Complications of Labour

2021 WHISM Revision Lecture

Topics covered

• PPROM / PROM / Preterm labour
• APH
• Placenta previa
• Placenta accreta
• Vasa previa
• Placental abruption
• Uterine rupture
• PPH
• The 4 T’s
• Perineal trauma

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• Shoulder dystocia
• Cord prolapse
• Breech presentation
• Amniotic fluid embolism

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Acknowledgements

• PROMPT & MH guidelines
• RANZCOG
• WHISM
• 2020 WH lecture series
• Ben Amburg notes & student compiled resources
• Shavi Fernando

PPROM / PROM / Preterm labour

PPROM / PROM / Preterm labour

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• Definitions
• Term = 37+0 weeks gestation
• Preterm labour = the onset of cervical dilation and effacement in the presence of regular painful contractions before 37 weeks
• Threatened preterm labour = the onset of regular painful contractions <37 weeks, without cervical change
• Preterm birth = delivery before 37 weeks
• Spontaneous Rupture of Membranes (SROM) = Term rupture of membranes started by normally laboring contractions
• Premature Rupture of Membranes (PROM) = Ruptured membranes after term without transition to labour
• Preterm Premature Rupture of Membranes (PPROM) = rupture of membranes preterm without transition to labour

• Incidence
• Preterm births occur in 10% of all pregnancies
• ⅔ are spontaneous
• ⅓ are iatrogenic (maternal or foetal complications warranting delivery of the baby before term)
• PPROM complicated up to 3% of all pregnancies, is associated with 30-40% of preterm births

PPROM / PROM / Preterm labour

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• Causes of preterm birth
• PPROM (amniotic fluid contains a lot of prostaglandins, so when it ruptures it promotes contractility of the uterus and cervical changes)
• Cervical insufficiency → hx of LOOP or LLETZ
• Drugs → cocaine, smoking
• Trauma
• Iatrogenic → anything that merits preterm delivery → PET, IUGR, abnormal CTG

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• Causes of PPROM
• Infection (MOST COMMON, associated with inflammatory response and thereby prostaglandins) → bacterial vaginosis, chlamydia, gonorrhea, trichomoniasis
• Antepartum haemorrhage
• Uterine overdistension → multiple pregnancy, macosomnia, polyhydramnios

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PPROM / PROM / Preterm labour

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• Ix of PROM / PPROM
• Amnisure → assesses whether membranes have ruptured
• vaginal swab tested for specific proteins in amniotic fluid
• 99% sensitive
• Fetal Fibronectin → assesses imminence of delivery
• High vaginal swab
• fFN is a glycoprotein involved in the adherence of the chorion to the endometrium in the later stages of pregnancy (the glue holding baby to uterus)
• From 20 - 35 weeks levels should be 0
• When delivery is about to occur, fFN is broken down and can be detected in cervical and vaginal cavity. Raised FFN suggests delivery is imminent within 7 days.
• Good sensitivity but not specificity → PPV = 30%, NPV = 97%

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• Speculum → avoid VE if PPROM suspected
• Assess membrane status
• Visualize cervix for dilation
• If >3cm, admit for preterm labour rx

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PPROM / PROM / Preterm labour

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• Preterm labour management → STATIN
• S → Steroids
• T → Transfer & Admit
• A → Antibiotics
• T → Tocolysis
• I → Intrapartum care
• N → Neuroprotection

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• Steroids
• Cortisol plays critical role in late stage fetal development, namely lung maturation
• Indicated if <34+6 weeks and delivery is expected within next 7 days
• 2 x Betamethasone (celestone) 11.4mg IM, 24 hours apart
• Antibiotics (with PPROM)
• Pre partum → Erythromycin 250 mg oral, 4 times a day *for a maximum of 10 days or until established labour (whichever is sooner)
• Intrapartum → Benzylpenicillin IV

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PPROM / PROM / Preterm labour

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• Preterm labour management → STATIN
• S → Steroids
• T → Transfer & Admit
• A → Antibiotics
• T → Tocolysis
• I → Intrapartum care
• N → Neuroprotection

