Labour

Question 1

What is labour and state four characteristics of a normal labour

Answer 1

Spontaneous onset of regular,rhythmic painful uterine contractions with increasing intensity,frequency,duration associated with progressive effacement and dilation of cervix and with the descent of the presenting part leading with delivery of products of conception (foetus,liquor,membrane,placenta)

Normal:
Singleton baby
Baby In occipitoanterior position
Baby at term
Spontaneous onset (it begins on its own, without medical intervention)
Rhythmic and regular uterine contractions
Vertex or cephalic presentation (the ‘crown’ of the baby’s head is presented to the opening cervix, as you learned in Study Session 6 of the Antenatal Care Module)
Vaginal delivery occurs without active intervention in less than 12 hours for a multigravida mother and less than 18 hours for a primigravida (first birth)
No maternal or fetal complications.
No induction of labour
Should be delivered by SVD
Not be assisted Vaginal delivery

Question 2

Whatis true labour and false labour
State the differences between the two
How will you know if true labour is progressing

Answer 2

True labour is characterised by regular, rhythmic and strong uterine contractions that will increase progressively and cannot be abolished by anti-pain medication. Pain symptoms may be relieved a little if the woman takes painkilling drugs, but true labour will still progress.

Tell her that true labour is:
Regularly and progressively increasing pushing-down pain, which happens about 3–5 times in every 10 minutes. (Check whether she knows or can estimate how long 10 minutes is).
Characterised by a pushing down pain, which is usually felt first in her lower back and moving around to the front in the lower abdomen below her belly button.

False labour: It is characterised by irregular contractions which are less painful than in true labour and they don’t progress

Characteristics True labour False labour
1.Uterine contractions: i.True labour- Contractions occur at regular intervals, but the interval between each contraction gradually becomes shorter False- Contractions occur at irregular intervals
ii. True - Duration of each contraction gradually increases
False- Duration remains unchanged — either long or short
iii. True- Intensity of contractions becomes stronger and stronger
False- Intensity remains unchanged

2.Cervical dilation
True - Cervix progressively dilates False- Cervix does not dilate, remains less than 2 cm

3. Pain
   True- Discomfort at the back in the abdomen, cannot be stopped by strong anti-pain medication
   False- Discomfort is non-specific (has no particular location) and is usually relieved by strong anti-pain medication or by walking

If true labour is progressing, there will be adequate uterine contraction, evaluated on the basis of three features — the frequency, the duration and the intensity of the contractions:

The frequency of uterine contractions will be 3-5 times in every 10 minute period.
Each contraction lasts 40–60 seconds; this is known as the duration of contractions.
The woman tells you that her contractions feel strong; this is the intensity of contractions.

Question 3

What is show and what does it mean when you see it

Babies often drop lower in the mother’s belly about 2 weeks before birth, which is known as lightening; commonly, mothers feel that the baby is no longer lying ‘high’ in the abdomen, and not pushing her stomach upwards.
True or false

Answer 3

In the last few days of pregnancy, the cervix may begin to open. Sometimes the mucus and a little bit of blood drip out of the vagina. This is called show. It may come out all at once, like a plug, or it may leak slowly for several days. When you see the show, you know that the cervix is softening, thinning and beginning to efface (open). Be careful not to confuse the show with the normal discharge (wetness from the vagina) that many women have in the two weeks before labour begins. That discharge is mostly clear mucus and is not coloured a little bit red with blood.

Question 4

the fetal membranes rupture before labour begins, there should only be a few hours delay before labour starts. If labour does not start within 6 hours after the bag of waters breaks, there is a risk of infection entering the uterus, which gets stronger the more time that goes by after the membranes rupture.
State two complications of PROM during labour

Answer 4

Potential complications of rupture of fetal membranes during labour are:

Infection: Since the ‘door’ to the uterus is open and you are going to do pelvic examinations with your gloved fingers to assess the progress of labour, there is a risk of transferring infection into the uterus unless you are very careful about hygiene (as you will learn in later study sessions of this Module). This risk gets bigger if the labour is prolonged.
The umbilical cord may prolapse (be pushed out ahead of the baby as the waters gush out through the cervix), or the cord may become trapped against the endometrial wall by the baby which is no longer kept ‘floating’ by the amniotic fluid. If the cord is compressed, the baby can develop hypoxia (low oxygen levels) because the blood flow is restricted in the cord, and it may die or be brain damaged.
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Question 5

What are the stages of labour and what occurs in the first stage ?
The first stage of labour is divided into two stages name them and explain
What is effacement

Answer 5

Labour is traditionally divided into four stages:

The first stage of labour (the cervical opening stage)-
The second stage of labour (the pushing stage, ending in the birth of the baby)
The third stage of labour (the birth of the placenta)
The fourth stage of labour (the first 4 hours after birth).

The first stage of labour is characterised by progressive opening of the cervix, which dilates enough to let the baby out of the uterus.

immediate effect of uterine contraction is to dilate the cervix and shorten the lower segment of the uterus, so the edges of the cervix are gradually drawn back and are taken up. This process is called effacement

Between contractions, the cervix relaxes. The first stage is divided into two phases: the latent and the active phase, based on how much the cervix has dilated.

Latent phase

The latent phase is the period between the start of regular rhythmic contractions up to cervical dilatation of 4 cm. During this phase, contractions may or may not be very painful, and the cervix dilates very slowly. The latent phase ends when the rate at which the cervix is dilating speeds up (it dilates more quickly). This signals the start of the active phase.

