Intrapartum Care

Question 1

Stages of Labour

Answer 1

1. The onset of regular contractions (increasing in length and frequency) to full dilation of the cervix (10cm); process of cervix softening, opening and thinning out.
2. Full dilation of the cervix to delivery of the neonate; process of pushing the foetus out of the birth canal.
3. Birth of infant to delivery of placenta; process of gentle uterine contractions to loosen and push out placenta and to stop bleeding.
4. Delivery of placenta and control of bleeding until 1hour post-birth.

Question 2

Stage 1
Signs & Symptoms (6)

Answer 2

1. Discomfort progressing to pain (incl. lower-back pain)
2. Lightening – movement of infant in maternal pelvis
3. Braxton Hicks contractions – intermittent period-like cramps
4. Bloody show – blood-stained discharge of mucous (operculum)
5. Waters breaking – spontaneous rupture of amniotic membrane; clear-pink water.
6. GIT discomfort - nausea/vomiting and/or diarrhoea

Question 3

Stage 1
Duration & Factors

Answer 3

Approx. 12-14 hours (primigravida) or 6-10 hours (multigravida).
Factors:
1. Passenger – foetal size, position and HR pattern.
2. Power – strength, frequency and duration of contractions,
3. Passage – pelvic anatomy and measurements.

Question 4

Stage 1
Stages

Answer 4

1. Latent - cervix dilates to 3cm; contractions are mild and irregular.
2. Active (est. labour) - cervix dilates 7-8 cm; contractions become stronger, more regular and more painful (approx. 30-60sec/3-4min)
3. Transition - cervix dilates to 10cm; continuous painful contractions and rectal pressure.

Question 5

Stage 1
Speeding-up Labour

Answer 5

A. Artificial rupture of membranes
B. Oxytocin infusion

Question 6

Stage 1
When to transfer to hospital?

Answer 6

1. Contractions <3-5min apart
2. Waters break
3. Bright red bloody discharge
4. Spontaneous labour if planned c-section
5. Changes in foetal movement pattern

Question 7

Stage 1
Midwifery Care (9)

Answer 7

1. Maternal observations
2. Foetal observations
3. Encourage upright/active movement
4. Pain-relief
5. Psychosocial support
6. Nutrition and hydration
7. Education
8. Involve support person
9. Review birth plan
10. Encourage 2-3hrly voiding

Question 8

Non-Pharmacologic Pain Relief

Question 9

Pharmacologic Pain Relief

Question 10

Stage 1
Initial Assessment (10)

Answer 10

1. Emotional/psychological state
2. Foetal movements in past 24hrs
3. Vaginal losses - colour, volume, odour, blood.
4. Contractions - time of onset, frequency, strength, duration, resting tone.
5. Pregnancy care record - parity/gestation, antenatal events/complications, PMHx.
6. Maternal vital signs
7. Urinalysis - ketones, flucose, protein.
8. Palpate abdomen - foetal size, foetal presentation/position, symphyseal-fundal height.
9. Foetal heart rate
10. Vaginal examination - cervical dilation.

Question 11

Stage 1
Signs of Progress

Answer 11

1. Cervical dilatation
2. Cervical effacement
3. Descent of the presenting part (confirmed by abdominal or vaginal examination)
4. Increasing strength and duration of contractions.

Question 12

Stage 1
Maternal Observations

Answer 12

Every 30min:
1. Palpate uterine activity and contractions
2. HR
3. Vaginal losses
Every 4hours (or as indicated)
1. Vital signs
2. Vaginal examination

Question 13

Stage 1
Foetal Observations

Answer 13

A) CTG only if indicated - e.g. prolonged labour, maternal fever, abnormal foetal HR, bleeding; OR
B) Intermittent auscultation toward end of contraction

Question 14

Stage 2
Foetal Observations

Answer 14

A) CTG ; OR
B) Not actively pushing - 15min; OR
C) Active pushing - 5min or post-contraction

Question 15

Stage 2
Maternal Observations

Answer 15

1. HR - 15min
2. Palpate uterine activity and contractions - 30min
3. Vital signs - 60min

Question 16

Urinary Catheterisation (in/out)
Indications

Answer 16

Pregnant woman:
1. Has not passed urine for 2-3 hours
2. Has difficulty passing urine
3. Has a palpable bladder

