Normal Pregancy and Labour Flashcards
At what stage of development does an embryo implant
Fertilised ovum with divide to the blastocyst stage then move from the ampulla to the uterus - day 3-5
Blastocyst implants at day 5-8
Becomes the trophoblast
What do the different parts of the blastocyst become
Inner cells develop into embryo
Outer cells burrow into uterine wall and become placenta
How does the blastocyst implant
Cords of trophoblastic cells from the surface begin to penetrate the endometrium.
This creates the space for the blastocyst to develop
When implantation is finished the blastocyst is completely buried in the endometrium - by day 12
What is the placenta derived from
Trophoblast and decidual tissue - outer cells of blastocyst
What happens when the trophoblast cells start to differentiate
They become multinucleate cells (syncytiotrophoblasts) which invade decidua and break down capillaries to form cavities filled with maternal blood
How does the foetal blood supply contact the developing placenta
Developing embryo sends capillaries into the syncytiotrophoblast projections to form placental villi
Each villus contains fetal capillaries separated from maternal blood by a thin layer of tissue
Is there direct contact between maternal and foetal blood
No
There a thin layer of tissue between them
At what point does the placenta become functional
5th week of pregnancy
Foetal heart also starts functioning
How does exchange occur through the placenta
2 way exchange of respiratory gases, nutrients, metabolites between mother and foetus, largely down diffusion gradient
How does HCG maintain a pregnancy
signals the corpus luteum to continue secreting progesterone
Progesterone stimulates decidual cells to concentrate glycogen, proteins and lipids
How does the developing foetus receive oxygen
The placenta plays the role of the foetal lungs
Done through exchange of maternal blood and the umbilical blood
Oxygen diffuses from the maternal into the foetal circulation
CO2 does the reverse
The umbilical veins carries the O2 rich blood to the foetus
How is the foetal circulation designed to get sufficient oxygen
Foetal haemoglobin has a higher affinity for oxygen than adult
There is also 50% more Hb to maximise oxygen transport
Bohr effect (Foetal Hb can carry more oxygen in low pCO2 than in high pCO2)
How do water and electrolytes reach the foetus
Water diffuses into placenta along its osmotic gradient
Exchange increases during pregnancy up to the 35th week
Electrolytes follow H20
What is a developing foetus’ main energy source
Glucose
Passes through the placenta via simple transport
Can drugs cross the placenta
YES
Must be careful when prescribing as can lead to problems for the baby
What is the role of human placental lactogen in pregnancy
Produced from ~ week 5 of pregnancy
Growth hormone-like effects - protein tissue formation.
Decreases insulin sensitivity in mother which means more glucose for the foetus
Involved in breast development - cause of tender breasts in pregnancy
What is the function of progesterone in pregnancy
Development of decidual cells
Decreases uterus contractility - can therefore be given to those with recurrent miscarriage to try and prevent
Preparation for lactation
What is the role of oestrogen in pregnancy
Enlargement of uterus
Breast development - contributes to tender breasts with HPL
Relaxation of ligments
How quickly should HCG rise
Serum levels should double every 48 hours in a singleton early pregnancy
Start falling again from 12-14 weeks after it peaks
What may be happening if HCG levels aren’t rising quickly or at all
If HCG levels aren’t rising quickly enough then it suggests an ectopic pregnancy
If the levels are falling it suggests a failing pregnancy
What do very high HCG levels suggest
Multiple pregnancy
Molar pregnancy
What is the side effect of HCG production
N and V
It is the rising HCG that causes morning sickness
Worse in multiple/molar pregnancy due to higher HCG
How can increase Ca demands in pregnancy affect the mother
Can lead to hyperparathyroidism
What happens to cardiac output in pregnancy
Cardiac output increases by up to 50% in pregnancy to cope with the increased demand of supplying the foetal circulation
Plasma volume increases
Caused by increased stroke volume and reduced systemic vascular resistance, in combination with an increased heart rate
What happens to CO in labour
Increases 30% more during labour.
