Week 4- Week 4: The placenta and membranes Flashcards
(186 cards)
1
Q
List 4 unique and amazing facts about the placenta
A
- only temporary organ
- only organ shared between two people
- only lasts for as long as it s needed
- expelled without leaving a scar
- a healthy placenta almost always means a healthy baby
2
Q
Explain the significance of the placenta in other cultures
A
Western= often thought of as gross or a taboo topic.
Maori and some Aboriginal peoples= sacred and will bury placenta often under a tree to ground the child to the earth. This spiritually links the child to country.
Chinese culture= it is traditionally dryied and used in traditional Chinese medicines as it is though to prevent/manage post natal depression as it is still rich in pregnancy hormones and nutrients.
3
Q
Briefly explain the development of the placenta and when it is functional.
A
Placenta may commence development early when the trophoblast embeds in the endometrium and continues to develop through the embryonic period. However, it is not fully functional until the beginning of the second trimester, as the corpus luteum degenerates.
4
Q
List 4 functions of the placenta
A
Respiratory: O2 and Co2 gas exchange between woman and fetus
Nutritive: baby receives nutrients though placenta
Excretory: baby removes waste products through placenta
Hormonal: some pregnancy specific hormes are produced by the placenta e.g. HCG, HPL, Relaxin, Oestrogen and progesterone
5
Q
What is the process of development and formation of the placenta called
A
Placentation
6
Q
What kind of tissue is a placenta attracted to and more likely to attach to?
A
Scar tissue from a previous pregnancy
7
Q
Where is the most ideal place for a placenta to grow?
A
posterior wall of uterus (well away from the cervix os)
anterior placenta is still safe and normal, howeverrm can be more difficult for mother to feel fetal movements as the placenta reduces sensation and impact of movements.
8
Q
Outline the development of the placenta
A
begins at implantation
- blastocyst adheres to the endothelium
- trophobast cells differentiate into an outer cytotrophoblast layer and an inner syncytiotrophoblast layer.
- as the cytotrophoblast proliferates, newly formed cells migrate into the syncytiotrophoblast and lose their cell membranes. This forms a rapidly growing mass.
- cytotrophoblast secretes proteolytic enzymes
- syncytiotrophoblast secretes sends out finger like projections allowing blastocyst to ashere to the endometrum.
- Lacunae or spaces begin to form within syncytiotrophoblast.
- syncytiotrophoblast errodes endometrial blood vessels and glands, lacunse become filled with maternal blood and glandular secretions
- lacunae fuse to form a network of which maternal blood flows
- by the end of week 2, small projections fo the cytotrophoblast begin to protrude into the syncytiotrophoblast forming primary chronic villi
- early in the second week extraembryonic mesoderm grows into these villi forming a core of loose connective tissue. (known as secondary chronic villi)
- by the end of the third week, embryonic blood vessels have begun to form in the extra embryonic mesoderm of secondary chronic villi transforming into tertiary chronic vili
- cytotrophoblast cells from the tertiary villis grow towards the decidua bisallis and spread across it to form a cytotrophoblast shell
- villis that are connected to the decidua basalis though the side of the trophoblastic cell are called anchoring villus
- villi growing from the sides of stem billi are called branch villis
- branch villis are surrounded by intra villi space= serves as the main site of exchange between mother and fetus
- by the 4th week fetal blood flow is established.
- 2 A and 1V divide into capillaries in the branch villi and exchange across placental membrane
9
Q
By what week of pregnancy is fetal blood flow established?
A
4th week
10
Q
How may artier and veins does an umbilical cord have and which are oxygenated?
A
2 arteries (deoxygenated) 1 vein (oxygenated)
11
Q
Placenta previa
A
When the placenta grows over the OS. Makes vaginal birth impossible
An indication for a caesarean.
12
Q
Name the three component of the placenta and whether they are maternal or fetal.
A
- Basal plate (maternal)
- Pool of blood (shared)
- Chronic plate + trophoblast projections (fetal)
13
Q
What is the decidua basalis?
A
a layer of the basal plate
Roles:
- regulate syncytiotrophoblast invasion
- provide nutrition and gas exchange
- produce hormones
14
Q
What is the chorioamnion membrane composed of?
A
Fromed by the basal and chrnoic plate coming together and meeting at the edge of the placenta.
Composed of two membranes:
- amnion (fetal)
- Chorion (maternal)
15
Q
Describe the amnion, its function and any complications associated with it.
A
- The inner membrane (fetal)
- derived from inner cell mass and consists of epithelium with a connective tissue base.
- tough, smooth and transculent membrane
- continuous with the outer surface of the umbilical cord
- moves over the chorion aided by muscus
Function
- contain amniotic fluid
- produce small amounts of amniotic fluid
- produce prostaglandin E2 (aid in induction of labour)
Complications
- In rare instances, the amnion can peel away from the sack in early pregnancy and wrap around the limbs of the fetus, causing amniotic bands that can affect the growth of that limb.
16
Q
Describe the Chorion, its composition, its function and any complications associated with it.
A
- Outer membrane (maternal)
- continuous with the placenta
- fragile and can easily rupture
Composed of;
- mesenchyme
- cytotrophoblasts
- vessels form the extended spiral arteries of the decidua basalis (this is the membrane closest to the woman’s uterus - the maternal surface)
- rough, fibrous, opaque
- loosely attached
Function
- produces enzymes that can reduce progesterone levels (help to induce labour)
- produces prostaglandins, oxytocin and platelet-activating factor which stimulate uterine activity
Complications
- friable and can rupture easily, which makes it relatively easy to be retained in the uterus following birth (usually coming away on its own within days after birth, other times requiring surgical removal).
