Abnormal Labour and Postpartum Care

Question 1

Characteristics of failure to start labour

Answer 1

• 1 in 5 pregnancies induced
• Less efficient, more painful
• Need foetal monitoring
• Risk of uterine ‘hyperstimulation’ with prostaglandin/oxytocin induction

Question 2

Indications for induction of labour

Answer 2

• Diabetes (usually before due date)
• Post date - term + 7 days
• maternal health problems that necessitate planning of delivery e.g. treatment of DVT
• Foetal reasons - growth concerns, oligohydramnios
• Other
  
  • Social/maternal request/pelvic pain/’big’ babies

Question 3

What is induction of labour

Answer 3

• An attempt is made to instigate labour artificially using medications and/or devices to ‘ripen cervix’ followed usually by artificial rupture of membranes (performing an amniotomy)

Question 4

What score is used to assess the cervix in labour

Answer 4

• Bishop’s - the higher the score the more progressive change there is in the cervix and indicates that induction is likely to be successful
• Cervix Assessment

0

1

2

3

Dilation (cm)

0

1-2

3-4

5+

Length if cervix (effacement) (cm)

3

2

1

0

Position

Posterior

Mid

Anterior

Consistency

Firm

Medium

Soft

Station (cm)

• 3
• 2
• 1,0

+1, +2

Question 5

How is labour induced if low Bishop’s score

Answer 5

• Cervix not dilated and effaced
• Vaginal prostaglandin pessaries/Cook Balloon can be used to ripen (open) cervix

Question 6

What can be performed once the cervix is dilated and effaced

Answer 6

• Amniotomy

Question 7

What Bishop’s score is considered favourable for amniotomy

Answer 7

• 7 or more

Question 8

What is an amniotomy

Answer 8

• Artificial ruptire of foetal membranes (‘waters’)
• Usually a sharp device e.g. amniohook

Question 9

In induction of labour what happens once the amniotomy has been performed

Answer 9

• IV oxytocin can be used to achieve adequate contractions - aim for 4-5 in 10 mins

Question 10

What are the stages of labour

Answer 10

*

Question 11

What progress problems can occur during labour

Answer 11

• Cephalopelvic disproportion (CPD)
• Malposition - head in wrong position (occipito-posterior, occipito-transverse)
• Malrepresentation (lie)
• Inadequate uterine activity
• Other reasons for obstruction (e.g. ovarian cyst of fibroid)
• Foetal disease

Question 12

How is progress of labour evaluated

Answer 12

• Combination of abdominal and vaginal examinations to determine
  
  • Cervical effacement
  • Cervical dilatation
  • Descent of the foetal head through the maternal pelvis

Question 13

What is considered suboptimal progress in the first stage of labour

Answer 13

• defined by cervical dilation
  
  • <0.5cm per hour in primigravid
  • <1cm per hour for parous women

Question 14

what happens if contractions are not adequate

Answer 14

• The foetal head will not descend and exert force on the cervix and the cervix will not dilate
• Important to check no obstruction as stimulation can result in ruptured uterus

Question 15

What is cephalopelvic disproportion

Answer 15

• Foetal head is in the correct position but is too large to negotiate the maternal pelvis
• Caput and moulding develop

Question 16

What can cause foetal distress

Answer 16

• too many contractions (uterine hyper-stimulation) due to lack of blood flow to the placenta

Question 17

How is foetal well-being monitored during labour

Answer 17

• Intermittent auscultation of the foetal heart
• Cardiotocography (CTG)
• Foetal blood sampling
  
  • Used when abnormal CTG
  • Provides direct measurements
    
    • pH and base excess - measure hypoxia
• Foetal ECG

Question 18

When would advise not to labour be given

Answer 18

• Obstruction of birth canal
  
  • Major placenta praevia, masses
• Misrepresentations
  
  • Transverse, should, hand, breech
• Medical conditions where labour would not be safe
• Specific previous labour complications
  
