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Year 5: Conditions > O&G- Labour > Flashcards

O&G- Labour Flashcards

1
Q

What is labour

A

Onset of regular + painful contractions associated with cervical effacement (shortening) + dilation

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2
Q

How is foetal position determined

A

• In a vertex (headfirst) labour, the foetal position is determined according to relation of occiput (back of head) to maternal pelvis (pubic symphysis)

• E.g right occipitoanterior= foetal occiput is closest to the right anterior part of the pelvis.

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3
Q

What plane is female pelvic inlet widest (and what position should foetus be)

A

• Female pelvis inlet is widest in the transverse plane
◦ Therefore foetus should be in occipitotransverse position

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4
Q

What plane is female pelvic outlet widest (and what position should foetus be)

A

• Female pelvis outlet is widest anterior-posterior
◦ Therefore internal rotation to occipitoanterior position required

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5
Q

What are the different types of foetal lie

A

• Can be:
‣ Longitudinal (straight): RECOMMENDED
◦ Can present as cephalic (normal, head first) or breech (feet first)
‣ Transverse
‣ Oblique

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6
Q

What occurs in the 1st stage of labour

A

Painful uterine contractions-> Full (10cm) cervical dilation
◦ Involves cervical effacement (gets thinner and shortens) and dilation

						◦ The ‘Show’: mucus plug in cervix (prevents bacteria from entering during pregnancy) falls out to create space for baby to pass

						◦ Latent Phase: Painful, irregular contractions (cervical dilation 0-4cm)
						◦ Active Phase: Painful regular contractions (cervical dilation 4-7cm)
						◦ Transition phase: Strong regular contractions (cervical dilation 7-10cm)
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7
Q

What occurs in Stage 2 of labour

A

10cm cervical dilation -> Urge to push -> Delivery of baby
◦ Passive Phase: no active pushing, until head reaches pelvic floor
◦ Active Phase: Involuntary expulsive contractions and maternal urge to push, phase ends with birth of baby

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8
Q

How long does Stage 2 of labour last in nulliparous vs multiparous women

A

◦ Nulliparous women: 2nd stage takes 2-3 hours
◦ Multifarious women: 2nd stage takes 1-2 hours
◦ Use of epidural can prolong labour

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9
Q

What occurs in Stage 3 of labour

A

Delivery of placenta and foetal membranes
◦ Lasts 5-30min
◦ If >1 hour, then theatre and removal under GA is needed

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10
Q

What can be done in Stage 3 of labour to aid expulsion of placenta

A

◦ Augment with IM Syntocinon + breastfeeding can stimulate spontaneous expulsion

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11
Q

What are the steps making up the mechanism of labour

A

1) Engagement: Widest part of foetal head fits into widest part of maternal pelvic inlet (either right or left occipitotransverse)

2) Descent: Foetal head descends through pelvic inlet to pelvic floor due to uterine contractions, amniotic fluid pressure and abdominal contractions

3) Flexion: Foetal head makes contact with pelvic floor, causing flexion of neck (chin to chest)

4) Internal Rotation: Pelvic floor has gutter shape, causing head to rotate 90 degrees medially from R or L occipitotransverse to occipito-anterior position (occiput facing pubic symphysis)

5) Crowning: Head is visible at vulva and no longer retreats between contractions

6) Extension: Occiput slips beneath suprapubic arch causing nape of neck to pivot against arch and causing head to extend up

7) External rotation + Restitution: Head externally rotates to face R or L medial thigh of mother. At the same time, Restitution occurs (shoulders rotate 90 degrees from transverse to anterior-posterior position to realign with head)

8) Expulsion of baby

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12
Q

What pain relief can be provided during Stage 1 of labour

A

During 1st Stage of Labour:
• Paracetamol
• Co-dydramol
• IM pethidine

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13
Q

Side effect of giving opioids (e.g. pethidine) during Stage 1 of labour

A

‘sleepy baby’, low baby RR, constipation

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14
Q

Non-pharmacological pain relief methods during Labour

A

• Transcutaneous Electrical Nerve Stimulation (TENS)
• Breathing techniques
• Massage

