Chapter 8: Care In Labour Flashcards
You are a trainee intern in birthing suite seeing Kāhu a 25 year old G1P0 wahine Māori who was admitted four hours ago at 37+3 weeks gestation. Kāhu has had uncomfortable uterine contractions that last 20-30 seconds and occur every 3 – 5 minutes and started half an hour before admission. No analgesia has been required. Fetal heart monitoring is normal and the fetal presentation is cephalic, Left Occipito Anterior (LOA), 3/5 head palpable abdominally. Kāhu’s cervix is posterior, closed, soft and 2cm long. Her membranes are intact. You are reviewing her four hours after admission. There has been no change to her symptoms, abdominal or vaginal findings at admission.
From the following options, what best describes Kahu’s situation?
Kāhu is not in labour
Kāhu’s labour is obstructed
Kāhu is in established labour
Kāhu has threatened preterm labour
Kāhu is having a prolonged latent phase of labour
Kāhu is not in labour
Prolonged latent >20 hours
You are a trainee intern in birthing suite admitting Suyin, a 24 year old primigravid Malaysian woman who is 40 weeks gestation and is in early labour. Her vital signs are normal. Your next step will be to do an abdominal examination, and then Suyin has consented for you to do a vaginal examination.
Which of the following options will be determined by the vaginal examination and not the abdominal examination?
The station of the fetal head
The fetal heart rate
The fetal size
The engagement of the fetal head
The presenting pole of the fetus
The fetal lie
The station of the fetal head
To feel the ischial spines
You are a trainee intern in birthing suite admitting Steph, a 25 year old G1 P0 Pākehā woman at 39 weeks gestation. Steph has been aware of mild uterine contractions for the last 3 hours but these are not causing discomfort. The fetal presentation is cephalic and fetal monitoring is normal. Steph’s cervix is posterior, closed, soft and 2cm long. Her membranes are intact. Four hours later you review her and there has been no change in her abdominal or vaginal examination findings. Analgesia has not been required.
Which of the following options is the appropriate management?
Reassure Steph that she is not yet in labour, and send her home
Offer Steph an induction of labour with oxytocin
Offer an induction with ARM (artificial rupture of membranes)
Offer an induction of labour with prostaglandins
Transfer Steph to the antenatal ward for observation
Offer an epidural
Perform a caesarean section
Reassure Steph that she is not yet in labour, and send her hom
You are a trainee intern in birthing suite with Nina, a 25 year old G1P0 wahine Māori who is 39 weeks gestation and who was admitted an hour ago in labour. On admission Nina was contracting every 3 minutes. Abdominally the lie is longitudinal and 3/5 of head is palpable abdominally. Nina was 3 cm dilated and the cervix was fully effaced. Her membranes had spontaneously ruptured 1 hour prior to admission to hospital and the liquor was clear. Fetal heart monitoring was normal.
Four hours after admission, Nina is reassessed. She continues to contract every 3 minutes and her contractions last for one minute. Fetal heart monitoring is normal. The lie is longitudinal, presentation cephalic and 2/5 of head is palpable abdominally. On vaginal examination the cervix is 7 cm dilated, the head is at station 0, position ROA (right occiput anterior).
Which of the following is the best next step in her management?
Perform a forceps birth
No intervention is required as labour is progressing normally
Perform a caesarean section for inadequate progress in labour
Commence oxytocin augmentation for a prolonged first stage
Begin pushing
Commence continuous CTG monitoring as Nina is now in advanced labour
No intervention is required as labour is progressing normally
You are a trainee intern in birthing suite with Megan, a 34 year old primigravid Pākehā woman who is in spontaneous labour at term gestation. Megan is a healthy woman who has had an uncomplicated pregnancy. On arrival her observations were normal. Abdominal examination revealed a longitudinal lie, cephalic presentation with the head 2/5 palpable. On vaginal examination she was 3 cm dilated and the cervix was fully effaced and the membranes were bulging. Fetal heart auscultation was normal. Megan has been staying mobile. Her membranes have just spontaneously ruptured and the liquor is meconium stained. Her contractions have increased in strength and she is contracting 4 in 10 (4 contractions every 10 minutes). Megan would like to get into the bath but her LMC midwife advises that Megan needs continuous CTG monitoring.
What is the indication for continuous CTG monitoring?
