PERIPARTUM
Normal labour
1. Minimal dilatation of 1cm/hr occurs in active phase in a primigravida
2. Contractions lasting 120sec in 1st stage is normal
3. Lower segment facilitates the initiation of uterine contractions in
labour.
4. Uterine contractions are initiated in cornual sites in labour.
5. In partogram the action line is drawn to the right to the alert line.
1) F – Normal dilatation rate of a primigravida is 1cm/hr where as it is
around 1.5cm/hr in multigravida. But minimal dilatation upon which
prolonged dilatation is diagnosed is < 2cm/4hours.
2) F – Contractions are categorized as mild, moderate, severe according
to their persisting time.
Mild - <20 sec
Moderate – 20-40 sec
Severe - >40 sec
Even if severe contractions occur in normal labour, they are usually
limited to less than 90 sec. More than this, there is risk of fetal
compromise.
During 1st stage, commonly mild contractions occur, which
increase in duration and frequency with progression of labour
3) F – upper segment facilitates contractions while the lower segment
dilates
4) T – pace maker of uterus is thought to be near the cornu of the
uterus, from where contractions originate and spread both up and
down
5) T – Alert line to be drawn at 1cm/hr, when dilatation is more than or
equal to 4cm. Action line to be drawn at 1cm/hr, parallel and 4 hours to
right of alert line.
6. Active phase of labour in primigravida begins at 3 cm dilatation.
7. Woman who is sure of her dates in her 41st week needs delivery.
8. Gastric emptying is increased in labour and is diminished by giving
metoclopramide.
9. In the second stage of labour occipito posterior position causes
prolongation.
10. Braxton Hick contractions cause pain.
6) T – In Sri Lanka, taken to be 4cm
7) T – Induction is recommended for low risk women who is sure to
have reached 41 weeks
8) F – gastric emptying is delayed in labour with increased
catecholamine release & sympathetic overactivity, hence a prokinetic is
given to increase emptying and prevent vomiting & aspiration
9) T – also causes prolongation of 1st stage
10) F – infrequent irregular contractions causing mild cramping which
are painless, commonly starting around 20 weeks
11.
12.
13.
14.
15.
Fetal pituitary adrenal axis plays a role in onset of labour.
Mento ant. Presentation can deliver vaginally.
Action line is drawn to the right of alert line.
Oxygen supply to the placenta decreases during uterine contractions.
In vertex presentation when head enters pelvic brim, the occiput is
directed anterior.
11) T – secretion of cortisol which aids in conversion from progesterone
high state to estrogenic state, also secretion of oxytocin by fetal
pituitary takes place
12) T – Can deliver by flexion in face presentation. Mento posterior, in
40-60% can rotate anterior and deliver. If this doesn’t take place,
caesarean section has to be done.
13) T – at a rate of 1cm/hr, parallel and 4 hours apart to right of alert
line
14) T – criss crossing of myometrial muscles acts as a living ligature
reducing placental blood flow
15) T – commonly occipito-anterior
16. Uterine contractions of normal labour occur in all parts of the uterus
simultaneously.
17. The first event of the mechanism of labour is the internal rotation of
the head.
18. Onset of labour depends on fetal production of glucocorticoids, which
interact with maternal oxytocin and lower genital tract
prostaglandins.
19. If immediate prelabour placental function is normal, optimal
contractions of uterine muscle during labour does not cause fetal
hypoxia.
20. Optimum uterine contractions in labour lasts 60 seconds with a
relaxation time of 90-seconds.
16) F – starts near cornual sites and spreads. More contractions occur in
the upper segment than lower segment
17) F – Flexion, Internal Rotation, Extension, Restitution, External
rotation
18) F – fetal cortisol enhances oestrogen, which interacts with oxytocin
increasing its sensitivity by increasing receptors, prostaglandin synthesis
leading to increase in gap junction formation in myometrium and
loosening of tissues in cervix
19) T – If contractions are prolonged and prelabour functions are
normal, it can cause fetal hypoxia
20) T – Relaxation phase is important for co-ordinated contractions and
restoration of placental blood supply
21. Normal uterine contractions have polarity with contractions
spreading from fundus to cervix and fundal dominance of force of
contraction.
