Labour

Question 1

Labour may be defined as

Answer 1

onset of regular and painful contractions associated with cervical dilation and descent of the presenting part

Question 2

Signs of labour include

Answer 2

regular and painful uterine contractions
a show (shedding of mucous plug)
rupture of the membranes (not always)
shortening and dilation of the cervix

Question 3

Labour may be divided in to three stages which are:

Answer 3

stage 1: from the onset of true labour to when the cervix is fully dilated
stage 2: from full dilation to delivery of the fetus
stage 3: from delivery of fetus to when the placenta and membranes have been completely delivered

Question 4

Monitoring in Labour

Answer 4

FHR monitored every 15min (or continuously via CTG)
Contractions assessed every 30min
Maternal pulse rate assessed every 60min
Maternal BP and temp should be checked every 4 hours
VE should be offered every 4 hours to check progression of labour
Maternal urine should be checked for ketones and protein every 4 hours

Question 5

Stage 1 - from the onset of true labour to when the cervix is fully dilated. In a primigravida lasts typical

Answer 5

10-16 hours

Question 6

Stage 1 phases?

Answer 6

latent phase = 0-3 cm dilation, normally takes 6 hours

active phase = 3-10 cm dilation, normally 1cm/hr

Question 7

?% of babies are vertex at present

Answer 7

90%

Question 8

Head enters pelvis in ?position. The head normally delivers in an ?position.

Answer 8

Head enters pelvis in occipito-lateral position. The head normally delivers in an occipito-anterior position.

Question 9

Labout stage 2 different parts of second stage?

Answer 9

‘passive second stage’ refers to the 2nd stage but in the absence of pushing (normal)
active second stage’ refers to the active process of maternal pushing

Question 10

Which stage is most painful 1 or 2

Answer 10

1 as pushing masks pain

Question 11

Stage 2 lasts approximately ?

What to do if longer than this?

Answer 11

1 hours
if longer than 1 hour (can be left longer if epidural) consider Ventouse extraction, forceps delivery or caesarean section

Question 12

in stage 2 episiotomy may be necessary following crowning

Answer 12

true

Question 13

Stage 2 is associated with transient fetal tachy/bradycardia

Answer 13

bradycardia

Question 14

Induction of labour describes a process where labour is started artificially. It happens in around ?% of pregnancies

Answer 14

Induction of labour describes a process where labour is started artificially. It happens in around 20% of pregnancies

Question 15

Induction of labour , Indications

Answer 15

prolonged pregnancy, e.g. > 12 days after estimated date of delivery
prelabour premature rupture of the membranes, where labour does not start
diabetic mother > 38 weeks
rhesus incompatibility

Question 16

Induction of labour methods?

Answer 16

membrane sweep
intravaginal prostaglandins
breaking of waters
oxytocin

Question 17

Cardiotocography (CTG) records what?

Answer 17

pressure changes in the uterus using internal or external pressure transducers

Question 18

The normal fetal heart rate varies between

Answer 18

100-160 / min

<100 brady, >160 tachy

Question 19

Baseline fetal bradycardia causes

Answer 19

Increased fetal vagal tone, maternal beta-blocker use

Question 20

Baseline fetal tachycardia causes

Answer 20

Maternal pyrexia, chorioamnionitis, hypoxia, prematurity

Question 21

Loss of baseline variability is what?

Causes?

Answer 21

< 5 beats / min

Prematurity, hypoxia

Question 22

What is Early deceleration

Answer 22

Deceleration of the heart rate which commences with the onset of a contraction and returns to normal on completion of the contraction

Question 23

What is Early deceleration caused by

Answer 23

Usually an innocuous feature and indicates head compression

Question 24

What is late deceleration

Answer 24

Deceleration of the heart rate which lags the onset of a contraction and does not returns to normal until after 30 seconds following the end of the contraction

Question 25

What is late deceleration caused by

Answer 25

Indicates fetal distress e.g. asphyxia or placental insufficiency

Question 26

Variable decelerations are Independent of contractions

Answer 26

true

Question 27

Variable decelerations may indicate

Answer 27

cord compression

Question 28

Risk factors for perineal tears

Answer 28

``` primigravida large babies precipitant labour shoulder dystocia forceps delivery ```

Question 29

The RCOG has produced guidelines suggesting the following classification of perineal tears?

Answer 29

first degree: superficial damage with no muscle involvement second degree: injury to the perineal muscle, but not involving the anal sphincter third degree: injury to perineum involving the anal sphincter complex (external anal sphincter, EAS and internal anal sphincter, IAS):

Question 30

Describe the sub classifications of third degree perineal tears

Answer 30

3a: less than 50% of EAS thickness torn 3b: more than 50% of EAS thickness torn 3c: IAS torn fourth degree: injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa

Question 31

Preterm prelabour rupture of the membranes (PPROM) occurs in around ?% of pregnancies but is associated with around ?% of preterm deliveries

Answer 31

Preterm prelabour rupture of the membranes (PPROM) occurs in around 2% of pregnancies but is associated with around 40% of preterm deliveries

Question 32

Complications of PPROM

Answer 32

fetal: prematurity, infection, pulmonary hypoplasia maternal: chorioamnionitis

Question 33

Ix PPROM

Answer 33

A sterile speculum examination should be performed (to look for pooling of amniotic fluid in the posterior vaginal vault) Ultrasound may also be useful to show oligohydramnios.

Question 34

PPROM - digital exam indicated

Answer 34

digital examination should be avoided due to the risk of infection

Question 35

PPROM Mx

Answer 35

admission regular observations to ensure chorioamnionitis is not developing oral erythromycin should be given for 10 days antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome delivery should be considered at 34 weeks of gestation

Question 36

PPROM - why should delivery be considered at 34 weeks of gestation

Answer 36

there is a trade-off between increased risk of maternal chorioamnionitis with a decreased risk of respiratory distress syndrome as the pregnancy progresses

Question 37

which score is used to help assess the whether induction of labour will be required?

Answer 37

The Bishop score

Question 38

components of bishop score?

Answer 38