The active phase is said to be when the cervix is greater than 4 cm dilated. Contractions become regular, frequent and usually painful. The rate of cervical dilation becomes faster and it may increase in diameter by as much as 1.2 to 1.5 cm per hour, but the minimum dilation rate should be at least 1 cm per hour. You should start to plot data on the partograph at this stage, as you will learn to do in Study Session 4 of this Module.

Cervical dilatation continues until the cervix is completely open: a diameter of 10 cm is called fully dilated. This is wide enough for the baby to pass through (Figure 1.2). At this diameter, you would not feel the cervix over the fetal head when you make a vaginal examination with your gloved fingers.

Question 6

What happens in the second and third stage of labour

Answer 6

The second stage begins when the cervix is fully dilated (10 cm) and is completed when the baby is completely born. After the cervix is fully dilated, the mother typically has the urge to push. Her efforts in ‘bearing down’ with the contractions of the uterus move the baby out through the cervix and down the vagina. This is known as fetal descent. The rate of fetal descent is an important indicator of the progress of labour, which will be described in more detail later. The average duration of second stage is 1 hour and usually not longer than 2 hours.

The third stage of labour is the delivery of the placenta and membranes after the baby has been born. The duration is usually a maximum of 30 minutes.

Question 7

What happens in the fourth stage of labour and why?
How often should vitals be done after delivery?

Answer 7

The first four hours immediately following placental delivery are critical, and have been designated by some experts as the fourth stage of labour. This is because after the delivery of the placenta, the woman can have torrential vaginal bleeding due to failure of uterine contractions to close off the torn blood vessels where the placenta detached from the uterine wall.

Maternal blood pressure and pulse should be recorded immediately after delivery and every 15 minutes for the first four hours. Normally, after the delivery of the placenta, the uterus will become firm due to sustained contraction, so the woman might feel strong contractions after the birth. Reassure her that these contractions are healthy, and help to stop the bleeding.

Question 8

What are the mechanisms of normal labour
Define engagement and descent

Answer 8

The seven cardinal movements are the series of positional changes made by the baby which assist its passage through the birth canal.

Engagement is when the fetal head enters into the pelvic inlet (Figure 1.3, diagram 2). The head is said to be engaged when the biparietal diameter (measuring ear tip to ear tip across the top of the babys head, see Figure 1.4 below) descends into the pelvic inlet, and the occiput is at the level of the ischial spines in the mother’s pelvis (see Figure 1.5).

The term fetal descent is used to describe the progressive downward movement of the fetal presenting part (commonly the head) through the pelvis. When there is regular and strong uterine contraction, and the size of the babys’ head and the size of the mother’s pelvic cavity are in proportion so the baby can pass through, there will be continuous fetal descent deep into the pelvic cavity. Since the pelvic cavity is enclosed with pelvic bones, when the uterus is strongly pushing down, occasionally the fetal scalp bones undergo overlapping at the suture lines in order to allow the head to pass through the narrow space. This overlapping is called moulding. The commonest types of moulding include one parietal bone overlapping over the other parietal bone along the sagittal suture (Figure 1.4), the occipital bone overlapping the temporal bone, and the frontal bone overlapping the parietal bones.

Question 9

What are the 7 movements of babies during labour
Signs of true labour

Answer 9

There are four stages of labour:
The first stage starts with true labour and ends with full cervical dilatation (10 cm); it is divided into latent and active phases.
The second stage is from full cervical dilatation to delivery of the baby.
The third stage is from the delivery of the baby to delivery of the placenta.
The fourth stage is the first 4 hours after placental delivery when you need to follow the mother as closely as during labour and delivery.
In a normally progressing labour, the baby performs seven cardinal movements as it passes down the birth canal: engagement - descent - flexion - internal rotation - extension - external rotation/restitution - expulsion.
There is fetal descent during every cardinal movement.

Mrs Abeba is in true labour because her pains are signs of adequate uterine contractions: they are regular, frequent (2-3 every 8 minutes), and the duration is about 40 seconds, which is expected in true labour. Her cervix is effaced and dilated to 4 cm after 3 hours of contractions.
b.She is in the first stage of labour, at the cross-over point between the latent phase and the active phase, which occurs when the cervix is dilated to 4 cm.
c.Reassure Mrs Abeba that labour can begin normally without a ‘show’. Her contractions have been coming for 3 hours without stopping, and their strength and regularity are as expecedt in a normal labour.

Question 10

List ten indications for CS

Answer 10

Here are ten common indications for caesarean section:

1. Fetal distress
2. Breech presentation
3. Placenta previa
4. Prolonged labor
5. Multiple gestation
6. Fetal macrosomia
7. Maternal medical conditions (e.g. hypertension, diabetes)
8. Abnormal fetal position (e.g. transverse lie)
9. Umbilical cord prolapse
10. Previous caesarean section
11. Maternal request
12. Abnormal presentation (e.g. face or brow presentation)
13. Obstructed labor
14. Cephalopelvic disproportion
15. Placental abruption.

Question 11

What is the difference between prolonged and obstructed labor

Answer 11

According to Medscape, prolonged labor is defined as a labor that lasts longer than 20 hours in a first-time mother or longer than 14 hours in a woman who has given birth before. Prolonged labor can be caused by a variety of factors, including a slow or inefficient labor, a large baby, or a narrow pelvis.

