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Labour > Management of labour > Flashcards

Management of labour Flashcards

1
Q

What risks are associated with VBAC?

A

perinatal death
hypoxic ischaemic encephalopathy
uterine rupture
Blood transfusion or endometritis

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2
Q

How would you repair an anorectal mucosal tear?

A

3-0 vicryl continuous/interrupted sutures (polyglactin)

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3
Q

What is the recommended dose of oxytocin for vaginal delivery?

A

10iu IM

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4
Q

What is the recommended dose of oxytocin for caesarean section?

A

5iu by slow IV injection

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5
Q

By how much do prophylactic oxytocics reduce the risk of PPH?

A

60%

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6
Q

What are the indications for fetal blood sampling in labour?

A

cervix >3cm dilated and
1) pathological ctg
or
2)Suspected acidosis in labour

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7
Q

What are the contraindications to FBS?

A

Fetal compromise
Active maternal infection
prematurity <34weeks
Fetal coagulopathy

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8
Q

What is a normal, borderline and abnormal pH for an FBS?

A 
Normal = pH >7.25
Bordeline = pH 7.21 - 7.24
Abnormal = pH <7.20
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9
Q

Risk of perinatal death with VBAC

A

2-3 in 10,000

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10
Q

Risk of hypoxic ischaemic encephalopathy with VBAC

A

8 in 10,000

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11
Q

Risk of uterine rupture with VBAC

A

24-72 in 10,000

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12
Q

Risk of blood transfusion and endometritis with VBAC

A

1%

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13
Q

Benefit of VBAC for neonate

A

Reduces risk of neonatal respiratory problems from 3-4% to 2-3%

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14
Q

What is the frequency of obstetric anal sphincter injuries in nulliparous women?

A

6%

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15
Q

What is the frequency of obstetric anal sphincter injuries in multiparous women?

A

1.7%

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16
Q

What is the frequency of obstetric anal sphincter injuries overall?

A

2.9%

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17
Q

What blood pressure reading would prompt transfer to obstetric led care?

A

1 reading of diastolic >110 or systolic >160
2 readings over 30 mins diastolic >90 or systolic >140
Or protein++ on urinalysis and either diastolic >90 or systolic >140

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18
Q

What are the main causes of meconium stained liquour?

A

Maturity - late gestation >40 weeks
Fetal distress
Fetal hypoxia

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19
Q

When would a H2 receptor antagonist be offered?

A

Never routinely
If risk factors suggest GA is a possibility
If woman receives opioids

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20
Q

If you give iv or im opioid, what else should you give?

A

An antiemetic

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21
Q

What stage of labour is an epidural likely to prolong?

A

Second stage

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22
Q

What are the risks of an epidural?

A

longer second stage, more likely to require vaginal instrumentation, more likely to be less mobile, will need IV access and additional monitoring

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23
Q

How do you manage a women with regional anaesthesia who is fully dilated?

A

If urge to push or head visible - continue to second stage
if no urge to push or head not visible - wait one hour or longer
Second stage should be initiated within 4 hours

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24
Q

what regional analgesia is used when rapid analgesia is required?

A

spinal-epidural with bupivicane and fentanyl

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25
Q

What dose solution do you usually use for an epidural?

A

0.0625–0.1% bupivicane or equivalent

2 micrograms fentanyl

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26
Q

What rate of contractions would prompt CTG use?

A

contractions longer than 60 seconds or more than 5 per minute

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27
Q

What does NICE recommend as a tocolytic?

A

terbutaline 0.25mg subcut

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28
Q

What kind of drug is terbutaline?

A

A B2 agonist

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29
Q

What are the potential side effects of terbutaline?

A

tachycardia, hyperglycaemia, hypokalaemia, hypotension, pulmonary oedema, anxiety, headache
fetal - hypoglycaemia and tachycardia

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30
Q

What is the half life of tebutaline?

A

6h

31
Q

when might a FBS be falsely reasurring?

A

if there is significant meconium or maternal sepsis

32
Q

When is FBS contraindicated?

A

Risk of materno-fetal transmission of infection
fetal coagulopathy
delivery needs to be expedited or acute cause of fetal distress identified i.e. cord prolapse

33
Q

Maternal position for FBS

A

left lateral

34
Q

normal pH on FBS

A

7.25 or above

35
Q

Borderline pH on FBS

A

7.21-7.24

36
Q

abnormal pH on FBS

A

7.20 or less

37
Q

normal lactate on FBS

A

4.1 or less

38
Q

Borderline lactate on FBS

A

4.2-4.8

39
Q

abnormal lactate on FBS

A

4.9 or above

40
Q

Management of a normal FBS with no acceleration to stimulation

A

(7.25 or more) Consider taking repeat FBS in 1 hour

41
Q

Management of borderline FBS with no acceleration to stimulation

A

(7.21-7.24) Consider taking repeat FBS in 30 mins

42
Q

what is the risk of infection with prelabour rupture of membranes at term?

