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Hi, everyone. Thanks so much for joining. We're just gonna wait a couple of minutes for some more people to join and then we'll get started. Ok, so, hi, everyone. I'm Jade. I'm going to be doing session six of our OB and Gyne in the spotlight um revision series and it's going to be on labor today. Um So we'll be covering um normal labor prematurity, failure to progress and also umbilical cord prolapse. Um Before we get started, um we just have a disclaimer. Um We want to thank everyone for joining um and hope that you find it useful. Um We just want to make sure, you know that um all content has been created and put together by us students. Um So things might not be 100% correct. Um And there might be some like discrepancies. Um And please do not rely on this as your um only forms revision. We're not covering everything, um just some high yield topics and of course, at the end, there'll be a feedback form which will give you access to recordings and these slides as well. Six, starting with our first case, we have Jennifer who is 38 plus two, weeks pregnant. And with this is her first baby, she believes she might be in labor. She describes feeling painful, tight sensations in her abdomen and she has contacted her midwife and she is unsure of whether to come in or not. How would you assess whether she is in labor? Yup. If she's passed any of um the show, any other ideas from anyone? Yeah. Perfect. Ok. So um these are some signs of labor. So you would want regular um yep check for dilatation too would be um great idea as well. So she's got regular and painful uterine contractions. Um In order to be admitted, you want them to be usually every five minutes or more often. Um whether she's um pass the show and that would be um shedding of the mucus plug. Um It may be blood stains. So they might describe passing some like pink mucus or if they're not sure if they've not done it before. Um They might also have a um rupture of the membranes. Um But that's not always the case. They could still be in labor. Um You'd want to examine the cervix and check for shortening and dilatation and they may also describe some onset of backache as well that can be quite um frequent in pregnancy. So she states that they are occurring, these painful sensations are occurring every 3 to 5 minutes and did notice an odd jelly like substance last time she went to the toilet. So the midwife advises her to come into the birth center on arrival. She is assessed and her has a cervical examination. Her membranes are still intact and she's six centimeters dilated, which stage of labor is represented here. Ok. Pop up the po ok. So we've got quite a mix of answers here. Um Most people have gone for first stage and that is correct. So she is in the first stage of labor. So there's three different stages of labor. There's the 1st, 2nd and 3rd stages. Um First stage is um classified as the onset of labor until full cervical dilatation and that's 10 centimeters. Um It usually lasts for eight hours hours if it's the first birth or five hours, if um they've had multiple births before. Um and the typical rate of progression would be one centimeter every 1 to 2 hours. Second stage can be split into the passive and active stage. Um And this is classed as from full dilatation to the delivery of the baby. The passive stage is just when the woman isn't pushing. And then active stage is um when she is pushing. And this normally lasts for up to an hour in first um pregnancies and about a quarter of an hour in um subsequent pregnancies. And then the third stage is um from when the baby's delivered until the um placenta and the membranes have been completely delivered. And that normally lasts between a quarter to half an hour and there isn't much difference between if it's a first or, um, second pregnancy. Um, and they can give, um, like, um, Oxytocin. Um, so Syntocin is the, um, synthetic form of that and ergometrine to help, um, make this process, um, a bit quicker and also, um, prevent any, um, abnormal bleeding. So, she's admitted to the delivery suite and then mentions she's struggling to cope with the pain of labor. What options have we got for management of intrapartum pain? Yeah. Yeah. Yeah. Yeah. Got some really good suggestions in the chat there. So there are quite a few different options that we can have um for management of pain. Um So um a common one is a epidural um and that would be either levobupivacaine or bupivacaine mixed with fentaNYL and that is inserted in via a catheter in the epidural space. Um And that allows the medications to um diffuse into surrounding tissues and through the spinal cord. So that's why we do it at um around level. Um like L3 L4 in the spine because that's where you have your abdomen. So we want to diffuse it into the surrounding structures. Um Another really common one is Entonox, which is our nitrous oxide and oxygen. It's a 5050 mix of the both and that offers short term pain relief. So people tend to have it during contractions and then stop when they're not um contracting um it can cause lightheadedness, nause nausea and drowsiness. But the