1. Obstetrics Phase 3A Stephen Lau & George Lam
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2. Outline Labour Abnormal Fetal Presentations Preterm Birth
Postterm Birth
Puerperium
NOT Multiple Pregnancy
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3. Labour
G1P0 34+2/40 26 year old woman is experiencing contractions. They are decreasing in frequency and intensity.
List 3 Clinical Features of Labour
If this is not labour, what is it?
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4. Labour
G1P0 34+2/40 26 year old woman is experiencing contractions. They are decreasing in frequency and intensity.
List 3 Clinical Features of Labour
If this is not labour, what is it?
Braxton-Hicks Contractions
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5. Labour
Same woman is now 39+1/40 and experiencing regular strong contractions.
What Are The 3 Stages of Labour?
Describe Start/End Points of Each
Name 2 Maternal and 2 Fetal Parameters to be Monitored Initially and How Frequently
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6. Labour
Same woman is now 39+1/40 and experiencing regular strong contractions.
What Are The 3 Stages of Labour?
Stage 1  Regular Contractions to Full Cervical Dilatation/Effacement
Stage 2  Full Cervical Dilatation/Effacement to Delivery of Baby
Stage 3  Delivery of Baby to Delivery of Placenta
Name 2 Maternal and 2 Fetal Parameters to be Monitored Initially and How Frequently
Maternal Obs q2h
Maternal Contractions q30 min
Maternal Cervix q4h
Fetal HR q15 min/After Contraction
Fetal Station q4h
Fetal Liquor on ROM
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7. Labour
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8. Labour You assess the woman’s cervix to be fully effaced.
What Are The 2 Phases of Stage 1 Called?
What Is The Cervical Dilatation Cut-Off Between Them?
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9. Labour You assess the woman’s cervix to be fully effaced.
What Are The 2 Phases of Stage 1 Called?
Latent
Active
What Is The Cervical Dilatation Cut-Off Between Them?
4 cm (…6 cm)
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10. Labour The woman’s cervix is now dilated 6 cm.
What is the minimum rate of cervical dilatation for nulliparous and multiparous women in the active phase?
Name 1 hormone involved in cervical ripening and where it’s synthesized
Name 1 hormone involved in promoting contractions and where it’s synthesized
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11. Labour The woman’s cervix is now dilated 6 cm.
What is the minimum rate of cervical dilatation for nulliparous and multiparous women?
Nullip  1 cm/h
Multip  2 cm/h
Name 1 hormone involved in cervical ripening and where it’s synthesized
Prostaglandins  Uterus
Relaxin  Ovaries (CL)
Name 1 hormone involved in promoting contractions and where it’s synthesized
Prostaglandins
Oxytocin  Hypothalamus (to Post. Pituitary)
Estrogen  Placenta
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12. Labour
The woman’s cervix is now dilated 10 cm and is feeling the urge to push.
How frequently do you monitor the baby’s HR now?
Fill in the blanks
Engagement in ___ Position
Descent ?
Extension
Expulsion
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13. Labour
The woman’s cervix is now dilated 10 cm and is feeling the urge to push.
How frequently do you monitor the baby’s HR now?
q5 min
Fill in the blanks
Engagement in OT Position
Descent
Flexion
IR  OA Position
Extension
ER (Restitution)  OT Position
Expulsion
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14. Labour The baby is delivered and the umbilical cord is clamped.
What is the cut-off time before worrying about retained placenta?
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15. Labour The baby is delivered and the umbilical cord is clamped.
What is the cut-off time before worrying about retained placenta?
30 min
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16. Labour Summary Labour Dx vs. Braxton-Hicks
Stage 1  Contractions to 10 cm Dilatation
Monitoring
Latent Phase  4 cm
Active Phase
1 cm/h (Nullip), 2 cm/h (Multip)
Hormones Involved
Stage 2  10 cm Dilatation to Baby Delivery
Monitoring (FHR)
7-Step Process
Stage 3  Baby Delivery to Placental Delivery
Prolonged After 30 min
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17. Abnormal Fetal Presentation
Define & Give Example
Lie
Presentation
Position
Engagement
Station
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18. Abnormal Fetal Presentation
Define
Lie  Fetal Long Axis WRT Maternal Long Axis
E.g.) Longitudinal, Transverse, Oblique
Presentation  Fetal Lower Uterine Pole
E.g.) Cephalic, Breech, Shoulder, Cord
Position  Leading Fetal Part WRT Transverse Plane
E.g.) Occiput (OA, OT, OP, etc.), Chin (MA, MP), Sacrum
Engagement  Leading Fetal Part WRT Pelvic Inlet
0-1/5 (5/5 completely above pelvic brim)
Station  Leading Fetal Part WRT Ischial Spine
+5 to -5 (+5 Outwards, -5 Inwards)
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19. Abnormal Fetal Presentation
Define & Give Example
Lie
Presentation
Position
Engagement
“Engaged” = Station 0 = At Ischial Spine
Station
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20. Abnormal Fetal Presentation
What is the ideal lie, presentation and position?
