Labour - Management Flashcards
How should blood pressure and temperature of a woman in labour be managed?
temperature and BP monitored every 4 hours - pulse every hour (1st stage) and then every 15 mins (2nd stage) and contraction frequency should be measured every 30 mins
In what position do most ladies deliver in?
Semi-recumbent position - e.g. squatting, kneeling, or left-lateral position
supine is avoided as can lead to compression of main blood vessels leading to reduced CO, hypotension and foetal distress
Can women eat during labour?
Yes, unless high risk, as may need general anaesthetic
What is pyrexia in labour associated with?
what is the management of pyrexia in labour?
Increased risk of neonatal illness - more common with epidural and prolonged labour. Paracetamol is administered, and IV antibiotics and CTG monitoring are warranted if the fever reaches 38 degrees.
What is the effect of retention of urine?
Irreversible damage fo the detrusor muscle - frequent micturition is encouraged in labour
catheterisation is required if an epidural is in situ.
What is progress in labour dependent?
Power (uterine contractions)
Passenger (size, presentation and position of the baby)
Passage (the shape and size of the pelvis and soft tissues)
What is the minimum rate of dilation after the latent phase?
1cm/hr
What is the most common cause of slow progression of labour?
inefficient uterine action - common in nulliparous women and induced labour
Persistently slow progress is treated with augmentation, initially with amniotomy and then oxytocin
In what circumstances does hyperactive uterine action occur?
Excessively strong, frequent or prolonged contractions
What are the complications of hyperactive uterine action?
foetal distress occurs as placental blood flow is diminished and labour may be very rapid
associated with placental abruption, too much oxytocin or a side effect of PG administered to induce labour.
What is the treatment of hyperactive uterine action?
if no abruption - can be treated with a tocolytic (salbutamol IV) - but C-section is often indicated because of foetal distress
What is slow progress in nulliparous women usually due to?
Inefficient uterine action
How can slow progress in nulliparous women be managed?
Amniotomy, also known as artificial rupture of membranes (ARM) for women with intact membranes
Oxytocin infusion
Instrumental delivery
Caesarean section
Oxytocin - first-line to stimulate uterine contractions during labour. It is started at a low rate and titrated up at intervals of at least 30 minutes as required. The aim is for 4 – 5 contractions per 10 minutes.
What is the management for poor descent?
oxytocin induction - pushing not encouraged until the woman feels the urge - epidural diminishes this urge
If active 2nd stage lasts longer than 1-2 hours, what is the management?
Instrumental delivery - maternal exhaustion, foetal hypoxia and maternal trauma
What needs to be excluded in augmentation of labour in a multiparous woman?
Malpresentation
In what ways can the foetus contribute to poor progress in labour?
OP position
OT position
Brow presentation
Face presentation
What are the indications for instrumental delivery?
Failure to progress
Fetal distress
Maternal exhaustion
Control of the head in various fetal positions
What positions of the head make labour more difficult?
OA preferred
OP or OT make difficult
What is the management of OT position?
OP?
rotation with traction is required for delivery to occur and is achieved with the ventouse
OP: Keilland’s forceps
What is the effect of Brow presentation?
extension of the foetal head on the neck results in a large diameter that will not normally delivery vaginally.
anterior fontanelle, supraorbital rides and nose are palpable vaginally
What is the management of Brow presentation?
C-section is required
What is the effect of face presentation?
Complete extension of the head resulting in the face being the presenting part.
Foetal compromise in labour is more common. Presenting diameter is 9.5cm allowing vaginal delivery in most cases, as long as the chin is anterior.
Delivery is completed by flexion over the perineum. If the chin is posterior, then a C-section is indicated
What is cephalo-pelvic disproportion?
When the pelvis is too small to allow passage of the head, but can almost ever be diagnosed with certainty.
Depends on foetal and pelvic size and usually diagnosed retrospectively.
Defined as: inability to delivery a particular foetus despite presence of adequate uterine activity and absence of a malposition or presentation
What increases the chance of cephalo-pelvic disproportion?
Large baby
very short woman
where the head in a nulliparous woman remains high at term
What pelvic abnormalities prevent engagement and descent of the head?
Pelvic mass
ovarian tumour or uterine fibroid
C-section indicated
What are the causes of permanent foetal damage?
Foetal hypoxia - commonly described as distress
Infection/inflammation in labour - e.g. GBS
Meconium aspiration leading to chemical pneumonitis
Trauma - commonly due to obstetric intervention (e.g. forceps)
Foetal blood loss
What is foetal distress?
Hypoxia that might result in foetal damage or death if not reversed or the foetus delivered urgently.
What is the threshold that indicates severe hypoxia?
Foetal scalp blood with pH of <7.2 indicated significant hypoxia.
pH <7 - neurological damage is considerably more common and even then, most babies with neurological damage had a normal pH at birth. this suggests other influences, such as IUGR or maternal fever on neonatal outcome
What can acute hypoxia in labour be due to?
Long labour Placental abruption Hypertonic uterine states Use of oxytocin Prolapse of the umbilical cord Maternal hypotension
What are the intrapartum risk factors of foetal distress?
long labour
meconium
epidurals
oxytocin
What are the antepartum risk factors of foetal distress?
Pre-eclampsia
IUGR
How is foetal distress diagnosed?
Colour of the liquor
Foetal heart auscultation
CTG
Foetal blood sampling
What is meconium?
Bowel contents of the foetus that stains the amniotic fluid
Rare in preterm foetuses, but common after 41 weeks.
Why is colour of the liquor an indication for caution?
meconium very diluted in amniotic fluid is not significant but undiluted - increase in perinatal mortality
- foetus may aspirate it - meconium aspiration syndrome
- Hypoxia more likely