Intrapartum and Postpartum Care

Question 1

What are the phases of labour?

Answer 1

-Latent Phase
=Painful contractions
=Cervical change up to 4cm dilatation
=Breathing exercises, immersion in water, massage for pain relief

-First Stage
=4cm to fully dilated (10cm)
=8 to 18 hours P0
=5 to 12 hours >/=P1
=Regular painful contractions (true labour pains, every 10 minutes= effective, lasting 30-40 seconds)

-Second Stage
=Fully dilated until the birth of the baby
=Passive: without explosive contractions
=Active: active maternal effort following confirmation of full dilatation of cervix

-Third Stage
=Delivery of the placenta
=Oxytocin

Question 2

Describe the latent phase of labour

Answer 2

-No defined time period
-Patients can be in own home
-Breathing exercises, water and massage are effective pain relief

Question 3

Describe the first phase of labour

Answer 3

-Commence partogram
-FH every 15 minutes or CTG
-Assess contractions
-Maternal pulse, BP, temperature
-Offer VE every 4 to 6 hours

-P0 – 0.5cm per hour dilatation
=Power
=Passenger
=Passage

Question 4

Describe initial assessment of labour

Answer 4

-Observations
-Urinalysis
-FH auscultation (intermittent if low risk: 15 mins first stage, 5 mins 2nd stage- 1 min immediately after contraction, continuous cardiotocography for high risk)
-Fundal height
-Abdominal Examination
-?Vaginal examination

Question 5

Describe a partogram

Answer 5

-Heart rate and contractions
=How baby is doing during journey

Active 1st stage
-Frequency of contractions every 30 mins
-Hourly pulse
-4-hourly temp and bp
=Baby monitor

-Vaginal examination every 4 hours P0-0.5cm per hour dilatation

Question 6

Who delivers intrapartum care?

Answer 6

-Location
=Home, Midwifery lead unit, Consultant lead unit
-One to one care
-Mobilisation
-Birth partners

Question 7

What happens if there is a delay in the first phase of labour?

Answer 7

-Transfer to consultant lead unit
=Hydration, obs
-Review examinations and observations, uterine contractions, pain
-Amniotomy (break water around baby to release prostaglandins) and reassess in 2 hours
-If no progress consider oxytocin
-If parous consider why labour hasn’t progressed

Question 8

Describe the second phase of labour

Answer 8

-Passive and active
-Hands on: frequency of contractions every 30 mins, hourly BP, 4 hour temp, frequency passing urine, hourly vaginal exam in active stage, baby monitoring (5 mins)
-Warm compress
-Episiotomy
-Deferred cord clamping, check cord gases
-?Delay= abdo exam, monitor, oxytocin? Vaginal: moulding (overlap of sutures= obstruction), caput (swelling on baby head= oedema= obstruction?)
=Delivery of head ensure perineal support
=Skin to skin and early breastfeeding

Question 9

Describe the third phase of labour

Answer 9

-Active management
=Reduced rate of PPH >1L
=Reduced anaemia
=Reduced length of third stage
=Reduced need for blood transfusion

-Physiological
=Routine use of uterotonic drugs/ deferred clamping and cutting of cord (1 min), controlled cord traction after signs of placental separation
=Allow cord to stop pulsating
=Placenta delivers with maternal effort: active management if haemorrhage and placenta not delivered within 1 hour of birth of baby (retained placenta)
=>30 min delayed

Question 10

Home birth statistics

Answer 10

-80% in 1930
-1% in 1990
-11.5% parous patients transferred to obstetric unit
-45% nulliparous patients transferred to obstetric unit
=Most transfers for delay in labour or analgesia
=Nulliparous 0.9% risk of serious neonatal medical problem at home vs 0.5% in hospital
=Parous similar risk of serious neonatal medical problem at home or hospital

Question 11

What happens in a midwifery lead unit?

Answer 11

-One to one care
-Analgesia– Pool, NO2, opioids
-Light diet and isotonic drinks
-Intermittent foetal auscultation
-Half hourly assessment of contractions
-Hourly pulse
-4 hourly temperature and BP
-4 hourly vaginal examination

Question 12

What happens in a consultant lead unit?

