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My MRCOG Part 2 > Module 7: NICE - Intrapartum Care > Flashcards

Module 7: NICE - Intrapartum Care Flashcards

1
Q

What 4 birth settings must be offered by maternity services?

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

What are the advantages of home birth or mw lead units for low risk mulitps?

A

Lower rate of intervention and higher spontaneous vaginal delivery rate.

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3
Q

What is the difference in neonatal outcomes between home/ freestanding/ alongside units compared to obstetric units for low risk multips?

A

There is no difference.
3/1,000 born with medical problems.

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4
Q

For who?????? Edit this
What is the rate of transfer into obstetric unit from:
- home
- freestanding mw unit
- alongside mw unit?

A

Home - 115 / 1,000
Freestanding - 94 / 1,000
Alongside - 125 / 1,000.

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5
Q

What is the rate of instrumental delivery in low risk multips who deliver at:
- home
- freestanding mw unit
- alongside mw unit
- obstetric unit?

A

Home: 9 / 1,000
Freestanding: 12 / 1,000
Alongside: 23 / 1,000
Obstetric unit: 38 / 1,000

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5
Q

What is the difference in neonatal outcomes between home/ freestanding/ alongside units compared to obstetric units for low risk NULLIPS?

A

Home birth is associated with small increased risk in adverse neonatal outcomes (4 / 1,000 more) compared to any other setting.

9 / 1000 babies born with medical problems at home compared to 5 / 1000 anywhere else.

75% neonatal medical problems due to meconium aspiration.
13% stillbirth after start of labour.
4% fractured humorous or clavicle.

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6
Q

What is the risk of transfer to obstetric unit in low risk NULLIPS who labour at:
- home
- freestadning mw
- alongside mw?

A

Home: 450 / 1,000
Freestanding: 363 / 1,000
Alongside: 402 / 1,000

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7
Q

What is the rate of instrumental delivery in low risk NULLIPS who labour at:
- Home
- Freestanding
- Alongside
- Obstetric unit?

A

Home: 126 / 1,000
Freestanding: 118 / 1,000
Alongside: 159 / 1,000
Obstetric unit: 191 / 1,000.

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8
Q

What are the reasons for transfer to obstetric unit (and the rates)?

A

DELAY IN FIRST STAGE - 35%

Meconium - 12%
Abnormal FH - 10%
Retained placenta - 7% (but 4% in alongside units)
Wanting regional anasthetic - 5% home but 13% alongside units
Perineal repair - 11% home by 8% in any mw unit
Neonatal concerns - 5% (but 0.1% in alongside unit).

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9
Q

Over what BMI is there an increased risk of complications?
What are these complications?

A

BMI > 35.

Increased risk of LSCS, PPH, Transfer to obstetric unit, stillbirth and neonatal death.

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10
Q

Is a co-existing medical problem reason enough to recommend delivery in obstetric lead unit?

A

No, but should prompt further consideration about birth location.

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11
Q

What factors in a patient’s previous pregnancy would lead to recommendation of delivery in obstetric unit?

A

Stillbirth or neonatal death or encephalopathy. Or IUFD.
PET (eclampsia or requiring premature delivery).
Abruption with adverse outcome.
Uterine rupture.
Primary PPH.
Previous LSCS or uterine surgery or shoulder dystocia.
LGA.
Extensive perineal tear.
MROP.

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12
Q

What factors in a patient’s current pregnancy would lead you to recommend delivery in obstetric unit?

A

Multiple babies on board.
Grand multip (4+).
Age 40+.
Previa.
PET (HTNx2 readings).
PPROM.
Abruption or recurrent APH.
Anaemia <85 at start of labour.
IUFD.
Medicated GDM.
Not cephalic lie.
SGA < 3rd centile or LGA.
Abnormal FH or Doppler.
Oligo or polyhydramnios.
Foetal abnoramlity.
Fibroids.

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13
Q

What non-pharmacological options for analgesia in labour?

A

Breathing, shower or bath (ensure water not above 37.2C) or massage.

TENS machine (little evidence of effectiveness but no evidence of harm).

Sterile water injections (AKA sterile water blocks or papules).
Intra or subcutaneous sterile water injections. For back pain. Analgesia for 10 mins to 3 hours. Given at 4 injections points around Rhombus of Michaelis. Poor quality evidence.

