Normal Labour & Pueperium Flashcards
Define labour.
- physiological process during which the Fetus, membranes, umbilical cord and placenta are EXPELLED from the uterus
What occurs during labour ?
- regular, painful uterine contractions
- increasing freq., intensity, duration
- biochem. changes in the cervical tissue allowing cervical dilatation
Where can on one give birth?
- consultant led unit
- Midwife led unit
- homebirth
Does a woman require a birth plan?
- no
- it is her personal choice (just so she knows what to expect)
What takes part in the initiation of labour?
- change in estrogen/proges. ratio
- fetal adrenals and pituitary hormones CONTROL the timing of the labour onset
- myometrial stretch INCREASES excitability
of myometrial fibres - mechanical stretch of cervix and strips fetal membranes
- Fergusons Reflex
How does progesterone affect the onset of labour?
- keeps the uterus settled
- prevents formation of gap junctions
- HINDERS myocyte contractility
What are gap jxns?
- contractions in the the myometrium is said to be caused by the flow of positive ions into a muscle cell via small protein complexes called gap jxns.
- these multiply near the END of Labour
The role of estrogen in Labour?
- makes the uterus contract
- promotes PROSTAGLANDIN prodn
What is the role of oxytocin during labour?
- initiates and sustains contractions
- acts on decidual tissue to promote prostaglandin release
- —–oxytocin is synthesized directly in decidual, extraembryonic fetal tissues and in the placenta
Apart from oxytocin, name another stimulant for prostaglandin release.
- pulmonary surfacant secreted in to the Amniotic fluid
- —also a basis of knowing the fetus’ lung maturity
What does the increase in detal cortisol stimulate?
- an incr. in maternal estriol
Oxytocin receptors increase in numbers in the myometrium when reaching term.
What occurs with their activation?
- results in phospholipase C activity
- subsequent increase in cytosolitic calcium and uterine contractility
What is the role of liquor?
- nurtures, protects and facilitates movement
What biochemical changes allow cervical softening to occur?
- incr. in hyaluronic acid increases molecules among the collagen fibres
- decr. the bridging among collagen fibres = decr. the firmness of the cervix
What is the cervical tissue made of?
- collagens type 1,2,3,4
- smooth muscle
- elastin
- —-all held together by connective tissue ground substance
What occurs in cervical ripening?
- decr. in collagen fibre alignment
- decr. in collagen fibre strength
- decr. in tensile strength of the cervical matrix
- incr. in cervical decorin (dermatin sulphate proteoglycan 2)
What does the Bishops score take into account?
When is the cervix considered to be ripe for delivery?
- best method to determine if its safe to INDUCE labour
- considers: cervical POSITION (post. mid. ant.) / Cervical CONSISTENCY/ EFFACEMENT/ DILATATION/ STATION IN PELVIS
- GOOD chance of vaginal delivery if score is >8 (ripe for labour)
- unripe, if <6
- labour within a few days if >10
List the stages of labour.
- First stage
- Latent stage (3-4 cm dilated)
- Active stage (4-10cm “full dilatation”)
- Second Stage
- Full dilatation—delivery of bby
- third stage
- delivery + expulsion of placenta and membranes
What occurs in the first stage?
- Latent phase: mild contractions, cervix shortens and softens (can last a few days)
- Active phase: 4cm onwards; slow descent of baby; more rhythmic and strong contractions. (1-2cm. hr)
What occurs with the second stage of labour?
- complete 10cm cervical dilatation > delivery of baby
-
When is the 2nd stage of labour considered to be prolonged in nulliparous and multiparous women?
Nulliparous: prolonged if exceeds 3 hrs with regional analgesia/ 2hrs w.o
Multiparous: prolonged if it exceeds 2 hrs with analgesia or 1hr w.o
What occurs in the third stage of labour?
- delivery + expulsion of placenta and fetal membranes
- avg. time is 10 mins (>3mins)
What management is in place with the 3rd stage of labour?
Expectant managem.: Spontaneous delivery of the placenta
Active management: use of OXYTOCIC drugs and controlled cord traction(to lower risk of PPH)
What are Braxton-Hicks contrxns?
- FALSE labour; false sensation of having real contractions
- tightening of uterine muscles (aid body for birth)
- —-starts 6 wks into preg. (felt in 3rd trimester usually)
How does the BHC feel and relieved?
- resolved with ambulation/ change in activity
- relatively painLESS
How is true labour contractions different?
- occurs with release of oxytocin
- —these are evenly spaced timings between the contractions (w. time gets shorter and MORE intense)
- —contrxns tighten the TOP part of the uterus pushing the baby downward
What are the 3 key factors during labour?
Power: Uterine Contraction
Passage: Maternal Pelvis
Passenger: fetus
Where is the uterine pacemaker located?
