Labour and Delivery Complications Flashcards
What is a hypoactive uterus?
A hypoactive uterus refers to inadequate uterine contractions, which can lead to delayed labor progression or postpartum hemorrhage (PPH).
What are the main causes of a hypoactive uterus?
Uterine overdistension (e.g., multiple pregnancy, polyhydramnios).
Prolonged labor.
Maternal exhaustion.
Chorioamnionitis.
Oxytocin receptor desensitization.
One common cause of a hypoactive uterus is __________, which refers to an infection of the fetal membranes.
Chorioamnionitis.
What are the clinical signs of a hypoactive uterus?
Poor uterine contractions during labor.
Slow cervical dilation or labor progression.
Postpartum hemorrhage.
How is hypoactive uterus diagnosed?
Clinical assessment of contraction strength.
Partogram showing slow labor progression.
Palpation of the uterus after delivery to assess uterine tone.
What are the management options for hypoactive uterus during labor?
Augmentation with oxytocin to stimulate stronger contractions.
Consider amniotomy.
Monitor maternal and fetal well-being.
What are the management options for a hypoactive uterus postpartum?
Uterine massage.
Oxytocin administration to improve uterine tone.
Consider carboprost or ergometrine for refractory cases.
Surgical options if medical management fails (e.g., Bakri balloon, surgery).
The first-line treatment for a hypoactive uterus is administration of __________ to stimulate uterine contractions.
Oxytocin.
What are the potential complications of a hypoactive uterus?
Prolonged labor.
Failure to progress.
Postpartum hemorrhage (PPH).
Maternal infection.
A woman in active labor shows slow cervical dilation and weak uterine contractions. What management steps should be considered?
Administer oxytocin to augment labor.
Consider amniotomy if membranes are intact.
Monitor for signs of maternal or fetal distress.
What is premature labor?
Premature labor is defined as labor occurring before 37 weeks of gestation.
What are the main risk factors for premature labor?
Multiple pregnancy
Previous preterm birth
Cervical insufficiency
Infections (e.g., chorioamnionitis, bacterial vaginosis)
Polyhydramnios
Smoking, alcohol, or drug use
Maternal age <18 or >35
Short inter-pregnancy interval
Placental abruption
A major risk factor for premature labor is ____________, which refers to an incompetent cervix that dilates too early in pregnancy.
Cervical insufficiency
What are the clinical signs and symptoms of premature labor?
Regular uterine contractions before 37 weeks
Cervical dilation and effacement
Pelvic pressure
Lower back pain
Vaginal discharge (mucus plug or bloody show)
What investigations are used to assess premature labor?
Fetal fibronectin test (fFN): Indicates likelihood of preterm labor.
Transvaginal ultrasound (TVUS): Assesses cervical length.
CTG (Cardiotocography): Monitors fetal well-being.
Speculum examination: Evaluates cervical changes.
Infection screening: Checks for chorioamnionitis or BV.
What criteria are used to diagnose premature labor?
Contractions: Regular uterine contractions (>4 in 20 mins).
Cervical changes: Dilation and effacement before 37 weeks.
True/False
Q: A positive fetal fibronectin (fFN) test indicates a high risk of imminent delivery.
True.
What medications are used to suppress contractions in premature labor?
Nifedipine (calcium channel blocker)
Atosiban (oxytocin receptor antagonist)
Indomethacin (NSAID)
What steroid is used to promote fetal lung maturity in premature labor?
Betamethasone or dexamethasone.
Administration of __________ before 34 weeks of gestation reduces the risk of neonatal respiratory distress syndrome (RDS).
Corticosteroids
What is the purpose of administering magnesium sulfate in premature labor?
Neuroprotection for the fetus, reducing the risk of cerebral palsy.
What antibiotics are used in the management of premature labor with prolonged rupture of membranes?
IV erythromycin or penicillin (to reduce infection risk).
A 30-week pregnant woman presents with regular contractions and cervical dilation of 2 cm. What should be the next steps in management?
Administer corticosteroids for lung maturity.
Start tocolytics to suppress labor if no contraindications.
Magnesium sulfate for neuroprotection.
Monitor for infection and fetal distress.
When is tocolysis contraindicated in premature labor?
Chorioamnionitis
Severe pre-eclampsia
Placental abruption
Fetal distress
Severe intrauterine growth restriction (IUGR)
Match the intervention with its purpose:
Corticosteroids
Magnesium sulfate
Tocolytics
A: Suppresses uterine contractions
B: Reduces neonatal respiratory complications
C: Provides neuroprotection
1 → B
2 → C
3 → A
What are potential complications of premature labor?
