Management of labour and delivery

Question 1

Go through the normal stages/mechanisms of labour

Answer 1

• Term 37-42 wks gestation
• The mucus plug usually detaches before labour begins. It is called a “show” – jelly like and often blood streaked.
• Stage 1
  
  • Latent/Initial
    
    • Labour starts when regular and painful contractions start and the cervix starts to efface (thins and shortens)
    • Cervix is stretched by baby head, which signals hypothalamus + post pit to release oxytocin–> stimulates uterine contractions–> cervix stretches and so on. Also the placenta produces prostaglandins–> stimulates uterine contractions
    • The cervix will begin to efface and dilate
    • This stage shouldn’t go on longer than 20 hrs primip/ 14 hrs multip (failure to progress) but this is usually managed conservatively if there is no sign of fetal compromise
  • Active/Established:
    
    • Once the cervix reached 3cm dilated this is known as the active phase of labour
    • Contraction become more regular and painful
    • Full dilation = 10cm
    • If this stage does not progress at, at least 0.5 cm/hr (14 ish hours overall) it is deemed failure to progress and may be treated e.g. AROM syntocinon/oxytocin
• Stage 2
  
  • This is from full dilation to birth of baby i.e. the pushing part
• The amniotic sac may rupture (waters breaking) spontaneously (SROM) anytime during stage 1 or 2 due to increased uterine pressure or they may be ruptured artificially (AROM) as a means to speed up labour as the babies head may be bouncing on a sac of fluid and not on the cervix thereby not stimulating oxytocin–>uterine contractions–>slowing labour down. The liquor/amniotic fluid should be clear if green that means it is meconium stained, which is bad as it may lead to fetal meconium aspiration
• Stage 3
  
  • Placenta delivery
  • This may be physiological i.e. no intervention or active where the woman is given an injection of syntocinon (oxytocin) or syntometrine (combo of syntocinon i.e. oxytocin and ergometrine this one is contraindicated in high BP)
  • These drugs serve the dual purpose of helping the placenta detach and constricting blood vessels preventing PPH
  • Cord blood is taken for pH analysis

Question 2

Cardinal positions (picture from side)

Answer 2

1. Engagement.
2. Descent.
3. Flexion.
4. Internal rotation.
5. Extension.
6. Restitution and external rotation.
7. Expulsion.

Question 3

Cardinal positions (picture from vag)

Answer 3

1. Engagement
2. Descent
3. Flexion
4. Internal rotation
5. Extension
6. Restitution and external rotation
7. Expulsion

Question 4

Methods of induction and augmentation of labour

Answer 4

• AROM
• Cervical sweep – used to stimulate prostaglandin release and initiate labour
• Syntocinon
• Syntometrine – only used for active management of third stage of labour
• Birthing positions (upright positions)
• Propess – prostaglandin pessary
• Emptying bladder

Question 5

What is included in a partogram (monitoring fetal and maternal well being)

Answer 5

• Fetal heart rate
• Maternal heart rate
• Presence and colour of amniotic fluid
• Temperature
• Blood pressure
• Urinanalysis
• Frequency strength and regularity of contractions
• Cervical dilation
• Head descent
• CTG check

Question 6

Pain relief options in labour

Answer 6

• Gas and air (oxygen and nitrous oxide)
• Pethidine injections (not used in second stage of labour)
• Epidural
• Alternative e.g. acupuncture, aromatherapy, massgae
• Paracetamol
• Codeine

Question 7

Top deviations from normal labour

Answer 7

• Prolongation of any stage (failure to progress)
• Meconium stained liqour
• PPH
• Shoulder distocia
• Breech
• C section
• Assisted delivery
• 3/4th degree tear
• Induction
• Pre-term
• Overdue

Question 8

Operative vaginal delivery (assisted): indications, methods, complications

Answer 8

Indications

• Fetal compromise
• Shorten second stage of labour due to maternal health e.g. cardiac disease, hypertensive crisis
• Failure to progress
• Maternal fatigue

Methods

• Ventouse
• Forceps
• Episeotomy

Complications

• Trauma to baby head and neck
• Trauma to vagina, perineum, pelvic floor and other pelvic contents
• Infection
• Bleed

Question 9

Caesarian section: indications, procedures and complications

Answer 9

Indications

• Fetal distress
• Malpresentation (breech)
• Cephalopelvic disproportion
• Severe hypertension
• Multiple pregnancy
• Maternal infection e.g. HIV
• Previous C-secttion
• Failure to induce labour

Procedures

• Traditional (vertical midline)
• Lower uterine segment c-section (LUCS) most common horizontal
• C-section hysterectomy

Complications

• Bleed
• Infection
• Clots
• Trauma to other organs