Partogram, analgesia, monitoring, CS category Flashcards
What is a partogram?
Pictorial represenation of labour
Helps to identify pathological labour and allows for earlier intervention
Variations of the partogram exist but most derive from Friedmans curve
More recent versions include colour coded sections on the graph to represent normal progress (green),need for greater vigilence (amber), dangerously slow progress (red)
Partograms are used to record ALL observations made when a woman is in labour
In 2021 a paper was published in the BJOG regarding the new WHO monitoring tool – Labour Care Guide
What is the alert line?
Mean rate of the slowest progress of labour
What is the action line?
Appropriate action should be taken
If a patient crossed this action line, they were referred into a tertiary unit.
What does the partogram show?
The progress of labor:
cervical dilatation, descent of head and uterine contractions
The fetal condition:
fetal heart rate, color of amniotic fluid and moulding of the fetal skull
Maternal condition:
pulse, BP, temperature, urine output and urine for protein
A separate space is given to enter drugs, IV fluids and oxytocin
What are the stages of the pain pathway?
First stage -
Pain from lower uterine and cervical change
Visceral afferent nerve fibres
T10-L1 Segments
Second stage -
Pain from distension of the pelvic floor, vagina and perineum
Somatic nerve fibres, pelvic splanchnic and pudendal nerve
S2-S4
Non- pharmalogical ways to help the pain pathway
Water:
May help relaxation and contractions feel less painful
Works immediately
Risks of infection (rare)
No manual perineal protection if deliverys in pool (risk of OASI)
Tens:
Gentle electric current passes through pads on their back
Can control strength
Mild tingling feeling,reduce backache in early labour
No associated risks
May reduced the request for further analgesia and need for opioids by 5 hours
Alternative therapies:
Acupuncture, Acupressure and hypnotherapy
Pharmacological ways to help pain pathway
Entonox:
Nitrous oxide and oxygen
Works immediately
Spaced out, nauseas,tiring, mouth dry
Don’t use when pushing
Diamorphine:
IM/SC Injection
Takes around 30 minutes to work, lasts a few hours
Baby – may be sleeping,slow to breathe, poor feeding initially
Mum – sickness, sleepiness
PCIA:
Remifentanil
Requires the patient to press a button everytime they feel a contraction coming
Works within 30s and wears off after a few minutes
Often entonox used as well
Baby – may be slow to breath at first
Mum – sickness, sleepiness, slow breathing, O2 via nasal cannula (pulse ox monitoring)
Where is an epidural given during labour?
Area of nerve block provided by epidural analgesia for contraction pain (T8-10)
Extension to T4 for emergency CS
General area of numbness from a T8-T10 level epidural for contraction pains
Regional
Epidural or combined CSE
Local anaesthetic and a painkiller given through a fine tube in their back
1:10 times it may not work as well and need replacing
Takes around 20 minutes for it to work (CSE is quicker)
Catheter, IVF
Baby – heart rate can be affected if maternal low BP
Mum – multiple risks
Features of feta; monitoring
Should be discussed as part of antenatal care and documented in the patients notes
Perform and document systematic assessment of the womans and baby’s condition every hour (more frequent if concerns)
Fetal heart rate monitoring is guidance only not a diagnostic tool
Remember the whole clinical picture
Initial assessment:
Assess risk factors for fetal compromise at onset of labour
Determine whether Intermittent auscultation or CTG monitoring is preferable
If no identified risk factors:
Increased risk of interventions if continuous CTG is used compared to IA
What is and when do we do intermittent auscultation?
Carry out immediately after a palpated contraction for at least 1 minute
Repeat every 15 minutes in the first stage
Record accelerations and decelerations, if heard
Palpate maternal pulse hourly
If no fetal heart hear, urgent USS
2nd stage of labour:
1 minute every 5 minutes after a contraction
If increase in FHR of 20bpm or more from the start of labour or a decel is heart:
Carry out IA more frequently
Carry out a full clinical review of the situation
If FHR concerns:
Summon help
Advise continuous CTG monitoring
Transfer to CLC
Return to IA if continous CTG is normal after 20 minutes
What is a CTG?
Antenatal CTG Vs Intrapartum CTG
Can restrict mobility/water birth
A normal CTG indicates baby is coping well in labour
Changes to FHR pattern is common and are not necessarily a cause for concern, can represent developing fetal compromise so keep on CTG
Why should we image in pregnancy?
Assess
Maternal anatomy
- Uterus
- Amniotic fluid
Fetal anatomy
- Fetus
- placenta
What do we need imaging for?
Check normality
Assess for abnormality
Management
Treatment
Delivery options
NHS costs
Patient expectations
What are some imaging that you can do for pregnancy?
X- Ray?
CT?
US?
Nuclear Medicine?
MRI?
