Labour and Delivery Flashcards

Question

What is considered the latent phase of first stage of labour, and how quickly does it progress?

Answer 1

from 0 to 3cm dilation of the cervix. This progresses at around 0.5cm per hour. There are irregular contractions.

Answer 2

from 3cm to 7cm dilation of the cervix. This progresses at around 1cm per hour, and there are regular contractions.

Answer 3

from 7cm to 10cm dilation of the cervix. This progresses at around 1cm per hour, and there are strong and regular contractions

Answer 4

It involves cervical dilation (opening up) and effacement (getting thinner).

Answer 5

37 and 42 weeks gestation.

Answer 6

Oxytocin stimulates the ripening of the cervix and contractions of the uterus during labour and delivery.

Answer 7

Induce labour Progress labour Improve the frequency and strength of uterine contractions Prevent or treat postpartum haemorrhage

Answer 8

Brand name of oxytocin

Answer 9

Atosiban is an oxytocin receptor antagonist that can be used as an alternative to nifedipine for tocolysis in premature labour (when nifedipine is contraindicated).

Answer 10

Ergometrine is derived from ergot plants. It stimulates smooth muscle contraction, both in the uterus and blood vessels. This makes it useful for delivery of the placenta and to reduce postpartum bleeding. It may be used during the third stage of labour (delivery of the placenta) and postpartum to prevent and treat postpartum haemorrhage. It is only used after delivery of the baby, not in the first or second stage.

Answer 11

Due to the action on the smooth muscle in blood vessels and gastrointestinal tract, it can cause several side effects, including hypertension, diarrhoea, vomiting and angina

Answer 12

It needs to be avoided in eclampsia, and used only with significant caution in patients with hypertension.

Answer 13

Syntometrine is a combination drug containing oxytocin (Syntocinon) and ergometrine. It can be used for prevention or treatment of postpartum haemorrhage.

Answer 14

Vaginal pessaries (Propess) Vaginal tablets (Prostin tablets) Vaginal gel (Prostin gel)

Answer 15

Misoprostol is a prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them. It is used as medical management in miscarriage, to help complete the miscarriage. Misoprostol is used alongside mifepristone for abortions, and induction of labour after intrauterine fetal death.

Answer 16

Mifepristone is an anti-progestogen medication that blocks the action of progesterone, halting the pregnancy and ripening the cervix. It enhances the effects of prostaglandins to stimulate contraction of the uterus. Mifepristone is used alongside misoprostol for abortions, and induction of labour after intrauterine fetal death. It is not used during pregnancy with a healthy living fetus.

Answer 17

Nifedipine is a calcium channel blocker that acts to reduce smooth muscle contraction in blood vessels and the uterus. It has two main uses in pregnancy: Reduce blood pressure in hypertension and pre-eclampsia Tocolysis in premature labour, where it suppresses uterine activity and delays the onset of labour

Answer 18

Tocolytics are medications used to suppress premature labor.

Answer 19

Terbutaline is a beta-2 agonist, similar to salbutamol. It stimulates beta-2 adrenergic receptors. It acts on the smooth muscle of the uterus to suppress uterine contractions. It is used for tocolysis in uterine hyperstimulation, notably when the uterine contractions become excessive during induction of labour.

Answer 20

Carboprost is a synthetic prostaglandin analogue, meaning it binds to prostaglandin receptors. It stimulates uterine contraction. It is given as a deep intramuscular injection in postpartum haemorrhage, where ergometrine and oxytocin have been inadequate.

Answer 21

Notably, it needs to be avoided or used with particular caution in patients with asthma, as it can cause a potentially life-threatening exacerbation of the asthma.

Answer 22

Notably, it needs to be avoided or used with particular caution in patients with asthma, as it can cause a potentially life-threatening exacerbation of the asthma.

Answer 23

Tranexamic acid is an antifibrinolytic medication that reduces bleeding. It binds to plasminogen and prevents it from converting to plasmin. Plasmin is an enzyme that works to dissolve the fibrin within blood clots. Fibrin is a protein that helps hold blood clots together. Therefore, by decreasing the activity of the enzyme plasmin, tranexamic acid helps prevent the breakdown of blood clots. Tranexamic acid is used in the prevention and treatment of postpartum haemorrhage.

Answer 24

Understanding what to expect Having good support Being in a relaxed environment Changing position to stay comfortable Controlled breathing Water births may help some women TENS machines may be useful in the early stages of labour Hyponobirthing Music therapy

Answer 25

Paracetamol is frequently used in early labour. Codeine may be added for additional effect. NSAIDs are avoided.

Answer 26

Gas and air contains a mixture of 50% nitrous oxide and 50% oxygen. This is used during contractions for short term pain relief. The woman takes deep breaths using a mouthpiece at the start of a contraction, then stops using it as the contraction eases.

Answer 27

It can cause lightheadedness, nausea or sleepiness.

Answer 28

Pethidine and diamorphine, usually given by intramuscular injection.

Answer 29

Patient-controlled analgesia requires careful monitoring. There needs to be input from an anaesthetist, and facilities in place if adverse events occur. This includes access to naloxone for respiratory depression, and atropine for bradycardia.

Answer 30

Patients may be offered the option of patient-controlled intravenous remifentanil. This involves the patient pressing a button at the start of a contraction to administer a bolus of this short-acting opiate medication.

Answer 31

An epidural involves inserting a small tube (catheter) into the epidural space in the lower back. This is outside the dura mater, separate from the spinal cord and CSF. Local anaesthetic medications are infused through the catheter into the epidural space, where they diffuse to the surrounding tissues and through to the spinal cord, where they have an analgesic effect. This offers good pain relief during labour.

Answer 32

Levobupivacaine or bupivacaine, usually mixed with fentanyl.

Answer 33

Headache after insertion Hypotension Motor weakness in the legs Nerve damage Prolonged second stage Increased probability of instrumental delivery

Answer 34

Headache after insertion Hypotension Motor weakness in the legs Nerve damage Prolonged second stage Increased probability of instrumental delivery

Answer 35

PHYSIOLOGICAL MANAGEMENT - placenta is delivered by maternal effort without medications or cord traction ACTIVE MANAGEMENT - midwife or doctor assist in delivering of the placenta.

Answer 36

Patient given a dose of intramuscular oxytocin to help the uterus contract, and careful traction to the umbilical cord to guide the placenta out of the uterus and vagina. Intramuscular dose of oxytocin (10 IU) after delivery of the baby. The cord is clamped and cut within 5 minutes of birth. There should be a delay of 1 – 3 minutes between delivery of the baby and clamping of the cord to allow blood to flow to the baby (unless the baby needs resuscitation). The abdomen is palpated to assess for a uterine contraction before delivery of the placenta. Controlled cord traction is carefully applied during uterine contractions to help deliver the placenta, stopping if there is resistance. At the same time the other hand presses the uterus upwards (in the opposite direction) to prevent uterine prolapse. The aim is to deliver the placenta in one piece. After delivery the uterus is massaged until it is contracted and firm. The placenta is examined to ensure it is complete and no tissue remains in the uterus.

Answer 37

Active management shortens the third stage and reduces the risk of bleeding, but can be associated with nausea and vomiting.

Answer 38

Routinely offered to ALL WOMEN reduce the risk of PPH Initiated in hemorrhage Initiated if more than a 60-minute delay in delivery of the placenta (prolonged third stage)

Answer 39

Attached to back delivers small electric pulses for pain relief in early labour

Answer 40

Pros Effective pain relief Relaxing effects allows for smoother contractions Cons Baby may need naloxone if given too close to birth Mother may not like numb feeling detached from contractions

Answer 41

Can be patchy if anesthetic fails to reach all areas Hypotension, will require if fluids Headache Prolonging of second stage of labour More likely to need assisted delivery

Answer 42

Pros O2 good for baby Doesn’t linger in system for long Cons Drowsiness light headedness Relatively mild

Answer 43

You can attempt external cephalic version for a transverse lie if the amniotic sac has not ruptured

Answer 44

The Bishop score should be assessed in all women prior to induction of labour.

Answer 45

Cervical position (posterior/intermediate/anterior) Cervical consistency (firm/intermediate/soft) Cervical effacement (0-30%/40-50%/60-70%/80%) Cervical dilation (<1 cm/1-2 cm/3-4 cm/>5 cm) Foetal station (-3/-2/-1, 0/+1,+2)

Answer 46

ultrasound may be used to look for oligohydramnios

Answer 47

History PLUS positive speculum examination (pool of fluid noted in the vagina) is required to make a diagnosis of PPROM.

