Obstetrics Pt.3 Flashcards

Question 1

Q

How is Rubella spread?

Why is its perinatal infection uncommon?

Answer

A

Togavirus spread by droplet transmission

- Very uncommon in the UK thanks to MMR

Question 2

Q

Describe Rubella screening

Answer

A

Prevalence of rubella has reached such low levels in the UK that screening is NO LONGER ROUTINELY OFFERED
For women who are screened and rubella antibody is NOT detected, they should be offered the MMR after pregnancy
NOTE: the vaccine itself is contraindicated in pregnancy because it is a live vaccine

Question 3

Q

What are the clinical features of Congenital Rubella Syndrome?

Answer

A

Sensorineural deafness
Congenital cataracts
Blindness
Encephalitis
Endocrine problems

Question 4

Q

What is the risk of CRS?

Answer

A

The risk of CRS decreases with gestation and the manifestations are less severe
Rubella infection before 11 weeks has 100% risk of CRS
Rubella infection > 20 weeks has no risk of CRS

Question 5

Q

What is the management of CRS?

Answer

A

If infection during pregnancy is confirmed, risk of CRS should be assessed
If it has occurred < 16 weeks, termination of pregnancy should be offered

Question 6

Q

What is Syphilis and its clinical features?

Answer

A

Caused by Treponema pallidum

Clinical Features
- Painless genital ulcer 3-6 weeks after infection is acquired (condylomata lata)

NOTE: this may be on the cervix and hence go unnoticed
Secondary manifestations occur 6 weeks to 6 months after infection with a maculopapular rash or lesions affecting the mucous membranes
If untreated, some will develop symptomatic cardiovascular tertiary syphilis and some will develop neurosyphilis
In pregnant women with early, untreated syphilis, most infants will be infected and 25% will be stillborn

Question 7

Q

What are the risks of syphilis in pregnancy?

Answer

A

FGR
Foetal hydrops
Congenital syphilis (may cause long-term disability)
Stillbirth
Preterm birth
Neonatal death
IMPORTANT: adequate treatment with benzathine penicillin markedly improved the outcome for the foetus

Question 8

Q

Describe Syphilis Screening in pregnancy

Answer

A

Routine antenatal screening is offered for ALL pregnant women
Treponemal antibodies are detected in serology
Non-treponemal tests detect non-specific treponemal antibodies
- Venereal disease research laboratory (VDRL) test
- Rapid plasma reagin test (RPR)
- NOTE: they have a high false-positive rate
Treponemal tests detect specific treponemal
- EIAs
  - Very sensitive and specific
- Treponema pallidum haemagglutination assay (TPHA)
- Fluorescent treponemal antibody-absorbed test (FTA-abs)
IMPORTANT: none of these tests will detect syphilis in the incubation stage

Question 9

Q

What is the management of syphilis in pregnancy?

Answer

A

Confirm the diagnosis and test for other STIs
GUM clinic should initiate appropriate contact tracing
Parenteral penicillin (benzathine penicillin) has a 98% success rate at preventing congenital syphilis
A Jarish-Herxheimer reaction may occur with treatment as a result of the release of proinflammatory cytokines in response to dying organisms
- Causes worsening of symptoms and fever for 12-24 hours after starting treatment
- May be associated with uterine contractions and foetal distress
- So, women may be admitted during treatment for monitoring
If the woman is NOT treated during pregnancy, the baby should be treated after delivery immediately

Question 10

Q

What is Toxoplasmosis?

Answer

A

Caused by Toxoplasma gondii which is a protozoan found in cat faeces, soil or uncooked meat
1/3 of people in the UK are probably infected with Toxoplasma at some point in their lives

Question 11

Q

Is toxoplasmosis screening offered?

Answer

A

NOT offered routinely because it is very rare for babies to be affected
Little evidence for the benefits of screening

Question 12

Q

What is some advice about toxoplasmosis prevention?

Answer

A

Avoiding eating rare or raw meat
Avoiding handling cats and cat litter
Wearing gloves and washing hands when gardening or handling soil

Question 13

Q

What are the clinical features of toxoplasmosis?

How does foetal damage and transmission rate change during pregnancy?

Answer

A

Initial infection is usually ASYMPTOMATIC or may cause flu-like illness
Parasitaemia occurs within 3 weeks
Infection in the first trimester is most likely to cause severe foetal damage but the transmission rate is low (10%)
In the third trimester, the transmission rates are much higher (85%) but the risk of foetal damage is low (10%)

Question 14

Q

What are the features of Severely Affected Infants of Toxoplasmosis?

Answer

A

Ventriculomegaly
Microcephaly
Chorioretinitis
Cerebral calcification
NOTE: most infants are asymptomatic at birth and develop symptoms later on

Question 15

Q

What is the management of toxoplasmosis?

Answer

A

`- Diagnosis is made by the Sabin Feldman Dye Test

NOTE: IgM antibody tests are also available but IgM may persist for months or years after infection
If an abnormal US raises suspicion of congenital toxoplasmosis, amniocentesis can be performed
PCR of amniotic fluid is highly accurate for identification of T. gondii
Spiramycin treatment can be used in pregnancy (3 week course of 2-3 g/day)
This reduces incidence of transplacental infection
If toxoplasmosis is found to be the cause of abnormalities on ultrasound, termination of pregnancy should be offered

Question 16

Q

What is cytomegalovirus?

Answer

A

CMV is a DNA herpes virus transmitted by the respiratory droplet route and excreted in the urine
60% of women are seropositive for CMV when they become pregnant
1-2 out of 200 infants in the UK are born with congenital CMV
Some will have problems at birth (e.g. hearing loss, learning difficulties) and others will be asymptomatic but go on to develop problems later on
Primary infection is more likely to cause congenital CMV

Question 17

Q

What are the clinical features of cytomegalovirus?

Answer

A

Primary infection usually produces no symptoms or mild flu-like symptoms in the mother
Diagnosis is usually made after abnormalities are seen on the ultrasound
Features in the foetus
- Growth restriction
- Microcephaly
- Intracranial calcification
- Ventriculomegaly
- Ascites
- Hydrops
Infants may present later with blindness, deafness or developmental delay
The neonate can also be anaemic and thrombocytopaenic with hepatosplenomegaly, jaundice and a purpuric rash

Question 18

Q

What is the management of CMV?

Answer

A

Serological diagnosis (CMV antibodies in an initially seronegative woman)
NOTE: IgM can persist for several months so IgM is insufficient to diagnose infection, it has to be a new finding in a woman who was IgM negative at the time of booking
The amniotic fluid can be tested by PCR
If abnormalities suggestive of congenital CMV are detected, termination of pregnancy should be discussed
CMV is a herpes virus, so it can be latent and be reactivated
It persists in the lymphocytes throughout life
Reactivation occurs via shedding in the genital, urinary or respiratory tract

Question 19

Q

What virus causes chickenpox?

What can chickenpox cause?

Answer

A

Caused by varicella zoster virus (VZV) which is transmitted by droplets and direct personal contact
Screening is NOT routinely recommended
Women identified as being seronegative can be considered for vaccination either prepregnancy or in the postnatal period
It can cause foetal varicella syndrome

Question 20

Q

What are complications of chickenpox in pregnant women?

Answer

A

Pneumonia
Hepatitis
Encephalitis
Non-immune pregnant women are more vulnerable to complications of chicken pox
The mortality rate is 5 times high in pregnant women compared to non-pregnant adults

Question 21

Q

What is the advice for pregnant women regarding chickenpox?

Answer

A

Asked whether they have had chickenpox before at the booking visit
If NOT, be advised to avoid contact during pregnancy
If they do come into contact with chickenpox, they should seek medical advice ASAP
Significant contact is defined as being in the same room as someone for 15 mins or more, or face-to-face contacts
Individuals with the virus are infectious 48 hours prior to the appearance of the rash until the vesicles crust over (around 5 days)
VZV IgG can be detected to confirm VZV immunity

Question 22

Q

How should non-immune women with chickenpox be managed?

Answer

A

Given VZIG as soon as possible
- It is effective when given up to 10 days after contact
Women should be advised to inform the doctor if a rash develops

Question 23

Q

How is chickenpox in pregnancy managed?

Answer

A

Avoid contact with other pregnant women and neonates until the lesions have crusted over
Aciclovir 800 mg 5/day for 7 days should be prescribed if they present within 24 hours of the onset of the rash and they are > 20 weeks gestation
VZIG has NO therapeutic benefit once chickenpox has developed
Hospital admission should be considered if the following risk factors are present: smoking, chronic lung disease, corticosteroids or in latter half of pregnancy
Women who are hospitalised should be nursed in isolation from babies and pregnant women
Delivery during the viraemic period may be EXTREMELY HAZARDOUS
Patients should be given supportive treatment with IV aciclovir

Question 24

Q

What are the risks of chickenpox in pregnancy?

Answer

A

Thrombocytopaenia
DIC
Hepatitis
Varicella infection of the newborn

Question 25

Q

What is Congenital Varicella Syndrome?

Answer

A

Characterised by one or more of the following:
- Skin scarring in a dermatomal distribution
- Eye defects (microphthalmia, chorioretinitis, cataracts)
- Hypoplasia of the limbs
- Neurological abnormalities (microcephaly, cortical atrophy, mental restriction and dysfunction of bowel and bladder sphincters)
This occurs in a minority of infected foetuses (1%)
No cases have been reported if maternal infection has occurred after 28 weeks
If the mother has contracted chickenpox during the pregnancy, referral to foetal medicine specialist should be considered at 16-20 weeks or 5 weeks after infection for discussion and detailed ultrasound examination
- NOTE: 5 week time lag is required as it takes time for features to manifest

Question 26

Q

How should maternal infection around the time of delivery be managed?