22. Mechanism in the 2nd stage of labour are internal rotation and
descent of the fetus.
23. During the progression of labour, uterine contractions become more
stronger, more frequent with a longer contraction relaxation cycle,
24. In established labour the contraction, relaxation cycle should not be
less than 2 min and 30 seconds.
25. Contractions in labour are caused by rhythmical electrical discharge
from the isthmus to the cervix.
26. Prostaglandin introduced into the vagina act by myometrial
contraction.
21) T
22) T – occurs as a result of increasing uterine contractions in 2nd stage
23) F –
Duration of contractions increase (Period from start of uterine
contractions to end of contraction)
Intensity of contractions increase (Strength of contraction)
Frequency of contractions increase, thus reducing length of contractionrelaxation cycle (length of relaxation phase = interval: reduces)
24) T – generally greater than this. Uterine hyperstimulation should be
suspected when contraction frequency exceeds 5 per 10 minutes
25) F – Pacemaker is thought to be around the cornu
26) T – available as vaginal gel, tablet or controlled release pessary.
Second dose can be considered after a minimum of 6 hours. Promote
co-ordinated contractions of uterus. Also contributes to cervical
relaxation.
Pain relief in labour
1. Pain in 1st stage of labour goes through S1,2,3
2. Pain in labour causes vasoconstriction at the placental bed
3. Epidural anaesthesia is contraindicated in diabetes mellitus
complicating pregnancy
4. IM pethidine is the DOC for pain relief in labour.
5. In 1st stage of labour, pain goes through T11-T12 pathways.
1) F
1st stage – Pain by uterine contractions & cervical dilatation – visceral
afferent nerve fibres along sympathetics from T10 to L1 (mainly T11 &
12)
2nd stage – Pain by perineal pressure by fetal head – Somatic afferents
via pudendal nerve – S2 to S4
2) T – catecholamine release and sympathetic overactivity can cause
uterine vasoconstriction, leading to fetal hypoxia
3) F – considered the ideal choice for diabetic mother. Contraindications
to epidural anaesthesia include coagulation disorders, local sepsis,
spinal deformity and hypovolaemia
4) T – most commonly used drug in Sri Lanka.
Given as 1-1.5mg/kg IM, which can be repeated once safely after 4-6
hours. Should be coupled with metoclopramide 5mg IV or 10mg IM.
Naloxone should be available to be given to baby in case of respiratory
depression (100μg/kg IV)
5) T – via sympathetic afferents
6. 1st stage of labour, uterine pain is carried to T10 to LI segments of
segments of spinal cord.
7. Pethidine given to mother enters fetus.
8. Pethidine given for pain relief for a woman, naloxone should be
readily available.
9. Pudendal nerve rises from the ventral rami of S2.S3 & S4.
10. Secondary apnoea is caused by opioid pain relieving drugs use in
labour.
11. Pudendal block causes anaesthesia around clitoris.
6) T – via sympathetic afferents
7) T – risk of neonatal respiratory depression. Maternal side effects
include nausea, vomiting and reduction in gastric motility with increase
in gastric acidity
8) T - 100μg/kg IV to be given to baby, for opioid antagonism
9) T
10) T
Primary Apnoea - When asphyxiated, infant responds with increased
RR. If episode continues, it will become apnoeic with a drop in HR and
slight increase in BP. It will respond to stimulation and therapy with
spontaneous respiration.
Secondary Apnoea – After primary apnoea, infant responds with a
period of gasping respirations, fall in HR and BP. Infant takes a last
breath and enters secondary apnoea period. It will not respond to
stimulation and death will occur if resuscitation is not done.
