INSTRUMENTS AND MEDICATIONS IN LABOUR ROOM & OT

Vacuum

Instrument used as alternative to forceps, which adheres to fetal scalp by suction cup & is used to assist maternal expulsive efforts

Metal Vacuum cup

Silicone rubber cup

Kiwi omnicup

Indication Prolonged 2nd stage of labor To shorten 2nd stage of labor Presumed fetal distress Poor maternal contraction

Contraindication Malposition (Face, breech) POA less than 35 weeks Cephalic pelvis disporpotion Uncertainty on fetal position and station

Prerequisite

Precaution Dilatation and full engagement of the head

Prolonged or excessive traction should not be used. Traction is be applied during uterine contraction

Contraction present

No CPD

vaginal skin should be excluded from the edge of the cup.

POA: >35w

Complication

Maternal

Lacerations to the cervix, vagina, perineum, or bladder Extension of episiotomies Increase in blood loss Pelvic organ prolapse Urinary stress incontinence anal sphincter injuries

Fetal

Scalp abrasions Caput succedaneum Intracranial bleeding Subaponeurotic hemorrhages

Forceps
Instruments designed to aid in the delivery of the fetus by applying traction to the fetal head.
High forceps

Mid forceps

Types of for forceps delivery

Outlet forceps

Low forceps

Prerequisite

F fully dilated O OA & OP position R Rupture of membrane C No CPD E Engaged, episotomy P pudendal nerve block S sterilization, skills and experties

Indication

Prolong 2nd stge of labour Fetal distress Maternal condition such as cerebrovascular disease, hypertensive disorder

Contraindication

Refusal of the patient Cervix not fully dilated Inability to determine the presentation and fetal head position Confirmed cephalopelvic disproportion Severe moulding/caput Unsuccessful trial of vacuum extraction

Complication

Lacerations to the cervix or vagina Trauma to maternal anal sphincter Fetal facial nerve injury Fetal skull fracture

Episiotomy Set
1 2 3

5 4

10

1 : Episiotomy scissor 2 : artery forcep straight 3 : Tissue tooth forcep 4 : kidney dish 5 : sponge holder 6 : needle holder 7 : Gallipot 8 : straight scissor 9 : artery forcep curve 10: instrumental tray

Indication Prolonged 2nd stage due to rigid perineum Instrumental delivery Premature delivery

Complication hemorrhage Infection Extension to anal sphincter Dyspareunia

Fetal Scalp Electrode

WHAT IS THE INDICATION? 1) When external CTG inadequate to detect accurate interpretation 2) For 1st twin in twin prengnancy WHAT IS THE CONTRAINDICATION? - Face presentation - Unknown presentation - HIV seropositive/Hep B,C - Active genital herpes - Suspect thrombocytopenia/ ITPP WHAT IS THE WEAKNESS? 1) invasive 2) more tedious to apply 3) mmbrane must absent 4) just apply during intra-partum 5) direct contact to fetus 6) high risk for infection

CARDIOTOCOGRAPHY
What is Cardiotocography?
Cardiotocography (CTG) is used in pregnancy to monitor both the fetal heart as well as the contractions of the uterus. It is usually only used in the 3rd trimester. Its purpose is to monitor fetal well-being & allow early detection of fetal distress. An abnormal CTG indicates the need for more invasive investigations & ultimately may lead to emergency caesarian section.

 How it works?
It involves the placement of 2 transducers on the abdomen of a pregnant women. One transducer records the foetal heart rate using ultrasound. The other transducer monitors the contractions of the uterus. It does this by measuring the tension of the maternal abdominal wall. This provides an indirect indication of intrauterine pressure.

HOW TO INTERPRET CTG?

CONTRACTION
Record the number of contractions present in a 10 minute period - e.g. 3 in 10 Each big square is equal to 1 minute, so you look how many contractions occurred in 10 squares Individual contractions are seen as peaks on the part of the CTG monitoring uterine activity

FETAL HEART RATE

The baseline rate is the average heart rate of the fetus in a 10 minute window Look at the CTG & assess what the average heart rate has been over the last 10 minutes Normal fetal heart rate 110160bpm
Fetal tachycardia >160bpm - Fetal hypoxia - Chorioamnionitis if maternal fever also present - Hyperthyroidism - Fetal or Maternal Anaemia -Fetal tachyarrhythmia Fetal bradycardia <110bpm - Post-date gestation -Occiput posterior or transverse presentations - Prolonged cord compression - Cord prolapse - Epidural & Spinal Anaesthesia - Maternal seizures - Rapid fetal descent

