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RANZCOG - Intrapartum care Edward > Normal labour > Flashcards

Normal labour Flashcards

1
Q

What are the definitions for moulding
0
+1
+2
+3

A

Def of moulding
0 = bones are separated and sutures can be easily felt
+1 = Bones are touching each other
+2 = Bones are overlapping but can be reduced with finger pressure
+3 = bones are over lapping and can’t be easily reduced

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2
Q

Discuss 5ths palpable and corresponding station

A

5/5 - Station -4/-5
4/5 - Station -3
3/5 - Station -2
2/5 - Station -1
1/5 - Station at spines
0/5 - Below spines

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3
Q

Discuss the stages of labour
-Definition of latent phase
-Average duration of latent phase for a nullip
-Average duration of latent phase for a multip
-Definition of active phase
-Average duration of active phase in a nulip
-Average duration of active phase in a multip
-Slow labour definition

A
  1. Definition of latent phase
    -Painful contractions with some cervical change including effacement and dilation up to <4cm
  2. Average length in nulip - 1.7 - 15 hrs
  3. Average length in multip - not studies
  4. Definition of active phase
    -Strong regular contractions with progressive dilation from 5cm
  5. Average time of active phase in nulip
    -10th centile 0.9cm/hr
    -1.0 - 19.4
    -Average 8 hrs
  6. Average duration in a multip
    -10th centile 1.2cm/hr
    -Average 5hrs
    -0.5-14.9 hrs
  7. Slow labour def
    -Less than 2cm dilation in 4 hrs once in active labour
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4
Q

Discuss second stage of labour
-Definition of passive second stage
-Definition of active second stage
-Duration of active second stage in nulips
-Duration of active second stage in multips

A
  1. Definition
    -Full dilation prior to or in the absence of involuntary expulsive contractions
  2. Definition of active second stage - any of these
    -When the baby is visible
    -There are expulsive contractions
    -There is active pushing with maternal effort
  3. Duration of active second stage in nulips
    -suspect delay if >2hrs
    -Average 54 mins
  4. Duration of active second stage in multips
    -Suspect delays if >1hr
    -Average 18mins
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5
Q

Discuss third stage of labour
-Definition
-Management approaches - active
-Management approach - physiological
-When action needs to be taken

A
  1. Definition
    -From time of birth of baby until time placenta is delivered
  2. Management - active third stage
    -Routine oxytocin
    -Delayed cord clamping
    -CCT after signs of separation
  3. Management - physiological
    -No routine use of uterotonics
    -No clamping of cord till pulsation has stopped
    -2 times risk of PPH and transfusion
    -Delivery by maternal effort
  4. When should action be taken
    -30mins if not delivered involve obstetrics
    -60mins if not delivered to OT
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6
Q

Describe the mechanics of delivery (7 steps)

A
  1. Engagement of the presenting part - usually transverse
  2. Descent of the presenting part t below the spines
  3. Flexion of the head against the pelvic floor
  4. Internal rotation - head to OA and shoulders transverse
  5. Extension - of the fetal head under the pubic arch
  6. Restitution of the head so that shoulders are AP
  7. Delivery of shoulders
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7
Q

Describe labour cares
-Care in first stage (10 points)

A
  1. Initial assessment
    -Determine level of risk of pregnancy to guide monitoring and location of birth
  2. One on one care
    -Undertake once in established labour
    -Reduces rate of CS, operative vaginal delivery, use of analgesia, shortens duration of labour, improved apgar scores
    3.Fetal monitoring
    - intermittent ascultation or continuous CTG
  3. Maternal obs - hrly
  4. Monitor progress
    - 4hrly VE. (RANZCOG)
  5. Monitor uterine activity - palp, toco, intrauterine pressure transducer
  6. Regular bladder emptying
  7. Encourage mobilisation
  8. Provide analgesia
  9. Routine amniotomy and oxytocin not recommended - No diff in CS, SVB, instrumental, epidural. No diff in length of first stage (RANZCOG)
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8
Q

