Management of labour Flashcards
What risks are associated with VBAC?
perinatal death
hypoxic ischaemic encephalopathy
uterine rupture
Blood transfusion or endometritis
How would you repair an anorectal mucosal tear?
3-0 vicryl continuous/interrupted sutures (polyglactin)
What is the recommended dose of oxytocin for vaginal delivery?
10iu IM
What is the recommended dose of oxytocin for caesarean section?
5iu by slow IV injection
By how much do prophylactic oxytocics reduce the risk of PPH?
60%
What are the indications for fetal blood sampling in labour?
cervix >3cm dilated and
1) pathological ctg
or
2)Suspected acidosis in labour
What are the contraindications to FBS?
Fetal compromise
Active maternal infection
prematurity <34weeks
Fetal coagulopathy
What is a normal, borderline and abnormal pH for an FBS?
Normal = pH >7.25 Bordeline = pH 7.21 - 7.24 Abnormal = pH <7.20
Risk of perinatal death with VBAC
2-3 in 10,000
Risk of hypoxic ischaemic encephalopathy with VBAC
8 in 10,000
Risk of uterine rupture with VBAC
24-72 in 10,000
Risk of blood transfusion and endometritis with VBAC
1%
Benefit of VBAC for neonate
Reduces risk of neonatal respiratory problems from 3-4% to 2-3%
What is the frequency of obstetric anal sphincter injuries in nulliparous women?
6%
What is the frequency of obstetric anal sphincter injuries in multiparous women?
1.7%
What is the frequency of obstetric anal sphincter injuries overall?
2.9%
What blood pressure reading would prompt transfer to obstetric led care?
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
What are the main causes of meconium stained liquour?
Maturity - late gestation >40 weeks
Fetal distress
Fetal hypoxia
When would a H2 receptor antagonist be offered?
Never routinely
If risk factors suggest GA is a possibility
If woman receives opioids
If you give iv or im opioid, what else should you give?
An antiemetic
What stage of labour is an epidural likely to prolong?
Second stage
What are the risks of an epidural?
longer second stage, more likely to require vaginal instrumentation, more likely to be less mobile, will need IV access and additional monitoring
How do you manage a women with regional anaesthesia who is fully dilated?
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
what regional analgesia is used when rapid analgesia is required?
spinal-epidural with bupivicane and fentanyl
What dose solution do you usually use for an epidural?
0.0625–0.1% bupivicane or equivalent
2 micrograms fentanyl
What rate of contractions would prompt CTG use?
contractions longer than 60 seconds or more than 5 per minute
What does NICE recommend as a tocolytic?
terbutaline 0.25mg subcut
What kind of drug is terbutaline?
A B2 agonist
What are the potential side effects of terbutaline?
tachycardia, hyperglycaemia, hypokalaemia, hypotension, pulmonary oedema, anxiety, headache
fetal - hypoglycaemia and tachycardia
What is the half life of tebutaline?
6h
when might a FBS be falsely reasurring?
if there is significant meconium or maternal sepsis
When is FBS contraindicated?
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
Maternal position for FBS
left lateral
normal pH on FBS
7.25 or above
Borderline pH on FBS
7.21-7.24
abnormal pH on FBS
7.20 or less
normal lactate on FBS
4.1 or less
Borderline lactate on FBS
4.2-4.8
abnormal lactate on FBS
4.9 or above
Management of a normal FBS with no acceleration to stimulation
(7.25 or more) Consider taking repeat FBS in 1 hour
Management of borderline FBS with no acceleration to stimulation
(7.21-7.24) Consider taking repeat FBS in 30 mins
what is the risk of infection with prelabour rupture of membranes at term?
1% vs. 0.5% in non PROM
What proportion of women who PROM go on to start labour within 24 hours?
60%
When should women who PROM be offered induction?
After 24 hours without onset of labour
Recommended site of an episotomy
mediolateral at the vaginal fourchette at 60 degrees
Definition of delayed third stage of labour
> 30mins if active labour (with uterotonics)
>60mins if physiological
Dose of oxytocin for active third stage of labour
10iu IM oxytocin given with delivery of first shoulder or after delivery before cord clamped and cut
When should the cord be clamped?
After 1 minute of delivery and before 5 minutes (unless mother would prefer otherwise)
First line medical treatment for PPH
10iu oxytocin IV or 0.5mg ergometrine or 5iu/0.5mg IM syntometrine
Second line medical treatment for PPH
repeat bolus of first line med or add misprostol, oxytocin infusion or carboprost (IM)
May consider tranexamic acid
Degrees of perineal tear
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
Dose of local anaesthesia for perineal repair
up to 20ml 1% lidocaine
Repair of skin of perineum
continuous subcuticular
Repair of perineal muscle and vaginal wall
continuous non-locking -absorbable synthetic suture
Acidotic threshold for neurologic injury
7.1
Suture material for anal mucosa repair
3-0 polyglactin interrupted or continuous
NOT PDS!
Repair of the internal anal sphincter
interrupted or mattress
3-0 PDS (monofilament) or 2-0 polyglactin (modern braided)
Repair of the external anal spincter
overlapping or end to end if 3c
end to end if 3a/3b
3-0 PDS (monofilament) or 2-0 polyglactin (modern braided)
post OASIS repair care
analgesia
laxatives
follow up in 6-12 weeks
physio
Prognosis post EAS repair
60% asymptomatic at 12 months
FBS not obtained and CTG still abnormal
Expedite birth
When do you tend to perform an FBS?
If pathological CTG not improving with conservative measures
What is polyglactin and what is it used for?
Synthetic braided suture, absorbable - used for uterine closure in C-section and can be used in anal sphincter and perineal muscle repair
What is the correct placement of a ventouse?
sagittal suture line anterior to posterior fontanelle
Management of delay in first stage of labour
amniotomy for all women with intact membranes
Transfer to obstetric led care
oxytocin Infusion
VE in 2 hours
If oxytocin started in first stage of labour - what would you expect?
> 2cm cervical dilation over 4 hours
If yes - 4 hourly VEs
If no - obstetric review ?c-section
Diagnosis of delay in established first stage of labour
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
VE timing in delayed first stage
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
Diagnosis of delay in second stage of labour
> 2 hours in nullips
>1 hour in mulitps
At onset of second stage if contractions are weak in a nullip
consider oxytocin
PDS suture
synthetic absorbable monofilament - may be used for sphincter repair but not recto-anal mucosa!
What is the vertex?
Presentation of the fetal head in cephalic presentation where the occiput is the leading part
In a vertex presentation where do you want the occiput?
occiput anterior (back of the head facing the anterior of the pelvis)
Most common presentation at birth?
left ocipitoanterior
