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Y4 - GOSH > stages of labour > Flashcards

stages of labour Flashcards

1
Q

what re the 7 steps of engagement and descent which allow a baby to be born

A

engagement and descent

flexion

internal rotation of the head

extension of the head

restitution

internal rotation of the shoulder

lateral flexion

delivery of the anterior then posterior shoulder

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2
Q

how do you differentiate between Braxton-Hicks contraction and labour

A

Labour is painful, progressive in frequency, amplitude and duration

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3
Q

what are the different stages of labour

A

1st stage - labour
2nd stage - delivery of the baby
3rd stage - delivery of placenta

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4
Q

what are the different phases of 1st stage of labour

A

1st stage of labour = from onset of labour to full dilatation of the cervix

latent phase - painful contraction which are not necessarily continuous along with some changes eg effacement and dilatation to 4 cm

active/established phase - regular painful contraction (5 mins apart and getting closer and short) and progressive dilation from 4 cm to full dilatation (10cm)

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5
Q

what is considered to be a failure to progress in a primigravid lady?

A

< 2cm per 4 hours of dilatation

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6
Q

what is considered to be a failure to progress in a multip lady?

A

< 2cm per 4 hour of dilatation or regression of dilatation

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7
Q

what are some causes of failure to progress?

A

Power - insufficient uterine activity
Passenger - malpositions, large baby
Passage - inadequate pelvis

or a combination of all those

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8
Q

what is the management of failure to progress?

A

if in the latent phase - manage conservatively

active phase

  • ARM and reassess in 2 hours
  • amniotomy + syntocinon infusion and reassess in 2 hours
  • LSCS
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9
Q

when is passive and active stages of 2nd stage of labour

A

passive 2nd stage - full dilatation of cervix prior to or in absence of involuntary expulsive contractions

active 2nd stage - when mother starts expulsive efforts using her abdo muscles

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10
Q

when is delayed of 2nd stage of labour diagnosed?

A

primi -
once actively pushing, delay of the second stage is diagnosed wif birth not imminent in 2 hours

multi-
once actively pushing, delay of the second stage is diagnosed if birth is not imminent in 1 hour

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11
Q

mx of delayed of 2nd stage of labour

A

instrumental delivery or C-section

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12
Q

what is active management of 3rd stage of labour

A

reduces risk of maternal haemorrhage, anaemia & need for transfusion and shorten 3rd stage

  • syntocinon
  • early clamping and cutting of the cord
  • controlled cord traction

prolonged active 3rd stage of labour - 30 minutes

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13
Q

what is physiological management of 3rd stage of labour

A

no routine use of uterotonic drugs
no clamping of cord until pulsation has ceased
delivery of placenta by maternal effort

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14
Q

when should a physiological management of 3rd stage of labour converted into active

A

when haemorrhage
failure to deliver the placenta in 1 hour
maternal desire to shorten 3rd stage

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15
Q

what are some maternal monitoring during labour

A 
BP
HR 
temp 
urineanalysis 
vaginal loss - colour 
contraction frequency, strength & length 
abdo palpatations 
VE to determien progress

all recorded on partogram

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16
Q

what are some foetal monitoring

A

low risk
- intermittent auscultation of fetal heart using sonicaid/doppler

high risk

  • continuous monitoring - CTG using foetal scalp electrode- DR C BRAVADO
  • foetal blood sampling
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17
Q

what are the management of worrying CTG

A

1) left lateral position
2) IV fluids
3) foetal scalp stimulation
4) foetal blood sample
- deliver if FBS is bad

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18
Q

how do you interpret FBS

A

pH > 7.25 = nomral
7.20-7.25 = bordeline
< 7.20 = deliver

must be 3 cm dilated to conduct FBS

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19
Q

what are the non-pharmacological methods of managing pain

A

education regarding what to expect
warm bath, acupuncture, hypnosis, aromatherapy and homeopathy
transcutaneous electricl nerver stimulation (TENS) - may not be adequate as labour advances

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20
Q

what are the pharmacological methods of managing pain

A

Entonox - works on the NMDA receptor, short half life so can not overdose on it

paracetamol

opioids - Daimorphine is 1st line in labour

opioids - pethidine - can cause neonatal respiratory distress and so will need naloxone

regional anesthesia

  • pudendal nerve block for operative vaginal delivery
  • local anesthetics - before performing an episiotomy

epidural or combined spinal analgesia

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21
Q

disadvantage of epidural

A 
inc supervision 
maternal fever 
reduced mobility - inc PE risk 
inc instrumental delivery rate 
hypotension 
urinary retentions
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22
Q

advantage of epidural

A

most effective analgesia in labour

can be topped up

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23
Q

what are some general indication for induction of labour

A

when it is agreed that the foetus or mother will benefit from a higher probability of a healthy outcome that if birth is delayed

prolonged pregnancy

IUGR

HTN and pre-eclampsia

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24
Q

obstetric indications for induction of labour?

