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O&G > Obs 3 (labour) > Flashcards

Obs 3 (labour) Flashcards

1
Q

Define labour

A

Painful uterine contractions leading to effacement and dilation of the cervix (normal length = 4cm)

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2
Q

What are Braxton-Hicks contractions?

A

PAINLESS and NO CERVICAL CHANGE

  • False labour contractions
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3
Q

What are the 3 stages of labour?

A

3rd trimester / before labour:

  • Plug of mucus and blood (bloody show)
  • Rupture of amniotic sac (water breaking)
  • Braxton-Hicks contractions

1st stage:

  • From onset of true labour (painful uterine contractions) to full cervical dilatation (10cm)

2nd stage:

  • From full dilation / urge to push to delivery of foetus

3rd stage:

  • From delivery of foetus to complete delivery of placenta / foetal membranes
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4
Q

Describe the 3 stages of labour

A

1st stage:
Early phase

  • Begins with irregular, painful contractions (every 5-30 mins, lasting ~30s)
  • Dilation 0-4cm

Active stage

  • Intense contractions (every 60-90s, lasting 0.5-2 mins)
  • Dilation 4-10cm, effacement up to 100%
  • Amniotic sac often ruptures here (if it hasn’t already)

2nd stage:

  • Passive stage (not pushing) > Active stage (pushing)
  • Analgesia (‘1, 2, 3’ and analgesia = +1 hour):
  • In nulliparous women > 3 hours (epidural) or 2 hours (no epidural)
  • In multiparous women > 2 hours (epidural) and 1 hour (no epidural)

3rd stage:

  • After delivery of foetus, uterus contracts and placenta separates from uterine wall
  • Can last as long as 30 mins (usually 5-10)

(Fourth stage):

  • Few hours after delivery
  • Adaptation to blood loss
  • Start of uterine involution
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5
Q

What factors affect the 2nd stage of labour?

A

Fetal size:

  • Foetal head size
  • If larger - more difficulty making it through pelvic passage

Fetal attitude:

  • Normally fully flexed head (chin on chest, rounded back, flexed limbs)
  • Means suboccipitobregmatic diameter is at pelvic inlet
  • If not fully flexed - more difficulty making it through pelvic passage

Foetal lie:

  • Ideal = longitudinal
  • Not ideal = transverse, oblique

Foetal presentation:

  • Ideal = cephalic - vertex (full flexion of head)
  • Unideal = breech, shoulder
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6
Q

Describe the cardinal movements of the 2nd stage of labour

A

1. Descent:
Downward movement of foetus into pelvic inlet

  • Degree of descent is called the foetal station (described in terms of relation of presenting part to maternal ischial spine)
  • Moves from pelvic inlet (-5 station), to ischial spines (station 0 - engagement)

2. Flexion:
Foetal chin presses against chest as it’s head meets resistance from the pelvic floor

3. Internal rotation:
Foetus’s head internally rotates by 45 degrees so widest part of the head is in-line with widest part of pelvic outlet

  • Head can then pass under the symphysis pubis to +4 station

4. Extension:
Foetal head extends

  • Moves to +5 station
  • Emerges from vagina

5. Restitution:
After delivery of the head, head externally rotates so shoulders can pass through the pelvic outlet and under the symphysis pubis

6. Expulsion:

  • Anterior shoulder slips under symphysis pubis
  • Followed by posterior shoulder
  • Followed by rest of body
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7
Q

What is pre-labour rupture of the membranes (PROM)?

A

Spontaneous rupture of mebranes prior to onset of labour at term.

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8
Q

What is pre-term pre-labour rupture of the membranes (PPROM)?

A

Spontaneous rupture of membranes prior to onset of labour in a pregnancy <37 weeks.

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9
Q

What is shoulder dystocia?

A

Obstetric emergency

When the baby’s head has been born but one of the shoulders becomes stuck behind the mother’s pubic bone, delaying the birth of the baby’s body

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10
Q

What are the types of shoulder dystocia?

A

Anterior shoulder:

  • More common
  • Caused by impaction of the maternal pubic symphysis

Posterior shoulder:

  • Caused by impaction of the maternal sacral promontory
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11
Q

What are the RFs for shoulder dystocia?

