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A - ObsNGynae > Obs - Labour > Flashcards

Obs - Labour Flashcards

1
Q

when can you say some1 isi going nto labour?

A

Diagnosis of labour is made when painful uterine contactions accompany dilatation and effacement of the
cervix.

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2
Q

what are the stages of labour?

A

 First stage: cervix opens to full dilatation
 Second stage: full dilatation to delivery of the fetus
 Third stage: delivery of fetus to delivery of placenta

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3
Q

what are the diameters of the pelvc inlet and outlet?

A

Inlet = transverse diameter: ~13cm, AP diameter = 11cm

The outlet, the transverse diameter (11cm) and the AP diameter is 12.5cm

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4
Q

what is the Attitude of a fetus?

A

the degree of flexion/extension of the head

can be vertex, brow or face

 Ideal attitude = maximum flexion (vertex presentation)

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5
Q

how many cm is fully dilated?

A

10cm

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6
Q

describe the events of the 1st stage of labour?

A

Fetus: Descent, flexion and internal rotation

2 phases:
Latent phase = cervix dilates slowly for first 3cm – takes several hours

Active phase = 0.5-1cm/h (nullips) or 2cm/h (multips)
o Shouldn’t last >12h

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7
Q

describe the events of the 2nd stage of labour?

A

Full dilatation of the cervix to delivery

Passive stage = full dilataion until head reaches pelvic floor and woman experiences desire to push
o May last a few minutes or longer

Active stage = when mother is pushing
o Pushes with contraction
o Usually takes 40 minutes (nulliparous) or 20 minutes (multiparous)
o If it takes >1h, unlikely to be SVD

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8
Q

describe movements of baby in the 2nd stage of labour?

A

Head comes up and out of the pelvis
 Head restitutes (external rotation 90degrees) to adopt transverse position

 Shoulders then deliver
 Anterior shoulder first, aided by lateral body flexion in posterior derection
 Then posterior shoulder aided by lateral body flexion in anterior direction

 Rest of body follows

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9
Q

what iis the overview of thee mechanisms of labour

A

Stage 1:
Descent
Flexion
Internal rotation

Stage 2:
Extension
External rotation/restitution

Enters inlet as OT -> OA in midcavity and delivery -> OT again with restitution when head is outside. PAGE 60 NINA

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10
Q

why is left lateral postion adopted in examination or labour in heavly pregnant women?

A

to prevent aortocaval compression which could lead to Low BP and reduced CO

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11
Q

if woman gets low bp due to epidural, what you do?

A

Iv fluids +- ephedrine

giive iv fluids prophylactically if using epidural

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12
Q

If GA used in labour/delivery, what are the risks and how s this mitigated?

A

aspiration of gastric contents

giive ranitidine

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13
Q

how would you manage fever in labour?

A

If feveer > 38C

Cultures of vagina, urine and blood taken
IV abx if fever 38C or risk factors for sepsis

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14
Q

what is the most common cause of failure to progress (or slow progress)?

A

ineffective uterine action or incoordinate uterine activity

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15
Q

how would you manage ineffective uterine action?

A

Amniotomy

Oxytocin (syntocinon infusion ‘drip’)

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16
Q

what could cause hyperstimulation/ Hyperactive Uterine Action

A

too much oxytocin

side effect of PGE2 administration to induce labour

placental abruption

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17
Q

how is hyperstimulation treated?

A

Tocolytic (salbutamol) IV or SC

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18
Q

how would you manage an OP presentation?

A

attempt normal vaginal delivery

if not achieved in 1 hour:
ventouse
or rotational forceps - keillands

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19
Q

how would you manage an OT presentation?

A

Ventouse

dont use forceps where head is not in a DIRECT position!

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20
Q

a woman is in labour. On VE the anterior fontanelle,
supraorbital ridges and the nose are palpable
vaginally. meaning? rx?

A

Brow presentation - hyperextended

C-Section

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21
Q

how would you manage a face presentation?

A

vaginal delivery if chin anterior

otherwise c-section

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22
Q

how can you determine fetal hypoxia/distress in labour?

A
  1. Colour of liquor: meconium
    o Indication for caution and CTG surveillance
  2. Use Pinard’s stethoscope or hand held Doppler
  3. CTG
  4. Fetal ECG
  5. Fetal scalp sampling

Scalp blood pH <7.20 (capillary) indicates significant hypoxia

can do cord ph but not often done

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23
Q

what are the causes of hypoxia in labour?

