Labour - Management

Question 1

How should blood pressure and temperature of a woman in labour be managed?

Answer 1

temperature and BP monitored every 4 hours - pulse every hour (1st stage) and then every 15 mins (2nd stage) and contraction frequency should be measured every 30 mins

Question 2

In what position do most ladies deliver in?

Answer 2

Semi-recumbent position - e.g. squatting, kneeling, or left-lateral position

supine is avoided as can lead to compression of main blood vessels leading to reduced CO, hypotension and foetal distress

Question 3

Can women eat during labour?

Answer 3

Yes, unless high risk, as may need general anaesthetic

Question 4

What is pyrexia in labour associated with?

what is the management of pyrexia in labour?

Answer 4

Increased risk of neonatal illness - more common with epidural and prolonged labour. Paracetamol is administered, and IV antibiotics and CTG monitoring are warranted if the fever reaches 38 degrees.

Question 5

What is the effect of retention of urine?

Answer 5

Irreversible damage fo the detrusor muscle - frequent micturition is encouraged in labour

catheterisation is required if an epidural is in situ.

Question 6

What is progress in labour dependent?

Answer 6

Power (uterine contractions)
Passenger (size, presentation and position of the baby)
Passage (the shape and size of the pelvis and soft tissues)

Question 7

What is the minimum rate of dilation after the latent phase?

Answer 7

1cm/hr

Question 8

What is the most common cause of slow progression of labour?

Answer 8

inefficient uterine action - common in nulliparous women and induced labour

Persistently slow progress is treated with augmentation, initially with amniotomy and then oxytocin

Question 9

In what circumstances does hyperactive uterine action occur?

Answer 9

Excessively strong, frequent or prolonged contractions

Question 10

What are the complications of hyperactive uterine action?

Answer 10

foetal distress occurs as placental blood flow is diminished and labour may be very rapid

associated with placental abruption, too much oxytocin or a side effect of PG administered to induce labour.

Question 11

What is the treatment of hyperactive uterine action?

Answer 11

if no abruption - can be treated with a tocolytic (salbutamol IV) - but C-section is often indicated because of foetal distress

Question 12

What is slow progress in nulliparous women usually due to?

Answer 12

Inefficient uterine action

Question 13

How can slow progress in nulliparous women be managed?

Answer 13

Amniotomy, also known as artificial rupture of membranes (ARM) for women with intact membranes
Oxytocin infusion
Instrumental delivery
Caesarean section

Oxytocin - first-line to stimulate uterine contractions during labour. 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.

Question 14

What is the management for poor descent?

Answer 14

oxytocin induction - pushing not encouraged until the woman feels the urge - epidural diminishes this urge

Question 15

If active 2nd stage lasts longer than 1-2 hours, what is the management?

Answer 15

Instrumental delivery - maternal exhaustion, foetal hypoxia and maternal trauma

Question 16

What needs to be excluded in augmentation of labour in a multiparous woman?

Answer 16

Malpresentation

Question 17

In what ways can the foetus contribute to poor progress in labour?

Answer 17

OP position

OT position

Brow presentation

Face presentation

Question 18

What are the indications for instrumental delivery?

Answer 18

Failure to progress
Fetal distress
Maternal exhaustion
Control of the head in various fetal positions

Question 19

What positions of the head make labour more difficult?

Answer 19

OA preferred

OP or OT make difficult

Question 20

What is the management of OT position?

OP?

Answer 20

rotation with traction is required for delivery to occur and is achieved with the ventouse

OP: Keilland’s forceps

Question 21

What is the effect of Brow presentation?

Answer 21

extension of the foetal head on the neck results in a large diameter that will not normally delivery vaginally.
anterior fontanelle, supraorbital rides and nose are palpable vaginally

Question 22

What is the management of Brow presentation?

Answer 22

C-section is required

Question 23

What is the effect of face presentation?

Answer 23

Complete extension of the head resulting in the face being the presenting part.

Foetal compromise in labour is more common. Presenting diameter is 9.5cm allowing vaginal delivery in most cases, as long as the chin is anterior.

Delivery is completed by flexion over the perineum. If the chin is posterior, then a C-section is indicated

Question 24

What is cephalo-pelvic disproportion?

Answer 24

When the pelvis is too small to allow passage of the head, but can almost ever be diagnosed with certainty.

Depends on foetal and pelvic size and usually diagnosed retrospectively.

Defined as: inability to delivery a particular foetus despite presence of adequate uterine activity and absence of a malposition or presentation

Question 25

What increases the chance of cephalo-pelvic disproportion?