Obstructed labor, on the other hand, occurs when the baby is physically unable to pass through the birth canal, despite strong contractions. This can be caused by a variety of factors, including a baby that is too large for the pelvis, an abnormal fetal position, or a birth canal that is too narrow.

So, the main difference between prolonged and obstructed labor is that prolonged labor refers to a labor that lasts longer than usual, while obstructed labor refers to a situation where the baby is physically unable to pass through the birth canal.

Question 12

What are the Norma contractions in a woman?
How many is hyper contractions?

Answer 12

3-4
Above 5 contractions is hyper

30-50 seconds in each contraction

Labour
Latent and active phase difference
Latent: 0-4cm
Active -
Latent phase in nullips can prolong for how many hours 18hours
Multiparous 12 hours
Second stage of labour - 30-1hour . Full dilation to expulsion

Mechanisms of labour
Third stage of labour - 15-30 minutes

Active management of third stage of labour:
2.Controlled cord traction- 1.Administer oxytocin(max is 40iudually give 5iu depending on the bleed (or cytotec) in first minute
3.Uterine massage

Abnormalities in placenta situation if it’s not coming out after controlled cord traction

Any woman should be able to deliver on her on

APH:
28weeks till before term

Placenta praevia:
Implantation of placenta in lower segment of uterus from 28weeks till before term .
You don’t diagnose before 28 cuz of
Placenta migration

Difference between upper and lower anatomical segment of uterus

Bleeding before 26 weeks: threatened abortion

Question 13

The definitions of retained placenta range from 15-60 minutes without placental delivery but are most commonly 20-30 minutes.

Question 14

State some symptoms of labour How does labour occur?

Answer 14

Symptoms:
Ask about the increase in intensity or frequency or duration of contractions
Ask if pain is getting worse or it lasts longer
Ask about loss of liquor and the time it happened
Ask about show( it’s a slimy think like phlegm (mucus plug) or with streaks of blood

increased Oxytocin and Prostaglandins (PGL) levels with multiplication of their receptors.
b\ Formation of gap junctions between myometrial cells to facilitate cell to cell communication
with passage of products of metabolism and electric current
c) Formation of the lower uterine segment (LUS), where the upper uterine segment (UUS) myometrium becomes thicker and LUS myometrium thinner.
d) increased myometrial tone with irregular intermittent contractions due to interactions between myometrial proteins (actin & myosin) caused by myosin light chain kinase enzyme stimulated by PGL and calcium ions which show increased intracellular calcium influx.
e) Cervical Softening: due to increased water content secondary to increased levels of oxytocin
and PGL which lead to breaking of the Disulphide linkage of collaged fibres within the cervix.
f) Cervical Effacement; The soft cervix gradually thins out with shortening of cervical canal.
g) Cervical Dilatation: this occurs when the passive LUS is thinned out and pulled up by the active
UUS during the first stage of labour. Cervical dilatation is expressed in cm, being slow in the
latent phase (till 3-4 cm), then more rapid in the active phase till complete dilatation reaching
almost L0 cm.
or at term, progesterone drops and leads to increased contractions
There is increased oxytocin receptors produced by posterior pituitary (plus Vaso pressin)

Question 15

What is termed post date and what is termed post term
What is termed early term, full term, late term
Calculate the EDD for LMP 30th March 2023

Answer 15

Post date refers to a date that extends beyond the EDD or more than 40 weeks
Post term refers to a GA that extends to 42weeks or beyond 42weeks or more than 41weeks +6 days

Early term- 37-38+6days
Full term- 39-40+6days
Late term- 41-41+6days

EDD=9months +7 days

6th April 2023
Plus 9 months
6th January 2024

Question 16

What are stages of labour
How do you give a diagnosis to a patient in labour?

Answer 16

The 1st stage begins with the onset of regular painful uterine contractions and ends with complete cervical dilation (10cm)
The 2nd stage begins with full cervical dilatation and ends with delivery of the neonate.
The 3rd stage begins after delivery of the neonate and ends with delivery of the placenta.
The 4th stage is the first six hours following delivery of the placenta

The weeks of gestation plus the stage of the labour

Question 17

How is the latent phase of the first stage of labour managed if the woman comes in the latent phase

Answer 17

First you welcome the woman and companion to labour ward and Assure them
Check Antenatal health record book or maternal and child health record book for lab tests done during ANC and previous CS, previous scan,co morbidities
Insert IV wide bore cannula(green) and take blood for labs FBC and grouping and cross matching
If from ANC she didn’t do all the tests, you can add that
Don’t give IV fluids unless necessary cuz it prevents them from being mobile and during this period you want them to be mobile to help with descent or contractions
Take history asking the symptoms of labour plus if there’s bleeding or there’s fever, chills, fetal movements etc
Do physical exam
Do V/E checking for warts,etc

