Labour

Question 1

Define Labour.

Answer 1

Painful uterine contractions leading to effacement and dilation of the cervix

Question 2

What percentage of births are natural, instrumental and C-section?

Answer 2

• Natural = 60%
• Instrumental = 10%
• C-section = 30%

Question 3

Define Braxton-Hicks contractions.

Answer 3

Painless contractions with no cervical change

Question 4

What are the stages of labour?

Answer 4

• 1st stage = painful uterine contractions up to full (10cm) cervical dilatation
  
  • Latent phase = painful, irregular contractions; dilation up to 4cm
  • Established stage 1 = regular painful contractions; ≥4cm dilation
• 2nd stage = urge to push until delivery of the foetus
  
  • In nulliparous women = 3 hours (epidural) or 2 hours (no epidural)
  • In multiparous women = 2 hours (epidural) and 1 hour (no epidural)
• 3rd stage = delivery of placenta and foetal membranes
  
  • Normally 5-10 mins but up to 30 mins

Question 5

What is the widest point of the pelvic inlet and outlet?

Answer 5

• Pelvic inlet = Transverse
• Pelvic outlet = Anterior-posterior

Question 6

What determines the progress of labour?

Answer 6

• 3 P’s
  
  • Power - contractions
  • Passage - dimensions of pelvis
  • Passenger - diameter of foetal head

Question 7

Define Restitution.

Answer 7

Brining head in line with the shoulders

Question 8

Define Shoulder Dystocia.

Answer 8

When a baby’s head has been born but one of the shoulders becomes stuck behind the mother’s pubic bone, delaying the birth of the baby’s body.

Question 9

What are the risk factors for shoulder dystocia?

Answer 9

• Macrosomia
• High maternal BMI
• DM or GDM
• Prolonged labour

Question 10

What are the signs and symptoms of shoulder dystocia?

Answer 10

• Difficult face/chin delivery
• ‘Turtling’ head (retracting)
• Failure of restitution
• Failure of shoulder descent

Question 11

What is the management of shoulder dystocia?

Answer 11

1) Call for senior help + discourage pushing
2) McRobert’s manoeuvre (legs up to abdomen) and suprapubic pressure – 90% success
3) Evaluate for episiotomy
4) Either:

• Rubin’s manoeuvre (push anterior shoulder towards baby’s chest)
• Woods’ Screw (Rubin’s + push posterior shoulder towards baby’s back à rotation)
• Deliver posterior arm (then, rotate 180 and deliver the other arm)

5) Change position to all fours and repeat the above manoeuvres
6) Symphysiotomy, cleidotomy (divide clavicles) or Zavanelli (reversal of normal delivery movements)
* Should all take <5 minutes

Question 12

What scoring system is used to assess how likely a women is to go into labour soon?

Answer 12

Bishop’s score

Question 13

Define Effacement/Thinning.

Answer 13

Percentage from 0% (normal length cervix) to 100% or complete (paper thin cervix).

Question 14

Define Foetal station.

Answer 14

Position of the baby’s head relative to the ischial spines of the maternal pelvis.

• If the head is level with the spines, the score is 0; however, above or below them can modify the score

Question 15

Describe the Bishop’s score.

Answer 15

• <3 = IOL unlikely to be successful
• 3-5 = IOL with PV prostaglandin gel (should start labour or ripen cervix)
• 6-8 = ARM (amniotomy ± oxytocin infusion if labour does not begin)
• ≥9 = labour likely to occur spontaneously

Question 16

If induction of labour doesn’t occur, what should be offered to try and induce labour?

Answer 16

Offer x2 PGE2 and then ARM

Question 17

What is the management of the 1st stage of labour?

Answer 17

• One-to-one midwifery care
  
  • Vaginal examinations performed 4-hourly or as clinically indicated
• Progress of labour is monitored using a partogram with timely intervention if abnormal
• Ensure adequate:
  
  • Analgesia ± antacids
  • Hydration and light diet to prevent ketosis (which can impair uterine contractility

Question 18

What is the normal rate of progress in Latent 1st phase?

