Normal labour Flashcards
Define Preterm Term Postterm True labour Braxton-Hicks contraction
Preterm between 20-36 and 6 days
Term 37 to 41 and 6days
Post term is over 42wk
True labour - regular, painful contractions of increasing intensity associated with progressive dilatation and effacement of cervix and descent of presenting part or progression of station.
Braxton Hicks contraction- Irregular contraction, with unchanged intensity and long interval, occur throughout pregnancy and not associated with any dilatation, effacement or descent. Relieved by rest and sedation.
What to examine and comment on an abdominal exam of a pregnancy belly
Fetal lie- Longitudinal, transverse, oblique
Fatal presentation - breech (complete, frank, footling), cephalic (vertex, face, asynclitic), transverse, compound. Everything but vertex is malpresentation
Fetal position - Position of presenting part of fetus relative to the maternal pelvis. OA most common, OP (spontaneous to OA but can prolong 2rd stage), OT leads to arrest of dilation.
Attitude - flexion or extension of head. Brow presentation (partially extended requires CS), Face presentation is head fully extended. if mentum posterior it requires CS, mentum anterior then will deliver vaginally.
Engagement
Fundal Ht
FHR
BP
WT
Urine for protein and glucose
Vaginal examination in labour
Station - position compared to ischial spines. 0 is engaged, -5 to -1 above. 1 to 5 is below.
Membrane status
Cervical effacement, dilatation, consistency, position, application.
Fatal presenting part, position and station
bony pelvis shape and shape.
Symphysis fundal ht landmark
12wk - uterine funds at pubic synthesis
20 wk - Fundus at umbilicus, SFH should by within 2cm of GA between 20-36wk
37wk at sternum
DDX for small for gestational age
Date miscalculation
IUGR
fetal demise
Oligohydramnios
DDX for large for dates
Date miscalculation, multiple gestation, polyhydramnios, LGA eg familial or DM, Fibroids.
Bishop Score
Cervical characteristics
Position - Posterior (0), Mild (1), anterior (2),
Consistency - Firm (0), medium (1), soft (2),
Effacement (%) - 0-30 (0), 40-50 (1), 60-70 (2), greater then 80(3)
Dilatation (cm)- 0 (0), 1-2 (1), 3-4 (2), greater then 5(3)
Station of fetal head - -3 (0), -2(1), -1,0 (2), +1,2or3 (3)
Stages of labour
1st - N 6-15 hr and M 2-10 hr.
- Latent phase - contraction infreq and irreg. Dilation 3-4cm and effacement.
- Active phase - Dilation is rapid, N 1.2cm/hr, M 1.5cm/hr. Contractions are painful and reg at 2-3mins for 45-60s. Strongest at fundus.
2rd N 30m - 3hr, M 5-30min. Dilation full. contraction: desire to push. Measured by degree of descent.
3rd - N and M 5-30min. Separation and expulsion of placenta. Active by Oxytocin IV 5mg or 10U IM to decrease risk of PPH by 40%.
4th - 1st hr of postpartum, monitor vitals and bleeding, repair tears, ensure uterus is contracted, Inspect placenta for completeness and umbilical cord for 2 arteries and 1 vein.
Cardinal movements of fetus in labour
- head floating before engagement
- Engagement descent, flexion
- further descent internal rotation
- Complete rotation beginning extension
- Complete extension
- Restitution (external rotation)
- Delivery of anterior shoulder
- Delivery of posterior shoulder
Pain relief in labour
Pain and anxiety cause direct inhibition of uterine contractions by catecholamines
1 - Maternal movement, position change, counter-pressure, abdominal compression
2 - Activation of peripheral sensation
- Heat and cold, Immersion in water, touch and massage, acupuncture and acupressure, TENS, intradermal injection of sterile water, Aromatherapy
3 - Enhancement of descending inhibitory pathways. Attention focusing and distraction, hypnosis, music and audio analgesia, biofeedback.
Drugs
1 - nitrous oxide
2 - Narcotics may need anti emetic - risk of neonatal depression and delayer gastric emptying
3 - Pudendal verne block
4 - Perineal infiltration with local anaesthetic
5 - Regional anaesthesia eg epidural block, combined spinal-epidural, spinal.
Counsel for patient on epidural
Injects local anaesthesia into the epidural space. At level of L3-4 or L4-5 below the end of the spinal cord (L2). Landmark is iliac crest at L4.
Goes through the skin, subcutaneous fat, supraspinous ligament, interspinous ligament, Ligamentum flavum above epidural space.
That 10-15 mins for total block.
AE - dural puncture headache (6hr to 3d after, worse on sitting, site at occipital or frontal, may have tinnitus, diplopia), failure, hypotension (most common), Bradycardia if cardiac sympathetics blocked, Heamatoma at site, accidental subarachnoid injection, systemic toxicity if into vessel, Catheter complications - shearing, kinking, vascular, infection, dural puncture
Contraindications - allergy, tissue infected, coagulopathy, Raised ICP, Sepsis, bacteria, severe hypotension, severe mitral and aortic stenosis, lack of IV access.
Relative contraindication - Demyelinating lesion, Previous spinal surgery or deformity, prolonged surgery of major blood loss.
Caesarean section
Indication - material: obstruction, active herpes, invasive cervical cancer, previous uterine surgery, Materal illness e.g. eclampsia, HELLP syndrome, heart disease. Maternal/fetal: Failure to progress, placental abruption or previa, vasa previa. Fetal: abnormal FHR, malpresentation, cord prolapse, certain congenital anomalies.
Anaesthesia - Spinal or epidural or general if others are contraindicated or time is too long for a block.
Types: Low transverse, of classical
AE: Anesthesia, haemorrhage, Infection, Injury to surrounding tissue, thromboembolism, Increase recovery time/ hospital stay, Maternal mortality (less than 0.1%).
7 Layers to dissect in cesarean
Skin Fatty layer fascia, Muscle separation - rectus abounds Peritoneum Blader flap Uterus
Layers of the rectus sheath
Above the arcuate line: external oblique, internal oblique, rectus abdominis, internal oblique, transverse abdominis,
Below arcuate line: external oblique, internal oblique, transverse abdominis, rectus abdominis.
Monitoring in pregnancy
If low risk then Dopplers and Fetal movement. In 1st stage active phase monitoring 15-30mins at the end of contraction for 30-60s. 2rd stage every 5min or after every contraction.
If risk factors then continuous CTG.
