Abnormal labour

Question 1

What kinds of breech are there?

Answer 1

Complete breech Footling breech Frank breech

Question 2

What are the kinds of malpresentation?

Answer 2

• Breech
• Transverse
• Shoulder/arm
• Face
• Brow

Question 3

What is abnormal labour?

Answer 3

• too early- preterm birth
• too late- induction of labour
• too painful- requires anaesthetic input
• too long- failure to progress
• too quick- hyperstimulation
• foetal distress- hypoxia/sepsis
• wrong part presenting

Question 4

What analgesia can be used?

Answer 4

• support
• massage/relaxation techniques
• inhalational agents- entonox
• TENS (T10-L1, S2-S4)
• Water immersion
• IM opiate analgesia e.g. morphine
• IV remifentanil PCA
• regional anaesthesia

Question 5

How often does epidural give complete pain relief?

Answer 5

95%

Question 6

What are the complications with epidural anaesthesia?

Answer 6

May inhibit progress during stage 2

• hypotension 20%
• dural puncture 1%
• Headache
• high block
• atonic bladder 40%

Question 7

Epidural anaesthesia ______ impair uterine activity

Answer 7

Epidural anaesthesia doesn’t impair uterine activity

Question 8

What is given in epidural anesthesia?

Answer 8

Levobupivacaine +/- opiate

Question 9

What are the risks of obstructed labour?

Answer 9

• sepsis
• uterine rupture
• obstructed AKI
• postpartum haemorrhage
• fistula formation
• foetal asphyxia
• neonatal sepsis

Question 10

How do we assess progress in labour?

Answer 10

• cervical dilatation
• descent of presenting part
• signs of obstruction

Question 11

What are the signs of obstruction

Answer 11

Moulding

Caput

Anuria

Haematuria

Vulval oedema

Question 12

When would you suspect a delay in a stage 1 nulliparous woman?

Answer 12

<2cm dilatation in 4 hours

Question 13

When would you suspect a delay in a stage 1 parous woman?

Answer 13

<2cm dilatation in 4 hours or slowing in progress

Question 14

Describe the 3 Ps in failure to progress

Answer 14

Powers

inadequate contractions: frequency and/or strength

Passages

Short stature/trauma/shape

Passenger

• Big baby*
• malposition- relative cephalo-pelvic disproportion*

Question 15

What is recorded on a partogram?

Answer 15

• Fetal heart
• Amniotic fluid
• cervical dilatation
• descent
• contractions
• Obstruction-moulding
• Maternal observations

Question 16

Describe intra-partum fetal assessment?

Answer 16

Doppler auscultation of foetal heart

Stage 1: during and after a contraction, every 15 minutes

Stage 2: at least every 5 minutes during & after a contraction for 1 whole minute & check mat pulse at least every 15 minutes

Electronic foetal monitoring- cardiotocograph (CTG)

Colour of amniotic fluid

Question 17

What are the risk factors for foetal hypoxia?

Answer 17

• small foetus
• preterm/post dates
• antepartum haemorrhage
• hypertension/pre-eclampsia
• diabetes
• meconium
• epidural anesthesia
• VBAC- vaginal birth after caesarean
• PROM >24hr- pre leabour rupture of membranes
• Sepsis (Temp >38)
• induction/augmentation of labour

Question 18

What is the aetiology for acute foetal distress?

Answer 18

Abruption

Vasa praevia

Cord prolapse

Uterine rupture

Feto-maternal haemorrhage

Uterine hyperstimulation

Regional anaesthesia

Question 19

What is the aetiology for chronic foetal distress?

Answer 19

Placental insufficiency

Fetal anaemia

Question 20

What is assessed and documented in CTG?

Answer 20

Baseline fetal heart rate

Baseline variability

Presence or absence of decelerations

Presence of accelerations

Question 21

What should CTG be classified as?

Answer 21

Normal/suspicious/pathological

Question 22

What is gradually evolving hypoxia in labour characterised by?

Answer 22

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

Question 23

What is the acronym for CTG interpretation?

Answer 23

D- etermine

R- isk

C- ontractions

B- aseline

R

A - TE

V- ariability

A- ccelerations

D- ecelerations

O- verall impression

Question 24

Describe the management of foetal disease?

Answer 24

• change maternal position
• IV fluids
• stop syntocinon
• scalp stimulation
• consider tocolyisis- terbutaline 250mcg s/c- anticontraction meds
• maternal assessment- pulse/BP/abdomen/VE
• foetal blood sampling
• operative delivery

Question 25

Describe the interpretation of fetal blood sampling

Answer 25

Scalp pH- >7.5 = normal

Scalp pH 7.20-7.25- borderline- repeat in 30 minutes

Scalp pH <7.20 - abnormal- deliver

Question 26

What are the indications for operative vaginal delivery?

Answer 26

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

Question 27

What is the expected duration of stage 2 in a primiparous woman with an epidural?

Answer 27

3 hours

Question 28

What is the expected duration of stage 2 in a multiparous woman with an epidural?

Answer 28

2 hr

Question 29

What is ventouse associated with?

Answer 29

Increased;

failure

Cephalohaematoma

Retinal haemorrhage

Maternal worry

decreased;

Anaesthesia

Vaginal trauma

perineal pain

Question 30

What are the main indications for CS?

Answer 30

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

Question 31

What is the risk of maternal mortality associated with CS?

Answer 31

4 x greater

Question 32

Describe the morbidity in CS?

Answer 32

Sepsis

Haemorrhage

VTE

Trauma

TTN- transient tachypnoea of the newborn

Subfertility

Regret

Complications in future pregnancy