Labour and Delivery

Question 1

How do you describe gravidy and parity?

Answer 1

Question 2

What is a wood uterus which is painful on palpation indicative of?

Answer 2

Placental abruption

Question 3

What is chorioamnionitis

Answer 3

Infection of the membranes in the uterus

Typical signs: maternal and feotal tachycardia, Pyrexia and uterine tenderness

Typical symptoms: fever abdominal pain offensive Vaginal discharge

Indications for admission and delivery

Question 4

When should delivery be aimed for in Obstetric choleostasis?

Answer 4

37-38 weeks

Question 5

Classic triad of amniotic fluid embolism

Answer 5

Coagulopathy, hypoxia and hypotension

Question 6

What is the most popular analgesia for mild labour pain and what advantages does it have?

Answer 6

Entonox (1:1 inhaled NO and O2)

Does not interfere with endogenous oxytocin nor labour progression.

Does not cross placenta readily therefore does not affect foetal HR nor newborn respiratory rate

Question 7

What might be required if pre eclampsia complications occur of maternal BP cannot be controlled?

Answer 7

Planned early birth may be necessary if the blood pressure cannot be controlled or complications occur.

Question 8

What should be given to women having a premature birth to help mature fetal lungs?

Answer 8

Corticosteroids

Question 9

At what point following delivery will blood pressure return to normal in a woman with pre eclampsia?

Answer 9

Blood pressure is monitored closely after delivery. Blood pressure will return to normal over time once the placenta is removed.

Question 10

Pre eclampsia management following delivery?

Answer 10

For medical treatment, NICE recommend after delivery switching to one or a combination of:

Enalapril (first-line)
Nifedipine or amlodipine (first-line in black African or Caribbean patients)
Labetolol or atenolol (third-line)

Question 11

Braxton-Hicks contractions

Answer 11

Braxton-Hicks contractions are occasional irregular contractions of the uterus. They are usually felt during the second and third trimester. Women can experience temporary and irregular tightening or mild cramping in the abdomen. These are not true contractions, and they do not indicate the onset of labour. They do not progress or become regular. Staying hydrated and relaxing can help reduce Braxton-Hicks contractions.

Question 12

What is ‘the show’?

Answer 12

The “show” refers to the mucus plug in the cervix, that prevents bacteria from entering the uterus during pregnancy, falling out and creating space for the baby to pass through.

Question 13

What is meant by presentation?

Answer 13

Presentation: the part of the fetus closest to the cervix

Question 14

Types of presentation?

Answer 14

Cephalic presentation – the head is first.
Shoulder presentation – the shoulder is first.
Breech presentation – the legs are first. This can be:
Complete breech – with hips and knees flexed (like doing a cannonball jump into a pool)
Frank breech – with hips flexed and knees extended, bottom first
Footling breech – with a foot hanging through the cervix

Question 15

Types of lie?

Answer 15

Longitudinal lie – the fetus is straight up and down.
Transverse lie – the fetus is straight side to side.
Oblique lie – the fetus is at an angle.

Question 16

What is meant by lie?

Answer 16

The position of the fetus in relation to the mother’s body

Question 17

What is meant by attitude of the fetous?

Answer 17

the posture of the fetus. For example, how the back is rounded and how the head and limbs are flexed.

Question 18

What are the seven cardinal movements of labour?

Answer 18

Engagement

Descent

Flexion

Internal Rotation

Extension

Restitution and external rotation

Expulsion

Question 19

dWhat is descent and how is it measured?

Answer 19

Obstetricians describe the position of the baby’s head in relation to the mother’s ischial spines during the descent phase. Descent is measured in centimetres, from:

-5: when the baby is high up at around the pelvic inlet
0: when the head is at the ischial spines (this is when the head is “engaged”)
+5: when the fetal head has descended further out

Question 20

Signs of labour?

Answer 20

Show (mucus plug from the cervix)
Rupture of membranes
Regular, painful contractions
Dilating cervix on examination

Question 21

Latent first stage of labour

Answer 21

Painful contractions

Changes to the cervix, with effacement and dilation up to 4cm

Question 22

Established first stage of labour

Answer 22

Regular, painful contractions

Dilatation of the cervix from 4cm onwards

Question 23

Established vs latent first stage of labour

Answer 23

Established: contractions are REGULAR, cervix dilated from 4cm onwards

Question 24

From which point until when is the first stage of labour

Answer 24

The first stage of labour is from the onset of labour (true contractions) until the cervix is fully dilated to 10cm.

Question 25

What is considered the latent phase of first stage of labour, and how quickly does it progress?

Answer 25

from 0 to 3cm dilation of the cervix. This progresses at around 0.5cm per hour. There are irregular contractions.

Question 26

What is considered the active phase of first stage of labour and how quickly does it progress?

Answer 26

from 3cm to 7cm dilation of the cervix. This progresses at around 1cm per hour, and there are regular contractions.

Question 27

What is considered the transition phase of the first stage of labour and how quickly does it progress?

Answer 27

from 7cm to 10cm dilation of the cervix. This progresses at around 1cm per hour, and there are strong and regular contractions

Question 28

Cervical changes in first stage of labour?

Answer 28

It involves cervical dilation (opening up) and effacement (getting thinner).

Question 29

Labour and delivery normally occur between how many weeks gestation?

Answer 29

37 and 42 weeks gestation.

Question 30

Role of oxytocin during labour?

Answer 30

Oxytocin stimulates the ripening of the cervix and contractions of the uterus during labour and delivery.

Question 31

When might an oxytocin infusion be used?

Answer 31

Induce labour

Progress labour

Improve the frequency and strength of uterine contractions

Prevent or treat postpartum haemorrhage

Question 32

What is Syntocinon?

Answer 32

Brand name of oxytocin

Question 33

What is Atosiban and when might it be used?

Answer 33

Atosiban is an oxytocin receptor antagonist that can be used as an alternative to nifedipine for tocolysis in premature labour (when nifedipine is contraindicated).

Question 34

What is Ergometrine and when is it used?

Answer 34

Ergometrine is derived from ergot plants. It stimulates smooth muscle contraction, both in the uterus and blood vessels.

This makes it useful for delivery of the placenta and to reduce postpartum bleeding. It may be used during the third stage of labour (delivery of the placenta) and postpartum to prevent and treat postpartum haemorrhage.

It is only used after delivery of the baby, not in the first or second stage.

Question 35

Ergometrine Side Effects

Answer 35

Due to the action on the smooth muscle in blood vessels and gastrointestinal tract, it can cause several side effects, including hypertension, diarrhoea, vomiting and angina

Question 36

In what conditions can ergometrine not be used/be used with significant caution?

Answer 36

It needs to be avoided in eclampsia, and used only with significant caution in patients with hypertension.

Question 37

What is Syntometrine and what can it be used to treat?

Answer 37

Syntometrine is a combination drug containing oxytocin (Syntocinon) and ergometrine. It can be used for prevention or treatment of postpartum haemorrhage.

Question 38

Dinoprostone, which is prostaglandin E2, can come in which three forms?

Answer 38

Vaginal pessaries (Propess)
Vaginal tablets (Prostin tablets)
Vaginal gel (Prostin gel)

Question 39

What is misoprostol and when is it used?

Answer 39

Misoprostol is a prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them. It is used as medical management in miscarriage, to help complete the miscarriage. Misoprostol is used alongside mifepristone for abortions, and induction of labour after intrauterine fetal death.

Question 40

What is Mifepristone and when is it used?

Answer 40

Mifepristone is an anti-progestogen medication that blocks the action of progesterone, halting the pregnancy and ripening the cervix. It enhances the effects of prostaglandins to stimulate contraction of the uterus. Mifepristone is used alongside misoprostol for abortions, and induction of labour after intrauterine fetal death. It is not used during pregnancy with a healthy living fetus.

Question 41

What is Nifedipine and when is it used in pregnancy?

Answer 41

Nifedipine is a calcium channel blocker that acts to reduce smooth muscle contraction in blood vessels and the uterus. It has two main uses in pregnancy:

Reduce blood pressure in hypertension and pre-eclampsia
Tocolysis in premature labour, where it suppresses uterine activity and delays the onset of labour

Question 42

What are tocolytics?

Answer 42

Tocolytics are medications used to suppress premature labor.

Question 43

What is Terbutaline and when is it used?

Answer 43

Terbutaline is a beta-2 agonist, similar to salbutamol. It stimulates beta-2 adrenergic receptors. It acts on the smooth muscle of the uterus to suppress uterine contractions. It is used for tocolysis in uterine hyperstimulation, notably when the uterine contractions become excessive during induction of labour.

Question 44

What is carboprost and when is it used?

Answer 44

Carboprost is a synthetic prostaglandin analogue, meaning it binds to prostaglandin receptors.

It stimulates uterine contraction. It is given as a deep intramuscular injection in postpartum haemorrhage, where ergometrine and oxytocin have been inadequate.

Question 45

In which patients should carboprost be avoided/used with particular caution?

Answer 45

Notably, it needs to be avoided or used with particular caution in patients with asthma, as it can cause a potentially life-threatening exacerbation of the asthma.

Question 46

In which patients should carboprost be avoided/used with particular caution?

Answer 46

Notably, it needs to be avoided or used with particular caution in patients with asthma, as it can cause a potentially life-threatening exacerbation of the asthma.

Question 47

What is tranexamic acid and when might it be used in delivery?

Answer 47

Tranexamic acid is an antifibrinolytic medication that reduces bleeding. It binds to plasminogen and prevents it from converting to plasmin. Plasmin is an enzyme that works to dissolve the fibrin within blood clots. Fibrin is a protein that helps hold blood clots together. Therefore, by decreasing the activity of the enzyme plasmin, tranexamic acid helps prevent the breakdown of blood clots.

Tranexamic acid is used in the prevention and treatment of postpartum haemorrhage.

Question 48

What can improve pain symptoms in labour without the used of medications?

Answer 48

Understanding what to expect
Having good support
Being in a relaxed environment
Changing position to stay comfortable
Controlled breathing
Water births may help some women
TENS machines may be useful in the early stages of labour
Hyponobirthing
Music therapy

Question 49

Simple analgesia in early labour?

Answer 49

Paracetamol is frequently used in early labour. Codeine may be added for additional effect. NSAIDs are avoided.

Question 50

What is Gas and air (Entonox) and how is it used?

Answer 50

Gas and air contains a mixture of 50% nitrous oxide and 50% oxygen.

This is used during contractions for short term pain relief.
The woman takes deep breaths using a mouthpiece at the start of a contraction, then stops using it as the contraction eases.

Question 51

Entonox side effects?

Answer 51

It can cause lightheadedness, nausea or sleepiness.

Question 52

What opioid medications can be used in labour which may also help with anxiety and distress?

Answer 52

Pethidine and diamorphine, usually given by intramuscular injection.

Question 53

Considerations when using PCA for patients in labour?

Answer 53

Patient-controlled analgesia requires careful monitoring. There needs to be input from an anaesthetist, and facilities in place if adverse events occur. This includes access to naloxone for respiratory depression, and atropine for bradycardia.

Question 54

What might be given as PCA for a woman in labour?

Answer 54

Patients may be offered the option of patient-controlled intravenous remifentanil. This involves the patient pressing a button at the start of a contraction to administer a bolus of this short-acting opiate medication.

Question 55

What is an epidural, and where is it placed?

Answer 55

An epidural involves inserting a small tube (catheter) into the epidural space in the lower back. This is outside the dura mater, separate from the spinal cord and CSF.

