Labour and Delivery

Postpartum

Lynne McLeod
CRAM 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)

Malpresentations
Breech
Complete

Frank

Footling

Malpresentations
Face
Brow
Shoulder
Compound
Cord

Position
Occiput ANTERIOR
OA
LOA
ROA
Occiput POSTERIOR
OP
LOP
ROP
Occiput TRANSVERSE
LOT
ROT

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

Dilatation
Effacement
Station
Consistency
Position

closed

1-2

0-30

2
3-4

40-50 60-70

-3

-2

-1

firm

med

soft

post

mid

ant

3
>5
80+
+1

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
Fetal tone
Fetal breathing movements
Amniotic fluid volume
Non stress test
Score:

Normal = 2 Abnormal = 0

FM
FT
FBM
AFV
NST**

Significance

BPP score correlated with:

cord pH:
BPP 8-10: pH ~ 7.28
BPP 6: pH ~ 7.19
BPP 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, nonreassuring 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, nonreassuring 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

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

Management

Prepare for Shoulder Dystocia

Call for HELP!
Maneuvres

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

Prognosis/Risks

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

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