Answer

A

Significant risk of varicella of the newborn
Elective delivery should be avoided until 5-7 days after the onset of the rash to allow time for passive transfer of antibodies to the foetus
Neonatal ophthalmic examination done after birth
If birth occurs within 7 days of the onset of the rash or the mother develops chickenpox within 7 days of delivery, the neonate should be given VZIG
The infant should be monitored for signs of infection until 28 days after the onset of maternal infection
Neonatal infection should be treated with aciclovir

Question 27

Q

Is contact with shingles a problem?

Answer

A

Low risk of a non-immune pregnant woman getting chickenpox from someone with shingles

Question 28

Q

What is parvovirus infection and how is it transmitted?
What percentage of women are immune?
Is screening recommended?

Answer

A

Caused by parvovirus B19 which is transmitted through respiratory droplets
50% of women of child-bearing age are immune and 50% are susceptible
Routine screening is NOT recommended

Question 29

Q

What are the clinical features of parvovirus?
When is the foetus most vulnerable?
What are complications of the virus and how is this investigated?

Answer

A

Asymptomatic or cause a mild flu-like illness and/or arthropathy
In children it causes slapped cheek syndrome (aka fifth disease, erythema infectiosum)
Foetus is most vulnerable in the second trimester
In most foetuses infected with parvovirus, there will be spontaneous resolution with no long-term sequelae
However, the infection can cause aplastic anaemia
The anaemic foetus could be come hydropic due to high output cardiac failure and liver congestion
Seen on ultrasound (high velocity in the foetal middle cerebral artery suggests anaemia)

Question 30

Q

How is parvovirus diagnosed?
When is foetal loss due to virus higher?
How is the virus managed?

Answer

A

Diagnosed by serology in mother (development of IgM antibodies to Parvovirus B19) having previously tested negative
PCR of virus in maternal and foetal serum/amniotic fluid is the most accurate test
A hydropic foetus may recover spontaneously or may require in utero transfusion
Infection in the first 20 weeks can lead to hydrops fetalis and intrauterine death (intrauterine transfusion is not possible at early gestations)
Foetal loss rate is much higher (10%) in the first 20 weeks
If the anaemia is treated by in utero transfusions, the foetus can make a complete recovery
Parvovirus does NOT cause neurological damage so if they survive the anaemia the outcome is usually normal

Question 31

Q

What is Listeria?

Where does it originate?

Answer

A

Caused by Listeria monocytogenes which is an aerobic and facultatively anaerobic motile Gram-positive bacillus
It is an obligate intracellular parasite
People with reduced cell-mediated immunity (i.e. pregnant women) are most at risk
Incidence of Listeria infection in pregnant women is 18 x higher than in the non-pregnant population
Usually comes from contaminated food, most commonly:
- Unpasteurised milk
- Ripened soft cheeses
- Paté
Listeria does NOT survive in cooked or frozen food but can survive in refrigerated food (e.g. milk, soft cheese, prawns)

Question 32

Q

What are the clinical features of Listeria?
How does transmission to the foetus occur?
What are Listeria complications in pregnancy?

Answer

A

Flu-like illness with fever and general malaise
1/3 of women will be asymptomatic
Transmission to the foetus can occur via:
- Ascending route through the cervix
- Transplacental
20% of affected pregnancies result in miscarriage or stillbirth
50% result in premature delivery
38% neonatal mortality (due to respiratory distress, fever, sepsis or neurological symptoms)

Question 33

Q

What is the management of Listeria?

Answer

A

Diagnosed by isolation of the organism from blood, vaginal swabs or the placenta
Meconium staining of amniotic fluid may raise suspicion
IV antibiotics (AMPICILLIN 2 g every 6 hours)

Question 34

Q

What is Malaria?
Which pregnant women have increased risk of malaria?
Why may the parasite be missed in blood films?

Answer

A

Plasmodium falciparum carries the worse prognosis for mother and foetus
Most common in sub-Saharan Africa
Pregnant women have an increased risk of infection (especially if primiparous)
The parasite can sequestrate in the placenta (and be missed by blood films)

Question 35

Q

What are the clinical features of Malaria?

Answer

A

Pyrexia
Associated with miscarriage and preterm labour
Hypoglycaemia is common and may be severe in pregnancy
Pulmonary oedema can occur (high mortality)
Jaundice
Renal failure

Question 36

Q

What are the effects of Malaria on the foetus?

Answer

A

Preterm delivery
FGR
Higher rate of HIV transmission

Question 37

Q

What is the management of Malaria?

Answer

A

Symptomatic and supportive treatment
Antimalarials (depends on drug resistance and local patterns of disease)
Pregnant women planning to travel to endemic areas should be counselled about insecticides, mosquito nets and appropriate clothing

Question 38

Q

Describe herpes in pregnancy

Answer

A

This is DANGEROUS if acquired around the time of delivery
Double-stranded DNA virus
Neonatal herpes has a high morbidity and mortality
It occurs due to contact with infected secretions

Question 39

Q

What are the clinical features of herpes?

What are the subgroups of neonatal herpes?

Answer

A

Genital herpes causes ulcerative lesions on the vulva, vagina and cervix
Primary infection is usually more severe and can cause systemic symptoms and urinary retention
Neonatal herpes can be caused by HSV1 and HSV2
Neonatal herpes has THREE subgroups:
- Localised to the skin, eye and mouth
- Local central nervous system disease (encephalitis alone)
- Disseminated infection with multiple organ involvement
Risk is greatest when the woman acquires a new infection (primary genital herpes) particularly within 6 weeks of delivery

Question 40

Q

What is the general management of herpes?

Answer

A

Swab to diagnose HSV
If herpes suspected, refer to a genitourinary physician to confirm the diagnosis by viral culture and PCR
Aciclovir (400 mg tds) is recommended
For women presenting within 6 weeks of expected delivery, type-specific HSV antibody testing is advisable

Question 41

Q

What is the management of primary infections of herpes in pregnancy?

Answer

A

If the infection occurs before the 6 weeks prior to expected delivery, the pregnancy should be managed expectantly and vaginal delivery anticipated
C-section for ALL women developing first-episode genital herpes in the 3rd trimester (particularly if within 6 weeks of delivery)
If the woman chooses vaginal delivery, rupture of membranes and invasive procedures should be avoided
IV aciclovir should be given intrapartum to the mother

Question 42

Q

What is the management of recurrent episodes of herpes?

Answer

A

Aciclovir 400 mg tds considered from 36 weeks gestation
Recurrent episodes occurring during pregnancy is NOT an indication for delivery by C-section
Invasive procedures during labour should be avoided if there are genital lesions

Question 43

Q

What is Group B Streptococcus?

When does transmission occur?

Answer

A

Streptococcus agalactiae is a Gram-positive coccus
It is a vaginal commensal that can cause sepsis in the neonate
Transmission occurs between the time of rupture of membranes to delivery
It is the most common cause of severe early-onset (within 7 days of delivery) infection in newborns
21% of women carry GBS as a commensal
Routine screening is NOT carried out in the UK

Question 44

Q

What are the clinical features of Group B Streptococcus?

Answer

A

The mother does NOT experience symptoms because GBS is a commensal
Sepsis in the neonate
- Collapse
- Tachypnoea
- Nasal flaring
- Poor tone
- Jaundice

Question 45

Q

What is the management of Group B Streptococcus?

Answer

A

Antenatal
- If detected incidentally, antenatal treatment is NOT recommended because it does not reduce the likelihood of GBS colonisation at the time of delivery
Intrapartum antibiotic prophylaxis
- Infection of the neonate occurs during labour
- Antibiotics (penicillin or clindamycin) given in labour are 60-80% effective in reducing early-onset neonatal GBS infection
- IV penicillin 3 g should be given as soon as possible after the onset of labour and 1.5 g four-hourly until delivery
- Clindamycin 900 mg should be given IV 8 hourly if allergic to penicillin
Women undergoing an elective C-section in the absence of labour or membrane rupture do NOT need antibiotic prophylaxis

Question 46

Q

What are risk factors requiring GBS prophylaxis?

Answer

A

Intrapartum fever
Prolonged rupture of membranes greater than 18 hours
Prematurity less than 37 weeks
Previous infant with GBS
Incidental detection of GBS in current pregnancy
GBS bacteriuria

Question 47

Q

How does GBS affect the Neonate?

Answer

A

Symptoms occur at or soon after birth
Neonatal sepsis can rapidly kill
Blood cultures should be obtained before antibiotics are commenced
Antibiotics should be given based on trust guidelines

Question 48

Q

What is Chlamydia caused by?
Is there screening?
When does transmission occur and what are complications of chlamydia in the infant?

Answer

A

Caused by Chlamydia trachomatis which is an obligate intracellular organism
NOT routinely screened
Women under the age of 25 booking for antenatal care should be informed about the National Screening Programme
Transmission occurs at the time of delivery
Transmission can cause conjunctivitis and pneumonia in the infant

Question 49

Q

What are the clinical features of chlamydia in pregnancy?

What are the pregnancy risks?

Answer

A

Often asymptomatic in pregnancy
Risks
- Preterm rupture of membranes
- Preterm delivery
- LBW

Question 50

Q

What is the management of chlamydia?

Answer

A

Azithromycin or erythromycin

- NOTE: tetracyclines should be avoided in pregnancy

Question 51

Q

What is gonorrhoea caused by?

How does infection present?

Answer

A

Caused by Neisseria gonorrhoeae which is a Gram-negative diplococcus
Infection is often asymptomatic or may present with mucopurulent discharge or dysuria
Transmission occurs at the time of delivery and can cause ophthalmia neonatorum

Question 52

Q

What are the risks of gonorrhoea?

Answer

A

Preterm rupture of membranes

- Preterm birth

Question 53

Q

What is the management of gonorrhoea?

Answer

A

Bacteriological swabs should be taken
Cephalosporins are effective against gonococcus
Empirical treatment for chlamydia should also be considered
Contact tracing should be arranged via a GUM clinic

Question 54

Q

When does HIV transmission occur?

