Labour Mx (include operative del)

Question 1

Mx of prolonged 2nd stage with NRCTG

Answer 1

Hx
- emergency, hx need to be brief
- parity, gestation
- AN course - cx, fetal size
- analgesia, UOP, liquor
- partogram, CTG indication/abn

Exam
- vitals
- abdominal palpation (?head above)
- vaginal examination
dilation/station/position/descent/maternal effort

Decision & consent for instrumental delivery
Discuss with senior consultant

Question 2

Perform a pudendal

Answer 2

• consent
• clean area
• identify ischial spine bilaterally
  finger breadth into the vag 4 & 8’oclock
• LA infiltration (aspirate/inject) either
• 1cm anterior medial from IS
• 1cm posterior medial from IS
• Bilaterally
• Perineal infiltration
• Make sure IDC inserted
• Wait time to work

Question 3

Performing an instrumental delivery

Scenario 1 - 48/24 PPROM - NRCTG needing delivery

Answer 3

• AN hx/Progress
• Indication
• CTG/Contraction ?synt/IDC
• VE - present/position/cap/mould/liqu
• RFs - ? trial in OT, BMI/LGA/+1
• OT availability
• Consent
• Lithotomy
• Empty bladder
• Perineal hygiene
• Perineal or pudendal LA infiltration
• Neonatologist/Scribe
• PPH kit/suture trolley ready

NBFD
- check blades unlock
- blades btw contraction
- posterior fontanelle midway
- no rotations
- max 3 pulls (if fail -> emCS)
- RMLE once head on perineum

Ventouse
- 6cm from anterior fontanelle
- 3cm from posterior fontanelle (OA)
- evenly across sagittal sutures
- no vaginal tissue caught
- let chignon formation
- axial traction/finger on head/cup
- max 3 pulls to pelvic floor
- abort if not achieved

Question 4

Mx of shoulder dystocia

Scenario 1 - in setting of instrument delivery, presumed episiotomy already cut

Answer 4

• Emergency = call for help - anticipate difficult delivery & PPH
• MDI - Obs/MW/Paed +/ - anaesthetic
• Scribe - call out time - instruct to stop pushing (# risk) - flatten bed
• McRoberts - knee to chest (flexion/abduction of hip)
• Suprapubic pressure - on side of baby’s back, downward lateral for up to 30s
• Internal maneuvers - Rubin II (push anterior shoulder from behind) - > add woodscrew (push posterior shoulder from front) -> then reverse woodscrew (push posterior shoulder from behind)
• Posterior arms - wrist -> withdraw in a straight line or flex elbow - sweep arm across the chest
• All fours position

Maneuvers of last resort
- Cleidotomy - clavicular #
- Maternal symphysiotomy
- Zavanelli - push head back into birth canal for emCS
- GA - uterine muscle relaxation

Cord gases required after birth
Accurate documentation of head/shoulder position/timing of delivery/cord gases/APGARs/maneuvers used/PPH/injury/staff involved

Question 5

Mx of foetal bradycardia

Answer 5

DDx
- cord prolapse
- rapid descent
- uterine rupture
- abruption
- uterine hyperstimulation by hypertonus

Mx
- emergency
- call for help
- may req MDI
- simultaneous ax & mx
- maintain communication with pt/team
- VE to exclude cord & ?deliverable
- intrauterine resus - synt/IVT/left lat
+/- terbuatline if del not imminent
- response to intrauterine resus
+/- code green
- bFHR prior to event/predisposing
- bFHR post event
- ongoing labour mx plan

Question 6

Preterm labor check list

Answer 6

• MDI - Obs/MW/Paeds
• Inform consultant/Paeds
• Transfer out or keep
• CEFM/RTS
• IV Benpen
• +/- steroids +/- MgSo4
• IVT/analgesia
• Caution with vacuum