Problems during Labor Flashcards
Pain Relief in Labor
what to avoid?
AVOID NSAIDS
PEPE Cody
Paracetamol
Entonox
Pethedine or diamorphine (opiods)–>IM (cause respiratory depression in the neonate if given too close to birth.)
Epidural–> levobupivacaine or bupivacaine, usually mixed w/ fentanyl.
Codeine
SE of epidural
- Headache after insertion
- Hypotension
- Motor weakness in the legs
- Nerve damage
- Prolonged second stage
- Increased probability of instrumental delivery
- epidural hematoma
- Your back might be a bit sore for a day or two, but epidurals do not cause long-term backache.
Contraindications of an epidural (6)
- Maternal refusal
- Local and untreated systemic infection
- Coagulopathy (platelets <80, INR>1.4)
- Uncontrolled hypovolaemia or haemorrhage
- Certain spinal surgery and spinal abnormality
- Lack of trained staff to provide safe care
complications of epidural (6)
EPIDURAL HEMATOMA
Lower BP
Urinary incontinence
nerve damage
infection
breathing difficulties
what are the 3 stages of labour?
- The first stage is from the onset of labour (true contractions)–> 10cm cervical dilatation.
- The second stage from 10cm cervical dilatation—> delivery of the baby.
- The third stage is from delivery of the baby to delivery of the placenta.
what are the 4 signs of labour?
- Show (mucus plug from the cervix)
- Rupture of AM
- Regular, painful contractions
- Dilating cervix on examination
what is involved in the First Stage?
Delay in the 1st stage of labour?
Cervical dilation and effacement
The “show” refers to the mucus plug in the cervix, that prevents bacteria from entering the uterus during pregnancy, falling out and creating space for the baby to pass through.
The first stage has 3 phases:
Latent phase: 0→3cm (irregular contractions.)
Active phase: 3cm→7cm (regular contractions)
Transition phase: 7→10cm (strong,reg contractions).
Delay in the 1st 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
monitoring 1st stage of Labor? (6)
USING A PARTOGRAM
- Cervical dilatation (measured by a 4-hrly vaginal examination)
- Descent of the fetal head (in relation to the ischial spines)
- Maternal urine – every 4 hrs for ketones and protein, (if Ketones +ve –> give IV 10% dextrose)
- BP and temp of mum – 4 hrly
- Pulse – 1 hrly
- Frequency of Contractions – measure in contractions per 10 minutes.
- Fetal HR – every 15 mins
- Status of the membranes, presence of liquor and whether the liquor is stained by blood or meconium
- Drugs and fluids that have been given
- Particularly before and after each contraction (forceful uterine contractions can temporarily reduce placental blood flow and hence oxygen supply to the foetus, resulting in distress*
what on the partogram indicates when labour may not be progressing adequately?
Mx?
These are labelled “alert” and “action”.
The dilation of the cervix is plotted against the duration of labour (time).
When it takes too long for the cervix to dilate, the readings will cross to the right of the alert and action lines.
►► Crossing the alert line is an indication for AMNIOTOMY
Crossing the action line means care needs to be escalated to obstetric-led care and senior decision-makers for appropriate action.
second stage labor? (3)
1) “the three Ps”: power, passenger and passage.
- Power: the strength of the uterine contractions.
- Passenger: the 4 descriptive qualities of the fetus
- Passage: the size and shape of the passageway, mainly the pelvis.
2) The cardinal movement of labour
3) The descent
what do u do if 2nd stage is prolonged ?
what do I mean my “prolonged alaa?”
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
If prologed >3hrs –> Consider giving OXYTOCIN, with the offer of regional analgesia,
what is the aim of contractions per 10 minutes?
The aim is for 4 – 5 contractions per 10 minutes.
What are the 4 qualities of the fetus during the second stage?
Third stage of labour
what does the package of care (active managment) comprise of? (3) and why is it there
Offered to all to attempt reduction in post-partum haemorrhage
Involves giving a
- prophylactic uterotonic drugs
- early cord clamping
- controlled cord traction
§ IM syntometrine after birth of the baby
· Ergometrine + Oxytocin·
Contraindications – pre-eclampsia, HTN, liver/renal impairment, familial hypercholesterolaemia
§ Cord clamping and cutting;
The cord is clamped and cut within 5 minutes of birth. There should be a delay of 1 – 3 minutes btw delivery of baby and clamping of the cord to allow blood to flow to the baby (unless the baby needs resuscitation).
