Abnormal labour

Question 1

Contents of an epidural (2)

Answer 1

Levobupivacaine + opiate e.g. fentanyl

Question 2

Site of insertion of epidural

Answer 2

Between L3 and L4 vertebrae

Question 3

Which ligament lies directly above, and is pierced to gain entrance to, the epidural space?

Answer 3

Ligamentum flavum

Question 4

Complications of epidural (5)

Answer 4

Postural hypotension
Dural puncture
Headache
Back pain
Atonic bladder

Question 5

Why is IV access needed for an epidural?

Answer 5

To give 500ml Hartmann solution (sodium lactate) at the outset, to help prevent hypotension

Question 6

Why is Hartmann’s solution useful to correct hypovolaemia?

Answer 6

IV solution which is most closely isotonic with blood

Question 7

Why might an epidural inhibit phase 2 of labour?

Answer 7

Might interfere with the woman’s desire to push

Question 8

By what three criteria is the progress of labour assessed?

Answer 8

Cervical dilatation
Descent of the presenting part
Signs of obstruction

Question 9

What is the desired rate of contraction after 3cm?

Answer 9

1cm/hour

Question 10

When is delay suspected in stage 1?

Answer 10

Dilatation less than 2cm in 4 hours, or in parous women, less than 2cm in 4 hours or slowing in progress

Question 11

What is the alert line on a partogram?

Answer 11

Line drawn illustrating 1cm/hour dilatation

Question 12

When will the “action” line be intersected?

Answer 12

If the rate of cervical dilatation lags more than 2 hours behind expected

Question 13

By what landmark is the descent of the presenting part measured?

Answer 13

Level of the ischial spines (0)

Question 14

Uterine cause of failure to progress

Answer 14

Inadequate contraction frequency/strength

Question 15

How might cephalopelvic disproportion occur? (2)

Answer 15

Macrosomia; small pelvis

Question 16

In a well-flexed vertex presentation, what is the name of length of the presenting diameter?

Answer 16

Sub-occipitobregmatic (around 9.5)

Question 17

Signs of obstruction (2)

Answer 17

Moulding, caput formation

Question 18

How often should fetal heart doppler be carried out in a) 1st stage and b) second stage?

Answer 18

a) during and after contractions, for at least 1 minute every 15 minutes
b) every 5-10 minutes

Question 19

Which features of the CTG should be analysed? (4)

Answer 19

Heart rate
Baseline variability
Accelerations
Decelerations

Question 20

Normal foetal heart rate

Answer 20

110-160bpm

Question 21

Normal baseline variability

Answer 21

5-25bpm

Question 22

Which types of deceleration are physiological and which are indicative of foetal hypoxia?

Answer 22

Early decelerations are physiological. Late decelerations and variable decelerations are non-reassuring

Question 23

What causes late decelerations?

Answer 23

Placental insufficiency

Question 24

What is tocolysis? What drug can be used to achieve this?

Answer 24

Stops labour contractions. Terbutaline

Question 25

What are the cut-off for borderline and abnormal fetal blood pH?

Answer 25

Borderline is 7.2-.7.25, repeat in half hour. | Abnormal is less than 7.2

Question 26

Options for instrumental and operative delivery

Answer 26

Instrumental- forceps, Ventouse | C-section

Question 27

What is the major concern in VBAC patients?

Answer 27

Dehiscence of the uterine scar

Question 28

How long should stage 2 take in prims and multips? How is this extended for patients with epidural?

Answer 28

Prims- 2hours Multips- 1 hour Epidural extends by an hour

Question 29

What are the indications for instrumental delivery?

Answer 29

Delay and foetal distress

Question 30

Complications of ventouse (2)

Answer 30

Cephalohaematoma, retinal haemorrhage

Question 31

What factors are included in Bishop score? (5)

Answer 31

``` Cervical position Cervical consistency Cervical effacement Cervical dilatation Foetal station ```

Question 32

How is labour usually induced?

Answer 32

Intra-vaginal prostaglandin pessary (ripens the cervix) followed by Artificial membrane rupture

Question 33

If artificial membrane rupture does not stimulate labour, what drug can be given?

Answer 33

Syntocinon infusion (oxytocin), titrated to achieve regular contractions

Question 34

What is shoulder dystocia?

Answer 34

Inability to deliver the anterior shoulder of the fetus due to impaction on the symphysis pubis

Question 35

Complications of shoulder dystocia a) maternal b) foetal?

Answer 35

a) post-partum haemorrhage, perineal tears | b) brachial plexus injury, limb fractures, neonatal death due to asphyxia

Question 36

Risk factors for shoulder dystocia? (3)

Answer 36

Macrosomia Prolonged labour High maternal BMI

Question 37

Management of shoulder dystocia?

Answer 37

Call for help immediately | McRobert's manouevre

Question 38

How is McRoberts manouevre performed? (4)

Answer 38

Hip abduction and flexion Suprapubic pressure Manual rotation of foetal shoulders (+ episiotomy)