Week 4 - C - Abnormal Labour - Failure to progress, analgesia, foetal distress and management

Question 1

When is a pregnancy pre-term (premature)? When is a pregnancy term? When is a pregnancy post-term?

Answer 1

Pre-term pregnancy is when baby is delivered before 37 weeks Term is from 37-42 weeks Post-term pregnancy is when baby is delivered after 42 weeks

Question 2

What are the non-pharmacological options for analgesia in pregancy?

Answer 2

Massage Change positioon Warm bath

Question 3

What are the pharmacological options for analgesia during pregnancy?

Answer 3

TENS - trans-cutaneous electrical nerve stimulation - can target the different level in the spinal cords which monitor pain in pregnancy (and provide motor function) Entonox - laughing gas - nitrous oxide with oxygen IM opiate - diamporphinne Regional anesthetic - epidural or spinal

Question 4

What spinal cord level relays pain from the pelvic organs? Which spinal cord level relays pain from the perineal strucutres?

Answer 4

Superior apsect of pelvic organs - sensations runs alongside the sympathetic nerve fibres to enter the spinal cord at T11-L2 level Inferior aspect of pelvic organs - sensation run alongside the parasympathetic nerve fibres to enter the spinal cord at S2-4 level Sensation from perineum enters the spinal cord at S2-4 level

Question 5

What is considered prolonged second stage of labour in nullparous and multiparous women? Both using and not using regional anaesthesia What is nullparous? What is primigravida?

Answer 5

IN nullparous, second stage of labour is considered prolonged labour if it is labour exceeding three hours with regional anaesthesia or 2 hours without In multiparous women, second stage of labour is considered prolonged labour if it is labour exceeding 2 hours with regional anaesthesia or 1 hour without Nullparous means a women who has never had a child Primigravida means this is the women first pregnancy

Question 6

Epidural anaesthetic is effective and provides complete pain relief in 95% of patients What spinal level is it carried out at? What layers are penetrated by the needle? What are its complications?

Answer 6

Carried out at the L3/4 spinal cord level Skin, subcutaneous tissue, supraspinous ligament, interspinous ligament, ligamentum flavum, epidural space Can cause hypotension, can potentially inhibit progress during the second stage of labour (shouldnt affect uterine contractions)

Question 7

What are the 3Ps that could result in a failure to progress in a pregnancy?

Answer 7

Powers: Inadequate contractions: frequency and/or strength

Passages: Short stature / Trauma / Shape

Passenger: Big baby Malposition - relative cephalo-pelvic disproportion

Question 8

When a midwife or doctor is assessing the progress in labour, when is there a suspected delay in labour during the 1st stage of labour? For nullparous or parous women

Answer 8

Suspected delay if Nullparous - if there is less than 2cm cervical dilation in 4hours of 1st stage of labour Parous - less than 2cm cervical dilation in 4 hours or slowing in progress during 1st stage of labour

Question 9

What position is best for the foetal head entering the pelvic inlet and exiting the pelvic outlet?

Answer 9

Pelvic inlet - occipito-transverse (transverse diameter of pelvis widest here) Pelvic outlet - occipitoanterior (AP diameter of pelvis widest here)

Question 10

As soon as the women enters the labour ward, what is the graphical record of data collection called that the patient is started on? Covers all of the below * Fetal Heart * Amniotic Fluid * Cervical Dilatation * Descent * Contractions * Obstruction - Moulding * Maternal Observations

Answer 10

This is the partogram - contractions are recorded in the number of contractions per every 10 minutes

Question 11

Describe what is shown in the partogram and the possible management

Answer 11

• Feotal liquor is clear however the cervix is not dilating and the foetal descent has halted
• Uterine contractions are weak and not rhythmic which may be a problem (weak uterine contractions could be causing the failure to the cervix to dilate)
• Possible management - give mother syntometrine or oxyctocin to increase uterine contractions

Question 12

Describe what is shown in the partogram and the possible management

Answer 12

Cervix is not dilating and foetus is not descending despite strong uterine contractions - already been given oxytocin

Carry out cardiotocography and possibly Cesarean section if results show the baby is hypoxic

Question 13

In the intra-partum foetal assessment,, regular doppler auscultation of the foetal heart is carried out How often is the foetal heart rate assessed in stage 1 of labour? How often is the foetal heart rate assessed in stage 2? How often is the maternal pulse rate check in stage 2 of labour?