Intermittent auscultation of a fetal heart at 140 beats per minute
Meconium stained liquor
A head 2/5 palpable abdominally
Term gestation
Strong contractions 4 in 10
Meconium stained liquor
You are a trainee intern in birthing suite with Ella, a 25 year old Pākehā primiparous woman who is in spontaneous labour at 41 weeks gestation. Ella is 6cm dilated and has requested an epidural for analgesia. The LMC midwife has attached a CTG monitor to ensure fetal wellbeing prior to an epidural being sited. You review the CTG.
Which of the following statements is correct?
A baseline fetal heart rate of 140 is concerning and would require further investigation
If the fetal heart sits at 180 for more than 5 minutes then this is classed as a bradycardia
All women in labour should have continuous CTG monitoring
A baseline fetal heart rate of 170 is normal
A baseline fetal heart rate of 120 is normal
A baseline fetal heart rate of 120 is normal
You are a trainee intern in birthing suite with Maxine, a 25 year old G1P0 NZ European woman in labour at term who had a normal pregnancy antenatally. When she was admitted to birthing suite the fetal lie was longitudinal, presentation cephalic and she was 6cm dilated with clear liquor. Maxine has been using nitrous oxide (‘gas and air’) for analgesia. Three hours later a fetal heart of 80 was heard on intermittent auscultation. The CTG was attached and this confirms a bradycardia at 80 beats per minute. The obstetric registrar performs an examination. Maxine is fully dilated with the station +2 and the position is ROA (right occiput anterior).
Which of the following is the most appropriate management?
Ask the anaesthetist to site an epidural and then perform a ventouse delivery
Immediate caesarean section under spinal anaesthetic
Immediate caesarean section under general anaesthetic
Immediate ventouse delivery with local anaesthetic to the perineum
Await spontaneous birth
Immediate ventouse delivery with local anaesthetic to the perineum
You are a trainee intern in delivery suite with Li, a 25 year old G1P0 Chinese woman at 38 weeks gestation. Li has presented with ruptured membranes and on examination thick, meconium stained liquor is confirmed. Li’s cervix is 1cm dilated and fully effaced and she is contracting mildly 2 in 10.
A midwife attaches a CTG monitor. The CTG is abnormal with a baseline tachycardia of 170 beats per minute, complicated variable decelerations and reduced beat to beat variability.
Which of the following is the most appropriate management?
Perform fetal scalp pH measurement
Commence oxytocin augmentation to expedite delivery
Immediate forceps delivery
Immediate ventouse delivery
Immediate caesarean section
Immediate caesarean section
You are a trainee intern in delivery suite at 2100 hours with Alice, a 25 year old G2P2 Pākehā woman who has just birthed her second baby. You are reviewing Alice’s progress in labour on her partogram. Note that the “X” plotted on the graph refers to the dilatation of the cervix in cms, and the “O” to the descent of the head/degree of engagement as measured by the number of fifths of the head that are palpable abdominally. Also the findings were transposed (TR) to the alert line when Alice moved into the active phase of labour.
At 1700 hours, 4/5 of the fetal head was palpable abdominally, and the cervix was 5 cm dilated.
Talia is a 32 year old New Zealander of Samoan ethnicity who is in birthing suite having her first baby. Talia is a well lady who has had a normal pregnancy. She is anxious because her friend’s baby was admitted to the neonatal unit with early onset Group B Streptococcus infection. Talia asks you whether she will require antibiotics in labour.
Which of the following is an indication for intravenous antibiotics in labour?
Talia had a Group B Streptococcus urine infection at 12 weeks gestation. This was treated with penicillin
Talia’s temperature is 37.2 degrees Celsius
A low vaginal swab at 28 weeks grew Group B Streptococcus
Talia’s liquor is meconium stained
Talia’s membranes ruptured 10 hours ago
Talia had a Group B Streptococcus urine infection at 12 weeks gestation. This was treated with penicillin
You are a trainee intern in delivery suite with Pania, an 18 year old G1P0 wahine Māori who is in labour at 41 weeks’ gestation. Three fifths (3/5) of the fetal head is palpable abdominally. The baby palpates as an ‘average’ size. The cervix is 9 cm dilated. Two hours ago the cervix was 9 cm dilated. Pania is distressed and exhausted and requests stronger pain relief. She has had two IM injections of morphine and the last one was one hour ago. Fetal heart rate monitoring has been normal.
Which of the following is the most appropriate next management step?
Ask Pania to start pushing
Insert a urinary catheter
Attempt delivery using a Ventouse
Recommend an epidural
Undertake a trial of forceps
Reassure, and reassess in 2 hours
Recommend an epidural
No pushing before full dilatation
Sandra is a 24 year old primiparous Pakeha woman in the birthing suite at term gestation. She has no underlying medical conditions and has had an uncomplicated pregnancy. On admission the baby was longitudinal lie, cephalic and the head was engaged. Sandra was 4cm dilated and her membranes were ruptured and clear liquor drained. Fetal heart monitoring was normal. Four hours later she was contracting 2 in 10 and still 4 cm dilated so oxytocin augmentation was commenced.