Answer

A

Vertical transmission mainly occurs in the late third trimester, during labour, delivery or breast feeding
Part of routine antenatal screening

Question 55

Q

What are clinical features of HIV?

Answer

A

Begins with an asymptomatic stage
Followed by gradual compromise of immune function leading to AIDS
The interval from HIV to AIDS can be very long

Question 56

Q

What is the management of HIV in the mother?

Answer

A

The risk of vertical transmission is affected by maternal viral load, obstetric factors and infant feeding
Reducing the risk of vertical transmission
- Antiretroviral therapy (antenatally and intrapartum in the mother, for the first 4-6 weeks of life for the baby)
- Delivery by elective C-section in the presence of high viral load
- Avoid breastfeeding
Planned vaginal delivery is possible if mother’s viral load < 50 copies/mL at 36 weeks gestation
C-section recommended in women with hepatitis C coinfection
Women with a high viral load should receive IV azidothymidine (AZT) if they are undergoing a planned C-section or present with spontaneous rupture of membranes

Question 57

Q

What is the management of HIV in the infant?

Answer

A

Cord clamped ASAP and the baby bathed immediately after birth
Advised not to breastfeed baby
All infants given azidothymidine for 4-6 weeks after birth
Neonates test positive for HIV antibodies because of passive transfer from the mother
HIV diagnosis in the neonate requires PCR (normally carries out at birth, 3 weeks, 6 weeks and 6 months)

Question 58

Q

What Hepatitis B and how is it mainly transmitted?
Is it part of the routine screening?
How can transmission be prevented?

Answer

A

DNA virus that is mainly transmitted in the blood, but also saliva, semen and vaginal fluid
It is part of the routine screening for pregnant women
High rate of vertical transmission in women who are positive for HBeAg
Transmission is 95% preventable through administration of the vaccine and immunoglobulin at birth

Question 59

Q

What are the clinical features of Hepatitis B?

Answer

A

Many people have no symptoms

- The incubation period can be 6 weeks to 6 months

Question 60

Q

How and when can HepB vertical transmission be reduced?

Answer

A

Hepatitis B immunoglobulin and the vaccine help reduce vertical transmission
The immunoglobulin should be given immediately after delivery
The vaccine is given at birth, 1 month and 6 months

Question 61

Q

In what conditions is the risk of HepC transmission increased?
Is HepC included in routine screening?

Answer

A

Risk of transmission is higher in HIV co-infection

- NOT part of routine screening

Question 62

Q

What are the clinical features of Hepatitis C?

Answer

A

Can lead to cirrhosis and hepatocellular carcinoma

- 80% are asymptomatic

Question 63

Q

What is the management of Hepatitis C?

Answer

A

Detect anti-HCV antibodies
Confirm with PCR for the virus
In non-pregnant adults, administer interferon and ribavirin (CONTRAINDICATED in pregnancy)

Question 64

Q

What are the three stages of labour?

Answer

A

1st STAGE: begins with the onset of contractions and ends when full cervical dilatation has been reached
2nd STAGE: begins with full cervical dilatation and ends with the birth of the baby
3rd STAGE: begins with the birth of the baby and ends with complete delivery of the placenta and membranes

Answer 65

A

Powers
Passage
Passenger
If any of these three are abnormal, it is likely to result in an abnormal delivery

Answer 66

A

Anteriorly - upper border of the symphysis pubis
Laterally - upper margin of the pubic bone, ileopectineal lien and the ala of the sacrum
Posteriorly - promontory of the sacrum

Answer 67

A

Transverse = 13.5 cm
Anterior-posterior = 11.0 cm
The foetal head usually enters the pelvis orientated in the transverse position

Answer 68

A

The angle of the inlet is normally 60 degrees to the horizontal
NOTE: this can be higher in Afro-Caribbean women

Answer 69

A

Described as the area bounded anteriorly by the middle of the symphysis pubis , laterally by the pubic bones, the obturator fascia and the inner aspect of the ischial bone and spines, and posteriorly by the junction of the second and third sections of the sacrum
The midpelvis is almost round (similar transverse and anterior-posterior diameter of around 12 cm)

Answer 70

A

To assess descent of the presenting part on vaginal examination
- Station zero is at the level of the ischial spines
- Instrumental delivery is only possible if the foetal head has reached the level of the ischial spines or below
To provide a local anaesthetic pudendal nerve block (this may be used for a vacuum or forceps delivery)

Answer 71

A

Anteriorly - lower margin of the symphysis pubis
Laterally - descending ramus of the pubic bone, ischial tuberosity and the sacrotuberous ligament
Posteriorly - last piece of the sacrum

Answer 72

A

Anterior-posterior = 13.5 cm
Transverse = 11 cm
IMPORTANT: this means that at the inlet, the transverse diameter is widest, then at the outlet, the AP diameter is widest. This means that the foetal head must rotate from a transverse to AP position as it passes through the pelvis
- This usually happens at the midpelvis where the dimensions are roughly equal

Answer 73

A

Pelvic ligaments loosen towards the end of the third trimester, the pelvis becomes more flexible and the diameters may increase during labour
The pelvic dimensions can also be enhanced by changing the maternal position during labour

Answer 74

A

The gynaecoid pelvis is the most favourable for labour and is also the MOST COMMON
The android-type pelvis predisposes to failure of rotation and deep transverse arrest
The anthropoid pelvis encourages an occipito-posterior position
A platypelloid pelvis is also associated with an increased risk of obstructed labour due to failure of the head to engage, rotate or descend

Answer 75

A

Formed by the two levator ani muscles which form a musculofascial gutter during the 2nd stage of labour
This encourages the foetal head to flex and rotate as it descends from the midpelvis to the pelvic outlet

Answer 76

A

This is the final obstacle
The perineal body is a mass of fibrous and muscular tissue lying between the vagina and the anus
This is relatively resistant in the nulliparous woman
Vaginal birth may result in tearing or an episiotomy
The perineum is more stretchy in multiparous women, resulting in faster labour

Answer 77

A

Vault
Face
Base

Answer 78

A

At the time of labour the sutures of the vault are soft, unossified membranes
The sutures of the face and skull base are firmly united
The sutures allow the bones to move and overlap

Answer 79

A

The vault is composed of the parietal bones and parts of the occipital, frontal and temporal bones

Answer 80

A

4 membranous structures

Sagittal
Frontal
Coronal
Lambdoidal

Answer 81

A

Fontanelles are the junctions of the sutures

Answer 82

A

The anterior fontanelle (aka bregma) is at the junction of the sagittal, frontal and coronal sutures

Answer 83

A

The posterior fontanelle lies at the junction of the sagittal suture and the lambdoidal suture (this is smaller and triangular)

Answer 84

A

Allows moulding to occur as the head passes through the pelvis

Answer 85

A

Obstructed labour
Foetal malposition (failure of the head to rotate)
Cephalopelvic disproportion (mismatch between the size of the foetal head and maternal pelvis)

Answer 86

A

The vertex is the area bounded by the two parietal bones and the anterior and posterior fontanelles
In normal labour, this is the presenting part

Answer 87

A

The position of the foetal head in relation to the pubic symphysis
By feeling the position of the anterior and posterior fontanelles on vaginal examination, the foetal head position during labour can be ascertained

Answer 88

A

Occipito-anterior (OA) position

Answer 89

A

Occipito-transverse (OT) position

Answer 90

A

The attitude of the foetal head refers to the degree of flexion and extension of the upper cervical spine
Different longitudinal diameters are presented to the pelvis depending on the attitude of the femoral head
With further extension of the head, the occipito-frontal diameter presents

Answer 91

A

The mento-vertical and is around 13 cm

- This is known as brow presentation and is usually too large to pass through the normal pelvis

Answer 92

A

The submento-bregmatic diameter is from below the chin to the anterior fontanelle (roughly 9.5 cm)
- This is called face presentation
- This can deliver vaginally when the chin is anterior (mento-anterior position)

Answer 93

A

The trigger that initiates human labour is poorly understood
The cervix, which is initially long, firm and closed with a protective mucus plug must soften, shorten, thin out (effacement) and dilate for labour to progress
The uterus must change from a state of relaxation to an active state of regular, strong, frequent contractions to facilitate transit of the foetus through the birth canal

Answer 94

A

Prostaglandins and oxytocin increase intracellular calcium ions, thereby stimulating contraction
Beta-adrenergic compounds and CCBs do the opposite
Unique to the uterus, the actin-myosin interaction occurs along the full length of the filaments so that there is a degree of shortening with each successive interaction
This progressive shortening is called retraction and occurs in the upper part of the uterus
This results in the development of the thicker, actively contracting ‘upper segment’
Meanwhile, the lower segment of the uterus becomes thinner and more stretched
This will eventually result in the cervix being taken up (effacement) into the lower segment of the uterus thereby forming a continuum for the passage of the foetus
There are gap junctions between myometrial cells in the uterus which facilitates the passage of various products of metabolism and electrical current between cells
These gap junctions are absent during pregnancy but appear in abundance at term
The increase in the number of gap junctions allows greater coordination of myocyte activity
Prostaglandins stimulate the formation of gap junctions
Uterine contractions are involuntary
Frequency of contractions varies during labour and with parity
Through most of labour, they occur at intervals of 2-4 minutes
- This is described in terms of frequency within a 10-minute period (e.g. 2 in 10)
The duration of contractions varies from 30-60 seconds
The frequency of contractions can be recorded using a CTG
The amplitude of intrauterine pressure generated with each contraction ranges from 30-60 mm Hg

Answer 95

A

Contains myocytes and fibroblasts separated by ECM
Interactions between ECM components keeps the cervix closed early in pregnancy
Under the influence of hormonal mediators (e.g. prostaglandins), there is an increase in proteolytic activity and a reduction in collagen and elastin
Interleukins cause pro-inflammatory changes with significant invasion of neutrophils
Dermatan sulphate is replaced by hyaluronic acid (more hydrophilic) resulting in an increase in water content of the cervix
This leads to cervical softening/ripening so that when contractions begin, they can bring about effacement and dilatation

