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Year 5 - Obstetrics and Gynaecology > Labour (term, preterm) > Flashcards

Labour (term, preterm) Flashcards

1
Q

What is the mechanism of labour?

A

Mechanism of labour:

  1. Engagement
  2. Descent
  3. Flexion
  4. Internal rotation
  5. Crowning
  6. Extension
  7. Restitution
  8. External rotation
  9. Delivery of the shoulders and foetal body
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2
Q

Define lie.

A

Lie of the foetus – describes the relationship of the foetus to the longitudinal axis of the uterus (can be longitudinal, transverse or oblique)

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3
Q

Define engagement.

A

Engagement – if ≤ 2/5th of the foetal head is palpable abdominally, the head is said to be ‘engaged’ (i.e. the widest part of the head has passed through the pelvic inlet)

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4
Q

Define position.

A

Position – describes the relationship of the foetal occiput to the sacrum of the mother once the foetal head is in the pelvic inlet (occipito-anterior (OA) is best for vaginal delivery)

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5
Q

Define station.

A

Station – the distance of the presenting part from the ischial spines, estimated as part of the vaginal examination, in cm.

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6
Q

Define presentation. When is it not applicable?

A

Presentation (N/A if transverse lie) – describes the part of the foetus that is occupying the lower segment of the uterus or pelvis (can be cephalic or breech: flexed, extended, footling, kneeling).

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7
Q

What are the types of breech presentation?

A

Footling - can be complete i.e. two legs down, or incomplete i.e. one leg down - the foot is the presenting part.

Frank (aka incomplete- extended legs) - both legs are flexed at the hip and extended at the knee. This is the most common type of breech presentation.

Flexed (aka complete) - both legs are flexed at the hips and knees, looks like fetus is sitting cross-legged

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8
Q

A 26-year-old woman is in the process of labour - she is having an increased frequency of contractions. She is currently 36+4 weeks into her term and up until now she has had no complications or problems with her pregnancy. All her antenatal scans were normal and had no concerns. She has already had one child, which was premature but had no complications during that birth. The patient is going through labour when the doctors remember that they must give her some medication during labour. What should the doctors prescribe for her?

  • Benzylpenicillin
  • Dexamethasone
  • Gentamicin
  • Oxytocin
  • Paracetamol
A

According to the NICE guidelines, any pre-term baby (as this baby is being delivered before 37 weeks) should be given GBS prophylaxis i.e. benpen

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9
Q

Name 4 signs of labour.

A
  • regular and painful uterine contractions
  • a show (shedding of mucous plug)
  • rupture of the membranes (not always)
  • shortening and dilation of the cervix
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10
Q

What are the 3 stages of labour? How long is each stage on average?

A

stage 1: from the onset of true labour to when the cervix is fully dilated; 8hrs in nullips

stage 2: from full dilation to delivery of the fetus; 1-2hr usually

stage 3: from delivery of fetus to when the placenta and membranes have been completely delivered; 5-10mins

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11
Q

How often is FHR monitored in stage 1 of labour?

A

FHR monitored every 15min (or continuously via CTG)

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12
Q

How frequently and what type of maternal obs are assessed in stage 1 of labour?

A
  • Contractions assessed every 30min
  • Maternal pulse rate assessed every 60min
  • Maternal BP, temp, VE, urine (volume, ketones, protein) every 4 hours
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13
Q

How often is vaginal examination (VE) done in stage 1 of labour? How often is urine checked and what for?

A
  • VE should be offered every 4 hours to check progression of labour
  • Maternal urine should be checked for ketones and protein every 4 hours
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14
Q

What is the difference between the active and latent phases of stage 1 of labour? How long does each stage take?

A

1st stage of labour

  1. latent phase = 0-3 cm dilation; usually takes 6hrs
  2. active phase = 3-10 cm dilation; usually 1cm/hr
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15
Q

How would you define normal and abnormal progress of active phase of stage 1 labour?

A

Normal progress = cervical dilatation of at least 1cm every 2 hours (usually 1cm/hr)

Abnormal progress = cervical dilatation of <2cm in 4 hours

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16
Q

What position does the fetal head enter and exit the pelvis in?