Since it is impossible to differentiate this clinically, resuscitation is
started if in distress, assuming as in secondary apnoea.
d) T – reduced maternal urge for pushing. But it does not prolong the
first stage. Hence, incidence of instrumental delivery is increased with
no increase in incidence of caesarean section
e) T – rarely occurs resulting in accidental total spinal anaesthesia. CSF
may leak causing headache relieving on lying down and worse on
standing. Injection of high epidural doses as spinal will cause severe
hypotension and respiratory failure
Management of third stage of labour on a physiological basis
11) T – nerve supply is via dorsal nerve of clitoris. Pudendal block is
done near the level of the ischial spine.
12. Regarding epidural anaesthesia
a) Contraindicated in patients with cardiovascular disease
b) 0.5% plain bupivacaine 0.1ml/kg given as a bolus
c) Its action is potentiated when combined with opioids
d) Prolong the second stage of labor
e) Rarely causes post dural puncture
a) F – used in patients with cardiovascular disease because of its CVS
stabilizing effect
b) F – 0.5% plain/hypobaric bupivacaine should be diluted to 0.1% to be
given as 0.1ml/kg bolus
c) T – commonly fentanyl 2μg/ml is added to bupivacaine dose. It will
reduce dose of local anaesthetic required, reducing motor blockage and
peripheral autonomic effects
1. Haemostasis from placental site is happened due to uterine
contraction.
2. In third stage of labour separation of placenta is indicated by
elevation of the fundus, elevation of the umbilical clip and gush of
blood.
3. Active management of third stage of labour should be started when
signs of placental separation has observed.
4. Active management of labour is known to increase the risk of
vesicovaginal fistula.
5. In active management of third stage of labour, ergometrine should be
given to a mother who is having mitral stenosis.
1) T- with each successive contraction, uterine muscles undergo
progressive shortening (retraction) and act as a living ligature to
compress myometrial arteries
2) F – Cord lengthening occurs. Hence umbilical clip can’t be elevated.
Also the uterus becomes firm globular and ballotable. Controlled cord
traction is applied by pulling on the cord while applying counter
pressure on uterus
3) F – starts with administration of uterotonic with delivery of anterior
shoulder or baby
4) F – reduces obstetric trauma, hence may have a reduced risk. But
active management is mainly defined for third stage of labour, where
vesovaginal fistulae occurs mainly in prolonged obstructed labour in 1st
or 2nd stage
5) F – Ergometrine is contraindicated in hypertension and mothers with
heart disease, since it causes blood pressure elevation and coronary
artery spasm
PPH and other third stage complications
1.
2.
3.
4.
5.
Uterine inertia is the commonest cause for post partum haemorrhage
Amniotic fluid embolism leads to DIC
Retained products of conception is the commonest cause for 1ry PPH.
Prolonged labour is a known cause for atonic PPH.
Maintaining a partogram reduce the risk of primary PPH.
1) F – Uterine inertia is the absence of effective uterine contractions
during labour. PPH is commonly due to Uterine atony, which is failure of
uterus to contract after delivery of placenta
2) T – Thought to be due to massive anaphylactic reaction/ complement
activation or both
3) F – commonest cause is uterine atony. Retained placenta is also a
cause.
4) T – fatigue from labour leads to poor myometrial contractions.
Other causes of atony include
Multiple gestation
Fetal macrosomia
Polyhydramnios
Fetal anomalies - Hydrocephalus
Rapid induced labour
Contraction inhibition by drugs
Bacterial toxins
Hypoxia
Couvelaire uterus in abruption placentae
Hypothermia
5) T – reduces risk of prolonged and obstructed labour, allows close
monitoring of mother and fetus
6. After 24 hours of delivery uterus is not palpable through the
abdomen.
7. APH due to placental abruption is a risk factor for primary PPH.
8. PPH can cause even with a 100 ml of bleeding.
9. Severe PPH can necrose pituitary gland.
10. Commonest cause of PPH is genital tract trauma.
6) F – Immediately postpartum, fundus at level of umbilicus. Involution
rate is approximately 1cm in first few days. Uterus is not palpable
abdominally in most by end of 2 weeks
7) T – Also placenta praevia is a risk factor
8) F – defined as loss of 500 ml or more blood from genital tract after
birth of the baby
9) T – Known as Sheehan’s syndrome which presents with failure of
lactation, resumption of menses and other endocrine abnormalities
10) F – commonest cause is atony. Genital tract trauma is another
cause.