good thing is if women don't agree with it, they can just stop it straight away. Um, and those effects should go away as well. Um There's also the option of opioids so you can give im pethidine or diamorphine. Um, these can also cause drowsiness and nausea and there is also a risk of respiratory distress in the newborn if they're given too close to birth as opioids can um cause respiratory depression. Um There is also a risk of interfering with the um first feed um with the baby, it's given too close to birth. So um a lot of women opt not to have these um you can also do simple analgesia. So your paracetamol and codeine um especially in the very early stages of pregnancy, but we like to avoid nsaids um especially with that bleeding risk. And then there's other options as well like water births um have been proven to reduce pain and 10 ma tens machines are very useful in the um early stages of pregnancy, especially before the woman can be admitted um to the um delivery spree or labor ward. So Jennifer decides that she'd like to have an epidural and the anesthetist a record and discuss this with her. What adverse effects of an epidural should Jennifer be advised of? Yeah, both of those are great suggestions. Yeah. Yup. Brilliant. Ok. So we got a lot of good suggestions. There. Um, yeah, exactly. Perfect. Um, so there are quite a few, um, adverse effects that can happen with epidurals. Um, the main one, that most people tend to notice is they might have a, um, headache after it is inserted. Um, some women also during insertion, feel, um, like shocks down the legs. Um, that can be quite distressing for some women. Um, hypertension is a key one that will be regularly monitored throughout, um, labor, um, especially right before and she's due to have the, um, top ups of um, the medications. Um, she may get motor weakness in the legs. Um, there's nerve damage. A key one as well is prolonged, second stage of labor as they're not able to feel the contractions. Um, they sometimes struggle with, um, the ability to push, um, and that can make it a bit longer. Um, there is also an increased probability of instrumental delivery. So to kind of, um, combat that, um, once the women are fully dilated, um, depending on how, um, much the baby's head has descended, they may have to wait about an hour or so before. Um, being allowed to push. Um, as that helps reduce um, the pushing time and also risk of instrumental delivery. Um, they may also need a catheter. Um, some women, um, due to like loss of sensation are just unable to, um, pass urine after that and they might also have backache for a few days after. So as she's had an epidural, um she CTG monitoring is now indicated for her. So which feature would be um considered um a reassuring feature of a CTD? Ok. So again, we've got quite um varied answers here. Um But in this case, the correct answer is early decelerations and those occur um at the beginning of a contraction and the fetal heart rate will um decrease a little bit. Um and that's due to um the compression caused by the um contraction of the uterus um can compress on like um the vagus nerve of the baby and it's just a normal response to um the contractions. So, I've got um a graph here or a table of um different features of a CTG and whether they'd be classed as um like reassuring or more um non reassuring and also like more concerning. So, starting with our reassuring features, a heart rate between 100 and 10 and 100 and 60 is um considered normal um for a fetus. And you'd also want to have like a stable baseline, basically just not massive jumps um within that and also be appropriate for the gestation. Um The variability tends um is reassuring when it's between five and 25 BPM as cause um fetal heartbeats just aren't regular. There, there is quite a lot of um variation in those. So 5 to 25 is no cause for alarm. Um And then in terms of decelerations, either having no decelerations or early ones as I mentioned already. Um and also if they, they can be variable, but as long as they don't have any concerning characteristics, um which are mentioned in the other sections of the table may be considered um reassuring. Um And then in terms of um contractions, um a ratio of um less than five and 10. Um and as long is reassuring. And so when we get to our more concerning features, um if they're having more frequent contractions or they're lasting a really long time, that would be a cause for concern. Um If heart rate increases by 20 BPM or more, um that'll be concerning as well. Um heart rate between 100 and 100 and nine. And if the baseline is um very variable, um and then um for variability, if it's less than five for 30 to 50 or greater than 25 for 10, um Also, um concerning characteristics would be decelerations lasting more than um 60 seconds. If there's reduced variability, um they're slow to return to their baseline. And if there's loss of shouldering and that's um considered um uh acceleration um of um heart rate before um a contraction or um it's just a normal response shows that they're coping well with the conditions they're in. Um and if there's any repetitive decelerations or if they're