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Obstetrics > Problems in Labour > Flashcards

Problems in Labour Flashcards

1
Q

What are the causes of failure to progress in Labour

A

Cause – Powers, passenger or passage
• Inadequate contractions – most common
• Foetal malposition/malpresentation
• Cephalic disproportion (relative or absolute)
• Obstructed Labour (Caput and moulding, haematuria, vulval swelling or cervical swelling)
• Maternal Exhaustion

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2
Q

How should you assess someone who appears to be failing to progress?

A

Assess – parous or nulliparous, first or second stage then look for evidence of a cause.
If inefficient uterine contraction is the cause, then augment labour with oxytocin but remember that a parous uterus can rupture.

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3
Q

What is the definition of Failure to progress in the 1st stage of Labour?

A

Definition - <2cm in 4 hours for primips or <2cm in 4 hours or slowing in progress for multiparous women. Should also take into account changes in strength or number of contractions and descent and rotation of the baby’s head.

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4
Q

How should delay in the 1st stage be managed?

A

Management if slow progress then ARM and reassess in 2 hours. If no further cervical dilation after 1-2 hours, then augment. Inform mother ARM/oxytocin will not change mode of delivery only bring it forward but oxytocin can increase pain so should be offered epidural. If dilatation increased by less than 2cm in the next 4hours further review for caesarean section. If cervical dilatation increased by 2cm advise 4 hourly examinations.

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5
Q

What precautions should be taken when administering Oxytocin?

A

Before starting oxytocin, obstetrician should complete full abdominal and vaginal exam. Once started baby should be monitored with a CTG. Oxytocin should be increased until there are 4-5 contraction in 10 minutes and spaces in increments of 30mins apart

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6
Q

What is the definition and management of delay in the 2nd stage of Labour?

A

Nulliparous if not delivered after 1 hour of active pushing - VE and amniotomy. If not delivered in 2 hours, then review by senior obstetrician for CS or instrumental delivery.
Multiparous if not delivered after 1 hour of active pushing then review by senior obstetrician for instrumental or CS.

Can consider oxytocin in nulliparous women

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7
Q

What is malposition?

A

Malposition most common – baby in occipito-posterior position (i.e. looking up) also head doesn’t press on the cervix as well and so cervix doesn’t dilate properly.

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8
Q

How should malposition be managed?

A

90% spontaneously resolve otherwise operative delivery/rotation or C-section. OP delivery is possible but takes longer and can be more painful, generally women feel an urge to push earlier.

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9
Q

What is malpresentation?

A

Malpresentation – Breech, Face (sometimes delivered vaginally), brow (never delivered vaginally), shoulder, arm and cord (obstetric emergency).

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10
Q

What causes malpresetation?

A

Maternal: multiparity, pelvic tumours, congenital, and uterine anomalies (fibroids)
Foetal: prematurity, multiple pregnancy, IUD, macrosomia and foetal abnormalities
Placental: praevia, polyhydramnios and amniotic bands.

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11
Q

How should brow and face presentations be managed?

A

Brow – in between full extension and full flexion of head. Watch and wait for change but otherwise CS.
Face – mentoanterior can be delivered vaginally. If mentoposterior, then watch and wait as it may spontaneously rotate upon reaching pelvic floor. If poor progress or failure to rotate, then CS indicated. Ventouse absolutely contraindicated but forceps possible with MA

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12
Q

What is an abnormal lie?

A

Abnormal lie – oblique or transverse – can cause prolapse of the cord so is an obstetric emergency, also higher risk of PROM

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13
Q

How should an oblique or transverse lie be managed?

A

Abnormal lie – oblique or transverse – can cause prolapse of the cord so is an obstetric emergency, also higher risk of PROM
Prior to 36 weeks – reassure that in majority of cases the baby will rotate
After 36 weeks – ECV which can be performed up until active labour as long as membranes have not ruptured and it’s not a multiple pregnancy (unless second twin)
Elective Caesarea section if ECV unsuccessful or women opts for it

Unstable – regularly changing. Can attempt ECV but otherwise CS indicated at 41 weeks.

