Intrapartum: Key Stages of Labour

Question 1

What 9 key stages can labour be broken down into?

Answer 1

1) Descent
2) Engagement
3) Neck flexion
4) Internal rotation
5) Crowning
6) Extension of the presenting part
7) Restitution
8) External rotation
9) Lateral flexion

Question 2

What is the most low risk presentation?

Answer 2

Cephalic (vertex) presentation with a longitudinal lie

Question 3

What are the posterior, lateral & anterior borders of the pelvic inlet?

Answer 3

Posterior: sacral promontory

Lateral: Iliopectineal line

Anterior: pubic symphysis

Question 4

What are the posterior, lateral & anterior borders of the pelvic oulet?

Answer 4

Posterior: tip of coccyx
Lateral: ischial tuberosity
Anterior: pubic arch

Question 5

Descent of fetal head position in the pelvic inlet?

Answer 5

The transverse diameter is greater than the antero-posterior (AP) diameter in the pelvic inlet, so the widest circumference of the fetal head descends in a TRANSVERSE position.

I.e. the transverse diameter of the pelvic inlet is bigger than the AP diameter.

Question 6

Descent of fetal head position in the pelvic outlet?

Answer 6

When it gets closer to the pelvic outlet, the nature of the pelvic floor muscles encourages the fetal head to rotate from a transverse position to an anterior-posterior position, as the AP diameter is greater than the transverse diameter.

I.e. the AP diameter of the pelvic outlet > pelvic inlet.

Question 7

What is ‘descent’?

Answer 7

The fetus descends into the pelvis.

Note - descent and engagement occur together, rather than as completely separate/distinct stages, so consider them as 2 parts of the same process/stage.

Question 8

In the primigravida, when is descent likely to occur?

Answer 8

From 38 weeks gestation onwars

Question 9

In a multigravida, when is descent likely to occur?

Answer 9

May not occur until labour is established.

Question 10

What is descent encouraged by?

Answer 10

• Increased abdominal tone
• Braxton hicks in the late stages of pregnancy
• Fundal dominance of the uterine contractions
• Increased frequency and strength of contractions during labour

Question 11

As the head descends, it moves towards the pelvic brim in either the left or right occipito-transverse position.

What does this position mean?

Answer 11

This means the occiput can be facing the left side or right side of the mother’s pelvis.

This allows the widest part of the fetal head to fit through the widest part of the pelvic inlet.

Question 12

What is enagement?

Answer 12

This is when the largest diameter of the fetal head descends into the maternal pelvis.

The term engagement is referring to the widest part of the fetal head successfully negotiating its way down deep into the maternal pelvis.

Question 13

How is engagement identified?

Answer 13

Engagement is identified by abdominal palpation, where the fetal head is 3/5th palpable or less.

Question 14

What does descent occur due to?

Answer 14

1) Uterine contractions

2) Amniotic fluid pressure

3) Abdominal muscle contractions

Question 15

What occurs during ‘flexion’?

Answer 15

As the fetal head comes into contact with the pelvic floor, cervical flexion occurs (i.e. chin to chest).

This allows the the circumference of the fetal head to reduce to sub-occipitobregmatic (9.5cm).

In this position, the fetal skull has a smaller diameter which assists passage through the pelvis.

Question 16

What occurs during ‘internal rotation’?

Answer 16

Fetal head rotates from the left or right occipito-transverse position a total of 90-degrees, to an occipital-anterior (occiput facing forward) position, to lie under the subpubic arch.

With each maternal contraction, the fetal head pushes down on the pelvic floor. Following each contraction, a rebound effect supports a small degree of rotation.

Regular contractions eventually lead to the fetal head completing the 90-degree turn.

Further descent leads to the fetus moving into the vaginal canal and eventually, with each contraction, the vertex becomes increasingly visible at the vulva.

Question 17

Describe the shape of the pelvic floor

Purpose of this shape?

Answer 17

Gutter shape, with a forward and downward slope.

This allows the head to rotate from a left or right occipito-transverse position to an occipito-posterior position.

Question 18

When does internal rotation typically occur?

Answer 18

This occurs during established labour and it is commonly completed by the start of the second stage.

Question 19

What is ‘crowning’?

Answer 19

When the widest diameter of the fetal head successfully negotiates through the narrowest part of the maternal bony pelvis.

The fetal head is then considered to be ‘crowning’.

Question 20

When is crowning clinically evident?

Answer 20

When the head, visible at the vulva, no longer retreats between contractions.

Question 21

During crowning, what is the mother often encouraged to do?

