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Women's Health - Year 4 > Management of Labour and Delivery > Flashcards

Management of Labour and Delivery Flashcards

1
Q

what is normal labour?

A

A physiological process during which the products of conception are expelled outside of the uterus
Skull is proportionally very large and humans have adopted an upright stature which makes it difficult for humans
Human babies are born relatively premature compared to other species

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2
Q

maternal mortality

A

830 women die in childbirth every day
In 2015-303,000 worldwide
Most of these deaths are preventable-sepsis/haemorrhage etc

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3
Q

stillbirths

A

1.2 million a year
Risk is 50 times greater for an African woman that for a woman in the UK
55% of all stillbirths are for rural families in Africa, South Asia

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4
Q

hormones for retaining a pregnancy

A 
Progesterone 
Cervix
Hypervolaemia 
Adrenaline 
Relaxin 
CRH
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5
Q

describe the role of progesterone in maintaining pregnancy

A

Produced by corpus luteum initially and then placenta

Dampens down excitability of smooth muscle in uterus and strengthens sphincter at internal os

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6
Q

describe the role of the cervix in maintaining pregnancy

A

Long tubular structure made of strong connective tissue

In labour it softens and thins down and dilates

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7
Q

describe the role of hypervolaemia in maintaining pregnancy?

A

Inhibits hormones of posterior lobe of pituitary (oxytocin and vasopressin)
Dampen down contractility of uterus

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8
Q

describe the role of adrenaline in maintaining pregnancy

A

Act same way as progesterone

Inhibits oxytocin secretion

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9
Q

describe the role of relaxin in maintaining pregnancy

A

Relaxin is a hormone that regulates activation adenalol cyclase involved in energy uptake by fibres
Prevents uterine contraction

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10
Q

describe the role of CRH in maintaining pregnancy

A

Derived from placenta and secreted into maternal circulation in third trimester
Inhibits prostaglandin production
Increases contractility of myometrium (at term)

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11
Q

what is involved in the release of pregnancy

A 
Oestrogen
Oxytocin
Vasopressin
Cortisol
Prostaglandins 
Uterine distension 
CRH
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12
Q

describe the role of oestrogen in release of pregnancy

A

Sensitises uterine muscle to oxytocin

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13
Q

describe the role of oxytocin in release of pregnancy

A

Released from pituitary along with vasopressin

Specific oxytocin receptors in myometrium that are activated

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14
Q

describe the role of cortisol in release of pregnancy

A

Decrease progesterone secretion

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15
Q

describe the role of prostaglandins in release of pregnancy

A

Increase myometrium contractility

Smooth muscle relaxants on cervical sphincter

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16
Q

describe how distension of the uterus results in release of pregnancy

A

Causes increase in contractility of muscle

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17
Q

what are the aspects involved in the mechanism of labour

A

Passage
Power
Passenger

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18
Q

what are the 4 types of pelvis

A

Gynecoid
Android
Anthropoid
Platypelloid

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19
Q

gynecoid pelvis

A
  • Most common and favourable for delivery
  • Oval at outlet
  • Transverse diameter greater than AP
  • Shallow
  • Wide suprapubic arch
  • Short ischius spines
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20
Q

android pelvis

A
  • Usually in males
  • Triangular inlet
  • Narrow suprapubic arch
  • Prominent iscius spine
  • Blocks areas for rotation and extension
  • 20% of women
  • More common in afrocaribean women
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21
Q

anthropoid pelvis

A
  • Oval with AP diameter wider than transverse

* More likely to get babies in OP position (looking up) this slows down labour

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22
Q

platypelloid pelvis

A
  • Least common
  • Wide suprapubic arch
  • Wide sacrum
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23
Q

vaginal impediment of labour

A
  • If it has scarring

* Fatty tissue around

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24
Q

what is the role of the pelvic floor in labour

A

• Flexion and rotation of head

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25
Q

bladder impediment of labour

A
  • Sits in front of uterus so if it is full it can block the descent of the head
  • Lies behind the uterus so if full can block descent of head through pelvis
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26
Q

describe the inlet

A
  • Transverse diameter-13cm
  • AP diameter-12cm
  • Head usually engages in a transverse position and rotate as it comes through the pelvis and come out in AP position
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27
Q

describe the outlet

A
  • Transverse diameter-11cm

* AP diameter-12.5cm

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28
Q

describe the head position through pelvis

A
  • Transverse/oblique at inlet

* AP position at outlet

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29
Q

what muscles make up the pelvic floor

A
  • Coccygeus
  • Levator ani muscles

underneath pelvic floor
• Urogenital diaphragm containing deep transverse perineal muscle supporting the pelvic floor
• Superficially-bulbocavernosus muscle surrounding vagina and anus

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30
Q

what causes the power labour?

