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My MRCOG Part 2 > Module 7 - Intrapartum Care (NICE +TOG) > Flashcards

Module 7 - Intrapartum Care (NICE +TOG) Flashcards

1
Q

What are the 4 birth settings available to women?

A
  1. Home
  2. Freestanding mw unit
  3. Alongside me unit
  4. Obstetric unit.
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2
Q

What data should be published regarding non-obstetric lead units?

A

Transfer times, reason for transfer and reason for any delay in transfer.

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3
Q

What is the difference in outcomes for low risk primips between birth settings?

A

MW lead freestanding or alongside gives lower intervention and no difference in neonatal outcomes.

Home births lead to a small increase in adverse neonatal outcomes (inc of 4/1,000).

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4
Q

What is rate of NVD in a low risk multip at:
-Home
-Freestanding unit
-Alongside unit
-Obstetric unit

A
  1. 984 / 1,000 (Home)
  2. 980 / 1,000 (Freestanding)
  3. 967 / 1,000 (Alongside)
  4. 927 / 1, 000 (Obstetric).
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5
Q

What is the rate of NVD in low risk primips?

A
  1. 794 / 1,000 (Home)
  2. 813 / 1,000 (Freestanding)
  3. 765 / 1,000 (Alongside)
  4. 688 / 1, 000 (Obstetric).
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6
Q

What is the risk of requiring an LSCS as a low risk primip in an obstetric lead unit (compared to non-obstetric lead units)?

A

In obstetric lead unit - 121 / 1,000

Others - 70-80 / 1,000.

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7
Q

What is the most common reason for transfer to obstetric lead unit?

A

DELAY IN SECOND STAGE.
Approx 35% (all other places of birth).

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8
Q

What are reasons to transfer to Obstetric lead unit?

A
  1. DELAY IN SECOND STAGE
  2. Abnormal FH (10%)
  3. Regional anaesthetic (5-13%)
  4. Meconium (12%)
  5. Retained placenta (5-7%)
  6. Perineal repair (10%)
  7. Neonatal concerns (5% home, 2.5% freestanding and 0.1% alongside).
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9
Q

Above what BMI considered high risk?

A

> 35

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10
Q

What are the risks assocaited with increased BMI?

A
  • Unplanned LSCS
  • PPH
  • Transfer to obstetric unit
  • Stillbirth
  • Neonatal death/needing neonatal care

(Note that P0 higher risk than multips).

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11
Q

Does raised BMI impact rates of LSCS or instrumental delivery?

A

Yes for primps, but no for multips.

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12
Q

What previous complications will affect a woman’s place of birth?

A
  • VBAC.
  • Previous HIE.
  • Eclampsia.
  • Uterine rupture.
  • PPH requiring treatment or blood transfusion.
  • Shoulder dystocia.
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13
Q

What previous complications will require further discussion with a woman about her place of birth choice? (not an automatic reason to deliver in obs unit).

A
  • Extensive perineal trauma including OASI.
  • Previous MROP.
  • Jaundice term baby requiring exchange transfusion.
  • EFW >4.5kg.
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14
Q

How does a previous stillbirth affect a woman’s choice of where to deliver?

A

If unexplained or recurrent cause of stillbirth, neonatal or intrapartum death, then should deliver in obs unit.

If there was a known cause for stillbirth (and this not recurrent) then discuss options with woman.

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15
Q

How does previous PET affect a woman’s choice of where to deliver?

A

PET leading to Preterm delivery should be delivered in obs unit.

PET at term can have discussion about her options.

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16
Q

How does placental abruption affect a woman’s choice of where to deliver?

A

If associated adverse outcome, then deliver in obs unit.

But if good outcome, then discuss her options.

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17
Q

What are the two ambulance categories that are used to transfer women into obstetric unit in labout?

A

Category 1 (life-threatening).

Category 2 (urgent eg analgesia).

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18
Q

What positions should women be supported to adopt in labour?

A

Any comfortable position except for lying flat.

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19
Q

Where can initial review of women ?labour take place?

A

In any birth setting regardless of where they plan to birth.

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20
Q

What is the average length of the first stage of labour in P0 vs multips?

A

P0 - average 8 hrs (unlikely >18 hours).

Multips - average 5 hours (unlikely >12 hours).

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21
Q

Is the need for ARM due to delay in first stage a requirement for transfer to obstetric unit?

A

No. Unless there is no progress 2 hours after ARM.

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22
Q

What maternal observations should prompt transfer to obstetric lead unit?

A
  1. HR >120 x2.
  2. BP >160/110 (or 2x>140/90).
  3. RR <9 or >21 x2.
  4. Temperature >38 x1 (>37.5x2).
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23
Q

What examination findings would prompt transfer to obstetric unit?

A

Liquor blood stained, mec, poly or oligo.
Non cephalic.
High head (4 or 5 5ths palpable).
SGA or IUGR.
FM concerns.

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24
Q

Should PPI be routinely offered to low risk women?

A

No

Unless giving opioids.

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25
Q

What affect will oxytocin have on the MOD and duration of labour?

A

No difference in MOD.
Shortens duration of labour by 1 hour.

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26
Q

How does the consistency of the cervix affect intra-uterine pressure?

A

Compliant cervix can dilate even with low strength contractions whereas firm cervix may not dilate even with strong contractions.

Therefore if adequate cervical dilatation, synt is not required.

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27
Q

When should maternal observations be carried out in the first stage of labour.

A

30 minutely contraction frequency.
Hourly HR.
4 hourly full observations and VE.

(and if other concerns or maternal request).

