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OBGYN > Stages Of Labour > Flashcards

Stages Of Labour Flashcards

1
Q

What is the definition of labour

A

process whereby the products of conception are expelled from the uterus

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2
Q

When does labour normal occur?

A

Between 37-42 weeks
Lasting 3-18 hours

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3
Q

How is labour diagnosed?

A

When regular, painful uterine contractions lead to effacement and dilatation of the cervix

Commonly with show and or SROM

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4
Q

What is the Show in labour?

A

Pink/white mucus plug (operculum) from the cervix

(Comes out when cervix dilates)

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5
Q

How would you know someone had had their SROM?

A

History: liquor drainage PV (colour clear)

Speculum exam: pool of fluid in posterior fornix

Tests: amnisure or u/s (rarely)

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6
Q

Does the presence of the Show mean someone is in active labour?

A

Not always

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7
Q

What can be mistaken for SROM?

A

Urinary incontinence

Vaginal discharge

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8
Q

How do you confirm there was ROM?

A

AmniSure test

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9
Q

What is the AmniSure test testing for?

A

PAMG-1

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10
Q

What is PAMG-1?

A

One of the amniotic fluid proteins (1,000-10,000 times higher concentration in amniotic fluid than cervicovaginal fluid)

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11
Q

How do you carry out an AmniSure test?

A

Swab vaginal discharge and dip into testing agent and read from test strip

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12
Q

When does the FDA recommend doing an AmniSure?

A

As part of an overall clinical assessment ie not on its own

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13
Q

How is labour diagnosed based on history?

A

Regular painful uterine contraction

+/- SHOW

+/- rupture of membranes

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14
Q

How is labour diagnosed based on physical examination?

A

Palpability of contractions

Cervical effacement

Cervical dilation

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15
Q

What are some theories on what initiates labour?

A

Oxytocin theory:
- produced from post pituitary
- stimulates uterine contraction
- (increased production and incr expression of uterine receptors)

Oestrogen stimulation/progesterone withdrawal:
- Higher levels of oestrogen-v- progesterone make uterus more sensitive to substances that stimulate contractions

Foetal initiation theory:
- foetal adrenal glands release cortisol at term – alters prostaglandin production

Uterine distension:
-Uterus can only distend so far before contraction

Prostaglandin cascade theory:
-released from foetal membranes, myometrium

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16
Q

What are the stages of labour?

A

1st, 2nd and 3rd

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17
Q

What happens in the first stage of labour?

A

Initiation of full cervical dilatation (10cm)

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18
Q

What happens in the second stage of labour?

A

Full dilatation to delivery of foetus

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19
Q

What happens in the third stage of labour?

A

Delivery of foetus to delivery of placenta

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20
Q

Which stage of labour is the slowest?

A

First

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21
Q

What are the stages of labour?

A
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22
Q

When is labour in that stage one?

A

From diagnosis of labour until cervix fully dilated (10cm)

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23
Q

How long is the first stage of labour?

A

8 hours nullip

5hrs multip

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24
Q

What can stage 1 of labour be divided into?

A

Latent phase

Active phase

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25
Q

What is the latent phase of labour? (First stage)

A

Slowly 1st 4 cm

Over several hours

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26
Q

What is the active phase of the first stage of labour?

A

1cm/hr for nullip

2cm/hr for multip

(<16hrs)

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27
Q

What is cervical effacement?

A

Incorporation of cervical canal (initially tubular) into lower uterine segment

(Pulling the thinning cervix up into part of the uterus)

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28
Q

How does cervical effacement proceed?

A

From internal os to external os

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29
Q

What accompanies cervical effacement?

A

Show +/- ROM

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30
Q

What is the normal pre-labour cervical length?

A

2-4cm

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31
Q

How is cervical effacement described?

A

As a %

  • use fingers to determine if effaced
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32
Q

What does cervical effacement look like?

A
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33
Q

How is cervical dilatation measured?

A
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34
Q

How does the reporting of cervical dilatation and effacement compare?

A

Dilatation 0-10cm

Effacement 0-100%

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35
Q

When does the second stage of labour encompass?

A

From full cervical dilatation to the expulsion/delivery of the foetus

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36
Q

What is the happening during the passive stage of the second stage of labour?

A

Full dilatation -> head reaches pelvic floor

Before urge to push

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37
Q

How long does the passive stage of the second stage of labour usually last?