A
  • Contractions of the uterus

* Anterior abdominal wall muscle (initially)

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31
Q

physiological functions of uterus?

A
  • Tone
  • Contractility
  • Fundal dominance
  • Rhythmicity
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32
Q

describe contractility of uterus?

A
  • Coordinate contractility-all muscles contract in the same direction
  • Incoordinate-different direction of muscle contraction (may be why labour doesn’t progress)-synthetic version of oxytocin is used
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33
Q

describe fundal dominance of the uterus?

A
  • Contractions start at the fundus and travel downwards

* Contractions are also longer at the fundus

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34
Q

describe rhythmicity of the uterus?

A

• Rhythmicity of uterus depends of gestation and stage of labour

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35
Q

describe contractions in first stage of labour

A

3 times in 10 minutes and get stronger

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36
Q

describe contractions in advanced stage of labour

A

4 in 10 minutes and getting even stronger

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37
Q

describe contractions in second stage of labour

A
  • 4-5 in 10 minutes

* Much stronger

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38
Q

describe contractions in 3rd stage of labour?

A
  • After baby delivered
  • Space out
  • Important to contract uterus down and reduce blood loss
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39
Q

describe the sutures in the fetal skull

A
  • Lamboid
  • Sagittal
  • Coronal
  • Frontal
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40
Q

what is the most favourable diameter for fetal head during birth?

A
  • Suboccipito-bregmatic
  • As it is 9.5cm in diameter
  • Baby is in flexed position (head tucked in)
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41
Q

what is the largest diameter fetal head position

A

Mento-vertical

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42
Q

describe presentation of baby

A
  • In a transverse position because diameter is greater for a transverse position at the inlet
  • Feeling for the fontanel
  • Anterior fontanel (diamond shaped and big enough to fit a fingertip in)
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43
Q

what does occipitut anterior mean

A
  • Baby head faces downwards

* Anterior fontanel at the bottom

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44
Q

what does occiput posterior mean

A
  • Back to back
  • Occiput is posterior
  • Anterior fontanel at the front
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45
Q

what are the cardinal movements of labour

A
  • Engagement
  • Descent
  • Flexion
  • Internal rotation
  • Extension
  • External rotation
  • Expulsion
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46
Q

describe level of engagement of the fetus

A
  • Examining by feeling for head
  • By 5ths that are palpable
  • As labour progresses less of the baby head should be felt abdominally and more felt vaginally
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47
Q

describe descent

A

Occurs from pressure from amniotic fluid and contractions and extension and flexion of fetus

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48
Q

describe flexion

A
  • When head hits the pelvic floor

* Changes to the Suboccipito-bregmatic diameter

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49
Q

describe internal rotation

A
  • Head delivered under pubic arch and extend outwards

* Reverts back to OT position

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50
Q

what are the stages of labour

A
  • Latent phase
  • First stage
  • Second stage
  • Third stage
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51
Q

what is the latent phase of labour

A
  • Onset of contractions until they become regular
  • 3-4cms dilation
  • Cervix fully effaced
  • Uterus muscle tone increases
  • Cervix changes to a thin membrane
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52
Q

what is the first stage of labour

A
  • Regular contractions

* 3-4cm dilated until fully dilated

53
Q

what is the second stage of labour

A
  • Passive-no pushing

* Active-maternal pushing

54
Q

what is the third stage of labour

A
  • Delivery of placenta and membranes
  • Placenta separates from endometrial wall so uterus contracts down to reduce blood loss
  • 100-200ml blood loss
55
Q

how long is spent in each stage of labour for a primiparous woman

A
  • First stage-8.25 (2-12)
  • Second stage-1 (0.25-1.5)
  • Third stage-0.25 (0-1)
  • Total-9.5 (2.25-14)
56
Q

how long is spent in each stage of labour for a multiparous woman

A
  • First stage-5.5 (1-9)
  • Second stage-0.25 (0-0.75)
  • Third stage-0.25 (0-0.5)
  • Total-6 (1-10.25)
57
Q

cervical effacement and dilation

A

pressure from the baby’s head on cervix which causes prostaglandin release leading to softening

