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3002 > 85 Parturition > Flashcards

85 Parturition Flashcards

1
Q

How do you calculate the Estimated Date of Delivery (EDD)?

A

40 weeks/280 days from the first day of the last menstrual period

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2
Q

How do you calculate actual fetal age?

A

14 days less than EDD

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3
Q

When is “at term” delivery?

A

Between 37 and 42 completed weeks

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4
Q

When is “pre-term” delivery?

A

Before 37 weeks

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5
Q

When is “post-term” delivery?

A

Beyond 42 weeks

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6
Q

What are the boundaries for the 3 trimesters?

A
  • First trimester: Up to 12 weeks
  • Second trimester: 12-27 weeks
  • Third trimester: 28 weeks to term
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7
Q

What are the consequences of Pre-term birth?

A
  • Respiratory distress
  • Hypothermia
  • Cerebral palsy
  • Intraventricular haemorrhage
  • Hypoglycaemia
  • Jaundice
  • Sepsis
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8
Q

How can the estimated gestational age be calculated?

A
  1. From last menstrual period
    Things to consider: Memory reliability, cycle length, hormonal contraception (either regular use or emergency)
  2. Clinical examination
  3. Symptoms e.g. quickening
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9
Q

What features of the first trimester ultrasound biometry are used to estimate gestational age?

A
  • Gestation sac volume for very early gestation

* Crown-rump length

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10
Q

What features of the second trimester ultrasound biometry are used to estimate gestational age?

A
  • Head circumference
  • Biparietal diameter
  • Abdominal circumference
  • Femur length
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11
Q

Late pregnancy U/S biometry is for GROWTH not …

A

Dating

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12
Q

How is the pregnant state maintained?

A
  1. Uterine quiescence
  2. Abdominal arrangement of the cervix (provides barrier)
  3. Aminion and chorion membranes are intact
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13
Q

How does uterine quiescence maintain the pregnant state?

A
  • Gap junction expression down regulated
  • Oxytocin receptors down regulated
  • Relaxin plays a role
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14
Q

What anatomical arrangements of the cervix help maintain pregnancy?

A
  • Collagen fibres predominate over smooth muscle
  • Glycosaminoglycan ground substance

=> provides mechanical barrier

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15
Q

How does intact amnion and chorion membranes contribute to maintenance of pregnancy state?

A

Intact amnion and chorion membranes:

• Low level of prostaglandin biosynthesis

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16
Q

How is labour initiated?

A

(Trigger unknown)

  • Increased oestrogen towards end of pregnancy encourages uterine contraction
  • Increased PG production
  • Increased cytosol-free calcium needed for muscular contraction (PG + oxytocin)
  • Oxytocin (post-pit)- presenting part presses on pelvic floor
  • Increased gap junction numbers at term allow coordinated contractions (PG)
  • Cervical ripening
  • Uterine contractions
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17
Q

What is the process of cervical ripening?

A
  • Prostaglandin biosynthesis increase
  • Increases water content of glycosaminoglycan matrix
  • Myometrial activity results in “effacement” and thinning of the cervix
  • Relaxin upregulates matrix metalloproteinases
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18
Q

How do uterine contractions change in the initiation of labour?

A
  • Initially uncoordinated, non painful ‘Braxton Hicks’
  • Progressively regular, frequent, coordinated and painful
  • Upper segment (stronger contraction)/lower segment (weaker contraction)
19
Q

What are the average times for primiparous and multiparous labours?

A
  • Primiparous average 14 hours
  • Multiparous average 8 hours
  • 1st stage takes up most of this time and 2nd stage is about 1 hour
  • 3rd stage delivery of placenta & membranes
20
Q

What is the first stage of labour?

A

Onset of regular contractions to fully dilated cervix

  1. ‘Latent phase’
    • Onset of painful contractions 5-10min intervals
    • Cervical ripening and effacement
    • Cervix slowly dilating up to 3-4cm
  2. Active Phase
    • From cervix 3-4cm dilated, more rapidly 0.5-1cm/hr
    • Progressive increase in frequency and strength of contractions
    • Cervical dilatation
    • Descent of the presenting part
    • (Rupture of the membranes)
21
Q

What is the second stage of labour?

A 
Fully dilated cervix to birth
• Cervix fully dilated (10 cm)
• Contractions stronger 2-5 mins
• Presenting part descends
• Urge to bear down
• ‘Ferguson reflex’ of perineal stretching 
• Delivery
22
Q

What is the ferguson reflex?

A
  • Example of positive feedback and female body’s response to pressure application in the cervix or vaginal walls
  • Upon application of pressure, oxytocin is released and uterine contractions are stimulated (which will in turn increase oxytocin production, and hence, increase contractions even more), until baby is delivered
23
Q

What is the third stage of labour?

A

Expulsion of placenta and membranes
• Separation due to forceful uterine contraction and reduces size of placental bed which reduces bleeding
• Normally takes 5 mins
• Can be managed
1. Expectantly (traditional or physiological) (<60mins)
2. Actively - Oxytocic drugs (or ergotamine) may be used to assist this process (promotes contraction to reduce bleeding) coupled with physically pulling on umbilical cord (<30mins§)

24
Q

What factors influence uterine contractions?

