Labour and delivery

Question 1

What are the 3 stages of labour?

Answer 1

First stage - from the onset of labour (true contractions) until 10cm cervical dilatation
Second stage - from 10cm cervical dilatation until delivery of the baby
Third stage - from delivery of the baby until delivery of the placenta

Question 2

What are the 3 phases of stage 1 labour?

Answer 2

involves cervical dilation and effacement (getting thinner).
The “show = mucus plug in the cervix, which prevents bacteria from entering the uterus during pregnancy, falling out and creating space for the baby to pass through

Latent phase - from 0 to 3cm dilation of the cervix. This progresses at around 0.5cm per hour. There are irregular contractions.
Active phase - from 3cm to 7cm dilation of the cervix. This progresses at around 1cm per hour, and there are regular contractions.
Transition phase - from 7cm to 10cm dilation of the cervix. This progresses at around 1cm per hour, and there are strong and regular contractions.

Question 3

4 signs of labour

Answer 3

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

Question 4

difference between latent 1st stage and established 1st stage of labour

Answer 4

The latent first stage is when there are both:
Painful contractions
Changes to the cervix, with effacement and dilation up to 4cm

The established first stage of labour is when there are both:
Regular, painful contractions
Dilatation of the cervix from 4cm onwards

Question 5

3 classes of prematurity

Answer 5

Under 28 weeks: extreme preterm
28 - 32 weeks: very preterm
32 - 37 weeks: moderate to late preterm

Babies are considered non-viable below 23 weeks gestation
Jesus baby if ≥24 weeks

Question 6

how can you prevent preterm labour

Answer 6

vaginal progesterone

cervical cerclage - stich in cervix

Question 7

how is vaginal progesterone useful to prevent preterm labour?

Answer 7

role: maintain pregnancy and prevent labour by decreasing activity of the myometrium and prevent the cervix remodelling in preparation for delivery.

This is offered to women with a cervical length <25mm on vaginal US 16-24 weeks

Question 8

how is cervical cerclage useful to prevent preterm labour?

Answer 8

stitch in cervix to add support, keep it closed
under GA or spinal
remove stitch when in labour or reaches term

This is offered to women with a cervical length <25mm on vaginal US 16-24 weeks WHO HAVE had previous pre-term birth or cervical trauma (colposcopy, cone biopsy)

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

Question 9

how do you if woman has ruptured her membranes (amniotic sac)?

Answer 9

speculum –>pooling of amniotic fluid in the vagina. No tests are required.

If doubt:

• Insulin-like growth factor-binding protein-1 (IGFBP-1) = a protein present in high conc in amniotic fluid, which can be tested on vaginal fluid
• Placental alpha-microglobin-1 (PAMG-1) is a similar alternative to IGFBP-1

Question 10

how do you manage PPROM?

Answer 10

Preterm prelabour rupture of membranes is where the amniotic sac ruptures, releasing amniotic fluid, before the onset of labour and in a preterm pregnancy

Prophylactic antibiotics –> prevent chorioamnionitis.
- erythromycin 250mg TDS for 10/7 or until labour is established (if within 10 days)

Induction of labour may be offered from 34 weeks

Question 11

what is fetal fibronectin used to diagnose?

Answer 11

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

Question 12

5 methods of improving outcomes in preterm labour

Answer 12

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

Question 13

what medication causes tocolysis?

Answer 13

nifedipine - CCB
used to stop uterine contractions

aosiban = oxytocin R antagonist, for when if is CI

Question 14

when can tocolysis be used?

Answer 14

used to stop uterine contractions (Pre-term)

used 24-34 weeks in preterm labour to delay delivery
only use <48 hours
also administer maternal steroids, transfer to specialist unit with NICU

Question 15

why are maternal steroids given in premature labour?

Answer 15

helps to develop the fetal lungs and reduce respiratory distress syndrome after delivery.

used <36 weeks gestation.
regime: 2 doses IM
betamethasone, 24 hours apart.

Question 16

Why is IV MAGNESIUM SULFATE given to mother in premature labour?

Answer 16

protects fatal brain in premature delivery
dec risk and severity of cerebral palsy
give within 24 hours of delivery of PTB <34 weeks
give a bolus, then infusion for 24 hours or until birth

Question 17

how do you monitor for magnesium toxicity in treatment of PTB?

Answer 17

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 18

when is induction of labour offered?

Answer 18

41 - 42 weeks

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

Question 19

What is the Bishop score?