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14
Q

What is a breech presentation, describe the different types

A

Head not the presenting part but still longitudinal lie. Much more common preterm.
Extended – baby sucking toes
Flexed – legs bent at knees – both buttocks and feet are presenting – risk of cord prolapses
Footling – one leg flexed other extended (everything delivers except head – very dangerous)

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15
Q

What can be the causes of a breech presentation?

A

Breech can sometimes be due to uterine abnormalities (fibroids), scars or placenta praevia. Also, more common in multiple pregnancies, those with previous breech presentations and foetal abnormalities.

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16
Q

How should breech presentation be managed?

A

Management
Before 36 weeks no action needed
External Cephalic Version – from 36 in nulliparous and 37 in multiparous
If unsuccessful then CS at 39 weeks (note IOL contraindicated)

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17
Q

Discuss the ECV process?

A

Manually attempt to turn a breech or transverse presentation into a cephalic one. Note after attempt CTG should be performed and Anti-D given to Rh-ve mothers. 50% efficacy but spontaneous reversion is possible. Are small risks of distressing baby and PV bleeding, in which case immediate CS.

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18
Q

What are the contraindications for ECV?

A

Contraindications – CS already indicated, haemorrhage, foetal compromise, oligohydramnios and pre-eclampsia

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19
Q

What information should be provided to the mother regarding breech vaginal deliveries.

A

With Breech presentation it is safer to do Caesarean section but not by as much as previously thought. Breech vaginal delivery is an option. All breech deliveries have increased perinatal morbidity/mortality as well as foetal abnormalities and neuro developmental problems regardless of mode of delivery.

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20
Q

What are the complications of a breech vaginal delivery?

A

Complications of Vaginal Breech Delivery
Trapped head after everything else comes out
Cord prolapses
Intracranial haemorrhage due to contractions
Internal injuries

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21
Q

How should health care professionals manage breech deliveries?

A

Must leave the baby as much as possible until everything except the head is out, at this point you pick up the baby by its legs and allow the head to flex around the symphysis pubis.
Manoeuvres – MSV (Mauriceau-Smellie-Veit)
After this forceps are used

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22
Q

What would imply there is foetal compromise or distress in a CTG?

A

Non reassuring CTG
• Baseline tachycardia or bradycardia
• Reduced baseline variability (flat) - 5-10bpm from baseline
• Absence of acceleration/non-reactive (increased by 15bpm for more than 15sec)
• Presence of decelerations (decreased by 15bpm for more than 15sec)

Rate of contractions
Passage of Meconium

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23
Q

How can foetal distress by confirmed after an abnormal CTG?

A

CTG has high sensitivity but low specificity. Confirm by foetal acid-base status (FBS) from baby’s scalp. If unable to perform FBS deliver by speediest route.

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24
Q

What causes foetal distress?

A

Uterine hyperstimulation – iatrogenic from oxytocin
Hypotension (maternal) especially if lying on their back
Poor foetal tolerance of labour e.g. IUGR
Cord compression (normal CTG with short sharp decelerations with contractions)
Infection – maternal pyrexia is a good sign of this
Maternal disease

25
Q

How should foetal distress be managed?

A

Management
• Rectify reversible causes e.g. maternal hypotension
• Left lateral position (improves oxygen to the baby)
• Stop oxytocic
• Confirm compromise by blood sampling where possible
• Deliver by speediest route if unable to correct or if significant acidosis

26
Q

What should be done if there is foetal bradycardia < 100 for 3 minutes?

A

Bradycardia on CTG (below 100) after 3 minutes call for help, after 6 minutes move to theatre and after another 6 minutes baby should be out.`

27
Q

What is a VBAC and why is it important?

A

Previous caesarean section means a 70-75% chance of a vaginal delivery second time around. This is reduced because having a scar on the uterus means the acceptable time threshold for labour decreases also because of increased risks of foetal compromise due to the scar. If multiple pregnancy or macrosomia or maternal age > 40 requires a more cautious approach. VBAC is classified as high risk labour.

If 2 previous caesarean deliveries, then it is still possible to undergo a vaginal delivery, but it will not be induced, and no oxytocin will be used due to large risk of uterine rupture.

28
Q

What are the benefits of VBAC?

A

Avoid major abdominal surgery, reduced risk of infection, recovery quicker and risk of subsequent pregnancies is a lot less – 90% of vaginal delivery next time.