occurring in more than 50% of contractions, that would be um considered a repetitive deceleration So it would be a cause for concern. And then our um red flag features is heart rate under 100 or greater than 100 and 60. Um If it's got um less than five decelerations, um variability of less than five for more than 50 minutes or more than 25 for more than 10 minutes or if it's a sinusal pattern. Um And that's like um your sine wave pattern um very regular. Um um yeah, just the sine wave over and over again on, on the um CTG. Um And then again, it's due um different lengths of um repetitive um decelerations and late decelerations. And also if they have um a single, single, prolonged deceleration lasting more than three minutes, that'd be classed as a bradycardia. So again, it would be a red flag feature. Um And this is just a Pneumonic to help remember the different features of a CTG and so defining the risks. It's based on individual cases, then looking at the contractions, the baseline rate are variabilities, accelerations and decelerations and then your overall impression. So if you've got a non, concerning CTG and a non, concerning clinical picture, it would be non concerning, but if there's any causes for concern, they'd need to be taken into account as well. Se as um Jennifer's labor progresses, um there aren't any issues and she reaches the second stage, she begins pushing and after 45 minutes, she gives birth to her son during delivery, she does suffer a perineal tear which involves the perineal muscles and fascia, as well as the external and internal anal sphincters. There is no involvement of the anal mucosa. So what um degree of a perineal tear does Jennifer have? Um So um fetal bradycardia would be. Um So I think the anything under 100 and 10 is concerning um but it was um the um prolonged deceleration. So, if it's for longer than three minutes, that would be classed as a bradycardia rather than a deceleration. Ok. So again, I got a few different answers but majority have come with a third degree um three C um tear and that is the correct answer. So the classification um of perineal tears, um There's a 1st, 2nd, 3rd and 4th degree um first is our superficial ones. Um There's no muscle involvement and they very rarely require repair. Maybe if there's a bleeding vessel might require a stitch, but um not very common. Um Our second degree, sorry, second degree cares involve the perineal muscles and that would require um suturing on the ward. And AIOT tend to fall into this classification of um care as well and that suturing can be done by a trained midwife um or a doctor, whoever's around um our third degree, we have different categories within that. Um But the overall theme is that they involve the anal sphincter complex and would require repair in theaters. So, R three A is less than 50% of the external sphincter B is greater than 50% of the external. And then three C is if there's any involvement of the internal aim and sphincter and then fourth degree again, um requires repair in fetus and it's the most severe of the tears um as it goes all the way through to the rectal mucosa. Um So risk factors for that. Um if it's the first baby, um um large babies typically greater than 4 kg. If there's a shoulder dystocia, um Asian ethnicities are also more likely to have perineal tears. Um If you've got an occipitoposterior position of the baby. So that's also known as a face to pubes presentation and of course, um instrumental deliveries as well. So in terms of management of these, um they'd be repaired based on their classification. All um tears would also require some broad spectrum antibiotics and also laxatives. Um as we don't want um too much strain going on um for the perineal um body um as that could cause um wound defense. And also we don't want um women to get constipated as well. And you can also offer them some physiotherapy um if they're at risk of getting um urinary and fecal incontinence, so it can help reduce that risk and also the severity. So, moving on to case two, um Giovani is 30 plus two weeks pregnant and she has um with one baby and she presents to me with concerns about leaking down below. She's worried as this has not happened with her previous pregnancies and she thinks she might have developed urinary incontinence. So, what investigations and examinations would we like to carry out for this woman? So we got some really good suggestions in the chat there. So she's likely got preterm, prelabor rupture of her membranes. Um So the most important thing to remember here is that we do not want to do a digital vaginal examination um as it has been shown that this can reduce the time between the rupture of the membranes and latency. So that's um initiation of labor and there's also an increased risk of introducing some intrauterine infections. Um The key feature, um sorry, the key um Gold Standard investigation would be a speculum exam with a sterile speculum. And on that, you would see pooling of the amniotic fluid in the posterior vaginal fornix. Um So you need to lay them down for at least 30 minutes prior to that to allow them to collect in the area. Um If you don't