17
Q
Describe amniotic fluid and how it is produces.
A
- clear, the alkaline liquid contained within the amniotic sac.
Produces
- derived form maternal circulation across the placental membranes and exuded from fetal surface.
- from the waste of fetal metabolism e.g. urine and lung fluid
18
Q
List some function of amniotic fluid
A
- distended the amniotic sac to allow for growth and free movement of the fetus= this assists with symmetrical MSK development
- equalised pressure
- protects fetus from injury
- maintains constant intrauterine temp (protects fetus from health loss)
provides small amount of nutrients - in labour, as long as the membranes remain intact the amniotic fluid protects the placenta and umbilical cord from the pressure of uterine contractions, and assists in facilitating the rotation of the fetus into the pelvis
- aids effacement (shortening and thinning) of the cervix and dilation of the internal cervical os (internal opening of the cervix to the uterus), particularly where the presenting part is poorly applied.
19
Q
What composes amniotic fluid, volume + colours.
A
Amniotic fluid
- 99% water
- 1% being dissolved solid matter including food substances and waste products.
- During pregnancy, amniotic fluid increases in volume as the fetus grows: from 20 ml at 10 weeks to approximately 500 mls at term.
+ the fetus sheds skin cells, vernix caseosa and lanugo into the fluid.
- Normal amniotic fluid is clear/pink or even slightly straw coloured.
- Green or yellow amniotic fluid can indicate that the fetus has opened its bowels in-utero (this is called meconium-stained liquor - MSL), and this may be a cause for concern.
- Bright red or brown amniotic fluid can indicate intrauterine bleeding, possibly from the placenta or the fetus, and is usually an emergency.
20
Q
Define the first stage of labour + name the phases.
A
The onset of painful, regular contractions resulting in effacement and dilation of the cervix.
from nil/0 to fully dilated (10cm )
- can take up to 16hrs in first time mother
- up to 10 hours for a multi
- Think LAT
1. Latent
2. Active
3. Transitional - All women need thorough education during pregnancy
that labour and birth are a normal process - Encouraging women to listen and trust her body,
surrounding herself with supportive people and
remembering there are variations in ‘normal’ will help her
labour progress
21
Q
Explain each phase of the first stage of labour
A
Latent
- from very first contraction to cervix is 4cm
- 0-4cm dilation
- Cervix effaces – shortens from 3cm to 0.5cm long
- contractions= mild strength, infrequent
- slow dilation
- some may not experience this phase
- uncomfortable, cant sleep
- 1st baby 12hrs
- 2nd + 6-8 hrs
- effacement= fundance gets bigger and stronger and pulls upwards
- best for woman to be at home in this stage for relaxing.
- don’t diagnose active phase when in lateant as unnecessary intervention may occur.
Active
- from 4cm to fully dilated/8cm (usually not always- you can be latent at 4 cm!)
(approx 0.5-1.5cm per hour BUT EVEYONE IS DIFFERENT)
someone might dilate faster one hour and not at all in one hour.
- 4cm to 8cm
- more rapid dilation of cervix
- contractions= more frequent, coordinated, stronger and progressive descent of presenting part into pelvis.
RHYTHMIC
- 4 contractions in 10 mins that last 1 min long.
Transitional - just prior to second stage, - happens along with active labour - from 8cm - 10cm (fully dilated) - Crisis of confidence - characterised by woman feeling distressed, exhausted, like she is getting nowhere, and her mood, noises and responses might be completely out of character. (A LOT of women will say "I can't do this anymore!" or "I just want to go home!" in transition). - not all women experience this phase
22
Q
Define the second stage of labour and name its phases
A
Period form end of first stage (fully dilated) until birth of baby.
Lull
- After full dilation of cervix
10-30-60 mins
- the restful stage, women energy renews before baby is pushed out
- sometimes confused with labour stoping (some practitioners may try augmentation of labour ARP or oxytocin/syntocinon)
- Cervix may be fully dilated but the presenting part may have not yet reached the pelvic outlet.
- Woman may not feel expulsive urge until the presenting part (PP) has descended further
- Woman may ‘go into self’ or even sleep.
Expulsive/descent phase
- contractions shorten uterine cavity this forces the baby into the pelvis and women pushing efforts propel presenting part into the pelvis.
- The descent of the baby into the pelvis on to the pelvic floor triggers Ferguson’s reflex
- The woman may have an ‘uncontrollable’ urge to push or bearing down feeling
- Changes in vocalisation – ‘grunting’
- Urge to defecate or may defecate (completely normal, and actually can be beneficial to the baby, more on that later in the course).
- Pouting anus
- Perineum bulges
- Visible presenting part, retracts between contractions.
23
Q
Define the third stage of labour
A
- the separation of the placenta from the uterine wall
- expulsion of the placenta and membranes from the uterus and vagina
- control of bleeding.
24
Q
What role do contractions play after the birth of the baby? and how
A
Contractions occlude the bleeding vessels that have supplied placenta= controlling bleeding.
25
How are contractions initiated if the positive feedback system after labour is completed and baby is born?