Local anaesthetic medications are infused through the catheter into the epidural space, where they diffuse to the surrounding tissues and through to the spinal cord, where they have an analgesic effect. This offers good pain relief during labour.

Question 56

What are the anesthetic options for use in an epidural?

Answer 56

Levobupivacaine or bupivacaine, usually mixed with fentanyl.

Question 57

What are the potential adverse affects of an epidural?

Answer 57

Headache after insertion
Hypotension
Motor weakness in the legs
Nerve damage
Prolonged second stage
Increased probability of instrumental delivery

Question 58

Why do women with an epidural need urgent anaesthetic review if they develop significant motor weakness (unable to straight leg raise)?

Answer 58

Headache after insertion
Hypotension
Motor weakness in the legs
Nerve damage
Prolonged second stage
Increased probability of instrumental delivery

Question 59

The third stage of labour is from the completed birth of the baby to the delivery of the placenta. What are the two options for the third stage?

Answer 59

PHYSIOLOGICAL MANAGEMENT - placenta is delivered by maternal effort without medications or cord traction

ACTIVE MANAGEMENT - midwife or doctor assist in delivering of the placenta.

Question 60

Active management of third stage of labour?

Answer 60

Patient given a dose of intramuscular oxytocin to help the uterus contract, and careful traction to the umbilical cord to guide the placenta out of the uterus and vagina.

Intramuscular dose of oxytocin (10 IU) after delivery of the baby.

The cord is clamped and cut within 5 minutes of birth. There should be a delay of 1 – 3 minutes between delivery of the baby and clamping of the cord to allow blood to flow to the baby (unless the baby needs resuscitation).

The abdomen is palpated to assess for a uterine contraction before delivery of the placenta.

Controlled cord traction is carefully applied during uterine contractions to help deliver the placenta, stopping if there is resistance. At the same time the other hand presses the uterus upwards (in the opposite direction) to prevent uterine prolapse. The aim is to deliver the placenta in one piece.

After delivery the uterus is massaged until it is contracted and firm. The placenta is examined to ensure it is complete and no tissue remains in the uterus.

Question 61

Advantage and disadvantage of active management of third stage of labour

Answer 61

Active management shortens the third stage and reduces the risk of bleeding, but can be associated with nausea and vomiting.

Question 62

When will active management be used in third stage of labour?

Answer 62

Routinely offered to ALL WOMEN reduce the risk of PPH

Initiated in hemorrhage

Initiated if more than a 60-minute delay in delivery of the placenta (prolonged third stage)

Question 63

What is a TENS machine

Answer 63

Attached to back delivers small electric pulses for pain relief in early labour

Question 64

Pethidine pros and cons

Answer 64

Pros

Effective pain relief

Relaxing effects allows for smoother contractions

Cons

Baby may need naloxone if given too close to birth

Mother may not like numb feeling detached from contractions

Question 65

Epidural side effects

Answer 65

Can be patchy if anesthetic fails to reach all areas

Hypotension, will require if fluids

Headache

Prolonging of second stage of labour

More likely to need assisted delivery

Question 66

Entonox pros and cons

Answer 66

Pros
O2 good for baby
Doesn’t linger in system for long

Cons
Drowsiness light headedness
Relatively mild

Question 67

When can you attempt external cephalic version for a transverse lie

Answer 67

You can attempt external cephalic version for a transverse lie if the amniotic sac has not ruptured

Question 68

What should be assessed prior to induction of labour?

Answer 68

The Bishop score should be assessed in all women prior to induction of labour.

Question 69

Components of bishop score?

Answer 69

Cervical position (posterior/intermediate/anterior)
Cervical consistency (firm/intermediate/soft)
Cervical effacement (0-30%/40-50%/60-70%/80%)
Cervical dilation (<1 cm/1-2 cm/3-4 cm/>5 cm)
Foetal station (-3/-2/-1, 0/+1,+2)

Question 70

A bishop score lower than what number indicated labour is unlikely to start without induction?

Answer 70

5

Question 71

When suspecting PPROM if there is no fluid in the posterior vaginal on vault then how might you investigate?

Answer 71

ultrasound may be used to look for oligohydramnios

Question 72

What is required to make a diagnosis of PPROM?

Answer 72

History PLUS positive speculum examination (pool of fluid noted in the vagina) is required to make a diagnosis of PPROM.

Question 73

Intrahepatic cholestasis of pregnancy increases the risk of stillbirth; therefore how is delivery managed?

Answer 73

Induction of labour is generally offered at 37-38 weeks gestation

Question 74

Indications for a C section

Answer 74

absolute cephalopelvic disproportion

placenta praevia grades 3/4

pre-eclampsia

post-maturity

IUGR

fetal distress in labour/prolapsed cord

failure of labour to progress

malpresentations: brow

placental abruption: only if fetal distress; if dead deliver vaginally

vaginal infection e.g. active herpes

cervical cancer (disseminates cancer cells)

Question 75

Category 1 C section

Answer 75

Most urgent

an immediate threat to the life of the mother or baby

examples indications include: suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia or persistent fetal bradycardia

delivery of the baby should occur within 30 minutes of making the decision

Question 76

Category 2 C section

Answer 76

Urgent but less than cat 1

maternal or fetal compromise which is not immediately life-threatening
delivery of the baby should occur within 75 minutes of making the decision

Question 77

Cat 3 C section

Answer 77

Less urgent than Cat 1 and 2

delivery is required, but mother and baby are stable

Question 78

Category 4 C section

Answer 78

Elective

Question 79

Serious maternal complications of C Section

Answer 79

emergency hysterectomy

need for further surgery at a later date, including curettage (retained placental tissue)

admission to intensive care unit

thromboembolic disease

bladder injury

ureteric injury

death (1 in 12,000)

Question 80

“Serious” implications of C section on future deliveries

Answer 80

increased risk of uterine rupture during subsequent pregnancies/deliveries
increased risk of antepartum stillbirth
increased risk in subsequent pregnancies of placenta praevia and placenta accreta)

Question 81

Frequent risks of c section

Answer 81

Maternal

persistent wound and abdominal discomfort in the first few months after surgery

increased risk of repeat caesarean section when vaginal delivery attempted in subsequent pregnancies

readmission to hospital

haemorrhage

infection (wound, endometritis, UTI)

Fetal:

lacerations, one to two babies in every 100

Question 82

When is VBAC suitable/not suitable

Answer 82

planned VBAC is an appropriate method of delivery for pregnant women at >= 37 weeks gestation with a single previous Caesarean delivery

around 70-75% of women in this situation have a successful vaginal delivery

contraindications include previous uterine rupture or classical (vertical) caesarean scar

Question 83

What should be offered to women with a previous baby with early- or late-onset GBS disease who is in labour

Answer 83

Maternal intravenous antibiotic prophylaxis should be offered to women during labour with a previous baby with early- or late-onset GBS disease

Question 84

Actions to take in shoulder dystocia?

Answer 84

Initially, request senior help and ask the mother to hyperflex their legs (also called McRobert’s manouvere) and apply suprapubic pressure. This method works in 90% of cases.

If this method fails, episiotomy is required to allow internal manouveres. A number of potential options, including Wood’s screw manouvere and grasping and manipulation of the posterior arm are then possible.

Last resorts include symphisiotomy and the Zavanelli manouvere (which includes Caesarean section, however by this point fetal damage is often irreversible)

Question 85

Delivery in case of shoulder dystocia

Answer 85

Immediately after shoulder dystocia is recognised, additional help should be called.

Fundal pressure should not be used.

An episiotomy is not always necessary.

Induction of labour at term can actually reduce the incidence of shoulder dystocia in women with gestational diabetes.

McRoberts manoeuvre is the first line intervention as it is known to be simple, rapid and effective in most cases

Question 86

How is carboprost given in PPH?

Answer 86

IM

Question 87

Why is a hx of asthma significant in a woman with PPH?

Answer 87

IM carboprost should be avoided in patients with asthma as it can trigger bronchoconstriction.

Question 88

Example of indications for category 1 C section

Answer 88

suspected uterine rupture
major placental abruption
cord prolapse
fetal hypoxia
persistent fetal bradycardia

Question 89

What is the preferred method of induction of labour?

Answer 89

Vaginal PGE2 is the preferred method of induction of labour

Question 90

The thyrotoxicosis phase of postpartum thyroiditis is generally managed with what?

Answer 90

Propranolol alone

Question 91

What is Sheehan’s syndrome?

Answer 91

Sheehan’s syndrome is a complication of severe postpartum haemorrhage (PPH) in which the pituitary gland undergoes ischaemic necrosis which can manifest as hypopituitarism.

Question 92

Most common sign of Sheehan’s syndrome?

Answer 92

lack of postpartum milk production and amenorrhoea following delivery.

Question 93

How is Sheenans syndrome diagnosed?

Answer 93

Diagnosis of Sheehan’s is by inadequate prolactin and gonadotropin stimulation tests in patients with a history of severe PPH.

Question 94

Place of birth

Answer 94

Home birth
Midwife lead units
Hospital birth

Question 95

How often should contractions be in labour

Answer 95

3-4 every ten mins

Question 96

How long do contractions last in labour

Answer 96

Around a minute

Question 97

What dilation is established labour

Answer 97

4-6cm

Question 98

Medicated pain relief in labour

Answer 98

Codeine
Entonox
Pethidine/meptid- IM (note pethidine crosses placenta)
Epidural

Question 99

At what dilation can epidurals be put in

Answer 99

4cm onwards

Question 100

Frequency of observations on mother in labour - low risk

Answer 100

4hrly

Question 101

Established labour prior to full dilatation - feotal observation frequency

Answer 101

15 min observations with sonicade

Question 102

Full dilation - how often listen to to foetal HR

Answer 102

every five mins

Question 103

How long does the second stage of labour typically last in nulliparous women?

Answer 103

40 mins

Question 104

Occurrence of cervical ripening in relation to hormones

Answer 104

It occurs in response to oestrogen, relaxin and prostaglandins breaking down cervical connective tissue; prostaglandins are of particular importance. Prostaglandins are produced by the placenta, the uterine decidua, the myometrium and the membranes. Their synthesis increases throughout the third trimester as a result of an increase in the oestrogen:progesterone ratio.

Question 105

What does cervical ripening involve?

Answer 105

A reduction in collagen.

An increase in glycosaminoglycans.

An increase in hyaluronic acid.

Reduced aggregation of collagen fibres.

This means that the cervix offers less resistance to the presenting part of the foetus during labour.

Question 106

What changes towards the end of pregnancy help to facilitate an increase in uterine musculature excitability

Answer 106

The relative decrease in progesterone in relation to oestrogen that occurs towards the end of pregnancy helps to facilitate an increase in the excitability of the uterine musculature. This is because progesterone typically inhibits contractions and oestrogen increases the number of gap junctions between smooth muscle cells, increasing contractility.

Mechanical stretching of the uterus also helps to increase contractility – this means as the foetus grows, the contractility of the muscle increases.

Question 107

Why does oxytocin have only a limited action during most of the pregnancy

Answer 107

Throughout pregnancy it has limited action as there are a low number of oxytocin receptors and it is inhibited by relaxin and progesterone.

Question 108

How does to role of oxytocin change around 36 weeks gestation

Answer 108

At around 36 weeks gestation, under the influence of oestrogen there is an increase in the number of oxytocin receptors present within the myometrium. This means the uterus begins to respond to the pulsatile release of oxytocin from the posterior pituitary gland.

Question 109

What is the Ferguson reflex?

