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Becks obstetric Qs > Labour: management > Flashcards

Labour: management Flashcards

1
Q

Why is it important for the woman not to become stressed?

A

Because adrenaline is released and this is an inhibitor of uterine contractions - therefore prolonging labour.

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2
Q

What is measured during labour?

A

Temperature and blood pressure are monitored every 4 hours. Pulse every hour in the first stage and every 15 minutes in the second stage.

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3
Q

What positions are women often best to deliver in?

A

Semi-recumbent: left lateral lie, kneeling or squatting: all probably increase the dimensions of the pelvis.

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4
Q

Which position is avoided during delivery? Why?

A

Supine position due to the uterus compressing main blood vessels (aorta and vena cava), reducing cardiac output and causing hypotension, and often foetal distress.
Called: aortocaval compression.

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5
Q

What is pyrexia in labour associated with and what increases its likelihood?

A

Associated with neonatal illness.

More common with prolonged labour and epidural.

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6
Q

What is done when the mother has a temperature?

A

Paracetamol, IV antibiotics, CTG monitoring.

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7
Q

Why is it important to get the mother to urinate regularly during delivery with epidural?

A

Because epidural usually removes bladder sensation and neglected retention of urine can irreversibly damage the detrusor muscle.

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8
Q

How can you improve mental health during labour?

A

Environment - music playing, no resus kit out.
Birth attendant - continuous presence of a caregiver has been shown to reduce labour length, use of analgesia and the need for obstetric intervention.
Partner present.
Control - make sure the woman has realistic expectations before birth.

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9
Q

What is a partogram? What features does it have?

A

It is used to record progress in dilatation of the cervix and descent of the head. This is assessed on vaginal examination and plotted against time.
It has alert and action lines to try and indicate slow progress (NICE recommends slow progress has <2cm dilatation in 4 hours).
It also forms a record of maternal vital signs, foetal heart rate, contraction frequency and liquor colour.

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10
Q

What is the most common cause of slow progress in labour?

A

Inefficient uterine action.

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11
Q

What is the action for slow progress in labour?

A

Amniotomy and then 2 hours later if that hasn’t helped, you inject IV oxytocin.

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12
Q

What is hyperactive uterine action and what are the consequences?

A

Hyperactive uterine action = excessively strong or frequent or prolonged contractions.
Foetal distress occurs as placental blood flow is diminished and labour may be very rapid.

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13
Q

What is associated with hyperactive uterine action?

A

Too much oxytocin.
Placental abruption.
Side effect of prostaglandin administration to induce labour.

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14
Q

What is the treatment of hyperactive uterine action?

A

Salbutamol (which is a tocolytic) can be given if there is no evidence of an abruption.
Caesarian section is often indicated because of foetal distress.

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15
Q

How long does it take oxytocin to increase cervical dilatation? How long should you wait for full dilatation?

A

Should increased cervical dilatation within 4 hours.

You should wait 12-16 hours for full dilatation –> caesarian section after this time.

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16
Q

What should be used in the passive second stage if descent is poor?

A

Oxytocin infusion

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17
Q

In the active second stage, when should pushing be directed?

A

If pushing is ineffective or an epidural is present

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18
Q

How long should the active second stage of labour last?

A

Between 1-2 hours. Otherwise, traction is often applied to the foetal head with a ventouse or forceps.

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19
Q

Why do you need to be careful when giving oxytocin to a multiparous woman?

A

Because their uterus is more prone to rupture and slow progress in the first stage of labour is more likely to do with malpresentation or size of foetus than uterine contractions.

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20
Q

What is the difference between augmentation and induction?

A

Augmentation is the artificial strengthening of contractions in established labour.
Induction is the artificial initiation of labour.

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21
Q

As the head emerges from the public outlet in occiput-posterior position, what is the attitude over the perineum?

A

Flexion.

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22
Q

If there is a prolonged second stage in occiput-posterior delivery, what instrument is used?

A

Kielland’s forceps

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23
Q

If there is a prolonged second stage over an hour in the occipo-transverse position, what is used?

A

Ventouse.

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24
Q

When does the occipo-transverse position occur?

A

When normal rotation has not been completed. It is associated with poor ‘powers’.

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25
Q

What happens with brow or face presentation births?

A

Brow presentation - cannot be delivered vaginally, so caesarian section is used.
Face presentation - if the chin is anterior, it can be delivered vaginally with flexion at the perineum. If the chin is posterior, it cannot be as the head is already extended as much as it can be and so caesarian section is required.

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26
Q

What are the common causes of labour to fail?

A

Power: inefficient contractions
Passenger: foetal size, disorder of rotation, disorder of flexion (brow etc.)
Passage: cephalo-pelvic disproportion, pelvic mass, cervix possibly.

