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Obs & Gynae > Management of Labour and Delivery > Flashcards

Management of Labour and Delivery Flashcards

1
Q

Describe the three stages of Labour

A

Stage 1 = Initiation -Full Cervical Dilatation
Stage 2 = Full cervical dilation - Delivery of fetus
Stage 3 = Delivery of fetus - Delivery of Placenta

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2
Q

What are Braxton Hicks Contractions?

A

Involuntary contractions of the uterine smooth muscle throughout the third trimester of pregnancy

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3
Q

When is the diagnosis of labour made?

A

When regular painful contractions lead to effacement and then dilatation of the cervix

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4
Q

Summarise the ideal movements of the fetal head in labour.

A

Engagement in OT position to fit through pelvic inlet
Descent and Flexion of head
Rotation 90 degrees to OA to fit through pelvic outlet
Descent
Extension to deliver through perineum
Restitution (back to OT) and delivery of shoulders

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5
Q

How do we define Preterm Prelabour Rupture of Membranes (PPROM)?

A

Membranes rupture before initiation of labour at

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6
Q

What are the complications of PPROM?

A

Preterm Delivery follows within 48 hrs in 50% of cases
Infection of fetus, placenta (chorioamnionitis) or cord (may have caused ROM or may be as a result of it)
Prolapse of Umbilical Cord occurs rarely
Absence of liquor usually before 24 weeks can result in pulmonary hypoplasia or postural deformities

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7
Q

What would you expect on the History and Examination in a patient with PPROM?

A

History - gush of clear fluid from vagina, followed by further leaking
Examination - Pool of fluid in the posterior fornix on speculum examination is diagnostic

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8
Q

How might chorioamnionitis present?

A 
Contractions of abdominal pain
Fever, Tachycardia
Uterine Tenderness
Coloured, offensive liqour 
Although clinical signs can often appear late
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9
Q

What is the management of PPROM with evidence of infection and without.

A

INFECTION - IV antibiotics given, steroids given and fetus is delivered whatever the gestation
NO INFECTION - prophylactic antibiotics, once gestation reaches 36 weeks induction performed.

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10
Q

How would you check for infection in a woman with PPROM.

A

Clinical Signs
High Vaginal Swab
CRP and WCC on Bloods
In doubtful cases amniocentesis with gram stain and culture can be used.

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11
Q

When is a delivery considered preterm?

A

If it occurs between 24 and 37 weeks

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12
Q

What is the significance of Preterm Delivery.

A

Accounts for 80% of NICU occupancy, 20% of perinatal mortality and 50% of cerebral palsy.
The earlier the gestation the greater the risk

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13
Q

What are the risk factors/mechanisms of Preterm Labour?

A

TOO MANY DEFENDERS - multiple pregnancy, polyhydraminos
DEFENDERS JUMP OUT - fetal survival response e.g. pre-eclampsia, placental abruption, infection, IUGR
CASTLE DESIGN IS POOR - uterine abnormalities e.g. fibroids
CASTLE WALL IS WEAK - cervical incompetence = painless cervical dilatation that precedes some preterm deliveries. Loop biopsy can be a risk factor, often cause unknown
ENEMIES - infection

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14
Q

Is there anyway we can prevent preterm labour?

A

Usually only done in those who are at increased risk of preterm labour
Methods include - cervical cerclage, progesterone supplementation, treat infection with antibiotics, fetal reduction is higher multiple pregnancies and reduction of polyhydraminos

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15
Q

What is the role of fetal fibronectin in preterm labour?

A

if the cervix is uneffaced, fetal fibronectin should be checked. A negative result means preterm delivery is unlikely.

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16
Q

If a woman is in established preterm labour what is the management?

A

Steroids are given to promote fetal lung maturity
Tocolytics e.g. Nifedipine can be given to slow down labour e.g. to give time for steroids to act or in order to transfer mum to a unit with a NICU
Delivery - vaginal if possible as it decreases the incidence of neonatal distress syndrome in the neonate.

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17
Q

Briefly describe the analgesia available to women during labour.

A

Non-Medical - TENS, back rubbing, bath
Inhalation of Entonox
Systemic Opiates e.g. pethidine, diamorphine
Epidural

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18
Q

How might we define fetal distress?

A

Hypoxia that might result in fetal death or disability if not reversed or the fetus delivered urgently.

19
Q

How do you interpret a CTG recording?

A 
DR C M BRAVADO
DR  = define risk - any reason this baby might be in distress
C = contractions
M =  movements
BRa = baseline rate (110-160 bpm)
V = variability (should be >5 bpm)
A = accelerations
D = decelerations
O= overall picture
20
Q

Other than CTG how else can we monitor fetal distress in labour?

A

Check for presence of meconium in amniotic fluid

Fetal Blood Scalp Sampling

21
Q

How do we manage fetal distress?