• Perform general examination: pallor, jaundice, peripheral edema, state of hydration, blood pressure, pulse, respiratory rate, temperature
• Abdominal examination: the fundal height, lie of the fetus, presentation, descent, fetal heart tones and the uterine contractions which should be assessed for its frequency, duration over a 10-minute period. Also palpate for organ enlargement—liver, spleen and kidneys
• Vaginal examination (under aseptic conditions):
• Any abnormalities of the vulva (including FGM, warts, etc)
• Any vaginal discharge or bleeding
• The colour, odour and quantity of any amniotic fluid and whether it is clear, blood-stained or contains meconium
• The consistency, position, effacement and dilatation of the cervix
• Cervical dilation
• Assess the station (presenting part in relating to the ischial spines), position, moulding and caput (if vertex)
• Assess the bony pelvis for its adequacy for vaginal delivery (inlet, cavity and outlet)
• These findings should be carefully recorded in the woman’s folder and partograph when she enters the active phase of labour
• If cervical dilatation is 4 cm or more, she is admitted to the labour ward.
Give adequate pain relief
Make sure she is well hydrated(more of orals unless unable to drink)
Make her mobile
She should have a companion
Get good aeration
Bladder care (empty bladder cuz this helps presenting part to come down cuz the full nodded pushes baby up
Check FHR every 1 hour, VE four hourly , contractions every 4hours

Fourth stage of labour from 2-6 hours

Question 18

Name four drugs called tocolytic agents
When won’t you put patient on partogram

Answer 18

Mag sulphate -competes with calcium intracellularly
Labetalol(Beta-2 agonists such as ritodrine inhibit myometrial contractions by stimulating adenylyl cyclase activity via ADRB2.. they also reverse bronchospasms making them dilate or relax)
Indomethacin( is the prostaglandin inhibitor most frequently used for tocolysis and achieves its effect by reversibly binding to cyclooxygenase.)
Nifedipine
Terbutaline
Ritodrine ( An adrenergic beta agonist used to treat premature labor)
Atosiban

Drugs that prevent preterm labor and immature birth by suppressing uterine contractions (TOCOLYSIS). Agents used to delay premature uterine activity include magnesium sulfate, beta-mimetics, oxytocin antagonists, calcium channel inhibitors, and adrenergic beta-receptor agonists.

Do not put patient on partograph if;
Cervical dilatation is < 4cm
• Initial assessment indicates immediate referral
• Emergency caesarean section is indicated after initial assessment

Question 19

How is the active phase of labour (4cm to 10cm)

Answer 19

First you welcome the woman and companion to labour ward and Assure them
Check Antenatal health record book or maternal and child health record book for lab tests done during ANC and previous CS, previous scan,co morbidities
Insert IV wide bore cannula(green) and take blood for labs FBC and grouping and cross matching
If from ANC she didn’t do all the tests, you can add that
Don’t give IV fluids unless necessary cuz it prevents them from being mobile and during this period you want them to be mobile to help with descent or contractions
Take history asking the symptoms of labour plus if there’s bleeding or there’s fever, chills, fetal movements etc
Do physical exam
Do V/E checking for warts,etc

• Perform general examination: pallor, jaundice, peripheral edema, state of hydration, blood pressure, pulse, respiratory rate, temperature
• Abdominal examination: the fundal height, lie of the fetus, presentation, descent, fetal heart tones and the uterine contractions which should be assessed for its frequency, duration over a 10-minute period. Also palpate for organ enlargement—liver, spleen and kidneys
• Vaginal examination (under aseptic conditions):
• Any abnormalities of the vulva (including FGM, warts, etc)
• Any vaginal discharge or bleeding
• The colour, odour and quantity of any amniotic fluid and whether it is clear, blood-stained or contains meconium
• The consistency, position, effacement and dilatation of the cervix
• Cervical dilation
• Assess the station (presenting part in relating to the ischial spines), position, moulding and caput (if vertex)
• Assess the bony pelvis for its adequacy for vaginal delivery (inlet, cavity and outlet)
• These findings should be carefully recorded in the woman’s folder and partograph when she enters the active phase of labour
• If cervical dilatation is 4 cm or more, she is admitted to the labour ward.
Give adequate pain relief
Make sure she is well hydrated(more of orals unless unable to drink)
Make her mobile
She should have a companion
Get good aeration
Bladder care (empty bladder cuz this helps presenting part to come down cuz the full nodded pushes baby up
Check FHR every 30mins and contractions every 30mins
V/E 4hourly
Put on partograph
You can augment if not contracting well using oxytocin
10units in 1L or 5units in 500mls

Question 20

Induction is different than augmentation true or false
If a patient came at 6am and was 7cm, when will you do the next V/E?
How long should the active phase of labour last for a nulli and multi?
How long should the latent phase of labour last for a nulli and multi?
Who is a primi parous or a nulliparous woman?

Answer 20

True
You’ll do it at 9am cuz by 9am you expect the dilation to be 10cm since 1cm per hour
So 3hours plus 6am 9am

Active phase-
6-10hours nulli
4-6hours multi

Latent-
12hours nulli
8hours multi

Primi parous: first time carrying a pregnancy to more than 28 weeks or the first delivery
Nulli- has never delivered before 28 weeks or has never carried a pregnancy to more than 28 weeks

Question 21

What is termed as a normal contractions ?
If labour is not progressing well what could be the problem?
What are the three or four Ps?
How will you know if a pelvis is adequate or not?

