( 3 ) Management of labour and Fetal Assessment

Leader: Alanoud Alyousef

Sub-leader: Dana ALdubaib

Done by: Asma Al-Mohizea & Latifah Al-Fahad

Revised by: Hadeel AlSulimani

Doctor's note Team's note Not important Important 431 teamwork

MANAGEMENT  OF  LABOUR  &  FETAL  ASSESSMENT   1  
 
 Objectives:
 

1. Managements  of  the  stages  of  labour.  

2. Pain  relief  in  labour.  
3. Fetal  assessment  (antenatal  &  intra-­‐partum).  
 

Labor  

Defini0on   Managment   Stages   Mechanism   Pain  relief  

Fetal  
Assessment  

Special  
Antenatal   Intrapartum   procedures  

Umbilical  
fetal  movement   Contrac0on   Doppler  
coun0ng   Non-­‐stress  test   stress  test   Ultrasound   CTG  
Velocimetry  

Biophysical  
Profile  

Fetal  Growth  

MANAGEMENT  OF  LABOUR  &  FETAL  ASSESSMENT   2  

 
I: LABOR

1) Definition of labor:
Progressive  cervical  effacement  and  dilatation  resulting  from  regular  uterine  
contractions  that  occur  at  least  every  5  minutes  and  last  30-­‐60  seconds.  If  the  
sentence  is  incomplete  the  definition  is  false.  
 
Braxton  Hicks:  contractions  not  associated  with  cervical  changes.  False  labor.  
Irregular,  painless.  During  the  last  4-­‐8  wks.  Every  20  mins.  Prepare  uterus  
and  cervix.  
 
Lightening:  Descent  of  the  head  into  the  pelvis.  At  least  2  weeks  before  labor  
in  most  primigravid  women.  Noted  as  a  flattening  of  the  upper  abdomen  
and  prominence  of  lower  abdomen.  

Intra-­‐partum:  the  period  from  the  onset  of  labor  to  the  end  of  the  third  stage  
of  labor.  
 

   

MANAGEMENT  OF  LABOUR  &  FETAL  ASSESSMENT   3  

 
 Characteristics  of  normal  labor  

Monitoring  progress  of  labor  

ü In  primi,  effacement  precedes  dilation.  In  multi,  both  occur  simultaneously.    

ü Example:  patient  is  5cm  dilated,  50%  effaced,  station  0.

MANAGEMENT  OF  LABOUR  &  FETAL  ASSESSMENT   4  

 
2) Management of labor:
Initial  assessment:  
History:  
o Onset,  strength,  frequency  of  contractions.  
o Leakage  of  fluid.  Red/green  is  alarming.  
o Vaginal  bleed.  
o Fetal  movement.  Myth:  baby  doesn’t  move  during  labour.  
o Medications.  
o Last  oral  intake.  Patient  is  NPO  just  in  case  she  goes  for  a  c-­‐section.  
o Review  of  past  obstetric  history,  prenatal  lab  tests,  gestational  age,  
parity,  size  of  previous  infants,  any  antenatal  complications.  

3) Stages of labor:
 
1)  First  stage  of  labor:  
Starts:  from  onset  of  labor  pain  until  full  dilatation  of  the  cervix.  
Maternal  system:    HR  é10-­‐15bpm  and  systolic  é10mmhg  during  
contractions.      
Fetal  system:  as  long  as  membrane  is  intact,  no  adverse  effects  but  FHR  slows  
by  10-­‐20  bpm  with  contractions.  
 
2  phases:  
o Latent  phase:  Up  to  3cm  dilation  of  cervix.  Duration  influenced  by  
parity,  stress,  sedation,..etc.  
o Active  phase:  More  rapid  dilation.  
 
Management:    
I. Informed  consent  on  management  of  L&D.  Illegal  to  ask  for  consent  with  
patient  in  distress.  
II. Maternal  position:  lateral  recumbent.  Avoid  supine  hypotension.  
III. Partogram  (monitors  progress  of  labor).  
IV. IV  fluids  and  avoid  oral  intake.  
V. Maternal  vital  signs  every  1-­‐2  hrs.  
VI. Analgesia.  
VII. CTG.  
VIII. Vaginal  examination  for  cervical  dilation  and  position  in  active  phase  
every  2  hours.  

