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Block 5 > Labour & Birth > Flashcards

Labour & Birth Flashcards

1
Q

What causes the onset of labour?

A

Exact cause UNKNOWN but its thought to be mechanical due to overstretch because pre-term labour is more common when the women has had multiple pregnancies or polyhydramnious but inflammatory markers such as cytokines and PGs play a role too being present in the decidua and membranes in late pregnancy and being released if cervix is digitally stretched

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2
Q

How is the first stage of labour diagnosed?

A
  1. Regular painful contractions (can be felt at top of belly)
  2. Progressive cervical dilatation from 4cm
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3
Q

Why should women not be examined flat?

A

Risk of postural supine hypotensive syndrome as a result of IVC compression

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4
Q

What does the obstetric abdominal exam include?

A
  1. Observation
  2. Inspection
  3. Palpation
  4. Auscultation
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5
Q

What should be inspected in the obstetrics abdominal exam?

A

Abdominal mass other than baby
Stigmata of pregnancy (striae gravidarum)
Surgical scars

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6
Q

When should palpation be included in the abdominal exam?

A

From 36 weeks to determine the position of the foetus

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7
Q

What features are being assessed when palpating?

A
  1. Uterine size: SFH measured/recorded at each antenatal visit from 24 weeks using a tape measure that is non-elastic and reversed (to avoid bias) starting from highest point of uterus (fundus) of uterus along longitudinal axis of uterus to top of symphysis pubis
  2. No. of foetuses
  3. Foetal lie, presentations, engagement and positions
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8
Q

If you do not have a tape measure, how should you measure the symphysis-fundal height (SFH)?

A

Using landmarks:
< 12 weeks = symphysis pubis not palpable

20 weeks = fundus will be at level of umbilicus

36 weeks = fundus will be at level of xiphisternum (drops down as foetal height engages into maternal pelvis in primigravida - why they get relief from heart burn for e.g.)

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9
Q

What is foetal lie?

A

Relationship between long axis of foetus and long axis of uterus

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10
Q

What is a longitudinal lie?

A

When the foetus’ long axis is aligned to the long axis of the uterus - normal/ideal

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11
Q

What is a transverse lie?

A

When the long axis of the foetus is perpendicular to the mothers - baby will not be able to get out so not-ideal

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12
Q

What is an oblique lie?

A

When the long axis of the foetus is 90-180% to the mothers - not ideal either as could present with a shoulder

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13
Q

What is the foetal presentation?

A

The part of the foetus that presents to the maternal pelvis which can be:

  1. Cephalic if head/vertex is situated over the pelvis (classified according to position of occiput as brow/face can present)
  2. Malpresentation or breach if anything other than the vertex presents
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14
Q

What is the ideal foetal presentation?

A

Cephalic occipital-anterior presentation where narrowest part of head presents first

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15
Q

What different types of breach exist?

A
  1. Extended/frank: legs up
  2. Flexed: baby sits with heels down
  3. Complete/footling: one or both legs extended at hip and hanging down (most problematic as least well-fitted so cord prolapse can occur)
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16
Q

When is the foetal head said to be engaged?

A

When the widest biparietal diameter of the head has passed through the pelvic brim at the ischial spines and measured by palpating the angle between the head and symphysis pubis:

  • When 3 or > 1/5ths of the head are palpable abdominal the head is not engaged because its free-floating above the pelvic cavity
  • When 2 or < 1/5ths of the head are palpable the head is engaged
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17
Q

What terms are used in relation to the position of the foetus in utero?

A
  1. Presentation: as discussed e.g. cephalic or breach
  2. Denominator: fixed point on presenting part e.g. occiput in cephalic presentation, mentum (chim) in face presentation or sacrum in extended breach presentation
  3. Position: relationship of denominator to 6 areas of womens pelvis e.g. L and R anterior, L and R lateral or L and R posterior
  4. Attitude: relationship of foetal head and limbs to its body e.g. fully flexed, deflexed, partially extended or completely extended
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18
Q

When would you carry out an obstetric pelvic examination?

A

It is not done routinely but done in:

  • Assessment of labour
  • Assessment of membrane rupture
  • Per vaginal bleeding
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19
Q

What is included in the obstetric pelvic examination?

