8.Normal delivery. Stages of labor.

Question 1

Labour is called normal if?

Answer 1

spontaneous onset , vertex presentation , no prolongation , natural termination with minimal aids , without having any complications affecting the health of the mother

Question 2

describe false labour ?

Answer 2

more in primigravidae
prior to the onset of true labor pain by 1 or 2 weeks in primigravidae and by a few days in multiparae

no changes in cervix 
dull in nature , 
not in frequent intervals
confined to lower abdomen and groin , 
not associated with hardening of uterus , 
relived by enema and sedation

Question 3

what is true labour ?

Answer 3

painless BRAXTON Hicks contractions occur with hardening of uterus with no effect on dilatation of the cervix

then false labour

===becoming true labour ===

painful contraction at regular intervals

frequency, duration and intensity of contraction increase

said to be good - intervals at 3–5 minutes and at the height of contraction the uterine wall cannot be indented by the fingers

associated with SHOW, due to progressive effacement and dilation of cervix ( expulsion of the thick mucus plug blocking the cervical canal with blood)

descent of presenting part

bag of waters - stretching of the lower uterine segment, the membranes are detached
lower pole of the fetal membranes becomes unsupported and tends to bulge into the cervical canal. As it contains liquor, which has passed below the presenting part, it is called “bag of waters”.

not relived by enema or sedatives

Question 4

where is the pace maker of these contraction

Answer 4

tubal ostia

Question 5

pain of uterine contractions are mainly due to

Answer 5

compression of nerve ganglion distributed along cutaneous nerve T10 - L1

other cause of pain -

myometrial hypoxia ,

stretching of peritoneum over fundus ,

stretching of cervix during dilation

Question 6

how many stages of labour are there and describe them

Answer 6

1st stage - onset of true labour - complete dilation of the cervix
further subdivided into the latent and the active phase

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2nd stage of labour - from the complete dilation of the cervix - delivery of fetus

has subdivision
The propulsive phase—starts from full dilatation to the descent of the presenting part to the pelvic floor.

The expulsive phase -mother sires to bearing down with her abdominal muscles to expel the fetus

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3rd stage of labour - end of delivery of fetes to delivery of placenta

Question 7

describe the latent phase of first stage of labour

Answer 7

1)Effacement is the process by which the muscular fibers of the cervix are pulled upward and merges with the fibers of the lower uterine segment
cervix is dilated / thinning and mucus plug will come off - “show” .

In primigravidae, effacement precedes dilatation of the cervix, whereas in multiparae, both occur simultaneously

2) regular uterine contractions- causes cervix to be further dilated and increase in intrauterine pressure

Question 8

what happens if the amniotic fluid does not rupture and there has already been show ?

Answer 8

amniotic fluid does not rupture because there is weak uterine contractions
perform amniotomy which is artificial rupture of the amniotic sac
this will induce labour

Question 9

when is amniotomy contraindicated ?

Answer 9

baby is in breech , placental prevae - where placeta is lying over the cervix

Question 10

describe the active phase in the first stage of labour

Answer 10

4) once the cervix is over 3 cm dilated we are in the active phase , the cervix is constantly pulling up and it become part of the lower uterine wall .
5) uterine contraction continue with increasing intensity and regularly until cervix is fully dilated
6) With the full dilatation of the cervix, the membranes usually rupture and there is escape of good amount of liquor amnii

check if the amniotic fluid is clear - this is normal

green or smelly - indicates meconium - dangerous because meconium would go into the foetus lungs - aspiration - cause respiratory problems

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wall of upper segment of uterus is thick , while the passive lower segment is thin - the junction between the two is called the PHYSIOLOGICAL RETRACTION RING (not pathological retraction ring - feature obstructed by labour- bandyl)

Question 11

the first stage of labour can be very long in whom ?

Answer 11

nullipara (no delivery of fetus) women

Question 12

normally the latent stage of stage 1 in nullipara women should take ?

