Abnormal labour and obstetric complications

Question 1

Definition of Preterm Labour

Answer 1

Labour between 24 - 37 weeks

PPROM = rupture <37 weeks
Threatened premature labour - mild contractions, no labour

Question 2

Investigations in preterm labour?

Answer 2

CTG - assess fetal status
TV USS - assess cervical length
Cervico-vaginal swab for fetal fibronectin (fFN)

Question 3

Management of preterm labour?

Answer 3

Prophylactic Abx - erythromycin + penicillin
IV betamethasone
Tocolytics (nifedipine) if very preterm

Question 4

Presentation of placental abruption?

Answer 4

Painful bleeding PV + abdo pain + contractions in the second half of pregnancy

Thrombin is a powerful utero-tonic agent -> contractions high frequency, low amplitude

Question 5

Management of placental abruption?

Answer 5

Stabilised mother + assess fetal viability
Attempt vaginal delivery is >34 weeks
If <34 weeks/unstable - C-section

Question 6

Contraindications in placenta praevia?

Answer 6

Do not perform digital vaginal exam until position of the placenta has been ascertained by USS

Advise mother to avoid sex

Question 7

Presentation of placenta praevia

Answer 7

Painless PV bleeding

Can range from light to torrential

Question 8

What are the classifications of perineal tears?

Answer 8

1st degree - injury to skin only
2nd degree - perineum + perineal muscles torn
3a - <50% External anal sphincter (EAS)
3b - >50% EAS
3c - EAS + Internal anal sphincter (IAS)
4th degree - EAS + IAS + anorectal mucosa

Question 9

1st choices for augmentation of labour?

Answer 9

1) Stretch and sweep
2) Prostaglandins (gel/tablets - tablets can be removed in case of ovarian hyperstimulation)
3) Oxytocin infusion

Question 10

RCOG guidelines for shoulder dystocia

Answer 10

1) Call for help
2) McRobert’s manoeuvre - hips fully flexed
3) Suprapubic pressure
4) consider episiotomy
5) deliver posterior arm / internal rotational manoeuvres
6) All fours positioning
7a - Cleidotomy - break clavicle
7b - Zavanelli manoeuvre - replace head, C-section
7c - symphysiotomy - cut fibres of symphysis

Question 11

Classifications of obstetric haemorrhage

Answer 11

APH - bleeding after 24 weeks
- bleeding before 24 weeks is threatened miscarriage

PPH - primary - >500mls blood loss in first 24 hours following delivery
PPH - secondary - excessive bleeding between 24hrs and 6 weeks post-partum

Question 12

What are the 4 T’s of post-partum haemorrhage

Answer 12

Tone - atonic uterus
Tissue - retained placenta/products of conception
Trauma - genital tract damage, tears
Thrombin - clotting abnormality

Question 13

Stepwise management of atonic uterus PPH

Answer 13

1) Ergometrine IV bolus
2) commence syntocinon infusion
3) Consider prostaglandins if no response
4) Examination under GA +/- laparotomy

Question 14

Management of eclampsia?

Answer 14

ABC
Give diazepam or magnesium sulphate
Commence prophylactic magnesium sulphate infusion to prevent further fits
Stabilise blood pressure and maternal condition
Deliver baby

Question 15

Difference between malposition and malpresentation?

Answer 15

Malposition - always cephalic presentation, refers to orientation of the baby’s face - anything that isn’t LOA
- brow/face presentation the worst

Malpresentation
- breech - buttocks down, head in fundus
extended = feet by ears, flexed = legs bent at knees
footling = one leg flexed, one extended

Question 16

What is twin to twin transfusion syndrome (TTTS)

Answer 16

Abnormal connection in blood supply in monochorionic twins
One donor twin, one recipient

Recipient is overloaded –> HF
Donor –> hypovolaemic, priorities brain and heart

high mortality

Question 17

Indications for operative delivery?

Answer 17

Maternal - slow progression in 2nd phase, maternal exhaustion, to avoid raising BP/ICP

Fetal - presumed fetal compromise

Question 18

Complications of ventouse and forceps?

Answer 18

Ventouse - Cephalhaematoma, neonatal jaundice, retinal haemorrhages

Forceps - facial bruising/nerve damage, fractures, maternal genital tract trauma

Question 19

What are the categories of C-section + example indications?

Answer 19

Cat 1 - crash (within 30 mins) - abruption, cord prolapse, uterine rupture, scalp pH <7.2

Cat 2 - urgent - failure to progress + pathological CTG
Cat 3 - scheduled - severe pre-eclampsia, IUGR, failed induction
Cat 4 - elective - breech, twin, maternal HIV