A

External exam of vulva
Internal inspection of vagina/cervix using sterile technique and speculum
Digital vaginal exam if indicated (increases infection risk in ruptured membranes)

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20
Q

What is happening to the cervix?

A
  1. Dilatation: assessed in cms where 1 finger breadth = 1-1.5cm
  2. Length: normally 3cms but shortening occurs as effacement happens becoming part of lower uterus segment
  3. Position: becomes more anterior as it becomes more effaced
  4. Consistency: usually firm but becomes softened aiding effacement/dilatation
  5. Station of presenting part: how much part has descended into pelvis (use ischial spines as fixed point) - cm above or below?
  6. Position of presenting part: with cephalic, anterior/posterior fontanelles and sagittal sutures should be ID’d
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21
Q

What is cervical effacement?

A

Process by which cervix prepares for delivery occurring after the baby has engaged in the pelvis gradually dropping closer to the cervix where it softens, shortens, thins, becomes more anterior and draws up measured in 0-100% (occurs before cervical dilation and mark onset of back-ache and Braxton hicks contractions)

22
Q

What is cervical dilatation?

A

Gradual opening of the cervix measured in centimeters from 0-10cms

23
Q

What are Braxton Hicks contractions?

A

Painless irregular uterine tightenings/contractions prior to onset of labour that can be felt at fundus of uterus/top of belly

24
Q

What is station?

A

The relationship of the presenting part of the baby to an imaginary line drawn between the ischial spines of the maternity pelvis - how many cms above or below is it?

25
Q

What is Bishops score?

A

A score system used to evaluate the ripeness or favourability of the cervix - the higher the score the more favourable the cervix for delivery marked 0-2 on:

  1. Cervical dilatation (cm)
  2. Length of cervix (cm)
  3. Station of presenting part (cm)
  4. Consistency
  5. Position
26
Q

How is normal labour progress assessed?

A

Uterine contractions
Dilatation of cervix (rate should be 0.5-1 cm/h in nulliparous woman and 1-2cm/h in multiparous woman)
Descent of presenting part

Partogram is used to chart labour observations

27
Q

How would you know if labour had slow progress?

A

Lack of cervical dilatation

Failure of descent of presenting part

28
Q

What are the 3 stages of labour?

A
  1. From onset of regular contractions w/ associated dilatation of cervix to full dilatation of woman’s cervix (10cms)
  2. From full dilatation of cervix to birth of the baby
  3. From birth of baby to delivery of placenta and membranes - inc. control of associated bleeding
29
Q

What are the 3 P’s that contribute towards a successful labour?

A
  1. Power of contractions inc. strength, length, frequency and effectiveness
  2. Passage i.e. birth canal inc. bony pelvis/adaptations, soft tissues/pelvic floor and cervix/vagina/vulva
  3. Passenger i.e. baby inc. size, positioning and coping
30
Q

What is the mechanism of delivery of the baby i.e. how does it negotiate through the womans pelvis?

A

1st stage of labour:
1. Babies head flexes as cervix effaces and dilates

2nd stage of labour:
2. Internal rotation as head reaches pelvic floor bringing occiput into anterior position
3 Extension of head happens as head is delivered passing under pubic symphysis
4. External rotation (restitution) as head distends towards perineum to allow delivery of shoulders

31
Q

What is the pelvic inlet and outlet that the baby must negotiate through?

A

Inlet: bounded by pubic crest, iliopectineal line and sacral promontory being oval in shape, cavity being round and its widest diameter being transverse

Outlet: bounded by lower border of pubic symphysis, ischial spines and tip of sacrum with an oval shape and wider diameter being anteroposterior

32
Q

What is vernix?

A

Greasy white deposit covering the skin of a baby at birth to protect it

33
Q

What is induction of labour?

A

An artificial initiation of uterine contractions prior to spontaneous onset resulting in the delivery of the baby - relatively common occurring in 1/5 deliveries

34
Q

How does induced labour impact the birth experience of the woman?

A

It may be less efficiency and usually more painful than spontaneous labour so epidural analgesia and assisted delivery are more likely to be required

35
Q

What are the indications for induction of labour?