Answer 12

less than 20 hours - longer indicate failure to progress

Question 13

dilation should continue at what rate after 3 cm in nullipara

Answer 13

enter active phase

should continue every 1.2 cm/hr atleast – slower than this failure to progress

Question 14

the latent stage for multipara women is how long

Answer 14

less than 14 hours - more than this failure to progress

Question 15

dilation should continue at what rate after 3 cm effacement in multipara

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active phase is split into ?

Answer 15

less than 1.5cm /hr after 4cm dilation- failure to progress

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acceleration =3-4 in 2hrs
phase of maximum - 4-9cm in 2hrs
deceleration = 9-10cm in 2hrs

Question 16

what is the clinical management of first stage

Answer 16

maternal monitoring - check freq /intensity / duration of contractions

In primigravidae, the cervix may be completely effaced, feeling like a paper although not dilated to admit a fingertip. It may be mistaken for one that is fully dilated.

anterior lip of the cervix is the last to be effaced!!

-check blood pressure , temp , fluid intake and output

check fetal heart rate every 15-30 mins

analgesia if needed

amniotomy if needed

Question 17

second stage of labour begin when ? and what happens to the uterus shape during contractions ?

Answer 17

cervix is 10cm dilated

The uterus becomes elongated during contraction, while the anteroposterior and transverse diameters are reduced.

The elongation is partly due to the contractions of the circular muscle fibers of the uterus to keep the fetal axis straight.

Question 18

the 7 cardinal movement in the second stage of labour only occur when ?

Answer 18

FETUS PERFOMS 7 CARDINAL MOVEMENTS OF LABOUR ONLY PRESENT IN VERTEX POSITION

Question 19

what are the 7 cardinal movement in the second stage of labour

Answer 19

1 ) Engagment

2) descend
3) Flexion
4) Internal rotation
5) Extension
6) External rotation / resuscitation
7) expulsion

Question 20

what is engagement ?

Answer 20

fetus is said to be engaged when the widest part of the fetal head (biparital diameter) has passed through the pelvic inlet commonly the transverse diameter or less commonly the oblique

The engaging transverse diameter is biparietal 9.5 cm

The engaging anteroposterior diameter of the head is either suboccipitobregmatic (fully flexed) 9.5 cm

in slight deflexion—the suboccipitofrontal - 10.5cm

fully deflexed face - ocipitofrontal - 11.5cm

ocipitolateral is the most common

due to the head facing laterally the sagittal suture does not strictly correspond with the available transverse diameter of the inlet. Instead, it is either deflected anteriorly toward the symphysis pubis or posteriorly toward the sacral promontory causing asynclinitism - mild degrees are common but severe not

Question 21

what is descent ?

Answer 21

in multiparae, descent starts with engagement.
in primipare engagemnet in first stage and descend

Head is expected to reach the pelvic floor by the time the cervix is fully dilated

progression of fetal head is measured in -10 to +10

The negative indicate the presenting part is getting proximal from the maternal’s narrowest area the ischial spines

And positives indicates the presenting part is getting distal from the mothers ischial spines

Question 22

what is flexion ?

Answer 22

resistance by the soft tissues such as the cervix or the pelvis walls and floor

• the chin meets the chest , now the smallest diameter of the babies head -

has to know go
go to the suboccipitobregmatic plane =9.5cm in AP

Question 23

what is internal rotation

Answer 23

because the shape of the pelvis is downwards forwards and medially - internal rotation occurs

from the ocipitolateral position 2/8 of a circle anterior rotation
in oblique ocipitoanterioir - 1/8

placing the occiput behind the symphysis pubis- fetal in occipital anterioir position

prerequisites of anterior internal rotation : well-flexed head, efficient uterine contraction, favorable shape at the midpelvic plane, and good tone of the levator ani muscles

rotation of the head seen by by position of the sagittal suture, and the occiput

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rotation of the shoulders in the same direction of one-eighth of a circle placing the shoulders to lie in the oblique diameter with one-eighth of torsion in the neck

Question 24

what is extension ?

