Pregnancy/Parturition Flashcards
1
Q
How would you define Labour?
A
Painful uterine contractions accompany dilation & effacement of the cervix
2
Q
What is the 1st stage of labour?
A
cervix opens to full dilation — allows the head to pass through
3
Q
What is the 2nd stage of labour?
A
full dilation until delivery of the fetus
4
Q
What is the 3rd stage of labour?
A
delivery of the fetus till the delivery of the placenta
5
Q
What are the 3 mechanical factors that influence labour?
A
POWERS - force expelling fetus
PASSAGE - demensions of the pelvis and resistance of soft tissues
PASSENGER - diameters of the fetal head
6
Q
What problem to do with POWER normally effects nulliparous women?
A
Poor uterine activity is more common
7
Q
How are ischial spines used as landmarks to assess descent of the head? What are the stations?
A
Station 0 - head level with spines
Station +2 - head is 2cm below
Station -2 - head is 2cm above
8
Q
What is the anterior fontanelle known as?
A
bregma
9
Q
What is the posterior fontanelle known as?
A
occiput
10
Q
What is presentation? What are the different ways a fetus can present?
A
Part of the fetus that occupies lower segment or pelvis?
Cephalic (head)
Breech (buttocks)
11
Q
What are the variations of cephalic presentations? What are these known as?
A
Vertex (full flexion)
Brow (poor flexion)
Face (full extension)
known as attitude
12
Q
What is position? What are the different positions?
A
Describes the rotation of the fetus
occipito - transverse
occipito - posterior
occipito - anterior
13
Q
What are Braxton- Hicks contractions?
A
Involuntary contractions of uterine smooth muscle felt throughout 3rd trimester
14
Q
How do prostaglandins help the initiation of labour?
A
decreases cervical resistance
increase release of oxytocin from posterior pituitary - which aids stimulation of contractions
15
Q
What is effacement? What is normally accompanied by?
A
When the normally tubular cervix is drawn up into lower segment until it is flat
normally accompanied by -
i) ‘show’ - pink/white mucus plug
ii) rupture of membranes - release of liquor
16
Q
What occurs during the latent phase of the 1st stage of labour?
A
Cervix usually dilates slowly for first 3cm, takes several hrs
17
Q
What occurs during the active phase of the 1st stage of labour?
A
Average cervical delation is at the rate of
1cm/h in nulliparous women
2cm/h in multiparous women
18
Q
How long should the 1st stage of labour normally last?
A
12hrs
19
Q
What is the passive phase of the second stage of labour?
A
Full dilation until the head reaches the pelvic floor
women experiences desire to push
should last few mins, can be longer
20
Q
What is the active phase of the second stage of labour?
A
mother pushing
comfortable position, but not supine
fetus normally delivered in 40 mins (nulliparous), 20 mins (multiparous)
21
Q
After how long during the active phase of labour does the likelihood of spontaneous delivery decreasE?
A
> 1hr
22
Q
What happens during the 3rd stage of labour?
A
delivery of fetus —- delivery of placenta
lasts around 15 mins and blood loss of 500ml
uterine muscles contract, which compresses blood vessels formerly supplying the placenta
23
Q
What are the stages of perineal trauma? How are they defined?
A
1st degree - minor damage to fourchette
2nd degree - involves the perineal muscle
3rd degree - involves the anal sphincter
4th degree - involves the anal mucosa
24
Q
What are the stages of headmovement during labour?
A
Every Decent Female I Crown Rules Lovingly
engagement
descent
flexion
internal rotation
crown
restitution
lateral flexion
25
What position is the head in at engagement? What position does it rotate to ?
occipito-transverse
rotates 90 degrees to occipito-anterior
in 5% rotates to occipito-posterior
26
During restitution, what position does the head rotate to?
back to transverse before the shoulders are delivered
27
Why the supine position not good for labour?
aortocaval compression : hypotension and fetal distress
28
What measures should be taken into account for the physical well-being of a labouring mother?
Hydration - encourage drinking, IV fluid if epidural used or labour prolonged
Eating discouraged - ranitidine often given
Pyrexia in labour - >37.5 increases risk of neonatal illness, culture of vagina, urine and blood
antipyretics
IV abx is >38 degrees
Encourage urinating, if epidural used, catether may be needed
29
What is associated with inefficient uterine contractions?