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• Tocolysis
• Only to facilitate steroid loading, will not stop labour but can delay it
• Nifedipine is agent of choice → peripherally acting CCB with preference to the smooth muscle of the uterus
• CIs
• Gestation >34 weeks
• PPROM
• Fetal compromise
• Neuroprotection
• Indicated <30 weeks gestation when birth is expected within next 24 hours
• Maternal IV magnesium sulfate infusion
• Decreased risk of death and disability associated with cerebral palsy

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PPROM / PROM / Preterm labour

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• Prevention of preterm labour
• Diet & lifestyle management
• Avoid extremes in maternal age
• >12-18 months between pregnancies
• Smoking, ETOH and recreational drug limitations / cessation
• Ix and treat asymptomatic bacteriuria / urogenital infections pre- pregnancy
• Cervical cerclage if cervical insufficiency
• Vaginal Progesterone

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Antepartum Haemorrhage

Antepartum Haemorrhage

Definition

• Bleeding in early pregnancy → PV bleeding <20 weeks gestation
• Ectopic pregnancy
• Midcarriage
• GTD
• Other reproductive tract causes (ie. cervical ectropion)

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• Antepartum haemorrhage → PV bleeding >20ml, >20 weeks gestation
• Occurs in 2-5% of pregnancies
• Risk factor for FGR and preterm birth

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• Placental praevia
• Placental accreta
• Vasa previa
• Placental abruption

Placenta Previa

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• Insertion of the placenta close to or over the cervix
• Classification
• Low lying placenta = placenta within 20mm of internal os at >16 weeks gestation
• Placenta previa = placenta covering the internal os

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• Presentation
• Painless PV bleeding after 20 weeks

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• Risk factors
• Previous C section
• Multiple pregnancy
• Uterine fibroids
• Increased parity
• IVF
• Smoking

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Placenta Previa

• Monitoring
• Placental position is assessed at 20 week morphology scan
• If the placenta is low lying, a follow up confirmatory scan is offered at 32 weeks
• The uterus grows ‘up’, thus pulling the placenta away from the os. As a result, most cases of low lying placenta resolve
• For persistent previas, a final US is offered at 36 weeks.
• Serial growth scans and CTG throughout pregnancy
• Because placenta is within the less vascular fibrous segment of the uterus → higher risk of placental insufficiency → IUGR

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• Delivery
• LUSCS scheduled before 38 weeks

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• Advice
• No sex
• Avoid VEs

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Placenta Accreta

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• Imbedding of the placenta beyond the endometrium
• Classification
• Accreta → invasion just below the endometrium
• Increta → moderate to full invasion of the myometrium
• Percreta → complete invasion of the myometrium +/- invasion of other local structures

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M = myometrium, V = chorionic villi

V M

Placenta Accreta

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• Risk factors
• Low lying placenta / praevia & previous C section !!!!
• Praevia w/o hx LUSCS → 5% risk
• Praevia w 1 LUSCS → 24%
• Praevia w >3 LUSCS → 67%
• Clinical features
• Painless PV bleeding
• Ix
• Low lying anterior placenta on 20 week morphology scan
• Elevated AFP
• Complications
• Failure of placental separation at delivery → PPH
• Rx
• Plan cesarean section between 35+0 - 36+6, +/- hysterectomy

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Placental Abruption

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• Total or partial detachment of the placenta from the endometrium prior to the delivery of the foetus
• Types
• Partial vs complete
• Concealed vs apparent

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• Causes / Risk factors
• Placental ischemia
• PET
• Smoking & cocaine → stimulate vessel contraction
• Chorioamnionitis
• Trauma
• Shearing force of placenta off uterine wall → consider especially in MVAs
• Overstretch of uterus
• Multiple pregnancy
• Polyhydramnios
• Macrosomia