How might pulse change during pregnancy
Lots of pregnant women will have an increased HR of around 90bpm
Usually rises by around 10-20 bpm
May have a collapsing or bounding pulse
May also get new functional murmurs and ECG changes
What happens to BP in the second trimester
It drops
This is because uteroplacental circulation expands and peripheral resistance decreases
First dip at 10 weeks then rises again before a second dip at 21 weeks
What are the haematological changes that occur in pregnancy
Plasma volume increases proportionally with CO
RBC production increases
MCV and Hb conc stay the same
Maternal Hb is decreased by dilution (haemocrit and red cell count also fall)
Iron requirements increases significantly - may need supplements
Get a modest leukocytosis - high white cells
Platelet count falls progressively throughout pregnancy
How does progesterone impact lung function
Progesterone signals the brain to lower CO2 levels
To do this RR increases, Tidal and minute volume increases, pCO2 decreases slightly
What effect does pregnancy have on the respiratory system
Progesterone signals the brain to lower CO2 levels
O2 consumption increases to meet metabolic need of fetus, placenta and mother
Enlarging uterus has an impact on lung expansion
How does pregnancy affect the renal system
GFR and renal plasma flow increases due to the increased plasma volume - early in pregnancy
There is increased re-absorption of ions and water
Slight increase in urine formation
Increased protein excretion and glucose loss in urine
Collecting system dilates - can cause physiological hydronephrosis
What is the average healthy weight gain for a pregnant woman
Around 11kg
How many extra calories does a pregnant woman need per day
Around 200-300 extra calories per day
Most is used by the foetus and some is stored as fat
Describe the 2 metabolic phases of pregnancy
1st - 20th week - mother´s anabolic phase
In anabolic metabolism and has small nutritional demand from foetus
lower plasmatic glucose level
lipogenesis, glycogen stores increases
21-40 weeks - foetus has high metabolic demands and there is ‘starvation’ of the mother
get insulin resistance and lipolysis
At what stage of pregnancy is gestational diabetes more likely to develop
The later stage when there is high metabolic demand on mum
This is because there is increased insulin resistance
If a woman develops gestational diabetes early on she is more at risk of diabetes in later life as well
What causes insulin resistance in pregnancy
HPL, cortisol and growth hormone
What supplements may be needed in pregnancy
Folic acid - prevent neural tube defects
Vit D
High protein diet
Iron - not given routinely, only when needed for anaemia
B-vitamins - help with erythropoiesis
What hormone changes can trigger labour
Placenta produces increasing levels of peptide hormone CRH which increases oestrogen and prostaglandin synthesis and reduce progesterone levels
More oestrogen increases contractility
Mother releases oxytocin from pituitary which increases contractions and excitability (direct action at tissue and also increases prostagladins)
Foetal hormones: oxytocin, adrenal gland, prostaglandin
What increases contractility of the uterus
Oestrogen
Mechanical stretch of uterine muscles
Dilation of the cervix
How can you induce labour
Vaginal prostaglandins are given
Can do a membrane sweep – insert finger through the cervix to stretch it and stretch the membrane under the baby
Once the waters have been broken, IV oxytocin can be given
When do Braxton Hicks contraction occur
Increase toward the end of pregnancy
Thought to be the uterine muscles preparing for labour.