have any fluid seen or like no pooling seen, you can do um Actin pro which is a swab for um um insulin growth factor binding protein one which is found in amniotic fluid. And then there's also AMN um which is for um P MG which is in high concentrations in amniotic fluid. Um All women should also have a high vaginal swab as that could identify potential causes for why the membranes may have ruptured. And you would also want to check the GBS um, as they may need um, intrapartum antibiotics, especially if it's a premature baby. Um If you're unsure whether the membranes have ruptured or not, um, you can also do a transvaginal ultrasound and you'd see um so reduced amniotic fluid as it's already come out and you can also check their full blood count and their CRP for any signs of infection. Um It would also be important to um rule out any um incontinence. Um But if anything um is seen within the um vaginal canal, it's more likely to be that she's um ruptured her membranes um early. So she is confirmed and to have ruptured her membranes um as there was pooling seen in on spec examination and she's really concerned that she might have done something to cause this. So, um you reassure her that in most cases there aren't any identifiable risk factors. Um But what are some risk factors for um premature prelabel rupture of membranes? Yeah. Yeah. Lots of really good suggestions in the chat there. So there are a lot of um risk factors. Um but these are just um some of the main ones. Um So we've got um any invasive procedure. So if she's had amniocentesis, um if uh there is polyhydramnios because you've got an increased um amount of fluid is more pressure. So it's more likely to rupture early if it's a multiple pregnancy, any cervical insufficiency if she's had any bleeding from the vagina during pregnancy, um, lower genital tract infections, specifically bacterial vaginosis has, um, a high, um, um, association with it. Um, any previous premature or deliveries or rupture of membranes. Um, smoking is a key one, especially if it's, um, before 28 weeks. Um, if she's got a low BMI, um, if, um, she's previously had a placental abruption or any direct trauma to the stomach. So, how would you manage? Giovani? Yeah, lots of pretty good suggestions. So, the mainstay of our um management here would be to prolong the pregnancy for as long as safely possible. So, if we want to keep baby inside for as long as we can without causing risk to mother and also baby, so we'd want to admit her for observation um for at least 48 to 72 hours um and monitor for any clinical signs of chorioamnionitis. So that would be like R CRP levels and checking temperature. Um because she is um like 30 weeks pregnant, you'd want to give some corticosteroids um to help improve lung maturity as baby is likely to come early um prophylactic antibiotics. Um So specifically Erythromycin um for up to 10 days or until she goes into labor. And if um a woman presents and is 34 weeks or more, you could offer to induce labor at that point. So after 48 hours, um shy begins to have contractions and gets a sensation of pressure within her pelvis. She has a transvaginal ultrasound to um to assess for her cervical legs. So which of the below measurements is associated with a confirmed preterm labor? Ok. So again, we've got a few mixed answers here. Um But the correct answer in this case is eight millimeters. So for assessing um if there's preterm labor, the gold standard, um according to the nice guidelines is a transvaginal ultrasound to assess for cervical length. So, anything greater than 15 millimeters, it's unlikely that it would be preterm labor. So anything under 15 millimeters would be confirming preterm labor. So, of all the options in that question, um eight millimeters was the only one below 15. And if transvaginal ultrasound is not suitable for the um woman, um we can do um testing of fetal fibronectin. And you want to test that between um within 48 hours of rupture membranes if they are 30 weeks pregnant or more. And um this kind of acts as a glue between the chorion and the uterus and it is um found in the vagina during labor and a measurement of greater than 50 is consistent with labor. Um So, ASHA Barney has already completed a course of corticosteroids she was put on and has no signs of infection. How would we manage her labor? Yeah. Yep. So, again, really good suggestions in the chat. So, key thing is Julia is with the neonatology team. Um So making sure she's in a hospital that would be suitable for her birth. Um Also um neuroprotection for baby um with um magnesium sulfate. So you'd give a bolus of that and then infuse it. Um but it's important to um monitor the mother for magnesium toxicity. Um at least every four hours that involves checking heart rate, blood pressures, respirate and also deep tendon reflexes. Um If she requires transfer either um to a hospital with a neonatology team or someone that would be more suited for her case. Um Or if a woman um is in the community um and require transfer to a hospital, you can give um tocolysis um which is essentially um stopping and reducing um sorry um contractions. So you can give um