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Placental Abruption

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• Clinical Presentation
• PAINFUL uterus, +/- PV bleeding
• Constant pain, as opposed to fluctuating pain of contractions
• ‘Woody’ tender uterus on palpation → sustained uterine contraction due to infiltration of blood into myometrium causing
• Extent of CTG changes and fetal compromise dependant on severity of abruption / interruption of placental perfusion

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• Ix
• FBE + Coags + group and hold
• Kleihauer test
• Rx
• Stabilise (DRSABCD, fluid resus)
• Preterm prep
• +/- Anti-D
• LUSCS indicated with fetal distress

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Vasa Previa

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• ‘Vessels delivered first’
• Causes
• Velamentous Cord Insertion
• Umbilical cord inserts into the amniotic membranes, as opposed to directly into placenta
• Bilobed placenta
• Two lobes of the placenta mean there are communicating vessels between them
• Both cause increased mobility of vessels / closer proximity to cervical os, increased risk of prolapse following ROM

Vasa Previa

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• Presentation
• PV bleeding on ROM
• Risk factors
• Placenta previa / hx of LUSCS
• Lateral placental cord insertion → may become velamentous with migration of the placenta
• Complications
• Neonatal mortality > 70% if ROM
• Rx
• Planned caesar 34-36 weeks
• Immediate emergency LUSCS if ROM

Uterine Rupture

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• Rupture of the myometrium
• Risk factors
• VBAC
• Important to counsel pts on this risk when consenting for VBAC
• Risk of rupture during a VBAC is 0.5% or 1 in 200
• Risk of fetal demise following rupture is 10% or 1 in 10
• Global risk of fetal demise during VBAC due to uterine rupture is 0.05% or 1/2000
• Risk is less with hx of successful vaginal birth
• Risk is higher with classical (vertical) c section scar
• Cocaine use → associated with hyperstimulation of the uterus

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• Clinical presentation
• Pain
• Sudden maternal destabilization
• Peritonism on ex due to blood in peritoneal cavity
• Fetal compromise
• Rx
• Emergency C section +/- hysterectomy

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Postpartum Haemorrhage

Postpartum Haemorrhage

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• Classification
• PPH = blood loss of 500ml or more
• Severe PPH = blood loss of 1000ml or more
• Primary PPH = within 24 hrs of delivery
• Secondary PPH = between 24 hours - 6 weeks postpartum
• The majority of causes are caused by postpartum endometritis
• Management is antibiotic therapy
• Ampicillin
• Gentamycin
• Metronidazole

• Incidence
• Incidence in Australia is 5-15%
• ‘In 2016 PPH affected 17% of women giving birth at Monash Health. Of this, major PPH (>1000 mL) affected 5% of women’
• Leading cause of maternal death both in Australia and globally

Postpartum Haemorrhage

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• Maternal blood flow to the placental bed is approximately 750 ml/min at term
• Maternal blood volume is approximately 7L
• Blood loss can be life-threatening at 30% loss
• PPH can become life threatening in as little as a few minutes

Physiology

• In ‘normal’ labour, upon delivery of the fetus, surges in oxytocin cause the uterus to contract.
• As the uterine arteries supplying the placenta pass through the myometrium, this contraction constricts these vessels.
• Other physiological mechanisms which protect against blood loss include haemostasis, vasoconstriction, platelet aggregation and clot formation.
• Simultaneously, the shrinkage of the uterus as it contracts causes the placenta to detach from the uterine wall, allowing it to be delivered in the third stage of labour.

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Postpartum Haemorrhage

Causes → The 4 T’s of PPH

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Tone

Trauma

Tissue

Thrombin

Tone (70%)

• Over distended uterus → limits myometrium ability to contract & constrict vessels
• Multiple pregnancy, polyhydramnios, macrosomia
• Uterine exhaustion → limited contraction due to overexertion
• Prolonged labour, increasing parity, oxytocin use in labour
• Intrauterine Infections → inflammatory response can limit myometrium contraction
• Prolonged rupture of membranes
• Certain medications → can cause hypotonia
• Magnesium Sulfate (pre-eclampsia), Nifedipine (Ca2+ channel blocker for HTN), Salbutamol (asthma)

