Labour, delivery and puerperium

Question 1

What are the stages of labour?

Answer 1

First - initial to full dilatation
Second - full dilatation to delivery of baby
Third - delivery of baby to delivery of placenta

Question 2

What does a diagnosis of labour mean?

Answer 2

When painful uterine contractions accompany dilatation and effacement of the cervix.

Question 3

What is the average rate of dilatation in the active phase of first stage?

Answer 3

1cm/h in nulliparous and 2cm/h in muliparous women. The active first stage should normally not last longer than 12 hours.

Question 4

What happens in the second stage of labour?

Answer 4

Passive stage - full dilatation until the head reaches the pelvic floor and the woman experiences the desire to push. Normally rotation and flexion of the head are completed.
Active stage - when the woman is pushing with contractions.
If delivery takes >1hr, spontaenous delivery is unlikely.

Question 5

What is considered normal blood loss in the third stage of labour?

Answer 5

Up to 500ml.

Question 6

What are the order of head movements in delivery?

Answer 6

Engagement in OT position.
Descent and flexion
Rotation 90 degrees to OA position
Descent
Extension of head to deliver
Restitution

Question 7

What is defined as fetal distress?

Answer 7

Hypoxia which may result in fetal damage or death if not reversed or the fetus delivered urgently.
Convention is that pH<7.20 from FBG indicates significant hypoxia.

Question 8

What methods are used to diagnose fetal distress?

Answer 8

Colour of meconium.
CTG
FBG

Question 9

What are the ways in which labour can be induced or augmented?

Answer 9

Prostaglandins (usually 2mg PGE2)
Amniotomy and oxytocin infusion if labour has not started within 2 hours of labour - oxytocin alone is often used if SRM has already happened.
Stretch and sweep

Question 10

When is induction of labour contraindicated?

Answer 10

Absolute: acute fetal compromise, abnormal lie, placenta praevia, pelvic obstruction and >1 CS.
Relative: after 1 CS, prematurity

Question 11

What are the complications of induction?

Answer 11

Labour may fail to start or be slow.
Greater risk of instrumentation or CS.
Hyperstimulation, fetal distress and uterine rupture
Umbilical cord prolapse at amniotomy
PPH, intrapartum and post partum infection more likely

Question 12

What measures can be taken to prevent preterm delivery?

Answer 12

Antibiotics for BV, UTI, STD or history of infection in previous preterm labour
Cervical suture if cervical component likely, either at 12 weeks or if the cervix shortens.
Progesterone pessaries either at 12 weeks or if cervix shortens.

Question 13

How should preterm labour be managed?

Answer 13

Steroids if <34 weeks
Tocolysis (nifedipine or an oxytocin receptor antagonist) for max 24 hours to enable transfer to a unit with neonatal ITU
Antibiotics in confirmed labour only
C-section for normal indications
Inform neonatologists

Question 14

What are common causes of maternal collapse?

Answer 14

Haemorrhage
Eclampsia or severe pre-eclampsia
Total spinal, local anaesthetic toxicity
Pulmonary or amniotic fluid embolus
Maternal cardiac disease

Question 15

How should maternal collapse be managed?

Answer 15

ABC
If seizures, give diazepam. If eclampsia, give magnesium sulphate.
Review hx and examination.
Investigations: bloods - cross match, clotting, FBC, U&Es, LFTs. CTG is antepartum.
Treat depending on cause.

Question 16

What are indications for emergency C-section?

Answer 16

Prolonged first stage of labour - full dilatation not imminent by 12 hours.
If not all criteria for instrumental delivery are met
Insufficent uterine action
Malposition or malpresentation
Cephalopelvic disproportion

Fetal distress

Question 17

What are the indications for elective CS?

Answer 17

Absolute: placenta praevia, severe antenatal fetal compromise, abnormal lie, previous vertical C-section, gross pelvic deformity

Relative: breech, severe IUGR, twins, diabetes and other medical conditions, previous C-section

Maternal request.

It is usual to perform a C-section rather than induce labour if delivery is required before 34 weeks.

Question 18

When are elective CS carried out?