Answer 21

3-5 contractions lasting 40-60secs
So it’s not normal if it’s 3-5 in 20 seconds or 6 lasting 40 secs

Shape of the pelvis. The pelvis doesn’t change so if the pelvis is too small it won’t work
There could be a problem with the Ps of labour

It’s adequate if the fetal head passes through the pelvis. So if the pelvis is the normal pelvis but the fetal head can’t pass through then the pelvis is not adequate

Power-has to do with the uterine contractions
Passageway -the pelvis
Passenger -baby probably plus placenta
Psychology

Question 22

How will you manage inadequate progression of labour
What are Braxton hicks contractions
State five diff between true and false labour

Answer 22

If the woman has been in the latent phase for more than 8 hours and there is little or no sign of progress, review the diagnosis. The woman may not be in labour. Intramuscular Pethidine will differentiate false from true labour.
• If there has been little progress in cervical dilatation, augment labour: infuse oxytocin 2.5 units in 500mls of D/S or N/S at 10 drops per minute (2.5 mIU) and increase the infusion rate by 10 drops (2.5 mIU) per minute every 30-40 minutes until adequate contractions are established.
• If progress is slow, perform artificial rupture of membranes (ARM) if HIV and Hepatitis B are negative and presentation engaged
• Monitor with partograph
• Assess every 4 hours or earlier if indicated

False labour pains, called Braxton Hicks contractions are mild, often irregular, non-progressive contractions that may occur from 30wks gestation (more common after 36wks) and may often be confused with labour. However, contractions in labour are painful, with a gradual increase in frequency, amplitude, and duration.

True labour:
Rhythm is regular ,increasing frequency and strength ,bulging membranes are present ,cervical effacement is present
Pain meds don’t abort the contractions or pain
False- rhythm is irregular ,stationary or decreasing contractions
Absent bulging membranes ,cervical effacement is absent
Pain meds relieve pain

Question 23

Name the types of pelvis
Know how each of them look like
Who classified the types of pelvis this way?
And which can go through SVD

Answer 23

Caldwell-Moloy-Swenson Classification of the pelvis

Gynaecoid: the classical female pelvis with the inlet transversely oval and a roomier pelvic cavity.
• Anthropoid: a long, narrow and oval-shaped pelvis due to the assimilation of the sacral body to the fi fth lumbar vertebra.
• Android: the inlet is heart-shaped and the cavity is funnel-shaped with a contracted outlet.Has a narrow
• Platypolloid: a wide pelvis fl attened at the brim with the sacral promontory pushed forward. ; Cephalopelvic disproportion is more likely to happen with a: Flat (platypelloid) pelvic opening: A person with this type of pelvis has an oval opening that’s wide from side to side but narrow from top to bottom.

Android pelvis has poor prognosis for Vaginal delivery
And has a wide transverse diameter with a narrow posterior part of the inlet

Question 24

How is the second stage of labour managed in a normal lbour

How long should second stage last?

Answer 24

Always use an assistant
Get IV access take blood for labs be specific
Ask her which position she wants to deliver in (either dorsal,lithotomy,sitting,squating,water birth, all fours or on knees and hands)
For knees and hands birth make sure the person pushes with the contractions. If there are no contractions,don’t push
Check FHR every 5mins
Empty bladder
No mobility over here
Hydration
Pain relief
Companion or emotional support
Assess for need of episiotomy
Make sure the resus station for the baby or the tray is near the delivery room or close to mum so mum sees type of baby and the baby
Prepare for the third stage of labour

It shouldn’t last more than 1hour in a multip and more than 2hours in a nullip
If epidural anesthesia is added add one hour
So for a multip, it shouldn’t be more than two hours and for a nullip it shouldn’t be more than three hours

Question 25

Someone can deliver in first stage of labour depending on the size of the baby and if the baby is IUFD the person can deliver in the first stage
How is the third stage of labour managed?
After the placenta is delivered, what is done to it?
How many lobes does the placenta have?
How much should the placenta weigh?
When wouldn’t you want to wait for a while before clamping or cutting the placenta cord

Answer 25

It shouldn’t last more than 30 secs
Delayed cord clamping
There are 2arteries and one vein in the umbilical cord
Wait for 1-3 minutes before clamping the cord and cutting or make sur there are no pulsations in the cord by holding it in between your forefinger and middle finger
You won’t want to wait 1.if the mum is HIV positive or 2.the baby had birth asphyxia or 3.if mum is Rh negative ,or 4.in IUFD

After the placenta comes out:
A.Make sure the lobes are a complete number. If some is missing then it’s likely that some is left inside
The complete number is 10-20lobes
B.Weigh the placenta ( should weigh 1/6th baby’s weight
C. Make sure the membranes of the placenta are complete

AMsTEL:
Palpate the uterus to rule out a second twin
Give 10iu oxytocin IM in the thigh
Wait for the uterine contractions
Controlled cord traction with counter pressure on uterus (one hand pushing the cord out while the other is on the abdomen pushing the uterus back )

Question 26

How is the fourth stage of labour managed

Answer 26

1. Expel clots from uterus and vagina. Cuz clots prevent uterus from contracting
2. massage uterus to make it contract
3. Examine for tears and repair all tears and suture all tears from episiotomy (examine from the outside to inside either using speculum or your hand)
   4.empty bladder (by passing a catheter ) cuz a full bladder prevents contraction
   5.move to nursery or ward
   6.monitor vitals every 15mins for the next two hours
4. Teach the patient to massage the uterus every 15 mins. She should stop when the uterus becomes hard and wait for the next 15 minutes
5. Start breastfeeding
6. Analgesics
   10.good hydration
7. Companion
8. Emotional support
9. Encourage eating
   Tackle any other problem such as a high bp or uncontrolled sugars