Answer 19

used to determine wether to induce labour

min score 0 ,max 13
<8 suggests cervical ripening may be req to prepare cervix

Question 20

what 5 things are assessed on bishop score?

Answer 20

5 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 predicts a successful induction of labour.
<8 suggests cervical ripening may be required to prepare the cervix.

Question 21

5 options to induce labour

Answer 21

1. membrane sweep (adjunct only)
2. vaginal prostaglandins
3. cervical ripening balloon CRB
4. artificial rupture of membranes with oxytocin infusion
5. oral mifepristone + misoprostol (intrauterine fetal death)

Question 22

what 2 things do you monitor when induce labour?

Answer 22

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 23

what is the main complication of induction of labour?

Answer 23

uterine hyperstimulation

- contraction of the uterus is prolonged and frequent –> causes fetal distress and compromise.

Question 24

2 criteria for uterine hyperstimulation

Answer 24

1. Individual uterine contractions lasting > 2 minutes in duration
2. > 5 uterine contractions every 10 minutes

Question 25

3 consequences of uterine hyperstimulation

Answer 25

1. Fetal compromise, with hypoxia and acidosis 2. Emergency caesarean section 3. Uterine rupture

Question 26

management of uterine hyperstimulation

Answer 26

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

Question 27

Indications for Continuous CTG Monitoring in labour

Answer 27

``` 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 28

5 key features on CTG

Answer 28

1. Contractions - the number of uterine contractions per 10 minutes 2. Baseline rate - the baseline fetal heart rate 3. Variability - how the fetal heart rate varies up and down around the baseline 4. Accelerations - periods where the fetal heart rate spikes 5. Decelerations - periods where the fetal heart rate drops

Question 29

what is a good sign on CTG?

Answer 29

Accelerations (periods where the fetal heart rate spikes) are generally a good sign that the fetus is healthy, particularly when occurring alongside contractions of the uterus

Question 30

3 words to classify baseline rate and variability on CTG

Answer 30

reassuring, non-reassuring and abnormal BLR reassuring 110-160 VAR reassuring 5-25

Question 31

what is a concerning sign on CTG?

Answer 31

decelerations fetal HR drops in response to hypoxia (to save O2 for vital organs) ``` 4 types: Early decelerations Late decelerations Variable decelerations Prolonged decelerations ```

Question 32

what are Early decelerations on CTG?

Answer 32

gradual dips and recoveries in HR, correspond with uterine contractions. lowest point of the declaration corresponds to the peak of the contraction. Normal, not pathological. Caused by the uterus compressing the head of the fetus --> stimulae the vagus nerve of the fetus, slowing the heart rate.

Question 33

what are late decelerations on CTG?

Answer 33

gradual falls in HR that starts after the uterine contraction has already begun --> delay btw the uterine contraction and the deceleration. The lowest point of the declaration occurs after the peak of the contraction. 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 - maternal hypoxia.

Question 34

what are variable decelerations on CTG?

Answer 34

abrupt decelerations that may be unrelated to uterine contractions. Fall >15 BPM from the baseline. The lowest point of the declaration occurs within 30 seconds, and the deceleration lasts < 2mins in total. - 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 35

what are prolonged decelerations on CTG?

Answer 35

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 36

when is a CTG reassuring?

Answer 36

- no decelerations - early decelerations - less than 90 mins of variable decelerations with no concerning features Regular variable decelerations and late decelerations are classed as non-reassuring or abnormal, depending on the features. Prolonged decelerations are always abnormal.

Question 37

what are the 4 categories for CTG?

Answer 37

1. Normal 2. Suspicious: a single non-reassuring feature 3. Pathological: two non-reassuring features or a single abnormal feature 4. Need for urgent intervention: acute bradycardia or prolonged deceleration of more than 3 minutes

Question 38

what's the rule of 3s for metal bradycardia?

Answer 38

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

Question 39

sinusoidal CTG

Answer 39

sine wave pattern assoc with severe fatal anaemia - bc vasa praevia with fatal haemorrhage

Question 40

DR C BRaVADO for CTG

Answer 40

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) If you are asked to assess a CTG in your exams, use the DR C BRaVADO structure to describe each feature in turn. Give an overall impression of the CTG as being normal (all features are reassuring), suspicious, pathological, or need for urgent intervention, as described in the NICE guidelines (2017).

Question 41

what is cord prolapse?

Answer 41

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 42

risk factors for cord prolapse?

Answer 42

- abnormal lie >37 weeks = unstable, transverse or oblique --> space for cord to prolapse (in cephalic lie, no room for cord to descend)

Question 43

diagnosis of cord prolapse?

Answer 43

signs of fetal distress on CTG | vaginal exam or speculum

Question 44

management of cord prolapse

Answer 44

relieve pressure on cord - knee-chest position (all 4s) or lie in left lateral position totolytics (terbutaline) to minimise contractions emergency C-section do not push cord back in keep cord warm and wet, minimal handling (causes vasospasm)

Question 45

what medication do you give after instrumental delivery?

Answer 45

1 dose co-amoxiclav

Question 46

indications for instrumental delivery

Answer 46

Failure to progress Fetal distress Maternal exhaustion Control of the head in various fetal positions also inc risk of needing instrumental delivery when epidural used

Question 47

risks of instrumental delivery to mother

Answer 47

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

Question 48

risks of instrumental delivery to baby

Answer 48

The key risks to remember to the baby are: Cephalohaematoma with ventouse Facial nerve palsy with forceps (also fat necrosis, resolves) ``` Rarely there can be serious risks to the baby: Subgaleal haemorrhage (most dangerous) Intracranial haemorrhage Skull fracture Spinal cord injury ```

Question 49

what nerve injuries can mother get on instrumental delivery?

Answer 49

rare, resolves over 6-8 weeks Femoral N - may be compressed against the inguinal canal during a forceps delivery. - Injury --> weakness of knee extension, loss of the patella reflex and numbness of the anterior thigh and medial lower leg. Obturator nerve - may be compressed by forceps or by the fetal head during NVD - Injury --> weakness of hip adduction and rotation, and numbness of the medial thigh.

Question 50

3 nerve injuries in birth (usually unrelated to instrumental delivery)

Answer 50

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 - -> numbness of the anterolateral thigh. The lumbosacral plexus - may be compressed by the fetal head during the 2nd stage of labour. - Injury --> foot drop and numbness of the anterolateral thigh, lower leg and foot. The common peroneal nerve - may be compressed on the head of the fibula whilst in the lithotomy position. - Injury --> foot drop and numbness in the lateral lower leg.

Question 51

risk factors for perineal tear

Answer 51

