Labour and DeliveryPostpartum

Lynne McLeodCRAM Course

Which of the following is NOT a fetal presentation?

1. Breech

2. Face

3. Occiput posterior

4. Brow

Which of the following is NOT a fetal presentation?

1. Breech

2. Face

3. Occiput posterior

4. Brow

Presentation Normal presentations

Vertex (cephalic)

MalpresentationsBreech

Frank

Complete

Footling

Malpresentations

Face Brow Shoulder Compound Cord

Position

Occiput ANTERIOROALOAROA

Occiput POSTERIOROPLOPROP

Occiput TRANSVERSELOTROT

Which of the following is NOT part of the Bishop Score?

1. Presentation

2. Cervical dilatation

3. Position

4. Cervical consistency

Which of the following is NOT part of the Bishop Score?

1. Presentation

2. Cervical dilatation

3. Position

4. Cervical consistency

PV Exam-Bishops Score

Factor 0 1 2 3

Dilatation closed 1-2 3-4 > 5Effacement 0-30 40-50 60-70 80+Station -3 -2 -1 +1Consistency firm med softPosition post mid ant

An acceleration in an NST after 32 weeks gestation is defined as?

1. Peak 15 bpm above baseline for > 15 secs

2. Peak 20 bpm above baseline for > 15 secs

3. Peak 20 bpm above baseline for > 20 secs

4. Peak 15 bpm above baseline for > 20 secs

An acceleration in an NST after 32 weeks gestation is defined as?

1. Peak 15 bpm above baseline for > 15 secs

2. Peak 20 bpm above baseline for > 15 secs

3. Peak 20 bpm above baseline for > 20 secs

4. Peak 15 bpm above baseline for > 20 secs

Normal FHR

Early Decelerations

Variable Decelerations

The most appropriate next step in management of this patient at 4 cm in labour is?

1. Reassess FHR in 2 hours

2. Consider internal monitor/scalp pH

3. Immediate C section

4. Intermittent FHR monitoring

The most appropriate next step in management of this patient at 4 cm in labour is?

1. Reassess FHR in 2 hours

2. Consider internal monitor/scalp pH

3. Immediate C section

4. Intermittent FHR monitoring

Late Decelerations

Which of the following is NOT a component of a Biophysical Profile?

1. Amniotic Fluid assessment

2. Fetal movement

3. Fetal presentation

4. Breathing movements

Which of the following is NOT a component of a Biophysical Profile?

1. Amniotic Fluid assessment

2. Fetal movement

3. Fetal presentation

4. Breathing movements

Biophysical Profile (BPP)

Fetal movements FM Fetal tone FT Fetal breathing movements FBM Amniotic fluid volume AFV Non stress test NST**

Score: Normal = 2 Abnormal = 0

Significance

BPP score correlated with: cord pH:

BPP 8-10: pH ~ 7.28BPP 6: pH ~ 7.19BPP 0-4: pH ~ 6.99

perinatal outcomes long term outcomes

Which of the following is a clinical scenario where a vacuum might be an option?

1. G3P2, at 37 weeks, 9 cm, station -1, non-reassuring FHR

2. 34+6 weeks, fully dilated, station +2, FHR 60

3. 40 weeks, fully dilated, station +3, FHR reassuring

4. G1, 41 weeks, fully dilated, FHR 50, station 0

Which of the following is a clinical scenario where a vacuum might be an option?1. G3P2, at 37 weeks, 9 cm, station -1, non-

reassuring FHR

2. 34+6 weeks, fully dilated, station +2, FHR 60

3. 40 weeks, fully dilated, station +3, FHR reassuring

4. G1, 41 weeks, fully dilated, FHR 50, station 0

Vacuum

Assisted vaginal delivery Good option:

Multip Good progress Good maternal effort No epidural Not < 35 weeks

Set Up

In room In OR Empty bladder Fully dilated Know position Analgesia Neonates Ability to do CS

Potential Complications

Pop off Unsuccessful

forceps CS

Hematoma Subgaleal bleed

Which of the following are NOT necessary components of a forceps delivery?

1. Availability to perform a C-section

2. Pediatric resuscitation staff present

3. Epidural analgesia

4. Informed consent

Which of the following are NOT necessary components of a forceps delivery?

1. Availability to perform a C-section

2. Pediatric resuscitation staff present

3. Epidural analgesia

4. Informed consent

Forceps

Assisted vaginal delivery Good option:

Arrest in 2nd stage Multip maternal effort ? ++ Caput Analgesia < 35 weeks

Set Up

In room In OR Empty bladder Fully dilated Know position Analgesia Neonates Ability to do CS

Potential Complications

Unsuccessful CS

Lacerations Malplacement Hematoma Shoulder Dystocia Fracture

The turtle sign is a warning of what potential delivery complication?