- The emotions after birth trigger the release of oxytocin (love hormone) which stimulates contractions of the uterus.
- if baby suckles on breast oxytocin release is much greater.
Oxytocin can be injected to maintain contraction. This is active management of the third stage
26
What the term given when intervention is provided via injection of hormones and cord traction in the third stage.
Active management of the third stage of labour.
This is the opposite of physiological management which is free of intervention.
27
Describe the fourth stage of labour and what occurs in it.
- first hour (or the "Golden Hour") after birth for both mother and baby.
- monitoring
- preventing maternal bleeding
- baby observations to ensure normal adaption to extrauterine life.
28
What 9 stages will a new born move through in the first hours of life if left un disturbed and having skin on skin?
In this hour, if left undisturbed and skin-to-skin on mother's chest, a baby should
spontaneously move through the following 9 stages.
1) The Birth Cry
2) Relaxation
3) Awakening
4) Activity
5) Resting
6) Crawling
7) Familiarisation
8) Suckling
9) Sleeping
29
Define labour and what are the mechanics of it?
Regular and coordinated muscular contractions of the uterus.
The fundus hardens and tightens and pull the uterus up which effaces and dilates the cervix.
- this results in repulsive contraction and birth of baby + placenta
30
What are the 4 key events of labour?
- regular, strong, coordinated contractions (effective)
- effacement and dilation of the cervix
- Birth of the baby
- Birth of the placenta
31
List and explain some uterine changes that occur in preparation for labour.
1. Myometrial cells= are capable of activity without external stimulation (we don't fully understand this)
2. Uterotonic inhibitors (e.g. progesterone) decrease. During pregnancy, these uterotonic inhibitors prevent contraction, however as they diminish contractions gradually increase in intensity, frequency, strength, synchronicity and lead to effective labour
3. myometrial cells change the structure (activation) so they can contract more strongly + continue throughout labour
4. electrical activity increases
5. ratio of hormones changes
6. Myometrial cells become more responsive
7. Increase in number of ion channels (think back to muscle contraction and how increased Ca for example could be extremely helpful and increase strength of contraction)
In the last few weeks of pregnancy, uterotonic inhibitors
decrease, while oestrogen and contraction-associated
proteins (CAPs) increase
▪ More responsive to electrical activity and increased
responsiveness of target tissues
32
Explain how the cervix stretches if it has not stretched the whole pregnancy?
- High content of connective tissue (made up of collagen fibres) resists stretching during pregnancy
- Stretching of the cervix results in local release of prostaglandin F2alpha and the release of oxytocin from the posterior pituitary gland- which increases uterine activity = labour begins
33
Describe ripening
Ripening= a softening process characterised by infiltration of leucocytes, increase in water, decrease in collagen content
- separate to contractions meaning we don't need contractions for the cervix to ripen
the process of ripening begins well before labour
34
What are the 5 main processes that initiate and play a role in labour
- Corticotrophin-releasing hormone (CRH)
- Prostaglandins (PGE2 & PGF2alpha)
- Oxytocin
- Oestrogen
- Progesterone
35
What is the role Corticotrophin-releasing hormone (CRH)
Under the influence of oxytocin during labour it binds to different receptor types and promotes uterine contractions (enhances contractility)
36
What is the role of Prostaglandins (PGE2 & PGF2alpha)
Stimulate smooth muscle fibres to contract, formation of gap junctions (help to get rid of uterotonic inhibitors), increase calcium levels in myometrial cells (As well as
softening the cervix)
37
What is the role and release of oxytocin
Released in response to tactile stimulation of the reproductive tract (ripening cervix).
e. g. baby head pushes on cervix= contractions increase
- Increase of oxytocin receptors in decidua is 300 fold by term.
- Oxytocin binds to these receptors, stimulates the release of prostaglandins and stimulates uterine pacemakers.
- oxytocin is the love and labour hormone
38
What is the role of Oestrogen
Increases sensitivity of myometrial oxytocin receptors (facilitates myometrial contractility)
39
What is the role of Progesterone
During pregnancy, progesterone suppresses uterine excitement.
Before labour, the availability of progesterone decreases, and oestrogen synthesis increases resulting in an increased oestrogen/progesterone ratio that allows the uterotonic effect of oestrogen to dominate
40
What key events has to occur for labour to begin
Prior to labour, change in oestrogen/progesterone ratio
allows for activation of uterine muscle and ripening of
cervix
41
Why is it so important for a midwife to understand oxytocin?
Oxytocin is what relaxes the body and brings on contractions through a positive feedback loop.
For effective labour, we need to encourage the production of oxytocin by
- creating a safe space
- using soft language
- promoting physical contact and love
- promote trust
42
WHO definition of normal labour
Spontaneous onset between 37-42 completed weeks of pregnancy
– Low risk at the start and remaining throughout until birth
– Spontaneous birth of baby in vertex position
– Mother and baby in good condition after birth
43
Define effacement
Fundance gets bigger and stronger and pulls upwards
44
List some of the idea managements of labour
- remain at home in their space for as long as possible (+ explain why this is. Oxytocin will be released when you are calm and in your known space) Adrenaline is produced when scared to in a new space which will stop oxctocin
- ensure appropriate support
- encourage women to remain at home
- may be assessed in-home/hospital- VE/FH
- Sleep if possible
- continue to eat and drink
- Strategies for pain management (these keep gravity helping descent)
* Walk
* Warm bath/shower
* Continue normal activities
45
Why should you avoid paracetamol in the first stage of labour?