►►Palpate abdomen & wait for uterine contraction prior to delivery of placenta
§ Controlled cord traction to carefully deliver the placenta (stop if resistance), at the same time the other hand presses the uterus upwards to prevent uterine prolapse
· Aims to deliver placenta in one piece
§ Examination of the placenta afterwards to ensure no products remain in the uterus
Prolonged third stage and its complications (2)
referrel?
- postpartum haemorrhage
- retained placenta
- maternal collapse
transfer her to obstetric-led care
Describe the 7 Cardinal movement of labour?
LIE: position of the fetus in relation to the mother’s body
Presentation: refers to the part of the fetus closest to the cervix:
Management of retained placenta (2)
- Give IV oxytocic agents if bleeding excessively
if concerned about the woman’s condition…
- Manual removal of the placenta
(explain that this can be painful and advise her to have analgesia).
DO NOT do manual removal of the placenta without an anaesthetic.!!!!!!
Managment of Meconium-stained liquor w/ PPROM
- what consequence may occur?
- what does it mean if during labor meconium is passed?
This may be a:
- response to the stress of a normal labour or
- sign of distress,
>> so transfer to a consultant-led unit and do continuous CTG monitoring
requires immediate IOL in an obstetric-led unit + advanced neonatal life support available.
Aspiration of fresh meconium can cause severe pneumonitis (meconium aspiration syndrome)
what are indications for induction of Labour? (5)
- Prolonged Gestation >41 weeks
- Premature Rupture of Membranes
- Meconium-stained liquor
- Maternal Health Problems
- Intrauterine Fetal Death
- Maternal request for induction
- signs of chorioamnionitis
performing an Induction steps (5)
- Setting and timing
- monitoring and assessment
- fetal heart rate and uterine contraction monitoring.
- BISHOP SCORE
- Pain relief
- Membrane Sweep
- Vaginal PGE2
Methods of Induction (4)
- what r the 2 MAIN methods?*
- other?*
- Membrane sweep
- Vaginal PGE2 (dinoprostone)
other:
→ Artificial rupture of membranes (Amniotomy) + oxytocin infusion
→ Misoprostol or mifepristone in cases of foetal death during pregnancy
- Membrane sweep:* involves inserting a finger into the cervix to stimulate the cervix and begin the process of labour.
- Vaginal PGE2:* involves inserting a gel, tablet (Prostin) or pessary (Propess) into the vagina. The pessary is similar to a tampon, and slowly releases local prostaglandins over 24 hours.
Monitoring during induction of labor? (2)
- Cardiotocography (CTG) assess the fetal HR and uterine contractions before and during induction of labour
- Bishop score b4 & during induction of labour to monitor the progress
- The bishop score assesses the favourability of the cervix and is based on; dilatation, effacement, station, position and consistency of the cervix*
- a score of < 5 indicates that labour is unlikely to start without induction*
- a score of > 9 indicates that labour will most likely commence spontaneously*
Causes for prolonged labour
4 P’s
Passenger
- Abnormal position e.g. occipital posterior – bigger diameter
- Big baby
Powers>> Shitty Uterine contractions
Pelvis>> Small
Psyche >> pain
CI to induction of labour?
Absolute
- transverse Lie
- Cord prolapse
- Major placenta P.
- Vasa previa
- prev. classical C section scar
- active primary genital herpes
Relative
- Breech
indications for forceps delivery
(FORCEPS)
Foetus alive
Os dilated
Ruptured membrane, Rotation complete
Cervix take up
Engagement of head
Presentation suitable
Sagittal suture in AP diameter of inlet
Risks and Benefits of VBAC?
3 absolute Contraindications?
complication?
Contraindications:
- Previous uterine rupture
- Classical caesarean scar (a vertical incision)
- Other usual contraindications to vaginal delivery (e.g. placenta praevia)
Complix
UTERINE RUPTURE
Management of a VBAC Delivery?
- There should be continuous CTG monitoring.
- Avoid induction where possible
- Be cautious with augmentation (increased risk of uterine scar rupture)
- Any decisions about both induction and augmentation require input from a senior obstetrician.
what is Prematurity?
birth B4 37 weeks gestation.
- Under 28 weeks: extreme preterm
- 28 – 32 weeks: very preterm
- 32 – 37 weeks: moderate to late preterm
Risk factors for developing Preterm Labor?
Preventing preterm labour (2)
If Cervical shortening between 16-24 weeks, u can:
1. Vaginal Progesterone
Progesterone has a role in maintaining pregnancy and preventing labour by decreasing activity of the myometrium and preventing the cervix remodelling in preparation for delivery.
