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Labour Flashcards

1
Q

Define labour

A

The process in which the fetus, placenta and membranes are expelled via the birth canal.
Results in a spontaneous vaginal birth (SVD).

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2
Q

What is considered term in pregnancy?

A

37-42 weeks

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3
Q

What key physiological changes must take place to allow for expulsion of the fetus?

A
  • Cervix softens
  • Myometrial tone changes to allow for coordinated contractions
  • Progesterone decreases/Oxytocin and prostaglandins increase to allow initiation of labour
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4
Q

What does stage 1 of labour consist of?

A
  • Latent first stage

- Established first stage

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5
Q

What takes place in the latent first stage of labour?

A

-Uterine contractions, starting at the fundus

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6
Q

When does the established first stage of labour begin?

A

Cervix dilated to 5cm

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7
Q

When does the established first stage of labour end?

A

Cervix fully dilated (10cm)

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8
Q

What does stage 2 of labour consist of?

A

Full cervical dilation to birth of baby

Passive and Active second stage

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9
Q

What does stage 3 of labour consist of?

A

Expulsion of placenta and membranes

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10
Q

What is involved in active management of third stage of labour?

A

Routine use of uterotonic drugs, optimal cord clamping, controlled cord traction (oxytocins)

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11
Q

What defines prolonged third stage of labour?

A

If third stage is not completed within 30 minutes of birth.

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12
Q

What is involved in progress and monitoring of labour?

A
  • Maternal observations
  • Abdominal palpation
  • Vaginal examination
  • Monitoring of liquor
  • Auscultation of fetal heart
  • Palpation of uterine muscle contractions
  • External signs eg Rhomboid of Michaelis and cleft line
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13
Q

What is used to monitor fetal heartbeat?

A

CTG (Cardiotocography)

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14
Q

What are the different types of fetal lie in pregnancy?

A
  • Oblique lie
  • Longitudinal lie
  • Transverse lie
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15
Q

What head position is easiest for birth?

A

Occiput anterior (OA)

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16
Q

What are the mechanisms of labour?

A
  • Descent
  • Flexion
  • Internal rotation of the head
  • Crowning and extension of head
  • Restitution
  • Internal rotation of shoulders
  • External rotation of the head
  • Lateral flexion
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17
Q

What defines crowning?

A

The widest part of the vertex coming out?

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18
Q

What analgesia are used in labour?

A
  • Breathing, massage, TENS, paracetamol, dihydrocodeine,
  • Water
  • Entonox
  • Opioids
  • Remifentanil and patient controlled analegsia
  • Epidural
  • Maternal positioning
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19
Q

Approximately how many pregnancies are induced?

A

1 in 5

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20
Q

What risks may be involved in induction of labour?

A

Uterine ‘hyperstimulation’ with prostaglandin/oxytocin induction

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21
Q

List some indications for induction

A

Diabetes
Post dates - Term + 7 days
Maternal health problem that requires planning for delivery (eg DVT treatment)
Fetal reasons (growth concerns, oligohydraminos)

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22
Q

What is involved in induction?

A
  • Instigation of labour artificially using medications/devices to ‘ripen cervix’
  • Usually followed by artificial rupture of membranes
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23
Q

What scoring system is used to clinically assess the cervix in induction?

A

Bishop’s score

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24
Q

What can be used to ripen (open) the cervix?

A

Prostaglandin pessaries/Cook Balloon

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25
Q

What Bishop’s score is considered favourable for amniotomy?

A

7 or more

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26
Q

What is an amniotomy?

A

Artificial rupture of fetal membranes usually using a sharp device eg amniohook

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27
Q

What medication is used following amniotomy to achieve adequate contractions?

A

IV oxytocin

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28
Q

What factors are used to determine progress in labour?

A

Cervical effacement
Cervical dilatation
Descent of fetal head through maternal pelvis

29
Q

What defines suboptimal progress in the active first stage of labour?

A

Cervical dilatation less than 0.5cm/hour in primigravid women/ 1cm/hour in parous women

30
Q

What occurs in cephalopelvic disproportion (CPD)?

A

Fetal head is in the correct position for labour, but too large to negotiate maternal pelvis
Caput and moulding develop.

31
Q

Give an example of malpresentation

A

Transverse position

32
Q

What is malposition?

A

Fetal head is in incorrect position for labour, ‘relative’ CPD occurs.

Eg occipito-posterior and occipito-transverse

33
Q

What is used to monitor fetal well being in labour?

A

Intermittent auscultation of the fetal heart
Cardiotocography
Fetal blood sampling
Fetal ECG

34
Q

What is fetal heart rate?

A

110 - 160 bpm

35
Q

What can indicate stress reactions in CTG?

A

Prolonged/Slow to recover decelerations

36
Q

When is fetal blood sampling used?

