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Reproduction > Normal Labour and Puerperium > Flashcards

Normal Labour and Puerperium Flashcards

1
Q

Define labour

A

Labour is a physiological process during which the foetus, membranes, umbilical cord and placenta are expelled from the uterus.

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2
Q

What 3 options of where to birth to mothers have?

A

Consultant led unit
Midwife led unit
Home birth

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3
Q

What is a birth plan?

A

A Birth Plan is a record of what the woman would like to happen during herlabour and after the birth.
Not compulsory
May change with time and circumstances
Helps understand mothers feelings and priorities

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4
Q

What causes initiation of labour?

A

Degree of uncertainty
Change in the estrogen/progesterone ratio
Fetal adrenals and pituitary hormones may control the timing of the onset of labour
Myometrial stretch increases excitability of myometrial fibres
Mechanical stretch of cervix and stripping of foetal membranes
Fergusons Reflex - positive feedback by pushing down on cervix

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5
Q

List hormonl factors influencing onset of labour

A

Progesterone
Estrogen
Oxytocin

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6
Q

Role of progesterone in inducing labour

A

This keeps the uterus settled.
It prevents the formation of gap junctions
Hinders the contractibility of myocytes

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7
Q

Role of estrogen in inducing labour

A

uterine contraction

Promotes prostaglandin production

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8
Q

Role of oxytocin in inducing labour

A

Oxytocin initiates and sustains contractions
Oxytocin acts on decidual tissue to promote prostaglandin release
Oxytocin is synthesized directly in decidual and extraembryonic fetal tissues and in the placenta
The number of oxytocin receptors increases in myometrial and decidual tissues near the end of pregnancy

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9
Q

Other causes of labour induction

A

Pulmonary surfactant secreted into amniotic fluid has been reported to stimulate prostaglandin synthesis
Increase in production of fetal cortisol stimulates an increase in maternal estriol
Increase in myometrial oxytocin receptors and their activation results in phospholipase C activity and subsequent increase in cytosolitic calcium and uterine contractility

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10
Q

What are the two cervical changes that occur during labour

A

Occurs towards the end of pregnancy

Cervical softening

Cervical ripening

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11
Q

How to assess cervical changes and whether it is safe to induce labour?

A

Bishops score

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12
Q

What are the stages of labour?

A

First Stage

  • Latent phase up to 3-4cms dilatation – beginning stage (lengthy)
  • Active stage 4cms -10cms (full dilatation)

Second Stage
- Full dilatation –delivery of baby (lengthy stage, especially in first baby)

Third Stage
- Delivery of baby –expulsion of placenta and membranes

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13
Q

Describe how cervical softening occurs

A

Cervical tissue: collagen tissue mainly (types 1, 2, 3, 4) smooth muscle, elastin, held together by connective tissue ground substance.

Increase in hyaluronic acid gives increase in molecules among collagen fibres
The decrease in bridging among collagen fibres gives decrease in firmness of cervix

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14
Q

Describe how cervical ripening occurs

A

Decrease in collagen fibre alignment
Decrease in collagen fibre strength
Decrease in tensile strength of the cervical matrix
Increase in cervical decorin (dermatan sulphate proteoglycan 2)

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15
Q

What are the elements of Bishops Score?

A 
Position
Consistency
Effacement
Dilatation
Station in pelvis
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16
Q

Features of latent phase (Stage I of labour)

A

Mild, irregular uterine contractions
Duration variable
Cervix shortens and ripens

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17
Q

Features of active phase (Stage II of labour)

A

Slow descent of the presenting part
Contractions become more rhythmic and stronger
Normal progress is assessed at 1-2cms per hour
Analgesia, mobility and parity increase variability

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18
Q

Describe the events of second stage of labour

A

Begins with complete dilatation of the cervix (10cm)

Ends with delivery of the baby

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19
Q

When is second stage of labour considered to be prolonged in nulliparous women?

A

With analgesia = >3hrs

Without analgesia = >2hrs

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20
Q

When is second stage of labour considered to be prolonged in multiparous women?

A

With analgesia = >2hrs

Without analgesia = >1hr

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21
Q

Describe events of third stage of labour

A

Delivery of the baby to expulsion of placenta and foetal membranes

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22
Q

How long is the third stage of the labour?

