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1 Obs & Gyn > Labour, delivery, and analgesia > Flashcards

Labour, delivery, and analgesia Flashcards

1
Q

Discuss the anatomy of the maternal pelvis

A

ilium, pubic symphysis, pubic bone, iliac crest, ASIS, sacrum…

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2
Q

Discuss the anatomy of the fetal skull

A

ant and post fontanelle
frontal, coronal, saggital suture
frontal, parietal, occipital bone

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3
Q

Define vertex

A

the highest/apical point= fetal head (Vertix position)

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4
Q

List two mechanisms of normal labour and delivery

A

effacement and dilation of cervix

expulsion of the fetus by uterine contractions

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5
Q

List three factors that promote the initiation of labour

A

oxytocin, prostaglandins, CRH, inflammatory mediators

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6
Q

List two factors that promote pregnancy versus labour

A

progesterone
nitric oxide
relaxin
catecholamines

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7
Q

What is the source of progesterone during pregnancy?

A

corpus luteum for first 8 weeks then placenta

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8
Q

What is the MOA of mifepristone?

A

progseterone antagonist- increases myometrial contractility

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9
Q

What is the function of progesterone in pregnancy?

A

decreases uterine oxytocin receptor sensitivity and therefore promotes uterine smooth muscle relaxation

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10
Q

Where is oxytocin produced from?

A

post pituitary

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11
Q

What is the function of oxytocin?

A

stimulate uterine contractions

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12
Q

What is the effect of prostaglandins on labour?

A

promotes cervical ripening and stimulate uterine contractility

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13
Q

What is effacement?

A

Effacement refers to the thinning of the cervix during labor= ripening

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14
Q

Name one factor that promotes cervical ripening

A

prostaglandins, inflammatory cells

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15
Q

What happens to the collagen in the cervix during effacement?

A

concentration of collagen decreases, the cervix becomes softer and ready to dilate

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16
Q

Which score is used to assess cervical ripening?

A

Bishop’s score

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17
Q

How do you when the cervix is dilated?

A

dilatation of the external os

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18
Q

How do you know when effacement has taken place?

A

when the whole cervix has been ‘taken up’ into the lower segment of the uterus. Begins with the internal os, proceeds downwards to the external os until the cervical tissue becomes continuous with the uterine walls

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19
Q

When is a woman said to be in labour?

A

regular uterine contractions and fully effaced cervix

+spontaneous rupture of membranes and regular uterine activity

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20
Q

Does spontaneous rupture of membranes occur before or after regular uterine activity?

A

majority occur after uterine activity. Pre term rupture of membranes is when waters break before lady goes into labour (before 37 weeks)

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21
Q

How can rupture of membranes be visualised?

A

speculum- pool of liquor can be seen in posterior vaginal fornix

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22
Q

Name two complications of rupture of membranes?

A

ascending infection
chorioamnionitis
maternal and fetal sepsis (Rare)

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23
Q

How many stages are there in labour?

A

3

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24
Q

What does the first stage of labour comprise?

A

onset of labour until cervix is fully dilates

  • latent (cervical effacement +3-4cm dilated)
  • active (cervical dilatation)
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25
Q

What does the second stage comprise?

A

from cervical dilatation (10cm) until baby is delivered

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26
Q

What are the two phases of the second stage of labour?

A

Propulsive – from full dilatation until the head has descended onto the pelvic floor

Expulsive – from the time the mother has an irresistible urge to bear down and push until the baby is delivered

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27
Q

What is the third stage of labour?

A

From delivery of the baby until expulsion of the placenta and membranes

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28
Q

Name one risk associated with the third stage of labour

A

uterine inversion

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29
Q

How is engagement determined?

A

abdominally in fifths of fetal head palpable above the pelvic brim

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30
Q

List four assessments that should be conducted in labour

A

baseline recordings of maternal parameters

length, strength, frequency of contractions

foetal movements?

Spontaneous rupture of membranes?

abdo exam- fundal height, lie, presentation, engagement, auscultation

CTG

vaginal exam every 4 hours by the same person

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31
Q

What might meconium staining in the vagina suggest?

A

fetal distress

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32
Q

What might moulding seen in the vagina suggest?

