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TN Obstetrics > 10. Normal Labour and Delivery > Flashcards

10. Normal Labour and Delivery Flashcards

1
Q

Define: True labour (3)

A
  • regular, painful contractions of increasing intensity associated
  • with progressive dilatation and effacement of cervix
  • and descent of presenting part, or progression of station
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2
Q

Differentiate preterm, term and post-term (3)

A
  • preterm (≥20 to ≤36+6 wk GA)
  • term (37-41+6 wk GA)
  • postterm (≥42 wk GA)
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3
Q

Describe: False labour (6)

A
  • (Braxton-Hicks contractions)
  • irregular contractions
  • with unchanged intensity and long intervals
  • occur throughout pregnancy
  • and not associated with any cervical dilatation, effacement, or descent
  • often relieved by rest or sedation
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4
Q

Define: Fetal lie (1)

A

orientation of the long axis of the fetus with respect to the long axis of the uterus (longitudinal, transverse, and oblique)

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5
Q

Define: Fetal presentation (1)

A
  • Fetal body part closest to the birth canal
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6
Q

Name different fatal presentations (5)

A
  • breech (complete, frank, and incomplete)
  • cephalic (vertex/occiput, face, or brow)
  • transverse (shoulder)
  • compound (fetal extremity prolapses along with presenting part)
  • all except vertex are considered malpresentations
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7
Q

Describe: Fetal position (1)

A

position of presenting part of the fetus relative to the maternal pelvis

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8
Q

Name: Fetal positions (3)

A
  • OA: most common presentation (“normal”) – left OA most common
  • OP: most rotate spontaneously to OA; may cause prolonged second stage of labour
  • OT: leads to arrest of dilatation
    • normally, fetal head enters maternal pelvis and engages in OT position
    • subsequently rotates to OA position (or OP in a small percentage of cases)
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9
Q

Define: Attitude (2)

A

flexion/extension of fetal head relative to shoulders

  • brow presentation: head partially extended (requires C/S)
  • face presentation: head fully extended
    • mentum posterior always requires C/S, mentum anterior can deliver vaginally
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10
Q

Define: Station (3)

A

position of presenting bony part relative to ischial spines – determined by vaginal exam

  • at ischial spines = station 0 = engaged
  • –5 to –1 cm above ischial spines
  • +1 to +5 cm below ischial spines
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11
Q

Define: Asynclitism (2)

A
  • alignment of the sagittal suture relative to the axis of the birth canal
  • lateral tilt seen with either anterior or posterior asynclitism and may impact descent
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12
Q

Name the stages of labour (4)

A
  • First Stage of Labour (0 – 10 cm cervical dilation)
  • Second Stage of Labour (10 cm dilation – delivery of the baby)
  • Third Stage of Labour (delivery of the baby – delivery of the placenta)
  • Fourth Stage of Labour (First hour post-partum)
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13
Q

Name phases of first stage of labour (2)

A
  • Latent phase
  • Active phase
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14
Q

Describe latent phase of first stage of labour (2)

A
  • uterine contractions typically infrequent and irregular
  • slow cervical dilatation (usually to 4 cm) and effacement
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15
Q

Describe active phase of first stage of labour (4)

A
  • rapid cervical dilatation to full dilatation (nulliparous ≥1.0 cm/h, multiparous ≥1.2 cm/h)
  • phase of maximum slope on cervical dilatation curve
  • painful, regular contractions q2-3min, lasting 45-60 s
  • contractions strongest at fundus
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16
Q

Describe: Second stage of labour (4)

A
  • from full dilatation to delivery of the baby; duration varies based on parity, contraction quality, and type of analgesia
  • mother feels a desire to bear down and push with each contraction
  • women may choose a comfortable position that enhances pushing efforts and delivery
    • upright (semi-sitting, squatting) and left lateral decubitus position LLDP are supported in the literature
  • progress measured by descent
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17
Q

Describe: Third Stage of Labour (5)

