Labour and delivery

Question 1

What does CTG stand for and what is it?

Answer 1

Cardiotocography
It measures the fetal heartrate and uterine contractions
Two transducers are placed over the fetal heart and over the fundus of the uterus to monitor

Question 2

What are some of the indications for continous CTG monitoring?

Answer 2

Sepsis
Pre eclampsia
Maternal tachycardia
delay in labour
Fresh antepartum haemorrhage
Use of oxytocin

Question 3

What are the 5 key features to look for on a CTG?

Answer 3

Dr C BRaVADO
Define risk
CONTRACTIONS
BASELINE RATE
VARIABILITY
ACCELERATIONS
DECELERATIONS
Overall impression

Question 4

What needs to be assessed for contractions on a CTG?

Answer 4

The number of contractions in a 10 min period e.g. 2 in 10
The length of the contractions
Stregth of contractions - assessed by palpation

Question 5

What is tachy and brady for foetal heartrates?

Answer 5

More than 160 or less than 100

Question 6

What is normal heart rate variability on CTG?

Answer 6

Reassuring - 5-25bpm

Non reassuring - outside this range

Question 7

What are accelerations on a CTG?

Answer 7

These are increases in fetal heartrate greater than 15bpm for more than 15 seconds
This should occur with uterine contractions

Question 8

How long do the baby blues usually last post pregnancy?

Answer 8

Usually resolve by 3 days

Question 9

How can mothers with post natal depression be assessed?

Answer 9

With the edinburgh depression scale
Over 10 indicates depression
As long as no immediate risk to mother or baby watchful waiting is usually first line

Question 10

What are the complications of preterm rupture of membranes?

Answer 10

The main complication is preterm delivery (50%)
Infection or fetus or placenta (chorioamnionitis)
Prolapse of umbilical cord
Absence of liquor affects lung development before 22 weeks

Question 11

What are the investigations for preterm rupture of membranes?

Answer 11

A sterile speculum is performed to look for pooling in posterior vaginal vault - use actim partus to test fluid
US may show oligohydramnios

Question 12

What is the management of preterm rutpure of membranes?

Answer 12

Must balance risk of preterm delivery with risk of preterm infection
Admission for 48 hours to watch from signs of chroioamnonitis
10 days of erythromycin prophylactically
Steroids for fetal lungs
Delivery at 34 weeks

Question 13

What counts as prematurity?

Answer 13

less than 37 weeks

Question 14

At what prematurity are babies not viable or not resuscitated?

Answer 14

Less than 23 weeks non viable

23 to 24 weeks not resuscitated if not showing signs of life

Question 15

How can preterm labour be prevented?

Answer 15

Progesterone pessaries or gel can be used to stop cervical shortening and remodeling
A stich can be put in the cervix to keep it closed

Question 16

Once preterm labour has started what is the management?

Answer 16

Fetal monitoring CTG
Tocolysis with nifedipine - Ca channel blocker suppresses labour
Maternal corticosteroids reduce neonatal mortality
IV mag sulp - helps protect babies brain before 34 weeks
Delayed cord claming increases circulating volume

Question 17

What are the signs to diagnose the onset of labour?

Answer 17

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

Question 18

What are the latent and established first stages of labour?

Answer 18

The latent first stage of labour is:
-painful contractions
-Dilation of the cervix up to 4cm
The established first stage of labour is:
-Regular painful contractions
-Dilation of the cervix from 4cm onwards

Question 19

What is ergometrine and when is it used?

Answer 19

This stimulates smooth muscle contraction and vessel constriction
It is only used in the thrid stage of labour (after baby is born) to help deliver the placenta and help reduce postpartum haemorrhage

Question 20

What are prostoglandins such as dinoprostone used for?

Answer 20

They stimulate uterine contractions

Can be used as pessaries or gels to induce labour

Question 21

What is mifepristone and when is it used?

Answer 21

This is an anti-progestergen medication that blocks the action of progesterone to help enhance the effects of prostglandins in managing miscarriage
It is not used in pregnancy with a healthy living fetus

Question 22

What are the two uses of nifedipine in pregnancy?

Answer 22

Reduce blood pressure in hypertension and pre-eclampsia

Tocolysis in premature labour, it suppresses uterine activity and delays the onset of labour

Question 23

What are the 3 Ps that influence progress in labour?

Answer 23

Power (uterine contractions)
Passenger - size and presentation of the baby
Passage - the shape and size of pelvis

Question 24

How quickly should the cervix dilate in the first stage of labour?

Answer 24

Roughly 1 cm per hour
Progresses from irregular contractions in the latent phase to strong regular contractions in the active and transition phases

Question 25

What intervention may be considered if the cervix is dilating too slowly?

Answer 25

Amniotomy - artificially rupturing the membranes and switching to obstetric led care

Question 26

What counts as a delayed second stage of labour?

Answer 26

This is from 10cm dilated to delivery of baby | If this lasts longer than 2 hours in a nulliparous women of 1 hour in a multiparous women then this is delayed

Question 27

What counts as delayed thrid stage?

Answer 27

This is delivering the placenta | Longer than 30 min with active management or 60 min with physiological management

Question 28

What number of contractions is oxytocin titrated up to?

Answer 28

aim for 4-5 contractions in 10 mins

Question 29

What are some of the analgesia options for labour in a stepwise approach?

Answer 29

Paracetamol - codiene can be added - nsaids avoided Gas and air (entonox) Opiates -IM pethidine or diamorphine Patient controlled analgesia - IV remifentanil can be used Epidural - usually bupivicaine mixed with fentanyl - increases risk of requiring instrumental delivery

Question 30

What medication is given after an instrumental delivery?

Answer 30

A single dose of coamoxiclav is given prophylactically

Question 31

What are the risks to the baby with instrumental delivery?

Answer 31

Cephalohaematoma wtih ventouse | Facial nerve palsy with forceps

Question 32

What are the risks to the mother with having an instrumental delivery?

Answer 32

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

Question 33

What are the different degrees of perineal tear in labour?

Answer 33

First degree - injury limited to the frenulum of the labia minora (where they meet posteriorly) Second degree - Includes perineal muscles but not anal sphincter Third degree - including anal sphincter but not rectal mucosa: -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 Fourth degree - includes rectal mucosa

Question 34

What is the management for perineal tears following sutures or surgery?

Answer 34

Broad-spectrum antibiotics to reduce the risk of infection Laxatives to reduce the risk of constipation and wound dehiscence Physiotherapy to reduce the risk and severity of incontinence Followup to monitor for longstanding complications

Question 35

Where is an episiotomy cut made?

Answer 35

This is made mediolaterally to avoid damage to perineal body

Question 36

How can risk of perineal tears be improved?

Answer 36

Perineal massage done from 34 weeks onwards

Question 37

What are the steps in the active management of the thrid stage of labour?

Answer 37

IM oxytocin after delivery of the baby Cord cut and clamped within 5 mins of birth Gentle cord traction with contractions to help deliver placenta, one hand pushes uterus up at same time to reduce risk of prolapse After delivery the uterus is massaged until contracted and firm