Intrapartum Care & Normal Birth Flashcards
Define Normal Labour and spurious labour
Describe the three stages of labour
Normal labour: onset of regular, painful uterine contractions associated with cervical effacement & dilatation
Spurious labour: uterine contractions +/- pain but no cervical effacement & dilatation
1st stage of labour: cervical effacement + dilatation to full dilatation (10cm) –> Latent slow progress to full effacement & 3cm dilatation; Active faster cervical dilatation 1cm/hr.
2nd stage labour: full dilatation of cervix to baby
3rd stage labour: delivery of baby to delvieyr of placenta
Normal labour: Power, passenger, passage. Explain.
Power: uterine muscle contraction is STRONG, LONG (40s-1min), FREQUENT (3-5/10mins)
Passenger: fetal size/lie longitudinal or transvers/px cephalic or malpresentation/atitude flex or extend/position denominator to maternal pelvis
Passage: resistance to expulsion of fetus by bony pelvis, soft tissues of birth canal.
During normal labour, monitor mother for? monitor baby for?
Mother: infection (chorioamnionitis), pre-eclampsia (BP, urinalysis); Intrapartum haemorrhage, emotional well-bring, pain relief.
Fetal: auscultate fetal heart continuous CTG or intermittent after each contraction; Amount and colour of amniotic fluid (low = fetal distress due to fetal sparing of heart, adrenal, brain)
Pain relief in labour - options? (pharmacological)
Inhalational (NO) - labour pain comes and goes, NO works quickly and wears off quickly but not strong in terms of pain relief.
Systemic: Opioids take edge off peak o contractions but side effect of drowsiness.
Neuraxial analgesia: spinal one quick shot very fast very dense OR epidural can last length of labour
Local infiltration: pudendal nerve block/perineal infiltration.
First stage of labour
- the two stages and time
- maternal hx on admission
- exam on admission
- fetal well-being
- progress of labour
- ROUTINE CARE OVERVIEW
- (latent and active) Length of time depends on parity and duration of latent phase. Nullipara 6-18hrs, Multipara 2-10hrs. Roughly 1cm/hr
- Hx (Meds, use anti epileptics during labour; past obs hx; complications?; GBS status/HepC/HIV; Blood group) Labour hx (duration, show, ROM, bleeding, FM) Antenatal education and birth plan?
- Exam: pre-eclampsia, infection, bleeding + duration/frequency/intensity of contractions and pain control
- fetus: colour/volume amniotic fluid if membranes ruptures. Auscultate or CTG. Continuous CTG indication?
- Uterine contractions (strength, duration, intensity, frequency); Vaginal exam (cervical effacement dilatation descent of px part…EVERY FOUR HRs); Partogram documentation
- Routine care: Observe maternal/fetal/progress of labour + activity e.g. ambulate + Fluids and diet (light and clear for labour) + IV access not routine (High risk PPH, C section) + Abx prophylaxis (intrapartum prophylaxis if +ve vaginal swab)
Indications for continuous CTG (antenatal and intrapartum)
Antenatal (diabetes, hypertension, growth restriction, bleed during pregnancy)
Intrapartum (meconium/blood stained liqor, abnormal FHR in intermittent auscultation)
Second stage of labour
- overview and timing
- mechanics
- Full dilatation (bloody show/urge to push/N&V) to newborn; Maternal effort + uterine contractile forces; timing depends on parity AND epidural (head hit pelvic floor = feedback to push but not if epidural = Feguson reflex); Epidural (>3/>2hrs) No (>2/>1hrs).
- Mechanics of head: Moulding (head shape), Flexion (size), Rotation (position).
Second stage of labour
- Fetal head size
- Pelvic plane size
- note about station
Vertex Px (OA) - suboccipitobregmatic 9.5cm
Vertex Px (OP) - occipitofrontel diameter 11cm
Brow Px - supraoccipitomental diameter 13.5cm
Face Px - submentobregmatic 9.5cm
Inlet - AP 11.5cm - Transverse 13.5cm
Midpelvis - AP 11.5cm - Bispinous 10.5cm
Outlet - AP 11.5cm - Bituberous 11cm
Can we delvier? Depends on relationship of fetal head to ischial spines (station).
Engagement: passage fo widest diameter of px part below plane of pelvic inlet
Station: level above/below plane of ischial spines +2 = 2cm below spines, -2 = above spines
Second stage of labour
- how the head gets out during normal delivery
DESCENT: contractions from behind, gravity, maternal effort
FLEXION: resistance from cervix/pelvis/pelvic floor = flexion of fetal chin to chest - Occiput L Transverse
INT ROT: pressure behind+flexion+resistance from mid pelvis = rotate occiput so ant toward symphysis
EXTENSION: Vaginal outlet up and forward = head out occiput, siniput, nose, mouth, chin sweep over perineum
RESTITUTION: ext rot, head realign with shoulders so back to Occiput L Transverse
COMPLETION: check cord ard neck, ANT shoulder gentle downward traction/ POST shoulder elevate head/ REST of body follows
Clamp cord.
Second stage of labour
- Mx
Maternal: P, BP, T, UA
Fetal: FH auscultate after each contraction, colour of amniotic fluid
Progress of Labour: reassess descent, flexion, rotation of px part
Third stage of labour
- time
- signs of separation
Time from delivery of baby until separation and expulsion of placenta
- 5-10min of deliver (
Third stage of labour
- Active management
1) prophylactic oxytocic (Syntocinon/Ergometrine/Syntometrine)
2) controlled cord traction (placenta delviery)
3) Early cord clamping (active third stage, but if delayed = protects against Fe deficiency)
Third stage of labour
- post partum haemorrhage
Empty, intact, contracted uterus should not bleed
Causes:
- Antony (70%): uterine overdistension/infection/relaxants/fatigue/retained products of conception/uterine inversion
- Genital tract laceration
- Coagulopathy (preexisting, abruption, PET, FDIU, sepsis, AFE)
- Uterine inversion
Third stage of Labour
- Checklist and degree of laceration?
Perineal lacerations/episiotomy repair
- 1st degree (perineal skin or vaginal mucosa)
- 2nd (submucosal tissues of vagina or perineal muscles)
- 3rd (anal sphincter)
- 4th (rectal mucosa)
Check placenta
Check pack and needle count
Summary
- 3 stages of labour
- 3 principles of labour care
- progress in labour depends on
Contraction - full dilation - baby delivery - placenta delivery
Maternal/fetal/monitor progress of labour
Power, passage, passenger