Answer 48

Induction of labour is generally offered at 37-38 weeks gestation

Answer 49

absolute cephalopelvic disproportion placenta praevia grades 3/4 pre-eclampsia post-maturity IUGR fetal distress in labour/prolapsed cord failure of labour to progress malpresentations: brow placental abruption: only if fetal distress; if dead deliver vaginally vaginal infection e.g. active herpes cervical cancer (disseminates cancer cells)

Answer 50

Most urgent an immediate threat to the life of the mother or baby examples indications include: suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia or persistent fetal bradycardia delivery of the baby should occur within 30 minutes of making the decision

Answer 51

Urgent but less than cat 1 maternal or fetal compromise which is not immediately life-threatening delivery of the baby should occur within 75 minutes of making the decision

Answer 52

Less urgent than Cat 1 and 2 delivery is required, but mother and baby are stable

Answer 53

emergency hysterectomy need for further surgery at a later date, including curettage (retained placental tissue) admission to intensive care unit thromboembolic disease bladder injury ureteric injury death (1 in 12,000)

Answer 54

increased risk of uterine rupture during subsequent pregnancies/deliveries increased risk of antepartum stillbirth increased risk in subsequent pregnancies of placenta praevia and placenta accreta)

Answer 55

Maternal persistent wound and abdominal discomfort in the first few months after surgery increased risk of repeat caesarean section when vaginal delivery attempted in subsequent pregnancies readmission to hospital haemorrhage infection (wound, endometritis, UTI) Fetal: lacerations, one to two babies in every 100

Answer 56

planned VBAC is an appropriate method of delivery for pregnant women at >= 37 weeks gestation with a single previous Caesarean delivery around 70-75% of women in this situation have a successful vaginal delivery contraindications include previous uterine rupture or classical (vertical) caesarean scar

Answer 57

Maternal intravenous antibiotic prophylaxis should be offered to women during labour with a previous baby with early- or late-onset GBS disease

Answer 58

Initially, request senior help and ask the mother to hyperflex their legs (also called McRobert's manouvere) and apply suprapubic pressure. This method works in 90% of cases. If this method fails, episiotomy is required to allow internal manouveres. A number of potential options, including Wood's screw manouvere and grasping and manipulation of the posterior arm are then possible. Last resorts include symphisiotomy and the Zavanelli manouvere (which includes Caesarean section, however by this point fetal damage is often irreversible)

Answer 59

Immediately after shoulder dystocia is recognised, additional help should be called. Fundal pressure should not be used. An episiotomy is not always necessary. Induction of labour at term can actually reduce the incidence of shoulder dystocia in women with gestational diabetes. McRoberts manoeuvre is the first line intervention as it is known to be simple, rapid and effective in most cases

Answer 60

IM carboprost should be avoided in patients with asthma as it can trigger bronchoconstriction.

Answer 61

suspected uterine rupture major placental abruption cord prolapse fetal hypoxia persistent fetal bradycardia

Answer 62

Vaginal PGE2 is the preferred method of induction of labour

Answer 63

Propranolol alone

Answer 64

Sheehan's syndrome is a complication of severe postpartum haemorrhage (PPH) in which the pituitary gland undergoes ischaemic necrosis which can manifest as hypopituitarism.

Answer 65

lack of postpartum milk production and amenorrhoea following delivery.

Answer 66

Diagnosis of Sheehan's is by inadequate prolactin and gonadotropin stimulation tests in patients with a history of severe PPH.

Answer 67

Home birth Midwife lead units Hospital birth

Answer 68

3-4 every ten mins

Answer 69

Around a minute

Answer 70

Codeine Entonox Pethidine/meptid- IM (note pethidine crosses placenta) Epidural

Answer 71

4cm onwards

Answer 72

15 min observations with sonicade

Answer 73

every five mins

Answer 74

It occurs in response to oestrogen, relaxin and prostaglandins breaking down cervical connective tissue; prostaglandins are of particular importance. Prostaglandins are produced by the placenta, the uterine decidua, the myometrium and the membranes. Their synthesis increases throughout the third trimester as a result of an increase in the oestrogen:progesterone ratio.

Answer 75

A reduction in collagen. An increase in glycosaminoglycans. An increase in hyaluronic acid. Reduced aggregation of collagen fibres. This means that the cervix offers less resistance to the presenting part of the foetus during labour.

Answer 76

The relative decrease in progesterone in relation to oestrogen that occurs towards the end of pregnancy helps to facilitate an increase in the excitability of the uterine musculature. This is because progesterone typically inhibits contractions and oestrogen increases the number of gap junctions between smooth muscle cells, increasing contractility. Mechanical stretching of the uterus also helps to increase contractility – this means as the foetus grows, the contractility of the muscle increases.

Answer 77

Throughout pregnancy it has limited action as there are a low number of oxytocin receptors and it is inhibited by relaxin and progesterone.

Answer 78

At around 36 weeks gestation, under the influence of oestrogen there is an increase in the number of oxytocin receptors present within the myometrium. This means the uterus begins to respond to the pulsatile release of oxytocin from the posterior pituitary gland.

Answer 79

Oxytocin production is increased by afferent impulses from the cervix and vagina. This means that contractions result in a positive feedback loop to the posterior pituitary gland to release more oxytocin, leading to stronger contractions which then drives the process of labour. Brain stimulates PG to produce oxytocin -> oxytocin carried through blood stream to uterus -> oxytocin stimulates uterine contractions and pushes baby toward cervix -> Head of baby pushes on cervix -> nerve impulse from cervix travel to brain, which then stimulates PG to produce oxytocin again

Answer 80

1cm/hr in nulliparous women and 2cm/hr in multiparous women This phase should not normally last longer than 16 hours

Answer 81

The fibres of the myometrium are specially adapted to drive the process of labour as they do not fully relax following each contraction. This steadily reduces the uterine capacity, so the pressure inside becomes stronger as labour progresses and helps with expulsion of the foetus.

Answer 82

Contractions are made more forceful and frequent by the actions of two hormones: Prostaglandins – more intracellular calcium is released per action potential, increasing the force of contractions Oxytocin – lowers the threshold for action potentials, increasing the frequency of contractions

Answer 83

Once the head of the foetus reaches the perineum, it extends in order to come up and out of the pelvis. Following delivery of the head, it rotates by 90 degrees to assist with delivery of the shoulders. The anterior shoulder delivers first, coming under the symphysis pubis while the body flexes laterally and posteriorly to aid passage. Following this the body flexes laterally and anteriorly to help deliver the posterior shoulder. Once the shoulders have been delivered the rest of the body follows.

Answer 84

Contraction of the uterus constricts blood vessels in the myometrium Pressure is exerted on the placental site once it has been delivered by the walls of the contracted uterus The normal blood clotting mechanism

Answer 85

Increases contractibility

Answer 86

A faster rate of cervical dilatation until 10cm dilatation is reached. This phase should not normally last longer than 16 hours.

Answer 87

The woman experiences the desire to push during the passive stage of the second stage of labour. It is at this point that uterine contractions become expulsive, rotation and flexion of the foetal head are completed, and the foetus reaches the pelvic floor, resulting in the desire to push. This typically only lasts a few minutes. During the active stage of the second stage, the woman pushes in conjunction which her contractions in order to expel the foetus.

Answer 88

Following an umbilical cord prolapse, the presenting part of the fetus may be pushed back into the uterus to avoid compression

Answer 89

Magnesium treatment should continue for 24 hours after delivery or after last seizure

Answer 90

Amniotic fluid emboli

Answer 91

admit and administer steroids

Answer 92

Careful speculum examination to look for pooling of amniotic fluid in the posterior vaginal vault is the first-line investigation for preterm prelabour rupture of the membranes

Answer 93

Planned caesarean section at 37 weeks gestation Classical caesarean scar is a contraindication to vaginal birth after caesarean

Answer 94

A vaginal delivery is contraindicated in this scenario due to the increased risk of uterine rupture which could be potentially fatal for both the mother and the baby.