Answer 12

-One to one care
-Antacid suppression – omeprazole
-Avoid eating
-Epidural or PCA available
-CTG

Question 13

Normal changes postpartum

Answer 13

-HCG, oestrogen and progesterone fall
-Uterus weight falls from 1kg to 500g at 1/52
-After third stage cardiac output increases initially
-Diuresis reduces plasma volume
-HR decreases

Question 14

Describe postnatal midwifery care

Answer 14

-Minimum 10 days, up to 28
-Maternal observations within 1 hour of 3rd stage (tempt, pulse, resp, BP, lochia assessment uterine involution, first void 6 hours after birth)
Skin to skin contact initiated immediately
-Anti-D prophylactic immunoglobulin/ cord bloods and maternal bloods taken and sent
-Assess VTE risk
-Contraception
-Feeding: breastfeeding promoted and facilitated
-Vit K haemorrhage disease of new-born, physical exam of head, eye, mouth, abdomen, void, pass meconium 24 hours
-Perineum +/- caesarean wound= inspection
-Mental health
-Social health

Question 15

Types of lochia

Answer 15

-Lochia alba= heavy white vaginal discharge
-Lochia= red/brown/pink
-Lochia rubra= red and heavy blood loss, clots up to 6cm on D3/4

-10% of women at 6/52 still have lochia
-By D14 the uterus shouldn’t be palpable

=Shedding of blood and tissues after delivery: blood, mucous, uterine tissue
=Stale, musty odour like menstrual period discharge and can last several weeks, heavy at first but subsides to lighter flow

Question 16

Risk of venous thromboembolism in pregnancy

Answer 16

-4th most common cause of maternal mortality 2018-2020

Question 17

What is considered ‘the baby blues’?

Answer 17

-Day 4 to 10
-50-70% of women
-Usually lasts 24 to 48 hours
-30% migrainous headache

-Post-natal mental health: Suicide most common direct maternal death within 1year postpartum
-2.9 per 100 000 maternities

Question 18

Red flags of post-natal mental health

Answer 18

-Recent new symptoms or significant change in mentalstate
-New thoughts or acts of violent self-harm
-New and persistent expressions of incompetency as a mother or estrangement from the infant

Question 19

Epidemiology and management of postnatal depression

Answer 19

-10 to 15% of women
-2-4 weeks and 10-14 weeks postpartum
-Suicide most common cause of direct maternal death in first year postpartum

-Sertraline
-CBT

Question 20

Describe postpartum psychosis

Answer 20

-0.05 – 0.1% of births
-Rapid onset – hallucinations +/- delusions +functional impairment
-Sleeplessness, restlessness, confusion, agitation
-Weeks 2 to 4
-Bipolar – 20% risk
-Personal or family history – 50% risk
-Psychiatric assessment within 4 hours

Question 21

Describe bipolar in pregnancy/ postpartum care

Answer 21

-50% chance of relapse
-Sleep loss contributes
-Avoid breastfeeding if on lithium

Question 22

Describe breastfeeding

Answer 22

~800ml/day
-800 calorie excretion
-Breast feeding clinics
-Unrestricted in frequency and duration
-Milk ‘comes in’ ~ day 3

Question 23

Problems with breastfeeding and management

Answer 23

-Nipple pain improves ~ Day 7 – 10
=On going pain ?candidiasis

-Mastitis
=Continue to feed/express
=Analgesia and increased fluid intake
=Should improve within a few hours
= 4% are infective: ?Abscess= Fever, fluctuant, painful red mass

-Lactation suppression
=Perinatal death, HIV
=Cabergoline within 24 hours of delivery
=Not with pre-eclampsia/hypertension
=Side effects– Hand/foot numbness, dizziness, poor impulse control
=Firm bra and analgesia

Question 24

Prescribing in breast feeding

Answer 24

-Antibiotics
=Nitrofurantoin – haemolysis in G6PD deficient infants
=Ciprofloxacin – joint problems