Answer 18

• 1 cm every hour (a well flexed head will speed this up)

Question 19

What is delayed rate of progress in Latent 1st phase?

Answer 19

<1cm over 2 hours

Question 20

Describe Latent 1st phase.

Answer 20

• Is generally silent as the cervix gradually effaces over a period of days/weeks
• Intervention should be avoided where possible
• Standing upright may encourage progress of labour - mobility is encouraged
• Mobilise and managed away from the labour suite

Question 21

Why is delayed 1st stage defined at a conservative rate of <1cm per 2 hours?

Answer 21

Is conservative to unsure intervention isn’t started too early

Question 22

What are the management for delayed 1st phase?

Answer 22

• Membranes intact = ARM (Artificial Rupture of the Membranes) → review in 2 hours
• Membranes ruptured = oxytocin:
  
  • Increase every 15-30 mins until regular contractions
  • Once regular contractions, review in 4 hours

Question 23

What are the types of delay in labour?

Answer 23

• Primary dysfunctional labour → <2cm dilation in 2 hours, never progressed properly
• Secondary arrest of labour → progressed well and then stopped
• Prolonged latent phase → prolonged latent
• Cervical dystocia → rare; cervix doesn’t dilate properly

Question 24

What is the management of the normal 2nd stage of labour?

Answer 24

• Women discouraged from lying supine or semi-supine
• Use of regional anaesthesia (epidural or spinal)
• Encouragement

Question 25

What is the normal rate of progress in 2nd phase?

Answer 25

* **Nulliparous** women = 3 hours (epidural) or 2 hours (no epidural) * **Multiparous** women = 2 hours (epidural) and 1 hour (no epidural)

Question 26

What is the normal rate of progress in Latent 1st phase?

Answer 26

* **_1 cm every hour_** (a well flexed head will speed this up)

Question 27

What is the first sign of 2nd phase of labour?

Answer 27

Urge to push with 10cm dilation * Regional anaesthesia may interfere with the normal urge to push * 2nd stage is more often diagnosed on routine scheduled vaginal examination

Question 28

What is the management of delivery?

Answer 28

* Watch the perineum - between contractions, elastic tone of the perineal muscles will push the head back into the pelvic cavity * When head no longer recedes between contractions = **Crowning** * This indicates that delivery is imminent * As crowning occurs - hands of the midwife are used to flex the foetal head and guard the perineum * Once the head has crowned woman are discouraged from bearing down * Done by telling her to take rapid, shallow breaths

Question 29

What immediate care of the neonate is done?

Answer 29

* Baby will usually take its first breath within seconds * No need for immediate clamping * After clamping/cutting umbilical cord, baby should have an Apgar score calculated at 1 minute and at 5 minutes * The baby's head should be kept dependent to allow mucus in the respiratory tract to drain * Immediate skin-to-skin contact between mother and baby will help bonding and promote release of oxytocin * Helps stimulate lactation and bonding between mother and baby

Question 30

What is the Apgar score?

Answer 30

* Scoring system to assess a baby shortly after birth * 1 minute and 5 minutes after delivery → every 5 minutes after if condition remains poor * \>7 is considered normal

Question 31

Describe the Apgar score.

Answer 31

* Appearance, Pulse, Grimace, Activity, Respiration * \>7 is considered normal

Question 32

What management should the baby receive in the first hour of life?

Answer 32

* Dried and covered with a warm blanket or towel * Initiation of breastfeeding should be encouraged * Routine measurements of HC, birthweight and temperature * The first dose of baby’s vitamin K should be given in the delivery room - must be in first 24 hours

Question 33

What are the causes of PPH?

Answer 33

* **Tone** (uterine atony; 70%) * **Trauma** (laceration; 20%) * **Tissue** (retained products; 10%) * **Thrombin** (coagulopathy; \<1%)

Question 34

Describe active management of 3rd phase of labour.

