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O&G: Labour + delivery Flashcards

1
Q

Induction of labour

when is it offered

A
  • between 41-42w
  • prelabour rupture of membranes
  • FGR
  • pre-eclampsia
  • obstetric cholestasis
  • existing diabetes
  • intrauterine fetal death
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2
Q

Induction of labour

what is used to determine whether to induce labour.

A

the Bishop Score

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3
Q

Induction of labour

what is the Bishop score based on

A
  • fetal station
  • cervical position
  • cervical dilatation
  • cervical effacement
  • cervical consistency
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4
Q

Induction of labour

what bishop score predicts a successful induction of labour

A

8 or more (out of 13)

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5
Q

Induction of labour

what does a bishop score <8 suggest

A

cervical ripening may be required to prepare the cervix

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6
Q

Induction of labour

what are the 5 options

A
  • membrane sweep
  • vaginal prostaglandin E2 (dinoprostone)
  • cervical ripening balloon
  • artificial rupture of membranes with oxytocin infusion
  • PO mifepristone (anti-progesterone) + misoprostol
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7
Q

Induction of labour

what does Vaginal prostaglandin E2 (dinoprostone) involve

A

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.

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8
Q

Induction of labour

when is cervical ripening balloon used

A

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).
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9
Q

Induction of labour

when is Artificial rupture of membranes with an oxytocin infusion used

A

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.

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10
Q

Induction of labour

when are Oral mifepristone (anti-progesterone) plus misoprostol used

A

used to induce labour where intrauterine fetal death has occurred.

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11
Q

Induction of labour

what are the 2 methods for monitoring during the induction of labour

A

CTG: fetal HR and uterine contractions

and bishop score: monitors progress

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12
Q

Induction of labour

options for when there is slow or no progress

A
  • further vaginal prostaglandins
  • artificial RoM + oxytocin infusion
  • cervical ripening balloon
  • elective caesarean section
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13
Q

Induction of labour

what is the main complication of induction of labour with vaginal prostaglandins

A

uterine hyperstimulation : contraction of the uterus is prolonged and frequent, causing fetal distress and compromise

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14
Q

Induction of labour

criteria for uterine hyperstimulation

A
  • individual uterine contractions lasting >2min

- >5 uterine contractions every 10 min

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15
Q

Induction of labour

what can uterine hyperstimulation lead to

A
  • fetal compromise, with hypoxia + acidosis
  • emergency caesarean section
  • uterine rupture
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16
Q

Induction of labour

mnx of uterine hyperstimulation

A
  • removing vaginal prostaglandins, or stopping the oxytocin infusion
  • tocolysis with terbutaline
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17
Q

Postpartum haemorrhage

To be classified as postpartum haemorrhage, there needs to be a loss of?

A

500ml after a vaginal delivery

or 1L after a caesarean section

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18
Q

Postpartum haemorrhage

what is a minor PPH

A

<1L blood loss

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19
Q

Postpartum haemorrhage

what is a major PPH

A

> 1L blood loss

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20
Q

Postpartum haemorrhage

what can a major PPH be further sub-classified as

A

moderate PPH: 1L-2L

severe PPH: >2L

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21
Q

Postpartum haemorrhage

what is a primary PPH

A

bleeding within 24h of birth

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22
Q

Postpartum haemorrhage

what is a secondary PPH

A

bleeding from 24h 12w after birth

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23
Q

Postpartum haemorrhage

causes (4)

A

Tone: uterine atony (most common)