A
  1. Prostaglandins
  2. Oxytocin
  3. Relaxin
  4. Stretch response
  5. Positive feedback
25
Q

Role of prostaglandins in uterine contraction control?

A

(PGF2α and PGE2)

  • Paracrines released from uterine decidual cells
  • Stimulate uterine contractions
  • Soften, thin and dilate the cervix
  • Potentiate contractions induced by oxytocin
  • Increase gap junction numbers
26
Q

Role of oxytocin (posterior pituitary hormone) in uterine contraction control?

A

• Triggers the phospholipase C cascade and release of intracellular Ca2+ from smooth muscle SR (OT receptors on smooth muscle cells)
• Stimulates PGF2α production
• Fetal oxytocin (moving to maternal circulation) involved
in the onset of labour
• Maternal oxytocin is released in bursts as a consequence of dilation of the cervix (Ferguson reflex)
• Constricts uterine blood vessels at the site of the placenta

27
Q

Role of relaxin in uterine contraction control?

A

• Produced by the corpus luteum, placenta and decidua
• Contributes to uterine quiescence during pregnancy
• Release increases immediately before labour
• Softens and helps cervix dilate during labour
• Affects collagen metabolism
- softening of ligaments
• Pregnant women vulnerable to ligamentous strain
• Not just a pregnancy hormone (receptors in heart, smooth muscle and connective tissues)

28
Q

What is the decidua?

A
  • Uterine lining (endometrium) during a pregnancy, which forms the maternal part of the placenta
  • Formed under the influence of progesterone and forms highly characteristic cells
29
Q

Role of mechanical stretch in uterine contraction control?

A
  • Increase in uterine contents to critical level may stimulate uterine contractions via a uterine smooth muscle stretch reflex
  • E.g. multiple gestation pregnancy, polyhydramnios
30
Q

Role of positive feedback in uterine contraction control?

A
  • Uterine contractions stimulate prostaglandin release which increases the intensity of uterine contractions
  • Uterine contractions stretch the cervix which stimulates oxytocin release (Ferguson reflex) and stimulates further uterine contractions
31
Q

What are the characteristics of the uterus and physiology for stage 0?

A
  1. Characteristics of uterus:
    • Quiescent
  2. Physiology:
    • Maintained by progesterone and relaxin
32
Q

What are the characteristics of the uterus and physiology for stage 1?

A
  1. Characteristics of uterus:
    • Uterine ‘awakening’
    • Initiation of parturition –> complete cervical dilation
  2. Physiology:
    • Increase in gap junction connectivity (prostaglandins)
    • Increase in oxytocin receptor numbers (oestrogen)
33
Q

What are the characteristics of the uterus and physiology for stage 2?

A
  1. Characteristics of uterus:
    • Active labour
    • Complete cervical dilation –> delivery
  2. Physiology:
    • Oxytocin release triggered by Ferguson reflex
    • Prostaglandins
34
Q

What are the characteristics of the uterus and physiology for stage 3?

A
  1. Characteristics of uterus:
    • Delivery –> expulsion of placenta + final uterine contractions
  2. Physiology:
    • Oxytocin
35
Q

What is the process of the engagement of head during delivery and labour?

A
  • Engagement of head - ‘lightening’
  • 2-4 weeks prior to delivery in primiparous women
  • May not happen in multiparous women
  • Presenting part descends into the pelvis
36
Q

What are the different delivery presentations?

A
  • Engagement of and flexion of the head
  • Internal rotation
  • Delivery by extension of the head - nose scrapes the blanket
  • Delivery of the shoulders
37
Q

What is the normal lie and altitude of the foetus during pregnancy?

A
  • Lie: 99.5% are longitudinal – spines of mother and baby are parallel (transverse would be abnormal more common in preterm and multiple pregnancies)
  • Attitude: baby normally lies in the ‘fetal’ position – head tucked into the chest - crown of head/vertex presents first (neck extended would be abnormal)
38
Q

% of the different presentations (part that is delivered first)?

A
  • ACephalic 97%
  • A Breech is buttocks first 3%
  • Shoulder <1%
39
Q

What is external cephalic version?

A

• Manipulation of fetus through abdomen from breech to cephalic presentation
• Aim to reduce elective C section for breech
• Success rate about 50%
• <5% revert to breech if successful
• From 36 weeks nulliparous or 37 weeks
multiparous
• Can relax uterus with tocolysis (salbutamol
or terbutaline)

40
Q

Role of tocolytics?

A
  • Relax uterus

* e.g. salbutamol or terbutaline

41
Q

During intrapartum monitoring, what are you watching in the mother and foetus?

A
  1. Maternal
    • Vital signs, increasing in frequency as labour progresses
    • Progress (‘Partograph’)
  2. Fetal
    • Auscultation of the fetal heart rate and pattern
    • Inspection of the liquor once membranes are ruptured
42
Q

How is auscultation of the fetal heart rate and pattern performed?

A
  • Intermittent with Pinard stethoscope or hand held Doppler

* Continuous electronic monitoring with cardiotocography (CTG)

43
Q

What does a partograph measure?

A
  • Fetal HR
  • Rate of cervical dilatation
  • Descent of fetal head
  • Contraction characteristics
  • If membranes ruptured – colour of amniotic fluid
  • Volume of maternal urine
  • Record of medications
  • Maternal vitals

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