Answer 13

Stage 1

• Doppler asuclatation foetal heart rate every 15 minutes, and during and after every contraction

Stage 2

• Doppler auscultation foetal heart rate every 5 and after a during and after a contraction - after for 1 minute Assess mothers heart rate every 15 minutes in stage 2

CTG also a continuous assessment

Question 14

There are a lot of different risk factors for foetal hypoxia hence the continuous foetal heart monitoring Small fetus - Preterm / Post Dates - Antepartum haemorrhage - Hypertension / Pre-eclampsia - Diabetes - Meconium - Epidural analgesia - VBAC - PROM >24h - Sepsis (Temp > 38C) - Induction / Augmentation of labour What is VBAC? What is PROM?

Answer 14

VBAC - vaginal birth after cesarean Pre-labour rupture of membrane - 60% of women will go into spontaneous labour within 24 hours, if not it is appropriate to induce labour, babies are susceptible to infection here

Question 15

CTG is used for continuous foetal heart rate monitoring throughout labour How is the CTG assessed? What are the 4 features that are documented?

Answer 15

DR - define risk clincially C - Contractions of uterus (how mnay per 10 minuts) BRA - baseline rate of foetal heart V - variability of the foetal heart rate A - accelerations D - decelerations O- overall risk - reassuring or non-reassuring Document - Baseline rate, variability, presence or absence of decelerations, presence of accelerations

Question 16

https://s3.amazonaws.com/classconnection/403/flashcards/11907403/png/pjpgpn_gjpggif-160F0A5481C260EB9D1.png

Answer 16

• Low risk
• Contractions - 3 every 10 minutes
• Foetal heart rate - 130
• Good variation
• Accelerations present
• No deceleration

Reassuring

Question 17

https://s3.amazonaws.com/classconnection/403/flashcards/11907403/png/pjpgpn_gjpggifpngjpg-160F0A6AEB4618C80FF.png

Answer 17

• IOL - induction of labour
• High risk
• Contractions - 4 every 10 minutes
• Baseline rate - 170
• Variations present
• No accelerations
• LAte decelerations - worrying sign of hypoxia - take foetal blood sample and measure pH

Question 18

When taking foetal blood, it is the foetal scalp blood thats pH is tested WHat is the normal foetal scalp pH?

Answer 18

Normal foetal scalp blood pH - >7.25

Question 19

If labour is not progressing adequalty, ie non-reassuring cardiotocography, or delayed second stage of labour, what are other options that are not cesarean section?

Answer 19

Forceps delivery or Ventouse delivery (vacuum delivery)] “Standard” Indications: Delay (failure to progress stage 2) Fetal distress

Question 20

What is prolonged stage 2 of labour again?

Answer 20

Nullparous

• Epidural present - 3 hours
• No epidural - 2 hours

Multiparous

• Epidural present - 2 hours
• No epidural - 1 hour

Question 21

What has a higher failure rate between forceps and vacuum delivery? When can they be used in delayed second stage of labour?

Answer 21

Vacuum delivery has a higher failure rate but analgesia is not requried - preferred worldwide except UK Can only use if the head is engaged - ie below the level of the ischial spines

Question 22

What are the increased risks when using the Ventous oeprative vaginal delivery? What are the advantages?

Answer 22

Increased failure rate Increased risk of cephalohaemtoma in foetus Increased risk of retinal haemorrhage Advantages Less anaesthesia Less vaginal trauma Less perineal pain Use the most appropriate instrument for individual circumstances

Question 23

Caesarean section is an alternative to operative vaginal delivery WHat is the most common type of cesarean section? What layers are incised in this type of section?

Answer 23

Lower sement cesarean section (LCSC) * Skin * Subcutaenous fat * Rectus sheath anteriorly - no posterior sheath below the arcuate line of the abdomen * Rectus sheathed - pulled laterally * Fascia and peritoneum * Bladder is retracted * Uterine wall and amniotic sac incised

Question 24

What is a LSCS also known as?

Answer 24

Pfannenstiel incision, bikini line incision, suprapubic inscison

Question 25

What are the main indications for a CS?

Answer 25

* Previous CS * Foetal distress * Failure to progress in labour * Breech presentation * Maternal request

Question 26

What is the maternal mortality associated risk compared to spontaneous vaginal delivery with CS?

Answer 26

4x increased risk of maternal mortality Morbidity - sepsis, haemorrhage, VTE, trauma, TTN, subfertility, regret, complications in future pregnancy (think as this is a failure major surgery so a lot of the normal surgical complications)

Question 27

What is the most common type of delivery in Tayside? What do the acronyms stand for?

Answer 27

Spontaneous vaginal delivery is most common - approx 65%

• * CS - cesarean section
• * SVD - spontaneous vaginal delivery
• * OVD - operative vaginal delivery - forceps/ventouse
• * VBD - vaginal breech delivery
• * IOL - induction of labour