Answer 34

* 10 IU oxytocin (IM)/ergometrine (only oxytocin if hypertensive) * After birth of the anterior shoulder * Immediately after delivery (and before the cord is clamped and cut) * Clamp the cord between 1-5 mins * Controlled cord traction to remove the placenta * In 2% of cases, the placenta will not be expelled by this method * If no bleeding occurs, another attempt should be made after 10 mins

Question 35

What are the signs of placental separation?

Answer 35

* Gush of blood * Cord lengthening * Uterus rises * Uterus becomes round

Question 36

What is a rare complication of controlled cord traction to remove the placenta?

Answer 36

Uterine inversion

Question 37

Describe physiological management of 3rd phase of labour.

Answer 37

* Placenta is delivered by maternal effort with no uterotonic drugs * Associated with more bleeding and a greater need for blood transfusions * If haemorrhage occurs or the placenta is undelivered after 60 mins = active management should be recommended

Question 38

What needs to be assessed post-delivery of the placenta?

Answer 38

* Inspect placenta for: * Missing cotyledons * Succenturiate lobe * Vulva inspected for tears

Question 39

What is the management of a retained placenta?

Answer 39

Examination Under Anaesthetic + MROP (manual removal of placental tissue)

Question 40

What is defined as prolonged 3rd phase of labour?

Answer 40

* Active management = \>30 minutes * Physiological management = \>60 mins → move to active management

Question 41

What methods are available to induce labour?

Answer 41

1. Membrane Sweeping 2. Preparing the cervix with prostaglandins 3. Artificial Rupture of Membranes (ARM) 4. Syntocinon 5. C-Section

Question 42

Describe membrane sweeping.

Answer 42

* Offered prior to formal induction (not part of induction of labour) → repeat if labour not starting * Nulliparous women → offered at 40-41 weeks * Multiparous women → offered at 41 weeks

Question 43

Describe preparation of the cervix with prostaglandins.

Answer 43

* **Preferred formal method of induction** * Can be administered as a tablet, gel or pessary * Pessary: 1 dose over 24 hours * Tablet or Gel: 1 dose, followed by a second dose after 6 hours → max of 2 doses * Risk = Uterine hyperstimulation * In cases of intrauterine foetal death, misoprostol and mifepristone may be used instead

Question 44

What are the indications for induction of labour?

Answer 44

* Prevention of prolonged pregnancy - *offered from 41 weeks* * Maternal request for exceptional circumstances * Intrauterine foetal death

Question 45

When is an induction of labour contra-indicated?

Answer 45

Pre-term Pre-labour ROM Breech/transverse lie IUGR Suspected foetal macrosomia Previous C-section - isn't completely contra-indicated but is advised against due to increased risk of uterine rupture

Question 46

What is the IOL regimen for intrauterine foetal death?

Answer 46

* If membranes intact → offer induction * If rupture of membranes, infection or bleeding → immediate induction * **Induction regimen = oral mifepristone, followed by prostin or misoprostol**

Question 47

What forms of analgesia are available to a women in labour?

Answer 47

* Non-pharmacological methods: * TENS * Breathing techniques * Massage * Pharmacological: * Entonox (50% NO in O₂) * Meperidine (pethidine, IM 1mg/kg) * Morphine (0.1-0.15mg/kg) or Diamorphine (IM 5-7.5mg) * Fentanyl PCA 20μG bolus with 5 min lockout * Anaesthetic * Lumbar epidural - bupivacaine, ropivacaine, levobupivacaine, chloroprocaine * Combined lumbar spinal-epidural - fentanyl 10-25mcg ± bupivacaine 2.5mg

Question 48

What are the side effects to baby from opioid analgesia in labour?

Answer 48

* Sleepy baby * Low RR

Question 49

Define Puerperal pyrexia.

Answer 49

\>38^oC in the first 14 days following delivery

Question 50

What are the causes of puerperal pyrexia?

Answer 50

* **Endometritis** * Wound infection (tear, CS) * UTI * VTE * Mastitis

Question 51

What is the management of puerperal pyrexia?

Answer 51

* IV Clindamycin AND IV Gentamicin until \>24hrs without fever