What causes abdominal contraction in labour
Strong uterine contraction and pain from the birth canal cause neurogenic reflexes from spinal cord that induce intense abdominal muscle contractions
Where is oxytocin released from
The mother’s and foetus’ posterior pituitary
What are the stages of labour
1st = Cervical dilation (8-24 hours)
Latent phase is up to 4cm dilated and effaced
Active phase is 4-10cm
Will have contractions
2nd = passage through birth canal, delivery of baby
(few min to 120 mins)
3rd = time between delivery of baby and expulsion of the placenta and membranes
Where is prolactin released from
The anterior pituitary
What effect do progesterone and oestrogen have on breast development and milk production
Oestrogen: growth of ductile system
Progesterone: development of lobule-alveolar system
Both inhibit milk production
Sudden drop at birth triggers the milk
Which hormone stimulates milk production
Prolactin - it steadily rise from week 5-birth
Oxytocin also has a role
What is colostrum
First milk produced which is high in protein and contains lots of immunoglobulins
What are the principles of a good screening test
highly sensitive highly specific have a high positive predictive value easily used in a large population safe and cheap quick and straightforward to perform able to detect a disease with a known natural history and where early diagnosis has a proven benefit
What examinations are usually carried out at the booking visit
Height and weight
BP
CVS exam and abdo exam
What investigations are usually done at the booking visit
Hb
Blood type and Rhesus (+ other antibodies
Screen for syphilis, HIV, Hep B and C and haemoglobinopathies
Urinalysis; MSSU C and S
US - confirm viability, number of babies, estimate gestational age, look for major structural abnormality
Can measure nuchal thickness to screen for Down’s
What checks are usually done at each follow up antenatal appointment
Physical and mental health Foetal movements BP and urinalysis Symphysis- fundal height Lie and presentation Engagement of presenting part Foetal heart auscultation
How is foetal growth measured
Serial measurement of symphysis fundal height - plotted on a customised chart
Carried out at every appointment from 24 weeks
Which supplements should be taken in pregnancy
400 micrograms Folic acid pre-conception & first trimester (up to 12 weeks)
10 micrograms Vitamin D through pregnancy and continuation if breast feeding
Which groups are most at risk of malnutrition in pregnancy
Exclusion diets - vegan etc
Underweight /Overweight
Adolescents- improper mobilization of fat storage
Multiple pregnancies- increased risk of depletion
Low income Family
Previous poor pregnancy outcome
Smokers
Which women need a higher dose of folic acid
Obese women (BMI >30)
Diabetics
History of baby with NTD or FH
On anti-epileptics
These women need 5mg
What is the role of folic acid
Folates play a crucial role in many metabolic reactions such as the biosynthesis of DNA and RNA, and amino acid metabolism
In pregnancy it reduces risk of neural tube defects
Which women are at risk of developing anaemia in pregnancy
Young age at first pregnancy
Repeated pregnancies
Multiple pregnancies
What is the function of iron in pregnancy
Involved in numerous enzymatic processes
Plays essential roles in the transfer of oxygen to tissues.
By how much should a women increase her calorie intake during pregnancy
70 kcal/day in the first trimester
260 and 500 kcal/day in the second and third, respectively
Should also increase by 500 for the first 6 months of exclusive breastfeeding
What are the maternal risks of vitamin D deficiency
Osteomalacia Pre-eclampsia Gestational diabetes, Caesarean section, Bacteria vaginosis
What are the foetal risks of vitamin D deficiency
SGA,
Neonatal Hypocalcaemia
Asthma/Respiratory Infection
Rickets
What food/drink should pregnant women avoid
Unpasteurised cheese, pate, liver, cured meat, raw fish - due to infection risk
Alcohol
Should also reduce caffeine intake,
How does being underweight affect your fertility
It is reduced
2X more likely to take more tan 1 year to become pregnant
Causes hormonal imbalances
What are the risks of being underweight during pregnancy
Risk of nutritional depletion
Even higher if they suffer from hyperemesis
Risk of IUGR and low birthweight
Preterm labour more common
Which pathway are obese pregnant women put on
Red pathway - high risk pregnancy
Require more monitoring and review
Which hormones influence the onset of labour
Oestrogen makes the uterus contract and promotes prostaglandin production
Oxytocin initiates and sustains contractions and also promotes prostaglandins
Increase in production of foetal cortisol stimulates an increase in maternal estriol
What is the purpose of liquor
Nurtures and protects foetus and facilitates movement
What is the normal progress of cervical dilation
In the latent phase the duration varies = can take many hours
In active phase it is usually 1-2cm per hour
What is considered an prolonged second stage of labour
In nulliparous women considered prolonged if it exceeds 3 hours if there is regional analgesia, or 2 hours without
In Multiparous women it’s if it exceeds 2 hours with regional analgesia or 1 hour without
How long do you leave the third stage of labour before intervening
