Abnormal Labour

Question 1

what can cause an abnormal labour?

Answer 1

malpresentation - not head coming first

malposition - occipito-posterior or occipito-transverse

preterm (<37 weeks) or post term (>42)

obstruction

foetal distress

Question 2

what are the different types of breech presentation?

Answer 2

complete breech = both legs under foetus, born first

footling breech = one foot presents

frank breech = feet up by babys head, bottom presents first

Question 3

other than breech, how can a baby present in the wrong way?

Answer 3

transverse
shoulder / arm
face
brow

Question 4

how effective are epidurals in labour?

Answer 4

complete pain relief in 95%

Question 5

women can have an epidural and still experience contractions that allow them to push in pregnancy - true or false?

Answer 5

true - uterine muscles not affected by anaesthesia

Question 6

why may an epidural inhibit progress during stage 2 of labour?

Answer 6

numbs and relaxes the pelvic floor

pelvic floor muscles are needed to provide resistance to babys head causing it to flex before birth

Question 7

what else is usually injected alongside local anaesthetic in an epidural?

Answer 7

opiate

Question 8

what are the main complications of an epidural?

Answer 8

hypotension (20%)
dural puncture (1%)
headache (due to dural puncture - worst day after birth)
high block (may cause resp depression - SOB)
atonic bladder (women don’t know when bladder is full)

Question 9

what becomes a higher risk if a labour is obstructive?

Answer 9

maternal or neonatal sepsis

uterine rupture (esp if previous c-section)

obstructed AKI (if foetal head is compressing ureters)

PPH (uterus works so hard in obstructed labour that it gives up and does not constrict blood vessels after)

fistula formation (recto-vaginal)

foetal asphaxia

Question 10

how can progress during labour be assessed?

Answer 10

cervical dilatation

descent of presenting part

signs of obstruction - moulding, caput, vulval oedema

Question 11

what measurements of cervical dilatation would make you consider delayed labour?

Answer 11

<2cm dilation in 4 hours

OR if labour is slowing in progress in a lady who has had children before

Question 12

station is measured in relation to what landmark in the mother?

Answer 12

ischial spines

Question 13

what the 3 Ps considered when a labour shows failure to progress?

Answer 13

powers: inadequate contractions
passages: short stature / pelvis shape
passenger: big baby, malposition / malpresentation

Question 14

what is assessed on a partogram?

Answer 14

foetal heart rate 
amniotic fluid 
cervical dilatation 
descent 
contractions 
obstructions - moulding / caput 
maternal observations (BP, pulse)

Question 15

how often should a doppler be used to assess foetal heart rate in the 1st and 2nd stages of labour?

Answer 15

1st stage
- measure during and after contraction (every 15 mins)

2nd stage

• every 5 minutes
• and during and after a contraction for a 1 whole minute
• check maternal pulse at least every 15 minutes

Question 16

how else can the foetus be assessed during labour?

Answer 16

electrical foetal monitoring

cardiotocograph (CTG)

colour of amniotic fluid

Question 17

what factors can increase the risk of foetal hypoxia?

Answer 17

small foetus 
preterm / post dates 
antepatrum haemorrhage 
hypertension / pre-eclampsia 
diabetes 
meconium 
epidural analgesia 
sepsis 
IOL

Question 18

what acute causes are there for foetal distress?

Answer 18

abruption 
vasa praevia 
cord prolapse 
uterine rupture 
feto-maternal haemorrhage 
uterine hyperstimulation 
regional anaesthesia

Question 19

if a baby is presenting breech, what complication are they at increased risk of?

Answer 19

cord prolapse

due to feed presenting first -> space around feet for cord to prolapse

Question 20

what are the chronic causes of foetal distress?

Answer 20

placental insufficiency

foetal anaemia

Question 21

what features of a CTG should be assessed on review?

Answer 21

baseline foetal heart rate
variability
presence / absence of declerations
presence of accelerations

Question 22

how should a CTG be classified?

Answer 22

normal
suspicious
pathological

Question 23

what CTG changes may indicate foetal hypoxia has evolved in labour?

Answer 23

loss of accelerations

repetitive deeper and wider decelerations

rising foetal baseline HR

loss of variability

Question 24

what mnemonic is used to interpret a CTG?

Answer 24

“Dr C Bravado”

D ETERMINE
R ISK
C ONTRACTIONS
B ASELINE
R
A TE
V ARIABILITY
A CCELERATIONS
D ECELERATIONS
O VERALL IMPRESSION

Question 25

how should foetal distress be managed?

Answer 25

change maternal position 
IV fluids 
stop oxytocin 
scalp stimulation 
beta agonist - terbutaline 
maternal assessment - pulse / BP / abdomen / VT 
foetal blood sampling (check not too acidic - >7.2)
operative delivery

Question 26

when is an instrumental delivery normally indicated?

Answer 26

if women is at full dilatation

• labour delay (failure to progress to stage 2)
• foetal distress

Question 27

what are the special indications for an instrumental delivery?

Answer 27

maternal cardiac disease (due to valsalva manoeuvres in obstructive labour)

severe PET / eclampsia

intra-partum haemorrhage

umbilical cord prolapse stage 2

Question 28

how long would be considered a delay in labour?

Answer 28

first baby - 2 hours (3 if epidural)

subsequent baby - 1 hour (2 if epidural)

Question 29

what is ventouse delivery and what does this increase the risk of?

Answer 29

ventouse = cup shaped suction device

higher risk of:

• failure
• cephalohaematoma
• retinal haemorrhage
• maternal worry

Question 30

what are the main indications for a c-section?

Answer 30

previous CS
foetal distress
failure to progress in labour 
breech presentation 
maternal request

Question 31

maternal mortality is increased by how much in c-section?

Answer 31

4x

Question 32

what complications of c-section increase morbidity in mother?

Answer 32

sepsis 
haemorrhage 
VTE
trauma
subfertility 
complications in future pregnancy