58
Q

describe the changes in fetal head position in labour

A
  • Descent and flexion
  • LOT to LOA
  • LOA to OA
  • Extension
  • OA to LOA
  • LOA to LOT
59
Q

what are the issues if the shoulder doesn’t deliver

A
  • Baby could become hypoxic
  • As soon as the head is exposed to air the baby tries to breathe so placenta slows down function and also umbilical cord is squashed at this stage
60
Q

what is post partum haemorhage

A

Blood loss greater than 500ml

61
Q

what is expected blood loss from a caesarean section

A

500ml-1L

62
Q

describe the normal management of labour

A
  • Evaluation of maternal and fetal condition, risk assessment to determine if fetal monitoring is required
  • Evaluation of the birth plan
  • Partogram
  • One to one support
  • Regular bladder emptying
  • Analgesia
  • Vaginal examination every 4 hours
63
Q

why is vaginal examination important during labour

A
  • Ensure no CPD

* Ensure labour is progressing (complications-fetal stress, sepsis, future long term complications for mother)

64
Q

what is CPD

A
  • Cephalopelvic disproportion
  • Baby head too big for pelvis
  • If no intervention head can become impacted and the uterus could rupture leading to maternal and fetal death
65
Q

what maternal observations are monitored

A
  • Check for tachycardia or pyrexia signs of sepsis
  • Woman should be encouraged to push once the cervix is fully dilated, in a position they feel comfortable
  • Episiotomy is indicated
  • Hands on versus hands off delivery
  • Controlled delivery of the head
  • Offer active management of the third stage
  • Blood pressure-pre-eclampsia
66
Q

describe active management of third stage of labour

A
  • Injection of syntometrine which helps the womb contract so all the blood vessels are sealed
  • Placenta separates more quickly
  • Pull on umbilical cord whilst applying counter pressure to uterus so uterus doesn’t come out
67
Q

describe the use of oxytocin in labour

A
  • Increase contraction frequency, strength and contractility

* Doesn’t improve outcomes

68
Q

describe the use of analgesia in labour

A
  • Simple oral analgesics
  • TENS
  • Entenox (gas oxygen and nitrous oxide)
  • Systemic opiates-pethidine, meptid, morphine, diamorphine
  • Epidural
69
Q

describe foetal monitoring in labour

A
  • Intermittent auscultation

* Continuous monitoring-CTG (cardiotopograph)

70
Q

what is CTG

A
  • Duration and frequency of contractions (not the strength due to interference from abdominal wall muscle)
  • Fetus cardiac activity (variable)
71
Q

what is the role of the obstetrician

A
  • Failure to progress first stage
  • Failure to progress second stage
  • Fetal compromise-sepsis/hypoxia
  • Maternal compromise-sepsis, haemorrhage
  • Delayed third stage
72
Q

why do people choose home birth

A
  • Can be safe for women who are low risk
  • Emotionally satisfying for mother and family
  • If risk factors – hospital delivery safer
  • Familiar setting to feel relaxed and in control
  • Fear of hospital
  • Continuing relationship with known midwife
  • More family members for support
  • Previous home birth
  • Avoid intervention
73
Q

name some statistics regarding home births

A
  • Home births 80% in 1920 to 1% in 1990
  • Government committee recommendation and maternity matters – full choice incluin home birth should be offered
  • UK home birth rate now increasing and currently 2-3%
  • 10-14% of women would choose home birth if given the option

In women booked for home birth
• 29% change to hospital (more common in nulliparous)
• Most transfers due to failure to progress or pain relief
• Slight perinatal mortality with home births

