Week 6 Flashcards
What are the 7 distinct cardinal movements of labour?
ON EXAM
- Engagement
- Descent
- Flexion
- Internal rotation
- Extension
- External rotation/restitution
- Expulsion
Explain ENGAGEMENT - one of the cardinal movements of labour?
Entering of the widest diameter (biparietal diameter -measuring ear tip to ear tip across the top of the baby’s head) of the foetal presenting part through the plane of the pelvis/pelvic inlet.
-> the widest part of the babies presenting part passes through the inlet
Explain DESCENT - one of the cardinal movements of labour?
- Movement deep into the pelvic cavity or the downward passage of the presenting part through the bony pelvis.
- When the occiput is at the level of the ischial spines, it can be assumed that the widest diameter of the baby’s head is engaged -descent occurs after this happens.
- During descent the foetus moves downward into the pelvic cavity
Explain FLEXION - one of the cardinal movements of labour?
- Foetal chin flexes to chest
- Occurs during descent because of the resistance of the soft tissues in the pelvis against the baby’s head.
- This resistance causes flexion of the head (chin to chest).
- This is when the smallest diameter of the baby’s head presents into the pelvis
Explain INTERNAL ROTATION - one of the cardinal movements of labour?
• Rotation of the fetal head from occiput transverse to occiput either in anterior or posterior position
As the head reaches the pelvic floor, it rotates sothat the sagittal suture is in the anteroposterior diameter of the outlet. This means that the shoulders will pass through the widest part of the pelvic inlet, which is from right to left.
Explain EXTENSION - one of the cardinal movements of labour?
- At the end of internal rotation when the baby is at the level of the vaginal introitus (opening).
- This is the point when the birth canal curves upward.Head, face and chin curve up under and past the pubic symphysis
- You can also think of this as when the occiput is just past the level of the pubic symphysis and when the head, face and chin curve under and past the pubic symphysis and are born.
- The baby is still in an antero-posterior position
Explain EXTERNAL ROTATION/RESTITUION - one of the cardinal movements of labour?
- There is a short pause during labour after the head is born. During this pause, the baby needs to rotate from a face-down position to facing either one of the mother’s inner thigh’s
- This movement aka restitution, is necessaryfor the shoulders to fit under the pubic arch. Remember that the widest space in the pelvic outlet is in the anterior-posterior position.
- When the head is delivered in the ideal position, (either left occiput transverse or right occiput transverse), the baby’s shoulders are positioned anterior-posterior (AP) which is the widest diameter of the pelvic outlet.
- This is the point when you would notice a shoulder dystocia.
Explain EXPULSION - one of the cardinal movements of labour?
- Once the shoulders are positioned AP, the anterior shoulder (under the symphysis pubis) will deliver first followed by the posterior shoulder.
- Although this stage is often completed naturally, gentle traction is applied by pulling the head of the foetus downwards along the axis of the pelvis –this will aid in releasing the anterior shoulder
- After this, gentle traction is applied upwards to deliver the posterior shoulder
- The foetus is then placed on mums abdomen while drying occurs.
What does the LATENT phase in the first stage of labour include?
Early Latent phase
- last up to 20 hours
- irregular contractions
- cervix open to 3cm
Late latent phase
- Then regular contractions
- occur 3 - 5 mins
- cervix dilates up to 6cm
What does the ACTIVE phase in the first stage of labour include?
- intense contraction
- cervix opens up to 6-10cm
What is the second stage of labour?
The pushing phase.
Relies on the 3 p’s - Power/Passenger/Passage
define labour?
Normal process by which the foetus, placenta and membranes are expelled through the birth canal.
What are the theories around the onset of labour?
Hormonal
- oxytocin theory
- prostaglandin
- fetalsteroids
- oestrogen/progesterone
Mechanistic
Environmental
what are the premonitory signs of labour?
- Braxton Hicks Contractions
- Increased pelvic congestion / pressure
- Decent of foetus into pelvis
-Relaxed pelvic floor
–frequency of urine
–Stress incontinence
- Cervical effacement; Loss of operculum (Show)
- Static weight or weight loss
- Rupture of the membranes
What happens during the first stage of labour?
- Normal physiological process!!
- Marked by the onset of painful, regular uterine contractions
- Results in progressive effacement & dilation of the cervix
–> From 0cm to full dilation of 10 cms.
What are the 2 different types of labour?
True labour
Spurious labour
What is true labour?
Progressive dilatation and effacement of the cervix
Contractions -regular –increasing frequency & intensity
For many, discomfort radiates from back to lower abdomen
Pain is not relieved by ambulation
Descent of head
WHat is Spurious labour?
Contractions do not produce progressive cervical effacement and dilatation
Contractions may be irregular, do not increase in frequency, duration or intensity
There may be “tightness” rather than pain
Discomfort in lower abdomen and groin
Discomfort often improves when ambulating
What are the 5 P’s of labour?
ON EXAM
Passenger-Foetus Powers -primary uterine -secondary maternal effort Position-foetal position Passage -pelvis Psychological -maternal reaction
What are the elements of Passenger (5P’s of pregnancy)?
Passenger –baby –>Size of baby •Particularly head; –>foetal lie of baby; –>foetal attitude; –>presenting part (pp)
What are the elements of Powers (5P’s of pregnancy)?