Answer 109

Oxytocin production is increased by afferent impulses from the cervix and vagina.

This means that contractions result in a positive feedback loop to the posterior pituitary gland to release more oxytocin, leading to stronger contractions which then drives the process of labour.

Brain stimulates PG to produce oxytocin -> oxytocin carried through blood stream to uterus -> oxytocin stimulates uterine contractions and pushes baby toward cervix -> Head of baby pushes on cervix -> nerve impulse from cervix travel to brain, which then stimulates PG to produce oxytocin again

Question 110

Typical rate of active phase of second stage of labour

Answer 110

1cm/hr in nulliparous women and 2cm/hr in multiparous women

This phase should not normally last longer than 16 hours

Question 111

Why does uterine capacity decrease during the second stage of labour, and how does this help?

Answer 111

The fibres of the myometrium are specially adapted to drive the process of labour as they do not fully relax following each contraction. This steadily reduces the uterine capacity, so the pressure inside becomes stronger as labour progresses and helps with expulsion of the foetus.

Question 112

How are contractions made more forceful and frequent in the second stage of labour

Answer 112

Contractions are made more forceful and frequent by the actions of two hormones:

Prostaglandins – more intracellular calcium is released per action potential, increasing the force of contractions
Oxytocin – lowers the threshold for action potentials, increasing the frequency of contractions

Question 113

How long does the second stage of labour typically last in multiparous women?

Answer 113

20 mins

Question 114

After what duration of the active stage of labour does spontaneous delivery become increasingly unlikely?

Answer 114

1 hour

Question 115

What happens in delivery of a baby in terms of sequence of emergence?

Answer 115

Once the head of the foetus reaches the perineum, it extends in order to come up and out of the pelvis.

Following delivery of the head, it rotates by 90 degrees to assist with delivery of the shoulders.

The anterior shoulder delivers first, coming under the symphysis pubis while the body flexes laterally and posteriorly to aid passage.

Following this the body flexes laterally and anteriorly to help deliver the posterior shoulder.

Once the shoulders have been delivered the rest of the body follows.

Question 116

In the third stage of labour, by what mechanism is normal bleeding (>500ml) controlled?

Answer 116

Contraction of the uterus constricts blood vessels in the myometrium
Pressure is exerted on the placental site once it has been delivered by the walls of the contracted uterus
The normal blood clotting mechanism

Question 117

What effect does mechanical stretching have on the contractility of the uterus?

Answer 117

Increases contractibility

Question 118

First stage of labour

Answer 118

A faster rate of cervical dilatation until 10cm dilatation is reached. This phase should not normally last longer than 16 hours.

Question 119

At which point during labour does the woman typically experience the desire to push?

Answer 119

The woman experiences the desire to push during the passive stage of the second stage of labour. It is at this point that uterine contractions become expulsive, rotation and flexion of the foetal head are completed, and the foetus reaches the pelvic floor, resulting in the desire to push. This typically only lasts a few minutes. During the active stage of the second stage, the woman pushes in conjunction which her contractions in order to expel the foetus.

Question 120

Following an umbilical cord prolapse, what can be done to avoid compression

Answer 120

Following an umbilical cord prolapse, the presenting part of the fetus may be pushed back into the uterus to avoid compression

Question 121

For how long should magnesium sulfate be continued following a seizure?

Answer 121

Magnesium treatment should continue for 24 hours after delivery or after last seizure

Question 122

A history of sudden collapse occurring soon after a rupture of membranes is suggestive of what?

Answer 122

Amniotic fluid emboli

Question 123

Management of placental abruption when the fetus is alive, <36 weeks and not showing signs of distress?

Answer 123

admit and administer steroids

Question 124

First line investigation/examination of preterm prelabour rupture of the membranes

Answer 124

Careful speculum examination to look for pooling of amniotic fluid in the posterior vaginal vault is the first-line investigation for preterm prelabour rupture of the membranes

Question 125

What is the most appropriate mode of delivery for a patient with a classical Caesarian scar (vertical)?

Answer 125

Planned caesarean section at 37 weeks gestation

Classical caesarean scar is a contraindication to vaginal birth after caesarean

Question 126

Classical caesarean scar is a contraindication to vaginal birth after caesarean - why?

Answer 126

A vaginal delivery is contraindicated in this scenario due to the increased risk of uterine rupture which could be potentially fatal for both the mother and the baby.

Question 127

Risks of prematurity?

Answer 127

increased mortality depends on the gestation

respiratory distress syndrome

intraventricular haemorrhage

necrotizing enterocolitis

chronic lung disease, hypothermia, feeding problems, infection, jaundice

retinopathy of prematurity
important cause of visual impairment in babies born before 32 weeks gestation
the cause is not fully understood and multivariate. One of the contributing factors is thought to be over oxygenation (e.g. during ventilation) resulting in a proliferation of retinal blood vessels (neovascularization)
screening is done in at-risk groups

hearing problems

Question 128

What is complete breech presentation

Answer 128

Breech presentation – the legs are first. This can be:
Complete breech – with hips and knees flexed (like doing a cannonball jump into a pool)

Question 129

What is footling breech presentation

Answer 129

Breech presentation – the legs are first. This can be:

Footling breech – with a foot hanging through the cervix

Question 130

What is frank breech presentation?

Answer 130

Breech presentation – the legs are first. This can be:

Frank breech – with hips flexed and knees extended, bottom first

Question 131

What is transverse lie?

Answer 131

Fetus side to side

Question 132

What is longitudinal lie

Answer 132

Fetus straight up and down

Question 133

What is oblique lie?

Answer 133

Fetus is at an angle

Question 134

What is cephalic presentation

Answer 134

Head is the part of the Fetus closest to the cervix

Question 135

What is shoulder presentation

Answer 135

Shoulder is the part of Fetus closest to the cervix

Question 136

Cardinal movements of labour - 1.descent

Answer 136

The fetus descends into the pelvis.

In the primigravida this is likely to occur from 38 weeks gestation onwards, in a multigravida woman, this may not occur until labour is established.

Descent is encouraged by:

Increased abdominal muscle tone
Braxton hicks in the late stages of pregnancy
Fundal dominance of the uterine contractions during labour
Increased frequency and strength of contractions during labour
As the head descends, it moves towards the pelvic brim in either the left or right occipito-transverse position (this means the occiput can be facing the left side or right side of the mother’s pelvis).

Question 137

Cardinal movements of labour - 2. Engagement

Answer 137

This is when the largest diameter of the fetal head descends into the maternal pelvis.

The term engagement is referring to the widest part of the fetal head successfully negotiating its way down deep into the maternal pelvis. Engagement is identified by abdominal palpation, where the fetal head is 3/5th palpable or less.

Feotal head reaches station 0

Question 138

How much of the fetal head is palpable at engagement

Answer 138

3/5 or less

Question 139

Cardinal movements of labour 3. Flexion

Answer 139

As the fetus descends through the pelvis, fundal dominance of uterine contraction exerts pressure down the fetal spine towards the occiput, forcing the occiput to come into contact with the pelvic floor. When this occurs the fetal neck flexes (chin to chest) allowing the circumference of the fetal head to reduce to sub-occipitobregmatic (9.5cm).

In this position, the fetal skull has a smaller diameter which assists passage through the pelvis.

Question 140

Cardinal movements of labour - 4. Internal rotation

Answer 140

The pelvic floor has a gutter shape with a forward and downward slope, encouraging the fetal head to rotate from the left or right occipito-transverse position a total of 90-degrees, to an occipital-anterior (occiput facing forward) position, to lie under the subpubic arch.

With each maternal contraction, the fetal head pushes down on the pelvic floor. Following each contraction, a rebound effect supports a small degree of rotation. Regular contractions eventually lead to the fetal head completing the 90-degree turn.

This rotation will occur during established labour and it is commonly completed by the start of the second stage. Further descent leads to the fetus moving into the vaginal canal and eventually, with each contraction, the vertex becomes increasingly visible at the vulva.

Question 141

Cardinal movements,emits of labour 5.extensions

Answer 141

The occiput slips beneath the suprapubic arch allowing the head to extend. The fetal head is now born and will be facing the maternal back with its occiput anterior.

Question 142

What is crowning

Answer 142

When the widest diameter of the fetal head successfully negotiates through the narrowest part of the maternal bony pelvis, the fetal head is considered to be ‘crowning’. This is clinically evident when the head, visible at the vulva, no longer retreats between contractions. Complete delivery of the head is now imminent and often the woman, who has been pushing, is encouraged to pant so that the head is born with control.

Question 143

6th Cardinal movement of labour - expulsion

Answer 143

Because the shoulders at the point of the head being delivered are only just reaching the pelvic floor they are often still negotiating the pelvic outlet and the fetus may naturally align its head with the shoulders.

This is called restitution and visually you may see the head externally rotate to face the right or left medial thigh of the mother.

During the next contraction, the shoulders, having reached the pelvic floor, will complete their rotation from a transverse position to an anterior-posterior position. Evidence of this manoeuvre happening inside can be visualised by seeing the head externally rotating as the fetus keeps its spine aligned.

Question 144

Cardinal movements of labour -7. Expulsion

Answer 144

Downward traction by the healthcare professional will assist the delivery of the anterior shoulder below the suprapubic arch.

This is followed by upward traction assisting the delivery of the posterior shoulder.

The fetal body will be delivered by the contractions, the health professional’s role is only to assist safe negotiation of this last stage.

Question 145

Risks of prematurity

Answer 145

increased mortality depends on the gestation
respiratory distress syndrome
intraventricular haemorrhage
necrotizing enterocolitis
chronic lung disease, hypothermia, feeding problems, infection, jaundice
retinopathy of prematurity
important cause of visual impairment in babies born before 32 weeks gestation
the cause is not fully understood and multivariate. One of the contributing factors is thought to be over oxygenation (e.g. during ventilation) resulting in a proliferation of retinal blood vessels (neovascularization)
screening is done in at-risk groups
hearing problems

Question 146

False labour

Answer 146

Occurs in the last 4 weeks of pregnancy
Presentation: contractions felt in the lower abdomen. The contractions are irregular and occur every 20 minutes. Progressive cervical changes are absent.

Question 147

When and why might early delivery be considered

Answer 147

Early delivery is considered when growth is static on the growth charts, or other problems are identified (e.g. abnormal Doppler results).

This reduces the risk of stillbirth. Corticosteroids are given when delivery is planned early, particularly when delivered by caesarean section.

Paediatricians should be involved at birth to help with neonatal resuscitation and management if required.

Question 148

Delivery of monoamniotic twins

Answer 148

Monoamniotic twins require elective caesarean section at between 32 and 33 + 6 weeks.

Question 149

Delivery of diamniotic twins

Answer 149

Aim to deliver between 37 and 37 + 6 weeks

Vaginal delivery is possible when the first baby has a cephalic presentation (head first)
Caesarean section may be required for the second baby after successful birth of the first baby
Elective caesarean is advised when the presenting twin is not cephalic presentation

Question 150

Delivery in cardiac arrest

Answer 150

Immediate caesarean section is performed in a pregnant woman when:

There is no response after 4 minutes to CPR performed correctly
CPR continues for more than 4 minutes in a woman more than 20 weeks gestation

The aim is to deliver the baby and placenta within 5 minutes of CPR commencing.
The operation is performed at the site of the arrest, for example, in A&E resus or on the ward.

