O&G labour Flashcards
Signs of labour
- regular and painful uterine contractions
- a show (shedding of mucous plug)
- rupture of the membranes (not always)
- shortening and dilation of the cervix
Monitoring in labour
- FHR monitored every 15min (or continuously via CTG)
- Contractions assessed every 30min
- Maternal pulse rate assessed every 60min
- Maternal BP and temp should be checked every 4 hours
- VE should be offered every 4 hours to check progression of labour
- Maternal urine should be checked for ketones and protein every 4 hours
Stage 1 of labour
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.
Stage 2 of labour
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
Stage 3 of labour
From delivery of fetus to when the placenta and membranes have been completely delivered
First degree perineal tear
- superficial damage with no muscle involvement
- do not require any repair
Second degree perineal tear
- injury to the perineal muscle, but not involving the anal sphincter
- requiresuturing on the ward by a suitably experienced midwife or clinician
Third degree perineal tear
- injury to perineum involving theanal sphincter complex (external anal sphincter, EAS and internal anal sphincter, IAS)
- 3a: less than 50% of EAS thickness torn
- 3b: more than 50% of EAS thickness torn
- 3c: IAS torn
- require repair in theatreby a suitably trained clinician
Fourth degree perineal tear
- injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa
- require repair in theatre by a suitably trained clinician
Risk factors for perineal tear
- primigravida
- large babies
- precipitant labour
- shoulder dystocia
- forceps delivery
Lochia
Lochia is the passage of blood, mucus and uterine tissue that occurs during the puerperium*. This should be expected to cease after 4-6 weeks. Continue vaginal discharge beyond this time is an indication for ultrasound to investigate the possibility of retained products of conception.
Primary PPH
- Postpartum haemorrhage (PPH) is defined as blood loss of > 500mls within 24 hours of birth and may be primary or secondary
Primary PPH:
- occurs within 24 hours
- affects around 5-7% of deliveries
- most common cause of PPH is uterine atony (90% of cases). Other causes include genital trauma and clotting factors
Risk factors for primary PPH
- 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)
Secondary PPH
- Postpartum haemorrhage (PPH) is defined as blood loss of > 500mls within 24 hours of birth and may be primary or secondary
- occurs between 24 hours - 12 weeks**
- due to retained placental tissue or endometritis
- the effect of parity on the risk of PPH is complicated. It was previously though multiparity was a risk factor but more modern studies suggest nulliparity is actually a risk factor
- *previously the definition of secondary PPH was 24 hours - 6 weeks
Management of primary PPH
- 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