- region of the tubal ostia (wave spreads in downward direction)
Normal contractions occur________
up to 3-4 times in 10 mins
How long do contractions last initially then later?
- —initially 10-15 s
- —max 45 s; slowly builds up
What is the most suitable pelvis for delivery? What is not right with the other types of pelvis?
- Gynaecoid pelvis
- —Anthropoid: oval inlet (large AP diameter and smaller transverse diameter)
- —-Android Pelvis (triangular/heart-shaped inlet) —–common in african-caribbean
What is evaluated under “passenger” during labour?
- cervical assessment (effacement/position/dilatation/ firmness)
- fetal position (feel for the fontanelles and sutures)
What is considered to be normal fetal position?
- longitudinal lie
- cephalic
- vertex; the presenting part
- Occipito-anterior (head engages occipito-transverse)
What is considered to be abnormal fetal position?
- breech
- oblique
- transverse lie
- —-OP
What are some analgesic options for birth?
- PCM/ Co-codamol
- TENS
- etonox
- diamorphine
- epidural
- remifentanyl
- combine spinal/ epidural
What is a partogram?
- a graphic record of key data contained on one sheet to assess the progress of the labour
What are the 7 cardinal movements for the fetus’ head during labour whilst in the pelvis, IF in VERTEX position?
- engagement
- Descent
- Flexion (passively)
- Internal Rotation
- Crowning and extension
- Restitution and external rotation (head adopts optimal position)
- expulsion, anterior should first
When is the head said to be engaged?
- when the WIDEST part of the fetal head has entered the brim of the pelvis (3/5s engaged)
What is observed on descent of fetal head?
- maternal discomfort
- frontal synciput and occipital eminences
- vaginal examinations ( 4hrly and for cervical assessment)
What is the position of the fetal head on descent?
- occiput transverse position
What occurs on internal rotation?
- rotation from transverse to anterior position
On extension of the fetal head during the descent of the fetal head; what maternal body part does the fetal occiput come in contact with?
- inferior margin of the pubic symphysis
What is meant by crowning?
- appearance of large segment of fetal head at the introitus
- labia stretched to the max
- —burning and stinging for mum
What is recommended when guiding the delivery of the head with hands?
- done slowly with hands NOT leading the exit at crowning to prevent rapid extension of tissues
Is delayed clamping a good thing and why?
YES
- a higher RBC flow to vital organs in the 1st week is noted
- less anemia at 2 months + incr. duration of early breastfeeding
What benefits are shown with delayed cord clamping ?
- higher infant hematocrit and Hb levels
- higher blood volume and BP
- improved cardiopulmonary adaptation
- —–fewer days of oxygen and ventilation and blood transfusions
Why is skin-to-skin contact important post delivery?
- helps keep bbies warm and calm
- improves transition to life
- studies have shown that these women breastfeed MORE successfully
What occurs in the 3rd stage?
- expulsion of the placenta (5-10mins after delivery) —-normal for up to 30 mins
What are signs of placental expulsion?
- uterus HARDENS and rises
- umbilical cord LENGTHENS
- freq. gush of blood
- placenta and membranes at the introitus
WHat is done during ACTIVE management during the 3rd stage?
- prophylactive administr. of Syntometerine (1ml ampoule containg 500 mcg ergometrine maleate and 5IU oxytocin)
OR
- 10 units of oxytocin
- cord clamping and cutting
- bladder emptying
Most common type of placental separation ?
- Matthew Duncan
What is the plane of separation?
- spongy layer of decidua basalis
What is an abnormal amount of blood loss after delivery?
- > 500ml
- any blood loss in labour (prior to delivery) is abnormal
How is hemostasis achieved?
- by tonic contraction (uterine m. strangulates the BV)
- thrombosis of torn vessel ends: as preg. is a hypercoaguable state
WHat is puerperium?
- period of repair and recovery
- -return of tissues to non-pregnant state (6 wks)
What to expect with pueperium?
- lochia (vaginal discharge= blood+ mucus+ endometrial)
- Rubra (fresh red) 3-4 days
- Serosa (bronwish red, watery) 4-14 days
- Alba (yellow) 10-20 days
- —blood stained discharge for 10-14 days
How does the body rid the excess body fluid collected during pregnancy?
- by diuresis
- commences 2-3 days postnatal
- 3000ml per day
How long does it take it for the fundal height to go back to normal?
- umbilicus to within the pelvis in 2 weeks
- —endometrium regenerates by end of the week (except placenta)
What initiates lactation?
- placental expulsion
- decr. in estrogen and progesterone
—estro. and progest. acc INHIBITS milk secretion by blocking prolactin release
What is significant about colostrum?
- rich in immunoglobin
- protective for bby
What may cause trouble in breastfeeding?
- psychological trauma post delivery
- physical debility