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15
Q

What pain relief can be provided in-hospital during labour

A

‣ Entonox- Side effects (nausea, light-headedness, dry mouth)
‣ Remifentanil patient controlled analgesia (PCA)
‣ Epidural

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16
Q

What is normal cervical dilation progression during stage 1 of labour

A

‣ Normal progress= 1cm/hr dilation

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17
Q

What is delay in cervical dilation progress and how to manage it

A

• Delay= <1cm over 2hrs
• Conduct Artificial Rupture of Membranes if membrane still intact and review after 2hrs
• If membranes already ruptured: Oxytocin

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18
Q

How often are vaginal exams done in Stage 1 of labour

A

‣ Vaginal exams performed 4-hourly

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19
Q

When is instrumental delivery indicated in Stage 2 of labour

A

‣ Prolonged= >3 hours from full dilation

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20
Q

What are two types of instruments used in labour

A

Forceps or ventouse

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21
Q

What are forceps (in labour)

A

• Forceps: Metal instrument that fits around baby’s head
◦ Greater risk of trauma to mother
◦ Only used if baby is occipito-anterior
◦ Episiotomy done first
◦ Higher success rate than ventouse

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22
Q

What is ventouse (in labour)

A

• Ventouse: Vacuum extractor cup placed on baby
◦ Greater risk of haemorrhage to newborn
◦ Use if baby is occipito-posterior and needs to be rotated
◦ Can’t be used if <34 weeks due to risk of ICH

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23
Q

When is C-section indicated in an instrumental delivery

A

Do if instrument delivery fails after 3 pulls

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24
Q

What three things done in Stage 3 of labour

A

‣ 10 units IM Oxytocin (Following birth of anterior shoulder)
‣ Deferred cord clamping (between 1-5min after delivery)
‣ Controlled cord traction to remove placenta

