Labour - Normal and Failure to Start Flashcards
What is normal labour and what signs suggest
Spontaneous 37-42 weeks Show (mucous plug) Rupture of membrane Regular painful contractions
What 2 changes occur and what allows this
Cervical dilatation + effacement
Contractions
Progesterone decreases
Oxytocin and prostaglandin increase
What does a partogram monitor
Fetal HR Cervical dilatation Contractions - duration and strength Maternal BP Maternal pulse Urine output Temperature Medication given
What is plotted separately
If syntocin or epidural use
How often are contractions measured
Every 10 minutes
What is stage 1
0cm dilated - 10cm
Latent stage
Established
What is latent stage 1
Irregular painful contractions
Cervical effacement (thin and short)
Dilatation to 3cm
What is established stage 1
Regular painful contractions
Brings dilatation to 10cm
How many contractions in established
3-4 every 10 minutes
Lasting 30-40s
How do you assess progress
Abdominal and vaginal examination
Every 4 hours
What are the typical times stage 1
8 hours prim
5 hours multi
What is poor progress
<0.5cm-1cm per hour
What is passive stage 2
Full dilatation -> expulsive contration
How long in passive
1 hour
What is active stage 2
Presenting part is visible
Active maternal effort and pushing
How long in active
1-2 hours
What should you consider if active >2 hours
Ventouse
Forceps = best
C-section
When would you allow longer
If had epidural as slows down contractions
What are signs when in labour
Rhomboid of Michaelis - sacrum pushed out on skin
Anal cleft line - purple
What is stage 3
Expulsion of placenta and membranes
Membrane will rupture spontaneous or with a hook then placenta folds in
What is active management of stage 3
Empty bladder
Ureotonic drugs to get uterus to contract
- IM syntocin
Early clamping and cutting of cord - within 1 minute
Controlled cord traction to get placenta out
What is physiological mamnegemt
No drugs
No clamping until pulsating stop
Maternal effort to delivery
How long do you allow for physiological management
60 minutes
Only do if very low risk of PPH - active better to reduce the risk
How often should a foetus be monitored in each stage / fill in cartogram
15 minutes stage 1
5 minutes stage 2
Ausculate heart with special stethoscope
Continuous with CTG if any concern + partogram 30 minutes
What do you do if concerning CTG
Fetal scalp electrode
Fatal blood sampling to look at pH
If acidosis shown what do you do
Emergency C-section
If BE increased suggests compensating
What do you monitor on MEWS
Pulse BP RR Temp Sats Urine output
What does tachycardia suggest
Pain
Sepsis
Dehydration
Bleeding
What does tachypnoea suggest
Acidosis
Sepsis
PE
What does high BP suggest
New PET
Pain
What does low BP suggest
Blood loss
Shock
What should you look at when liquor passed
Colour - should be straw
Smell
Volume
Meconium if baby poos as distressed
What do you feel for in abdominal exam
Contraction
Presentation - cephalic / breech
Lie - transverse / longitudinal / oblique
Engagement
What do you feel for in VE
Dilatation Effacement Fetal station - Fetal position Fetal altitude - flexion
What does fetal station show
0 = engaged at level of ischial spine -3 = 3 above ischial spine 3+ = 3 below
What position do you want baby in
ROA or LOA
What do you do if baby OP
Longer and more painful delivery
Augmentation if slow
Forceps > ventouse
May need to rotate in theatre to OA
What is Lochia
Vaginal discharge after birth
Like a period
Normal for 4-6 weeks
What is the Apgar score
Physical state of infant 1 minute and 5 minutes + 10 after birth
What does Apgar look at
RR HR Colour Tone Reflexes
What score is normal and abnormal
> 7 =.normal
0-3 = very poor
What medication after labour
Vit K to baby to prevent haemorrhagic disease
VTE prophylaxis to mother
Ergometrine to help deliver placenta (not if raised BP)
Syntometrine (oxytocin + ergometrine) - more effective
Oxytocin alone if high BP
What does haemorrhagic disease present like
Bruising
Kidney necroiss
IVH
Anti-coagulant and breast feeding increase risk
What diseases in neonatal blood spot - day 5-9
Sickle cell Thalassemia Tay-Sachs CF PKU Congenital hypothyroid
Complications of labour
Slow progress Meconium aspiration Pyrexia Abnormal CTG APH PPH
What is a C-section indicated
Cephalic disproportion Malpresentation - ALL BREECH / transverse Placnta praevia / uterine rupture Fetus not engaged 2x previous C-section Uncontrolled HIV If abnormal CTG
What are relative indications
PET Post date IUGR Distress Failure to progress Abruption Infection Cervical cancer
What is most common C-section
- Anaesthetic
- What is given after
Low segment
Upper = higher risk of rupture
Usually done with spinal as less risk than general
Require TED stockings after and LMWH for 10 days if emergency
When is VBAC recommended and when is it CI
Always
Unless classic C-section scar or uterine rupture or praaevia
What is indications for forceps
Engaged foetus - can't do if not fully engaged and dilated Fetal or maternal distress in 2nd stage Failure to progress in 2nd stage Control of head in breech Rotate OP
What are risks to mother of C-section
Hysterectomy VTE Bladder / ureteric injury Haemorrhage Increased rupture / pravia risk in future pregnancy Wound infection Endometritis UTI Subfertility due to adhesion Ileus Death
What are risks to foetus
Laceration
Facial nerve palsy
Cephalohaematoma if ventouse
What causes ROPC
Uterus does not contract well as products still in cavity
Wha are symptoms of ROPC
Pain Heavy bleeding Discharge Offensive if infected Poorly contracted uterus
