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Obs & Gynae > Stages of Childbirth > Flashcards

Stages of Childbirth Flashcards

1
Q

The first stage occurs from ________ until _______

A

Onset of labour (true contractions)

10cm cervical dilatation

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2
Q

The second stage occurs from _______ until _______

A

10cm cervical dilatation

Delivery of the baby

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3
Q

The third stage occurs from _______ until _______

A

Delivery of the baby

Delivery of the placenta

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4
Q

What are Braxton-Hicks contractions?

When do they usually occur?

A

Occasional irregular contractions of the uterus. Not true contractions and DO NOT INDICATE ONSET OF LABOUR!

Usually felt in the 2nd and 3rd trimester.

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5
Q

What is the management for Braxton-Hicks contractions?

A

Staying hydrated and relaxing

No medicine needed

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6
Q

What is effacement and when does it occur?

A

Cervix stretching and getting thinner

Occurs in 1st stage of labour

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7
Q

What is the “show”?

When does it fall out?

A

Mucus plug in the cervix that prevents bacteria from entering uterus during pregnancy.

Falls out in 1st stage to create space for baby to pass through.

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8
Q

What are the 3 phases of the first stage?

A

LAT

  1. Latent phase
  2. Active phase
  3. Transition phase
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9
Q

What occurs in the latent phase of the first stage of labour?

A

Cervical dilation 0.5cm/hr

0 –> 3cm dilatation

Irregular PAINFUL contractions

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10
Q

What occurs in the active phase of the first stage of labour?

A

Cervical dilation 1cm/hr

3 –> 7cm dilatation

Regular contractions

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11
Q

What occurs in the transition phase of the first stage of labour?

A

Cervical dilation 1cm/hr

7 –> 10cm dilatation

Strong and regular contractions

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12
Q

What are the 3 P’s of the second stage?

Hint: these are critical to the success of delivery of the baby.

A

Power
Passenger
Passage

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13
Q

What is POWER in the second stage?

A

Strength of the uterine contractions

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14
Q

What is PASSENGER in the second stage? (Hint: 4 qualities)

A

SLAP

Size: size of head

Lie: position of foetus
compared to mother’s body

Attitude: posture of fetus (back rounded? head/limbs flexed?)

Presentation: Cephalic/shoulder/Breech

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15
Q

What is PASSAGE in the second stage?

A

Size and shape of the passageway, mainly pelvis

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16
Q

What are the 7 cardinal movements of labour?

A
  1. Engagement
  2. Descent
  3. Flexion
  4. Internal rotation
  5. Extension
  6. Restitution and external rotation
  7. Expulsion
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17
Q

What is descent in labour?

A

Position of baby’s head in relation to mother’s ischial spines during descent phase.

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18
Q

How is descent measured in labour?

Hint: There are 3 landmarks

A
  • 5cm: baby high up at round pelvic inlet
    0cm: head is at ischial spines (ENGAGED)

+5cm: when fetal head has descended further out

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19
Q

What is physiological management of the third stage of labour?

A

Placenta delivered by maternal effort without meds or cord traction.

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20
Q

What is active management of the third stage of labour?

A

Midwife/doctor assist in delivering placenta.

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21
Q

Why is active management of the third stage of labour carried out?

A

Shortens 3rd stage and reduces bleeding risk

Done if haemorrhage or 60 min+ delay in delivering the placenta

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22
Q

What drug is primarily used during active management of labour?

A

IM oxytocin to help uterus contract and expel the placenta

Done together with careful traction of umblical cord to guide it out of uterus and vagina.

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23
Q

What are the 4 signs of labour?

A

Show (mucus plug from cervix)

ROM

Regular,painful contractions

Dilating cervix on examination

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24
Q

When is induction of labour used?

A
  • When patients go over due date (41-42 weeks gestation)

or

When beneficial to start labour early:

  • Prelabour ROM
  • FGR
  • Pre-eclampsia
  • Obstetric cholestasis
  • Existing diabetes
  • Miscarriage
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25
Q

What is the Bishop score?

A

Scoring system used to determine whether to induce labour

Assesses 5 things: fetal station, cervical positon, cervical dilatation, cervical effacement and cervical consistency.

Score 8+ = predicts successful induction of
labour

Score below this = cervical ripening may be required to prepare the cervix

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26
Q

What are options for the induction of labour? (List 5)

A

Membrane sweep

Vaginal prostaglandin E2

Cervical ripening balloon (CRB)

Artifical ROM with oxytocin infusion

Oral mifepristone + misoprostol

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27
Q

When is membrane sweet performed?

A

40 weeks gestation+ to initiate labour in women over EDD

Labour induced within 48 hours!

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28
Q

What forms can vaginal prostaglandin be given in?

A

Pessary
Gel
Tablet

Done in hospital so woman can be observed before being let home.

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29
Q

What is the role of prostagladins in labour?

A

Stimulates cervix and uterus to cause onset of labour.