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25
How to check for preterm labour
regular + painful contractions, and cervical length <15mm • Can also check for elevated Foetal Fibronectin (fFN)
26
Risk factors for preterm labour
RISK FACTORS: • Previous preterm birth • Short cervix (<25mm) • PROM
27
Management of preterm labour
• Admit to antenatal ward 1) Nifedipine + Betamethasone: • Maternal corticosteroids (e.g. IM Betamethasone) accelerates foetal lung maturation • Tocolytics (e.g. (1)Nifedipine or (2) Atosiban (Oxytocin receptor antagonist)) • Delayed delivery long enough for corticosteroid administration • IV Magnesium Sulphate: for neuroprotection of neonate (if birth expected in next 24hrs)
28
2 options for prevention of preterm labour
• Prophylactic Vaginal Progesterone: ◦ Start at 16-24 weeks gestation and continue until 34 weeks • Prophylactic or Rescue Cervical Cerclage: ◦ Placing band around cervix
29
When is induction of labour offered
• Offered after 41 weeks gestation in uncomplicated pregnancy • Also offered if premature rupture of membranes (no labour start within 18-24hrs) , maternal request, fetal growth restriction, pre-eclampsia, obstetric cholestasis
30
When is induction of labour contraindicated
• NOT suggested for Preterm premature rupture of membranes, breech/transverse lie, severe IUGR
31
What score determines likelihood of going into labour
Bishop Score: • Cervix Assessment (determine how likely one is to go into labour and whether or not to induce) • 5 assessments (min score 0, max 13)
32
What does Bishop’s score of 8 or more indicate
high chance of spontaneous labour
33
What does Bishops score of 6 or less indicate
Spontaneous labour unlikely, therefore induction needed. Offer Vaginal prostaglandin gel
34
What does Bishops score of 7-8 indicate
offer induction with Artificial Rupture of Membranes (Amniotomy) + Oxytocin infusion
35
What are options for induction of labour
1) Membrane Sweep: ◦ Offered prior to formal induction ◦ Insert finger into cervix to stimulate release of physiological prostaglandins 2) Vaginal Prostaglandin E2 (PGE2): ◦ Stimulates cervix and uterus ◦ Can be given as tablet (1 dose, then 2nd after 6hrs), gel (1 dose, then 2nd after 6hrs) or pessary (1 dose over 24hrs) 3) Cervical Ripening Balloon: Used if prostaglandins contraindicated and low Bishop’s score 4) Artificial Rupture of Membranes: Should not be used first line, follow it with Oxytocin infusion ◦ Risk of umbilical cord prolapse 5) IV Syntocinon: Offer if 2 hours after ROM and labour has not ensued 6) C-Section
36
What is side effect of using vaginal prostaglandin E2 to induce labour
◦ Risk of Uterine Hyperstimulation: ◦ Can cause foetal hypoxia (late decelerations) by compressing umbilical and placental blood vessel
37
How to treat uterine hyperstimulation
Remove Prostaglandin, Continuous CTG monitoring, Tocolytics (Terbutaline- beta agonist to reduce rate of contraction)
38
How to induce labour for intrauterine foetal death
1) Oral Mifepristone (anti-progesterone) + Misoprostol (prostaglandin) to induce labour
39
Steps for neonatal resuscitation
1) Dry the baby 2) Assess APGAR (1 and 5 minutes): 3) If not breathing: Give 5 Inflation breaths 4) Reassess 5) Chest compressions 3:1
40
What to look for in APGAR (and what score is normal)
Assess APGAR (1 and 5 minutes): ◦ Also done at 10min if condition is poor ◦ A: Appearance (colour) ◦ P: Pulse ◦ G: Grimace (reflex irritability) ◦ A: Activity (muscle tone) ◦ R: Resp Rate ◦ >7 is normal (2 for each section)
41
What is cord prolapse
An obstetric emergency when the umbilical cord descends into either the cervical canal or vagina ahead of the presenting part of the foetus. This can lead to complete occlusion of the cord, or cord spasm
42
What can cord prolapse result in
• Occlusion of the cord of vasospasm of the umbilical artery can cause foetal hypoxia which can cause irreversible damage or death
43
What is non-overt cord prolapse
cord slips alongside
44
Risk factors for cord prolapse
MATERNAL: ‣ Premature Rupture of Membranes: Loss of amniotic fluid cushioning that normally keeps umbilical cord away from cervix. Also, high outward rush of amniotic fluid can carry the cord forward. ‣ Multiparity: Due to potential uterine overdistention ‣ Polyhydramnios: Excess amniotic fluid can cause outward gush ‣ Long umbilical cord FOETAL: ‣ Low birth weight: Smaller babies occupy less space, therefore more room for cord to surpass foetus ‣ Prematurity: “ ‣ Non-cephalic presentation: Breech or transverse lie increases chance of cord descending ahead of foetus IATROGENIC: • Iatrogenic rupture of membranes • Operative vaginal delivery: Use of forceps or vacuum extraction can increase risk • Cervical ripening
45
What is cause of most prolapses
