This is online clinical discussion with 6th year medical students in Muta university, given during CORONA quarantine weeks

1. Clinical online group
discussion 2
Hashem Yaseen MBBS, MSc (O&G), JBOG, Arab.BOG, MRCOG

2. Obstetric and Gynecology Department

3. Before we start...

4. Management
of Labour
and Birth
Induction of labour and prolonged pregnancy,
intrapartum management of vaginal multiple pregnancy
,preterm labour or vaginal breech,
Operative delivery, TOLAC
Intrapartum management with medical illness,
or vaginal Stillbirth delivery
Intrapartum emergency situation

5. Background Rules
❏ Keep on time: 10:00 -12:00
❏ 3 sessions = 25 min for each,3 breaks = 5 min for each
❏ Preliminary assessment before each session
❏ Case studies at the end of each session
❏ Attendance is mandatory
❏ Organised interaction = high evaluation mark
❏ Computer is prefered than mobile
❏ Mute on admission
❏ Raise your hand for any question
❏ Prepare your for online assignments

6. Agenda
Introduction, attendance check 5 min
0. Essential revision 10 min
A.Mechanisms of normal labour and birth 25 min 7 students will be evaluated
Break 5 min
B. Assessment of progress in labour 25 min 7 students will be evaluated
Break 5 min
C. Assessment of fetal wellbeing 25 min 7 students will be evaluated
Break 5 min
Feedback, Evaluation 5 min

7. 0. Essential revision

19. A. Mechanisms of normal
labour and birth

20. Preliminary assessment 1
Regarding anatomy of the fetal skull, the bregma is another term to describe the posterior
fontanelle
During normal labour, with the fetal head in an occipito-anterior position, the presenting
diameter is suboccipito-bregmatic
The average presenting diameter in a face presentation (submento-bregmatic) is 11.5 cm
During pregnancy, the uterus increases in size primarily by hypertrophy of the myometrial
smooth muscle cells
Towards the end of pregnancy, progesterone stimulates the production of gap junctions
between myometrial smooth muscle cells

21. Preliminary assessment 1
Signs that the placenta has separated from the uterus during the third stage of labour are: a
small vaginal bleed ('show'), shortening of the cord and a rising up and firming of the uterus
The use of a partogram with a 4 hour action line should be used to monitor progress of labour
in women in spontaneous labour with an uncomplicated singleton pregnancy at term,
because it reduces the likelihood of caesarean section
In normal labour at term, the head normally enters the pelvic brim in an occipito-anterior
position
Hypoxia within the uterus stimulates uterine contractions
Delaying active pushing until the woman has an involuntary urge or the fetal head is visible
on the perineum has been shown to reduce the incidence of forceps delivery and caesarean
section

22. Preliminary assessment 1
This is the widest diameter of the maternal pelvic outlet, measuring on average 12.5 cm: …...
During vaginal examination in labour, palpation of the coronal, frontal and sagittal sutures
allow identification of this structure: …………………………..
With a brow, the presenting diameter, measuring 13.5 cm is this: ……………….
This term describes the measurement from the sacral promontory to under the border of the
pubic symphysis: ………………………………...
This is the area bounded by the anterior and posterior fontanelles and the parietal
eminences: ……………...
Please, Write your answers in
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23. Mechanisms of normal labour
and birth

24. Stages of labour and
delivery - Cervical ripening

25. Stages of labour and delivery -
Descent, flexion, internal rotation

26. Stages of labour and delivery -
Extension

27. Stages of labour and delivery -
Delivery of the head

28. Stages of labour and delivery -
External rotation

29. Stages of labour and delivery -
Delivery of the shoulders

31. Case 1 - normal partogram
A 36-year-old para 1 presents to the maternity unit in
spontaneous labour at term. In her previous pregnancy she
had a ventouse (vacuum) delivery of a 3.32 kg baby. On
admission to the unit she is 3 cm dilated. She is contracting
4 in 10 minutes and her contractions are assessed as
moderate.
Two hours later, the vaginal examination is repeated and
her cervix is 4 cm dilated. She is encouraged to mobilise and
her membranes are left intact. Four hours later she has a
spontaneous rupture of the fetal membranes.
She is now 8 cm dilated. Three hours later she reports an
urge to push – on examination her cervix is fully dilated with
the fetal vertex below the ischial spines, in an
occipito–anterior position. Thirty minutes later she has a
spontaneous vertex delivery.

