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Labour & perinatal Flashcards

1
Q

What is the fetus’s role in labour induction?

A

ACTH production
-> Cortisol
-> Androgens
Stimulates placenta

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2
Q

What is the placenta’s role in labour induction?

A

Decreased progesterone synthesis stimulate uterus
Increased oestrogen
Increased prostaglandins simulate mother

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3
Q

What happens in the mother in the induction of labour?

A

Less progesterone-> increased sensitivity to uterine stretching
Prostaglandins -> uterine contractions, increased uterine sensitivity to oxytocin, softened cervix

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4
Q

What does stretching of the cervix initiate?

A

Oxytocin-> uterine contractions and labour

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5
Q

How is labour artificially induced?

A

Prostaglandins

Artificial rupture of membranes

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6
Q

When is Induction of labour indicated?

A

PROM but no spontaneous labour
Maternal diabetes
Post-term

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7
Q

Name some good positions for women in labour

A 
Birthing ball
Walking up stairs
Leaning against a wall
Standing
Sitting backwards on a chair
In birthing pool
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8
Q

What are the 3 Ps of labour

A

Passage
Passenger
Power

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9
Q

What is meant by passage in 4P’s of labour?

A

Maternal position
Cervical dilation
Pelvic laxity

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10
Q

What is meant by passenger in 4P’s of labour?

A

Fetal size, presentation, position, malformations

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11
Q

What is meant by power in 4P’s of labour?

A

Uterine contractions and voluntary bearing down

3 layers of uterus (outer longitudinal, inner circular, thick middle spiral)

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12
Q

What cephalic presentations are there?

A 
Fully flexed (vertex)-> deflexed (brow)-> extended (face)
Then described by occiput position (left occiput transverse/posterior/anterior)
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13
Q

What is the best rate for contractions

A

3-4 regular contractions every 10 mins

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14
Q

What types of breach presentation are there?

A 
Frank breech (extended)
Full breech (flexed)
Footling breech
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15
Q

What happens if there is a delay in the 1st stage of labour

A
  • Come to labour ward
  • Rupture the membrane (amniotomy)
  • Reassess after 2 hrs
  • Consider oxytocin infusion
  • C section if no advance
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16
Q

What happens in the 2nd stage of labour?

A

• Passive (full dilation, absence of involuntary expulsive contractions)
• Active (baby is visible, expulsive contractions)
• Active maternal effort once confirmed full cervical dilation
Birth of baby

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17
Q

What counts as delayed 2nd stage?

A

2hrs of active 2nd stage in nulliparous, 1hr multiparous
3hr nulli w/epidural, 2hrs multip w/epidural
30mins of active 2nd stage if severe cardiac disease, hypertensive crisis, myasthenia gravis, spinal cord injury

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18
Q

Management of delayed 2nd stage?

A

ARM (artificial rupture of membranes)
Instrumental delivery?
C-section

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19
Q

What is the 3rd stage of labour?

A

Birth of placenta

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20
Q

What is the normal time frame from birth of baby until birth of placenta

A

10-15mins

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21
Q

Explain difference between physiological 3rd stage and active 3rd stage

A

Physiological: no uterotonics, clamp once cord stopped pulsating, delivery by maternal effort
Active: Uterotonics, clamp cord early, controlled cord traction with guarding of the uterus

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22
Q

What is usually used as a uterotonic in active 3rd stage?

A

IM sintocin, ergometrin

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23
Q

What is done if placenta isn’t delivered within 30 mins of baby?

A

Uterotonic administration

Manual removal of placenta

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24
Q

How are perineal tears classified?

A

Into degrees:
• 1st degree: injury to perineal skin
• 2nd degree: injury inclused perineal muscles but not to anal sphincter
• 3rd degree: anal sphincter affected
• 4th degree: injury to perineum involving anal sphincter complex and anal epithelium

