O&G: Labour + delivery Flashcards
Induction of labour
when is it offered
- between 41-42w
- prelabour rupture of membranes
- FGR
- pre-eclampsia
- obstetric cholestasis
- existing diabetes
- intrauterine fetal death
Induction of labour
what is used to determine whether to induce labour.
the Bishop Score
Induction of labour
what is the Bishop score based on
- fetal station
- cervical position
- cervical dilatation
- cervical effacement
- cervical consistency
Induction of labour
what bishop score predicts a successful induction of labour
8 or more (out of 13)
Induction of labour
what does a bishop score <8 suggest
cervical ripening may be required to prepare the cervix
Induction of labour
what are the 5 options
- membrane sweep
- vaginal prostaglandin E2 (dinoprostone)
- cervical ripening balloon
- artificial rupture of membranes with oxytocin infusion
- PO mifepristone (anti-progesterone) + misoprostol
Induction of labour
what does Vaginal prostaglandin E2 (dinoprostone) involve
inserting a gel, tablet (Prostin) or pessary (Propess) into the vagina.
slowly release local prostaglandins
stimulates the cervix and uterus to cause the onset of labour.
Induction of labour
when is cervical ripening balloon used
an alternative where vaginal prostaglandins are not preferred, usually:
- in women with a previous caesarean section
- where vaginal prostaglandins have failed
- or multiparous women (para ≥ 3).
Induction of labour
when is Artificial rupture of membranes with an oxytocin infusion used
where there are reasons not to use vaginal prostaglandins.
It can be used to progress the induction of labour after vaginal prostaglandins have been used.
Induction of labour
when are Oral mifepristone (anti-progesterone) plus misoprostol used
used to induce labour where intrauterine fetal death has occurred.
Induction of labour
what are the 2 methods for monitoring during the induction of labour
CTG: fetal HR and uterine contractions
and bishop score: monitors progress
Induction of labour
options for when there is slow or no progress
- further vaginal prostaglandins
- artificial RoM + oxytocin infusion
- cervical ripening balloon
- elective caesarean section
Induction of labour
what is the main complication of induction of labour with vaginal prostaglandins
uterine hyperstimulation : contraction of the uterus is prolonged and frequent, causing fetal distress and compromise
Induction of labour
criteria for uterine hyperstimulation
- individual uterine contractions lasting >2min
- >5 uterine contractions every 10 min
Induction of labour
what can uterine hyperstimulation lead to
- fetal compromise, with hypoxia + acidosis
- emergency caesarean section
- uterine rupture
Induction of labour
mnx of uterine hyperstimulation
- removing vaginal prostaglandins, or stopping the oxytocin infusion
- tocolysis with terbutaline
Postpartum haemorrhage
To be classified as postpartum haemorrhage, there needs to be a loss of?
500ml after a vaginal delivery
or 1L after a caesarean section
Postpartum haemorrhage
what is a minor PPH
<1L blood loss
Postpartum haemorrhage
what is a major PPH
> 1L blood loss
Postpartum haemorrhage
what can a major PPH be further sub-classified as
moderate PPH: 1L-2L
severe PPH: >2L
Postpartum haemorrhage
what is a primary PPH
bleeding within 24h of birth
Postpartum haemorrhage
what is a secondary PPH
bleeding from 24h 12w after birth
Postpartum haemorrhage
causes (4)
Tone: uterine atony (most common)
Trauma: perineal tear
Tissue: retained placenta
Thrombin: bleeding disorder
Postpartum haemorrhage
RFs
- previous PPH
- multiple pregnancy
- obesity
- large baby
- failure to progress in the 2nd stage of labour
- prolonged 3rd stage
- pre-eclampsia
- placenta accreta
- retained placenta
- instrumental delivery
- general anaesthesia
- episiotomy of perineal tear
Postpartum haemorrhage
preventative measures
- treating anaemia during the antenatal period
- give birth with an empty bladder (a full one reduces uterine contraction)
- active mnx of the 3rd stage (w/ IM oxytocin)
- IV tranexamic acid can be used during c-section (in 3rd stage) in higher risk pts