MANAGEMENT  OF  LABOUR  &  FETAL  ASSESSMENT   5  

 
 IX. Amniotic  membrane  status  and  amniotic  fluid  colour.  
ü Vaginal  exam  should  be  done  sparingly  in  latent  phase  to  avoid  intrauterine  
infections.  In  active  phase  every  2  hours  to  assess  progress.  
ü Amniotomy:  artificial  rupture  of  membranes.  Risk  of  chorioamnionitis,  cord  
compression  or  prolapse.  
 
2)  Second  stage  of  labor:  
Starts:  from  full  dilatation  of  cervix  until  delivery  of  neonate.  
Mother  has  a  desire  to  bear  down  with  each  contraction.  This  
abdominal  pressure  +  contractions  expel  the  fetus.  
 
Management:    
I. Vaginal  examination  every  30  mins.  Particular  
attention  to:  
o Descent  and  flexion  of  presenting  part.  
o Extent  of  internal  rotation.  
o Development  of  molding  or  caput.  
II. Maternal  position:  any  comfortable  position  for  bearing  down.  
III. Bearing  down  -­‐Holds  her  breath  and  bears  down  with  expulsive  force.  -­‐  
with  each  contraction  -­‐To  avoid  tiring  the  mother.  Especially  important  
with  patients  on  regional  anesthesia  where  reflex  sensations  are  
impaired.  -­‐  
IV. Delivery  of  the  fetal  head  -­‐manual  perineal  support.  
V. Fetal  airway  clearance.  
VI. Umbilical  cord  clamping.  
VII. Place  infant  under  warmer.  
 
ü Molding:  alteration  of  the  relationship  of  the  fetal  cranial  bones  to  each  other  as  
a  result  of  the  compressive  forces  exerted  by  the  bony  pelvis.  
ü Caput:  localized  edematous  swelling  of  the  scalp  caused  by  pressure  of  the  
cervix  on  the  presenting  portion  of  the  fetal  head.  Gives  false  impression  of  
fetal  descent.  
ü Crowning:  When  the  largest  diameter  of  the  fetal  head  is  encircled  by  the  vulvar  
ring.  
ü Episiotomy:  Incision  the  perineum  after  crowning  (because  if  you  do  it  before  
and  then  decided  to  go  for  a  c-­‐section  you’ve  made  an  unnecessary  
intervention  +  easier  with  perineum  stretched  by  the  head  of  the  fetus)  to  aid  
delivery  and  avoid  laceration  of  the  perineum.  A  clean  cut  is  easier  to  treat  
than  a  laceration.  Right/left  mediolateral  and  central.  

MANAGEMENT  OF  LABOUR  &  FETAL  ASSESSMENT   6  

 
ü Perineal  laceration:  
I. First  degree:  involving  the  vaginal  epithelium/  perineal  skin.  
II. Second  degree:  sub-­‐epithelial  tissues  of  the  vagina  or  perineum  ±  
perineal  body.  
III. Third  degree:  anal  sphincter.  
IV. Fourth  degree:  involving  rectal  mucosa.    
 
3)  Third  stage  of  labor:  
Interval  between  delivery  of  the  infant  and  delivery  of  placenta.  
 
Signs  of  placental  separation:  
I. Fresh  blood  from  vagina.  
II. Umbilical  cord  lengthens  outside  the  vagina.  
III. Fundus  of  the  uterus  rises  up.  
IV. Uterus  becomes  firm  and  globular.  
ü Placenta  should  be  examined  to  ensure  that  it  is  complete.  
ü Blood  loss  should  be  estimated.  
 
Management:    
I. Cervix  and  vagina  should  be  thoroughly  inspected  for  lacerations  and  
surgical  repair  performed  if  necessary.  
II. Uterine  massage/oxytocin  to  hasten  contractions,  which  reduces  
bleeding.  
III. Best  time  to  repair  a  laceration  is  at  the  time  of  the  injury.  
 
4)  Fourth  stage  of  labor:  
ü Hour  immediately  following  delivery.  
ü Needs  close  observation  of:  
o Blood  pressure  
o Pulse  rate  
o Uterine  blood  loss  
 
ü Watch  for  postpartum  hemorrhage.    
ü Increase  in  pulse  rate,  if  out  of  proportion  with  any  decrease  in  BP  may  indicate  
hypovolemia.  
ü PPH  commonly  occurs  at  this  time  usually  because  of  relaxation  of  the  uterus,  
retained  placental  fragments  or  unrepaired  lacerations.  

