Obstetrics Labour Flashcards
What is the criteria for Hyperemesis Gravidarum?
> 5% loss in Pregnant weight
Electrolyte disturbance
Ketosis
What is the scoring system used in Hyperemesis Gravidarum, and what is considered severe?
Pregnancy- Unique Quantification of Emesis
> 12 is severe
How is Hyperemesis Gravidarum managed?
Midl:
- Home
- anti emetics (cyclizine) + oral rehydration
Moderate:
- Day cases
- IV fluid
- IV anti-emetics (metaclopramide)
- IV thiamine
Severe:
- admitted
- IV anti-emetics (ondansetron - carries risk) or really severe: Steroids (Dexamethasone)
- IV fluids
- Pabrinex/ thiamine
- VTE prophylaxis (enoxaparin + stockings)
**note that severe you try antiemetic first then use steroids
What is the criteria for pre-eclampsia?
HTN: >140/>90
Proteinuria: >30 P:C ratio
> 20 weeks gestation
What are the stages of labour?
Stage 1:
- latent stage:
- 3-4cm dilated:
- active stage:
- Regular painful contractions
- Full dilation of cervix >10cm
- Effacement of cervix
- Crowning of baby
Stage 2:
From full cervix dilation to delivery of the head of the baby
*propulsive - head reaches pelvic floor
*Expulsive - mother wants to push
Stage 3:
- From delivery of baby to Delivery of placenta
What are the cardinal movements of the labour?
Prelabour stage:
- occipital lateral position
Engagement
- anterior occipital
- station
Extension of head
Restitution
- turning transverse so shoulders sit antro-posterior
Expulsion
What are the pro-labour hormones?
Oxytocin
- increases for of contractions
- Receptors increase via fetal adrenocorticotrophin hormone
Prostaglandins
- Increase ripening of cervix
- increase uterine contractions
Inflammatory mediators
- promote membrane rupture by collagenases
Oestrogens
What score can be used to assess how “ripe” the cervix is, and when is it used?
Bishops Score
< 3 - not ripe
> 7 ready to deliver
Used when thinking about induction of labour.
If induction was to commenced on a low Bishop score there would be increased risk of:
- prolonged labour
- fetal distress
Takes into account:
- Dilation
- length of cervix
- Consistency (firmness)
- Engagement
- Position of fetus
What is the criteria for labour?
Regular painful contractions
Effacement of cervix
Dilation of cervix
What can be used to assess the maternal and fetal condition during labour?
Partogram
- gives a graphical representation including:
Maternal HR, BP
Fetal HR
Descent
Frequency of contractions
What instrument can be used to assess fetal heart sounds?
Pinard
or
Doppler
How often should the vagina be examined during labour?
Every 4 hours
What is meant by Caput?
Refers to oedema of the scalp during labour owing to pressure of the head against the pelvic rim.
denoted by +, ++, +++
What is meant by Moulding:
Refers to the compression of the head of the fetus during labour, where the individual cranial bones move.
+: bones opposed
++: bones overlap but are reducible
+++: Overlapped and cannot be reduced
What are the clinical progress times of labour?
Stage 1:
Prim - 8- 18hours
Multi - 5.5 - 12 hours
*dilation should continue at 0.5-1cm for prim and >1cm for multi
Stage 2:
Prim - 3 hours
Multi - 2 hours
Stage 3:
30 - 1 hour
What is it called when stages 1 and 2 of labour occur in <2-3 hours, and why is it dangerous?
Precipitate delivery
Can cause fetal distress
What is considered unacceptable dilation rates causing prolonging of labour/ failure to progress?
<2cm in 4 hours
or
<0.5cm per hour
What is the indication for induction of labour?
When the risk of induces labour outweighs continuing pregnancy
- 20% of pregnancy will have this occur
potential causes:
- Failure to progress
- Maternal diabetes
- Twins
- Pre-labour rupture of membranes
- Pre-eclampsia
- Maternal request
What would be some contraindications to induction of labour?