A

-When abormal CTG occurs (provides a direct measurement of pH - likely hypoxaemia etc)

37
Q

In which situations would you advise not to labour?

A

Obstruction to birth canal (major placenta praevia, masses)
Malpresentations (Transverse, shoulder, hand, ?breech?)
Medical conditions where labour would be unsafe
Specific previous labour complications
Fetal conditions

38
Q

What percentage of births are assisted/instrumental deliveries?

A

15%

39
Q

What types of instruments are used in instrumental deliveries?

A

Forceps

Vacuum extraction

40
Q

What is an essential procedure for management of obstructed labour or fetal distress before cervix is fully dilated?

A

Caesarean section

41
Q

What are the increased risks in caesarean section?

A

Increased risks of infection, bleeding, visceral injury and VTE.

42
Q

What third stage complications can occur in pregnancy?

A

Retained placenta
Post partum haemorrhage
Tears (1st - 4th degree)

43
Q

What are common problems in the post partum period?

A

Problems with infant feeding
Problems with bonding
Social issues

44
Q

List some postnatal problems?

A 
Post partum haemorrhage
Venous throboembolism
Sepsis
Psychiatric disorders of the puerperium
Pre-eclampsia
45
Q

What defines primary postpartum haemorrhage?

A

Blood loss of >500ml within 24hrs of delivery

46
Q

What defines secondary postpartum haemorrhage?

A

Blood loss of >500ml from 24hrs post partum to 6 wks

47
Q

Why does pregnancy/post partum period increase the likelihood of DVT/PE?

A

-Hypercoagulable state

6-10 times more likely to develop DVT or PE

48
Q

When do most eclamptic seizures take place?

A

In the postnatal period

49
Q

When may synthetic oxytocin be used?

A

Induction of labour (IOL) and augmentation of labour

50
Q

Roughly how long should birth take after active second stage of labour?

A

1-2 hours

(Depending on multigravida vs primagravida

51
Q

Give some reasons for inadequate progress during labour

A
  • Cephalopelvic disproportion (CPD)
  • Malposition
  • Malpresentation
  • Inadequate uterine activity
  • Other reasons for obstruction (cyst/fibroid)
52
Q

Why is it important to exclude an obstructed labour in the circumstances of inducing labour in inadequate uterine activity?

A

Stimulation of an obstructed labour could result in a ruptured uterus

53
Q

What risks are decrease in caesarean section?

A

Reduced risk of perineal injury compared to vaginal birth

54
Q

What would be the role of the midwife during the post partum period?

A
  • Continue to observe for signs of abnormal bleeding
  • Observe for evidence of infection (Wound/Endometriosis/Breast)
  • Debrief events around birth
55
Q

Why is warfarin not used to treat DVT/PE in pregnancy?

A

Teratogenic

But can be used in breast feeding

56
Q

When do most eclamptic seizures take place?

A

Postnatally

57
Q

List some drug-free methods of reducing pain in pregnancy?

A 
Birthing ball
Birthing pools
TENS machines
Hypnotherapy
Aromatherapy
58
Q

What simple drugs are available for labour?

A

Entonox

Diamorphine

59
Q

What advanced drugs are available during labour?

A 
Remifentanil PCA (Patient Controlled analgesia)
Epidural
60
Q

What are some absolute contraindications to induction of labour?

A

Abnormal lie
Known pelvic obstruction such as tumour or large ovarian cyst
Placenta praevia
Fetal distress

61
Q

What are some relative contraindications to induction of labour?

A

Previous caesarean section (Risk of rupture to scar tissue)

Asthma

62
Q

When is augmentation of labour required?

A

When contractions reduce in frequency or strength in active labour, even after spontaneous onset.

63
Q

What medication is used to augment labour, if indicated?

A

Oxytocin

64
Q

What medications are used in the active management of the third stage of labour?

A

Syntometrine (Oxytocin and ergotamine)

Oxytocin

65
Q

What medications are given if risk of preterm labour?

A

Steroids (Betamethasone/Dexamethasone) - improve fetal lung development

Tocolytics - inhibit uterine contractions

66
Q

Which drugs are used in tocolysis?

A

Calcium channel blocker eg Nifedipine
Oxytocin receptor antagonist eg Atosiban
Beta2 agonists eg Salbutamol
Indomethacin

Acutely - Terbutaline/GTN

67
Q

What is tocolysis

A

Inhibiting uterine contractions (sometimes to help prevent preterm labour)

68
Q

What are some contraindications to epidural use in labour?

A 
Thrombocytopenia,
Coagulopathy
Raised ICP
Local sepsis
Septic shock
Allergy to local anaesthetic
Recent anticoagulants
69
Q

What is the general management of labour in multiple pregnancy?

A

-If first fetus is vertex presentation, normal delivery.

If both breech/breech-vertex - caesarean section

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