Neonatal respiratory distress syndrome (RDS)
Intraventricular hemorrhage (IVH)
Sepsis
Cerebral palsy
Neonatal death
Premature labor is most commonly associated with __________, a condition where the membranes rupture before 37 weeks of gestation.
Preterm premature rupture of membranes (PPROM)
How does gestational age impact neonatal outcomes in premature labor?
Earlier gestational age is associated with higher neonatal morbidity and mortality. Neonatal outcomes improve significantly after 34 weeks.
What are the differential diagnoses for premature labor?
Braxton Hicks contractions
Cervical insufficiency
Urinary tract infection (UTI)
Chorioamnionitis
Placental abruption
What is the definition of Premature Rupture of Membranes (PROM)?
Rupture of membranes before the onset of labor, occurring after 37 weeks of gestation.
What is the definition of Preterm Premature Rupture of Membranes (PPROM)?
Rupture of membranes before 37 weeks of gestation, without labor onset.
What are the common risk factors for PROM and PPROM?
Previous PROM/PPROM
Multiple pregnancy
Polyhydramnios
Cervical insufficiency
Smoking
Infections (e.g., bacterial vaginosis)
Short cervix
Amniocentesis
PROM occurs when the membranes rupture __________ the onset of labor at ≥ 37 weeks
before
What are the clinical signs and symptoms of PROM?
Gush or trickle of fluid from the vagina
Wet underwear or pad
Clear or pale-yellow fluid
No contractions initially
How is PROM diagnosed?
History: gush or leakage of fluid
Sterile speculum examination: pooling of fluid in the posterior fornix
Nitrazine test: turns blue if amniotic fluid is present
Ferning test: amniotic fluid forms a fern-like pattern
What investigations should be done in PPROM?
Speculum examination (for fluid pooling)
High vaginal swab (HVS) for infection
Fetal heart rate monitoring
Ultrasound: assess amniotic fluid and fetal well-being
CRP and white cell count (to detect infection or chorioamnionitis)
True/False
Q: Digital vaginal examination is safe in suspected PROM or PPROM.
False – It increases the risk of infection.
What is the management for PROM at term (≥ 37 weeks)?
Induction of labor if labor does not start spontaneously within 24 hours
Maternal observations for infection (temperature, heart rate, etc.)
Fetal monitoring
How is PPROM managed before 37 weeks?
Admission to hospital
Prophylactic antibiotics (e.g., erythromycin for 10 days)
Steroids to promote fetal lung maturity
Regular monitoring for signs of chorioamnionitis
Delivery if infection or fetal distress develops
A 35-week pregnant woman presents with a sudden gush of fluid but no contractions. What is the likely diagnosis and first step in management?
Likely PPROM. Perform a sterile speculum examination to confirm rupture of membranes.
What are potential complications of PROM and PPROM?
Chorioamnionitis
Preterm labor and delivery
Neonatal sepsis
Oligohydramnios
Cord prolapse
Placental abruption
The main complication of PROM is __________, an infection of the fetal membranes.
Chorioamnionitis
Which antibiotic is typically given in PPROM?
Erythromycin for 10 days.
What measures can help reduce the risk of PROM and PPROM?
Smoking cessation
Treat infections (e.g., bacterial vaginosis)
Cervical cerclage for cervical insufficiency
Avoid unnecessary procedures (e.g., multiple amniocenteses)
Match the following terms with their definitions:
PROM
PPROM
Chorioamnionitis
A: Rupture of membranes before labor at < 37 weeks
B: Infection of the fetal membranes
C: Rupture of membranes before labor at ≥ 37 weeks
1 → C
2 → A
3 → B
Why are corticosteroids given in PPROM?
To promote fetal lung maturity and reduce the risk of neonatal respiratory distress syndrome.
What are the clinical signs of chorioamnionitis?
Maternal fever
Tachycardia (maternal and/or fetal)
Uterine tenderness
Purulent or foul-smelling vaginal discharge
A woman with PPROM at 33 weeks develops a fever, tachycardia, and uterine tenderness. What is the likely diagnosis, and what is the next step?
Likely chorioamnionitis. Initiate broad-spectrum antibiotics and consider immediate delivery.
What factors influence the prognosis in PPROM?
Gestational age at rupture
Presence of infection
Amniotic fluid levels
Fetal lung maturity
What is cord prolapse?