Question 27

State some differences between the male and female pelvis

Answer 27

The bony ring of the pelvis is made up of two symmetrical innominate bones and the sacrum. Each innominate bone is made up of the ilium, ischium, and the pubis, which are joined anteriorly at the symphysis pubis and posteriorly to the sacrum at the sacroiliac joints.
The female pelvis has evolved for giving birth, and differs from the male pelvis in the following ways:
• The female pelvis is broader, and the bones more slender than those of the male.
• The male pelvic brim is heart-shaped and widest towards the back, whereas the female pelvic brim is oval-shaped transversely and widest further forwards;
• The female pelvic cavity is more spacious and has a wider outlet than the male pelvis.
• The subpubic angle is rounded in a female pelvis

Question 28

Explain the 8 mechanisms of labour

Answer 28

The process of labour
therefore involves the adaptation of the fetal head to the various segments
of the pelvis.
The mechanism of labour (with vertex presentation) is usually described as: engagement, descent, flexion, internal rotation, extension, restitution,
external rotation and expulsion. These movements should not be viewed as independent discrete events, but occurring as a continuum.

Sequence for the passage through the pelvis for a normal
vertex delivery:
• Engagement and descent: the head enters the pelvis in the
occipitotransverse position with flexion i as it descends.
• Internal rotation to occipitoanterior: occurs at the level of the ischial
spines due to the forward and downward sloping of the levator ani
muscles.
• Crowning: the head extends, distending the perineum until it is
delivered.
• Restitution: the head rotates so that the occiput is in line with the
fetal spine.
• External rotation: the shoulders rotate when they reach the levator
muscles until the biacromial diameter is anteroposterior (the head
externally rotates by the same amount).
• Delivery of the anterior shoulder: occurs by lateral fLexion of the trunk
posteriorly.
• Delivery of the posterior shoulder: occurs by lateral flExion of the
trunk anteriorly and the rest of the body follows.

Question 29

Prolonged 1st stage is one that goes beyond 14 hours.
True or fslse
The 2nd stage begins with full cervical dilatation and ends with delivery of the neonate.
The average duration is 30 minutes for multiparous women and one hour for nulliparous
women. Beyond 1 hour for a multipara and 2 hours for a nullipara, the second stage is
considered prolonged. Epidural anaesthesia decreases the sensation of pelvic pressure
and urge to push, thus lengthening the normal limits. An additional 1 hour is added to the
duration of the 2nd stage if epidural analgesia is given.
The 2nd stage has 2 phases: the passive or propulsive phase where there is no urge to push,
and the active or expulsive phase where the low head causes a reflex urge to push.
If membranes have already ruptured, re-assess pelvic capacity and size of baby to
exclude CPD(cephalopelvic disproportion). If there is no CPD and there has been no progress in cervical dilation, augment labour with oxytocin infusion.
If membranes have not ruptured, rupture the membranes if cervical dilation is between
alert and action lines and head is 3/5th palpable. If contractions are occurring 3 in 10 minutes each and last more than 40 seconds, descent is poor and dilation slow suspect
CPD (big baby, malposition, mal-presentation, etc) or obstruction.
 Deliver by C-section
If fetal distress is noticed, stop any oxytocin infusion. Set up N/S, rule out cord prolapse,
ask woman to lie on her left side, give intranasal oxygen, then prepare for C/S.
State three findings suggestive of CPD
Stage four risk factors for a prolonged labour
State four complications of prolonged labour

Answer 29

Findings suggestive of CPD
Fetal head is not engaged.
Progress is slow or arrests despite efficient uterine contractions.
Vaginal examination shows severe moulding and caput formation.
Head is poorly applied to the cervix.
Haematuria.

Nulliparity
Macrosomia
CPD
Obesity
Use of regional anaesthesia
Fetal occiput in posterior or transverse position

Complications:
Fistula- abnormal conduction between two epithelial tissues or two body cavities
Vagina and bladder- vesico Vaginal fistula
Rectum and vagina- recto Vaginal fistula
Uterovesico fistula- uterus and bladder
Intestines and skin- enterocutaneous fistula
Pelvic organ prolapse
Maternal infection
Fetal distress
PPH- poor myometrial contractions due to fatigue from prolonged labour

Question 30

State three benefits of AMSTEL
What is induction and augmentation. of labour?

Answer 30

Benefi ts
• d Rates of PPH >1000mL.
• d Mean blood loss and postnatal anaemia.
• d Length of the 3rd stage.
• d The need for blood transfusions

Induction of labour is the artificial initiation of labour before its natural onset. It is done for both maternal and fetal reasons.
Augmentation of labour is the artificial stimulation of the uterus during labour to increase the frequency, duration and strength of contractions

Question 31

State ten indications for induction of labour

Answer 31

Maternal:
Post date
Pre eclampsia
Prolonged PROM
Dm

Fetal:
IUGR
IUFD

Obstetric indications
• Uteroplacental insuffi ciency (one of the most common indications).
• Prolonged pregnancy (41–42wks).
• IUGR.
• Oligo- or anhydramnios.
• Abnormal uterine or umbilical artery Dopplers.
• Non-reassuring CTG.
• PROM.
• Severe pre-eclampsia or eclampsia after maternal stabilization.
• Intrauterine death of the fetus (IUD).
• Unexplained antepartum haemorrhage at term.
• Chorioamnionitis.

