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Reproduction > Normal Labour and Puerperium > Flashcards

Normal Labour and Puerperium Flashcards

1
Q

what is puerperium

A

6 weeks after childbirth

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2
Q

what is expelled from the uterus in labour

A

fetus, membranes, umbilical cord and placenta

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3
Q

what is cervical effacement

A

thinning of the cervix during labour

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4
Q

what happens to contractions as labour progresses

A

become more frequent, intense and last longer

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5
Q

what causes the initiation of labour

A

unknown:
change in oestrogen/ progesterone ratio (oestrogen increases)
fetal adrenal and pituitary hormones may have an impact
myometrium stretch increases excitability of myometrial fibres
mechanical stretch of cervix
stripping of fetal membranes - baby pushes more on cervix
fergusons reflex- positive feedback system, pushing down on cervix causes more contractions and dilatation
pulmonary surfactant when secreted into amniotic fluid stimulates prostaglandin synthesis
increase in fetal cortisol -> increases maternal estriol
increases in myometrial oxytocin receptors + their activation = phospholipase C activity = increased cytosolitic calcium and uterine contractility

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6
Q

what is the role of progesterone in labour

A

(prevents it)
keep uterus settled
prevents the formation of gap junctions
hinders the contractibility of gap junctions

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7
Q

what is the role of oestrogen in labour

A

makes the uterus contract

promotes prostaglandin production

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8
Q

what is the role of oxytocin in labour

A

initiates and sustains contractions

acts on decidual (endometrial) tissue to promote prostaglandin release

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9
Q

where is oxytocin produced

A

decidual tissue
extraembryonic fetal tissues
placenta

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10
Q

what happens to oxytocin receptors in the myometrium and decidual tissues in pregnancy

A

numbers increase towards the end of pregnancy

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11
Q

what is the role or liquor

A

nutures and protects the fetus and facilitates movement

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12
Q

what doe it mean to be born in a caul

A

when membranes dont rupture and babies born inside them

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13
Q

what makes up cervical tissue

A

collagen tissue mainly (types 1-4), smooth muscle, elastin

held together by connective tissue ground substance

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14
Q

what causes cervical softening

A

increase in hyaluronic acid decreases bridging among the collagen fibres= decrease in the firmness of the cervix

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15
Q

what causes cervical ripening

A

decrease in collagen fibre strength and alignment
decrease in tensile strength of the cervical matrix
increase in cervical decorin

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16
Q

what does the bishops score determine

A

whether it is safe to initiate labour

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17
Q

what does the bishops score quantify

A 
dilatation 
effacement 
station 
cervical consistency (firm, med, soft) 
cervix position (post, mid, anterior)

higher the score more likely/ safer to go into labour
lower score need cervical priming and induction

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18
Q

what are the stages of labour

A

1st stage:

  • latent (0-3cm)
  • active (4cm-7cm)
  • transition (8-10cm)

2nd- from complete dilation and effacement to delivery
of baby

3rd- from delivery of baby to delivery of placenta

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19
Q

what happens in the latent phase of labour

A

mild irregular contractions
cervix shortens and softens
duration is variable- can last several days

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20
Q

what happens during the active first phase of labour

A

from 4cm to full dilatation
slow descent of the presenting part
contracting become more rhythmic and stronger
normal progress= 1-2cm dilation per hour

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21
Q

when is the 2nd stage of labour considered prolonged

A

nulliparous- when exceed 2 hours or 3 hours if regional anaesthesia
multiparous- if exceeds 1 hour or 2 hours with regional anaesthesia

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22
Q

are vaginal exams always done in the 2nd stage of labour

A

not if fully dilated in low risk pregnancies as associated with infections

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23
Q

what happens in the third stage of labour

A

delivery of baby

expulsion of placenta and fetal membranes

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24
Q

how long does the 3rd stage of labour usually last

A

average 10 mins

if longer than an hour emergency CS

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25
Q

what are the different managements for the delivery of the 3rd stage of labour

A 
spontaneous delivery 
active management- oxytocic drugs:
prophylactic administration of
Syntometerine (1ml ampoule containing 500 micrograms ergometrine maleate and 5IU oxytocin)
OR 
Oxytocin 10 units
Cord clamping and cutting, 
Controlled cord traction
Bladder emptying
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26
Q

what do oxytocic drugs and controlled cord traction lower the risk of

A

post partum haemorrhage

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27
Q

what are braxton hicks contractions

A

aka false labour
tightening of uterine muscles (aids body for birth)
can start 6 weeks into pregnancy, usually happen in 3rd trim
irregular, do not increase in frequency or intensity
resolve with movement/ change in activity
relatively painless

