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Normal Labour and Puerperium Flashcards

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1
Q

What is labour?

A

Physiological process during which foetal membranes, placenta and umbilical cord are expelled from uterus

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2
Q

What are the three options available for where to deliver?

A

Consultant-led unit, midwife-led unit or homebirth = 96% of women in UK still give birth in hospital setting

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3
Q

What are birth plans?

A

Record of what women would like to happen during her labour and after birth = depend on individual medical history and circumstances

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4
Q

What causes the initiation of labour?

A

Change in oestrogen:progesterone ratio

Myometrial stretch increases excitability of myometrial fibres

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5
Q

What hormones may control the timing of labour onset?

A

Foetal adrenal and pituitary hormones

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6
Q

What is the Feguson reflex in labour?

A

Pressure on internal end of cervix causes oxytocin release = stimulates uterine contractions which increase cervical pressure

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7
Q

What are the functions of progesterone in labour?

A

Keeps uterus settled, prevents formation of gap junctions, hinders myocyte contractility

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8
Q

What are the functions of oestrogen during labour?

A

Makes uterus contract, promotes prostaglandin production

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9
Q

What are the functions of oxytocin during labour?

A

Initiates and sustains contractions, acts on decidual tissue to promote prostaglandin release

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10
Q

Where is oxytocin synthesised?

A

Directly in decidual tissue and extra-embryonic foetal tissues and placenta

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11
Q

What happens to the number of oxytocin receptors as pregnancy goes on?

A

Number of receptors in myometrial and decidual tissues increases near end of pregnancy

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12
Q

How does pulmonary surfactant influence labour onset?

A

Secreted into amniotic fluid which stimulates prostaglandin synthesis

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13
Q

What does an increase in foetal cortisol during labour stimulate in th mother?

A

Stimulates increase in maternal oestriol

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14
Q

What does the increase in myometrial oxytocin receptors and their activation during labour result in?

A

Causes phospholipase C activity and subsequent increase in cytosolitic calcium and uterine contractility

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15
Q

What is the purpose of liquor during pregnancy?

A

Nurtures and protects foetus and facilitates movement

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16
Q

What are the different timings for membrane rupture?

A

Preterm, prelabour, first stage, second stage, born in caul

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17
Q

What does cervical tissue compose of?

A

Collagen tissue mainly (types 1-4), smooth muscle and elastin = held together by connective tissue ground substance

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18
Q

What cervical changes occur during labour?

A

Cervical softening and ripening

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19
Q

What causes cervical softening during labour?

A

Increase in hydraluronic acid gives increase in molecules among collagen fibres = decrease in bridging among fibres decreases cervical firmness

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20
Q

What happens in cervical ripening during labour?

A

Decrease in collagen fibre strength and alignment
Decrease in tensile strength of cervical matrix
Increase in cervical decorin

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21
Q

What are the advantages of the Bishops score?

A

Simple, easy to reproduce, good at predicting successful inductions

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22
Q

What is the Bishops score?

A

Assesses whether it’s safe to induce labour

Five elements = position, consistency, effacement, dilation, station in pelvis

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23
Q

What are the two components of the first stage of labour?

A

Latent and active phases

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24
Q

What occurs in the latent phase of the first stage of labour?

A

Up to 3-4cm dilation, mild irregular uterine contractions, cervix shortens and softens, duration variable (may be days)