After 1 hour preparation made for removal under GA
How can you manage the 3rd stage of labour
Watch and wait - spontaneous delivery of placenta, mum may feel like pushing
Active management: use of uterotonic drugs and controlled cord traction is preferred for lowering risk of post partum haemorrhage
How do contractions change throughout labour
Time between them gets shorter
The length of time they last gets longer
And they get more intense and painful over time
What are the 3 factors that are part of labour
Power = contractions Passage = the maternal pelvis Passenger = foetus
What are the paraments of cervical assessment in labour
Effacement Dilatation Firmness Position Level of presenting part or station
How should the baby present in the birth canal
Head should present first
Should be lying occipito-anterior; head engages occipito-transverse
Head should be flexed
How can you determine foetal position in the birth canal
Feel for the fontanelles
What are the analgesia options for labour
Paracetamol/ Co-codamol TENS Entonox - gas and air Diamorphine Epidural Remifentanyl Combined spinal/epidural
Describe the cardinal movements of labour
1= Engagement = widest part presents to a level below pelvic inlet 2= Decent = presenting part passes down through pelvis 3= Flexion = head flexes passively 4= Internal Rotation 5= Crowning and extension - neck extends once head is at the vaginal opening 6= Restitution and external rotation -head adopts optimal position for shoulder 7= Expulsion - anterior shoulder first, then rest if body delivered
What is the purpose of delayed cord clamping
Allows a higher red blood cell flow to the vital organs
What is an episiotomy
Incision made during labour to prevent trauma to anal sphincters
Is there a benefit to immediate skin to skin contact
Yes
It helps calm the baby and aids its transition
Recommended to have 1hr STS after birth
What is considered a normal blood loss during labour
Volume less than 500mls
What is puerperium
Period of repair and recovery after labour
Takes about 6 weeks
What type of discharge is expected after birth
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
What triggers lactation
It is initiated by placental expulsion and a decrease in oestrogen and progesterone
This allows prolactin to exert it effect on the mammary glands (previously blocked by the other hormones)
When are US scans carried out in pregnancy
Booking/Dating Scan - usually 10-12 weeks
Detailed Scan at 20 weeks to look for structural abnormalities
When are abnormalities picked up on US
Cardiac (12-20 weeks)
Microcephaly (Usually after 22 weeks)
Short Limbs (Usually after 22 weeks)
Brain malformations
How can you test foetal DNA in pregnancy
Chorionic Villus Biopsy from placenta between 11-13+6
Amniocentesis at 16+ weeks
Usually PCR based with results in 2-3 days
Is there a non-invasive option for pre-natal testing
Harmony test
Can take a blood sample and look for baby DNA
Placenta sheds DNA into the mother’s blood so some DNA can be found in the mother’s serum
Not yet available on the NHS
What does trisomy 18 cause
Edwards Syndrome
What are the side effects of using diamorphine in labour
Risk of respiratory depression in both mum and baby
Coma, respiratory depression, hallucination and pinpoint pupils in overdose
Arrhythmias and palpitations
Constipation
Confusion and drowsiness
What are the side effects of an epidural
Low BP
Light-headedness and nausea
Loss of bladder control
Headache (if there is a puncture)
Risk of developing an abscess at the site
High risk of haematoma in those with blood disorder
How are contractions recorded on a partogram
Recorded as the number per 10 mins and how long they last
What is moulding
Moulding is where the foetal skull bones overlap one another as the baby passes through – seen in an obstructive labour
Which forms of pain relief can be delivered in the midwife unit
Up to 2 doses of diamorphine
All others apart from an epidural, spinal or pudendal
Can midwives repair vaginal tears
A midwife can do it under local anaesthetic if 1st or 2nd
If 3rd or 4th then an obstetrician is needed
What typically abnormal heart sounds can be considered normal in pregnancy
Ejection systolic murmur
A loud first heart sound
A third heart sound
Ectopic beats.
Which ECG changes are considered non-pathological in pregnancy
Small Q waves and inverted T waves in lead III
ST depression and T wave inversion inferiorly and laterally
Left shift of the axis
What happens to tidal volume in pregnancy
Increased by up to 45%
This occurs from the first trimester
What happens to respiratory rate in pregnancy
It is unchanged
Does peak flow (PEFR) change in pregnancy
No
So can be used as normal in the assessment of patients with asthma.
What happens to functional residual capacity in pregnancy
Late in pregnancy this is reduced as a result of diaphragmatic elevation
What happens to inspiratory reserve volume in pregnancy
Is reduced early in pregnancy as a result of increased tidal volume
Then increases in the third trimester as a result of reduced functional residual capacity
How does pregnancy affect ABGs
Pregnancy causes relative hyperventilation
Leads to increased PaO2 and reduced PaCO2
Causes a mild, fully compensated respiratory alkalosis.
