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MBBS VI: O&G > Perinatal/intrapartum care > Flashcards

Perinatal/intrapartum care Flashcards

1
Q

What are the different pelvic diameters?

A
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2
Q

What are the different shapes of pelvis?

A
  • Gynecoid pelvis: most common and favorbale for labor. Oval in shape with transverse >AP diameter. Such as pelvis fits naturally into diameters of fetal skull with vertex presentation.
  • Anthropoid pelvis: similra to gynecoid pelvis except the pelvic inlet is ovoid in shape with transverse <AP diameter. Tends to encourage an occipito-posterior position
  • Android pelvis: male lik pevis which has a triangular inlet with beaking near the front. Funnel pelvis in which the pelvic outlet is smaller than the inlet and a side to side narrowing of pelvic canal. Significance: fetus to present with occipito-posterior position and head has difficulty in rotating to anterior position as pelvic canal is narrowed. Funnel shaped pelvis will result in obstructed labor. Contracted pelvis in the pelvic outlet leading to cephalopelvic disproportion at the pelvic outlet. Worse situation is arrest at 2nd stage of labor and will lead to failed instrumental delivery with its disastrious consequence
  • Platypoid pelvis. Plat = flat. Pelvic inlet is kidney shaped and small, and this contracted pelvis makes it difficult for fetal head to enter the pelvis. Clinical significance: contracted pelvis in the pelvic inlet leading to cephalopelvic disproportion (CPD) at the pelvic inlet
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3
Q

What are the different presentations of fetal neck and head?
What are the diameters and presentation?

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4
Q

What are the different types of presentation?

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5
Q

What are the different lies in pregnancy?

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6
Q

What is the different fetal head positions are there in pregnancy?

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7
Q

What is engagement and station?

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8
Q

What are the degrees of moulding?

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9
Q

What is the cause of caput succedaneum?

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10
Q

What are prelabor signs?
What are 3 cardinal signs signifiying onset of labor?

A

Prelabor signs:
* Occasional contractions without pattern: Braxton Hicks contractions = gently contract or relax to build strength so as to warm up. Aware of preterm labor if contraction occurs every 15 mins or less or more than 4-6 within 1 hour.
* Lightening: baby drops deeper into pelvis prior to birth. Mother can breath more easily with baby in pelvis. Less heartburn and urinary frequency.

3 cardinal signs:
* Regular painful uterine contractions: every 3-5 mins for >1 hour or 3-4 contractions/10 mins. Labor is defined as regular painful uterine contraction bringing about progressive cervical changes including cervical effacement and dilatation
* Bloody show
* Spontaneous rupture of membrane (water breaking)

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11
Q

What occurs in 1st stage of labor?

A

Every Decent Female I Employ Doesn’t Really Dance

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12
Q

What are the different phases of 1st stage of labor?
What needs to be monitored and how frequently?

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13
Q

What is the management of abnormal 1st stage?

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14
Q

What occurs in 2nd stage of labor?
What needs to be done by medical team?

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15
Q

What are the stages in 2nd stage of labor?

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16
Q

What are the different approaches for episiotomy?
What are the indications?
What are the complications?

A
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17
Q

What are degrees of perineal tear?
What are the complications?

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18
Q

What is the management of 1-4th perineal tear?
What is post procedure management?

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19
Q

What is the management of delivery after previous 34d/4th perineal tear?

A
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20
Q

What is the management of abnormal 2nd stage?
What is the 3P of prolonged second stage?

A
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21
Q

What are the different instruments used for instrumental delivery?
What level, head descent and position needed?

A
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22
Q

What are the indications for instrumental delivery (maternal and fetal)?
What are the prerequisites for instrumental delivery?

A
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23
Q

Compare between forceps and vacuum extraction

What are the indications for using forceps over vacuum extraction?

A
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24
Q

What is the general features of 3rd stage of labor?
What are 3 signs of placenta expulsion?

A
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25
Q

What is the examination of the placenta during 3rd stage of labor?

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26
Q

What is the active management of 3rd stage?

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27
Q

What is the management of abnormal 3rd stage of labor?

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28
Q

What is the classification of morbid adherence of placenta?