Nifedipine, which is our calcium channel blocker or Atan, which is a Oxytocin receptor antagonist. And this is only a short term measure. It shouldn't be used for more than 48 hours. Um should also be um suitable for continuous CTG monitoring. Um And um fetal scalp monitoring and blood sampling are contraindicated in um labor under um 34 plus zero weeks and she may also need intrapartum antibiotics. Um if she's um as the baby is more likely um to develop a neonatal sepsis. So, if there's no um signs of chorioamnionitis, um simply just um benzyl penicillin. But if she is um proven to have an um chorioamnionitis she would also need gentamicin and metroNIDAZOLE added on to that. Ok. So, um in this case, prevention wouldn't be suitable. However, if a woman does um prevent present earlier, um there are ways we can prevent preterm labor. So, um we can offer vaginal progesterone that can either be a gel or a pessary. And this and decreases activity of the myometrium and prevents the cervical remodeling that happens in preparation for delivery. So it helps keep the cervix more um thick and um undilated. And we can offer this if the cervical length is less than 25 millimeters and they are presenting between 16 and 24 weeks gestation. We can also offer cervical cerclage, which is essentially um a stitch in the cervix um which keeps it closed and supports it. Um We'd have to remove that um Either when labor um fully starts or um when the woman reaches term. And again, we can offer that if she is presenting with a cervical leg of less than 25 millimeters between 16 and 24 weeks. But also if a woman has had a previous premature birth or any cervical trauma. So, if she's had a colposcopy or a cone biopsy, um we can also offer this later on as a rescue um cage um and that can be up to 27 plus six weeks. Um And that'll be in cases of cervical dilatation without rupture of membranes. Um So our next case um we have Becca and she's in labor with her first child and the midwife is concerned that she might have a delay in the first stage of labor. Her phom shows that her membranes are still intact. She's five centimeters dilated and is contracting 2 to 3 and 10. So which of these features below would be consistent with a delay in the first stage of labor? OK. Got lots of responses coming in. So the right answer for this one would be a cervical dilatation of one centimeter in four hours. So um just first what our partogram is. Um So that's how we monitor progress in the first stage of labor. So it includes looking at the cervical dilatation, how far the fetal head has descended? Um how well mother's doing? So that's pulse, blood pressure, temperature and urine for her. Um the fetal heart rate, um how frequently the contractions are um state of the membrane. So whether they've um ruptured or not yet. Um and also um whether in the liquor is stained with blood or meconium as well and also any drugs and fluids that um have been given to mom. So, features for a um delay in the first stage of labor would be less than two centimeter, cervical dilatation in four hours and that's in all labors. And if a woman has already given birth before any slowing in the progress of um the first aid would also be considered a delay. Um So in the options we had before, the only one that was suited to a delay would be our one centimeter in four hours. So given that Becker has only dilated this much. Um she's given diagnosis of a delay in the first stage of labor. How would we manage this? Ok. Yeah, really good suggestions. So, um in the case of um Becca her membranes are still intact. So the first thing we'd want to do is um an amniotomy. So that's artificial rupture of membranes. Um And then you'd repeat your vaginal exam after two hours um to see if there's any further dilatation. Um And if you find that after that there is no progress or the membranes had already ruptured by that point, you would then want to transfer to an obstetric L care. So, um referring to the doctors um on the ward and you would also consider Oxytocin at this point. Um So that would be to increase the frequency and the strength of the contractions. Um And then if you find that after um four hours of the Oxytocin, um there's a less than two centimeter dilation, you would want to um consider you um a Cesarean section. Um And obviously that would involve discussions with um the woman, the family and also um all the doctors um and uh midwives involved in her care. So then we have Lucia, she's Gravida two para one and she is currently in labor. She is fully dilated and has been pushing for the last hour. So she's in the um active um second stage of labor and she has not had an epidural. How would we manage this, say? And yeah, perfect some good suggestions there. So, um Lucia has got a delay in the second stage of labor. So um the her active stage has been going on for um over an hour now. So that would be um she's already had a baby before um she falls into the greater than one hour in a multi Paris woman category. Um So, interventions we do first um as she's not had an epidural, she's able to get up and walk around and change positions. So that's what we'd like