Less normal labour

Question 1

What is induction of labour (IOL)?

Answer 1

to instigate labour artificially - 3 main stages

1) using medications and/or devices to “ripen cervix”
2) this is followed usually by artificial rupture of membranes (performing an amniotomy)
3) then, synthetic oxytocin can be used to initiate contractions and bring about labour

Question 2

How often is labour induced?

Answer 2

Approx 1 in 5 pregnancies

Question 3

Is induction of labour risky business?

Answer 3

It is indeed

Thats why in induced labour, there is always fetal monitoring

Question 4

For IOL, a key part is ripening the cervix

How can this be done?

Answer 4

Prostaglandins pessary (vaginal)

Balloon

Question 5

What is the Bishop’s score?

Answer 5

A clinical score used to guide us on when to do an amniotomy (break the waters)

The higher the score - the more progressive the change in the cervix and the more likely induction is to be successful

Question 6

What are the criteria for bishops score?

What score is considered fdavourable for amniotomy?

Answer 6

Dilation

Effacement (length of cervix)

Position

Consistency

Station (no clue)

A SCORE OF 7 is favourable

Question 7

Once an amniotomy has been performed - what is the next step?

Answer 7

IV oxytocin can be given to achieve adequate contractions (unless contractions start spontaneously)

The aim is 4/5 contractions every 10 mins

Question 8

Why do we induce labour? (ie what are the indications)

Answer 8

Diabetes

If term +7 days

Maternal need for planning of delivery - eg if on anticoagulants

Fetal reasons - growth concerns, oligohydramnios

Social/maternal request

Question 9

When talking about intra-partum complications during induced labour - they can be categorised as being under:

The powers

The passage

The passenger

What complications fall under these?

Answer 9

The powers:

• inadequate uterine activity
• hyperstimulation of uterus

The passage:

• Cephalopelvic disproportion (CPD)
• other obstructions - eg fibroids

The passanger:

• Malposition
• Malpresentation
• fetal distress

Question 10

How is progress in labour evaluated?

Answer 10

COmbination of abdominal and vaginal examinations to assess:

Cervical effacement

Cervical dilatation

Descent of fetal head thru pelvis

Question 11

On examination, what features would suggest sub-optimal labour progress in the active first stage?

Answer 11

In the active first stage of labour - sub-optimal progress is defined as:

• < 0.5cm per hour in primigravid women
• < 1cm per hour for parous women

Question 12

How is inedequate uterine activity dealt with?

Answer 12

IV oxytocin can be used to increase the strength and duration of contractions

However, before this is given - it is important to exclude an obstructed labour

Question 13

What is cephalopelvic disproportion?

Answer 13

This is when the fetal head is too large to negotiate through the maternal pelvis and be born - even when in the correct fetal position

Genuine CPD is quite rare

Question 14

What are the signs of CPD?

Answer 14

Caput - which is swelling at the top of the babies head

Moulding - when the cranial sutures of the baby overlap

Question 15

What are other forms of obstruction, other than CPD?

Answer 15

Placenta praevia - placenta covering cervix

Fetal anomalies - eg hydrocephalus

Fibroids

Question 16

Describe what malposition is?

Answer 16

When the fetal head is in a suboptimal position for labour and a relative CPD occurs

Much more common than malpresentation

Normal position - Occipito-anterior

Malposition - Occipito-transverse, occipito-posterior

Question 17

How is the position of the baby (way it faces) felt to determine if malposition?

Answer 17

Using the fontanelles of the fetal skull

Anterior fontanelle - diamond shaped

Posterior fontanelle - triangular

By feeling these we can determine which position the baby is facing

Question 18

What are the main causes of fetal distress

Answer 18

Hypoxia

Infection

Cord prolapse

Placental abruption

Vasa praevia

Uterine hyper-stimulation (causes hypoxia)

Often no cause

Question 19

How is fetal monitoring done?

Answer 19

Low risk:

• Intermittent auscultation of fetal heart
  
  • HHD or pinard’s stethoscope

High risk (incl induced labour, meconium, diabetes etc):

• Cardiotocography (CTG)

Fetal distress:

• Fetal blood sampling
• Fetal ECG

Question 20

When is fetal blood sampling done and why is it useful?

Answer 20

Speculum used to take fetal blood sample from scalp. Cervix must be at least 4cm dilated

Can give us:

• pH & base excess
• lactic acid
• pH gives measure of likely hypoxaemia

Used when abnormal CTG/worry of fetal distress

Question 21

What are the types of operative deliveries?

Answer 21

Instrumental:

• Forceps / Ventouse
• 15% of deliveries

Elective (planned) C section:

• C section performed before labour
• 20-30%

Emergency C section:

• 20-25%

Question 22

What are the 3rd stage complications of giving birth?

(3rd stage = birth –> delivery of placenta)

Answer 22

Retained placenta

Post partum haemorrhage:

• 4 Ts - Tone, trauma, tissue, thrombin

Tears:

• Graze
• 1st
• 2nd
• 3rd degree - involving anal sphincter complex
• 4th degree - involving rectal mucosa