Abnormal Labour

Question 1

What is induction of labour?

Answer 1

This is where you artificially start labour

Question 2

Describe the steps of induction of labour?

Answer 2

• 1/5 induced
• Needs foetal monitoring
• Needs cervical ripening
  
  • Get cervix ready for labour with prostaglandins (pharmacological) or balloon (mechanical)
• Then artificial rupture of membranes (by amniotomy)
  
  • Bishop’s score used to clinically assess cervix and when amniotomy can be performed, indicated by score of 7 or more, 5 or less means labour unlikely to start without induction
• Oxytocin then used to induce contractions
  
  • Aim for 4-5 per minute

Question 3

What is cervical ripening?

Answer 3

• Get cervix ready for labour with prostaglandins (pharmacological) or balloon (mechanical)

Question 4

What is used for cervical ripening?

Answer 4

• Get cervix ready for labour with prostaglandins (pharmacological) or balloon (mechanical)

Question 5

How are the membranes artificially ruptured?

Answer 5

By amniotomy

Question 6

What is used to assess the cervix and determine when amniotomy can be performed?

Answer 6

Bishops’ score

5 or less means labour unlikely to start without induction

7 or more means labour is likely

Question 7

What things does Bishop’s score look at?

Answer 7

Question 8

What is used to induce contractions?

Answer 8

Oxytocin

Question 9

What are some indications for labour induction?

Answer 9

• Diabetes
• Post dates
  
  • Term plus 7 days
• Maternal need for planning delivery
  
  • Such as treatment for DVT
• Foetal reasons
  
  • Such as growth concerns
  • Social/maternal request

Question 10

How far overdue is an indication for induction of labour?

Answer 10

• Term plus 7 days

Question 11

What are contraindications for labour induction?

Answer 11

• Malpresentation
• Placentral praevia
• Prolapsed umbilical cord
• Foetal distress
• Anatomical abnormalities

Question 12

What are possible complications of labour induction?

Answer 12

• Uterine hypertonicity
• Foetal distress
• Adverse effects of drugs
• Failed induction
• Caesarean section
• Uterine rupture

Question 13

What can inadequate progress in labour be due to?

Answer 13

• Inadequate uterine activity (power)
• Cephalopelvic disproportion (CPD) (passages)
• Other reasons for obstruction such as fibroid (passages)
• Malposition (passenger)
• Malpresentation (passenger)

Question 14

How is progress in labour evaluated?

Answer 14

Progress in labour is evaluated by abdominal and/or vaginal examinations to determine:

• Cervical effacement
• Cervical dilation
• Descent of the foetal head through the maternal pelvis

Question 15

Suboptimal progress in the first stage of labour is defined as?

Answer 15

Suboptimal progress in the first stage of labour is defined as cervical dilation less than:

• 0.5cm per hour for primigravid woman
• 1cm per hour for parous woman

Question 16

What is a complication of inadequate uterine activity?

Answer 16

• If contractions are inadequate foetal head will not descent and exert force on the cervix, so cervix will not dilate
• Strength and duration of contractions can be increased by giving synthetic IV oxytocin to the mother
• Important to exclude an obstructed labour, as could lead to ruptured uterus

Question 17

How can strength and duration of contractions be increased?

Answer 17

• Strength and duration of contractions can be increased by giving synthetic IV oxytocin to the mother

Question 18

What graph shows movement of head and dilation?

Answer 18

Partogram

Question 19

What does CPD stand for?

Answer 19

Cephalopelvic disproportion

Question 20

What is cephalopelvic disproportion?

Answer 20

Cephalopelvic disproportion (CPD) = complication where there is a size mismatch between mother’s pelvis and the foetus’ head (head to large or pelvis to small)

Question 21

Is CPD common or rare?

Answer 21

Rare

Question 22

Other than cephalopelvic disproportion, what other obstructions can be present?

Answer 22

• Placenta praevia
• Foetal anomaly
• Fibroids

Question 23

What is placenta praevia?

Answer 23

Placenta partially or completely covers the mothers cervix

Question 24

What are fibroids?

Answer 24

Non-cancerous growths that develop in and around the womb

Question 25

What is malpresentation?

Answer 25

Malpresentation = presenting part is not the vertex (baby is not head down)

Question 26

What are different lies for the baby (malpresentation)?