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30
Q

When are CRB and artificial ROM used?

A

To induce labour when vaginal prostagladins are contraindicated or failed.

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31
Q

When is oral mifepristone + misoprostol used?

A

To induce labour where intrauterine fetal death has occured. - Miscarriage :(

32
Q

What 2 monitoring forms are used during induction of labour?

A

CTG (fetal HR and uterine contractions before/during induction of labour)

Bishop score (before and during induction to monitor progress)

33
Q

What is the main complication of inducing labour with vaginal prostaglandins?

A

Uterine hyperstimulation

*Uterus contracts prolonged and frequent - causes fetal distress and compromise

34
Q

What are the 2 criteria for uterine hyperstimulation?

A

Individual uterine contractions lasting more than 2 minutes in duration

More than 5 uterine contractions every 10 minutes

35
Q

What are the risks of uterine hyperstimulation?

A

Fetal compromise (hypoxia/acidosis)

Emergency C-section

Uterine rupture

36
Q

How is uterine hyperstimulation managed?

A

Removing vaginal prostaglandins or stopping oxytocin infusion (stop medications causing contractions for labour)

Tocolysis with terbutaline (stop contractions)

37
Q

When does a perineal tear occur?

A

When external vaginal opening is too narrow to accommodate the baby.

Baby’s head passes and tears through.

38
Q

How are perineal tears classified?

A

Frenulum of labia minora and superficial skin (1st degree)

Perineal mucles (2nd degree)

Large tear involving anal sphincter (3rd degree)

Large tear involving rectal mucosa (4th degree)

39
Q

What are risk factors for perineal tears?

A 
First births (nulliparity)
Large babies (over 4kg)
Shoulder dystocia
Asian ethnicity
Occipito-posterior position of fetus
Instrument delivery
40
Q

How are perineal tears managed?

A

Depends on their degree.

First degree - no sutures

2+ degree - sutures + the following:

  • Broad spectrum abx to reduce infection
  • Laxatives to reduce constipation and wound dehiscence
  • Physio to reduce incontinence
  • Followup to monitor for longstanding complications

Women symptomatic after 3rd/4th degree tears are offered elective C-section in subsequent pregnancies.

41
Q

What are short term complications after repair of perineal tears?

A

Pain
Infection
Bleeding
Wound dehiscence/breakdown

42
Q

What are long-term complications of perineal tears?

A

Urine/faecal incontinence
Painful sex
Psych/mental health
Fistula between vagina/bowel (rare)

43
Q

Why is an episiotomy sometimes performed?

A

Cut in perineum

Done when anticipating more room for delivering baby

Avoids damaging the anal sphincter in a perineal tear

Cut is sutured after delivery

44
Q

Why is a perineal massage sometimes perfomed?

A

Done in advance of delivery to stretch and prepare the tissues for delivery.

45
Q

How much blood needs to be lost to be classified as a postpartum hemorrhage?

A

500ml (if vaginal delivery)

1000ml (after C-section)

46
Q

What are the 4 grades of postpartum hemorrhage?

A

Minor PPH <1000ml loss
Major PPH >1000ml loss

Moderate PPH 1000-2000 loss
Severe PPH >2000ml loss

47
Q

What is the difference between primary and secondary postpartum hemorrhage?

A

Primary PPH - bleeding within 24h of birth

Secondary PPH - bleeding from 24h - 12 weeks after birth

48
Q

What are the 4 causes of postpartum hemorrhage?

Hint: 4 T’s

A

Tone - uterine atony
Trauma - perineal tear
Tissue - retained placenta
Thrombin - bleeding disorder

49
Q

What are risk factors for postpartum hemorrhage?

A 
Previous PPH
Multiple pregnancy
Obesity
Large baby
Failure to progress in second stage of labour
Prolonged third stage
Pre-eclampsia
Placenta accreta
Retained placenta
Instrumental delivery
General anaesthesia
Episiotomy or perineal tear
50
Q

What are preventative measures against postpartum hemorrhage?

A

Treating anaemia antenatally

Giving birth with empty bladder (full bladder reduces uterine contraction)

Active management of 3rd stage (with IM oxytocin)

IV tranexamic acid (during C-section in 3rd stage in higher risk patients)

51
Q

List the management steps for postpartum hemorrhage.

A

MDT approach

ABCDE resuscitation

Lie woman flat, keep warm and communicate

Insert 2x large cannulas

Bloods - FBC, U&E, Clotting

Group+cross match 4 units blood

Warmed IV fluid and blood as required

Oxygen (regardless of saturations)

FFP when clotting abnormalities or after 4 units of blood

52
Q

What blood group can be used instead of crossmatched blood/

A

O negative

53
Q

What are MECHANICAL treatment options for stopping the bleeding with postpartum hemorrhage?

A

Rubbing uterus (stimulates contraction)

Catherisation (bladder distension prevents uterus contractions)

54
Q

What are possible sources of bleeding for postpartum hemorrhage?