Answer 95

increased mortality depends on the gestation respiratory distress syndrome intraventricular haemorrhage necrotizing enterocolitis chronic lung disease, hypothermia, feeding problems, infection, jaundice retinopathy of prematurity important cause of visual impairment in babies born before 32 weeks gestation the cause is not fully understood and multivariate. One of the contributing factors is thought to be over oxygenation (e.g. during ventilation) resulting in a proliferation of retinal blood vessels (neovascularization) screening is done in at-risk groups hearing problems

Answer 96

Breech presentation – the legs are first. This can be: Complete breech – with hips and knees flexed (like doing a cannonball jump into a pool)

Answer 97

Breech presentation – the legs are first. This can be: Footling breech – with a foot hanging through the cervix

Answer 98

Breech presentation – the legs are first. This can be: Frank breech – with hips flexed and knees extended, bottom first

Answer 99

Fetus side to side

Answer 100

Fetus straight up and down

Answer 101

Fetus is at an angle

Answer 102

Head is the part of the Fetus closest to the cervix

Answer 103

Shoulder is the part of Fetus closest to the cervix

Answer 104

The fetus descends into the pelvis. In the primigravida this is likely to occur from 38 weeks gestation onwards, in a multigravida woman, this may not occur until labour is established. Descent is encouraged by: Increased abdominal muscle tone Braxton hicks in the late stages of pregnancy Fundal dominance of the uterine contractions during labour Increased frequency and strength of contractions during labour As the head descends, it moves towards the pelvic brim in either the left or right occipito-transverse position (this means the occiput can be facing the left side or right side of the mother’s pelvis).

Answer 105

This is when the largest diameter of the fetal head descends into the maternal pelvis. The term engagement is referring to the widest part of the fetal head successfully negotiating its way down deep into the maternal pelvis. Engagement is identified by abdominal palpation, where the fetal head is 3/5th palpable or less. Feotal head reaches station 0

Answer 106

3/5 or less

Answer 107

As the fetus descends through the pelvis, fundal dominance of uterine contraction exerts pressure down the fetal spine towards the occiput, forcing the occiput to come into contact with the pelvic floor. When this occurs the fetal neck flexes (chin to chest) allowing the circumference of the fetal head to reduce to sub-occipitobregmatic (9.5cm). In this position, the fetal skull has a smaller diameter which assists passage through the pelvis.

Answer 108

The pelvic floor has a gutter shape with a forward and downward slope, encouraging the fetal head to rotate from the left or right occipito-transverse position a total of 90-degrees, to an occipital-anterior (occiput facing forward) position, to lie under the subpubic arch. With each maternal contraction, the fetal head pushes down on the pelvic floor. Following each contraction, a rebound effect supports a small degree of rotation. Regular contractions eventually lead to the fetal head completing the 90-degree turn. This rotation will occur during established labour and it is commonly completed by the start of the second stage. Further descent leads to the fetus moving into the vaginal canal and eventually, with each contraction, the vertex becomes increasingly visible at the vulva.

Answer 109

The occiput slips beneath the suprapubic arch allowing the head to extend. The fetal head is now born and will be facing the maternal back with its occiput anterior.

Answer 110

When the widest diameter of the fetal head successfully negotiates through the narrowest part of the maternal bony pelvis, the fetal head is considered to be ‘crowning’. This is clinically evident when the head, visible at the vulva, no longer retreats between contractions. Complete delivery of the head is now imminent and often the woman, who has been pushing, is encouraged to pant so that the head is born with control.

Answer 111

Because the shoulders at the point of the head being delivered are only just reaching the pelvic floor they are often still negotiating the pelvic outlet and the fetus may naturally align its head with the shoulders. This is called restitution and visually you may see the head externally rotate to face the right or left medial thigh of the mother. During the next contraction, the shoulders, having reached the pelvic floor, will complete their rotation from a transverse position to an anterior-posterior position. Evidence of this manoeuvre happening inside can be visualised by seeing the head externally rotating as the fetus keeps its spine aligned.

Answer 112

Downward traction by the healthcare professional will assist the delivery of the anterior shoulder below the suprapubic arch. This is followed by upward traction assisting the delivery of the posterior shoulder. The fetal body will be delivered by the contractions, the health professional’s role is only to assist safe negotiation of this last stage.

Answer 113

increased mortality depends on the gestation respiratory distress syndrome intraventricular haemorrhage necrotizing enterocolitis chronic lung disease, hypothermia, feeding problems, infection, jaundice retinopathy of prematurity important cause of visual impairment in babies born before 32 weeks gestation the cause is not fully understood and multivariate. One of the contributing factors is thought to be over oxygenation (e.g. during ventilation) resulting in a proliferation of retinal blood vessels (neovascularization) screening is done in at-risk groups hearing problems

Answer 114

Occurs in the last 4 weeks of pregnancy Presentation: contractions felt in the lower abdomen. The contractions are irregular and occur every 20 minutes. Progressive cervical changes are absent.

Answer 115

Early delivery is considered when growth is static on the growth charts, or other problems are identified (e.g. abnormal Doppler results). This reduces the risk of stillbirth. Corticosteroids are given when delivery is planned early, particularly when delivered by caesarean section. Paediatricians should be involved at birth to help with neonatal resuscitation and management if required.

Answer 116

Monoamniotic twins require elective caesarean section at between 32 and 33 + 6 weeks.

Answer 117

Aim to deliver between 37 and 37 + 6 weeks Vaginal delivery is possible when the first baby has a cephalic presentation (head first) Caesarean section may be required for the second baby after successful birth of the first baby Elective caesarean is advised when the presenting twin is not cephalic presentation

Answer 118

Immediate caesarean section is performed in a pregnant woman when: There is no response after 4 minutes to CPR performed correctly CPR continues for more than 4 minutes in a woman more than 20 weeks gestation The aim is to deliver the baby and placenta within 5 minutes of CPR commencing. The operation is performed at the site of the arrest, for example, in A&E resus or on the ward. The primary reason for the immediate delivery is to improve the survival of the mother. Delivery improves the venous return to the heart, improves cardiac output and reduces oxygen consumption. It also helps with ventilation and chest compressions. Delivery increases the chances of the baby surviving, although this is secondary to the survival of the mother.

Answer 119

Planned delivery is considered between 36 and 37 weeks gestation. It is planned early to reduce the risk of spontaneous labour and bleeding. Planned cesarean section is required with placenta praevia and low-lying placenta (<20mm from the internal os). Depending on the position of the placenta and fetus, different incisions may be made in the skin and uterus, for example, vertical incisions. Ultrasound may be around the time of the procedure to locate the placenta. Emergency caesarean section may be required with premature labour or antenatal bleeding.

Answer 120

Delivery is planned between 35 to 36 + 6 weeks gestation to reduce the risk of spontaneous labour and delivery. Antenatal steroids are given to mature the fetal lungs before delivery.

Answer 121

Hysterectomy with the placenta remaining in the uterus (recommended) Uterus preserving surgery, with resection of part of the myometrium along with the placenta Expectant management, leaving the placenta in place to be reabsorbed over time comes with significant risks, particularly bleeding and infection.

Answer 122

The RCOG guideline (2018) suggests that if placenta accreta is seen when opening the abdomen for an elective caesarean section, the abdomen can be closed and delivery delayed whilst specialist services are put in place. If placenta accreta is discovered after delivery of the baby, a hysterectomy is recommended.

Answer 123

Babies that are breech before 36 weeks often turn spontaneously, so no intervention is advised. External cephalic version (ECV) can be used at term (37 weeks) to attempt to turn the fetus. Where ECV fails, women are given a choice between vaginal delivery and elective caesarean section. Vaginal delivery needs to involve experienced midwives and obstetricians, with access to emergency theatre if required. Overall, vaginal birth is safer for the mother, and caesarean section is safer for the baby. There is about a 40% chance of requiring an emergency caesarean section when vaginal birth is attempted. When the first baby in a twin pregnancy is breech, caesarean section is required.

Answer 124

External cephalic version (ECV) is a technique used to attempt to turn a fetus from the breech position to a cephalic position using pressure on the pregnant abdomen. It is about 50% successful.

Answer 125

After 36 weeks for nulliparous women (women that have not previously given birth) After 37 weeks in women that have given birth previously

Answer 126

Women are given tocolysis to relax the uterus before the procedure. Tocolysis is with subcutaneous terbutaline. Terbutaline is a beta-agonist similar to salbutamol. It reduces the contractility of the myometrium, making it easier for the baby to turn. Rhesus-D negative women require anti-D prophylaxis when ECV is performed. A Kleihauer test is used to quantify how much fetal blood is mixed with the maternal blood, to determine the dose of anti-D that is required.