A

obstructed labour

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33
Q

List three things you should assess for during vaginal exam during labour

A 
meconium
dilatation of cervic
station of presenting part
position of head
moulding/caput?
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34
Q

What is caput succedaneum?

A

swelling of the scalp in a newborn. It is most often brought on by pressure from the uterus or vaginal wall during a head-first (vertex) delivery

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35
Q

What is station of the presenting part?

A

The station of the presenting part is recorded with respect to the ischial spines.

Spines is zero station.

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36
Q

List three positions that the fetal head can be in

A

L/R occipitoposterior
L/R occipitotransverse
L/R occipitoanterior

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37
Q

How is caput succedaneum classified?

A

Caput’ (succedaneum) is oedema of the scalp owing to pressure of the head against the rim of the cervix and is classified arbitrarily as ‘+’, ‘++’, or ‘+++’.

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38
Q

What is moulding?

A

describes the change in head shape, which occurs during labour, made possible by movement of the individual scalp bones.

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39
Q

How is moulding classified?

A

It is classified arbitrarily as ‘+’ if the bones are opposed, ‘++’ if the bones overlap but can be reduced, and ‘+++’ if the bones overlap, but cannot be reduced.

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40
Q

Is meconium a worrying sign?

A

Meconium is in itself not concerning. A healthy term baby will often pass meconium during labour. This will be thin and green-brown in colour. Thick meconium, green (pea-soup) can be a sign of fetal hypoxia or acidosis.

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41
Q

What is administered during the second stage of labour?

A

IM oxytocin after delivery of anterior shoulder

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42
Q

Why is oxytocin administered?

A

to reduce the risk of postpartum haemorrhage

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43
Q

What is a partogram?

A

Provides a graphic record of clinical findings and any relevant events during labour.

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44
Q

State three components of a partogram

A

Records maternal observations (BP, HR, temp), fetal heart rate, progressive cervical dilatation, descent of the presenting part, strength and frequency of contractions, and colour of amniotic fluid.

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45
Q

For how long is uterine activity recorded for during labour?

A

10 mins

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46
Q

Will a primiparous or multiparous labour take longer?

A

primiparous takes longer

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47
Q

What is precipitate labour?

A

expulsion of the fetus less then 2-3 hours of onset of contractions

48
Q

Name one complication of precipitate labour?

A

placental abruption

fetal distress

49
Q

How is a diagnosis of slow labour/delay in labour made?

A

cervical dilatation <2 cm in 4 hours

50
Q

What is malpresentation and provide two examples?

A

Any non-vertex position

e.g. face, brow, breech, shoulder

51
Q

List three risk factors/associations for breech

A 
multiple pregnancy
bicornate uterus
fibroids
placenta praevia
polyhydamnios
oligohydramnios
neural tube defect
52
Q

Before C-section, what should be tried with a baby in breech position?

A

external cephalic version = procedure used to help turn a baby in the womb before delivery

53
Q

Define breech birth

A

A breech baby, or breech birth, is when your baby’s feet or buttocks are positioned to come out of your vagina first.

54
Q

Define maposition

A

abnormal position of the vertex relative to the maternal pelvis

55
Q

Define prolonged pregnancy

A

> 42 weeks

56
Q

Name two risks associated with prolonged pregnancy

A

intrauterine death

intrapartum hypoxia

57
Q

When is induction of labour offered in prolonged pregnancy with no complications?

A

between 41 and 42 weeks

58
Q

What is the most common indication for induction of labour?

A

prolonged pregnancy

59
Q

List three indications for induction of labour (IOL), aside from prolonged labour

A

Maternal diabetes, including gestational diabetes
Twin pregnancy
Pre-labour rupture of membranes
Fetal growth restriction and suspected fetal compromise
Hypertensive disorders of pregnancy including pre-eclampsia
Deteriorating maternal medical conditions (e.g. cardiac or renal disease)
Maternal request

60
Q

State two contraindications to IOL

A

Situations were vaginal delivery is contraindicated (e.g. placenta praevia/transverse lie)

Caution in previous caesarean section or uterine surgery (increased risk of scar rupture)

Risk of hyperstimulation in those who have had a previous precipitate labour

61
Q

State three methods for IOL

A

prostaglanding gel/tablet
cooks balloon
artifical rupture of membrane
syntocinon (synthetic oxytocin)

62
Q

Why is CTG monitoring indicated during pharamcological IOL?