11. Fundal massage is contraindicated in PPH due to atony of the uterus.
12. Prolonged labour predispose to PPH
13. Ligation of internal iliac arteries stop post partum haemorrhage due
to cervical erosion.
14. Prostaglandins can be effectively used in management of PPH.
15. Postpartum haemorrhage, acute inversion of uterus and retained
products of conception are third stage complications which can recur
in subsequent-pregnancies.
16. Second degree PPH is commonly due to retained products and
infection.
11) F – First step in management is uterine massage. Fundal massage
can be done abdominally.
Uterine compression commonly performed bimanually with one hand in
the vagina compressing the body, massaging anterior part and other
hand compressing the fundus from above over abdomen, massaging
posterior part
12) T – Inadequate uterine retraction and fatigue of uterine muscle
13) F – Cervical erosion is a normal variant and not associated with PPH.
Cervical tears are associated with PPH, commonly left lateral tears. They
are treated by suturing. Ligation of internal iliac arteries stop PPH due to
uterine atony.
14) T – used when bleeding does not stop by Oxytocin or Ergometrine
15) T
16) Secondary PPH after 24 hours upto 12 weeks puerperium is
commonly due to an infected cotyledon which is retained
Abnormal progression of labour
1. Grade 1 moulding of fetal skull is indicative of obstructed labour.
2. Obstructed labour predisposing to vesico-vaginal filstula.
3. Moulding and caput formation indicates obstructed labour.
4. Forceps delivery is associated with vaginal tears more than vacuum
extraction.
5. Primary dysfunctional labour occurs due to occipito-posterior position
and inadequate uterine contraction.
1) F – Moulding is the alteration of shape of fetal skull vault due to
unossified sutures providing protection against brain compression
during passage through birth canal.
Grade I – Bones come together without overlap
Grade II – Bones overlap but can go back into position
Grade III – Fixed overlapping so that bones can’t go back
Grade I, II is normal, Grade III occurs in obstructed labour
2) T – Bladder base and urethra gets compressed between presenting
part and pubic symphysis, leading to pressure necrosis and devitalized
tissue sloughing off leading to a vesciovaginal fistula
3) T – Caput is a soft tissue swelling in connective tissue layer of fetal
scalp due to pressure exerted by maternal pelvis in obstructed labour,
interfering with venous and lymphatic drainage. Not limited to suture
lines, unlike cephalhematoma. Usually disappears spontaneously after
24 hours
4) T – In general, vacuum causes more neonatal scalp trauma while
forceps causes more maternal genital tract trauma
5) T
Prolonged First stage can be divided into
1. Prolonged latent phase – PROM, CPD, Occipito-posterior,
Unfavourable cervix, Uterine
dysfunction
2. Primary Dysfunctional labour – Slow progression of early active phase
– Ineffective uterine contractions, Malposition, CPD
(in order of decreasing incidene)
3. Secondary Arrest – Slowing or arrest of cervical dilatation in late
active phase (6-10cm)
CPD (commonest), Malposition, Ineffective uterine contraction
6. Epidural anaesthesia causes prolongation of 1st stage of labour.
7. Secondary arrest with 6cm cervical dilatation in a breech presentation
should be augmented with Syntocinon.
8. Cervical dilatation of >2 cm/hr indicates prolonged labour.
9. Facial nerve palsy is a recognized complication of forceps delivery.
10. Prolonged labour causes vesico-vaginal fistulae.
6) F – does not cause prolongation of 1st phase. Can cause prolongation
of second phase.
7) F – Augmentation is not recommended in active labour.
Augmentation of established labour is controversial. Caesarean section
should be performed.