Discuss care in labour
-Second stage

A
  1. Monitoring
    Offer VE every hr in multigravid and every 2 hrs in primigravida
  2. Pushing
    -Encourage pushing once fully dilated and woman has urge to push or head at perineum
    -Avoid sustained valsalva is associated with adverse fetal and maternal effects
    -Lower fetal O2
    -More frequent occurance of fetal heart rate pattern
    -Delayed recovery of fetal heart
    -Increased perineal trauma
    -Lower apgar scores
    -Delaying active pushing reduces forceps, CS
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9
Q

Discuss positioning for delivery
-Benefits of upright/lateral position (6)
-Benefits of supine (2)

A
  1. Benefits of upright position
    -Reduction in duration of second stage
    -Reduction in assisted deliveries and CS
    -Reduction in abnormal CTG
    -Less episitomies
    -Less painful
    -Reduction of labour by 80 mins
  2. Benefits of supine
    -Reduction in perineal trauma
    -Less blood loss
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10
Q

Discuss perineal management
-Methods to decrease trauma (4)
-Role of episiotomy (2)
-When should episiotomy be considered (4)

A
  1. Methods to reduce trauma
    -Encourage woman to stop pushing as baby is crowning
    -Use hands on/hands poised approach to flex head and control delivery
    -Use warm compress - reduces perineal tears (Cochrane review)
    -Deliver baby’s shoulders one at a time
    -Perineal care bundle reduces severe perineal trauma and should be offered
  2. Role of Episiotomy
    -Routine episiotomy not recommended
    -Epis not recommended even with previous severe perineal trauma
    -Epis can reduce posterior trauma but increase anterior trauma
  3. Consider episiotomy when:
    -Soft tissue dystocia
    -Requirement to accelerate birth
    -Facilitate operative delivery
    -Hx of GFM
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11
Q

Discuss the anatomy of the pelvis
-Boundaries of the pelvic inlet (3)
-Boundaries of the pelvic outlet (4)
-Types of pelvis (4)

A
  1. Boundaries of the pelvic inlet
    -Anterior - symphysis pubis
    -Posteriorly - sacral promontory, ala of the sacrum
    -Laterally - Ileopectineal line
  2. Boundaries of the pelvic outlet
    -Anterior - symphysis pubis
    -Posteriorly - tip of coccyx
    -Anterolaterally - ischiopubic ramus
    -Posteriolaterally - sacrotuberous ligament
  3. Types of pelvis
    -Android - narrow midcavity and pubic arch
    -Anthropooid
    -Gynecoid
    -Platypelloid
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12
Q

Discuss changes to the uterus
-Method of enlargement (1)
-Muscle composition (2)
-Types of uterine activity (2)
-Innervation

A
  1. Method of enlargement
    Smooth muscle hypertrophy from 50g to 950g
  2. Muscle composition
    Interdigitating smooth muscle fibres making up one muscle
    Consists of two layers
    -Inner layer fibres are circular
    -Outer layer fibres are longitudinal
  3. Types of uterine activity
    -Braxton-Hicks - low amplitude, long duration
    -Contractions - high amplitude, short duration
  4. Innervation
    -Sympathetic supply from hypogastric nerve
    -Noradrenalin./adrenalin acts on alpha receptors - contractions
    -Noradrenalin/adrenalin acts on beta receptors - relaxation (Beta agonists cause relaxation - salbutamol)
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13
Q

Discuss mechanics of uterine contractions
-Uterine activity inhibitors (5)
-Uterine activity stimulators (5)
-Mechanics of a uterine contraction

A
  1. Uterine activity inhibitors
    -Uterine quiescence is maintained throughout pregnancy
    -Progesterone - down regulates gap junctions
    -Nitric oxide
    -Beta-adrenergic stimulation
    -Relaxin
    -Hypoxia and acidosis
  2. Uterine activity stimulators
    -Oestrogen - increases from 34-35 weeks
    -Prostaglandins
    -Inflammation
    -Oxytocin
    -Alpha adrenergic stimulation
  3. Mechanism of contractions
    -Longitudinal fibres draw up the circular fibres to develop the lower segment
    -Contractions develop from the uterotubular junction at the fundus and spread downwards
    -Myometrial cells communicate via gap junctions
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14
Q

Discuss oxytocin and oxytocin receptors
-Method of initiating uterine activity (2)
-Changes in number over time (2)
-Location of oxytocin receptors (4)