Trauma (20%)

• Episiotomy / Perineal Tears
• abnormal presentation or position, instrumental delivery
• Surgical Incisions
• Cesarean section
• Uterine Rupture → generally from previous scar tissue
• VBAC, obstructed labour
• Uterine Inversion → if placenta is still adherent to the uterus
• Strong contractions, short umbilical cord, increased parity

Tissue (10%)

• Placenta Accreta / Increta / Percreta → adherence / imbedding of the placenta into the uterine wall, can rupture during delivery leading to massive haemorrhage (warrants emergency hysterectomy)
• Previous cesarean section / uterine surgery
• Retained products → non separation of placental tissue can cause the placental sinuses to remain patent
• Previous uterine surgery

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Thrombin (1%)

• Thrombocytopenia
• Disseminated Intravascular Coagulation
• Severe preeclampsia, placental abruption, sepsis
• Hereditary Bleeding Disorders
• Von Willebrand’s, haemophilia

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Postpartum Haemorrhage

Managing Primary PPH → general principles

• Recognition
• Visual estimation of blood loss often underestimates true blood loss
• Important to weigh drapes, pads and swabs, whilst remembering amniotic fluid will contribute to some aspect of the weight
• Monitor vital signs of indication of shock or tachycardia
• Communication
• Multidisciplinary team coordination → anaesthetics, obgyns, haematologists, nursing staff

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• Resuscitation
• Call for help
• Assess for danger
• Airway & breathing assessment w admin of high flow O2
• Wide bore IV access & bloods sent for FBE, coagulation profile & cross match
• Rapid fluid infusion +/- group O neg blood infusion
• Additional measures such as keeping the patient warm and positioned lying flat
• Monitoring & Investigation
• Regular vital observations
• Fluid balance & urine output
• +/- Transfer to high dependency / intensive care

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Postpartum Haemorrhage

Managing Primary PPH → Treating the cause

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• TONE
• Mechanical (aim is to stimulate contractions)
• Uterine massage or bimanual uterine compression
• Drain urine via catheter → can prevent uterus from contracting properly
• Pharmacological → uterotonics (in absence of contraindications, given in combinations & simultaneously)

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Postpartum Haemorrhage

Managing Primary PPH → Treating the cause

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• TRAUMA
• Thorough assessment of the entire genital tract for bleeding sources → perineum, vagina & cervix
• Pressure applied to bleeding site and surgical repair either in theatre or on ward
• THROMBIN
• Replacement of platelets & clotting factors
• TISSUE
• Examine the placenta to ensure it is intact and there is no missing tissue
• Manual placenta removal (+++ pain, likely require anaesthetic)
• Oxytocin first line for placenta in situ (same admin as first line for atonic uterus)
• Other pharm for bleeding → Tranexamic acid
• Administered 1g IV infusion over 10-20 minutes
• Antifibrinolytic drug, inhibits clot breakdown by preventing activation of plasminogen and plasmin
• CI with thromboembolic disease (unless anticoagulants given simultaneously)

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Postpartum Haemorrhage

Managing Primary PPH → Severe PPH

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Additional measures

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→ Balloon Tamponade

→ Haemostatic Brace Suturing (mechanical compression of the atonic uterus)

→ Uterine artery ligation

→ Internal iliac artery ligation

→ Hysterectomy

Perineal Tears & Episiotomy

(pick your poison)

Perineal Tears

Risk factors

• Primigravida
• 90% of nulliparous vs 68% multiparous
• Only 0.6–11% will be 3rd or 4th degree
• Asian ethnicity
• Large babies > 4kg
• Shoulder dystocia
• OP position
• Instrumental birth
• Risk of OASI with ventouse: 1-4%
• Risk of OASI with Forceps: 8-12%
• Precipitate (rapid) labour