Answer 127

Unexplained (around 50%) Pre-eclampsia Placental abruption Vasa praevia Cord prolapse or wrapped around the fetal neck Obstetric cholestasis Diabetes Thyroid disease Infections, such as rubella, parvovirus and listeria Genetic abnormalities or congenital malformations

Answer 128

Fetal growth restriction Smoking Alcohol Increased maternal age Maternal obesity Twins Sleeping on the back (as opposed to either side)

Answer 129

A risk assessment for having a baby that is small for gestational age (SGA) or with fetal growth restriction (FGR) is performed on all pregnant women. Having risk factors for SGA increases the risk of stillbirth. Those at risk have the fetal growth closely monitored with serial growth scans. This helps identify women that need further investigations and management. They may need planned early delivery when the growth is static, or other concerns are identified.

Answer 130

Women at risk of pre-eclampsia are given aspirin.

Answer 131

Any modifiable risk factors for stillbirth are treated, for example, stopping smoking, avoiding alcohol and effective control of diabetes. Sleeping on the side (not the back) is advised.

Answer 132

Reduced fetal movements Abdominal pain Vaginal bleeding

Answer 133

Vaginal birth is first-line for most women after IUFD, unless there are other reasons for caesarean section. Women are given a choice of induction of labour or expectant management (provided immediate delivery is not required, for example with sepsis, pre-eclampsia or haemorrhage). Expectant management involves awaiting natural labour and delivery. Women with expectant management need close monitoring. The condition of the fetus will deteriorate with time. Induction of labour involves using a combination of oral mifepristone (anti-progesterone) and vaginal or oral misoprostol (prostaglandin analogue).

Answer 134

With parental consent, testing is carried out after stillbirth to determine the cause: Genetic testing of the fetus and placenta Postmortem examination of the fetus (including xrays) Testing for maternal and fetal infection Testing the mother for conditions associated with stillbirth, such as diabetes, thyroid disease and thrombophilia Identifying the cause can help reduce the risk in future pregnancies. Pregnancies are closely monitored in women with previous stillbirth.

Answer 135

The amniotic sac has ruptured

Answer 136

Amniotic sac has ruptured spontaneously

Answer 137

The amniotic sac has ruptured before the onset of labour.

Answer 138

The amniotic sac has ruptured before the onset of labour and preterm (prior to 37 weeks gestation)

Answer 139

Amniotic sac ruptures over 18 hours prior to delivery

Answer 140

Babies are considered non-viable below 23 weeks gestation. Generally, from 23 to 24 weeks, resuscitation is not considered in babies that do not show signs of life. Babies born at 23 weeks have around a 10% chance of survival. From 24 weeks onwards, there is an increased chance of survival, and full resuscitation is offered.

Answer 141

Under 28 weeks

Answer 142

28-32 weeks

Answer 143

32-37 weeks

Answer 144

Progesterone can be given vaginally via gel or pessary as prophylaxis for preterm labour. Progesterone has a role in maintaining pregnancy and preventing labour by decreasing activity of the myometrium and preventing the cervix remodelling in preparation for delivery. This is offered to women with a cervical length less than 25mm on vaginal ultrasound between 16 and 24 weeks gestation.

Answer 145

Cervical cerclage involves putting a stitch in the cervix to add support and keep it closed. This involves a spinal or general anaesthetic. The stitch is removed when the woman goes into labour or reaches term. Cervical cerclage is offered to women with a cervical length less than 25mm on vaginal ultrasound between 16 and 24 weeks gestation, who have had a previous premature birth or cervical trauma (e.g. colposcopy and cone biopsy). “Rescue” cervical cerclage may also be offered between 16 and 27 + 6 weeks when there is cervical dilatation without rupture of membranes, to prevent progression and premature delivery.

Answer 146

Rupture of membranes can be diagnosed by speculum examination revealing pooling of amniotic fluid in the vagina. No tests are required. Where there is doubt about the diagnosis, tests can be performed: Insulin-like growth factor-binding protein-1 (IGFBP-1) is a protein present in high concentrations in amniotic fluid, which can be tested on vaginal fluid if there is doubt about rupture of membranes Placental alpha-microglobin-1 (PAMG-1) is a similar alternative to IGFBP-1

Answer 147

Prophylactic antibiotics should be given to prevent the development of chorioamnionitis. The NICE guidelines (2019) recommend erythromycin 250mg four times daily for ten days, or until labour is established if within ten days. Induction of labour may be offered from 34 weeks to initiate the onset of labour.

Answer 148

Preterm labour with intact membranes involves regular painful contraction and cervical dilatation, without rupture of the amniotic sac.

Answer 149

Clinical assessment includes a speculum examination to assess for cervical dilatation. The NICE guidelines (2017) recommend: Less than 30 weeks gestation, clinical assessment alone is enough to offer management of preterm labour. More than 30 weeks gestation, a transvaginal ultrasound can be used to assess the cervical length. When the cervical length on ultrasound is less than 15mm, management of preterm labour can be offered. A cervical length of more than 15mm indicates preterm labour is unlikely. Fetal fibronectin is an alternative test to vaginal ultrasound. Fetal fibronectin is the “glue” between the chorion and the uterus, and is found in the vagina during labour. A result of less than 50 ng/ml is considered negative, and indicates that preterm labour is unlikely.

Answer 150

Fetal monitoring (CTG or intermittent auscultation) Tocolysis with nifedipine: nifedipine is a calcium channel blocker that suppresses labour Maternal corticosteroids: can be offered before 35 weeks gestation to reduce neonatal morbidity and mortality IV magnesium sulphate: can be given before 34 weeks gestation and helps protect the baby’s brain Delayed cord clamping or cord milking: can increase the circulating blood volume and haemoglobin in the baby at birth

Answer 151

Tocolysis involves using medications to stop uterine contractions. Nifedipine, a calcium channel blocker, is the medication of choice for tocolysis. Atosiban is an oxytocin receptor antagonist that can be used as an alternative when nifedipine is contraindicated.

Answer 152

Tocolysis can be used between 24 and 33 + 6 weeks gestation in preterm labour to delay delivery and buy time for further fetal development, administration of maternal steroids or transfer to a more specialist unit (e.g. with a neonatal ICU). It is only used as a short term measure (i.e. less than 48 hours).

Answer 153

Giving the mother corticosteroids helps to develop the fetal lungs and reduce respiratory distress syndrome after delivery. They are used in women with suspected preterm labour of babies less than 36 weeks gestation. An example regime would be two doses of intramuscular betamethasone, 24 hours apart.

Answer 154

Giving the mother IV magnesium sulfate helps protect the fetal brain during premature delivery. It reduces the risk and severity of cerebral palsy. Magnesium sulphate is given within 24 hours of delivery of preterm babies of less than 34 weeks gestation. It is given as a bolus, followed by an infusion for up to 24 hours or until birth.

Answer 155

Mothers need close monitoring for magnesium toxicity at least four hourly. This involves close monitoring of observations, as well as tendon reflexes (usually patella reflex). Key signs of toxicity are: Reduced respiratory rate Reduced blood pressure Absent reflexes

Answer 156

Between 40 and 41 weeks Prelabour rupture of membranes Fetal growth restriction Pre-eclampsia Obstetric cholestasis Existing diabetes Intrauterine fetal death

Answer 157

The Bishop score is a scoring system used to determine whether to induce labour. Five things are assessed and given a score based on different criteria (minimum score is 0 and maximum is 13): Fetal station (scored 0 – 3) Cervical position (scored 0 – 2) Cervical dilatation (scored 0 – 3) Cervical effacement (scored 0 – 3) Cervical consistency (scored 0 – 2) A score of 8 or more predicts a successful induction of labour. A score below this suggests cervical ripening may be required to prepare the cervix.

Answer 158

Membrane sweep Vaginal prostaglandin E2 (dinoprostone) Cervical ripening ballon (CRB) Artificial rupture of membranes with an oxytocin infusion (Oral mifepristone (anti-progesterone) plus misoprostol are used to induce labour where intrauterine fetal death has occurred)

Answer 159

Membrane sweep involves inserting a finger into the cervix to stimulate the cervix and begin the process of labour. It can be performed in antenatal clinic, and if successful, should produce the onset of labour within 48 hours. A membrane sweep is not considered a full method of inducing labour, and is more of an assistance before full induction of labour. It is used from 40 weeks gestation to attempt to initiate labour in women over their EDD.

Answer 160

Vaginal prostaglandin E2 (dinoprostone) involves inserting a gel, tablet (Prostin) or pessary (Propess) into the vagina. The pessary is similar to a tampon, and slowly releases local prostaglandins over 24 hours. This stimulates the cervix and uterus to cause the onset of labour. This is usually done in the hospital setting so that the woman can be monitored before being allowed home to await the full onset of labour.