A

3-10 mins

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23
Q

Describe both expectant and active management of third stage of labour

A

Expectant: spontaneous delivery of the placenta

Active: use of oxytocic drugs & controlled cord traction is preferred for lowering risk of post-partum haemorrhage

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24
Q

What are braxton hicks contractions?

A

“false labour” - give a woman the false sensation that she is having real contractions

Tightening of the uterine muscles - aid the body in preparing for birth

Painless, resolve with ambulation of change in activity

Do not increase in frequency or intensity

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25
Q

When are Braxton hicks contractions most commonly felt?

A

3rd trimester

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26
Q

What are true labour contractions?

A

True labour is when the timing of contractions become evenly spaced, and the time between them gets shorter and shorter (three minutes apart, then two minutes, then one).

Length of time contraction lasts also increases 10secs—-45secs

Real contractions will also get more intense and painful over time.

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27
Q

Which hormone induces true labour contractions?

A

Oxytocin

28
Q

What are the 3 key factors during labour?

A

POWER - uterine contractions
PASSAGE - maternal pelvis
PASSENGER - foetus

29
Q

Where is the density of the uterine muscle highest?

A

Fundus

30
Q

What is the role of tubal ostia in power during labour?

A

Pacemaker region - waves spread in a downwards direction

Synchronisation of contractions waves from both ostia

31
Q

Significance of polarity of uterus in asserting power during labour

A

Upper segment contracts an retracts
Lower segment and cervix stretch, dilate and relax

Normal contractions have a fundal dominance witha regular pattern and an adequate “resting tone”

32
Q

Features of power of contractions

A 
Frequency: 3 to 4 in 10 minutes 
Duration: builds up
- initially 10 to 15 s
- max is 45 seconds
Intensity: degree of uterine systole (max in second stage, can be mild, moderate or strong)
33
Q

Types of Pelvis (passage)

A

Anthropoid - oval shaped inlet, AP>transverse diameter

Gynaecoid - most suitable female pelvic shape

Android - triangular/heart shaped inlet, narrower from the front

34
Q

What are the 5 parameters used to in a cervical assessment (passage)?

A 
Effacement
Dilatation
Firmness
Position
Level of presenting part or station
35
Q

What is a normal foetal position (passenger)?

A

Lie: longitudinal
Presentation: cephalic
Presenting part: vertex
Position: OA, head engages OT, flexed head

36
Q

How is the foetal position assessed during a vaginal exam?

A

By identifying fontanelles.
Anterior fontanelle - 4 bones
Posterior fontanelle - 3 bones

37
Q

What are the analgesic options for birth?

A 
Paracetamol**/Co-codamol
TENS
Entonox**
Diamorphine** 
Epidural
Remifentanyl
Combined spinal/epidural
38
Q

List the 7 cardinal movements involved in mechanism of labour

A
  1. Engagement
  2. Descent
  3. Flexion
  4. Internal rotation
  5. Crowning and extension
  6. Restitution and external rotation (head adopts optimal position for shoulder)
  7. Expulsion (anterior shoulder first)
39
Q

Define engagement

A

Passage of the widest diameter of presenting part through widest diameter of maternal pelvis

40
Q

Describe position of foetal head during engagement

A

As the foetal head engages, it moves towards pelvic brim in either R or L occipito-transverse position

41
Q

Define descent

A

Downward passage of the presenting part through pelvic inlet towards pelvic floor

42
Q

How can engagement be determined abdominally?

A

Number of fifths above the pubic symphysis that head is still palpable.
(if engaged, baby’s head is felt 2/5 abdominally and engaged 3/5ths)

43
Q

What is to be observed during decent of the head?

A

Abdominal 5ths
Maternal discomfort and feeling of pressure
Frontal synciput and occipital eminences

Vaginal exam every 4hrly

44
Q

What is the position of foetal head during descent?

A

Occiput transverse

45
Q

What is flexion of foetal head during labour?

A

Passive flexion of baby’s head as it comes into contact with pelvic floor.
Reduces diameter and overcomes resistance

46
Q

Describe internal rotation of foetus during labour

A

Rotates from occipito transverse to occipito anterior

Allows baby to pass smoothly through forwards and downwards slope of the pelvic floor

47
Q

What is crowning?