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27
Q

What is cephalo-pelvic disproportion?

A

It is a retrospective diagnosis best defined as the inability to deliver a particular foetus despite:

  1. Presence of adequate uterine activity.
  2. Absence of a malposition or presentation
28
Q

What is the point of the cervix before term?

A

To stop the foetus dropping out.

29
Q

What are the most common causes of foetal damage during labour?

A
  1. Hypoxia (foetal distress)
  2. Infection/inflammation in labour (e.g. group B streptococcus)
  3. Meconium aspirate leading to chemical pneumonitis
  4. Trauma is rarely spontaneous and more commonly due to obstetric intervention e.g. forceps.
  5. Foetal blood loss
30
Q

What is the definition of foetal distress?

A

Defined as hypoxia that might result in foetal damage or death if not reverse or the foetus delivered immediately.

31
Q

Why is immediate delivery required in foetal distress and what are the possible consequences?

A

Delivery allows ex utero resuscitation.

Hypoxia is the best known cause of intra-partum foetal damage - its affects vary considerably and are unpredictable.

32
Q

How is foetal distress diagnosed?

A

By foetal scalp (capillary) blood - pH < 7.20 indicates significant hypoxia, however the cord blood is usually 7.22. This means foetal distress is over diagnosed, and it is only below 7.00 that neurological damage is considerably more common.

33
Q

What mechanisms could lead to hypoxia?

A

Prolonged labour and those with excessive time pushing is more likely to end in hypoxia due to contractions temporarily reducing placental perfusion.
Acute hypoxia in labour can be due to placental abruption, hypertonic uterine states and use of oxytocin, prolapse of the umbilical cord and maternal hypotension.
Meconium and the use of epidurals can also lead to hypoxia.
Antepartum factors could be IUGR and pre-eclampsia.

34
Q

What methods are used to detect foetal distress?

A

Colour of the liquor: meconium –> when undiluted, perinatal mortality increases due to aspiration of the ‘pea soup’.
Foetal heart rate auscultation using a Pinard’s stethoscope or hand-held Doppler after a contraction. Every 15 minutes during stage 1 and every 5 minutes during stage 2.
Cardiotocography - measures foetal HR using a transducer vaginally or abdominally and another transducer synchronously records the uterine contractions.
Foetal ECG monitoring
Foetal blood sampling - uses a mental amnioscope inserted vaginally and through the cervix to clean and cut the scalp to take blood - this is measured for pH and lactate.

35
Q

What are the different levels for screening and diagnosing foetal distress?

A

Level 1: intermittent auscultation of foetal heart. If abnormal, or meconium, or long or high-risk labour, proceed to…

Level 2: continuous CTG.
If sustained bradycardia (>5 minutes), delivery immediately.
If abnormal on other criteria, simple measures to correct. If these fail, proceed to…

Level 3: Foetal blood sampling. If abnormal, proceed to…

Level 4: Delivery by quickest route.

36
Q

CTGs are classified as reassuring, non-reassuring and abnormal, according to which 4 features?

A
  1. Foetal heart rate (110-160bpm)
  2. Baseline variabilities (>5bpm)
  3. Accelerations (with movement or contractions are reassuring)
  4. Decelerations (benign if they are synchronous with a contraction as a normal response to head compression).
37
Q

What are the prelabour and in labour indications for using a CTG?

A

Pre-labour: pre-eclampsia, IUGR, previous caesarian section, induction.

In labour: presence of meconium, use of oxytocin, presence of a temperature >38*C, during administration of epidural analgaesia. Intermittent auscultation abnormalities.

38
Q

What is the management of foetal distress?

A

In utero resuscitation: oxygen and IV fluids to mother. Any oxytocin infusion is stopped and contractions can be stopped with terbutaline (beta-2 agonist).

Confirmation of distress and delivery: If simple measures fail, blood sampling is performed - if <7.20, deliver immediately. If >7.20 but abnormal HR, repeat in 30 minutes. If there is sustained bradycardia - delivery.

39
Q

What is maternal low-grade fever a risk factor for?

A

Seizures, foetal death and cerebral palsy.

40
Q

What is meconium aspirate?

A

Where meconium is aspirated by the foetus into its lungs where it causes severe pneumonitis.

41
Q

What are the non-medical pain reliefs in labour?

A

Antenatal classe preparation, the presence of a birth attendant and the maintenance of mobility all help women cope with labour pain.
Immersion in water at body temperature (different to water bath).

42
Q

What are the medical pain reliefs in labour?

A

Inhalation agents
Systemic opiates
Epidural anaesthesia

43
Q

What is the inhalation agent used for pain relief in labour?