A

Only minutes

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38
Q

What is happening in the active stage of the second stage of labour?

A

Irresistible urge to push

Push with contractions

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39
Q

How long does the active stage of the second stage of labour last?

A

40 min in nullip

20 min in multip

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40
Q

What is the case if the active stage of the second stage of labour is >1hr?

A

Spontaneous delivery unlikely

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41
Q

What is perineal trauma?

A

Damage to the genitalia during childbirth

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42
Q

How common is perineal trauma?

A

85% some degree of trauma

60-70% need suturing

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43
Q

What has been injured in a 1st degree tear?

A

Perineal skin and/or vaginal mucosa

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44
Q

What has been injured in 2nd degree tears?

A

Involve the perineal muscle

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45
Q

What has the same degree of injury as a 2nd degree tear?

A

Episiotomies

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46
Q

What is involved in a 3rd degree tear?

A

Anal sphincter

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47
Q

What is involved in a 4th degree tear?

A

Anal mucosa

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48
Q

How are 3rd and 4th degree tears repaired?

A

In theatre with analgesia

Do spincter first then vaginal wall

Will need to avoid constipation and do physio

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49
Q

How do the internal and external anal sphincters differ?

A

Internal = involuntary - autonomic - relaxes on distension

External = voluntary

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50
Q

What is the major risk with 3rd and 4th degree tears?

A

Incontinence and infection so give antibiotics and physio

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51
Q

What are OASIS?

A

3rd and 4th degree tears

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52
Q

What are the different tears that women can have during labour?

A
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53
Q

What is the anatomy of the area that can be damaged during labour?

A
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54
Q

What are the short term complications of perineal trauma?

A

6% wound complications like infection and dehiscence

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55
Q

What are some longer term complications of perineal trauma? (5)

A

Dyspareunia

Incontinence

Fistula

Prolapse

Depression

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56
Q

What are the risks for OASIS? (6)

A

First baby

Long second stage

Large baby

Shoulder dystocia

IOL

Assisted delivery

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57
Q

Who is more at risk of OASIS nullip or multip?

A

6.1% for N

1.9% for M

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58
Q

What does stage 3 of labour encompass?

A

From delivery of the fetus to the delivery of the placenta

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59
Q

What happens to the placenta in stage 3 of labour?

A

Placenta shears away from the uterine wall and fibres contract to compress blood vessels

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60
Q

How long does stage 3 of labour last?

A

About 15 mins (>30 mins prolonged)

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61
Q

How much blood is lost in stage 3 of labour?

A

Up to 500mls

(Some studies average 150mls)

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62
Q

What are the 3 mechanical factors of labour?

A

Powers

Passage

Passenger

3 Ps

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63
Q

What is involved in the power in labour?

A

Uterine contractions forcibly expelling the foetus

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64
Q

What are the pressures involved in power in labour?

A

Intrauterine pressure (mmHg)

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65
Q

What is the normal resting tone intrauterine pressure?

A

10mmHg

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66
Q

At what intrauterine pressure are contractions painful?

A

25mmHg

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67
Q

What intrauterine pressure is seen in the first stage?

A

50mmHg

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68
Q

What intrauterine pressure is seen in the second stage?

A

100mmHg

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69
Q

What is meant by retraction?

A

When muscle fibres of the myometrium relax they do not return to their former length but become progressively shorter

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70
Q

What does the progressive retraction of the upper segment of the uterus do?

A

Stretches and thin out the lower segment causing effacement (pulling up of) and dilattaion of the cervix

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71
Q

Why is relaxation of the uterus between contractions so vital?

A

As reduced oxygenation to the baby if the contractions are constant and can cause fetal distress if no relaxation

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72
Q

What theory is there about what controls the uterine contractions?

A
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73
Q

How do the powers of labour change over the course of labour?

A

Increase in frequency, duration and amplitude

74
Q

What is the power of the expulsive phase of labour?

A

60-80mmHg

75
Q

What is relaxation vital for in labour?

A

Foetal oxygenation

76
Q

What are Braxton-Hicks contractions?

A

Non-painful (can feel cramps) uterine contractions

77
Q

How do Braxton-Hicks Contractions vary?

A

Vary in frequency, duration and amplitude

78
Q

Do Braxton-Hicks contractions include cervical changes?

