The Stages Of Labour And Normal Delivery Flashcards
Mechanism, management and special circumstances
1
Q
Define Term
A
A baby born at 37 to 42 weeks gestation
2
Q
What is the working definition of labour?
A
Painful uterine contractions accompanied by dilatation and effacement of the cervix
3
Q
Define the first stage of labour
A
Initiation of labour to full cervical dilatation
4
Q
Define the second stage of labour
A
Full cervical dilatation to delivery of the fetus
5
Q
Define he third stage of labour
A
Delivery of the fetus to delivery of the placenta
6
Q
List the 3 mechanical factors of labour
A
- Degree of force expelling the fetus (powers)
- Dimensions of the pelvis and the resistance of soft tissues (passage)
- Diameters of the fetal head (passenger)
“3 Ps”
7
Q
What are the risk factors for poor uterine activity
A
- Nulliparity
2. Induced labour
8
Q
What is the level of descent of the fetal head and how is it measured?
A
- Level of descent called stations and measured by level in relation to ischial spines:
- Station 0 = level of spines
- Station +2 = 2cm below spines
- Station -2 = 2cm above spines
9
Q
How can the passage impact delivery?
A
- The bony pelvis:
- Inlet transverse > AP
- midcavity transverse = AP
- outlet AP > transverse - Soft tissues:
- Cervical dilatation - depends on contractions, pressure of fetal head, ability of cervix to soften and allow distension
- soft tissues of vagina and perineum
10
Q
Define attitude
A
Degree of flexion of the fetal head on the neck
11
Q
What is the ideal attitude for normal delivery?
A
Maximal flexion, vertex presentation, presenting diameter 9.5cm
12
Q
How does extension of the fetal head affect the presentation?
A
Small extension leads to a larger diameter
13
Q
List the types of presentation the fetus can have in labour
A
- Vertex
- Brow
- Face
14
Q
Define position of the head in labour
A
Degree of rotation of the head in the neck
15
Q
Describe how the head rotates during labour
A
- Saggital suture transverse head fits in pelvic inlet best
- Saggital suture vertical head fits in outlet best
- Head must rotate 90 degrees during labour
- Usually delivered with the occiput anterior
- More difficult to deliver if position occiput posterior and needs assistance for delivery if position occiput transverse
16
Q
What hormones are produced during labour and what is their function?
A
- Prostaglandin:
- decrease cervical resistance
- increase release of oxytocin from posterior pituitary - Oxytocin:
- aids stimulation of contractions
17
Q
Define effacement
A
When the normally tubular cervix is drawn up into lower segment until flat
18
Q
What are the phases of the first stage of labour?
A
- Latent phase - cervix dilates slowly for first 4cm
2. Active phase - follows latent phase
19
Q
What is the cervical dilatation rate?
A
1cm/hr nulliparous
2cm/hr multiparous
20
Q
What are the phases of the second stage of labour?
A
- Passive stage - full!l dilatation until head reaches pelvic floor and woman experiences desire to push
- Active stage - when mother is pushing
21
Q
Describe the moment of delivery
A
- Head reaches perineum and extends to come out of the pelvis
- Perineum stretches and often tears
- Head adopts transverse position to deliver the shoulders
22
Q
What is the normal length and blood loss for third stage of labour?
A
Length roughly 15mins
Blood loss roughly 500ml
23
Q
Describe the different degrees of perineal tears
A
First degree tear = minor damage to fourchette
Second degree tear and episiotomies = involve perineal muscle
Third degree tears = involve anal sphincter
Fourth degree tears = involve anal mucosa
24
Q
What observations need to be done in labour?
A
- Temp and BP every 4hrs
- Pulse every hour in first stage and every 15mins in second stage
- Contraction frequency every 30mins
Do more frequently if abnormal
25
Comment on mobility and position, hydration and eating in labour
- Freedom of movement encouraged, avoid supine position
- Encourage to drink isotonic drinks or water
- IV fluids may be necessary if prolonged
- Eating is appropriate, contents can be aspirated if GA required
- Eating discouraged if labour high risk
- Ranitidine given to decrease stomach acidity
26
How do we manage pyrexia in labour?
- Defined as temp >37.5
- More common with epidural and prolonged labour
- Cultures of vagina, urine and blood taken
- Give paracetamol
- IV antibiotics and CTG monitoring if fever ≥38
27
How do we manage urine output during labour?
- Encourage to micturate frequently
| - Catheterisation may be needed if epidural
28
What measures can be taken to reduce anxiety for the mother during labour?
1. Ensure nice environment
2. Birth attendent for continuous support
3. Include the partner - important potential source of support but may also need support
4. Give patient control - birth plan
29
What is a partogram used for?
