
  • uterine malformation, fibroids
  • fetal abnormality e.g. CNS disorder, chromosomal abnormality.
55
Q

management of breech if 1st ECV fails?

A

-can d/c reattempting ECV. success markedly increased if tocolysis used when it was used for the 1st attempt. Use of epidural analgesia may also increase success rates, but note that pain in mum might indicate a complication so safety regarding giving analgesia is uncertain.

56
Q

management of rhesus -ve women who undergo ECV?

A

should receive anti-D Ig, but no need for kleihauer test

57
Q

absolute contraindications to ECV?

A
  • ruptured membranes
  • where C section is required
  • APH within the last 7 days
  • abnormal CTG
  • major uterine anomaly
  • multiple pregnancy (except delivery of 2nd twin)
58
Q

relative contraindications to ECV?

A
  • oligohydramnios
  • SGA fetus with abnormal doppler parameters
  • proteinuric pre-eclampsia
  • major fetal anomalies
  • unstable lie
  • scarred uterus
59
Q

RFs for PPH?

A
  • previous PPH
  • APH
  • multiple gestation
  • polyhydramnios
  • fetal macrosomia
  • prolonged labour (failure to progress in 2nd stage or prolonged 3rd stage)
  • induction of labour
  • multiparous
  • bleeding disorder
  • pre-eclampsia (thrombin disordered)
  • placenta accreta
  • episiotomy or perineal laceration

can be thought of in relation to the 4 Ts of PPH=tone, trauma, tissue and thrombin.

60
Q

recommended prophylaxis for PPH in women with no RFs delivering vaginally in 3rd stage of labour?

A

10iu of oxytocin IM
(but most women given syntometrine?, except if C section-given 5iu of oxytocin, + may also be given tranexamic acid)

syntometrine (oxytocin+ergometrine), should be given in absence of HTN in those at increased risk of haemorrhage.

61
Q

how can the risk of PPH be reduced?

A
  • active management of 3rd stage of labour-early cord clamping, controlled cord traction and syntometrine-better than oxytocin along at reducing PPH but more severe ADRs-HTN, N+V, headache.
  • PGs e.g. carboprost (PG F2) have not been shown to be preferable to oxytocin and/or ergometrine.
62
Q

definition of minor PPH?

A

blood loss 500ml-1000ml

major=more than 1L, moderate(up to 2L) and severe

63
Q

management recommendations for major PPH?

A
  • A to E assessment of pt
  • regular obs (contin. pulse, SpO2, BP)
  • insert 2 large bore cannulae (14G), take urgent bloods-FBC, G+S, X match (at least 4 units), clotting profile including fibrinogen, U+Es and LFTs for baseline.
  • lay pt flat, keep warm, transfuse blood as soon as available, can give O rhesus -ve, until blood available infuse up to 3.5L warmed clear fluids, intially 2L isotoni crystalloid, can then give crystalloid or colloid (NOT hydroxyethylstarch).
  • consider use of blood products as well as red cells, including FFP, cryoprecipitate for low fibrinogen, PLTs when less than 75
  • Foley catheter to monitor UO
  • senior help, escalate promptly, document fluid balance, blood, blood products+procedures.
  • consider arterial line monitoring, and need for ITU r/f.
64
Q

mechanical+pharmacological management for primary PPH?

A

usually due to uterine atony (90%)

  • massage uterus (palpate uterine fundus)
  • sytometrine
  • oxytocin infusion
  • carboprost (PG F2alpha analogue) IM, can be rpted up to 8 dose, caution if pt has asthma-PGF2alpha causes bronchoconstriction.
  • misoprostol (PG E1 analogue) SL
65
Q

surgical management of primary PPH?

A
  • intrauterine balloon tamponade (Bakri balloon)
  • B-lynch suture
  • uterine artery ligation
  • selective arterial occlusion
  • hysterectomy-resort to sooner rather than later, espec. in cases of uterine rupture or placenta accreta-placenta attached too deeply to uterine wall).
66
Q

secondary PPH specific management?

