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Yr4: Obstetrics & Gynaecology > Obstetrics: Labour & Delivery 1 > Flashcards

Obstetrics: Labour & Delivery 1 Flashcards

1
Q

At what gestation does labour and delivery normally occur?

A

37 - 42 weeks gestation

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2
Q

State, and define, each of the 3 stages of labour

A
  • First stage: onset of labour (true contractions) until 10cm cervical dilation
  • Second stage: from 10cm cervical dilation until delivery of baby
  • Third stage: from delivery of baby until delivery of placenta
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3
Q

What happens to the cervix during the first stage of labour?

What is meant by the ‘show’?

A
  • Dilation (full dilation is 10cm)
  • Effacement (getting thinner)
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4
Q

What is the purpose of the mucus plug?

A

Prevent bacteria entering uterus during pregnancy

***In labour it falls out to create space for baby to pass through

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5
Q

First stage of labour has 3 phases; state and describe each including:

  • Cervical dilation
  • Progression
  • Contractions
A

Latent phase

  • 0-3cm dilated
  • Progresses ~0.5cm/hr
  • Irregular contractions

Active phase

  • 3-7cm dilated
  • Progresses ~1cm/hr
  • Regular contractions

Transition phase

  • 7-10cm dilated
  • Progresses ~1cm/hr
  • Strong & regular contractions
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6
Q

When talking about first stage of labour, NICE talk about the latent first stage and the established first stage; describe what they mean by each in regards to contractions & cervical changes

A

Latent first stage (Passmed says takes about 10-16hrs in primigravida)

  • Painful contractions
  • Changes to cervix: effacement & dilation up to 4cm

Established first stage (Passmed says takes about 6hrs)

  • Regular, painful contractions
  • Dilation of cervix from 4cm onwards
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7
Q

What do we mean by passive second stage and active second stage?

A
  • Passive second stage= 2nd stage but in absence of pushing
  • Active second stage= active process of maternal pushing
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8
Q

State some of the signs of labour

A
  • Show (mucus plug from the cervix)
  • Rupture of membranes
  • Regular, painful contractions
  • Dilating cervix on examination
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9
Q

What are Braxton-Hicks contractions?

What can women do to help reduce Braxton-Hicks contractions?

A
  • Occasional irregular contractions of uterus
  • Usually felt in 2nd & 3rd trimester
  • May be described as ‘tightening’ or ‘mild cramping’ in abdomen
  • Not true contractions & don’t indicate labour. Don’t progress or become regular
  • Staying hydrated & relaxing can help to reduce them
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10
Q

What is the birth canal?

A

Passage between uterus and vagina through which fetus passes through during vaginal birth

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11
Q

Describe how we create a birth canal

A

To create a birth canal cervix must dilate and be retracted anteriorly; two main steps:

  • Effacement: the gradual merging of the cervix into the lower uterine segment- this thins the cervix
  • Dilation: uterine smooth muscle contracts, but then doesn’t relax fully back to pre-contraction length hence with each contraction relaxing length of muscle fibres is shorter. This puts pressure on the cervix and causes dilation of cervix- this is assited by cervical ripening
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12
Q

What is brachystasis?

How does it help formation of the birth canal?

A

Property of uterine smooth muscle in which after contraction, in which muscle fibres shorten, fibres do not then fully relax and return to full pre-contraction length. Consequently, the uterus shortens progressively (particularly the fundal region) and pushes the presenting part of the fetus into the birth canal

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13
Q

Describe the Ferguson reflex

A

**Sensory receptors in cervix and vagina

**Oxytocin makes contractions more frequent and forceful

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14
Q

Describe how the fetus exits pelvis in 2nd stage of labour

A
  1. Descended head flexes as it meets pelvic floor as this reduces the diameter of presentation
  2. Internal rotation (left or right) so that baby’s face now faces down/towards sacrum
  3. Flexed head descends into vulva and stretches vagina and perineum
  4. The head is then delivered (crowning) and as it emerges it rotates back to origin position by external rotation (to face right or left medial thigh of mother) and extends
  5. Restitution occurs: at same time as head rotating externally shoulders also rotate from transverse to anterior-posterior position
  6. Anterior shoulder delivered
  7. Posterior shoulder delivered
  8. Rest of body delivered by lateral flexion as spine bends sideways thorugh curved birth canal
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15
Q