Perineal Tears

Classification

• First Degree → Laceration of the vaginal mucosa or perineal skin only (no muscle involvement)
• Second Degree → injury to the perineal muscles, but not involving the anal sphincter
• Third Degree → injury to the perineum involving the anal sphincter complex (a combination of the internal and external anal sphincters)
• 3a: less than 50% of EAS thickness torn
• 3b: more than 50% of EAS thickness torn
• 3c: IAS torn
• Fourth Degree → injury to perineum involving the anal sphincter complex (EAS & IAS) and rectal mucosa

Perineal Tears

Prevention

• Antenatal perineal massage
• Warm compress during second stage labour
• Perineal guarding at crowning
• Episiotomy
• Evidence does not support specific positions for the protection of the perineum during active pushing

Episiotomy

• Indications
• A high likelihood of third-degree or fourth-degree perineal tear
• Soft tissue dystocia
• A requirement to accelerate delivery of a compromised fetus
• Need to facilitate operative vaginal delivery
• History of female genital mutilation.
• Procedure
• Almost always mediolateral in Australia
• Incision of posterior vaginal wall & perineum at 60 degree angle or ‘8 o’clock’
• Local anaesthetic (1% lignocaine) or epidural
• Risks
• Infection
• Trauma sustained from episiotomy may be more severe than that encountered from a perineal tear

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Postpartum Perineal Trauma

Rx

• Rectal examination
• Immediate suturing (3rd and 4th in theatre)
• Antibiotic prophylaxis for 3rd or 4th degree
• NSAID suppositories
• Rest, ice, compression, elevation / exercise
• Stool softening laxatives
• Refer women with 3rd or 4th degree tearing to physiotherapist and 6 month follow up at perineum clinic

Prognosis

• 60-80% women asymptomatic at 12 months following a OASI
• Women who remain symptomatic often report incontinence of flatus or faecal urgency
• Risk of recurrent OASI in subsequent births is 5-7%

Shoulder Dystocia

Shoulder Dystocia

Description & Risk Factors

• Delivery of the head but impaction of the shoulders at the pelvic outlet
• Classification
• Anterior → impaction on pubic synthesis, most common
• Posterior → impaction on sacral promontory
• Risk Factors → 50% have none
• Hx of shoulder dystocia
• Macrosomia (>4.5 kg)
• GDM → Macrosomia
• Maternal obesity → GDM
• Prolonged labour
• Oxytocin augmentation
• Instrumental births

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Shoulder Dystocia

Clinical Features

• Difficulty delivering the face and chin
• Head remaining tightly to the vulva or even retracting
• turtle neck sign
• Failure of he head to restitute / external rotation
• Failure of shoulders to descend
• Plethoric fetal face

Shoulder Dystocia

Complications

• To baby
• Brachial Plexus Injury → most common (2-16%)
• Upper brachial plexus injury (C5 - C6) → Erb’s palsy / waiter’s tip position
• Clavicle or humerus fractures
• Cord compression → hypoxia
• To mum
• PPH
• Perineal trauma
• Uterine rupture
• Psychological distress

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Shoulder Dystocia Rx

• Suprapubic pressure aka Rubins I
• Aim is to twist the anterior shoulder around and under the pubic bone
• Pressure should be applied downward and lateral from the side of the fetal back

Reduces traction force on baby

Shoulder Dystocia Rx

Shoulder Dystocia Rx

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• Removing posterior arm
• Whole hand into vagina via pringle's maneuver
• Grab the posterior wrist
• Pull arm across chest to deliver baby’s posterior arm. If elbow is straight should be bent before attempt.
• Reduces fetal shoulder diameter allowing anterior shoulder to drop down under the pubic synthesis
• Perform rotatory maneuvers
• Aim is to place the biacromial diameter into the oblique (wider) plane of the pelvis
• Use supra pubic pressure to aid rotation
• Maneuvers should not be tried for >30 seconds each !!!
• Position Mum on all 4’s & repeat maneuvers
• Can be done after failing maneuvers in McRoberts, or initially

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Rubins II

Insert hand into the hollow of the sacrum and apply pressure to the posterior aspect of the anterior shoulder of the fetus

Woodscrew

Maintain Rubin 2 and insert other hand to apply pressure to the anterior aspect of the posterior shoulder