MANAGEMENT  OF  LABOUR  &  FETAL  ASSESSMENT   7  

 
 4) Mechanism of labor:
Six  movements  of  the  baby  enable  it  to  adapt  to  the  
maternal  pelvis:  descent,  flexion,  internal  
rotation,  extension,  external  rotation,  and  
expulsion.  The  fetus  itself  does  not  “squirm”  into  
these  movements,  remember;  a  demised  fetus  will  
go  through  the  cardinal  movements  of  labor  the  
same  way  a  live  fetus  would.    

 
5) Pain relief in labor:
I. Nonpharmacologic  methods:  
o Back  massage  
o Accupuncture  (decreases  pain  in  most  studies)  
o Hynosis  
o Breathing  exercises  
o Education  and  psychoprophylaxix  (Lamaze  method)  
 
II. Pharmacologic  methods:  
Narcotic  analgesics:  
o Cross  placenta  -­‐  cause  fetal  (respiratory  depression).  Gives  a  flat  trace.  
o Nitrous  oxide,  Pethidine.  
Epidural  analgesia:  
o Most  common  form  of  neuraxial  analgesia  (60%)  
o The  most  effective    
o Contraindicated  if  coagulopathy,  infection  at  needle  site,  severe  
hypovolemia.  
o ADRs:  hypotension,  headache,  impaired  ability  to  (push  =  prolonged  
2nd  stage)  
o Pudendal  block:  for  S2-­‐S4  for  2nd  stage  of  labor/instrumental  delivery.  
ü Parenteral  narcotics  have  very  limited  efficacy  for  relief  of  labor  pain.  They  
work  best  in  the  early  stage  when  the  pain  is  primarily  visceral  and  less  intense.    

   

MANAGEMENT  OF  LABOUR  &  FETAL  ASSESSMENT   8  

 
II: Fetal Assessment
Aims:  
1. Ensure  fetal  wellbeing  (Identify  patients  at  risk  of  fetal  asphyxia)  
Screening  for  high  risk  pregnancy:  History
*  Age   *Past  medical  conditions  e.g  
*Social  burden   D.M,  HTN  
*Smoking   *Past  Obstetric  history  
 
What  are  the  complications  associated  with  antepartum  asphyxia?  

§Stillbirth  (Mortality)   § Intracranial  haemorrhage  

§Metabolic  acidosis  at  birth     § Seizures  
§Hypoxic  renal  damage   § Cerebral  palsy  
§Necrotizing  enterocolitis  
 
2. To  prevent  prenatal  mortality  &  morbidity  

Conditions  associated  with  increased  perinatal  morbidity/mortality:  

§ Small  for  gestational  age  fetus   § Pre-­‐pregnancy  diabetes  

§ Decreased  fetal  movement   § Insulin  requiring  gestational  
§ Postdates  pregnancy  (>294   diabetes  
days)   § Preterm  premature  rupture  
§ Pre-­‐eclampsia/chronic   of  membranes  
hypertension   § Chronic  (stable)  abruptio

When to start fetal Assessment antenatally?

Risk  assessed  individually:  
1. For  D.M.  fetal  assessment:  should  start  from  32  weeks  onward  if  
uncomplicated.  If  it’s  complicated  D.M.  start  at  24  weeks  onward.  
2. For  Post-­‐date  pregnancy:  start  at  40  weeks.  
3. For  any  patient  with  decrease  fetal  movement:  start  immediately.  
Then  once  or  twice  weekly.  
 
 

MANAGEMENT  OF  LABOUR  &  FETAL  ASSESSMENT   9  

 
Antenatal Fetal Assessment
1) Fetal movement counting
I. Cardiff  technique:  
This  is  done  in  the  morning.  Patient  should  calculate  how  long  it  takes  to  have  
10  fetal  movements.  10  movements  should  be  appreciated  in  12  hours.  

II. Sadovsky  technique:  

For  one  hour  after  meal  the  woman  should  lie  down  and  concentrate  on  fetal  
movement.  4  movements  should  be  felt  in  one  hour.  

ü If  not,  she  should  count  for  another  hour.  If  after  2  hours  four  
movements  are  not  felt,  she  should  have  fetal  monitoring.    
 
2) Non-Stress Test (NST) See  CTG  on  
page  14  

Done  using  the  Cardiotocometry  (CTG)  with  the  patient  in  left  lateral  position,  
and  it  is  recorded  for  20  minutes.  The  mother  reports  each  fetal  movement,  
and  the  effect  of  its  movement  on  its  heart  rate  is  recorded.  