32. Case 2 - delay in the second stage
A 36-year-old para 0 (primigravida) presents to the
maternity unit in spontaneous labour at term. On admission
to the unit she is cm dilated.
She is contracting 4 in 10 minutes and her contractions are
assessed as moderate. Two hours later the vaginal
examination is repeated and her cervix is cm dilated.
She is encouraged to mobilise and her membranes are left
intact.
Four hours later she has a spontaneous rupture of the fetal
membranes. She is now cm dilated. Three hours later she
is reassessed and is found to be ……….. dilated.

33. You are the resident on call in the labour ward.
What information do you want to know from the
midwife who is attending the woman and who
undertook the vaginal examinations?

34. From the midwife attending the woman, you would want
to know:
● is the woman contracting well?
● does she have adequate pain relief?
● is the assessment of the fetal heart rate reassuring?
● is there any fetal head palpable per abdomen?
● what is the position of the fetal head?
● what is the station of the fetal head?
● is there evidence of caput or moulding?

35. From the midwife attending the woman, you would want
to know:
● is the woman contracting well?
● does she have adequate pain relief?
● is the assessment of the fetal heart rate reassuring?
● is there any fetal head palpable per abdomen?
● what is the position of the fetal head?
● what is the station of the fetal head?
● is there evidence of caput or moulding?
In this case the attending midwife tells you that:
● the fetal head is in an occipito–posterior position with
the presenting part at the ischial spines
● there is no evidence of obstruction (caput or moulding)
● there is one-fifth of fetal head palpable per abdomen
● the woman is contracting well and the decision is
made to repeat the vaginal examination to assess for
progress in two hours' time.

36. Case 2 - outcome
The woman is reassessed two hours later and the clinical findings are
essentially unchanged apart from the presence of some caput and moulding.
An oxytocin infusion is commenced and she is examined an hour later.
The presenting part is now at 0+1 and there is no head palpable per abdomen.
The degree of caput and moulding is greater.
She is taken to the delivery theatre where she is delivered by Kielland's
rotational mid-cavity forceps by an experienced doctor.

37. Case 3 - delay in the first stage of labour
A 36-year-old para 1 presents to the maternity unit in
spontaneous labour at term. In her previous pregnancy, she
had a ventouse (vacuum) delivery of a 3.32 kg baby.
On admission to the unit, she is 3 cm dilated. She is
contracting 4 in 10 minutes and her contractions are
assessed as moderate. Three hours later the vaginal
examination is repeated and her cervix is cm dilated.
She is encouraged to mobilise and her membranes are left
intact. Four hours later she has a spontaneous rupture of
the fetal membranes. She is now 7 cm dilated. Four hours
later she is assessed again and the findings are …….. cm

38. What information do you want to know
from the midwife who is attending the
woman and who undertook the vaginal
examinations?

39. From the attending midwife you would want to know:
● does she have adequate pain relief?
● is the assessment of the fetal heart rate reassuring?
● how much of the fetal head, if any, is palpable per abdomen?
● what is the position of the fetal head?
● what is the station of the fetal head?
● is there evidence of caput or moulding?

40. From the attending midwife you would want to know:
● does she have adequate pain relief?
● is the assessment of the fetal heart rate reassuring?
● how much of the fetal head, if any, is palpable per abdomen?
● what is the position of the fetal head?
● what is the station of the fetal head?
● is there evidence of caput or moulding?
The attending midwife tells you that:
● the woman is contracting well and has
requested an epidural
● the fetal heart rate (CTG) shows no
abnormalities
● there is two-fifths of the fetal head palpable
per abdomen
● the fetal head is in OP, 0 station

41. Case 3 - outcome
The findings are suggestive of cephalo–pelvic
disproportion and the woman is delivered by
caesarean section – she has a male infant, born in
good condition and weighing 4.7 kg

42. Case 4 - The diagnosis of labour
A 17-year-old primigravida presents to the maternity unit at
39 weeks of gestation with painful uterine activity. Her
cervix is 3 cm dilated. She believes she is in labour, is
distressed and requests an epidural. The epidural is sited.
Four hours after admission she is reassessed – her cervix is
still 3 cm dilated, and an artificial rupture of the fetal
membranes is performed. Four hours later her cervix
remains unchanged and an oxytocin infusion is commenced.
Four hours later, her cervix is still 4 cm dilated and the fetal
head is said to be 'poorly applied'. She is tired, upset and
frustrated. She demands a caesarean section and this is
performed.