A
  • from baby’s birth to separation and expulsion of the placenta
  • can last up to 30 min before intervention is indicated
  • demonstrated by gush of fresh blood, umbilical cord lengthening, uterine fundus changing shape (firm and globular), and rising upward
  • active management: start oxytocin IV drip, or give 10 IU IM or 5 mg IV push, after delivery of anterior shoulder in anticipation of placental delivery, otherwise give after delivery of placenta
  • routine oxytocin administration in third stage of labour can reduce the risk of postpartum hemorrhage PPH by >40%
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18
Q

Describe: Fourth Stage of Labour (5)

A
  • first postpartum hour
  • monitor vital signs and bleeding, repair lacerations
  • ensure uterus is contracted (palpate uterus and monitor uterine bleeding)
  • inspect placenta for completeness and umbilical cord for presence of 2 arteries and 1 vein
  • 3rd and 4th stages of labour most dangerous to the mother (i.e. hemorrhage)
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19
Q

Describe time of course of normal labour (Nulliparous vs Multiparous)

  • First
  • Second
  • Third
A
  • First: 6-18 h vs 2-10 h
  • Second: 30 min-3 h vs 5-30 min
  • Third: 5-30 min vs 5-30 min

*without epidural

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20
Q

Name: Signs of Placental Separation (4)

A
  • Gush of blood
  • Lengthening of cord
  • Uterus becomes globular
  • Fundus rises
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21
Q

Name: The Cardinal Movements of the Fetus During (8)

A
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22
Q

Name: Non-Pharmacologic Pain Relief Techniques (11)

A
  • reduction of painful stimuli
    • maternal movement, position change, counter-pressure, and abdominal compression
  • activation of peripheral sensory receptors
    • superficial heat and cold
    • immersion in water during labour
    • touch and massage, acupuncture, and acupressure
    • transcutaneous electrical nerve stimulation TENS
    • intradermal injection of sterile water
    • aromatherapy
  • enhancement of descending inhibitory pathways
    • attention focusing and distraction
    • hypnosis
    • music and audio analgesia
    • biofeedback
23
Q

Name Pharmacologic Methods for pain relief (5)

A
  • nitrous oxide (e.g. self-administered Entonox®)
  • narcotics (usually combined with anti-emetic)
  • pudendal nerve block
  • perineal infiltration with local anesthetic
  • regional anesthesia (epidural block, combined spinal-epidural, and spinal)
24
Q

Name techniques for Fetal Monitoring in Labour (5)

A
  • Vaginal Exam
  • Intrapartum Fetal Monitoring
  • Electronic FHR Monitoring
    • Baseline FHR
    • Variability
    • Periodicity
  • Fetal Scalp Blood Sampling
  • Fetal Oxygenation
25
Q

In Fetal Monitoring in Labour, describe: Vaginal Exam (5)

A
  • membrane status, as indicated by amniotic fluid (clear, pink, bloody, and meconium)
  • cervical effacement (thinning), dilatation, consistency, position, and application
  • fetal presenting part, position, and station
  • bony pelvis size and shape
  • monitor progress of labour at regular intervals and document in a partogram
26
Q

In Fetal Monitoring in Labour, describe: Intrapartum Fetal Monitoring (2)

A
  • intermittent fetal auscultation with Doppler device q15-30min for 1 min in first stage active phase following a contraction, q5min during second stage when pushing has begun
  • fetal scalp sampling should be used in conjunction with electronic FHR monitoring and contraction monitoring (CTG) to resolve the interpretation of abnormal or atypical partterns
27
Q

Continuous electronic FHR monitoring reserved for when? (6)

A
  • abnormal auscultation
  • prolonged labour
  • labour which is induced or augmented
  • meconium present
  • multiple gestation/fetal complication
  • and concerns about the fetus tolerating labour
28
Q

Use of continuous electronic monitoring when used routinely in all patients (i.e. no risk factors) shown to lead to what? (1)

A

higher intervention rates and no improvement in outcome for the neonate

29
Q

Name techniques for continuous monitoring (2)

A
  • external (Doppler)
  • internal (fetal scalp electrode) monitoring
30
Q

Describe: Electronic FHR Monitoring (2)

A
  • FHR measured by Doppler; contractions measured by tocometer
  • described in terms of baseline FHR, variability (short-term, long-term), and periodicity (accelerations, decelerations)
31
Q