A

pharmacological preparations all cause uterine contractions and have the potential to reduce uterine blood flow and compromise the fetus

63
Q

Which IOL methods can be used for unfavourable cervix? (bishop score<6)

A

prostaglandins and cooks balloon

64
Q

Which IOL methods can be used for favourable cervix? (bishop score >6)

A

artifical rupture of membranes

oxytocin

65
Q

Name one risk associated with prostaglandin induction?

A

hyperstimulation

66
Q

Define hyperstimulation

A

> 5 contractions: 10 mins for 20 mins associated with signs of fetal compromise

67
Q

What is augmentation?

A

the process of accelerating labour which is already underway

68
Q

Name two non-pharmacological pain relief options in labour

A

1:1 support
environment
birthing pools
education

69
Q

Name two pharmacological agents for pain relief in labour

A

inhaled analgesics- entonox

opioids- diamorphine + antiemetic

Pudendal analgesia

Epidural/spinal

GA

70
Q

List two options for regional anaesthetics

A

epidural

spinal

71
Q

State three complications of regional anaesthetics

A 
dural puncture headache
hypotension
local anaesthetic toxicity 
accidental total spinal block
neurological complications- peripheral nerve injury
bladder dysfunction
72
Q

List three risks associated with general anaesthesia during labour

A

Reduced gastro-oesophageal tone
Increased intra-abdominal mass
Reduced gastric emptying
Regurgitation of gastric contents and aspiration - leading to pneumonitis
Difficult and failed intubation more likely

73
Q

What is a first degree perineal tear?

A

Injury to the vaginal epithelium and vulval skin only

74
Q

Second degree perineal tear?

A

Injury to the perineal muscles, but not the anal sphincter

75
Q

Third degree?

A

Injury to the perineum involving the anal sphincter complex

76
Q

Fourth degree?

A

Injury to the perineum involving the anal sphincter complex and anal/rectal mucosa

77
Q

What is an episiotomy?

A

Episiotomy, also known as perineotomy, is a surgical incision of the perineum and the posterior vaginal wall generally done by a midwife or obstetrician.

78
Q

Name two indications for episiotomy

A
  1. a rigid perineum which is preventing delivery
  2. If it is judged that a large tear is imminent
  3. Most instrumental deliveries (ventouse or forceps)
  4. Suspected fetal compromise
  5. Shoulder dystocia (to improve access to the birth canal)
79
Q

List three components of immediate post-birth care

A

Skin-to-skin contact if no neonatal resus required – supports physiological transition of the newborn and mother

Neonatal thermoregulation, respiratory regulation, increases successful breastfeeding

Maternal stimulation of oxytocin, which increases uterine contractions and milk production

Rhesus bloods and Anti-D if required

Assessment of risk postpartum psychosis/depression, child protection or social concerns

6-hour discharge if mother and baby are well

80
Q

List three assessments of the newborn immediately post-birth

A 
APGAR 1,5,10 mins
Clamp cut umbilical cord
Birth weight temp
Head, facial, digits, spine, external rotation
First micturation and feed
81
Q

What should be administered to the baby immediately post-birth?

A

vit K

82
Q

List three assessment of the mother immediately post-birth

A 
vagina, uterine fundus
observe for trauma- e.g. perineal tear
baseline obs
record first micturition after birth 
categories VTE risk
83
Q

List three benefits of breast feeding for baby

A 
reduced risk of infections
reduced risk of vomiting and diarrhoea
reduced risk of obesity
reduced risk of CDV in adult
strong emotional bond
84
Q

State three benefits of breastfeeding for mum

A

lowers risks of breast cancer, ovarian cancer, osteoporosis, CVD, obesity

85
Q

What should be discussed/assessed in the first 10 days post birth

A

Postnatal depression assessment
Physical exam of mum and baby
Discuss contraception
Emotional problems, support breastfeeding and parenting

86
Q

Which investigations should you carry out on the mother at the late postnatal exam? (6 weeks)

A

FBC

cervical smear

87
Q

List three post natal complications

A

Anaemia

Bowel problems

Breast Problems

Perineal breakdown

Incontinence

Puerperal pyrexia

Secondary PPH

VTE

Mental Health Problems; Postnatal depression, Postpartum psychosis

88
Q

Name one breast complication in women

A

mastitis= blocked mammary duct

89
Q

Why does incontinence arise in women post natal?