-Analgesia
=Avoid aspirin – Reye’s
=Avoid codeine – neonatal respiratory depression

-Anticoagulants
=LMWH and warfarin are safe

Question 25

Problems with the perineum in pregnancy/ postpartum care

Answer 25

-85% women sustain perineal trauma after vaginal delivery
-Ice packs (up to 20 mins)
-Lidocaine gel/spray
-Analgesia
-Pelvic floor exercises

Question 26

Postpartum contraception

Answer 26

-1 in 2 women having sex by 6 weeks
-Thread check for coil inserted postpartum
-No threads? Refer for ultrasound

=Hormonal/ copper coil
=Implant
=Injection

Question 27

Describe the postnatal check

Answer 27

-Mental and physical health
-Feeding and behaviour of the baby
-Urinary, bowel and sexual function as incontinence and dyspareunia or anxiety about sexual intercourse are issues that many women will not discuss voluntarily.
-Blood pressure, urinalysis (resolution of proteinuria in pre-eclampsia) and a general, breast, abdominal and pelvic/perineal examination is performed to ascertain that the uterus has involuted adequately and that any perineal trauma has healed.
-A cervical smear is also taken if it is due and contraception is discussed, if it has not already been initiated.
-Adjustment to parenthood and any anxieties

Question 28

Criteria of normal labour

Answer 28

-Spontaneous in onset and at term
-With vertex presentation
-Without undue prolongation
-Natural delivery with minimal aids
-Without having any complications affecting health of mother and/or baby

Question 29

Mechanism of labour

Answer 29

-Engagement and descent (occipital transverse)
-Flexion (chin to chest)
-Internal rotation to OA (90 degrees to occipital anterior)
-Crowning (head visible through vagina without receding in between contractions)
-Restitution (head extension to realign head and back)
-External rotation (face turned to side)
-Delivery of anterior shoulder
-Delivery of posterior shoulder

Question 30

Duration of second stage

Answer 30

-Nulliparous: delay when 2 hours active
-Multiparous: delay 1 hour active

Consider assisted delivery of concerns about baby wellbeing/ delay in 2nd stage/ maternal comorbidity

Question 31

Signs of placental separation

Answer 31

-Gush of blood at vagina
-Lengthening of umbilical cord
-Globular shaped uterine fundus palpation

Question 32

Pain relief options

Answer 32

-NO
-IV opioids
-Epidural analgesia

Question 33

Signs and symptoms of postpartum haemorrhage

Answer 33

Sudden and profuse blood loss or persistent increased blood loss faintness dizziness or palpitations/ tachycardia

Question 34

Signs and symptoms of Infection

Answer 34

Fever, shivering, Abdominal pain and/or offensive vaginal loss

Question 35

Signs and symptoms of Pre-eclampsia

Answer 35

Headaches within 72 hours of birth with visual disturbance/ nausea/ vomiting

Question 36

What is mastitis

Answer 36

Inflammation of breast= build up of milk= milk duct blockage

=Breast pain, thrush
-Continue to feed/ express, analgesia, fluid intake, exclude abscess

Question 37

Aim of fetal monitoring

Answer 37

-Reduce hypoxic ischaemic encephalopathy and cerebral palsy
-Reduce perinatal death
-Reduce unnecessary intervention

Question 38

Main types of fetal heart rate monitoring

Answer 38

-CTG machine (cardio topography, continuous): high risk
-Hand held sonic device (intermittent auscultation): low risk

Question 39

CTG interpretation pneumonic

Answer 39

DR C BRAVADO
=Dr – determine risk
=C - contractions
=Bra – baseline rate
=V - variability
=A - accelerations
=D - decelerations

Overall plan with clinical assessment: indication to expedite birth?