A

Head enters pelvis in occipito-lateral position.

The head normally delivers in an occipito-anterior position.

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17
Q

What are the two phases of stage 2 of labour?

A
  1. ‘Passive second stage’
    • no maternal urge to push
    • begins with full dilatation until head reaches pelvic floor
    • ends with onset of involuntary expulsive contraction
  2. ‘Active second stage’ refers to the active process of maternal pushing
    • there is maternal urge to push
    • begins with onset of involuntary expulsive contractions
    • ends with birth of baby

NB: stage 2: from full dilation to delivery of the fetus

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18
Q

What monitoring is done in the second stage of labour?

A
  • Every 5 mins (1: every 15min) – foetal HR (or continuous CTG if indicated)
  • Every 30 mins (1: every 30min) – frequency of contractions
  • Every 1 hour (1: every 1hr HR and rest every 4hrs respectively)– maternal HR, BP and vaginal examination
  • Document volume of urine passed, and test for ketones and protein

NB: brackets show how often these are done in stage 1

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19
Q

Define prolonged (2nd stage) labour.

A

Lasting:

  • >2 hours in a nulliparous woman OR
  • >2hr if the woman has an epidural OR
  • >1 hour in a multiparous woman
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20
Q

Define the 3rd stage of labour. How long does it last?

A

Begins with the birth of the baby and ends with complete delivery of the placenta and membranes

Average duration = 5-10 mins

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21
Q

When is the third stage of labour defined as prolonged?

A

Physiological if lasting >60mins

Active if lasting >30min

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22
Q

How is the third stage of labour managed? What is recommended?

A

Management of the 3rd stage can be described as:

Physiological

  • Where the placenta is delivered by maternal effort
  • Associated with heavier bleeding
  • Prolonged = lasting >60mins

Active

  • Recommended to all women
  • Involves administering 10 iU oxytocin IM to the mother (with the birth of the anterior shoulder or immediately after delivery)
  • Reduces incidence of PPH (from 15% → 5%)
  • Prolonged = lasting >30mins
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23
Q

What are the advantages of active management of 3rd stage of labour?

A

Reduces incidence of PPH (from 15% → 5%). Physiological is associated with heavier bleeding.

24
Q

What investigations and monitoring are done in the 3rd stage of labour?

A

Maternal obs for at least 2 hours AND:

  • Document volume of vaginal blood loss
  • Examine the delivered placenta for completeness
  • Inspect the vulva for evidence of tears
25
Q

What does the immediate care of the newborn involve?

A
  • Delayed cord clamping - 60seconds
  • Agpar score - at 1min, at 5min and at 10min (A score of 0-3 is very low score, between 4-6 is moderate low and between 7 - 10 means the baby is in a good state)
  • Dry the baby with warm blanket or towel
  • Encourage skin to skin contact
  • Encourage breastfeeding within 1hour
  • Measure newborn head circumference, birth weight, temperature,
  • Administer vit K
  • Attach wrist label for identification
26
Q

Define induction of labour. How common is it?

A

Induction of labour describes a process where labour is started artificially. It happens in around 20% of pregnancies.

27
Q

What are the indications for induction of labour?

A
  • prolonged pregnancy, e.g. 1-2 weeks after the estimated date of delivery
  • PPROM - labour does not start
  • diabetic mother > 38 weeks
  • pre-eclampsia
  • rhesus incompatibility
28
Q

Describe how the Bishop’ score is calculated. What score indicates that spontaneous labour is unlikely?

A

a score of < 5 indicates that labour is unlikely to start without induction

a score of ≥ 8 indicates that the cervix is ripe, or ‘favourable’ - there is a high chance of spontaneous labour, or response to interventions made to induce labour

29
Q

Name 5 methods for induction of labour.

A
  • Membrane sweep
  • Vaginal prostaglandins (PGE2)
  • Maternal oxytocin infusion
  • Amniotomy
  • Cervical ripening balloon
30
Q

How would you describe the options for IOL to the patient? What if IOL is declined?