The primary reason for the immediate delivery is to improve the survival of the mother.
Delivery improves the venous return to the heart, improves cardiac output and reduces oxygen consumption.
It also helps with ventilation and chest compressions.
Delivery increases the chances of the baby surviving, although this is secondary to the survival of the mother.

Question 151

Delivery in placenta praevia

Answer 151

Planned delivery is considered between 36 and 37 weeks gestation. It is planned early to reduce the risk of spontaneous labour and bleeding. Planned cesarean section is required with placenta praevia and low-lying placenta (<20mm from the internal os).

Depending on the position of the placenta and fetus, different incisions may be made in the skin and uterus, for example, vertical incisions. Ultrasound may be around the time of the procedure to locate the placenta.

Emergency caesarean section may be required with premature labour or antenatal bleeding.

Question 152

Delivery in placenta acretta

Answer 152

Delivery is planned between 35 to 36 + 6 weeks gestation to reduce the risk of spontaneous labour and delivery. Antenatal steroids are given to mature the fetal lungs before delivery.

Question 153

Options of c section in placenta acretta

Answer 153

Hysterectomy with the placenta remaining in the uterus (recommended)
Uterus preserving surgery, with resection of part of the myometrium along with the placenta
Expectant management, leaving the placenta in place to be reabsorbed over time comes with significant risks, particularly bleeding and infection.

Question 154

Placenta accreta

Question 155

RCOG guidelines on placenta accreta discovered during delivery

Answer 155

The RCOG guideline (2018) suggests that if placenta accreta is seen when opening the abdomen for an elective caesarean section, the abdomen can be closed and delivery delayed whilst specialist services are put in place. If placenta accreta is discovered after delivery of the baby, a hysterectomy is recommended.

Question 156

Management of breech postion

Answer 156

Babies that are breech before 36 weeks often turn spontaneously, so no intervention is advised. External cephalic version (ECV) can be used at term (37 weeks) to attempt to turn the fetus.

Where ECV fails, women are given a choice between vaginal delivery and elective caesarean section. Vaginal delivery needs to involve experienced midwives and obstetricians, with access to emergency theatre if required.

Overall, vaginal birth is safer for the mother, and caesarean section is safer for the baby. There is about a 40% chance of requiring an emergency caesarean section when vaginal birth is attempted.

When the first baby in a twin pregnancy is breech, caesarean section is required.

Question 157

What is external cephalic version

Answer 157

External cephalic version (ECV) is a technique used to attempt to turn a fetus from the breech position to a cephalic position using pressure on the pregnant abdomen. It is about 50% successful.

Question 158

External cephalic version is used in babies that are breech - when?

Answer 158

After 36 weeks for nulliparous women (women that have not previously given birth)
After 37 weeks in women that have given birth previously

Question 159

What are women given when ECV is performed

Answer 159

Women are given tocolysis to relax the uterus before the procedure. Tocolysis is with subcutaneous terbutaline. Terbutaline is a beta-agonist similar to salbutamol. It reduces the contractility of the myometrium, making it easier for the baby to turn.

Rhesus-D negative women require anti-D prophylaxis when ECV is performed. A Kleihauer test is used to quantify how much fetal blood is mixed with the maternal blood, to determine the dose of anti-D that is required.

Question 160

Conditions increasing the risk of still birth

Answer 160

Unexplained (around 50%)
Pre-eclampsia
Placental abruption
Vasa praevia
Cord prolapse or wrapped around the fetal neck
Obstetric cholestasis
Diabetes
Thyroid disease
Infections, such as rubella, parvovirus and listeria
Genetic abnormalities or congenital malformations

Question 161

Factors increasing the risk of still birth

Answer 161

Fetal growth restriction
Smoking
Alcohol
Increased maternal age
Maternal obesity
Twins
Sleeping on the back (as opposed to either side)

Question 162

Still birth prevention - SGA

Answer 162

A risk assessment for having a baby that is small for gestational age (SGA) or with fetal growth restriction (FGR) is performed on all pregnant women. Having risk factors for SGA increases the risk of stillbirth. Those at risk have the fetal growth closely monitored with serial growth scans. This helps identify women that need further investigations and management. They may need planned early delivery when the growth is static, or other concerns are identified.

Question 163

Prevention of still birth - pre eclampsia

Answer 163

Women at risk of pre-eclampsia are given aspirin.

Question 164

Modifiable risk factors for still birth

Answer 164

Any modifiable risk factors for stillbirth are treated, for example, stopping smoking, avoiding alcohol and effective control of diabetes. Sleeping on the side (not the back) is advised.

Question 165

Key symptoms which may cause concerns re still birth

Answer 165

Reduced fetal movements
Abdominal pain
Vaginal bleeding

Question 166

Delivery following IUFD

Answer 166

Vaginal birth is first-line for most women after IUFD, unless there are other reasons for caesarean section. Women are given a choice of induction of labour or expectant management (provided immediate delivery is not required, for example with sepsis, pre-eclampsia or haemorrhage).

Expectant management involves awaiting natural labour and delivery. Women with expectant management need close monitoring. The condition of the fetus will deteriorate with time.

Induction of labour involves using a combination of oral mifepristone (anti-progesterone) and vaginal or oral misoprostol (prostaglandin analogue).

Question 167

Investigating cause of still birth

Answer 167

With parental consent, testing is carried out after stillbirth to determine the cause:

Genetic testing of the fetus and placenta
Postmortem examination of the fetus (including xrays)
Testing for maternal and fetal infection
Testing the mother for conditions associated with stillbirth, such as diabetes, thyroid disease and thrombophilia

Identifying the cause can help reduce the risk in future pregnancies. Pregnancies are closely monitored in women with previous stillbirth.

Question 168

Rupture of membranes (ROM)

Answer 168

The amniotic sac has ruptured

Question 169

Spontaneous rupture of membranes (SROM)

Answer 169

Amniotic sac has ruptured spontaneously

Question 170

Prelabour rupture of membranes (PROM)

Answer 170

The amniotic sac has ruptured before the onset of labour.

Question 171

Preterm prelabour rupture of membranes (P‑PROM)

Answer 171

The amniotic sac has ruptured before the onset of labour and preterm (prior to 37 weeks gestation)

Question 172

Prolonged rupture of membranes (also PROM)

Answer 172

Amniotic sac ruptures over 18 hours prior to delivery

Question 173

Before what gestation is considered prematurity

Answer 173

37 weeks

Question 174

The more premature a baby, the worse the probable outcome is considered. When is resuscitation considered in a premature birth

Answer 174

Babies are considered non-viable below 23 weeks gestation.

Generally, from 23 to 24 weeks, resuscitation is not considered in babies that do not show signs of life. Babies born at 23 weeks have around a 10% chance of survival.

From 24 weeks onwards, there is an increased chance of survival, and full resuscitation is offered.

Question 175

Extreme preterm

Answer 175

Under 28 weeks

Question 176

Very preterm

Answer 176

28-32 weeks

Question 177

Moderate to late preterm

Answer 177

32-37 weeks

Question 178

Prophylaxis for preterm labour - vaginal progesterone

Answer 178

Progesterone can be given vaginally via gel or pessary as prophylaxis for preterm labour.

Progesterone has a role in maintaining pregnancy and preventing labour by decreasing activity of the myometrium and preventing the cervix remodelling in preparation for delivery.

This is offered to women with a cervical length less than 25mm on vaginal ultrasound between 16 and 24 weeks gestation.

Question 179

Prophylaxis of preterm labour - cervical cerclage

Answer 179

Cervical cerclage involves putting a stitch in the cervix to add support and keep it closed. This involves a spinal or general anaesthetic. The stitch is removed when the woman goes into labour or reaches term.

Cervical cerclage is offered to women with a cervical length less than 25mm on vaginal ultrasound between 16 and 24 weeks gestation, who have had a previous premature birth or cervical trauma (e.g. colposcopy and cone biopsy).

“Rescue” cervical cerclage may also be offered between 16 and 27 + 6 weeks when there is cervical dilatation without rupture of membranes, to prevent progression and premature delivery.

Question 180

Diagnosis of preterm prelabour rupture of membranes

Answer 180

Rupture of membranes can be diagnosed by speculum examination revealing pooling of amniotic fluid in the vagina. No tests are required.

Where there is doubt about the diagnosis, tests can be performed:

Insulin-like growth factor-binding protein-1 (IGFBP-1) is a protein present in high concentrations in amniotic fluid, which can be tested on vaginal fluid if there is doubt about rupture of membranes
Placental alpha-microglobin-1 (PAMG-1) is a similar alternative to IGFBP-1

Question 181

Management of preterm prelabour rupture of membranes

Answer 181

Prophylactic antibiotics should be given to prevent the development of chorioamnionitis. The NICE guidelines (2019) recommend erythromycin 250mg four times daily for ten days, or until labour is established if within ten days.

Induction of labour may be offered from 34 weeks to initiate the onset of labour.

Question 182

Preterm Labour with Intact Membranes

Answer 182

Preterm labour with intact membranes involves regular painful contraction and cervical dilatation, without rupture of the amniotic sac.

Question 183

Preterm Labour with Intact Membranes - Diagnosis

Answer 183

Clinical assessment includes a speculum examination to assess for cervical dilatation. The NICE guidelines (2017) recommend:

Less than 30 weeks gestation, clinical assessment alone is enough to offer management of preterm labour.
More than 30 weeks gestation, a transvaginal ultrasound can be used to assess the cervical length. When the cervical length on ultrasound is less than 15mm, management of preterm labour can be offered. A cervical length of more than 15mm indicates preterm labour is unlikely.

Fetal fibronectin is an alternative test to vaginal ultrasound. Fetal fibronectin is the “glue” between the chorion and the uterus, and is found in the vagina during labour. A result of less than 50 ng/ml is considered negative, and indicates that preterm labour is unlikely.

Question 184

Improving outcomes in preterm labour without rupture of membranes

Answer 184

Fetal monitoring (CTG or intermittent auscultation)
Tocolysis with nifedipine: nifedipine is a calcium channel blocker that suppresses labour
Maternal corticosteroids: can be offered before 35 weeks gestation to reduce neonatal morbidity and mortality
IV magnesium sulphate: can be given before 34 weeks gestation and helps protect the baby’s brain
Delayed cord clamping or cord milking: can increase the circulating blood volume and haemoglobin in the baby at birth

Question 185

What is tocolysis, and what are the options?

Answer 185

Tocolysis involves using medications to stop uterine contractions. Nifedipine, a calcium channel blocker, is the medication of choice for tocolysis. Atosiban is an oxytocin receptor antagonist that can be used as an alternative when nifedipine is contraindicated.

Question 186

When is tocolysis used

Answer 186

Tocolysis can be used between 24 and 33 + 6 weeks gestation in preterm labour to delay delivery and buy time for further fetal development, administration of maternal steroids or transfer to a more specialist unit (e.g. with a neonatal ICU). It is only used as a short term measure (i.e. less than 48 hours).

Question 187

Antenatal steroids

Answer 187

Giving the mother corticosteroids helps to develop the fetal lungs and reduce respiratory distress syndrome after delivery. They are used in women with suspected preterm labour of babies less than 36 weeks gestation.

An example regime would be two doses of intramuscular betamethasone, 24 hours apart.

Question 188

Role of magnesium sulfate in preterm labour

Answer 188

Giving the mother IV magnesium sulfate helps protect the fetal brain during premature delivery. It reduces the risk and severity of cerebral palsy. Magnesium sulphate is given within 24 hours of delivery of preterm babies of less than 34 weeks gestation. It is given as a bolus, followed by an infusion for up to 24 hours or until birth.