Question 40

Describe a CTG recording

Answer 40

-Top line= fetal HR (abdominal transducer/ fetal scalp electrode)
-Bottom line= toco monitor, change in pressure from around abdomen, frequency and duration of uterine activity (no strength or pressure of contraction): peaks
-Space between columns= 10 mins

Question 41

Determining risk: maternal factors

Answer 41

-Medical conditions: BP, proteinuria, diabetes
-Previous caesarean section
-Obesity >35
-Significant abdominal pain that is not uterine activity
-Post term pregnancy (>42 weeks): induction or augmentation
-Prolonged rupture of membranes >24 hours
-Maternal tachycardia >120bpm on 2 occasions, 30mins apart
-Delay in first or second stage of labour- epidural for analgesia
-Antepartum haemorrhage
-Maternal pyrexia >38

Question 42

Determining risk: fetal factors

Answer 42

-Small baby abnormal liquor or doppler
-Multiple pregnancy
-Prematurity (<37 weeks)
-Breech or other malpresentation
-Intrauterine infection
-Oligohydramnios
-Meconium: stained liqor dark green black, thick
-Abnormal umbilical artery doppler
-History of reduced fetal movements in last 24hours

Question 43

Normal fetal heart rate

Answer 43

-Normal variability 5-25bpm, normal 110-160bpm but 150-160bpm in baby at term could be sign of hypoxic stress or infection (pre term babies usually have higher HR)
=Tachycardia >160bpm >10 min, term babies may have low baseline
-Fewer than 5 contractions
-Rise in baseline 20bpm is not normal

=Reassuring normal: CTG in which all 3 features are reassuring
=Non reassuring suspicious: 1 non-reassuring and 2 reassuring
=Abnormal: 1 abnormal feature or 2 non-reassuring

Question 44

Types of hypoxia

Answer 44

-Chronic
-Gradually evolving
-Subacute
-Rapidly evolving
-Acute

Question 45

Physiology of hypoxia in fetus

Answer 45

-Hypoxic environment: arterial oxygen saturation 70% at start of labour, 30% in uterine contractions
-Placenta= respiratory organ: 18-22g fetal haemoglobin to increase oxygen carrying and accessing capabilities
-Fetal haemoglobin acts as buffering system to prevent neurological damage in metabolic acidosis
-Circulation system: ductus arteriosus (diverts blood from pulmonary artery to ascending aorta), foramen ovale- shunt oxygenated blood from umbilical vein to heart and brain
-Beats faster than adult: rapidly distribute blood to organs
-HR drops as approaching term gestation (140-145bpm): 150+ at term sign of hypoxia stress infection

Question 46

Placenta gas exchange

Answer 46

-Chorionic plate (fetal side of placenta) covered in blood vessels that originate from umbilical vein arteries in umbilical cord
=Arterial vessels on chorionic plate dive down into main body, progress to smaller fetal capillaries bathed in maternal blood
-Maternal side implanted into myometrium, tiny spiral vessels form gas exchange- oxygen and nutrients into placental unit, waste products out to maternal circulation
=Hypertension impairs development: impaired vascular endothelial function= suboptimal gas exchange and less formation of blood vessels
=Diabetes: fewer pools of maternal blood, fewer places for effective gas exchange

Question 47

What is cycling?

Answer 47

-Hallmark of fetal neurological responsiveness and absence of hypoxia/ acidosis= alteration of different behavioural states
-Fetal quiescence (deep sleep, lasts up to 50 mins, stable baseline, rare accelerations, borderline variability)
=Active sleep (REM sleep, most frequent state, moderate accelerations, normal variability)
=Wakefulness (rarer, large number of accelerations can lead to confluence and difficult baseline interpretation, normal variability)

-Transitions between the different patterns become clearer after 32-34 weeks of gestation

Question 48

Compensated response to hypoxia

Answer 48

-Decelerations= transient times to greater hypoxic stress (contractions) to protect myocardium (stop full capacity)
-Stops moving (conserve non essential activity)= loss of accelerations (insufficient oxygenation to vital organs)

Question 49

Decompensated response to hypoxia

Answer 49

-Continuing hypoxia causes decompensation in the central nervous system (inadequate oxygen reaching the fetal brain)
-If the hypoxia continues, stress hormones (catecholamines) are released from fetal adrenal gland (adrenaline and noradrenaline) which increases the HR (tachycardia) to increase oxygenation.
=This requires energy- glycogen is broken down to glucose which also maintains positive energy balance in the heart (further protection)
-Loss of baseline variability and ultimately myocardial hypoxia- unstable baseline and progressive reduction in Fetal HR (bradycardia)