A

1.Method of initiating uterine activity
-Oxytocin acts on voltage mediated calcium channels
-Oxytocin can act to increase prostaglandin production
2. Changes in number over time
-Low in first trimester
-12 times increased number by term
3. Location of oxytocin receptors
-Greatest in fundus
-Less in lower segment
-Least in cervix
-parietal decidua

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15
Q

Discuss the impact of obesity on uterine contractions (4 points)

A
  1. Obesity results in reduced frequency of contractions
  2. Obesity results in reduced strength of contractions
  3. Higher levels of cholesterol thought to interfere with signal transduction
  4. Worsens with increasing weight
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16
Q

Discuss cervical ripening
-Definition (1)
-Biochemical changes to cervix (4)
-Biochemical factors which control cervical ripening (5)

A
  1. Definition
    -Softening, effacement, dilation of the cervix
  2. Biochemical changes
    -Increase in water contents
    -Alteration in glycoaminoglycans and proteoglycan content
    -Reduction in collagen
    -Rearrangement of collagen - widely scattered and dissociated fibres
  3. Biochemical factors controlling cervical ripening
    -Prostaglandins
    -Oestrogen and progesterone
    -Relaxin
    -Nitric oxide
    -inflammatory mediators
17
Q

Discuss initiation of labour
1. General points (2)
2. Withdrawal of inhibitory factors (1)
3. Stimulatory factors (2)
4. Fetal factors (2)

A
  1. General points
    -Multifactorial and poorly understood
    -Due to a change in balance from inhibitory to stimulatory factors
  2. Withdrawal of inhibitory factors
    Progesterone withdrawal
    -Inhibits gap junction in myometrium
    -Inhibits oxytocin
    -Is anti-inflammatory
    -While serum levels don’t fall there may be decreased progesterone sensitivity of the tissues
  3. Stimulatory factors
    Corticotrophin releasing hormone
    -Released by placental trophoblasts
    -Action at CRH receptors retarded by CRH binding protein
    -As CRH binding protein drops CRH activity at receptors increases - increases release of prostaglandins and potentiates oxytocin
    Increased levels of oestrogen - up regulate myometrial gap junctions and increase oxytocin release
  4. Fetal factors
    -Increases in circulating fetal cortisol up regulates prostaglandins
    -Increase in fetal cortisol stimulate placental production of CRH
18
Q

Discuss slow progress in labour
-Prevalence (1)
-Definition in latent phase (1)
-Definition in first stage (5)
-Definition in second stage - nulips (2) and multips (2)

A
  1. Prevalence
    -Indication for 37% of CS
  2. Definition in latent phase
    - >8hrs despite augmentation
  3. Definition in first stage
    -Applies to both multips and nulips
    -<2cm in 4hrs (<0.5cm / hr) once in active labour
    -Slowing of progress of labour for multips
    -No change in cervix or dilation after 2 hrs of adequate contractions
    -Crossing of the 4hr line on the partogram
  4. Definition in second stage
    Nulips:
    -No delivery after 2hrs of active phase / 3 if epidural
    Multips:
    -No delivery after 1hr active phase / 2 if epidural
19
Q

Discuss using a partogram (5)

A

-Reduction in prolonged labour
-Reduction in augmentation of labour
-Reduction of sepsis
-Doesn’t impact CS rates
-Recommended by WHO

20
Q

What factors contribute to slow progress in labour (5)

A

-Maternal age
-Maternal obesity
-Nulliparity
-Maternal exhaustion
-Maternal infection

21
Q

Discuss the causes of slow progress in labour (3 categories)

A
  1. Power of contractions due to:
    -Dehydration
    -Infection
    -Obesity
    -Exhaustion
    -Stress
  2. Passenger
    -Macrosomia
    -Malposition
    -Malpresentation
    -Fetal anomaly - hydrocephaly / large abdo
  3. Passage
    -True CPD - rare and dx of exclusion
    -Fibroids
    -Congenital abnormality of the genital tract
    -Cervical stenosis
    -Pelvic anomalies or previous fractures
22
Q

Discuss management of slow progress in labour
-Prevention (5)
-First stage (7)
-Second stage (4)