Answer 24

subocciput lies underneath the pubic arch. At this stage, the maximum diameter of the head (biparietal diameter) stretches the vulval outletnd there is no recession even after the contraction passes off

before extension in dutta there is crowning

EXTENSION- as fetal head passes under subpubiic arch - releasing the brow , face and chin as the nape pivots underneath the arch

Question 25

what is external rotation

Answer 25

restitution

rotating the head through one-eighth of a circle in the direction opposite to that of internal rotation (1/8 posterioir rotation )

The occiput thus points to the maternal thigh

the is so the anterior shoulder can give birth .the anterior shoulder rotates toward the symphysis pubis from the oblique diameter, The shoulders now lies in the anteroposterior diameter

Question 26

what is expulsion ?

Answer 26

After the shoulders are positioned in anteroposterior diameter of the outlet

maternal pushing bring the anterior shoulder under symphysis pubis

lateral flexion of the spine, the posterior shoulder sweeps over the perineum. Rest of the trunk is then expelled out by lateral flexion

Question 27

duration of second stage

nullipara?

Answer 27

30mins -3hours

if it takes longer forceps or c section is needed

Question 28

duration of second stage multipara ?

Answer 28

5-60 mins

if it takes longer forceps or c section is needed

Question 29

what is the clinical management in second stage

Answer 29

PATIENT IS TAUGHT TO ONLY bear down during contractions - spontaneous forcible delivery of the head is avoided because it can damage the perineum

fetal monitoring - heat heart rate deceleration due to head or cord compression

Normal fetal heart rate ranges from 110 to 150 per minute

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when delivery is about to happen patient placed in lithotomy position and skin over lower abdomen , vulva , anus and upper thighs is cleansed with antiseptic solution

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When scalp is visible for about 5 cm in diameter, flexion of the head is maintained during contractions -by pushing the occiput downward and backward using thumb and index fingers of the left hand while pressing the perineum by the right palm
repeated during subsequent
contractions until the subocciput is placed under the
symphysis pubis.
At this stage, the maximum diameterof the head (biparietal diameter) stretches the vulval
outlet without any recession of the head
= when crowning of head seen - episiotomy may be performed to prevent perineal lacerations

Bulging thinned out perineum is a better criterion

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RITEGEN manoeuvre is performed when the suboccipitofrontal diameter emerges out.
Delivery by early extension is to be avoided to prevent perineal tea

right hand draped with sterile towel exerts upward pressure to to chin of baby one the perineum near coccyx - the other hand exerts pressure on the occiput backwards

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once head delivered air way is cleared of blood and amniotic fluid using bulb suction device - after that neck palpated to check if umbilical cord is around the neck - if so usually they can be easily untangled manually if not it can be cut between two kosher forceps

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delivery of the anterior shoulder ONLY AFTER RESUCUITATION AND EXTERNAL ROTATION

aided by gentle downward and posterioir traction of the head - brachial plexus may be damaged if excessive pressure used

the posterior shoulder is delivered by elevating and anterior traction of the head

then the whole body is extracted by index finger under the axilla and delivered by lateral flexion

cord is clamped and cut

Question 30

usually the cord is clamped and cut within ?

Answer 30

1-3 minutes

Question 31

delayed cord clamping leads to ?

Answer 31

neonatal hyperbilirubinemia as additional blood is transferred from placenta to newborn

Question 32

what is the 3rd stage of labour ?

Answer 32

delivery of placenta

Question 33

in third stage of labour immediately after the delivery of the baby what should be checked ?

Answer 33

cervix and vagina should be thoroughly inspected for lacerations and surgical repair

Question 34

After birth of baby uterus measures to ?

Answer 34

after expulsion - uterine cavity is permanently reduced in size only to accommodate the afterbirths

about 20 cm vertically and 10 cm anteroposteriorly

Question 35

after the birth of the baby what is the uterus shape ?

Answer 35

becomes discoid - upper segment much thickened and while the thin flabby lower segments is in folds

Question 36

the plane of separation of the placenta is through what ?