• Uncontrolled diabetes mellitus.
• Renal disease with deteriorating renal function.
• Malignancies (to facilitate defi nitive therapy)

Question 32

What is the Bishops score?

Answer 32

The success of induction of labour depends on the state of the cervix at the start of the
induction. It is imperative therefore to assess the cervix by examination and assign a
score—Bishop score—based on 5 parameters.
Total maximum score is 13
• The cervix is favorable if the score is ≥6. Induction of labour is likely to succeed.
• The cervix is unfavorable if the score is 5 or less; in this case the cervix must be
ripened before induction or else, it is likely to fail.
The pictures are on the phone go and look and confirm

Question 33

State the three main methods of induction
State four complications of induction

Answer 33

METHODS OF INDUCTION
• Medical-Prostaglandins, Misoprostol
• Surgical-Membrane sweeping, Amniotomy/Artificial rupture of membranes (ARM).
• Mechanical- Foley’s catheter,Nipple stimulation,Laminaria tents

Medical methods
1. Oxytocin. This is given as an IV infusion (dextrose or normal saline). Usually
5 IU of oxytocin is added to 500ml of N/S to run at a rate of 15-20 drops per
minute. The rate of administration is increased every 40-60 minutes till the
desired contractions are attained, then maintained. The rate of increase could be
arithmetic, i.e by a fixed number of drops (eg 10 drops), or geometric, i.e doubling
the rate at each increase. Oxytocin must be used with caution as it can cause
uterine hyperstimulation, uterine rupture or fetal distress.
2. Prostaglandins. Prostaglandin E2
is available as a vaginal pessary. It is inserted in
the posterior fornix and repeated after 6 hours if no response. Oxytocin infusion
may be started once contractions have begun.
3. Misoprostol (Cytotec). This is a prostaglandin analogue originally designed to
treat NSAID-induced gastric ulcer. The tablets can be placed vaginally, orally or
rectally. They are repeated at 4-6 hours intervals till desired contractions are
obtained. The usual starting dose is 50μg. It is advised not to give more than 4
doses.
Surgical methods
1. Membrane stripping/sweeping. The finger is inserted into the cervical os and
canal into the uterus and the membranes stripped from the cervix and lower
112 SMS Handbook of Obstetrics
Induction and Augmentation of Labour
segment as far as the fingers can reach. This stimulates the release of local
prostaglandins that then act on the uterus to begin contractions. Several studies
have suggested that membrane stripping is safe and decreases the incidence of
postterm pregnancy without consistently increasing the incidence of ruptured
membranes, infection or bleeding.
2. Amniotomy/Artificial rupture of membranes (ARM). The membranes are
ruptured to expel amniotic fluid. This leads to reduction in uterine volume and
production of local prostaglandins.
Mechanical methods
1. Foley’s catheter. A Foley’s catheter is inserted into the cervix and beyond the
internal os and the balloon instilled with 20-30 ml of water. The aim is to exert
gradual pressure on the cervix to dilate and release local prostaglandins and thus
ripen the cervix and stimulate uterine contractions. Once the catheter falls out,
oxytocin infusion may be given.
2. Laminaria tents. These are hygroscopic seaweeds that when inserted into the
cervix, absorb water and expand, mechanically dilating the cervix. Different sizes
are available that can be used sequentially to achieve the desired result. They are
mainly used to ripen the cervix.
3. Nipple stimulation, especially at term ripens the cervix and may start labour

COMPLICATIONS OF INDUCTION
1. Failed induction
2. Hyperstimulation of the uterus
3. Fetal distress
4. Uterine rupture
5. PPH due to uterine aton

Question 34

State six complications that can occur during labour

Answer 34

Hypovolaemia – haemorrhage, dehydration
•Myometrial hypertonus – prolonged labour,
Hyperstimulation
Cord compression
Pelvic organ prolapse
Fetal distress
Infection
PROM
Shoulder dystocia
PPH
Perineal tears
Retained placenta

Question 35

What are the different ways of monitoring well being during labour(state six)
State four causes of fetal tachycardia and four causes of fetal bradycardia

Answer 35

V/E
Vitals
Fetoscope
Fetal Doppler
Partograph
Cardiotocograph
Monitoring urine output and analysis

Tachy:
Maternal fever due to infections
Fetal infection
Maternal dehydration
Maternal anemia
Drugs given to mother

Brady:
Congenital heart block
Maternal medications such as sedatives and opiates
Uterine hypertonicity
Cord compression
Cord prolapse

Question 36

State 8 causes of fetal distress jn labour

Answer 36

Maternal:
Poor placenta perfusion
Hypovolaemia due to haemorrhage or dehydration
Hypotension due to shock drugs epidural supine hypotension
Myometrial hypertonus due to prolonged labour or hyper stimulation

Fetal:
Cord compression due to oligohydramnios , entanglement, prolapse
IUGR
Infection
Cardiac problem
Placenta Abruptio

Question 37

How will you manage fetal distress?
Why will you use IV NS not dextrose in giving oxytocin
What will cause maternal distress usually in labour ?

