Labor

Question 1

Indication of induction of labor

Answer 1

> Maternal

• Postdate
• PE, Eclampsia, PIH
• GDM
• Prolonged PROM
• Indeterminate APH

> Fetus

• Multiple pregnancy
• Oligohydramnios
• Reduced fetal movement
• IUD
• Chorioamnionitis

Question 2

Contraindication for induction of labor

Answer 2

> Maternal

• Previous C-section
• Previous myomectomy
• Placenta praevia
• Obstruction of birth canal
• Active genital herpes
• Invasive cervical cancer

> Fetus

• Malpresentation: face/ brow
• Abnormal lie: transverse/ oblique
• Unstable lie at term
• Breech presentation
• Severe fetal compromised - IUGR
• Cord prolapse

Question 3

Prostin protocol in SGH

Answer 3

> Day 1

• Maximum 2 prostin per day, 6 hours apart
• If cervix remain unfavorable, rest for the night and come tomorrow

> Day 2

• Insert 3rd prostin in the morning
• If still unfavorable, discuss with specialist

> Day 3
- 4th prostin (if specialist decide)

Question 4

Contraindication for Prostin

Answer 4

• Allergy to prostaglandin
• Prior C-section or other prior major uterine surgery (eg: myomectomy)
• Asthma (PG cause bronchoconstriction)
• Preexisting regular painful uterine activity - relative CI

Question 5

Pros and Cons of Mechanical induction of labour

Answer 5

> Pros
- Effective, safe, cheaper and associated with low incidence of uterine hyper stimulation

> Cons

• Bleeding
• Device expulsion
• Cervical laceration

Question 6

Contraindication for amniotomy

Answer 6

• Maternal Hep B, HSV

- High presenting part (cord prolapse if not engaged)

Question 7

Complication of IOL

Answer 7

> Amniotomy

• Cord prolapse
• Injury to fetal part
• Amniotic fluid embolism

> Prostin/ Oxytocin

• Uterine hyperstimulation
• Uterine rupture

> Others

• Fetal distress
• Chorioamnionitis
• Failed induction -> EMLSCS

Question 8

Management of uterine hyperstimulation

Answer 8

> CTG normal

• Reduce the oxytocin infusion rate
• Place in left lateral position
• Continuous CTG monitoring
• Close monitoring of contraction

> CTG non-reassuring

• Stop oxytocin infusion
• Consider tocolytic (eg: IV salbutamol 100ug or subQ terbutaline 250ug)

Question 9

Induction vs Augmentation of labor

Answer 9

> Induction

• Not in labor
• Labor not start spontaneously
• To initiate the onset of labor

> Augmentation

• In labor
• Labor start spontaneously
• To speed up the process of labor

Question 10

Type of breech presentation

Answer 10

• Extended (frank): Most common
• Flexed (complete)
• Footling: least common

Question 11

Contraindication for ECV

Answer 11

> Maternal

• Placenta previa
• Recent APH
• PROM
• Multiple pregnancy
• Preeclampsia
• Uterine scar

> Fetus

• Oligohydramnios
• Polyhydramnios
• Unstable lie
• Abnormal CTG

Question 12

Step for ECV

Answer 12

• Patient lie supine with 30” tilt either to left or right
• Apply talcum powder/ gel over abdomen
• With pelvic grip, breech is displaced to one iliac fossa
• The other hand is placed over fetal head
• Both hand works together to turn the fetus in FORWARD SUMMERSAULLT
• Gentle, intermittent version force is applied over both pole
• Max 3 attempts
• Done at/ after 37 weeks
• Failed -> repeat 1 week later/ ELSCS at 39 weeks

Question 13

Possible presenting diameter of fetal skull

Answer 13

• 9.5cm: suboccipito-bregmatic (vertex, flexed)
• 9.5cm: submento-bregmatic (face)
• 11.0cm: oxxipito-frontal (vertex, military)
• 13.5cm: vertico-mental (brow)

Question 14

Contraindication of VBAC

Answer 14

• Previous uterine rupture
• Previous classical C-section
• > = 2 previous C-section scar
• Prior inverted T or J incision
• Interval <18 months

Question 15

Sign of impending uterine rupture

Answer 15

• Abnormal CTG
• Maternal pulse >100 bpm
• Maternal BP <100/60
• Persistent suprapubic pain
• Hematuria
• Increase PV bleeding
• Loss of station of the presenting part

