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GOSH > Obstetrics (Intrapartum care): Normal pregnancy + IOL > Flashcards

Obstetrics (Intrapartum care): Normal pregnancy + IOL Flashcards

1
Q

What is the definition of stage 1 of labour?

Explain the features

A

Onset of labour to full dilatation (10cm)

  • Involves decent, flexion, internal rotation
  • membranes usually rupture
  • Primigravida dilates at 1cm/hr - takes 8hrs (delay < 2cm in 4hrs)
  • Multigravida dilates at 2cm/hr - takes 5hrs (delay < 2cm in 4hrs or slowing in progress)
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2
Q

What is the definition of stage 2 of labour?

Explain the features (i.e. difference between passive and active)

A

Full dilatation to birth of baby

a. Passive
- delivery with no expulsive contractions
- takes a few mins

b. Active
- delivery with expulsive contractions and maternal effort
- other features: anal dilatation, bulging perineum, red congestion mark

Nuliparous - usually 40 mins
Multiparous - usually 20 mins

if delay > 1hr, unlike to have normal vaginal delivery

Delivery

  • head extends (crowns) and perineum stretches (can tear)
  • if slow may have IUGR
  • head rotates 90 degrees to transverse position
  • shoulders delivered
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3
Q

What is the definition of stage 3 of labour?

Explain the features (i.e. difference between physiological and active)

A

From birth of baby to delivery of placenta and membranes

a. Physiology
- no uterotonic drugs or clamping cord (until pulsations stop)
- delivery of placenta by maternal effort (placenta separates from wall + uterus contracts down to prevent haemorrhage, normal blood loss 500ml)

b. Active
- Uterotonic drugs such as IM syntometrine (oxytocin)
- Delayed cord clamping and cutting of cord (until baby’s circulation is independent of mothers)
- Controlled cord traction
- Decreases risk of haemorrhage and shortens 3rd stage

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4
Q

What is the average duration of stage 1 labour for primigravida and multigravida women?

How do you know if its delayed?

A

5 hours - multigravida (delay if <2cm in 4hrs or slowing in progression)
8 hours - primigravida (delay if <2cm in 4 hrs)

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5
Q

What are the features of active stage 2 of labour?

A

Maternal effort
Expulsive contractions
Bulging perineum, Anal dilatation, Red congestion mark

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6
Q

What is the average duration of stage 2 labour for primigravida and multigravida women?

How do you know if its delayed?

A

20 mins - multigravida
40 mins - primigravida

Delay if > 1hr - normal vaginal delivery is therefore unlikely

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7
Q

what is normal blood loss during physiological 3rd stage of labour?

A

500 ml

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8
Q

Which cell creates foetal lung surfactant and at what age? What is its function

A

24 weeks - T2 pneumocytes create foetal lung surfactant stimulated by foetal gluco-corticoid and thyroid hormones.

Lung surfactant - decreases surface tension at liquid/air interface

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9
Q

Does the mother or foetus blood have a high O2 conc?

A

Foetal - higher concentration of oxygen due to foetal Hb (HbF) has higher concentration and affinity

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10
Q

What is the monitoring offered to low risk pregnancy?

A

Intermittent monitoring of foetal HR using a Pinard Stethescope (Sonicaid) or Doppler USS

  • Monitor for 1 minute after every contraction
  • Interval of 15 minutes
  • record any accelerations or decelerations
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11
Q

How is a high risk pregnancy detected?

A
  1. Maternal uterine artery doppler
    - 23 weeks
    - uterine.a pressure is normally low resistance
    - increased resistance indicates pre-eclampsia, placental abruption or IUGR
  2. Blood test
    - B-HCG and AFP measured
    - Raised AFP indicates neural tube defect and increased risk for pregnancy
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12
Q

How does the baby move through the uterus from start to finish? (manoeuvres)

A

Don’t Forget I Eat Rhubarb In Labour

Descent 
Flexion 
Internal rotation of head 
Extension of head 
Restitution 
Internal rotation of shoulder 
Lateral flexion
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13
Q

Name some of the indications for high risk monitoring?

A

POP HAMM CSF

Prolonged stage 1 or 2 of labour Evidence of Use of Oxytocin
Prolonged period since rupture of membranes > 24hrs

Hypertension > 160/110
Abnormal intermittent foetal monitoring
Meconium stained liquor or bleeding
Multiple pregnancy or IUGR

Chorioamnionitis, Sepsis or Fever > 38

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14
Q

What are the features of a normal CTG?