ü The  positive  predictive  value  of  NST  to  predict  fetal  acidosis  at  birth  is  
44%.  

Interpretation:  The  base  line  -­‐for  fetal  heart  rate-­‐  is  120-­‐160  beats/minute.  

1. Reactive:    At  least  two  accelerations  from  base  line  of  15  bpm,  for  at  least  
15  sec,  within  20  minutes.    This  is  the  normal.  
2. Non-­‐reactive:  No  acceleration  after  20  minutes  è  proceed  for  another  20  
minutes.  è  If  non-­‐reactive  in  40  minutes,  proceed  for  contraction  stress  
test  or  biophysical  profile.  

  Reactive  NST:  

Arrow  heads:  accelerations.  

Fetal  m ovements.  

MANAGEMENT  OF  LABOUR  &  FETAL  ASSESSMENT   1

  0  
 3) Contraction stress test
Fetal  response  to  induced  stress  of  uterine  contraction  and  relative  placental  
insufficiency.  Contraction  is  initiated  by  nipple  stimulation  or  by  oxytocin  I.V.  

ü Should  not  be  used  in  patients  at  risk  of  preterm  labor  or  placenta  previa.  
ü Should  be  proceeded  by  NST.  
See  CTG  on  
ü Rarely  done  nowadays.   page  14  

Interpretation:    

The  objective  is  to  induce  3  contractions  in  10  minutes.  If  late  deceleration  
occurs  è  positive  CST  (abnormal,  the  baby  should  be  delivered  immediately).  

4) Ultrasound
o Assessment  of  growth:   U/S  

I. Biometry:  
Assessment  of   Biophysical  
a. Biparietal  diameter  (BPD).   growth   promile    
b. Abdominal  Circumference  (AC).  
c. Femur  Length  (FL).   Biometry  
d. Head  Circumference  (HC).  
  Amniotic  
BPD   AC   FL   Oluid  
 
 
Placental  
  localization  
 

 
 
 
Growth  
 
Chart  
 
 
 

MANAGEMENT  OF  LABOUR  &  FETAL  ASSESSMENT   1

  1  
 II. Amniotic  fluid  
III. Placental  localization  
 
 
o Biophysical  Profile:  
No  zero  score.  Starts  from  1-­‐10.

Biophysical  Variable Normal  (score=2) Abnormal  (score=  0)

Fetal  breathing   1  episode  FBM  of  at  least  30  s   Absent  FBM  or  no  episode  >30  s  in  
movements duration  in  30  min 30  min
Fetal  movements 3  discrete  body/limb   2  or  fewer  body/limb  movements  
movements  in  30  min in  30  min
Fetal  tone 1  episode  of  active  extension   Either  slow  extension  with  return  
with  return  to  flexion  of  fetal   to  partial  flexion  or  movement  of  
limb(s)  or  trunk.  Opening  and   limb  in  full  extension  Absent  fetal  
closing  of  the  hand  considered   movement
normal  tone
Amniotic  fluid   1  pocket  of  AF  that  measures   Either  no  AF  pockets  or  a  pocket<2  
volume at  least  2  cm  in  2   cm  in  2  perpendicular  planes
perpendicular  planes
Non stress test reactive nonreactive

MANAGEMENT  OF  LABOUR  &  FETAL  ASSESSMENT   1

  2  
 5) Umbilical Doppler Velocimetry
Use  a  free  loop  of  umbilical  cord  to  measure  blood  flow  in  it.  

Indication:  

ü IUGR   ü D.M.  
ü PET   ü Any  high  risk  pregnancy
Management  of  umbilical  artery  Doppler  results:  
Depends  on:  

ü Fetal  maturity    
ü Gestational  age  
ü Obstetric  history  

 
Normal  flow:  repeat   High-­‐resistance  
in  2    weeks  if  indicated.   index:  repeat  in  few  
days  or  deliver.  
 
 
  flow  or  
Reverse  
absent  end  diastolic  
flow:    Immediate  
delivery  
   

MANAGEMENT  OF  LABOUR  &  FETAL  ASSESSMENT   1

  3  
 Note:  in  the  original  lecture,  CTG  
Intrapartum Assessment was  only  listed  under  NST  and  
not  as  an  intrapartum  assessment  

