Complications of labour + delivery

Question 1

Abnormal labour evidenced by

Answer 1

• A delay in cervical dilatation (<2cm in a 4 hr period) or descent of the presenting part of the foetus
• signs of foetal compromise
• Foetal malpresentation
• multiple gestation
• uterine scars
• induced labour

Question 2

Causes of abnormal labour

Answer 2

• Dysfunctional uterine activity
• Cephalopelvic disproportion
• Malpresentations
• Abnormality of the birth canal: uterine fibroids, cervical dystocia (doesn’t dilate bc scarring)
• Foetal compromise

Question 3

3 dependent variables of labour

Answer 3

The powers: efficacy of muscular contractions
The passenger: the foetus (size, presentation, position)
The passages: uterus, cervix and bony pelvis

Question 4

Indicators of presumed foetal compromise

Answer 4

Abnormal CTG
Fresh meconium staining amniotic fluid

(can be false positives of CTG and benign meconium stains, so “presumed”)

Question 5

Risk factors for foetal compromise

Answer 5

• Placental insufficiency
• Prematurity
• Postmaturity
• Multiple pregnancy
• Prolonged labour
• Augmentation with oxytocin
• Uterine hyperstimulation
• Precipitate labour (quick, less than 3 hrs)
• Intrapartum abruption
• Cord prolapse
• Uterine rupture
• Maternal diabetes
• Cholestasis of pregnancy
• Maternal pyrexia
• Chorioamnionitis
• Oligohydramnios

Question 6

Clinical features of foetal compromise

Answer 6

Thick/tenacious meconium staining (of amniotic fluid) that is either dark green, bright green or black

Thin and light meconium is a sign of foetal maturity

Question 7

Investigations for foetal compromise

Answer 7

Signs on CTG monitoring
Foetal tachycardia (>160)

others:
Loss of baseline variability (<5bpm)
Recurrent decelerations
Persistent variable decelerations
Foetal brady (<100 for >3 mins)

Question 8

Management of foetal compromise

Answer 8

Exclude pathology including malpresentation and cord prolapse
Consider foetal blood sampling (cervix must be >3cm)
- abnormal result is indication for delivery

Question 9

Uterine rupture risks

Answer 9

“classical” rather than LSCS
Oxytocin (in multiparous mother) and prostacyclin
Factors that inc force applied to uterine muscle: eg shoulder dystocia, breech extraction, accrete

Question 10

Uterine rupture classification

Answer 10

Complete - direct communication of uterine cavity with peritoneal cavity
(MEDICAL EMERGENCY)
Incomplete - uterine cavity separated from peritoneal cavity by a thin layer of peritoneum

Question 11

Uterine rupture clinical features

Answer 11

Acute onset of significant CTG changes
Maternal tachycardia
Vaginal bleeding
Abdo pain
Easily palpable foetal parts per abdomen
Hypovolaemic shock

Question 12

Management of uterine rupture

Answer 12

Call for help!
Rescitation
Emergency laparotomy (with repair of defect)
Emergency hysterectomy may be required if massive haemorrhage, complete rupture

75% perinatal mortality in complete ruptures
prevent: offer those with midline scar an elective c section

Question 13

Vasa previa

Answer 13

Umbilical cord vessels run in the foetal membranes and cross the internal os

Question 14

Clinical features of vasa previa

Answer 14

Severe foetal distress or foetal death following a relatively small intrapartum haemorrhage

Question 15

Investigation for vasa previa

Answer 15

Kleihauer test - to distinguish between foetal and maternal red cells

Usually a retrospective diagnosis after delivery

Question 16

Management for vasa previa

Answer 16

Immediate delivery of foetus