Normal labour and delivery

Question 1

What are the 3 factors which affect progression of labour? [can contribute to Failure of progression]

Answer 1

The Passage (birth canal&raquo_space; eg Pelvic inlet/outlet; Pelvic floor, Pernieum etc…)

The Power

The Passenger (eg Macrosomia + Lie//Presentation//Position)

Question 2

What are the frequency of normal contractions in early and advanced labour?

Answer 2

Every 3-4 minutes in early labour

Every 2-3 minutes in advanced labour

Question 3

What are the 3 factors which are at play by “the passenger” during delivery

Answer 3

LIE // PRESENTATION // POSITION:

Lie = relationship of fetal long axis of the baby to that of the mother
» Longitudinal. Oblique. Transverse.

Presentation = the part of the fetus lowermost in the uterus
» Cephalic [vertex, brow, face]. Breech. Shoulder.

Position = relation of the fetal denominator to the maternal pelvis
»Occipitoanterior, Occipitotransverse, Occipitoposterior
» (Denominator = part of fetus used as reference point to describe position in maternal pelvis)&raquo_space; Occiput. Mentum. Sacrum. Acromion.

Question 4

What are the stages of fetal movements in labour?

Answer 4

1. Engagement
2. Flexion
3. Descent
4. Internal rotation
5. Extension
6. External rotation

Question 5

What features of the mother are monitored in labour?

Answer 5

Obs&raquo_space; BP, Pulse, Temp
Hydration, Analgesia, Antacids, Bladder care, Position

Progress:
* Contractions
* Cervical dilation
* Descent of presenting part

3rd stage:
* Active management
* Oxytocics and controlled cord traction

Perineum (for tears – include PR exam)

Question 6

What features of the fetus are monitored in labour?

Answer 6

Fetal heart monitor
Colour of liquor

Question 7

Name 5 common problems in labour

Answer 7

Failure to progress
Malpresentation / Malposition
Suspected fetal compromise (Fetal distress)
Vaginal Birth After Caesarean Section (VBAC)
Operative delivery
Shoulder dystocia

Question 8

Give 4 causes of failure to progress

Answer 8

Think&raquo_space; Powers, Passenger, Presentation

Inadequate contractions
Fetal malposition / malpresentation
Cephalopelvic disproportion (relative, absolute)
Obstructed labour
Maternal exhaustion

Question 9

What are the complications associated with a breech presentation?

Answer 9

Trapped aftercoming head

Cord prolapse

Intracranial haemorrhage

Internal injuries

Question 10

Give 4 possible causes of Suspected Fetal Compromise during labour

Answer 10

Uterine hyperstimulation (? iatrogenic)
Hypotension
Poor fetal tolerance of labour (eg IUGR)
Cord compression
Infection
Maternal disease

Question 11

What is the management for Suspected Fetal Compromise?

Answer 11

Rectify reversible causes (eg Maternal hypotension)

Left lateral position

Stop Oxytocics

Confirm compromise by blood sampling (Fetal Scalp Blood Sampling) where possible delivery by speediest route if unable to correct or if significant acidosis

Question 12

Give 3 pre-cautions used during Vaginal Birth After Caesarean (VBAC)?

Answer 12

IV access + G&S
Continuous electronic fetal monitoring
Avoid prolonged labour
Augmentation / Induction should be senior decision only

Question 13

Give 2 indications for Operative delivery (Ventouse/Forceps)

Answer 13

Failure to progress in 2nd stage
Fetal distress in 2nd stage
Maternal reasons

Question 14

Give 2 complications associated with Operative delivery (Ventouse/Forceps)

Answer 14

Failure
Fetal trauma (eg Subaponeurtoic haematoma with Ventouse delivery)
Maternal trauma
Postpartum hemorrhage
Urinary retention

Question 15

What is a Cephalohaematoma?

