Labour

Question 1

Define labour. (2)

Answer 1

The process whereby the fetus and placenta are expelled from the uterus, which normally occurs during weeks 37-42.

Question 2

How is labour diagnosed? (2)

Answer 2

Painful uterine contractions are accompanied by dilatation and effacement of the cervix

Question 3

What are the three stages of labour. (3)

Answer 3

1: Initiation to full cervical dilatation
2: Full cervical dilatation to delivery of the fetus
3: Delivery of fetus to delivery of placenta

Question 4

What are the three mechanical factors that determine progress through labour? (3)

Answer 4

Power
Passage- dimensions of pelvis and resistance of soft tissues
Passenger- dimensions of fetal head

Question 5

What bony prominences are used to measure the degree of fetal decent? (1)

Answer 5

Ischial spines

Question 6

What is the ideal presentation of the fetus at birth? (1)

Answer 6

Flexed vertex presentation

extension of various degrees causes increased presenting diameter

Question 7

How does the fetus rotate during the second stage of labour? (6)

Answer 7

Engagement in occipito-transverse (OT)
Descent and flexion
Rotation 90' to OA
Descent
Extension to deliver
Restitution and delivery of shoulders

(in 5% it rotates to occipital-posterior and increased difficulty of delivery)

Question 8

With regards to describing the fetal head, what does presentation and presenting part mean? (2)

Answer 8

Presentation: part of fetus that occupies the lower segment or pelvis.
Presenting part: lowest part of the fetus palpable on vaginal examination. e.g. vertex, brow, face.

Question 9

What does the position and attitude of the head describe/ (2)

Answer 9

Position: describes the rotation. OT, OA or OP
Attitude: describes the degree of flexion.

Question 10

What is effacement of the cervix? (2)

Answer 10

Normally tubular cervix is pulled up into the lower segment until it is flat. Commonly associated with bloody show.

Question 11

Name the 2 phases of the first stage of labour. (2)

Answer 11

Latent (first 3 cm)

Active: 1cm/hour in nulliparous, 2cm/hour in multiparous

Question 12

Define slow labour and prolonged labour. (2)

Answer 12

Slow labour: after latent phase, progress less than 1cm/hr

Prolonged labour: after latent phase >12 hours duration

Question 13

Name 3 causes of slow progress in labour. (3)

Answer 13

Power: inefficient uterine action
Passenger: fetal size, disorder of rotation, disorder of flexion
Passage: cephalo-pelvic disproportion, rarely cervical resistance

Question 14

How is slow progressing labour managed? (3)

Answer 14

Generally: can wait if desired, mobilise
Nulliparous: amniotomy, oxytocin
Multiparous: amniotomy, oxytocin if malpresentation excluded
If fails: C/S in first stage or instrumental delivery if second stage.

Question 15

What is Bishop’s score? (1)

Answer 15

Pre-labour scoring tool to help determine whether induction of about will be required.

Question 16

Name 2 methods of inducing labour. (2)

Answer 16

Vaginal PGE2.
Amniotomy (artificial rupture of membranes)
Oxytocin after SROM or ARM.

(Cervical sweeping of membranes)

Question 17

Name 3 indications for induction of labour. (3)

Answer 17

Fetal: prolonged pregnancy, suspected IUGR or compromise, antepartum haemorrhage, Prelabour term rupture of membrane
Maternal: Pre-eclampsia, hypertension and diabetes

Question 18

Name 2 absolute contraindications for inducing labour. (2)

Answer 18

Acute fetal compromise
Abnormal lie
Placenta praevia
Pelvic obstruction
After 2+ caesarean sections (increased risk of scar rupture)

Question 19

Name 2 complications of induction of labour. (2)

Answer 19

Failure to start- inefficient uterine activity
Hyperstimulation of uterus- rare but can cause distress
Umbilical cord prolapse
Post partum haemorrhage
Intrapartum and postpartum infection

Question 20

What is a PROM? (1)

What is PPROM? (1)

Answer 20

Premature rupture of membranes

Preterm Premature Rupture of Membranes

Question 21

Name 1 risk of premature rupture of membranes. (1)

Answer 21

Cord prolapse

Neonatal infection

Question 22

Felicity has had a premature rupture of membranes. How will you manage her? (2)

Answer 22

Vaginal swab (look for infection)
Avoid digital vaginal exam (unless risk of cord prolapse- abnormal lie or fetal distress)
CTG
Await SROM or induce labour

Question 23

Name 2 indications for instrumental delivery. (2)

Answer 23

Prolonged active second stage
Fetal distress
Prophylactic to prevent pushing in patients with heart disease or hypertension
Breech delivery to control delivery of head

Question 24

Name the 2 methods of caesarean sections. (2)

Answer 24

Lower segment caesarean section (LSCS)

Classical (vertical incision)

Question 25

Define emergency caesarean section. (2)

Answer 25

Caesarean section performed in labour due to immediate threat to mother or fetus.

