Abnormal Labour

Question 1

examples of what can go wrong in labour?

Answer 1

mlapresentation (non-vertex e.g breech)
malposition (OP or OT)
pre-term (<37 weeks)
post term (>42 weeks)
obstruction
fetal distress

Question 2

what bounds the vertex?

Answer 2

bounded by the anterior and posterior fontanelles and the parietal eminences

Question 3

types of breech?

Answer 3

complete = legs folded with feet at level of bottom
footling = one or both feet point down so the legs will engage first
frank (most common) = legs point up with feet y the babys head so the bottom engages first

Question 4

complications of breech?

Answer 4

cord collapse

foetal head prolapse

Question 5

other types of malpresentation?

Answer 5

transverse
shoulder/arm
face
brow

Question 6

complications of post term?

Answer 6

malpositioning of baby (back to back with mum)
more likely to need C section
sepsis

Question 7

analgesia techniques in labour?

Answer 7

support
massage/relaxation techniques
inhalaiton agents (entonox)
TENS
water immersion
IM opiate (morphine)
IV remifentanil PCA (good for fast moving labour who cant have nerve block etc)
regional anaesthesia (epidural etc)

Question 8

what is an epidural and what are the benefits?

Answer 8

levobupivacine +/- opiate
gives complete pain relief in 95%
does not impair uterine activity

Question 9

complications of epidural?

Answer 9

may inhibit progress during stage 2 labour
hypotension (mainly) - due to vasodilation
dural puncture (will cause crashing, horrible headache)
headache
high block (anaesthesia rises too high up and can impair breathing)
atonic bladder

Question 10

what does needle go through in epidural?

Answer 10

skin
fat
supraspinous ligament
interspinous ligament
ligamentum flavum

Question 11

what risks come along with obstructed labour?

Answer 11

sepsis
uterine rupture (common in previous C section)
obstructed AKI (baby head pushing down obstructs urine tracts)
postpartum haemorrhage
fistula formation (between vagina and rectum/bladder)
foetal asphyxia
neonatal sepsis

Question 12

how is progress in labour assessed?

Answer 12

cervical dilation (0-10cm)
descent of presenting part
any signs of obstruction (moulding, caput, anuria, haematuria, vulval oedema)

Question 13

normal progression of cervical dilation in nulliparous women?

Answer 13

2cm in 4 hours

anything less is abnormal

Question 14

normal progression of cervical dilation in parous women?

Answer 14

2cm in 4 hours

anything less or slowing in progress is abnormal

Question 15

normal number of contractions?

Answer 15

3-4 in 10 mins

Question 16

what are the 3 Ps which can impact progression of labour?

Answer 16

powers
- contractions (frequency and/or strength)
passages
- short stature/trauma/shape of pelvis
passenger
- big baby
- malposition (relative cephalo-pelvic disproportion)

Question 17

one of the most common reasons for problem with progression of labour?

Answer 17

non-flexion of the foetal head so widest part is trying to pass through pelvis

Question 18

what is the partogram and what does it measure?

Answer 18

graphic representation of progress of labour
commence as soon as in established labour
- fetal heart
- amniotic fluid
- cervical dilation
- descent
- contractions
- obstructions
- maternal obs

Question 19

what may be given to help labour progress?

Answer 19

oxytocin infusion

Question 20

when is doppler auscultation of the foetal heart used?

Answer 20

stage 1
- during and after contraction every 15 mins for a whole minute
stage 2
- at least every 5 mins during and after a contraction for 1 min and check maternal pulse at least every 15 mins

Question 21

other monitoring during labour?

Answer 21

electronic foetal monitoring (cardiotocograph - CTG)

colour of amniotic fluid (e.g green can indicate maeconium)

Question 22

risk factors for fetal hypoxia?

Answer 22

small foetus
pre-term/post term
antepartum haemorrhage
hypertension/pre-eclampsia 
diabetes
meconium 
epidural analgesia
VBAC (vaginal birth after caesarean)
continuous PROM >24hrs (premature rupture of membranes)
sepsis (temp >38)
induction/augmentation of labour

Question 23

acute causes of fetal distress?

Answer 23

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

Question 24

chronic causes of fetal distress?

Answer 24

placental insufficiency

fetal anaemia

Question 25

normal neonatal baseline HR at term?

Answer 25

110-150

• accelerates when baby is moving about
• decelerates at times, e.g when head descends into pelvis, during contraction
• deceleration after contraction (late) can indicate hypoxia
• variable decelerations can indicate cord compression

Question 26

normal variability in HR in term neonate?

Answer 26

5-25 bpm

higher or lower indicates hypoxia

Question 27

what 4 features should be commented on in CTG assessment?

Answer 27

baseline foetal HR
baseline variability
presence or absence of decelerations
presence of accelerations
CTG should be classed as normal/suspicious/pathological

Question 28

characteristics of hypoxia in baby?

Answer 28

loss of accelerations
repetitive deeper and wider decelerations
rising foetal baseline heart rate
loss of variability

Question 29

acronym for CTG interpretation?

Answer 29

DR C BRAVADO

• determine
• risk
• contractions
• baseline
• R
• ate (rate)
• variability
• accelerations
• decelerations
• overall impression

Question 30

definition of pathological CTG?

Answer 30

2+ abnormal features

Question 31

how is foetal distress managed?

Answer 31

change maternal position
IV fluids
stop syntocinon
scalp stimulation
consider tocolysis (terbutaline 250mcg S/C)
maternal assessment (pulse, BP, abdo, VE)
fetal blood sampling
operative delivery

Question 32

interpretation of foetal blood sampling?

Answer 32

normal
- scalp pH >7.25
- no action needed
borderline
- scalp pH = 7.2-7.25
- repeat test in 30 mins
abnormal
- scalp pH = <7.2
- deliver baby immediately

Question 33

indications for operative vaginal delivery?

Answer 33

delay (failure to progress to stage 2)
fetal distress
special indications
- maternal cardiac disease
- severe PET/eclampsia 
- intra-partum haemorrhage
- umbilical cord prolapse stage 2

Question 34

normal duration of stage 2 in first and multiple babies?

Answer 34

first 
- no epidural = 2 hrs
- epidural = 3 hrs
multiple
- no epidural = 1 hr
- epidural = 2 hrs

Question 35

what are the risks with use of ventouse in operational vaginal delivery?

Answer 35

failure
cephalohaematoma
retinal haemorrhage
maternal worry
but
- reduced vaginal trauma and perineal pain

Question 36

main indications for C section?

Answer 36

previous CS
fetal distress
failure to progress to labour
breech presentation
maternal request