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28
Q

what hormone causes true labour contractions

A

oxytocin- stimulates the uterus to contract

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29
Q

what are true labour contractions like

A

timing = evenly spaces, time between gets shorter
length of contraction increases usually from 10 -> 45 seconds
get more painful
starts in fundus and spreads downwards

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30
Q

what is the role of contractions

A

tightens to top part of uterus pushing baby downward into canal to prepare for delivery
promotes the thinning of the cervix

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31
Q

where is the uterus highest in density of smooth muscle

A

at the fundus

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32
Q

what is the pacemaker of the uterus

A

region of the tubal ostia
wave of contraction spreads downwards from here
synchronisation of contraction waves from both ostia

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33
Q

what happens to either end of the uterus during contractions

A 
upper segment contracts and retracts 
lower segment (and uterus) stretch, dilate and relax
34
Q

how many contractions is it normal to have in 10 mins

A

3-4

35
Q

is resting tone between contraction important

A

yes

36
Q

when are contractions at their maximum

A

in 2nd stage of labour

37
Q

what are the types of female pelvis

A

anthropoid- oval shaped, large AP diameter, smaller transverse diameter

android- triangular/ heart shaped inlet, narrower at the front, more common in african caribbean women

gynaecoid pelvis- most suitable for child birth

38
Q

what is the cervix assessed for in labour

A 
effacement 
dilatation 
firmness
position 
level of presenting part/ station
39
Q

what is the normal fetal position in labour

A 
longitudinal lie 
cephalic presentation (vertex is presenting part)
occipito-anterior, flexed
40
Q

what is an abnormal fetal presentation

A

breech, oblique or transverse lie

occipito- posterior

41
Q

what are the fetal positions within the pelvis (cephalic presentation)

A

right and left occipito posterior

right and left occipito anterior

42
Q

what can be felt on vaginal exam to determine the position of the fetus in pelvis

A

fontanelles

43
Q

what are the analgesic options of birth

A

paracetamol/ co-codamol (taken in initial stages)
TENS
entonox
diamorphine (1st line for when too sore for paracetamol)
epidural
remifentanyl
combined spinal/ epidural

44
Q

what is recorded in a partogram

A
  • fetal HR and how it is monitored (continuous electronic, intermittent, fetal scalp electrode, handheld doppler, pinard stethescope)
  • fetal pH
  • liquor
  • caput/ moulding
  • position
  • cervical dilatation
  • descent of presenting part
  • contractions per 10 mins
  • duration of contractions
  • time
  • syntocinon given?
  • epidural given?
  • medications given
  • maternal BP
  • maternal pulse
  • maternal urinalysis
45
Q

what are the cardinal movements of the babies head in the fetus

A

engagement (passage of widest part into plevic inlet, 3/5ths of head in pelvis, 2/5ths abdominal)
decent (through pelvis, in occipito transverse position)
flexion (passive movement)
internal rotation (of presenting part from -usually- transverse to anterior position)
crowning and extension (occiput in contact with inferior margin of symphysis pubis)
restitution (aka external rotation) (optimal position for shoulder)
expulsion (anterior shoulder first)

46
Q

how often should vaginal exams be done in normal labour

A

every 4 hours

47
Q

what happens at crowning

A

Appearance of a large segment of fetal head at the introitus
Labia are stretched to full capacity
Largest diameter of fetal head is encircled by the vulval ring
Burning and stinging feeling for the mother

48
Q

when should the umbilical cord be clamped

A

should be delayed- after pulsations have stops/ 3 mins after birth
unless immediate resuscitation is necessary

49
Q

how long skin to skin time after birth

A

1 hour uniterrupted following birth

50
Q

when is the placenta usually delivered

A

5-10 mins after birth

considered normal after 30 mins

51
Q

what are the signs that indicate a separation of the uterus

A

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

52
Q

what layer is separated when the placenta is delivered

A

the spongy layer of decidua basalis

53
Q

what is the mechanism of placental separation

A

Shearing force

Inelastic placenta reduces surface area on the placental bed due to the sustained contraction of the uterus

54
Q

what is a normal amount of blood loss in childbirth

A

less than 500ml

55
Q

when is blood loss in childbirth significant

A

when >1000ml

56
Q

how is haemostasis achieved in labour (to prevent blood loss)

A

Tonic contraction: Lattice pattern of uterine muscle strangulates the blood vessels
Thrombosis of the torn vessel ends: pregnancy is a hyper-coaguable state
Myo-tamponade-opposition of the anterior/posterior walls.