A

 Placenta acreta = Placenta reaches the myometrium
 Placenta increta = Placenta invades into > 50% of myometrium
 Placenta percreta = Placenta reaches serosa of uterus and may even perforate the uterus

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29
Q

What are the complications of manua,l removal of placenta (MROP)?

A

o Post-partum hemorrhage (PPH)
o Uterine perforation
o Introduction of infection into uterine cavity

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30
Q

What are the maternal and fetal indications for induction of labor?

A
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31
Q

What are the contraindications for induction of labor?

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32
Q

What are the methods for induction of labor?

A
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33
Q

What scoring system is used to determine ripeness of cervix?

A

Modified Bishops score

B-ishop
I-ffacement
S-tation
H-ard or soft (consistency)
O-pening (dilatation)
P-resenting part (position)

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34
Q

What situations are the use of prostin vaginal tablet (3mg) and propess vaginal pessary (10mg) as a form of induction of labor restricted to?
What contraindications need to be ruled out?

A

Restricted to following situations
o Singleton pregnancy
o Cephalic presentation
o Term fetus
o Fetus with normal NST
o Nulliparous with Bishop score ≤ 6 or multiparous with Bishop score ≤ 4

Rule out contraindications
* Asthma
* Glaucoma
* Cardiac diseases or allergy

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35
Q

What drugs used for cervical ripening of unfavorable cervix as a form of induction of labor?

A

Prostin vaginal tablet (3mg): 3mg prostin vaginal tablet inserted into the posterior fornix of the vagina 1 day before the planned induction
* Fetal monitoring following admin of prostin: 2 hour continuous tracingo fetal heart is undertaken. In the absence of regular uterine contractions, a normal tracing can be discontinued and the women is allowed to mobilize.
* Cervical assessment performed 6 hours later and repeat 3mg dose can be used if cervix is still not favorable. No more than 2 doses should be used within 24 hours. If labor is still not established, senior staff should be consulted to decide on subsequent management

Propess vaginal pecessary (10mg): sustained release system with 10mg of dinoprostone. 10mg propoess vaginal pessary is inserted into the posterior fornix of the vagina 1 day before the planned induction. Should be removed 24 hours after insertion or in the next morning or if any of the below indications are present
* Regular pain contractions every 3 mins irrespective of cervical change
* Spontaneous rupture of membrnaes
* Antepartum hemorrhage (APH)
* Any suggestion of uterine hyperstimulation or hypertonic uterine contractions
* Fetal distress or suspicious CTG
* Maternal systemic AE of dinoprostone: nausea/ vomiting, hypotension, tachycardia

Do not replace pessary back to vagina if accidentally dislodged and upon dislodgeemnt or removal, the doctor or midwife should check and document if propoess is intact in hte medicla record progress

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36
Q

What is the monitoring after prostin/propess insertion as a form of induction of labor?

A
  • Continous electrical fetal monitoring should be carried out for 2 hours after insertion
  • If patients report painful contractions every 3 mins, CTG should be performed and medical officer should be performed for review
  • Bishop score should be reassesed after 24 hours or the next morning
  • If cervix favorable: artifical rupture of membranes (amniotomy), syntocinon induction: commneced 30 mins after removal of propess if contraction not regular
  • If cervix unfavorable: review with specialist to consider prostaglandin priming of PGE2 induction
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37
Q

What is the assessment of mother and fetus for medical induction or augmentation by syntocinon drip infusion?
What does the procedure involve?

A
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38
Q

How is amniotomy (artificial rupture of membrane) done as a method of induction of labor?
What are the associated risks?

A
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39
Q

What are the maternal and fetal complications of induction of labor?

A
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40
Q

What are the pain pathways in 1st and 2nd stage of labor?

A
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41
Q

What are the different types of non pharmacological pain relief?

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42
Q

What are the systemic analgesics used for management of pain in labor?

A

Nitrous oxide (entonox)
* Non opioid analgeic which is a gas mixture of oxygen and nitrous oxide with 50% each
* Effect is peak at 20-30s and offset in 1 min. Patient instructed to inhale when uterus is starting to contract and continue inhalation until contraction begins to subside for maximal analgesic effect
* Adv: self administered, fast acting and has minimal maternal and fetal side effects. Quickly eliminated via lungs and does not accumulate to cause respiratory depression
* Disadv: nausea, vomiting, dizziness, tetany, hypocapnia and fetal hypoxia after prolonged use. Difficult in second stage of labor when patient has to be alert to push during the contraction

Pethidine: opioid analgesic
* Administerd IV or IM (contraindicated in patients with thrombocytopenia or coagulopathy)
* Adv: offerred when neuraxial analgesia is not an option. Less invasive than neuraxial tecnique.
* Disadv: less pain relief compared to neuraxial technique. Placental transfer of opioids to fetus may cause neonatal respiratory depression which is readily reversible with naloxone.