Anything that contraindicates a vaginal birth
- Placenta Previa
- transverse lie
- breech presentation
- cord prolapse
- genital herpes
Caution with:
- previous C section - risk of scar rupture
Why is Continual cardiotocography monitoring required when inducing labour?
Induction can cause uterine contractility reducing blood flow, compromising fetus
What are the methods used for inducing labour?
Bishop score <6:
- Prostaglandins (intra-vaginally).
- repeat if needed
- when >6 move to:
Bishop Score >6:
- artificial rupture of membranes
+
- Syntocinon (Oxytocin)
What is the inhaled analgesia used during labour?
Entonox
- 50:50 of oxygen and nitrogen
What opioid should be used in pregnancy and when should it be avoided?
Diamorphine
Avoid if possible within 4 hours of delivery
When is the APGAR score done?
1, 5, 10 minutes after birth
When is clamping of the umbilical cord?
1 minute
What is the discharge called following post-partum?
Lochia
- mucus
- blood
- uterine tissue
Lochia rubra
- blood stained for first few days
Lochia serosa
- watery discharge for few weeks
Lochia alba
- Yellowish discharge
What are the 7 B’s of post partum care?
Breastfeeding
- aid in assistance
Bladder
- many women may have incontinence following birth
Bowel
- damage from tears
- use of opioids
Bleeding
- Clots
- volume
Blues
- Post partum depression
Bottom
- Damage/ pain
Birth control
When does post partum depression usually begin?
2-4 months following birth
What is the time line for postpartum psychosis and what are some symptoms and risk factors?
<2 weeks post partum
*can occur within hours
Signs of psychosis and mania:
- rapid mood changes
- grandiose delusions
- paranoid delusions -especially towards baby
- hallucinations
- confusion
Risk factors:
- previous psychosis
- Psychotic illness prior to illness
- stopping medication for pregnancy of a mental health
- poor social or relationship networks
What are the options for monitoring the fetus during labour:
CTG
- sensitive to distress but not specific
Fetal electrocardiogram
- more specific, identifying acidosis and need/ not need for delivery
Fetal blood sample
- used in conjunction with CTG
What actions should be taken during labour following abnormal CTG?
Suspicious results:
- correct any underlying causes (maternal hypotension, uterine hyperstimulation)
- change syntocinon infusion
Clearly pathological:
- exclude uterine rupture, cord prolapse
- stop infusions if needed
- Gain fetal blood sample
- consider delivery
Define what caput means?
refers to the change in shape of the skull as the fetus passes through the birth canal
List some reasons for C-section:
Pre-labour:
- placenta previa
- placenta abruption
- severe growth restriction
- pre-eclampsia
- breech presentation
- maternal request
Labour:
- Emergancy
- non-dilating
List some of the pre-operative preparations done for elective C-section:
- IV access
- Group and save / cross match (if large amount of blood loss anticipated)
- Ranitidine + sodium alginate (to prevent aspiration from stomach content)
- VTE prophylaxis (this was a large killer before)
- Antibiotic prophylaxis
- Epidural/ spinal/ GA
- Bladder catherization
What are the complications of a C section:
Short term:
- PPH
- Pain
- Prolonged hospital stay
- Damage to internal organs
Long term:
- reduced chance of vaginal birth
- uterine rupture in future
- placenta previa
- reduced conception
What must be in place prior to an instrumental delivery and name some common causes of a instrumental delivery:
Criteria:
- consent
- fully dilated
- head fully engaged
- position of head known
- bladder empty
- analgesia onboard
Indications:
- fetal compromise (CTG, Fetal cardiograph)
- 2nd stage delay
In Scotland there are certain times abortion is allowed before a referral is needed to England, what are these times?
Medical: 18 weeks
Surgical 13 weeks
referral via PBAS
What are the non-pharmacological things that can be done to reduce PPH?
Early suckling
- stimulates oxytocin release
Rubbing the uterine contraction
- stimulate fundus to contract
What is your immediate management of a new-born?
Clamp cord and cut
Dry baby and wrap warm towel
Record APGAR - 1, 5, 10
Inspect for gross abnormalities
Vitamin K
Hand back to bother for early skin to skin and suckling