Primaryuterine –contractions; 1ststage
Secondarymaternal effort –pushing; 2ndstage
What are the elements of Position (5P’s of pregnancy)?
–Relationship of presenting part (pp) to pelvis
–Engagement
–Station
What are the elements of Passage (5P’s of pregnancy)?
Pelvis (True)
–Size
–Shape
Soft tissue: •Uterus •Cervix •Vagina •Perineum
What are the elements of Psychological response (5P’s of pregnancy)?
Attitude towards labour
–Anxiety; fear; experiences; pain
Culture
–Expectations
Preparation
–Antenatal care
–Antenatal classes;
Problems encountered
WHat causes the pain of labour?
contractions
dilatation of cervix
stretching vagina & perineum
pressure of baby as it distends pelvic floor
Body produces endorphins (endogenous opioids)
how do you document contractions? what do you record?
start
duration
finish
Assess progress
– No. over a 10 min period every 30 min
– Describe: -2 in 10 or 5 minutely
– Mild / mod /strong
– 30 sec / 40 sec / 55+ sec
• Recorded on partograph in midwifery documents
• Dots / stripes / block in on partogragh
What are the types of vaginal loss during labour?
May be absent or -
Liquor/Amniotic fluid –Clear –Meconium stained –Blood stained –Offensive
Operculum/‘show’ –mucousy+/-blood stained
–Signifies dilation of cervix
Bleeding
What history do you want to get from the patient when they in labour?
–Contractions
•Onset; Urge to push;
•frequency; intensity; length
–Membranes
•Intact or not?; Colour of fluid
–Gestation
•How many weeks? When is the due date?
–Last time felt baby move
–Last time ate or drank
–Any analgesia already taken during labour
What are some non-pharmacological gechniques to assist with pain management?
Maternal movement –
–walking / rocking / dancing / swaying
Positioning–
–sitting / kneeling / standing /
–leaning forward / squatting
Use of instinct –
–tendency towards upright
Counter pressure –
–strong steady force on lower back
define the second stage of labour?
From end of first stage to full dilatation of the cervix to birth of the baby
Labour is a continuous process –the differentiation between 1st& 2ndstage is difficult
what are the phases of the second stage?
Passive phase
Active 2ndstage
What characterises the transitional phase (end of 1st stage of labour)
Loss of control ‘Can’t do it anymore’ Fearfulness; Disorientation Nausea Uncontrolled shivering Demands for pain relief Vocalisation Variable urge to ‘bear down’
Explain the passive phase in the second stage of labour?
Initially a lull –calm before the storm
Contractions change characteristic often become shorter & stronger
Beginning of involuntary expulsive contractions
No need or urge to push
Foetus head is still high in the pelvis
Explain the active phase in the second stage of labour?
Pushing urge varies
–Become uncontrollable
Changes in vocalisation –
–Guttural ‘grunt’
Uncontrollable urge to push
Urge to defecate or defecates (bear down)
–Uncontrollable
Pouting anus
Perineum bulges
Foetal head is low
Visible presenting part
What are the presumptive signs of 2nd stage labour?
? Show/? Ruptured membranes Uncontrollable Urge to push Anal dilatation Perineal bulging Anal cleft line -“red line”
What are the definitive signs of 2nd stage labour?
Head on view
VE –cervix fully dilated
What is the primary physiology of the second stage
Primary –uterus contracts & retracts pushing down
»expels the foetus
Foetal axis causes pressure
Nerve receptors in pelvic floor stimulated
–‘Ferguson’s reflex’
Displacement of pelvic floor
–Anteriorly, bladder pushed up
–Posteriorly, the rectum becomes flattened
»into the sacral curve
What is the secondary physiology of the second stage
voluntary muscles of diaphragm & abdominal wall assist in expulsion (pushing phase
What do you need to remember in regards to INTERNAL ROTATION in the 7 cardinal signs of labour?
- At the pelvic inlet, the diameter of the pelvis is widest from right to left.
- At the pelvic outlet, the diameter is widest from front to back
What is non-directive pushing?
Non directive
–Head descends with physiological process
–Stimulates‘Ferguson’s reflex
–May be longer 2ndstage
What is directive (active) pushing?
Directive (Active) –
–Mimics valsalvamanoevre-pushing
–Used for maternal or foetaldistress
–Can cause oedemaof vulva causing perineal trauma
what should you direct the mother to do when crowning occurs?
- discourage pushing
- encourage mother to pant through next few stages
What should you prepare for birth in pre-emerg
Backup!Prepare for 2 patients
PIPERon the phone
Pre-hospital birth pack –
–Cord clamps; scissors; paper towel; Peri-pads;
Gloves/ goggles/ protective gear
Towels+++/maternity pads for mother
Warm water
Prepare neonatal resuscitation equipment –
–Wraps (warm if able); neonatal BVM; O2(low flow)
Documentation
What are the key points to the birth procedure?
Probs on exam
Support baby’s head to prevent sudden birth
May need to check chin is out
Watch for restitution
With the next contraction
Depress head towards mothers anus
Observe for cord -birth baby through it
–Never cut cord before delivery of anterior shoulder
Release anterior shoulder & lift head up towards abdomen
Posterior shoulder is released & follows
Place baby on mothers on abdomen
If not cut, leave cord intact until stops pulsating