Trauma: perineal tear

Tissue: retained placenta

Thrombin: bleeding disorder

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24
Q

Postpartum haemorrhage

RFs

A
  • 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
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25
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
26
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
27
Postpartum haemorrhage in severe cases, what do you activate
the major haemorrhage protocol: | - rapid access to 4U of crossmatched or O negative blood
28
Postpartum haemorrhage mechanical trx to stop the bleeding
- rubbing the uterus | - catheterisation
29
Postpartum haemorrhage medical trx to stop the bleeding
- IV Oxytocin 40U in 500ml - ergometrine - carboprost - misoprostol - tranexamic acid
30
Postpartum haemorrhage medical trx: what does ergometrine do
stimulates smooth muscle contraction (contraindicated in hypertension)
31
Postpartum haemorrhage medical trx: what does Carboprost do
IM prostaglandin analogue and stimulates uterine contraction (caution in asthma)
32
Postpartum haemorrhage medical trx: what does Misoprostol do
sublingual prostaglandin analogue stimulates uterine contraction
33
Postpartum haemorrhage medical trx: what does Tranexamic acid do
IV an antifibrinolytic that reduces bleeding
34
Postpartum haemorrhage surgical trx options to stop the bleeding
- Intrauterine balloon tamponade - B-Lynch suture - Uterine artery ligation - Hysterectomy (last resort)
35
Postpartum haemorrhage surgical trx: what is a B-lynch suture
putting a suture around the uterus to compress it
36
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
37
Postpartum haemorrhage what is a secondary PPH more likely be due to
retained products of conception (RPOC) or infection (i.e. endometritis).
38
Postpartum haemorrhage inx of a secondary PPH
- US: for retained products of conception | - endocervical + high vaginal swabs for infection
39
Postpartum haemorrhage mnx for retained products of conception
surgical evacuation
40
Postpartum haemorrhage mnx for infection
abx
41
Amniotic Fluid Embolism what is it
the amniotic fluid passes into the mother’s blood usually around labour
42
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
43
Amniotic Fluid Embolism RFs (4)
- Increasing maternal age - Induction of labour - Caesarean section - Multiple pregnancy
44
Amniotic Fluid Embolism presentation
It can present similarly to sepsis, PE or anaphylaxis: - SOB - hypoxia - hypotension - coagulopathy - haemorrhage - tachycardia - confusion - seizures - cardiac arrest
45
Amniotic Fluid Embolism mnx
supportive, ABCDE
46
Onset of Labour when does labour and delivery normally occur
37 - 42w gestation
47
Onset of Labour when is the 1st stage of labour
from the onset of labour (true contractions) until 10cm cervical dilatation
48
Onset of Labour when is the 2nd stage of labour
from 10cm cervical dilatation until delivery of the baby
49
Onset of Labour when is the 3rd stage of labour
from delivery of the baby until delivery of the placenta
50
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
51
Onset of Labour what are the 3 phases in the 1st stage of labour
latent active transition
52
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
53
Onset of Labour 1st stage: what is the active phase
- from 3cm to 7cm dilation of the cervix - progresses at 1cm/hr - regular contractions
54
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
55
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.
56
Onset of Labour how to help reduce Braxton-Hicks contractions
hydration and relaxing
57
Onset of Labour what are the 4 signs of labour
1. show 2. rupture of membranes 3. regular, painful contractions 4. dilating cervix on examination
58
Onset of Labour NICE dx of latent 1st stage
both of: - painful contractions - changes to cervix, with effacement and dilation up to 4cm
59
Onset of Labour NICE dx of established 1st stage of labour
both of: - regular, painful contractions - dilatation of cervix from 4cm onwards
60
Active Management of the Third Stage what are the 2 options for the 3rd stage
physiological active
61
Active Management of the Third Stage what is physiological mnx
where the placenta is delivered by maternal effort without medications or cord traction.
62
Active Management of the Third Stage what is active mnx
- IM 10U oxytocin | - traction to umbilical cord
63
Active Management of the Third Stage benefits of active mnx
shortens the third stage and reduces the risk of bleeding
64
Active Management of the Third Stage disadvantages of active mnx
associated with nausea and vomiting.
65
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)
66
Uterine Rupture what is it
a complication of labour the muscle layer of the uterus (myometrium) ruptures.
67
Uterine Rupture what is incomplete rupture (aka uterine dehiscence)
the uterine serosa (perimetrium) surrounding the uterus remains intact.
68
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.
69
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)
70
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
71
Uterine Rupture presentation
- acutely unwell moth - abnormal CTF - ceasing of uterine contractions - abdo pain - vaginal bleeding - Hypotension - Tachycardia - Collapse
72
Uterine Rupture mnx
emergency - resus + transfusion - emergency c-section is necessary to remove baby, stop any bleeding and repair or remove the uterus (hysterectomy).
73
Uterine Inversion what is it
a rare complication of birth the fundus of the uterus drops down through the uterine cavity and cervix
74
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)
75
Uterine Inversion what is complete inversion
the uterus descends through the vagina to the introitus.
76
Uterine Inversion what is a possible cause
pulling too hard on the umbilical cord during active management of the third stage of labour
77
Uterine Inversion presentation
- large post partum haemorrhage | - maternal shocl or collapse
78
Uterine Inversion examination findings of incomplete uterine inversion
may be felt with manual vaginal examination
79
Uterine Inversion examination findings of complete uterine inversion
the uterus may be seen at the introitus of the vagina
80
Uterine Inversion 3 options for trx
1. Johnson manoeuvre 2. Hydrostatic methods 3. Surgery
81
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
82
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

Finals (47 decks)

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