43
Q

What are the methods of neuraxial analgesics for labor?

A
  • Spinal anesthesia (for C section)
  • Epidural anesthesia (EA top up) for vaginal delivery/caesarean section
  • Combined spinal epidural (CSE)
    — Spinal component = rapid onset of a predictable block
    — Epidural = long lasting analgesia + titrate dose given to the desired effect

Neuraxial technique is the most effective and commonly used therapy for pain relief during labor and delivery

44
Q

What sensory level is required for neuraxial analgesics?

A

T4 = Caesarean delivery, T10 = vaginal delivery

Level required for surgery depends on dermatome level of skin incision and by level required for surgical manipulation.
Low abd incision for C-section is made at T11-12 dermatome but a T4 spinal level is required to prevent pain with peritoneal manipulation since the innervation of peritoneum is up to T4 level.

45
Q

What are the contraindications for neuraxial analgesics in labor?

A
  • Absolute contraindications
    o Increased intracranial pressure (ICP)–>Cerebral herniation
    o Uncontrolled bleeding diathesis–>Epidural or subdural hematoma
    o Severe hypovolemia
    o Patient’s refusal
  • Relative contraindications
    o Spinal or soft tissue infection
    Meningitis/ Osteomyelitis/ Epidural abscess
46
Q

What are the complications of neuraxial analgesics in labor?

A
47
Q

Compare adv and disadv of spinal vs epidural anesthesia?

A
48
Q

What are the different types of abd incision for delivery?

A
49
Q

What are the different types of hysterotomy for delivery?

A
50
Q

When is elective C/S normally done?

A

Elective C/S is usually performed at 38 – 39 weeks of gestation

51
Q

What are the maternal indications for C/S?

A
  • Maternal distress or complications
    o Preeclampsia/ Eclampsia
  • Failure to progress during labor
  • Failed induction of labour
  • Failed instrumental delivery
  • Abnormal placentation
    o Placental previa (< 2 cm from os) o Placental abruption (unstable)
    o Placenta accreta
    o Vasa previa
  • Chorioamnionitis
  • Previous uterine scar or rupture
    o High risk in classical scar, myomectomy that enters uterine cavity or previous history of uterine tear
52
Q

What are the fetal indications for C/S?

A
  • Non-reassuring fetal status
    o Cord prolapse
    o Prolonged bradycardia
  • Fetal malpresentation
    o Breech presentation particular footling breech
    o Transverse fetal lie
  • IUGR
    o Fetus may be in distress when undergoing the stress of labour
  • Macrosomia
    o > 4500 g in women with DM
    o > 5000 g in women without DM
53
Q

What are the maternal request indications for C/S?

A
54
Q

What is the procedures for C/S?

A
55
Q

What is the prophylactic antibiotics for C-section?

A

Administered to patients underoing both elective and emergency C-section.
Standard regimen = cefazolin 1g IV given 15-60 mins prior to skin incision
Alternative regimen for patient with penicillin allergy: clindamycin 600-900mg IV, erythromycin 500mg IV

Additional dose of prophylactic antibiotics may be given 3-4 hours after initial dose if the procedure is lengthy >3 hours or estimated blood loss >1500ml

56
Q

What are the low, medium and high risk patients for thromboprophylaxis for C-section?

A
57
Q

Compare the adv and disadv of vagianal delivery vs caesarean section for maternal and fetal side

A
58
Q

What options are available for delivery in 2nd birth?

A

VBAC (vaginal birth after Cesarean section) is the attempt for vaginal birth in pregnancies after previous C/S: also known as trial of scar. Healed scarred uterus may still not be as strong as the normal unscarred uterus during pregnancy and thus patients are at relatively higher risk of scar rupture.

