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Obstetrics & Gynaecology > Normal Labour > Flashcards

Normal Labour Flashcards

1
Q

What hormonal changes occur to initiate labour?

A
  • Progesterone levels decrease which lead to an increase in intrauterine prostaglandin release
  • Intrauterine prostaglandin release will lead to uterine contractions and softening of the cervix
  • This then causes oxytocin release from the posterior pituitary leading to positive feedback loops occurring to increase contractions further
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2
Q

What are the three Ps of labour?

A
  • POWER - the force of the expulsion of the foetus and placenta (controlled by uterine contractions and mother’s pushing)
  • PASSAGE - the dimensions of pelvis and resistance of soft tissues and structures i.e. ability of cervix to soften and dilate
  • PASSENGER :
  • Attitude = the degree of flexion/ extension of the neck - ideal position is hyperflexed which allows easier passage
  • Size - head size can be compressed by pelvic bones - moulding
  • Rotation - occipito-transverse, occipito-posterior and occipito-anterior
  • Presentation - ideally cephalic but if in breech, Frank breech is best (both legs face superiorly)
  • Station - refers to foetal position in relation to ischial spine - high station = not descended through pelvis yet
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3
Q

What is the worst attitude of the foetus’ head, and why?

A

Hyper-extension of the neck is the worst as this would cause face presentation which has the largest diameter - most likely too large to pass through the vagina.

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4
Q

What are Braxton-Hick’s contractions?

A

Most commonly occur after 36 weeks - non-painful uterine contractions which are thought to be preparing the body for delivery .
They do not contribute to cervical dilatation or effacement of the baby.

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5
Q

What are the stages of labour, and how long is the duration of each?

A

First stage = cervical dilatation from 4 cm (onset of labour) to 10 cm.
8 hrs for nulliparous women and 5 hrs for multiparous women

Second stage = full cervical dilatation to delivery of the baby
Active stage = 40 mins for nulliparous women, 20 mins for multiparous women

Third stage = delivery of the placenta
Normally takes around 15 minutes

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6
Q

What happens during first stage of labour?

A

LATENT PHASE:
Contractions occurring every 5-10 mins, gradually dilating up to 4cm - when onset of labour begins.
Women are usually told to go home at this point until contractions become far more frequent and painful.

ACTIVE PHASE:
Cervix is effaced and dilated to 4cm and continuing to dilate more as foetus descends into pelvis

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7
Q

Management in first stage of labour…

A
  • Measuring frequency of contractions every 30 mins
  • Checking foetal heart beat for 1 min after contraction - every 15 mins
  • Maternal obs- 4 hourly temp, BP UO, hourly pulse
  • Vaginal examination every 4 hours to check for descent
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8
Q

What happens in second stage of labour?

A

PASSIVE PHASE:
As foetus descends into pelvis and reaches pelvic floor, mother will have desire to push.
1. Foetus descends into pelvis in occipito-transverse position - engagement occurs
2. Flexion of the neck occurs
3. Rotation of the head into occipito -anterior position - leading to crowning

ACTIVE PHASE:
This is when mother is pushing the baby out…
4. Extension of the neck as it passes under suprapubic arch, then hyper extension as whole head emerges
5. Restitution - rotation of the head to occipito-transverse position
6. Anterior shoulder emerges via downwards traction
and posterior shoulder emerges via upwards traction
7. Rest of the body is then pulled through by lateral flexion onto mother’s abdomen

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9
Q

Management of second stage of labour…

A
  • Adequate pain relief
  • Monitor contractions, maternal and foetal pulse every 5 mins
  • Normally allow active phase for maximum of 4 hours before intervention is required due to exhaustion of mother and risk of acidosis to baby
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10
Q

What happens in third stage of labour?

A

The placenta is normally delivered at this point when the placenta can shear away from the uterine wall - around 500ml of blood loss is considered normal.

EXPECTANT MANAGEMENT:
Allowing the mother to deliver the placenta by herself with a big contraction - may take up to an hour.

ACTIVE MANAGEMENT:
Use of IM syntocinon or syntometrine immediately after birth and clamping of umbilical cord.
Signs of placental separation indicate the placenta can be expelled by controlled traction of the umbilical cord.

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11
Q

What are the signs of placental separation?

A
  • Blood at introitus
  • Firming and rising of the fundus
  • Lengthening of the umbilical cord
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12
Q

What monitoring is used during labour?

A

PARTOGRAM - measures different variables for foetal and maternal health during active stage of labour.

Foetal health:

  • Foetal heart rate - every 5 mins in active stage (100-160 bpm)
  • Liquor - colour of amniotic fluid -should be clear with hints of pink
  • Moulding - skull may be irreducible
  • Descent of head

Maternal health:

  • Dilatation and effacement - checked every 4 hours
  • Contraction frequency and strength - every 10 mins (4-5 contractions per 10 mins in 2nd stage)
  • Maternal pulse and BP - measured every hour then every 15 mins in second stage
  • Maternal obs - temp and UO every 4 hours
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13
Q

What is the normal rate of dilatation expected?