Answer 161

Cervical ripening balloon (CRB) is a silicone balloon that is inserted into the cervix and gently inflated to dilate the cervix. This is used as an alternative where vaginal prostaglandins are not preferred, usually in women with a previous caesarean section, where vaginal prostaglandins have failed or multiparous women (para ≥ 3).

Answer 162

Artificial rupture of membranes with an oxytocin infusion can also be used to induce labour, although this would only be used where there are reasons not to use vaginal prostaglandins. It can be used to progress the induction of labour after vaginal prostaglandins have been used.

Answer 163

Cardiotocography (CTG) to assess the fetal heart rate and uterine contractions before and during induction of labour Bishop score before and during induction of labour to monitor the progress

Answer 164

Most women will give birth within 24 hours of the start of induction of labour. The options when there is slow or no progress are: Further vaginal prostaglandins Artificial rupture of membranes and oxytocin infusion Cervical ripening balloon (CRB) Elective caesarean section

Answer 165

Uterine hyperstimulation is the main complication of induction of labour with vaginal prostaglandins. This is where the contraction of the uterus is prolonged and frequent, causing fetal distress and compromise. The criteria for uterine hyperstimulation varies slightly between guidelines (always check local policies and involve experienced seniors). The two criteria often given are: Individual uterine contractions lasting more than 2 minutes in duration More than five uterine contractions every 10 minutes

Answer 166

Fetal compromise, with hypoxia and acidosis Emergency caesarean section Uterine rupture

Answer 167

Removing the vaginal prostaglandins, or stopping the oxytocin infusion Tocolysis with terbutaline

Answer 168

Cardiotocography (CTG) is used to measure the fetal heart rate and the contractions of the uterus. It is also known as electronic fetal monitoring. It is a useful way of monitoring the condition of the fetus and the activity of labour.

Answer 169

Two transducers are placed on the abdomen to get the CTG readout: One above the fetal heart to monitor the fetal heartbeat One near the fundus of the uterus to monitor the uterine contractions The transducer above the fetal heart monitors the heartbeat using Doppler ultrasound. The transducer above the fundus uses ultrasound to assess the tension in the uterine wall, indicating uterine contraction.

Answer 170

Sepsis Maternal tachycardia (> 120) Significant meconium Pre-eclampsia (particularly blood pressure > 160 / 110) Fresh antepartum haemorrhage Delay in labour Use of oxytocin Disproportionate maternal pain

Answer 171

Contractions – the number of uterine contractions per 10 minutes Baseline rate – the baseline fetal heart rate Variability – how the fetal heart rate varies up and down around the baseline Accelerations – periods where the fetal heart rate spikes Decelerations – periods where the fetal heart rate drops

Answer 172

The number of uterine contractions per 10 minutes Contractions are used to gauge the activity of labour. Too few contractions indicate labour is not progressing. Too many contractions can mean uterine hyperstimulation, which can lead to fetal compromise. It is also important to interpret the fetal heart rate in the context of the uterine contractions.

Answer 173

Periods where fetal HR spikes Accelerations are generally a good sign that the fetus is healthy, particularly when occurring alongside contractions of the uterus.

Answer 174

Baseline fetal HR

Answer 175

110 – 160

Answer 176

100 – 109 or 161 – 180

Answer 177

100 – 109 or 161 – 180

Answer 178

Less than 5 for 30 – 50 minutes or More than 25 for 15 – 25 minutes

Answer 179

Less than 5 for over 50 minutes or More than 25 for over 25 minutes

Answer 180

Variability – how the fetal heart rate varies up and down around the baseline

Answer 181

Decelerations are a more concerning finding. The fetal heart rate drops in response to hypoxia. The fetal heart rate is slowing to conserve oxygen for the vital organs. Decelerations – periods where the fetal heart rate drops

Answer 182

Decelerations are a more concerning finding. The fetal heart rate drops in response to hypoxia. The fetal heart rate is slowing to conserve oxygen for the vital organs.

Answer 183

Early decelerations Late decelerations Variable decelerations Prolonged decelerations

Answer 184

Early decelerations are gradual dips and recoveries in heart rate that correspond with uterine contractions. The lowest point of the declaration corresponds to the peak of the contraction. Early decelerations are normal and not considered pathological. They are caused by the uterus compressing the head the fetus, stimulating the vagus nerve of the fetus, slowing the heart rate.

Answer 185

They are caused by the uterus compressing the head the fetus, stimulating the vagus nerve of the fetus, slowing the heart rate. Not normally pathological

Answer 186

Late decelerations are gradual falls in heart rate that starts after the uterine contraction has already begun. There is a delay between the uterine contraction and the deceleration. The lowest point of the declaration occurs after the peak of the contraction.

Answer 187

Late decelerations are caused by hypoxia in the fetus, and are a more concerning finding. They may be caused by excessive uterine contractions, maternal hypotension or maternal hypoxia.

Answer 188

Variable decelerations are abrupt decelerations that may be unrelated to uterine contractions. There is a fall of more than 15 bpm from the baseline. The lowest point of the declaration occurs within 30 seconds, and the deceleration lasts less than 2 minutes in total. Variable decelerations often indicate intermittent compression of the umbilical cord, causing fetal hypoxia. Brief accelerations before and after the deceleration are known as shoulders, and are a reassuring sign that the fetus is coping.

Answer 189

Prolonged decelerations last between 2 and 10 minutes with a drop of more than 15 bpm from baseline. This often indicates compression of the umbilical cord, causing fetal hypoxia. These are abnormal and concerning.

Answer 190

CTG is reassuring when there are no decelerations, early decelerations or less than 90 minutes of variable decelerations with no concerning features.

Answer 191

Regular variable decelerations and late decelerations are classed as non-reassuring or abnormal, depending on the features. Prolonged decelerations are always abnormal.

Answer 192

Regular variable decelerations and late decelerations are classed as non-reassuring or abnormal, depending on the features.

Answer 193

Normal Suspicious: a single non-reassuring feature Pathological: two non-reassuring features or a single abnormal feature Need for urgent intervention: acute bradycardia or prolonged deceleration of more than 3 minutes

Answer 194

Escalating to a senior midwife and obstetrician Further assessment for possible causes, such as uterine hyperstimulation, maternal hypotension and cord prolapse Conservative interventions such as repositioning the mother or giving IV fluids for hypotension Fetal scalp stimulation (an acceleration in response to stimulation is a reassuring sign) Fetal scalp blood sampling to test for fetal acidosis Delivery of the baby (e.g. instrumental delivery or emergency caesarean section)

Answer 195

3 minutes – call for help 6 minutes – move to theatre 9 minutes – prepare for delivery 12 minutes – deliver the baby (by 15 minutes)

Answer 196

A sinusoidal CTG is a rare pattern to be aware of, as it can indicate severe fetal compromise. It gives a pattern similar to a sine wave, with smooth regular waves up and down that have an amplitude of 5 – 15 bpm. It is usually associated with severe fetal anaemia, for example, caused by vasa praevia with fetal haemorrhage.

Answer 197

DR C BRaVADO is a mnemonic often taught to assess the features of a CTG in a structured way. It involves assessing in order: DR – Define Risk (define the risk based on the individual woman and pregnancy before assessing the CTG) C – Contractions BRa – Baseline Rate V – Variability A – Accelerations D – Decelerations O – Overall impression (given an overall impression of the CTG and clinical picture)

Answer 198

Cord prolapse is when the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after rupture of the fetal membranes. There is a significant danger of the presenting part compressing the cord, resulting in fetal hypoxia.

Answer 199

The most significant risk factor for cord prolapse is when the fetus is in an abnormal lie after 37 weeks gestation (i.e. unstable, transverse or oblique). Being in an abnormal lie provides space for the cord to prolapse below the presenting part. In a cephalic lie, the head typically descends into the pelvis, without room for the cord to descend.

Answer 200

Umbilical cord prolapse should be suspected where there are signs of fetal distress on the CTG. A prolapsed umbilical cord can be diagnosed by vaginal examination. Speculum examination can be used to confirm the diagnosis.

Answer 201

Emergency caesarean section is indicated where cord prolapse occurs. (A normal vaginal delivery has a high risk of cord compression and significant hypoxia to the baby) The cord should be kept warm and wet and have minimal handling whilst waiting for delivery (handling causes vasospasm) (Pushing the cord back in is not recommended) When the baby is compressing a prolapsed cord, the presenting part can be pushed upwards to prevent it compressing the cord. The woman can lie in the left lateral position (with a pillow under the hip) or the knee-chest position (on all fours), using gravity to draw the fetus away from the pelvis and reduce compression on the cord. Tocolytic medication (e.g. terbutaline) can be used to minimise contractions whilst waiting for delivery by caesarean section.