``` Perineal tears are more common with: First births (nulliparity) Large babies (over 4kg) Shoulder dystocia Asian ethnicity Occipito-posterior position Instrumental deliveries ```

Question 52

4 degrees of perineal tear

Answer 52

each involving injury to tissue beyond the previous: First-degree - injury limited to the frenulum of the labia minora (where they meet posteriorly) and superficial skin Second-degree - including the perineal muscles, but not affecting the anal sphincter Third-degree - including the anal sphincter, but not affecting the rectal mucosa Fourth-degree - including the rectal mucosa Third-degree tears can be subcategorised as: 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 53

what are the 2 options for management of the 3rd stage of labour?

Answer 53

physiological - placenta delivered by maternal effort (no meds or cord traction) or active - assisted

Question 54

how can you actively manage 3rd stage labour?

Answer 54

- IM oxytocin (10 IU) --> contracts uterus cord clamped and cut within 5 mins of birth (wait 1-3 mins before clamp unless baby needs resus) palpate abdo for uterine contractions - controlled cord traction during contractions - 1 hand presses uterus upwards --> prevent uterine prolapse Aim: deliver placenta in 1 piece massage uterus until contracted and firm examine placenta to ensure complete and no tissue remains shortens 3rd stage, dec risk of bleeding assoc with nausea and vomiting

Question 55

when is active management of 3rd stage labour initiated?

Answer 55

routinely offered to all women to reduce the risk of PPH Also if: Haemorrhage >60-minute delay in delivery of the placenta (prolonged third stage)

Question 56

criteria for PPH

Answer 56

500ml after vaginal delivery | 1000ml after C-section

Question 57

minor or major PPH

Answer 57

Minor PPH - under 1000ml blood loss Major PPH - over 1000ml blood loss Major PPH can be further sub-classified as: Moderate PPH - 1000 - 2000ml blood loss Severe PPH - over 2000ml blood loss

Question 58

primary or secondary PPH

Answer 58

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

Question 59

four T's for PPH causes

Answer 59

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

Question 60

mechanical management of PPH

Answer 60

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

Question 61

medical management of PPH

Answer 61

Oxytocin (slow injection followed by continuous infusion) (infuse 40 units in 500mls) Ergometrine IV or IM stimulates smooth muscle contraction (contraindicated in hypertension) Carboprost (IM) is a prostaglandin analogue and stimulates uterine contraction (caution in asthma) Misoprostol (sublingual) is also a prostaglandin analogue and stimulates uterine contraction Tranexamic acid (IV) is an antifibrinolytic that reduces bleeding