Answer 96

A

Suppresses prostaglandin production
Inhibits communication between myometrial cells
Prevents oxytocin release

Answer 97

A

Oestrogen opposes the action of progesterone
Prior to labour, there is a decrease in progesterone receptors and an increase in oestrogen concentration relative to progesterone
Prostaglandin synthesis by the chorion and decidua is enhanced, leading to an increase in calcium in the myometrial cells
The changes in hormones also increases gap junction formation

Answer 98

A

In the placenta

- Potentiates prostaglandins and oxytocin for myometrial contractility

Answer 99

A

Production of oxytocin and cortisol by the foetus also stimulates the conversion of progesterone to oestrogen

Answer 100

A

Ferguson reflex

Answer 101

A

This is a phenomenon where pressure from the foetal presenting part against the cervix is relayed via a reflex arc and results in increased oxytocin release from the maternal pituitary gland
This stimulates uterine contractions, which, in turn, increases pressure on the cervix

Answer 102

A

Strong regular painful contractions resulting in progressive cervical change
In practice, a diagnosis is confirmed when a woman presents with contraction-like pains and the midwife performs a vaginal examination revealing effacement and dilatation of the cervix
Loss of a ‘show’ (blood-stained plug of mucus passed from the cervix) or spontaneous rupture of membranes does NOT define labour

Answer 103

A

Defined as the time from the diagnosis of labour to full dilatation of the cervix (10 cm)

Answer 104

A

Latent phase- ime between the onset of regular painful contractions and 3-4 cm cervical dilatation
- The cervix becomes fully effaced
- Effacement is a process by which the cervix shortens and becomes incorporated into the lower segment of the uterus
- Effacement may begin in the weeks before the onset of labour but is complete by the end of the latent phase
- Effacement and dilatation occur as consecutive events in the nulliparous woman (but may occur simultaneously in the multiparous woman)
- Dilatation is expressed in centimetres from 0 to 10 cm
- The latent phase usually lasts from 3-8 hours
Active phase- time between the end of the latent phase (3-4 cm dilatation) and full cervical dilatation (10 cm)
- Usually lasts 2-6 hours (shorter in multiparous women)
- Rate of cervical dilatation is considered abnormal if it is < 1 cm in 2 hours

Answer 105

A

Defined as the time from full dilatation of the cervix to delivery of the foetus

Answer 106

A

Passive Phase - time between full dilatation and the onset of involuntary expulsive contractions
- There is NO maternal urge
- Foetal head is relatively high in the pelvis
- Duration of 1-2 hours is recommended to allow the head to rotate and descend before active pushing
Active Second stage
- There is maternal urge to push because the foetal head is low causing a reflex to bear down
- This should last no longer than 2 hours in a nulliparous woman

Answer 107

A

From delivery of the foetus until complete delivery of the placenta and membranes
The placenta is usually delivered within minutes of the baby
The third stage lasting > 30 mins is considered abnormal (unless the woman has opted for ‘physiological management’

Answer 108

A

The foetal head normally enters the pelvis in the transverse position
Engagement is said to have occurred when the widest part of the presenting part has passed successfully through the pelvic inlet
In most nulliparous women, this will have occurred prior to labour
If > 2/5 of the foetal head is palpable abdominally, the head is NOT yet engaged

Answer 109

A

During the first stage and passive second stage, descent results from uterine contractions
In the active second stage, voluntary efforts by the mother help push the foetus along

Answer 110

A

As the head descends into the narrower midpelvis, flexion of the head occurs
This reduces the presenting diameter of the foetal head

Answer 111

A

If the head is well flexed, the occiput will be the leading point
As it reaches the sloping gutter of the levator ani muscles, it will be encouraged to rotate anteriorly so that the sagittal suture lies in the AP diameter of the pelvic outlet
If the foetus is engaged in the OP position, internal rotation can occur to an OA position (this may increase duration of labour as it is a longer internal rotation)
Alternatively, the OP position may persist resulting in a ‘face to pubes’ delivery
This may result in obstructed labour

Answer 112

A

After internal rotation, the occiput is beneath the pubic symphysis and the bregma is near the lower border of the sacrum
The flexed head then extends
The occiput escapes from underneath the pubic symphysis and distends the vulva
This is called crowning of the head
The head extends further and the bregma, face and chin appear in succession over the posterior vaginal opening and the perineal body
Some degree of perineal tearing may occur

Answer 113

A

When the head is delivering, the occiput is directly anterior
After it has crossed the perineum, the head realigns itself with the shoulders which have entered the pelvis in an oblique position
This is a very slight movement (through 1/8 of a circle)

Answer 114

A

To be delivered, the shoulders rotate into the direct AP plane
When this happens, the occiput rotates further and into the transverse position

Answer 115

A

After restitution and external rotation have occurred, the shoulders will be in the AP position
The anterior shoulder (under the pubic symphysis) delivers first, followed by the posterior shoulder
Traction may be applied by pulling downwards on the foetal head to help release the anterior shoulder from beneath the pubic symphysis
The rest of the foetal body is usually delivered quite easily

Answer 116

A

Previous births and size of previous babies
Previous C-section
Onset, frequency, duration and perception of strength of contractions
Whether membranes have ruptured and, if so, colour and amount of amniotic fluid lost
Presence of abnormal vaginal discharge or bleeding
Recent activity of the foetus (foetal movement)
Medical or obstetric issues of notes (e.g. diabetes, hypertension, FGR)
Any special requirements
Maternal expectations of labour and delivery
Birth preferences or birth plan

Answer 117

A

BMI- High BMI may complicate labour
Temperature, pulse and blood pressure should be recorded
Urine tested for protein, blood, ketones, glucose and nitrates

Answer 118

A

Foetal lie (longitudinal, transverse or oblique)
Presentation (cephalic or breech)
- If cephalic, the degree of engagement must be determined in terms of fifths of the face that are palpable abdominally
A head that remains high (5/5 palpable) and unengaged (>2/5 palpable) is a poor prognostic sign for vaginal delivery
If there is any doubt, an ultrasound scan should be performed to identify the reason for the head being high (e.g. placenta praevia, OP position)
Abdominal examination should include an assessment of the contractions (mainly the strength of contractions, which is not shown on CTG)

Answer 119

A

The cervix should be examined for position, length and effacement, dilatation and application to the presenting part
‘Station’ refers to how far the foetal head has descended into the pelvis
The length of the cervix at 36 weeks gestation should be around 3 cm - this gradually shortens through the process of effacement
Dilatation is assessed digitally in centimetres
At around 4 cm dilated the cervix should be fully effaced
When no cervix can be felt, it means that the cervix is fully dilated (10 cm)
Vaginal examination also allows assessment of foetal head position, station, attitude and the presence of caput or moulding
Normally, the vertex is the presenting point
The occiput can be identified by feeling the triangular posterior fontanelle with the three suture lines
Failure to feel the posterior fontanelle may be due to the head being deflexed, the occiput is posterior or there is so much moulding that the sutures cannot be felt
Normally the occiput is transverse (OT position) or anterior (OA position)
Assessing the distance between the leading part of the head to the ischial spines will give an estimation of the station
If the membranes have ruptured, the amount and colour of amniotic fluid draining should be noted (a good amount of clear fluid is good)

Answer 120

A

Midwifery care

- If there are risk factors, involvement of the on-call obstetric team may be necessary

Answer 121

A

Pulse measured hourly
Blood pressure and temperature measured every 4 hours
Passage of urine should be noted and it should be tested for ketones and protein
Once the second stage of labour has been entered, blood pressure and pulse should be measured hourly and vaginal examinations should be offered every hour

Answer 122

A

Contractions disrupt placental blood flow and oxygen transfer
The hypoxia leads to anaerobic respiration, which can result in metabolic acidosis if prolonged and severe
- This can cause neuronal damage
Hypoxia and acidosis cause a characteristic change in foetal heart rate (FHR) pattern
- This can be detected by auscultation or CTG

Answer 123

A

Meconium is often passed by a healthy foetus at or after term due to maturation of the GI tract (usually thin and dark green/brown)
- It may also be expelled when a foetus is exposed to marked intrauterine hypoxia or acidosis (thick and brighter green)

Answer 124

A

Inspection of amniotic fluid
Intermittent auscultation using a Pinard stethoscope or hand-held Doppler
Continuous external electronic foetal monitoring (EFM) using CTG
Continuous internal electronic foetal monitoring (EFM) using foetal scalp electrode (FSE) and CTG
Foetal scalp blood sampling (FBS)

Answer 125

A

Using a Pinard stethoscope or by using a hand-held Doppler device
It should be listened to for at least 1 minute after a contraction
Repeat every 15 mins during the first stage of labour
Repeat every 5 mins during the second stage of labour
EFM (electronic foetal monitoring using CTG) may be used if complications occur

Answer 126

A

Significant meconium staining of the amniotic fluid
Abnormal FHR detected by intermittent auscultation
Maternal pyrexia
Fresh vaginal bleeding
Augmentation of contractions with oxytocin infusion
Maternal request

Answer 127

A

Due to

foetal position
maternal obesity

Answer 128

A

FSE may overcome this issue
It is fixed onto the foetal scalp and picks up the FHR directly
It does NOT cause any harm to the foetus but requires a certain degree of cervical dilatation and the membranes must be ruptured

Answer 129

A

Baseline rate
Variability
Accelerations
Deccelerations

Answer 130

A

If all features are reassuring = normal CTG
If 1 feature is non-reassuring = suspicious CTG
If 2 or more features are non-reassuring or any one abnormal feature = pathological CTG

Answer 131

A

Foetal scalp blood sampling (FBS) may be performed during labour to measure foetal pH and base excess

