Normal Labour and Puerperium Flashcards by Joanna Mitchell

What is the definition of labour?

Physiological process during which the foetus, membranes, umbilical cord and placenta are expelled from the uterus
Assoc with regular, painful uterine contractions with increased frequency, intensity and duration

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What are the 3 birth options?

Consultant led unit
Midwife led unit
Homebirth

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What is a birth plan?

Record of what the women would like to happen during her labour and afterbirth

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What hormonal changes are thought to initiate labour?

Change in oestrogen/ progesterone ratio
Foetal adrenals and pituitary hormones
Myometrial stretch increases excitability of myometrial fibres
Mechanical stretch of cervix and stripping of foetal membranes

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What is ferguson’s reflex?

Neuroendocrine reflex comprising the self-sustaining cycle of uterine contractions initiated by pressure at the cervix or vaginal walls

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What is the role of progesterone in labour?

None; the reduction in progesterone initiates labour
Progesterone will keep the uterus settles, prevent the formation of gap junctions and hinders the contractibility of myocytes

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What is the role of oestrogen in labour?

Uterine contraction

Promotes prostaglandin production

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What is the role of oxytocin in labour?

Initiates and sustains contractions
Acts on decidual tissue to promote prostaglandin release
Synthesized directly in decidual and extraembryonic foetal tissues
Number of oxytocin receptors increases in myometrial and decidual tissues near end of pregnancy

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What is the role of pulmonary surfactant in labour initiation?

Pulmonary surfactant in amniotic fluid stimulates prostaglandin synthesis

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What is the role of foetal cortisol in labour initiation?

Increases maternal oestriol

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What is the role of increased myometrial oxytocin receptors in labour initiation?

Increased phospholipase C activity and subsequently increase in calcium and uterine contractility

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When can membranes rupture?

Pre-term 
Pre-labour 
First stage
Second stage
Born in caul

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What makes up cervical tissue

Collagen tissue (1,2,3,4), smooth muscle, elastin, held together by connective tissue ground subtance

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What are the factors that lead to cervical softening?

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

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What isi cervical ripening?

Decrease in collagen fibre alignment
Decrease in collagen fibre strength
Decrease in tensile strength of cervical matrix
Increase in cervical decorin

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What are the 5 elements of bishops score?

Position 
Consistency
Effacement 
Dilatation 
Station in pelvis

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What is the bishop’s score used for?

Safe to induce labour

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What does a score of less than 5 on the bishop’s score indicate?

Candidate for cervical ripening prior to induction

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What are the 2 phases of 1st stage of labour?

Latent and active
Latent; mild, irregular contractions, cervix shortens and softens, duration variable
Active phase; 4cm to full dilatation. Slow descent of presenting part. Contractions become rhythmic and strong.

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What is normal progress in the active stage of 1st stage of labour?

1-2cm per hour

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What is the 2nd stage of labour?

10cm to delivery of baby

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What is a normal length for 2nd stage of labour in a nulliparous woman?

Prolonged if over 2 hours

Prolonged if over 3 hours with regional analgesia

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What is a normal length for 2nd stage of labour in a multiparous woman?

Prolonged if over 1hr

Prolonged if over 2hr with regional analgesia

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Should vaginal examinations be carried out in low risk women who are fully dilated?

No; high risk of introduction of infection

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What is the 3rd stage of labour?

Delivery of baby to expulsion of placenta and foetal membranes

What is the average duration of 3rd stage of labour?

10 mins

What will occur after 1hr of 3rd stage?

Removal under GA

What is active management of 3rd stage?

Use of oxytocic drugs and controlled cord traction | Preferred for lowering risk of PPH

What are braxton hicks contractions?

"False labour" Tightening of uterine muscles, to aid body for birth Irregular, do not increase in frequency or intensity Resolve with ambulation or change in activity

When can braxton hicks start?

6 weeks into pregnancy Much more likely to be 3rd trim More likely in multiparous women

What is true labour?

Timing of contractions becomes evenly spaces, and time between them gets shorter with the length of contractions increasing

What are the 3 key factors to labour?

Power; uterine contractions Passage; maternal pelvis Passenger; foetus

Where will contractions start and how will they spread?

Pacemaker is in the tubal ostia | Wave spreads symmetrically in a wave down the uterus

What is polarity of uterine contractions?

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

What is normal and sufficient contractions in active labour?

3-4 every 10 mins Initially 10-15 secs to a max of 4 secs Intensity; degree of uterine systole

What is an anthropoid pelvis?

Oval shaped inlet with large AP diameter and comparatively smaller transverse diameter

What is an android pelvis?

Triangular or heart shaped inlet with a narrower front

What is the most suitable pelvic shape for labour?

Gynaecoid

What impact will anthropoid and android pelvices have on labour respectively?