A
  • Explore the sequence - need to come to hospital for induction
  • If they do not want IOL then offer elective LSCS
31
Q

What is a membrane sweep? When is it indicated?

A

Involves the examining finger passing through the cervix to rotate against the wall of the uterus, to separate the chorionic membrane from the decidua. Regarded as an adjunct to IOL rather than IOL.

Can be done by a midwife at the antenatal clinic.

Indications:

  • Nulliparous women are typically offered this at the 40- and 41-week antenatal visit,
  • Whereas parous women are offered it at the 41-week visit
32
Q

What is the preferred method for IOL by NICE?

A

NICE state that vaginal PGE2 is the preferred method of induction of labour, unless there are specific clinical reasons for not using it

33
Q

What are 5 contraindications to PGE2/Propess use for IOL?

A

Any contraindications to vaginal delivery OR

Fetal:

  • macrosomia
  • breech position
  • fetal distress

Maternal:

  • previous major surgery or rupture of the cervix
  • untreated PID
  • any previous Caesarean birth for uterine surgery
  • allergy to dinoprostone or any of the other ingredients of PROPESS

Placental:

  • placenta praevia, vasa praevia
34
Q

What does cervical ripening balloon involve?

A

Foley catheter balloon passed through the endocervical canal and gently inflated to dilate the cervix

35
Q

What are the complications of IOL?

A

Uterine hyperstimulation (main) = prolonged and frequent uterine contractions - sometimes called tachysystole. This can lead to….

Interruption of blood flow to placenta –> fetal hypoxaemia and acidaemia

Uterine rupture

36
Q

What is the management of uterine hyperstimulation?

A
  • removing the vaginal prostaglandins if possible and stopping the oxytocin infusion if one has been started
  • tocolysis with terbutaline
37
Q

Define preterm labour.

A

Onset of labour before 37 weeks gestation

Can be spontaneous or iatrogenic (induced to prevent fetal or maternal risks)

38
Q

How common is preterm delivery?

A

5-8%

Further 6% present with preterm labour but deliver at term

39
Q

What are the risk factors for preterm labour?

A

Maternal:

  • Previous preterm labour
  • Infection - e.g. haematogenous
  • Cervical weakness - e.g. cervical surgery
  • Haemorrhage - e.g. from plantal abruption,
  • Maternal stress i.e. socioeconomic conditions

Foetal:

  • Multiple pregnancy - myometrial stretch effect
  • Foetal stress - may be due to premature CRH release

Placento-uterine:

  • Chorioamnionitis - due to ascending infection
  • Polyhydramnios
  • Uterine anomalies e.g. abnormal cavity, bircnuate or arcuate uterus
40
Q

List 3 causes of ‘cervical incompetence’.

A

= the painless cervical dilatation that precedes some preterm deliveries.

  1. Surgery for CIN or cervical cancer
  2. Multiple dilatations of the cervix
  3. Unknown in many
41
Q

What investigations can be done for those at risk of preterm labour?

A

Tst cervicovaginal fluid for fetal fibronectin (fFN)

  • Presence between 22-36 weeks is a strong predictor of preterm delivery.
  • Those with negative test can be safely sent home (high negative predictive value of test)

Imaging

  • TVUSS scanning of the cervical length - can be done regularly and interventions carried out only if necessary
42
Q

What are the mechanisms of preterm labour?

A
43
Q

What is a good biochemical marker of preterm labour?

A

Fetal fibronectin (fFN)

This is present earlier than cervical dilation

Generally high >200ng/ml and >500ng/ml will mean high risk of delivery in <7 days at 34 weeks is 33% and 75% respectively.

44
Q

When can you not use fFN?

A
  • ROM
  • Placenta praevia
  • Cervical cerclage
  • Cervical dilation >3cm
  • Moderate or gross bleeding (although if there is only some blood then it can still be used)
45
Q

What are the types of prevention offered for those at high risk of preterm labour?