A 
o Placental abruption
o Hypertonic uterine states
o Use of oxytocin
o Umbilical cord prolapse
o Maternal hypotension
24
Q

what does the term fetal distress refer to?

A

hypoxia that might result in fetal damage

or death if not reversed or the fetus delivered urgently delivered.

25
Q

you find that a fetus has meconium stained liqour in-utero. what does this mean? rx?

A

the presence or absence of meconium is not a reliable indicator of fetal well-being.

It is an indication for caution (and hence closer surveillance with a CTG) because (i) the fetus may aspirate it, causing
meconium aspiration syndrome, and (ii) hypoxia is
more likely.

If meconiium is thick - amniofusion of
saline into the uterus to dilute the meconium reduces
the incidence of meconium aspiration

26
Q

what findings on ctg are abnormal?

A

tachy/bradycardia

Hyperstimulation = >5 in 10 minutes AND fetal distress (if no distress -> tacchysystole)

Loss or increase in baseline variability

Variable decelerations:
o Classically reflect cord compression
o Can lead to hypoxia

Late decelerations
o Persist after the contration is completed
o Suggestive of fetal hypoxia

27
Q

persistent bradycardia would require?

A

immedate delivery

bun ctg monitoring

28
Q

how would you know a fetus is distressed/hypoxic before dong a FBS?

A

CTG abnormalities

29
Q

how iiis fetal distress managed overall?

A

Place woman in left lateral position
 Oxygen and IV fluids
 Stop oxytocin infusion
 VE to exclude prolapse or rapid progress
 FBS and rapid delivery if pH <7.20
 Second scalp in 30 min if >7.20
 Sustained bradycardia or impossible FBS  deliver by quickest route

30
Q

what are the indications for CTG use?

A

indications for ctg:
Prelabour risk factors include pre-eclampsia, IUGR,
previous caesarean section, induction.

In labour risk factors include the presence of meconium,
the use of oxytocin, the presence of a temperature >38 °C, during the administration of epidural analgesia.

31
Q

when can a woman NOT have an epidural?

A 
Sepsis
o Coagulopathy or anticoagulant therapy (unless LMWH)
o Active neurological disease
o Spinal abnormalities
o Hypovolaemia
32
Q

list some complications of epidural?

A

Puncture of dura mata  leakage of CSF and severe headache

Inadvertent IV injection  convulsions and cardiac arrest

o Inadvertent injection of local anaesthetic into CSF -> total spinal paraesthesia

33
Q

in normal labour when is intrumental indicated?

A

If baby not delivered with 1 hour of pushing in 2nd stage

OP/OT

34
Q

what is an active third stage?

A

when drugs given to stimulate uterine contraction to reduce incidence of PPH

Normal circumstance:
IM oxytocin
Ergometrine and oxytocine = Syntometrine - dont giive iif BP issues
followed by Controlled cord traction

If there is a retained placenta (third stage >30 minutes)
 Oxytocin infusion started and 10 units injected into vein of cord and milked up
 An hour is left for natural separation, after which the placenta is manually removed
 Hand in uterus under general or spinal anaesthesia

35
Q

what aree the levels of perineal trauma?

A

First degree Injury to skin only

Second degree Involving perineal muscles but not
anal sphincter

Third degree Involving anal sphincter complex

3a: <50% of external anal sphincter torn
3b: >50% of external anal sphincter torn
3c: internal anal sphincter also involved

Fourth degree Involving anal sphincter and anal
epithelium

36
Q

how to manage perineal tears?

A

1 & 2 - suture under LA

3&4 - repair sphincters under epidural or spinal
- give laxatives and abx

37
Q

what are the different birth options for women - wiithout complications?

A

Home birth - if low risk

Birth centre - midwiife led unit

Water birth - labour and delivery are
conducted in a large bath of water maintained at 37 °C.
Water is relaxing and analgesic. Baby. doesnt breath till surface

Epidural - allows fast labour, painless - labour ward or birth centre

c-section if valid reason eg trauma or medical contraindication

38
Q

what is the Bishop score?

A

assesses the favourability of the cervix for induction of labour.

out of 10

if less than 6, cervical riipening agents may need to be used

39
Q

what options for IOL are available ? indications?