• 50% of prolapses occur at artificial rupture of membranes
46
Presentation of cord prolapse
• Abnormal Foetal Heart Rate: • Most COMMON presenting feature of cord prolapse • Sudden onset of severe, variable decelerations on CTG • Deep- drop below 60bpm and last more than 60 seconds • Foetal Bradycardia: Sustained foetal heart rate of <110bpm • Palpable umbilical cord: Cord may be palpable during vaginal examination • Sudden onset of symptoms post rupture of membranes: Usually symptoms of rupture would coincide with symptoms of cord prolapse • Patient reported sensation: Patient may feel something coming through vagina (feels like ball between legs)
47
Investigations for cord prolapse
• Ultrasound: Can identify location of cord in relation to presenting part of the foetus. Can also provide information on foetal presentation + position, amniotic fluid volume, placental location and signs of foetal distress. • Cardiotocography (CTG): Continuous monitoring of foetal heart rate can increase chance of picking up changes in foetal heart rate pattern. HOWEVER, normal CTG does not exclude cord prolapse due to intermittent compression • Speculum Examination: Pulsating umbilical cords at or beyond the vaginal introitus confirms overt cord prolapse
48
Management of cord prolapse
• Call senior + anaesthetist for help • Adopt knee-chest or on all fours position to reduce pressure on cord • High-flow oxygen via non-rebreather mask • Elevate presenting part of foetus: a full bladder can also do this • Keep cord warm and moist: reduce handling as well to prevent vasospasm • Tocolytics: can be used to reduce uterine contractions (e.g. terbutaline) • EMERGENCY C-SECTION: First-line delivery method
49
What is an ectopic pregnancy
Life-threatening obstetric emergency where a fertilised ovum implants outside the uterine cavity, typically in the fallopian tube (97%) (ampulla)
50
What is most common cause of death in first trimester
Ectopic pregnancy
51
Risk factors for ectopic pregnancy
◦ Prior ectopic pregnancy ◦ Tubal Factors: ◦ Tube abnormalities: Scarring, adhesions, congenital abnormalities ◦ Prior pelvic infection: PID is a significant risk factor due to tubal inflammation and reduced motility ◦ Fertility treatments: IVF ◦ IUD use: Chance of pregnancy decreases, however if pregnancy occurs, there is higher risk of ectopic ◦ Endometriosis ◦ Smoking ◦ Tubal surgery
52
Presentation of ectopic pregnancy
• Amenorrhoea: Occurs 6-8 weeks after LMP • Lower abdominal pain: Pain is usually constant and normally unilateral • Abnormal vaginal bleeding: May be dark brown in colour • Adnexal tenderness • Adnexal mass • Shoulder tip pain, pain on delectation or urination: Can occur due to peritoneal bleeding that irritates the diaphragm • Nausea and vomiting
53
Investigations for ectopic pregnancy
• Pelvic exam: Cervical excitation (cervical motion tenderness) • Pregnancy Test: Will be positive for beta-hCG • Transvaginal Ultrasound: To identify location of pregnancy
54
What is medical management of ectopic pregnancy and what are the indications
• Indications: • Size <35mm • Unruptured • No significant pain • No foetal heartbeat • Serum hCG <1500IU/L • Not suitable if there is intrauterine pregnancy (confirmed on USS) • Involves giving patient Methotrexate ◦ Follow-up with serial hCG on day 4 and 7, then once a week until hCG is negative ◦ Avoid sexual intercourse, alcohol and prolonged exposure to sunlight whilst on treatment ◦ Avoid conceiving for at least 3 months after methotrexate
55
What is surgical management of ectopic pregnancy and what are the indications
• Indications: • Size >35mm • Potentially ruptured • Pain • Visible foetal heartbeat • Serum hCG >5000IU/L • Compatible with another intrauterine pregnancy • Involves salpingectomy or salpingotomy ◦ Laparoscopic salpingectomy is first-line for women with no risk factors for infertility ◦ Salpingotomy for women with risk factors for infertility OR contra lateral tubal damage ◦ However, 1 in 5 women who had a salpingotomy will require further treatment (methotrexate or salpingectomy)
56
What is placenta praevia
Describes a placenta that is lying wholly or partially in the LOWER uterine segment, covering the cervical os.
57
When is placenta praevia diagnosed
• Typically diagnosed in the second trimester (diagnosed at 20 week scan, then reassessed at 32 week scan) Placenta within 2cm of internal os is at risk
58
Risk factors for placenta praevia
• Previous uterine scarring: previous c-sections can cause this. Presence of scar can interfere with process of blastocyst implantation • Older maternal age • Multiparity • Smoking • Abortion • IVF
59
Presentation of placenta praevia