A
  1. Prevention
    -Avoid early hospitalisation to avoid erroneous dx
    -Provide 1:1 care in active labour
    -Use a partogram
    -Encourage mobilisation
    -Encourage positioning to avoid malpresentation - No evidence for peanut balls !!
  2. First stage
    -Transfer to an obstetric lead unit
    -Rehydrate
    -Empty bladder
    -Offer effective analgesia
    -If not fetal or maternal distress and no evidence of obstruction or poor uterine activity can consider expectant management
    -Consider amniotomy
    -Consider oxytocin
  3. Second stage
    -Empty bladder
    -Offer amniotomy
    -Offer oxytocin to nullips. Care with multips
    -Change position to see if helps (Upright or L lateral)
    -Do not expedite delivery based on time targets alone. If maternal and fetal wellbeing OK then can consider a further hr(Increased SVB. No impact to pelvic floor/ PPH in one RCT)
23
Q

Discuss advantages and disadvantages of amniotomy in slowly progressing labour
-Advantages (4)
-Disadvantages (8)
-When should ARM be avoided (5)

A
  1. Advantages
    -Moderate reduction in risk of CS
    -Improves application of head to cervix
    -Allows assessment of colour of liquor
  2. Disadvantages
    -Doesn’t change the duration of labour for routine ARM
    -Increase in painful contractions
    -Does not change rates of oxytocin use
    -Does not change rates of instrumental delivery
    -Doesn’t change use of analgesia
    -Increased risk of cord prolapse
    -Increased risk of infection
    -Increased risk of cord compression and fetal distress
  3. When should ARM be avoided
    -HepB, HepC, HIV
    -High head
    -Head not engaged
24
Q

When should progress be reassessed in slow progressing labour (2)

A

Once identified if:
-Expectant management or amniototomy reassess in 2 hrs. If cervical change <1cm needs further action
-If oxytocin repeat VE in 4 hrs. If progress is <2cm consider CS

25
Q

Discuss oxytocin use in slowly progressing labour
-When to use (2)
-Advantages (3)
-How to use (2)

A
  1. When to use
    -Offer with care in multips after examination to rule out CPD or obstruction
    -Use routinely in nulips
  2. Advantages
    -Shortens time to delivery by 2 hrs
    -Doesn’t impact mode of delivery
    -Doesn’t impact maternal or neonatal morbidity outcomes
  3. How to use
    -Titrate up with an increase in dose no closer than 30mins apart. Can do much faster in second stage.
    -Repeat VE in 4hrs and if <2cm progress consider CS
26
Q

Discuss delayed cord clamping
-Definitions (2)
-Volume of blood received by baby (2)
-Recommendations (3)

A
  1. Definitions
    - <30 seconds = immediate cord clamping
    - >2 mins = deferred cord clamping
  2. Volume of blood received by baby - 80-100mL
    -75% of placental blood for transfusion is received in the first minute after birth
    -Provides baby with approx 3 months of Fe
  3. Recommendations
    -Delayed cord clamping for at least a minute
    -Don’t delay if baby needs resus
    -Can have IM uterotonics while cord unclamped
    -Baby on the maternal chest / abdomen doesn’t impact transfusion amount
    -Role of cord milking is unclear. May have some benefit in preterm babies
27
Q

Discuss the benefits of delayed cord clamping
-Benefits for preterm / LBW babies
in short term (11)
-Benefits for preterm / LBW babies in the long term (2)
-Benefits for term babies in the short term (2)
-Benefits for term babies in the long term (2)

A
  1. Short term benefits for preterm/LBW babies
    -Decreased IVH, NEC, Sepsis
    -Decrease need for blood transfusions, surfactant, mechanical ventilation
    -Increase in haematocrit, Hb, BP, cerebral oxygenation, RBC flow
  2. Long term benefits for preterm/LBW
    -Increases Hb at 10 weeks of age
    -May benefit neurological outcomes
  3. Short term benefits for term babies
    -Provides adequate blood volume and iron stores
    -Increases Hb
  4. Long term benefits for term babies
    -Improves Hb and haematocrit at 2-4months
    -Improves Fe status up to 6 months
28
Q

Discuss cord blood banking
-What is it (1)
-What can it be used for (2)
-What types of cord blood donation is there (2)
-What are the benefits
-What are the downsides
-What is the RANZCOG recommendation

