Labour and Delivery 4

Question 1

What is preterm labour?

Answer 1

between 24 and 37 weeks gestation

Question 2

What are the causes of preterm labour?

Answer 2

subclinical infection 
cervical 'incompetence'
multiple pregnancy 
antepartum haemorrhage 
diabetes 
polyhydramnios 
fetal compromise 
uterine abnormalities 
idiopathic 
iatrogenic

Question 3

How can preterm labour be prevented?

Answer 3

abs if bacterial vaginosis, UTI, STD or Hx of infection in prev preterm labour
cervical suture if cervical component likely (at 12 weeks if cervix shortens)
progesterone pessaries (at 12 weeks if cervix shortens)
fetal reduction/amnioreduction

Question 4

What are the features of preterm labour?

Answer 4

abdo pain
antepartum haemorrhage
ruptured membranes
cervical incompetence silent

Question 5

How is preterm labour managed?

Answer 5

steroids if <34 weeks, tocolysis for max 24 hours
abs if in confirmed labour
C-section for normal indications
inform neonatologists

Question 6

What are the indications for instrumental delivery?

Answer 6

prolonged second stage
fetal distress in second stage
when maternal pushing is contraindicated

Question 7

What are the different method of instrumental delivery?

Answer 7

ventouse attaches by suction. allowing traction with rotation
non rotational forceps grip and allow traction
rotational forceps, allow rotation and then traction

Question 8

How often is the perineum left intact after vaginal delivery?

Answer 8

in 1/3 of nulliparous women and 1/2 of multiparous women

Question 9

How are perineal tears classified?

Answer 9

1st degree - minor damage to fourchette
2nd degree - perineal muscle
3rd degree - anal sphincter
4th degree - anal mucosa

Question 10

What are the indication for episiotomy?

Answer 10

1) delay due to rigid perineum, and cutting will expedite delivery + prevent tear
2) tear seems imminent + episiotomy deemed preferable
3) if instrumental delivery inc breech delivery with forceps

Question 11

How is the perineum repaired?

Answer 11

adequate analgesia (top up epidural or LA)

place pad high in vagina to prevent blood from uterus obscuring view

Check extent of cuts and lacerations

Repair mucosa

Repair muscle layers

Put finger in rectum to ensure rectal mucosa intact

Question 12

What are the different types of C section?

Answer 12

emergency section
maternal or fetal compromise which isn’t immediately life threatening
no maternal or fatal compromise but needs early delivery
delivery times to suit woman or staff

Question 13

What are the indications for an emergency c-section?

Answer 13

cord prolapse
fetal distress in first stage
antepartum haemorrhage

Question 14

What are the indications for a c-section?

Answer 14

cephalopelvic disproportion 
breech or transverse lie at term 
multiple pregnancy 
severe hypertensive disease in pregnancy 
fetal distress, VLBW
failed induction of labour 
prev c-section 
pelvic cyst or fibroid 
maternal infection (herpes/HIV)

Question 15

What are the benefits of having a c-section?

Answer 15

reduced perineal and abdominal pain during birth and 3 days post partum
reduced injury to vagina
reduced early PPH
reduced obstetric shock

Question 16

What are the risks of C-section?

Answer 16

increased risk of NICU admission 
longer hospital stay 
increased risk of hysterectomy 
risk of infection 
increased risk of cardiac arrest 
affects future pregnancies as risk of uterine rupture

Question 17

How many women successful have a vaginal birth after c-section (VBAC)?

Answer 17

2/3

Question 18

How is maternal collapse managed in pregnancy?

Answer 18

resuscitation - clear airway, oxygen, CPR if necessary, IV access

Question 19

What is placenta praevia managed if patient is in shock/heavy bleeding and is >37 weeks?

Answer 19

lower segment C-section, give blood

Question 20

What is placenta praevia managed if blood loss has stopped or they are <37 weeks?

Answer 20

give steroids if <34 weeks, anti-D rhesus -ve, keep in hospital +c-section at 39 weeks

Question 21

How is placental abruption managed if the CTG is abnormal?

Answer 21

emergency c section

give blood

Question 22

How is placental abruptions managed when the fetes is dead?

Answer 22

anticipate anticoagulopathy + transfuse blood +/- fresh frozen plasma, induce labour with intense monitoring

Question 23

How is placental abruption managed when the CTG is normal >37 weeks?

Answer 23

induce unless small painless bleed

Question 24

How is placental abruption managed when the CTG is normal <37 weeks?

Answer 24

steroids if <34 weeks anti D if rhesus -ve

serial US

Question 25

What are the causes of massive PPH?

Answer 25

perineal/vaginal trauma –> suture
Uterus poorly contracted –> ergometrine and oxytocin infusion
bleeding persistent –> examine under anaesthetic
Uterine atony –> intra-myometrial prostaglandin if oxytocin fails
Uterine bleeding persists - laparotomy, consider brace suture/tamponade with ballon/embolization/hysterectomy/vacular ligation

Question 26

How else should a massive PPH be managed?

Answer 26

as per protocol
replace blood with fresh frozen plasma if >4 units given at same time as treating cause

check clotting, FBC, watch fluids and oxygen

Question 27

How should cardiac problems be managed when there is maternal collapse?

e.g. MI

Answer 27

control pain with IV diamorphine + LVF with iv furosemide
correct arythmies as determined by ECG
100% oxygen
if complete heart block, maintain ventricular rate with IV atropine until able to keep pace
tilt mu to left
CPR
Intubate early
C section if adequate circulation is not established

Question 28

How is a pulmonary embolism managed in labour and delivery?

Answer 28

treat with LMWH
does adjusted to factor Xa level
more in needed than for non-preganant women
stop treatment shortly before labour

Question 29

What is an amniotic embolism?

Answer 29

Liquor enters maternal circulation

presents with anaphylaxis, with sudden dyspnoea, hypoxia and hypotension, accopanyied by seizures and cardiac arrest

if survive –> DIC, pulmonary oedema

Question 30

How is amniotic embolism managed?

Answer 30

blood for clotting, FBC, electrolytes and cross match taken
blood and fresh frozen plasma required
transfer to ITU