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O&G > Normal labour + delivery > Flashcards

Normal labour + delivery Flashcards

1
Q

The APGAR score - Acronym meaning

A
  • Appearance: Colour
  • Pulse: Heart rate
  • Grimace: Reflex irritability
  • Activity: Muscle tone
  • Respirations: Respiratory effort

Each category has a maximum score of 2
(Possible score of 0-10)

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2
Q

(A)PGAR: Appearance (Colour) score

A

0: Blue or pale
1: Blue extremities, pink body
2: Body and extremities pink, no cyanosis

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3
Q

A(P)GAR: Pulse (Heart rate) score

A

0: Absent
1: <100 bpm
2. >100 bpm

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4
Q

AP(G)AR: Grimace (Reflex irritability) score

A

0: No response to stimulation, floppy
1: Grimace on suction or aggressive stimulation
2: Cry on stimulation

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5
Q

APG(A)R: Activity (Muscle tone) score

A

0: None
1: Some flexion of arms and legs
2: Active flexion against resistance

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6
Q

APGA(R): Respirations (Respiratory effort) score

A

0: Absent
1: Weak, irregular and slow
2: Strong crying

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7
Q

Pelvic girdle: Adaptation for childbirth

A

Female: gynaecoid pelvis
Male: android pelvis

Gynaecoid vs. android pelvis:

  • Wider and broader structure
  • Lighter in weight
  • Oval-shaped inlet
  • Less prominent ischial spines
  • Greater bispinous diameter
  • Greater angled pubic arch
  • Sacrum = shorter + more curved
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8
Q

Post-partum haemorrhage: Definition

A

Losing:
> 500ml following vaginal delivery
> 1000ml following c-section

Primary: within 24 hr
Secondary: from 24 hr to 6 wks.

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9
Q

FOUR Ts that determine cause of PPH

A
  • Tone (uterine atony)
  • Trauma (e.g. vaginal tear)
  • Tissue (e.g. retained placenta)
  • Thrombin (e.g. coagulopathy in pre-eclampsia)
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10
Q

ACTIVE management of the 3rd stage of labour

  • Description
  • What does it involve (3)
A
  • Active management of 3rd stage recommended.
  • Reduces risk of PPH
  • Low risk women may opt for physiological third stage.

Active management usually involves:

  • IM oxytocin
  • Cutting of umbilical cord
  • Controlled cord traction
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11
Q

Partograph: Definition

A

The partograph is a simple chart for recording information about the progress of labour and the condition of a women and her baby during labour. It is a printed graph representing the stages of labour.

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12
Q

Partograph: Information plotted regarding condition of mother and foetus

A
  • Descent of baby
  • Dilation of women’s cervix
  • Foetal heart rate
  • Colour of amniotic fluid
  • Presence of molding
  • Contraction pattern
  • Medications that have been given to woman
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13
Q

Prolonger labour: Complications

A
  • Obstructed labour
  • Dehydration
  • Exhaustion
  • Rupture of the uterus
  • Maternal infection
  • Haemorrhage
  • Neonatal infection
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14
Q

Partograph: ALERT line

A

The alert line is plotted to correspond with the onset of the active phase of labour (dilation of the cervix to 4cm). When the women’s cervix reaches 4cm, the provider should expect dilation to continue at about a rate of 1cm/hour.

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15
Q

Partograph: ACTION line

A

Plotted 4 hours after the alert line. If the women’s labour is not following the expected course after 4 hours, the plot of her labour will begin to approach the action line, signalling the need to take action.

Interventions may be appropriate when the action line is crossed, this includes:

  • Oxytocin - to augment labour
  • Vacuum assisted birth (if cervix = fully dilated)
  • C-section
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16
Q

Partograph: Function

A

Having a visual representation of the conditions of both mother and foetus helps providers determine whether and when to intervene if labour is not progressing normally.

Use of the partograph helps providers ensure that women are being carefully monitored during labour, avoid unecessary interventions and recognise and respond to complications in a timely manner.

The partograph is of little use without management protocols that give clear directives about what actions should be taken at what point.

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17
Q

LIE: Definition

A

The relationship between the long axis of the foetus in respect to the long axis of the mother.

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18
Q

PRESENTATION: Definition

A

The part of the foetus at the pelvic brim.

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19
Q

NORMAL presentation: Definition

A

The vertex of the foetal head is at the pelvic brim - also known as cephalic presentation.

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20
Q

MALPRESENTATION: Definition

A

Any non-cephalic presentation.

Can be face, brow, breech (buttocks first), or another part of the body if the body is lying in the transverse or oblique position.

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21
Q

POSITION: Definition

A

The way in which the presenting part is positioned in relation to the maternal pelvis.