Paracetamol is a prostaglandin inhibitor
46
What are the two types of labour?
True labour
| Spurious
47
Describe True labour
- causes effacement and dilation
- contractions are effective, regular, increasing in frequency and intensity
characterised by discomfort in the lower back radiating to the abdomen
- pain is not relieved by ambulation
- head descends
48
Describe spurious labour
- contractions don't change cervix
- not just not change in a few hours. Its ' been 24hrs with no changes and we thought this was a long latent phase so maybe this is spurious labour'
- tightness not pain (stomach and groin)
to assist
- position of baby? work to chnage this if bad
- massage and relax women to encourage oxytocin and therefore true contractions
49
What are some support factors that can affect labour process?
- trust woman's body and the birthing process (creates oxytocin)
- sensitive, encouraging and appropriate support people
- comfortable environment
- known, trusted caregiver (require less pain management and progress though labour faster)
- opportunity for rest, and ability to eat and drink as the woman wants
- sitting on a toilet= private, pelvic floor relaxes
50
When should a women call and come into hospital?
- Ruptured membranes
- Regular, painful contractions that she is not managing/needs advice about
- Vaginal bleeding (as opposed to a ‘show)
- Any continuous pain
- Reduced fetal movements OR change in fetal movements from normal
- If she is concerned (about anything)
51
When should be assessed?
- Regular, strong, painful contractions she wants to come in
– Ruptured membranes (may be able to go home again if not mec- green, yellow fluid)
– Bleeding
– Decreased fetal movements
52
What is an Iatrogenic complication
illness or complication created by a medical practitioner
53
What is the midwifes role in the first stage of labour?
- Assess well-being woman and baby (mental health pf mother, fetal heart rate from start of contraction until 1 min after contraction)
- Support woman and partner – reassurance
- Keep informed (let them know the assessment findings)
- Assess progress (abdominal palpations, FHR)
- Ensure appropriate nutrition & fluids
- Provide coping strategies- positioning/mobile/heat/water
- ‘Being there’ what do they need?
- Escalate and manage with collaborative team when things deviate from normal
54
List some assessments carried out during active labour
```
Vital signs
▪ Fetal heart rate
▪ Contractions
▪ Abdominal palpation
▪ Vaginal examination
▪ Vaginal loss
▪ Fluid balance
▪ Coping / pain
```
Pulse for 30mins (Along with FH to ensure they are different and that we haven't listening to baby)
BP 2hrly
Temp 4hrly
FHR 30mins 1st stage (more in second)
Abdominal palp 4rly (woman needs to lye on their back and this can be uncomfortable so they can decline)
VE 4hrs when in established labour
55
What is the normal range of fetal heart rate
120-160 bpm
Tacycardia >160 (may need CTG)
Bradycardia <110 (may need CTG)
56
Emergency type of fetal tachycardia is characterised by
A drop in FHR below 100bpm for >5mins (emergency situation)
Deceleration= dropping below baseline >15bpm then returning
▪ potential problem need full CTG
57
During the second stage of labour (lull + explosive) how frequently do we check fetal HR?
Every 5 mins (after each contraction)
58
What is a CTG
Fetal ECG
59
Describe the mechanics of a contractions
```
The fundus (top thick muscle) retracts/ contractions (shortens)
- retracts after this
```
- pushes fetus down
contracts are rhythmic and regular which assists in pushing the baby down.
60
How to assess if contractions have changes
Number of contractions in a minute.
- assess regularity and strength
- from the beginning on one to the next one
e.g. Measurement of contractions (hold hand on fundus for 10 minutes)
2 in 10 mins
mild/moderate/strong
30 sec/ 40 sec/ 55+ sec
61
What are the main goals of fluid balance in labour?
- maintain fluids (prevent dehydration)
- light diet (prevent ketosis/maintain energy)
- empty bladder (provides room in pelvis + reduces the likelihood of damage to bladder and urethra at birth) sitting on toilet relaxes pelvic floor
- vomit (maybe a sign of progressing labour)
62
Why is it important for a women to empty her bladder during labour and post birth?
- provides room in pelvis
- reduces likelihood of damage to bladder and urethra at birth
Post birth
- it may shift the uterus to one side and therefore prevent it from correctly contracting and make it hard to palpate/assess thus making it hard to recognise complications.
63
Outline he causes of pain in pregnancy
- contractions
- dilation of the cervix
- stretching of the vagina + perineum
- pressure of baby on pelvic floor
64
Describe is the pathway of pain in relation to labour
- site experiences pain
First neuron
- impulse travels along asending sensory tract
- impulse arrives at dorsal root ganglion of posterior horn
Second neuron
- from psterior horn, impulse crosses spinal cord
- impulse travels to medulla oblongate to pons vatoli to mid brain then to thalamus.
Third neuron
- impulse travels from the thalamus to the sensory cortex.
65
Explain the bodies natural pain relief
Endorphins from the experience are opiate-like peptides (neuropeptides) produced naturally
in the body at neural synapses in CNS pathways
▪ How they work:
– They bind to presynaptic membrane, and inhibit the release of
substance P (inhibit the transmission of pain).