A

Maternal:

  • Severe pre-eclampsia
  • Recurrent antepartum haemorrhage
  • Pre-existing disease e.g. diabetes due to HBW and IUGR

Foetal:

  • Prolonged pregnancy
  • IUGR
  • Rhesus disease
36
Q

What is the difference between an favourable and unfavourable cervix?

A

Favourable = soft, beginning to dilate and efface

Unfavourable = hard, long, closed and not effaced

Use Bishops score to assess

37
Q

What must occur immediately after a C-section delivery?

A

Skin-to-skin of baby with mum (unless in severe stress) so bonding occurs - baby more likely to need suction treatment because they have come straight from the watery environment

38
Q

What are the main methods of labour induction?

A
  1. PGE2 Dinoprostone: locally applied as vaginal gel, tablet or pessary to ripen the cervix (follow guidelines to reduce risk of uterine hyperstimulation i.e. no > than 5 contractions in 10 mins)
  2. Amniotomy: causes release of endogenous PGs
  3. Oxytocin: IV infusion of Syntocinon with strength titrated according to strength/frequency of uterine contractions
39
Q

When would you want to operatively intervene in labour?

A
  1. Delay in 1st/2nd stage
  2. Foetal: large baby, suspected distress (electrodes on head/CTG), APH, breech, severe IUGR or twins (may get a 1st normal presentation and malpresentation with 2nd)
  3. Maternal: HIV, ITP, increased ICP or severe pre-eclampsia/eclampsia (in a validated 24-hr urine sample proteinuria has to be >300mg to diagnose pre-eclampsia)
40
Q

What operative interventions are available for delivery?

A

Ventouse
Forceps (rotational if baby is facing wrong way e.g. Keilland’s or non-rotational if just need to be lifted out e.g. Simpsons, Neville Barnes + Wrigleys)
Episiotomy
Caesarean section

41
Q

What is the issue with giving an epidural anaesthetic?

A

The mum cannot push as well

42
Q

When would you not want to perform a caesarean section (C-section)?

A

If the baby has moved down into the pelvic cavity, you wouldn’t want to perform a C-section and get it out of the abdomen

43
Q

What are the 2 main types of foetal monitoring in labour?

A
  1. Intermittent auscultation using a pinard stethoscope or doppler US
  2. Continuous cardiotocographausc (CTG) monitoring (only in high-risk women or evidence on auscultation of baseline <110bpm or >160bpm)
44
Q

What does NICE recommend for a healthy women who has had an uncomplicated pregnancy?

A

Intermittent auscultation should be offered an recommended in labour to monitor foetal wellbeing immediately after contraction for at least 1 minute or at least every 15 minutes in 1st stage and every 5 minutes inc. after contractions in the 2nd stage

45
Q

What should you do if a foetal heart rate abnormality is detected?

A

Palpate maternal pulse to differentiate between 2 HRs and record accelerations/decelerations if heard

46
Q

What is a normal foetal heart rate (HR)?

A

110-160bpm with baseline variability and accelerations/decelerations (HR will increase as a result of uterine contractions)

47
Q

Why is foetal heart rate (HR) monitored?

A

To detect foetal hypoxia

48
Q

What is meconium?

A

The first stool of the baby which is blackish green and tenacious - be aware of it as presence in liquor may indicate foetal distress

49
Q

What is meconium aspiration syndrome (MAS)?

A

Aspiration of the stained amniotic fluid with meconium which can cause severe respiratory distress in newborn as chemical composition can cause chemical pneumonitis but not bacterial pneumonitis because it is sterile and does not contain bacteria

50
Q

What occurs in the 3rd stage of labour?

A
  1. Physiological where no oxytocic drugs are given you just wait for delivery of placenta passively or active where an oxytocic drug (e.g. Syntocinil) is injected into thigh to help everything clamp down and stop bleeding
  2. Clamp and cut cord only after it stops pulsating to prevent bleeding (delayed cord clamping after 1-3mins improves iron status at 4m and blood volume esp. in premature babies)
  3. Controlled cord traction by modified Brandt Andrews method where L hand palmar surface of fingers placed above pubic symphysis and pushes uterus (feels hard/contracted) body up and back and R hand does cord traction in downward and backward direction
51
Q

When can a post-partum haemorrhage (PPH) occur?

A

Need all of the placenta to be removed because if not this can occur as a result of bits being left behind

Block 5 (29 decks)

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