Normal delivery Flashcards

Question

How frequently are women examined during the second stage of labour?

Answer 1

As the foetus passes through the birth canal the direction of the head changes to accommodate the bends imposed by the bony pelvis.

Answer 2

1. Engagement: the foetus is engaged when the widest parts of its head have passed the pelvic inlet. The lowest part of the head (known as the vertex) can be felt 1cm above the ischial spines 2. Descent: downward movement of the foetal head occurs with uterine contractions 3. Flexion: descent is most efficient when the foetal head is flexed. Uterine contractions force the foetal head forwards as it presses against the lower segment of the uterus. This ensures that the smallest diameter of the head passes through the birth canal 4. Internal rotation: the foetal head gradually rotates so that the occipital can’t pass below the symphysis pubis. By rotating the foetal head maintains the smallest presenting diameter 5. Extension: further contractions aided by voluntary pushing from the mother force the occiput under the symphysis pubis. This causes extension of the foetal head as the birth canal curves upwards. The head delivers through the vaginal introitus by extension. The occiput delivers first followed by the bregma, forehead, nose then chin 6. Restitution and external rotation: as the head delivers it rotates back to the position in which it entered the birth canal so that the anterior shoulder lies under the symphysis pubis and the posterior shoulder lies in front of the sacral promontory 7. Expulsion: birth is completed with delivery of the anterior shoulder and lateral flexion of the head to facilitate delivery of the posterior shoulder

Answer 3

1. Power: the expulsive force supplied by uterine contractions and in the second stage by voluntary pushing by the mother 2. Passage: the diameter of the birth canal 3. Passenger: position, flexion and size of the foetal head affected by the rate of descent

Answer 4

Shape of the female pelvis, wider and shallower than the male pelvis

Answer 5

* Bones of the cranium overlap * When fully flexed the presenting diameter of the head is at its smallest

Answer 6

* Surgical incision in the perineum to increase the size of the vagina opening. Restricted for cases of foetal compromise or instrumental delivery. Performed when the head has crowned and the perineum is maximally stretched * A posterior episiotomy is usually done, scissors are used to make a mediolateral cut from the fourchette usually towards the right * An anterior cut may be needed for women who have had suffered FGM * Suturing is needed immediately after immediately after delivery of placenta

Answer 7

1st degree: perineal skin alone 2nd degree: perineal muscle 3rd: involves anal sphincter 4th: involves external anal sphincter, internal anal sphincter and anal epithelium

Answer 8

When head is crowning and perineum maximally stretched

Answer 9

1-2h nulliparous 5-60min subsequent

Answer 10

Stage from full dilatation \> delivery of baby

Answer 11

30 mins long Delivery of the placenta and membranes * Within 30mins of birth contractions of the uterus rapidly decrease it’s size and cause the placenta to be expelled. * Shrinking of the uterine wall shears the placenta away from its attachments. * Fibrinous thrombi form to plug the exposed sinuses in the deciduous basalis to prevent further bleeding. * A retroplacental clot forms and aids detachment of the placenta

Answer 12

Oxytocin is given IM either alone or combined with ergometrine which are used to prevent haemorrhage. Active management reduces the risk of post partum haemorrhage by 60%

Answer 13

85% of women sustain perineal injury and 60-70% require stitches

Answer 14

Delay in the first stage of labour, considered when: * \<2cm dilation in 4h (partogram) or slowing in progress in parous women. * May be due to power, passenger, passage.

Answer 15

Blood flow decreases as spiral arteries are occluded during uterine contractions When each contraction ends, large volumes of blood enter the intervillous soaces allowing for gas transfer If contractions are too frequent less gas exchange occurs and foetal hypoxia can occur

Answer 16

If a woman is low risk, intermitten auscultation only - baby's heart auscultated for 1min after each contraction High risk: continuous CTG is done * **Foetal heart rate** is monitored to asses baby’s wellbeing either by auscultation in low risk pregnancy or cardiotocography in high risk pregnancy * **Intermittent auscultation:** pinard stethoscope is Doppler ultrasound used once the active first stage of labour is diagnosed. Done for 1 min immediately after contraction and at least every 15 mins in the first stage and 1 min after contraction and every 5 mins in second stage \*important to differentiate between foetal and maternal pulse by palpating maternal pulse\* **Cardiotocography:** used to monitor high risk labours. USS transducer measures foetal heart rate. Contraction transducer measures frequency of contractions. If foetal heart rate cant be detected with an abdo transducer a foetal scalp electrode clip is used **Foetal scalp electrodes** can cause trauma so are used in selective cases only