VARIABILITY
Minor fluctuation in baseline fetal heart rate occurring at 3 to 5 cycle per minute Measure by estimating the difference in beats perminute between the highest peak and lowest through of fluctuation in a one minute segment of the trace

Acceleration Transient increase in FHR of 15bpm or more lasting 15s or more

Deceleration Transient episode of slowing FHR below the baseline level of more than 15bpm and lasting 15s or more 1. Early deceleration Uniform repetitive, periodic slowing of FHR with onset early in the contraction and return to baseline at the end of contraction

1.

Late deceleration uniform repetitive, periodic slowing of FHR with onset mid to end of the contraction and nadir more than 20s after the peak of the contraction and ending after the contraction.

Catheter
A. Name of the instrument. Foley catheter
What are the use of this instruments? - Urine drainage - Mechanical IOL How it is used as mechanical IOL - it cause the cervix to mechanically open and make the cervix more favorable

B.

C.

Fetal Blood Sampling

A. Name of the instrument. Amnioscope What are these instruments for? Fetal Blood Sampling procedure to determine fetal pH Indication for the procedure. - non reassuring CTG with either clear liquor or LMSL or MMSL, when cervical dilatation is >= 3 cm. Contraindication for the procedure. - Maternal infection (HIV,Hep B/C) - Fetal bleeding disorders - Prematurity (<34weeks) - Face presentation B.

C.

D.

Partogram
Defintion:
graphical record that record the progress of labour.

Part 1:Fetal condition

fetal heart rate liqour moulding

Part 2:Progress of labour

Cervical dilation Descent of head contraction

Part 3:maternal condition pulse rate blood pressure temperature

Abnormal progress of labour

1.Prolong latent phase
Def: more than 8 hours

2.Prolong active phase -primary dysfunction labour - cervical dilation less

than 1cm/hour -secondary arrest -Progress active phase initialy good but become slow/stop typically after 7cm dilation.

Causes: 1.Powers -inefficient uterine action Mx:maternal rehydration :artificial rupture membrane :IV oxytocin(syntocinon)

2.Passenger(fetus) -big size -malposition -malpresentation 3.Passages( uterus,cervix,bony pelvis) eg:cephalopelvic disproportion Mx:ceaserean section

Syntocinon & Syntometrine

Indication

active management of 3 stage of labour Prevention and treatment of PPH with uterine atony

Contraindication

Hypersensitivity to oxytocin and ergometrine Severe hypertension Severe cardiovascular disorders Pre-eclampsia/eclampsia

Side Effects

Nausea, vomiting Abdominal pain Headache, dizziness Rash

Anelgesia In labour

Pethidine
Given intramuscularly Dosage:
1-2 mg/kg (usual dose 50-100mg) together with phenergan 0.5 mg/kg (usual dose 25 mg)

Administered during early labour or When the delivery is not expected within 4 hour of injection Used to relieve moderate to severe pain

 Side-effects:
Drowsiness Nausea Vomiting

The baby may require naloxone to treat respiratory depression if delivered within 4 hours of pethidine injection An overdose of pethidine may cause convulsions (fits), respiratory depression (breathing difficulties), hypotension, shock and coma

Entonox
A gas made up of 50% oxygen and 50% nitrous oxide(NO) Self administered via a face mask or mouth piece Instruction: start inhaling at the beginning of contraction, continue deep shallow breathing during contraction and remove the mask from the face when contraction eases off.

 Can be given at any time of labour, as sole analgesic or in combination with epidural analgesia during late first stage or second stage of labour. Side-effects:
Drowsiness Nausea Vomiting

Epidural
A type of regional analgesia Involves the administration of a dilute amount of local anesthetic either in the form of bupivacaine or ropivacaine combined with a low concentration of short-acting narcotic like fentanyl through a catheter placed in the epidural space Onset of analgesia can take 20-30 minutes

 Suitable for most patient except those with bleeding disoders, generalized or localized infection, hypovolemia or history of surgery to the lower back. Indicated in patient with:
Hypertension Cardiac disease Multiple pregnancy Previous caesarean delivery for trial of scar Increased risk of caesarean delivery

 Complications:
Hypotension Incomplete pain relief Accidental total spinal