Too Posh To Push Or To Poor To Be cared for - week 2 Flashcards
Labour
Sequence of events by which a baby and the afterbirth (placenta) are expelled from the uterus at childbirth which normally occurs spontaneously between 37 and 42 completed weeks gestation
Normal birth in a full term pregnancy occurs with …
- spontaneous onset
- vertex presentation of the foetus
- low obstetric risk throughout pregnancy and labour
- a physiological and sequential nature
- regular painful uterine contractions
- progressive cervical effacement and dilatation
- progressive fetal descent
- strenuous maternal effort
- maternal movement
- spontaneous vaginal delivery of the baby , placenta and membranes
Normal birth Full term pregnancies occur without …
- induction of labour
- instrumental assistance
- operative assistance
- epidural anesthesia
- spinal anaesthesia
- general anaesthesia
Not all vaginal deliveries are normal births
Are these things normal and necessary? Medical model of birth
- augmentation/acceleration of labour with oxytoxics or amniotomy
- electronic fetal monitoring
- active third stage mangement of labour
- labouring in bed ?
- directed pushing it spontaneous pushing ?
- presenting part
- maternal ambulation
Birth as a social event
Birth of a child makes landmark event in the lives of all Involved
Profound physical , mental, emotional and social effect
Invoked pain , emotional stress , vulnerability
Possible physical injury or death , permanent role of change and responsibility
Psychophysiological model - ginesi
A woman has a baby and her life is literally never the same again
Chamberlens midwifery forceps
Influential French family
Man midwife who invented midwifery forceps to allow to deliver live infants
Before that craniotomy was used to deliver dead foetus
Caesarean section
Previously considered to be a life saving procedure
Following tissue layers dissected during surgery in 500 AD
Skin epidermis / dermis Subcutaneous layer Peritoneum Abdominal muscles Lower uterine segment muscles
Midwifes
Midwifes Act 1902
Enshrines normality in child bearing as the midwifed role referring to doctors as soon as abnormality occurs
Lying in hospitals for maternity care were innovated in the 18th century
Women in institutions who were cared for by doctors and medical students were being at risk of maternal mortality due to cross contamination and lack of hygiene and puerperal sepsis ( child bed fever )
Women cared for by midwifes in institutions or at home were significantly lower risk of contracting child bed fever
Peel committee report 1970
Recommended that sufficient facilities should be made available for 100% of child bearing women to give birth in hospital
Hospital confinement is inherently safer and preferable for all women
Birth rates
Normal birth rates have done down in England from 1990 to 2011 so women are 20% less capable of giving birth without intervention in two decades
Caesarean section
Rates have gone up from 1953 to 2013
NOCE advocate that “ if after discussion and offer of support (incl perinatal mental health support for women with anxiety about childbirth ) , a vaginal birth is still not acceptable option - offer a planned CS
Before 1950’s the CS section was considered high risk due to
- no general anaesthesia
- danger of mendelsons syndrome ( aspiration pneumonia )
- paralytic ileus
- surgical techniques
- quite radical abdominal surgery
- risk to other internal organs from surgical trauma
- child bearing risks for future births
While watching for dystocia ( obstructed labour )
You can have a partogram done
Friedmans curve
Alert line / action line
Active management of labour
- labour diagnosis at 2cm
- early artificial rupture of membranes
- 2 hourly vaginal examination
- syntocinon when progress is less than 1 cm per hour
- and in 2nd stage for descent or weak contractions
Child birth can only be considered normal in retrospect
Cons of that statement :
Turns physiological event into a medical procedure
Interferes with freedom to experience birth hoe and where woman chooses
Leads to unnecessary interventions
Concentrates women to technically equipped hospital - costly and influenced by standardised protocols
Intrapartum care guidelines (2007) highlights risk factors
- LSCS
- psychiatric disorders
- group B strep
- multiple pregnancy
- maternal age
- prev Pph
- borderline BMI
How does labour start ?
Don’t know just hypothesis and theories …
- onset - PG / incr oxytocin
- relaxin / calcium / pacemaker potentials / gap junctions
- myogenic
- neurogenic - sympathetic and parasympathetic divisions of autonomic nervous system
How oxytocin is stimulated naturally
Instinctive Innate Primeval ( hypothalamus / limbic cortex) - eustress - physically stressful
- pressure on cervix
- vaginal fullness
- pelvic floor pressure
- crowning
Oxytocin - positive feedback loop stretch / Ferguson reflex
Endorphins
Beta endorphins may dampen down contractions to modulate coordination
Modulate perception of pain ( gate theory )
Opoid influences to induce euphoria ( exercise )
No of interventions decr natural production of oxytocin
- anaesthetic injections ( epidural ? Inhibit Ferguson reflex
- induction / augmentation flooding receptor sites - less sensitivity to natural oxytocin
Poor fetal position. - less distension of lower genital tract
Episiotomy - less stretching of perineum
Fear / anxiety - lack of nipple stimulation
Indirect - embarrassment / abuse
NMC - nursing and midwifery council
To recognise warning signs of abnormality in the mother of infant which necessitate referral to a doctor and assist the latter where appropriate
2 incidents of bad clinical management and MDT work
1- Furness general morecombe bay 2004/2013
Dominant midwifes over zealous pursuit of natural childbirth let to times of unsafe. Care and poor working relationships between the MDT
2- Manchester general and Royal Oldham hospitals 2016
Death and appalling harm as a result of bad clinical decisions and staff relationships breakdowns