How might LFTs change in pregnancy
Liver metabolism increases leading to:
Decreased albumin
Raised ALP = produced by placenta
ALT/AST in the upper limit of normal
Gastric motility is reduced in pregnancy - true or false
True
Can cause reflux and constipation
Urinary tract infection is more common in pregnancy - true or false
True
List the red flags of a pregnant woman presenting with headache
Sudden onset headache/thunderclap or worst headache ever
Headache that takes longer than usual to resolve or persists for more than 48 hours
Has associated symptoms such as fever, seizures, focal neurology, photophobia, diplopia
Excessive use of opioids
Which neurological conditions may present/worsen in pregnancy
Headaches are common - migraines can get worse
Compression neuropathies including carpal tunnel syndrome occur more frequently
Women with epilepsy may have more seizures due to fear of taking medication and/or drug levels falling due to haemodilution and increased renal clearance
What changes to the skin can occur in pregnancy and postpartum period?
Hyperpigmentation
Melasma - light brown facial pigmentation
Spider naevi
Palmar erythema
Hair loss - commonly between 4 and 20 weeks postpartum
Pruritis
What is Polymorphic eruption of pregnancy
A rash of pruritic, urticarial papules and plaques most commonly on abdomen (but sparing umbilicus) and thighs
Occurs in pregnancy usually around 34 weeks
Will rapidly resolve after delivery - doesnt affect baby
What is Pemphigoid gestationis
Rare skin condition of pregnancy - usually third trimester
Often occurs on abdomen (involving umbilicus), spreading to limbs, palms and soles
Associated with low birthweight, preterm delivery and stillbirth
Neonate can be affected by same eruption, which is mild and transient
What is atopic eruption of pregnancy
The commonest pregnancy specific dermatosis - mainly occurs in the second or third trimester,
It is associated with atopy. More commonly in multiparous women. I
Patches of intensely itchy papules which become excoriated.
Treatment includes emollients, antihistamines and topical steroids.
What causes the hypercoagulable state in pregnancy
Increased factors VIII, IX and X and fibrinogen, reduced fibrinolytic activity and a decrease in antithrombin and protein S all contribute
Pregnancy is an insulin resistant state - true or false
True
Due to increased production of hormones
An increase in thyroid hormone production is required in pregnancy to maintain circulating levels - true or false
True
50% more thyroid hormone is required
This is due to the effect of oestrogen on TBG and thyroid hormone metabolism by the placenta
Women on levothyroxine may need an increased dose
Why might thyroid tests on a pregnant woman show a false hyperthyroidism result
βHCG is structurally similar to TSH.
In early pregnancy, the high βHCG levels can result in increased T4 production and TSH suppression
The women will have no symptoms so just monitor them
How can pregnancy affect RA
Many women find their symptoms improve
However, they will have to stop their DMARDs in pregnancy so flares are common, particualrly post-partum
There is an increases risk of an SLE flare during pregnancy - true or false
True
It also increases risk of iscarriage, fetal death, pre-eclampsia and preterm delivery. if there is renal involvement or antiphospholipid antibodies
Which women get uterine artery doppler scans
It is a screening test used for those at high risk of pre-eclampsia
Done around 20 weeks
Abnormal measurements are associated with the subsequent development of pre-eclampsia and/or fetal growth restriction
Can pregnant women be given the COVID Vaccine
Yes
Should avoid the 1st trimester
Which radiological tests are safe to use in pregnancy
Chest X-ray
V/Q scan
MRI
CT head
What is meant by gravidity
Gravidity refers the number of times a women has been pregnant regardless of the outcome
What is meant by parity
Parity is the number of deliveries after 24 weeks gestation (regardless of outcome).
When should an elective section be performed
After 39 weeks gestation
This reduced the risks to baby
What is considered term for a pregnancy
37-42 weeks
What is involved in the first stage of labour
The first stage of labour is where there is regular contractions with dilation of the cervix to fully dilated
What is involved in the second stage of labour
The second stage of labour is from fully dilated to delivery of the baby
What is involved in the third stage of labour
The third stage of labour is from delivery of the baby to delivery of the placenta.