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25
Define epesiotomy
Deliberate right medio-lateral perineal incision involving perineal muscles
26
What does CTG stand for?
CardioTocoGraph
27
Options for analgesia during labour?
``` • Breathing, relaxing and massage • Labouring in water • TENS (trans electrical nerve stimulation) • Entonox (O2, nitrous oxide) • Opioids (pethidine, remifentanyl) • Epidural Spinal (into subarachnoid space) Perineal infiltration Pudendal block ```
28
Define lochia
Lochia: postpartum vaginal discharge (blood, mucus, uterine tissue) can be for up to 8 weeks
29
Define perinatal mortality
Number of stillbirths plus the number of early neonatal deaths/1000 births The pregnancy has to be more than 24 weeks. Early neonatal is within 7 days after birth.
30
Risk factors for neonatal deaths
* Twins * Black/black British * Asian/Asian British * Mothers living in poverty * Teenage mothers
31
6 causes of still births (in order of magnitude)
* 46% unknown * 22% placental problems * 6% congenital anomalies * 11% complications before or during labour * 4% umbilical cord * 3% infections
32
What are the main infections causing neonatal mortality?
* TORCH * Toxoplasmosis * Rubella * CMV * Chlamydia * Zika
33
Can twins be born vaginally?
Yes if 1st baby is cephalic presentation 2nd must be delivered within 60 mins Give birth in an operating theatre as likely to need intervention Give epidural, may need ECV, episiotomy CTG and monitoring done (one vaginally via cephalic monitor) Risk of chin locking -> emergency C section
34
Incidence of prematurity
5-10% incidence
35
Causes of prematurty
1/3 pre-term labour 1/3 PPROM 1/3 clinically indicated induced
36
Definition of preterm labour
Spontaneous onset of labour (regular contractions, progressive cervical changes and ruptured membranes) between 24+0 and 36+6 weeks gestation
37
Classifications of preterm
* Mildly preterm: 32+0 -37+0 * Very preterm: 28+0 -32+0 * Extremely preterm: <28+0
38
Implications of prematurity
* Highest cause of perinatal morbidity and mortality * Long-term morbidity including developmental delay, cerebral palsy and chronic lung disease * The lower the gestation, the higher the morbidity
39
Mechanisms of prematurity?
Poorly understood: • Declining progesterone levels • hCG binding reduced earlier, therefore reduced tocolytic effect -> myometrial contraction via oxytocin and Ca2+ influx • Changes in GPCR expression (oxytocin receptors, endothelin receptors, prostaglandin receptors) • Gap junctions forming earlier between myometrial cells-> synchronised contraction
40
Risk factors for prematurity
* 30% are unexplained and spontaneous * Antepartum haemorrhage * Overdistention of the uterus (eg multiple pregnancy) * Infections (eg STIs, endometritis, UTI, BV) * Fetal congenital abnormalities * PPROM * Cervical insufficiency * Previous Hx * Extremes of maternal age * Pregnancy complications (PET) * Uterine abnormalities (eg bicornuate uterus) * Maternal lifestyle (smoking, stress, extremes of weight) * Poorly controlled maternal medical conditions
41
Preconception prevention of prematurity
* General lifestyle * Fewer embryo’s transferred in IVF * HPV vaccination (less invasive CIN treatment, less risk)
42
Modifiable risk factors of prematurity
* Smoking cessation * Recreational drug use * Low maternal weight * Domestic violence * Asymptommatic UTIs
43
What does NOT help reduced prematurity?
* Bed rest * Abstinence from sexual intercourse * Dietary manipulation (eg caffeine) * Increased antenatal care for socially deprived populations
44
What can be used as prophylaxis for premature labour?
* Vaginal progesterone (anti inflammatory and reduced calcium influx) * Cervical cerclage (increases mechanical support to maintain cervical length and mucus plug)
45
When are tocolytics used in preterm labour?
Use tocolytics ONLY to transfer to tertiary centre if very prem or to aid completion of corticosteroid course (no effect on perinatal/neonatal morbidity)
46
How do you monitor for magnesium toxicity?
HR, BP, RR, deep tendon reflexes
47
What is given for neural protection in premature labour?
IV MgSO4 for neural protection (4g IV bolus, IV infusion 1g/hr for 24hrs/birth)
48
What should be avoided before 34weeks gestation?
* Fetal blood sampling if <34 weeks | * Avoid vontouse <34 weeks
49
When are maternal corticosteroids given? Function?
24-34 weeks gestation to lower perinatal mortality by improving lung maturity, reducing intraventricular haemorrhage and necrotisin enterocolitis Dexamethasone IM 12-24hrs apart
50
Define PPROM
* Preterm premature rupture of membranes * Preterm: 24-37weeks gestation * Premature: Pt presents with ROM prior to onset of labour
51
What is prolonged ROM?
Any Rom that persists for more than 24hrs prior to labour
52
Fetal risks and maternal risks of PPROM
* Fetal risks: prematurity, pulmonary hypoplasia, RDS, sepsis, IVH) * Maternal risks: chorioamonitis, sepsis, abruption
53
Management of PPROM