Nulliparous Women
Induced Labour
30
How would you manage inefficient uterine action?
Support
Mobility Encouraged
Amniotomy and then Oxytocin
31
What can hyperactive uterine action cause?
Fetal Distress
Labour very rapid
Risk of placental abruption
32
What medications causes the hyperactive uterine action and as a result increased risk of placental abruption?
Oxytocin
Prostglandins
33
How would you treat hyperactive uterine action?
Salbutamol IV or SC
C-Section normally indicated due to fetal distress
34
How would you manage a nulliparous women who is having a slow first stage of labour?
artificial membrane rupture
if fails - IV oxytocin
if full dilation not imminent within 12-16 hrs - C-section
35
How would a occipito-posterior position during labour present?
labour longer
pain
backache
early desire to push
36
How would you manage a occipito-posterior position?
many fetuses auto-rotate to OA or deliver OP
If labour slow, use augmentation
delivery can be done by flexion rather than extension
If fails - C-section
*if in active second stage - ventouse or manual rotation
37
How would you manage a Occipito-transverse position?
If no delivery after an hour
use ventouse rotation
38
How could you diagnose cephalo-pelvic disproportion?
inability to deliver despite
i) presence of adequate uterine delivery
ii) absence of malposition or malpresentation
39
What are some causes of fetal damage during labour?
Fetal hypoxia and distress
Infection/Inflammation
Meconium Aspiration
Trauma
Fetal Blood loss
40
How would you define fetal distress?
pH <7.2 in fetal scalp sample
*however average tends to be 7.22, in reality below 7 is when there is neuro damage
41
Causes of fetal distress?
decrease due to compression
longer labours
placental abruption
hypertonic uterine states
maternal hypotension
42
What are some signs of fetal distress?
Colour of liquor : meconium (pea-soup)
FHR
CTG
Fetal blood scalp sampling
43
Acronym for using CTG to assess fetal distress?
DR C BRAVADO
DR - define risk - e.g. meconium, fever, IUGR
C - contractions - >5/10mins = hyperstimulation
BR - baseline rate - should be 110-160 bpm
V - Variability - should be >5 beats/minute - if prolonged suggests hypoxia
Accelerations - accelerations of fetal heart with movements.contractions are reassurring
Decelerations - 'variable' - vary in timing = cord
compression = hypoxia
'late' - suggestive of fetal hypoxia
Overall Assess - false positive is high, hypoxia confirmed by blood sample
44
What is the protocol for fetal distress?
Intermittent auscultation of FHR (if abnormal, meconium, long/high risk labour) >>>>>
```
Continuous CTG (if sustained bradycardia > deliver)
(if abnormal and simple measures fail > fetal blood sampling
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If abnormal > deliver by quickest route
* oxytocin stopped and contractions stopped with beta-2 agonists
* vaginal exam to exclude cord prolapse
45
What groups are risk for fetal infection?
maternal fever during labour
prolonged rupture of membranes
46
What are complications of meconium aspirate? How would you treat it?
Severe pneumonitis
treat with amniofusion of saline into the uterus
47
What is an inhaled form of pain relief during labour? What are it's side effects?
Entonox - rapid onset
Can cause light-headedness, nausea and hyperventilation
48
What are systemic opiates that can be used during labour? What are some side effects?
Pethidine or Meptid (IM)
Analgesic effect cause small patients to become sedated and confused
Can cause respiratory depression in newborn - can be reversed with naloxone
49
What can spinal anaesthesia be used for? What are some complications associated?
C-section or Instrumental Vaginal Delivery
Hypotension and respiratory paralysis
50
What is epidural anaesthetic? What are it's effects?
Local anaesthetic w or w/o opiates via an epidural space (L3/L4)
Complete sensory and partial motor blockade from upper abdomen downwards
51
What are the disadvantages to epidural anaesthesia?
Increased supervision to check BP and HR
Women bed bound (bed sores)
Decreased bladder sensation - urinary retention
maternal fever more common
Instrumental delivery more likely
transient fetal bradycardia
52
What are the contraindications to epidural analgesia?
Sepsis
Coagulopathy
Active neurological disease
Spinal Abnormal
Hypovolaemia
53
When should a women admit herself for labour?
Painful contractions at 5-10 minute intervals
Membranes have ruptured
54
What is done when a women is admitted for labour?