Majority of women with 1 previous C/S can have a normal udelivery and therefore given a choice of either VBAC or ERCS (elective repeat Caesarean section).

Patient without previous C/S or uterine tear or surgery will not be offered elective C-section in public hospital unless deemed necesary for obstretic indications

59
Q

All patients with previous C/S are recommended to have VBAC unless it has the following indications

A
  • More than 1 previous C/S
  • Previous classical C/S
  • Previous myomectomy with entry into uterine cavity
  • Previous hysterotomy
  • Previous uterine tear
  • Other obstretic indications for C/S
60
Q

What is the success rate of VBAC (vaginal birth after C section)?
What is done if failure of VBAC?

A

Rate of successful vaginal delivery after spontaneous onset of labor following C-section = 72-76%
Chance will be higher and up to 90% in women who have given birth vaginally before.
Chance will be lower in women who require induction or augmentation of labor

Failure of VBAC –> emergency C section will be performed

61
Q

What are the benefits of VBAC?
What are the risks and complications?

A

Benefits of VBAC
* Shorter recovery period
* Shorter hospital stay
* Less bleeding/blood loss
* Less infection/fever
* Less injury to surrounding organs such as bladder, ureter and bowel

Risk and complications
* Scar rupture: after 1 C/S = 0.5-.7%. Risk after 2 C/S = 2.5%
* Rare complication but its chance increases in women having VBAC compared with virtually zero risk in women having ERCS

62
Q

Where does the pathology lie in shoulder dystocia?

A
63
Q

What are the antepartum/intrapartum RF for shoulder dystocia?

A
64
Q

What are the maternal and fetal complications of shoulder dystocia?

A
65
Q

What is the PE of shoulder dystocia?
What are the general treatment principles?

A
66
Q

What is the HELPERR mnemonic for managing shoulder dystocia?

A
67
Q

What are the general features of cardiotography (CTG)?

A
68
Q

What is the baseline rate for cardiotocography and ddx?

A
69
Q

What is variability for cardiotocography?
What is a poor indicator?

A
70
Q

What is accelerations for cardiotocography?
What is a poor indicator?

A
  • Accelerations associated with fetal movement possibly resultng from stimuilation of peripheral proprioceptors, increased catecholamines release and autonomic stimulation of heart
  • Presence of acceleration predicts absence of ongoing hypoxic injury and metabolic acidosis
  • Absence of accleration alone is a poor predictor of hypoxic injury and metabolic acidosis

Conditions associated with absence of acceleration
* Fetal sleep cycle
* Prematurity
* Fetal hypoxia
* Fetal arrhythmia
* Fetal anemia
* Congenital CVS or CNS anomalies

71
Q

What is the physiology and causes for early and late decelerations?

A
72
Q

What is the physiology and causes variable, prolonged and sinusoidal decelerations?

A
73
Q

What is reassuring, non reassuring and abnormal CTG?

A
74
Q

What is the definition of normal, suspicious and pathological CTG?
What is the Mx?

A
75
Q

What CTG features require urgent intervention?

A
76
Q

What are the 4 main tolocytis that are used?

A
  • Nifedipine, atosiban, terbutaline, salbutamol
  • Toco =labor, lysis =dissolve
77
Q

What are the indications for use of tocolytics?

A
  • Preterm labor: delay delivery in the absence of signs or fetal distress for at least 48 hours to enable the effect of corticosteroids to enhance fetal lung maturation. Delay delivery until fetus has reached a gestation when perinatal survival is reasonable such as after 30 completed weeks of gestation
  • External cephalic version: relax the uterus to increase chance of success of ECV
  • Uterine hyperstimulation: relax the uterus rapidly and relieve fetal stress during uterine hyperstimulation
78
Q

Suppression of labor is generally not indicated for what conditions?

A
  • Preeclampsia
  • Placental abruption
  • Chorioamnionitis
  • Gestation >34 weeks
  • Fetal death in utero
  • Fetal malformation where palliative care is plannewd
  • Suspected fetal compromise as deteremined by USG or CTG warranting delivery

Relative contraindications
* Maternal cardiac disease, DM, thyrotoxicosis, ruptured membrane and abnormal fetus

78
Q

What is 1st line tocolytic agent?
MoA?