Answer 37

Stop oxy infusion
Turn mother I left side
Give oxygen
Do VE to exclude cord prolapse
Ct monitoring FHR
If FHR abnormality persists assist Vaginal delivery by episiotomy, vacuum or forceps,CS

You’ll use NS because in fetal distress there is reduced oxygen leading to reduced production of ATP by Krebs cycle
The Embden Meyerhoff glycolytic pathways therefore leads to lactate production and so if dextrose is given it promoted the situation leading to more acidosis
NS increases blood volume leading to increased blood flow to placenta and eventual elimination of acidosis

Ketoacidosis and it usually develops slowly with prolonged labour
Prevent by preventing prolonged labour and adequately hydrating woman and using partograph to monitor labour and intervene appropriately

Question 38

What are the causes of pre term labour and what is pre term labour
State six risk factors for
Pre term labour

Answer 38

Pre term labour is labour occurring after 28weeks but before 37 completed weeks resulting in premature delivery

Causes:
Idiopathic
Local infections such as chorioamnionitis
Systemic infections such as pyelonephritis
Abruptio placenta
Cervical incompetence
Iatrogenic
Maternal infection such as malaria and pyelonephritis
PROM
Multiple pregnancies
DM
Pre eclampsia/eclampsia

Risk factors:
Previous pre term birth
Multiple pregnancy
Polyhydramnios
Stress or abused women
Socioeconomic factors
Smoking
Extremes of age less than 17 more than 35
Vaginal infections such as bacterial vaginosis and trichomoniasis
Febrile conditions such as UTI and malaria

Question 39

Symtpms of premature laborj
State four investigations done and how it’s managed
When will you avoid giving dexamethasone

Answer 39

Contractions
Leaking fluid or BpV(show)
Low or dull back ache
On VE there will be progressive dilation and effacement if cervix

Investigations:
FBC
Urine RE and CE
High vagina is swab
Blood CS
USS for those not established in labour to check for GA fetal
Lie presentation amniotic fluid volume placental site fetal weight

Management:
If labour has to be delayed, give broad spectrum antibiotics, steroids(dexamethasone for baby) and tocolytics

So if person has come already in labour, do things done in normal labour but get NICU services give pain meds like in normal labour
Leave membranes Intact fro as long as possible
Avoid the use of the vacuum if gestation is more than 34 weeks

Or from STG:
You’re trying to promote fetal lung maturity ( for gestation 28-34weeks)

Non pharma management-
Avoid sexual intercourse
Avoid strenuous activity
Bed rest
Cervical cerclage suture for cases due to cervical incompetence

Pharma management;
Give tocolytics
Salbutamol IV 2.5mg in 100ml
Of dextrose 5%
Start 10mg per minute or 2mls per minute and increase rate gradually according to response at 10mg it’s interval until contractions diminish then increase rate slowly until contractions cease (max is 45mg(microgram) per minute)
Or you can give nifedipine instead 20mg oral initially then 20mg after 90 minutes
If contractions persist, therapy can be continued with 20mg every 3-8 hours for 48-72hiurs as tolerated by patient and max dose is 160mg per day

Be monitoring the blood pressure through all this

You can also give mag sulphate IV 6g loading dose over 29 minutes then 2g infusion per hour after infusion rate is based on response

For fetal
Maturation give dexamethasone 6mg 12hourly for 4 doses

Avoid steroids if there’s an infection present cuz it can make you more susceptible to it and cause fluid retention pulmonary edema too

So the steroids is most effect if delivery occurs at least 24 hours after first dose of medicine has been given and less than 7 days after last dose of
Emdicine

Refer us yoh don’t have faculties that can take care of the pre term neonate so refer the mother if you can’t care for the premature neonate. It’s better to transfer fetus In utero

Question 40

State six complications of pre term labour

Answer 40

Prolonged hospital stay
Economic and emotional cost
Perinatal mortality is increased
Fetal morbidity- respiratory distress syndrome, hypothermia, hypoglycemia, jaundice, CNs complications
Altered pulmonary function
Cerebral
Plays

Question 41

State the types of breech presentation

Answer 41

Complete or flexed breech- common in multiparous wimen
Both legs and hips are fully flexed

Frank or extended breech:
Both hips are fully flexes but knees are extended
Buttocks fit the lower segment and coerced and prolapse of the cord is an uncommon complication ht it can occur here
This type is more common.

Footling breech:
Fetus with one or both lower extremities extended below the level of the fetal butt is

Question 42

What is lochia
What is liquor

Answer 42

Lochia and liquor:

Amniotic fluid:Sometimes called liquor (lie-kwa), this is the fluid that surrounds the baby in the uterus (womb).

Lochia:For a couple of weeks or more after the birth the woman loses a mixture of blood and mucus through the vagina, like a very heavy period at first but lessening over time. It generally begins as a bright red discharge and gradually turns a brownish colour. Some women find it becomes bright red again if they are too active too soon

Lochia is sterile for the first two days, but not so by the third or fourth day, as the uterus begins to be colonized by vaginal commensals such as non-hemolytic streptococci and E. coli.[4]

Immediately after delivery, a large amount of red blood flows from the uterus until the contraction phase occurs. Thereafter, the volume of vaginal discharge (lochia) rapidly decreases. The duration of this discharge, known as lochia rubra, is variable. The red discharge progressively changes to brownish red, with a more watery consistency (lochia serosa). Over a period of weeks, the discharge continues to decrease in amount and color and eventually changes to yellow (lochia alba). [1] The period of time the lochia can last varies, although it averages approximately 5 weeks. [2]