A 
Uterine rupture
High vaginal tear
Cervical tear
Perineal trauma
Retained placenta

Usually atonic uterus is the cause or fails to contract properly.

55
Q

When is an atonic uterus more common?

A

During prolonged labour

Grand multiparity

OVerdistension of uterus (polyhydramnios, multiple pregnancy)

56
Q

What are MEDICAL treatment options for stopping the bleeding with postpartum hemorrhage?

A

Oxytocin (IM + IV infusion) - stimulates uterus contraction

Ergometrine (IV/IM) - stimulates smooth muscle contraction. Don’t use if HTN.

Carboprost (IM) - prostagladin analogue - stimulates uterus contraction. Don’t use if asthma.

Misoprostol (SL) - prostagladin analogue - stimulates uterus contraction.

Tranexamic acid (IV) - antifibrinolytic reduces bleeding

57
Q

What are SURGICAL treatment options for stopping the bleeding with postpartum hemorrhage?

A

Intrauterine balloon tamponade (presses against bleeding)

B-Lynch suture (around uterus, compresses it)

Uterine artery ligation

Hysterectomy (last resort, only to save woman’s life)

58
Q

What is likely to cause secondary postpartum hemorrhage?

A

Retained placenta

Infection (endometritis)

59
Q

What are investigations that can be done for secondary postpartum hemorrhage?

A

USS for retained placenta

Endocervical/high vaginal swabs for infection

60
Q

How is secondary postpartum hemorrhage managed?

A

Depends on cause

Surgical input - retained placenta

Antibiotics - infection

61
Q

What is cord prolapse?

A

Umbilical cord goes below presenting part of the fetus –> through cervix —> into vagina

Happens after ROM

62
Q

What is the most dangerous complication of cord prolapse?

A

Fetal hypoxia due to cord being compressed

*cord compression due to presenting part of the fetus pressing on the cord

63
Q

What is the most significant risk factor for cord prolapse?

A

Abnormal lie after 37 weeks gestation (unstable, transverse, oblique)

64
Q

How is umbilical cord prolapse diagnosed?

A

Signs of fetal distress on CTG

Vaginal speculum examination

65
Q

How is umbilical cord prolapse managed?

A

Emergency C-section

Left-lateral position or knee-chest position (all 4s) to draw fetus away from pelvis and reduce cord compression

Tocolysis (terbutaline) to minimise contractions while waiting for C-section

66
Q

What is the role of oxytocin in labour and delivery?

A

Ripens cervix

Causes uterus contractions

*Also role in lactation during breastfeeding

Induce/progress labour

Prevent/treat PPH

67
Q

Where is oxytocin secreted?

A

Posterior pitutary gland

*Produced in the hypothalamus first

68
Q

What is atosiban and when can it be used?

A

Oxytocin receptor antagonist

Used as alternative to nifedipine in tocolysis in premature labour when nifedipine is contraindicated.

69
Q

What is ergometrine used for?

A

Reduce/treat PPH when delivering placenta

  • Used only AFTER delivery of baby (3rd stage)
  • Works by stimulating smooth muscle contraction in uterus and blood vessels
70
Q

What is the role of prostaglandins in labour and delivery?

A

Stimulating contraction of uterine muscles

Ripening cervix before delivery

*Also involved in menstruation - contracting uterine muscles

71
Q

Which specific prostaglandin is used for the induction of labour?

What are the 3 forms?

A

Prostaglandin E2

Pessary, tablets, gel

72
Q

What is the effect of prostaglandins on blood vessels?

A

Vasodilators

Reduce BP

*NSAIDs work antagonistically so increase BP

73
Q

What is misoprostol and what is it used for?

A

Prostaglandin analogue
Binds prostagladin receptors and activates them

Inducing labour after intrauterine fetal death

Abortions

*Hint: Miso = Misery

74
Q

What is nifedipine and what is it used for in pregnancy?

A

Calcium channel blocker

  1. Reduce BP in HTN and pre-eclampsia
  2. Tocolysis in premature labour - suppresses uterine contractions and delays onset of labour
75
Q

What is terbutaline and what is it used for in pregnancy?

A

Beta 2 agonist

Acts on smooth muscle of uterus to suppress uterine contractions

Used for tocolysis in uterine hyperstimulation (if contractions +++ during induction of labour)

76
Q

What is carboprost and what is it used for?

A

Synthetic prostaglandin analogue

Stimulates uterine contraction

Deep IM injection to stop PPH *used when ergometrine/oxytocin unsuccessful

*Can cause life-threatening complication with asthma

77
Q

What is tranexamic acid and what is it used for in pregnancy?

A

Antifibrinolytic (binds plasminogen and prevents conversion to plasmin)

Plasmin = breaks down fibrin blood clots

Prevention + treatment of PPH

Obs & Gynae (13 decks)

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