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Reproductive & Sexual Health > Normal labour and puerperium > Flashcards

Normal labour and puerperium Flashcards

1
Q

Define labour

A

Physiological process during which the fetus, membranes, umbilical cord and placenta are expelled from the uterus

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2
Q

What may initiate labour

A
  • change in oestrogen/progesterone ratio
  • fetal adrenals and pituitary hormones
  • myometrial stretch increasing excitability
  • mechanical stretch of cervix and stripping of fetal membranes
  • fergusons reflex
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3
Q

What is the role of progesterone in influencing onset of labour?

A

Keeps the uterus settled

Prevents the formation of gap junctions

Hinders the ocntractibility of myocytes

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4
Q

What is the role of oestrogen in the onset of labour?

A

Makes the uterus contract

Promotes prostaglandin production

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5
Q

What is the role of oxytocin in the onset of labour?

A

Initiates and sustains contractions

Acts on decidual tissue to promote prostaglandin release

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6
Q

Where is oxytocin synthesised?

A

In decidual and extraembryonic fetal tissue in the placenta

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7
Q

What happens to the number of oxytocin receptors near the end of pregnancy?

A

Number of receptors increases in myometrial and decidual tissues near the end of pregnancy

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8
Q

What is the role of pulmonary surfactant secreted into amniotic fluid

A

Stimulates prostaglandin synthesis

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9
Q

What does increase in production of fetal cortisol stimulate?

A

An increase in maternal estriol

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10
Q

What does increase in myometrial oxytocin receptors cause?

A

Phosphatase C activity and subsequent increase in cytosolitic calcium and uterine contractility

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11
Q

What is the role of liquor?

A

Nurtures and protects fetus and facilitates movement

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12
Q

What is the timing of rupture of membranes?

A
  • pre-term
  • pre-labour
  • first stage
  • second stage
  • born in a caul
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13
Q

What does cervical tissue consist of?

A

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

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14
Q

Describe the processes in cervical softening?

A
  • increase in hyaluronic acid gives increase in molecules among collagen fibres
  • decrease in bridging among collagen fibres gives decrease in firmness of cervix
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15
Q

What happens in cervical ripening?

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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16
Q

What is the bishops score?

A
  • position
  • consistency
  • effacement
  • dilatation
  • station in pelvis

most simple way to determine if it is safe to induce labour

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17
Q

What are the stages of labour?

A
  • first stage
    • latent phase up to 3-4cms dilatation
    • active stage 4cms-10cms (full dilatation)
  • second stage
    • full dilatation- delivery of baby
  • third stage
    • delivery of baby- expulsion of placenta and membranes
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18
Q

What happens in the latent phase of 1st stage of labour?

A
  • mild irregular contractions
  • cervix shortens and softens, duration variable

may last an uncomfortable few days…

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19
Q

What happens in the active phase of labour?

A
  • 4cms -> full dilatation
  • slow descent of the presenting part
  • contractions progressively become more rhythmic and stronger
  • normal progress is assessed at 1-2cms per hour
  • analgesia, mobility and parity is increased variably
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20
Q

What is the second stage of labour?

A

Complete dilatation of the cervix (10cm) to delivery of the baby

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21
Q

When is the second stage of labour considered to be prolonged?

A
  • in nulliparous women- if it exceeds 3 hours if there is regional anaesthesia, or 2 hours without
  • in multiparous women, the second stage considered prolonged if it exceeds 2 hours with regional analgesia or 1 hour without
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22
Q

What is the third stage of labour?

A

Delivery of the baby to expulsion of the placenta and foetal membranes

Average duration 10 minutes but can be 3 minutes or longer

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23
Q

When is preparation made for removal of the placenta and fetal membranes under GA?

A

after 1 hour

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24
Q

Describe expectant and active management of the third stage of labour?

A

Expectant: spontaenous delivery of the placenta

Active management: use of oxytoxic drugs and controlled cord traction is preferred for lowering risk of post partum haemorrhage

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25
Q

What are braxton-hicks contractions?