Answer 132

A

A graphic record of labour
Allows instant visual assessment of the progress of labour based on the rate of cervical dilatation compared with an expected norm (according to parity)
Other important observations include frequency and strength of contractions, descent of the head, station, amount and colour of amniotic fluid draining and basic observations of maternal wellbeing

Answer 133

A

Pain relief when needed
Adequate hydration and light diet to prevent ketosis (which can impair uterine contractility)
Women in the latent phase of labour should be encouraged to mobilise and should be managed away from the labour suite
Intervention should be avoided where possible
Vaginal examinations performed every 4 hours to determine whether the active phase has been reached (around 4 cm dilatation and full effacement)
Increase vaginal examinations if the midwife suspects that progress of labour is unusually slow or fast or if there are foetal concerns
Descent of the presenting part should also be recorded
During this phase, the membranes may be intact or may have ruptured
Standing upright may encourage progress of labour (so mobility should be encouraged)
Antacids should be given to women who have been given opioid analgesia

Answer 134

A

First sign of the second stage is likely to be an urge to push experienced by the mother
Full dilatation of the cervix should be confirmed by a vaginal examination if the head is not visible
The woman will get an expulsive reflex with each contraction and will generally take a deep breath, hold it and strain down (Valsalva)
Women should be discouraged from lying supine or semi-supine
Maternal and foetal surveillance should intensify
Use of regional anaesthesia (epidural or spinal) may interfere with the normal urge to push - meaning that the second stage is more often diagnosed on routine scheduled vaginal examination
In all cases, the baby should be delivered within 4 hours of reaching full dilatation

Answer 135

A

Can be judged by watching the perineum
Between contractions, the elastic tone of the perineal muscles will push the head back into the pelvic cavity
When the head no longer recedes between contractions it is called crowning
This indicates that delivery is imminent
As crowning occurs, the hands of the midwife are used to flex the foetal head and guard the perineum
Once the head has crowned, the woman should be discouraged from bearing down by telling her to take rapid, shallow breaths

Answer 136

A

The baby will usually take its first breath within seconds
There is no need for immediate clamping
The baby’s head should be kept dependent to allow mucus in the respiratory tract to drain
After clamping and cutting the umbilical cord, the baby should have an Apgar score calculated at 1 minute of age and then repeated again at 5 minutes
Immediate skin-to-skin contact between mother and baby will help bonding and promote the further release of oxytocin which will encourage uterine contractions
The baby should be dried and covered with a warm blanket or towel
Initiation of breastfeeding should be encouraged within the first hour of life
Routine measurements of newborn head circumference, birthweight and temperature should be measure soon after this hour
The first dose of vitamin K should be given in the delivery room

Answer 137

A

If > 30 minutes

Answer 138

A

Recommended to ALL women
Controlled cord traction
Reduces postpartum haemorrhage from 15% to 5%
When the signs of placental separation are recognised, controlled cord traction is used to expedite delivery of the placenta
When a contraction is felt, the left hand should be moved suprapubically and the fundus elevated with the palm of the hand facing towards the mother
Uterine inversion is a rare complication
In 2% of cases, the placenta will not be expelled by this method
If no bleeding occurs, another attempt should be made after 10 mins
If this fails, the placenta is ‘retained’ and requires manual removal under general or regional anaesthesia in the theatre
NOTE: delayed cord clamping from 1-3 minutes may be preferable

Answer 139

A

Placenta is delivered by maternal effort with no uterotonic drugs
Associated with heavier bleeding
If haemorrhage occurs or the placenta is undelivered after 60 mins, active management should be recommended

Answer 140

A

After completion of the third stage, the placenta should be inspected for missing cotyledons or a succenturiate lobe
- If suspected, examination under anaesthesia and manual removal of placental tissue (MROP) should be arranged
Finally, the vulva should be inspected for tears

Answer 141

A

Spontaneous onset at 37-42 weeks
Singleton pregnancy
Cephalic vertex presentation
No artificial interventions
Cervical dilatation of at least 1 cm every 2 hours in the active phase of the first stage
Active second stage no more than 2 hours in primiparous and 60 mins in multiparous women
Spontaneous vaginal delivery
Third stage lasting no more than 30 mins with active management

Answer 142

A

Poor progress (delayed cervical dilatation or descent of presenting part)
Foetus shows signs of compromise
Foetal malpresentation
Multiple pregnancy
Uterine scar
Induced labour

Answer 143

A

Partograms help detect poor progress
Prolonged Latent Phase
- Latent phase is longer than expected
- More common in primiparous women
- Best managed with simple analgesics, mobilisation and reassurance
- This is very frustrating for the woman
Primary Arrest
- < 2 cm cervical dilatation per 4 hours in active 1st stage
- More common in primiparous women
- Most commonly caused by insufficient uterine contractions
- Other causes: cephalopelvic disproportion, malposition and malpresentation
Secondary Arrest
- Occurs when progress in the active first stage is initially good but then slows or stops altogether, usually after 7 cm dilatation
- May be due to inefficient uterine contractions, malposition, malpresentation and cephalopelvic disproportion
Arrest in second stage of labour
- Occurs when delivery is NOT imminent after the usual interval of pushing in the second stage of labour
- May be due to inefficient uterine activity, malposition, malpresentation, CPD or resistant perineum

Answer 144

A

Defined as cervical dilatation of less than 2 cm in 4 hours
Usually associated with failure of descent and rotation of the foetal head
May be due to any of the 3 Ps: powers, passage, passenger

Answer 145

A

MOST COMMON cause of poor progress in labour
More common in primigravidae and in older women
Characterised by weak, irregular and infrequent contractions
Uterine contractions are usually assessed by carrying out clinical examination and by external uterine tocography
NOTE: intrauterine pressure catheters are available but are invasive
4-5 contractions per 10 mins is ideal
If contractions are less frequent, more frequent examinations may be required (vaginal examination every 2 hours rather than 4 hours)
If delay is confirmed, the woman should be offered artificial rupture of membranes (ARM)
If there is still poor progress after 2 more hours, advice should be sought from an obstetrician about using an oxytocin infusion to augment the contractions
- The infusion is started slowly initially, then increased every 30 mins according to a protocol
- Continuous EFM is necessary because excessive contractions can cause foetal compromise
- Women should be offered an epidural before oxytocin is started

Answer 146

A

Less likely

Always exclude alternative causes e.g. malposition

Answer 147

A

Uterine rupture

Answer 148

A

Caesarean section

Answer 149

A

CPD implies an anatomical disproportion between the foetal head and the maternal pelvis (either due to large head or small pelvis)
The pelvis may be abnormally small due to previous fracture or metabolic bone disease
Obstructive hydrocephalus can cause macrocephaly
Relative CPD is more common and occurs with malposition of the foetal head
The occipito-posterior position is associated with deflexion of the foetal head, which present a larger skull diameter to the maternal pelvis
Oxytocin can be given with caution in a primigravida woman with mild to moderate CPD provided that the CTG is normal
Oxytocin must NEVER be used in a multiparous woman where CPD is suspected

Answer 150

A

Foetal head not engaged
Progress is slow or arrests despite efficient uterine contractions
Vaginal examination shows severe moulding and caput formation
Head is poorly applied to the cervix
Haematuria

Answer 151

A

Firm application of the foetal presenting part onto the cervix is necessary for good progress
A face presentation may apply poorly to the cervix resulting poor progress, but vaginal birth is still possible
Brow presentation (neck is slightly less extended than in face presentation) is associated with mento-vertical diameter presenting
- This is too large to fit through the bony pelvis unless flexion or hyperextension to a face presentation occurs
- Brow presentation often manifests as poor progress in the first stage
Shoulder presentations cannot be delivered vaginally so poor progress will occur
Malpresentation is more common in women of high parity
Malpresentation carries a risk of uterine rupture if labour is allowed to continue without progress

Answer 152

A

CPD can delay progress
Unsuspected fibroids in the lower uterine segment can prevent descent of the foetal head
Cervical dystocia can also cause delay - this is when the cervix is non-compliant and effaces but fails to dilate because of severe scarring or rigidity (usually due to previous cervical surgery)
C-section may be necessary

Answer 153

A

3 hours = nulliparous

- 2 hours = parous

Answer 154

A

if delivery is NOT imminent after:
- 2 hours of pushing = nulliparous
- 1 hour of pushing = parous

Answer 155

A

A common cause of second stage delay
This may be exacerbated by epidural analgesia
After achieving full dilatation, the uterine contractions may become weak
This is sometimes associated with maternal dehydration and ketosis
If NO mechanical problem is anticipated and the woman is primiparous, treatment is with rehydration and IV oxytocin
If the woman is multiparous, a full clinical assessment should be performed by a skilled obstetrician prior to considering oxytocin

Answer 156

A

Android pelvis (narrow pelvis) may cause delay in the second stage because it prevent internal rotation of the foetal head
- This may arrest descent of the foetal head at the level of the ischial spines in the transverse position (deep transverse arrest)

Answer 157

A

Android pelvis
Resistant perineum
Persistent OP position can also cause delay and would require long rotation to OA or be delivered in OP position (face to pubes)

Answer 158

A

Oxytocin should not be started

- So, inefficient uterine activity should be corrected at the beginning of the second stage

Answer 159

A

Instrumental vaginal delivery
Only if safety criteria are met
This can be done in the labour room or in the theatre (allowing C-section to be performed easily if needed)

Answer 160

A

Episiotomy

Answer 161

A

Continued pushing with encouragement
Regular reviews of progress and foetal wellbeing
Oxytocin to augment contractions
Episiotomy for a resistant perineum
Instrumental vaginal birth
C-section

Answer 162

A

Fresh meconium staining of the amniotic fluid
Abnormal CTG
NOTE: neither confirm foetal hypoxia or acidosis as meconium can be passed for physiological reasons (e.g. maturity) and abnormal CTG carries a high false-positive rate