A
  1. What is cord blood banking
    -Collecting of umbilical cord blood for haematopoetic stem cells to be used later for clinical purposed
  2. Can be used by other compatible receivers to treat
    -Haemoglobinopathies
    -Haemotological cancers
  3. Types of donation
    -Altruistic to unrelated people who don’t have a suitable bone marrow donor
    -Direct to a sibling who has a disease amenable to haematopoeitic stem cells
  4. Benefits
    -Tolerates greater HLA mismatch from recipient
    -Less graft vs host disease
    -Extends the donor pool
    -Lower risk of viral infection
  5. Down sides
    -Expensive
    -No publically funded bank in NZ
    -Logistically complex
    -Pubic banks in Australia are under represented by some ethnic groups
    -May not be enough sample to treat large children or adults.
  6. RANZCOG guideline
    -Supports collection of altruistic and direct cord blood donations for at risk families
29
Q

Discuss home births
-Incidence of home births in Australia and NZ
-Benefits for home births
-Risks of home birth

A
  1. Incidence of planned home births
    -NZ 4%
    -Australia 1%
    -25% of planned births of nulliparous women outside hospital need transfer
  2. Benefits of home birth
    -Increased Vaginal birth rate RR 3
    -Less interventions - CS, instrumental births, episiotomy
    -No increase risk in neonatal death
    -No worse outcome for women who have required transfer
    -Less perineal trauma RR 0.04
    -Less NICU admission
  3. Risks of home birth
    -No difference in perinatal death rate - SB or early neonatal (Hospitals should be higher as much higher risk pregnancies)
    -Transfer rates 1:3 nulliprous 1:17 multiparous
30
Q

What are the RANZCOG recommendations for home birth (9)

A
  1. College supports hospitals as the safest place of birth
  2. Women should have informed choice in maternity care including choice of birthing location
  3. Women contemplating planned home birth must be provided with accurate information free of bias
  4. Even in pregnancy without complicating factors the risk of home birth is at a level which is unacceptable to most women.
  5. When a pregnancy has any risk factors then home birth can be particularly dangerous
  6. Where women remain intent on a planned birth health practitioners should be confined to Ob/LMC
  7. Women should meet the criteria for homebirth as specified in the local / national guideline
  8. A midwife practising homebirth must have established professional relationships with an obstetrician for referral and consultation.
  9. All practitioners undertaking homebirth should have established referral pathways into a local hospital and transfer in a timely manner with for warning
31
Q

Discuss water immersion for labour and delivery
-Benefits (1)
-No impact (4)

A
  1. Benefits
    -Reduces regional analgesia use (RR 0.91)
  2. No impact
    -No difference between SVD, Instrumental delivery or CS
    -No difference in maternal, fetal or neonatal risks
32
Q

Discuss water birth
-Situations where possible
-Situations where not possible

A
  1. Situations where possible
    -If have telemetry and CFM is required
    -Can have third stage in water but be aware blood loss hard to estimate
    -Can use oxy in water if have CFM telemetry
    -PROM as long as on Abx
  2. Situations where not possible
    -Where staff are not trained to manage a woman labouring and birthing in water
    -During an obstetric emergency
33
Q

Discuss diet in labour

A

As per RANZCOG a light diet and drinking for hydration is fine in established labour unless concern for anesthetic possibility

34
Q

Discuss active vs physiological management of third stage in low risk women (RANZCOG guidelines)
-What does active management entail (3)
-What is the evidence for active management (5)
-What are RANZCOG recommendations (3)

A
  1. Active management
    -Clamping and cutting of the cord
    -CCT
    -IM or IV uterotonic
  2. What is the evidence for active management
    -Uncertain if reduces risk of PPH >1000mL
    -Probably reduces theraputic uterotonic use
    -Probably increases maternal Hb
    -Probably reduces risk of PPH 500mL
    -May reduce maternal blood transfusions
  3. RANZCOG recommendations
    -Discuss management of third stage and options in the AN period
    -Acknowledge that with low risk women the benefit of active management is less certain
    -Women should have info to make an informed choice.

RANZCOG - Intrapartum care Edward (10 decks)

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