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Summary Final year MD notes - labour and delivery

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A collection suite of final obstetrics and gynaecology MD notes to ace your penultimate and final year exams! Look no further and save the stress of accessing multiple resources as this PDF collates and summarises information from several resources including but not limited to: -Talley and O�...

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Document information

  • December 4, 2023
  • 9
  • 2023/2024
  • Summary

Subjects

  • labour
  • delivery
  • obstetrics
  • complication
  • abruption
  • stages
  • bishop
  • gynaecology
  • final
  • student
  • sydney
  • notes
  • md

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  • Macquarie University (MQ )
  • Unknown

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LABOUR AND DELIVERY
Malpresentation in pregnancy:
• Vertex ‘normal’ presentation è cephalic-presenting foetus in the occipito-anterior position ® foetal head diameter
Definitions minimise to fit through pelvic brim
• Malpresentation: any position other than the vertex presentation


BREECH PRESENTATION SHOULDER FACE/BROW COMPOUND PRESENTATION
(< 5% of pregnancies by 37 wks) PRESENTATION PRESENTATION
• When presenting part of fetus to pelvis Result of an oblique and • Face - when foetal neck is • foetal extremity precedes or is
is feet or buttocks transverse lie extended and face from adjacent to the presenting part
• Often rotates from cephalic to breech forehead to chin is (i.e. hand/arm next to head
before 28 wks gA presenting
Cause • Frank/extended – hip flexed, • Brow = presenting part
knees extended extending from the anterior
fontanelle to the orbital
• Complete – hips, knees flexed ridge WORST POSITION
• Footling (one or both feet flexed
or extending out)
• Small fetus (preterm, IUGR, SGA, LBW, ancephaly)
• Big fetus (GDM baby) (cephalopelvic disproportion, macrosomia, hydrocephaly,)
RF • Compliant uterus (multiparity, oligo/polyhydramnios),
• Obstructions (pelvic tumours, placenta previa, prior breech delivery)
• black race/ethnicity,
• Abdo palpation with Leopold maneuvers at 36wks GA (feel head superiorly)
® mother may feel subcostal discomfort
• If suspected non-cephalic presentation ® confirm on TVUS
Ix • Vag examination in 2nd stage of labour:
o Face only (cannot palpate anterior fontanelle) ® brow
o buttocks and/or feet ® breech
o ribs / shoulder / prolapsed arm ® shoulder
• Cord prolapse + prolonged cord compression ® fetal hypoxia ® infection risk, fetal resp. distress (anoxia), meconium aspiration
• Head/shoulder entrapment and birth trauma ® clavicle #, DDH, erb’s palsy, cerebral haemorrhage
Comp.
• Foetal trauma = to a prolapsed arm, bruising and oedema at the presenting part
• Maternal trauma = uterine rupture. Perineal tears
1) NVD (see below for technique) - if no • ECV before rupture of • Most deliver spontaneously, • Expectant mx because foetal
footling + head small enough to fit membranes • early consideration for LSCS extremity often retract as head
through pelvis • LSCS is indicated if for prolonged labour descends
2) ECV – if expertise available > 36% success active labor or rupture • LSCS for obstructed labour
Mx rate if near term) of membranes is
3) LSCS – if all else fails or elected by present
patient
4) 6 wk USS outpatients




External Cephalic Version in pregnancy:
• Breech presentation or incorrect lie after 36 weeks
Indication
• 50% success rate
• Abnormal CTG
Mx of breech babies:
• ROM 1. Hands OFF
Abs. CI • Contracted pelvis
2. Bring legs out
• Fetal death
• Placental abruption 3. Place Breech towel around hip
1) Consent needed 4. For upper limbs ® Lovset’s manoeuvre (Hold
2) Vitals + USS assessment for 40 mins® check for absolute CI hips and rotate foetus to either 10 or 2 o’clock
3) If CTG reactive ® give tocolytics (TERBUTALINE) to relax uterus position and bring down each anterior shoulder)
4) Perform ECV 30mins after tocolytics OR when maternal pulse > 100
5. Let go and led baby dangle
5) Arrange Kleihauer
Process o Anti-D for Rh-ve women (prevent fetalis hydrops in 2nd child) 6. For obstructed head ® Mauriceau manoeuvre
6) If successful ECV: (extend baby’s head upwards towards mum in
o Routine antenatal care w/ referring team/clinic in 1 week “J” shape position to deliver)
7) If unsuccessful ECV:
Additional help
o Refer to Obstetrics Registrar to discuss mode of delivery
(e.g. NVD vs elective LSCS) Ø Suprapubic pressure
• Placental abruption Ø Use forceps
• Uterine rupture
• ROM with umbilical cord prolapse
Comp.
• Amniotic fluid embolism
• Fetal distress
• Fetomaternal haemorrhage

, Stages of labour (37-42 weeks GA – term labour)