At which point does the position/lie of the baby become clinically relevant
In labour or at risk of labour, i.e., usually after 36 weeks gestation
Before this it is normal for the fetus to be in varied positions
What are the indications for examination of the pregnant abdomen
At each antenatal assessment from 24 weeks gestation (to assess growth)
Prior to auscultation of the fetal heart and use of CTG (to work out where to listen)
Prior to vaginal examination
During labour
Why should you avoid lying a pregnant woman flat on her back
The weight of the baby can cause aortocaval compression
This decreases maternal CO, and may reduce uteroplacental perfusion which may result in fetal acidosis
Should always keep her semi-recumbent
How should the symphisis-fundal height correlate to gestation
This distance in centimeters should correlate approximately with the
gestational age in weeks(+/- 2cm allowance)
12 weeks gestation –pubic symphysis
20 weeks gestation –umbilicus
36 weeks gestation –the xiphoid process of the sternum
What are the 3 main types of foetal lie
Longitudinal
Oblique
Transverse
How is foetal engagement assessed
The fetal head is divided into fifths when assessing engagement
If you are able to feel theentire headin the abdomen, it isfive fifthspalpable(not engaged)
If you arenot able to feel the headat all abdominally, it iszerofifthspalpable(fully engaged)
Where should you auscultate the foetal heart beat
You should aim to place the doppler between the fetal shoulders on the fetal back
Which other examination should always be performed prior to bimanual vaginal examination
Abdominal exam
At what point in pregancy should a pattern of foetal movement be established
By 24 weeks
Before 24 weeks an anterior placenta can reduce the
sensation of fetal movements for women but after 24 weeks the
location of the placenta has no bearing on movements
Reduced movement after 24 weeks should be investigated
What is included in the 36 week and above antenatal check
Abdominal examination, measure fundal height
plot on customised flow chart, presentation and fetal heart rate
in conjunction with maternal pulse rate, fetal movements, BP,
Urinalysis, symptoms check.
What are some risks of early induction of labour
Cord prolapse due to artificial rupture of membranes if the fetal
head is not engaged.
Failed induction (i.e. can’t get cervix to dilate, labour to establish)
Potentially a longer labour with increased risk of medical intervention - instrumental
Uterine hyperstimulation, and associated fetal distress and uterine rupture
What happens to the placental blood flow during contractions
It is reduced temporarily
Therefore O2 exchange is also reduced
The baby has enough reserves to cope with these short periods of hypoxia
What is the normal range for foetal HR
When first heard (earliest 4 weeks) its around 100bpm
It progressively rises to 140-150 bpm by 8 weeks
It then falls slightly to baseline rate
What causes acceleration in the foetal HR
Foetal activity and movement
Also responsible for the baseline variability
What 3 parameters are used to asses foetal behaviour
Foetal heart rate
eye movements
body/limb movements
There are 3 behavioural states
What are the potential adverse outcomes of intrapartum foetal hypoxia
Perinatal death (stillbirths and neonatal deaths)
Hypoxic ischemic encephalopathy (HIE) - damage to CNS
Cerebral palsy
What monitoring is performed on all women in labour (i.e. the minimum)
Temperature 4-hourly
Palpate the maternal pulse hourly, or more often if there are any concerns, to differentiate between the maternal and fetal heartbeats
Blood pressure and respiratory rate at least 4-hourly
Frequency and duration of contractions at 30 min intervals
Frequency of bladder emptying and the results of urinalysis if performed
Abdominal palpation findings 4-hourly
Description of vaginal loss and vaginal examination findings 4-hourly
How and when is intermittent auscultation performed in labour
Foetal heart is auscultated with stethoscope or doppler
Done for low risk pregnancy
In the first stage of labour, IA of the fetal heart should be undertaken after a uterine contraction for at least one minute, at least every fifteen minutes
During the second stage, IA should be performed after a contraction for at least one minute, at least every 5 minutes
What type of stethoscope is used to listen to foetal HR
A Pinard stethoscope
Why do you auscultate after a contraction in intermittent auscultation
This allows you to pick up on late decelerations
What are the indications for continuous monitoring in labour
Abnormal foetal HR (<100 or >160)
Decelerations after contraction that dont improve on position change
Fresh bleeding in labour
Oxytocin for augmentation
Maternal pyrexia 38 °C once or 37.5 °C on two occasions 2 hours apart
Suspected chorioamnionitis or sepsis
Maternal tachycardia of >120
Significant meconium stained liquor and particulate
Confirmed delay in the first or second stage of labour
Contractions that last longer than 60 seconds (hypertonus), or more than 5 contractions in 10 minutes (tachysystole)
Why does foetal HR increase in response to hypoxia
Hypoxia puts the baby under stress so it releases adrenaline = increased HR
Aims to improve oxygen circulation
Should maternal pulse be monitored in labour
Yes
You have to be able to differentiate between maternal and foetal HR to ensure accurate monitoring and action
What is considered preterm labour
It is defined as labour occurring before the commencement of the 37th week of gestation
The earlier they are born the more help babies will need
The average time for labour is 10 hours - true or false
False
The average is 5.5 hours but there is no ‘normal’ duration of labour
Prolonged labour is associated with which adverse outcomes
Increased fetal and maternal morbidity and mortality Foetal distress PPH Pelvic floor dysfunction Fistulae
How quickly should the cervix dilate in labour
It is expected that the cervix will dilate: More than or equal to 2cm in 4 hours during labour.