Postpartum haemorrhage
mnx
- ABCDE
- lie woman flat, keep warm, communicate with her
- insert 2 large-bore cannulas
- Bloods: FBC, U&E, clotting screen
- Group and cross match 4units
- warmed IV fluid + blood resus as required
- O2 (regardless of sats)
- FFP: where there are clotting abnormalities or after 4U of blood
Postpartum haemorrhage
in severe cases, what do you activate
the major haemorrhage protocol:
- rapid access to 4U of crossmatched or O negative blood
Postpartum haemorrhage
mechanical trx to stop the bleeding
- rubbing the uterus
- catheterisation
Postpartum haemorrhage
medical trx to stop the bleeding
- IV Oxytocin 40U in 500ml
- ergometrine
- carboprost
- misoprostol
- tranexamic acid
Postpartum haemorrhage
medical trx: what does ergometrine do
stimulates smooth muscle contraction (contraindicated in hypertension)
Postpartum haemorrhage
medical trx: what does Carboprost do
IM
prostaglandin analogue and stimulates uterine contraction
(caution in asthma)
Postpartum haemorrhage
medical trx: what does Misoprostol do
sublingual
prostaglandin analogue stimulates uterine contraction
Postpartum haemorrhage
medical trx: what does Tranexamic acid do
IV
an antifibrinolytic that reduces bleeding
Postpartum haemorrhage
surgical trx options to stop the bleeding
- Intrauterine balloon tamponade
- B-Lynch suture
- Uterine artery ligation
- Hysterectomy (last resort)
Postpartum haemorrhage
surgical trx: what is a B-lynch suture
putting a suture around the uterus to compress it
Postpartum haemorrhage
surgical trx: what is Uterine artery ligation
ligation of one or more of the arteries supplying the uterus to reduce the blood flow
Postpartum haemorrhage
what is a secondary PPH more likely be due to
retained products of conception (RPOC) or infection (i.e. endometritis).
Postpartum haemorrhage
inx of a secondary PPH
- US: for retained products of conception
- endocervical + high vaginal swabs for infection
Postpartum haemorrhage
mnx for retained products of conception
surgical evacuation
Postpartum haemorrhage
mnx for infection
abx
Amniotic Fluid Embolism
what is it
the amniotic fluid passes into the mother’s blood
usually around labour
Amniotic Fluid Embolism
why is there an immune reaction
The amniotic fluid contains fetal tissue
immune reaction to cells from the foetus leads to a systemic illness
Amniotic Fluid Embolism
RFs (4)
- Increasing maternal age
- Induction of labour
- Caesarean section
- Multiple pregnancy
Amniotic Fluid Embolism
presentation
It can present similarly to sepsis, PE or anaphylaxis:
- SOB
- hypoxia
- hypotension
- coagulopathy
- haemorrhage
- tachycardia
- confusion
- seizures
- cardiac arrest
Amniotic Fluid Embolism
mnx
supportive, ABCDE
Onset of Labour
when does labour and delivery normally occur
37 - 42w gestation
Onset of Labour
when is the 1st stage of labour
from the onset of labour (true contractions) until 10cm cervical dilatation
Onset of Labour
when is the 2nd stage of labour
from 10cm cervical dilatation until delivery of the baby
Onset of Labour
when is the 3rd stage of labour
from delivery of the baby until delivery of the placenta
Onset of Labour
what does the ‘show’ refer to
the mucus plug in the cervix, which prevents bacteria from entering the uterus during pregnancy
it falls out and creates space for baby to pass through
Onset of Labour
what are the 3 phases in the 1st stage of labour
latent
active
transition
Onset of Labour
1st stage: what is the latent phase
- from 0 to 3cm dilation of the cervix
- progresses at 0.5cm/hr
- irregular contractions
Onset of Labour
1st stage: what is the active phase
- from 3cm to 7cm dilation of the cervix
- progresses at 1cm/hr
- regular contractions
Onset of Labour
1st stage: what is the transition phase
- from 7cm to 10cm dilation of the cervix
- progresses at 1cm/hr
- strong regular contractions
Onset of Labour
what are Braxton-Hicks contractions
irregular contractions of the uterus
usually felt at the 2nd and 3rd trimester
not true contractions, and they do not indicate the onset of labour.