A 
uteroplacental insufficiency 
prolonged pregnancy 
IUGR 
oligo or anhydramnios - twins 
non-reassuring CTG 
PROM 
pre-elcampsia/eclampsia 
DM - induce at 38 weeks 
IUD 
antepartum haemorrhage 
chorioamnionitis
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25
Q

maternal indications for induction of labour?

A 
HTN 
DM
renal disease 
malignancies 
cardiac abnor 
 > 40 - induce @ term
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26
Q

what are some C/I to induction of labour

A

absolute

  • acute foetal compromise
  • placental praevia
  • unstable lie
  • pelvic obstruction

relative

  • previous C-section - still inc risk of uterine rupture
  • breech
  • prematurity
  • high parity
27
Q

when will you consider induction of labour according to Bishop score?

A

if Bishop score < 5 - labour unlikely to start on its own

28
Q

when will you not consider induction of labour according to Bishop score?

A

if Bishop score > 9, most likely to commence labour spontaneously

29
Q

what is the first thing to do before offering a formal induction of labour?

A

stretch and sweep

if nuiparious - 40-41 weeks
if miltiparious - 41 weeks onward

cervical ripening with prostaglandin in tablet, gel or tape form

30
Q

what is the general pathway of induction of labour

A

stretch and sweep

cervical ripening - prostaglandin, can try twice 6 hours after the other and allow 6 hours to work

oxytocin

or

amniotomy/ARM

if no uterine contraction after 2 hours from ARM - oxytocin infusion

31
Q

how would you use oxytocin to induce or agment a labour

A

start off with low dose
inc every 30 mints to achieve optimal contractions (3-4 every 10 mins, each lasting 30-60 sec)

continuous CTG should be use

32
Q

complications for oxytocin use for induction or agmentation?

A

hyperstimulation - reduce rate if using oxytocin, can use terbutalien (tocolytic)

operative delivery 
amniotic fluid embolus 
prematurity 
cord prolapse 
SE of oxytocin 
- inc pain or discomfort 
- foetal distress 
uterine rupture

prostaglandin
- N+V
diarrhoea
bronchorestriction - caution in asthmatic

C/S should induction fails

33
Q

when will you augment a labour

A

when failure to progress

  • muti - 2cm per 2 hours
  • pri - 1cm per 2 hours
34
Q

how would you augment the labour in 2nd stage of labour?

A

if after 2 hours of passive descent, push for 1 hour
- then no progress

  • is the baby above or below the ischial spines?
  • is above C-S
    if below - instrumental delivery
35
Q

what is the most common malposition?

A

occipito-posterior - often result in longer labour

36
Q

mx of occipito-posterior position?

A

close monitoring of both foetus and mother
epidural recommended
adequate fluids be given to mother
discourage any urge to push before full dilatation

forceps or C-Section maybe required

37
Q

mx of occipito transverse position

A

the head must be rotated using the Kielland’s focreps or delivered using vacuum extraction in theatre so can quickly transition into C-section

if fails –> C-section

38
Q

mx of face-presentation

A

if mento-anterior position - mento = chin, results in longer labour but should be fine

if mento-posterior - C-section

39
Q

mx of brwo’s position

A

C-section as vaginal delivery is not possible since the diameter of head is too big

40
Q

what are the different types of breech presentation

A

extended
flexed
footling - requires C-section

41
Q

what is breech position associated with

A

congenital abnor - pre-term baby and so contribute to congenital abnor

also associate with placenta praevia, abnor of the uteres eg fibroids

42
Q

mx of breech position

A

external cephalic version

  • from 36 weeks in nulliparous
  • from 37 weeks in multi
  • anti-D should be given if mother is Rh -ve

common practice for breech position is C-section although vaginal delivery is possible, emergency C-section risk is high

43
Q

contra-indication for ECV

A

absolute

  • when C-section already indicated
  • APH
  • foetal compromise
  • oligohydramnios
  • rhesus status
  • pre-eclampsia

relative

  • previous C-S
  • foetal abnor
  • maternal hypertension
44
Q

what are some risks associated with transverse and unstable lie

A

obstructed labour and potential uterine rupture

cord prolapse - 20%

45
Q

mx for transverse or unstablie lie

A

unstable lie - admit to hospital from 37 weeks, CS can be carried out if labour stars or membrane rupture

inc gestation will help to revert the lie to longituitonal

is lie is still unstable – >C/s at 41 weeks

46
Q

when should twins be delivered?