Methods of monitoring fetal heart method.  This  section  was  added  

to  meet  the  objectives  of  the  
lecture.  Grey-­‐colored  text  was  
1. Auscultation  of  fetal  heart   taken  from  Hecker  and  Moore’s  
and  therefore,  is  not  important.  
2. Continuous  Electronic  Fetal  Monitoring    
Done  by  cardiotocometry  (CTG).  There  are  two  ways  to  monitor  fetal  heart  rate  and  
uterine  contractions  (FHR-­‐UC),  (1)  external  transducer  and  (2)  internal  electrode  placed  on  the  
fetal  scalp.  It  is  important  to  monitor  fetal  heart  rate  because,  normally,  with  each  contraction,  the  
blood  flow  to  the  fetus  decreases.  Most  fetuses  can  tolerate  that  decrease,  but  those  who  have  
marginal  oxygen  supply  will  develop  hypoxia.    

Interpretation:  
§ Normal  Baseline  FHR  110–160  bpm  
§ Moderate  bradycardia  100–109  bpm  
Abnormal  bradycardia  <  100  bpm  
§ Moderate  tachycardia  161–180  bpm  
Abnormal  tachycardia  >  180  bpm  
Tachycardia  can  lead  to  hypoxia.  
Common  causes:  
-­‐ Chorioamnionitis   -­‐ Sepsis  
-­‐ Maternal  fever   -­‐ Heart  failure  
-­‐ B-­‐Mimetic  drugs   -­‐ Arrhythmias
-­‐ Fetal  anaemia  
Periodic  Fetal  Heart  Rate  Changes:  
Changes  of  fetal  heart  rate  related  to  maternal  contractions.  

1. No  change.  
2. Acceleration:  increases  with  uterine  contractions.  è  Normal  response  
3. Deceleration:  decreases  with  uterine  contractions.  There  are  4  patterns:  
I. Early  è  fetal  head  compression.  (Not  thought  to  be  associated  with  fetal  
distress)  it  is  considered  ok.  
II. Late  è  Uteroplacental  insufficiency.    Alarming!  
III. Variable  è  Cord  compression  or  primary  CNS  dysfunction.  Very  
alarming!  
IV. Mixed.  

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Special Procedures
 
1) Assessment for Chromosomal Abnormality  
General  Facts:  

ü The  general  incidence  of  Down  is  1:1000.  The  risk  by  maternal  age:  

o At  the  age  of  35  è  1:365  

o At  the  age  of  40è1:109  
o At  the  age  of  45  è  1:32  

ü Risk  of  recurrence  is  1%  (0.75%  higher  than  maternal  age  related  risk).  

ü In  case  of  parental  aneuploidy  è30%  risk  of  Trisomy  in  offspring.  

Methods  available  for  screening  for  chromosomal  abnormality:  

I. Maternal  age.   Triple  test:  is  a  second  

II. Biochemical:   trimester  screening  test  used  to  
identify  those  who  should  b e  
a. 1st  trimester  è  PAPPA  and  β HCG.   offered  a  diagnostic  test  to  
identify  fetal  aneuploidy.  It  
b. 2nd  trimester  è  Triple  and  quadruple  Test.   measures:  (1)  αFP,  (2)  βHCG.  
And  (3)  Estriol.  
III. Fetal  DNA.  
Quadruple  test:  when  dimeric  
IV. Ultrasound:   inhibin  A  (DIA)  is  added.  

Nuchal  translucency  (N.T):  

ü Skin  fold  thickness  behind  the  fetal  cervical  spine.  
ü Timing:      (11-­‐13  +6  days)  weeks  of  pregnancy.  
ü Will  be  positive  in  75-­‐80%  of  trisomy  21.  
ü Can  be  positive  in  5-­‐10%  of  normal  karyotype  (but  could  be  
associated  with  cardiac  defects,  diaphragmatic  hernia,  
Exomphalos).  
   

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2) Amniocentesis
Obtaining  a  sample  of  amniotic  fluid  
surrounding  the  fetus  during  pregnancy.    

ü Diagnostic  (at  11-­‐  20  weeks)    

ü Therapeutic  (at  any  time)  

Indications:    

I. Genetic  amniocentesis:  
§ Chromosomal  analysis  (Down  syndrome)  
§ Spina  bifida  (Alpha  fetoprotein)  
§ Inherited  diseases  (muscular  dystrophy)  
§ Bilirubin  level  in  isoimmunization  
§ Fetal  lung  maturation  (L/S  ratio)  è  greater  than  2  =  minimal  distress.  
II. Therapeutic  amniocentesis:  

§ Reduce  maternal  stress  in  polyhydramnios.  