– Substance P is a neurotransmitter that is ‘liberated’ at some
synapses when there is a pain impulse that facilitates information
about pain which is then transmitted to higher centres.
66
Name some techniques which activate peripheral sensory receptors
Superficial hot or cold - compresses / hot packs /cold face washer
▪ Hydrotherapy - Showers / baths
▪ Touch & Massage
▪ Acupressure, shiatsu, reflexology
▪ Transcutaneous Electrical Nerve Stimulation (TENS) (interrupts pain pathway)
▪ Water injections
These can actually reduce the pain signals getting to the brain.
67
List some techniques that enhance descending inhibitory paths
- Support person - therapeutic use of self
- Relaxation - breathing exercises
- Attention-focusing & distraction
- Music
- Aromatherapy
- Therapeutic touch
- Hypnosis
These help labour go smoothly
68
List some coping strategies for pain
- Reassurance
- Positioning
- Mobility (walking, rocking, swaying)
- Water
- Aromatherapy
- Music
- Heat packs
- Massage
- trust between provider/partner/support person and mother
- stay up right (sitting, kneeling, standing, leaning forward and squatting)
- intradermal water injections
- heat packs
- massage
- counter pressure
- transcutaneous electrical nerve stimulation (TENS) machine
69
List and explain some pharmacological pain relief
Nitrous oxide
- breathed in just during contraction
- something for women to focus that is rhythmic
Pethidine/Morphine
- can have resp depression in baby when born
- reduces awareness of the pain
Epidural
- lots of interventions occur when this is started
70
Name the 3 instances when a abdominal palpation may be helpful and what it would assist in finding
Admission assessment
- ensure size = dates
- position and engagement
Assessment of progress
- descent of head
- 4 hrly
Prior to VE
- match external findings with internal findings
71
What are some key practice points fo a VE
- Always after an abdominal palpation
- Often done to assess progress, but when performed by different clinicians can have inconsistent/differing findings
- increase risk of ascending infectionparticularly once membranes have ruptured
- Clinically it is common to perform VE’s 4 hourly, though this is not based on evidence
72
List some indications for a VE
- Prior to labour as part of determining induction method
- During labour to confirm onset
- Identify presentation and position
- Assess progress
- Perform ARM (artificial rupture of membrane)
- Apply FSE (fetal scalp electrodes)
- Exclude cord prolapse after ROM
- Confirm onset of second stage of labour (particularly for breech presentation or multiple pregnancy)
73
Contraindications of VE should not be completed!!
- If no consent
- Known placenta praevia or vasa praevia
- Active bleeding
- Suspected preterm labour (<37 weeks- may cause infection or onset labour)
- Pre-labour ROM (may introduce an infection)
74
List some key points of preparations prior to a VE
- Privacy (curtain, quiet room)
- Explanation (ensure what it intails, feeling, lube, right up at back of vagina)
- Consent (must be informed)
- Empty bladder (very uncomfortable)
- Position woman - semi-recumbent covered with sheet
- Waterproof sheet (bluey / pinky) underneath her
- Sterile gloves and lubricant
75
List the process points of a VE
- Hand hygiene
- Position woman
- Abdominal palpation
- Wash hands don (sterile) gloves
- Separate labia with non-dominant hand
- GENTLY insert two lubricated fingers downwards and backwards follow anterior vaginal wall
- Obtain all information before withdrawing hand, take care in moving hand not to contaminate external fingers on anus or put pressure on clitoris (if she doesn't ask you to remove it)
- Always check FHR following VE
76
What are some normal findings of a VE?
External genitalia
- No varicosities, oedema, warts, signs of infection, scarring, bleeding, discharge (colour and odour)
Vagina
- Should be warm and moist, soft distensible walls. Should not feel
hot and dry. Full rectum may be felt through posterior wall
▪ Cervix
– Position, consistency, effacement, dilation, application to presenting part (how well is it applied to babys presenting part)
77
Define effacement and how it may differ in findings.
= the length of the cervix.
is assessed by length of the cervix and
degree to which is protrudes into the vagina. Non-effaced
feels long, tubular with the os closed or partly dilated.
Fully effaced cervix feels like a continuation of the lower
uterine segment and does not protrude into the vagina
78
Explain dilation and how it is assessed
= how far the internal and external os are open.
assess in cm by inserting one or both fingers
through the external os and parting the fingers to assess diameter. At later stages in labour it is usually easier to feel the remaining rim of cervix. For example, a 1cm rim means the cervix is dilated 8cm as 2cm of cervix remains around the presenting part.
Full dilation (=10cm) is when there is no cervix remaining
79
Define application
when the presenting part is well applied to
the cervix, this is associated with good uterine activity,
whereas a poorly applied cervix has less efficient uterine
activity.
80
What should the membranes feel like in a VE?
Intact should feel like a shiny surface over
the presenting part, if the presenting part is well applied it may feel tense and like a full water balloon (especially during a contraction).
81
What is presentation?
the part of the fetus that lies at the pelvic brim
82
Define the presentations
Cephalic (head)
Breech (sacrum)
Shoulder
83
What will a cephalic presentation feel like in a VE
smooth, round and firm.
You should be able to feel features such as suture lines and fontanelles.
```
May also feel
- moulding
- caput succedaneum
- face
cord
```
84
Define moulding
```
Moulding is when the bones overlap.
