Abnormal Labour

Question 1

1 in 5 labour are induced.

Why don’t we induce all labours at a time convenient for us? [3]

Answer 1

• Less efficient labour
• More painful
• Risk of uterine hyperstimulation so requires foetal monitoring

Question 2

When would we induce a labour? [3]

Answer 2

• Certain maternal health problems such as on treatment for DVT or diabetic
• > 7days overdue
• Foetal concerns e.g. oligohydramnios or growth issues

Question 3

What is Bishop’s Score? [2]

Answer 3

Clinical score used to assess the change in the cervix and predict success of induction

Question 4

How do we go about inducing labour? [3]

Answer 4

1) Dilate and efface cervix with Vaginal Prostaglandin pessaries or Cook Balloon
2) Amniotomy once bishop score = 7
3) IV oxytocin to achieve adequate contractions

Question 5

When inducing labour what rate of contractions do we aim for?
How slow do we consider to be Inadequate Progress of labour?

Answer 5

4-5 contractions / 10mins

Dilation at <0.5cm/hr primagravida or <1cm/hr multigravida

Question 6

We split the causes of Inadequate Progress into Power vs Passages vs Passenger.
How can Power be a problem in labour?

Answer 6

Inadequate Uterine Activity

Inadequate contractions -> Failure to descend -> No pressure on cervix -> No dilation/effacement

Question 7

How do we treat Inadequate Uterine Activity? What is one thing to rule out?

Answer 7

IV oxytocin

Make sure to rule out Obstructed Labour as treating that with oxytocin will rupture the uterus

Question 8

What could cause inadequate progress of labour due to the passenger? [3]

Answer 8

• Malposition
• Malpresentation
• Cephalopelvic Disproportion (CPD - combination of the passenger and passage)

Question 9

What are the common forms of malpresentation and malposition? Explain in detail

Answer 9

Malpresentation - breech or transverse lie or footling

Malposition - Relative CPD occurs due to foetal head being in the wrong orientation e.g. Occipito-posterior or Occipito-transverse

Question 10

When might be better not to attempt normal delivery? [5]

Answer 10

• Obstruction e.g. Placental Praevia
• Malpresentation
• Unsafe maternal conditions e.g. cardiac problems
• Previous complications of labour e.g. uterine rupture
• Foetal conditions

Question 11

What other options are there when normal delivery isn’t recommended? [2]

Answer 11

• Assisted or Instrumental delivery if fully dilated using forceps or Vacuum Extraction (15%)
• C-section (25%)

Question 12

In what cases do you choose to do a C-section? [2]

Answer 12

• Obstructed Labour

- Foetal Distress prior to full dilation

Question 13

List the common stage 3 complications of labour?

Answer 13

• Retained PLacenta
• PPH
• Tears (grazes, 1st->4th degree tears)

Question 14

Indications for forceps delivery [4]

Answer 14

• fetal distress in the second stage of labour
• maternal distress in the second stage of labour
• failure to progress in the second stage of labour
• control of head in breech delivery

Question 15

Management of breech and transverse presentation

Out of the three malpresentation, which one is associated with greatest mortality at delivery?

Answer 15

Breech:

• ECV at 36w if prim
• or 37w if parous

Transverse:
- ECV may be attempted as long as amniotic sac has not ruptured

Footling:
- greatest mortality at delivery

Question 16

Failure to progress definition

NICE guidelines on mx of slow progress [3]

Answer 16

If the progress of cervical dilatation lags more than 2h behind the expected rate of dilatation
This indicates poor progress in active case of labour
Slow progress is <1cm in 3h with no changes (in cervical effacement or head descent), in the presence of ruptured membranes
> exclude CPD
> Give oxytocin

Question 17

Caesarean section
Types [2]
Indications

Answer 17

Types:

• lower segment caesarean section (LSCS)
• classic CS (longitudinal incisions in upper segment of uterus)

Indications:

• absolute cephalopelvic disproportion
• placenta praevia grades ¾, placental abruption (only if fetal distress; deliver stillbirths vaginally)
• pre-eclampsia, post-maturity
• IUGR
• fetal distress
• prolapsed cord
• failure to progress in labour, malpresentation (brow)
• vaginal infection e.g. active herpes
• cervical cancer (disseminates cancer cells)

Question 18

C-section complications that are dangerous to:

• Mother [6]
• Future pregnancies [3]

Answer 18

Maternal:

• emergency hysterectomy
• need for further surgery at a later date (e.g. cutterage for retained placental tissue)
• ICU admission, VTE
• bladder injury, ureteric injury
• death (1 in 12000)

Future pregnancies:

• increased risk uterine rupture
• increased risk antepartum stillbirth
• increased risk of placenta praevia or placenta accreta