What’s the normal range of baseline FHR? (1)

A

is 110-160 bpm

32
Q

Describe variability in Electronic FHR monitoring (5)

A
  • physiologic variability is a normal characteristic of FHR
  • variability is measured over a 15 min period and is described as:
    • absent
    • minimal (<6 bpm)
    • moderate (6-25 bpm)
    • or marked (>25 bpm)
  • normal variability indicates fetal acid-base status is acceptable
  • can only be assessed by electronic contraction monitoring (CTG)
  • variability decreases intermittently even in healthy fetus
33
Q

Describe: Accelerations in FHR monitoring (2)

A
  • increase of ≥15 bpm for ≥15 s
  • or ≥10 bpm for ≥10 s if <32 wk GA
34
Q

Describe: Decelerations in FHR monitoring (2)

A
  • 3 types
  • described in terms of shape, onset, depth, duration recovery, occurrence, and impact on baseline FHR and variability
35
Q

Describe: Approach to the Management of Abnormal FHR (11)

A

POISON – ER

  • Position (LLDP)
  • O2 (100% by mask)
  • IV fluids (corrects maternal hypotension)
  • Fetal scalp stimulation
  • Fetal scalp electrode
  • Fetal scalp pH
  • Stop oxytocin
  • Notify MD
  • Vaginal exam to rule out cord prolapse
  • Rule out fever, dehydration, drug effects, prematurity
  • If above fails, consider C/S
36
Q

Name Factors Affecting Fetal Heart Rate: Fetal Tachycardia (FHR >160 bpm) (13)

A
  • Maternal Factors
    • ​Fever
    • Hyperthyroidism
    • Anemia
    • Dhydration
  • Fetal factors:
    • Arrhythmia
    • Anemia
    • Infection
    • Prolonged activity
    • Chronic hypoxemia
    • Congenital anomalies
  • Drugs: Sympathomimetics
  • Uteroplacental:
    • Early hypoxia (abruption, HTN)
    • Chorioamnionitis
37
Q

Name Factors Affecting Fetal Heart Rate: Fetal Bradycardia (FHR <110 bpm) (17)

A
  • Maternal factors
    • Hypothermia
    • Hypotension
    • Hypoglycemia
    • Position
    • Umbilical cord occlusion
  • Fetal factors
    • Rapid descent
    • Dysrhythmia
    • Heart block
    • Hyopoxia
    • Vagal stimulation (head compression)
    • Hypothermia
    • Acidosis
  • Drugs
    • B-Blockers
    • Anesthetics
  • Uteroplacental
    • Late hypoxia (abruption, HTN)
    • Acute cord prolapse
    • Hypercontractility
38
Q

Name Factors Affecting Fetal Heart Rate: Decreased Variability (10)

A
  • Maternal Factors:
    • Infection
    • Dehydration
  • Fetal factors:
    • CNS anomalies
    • Dysrhythmia
    • Inactivity/sleep cycle
    • Preterm fetus
  • Drugs:
    • Narcotics, sedatives
    • Magnesium sulphate,
    • β-blockers
  • Uteroplacental: Hypoxia
39
Q

Describe: Early Decelerations (4)

A
  • Uniform shape with onset early in contraction, returns to baseline by end of contraction, mirrors contraction (nadir occurs at peak of contraction)
  • Gradual deceleration and return to baseline
  • Often repetitive; no effect on baseline FHR or variability
  • Benign, due to vagal response to head compression
40
Q

Describe: Variable Decelerations (4)

A
  • Variable in shape, onset, and duration
  • Most common type of periodicity seen during labour
  • Often with abrupt drop in FHR >15 bpm below baseline (>15 s, <2 min); usually no effect on baseline FHR or variability 120
  • Due to cord compression or, in second stage, forceful pushing with contractions
41
Q

Describe: Complicated Variable Decelerations (6)

A
  • FHR drop <70 bpm for >60 s
  • Loss of variability or decrease in baseline after deceleration
  • Biphasic deceleration
  • Slow return to baseline
  • Baseline tachycardia or bradycardia
  • May be associated with fetal acidemia
42
Q

Describe: Late Decelerations (4)