A

Nifedipine: half life (2-3 hours), maximum dose = 160mg daily
Protocal for acute tocolysis = adalt 20mg PO Q30 min x up to 2 doses, then adalt retard 20mg PO Q8H for up to 48 hours
20mg orally stat followed by 20mg orally after 30 mins if contractions persist, followed by slow release form 20mg orally 30 mins later at every 8 hours for 48 hours as indicated
Protocal for maintenance tocolysis = adalat retard 20mg BD to TDS. Long acting nifedipine 40-60mg orally per day

MoA
* Myometrial relaxation
* Block the influx of Ca2+ through cell membrane –> decrease intracellular free 2+

79
Q

When giving nifedipine as a tocolytic what must be monitored?

A
  • Baseline BP, pulse, RR, temp and FHR
  • Blood tests for CBC and LFT
  • Continuous CTG monitoring
  • Temperature Q4H
  • BP/P Q15min for the 1st hour, then Q30 min for the second hour, than Q1H in the first 24 hours, then q4h when on maintenance dose
80
Q

When to terminate treatment for nifedipine as a tocolytic?
What are the contraindications for use of nifedipine?
What are its side effects?

A

Termination of treatment
* Severe hypotension (stop treatment and IV rehydration with NS or Hartmanns solution)
* Tachycardia >120bpm
* Cannot tolerate side effects of nifedipine

Contraindications
* Significant maternal cardiac disease
* Hypotension
* Liver dysfunction
* Concurrent use of IV betamimetics
* Concurrent use of transdermal nitrates or antihypertensive medications
* Concurrent use of MgSO4

Side effects
* Hypotension (effect on BP is minimal on normotensive patients)
* Reflex tachycardia and palpitations
* Flushing/headache/dizziness
* Nausea
* Dyspnea

81
Q

What is the 2nd line tocolytic agent and what are its indications?

A

Atosiban: oxytocin and vasopressin antagonist

Indications
* Failed tocolysis with nifedipine (CCB)
* Intolerable side effects of other tocolytics
* In utero transfer of patients having preterm labor who has already started on atosiban at other hospitals

82
Q

What is the dosage and moA atosiban (2nd line tocolytic agent)?

A

Initial bolus IV injection: 0.9ml (7.5mg/ml) solution for injection over 1 min
High dose loading infusion: 5ml per vial concentrate for injection x 2 vials, added to 90ml normal saline or 5% dextrose or Hartmann solution
Low dose subsequent infusion: 5ml per vial concentrate for injeection x 2 vials, added to 90ml normal saline or 5% dextrose or Hartmann solution

Up to 3 further re-treatment are permitted

MOA: oytocin receptor antagonist compete with oxytocin for binding to oxytocin receptors in the myometrium and decidua
Prevents the increase in intracellular free Ca2+ that occurs when oxytocin binds to its receptors

83
Q

What must be monitored when using atosiban (2nd line tocolytic) and what are the side effects?

A

Monitoring
* Continous CTG monitoring
* Temperature q4h
* BP/P q15 min for first hour, than q30min

Side effects
* Chest pain
* Pulmonary edema
* Hypotension
* Tachycardia and palpitation
* Dyspnea
* Headache
* Nausea and vomiting

84
Q

When may terbutaline be indicated as a tocolytic?
What is the dosage?

A

3rd line tocolytic agent, 1st line for external cephalic version (ECV) due to faster onset)
Indicated when nifedipine or atosiban failed or cannot be tolerated

Dosage
* 8mg in 500ml of 5% dextrose solution
* The starting dose is 5ug.min increasing the rate at 10-min interval by 20ml/hour until there is evidence of patient response shown by diminution in strength, frequency and duration of contractions. The maximum dose should not exceed 25ug/min or 100ml/hour
* Apart from terbutaline, fluid replacement with Hartmanns solution should be given. Total infusion rate should be maintained 100ml/hour. Individualized adjustment can be made if clinically indicated.
* Drug should be used with caution in diabetics because of its hyeprglycemic effect.

85
Q

What is the moA of terbutaline as a tocolytic?

A

Myometrial relaxation: B2 agonists bind with receptors and increase intracellular adenyl cyclase
Increase in intracellular cyclic adenosine monophosphate activates protein kinase and results in phosphorylation of intracellular proteins,
Resultant drop in intracellular free Ca2+ interferes with the activity of myosin

86
Q

What must be monitored when using terbutaline as a tocolytic?
When is there termination of treatment?
What are the contraindications?
What are the side effects?