74
Q

what risk factors would make hospital delivery advisable over home birth

A

hypertension, diabetes, placenta previa

75
Q

what should be discussed with women opting for home birth

A
  • If low risk and mother wants home birth she should be counselled about the slight increasein perinatal mortality and possibility of transfer in labour
  • If risk arises before birth, booking should be changed
  • If risk is minimal – ofer choice and respect decision
76
Q

what are the risks of home birth

A
  • Rare
  • Transfer to hosptail may be needed
  • If delay in transfere, response to acute complications such as intrapartum fetal hypoxia, post partum haemorrhage may have worse outcomes
  • Facilities for neonatal resuscitation limited
  • Inadequate lightin and analgesia make diagnosing exten of perineal tears difficult and need transfer to hospital
77
Q

what is the role of GP in home birth

A
  • Should eb fully informed about local options for delivery and provide options in clear, understandable way
  • If there are litigation issues during birth – judge by bolam test
  • Support woman and midwife, help identify deviations from normal labour
  • Very few GPs offer care in labour and delivery
  • Do not have to attend home birth unless asked by midwife
78
Q

what are the risk factors for pre-term labour

A

Previous preterm birth or late miscarriage
Multiple pregnancy
Cervical surgery
Uterine anomalies
Medical conditions eg renal disease
Pre-eclampsia and IUGR (spontaneous and iatrogenic

79
Q

PRE-TERM LABOUR

management

A 
tocolysis
maternal corticosteroids
magnesium sulfate for neuroprotection
intrapartum antibiotics
fetal monitoring
mode of birth
timing of cord clamping
80
Q

PRE TERM LABOUR

tocolysis

A

delay delivery
• Nifedipine – 24-23+6 weeks with intact membranes
• If nifedipine contraindicated offer ocytocin receptor antagonists

81
Q

PRE-TERM LABOUR

when should maternal corticosteroids be given

A

23-33+6 weeks

82
Q

PRE-TERM LABOUR

magnesium sulfate for neuroprotection

A
  • 23-23+6 weeks
  • Offer IV 24-29+6 weeks / consider 30-33+6 weeks who are In established preterm or have preterm delivery planned within 24hrs
  • Give 4g bolus over 15 mins followed by 1g IV per hour until birth or 24hrs
83
Q

PRE TERM LABOUR

fetal monitoring

A
  • Cardiotocography and intermittent auscultation
  • Fetal scalp electrode
  • Fetal blood samping
84
Q

PRE-TERM LABOUR

time of cord clamping

A
  • May need resuscitation or If significant maternal bleed

* Wait 30secs – upto 3 mins before clamping if both stable

85
Q

FETAL MONITORING

intermittent auscultation

A
  • Low risk of consultations
  • Pinard or doppler
  • Immediately after contraction for 1 min at least every 15 mins
  • Record accelerations and decelerations
  • Palpate maternal pulse hourly
  • If rising baseline fetal HR – ausculate more frequently
86
Q

FETAL MONITORING

continuous cardiotocography and telemetry

A

•Not for low risk

Use if 
• Maternal pulse >120
• Temp 38
• Suspected chorioamnionitis or sepsis
• Pain different from normal pain of contractions
• Significant meonium
• Fresh vaginal bleeding
• Severe hypertension
• Proteinuria 
• Delay in first or second stage of labour
• Contractions longer than 60seconds
• Oxytocin use
87
Q

FETAL MONITORING

what should you review on CTG

A
  • Baseline rate
  • Baseline variability
  • Presence or absence of decelerations
  • Presence of accelerations
88
Q

FETAL MONITORING

baseline fetal heart rate

A
  • Reassuring – 110-160
  • Non reassuring – 100-109 / 161 – 180
  • Abnormal <100 / >180
89
Q

FETAL MONITORING

baseline variability

A
  • Reassuring 5-25 beats/mins
  • Non reassuring - <5 beats/min for 30-50mins or >25 beats/min for 15-25 mins
  • Abnormal - <5 beats/min for more than 50 mins / >25 beats/min for more than 25 mins / sinusoidal
90
Q

FETAL MONITORING

what should you specify when describing decelerations

A
  • Timing in relation to peaks of contractions
  • Duration of decelerations
  • Wether or not fetal HR reterns to baseline
  • How long they’ve been present
  • Wheterr they occur with over 50% of contractions
  • Presence or absence of biphasic W shape
  • Presence of shouldering
  • Presence or absence of reduced variability within deceleration
91
Q

FETAL MONITORING reassuring characteristics of decelerations

A

no decelerations, early deceleraions, variable with no concerning characeristics <90mins