A

Tightening of the uterine muscles, thought to be to aid the body prepare for birth

Can start 6 weeks into pregnancy but more usually felt in the third trimester

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26
Q

What is the character of braxton hicks contractions?

A

Irregular, do not increase in frequency or intensity

Resolve with ambulation or change in activity

Relatively painless

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27
Q

When do true labour contractions happen?

A

Under the influence of the release of oxytocin, which stimulates the uterus to contract

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28
Q

What is true labour?

A

When the timing of contractions become evenly spaced, and the time between them gets shorter and shorter.

Length of contraction lasts increases 10s-45s

WIll get more intense and painful over time

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29
Q

What are the three key factors in labour?

A

Power: uterine contraction

Passage: maternal pelvis

Passenger: Foetus

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30
Q

What contributes to the power of contractions?

A

Uterine muscle: Smooth muscle (myocyte) in connective tissue (collagen and elastin) density highest at the fundus

Pacemaker: region of the tubal ostia, wave spreads in a downward direction

Synchronisation of contractions waves from both ostia

Polarity: upper segment contracts and relaxes, lower segment and cervix stretch, dilate and relax

Normal contractions have a fundal dominance with a regular paterrern and an adequate resting tone

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31
Q

How often do contractions occur?

A

3-4 in 10 minutes

32
Q

How long do contractions last?

A

Initially 10-15 seconds, slowly builds up

33
Q

What are the types of pelvis?

A

Anhtropoid

Android

Gynaecoid

Platypelloid

34
Q

Descreibe an anthropoid pelvis

A

Oval shaped inlet with large anterior-posterior diameter and comparatively smaller transverse diameter

35
Q

Describe an android pelivs?

A

Has a triangular or heart-shaped inlet and is narrower from the front

African-caribbean women are more at risk of having an android shaped pelvis

36
Q

What are the 5 evaluating parameters for the cervix?

A
  • effacement
  • dilatation
  • firmness
  • position
  • level of presenting part or station
37
Q

What is the normal foetal position?

A

Longitudinal lie

Cephalic presentation

Presenting part: vertex

38
Q

In which position should the foetal head be?

A

Occiptoanterior; head engages in occipito-transverse

Flexed

39
Q

What is an abnormal foetal position?

A

Breech, oblique, transverse lie

Occipitoposterior

40
Q

What can be felt in vaginal examination to determine the position?

A

Fontanelles

41
Q

What are the analgesia options for birth?

A
  • paracetamol/co-codamol
  • TENS
  • entonox
  • diamorphine
  • epidural
  • remifentanyl
  • combined spinal/epidural
42
Q

What is a partogram?

A

A graphic record of key data (both maternal and foetal) contained on one sheet, used to assess the progress of labour

Cervical dilatation, foetal heart rate

43
Q

What are 7 cardinal movements?

A
  1. engagement
  2. descent
  3. flexion
  4. internal rotation
  5. crowning and extension
  6. restitution and external rotation (optimal position for shoulders)
  7. expulsion, anterior shoulder first
44
Q

What is engagement?

A
  • passage of the widest diameter of the presenting part to a level below the plane of the pelvic inlet
  • the sagittal suture is frequently deflected either posteriorly to the promontory or anteriorly to the symphysis pubis, such lateral deflection is known as anterior and posterior asynclitism
45
Q

What is descent?

A

Downward passage of the presenting part through the pelvis

46
Q

When is the foetal head engaged?

A

When the widest diameter of the head has entered the brim of the pelvis. This is also described as 3 fifths of the foetal head having entered the pelvis and 2 fifths still being felt abdominally.

47
Q

What do we need to observe during descent of the head?

A
  • abdominal fifths- reference points
  • maternal discomfort and feeling of pressure
  • frontal synciput and occupital eminences
  • vaginal examinations for cervical assessment
48
Q

vaginal examinations should be carried out approximately _ hourly in normal labour

should not be carried out inappropriately just for information

A

4

49
Q

Why does the foetal head change position as it descends?