Question 62

surgical management of PPH

Answer 62

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 63

most common cause of secondary PPH

Answer 63

RPOC or infection (endometritis)

Question 64

investigation and management of secondary PPH

Answer 64

Investigations involve: Ultrasound for retained products of conception Endocervical and high vaginal swabs for infection Management depends on the cause: Surgical evacuation of retained products of conception Antibiotics for infection

Question 65

4 categories of emergency C-section

Answer 65

Category 1: There is an immediate threat to the life of the mother or baby. Decision to delivery time is 30 minutes. Category 2: There is not an imminent threat to life, but caesarean is required urgently due to compromise of the mother or baby. Decision to delivery time is 75 minutes. Category 3: Delivery is required, but mother and baby are stable. Category 4: This is an elective caesarean,

Question 66

2 possible incisions for C-section

Answer 66

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 67

risks of spinal or general anaesthetic

Answer 67

``` 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 68

4 measures to reduce the risks during caesarean section

Answer 68

1. H2 receptor antagonists (e.g. ranitidine) or PPI(e.g. omeprazole) before the procedure - -> risk of aspiration penumonitis caused by acid reflux from prolonged period lying flat 2. Prophylactic antibiotics during the procedure to reduce the risk of infection 3. Oxytocin during the procedure to reduce the risk of PPH 4. VTE prophylaxis with LMWH

Question 69

2 key causes of sepsis in pregnancy

Answer 69

chorioamnionitis - MC | UTI

Question 70

3 signs of chorioamnionitis

Answer 70

Abdominal pain Uterine tenderness Vaginal discharge with sepsis signs

Question 71

what is an amniotic fluid embolism?

Answer 71

amniotic fluid into mom's blood (in labour and delivery) contains fetal tissue --> immune reaction bc foreign --> systemic illness, more similar to anaphylaxis than VTE 20% mortality rate presents like sepsis, PE, anaphylaxis manage ABCDE, supportive

Question 72

The main risk factors for amniotic fluid embolus

Answer 72

Increasing maternal age Induction of labour Caesarean section Multiple pregnancy

Question 73

difference between in/complete uterine rupture

Answer 73

comp of labour, myometrium ruptures incomplete or uterine dehiscene - uterine serosa (perimetrium) surrounding the uterus remains intact. complete - serosa ruptures with myometrium --> contents into peritoneal cavity baby into cavity, lots of bleeding

Question 74

risk factors for uterine rupture

Answer 74

main: previous C-section --> scar is point of weakness, may rupture with xc pressure (oxytocin stem) ``` Vaginal birth after caesarean (VBAC) Previous uterine surgery Increased BMI High parity Increased age Induction of labour Use of oxytocin to stimulate contractions ``` (rare if 1st birth)

Question 75

presentation of uterine rupture

Answer 75

acutely unwell mom + abnormal CTG ``` Ceasing of uterine contractions!! Abdominal pain Vaginal bleeding Hypotension Tachycardia Collapse ```

Question 76

management of uterine rupture

Answer 76

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 77

the 3 P's that influence progress in labour

Answer 77

Power (uterine contractions) Passenger (size, presentation and position of the baby) Passage (the shape and size of the pelvis and soft tissues) Psyche can be added as a fourth P, referring to the support and antenatal preparation for labour and delivery.

Question 78

consider delayed 1st stage of labour when

Answer 78

Less than 2cm of cervical dilatation in 4 hours | Slowing of progress in a multiparous women

Question 79

when is a partogram used?

Answer 79

Women are monitored for their progress in the first stage of labour using a partogram.

Question 80

what is recorded on a partogram?

Answer 80

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 81

how can you tell if labour progressing on a partogram?

Answer 81

2 lines labelled alert and action plot cervix dilation against duration of labour if cross to right, too slow Cross alert line --> indication for amniotomy (artificially ROM) and a repeat examination in 2 hours. Cross action line --> escalate care

Question 82

what is a delayed 2nd stage labour?

Answer 82

when the active second stage (pushing) lasts over: 2 hours in a nulliparous woman 1 hour in a multiparous woman

Question 83

what does attitude of foetus mean?

Answer 83

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

Question 84

3 types of breech presentation

Answer 84

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 85

how can you stimulate contractions during labour?

Answer 85

oxytocin - 1st line 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. monitor fetus