Answer 17

Used to monitor high risk labours Equipment: USS transducer to measure foetal HR + contraction transducer used to measure contractions **4 things are assessed:** 1. Baseline HR: settled rate of baby's HR (not during contractions) 2. Variability in BPM: healthy foetus will constantly adapt HR 3. Decelerations: absence is reassuring 4. Accelerations: presence is reassuring

Answer 18

Baseline HR levels: 110-160 = reassuring 100-109 = not reassuring \<100 or \>180 = abnormal

Answer 19

Healthy foetus will constantly adapt their HR Variability indicates an intact nervous system If there is no variation, the foetus is not responding appropriately Most common cause is that the baby is asleep (should occur for no more than 40 mins) Change of \>5bpm = reassuring \<5bpm change for 40-90 mins = not reassuring but baby may be asleep \<5bpm change for \>90 mins = abnormal

Answer 20

Decelerations means baby's HR is decreasing by \>15bpm for \>15s Absence of this is reassuring **Early decelerations** start when the uterine contraction begins and recover when uterine contraction stops - this is normal amd occurs because contractions compress baby's head is compressed which raised ICP and reduced vagal tone **Late decelerations** occur after the start of the contraction and do not return to normal until 30 seconds after contraction ends - this is a sign of foetal distress **Variable decelerations** are associated with cord compression

Answer 21

Transient rise in FHR of 15pbpm over baseline for \>15s = reassuring If these are absent but no other abnormalities are present, the significance is not know

Answer 22

Normal = all 4 features reassuring Suspicious = one non-reassuring feature Pathological = 2+ non-reassuring feature or 1+ abnormal feature

Answer 23

Rare but worrying sign, undulating pattern with no variability Can indicate foetal anaemia If occuring in short spells can be associated with foetal behaviour e.g. thumb sucking Should always be taken seriously - scan MCA for blood velocity to look for anaemia

Answer 24

Post-date gestation Occiput posterior or transverse lie Cord compression Cord prolapse Epidural/ spinal Maternal seizure Rapid foetal descent

Answer 25

Hypoxia Chorioamnionitis Hyperthyroidism Foetal/ maternal anaemia

Answer 26

Foetus sleeping: no more than 40mins Foetal acidosis due to hypoxia Prematurity Congenital heart disease

Answer 27

Used to improve specificty of CG in the detection of hypoxia Should be obtained if CTG trace is pathological unless obvious immediate delivery may be required Normal: pH \>=7.25, repeat if CTG remains abnormal for 1hr+ Borderline: pH 7.21-7.24 - repeat FBC within 30 mins if CTG remains abnormal Abnormal: pH \<=7.2 \>\>\> immediate delivery

Answer 28

Associated with perinatal norbidity and mortality Rare in preterm infants Incidence increases from 36-42 weeks Hypoxia can cause peristalsis of bowel and relaxation of anal sphincter \>\>\> meconium stained liquor Can block airway, chemical irritant can supress surfactant production, predisposes to bacterial infection Grade 1: light staining Grade 2: dark green Grade 3: thick, opaque, pea soup

Answer 29

2nd stage should take 1-2hrs in nulliparous and 5-60mins in parous Birth should take place within 3hrs from start of 2nd stage if nulliparous and within 2hrs if parous - beyond this = delay Vaginal examination and amnionotomy recommended If still no baby 2hrs after pushing - obstetrician to review and consider intrumental/ c-section delivery Causes: malposition or disproportion

Answer 30

Reduced risk of PPH by 60%

Answer 31

No syntometrine or oxytocin given, cord left to stop pulsating before being cut Placenta delivered by maternal effort alone Convert from physiological \>\> active if haemorrhage, no placenta within 1hr or maternal desire