A

Induction with PGE2 gel (2mg) eg Prostin - inserted into posterior vaginal fornix
 Best for nullips and most multips with favourable cervixes
 It either starts labour or induces cervical ripening
 Another dose may be given a minimum of 6h later providing there is no uterine activity

Amniotomy + Oxytocin
 Forewaters are ruptured with an amnihook = artificial rupture of membranes (ARM)
 Oxytocin infusion then started within 2h if labour has not ensued
 Can use oxytocin alone if SROM occurred
 PGEs are equally effective

Natural
 Membrane sweep
 At 40 weeks, it  chance of IOL and postdates pregnancy

40
Q

what are contraindications for induction of labour?

A 
Absolute
 Acute fetal compromise
 Abnormal lie
 Placenta praevia
 Pelvic obstruction e.g. mass or deformity
 cephalopelvic disproportion
 >1 CS

Relative
 1 previous CS
 prematurity

41
Q

what are complications of IOL?

A 
 Inefficient uterine activity
 Risk CS or instrumental delivery
 Hyperstimulation -> fetal distress and uterine rupture
 PPH
 Intra- and postpartum infection
42
Q

list some contraindications for VBAC?

A

Usual contraindications for CS
 Vertical uterine scar
 Multiple previous caesarean

  • IF labour is giong on too long
43
Q

chance of successful vbac?

A

60% first one, chances of success increases each subsequent vbac

44
Q

what are the factors required before a woman is selected for a VBAC?

A
  1. uncompliicated ceasarean
    - if it was very complicated c-section probably not vbac
  2. if the c-sectoin wound has adhesions and keloids / poor healing?
  3. fetus has: longitudnal liie, cephaliic presentation , fetal size; not macrosomic or growth restricted, singleton pregnancies only.
45
Q

what are the complicatoins of vbac?

A

0.7% risk of old c-section scar rupture during labour

may lead to emergency rescure c-sectiion

46
Q

what is the different between scar dehiscence and rupture?

A

Serosa preserved - scar dehiscence

Endometrium myometrium and serosa breeched - scar rupture

47
Q

what are special considerations in VBAC deliveries?

A

If they don’t spontaenoulsy go into labour; induce them -with a modified iniduction:

  • no prostin/prostaglandins to induce
  • can do balloon ripening
  • can do AROM
  • judiiciious use of syntocinon does not increase risk of scar rupture. (start low dose, tiitrate up gradually whilst monitoring mother and fetus) - only use if very low or no contractions.
48
Q

how is prelabour term rupture of membranes managed?

A

await spontaneous labour or iniduce labour

if gettinig to 1.5 days, give abx against GBS

49
Q

how do you know when there has been a uterine rupture?

A
  • Basiic observations
  • Pain around her previous scar, peritonism
  • Abdominal distension
  • Can perhaps feel baby in abdomen - as its left the
    uterus
  • Blood stained liqour
  • Blood stained urine
  • Can no longer feel fetal head on VE - or fetal station is higher
50
Q

when can you not attempt instrumental delivery

A

if not indcated eg woman can deliver naturally

fetal station is too high / head still palpable abdominally

51
Q

how does uterine inversion present?

A

profound bradycardia + Low BP out of keeping with observable loss

52
Q

What bishops score indicates likely spontaneous labour?

A

8+

Less than 6 indicates unlikely spontaneous labour - cervical ripening agents needed

53
Q

equate the presenting diameters of a fetus to the attitude

A

Vertex/OA - Suboccipito bregmatic - 9.5cm (fully flexed)

OP - occipitofrontal - 11cm (deflexed)

Brow - Verticomental - 13.5cm (partial extension) -> not compatible with vaginal delivery

Face - submentobregmatic - 9.5cm (full extension)

54
Q

how do you know if baby is brow presentation?

A

Can palpate orbital ridges and anterior fontanelle.

55
Q

wha t are the mechanical factors influencing labour?

A

Power:

  • degree of force expelling the fetus
  • Poor uterine activity is a common feature of nullips and in IOL
  • pressure from head adds to this

Passage:

  • Bony pelvis and its dimensions
  • Soft tissues eg cervix, vagina, perinuem and their ability to dilate

Passenger:
Diameter, attitude, position and size of fetal head

A - ObsNGynae (37 decks)

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