labour and puerperium Flashcards
1
Q
What are the 5 indications for induction of labour
A
- prolonged gestation (offered between 40 and 42 weeks)
- premature rupture of membranes (delay IOL if <34 weeks unless fetal distress etc)
- maternal health problems (common egs: HTN, pre- eclampsia, diabetes, obstetric cholestasis)
- Fetal growth restriction
- intrauterine fetal death (if mother well with intact membranes)
2
Q
Describe 4 absolute and 3 relative contraindications for induction of labour
A
Absolute: - cephalopelvic disproportion - major placenta praevia - vasa praevia - cord prolapse - transverse lie - active primary genital herpes - previous classical c section (unless consultant assessed and says otherwise) Relative: - breech presention - triplet or more - two or more previous low transverse c sections Contraindications generally same as for vaginal delivery
3
Q
What are the three methods of inducing labour?
A
- vaginal prostaglandins
- amniotomy
- membrane sweep
4
Q
What is the preffered method of induction (according to NICE) and how does it work
A
- vaginal prostaglandins (tabel/ gel or pessary regimes)
- prostaglandins prepare the cervix for labout by ripeining it and also have role in smooth muscle contraction of uterus
- can take multiple days
5
Q
When is a amniotomyused?
A
- Only when the cervix has been deemed as ripe under the bishop score
- often given with an oxytocin infusion to increase strength and frequency of contractions
- should not be used as a primaru method of induction unless prostaglandins are contraindicated eg high risk of uterine hyperstimulation
6
Q
When is a membrane sweep used?
A
- offered at 40-41 weeks to nulliparous women and 41 weeks to multiparous women
- classified ad adjunct- increases likelyhood of spontaneous delivery and reduces need for formal induction
- a gloved finger is inserted through the cervic and rotated against the fetal membranes to try separate the chorionic membrane from the decidua, releasing natural prostaglandins in an attempt to kick start labour
7
Q
What is a bishop score used to asses, what features score points?
A
- cervical ripeness- score >7= ripe and high change of response to interventions made to induce labour, score <4 suggests labour unlikely to progress naturally and prostaglandins will be required
- dilation,cervix length, station relative to ischial spines, consistency and position of cervix (posterior- anterior/mid) are assessed
8
Q
When should CTG be used during induction of labour?
A
- prior to induction
- after initiation when contractions begin, use it continiously until a normal heart rate is confirmed then assess using intermittent auscultation
- of oxytocin infusion is started then monitor using continuous CTG throughout pregnancy
9
Q
Give 5 complications of induction of labout
A
- failure of induction: offer further prostaglandins or c section
- uterine hyperstimulation (contractions last too long (>2mins) or are too frequent (>4 in 10), leading to fetal distress. manage with tocolytic agents such as terbutaline)
- cord prolapse (amniotomy esp if fetal head is high)
- infection
- pain (IOL often more painful than spontaneous and epidural anaesthetic often required)
- increased rate of further intervention eg emergency c section or instrumental delivery)
- uterine rupture (rare)
10
Q
What instruments are most commonly used in operative vaginal deliveries?
A
- ventouse: attaches cup to fetal head by vacuum. two types, ‘kiwi’ can be used in all positions and rotational deliveries
- forceps: double bladed instruments, 3 types, higher risk of tears, less often used to rotate and dont require maternal effort
11
Q
What are the indications for a operative vaginal delivery?
A
- decision made in 2nd stage of labour
- inadequate progress: nulliparous women- should expect delivery after 2 hrs of active pushing , multiparous women should deliver within one hr of active pushing
- maternal exhaustion
- maternal medical conditions that mean active pushing or prolonged exertion should be limited eg intracranial pathology, heart diseases, severe HTN
- suspected fetal compromise in 2nd stage of labour
- clinical concerns eg significant antepartum haemorrhage
12
Q
Give 5 contraindications of operative vaginal delivery
A
- unengaged fetal head in singleton pregnancies
- incompletely dilated cervix in singleton pregnancies
- true cephalo- pelvic disproportion (where fetal head is too large to pass through maternal pelvis)
- breech and face presentations, and most brow presentations
- preterm gestation (<34 weeks), for ventouse
- high likelyhood of any fetal coagulation disorder for ventouse
13
Q
Give 5 pre- requisites for instrumental/ operative delivery
A
- fully dilated
- ruptured membranes
- cephalic presentation
- defined fetal position
- fetal head at least at level of ischial spines and no more than 1/5 palpable per abdomen
- empty bladder
- adequate pain relief
- adequate maternal pelvis
14
Q
What are the 3 classifications of operative vaginal delivery and what is the significance of the class?