Answer 26

* Longitudinal lie vertex presentation * Longitudinal lie breech presentation * Many more

Question 27

What is malposition?

Answer 27

Malposition = foetal head being in a suboptimal position for labour and relative CPD occurs

Question 28

Is malpresentation or malposition more common?

Answer 28

Malposition

Question 29

What is the ideal position for birth?

Answer 29

* Ideal position is occipito-anterior (OA), refers to babies occopito facing the mothers symphysis (anterior)

Question 30

What are examples of malpositions?

Answer 30

* Malpositions includes occipito-posterior (OP) and occipito-transverse (OT)

Question 31

How can the position of the baby be detected?

Answer 31

Can detect position by feeling for suture lines – anterior and posterior fontanelle: * Anterior is diamond shape * Posterior is triangle shape

Question 32

What is foetal distress?

Answer 32

Foetal distress = signs before and during childbirth that indicate the foetus is not well

Question 33

What can foetal distress occur due to?

Answer 33

* Too many contractions (uterine hyper-stimulation) * Causes insufficient placental blood flow * Main causes are hypoxia, infection * Rare causes like cord prolapse, placental abruption and vasa praevia

Question 34

What are different methods of foetal monitoring?

Answer 34

* **Intermittent auscultation of foetal heart – in low risk labours** * Done by Doppler US for 1 minute after a contraction every 15 mins in first stage of labour, or 5 mins in second stage * If abnormality detected, do CTG * **Cardiotocography (CTG) – in high risk labours** * Represents autonomic and CNS activity, changes due to hypoxia * Foetal heart rate and contractions are monitored * Indications are basically any abnormal situations * **Foetal blood sampling** * Speculum used to take foetal scalp blood sample * Used when abnormal CTG * Provides direct measurements from baby of pH and base excess, lactic acid – giving an idea of if hypoxemic * **Foetal ECG**

Question 35

How is intermittent auscultation of the foetal heart done?

Answer 35

* Done by Doppler US for 1 minute after a contraction every 15 mins in first stage of labour, or 5 mins in second stage

Question 36

What should be done if anomaly detected with intermittent auscultation of foetal heart?

Answer 36

CTG

Question 37

What does CTG stand for?

Answer 37

Cardiotocography

Question 38

What is a cardiotocography?

Answer 38

* Represents autonomic and CNS activity, changes due to hypoxia * Foetal heart rate and contractions are monitored * Indications are basically any abnormal situations

Question 39

Out of auscultation of foetal heart and CTG, which is for low and high risk labours?

Answer 39

Auscultation - low risk CTG - high risk

Question 40

What are indications for CTG?

Answer 40

* Indications are basically any abnormal situations

Question 41

What is done if CTG is abnormal?

Answer 41

* Foetal blood sampling * Speculum used to take foetal scalp blood sample * Used when abnormal CTG * Provides direct measurements from baby of pH and base excess, lactic acid – giving an idea of if hypoxemic

Question 42

What does feotal blood sampling provide?

Answer 42

* Provides direct measurements from baby of pH and base excess, lactic acid – giving an idea of if hypoxemic

Question 43

What is the normal foetal heart rate?

Answer 43

100-160bpm

Question 44

What are different kinds of operative delivery

Answer 44

* Instrumental devices 15% of all births * Planned caesarean sections 20-30% * Emergency caesarean section 20-25%

Question 45

What is caesarean section?

Answer 45

Caesarean section = deliver baby through abdominal wall

Question 46

What are the 2 types of caesarean section?

Answer 46

* Lower uterine segment incision, 99% of cases * Classical – longitudinal section in upper uterus

Question 47

What are indications for caesarean section?

Answer 47

* Foetal distress * Failure to progress in labour * Failed induction of labour * Malpresentation * Severe pre-eclampsia * Placenta praevia * Repeat caesarean section

Question 48

What are the 4 grades of caesarean section?

Answer 48

Question 49

What are possible complications of caesarean section?

Answer 49

* Injuries to surrounding structures * Haemorrhage * DVT * Infection

Question 50

When is the 3rd stage of labour?

Answer 50

Third stage is from point of birth of baby to delivery of placenta

Question 51

What are possible third stage complications?

Answer 51

* Retained placenta * Post-partum haemorrhage * Tears * Classed from graze, 1^st, 2^nd, 3^rd (involving anal sphincter complex), 4^th degree (involving rectal mucosa)