  • LOA: Left occipitoanterior (most common)
  • ROA: Right occipitoanterior
  • ROP: Right occipitoposterior
  • LOP: Left occipitoposterior
  • LOT: Left occipitotransverse
  • ROT: Right occipitotransverse
  • OA: occipitoanterior
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22
Q

NORMAL POSITION: Definition

A
  • Head occipitotransverse @ pelvic brim

- Rotated to occipitoanterior @ pelvic floor

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23
Q

MALPOSITION: Definition

A

The head in cephalic presentation does not rotate to occipitoanteriorbut remains in the occipitotransverse or rotates to occipitoposterior position.

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24
Q

Risk factors for MALPRESENTATION

A
  • Prematurity
  • Multiple pregnancies
  • Abnormalities of uterus
  • Partial septate uterus
  • Abnormal foetus
  • Placenta praevia
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25
Q

LABOUR: Definition

A

The process by which the foetus is delivered after the 24th week of gestation.

The onset of labour is defined as the point as the point when uterine contractions become regular and cervical effacement and dilation becomes progressive. Hence, it is difficult to define the precise time of onset.

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26
Q

ONSET of LABOUR: Characteristics

A
  • Onset on uterine contractions
  • Cervical effacement and dilation
  • Rupture of membranes w/ leakage of amniotic fluid
  • Descent of the presenting part through the birthing canal
  • Birth of the baby
  • Delivery of the placenta and membranes
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27
Q

Mechanism of labour: OVERVIEW

A

The head usually engages in the (occipito)transverse position and the passage of the head and body follows a well-defined pattern through the pelvis.

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28
Q

How do women give birth? (4)

A
  • Emergency c-section (15%)
  • Elective c-section (11%)
  • Vaginal delivery (59%)
  • Assisted vaginal delivery (15%)
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29
Q

STAGES of labour: Overview

A

1st stage: onset - full dilation
- Latent: from onset - 4cm dilation
- Active: from 4cm dilation - full dilation (10cm)
2nd stage: full cervical dilation - baby being born
3rd stage: delivery of baby - delivery of placenta + membranes

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30
Q

BRAXTON HICKS contractions: Definition

A

Mild, often irregular, non-progressive contractions that may occur from 30 wks gestations (more common after 36wks) and may often be confused with labour.

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31
Q

LITHOTOMY position: Definition

A

A supine position of the body with the legs separated, flexed and supported in raised stirrups.

32
Q

PROS + CONS of ACTIVE management of the 3rd stage

A

PROS:

  • ↓ rates of PPH
  • ↓ mean blood loss and postnatal anaemia
  • ↓ length of the 3rd stage
  • ↓ the need for blood transfusions

CONS:

  • Nausea + vomiting
  • Headache
33
Q

A PLANNED physiological 3rd stage should be changed to ACTIVE management in the event of: (3)

A
  • Haemorrhage
  • Failure to deliver placenta within 1 hr
  • Maternal desire to shorten 3rd stage
34
Q

Abnormal labour: Definition (6)

A

Labour is deemed abnormal when there is poor progress, this is evidenced by either:

  • A delay in cervical dilation or descent of the presenting part of the feotus
  • Signs of foetal compromise
  • Foetal malpresentation
  • Multiple gestation
  • Uterine scars
  • Induced labour
35
Q

NORMAL dilation progression

  • Primip
  • Multip
A

Primip: 1/2 cm /hour
Multip: 1 cm/hour

36
Q

Abnormal labour: CAUSES

A
  • Dysfunctional uterine activity
  • Cephalopelvic disproportion
  • Malpresentations
  • Abnormality of the birth canal
  • Foetal compromise
37
Q

3 dependent variables of labour (3Ps)

A
  • POWER: efficacy of muscular contractions
  • PASSENGER: foetus (size, presentation and position)
  • PASSAGES: uterus, cervix and bony pelvis
38
Q

Monitoring in labour (recorded on the partogram) - (6)

A
  • FHR: every 15 mins (or continuously with CTG)
  • Contractions: every 15 mins
  • Maternal pulse: hourly
  • BP + temp: 4 hourly
  • VE: offered every 4 hours
  • Maternal urine: 4-hourly/when passed (for ketones + protein)
39
Q

FOETAL compromise: Definition

A

Major issue with labour and one that is difficult to confirm, largely due to the false positives with CTG and the possibility of meconium staining having a benign cause. Therefore indicators such as abnormal CTG and fresh meconium staining of the amniotic fluid should be seen as ‘presumed foetal compromise’.