A
  • Macrosomia
  • High maternal BMI
  • DM
  • Prolonged labour
  • GA > 42wks
  • Previous shoulder dystocia
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12
Q

What are the S/S of shoulder dystocia?

A

When routine practice of gentle downward traction of the foetal head fails to deliver the anterior shoulder

  • Difficult face/chin delivery
  • ‘turtling’ head (retracting)
  • failure of restitution
  • failure of shoulder descent
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13
Q

What is the management of shoulder dystocia?

A

1. Call for senior help

  • +Discourage pushing

2. McRobert’s manoeuvre:

  • 1 assistant on each side - legs up to abdomen (abducted and hyperflexed)
  • 90% success

3. Suprapubic pressure:

  • Attempts anterior shoulder disimpaction

4. Rubin’s manoeuvre:

  • Place 1 hand in vagina and on back of anterior foetal shoulder
  • Rotate anteriorly to disimpact anterior shoulder

5. Woods’ Screw:

  • Rubin’s + push other had on front of posterior

6. Try reverse:

  • Push on front of anterior shoulder and back of posterior shoulder

7. Deliver posterior arm:

  • Then, rotate 180 and deliver the other arm

8. Change position to all fours:

  • Repeat above manoeuvres

9. Surgery:

  • Symphysiotomy (separation of maternal pubic bones)
  • Cleidotomy (fracture foetal clavicle)
  • Zavanelli (return foetal head and attempt CS)
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14
Q

What is Bishop’s Score?

A

A score used to see how likely one is to go into labour soon

  • <5 = labour unlikely to start without induction
  • > 8 = high chance of spontaneous labour, or response to interventions to induce
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15
Q

What is effacement?

A

(Also called shortening or thinning) is reported as a percentage from 0% (normal length cervix) to 100% or complete (paper thin cervix)

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16
Q

What monitoring is required in labour?

A
  • Intermittent auscultation for 1 minute every 15 minutes to check FHR
  • If high risk = continuously via CTG
  • Contractions assessed every 30min
  • Maternal HR every 60min
  • Maternal BP, temp, urine (ketones/protein) every 4 hours
  • VE every 4 hours
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17
Q

Describe the management of the 1st stage of labour

A

Latent phase:

  • Managed away from the labour suite / at home
  • This stage is generally silent as the cervix gradually effaces over a period of days/weeks
  • Intervention should be avoided where possible
  • Standing upright may encourage progress of labour (so mobility should be encouraged)

Active phase:

  • 121 midwifery care
  • Vaginal examinations performed 4-hourly or as clinically indicated
  • Progress monitored using a partogram with timely intervention if abnormal
  • Ensure adequate: Analgesia ± antacids, Hydration and light diet to prevent ketosis (which can impair uterine contractility)
18
Q

What is the normal speed of dilation during labour?

A

Nulliparous = 0.5cm per hour
Multiparous = 1cm every hour
(a well flexed head will speed this up)

19
Q

What is considered delayed progress of dilation during the first stage of labour?

A

<1cm per 2 hours

20
Q

What are the types of delay in labour?

A

Primary dysfunctional labour:

  • <2cm dilation in 2 hours
  • Never progressed properly
  • Most commonly due to… ineffective uterine action

Secondary arrest of labour:

  • Progressed well and then stopped

Prolonged latent phase:

  • Prolonged latent

Cervical dystocia:

  • Rare
  • Cervix doesn’t dilate properly
21
Q

Describe the management of the 2nd stage of labour

A

First sign of the 2nd stage = urge to push (with 10cm dilation)

  • Full dilatation of cervix confirmed by vaginal examination (if head is not visible)
  • Women should be discouraged from lying supine or semi-supine
  • Use of regional anaesthesia (epidural or spinal) may interfere with the normal urge to push – meaning that the second stage is more often diagnosed on routine scheduled vaginal examination

Delivery:

  • Watch the perineum: between contractions, elastic tone of perineal muscles will push head back into pelvic cavity > when head no longer recedes between contractions = crowning - indicates delivery is imminent
  • As crowning occurs, hands of the midwife are used to flex the foetal head and guard the perineum
  • Once the head has crowned, the woman should be discouraged from bearing down by telling her to take rapid, shallow breaths
22
Q

What is the management for a prolonged 2nd stage of labour?