Answer 25

Large baby very short woman where the head in a nulliparous woman remains high at term

Question 26

What pelvic abnormalities prevent engagement and descent of the head?

Answer 26

Pelvic mass ovarian tumour or uterine fibroid C-section indicated

Question 27

What are the causes of permanent foetal damage?

Answer 27

Foetal hypoxia - commonly described as distress Infection/inflammation in labour - e.g. GBS Meconium aspiration leading to chemical pneumonitis Trauma - commonly due to obstetric intervention (e.g. forceps) Foetal blood loss

Question 28

What is foetal distress?

Answer 28

Hypoxia that might result in foetal damage or death if not reversed or the foetus delivered urgently.

Question 29

What is the threshold that indicates severe hypoxia?

Answer 29

Foetal scalp blood with pH of <7.2 indicated significant hypoxia. pH <7 - neurological damage is considerably more common and even then, most babies with neurological damage had a normal pH at birth. this suggests other influences, such as IUGR or maternal fever on neonatal outcome

Question 30

What can acute hypoxia in labour be due to?

Answer 30

``` Long labour Placental abruption Hypertonic uterine states Use of oxytocin Prolapse of the umbilical cord Maternal hypotension ```

Question 31

What are the intrapartum risk factors of foetal distress?

Answer 31

long labour meconium epidurals oxytocin

Question 32

What are the antepartum risk factors of foetal distress?

Answer 32

Pre-eclampsia | IUGR

Question 33

How is foetal distress diagnosed?

Answer 33

Colour of the liquor Foetal heart auscultation CTG Foetal blood sampling

Question 34

What is meconium?

Answer 34

Bowel contents of the foetus that stains the amniotic fluid Rare in preterm foetuses, but common after 41 weeks.

Question 35

Why is colour of the liquor an indication for caution?

Answer 35

meconium very diluted in amniotic fluid is not significant but undiluted - increase in perinatal mortality 1. foetus may aspirate it - meconium aspiration syndrome 2. Hypoxia more likely

Question 36

How often is the heart auscultated in labour?

Answer 36

every 15 minutes during the first stage and every 5 minutes during the second stage using a Pinard's stethoscope or handheld doppler. Distressed foetus normally exhibits abnormal heart rate patterns

Question 37

What does a CTG do?

Answer 37

CTG is used to measure the fetal heart rate and the contractions of the uterus It is a useful way of monitoring the condition of the fetus and the activity of labour. Two transducers are placed on the abdomen to get the CTG readout: One above the fetal heart to monitor the fetal heartbeat One near the fundus of the uterus to monitor the uterine contractions The transducer above the fetal heart monitors the heartbeat using Doppler ultrasound. The transducer above the fundus uses ultrasound to assess the tension in the uterine wall, indicating uterine contraction.

Question 38

How does foetal blood sampling work?

Answer 38

Blood taken from the scalp | if the pH is <7.2 then delivery is expedited in the fastest way possible

Question 39

What are the features looked for on CTG? (5)

Answer 39

Contractions – the number of uterine contractions per 10 minutes Baseline rate – the baseline fetal heart rate Variability – how the fetal heart rate varies up and down around the baseline Accelerations – periods where the fetal heart rate spikes Decelerations – periods where the fetal heart rate drops

Question 40

What should the baseline heart rate of the foetus be?

Answer 40

110-160

Question 41

What are tachycardias associated with?

Answer 41

fever, foetal infection, potentially foetal hypoxia A steep, sustained deterioration in rate suggests acute foetal distress

Question 42

What should the baseline variability be?

Answer 42

>5bpm, except during episodes of foetal sleep which usually last less than 45 minutes (5-25)

Question 43

What does prolonged reduced variability suggest?

Answer 43

Hypoxia

Question 44

Describe how accelerations should be viewed?

Answer 44

Increases in the FHR with movements or contractions are reassuring

Question 45

What are the types of decelerations? What do they indicate?

Answer 45

The fetal heart rate drops in response to hypoxia. Early decelerations are gradual dips and recoveries in heart rate that correspond with uterine contractions. Early decelerations are normal and not considered pathological. They are caused by the uterus compressing the head the fetus, stimulating the vagus nerve of the fetus, slowing the heart rate. Late decelerations are gradual falls in heart rate that starts after the uterine contraction has already begun. 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 or maternal hypoxia. Variable decelerations are abrupt decelerations that may be unrelated to uterine contractions. There is a fall of more than 15 bpm from the baseline. Variable decelerations often indicate intermittent compression of the umbilical cord, causing fetal hypoxia. Prolonged decelerations 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 46

What are the indications for using a CTG?

Answer 46

``` 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 47

What are the classifications of CTG? What management should be undertaken?