40
Q

FOETAL compromise: Risk factors

A
  • Placental insufficiency
  • Prematurity
  • Postmaturity
  • Multiple pregnancy
  • Prolonged labour
  • Augmentation with oxytocin
  • Uterine hyperstimulation
  • Precipitate labour
  • Intrapartum abruption
  • Cord prolapse
  • Uterine rupture
  • Maternal diabetes
  • Cholestasis of pregnancy
  • Maternal pyrexia
  • Chorioamnionitis
  • Oligohydraminos
41
Q

FOETAL compromise: Clinical features

A

Thick/tenacious meconium staining (of the amniotic fluid) that is either dark green, bright green or black (whereas thin and light meconium is usually a sign of foetal maturity).

42
Q

FOETAL compromise: Investigations (6)

A
  • CTG (signs of foetal compromise)
  • Foetal tachycardia (>160 bpm)
  • Loss of baseline variabilty (< 5bpm)
  • Recurrent decelerations
  • Persistent variable decelerations
  • Foetal bradycardia (<100 bpm for >3mins)
43
Q

FOETAL compromise: Management (3)

A
  • Exclude pathology (e.g. malpresentation, cord prolapse)
  • Consider foetal blood sampling (cervix must be >3cm dilated)
  • Abnormal result is indication for delivery
44
Q

UTERINE rupture:

  • Definition
  • Aetiology (4)
A

Definition: spontaneous tearing of the uterus

Aetiology:

  • Rupture occurs along site of previous c-section incision.
  • Greater risk with ‘classical c-section’ compared to ‘lower segment’
  • Oxytocin (in multip) + prostacyclin also increase risk.
  • Factors that increase the force applied to the muscle, such as: shoulder dystocia and breech extraction
45
Q

UTERINE rupture: Classification (2)

A
  • Complete (medical emergency) - direct communication of the uterine cavity with the peritoneal cavity
  • Incomplete - the uterine cavity is separated from the peritoneal cavity by a thin layer of peritoneum
46
Q

UTERINE rupture: Clinical features (6)

A
  • Acute onset of significant CTG changes (70% of cases)
  • Maternal tachycardia
  • Vaginal bleeding
  • Abdominal pain
  • Easily palpable foetal parts per abdomen
  • Hypovolaemic shock
47
Q

UTERINE rupture: Management (4)

A
  • Call for help
  • Resuscitation
  • Emergency laparatomy (with repair of defect)
  • Emergency hysterectomy (may be required)
48
Q

UTERINE rupture: Prevention

A

Offer those with a midline scar an elective c-section

49
Q

VASA praevia: Definition

A

Vasa praevia is a condition in which fetal blood vessels cross or run near the internal opening of the uterus. These vessels are at risk of rupture when the supporting membranes rupture, as they are unsupported by the umbilical cord or placental tissue

50
Q

VASA praevia: Clinical features

A

Severe foetal distress or foetal death following a relatively small intrapartum haemorrhage.

51
Q

VASA praevia: Investigation

A
  • Kleihaur test

- Usually a retrospective diagnosis made by examination of the placenta and membranes after delivery.

52
Q

VASA praevia: Management

A

Immediate delivery of the baby

53
Q

Labour: STAGE 1

A

Stage 1 - from the onset of true labour to when the cervix is fully dilated. In a primigravida lasts typical 10-16 hours
latent phase = 0-3 cm dilation, normally takes 6 hours
active phase = 3-10 cm dilation, normally 1cm/hr

Presentation: 90% of babies are vertex

Head enters pelvis in occipito-lateral position. The head normally delivers in an occipito-anterior position.

54
Q

Labour: Stage 2

A

Stage 2 - from full dilation to delivery of the fetus
‘passive second stage’ refers to the 2nd stage but in the absence of pushing (normal)
active second stage’ refers to the active process of maternal pushing
less painful than 1st (pushing masks pain)
lasts approximately 1 hours
if longer than 1 hour (can be left longer if epidural) consider Ventouse extraction, forceps delivery or caesarean section
episiotomy may be necessary following crowning
associated with transient fetal bradycardia

55
Q

SIGNS of labour (4)

A
  • regular and painful uterine contractions
  • a show (shedding of mucous plug)
  • rupture of the membranes (not always)
  • shortening and dilation of the cervix
56
Q

Preterm Premature Rupture Of Membranes (PPROM): Definition

A

Preterm prelabour rupture of the membranes (PPROM) occurs in around 2% of pregnancies but is associated with around 40% of preterm deliveries

57
Q

Preterm Premature Rupture Of Membranes (PPROM): Complications

A
  • fetal: prematurity, infection, pulmonary hypoplasia

- maternal: chorioamnionitis

58
Q

Preterm Premature Rupture Of Membranes (PPROM): Management

A
  • admission
  • regular observations to ensure chorioamnionitis is not developing
  • oral erythromycin should be given for 10 days
    antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome
    delivery should be considered at 34 weeks of gestation - there is a trade-off between increased risk of maternal chorioamnionitis with a decreased risk of respiratory distress syndrome as the pregnancy progresses
59
Q

Uterine ATONY: Definition

A

Occurs when the uterus fails to contract after the delivery of the baby - can result in PPH.