A
  • Vaginal progesterone = start at 16-24 weeks continued until 34 weeks
  • Prophylactic cervical cerclage = can be done as early as 12-14 weeks
  • Rescue cervical cerclage = done between 16 to 27+6 weeks gestation

Other:

  • Fetal reduction
  • Treatment of polyhydramnios
46
Q

What are the indications for each of the preventative options for preterm labour?

A

Vaginal progesterone

  • Hx of spontaneous preterm birth (<34 weeks)
  • Hx of mid-trimester loss (>16 weeks)
  • +/- cervical length <25mm on TV US scan

Prophylactic cervical cerclage

  • Hx of spontaneous preterm birth (<34 weeks)
  • Hx of mid-trimester loss (>16 weeks)
    • cervical length <25mm on TV US scan
  • OR
  • Cervical length <25mm on TV US scan WITH hx of cervical trauma#

Rescue’ cervical cerclage

  • Cervical dilatation (length >25mm) in the absence of uterine contractions (or other signs of labour) between 16 to 27+6 weeks gestation
47
Q

What investigations should be done for suspected preterm labour?

A
  • Cervical examination
  • ‘Point of care’ testing e.g. fetal fibronectin assay - negative means preterm delivery in the next week is unlikely
  • TVUSS - if length >15mm then delivery is unlikely
  • CTG and USS
  • Look for infection - vaginal swabs to check for infection +/- sterile speculum if membranes ruptures; CRP, WCC
48
Q

How do you manage preterm labour (i.e. presence of uterine contractions or other signs of labour)?

A
  1. Admit to antenatal ward
  2. Maternal corticosteroids - accelerate fetal lung maturation
  3. Tocolytics - delay delivery long enough for corticosteroid administration or transfer to a unit with neonatal facilities
  4. IV MgS - for neuroprotection of neonate IF BIRTH EXPECTED IN THE NEXT 24HRS
  5. Aim for delivery at 37 weeks
49
Q

What are the first and second line tocolytics of choice? When are the contraindicated?

A

1st line = nifedipine (calcium channel blocker)

2nd line = atosiban (oxytocin receptor antagonist)

Contraindicated in the presence of bleeding or infection

50
Q

What are the signs of toxicity of MgS and what is the management?

A

Toxicity can result in respiratory depression and arrhythmias

SO monitor for signs of toxicity every 4 hours (HR, BP, RR, deep tendon reflexes)

Antidote: 10ml 10% calcium gluconate over 10mins (and stop magnesium sulphate infusion)

51
Q

How is magensium sulfate given in preterm labour?

A
  • IV loading dose of 4g over 5-15min
  • Then IV infusion of 1g/hour
  • Continue until birth or for 24 hrs (whatever is sooner)
  • Monitor for signs of toxicity
52
Q

Why are NSAIDS like indomethacin not routinely used for mangement of preterm labour?

A

May lead to PPH in the fetal circulation. Reversible with early identification and discontinuation of treatment.

  • PG synthesis is responsible for the maintenance of PDA and inhibition can lead to its premature closure
  • Can occur as early as late second trimester but mostly at 32 weeks

Indomethacin use has been associated with an increased risk of necrotizing enterocolitis and neonatal renal dysfunction.

53
Q

What are the most effective management options for preterm labour?

A

Tocolysis does not improve neonatal outcomes.

Antenatal steroids reduce the risk of RDS.

Screening with TVUSS can detect women at high risk of preterm delivery.

Progesterone reduces the risk of preterm birth in women with a short cervix.

Cervical cerclage reduces the risk of preterm birth in high-risk women.

54
Q

What does a negative FfN indicate? What cervical length indicates that labour is unlikely?

A

Negative fFN means that patient is unlikely to deliver in the next 7 days and may be safely sent home (unless other risks)

Cervical length >15mm also means that delivery is unlikely in the next 7 days

55
Q

What is the prognosis with preterm delivery at 24 weeks vs 32 weeks?

A

At 24 weeks, approximately one-third of babies will be handicapped and one-third will die.

By 32 weeks both these risks are less than 5%.

56
Q
A

Year 5 - Obstetrics and Gynaecology (87 decks)

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