Labour

Question 1

Types of delivery

Answer 1

vaginal - SVD / induced ± instrumental

Caesarean section - emergency / elective

Question 2

Talk about instrumental delivery

Answer 2

Forceps and vontouse
only be done if needed in dystocic labour and abiding by certain rules including
- cervix is fully dilated, head at or below the spines, no maternal bleeding disorder and also it needs to be done with the woman’s permission

Reasons for instrumental delivery:
Fetal indications - concern of fetal distress based on CTG or FBS
Maternal - fatigue, failure to progress
Forceps poses less risk to the baby, can only be used if there is direct presentation of the baby
Vontouse - better for mother (less risk of perineal injury)
- can be used for rotational delivery. - risk of cephalohaematoma

Question 3

How do you know a woman is in labour?

Answer 3

Symptoms include Spontanous ROM, painful regular contractions
Signs - confirmation of ROM based on speculum examination
- can test the fluid to confirm liquor vs vaginal secretions - amnisure, pH, ferning

Question 4

What is the Bishop’s score?

Answer 4

Score based on examination of the cervix used to assess if induction of labour would be favourable. A higher Bishop score suggests a woman is more likely to progress in labour.

Question 5

Description of cervix when not in labour

Answer 5

Posterior, not effaced, firm, not dilated

Question 6

Description of cervix when labour begins

Answer 6

Anterior, soft, full effaced, starting to dilate, feta head should be at the ischial spines.

Question 7

What is a dystocic labour?

Answer 7

Dystocia refers to abnormal progression in labour
Ideally should progress with cervical dilation at 1cm/hr.
Can have primary or secondary arrest of labour.
Primary - labour is confirmed but fails to progress. Secondary - labour progresses a bit before stopping

Question 8

What are the causes of dystocia?

Answer 8

Powers - contractions
Passenger - position of the baby
Passage - Think cephalopelvic disproportion if pains are strong, regular, frequent and the baby is in an OA position.

Question 9

What can be done to help progress if the contractions aren’t regular?

Answer 9

Artificial ROM with woman’s permission if not already R

Oxytocin

Question 10

When should oxytocin not be used?

Answer 10

Used with caution in multiparous women and in women with previous C section due to risk of scar causing uterine rupture

Question 11

Maternal indications for induction of labour

Answer 11

Pre-eclampsia
Intra-hepatic cholestasis of pregnancy 
Diabetes - macrosomia 
Post dates
Choice
Ruptured membrane at term but not in labour ( allow 24hrs for spontaneous labour before inducing)

Question 12

Most likely cause of dystocia in a multiparous woman?

Answer 12

Passenger - position of baby

passage - cephalopelvic disproportion

Question 13

In what circumstances would you not wait 24hrs between SPROM and inducing labour?

Answer 13

If meconium in liquor -> fetal distress.

GBS, HIV, Hep B -> minimise time of exposure for the baby

Question 14

Fetal indications for induction of labour

Answer 14

Oligohydramnios
Reduced fetal movements

Macrosomia - hx of big babies, may induce before EDD
Growth restricted baby if could tolerate labour
Fetal anomaly that requires treatment at birth and need to plan for neonatal care e.g. cardiac abnormality, gastroschesis.

Question 15

Difference between induction and augmentation of labour?

Answer 15

Induction is when there are no s&s of labour and a decision is made to start the labour
Augmentation is intervention to help progress in a dystocic labour

Question 16

What are the stages of labour?

Answer 16

1st - from onset of labour to full dilatation
2nd - full cervical dilatation to delivery of fetus
3rd - from delivery of fetes to delivery of placenta

Question 17

How are contractions classified?

Answer 17

Based on their duration
mild - less than 30s
moderate 30-60s
severe 60s+

Question 18

Complications of CS

Answer 18

VTE
Bleeding
Infection 
Trauma - fetus, bladder, bowel. 
Scar on uterus for subsequent pregnancies

Question 19

What are the indications for a CS?

Answer 19

Fetal- distress -> emergency

Maternal

• Dystocia
• Condition requiring delivery that is not suitable for IOL e.g. chorioamnionitis
• Primary active herpes infection
• Choice
• Placenta praevia
• Previous classic CS
• 2 previous CS

Question 20

What are the pain relief options available for women in labour?

Answer 20

Complementary

Conventional - Entenox, opioids, epidural, pudendal block, spinal anaesthetic, GA

Question 21

What complementary pain relief methods are available?

Answer 21

There are lot of options and a combination of different methods using ‘labour hopscotch’ can work well.
one to one midwife care has been shown to help manage pain in labour

TENS machine 
Aromatherapy
Hypnotherapy
Acupuncture
Acupressure
Heat pack 
Water pool/ shower

Question 22

Conventional pain relief

Entenox and opioids

Answer 22

Entenox - mix of O2 and NO, inhale, peak efficacy at 20-30s, no harm to baby
Opioids - Pethidine IM ( can cause euphoria, cautious of resp depression, N&V). Morphine. - Remifentanyl (PCA, ultra short acting, may be used if epidural is contraindicated, requires constant supervision because risk of resp depression and arrest)

Question 23

Epidurals

Answer 23

Combination of local + opioid
Placed at the level of T10 for labour
Can be topped up and used if need to change to CS.
Onset of action 15-20mins

Question 24

Who can’t have an epidural?

Answer 24

§ Thrombocytopenia (less than 80)
§ Heparin prophy in last 12hrs or therapeutic dose in last 24hrs
§ Inherited bleeding disorder
§ Septic
§ Scoliosis
§ Caution with some cardiac issues e.g. aortic stenosis ( the epidural will drop their BP)
Haemodynamically unstable - can’t drop the BP further

Question 25

Possible complications of an epidural

Answer 25

Haematoma
Abscess
Dural puncture headache
Nerve damage

Question 26

Pudendal block

Spinal

Answer 26

Pudendal block - injection of local into the pudendal nerve (roots S2,3,4). Short lived, may be used in instrumental deliveries where an epidural hasn’t been given.

Spinal benefits - single shot, patient is awake

Question 27

Why is GA not generally used anymore?

Answer 27

• Only used if contraindication to spinal or if anaesthetic team choose GA as the fastest method in an emergency (category 1 CS)
• Mother won’t be awake for birth, can’t bond with baby immediately at birth
• inhaled anaesthesia can cross placenta to affect baby
• laryngeal oedema makes the intubation technically difficult.

Question 28

What’s the significance for labour of a woman being primiparous?

Answer 28

She is more likely to have a primary arrest

• Usually due to insufficient uterine contraction
• May require oxytocin to augment her labour

Question 29

What is the risk of uterine rupture in a woman having a VBAC?

Answer 29

<1%

Question 30

Risk of C section with induction?

Answer 30

Risk of having a c section if a woman comes in spontaneous labour is about 6%, if she’s a 2nd time mum that risk drops to 2%
If a women is induced her risk goes up to about 38%, a multiple induced goes up to 4%

Question 31

How is induction carried out?

Answer 31

First decide if woman is suitable for ARM - based on bishop score (anterior, soft, short cervix, open/ dilated os and fetal head at ischial spines).
If suitable ARM, followed by oxytocin ( care in primp and prep CS)
If not suitable for ARM, use PG gel to ripen the cervix first.
Other option to PG is dilapam to physically dilate the cervix