Question 189

Monitoring following use of magnesium sulfate in premature labour

Answer 189

Mothers need close monitoring for magnesium toxicity at least four hourly. This involves close monitoring of observations, as well as tendon reflexes (usually patella reflex). Key signs of toxicity are:

Reduced respiratory rate
Reduced blood pressure
Absent reflexes

Question 190

Indications for induction of labour

Answer 190

Between 40 and 41 weeks
Prelabour rupture of membranes
Fetal growth restriction
Pre-eclampsia
Obstetric cholestasis
Existing diabetes
Intrauterine fetal death

Question 191

Bishop score

Answer 191

The Bishop score is a scoring system used to determine whether to induce labour.

Five things are assessed and given a score based on different criteria (minimum score is 0 and maximum is 13):

Fetal station (scored 0 – 3)
Cervical position (scored 0 – 2)
Cervical dilatation (scored 0 – 3)
Cervical effacement (scored 0 – 3)
Cervical consistency (scored 0 – 2)

A score of 8 or more predicts a successful induction of labour. A score below this suggests cervical ripening may be required to prepare the cervix.

Question 192

Options for induction of labour

Answer 192

Membrane sweep

Vaginal prostaglandin E2 (dinoprostone)

Cervical ripening ballon (CRB)

Artificial rupture of membranes with an oxytocin infusion

(Oral mifepristone (anti-progesterone) plus misoprostol are used to induce labour where intrauterine fetal death has occurred)

Question 193

What is a membrane sweep and when is it performed

Answer 193

Membrane sweep involves inserting a finger into the cervix to stimulate the cervix and begin the process of labour.

It can be performed in antenatal clinic, and if successful, should produce the onset of labour within 48 hours.

A membrane sweep is not considered a full method of inducing labour, and is more of an assistance before full induction of labour.

It is used from 40 weeks gestation to attempt to initiate labour in women over their EDD.

Question 194

Use of dinoprostone in induction of labour

Answer 194

Vaginal prostaglandin E2 (dinoprostone) involves inserting a gel, tablet (Prostin) or pessary (Propess) into the vagina. The pessary is similar to a tampon, and slowly releases local prostaglandins over 24 hours. This stimulates the cervix and uterus to cause the onset of labour. This is usually done in the hospital setting so that the woman can be monitored before being allowed home to await the full onset of labour.

Question 195

What is a cervical ripening ballon and when is it used to induce labour

Answer 195

Cervical ripening balloon (CRB) is a silicone balloon that is inserted into the cervix and gently inflated to dilate the cervix. This is used as an alternative where vaginal prostaglandins are not preferred, usually in women with a previous caesarean section, where vaginal prostaglandins have failed or multiparous women (para ≥ 3).

Question 196

What is artificial rupture of membranes with oxytocin infusion and when is it used

Answer 196

Artificial rupture of membranes with an oxytocin infusion can also be used to induce labour, although this would only be used where there are reasons not to use vaginal prostaglandins. It can be used to progress the induction of labour after vaginal prostaglandins have been used.

Question 197

What are the means of monitoring during the induction of labour

Answer 197

Cardiotocography (CTG) to assess the fetal heart rate and uterine contractions before and during induction of labour

Bishop score before and during induction of labour to monitor the progress

Question 198

Ongoing management following induction of labour when there is slow or no progress

Answer 198

Most women will give birth within 24 hours of the start of induction of labour.

The options when there is slow or no progress are:

Further vaginal prostaglandins
Artificial rupture of membranes and oxytocin infusion
Cervical ripening balloon (CRB)
Elective caesarean section

Question 199

What is the main complication of induction of labour and what constitutes it

Answer 199

Uterine hyperstimulation is the main complication of induction of labour with vaginal prostaglandins. This is where the contraction of the uterus is prolonged and frequent, causing fetal distress and compromise.

The criteria for uterine hyperstimulation varies slightly between guidelines (always check local policies and involve experienced seniors). The two criteria often given are:

Individual uterine contractions lasting more than 2 minutes in duration
More than five uterine contractions every 10 minutes

Question 200

Potential consequences of uterine hyperstimulation

Answer 200

Fetal compromise, with hypoxia and acidosis
Emergency caesarean section
Uterine rupture

Question 201

Management of uterine hyperstimulation

Answer 201

Removing the vaginal prostaglandins, or stopping the oxytocin infusion
Tocolysis with terbutaline

Question 202

What is Cardiotocography (CTG)

Answer 202

Cardiotocography (CTG) is used to measure the fetal heart rate and the contractions of the uterus. It is also known as electronic fetal monitoring. It is a useful way of monitoring the condition of the fetus and the activity of labour.

Question 203

CTG operation

Answer 203

Two transducers are placed on the abdomen to get the CTG readout:

One above the fetal heart to monitor the fetal heartbeat
One near the fundus of the uterus to monitor the uterine contractions

The transducer above the fetal heart monitors the heartbeat using Doppler ultrasound. The transducer above the fundus uses ultrasound to assess the tension in the uterine wall, indicating uterine contraction.

Question 204

Indications for continuous CTG monitoring in labour

Answer 204

Sepsis
Maternal tachycardia (> 120)
Significant meconium
Pre-eclampsia (particularly blood pressure > 160 / 110)
Fresh antepartum haemorrhage
Delay in labour
Use of oxytocin
Disproportionate maternal pain

Question 205

What are the five key features on CTG

Answer 205

Contractions – the number of uterine contractions per 10 minutes
Baseline rate – the baseline fetal heart rate
Variability – how the fetal heart rate varies up and down around the baseline
Accelerations – periods where the fetal heart rate spikes
Decelerations – periods where the fetal heart rate drops

Question 206

CTG: contractions

Answer 206

The number of uterine contractions per 10 minutes

Contractions are used to gauge the activity of labour.

Too few contractions indicate labour is not progressing.

Too many contractions can mean uterine hyperstimulation, which can lead to fetal compromise.

It is also important to interpret the fetal heart rate in the context of the uterine contractions.

Question 207

CTG: Accelerations

Answer 207

Periods where fetal HR spikes
Accelerations are generally a good sign that the fetus is healthy, particularly when occurring alongside contractions of the uterus.

Question 208

What is baseline rate on CTG

Answer 208

Baseline fetal HR

Question 209

Reassuring baseline rate

Answer 209

110 – 160

Question 210

Baseline rate - non-reassuring

Answer 210

100 – 109 or 161 – 180

Question 211

Abnormal baseline rate

Answer 211

100 – 109 or 161 – 180

Question 212

Variability - reassuring

Answer 212

5 – 25

Question 213

Variability - non reassuring

Answer 213

Less than 5 for 30 – 50 minutes or

More than 25 for 15 – 25 minutes

Question 214

Variability - abnormal

Answer 214

Less than 5 for over 50 minutes or

More than 25 for over 25 minutes

Question 215

What is variability on CTG

Answer 215

Variability – how the fetal heart rate varies up and down around the baseline

Question 216

What are decelerations on CTG and why are they concerning

Answer 216

Decelerations are a more concerning finding. The fetal heart rate drops in response to hypoxia. The fetal heart rate is slowing to conserve oxygen for the vital organs.

Decelerations – periods where the fetal heart rate drops

Question 217

What are decelerations on CTG

Answer 217

Decelerations are a more concerning finding. The fetal heart rate drops in response to hypoxia. The fetal heart rate is slowing to conserve oxygen for the vital organs.

Question 218

Where are the four types of decelerations on CTG

Answer 218

Early decelerations
Late decelerations
Variable decelerations
Prolonged decelerations

Question 219

Early decelerations

Answer 219

Early decelerations are gradual dips and recoveries in heart rate that correspond with uterine contractions. The lowest point of the declaration corresponds to the peak of the contraction. Early decelerations are normal and not considered pathological. They are caused by the uterus compressing the head the fetus, stimulating the vagus nerve of the fetus, slowing the heart rate.

Question 220

What causes early decelerations

Answer 220

They are caused by the uterus compressing the head the fetus, stimulating the vagus nerve of the fetus, slowing the heart rate.

Not normally pathological

Question 221

Late decelerations on CTG

Answer 221

Late decelerations are gradual falls in heart rate that starts after the uterine contraction has already begun.

There is a delay between the uterine contraction and the deceleration.

The lowest point of the declaration occurs after the peak of the contraction.

Question 222

What causes late decelerations on CTG

Answer 222

Late decelerations are caused by hypoxia in the fetus, and are a more concerning finding. They may be caused by excessive uterine contractions, maternal hypotension or maternal hypoxia.

Question 223

Variable decelerations on CTG

Answer 223

Variable decelerations are abrupt decelerations that may be unrelated to uterine contractions. There is a fall of more than 15 bpm from the baseline. The lowest point of the declaration occurs within 30 seconds, and the deceleration lasts less than 2 minutes in total. Variable decelerations often indicate intermittent compression of the umbilical cord, causing fetal hypoxia. Brief accelerations before and after the deceleration are known as shoulders, and are a reassuring sign that the fetus is coping.

Question 224

Prolonged decelerations on CTG

Answer 224

Prolonged decelerations last between 2 and 10 minutes with a drop of more than 15 bpm from baseline. This often indicates compression of the umbilical cord, causing fetal hypoxia. These are abnormal and concerning.

Question 225

What makes a CTG reassuring

Answer 225

CTG is reassuring when there are no decelerations, early decelerations or less than 90 minutes of variable decelerations with no concerning features.

Question 226

What makes a CTG abnormal

Answer 226

Regular variable decelerations and late decelerations are classed as non-reassuring or abnormal, depending on the features.

Prolonged decelerations are always abnormal.

Question 227

Non reassuring CTG

Answer 227

Regular variable decelerations and late decelerations are classed as non-reassuring or abnormal, depending on the features.

Question 228

What are the four categories of CTG and what defines them

Answer 228

Normal

Suspicious: a single non-reassuring feature

Pathological: two non-reassuring features or a single abnormal feature

Need for urgent intervention: acute bradycardia or prolonged deceleration of more than 3 minutes

Question 229

The outcome of the CTG will guide management, such as what?

Answer 229

Escalating to a senior midwife and obstetrician
Further assessment for possible causes, such as uterine hyperstimulation, maternal hypotension and cord prolapse
Conservative interventions such as repositioning the mother or giving IV fluids for hypotension
Fetal scalp stimulation (an acceleration in response to stimulation is a reassuring sign)
Fetal scalp blood sampling to test for fetal acidosis
Delivery of the baby (e.g. instrumental delivery or emergency caesarean section)

Question 230

The rules of 3 for fetal bradycardia when they are prolonged

Answer 230

3 minutes – call for help
6 minutes – move to theatre
9 minutes – prepare for delivery
12 minutes – deliver the baby (by 15 minutes)

Question 231

What is a sinusoidal CTG, what does it indicate

Answer 231

A sinusoidal CTG is a rare pattern to be aware of, as it can indicate severe fetal compromise. It gives a pattern similar to a sine wave, with smooth regular waves up and down that have an amplitude of 5 – 15 bpm. It is usually associated with severe fetal anaemia, for example, caused by vasa praevia with fetal haemorrhage.

Question 232

DR C BRaVADO

Answer 232

DR C BRaVADO is a mnemonic often taught to assess the features of a CTG in a structured way. It involves assessing in order:

DR – Define Risk (define the risk based on the individual woman and pregnancy before assessing the CTG)
C – Contractions
BRa – Baseline Rate
V – Variability
A – Accelerations
D – Decelerations
O – Overall impression (given an overall impression of the CTG and clinical picture)

Question 233

What is cord prolapse and why is it serious?