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28
Q

How often should a risk assessment be carried out of mum and baby?

A

Hourly.
Transfer if risks have developed.

29
Q

When should a partogram be used?

A

When in established labour?

30
Q

How frequently should bladder care be carried out in labour?

A

4 hourly.

(sensation, volume, colour, frequency).

31
Q

When should fluid balance be started?

A

IV Synt.
IVI.
Retention (or oligourea).
Abnormal or absent sensation.

32
Q

Should ARM be routinely offered?

A

Not in normally progressing labour.

33
Q

What are the parameters to diagnose delay in first stage?

A

<2cm / 4 hours in P0 OR MULTIPS.
Slowing in progress in multips.

Descent or rotation of foetal head and changes to contractions.

34
Q

If suspect delay what is the next step?

A

Repeat VE in 2 hours.
Delay diagnosed if <1cm progress.

35
Q

When should ocytocin be started in the first stage?

A
  1. In obstetric unit.
  2. After ARM.
  3. Once delay in 1st stage has been diagnosed.
36
Q

What are the risks of syntocinon to augment labout?

A
  1. Tachysystole.
  2. Increased pain.
  3. Foetal distress.
  4. Need for further monitoring (cCTG and fluid balance).
  5. Hyponatremia
  6. Foetal acidosis at delivery.
37
Q

Should IVI be started when syntocinon is started?

A

NO

38
Q

When should VE be repeated after syntocinon is started?

A

4 hours from regular contractions.

39
Q

When should syntocinon dose be increased?

A

At least every 30 minutes until contractions are 3-4:10.

40
Q

What evidence is there for the affect of oxytocin on maternal or neonatal morbidity?

A

There is no evidence for this.

41
Q

What factors should be considered before starting synt in labour?

A

position.
cpd.
foetal distress.
vbac or uterine scar?

42
Q

Which non pharmacological analgesia option reduces pain in labour?

A

Accupuncture/accupressure decreases pain by 10% in first 30 mins of labour.

43
Q

What temperature should water be for labour?

A

Max temp 37.5C.
Hourly maternal and pool temperature.

44
Q

What evidence is there for TENS machine?

A

There is little evidence of effectiveness, but no evidence of harm.

45
Q

How and where is sterile water injected for analgesia?

A

Intra-cutaneous or sub-cut.
4 injection sites around rhombus of Michaelis.
0.1ml IM or 0.5ml SC at rach site.

46
Q

How long do sterile water injections provide analgesia for?

A

From 10 minutes to 3 hours.

47
Q

What is the composition of enenox?

A

50:50 O2 and NO

48
Q

What are the maternal and neonatal SEs of opioids in labour?

A

Maternal: N/V and drowsiness.

Neonatal: respiratory depression, drowsiness, difficulty establishing breast feeding.

49
Q

What PCA can be offered in labour?

A

IV Remifentanil
40 microgram boluses at 2 minute lock out.
(but need anasthetic support).

50
Q

What is benefit and risks of Remifentinil PCA compared to IM Pethidine?

A

Benefits:
- Less likely to need epidural. - Less likely to need instrumental.

Risks:
- More likely to need o2.
- Requires intensive continuous monitoring (eg continuous pulse ox).

No Difference:
- Respiratory depression maternal.
- LSCS rates.
- Pain in labour.
- Rates of breast feeding within an hour.

51
Q

What is the underlying cause of a post epidural headache?

A

Accidental dural puncture.

52
Q

What are the risks of epidural or CSE?

A

Dural tap (headache).
Longer second stage.
Increased risk instrumental delivery.
More intensive monitoring.
Reduced mobility.

53
Q

What affect does epidural have on developing back ache and first stage?

A

No difference in length of first stage.
Does not affect future chance of developing back ache.

54
Q

Are IVI required with epidurals?

A

Pre loading is not required.
Slow IVI is required.

55
Q

Once epidural bolus has been given, how frequently do maternal observations need to be carried out?

A

BP every 5 minutes when establishing epidural or giving boluses.
Anaesthetic review if no analgesia after 30 mins.
Hourly sensory and motor block.

56
Q

How much passive time should be given to P0 vs multips.

A

P0: 2 hours
Multips: 1 hours

57
Q

What CTG needs to be carried out before an epidural is sited?

A

30 minutes of normal CTG is needed before epidural sited.
30 mins after established and after each bolus.

58
Q

Which drug should CSE be established?

A

Bupivicaine 0.06-0.1%
And Fentanyl 2.0 microg.

59
Q

What drug should be used for epidural?

A

Low concentration LA and fentanyl.

60
Q

What is the risk of neonatal infection in intact vs PROM at term?

A

0.5% in intact membranes.
1% in PROM.

61
Q

What % of women labour within 24 hours of PROM at term?

A

60%

62
Q

What should be monitored in a women with PROM chooses 24 hours of expectant management?

A

Temperature 4 hourly.
Vaginal loss.
FH and MHR 24 hourly until in labour.

63
Q

When should augmentation be offered immediately after PROM?

A

GBS positive.

64
Q

Define latent stage of labour

A

Period of time (may not be continuous) with contractions and cervical change up to 4cm.

65
Q

Define established first stage.

A

Regular contractions AND progressive cervical dilatation.

66
Q

How often should IA be carried out in second stage?

A

For one minute after each contraction at least every 5 minutes.

67
Q

In women with an epidural in situ, what factors regarding pushing will shorten second stage?

A

Spontaneous pushing (compared to directed).
If directed pushing is used, pushing during exhale will shorten second stage.

68
Q
A

My MRCOG Part 2 (37 decks)

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