A

Little or no cervical changes

79
Q

What is the approx amplitude of Brixton-Hicks Contractions?

A

15mmHg

80
Q

When are Braxton-Hicks contractions seen?

A

Normal more from 30 weeks

But can be earlier

81
Q

What is the suggested theory for Brixton Hicks Contractions?

A

? Improve uterine tone and promote uterine blood flow and foetal oxygenation

82
Q

What are the 2 parts of the passage the baby has to get through in labour?

A

Bony pelvis

Soft tissue

83
Q

What are the different measurements of the bony pelvis?

A
84
Q

What is the size of the inlet of the bony pelvis?

A

13x11cm

85
Q

What is the size of the mid-cavity of the bony pelvis?

A

Round
11cm

86
Q

What is the size of the outlet of the bony pelvis?

A

11x12.5cm

87
Q

What soft tissues does a baby have to pass through?

A

Cervix

Vagina

Perineum

88
Q

What are the measurements of the bony pelvis?

A
89
Q

What is the anatomical axis of the bony pelvis?

A

Curve of carus

(C-shaped)

90
Q

What is the obstetric axis that the head passes through during labour?

A

J-shaped

(Down and back then forward and down)

91
Q

What is a station?

A

The degree of descent of the (presenting part) head on vaginal examination

92
Q

How is station expressed?

A

In terms of distance in cms from the ischial spines (in vaginal side walls at 3/9 o’clock position)

93
Q

What are the ischial spines?

A

Bony prominences palpable vaginally

94
Q

At what station is the head engaged?

A

Station 0

95
Q

How are stations reported?

A

“Station of +2cm”

96
Q

How are the stations represented?

A
97
Q

What is cervical dilatation dependent on?

A
  • contractions
  • pressure of the fetal head on cervix
  • ability of the cervix to soften and allow distension (hydration of collagen)
98
Q

What often happens to the soft tissue of the vagina and the perineum during labour?

A

Needs to overcome the pressure and it often tears or is cut

99
Q

How does the passenger (ie the baby) present?

A
  • cephalic (95%)
  • breech (3-4%)
  • shoulder/back/limb
100
Q

What are the 3 main considerations of foetal head?

A
  1. Attitude
  2. Position
  3. Size/moulding
101
Q

What is Attitude in relation to the baby?

A

Degree of flexion of the fetal head on the neck

102
Q

What is the ideal level of attitude?

A

Max flexion

103
Q

What is the ideal max flexion attitude called?

A

Vertex presentation (9.5cm)

104
Q

What is presenting in the Vertex presentation?

A

Between Bregma (ant font) and occiput

105
Q

Why is Extension not the ideal presentation?

A

Results in larger diameter (eg brow or face presentation)

Can mean the foetal diameters are too large to deliver vaginally

106
Q

What is the Position in relation to the baby in labour?

A

Degree of rotation of the head on the neck

107
Q

How must the head rotate through labour?

A

90* during labour

108
Q

What position is a baby usually delivered in?

A

Occiput anterior (OA)

109
Q

What position is more difficult for the delivery of a baby?

A

OP (5%)

110
Q

What position is not possible for delivery without assistance?

A

Transverse

111
Q

How does the position impact the delivery?

A

Head must rotate 90* in labour - when you are talking about position of head in labour base it off back of the head/occipital
- normal is go in occipital transverse and turn occipital anterior
- if the go in and turn occipital posterior then need an instrument or to rotate them
- if they go in occipital posterior then need assistance with instruments

112
Q

How do you define the position of the baby during delivery?

A

Anterior Fontanelle = ♦️

Posterior Fontanelle = 🔺

113
Q

What is moulding with regard to the size of the head?

A

**as head is compressed in the pelvis, the sutures allow the bones to come together and overlap slightly

114
Q

How is Moulding expressed?

A
  • 0 = sutures not touching
  • +1= sutures touching
  • 2+= sutures overlap but is reducible
  • 3+= sutures overlap and not reducible
115
Q

What is Caput?

A

Swelling due to pressure on the scalp during delivery

116
Q

What is cephalopelvic disproportion?

A

Head is too big to pass through the bony pelvis

117
Q

What is Caput Succedaneum?

A

Odematous swelling within superficial CT layer of scalp

118
Q

What causes Caput Succedaneum?