Define the following:

  • Rupture of membranes (ROM)
  • Spontaneous rupture of membranes (SROM)
  • Prelabour rupture of membranes (PROM)
  • Preterm prelabour rupture of membranes (P-PROM)
  • Prolonged rupture of membranes (also PROM)
A
  • Rupture of membranes (ROM): The amniotic sac has ruptured.
  • Spontaneous rupture of membranes (SROM): The amniotic sac has ruptured spontaneously.
  • Prelabour/premature rupture of membranes (PROM): The amniotic sac has ruptured at least 1hr before the onset of labour at ≥ 37 weeks gestation
  • Preterm prelabour/premature rupture of membranes (P‑PROM): The amniotic sac has ruptured before the onset of labour and before 37 weeks gestation (preterm).
  • Prolonged rupture of membranes (also PROM): The amniotic sac ruptures more than 18 hours before delivery.
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16
Q

Discuss the pathophysiology of premature rupture of membranes

A
  • Fetal membranes (chorion & amnion) become weaker at term in preparation for labour
  • Become weaker due to apoptosis and enzymes breaking down collagen
  • Combination of factors can lead to early weakening & rupturing:
    • Early activation of physiological processes
    • Infection
    • Genetic predisposition
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17
Q

In many cases of premature rupture of membranes, there are no identifiable risk factors; however, there are some known risk factors. State some

A
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18
Q

How may a woman with premature rupture of membranes present?

A
  • Hx of broken waters (painless popping sensation then gush of watery fluid from vagina)
  • Gradual leakage of fluid which could present as change in vaginal discharge
  • On speculum examination there is pooling of fluid in posterior vaginal fornix (ensure woman led on couch for at least 30mins before checking)
  • If ask woman to cough may see amniotic fluid expelled from cervix

*NOTE: don’t perform digital vaginal examination in women with suspected PROM or P-PROM due to risk of infection

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19
Q

How is rupture of membranes diagnosed?

A

Clinical diagnosis based on hx and examination. If in doubt, can do additional tests e.g.:

  • Insulin-like growth factor-binding protein-1 (IGFBP-1): is a protein present in high concentrations in amniotic fluid, which can be tested on vaginal fluid if there is doubt about rupture of membranes
  • Placental alpha-microglobin-1 (PAMG-1) is a similar alternative to IGFBP-1

Ultrasound may also be useful to show oligohydramnios

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20
Q

Discuss the management of premature rupture of membranes (just asking about premature rupture of membranes, will cover preterm labour in separate FC)

A

Management depends on gestation as it is a balance between risk of infection and increasing gestation time for fetus.

All women, regardless of gestation, should have:

  • Monitoring for signs of clinical chorioamnionitis
  • High vaginal swab to check for group B strep
    • If GBS isolated then clindamycin/penicillin during labour
  • Oral erythromycin 250mg QDS for 10 days or until labour established (whichever sooner)

Gestation specific management:

  • >36 weeks: ~60% go into labour naturally so can observe for 24hrs then consider IOL
  • 34-36 weeks: maternal corticosteroids up to 34+6, IOL and delivery recommended
  • 24-34 weeks: maternal corticosteroids, aim for expectant management until 34 weeks
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21
Q

State some potential maternal and fetal complications of PROM

A

The outcome of PROM generally correlates with the gestational age of the fetus.

The majority of women at term will enter spontaneous labour within 24 hours after membrane rupture, but there is a greater latency period the younger the gestational age. This pre-disposes to a greater risk of maternal and fetal complications:

  • Chorioamnionitis – inflammation of the fetal membranes, due to infection. The risk increases the longer the membranes remain ruptured and baby undelivered.
  • Oligohydramnios – this is particularly significant if the gestational age is less than 24 weeks, as it greatly increases the risk of lung hypoplasia.
  • Neonatal death – due to complications associated with prematurity, sepsis and pulmonary hypoplasia.
  • Placental abruption
  • Umbilical cord prolapse
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22
Q