A

Monitoring
* Continuous CTG monitoring
* Temperature Q4h
* BP/P q15 min for first hour then q30min
* Check serum Na+, K+, urea, glucose before commencing terbutaline infusion as baseline but infusion can be commenced before results are available. Serum electrolytes and glucose level should be determined at regular intervals q12h.

Termination of treatment
* Severe hypotension
* Tachycardia >120bpm
* Cannot tolerate side effects of terbutaline

Contraindications (specific to B adrenergic agonists)
* Hypotension
* Severe cardiac diseases
* Thyrotoxicosis or taking B blocker for palpitation
* Poorly controlled DM

Side effects
* Hypotension
* Tachycardia and palpitation
* Dyspnea

87
Q

When may salbutamol be used as a tocolytic?
What is its MoA?

A

Considered if patient is allergic to terbutaline or if patients has been on salbutamol infusion when before transferral to our unit
Dosage: 20mg in 500ml 5% dextrose starting at 10ug/min, increasing by 15ml/hour every 10 min to a maximum of 45ug/min.

MoA
* Myometrial relaxation: B2 agonist bind with receptors and decrease in intracellular Ca2+ –> interferes with activity of mysoin light hcain kinase

Monitoring
* Continous CTG monitoring
* Temperature Q4h
* BP/P q15 min for first hour, then q30min
* Check serum Na+, K+, urea, glucose before commencing terbutaline infusion as baseline but infusion can be commenced before results are available: serum electrolytes and glucose level should be determined at regular intervals q12h. In between regular blood taking serum glucose should be further monitored by Hstix Q4h

Contraindications
* Hypotension
* Severe cardiac diseases
* Thyrotoxicosis or taking B blocker for palpitation
* Poorly controlled DM

Side effects
* Hypotension
* Tachycardia and palpitation
* Dypsnoea

88
Q

When is corticosteroids for fetal lung maturation indicated?
What is the lower limit for administration of antenatal cortiosteroids?

A
  • Patients with preterm labor or at risk of emergency or elective deliveries between 26-34 weeks, corticosteroids should be given to the mother for fetal lung maturation

Lower limit for admin of antenatal corticosteroids is 23 weeks of gestation since only a few primitive alveoli are present below this gestation age
Lungs need to have reached a stage of development that is biologically responsive to corticosteroids for it function

89
Q

What is the MoA of corticsteroids for fetal lung maturation?
Is it effective?

A
  • Accelerates the development of tyep 1 and 2 pnuemocytes leading to structural and biochemical changes that improve lung mechanics (maximal lung volume, compliance) and gas exchange
  • Induction of type 2 pneumocytes increases surfactant production by incuding production of surfactant proteins and enzymes necessary for phospholipid synthesis

Effectiveness
* 65% reduction in respiratory distress syndrome for babies delivered >24 hours and <7 days: maximal neonatal benefits are achieved when preterm birth occurs between 24 hours adn 7 days after corticosteroid administration. Efficacy appears to be incomplete <24 hours and appears to decline >7 days
* 20% reduction in RDS for babies delivered <24 hours: tocolysis is therefore indicated to delay delivery in the absence of signs of maternal or fetal distress for at least 48 hours to enable to effect of corticosteroids to enhance fetal lung maturation

Other beneficial effeects: reduce incidence of intraventricular hemorrhage (IVH), necrotizing entercolitis (NEC), sepsis and neonatal mortality

90
Q

What is the regimen and choice of corticosteroids for fetal lung maturation (preterm baby)?

A
  • Standard regimen = betamethasone 12mg IMI q24h for 2 doses
  • Alternative regimen = dexamethasone 6mg IMI 16h for 4 doses: to be used if patient has been given dexamethasone before transferral to our unit or when betamethasone is not available

Betamethasone vs dexamethasone
Dexamethasone is associated with lower incidence of neonatal intracranial hemorrhage but is associated with a higher NICU admission rate –> betamethasone thus remains the standard of choice

91
Q

What are the precautions of using corticosteroids for fetal lung maturation?