Reverse Wood Screw

Opposite to wood screw, pressure on anterior aspect of anterior shoulder and posterior aspect of posterior shoulder

Shoulder Dystocia Rx

Management

• Progress to emergency measures
• Cleidotomy (most common)
• Clavicle of baby is broken to collapse the shoulder diametre
• Posterior axillary sling
• Symphysiotomy (dissection of the pubic synthesis)
• Zavanelli maneuver and cesarean (may not be possible depending on extent of fixture of head to perineum
• Postpartum procedures

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Cord Prolapse

Cord Prolapse

Classification

• Cord presentation → cord lies between presenting part and cervix, with membranes intact
• Cord prolapse → cord descends through the cervix, with or in front of presenting part

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• Risk factors
• Breech presentation
• AROM
• Polyhydramnios
• Multiple pregnancy
• Prematurity
• Complication
• Cord occlusion → fetal hypoxia
• Clinical presentation
• Fetal heart rate abnormality following ROM
• Visible / palpable (pulsatile mass at top of vagina) cord on VE / speculum

Cord Prolapse

Management

• Expedite delivery → code green
• Position mother, knee to chest with head down bum up to relieve gravitation pressure on cord
• Insert fingers into vagina and lift presenting part up in the pelvis to prevent cord compression

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Breech Presentation

Breech Presentation

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• Classification

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• Epi
• 30% at 30 weeks, 3% at term
• Risk factors
• Multiple pregnancy
• Fetal anomalies
• Uterine fibroids
• Polyhydramnios
• Increased parity (uterus and anterior abdo wall lack tone)
• Placenta previa (keeps the foetus higher in the pelvis)
• Balloon induction

Frank

Complete

Footling

Breech Presentation

Management

• Antenatal management
• Watchful waiting
• Most will resolve before term
• External Cephalic Version → success rate 68%
• Baby is basically flipped
• Generally performed at term for women who prefer a vaginal delivery
• AEs
• Abruption of placenta or uterus → feto-maternal hemorrhage (must give anti-D prior)
• Cord entanglement → rare as cord complications are cleared on US first
• CIs
• Footling breech
• Multiple pregnancy
• Hyperextension of fetal head
• ROM

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Breech Presentation

Management

• Planning delivery
• Vaginal delivery can be attempted, but women should be recommended LUSCS in high risk cases
• Footling breech
• High or low fetal weight
• Hyperextended neck on US
• 40% of vaginal attempts will require emergency LUSCS
• During delivery
• No pushing until full dilation of cervix
• NO fetal traction
• LUSCS indicated if birth not imminent after 60 minutes of pushing

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Amniotic Fluid Embolism

Amniotic Fluid Embolism

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• Pathophys
• Amniotic fluid enters the maternal circulation
• Exact pathophysiology is unclear, but theorised maternal demise theorised to be attributable to inflammatory / anaphylactic response to fetal material
• Risk factors
• None identified
• Presentation
• Acute maternal collapse / cardiorespiratory arrest
• 80% arrest within minutes
• Most often during labour (70%)
• 19 % during c section
• 11 % immediately after vaginal birth

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• Diagnosis
• Dx of exclusion, or by postmortem by identification of fetal material in maternal lungs
• Prognosis
• Maternal mortality rate is 35%
• Neurological impairment in 7 % of survivors
• Fetal mortality is 18-19%

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MCQs

Q1

A 32 year old pregnant multiparous woman presents complaining of progressively worsening intermittent abdominal cramping, as well as watery vaginal leakage. Her gestation is 34+3 weeks. Which of the following is LEAST appropriate for her management at this time

1. Perform an amnisure
2. Administer betamethasone
3. Administer nifedipine
4. Admit her to the ward and commence fetal monitoring

Q2

A 28 year old nulliparous pregnant woman attends her 20 week morphology ultrasound. She is found to have a low lying placenta, located 1.5cm from the internal cervical os. Which of the following is appropriate advice for her?