P-PROM has higher rates of complications than PROM. State some potential maternal and fetal complications of preterm prelabour rupture of membranes

A
  • Maternal: chorioamnionitis
  • Fetal: prematurity, infection/sepsis, pulmonary hypoplasia
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23
Q

There are two options for prophylaxis of premature labour: vaginal progesterone and cervical cerclage. For vagina progesterone as prophylaxis for pre-term labour, discuss:

  • How it is given
  • How it works
  • Who it is offered to
A
  • Vaginally (via gel or pessary)
  • Decreases activity of myometrium and prevents cervix from remodelling in preparation for delivery
  • Women with cervical length <25mm on transvaginal ultrasound between 16-24 weeks gestation
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24
Q

There are two options for prophylaxis of premature labour: vaginal progesterone and cervical cerclage. For cervical cerclage as prophylaxis for pre-term labour, discuss:

  • What it involves
  • Who it is offered to
  • When may rescue cervical cerclage be offered
A
  • Put stitch in cervix to add support & keep it closed (need spinal or general anaesthetic). Stitch removed when woman goes into labour or reaches term
  • Women with cervical length <25mm on transvaginal ultrasound between 16-24 weeks gestation who have had previous birth or cervical trauma (e.g. colposcopy, cone biopsy)
  • “Rescue” cervical cerclage may also be offered between 16 and 27 + 6 weeks when there is cervical dilatation without rupture of membranes, to prevent progression and premature delivery.
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25
Q

Preterm labour with intact membranes involves regular painful contractions and cervical dilation without rupture of the amniotic sac; discuss how premature labour with intact membranes is diagnosed (think about how diagnosed at different gestations)

A
  • <30 weeks gestation: clinical assessment enough to diagnose
  • >30 weeks gestation, two options:
    • Transvaginal ultrasound to assess cervical length; if >15mm preterm labour is unlikely
    • Fetal fibronectin is an alternative (fetal fibronectin is glue between chorion and uterus and is found in vagina during delivery. <50ng/L preterm labour unlikely)
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26
Q

Discuss the options for improving outcomes in preterm labour

A
  • Fetal monitoring: CTG or intermittent auscultation
  • Tocolysis with nifedipine: supresses labour
  • Maternal corticosteroids: offered before 35 weeks gestation to help mature fetal lungs
  • IV magnesium sulphate: offered before 34 weeks gestation for fetal neuroprotection
  • Delayed cord clamping or cord milking: increased circulating blood volume & Hb in baby at birth
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27
Q

What do we mean by tocolysis?

State two medications that can be used for tocolysis

When can tocolysis be used?

A
  • Use of medications to stop uterine contractions
  • Medications:
    • Nifedipine (1st line)
    • Atosiban- an oxytocin receptor antagonist (alternative)
  • Between 24 and 33+6 weeks gestation in preterm labour to delay delivery and buy time for things such as administration of maternal steroids, transfer to more specialist unit etc… Only used as short term measure e.g. <48hrs
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28
Q

When are antenatal steroids used?

Why are they used?

State example regime

A
  • Preterm labour <36 weeks gestation
  • Mature fetal lungs to reduce risk of respiratory distress syndrome after delivery
  • Example regime: 2 doses of IM betamethasone 24hrs apart
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29
Q

When is magnesium sulphate used?

Why is it used?

How is it given?

Discuss what monitoring is required

A
  • Preterm babies <34 weeks gestation (CHECK ZtoF says 34, RCOG suggests 29+6)
  • Protect fetal brain during delivery (reduces risk cerebral palsy)
  • Give within 24hrs of delivery as IV bolus, followed by infusion for up to 24hrs or until birth
  • Mother needs monitoring for magnesium toxicity:
    • Reduced respiratory rate
    • Reduces oxygen saturations
    • Hypotension
    • Absent reflexes
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30
Q

What do we mean by induction of labour?