A
  • Multiple course of steroid in PPROM may be associated with increase early onset neonatal sepsis
  • Used in caution with combination with tocolytics because of the risk of maternal pulmonary edema
92
Q

Type of C/S

A
93
Q

Indication for classical caesarean section

A
94
Q

What is the tool used to assess for induction of labor?
What score suggests labor will not begin without induction?
What score suggests that labor will likely begin spontaneously?

A

Bishop score is below

Modified Bishop score (position, station, cervical length, cervical dilatation, consistency)

95
Q

What is the 3 classic signs of placental separation?

A
  • Lengthening of the umbilical cord
  • Gush of blood from the vagina signifying separation of the placenta from the uterine wall
  • Change in shape of the uterine fundus from discoid to globular with elevation of the fundal height.
96
Q

What is the concern with doing too much cord traction after delivery of fetus?

A

Ask mother to bear down and gently tug on the umbilical cord to deliver it.
Place a hand on the abd to secure the uterine fundus to prevent uterine inversion. After placental expulsion, massage the uterine fundus to help it contract into a firm globular mass. A flabby fundus suggests atony, which is the most common cause of postpartum hemorrhage. (administer oxytocin 20 units in 500ml saline over 1 hour or 10 units IM)

97
Q

What to inspect for in complete expulsion of placenta?

A
  • Umbilical cord: 2 arteries and 1 vein (thicker)
  • Insertion point of the umbilical cord (smooth side of placenta): central, eccentric, marginal
  • 2 membranes layer: chorion is the outer, opaque, friable membrane that lines the uterus and extends to the edfge of the placenta. The amnion is the smooth, stronger, inner, translucent membrane that covers the umbilical cord.
  • Look for blood vessels leading into the membranes that may suggest a succenturiate lobe is retained in the membranes.
  • Examine maternal surface, ensure all the cotyledons are present, fit together without gaps and with a uniform edge.

Take cord blood samples for BG analysis if baby is born by C section or low Apgar score. Samples for blood group and Rhesus factor will be taken if mother has a Rh-ve blood group.

Where maternal sepsis is suspected or confirmed eg. chorioamnionitis or prolonged membrane rupture, cord samples will be taken for blood culture. Swabs from the fetal and maternal surfaces are also required.

98
Q

Define SROM, PROM and PPROM

A

Spontaneous rupture of membrane when in labor (regular, usually painful, contractions that bring about progressive cervical changes)
Premature ROM: ROM before onset of labor
Preterm PROM: PROM occurring when preterm

99
Q

What to be careful of during controlled cord traction for delivery of placenta?

A

Dont pull too hard during CCT –> risk of uterine inversion
Dont pull on placenta and membran directly –> risk of placenta and membrane breaking apart –> RPOG

100
Q

What are the 3 types of decelerations and their appearance in CTG?
What do they indicate?

A

Late and variable decelerations are pathological and must be managed immediately

Late deceleration: uterine contraction compresses maternal blood vessels which decreases maternal perfusion of intervillous space of placenta. pO2 decreases initiating an autonomic sympathetic reflx to cause peripheral vasoconstriction. Increase in BP stimulates baroreceptors to slow the HR, reduce the CO and return BP to normal
Variable deceleration: compression of umbilical cord –> decreases fetal venous return causing a baroreceptor mediated reflex rise in FHR. Further compression occludes the umbilical arteries causing an abrupt increase in fetal resistance and BP.

101
Q

What is normal variability in CTG?
Causes of reduced variability?

A

Reassuring: 5-25bpm
Non reassuring: less than 5bpm for between 30-50 mins, more than 25bpm for 15-25 mins
Abnormal: less than 5bpm for more than 50 mins, more ethan 25bpm for more than 25 mins

Causes of reduced variability
* Fetal sleeping: should lsat no longer than 40 mins (most common cause)
* Fetal acidosis (due to hypoxia): more likely if late decelerations also present
* Fetal tachycardia
* Drugs: opiates, BDZ, methyldopa
* Prematurity
* Congenital heart abnormalities

102
Q

How to categorize impression of CTG?
What features are included?

A

Reassuring, suspicious or abnormal
Factors incuded:
* baseline HR: 110-160bpm
* Baseline variability: 5-25bpm
* None or early, varaible decelerations with no concerning characteristics for <90 mins

MBBS VI: O&G (109 decks)

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