Answer 47

Normal Suspicious: a single non-reassuring feature Pathological: two non-reassuring features or a single abnormal feature Need for urgent intervention: acute bradycardia or prolonged deceleration of more than 3 minutes The outcome of the CTG will guide management, such as: Escalating to a senior midwife and obstetrician Further assessment for possible causes, such as uterine hyperstimulation, maternal hypotension and cord prolapse Conservative interventions such as repositioning the mother or giving IV fluids for hypotension Fetal scalp stimulation (an acceleration in response to stimulation is a reassuring sign) Fetal scalp blood sampling to test for fetal acidosis Delivery of the baby (e.g. instrumental delivery or emergency caesarean section)

Question 48

How many births does GBS affect?

Answer 48

1.7 per 1000 live births

Question 49

What is a fever a strong risk factor for?

Answer 49

Fever = strong risk factor for seizures, foetal death and cerebral palsy, even in the absence of evidence of infection

Question 50

How is Maternal fever treated?

Answer 50

Antibiotics and antipyretics

Question 51

What is the effect of meconium aspiration?

Answer 51

when aspirated into the lungs, it causes severe pneumonitis more common in the presence of foetal hypoxia, but can occur without it

Question 52

How can meconium be treated if it is thick?

Answer 52

diluted in the uterus

Question 53

How can foetal trauma be caused?

Answer 53

Iatrogenic | or from shoulder dystocia

Question 54

What are the causes of foetal blood loss?

Answer 54

Vasa praevia | foeto-maternal haemorrhage or occasionally, placental abrupsion

Question 55

What non-medical techniques can be employed for pain relief in labour?

Answer 55

Immersion in water at body temperature ``` TENS hypnotherapy acupuncture localised pressure on back superficial heat or cold massage aromatherapy ```

Question 56

What inhalation agents are available?

Answer 56

Entonox - contains a mixture of 50% nitrous oxide and 50% oxygen. This is used during contractions for short term pain relief. The woman takes deep breaths using a mouthpiece at the start of a contraction, then stops using it as the contraction eases. It can cause lightheadedness, nausea or sleepiness.

Question 57

What are the effects of entonox?

Answer 57

rapid onset and mild analgesia insufficient for most mothers and can cause light-headedness, nausea and hyperventilation

Question 58

What systemic opiates are available?

Answer 58

Pethidine and diamorphine are opioid medications, usually given by intramuscular injection. They may help with anxiety and distress. They may cause drowsiness or nausea in the mother, and can cause respiratory depression in the neonate if given too close to birth. The effect on the baby may make the first feed more difficult.

Question 59

What are the effects of systemic opiates?

Answer 59

Analgesic effect = small and many women become sedated, confused or feel out of control anti-emetics normally needed. can also cause respiratory depression in the newborn

Question 60

What is an epidural?

Answer 60

An epidural involves inserting a small tube (catheter) into the epidural space in the lower back. Local anaesthetic medications are infused through the catheter into the epidural space, where they diffuse to the surrounding tissues and through to the spinal cord, where they have an analgesic effect. levobupivacaine or bupivacaine, usually mixed with fentanyl.

Question 61

What are the effects of epidural anaesthesia?

Answer 61

GOOD pain relief Adverse effects: ``` Headache after insertion Hypotension Motor weakness in the legs Nerve damage Prolonged second stage Increased probability of instrumental delivery ```

Question 62

Name the three types of anaesthesia for obstetric procedures

Answer 62

1. spinal anaesthesia 2. epidural anaesthesia 3. Pudendal nerve block

Question 63

How is a spinal anaesthetic administered?

Answer 63

Local anaesthetic is injected as a single shot through the dura mater into the CSF. This rapidly produces a short-lasting but effective local analgesia (and motor blockade) that is suitable for C-section or mid-cavity instrumental vaginal delivery Complications include hypotension

Question 64

What are the indications of epidural anaesthesia?

Answer 64

higher dose epidural anaesthesia can be used for both instrumental delivery and C-section for the latter, a combination of spinal and epidural is best - allowing rapid onset due to spina and longer lasting anaesthesia with the opportunity for top ups due to the epidural

Question 65

How is a pudendal nerve block done?

Answer 65

local anaesthetic is injected bilaterally around the pudental nerve where it passes the ischial spine. This is suitable for low-cavity instrumental vaginal delivery

Question 66

When is a woman advised to contact maternity services RE labour?

Answer 66

If contractions are regular, painful, lasting at least 30 seconds and occurring every 3-4 minutes, or if the membranes rupture

Question 67

What is done to diagnose labour?