Higher risk of RPOC
C-section
How do you Dx
EUA
Speculum to see if os open or closed
How do you treat
Remove under anasthesia
Iv Ax
What are causes of failed 1st or 2nd stage
Inadequate uterine activity Cephalopelvic disproportion Malposition Cervical dystocia Cerivcal Rx Obstruction Distress
What are causes of failed 3rd stage
Placenta doesn’t detach
Cervix starts to close
Placenta accretia
When should you NOT induce
Obstruction e.g. praaevia as induction can cause rupture Malpresentation Asthma - prostaglandins Complication Fetal condition / distress / Abnormal CTG
What are 3P’s
Power
Passage
Position - OP
What are indications for induction
DM / macrosomia 7+ days term Bishops <5 CI C-section Maternal health - PET / cancer Rhesus incompatbility Reduced foetal movement Growth concern Oligohydramnio Maternal request Social Pain PPROM Twins
What is Bishops score
Assess whether induction is required or if spontaneous labour will occur
- Assess station, cervical dilatation, effacement + position
<5 = unlikely spontaneous
>9 = spontaneous
What does CTG do
Monitor contraction and fatal HR
What is likely cause of foetus not engaged
Malpositoin
DIsproportion of size
If not engaged wat is needed
C-section
If foetus engaged
Forceps if not progressing
May need to rotate
How do you attempt to start labour
Vaginal prostaglandin pessary if cervix not dilated
Membrane sweep
2nd line
Amniotomy
IV oxytocin after amniotomy to achieve contraction after amniotomy or if poor progress
Balloon catheter
What score before amniotomy
Bishops >7
If high risk after delivery what do you get
15 minute obs Ensure no abnormal bleeding Ensure uterus contracted Ax VTE
What does assisted delivery need
Full dilatation
When are C-sections essential
Obstructed / distress
Not fully dilated
Where do you want placenta
Posterior as cutting anteriorly
Complications of induction
Higher chance of instrumental / CS Less efficient More painful Anasthesia Fetus distress = CTG Hyperstimulation
What is normal post partum
Midwife
HV
Observe for bleeding / infection
Infant bonding / social issues
Relationship between oxytocin and oliguria
Produced in PP
Same place as where ADH produced
Small ADH effect
Cause oedema and marked diuresis after delivery
When do you do continuous CTG
Risk of hypoxia Suspect sepsis Severe hypertension / PET APH Post date Induction Epidural Oxytocin use Prolonged labour Meconium passed Fresh vaginal bleed - sign of PPH Fetal distress Medical conditions
How do you read CTG
DR C BRAVADO
DR
Define risk
If high risk pregnancy = lower threshold
C
Contraction
How many
Duration
Intensity
BRA
Baseline rate
Average in 10 minutes
Ignore accelerations
110-160 normal
What does Brady suggest
Maternal BB
Cord prolapse
Hypoxia
Increased vagal tone
What does tachy suggest
Maternal pyrexia
Chorioamnitis
Hypoxia
Premature
V
Variability
Want 5-25BPM - shows intact near changing to environment
If poor >40 minutes = bad
What does poor variability suggest
Premature Hypoxia Acidosis Benzo / opioids Congenital heart Sleeping
A
Acceleration
Reassuring
Occur with contraction
D
Deceleration If with contraction + resolve by end = fine If persistent = close monitor Shallow = worry if late = fatal blood sample
What does late deceleration suggest
Distress
Asphyxia
Placental insufficiency
Usually need emergency C-section and senior review but get foetal blood sampling if no condition
What does early suggest
Head compression
What does variable suggests
Cord compression
O
Overall impression
- Reassuring
- Suspicious
- Abnormal
What is needed before assisted delivery
F –fully dilated cervix O – OA but oP possible R – ruptured membrane C – cephalic E – engaged P – painrelief S – sphincter empty ( catheter)
What is associated with high mortality if breech
Footing
What increases risk of breech
Uterine malformation / fibroid Praevia Poly or oligohyramnios Premature Fetal abnormality
What do you do if breech and <36 weeks
Resolve spontaneously
What would you do if breech and >36 weeks
External cephalic version
- Applying pressure on the abdomen to try turn the baby
What do you do if ECV doesn’t work and when would you require C-section
Discuss options for vaginal birth or C-section C- section safer Footling birth - feet below bottom SGA or LGA Placenta praevia PET
What is CI to ECV
If C-section required Abnormal CTG APH Major uterine anomaly Ruptured membrane Multiple babies
What are complications of breech / transverse
Cord prolapse
DDH
If breech and in labour what do you do
C-section
Breech extraction is difficult
What is used if failure to progress
IV syncotin to stimulate contractions
Want 4 in 10 minutes
What are complications of C-section
Anaesthetic risk General - bleeding, pain, infection, VTE Damage to local structures Adhesions Hernia Increased risk of C-section, uterine rupture, praevia and still birth
What are complications for baby
Laceration
TTN
What happens after birth
Vit K to baby Skin to skin contact Initiate breast Newborn exam within 24 hours Neonatal blood spot Newborn hearing
Complications of traumatic labour to baby
Cephalohaematoma Facial paralysis Erb's Fractured clavicle Lacerations
How does fractured clavicle present
Dx on baby exam Asymmetry Lack of movement Pain and distress Dx on USS / X-ray
How do you treat
Immobilisation
What features on CTG need senior review / foetal blood sampling
1+ abnormal
What features require C-section
Bradycardia
Single prolonged deceleration >3 minutes
What are conservative measures in meantime
Increase fluid
Move to left lateral