Hx
Temp
BP
HR
Urinalysis
Presentation checked and vaginal exam performed checked effacement and dilation
Degree of descent assessed
Colour of liquor noted
Every 15 mins check FHR for 1 min
Birth plans and wishes read
55
What is done during the first stage of labour?
Analgesia? - if epidural, catheterization is needed
Fetal liquour colour observed
FHR after a contraction
CTG if high risk
Oxygen, IV Fluid and Left Lateral Position
Oxytocin Stopped
If abnormal HR persists - fetal scalp blood is taken
If there is fetal distress - C-section
Progress assessed 2-4 hourly via vaginal exam
Descent measured by ischial spines and dilation
56
What should be done if there is slow dilation after laten phase?
Artificial Rupture of Membrane
if still slow - oxytocin in nulliparous women
*in multiparous women malpresentation or malposition must be excluded first
If cervix not full dilated by 12 hrs - c-section
57
During the second stage of labour what is instructed to the mother if NO epidural?
'non-directed' pushing - when mother has desire to push
58
During second stage of labour, what is instructed to the mother if there IS epidural?
normal to wait one hour before pushing
| 'directed pushing' - push 3 times for 10 seconds
59
During the second stage of labour when is an instrumental delivery indicated?
Delivery not imminent after 1hr of pushing
If fetal distress
60
In the 3rd stage of labour what is normally given to the mother? What is it's use?
Syntometrine (ergometrine + oxytocin)
Helps uterus contract once the shoulders are delivered
61
How would you define retained placenta?
When the 3rd stage of labour lasts for more than 30 mins
62
What is the management for retained placenta?
If there is partial separation = bleeding w/o external signs, oxytocin infusion is started
In the absence of bleeding =
1. one hour left for natural expression
2. placenta manually removed if not delivered naturally after an hour
63
What are the advantages and disadvantages to the active management (syntometrine) of the 3rd stage of labour?
Disadv - causes maternal vomiting, can be unecessary
Adv - reduces the risk for postpartum haemorrhage
64
What is are the degrees of perineal tear?
1st degree - injury to skin only
2nd degree - involving perineal muscle but not anal sphincter
3rd degree - involving anal sphincter complex
4th degree - anal sphincter and anal epithelium
65
How would you manage the different degrees of perineal tear?
1st and 2nd - sutured under local
3rd and 4th - sphincter repaired under epidural/spinal in operation theatre
abx and laxatives given + analgesia
physio assessment and anal manometry
66
What some risk factors for a 3rd or 4th degree perineal tear?
Forceps
Large Baby
Nullparity
Use of midline episiotomy
67
How would pregnancy be induced using Prostaglandins?
Prostaglandin E2 gel inserted into posterior vaginal fornix
If one does doesn't increase ripeness, another is given 6hrs later
May be more effective if administered in the evening
68
How does an amniotomy work?
Rupture water with amnihook
then oxytocin infusion started within 2h if labour hasn't started
69
What are some fetal indications for induction?
prolonged pregnancy
IUGR
Antepartum Haemorrhage
Poor Obstetrics History
Prelabour rupture of membranes
70
What are some maternal indications for induction?
Pre-eclampsia
Diabetes
Social reasons
In Utero death
71
What are some absolute contra-indications for induction?
abnormal lie
placenta praevia
pelvic obstruction
after 2 or more c-sections
72
What are some relative contra-indications for induction?
One c section
| prematurity
73
After administration of PGE , what other steps should you be taken?
CTG for an hour
Oxytocin commonly required in labour
74
What does a ventouse delivery allow?
Traction during maternal pushing
Allows rotation of head to occipito-anterior position
can be used for most instrumental deliveries
75
What can a Simpson's or Neville-Barnes' forceps do? What is a disadvantage of this kind of forcep?
Grips head at whatever position and allows traction
disadvant - only suitable for occiput anterior position
Otherwise use rotational forceps such as Kieland's
76
What are some disadvantages of Ventouse?
More likely to fail
Chignon
Scalp Lacerations
Cephalhaematomata
Neonatal Jaundice
77
What are some disadvantages of Forceps?
Increased risk of maternal complication
need for analgesia is higher
facial bruising
facial nerve damage
skull and neck fractures
78
What is the disadvantage of changing instruments? When is it indicated?