Answer 163

A

Placental insufficiency (FGR and pre-eclampsia)
Prematurity
Postmaturity
Multiple pregnancy
Prolonged labour
Augmentation with oxytocin/hyperstimulation
Precipitate labour
Intrapartum abruption
Cord prolapse
Uterine rupture/dehiscence
Maternal diabetes
Cholestasis of pregnancy
Maternal pyrexia/chorioamnionitis
Oligohydramnios

Answer 164

A

If it is
- Thick or tenacious (clingy)

Dark green, bright green or black

Answer 165

A

Foetal gut maturity

Answer 166

A

Do EFM and CTG

- This is MANDATORY if the meconium is THICK and DARK

Answer 167

A

If there is
- foetal tachycardia, bradycardia or FHR decelerations
CTG can be classified as normal, suspicious or pathological

Answer 168

A

If the CTG is suspicious

Repositioning the mother
IV fluids
Reducing or stopping oxytocin
Correction of epidural-associated hypotension
Continue CTG observation

If the CTG is pathological, consider above factors but also carry out an immediate vaginal examination to exclude malpresentation and cord prolapse and to assess the progress of labour

If the cervix is fully dilated, instrumental delivery may be possible
If the cervix is NOT fully dilated, foetal blood sampling may be considered
- If the result is NORMAL, labour can continue but repeat samples may be needed every 30-60 mins if CTG abnormalities persist
An ABNORMAL result requires immediate C-section if the cervix is not fully dilated

Fresh, thick meconium with a reassuring CTG is still a cause of concern
- `Threshold for intervention should be lower and a paediatrician should be present at delivery

Answer 169

A

Maternal dehydration and ketosis
- Give IV fluids
Maternal hypotension secondary to an epidural
- Reversed by fluid bolus (vasoconstrictor such as ephedrine may occasionally be used)
Uterine hyperstimulation from excess oxytocin
- Turn off infusion temporarily and use tocolytic drugs (e.g. terbutaline)
Venocaval compression and reduced uterine blood flow
- Turn woman to left lateral position

Answer 170

A

Woman is asked to lie in the left lateral position
Amnioscope is inserted into the vagina and the end is applied to the foetal head
The scalp is cleaned and a small cut is made and blood is collected into microtube (about 0.25 mL of blood is required)
Normal pH = 7.25
- pH < 7.20 is considered foetal compromise
- pH 7.20-7.25 is borderline

Answer 171

A

One-to-one care from a midwife can reduce the need for analgesia
Relaxation and breathing exercises
NOTE: prolonged hyperventilation can cause alkalosis and dizziness
Relaxation in warm water during first stage
Transcutaneous electrical nerve stimulation (TENS)
- Blocks pain fibres in the posterior ganglia of the spinal cord
- May be used in the latent phase

Answer 172

A

Opiates (e.g. pethidine and diamorphine) are used in most obstetric units
They should be available at all pregnancies but beware of side-effects
Opiates tend to be given as IM injections
Alternative route is a subcutaneous or IV infusion by a patient-controlled analgesic device (PCA)
If a very short-acting opiate is used, the opiate dose can be timed with the contractions

Answer 173

A

Nausea and vomiting (should always be given with an antiemetic)
Maternal drowsiness and sedation
Delayed gastric emptying (increasing the risks of general anaesthesia)
Short-term respiratory depression of the baby
Possible interference with breastfeeding

Answer 174

A

Nitrous oxide in the form of Entonox (NO and oxygen) is available on most labour wards
It has a quick onset and short duration of effect
May cause light-headedness and nausea
NOT suitable for prolonged use from early labour because hyperventilation can lead to hypocapnia, dizziness and (rarely) foetal hypoxia
It is most suitable later in labour or whilst awaiting epidural analgesia

Answer 175

A

MOST RELIABLE means of providing effective analgesia in labour
The decision to opt for epidural analgesia lies with the woman (unless there are contraindications)
Warn the woman that:
- She may lose sensation and movement in her legs temporarily
- IV access and more intensive maternal and foetal monitoring will be necessary (e.g. with continuous EFM)
Epidural analgesia does NOT increase C-section rates
It does, however, cause a longer second stage and increases risk of instrumental delivery
Epidural is not ideal for women in the first stage because it limits mobility

Answer 176

A

Prolonged labour/oxytocin augmentation
Maternal hypertensive disorders
Multiple pregnancy
Selected maternal medical conditions
A high risk of operative intervention

Answer 177

A

Coagulation disorders (e.g. low platelet count)
Local or systemic sepsis
Hypovolaemia
Logistical: insufficient numbers of trained staff (anaesthetic and midwifery)

Answer 178

A

Accidental dural puncture
Leakage of CSF if the subarachnoid space is reached causing a spinal headache
- If the headache is severe or persistent, a blood patch may be necessary - involves injecting a small volume of the woman’s blood into the epidural space at the level of the accidental dural puncture
Bladder dysfunction (loss of awareness of needing to micturate)
Overdistension of the bladder can cause permanent damage and voiding problems
- To avoid this, catheterisation should be carried out during labour if the woman does not void significant volumes of urine spontaneously
Hypotension
- Treated with IV fluids and vasopressors
Accidental total spinal anaesthesia (injection of the analgesic into the subarachnoid space)
- Severe hypotension
- Respiratory failure
- Unconsciousness
- Death
Spinal haematoma
Drug toxicity
Short-term respiratory depression of the baby (because epidural solutions contain opioids)

Answer 179

A

Woman’s back is cleansed and local anaesthetic is used to infiltrate the skin
The woman may be in the left lateral position or sitting upright but leaning over
Aseptic technique is used
The epidural catheter is normally inserted at L2-L3, L3-L4 or L4-L5 interspace and should lie in the epidural space
The catheter is aspirated to check for position and, if no blood or CSF is obtained, a test dose is given to confirm the catheter position
The test dose is a small volume of dilute local anaesthetic that should not have any clinical effect if applied in the epidural space
If there is no change in sensation in the lower limbs, then the catheter is in the correct position
If there is sensory block, leg weakness and peripheral vasodilation, the catheter has been inserted into the subarachnoid space
If no signs have been observed within 5 mins of the test dose, the loading dose can be administered
The epidural solution is usually a mixture of low-concentration local anaesthetic (e.g. bupivicane) and an opioid (e.g. fentanyl)
After the loading dose, the mother should be kept in the right or left lateral position and her blood pressure should be measured every 5 mins for 15 mins
A fall in blood pressure may be caused by blocking the sympathetic tone to peripheral blood vessels
- This can cause foetal bradycardia
- Treat with IV fluids and vasoconstrictors (e.g. ephedrine) if necessary
The woman should NOT lie supine because it can cause aorto-caval compression (compression of the aorta and inferior vena cava but the gravid uterus)
Hourly assessment of the level of sensory block using a cold spray is critical in the detection of a block that is creeping too high and risking respiratory compromise
Regional anaesthesia can be maintained through labour with either intermittent boluses or continuous infusions

Answer 180

A

A spinal block is more effective than an epidural and has a faster onset
The needle is inserted through the dura into the subarachnoid space
They may be used for:
- C-section
- Trial of instrumental deliveries
- Manual removal of retained placenta
- Repair of difficult perineal and vaginal tears
- Combined spinal-epidural (CSE) analgesia is a viable option for pain relief in labour

Answer 181

A

Previous C-section

Answer 182

A

Because risk of uterine rupture is lower

Answer 183

A

Risk of uterine rupture or dehiscence (scar separation) occurs in 1 in 200 women who labour spontaneously with pre-existing lower segment uterine scar

Answer 184

A

Severe lower abdominal pain
Vaginal bleeding
Haematuria
Cessation of contractions
Maternal tachycardia
Foetal compromise (often bradycardia)

Answer 185

A

Mother: shock, need for blood transfusion, operative repair, hysterectomy
Foetus: hypoxia, permanent neurological injury and perinatal death

Answer 186

A

Late in the first stage of labour with induced or accelerated labour

Answer 187

A

70-80% of women who attempt vaginal birth after caesarean (VBAC) will be successful and the remainder will require C-section

Answer 188

A

Close surveillance to identify early signs of uterine rupture
Continuous CTG monitoring is recommended with a low threshold for delivery by C-section

Answer 189

A

Two or more previous C-section scars
Need for induction of labour
Cephalopelvic disproportion in previous labour
Previous classical C-section is an ABSOLUTE contraindication

Answer 190

A

Increased risk of cord prolapse (particularly with footling breech)
Increased risk of CTG abnormalities as cord compression is common
Mechanical difficulties with delivery of the shoulders leading to damage to the visceral organs/brachial plexus
Delay in the delivery of the head leading to prolonged compression of the umbilical cord and asphyxia
Uncontrolled rapid delivery of the head may occur with a small foetus and predisposes to tentorial tears and intracranial bleeding
A small or preterm foetus may deliver through an incompletely dilated cervix resulting in head entrapment

Answer 191

A

Occurs in 1 in 500 labours due to complete extension of the foetal head
The presenting diameter is the submento-bregmatic which is about 9.5 cm in diameter and has roughly the same dimensions as the suboccipito-bregmatic presentation
Engagement of the foetal head is late and progress in labour is usually slow
Diagnosed by palpating the nose, mouth and eyes on vaginal examination
If there is good progression in labour and the chin remains mento-anterior, vaginal delivery is possible with the head being delivered in flexion
If the chin is posterior (mento-posterior), delivery is IMPOSSIBLE
- C-section should be performed
- Oxytocin should NOT be used

Answer 192

A

Arises when there is less extreme extension of the foetal neck than with face presentation
It is a midway position between vertex and face presentation
It is the LEAST COMMON malpresentation
The presenting diameter is mento-vertical (13.5 cm) and is incompatible with vaginal delivery
It is diagnosed by palpating the anterior fontanelle, supraorbital ridges and nose on vaginal examination
If this position persists, C-section is necessary

