Abnormal labour

Question 1

What is purpose of prostaglandin in pregnancy and labour?

Answer 1

the uterine cells produce prostaglandins to help dilate your cervix (make it wider) and cause uterine contractions.

These contractions help move the baby through the birth canal.

Question 2

What is induction of labour (IOL)?

Answer 2

the use of medications to stimulate the onset of labour.

Question 3

At what point during pregnancy is IOL offered?

Answer 3

Between 41-42 weeks gestation

Question 4

At how many weeks is normal delivery and labour?

Answer 4

Between 37-42 weeks gestation

Question 5

In what other cases is IOL offered?

Answer 5

also offered in situations where it is beneficial to start labour early, such as:

Prelabour rupture of membranes
Fetal growth restriction
Pre-eclampsia
Obstetric cholestasis
Existing diabetes
Intrauterine foetal death

Question 6

What is Bishops score?

Answer 6

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

Question 7

How many components are in Bishop score and what is the minimum and maximum score that can be given?

Answer 7

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

A score of 8 or more indicates reason for induction

Question 8

Components of the Bishop score?

Answer 8

Foetal station/foetal position (scored 0 – 3).
- Position of baby head to ischial spine. Value of number indicates distance. Positive number = baby’s head has descended into birth canal. Negative number = baby head still high.

Cervical position (scored 0 – 2).
- Cervix moves closer to birth canal during labour. Referred to as anterior. Posterior = cervix further from birth canal, further from labour.

Cervical dilatation (scored 0 – 3).
- How open the cervix is, fully dilated =10cm. Measured with fingers and translated to cm.

Cervical effacement (scored 0 – 3).
- How short or thin cervix is, 100% effacement means “paper thin”.

Cervical consistency (scored 0 – 2).
- How tough the cervix is. Softer, more flexible cervix is more likely top dilate.

Question 9

What are the options for IOL?

Answer 9

Membrane sweep
Vaginal prostaglandin E2 (dinoprostone)
Cervical ripening balloon (CRB)
Artificial rupture of membranes with an oxytocin infusion
Oral mifepristone (anti-progesterone) plus misoprostol

Question 10

Features of membrane sweep IOL?

Answer 10

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.

Membrane sweep is NOT considered a full method of inducing labour but rather assistance before full method of labour occurs.

Question 11

Features of vaginal prostaglandin E2 IOL?

Answer 11

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.

Question 12

Process of cervical ripening balloon as a method of IOL?

Answer 12

Cervical ripening balloon (CRB) is a silicone balloon that is inserted into the cervix and gently inflated to dilate the cervix.

Question 13

When can CRB be used as an alternative to vaginal prostaglandin E2?

Answer 13

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 14

When is artificial rupture of membranes with an oxytocin infusion used?

Answer 14

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 15

Oral mifepristone (anti-progesterone) plus misoprostol is used in what circumstance?

Answer 15

used to induce labour where intrauterine foetal death has occurred.

Question 16

What is failure to progress?

Answer 16

<2cm dilation in 4 hours in nulliparous (never given birth) women

and

<2cm dilation in 4 hours in multiparous women

Question 17

Aetiology of failure to progress?

Answer 17

Most common reason is deflexion of foetal head

Question 18

Clinical features of failure to progress/signs of obstruction?

Answer 18

Signs of obstruction:

• Moulding (pressure on the head caused by the tight birth canal may “mould” the head into an oblong rather than round shape).
• Caput (newborn scalp swelling)
• Anuria (failure to produce urine from kidneys)
• Haematuria (blood in urine)
• Vulval oedema

Question 19

What is Bandl’s ring in obstructed labour?

Answer 19

Bandl’s ring of the uterus is a constriction located at the junction of the thinned lower uterine segment and the thick retracted upper uterine segment that is associated with obstructed labor.

Question 20

Investigations for failure to progress?

Answer 20

Parogram - graphic representation of labour progress

Should be commenced as soon has labour is established

Question 21

Management of failure to progress due to obstruction?

Answer 21

Operative delivery/caesarian section

Question 22

Complications of obstructed labour?

Answer 22

• Sepsis
• Uterine rupture
• PPH (postpartum haemorrhage)
• Neonatal sepsis
• Obstructed AKI

Question 23

What is the vertex in pregnancy?

Answer 23

“crown of the head.” This means that the crown of the foetus’s head is presenting towards the cervix.

A vertex presentation means a foetus is in a headfirst, head down position with its chin tucked towards its chest, facing the spine.

Question 24

What are malpresentations?

Answer 24

All presentations of the foetus other than vertex

Question 25

Aetiology (predisposing factors) of malpresentations?

Answer 25

• Prematurity
• Multiple pregnancy
• Abnormalities of uterus i.e. fibroids
• Abnormal foetus
• Primiparity (giving birth for first time)

Question 26

Most common type of malpresentation?

Answer 26

Breech presentation

Occurs when foetus presents “bottom down” in the uterus

Question 27

Management of uncomplicated breech presentation?

Answer 27

Should be offered external cephalic version.

This is a procedure to change the presentation of the foetus from breech, transverse, or oblique to vertex by applying pressure externally to the foetus through the gravid abdomen

Question 28

Types of breech presentation?

Answer 28

Frank breech - both legs up with bum first.
Complete breech - bum first along with legs together.
Footling breech - one foot first

Question 29

What is a transverse lie?

Answer 29

Foetus is positioned with the head on one side of the pelvis and the buttocks on the other.

Question 30

Transverse lie can be carried out with normal vaginal delivery. true/false?

Answer 30

False

Vaginal delivery is impossible - requires caesarean section unless it converts or is converted later in pregnancy.

Question 31

When is IOL usually offered?

Answer 31

between 41-42 weeks

Question 32

What is uterine hyperstimulation?

Answer 32

Uterine hyperstimulation is defined as greater than 5 contractions occurring within 10 minutes and is due to the administration of prostaglandins or oxytocin for labour induction.