Module Five Flashcards
Defining sign of labour
presence of regular uterine contractions that become progressively stronger, frequent, and longer
Positive sign of labour
regular contractions with cervical changes - cervix moving from posterior –> anterior, shortening, thinning (effacing) and dilating
Maternal Prep for Labour
- inc estrogen activates uterus
- inc oxytocin and prostaglandin –> cervical ripening
- inc inflm activates cervix & uterus
- inc uterine oxy receptors
- inc central receptors (brain) for beta-endorphins continuing to endogenous analgesia in labour
- inc mammary & central oxytocin and prolactin receptors
Fetal Prep for Labour
- Pre-Labour lung and organ maturation
- develop. of oxy neuroprotection
- inc epinephrine and norepinephrine receptors to protect from hypoxia
- preservation of blood supply to <3 and brain via catecholamine surge and neuroprotection effects
Oxytocin
produced by posterior pituitary gland, optimizes rhythmic contractions, promotes calm, reduces fear and stress, promotes attachment
Beta-Endorphins
secreted by posterior pituitary gland, provides analgesia and adaptive responses to stress and pain
Catecholamines
epinephrine, norepinephrine, dopamine- released in response to fear, stress and perceived danger. Supports newborn transition to extrauterine life. Primary mediators that prepare fetus for birth and support multi-organ transition.
Cortisol
Stress hormone, elevated during labour, may promote contractions, increase central oxytocin effects on mat adaptations, attachment, postpartum mood. Prepares fetus for birth- promotes lung maturation and clearance of fetal lung fluid
True Labour
- Regular contractions that become stronger, longer, and more frequent
- Contractions become more intense with walking
- Contractions felt in lower back and radiates to lower abdomen
- Contractions continue despite use of comfort measures & rest
- Cervix softens, moves from post–> ant position, thins and dilates
- Presenting part of fetus is engaged in pelvis
- Bloody Show
False Labour
- Contractions continue irreg or stop/start
- Contractions may stop with activity or stop with rest
- Contractions can be felt in low back or abdomen above umbilicus
- Contractions stop/slow with comfort measures
- Cervix does not change
- Fetus may not be engaged
5 Ps of Labour
Passenger Passage Powers Position Psyche
Passenger
Fetus- size, presentation, lie, attitude, position
Passage
Mat pelvis- bones, soft tissues, cervix, pelvic floor, vagina
Powers
Contractions, voluntary bearing down efforts
Position
Woman’s position as she labours
Psyche
Woman’s strength, PMHx, ability to cope, perception of pain, level of fear/anxiety, values & beliefs, intentions
6 bones of fetal skull
two parietal, two temporal, occipital, frontal
fontanelles
anterior- diamond shaped, posterior - triangular
Primary powers
uterine contractions
Secondary powers
maternal pushing efforts
Position changes
relieve fatigue, increase comfort, improve circulation, gravity, opening pelvic diameters
7 Cardinal movements
- Engagement
- Flexion
- Descent
- Internal Rotation
- Extension
- Restitution and External Rotation
- Expulsion
First Stage
onset of regular contractions and ends when cervix fully dilated
Latent Phase (First Stage)
Starts when contractions become regular and painful, cervical effacement and dilation commences, complete at 3cm. Lasts 6-8h, contractions q5-30mins
Active Phase (First Stage)
time when labour is well established, contractions more painful, frequent, longer - cervix dilates from 4-7cm. Lasts 3-6 hours, contractions q3-5mins
Transition (Accelerated) Phase (First Stage)
cervix 8-10cm, signals approach of 2nd stage, contractions more expulsive in nature
Second Stage
Commences with full dilation and ends with birth of baby
Expulsive contractions and maternal efforts, gravity enhancing positions. Fetal head descends under public arch, gradually thinning and stretching the vaginal opening.
