Intrapartum management

Question 1

Contraindications to forceps delivery

Answer 1

Face presentation
Vertical transmission risks
Fracture risk
Relative: suspected fetal bleeding disorder

Question 2

Vacuum vs forceps for preterm delivery

Answer 2

Higher risk of subgleal haematoma and scalp trauma with vacuum
- avoid vacuum if <32/40, caution if 32-36/40

Question 3

Classification of fetal head position wrt OVD

Answer 3

Outlet:
-fetal scalp visible witout parting labia
- OA/ OP, ROA/P, LOA/P
- rotation doesn’t exceed 45 degrees
Low:
- vertex +2, not caput
- <45deg or >45 deg from OA/OP
Mid:
- fetal head no more than 1/5 palpable abdominally
- <45 deg or >45 deg from OA/OP
High:
- not recommended if head >/= 2/5

Question 4

Placement of vacuum

Answer 4

3cm from post fontanelle
Halfway point = flexion point

Question 5

Indications for OVD

Answer 5

Fetal compromise
Maternal:
- shorten second stage (eg med condition)
- fatigue/ exhaustion
Inadequate progress:
-P0: no progress 3 hours passive/ active w analgesia; 2 hours w/out analgesia
- P1: No progress w 2 hours passive/ active w analgesia; 1 hour w/out analgesia

Question 6

Prerequisites for OVD

Answer 6

Verbal consent
Abdo/ VE:
- </= 1/5 palpable per abdo
- Vx presentation
- fully dilated and ROM
- need to know position for instrument placement
- assess caput/ moulding
- ? adequate pelvic
-? US

Question 7

Preparation for OVD

Answer 7

Explain and consent (written consent if trial in OT)
Appropriate analgesia
Mat bladder empty
Aseptic technique
Staff - adequate facilities, lighting, staff, knowledge
Anticipate cx: failure, SD, PPH
Epis scissors: MLE to prevent OASIS, 60* angle

Question 8

Failure risks with OVD

Answer 8

Increased failure risk with:
- BMI >30, EFW >4kg, OP, head >1/5
- vacuum > forceps

Question 9

Risks assoc w OVD

Answer 9

OASIS
- 3rd deg w kiwi 8:100 w forceps
Incr risk of bleeding 4:100
If failure - increase risk of fetal head impaction
Vacuum - cepalohaematoma, retinal hge, maternal worries re baby
– dec risk vaginal/ perineal trauma
– no more likely assoc w CS, low Apgar or need for phototx

Question 10

Aftercare following OVD

Answer 10

IV dose co-amox
Reassess VTE
NSAIDS and paracetamol
Document void
? retention - PVR, UC
Offer physio at 3/12 PN to reduce UI

Question 11

Factors assoc w breech presentation

Answer 11

Prev breech birth
Premature labour
High parity
Multiple pregnancy
Polyhydramnios
Oligohydramnios
Uterine anomales
Pelvic tumour or fibroids
Placenta praevia
Hydrocephaly/ anencephaly
Fetal neuromuscular disorders
Fetal head and neck tumours

Question 12

Complications breech delivery

Answer 12

Cord prolapse 1% (0.5% w cephalic)
Fetal head entrapment
PROM
Birth asphyxia
ICH
Intrapartum death
BPI
Rupture of liver/ kidneys/ spleen
Dislocation or fractures

Question 13

Mx twin delivery after first twin delivered

Answer 13

Assistant to stabilise fetus in longitudinal lie
Continuous CTG
US - FH/lie
Oxytocin when lie confirmed
ARM only when fixed, best with contraction
Aim for birth within 30 min

Question 14

Mx twin delivery if second twin transverse

Answer 14

ECV
Internal podalic version
- one or both feet grasped inside uterus –> breech extraction
- don’t ARM too early –> cord prolapse
- ** caution for head entrapment

Question 15

Length of inter-twin birth interval

Answer 15

30 min

Question 16

Prevention of OASIS

Answer 16

MLE considered for OVD
- 60 degrees from midline when perineum distended
Perineal protection at crowning
Warm compression during second stage

Question 17

Pointers on OASIS repair

Answer 17

OT
Regional/ general anaesthesia
Good lighting
Vaginal pack for excessive bleeding
Avoid figure of 8s- good for haemostasis but cause ischaemia
PR before and after

Question 18

Technique for repairing anal mucosa

Answer 18

Continous or interrupted

Question 19

Technique for repairing IAS

Answer 19

Interrupted OR
mattress without any attempt to overlap IAS

Question 20

Technique for repairing full thickness EAS

Answer 20

either overlapping OR
end to end

Question 21

Technique for repairing partial thickness EAS

Answer 21

end to end

Question 22

Suture choice for OASIS

Answer 22

Anorectal mucosa:
- 3-0 polyglactin (less irritation and discomfort than PDS)
IAS/ EAS:
- monofilament (3-0 PDS) OR
- modern braided (2-0 polyglactin)
- mattress without any attempt to overlap
Burying of knots beneath superficial perineal muscles recommended to minimise knot and suture migration to skin