A

Pressure of cervix/lower uterine segment

119
Q

How long does Caput Succedaneum last?

A

Disappears in 24-48 hours

120
Q

What are the cardinal movements of the foetus during labour?

A
  • Engagement
  • Descent
  • Flexion
  • Internal rotation
  • Extension
  • Restitution
  • External rotation
  • Expulsion

*Everybody Don’t Forget I Enjoy Really Expensive Escorts

  • Pelvic floor is shaped like a gutter (V) so he turns to line up with it at internal rotation
    Extension when releases from pelvic floor
    Restitution is turning head slightly to line up with shoulders
    Then their shoulders hit the pelvic floor and turn to side and so head externally rotates again and then they are expelled

Cardinal movements = think of us using the doll in the pelvis *

121
Q

What are the 7 cardinal movements of the foetus during labour?

A
122
Q

MCQ

Which of the following is correctly matched?

  1. First stage of labour: from full cervical dilatation to delivery of the foetus
  2. Attitude: the degree of rotation of the foetal head during delivery
  3. Position: the degree of flexion of the foetal head during delivery
  4. Anterior fontanelle: diamond shaped
  5. Moulding: Connective tissue swelling in the scalp post-delivery
A

4.

123
Q

MCQ

Which of the following statements is true?

  1. Cervical dilatation is normally expressed as a percentage
  2. The second stage of labour is usually the longest stage
  3. The AmniSure test checks for the PAMG-1 protein
  4. Average blood loss in the third stage is > 500ml
  5. The final cardinal movement of the foetus in delivery is extension
A

3.

124
Q

What is used to aid monitoring in labour?

A

Partogram = progress in labour

125
Q

What does the Partogram monitor about the maternal condition during labour?

A

Obs:
* temp: >38 or >37.5 on 2 occasions
* BP: increased or decreased
* HR
* urine: volume, ketones, protein

126
Q

What parts of the foetal condition does the partogram monitor in labour?

A
  • abdominal palpation
  • foetal heart monitoring
  • liquor
  • intact membrane (I)
  • Clear (c)
  • Meconium stained (m1/2/3)
  • blood stained (b)
  • absent (a)

*moulding
- 0, +1, +2, +3

127
Q

What two ways can foetal heart be monitored for the partogram?

A
  • Intermittent auscultation (every 15 mins in 1st stage, or every 5 mins in 2nd stage - 60 sec after contraction)
  • CTG
128
Q

How is progress of labour assessed on the partogram?

A
  • 2-4 hourly VE
  • cx dilatation (marked with X)
  • descent (marked with O)

*monitor contractions
- on palpation or CTG
- dots/lines/shaded squares

129
Q

What can cause failure to progress in labour?

A
  • Powers: inefficient uterine contractions (N, Induced)
  • Passenger: Foetal size (hydrops), disorder of rotation (OP or OT), disorder of attitude (brow or face presentation)
  • Passage: CPD, normal pelvic variants, abnormal pelvic architecture, pelvic mass, cervical role
130
Q

What is Friedman’s curve?

A

Cervical Dilatation
Prolonged latent phase: (20 hrs N, 14 hours M)
Protracted active phase dilatation- slow progress
< 1.2 cms/hour in primigravida
< 1.5 cms/hour in multip

Arrest disorders
-Arrest of Active Phase of cervical dilatation
No change in 2 hours

Descent:
-Protraction of Descent < 1cm/hr in N, < 2cm/hr in M
-Arrest of Descent
No change in 2 hours for nullip & 1 hour for multip

outdated - dont need to know the numbers just the terms like protraction and arrest

131
Q

What are some possible interventions in arrested or protracted first stage?

A
  • ARM
  • Oxytocin infusion
132
Q

What are some possible interventions in second stage of labour if arrested or protracted?

A
  • oxytocin infusion
  • assisted delivery
  • episiotomy
  • c-section
133
Q

When should a woman come to hospital in labour?

A

Admitted when painful contractions are regular (5-10min intervals) or if SROM

134
Q

What should be done as initial assessment of a women presenting in labour?

A
  • Hx: pregnancy, past obs history
  • Ex: temp, BP, HR, urine, abdominal exam (presentation), VE (cx, station, liquor)

*foetal heart
- intermittent auscultation
- CTG

135
Q

What should be done for the mother in the first stage of labour?

