Management of Normal Birth and Labour

Question 1

What are the features of normal birth?

Answer 1

1) Spontaneous onset, low-risk at the start of labour and remaining so throughout labour and delivery
2) The infant is born spontaneously in the vertex position between 37 and 42 completed weeks of pregnancy
3) After birth, mother and infant are in good condition

Question 2

Aside from women whose labour starts spontaneously, progresses spontaneously without drugs, and who give birth spontaneously what other women does the normal delivery group include?

Answer 2

Women who experience…

1) Augmentation of labour - slow natural progress but membranes are ruptured artificially to speed up process
2) Artificial rupture of the membranes (ARM) if not part of medical induction of labour
3) Entonox (gas and air)
4) Opioids
5) Electronic fetal monitoring
6) Managed third stage labour
7) Antenatal, delivery or postnatal complications incl. PPH, perineal tear, repair of perineal trauma, admission to SCBU or NICU

Question 3

Why is encouraging normal birth important?

Answer 3

1) Safety
2) Physical - easier to recover from than C section, iatrogenesis
3) Psychological - reduced incidence of PTSD in normal birth
4) Financial
5) Natural bonding process
6) Colonisation of baby - when passing through the birth canal, the baby is colonised through maternal gut which improves feeding and gut health of infant long into childhood
7) Higher rates of successful breastfeeding

Question 4

What maternal features do we monitor during labour (on a partogram)?

Answer 4

1) Contractions - marked wider lines if mild and v thick if stronger, and can see number of contractions in 5 mins
2) Cervical dilation - crosses on second chart down
3) Vital signs
4) Drugs/fluid
5) Urine output and input
6) PV (per vaginum) loss
7) Pain - coping? pain relief?
8) Emotional state

Question 5

What maternal vital signs do we monitor and how often?

Answer 5

Maternal temp hourly and maternal pulse and BP half hourly

Question 6

What are the types of PV loss?

Answer 6

1) Liquor - clear, comes if membranes have gone, distinct smell
2) Blood - a little bit is normal
3) Meconium - think black tarry stuff passed by baby in utero - if they are distressed they may open bowels

Question 7

When will the baby pass meconium if they don’t pass it in utero?

Answer 7

• If they don’t pass it in utero they will pass it in the first few days of life

Question 8

What does the type of meconium indicate?

Answer 8

• Look at consistency, thickness and colour
• Straw colour = baby has been stressed at some point but probably ok
• Thick and brown = baby is stressed

Question 9

Why do we monitor maternal urine output and input in labour?

Answer 9

A distended bladder will delay progress of descent of baby’s head or cause problems passing urine post birth

Question 10

What fetal features do we monitor during labour?

Answer 10

1) Fetal heart activity (FHR)
2) Position
3) Descent of baby’s head -circles on partogram

Question 11

How does position of the fetus affect labour?

Answer 11

• If the baby is lying with its back against its mum’s back this can cause lots of back ache and slower labour
• The baby should rotate before it is born (short or long way)
• Or it can stay as persistent occipito-posterior - back of baby’s head is against mum’s back

Question 12

How does the descent of the baby’s head affect affect affect labour?

Answer 12

OP position (wider diameter coming down) descent will be slower than in vertex position

Question 13

What are non-pharmalogical methods of pain relief in labour?

Answer 13

1) Breathing and relaxation
2) Massive
3) Water - although most women end up wanting to actually deliver out of the pool
4) Hypnobirthing
5) Aromatherapy
6) Music therapy
7) TENS (transcutaneous electrical nerve stimulation) machine

Question 14

Describe use of TENS for pain relief in labour

Answer 14

Very effective if pads are placed low down either side of maternal spine and really stimulates endorphins which helps pain esp. in early first stage of labour

Question 15

What are pharmacological methods of pain relief in labour?

Answer 15

1) Entonox

2) Opioids e.g. pethidine

Question 16

What is regional analgesia given as pain relief in labour?

Answer 16

Epidural - can walk around as lower dosage but often tired

Question 17

Describe treatment with Entonox for pain relief in labour

Answer 17

• Usually with mouth piece
• Well controlled
• Breathed in as they feel contraction coming therefore peaks when contraction peaks and as they breathe out it is expelled from the system v quickly afterwards

Question 18

What is the problem with opioids for pain relief in labour?