A

induced at 38 weeks

47
Q

management of twins delivery

A

continuous CTG monitoring
monitor leading twin with foetal scalp electrode

deliver twins in theatre

the 1st twin can be delivered vaginally, after the 1st twin is delivered, the lie of twin 2 should be check and stabilise with abdominal palpitation

2nd twin is usually delivered within 20 minutes of the 1st

oxytocin may help with diminishing contraction

if any distress with twin 2 - forceps or ventouse

C-section if failed

48
Q

what are some of the risk of labour of twins

A 
malpresentation 
foetal hypoxia in second twin after delivery of 1st 
cord prolapse 
operative delivery 
post-partum haemorrhage

rare
cord entanglement - MCMA twins only
head entrapment with each other - locked twins

49
Q

what are some maternal indication for instrumental delivery

A 
exhaustion 
to avoid inc ICP 
to avoid inc BP 
prolonged 2nd stage 
> 1 hour of active pushing in multi, > 2 hours of active pushing in premip
50
Q

what are some foetal indication for instrumental delivery

A

foetal compromise

to control the after coming head of breech

51
Q

when should you not use a ventouse

A

when foetus < 34 weeks

52
Q

what is the requirement for instrutmental delivery

A

FORCEPS

Fully dilated cervix 
OA position preferable 
Ruptured membranes 
cephalic presentation 
Engaged presenting part 
pain relief is adequate 
- vacuum or low forceps - perineal nerve block 
- mid - forceps - epidural or pudeneal nerve block or general anaesthetic 
sphincter bladder - empty
53
Q

what are some side effect of C-section

A

abdo pain
VTE
bladder or uretric injury
hysterectomy

54
Q

what are the main indication for C-S

A 
breech presentation 
foetal compromise 
repeated C-S 
failure to progress 
maternal request
55
Q

what are the different categories of C-Section

A

Cat 1 - immediate threat to life of the women or foetus
Cat 2 - maternal or foetus compromise which is not immediate threat to life
Cat 3 - no maternal or foetal compromise but needs early delivery
Cat 4 - elective

56
Q

what requires Cat 1 C-section

A

crash C-section should be done within 30 minutes

  • placental abruption with abnor FHR or uterine irritability
  • cord prolapse
  • uterine scar rupture
  • prolonged bradycardia
  • scalp pH < 7.2
57
Q

what requires a Cat 2 C-section

A

failure to progress with pathological CTG

58
Q

what requires a Cat 3 C-section

A

severe pre-eclampsia
IUGR with poor foetal function tests
failed induction of labour

59
Q

what requires a Cat 4 C-section

A

elective - delivery timed to suit woman and staff

  • twin pregnancy with no-cephalic 1st twin
  • maternal HIV
  • primary genital herpes in 3rd trimester
  • placenta praevia
  • prev hysterotomy or classical C-S

usually carried out at around 39 weeks

60
Q

what are some complications for C-section

A

intra-op

  • bladder laceration
  • bowel laceration
  • uterine or uterocervical laceration
  • inc blood loss
  • hysterectomy

post-op

  • endometritis
  • wound infections
  • pulmonary atelectasis +/- infection
  • VTE
  • UTI

longterm

  • urinary and bowel incontinence
  • uterine rupture
  • placenta praevia & plaenta accreta
  • antepartum stillbirth
61
Q

What does shoulder dystocia

A

Usually the anterior shoulder is impacted against the synthesis pubis due to failure of internal rotation of the shoulder

Posterior shoulder can also be impacted leading to bilateral impaction which greatly increase mortality

62
Q

What are the complications of shoulder dystocia

A

foetal

cerebral palsy 
brachial plexus palsy - Erbs & Klumpkes 
fracture of the clavicle or humerus 
intracranial haemorrhage 
cervical spine injury 
rarely foetal death

maternal

PPH
genital tract trauma - 3rd and 4th-degree tear

63
Q

RF for shoulder dystocia

A

Antenatal

Previous history of shoulder dystocia
foetal macrosomia
BMI > 30 & excessive weight gain in pregancny
Diabetes
post-term

intrapartum

lack of Progress in late first stage of labour
Induction of labour
Prolong second stage
Instrumental vagina delivery
Oxytocin augmentation of labor
64
Q

management of shoulder dystocia

A

MCroberts
suprapubic pressure
episotomy - only if advanced intervention is required

advance intervention 
- rotate shoulder - woodscrew 
- deliver posterior arm - woodscrew 
- break clavicle 
emergency C-section

Y4 - GOSH (12 decks)

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