Answer 193

A

Occurs in 1 in 300 pregnancies at term
Occurs as a result of transverse or oblique lie of the foetus
This can be caused by:
- Placenta praevia
- High parity
- Pelvic tumour
- Uterine anomaly
Delivery should be by C-section
Delay in diagnosing shoulder presentation could result in cord prolapse and uterine rupture

Answer 194

A

1 in 80 pregnancies are multi-foetal
Incidence is rising due to increasing maternal age and assisted contraception
High-order multiples tend to be delivered by C-section
For twin pregnancies, the second twin is at greater risk of intrapartum compromise than the presenting twin
C-section is not necessarily indicated in twin pregnancies, however they end up being performed in almost half of all twin pregnancies
In 70-80% of pregnancies the presenting twin is cephalic (the remainder are mainly breech)
Vaginal delivery is usually achievable if the presenting twin is in a cephalic vertex presentation
Planned C-section will usually be performed if the first twin is in breech, and almost certainly if it is transverse

Answer 195

A

This is the planned initiation of labour prior to its spontaneous onset
20-25% or deliveries in the UK occur following IOL
Generally, IOL is performed when the risks to the foetus and/or the mother of the pregnancy continuing outweigh those of bringing the pregnancy to an end
MOST COMMON reason is prolonged pregnancy (used to be known as post-term or postdates)
Pregnancies extending beyond 42 weeks are associated with increased risk of stillbirth, foetal compromise in labour, meconium aspiration and mechanical problems at delivery
So, women are usually offered IOL between 41-42 weeks
Prelabour rupture of membranes (PROM) is another common indication for IOL
If there is a long delay between membrane rupture and delivery of the baby, there is a greater risk of ascending infection (chorioamnionitis)
If beyond 37 weeks, evidence supports use of IOL around 24 hours following membrane rupture
If < 34 weeks, another additional indication is needed to justify IOL if the membranes rupture (e.g. foetal compromise, growth restriction)
If 34-37 weeks, in an otherwise straight forward pregnancy, the benefits of IOL need to be assessed on an individual basis
Pre-eclampsia and other maternal hypertensive disorders often indicate earlier delivery
- If it occurs at term, it is normally managed with IOL
- If very preterm (< 34 weeks) or if there is rapid foetal or maternal compromise, C-section may be a better option

Answer 196

A

Prolonged pregnancy (> 41 weeks)
PROM
Pre-eclampsia and other maternal hypertensive disorders
FGR
Diabetes mellitus
Deteriorating maternal illness
Unexplained antepartum haemorrhage
Twin pregnancy continuing beyond 38 weeks
Intrahepatic cholestasis of pregnancy
Maternal isoimmunisation against red cell antigens
Social reasons

Answer 197

A

Placenta praevia

- Severe foetal compromise

Answer 198

A

Deteriorating maternal condition
Major antepartum haemorrhage
Pre-eclampsia
Maternal cardiac disease
Breech (relative contraindication)
Preterm
- Not an absolute contraindication but induction < 34 weeks is associated with higher risk of failure and the need for C-section

Answer 199

A

If labour is induced before cervical changes take place, the labour will take longer
The Bishop score is used to quantify how far the process of cervical changes has progressed before IOL
High scores (favourable cervix) are associated with an easier, shorter induction process
Low scores (unfavourable cervix) is more likely to take longer and more likely to fail and result in C-section

Answer 200

A

Prostaglandin E2 (PGE2) is the most commonly used formulation
It is inserted vaginally into the posterior fornix as a tablet or gel
Two doses are often required, given at least 6 hours apart
A controlled-released pessary is also available and this is left in place for up to 24 hours
Labour may ensure following administration of prostaglandins but ARM and oxytocin are often also necessary (particularly in primiparous women)
Oxytocin is given IV as a dilute solution (as it has a short half-life)
- NOTE: the response to oxytocin is highly variable so strict protocol must be followed
- The starting infusion rate is low and defined increments will follow every 30 mins until 3-5 contractions are achieved every 10 mins
Mifepristone (antiprogesterone) and misoprostol (another prostaglandin) can be used to induce labour
Membrane sweeping describes insertion of a gloved finger through the cervix and its rotation around the inner rim of the cervix
- This strips off the chorionic membrane from the underlying decidua and releases natural prostaglandins
- It can be uncomfortable and is only possible if the cervix is beginning to dilate and efface
- It reduces the need for induction
- Usually only performed at term
- Placenta praevia must be excluded before it is performed

Answer 201

A

More pain experienced with induced labour
Epidural analgesia is more commonly used
Rates or instrumental delivery are higher when epidural analgesia is used
NO higher rate of C-section
Increased risk of PPH secondary to uterine atony
Uterine hyperstimulation may cause foetal compromise as a side-effect of using prostaglandins and oxytocin
Contraction frequency of >5 per 10 mins should be treated by stopping oxytocin and, if necessary, administering a tocolytic drug (usually SC injection of terbutaline (beta-2 agonist))
Uterine hyperstimulation may cause foetal bradycardia and the need for an emergency C-section if FHR fails to resolve promptly
If ARM is performed when the foetal head is high, cord prolapse can occur which may need a C-section
The risk of uterine rupture in women with a previous C-section scar who are induced is higher than if they went through spontaneous labour
IOL failure is said to have occurred if ARM is still impossible after the maximum number of doses of prostaglandin have been given or if the cervix remains uneffaced and < 3 cm dilated after an ARM has been performed and oxytocin has been running for 6-8 hours with regular contractions

Answer 202

A

Rest then attempt induction again

- C-section

Answer 203

A

Prolonged labour
Big babies
Instrumental delivery
During active second stage

Answer 204

A

Faecal urgency

Answer 205

A

Faecal incontinence

Answer 206

A

Third and fourth degree tears

Answer 207

A

Adequate analgesia should be provided by topping up an epidural or by infiltration with local anaesthetic
A pad or tampon to prevent blood loss from the uterus obscuring the view
Vaginal mucosa is repaired first using rapidly absorbable suture material
A continuous stitch should be used to close the vaginal mucosa
Interrupted sutures are placed to close the muscle layer
Closure of perineal skin is done with either interrupted sutures or a continuous subcuticular stitch
A gentle vaginal examination should be performed to check for any missed tears and to ensure that good opposition is achieved
A rectal examination should be performed to confirm that the sphincter feels intact and to ensure that no sutures have been inadvertently placed through the rectal mucosa

Answer 208

A

Regional or general anaesthetic (to achieve relaxation of the sphincter)
Repair rectal mucosa
Repair torn external sphincter
Some surgeons do an end-to-end repair whereas others prefer an overlap method
The rest of the perineal repair is as for second-degree trauma

Answer 209

A

Lactulose and a bulking agent (e.g. Fybogel) are recommended for 5-10 days
Remain in hospital until first bowel motion happens
An oral broad-spectrum antibiotic should be prescribed for 5-7 days to reduce the risk of infection
Regular oral analgesia
At 6-12 weeks, a full evaluation of the degree of symptoms should take place
Asymptomatic women should be told that the risk in future pregnancy is 6-8% and vaginal delivery is safely achievable

Answer 210

A

An episiotomy is a surgical incision of the perineum performed during the second stage of labour to enlarge the vulval outlet and assist vaginal birth
Episiotomies are used in about 10% of spontaneous vaginal deliveries in the UK (rates vary in other countries)

Answer 211

A

Episiotomy is performed in the second stage when the perineum is being stretched
If there is NOT a good epidural, the perineum should be infiltrated with local anaesthetic
If an effective epidural is in place, it should be topped up for delivery with the patient upright to get best coverage of the perineal area
The incision can be midline or at an angle from the posterior end of the vulva
A mediolateral episiotomy at a 60 degree angle to midline is usually recommended
The midline episiotomy results in less bleeding, quicker healing and less pain but there is an increased risk of extension to involve the anal sphincter (OASI)
The episiotomy should be repaired in the same way as a second-degree tear unless involvement of the anal sphincter requires OASI repair

Answer 212

A

Pain
Infection
Haemorrhage
Dyspareunia
Incontinence of urine
Incontinence of flatus or faeces
Risks are highest with OASI

Answer 213

A

Refers to vaginal birth with the use of any type of forceps or vacuum extractor (ventouse)
The goal is to speed up delivery with a minimum of maternal and neonatal morbidity
10-15% of deliveries in the UK are assisted with instruments
The rate is higher in nulliparous women (around 30%)

Answer 214

A

Suspected foetal compromise is the MOST COMMON foetal factor
It is based on an pathological CTG

Answer 215

A

Prolonged active second stage of labour

Answer 216

A

If the safety criteria is NOT met, OVD is contraindicated
NOT to be used if < 34 weeks because of high risk of cephalhaematoma and intracranial haemorrhage
NOT used for face or breech presentation
Minimal risk of haemorrhage if a vacuum extractor is used following foetal blood sampling or foetal scalp electrode
Forceps or vacuum extractor delivery is contraindicated before full dilatation of the cervix

Answer 217

A

Lower risk of pelvic floor trauma with ventouse
Lower risk of anal sphincter injury with ventouse
Higher risk of lacerations and facial palsy with forceps
Less likely to need maternal regional or general anaesthesia
Less likely to cause significant perineal pain at 24 hours
No difference in pelvic floor symptoms 5 years after instrumental delivery between forceps and ventouse
Both are associated with low 5 minute Apgar scores

Answer 218

A

Lower failure rate than Ventouse for vaginal delivery
Lower risk of cephalohaematoma and cerebral haemorrhage than ventouse
Lower risk of retinal haemorrhage than ventouse
No difference in pelvic floor symptoms 5 years after instrumental delivery between forceps and ventouse
Both are associated with low 5 minute Apgar scores