8) F – less than 2cm for 4 hours
9) T – transient neuropraxias common in forceps delivery
Maternal – Perineal damage, PPH, Puerperal sepsis, Trauma to bladder
& urethra, Urinary retention
Fetal – Traumatic ICH, Cephalhematoma and neonatal jaundice
12. In prolonged labour the mother is likely to have high fever,
hypoglycaemia and fetal distress.
13. Occipito posterior position leads to prolong labour due to poor
maternal effort
11) T – both during 1st stage and 2nd stage
12) T – high fever due to sepsis, hypoglycaemia and maternal acidosis,
psychological and social impact, fetal hypoxia, maternal dehydration,
uterine rupture, obstetric haemorrhage
13) T – one of the predisposing factors since premature desire of
bearing down earlier than necessary, due to compression of rectum by
wide occiput leading to maternal exhaustion and poor uterine
contractions when it is needed
Preterm labour and premature rupture of membranes
1. Prelabour rupture at 32 weeks is a contraindication for corticosteroid
therapy
2. Spontaneous preterm labour recurs in subsequent pregnancy
3. In a premature labour with POA of 32 the child may present with
idiopathic respiratory distress syndrome.
4. Nifedipine is given for treatment of premature labour.
5. Beta agonists are effective in stopping established labour.
10) T – pressure on bladder neck and urethra leads to necrosis and
development of fistula
1) F - This is a case of PPROM, where fetal lung maturity has not been
obtained yet. Hence IM corticosteroids are indicated.
Given as two doses of betamethasone, 12mg each, 24 hourly or four
doses of dexamethasone,6mg each, 12 hourly
11. Occipito post. Presentation cause prolonged labour.
2) T
3) T – Mature Surfactant production occurs at around 34 weeks, which is
said to be the prime factor in lung maturity
4) T – tocolytics can be given with the intention of inhibiting and
prolonging labour. Commonly used are Salbutamol, Terbutaline,
Ritodrine, Nifedipine, Magnesium sulphate and Atosiban
5) F – Tocolytics are contraindicated in established labour. They are
unable to prevent to stop established labour.
6. Pre labour rupture of membrane at 28 weeks of gestation lead to
pulmonary hyperplasia of foetus.
7. Pre term babies cause more maternal mortality than IUGR.
8. Woman who has rupture of membranes for more than 24 hours is
likely to develop neonatal infection.
9. PROM - Commonest cause is subclinical chorioamnionitis.
10. Commonest cause of premature labour is sub clinical
chorioamnionitis.
6) F – pulmonary hypoplasia
7) Both are identified causes of perinatal mortality, out of which Preterm babies predominate.
8) T
9) T – Other causes include
Cervical incompetence
Multiple pregnancy/polyhydramnios
Iatrogenic – Amniocentesis
Lifestyle – Vit C, Zn, Cu deficiency/ Smoking
Coitus – in last month of pregnancy
Connective tissue disorders – Ehlers Danlos syndrome
11. Multiple pregnancy is a known cause for premature rupture of
membranes.
12. Idiopathic premature rupture of membranes is caused by subclinical
chorio-amnionitis.
13. Pre term labour occurs in multiple pregnancies.
11) T – due to increased intrauterine pressure
12) T – commonest aetiology is maternal genital tract infection
(vaginitis, chorioamnionitis, cervicitis) by Group B streptococci,
Gonorrhoea, Chlamydia, Trichomonas, etc.
13) T – commonest cause for preterm labour is idiopathic
Other causes are
Uterine anomalies
Extremes of maternal age
Multiple pregnancy/polyhydramnios
PIH
APH
Maternal smoking/passive smoking
Stress
Maternal infection
PROM
Cervical incompetence
Intrauterine fetal infection
Iatrogenic – ECV, Amniocentesis
Low socio-economic background
Previous history of preterm labour
Emergencies in obstetrics
10) F – idiopathic. Subclinical chorioamnionitis is the commonest cause
in prelabour rupture of membranes
1. Shoulder dystocia is a recognized cause of Erb's palsy in later life.
2.
