O&G: Obstetrics > Labour > Flashcards

Labour Flashcards

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1
Q

What is this describing?
The process of uterine contraction and cervical dilation enabling uterus to deliver viable foetus, placenta, and membranes.

A

Labour

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2
Q

What confirms the diagnosis of labour?

A

Regular and increasingly painful uterine contractions bringing about progressive cervical effacement and/or dilation.

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3
Q

Which stage of labour is this?

Period between onset of regular contractions to full cervical dilation.

A

Stage 1

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4
Q

What are the two phases of stage 1 of labour?

A
  1. Latent - duration for cervix to become effaced and dilated to 3cm
  2. Active - duration for cervix to dilate from 3-10cm, should be 1cm/hour
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5
Q

How long does the latent phase of labour take for nulliparous and multiparous women?

A
  1. 6-8 hours nulliparous

2. 4-5 hours multiparous

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6
Q

Which stage of labour is this?

From full cervical dilation to delivery of foetus.

A

Stage 2 (30-60 mins)

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7
Q

Which stage of labour is this?

From delivery of the foetus to delivery of the placenta and membranes.

A

Stage 3 (15 mins)

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8
Q

What are the steps in head movement in labour?

A
  1. Engagement
  2. Descent and flexion
  3. Rotation - face facing sacrum
  4. Rotation completed, further descent
  5. Extension and delivery
  6. Restitution - rotates to previous position
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9
Q

What three factors does progress of labour depend on?

A

Power, passage, passenger

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10
Q

Where do you record cervical dilation and what is the definition of latent phase?

A
  1. Partogram

2. <2cm dilation in 4 hours

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11
Q

What causes a lack of power in stage 1 of labour?

A

Insufficient uterine action, most common cause of slow labour.

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12
Q

How do you manage insufficient uterine action in 1st stage of labour?

A
  1. 1st line is artificial rupture of membranes
  2. If this fails, IV oxytocin with CTG monitoring
  3. If full dilation does not occur within 8 hours, C-section
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13
Q

What is the targeted uterine activity for the first stage of labour?

A

4-5 contractions every 10 mins, each lasting >40 seconds.

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14
Q

What causes a lack of power in stage 2 of labour?

A

Insufficiency in uterine action and maternal exhaustion.

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15
Q

When should women in second stage of labour be reviewed for ability to push?

A
  1. After 1 hour pushing nulliparous, if CTG good and progress being made, she can push for 2 hours before considering instrument/C-section.
  2. Multiparous women can push for one hour before considering intervention.
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16
Q

What are the different foetal head positions that can impede labour?

A
  1. Occipito-posterior position
  2. Occipito-transverse position
  3. Brow presentation
  4. Face presentation
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17
Q

What is the management for occipito-posterior position of foetal head during labour?

A
  1. If progressing normally, no action, may spontaneously resolve.
  2. If not progressing to full cervical dilation, LSCS needed.
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18
Q

What is the management for occipito-transverse position of foetal head during labour?

A

Rotation with ventouse required to deliver

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19
Q

What is the management for a brow presentation during labour?

A

Usually does not deliver vaginally, C-section needed.

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20
Q

What is the main problem with passage affecting labour?

A

Cephalo-pelvic disproportion - pelvis is too small to allow head to pass through due to android pelvis

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21
Q

What shape pelvis do most women have?

A

Gynaecoid pelvis

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22
Q

What is the management for cephalo-pelvic disproportion in labour?

A

C-section usually needed

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23
Q

What are the options for pharmacological pain relief in labour?

A
  1. Entonox - 50% oxygen, 50% nitrogen; rapid onset, mild, nausea, faint feeling.
  2. Systemic opioids - IM pethidine and IM cyclizine, drowsiness, nausea, neonatal respiratory depression (not for use in birthing pool)
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24
Q

What is a pudendal nerve block for and where is it injected?

