Management of Labour Flashcards
How should women be counselled if GBS was detected in a previous pregnancy?
The likelihood of GBS carriage in this pregnancy is 50%. They should have the option for IAP or testing in late pregnancy followed by IAP if GBS still detected
If testing for GBS is planned, when should it be carried out?
35-37 weeks or 3-5 weeks prior to the anticipated delivery date
How should GBS UTI be managed?
The woman should receive antibiotics at the time of diagnosis, as well as IAP
How should IOL be managed differently for women with GBS?
GBS status should not affect method of induction of labour
GBS is not a contraindication to a membrane sweep
How should term PROM be managed in women with GBS?
They should be offered IAP and immediate induction of labour
How should preterm labour be managed for women without GBS colonisation?
Women in preterm labour should be offered IAP
Can a woman with GBS have a waterbirth?
Birth in a pool is not contraindicated in women with GBS as long as they have IAP
How should women known to have GBS be managed if they have PPROM?
Before 34 weeks, the risks of prematurity outweigh the risks of GBS. If >34 weeks, it may be beneficial to expedite delivery if the woman is known to have GBS
Which antibiotic should be given for IAP in women with penicillin allergy?
If not severe allergy: Cephalosporin
If severe allergy: Vancomycin
How should women who decline IAP be managed?
They should be advised the baby will need close monitoring for 12 hours and they should be strongly discouraged from an early discharge home
How should well babies at risk of early onset GBS disease whose mothers have not had IAP be managed?
They should have obs at 0, 1 and 2 hours, then 2 hourly til 12 hours
How should a baby with clinical signs of early onset GBS disease be managed?
They should be treated with Penicillin and Gentamicin within 1 hour
What is the rate of stillbirth in the UK?
1 in 200 babies are born dead
How should you manage the situation of a mother feeling fetal movement after diagnosis of an IUD on scan?
A repeat scan should be offered
How should testing to identify DIC be carried out in women choosing expectant management of late intrauterine fetal death?
Clotting, platelets and fibrinogen should be measured twice daily in women choosing expectant management of IUD
What is the prevalence of Factor V Leiden?
5%
How should women with intrauterine fetal death who are Rhesus negative be managed?
They should have an urgent Kleihauer to identify recent fetal maternal haemorrhage ad should be given immediate Anti-D
How should large fetomaternal haemorrhage resulting in intrauterine fetal death be managed?
The dose of Anti-D should be increased and the Kleihauer should be repeated at 48 hours
What is the optimal timing of Anti-D administration?
72 hours
How should fetal infection be investigated for in late intrauterine fetal death?
With cord or cardiac blood
In late intrauterine fetal death, how should uncertainty about fetal sex on examination be managed?
rapid karyoptying with PCR or FISH should be offered
What percentage of stillborn babies will have a chromosomal abnormality?
6%
Which tissue type is the most likely to result in unsuccessful culture for karyotyping?
Skin
What is the disadvantage of using placental tissue for karyotyping?
There is a risk of pseudomosaicism
Fetal postmortem examination provides information useful in guiding management of subsequent pregnancy in what proportion of cases?
51%
What proportion of placental histological examinations show a major contributer to the cause of IUFD?
88%
What is the chance of maternal DIC within 4 weeks of IUD if choosing prolonged expectant management?
10%
What dose of Mifepristone is recommended prior to Misoprostol for induction of labour in IUD?
200mg
What dosing regime of Misoprostol does NICE recommend for IOL in IUD?
- 100 micrograms 6 hourly before 26+6 weeks
- 25-50 micrograms 4 hourly at 27/40 or more
What should women with more than 1 uterine scar be advised about IOL for IUD?
Women with 2 previous LSCS should be advised that the absolute risk of IOL for IUD is low
Which opioid analgesia should be used in IOL for IUFD?
Diamorphine or regional analgesia
What advice should women with late IUFD be given about non-pharmacological methods of milk suppression?
Almost 1 third are troubled by unacceptible discomfort
What medication should be used for milk suppression in IUD and when is it contraindicated?
- Cabergoline should be used for milk suppression
- It is contraindicated for women with hypertension or pre-eclampsia
What is different about fertility after IUD?
Fertility may return more quickly than following a live birth, especially if lactation suppression is used
What additional investigations should women have in a pregnancy following IUD?
They should be offered screening for GDM
Below what gestation must Ventouse delivery be avoided and why?
- Must avoid before 32 weeks gestation
- Use with caution before 36 weeks gestation
Both because of increased risk of subgaleal haemorrhage
What is the guidance for Ventouse birth when the head is not born after three pulls?
3 further gentle pulls can be considered if the head is already on the perineum
What are the rules for discontinuation of forceps birth?