Answer 219

A

Women who deliver by C-section more likely to have a major haemorrhage and to need a hospital stay for more than 5 days
Babies delivered by C-section were less likely to have trauma than babies delivered by forceps but were more likely to require intensive care
Women who had a C-section are much more likely to require a C-section in future pregnancies

Answer 220

A

Thorough vaginal and abdominal examination should take place to confirm the foetal lie, presentation, engagement, station, position, attitude and degree of caput or moulding
This will confirm whether the basic safety criteria for OVD have been met
Anthropoid (narrow), android (male/funnel-shaped) or platypelloid (elliptical) pelvises make instrumental delivereis MORE difficult
A trial push is helpful to determine whether descent is possible and allows attempted correction of malposition

Answer 221

A

More analgesia is required for forceps compared to ventouse
Forceps - regional anaesthesia is preferred
Rigid cup ventouse - pudendal block with perineal infiltration
Soft cup ventouse - perineal infiltration with local anaesthetic

Answer 222

A

Classically performed with patients in the lithotomy position
The bladder should be emptied

Answer 223

A

A failed vacuum delivery may be completed with low-pelvic forceps
But a failed or abandoned forceps delivery will almost always result in C-section
The risk of shoulder dystocia and postpartum haemorrhage should always be considered

Answer 224

A

Soft cups are more likely to fail than rigid cups
However, soft cups cause less scalp injury
Soft cups are suitable for uncomplicated deliveries with an OA position
Metal cups are better for OP, transverse and difficult OA position
For successful use of the ventouse, determination of the flexion point is vital
This is at the vertex, which is on the saggital suture 3 cm anterior to the posterior fontanelle and 6 cm posterior to the anterior fontanelle
The centre of the cup should be positioned directly over this
Operating suction pressure is 0.6-0.8 kg/cm2
Check that no maternal tissue is caught under the edge
Traction must along in the plane of least resistance along the axis of the pelvis (usually at exactly 90 degrees to the cup)
Operator should keep a thumb and forefinger on the cup and foetal scalp to ensure traction direction is correct and to feel for slippage
Safe and gentle traction is applied and coordinated with uterine contractions and maternal expulsive efforts
The descent phase brings the head onto the perineum
The crowning phase occurs shortly afterwards
Rotation is achieved through the natural passage of the head through the pelvis
The operator should not allow any more than 2 episodes of the suction popping off during delivery
The maximum time from application to delivery should be < 15 mins

Answer 225

A

Blades may be fenestrated, pseudofenestrated or solid
Length of shanks and design of the lock vary between models
Non-rotational forceps are used when the head is OA with no more than 45 degrees deviation to the left or right
Examples of non-rotational forceps
- Neville Barnes
- Simpson
If the head is positioned > 45 degrees from the vertical, rotation must be accomplished before tractions
Examples of rotational forceps
- Kielland

Answer 226

A

The left blade is usually inserted before the right with the operators hand protecting the vaginal wall from the blades
The forceps blades will end up lying parallel to the axis of the foetal head
The operator will then lock the blades
Traction should be applied intermittently coordinated with uterine contractions and maternal expulsive efforts
The axis of traction changes during delivery and is guided along the J-shaped curve of the pelvis
As the head crowns, the blades are directed to the vertical and the head is delivered
Most forceps deliveries will be completed with no more than three pulls
In practice, most obstetricians cut an episiotomy routinely for forceps delivery
This is more likely in nulliparous women

Answer 227

A

Maternal deaths have been reported with vacuum deliveries as a result of cervical tearing in women delivered before full dilatation
Faecal incontinence
Postpartum haemorrhage
Underestimation of blood loss
Cephalhaematoma (ventouse)
Risk of trauma to the baby correlates with duration of operative vaginal delivery and difficulty of the delivery

Answer 228

A

A C-section is a surgical procedure where incisions are made through a woman’s abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies
25-30% of all babies in the UK are delivered by C-section

Answer 229

A

Previous C-section
Malpresentation (mainly breech)
Failure to progress in labour
Suspected foetal compromise

Answer 230

A

Multiple pregnancy
Placental abruption
Placenta praevia
Foetal disease
Maternal disease

Answer 231

A

Irrational fear of childbirth
It is important to distinguish mothers who request C-section because they want to avoid labour from those that want to avoid it because of a previous traumatic birth experience

Answer 232

A

Informed consent
Preparation
Abdominal incision
Uterine incision
Closure

Answer 233

A

Must be obtained before surgery

- Potential indications should be discussed in the antenatal period

Answer 234

A

Most scheduled C-sections are performed under spinal anaesthesia with the mother awake
If an epidural has been placed during labour there is usually enough time to top-up the anaesthesia before emergency C-section
General anaesthesia is occasionally required
Bladder should be emptied before the procedure and a urinary catheter is usually kept in situ
A left lateral tilt minimises aorto-caval compression and reduces the incidence of hypotension and reduced placental perfusion
The anaesthetic block is confirmed and the woman’s abdomen is cleaned and draped
Prophylactic antibiotics should be administered IV before the surgical incision

Answer 235

A

The skin and subcutaneous tissues are incised using either a transverse curvilinear incision 2 finger breadths above the symphysis pubis extending from and to points lateral of the lateral margins of the abdominal rectus muscles (Pfannenstiel incision)
An alternative incision is a transverse suprapubic incision with no curve
Subcutaneous tissues are separated by blunt dissection and the rectus sheath is incised transversely along the middle 2 cm
The incision is extended with scissors before the fascial sheath is separated form the underlying muscle by blunt dissection
The recti are separated, the peritoneum incised and the abdominal cavity entered
A vertical incision is used in cases of extreme maternal obesity, suspicion of other intra-abdominal pathology or where access to the uterine fundus is required
- The vertical incision allows easy access to the pelvic and intra-abdominal organs but there is an increased incidence of wound dehiscence (splitting open)

Answer 236

A

A lower uterine segment transverse incision is used in >95% of C-section deliveries due to ease of repair, reduced blood loss and low incidence of dehiscence or rupture in subsequent pregnancies
The classical C-section incision incorporates the upper uterine segment with a vertical incision - this has few absolute indications but include:
- Lower uterine segment obscured by fibroids
- Lower segment covered with dense adhesions
- Placenta praevia
- Transverse lie with the back down
- Foetal abnormality (e.g. conjoined twins)
- C-section in the presence of carcinoma of the cervix
Once the uterus is incised, the membranes are ruptured if still intact and the operator’s hand is placed below the presenting part
If cephalic, the head is flexed and delivered by elevation through the uterine incision either manually or with forceps
Fundal pressure is applied by the assistant to aid delivery
Once the foetus is delivered, an oxytocic agent (5 IU syntocinon IV) is administered to aid uterine contraction and placental separation
The placenta is delivered by controlled cord traction

Answer 237

A

Closure should be performed in either single or double layers with continuous or interrupted sutures
A running stitch is usually employed
A second layer is commonly used to improve haemostasis and the integrity of the scar
Peritoneal closure is NOT routine and depends on the operator’s preference
Abdominal closure is performed in the anatomical planes
The skin can be closed by absorbable or non-absorbable suture material or with clips

Answer 238

A

Haemorrhage
Infections of the wound
Urinary tract infection
Infection of the endometrium
Transient tachypnoea of the newborn
Fatality from C-section is 5 x that of vaginal delivery (but this is mainly because of emergency C-section)

Answer 239

A

Haemorrhage
- May be due to damage to uterine vessels
- May occur as a consequence of uterine atony or placenta praevia
- In patients with an anticipated high risk of haemorrhage (e.g. placenta praevia), blood should be routinely cross-matched
Caesarean Hysterectomy
- The most common indication is uncontrollable maternal haemorrhage
- Life-threatening haemorrhage occurs in about 1 in 1000 deliveries
- The most important risk factor for emergency postpartum hysterectomy is a previous C-section
  - This is especially bad if the placenta overlies the old scar –> increased risk of placenta accreta
- Other indications for hysterectomy:
  - Atony
  - Uterine rupture
  - Extension of a transverse uterine incision
  - Fibroids preventing uterine closure and haemostasis
Placenta praevia
- Risk of placenta praevia increases with each previous C-section
- So, future reproductive intensions are important when considering C-section
Organ damage
- Bowel damage may occur during a repeat procedure if adhesions are present from a previous surgery
Bladder injury
Damage to ureters

Answer 240

A

Infection
- C-section has a 5-20 fold increased risk of infectious complications compared to vaginal delivery
- Fever
- Wound infection
- Endometritis
- Bacteraemia
- UTI
- Other causes of post-operative fever: haematoma, atelectasis, DVT
- The duration of labour and the presence of ruptured membranes seem to be the biggest risk factors
- Infections are often polymicrobial and include E. coli, aerobic Gram-negative rods and group B streptococcus
- Prophylactic antibiotics reduce the risk of infection
Venous Thromboembolism
- C-section is a major risk factor
- Incidence can be reduced by:
  - Adequate hydration
  - Early mobilisation
  - Prophylactic heparin
Psychological
- Delayed contact with the baby can contribute to psychological distress

Answer 241

A

Up to 70% of women with a previous C-section who labour achieve vaginal delivery
Two options for women with previous C-section:
- Elective repeat caesarean section (ERCS)
- Attempted vaginal birth after caesarean section (VBAC)
If the first operation was carried out for a non-recurrent indication, and providing the obstetric situation close to term in the subsequent pregnancy is favourable, then it is appropriate to offer a trial of labour after caesarean (TOLAC) to any woman with a previous uncomplicated lower segment C-section

Answer 242

A

Avoid pelvic floor trauma (urinary and faecal problems)
Avoid the need to undergo emergency C-section
Avoid scar dehiscence or rupture

Answer 243

A

Increased bleeding
Febrile morbidity
Prolonged recovery
Thromboembolism
Long-term bladder dysfunction
Increased risk of placenta praevia in subsequent pregnancies

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Obstetrics Pt.3 Flashcards

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