Question 23

Post-op mx OASIS

Answer 23

Broad spec Ab - reduce infection and dihiscence
Laxatives
Physio
R/V 6-12/52
Incontinence or pain at review –> refer gynae/ colorectal

Question 24

Prognosis of OASIS

Answer 24

60-80% asymptomatic 12/12 after repair

Question 25

Normal umbilical vein and artery blood gas values

Answer 25

pH: v 7.35/ a 7.28
pCO2: v 38/ a. 49
pO2: v 29/ a 18
BE: v -4/ a -4
HCO3: v 20/ a 22

Question 26

FBS interpretation

Answer 26

pH:
>7.25 - normal - no action
7.20 - 7.25 - borderline - repeat in 30-60min if not delivered
<7.20 - abnormal - deliver (OVD/ CS)

Question 27

What is oxytocin and MOA

Answer 27

Mammalian neurohypophysial hormone
Produced in supraoptic and paraventricular nuclei of hypothalamus
= neuropeptide
Causes uterotonic stimulation and myoepithelial cell contraction
Uterine sensitivity to oxytocin markedly increases at onset of labour

Question 28

What is syntocinon and formulation

Answer 28

Synthetic nonapeptide identical to oxytocin
5u in 1ml and 10u in 1ml

Question 29

Clinical problems assoc w intrapartum oxytocin use

Answer 29

Fetal intolerance
Uterine overcontracting- tachysystole
- = 7 contractions in 15min in nullip/ 5 contractions in 15min in multip
- hypertonus - prolonged contraction
- hyperstimulation - tachysystole or hypertonus –> NRCTG

Question 30

Contraindications to oxytocin

Answer 30

Non-reassuring fetal trace
Overcontracting
Prev. scar - prev uterine perf, classical CS or myomectomy
Transverse lie/ oblique presentation
Malpresentation

Question 31

Extra caution with oxytocin in which patients

Answer 31

Prev CS
Grand multip
PTL
Hx. of MI/ CVS due to effects on BP and HR
Long QT interval

Question 32

Risks assoc w oxytocin use

Answer 32

Fetal hypoxia (esp FGR)
Uterine rupture (multips)
Water intoxication assoc w mat/neonatal hypoNa
Interaction with inhaled anaesthetics –> hypoTN, cardiac rhythm disturbances
PGE may potentiate uterotonic effect

Question 33

Infusion rate of oxytocin - augmentation

Answer 33

6-30ml/hr
(1-5mU/min)
Increase by 1-5mU/min every 15-30 minutes up to a max of 30mU/min (180ml/hr)

Question 34

Absorbable suture materials in LSCS + rationale for use

Answer 34

Gut
Polyglactin (vicryl) - 60 days
- braided polyfilament
- less likely to loosen at knot
- inc tissue rxn/ infection
Polyglecaprone (monocryl) - t1/2 = 7-14/7
- monofilament
- 20-30% breaking strength at. 2/52
- completely absorbed by 100/7
Polydioxane (PSD) - 200 days
- monofilament
- longest lasting

Question 35

Non-absorbable sutures used at LSCS

Answer 35

Clips - remove after 5-7/7
Nylon
Polypropylene (prolene)

Question 36

Needles used at LSCS and rationale

Answer 36

Round bodied:
- use @ friable tissues
Cutting needle:
- triangular shape w 3 cutting edges
- penetrates tough tissues (eg skin)
Reverse cutting needle:
- cutting surface at convex edge
- good for tough tissue (eg tendon/ subcut)
- decr risk of cutting through tissue
Point:
- blunt: abdo wall closure, friable tissue
- sharp: pierce and spread tissue w minimal cutting

Question 37

Risk of bad outcome with IOL for postdates

Answer 37

1 in 200

Question 38

Intrapartum management of VBAC

Answer 38

Review chart and confirm safe for VBAC
Obs team notified
16G IVC, FBC and GXH
One-to-one midwife care
CEFM

Question 39

Signs and symptoms of uterine rupture

Answer 39

Prolonged, persistent and profound bradycardia
AbN FHR. suggesting fetal compromise
Abdo pain, acute onset scar tenderness
AbN progress in labour, prolonged first or second stage
Vaginal bleeding
Cessation of prev efficient uterine activity
Loss of station of presenting part
Chest pain or shoulder tip pain
Maternal tachy, hypoTN or shock

Question 40

Absolute contraindications to VBAC

Answer 40

classical CS
Uterine rupture
Placenta praevia
Declines VBAC

Question 41

Relative contraindications to VBAC

Answer 41

breech
macrosomia
twins
2x previous

Question 42

Risks with VBAC

Answer 42

Most serious= uterine rupture, 0.2-0.7%, higher if IOL or augmented labour
- Note: CTG, PVB, maternal decline, pain out of proportion, cessation of regular contractions, change in stage
Subsequent pregnancies: r/o PAS, hyst
Inc TTN w ERCS
Success rate: 72-75%, prev SVD 85-91%
EmLSC