A

1% vs. 0.5% in non PROM

43
Q

What proportion of women who PROM go on to start labour within 24 hours?

A

60%

44
Q

When should women who PROM be offered induction?

A

After 24 hours without onset of labour

45
Q

Recommended site of an episotomy

A

mediolateral at the vaginal fourchette at 60 degrees

46
Q

Definition of delayed third stage of labour

A

> 30mins if active labour (with uterotonics)

>60mins if physiological

47
Q

Dose of oxytocin for active third stage of labour

A

10iu IM oxytocin given with delivery of first shoulder or after delivery before cord clamped and cut

48
Q

When should the cord be clamped?

A

After 1 minute of delivery and before 5 minutes (unless mother would prefer otherwise)

49
Q

First line medical treatment for PPH

A

10iu oxytocin IV or 0.5mg ergometrine or 5iu/0.5mg IM syntometrine

50
Q

Second line medical treatment for PPH

A

repeat bolus of first line med or add misprostol, oxytocin infusion or carboprost (IM)
May consider tranexamic acid

51
Q

Degrees of perineal tear

A 
first - skin injury + vaginal muscle
second - perineal muscles
third - perineal and anal sphincter
3a <50% external anal sphincter
3b>50% external anal sphincter
3c internal anal spincter
Fourth - anal canal
52
Q

Dose of local anaesthesia for perineal repair

A

up to 20ml 1% lidocaine

53
Q

Repair of skin of perineum

A

continuous subcuticular

54
Q

Repair of perineal muscle and vaginal wall

A

continuous non-locking -absorbable synthetic suture

55
Q

Acidotic threshold for neurologic injury

A

7.1

56
Q

Suture material for anal mucosa repair

A

3-0 polyglactin interrupted or continuous

NOT PDS!

57
Q

Repair of the internal anal sphincter

A

interrupted or mattress

3-0 PDS (monofilament) or 2-0 polyglactin (modern braided)

58
Q

Repair of the external anal spincter

A

overlapping or end to end if 3c
end to end if 3a/3b
3-0 PDS (monofilament) or 2-0 polyglactin (modern braided)

59
Q

post OASIS repair care

A

analgesia
laxatives
follow up in 6-12 weeks
physio

60
Q

Prognosis post EAS repair

A

60% asymptomatic at 12 months

61
Q

FBS not obtained and CTG still abnormal

A

Expedite birth

62
Q

When do you tend to perform an FBS?

A

If pathological CTG not improving with conservative measures

63
Q

What is polyglactin and what is it used for?

A

Synthetic braided suture, absorbable - used for uterine closure in C-section and can be used in anal sphincter and perineal muscle repair

64
Q

What is the correct placement of a ventouse?

A

sagittal suture line anterior to posterior fontanelle

65
Q

Management of delay in first stage of labour

A

amniotomy for all women with intact membranes
Transfer to obstetric led care
oxytocin Infusion
VE in 2 hours

66
Q

If oxytocin started in first stage of labour - what would you expect?

A

> 2cm cervical dilation over 4 hours
If yes - 4 hourly VEs
If no - obstetric review ?c-section

67
Q

Diagnosis of delay in established first stage of labour

A

painful contractions + cervix dilated 4cm
but progress less than 2cm per 4 hours in nullips and mulitps or slowing in multips
Mgt - obstetric led care/amniotomy/oxytocin infusion

68
Q

VE timing in delayed first stage

A

VE 2 hours post amniotomy
VE 4 hours post oxytocin infusion
If less than 2cm progression with oxytocin after 4 hours - review for c-section
If more than 2cm progression - continue 4 hour exams

69
Q

Diagnosis of delay in second stage of labour

A

> 2 hours in nullips

>1 hour in mulitps

70
Q

At onset of second stage if contractions are weak in a nullip

A

consider oxytocin

71
Q

PDS suture

A

synthetic absorbable monofilament - may be used for sphincter repair but not recto-anal mucosa!

72
Q

What is the vertex?

A

Presentation of the fetal head in cephalic presentation where the occiput is the leading part

73
Q

In a vertex presentation where do you want the occiput?

A

occiput anterior (back of the head facing the anterior of the pelvis)

74
Q

Most common presentation at birth?

A

left ocipitoanterior

Labour (4 decks)

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