92
Q

FETAL MONITORING

non reasuring characteristics of decelerations

A
  • Variable decelerations with no concerning characteristics for >90 mins
  • Variable decelraion with concerning characteristics in 50% of contractions for 30 mins
  • Variable decelrations with concnerning characteristics >50% contractions less than 30 mins
  • Late decelerations in over 50% contractions for less than 30 mins
93
Q

FETAL MONITORING

abnormal decelerations

A
  • Variable decelerations with concerning characteristics in over 50% of contractions for 30 mins
  • Late decelerations for 30 mins
  • Acute bradycardia or single prolonged deceleration lasting 3 mins or more
94
Q

FETAL MONITORING

concerning characteristics of variable decelerations

A
  • More than 60 secs
  • Reduced baseline variability
  • Failure to return to baseline
  • Biphasic shape
  • No shouldering
95
Q

FETAL MONITORING

accelerations

A

the presence of fetal heart rate accelerations, even with reduced baseline variability, is generally a sign that the baby is healthy

96
Q

FETAL MONITORING

when is fetal scalp stimulation indicated

A

If cardiotocograph is pathological

97
Q

describe the first stage of labour

A

Dilatation
From onset of labour until cervix fully dilated
2 phases
• Latent phase – effacement of cervix to 3cm dilation
• Active phase – active cervical dilatation – from 3cm to full dilation

98
Q

describe the second stage of labour

A

From full cervical dilatation to birth

99
Q

describe the third stage of labour

A

From birth of baby to delivery of placenta

100
Q

describe the pelvic organs during labour

A

Cervix becomes effaced and dilates fully
The uterus and vagina become one elongated tube
Pelvic floor muscles stretched backwards
Bladder becomes an abdominal organ and urethra lengthenes
Bowel compressed

101
Q

describe uterine action in labour

A
  • Fetus propelled down birth canal by myometrium
  • Fundally dominant so waves of contraction pass down
  • Contractions increase in frequency and strength
  • Painful due to; hypoxia, compression of nerve endings, cervica stretch and dilatation
102
Q

describe the uterus in first stage of labour

A
  • Contract and retract – remain shorter
  • Heaping up and thickening of upper uterine segment and lower becomes thinner and stretched
  • Cervix pulled up and canal is effaces so length diminishes
  • Cervix pulled up and open
  • Often start with Braxton hicks (painless)
103
Q

describe the uterus in the second stage of labour

A
  • Diminution in transverse diameters
  • Fetal head is forced into upper vagina
  • Expulsive efforts made by abdominal wall muscles, fixed diaphragm
  • Voluntary efforts not essential. Pushing instinctive
104
Q

describe the uterus in the third stage of labour

A
  • Uterine muscle contract – constrict blood vessles preventing bleeding
  • Placenta seperates at delivery of fetus.
105
Q

monitoring the first stage of labour

A
  • Monitored by descent of fetal head and dilatation of cervix
  • Partogram used to assess progress and contains; high risk factors, fetal heart rate, cervicogramo, descent of fetal head, contractions, amniotic fluid colour, maternal urine output, drugs given, BP, pulse, temp
106
Q

describe the management of second stage of labour

A
  • Woman encouraged to push with contractions
  • Monitor progress by vaginal examination
  • Inhalation analgesia
  • Episiotomy if – fetal distress, operative vaginal delivery, rigid perineum, if experienced midwife believes there is going to be major tear
  • Episiotomy – lignocaine 1%
  • When head delivered it is allowed to rotate and then lateral traction is applied in direction of mothers anus allowing birth of fetal anterior shoulder
  • 0.5mg syntometrine IM
  • Babys head raised towards mothers abdomen so posterior shoulder passes over perineum and rest of baby slips out
  • Suck mouth and nasal passages free of mucus and clear mouth
  • Umbilical cord clamped twice
  • Baby starts breathing within 1 min of delivery
107
Q

describe management of third stage of labour

A
  • Apply controlled cord traction
  • Place left hand above symphysis pubis and guards front wall of uterus to prevent uterine inversion
  • Traction on umbilical cord until placenta delivered into vagina and kidney dish
  • Membranes usually follow placenta and removed by rotation of placenta
  • Check placenta and membrane
  • Estimate blood loss
  • Active management if – haemorrhage, failure to deliver placenta within 1 hour, maternal desire to shorten 3rd stage
108
Q

