Labour, delivery, and analgesia Flashcards
(115 cards)
1
Q
Discuss the anatomy of the maternal pelvis
A
ilium, pubic symphysis, pubic bone, iliac crest, ASIS, sacrum…
2
Q
Discuss the anatomy of the fetal skull
A
ant and post fontanelle
frontal, coronal, saggital suture
frontal, parietal, occipital bone
3
Q
Define vertex
A
the highest/apical point= fetal head (Vertix position)
4
Q
List two mechanisms of normal labour and delivery
A
effacement and dilation of cervix
expulsion of the fetus by uterine contractions
5
Q
List three factors that promote the initiation of labour
A
oxytocin, prostaglandins, CRH, inflammatory mediators
6
Q
List two factors that promote pregnancy versus labour
A
progesterone
nitric oxide
relaxin
catecholamines
7
Q
What is the source of progesterone during pregnancy?
A
corpus luteum for first 8 weeks then placenta
8
Q
What is the MOA of mifepristone?
A
progseterone antagonist- increases myometrial contractility
9
Q
What is the function of progesterone in pregnancy?
A
decreases uterine oxytocin receptor sensitivity and therefore promotes uterine smooth muscle relaxation
10
Q
Where is oxytocin produced from?
A
post pituitary
11
Q
What is the function of oxytocin?
A
stimulate uterine contractions
12
Q
What is the effect of prostaglandins on labour?
A
promotes cervical ripening and stimulate uterine contractility
13
Q
What is effacement?
A
Effacement refers to the thinning of the cervix during labor= ripening
14
Q
Name one factor that promotes cervical ripening
A
prostaglandins, inflammatory cells
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
16
Q
Which score is used to assess cervical ripening?
A
Bishop’s score
17
Q
How do you when the cervix is dilated?
A
dilatation of the external os
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
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
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)
21
Q
How can rupture of membranes be visualised?
A
speculum- pool of liquor can be seen in posterior vaginal fornix
22
Q
Name two complications of rupture of membranes?
A
ascending infection
chorioamnionitis
maternal and fetal sepsis (Rare)
23
Q
How many stages are there in labour?
A
3
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)
25
What does the second stage comprise?
from cervical dilatation (10cm) until baby is delivered
26
What are the two phases of the second stage of labour?
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
27
What is the third stage of labour?
From delivery of the baby until expulsion of the placenta and membranes
28
Name one risk associated with the third stage of labour
uterine inversion
29
How is engagement determined?
abdominally in fifths of fetal head palpable above the pelvic brim
30
List four assessments that should be conducted in labour
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
31
What might meconium staining in the vagina suggest?
fetal distress
32
What might moulding seen in the vagina suggest?
obstructed labour
33
List three things you should assess for during vaginal exam during labour
```
meconium
dilatation of cervic
station of presenting part
position of head
moulding/caput?
```
34
What is caput succedaneum?
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
35
What is station of the presenting part?
The station of the presenting part is recorded with respect to the ischial spines.
Spines is zero station.
36
List three positions that the fetal head can be in
L/R occipitoposterior
L/R occipitotransverse
L/R occipitoanterior
37
How is caput succedaneum classified?
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 ‘+++’.
38
What is moulding?
describes the change in head shape, which occurs during labour, made possible by movement of the individual scalp bones.
39
How is moulding classified?
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.
40
Is meconium a worrying sign?
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.
41
What is administered during the second stage of labour?
IM oxytocin after delivery of anterior shoulder
42
Why is oxytocin administered?
to reduce the risk of postpartum haemorrhage
43
What is a partogram?
Provides a graphic record of clinical findings and any relevant events during labour.
44
State three components of a partogram
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.
45
For how long is uterine activity recorded for during labour?
10 mins
46
Will a primiparous or multiparous labour take longer?
primiparous takes longer
47
What is precipitate labour?
expulsion of the fetus less then 2-3 hours of onset of contractions
48
Name one complication of precipitate labour?
placental abruption
| fetal distress
49
How is a diagnosis of slow labour/delay in labour made?
cervical dilatation <2 cm in 4 hours
50
What is malpresentation and provide two examples?
Any non-vertex position
| e.g. face, brow, breech, shoulder
51
List three risk factors/associations for breech
```
multiple pregnancy
bicornate uterus
fibroids
placenta praevia
polyhydamnios
oligohydramnios
neural tube defect
```
52
Before C-section, what should be tried with a baby in breech position?
external cephalic version = procedure used to help turn a baby in the womb before delivery
53
Define breech birth
A breech baby, or breech birth, is when your baby's feet or buttocks are positioned to come out of your vagina first.
54
Define maposition
abnormal position of the vertex relative to the maternal pelvis
55
Define prolonged pregnancy
>42 weeks
56
Name two risks associated with prolonged pregnancy
intrauterine death
| intrapartum hypoxia
57
When is induction of labour offered in prolonged pregnancy with no complications?
between 41 and 42 weeks
58
What is the most common indication for induction of labour?
prolonged pregnancy
59
List three indications for induction of labour (IOL), aside from prolonged labour
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
State two contraindications to IOL
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
State three methods for IOL
prostaglanding gel/tablet
cooks balloon
artifical rupture of membrane
syntocinon (synthetic oxytocin)
62
Why is CTG monitoring indicated during pharamcological IOL?