Is written as
1+ (bones touching)
2+ (overlapped but can be separated with gentle digital pressure)
3+ (cannot be separated)
```
85
Define caput succedaneum
a soft/firm mass on the presenting
| part, makes it more difficult to feel sutures/fontanelles
86
Describe what feeling a face presentation may be like
soft and irregular, face presentation features of
| the face can be felt, the finger may be sucked on if it is inserted into the mouth.
87
Describe what a cord presentation may feel ike
If a cord presents the person doing the VE keeps their hand in to try and push the presenting part off the cord, calls for help and informs the woman. Women can be helped move to change the positive of the cord if not this will result in an emergency C/S.
88
Define the presenting part
part of the fetus that lies closest to the internal os of the cervix
89
What are the various presentations within cephalic
when the head is well flexed the presenting part is the vertex
– When the head completely extended then the presenting part is the face
90
Define and explain position
Identification of sutures and fontanelles in relation to the maternal pelvis/spine confirm position and attitude.
91
Define station and what it refers to
The distance of the presenting part to
the ischial spines in cm. The ischial spines are referred to as ‘0’ stations.
Above that is -1, -2, -3.
Below is +1, +2, +3 etc.
+3 is usually when baby is being born
- measured from head not caput
92
List some key examination points of vagina loss
Check every 30 min or as necessary
- Amount / type
- ‘show’ – mucousy +/- blood stained
- Liquor
- clear
- meconium stained
- blood stained
- offensive
- Blood
93
Explain some of the pros and cons for VE's
Considered ‘gold standard’ however..
- imprecise (accuracy estimated at ~50%)
- Potentially unpleasant, intrusive and embarrassing for women
- interfere with oxytocin production
- Associated with the risk of infection
Use with discretion
Consider other clinical signs of progress; descent, maternal behaviour, vocalisation, and purple line….
94
Contractions
thickening of the fundus that tightens the uterus and pushes down on the baby then releases.
95
Cx
cervix (bottom of uterus)
96
Effacement
shortening of cervix
97
Dilation
opening of cervix
98
Oxytocin
labour hormone
99
Operculum
blood slow/mucus plug
100
Braxton Hicks
practice contractions that can happen any time from 15 weeks
101
Endorphins
hormone that helps with pain management
102
RM/ARM/SRM
Rupture of membranes
Artificial rupture of membranes
Spontaneous rupture of membranes
103
Liquor
Amniotic fluid
104
Parturition
during labour
105
Station
Where the babys head is in relations to the ischial spines on a VE
106
PP
presenting part (what part is coming though cervix)
107
Explain Friedman's curve
This is a graph that shows the 'average womens' progress through the stages of labour.
108
os
cervix
| we have an internal os and an external os
109
What are the 5 P's that influence labour?
```
Passage
Passenger
Powers
Psyche
Problems
```
110
Explain the characteristics of PASSAGE (an influence of progression of labour)
Passage involves the pelvis and other soft tissues.
Shapes of the pelvis
- gynaecoid (most favourable for birth)
- android (male with prominent coccyx)
- anthropoid (deep)
- playtypelloid (refer to diagram)
The resistance caused by the soft tissue including:
- pelvic floor
- perineum
- the birth passage e.g. uterus, vagina, cervix
- bladder
111
Explain the characteristics of PASSENGER (an influence of progression of labour)
Passenger= the baby
Factors include; PEALP
Position: what is the presenting part, is it entering the pelvis at the widest diameter? Where is the baby's back?
Relationship of the denominator to six points of the pelvic brim. Vertex presentation - left occiput anterior (LOA), left occiput posterior (LOP), left occiput transverse (LOT), right occiput anterior (ROA), right occiput posterior (ROP) or right occiput transverse (ROT)
Engagement: Occurs when the widest presenting diameter has passed through the brim of the pelvis.
Lie: Relationship of the long axis of the fetus to the long axis of the uterus: e.g.Longitudinal (favourable for birth), transverse or oblique
Attitude: the relationship of the baby's head to its body e.g. Well flexed (favourable for birth), incomplete flexed (neutral/militant), partial extension, complete extension (deflexed) (also favourable for birth except face presentation is not common)
Occiput anterior position with well flexed head will progress better than posterior position with deflexed head
Presentation: The part of the fetus that lies at the pelvic brim. i.e. cephalic (head/vertex), sacrum (bottom/breech) or shoulder (transverse/oblique)
Presenting part:
- If there is a cephalic (head) presentation and the attitude is one of flexion then the vertex is the presenting part.
- If the fetus is is a breech presentation then the sacrum is the presenting part
Size of the baby: particularly the head
112
Explain position in terms of the baby in the birth canal.
Relationship of the denominator to six points of the pelvic brim. Vertex presentation - left occiput anterior (LOA), left occiput posterior (LOP), left occiput transverse (LOT), right occiput anterior (ROA), right occiput posterior (ROP) or right occiput transverse (ROT)
113
Explain engagement in terms of the baby
Occurs when the widest presenting diameter has passed through the brim of the pelvis.
114
Explain lie in terms of the baby
Relationship of the long axis of the fetus to the long axis of the uterus: e.g.Longitudinal (favourable for birth), transverse or oblique
115
Explain attitude in terms of the baby
the relationship of the baby's head to its body e.g. Well flexed (favourable for birth), incomplete flexed (neutral/militant), partial extension, complete extension (deflexed) (also favourable for birth except face presentation is not common)
116
Explain presentation in terms of the baby
The part of the fetus that lies at the pelvic brim. i.e. cephalic (head/vertex), sacrum (bottom/breech) or shoulder (transverse/oblique)
117
Explain the characteristics of POWERS (an influence of progression of labour)
Uterine contractions
- active labour contractions come in a rhythmic, regular wave.