A
  1. Regional pain relief in instrumental delivery

2. Lidocaine injected near ischial spine on each side of S2-4 vertebrae

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25
What is injected into the perineum before an episiotomy?
Local lidocaine
26
What is the epidural pain relief given in labour, where is it administered, and how?
1. Opioid and local anaesthetic 2. L3/4 or L4/5 3. Indwelling epidural catheter
27
What can epidural pain relief cause in the foetus?
Transient foetal bradycardia
28
What are the side effects of regional pain relief in labour?
1. Transient hypotension 2. Reduced bladder sensation - urinary retention 3. Spinal tap - inadvertent puncture of dura, severe headache worse when sat up, better lying down
29
What are the contraindications for regional pain relief in labour?
1. Sepsis 2. Coagulopathy 3. Spinal abnormalities 4. Hypovolaemia
30
How is spinal anaesthesia administered and what is it used for?
1. Local anaesthetic injected as single shot through dura and arachnoid into CSF. 2. Used for most C-sections
31
What is this describing? | Hypoxia that may result in foetal damage or death of not reverse or the foetus delivered immediately.
Foetal distress
32
How frequently is the foetal heart sound auscultated in the 1st and 2nd stages of labour?
1. Every 15 mins | 2. every 5 mins
33
What does foetal distress show on doppler USS in labour?
Abnormal heart rate patterns - CTG monitoring
34
What does DR C BRaVADO stand for and what is it for?
1. Define Risks 2. Contractions 3. Baseline RAte 4. Variability 5. Accelerations 6. Decelerations 7. Overall impression Used to interpret cardiotocograph (CTG)
35
What is the DR in DR C BRaVADO?
# Define Risks: 1. Maternal conditions | 2. Foetal complications
36
What is the C in DR C BRaVADO?
Contractions: 1. Number in 10 mins 2. Each big square is 1 min, count number of peaks in 10 big squares.
37
What is the BRa in DR C BRaVADO?
Baseline RAte: 1. Average heart rate of foetus in 10 mins (normal 110-160bpm) 2. Tachycardic - dehydration, acute foetal hypoxia, maternal pyrexia, infection, hyperthyroidism, anaemia. 3. Bradycardic - prolonged cord compression, epidural anaesthesia, maternal seizures, drugs, congenital heart disease.
38
What is the V in DR C BRaVADO?
Variability: 1. Look at amplitudes of peaks and troughs, controlled by foetal brain )integrity of ANS), normal 5-25bpm 2. Reduced - foetal sleeping, narcotics, foetal acidosis, prematurity, foetal tachycardia
39
What is the A in DR C BRaVADO?
Accelerations: 1. Abrupt increases in baseline HR >15bpm for >15s, normal 2 per 20 mins. 2. Presence is reassuring, during contractions indicates healthy foetus.
40
What is the D in DR C BRaVADO?
Decelerations: 1. Abrupt decrease in baseline HR <15bpm for >15s 2. Early - caused by head compression (physiological) 3. Variable - caused by cord compression (pathological) 4. Late - due to maternal hypotension, PET, uterine hyperstimulation (foetal distress)
41
What is the O in DR C BRaVADO?
Overall impression: 1. Reassuring - HR 110-160bpm, variability 5-25bpm, decelerations (none or early) 2. Non-reassuring - HR or variability outside range, decelerations (some variable/some late). 3. Abnormal - HR way outside range, variability for longer time period, decelerations over a long period.
42
How is foetal distress managed?
1. Place women in left lateral position (avoid aortocaval compression). 2. Oxygen and IV fluids, stop oxytocin, stop contractions with terbutaline, PV exam to exclude cord prolapse, plan to expedite delivery. 3. If simple measured fail - proceed to foetal blood sampling.
43
What is foetal blood sampling, what is it for, and when should delivery take place immediately?
1. Small scratch on foetal scalp and blood collected. 2. If CTG abnormal 3. If pH <7.2 then deliver immediately
44
When should a woman come to hospital in labour?
When contractions are regular, painful, and lasting 30 seconds, occurring every 3-4 mins, or if the membranes have ruptured.
45
What is done for the mother in the 1st stage of labour?
1. Comfort, mobile, support, attention 2. Analgesia 3. Vital signs, fluid balance monitored 4. Plot on partogram
46
What is done for the foetus in the 1st stage of labour?
Foetal heart auscultated every 15 mins of if high risk then CTG, follow steps in managing results of CTG as per DR C BRaVADO then carry out foetal blood sampling if necessary.
47
What can be done for progression in the 1st stage of labour?
1. Vaginal examination every 4 hours | 2. Otherwise if slow progress - artificial rupture of membranes +/- oxytocin - C-section
48
What can be done in 2nd stage of labour when the head is not passing over the perineum despite maternal effort/to prevent tears?
Episiotomy
49
What is the process of an episiotomy?
LA given, 3-5cm cut made from centre of fourchette at 45 degree angle to mother's right side of perineum.
50
What are the different degrees of perineal tear?
1. 1st degree - superficial 2. 2nd degree - involves perineal muscles 3. 3rd degree - involves anal sphincter 4. 4th degree - involves rectal mucosa
51
What is the difference between 1st and 2nd degree, and 3rd and 4th degree perineal tear repair?
1. Resorbable sutures under local anaesthetic | 2. Repair under general/spinal anaesthetic
52