Describe the passive second stage of labour
Full dilatation of the cervix prior to or in the absence of persistent (occurring with every contraction) involuntary expulsive contractions
Describe the active second stage of labour
This is when baby is visible
Will have full dilation
Either persistent involuntary expulsive contractions or maternal effort to push baby
Describe physiological management of the 3rd stage of labour
Uterotonic drugs (oxytocin) are not used
The cord is not clamped until the pulsations have ceased
The placenta is delivered by maternal effort.
Describe active management of the 3rd stage of labour
Involves use of uterotonic drugs (oxytocin or syntometrine) with the birth of the anterior shoulder or immediately after the birth of the baby and before the cord stops pulsating or is clamped and cut
Bladder catheterisation
Deferred clamping and cutting of the cord
Controlled cord traction after signs of separation of the placenta.
What is the purpose of active management of the 3rd stage of labour
Shortens the stage
Reduced risk of PPH and need for transfusion
List the 4 main signs of placenta and membrane separation
The uterus contracts, hardens and rises
Umbilical cord lengthens permanently
There’s a gush of blood variable in amount
Placenta and membranes appears at introitus.
What are the indications for active management of the 3rd stage of labour
Excessive bleeding or haemorrhage occurs
Failure to deliver the placenta within one hour
The patient desires to shorten the third stage.
List the clinical signs of the onset of labour
Regular, painful contractions which increase in frequency and duration and that produce progressive cervical dilatation
The passage of blood-stained mucus from the cervix (the ‘show’) is associated with but not on its own an indicator of onset of labour.
Rupture of membranes can be at the onset of labour but this is variable and can occur without uterine contractions.
The integrity of the cervix is important to retain the products of conception - true or false
True
However, at term it has to soften to allow birth
What happens to the cervix towards term
It softens and stretches
This is due to a decrease in collagen caused by the increase in enzyme activity.
Progressive uterine contractions cause effacement and dilatation of the cervix - caused by changes in myometrial fibres
Generally, parous women have less operative delivery - true or false
True
When is the booking visit carried out
10-12 weeks
This is the first appointment the women gets when she finds out she is pregnant
When are pregnant women offered the whooping cough vaccine
offered between 28-32 weeks gestation if they are not yet vaccinated
List the tests/exams that are carried out routinely in pregancy
Offered BP, urinalysis checks and abdominal palpation to check SFH measurement, position and lie of baby, fetal heart auscultation
How does the uterus change in the puerperium period
The endometrial lining of the uterus rapidly regenerates by day 7
post-partum.
The fundus of the uterus, which usually sits around the umbilical level during
pregnancy, returns to its physiological location within the pelvis by around 2 weeks.
Uterine weight decreases to around 5% of what it was immediately after birth by
the end of puerperium
All termed uterine involution
It is normal for pregnant women to have a lower Hb - true or false
True
Haemoglobin is decreased by dilution as plasma volume increases
Physiological process
Can lead to anaemia = defined as <110 g/l in the first
trimester
What is implantation bleeding
Minimal bleeding in early pregnancy - light brown and limited
This occurs in around 20% of pregnancies
Occurs just before the
woman’s period would have been due (roughly 10 days post ovulation)
Should settle as pregnancy continues