Anthropoid; long 2nd stage | Android; long 1st stage

How is thee cervix assessed in labour to determine passage?

``` Effacement Dilatation Firmness Position Station ```

What is the normal position of the foetus?

Longitudinal lie Cephalic presentation with the vertex presenting OA, head engages occipito transverse Flexed head

What are abnormal presentations and positions of the foetus?

Presentation; breech, oblique, transverse lie | Position; occipito posterior

How can the position of the foetus be determined on vaginal exam?

Fontanelles Anterior; diamond shaped with 4 sutures coming off Posterior; triangular with 3 sutures

What are the analgesia option for birth?

``` Paracetamol TENS Entonox Diamorphine Epidural Combined spinal/ epidural ```

What is a partogram?

Graphic record of key data contained on one sheet, used to assess the progress of labour i.e. cervical dilation, foetal heart rate

What are the 7 cardinal movements of labour?

``` Engagement Descent Flexion Internal rotation Crowning and extension Restitution and external rotation Expulsion ```

What is engagement?

Passage of occipitofrontal diameter transversely past pelvic inlet

What is descent?

Downward passage of presenting part through pelvis

How is engagement described in terms of fifths?

3 fifths with engaged

What needs to be observed in decent of the foetus?

Abdominal fifths Maternal discomfort and feeling of pressure Frontal synciput and occiput eminences Vaginal examination for cervical assessment

What is flexion of the foetal head in labour?

Occurs passively as the head descends due to shape of bony pelvis and resistance of soft tissues

What is internal rotation of the foetal head in labour?

Rotation of presenting part from transverse position to AP position to allow passage through pelvic outlet

What is extension of the foetal head in labour?

Occurs once the foetus has reached level of introitus, bringing the base of the occiput in contact to the inferior margin at the symphysis pubis

What is external rotation (restitution) of the foetus in labour?

Return of foetal head to correct anatomical position in relation to foetal torso

What is the role of external rotation?

Allows delivery of shoulder; anterior shoulder first

What is crowning?

Appearance of large segment of foetal head at introitus Labia are stretched to full capacity Largest diameter of foetal head is encircles by vulvar ring

Why should delivery of head by managed carefully?

Prevent rapid extension and perineal tearing

What is the rationale behind delayed cord clamping?

Higher red blood cell flow to vital organs in first week, less anaemia, increased duration of breastfeeding Higher infant haematocrit, Hb levels, BP, BV Improved cardiopulmonary adaptation

When will delayed cord clamping not be performed?

If immediate resuscitation is required

Why is immediate skin to skin recommended?

Keeps babies warm Improve babies transition to life outside womb Increased breastfeeding

What is the current recommendation regarding skin to skin after birth?

Uninterrupted SSC for 1 hour following birth

What are the 3 classical signs of separation of placenta?

Uterus contracts, hardens and rises Umbilical cord lengthens permanent Gush of blood Placenta and membranes appear at introitus

What is included in active management of the 3rd stage of labour?

``` Prophylactic administration of syntometrine and oxytocin OR just oxytocin Cord clamping and cutting Controlled cord traction Bladder emptying ```

What is the plane of separation for the placenta?

Spongy layer of decidua basalis

What is the most common method of separation?

Matthew duncan; detachment of the leading edge of the placenta, and the entire organ slips down and out of the uterus sideways

What is the schultz method of separation?

Separation begins in the center of the placenta (the fetal surface), and this part descends first, with the remainder following

What is a normal amount of blood loss post birth?

Less than 500ml

How is haemostasis achieved in the postpartum period?

Tonic contraction; lattice pattern of uterine muscles strangulates blood vessels Thrombosis of torn vessels; pregnancy is a hypercoagulable state Myo-tamponade-opposition of AP walls

What is lochia?

Vaginal discharge containing blood, mucus and endometrial castings

Describe the vaginal discharge in the puerperium stage?

Rubra; fresh red; 3-4 days Serosa; brown/ red, watery; 4-14 days Alba; yellow; 10-20 days

At what time will the tissues be returned to the non-pregnant state?

6 weeks

When will the fundal height return to normal post birth?

Umbilicus to within pelvis by 2 weeks

When will the endometrium regenerate post birth?

By the end of the week; except the placental site

What areas of the reproductive system of women will never return to pre-pregnancy state?

Cervix Vagina Perineum

When will physiological diuresis occur post birth?

2-3 days

What is lactation initiated by?

Placental expulsion | Decrease in oestrogen and progesterone

Why is milk not produced in pregnancy?

Oestrogen and progesterone act negatively on pituitary gland to prevent prolactin release Render mammary glands unresponsive to prolactin

What is colostrum rich in?

Immunoglobulin; has long term protective effect for baby