What medication is given during the 3rd stage of labour as the anterior shoulder is delivered?
IM syntometrine (oxytocin and ergometrine)
53
What medication is given during the 3rd stage of labour as the anterior shoulder is delivered in patients with PET/severe HTN/CVD?
IM oxytocin alone (without ergometrine)
54
What indicates that the placenta has separated during the 3rd stage of labour?
Cord lengthening and passage of blood
55
What checks must you carry out after placental delivery?
1. Check placenta to completeness and estimated blood loss 2. Check perineum for tears and suture 3. Clean mother and make comfortable
56
What is the management for a retained placenta?
1. 3rd stage delayed 2. Manual removal of the placenta under general/spinal anaesthetic 3. Cross-match blood and give IV antibiotics
57
What are the indications for forceps/ventouse?
1. Prolonged 2nd stage, maternal exhaustion 2. Foetal distress 3. Prophylactic use to prevent pushing in mothers with HTN/severe cardiac issues
58
At what stations are different delivery mechanisms used?
1. 0 = forceps 2. >0 ventouse 3. <0 = C-section
59
What is necessary before forceps/ventouse can be used?
1. 0/5 or 1/5 head palpable abdominally 2. Ruptured membranes 3. Fully dilated cervix 4. Epidural or pudendal block 5. Adequate contractions 6. Bladder empty 7. Cephalic presentation 8. Satisfactory foetal condition
60
What are the pros and cons to forceps?
1. Pros - less maternal effort, less likely to fail | 2. Cons - can cause trauma to genital tract
61
What are the pros and cons to ventouse?
1. Pros - less likely to cause maternal trauma 2. Cons - more likely to cause foetal trauma (chignon swelling on foetal head, diminishes over time), more likely to fail
62
When should instrumental delivery be abandoned for C-section?
If no descent with each pull or if delivery not imminent after 3 pulls.
63
What are the two types of C-section?
1. LSCS - transverse incision in lower segment of uterus | 2. Classical CS - vertical incision in uterus
64
What are the indications for classical C-section?
Very premature, transverse foetal lie, multiple fibroids
65
What are the indications for a C-section?
Foetal bradycardia, scalp pH <7.2, cord prolapse, failure to progress in labour, failed induction of labour, malpresentation, severe PET, IUGR with AEDF, twin pregnancy with non-cephalic twin, placenta praevia.
66
What are the four different time frames of a C-section?
1. Emergency - immediate threat to mother/foetus 2. Urgent - maternal/foetal compromise not immediately life threatening 3. Scheduled - needing early deliver but no compromise 4. Elective - at term to suit mother and team
67
What are the maternal risks involved in a C-section?
1. Haemorrhage - blood transfusion 2. Infection of uterus 3. Bladder/bowel damage 4. Post-operative pain 5. VTE 6. Increase in future placenta praevia, accreta, percreta.
68
What is given to the mother after a C-section to prevent complications?
1. Prophylaxis antibiotics and VTE are routine | 2. Give ranitidine to prevent aspiration
69
What are the foetal risks involved in C-section?
1. Transient tachypnoea of the new born 2. Bonding and breastfeeding affected in emergency 3. Increase in atopy, obesity, DM
70
How long is the average stay in hospital after a C-section?
2-3 days
71
What is the Bishop's score for and what does a score over and under 6 indicate?
1. Assessing favourability/ripeness of the cervix, the greater the score, the more favourable. 2. Under 6, use prostaglandins 3. Over 6, artificial rupture of membranes
72
What are the indications for induction of labour?
Prolonged pregnancy, IUGR (>34/40), APH, prelabour term rupture of membranes, PET, HTN, DM, in utero death.
73
What are the absolute contraindications to induction of labour?
Foetal compromise from CTG, abnormal lie, placenta praevia, after >1 C-section.
74
What are the problems associated with induction of labour?
Failed induction, uterine hyperstimulation, PPH, infection, higher risk of instrumental delivery and C-section.
75
What are the absolute contraindications to a vaginal birth after a previous C-section?
Vertical uterine scar, previous uterine rupture, >2 C-sections.
76
What is the definition of a stillbirth?
Foetus is delivered dead after 24 completed weeks gestation.
77
What are the causes of stillbirth?
1. IUGR/SGA 2. Unexplained very common 3. Chromosomal abnormalities 4. APH 5. DM, SCD, autoimmunity, renal disease 6. PET, GDM 7. Infection
78
How is stillbirth diagnosed?
1. Mothers report reduced/absent foetal movement | 2. Absent foetal heart beat on USS
79
What is the management for a stillbirth?
1. Give anti-D if RhD -ve 2. Kleihauer to diagnose foeto-maternal haemorrhage 3. Induce labour with mifepristone PO 4. Oxytocin may be needed later 5. Wrap and offer to give to mother, photos taken, lock of hair and palm print given 6. Lactation suppression with cabergoline 7. Certificate of Stillbirth is required
80
What maternal tests are done to establish a cause of stillbirth?
Kleihauer, FBC, CRP, LFT, TFT, HbA1c, blood culture, HVS, viral screen, thrombophilia screen, SLE screen, MSU, UDS.
81
What foetal tests are done to establish a cause of stillbirth?
Placental histology and culture, post-mortem if not declines, consider foetal MRI.
O&G: Obstetrics
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