O&G Written - Labour Flashcards

1
Q

Foetal movements during labour

A
  1. Engangement in occipito-transverse
  2. Descent + flexion
  3. Rotation 90 degrees to occipito-anterior
  4. Descent
  5. Extension to deliver
  6. Restitution + delivery of shoulders
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2
Q

NICE indications for continuous CTG during labour

A

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

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3
Q

Interpreting a CTG - basics

A

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

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4
Q

Levels of intervention for abnormal CTGs?

A

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

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5
Q

Classification of perineal tears

A

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

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6
Q

Management of 1st degree perineal tear

A

No repair needed?

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7
Q

Management of 2nd degree perineal tear

A

Suturing on ward by midwife or clinician

under local anaesthetic

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8
Q

Management of 3rd and 4th degree perineal tears

A

Repair in theatre by trained clinician (senior trainee or consultant)
epidural or spinal anaesthesia

+ Abx, laxatives, analgesia

Follow up: physiotherapy +/- anal manometry

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9
Q

Indications for IOL

A

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
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10
Q

Preferred form of IOL

A

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

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11
Q

Bishop’s score interpretation

A

<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

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12
Q

Factors of Bishop’s score

A

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

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13
Q

Absolute contraindications to vaginal delivery after CS?

A

Previous uterine rupture
Vertical/classical CS uterine scar
Usual indications for CS: placenta praevia

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14
Q

Confirmation of pre-labour/premature rupture of membranes

A

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

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15
Q

Requirements for Neville-Barnes / Simpson’s forceps delivery

A

FORCEPS

Fully dilated
Occipito-anterior
Ruptured membranes
Cephalic presentation
Engaged presenting part i.e. head not palpable abdominally
Pain relief adequate
Sphincter (bladder empty)
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16
Q

Indications for instrumental delivery

A

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

17
Q

Categories of CS delivery

A

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

17
Q

Indications for CS

A

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?

18
Q

Maternal complications from CS

A

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)
19
Q

Foetal complications from CS

A

Respiratory morbidity - TTN

Lacerations

Bonding & breastfeeding issues (especially if EMCS)

?Increased atopic conditions, obesity, diabetes

20
Q

Management of abnormal lie <37 weeks

A

If not in labour –> nothing

In labour –> CS or ECV + amniotomy (if expert present)

21
Q

Management of abnormal lie >37 weeks

A

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

22
Q

Causes of abnormal lie

A

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
23
Q

Risk factors/associations with breech

A

Foetal abnormalities - CNS malformation, chromosomal disorders
Uterine abnormalities - malformation, fibroids
Twin pregnancy
Polyhydramnios, oligohydramnios
Placenta praevia
Pelvic tumour or deformity

24
Q

Timing for ECV

A

36 weeks primiparous/nulliparous

37 weeks multiparous