Labour - Normal labour, Induction, Assisted delivery, Perineal tears and episiotomies, Umbilical cord prolapse, CSection Flashcards
Signs of labour
Regular, painful uterine contractions
Mucus plug/bloody show
Rupture of membranes
Cervical shortening and dilation
Stages of labour
-Stage 1
-Stage 2
-Stage 3
Stage 1 - onset of labour => 10cm dilation
-latent phase - 0-3cm dilation (6hrs)
-active phase - 3-10cm dilation (1cm/hr)
Head enters pelvis in occipito-lateral position
Head delivered in occipito-anterior position
Stage 2 - dilation => delivery of baby
-passive 2nd stage - no maternal pushing
-active 2nd stage - active maternal pushing
Less painful and faster than Stage 1 (lasts 1hr)
Associated with transient fetal bradycardia
Stage 3 - delivery of baby => delivery of placenta
Labour monitoring
FHR every 15mins/continuously via CTG
Contractions assessed every 30mins
Maternal HR assessed every 60mins
Maternal BP and temp assessed every 4hrs
VE offered every 4hrs - check progression of labour
Maternal urine assessed for ketones, protein every 4hrs
Perineal tears and episiotomies
-degree of tears and their management (1st-4th)
-risk factors
-role of episiotomies
Degree of tears
1st - superficial, no muscle involvement => no repair
2nd - perineal muscle injury only => suturing
3rd - EAS and IAS involvement => surgical repair
4th - EAS, IAS and rectal mucosa => surgical repair
Primigravida
Large babies
Precipitant labour - born within 3hrs of labour starting
Shoulder dystocia
Forceps
Mediolateral incision to hep prevent perineal tears
Assisted delivery
-forceps
-ventouse
Forceps - placed around baby’s head so they can gently be pulled out
Can leave bruises on side of head, but they heal quickly
Ventouse - use suction to pull baby out
Slight risk of cephalohematoma, but this rarely causes problems
Umbilical cord prolapse
-what is it
-risk factors
Umbilical cord descending before fetus
=> cord spasm or compression, leading to fetal hypoxia and irreversible death
Prematurity, multiparity, twin pregnancy
Polyhydramnios
Cephalopelvic disproportion
Abnormal presentation
COMMONLY CAUSED BY ARTIFICAL RUPTURE OF MEMBRANES
Diagnosed when FHR abnormal + cord is palpable vaginally/beyond level of introitus
Presenting part of fetus pushed back into uterus to avoid compressions
Minimal handling of cord to avoid vasospasm
Mother on all 4s until emergency CSection preparation made
If cervic dilated and head low, can try instrumental delivery
Tocolytics - terbutaline
Refill bladder with 500-700ml saline to elevate presenting part
Risks with prematurity
Increased mortality depends on gestation
Resp distress syndrome
Intraventricular hemorrhage
Necrotizing enterocolitis => gut inflammation, leading to necrosis and perforation
Chronic lung disease, hypothermia, feeding problems, infection jaundice
Retinopathy of prematurity
-cause of visual impairment before 32wks
Hearing problems
Shoulder dystocia
-why does this happen
-risk factors
-management
-complications
Impaction of anterior fetal shoulder on pubic symphysis
Cause of maternal and fetal morbidity
Fetal macrosomia (maternal DM)
High maternal BMI
Prolonged labour
McRoberts - flex, abduction maternal hips
Maternal
-PPH
-perineal tears
Fetal
-brachial plexus injury
-neonatal death
Induction of labour
-indications
-score to assess whether induction is needed
-management
-complications
Labour started artifically when
-prolonged pregnancy
-PPROM where labour does not start
-maternal medical problems (diabetic mother, pre-eclampsia, obstetric cholestasis
Bishop score - assess whether induction of labour will be needed
-look at cervical position, consistency, effacement, dilation, fetal station
U6 - PV prostaglandin or PO misoprostol
6+ - artifical rupture of membrane and IV oxytocin infusion
Other methods
-membrane sweep - separate chorionic membrane from decidua
MOST COMMON COMPLICATION - Uterine hyperstimulation
-prolonged, frequent uterine contractions which canl lead to fetal hypoxia
=> remove vaginal prostaglandin and stop IV oxytocin, can consider tocolysis
CSection
-indications
Absolute cephalopelvic disproportion
Placenta previa covering part of/whole cervix
Preeclampsia
Postmaturity
IUGR
Fetal distress in labour
Prolapsed cord
Failure of labour to progress
Malpresentation
Placental abruption if fetal distress
Vaginal infection
Cervical cancer - disseminates cancer cells
CSection
-categorisation by urgency
Cat 1 - immediate threat to life of mother or baby
-suspected uterine rupture
-major placental abruption
-cord prolapse
-fetal hypoxia
-persistent fetal bradycardia
Delivery within 30mins of decision
Cat 2 - maternal or fetal compromise
Delivery within 75mins of decision
-minimal abruption
-antepartum hemorrhage
-failure to progress
-maternal exhaustion
-maternal request
-non reassuring CTG findings
-undiagnosed breech
Cat 3 - delivery needed but MB stable
Cat 4 - elective
Maternal risks of CSection
Serious
-Emergency hysterectomy
-need for more surgery
-ICU admission
-VTE
-bladder/ureteric injury
-death
Common
-persistent wound and abdominal discomfort in first few months
-increased risk of repeat CSection when vaginal delivery attempted in subsequent pregnancies
-readmission
-hemorrhage
-infection (wound, endometritis, UTI)
Future pregnancy
-increased risk of uterine rupture
-increased risk of antepartum stillbirth
-increased risk of subsequent placenta previa
Fetal risks of CSection
Laceration
When is vaginal birth after CSection possible
VBAC 37wks+ with 1 past CSection
UNLESS PREVIOUS UTERINE RUPTURE OR CLASSICAL (vertical) CSection scar
Layers that need to be cut through in a CSection
Skin
Superficial fascia
Deep fascia
Rectus abdominis pushed laterally after incision of linea alba
Transversalis fascia
Extraperitoneal connective tissue
Peritoneum
Uterus
