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Normal labour Flashcards

1
Q

Define labour.

A

Labour is the process in which the fetus, placenta and membranes are expelled via the birth canal.

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2
Q

Normal labour description.

A
  • Spontaneous
  • 37-42 weeks gestation
  • foetus presenting by the vertex
  • Results in a spontaneous vaginal delivery (SVD)
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3
Q

What key physiological changes must occur to allow for expulsion of the foetus?

A
  • Cervix softens
  • Myometrial tone changes to allow for coordinated contractions
  • Progesterone decreases whilst oxytocin and prostaglandins increase to allow for labour to initiate
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4
Q

Define stage I of labour.

A

Time from the onset of labor until complete dilation of the cervix has occurred.

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5
Q

Stage I latent phase.

A

Occurs during onset of labor, ends at 6 cm of cervical dilation. Characterized by mild, infrequent, irregular contractions with gradual change in cervical dilation (< 1 cm per hour).

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6
Q

Stage I active phase.

A

Occurs after the latent phase at ≥ 6 cm of cervical dilation, ends with complete (∼ 10 cm) cervical dilation. Characterized by an increase in the rate of cervical dilation (1–4 cm per hour).

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7
Q

Anticipated progress of stage I of labour.

A

0.5 – 1.0 cm per hour.

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8
Q

Definition of stage II of labour.

A

From full cervical dilatation to the birth of the baby.

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9
Q

How long should the active second stage of labour last?

A
  • Primigravida birth would be expected within two hours of active second stage
  • Multigravida birth would be expected within one hour of active second stage
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10
Q

Definition of stage III of labour.

A

The time from the birth of the baby to the expulsion of the placenta and membranes.

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11
Q

What is prolonged third stage of labour?

A

If it is not completed within 30 minutes of the birth with active management or within 60 minutes of the birth with physiological management.

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12
Q

What does active management of the 3rd stage involve?

A
  • Early clamping and cutting of the umbilical cord (now routine practice is to allow 2-5 minutes of delayed cord clamping for all women unless contraindicated)
  • Use of uterotonic medications
  • Delivery of the placenta by controlled cord traction
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13
Q

Which drugs does the active management of the 3rd stage use?

A
  • Syntometrine
  • Oxytocin
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14
Q

Progress and monitoring

A
  • Maternal observations
  • Abdominal palpation
  • Vaginal examination
  • Monitoring of liquor
  • Auscultation of the fetal heart
  • Palpation of uterine muscle contractions
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15
Q

Mechanism of labour

A
  • Descent
  • Flexion
  • Internal rotation of the head
  • Crowning and extension of the head
  • Restitution
  • Internal rotation of the shoulders
  • External rotation of the head
  • Lateral flexion
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16
Q

Non pharmacological analgesia.

A
  • breathing exercises
  • aromatherapy
  • water
  • hyponobaby
  • TENS machine
17
Q

Simple analgesia

A
  • paracetamol
  • dihydocodeine
  • aspirin
18
Q

Other analgesia

A
  • Entonox - nitrous oxide
  • opiates
  • epidural
  • spinal anaesthesia
19
Q

Paracetamol

A

Safe throughout pregnancy; may be used in latent phase of labour for pain relief

20
Q

Dihydrocodiene

A
  • May be useful in latent phase of labour
  • Make sure patient aware of side effects (nausea, constipation, drowsiness)
  • Risk of neonatal respiratory depression
21
Q

Aspirin

A

Avoid in labour for acute pain relief as it increases bleeding risk

22
Q

Risks from taking NSAIDs in pregnancy

A
  • premature closure of the foetal ductus arteriosus
  • foetal oliguria
  • oligohydramnios after 30 weeks gestation
  • bleeding in foetus
23
Q

Entonox

A
  • Patient can self-administer during contractions by inhaling through a mouthpiece attached to the wall
  • Quick onset, short half-life
  • Usually reserved until in active labour
24
Q

Opiates

A
  • Can cause nausea and vomiting, drowsiness and respiratory depression in the woman
  • Can cause neonatal respiratory depression
  • Usually co-prescribe with an antiemetic
  • example is Remifentanyl PCA (Patient controlled analgesia)
25
Q

Antidote to opiate

A

Naloxone

26
Q

When is local anaesthetic used?

A
  • injected intradermally before a woman has a large bore IV cannula inserted
  • used after delivery to suture an episiotomy or vaginal tear
  • pudendal nerve block before an assisted/instrumental vaginal delivery
27
Q

What drug is normally used for a local anaesthetic?

A

Lidocaine

28
Q

Epidural

A
  • Woman and fetus require monitoring when epidural in situ; labour must be managed on a labour ward
  • Epidurals are sited by an anaesthetist
  • Involves injection of local anaesthetic and opiate medications into the epidural space using a catheter
29
Q

Epidural advantages

A
  • Effective analgesia during labour
  • Can be topped up if need to transfer to theatre for instrumental or caesarean section delivery
  • Effective after delivery if need to repair vaginal tears or manual removal of placenta (MROP)
  • Best for baby
  • Can prevent further raised blood pressure in pre-eclampsia
30
Q

Epidural disadvantages

A
  • Can fail to provide adequate analgesia (1 in 10 need re-sited)
  • Causes hypotension (1 in 50 chance; dose-dependent)
  • Reduces woman’s mobility
  • Dural puncture (1 in 100 chance)
  • Epidural haematoma / abscess (<1 in 10000 chance)
  • Risk of respiratory depression (1 in 100 to 1 in 1000 chance)
  • Risk of neurological deficits (1 in 10000 to 1 in 40000 chance)
31
Q

Spinal anaesthesia

A
  • Used for most caesarean sections (elective and emergency)
  • Usually a local anaesthetic and opiate medication are injected into the subarachnoid space
  • The anaesthetist must check the level of the anaesthetic block is adequate before the operation begins
32
Q

Spinal anaesthesia advantages

A
  • Gives dense, anaesthetic bilateral block
  • Patient can stay awake & protect own airway during operation
  • woman can stay awake to meet her baby
33
Q

Spinal anaesthesia disadvantages

A
  • 2-3% risk of inadequate pain relief - may need other analgesics or may require general anaesthetic
  • Shorter duration - can wear off. May be problem if surgery takes longer than expected (>60-90mins)
  • Causes hypotension (due to blockade of the sympathetic nerves) similar to epidural and general anaesthetic
  • Patient needs urinary catheter
  • Risk of dural puncture - post dural puncture headache
  • Patient may suffer from pruritus or nausea and vomiting
  • Small risk of nerve damage
34
Q

Dural puncture

A
  • post dural puncture headache (worse on sitting up or standing; can be treated using a epidural blood patch)
35
Q

When may a general anaesthetic be required for a pregnant woman and what are the risks?

A
  • General anaesthetic (GA) agents may be required for pregnant women for example if an emergency caesarean section is needed and there is not enough time to site a spinal anaesthetic block or if spinal anaesthesia fails
  • General anaesthesia can be more difficult in pregnancy due to increased risk of aspiration of stomach contents and more difficult intubation in pregnant women

Reproduction (34 decks)

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