Problems with labour and delivery

Question 1

WHat is labour characterised by?

Answer 1

O nset of uterine contractions, which i in frequency, duration, and
strength over time.
• Cervical effacement and dilatation.
• Rupture of membranes with leakage of amniotic fl uid.
• Descent of the presenting part through the birth canal.
• Birth of the baby.
• Delivery of the placenta and membranes.

Question 2

Give the sequence of passage through the pelvis for normal vertex delivery.

Answer 2

Engagement and descent (in occipitotransverse position)
Internal rotation to occipitoanterior (at level of ischial spines)
Crowning - the head extends, distending the perineum until it is
delivered.
Restitution - the head rotates so that the occiput is in line with the
fetal spine.
External rotation - shoulders rotate when they reach the levator
muscles until the biacromial diameter is anteroposterior
Delivery of the anterior shoulder
Delivery of the posterior shoulder

Question 3

Describe the two phases of the 1st stage?

Answer 3

Latent phase: the period taken for the cervix to completely efface
and dilate up to 3cm.
Active phase: from 3cm to full dilatation (10cm).

Question 4

WHen is failure to progress suspected?

Answer 4

There is <2cm dilatation in 4h (on a 4hr action line partogram the
plotted progress falls to the right).
Slowing in progress in parous women.

Question 5

Causes of poor progress in first stage of labour?

Answer 5

Power - inefficient uterine activity
Passenger - malpositions, malpresentation, large baby
Passage - inadequate pelvis

Question 6

Mx of poor progress in 1st stage of labour?

Answer 6

Amniotomy (artifical rupture of membranes (ARM)) and reassess in 2h.

Amniotomy + oxytocin infusion and reassess in 2h: this should
always be considered in nulliparous women.

Lower segment CS (if there is fetal distress).

Question 7

What monitoring should be done during labour?

Answer 7

FHR every 15mins (or continuously with CTG)
Contractions asssessed every 30mins
maternal pulse checked hourly
BP, temp 4hourly
VE every 4hrs
maternal urine every 4hours

Question 8

Define 2nd stage

Answer 8

time from full cervical dilatation until the baby is born.

Question 9

When is delay suspected in 2nd stage of labour?

Answer 9

Nulliparous women - suspected if delivery is not imminent after 1h of active pushing: VE should be offered and amniotomy
recommended.
If not delivered in 2h: requires review by obstetrician to consider instrumental delivery or CS.

Multiparous - I f delivery is not imminent after 1h of active pushing: requires review by obstetrician to consider instrumental delivery or CS.
- should raise suspicion of malposition or disproportion

Question 10

Define 3rd stage of labour

Answer 10

duration from delivery of the baby to delivery of the

placenta and membranes.

Question 11

Describe active Mx of 3rd stage of labour? Advantages and disadvantages?

Answer 11

Consists of:
• U se of uterotonics.
• C lamping and cutting of the cord.
• C ontrolled cord traction.

reduces rates of PPH>1000ml, mean blood loss and postnatal anaemia, length of 3rd stage, need for blood transfusions

SEs: N+V, headache

Question 12

Describe physiological Mx of 3rd stage.

Answer 12

Consists of:
• N o Syntometrine® or oxytocin is given.
• C ord is allowed to stop pulsating before it is clamped and cut.
• T he placenta is delivered by maternal effort alone.

Question 13

When to convert from planned physiological 3rd stage to active?

Answer 13

in the event of:
• H aemorrhage.
• F ailure to deliver the placenta within 1h.
• M aternal desire to shorten the 3rd stage .

Question 14

Indications for IOL?

Answer 14

Obstetric indications:
Uteroplacental insuffi ciency (one of the most common indications).
• Prolonged pregnancy (41–42wks).
• IUGR.
• Oligo- or anhydramnios.
• Abnormal uterine or umbilical artery Dopplers.
• Non-reassuring CTG.
• PROM.
• Severe pre-eclampsia or eclampsia after maternal stabilization.
• Intrauterine death of the fetus (IUD).
• Unexplained antepartum haemorrhage at term.
• Chorioamnionitis.

Medical indications:
S evere hypertension.
• U ncontrolled diabetes mellitus.
• R enal disease with deteriorating renal function.
• M alignancies (to facilitate defi nitive therapy).

Question 15

Methods of IOL?

Answer 15

membrane sweep
intravaginal prostaglandins
breaking of waters - amniotomy -
oxytocin

Question 16

describe bishops score.

Answer 16

a score of < 5 indicates that labour is unlikely to start without induction
a score of > 9 indicates that labour will most likely commence spontaneously

Question 17

What are the risks of IOL?

Answer 17

prematurity - iatrogenic (severe preeclampsia) or unintentional (failure to assess gestational age
cord prolapse with rupture of membranes

SEs of medicaitons

Question 18

SEs of medications used for IOL?

Answer 18

p ain or discomfort
• u terine hyperstimulation
• f etal distress
• u terine rupture (rare but increased in grand multipara or a scarred
uterus).
- C S due to failed induction.
• A tonic post-partum haemorrhage.
• I ntrauterine infection with prolonged induction.

prostaglandins can cause non-selective stimulation of other
smooth muscle leading to:
• nausea and vomiting
• diarrhoea
• bronchoconstriction (caution in asthmatics)
• maternal pyrexia may result due to the effect on thermoregulation in the hypothalamus.

Question 19

When should electronic fetal monitoring be used in labour?

Answer 19

Maternal: 
Previous CS.
• C ardiac problems.
• P re-eclampsia.
• P rolonged pregnancy (>42wks).
• P relabour rupture of membranes (>24h).
• I nduction of labour.
• D iabetes.
• A ntepartum haemorrhage.
• O ther signifi cant maternal medical conditions.

Fetal: 
I UGR.
• P rematurity.
• O ligohydramnios.
• A bnormal Doppler velocimetry.
• M ultiple pregnancy.
• M econium-stained liquor.
• B reech presentation.

Intrapartum: 
O xytocin augmentation.
• E pidural analgesia.
• I ntrapartum vaginal bleeding.
• P yrexia >37.5º C .
• F resh meconium staining of liquor.
• A bnormal FHR on intermittent auscultation.
• P rolonged labour.

Question 20

Causes of decreased baseline variability of CTG?

Answer 20

F etal hypoxia.
• F etal sleep cycle (should be for <40 and maximally 90min).
• F etal malformation (CNS or cardiac) or arrhythmias.
• A dministration of drugs including: methyldopa, magnesium sulphate, narcotic analgesics, tranquillizers, barbiturates, general anaesthesia,
severe prematurity,
fetal heart block,
fetal anomalies.

Question 21

Indications for instrumental delivery?

Answer 21

Maternal:
Exhaustion.
Prolonged 2nd stage:
• > 1h of active pushing in multiparous women
• > 2h in primiparous women.
Medical indications for avoiding Valsalva manouevre, such as:
• s evere cardiac disease
• h ypertensive crisis
• u ncorrected cerebral vascular malformations.
Pushing is not possible (paraplegia or tetraplegia).

Fetal: F etal compromise, to control the after-coming head of breech (forceps).

Question 22

Complications of operative vaginal delivery?

Answer 22

Forceps - increased maternal trauma inc. anal sphincter tear
Fetal injuries from forceps: 
facial nerve palsy
• s kull fractures
• o rbital injury
• i ntracranial haemorrhage

Ventouse fetal injuries:
• s calp lacerations and avulsions (rarely, alopecia in the long term)
• cephalohaematoma
• retinal haemorrhage
• rarely, subgaleal haemorrhage and/or intracranial haemorrhage.