Obstetrics - Labour Flashcards
1
Q
Normal labour definition and characteristics
A
Onset of painful and regular contractions
- Contractions
- Cervical show - Shedding of mucus plug
- ROM
- Shortening and dilation of cervix
2
Q
Hormones in labour
A
Prostaglandins
- Decrease cervical resistance
- Stimulate release of oxytocin from posterior pituitary
Oxytocin - Stimulates uterine contraction
3
Q
Monitoring in labour
A
- Foetal HR - Continuously
- Uterine contractions - 30 minutes
- Maternal HR - 1 hour
- Maternal BP - 4 hours
- Maternal temperature - 4 hours
- Urine - 4 hours
- PV - 4 hours
4
Q
Diagnosis of labour
A
Regular painful contractions
Cervical dilation and effacement
5
Q
Stage 1 labour
A
Onset of true labour to full dilation of cervix
10-16 hours
Latent - 0-3cm - 6 hours
Active - 3-10cm
- 2cm / hour if multiparous
- 1cm / hour if nulliparous
6
Q
Abnormal stage 1 causes
A
Inefficient uterine contractions - Most common in nulliparous
Cephalopelvic disproportion - Most common in multiparous
7
Q
Management of inefficient uterine contractions
A
Augment labour
- Amniotomy
- Syntocinon
8
Q
Cephalopelvic disproportion causes, presentation and management
A
Causes
- Malposition
- Malpresentation
- Inadequate pelvis
- May lead to secondary arrest
Signs - Caput and moulding
Management - CS
9
Q
Stage 2 labour
A
Full dilation of cervix to delivery of baby
Passive - No pushing
Active - Pushing
- 20 minutes if multiparous
- 40 minutes if nulliparous
Transient foetal bradycardia!
10
Q
Abnormal stage 2 diagnosis and management
A
Multiparous > 1 hour
Nulliparous > 2 hours
Management
- Ventouse
- Forceps
- CS
- Episiotomy
11
Q
Stage 3 labour
A
Delivery of foetus to delivery of placenta
15 minutes
12
Q
Stage 3 labour management
A
Physiological - Maternal effort alone
- No synometrine or syntocinon
- Cord allowed to stop pulsating before clamping and cutting
Active - Decreases risk of PPH
- IM synometrine or syntocinon
- Clamping and cutting of cord
- Controlled cord traction - Push down suprapubically to prevent uterine inversion
13
Q
Presentation
A
Part of the foetus occupying the lower segment
90% vertex
Breech
Cephalic
14
Q
Presenting part
A
Lowest palpable part of foetus
15
Q
Position
A
Where the head is in the outlet
Occiput
OA
OP
OT
16
Q
Attitude
A
Degree of head flexion
Brow
Vertex
Face
17
Q
Lie
A
Longitudinal axis of foetus
Longitudinal
Oblique
Transverse
18
Q
Engagement
A
Widest part of the presenting part (usually head) has passed through the widest part of the pelvic inlet
19
Q
Station
A
How far in the pelvis the baby’s head is
20
Q
Movements in stage 2 labour
A
- Engage in OT
- Descent in flexion
- Internal rotation to OA
- Descent in OA
- Crowning
- Extension to deliver
- Internal rotation of shoulders to AP
- Restitution of head - In line with shoulders
- Lateral flexion of shoulder to deliver
21
Q
Induction of labour indications
A
BISHOP SCORE < 5
Maternal
- Post-date > 12 days
- Diabetes > 38 weeks
- Pre-eclampsia
Foetal
- IUGR
- Pre-labour preterm ROM
Rhesus incompatibility
22
Q
Bishop score
A
Spontaneous > 9
Requires induction < 5
Cervical position Cervical consistency Cervical effacement Cervical dilation Foetal station
23
Q
Induction of labour methods
A
Prostaglandins - E2
- Best for nulliparous
- Inserted into post-vaginal fornix
Amniotomy + Oxytocin
- Amniotic hook - Risk of chorioamnitis
- No response on 2 hours - Oxytocin
Cervical sweep - Painful!
- Finger inserted through cervix between membranes and uterus
24
Q
Induction of labour contraindications
A
Maternal - Something in the way?
- Vasa previa
- Cord prolapse
- Placenta previa
- Obstruction - Pelvic mass
- Premature
- Previous CS
Foetal - Distress!