Cord prolapse occurs when the umbilical cord descends ahead of or alongside the presenting fetal part after rupture of membranes.
What are the types of cord prolapse?
Overt cord prolapse: Cord is visible or palpable in the vagina or outside the introitus.
Occult cord prolapse: Cord is compressed but not visible or palpable.
What are the key risk factors for cord prolapse?
Polyhydramnios
Multiple pregnancy
Preterm labor
Malpresentation (e.g., breech or transverse)
High presenting part
Artificial rupture of membranes (ARM)
Low birth weight
A significant risk factor for cord prolapse is __________, where there is excessive amniotic fluid.
Polyhydramnios
What are the clinical signs of overt cord prolapse?
Visible umbilical cord at the vulva
Palpable cord on vaginal examination
Fetal bradycardia or abnormal heart rate patterns
How is cord prolapse diagnosed?
Clinical examination: Visual or palpable cord in the vagina
Fetal heart rate monitoring: Sudden fetal bradycardia or decelerations
A woman in labor has sudden fetal bradycardia following rupture of membranes. What should be suspected, and how should it be confirmed?
Cord prolapse should be suspected. Perform a vaginal examination to confirm.
What are the immediate steps to take when cord prolapse is confirmed?
Call for help immediately.
Relieve pressure on the cord:
Manually elevate the presenting part.
Position the patient in knee-chest or Trendelenburg position.
Avoid handling the cord to reduce vasospasm.
Consider tocolysis to reduce uterine contractions.
Prepare for immediate delivery (usually emergency C-section).
What maternal positions can help relieve cord compression in cord prolapse?
Knee-chest position
Trendelenburg position (head-down, feet elevated)
True/False
Q: Cord prolapse requires immediate vaginal delivery in all cases.
False – Most cases require emergency C-section.
What are the potential complications of cord prolapse?
Fetal hypoxia or asphyxia
Fetal acidosis
Stillbirth
Maternal anxiety and trauma
A woman with cord prolapse is prepared for C-section, but fetal bradycardia persists. What is the most important action?
Ensure manual elevation of the presenting part until the baby is delivered.
What measures can reduce the risk of cord prolapse?
Avoid artificial rupture of membranes (ARM) in high-risk cases.
Ensure proper fetal presentation before rupture of membranes.
Continuous fetal monitoring for high-risk labors.
How can continuous fetal heart rate monitoring help in suspected cord prolapse?
Detects fetal bradycardia or decelerations, which are critical signs of cord compression.
The primary method of delivery in cord prolapse is typically __________
Emergency C-section
Match the following actions with their purpose in cord prolapse management:
Manual elevation of presenting part
Trendelenburg position
Avoid handling the cord
Tocolysis
A: Prevent uterine contractions
B: Prevent vasospasm and injury to the cord
C: Relieve pressure on the cord
D: Reduce compression by gravity
1 → C
2 → D
3 → B
4 → A
What factors influence the prognosis in cord prolapse?
Speed of delivery
Duration of cord compression
Gestational age
Access to emergency care
A healthcare provider notices a visible cord but is unsure whether to reposition it. What is the correct action?
Do not handle the cord to avoid vasospasm and trauma. Focus on relieving pressure on the cord.
What is assisted vaginal birth (by forceps or vacuum) also known as?
Instrumental Delivery
How common are instrumental deliveries in the UK?
10-15% of deliveries ; ; ⅓ of first deliveries for nulliparous women.
What are the 2 types of instrumental delivery?
Forceps and Vacuum
What is typical for forceps delivery?
Interlocking blades fit around the baby’s head and guide it down the birth canal,
typically alongside medio-lateral episiotomy.
What is vacuum delivery?
Suction cup adheres to the baby’s head to assist with delivery
What is an outlet classification in assisted vaginal birth?
The fetal scalp is visible, the skull has reached the perineum, and the required rotation is less than 45 degrees.
What is a low cavity classification in assisted vaginal birth?
The fetal station is at +2 cm, but the skull has not yet reached the perineum.
What is a mid cavity classification in assisted vaginal birth?
The fetal head is less than 1/5th palpable abdominally, and the station is between +1 cm and 0 cm.
What type of instruments are used for non-rotational assisted deliveries?
Neville Barnes forceps (low cavity) : Simpson’s forceps
Wrigley forceps (outlet, also used in caesarean sections)
Anterior cup
What type of instruments are used for rotational assisted deliveries?