Answer 202

Shoulder dystocia is when the anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis, after the head has been delivered. This requires additional obstetric manoeuvres to enable delivery of the rest of the body. Shoulder dystocia is an obstetric emergency.

Answer 203

Shoulder dystocia is often caused by macrosomia secondary to gestational diabetes.

Answer 204

Shoulder dystocia presents with difficulty delivering the face and head, and obstruction in delivering the shoulders after delivery of the head. There may be failure of restitution, where the head remains face downwards (occipito-anterior) and does not turn sideways as expected after delivery of the head. The turtle-neck sign is where the head is delivered but then retracts back into the vagina.

Answer 205

Episiotomy can be used to enlarge the vaginal opening and reduce the risk of perineal tears. It is not always necessary. McRoberts manoeuvre involves hyperflexion of the mother at the hip (bringing her knees to her abdomen). This provides a posterior pelvic tilt, lifting the pubic symphysis up and out of the way. Pressure to the anterior shoulder involves pressing on the suprapubic region of the abdomen. This puts pressure on the posterior aspect of the baby’s anterior shoulder, to encourage it down and under the pubic symphysis. Rubins manoeuvre involves reaching into the vagina to put pressure on the posterior aspect of the baby’s anterior shoulder to help it move under the pubic symphysis. Wood’s screw manoeuvre is performed during a Rubins manoeuvre. The other hand is used to reach in the vagina and put pressure on the anterior aspect of the posterior shoulder. The top shoulder is pushed forwards, and the bottom shoulder is pushed backwards, rotating the baby and helping delivery. If this does not work, the reverse motion can be tried, pushing the top shoulder backwards and the bottom shoulder forwards. Zavanelli manoeuver involves pushing the baby’s head back into the vagina so that the baby can be delivered by emergency caesarean section.

Answer 206

Rubins manoeuvre involves reaching into the vagina to put pressure on the posterior aspect of the baby’s anterior shoulder to help it move under the pubic symphysis.

Answer 207

Wood’s screw manoeuvre is performed during a Rubins manoeuvre (reaching into the vagina to put pressure on the posterior aspect of the baby’s anterior shoulder to help it move under the pubic symphysis) The other hand is used to reach in the vagina and put pressure on the anterior aspect of the posterior shoulder. The top shoulder is pushed forwards, and the bottom shoulder is pushed backwards, rotating the baby and helping delivery. If this does not work, the reverse motion can be tried, pushing the top shoulder backwards and the bottom shoulder forwards.

Answer 208

involves pushing the baby’s head back into the vagina so that the baby can be delivered by emergency Caesarean section

Answer 209

Fetal hypoxia (and subsequent cerebral palsy) Brachial plexus injury and Erb’s palsy Perineal tears Postpartum haemorrhage

Answer 210

Instrumental delivery refers to a vagina delivery assisted by either a ventouse suction cup or forceps. Tools are used to help deliver the baby’s head. About 10% of births in the UK are assisted by an instrumental delivery. The procedure can usually be carried out on the labour ward. However, if there are concerns about whether it will be successful, the woman may be moved to theatre so that rapid delivery by caesarean section can be performed if necessary.

Answer 211

A single dose of co-amoxiclav

Answer 212

Failure to progress Fetal distress Maternal exhaustion Control of the head in various fetal positions

Answer 213

Postpartum haemorrhage Episiotomy Perineal tears Injury to the anal sphincter Incontinence of the bladder or bowel Nerve injury (obturator or femoral nerve)

Answer 214

Key risks Cephalohaematoma with ventouse Facial nerve palsy with forceps Rare but more serious risks Subgaleal haemorrhage (most dangerous) Intracranial haemorrhage Skull fracture Spinal cord injury

Answer 215

A ventouse is essentially a suction cup on a cord. The suction cup goes on the baby’s head, and the doctor or midwife applies careful traction to the cord to help pull the baby out of the vagina. The main complication for the baby is cephalohaematoma. This involves a collection of blood between the skull and the periosteum.

Answer 216

Forceps look like large metal salad tongs. They come as two pieces of curved metal that attach together, go either side of the baby’s head and grip the head in a way that allows the doctor or midwife to apply careful traction and pull the head from the vagina. The main complication for the baby is facial nerve palsy, with facial paralysis on one side. Forceps delivery can leave bruises on the baby’s face. Rarely the baby can develop fat necrosis, leading to hardened lumps of fat on their cheeks. Fat necrosis resolves spontaneously over time.

Answer 217

Femoral nerve Obturator nerve

Answer 218

Compression against the inguinal canal during delivery, leading to: Weakness of knee extension Loss of patella reflex Numbness over the anterior thigh and medial lower leg

Answer 219

The obturator nerve may be compressed by forceps during instrumental delivery or by the fetal head during normal delivery. Injury causes weakness of hip adduction and rotation, and numbness of the medial thigh.

Answer 220

Obturator nerve Lateral cutaneous nerve of the thigh Lumbosacral plexus Common peroneal nerve

Answer 221

The lateral cutaneous nerve of the thigh runs under the inguinal ligament. Prolonged flexion at the hip while in the lithotomy position can result in injury, causing numbness of the anterolateral thigh.

Answer 222

The lumbosacral plexus may be compressed by the fetal head during the second stage of labour. Injury to this network of nerves nerve can cause foot drop and numbness of the anterolateral thigh, lower leg and foot.

Answer 223

The common peroneal nerve may be compressed on the head of the fibula whilst in the lithotomy position. Injury to this nerve causes foot drop and numbness in the lateral lower leg.

Answer 224

A perineal tear occurs where the external vaginal opening is too narrow to accommodate the baby. This leads to the skin and tissues in that area tearing as the baby’s head passes. Perineal tears can range from a graze, to a large tear involving the anal sphincter (third-degree) and rectal mucosa (fourth-degree).

Answer 225

First births (nulliparity) Large babies (over 4kg) Shoulder dystocia Asian ethnicity Occipito-posterior position Instrumental deliveries

Answer 226

First-degree – injury limited to the frenulum of the labia minora (where they meet posteriorly) and superficial skin

Answer 227

Second-degree – including the perineal muscles, but not affecting the anal sphincter

Answer 228

Third-degree – including the anal sphincter, but not affecting the rectal mucosa

Answer 229

Fourth-degree – including the rectal mucosa

Answer 230

Third-degree – including the anal sphincter, but not affecting the rectal mucosa 3A – less than 50% of the external anal sphincter affected 3B – more than 50% of the external anal sphincter affected 3C – external and internal anal sphincter affected

Answer 231

First-degree tears usually do not require any sutures. When a perineal tear larger than first degree occurs, the mother usually requires sutures to correct the injury. A third or fourth-degree tear is likely to need repairing in theatre.

Answer 232

Broad-spectrum antibiotics to reduce the risk of infection Laxatives to reduce the risk of constipation and wound dehiscence Physiotherapy to reduce the risk and severity of incontinence Followup to monitor for longstanding complications

Answer 233

Women that are symptomatic after third or fourth-degree tears are offered an elective caesarean section in subsequent pregnancies.

Answer 234

Pain Infection Bleeding Wound dehiscence or wound breakdown

Answer 235

Urinary incontinence Anal incontinence and altered bowel habit (third and fourth-degree tears) Fistula between the vagina and bowel (rare) Sexual dysfunction and dyspareunia (painful sex) Psychological and mental health consequences

Answer 236

An episiotomy is where the obstetrician or midwife cuts the perineum before the baby is delivered. This is done in anticipation of needing additional room for delivery of the baby (e.g. before forceps delivery). It is performed under local anaesthetic. A cut is made at around 45 degrees diagonally, from the opening of the vagina downwards and laterally, to avoid damaging the anal sphincter. This is called a mediolateral episiotomy. The cut is sutured after delivery.

Answer 237

Perineal massage is a method for reducing the risk of perineal tears. It involves massaging the skin and tissues between the vagina and anus (perineum). This is done in a structured way from 34 weeks onwards to stretch and prepare the tissues for delivery.