Answer 233

Cord prolapse is when the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after rupture of the fetal membranes.

There is a significant danger of the presenting part compressing the cord, resulting in fetal hypoxia.

Question 234

What is the highest risk factor for cord prolapse

Answer 234

The most significant risk factor for cord prolapse is when the fetus is in an abnormal lie after 37 weeks gestation (i.e. unstable, transverse or oblique). Being in an abnormal lie provides space for the cord to prolapse below the presenting part. In a cephalic lie, the head typically descends into the pelvis, without room for the cord to descend.

Question 235

How is umbilical cord prolapse diagnosed

Answer 235

Umbilical cord prolapse should be suspected where there are signs of fetal distress on the CTG. A prolapsed umbilical cord can be diagnosed by vaginal examination. Speculum examination can be used to confirm the diagnosis.

Question 236

Management of cord prolapse

Answer 236

Emergency caesarean section is indicated where cord prolapse occurs. (A normal vaginal delivery has a high risk of cord compression and significant hypoxia to the baby)

The cord should be kept warm and wet and have minimal handling whilst waiting for delivery (handling causes vasospasm) (Pushing the cord back in is not recommended)

When the baby is compressing a prolapsed cord, the presenting part can be pushed upwards to prevent it compressing the cord.

The woman can lie in the left lateral position (with a pillow under the hip) or the knee-chest position (on all fours), using gravity to draw the fetus away from the pelvis and reduce compression on the cord.

Tocolytic medication (e.g. terbutaline) can be used to minimise contractions whilst waiting for delivery by caesarean section.

Question 237

What is shoulder dystocia

Answer 237

Shoulder dystocia is when the anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis, after the head has been delivered. This requires additional obstetric manoeuvres to enable delivery of the rest of the body. Shoulder dystocia is an obstetric emergency.

Question 238

What is the most common cause of shoulder dystocia

Answer 238

Shoulder dystocia is often caused by macrosomia secondary to gestational diabetes.

Question 239

Presentation of shoulder dystocia

Answer 239

Shoulder dystocia presents with difficulty delivering the face and head, and obstruction in delivering the shoulders after delivery of the head.

There may be failure of restitution, where the head remains face downwards (occipito-anterior) and does not turn sideways as expected after delivery of the head.

The turtle-neck sign is where the head is delivered but then retracts back into the vagina.

Question 240

Delivery techniques for shoulder dystocia

Answer 240

Episiotomy can be used to enlarge the vaginal opening and reduce the risk of perineal tears. It is not always necessary.

McRoberts manoeuvre involves hyperflexion of the mother at the hip (bringing her knees to her abdomen). This provides a posterior pelvic tilt, lifting the pubic symphysis up and out of the way.

Pressure to the anterior shoulder involves pressing on the suprapubic region of the abdomen. This puts pressure on the posterior aspect of the baby’s anterior shoulder, to encourage it down and under the pubic symphysis.

Rubins manoeuvre involves reaching into the vagina to put pressure on the posterior aspect of the baby’s anterior shoulder to help it move under the pubic symphysis.

Wood’s screw manoeuvre is performed during a Rubins manoeuvre. The other hand is used to reach in the vagina and put pressure on the anterior aspect of the posterior shoulder. The top shoulder is pushed forwards, and the bottom shoulder is pushed backwards, rotating the baby and helping delivery. If this does not work, the reverse motion can be tried, pushing the top shoulder backwards and the bottom shoulder forwards.

Zavanelli manoeuver involves pushing the baby’s head back into the vagina so that the baby can be delivered by emergency caesarean section.

Question 241

What is Rubin’s manouever

Answer 241

Rubins manoeuvre involves reaching into the vagina to put pressure on the posterior aspect of the baby’s anterior shoulder to help it move under the pubic symphysis.

Question 242

What is the Woods screw manoeuvre

Answer 242

Wood’s screw manoeuvre is performed during a Rubins manoeuvre (reaching into the vagina to put pressure on the posterior aspect of the baby’s anterior shoulder to help it move under the pubic symphysis)

The other hand is used to reach in the vagina and put pressure on the anterior aspect of the posterior shoulder.
The top shoulder is pushed forwards, and the bottom shoulder is pushed backwards, rotating the baby and helping delivery. If this does not work, the reverse motion can be tried, pushing the top shoulder backwards and the bottom shoulder forwards.

Question 243

What is the Zavanelli manoeuver

Answer 243

involves pushing the baby’s head back into the vagina so that the baby can be delivered by emergency Caesarean section

Question 244

What are the key complications of shoulder dystocia

Answer 244

Fetal hypoxia (and subsequent cerebral palsy)
Brachial plexus injury and Erb’s palsy
Perineal tears
Postpartum haemorrhage

Question 245

What is meant by instrumental delivery

Answer 245

Instrumental delivery refers to a vagina delivery assisted by either a ventouse suction cup or forceps. Tools are used to help deliver the baby’s head. About 10% of births in the UK are assisted by an instrumental delivery.

The procedure can usually be carried out on the labour ward. However, if there are concerns about whether it will be successful, the woman may be moved to theatre so that rapid delivery by caesarean section can be performed if necessary.

Question 246

What is recommended after instrumental delivery to reduce the risk of maternal infection?

Answer 246

A single dose of co-amoxiclav

Question 247

Potential indications for instrumental delivery

Answer 247

Failure to progress
Fetal distress
Maternal exhaustion
Control of the head in various fetal positions

Question 248

What method of analgesia increases the risk of need for instrumental delivery

Answer 248

Epidural

Question 249

What are the increased risks to the mother during and instrumental delivery

Answer 249

Postpartum haemorrhage
Episiotomy
Perineal tears
Injury to the anal sphincter
Incontinence of the bladder or bowel
Nerve injury (obturator or femoral nerve)

Question 250

Potential risks to fetus during instrumental delivery

Answer 250

Key risks
Cephalohaematoma with ventouse
Facial nerve palsy with forceps

Rare but more serious risks
Subgaleal haemorrhage (most dangerous)
Intracranial haemorrhage
Skull fracture
Spinal cord injury

Question 251

What is a ventouse and what is the main complication of its use

Answer 251

A ventouse is essentially a suction cup on a cord. The suction cup goes on the baby’s head, and the doctor or midwife applies careful traction to the cord to help pull the baby out of the vagina.

The main complication for the baby is cephalohaematoma. This involves a collection of blood between the skull and the periosteum.

Question 252

What is forceps delivery and what are the associated risk

Answer 252

Forceps look like large metal salad tongs. They come as two pieces of curved metal that attach together, go either side of the baby’s head and grip the head in a way that allows the doctor or midwife to apply careful traction and pull the head from the vagina.

The main complication for the baby is facial nerve palsy, with facial paralysis on one side.

Forceps delivery can leave bruises on the baby’s face. Rarely the baby can develop fat necrosis, leading to hardened lumps of fat on their cheeks. Fat necrosis resolves spontaneously over time.

Question 253

Rarely an instrumental delivery may result in nerve injury for the mother. How long can this take to resolve

Answer 253

6-8 weeks

Question 254

Rarely an instrumental delivery may result in nerve injury for the mother. Which nerves may be injured?

Answer 254

Femoral nerve
Obturator nerve

Question 255

Rarely an instrumental delivery may result in nerve injury for the mother. What will happen in the femoral nerve is damaged?

Answer 255

Compression against the inguinal canal during delivery, leading to:

Weakness of knee extension
Loss of patella reflex
Numbness over the anterior thigh and medial lower leg

Question 256

Rarely an instrumental delivery may result in nerve injury for the mother. What will happen in the obturator nerve is damaged?

Answer 256

The obturator nerve may be compressed by forceps during instrumental delivery or by the fetal head during normal delivery.

Injury causes weakness of hip adduction and rotation, and numbness of the medial thigh.

Question 257

What nerves can be damaged in an unassisted vaginal birth

Answer 257

Obturator nerve
Lateral cutaneous nerve of the thigh
Lumbosacral plexus
Common peroneal nerve

Question 258

How can the lateral cutaneous nerve be injured during childbirth and how will this present

Answer 258

The lateral cutaneous nerve of the thigh runs under the inguinal ligament. Prolonged flexion at the hip while in the lithotomy position can result in injury,

causing numbness of the anterolateral thigh.

Question 259

How can the lumbosacral plexus be injured during childbirth and how will this present

Answer 259

The lumbosacral plexus may be compressed by the fetal head during the second stage of labour. Injury to this network of nerves nerve can cause foot drop and numbness of the anterolateral thigh, lower leg and foot.

Question 260

How can the common peroneal nerve be injured during childbirth and how will this present

Answer 260

The common peroneal nerve may be compressed on the head of the fibula whilst in the lithotomy position. Injury to this nerve causes foot drop and numbness in the lateral lower leg.

Question 261

What is a perineal tare

Answer 261

A perineal tear occurs where the external vaginal opening is too narrow to accommodate the baby. This leads to the skin and tissues in that area tearing as the baby’s head passes.

Perineal tears can range from a graze, to a large tear involving the anal sphincter (third-degree) and rectal mucosa (fourth-degree).

Question 262

In which situations is perineal tare more common

Answer 262

First births (nulliparity)
Large babies (over 4kg)
Shoulder dystocia
Asian ethnicity
Occipito-posterior position
Instrumental deliveries

Question 263

What is a first degree perineal tare

Answer 263

First-degree – injury limited to the frenulum of the labia minora (where they meet posteriorly) and superficial skin

Question 264

What is a second degree perineal tare

Answer 264

Second-degree – including the perineal muscles, but not affecting the anal sphincter

Question 265

Third degree perineal tare

Answer 265

Third-degree – including the anal sphincter, but not affecting the rectal mucosa

Question 266

Fourth degree perineal tare

Answer 266

Fourth-degree – including the rectal mucosa

Question 267

Subcategories of third degree perineal tear

Answer 267

Third-degree – including the anal sphincter, but not affecting the rectal mucosa

3A – less than 50% of the external anal sphincter affected
3B – more than 50% of the external anal sphincter affected
3C – external and internal anal sphincter affected

Question 268

Repair of pernieal tear

Answer 268

First-degree tears usually do not require any sutures.

When a perineal tear larger than first degree occurs, the mother usually requires sutures to correct the injury.

A third or fourth-degree tear is likely to need repairing in theatre.

Question 269

Additional management measures to prevent complications following perineal tare repair

Answer 269

Broad-spectrum antibiotics to reduce the risk of infection
Laxatives to reduce the risk of constipation and wound dehiscence
Physiotherapy to reduce the risk and severity of incontinence
Followup to monitor for longstanding complications

Question 270

When might a c section be indicated following a perineal tear

Answer 270

Women that are symptomatic after third or fourth-degree tears are offered an elective caesarean section in subsequent pregnancies.

Question 271

Short term complications of perineal tear

Answer 271

Pain
Infection
Bleeding
Wound dehiscence or wound breakdown

Question 272

Perineal tear long term complications

Answer 272

Urinary incontinence
Anal incontinence and altered bowel habit (third and fourth-degree tears)
Fistula between the vagina and bowel (rare)
Sexual dysfunction and dyspareunia (painful sex)
Psychological and mental health consequences

Question 273

What is an episiotomy and why might it be done

Answer 273

An episiotomy is where the obstetrician or midwife cuts the perineum before the baby is delivered.

This is done in anticipation of needing additional room for delivery of the baby (e.g. before forceps delivery).

