Lecture 11 Normal Labour Abnormal Labour and Postnatal Period Flashcards
What period of gestation does normal labour occur
37-42 weeks gestation
Name the 4 key changes at the beginning of labour
Cervix softens
Myometrial tone changes
Progesterone decreases
Oxytocin and Prostaglandin increase to initiate labour
Name the 3 phases of the first stage of labour
Latent- dilatation up to 4cm
Active- 4-10cm
Transition- 8-10cm
What happens during the second stage of labour
Passive and Active stage
Ful dilatation to birth
What happens during the third stage of labour
Birth of baby
Expulsion of the placenta
Name the 3 foetal lies
Cephalic
Breech
Transverse lie
Name the 5 Foetal presentation
Face Brow Vertex Breech Shoulder
Name the 3 Feotal Positions
Occipitoposterior
Occipitotransverse
Occipitoanterior
What is a normal foetal heart rate?
110-160bpm
Name drug free labour analgesia
Birthing ball
Birthing pool
Hypnobirthing
Aromatherapy
Name simple drug therapies for labour analgesia
Entonox (Gas and Air)
Diamorphine
Name the benefits of Entonox
Takes 30 seconds to work
Safe
Mother in control
Can be used with other pain relief techniques
Name disadvantages of Entonox
Wears off quickly
Dizzy, dry mouth, sick
Won’t take pain away
Name benefits of diamorphine
Injection at top of the leg
Last 4 hours
Strong pain relief and relaxation
Name disadvantages of diamorphine
Makes you feel sick, sleep and slow down breathing. Has same effect on baby
Name advanced drug techniques for labour analgesia
Remifentanil PCA
Epidural
What are the benefits of Remifentanil PCA
Morphine like pain relief
Mother in control
Small amount given as a pump when button is pressed
Works quickly
What are the disadvantages of Remifentanil PCA
Wears off quickly Can slow down breathing Can make you feel drowsy Cannot start this drug if you've have diamorphine after 4 hours Drowsy, sick and itchy
What are the benefits of epidural
Can self-administer 20 minutes to work Can still use gas and air Does not affect baby You are in control Can be topped up with stronger medicine Does not slow down cervix dilatation
What are the disadvantages of an epidural
Can slow pushing phase Risk of forceps/suction cups Drop in blood pressure Itching, fever Sore back Headache
Name the complications of an epidural
Nerve damage Epidural abscess Meningitis Haematoma Unconsciousness Severe injury
Name potential indications for the induction
Hypertensive disorders Maternal diabetes Prolonged pregnancy Twin pregnancy Prelabour rupture of membranes Foetal growth restriction or macrosomia Previous stillbirth or in utero death
Name contraindications for induction of labour
Malpresentation Placenta praaevia Prolapsed umbilical cord Foetal distress Pelvic tumour Previous C-section Maternal asthma
What is a bishop score used to assess
Cervix position, consistency, dilatation
What does a low bishop score mean
Not ready for labour
What does a high bishop score mean
Ready for labour
What medications can be done to induce labour
Topical prostaglandin analogues (misoprostol)
IV synthetic oxytocin
What does Oxytocin causes
Initiates uterine contractions
Describe the process of induction of labour
Once cervix has dilated and effaced an amniotomy is performed
IV oxytocin id administered(4-5 contractions in 10 minutes)
What Bishop score is considered favourable for amniotomy
7+
Name Intrapartum complications
Inadequate uterine activity
Cephalopelvic (powers)
disproportion, obstruction (passages)
Malposition (passenger)
What are the main causes of foetal distress
Hypoxia, infection, cord prolapse, placental abruption and vasa praaevia
Name 4 types of foetal monitoring
Intermittent auscultation of the foetal heart
CTG
Foetal blood sampling
Foetal ECG
When is foetal blood sampling carried
Used when abnormal CTG