43. Would you manage her 'labour'
differently, and if so, how?

45. B. Assessment of progress in
labour

46. Preliminary assessment 2
Q. A 32-year-old G2P1 woman at 39+4 weeks of gestation presents for the second time to the labour
ward with periodic abdominal pains. Vital signs were stable and on abdominal examination there were
palpable uterine contractions, and the uterus was not tense or tender. Vaginal examination revealed a 2
cm long cervix that was 3 cm dilated; membranes were intact and the presenting part was at –3 station.
Her urine was normal. What is your proposed diagnosis?
A. Abruption
B. Active phase of labour
C. Latent phase
D. Symphysis pubic dysfunction
E. Urinary tract infection

47. Preliminary assessment 2
Q. the following patient would not be considered to
be making adequate progress in the active phase
of labour:
A. P1, 5 cm at 10:00 and 7 cm at 13:00
B. P0, fully dilated and pushing for 90 minutes
C. P0, 5 cm at 10:00 and 7 cm at 15:00
D. P0, fully dilated and pushing for 60 minutes
E. P1 Fully dilated and pushing for 60 minutes

48. Preliminary assessment 2
Q. During labour, flexion of the fetal head occurs:
A. After internal rotation and prior to descent
B. After descent and immediately prior to explusion
C. Prior to engagement
D. After descent and prior to internal rotation
E. After descent and after external rotation

49. B. Assessment of progress in
labour

50. Active management of labour
Active management of labour includes:
● one-to-one continuous support
● strict definition of established labour
● early routine amniotomy
● routine 2-hourly cervical examination
● oxytocin if labour becomes slow.

51. Delay in labour
Take into account:
● cervical dilatation of <2 cm in 4 hours (primigravida)
● cervical dilatation of <2 cm in 4 hours or a slowing of progress
(multiparous)
● descent and rotation of the fetal head
● changes in strength, duration and frequency of uterine
contractions.

52. Secondary arrest
Secondary arrest occurs when there is no change
in cervical dilatation for more than 2 hours
following a period of normal active phase
dilatation.
Causes of secondary arrest include:
● cephalopelvic disproportion
● malposition or malpresentation
● inadequate or incoordinate uterine action.

55. Case 5
The partograph below that
records the progression of
labour in a multiparous woman.
The partograph shows cervical
dilation in the first eight hours
of labour (recording stops at
the point marked by a green
asterisk).
1) What does the shape of the line tell you about the progression of labour?
2) How would you manage this situation?

56. Case 5 cont;
Despite an increase in
frequency and strength of
uterine contractions following
the administration of
intravenous oxytocin
(Syntocinon®), there was no
further dilatation of the cervix.
Q3) Following administration of intravenous Syntocinon® there was no
increase in cervical dilatation. What would you do now?

57. Morbidity from prolonged labour
includes:
➔ increased risk of instrumental delivery and caesarean section
➔ traumatic delivery resulting in fetal and maternal morbidity, e.g shoulder dystocia
➔ ketosis resulting from dehydration and anaerobic metabolism
➔ third stage complications such as postpartum haemorrhage and retained placenta
➔ uterine rupture
➔ fistula formation resulting from prolonged compression of the anterior vaginal wall
and bladder by the presenting part. This is a particular concern in the developing
world.

58. A 31-year-old primigravida with an uneventful
antenatal course is admitted at 39 weeks of
gestation with painful uterine activity.
What initial assessments should be performed, either by
the midwife or doctor?
Case 6

59. The woman is found to be 4 cm, fully effaced with
5/5 head palpable abdominally. Four hours later
she is very distressed and involuntarily pushing.
The midwife asks you to make a plan of
management for the woman.
What information do you need to know before you can
make a management plan?
Case 6 cont’

60. The maternal and fetal condition are satisfactory.
The uterine activity is irregular and there is clear
liquor draining. There are 4/5 head palpable
abdominally and the midwife thinks the woman is
still 4 cm but is unsure.
What would your management be and what would you
discuss with the woman?
Case 6 cont’