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21. Abnormal Fetal Presentation
What is the ideal lie, presentation and position?
Longitudinal
Cephalic OA
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22. Abnormal Fetal Presentation
Woman is pregnant. On examination, wide uterus and fetal head at mother’s left flank are appreciated.
Diagnosis?
Investigation?
2 Things on Ix?
2 Management Options
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23. Abnormal Fetal Presentation
Woman is pregnant. On examination, wide uterus and fetal head at mother’s left flank are appreciated.
Diagnosis?
Transverse Lie
Investigation?
USS  Confirm Lie + ?Placenta Previa
2 Management Options
ECV + Normal Delivery
C/S
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24. Abnormal Fetal Presentation
Woman is pregnant. On examination, subcostal tenderness and presenting part is softer than expected.
Diagnosis?
Investigation?
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25. Abnormal Fetal Presentation
Woman is pregnant. On examination, subcostal tenderness and presenting part is softer than expected.
Diagnosis?
Breech
Investigation?
USS
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26. Abnormal Fetal Presentation
Woman is pregnant. On examination, subcostal tenderness and presenting part is softer than expected.
Name 2 other types of breech presentation other than a frank breech presentation
Apart from traumatic injury, what is another important complication that can occur delivering
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27. Abnormal Fetal Presentation
Woman is pregnant. On examination, subcostal tenderness and presenting part is softer than expected.
Name 2 other types of breech presentation other than a frank breech presentation
Frank  Flexed Thighs, Extended Legs
Complete  Flexed Thighs, Flexed Legs
Incomplete/Footling  Extended Thighs
Apart from traumatic injury, what is another important complication that can occur delivering
Cord Prolapse
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28. Abnormal Fetal Presentation
A 30 year old G3P0+2 with PMH of DM and BMI of 35. After the head is delivered, the baby retracts backwards.
Name of the sign?
Diagnosis?
What Is It?
Management?
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29. Abnormal Fetal Presentation
A 30 year old G3P0+2 with PMH of DM and BMI of 35. After the head is delivered, the baby retracts backwards.
Name of the sign?
Turtle Sign
Diagnosis?
Shoulder Dystocia
What Is It?
Anterior Shoulder Trapped Under Symphysis
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30. Abnormal Fetal Presentation
A 30 year old G3P0+2 with PMH of DM and BMI of 35. After the head is delivered, the baby retracts backwards.
Management
Help
Episiotomy
Legs in MacRoberts (Knee to Chest)
Pressure on Suprapubic Area
Enter Pelvis
Rotational Manoeuvres
Remove Posterior Arm
Roll Pt on All Fours
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31. Abnormal Fetal Presentation
Summary
Definitions
Transverse Lie
Breech Presentation
Shoulder Dystocia
Didn’t Cover Brow/Face Presentation
Didn’t Cover Malpositions (OP, OT)
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32. Preterm Birth
A 24 year old, G2P1 32+3/40 woman presents at A&E complaining of contractions.
How can we classify prematurity?
What are the clinical manifestations for preterm labour?
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33. Preterm Birth
A 24 year old, G2P1 32+3/40 woman presents at A&E complaining of contractions.
How can we classify prematurity?
Week of Pregnancy
Birth Weight of the Baby
What are the clinical manifestation of preterm labour?
Regular, painful contractions
Cervical Effacement/Dilation
Backache
Cervical Discharge
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34. Preterm Birth Her previous pregnancy was delivered at 34 weeks.
What are the risk factors for preterm birth?
What is a biomarker for predicting preterm birth?
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35. Preterm Birth Her previous pregnancy was delivered at 34 weeks.
What are the risk factors for preterm birth?
Infection
Reproductive History
Multifetal Gestation
Lifestyle Factors
Autoimmune Disease
Cervical Surgery
Uterine Malformations
What is a biomarker for predicting preterm birth?