Increase fetal trauma
Only indicated when ventouse achieved descent but then comes off head
79
What are some general disadvantages of instrumental deliveries?
Vaginal Laceration
Blood Loss
3rd Degree tear
80
What are indications for instrumental vaginal delivery?
Prolonged Second Stage (1hr of pushing has failed)
Fetal Distress
Prophylactic use (women who can't push, cardiac disease etc)
Breech Delivery
81
What increases the risk of instrumental delivery?
Epidural Analgesia
Induction
82
When would you choose forceps or ventouse?
Forceps appropriate unless rotation is needed
83
What are some pre-requisites for instrumental delivery?
head MUST NOT be palpable abdominally
must be at or below ischial spines
cervix must be full dilated
position of head must be known
adequate analgesia
bladder empty
84
What is the common type of C-section? Why would you not do that type of C-section? What is the alternative?
Lower Segment C-Section
If extreme prematurity, Multiple Fibroids and Fetus transverse
Uterus incised vertically - Classical C-section
85
What are indications for C-section?
Prolonged 1st stage (full dilation not imminent by 12 h)
Fetal Distress
86
When is an Elective C-section done? Why?
39 weeks
to reduce risk of neonatal lung immaturity
87
What are some absolute indications for Elective C-Section?
placenta praevia
severe antenatal fetal compromise
uncorrectable abnormal lie
previous vertical c-section
gross pelvic deformity
88
What are some relative indications for Elective C-Section?
breech
severe IUGR
twins
diabetes
previous c-section
older nulliparous patients
89
If less than 34 weeks gestation and delivery needed (severe pre-eclampsia, severe IUGR) which is more appropriate? C -sec or Induction?
C -section
90
What are some maternal and fetal complications assoc. with c-section?
Haemorrhage
Infection of uterus or wound
Visceral, Bladder or Bowel damage
VTE
Increased risk of fetal respiratory morbidity
Fetal lacerations
Bonding and breast-feeding affected
91
How does a c-section affect subsequent pregnancies?
They become increasingly difficult
placenta praevia more common
placenta may implant more deeply
92
Risk factors for Shoulder Dystocia?
large baby
previous shoulder dystocia
high maternal bmi
labour induction
low height
maternal diabetes
instrumental delivery
93
How would you manage shoulder dystocia?
McRobert's manoeurve - hyperextension of mothers legs
Episiotomy
Wood's screw manoeurve
Symphisiotomy
Zavanelli manoeurve - replacement of fetal head and c section
94
What is the risk with untreated cord prolapse?
baby becomes hypoxic
95
Risk factors for cord prolapse?
pre term labour
breech
polyhydramnios
abnormal lie
twin
artificial amniotomy
96
How is diagnosis of cord prolapse made?
FHR becomes abnormal
Cord is palpated vaginally
97
Management for cord prolapse?
presenting part pushed up
tococlytics 0 terbutaline
if cord is out of introitus - keep warm and moist
patient asked to go on all fours
then c-sections
98
What is an amniotic fluid embolism?
When liquor enters maternal circulation
causes anaphylaxis with dyspnoea, hypoxia, hypotension, seizures and cardiac arrest
If woman survives develops - DIC, Pulm Oedema and ARDS
99
What are risk factors for Amniotic fluid embolism?
When membranes rupture
Labour
C-sec
termination
strong contractions in presence of polyhydramnios
100
What is management of amniotic fluid embolism?
Resus and supportive
O2 and fluid IV
FBC, U&E and cross-match taken
patient to ICU
101
What are complications of uterine rupture?
acute fetal hypoxia
massive internal maternal haemorrhage
102
What are risk factors for uterine rupture?
labours with a scarred uterus
classical c-section
deep myomectomy
congenital uterine abnormality
103
How to avoid uterine rupture?
avoid induction
caution using oxytocin on women with previous c -section
104
How would you manage uterine rupture?
Maternal resus - IV fluid and blood
Laparotomy
105
Components of Bishops score?
```
Cervical position
Posterior
Intermediate
Anterior
-
Cervical consistency
Firm
Intermediate
Soft
-
Cervical effacement
0-30%
40-50%
60-70%
80%
Cervical dilation
<1 cm
1-2 cm
3-4 cm
>5 cm
Fetal station
-3
-2
-1, 0
+1,+2
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