What can you measure from foetal blood sampling
pH (hypoxaemia) and base excess, lactic acid
Name third stage complications
Retained placenta
Pst-partum haemorrhage
Tears
What are the 4 causes of Postpartum Haemorhage
Tone
Trauma
Tissue
Thrombin
Describe a 3rd degree tear
Involving anal sphincter complex
Describe a 4th degree tear
Involving rectal mucosa
Name complications with breast feeding
Mastitis
Blocked milk ducts
Difficulty feeding/baby latching
Cracked nipples
Name 5 key postnatal conditions
Post-partum haemorrhage Venous thromboembolism Sepsis Psychiatric disorders Pre-eclampsia
What is primary postpartum haemorrhage
Blood loss >500ml within 24 hours
Tone, trauma, retained tissue, thrombin
What is secondary postpartum haemorrhage
Blood loss >50ml from 24 hours post party to 6 weeks
What is the presentation of thromboembolic disease
Unilateral leg swelling
SOB or chest pain
Unexplained tachycardia
How do you investigate thromboembolic disease
ECG
Leg dopplers
CXR +/- VQ scan
How do you treat thromboembolic disease
Low molecular weight heparin
Warfarin is teratogenic (can be used when breast feeding)
Not breastfeeding increases what risks for babies
Gastroenteritis Respiratory infections Allergies Obesity Type I and II diabetes SIDS
Not breastfeeding increases what risks for mothers
Breast cancer
Ovarian cancer
Hip fractures
Heart disease
What is the WHO/Unicef UK baby friendly initiative
Requires that all baby friendly accredited services adhere to the international code of marketing of breastmilk substitutes (the code)
Name the 3 stages of lactation
- Breast development and colostrum production
- Onset of copious milk secretion
- Maintenance of milk production
What happens to the oestrogen and progesterone levels after birth
They drop
What is role of Prolactin
Responsible for milk production (lactocyte production)
Responsive to touch and stimulation
Levels higher at night
What is the role of oxytocin
Responsible for milk delivery
Acts on muscle cells in pulsatile action
Levels higher when baby is near
What is the importance of skin to skin contact
Triggers lactation and mothering hormones
Regulates tem, HR and breathing
Colonises baby with microbes from mother
Stimulates feeding behaviour
Reduces stress hormones in mother and baby
What is Shoulder Dystocia
Occurs when the anterior foetal shoulder becomes impacted behind the maternal pubic symphysis after delivery of the foetal head
What is the management of Shoulder Dystocia
- H – Call for Help
- E – Evaluate for Episiotomy
- L – Legs (McRoberts Position)
- P – Suprapubic Pressure
- E – Enter Manouvers (Internal Rotation)
- R – Remove the Posterior Arm
- R – Roll the Patient (Onto all Fours)
Name thrombin related causes of PPH
Pre-eclampsia
Placental abruption
Pyrexia in labour
Bleeding disorders
Name tissue related causes PPH
Retained placenta
Placenta accreta
Retained POC
Name tone related causes of PPH
Placenta praaevia
Over distention of uterus
Uterine relaxants
Previous PPH
Name trauma related causes PPH
C-section
Epiostomy
Macrosomia
Name other causes of PPH
Asian ethnicity Anaemia Induction BMI>35 Prolonged labour Age
What is the medical management of PPH
ABCDE Empty bladder - Oxytocin 5iu slow iv injection - Ergometrine 0.5mg slow iv injection (not if high BP)- cause heavy contractions - Oxytocin infusion - Tranexamic acid 1g IV - controls bleeding - Carboprost 0.25mg im (max 8 doses - Misoprostol 800 micrograms)
What is the surgical management of PPH
Intrauterine balloon tamponade Interventional radiology B-lynch suture Hysterectomy Fluid replacement +/- blood products
What is the management for a cord prolapse
Replace cord in vagina
Catheterise and fill bladder
Encourage mother to adopt knee chest or left lateral position with raised hip
Arrange for c-section