Answer 67

Presentation is checked and vaginal examination looks at cervical effacement and dilation to confirm diagnosis of labour. The degree of descent is also assessed and the colour of leaking liquor is noted

Question 68

How is it decided whether to start CTG?

Answer 68

Every 15 minutes, foetal heart is listened to for 1 minute following a contraction. If the pregnancy is high risk of meconium is seen or there is maternal fever - CTG started

Question 69

What position is the mother advised to avoid?

Answer 69

Supine encouraged to remain mobile

Question 70

What analgesia is administered in the first stage of labour?

Answer 70

Entonox for short term relief Commonly - epidural. Catheterisation will be required if an epidural is given, but otherwise not routine

Question 71

How is progress over the first stage of labour monitors?

Answer 71

foetal heart auscultated every 15 minutes - if abnormal delivery needs to expedited, the only option is a C-section Vaginal examination every 4 hours - dilation and descent are estimated digitally in centimetres

Question 72

How can slow dilation after the latent phase be treated?

Answer 72

ARM - if progress continues to be slow, oxytocin is used in a nulliparous women and a multiparous woman (if malpresentation has been excluded)

Question 73

What is the management if a cervix is not fully dilated by 12-16 hours?

Answer 73

C-section unless delivery can be anticipated in the next hour or two

Question 74

When is pushing encouraged in the second stage of labour?

Answer 74

(if no epidural) pushing encouraged when mother has desire, or the head is visible (if epidural) at least an hour is waited before pushing and oxytocin is administered to a nulliparous woman if descent is poor

Question 75

What is directed pushing?

Answer 75

If an epidural is in situ, the woman is instructed to push three times for about 10 seconds during each contraction

Question 76

What are the indications for expedition of delivery?

Answer 76

if delivery is not imminent after 2 hours of pushing (1 hour in multiparous) or there is foetal distress usually done with ventouse or forceps

Question 77

What is the indication of episiotomy?

Answer 77

Reserved for when there is foetal distress or where the head is not passing over the perineum despite maternal effort, or if a large tear is likely.

Question 78

How is episiotomy performed?

Answer 78

the perineum is infiltrated with local anaesthetic and a 3-5cm cut is made from the centre of the fourchette at a 45 degree angle to the mother's right side of the perineum

Question 79

What should the mother be asked to do when the head starts to deliver?

Answer 79

Stop pushing, pant slowly Attendant may press on the perineum and the head to prevent a rapid delivery and perineal damage

Question 80

What gets delivered after the head?

Answer 80

Anterior shoulder - then traction is directed upward to deliver the posterior shoulder

Question 81

When should the umbilical cord be clamped?

Answer 81

After 1 minute, unless resuscitation is urgently required

Question 82

What drug is administered IM to help the uterus contract once the shoulders are delivered

Answer 82

Oxytocin Ergometrine and oxytocin often used, but this frequently leads to maternal vomitng

Question 83

How is delivery of the placenta achieved?

Answer 83

Physiological Active management of the third stage is where the midwife or doctor assist in delivering of the placenta. It involves a dose of intramuscular oxytocin to help the uterus contract, and careful traction to the umbilical cord to guide the placenta out of the uterus and vagina. Active management shortens the third stage and reduces the risk of bleeding, but can be associated with nausea and vomiting. Active management is routinely offered to all women to reduce the risk of postpartum haemorrhage. It is also initiated if there is: Haemorrhage More than a 60-minute delay in delivery of the placenta (prolonged third stage)

Question 84

What happens following placental delivery?

Answer 84

mother cleaned, made comfortable and encouraged to breast feed Maternal observation continued for at least 2 hours

Question 85

What is the effect/management of retained placenta?

Answer 85

Partial separation may cause blood loss in the uterus, causing it to enlarge and leading to hypovolaemia 1 hour is left for natural separation, after which the placenta is manually removed, blood cross matched and IV abx given

Question 86

What is the managment of first and second degree tears?

Answer 86

(along with uncomplicated epiostomies and anal sphincter damage) are sutured under local anaesthetic Absorbable synthetic material used, continues sutures for eh muscle and subcuticular layers for the skin. Rectal and vaginal examination excludes sutures that are too deep and retained swabs

Question 87

How are third and fourth degree tears managed?

Answer 87

Sphincter is repaired under epidural or spinal anaesthetic with the visualisation and asepsis of an operating theatre. Torn ends of the external sphincter are mobilised and sutured, with the internal sphincter sutured separately if damaged. 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 88

What is the long term effect of third/fourth degree tears?

Answer 88

Incontinence or urgency