Labour

Question 1

What is labour?

Answer 1

=Process of Delivery after 24/40; Onset is defined as point when Uterine Contractions become regular and Cervical Effacement and Dilatation becomes Progressive
o Show and ROM may or may not be associated with labour; Presence does not define

Question 2

Braxton Hicks Contractions

Answer 2

Mild, Irregular, Non-progressive with may occur from 30/40; More common after 36/40; C/f Labour – Painful with gradual increments of Frequency, Amplitude and Duration

Question 3

Normal Vertex Delivery

Answer 3

• Head enters pelvis in Occipitotransverse position; Increasing flexion of the head with descent
• Internal Rotation to Occipitoanterior occurs at the level of the Ischial Spines
• Crowning – Head extends and distends the perineum
• Restitution – Head rotates so Occiput is aligned with Foetal spine
• External Rotation, Delivery of Anterior and Posterior shoulder

Question 4

First Stage of Labour

Answer 4

Divided into Latent Phase – Time taken for Cervix to completely Efface, plus Dilate to 3cm and
Active Phase – Dilatation from 3cm to completion (10cm)

Question 5

Failure to progress

Answer 5

suspected if <2cm dilatation/4hrs (4hr Action Line on Partogram), or
Slowing in progress in parous women

Question 6

Causes of failure to progress

Answer 6

Power =Inefficiency Uterine activity (Most common),

Passenger =Malpresentation, Malposition, Large baby, or Passage (Inadequate Pelvis)

Question 7

Management of Failure to Progress

Answer 7

Review Maternal Hydration, Analgesia; Management options include Amniotomy,
Oxytocin Infusion (Especially in Primiparous women); Lower segment Caesarean
might be required if Foetal Distress

Question 8

Monitoring In Labour

Answer 8

• FHR monitored every 15 minutes, or continuously with CTG; Contractions assessed every 30
minutes; Maternal HR every hour; BP and Temperature 4-hourly
• Vaginal Examinations offered every 4 hours to assess progress
• Maternal Urine tested 4-hourly or when passed – Ketones (DM) and
Protein (Pre-Eclampsia)

Question 9

Second Stage of Labour

Answer 9

=Time between Full Cervical

Dilatation and Birth of Baby

Question 10

Expulsion of baby

Answer 10

Expulsive efforts using abdominal muscles with Valsalva manoeuvre to bear down; Squatting, Standing, All-fours or Supine;
Lithotomy position for Instrumental Deliveries

Question 11

What should be done when baby’s head is visible

Answer 11

Hand should be used to maintain Baby Head Flexion and prevent sudden Deflexion; Also, to
control rate of delivery (Slows down Perineal distention, Minimising tears)
o Episiotomy performed if concerns that Perineum is tearing towards Anal Sphincter; Should not be
performed routinely

Question 12

What should be done after presentation of the head?

Answer 12

With next contraction, gentle
traction guides head towards Perineum until Anterior Shoulder delivered; Subsequent gentle traction supero-anteriorly to delivery Posterior
Shoulder and remainder of baby

Question 13

Cord Clamping

Answer 13

Cord double-clamped and cut; Delayed cord clamping for 2-3 minutes results in higher Haematocrit levels in Neonate

Question 14

What should be done once baby is delivered?

Answer 14

APGAR scoring, and if good progress, handed to mother as soon as possible

Question 15

Delayed Second Stage

Answer 15

Suspected if not imminent after 1hr of active pushing; If Primiparous, Vaginal Exam and Amniotomy recommended (and if not delivery within 2hr for Obstetrician);
If Multiparous, for Obstetrician immediately; Suspect Malposition or Disproportion

Question 16

Third Stage of Labour

Answer 16

Duration from Delivery of Baby to Delivery of Placenta and Membranes

Question 17

Active Management of Third Stage

Answer 17

Uterotonics (Syntometrine, Oxytocin), Clamping and Cutting of cord, Controlled Cord Traction; Lower rates of PPH >1L, Blood loss and Anaemia, Duration and
reduced Transfusion requirements; SE: N+V, Headache
IM Syntometrine (Ergometrine 0.5mg, Oxytocin 5IU), or Oxytocin 10IU given as
Anterior Shoulder is born; Hand placed over Uterine Fundus with CCT (Brandt-
Andrew Technique)

Question 18

Physiological Management of Third Stage

Answer 18

No Uterotonics; Cord allowed to stop pulsating before clamped and cut; Placenta delivered by maternal effort alone (No traction or Uterine manipulation)
o Convert to Active if Haemorrhage, Failure to delivery within 1hr, or patient request