57
Q

how long till tissues return to non pregnant state

A

6 weeks

58
Q

what is lochia and what are the different forms

A

Vaginal discharge containing blood, mucus and endometrial castings
Rubra (fresh red) 3-4 days after birth
Serosa (brownish-red, watery) 4-14 days
Alba (yellow) 10-20 days
Bloodstained discharge lasts for about 10-14 days following birth

59
Q

what uterine changes occur in the puerperuim

A

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

60
Q

what initiates lactation

A

placental expulsion and a decrease in oestrogen and progesterone
increase in prolactin

61
Q

what is colostrum rich in

A

immunoglobulins

62
Q

what are the indications for induction of labour

A

maternal:
- pre eclampsia
- poor obstetric Hx
- medical disorders

fetal:

  • susoected IUGR
  • rhesus isoummunisation
  • antepartum haemorrhage
  • PROM

post dates pregnancy
diabetes mellitus
obstetric cholestasis

63
Q

what are the mechanisms of induction of labour

A

Prostaglandins - PGE2 Dinoprostone (Prostin gel / Propess pessary)

Mechanical: Membrane sweep, Foley Balloon Catheter

Amniotomy

IVI Syntocinon

64
Q

what is the action of diamorphine

A

opiate mu receptor agonists in peri aqueduct grey matter, blocks pain signals

65
Q

what are common SEs of diamorphine

A 
arrhythmias 
confusion
constipation 
dizziness
drowsiness
dry mouth 
euphoric mood 
flushing
hallucinations 
HA
hypotension 
miosis 
nausea and vomiting (more common in first dose)
resp depression 
pruritis 
urinary retention 
bradycardia
66
Q

how can a fetus be affected by diamorphine

A

resp depression
withdrawal symptoms
gastric stasis
inhalation pneumonia

67
Q

what is an epidural

A

bupivacaine and fentanyl into epidural space, regional anaesthetic

68
Q

what nerves does an epidural block

A

from T10-12 downwards (uterus supplied by t10-12, vagina S2,3,4)

69
Q

what special precautions should be taken with epidural anaesthesia

A

before doing it get IV access for fluids- hypotension a SE, risk of fetal distress
loose bladder control- catheterise
loss of power in legs (when light can move but loose proprioception, when heavy cant move legs (forceps delivery))
measure BP every 5 minutes for 15 minutes
if still not pain free 30 mins after administration then get anaesthetist
unless the woman has an urge to push or the baby’s head is visible, pushing should be delayed for at least 1 hour and longer if the woman wishes, after which actively encourage her to push during contractions.

Do not routinely use oxytocin in the second stage of labour for women with regional analgesia.

70
Q

how is an epidural topped up

A

patient controlled- patient presses button every time they feel pain

71
Q

which has more SEs diamorphine or an epidural

A

epidural

72
Q

what are the SEs of an epidural

A 
arrhythmias
dizziness
hypertension 
hypotension 
nausea
paraesthesia
urinary retention 
vomiting
longer labour 
infection from insertion site (abscesses)
haematoma 
dural headache 
nerve damage 
increases risk of instrumental delivery
73
Q

what are the risk to the fetus from an epidural

A

neonatal resp depression
hypotonia
bradycardia

hypotension in mother can cause bradycardia

74
Q

What observations/assessments are made to assess the progress in labour?

A 
partogram 
cardiotocography 
station 
vaginal exams 
abdominal palpation (shows descent of head)
75
Q

what is meconium

A

early faeces of infant
can be passed due to previous stress of the baby
puts baby at risk of aspiration

76
Q

what are the different appearances of liquor

A

clear
meconium stained
blood stained
absent liquor

77
Q

what is caput

A

oedema under scalp, more significant in longer labours

78
Q

when do you worry about moulding

A

when bones overlapping each other and fixed there- worry about whether head will fit through pelvis

79
Q

what can be given to increase the strength of contractions

A

syntocinon (synthetic oxytocin)

80
Q

what should you do if 2nd stage of labour prolonged

A

Start on IV oxytocin then reassess in 4 hours
Give epidural
When dilated 10cm and have epidural already then wait an hour to progress naturally (without epidural then will feel urge to push so cant usually wait an hour)
If still failing to progress -> emergency CS

81
Q

what stage of labour is the baby born

A

2nd

Reproduction (51 decks)

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