Management of labour 2

Question 1

What is spinal anaesthesia?

Answer 1

local anaesthetic is injected as a single shot through the dura mater into the CSF
rapidly produces a short-lasting, but effective local analgesia (& motor blockade) that is suitable for C-section or mid-cavity instrumental vaginal delivery
complications include hypotension

Question 2

What is epidural anaesthesia?

Answer 2

higher dose epidural analgesia can be used for both instrumental delivery and C- section
for the latter, a combination of spinal and epidural is best, allowing rapid onset due to spina; and longer lasting anaesthesia with the opportunity for top ups due to the epidural

Question 3

What is a pudendal nerve block?

Answer 3

local anaesthetic is injected bilaterally around the pudendal nerve where it passes the ischial spin, this is suitable for low-cavity instrumental vaginal deliveries

Question 4

What is assessed during the initiation of labour?

Answer 4

• Women is advised to contact maternity services if contractions are regular, painful, lasting at least 30 seconds and occurring every 3-4 minutes, or if the membranes rupture
• Presentation is checked and vaginal examination looks at cervical effacement and dilation to confirm diagnosis of labour- the degree of descent is also assessed and the colour of leaking liquor is noted
• Every 15 minutes the foetal heart is listened to for 1 minutes following a contraction

Question 5

What is the management for the first stage of labour?

Answer 5

Entonox can be used for short-term relief, but commonly an epidural is used,
catheterisation will be required if an epidural is given, but otherwise not routine
• The foetal heart is ausculated every 15 minutes or monitored on a CTG
• Progress is assessed every 4hrs by vaginal examination, dilation and descent are estimated digitally in centimetres
• Slow dilation after the latent phase can be treated with ARM
• If the cervix is not fully dilated by 12-16hrs then a C-section is appropriate unless delivery can be anticipated in the next hour or two

Question 6

What is the advice given for pushing in the second stage of labour?

Answer 6

• If there is no epidural, pushing is encouraged when the mother has the desire to push or the head is visible
if an epidural is in situ then at least an hour is waited before pushing and oxytocin is administered to a nulliparous women and descent is poor
• Directed pushing- if an epidural is in situ the women is instructed to push three time for about 10 seconds during each contraction

Question 7

What is the management for the second stage of labour?

Answer 7

• Foetal distress is normally diagnosed the same as in the 1st stage using FHR and scalp blood sampling
• If delivery is not imminent after 2hrs of pushing (1hr in multiparous) or there is foetal distress, expiedition of delivery is usually recommended, with ventouse or forceps
• Episiotomy should be reserved for when there is foetal distress or where the head is not passing over the perineum despite maternal effort, or if a large tear is likely if it is performed, the perineum is infiltrated with local anaesthetic and a 3-5cm cut is made from the centre of the fourchette at a 45o angle to the (mother’s) right side of the perineum

Question 8

What advice is given when the head starts to deliver?

Answer 8

the mother is asked to stop pushing and to pant slowly the attendant may press on the perineum and the head (hands on) to prevent a rapid delivery and perineal damage the head then resitutes
• With the next contraction, maternal pushing and gentle downward traction on the head leads to delivery of the anterior shoulder, traction is then directed upward to deliver the posterior shoulder

Question 9

How is the third stage of labour managed?

Answer 9

• Oxytocin is administed IM to help the uterus contract once the shoulder are delivered
continuous gentle traction on the cord allows delivery of the placenta, at the same time the left hand pushes down suprapubically to prevent uterine inversion
• The placenta ia checked for missing cotyledons and the vagina and perineum for tears
• Once these are sutured, a check has been performed, blood loss recorded- the mother can be cleaned, made comfortable and encourage to breast feed

Question 10

What is a retained placenta?

Answer 10

a 3rd stage longer than 30mins and occurs at 2.5% of deliveries
partial separation may provoke considerable blood loss into the uterus causing it to enlarge and leading to hypovolaemia
in the absence of bleeding, 1hr is left for natural separation, after which the placenta is ‘manually’ removed
blood is cross matched and IV antibiotics given

Question 11

How are first and second degree tears repaired?

Answer 11

along with uncomplicated episiotomies without anal sphincter damage are sutured under local anaesthetic
failure to suture reduced healing may cause more pain
absorbable synthetic material is used, continuous sutures for the muscle and subcuticular layer for the skin
a rectal and vaginal examination excludes sutures that are too deep and retained swabs

Question 12

How are third and fourth degree tears repaired?

Answer 12

occur in 1-3% of deliveries
the sphincter is repaired under epidural or spinal anaesthetic with the visualisation and asepsis of an operating theatre
the torn ends of the external sphincter are mobilised and sutured, with the internal sphincter sutured separately if damaged
antibiotics and laxatives are given, as well as analgesia
physiotherapy assessment- long-term up to 30% of women have sequelae – incontinence or urgency