Question 19

Immediate post natal complications

Answer 19

Most complications occur in first 2h after delivery – PPH, Uterine Inversion, Haematoma
formation; Monitor Observations, Uterine Size and Contractions, PV bleeding or painful
welling of Genitourinary Tract
Prophylaxis of PPH with Oxytocin Infusion (40IU in 500ml NaCl) if high risk e.g. Multiple preg,
given for 3-4hrs

Question 20

What should be done immediately

Answer 20

Skin-to-skin contact as soon as possible; Mother and baby should not be separated first hour;
Breast feeding should be initiated within first hour
• Transfer to Post-natal ward if no complications; Home after further 3 – 4hrs observation

Question 21

Foetal surveillance in labour

Answer 21

Blood supply to Placenta is restricted due to Uterine contractions, especially in the second stage, placing
physiological strain on foetus during labour; Dependent on Foetal Reserve
• Intermittent Auscultation, or Continuous Cardiotocography (CTG,
also =EFM)
• If no risk factors, IA performed for a minute after contraction; At least
every 15 minutes in first stage, and every 5min, or after every other
contraction in second

Question 22

Interpretation of CTG: Baseline Rate

Answer 22

– Mean FHR when
stable, after excluding Accelerations and Decelerations
o Bradycardia (<110bpm); <100 should raise possibility of Hypoxia
o Tachycardia (>160bpm); Associated with Maternal Pyrexia and Tachycardia,
Prematurity, Foetal Acidosis

Question 23

Interpretation of CTG: Baseline variability

Answer 23

– Bandwidth after exclusion of Accelerations and Decelerations
o Decreased Variability can occur in Foetal Hypoxia, Foetal Sleep (Usually <40 mins, max 90 mins), Malformation or Arrhythmias, Drugs (Methyldopa, MgSul, Narcotic Analgesia, Tranquilisers, Barbiturates, GA), Severe Prematurity

Question 24

Interpretation of CTG: Acceleration

Answer 24

Transient rise in FHR >15bpm lasting 15s or more

o Presence is normal but absence in otherwise normal is of uncertain significance

Question 25

Interpretation of CTG: Deceleration

Answer 25

Reduction in FHR
>15bpm lasting 15s or more
o Early Decelerations – Peak of Deceleration Coincides with Peak of Contraction; Related to Head compression and seen in active second-stage
o Late Decelerations – 15s lag between peak of Contraction
and nadir of Deceleration;
Might be suggestive of
Acidosis especially if
accompanied with
Tachycardia and reduced
Baseline Variability

Question 26

Interpretation of CTG: Variable decelerations

Answer 26

Variable pattern of Timing, Size and Shape, associated with Cord Compression;
Typically, U or V shaped, quick to drop and recover; Not usually associated
with Hypoxia; Atypical features such as >60s, >60bpm dips, slow recovery

Question 27

Interpretation of CTG: Sinusoidal Pattern

Answer 27

Rare undulating pattern with little to no variability; Can indicate significant foetal anaemia, or foetal behaviour (thumb-sucking)
o Blood group antibodies, Kleihauer test, MCA velocity scan to detect foetal anaemia

Question 28

Foetal blood sampling

Answer 28

• Improve specificity of CTG to detect Foetal Hypoxia; Should be obtained if Pathological trace
unless obvious immediate delivery required
• Normal if pH >7.25; Borderline if 7.21 – 7.25; Immediate Delivery if ≤7.20

Question 29

Meconium

Answer 29

Meconium comprises Water, Bile pigments, Mucous and Amniotic Fluid Debris;

Question 30

Meconium-

Stained Amniotic fluid (MSAF)

Answer 30

assoc with Perinatal Morbidity/Mortality; May be Aspirated
o Incidence increases gradually from 36 – 42/40; Hypoxia can cause peristalsis of GI
tract and relaxation of Anal sphincters leading to MSAF
o Induction if ROM before labour; Continuous Foetal Monitoring, Foetal Blood
Sampling and Neonatal Life Support on standby
▪ Close monitoring 12h if born in good condition

Question 31

Meconium Aspiration Syndrome

Answer 31

0.1% of births; Can happen In-utero, believed to be
associated with Prolonged Decelerations that cause Transient Hypoxia
o Mechanical Blockage, Chemical Irritation (Pneumonitis, Alveolar collapse), Predisposes to secondary bacterial infection
o Suction of mouth and upper airway not recommended if active baby crying; If Respiratory difficulty, should be cleared ± Laryngoscopy