2. Cervical Cerclage
putting a stitch in the cervix to add support and keep it closed.
Investigations for Preterm Labor?
Goldstandard?
Fetal fibronectin (fFN) is a protein (glue) produced at the boundary between the amniotic sac (which surrounds the baby) and the lining of the mother’s uterus (the decidua)
what is Preterm Prelabour Rupture of Membranes (PPROM)
Normally amniotic sac ruptures just before labour due to uterine contractions
is where the amniotic sac ruptures, releasing amniotic fluid (in the abscence of uterine contractions!!) before the onset of labour and in a preterm pregnancy (under 37 weeks gestation).
why 37 wks? bc thats when baby is fully formed
- PROM : “prelabour rupture of membranes” is defined as rupture of membranes > 1 hour prior to the onset of labour occurring ≥ 37 weeks gestation.
- P-PROM :_Preterm_ prelabour rupture of membranes : is rupture of the amniotic sac < 37 weeks gestation.
managment of Prematurity (with intact membranes) (7)
- Discussing mode of birth
- Fetal monitoring (CTG or intermittent auscultation)
- Tocolysis with nifedipine: a Ca+ channel blocker that stop uterine contractions
- Maternal corticosteroids: IM betamethasone aids foetal lung development and reduces risk of ARDS after delivery
- IV magnesium sulphate: can be given before 34 wks, helps protect the baby’s brain
- Prophylactic antibiotics: Group B Strep
- Delayed cord clamping or cord milking: can increase the circulating blood volume and haemoglobin in the baby at birth
complications of Prematurity
(short and long term)
Short-Term
- Breathing problems–> ARDS
- Brain hemmorhage
- Necrotising enterocolitis
- Death
Long Term
- congential Heart defects
- Cerebral palsy
- Behavioural difficulties
- Problems with vision and hearing
risk factors of PPROM
diagnosis of P-PROM? (3)
Offer a speculum examination to look for pooling of amniotic fluid in the vagina—>itha MAKU…..
Do you want to do it on the spreadsheet into an ultrasound scan to check for a oligohyramnios
►►insulin-like growth factor (ILGF-BP-1) is a protein found in high concentrations in amniotic fluid, which can be tested on vaginal fluid
►►Placental alpha-microglobin-1 (PAMG-1) is a similar alternative to IGFBP-1
Management of P-PROM? (3)
1. Prophylactic Antibiotics :10 day oral erythromycin 250 mg (avoid co-amoxiclav as this can result in gangrenous bowel for the baby)
2. Identifying intrauterine infection
- C-reactive protein
- WBC
- CTG > Fetal HR
3. Maternal Corticosteroids: aids foetal lung development and reduces risk of ARDS after delivery
complications of P-PROM (baby and mum)
(3 each)
Fetal
- Prematurity
- Infection: Chorionoamnitis
- Neonatal death – due to complix of prematurity, sepsis and pulmonary hypoplasia.
Mummy
- Placental Abruption
- Cord prolapse
- PPH
Perineal trauma consequences (5)
- UI
- Anal Incont. and altered bowel habit (3rd and 4th tears)
- Fistula btw vagina and bowel (rare)
- Sexual dysfunction and dyspareunia
- Psychological and mental health consequences
Perineal tears
- Rf (4) and degrees (4)
- Management (5)
- first baby
- large babies (over 4kg)
- shoulder dystocia
- forceps delivery
Mx–> sutures
- Broad-spectrum antibiotics-->infection risk
- Laxatives--> risk of constipation
- Pain relief--> NSAIDS or PR diclofenac
- Physiotherapy –> risk of incontinence
- Follow up to monitor for long standing complications
what is an Episiotomy?
how and when do u do it?
- Surgical incision of the perineum prior to the delivery of the baby during the 2nd stage of labour
- Cutt made diagonally at around 45º from the opening of vagina downwards and laterally (to avoid damaging anal sphincter)
- Sutured after delivery
- Performed in anticipation of the need for additional room for delivery e.g. prior to forceps delivery
- Performed under local anaesthetic
how can u prevent perineal tear?
Perineal massage
It involves massaging the skin and tissues between the vagina and anus (perineum). This is done in a structured way from 34 weeks onwards to stretch and prepare the tissues for delivery.
During labour which woman do you monitor by CTG?
Shoulder dystocia management
layers needed to pass by when doing an epidural
SSS I LE
