Week 4 - Childbirth Week Tutorial - Cardiotocography, vaginal exam, mechanism of labour

Question 1

Ideally the baby’s head presents in the birth canal in the occipito-anterior position. This means that the vertex is facing the anterior aspect of the mother, and the baby’s face is looking down toward the floor. What is visible on vaginal examiantion when the foetus is in the occipito-anterior position?

Answer 1

Can palpate the anterior fontanelle, saggital suture, posterior fontanelle and vertex

Question 2

The brow presentation is difficult to deliver as it has a wide diameter; the occiput faces the posterior aspect of the mother, and the baby’s face is upward. Brow presentation happens when your baby’s neck and head are slightly extended (deflexed), as if your baby is looking up. The ideal position for your baby to be born in is with her chin tucked into her chest (flexed position), so her head is well down. What is palpable on vaginal examination in the brow presentation?

Answer 2

Can palpate the anterior fontanelle and the orbital margins

Question 3

A transverse position is where the baby’s head is facing to the mother’s left or right. It is impossible to deliver in this position. However in many cases the fetal head can be rotated to the occipito-anterior position What can be used for the rotation?

Answer 3

Can use manual rotation, vacuum extraction or use Kielland’s rotational forceps

Question 4

Mrs White is 39 weeks into her second pregnancy. She had a normal delivery last time. She is booked for delivery in the local midwifery unit. Q1. Who would have performed this assessment?

Answer 4

The midwife would have performed this assessment

Question 5

Q2. Is it appropriate for her to deliver in the midwife unit?

Answer 5

Yes it is appropriate - she is due to have a spontaneous vaginal delivery with baby in cephalic presentation

Baby is not engaged as 3 abdominal fifths are felt

Question 6

Two hours after admission, the uterine contractions are every two minutes. Mrs White requests pain relief. On examination the cervical os is 2cm dilated. Q3. What options for pain relief can be offered?

Answer 6

• Own means of relaxation
• Position changes or water immersion
• TENS (Transcutaneous electrical nerve stimulation)
• Inhaled nitrous oxide (Entonox)
• IM diamorphine
• Epidural anaesthesia (not spinal because spinal is usually only for emergency cesarean sections)

Question 7

Q4. What options for pain relief can be offered in a midwife delivery unit? TENS, IM diamorphine, Entonox, EPidural? What does Tens and entonox involve?

Answer 7

All apart from the epidural - the epidural anaesthetic requires the presence of an anaesthetist TENS - transcutaneous electrical nerve stimulation Entonox - nitrous oxide and oxygen (laughing gas) Transcutaneous electrical nerve stimulation (TENS) is a method of pain relief involving the use of a mild electrical curren

Question 8

Labour progresses rapidly and three hours later Mrs White has the urge to ‘push.’ The vertex becomes visible at the introitus and she goes on to have an SVD. 5. What is an SVD? 6. Who would perform the repair of the vaginal laceration if deemed necessary?

Answer 8

SVD - this is a spontaneous vaginal delivery The midwife can perform the repair of the vaginal laceration if deemed necessary

Question 9

What is a term baby? When can a baby by delivered in the midwifery unit?

Answer 9

A term baby is a baby at gestation 37-42weeks A baby can be delivered in the midwifery unit if it is an uncomplicated term birth

Question 10

7) What kind of analgesia will be used for the repair of a vaginal laceration in a spontaneous vaginal delivery? Spinal Epidural Pudendal nerve block Topical lignocaine

Answer 10

Topical lignocaine will be given for analgesia to repair the vaginal laceration (or vaginal episiotomy)

Question 11

Case 2 Mrs Johnstone has also booked for delivery in the midwife unit. This is her second pregnancy, having had a normal delivery last time. She presents herself to the midwife unit. Who would have performed this assessment?

Answer 11

Midwife or obtetrician

Question 12

Ms Johnstone is 36 weeks pregnant with the baby in breech presentation Is it appropriate for her to deliver in the midwife unit?

Answer 12

It is not appropriate as she is pre-term with a breech presentation baby

Question 13

Ms Johnstones uterine contractions have began 2every10minutes, lasting 30seconds at moderate intensity Here membranes are intact Q10. What is your subsequent management plan?

Answer 13

Emergency cesarean section as the mother is in labour prematurely and the baby is in breech position

Question 14

The cardiotocograph (CTG) is widely used as a method of assessing fetal condition during labour. It consists of two traces: What are the two traces?

Answer 14

The upper trace is the foetal heart rate The lower trace is the uterine contractions pattern Both traces are plotted against time Cardiotocography is widely used to measure the foetal heart rate - gives an assessment of the foetal condition during labour

Question 15

How is the interpretation of the foetal heart rate interpreted in a cardiotocography scan?

Answer 15

DR - Define rate C - Contractions BRA - Baseline RAte V - Variations A - Accelerations D - Decelerations O - Overall

Question 16

What are the options for defining risk of a CTG? What are the options for overall? WHat is noticed regaridning the contractions?