A
  • comfort/mobility
  • hydration, eating
  • urine
  • psychological considerations (adrenaline inhibits contractions)
  • support, attention, explanation
136
Q

What analgesia can be offered during labour?

A
  • Entonox
  • opiates/Pethidine
  • Pudendal N block
  • epidural
  • others = rubbing, TENS (early), water (body temp), hypnotherapy, acupuncture, heat, cold, massage
137
Q

What are potential side effects of Entonox?

A

Lightheaded

Nausea

Hyperventilating

138
Q

What are potential side effects of Opiates/Pethidine?

A

Sedation

Confusion

Nausea

Resp distress of baby if given <2 hours prior to delivery

139
Q

What are the pre-requisites of epidural analgesia during labour?

A

3 Cs

Consent
Cannula
Catheter

  • consent = written
  • pre-load with IV fluids (hypotension may occur - may need ephedrine)
  • urinary catheter in situ
140
Q

Where is an epidural inserted?

A

Inject LA (+/- opioid) via an epidural catheter between vertebra L3/L4 or L4/L5

141
Q

How do you dose an epidural?

A

Loading dose with top-ups

142
Q

What does an epidural do?

A

Complete sense (-pressure) and partial motor block from upper abdomen down

143
Q

What are contraindications of epidurals? (5)

A
  • Sepsis
  • Coagulopathy/A- coagulant
  • Active neurological disease
  • spinal abnormalities
  • hypovolaemia
144
Q

What are the advantages of an epidural? (5)

A
  • pain free
  • decrease BP in hypertensives
  • abolish premature urge to push
  • analgesia for instrumental or c-section
  • if long labour
145
Q

What are the disadvantages of epidurals? (7)

A
  • risk of spinal tap and total spinal analgesia
  • hypotension (give IVF)
  • maternal fever
  • poor mobility
  • unitary retention (catheter)
  • higher instrumental delivery
  • local anaesthetic toxicity
146
Q

What would you do in the first stage of labour if abnormal foetal HR on auscultation?

A

Then proceed to CTG

  • if abnormal: O2, IV fluids, left lateral position, stop oxytocin
  • if persists foetal scalp blood sample
  • may need to consider delivery
147
Q

What is required in order to be able to obtain a foetal blood sample?

A

ROM

Dilated 2-3cm

148
Q

What needs to be done to obtain a Foetal Blood Sample?

A
  • informed consent (verbal)
  • left lateral position
  • insert amnioscope into vagina and visualise foetal scalp
  • clean and spray with local anaesthetic (ethyl chloride to improve hyperaemia)
  • apply silicone gel (thin layer = blood clumps)
  • use blade and capillary tube to take a small sample of blood to see how baby is tolerating labour
149
Q

What determines if further assessment of abnormal CTGs is needed?

A

Foetal scalp pH

150
Q

What is a normal foetal scalp pH?

A

> 7.25 (lactate <= 4.1mmol/L)

  • may need to repeat every 30-60min if CTG changes persist or worsen
151
Q

What is a suspicious foetal scalp pH?

A

7.2 - 7.25 (4.2-4.8 mmol/L lactate)

-repeat after 30 min

152
Q

What is an abnormal foetal pH?

A

<7.2 (>= 4.9mmol/L)

-deliver by LSCS or instrumental delivery if fully dilated

153
Q

When is the second stage of labour slower?

A

Nullip S and epidurals

154
Q

How should a baby be delivered?

A

Mother in whatever position comfortable with - not flat on back

Attendant scrubbed and gloved

Swab pushing against perineum as it bulges to guard it

Woman asked to stop pushing and pant slowly once head crowns

Head delivers - check for nuchal cord

External rotation/ restitution

Maternal pushing and downward pull on head to deliver ant shoulder, then pull up to deliver post shoulder

Clamp & cut cord (doesn’t have to be immediately)

Record time of birth & apgar score

Skin to skin contact (keep warm)

155
Q

When does oxytocin need to be considered in the second stage of labour?

A

If nullip and high station

156
Q

What needs to be considered if an epidural in situ (numb) during second stage of labour?

A

Wait 1 hour before pushing

Directed pushing = 3 times for 10 second during a contraction (no urge)

157
Q

What needs to be considered if baby can’t get out during second stage?

A

Instrumental delivery - if delivery not imminent after 1 hour

Episiotomy

158
Q

What is an Episiotomy?