Question 17

Stage 2
Perineal Care

Question 18

Stage 2
Directed Pushing

Question 19

Stage 2
Self-directed Pushing

Question 20

Stage 2
Birth & Hands-on Technique

Answer 20

1. Call for second-clinician
2. Support perineum
3. Apply gentle counter-pressure on foetal head
4. Apply gentle traction to release anterior shoulder (if required) and allow posterior shoulder to be released
5. Place baby skin-to-skin with mother immediately post-birth
6. Delayed cord clamping (>1min)

Question 21

Stage 2
Episiotomy - Indications

Answer 21

1. First vaginal birth requiring forceps/ventouse
2. Suspected or confirmed fetal compromise
3. Delayed second stage
4. A severe perineal tear is judged to be imminent (‘button-holing’, significant blanching).

Question 22

Assisted Birth
Definition & Indications

Answer 22

The use of instruments to assist in delivery of foetus.
Indications:
- failure to progress
- maternal exhaustion in 2nd stage,
- foetal distress
- awkward positioning of infant
- vaginal delivery of premature infant.

Question 23

Assisted Birth
Methods

Answer 23

A. Ventouse – vacuum cap attached to infant’s head by suction; clinician assists to deliver infant during maternal contraction/pushing.
B. Forceps – positioning of forceps around infant’s head; clinician gently pulls to assist delivery; may be specially designed to turn the infant to particular sides.
*Administration of local anaesthetic to perineum/vagina +/- episiotomy

Question 24

Induction
Definition & Indications

Answer 24

Assisting commencement of labour using artificial methods.
Indications
- Maternal hypertension
- Pre-eclampsia
- Miscarriage
- Enlarged foetus
- Cephalon-pelvic disproportion
- Diabetes.
- Intra-uterine growth restriction
- Mild foetal distress
- Foetal post-maturity.

Question 25

Induction Methods

Answer 25

1. Prostin E2 (prostaglandin) – administered as pessary or gel to ripen cervix; requires careful monitoring of mother and infant. 2. Balloon catheter – inserted into cervix and inflated with water to apply pressure; left in situ for approx. 12hours. 3. Artificial rupture of membranes – use of amnihook/amnicot to break membranes per vagina. 4. Synoticinon IV infusion – stimulates uterine contractions; requires careful dosing and monitoring; midwife increases dose every 30min until labour commenced; foetal heart rate monitored via CTG.

Question 26

Stage 3 Active Management

Answer 26

Complete within 30min of birth: 1. Administer uterotonic agent - 10iu IM/IV oxytocin 2. Cut umbilical cord once pulsations cease 3. Perform controlled cord traction WITH conter-pressure to uterus (guarding) 4. Post-delivery check fundus for uterine tone and perform fundal massage if active bleeding 5. Monitor blood loss *Recommended method

Question 27

Stage 3 Physiological Management

Answer 27

Completed within 60min of birth: 1. Leave cord intact until pulsation ceased and/or placenta birthed 2. Encourage skin-to-skin and breast-feeding 3. Encourage upright maternal position 4. Monitor signs of separation

Question 28

Stage 4 Placental Examination

Answer 28

1. Completeness and deviation from normal

Question 29

Stage 4 Maternal Care (9)

Answer 29

1. Uninterrupted skin-to-skin contact for min 1hr 2. Encourage breast-feeding and educate about secure attachment 3. Ensure warmth and comfort 4. Encourage food, fluids and rest 5. Assess emotional/psychological response to labour/birth 6. Encourage presence of support person 7. Regular maternal observations 8. Perineal care 9. Bladder care

Question 30

Stage 4 Postpartum Maternal Observations

Answer 30

Immediately post-birth and 15min for 1hour: 1. Vital signs 2. Uterus tone and height (firm and central 3. Blood loss Immediately post-birth and 1hr 1. Perineum 2. Pain/discomfort

Question 31

Stage 4 Neonatal Care

Answer 31

1. Clean and dry infant 2. APGAR score - 1 and 5min. 3. Uninterrupted skin-to-skin contact for first hour (thermoregulation) 4. Explain importance of positioning for patent airway 5. Observe and support initial feed 6. Weight, height and head circumference 7. Administer Vitamin K (Konakion) 8. Administer HepB vaccine

Question 32

Stage 3 Signs of Separation

Answer 32

1. Uterus rises in the abdomen 2. Uterus becomes firmer. 3. A trickle or gush of blood from the vagina 4. Lengthening of the cord 5. Cord does not retract with supra-pubic pressure.