Fetal fibronectin
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36. Preterm Birth
Your history and examination confirms that she is undergoing preterm labour.
What medicines should now be given to the patient?
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37. Preterm Birth
Your history and examination confirms that she is undergoing preterm labour.
What medicines should now be given to the patient?
Tocolytics
Calcium Channel Blockers (nifedipine)
NSAIDs (indomethicin)
Beta adregenic receptor antagonists (salbutamol/ritodrine)
Steroids
Antibiotics
Magnesium Suphate
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38. Postterm Birth 5% of pregnancies are delivered after term
What is the upper limit of time for a pregnancy?
What are the strongest risk factors for a postterm birth?
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39. Postterm Birth 5% of pregnancies are delivered after term
What is the upper limit of time for a pregnancy?
42+6 weeks
What are the strongest risk factors for a postterm birth?
Previous postterm birth
Nulliparity
Obesity
Male Foetus
Older maternal age
Maternal or Paternal history of postterm birth
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40. Postterm Birth
A 26 year old woman, G1P0 with a 41+1 week pregnancy of a single male foetus wants have a home birth. The foetus is in a cephalic, left occiput anterior position.
Will you let this woman give birth at home? Explain your answer
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41. Postterm Birth
Liz, 26 year old woman, G1P0 with a 41+1 week pregnancy of a single male foetus wants have a home birth. The foetus is in a cephalic, left occiput anterior position.
Will you let this woman give birth at home? Explain your answer
No, pregnancies past the 41st week should be induced.
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42. Postterm Birth What are the dangers of a postterm pregnancy? Mother
Child
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43. Postterm Birth What are the dangers of a postterm pregnancy? Mother
Child
Postpartum Haemmorhage
Macrosomia
3/4th degree perineal tears
Fetal Dysmaturity Syndrome
Failed Induction
Perinatal Mortality
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44. Postterm Birth Liz arrives at the maternity unit in hospital.
How is labor iatrogenically induced?
Cervical status is important for predicting success of induction. What scoring system is used for assessing cervical status?
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45. Postterm Birth Liz arrives at the maternity unit in hospital.
How is labor iatrogenically induced?
Oxytocin IV
Amniotomy
PGE1/PGE2
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46. Postterm Birth
2. Cervical status is important for predicting success of induction. What scoring system is used for assessing cervical status?
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47. The Puerperium
What changes can you expect in the postpartum period in the following areas?
Uterus
Cervix
Vagina/Vulva
Reproductive Hormones
Breasts
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48. The Puerperium
What changes can you expect in the postpartum period in the following areas?
Uterus
Uterine involution and Lochia
Cervix
Contraction of the cervix. External os never fully recpovers.
Vagina/Vulva
Contracts but not to its nulligravid size
Reproductive Hormones
Beta HCG returns to normal levels in 12 days. 70% menstruate by week 12 postartum
Breasts
Swelling of the breasts and milk production
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49. The Puerperium
The observations show Liz has a temperature of 38 C. Are you worried?
What other routine procedures should be done for Liz after birth?
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50. The Puerperium
The observations show Liz has a temperature of 38 C. Are you worried?
No, only after the first 24 hours. Most common is cause is infection.
What other routine procedures should be done for Liz after birth?
Counselling/Practical help with breastfeeding
HR/BP/RR/Temp monitoring.
Examine for signs of bleeding
Distended bladder examination
Examine for perineal damage
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51. The Puerperium
Liz bled a lot during the birth. The nurse tells you she bled 800mls of blood.
What is the definition of primary postpartum haemorrhage in a vaginal delivery? What about after Caesarean section?
What are the causes of postpartum haemorrhage?
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52. The Puerperium
Liz bled a lot during the birth. The nurse tells you she bled 800mls of blood.
What is the definition of primary postpartum haemorrhage in a vaginal delivery? What about after Caesarean section?
>500ml blood loss, >1000ml in C - Section
What are the causes of postpartum haemorrhage?
Retained Placenta
Uterine atony
Trauma to uterus and vaginal tract
Clotting abnormalities
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53. The Puerperium
Venous thrombosis is 21 – 84x more common in women postpartum.
Risk assess and treat with stockings and LMWH
Urinary Retention
Urinary/Fecal Incontinence.
Haemorrhoids
Varicose Veins
Postpartum Depression – 10% of women
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