Used to record progress in dilatation of the cervix and descent of the head
Assessed on VE and plotted against time
Alert and Action lines indicate slow progress
30
Define slow progress in stage one
Slow progress is diagnosed if <2cm dilatation in 4hrs
31
What problems with the powers can cause slow progress?
1. Inefficient uterine contraction - most common cause; nulliparous and induced labour
- Persistently slow tx is augmentation - first amniotomy and then oxytocin
2. Hyperactive uterine contraction - associated with placental abruption, too much oxytocin or SE of induction
- Tx depends on cause - tocolytic given IV or subcut if no sign of abruotion; C-section often indicated due to fetal distress
32
How is slow progress managed in a nulliparous labour?
FIRST STAGE
1. Augmentation:
- ARM
- Oxytocin if ARM fails to further cervical dilatation in 2hrs
- Use electronic fetal monitoring
- Full dilatation not imminent within 12-16hrs = C-SECTION
PASSIVE SECOND STAGE
- Start oxytocin infusion if poor descent
- Pushing not encouraged until feel urge
- Urge diminished with epidural
ACTIVE SECOND STAGE
- Direct pushing if ineffective or epidural present
- Stage longer than 1-2hrs spontaneous delivery less likely due to maternal exhaustion
- INSTRUMENTAL DELIVERY
33
How is slow progress managed in a multiparous labour?
FIRST STAGE
- Exclude malpresentation of fetus
- Augment with oxytocin CAREFULLY - more prone to rupture
SECOND STAGE
- Oxyticin should not be started for the first time
- Caution with instrumental delivery
34
What issues with the fetus can contribute to slow progress?
1. OP position - labour longer and more painful; use augmentation for slow progress; prolonged active second stage use instrumental delivery with rotation to OA position
2. OT position - only significant if vaginal delivery not achieved after 1hr of pushing in 2nd stage; rotation with traction required for delivery (ventouse)
3. Brow presentation - caesarean section required; anterior fontanelle, supraorbital ridges and nose palpable
4. Face presentation - mouth, nose and eyes palpable; vaginal delivery in most cases if chin anterior to allow extension over oerineum; C-section if chin posterior
5. Fetal abnormality - hydrocephalus, breech presentation, transverse or oblique lie
35
List the causes of damage to the fetus during labour
1. Fetal hypoxia (distress)
2. Infection/inflammation in labour
3. Medium aspiration
4. Trauma (usually due to obstetric intervention)
5. Fetal blood loss
36
Define fetal distress and hypoxia
- Hypoxia that might result in fetal damage or death if not reversed of the fetus urgently delivered
- pH <7.2 in fetal scalp blood sample indicates significant hypoxia
- pH <7 neurological damage more common
37
List the causes of acute hypoxia
1. Placental abruption
2. Hypertonic uterus states and use of oxytocin
3. Prolapse of umbilical cord
4. Maternal hypotension
38
List the intrapartum risk factors for fetal dustress
1. Long labour
2. Meconium
3. Use of epidurals and oxytocin
39
List the antepartum risk factors for fetal distress
1. Pre-eclampsia
| 2. IUGR
40
How is fetal distress diagnosed?
Made from funding if significant fetal acidosis or ominous FHR abnormalities
41
List the methods of monitoring fetal wellbeing in labour
1. Liquor colour
2. FHR auscultation - every 15mins during first stage and every 5mins during second stage
3. CTG
4. Fetal ECG monitoring
5. Fetal blood sampling (FBS)
42
What are the indications of fetal distress on CTG?
1. Tachycardias
2. Sustained bradycardia
3. Prolonged reduced variability
4. Late decelerations - persist after contraction is completed
43
List the indications for CTG
1. Prelabour risk factors:
- Pre-eclampsia
- IUGR
- Previous caesarean section
- Induction
2. In labour risk factors:
- Presence of meconium
- Use of oxytocin
- Presence of temp >38
- During the administration of epidural analgesia
3. Intermittent auscultation abnormalities
44
Describe the levels of investigation fetal distress
Level 1 = intermittent auscultation of fetal heart; if abnormal proceed to level 2
Level 2 = CTG; sustained bradycardia >5mins deliver; abnormal on other criteria correct, if correction fails move to level 3
Level 3 = FBS ; if abnormal proceed to level 4
Level 4 = Delivery by quickest route
45
What is the management of fetal distress?