§ Mainly  in  twin-­‐twin  transfusion  or  if  abnormality  associated.  

3) Chorionic villus sampling

Sampling  is  done  to  the  cyto-­‐trophoblasts  between  10-­‐14  weeks  of  
pregnancy.  (Earlier  diagnosis  compared  to  amniocentesis).  

 
 

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 Summary
 
ü Progressive  cervical  effacement  and  dilatation  resulting  from  regular  uterine  
contractions  that  occur  at  least  every  5  minutes  and  last  30-­‐60  seconds.    
ü Duration  of  labor  is  longer  in  primi  para.  
ü Dilation  is  recorded  in  centimeters;  effacement  in  percentages.  
ü Management  of  labor  includes  proper  history  taking  and  physical  examination.  
ü The  so-­‐called  “cardinal”  movements  of  labor  are  created  by  vector  forces  on  the  
fetus  from  the  uterine  contractions,  pelvic  floor,  and  bony  pelvic  structures.  
ü Lumbar  epidural  is  the  most  common  form  of  neuraxial  analgesia  used  for  labor  
pain.    
ü Postpartum  hemorrhage  most  commonly  occurs  the  hour  immediately  following  
delivery.  This  requires  close  observation  of  the  patient.
ü  Early  fetal  assessment  reduces  morbidity  and  mortality.  
ü Fetal  assessment:  
1. Kick  count:  
§ Cardiff  technique:  10  movements  in  12  hours.  
§ Sadovsky  technique:  4  movements  in  one  hour.  
2. NST:  
§ Reactive:  2  acceleration  of  15  bpm  for  15  sec  within  20  min.  
§ Non-­‐reactive:  no  acceleration  within  40  min.  
3. Contraction  stress  test:  
§ Early  deceleration.  è  OK.  
§ Late  deceleration.  è  Not  OK.  
§ Variable  deceleration.  è  Very  not  OK.  
4. Ultrasound:  
§ Biometry:  BPD,  HC,  AC,  and  FL.  
Fetal  growth  
§ Amniotic  fluid.  
§ Placental  localization.  
§ Biophysical  profile:  breathing,  movement,  tone,  AFI,  and  NST.  
5. Doppler:  umbilical  artery  flow  assessment  (normal,  high-­‐resistance,  absent,  and  
revered  flow).  
6. CTG:  normal  FHR=  120-­‐160  bpm.  
7. Nuchal  translucency  is  skin  fold  thickness  behind  the  fetal  cervical  spine.  Done  
around  11-­‐13  weeks  to  diagnose  trisomy  21  and  other  abnormalities.  
8. Amniocentesis  can  be  diagnostic  for  genetic  abnormalities  and  therapeutic  for  
polyhydroamnios  or  TTNS.   MANAGEMENT  OF  LABOUR  &  FETAL  ASSESSMENT   1
 
9. Chorionic  villus  sampling  provides  early  diagnosis  for  genetic  disorders.   7  
 MCQ's:  
Question  1:  A  primigravid  patient  comes  to  the  hospital  with  
spontaneous  rupture  of  membranes  at  term  and  is  found  to  be  6  cm  
dilated  and  is  contracting  every  5  minutes.  Her  group  B  streptococcus  
(GBS)  culture  is  negative.  She  is  admitted  with  a  plan  for  expectant  
management  of  labor.  Three  hours  later,  her  exam  is  unchanged.  At  this  
point,  what  is  the  next  best  step  in  management?  
A. Place  an  intrauterine  pressure  catheter  and  begin  oxytocin  
augmentation  (IUPC)  
B. Begin  oxytocin  without  IUPC  
C. Continue  expectant  management  
D. Cesarean  delivery  for  arrest  of  dilation  
 
Correct  answer  (A):  
This  patient  may  not  have  contractions  adequate  enough  to  continue  progress  
in  labor,  or  the  fetus  may  be  too  large  for  her  pelvis.  The  only  way  to  
distinguish  the  cause  of  her  dystocia  is  to  accurately  measure  the  strength  of  
her  contractions  with  an  IUPC.  One  can  safely  titrate  oxytocin  to  achieve  
adequate  contractions  with  the  use  of  an  IUPC.  
The  possibility  of  inadequate  contraction  strength  despite  oxytocin  
augmentation  cannot  be  raised  if  the  strength  of  the  contraction  is  unknown.  
Expectant  management  would  be  inappropriate  in  this  patient,  who  should  be  
dilating  a  minimum  of  1  cm/hour  (in  keeping  with  the  normal  labor  curve).  
 
