Problems in Labour Flashcards
Poor Progress - 3 most common reasons / common end result / defintion and how discovered
Passenger (too big), Passages (too small), Propulsion (less maternal effort)
35% of C-sections due to poor progress
defined as 0.5cm/hour in 1st stage and 2-3 hours for 2nd stage which is discovered by using the partogram
RF/C and T for poor progress
complications if unresolved
1st labour/ poor contractions (give syntocinon)
malpositions (should resolve spontaneously)
CPD (small pelvis) or Big Baby (c-section?)
inadequate analgesia
if not immediately resolvable, C-section
complication - Maternal infection/uterine rupture/ PPH or fetal mortality risk
DM in preg - antenatal care/advice / delivery precautions / complications
encourage good glyc control, stop smoking, increase insulin by 50-100% judged by constant check-ups and monitoring (aim for fasting BM of 3.5-4)
also give glycogel pack and educate partner
Delivery:
elective at 38 weeks, monitoring fetus throughout (maternal hyperglyc causes fetal hypoglyc).
Baby may be large so prepare
Complication:
HYPOGLYC, polyhydramnios, stillbirth, preterm labour, big baby, polychythaemia
managing gestational DM
diet controlled if possible, oral metformin or glibenclamide if needed.
check BM 6 weeks post partum in case DM has dveloped
malpresentation - ? / 4 most common
anything other than head is presented / shoulder, breech, face, brow
breech - forms/ management
footling, flexed, extended / during pregnany ECV can attempt to resolve (50% success)
ECV - process / comp / CI
scan, attach CTG, re-scan after
must have access to c-section if required
available anytime >37 weeks
in combo with tocolysis it is 50% successful
comp - cord accident, feto-maternal haemorrhage
CI - Placenta Praev / uterine abnorm/ SROM
management of breech during labour
vaginal breech delivery - only if flexed or extended if experienced staff +small baby
elective c-section recommended
malposition - ? / T
anything other than OA (head flexed, face down)
T - oxytocin/manual rotation
- vacuum extraction (ventouse)\kiellands forceps
- c section
prolapsed cord - ? / conseq / RF / T
descent of cord through cervix in front of/beside presenting part of baby, only occuring after membranes have ruptured.
conseq: fetal asphyxia
RF: 2nd twin, footling, shoulder, polyhydramnios, unengaged head
T - 2 outcomes
if prolapse noted BEFORE membranes rupture –> c sect
if AFTER: get help, keep cord in VAG but try not to touch, turn mother head down, tocolysis, immediate C sect/forceps
shoulder dystocia - ? / conseq / C / T
anterior shoulder impacted behind pubic symphisis after head delivered
increased risk of fetal mortality, PPH, increased risk perineal tear, uterine rupture, brachial plexus injury, fx clavicle/humerus, cord entrapment
C - large baby, post term, induced labour, 1st/2nd stage arrest, gest DM
T - danger is fetal asphixiation so act quickly. put mother into correct position and attempt delivery again
(check for erbs palsy when born)
meconium stained liquor - c / T / conseq
C - can be normal, however often indicates fetal distress
T - transfer to consultant ward and attach CTG monitoring
as soon as fetus born aspirate oropharynx and nose
paediatrician should aspirate trachea and pharynx using laryngoscope
conseq: aspiration causing pneumonitis
fetal distress - ? / CF / I / T
this signifies hypoxia and if prolonged causes acidosis
CF - meconium in labour / fetal HR increase >160 / less variability in HR (bad thing)
I - fetal blood sample (ph lower - approx 7.24)
T - if acidotic deliver quickly - c sect or vag
instrument delivery - RF / indication / conseq
RF - maternal BMI >30 / big baby / OP presentation
Indications
FORCEPS
c - use when delay in second stage labour (often failed maternal effort / protective for mother i.e CV, resp disease or pre-eclampsia) RELATIVE INDICATION
or else in emergency (malposition of head/ fetal distress/ eclampsia/ prolapsed cord) ABSOLUTE INDICATIONS
conseq - Maternal psych trauma / fetal bruising on face, VII nerve paralysis/ brachial plexus inj
VENTHOUSE
c - preferred to forceps everywhere except UK
uses vacuum to extract
same indications as RELATIVE ind for forceps
CI - prem baby/ face presentation
C-SECTION
c - failure to prgress labour, elective mothers request, fetal distress, placenta praevia, some malpresentations, HIV, breech, prev c-section
EMERG SECTION = severe pre-eclampsia, abrupto placenta, intra-labour reasons (mentioned above), twins with 1st non cephalic
risks of c-section
CURRENT - haemorrhage, DVT, infection, bladder inj, longer hosp stay
FUTURE - delay in getting preg again, need for future CS, placenta praevia, adhesions
impact on NHS of c section
cost, complications, de-skilling, fertility
thromboprophyllaxis before C section - RF’s (low risk, mod risk, high risk) /T
RF’s - age >35, obesity, para 4+, pre-eclampsia, labour >12 hours, varicose veins, current infection,
low risk - woman with no risk factors undergoing elective section in uncomplicated pregnancy
mod risk - any of RF’s
T - LMWH before section
High risk - >3 RF’s, extended abdo surg, thrombophillia FHx, antiphospholipid syn
T - LMWH until 5 days post-op +/- leg stockings
post maturity - ? / T / conseq
gestation >42 weeks
T - induction offered at 41 weeks
cons - worry is increased peri-natal mortality due to placental insuff + increasing fetal size leading to birth trauma.