You review Sandra with the obstetrics registrar on the evening ward round. She is contracting 5 in 10 and her contractions are lasting for 90 seconds. Sandra is distressed with pain. The CTG which was previously normal now shows a fetal tachycardia at 170 beats per minute. The registrar tells you that the CTG is non-reassuring, but as the beat to beat variability is normal and there are no decelerations, which makes it more reassuring and unlikely that the baby is significantly hypoxic.
Which of the following is the most appropriate management?
Arrange for an epidural to be inserted. Continue the oxytocin in the meantime
Continue the oxytocin, arrange for an epidural and administer terbutaline as a tocolytic
Continue and re-examine vaginally 4 hours after the oxytocin was commenced
Perform a vaginal examination. If Sandra is still 4 cm dilated, perform a caesarean section
Turn down the oxytocin infusion as Sandra is hyperstimulated. Analgesia can be offered
Apply a fetal scalp electrode (FSE) so that the fetal heart can be monitored more accurately
Arrange an emergency caesarean section unless Sandra is fully dilated, in which case perform a forceps
Turn down the oxytocin infusion as Sandra is hyperstimulated. Analgesia can be offered
You are a trainee intern in delivery suite examining with Deanna, a 26 year old primiparous Pākehā woman who has just birthed a healthy baby . You are checking her placenta - a picture of the fetal and maternal surfaces is shown below.
Looks gross and red, unequal lobes
Succenturiate
Accessory lobe
You are a trainee intern on birthing suite with Bronwyn, a 20 year old G1P0 British woman who was admitted four hours ago in labour. On admission the cervix was 6 cm dilated, thin and the fetal head Right Occipito Posterior (ROP) at station -2. Her membranes had ruptured and she had clear liquor draining. Two hours later an epidural was inserted as she requested pain relief. Four hours after admission, she is having regular uterine contractions lasting about 45 seconds and occurring about every five minutes. The CTG shows no evidence of fetal distress. Abdominal and vaginal examination findings are the same as on admission four hours earlier.
Which of the following most accurately describes her clinical situation?
Prolonged second stage
Prolonged latent phase
Secondary arrest of labour
Primary dysfunctional labour
Normal labour
Secondary arrest of labour
You are a trainee intern in birthing suite and have been involved in the labour care of Manaia, a 33 year old Māori lawyer who has just birthed her third pēpi. Her pēpi was unexpectedly born in poor condition and required admission to the neonatal unit. The neonatal team request that the placenta be sent to the lab for histological examination.
From your whakawhanaungatanga with Manaia, you are aware that she is planning on taking her whenua home to her turangawaewae in the Wairarapa.
She is concerned that sending the whenua to the laboratory would mean that she is unable to do this.
Which of the following statements is CORRECT?
You understand that it is important that she takes her whenua home. While this means that it won’t be able to be assessed completely at the laboratory, you counsel her if she would consent to a small section of it being sent for histology and for you to take swabs it to test for infection which may not give as much information.
Histological and pathologic assessment of the whenua may explain why her pēpi is unwell and provide information for the management of future pregnancies. The whenua will be placed in formalin and returned to her after the laboratory assessment. This will mean a delay before she can take it to the Wairarapa which may or may not be acceptable to her and the formalin will change the colour of the placenta and limit where she can safely dispose of it
The placenta is human tissue and she risks spreading infection, contamination of the household and land by taking it to the Wairarapa. You recommend that the hospital dispose of it in a respectful manner.
She is very welcome to take her whenua home. Unfortunately, this means that it won’t be able to undergo histological examination and potential information gained cannot be recovered at a later date. Respecting her autonomy is more important though and there is no satisfactory alternative.
It is important the whenua is sent to the laboratory as it may explain why her pēpi is unwell and provide information for management of future pregnancies. The whenua is stored in formalin to preserve it and because formalin is poisonous she won’t be able to take it home. The whenua will be disposed of respectfully by the laboratory.
Histological and pathologic assessment of the whenua may explain why her pēpi is unwell and provide information for the management of future pregnancies. The whenua will be placed in formalin and returned to her after the laboratory assessment. This will mean a delay before she can take it to the Wairarapa which may or may not be acceptable to her and the formalin will change the colour of the placenta and limit where she can safely dispose of it