A

Occurs after internal rotation and before extension

It is the appearance of a large segment of foetal head at the introitus.

48
Q

Describe the appearance of crowning

A

labia stretched to full capacity
Largest diameter of foetal head is encircled by vulval ring
Burning and stinging for mother
Care of the perineum at birth is vital to reduce trauma (episiotomy may be required)

49
Q

What is extension?

A

Once foetus has reached level of introitus, head extends as nape of the neck pivots against suprapubic arch

50
Q

Which movement causes stretching of the perineum during labour?

A

Extension

51
Q

What is external rotation and restituition?

A

Head externally rotates to face right or left medial thigh of the mother

At the same time shoulders are rotating from a transverse to AP position - restituition

52
Q

Describe the stage of expulsion and how the foetus is delivered

A

Midwife applies traction on foetal head in the downward direction

This assists the delivery of the anterior shoulder below the suprabpubic arch. This is followed by upward traction to deliver the posterior shoulder. The rest of the baby can now be delivered.

53
Q

What is the drawback of immediate cord clamping?

A

Reduce the RBC an infant receives at birth - potential short and long-term neonatal problems

54
Q

Benefits of delayed cord clamping

A

Higher red blood cell flow to vital organs in the first week was noted, and term infants had less anaemia at 2 months and increased duration of early breastfeeding

55
Q

Indications for immediate cord clamping

A

If immediate resuscitation is necessary, this is from cessation of pulsations, or up to 3 minutesafter expulsion.

56
Q

Why is skin to skin contact required immediately after birth

A

Early placing of the naked baby on the mother’s chest (SSC) helps keep babies warm and calm and considered to improve other aspects of a baby’s transition to life outsidethe womb

57
Q

What are the 3 classic signs that indicate placental separation in stage 3 of labour?

A

Uterus contracts, hardens and rises
Umbilical cord lengthens permanently
Frequently a gush of blood (variable in amount)
Placenta and membranes appear at intoritus

58
Q

Active management of 3rd stage

A

Syntometerine ..1ml ampoule containing 500 micrograms ergometrine maleate and 5IU oxytocin.
OR
Oxytocin 10 units

Cord clamping and cutting,
Controlled cord traction
Bladder emptying

59
Q

Placental separation

A

Plane of separation: Spongy layer of decidua basalis
Mechanics: Shearing force
Inelastic placenta reduces surface area on the placental bed due to the sustained contraction of the uterus
Method of separation: “Matthew Duncan”, most common type of separation
“Schultz”, separation from central aspect

60
Q

Blood loss

A

Normal - <500ml
Abnormal - >500ml

Any blood loss in labour prior to delivery apart from “show” is considered abnormal and requires referral to consultant unit

Haemostasis: Achieved by:

a) Tonic contraction: Lattice pattern of uterine muscle strangulates the blood vessels
b) Thrombosis of the torn vessel ends: pregnancy is a hyper-coaguable state

Myo-tamponade - opposition of the anterior/posterior walls.

61
Q

What is peurperium?

A

Period of repair and recovery

Return of tissues to non-pregnant state

62
Q

How long does peurperium last?

A

6 weeks

63
Q

What are the different types of blood and discharge during peurperium?

A

Lochia: Vaginal discharge containing blood, mucus and endometrial castings
Rubra (fresh red) 3-4 days
Serosa (brownish-red, watery) 4-14 days
Alba (yellow) 10-20 days

64
Q

Uterine changes during peurperium

A

Uterine Involution
Weight -1000gms reduces to–50-100gms
Fundal height –umbilicus to within pelvis in 2 weeks
Endometrium regenerates by end of a week (except the placental site)
Regression but never back to pre-pregnancy state; cervix, vagina and perineum
Physiological diuresis commences 2-3 days postnatally

65
Q

Which events initiate lactation?

A

Expulsion of placenta

Fall in oestrogen and progesterone levels

66
Q

How is prolactin levels regulated during pregnancy?

A

During pregnancy the combination of estrogen and progesterone circulating in the blood appears to inhibit milk secretion by blocking the release ofprolactinfrom the pituitary gland and by making the mammary gland cells unresponsive to this pituitaryhormone
Prolactin is maintained

67
Q

Why does colostrum have a protective effect on baby?

A

Rich in immunoglobulin

Reproduction (32 decks)

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