A

Process of starting labour artificially

**Roughly 1 in 5 pregnancies require induction

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31
Q

State some indications for induction of labour

A
  • Prolonged pregnancy e.g. from 40+0 to 40+14
  • Prelabour/premature rupture of membranes
  • Maternal health problems:
    • Pre-eclampsia
    • Obstetric cholestasis
    • Diabetes
  • Fetal problems
    • Intrauterine fetal death
    • Fetal growth restriction
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32
Q

What scoring system is used to determine whether to induce labour? Describe what is included in this scoring system and what different scores suggest

A

Bishop scoring system. Assesses following 5 things:

  • Fetal station (0-3)
  • Cervical position (0-2)
  • Cervical dilation (0-3)
  • Cervical effacement (0-3)
  • Cervical consistency (0-2)

Score <5 indicates labour unlikely to start without induction

Score ≥8 indicates cervix is ripe/favourable and high chance of spontaneous labour or good response to interventions made to induce labour

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33
Q

State 6 options for induction of labour

A
  • Membrane sweep
  • Vaginal prostaglandin E2 (dinoprostone)
  • Cervical ripening balloon
  • Amniotomy
  • Oxytocin infusion
  • PO mifepristone + misoprostol (IUFD occured)
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34
Q

What are some contraindications to induction of labour?

A
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35
Q

For a membrane sweep, discuss:

  • What it involves
  • When it is used
  • Is it a full method of inducing labour?
A
  • Insert finger into cervix to stimulate and begin process of labour. Can be done in antenatal clinic and should produce onset of labour in 48hrs if successful
  • From 40 weeks gestation
  • Not considered full method of inducing labour (more of an assistance before full induction)
36
Q

For vaginal prostaglandin E2 (dinoprostone), discuss:

  • How it is given
  • How it works
A
  • Give vaginal prostaglandins (gel, pessary or tablet)
  • Stimulates cervix and uterus to cause onset of labour. Usually give in hospital so can monitor before sending home to wait for full onset of labour
37
Q

For a cervical ripening balloon, discuss:

  • What it involves
  • When it is used
A
  • Insert silicone balloon into cervix and gently inflate to dilate cervix
  • As alternative to vaginal prostaglandins (usually in women with previous caesarean section, if prostaglandins have failed or ≥3 multiparous)
38
Q

For oxytocin infusion, discuss:

  • When it would be used
A

Only used if contraindications to vaginal prostaglandins or prostaglandins have failed (not a first line option)

39
Q

For amniotomy, discuss:

  • What it involves
  • When it is used
A
  • Use amnihook to artificially rupture membranes; process releases prostaglandins in attempt to stimulate labour. Often given alongside oxytocin infusion
  • Only performed when cervix is ripe. Can be used if contraindications to vaginal prostaglandins or failure of prostaglandins
40
Q

What is the preferred method of induction according to NICE?

A

Vaginal prostaglandins (e.g. dinoprostone)

41
Q

What is used to induce labour when IUFD has occurred?

A

oral mifepristone followed by vaginal prostaglandin dinoprostone or oral or vaginal misoprostol.

*Woman may chose to wait for natural labour, risk of maternal complications e.g. DIC so should have DIC testing twice weekly.

42
Q

What monitoring is done during induction of labour? (2)

A
  • Bishop score: before and during induction to monitor progression
  • CTG: assess fetal HR and uterine contractions before & during induction of labour
43
Q

Most women will give birth within 48hrs of start of induction of labour; true or false?

A

FALSE; most give birth within 24hrs of the start of induction of laobur

44
Q

If, after induction of labour, there is slow or no progress what are the options?

A
  • Further vaginal prostaglandins
  • Amniotomy and oxytocin infusion
  • Cervical ripening balloon (CRB)
  • Elective caesarean section
45
Q

State some potential complications of the induction of labour

A
  • Failure of induction
  • Uterine hyperstimulation (main complication of vaginal prostaglandins)
  • Infection
  • Pain (often more painful than spontaneous labour)
  • Cord prolapse (after amniotomy)
  • Uterine rupture (rare)
46
Q

Uterine hyperstimulation is the main complication of induction of labour with vaginal prostaglandins & oxytocin infusions. Discuss:

  • What it is
  • Criteria often used (although varies between guidelines)
  • Complications
  • Management
A
  • Prolonged & frequent uterine contractions causing fetal distress & compromise
  • Criteria (although varies so check local guidelines):
    • Individual uterine contractions lasting >2minutes in duration
    • >5 uterine contractions every 10 minutes
  • Complications:
    • Fetal compromise → hypoxia, acidosis
    • Emergency caesarean section
    • Uterine rupture
  • Management:
    • Removing vaginal prostaglandins or stopping oxytocin infusion
    • Tocolysis with terbutaline (beta agonist)
47
Q

What do we mean by failure to progress?