A
  • assessment of vaginal microbiology-high vaginal and endocervical swabs, appropriate antimicrobials when endometritis suspected
  • pelvic USS may help exclude retained products of conception.
  • surgical evacuation of retained placental tissue.
67
Q

why is syntometrine better than oxytocin alone for active 3rd stage of labour management and prevention of PPH?

A

has a longer duration of utertonic action, as oxytocin has a short t1/2 so the drug gets to work straight away, but with ergometrine aswell, effect can last for around3 hrs.

68
Q

contraindications to syntometrine?

A 
HTN
severe cardiac disorders
peripheral vascular disease, raynauds
sepsis
severe hepatic or renal impairment
69
Q

what management may be required in primary PPH after initial steps have been taking and it’s thought that uterine atony is not the cause?

A

examination of the pt in theatre to look at reproductive tract for trauma and to see if RPOC, with privacy and analgesia

70
Q

what might a pt complain of that is a sign of RPCO-cause of secondary PPH?

A

heavy/offensive lochyia-the vaginal discharge following birth up until 6wks after birth

71
Q

clinical features of chorioamnionitis?

A
  • maternal pyrexia
  • offensive vaginal discharge
  • uterine tenderness
  • fetal tachycardia

in PPROM, monitoring of maternal temp, pulse, and fetal HR should be between every 4 and 8 hrs.

72
Q

what does a biophysical profile assess?

A 
fetal HR-CTG
fetal movements
fetal tone
fetal breathing
fetal liquor
73
Q

role of tocolysis in PPROM?

A

these are drugs used to stop labour from happening, so can be used in PPROM to give time for steroids to work and to get the patient to a hospital with a neonatal unit
e.g. beta agonists, Ca2+ channel blocker, oxytocin receptor blocker.
BUT no clear evidence that it improves outcome after PPROM.

74
Q

what is the ‘lie’ of a fetus?

A

this is the relationship between the longitudinal axis of the fetus and that of its mother, which may be longitudinal, transverse or oblique.

75
Q

what is an unstable lie?

A

frequent changing of fetal lie and presentation in late pregnancy (after 37weeks).

76
Q

risks associated with an unstable lie?

A
  • cord presentation or prolapse if membranes rupture or at onset of labour
  • fetal hypoxia if left unattended in labour
  • shoulder presentation and transverse lie in labour
  • uterine rupture
77
Q

management prior to labour in an unstable lie?

A
  • abdo palpation-assess for polyhydramnios
  • pelvic examination as indicated to assess pelvic size and shape
  • US-exclude a mechanical cause-placenta praevia-will need C section, uterine abnormalities e.g. bicornuate uterus-uterus has 2 horns separated by a septum, fibroids.
  • hosp admission from 37wks onwards is recommended
  • immediate clinical assistance if membranes rupture or signs of labour
  • may attempt ECV in early labour with access to facilities for immediate delivery if required
78
Q

intrapartum management of an unstable lie?

A

-is SROM occurs, need PV examination to exclude presence of a cord or malpresentation
-assess if polyhydramnios, and assess cervical dilatation
-if longitudinal lie-normal labour management
-if lie not longitudinal, consider external version
a stabilising ARM should be done with caution. bladder distension can cause a changing fetal lie so encourage woman to void before performing any procedures.
-if lie not longitudinal and cannot be corrected, do a C section.

79
Q

contributing factors to an unstable lie?

A
  • placenta praevia
  • multiparity
  • polyhydramnios
  • undiagnosed twins
  • poorly formed lower segment
  • uterine abnormality e.g. bicornuate uterus
  • wrong dates
  • distended maternal bladder
  • fetal anomaly
80
Q

contraindicated drugs in breastfeeding?

A
  • tetracycline antibiotics, chloramphenicol, ciprofloxacin, sulfonamides
  • lithium
  • BZDs
  • aspirin
  • sulfonylureas
  • carbimazole
  • cytotoxics
  • amiodarone
  • methotrexate
81
Q

what is the normal position for the fetal head to be in when it becomes engaged?