A

1st: Membranes intact:

  • ARM
  • Review in 2 hours

2nd: Membranes ruptured:

  • IV oxytocin - increase every 15-30 mins until 3-4 in 10 contractions
  • Must now use CTG and assess every hour
23
Q

Describe the immediate care of the neonate post-delivery

A
  • Baby will usually take its first breath within seconds
  • Baby should be dried and covered with a warm blanket or towel
  • No need for immediate clamping
  • After clamping/cutting umbilical cord, baby should have an Apgar score calculated at 1 minute and at 5 minutes
  • Immediate skin-to-skin contact between mother and baby will help bonding and promote release of oxytocin
  • Baby’s head should be kept dependent to allow mucus in the respiratory tract to drain
  • Initiation of breastfeeding should be encouraged within the first hour of life
  • Routine measurements of HC, birthweight and temperature should be measured soon after this hour
  • The first dose of baby’s vitamin K should be given in the delivery room (in first 24 hours)
24
Q

What is the Apgar score?

A

APGAR = Appearance, Pulse, Grimace, Activity, Respiration

  • Used at 1 minute and 5 minutes after delivery (and every 5 minutes after if condition remains poor)
  • > 7 is considered normal

Appearance: Cyanotic/pale, peripheral cyanosis, pink
Pulse: 0, <100, >100
Grimace: No response to stimulation, grimace/weak cry when stimulated, cry when stimulated
Activity: Floppy, some flexion, well flexed/resisting extension
Respiration: Apneic, slow/irregular, strong cry

25
Q

Describe the management of the 3rd stage of labour

A

Active Management:
Recommended to ALL women

  • Give prophylactic uterotonic e.g. 10 IU oxytocin (IM) / ergometrine (only oxytocin if hypertensive) after birth of anterior shoulder and immediately after delivery (before cord is clamped / cut)
  • Early clamping of the cord between 1-5 mins
  • Use controlled cord traction to deliver the placenta

Complications:

  • Uterine inversion is a rare complication
  • In 2% of cases, the placenta will not be expelled by this method

Physiological Management:

  • Placenta is delivered by maternal effort with no uterotonic drugs
  • Associated with more bleeding and a greater need for blood transfusions > if haemorrhage occurs OR the placenta is undelivered after 60 mins, active management should be recommended
26
Q

What are signs of placental separation?

A
  • Gush of blood
  • Cord lengthening
  • Uterus rises
  • Uterus becomes round
27
Q

What is considered a prolonged 3rd stage of labour?

A
  • Active management >30 minutes
  • Physiological management >60 mins (move to active management)
28
Q

What is the induction of labour?

A

Stimulation of uterine contractions with the intent to cause vaginal delivery prior to spontaneous onset of labour

29
Q

What is meant by cervical ripening (CR)?

A

Softening / thinning / dilating of the cervix to facilitate successful induction of labour

30
Q

Describe the induction of labour

A

1. Membrane Sweeping

  • Adjunct to IOL - offered prior to formal induction
  • Involves examining finger passing through cervix to rotate against wall of the uterus to separate the chorionic membrane from the decidua
  • Can be done by midwife at antenatal clinic
  • Nulliparous women: Offered at 40- and 41-week antenatal visit
  • Multiparous women: Offered at 41-week antenatal visit

2a. Prostaglandins:

  • Preferred formal method of induction
  • Propess = Pessary: 1 dose inserted vaginally and left in for 24 hours
  • Prostin (if pessary wasn’t sufficient ) = Gel: 1 dose, followed by 2nd dose after 6 hours (MAX: 2 doses)

2b. Balloon Catheter:

  • Cervix must be dilated enough to make it possible

3. ARM / Amniotomy

  • Once partially effaced and 1-2cm dilated
  • Amniohook used
  • Some women will start spontaneously contracting (esp if had a baby before)

4. Syntocinon

  • Maternal oxytocin infusion
  • Up-titrate until 3-4 contractions in 10 minutes, with each lasting at least 1 minute, with a clear break between them

5. Review

  • Firstly after 6 hours, then every 4-hourly

If fails = C section

31
Q

What are the indications for the induction of labour?