Stage Define Key event Clinical Issues
Alvarez- Physiological; Low intensity, high frequency contractions • Reassurance
waves after 20 GA • Assess bishop score to indicate whether labour will begin spontaneously
Braxton Physiological; • Irregular, uncoordinated uterine contractions of moderate (score 8 = yes)
Hicks 2nd or 3rd intensity + NO PAIN Red flags:
contractions trimester • Typically stop with rest, walking, and/or a change in position. • Vaginal discharge (fluid, blood)
Irregular contractions of high intensity ® every 5–10 min to • Strong regular contraction unable to “walk through”
correctly position fetal head in pelvis • Reduced foetal movement
3–4 days before 1. Baby descent = Increased cortisol = increased estriol = If pre-term ® delay labour
Prelabor
birth stimulate contraction Ø Tocolytics = nifedipine
2. Prostaglandin release = initiate labour (breakdown
collagen in cervix)

0 to 3cm cervix
• Irregular Painful contractions
• Analgesia – GAS (NO) or opioids
1st stage • The show – (eject protective cervical mucus plug)
dilation • Fetal HR
(latent) (0.5cm/hr) • CERVICAL DILITATION AND EFFACEMENT (MUST know)
• Check fetal position (abdo/pelvic exam or USS)
• Rupture of membranes
• Regular assessment of cervical dilation and descent of fetal head
1st stage 3 to 7cm cervix BOTH (cm, + 0 – )
dilation Ø Regular Painful contractions
(active) (1.0cm/hr) Ø Changes to cervix effacement and dilatation
7 to 10cm
1st stage
cervix dilation
(transition)
(1.0cm/hr)

Things to do
Ø Analgesia – EPIDURAL (bupivacaine)
Ø Check descent or foetla station (-5 to +5) = (+2 = time to push)
Ø Warm compresses and perineal massage
Ø Consider episiotomy? ® mediolateral incision to enlarge vaginal
opening (cuts through bulbospongiosus muscle)
o C-section = foetal distress (CTG, scalp pH)
o McRoberts’s = shoulder dystocia
o Oxytocin = contractions
Foetal station (+2 = time to push) Success depends on three P’s
10cm to Power Strength of contractions
delivery of • Size = esp. head (CPD)
2nd stage baby o ED LSCS ® if CPD or IoL w/ gel pessary
• Posture = flexed head/limbs?
• Lie = longitudinal (up/down) vs transverse (side/side)
or oblique
Passenger
BENEFITS OF NVD • Presentation = cephalic (head), shoulder, breech (legs)
Ø Sense of accomplishment o Complete breech – hips and knees flexed
Ø Natural – shorter labour time (cannonball)
Ø Skin-skin contact immediate o Frank – bottom 1st, hips flexed, knees extended
® encourages breastfeeding o Footling - foot hanging through cervix
and increase oxytocin and Immediate things to do ® paeditrics:
Size / shape of passageway
decreases cortisol (↓stress) 1. Hepatitis + Vit K inject. Ø Pelvic inlet diameter
Ø Impart natural immunity (IgA) Passage
2. Skin-skin è Begin 1st BF. Ø Cervical stenosis
Ø Shorter recovery
3. Measure Wt, Length, HC Ø Masses

Physiological Placenta delivered by maternal effort • Uterus fundal massage: induce contractions and stop
Mx without medications or cord traction bleeding + minimise tearing
From birth to Need assistance of midwife or doctor to o PPH = check maternal BP
delivery placenta (e.g. prolonged 3rd stage)
placenta Active Mx • Asses perineal tears
delivery Ø IM 10IU oxytocin injection to help
shorten 3rd uterus contract and expel placenta o 1st deg = fourchette skin
1) Blood gush stage to:
(50-100mL)
Ø Controlled cord traction to guide o 2nd deg = “ + perineum + perineal body
3rd stage 1) reduce risk placenta out while uterus pushed
2) Cord of PPH o 3rd deg -= “ + anal sphincter
lengthens upwards to prevent uterine prolapse
Ø Massage uterus until firm/contracted
o 4th deg = “ + rectal mucosa
3) Uterus rise
4) Placental Minimise by:
removed *For 3rd + 4th deg tear è needs sterile OR to re-stitch (to minimise
Ø Hydrate, verbal guidance,
Perineal Tears risk of faecal/anal incontinence)
Ø Perineal massage or epino (dilating
balloon to help expand the perineum)

• Irregular contractions Monitor BP, HR + temp to rule out:
• Expel remaining contents • PPH (tone ® trauma ® tissue ® thrombin)
4 stage
th
12 hr recovery • preeclampsia
• uterine involution and bleeding cessation
(After pain) stage Inspect perineum
• Delayed Cord clamping for 1min (esp. if pre-term)
• Vulva haematoma vs PPH
o Reduce IVH, NEC, Anaemia, infections

Note: Multiparous women will have shorten time during each stage

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