Question 50

Pathogenesis of HIE

Answer 50

-Release of adrenaline stimulate glycogenolysis
-When fetal oxygen supply is no longer sufficient to maintain energy requirements, glucose is released from glycogen stores and metabolised anaerobically (without oxygen)
-During anaerobic metabolism, stores of glycogen in the heart, muscle and liver are broken down to provide energy
-Lactate is the by-product of anaerobic metabolism, which eventually causes the pH of the fetal blood to fall further (metabolic acidosis)
=Leads to HIE (Hypoxic ischaemic encephalopathy)

Question 51

Describe antenatal chronic hypoxia

Answer 51

-Significantly reduced variability with without raised baseline and shallow decelerations
-Develops over weeks or days
=Expedite delivery ASAP so urgent birth (will not have the reserve to cope with labour)

-Features: Baseline rate of the upper end of normal, reduced variability and absence of cycling, usually shallow chemoreceptor decelerations
-Physiology: catecholamine release, vasoconstriction- fetal CNS compromise, acidosis secondary to placental insufficiency
-Escalation: if classified as abnormal antenatal CTG, likely needs delivery- should be discussed with LW coordinator, ST67 or consultant obstetrician

Question 52

Contractions in labour

Answer 52

-Cause hypoxic state: during contraction, gas exchange in placental unit impaired= retention of CO2 and lowering of fetal pH
-Intercontraction interval= gas exchange occurs again= reperfusion baby

-Normal frequency, strength, duration, and the resting tone
=Less than or equal to 4 in 10 mins with good resting tone; important to palpate manually to assess strength.
=If frequency of contractions cannot be assessed reliably by the tocodynamometer, manual palpation for 10 minutes every 30 minutes is required

-Tachysystole- contractions >5 in 10 mins (inadequate gas exchange= fetal compromise and abnormal HR)
-Hypertonus – contraction lasting more than 2 mins
-Hyperstimulation – iatrogenic (prostaglandin oxytocin) or physiological contractions >5 in 10 or hypertonus leading to CTG abnormalities OR Contractions of normal duration occurring within 60 seconds of each other.
-Lack of baseline resting tone

Question 53

Accelerations in fetal HR

Answer 53

-Accelerations: transient increase above baseline by 15bpm for 15 seconds. 2+ in 20 mins (reassuring), absence is less certain (normal in deep sleep, chronic or evolving hypoxia)
=Erroneous monitoring of maternal pulse show accelerations of greater magnitude often in contractions (second stage especially)
=Fetus raise HR also in contractions
=Maternal/fetal HR monitored?

Question 54

Decelerations in fetal HR

Answer 54

-Early – coincide with contractions – typically late first stage and early second stage; Do not indicate hypoxia: (Parasympathetic)- short lasting and return quickly to baseline (reflex neurological response)
-Variable – variable in shape, timing + duration. Occur due to cord compression due to baro-receptor and/or peripheral chemoreceptor stimulation
-Late – typically start 20 secs after peak contraction and recover after the contraction ends (longer and later recovery to baseline) indicative of a chemoreceptor-mediated response to fetal hypoxaemia

-Chemical induced: suggest decompensation (take much longer to recover, loss of accelerations, reduction in variability), loss of shouldering, drop below 60bpm, delay in return to baseline, overshoot present
=Give terbutaline early: if no improvement expedite delivery

Question 55

Recognition and management of evolving hypoxia

Answer 55

-Hypoxia begins with decelerations
-Accelerations disappear (reduce non essential activity)
-Baseline HR: increases (catecholamines)
-Compensated stress (stable baseline HR and normal variability but deep wide decelerations)
-Decompensation (unstable baseline and changes in variability: reduced variability or significantly increased above 25bpm)
-End stage: myocardial failure with step ladder to death