Answer 32

Efficacy the same but oxytocin associated with fewer AE

Answer 33

**a)** **breathing exercises, massage, TENS:** \>\> not effective in active labour **b) entonox:** mechanism unknown, no adverse effects but does not relieve pain completely, can cause nausea but entonox is short acting so quickly wears off **c) opioids e.g. pethidine:** given IM, not given to women in birthing pools, effective pain relief but can cause N+V so give antiemetic, can cause neonatal drowsiness and reps. depression \>\> this can cause baby to be too drowsy to feed when born **d) regional analgesia:** epidural ± spinal, most effective form of pain relief, required CTG, icnreases risk of operative vagnal delivery, can cause maternal HypoTN, rarely causes nerve injury and infection

Answer 34

Education regarding what to expect Trusted companion present Warm bath Breathing exercises TENS

Answer 35

Entonox Pethidine Diamorphine Meptazinol (opioid) Regional anaesthesia: epidural/ spinal into L3/L4, blocks nerve transmission

Answer 36

**Spinal:** majority of cases in UK, bupivacaine used, LA injection into CSF in subarachnoid space Easier than epidural, most reliable way to produce dense bilateral block, patients have absolutely no sensation with this block _Two 'pops' one\>ligamentum flavum, two\>arachnoid mater \>\> you see CSF_ Disadvantages: may cause severe hypoTN and can wear off **Epidural:** good anaesthesia but not profound so patients still feel pressure, surgeons hand etc, good because catheter stays in place so top up can be given Disadvantages: patchy block, tricky, takes longer to insert

Answer 37

Used for operative vaginal delivery, lidocaine injected into R&L pudendal nerves

Answer 38

Stool softeners Broad spec antibiotics PT Incontinence @ 6 weeks: see gynae Future births: offer c-section

Answer 39

Used to avoid prolonged pregnancy Done in 10-20% pregnancies

Answer 40

Bishop score looks at the favourability of the cervix. Low score means unlikely to go into labour; high score means could immediately go into labour \<5 = labour unlikely to start without induction \>9 = will commence spontaneously Factors: - Cervical position - Cervical consistency - Effacement - Dilatation - Foetal station

Answer 41

**Mechanical:** membrane sweep - finger passed through cervix and rotated against wall of uterus to separate chorionic membrane from decidua - this causes prostaglandins to be released which ripens the cervix and stimulates contractions. A low risk means of starting labour **Pharmacological:** synthetic prostaglandins are first line for inducing labour. Available as tablet, gel or controlled release pessary. Complication of use of prostaglandins: uterine hyperstimulation and frequent contractions cause foetal distress by reducing oxygen delivery

Answer 42

Uterine hyperstimulation and frequent contractions cause foetal distress by reducing oxygen delivery

Answer 43

Remove source of possible and give tocolytic agent such as terbutaline to inhibit contractions

Answer 44

In cases where women have had a c-section because prostaglandins are associated with uterine rupture

Answer 45

Meaning 5+ babies Uterus is especially prone to rupture so pharmacological IOL is only used if absolutely needed

Answer 46

* From delivery - 6 weeks later * Frequency of midwife visits depends on individual * UK: visit the day after delivery, on day 5 and on day 10 * 6-8 weeks after delivery a check is carried out by GP

Answer 47

* Discussed shortly after delivery as ovulation can resume 21 days after delivery if mother isn’t breast feeding * Breastfeeding women shouldn’t use combined pill because it suppressed milk production * Full breast feeding is a reliable contraceptive for 6mo after delivery because increased prolactin levels inhibit production and secretion of gonadotropin releasing hormone which lowers oestrogen levels and prevents ovulation

Answer 48

**Baby:** - reduced risk of infective diarrhoea, chest and ear infections, eczema, SIDS - less constipation - reduced incidence of T2DM in later life - improves bonding with mother **Mother:** - Reduces risk of ovarian and breast cancer by inhibiting ovulation and reducing oestrogen exposure - Provides contraception by inhibiting ovulation - Increased calories expenditure by 500/ day - Improves bonding with baby

Normal delivery Flashcards

(73 cards)