A
  • Prevention of prolonged pregnancy (offered from 41 weeks, if declined > twice weekly USS and CTG)
  • Maternal request (exceptional circumstances i.e. partner has to go away for armed service - considered from 40 weeks)
  • Intrauterine foetal death (oral mifepristone, followed by prostin or misoprostol)
  • PPROM
  • Maternal medical problems e.g. diabetic >38wks, pre-eclampsia, obstetric cholestasis
32
Q

Describe the analgesia used during labour

A

Non-pharmacological methods:

  • TENS machine
  • Breathing techniques
  • Massage

Pharmacological:

  • Entonox (50% NO in O2) > nausea, light-headed, dry mouth
  • Pethidine IM > ‘sleepy baby’, low baby RR, constipation
  • Morphine or Diamorphine (IM) > ‘sleepy baby’, low baby RR, constipation
  • Fentanyl PCA bolus with 5 min lockout > ‘sleepy baby’, low baby RR, constipation
  • Avoid opioids within 4 hours of delivery

Surgical: > slow labour, increased instrumental risk

  • Lumbar epidural = dose easily controlled by mother, can last 12+ hours
  • Spinal = one dose, lasting a few hours
  • Combined lumbar spinal-epidural = immediate and long term pain relief
  • Must now monitor continuously with CTG
33
Q

What is a partogram?

A
  • Records condition of mother, condition of foetus, progress of labour
  • Can be used to calculate a Bishop’s score (collects all necessary pieces of data)
34
Q

What are obstetric emergencies?

A
  • Sepsis
  • APH or PPH
  • Placenta praevia
  • Placenta accreta
  • Vasa praevia
  • Prolonged 3rd stage
  • Eclampsia
  • Amniotic fluid embolism
  • Cord prolapse
  • Shoulder dystocia
  • DVT PE
  • Uterine inversion
  • Uterine rupture
  • Puerperal pyrexia
35
Q

Describe puerperal pyrexia

A

>38C in the first 14 days following delivery

Causes:

  • Endometritis
  • UTI
  • VTE
  • Wound infection (tear, CS)
  • Mastitis

Management:
Until fever has abated for ≥24 hours…

  • IV Clindamycin; AND
  • IV Gentamicin
36
Q

Describe the management of the mother post-delivery

A

1. Inspect placenta for:

  • Missing cotyledons
  • Succenturiate lobe
  • If retained > EUA + MROP (manual removal of placental tissue)

2. Vulva inspected for tears

37
Q

How does the Bishop’s score guide which method of IOL is used?

A

Bishops score </=6

  • Vaginal prostaglandins or oral misoprostol
  • Mechanical methods e.g. balloon catheter can be considered if woman at higher risk of hyperstimulation or had previous CS

Bishops score >6

  • Amniotomy or IV oxytocin infusion
38
Q

What are the complications of IOL?

A

Uterine hyperstimulation:
Prolonged and frequent uterine contractions

  • Can cause foetal hypoxaemia and acidaemia
  • Rarely causes uterine rupture
  • Managed by removing vaginal prostaglandins / stopping oxytocin infusion
  • Consider tocolysis
39
Q

Describe the 4-hourly examination during labour

A

Abdominal:
Assess…

  • Lie
  • Presentation
  • Engagement

Vaginal:
Assess…

  • Dilation
  • Effacement (fully, partial, uneffaced)
  • Position of cervix (A/P)
  • Consistency of cervix (firm, intermediate, soft)
  • Foetal position / station / caput or molding
40
Q

What is the management if the second stage of labour fails to progress?

A

> Instrumental delivery

1st line = kiwi ventouse

  • Ca must sit in front of posterior fontanelle
  • Can be used maximum 4x, for 15 minutes each
  • Do not use if baby has bleeding disorder of excessive caput / moulding

2nd line = Forceps:

  • 3 types - Neville Barnes most common
  • Must be 100% sure on foetal head position (examine +/- USS)

3rd line = CS

41
Q

When do you offer CS?

A
  • Labour not progressed
  • Foetal distress during labour
  • Breech / malpresentation
  • Placenta praevia
  • Previous C section

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