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Flashcards in Intrapartum Care & Normal Birth Deck (17):
1

Define Normal Labour and spurious labour

Describe the three stages of labour

Normal labour: onset of regular, painful uterine contractions associated with cervical effacement & dilatation
Spurious labour: uterine contractions +/- pain but no cervical effacement & dilatation

1st stage of labour: cervical effacement + dilatation to full dilatation (10cm) --> Latent slow progress to full effacement & 3cm dilatation; Active faster cervical dilatation 1cm/hr.

2nd stage labour: full dilatation of cervix to baby

3rd stage labour: delivery of baby to delvieyr of placenta

2

Normal labour: Power, passenger, passage. Explain.

Power: uterine muscle contraction is STRONG, LONG (40s-1min), FREQUENT (3-5/10mins)

Passenger: fetal size/lie *longitudinal or transvers*/px *cephalic or malpresentation*/atitude *flex or extend*/position *denominator to maternal pelvis*

Passage: resistance to expulsion of fetus by bony pelvis, soft tissues of birth canal.

3

During normal labour, monitor mother for? monitor baby for?

Mother: infection (chorioamnionitis), pre-eclampsia (BP, urinalysis); Intrapartum haemorrhage, emotional well-bring, pain relief.

Fetal: auscultate fetal heart continuous CTG or intermittent after each contraction; Amount and colour of amniotic fluid (low = fetal distress due to fetal sparing of heart, adrenal, brain)

4

Pain relief in labour - options? (pharmacological)

Inhalational (NO) - labour pain comes and goes, NO works quickly and wears off quickly but not strong in terms of pain relief.

Systemic: Opioids take edge off peak o contractions but side effect of drowsiness.

Neuraxial analgesia: spinal one quick shot very fast very dense OR epidural can last length of labour

Local infiltration: pudendal nerve block/perineal infiltration.

5

First stage of labour
- the two stages and time
- maternal hx on admission
- exam on admission
- fetal well-being
- progress of labour
- ROUTINE CARE OVERVIEW

- (latent and active) Length of time depends on parity and duration of latent phase. Nullipara 6-18hrs, Multipara 2-10hrs. Roughly 1cm/hr

- Hx (Meds, use anti epileptics during labour; past obs hx; complications?; GBS status/HepC/HIV; Blood group) Labour hx (duration, show, ROM, bleeding, FM) Antenatal education and birth plan?

- Exam: pre-eclampsia, infection, bleeding + duration/frequency/intensity of contractions and pain control

- fetus: colour/volume amniotic fluid if membranes ruptures. Auscultate or CTG. Continuous CTG indication?

- Uterine contractions (strength, duration, intensity, frequency); Vaginal exam (cervical effacement dilatation descent of px part...EVERY FOUR HRs); Partogram documentation

- Routine care: Observe maternal/fetal/progress of labour + activity e.g. ambulate + Fluids and diet (light and clear for labour) + IV access not routine (High risk PPH, C section) + Abx prophylaxis (intrapartum prophylaxis if +ve vaginal swab)

6

Indications for continuous CTG (antenatal and intrapartum)

Antenatal (diabetes, hypertension, growth restriction, bleed during pregnancy)

Intrapartum (meconium/blood stained liqor, abnormal FHR in intermittent auscultation)

7

Second stage of labour
- overview and timing
- mechanics

- Full dilatation (bloody show/urge to push/N&V) to newborn; Maternal effort + uterine contractile forces; timing depends on parity AND epidural (head hit pelvic floor = feedback to push but not if epidural = Feguson reflex); Epidural (>3/>2hrs) No (>2/>1hrs).

- Mechanics of head: Moulding (head shape), Flexion (size), Rotation (position).

8

Second stage of labour
- Fetal head size
- Pelvic plane size
- note about station

Vertex Px (OA) - suboccipitobregmatic 9.5cm
Vertex Px (OP) - occipitofrontel diameter 11cm
Brow Px - supraoccipitomental diameter 13.5cm
Face Px - submentobregmatic 9.5cm

Inlet - AP 11.5cm - Transverse 13.5cm
Midpelvis - AP 11.5cm - Bispinous 10.5cm
Outlet - AP 11.5cm - Bituberous 11cm

Can we delvier? Depends on relationship of fetal head to ischial spines (station).
Engagement: passage fo widest diameter of px part below plane of pelvic inlet
Station: level above/below plane of ischial spines +2 = 2cm below spines, -2 = above spines

9

Second stage of labour
- how the head gets out during normal delivery

DESCENT: contractions from behind, gravity, maternal effort
FLEXION: resistance from cervix/pelvis/pelvic floor = flexion of fetal chin to chest - Occiput L Transverse
INT ROT: pressure behind+flexion+resistance from mid pelvis = rotate occiput so ant toward symphysis
EXTENSION: Vaginal outlet up and forward = head out occiput, siniput, nose, mouth, chin sweep over perineum
RESTITUTION: ext rot, head realign with shoulders so back to Occiput L Transverse
COMPLETION: check cord ard neck, ANT shoulder gentle downward traction/ POST shoulder elevate head/ REST of body follows
Clamp cord.

10

Second stage of labour
- Mx

Maternal: P, BP, T, UA
Fetal: FH auscultate after each contraction, colour of amniotic fluid
Progress of Labour: reassess descent, flexion, rotation of px part

11

Third stage of labour
- time
- signs of separation

Time from delivery of baby until separation and expulsion of placenta
- 5-10min of deliver (

12

Third stage of labour
- Active management

1) prophylactic oxytocic (Syntocinon/Ergometrine/Syntometrine)
2) controlled cord traction (placenta delviery)
3) Early cord clamping (active third stage, but if delayed = protects against Fe deficiency)

13

Third stage of labour
- post partum haemorrhage

Empty, intact, contracted uterus should not bleed
Causes:
- Antony (70%): uterine overdistension/infection/relaxants/fatigue/retained products of conception/uterine inversion
- Genital tract laceration
- Coagulopathy (preexisting, abruption, PET, FDIU, sepsis, AFE)
- Uterine inversion

14

Third stage of Labour
- Checklist and degree of laceration?

Perineal lacerations/episiotomy repair
- 1st degree (perineal skin or vaginal mucosa)
- 2nd (submucosal tissues of vagina or perineal muscles)
- 3rd (anal sphincter)
- 4th (rectal mucosa)
Check placenta
Check pack and needle count

15

Summary
- 3 stages of labour
- 3 principles of labour care
- progress in labour depends on

Contraction - full dilation - baby delivery - placenta delivery

Maternal/fetal/monitor progress of labour

Power, passage, passenger

16

Summary
- 3 features progress in 1st stage labour
- 3 features progress in 2nd stage labour
- 3 mechanisms by which fetus navigates pelvis

- head descent, cervical effacement, cervical dilatation
- head descent, flexion, rotation
- moulding, flexion, rotation

17

Summary
- 3 signs of placental separation
- 3 components of active management of S3

- fresh show/lengthening of umbilical cord/ firm uterus
- prophylactic administration of oxytocic/ controlled cord traction/ early cord clamping