Answer 18

Normally at 39 weeks gestation.

Question 19

What are the complications of CS?

Answer 19

Maternal: haemorrhage, sepsis, VTE, anaesthetic, increased chance of placenta praevia, accreta and percreta in future pregnancies.

Fetal: increased respiratory morbidity, fetal laceration.

May affect bonding and breastfeeding.

Question 20

What criteria must be fulfilled for an instrumental delivery?

Answer 20

Head must be deeply engaged
Head must be at or lower than the ischial spines on VE
Full dilatation
Position of head must be known
Adequate analgesia
Bladder must be empty (usually catheterised)

Question 21

What is an example of non-rotational forceps and when can it be used?

Answer 21

Simpson’s or Neville-Barnes.
Grips the head in whatever position and allows traction only.
Suitable only in the OA position.

Question 22

What is an example of rotational forceps and when can it be used? Which other instrument allows for rotation?

Answer 22

Kielland’s. The Ventouse also allows for rotation.
Allows for rotation, then traction, so a malpositioned head can be rotated to the OA position before traction is applied.

Question 23

What are the side effects of using Entonox (gas and air)?

Answer 23

Lightheadedness, nausea and hyperventilation

Question 24

What are the side effects of using opioids as pain relief?

Answer 24

Maternal: nausea and vomiting, sedation and confusion. delayed gastric emptying and hypoventilation
Neonatal: respiratory depression, neurobehaviour changes

Question 25

When are epidurals used?

Answer 25

Maternal requrest
Pre-eclampsia
Co-existing disease
Airway problems (avoid GA)
High risk delivery

Question 26

What are the possible disadvantages of epidurals?

Answer 26

BP and pulse must be regularly monitored
Pressure sores
Urinary retention due to reduced bladder sensation
Transient hypotension unless fluid given first
Transient fetal bradycardia
Instrumental delivery more common
Increased risk of maternal fever

Question 27

What are the possible complications of epidurals?

Answer 27

Spinal tap and headache
IV injection - convulsions, cardiac arrest
total spinal analgesia

Question 28

How should mastitis be treated?

Answer 28

Give analgesia
Continue breast feeding
Give antibiotics, usually oral flucloxacillin

Question 29

What options are available for post-partum contraception?

Answer 29

Lactation not adequate alone
Usually started 4-6 weeks after delivery
COCP is contraindicated with breastfeeding, but progesterone only methods are safe.
IUDs can be inserted at the end of 3rd stage or at 6 weeks.

Question 30

What is the definition of primary PPH?

Answer 30

Loss of >500ml of blood 1000ml after CS)

Question 31

How is primary PPH routinely prevented?

Answer 31

Use of oxytocin in the 3rd stage of labour (reduces incidence by 60%). Oxytocin is as effective as ergometrine which often causes vomiting and is contraindicated in the hypertensive woman.

Question 32

What is the management of primary PPH?

Answer 32

Resuscitation with patient lying flat and get IV access.
Cross match and blood transfusion.
Check if placenta is complete. Retained placenta should be manually removed if there is bleeding or not expelled within 60 minutes of delivery.
Identify and treat cause: VE, bimanual compression, treat lacerations, oxytocin/ergometrine - if atony persists, PGF2a is injected into myometrium.
For persistent haemorrhage, balloon tamponade, B-Lynch sutures, uterine artery embolisation and hysterectomy.

Question 33

What is the commonest cause of secondary PPH?

Answer 33

Endometritis - the uterus is enlarged and tender with an open internal cervical os.

Question 34

How should secondary PPH be investigated and managed?

Answer 34

Vaginal swabs, FBC and USS.
Give antibiotics. If there is heavy bleeding, evacuation of the retained products of conception may be required. Tissues should be examined to exclude gestational trophoblastic disease.

Question 35

How common is postnatal depression?

Answer 35

10% of women.

About 50% will have third day blues.

Question 36

What is puerperal psychosis?

Answer 36

abrupt onset of psychotic symptoms starting usually around 4th day. More common in primigravid women with family history. Treated with psychiatric admission and major tranquillisers. Usually a full recovery.