Answer 36

plane of separation - runs through deep spongy layer of DECIDUA BASALIS - so when the placenta is extracted there is a variable thickness of decidua attached to it

Question 37

seperation of the placenta fro the uterus should occur within ?

Answer 37

2-10 mins after the end of second stage labour

Question 38

why is Squeezing of fundus to accelerate the process 3rd stage of labour not recommenced ?

Answer 38

increases passage of fetal cells into maternal circulation

Question 39

what are the signs of placental separation in 3rd stage you should look for ?

Answer 39

umbilical cord permanently lengthens outside the vagina

per abdomen - Uterus becomes globular, firm, and ballottable
The fundal height is slightly raised
Slight bulging in the suprapubic region due to distension of the lower segment by the separated placenta.

per vaginum
fresh flow of blood from vagina

elicited by pushing down the
and the length of the cord remains permanent even after the pressure is released. Alternatively, on suprapubic upward pressure by the fingers,

Question 40

only when the signs of placental separation is met can we deliver the placenta and how do we deliver the placenta ?

Answer 40

Manual removal extracts the placenta from the Decidua basalaris - with general anaesthesia not recommended

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physiological management
oxytocin’s not given
placenta delivered by gravity and maternal efforts

Or

ACTIVE MANAGEMNTE - recommended for all women
Clamp the cord

oxytocin is given -routine to add 20IU of oxytocin in intravenous infusion after the baby has been delivered to avoid pph

apply gentle traction on the cord
Use the other hand place it between the fundus and symphysis and apply counter pressure to stop the descend of the uterus

the chorioamnitoc membrane is also delivered with the placenta

Question 41

there are two ways the placenta can separate and be delivered what are they ?

Answer 41

central seperation - dettachment of placenta starts from the centre
uterine sinuses open - and accumulation of blood behind the placenta - RETROPLACENTAL HEMATOMA
with contraction, weight of placental and retroplacental hematoma the whole placenta gets detached

marginal seperation - more frequent , more area of placenta seperated as uterine contracts

Question 42

following delivery of the placenta what should be assessed ?

Answer 42

if there is any uterine bleeding

can be reduced through by massaging by cup it between both hands and avoided if routine oxytocin has been administered

then placenta should be examined for missing condyletons of pathology of fatal membranes and cord and placenta

Question 43

what are the cord abnormalities that should be checked

Answer 43

Thin cord

FLAT cord

varicosity of umbilical vessels

cord knots

lateral cord insertion- not of clinical significance

battledore cord -not of clinical significance

velamentous cord insertion

Question 44

what is a flat cord ?

Answer 44

reduced amount of Wartons jelly

Question 45

what is the definition of a thin cord ?

Answer 45

if the diameter of the vein is less than 7 cm it is also described as a thin cord - the blood flow was compromised

Question 46

what is varicosity of umbilical veins and what causes it ?

Answer 46

vessels dilated and show blood clots due to compression of cords -

due to prolapse or head compression , fetal hyper coagulation(due to sepsis or thrombophilia)

Question 47

Abdominal assessment of progressive descent of the head (using fifth formula) ?

Answer 47

the width of the 5 fingers is a guide to the expression in fifths

. A head that is mobile above the brim will accommodate the full width of 5 fingers - above the pelvic brim

As the head descends, the portion of the head remaining above the brim will be represented by fewer fingers (4/5, 3/5,

generally accepted that the head is engaged when the portion above the brim is represented by 2 fingers width or less

Question 48

two types of episiotomy which can occur what are they ?

Answer 48

a midline or mediolateral

Question 49

what is the advantge of epistiotmy

Answer 49

if incase a tear occurs we can control the direction of the tear by doing the epistiotomy and because we do not want the tear to occur medially where the sphincter muscles are - we manipulate it

Question 50

how to do a epstiotomy ?

Answer 50

 Two fingers enter the vagina along the proposed line for the episiotomy, to protect the presenting part, episiotomy at a 60 degree angle;

episcissors guided and cut is made