Part 2: ABNORMAL LABOUR

A-Hydroceplus

B- Occipto –anterior

C-Face presenation

D- Occipto –Posterior

E-Ovarian mass

F- Shoulder dystocia

Answer B

Difficult labor, but refers to abnormally slow progress of labor

Things are moving slower than expected

No change occurs

Nulliparous: dilation <1.2cm/hr, descent <1.0cm/hr

Multiparous: dilation <1.5cm/hr, descent <2.0cm/hr

-Nulliparous: NOdilation >2hr, no descent >1hr

-Multiparous: NO dilation >2hr, no descent >1hr

A-1 hr if multi,2hrs if nulli ,add 1hrs if epidural

B-2 hrs if mulli,3 hrs if nulli ,add 1hrs if epidural

C-1.5 hr if multi ,2.5 hrs, add 1 hr if epidural

ANSWER A

A-Chorioamnionitis

B-Uterine rupture

C-Reassuring FHR trace

D-Pelvic floor injury

ANSWER C

A-Power: uterine contractions B-Passenger: the baby C-Passage: the patient's pelvis, pelvic floor

During first stage of labor, you are concerned with the power of the uterine contractions

During the second stage of labor, you are concerned with the power of the patient's pushing efforts

-External tocodynamometry or an intrauterine pressure catheter (IUPC)

For IUPC, patient must be ruptured and increased the risk of infection

Strong enough to cause cervical change

Optimal frequency is a minimum of three contractions in a 10 min period (ideal is every 2 min)

Greater than or equal to 200 Montevideo units

-If contraction pattern is irregular or less than 3 in 10 minutes or if MVU's are less than 200, use Pitocin to increase intensity and frequency of contractions.

1) Allow patient to rest through a few contractions to catch her breath.

2) Try different positions for more effective pushing

3) If everything fails, operative vaginal delivery or Cesarean section

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Lie

Presentation

Size

Anomalies

-Fetal lie: non-longitudinal presentation-transverse, oblique or shoulder

-Fetal presentation: breech, face (1 in 600), or brow (1 in 3000), compound presentation (1 in 700)-hand or arm prolapses along fetal head

Asynclitism-lateral deflection of the head to a more anterior or posterior position in pelvis

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frank breech: legs are piked-complete breech: indian style or curled legs-footling breech: one leg down, monitor for if umbilical cord falls through pelvis

A- Pinard manouverto deliver leg,rotate sacrum anterior,wrap trunk in tawel,deliver arm when scapula visible,downward pr on maxilla to deliver the head

B- Pinard manouverto deliver leg,rotate sacrum anterior,wrap trunk in tawel,deliver arm when scapula visible,downward pr on mandible to deliver the head

C- Pinard manouverto deliver leg,rotate sacrum posterior,wrap trunk in tawel,deliver arm when scapula visible,downward pr on mandible to deliver the head

ANSWER B

A-ant hip has a more rapid decent than post hipB- ant hip is beneath the symphysis pubis and

intertrochanteric diameter rotates around a 45 degree axis

C- if post hip is beneath the symphysis pubis it has to go through 225 degree axis rotation

D-for sacrum ant or post position, the axis of rotation is around 45 degrees

Ans: C

A- multiparity

B-placenta previa

C- presenting part engagement

D- CPD

Ans: A

A- This is a rare presentation above inlet

B-brow presentation most of the time changes to face presentation

C- decent mechanism is completely different from vertex presentation

D-delivery is possible if mentum appears beneath the symphysis.

Ans:C

A-induction of labor

B- internal rotation to make mentum ant position

C- observation to allow spontaneous rotation

D- C/S

Ans:C

A-Forceps can be applied

B-manual rotation of the head can be done

C- manual rotation of the head can’t be done

D-there is no place for observation

Ans:D

-Macrosomia is defined as an infant weighing greater than 4,000-4,500 g

Risk factors include maternal obesity, diabetes, multiparity, excessive maternal weight gain, prolonged gestation and a history of a macrosomic infant

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-Hydrocephalus

large fetal abdomen from tumor Ascites

distended bladder Conjoined twins

• -not much we can do about fetal weight or anomalies-external cephalic version prior to labor can be performed to convert breech or transverse to vertex-rotation of fetal head to direct OA presentation manually or with forceps

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-The size of the maternal pelvis is inadequate to the size of the presenting part of the fetus