Who is it more common in?

A
  • Labour not developing at a satisfactory rate; increase risk to fetus & mother
  • More likely to occur in primips
48
Q

Progress in labour is influenced by the 3P’s (sometimes 4P’s); state these

A
  • Power (uterine contractions)
  • Passenger (size, presentation and position of the baby)
  • Passage (the shape and size of the pelvis and soft tissues)
  • Psyche can be added as a fourth P, referring to the support and antenatal preparation for labour and delivery
49
Q

What parameters define delay in the first stage of labour?

A

Delay in the first stage of labour is considered when there is either:

  • Less than 2cm of cervical dilatation in 4 hours
  • Slowing of progress in a multiparous women
50
Q

What is used to monitor progress in first stage of labour? Describe what is included in this monitoring

A

Partograms which record:

  • Cervical dilatation (measured by a 4-hourly vaginal examination)
  • Fetal station (descent of the fetal head in relation to the ischial spines)
  • Maternal pulse, blood pressure, temperature and urine output
  • Fetal heart rate
  • Frequency of contractions
  • Status of the membranes, presence of liquor and whether the liquor is stained by blood or meconium
  • Drugs and fluids that have been given
51
Q

How are uterine contractions measured?

A

Number of contractions in 10 minutes

52
Q

There are two lines on the partogram; state the name of each line and what each indicates

A
  • Alert line: if goes to R progressing at <1cm per hr. indication for amniotomy & repeat examination in 2hrs
  • Action line: escalate to obstetric-led care

CHECK

53
Q

Success in second stage of labour depends on the 3P’s (power, passenger and passage). What parameters define delay in the second stage of labour?

A

Delay in the second stage is when the active second stage (pushing) lasts over:

  • 2 hours in a nulliparous woman
  • 1 hour in a multiparous woman
54
Q

What is meant by power (when talking about 3P’s)?

A

Strength of uterine contractions

55
Q

What is meant by passenger (when talking about 3P’s)?

A

Four qualities of fetus:

  • Size (larger babies more difficult to deliver. Size of head most important)
  • Attitude (posture of fetus e.g. how rounded back is, how head and limbs are flexed)
  • Lie (longitudinal, transverse, oblique)
  • Presentation (cephalic, shoulder, breech [complete, Frank, Footling])

*Hint for remember breech presentations: complete breech= cannonball, Frank is folded)

56
Q

What is meant by passage (when talking about 3P’s)?

A

Size & shape of passageway (mainly pelvis)

57
Q

If there are problems in the second stage of labour, what interventions may be required?

A
  • Changing positions
  • Encouragement
  • Analgesia
  • Oxytocin
  • Episiotomy
  • Instrumental delivery
  • Caesarean section
58
Q

What parameters define delay in the 3rd stage of labour?

A

Delay in the third stage is defined by the NICE guidelines (2017) as:

  • More than 30 minutes with active management
  • More than 60 minutes with physiological management
59
Q

There are two options for the 3rd stage of labour; describe each

A
  • Physiological management: placenta delivered by maternal effort
  • Active management: midwife or doctor assists with delivering placenta
60
Q

Who is active management of the 3rd stage offered to?

A
  • Routinely offered to ALL WOMEN to reduce risk PPH
  • Also initiated if:
    • Haemorrhge
    • >60 minute delay in delivery of placenta/prolonged 3rd stage
61
Q

What is involved in the active management of the 3rd stage of labour?