Build to a peak then subside
Maternal effort
- pushing that occurs in the second stage can help being baby out
Although when a woman does not have analgesia, most of this effort is spontaneous and involuntary
if a woman has, for instance, an epidural, she may need to make concerted physical effort to help her baby to be born.
118
Explain the characteristics of PSYCHE (an influence of progression of labour)
- woman's feelings and attitudes towards labour (e.g. fear, anxiety, previous experiences)
- can also be influenced by her culture and expectations
- good preparation e.g. antenatal acre and education is an excellent mitigation for these fear and therefore psyche of birth.
119
Explain the characteristics of PROBLEMS (an influence of progression of labour)
```
includes any
- physical
- emotional
- psychological stress
These can disturb the normal process of labour
```
120
Describe the partogram and its use
it is a graphical representation of events through which maternal or fetal condition is assessed simultaneously in single sheet.
The Partogram was designed based on the works of Friedman (1954). Friedman developed a ‘cervicograph’ and defined what is ‘normal’ and ‘abnormal’ progress represented by a graphical assessment of labour.
He defined dysfunctional labour as a dilation rate of less than 1.2cm/hour in nulliparas women and less than 1.5cm/hour in multiparous women during the active phase
121
Describe the faltspartogram
- based of 'normal lanour' which is different for everyone
- starts based on a subjective measure which could be wrong (VE and presumption of stage of labour)
- Freidman's partogram was based on a study of 100 women
- if the woman does not progress in the way the partigram describes, interventions occur.
122
List some ways to track labour that do not include cervical dilations
- contraction strength
- contraction frequency and pattern
- abdominal palpation (particularly descent of the fetus)
- the woman's voice and behaviour
123
Explain the positive feedback loop of the baby
- SROM= membranes rupture and bbys presenting art descend into the vagina.
- The stimulation of the cervix results in a message sent by nerve pathways to the neuro-hypophysis of the hypothalamus.
- A message is then sent to the adenohypophysis causing the release of oxytocin releasing factors which act upon the posterior lobe of the pituitary gland
- Oxytocin, a peptide hormone, is released in the bloodstream and binds to receptor sites on the uterine fundus which further stimulates contractions.
- These contractions result in contraction and shortening of the uterine fibres resulting in increasing pressure of the presenting part onto the cervix, which further increases stimulation.
124
What is the action of oxytocin
Oxytocin, a peptide hormone, is released in the bloodstream and binds to receptor sites on the uterine fundus which further stimulates contractions.
125
What sis the term used to describe when a baby is born with the membranes intact
En Caul birth
126
What are the benefits of psychological management of labour
not interfering with the natural process of labour, reduced risk of infection to woman and fetus, additional cushioning and protection for the fetus/cord/placenta against uterine contraction, increased ability for the fetus to rotate into an optimal position, reduced pain for the woman, etc.
127
Where is pain most commonly felt in the first stage of labour?
- abdomen (above the pelvis)
- back (especially around the coccyx)
- hips
- legs (some women report this)
128
Where may a women begin to feel pain in the second stage of labour that they don't in the first?
- the perineal area
129
List some pharmacological options for pain relief in labour
Nitrous oxide
N2O2 gas; distorts reality & can be increased in concentration (strength of the drug) as required
Narcotics
Given during active phase but not close to birth
Can cause respiratory depression in baby at/after birth
Epidural
- Preformed by anaesthetist who give an anaesthetic in the epidural space
- Causes numbness from fundus down but the woman must be assessed frequently to ensure anaesthetic is not affecting areas it shouldn't such as the thoracic cavity.
130
What is the second stage of labour
2nd stage of labour is the period from the end of 1st stage/full dilation of cervix until the birth of the baby
131
List some characteristics of the transition phase of the first 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
132
List the phases of second stage of labour
- passive/lull
| - Active/descent/perineal phase
133
Describe the passive phase of second stage of labour
The finding of full dilatation of the cervix before or in the absence of involuntary expulsive contractions.
134
Describe the active phase of second stage of labour
- Expulsive contractions (Fergusons reflex)
- a finding of full dilatation of the cervix or other signs of full dilatation of the cervix
- Descent occurs and the baby becomes visible
- Active maternal effort following confirmation of full dilatation of the cervix in the absence of expulsive contractions.
135
Explain the lull phase of the second stage
- not all women experience
- cervix may be fully dilated but presenting part (pp) has not yet reached the pelvic outlet
- women may not feel expulsive urge until pp has descended further
- woman 'go into self'
- contractions may seem to stop
136
What are signs that a woman is ready to push?
