Abnormal Labour

Question 1

What is meant by malpresentation?

Answer 1

• non-vertex

- commonly breech

Question 2

What is meant by malposition?

Answer 2

• OP or OT

- ABNORMAL position of the head

Question 3

What is pre-term and post-term baby?

Answer 3

• pre-term: <37 wks

- post-term: >42 wks

Question 4

How many percent of deliveries are c-sections in sCOTLAND?

Answer 4

• 30%

Question 5

What are the diff. types of breech?

Answer 5

• Complete breech (feet folded at baby’s bottom)
• Footling breech
• frank breech (bottom first- legs point up to head)

Question 6

What are the risks of a breech baby?

Answer 6

• cord prolapse are common, esp. in pre-term
• skinny baby
• delivery through a non-fully dilated cervix ; head entrapment —-C-SECTION

Question 7

When is vaginal delivery NOT possible at all?

Answer 7

• when bby’s arm comes first
• commonly seen in twins
• pre-term baby

Question 8

What is meant by brow presentation?

Answer 8

• bby’s chin is untucked
• slightly extended backwards (not as sharp as the face presentation)
• —- if chin is at the back; bby won’t deliver

Question 9

How may labour be abnormal?

Answer 9

Too early - preterm birth
Too late – induction of labour
Too painful - requires anaesthetic input
Too long - failure to progress
Too quick- hyperstimulation; fetal hypoxia ! ----uterine contractions on baby 
Fetal distress - hypoxia/sepsis
Wrong part presenting

Question 10

What forms of analgesia is used for labour?

Answer 10

• support (other people- females)
• massage techniques
• TENS (transcutaneous electrical nerve stimulation)—–electric pads on lower thoracic and lumbar
• water immersion
• IM opiate analgesia (at peak of contrxn; good for fast labour)
• IV Remifentanil PCA
• regional anaesthesia
• entonox (inhalation agents)

Question 11

Benefits of Epidural anaethesia?

Name one.

Answer 11

• can be topped up during LONG period of labour
• 95% effective
• no uterine activity impairment
• Levobupivacaine +/- Opiate

Question 12

Complications of epidural anesthesia?

Answer 12

Hypotension (20%)
Dural puncture (1%)
—>Headache
High block (excessive block; respiratory distress)

Atonic bladder (40%)

Question 13

Risks of Obstructed labour?

Answer 13

1. sepsis
2. uterine rupture (as uterus thins with every pregnancy; or previous c-section)
3. obstructed AKI
4. postpartum haemorrhage
5. fistula formation (fetal head pressing on surrounding structures)
6. fetal asphyxia
7. neonatal sepsis

Question 14

Extent of cervical dilatation?

Answer 14

-0-10cm

Question 15

Who usually progresses faster with their deliveries?

Answer 15

• Parous women

Question 16

Expected contractions in 10mins?

Answer 16

3-4

Question 17

What is indicative of delay in delivery?

Answer 17

• <2cm dilatation in 4hrs in Stage 1 for Parous women (same with Nulliparous)

Question 18

How may passages pose a problem in delivery?

Answer 18

• short stature
• trauma
• shape

Question 19

What factors to consider for the “passenger”?

Answer 19

• bigbaby

- malposition

Question 20

List the change in fetal head orientation as it descends the pelvis?

Answer 20

1. DESCENT: Head engages and in OCCIPUT TRANSVERSE position
2. FLEXION: whilst descending through the pelvis; head flexes (chin-to-chest); still in OCCIPUT TRANSVERSE position; anterior fontanelle hard to feel
3. INTERNAL ROTATION: occiput rotates anteriorly; head is now oblique or may be in OA
4. Extension of head (not touching chest)
5. shoulder to rotate to AP position
   - –foetal head returns to TRANSVERSE position

Question 21

What is the MAIN deterrent in the delivery of the baby?

Answer 21

• flexion of the fetal head

Question 22

What is set as 0 for measuring the descent of the fetus?