describe the active management of third stage of labour

A
  • Syntometrine IM or oxytocin 10IUM given as anterior shoulder is born
  • Dish placed at introitus to collect placenta and blood loss
  • As the uterus contracts to 20-wk size, the placenta separates from the uterus through the spongy layer of the decidua basalis.
  • The uterus will then feel firmer, the cord will lengthen, and there is often a trickle of fresh blood (separation bleeding).
  • Controlled cord traction (CCT) is applied with the right hand, whilst supporting the fundus with the left hand (Brandt–Andrew’s technique).
109
Q

pain relief in labour

A

Nitrous oxide
Pethidine – can cause neonatal depression and poor analgesia
Water – water birth / first and second stage
Relaxation – training in pregnancy
Hypnosis – expensive
Acupuncture
TENS
Spinal block – nupivercaine
Epidural – bupivacaine 1% or marcain 0.25-0.5% - 2-3 hours
Caudal block
Local – pudendal

110
Q

describe potential abnormal labour

A
  • Dysfunctional uterine activity – prolonged labour more common in primigravidae
  • Prolonged latent phase. – rare usually primigravidae
  • Secondary arrest of cervical dilatation – enters active phase, reaches 5-7cm dilatation then cervix stops dilating, contractions may stop
  • Primary dysfunctional labour – slow progress after onset of established labour can lead to fetal distress, prolonged labour, incoordinate uterine activity, maternal dehydration
  • Shoulder dystocia – emergency, shoulders don’t spontaneously deliver after the head
  • Cephaopelvic disproportion – absolute (no possibility of normal vaginal delivery) or relative (baby is large but baby would pass through pelvis if mechanisms of labour function correctly
  • Breech presentation
  • Shoulder presentation (transverse lie)
  • Occipitoposterior positions
  • Face presentation
  • Brow presentation
111
Q

describe the management of multiple pregnancy

A
  • All defined as high risk and care should be consultant led.
  • Establish chorionicity – diagnose in 1st trimester
  • Routine iron and folate
  • Detailed anomaly scan
  • Aspirin 75mcg of if other risk factors for preeclampsia
  • Growth scans at 28, 32, 36 weeks for DC twins
  • More frequent antenatal checks due to increase risk of pre-eclampsia
  • Offer delivery at 37-38 weeks
112
Q

describe the risk of preterm delivery in multiple pregnancy

A
  • Increased incidence
  • Predictabl with transvaginal cervical scanning
  • Not preventable by cervical cerclage
  • Beneficial effect of progesterione limited
113
Q

what are the maternal risks in multiple pregnancy

A
  • Pregnancy risks heightened
  • Hyperemesis gravidarum
  • Anaemia
  • Pre-eclampsia (x5)
  • Gestational diabetes
  • Polyhydramnios
  • Placenta praevia
  • Antepartum and post partum haemorrhage
  • Operative delivery
114
Q

what are the fetal risks in multiple pregnancy

A
  • All risks increased
  • Increased risk of miscarriage (especially with MC twins)
  • Congenital abnormalities (especially with MC twins) – neural tube defects, cardiac abnormalities, gastrointestinal atresia
  • IUGR
  • Preterm labour – 40% before 37 / 10% before 32 weeks
  • Increase perinatal mortality
  • Increase risk of intrauterine death
  • Increase risk of disability
  • Increase incidence of cerebral palsy
  • Vanishing twin syndrome
115
Q

describe twin to twin transfusion syndrome

A
  • 80% mortality if untreated
  • Can lead to severe fetal compromise at gestation too early for delivery
  • Caused by aberrant vascular anastomoses in placenta which redistribute the fetal blood (blood from donor twin transfused to recipient twin)
  • MC twins need intensive monitoring – serial USS every 2 weeks from 16-24 weeks and every 3 weeks until delivery. Treatment with - laser ablation of placental anastomoses or selective feticide by cord occlusion
  • Laser treatment leads to survival of one in 80% and both in 50%
  • Effect on donor twin: hypovolaemia and anaemia, oligohydramnios, growth restriction
  • Effect on recipient twin: hypovolaemia and polycythaemic, large bladder and polyhydranios, cardiac overload and failure, evidence of fetal hydrops, often more at risk than donor
116
Q