29
Q

Compare VBAC and CS

A

VBAC
Uterine rupture = 0.5%
Shorter hospital stay and recovery
If successful, then then VBAC more likely next time

Elective repeat caesarean section
Uterine rupture <0.02%
Longer recovery
Likely to have to have CS next time

30
Q

What precautions should be taken for a VBAC?

A

Precaution taken: IV access and Group and Save, continuous electronic foetal monitoring, avoid prolonged labour and augmentation/induction should be senior decision only. Additional analgesic requirements may indicate impeding uterine rupture. After 39 weeks elective repeat caesarean is recommended.

31
Q

Define PROM and P-PROM

A

PROM – rupture of foetal membrane at least 1 hour prior to the onset of labour at >37 weeks gestation. – Fairly common occurring 10-15% of the time

P-PROM – preterm premature rupture of membranes – rupture of foetal membranes prior to 37 weeks gestation.

32
Q

What makes up the foetal membranes?

A

Foetal membranes consist of the chorion and amnion. These become weaker through apoptosis and enzyme breakdown towards term.

33
Q

What causes PROM?

A

Early activation of normal physiological processes
Infection – cytokines weaken membranes
Genetic predisposition

34
Q

What are the risk factors for PROM?

A 
Smoking
Previous PROM
Vaginal bleeding during pregnancy 
Lower genital tract infection 
Invasive procedures – amniocentesis
Polyhydramnios
Multiple pregnancy 
Cervical Insufficiency
35
Q

Describe how PROM usually presents?

A

Painless pop and gushing of liquid from the vagina. Can be gradual leakage or change in colour/consistency of discharge. May be seen on speculum examination – allow mother to lie for period of times so liquid pools in posterior vaginal fornix, coughing may show leakages from cervix.

36
Q

What must you rule out before diagnosing PROM

A

Must rule out urinary incontinence – common in later stage of pregnancy, sweat increase, normal vaginal secretions, vesico-vaginal discharge, loss of mucus plug and infection causing increased discharge.

37
Q

How should you investigate a women with suspected PROM

A

Colour of liquor – blood/meconium (avoid VE due to infection risk)
Temperature, pulse and BP
High vaginal swab – to look for infection (GBS)
Ferning test – cervical secretions into a glass slide – fern-patterned crystal if PROM
Actim-PROM- looks for IGF binding protein – high in amniotic fluid
CTG

38
Q

How should a women be managed with P-PROM at < 34 weeks

A

Labour likely to start 24-48 hours after rupture
If labour doesn’t start must balance risk of expectant management vs IOL

<34 weeks – better to increase gestation. Monitor for infection and avoid sexual intercourse. Prophylactic erythromycin 250mg QDS for 10 days. Benzylpenicillin during labour if GBS isolated (Group B streptococcus) and corticosteroids. Also, twice daily temperature check, weekly CRP and FBC check

39
Q

How should a women be managed with PROM at 34-36 weeks

A

34-36weeks – depends. Monitor for infection (chorioamnionitis) and avoid sexual intercourse. Prophylactic erythromycin 250mg QDS for 10 days. Benzylpenicillin during labour if GBS isolated (Group B streptococcus) and corticosteroids. Also, twice daily temperature check, weekly CRP and FBC check.

40
Q

How should a women be managed with PROM at >36 weeks

A

> 36 weeks IOL after 48 hours due to infection risk – monitor for infection during those 48 hours. If high risk pregnancy may IOL immediately. Avoid sexual intercourse.

41
Q

Can PPROM be prevented in high risk women?

A

Intravaginal progesterone can be offered to women at high risk of PPROM

42
Q

What are the potential complications from PROM and P-PROM

A

Outcomes correlates to gestational age of the foetus
Chorioamnionitis and or endometritis 1% risk vs normally 0.5%
Oligohydramnios – significant if <24 weeks as risk lung hypoplasia
Neonatal death
Placental abruption
Umbilical cord prolapses

43
Q

What are the features of chorioamnionitis

A 
Chorioamnionitis Features:
•	Foetal tachycardia
•	Maternal tachycardia 
•	Maternal pyrexia 
•	Rising WCC and CRP
•	Irritable or tender uterus
44
Q

What is the definition of preterm delivery?