``` Cervical position Cervical consistency Cervical effacement Cervical dilation Fetal station ``` Each component can have 0-3 points or 0-2

Question 39

Interpretation of bishop score?

Answer 39

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

Question 40

Descibe scoring for Cervical position in Bishop score?

Answer 40

Posterior 0 Intermediate 1 Anterior 2

Question 41

Descibe scoring for Cervical consistency in Bishop score?

Answer 41

Firm 0 Intermediate 1 Soft 2

Question 42

Descibe scoring for Cervical effacement in Bishop score?

Answer 42

0-30% 0 40-50% 1 60-70% 2 80% 3

Question 43

Descibe scoring for Cervical dilation in Bishop score?

Answer 43

<1 cm = 0 1-2 cm = 1 3-4 cm = 2 >5 cm = 3

Question 44

Descibe scoring for Fetal station in Bishop score?

Answer 44

-3 (0 point) -2 (1 point) -1,0 (2 point) +1,+2 (3 point)

Question 45

The World Health Organization defines a post-term pregnancy as

Answer 45

one that has extended to or beyond 42 weeks.

Question 46

Post-term pregnancy Potential complications/consequences: Neonatal?

Answer 46

Reduced placental perfusion | Oligohydramnios

Question 47

Post-term pregnancy Potential complications/consequences: Maternal?

Answer 47

Increased rates of intervention including forceps and caesarean section Increased rates of labour induction

Question 48

Shoulder dystocia is

Answer 48

complication of vaginal cephalic delivery. It entails inability to deliver the body of the fetus using gentle traction, the head having already been delivered. Shoulder dystocia is a cause of both maternal and fetal morbidity. It usually occurs due to impaction of the anterior fetal shoulder on the maternal pubic symphysis

Question 49

Shoulder dystocia complications?

Answer 49

postpartum haemorrhage and perineal tears with respect to the former, and brachial plexus injury with respect to the latter, amongst other complications. Neonatal death occasionally occurs.

Question 50

Key risk factors for shoulder dystocia include

Answer 50

fetal macrosomia, high maternal body mass index, diabetes mellitus and prolonged labour.

Question 51

shoulder dystocia mx

Answer 51

help should be called as soon as shoulder dystocia is identified and McRoberts' manoeuvre should be performed. This manoeuvre entails flexion and abduction of the maternal hips, bringing the mother's thighs towards her abdomen. This rotation increases the relative anterior-posterior angle of the pelvis and often facilitates a successful delivery. An episiotomy will not relieve the bony obstruction but is sometimes used to allow better access for internal manoeuvres.

Question 52

Oxytocin administration is not indicated in shoulder dystocia.

Answer 52

true

Question 53

Symphysiotomy and the Zavanelli manoeuvre can cause significant maternal morbidity and are not first-line options in shoulder dystocia

Answer 53

true

Question 54

Cord prolapse is

Answer 54

involves the umbilical cord descending ahead of the presenting part of the fetus

Question 55

Cord prolapse complications?

Answer 55

Left untreated, this can lead to compression of the cord or cord spasm, which can cause fetal hypoxia and eventually irreversible damage or death.

Question 56

Risk factors for cord prolapse include:

Answer 56

``` prematurity multiparity polyhydramnios twin pregnancy cephalopelvic disproportion abnormal presentations e.g. Breech, transverse lie placenta praevia long umbilical cord high fetal station ```

Question 57

The majority of cord prolapses occur at

Answer 57

artificial rupture of the membranes.

Question 58

Diagnosis cord prolapse?

Answer 58

The diagnosis is usually made when the fetal heart rate becomes abnormal and the cord is palpable vaginally, or if the cord is visible beyond the level of the introitus.

Question 59

cord prolapse mx

Answer 59

For management of cord prolapse, the presenting part of the fetus may be pushed back into the uterus to avoid compression. Tocolytics may be used. If the cord is past the level of the introitus, it should be kept warm and moist but should not be pushed back inside. The patient is asked to go on 'all fours' until preparations for an immediate caesarian section have been carried out. Although this is the usual first-line method of delivery, an instrumental vaginal delivery is possible if the cervix is fully dilated and the head is low. If treated early, fetal mortality in cord prolapse is low.

Question 60

Incidence of cord prolapse is reduced by

Answer 60

reduced by the increase in caesarian sections being used in breech presentations.