Answer 22

• ischial spine

- below = +1 , +2…

Question 23

• bby feels big
• labor all day
• at 6 cm for 4 hrs
  —-only -1 descent if baby
  What is the course of action?

Answer 23

• offer c-section

Question 24

What is involved in the intra-partum fetal assessment?

Answer 24

• color of amniotic fluid
• CTG
• Doppler Auscultation

Question 25

When to monitor fetal heart during Stage 1 and 2?

Answer 25

Stage 1: During and after a contraction Every 15 minutes Stage 2: - At least every 5 minutes during and after a contraction for 1 whole minute - check Maternal pulse at least every 15 mins

Question 26

Acute causes of fetal distress?

Answer 26

``` Abruption Vasa Praevia Cord Prolapse- deceleration Uterine Rupture Feto-maternal Haemorrhage Uterine Hyperstimulation Regional Anaesthesia ```

Question 27

Chronic causes of fetal distress?

Answer 27

Placental insufficiency | - fetal anemia

Question 28

What do Late decelerations indicate?

Answer 28

- bby is hypoxic

Question 29

How does complicated variable decelerations appear?

Answer 29

- deep and broad deceleration | - --

Question 30

What should CTG be classified as?

Answer 30

- normal/ suspicious/ pathological

Question 31

How does hypoxia appear on CTG?

Answer 31

- loss of accelerations - Repetitive deeper and wider decelerations - Rising fetal baseline heart rate - Loss of variability

Question 32

Management of fetal distress

Answer 32

- Change maternal position - IV Fluids -Stop syntocinon -Scalp stimulation -Consider tocolysis--- Terbutaline 250 micrograms s/c -Maternal assessment - Pulse / BP / Abdomen / VE Fetal blood sampling Operative Delivery (Category 1 delivery)

Question 33

How is fetal blood sampling done?

Answer 33

- edoscope through the vagina into the uterus; is used to obtain blood sample from the baby's scalp

Question 34

What is operative vaginal delivery? | When can it be done?

Answer 34

- the delivery of the bby PV; with the aid fof forceps/ vaccum by the operator - if baby is at or below the ischial spine

Question 35

When is forcep delivery indicated?

Answer 35

“Standard” Indications: Delay (failure to progress stage 2) OR Fetal distress

Question 36

Special indications for forcep use?

Answer 36

Maternal cardiac disease Severe PET / Eclampsia Intra-partum haemorrhage Umbilical cord prolapse Stage 2

Question 37

Ventouse is a.w :

Answer 37

- INCREASED: failure/ cephalohematoma/ retinal hemorrhage/ maternal worry - DECREASED: anaesthesia/ vaginal trauma/ perineal pain

Question 38

Main indications of C-section?

Answer 38

``` previous CS fetal distress failure to progress in labour breech presentation maternal request ```

Question 39

Risk of C-section?

Answer 39

- 4x GREATER maternal mortality a.w CS

Question 40

Why is there a huge risk with c-section

Answer 40

sepsis, haemorrhage, VTE, trauma, TTN (transient tachypnea of newborn- fluid in lungs) , subfertility, regret, complications in future pregnancy

Question 41

Best head position for the baby to smoothly delivered?

Answer 41

- if the head is well flexed; with chin tucked into the chest - -----smallest diameter of 9.5cm

Question 42

What 3 things are considered for assessing the progress in labour?

Answer 42

- cervical dilatation - descent of presenting part - signs of obstruct.

Question 43

What are the signs of obstruction?

Answer 43

- moulding - caput - anuria - hematuria - vulval edema

Question 44

How is the power of the labour affected?

Answer 44

- inadequate contractions - frequency - and/or strength

Question 45

If the result from the fetal blood sampling is <7.2 ph; what does it mean?

Answer 45

- means HYPOXIA! so DELIVER! ----DON'T deliver if >7.2 ph

Question 46

Signs of fetal asphyxia?

Answer 46

- abnormal HR - pathological CTG readings - green-meconium stained amniotic fluid - LOW blood- fetal scalp ph (<7.5) = fetal hypoxia!!!