A
- outlet: skull reached pelvic floor, scalp visible or fetal head on perineum
- Low
- midline
- lower class= less risk of classifications as less rotation needed and fewer pulls
15
Q
Give 4 fetal complications of operative vaginal delivery
A
- neonatal jaundice
- scalp lacerations
- cephalhaematoma
- subgaleal haematoma
- facial bruising
- facial nerve damage
- skull fractures
- retinal haemorrhage
16
Q
Give 4 maternal complications of operative vaginal delivery
A
- vaginal tears of 3rd/ 4th degree: 4x more likely in ventouse delivery and 10x more likely (1 in 10) if forceps
- VTE
- incontinence
- PPH
- shoulder dystocia
- infection
17
Q
What is the definition of premature rupture or membranes?
A
- rupture of membranes at least 1 hr prior to onset of labour at >37 weeks gestation
- preterm premature rupture (P-PROM): rupture of membranes at <37 weeks
18
Q
What is thought to cause premature rupture of membranes?
A
- early activation of normal physiological processes (higher than normal levels of apoptotic markers and MMPs in amniotic fluid)
- infection- 1/3 women with P-PROM have +ve amniotic fluid cultures
- genetic predisposition
19
Q
Give 5 RFs for PROM and P- PROM
A
- smoking (esp at <28 weeks)
- previous PROM/ preterm delivery
- vaginal bleeding during pregnancy
- lower genital traction infection
- invasive procedures eg amniocentesis
- polyhydramnios
- mutliple pregnancies
- cervical insufficiency
20
Q
Describe the clinical features of PROM
A
- painless popping sensation followed by gush of watery fluid from vagina
- sometimes can be gradual leakage of watery fluid and damp underwear/ pad
- on speculum: fluid draining from cervix and pooling in posterior fornix , fluid may be expelled if you ask them to cough
21
Q
How should premature rupture of membranes be investigated?
A
- USS if diagnosis unclear from examination and hx
- high vaginal swab for GBS
- ferning test can be used to confirm PROM- if no vaginal pooling on speculum examination
- actim prom: swab to look for IGFBP-1 in vaginal samples
22
Q
How should PROM be managed if >36 weeks
A
- most will start labour spontaneously
- monitor for clinical signs of chorioamnioitis
- give penicillin if GBS isolated
- wait for 24hrs then consider induction of labour
- steroids
- IOL and delivery recommended if >24hrs but they can wait up to 96hrs
23
Q
how should P- PROM from 34-36 weeks be managed?
A
- monitor for chorioamnionitis and advise to refrain from sex
- prophylactic erythromycin for 10 days
- penicillin if GBS isolated
- give corticosteroids
- IOL and delivery is recommended if labour doesnt commence within 24hrs
24
Q
How should P-PROM be managed if 24-33 weeks?
A
- monitor for chorioamnionitis and advise to refrain from sex
- prophylactic erythromycin for 10 days
- penicillin if GBS isolated
- give corticosteroids
- give magnesium sulphate for neuroprotection incase they do go into labour
- aim expectant management until 34 weeks
25
Q
Give 4 complications of PROM
A
- chorioamnionitis: inflammation of fetal membranes due to infection, risk increases the longer membranes the membranes remain ruptured and baby undelivered
- oligohydramnios: if age <24 weeks as greatly increases risk of lung hypoplasia
- neonatal death: due to prematurity, sepsis and pulmonary hypoplasia
- placental aburption
- umbilical cord prolapse
26
Q
What are the major benefits of VBAC vs planned c section?
A
- shorter hospital stay
- lower risk of maternal death (4/100,000 vs 13/100,000)
- good chance of future VBACs if successful
- lower risk of transient resp difficulties for neonate
- risk of still birth beyond 39 weeks whilst awaiting spontaneous labour
- avoids anaesthetic risk, bleed risk, infection risk, risk to local structures (bladder, bowel), accidental risk to baby etc associated with c section
27
Q
What are the major benefits to planned C section over VBAC?
A
- negates risk of uterine rupture
- no risk of anal sphincter injury
- lower risk HIE
- lower risk still birth
- generally thought to be lower risk if multiple pregnancy, macrosomia, older maternal age
28
Q
Give 5 RFs for uterine rupture in vaginal delivery after c section
A
- previous c section- classical (vertical) incisions carry highest risk
- previous uterine surgery eg myomectomy
- induction or augmentation of labour
- obstruction of labor
- multiple pregnancies
- multiparity
29
Q
If vaginal birth after c section is opted for, how should it be managed?
A
- in hospital setting with facilities for emergency c section and advanced neonatal resus
- continuous CTG monitoring
- beaware of needing additional analgesia as may indicate impeding uterine rupture
- avoid induction where possible (if need todo it, risk is lower with mechanical techniques than prostaglandins)
- after 39 weeks an elective c section is recommended delivery method
30
Q
Give 2 absolute and 2 relative contraindications for vaginal birth after c section
A
Absolute: - classical c section scar - previous uterine rupture - anything else that contraindicates vaginal delivery eg palacenta praevia Relative: - complex uterine scars - >2 lower segment c sections
31
Q
What is shoulder dystocia?
A
Where, after delivery of the head, the anterior shoulder of the fetus becomes impacted on the maternal pubic symphysis, or less commonly, the sacral promontory.
It is a obstetric emergency with an incidence of 0.7% of all pregnancies.