to try first for her um analgesia. If she's in a lot of pain, she might not um feel like she can push enough, uh might not have enough energy to push um appropriately. Um And also again, um give um Oxytocin to help increase the frequency and strength of those contractions might also want to consider an episiotomy. Um If the cause for delay is that um the um vaginal opening is not um big enough for the baby to come out. Um And again, can consider a Cesarean delivery or um instrumental delivery. Um If that's what the cause for delay is. Ok. So this is our final case. Now we have Sophia and she's 37 plus three weeks. Um gestation and she's in the delivery suite following a spontaneous onset of labor, she's eight centimeters dilated and her labor is progressing normally. Um Her membranes haven't ruptured. So she decides to have um a artificial rupture of membranes and then suddenly the fetal heart rate on the CT D drops. So how would we assess for whether this is an umbilical cord prolapse? Yeah. Yep. So again, really good suggestions in the chat. So, um key features of assessing for an umbilical cord prolapse is um the signs of of fetal distress on CTG. Um suggests that there is a possible umbilical cord prolapse as there was in this case, um any decelerations and fetal bradycardia um suggests there might be occlusion of the cord occurring. Um So that is a concerning feature. Um We can do a vaginal examination. So um the cord either may be visible or palpable on examination and you can also use a speculum to confirm um if you're unable if you're unsure on palpation. And that allows you to visualize the um umbilical cord. So which of these features is a risk factor for um umbilical cord prolapse? Ok. Um Quite a answer is coming in. So the correct answer here is our breach presentation. So going through the risk factors. So a bruise presentation and this allows the cord to be able to pass easily into the pelvis as normally you have baby's head kind of blocking that passage. But um especially if it's a footling breech. Um The cord can really easily pass through that. Um artificial rupture of membranes is a risk factor as well. Um polyhydramnios rather than um oligohydramnios. Um as if you've got more fluid baby can move around more easily and um the cord could quite easily get um in front of the head and prolapse and prematurity as you've got a smaller baby. So again, the cord is um got more room so it can um more easily come out um multiple pregnancies um as well. Um and multiparity as well as um in subsequent deliveries, the fetus is less likely to be engaged at the onset of labor. Um So um the quad would be able to slip around and um prolapse. Um if there is a cephalo cephalopelvic disproportion. So, if baby's head is um significantly smaller than the pelvis, um the chord could sit through there and if they've got an unstable life. So if they keep changing between transversely can breach um presentations as they're moving around quite a lot, the chord would have more opportunity to prolapse. So the um umbilical cord is palpated within the vagina um for Sophia. So how should we manage um this umbilical cord prolapse? Yeah, lots of really, really good suggestions there. So, um in terms of management, so a mi cord prolapse is considered a obstetric emergency. Um And the first thing we'd want to do is reduce pressure on the cord as um this can cause um hypoxia in the fetus and can be fatal. So you can manually lift the presenting part of the baby off the cord. Um And another way to do this as well is to fill the bladder um with around 500 mL of warmth, normal saline. Um and also position the woman in either the left lateral position or the knee chest position, which, which is essentially on four on all fours. And that reduces pressure, um takes the effect of gravity off, um going downwards through the vagina and helps lift baby off. Um be called, um, main thing we want to do is avoid handling the cord and um make sure we keep it warm and moist as if we handle it too much. Um that can cause um vasospasm. And again, that is a risk of um hypoxia for baby. Um You'd want to consider um tool as well. Um If you're not able to deliver baby imminently and that reduces our uterine contractions and um reduces that pressure on the cord. And then in terms of deliveries, it's normally an emergency c section. However, if on examination, you see that the woman is fully dilated, the head is really low. Um and babies can um likely to be born imminently. Um You can either do an instrumental, um you can do an instrumental vaginal delivery and encourage pushing as that might be quicker than um doing ac section. And the main thing here is getting baby out quickly and safely and to reduce the risks of um hypoxia. So that is everything I have for today. Thank you, everyone so much for attending, participating. Um If you could kindly fill in the feedback form, um, it will give you your um attendance certificate and also allow you access to the slides and recordings after. Um Yeah, thank you very much. I'll still be here if anyone has any questions or anything they wanted clarifying. Um So, yeah, thank you very much.