A

Surgical incision to increase diameter of vulva

159
Q

What are the indication for an episiotomy?

A
  • foetal distress
  • head not passing over perineum -> large tear likely -> delay
160
Q

What are the indications for instrumental deliveries?

A

MEDALS

M = medical problems (eg HTN/ cardiac disease and dont want them pushing)

E = exhaustion (maternal)

D = distress (foetal)

A = additional (eg breach)

L = long second stage

S = spinal tap

161
Q

What are contraindications to instrumental delivery? (3)

A
  • foetal bleeding disorders
  • foetal predisposition to fracture
    osteogenesis imperfecta
  • vacuum (Ventouse) extractors
    face presentation
    <32 weeks
    32-36 weeks - unclear re the ventouse but not recommended
162
Q

What are the pre-requisites for instrumental delivery? (Operative vaginal delivery)

A
  1. Full abdominal and vaginal examination

2 preparation of mother

  1. Preparation of staff
163
Q

What needs to be determined by the full abdominal and vaginal examination before instrumental delivery?

A

• Head </= 1/5th palpable per abdomen
• Vertexpresentation
• Cervix fully dilated, the membranes ruptured
• Exact position of head
• Assessment of caput and moulding (suggest inadequate pelvis) (if 2+/3+ then likely won’t do instrumental delivery)
• Pelvis is deemed adequate

164
Q

How must the mother be prepared before instrumental delivery of the baby?

A

• Clear explanation given and informed consent obtained
• (Effective) analgesia
• Empty maternal bladder, indwelling
catheter removed or balloon deflated
• Aseptic technique
• Intravenous antibiotics (new) (Augmentin)

165
Q

How must staff preparation be insured before the use of instrumental delivery?

A

Operator must have knowledge, experience and skill necessary (K/S/E)

Adequate facilities

Back up plan

Anticipation of complications (SD, PPH)

Personnel trained in neonatal resuscitation present

166
Q

What are the 3Ws of instrumental delivery?

A

Where to deliver?

What instrument? (Based on operators skill and clinical circumstance)

When to stop

167
Q

What are the 3 types of vacuum extraction?

A
  1. Metal cup
  2. Kiwi cup
  3. Soft cup
168
Q

Where should the cup be placed?

A

2cm anterior to the posterior Fontanelle

169
Q

What are the 2 types of forceps?

A

Non rotational NBF

Rotational KF

170
Q

How do vacuum compare to forceps?

A

*vacuum more likely to:
- fail
- cause a fetal cephalohaematoma / subgaleal haemorrhage
- cause a neonatal retinal haemorrhage

*vacuum less likely to:
- cause significant maternal perineal and vaginal trauma

171
Q

Why is the third stage fo labour actively managed?

A

Shortens 3rd stage = decreased risk of PPH and blood transfusion

172
Q

How can the third stage of labour be actively managed?

A
  1. Syntocinon 10 IU IM (syntometrine) with delivery ant shoulder (early cord clamping)
  2. CCT (Brandt-andrews method) after placental separation
    - fundus contracts/globular
    - passage of blood
    - cord lengthening
173
Q

How is the third stage of labour managed physiologically?

A

3 features
- division after pulsation stopped
- delivery by maternal effort and gravity
- oxytocics only if haemorrhage

Spontaneous delivery

174
Q

How long can physiological management of third stage of labour take?

A

Up to 60 minutes

175
Q

What is there an increased risk of with physiological management of third stage of labour as opposed to active management?

A

PPH

176
Q

What is the Brandt-Andrews Method of extracting the placenta?

A
177
Q

What are the complications of the third stage of labour?

A
  • incomplete placenta
  • retained placenta
  • haemorrhage
  • acute inversion of uterus
178
Q

What is seen in normal CTG?

A

Rate 110-160bpm

STV 5-25bpm

No declarations

Accelerations

179
Q

What 4 things can cause a suspicious or pathological CTG?

A
  • after an epidural
  • hypert insulation (with oxytocin)
  • haemorrhage
  • fetal hypoxia or acidosis
180
Q

What are the risks of oxytocin infusion?

A

• Can get fetal intolerance (abnormal CTG) and tachysystole
• May occur at low or high doses of oxytocin- it is essentially the effect on the fetus and the uterus that is the final arbitrator of safety.

OBGYN (25 decks)

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