- Abnormal lie
- Malpresentation
25
Induction of labour complications
Slow labour
Fast labour
PPH
Infection
26
Preterm pre-labour ROM
2% pregnancies
Associated with 40% preterm deliveries
ROM < 37 weeks
No contractions
27
PPROM complications
Foetal
- Prematurity
- Infection
- RDS
Maternal - Chorioamnitis
28
PPROM investigations and management
Admit and monitor!
Sterile speculum exam
USS - Assess foetal presentation
CTG - Assess foetal state
Infection swab
Oral erythromycin - 10 days
Dexamethasone - Reduce risk of RDS
Delivery at 34-36 weeks
29
Prolonger labour causes
The Ps!
Power - Nulliparous ladies?
- Insufficient uterine contraction
- Augmentation - Amniotomy + Oxytocin
Passenger
- Malpresentation
- Abnormal lie
Passage - CPD
30
Prolonged labour diagnosis
1st stage
< 2cm / 4 hours
2nd stage
Nulliparous > 2 hours
Multiparous > 1 hour
31
Premature labour definition and RFs
24-37 weeks
RFs
- Smoking
- Previous prem
- Maternal disease
- Maternal age
32
Premature labour aetiology
THE CASTLE!
Too much inside the castle
- Polyhydramnios
- Multiple pregnancy
Defendants flee
- IUGR
- Pre-eclampsia
- Maternal disease
Wall breach
- Cervix - CIN
- Uterine abnormality
Enemy invasion - Infection
33
Premature labour prevention
Cervical cerclage - Sutures
Progesterone - From early pregnancy
Foetal reduction @ 10-14 weeks
Manage maternal disease
34
Premature labour investigations
Assess likelihood of delivery
- Foetal fibronectin
- Transvaginal sonography
Assess foetal state - CTG
Swab for infection
35
Premature labour management
Steroids - Allow lung maturity - Reduce risk of RDS
Tocolytics - Nifedipine - Give the steroids time to work
Magnesium sulphate - Neuroprotection @ 24-34 weeks
36
Premature labour delivery
Vaginal if possible
May require CS - Abnormal lie
Delayed cord clamping - 45 seconds
37
Premature ROM
Term baby
ROM
No contractions
38
Premature ROM aetiology
"I-I-I... Me waters have broken but I'm not having contractions!"
Idiopathic
Infection
Incompetency - Cervical
39
Premature ROM management
Antibiotics
Wait 24 hours
Induce labour
40
Forceps delivery indications
Prolonged 2nd stage
Foetal distress
Abnormal lie
Malpresentation
Prophylactic
- Reduce maternal exhaustion
- Cardiac disease
41
Forceps delivery prerequisites
FORCEPS!
```
Fully dilated
OA
Ruptured membranes
Cephalic
Empty bladder
Pain relief
Size - Baby/pelvis ratio
```
42
CTG monitoring
Baseline HR
Variability
Accelerations
Decelerations
43
CTG findings and management
1 non-reassuring = Non-reassuring
- Left lateral position
- Fluids
- Observe
2 non-reassuring or 1 abnormal = Abnormal and test
- Foetal blood sample
> 2 abnormal or brady < 100 for 3 minutes = Abnormal and treat
- Category 1 CS
44
CTG reporting
DR C BraVADO
```
DR - Define Risk
C - Contractions / 10 minutes
Bra - Baseline rate / 10 minutes
V - Variability
A - Accelerations - Abrupt increase for > 15 seconds
D - Decelerations
O - Overall impression
```
45
CTG variability
Variation from one beat to the next
Normal > 5
Non-reassuring < 5 for 40-90 minutes
Abnormal < 5 for 90 minutes
Causes
- Foetal sleeping
- Foetal acidosis - With late decelerations
- Foetal tachycardia
- Drugs
- Prematurity
- CHD
46
CTG decelerations
Normal - Early
- In line with uterine contractions
Non-reassuring - Variable
- No relationship to uterine contractions
- Cord compression
Abnormal - Late
- Begin at peak of uterine contraction
- Caused by insufficient blood flow to uterus and placenta
- Maternal hypotension
- Pre-eclampsia
- Uterine hyperstimulation
47
CTG baseline rate
Normal - 110-160
Non-reassuring
- 100-110
- 160-180
Abnormal < 100 or > 180
Bradycardia causes
- Increased foetal vagal tone
- Maternal BB use
Tachycardia causes
- Maternal pyrexia
- Chorioamnitis
- Hypoxia
- Prematurity
48
Foetal distress aetiology
Hypoxia of the foetus
Prolonged labour
APH
Cord prolapse
Oxytocin use - Too many contractions - Hypoxia
49
Foetal distress diagnosis
CTG anomaly - Decelerations / bradycardia
Foetal blood pH < 7.2
Meconium stained liquor
50
Foetal distress management
Conservative
- Stop contractions - Terbutaline
- Left lateral position
- Oxygen
- Fluids
Foetal blood sample - Scalp?