Crowning
Widest diameter of the head distends the opening
Restitution
Once head is born it rotates briefly to position it was in when entering the pelvis
Latent Phase (Second Stage)
Cervix fully dilated, fetus continues to descend, no urge to push
Active Phase (Second Stage)
Stretch receptors in pelvic floor trigger a strong urge to push - Ferguson’s reflex
Third Stage
Birth of a baby –> delivery of placenta and membranes
Signs of Placenta separation
- firmly contracted fundus
- change in uterine shape
- sudden gush of blood
- apparent lengthening of cord
- Feeling of vaginal fullness
Fourth Stage
One - Four hours postpartum
- physiologic adjustment & stabilization, uterus well contracted, moderate amount of vaginal bleeding
Assessing Fetal Well-being
FHR- 110-160 bpm
Assess q 15-30 min in active phase, q5min in 2nd stage
Assessing Contractions
palpate before, during, after contraction
- resting tone
- strength, duration, frequency
Non-pharmacological pain management
- intradermal sterile water injection
- music
- hypnosis
- relaxation
- breathing techniques
- massage
- heat/cold application
- acupressure & acupuncture
- transcutaneous electrical nerve stimulation
- water therapy
- position changes
Pharmacologic
- Inhalation - Nitronox and Entonox
- Narcotics- Opioids in early stages
- Regional Analgesia/Anesthesia - Epidural
Assessments during Second Stage
Mat VS q1h FHR q5min Contraction strength, freq, dur Descent Pushing strength, effectiveness Pain and Coping Position Changes- q20mins Spontaneous Pushing
Risk of PPH
10 IU Oxy @ delivery
Cord Clamped within 3 mins
Controlled traction to help with placental delivery
Maternal Assessment
signs of placental separation
VS q15mins for first hour
fundus and flow Q15 mins
assess pain
Newborn Assessment
Apgar 1+5 mins VS within 15mins VS hourly until temp stable Head to Toe Readiness to feed
Labour Dystocia
long, difficult, abnormal labour - variance in one of the 5Ps –> leading cause of c/s
Increased risk: obesity, short stature, advanced mat age, infertility, uterine abn, malpresentation, malposition, overstimulation of uterus with oxy, mat fatigue, dehydration, fear, use of epidural
Dysfunctional Labour
alteration in characteristics of uterine contractions - lack of progress in cervical dilation, lack of progress in fetal descent and expulsion
Passenger Variations
fetal size, fetal presentation, multifetal pregnancy, fetal anomalies
Cephalopelvic Disproportion
fetal head too big to move through pelvis - may result from malposition
Macrosomia
SFH measures larger than wk gest. Excess wt gain, partner above average height and weight
Shoulder Dystocia
Obstetrical Emergency***
head is born but ant shoulder cannot pass under pubic arch - asphyxia, fractures to humerus/clavicle, brachial plexus nerve injury, trauma, rectal injuries, PPH
Malpresentation
something other than head is presenting part
External Cephalic Version
OB attempts to turn fetus from breech –> cephalic
Malposition
most common- persistent occiput posterior position - OP, ROP, LOP
- irreg contraction pattern, long and slow labour, back pain
- Upright forward leaning, lunging, rocking –> fetal descent and rotation
Deflexed Head
presents a wider diameter of the head and is associated with a longer, slower labour
Asynclitism
Head is tilted to one side or other instead of in alignment with the shoulders
Persistent Cervical lip
thin ribbon or lip of cervix at front or side
Oxytocin for Induction
RISKS: uterine hyperstimulation, Placental abruption, uterine rupture, unnecessary c/s d/t abn FHR, PPH, poor fetal oxy, hypoexmia, acidosis
hyperstimulation
6 or more contractions in 2 consecutive 10 min windows OR contractions lasting >120s
tachysystole
more than 5 contractions per 10 min period over 30 mins
hypertonus
contraction lasting greater than 120s
Vacuum Assisted Delivery
Trauma to perineum, vagina, cervix, cephalhematoma, scalp lacerations, subdural hematoma
Forcep Assisted Birth
Trauma to vagina, cervix, perineum, PPH, lacerations, bruising, facial palsy, subdural hematoma
Conditions for Vac & Forcep deliveries
- Fully dilated cervix
- Ruptured Membranes
- Empty Bladder
- Engagement
- Maternal Pelvis Assessment
- Maternal Consent
C/S complications
Anesthesia issues Hemorrhage Bowel/Bladder injury Amniotic Fluid Embolism UTI Abd Wound Hematoma Wound Dehiscence Infection Thromboembolism
Preterm Birth
Inc incidence of resp distress and tachypnea
separation of mum and babe affecting attachment
Contraindications to VBAC
“T’ Classic scar from prev C/S
prev uterine rupture
presence of contraindication to labour
Uterine Rupture- S&S
- atypical/abn FHR pattern
- cessation of contractions
- constant abd pain
- vag bleeding
- hematuria
- mat shock