A

Conservative - woman placed in left lateral position to avoid aorto-caval compression, oxygen and IV fluids are administered. Oxytocin infusion is stopped, contractions can be stopped a beta2 agonist and vaginal examination can exclude cord prolapse
If this fails, fetal blood scalp sampling is done, if 7.20 it is repeated in half an hour, FHR monitord with CTG
If FHR shows sustained bradycardia delivery is undertaken anyway

22
Q

How common is instrumental delivery in the UK?

A

20% in nulliparous

2% of multips

23
Q

What are the common indications for instrumental vaginal delivery?

A

Prolonged second stage of labour (> 1 hour) or if maternal exhaustion before then
Fetal Malposition
Fetal Distress - instruments can expedite labour
Prophylactically to prevent pushing e.g. in women with severe cardiac disease or hypertension
Breech delivery - forceps are often applied to after coming head to control delivery

24
Q

List some of the prerequisites required for instrumental delivery.

A 
Head not palpable abdominally
Head at or below ischial spines on examination
Position of head known
Adequate Analgesia
Full Dilatation of the cervix
Empty Bladder
25
Q

Discuss Forceps vs Ventouse.

A

Ventouse has a higher failure rate, BUT rate of c-section not higher if forceps then used)
More fetal trauma, but less maternal trauma
No difference in the APGAR score between the two.

26
Q

List some of the indication (absolute and relative) for an elective caesarean section.

A

ABSOLUTE - placenta praevia, severe antenatal fetal compromise, uncorrectable abnormal lie, previous vertical caesarean section and gross pelvic deformity
RELATIVE - breech presentation, severe IUGR, twin pregnancy, diabetes mellitus and other medical diseases, previous c-section and older nulliparous patients

27
Q

List some of the common maternal complications of caesarean section.

A

More common in emergency rather than elective but
Haemorrhage and the need for transfusion
Infection of uterus or wound (up to 20%)
Rare visceral damage e.g. bowel or bladder
Post op pain and immboility - increased risk of VTE

28
Q

What is done to decrease the risk of maternal complications following a C-section?

A

Prophylactic Antibiotics and thromboprophylaxis are routine

29
Q

List some of the common fetal complications of caesarean section.

A

Fetal respiratory morbidity
Fetal Lacerations - rare and usuallly minor
Bonding and breastfeeding are particularly affected by emergency procedures.

30
Q

How are subsequent pregnancies affected post C-section

A

Incidence of placenta praevia is more common

Risk of placenta accreta and placenta percreta

31
Q

Describe the different types of breech presentation

A

Frank (extended) 70% - both legs are extended at the knee
Complete (flexed) 15% - both legs are flexed at the knee
Footling 15% one or both feet present below the buttocks

32
Q

List some of the complications of Breech delivery.

A

Increased incidence of cord prolapse
After coming head may get trapped
Higher rates of long term neurological handicap

33
Q

What is External Cephalic Version, its success rates and the complications associated.

A

Success rates 50%

Complications include - placental abruption and uterine rupture

34
Q

What are contra-indications to attempting ECV?

A 
If the fetus is compromised
If vaginal delivery is CI anyway e.g. placenta praevia
Twin pregnancy
Membranes have ruptured
If there has been a recent APH
35
Q

If ECV is unsuccessful or CI, what is the management of a breech presentation

A

Safest mode of delivery is caesarean section

Some women still wish to deliver vaginally, but skills are being lost due to lack of experience.

36
Q

Erbs Palsy is associated with shoulder dystocia, how does it occur?

A

Excessive traction of the neck in shoulder dystocia results in damage to the brachial plexus
Erbs palsy is permanent in about 50% of cases.

37
Q

What are the risk factors for Shoulder Dystocia?

A

Large baby is the principal risk factor.

others include; previous shoulder dystocia, increased maternal BMI, induction of labour

38
Q

What is the management of Shoulder Dystocia?

A

A sequence of events is recomended.
McRoberts Manoouvre
Suprapubic pressure - constant and intermittent
Episiotomy for internal manouvres
if these fail go back to the beginning and start again.

39
Q

The second twin has a 5-fold increase risk of death after the first twin has been delivered, why is this?

A 
Hypoxia
Cord Prolapse
Tetanic Uterine Contraction
Placental Abruption
He may also present as breech
40
Q

Caesarean is bring used increasing for twin deliveries due to the increased risk of death for the second twin. What other indications are there for caesarean section?

A

First twin is breech
With higher order multiples
If there have been antepartum complications
Some hospitals insist on it for all MC twins

41
Q

How would you define a primary post-partum haemorrhage?

A

Loss of >500mls of blood after vaginal delivery or >1000mls after Caesarean section LESS THAN 24 HOURS after delivery

42
Q

What are the causes of PPH?

A

The 4 Ts
TONE - uterus fails to contract properly due to atonicity
TISSUE - Retained placenta in uterus
TRAUMA - Bleeding from episiotomy or perineal tear is obvious, but look for a high vaginal/cervical tear
THROMBIN - problem with coagulation

43
Q

What is done to prevent PPH?

A

Routine use of oxytocin in the third stage of labour reduces the incidence of PPH by about 60%

Obs & Gynae (6 decks)

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