A
  • IM oxytocin after delivery of baby
  • Cord clamped (1-3 minutes after delivery, but within 5 minutes)
  • Palpate abdomen for uterine contraction. Once uterus is contracting, controlled cord traction (stopping if resistance) whilst simultaneously using other hand to put put pressure on uterus- pushing it up/opposite direction to prevent uterine prolapse
  • After delivery, uterus massaged until contracted & firm
62
Q

Failure to progress is managed by experienced midwives and obstetricians; state the main options for failure to progress

A
  • Amniotomy, also known as artificial rupture of membranes (ARM) for women with intact membranes
  • Oxytocin infusion
  • Instrumental delivery
    • Ventouse
    • Forceps
  • Caesarean section
63
Q

Oxytocin is used 1st line to stimulate uterine contractions during labour, discuss:

  • How it is given
  • Aim
  • What must be monitored throughout
A
  • IV infusion, start at low rate then titrate up at intervals of at least 30mins as required
  • Aim: 4-5 contractions per 10 minutes
  • Condition of fetus via CTG as too many contractions may lead to fetal compromise as fetus doesn’t have opportunity to recover between contractions
64
Q

Summarise some of the options for pain relief in labour

A
  • Antenatal classes (help prepare woman. More in separate FC)
  • Simple analgesia (e.g. paracetamol. Avoid NSAIDs)
  • Non-opioid analgesia (e.g. codeine)
  • Gas & air (entonox)
  • Opioids (e.g. IM pethidine or diamorphine. Or PCA IV remifentanil)
  • Epidural
65
Q

Explain how antenatal classes can help woman manage pain during labour

A

Antenatal classes help prepare women for what to expect in labour, and can make the experience more comfortable and less scary. Several things can improve the symptoms without medications:

  • Understanding what to expect
  • Having good support
  • Being in a relaxed environment
  • Changing position to stay comfortable
  • Controlled breathing
  • Water births may help some women
  • TENS machines may be useful in the early stages of labour
66
Q

Gas & air (entonox) is often used for pain relief in labour. Discuss:

  • What it is
  • How taken
  • Side effects
A
  • 50% nitrous oxide, 50% oxygen
  • Used during contractions for short term pain relief, take deep breaths using mouthpiece at start of contraction and stop when contraction ends
  • Side effects: light-headedness, sleepiness, nausea
67
Q

What opioids can be given as IM injections for pain relief in labour?

State some side effects

A
  • IM pethidine or diamorphine
  • Side effects:
    • Mother → drowsiness, nausea
    • Fetus/baby → respiratory depression (if given too close to birth) which may make 1st feed more difficult
68
Q

What opioid can be given in form of PCA during labour?

How does pt use it?

What precautions must be in place?

A
  • IV remifentanil
  • Press button at start of contraction to administer bolus
  • Needs:
    • Careful monitoring
    • Input from anaesthetist
    • Naloxone available for respiratory depression
    • Atropine available for bradycardia
69
Q

Remind yourself what layers an epidural goes through

A
  • Skin
  • Subcutaneous tissue
  • Supraspinous ligament
  • Interspinous ligament
  • Ligamentum flavum

… into epidural fat in epidural space

70
Q

What is involved in an epidural?

What medications are often used in epidurals during labour?

A
  • Insert catheter into epidural space and local anaesthetic medications are infused into epidural space
  • Usually levobupivacaine or bupivacaine (a local anaesthetic) mixed with fentanyl
71
Q

State some adverse effects of epidurals

A
  • Headache after insertion
  • Hypotension
  • Motor weakness in the legs
  • Nerve damage
  • Prolonged second stage
  • Increased probability of instrumental delivery

**NOTE: women need urgent anaesthetic review if develop significant motor weakness (e.g. unable to straight leg raise) as may be inserted into SA space

72
Q

Next few FC are summary of common drugs used in labour

A
73
Q

Remind yourself for oxytocin:

  • Where it is released from
  • Role in labour & post-natal period
  • Indications for oxytocin infusion
  • Indications for oxytocin IM
  • Brand name for oxytocin
A
  • Produced by hypothalamus but stored and released by posterior pituitary
  • Roles:
    • Labour → ripening of cervix & contractions of uterus
    • Post-natal → lactation
  • Indications for oxytocin infusion:
    • Induce labour
    • Progress labour
    • Improve frequency or strength of uterine contractions
    • Prevent or treat PPH
  • Oxytocin IM in active management 3rd stage
  • Syntocinon
74
Q