A
  • Uniform shape with onset, nadir, and recovery occurring after peak of contraction, slow return to baseline 120
  • May cause decreased variability and change in baseline FHR
  • Due to fetal hypoxia and acidemia, maternal hypotension, or uterine hypertonus
  • Usually a sign of uteroplacental insufficiency (an ominous sign)
43
Q

Describe: Classification of Intrapartum EFM Tracings (3)

A
  • Normal Tracing (Category 1)
  • Atypical Tracing* (Category 2)
  • Abnormal Tracing* (Category 3)
44
Q

Describe: Normal EFM Tracing (Category 1)

  • Baseline
  • Variability
  • Decelerations
  • Accelrations
  • Action
A
  • Baseline: 110-160 bpm
  • Variability:
    • 6-25 bpm
    • ≤5 bpm for <40 min
  • Decelerations:
    • None
    • Early decelerations
    • Occasional uncomplicated variable decelerations
  • Acceleration:
    • Accelerations spontaneous or during scalp stimulation
  • Action: EFM may be interrupted for ≤30 min if mother/fetus stable
45
Q

Describe: Atypical Tracing* (Category 2)

  • Baseline
  • Variability
  • Decelerations
  • Accelrations
  • Action
A
  • Baseline:
    • Bradycardia 100-110 bpm
    • Tachycardia >160 for 30-80 min
    • Rising baseline
  • Variability:
    • ≤5 bpm for 40-80 min
  • Decelerations:
    • Repetitive (≥3) uncomplicated variable decelerations
    • Occasional late decelerations
    • Any prolonged deceleration (2-3 min)
  • Acceleration: Absent with scalp stimulation
  • Action: Further assessment required
46
Q

Describe: Abnormal Tracing* (Category 3)

  • Baseline
  • Variability
  • Decelerations
  • Accelrations
  • Action
A
  • Baseline:
    • Bradycardia <100 bpm
    • Tachycardia >160 bpm for >80 min
    • Erratic baseline
  • Variability:
    • <5 bpm for >80 min
    • ≥25 bpm for >10 min
  • Decelerations:
    • Repetitive (≥3) complicated variable decelerations
    • Repetitive late decelerations
    • Any prolonged deceleration (≥3 min)
  • Acceleration: Nearly absent
  • Action:
    • review clinical

situation

* obtain scalp pH
* prepare for possible delivery
47
Q

Describe: Fetal Scalp Blood Sampling (3)

A
  • cervix must be adequately dilated
  • indicated when atypical or abnormal fetal heart rate is suggested by clinical parameters including
    • heavy meconium
    • moderately to severely abnormal FHR patterns (including unexplained low variability, repetitive late decelerations, complex variable decelerations, and fetal cardiac arrhythmias)
  • done by measuring pH or more recently fetal lactate
48
Q

Describe results: Fetal Scalp Blood Sampling (pH and lactate) (3)

A
  • pH ≥7.25, lactate <4.2 mmol/L: normal, repeat if abnormal FHR persists
  • pH 7.21-7.24, lactate 4.2-4.8 mmol/L: repeat assessment in 30 min or consider delivery if rapid fall since last sample
  • pH ≤7.20, lactate >4.8 mmol/L indicates fetal acidosis, delivery is indicated
49
Q

Name contraindications: Fetal Scalp Blood Sampling (2)

A
  • known or suspected fetal blood dyscrasia (hemophilia, vWD)
  • active maternal infection (HIV, genital herpes)
50
Q

Describe: Fetal Oxygenation (3)

A
  • uterine contractions during labour decrease uteroplacental blood flow, which results in reduced oxygen delivery to the fetus
  • most fetuses tolerate this reduction in flow and have no adverse effects
  • distribution of oxygen to the fetus depends on maternal, uteroplacental, and fetal factors
51
Q

Describe fetal response to hypoxia/asphyxia (4)

A
  • decreased movement, tone, and breathing activities
  • anaerobic metabolism (decreased pH)
  • transient fetal bradycardia followed by fetal tachycardia
  • redistribution of fetal blood flow
52
Q

Name: Factors Affecting Fetal Oxygenation (7)

A
53
Q
A

TN Obstetrics (16 decks)

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