Labour

Question 1

What is the management of Monochorionic Monoamniotic Twin Pregnancy?

Answer 1

28 weeks hospitalisation for monitoring

Delivery between 32-34 weeks

Question 2

What is the Ferguson reflex for oxytocin release?

Answer 2

Oxytocin release from pituitary causes contraction of the uterus, pushing the baby onto the cervix, there is increased pressure on the cervix, this leads to even more oxytocin release. Cycle

Question 3

What is the definition of labour?

Answer 3

Strong, painful contractions in the presence of cervical changes

Question 4

What are the stages of labour?

Answer 4

Stage 1:
Latent phase: Beginning of contractions and 3-4cm cervical dilation.
- The cervix becomes fully effaced (shortened till fuses with uterus)
Active phase: Cervical dilation to 10cm
- Normal rate is 1cm every 2 hours

Stage 2:
Passive phase: Time between full dilation and onset of involuntary expulsive contractions
- There is no maternal urge
Active phase: Voluntary contractions to baby delivery
- The baby is low, so there is a reflex to bear down and push baby out

Stage 3:
Delivery of placenta and membranes
- Should not take more than half an hour

Question 5

What is the mechanism of labour?

Answer 5

Engagement - When the widest part of head has passed through pelvic inlet
Descent
Flexion - Head flexes to reduce diameter of presenting part
Internal rotation - The head rotates from transverse position to OA
Crowning - The head extends once below the pubic symphysis and presents over the vaginal opening
Restitution - The occiput is anterior but the shoulders are oblique, so the head rotates to align itself with shoulders
External rotation - Shoulders rotate into AP plane (one shoulder anterior, other posterior)
Anterior shoulder - Delivered first
Posterior shoulder - Delivered next
Lateral flexion

Question 6

What should be done if there are poor number of contractions during labour?

Answer 6

Dysfunctional uterine activity - If membranes have not ruptured, ARM may be conducted. Following on, an oxytocin infusion may be considered

Question 7

What should be done if there is cephalopelvic disproportion?

Answer 7

This can be the result of a large head or a small pelvis
If they are primigravid, then oxytocin can be considered
Never use oxytocin in a multigravid patient with cephalopelvic disproportion

Question 8

What should be done if you see meconium in the liqour?

Answer 8

Start continuous electronic foetal monitoring and CTG as it could be a sign of foetal compromise

Question 9

What is the management of potential foetal compromise?

Answer 9

If CTG looks suspicious:

• Change mother’s position
• IV fluids
• Reduce oxytocin
• Correct hypotension
• Keep monitoring

If CTG looks pathological:

• Do above
• Conduct vaginal exam (looking for cord prolapse and malpresentation)
• If cervix fully dilated, consider instrumental delivery
• If cervix not fully dilated, conduct foetal blood sampling
  
  • If result normal, keep monitoring, but repeat if CTG still abnormal every 30-60 minutes
  • If result abnormal (pH <7.20), immediate C-section

Question 10

What are the contraindications to epidural?

Answer 10

Coagulation disorder
Sepsis
Hypovolaemia

Question 11

What are the clinical features of uterine rupture?

Answer 11

Normally occurs in women who are having vaginal delivery following a previous c-section. The c-section scar on the uterus may rupture during labour (normally during the first stage.

• Severe abdominal pain
• Vaginal bleeding
• Haematuria
• Cessation of contractions
• Maternal tachycardia
• Foetal compromise (bradycardia)

Women with a C-section scar need continuous monitoring and a low threshold for c-section if there are any CTG abnormalities

Question 12

What are contraindications to vaginal birth after c-section (VBAC)?

Answer 12

Two or more C-section scars
Previous uterine rupture
Need for induction of labour
Previous cephalopelvic disproportion
CLASSICAL C-SECTION SCAR (ABSOLUTE CONTRAINDICATION)

Question 13

What is the management of face presentation?

Answer 13

If mento-anterior = Watchful waiting, try for natural

If mento-posterior (chin is posterior) = Delivery is impossible. Stop oxytocin and conduct c-section

Question 14

What is the management of brow presentation?

Answer 14

Delivery is nearly impossible, if position doesn’t change, proceed with c-section

Question 15

What are the causes, risks and management of shoulder (transverse lie) presentation?

Answer 15

Causes:

• Placenta praevia
• Pelvic tumour
• High parity
• Uterine abnormality

Risks:

• Cord prolapse
• Uterine rupture

Management:
- C-section

Question 16

What are the indications for induction of labour?

Answer 16

Prolonged pregnancy (>41 weeks)
PROM
Pre-eclampsia
FGR
Diabetes Mellitus
Worsening maternal condition
Antepartum haemorrhage

Question 17

What are the contraindications for induction of labour?

Answer 17

Placenta praevia
Severe foetal compromise
Cord prolapse
Transverse lie

Relative CI:
Breech
Triplets

Question 18

What is the process of induction of labour?

Answer 18

1) Stretch and sweep
- This stimulates prostaglandin release
2) Prostaglandin pessary/gel
- Typically mispoprostol or mifepristone
- Ripens cervix and initiates contractions
3) Artificial rupture of membranes
4) IV Oxytocin infusion