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25
What occurs in the active phase of the first stage of labour?
4cm to full dilation (10cm), slow descent of presenting part, contractions progressively become stronger and more rhythmic, normal progress is 1-2cm per hour
26
What contribute to the variability in the active phase of the first stage of labour?
Analgesia, mobility and parity
27
When is the second stage of labour?
From complete dilation of cervix to the delivery of the baby
28
When would the second stage of labour be considered prolonged in nulliparous women?
If it exceeds 3 hours with regional analgesia or 2 hours without
29
When would the second stage of labour be considered prolonged in multiparous women?
If it exceeds 2 hours with regional analgesia or 1 hour without
30
When is the third stage of labour?
From delivery of baby to expulsion of placenta and foetal membranes
31
What is the average duration of the third stage of labour?
10 minutes = can be as little as 3 minutes or much longer
32
When would you prepare for removal in the third stage of labour?
After 1 hour duration = give general anaesthetic
33
What is the management of the third stage of labour?
``` Expectant = spontaneous delivery of placenta Active = use of oxytocic drugs and controlled cord traction ```
34
What are Braxton-Hicks contractions?
Tightening of uterine muscles to aid body's preparation for birth = sometimes called false labour
35
When do Braxton-Hicks contractions occur?
Can start from as early as 6 weeks gestation but more usually felt in third trimester
36
What are the features of Braxton-Hicks contractions?
Irregular, don't increase in frequency or intensity, relatively painless, resolve with ambulation or change in activity
37
What are the features of true labour contractions?
Timing of contractions become evenly spaced and time between them gets progressively shorter Duration of contraction increases and they become more intense and painful over time
38
What effect do contractions have?
Tighten the top part of the uterus = promotes cervical thinning, pushes baby downward into birth canal in preparation for delivery
39
Where is the smooth muscle density of uterine muscle highest?
At the fundus
40
What is the pacemaker for uterine contractions?
Region of tubal ostia = wave spreads downwards, waves from both ostia are synchronised
41
How does the uterus display polarity during contractions?
Upper segment contracts and retracts | Lower segment and cervix stretch, relax and dilate
42
What is the normal power of true labour contractions?
They have fundal dominance with regular pattern and adequate resting tone
43
What is the normal frequency and duration of labour cotractions?
``` Frequency = 3-4 in 10 minutes (allows time for resting tone) Duration = initially 10-15s, slowly builds to max of 15s ```
44
What determines the intensity of labour contractions?
Degree of uterine systole = greatest in second stage
45
What are the grades of labour contraction?
Mild, moderate, strong
46
What are the different types of pelvis?
Anthropoid, gynaecoid, android
47
What are the features of an anthropoid pelvis?
Oval shaped inlet with large antero-posterior diameter and relatively smaller transverse diameter
48
What is the most suitable pelvic shape for labour?
Gynaecoid
49
What are the features of an android pelvis?
Triangular or heart shaped inlet and narrower front | More common in Afro-Caribbean women
50
What are the five parameters used to assess the cervix?
Effacement, dilatation, firmness, position, level of presenting part
51
What are the normal positions for the foetus during labour?
Longitudinal lie with cephalic presentation = flexed head, presenting part is vertex Position is occipito-anterior, head engages occipito-transverse
52
What are the abnormal foetal positions during labour?
Breech, oblique or transverse lie | Position is occipito-posterior
53
How can you determine foetal position?
Fontanelles can be felt on vaginal examination
54
What are the analgesia options during labour?
Paracetamol, co-codamol, TENS, entonox, remifentanyl, diamorphine, epidural or combined spinal/epidural
55
What is a partogram?
Graphic record of key maternal and foetal data contained in one sheet = used to assess progress of labour
56
What do the 7 cardinal movements refer to?
Changes in position of baby's head in the pelvis = described in relation to vertex position
57
Do the cardinal movements occur in sequence?
Yes = continuous process with movements occurring one after the other
58
What are the seven cardinal movements?
Engagement, descent, flexion, internal rotation, crowning and extension, restitution and external rotation, expulsion
59
What occurs in restitution and external rotation?
Head adopts optimal position for shoulder = foetal head returns to correct anatomical position for torso
60
What foetal body part comes first in expulsion?
Anterior shoulder
61
What occurs in engagement?
