Abnormal labour

Question 1

how is diagnosis of breech position made?

Answer 1

head felt at upper end of uterus on obstetric examination, vaginal examination confirms no head found in pelvis

Question 2

management of breech birth?

What must you give the mother before this if Rh-ve?

What else is given to all women in breech?

Answer 2

• ECV offered from 37 weeks
• Anti-D
• SC salbutamol as uterine relaxant

Question 3

When is vaginal breech delivery possible?

When is vaginal breech delivery likely to become unsuccessful?

Answer 3

• pelvic inlet >11cm AP and outlet >11cm transverse
• estimated foetal weight <3.5kg
• other contraindications to vaginal delivery (e.g. placenta praevia)
• footing or kneeling breech
• previous C-section

Question 4

what is done in all vaginal breech births?

what is the pros and cons of vaginal breech birth?

Answer 4

• routine episiotomy
• foetal CTG
• pros: decreased morbidity and mortality
• cons: 3x higher risk of foetal hypoxia, increased risk of head entrapment and intracranial damage leading to emergency section

Question 5

What are the complications specific to twin delivery?

What should you ensure regarding positioning in twins?

Answer 5

• prolapse of umbilical cord is more common
• PPH more common
• delay in delivery of second twin associated with high mortality
• first twin has longitudinal lie

Question 6

What is a ventouse? and how often is it used?

What are the indications?

Answer 6

• vacuum extractor
• used more in developing countries, 5-10% in UK
• delay in 2nd stage
  medical indications for avoiding valsalva manoeuvre
• foetal compromise

Question 7

Contraindications of ventouse? (4)

What are the complications? maternal and foetal

Answer 7

• breech position
• malposition of face
• premature infants (<36 weeks)
• mother has HIV or HEP B
• maternal: vaginal wall damage, cervical damage, urinary retention
• foetal: skin abrasions, cephalohaematoma, retinal haemorrhage

Question 8

indications for use of forceps? (4)

Answer 8

• poor progress in 2nd stage (2 hours for primp, 1 hour for multip)
• clinical foetal distress on CTG or passage of meconium
• FBS pH <7.15
• maternal distress: tired after a long first page,

Question 9

complications of forceps?

Mother

baby

Answer 9

• urinary retention due to bladder neck oedema
• perineal tear
• damage to anal sphincter and or rectal mucosa leading to occasional incontinence
• bruising
• facial palsy
• intracranial haemorrhage

Question 10

What is shoulder dystocia?

Answer 10

• anterior shoulder becomes trapped behind/ above the pubic symphysis
• posterior shoulder in hollow/ sacral promontory

Question 11

predisposing factors to shoulder dystocia?

signs of dystocia?

Answer 11

• previous baby >4.5kg
• big baby
• diabetes/ obesity
• prolonged second stage
• foetal chin pulls back against perineum
• no external signs for restitution
• anterior shoulder fails to deliver with contraction

Question 12

how is it managed?

Answer 12

H- call for help 
E- episiotomy 
L- legs- (mcroberts manoeuvre) 
P- suprapubic pressure 
E- enter rotational manoeuvres 
R- remove posterior arm 
R- roll patient to hands and knees

Question 13

How do you treat 1st and 2nd degree tears?

in what direction is an episiotomy performed? why?

what are the risk factors for a tear?

Answer 13

• sutured under LA
• mediolaterally, reduces risk of 3rd + 4th degree tears
• forceps delivery, large babies, nulliparity

Question 14

what is involved in a 1st, 2nd 3rd and 4th degree tear?

Answer 14

1st: skin
2nd: superficial perineal muscles
3rd: external anal sphincter
4th: internal anal sphincter and mucosa

Question 15

what are the long term complications of 3rd/4th degree tears?

Answer 15

• incontinence of flatus or urgency in 30%

- 70% asymptomatic 12 months after delivery