- Discontinue if they cannot be applied easily
- Discontinue rotational forceps if rotation is not achieved with gentle pressure
- Discontinue if birth is not imminent after 3 pulls
What is the guidance on antibiotic prophylaxis following asssited vaginal birth?
A single dose of Co-Amoxiclav should be given prophylactically
What is the reported incidence of shoulder dystocia? (range)
0.58-0.7%
What is the incidence of PPH following shoulder dystocia?
11%
What is the incidence of OASI following shoulder dystocia?
3.8%
What is the incidence of brachial plexus injury following shoulder dystocia? (range)
2.3-16%
What percentage of brachial plexus injuries result in permanent disability?
Fewer than 10%
What is the relationship between maternal diabetes and shoulder dystocia?
Infants of diabetic mothers have a 2 to 4-fold increased risk of shoulder dystocia compared to babies of the same weight born to non-diabetic mothers
What are the prelabour risk factors for shoulder dystocia?
Macrosomia (EFW >4.5Kg)
Maternal diabetes
maternal BMI >30
Previous shoulder dystocia
Induction of labour
What are the intrapartum risk factors for shoulder dystocia?
Prolonged first stage of labour
Secondary arrest
Prolonged second stage of labour
Oxytocin augmentation
Assisted vaginal delivery
What is the role of induction of labour in prevention of shoulder dystocia?
- Induction of labour does not reduce the risk of shoulder dystocia for women with a macrosomic fetus in the absence of diabetes
- Women with diabetes and a normally grown baby should be offered IOL or ELCS after 38 weeks to reduce the risk of shoulder dystocia
What is the relative risk of shoulder dystocia in a woman with previous shoulder dystocia compared to the general population?
10 times higher
What is the recurrence rate of shoulder dystocia? (range)
1-25%
What is the incidence of humeral fractures following delivery of the posterior arm at shoulder dystocia? (range)
2-12%
What is the risk of emergency hysterectomy with placenta praevia?
Up to 11 in 100
What is the risk of recurrent placenta praevia?
23 in 100
What is the risk of massive obstetric haemorrhage with placenta praevia?
21 in 100
What is the commonest reason for transfer to an obstetric unit in labour?
Delay in the first or second stage
What are the increased risks associated with BMI >35 in pregnancy?
Unplanned Caesarean
PPH
Stillbirth
Neonaral death
Admission to NICU
For low risk multiparous women, how many babies per 1,000 are born with serious medical problems at home or in an obstetric unit?
3 in 1,000 for both
For low risk nulliparous women, how many babies per 1,000 are born with serious medical problems at home or in an obstetric unit?
9 per 1,000 at home
5 per 1,000 in an obstetric unit
Below what platelet count should women be advised to birth in an obstetric unit?
100
What are the side effects of intrapartum opioids for baby?
Short term respiratory depression and drowsiness
Potential difficulty with breastfeeding
What are the advantages of Remifentanil PCA?
Less likely to need epidural or have birth using forceps or ventouse
More likely to have spontaneous vaginal birth
What should women be informed about epidurals?
It may cause severe postnatal headache
It is not associated with longer first stage of labour or increased chance of unplanned Caesarean
It is associated with a longer second stage of labour and an increased chance of instrumental birth
How should a woman’s blood pressure be monitored following siting of an epidural?
Measure BP every 5 minutes for 15 minutes
How should primiparous and multiparous women with an epidural be managed in the second stage?
Allow 1 hour for passive descent if multiparous
Allow 2 hours for passive descent if primiparous
How long does the average first labour last?
Average 8 hours
Unlikely over 18 hours
How long does the average second and subsequent labour last?
Average 5 hours
Unlikely over 12 hours
How is suspected delay in the first stage of labour diagnosed?
Cervical dilatation of <2cm in 4 hours or a slowing in the progress of labour for multips
How should delay in the first stage of labour be managed?
Advise the woman to have another VE in 2 hours and diagnose delay if progress is less than 1cm
What is the advice for amniotomy in delay in the first stage of labour?
Advise it will shorten labour by around an hour and may increase the strength and pain associated with contractions
How should a woman be managed after amniotomy for delay in the first stage?
Repeat examination after 2 hours
How should intermittent auscultation be performed in the second stage of labour?
Listen in for at least 1 minute every 5 minutes
What should women with previous severe perineal trauma be advised about the risk of recurrence?
The risk of repeat severe perineal trauma is not increased in a subsequent birth
How should a primparous woman without an epidural be managed after 1 hour of active pushing?
Assess the clinical picture and if there are signs of progress, allow up to another hour of pushing if safe to do so
How should a multiparous woman without an epidural be managed after 30 minutes of active pushing?