Passage of widest diameter of presenting part to the level below the plane of the pelvic inlet
62
What occurs in descent?
Downward passage of presenting part through pelvis
63
When is the foetal head said to be engaged?
When widest diameter of head has entered brim of pelvis = also described as 3/5 of head entered pelvis and 2/5 still felt abdominally
64
What are used as reference points during descent?
Abdominal fifths
65
What should you observe during descent?
Maternal discomfort, feeling of pressure, frontal synciput and occipital eminences
66
How often are vaginal examinations carried out during descent in a normal labour?
Carried out 4 hourly for cervical assessment
67
What position does the foetal head assume during descent?
Occiput transverse position = widest pelvic diameter for widest part of head
68
When does extension occur?
Once foetus has reached level of interoitus = brings base of occiput in contact with inferior margin at symphysis pubis
69
What occurs during expulsion?
Delivery of rest of foetal body
70
What does crowning describe?
Appearance of large segment of foetal head at interoitus = labia stretched to full capacity, largest diameter of foetal head encircled by vulval ring
71
What may the mother feel during crowning?
Burning and stinging
72
How should the head be delivered during crowning?
Carefully and slowly with hands guiding exit to prevent rapid extension of tissues and perineal tearing = care of perineum vital to reduce trauma
73
Why may an episiotomy be required after crowning?
To prevent anal sphincter trauma
74
Why can immediate cord clamping cause neonatal problems?
Can reduce red blood cells received by the infant at birth by >50%
75
When should you delay clamping until?
Cessation of pulsations or up to three minutes post-expulsion
76
How long should babies have skin to skin contact with mother after birth?
Uninterrupted contact for 1 hour immediately after birth = keeps baby warm and calm, improves other aspects of transition to life outside womb
77
How long does it take for the placenta to be expelled after birth?
Usually occurs 5-10 minutes after delivery = considered normal up to 30 minutes
78
What are the signs of the third stage of labour?
Uterus contracts, hardens and rises Permanent lengthening of umbilical cord Gush of blood (variable in amount) Placenta and membranes appear at introitus
79
What is the active management of the third stage of labour?
Prophylactic syntometrine OR oxytocin 10 units | Cord clamping and cutting, controlled cord traction and bladder emptying
80
How is syntometrine given in the third stage of labour?
1ml ampoule = 500mg ergometrine inaleate and 5IU oxytocin
81
What causes placental separation?
Shearing force = separates spongy layer of decidua basalis
82
What is the underlying pathophysiology of placental separation?
Inelastic placenta reduces surface area on placental bed due to sustained contraction of uterus
83
What are some categories of placental separation?
Matthew Duncan = most common | Schultz = separation from central aspect
84
How much blood can be lost in the third stage?
Normal <500ml Abnormal >500ml Significant if >1000ml
85
Is blood loss during labour considered normal?
No = any blood loss during labour prior to delivery apart from "show" is abnormal and requires referral to consultant unit
86
How is haemostasis achieved during pregnancy?
Tonic contraction = lattice pattern of uterine muscle strangulates vessels Thrombosis of torn vessel ends Myotamponade-opposition to anterior/posterior walls
87
What is puerperium?
Period of repair and recovery = return of tissue to non-pregnant state, takes 6 weeks
88
What are the discharges that can occur in puerperium?
``` Lochia = contains blood, mucus and endometrial castings Rubra = fresh red, 3-4 days Serosa = brownish red and watery, 4-14 days Alb = yellow, 10-20 days ```
89
How long would you expect blood stained discharge after birth?
10-14 days
90
What uterine changes occur during puerperium?
Uterine involution = reduction in weight from 1kg to 50-100g
91
How long does it take the fundal height to move from the umbilicus after delivery?
Moves from umbilicus to within pelvis within 2 weeks
92
How long does it take the endometrium to regenerate after birth?
Occurs by 7 days (except placental site)
93
What happens to the cervix, vagina and perineum after birth?
They regress, but never back to pre-pregnancy state
94
When does physiological diuresis commence after delivery?
Commences 2-3 days postnatally
95
What initiates lactation?
Placental expulsion and decrease in oestrogen and progesterone
96
What effect to oestrogen and progesterone have during pregnancy to prevent lactation?
Block prolactin release during pregnancy and make mammary gland cells unresponsive to prolactin
97
What happens to prolactin during puerperium?
Prolactin is maintained
98
What are the benefits of colostrum?
Rich in immunoglobulin = long term protective effect for foetus

Reproduction (62 decks)

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