Question 26

Give 2 complications of a caesarean section. (2)

Answer 26

Haemorrhage, uterine/wound sepsis, thromboembolism, anaesthetic problems, subsequent pregnancy delivery method complications.

Question 27

Why should a pregnanct lady not lie completely supine? (1)

Answer 27

May cause aortocaval compression, decreasing cardiac output and causing hypotension.

Question 28

Why should pregnant ladies lie on the left lateral position? (1)

Answer 28

Prevention of aortocaval compression. | If must lie supine, the table should be at 15' left tilt.

Question 29

What is recorded on a partogram? (2)

Answer 29

Records dilatation of the cervix with or without the descent of the head plotted over time. It is also used to record maternal vital signs, fetal heart rate and colour of liquor.

Question 30

Define fetal distress. (2)

Answer 30

Hypoxia that may result in fetal damage or death if not reversed or delivered urgently.

Question 31

Name 2 methods that can determine fetal distress. (2)

Answer 31

- Meconium in liquor - FHR every 15 mins in 1st stage and every 5 mins in the 2nd stage, using doppler or Pinards, or CTG. - CTG: records fetal hr and contractions - Fetal blood sampling: if pH<7.2 deliver by quickest method

Question 32

What are the stages of assessing a Cardiotocogram? (5)

Answer 32

DR C BRAVADO DR: define risk C: contractions per 10 mins BR: basline rate (110-160bpm) V: variability (<5bpm) unless during fetal sleep that should last less than 45 mins A: accelerations with movements and during contractions is encouraging D: decelerations (early, variable or late) O: overall assessment

Question 33

Describe the 3 different types of decelerations. (3)

Answer 33

Early: synchronous with contraction as normal response to head compression Variable: vary in timing and reflect cord compressions Late: presist afetr contraction has completed and are suggestive of hypoxia

Question 34

What is the management of fetal distress? (4)

Answer 34

1: intermittent auscultation of FHR: if abnormal or meconium or long/high risk labour then go to 2. 2: continuous CTG: if sustained bradycardia, deliver; for other abnormalities, try alleviate with simple measures then if fails go to 3. 3: fetal blood sample: if abnormal go to 4 4: deliver by quickest method

Question 35

Name 2 simple methods that may alleviate CTG abnormalities. (2)

Answer 35

``` Oxygen Move to left lateral position IV fluids Stop oxytocin infusion if applicable Vaginal exam to check for cord prolapse. ```

Question 36

Name 2 non-medical and 2 medical methods of anagesia in labour. (4)

Answer 36

Non-medical: TENS, antenatal classes, mobilising, back rubbing, water at body temperature medical: Entonox (O2 and NO), Pethidine, Spinal anaesthetic, Epidural, Pudenal nerve block

Question 37

Lucy has decided to have an epidural, what level will Dr Hoy inject? (1) What layers will he have to inject through? (4)

Answer 37

``` L3/4 Skin Subcutaneous fat Supraspinous ligament Interspinous ligament Ligamentum flavum NOW IN EPIDURAL SPACE Dura mata Arachnoid mata NOW IN SPINAL ANAESTHETIC SPACE ```

Question 38

name an advantage and a disadvantage of using an epidural in labour. (2)

Answer 38

Advantage: pain free, can lower bp in hyertensive patient Disadvantage: regular bp and pulse monitoring, mother is bed bound, Can develop urinary retention due to loss of bladder sensation.

Question 39

name 2 complications with epidural. (2)

Answer 39

Spinal tap (accidentally cause leakage of CSF from subarachnoid space and cause headache) Total spinal anaesthetic (respiratory paralysis) Hypotension Increased rate of instrumental delivery Urinary retention

Question 40

What is active management of the third stage of labour? (2) | Give one benefit. (1)

Answer 40

``` IM oxytocin (Syntocin) or Syntometrine (with ergometrine) can be injected after shoulders of last fetus have been delivered to encourage uterine constriction. (NB ergometrine can cause vomiting and is contraindicated in hypertensive disease) ``` Decreases risk of post partum haemorrhage and thus less chance of transfusion.

Question 41

Clinically, how can partial separation of the placenta be indicated? (1) How should the placenta be removed? (1)

Answer 41

Elongation of the cord and passage of blood. Gentle traction on the cord, while the left hand presses on the suprapubic region to prevent uterine inversion.

Question 42

Define a retained placenta. (1)

Answer 42

Third stage of labour lasting over 30 minutes. | if there is no bleeding, it may be left for up to one hour to separate naturally.