pharmacological preparations all cause uterine contractions and have the potential to reduce uterine blood flow and compromise the fetus
63
Which IOL methods can be used for unfavourable cervix? (bishop score<6)
prostaglandins and cooks balloon
64
Which IOL methods can be used for favourable cervix? (bishop score >6)
artifical rupture of membranes
| oxytocin
65
Name one risk associated with prostaglandin induction?
hyperstimulation
66
Define hyperstimulation
>5 contractions: 10 mins for 20 mins associated with signs of fetal compromise
67
What is augmentation?
the process of accelerating labour which is already underway
68
Name two non-pharmacological pain relief options in labour
1:1 support
environment
birthing pools
education
69
Name two pharmacological agents for pain relief in labour
inhaled analgesics- entonox
opioids- diamorphine + antiemetic
Pudendal analgesia
Epidural/spinal
GA
70
List two options for regional anaesthetics
epidural
| spinal
71
State three complications of regional anaesthetics
```
dural puncture headache
hypotension
local anaesthetic toxicity
accidental total spinal block
neurological complications- peripheral nerve injury
bladder dysfunction
```
72
List three risks associated with general anaesthesia during labour
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
What is a first degree perineal tear?
Injury to the vaginal epithelium and vulval skin only
74
Second degree perineal tear?
Injury to the perineal muscles, but not the anal sphincter
75
Third degree?
Injury to the perineum involving the anal sphincter complex
76
Fourth degree?
Injury to the perineum involving the anal sphincter complex and anal/rectal mucosa
77
What is an episiotomy?
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
Name two indications for episiotomy
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
List three components of immediate post-birth care
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
List three assessments of the newborn immediately post-birth
```
APGAR 1,5,10 mins
Clamp cut umbilical cord
Birth weight temp
Head, facial, digits, spine, external rotation
First micturation and feed
```
81
What should be administered to the baby immediately post-birth?
vit K
82
List three assessment of the mother immediately post-birth
```
vagina, uterine fundus
observe for trauma- e.g. perineal tear
baseline obs
record first micturition after birth
categories VTE risk
```
83
List three benefits of breast feeding for baby
```
reduced risk of infections
reduced risk of vomiting and diarrhoea
reduced risk of obesity
reduced risk of CDV in adult
strong emotional bond
```
84
State three benefits of breastfeeding for mum
lowers risks of breast cancer, ovarian cancer, osteoporosis, CVD, obesity
85
What should be discussed/assessed in the first 10 days post birth
Postnatal depression assessment
Physical exam of mum and baby
Discuss contraception
Emotional problems, support breastfeeding and parenting
86
Which investigations should you carry out on the mother at the late postnatal exam? (6 weeks)
FBC
| cervical smear
87
List three post natal complications
Anaemia
Bowel problems
Breast Problems
Perineal breakdown
Incontinence
Puerperal pyrexia
Secondary PPH
VTE
Mental Health Problems; Postnatal depression, Postpartum psychosis
88
Name one breast complication in women
mastitis= blocked mammary duct
89
Why does incontinence arise in women post natal?
neuropraxia= impaired pudendal nerve function after compression during delivery
90
What is puerperal pyrexia?
temp >38 degrees on any occasion in the first 14 days after birth
91
Name two causes of puerperal pyrexia
genital tract infection (endometritis)
UTI
DVT
Infection of breast
92
List two risk factors for maternal sepsis
maternal obesity
| c-section
93
What is the treamtent for DVT post partum?
LMWH
94
Differential for DVT?
thrombophlebitis 1%
95
List three signs of postpartum psychosis
```
fear
insomnia
agitation
irritation
anger
fear for own health and baby
grandiosity, suspisciousness, depression
```
96
Where should mother go with postpartum psychosis?
admission to a mother and baby unit with baby
97
How to distinguish between miscarriage and stillbirth?
miscarriage<24 weeks
| stillbirth >24 weeks
98
List three associations with stillbirth
```
advanced maternal age
maternal obesity
social deprivation
smoking
non-white
domestic violence
```
99
Discuss three causes of stillbirth
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
State two placental mediated causes of still birth
uterine rupture
placenta praevia
uterine abnormality
101
What are the components of still birth after care?
```
psychological care
memory box with photos, hand footprints
post-mortem
support groups
suppression of lactation
funeral arrangements
```
102
How is an active labour diagnosed?
fully effaced + around 3 cm dilated AND regular painful contractions
(+persistent backpain, spontaneous rupture of membranes, nausea/vomiting/diarrhoea)
103
What are Braxton-Hicks contractions?
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
What happens during the first stage of labour?
cervix fully dilated: 10 cm
105
What happens in the second stage of labour
delivery of baby
106
What happens in the third stage of labour?
delivery of placenta
107
List three mechanisms of birth (e.g. engagement)
```
engagement
descent and flexion
internal rotation
delivery by extension
external rotation
restitution
delivery of shoulders
```
108
What is a partogram?
A partogram is used to record all observations made when the woman is in labor.
109
What is measured on a partogram?
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
Name three differences between a spinal and epidural
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
List three analgesic options during labour
```
entonox
diamorphine IM
epidural
pudendal and perineal infiltration
bath, birthing pool
```
112
What are the first signs of labour?
mucus plug- pink substance
ruptured amniotic sac- 'my water broke'
both stimulate contractions
113
What are BRaxton hicks contractions?
pre-labour contractions
114
What is the maximum duration of the first stage of labour?
<12 hours
115
What are the 3 P's of the second stage of labour?
powers- 4-5 times every 10 mins
passage
passenger
