Labour & C Section Flashcards
Why would you induce labour? (maternal indications)
Maternal Indications: 4 P’s
PPROM / PROM
Prolonged pregnancy (1-2 weeks over due date)
Pre-eclampsia
aPh
GDM
OC
Why would you induce labour? (fetal indications)
FGR
Twins
LGA
IUD
SROM >37weeks & GBS +ve
Contraindications of labour?
Malpresentation
Unstable lie
PP
Fetal Distress
Cephalopelvic disproportion
Define labour
- Regular painful contractions w/
- progressive effacement and dilatation of the cervix +/- show
- +/- ROM
Cervix does not need to be fully dilated to be in labour
Define show
Mucus plug
Define effacement
Cervix progressively shortens and then dilates
What is first stage of labour?
Latent Phase + Active Phase
Latent:
1. Regular contractions
2. Cervical Dilatation to 4cm
2. ROM
Active:
1. Complete dilation (10cm)
2. Descent of presenting part
3. Contractions 2-3 min apart
When would you intervene to do c section during labour?
- Abnormal progress in first stage
(No change in dilation despite adequate contractions, obstructed labour, fetal distress) - Abnormal progress in second stage
(Delivery does not occur within 1 hour of maternal pushing, maternal exhaustion, fetal distress)
What is the second stage of labour?
Full dilation to delivery
Contractions every 2 mins and last 60-90s
What is the third stage of labour?
Delivery of baby to delivery of placenta and membranes.
This is actively managed to reduce risk of PPH.
Active = Oxytocin + cord traction
Cardinal Movements of Labour (Every Damn Fool In Egypt Eats Raw Eggs)
Occiput anterior (smallest part of the head hits pelvic floor)
1. Engagement: BPD enters pelvic inlet
2. Descent: Pressure of amniotic fluid with contractions
3. Flexion: Head meets pelvic floor, chin tuck
4. Internal Rotation: Occiput anterior (OA), crowning
5. Extension: Birth of head
6. External Rotation: LOA to LO transverse
7. Expulsion.
Components of Normal Labour (3 P’s)
Power
Passages
Passenger
What is defined as prolonged labour?
Primip >20 hours
Multip >14 hours
What are the arrest disorders?
- Arrest of active phase - no change in 2 hours.
- Arrest of descent - No change in 2 hours for primip, 1 hour for multip (w/o anasthesia)
What problems may result in abnormal labour?
Paul Feeney Drives Cars in Uganda
Dystocia
Intrapartum infection
Uterine rupture
Constriction ring
Fistula formation
Pelvic floor injury
Fractures/trauma
Oxytocin Side Effects
Hyperstimulation
Placental abruption
Uterine rupture
What can go wrong with normal labour?
Power issue - poor contraction - (should be duration of 60-80s x 7 in 15 minutes)
Passage - Small pelvis/abnormal pelvis
Passenger - Big baby, abnormal presentation
If labour is prolonged due to a power issue, what can be done?
AROM +/- oxytocin infusions to augment contractions.
Abnormal presentation in labour (FiT BOB)
FiT BOB
Face presentation
Transverse lie
Breech presentation
Occiput presentation
Brow presentation
What can be done for breech presentation at 37 week?
ECV - 50% success., cannot be in labour/ROM
Risk of cord prolapse - Emergency CS
Types of Breech Presentation
Frank
Incomplete
Complete
Single/Double footling
Define transverse lie
Baby spine is perpendicular to maternal spine. Must be managed with CS.
Spine down - Longitudinal incision
Spine up - Normal CS
What is the risk with a transverse lie?
1st contraction = ROM
2nd contraction = Cord prolapse
3rd contraction = Baby death
4th contraction = uterus rupture
5th contraction = Mother death
Risk factors for transverse lie?
Placenta previa (structural obstruction prevention cephalic presentation)
Polyhydramnios
Abnormal uterus - fibroids
Multiparity - abdominal wall loose
Types of Perineal Tears (SPAR)
First degree: Superficial skin
Second degree: Perineal skin (+superficial)
Third degree: Anal sphincter (+ perineal + superficial) partial
Fourth degree: Rectal tear complete
What is done prior to inducing labour?
