Normal labour and delivery Flashcards
What are the 3 factors which affect progression of labour? [can contribute to Failure of progression]
The Passage (birth canal»_space; eg Pelvic inlet/outlet; Pelvic floor, Pernieum etc…)
The Power
The Passenger (eg Macrosomia + Lie//Presentation//Position)
What are the frequency of normal contractions in early and advanced labour?
Every 3-4 minutes in early labour
Every 2-3 minutes in advanced labour
What are the 3 factors which are at play by “the passenger” during delivery
LIE // PRESENTATION // POSITION:
Lie = relationship of fetal long axis of the baby to that of the mother
» Longitudinal. Oblique. Transverse.
Presentation = the part of the fetus lowermost in the uterus
» Cephalic [vertex, brow, face]. Breech. Shoulder.
Position = relation of the fetal denominator to the maternal pelvis
»Occipitoanterior, Occipitotransverse, Occipitoposterior
» (Denominator = part of fetus used as reference point to describe position in maternal pelvis)»_space; Occiput. Mentum. Sacrum. Acromion.
What are the stages of fetal movements in labour?
- Engagement
- Flexion
- Descent
- Internal rotation
- Extension
- External rotation
What features of the mother are monitored in labour?
Obs»_space; BP, Pulse, Temp
Hydration, Analgesia, Antacids, Bladder care, Position
Progress:
* Contractions
* Cervical dilation
* Descent of presenting part
3rd stage:
* Active management
* Oxytocics and controlled cord traction
Perineum (for tears – include PR exam)
What features of the fetus are monitored in labour?
Fetal heart monitor
Colour of liquor
Name 5 common problems in labour
Failure to progress
Malpresentation / Malposition
Suspected fetal compromise (Fetal distress)
Vaginal Birth After Caesarean Section (VBAC)
Operative delivery
Shoulder dystocia
Give 4 causes of failure to progress
Think»_space; Powers, Passenger, Presentation
Inadequate contractions
Fetal malposition / malpresentation
Cephalopelvic disproportion (relative, absolute)
Obstructed labour
Maternal exhaustion
What are the complications associated with a breech presentation?
Trapped aftercoming head
Cord prolapse
Intracranial haemorrhage
Internal injuries
Give 4 possible causes of Suspected Fetal Compromise during labour
Uterine hyperstimulation (? iatrogenic)
Hypotension
Poor fetal tolerance of labour (eg IUGR)
Cord compression
Infection
Maternal disease
What is the management for Suspected Fetal Compromise?
Rectify reversible causes (eg Maternal hypotension)
Left lateral position
Stop Oxytocics
Confirm compromise by blood sampling (Fetal Scalp Blood Sampling) where possible delivery by speediest route if unable to correct or if significant acidosis
Give 3 pre-cautions used during Vaginal Birth After Caesarean (VBAC)?
IV access + G&S
Continuous electronic fetal monitoring
Avoid prolonged labour
Augmentation / Induction should be senior decision only
Give 2 indications for Operative delivery (Ventouse/Forceps)
Failure to progress in 2nd stage
Fetal distress in 2nd stage
Maternal reasons
Give 2 complications associated with Operative delivery (Ventouse/Forceps)
Failure
Fetal trauma (eg Subaponeurtoic haematoma with Ventouse delivery)
Maternal trauma
Postpartum hemorrhage
Urinary retention
What is a Cephalohaematoma?
Cephalohaematoma = Subperiosteal swelling on fetal head (boundaries are therefore limited by bone margins). [COLLECTION OF BLOOD]
* It is fluctuant
* Spontaneous absorption (may cause or contribute to Jaundice)
What is a Caput Succedaneum
Caput succedaneum = Oedematous swelling of the scalp, superficial to the cranial periosteum (which does not, therefore, limit its extent) [OEDEMATOUS SWELLING]
What is a Subaponeurotic Haematomia?
Subaponeurotic haematoma = blood lies between the aponeurosis and the periosteum.
* Haematoma is not confined to the boundaries of one bone, collections of blood may be large enough to result in anaemia or jaundice.
* They are associated with Vacuum extractions.
Give 4 symptoms of intracranial haemorrhage in babies
Babies affected may have:
Convulsions,
Apnoea,
Cyanosis,
Abnormal pallor,
Low heart rate,
Alterations in muscle tone,
Restlessness, somnolence, or
Abnormal movements
Give 3 indications for Caesarean section
Failure to progress
Fetal distress
Malpresentation / Malposition
Failed instrumental delivery
Give 4 complications of Caesarean section
Haemorrhage, Infection
Bladder/Bowel injury
Thromboembolic disease
Requirement for blood transfusion
TTN (Transient tachypnoea of newborn)
Fetal trauma
What scoring system is used to indicate whether mothers will go into labour soon?
Bishop score
>=8 indicates induction of labour is likely to be successful
<5 indicates induction of labour likely to be of benefit
What are the components of the Bishop score?
Dilation
Effacement
Station
Consistency
Position
What are the risks of shoulder dystocia? (give 3)
Fetal death
Asphyxia with resulting hypoxic damage
Birth trauma (Erb’s palsy, Fractured clavicle)
Maternal trauma (Soft tissue trauma, psychological)
What are the substages in the first stage of labour
Latent phase – there are painful, often irregular contractions, the cervix initially effaces (becomes shorter and shorter) then dilates to 4cm
Established phase – regular contractions with dilation from 4cm
o Satisfactory rate from 4cm is 0.5cm/h
1st stage generally takes 8-18h in a primip and 5-12h in a multip
What is monitored during the first stage of labour?
Maternal BP + Temp 4 hourly.
Pulse hourly.
Assess contractions every 30 minutes, their strength (you should not be able to indent the uterus on abdominal palpation during a contraction)
Note frequency of bladder emptying
Offer vaginal examination (eg every 4h to assess the degree of cervical dilation, the position, and the station of the head (measured in cm above or below the ischial spines) and note the degree of moulding
Note the state of the liquor
Auscultate fetal heart rate (if not continuously monitored), by Pinard or Doppler every 15 minutes, listening for 1 minute after a contraction
What are the substages of the second stage of labour
Passive stage – this is complete cervical dilation but no pushing.
o This is seen particularly in women with epidural anaesthesia where 1-2h of passive stage is recommended to reduce the instrumental delivery rate.
Active stage – maternal pushing uses abdominal muscles and the Valsalva manoeuvre until the baby is born
What monitoring is performed during the second stage of labour
Check BP + Pulse hourly.
Temperature 4 hourly.
Assess contractions every 30 minutes
Auscultate for 1 minute after a contraction every 5 minutes
Offer vaginal examination hourly
Record urination during 2nd stage.
What drug should be given in the third stage of labour to reduce incidence of post-partum haemorrhage
Syntometrine (Ergometrine maleate 500mcg IM + Oxytocin 5iu IM)
Note, Ergometrine is contraindicated in:
Pre-eclampsia,
Severe hypertension,
Severe liver or renal impairment, and
Severe heart disease.
If BP isnt measured in labour»_space; just give Oxytocin