1. Postpartum hemorrhage

2. Compound presentation

3. Wound infection

4. Shoulder dystocia

The turtle sign is a warning of what potential delivery complication?

1. Postpartum hemorrhage

2. Compound presentation

3. Wound infection

4. Shoulder dystocia

Obstetric emergency Incidence

1-4% term vaginal deliveries Risk Factors

Macrosomia Maternal diabetes Previous shoulder dystocia Older mom Grand multiparity Increased maternal weight Operative vaginal delivery

Shoulder Dystocia

Prepare for Shoulder Dystocia Call for HELP! Maneuvres

Episiotomy McRoberts Suprapubic Pressure Rotate shoulders Woods Screw Posterior Arm Fracture Clavical Symphysiotomy Zavenelli Maneuvre

Management

85-90% relieved with first 1-2 maneuvres

Most SD mild-mod

Maternal Risks Perineal trauma Lacerations Bleeding PPH

Prognosis/Risks

Neonatal Risks Asphyxia Trauma Brachial Plexus injuries Death

Prognosis/Risks

Which of the following is a risk factor for a cord prolapse?

1. Polyhydramnios

2. Oligohydramnios

3. Post dates

4. Previous Classical C-section

Which of the following is a risk factor for a cord prolapse?

1. Polyhydramnios

2. Oligohydramnios

3. Post dates

4. Previous Classical C-section

Cord Prolapse Part of umbilical cord falls in front of the fetal

presenting part

1/300-1/600 deliveries 0.2-0.4% singletons 3% breech ~ 10% transverse

When membranes intact cord presentation

Predisposing Factors

Malpresentation Prematurity Abnormal Fetus Multiple Gestation Polyhydramnios PROM Previa Pelvic Mass Obstetric Procedures version, rotation, forceps

Diagnosis

Sudden appearance of loop of cord at introitus

PV exam feel pulsatile cord

Nonreassuring FHR

Ultrasound

Which stage of pregnancy is the highest risk of developing a venous thromboembolic event?

1. Preconception

2. Antenatal

3. Intrapartum

4. Postpartum

Which stage of pregnancy is the highest risk of developing a venous thromboembolic event?

1. Preconception

2. Antenatal

3. Intrapartum

4. Postpartum

What is the most common etiology of postpartum hemorrhage?

1. Perineal trauma

2. Uterine atony

3. Hematological abnormalities

4. Retained products

What is the most common etiology of postpartum hemorrhage?

1. Perineal trauma

2. Uterine atony

3. Hematological abnormalities

4. Retained products

Which of the following are NOT SAFE to consider in breastfeeding?

HIV + with N CD4 and undetectable viral load

Hepatitis B positive mother

Methadone use in the mother

Warfarin prescription postpartum

Which of the following are NOT SAFE to consider in breastfeeding?

HIV + with N CD4 and undetectable viral load

Hepatitis B positive mother

Methadone use in the mother

Warfarin prescription postpartum

Labour and DeliveryPostpartumWhich of the following is NOT a fetal presentation?Which of the following is NOT a fetal presentation?PresentationMalpresentationsMalpresentationsPositionWhich of the following is NOT part of the Bishop Score?Which of the following is NOT part of the Bishop Score?PV Exam-Bishops ScoreAn acceleration in an NST after 32 weeks gestation is defined as?An acceleration in an NST after 32 weeks gestation is defined as?Normal FHREarly DecelerationsVariable DecelerationsSlide Number 16The most appropriate next step in management of this patient at 4 cm in labour is?The most appropriate next step in management of this patient at 4 cm in labour is?Late DecelerationsWhich of the following is NOT a component of a Biophysical Profile?Which of the following is NOT a component of a Biophysical Profile?Biophysical Profile (BPP)SignificanceWhich of the following is a clinical scenario where a vacuum might be an option?Which of the following is a clinical scenario where a vacuum might be an option?VacuumSet UpPotential ComplicationsWhich of the following are NOT necessary components of a forceps delivery?Which of the following are NOT necessary components of a forceps delivery?ForcepsSet UpPotential ComplicationsThe turtle sign is a warning of what potential delivery complication?The turtle sign is a warning of what potential delivery complication?Slide Number 36Slide Number 37Slide Number 38Slide Number 39Which of the following is a risk factor for a cord prolapse?Which of the following is a risk factor for a cord prolapse?Cord ProlapsePredisposing FactorsDiagnosisWhich stage of pregnancy is the highest risk of developing a venous thromboembolic event?Which stage of pregnancy is the highest risk of developing a venous thromboembolic event?What is the most common etiology of postpartum hemorrhage?What is the most common etiology of postpartum hemorrhage?Which of the following are NOT SAFE to consider in breastfeeding?Which of the following are NOT SAFE to consider in breastfeeding?