Reproductive Health Other Flashcards
What causes labour pains?
- Frequency of contractions: more frequent is more painful (less refractive time pain free between contractions)
- Effectiveness of pushing: e.g. obstructed labour pushing against, or intrauterine pressure not sufficient
Pain experience depends on the
- type of pelvis
- the ability of the cervix to dilate
- vaginal canal to distend
Three factors about contractions
Duration
Intensity
Frequency
Factors relevant to pain level in labour
- Pain threshold
- Medical conditions ( cervical readiness, labour intensity, pelvis)
- Sources of pain during labour
- Foetal position and presentation
What is the major pain pathway of labour pain?
Ist stage - visceral pain from uterine contractions and cervical dilation and the afferent impulses enter the spinal cord via the accompanying nerves that enter the spinal cord via T10- L1
2nd stage – somatic pain from vaginal and perineal region. nerve impulses travel via S2- 4 through pudental nerves
Consequences of pain in labour
• Pain is a noxious and unpleasant stimulus—produces fear and anxiety.
• Unrelieved stress in labour produces increased plasma cortisol and catecholamine concentrations.
• Leads to reduction in utero-placental blood flow.
• Effective pain relief reduces plasma nor-adrenaline, prevents
the rise during first & second stage of labour.
• Prevents metabolic acidosis by reducing the rate of rise of lactate and pyruvate.
• Decreases maternal O2 consumption by 14%.
Pain relief methods in labour
- Non pharmacological: relaxation, thermal, positioning, distraction, hydrotherapy, touch
- Inhalational Entonox
- Systemic Opioids: pethidine or diamorphine
- Epidural
- Combined Spinal and Epidural (CSE)
Effects of systemic opioids in labour
Analgesia <50%
“Failure” > 30%
Side effects
- Sedation
- Nausea
- Decreased Labour progress
Fetal effects
- increased Heart rate abnormalities
- Increased Acidosis
Active metabolites - Norpethidine is epilepticogenic
Benefits of Epidural analgesia for labour
Effective Safe No increased Risk C-Section Satisfaction No fetal compromise
List potential problems of Epidural analgesia for labour
Prolonged 2nd Stage
Increased Labour augmentation
Increased Instrumental Delivery - Perineal trauma - Hospital stay - Incontinence - Sexual dysfunction
When is pethidine contraindicated as analgesic for labour?
It is epileptogenic
eclampsia, history epilepsy
A patient on the L&D unit has been in labor for four hours with an epidural block for pain management for the last hour. The patient’s blood pressure has been averaging 125/70 to 130/72. During a routine nursing assessment, the patient’s blood pressure has decreased to 100/60 and the fetal heart rate pattern exhibits a decrease in variability with an occasional late deceleration.
What is the physiologic basis for what is happening?
Likely maternal position
(flat position with regional analgesia)
aortic compression
ABCDE
change to left lateral position
list emergency gene conditions
- pelvic Infection.
- ovarian cysts.
- Bartholin’s abscess/cyst.
- abdominal pain of uncertain origin. • acute unscheduled vaginal bleeding.
Outline gyne history
• Presenting complaint:
Abdominal pain, bleeding, vulval swelling, vaginal lump,
vaginal discharge
• Menstrual History:
LMP, no. of days/ cycle length, heavy? Soils clothes? Dysmenorrhoea, intermenstrual bleeding, irregular? amenorrhea
• Age
• Previous obstetric History:
• Gravidity, Parity, Mode of delivery / outcome, Age of Last childbirth
• Sexual History:
• Postcoital bleeding, dyspareunia deep / superficial
• Contraception:
• COCP/POP/mirena/coil/depot…
• Cervical smear:
• Date of Last smear, previous irregularity
• Medical History: medication, allergies
• Surgical History:
• Social History: smoker? Alcohol? Work? Exercise
GYne examination
Bimanual examination
Cervix: position, attitude, texture
Uterus: size, mobility, position (Anteverted/axial/retroverted)
Speculum Examination Discharge, Cervical Os, Vaginal walls
Common Gynaecological problems
- Vaginal Bleeding
- Abdominal / Pelvic Pain
- Abdominal masses
- Early pregnancy loss: ectopic / miscarriage • Vulval swelling
- Vulval / Vaginal mass,
- Foreign body in vagina, Trauma
Lower Abdominal Pain differentials
- Ectopic
- Miscarriage •Dysmenorrhoea •Fibroid degeneration •PID
- Ovarian cyst
GYne examination
General Condition:
PR, BP, RR, Pallor Abdominal Examination:
Abdominal tenderness, guarding, rigidity, rebound tenderness
Vaginal Examination:
Cervix soft? Tender?, Dilated?
Tender fornix?, Size of uterus?
Speculum Examination:
Cervical os, Products of conception, Blood
gyne Investigations
- Urine pregnancy test
- Bloods: FBC, Group and save, b hCG • Ultrasound scan (Trans vaginal)
- Triple Swabs and ensure follow up:
Treatment of gyne emergencies
- Venflon if suspected ectopic pregnancy if bleeding heavily
- Discuss with senior collegue
- Book emergency theatre
- Inform anaesthetist
- Keep the patient nil by mouth
Early pregnancy bleeding differentials
- Ectopic
- Miscarriage
- Molar pregnancy • Cervical ectropion • Cervical trauma
- Cervical polyp
- Cervical cancer
Hyperemesis Gravidarum - managment
- Recurrent hyperemesis- TFT
- Scan for viability
- Scan for multiple gestation and molar pregnancy
- Venflon
- Fluids
- Anti emetics
- Bloods: U&E, LFT, FBC
Fluid replacement and electrolyte balance post op
Retention of fluid and sodium resulting from the stress of surgery
redistribution of water between interstitial and intravascular compartments of extracellular space.
This process is initiated by blood loss and neuro-endocrinological response to stress, and
can be modified by anaesthesia and other administered medications.
Post c-section Catheterisation is done to-
- To minimise the risk of bladder damage
- the inconvenience of a full bladder obscuring the surgical field.
- This may also reduce the risk of patient discomfort in the acute postoperative phase
- Should be removed -ability of the patient to mobilise to void comfortably
What is the difference between active and passive drains?
- Active drains are sealed systems where a vacuum removes fluid from a potential space created by the surgery.
- Passive drains are better suited to the peritoneal cavity, where soft tissue can block the fenestrations of an active drain.
- Source of infection
- Hygiene of port site