It is performed under local anaesthetic. A cut is made at around 45 degrees diagonally, from the opening of the vagina downwards and laterally, to avoid damaging the anal sphincter. This is called a mediolateral episiotomy. The cut is sutured after delivery.

Question 274

What can be done to reduce the risk of perineal tear

Answer 274

Perineal massage is a method for reducing the risk of perineal tears. It involves massaging the skin and tissues between the vagina and anus (perineum). This is done in a structured way from 34 weeks onwards to stretch and prepare the tissues for delivery.

Question 275

When during the first stage of labour would be considered delayed

Answer 275

Less than 2cm of cervical dilatation in 4 hours

Slowing of progress in a multiparous women

Question 276

Women are monitored for their progress in the first stage of labour using what?

Answer 276

Partogram

Question 277

What is recorded on a partogram

Answer 277

Cervical dilatation (measured by a 4-hourly vaginal examination)
Descent of the fetal head (in relation to the ischial spines)
Maternal pulse, blood pressure, temperature and urine output
Fetal heart rate
Frequency of contractions
Status of the membranes, presence of liquor and whether the liquor is stained by blood or meconium
Drugs and fluids that have been given

Question 278

What are uterine contractions measured in

Answer 278

Number in ten mins (e.g. 2 in 10)

Question 279

There are two lines on the partogram that indicate when labour may not be progressing adequately, what are they

Answer 279

Alert and action

Question 280

What is meant by the alert and action lines on a partogram

Answer 280

There are two lines on the partogram that indicate when labour may not be progressing adequately.

These are labelled “alert” and “action”.

The dilation of the cervix is plotted against the duration of labour (time).

When it takes too long for the cervix to dilate, the readings will cross to the right of the alert and action lines.

Question 281

Crossing the alert line is an indication for what

Answer 281

Amniotomy (artificial rupture of membranes) and a repeat examination in 2 hours.

Question 282

What should be done when the action line is crossed on a partogram

Answer 282

Crossing the action line means care needs to be escalated to obstetric-led care and senior decision-makers for appropriate action.

Question 283

Possible interventions when there is failure to progress in the second stage of labour

Answer 283

Changing positions
Encouragement
Analgesia
Oxytocin
Episiotomy
Instrumental delivery
Caesarean section

Question 284

What is delay in the third stage of labour classed as?

Answer 284

More than 30 minutes with active management (intramuscular oxytocin and controlled cord traction)

More than 60 minutes with physiological management

Question 285

What are the main options for managing failure to progress

Answer 285

Amniotomy, also known as artificial rupture of membranes (ARM) for women with intact membranes
Oxytocin infusion
Instrumental delivery
Caesarean section

Question 286

What is used to stimulate uterine contractions in labour

Answer 286

Oxytocin is used first-line to stimulate uterine contractions during labour. It is started at a low rate and titrated up at intervals of at least 30 minutes as required. The aim is for 4 – 5 contractions per 10 minutes. Too few contractions will mean that labour does not progress. Too many contractions can result in fetal compromise, as the fetus does not have the opportunity to recover between contractions.

Question 287

How much blood loss quantifies PPH

Answer 287

500ml after a vaginal delivery
1000ml after a caesarean section

Question 288

Minor vs major PPH

Answer 288

Minor PPH – under 1000ml blood loss
Major PPH – over 1000ml blood loss

Question 289

Major PPH: moderate vs severe

Answer 289

Moderate PPH – 1000 – 2000ml blood loss
Severe PPH – over 2000ml blood loss

Question 290

Primary vs secondary PPH

Answer 290

Primary PPH: bleeding within 24 hours of birth
Secondary PPH: from 24 hours to 12 weeks after birth

Question 291

What are the four causes of PPH

Answer 291

T – Tone (uterine atony – the most common cause)
T – Trauma (e.g. perineal tear)
T – Tissue (retained placenta)
T – Thrombin (bleeding disorder)

Question 292

Risk factors for PPH

Answer 292

Previous PPH
Multiple pregnancy
Obesity
Large baby
Failure to progress in the second stage of labour
Prolonged third stage
Pre-eclampsia
Placenta accreta
Retained placenta
Instrumental delivery
General anaesthesia
Episiotomy or perineal tear

Question 293

Preventative measures against PPH

Answer 293

Treating anaemia during the antenatal period
Giving birth with an empty bladder (a full bladder reduces uterine contraction)
Active management of the third stage (with intramuscular oxytocin in the third stage)
Intravenous tranexamic acid can be used during caesarean section (in the third stage) in higher-risk patients

Question 294

What does management of PPH entail

Answer 294

Resuscitation with an ABCDE approach
Lie the woman flat, keep her warm and communicate with her and the partner
Insert two large-bore cannulas
Bloods for FBC, U&E and clotting screen
Group and cross match 4 units
Warmed IV fluid and blood resuscitation as required
Oxygen (regardless of saturations)
Fresh frozen plasma is used where there are clotting abnormalities or after 4 units of blood transfusion

In severe cases, activate the major haemorrhage protocol. Each hospital will have a major haemorrhage protocol, which gives rapid access to 4 units of crossmatched or O negative blood.

Question 295

PPH: treatment to stop the bleeding

Answer 295

Mechanical:

• Rubbing the uterus through the abdomen to stimulates a uterine contraction (referred to as “rubbing up the fundus”)
• Catheterisation (bladder distention prevents uterus contractions)

Medical:

xytocin (slow injection followed by continuous infusion)
Ergometrine (intravenous or intramuscular) stimulates smooth muscle contraction (contraindicated in hypertension)
Carboprost (intramuscular) is a prostaglandin analogue and stimulates uterine contraction (caution in asthma)
Misoprostol (sublingual) is also a prostaglandin analogue and stimulates uterine contraction
Tranexamic acid (intravenous) is an antifibrinolytic that reduces bleeding

Surgical:

Intrauterine balloon tamponade – inserting an inflatable balloon into the uterus to press against the bleeding
B-Lynch suture – putting a suture around the uterus to compress it
Uterine artery ligation – ligation of one or more of the arteries supplying the uterus to reduce the blood flow
Hysterectomy is the “last resort” but will stop the bleeding and may save the woman’s life

Question 296

When does secondary PPH occur

Answer 296

Secondary postpartum haemorrhage is where bleeding occurs from 24 hours to 12 weeks postpartum. This is more likely to be due to retained products of conception (RPOC) or infection (i.e. endometritis).

Question 297

Secondary PPH - management and investigation

Answer 297

Investigations involve:

Ultrasound for retained products of conception
Endocervical and high vaginal swabs for infection

Management depends on the cause:

Surgical evaluation of retained products of conception
Antibiotics for infection

Question 298

Two key causes of sepsis in pregnancy

Answer 298

Chorioamnionitis
Urinary tract infections

Question 299

What is chorioamnionitis

Answer 299

Chorioamnionitis is an infection of the chorioamniotic membranes and amniotic fluid. Chorioamnionitis is a leading cause of maternal sepsis and a notable cause of maternal death (along with urinary tract infections). It usually occurs in later pregnancy and during labour.

Chorioamnionitis can be caused by a large variety of bacteria, including gram-positive bacteria, gram-negative bacteria and anaerobes.

Question 300

Non specific signs of sepsis

Answer 300

Fever
Tachycardia
Raised respiratory rate (often an early sign)
Reduced oxygen saturations
Low blood pressure
Altered consciousness
Reduced urine output
Raised white blood cells on a full blood count
Evidence of fetal compromise on a CTG

Question 301

Signs of chorioamnionitis

Answer 301

Abdominal pain

Uterine tenderness

Vaginal discharge

Non specific signs of sepsis (fever, tachycardia, hypotension, increase RR, reduced sats, altered conciousness, reduced urine output, evidence of feotal compromise on CTG)

Question 302

What additional investigations can be done to help find the source of infection in maternal sepsis

Answer 302

Urine dipstick and culture
High vaginal swab
Throat swab
Sputum culture
Wound swab after procedures
Lumbar puncture for meningitis or encephalitis

Question 303

Management of maternal sepsis

Answer 303

Continuous maternal and fetal monitoring is required. Depending on the condition of the mother and fetus, early delivery may be needed. Emergency caesarean section may be indicated when there is fetal distress, guided by a senior obstetrician. General anaesthesia is usually required for women with sepsis, as spinal anaesthesia is avoided.

Sepsis six

Question 304

What is amniotic fluid embolism

Answer 304

Amniotic fluid embolisation is a rare (2 per 100,000 deliveries) but severe condition where the amniotic fluid passes into the mother’s blood. This usually occurs around labour and delivery. The amniotic fluid contains fetal tissue, causing an immune reaction from the mother. This immune reaction to cells from the foetus leads to a systemic illness. It has more similarities to anaphylaxis than venous thromboembolism. The mortality rate is around 20% or above.

Question 305

What are the main risk factors for an amniotic fluid embolism

Answer 305

Increasing maternal age
Induction of labour
Caesarean section
Multiple pregnancy

Question 306

Symptoms of amniotic fluid embolism

Answer 306

Shortness of breath
Hypoxia
Hypotension
Coagulopathy
Haemorrhage
Tachycardia
Confusion
Seizures
Cardiac arrest

Question 307

Management of amniotic fluid embolism

Answer 307

The overall management of amniotic fluid embolism is supportive. There are no specific treatments.

Amniotic fluid embolism is a medical emergency – get help immediately. It requires the input of experienced obstetricians, medics, anaesthetics, intensive care teams and haematologists. They are likely to need transfer to the intensive care unit.

The initial management of any acutely unwell patient is with an ABCDE approach, assessing and treating:

A – Airway: Secure the airway
B – Breathing: Provide oxygen for hypoxia
C – Circulation: IV fluids to treat hypotension and blood transfusion in haemorrhage
D – Disability: Treat seizures and consider other neurological deficits
E – Exposure

Cardiopulmonary resuscitation and immediate caesarean section are required if cardiac arrest occurs.

Question 308

What is uterine rupture

Answer 308

Uterine rupture is a complication of labour, where the muscle layer of the uterus (myometrium) ruptures. With an incomplete rupture, or uterine dehiscence, the uterine serosa (perimetrium) surrounding the uterus remains intact. With a complete rupture, the serosa ruptures along with the myometrium, and the contents of the uterus are released into the peritoneal cavity.

Uterine rupture leads to significant bleeding. The baby may be released from the uterus into the peritoneal cavity. It has a high morbidity and mortality for both the baby and mother.

Question 309

Risk factors for uterine rupture

Answer 309

Previous C section

Vaginal birth after caesarean (VBAC)
Previous uterine surgery
Increased BMI
High parity
Increased age
Induction of labour
Use of oxytocin to stimulate contractions

Question 310

What is the main risk factor for uterine rupture and why?

Answer 310

The main risk factor for uterine rupture is a previous caesarean section. The scar on the uterus becomes a point of weakness, and may rupture with excessive pressure (e.g. excessive stimulation by oxytocin). It is extremely rare for uterine rupture to occur in a patient that is giving birth for the first time.

Question 311

How does uterine rupture present

Answer 311

Uterine rupture presents with an acutely unwell mother and abnormal CTG. It may occur with induction or augmentation of labour, with signs and symptoms of:

Abdominal pain
Vaginal bleeding
Ceasing of uterine contractions
Hypotension
Tachycardia
Collapse

Question 312

How is uterine rupture managed

Answer 312

Uterine rupture is an obstetric emergency. Resuscitation and transfusion may be required. Emergency caesarean section is necessary to remove the baby, stop any bleeding and repair or remove the uterus (hysterectomy).