Assess the clinical picture and if there are signs of progress, allow up to another 30 minutes of pushing if safe to do so
After initial diagnosis of delay in the first stage, how often should a woman have repeat obstetric review following start of Oxytocin?
Every 15 to 30 minutes
How many women per 1,000 would be expected to have primary PPH >500mls with active versus physiological third stage labour?
68 per 1,000 with active third stage
188 per 1,000 with physiological third stage
Which is the dose of syntometrine for the active third stage?
5 units of Oxytocin with 500 micrograms of Ergometrine
How is prolonged 3rd stage diagnosed?
If the placenta has not delivered within 30 minutes for active 3rd stage or 60 minutes for physiological 3rd stage
What is the second line uterotonic option for postpartum haemorrhage?
Carboprost (Haemabate)
What are the third line uterotonic options for postpartum haemorrhage?
Repeat Carboprost up to every 15 minutes
Misoprostol 800 micrograms sublingually or rectally
For how long do the effects of Ergometrine last?
3 hours
For how long do the effects of IM oxytocin last?
30-60 minutes
What are the neonatal risks associated with maternal use of SSRIs or SNRIs?
Small increase in risk of persistent pulmonary hypertension or neonatal withdrawal symptoms
By how long after birth should a woman who has had regional anaesthesia be able to perform a straight leg raise?
By 4 hours
What percentage of spontaneous labours will have started by 41+6 weeks gestation?
99%
What percentage of spontaneous labours will have started by 40+6 weeks?
82.8%
What risks are associated with a pregnancy continuing beyond 41 weeks gestation?
Increased likelihoood of Caesarean birth
Increased likelihood of NICU admission
Increased likelihood of stillbirth and neonatal death
What is the stillbirth rate for white, black and Asian babies per 10,000?
34/10,000 white babies
74/10,000 black babies
53/10,000 Asian babies
For women choosing expectant management for post-dates gestation, how often should they be offered fetal monitoring?
Twice weekly
How should PPROM be managed between 34 and 37 weeks gestation?
Discuss expectant management or Caesarean with her unless she has Group B Streptococcal infection in which case she should be recommended immediate IOL/Caesarean
What advice should be given regarding induction of labour to women with fetal macrosomia without gestational diabetes? (3 points)
- IOL reduces overall rates of shoulder dystocia
- IOL increases the risk of 3rd and 4th degree perineal tears
- Rates of perinatal death, brachial plexus injuries and need for emergency Caesarean birth are similar in the IOL and expectant management groups
A Bishop score greater than what should indicate IOL with immediate ARM?
6
If a woman is started on a CTG because of a concern on intermittent auscultation such as a single deceleration or increased fetal heartrate, she could be de-escalated back to intermittent auscultation after how much normal CTG trace?
20 minutes
What are the maternal risk factors which should indicate continuous CTG in labour? (6 of them)
- Previous Caesarean birth or full thickness uterine scar
- Any hypertensive disorder needing medication
- Prolonged rupture of membranes (unless already established in labour by 24 hours post SROM)
- Any vaginal blood loss other than a show
- Suspected chorioamnionitis or maternal sepsis
- Pre-existing diabetes or gestational diabetes requiring medication
What are the fetal risk factors which should indicate continuous CTG in labour? (6 of them)
- Non-cephalic presentation
- Fetal growth restriction
- Small for gestational age with additional high risk factors such as abnormal dopplers, reduced liquor volume or reduced growth velocity
- Gestational age >42 weeks
- Anhydramnios or polyhydramnios
- Reduced fetal movements in the 24 hours preceeding onset of regular contractions
What are the intrapartum risk factors which should trigger continuous CTG monitoring of a woman in labour? (14 in total)
- Contractions lasting >2 minutes or >=5:10
- Meconium
- Maternal pyrexia
- Suspected chorioamnionitis or sepsis
- Pain out of keeping with normal labour pains
- Fresh vaginal bleeding in labour
- Blood-stained liquor not associated with vaginal examination
- Maternal pulse >120 on 2 occasions 30 minutes apart
- Severe hypertension on 1 occasion
- Hypertension on 2 occasions
- 2+ protein as well as 1 occasion of hypertension
- Confirmed delay in the first or second stage
- Insertion or regional analgesia
- Use of oxytocin
What should be suspected if fetal heartrate accelerations are recorded in the second stage of labour?
That the maternal heartrate may be what is actually being monitored
What percentage of women will labour within 3 weeks of IUD with expectant management?
85%
When should delay in the third stage of labour be diagnosed?
Within 30 minutes if active third stage
Within 1 hour if physiological third stage
Which muscles are cut with a mediolateral episiotomy?
Bulbocavernosus
Transverse perineal
What is the rate of PPH with operative vaginal birth?
3%
What is the rate of PPH with second stage Caesarean?
10%