Membrane sweep - can stimulate prostaglandin release, triggering labour
What is step 1 of inducing labour?
Vaginal prostaglandins - Get it ready for AROM
What is step 2+3 of inducing labour?
- ARM +/-
- Oxytocin infusion (if spontaneous contractions haven’t started in 24 hours). Monitor with CTG.
What is step 4 of labour induction?
Balloon induction
Catheter is inserted through the cervix and the balloon inflated with normal saline.
The woman is then asked to mobilise on the ward, where gravity puts pressure of the
balloon down on the cervix.
These can be left in situ for up to 24 hours or until they fall out. These are particularly useful in women for whom prostaglandins are not suitable.
What are the risks of IOL?
I-FUCUP
Increased obstetric interventions
Failure of OIL
Uterine hyperstimulation
Cord prolapse
Uterine rupture
PPH risk increased
What happens if Bishops score is <6?
This means the cervix is unfavourable and prostaglandins or propess pessary (like a balloon catheter) should be offered
What happens if Bishops score is >6?
This means the cervix of favourable and amniotomy +/- oxytocin infusion is recommended.
How to give prostaglandin E2 gel?
1-2mg at a time (do not exceed 6mg)
Give every 6 hours
Max 2 gels/day (not at night)
If maxed out dosage - elective CS
Disadvantages of prostaglandin E2?
Hyperstimulation (CTG 1 hour pre and post administration)
Gel can fall out
No reversal - once in vagina, cannot remove it
How to manage hyperstimulation as a result of prostaglandin E2?
Give terbutaline
If performing an ARM (amniotomy), what must be done?
Confirm that the head is engaged by palpating the abdomen.
If not engaged - risk cord prolapse
Check liqour colour
CTG
If no pain in 1-2 hours, give oxytocin
When is ARM indicated?
- Given gel and cervix is favourable
- CTG, baby, liqour volume is all fine
- If there are issues like HTN or evidence of meconium - do urgently.
What must be done prior to giving Oxytocin?
ROM due to risk of amniotic fluid embolism.
Components of Bishop’s Score
Cervical dilation
Effacement
Cervix position
Cervix consistency
Fetal head station
<6 labour unlikely
>6 labour likely
Outline process of C section
Spinal or general anaesthesia
Urinary catheter
Abdomen sterilised, incision across the lower abdomen
LCSC incision to uterus
Fetal head delivered first
Recovery with VTE prophylaxis, mobilising and monitored for 3-5 days in hospital.
Elective CS indications
Malpresentation - Brow/Face
Fetal growth restriction
Pre-eclampsia
Placentia Praevia
Prev C section
Maternal request
Emergency CS indications
Failure to progress from 1st to 2nd stage
Non-reassuring fetal status (decelerations exceeding 5 minutes)
Obstetric emergency - Cord prolapse, abruption, face presentation
Most common complications post C section
Abdo discomfort
Re-admission to hospital
Infection
Bleed - Hemorrhage
Fetal lacerations
Uncommon Risks of C section
PPH
Damage to bladder/ureters/Bowel
Infection
VTE
Emergency hysterectomy
Risks associated with VBAC after C section?
Uterine rupture/dehiscence of scar
Contraindications for a vaginal breech delivery
Fetal weight >3.8kg
Footling breech presentation
Lack of maternal consent
Risks of vaginal breech delivery
Head entrapment
Cord prolapse
Trauma
Nuchal arm (abduction of fetal arm becomes trapped behind fetal head)
In breech presentations, why does C section delivery at 39 weeks reduce risks?
Avoidance of risking stillbirth
How is progress in labour monitored?
Using a partogram - monitors fetal heart rate.
What is the action line on a partogram?
Action line - If the line is crossed, labour is delayed and action should be taken for augmentation/acceleration.
The graph has cervix dilatation on Y axis and time on X axis.
What are the categories of C section?
Cat 1: Immediate threat to life. Delivery should occur within 30 minutes
Cat 2: Maternal or fetal compromise which is not immediately life threatening - Deliver within 75 minutes
Cat 3: Mother & baby stable, but delivered is required.
Cat 4: Elective