1. In utero resuscitation:
- Place mother in left lateral position
- Administer O2 and IV fluid
- Stop any oxytocin infusion
- Stop contraction using beta 2 agonists
- VE to exclude cord prolapse or very rapid progress
2. Confirmation of distress and delivery:
- FBS
- Expedite delivery if pH <7.2
- Scalp sampling impossible or FHR shows sustained bradycardia DELIVER
46
List the other causes if fetal damage and their treatments
1. Infection - screening for organism and treatment of high risk groups (IAP)
2. Meconium aspiration - amnioinfusion of saline into the uterus
3. Fetal trauma - iatrogenic usually
4. Fetal blood loss
47
What are the options for pain relief in labour?
1. Non-medical:
- antenatal classes prep
- birth attendent
- immersion in water at body temperature
2. Inhalational agents:
- Entonox (NO + O2); SE lightheadedness, nausea, hyperventilation
3. Systemic opiates; small analgesic effect; SE sedation, confusion, feeling of loss of control, resp depression in the Newborn
4. Epidural analgesia; indwelling epidural catheter between L3 and L4 or L4 and L5
48
List the advantages and disadvantages of epidural analgesia
ADVANTAGES
1. Only method that makes pain free
2. Advised on medical grounds if labour is long, to decrease BP in HTN and to abolish premature urge to push
DISADVANTAGES
1. Occasionally ineffective or incomplete
2. IV access required
3. Transient hypotension common after loading dose
4. Mobility decreased
5. Reduced bladder sensation
6. Maternal fever more common
7. Instrumental delivery more common
8. May need directed pushing
49
List the contraindications to epidural analgesia
1. Severe sepsis
2. Coagulopathy or anticoagulant therapy
3. Active neurological disease
4. Some spinal abnormalities
5. Hypovolemia
50
List the major complications of epidural anakgesia
1. Spinal tap (inadvertent puncture of duration causing CSF leakage and severe headache)
2. Inadvertent intravenous injection (convulsions and cardiac arrest)
3. Inadvertent injection of local anaesthesia into CSF (total spinal analgesia, respiratory paralysis)
51
List the different types of anaesthesia for obstetric procedures
1. Spinal anaesthesia - C-section or midcavity instrumental delivery
2. Higher dose epidural analgesia - combination with spinal best for c-section
3. Pudendal nerve block - low cavity instrumental vaginal deliveries
52
What needs to be done at the initiation and diagnosis of labour?
1. Contact maternity if contractions regular, painful, lasting at least 30secs and occurring every 3-4mins
2. Brief hx pregnancy and past obstetric hx
3. Temp, pulse, BP, Urinalysis
4. Check presentation
5. VE - cervical effacement and dilatation; confirm dx labour
6. Assess descent
7. Assess liquor colour
8. FHR every 15mins
9. CTG if high risk
10. Read birth plan
53
How is the mother managed in the first stage of labour?
1. Position
2. Fluid
3. Observations
4. Analgesia
54
How is the fetus managed in the first stage of labour?
1. Intermittent auscultation
2. CTG if high risk
3. Resuscitation +/- FBS if HR abnormal
4. LSCS is fetal distress
55
How is progress managed in the first stage of labour?
1. VE (4hrly)
2. Augmentation with ARM +/- oxytocin if nulliparous and progress
3. LSCS if full dilatation not imminent by 12hrs
56
What observations are performed on the mother and how frequently are they done in the first stage of labour?
1. Contraction frequency - every 30mins
2. Pulse - every hr
3. BP, temp, VE - every 4hrs
57
What observations are performed on the fetus and how frequently are they done in the first stage of labour?
1. FHR - every 15mins
58
When should pushing be initiated during the second stage of labour?
- Non-directed pushing when mother has urge if no epidural
| - Directed pushing and wait at least 1hr before starting if epidural
59
When is an episiotomy performed?
1. Fetal distress
2. Head not passing over perineum despite maternal effort
3. Large tear likely
60
How are the shoulders delivered?
Anterior shoulder:
- Maternal pushing and gentle downward traction on the head
Posterior shoulder:
- Traction directed upwards
61
When is the umbilical cord clamped after a normal delivery?
Not for at least 1min post delivery unless urgent resuscitation required
62
How is the mother managed in the second stage of labour?
1. Position
2. Fluid
3. Observations
4. Analgesia
63
How is the fetus managed in the second stage of labour?
1. Intermittent auscultation
OR
2. CTG
64
How is progression managed in the second stage of labour?
1. Oxytocin if nulliparous and station high
2. Start pushing when mother has desire or visible head
3. Instrumental delivery if not delivered after 1hr of pushing and prerequisites met
65
What observations are performed on the mother in the second stage of labour and how often are they done?
1. Pulse - every 15mins
66
What observations are performed on the fetus in the second stage of labour and how often are they performed?