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14
Q

What is entenox comprised of?

A

50:50 O2 and NO

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15
Q

What pharmacological options for analgesia are available in labour?

A

Entenox
Opioids
Remifentanil PCA (40mcg bolus 2 min lock)
Regional anaesthetic

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16
Q

What are the potential side effects of epidural anasthetic?

A

May not be fully effective.
Accidental dural tap (severe headache).
Longer second stage and increased instrumental delivery.
More intensive monitoring.
Reduced mobility.

NOT associated with:
- long term back ache
- increased rates of LSCS
- longer first stage.

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17
Q

What monitoring should be carried out after an epidural is sited?

A

BP every 5 minutes for minimum 3 times.
Anaesthetic review if no analgesia after 30 mins.
Hourly sensory and motor block.

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18
Q

Should oxytocin be used routinely in women with an epidural in second stage?

A

NO

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19
Q

What examination should be carried out in women with suspected SROM?

A

Speculum (only if SROM not confirmed).
Avoid VE unless contracting.

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20
Q

What are the risks of pre-labour rupture of membranes at term?

A

1% neonatal infection (0.5% intact membranes).
60% labour within 24 hours.

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21
Q

In women with pre-labour rupture of membranes, how does bathing affect their risk of infection?

A

Taking a bath does not increase risk of infection. Remains at 1%.

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22
Q

Define latent phase of labour.

A

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

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23
Q

What defines active first stage?

A

Regular contractions AND progressive cervical change.

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24
Q

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

A

Primips: 8 hours (unlikley > 18 hours).

Multips: 5 hours (unlikley > 12 hours).

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25
Q

Is ARM a reason for transfer to obstetric lead unit?

A

No.
Unless there is no progress after 2 hours.

26
Q

Will the use of oxytocin shorten labour or influence MOD or neonatal outcomes?

A

Does shorten length of labour.
No change to MOD or neonatal outcomes.

27
Q

How often is oxytocin dose increased?

A

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

28
Q

How often should a VE be carried out in the active stage of labour?

A

Hourly.

29
Q

If using IA, how should this be done in the active stage of labour?

A

For 1 minute after each contractions
At least every 5 minutes
Also palpate maternal pulse every 5 minutes.

30
Q

In nullips, how can the second stage of labour be shortened?

A

Passive time up to 2 hours.

Directed pushing (rather than spontaneous) reduces need for LSCS.

31
Q

When should a multip be assessed for progress in second stage of labour with an epidural vs without?

A

WITH: up to 1 hour passive. Assess 30 mins after active pushing and senior review at 60 mins.

WITHOUT: Assess after 30 mins of active pushing and senior review after 1 hour.

If intact membranes at 30 mins (either above) then do ARM.

32
Q

When should primips be assessed in active second stage of labour?

A

Reassess after 1 hour. Senior review after 2 hours.

Remember with an epidural can have passive time up to 2 hours.

33
Q

How can perineal trauma be reduced?

A

Warm perineal compress.
Perineal massage.

NOT lidocaine spray or routine episiotomy.

34
Q

What affect does a previous OASI have on the risk of OASI in next pregnancy?

A

risk is NOT increased compared to first birth.

35
Q

What is the risk of OASI in Primip vs Multips in the general population?

A

Primips - 6%
Multips - 2%

36
Q

What evidence is there for labouring in water in women who have suffered FGM?

A

Insufficient evidence for or against.

37
Q

Why is syntometrrine used for active management of third stage of labour?
What is it’s SE?

A

Syntometrine commonly used (10 units synto IM + 500microg erogometrine).

Not if HTN.

Causes nausea therefore give with anti emetic.

38
Q

What are CI to ergometrine?

A

HTN
PET
Severe cardiac disease
Hepatic or renal disease.

39
Q

Can cord oxytocin or prostaglandin be used in the third stage of labour?

A

NO

40
Q

What is the risk of PPH>500 mls and PPH>1L in active vs physiological management ?

A

Active management:
- >500mls - 68/1,000
- >1L - 13/1,000

Physiological management:
- >500mls - 188/1,000
- >1L - 29/1,000

41
Q

What is the risk of blood transfusion in active vs physiological management?

A

Active management - 13 / 1,000

Physiological management - 35 / 1,000

42
Q

What is the risk of post natal Hb <90 in active vs physiological management?