pH < 7.2 - Emergency CS
pH > 7.2 - Observe
Brady > 3 minutes - Emergency CS
51
Cord prolapse aetiology
Artificial ROM
Premature labour
Multiparity
Multiple pregnancy
Polyhydramnios
Abnormal presentation - Breech?
Placenta previa
52
Cord prolapse presentation
Cord descends ahead of presenting part
Palpable or visible O/E
Foetal distress on CTG - Variable decelerations
53
Cord prolapse management
Trendelenburg - All fours
Push foetus back up and hold
Tocolytics - Nifedipine
Emergency CS
54
Cord prolapse complications
Cord spasm
Foetal asphyxiation
Brain damage - Death
55
Uterine rupture aetiology
High pressure - Multiple pregnancy
Low resistance
- VBACS
- Previous uterine surgery
56
Uterine rupture presentation
Cessation of contractions
PV bleeding
Abdo pain
Maternal shock
57
Uterine rupture management
ABC
Fluids
CS then...
- Surgical repair
- Hysterectomy
58
Uterine rupture complications
Maternal death
| Foetal hypoxia
59
Post-partum haemorrhage definition
Vaginal blood loss > 500ml
CS blood loss > 1L
Primary < 24 hours
- Uterine atony
Secondary - 24 hours - 2 weeks
- Retained placental tissue
60
PPH causes
TTTTTTTTTTT
Tone
- Large uterus
- Prolonged labour
- Multiparous
- Fibroids
Tissue - Retained placenta
Trauma
- Shoulder dystocia
- Macrosomia
- CPD
- Ventouse
Thrombin - Blood disorders
61
PPH management
```
ABC
Fluids
IV access
FBC
Cross match
```
IV syntocinon
IV ergometrine - CI in HTN
IM carboprost into myometrium - CI in asthma
Abx if caused by endometriosis
Remove retained placenta
```
Balloon tamponade
B-lynch suture
Uterine artery ligation
Hysterectomy
ERCP
```
62
Shoulder dystocia
Impaction of anterior foetal shoulder on maternal pubic symphysis
RFs
- Macrosomia
- Maternal DM
- Maternal obesity
- Prolonged labour
- Previous
- CPD
63
Shoulder dystocia complications
Maternal
- PPH
- Tear
- Psychological
Foetal
- Hypoxia
- Clavicle fracture
- Death
64
Breech presentation types
Frank - Buttocks first
| Footling - Feet first
65
Breech RFs
```
Premature
Foetal anomaly
Multipregnancy
Polyhydramnios
Uterine abnormalities
```
66
Breech management
< 36 weeks - Leave
> 36 weeks
- ECV - Sensitising event
- Tocolytics - Nifedipine
- CS @ 39 weeks
- Can deliver vaginally - On all fours
67
Breech complications
Cord prolapse
PPH
Foetal
- Clavicle fracture
- Brachial plexus palsy
- DDH
68
ECV contraindications
Abnormal CTG
Multiple pregnancy
APH in last 7 days
Major uterine anomaly
Ruptured membranes
CS required
69
Caesarean section indications
Indications
Maternal
- Eclampsia or severe pre-eclampsia
- APH - Previa, accreta, abruption, previa
- Previous CS - Classical scar
- Infection
Foetal
- Distress
- Cord prolapse
- Malpresentation
- IUGR
- Twin
70
CS risks
Maternal
- Bladder damage
- Ureter damage
- Haemorrhage
- Infection
- Death
Later pregnancies
- Need CS
- Accreta
- Uterine rupture
Foetal
- RDS
- Injury
71
Vaginal birth after CS contraindications
Classical CS scar
> 2 CS
Previous uterine rupture
72
VBAC risks
Uterine rupture
| Need for emergency CS
73
VBAC positive predictors
< 2 years since last pregnancy
Low age
Low BMI
Previous successful vaginal delivery