A

As it engages it assumes an occiput transverse position because that is the widest pelvic diameter available for the widest part of the foetal head

50
Q

Describe the cardinal movement of flexion

A

Flexion of the foetal head occurs passively as the head descends due to the shape of the bony pelvis and the resistance offered by soft tissues

51
Q

Describe internal rotation of the head

A

Rotation of the presenting part from its original position (usually transverse with regard to the birth canal) to the anterior position as it passes through the pelvis

52
Q

Describe extension

A

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

53
Q

Describe external rotation (restitution)

A

is return of the foetal head to the correct anatomic position in relation to the foetal torso

54
Q

Describe expulsion

A

Delivery of the rest of the foetal body

55
Q

What is crowning?

A

Appearence of a large segment of foetal head at the interoitus

Labia are stretched to full capacity

Largest diameter of foetal head is encircled by the vulval ring

56
Q

What does crowning feel like for mum?

A

Burning and stinging

57
Q

How should delivery of the head be managed?

A

Slowly with hands guiding but not leading the exit at crowning to prevent rapid extension of the tissues and perineal tearing

Episiotomy may be required

58
Q

What can immediate clamping of the umbilical cord cause?

A

Reduction in the red blood cells an infant recieves at birth by more than 50%, resulting in potential short-term and long-term neonatal problems

59
Q

When should delayed cord clamping be carried out?

A

All the time, unless immediate resuscitation is necessary, this is from cessation of pulsations or up to 3 minutes after expulsion

60
Q

Why is skin to skin important?

A

Helps keeps babies warm and calm and improve other aspects of babies life outwith the womb

61
Q

How long should uninterupted SSC be after birth?

A

1 hour

62
Q

When does expulsion of placenta normally occur?

A

5-10 minutes after delivery, considered normal up to 30 minutes

63
Q

What are the 3 classic signs indicating separation?

A

Uterus contracts, hardens and rises

Umbilical cord lengthens permanently

Frequently a gush of blood in variable amounts

Placenta and membranes appear at introitus

64
Q

What is the active management of 3rd stage?

A
  • prophylactic administration of syntometerine.. 1ml ampule containing 500micrograms ergometrine maleate and 5IU oxytocin

OR

  • oxytocin 10 units
  • Cord clamping and cutting, controlled cord traction
  • Bladder emptying
65
Q

What is the plane of separation of the placenta?

A

Spongy layer of decidua basalis

66
Q

What are the mechanics of placental separation?

A

Shearing force

67
Q

What is a normal volume of blood loss?

A

500ml

68
Q

When is blood loss abnormal?

A
  • if >500mls, more significant if >1000ml
  • any blood loss in labour prior to delivery apart from ‘show’ is considered abnormal and requires referral to a consultant unit
69
Q

How is haemostasis achieved?

A
  • tonic contraction
    • lattice pattern of uterine muscle strangulates the blood vessles
  • thrombosis of the torn vessel ends
    • pregnancy is hyper-coagulable state
  • myo-tamponade-opposition of the anterior/posterior walls
70
Q

What is the puerperium?

A

Period of repair and recovery

6 weeks of return of tissues to non-pregnant state

71
Q

What happends during the puerperium

A
  • lochia: vaginal discharge containing blood, mucus and endometricla castings
  • rubra: fresh red 3-4days
  • serosa: brownish red, wattery 4-14 days
  • alba (yellow) 10-20 days
  • bloodstained discharge lasts for about 10-14 days following birth
72
Q

What uterine changes happen in the puerperium?

A

Uterine involution

Weight reduction from 1000gms to 50-100grms

Fundal height- umbilicus to within pelvis in 2 weeks

Endometrium regenerates by the end of a week (except the placental site)

73
Q

When does physiological diuresis occur?

A

2-3 days postnatally

74
Q

What initiates lactation?

A

Placental expulsion and a decrease in oestrogen and progesterone

75
Q

How do oestrogen and progesterone block milk production?

A

Block the release of prolactin form the pituitary gland and make the mammary cells unresponsive to this pituitary hormone

76
Q

Why is colostrum important

A

Rich in immunoglobulin

Reproductive & Sexual Health (54 decks)

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