Onset of Labour
how to help reduce Braxton-Hicks contractions
hydration and relaxing
Onset of Labour
what are the 4 signs of labour
- show
- rupture of membranes
- regular, painful contractions
- dilating cervix on examination
Onset of Labour
NICE dx of latent 1st stage
both of:
- painful contractions
- changes to cervix, with effacement and dilation up to 4cm
Onset of Labour
NICE dx of established 1st stage of labour
both of:
- regular, painful contractions
- dilatation of cervix from 4cm onwards
Active Management of the Third Stage
what are the 2 options for the 3rd stage
physiological
active
Active Management of the Third Stage
what is physiological mnx
where the placenta is delivered by maternal effort without medications or cord traction.
Active Management of the Third Stage
what is active mnx
- IM 10U oxytocin
- traction to umbilical cord
Active Management of the Third Stage
benefits of active mnx
shortens the third stage and reduces the risk of bleeding
Active Management of the Third Stage
disadvantages of active mnx
associated with nausea and vomiting.
Active Management of the Third Stage
when is it offered
- routinely offered to all women to reduce the risk of postpartum haemorrhage
- Haemorrhage
- More than a 60-minute delay in delivery of the placenta (prolonged third stage)
Uterine Rupture
what is it
a complication of labour
the muscle layer of the uterus (myometrium) ruptures.
Uterine Rupture
what is incomplete rupture (aka uterine dehiscence)
the uterine serosa (perimetrium) surrounding the uterus remains intact.
Uterine Rupture
what is complete rupture
the serosa (perimetrium) ruptures along with the myometrium
and the contents of the uterus are released into the peritoneal cavity.
Uterine Rupture
what is the main RF
a previous caesarean section
the scar on the uterus becomes a point of weakness and may rupture with excessive pressure (e.g. excessive stimulation by oxytocin)
Uterine Rupture
RFs
- Vaginal birth after caesarean (VBAC)
- Previous uterine surgery
- Increased BMI
- High parity
- Increased age
- Induction of labour
- Use of oxytocin to stimulate contractions
Uterine Rupture
presentation
- acutely unwell moth
- abnormal CTF
- ceasing of uterine contractions
- abdo pain
- vaginal bleeding
- Hypotension
- Tachycardia
- Collapse
Uterine Rupture
mnx
emergency
- resus + transfusion
- emergency c-section is necessary to remove baby, stop any bleeding and repair or remove the uterus (hysterectomy).
Uterine Inversion
what is it
a rare complication of birth
the fundus of the uterus drops down through the uterine cavity and cervix
Uterine Inversion
what is incomplete uterine inversion (partial inversion)
the fundus descends inside the uterus or vagina, but not as far as the introitus (opening of the vagina)
Uterine Inversion
what is complete inversion
the uterus descends through the vagina to the introitus.
Uterine Inversion
what is a possible cause
pulling too hard on the umbilical cord during active management of the third stage of labour
Uterine Inversion
presentation
- large post partum haemorrhage
- maternal shocl or collapse
Uterine Inversion
examination findings of incomplete uterine inversion
may be felt with manual vaginal examination
Uterine Inversion
examination findings of complete uterine inversion
the uterus may be seen at the introitus of the vagina
Uterine Inversion
3 options for trx
- Johnson manoeuvre
- Hydrostatic methods
- Surgery
Uterine Inversion
initial mnx and what is it
Johnson manoeuvre
using a hand to push the fundus back up into the abdomen and the correct position
oxytocin used to a create a uterine contraction
ligaments and uterus need to generate enough tension to remain in place
Uterine Inversion
mnx: what does the hydrostatic method involve
filling the vagina with fluid to “inflate” the uterus back to the normal position
tight seal required at entrance of vagina