3.
4.
5.
Acute inversion of the uterus can recur in future pregnancies
Acute inversion of the uterus in 3rd stages neurogenic shock.
Acute inversion of uterus does not recur in subsequent pregnancies.
Acute uterine inversion leads to post partum collapse.
1) T – also cervical cord injuries, Klumpke’s palsy, phrenic nerve palsy.
Hypoxic ischaemic encephalopathy, Fractures of clavicle and humerus
are also possible risks to the baby
2) T – Uterus is turned inside out, which has to be manually
repositioned. Instability makes it liable to get inverted again
3) T – initial shock is thought to be due to traction of surrounding
ligaments leading to parasympathetic effect causing bradycardia and
hypotension. However major haemorrhage is associated and often
undervalued.
4) F
5) T – Classically said to be a shock where symptoms are out of
proportion to blood loss
1) T – also can be seen in post partum depression as well
2) T – Sheehan’s syndrome leading to endocrine abnormalities
3) F – Caused by maternal infection – endometritis (not endometriosis),
UTI, breast abscess, etc
4) T – within 2 weeks, uterus returns to the pelvic cavity
5) T – involution by autolysis (enzymatic degradation of cytoplasm)
leading to decrease in size of muscle cells. Endometrial regeneration
complete by third week.
6) F – usually at 6th day, fundus is at level of midpoint between
umbilicus and pubic symphysis. This uterus has involuted far quicker
than that, which could be pathological as well.
Sub-involution is failure of involution
Perinatal and maternal mortality
1. Mother refusing to handle the baby is sign of puerperal psychosis.
1. Perinatal mortality is not a good indicator to measure improvements
in health care facilities in a country.
2. Perinatal deaths are defined as number of still births and early
neonatal deaths per 1000 total births.
3. Macerated still births are excluded in perinatal mortality.
4. In Sri Lanka maternal deaths are more due to PPH than heart disease.
5. Perinatal mortality rate includes infant deaths.
2. Post partum pituitary necrosis due to haemorrhage causes failure to
lactation.
3. Puerperial pyrexia Is caused by endometriosis, UTI & breast abscess,
4. Fundus is not palpable abdominally 2weeks post partum
5. The puerperal changes of uterus include involution of myometrium
and regeneration of endometrium.
6. If fundus of the uterus is felt just at the level of symphysis pubis on
the 6th day of the puerperium indicates sub-involution.
1) F – good indicator along with maternal mortality
2) T – early neonatal deaths are deaths occurring within 7 days after
birth. Total births include live births and still births
3) F – All still births both macerated and fresh are included
4) T
5) F – infant deaths are deaths of children below one year. Not included
in perinatal mortality
PUERPERIUM
6. In Sri Lanka MMR is 5 per 1000 live births.
7. Maternal mortality includes death due to ectopic pregnancies,
8. MMR indicates deaths during pregnancy, partus and puerperium for 1
months per 100,000 of mid year population.
9. Poor use of family planning contributing to MMR is confined to
deaths due to abortion.
10. Death of a pregnant woman due to Dengue haemorrhagic fever is an
incidental cause for maternal mortality.
11. Haemorrhage, septic abortion and eclampsia are the major causes of
maternal deaths in Sri Lanka.
6) F – 37 per 100,000 live births
7) T – Includes all deaths of women who are pregnant or within 42 days
of termination of pregnancy, irrespective of duration and site of
pregnancy, from any cause related to or aggravated by the pregnancy or
its management, but not from accidental or incidental causes
8) F – deaths during Preganncy + Partus + Puerperium for 6 weeks/
100,000 live births
9) F – can have an impact on other factors such as ectopic pregnancy,
increasing parity leading to more maternal complications
10) F – incidental causes are not included for maternal mortality. This
can be included as an indirect cause, since DHF is aggravated by
physiological changes in pregnancy
11) T –also heart disease complicating pregnancy