Answer 18

• If given too close to time of the delivery, the baby may need narcan to reduce its effects as it stays in the system
• Half life

Question 19

When do you clamp the umbilical cord?

Answer 19

When pulsation has stopped

Question 20

Why do you delay cord clamping until the cord has stopped pulsating?

Answer 20

• The cord and placental system will contain about ⅓ of the baby’s blood (remaining ⅔ is in baby)
• Therefore want to wait for the cord to stop pulsating so that the baby gets as much blood out of the placenta as it needs

Question 21

What needs to be done once the placenta is delivered?

Answer 21

• The midwife will check it to ensure that it is complete incl. all the membranes
• They will also check that none is left inside the mother as this can lead to postpartum infection and haemorrhage

Question 22

What can be done to induce the third stage of labour?

Answer 22

Breastfeeding

- It can stimulate a contraction and help the placenta separate from the womb

Question 23

What are parts of active management of the third stage of labour recommended by WHO?

Answer 23

1) Routine use of IM uterotonic drugs e.g. syntometrine
2) Deferred clamping and cutting of the cord
3) Once the placenta is in the lower segment, the midwife will guard the uterus and apply gentle downward traction to deliver placenta - controlled cord traction after signs of separation of the placenta

Question 24

What is the benefit of active management of the third stage of labour?

Answer 24

• Active management reduces (immediate) blood loss but overall blood loss is similar in active and physiological management
• However if have PPH likely to be around time of delivery in first 24h (remains a killer of women)

Question 25

Describe routine use of uterotonic drugs as part of active management of the third stage of labour

Answer 25

• Given IM to the mother when the anterior shoulder of the baby is born
• They force the uterus to clamp down, causing the placenta to sear off the wall and then pass down into the lower segment
• e.g. syntometrine

Question 26

What are the features of physiological management of the third stage of labour (compared to active management)?

Answer 26

1) No routine use of uterotonic drugs
2) No clamping of the cord until pulsation has stopped
3) Delivery of the placenta by maternal effort once placenta has separated and in lower segment - mother expels placenta

Question 27

Why do we tend to deliver the baby straight up onto the mother’s abdomen?

Answer 27

Many women instinctively want to cuddle their newborn baby ‘skin-to-skin’ straight after birth so tend to deliver baby straight up onto mother’s abdomen (this instinct is supported by scientific research)

Question 28

What should the mother (or father) and baby do immediately after birth?

Answer 28

• Early skin-to-skin contact has important benefits for both mums and babies, helping them both to recover from the birth and get to know one another
• If mum is unwell then skin-to-skin contact with father or birth partner is beneficial for child

Question 29

What are the benefits to the baby of early skin-to-skin contact immediately after birth?

Answer 29

1) More likely to latch on and latch on well
2) Will indicate to his mother when he is ready to feed
3) Less likely to cry - quite awake, quiet
4) Maintains his temperature, HR, RR and BP
5) Has higher blood sugar - sometimes their blood sugar can plummet otherwise
6) More likely to breastfeed exclusively and breastfeed longer

Question 30

What are the options for birth locations for both multiparous and nulliparous women?

Answer 30

1) Home (small increase in risk of adverse outcome for baby for nulliparous women)
2) Free-standing midwifery unit (midwifery units are good bc rate of interventions is lower and outcome for baby is no different compared to obstetric unit)
3) Alongside midwifery unit
4) Obstetric unit

Question 31

What is the puerperium?

Answer 31

• The time from the end of the third stage thorough the first few weeks after delivery
• Usually considered to be 6-8 weeks in duration
• Also known as postnatal or postpartum period

Question 32

What are the objectives of care during the puerperium?

Answer 32

1) Monitor physiological changes for mother (returning to pre-pregnant self) and baby (adaptation to life)
2) Diagnose and treat postnatal complications
3) Give/offer mother emotional support
4) Establish infant (breast)feeding
5) Advice about contraception - used to be idea that if breastfeeding can’t get pregnant again