A

Baseline Rate: 100-160bpm (usually ~ 130bpm)
Assess Variance: ≥ 5
Accelerations: present (not necessarily bad if absent)
Decelerations: none or early

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15
Q

What are the features of a non-reassuring CTG?

A

Baseline Rate: 161-180
Assess Variance: < 5 for 30-90mins
Accelerations: present or absent
Decelerations: Variable (>60bpm for <30mins) or Late (>60bpm for <30mins for >50% contractions)

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16
Q

What are the features of abnormal CTG?

A

Baseline rate: > 180 (tachycardia) or < 100 (bradycardia)
Assess Variance: < 5 for > 90mins
Accelerations: present or absent
Decelerations: Non-reassuring decelerations or Late (>60bpm for >30mins for >50% contractions)

17
Q

What is the definition of normal, non-reassuring and abnormal CTG?

A

Normal = all four features are normal

Suspicious (non-reassuring) = one feature is classed as non-reassuring, remaining are normal

Pathological (abnormal) = two or more features are classed as non-reassuring or one or more features classed as abnormal

18
Q

What are the actions you can take if you are worried about foetal wellbeing following?

A
  1. Move maternal position - mobilise or lateral position
  2. Give fluids and oxygen (if required)
  3. Paracetamol (if pyrexic)
  4. Foetal scalp stimulation - may cause accelerations :)
  5. Reduce contraction frequency by stopping oxytocin infusion - give tocolytic agent (e.g. Terbutaline 0.25mg
  6. Foetal blood sample - pH
  7. Delivery
19
Q

What two features are monitored on foetal blood sample?
What are the requirements to do this?
What will you do for a normal, borderline and abnormal score?

A

pH and Lactate - invasive procedure of sampling blood, requires >3cm dilated

  1. pH
    - normal ≥ 7.25
    - borderline 7.21-7.24
    - abnormal < 7.2
  2. Lactate
    - normal ≤ 4.1
    - borderline 4.2-4.8
    - abnormal ≥ 4.9
  • Abnormal - inform obstetrics and aim to expedite birth
  • Borderline - repeat sample in 30 mins
  • Normal - repeat sample in 1 hour
20
Q

What other tests can be used to determine foetal health and wellbeing? not necessarily during labour (4)

A
  1. Foetal USS
    - measure head and abdo circumference
    - determine features of healthy growth
    - i.e. measure rate of growth (compare scans 2 weeks apart), compare actual growth against expected growth, foetal abdo should stop growing before head
  2. Doppler waveform of umbilical.a
    - measure pressure - should have little resistance
    - increased resistance suggests IUGR, placental abruption or pre-eclampsia
  3. Doppler of foetal waveform
    - measure MCA and ductus venous
    - foetal compromise = low MCA resistance compared to thoracic aorta or renal vessels
  4. USS of foetal biophysical characteristics
    - measure arm and breathing movements, tone and liquor volume
    - each scores 2, max 8 (10 if measured on CTG)
    - Low score = high risk foetal compromise
    - Low liquor volume = high risk of foetal distress during labour
21
Q

What are the types of pain during stage 1 labour

A

Visceral pain - poorly localised + colicky
Uterine contractions (T10-L1)
Due to dilatation and pressure on pelvic organs (L1-S1)

22
Q

What are the types of pain during stage 2 labour?

A

Sharp stabbing - well localised pain
Due to stretching of uterus and pressure on pelvic organs and floor structures
Via Pudendal nerve + Perineal (S2, 3, 4)

23
Q

What are the non-pharmacological and pharmacological options for pain during labour?

A

Non-pharmacological
1. Acupuncture - do not offer, but do not stop if already started

  1. TENS (transcutaneous electrical nerve stimulation) - do not offer if in established labour
  2. Hydrotherapy - labour in water 37^o, must monitor temp hourly

Pharmacological

  1. Entonox - NO/O2
    - quick onset + offset
    - SE - amnesia, light headed, dizzy, nausea
  2. Opioids - pethidine, morphine, MST, diamorphine
    - SE mother - nausea, vomiting, constipated, respiratory depression
    - SE baby - short term resp depression, drowsy (may last weeks)
24
Q

What is the difference between a spinal and epidural block?

A
  1. Epidural
    - Injection of LA ± opioid into epidural space at L3/4
    - Administered via epidural catheter
    - Bupivicane and Fentanyl used to induce
    - Provides complete sensory (except pressure) and partial motor block from upper abdomen downward
    - requires CTG monitoring for 30 mins post admin during establishment of analgesia + for every further 10mls injected
  2. Spinal
    - Injection of LA into subarachnoid space into CSF
    - L3/L4
    - preferred analgesia for CS (if epidural not already in place)
    - More dense block
25
Q

What are the absolute and relative contraindications of regional block?