  • Previous uterine rupture
• Foetal conditions

Question 19

Types of assisted/instrumental delivery

Answer 19

• 15% of all births
• Forceps
• Vacuum extraction

Question 20

When is C-section essential

Answer 20

• Obstructed labour or foetal distress before cervix is fully dilated
• UK rate 25%

Question 21

Risks of C-section

Answer 21

• Infections
• Bleeding
• Visceral injury
• VTE

Question 22

Benefits of C-section

Answer 22

• Reduced risk of perineal injury

Question 23

3rd stage labour complications

Answer 23

• Retained placenta
• Post-partum haemorrhage
• Tears

Question 24

What are the causes of post-partum haemorrhage

Answer 24

• 4Ts
  
  • Trauma
  • Tissue
  • Tone
  • Thrombin

Question 25

Types of tears in labour

Answer 25

* Graze * 1st degree * 2nd degree * 3rd degree * 4th degree

Question 26

What is the postpartum period of time called

Answer 26

* puerperium

Question 27

Why is the midwife/health visitor seen for 9-10 days after birth

Answer 27

* Observe for signs of abnormal bleeding * Observe for evidence of infection * Wound/endometritis/breast * Debrief events around birth (especially if emergency C-section)

Question 28

When do all women have a postnatal check up

Answer 28

* 6 weeks at GP

Question 29

What are the common postnatal problems picked up on checkup (non-medical)

Answer 29

* Problems with feeding * Problems with bonding * Social issues (partner, other children, financial)

Question 30

What are some postnatal problems (medical)

Answer 30

* Post-partum haemorrhage * VTE * Sepsis * Psychiatric disorders of the puerperium * Pre-eclampsia

Question 31

Types of post partum haemorrhage

Answer 31

* Primary - blood loss of \>500ml within 24hrs of delivery * Secondary - blood loss of \>500mls from 24hrs postpartum to 6 weeks * Lochia is normal for 3-4 weeks (normal period or less)

Question 32

Why is thromboembolic disease more of a risk when pregnant

Answer 32

* Pregnancy and the postpartum period is a hypercoagulable state * 6-10x more likely to develop TE

Question 33

What is suspicious of thromboembolic disease

Answer 33

* Unilateral leg swelling and/or pain * SOB * Chest pain * Tachycardia * May present atypically

Question 34

What further increases the risk of VTE in pregnancy

Answer 34

* Immobilisation - spinal anaesthetic, C-section

Question 35

How should VTE be investigated in pregnancy

Answer 35

* D-dimer unreliable * ECG * Leg doppler * CXR +/- VQ scan (radiation exposure during pregnancy/breast feeding)

Question 36

How should VTE be treated in pregnancy

Answer 36

* Low molecular weight heparin * Warfarin is teratogenic, can be used in breastfeeding

Question 37

What is the leading cause of maternal death in the UK

Answer 37

* Sepsis * May present atypically

Question 38

What is the treatment for maternal sepsis

Answer 38

* Prompt IV antibiotics * Antipyretic measure * IV fluids

Question 39

How is maternal sepsis investigated

Answer 39

* Full septic screen - blood cultures, LVS, MSSU, wound swabs

Question 40

What are the baby blues

Answer 40

* Affect most women due to hormonal changes around the time of birth - after 1-3 days

Question 41

What is postnatal depression

Answer 41

* Can continue from baby blues or start sometime later * Has classical depressive symptoms * Affects functioning, bonding and often requires treatment * Increased risk if personal or family history of affective disorder

Question 42

What is puerperal psychosis

Answer 42

* rare but serious illness * Can be a danger to themselves and their baby * Inpatient psychiatric care * More common in women with personal/family history of affective disorder, bipolar, psychosis

Question 43

What occurs in postpartum hypertensive disorders

Answer 43

* Most eclamptic seizures occur in the post-natal period * Pre-eclampsia can develop postnatally or may worsen several days following delivery