A

0.5 cm per hour

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14
Q

Different types of pain relief in labour…

A

*Pain relief is normally started during the active stage of labour

Non-pharmacological:

  • Antenatal classes prepare for this - breathing exercises and different positions
  • Immersion in warm water - different to water bath
  • Acupuncture, aromoatherapy, hypnotherapy

Pharmacological:

  • ENTONOX - inhaled usually during painful contractions (usually not enough on its own)
  • Pethidine and diamorphine - last approx 2-3 hours (may cause confusion and sedation) + anti-emetic
  • Epidural - opiate and LA injected via indwelling cathter into epidural space between L3-4 or L4-L5. Started during active phase and topped up every 2 hours.
  • Spinal anaesthesia - shot of LA into dura mater - short acting so used during C section
  • Dihydrocodeine during early stages of labour
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15
Q

What are the advantages and disadvantages of epidurals?

A

Advantages:

  • Pain free for women
  • Reduces BP in hypertensive women
  • Reduces premature urge to push

Disadvantages:

  • May be incomplete block
  • Longer second stage of labour due to reduced pushing urge
  • Hypotension
  • Urinary retention
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16
Q

Indications for induction of labour…

A
  • Gestation > 41 weeks
  • Antepartum haemorrhage
  • Pre-eclampsia
  • Rhesus incompatibility
  • IUGR
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17
Q

Contraindications for induction of labour…

A
  • Abnormal lie
  • Placental abnormality
  • > 1 previous C section
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18
Q

What is Bishop’s score?

A

Bishop’s score is used to determine cervical favourability with regards to induction of labour

Looks at : cervical position, dilatation, effacement, consistency, foetal station
Score <5 = induction will be required
Score >9 = spontaneous induction is likely

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19
Q

Different methods of induction…

A
  • If cervix is not ripe - use prostaglandin pessary followed by amniotomy (artificial rupture of membranes)
  • If contractions do not start within 4 hours of amniotomy- set up oxytocin infusion
  • Cervical sweeping can be used - finger inserted into cervix to manually move the membranes

*Prostaglandin can be administered as gel/ slow release preparation - best method for nulliparous women

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20
Q

When should C-section be considered during induction of labour?

A

If there is a delay > 16 hrs for first stage of labour.

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21
Q

What foetal damage can occur during labour?

A
  • Foetal hypoxia - due to placental problems, cord prolapse..
  • Infection during delivery - GBS
  • Trauma - from instrumentation
  • Meconium aspiration
  • Foetal blood loss
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22
Q

What is the definition of foetal distress?

A

Foetal hypoxia that may occur as a result of foetal death or foetal damage

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23
Q

What are the risk factors for foetal distress ?

A
  • Cord prolapse
  • Prolonged second stage of labour
  • Meconium aspiration
  • Use of oxytocin
  • IUGR
  • Pre-eclampsia
24
Q

Indicators of foetal distress…

A
  • Meconium staining of liquor
  • Foetal HR needs to be monitored - every 15 mins in first stage, and every 5 mins in second stage
  • Foetal blood sample from scalp - lactate and pH
25
Q

What is a CTG, and what does it record?

A

CTG = cardiotography
Two transducers are placed on the woman’s abdomen: one is to measure and record uterine contractions, and the other is to measure foetal heart rate

26
Q

What are the basic principles of interpreting CTG readings?

A

DR C BRAVADO:
Define Risk - low/ high risk
Contractions
Baseline RAte - should be between 100-160bpm
Variabiity - should be >5bpm, reduced variability could be a sign of hypoxia
Accelerations - occurring alongside contractions is good
Decelerations -persisting after contractions is bad
Overall impression

27
Q

What are the indications for CTG monitoring?

A
  • Pre-labour risks e.g. IUGR, pre-eclampsia
  • Meconium
  • Oxytocin
  • Epidural anaesthesia
28
Q

When is operative delivery indicated?

A
  • Prolonged second stage of labour
  • Foetal distress
  • Breech delivery
  • Maternal disease e.g. hypertension, cardiac disease
29
Q

When is operative delivery indicated?

A
  • Prolonged second stage of labour
  • Foetal distress
  • Breech delivery
  • Maternal disease e.g. hypertension, cardiac disease
30
Q

What things must be in place in order for operative delivery?

A
  • Maternal bladder emptied
  • Cervix fully dilated
  • Position known
  • Cephalic presentation
  • Presenting part is fully engaged
  • Mediolateral episiotomy to prevent tearing during delivery
31
Q

What are the different types of operative delivery, and what risks are they associated with?

A
  • Forceps - curved blades which fit around baby’s head to allow for traction so the head can be pulled - non-rotational used when head is in OA, rotational used in OP
    Risks= brachial plexus injury, facial trauma, injury to maternal genital tract
  • Ventouse - metal/plastic cup attached to suction device - placed on head which allows pulling of the head
    Risks= cephalohaematoma, retinal haemorrhage, facial bruising
32
Q

When is c-section indicated in operative delivery ?

A

After 3 unsuccessful pulls

33
Q

When is an emergency C-section performed?