61. Seven hours later she is fully dilated. The position
is OP at the 0 station and there are 2/5 palpable
abdominally. There are 2+ caput and no moulding.
In the absence of fetal distress explain when and why you would
reassess her.
What would you do if, despite active pushing for 1 hour, she was
undelivered?
Case 6 cont’

63. C. Assessment Assessment
of fetal wellbeing

64. Preliminary assessment 3
Variable decelerations are due to cord compression
Early decelerations are a normal feature
Variable decelerations are due to head compression
A baseline of 105 is non-reassuring
A CTG with variable decelerations with >60 beats drop from baseline,
lasting >60 seconds for over 90 minutes is categorised as non-reassuring.

65. Q. The following circumstances, if associated with an abnormal CTG, may lead
to a more rapid development of fetal hypoxia and a poor neonatal outcome.
Preliminary assessment 3
A. Intra uterine infection
B. The presence of thick meconium with scanty fluid
C. The presence of fetal growth restriction
D. In a labour with rapid progress and contractions of six in 10
E. The presence of feto–maternal haemorrhage
F. When there is antepartum haemorrhage

66. Preliminary assessment 3
Intrapartum fetal hypoxia is the most common cause of cerebral
palsy
The Apgar score is the best predictor of neurological outcome
A low Apgar score is always associated with acidosis
There is a good correlation between fetal scalp blood pH and
umbilical arterial pH
A fetal blood sample measuring lactate concentration requires a
smaller sample and is associated with a lower failure rate at
obtaining a fetal blood sample

67. C. Assessment Assessment
of fetal wellbeing

68. Q. What are the antepartum and
intrapartum risk factors for
development of fetal hypoxia?

70. Methodology

71. Intermittent auscultation of the fetal heart

91. Q. In what situations would it
be inappropriate to perform
an FBS?

92. Fetal electrocardiogram (ECG),
STAN

93. Case 7
A 30-year-old at 35 weeks of gestation is admitted
in spontaneous labour. She is fully dilated. On
examination the head is 0/5 palpable per
abdomen, in LOA position with minimal caput and
no moulding. She has made good progress from 3
cm to full dilation in 3 hours. She has been pushing
for 1 hour. You are asked to assess the CTG.
Determine the mnemonic (DR C BRAVADO)
for this trace.

94. What would your next action be?
A. Affix the fetal scalp electrode/ST analysis CTG machine
B. Consider instrumental delivery
C. Start an oxytocin infusion to speed up delivery

95. Case 7 - outcome
After determining the results of the CTG as abnormal, the next action would be to consider
instrumental delivery. This would ensure safe delivery, unless the fetal head is visible or delivery is
imminent.
This would result in a good outcome, with the following measurements:
● A pH = 7.29
● V pH = 7.39
● BE –5.1
● Apgars 9,10.

96. Case 8
A 35-year-old with an IVF
pregnancy is at 42+ weeks of
gestation. She has been induced
into labour and had an oxytocin
drip for the last six hours. You are
asked to assess the CTG at 8 cm
dilation.
Determine the mnemonic (DR C BRAVADO) for this
trace.

97. What would your next action be?
A. Increase oxytocin
B. Reduce oxytocin infusion
C. Stop oxytocin infusion

98. Unfortunately the oxytocin was not
stopped, and the labour was allowed
to continue because the trace was
erroneously interpreted as having
accelerations.
The woman is still 8 cm dilated, head
2/5 palpable per abdomen and left
OP position with caput +++ and
moulding ++. She has made a 2 cm
progress over the last eight hours.
Again, determine the mnemonic (DR
C BRAVADO) for this trace.

99. What would your next action be?
A. Perform FBS
B. Perform a caesarean section
C. Give maternal oxygen at a fast flow rate of 5 l/min
via a face mask
D. Trial of instrumental delivery

100. Case 8 - outcome
After determining the results of the second CTG as abnormal, the next action would be to consider
performing a caesarean section because of the lack of progress with signs of disproportion and worsening
CTG.
Also consider stopping the oxytocin and initiating terbutaline if there is any delay in the transfer to
theatre.
This would result in a good outcome, with the following measurements:
● A pH = 7.19
● V pH = 7.29
● BE –8.1
● Baby outcome: good
● Apgars 5,10.

101. Feedback