describe selective intrauterine growth restriction

A
  • Growth discordance even without TTTS Is more common
  • Variable pattern f umbilial artery doppler signals indicates risk of sudden demise
  • Treatment: if >28 weeks – delivery safest / if <28 weeks – selective termination or laser ablation considered
117
Q

describe termination of pregnancy issues in multiple pregnancies

A
  • MC twins are identical but may have different structural abnormalities
  • Selective termination of pregnancy requires closure of shared circulation so normally performed with diathermy cord occlusion
118
Q

what is twin reversed arterial perfusion

A

One of an MC twin pair is structurally very abnormal with no or a rudimentary heart, and receives blood from other which is called the pump twin. The normal twin may die of cardiac failure and unless the abnormal twin is very small or flow to it ceases, selsective terminatin using radiofrequency ablation or cord occlusion is indicated

119
Q

describe intrauterine death of twin

A
  • Dichorionic – death of one twin in 1st trimester or early 2nd doesn’t adversely affect remaining fetus however loss in late 2nd or 3rd precipitates labour
  • Monochorionic – due to shared circulation, subsequent death or neurological damage from hypovolaemia follows in upto 25% where one of the pair dies. Delivery doesn’t increase the risk of brain injury.
120
Q

in multiple pregnancies describe labour

A
  • Second twin is at increased risk of perinatal mortality
  • Leading twin should be cephalic and no absolute contraindication eg placenta praevia
  • Triplets and more are delivered by CS
121
Q

what are the intrapartam risks of multiple pregnancy

A
  • Malpresentation
  • Foetal hypoxia in second twin after delivery of first
  • Cord prolapse
  • Operative delivery
  • Post partum haemorrhage
  • Rare- cord entanglement, head entrapment with each other, fetal exsanguination due to vasa praevia
122
Q

describe the management of labour in multiple pregnancies

A
  • Usually induced at 38 weeks (many deliver before this)
  • IV access and group and save
  • Fetal monitoring with CTG through labour
  • Can monitor leading twin with fetal scalp electrode and other abdominally
  • Epidural?
  • Delivery in theatre – immediate recourse to surgical intervention if needed
  • First delivered as normal
  • After first deliverd – the lie of the second should be checked and stabilised by abdo palpation while VE performed to assess station of presenting part
  • Ultrasound scanner in case of concerns about malpresntation of 2nd twin
  • Once presenting part enters pelvis and membranes can be broken and the second twin usually delivered within 20 mins
  • Ocytocin may help if contractions diminish
  • Forceps or ventouse?
123
Q

describe occiput posterior presentation

A

In occiput posterior presentation (also called sunny-side up), the fetus is head first but is facing up (toward the mother’s abdomen). It is the most common abnormal position or presentation.
When a fetus faces up, the neck is often straightened rather than bent, and the head requires more space to pass through the birth canal. Delivery by a vacuum extraction, forceps or caesarean may be necessary.

124
Q

describe breech presentation

A
  • buttocks/feet present firs
  • 3-4% of full term deliveries
  • 2nd most common abnormal presentation
  • injuries more common
  • more likely in preterm, fibroids etc, birth defect
125
Q

how can breech presentation be prevented

A

Sometimes the doctor can turn the fetus to present head first by pressing on the woman’s abdomen before labor begins, usually after 37 weeks of pregnancy. Some women are given a drug (such as terbutaline) to prevent labor from starting too soon. If labor begins and the fetus is in breech presentation, problems may occur.

126
Q

what issues may be a result of breech delivery

A
  • Brain damage due to lack of oxygen is more common among babies presenting buttocks first than among those presenting head first.
  • more frequent in first delivery as tissues not stretched
127
Q

what is face presentation

A

neck arches back so that the face presents first.

128
Q

what is brow presentation

A

the neck is moderately arched so that the brow presents first.
Usually, fetuses do not stay in a face or brow presentation. They often correct themselves. If they do not, forceps, vacuum extractor, or cesarean delivery may be used.

129
Q

what is transverse lie

A

the fetus lies horizontally across the birth canal and presents shoulder first. A cesarean delivery is done, unless the fetus is the second in a set of twins. In such a case, the fetus may be turned to be delivered through the vagina.

Women's Health - Year 4 (15 decks)

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