A

neuropraxia= impaired pudendal nerve function after compression during delivery

90
Q

What is puerperal pyrexia?

A

temp >38 degrees on any occasion in the first 14 days after birth

91
Q

Name two causes of puerperal pyrexia

A

genital tract infection (endometritis)
UTI
DVT
Infection of breast

92
Q

List two risk factors for maternal sepsis

A

maternal obesity

c-section

93
Q

What is the treamtent for DVT post partum?

A

LMWH

94
Q

Differential for DVT?

A

thrombophlebitis 1%

95
Q

List three signs of postpartum psychosis

A 
fear
insomnia
agitation
irritation
anger
fear for own health and baby
grandiosity, suspisciousness, depression
96
Q

Where should mother go with postpartum psychosis?

A

admission to a mother and baby unit with baby

97
Q

How to distinguish between miscarriage and stillbirth?

A

miscarriage<24 weeks

stillbirth >24 weeks

98
Q

List three associations with stillbirth

A 
advanced maternal age
maternal obesity
social deprivation
smoking
non-white
domestic violence
99
Q

Discuss three causes of stillbirth

A

fetal: fetal growth restriction, infection, anaemia, cord obstruction
maternal: DKA, diabetes, Ab production, reduced oxygen state

placental mediated: pre-eclampsia, placental abruption, antiphospholipid syndrome. cocain use, smoking

100
Q

State two placental mediated causes of still birth

A

uterine rupture
placenta praevia
uterine abnormality

101
Q

What are the components of still birth after care?

A 
psychological care
memory box with photos, hand footprints
post-mortem
support groups
suppression of lactation
funeral arrangements
102
Q

How is an active labour diagnosed?

A

fully effaced + around 3 cm dilated AND regular painful contractions
(+persistent backpain, spontaneous rupture of membranes, nausea/vomiting/diarrhoea)

103
Q

What are Braxton-Hicks contractions?

A

Braxton Hicks are when the womb contracts and relaxes. Sometimes they are known as false labour pains. Not all women will have Braxton Hicks contractions.

104
Q

What happens during the first stage of labour?

A

cervix fully dilated: 10 cm

105
Q

What happens in the second stage of labour

A

delivery of baby

106
Q

What happens in the third stage of labour?

A

delivery of placenta

107
Q

List three mechanisms of birth (e.g. engagement)

A 
engagement
descent and flexion
internal rotation
delivery by extension
external rotation
restitution
delivery of shoulders
108
Q

What is a partogram?

A

A partogram is used to record all observations made when the woman is in labor.

109
Q

What is measured on a partogram?

A
  1. fetal condition (fetal heart rate, color of amniotic fluid and molding of the fetal skull)
  2. Maternal condition (pulse, BP, temperature, urine output and urine for protein and acetone)
  3. The progress of labor is monitored by cervical dilatation, descent of head and uterine contractions
  4. A separate space is given to enter drugs, IV fluids and oxytocin
110
Q

Name three differences between a spinal and epidural

A

Spinal- local anaesthetic directly into spinal cord (subarachnoid space) while epidural injected outside the dura, therefore affects nerve roots

Spinal is a one off dose and lasts 2 hours while epidural can have catheter inserted to top up analgesia

Onset in spinal is much faster- around 5 mins while epidural is slower- around 25-30 mins

epidural can be cervical, thoracic, or lumbar spine, while spinal must be L3/L4

111
Q

List three analgesic options during labour

A 
entonox
diamorphine IM
epidural 
pudendal and perineal infiltration
bath, birthing pool
112
Q

What are the first signs of labour?

A

mucus plug- pink substance
ruptured amniotic sac- ‘my water broke’
both stimulate contractions

113
Q

What are BRaxton hicks contractions?

A

pre-labour contractions

114
Q

What is the maximum duration of the first stage of labour?

A

<12 hours

115
Q

What are the 3 P’s of the second stage of labour?

A

powers- 4-5 times every 10 mins
passage
passenger

1 Obs & Gyn (31 decks)

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