State some side effects of oxytocin

A

Common or very common

  • Arrhythmias; headache; nausea; vomiting

Rare or very rare

  • Dyspnoea; hypotension; rash
75
Q

Ergometrine can be used in labour. Discuss:

  • Mechanism of action
  • When it may be used
  • Side effects
  • What other medication may be given with as a combined drug
A
  • Derived from ergot plants & stimulates smooth muscle contraction in both uterus & blood vessels
  • Uses:
    • Active management 3rd stage
    • Prevent PPH
  • Side effects (due to action on blood vessels):
    • Hypertension
    • Angina
    • Diarrhoea
    • Vomiting
  • Syntometrine is combination drug of oxytocin & ergometrine
76
Q

Remind yourself of:

  • Role of prostaglandins in labour & delivery
  • Key prostaglandin to be aware of
  • Forms can be given in
A
  • Stimulate uterine contractions
  • Prostaglandin E2 (dinoprostone)
  • Forms:
    • Vaginal pessaries
    • Vaginal gels
    • Vaginal tablets
77
Q

For misoprostol, discuss:

  • Mechanism of action
  • Indications/uses
A
  • Prostaglandin analogue so binds to prostaglandin receptors & activates
  • Used alongside mifepristone in:
    • Abortions
    • Induction of labour after IUFD
78
Q

For mifepriestone, discuss:

  • Mechanism of action
  • Indications/uses
A
  • Anti-progestogen that blocks action of progesterone hence halts pregnancy and ripening of cervix. Also enhances effects of prostaglandins
  • Used alongside misoprostol in:
    • Abortions
    • Induction of labour after IUFD
79
Q

For nifedipine, discuss:

  • Mechanism of action
  • Uses
A
  • Calcium channel blocker that reduces smooth muscle contractions in blood vessels & uterus
  • Uses:
    • Reduce BP in pregnancy
    • Tocolysis in premature labour
80
Q

For terbutaline, discuss:

  • Mechanism of action
  • Uses
A
  • Beta-2 agonist that stimulates beta-2 adrenergic receptors; acts on smooth muscle of uterus to supress uterine contractions
  • Uses:
    • Tocolysis in uterine hyperstimulation
81
Q

For carboprost, discuss:

  • Mechanism of action
  • Uses
A
  • Synthetic prostaglandin analogue that stimulates uterine contraction (IM ijection)
  • Uses:
    • PPH when ergometrine & oxytocin inadequate

*NOTE: avoid or caution in those with asthma as can cause sevee asthma attack

82
Q

For tranexamic acid, discuss:

  • Mechanism of action
  • Uses
A
  • Antifibrinolytic that binds to plasminogen and prevents it converting to plasmin to reduce bleeding (remember plasmin is enzyme that breaks down fibrin in clots)
  • Uses:
    • Prevention & treatment PPH
83
Q

State some methods of fetal monitoring during labour

A
  • Intermittent auscultation with pinards every 15 mins (at least 1 minute after a contraction)
  • CTG
  • Fetal scalp electrode
  • Fetal blood sampling
84
Q

State some indications for CTG

A
  • Sepsis
  • Maternal tachycardia (> 120)
  • Significant meconium
  • Pre-eclampsia (particularly blood pressure > 160 / 110)
  • Fresh antepartum haemorrhage
  • Delay in labour
  • Use of oxytocin
  • Disproportionate maternal pain
  • Contractions lasting longer than 60 seconds or greater than 5 in 10
  • Epidural
  • PROM
85
Q

Discuss what you could do if CTG is suspicious

A
  • Perform full set maternal obs
  • Inform senior midwife or obstetriciain
  • Conservative measures:
    • Different position (avoid supine)
    • Mobilise
    • IV fluids
    • Reduce/stop oxytocin
  • NICE states offer digital fetal scalp stimulation but in teaching Miss Malik said they don’t do it
86
Q

If CTG trace is pathological you should do fetal blood sampling, what are you testing for and what are the limits?

A

pH (<7.2 is abnormal)

Lactate (>4.8 is abnormal)

Yr4: Obstetrics & Gynaecology (24 decks)

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