O&G Written - Labour Flashcards
Foetal movements during labour
- Engangement in occipito-transverse
- Descent + flexion
- Rotation 90 degrees to occipito-anterior
- Descent
- Extension to deliver
- Restitution + delivery of shoulders
NICE indications for continuous CTG during labour
Suspected chorioamnionitis or sepsis OR temp 38+
Severe HTN (160/110 +)
Oxytocin use
Presence of significant meconium
Fresh PV bleed that develops during labour
Extra Impey & Child indications
Pre-labour: IUGR, previous CS, IOL
Labour: during epidural administration
Interpreting a CTG - basics
DR C BRAVADO
Define Risk - why is patient on CTG monitor?
Contractions - up to 5 in 10 mins is normal
Baseline Rate - 110-160bpm
Variability - 5-25bpm
Accelerations - rise in foetal HR of at least 15bpm for 15secs or more. 2 every 15 mins with contractions is normal.
Decelerations - reduction in foetal HR by at least 15bpm for 15 secs or more.
Overall impression
Levels of intervention for abnormal CTGs?
Non-reassuring (1 non reassuring feature + 2 normal) –> inform senior, left lateral position + encourage fluids
Abnormal (1 abnormal feature or 2 non reassuring) –> inform senior, start conservative measures + offer foetal blood sampling to check hypoxia (pH <7.2)
Prolonged foetal bradycardia OR single prolonged deceleration (baseline <100 for >3 mins) –> inform senior, Conservative measures, prep for urgent Cat 1 CS
Classification of perineal tears
1st degree = superficial damage to skin + subcut tissues, no muscle involvement
2nd degree = injury to perineal muscle, not involving anal sphincter
3rd degree = injury to perineum involving anal sphincter complex
- A = <50% external anal sphincter
- B = >50% external anal sphincter
- C = internal anal sphincter
4th degree = anal sphincter complex + anal mucosa
Management of 1st degree perineal tear
No repair needed?
Management of 2nd degree perineal tear
Suturing on ward by midwife or clinician
under local anaesthetic
Management of 3rd and 4th degree perineal tears
Repair in theatre by trained clinician (senior trainee or consultant)
epidural or spinal anaesthesia
+ Abx, laxatives, analgesia
Follow up: physiotherapy +/- anal manometry
Indications for IOL
Maternal: social, intra-uterine death
Materno-foetal: diabetes (at term), preeclampsia
Foetal:
- suspected IUGR
- rhesus incompatibility
- prolonged pregnancy (1-2 weeks post EDD)
- antepartum haemorrhage
- prelabour (term?) rupture of membranes
Preferred form of IOL
Vaginal prostaglandin E2
- pessary inserted into posterior fornix for 24 hours
- ripens cervix, may start labour and contractions
After 24h, can have vaginal gel every 6 hours if needed
Bishop’s score interpretation
<5 = unlikely to progress without induction
8+ = ripe/favourable cervix, high change of spontaneous labour OR likelihood of response to interventions made to induce it
Factors of Bishop’s score
Cervical position: 0 = posterior, 1 = intermediate, 2 = anterior
Cervical consistency: 0 = firm, 1 = intermediate, 2 = soft
Cervical effacement: 0 = 0-30%, 1 = 40-50%, 2 = 60-70%, 3 = 80% +
Cervical dilatation: 0 = <1cm, 1 = 1-2cm, 2 = 3-4cm, 3 = >5cm
Foetal station: 0 = -3, 1 = -2, 2 = -1 or 0, 3 = +1 or +2
Absolute contraindications to vaginal delivery after CS?
Previous uterine rupture
Vertical/classical CS uterine scar
Usual indications for CS: placenta praevia
Confirmation of pre-labour/premature rupture of membranes
Speculum exam - fluid pooling in posterior vaginal fornix
+/- Nitrazine test (fluid placed on pH strip, dark blue = pH >7.1)
+/- Fern test (microscopy shows ferning patten)
USS –> oligohydramnios, AFI<5
Commercial test e.g. AmnioSure, Actim PROM
Requirements for Neville-Barnes / Simpson’s forceps delivery
FORCEPS
Fully dilated Occipito-anterior Ruptured membranes Cephalic presentation Engaged presenting part i.e. head not palpable abdominally Pain relief adequate Sphincter (bladder empty)
Indications for instrumental delivery
Prolonged 2nd stage of labour (1-2 hours of pushing)
Maternal exhaustion
Foetal distress - to expedite labour
Prevent pushing in women with medical conditions e.g., cardiac disease
Breech delivery - occasionally used for ‘after-coming’ of head
Categories of CS delivery
Cat 1 emergency = immediate threat to mother or foetus, within 30 mins
Cat 2 urgent = maternal / foetal compromise, not immediately life threatening, within 75 mins
Cat 3 scheduled = needing early delivery but no compromise
Cat 4 elective = at time to suit mother & team
Indications for CS
Absolute:
- severe antenatal foetal compromise - emergency
- previous vertical/classical CS scar
- placenta praevia
- uncorrectable abnormal lie
- gross pelvic deformity
Relative
- twins
- breech
- severe IUGR
- diabetes + other medical conditions
- previous CS
- older nulliparous patient
+/- maternal request?
Maternal complications from CS
Serious
- PPH + need for emergency hysterectomy
- need for further surgery
- ICU admission
- VTE
- damage to viscera (bowel, bladder)
- death (1 in 5000)
Frequent:
- persistent post-op pain & immobility
- uterine / wound infection
- haemorrhage needing transfusion
- anaesthetic complications
For future pregnancies:
- placenta praevia, accreta
- uterine rupture
- antepartum stillbirth
- increased need for CS (when attempting vaginal delivery)
Foetal complications from CS
Respiratory morbidity - TTN
Lacerations
Bonding & breastfeeding issues (especially if EMCS)
?Increased atopic conditions, obesity, diabetes
Management of abnormal lie <37 weeks
If not in labour –> nothing
In labour –> CS or ECV + amniotomy (if expert present)
Management of abnormal lie >37 weeks
Admission (in case of SROM)
USS to exclude:
- placenta praevia
- polyhydramnios
If spontaneous version occurs + persists for 48 hours –> discharged
ECV not recommended as most will stabilise by 41 weeks
Causes of abnormal lie
Unstable, continuously changing:
- polyhydramnios
- high parity (lax uterus)
Persistent transverse lie:
- conditions that prevent turning e.g. foetal or uterine abnormality, twin pregnancy
- conditions that prevent engagement e.g. placenta praevia, pelvic tumour, uterine deformity
Risk factors/associations with breech
Foetal abnormalities - CNS malformation, chromosomal disorders
Uterine abnormalities - malformation, fibroids
Twin pregnancy
Polyhydramnios, oligohydramnios
Placenta praevia
Pelvic tumour or deformity