* Maternal and fetal surveillance (CTG) * Sterile speculum examination for inspection of cervical dilation (avoid DVE) * DVT prophylaxis & avoid bed rest (TEDs, flowtrons, LMWH) * USS (gestational age, fetal weight and growth, presentation, amniotic fluid index) * Cervical cultures (c. trachomatis, N. gonorrhoeae, Strep) * Can be managed in community BUT warning signs: fever, abdo pain, vaginal spotting, foul smelling discharge, tachycardia) * Broad spectrum antibiotics * Steroids * MgSO4
54
When is immediate delivery indicated in PPROM?
* Chorioamonitis * Advanced labour * Fetal distress * Placental abruption * Non-cephalic fetus with advanced cervical dilation (risk of cord prolapse)
55
Causes of abdominal pain in 3rd trimester
Obs (labour, placental abruption, symphysis pubis dysfunction, ligament pain, PET/HELLP, acute fatty liver of pregnancy) Gynae (ovarian cyst rupture/torsion, fibroid degeneration) GI (constipation, appendicitis, gall stones/cholecysitis, pancreatitis, peptic ulcer) GU (cystitis, pyelonephritis, renal colic)
56
Define stillbirth
A baby born without signs of life after 24 weeks gestation
57
Define intrauterine death
A fetus in utero, greater than 24 weeks, found to have no cardiac activity
58
Name 7 maternal causes of stillbirth
``` Diabetes PET Sepsis Obstetric cholestasis Acute fatty liver Thrombophilia V Leiden mutation ```
59
Name 6 fetal causes of stillbirth
``` Infection (toxoplasma, syphilis, parvovirus) Chromosomal abnormality Sturctural abnormality Rhesus disease-> anaemia TTTS IUGR Autoimmune thrombocytopenia ```
60
Name 4 placental causes of stillbirth
Postmaturity Abruption Significant placenta praevia bleed Cord prolapse
61
What defines onset of labour?
Painful regular contractions Cervical dilation>4cm and effacement +/- mucus plug 'show' and ROM
62
Describe the mechanism of delivery of baby
Flexion of head Internal rotation Extension External rotation
63
Causes of malpresentation (eg transverse lie)
``` Contraction of pelvis Fibroid Mullerian abnormality (eg uterine septum) Multiparity Prematurity Placenta praevia Polyhydramnios Fetal anomaly (hydrocephalus, neck tumours, anencephaly, decreased fetal tone) ```
64
Define ECV
External cephalic version Manual manipulation to turn baby to cephalic presenatation To return to a low risk pregnancy Done at 37 weeks
65
Success of ECV
35%
66
Complications of ECV
Placental abruption Cord entanglement -> fetal distress in 1% Turn back to breech (5%)
67
Contraindications for ECV
``` Needs a c-section anyway Uterine abnormality Fibroids Previous C-section Fetal abnormality (eg hydrocephalus) ```
68
How is ECV carried out?
USS guided With use of tocolytics? On the labour ward when an emergency theatre is available If Rh-ve need Anti-D
69
Causes of failure to progress
Passage (abnormal shaped pelvis, cephalopelvic disproportion) Passage (fibroids, cervical stenosis, circumcision) Passenger (fetal size/abnormality/malpresentation/malposition) Power (lack of coordinated regular strong contractions)
70
Define shoulder dystocia
Problem if the pelvic inlet preventing delivery of the shoulders once the head has been born Pulling risks brachial plexus, hypoxia, pressure on umbilical cord
71
Management of shoulder dystocia
Lie pt flat, hips flexed, knees to chest Suprapubic pressure to dislodge anterior shoulder Internal rotation Deliver posterior arm
72
What do you look at on a CTG?
``` Define risk Contractions BRAVADO Baseline Rate Accelerations Variability And Decelerations Overall assessment ```
73
Normal baseline on CTG?
100-160bpm
74
Indications for continuous CTG in labour
``` Prev C section PET Diabetes Antepartum haemorrhage IUGR Prematurity Oligohydramnios Abnormal doppler artery study Multiple pregnancy Breech Meconium liquor Vaginal bleeding in labour Oxytocin use Epidural anaesthesia Maternal pyrexia PrlongedROM Induced labour ```
75
What can cause acute fetal hypoxia?
Uterine hyperstimulation Placental abruption Umbilical cord compression Sudden maternal hypotension (eg regional anaesthesia)
76
Describe ventouse delivery
KIWI cup used: - In delay of 2nd stage due to maternal exhaustion/fetal malposition - If CTG is abnormal - Only if head is below ischial spines - Only after 34 weeks gestations Place anterior to occiput, suction Traction with maternal contraction along pelvic curve (down then up) CTG throughout Should be done within 15 mins
77
2 types of forceps
Non-rotational | Rotational (sliding lock)
78
Indications for forceps delivery
Cardiovascular disease complicating labour Unconscious mother (cannot assist with pushing) Gestation less than 34 weeks Face presentation Fetal bleeding disorder Head of a breech delivery At c-section
79
Negatives of ventous delivery
Fetal cephalohaematoma More likely to fail than forceps Fetal retinal haemorrhage Neonatal jaundice
80
In a VBAC, what should be avoided in labour?
Amniotomy | Any intervention increases risk of scar rupture

O&G (12 decks)

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