A
  • Ante-partum hameorrhage
  • Prolonged first stage (>16 hrs)
  • Suspected foetal distress - where operative delivery is not recommended
34
Q

When is elective C-section indicated?

A

Absolute indications:

  • Placenta praevia
  • Uncorrectable abnormal lie e.g. transverse

Relative indications:

  • Breech
  • Twins
  • IUGR
  • Previous C-section
35
Q

What are the risks of C-section ?

A

Maternal risks:

  • Bleeding
  • Infection
  • Bladder/ bowel damage
  • VTE
  • Post-operative pain

Foetal risks:

  • Lacerations
  • Bonding and breastfeeding affected
  • Obesity and diabetes risk
36
Q

How is transverse lie managed?

A
  • Before 36 weeks: reassurance of parents as most will return to longitudinal lie during pregnancy
  • After 36 weeks:
    • Active management = ECV is carried out to try return to normal lie - 50% success rate
  • Elective C- section if ECV has been unsuccessful
37
Q

What is cord prolapse?

A

Where the cord descends beyond the presenting part into the cervix - and is at risk of cord compression which may lead to foetal hypoxia.

38
Q

Risk factors for cord prolapse…

A
  • Amniotomy = major RF
  • Preterm labour
  • Polyhydramnios
  • Multiple pregnancy
  • Abnormal lie
39
Q

Management of cord prolapse…

A
  • Initially fingers can be used to push presenting part back BUT if cord is visible beyond introitus this should NOT be pushed back
  • Patient should be on all fours as preparations are made for emergency C-section (first line)
  • Instrumental delivery can be used if presenting part is low and patient is fully dilated
40
Q

What is shoulder dystocia?

A

Where the shoulders cannot pass through the pelvis once the head has been delivered

41
Q

Risk factors for shoulder dystocia…

A
  • Macrosomia (>4kg)
  • High maternal BMI
  • GDM
  • Small pelvic outlet
42
Q

Complications of shoulder dystocia…

A
  • Brachial plexus injury (Erb’s plasy)
  • Brain injury
  • Clavicle fracture
43
Q

Management of shoulder dystocia…

A
  • McRoberts manoeuvre= first line - flexion of the hip and knee, pressing patient’s thigh against abdomen to open up the angle under the suprapubic arch
  • Episiotomy can be done to allow for manipulation
  • Symphisiotomy - significant maternal morbidity
44
Q

How does an amniotic fluid embolism present, and why?

A

Amniotic fluid enters maternal circulation which leads to an immune-mediated response that causes:
Sx= chills, shivering, dyspnoea
Signs= cyanosis, hypotension, seizures, collapse

45
Q

How does uterine rupture present?

A
  • Constant lower abdominal pain
  • Vaginal bleeding
  • Maternal collapse
46
Q

Management of uterine rupture…

A
  • Resuscitation with IV fluids and blood products depending on level of blood loss
  • G+S and cross match required
  • Uterus may need repair / removal
47
Q

What are the degrees of perineal tears in labour?

A 
1= Vaginal mucosa damaged but underlying muscle intact 
2= Underlying muscle damaged but anal sphincter intact 
3= Anal sphincter damaged but rectal mucosa intact 
4= Rectal mucosa damaged
48
Q

What is the definition of preterm labour?

A

Woman going into labour between 24-37 weeks

49
Q

Risk factors for preterm labour…

A
  • Extremes of age
  • Maternal disease e.g. renal failure
  • Pre-eclampsia
  • Multiple pregnancies
  • IUGR
  • STI
50
Q

Investigations for preterm labour…

A
  • Transvaginal USS - to look at cervical length
  • Women <29+6 should be admitted straight away
  • Women > 30 weeks need TV USS to assess cervical effacement, high vaginal swab to check for infection
51
Q

How can preterm labour be prevented?

A
  • Cervical cerclage = stitching to keep the cervix strong and closed - done at 12-14 weeks if cervix is seen to be short
  • Progesterone supplements
  • Screening and treating any infections e.g. STI, UTI
  • Polyhydramnios - drained using needle aspiration
  • Treatment of maternal disease e.g. hypothyroidism
52
Q

Management of preterm labour…

A
  • Steroids between 23-35 weeks for lung maturation
  • Tocolytic therapy e.g. nifedipine which allows more time for steroids to work
  • Magnesium sulphate given <12h to delivery as neuroprotection for cerebral palsy
  • TRANSFER TO NEONATAL ICU
  • C-section is preferred delivery method
53
Q

What is premature rupture of membranes, and how does it present?

A

When the membranes have ruptured prior to onset of labour leading to gush of clear fluid.
PROM = after 37 weeks
P-PROM = before 37 weeks (pre-term PROM)

54
Q

Complications of PROM…

A
  • Preterm labour
  • Infection
  • Cord prolapse
55
Q

Management of PROM…

A
  • PROM = If labour has not started within 24 hrs - induce and give prophylactic erythromycin
  • P-PROM = admit patient, give steroids and prophylactic erythromycin - can have normal delivery if they reach 34-36 weeks gestation

Obstetrics & Gynaecology (10 decks)

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