Question 16

VBAC vs Repeat C-section

Answer 16

> VBAC

• Able to move around earlier, shorter hospital stay
• Higher risk of uterine scar rupture, additional risk of requiring transfusion
• Higher risk of hypoxic-ischemic encephalopathy
• Success rate reduce in: induction or augmentation of labor is required, BMI >30kg/m2, no previous vaginal birth, had previous C-section for shoulder dystocia

> Repeat C-section

• Planned date of delivery
• Higher risk of both placenta previa and accreta in subsequent pregnancy
• Higher risk of respiratory morbidity
• Required C-section in the future

Question 17

Cause of prolonged 2nd stage of labor

Answer 17

• Passage: CPD, mass obstructing the passage
• Passenger: macrosomic baby
• Power: maternal exhaustion

Question 18

Retained placenta and its management

Answer 18

• Definition: when the placenta is not delivered within 30 minutes of delivering the fetus
• Monitor vital sign
• Insert large bore IV access
• Attempt CCT again
• If still not delivered - Manual removal of placenta

Question 19

Indication and contraindication of tocolytic therapy

Answer 19

> Indication

• To complete dexamethasone
• For transport to tertiary centre

> Contraindication

• IUGR
• IUD
• Severe APH
• Chorioamnionitis
• Maternal heart disease

Question 20

Example of tocolytic agents

Answer 20

• Beta agonist: Terbutaline
• Oxytocin antagonist: Atosiban
• Calcium channel blocker: Nifedipine

Question 21

Pre-requisite for induction of labor

Answer 21

• GSH 2 unit of blood
• Absence of contraindication
• Adequate counselling on indication, risk and option available
• Reactive CTG
• Presentation – cephalic
• Level of presenting part – head must be engaged
• Determine cervical favourability (Bishop’s score)

Question 22

Stages of labor

Answer 22

> 1st stage

• Cervix dilated from 0-10cm
• Latent phase (0-4cm): uterine contractions typically infrequent and irregular; slow cervical dilation and effacement
• Active phase (4-10cm): rapid cervical dilatation to full dilatation; painful, regular contraction 2 min, lasting 45-60 seconds

> 2nd stage
- From full dilatation to delivery of the baby

> 3rd stage
- From full delivery of the baby to full delivery of placenta

Question 23

Management of prolonged 2nd stage of labor

Answer 23

• Identify cause
• If passage -> proceed to C-section
• If passenger -> proceed to C-section
• If power -> assisted vaginal delivery/ augmentation with oxytocin

Question 24

Pre-op preparation for LSCS

Answer 24

• Take written consent
• Catheterize, do vaginal examination
• Ready GXM 2 units
• Antibiotics: if membrane rupture >8 hours, operate after a failed vacuum or forceps delivery
• Anaesthesia: spinal preferable
• Preventing Mandelson syndrome: ranitidine 50mg (slow IV immediate before surgery)

Question 25

Post-operative care for LSCS

Answer 25

- Allow orally - ¼ hourly vital signs monitoring - Adequate analgesia - Resume oral fluid after 12-24 hours - Contraception discussed - Sterilization during C-section after 3rd LSCS

Question 26

Neonatal complication of LSCS

Answer 26

- Iatrogenic prematurity - Birth trauma (mild laceration, more common in emergency delivery) - Transient tachypnoea of newborn

Question 27

Degree of perineal tear

Answer 27

- First degree: through skin and structure superficial to muscle - Second: through muscles of perineal body - Third: through the anal sphincter muscle - Fourth: anal sphincter muscle with a breach of the rectal mucosa

Question 28

Success rate of planned VBAC

Answer 28

- 72-75% (Royal collage of OnG)

Question 29

Causes of breech presentation

Answer 29

- Prematurity (most common) - Short cord - Poly/ Oligohydramnios - Uterine abnormalities (eg: fibroid, bicornuate, septate) - Placenta praevia

Question 30

Complication of preterm labor

Answer 30

- Hypothermia - Respiratory distress syndrome - Patent ductus arteriosus - Intraventricular hemorrhage - Necrotizing enterocolitis

Question 31

Management of chorioamnionitis

Answer 31

- Immediate delivery under antibiotic cover - Postpartum: 3 dose of IV antibiotics + oral antibiotic for >= 10 days - Ab of choice: IV cefuroxime and IV metronidazole