 Question  2:  A  patient  with  a  history  of  juvenile  rheumatoid  arthritis  has  
had  the  disease  well  controlled  with  prednisone  20  mg  PO  daily  
throughout  her  pregnancy.  She  presents  at  term  in  labor  and  delivers  
precipitously  with  normal  blood  loss.  The  patient  was  given  10  mg  of  IM  
oxytocin  to  maintain  uterine  tone  and  was  transferred  to  the  
postpartum  unit.  The  next  day,  the  patient  complains  of  headache,  
nausea,  intense  abdominal  cramps,  and  extreme  fatigue.  The  nurse  is  
concerned  because  the  patient  seems  to  be  confused  and  her  blood  
pressures  (BPs)  are  low  (systolic  pressures  in  the  70s  and  diastolic  
pressures  in  the  40s).  What  is  her  most  likely  diagnosis?  
A. Conn  Syndrome  
B. Adrenal  Crisis  
C. Sheehan  Syndrome  
D. Water  intoxication  
MANAGEMENT  OF  LABOUR  &  FETAL  ASSESSMENT   1
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 E. Normal  postpartum  course  
 
Correct  answer  (B):  
Acute  adrenocortical  insufficiency  can  result  after  the  sudden  withdrawal  of  
steroids  in  a  patient  who  had  previously  been  on  an  oral  moderate-­‐  to  high-­‐
dose  steroid  treatment  in  pregnancy  for  more  than  2  weeks.  The  patient  may  
present  with  headache,  abdominal  pain,  diarrhea,  fatigue,  altered  mental  
status,  and  hypotension.  Prevention  involves  the  use  of  “stress-­‐dose”  steroids  
intrapartum  and  post  partum.  
Although  in  the  postpartum  period  patients  may  experience  fatigue,  pelvic  
cramps  (especially  with  breast  feeding),  and  low  BPs,  confusion  is  not  normal.  
The  constellation  of  the  above  symptoms  in  a  patient  who  has  been  on  long-­‐
term  steroids  warrants  investigation.  This  patient  should  be  evaluated  and  
treated  immediately  and  her  symptoms  should  not  be  regarded  as  part  of  a  
normal  postpartum  course.  
 
Question  3:  Which  of  the  following  choices  lists  the  six  movements  of  the  
mechanism  of  labor  in  the  correct  order?  
A. Descent,  extension,  internal  rotation,  flexion,  external  rotation,  
expulsion  
B. Descent,  internal  rotation,  flexion,  extension,  external  rotation,  
expulsion  
C. Descent,  flexion,  internal  rotation,  extension,  external  rotation,  
expulsion  
D. Descent,  internal  rotation,  flexion,  external  rotation,  extension,  
expulsion  
 
Correct  answer  (C):  
Acute  adrenocortical    

 
Question  4:  A  32-­‐year-­‐old  poorly  controlled  diabetic  G2P1  is  undergoing  
amniocentesis  a  t  38  weeks  for  fetal  lung  maturity  prior  to  having  a  
repeat  cesarean  section.  Which  of  the  following  laboratory  tests  results  
on  the  amniotic  fluid  would  best  indicate  that  the  fetal  lungs  are  mature?  
 
 
 
 

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Correct  answer  (E):  
 
Question  5:  A  26-­‐year-­‐old  G1P0  patient  at  34  weeks  gestation  is  being  
evaluated  with  Doppler  ultra  sound  studies  of  the  fetal  umbilical  
arteries.  The  patient  is  a  healthy  smoker.  Her  fetus  has  shown  evidence  
of  intra  uteri  ne  growth  restriction  (IUGR)  on  previous  ultra  sound.  The  
Doppler  currently  show  that  the  systolic  to  diastolic  ratio  (S/D)  in  the  
umbilical  arteries  is  much  higher  than  it  was  on  her  last  ultra  sound  3  
weeks  ago  and  there  is  now  reverse  diastolic  flow.  Which  of  the  
following  i  s  correct  information  to  share  with  the  patient?  

 
Correct  answer  (E):  
 
 
Question  6:    

 
Correct  answer  (E):  
 
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MANAGEMENT  OF  LABOUR  &  FETAL  ASSESSMENT   2

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