1. Her low lying placenta will most likely persist to term
2. Being nulliparous places her at a higher risk of placenta praevia
3. She can attempt a normal vaginal delivery regardless of placental location
4. She will require a confirmatory scan at 32 weeks

Q3

Sarah is 34 weeks pregnant with twins. Today at her antenatal appointment, the leading twin is found to be breech, and the following cephalic. Which of the following is true?

1. She can be offered an external cephalic version at 36 weeks
2. She may attempt a vaginal delivery only if the leading twin is cephalic at term
3. If her twins remain in the same position, she may attempt a vaginal delivery at term
4. She can attempt a vaginal delivery, as long as both twins are cephalic, OR both twins are breech

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Q4

Claire was induced at 37 weeks gestation due to severe pre eclampsia. Following the birth of a healthy baby boy and the delivery of the placenta, Claire begins bleeding profusely. On palpation Claire’s uterus is poorly contracted. Which of the following uterotonics is most appropriate for first line management of Claire's PPH?

1. Ergometrine, 0.25mg IM
2. Syntometrine, 1ml IM
3. Oxytocin, 10 units IM
4. Oxytocin, 10 units / hour infusion

Q5

Amanda is a 37 year old multiparous woman, attempting a VBAC after a history of 2 previous LUSCSs. She is induced at 41 weeks. 8 hours into a slowly progressing labour despite a continuous syntocinon infusion, Amanda complains of severe abdominal pain, she becomes pale and her blood pressure plummets. How should Amanda be managed?

1. Increase syntocinon infusion
2. Change Amanda’s position and commence IV hydration
3. Reduce syntocinon infusion and offer additional analgesia
4. Code green and immediate transfer to theatre

Q6

Lucy presents following spontaneous ROM at 40 weeks gestation. On examination, a pulsatile mass is felt at the top of the vagina. Which of the following is NOT appropriate in managing Lucy?

1. Commence fetal monitoring
2. Change maternal position
3. Commence syntocinon infusion
4. Code green and immediate transfer to theatre

Q7

Vanessa is a 24 year old primip who presents in spontaneous labour at 42 weeks gestation. After delivery of the head, the fetus retracts, with baby's chin pressed firmly against the perineum. Which of the following is an appropriate step in managing Vanessa?

1. Encourage maternal pushing
2. Apply traction to the fetal head
3. Code pink and call for senior help
4. Code green and immediate transfer to theatre

Q8

30 year old Eleanor attends her first antenatal appointment. She is 8 weeks pregnant, but is already highly anxious, and is keen to discuss labour. She is particularly concerned about the prospect of perineal tearing, as she has read some horror stories online. Which of the following would be appropriate advice for Eleanor?

1. As a primip, she is at lower risk of perineal trauma that a multi
2. The majority of perineal tears do not involve the anal spinchter, and can be sutured immediately in birthsuite
3. If required, an episiotomy can be cut at a 90 degree angle from the midline to prevent anal sphincter involvement
4. Most women who sustain an anal sphincter injury will have symptoms persisting 12 months after delivery

Q9

Kate is pregnant with her third baby. She goes into spontaneous labour at 39 weeks and has a successful VBAC with no complications surrounding the delivery of her baby. However, after failure to deliver the placenta with cord traction on birth suite and later manual placenta removal in theatre, Kate is discovered to have placenta accreta and has to have her placenta surgically removed. Which of the following is FALSE regarding Kates situation

1. Her biggest risk factor for placenta accreta would be a prior history of LUSCS
2. Placenta accreta most commonly occurs in the superior portion of the uterus
3. Prenatal serum screening would likely have revealed high levels of AFP
4. Many placenta accretas will require a hysterectomy

Q10

Remi is a 30 year old primip under shared care. She presents to the hospital with an urgent referral from her GP due to a suspected placental abruption at 36 weeks. Which of the following would you NOT expect to find on ex / ix?

1. Painless PV bleeding
2. A firm, ridgid uterus on palpation
3. HbF on a maternal serum Kleihauer test
4. Fetal compromise on CTG