Answer 15

Cephalohaematoma = Subperiosteal swelling on fetal head (boundaries are therefore limited by bone margins). [COLLECTION OF BLOOD]
* It is fluctuant
* Spontaneous absorption (may cause or contribute to Jaundice)

Question 16

What is a Caput Succedaneum

Answer 16

Caput succedaneum = Oedematous swelling of the scalp, superficial to the cranial periosteum (which does not, therefore, limit its extent) [OEDEMATOUS SWELLING]

Question 17

What is a Subaponeurotic Haematomia?

Answer 17

Subaponeurotic haematoma = blood lies between the aponeurosis and the periosteum.
* Haematoma is not confined to the boundaries of one bone, collections of blood may be large enough to result in anaemia or jaundice.
* They are associated with Vacuum extractions.

Question 18

Give 4 symptoms of intracranial haemorrhage in babies

Answer 18

Babies affected may have:

Convulsions,
Apnoea,
Cyanosis,
Abnormal pallor,
Low heart rate,
Alterations in muscle tone,
Restlessness, somnolence, or
Abnormal movements

Question 19

Give 3 indications for Caesarean section

Answer 19

Failure to progress
Fetal distress
Malpresentation / Malposition
Failed instrumental delivery

Question 20

Give 4 complications of Caesarean section

Answer 20

Haemorrhage, Infection
Bladder/Bowel injury
Thromboembolic disease
Requirement for blood transfusion

TTN (Transient tachypnoea of newborn)
Fetal trauma

Question 21

What scoring system is used to indicate whether mothers will go into labour soon?

Answer 21

Bishop score
>=8 indicates induction of labour is likely to be successful
<5 indicates induction of labour likely to be of benefit

Question 22

What are the components of the Bishop score?

Answer 22

Dilation
Effacement
Station
Consistency
Position

Question 23

What are the risks of shoulder dystocia? (give 3)

Answer 23

Fetal death
Asphyxia with resulting hypoxic damage
Birth trauma (Erb’s palsy, Fractured clavicle)
Maternal trauma (Soft tissue trauma, psychological)

Question 24

What are the substages in the first stage of labour

Answer 24

Latent phase – there are painful, often irregular contractions, the cervix initially effaces (becomes shorter and shorter) then dilates to 4cm

Established phase – regular contractions with dilation from 4cm
o Satisfactory rate from 4cm is 0.5cm/h
 1st stage generally takes 8-18h in a primip and 5-12h in a multip

Question 25

What is monitored during the first stage of labour?

Answer 25

Maternal BP + Temp 4 hourly.
Pulse hourly.

Assess contractions every 30 minutes, their strength (you should not be able to indent the uterus on abdominal palpation during a contraction)

Note frequency of bladder emptying

Offer vaginal examination (eg every 4h to assess the degree of cervical dilation, the position, and the station of the head (measured in cm above or below the ischial spines) and note the degree of moulding

Note the state of the liquor
Auscultate fetal heart rate (if not continuously monitored), by Pinard or Doppler every 15 minutes, listening for 1 minute after a contraction

Question 26

What are the substages of the second stage of labour

Answer 26

Passive stage – this is complete cervical dilation but no pushing.
o This is seen particularly in women with epidural anaesthesia where 1-2h of passive stage is recommended to reduce the instrumental delivery rate.

Active stage – maternal pushing uses abdominal muscles and the Valsalva manoeuvre until the baby is born

Question 27

What monitoring is performed during the second stage of labour

Answer 27

Check BP + Pulse hourly.
Temperature 4 hourly.

Assess contractions every 30 minutes

Auscultate for 1 minute after a contraction every 5 minutes

Offer vaginal examination hourly
Record urination during 2nd stage.

Question 28

What drug should be given in the third stage of labour to reduce incidence of post-partum haemorrhage

Answer 28

Syntometrine (Ergometrine maleate 500mcg IM + Oxytocin 5iu IM)

Note, Ergometrine is contraindicated in:
Pre-eclampsia,
Severe hypertension,
Severe liver or renal impairment, and
Severe heart disease.

If BP isnt measured in labour&raquo_space; just give Oxytocin