Kjelland’s forceps ; Posterior cup (e.g., Kiwi)
When are rotational instruments used in assisted vaginal deliveries?
Rotational instruments are used when the fetal position is occipito-posterior or occipito-transverse.
When are Wrigley forceps typically used?
Wrigley forceps are used for outlet deliveries and during caesarean sections
What classifies an outlet-assisted vaginal birth?
Visible scalp, <45° rotation.
What classifies a low cavity-assisted vaginal birth?
Station +2cm, not perineum.
What classifies a mid cavity-assisted vaginal birth?
Station +1 to 0cm.
When are rotational instruments used in assisted deliveries?
Occipito-posterior/transverse position.
Non-rotational forceps examples
Neville Barnes, Simpson’s, Wrigley
Rotational forceps example
Kjelland’s
Use of Wrigley forceps
Outlet, caesarean sections
Indications for Instrumental Delivery
- Suspected foetal compromise 2. Delayed second stage 3. Maternal exhaustion / distress 4. Medical contraindication to Valsalva
Risks of Forceps
- Vaginal trauma 2. Postpartum haemorrhage 3. Obstetric anal sphincter injury (3rd degree tear) 4. Facial / scalp laceration
Risks of Vacuum
- Vaginal trauma 2. Postpartum haemorrhage 3. OASI 4. Facial / scalp laceration 5. Retinal haemorrhage 6. Cephalohematoma 7. Subgaleal haemorrhage
How are obstectric injuries classified?
Degrees of Tears
1st Degree Tear
Skin only
2nd Degree Tear
Perineal muscle
3rd Degree Tear Types
Type A <50% external AS, Type B >50% external AS, Type C internal & external AS
4th Degree Tear
Anorectal epithelium
What is obstructed labour?
Obstructed labour occurs when there is a physical barrier preventing the descent of the fetus despite adequate uterine contractions.
What are common causes of obstructed labour?
Cephalopelvic disproportion (CPD)
Malpresentation or malposition (e.g., brow, face, transverse lie)
Fetal macrosomia
Pelvic abnormalities (e.g., contracted pelvis)
Uterine fibroids or tumors
Cervical stenosis
What are the maternal risk factors for obstructed labour?
Short maternal stature
Previous obstructed labour
Multiple pregnancy
Pelvic trauma or deformity
Obesity
Prolonged labour in a previous pregnancy
The most common cause of obstructed labour is __________.
Cephalopelvic disproportion (CPD)
What are the clinical features of obstructed labour?
Prolonged first or second stage of labour
Bandl’s ring (pathological uterine retraction ring)
Fetal distress (abnormal fetal heart rate)
Maternal exhaustion
Maternal tachycardia and dehydration
Hematuria or bladder distention
What is Bandl’s ring, and what does it indicate?
Bandl’s ring is a pathological uterine contraction ring seen in obstructed labour, indicating impending uterine rupture.
How is obstructed labour diagnosed?
History: Prolonged labour, no progress despite adequate contractions
Examination: High fetal station, Bandl’s ring, maternal signs of distress
Fetal monitoring: Abnormal heart rate
What investigations are used in obstructed labour?
Continuous cardiotocography (CTG)
Ultrasound: Assess fetal position and size
Urinalysis: Detect hematuria (sign of bladder injury)
What is the initial management for obstructed labour?
Call for help immediately.
Stop oxytocin if being administered.
Administer IV fluids.
Continuous fetal monitoring.
Prepare for delivery (usually C-section).
What are the delivery options in obstructed labour?
C-section: Most common and safest option.
Instrumental delivery: Only if safe and indicated.
Symphysiotomy: Rarely performed in resource-limited settings.
What are maternal complications of obstructed labour?
Uterine rupture
Postpartum hemorrhage (PPH)
Infection (e.g., sepsis)
Bladder injury
Fistula formation (e.g., vesicovaginal fistula)
Maternal death
The most serious maternal complication of obstructed labour is __________.
Uterine rupture
What are the fetal complications of obstructed labour?
Hypoxia
Birth trauma
Fetal acidosis
Stillbirth
Neonatal death
A woman in prolonged labour shows a Bandl’s ring and abnormal CTG. What should be the immediate management?
Prepare for emergency C-section immediately to avoid fetal hypoxia and maternal complications.
True/False
Q: Instrumental delivery is the first-line treatment for obstructed labour.
False – C-section is the safest and most common management.