A

OA (occipito-anterior), usually left OA

it will then undergo a short rotation to be directly OA in the mid-cavity of the pelvis.

82
Q

commonest malposition of baby?

A

OP (occipito-posterior)

83
Q

problems with OP malposition of baby?

A
  • longer labour
  • more pain (back pain!) for mum
  • mum may have urge to push before full dilation
84
Q

management of a baby in the occipito-transverse malposition in labour?

A

this occurs when baby’s head engages in the left or right OT position, but rotation to OA then fails to occur.
if the 2nd stage is reached, the head must be manually rotated, rotated with appropriate forceps e.g. keilland’s (no pelvic curve) or using vacuum extraction.
often C section performed.

85
Q

what happens if the membranes rupture and the presenting part of the fetus does not fit the pelvis?

A

the UC can slip past and present in the cervix, or prolapse into the vagina
must aim to stop compression of the UC during contractions that could cut off blood, nutrient and O2 supply to baby
urgent C section required

86
Q

management of a transverse lie in pregnancy?

A

if lie has not resorted to longitudinal by time of delivery, C section is needed.

87
Q

types of malpresentation?

A

breech
face
brow
shoulder

88
Q

examples of abnormal lie?

A

transverse

oblique

89
Q

anatomical layers to be dissected during a lower segment C section?

A 
skin
superficial and deep fascia
anterior rectus sheath
rectus abdominis
transversalis fascia
extra-peritoneal fat
peritoneum
uterus
90
Q

labour monitoring required if significant meconium is present?

A

continuous CTG

also ensure healthcare professionals trained in fetal blood sampling are available during labour and that those trained in advanced neonatal life support are readily available for the birth.

91
Q

indications for continuous CTG in labour?

A
  • maternal temp 38 or above, or suspected chorioamnionitis or sepsis
  • severe HTN (160/110 or above)
  • oxytocin use
  • significant meconium
  • fresh PV bleed
92
Q

definition of an abnormal CTG which indicates need for urgent intervention in labour?

A

bradycardia or single prolonged deceleration with baseline below 100 beats/min, persisting for 3 mins or more
make preps for urgent birth

93
Q

management steps if CTG in labour shows baseline fetal HR 161-180 with no other non-reassuring or abnormal features on the CTG?

A
  • think about infection as possible underlying cause and appropriate investigation
  • check woman’s temp and pulse, if either raised start fluids and paracetamol
  • start 1 or more conservative measures:
  • encourage woman to mobilise or adopt left lateral position
  • offer PO or IV fluids
  • offer paracetamol if raised temp
  • reduce contraction frequency by stopping oxytocin if it is being used, and/or offering a tocolytic drug.
94
Q

what is measured on fetal blood sampling?

A

lactate or pH
pH 7.25 or greater and lactate 4.1 or less is normal
abnormal=pH 7.2 or less, lactate 4.9 or more

95
Q

time allowed for normal 2nd stage of labour?

A

1 passive hour is allowed (no pushing)
then if nulliparous, 2 active hours
if multiparous, then 1 active hour

96
Q

define failure to progress in the 1st stage of labour?

A

less than 2cm dilation in 4 hours

remember, latent 1st stage is from onset of regular painful contractions to 4 cm dilated
established 1st stage is dilation from 4cm to being fully dilated (10cm).

97
Q

what is fetal fibronectin?

A

protein released from the gestational sac, a high level is related to early labour.

98
Q

most common explanation for short episodes (less than 40min) of decreased variability on the CTG?

A

fetus is sleeping

if decrease in HR variability (normal variability of 5 beats/min) for more than 40mins, then start to worry.

99
Q

causes of decreased fetal HR variability on CTG?

A
  • baby is sleeping (decrease in variability for less than 40min)
  • fetal acidosis-usually hypoxia
  • fetal tachycardia-more than 140
  • prematurity (less than 28wks)
  • congenital heart abnormalities
  • maternal drugs e.g. opioids, BZDs.

Obstetrics and Gynaecology (18 decks)

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