-manual evaluation of the diameters of the pelvis

• A-Ability to touch sacral promontory with index finger•

B-Significant divergence of the pelvic side wall•

C-Forward inclination of a straight sacrum•

D-Sharp ischial spines with a narrow interspinous• diameter

E -Narrow suprapubic archANSWER B

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Obstetric: shortest anteroposterior diameter of pelvis

Diagonal: distance from the lower margin of the symphysis to the promontory of the sacrum and subtracting 1.5cm (you want diagonal conjugate to be greater than 11.5cm)

-normal female type male type- inlet triangular or heart-shaped

-Ape-like type-Anteroposterior

diameters long, Transverse short, Sacrum long and narrow, Subpubic angle narrow

All anteroposterior diameters are short, Transverse are long, subpubic angle is wide

A-Prolonged latent phase: question if false labor, treat with observation and sedation if needed

B-Protraction disorder of active phase: augment with amniotomy or oxytocin

C-Arrest disorder with adequate contractions: C-section

D- All of the above

Answer D

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-Rotate fetal head if necessary

Change positions

Operative delivery

-If placenta not delivered w/in 30 min: manual sweep should be performed

-Fetal head delivers but the shoulder is impacted behind the pubic symphysis

Risk factors: fetal macrosomia, diabetes, operative delivery

• A-McRobert's Maneuver:sharply flex maternal thigh

• B-Cut episiotomy if needed for more roomC. Fundal pressure D-woods screw maneuverE. Delivery of the posterior arm

ANSWER C

A-rotation of post. shoulder to deliver ant. shoulder

B- abduction of shouldersC- flex of mother’s knees and suprapubic

pressureD- rotation and extraction of ant. shoulderAns:BWoods screw=AMcRoberts m.=CZavanelli m.= repositioning of fetal head back

into the uterus and C/S

1. get help2. be sure bladder is drained3. cut episiotomy if needed for more room4. suprapubic pressure5. McRobert's Maneuver:sharply flex maternal thigh6. woods screw maneuver:turn shoulders to a more direct AP position7. delivery of the posterior arm8. fracture clavicle or humerus9. zavanelli maneuver: flex and reinsert fetal head and do C-section

A-Maternal heart disease, pulmonary compromise

B- prolonged first stage of labor,

C-maternal exhaustion

D- non-reassuring fetal heart rate pattern

ANSWER B

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• A-inability to definitely determine position of fetal vertexB-fetus with presentation other than vertex or face with chin anteriorC-fetus not engaged or above +2 stationD-CPD: inadequate pelvis, estimated fetal weight >4000gE-membranes ruptured or cervix fully dilated

F-fetus <34 weeks for vacuum delivery• ANSWER C

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• -maternal complications*perineal trauma*hematoma*pelvic floor injury-fetal complications*facial nerve injury*skull fracture*intracranial hemorrhage*corneal abrasion if misplaced

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EPISIOTOMY – midline vs mediolateralPERINEAL TEAR – first to fourth degree

A-1st degree: involve the forchette, perineal skin and vaginal mucous membrane

B-2nd degree: the fascia and muscles of the perineal body

C-3rd degree: involve the anal CANALD-4th degree: extends through the rectal

mucosa to expose the lumen of the rectum• ANSWER C

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Fourth-degree Fourth-degree Perineal tearPerineal tear

A- immediately

B-3 months later

C- 6 months later

D- 9 months later

Ans:A

Which of the following is appropriate deviceA- LOW FORCEPS

B-MID FORCEPS

C- SOFT CUP VACCUM

D- PIPER FORCEPS

ANSWER A

-less maternal trauma-neonatal risks

*intracranial hemorrhage*subgaleal hematoma*scalp laceration*hyperbilirubinemia*retinal hemorrhage*cephalohematoma

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• -Caput succedaneum: subcutaneous bleeding and swelling-Cephalohematoma: bleeding beneath the periosteum and therefore does not cross suture lines unless there is a skull fracture

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This patient has a bishop score of A- 4

B-5

C-6

D-8

ANSWER B

The most like explanation of deccleration is A- Maternal position on left lateral side

B- Uterine hyperstimulation from cervical ripening agent

C- Compression of the fetal head mediated by vagus

D- Umbilical cord compression

ANSWER B

A- prior C-section or uterine scar

B- Face mento anterior

C- labor dystocia

D- Breech presentation<35 WKS

E- fetal distress

F- persistent mento posterior

• ANSWER B•

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