Answer 16

First stage is determining whether the pregnancy is a high or low risk clinically At the end of assessing the foetal heart rate in response to uterine contractions, have to state whether it is overall reassuring or non-reassuring Regarding the contractions - just look at frequency, how many in 10 minutes

Question 17

What should the baseline foetal heart rate be between? What should the variability of the heart rate within the baseline be? SHould the baseline foetal heart rate include decelerations and accelerations?

Answer 17

Baseline foetal heart should be between 120-160bpm Variability of the heart rate should be >5bpm Do not include accelerations and decelerations when determining the foetal heart rate

Question 18

What does reduced variability in the foetus signify?

Answer 18

Reduced variability signifies that the baby may be sleeping (if lasting only 40 minutes) Foetal acidosis (due to hypoxia) Gestation less than 28 weeks

Question 19

If the baby has reduced variations and late decelerations are present, what is the most likely cause?

Answer 19

Most likely cause is that the baby is hypoxic causing foetal acidosis and reduced variations

Question 20

The presence of accelerations in the heart beat in response to stress eg movement or contractions. Accelerations represent a healthy response. What do decelerations which coincide with uterine contractions mean? Often variable in duration WHat decelerations occuring after a contraction mean?

Answer 20

Variable deceleration - occurring with uterine contractions and Late decelerations, occuring after a contraction are both signs of foetal hypoxia

Question 21

What is variable decelerations usually caused by?

Answer 21

They are usually due to cord compression Late deceleration - usually due to uteroplacental insufficiency

Question 22

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Answer 22

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Question 23

Failure to progress in labour can occur due to: 3Ps, what are these 3 Ps?

Answer 23

Power (uterine contractions) Passages - size of foetus Passenger (size of foetus, presentation of foetus (ie occipito-posterior))

Question 24

A partogram or partograph is a composite graphical record of key data (maternal and fetal) during labour entered against time on a single sheet of paper. Relevant measurements might include statistics such as cervical dilation, fetal heart rate, duration of labour and vital signs.

• WHat is the nomral increase in cervical dilation?
• What does it dilate up to?
• What is measured on Bishop’s score?

Answer 24

Cervical dilatation increases at 1-2cm per hour - dilates up to a max of 10cm

Bishop’s score - likelihood to require induction of labour

• Cervical position - max score of 2
• Cervical consistency - max score of 2
• Cervical effacement - thinness of cervix - max score of 3
• Cervical dilatation - max score of 3
• Station of foetus - cm above/below ischial spines- max of 3

Question 25

A bishops score of what indicates the labour will continue spontaneously or require induction?

Answer 25

Bishop score, also Bishop’s score, also known as cervix score is a pre-labor scoring system to assist in predicting whether induction of labor will be required A score of 5 or less suggests that labour is unlikely to start without induction. A score of 9 or more indicates that labour will most likely commence spontaneously.

Question 26

When performing a digital vaginal examination on a woman in labour it is essential that the position of the fetus is identified. What is the position of the foetus defined as?

Answer 26

The relationship between the denominator of the presentation and the pelvic brim

Question 27

What is the denominator in a vertex presentation of the foetus?

What is the denominator in the breech presentation?

What is the denominator in the face presentation?

What is the denominator in the brow presentation?

Answer 27

Vertex - occiput

Breech - sacrum

Face - chin (mentum)

Brow - frontum

The presentation of a fetus about to be born refers to which anatomical part of the fetus is leading, that is, is closest to the pelvic inlet of the birth canal.

Question 28

Ideally the baby’s head presents in the birth canal in the occipito-anterior position. This means that the vertex is facing the anterior aspect of the mother, and the baby’s face is looking down toward the floor. WHat part of the foetal skull will be palpable on vaginal examiantion?

Answer 28

The posterior fontanelle, sagittal suture, anterior fontanelle and vertex are all palpable The normal process of delivery though the maternal pelvis involves the fetal head entering the pelvic inlet (widest diameter transverse) in an occipitotransverse position. It then rotates to an occipitoanterior position as it reaches the pelvic outlet (widest diameter anteroposterior). As the fetal head descends beyond the ischial spines it extends, resulting in a normal vaginal delivery.

Question 29

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Answer 29

1. Lamboid suture 2. Sagittal suture 3. Coronal suture 4. Frontal suture 5. Posterior fontanelle 6. Parietal eminence 7. Parietal bone 8. Anterior fontanelle

Question 30

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Answer 30

• 1. Left occipito lateral - C
• 2. Direct occipitoposterior - A
• 3. Right occipito Posterior - B
• 4. Direct occipitoanterior - D

Whatever side of the mother the occiput is on is the side (right or left)

Question 31

What is shown on the pelvic diagram on the left?

After the head exits the vagina in labour, the head now rotates to its natural position with the shoulder.

• What is this known as?

Answer 31

1. Pubic symphysis
2. Ischial spine
3. Sacral promontory

This is known as Restitution