A

Entonox - an equal mix of nitrous oxide and oxygen.

44
Q

What systemic opiates can be given during labour? How are they administered?

A

Pethidine and Meptid (occasionally diamorphine).

Intramuscular injection.

45
Q

What are the side effects of opiates being used during labour?

A

Maternal sedation, confusion or not feeling in control. Antiemetics are needed.
Respiratory depression in the newborn which requires reversal with naloxone.

46
Q

What is epidural anaesthesia?

A

Injection of a combination of opiate and local anaesthetic, delivered by an indwelling ‘epidural catheter’ into the epidural space between vertebrae L3-4 or L4-5.

47
Q

What are the disadvantages of epidural anaesthesia?

A 
Urinary retention
Not feeling the urge to push
Reduced mobility
Maternal fever 
Total spinal analgesia
Spinal tap
Higher instrumental delivery rate
48
Q

What anaesthesia are used for obstetric procedures?

A 
Spinal anaesthesia (into the CSF - short lasting but total analgesia for c-section or mid-cavity instrumental delivery)
Epidural anaesthesia (higher dose can be used for both instrumental delivery and caesarian section)
Pudendal nerve block (for low-cavity instrumental vaginal deliveries).
49
Q

What symptoms does accidental spinal tap cause?

A

Severe headache which is worse when sitting up.

50
Q

What is checked when a woman presents with labour?

A

Urinalysis, temperature, BP and pulse.
Presentation is checked.
Vaginal examination to check for cervical effacement and dilatation to confirm the diagnosis of labour.
Degree of descent
Colour of any leaking liquor to check for concentrated meconium.
Foetal HR every 15 minutes for 1 minute after a contraction.
CTG for those at risk

51
Q

How is progress assessed in the first stage of labour? How often is this?

A

It is assessed through vaginal examination to measure the cervical dilatation in cm.
Descent of the head is measured by its relationship to the ischial spines.
Measurements are recorded on the partogram.
Progress is assessed every 4 hours.

52
Q

If the mother is numb from the epidural, in stage 2, how long is she to push for on directed pushing?

A

3 times for about 10 seconds during each contraction.

53
Q

If delivery is not imminent after how long should a woman have expedition of delivery? How is this carried out?

A

2 hours for nulliparous and 1 hour for multiparous women.

This is achieved with a ventouse or forceps.

54
Q

What position should the mother not be in for delivery?

A

On her back

55
Q

What position is the resuscitation position for a hypoxic foetus?

A

Mother in the left lateral lie (fluids are given and oxytocin stopped).

56
Q

How is an episiotomy performed?

A

Perineum is infiltrated with local anaesthetic and a 3-5cm cut is made with scissors from the centre of the fourchette at a 45* angle to the mother’s right side of the perineum.

57
Q

Why is the mother told to stop pushing as the head starts to deliver, and what else is done to prevent this?

A

She is told to stop pushing to prevent perineum damage. The attendant may press on the perineum and head to prevent rapid delivery and perineal damage.

58
Q

What is administered in the third stage of labour to help the uterus contract? When exactly is this given?

A

Oxytocin.

This is given after the shoulders have been delivered (shoulders of the last neonate in multiple pregnancy).

59
Q

What does administration of oxytocin reduce in the third stage of labour?

A

Postpartum haemorrhage and the need for a blood transfusion.

60
Q

What makes placental delivery evident?

A

Lengthening of the cord and the passage of blood.

61
Q

What is the placenta checked for on delivery?

A

Any missing cotyledons.

62
Q

What is checked on the woman after delivery?

A

Perineal or vaginal tears.

63
Q

What is a retained placenta and how is it managed?

A

It is when the 3rd stage is >30 minutes.
Unless there is blood present (and hence partial separation of the placenta), this stage can be left for 60 minutes before the placenta is manually removed (a hand in the uterus under general or spinal anaesthesia and the other hand pushing suprapubically to prevent uterus being pushed up).

64
Q

What is the classification for perineal tear?

A

First degree tear: Injury to skin only

Second degree tear: Involving perineal muscles but not anal sphincter

Episiotomy: Equivalent to second degree, but may extend to 3rd/4th

Third degree: Involving anal sphincter complex.

Fourth degree: Involving anal sphincter and anal epithelium.

65
Q

How are perineal tears treated?

A

First and second degree tears, and episiotomies are sutured under local anaesthetic. Absorbable synthetic material is used.

3rd and 4th degree tears: sphincter is repaired under epidural or spinal anaesthesia - this requires experience. Antibiotics and laxatives are given, as well as analgesia.

Becks obstetric Qs (18 decks)

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