• Asymptomatic: Often diagnosed before symptom development due to routine USS. Symptoms typically develop in 3rd trimester • Painless vaginal bleeding: ‣ Most common clinical feature (can be light to heavy) ‣ Vaginal and rectal examinations are not recommended ‣ Sexual intercourse should be avoided • Lack of pain
60
Investigations for placenta praevia
• Ultrasound Scan: ◦ Transvaginal is the most effective ◦ Typically detected at around 20 weeks during routine anomaly scan. ◦ Most cases self-resolve ◦ Follow-up scan at 32 weeks to check for unresolved cases If bleeding: • FBC: anaemia or platelet disorder • Blood type and cross match: preparation for surgery • Kleihauer test/Rhesus status: If mother is Rh negative, then anti-D immunoglobulin should be given
61
What not to do in placenta praevia
NEVER DO vaginal examination
62
Management of placenta praevia
General Advice: • Recommend pelvic rest: Avoid sex, vaginal douching, vaginal examinations • Corticosteroids: ◦ Should be considered for all patients (24-34 weeks) ◦ Betamethasone or Dexamethasone can accelerate foetal lung maturation Counsel for ELECTIVE C-SECTION
63
Management of bleeding placenta praevia
1) Tranexamic acid, blood transfusion can help stabilise the patient. 2) Emergency C-Section (If at risk of preterm labour, tocolytics can be given to prolong pregnancy and enable corticosteroids to be given)
64
What is post partum haemorrhage
Heavy bleeding after birth: defined as >500ml at vaginal delivery or >1000ml at caesarean
65
What are the two types of post partum haemorrhage
• Primary: ‣ Within 24 hours of delivery • Secondary: • >24hrs to 6 weeks following delivery • Due to retained placental tissue or endometritis
66
What are 4 causes of post-partum haemorrhage
• 4 T’s: ◦ TONE: • Uterine atony (most common cause): uterus fails to contract after birth ◦ TRAUMA: damage to genital structures (e.g. episiotomy, perineal tear) ◦ TISSUE: retained placental fragments in uterine cavity ◦ THROMBIN: underlying clotting disorder
67
What are risk factors for post-partum haemorrhage
• Previous PPH • Prolonged labour • Placenta praevia • Placenta accreta • Polyhydramnios • Episiotomy • Macrosomia
68
Presentation of post-partum haemorrhage
• Heavy bleeding from vagina • Shock • Dependent on cause: ‣ Tone: Enlarged uterus (above umbilicus) that is soft + boggy ‣ Trauma: visible lacerations ‣ Tissue: examination of placenta reveals incomplete membranes/tissue • Secondary: Tender uterus
69
Investigations for post-partum haemorrhage
Clinical diagnosis
70
Medical management steps of major post partum haemorrhage
1) Call for senior + Initiate Major Obstetric Haemorrhage Protocol (start warmed crystalloid infusion, G&S, Crossmatch, Transfuse blood ASAP) 2) Bimanual compression (also give fundal massage if uterine atony suspected) 3) IM/IV Syntocinon 4) IM Ergometrine/Syntometrine (contraindicated in HTN/pre-eclampsia and asthma) 5) IM Carboprost (contraindicated in asthmatics)
71
Surgical management of post-partum haemorrhage
6) Surgical (balloon tamponade- Bakri Catheter, B-lynch suture, Hysterectomy)
72
Prevention of post-partum haemorrhage
1) Prophylactic uterotonics to all women in Stage 3 ◦ Vaginal delivery- IM Oxytocin ◦ C-section- IV Oxytocin
73
What is rhesus disease
Development of Rhesus antibodies in RhD -ve mother post exposure to RhD +ve blood
74
Pathophysiology of rhesus disease
• 15% of mothers are RhD -ve ◦ Sensitising event causes mixing of blood ‣ Mother develops IgM anti-Rh Abs (IgM cannot cross placenta) • No issues with first pregnancy ◦ Time passes and mother develops IgG anti-Rh Abs ‣ If next pregnancy is RhD +ve then IgG crosses placenta and causes haemolytic disease of the newborn • Causes Hydrops Fetalis
75
What are the sensitising events that can lead to rhesus disease
◦ Delivery ◦ Amniocentesis, CVS ◦ Ectopic pregnancy ◦ Trauma ◦ Miscarriage ◦ Stillbirth
76
Presentation of rhesus disease
• Affected foetus: • Oedematous • Jaundice • Anaemia • Hepatosplenomegaly • Heart failure • Hydrops fetalis (Heart failure with fluid accumulation in two or more areas)
77
Investigations for rhesus disease
• Red Cell Alloantibody Test (indirect Coombs test): ◦ Done at Booking Visit (8-12 weeks) ◦ Blood group also done • Kleihauer Test (ONLY >20 weeks): ◦ Checks how much foetal blood has passed into mother’s blood
78
Management of rhesus disease (and when to give it)
• Anti-D: ‣ Either 1500IU at 28 weeks OR 500IU at 28 and 34 weeks ‣ Attaches to rhesus-D antigens on foetal RBC in mother circulation and destroys them (prevents mother’s immune system recognising it) ‣ Also give within 72hrs after sensitising event
79
Complications of rhesus disease
• Hydrops Fetalis • Intrauterine death • Neonatal Kernicterus

Year 5: Conditions (17 decks)

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