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Obs and Gyn > Problems in Labour > Flashcards

Problems in Labour Flashcards

1
Q

Poor Progress - 3 most common reasons / common end result / defintion and how discovered

A

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

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2
Q

RF/C and T for poor progress

complications if unresolved

A

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

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3
Q

DM in preg - antenatal care/advice / delivery precautions / complications

A

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

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4
Q

managing gestational DM

A

diet controlled if possible, oral metformin or glibenclamide if needed.
check BM 6 weeks post partum in case DM has dveloped

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5
Q

malpresentation - ? / 4 most common

A

anything other than head is presented / shoulder, breech, face, brow

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6
Q

breech - forms/ management

A

footling, flexed, extended / during pregnany ECV can attempt to resolve (50% success)

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7
Q

ECV - process / comp / CI

A

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

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8
Q

management of breech during labour

A

vaginal breech delivery - only if flexed or extended if experienced staff +small baby

elective c-section recommended

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9
Q

malposition - ? / T

A

anything other than OA (head flexed, face down)

T - oxytocin/manual rotation

  • vacuum extraction (ventouse)\kiellands forceps
  • c section
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10
Q

prolapsed cord - ? / conseq / RF / T

A

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

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11
Q

shoulder dystocia - ? / conseq / C / T

A

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)

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12
Q

meconium stained liquor - c / T / conseq

A

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

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13
Q

fetal distress - ? / CF / I / T

A

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

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14
Q

instrument delivery - RF / indication / conseq

A

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

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15
Q

risks of c-section

A

CURRENT - haemorrhage, DVT, infection, bladder inj, longer hosp stay

FUTURE - delay in getting preg again, need for future CS, placenta praevia, adhesions

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16
Q

impact on NHS of c section

A

cost, complications, de-skilling, fertility

17
Q

thromboprophyllaxis before C section - RF’s (low risk, mod risk, high risk) /T

A

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

18
Q

post maturity - ? / T / conseq

A

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.

19
Q

rupture of membranes at term, but with no labour ensuing - T

A

prostaglandins –> oxytocin (>12 hours) –> misoprostol PO/4hrly

20
Q

pre-term rupture of memb - RF / T / conseq

A

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)

21
Q

risks of stalling labour in pre term rupture of memb

A

keep baby in = risk to mother (infections)

deliver baby = risk to baby (RDS)

22
Q

prematurity - ? / c / RF / conseq / T plan

A

regular contractions leading to dilation of cervix

23
Q

what effect do steroids have on fetus?

A

increase lung development, increase surfactant production, closure of patent ductus’s, prevent periventricular malacia (cerebral palsy)

24
Q

ante-partum haemorrhage - ? / c / T

A

? - 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

25
Q

placental abruption - ? / RF / conseq

A

? - 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)

26
Q

placenta praevia - ? / c / classify / CF / I / T

A

? - 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!!!
27
Q

abruption vs placenta praevia

A

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

28
Q

PPH - ? / c / RF / T

A

? - loss of >500ml blood from genital tract

29
Q

what is secondary PPH / c / t

A

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)

30
Q

uterine inversion - c /conseq/t

A

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

31
Q

maternal shock - ? / c/CF/T

A

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

32
Q

pre-eclampsia - ? / CF / RF / conseq / preventitive T

A

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

33
Q

eclampsia / severe pre-eclampsia management

A

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

34
Q

ECV - ? / must be advised beforehand (3) / CI

A

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

35
Q

small for date - ? / c / I / T / conseq

A

baby is

36
Q

large for date - ? / c / conseq

A

> 90th centile weight for gest age
c - familial trait, maternal DM, hyperinsulinaemia
conseq - birth injury, hypoglyc, hypo CA2+

Obs and Gyn (7 decks)

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