A woman in labour for 20 hours has no cervical dilation for 3 hours despite strong contractions. What should be suspected, and what investigation is most helpful?
Suspect obstructed labour. Perform an ultrasound to assess fetal size, position, and presentation.
How can obstructed labour be prevented?
Antenatal care: Early detection of risk factors
Planned C-section: For known cephalopelvic disproportion or malpresentation
Avoid prolonged labour without monitoring
Match the following clinical signs with their meanings:
Bandl’s ring
Maternal tachycardia
Fetal bradycardia
Hematuria
A: Compression of the fetal cord
B: Bladder injury
C: Uterine rupture risk
D: Maternal exhaustion
1 → C
2 → D
3 → A
4 → B
What factors influence the prognosis of obstructed labour?
Timeliness of intervention
Access to emergency care
Severity of complications (e.g., uterine rupture, infection)
A woman in obstructed labour shows signs of dehydration and maternal tachycardia. What should be done immediately?
Administer IV fluids, provide continuous monitoring, and prepare for C-section.
What is a malpresentation in obstetrics?
Malpresentation refers to any fetal presentation that is not vertex (head-down), including breech, face, brow, and shoulder presentations.
What are the common types of fetal malpresentations?
Breech presentation
Face presentation
Brow presentation
Shoulder presentation (transverse lie)
What is breech presentation?
Breech presentation is when the buttocks or feet are the presenting part instead of the head.
What are the types of breech presentation?
Frank breech: Thighs flexed, legs extended.
Complete breech: Thighs and legs flexed.
Footling breech: One or both feet present first.
The most common type of breech presentation is ________
Frank breech
What are risk factors for malpresentations?
Prematurity
Multiple pregnancy
Polyhydramnios or oligohydramnios
Placenta previa
Uterine anomalies (e.g., fibroids, bicornuate uterus)
Fetal anomalies (e.g., anencephaly)
What is face presentation, and what is its significance?
In face presentation, the fetal head is hyperextended, and the face is the presenting part. It can complicate vaginal delivery due to fetal head extension.
What is brow presentation?
Brow presentation occurs when the fetal head is partially extended, and the brow is the presenting part. It often leads to cephalopelvic disproportion.
What is shoulder presentation (transverse lie)?
The fetus lies horizontally across the uterus, with the shoulder or arm as the presenting part. Vaginal delivery is not possible.
How is malpresentation diagnosed?
Abdominal palpation: Leopold’s maneuvers to identify fetal position.
Vaginal examination: Can detect non-vertex presentation.
Ultrasound: Confirms fetal presentation and position.
What investigation is the gold standard for confirming malpresentation?
Ultrasound
What are the management options for breech presentation?
External cephalic version (ECV): Manual turning of the fetus to head-down.
Planned C-section: If ECV fails or not possible.
Vaginal breech delivery: Only in selected cases with experienced staff.
What is external cephalic version (ECV)?
A procedure used to manually rotate a breech fetus to a vertex presentation after 36–37 weeks gestation.
What are contraindications to ECV?
Placenta previa
Multiple pregnancy
Uterine anomalies
Oligohydramnios
Fetal compromise or abnormalities
External cephalic version (ECV) is most effective when performed at __________ weeks of gestation.
36–37 weeks
True/False
Q: Vaginal breech delivery is safe for all breech presentations.
False – Vaginal breech delivery is only recommended in selected cases.
How is face presentation managed?
Continuous monitoring of labour.
C-section if vaginal delivery is not progressing.
Attempt vaginal delivery only if chin is anterior.
How is shoulder presentation managed?
Immediate C-section is required, as vaginal delivery is not possible in transverse lie.
What are potential complications of malpresentations?
Obstructed labour
Uterine rupture
Fetal hypoxia or distress
Birth trauma
Cord prolapse
A 37-week pregnant woman is diagnosed with a frank breech presentation. What are the next steps in management?
Offer external cephalic version (ECV) if no contraindications. If ECV fails, plan for C-section or consider vaginal delivery if appropriate.
A woman in labour is diagnosed with a transverse lie at term. What should be done?
Immediate C-section is required to prevent complications.
Match the malpresentation type with its description:
Breech
Face
Brow
Shoulder
A. Hyperextended fetal head
B. Buttocks or feet presenting
C. Transverse lie
D. Partially extended head
1 → B
2 → A
3 → D
4 → C
A woman at 37 weeks gestation undergoes ECV for breech presentation, but it fails. What should be recommended next?
Planned C-section should be scheduled.