rupture of membranes at term, but with no labour ensuing - T
prostaglandins –> oxytocin (>12 hours) –> misoprostol PO/4hrly
pre-term rupture of memb - RF / T / conseq
RF - multibirth, APH, unknown, cervical incompetence, diabetes, polyhydramnios, infections
T - admit and assess (ABC)
take temp, MSU, HVS (sterile speculum exam) which will confirm rupture by colour of liquor
80% will continue to pre-term labour, but 20% will not.
conseq - preterm labour, fetal distress/death, intra-uterine inf (chorioamniotis)
risks of stalling labour in pre term rupture of memb
keep baby in = risk to mother (infections)
deliver baby = risk to baby (RDS)
prematurity - ? / c / RF / conseq / T plan
regular contractions leading to dilation of cervix
what effect do steroids have on fetus?
increase lung development, increase surfactant production, closure of patent ductus’s, prevent periventricular malacia (cerebral palsy)
ante-partum haemorrhage - ? / c / T
? - any bleeding from vaginal tract after 24 weeks
c - placental abruption, placenta praevia, uterine rupture, vaginal infection, vasa praevia, cervical lesion (polyps/CA etc)
T - always admit! but never examine until placenta praevia excluded
MILD : assess (HR,BP, Blood loss), IV infusion? draw blood (Hb, cross-match, co-ag study, U+E) US abdomen to find cause. if bleeding stops and fetus stable discharge but follow up + switch to RED pathway +/- antiD
SEVERE: emergency ambulance if not in hospital already
asses, IV infusion, draw blood + clotting screen, raise legs, give O2 +/- blood transfusion if BP low
- deliver via C-section
placental abruption - ? / RF / conseq
? - part of placenta becomes detached from uterus (can be concealed)
CF - backache, abdopain, bleeding??
RF - pre-eclampsia, prev similar, smoker, prev C-section, thrombophilia, ECV
conseq - fetal anoxia, fetal death, PPH, DIC, maternal shock (if concealed)
placenta praevia - ? / c / classify / CF / I / T
? - placenta lying in region near OS
c - LARGE PALCENTA = multibirth, uterine abnorm, fibroids
DAMAGED PLACENTA = multiparity, prev C section
classify - 1 lower segment but doesnt reach OS
2 - reaches doesnt cover
3 - partial cover
4 - completely covered OS
CF - small painless bleeding initially (28-32 weeks) then increasing bleeding
I - TV US repeated again at 36-38 weeks
T - depends on severity: Severe = c section Non-S = aim for norm delivery - cross match - ted stocking - steroids if pre term - if PP gets worse --> section DO NOT EXAMINE!!!
abruption vs placenta praevia
shock, pain, uterus tenderness are all massively increased in ABRUPTION, and only slightly increased in PP.
often fetus is abnormally presented in PP but normal in ABRUPTION
PPH - ? / c / RF / T
? - loss of >500ml blood from genital tract
what is secondary PPH / c / t
blood loss >24 hours after delivery (usual is 5-12 days)
c - usually retained tissue leading to secondary infection
t - if heavy crossmatch 2 units blood and give abx’s (ampicillan)
uterine inversion - c /conseq/t
usually due to medical mismanagement
can lead to maternal shock even without haemorhage
T - manually reduce uterus if possible
if shocked, IV infusion colloid and get help
maternal shock - ? / c/CF/T
always remember blood loss may not be visible
c - severe haem / ruptured uterus/inverted uterus/PE/SEPSIS
CF - if SEPTIC = N+V, diarr, abdo pain, +/- fever +/- rash plus obvious SIRS signs
other= oliguria, metab acidosis, low O2 sats
*important to remember young women will compensate really well then crash
T - ABC / sepsis6/resus + monitor vitals + u+e’s
pre-eclampsia - ? / CF / RF / conseq / preventitive T
eclampsia is seizures induced by pre-eclampsia. pre-eclampsia is a combo of high BP, proteinuria and oedema
PRE ECLAMPSIA:
often pre-eclamp develops >20 weeks and resolves 30 , age 35, HTN before preg, twins, prim ((SMOKING is protective))
conseq - Eclampsia is the main, renal failure, liver failure, stroke and HELLP syndrome are other serious
preventing eclampsia T: give MgSO4 + assess doppler for use of low dose aspirin
eclampsia / severe pre-eclampsia management
SEVERE PRE-ECLAMPSIA
- admit and give MgSO4
Assess
- (BP, urinanlysis + bloods for severity)
- US and CTG to assess fetus (growth, liquor, blood supply, fetal movements)
Treat
- only delivery cures
- manage with betamethasone + MgSO4 + anti-hypertensives (1+2 trimester = methyldopa/3rd = labetalol) + FLUID RESTRICT
ECLAMPSIA
MgSO4 in 100ml saline
monitor reflexs + RR (MgSO4 can decrease RR) –> stop if
ECV - ? / must be advised beforehand (3) / CI
turning of breech baby after 37 weeks
must mention:
- 50% success
- may revert to breech
- uncomfortable procedure
- can avoid need for C-section
- CTG monitoring throughout
CI - planned elective CS . twins, oligohydramnios, placenta praev/aph, fetal anamoly
small for date - ? / c / I / T / conseq
baby is
large for date - ? / c / conseq
> 90th centile weight for gest age
c - familial trait, maternal DM, hyperinsulinaemia
conseq - birth injury, hypoglyc, hypo CA2+