60
Q

Uterine ATONY: Clinical features

A
  • Blood loss is usually obvious
  • But may be concealed in cases of uterine atony
  • Signs of shock if treatment is not prompt
61
Q

Uterine ATONY: Management (4)

A
  • Abdominal massage
  • Bimanual compression
  • B-lynch sutures
  • Uterotonics (e.g. Synctocinon)
62
Q

RETAINED placenta: Definition

A

Failure to deliver the placenta within 30 minutes of the foetus.

63
Q

RETAINED placenta: Classification

A

The placenta can either be adherent (placenta adherens) or trapped behind a closed cervix (trapped placenta) or less commonly, the placenta invades the uterus:

  • Placenta accreta: invasion of the myometrium but does not penetrate entire thickness
  • Placenta increta: further penetration but not entire
  • Placenta perceta: entire penetration of the myometrium
64
Q

RETAINED placenta: Clinical features

A

Major post-partum haemorrhage

65
Q

Puerperium: Definition

A

The period of about 6-weeks after childbirth during which the mothers reproductive organs return to their original non-pregnant condition.

66
Q

INDUCTION of labour: Definition

A

Induction of labour describes a process where labour is started artificially. It happens in around 20% of pregnancies.

Indication:

  • Obstetric
  • Medical
67
Q

INDUCTION of labour: Methods (4)

  • Mechanical (2)
  • Pharmacological (2)
A

MECHANICAL:

  • membrane sweep
  • breaking of waters (ARM)

PHARMACOLOGICAL:

  • intravaginal prostaglandins
  • oxytocin
68
Q

INDUCTION of labour: OBSTETRIC indictions

A
  • Uteroplacental insufficiency
  • Prolonged pregnancy (>41 wks)
  • IUGR
  • Oligo- or anhydraminos
  • Abnormal uterine or umbilical artery doppler
  • Non-reassuring CTG
  • PROM
  • Severe pre-eclampsia
  • IUD
  • Unexplained APH
  • Chorioamnionitis
69
Q

INDUCTION of labour: MEDICAL indications

A

With underlying maternal medical conditions, planned early IOL may potentially limit the maternal risks associated with pregnancy. For example:

  • Severe hypertension
  • Uncontrolled DM
  • Renal disease with decreased renal function
  • Malignancies
70
Q

UTEROPLACENTAL insufficiency: Definition

A

A complication of pregnancy where the placenta is unable to deliver and adequate supply of nutrients and oxygen to the foetus and this cannot fully support the developing baby.

71
Q

IOL: Membrane sweep

A
  • Separation of the membranes from the cervix leads to local release of prostaglandins
  • Common method is artificial separation - ‘stretch and sweep’
  • This requires that the cervical os admits a finger.
  • Involves digitally separating the membrane from the cervix.
  • It is uncomfortable and may lead to some bleeding.
72
Q

IOL: Intravaginal prostaglandins

A
  • Preferred agents for cervical ripening.
  • Usually given intravaginally into posterior fornix.
  • The gel is absorbed well.
  • Tablet forms are easier to remove if hyperstimulation occurs (5-7%)
73
Q

IOL: Breaking of waters (ARM)

A
  • ARM or amniotomy releases local prostaglandins causing cervical ripening and myometrial contractions.
  • ARM alone is not recommended for IOL.
74
Q

IOL: Oxytocin

A
  • Has been shown to increase cervical prostaglandin level
75
Q

UTERINE hyperstimulation: Definition

A

A serious complication of labour induction. It is defined as single contractions lasting 2 minutes or more, or five or more contractions in a 10 minute period.

76
Q

Primary PPH: Risk factors

A
  • previous PPH
  • prolonged labour
  • pre-eclampsia
  • increased maternal age
  • polyhydramnios
  • emergency Caesarean section
  • placenta praevia, placenta accreta
  • macrosomia
  • ritodrine (a beta-2 adrenergic receptor agonist used for tocolysis)
77
Q

PPH: Management

A
  • ABC including two peripheral cannulae, 14 gauge
  • IV syntocinon (oxytocin) 10 units or IV ergometrine 500 micrograms
  • IM carboprost
  • if medical options failure to control the bleeding then surgical options will need to be urgently considered
    the RCOG state that the intrauterine balloon tamponade is an appropriate first-line ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage
  • other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
  • if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure

O&G (13 decks)

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