A

Definition – birth between 24- and 37-weeks’ gestation

In reality it is birth before 34 weeks that we worry about the most.

45
Q

What are the complications of Preterm delivery?

A 
Increased C section rate 
Necrotising enterocolitis
HIE (hypoxic ischaemic encephalopathy)
Neonatal death 
Long term handicaps such as blindness, deafness and cerebral palsy 
Sepsis 
Brocho-pulmonary dysplasia
46
Q

What are the risk factors for preterm delivery?

A

Previous preterm birth or late miscarriage
Multiple pregnancy
Cervical surgery
Uterine anomalies
Medical conditions such as renal disease and infections
PET and IUGR

47
Q

How does acute preterm labour present?

A

Contractions
SROM or PV bleeding
Uterine tenderness – infection

48
Q

How should acute preterm labour be investigated?

A

USS for foetal presentation
FBC and CRP
Swabs and MSU
Fibroconnectin and TV USS – can be used to predict risk of preterm labour as well

49
Q

How should acute preterm labour be managed?

A

Is this labour? Transvaginal cervical length >15mm and negative Fibroconnectin assay indicates that labour is unlikely.
Admit and inform neonatal unit if real
Steroids 12mg betamethasone IM two doses 24 hours apart - continue until 35+6 weeks
Consider Tocolysis – Nifedipine and Atosiban IV
Antibiotics if labour confirmed

50
Q

How can preterm labour be prevented?

A

Treatment for bacterial vaginosis
Progesterone especially in high risk women e.g. previous late miscarriage or preterm delivery or low risk women with a short cervix.
Selective reduction of pregnancy number

51
Q

What is the definition of retained placenta?

A

Non delivery of placenta after 30 mins of the baby in actively managed 3rd stage and 1 hour of physiological 3rd stage. Biggest issue is blood accumulating behind the placenta and so significant invisible blood loss.

52
Q

How should retained placenta be managed?

A

IV access, FBC and crossmatch
Revert to active management of physiological
If oxytocin not effective within 30mins transfer to theatre for regional block and manual removal of the placenta.
Intraoperative prophylactic antibiotics should be given

53
Q

What are the indications for episiotomy?

A

Complicated vaginal deliveries: breech, shoulder dystocia, forceps and Ventouse
Extensive genital tract scaring such as FGM or poorly healed 3rd or 4th degree tears
Foetal distress

54
Q

How should an episiotomy be carried out?

A

Regional block should be in place otherwise local anaesthetic must be given.
Two fingers places between baby’s head and the perineum
Sharp scissors used to make a single cut
In the UK this is done mediolaterally away from the anal sphincter.

55
Q

What are the classifications of perineal tears?

A

1st degree – injury to the skin only
2nd degree – injury to skin and perineal muscles (includes episiotomy)
3rd degree – injury to the perineum involving the anal sphincter. 3a, 3b and 3c divided between <50% of EAS torn, >50% of EAS torn and internal sphincter torn
4th degree – internal anal sphincter torn as well as anal/rectal epithelium

56
Q

How should perineal tears be managed?

A

Assess and perform rectal exam to classify tear.
Suturing should take place as soon as possible to reduce risk of infection and haemorrhage

Difficult trauma should be undertaken by an experienced doctor.

57
Q

What are the risk factors for 3rd and 4th degree tears?

A 
Risk Factors for 3rd and 4th degree tears
•	Forceps delivery
•	Nulliparity
•	Shoulder dystocia
•	2nd stage >1 hour 
•	Persistent OP position 
•	Midline episiotomy 
•	Macrosomic baby
•	Epidural anaesthesia 
•	Induction of labour
58
Q

How should 3rd and 4th degree tears be managed?

A

Careful examination before suturing commences
Should be carried out be experienced clinicians in theatre under analgesia
Broad spectrum antibiotics and stool softeners
Reviewed 6 weeks later by gynaecologist
If symptomatic offer C section at next delivery

59
Q

How long should mothers wait before having another baby after a caesarean section?

A

Generally, it is best to have 2 years after a C section before delivering another baby either vaginally or by C section

Obstetrics (30 decks)

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