A

Absolute

  • Anti-coagulation or bleeding disorder
  • LA anaphylaxis
  • Local or severe systemic infection
  • patient refusal

Relative

  • Massive haemorrhage
  • Spinal surgery
26
Q

What are the possible complications from regional block?

A

Immediate

  • LA toxicity - tinitis, tingling around mouth, numb tongue
  • Total spinal analgesia - LA runs upwards and causes paralysis of C3, 4, 5 and causes respiratory paralysis
  • Hypotension

Delayed

  • Spinal tap - puncture of dura causes headache (post-dural puncture headache PDPH)
  • Infection
  • Haematoma
  • Neuro damage
27
Q

What are the Absolute and Relative contraindications for IOL?

A

Absolute

  • Pelvic obstruction
  • Placenta praaevia
  • Abnormal or unstable lie
  • Acute foetal compromise

Relative

  • Previous CS
  • Breech
  • Prematurity
  • High Parity
28
Q

What are the Absolute and Relative contraindications for IOL?

A

Absolute

  • Pelvic obstruction
  • Placenta praaevia
  • Abnormal or unstable lie
  • Acute foetal compromise

Relative

  • Previous CS
  • Breech
  • Prematurity
  • High Parity
29
Q

What scoring system is used during IOL?

A

Bishops score

  • Group of measurements following vaginal exam to determine cervical ripeness and chance of success for IOL
  • Measures: cervical position, effacement, dilatation, station, consistency
  • Score > 8 = good
  • Score > 5 = acceptable
  • Score < 5 = may require interventions for ripening e.g. prostaglandins, oxytocin, membrane sweep
30
Q

What are the predictors of successful IOL?

A

Gestational age
Parity
Bisops score

31
Q

What is the ideal process of IOL (i.e. prior to rupture of membranes and oxytocin)? (4 stages)

A
  1. Monitoring and assessment
    - CTG measuring HR and contractions 30 mins before and after PGE is given
    - Bishop score
    - Palpate umbilical cord - reduce risk of cord prolapse
  2. Analgesia
    - IOL more painful than normal delivery - consider epidural, spinal, opioids if not already
  3. Membrane sweep
    - separate chorionic membrane from cervix decide
    - releases PG to promote cervical ripeness and contractions
    - nulliparous offer at 40-41 weeks
    - multiparous offer at 41 weeks
  4. PGE2
    - administer PGE2 into posterior fornix of vagina
    - tablet (3mg), gel (2mg) or pessary
    - 2 doses max
    - give 2nd dose if not in labour 6hrs first dose
32
Q

What is the ideal process of IOL (i.e. prior to rupture of membranes and oxytocin)? (4 stages)

A
  1. Monitoring and assessment
    - CTG measuring HR and contractions 30 mins before and after PGE is given
    - Bishop score
    - Palpate umbilical cord - reduce risk of cord prolapse
  2. Analgesia
    - IOL more painful than normal delivery - consider epidural, spinal, opioids if not already
  3. Membrane sweep
    - separate chorionic membrane from cervix decide
    - releases PG to promote cervical ripeness and contractions
    - nulliparous offer at 40-41 weeks
    - multiparous offer at 41 weeks
  4. PGE2
    - administer PGE2 into posterior fornix of vagina
    - tablet (3mg), gel (2mg) or pessary
    - 2 doses max
    - give 2nd dose if not in labour 6hrs first dose
33
Q

If the previous four methods fail, how then do you proceed with IOL?

A
  1. Artificial rupture of membranes (ARM)
    - using amnihook rupture membranes with aim to release prostaglandins and promote cervical ripening and contractions
    - 88% go into labour immediately
  2. Oxytocin
    - if after 2hrs primip or 4hrs multip no uterine contractions then give IV Oxytocin infusion
  3. Monitor during this period using CTG
34
Q

What are the complications of IOL?

A
  1. Uterine hyperstimulation - can reduce using tocolytics (terbutaline or nifedipine)
    - -> Uterine rupture (rare) - emergency CS
    - -> Foetal distress
  2. Infection
  3. Pain or discomfort
  4. Cord prolapse
  5. PG side effects: diarrhoea, nausea, vomiting, bronchoconstriction
35
Q

What is the maximum amount of doses of PGE2 can you give?

A

2 doses

GOSH (14 decks)

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