Answer 238

Less than 2cm of cervical dilatation in 4 hours Slowing of progress in a multiparous women

Answer 239

Cervical dilatation (measured by a 4-hourly vaginal examination) Descent of the fetal head (in relation to the ischial spines) Maternal pulse, blood pressure, temperature and urine output Fetal heart rate Frequency of contractions Status of the membranes, presence of liquor and whether the liquor is stained by blood or meconium Drugs and fluids that have been given

Answer 240

Number in ten mins (e.g. 2 in 10)

Answer 241

Alert and action

Answer 242

There are two lines on the partogram that indicate when labour may not be progressing adequately. These are labelled “alert” and “action”. The dilation of the cervix is plotted against the duration of labour (time). When it takes too long for the cervix to dilate, the readings will cross to the right of the alert and action lines.

Answer 243

Amniotomy (artificial rupture of membranes) and a repeat examination in 2 hours.

Answer 244

Crossing the action line means care needs to be escalated to obstetric-led care and senior decision-makers for appropriate action.

Answer 245

Changing positions Encouragement Analgesia Oxytocin Episiotomy Instrumental delivery Caesarean section

Answer 246

More than 30 minutes with active management (intramuscular oxytocin and controlled cord traction) More than 60 minutes with physiological management

Answer 247

Amniotomy, also known as artificial rupture of membranes (ARM) for women with intact membranes Oxytocin infusion Instrumental delivery Caesarean section

Answer 248

Oxytocin is used first-line to stimulate uterine contractions during labour. It is started at a low rate and titrated up at intervals of at least 30 minutes as required. The aim is for 4 – 5 contractions per 10 minutes. Too few contractions will mean that labour does not progress. Too many contractions can result in fetal compromise, as the fetus does not have the opportunity to recover between contractions.

Answer 249

500ml after a vaginal delivery 1000ml after a caesarean section

Answer 250

Minor PPH – under 1000ml blood loss Major PPH – over 1000ml blood loss

Answer 251

Moderate PPH – 1000 – 2000ml blood loss Severe PPH – over 2000ml blood loss

Answer 252

Primary PPH: bleeding within 24 hours of birth Secondary PPH: from 24 hours to 12 weeks after birth

Answer 253

T – Tone (uterine atony – the most common cause) T – Trauma (e.g. perineal tear) T – Tissue (retained placenta) T – Thrombin (bleeding disorder)

Answer 254

Previous PPH Multiple pregnancy Obesity Large baby Failure to progress in the second stage of labour Prolonged third stage Pre-eclampsia Placenta accreta Retained placenta Instrumental delivery General anaesthesia Episiotomy or perineal tear

Answer 255

Treating anaemia during the antenatal period Giving birth with an empty bladder (a full bladder reduces uterine contraction) Active management of the third stage (with intramuscular oxytocin in the third stage) Intravenous tranexamic acid can be used during caesarean section (in the third stage) in higher-risk patients

Answer 256

Resuscitation with an ABCDE approach Lie the woman flat, keep her warm and communicate with her and the partner Insert two large-bore cannulas Bloods for FBC, U&E and clotting screen Group and cross match 4 units Warmed IV fluid and blood resuscitation as required Oxygen (regardless of saturations) Fresh frozen plasma is used where there are clotting abnormalities or after 4 units of blood transfusion In severe cases, activate the major haemorrhage protocol. Each hospital will have a major haemorrhage protocol, which gives rapid access to 4 units of crossmatched or O negative blood.

Answer 257

Mechanical: - Rubbing the uterus through the abdomen to stimulates a uterine contraction (referred to as “rubbing up the fundus”) - Catheterisation (bladder distention prevents uterus contractions) Medical: xytocin (slow injection followed by continuous infusion) Ergometrine (intravenous or intramuscular) stimulates smooth muscle contraction (contraindicated in hypertension) Carboprost (intramuscular) is a prostaglandin analogue and stimulates uterine contraction (caution in asthma) Misoprostol (sublingual) is also a prostaglandin analogue and stimulates uterine contraction Tranexamic acid (intravenous) is an antifibrinolytic that reduces bleeding Surgical: Intrauterine balloon tamponade – inserting an inflatable balloon into the uterus to press against the bleeding B-Lynch suture – putting a suture around the uterus to compress it Uterine artery ligation – ligation of one or more of the arteries supplying the uterus to reduce the blood flow Hysterectomy is the “last resort” but will stop the bleeding and may save the woman’s life

Answer 258

Secondary postpartum haemorrhage is where bleeding occurs from 24 hours to 12 weeks postpartum. This is more likely to be due to retained products of conception (RPOC) or infection (i.e. endometritis).

Answer 259

Investigations involve: Ultrasound for retained products of conception Endocervical and high vaginal swabs for infection Management depends on the cause: Surgical evaluation of retained products of conception Antibiotics for infection

Answer 260

Chorioamnionitis Urinary tract infections

Answer 261

Chorioamnionitis is an infection of the chorioamniotic membranes and amniotic fluid. Chorioamnionitis is a leading cause of maternal sepsis and a notable cause of maternal death (along with urinary tract infections). It usually occurs in later pregnancy and during labour. Chorioamnionitis can be caused by a large variety of bacteria, including gram-positive bacteria, gram-negative bacteria and anaerobes.

Answer 262

Fever Tachycardia Raised respiratory rate (often an early sign) Reduced oxygen saturations Low blood pressure Altered consciousness Reduced urine output Raised white blood cells on a full blood count Evidence of fetal compromise on a CTG

Answer 263

Abdominal pain Uterine tenderness Vaginal discharge Non specific signs of sepsis (fever, tachycardia, hypotension, increase RR, reduced sats, altered conciousness, reduced urine output, evidence of feotal compromise on CTG)

Answer 264

Urine dipstick and culture High vaginal swab Throat swab Sputum culture Wound swab after procedures Lumbar puncture for meningitis or encephalitis

Answer 265

Continuous maternal and fetal monitoring is required. Depending on the condition of the mother and fetus, early delivery may be needed. Emergency caesarean section may be indicated when there is fetal distress, guided by a senior obstetrician. General anaesthesia is usually required for women with sepsis, as spinal anaesthesia is avoided. Sepsis six

Answer 266

Amniotic fluid embolisation is a rare (2 per 100,000 deliveries) but severe condition where the amniotic fluid passes into the mother’s blood. This usually occurs around labour and delivery. The amniotic fluid contains fetal tissue, causing an immune reaction from the mother. This immune reaction to cells from the foetus leads to a systemic illness. It has more similarities to anaphylaxis than venous thromboembolism. The mortality rate is around 20% or above.

Answer 267

Increasing maternal age Induction of labour Caesarean section Multiple pregnancy

Answer 268

Shortness of breath Hypoxia Hypotension Coagulopathy Haemorrhage Tachycardia Confusion Seizures Cardiac arrest

Answer 269

The overall management of amniotic fluid embolism is supportive. There are no specific treatments. Amniotic fluid embolism is a medical emergency – get help immediately. It requires the input of experienced obstetricians, medics, anaesthetics, intensive care teams and haematologists. They are likely to need transfer to the intensive care unit. The initial management of any acutely unwell patient is with an ABCDE approach, assessing and treating: A – Airway: Secure the airway B – Breathing: Provide oxygen for hypoxia C – Circulation: IV fluids to treat hypotension and blood transfusion in haemorrhage D – Disability: Treat seizures and consider other neurological deficits E – Exposure Cardiopulmonary resuscitation and immediate caesarean section are required if cardiac arrest occurs.

Answer 270

Uterine rupture is a complication of labour, where the muscle layer of the uterus (myometrium) ruptures. With an incomplete rupture, or uterine dehiscence, the uterine serosa (perimetrium) surrounding the uterus remains intact. With a complete rupture, the serosa ruptures along with the myometrium, and the contents of the uterus are released into the peritoneal cavity. Uterine rupture leads to significant bleeding. The baby may be released from the uterus into the peritoneal cavity. It has a high morbidity and mortality for both the baby and mother.

Answer 271

Previous C section Vaginal birth after caesarean (VBAC) Previous uterine surgery Increased BMI High parity Increased age Induction of labour Use of oxytocin to stimulate contractions

Answer 272

The main risk factor for uterine rupture is a previous caesarean section. The scar on the uterus becomes a point of weakness, and may rupture with excessive pressure (e.g. excessive stimulation by oxytocin). It is extremely rare for uterine rupture to occur in a patient that is giving birth for the first time.

Answer 273

Uterine rupture presents with an acutely unwell mother and abnormal CTG. It may occur with induction or augmentation of labour, with signs and symptoms of: Abdominal pain Vaginal bleeding Ceasing of uterine contractions Hypotension Tachycardia Collapse

Answer 274

Uterine rupture is an obstetric emergency. Resuscitation and transfusion may be required. Emergency caesarean section is necessary to remove the baby, stop any bleeding and repair or remove the uterus (hysterectomy).