Answer 21

Often the woman, who has been pushing, is encouraged to pant so that the head is born with control.

Question 22

What occurs during ‘extension of the presenting part’?

Answer 22

The occiput slips beneath the suprapubic arch allowing the head to extend.

The fetal head is now born and will be facing the maternal back with its occiput anterior.

Question 23

What occurs during ‘external rotation & restitution’?

Answer 23

The head externally rotates to face the right or left medial thigh of the mother.

During the next contraction, the shoulders, having reached the pelvic floor, will complete their rotation from a transverse position to an anterior-posterior position.

Question 24

What is involved in ‘delivery of the shoulders and body’?

Answer 24

Downward traction by the healthcare professional will assist the delivery of the anterior shoulder below the suprapubic arch.

This is followed by upward traction assisting the delivery of the posterior shoulder.

The fetal body will be delivered by the contractions, the health professional’s role is only to assist safe negotiation of this last stage.

Question 25

Horizontal vs vertical muscles of the uterus during labour?

Answer 25

Horizontal:
- bands are drawn upwards during labour, causing the cervix to thin and dilate (open)
- bands of muscle are thicker and stronger nearer to the cervix

Vertical:
- these muscles actively contract and shortern, drawing the horizontal layers upwards

Question 26

What is the latent phase of labour

Answer 26

This is a period of time, not necessarily continuous, when there are painful contractions, and some cervical change, including cervical effacement and dilatation up to 4cm.

Question 27

What is established labur

Answer 27

There are regular painful contractions, and progressive cervical dilatation from 4cm.

Question 28

Up to what cervical dilatation is labour ‘latent’?

Answer 28

Up to 4c,

Question 29

What are the 3 stages of established labour?

Answer 29

1st: From onset of established labour (4cm) to full dilatation of the cervix (10cm)

2nd: From full dilatation to birth of the baby

3rd: From birth of the baby to expulsion of the placenta and membranes

Question 30

What is cervical dilation?

Answer 30

The gradual opening of the cervix measured in cm from 0 to 10cm.

Question 31

What can assist in the cervical dilatation and descent of the head?

Answer 31

Encourage the woman to mobilise e.g. walking, birthing balls, squatting, rocking, on hands and knees

This reduces the duration of labour, the risk of caesarean birth, the need for epidural.

Question 32

Passive vs active 2nd stage of labour?

Answer 32

Passive: The finding of full dilatation of the cervix prior to or in the absence of involuntary expulsive contractions.

Active: Expulsive contractions or active maternal effort with a finding of full dilatation of the cervix (this occurs as the head moves down to the pelvis and applies pressure to the pelvic floor).

Question 33

Active vs passive management of 3rd stage of labour?

Answer 33

Active:
- Routine use of uterotonic drugs (i.e syntometrine)
- Deferred clamping and cutting of the cord (>1 min)
- Controlled cord traction

Passive:
- No routine use of uterotonic drugs
- No clamping of the cord until pulsation has ceased
- Delivery of the placenta by maternal effort.

Question 34

Benefits of active management of 3rd stage of labour?

Answer 34

1) Reduces the risk of postpartum haemorrhage

2) Shortens the length of the 3rd stage

Question 35

Disadvantages of active management of 3rd stage of labour?

Answer 35

The uterotonic drugs can increase the amount of nausea and vomiting experienced by women.

Question 36

What does delayed cord clamping and waiting for the cord to stop pulsating reduce the risk?

Answer 36

Anaemia in babies

Question 37

What are some non-pharmacological options for pain relief in labour?

Answer 37

• massage
• relaxation & breathing
• water
• mobilisation

Question 38

What are some pharmacological options for pain relief in labour?

Answer 38

• paracetamol
• nitrous oxide (gas & air)
• opiates (diamorphine)
• epidural

Question 39

What does an epidural increase the risk of ?

Answer 39

Instrumental delivery

Question 40

What should monitoring of mother during labour involve?

Answer 40

1) Contractions: frequency, strength and length of contractions gives a good indication of progress in labour.

2) Vaginal loss: once membranes have ruptured, observe for meconium or heavy blood staining that could indicate an antepartum haemorrhage.

3) Vital signs: to pick up problems such as infection, hypertension, or early signs of shock from concealed bleeding.

Question 41

How is fetus monitored in low risk women during labour?

Answer 41

Intermittent ausculation of the fetal heart using a Doppler US or Pinard stethoscope.

Question 42

How is fetus monitored in high risk women during labour?

Answer 42

Continuous fetal monitoring using a cardiotocograph (CTG).