A

Active management - 30/1,000

Physiological management - 60/1,000

43
Q

What is the risk of requiring further uterotnics in active vs physiological management?

A

Active management - 47/1,000

Physiological management - 247/1,000.

44
Q

After how long would you consider there to be a delay in the third stage?

A

Active management - after 30 mins.

Physiological management after 60 minutes.

45
Q

What are the 8 main principles of PPH management

A
  1. Call for help
  2. Empty bladder
  3. Uterine massage
  4. Uterotonics
  5. IVI
  6. CCT placenta
  7. Identify source of bleeding
  8. Transfer to obstetric lead unit.
46
Q

What medical management of PPH should be used in physiological third stage?

A
  1. TXA
  2. IM ergometrine (Caprboprost if CI) OR 40 units synt.
  3. IM carboprost
  4. Repeat carboprost (15 mins) or Misoprostol
    or Slow IV carbetocin.
47
Q

What is the dose and frequency of Carborpost that can be used?

A

250 micrograms
IM
15 minutely up to 8 doses.

48
Q

What PPH medications can be used if oxytocin alone was used in third stage?

A
  1. IM ergometrine (carboprost if CI) or 40 units synt.
  2. IM carboprost
  3. Repeat carboprost
    or misoprostol
    or Slow IV Carbetocin.
49
Q

What medical management of PPH should be used if syntometrine was used in third stage?

A
  1. IM Carborpost
    or 40 units synto
  2. Repeat carboporst after 15 mins
  3. Repeat carboprost up to 8 times
    or Misoprostol
    or Carbetocin.
50
Q

What dose of Misoprostol can be used in management of PPH?

A

800 micrograms SL or PR

51
Q

Does the skin need to be closed in a perineal repair?

A

1st degree - not if skin edges well opposed.
2nd degree - not if skin edges well opposed after muscles closed.

52
Q

Should paired cord samples be routinely taken after delivery?

A

No, only if concerns about baby’s wellbeing at delivery or assisted delivery.

53
Q

At what times should APGAR be carried out?

A

1 and 5 minutes

(+/- 10 minutes).

54
Q

What does APGAR stand for?

A

Appearance (cyanotic all over, peripheral cyanosis or pink)

Pulse (0, <100, 100-140)

Grimace AKA reflex (no response, weak cry, cry when stimulated)

Activity AKA Tone (floppy, some flextion, well flexed with resting extension)

Respiration (Apneic, slow irregular, strong cry).

55
Q

What mental health medications require foetal observations post natally? And why?

A

SSRI or SNRI

Pulmonary hypertension or neonatal withdrawal.

56
Q

How often are neonatal observations carried out if meconium is present at delivery?

A

Insignificant mec: observations at 1 and 2 hours.

Significant mec: 1 and 2 hours then 2 hourly until 12 hours.

57
Q

What does evidence show about the difference in perineal trauma when using hands on vs hands poised approach during delivery?

A

No difference in perineal trauma.

58
Q

What evidence supports the dose to restart oxytocin intrapartum (after it has been turned off)?

A

There is no evidence to support the dose to restart synt. Use clinical judgement.

59
Q

Is there evidence to support TXA in PPH?

A

Yes, there is good evidence to support TXA reducing maternal death compared to placebo.

60
Q

What is the evidence for syntocinon and ergometrine in PPH management?

A

There is no evidence, but this is included based on clinician’s experience.

61
Q

What is the risk of Stillbirth in women with BMI<35 vs BMI>35?

A

BMI <35
P0 - 82 / 1,000
P1+ - 7 / 1,000

BMI > 35
P0 138 / 1,000
P1+ 7 / 1,000

62
Q

What is the risk of Intra-partum LSCS (cat 1/2/3) in BMI < 35 vs BMI > 35.

A

BMI <35
P0 - 82 / 1,000
P1+ - 5 / 1,000

BMI > 35
P0 - 122 / 1,000
P1+ - 5 / 1,000

63
Q

What is the risk of transfer to obstetric unit in women with BMI <35 vs BMI>35?

A

BMI < 35
P0 - 448 / 1,000
P1+ - 102 / 1,000

BMI > 35
P0 - no data
P1+ - BMI>30 = 145 / 1,000

My MRCOG Part 2 (37 decks)

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