Answer 275

Uterine inversion is a rare complication of birth, where the fundus of the uterus drops down through the uterine cavity and cervix, turning the uterus inside out. It is a very rare occurrence. It is a life-threatening obstetric emergency.

Answer 276

Incomplete uterine inversion (partial inversion) is where the fundus descends inside the uterus or vagina, but not as far as the introitus (opening of the vagina). Complete uterine inversion involves the uterus descending through the vagina to the introitus.

Answer 277

Uterine inversion may be there result of pulling too hard on the umbilical cord during active management of the third stage of labour.

Answer 278

Uterine inversion typically presents with a large postpartum haemorrhage. There may be maternal shock or collapse. An incomplete uterine inversion may be felt with manual vaginal examination. With a complete uterine inversion, the uterus may be seen at the introitus of the vagina.

Answer 279

Johnson manoeuvre Hydrostatic methods Surgery

Answer 280

Initial management of an inverted uterus is with the Johnson manoeuvre, which involves using a hand to push the fundus back up into the abdomen and the correct position. The whole hand and most of the forearm will be inserted into the vagina to return the fundus to the correct position. It is held in place for several minutes, and medications are used to create a uterine contraction (i.e. oxytocin). The ligaments and uterus need to generate enough tension to remain in place.

Answer 281

Where the Johnson manoeuvre fails, hydrostatic methods can be used. This involves filling the vagina with fluid to “inflate” the uterus back to the normal position. It requires a tight seal at the entrance of the vagina, which can be challenging to achieve.

Answer 282

Used when Johnson manouever and hydrostatic methods have failed A laparotomy is performed (opening the abdomen) and the uterus is returned to the normal position.

Answer 283

Previous caesarean Symptomatic after a previous significant perineal tear Placenta praevia Vasa praevia Breech presentation Multiple pregnancy Uncontrolled HIV infection Cervical cancer

Answer 284

after 39 weeks

Answer 285

Pfannenstiel incision is a curved incision two fingers width above the pubic symphysis Joel-cohen incision is a straight incision that is slightly higher (this is the recommended incision)

Answer 286

very premature deliveries and anterior placenta praevia.

Answer 287

Blunt dissection is used, after the initial incision with a scalpel, to separate the remaining layers of the abdominal wall and uterus. Blunt dissection involves using fingers, blunt instruments and traction to tear the tissues apart, rather than to cut them with sharp tools such as a scalpel. This results in less bleeding, shorter operating times and less risk of injury to the baby.

Answer 288

Skin Subcutaneous tissue Fascia / rectus sheath (the aponeurosis of the transversus abdominis and external and internal oblique muscles) Rectus abdominis muscles (separated vertically) Peritoneum Vesicouterine peritoneum (and bladder) – the bladder is separated from the uterus with a bladder flap Uterus (perimetrium, myometrium and endometrium) Amniotic sac

Answer 289

The baby is delivered by hand with the assistance of pressure on the fundus. Forceps may be used if necessary. The uterus is closed inside the abdomen using two layers of sutures. Exteriorisation (taking the uterus out of the abdomen) is avoided if possible. The abdomen and skin are then closed.

Answer 290

Allergic reactions or anaphylaxis Hypotension Headache Urinary retention Nerve damage (spinal anaesthetic) Haematoma (spinal anaesthetic) Sore throat (general anaesthetic) Damage to the teeth or mouth (general anaesthetic)

Answer 291

A spinal anaesthetic involves giving an injection of a local anaesthetic (such as lidocaine) into the cerebrospinal fluid at the lower back. This blocks the nerves from the abdomen downwards. A spinal anaesthetic is safer, and leads to fewer complications and a faster recovery than a general anaesthetic. The potential problems are that the patient remains awake (most patients tolerate this well, but some prefer to be asleep), and it takes longer to initiate than a general anaesthetic.

Answer 292

H2 receptor antagonists (e.g. ranitidine) or proton pump inhibitors (e.g. omeprazole) before the procedure Prophylactic antibiotics during the procedure to reduce the risk of infection Oxytocin during the procedure to reduce the risk of postpartum haemorrhage Venous thromboembolism (VTE) prophylaxis with low molecular weight heparin

Answer 293

There is a risk of aspiration pneumonitis during caesarean section, caused by acid reflux and aspiration during the prolonged period lying flat. H2 receptor antagonists (e.g. ranitidine) or proton pump inhibitors (e.g. omeprazole) are given before the procedure to reduce the risk of this happening.

Answer 294

Bleeding Infection Pain Venous thromboembolism

Answer 295

Postpartum haemorrhage Wound infection Wound dehiscence Endometritis

Answer 296

Ureter Bladder Bowel Blood vessels

Answer 297

Ileus Adhesions Hernias

Answer 298

Increased risk of repeat caesarean Increased risk of uterine rupture Increased risk of placenta praevia Increased risk of stillbirth

Answer 299

Risk of lacerations (about 2%) Increased incidence of transient tachypnoea of the newborn

Answer 300

Previous uterine rupture Classical caesarean scar (a vertical incision) Other usual contraindications to vaginal delivery (e.g. placenta praevia)

Answer 301

Pfannenstiel incision is a curved incision two fingers width above the pubic symphysis

Answer 302

Joel-cohen incision is a straight incision that is slightly higher (this is the recommended incision)

Answer 303

The requirements for instrumental delivery can be easily remembered by the mnemonic FORCEPS: Fully dilated cervix generally the second stage of labour must have been reached OA position preferably OP delivery is possible with Keillands forceps and ventouse. The position of the head must be known as incorrect placement of forceps or ventouse could lead to maternal or fetal trauma and failure Ruptured Membranes Cephalic presentation Engaged presenting part i.e. head at or below ischial spines the head must not be palpable abdominally Pain relief Sphincter (bladder) empty this will usually require catheterization

Answer 304

ARound 50% of cord prolapse occurs after artificial rupture of membranes

Answer 305

The mother’s viral load will determine the mode of delivery: Normal vaginal delivery is recommended for women with a viral load < 50 copies / ml Caesarean section is considered in patients with > 50 copies copies / ml and in all women with > 400 copies / ml IV zidovudine should be given during the caesarean if the viral load is unknown or there are > 10000 copies / ml Prophylaxis treatment may be given to the baby, depending on the mothers viral load: Low-risk babies, where the mother’s viral load is < 50 copies per ml, are given zidovudine for four weeks High-risk babies, where the mother’s viral load is > 50 copies / ml, are given zidovudine, lamivudine and nevirapine for four weeks

Answer 306

A terminal bradycardia is when the baseline fetal heart rate drops to below 100 beats per minute for more than 10 minutes. A terminal deceleration is when the heart rate drops and does not recover for more than 3 minutes. These make up a 'pre-terminal' CTG and are indicators for Emergency Caesarean section.

Answer 307

15 beats or more for at least 15 seconds

Answer 308

The fetal head may rotate spontaneously to an OA position Delivery is possible in the OP position, however labour is likely to be longer and more painful. Augmentation should be used if progress is slow. Kielland's forceps are associated with the most successful outcomes, however require particular expertise. Generally, women will experience an earlier urge to push in OP than OA.

Answer 309

Applying suprapubic pressure

Answer 310

5U of IV Syntocinon (oxytocin), followed by 0.5 mg of ergometrine.

Answer 311

Late decelerations on CTG are a pathological finding and urgent fetal blood sampling is needed to assess for fetal hypoxia and acidosis. A pH of >7.2 in labour is considered normal. Urgent delivery should be considered if there is fetal acidosis.

Answer 312

admit and administer steroids

Answer 313

Uterine hyperstimulation

Answer 314

Muliparity Maternal trauma Maternal age advanced

Answer 315

benzylpenicillin as GBS prophylaxis

Answer 316

chorioamnionitis

Answer 317

Both involve injury to the perineum involving the anal sphincter complex 4th also involves anal epitheilium/rectal mucosa

Answer 318

Following an ABC approach, initial steps to manage a postpartum haemorrhage include palpating the uterine fundus and catheterising the patient

Answer 319

SD ART EPU Skin Superficial fascia Deep fascia Anterior rectus sheath Rectus abominus muscle Transversalis fascia Extraperiotneal connective tissue Peritoneum Uterus

Answer 320

Magnesium sulphate - monitor reflexes + respiratory rate Give calcium gluconate if problems

Labour and Delivery Flashcards

(361 cards)