Question 313

What is uterine inversion

Answer 313

Uterine inversion is a rare complication of birth, where the fundus of the uterus drops down through the uterine cavity and cervix, turning the uterus inside out. It is a very rare occurrence. It is a life-threatening obstetric emergency.

Question 314

Complete vs incomplete uterine inversion

Answer 314

Incomplete uterine inversion (partial inversion) is where the fundus descends inside the uterus or vagina, but not as far as the introitus (opening of the vagina).

Complete uterine inversion involves the uterus descending through the vagina to the introitus.

Question 315

When might uterine inversion occur

Answer 315

Uterine inversion may be there result of pulling too hard on the umbilical cord during active management of the third stage of labour.

Question 316

How does uterine inversion present

Answer 316

Uterine inversion typically presents with a large postpartum haemorrhage. There may be maternal shock or collapse.

An incomplete uterine inversion may be felt with manual vaginal examination. With a complete uterine inversion, the uterus may be seen at the introitus of the vagina.

Question 317

What are the three methods of treating uterine inversion

Answer 317

Johnson manoeuvre
Hydrostatic methods
Surgery

Question 318

What is the Johnson manouever

Answer 318

Initial management of an inverted uterus is with the Johnson manoeuvre, which involves using a hand to push the fundus back up into the abdomen and the correct position. The whole hand and most of the forearm will be inserted into the vagina to return the fundus to the correct position. It is held in place for several minutes, and medications are used to create a uterine contraction (i.e. oxytocin). The ligaments and uterus need to generate enough tension to remain in place.

Question 319

Hydrostatic methods of managing uterine inversion

Answer 319

Where the Johnson manoeuvre fails, hydrostatic methods can be used. This involves filling the vagina with fluid to “inflate” the uterus back to the normal position. It requires a tight seal at the entrance of the vagina, which can be challenging to achieve.

Question 320

Surgical management of uterine inversion

Answer 320

Used when Johnson manouever and hydrostatic methods have failed

A laparotomy is performed (opening the abdomen) and the uterus is returned to the normal position.

Question 321

What are the indications for an elective Caesarian section

Answer 321

Previous caesarean
Symptomatic after a previous significant perineal tear
Placenta praevia
Vasa praevia
Breech presentation
Multiple pregnancy
Uncontrolled HIV infection
Cervical cancer

Question 322

When are elective c sections normally performed

Answer 322

after 39 weeks

Question 323

What are the two possible incisions made in a c section

Answer 323

Pfannenstiel incision is a curved incision two fingers width above the pubic symphysis

Joel-cohen incision is a straight incision that is slightly higher (this is the recommended incision)

Question 324

A vertical incision down the middle of the abdomen is also possible, but this is rarely used. It may be used in certain circumstances, such as when?

Answer 324

very premature deliveries and anterior placenta praevia.

Question 325

Dissection in c section

Answer 325

Blunt dissection is used, after the initial incision with a scalpel, to separate the remaining layers of the abdominal wall and uterus. Blunt dissection involves using fingers, blunt instruments and traction to tear the tissues apart, rather than to cut them with sharp tools such as a scalpel. This results in less bleeding, shorter operating times and less risk of injury to the baby.

Question 326

What layers are dissected during a c section

Answer 326

Skin
Subcutaneous tissue
Fascia / rectus sheath (the aponeurosis of the transversus abdominis and external and internal oblique muscles)
Rectus abdominis muscles (separated vertically)
Peritoneum
Vesicouterine peritoneum (and bladder) – the bladder is separated from the uterus with a bladder flap
Uterus (perimetrium, myometrium and endometrium)
Amniotic sac

Question 327

What happens following dissection of relevant layers in a c section

Answer 327

The baby is delivered by hand with the assistance of pressure on the fundus. Forceps may be used if necessary.

The uterus is closed inside the abdomen using two layers of sutures. Exteriorisation (taking the uterus out of the abdomen) is avoided if possible. The abdomen and skin are then closed.

Question 328

What risks are associated with having anaesthetic

Answer 328

Allergic reactions or anaphylaxis
Hypotension
Headache
Urinary retention
Nerve damage (spinal anaesthetic)
Haematoma (spinal anaesthetic)
Sore throat (general anaesthetic)
Damage to the teeth or mouth (general anaesthetic)

Question 329

What anaesthetic is usually used in c section and what are the pros and cons

Answer 329

A spinal anaesthetic involves giving an injection of a local anaesthetic (such as lidocaine) into the cerebrospinal fluid at the lower back. This blocks the nerves from the abdomen downwards.

A spinal anaesthetic is safer, and leads to fewer complications and a faster recovery than a general anaesthetic. The potential problems are that the patient remains awake (most patients tolerate this well, but some prefer to be asleep), and it takes longer to initiate than a general anaesthetic.

Question 330

What measures are taken to reduce risks prior to a c section

Answer 330

H2 receptor antagonists (e.g. ranitidine) or proton pump inhibitors (e.g. omeprazole) before the procedure
Prophylactic antibiotics during the procedure to reduce the risk of infection
Oxytocin during the procedure to reduce the risk of postpartum haemorrhage
Venous thromboembolism (VTE) prophylaxis with low molecular weight heparin

Question 331

During a c section, why are H2 receptor antagonists (e.g. ranitidine) or proton pump inhibitors (e.g. omeprazole) given before the procedure

Answer 331

There is a risk of aspiration pneumonitis during caesarean section, caused by acid reflux and aspiration during the prolonged period lying flat. H2 receptor antagonists (e.g. ranitidine) or proton pump inhibitors (e.g. omeprazole) are given before the procedure to reduce the risk of this happening.

Question 332

C section risks - general surgical

Answer 332

Bleeding
Infection
Pain
Venous thromboembolism

Question 333

C section risks - complications in the post partum period

Answer 333

Postpartum haemorrhage
Wound infection
Wound dehiscence
Endometritis

Question 334

Risks of c section - damage to local structures

Answer 334

Ureter
Bladder
Bowel
Blood vessels

Question 335

C section risk - effect on abdominal organs

Answer 335

Ileus
Adhesions
Hernias

Question 336

C sections - risk to future pregnancies

Answer 336

Increased risk of repeat caesarean
Increased risk of uterine rupture
Increased risk of placenta praevia
Increased risk of stillbirth

Question 337

Risk of c section - effects on the baby

Answer 337

Risk of lacerations (about 2%)
Increased incidence of transient tachypnoea of the newborn

Question 338

VBAC contraindications

Answer 338

Previous uterine rupture
Classical caesarean scar (a vertical incision)
Other usual contraindications to vaginal delivery (e.g. placenta praevia)

Question 339

What type of incision is this

Answer 339

Pfannenstiel incision is a curved incision two fingers width above the pubic symphysis

Question 340

What type of incision is this

Answer 340

Joel-cohen incision is a straight incision that is slightly higher (this is the recommended incision)

Question 341

Requirements for forceps delivery

Answer 341

The requirements for instrumental delivery can be easily remembered by the mnemonic FORCEPS:

Fully dilated cervix generally the second stage of labour must have been reached

OA position preferably OP delivery is possible with Keillands forceps and ventouse. The position of the head must be known as incorrect placement of forceps or ventouse could lead to maternal or fetal trauma and failure

Ruptured Membranes

Cephalic presentation

Engaged presenting part i.e. head at or below ischial spines the head must not be palpable abdominally

Pain relief

Sphincter (bladder) empty this will usually require catheterization

Question 342

Common cause of cord prolapse

Answer 342

ARound 50% of cord prolapse occurs after artificial rupture of membranes

Question 343

Prevention of vertical transmission of HIV

Answer 343

The mother’s viral load will determine the mode of delivery:

Normal vaginal delivery is recommended for women with a viral load < 50 copies / ml
Caesarean section is considered in patients with > 50 copies copies / ml and in all women with > 400 copies / ml
IV zidovudine should be given during the caesarean if the viral load is unknown or there are > 10000 copies / ml
Prophylaxis treatment may be given to the baby, depending on the mothers viral load:

Low-risk babies, where the mother’s viral load is < 50 copies per ml, are given zidovudine for four weeks
High-risk babies, where the mother’s viral load is > 50 copies / ml, are given zidovudine, lamivudine and nevirapine for four weeks

Question 344

What is a ‘pre-terminal’ CTG and what does it indicate?

Answer 344

A terminal bradycardia is when the baseline fetal heart rate drops to below 100 beats per minute for more than 10 minutes. A terminal deceleration is when the heart rate drops and does not recover for more than 3 minutes. These make up a ‘pre-terminal’ CTG and are indicators for Emergency Caesarean section.

Question 345

How much and for how long is a deceleration on CTG

Answer 345

15 beats or more for at least 15 seconds

Question 346

Labour of OP position

Answer 346

The fetal head may rotate spontaneously to an OA position

Delivery is possible in the OP position, however labour is likely to be longer and more painful.

Augmentation should be used if progress is slow.

Kielland’s forceps are associated with the most successful outcomes, however require particular expertise.

Generally, women will experience an earlier urge to push in OP than OA.

Question 347

Which additional measure can aid the effectiveness of the McRoberts manoeuvre?

Answer 347

Applying suprapubic pressure

Question 348

Firstline management of primary PPH secondary to uterine atony

Answer 348

5U of IV Syntocinon (oxytocin), followed by 0.5 mg of ergometrine.

Question 349

Management of late decelerations on CTG

Answer 349

Late decelerations on CTG are a pathological finding and urgent fetal blood sampling is needed to assess for fetal hypoxia and acidosis. A pH of >7.2 in labour is considered normal. Urgent delivery should be considered if there is fetal acidosis.

Question 350

Management of placental abruption when the fetus is alive, <36 weeks and not showing signs of distress is what?

Answer 350

admit and administer steroids

Question 351

Normal fetal HR range on CTG

Answer 351

100-160

Question 352

What is the main complication of induction of labour?

Answer 352

Uterine hyperstimulation

Question 353

Risk factors for placental abruption - MMM

Answer 353

Muliparity
Maternal trauma
Maternal age advanced

Question 354

Women with pyrexia >38 degrees during labour should be given what and why

Answer 354

benzylpenicillin as GBS prophylaxis

Question 355

Important differential in women with preterm-PROM with a triad of maternal pyrexia, maternal tachycardia, and fetal tachycardia

Answer 355

chorioamnionitis

Question 356

3rd vs 4th degree perineal tare

Answer 356

Both involve injury to the perineum involving the anal sphincter complex

4th also involves anal epitheilium/rectal mucosa

Question 357

Following an ABC approach, initial steps to manage a postpartum haemorrhage include what?

Answer 357

Following an ABC approach, initial steps to manage a postpartum haemorrhage include palpating the uterine fundus and catheterising the patient

Question 358

Cervical dilation of greater than how much is a contraindication to tocolysis

Answer 358

4cm

Question 359

Tocolysis is contraindicated in pregnancies of greater than how many weeks gestation?

Answer 359

34

Question 360

During a lower segment Caesarian section, what layers must be cut through to reach the feuts

Answer 360

SD ART EPU

Skin

Superficial fascia

Deep fascia

Anterior rectus sheath

Rectus abominus muscle

Transversalis fascia

Extraperiotneal connective tissue

Peritoneum

Uterus

Question 361

Concenrs with use of MgSO4 in pre eclamspia

Answer 361

Magnesium sulphate - monitor reflexes + respiratory rate

Give calcium gluconate if problems