1. FHR - every contraction
67
How is the third stage of labour managed?
1. Oxytocin administered IM - combination with ergometrine often used but can cause maternal vomiting
2. 'Active management' - reduces incidence of PPH
68
How can we tell placental separation has occurred and what do we do then?
- Lengthening of cord and passage of blood
- Apply continuous gentle traction to deliver placenta
- Check placenta for missing cotyledons and vagina and perineum for tears
- Record blood loss
- Continue maternal obs for at least 2hrs
69
What indicates retained placenta and how is it managed?
1. Third stage longer than 30mins
2. Partial separation - blood loss and hypovolaemia
3. Absence of bleeding - Allow 1hr for natural separation
- Manage with manual removal
70
Describe how perineal tears are managed
- 1st and 2nd degree tears - sutured under local anaesthetic
- 3rd and 4th degree tears:
* Repaired under epidural or spinal
* Antibiotics and laxatives given plus analgesia
* Risk factors = forceps delivery, large babies, nulliparity, use of midline episiotomy
71
List the criteria for a home birth
1. Woman's request
2. Low risk
3. 37-41wks
4. Cephalic presentation
5. Clear liquor
6. Normal FHR
7. All maternal obs normal
72
Define induction of labour and explain when it is performed
IOL is labour that is started artificially.
It is performed in situations where allowing the pregnancy to continue would expose the fetus and/or mother to risk greater than that of induction
73
List the methods of induction
1. Medical:
i) Prostaglandins
ii) Oxytocin (after ARM)
2. Surgical:
i) Amniotomy
74
What determines whether induction will be successful?
Success depends on favourability of the cervix.
Related to consistency, degree of effacement or early dilatation, how low in the pelvis the head is and the cervical position.
Bishop's score is predictor - the lower the score the less favourable the cervix.
75
Discuss induction with prostaglandins
- Prostaglandin E2 as gel or SR preparation
- Inserted into posterior vaginal fornix
- Best method in nullips and most multips
- Starts labour or improves cervix to allow amniotomy
76
Describe induction with amniotomy +/- oxytocin
- Membranes ruptured with amnihook
| - Oxytocin infusion started within 2hrs if labour has not ensued
77
What is natural induction?
- Cervical sweeping
| - Finger passed through cervix and 'stripping' between membranes and lower segment of uterus
78
List the indications for induction
1. Fetal indications:
- Prolonged pregnancy
- Suspected IUGR or compromise
- Antepartum haemorrhage
- Poor obstetric history
- Prelabour term rupture of membranes
2. Materno-fetal indications:
- Pre-eclampsia
- Maternal disease (e.g. DM)
3. Maternal indications:
- Social reasons
- In utero death
4. Routine induction
79
List the common indications for induction
1. Prolonged pregnancy
2. Suspected growth restriction
3. Prelabour term rupture of membranes
4. Pre-eclampsia
5. Medical disease - DM, HTN
80
List the absolute contraindications to IOL
1. Acute fetal compromise
2. Abnormal lie
3. Placenta praevia
4. Pelvic obstruction
5. After more than one C-section
81
List the relative contraindication to IOL
1. One previous C-section
| 2. Prematurity
82
What are the complications of IOL?
1. Failure to start or slow labour
2. Hyperstimulation of uterus
3. Increased risk of PPH
4. Increased risk of intrapartum and postpartum infection
5. Prematurity
6. Increased instrumental delivery and C-section
83
List the contraindications to a vaginal birth after a previous C-section
1. Absolute indications for a C-section
2. Verticle uterine scar
3. Previous uterine rupture
4. Multiple previous C-sections
84
What are the increased risks if the mother has had a previous C-section?
1. Placenta praevia
2. Placenta accrete
3. Difficult surgery
4. Perinatal death
85
How is labour managed after a previous c-section?
1. Hospital delivery and CTG
2. AVOID INDUCTION
3. Cautious with augmentation
4. Epidurals are safe
5. Increased risk of scare rupture:
* Fetal distress
* Pain
* Cessation of contractions
* Vaginal bleeding
* Maternal collapse
86
What are the risks of prelabour term rupture of membranes?
1. Cord prolapse
| 2. Neonatal infection
87
How is prelabour term rupture of membranes managed?
1. Confirm dx
2. Check lie and presentation
3. Avoid VE - only perform in sterile manner if risk of cord prolapse
4. Intermittent auscultation or CTG
5. Await spontaneous onset - 24hrs, obs every 4hrs
6. Induction
7. Presence of meconium or evidence of infection - IMMEDIATE induction
8. After 18-24hrs - prescribe Abx and induction