- they verbalise they have an urge
- feels urge in bottom
- Changes in vocalisation –
‘grunt’
- Defecates
- Pouting anus
- Perineum bulges
- Visible presenting part
137
Describe some characteristics of the perineal phase
Presenting part remains on perineum between contractions
- Sometimes retracts but still visible
- this is normal and helps the perineal streach slowly
Widest part of pp moves through the curve of carus
‘Crowning’ occurs where widest diameter passes through perineum –
- does not retract back between contractions
encourage woman to pant
Birth of head
138
List some presumptive signs of the second stage of labour
* Vocalizing loudly and feeling out of control
* Uncontrollable - urge to push
* “Show”
* ROM’s
* Rectal pressure
* Anal dilatation
* Anal cleft line - “purple line”
139
List some definative signs of the second stage of labour
Passive phase:
• Finding of fully dilated on VE without expulsive urge to push
Active phase:
• Expulsive contractions with the findings of fully dilated on VE
• Baby is visible
140
What do the mechanisms of labour refer to?
the ability of the fetus to negotiate the pelvis during labour
- This involves changes in position of the baby’s head during its passage through the pelvis and perineal body
- The mechanisms of labor, also known as the
cardinal movements, are described in relation
to a vertex presentation, as is the case in 95%
of all pregnancies
141
What are the cardinal movement or mechanisms of a normal labour
7 actions
Descent – may begin before the onset of labour. Contractions result in retraction
and downward pressure on baby. As the fetus descends the head rotates so
enters the transverse diameter of the pelvic inlet
Flexion – Pressure down fetal axis causes flexion of the head resulting in smaller
presenting diameters
Internal Rotation – Following engagement, the fetal head rotates to align with
the largest diameter of the pelvic outlet (AP diameter). The head is no longer in
line with the shoulders
Extension of the head – The head is born by extension. The sinciput (brow) and
face sweep perineum and head born by extension
Restitution – Correction to internal rotation to bring head back into alignment
with the shoulders (The twist of the neck that resulted from internal rotation is
now corrected)
Internal rotation of shoulders –Shoulders rotate to enter the widest diameter of
the pelvic outlet (AP). Externally head moves with it. Generally anterior shoulder
born first – may be posterior if in all fours position
Lateral flexion – Body born following natural curve of Carus
142
What are the primary and secondary forces of labour
Primary
- Uterus contracts & retracts pushing down to expel the fetus
- Fetal axis 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
Secondary forces
- Voluntary muscles of diaphragm & abdominal wall assist in expulsion (mum bears down)
143
What are the expected milestones and labour duration for the respective stages
Nulliparous woman labour longer than multiparous woman
First stage:
• cervical dilatation > 0.5 cm/hour
Second stage:
• Combined passive and active second stage should be within 3 hours in nulliparous women and 2 hours in multiparous women
• Consult with the team if nulliparous women is in active phase for > 2 hours or multiparous women > 1 hour
Third stage
• Active management < 30 mins
• Physiological management < 60 mins
144
What are some signs of normal progress of the second stage of labour
- Regular contractions
- Visible descent of presenting part
- May have SROM’s, bloody ‘show’
- FH –may decelerate with pushing and returnto baseline at
end of contraction due to the pressure on the fetal head while descending in second stage (Decelerations are abnormal and should be reported)
- Vital signs pulse & B/P will increase during contraction but
return to normal after rest
- If delay or abnormal observations consult senior midwife and/or medical officer
145
What are some of the key aspects of birth care
- dont tell her/yell at her to push
- you may encourage when she has an epidural
```
Support
– Psychological
– Physical
– Position
– Pushing
```
```
Assessment
– Maternal well being
– Fetal well being
– Progress of labour
– Need for escalation / referral
```
Documentation
146
What are the psychological
During second stage the woman may experience a variety of emotions:
• Fear
• Anxiety
• Exhaustion
The midwife should provide woman-centred care:
• Listen
• Support – the midwife may be experiencing low emotional reserves
• Reassure and encourage
147
What are some physical means of support and management during the second stage
- Support hygiene – replace absorbent pads, remove fecal matter (use protective gloves to remove any articles contaminated with body fluids)
- Maintain fluids – sips water / ice (document)
- Encourage empty bladder - Up to toilet / catheter if required (Difficult to void at this stage)
- Cool compresses / fan – if feeling hot
- cool or warm compress
- Pillows to support positions
- Provide equipment to support the woman
with pushing e.g. birthing stool, mats and
equipment to lean on if all fours
148
Outline aspects of change of position and why they are important.
- Change positions as the positions that the woman adopted in first stage may not assist second stage
- Encourage a change of position as the woman may not recognise the need for change
- Changing position may assist fetal descent – a change may enhance pushing
- Discourage the woman from lying supine – encourages normal vaginal birth and reduces the risk of fetal heart rate abnormalities
- A woman’s pain changes in second stage
149
Where is pain in the first and second stages of labour
Early first stage/early second stage
Sever in abdo
Moderate in perineum
Sever in back
Second stage
Mild in abdo
Sever in perineum
Moderate in back
150
Outline key points surrounding pushing
- Non-directive but recommended
- guided by her own urge to push
Reasons to wait before starting pushing
– Allow head to descend with physiological process to stimulate ‘Ferguson’s reflex’
– Epidural – allow descention
Reasons for using directed pushing
– Fetal compromise / distress
– Woman no urge to push / non effective after giving physiological process time to work
151
What are contraindications of Active pushing with sustained breath holding?
– Abnormal FHR
– Oedema of vulva
– Vaginal perineal trauma
152
What are key points of partice that must be documented about maternal wellbeing?
Contractions half-hourly – frequency, strength and duration
- Vaginal loss half-hourly – show, liquor, blood
- Vital signs - full set; however particular to second stage:
– Maternal heart rate half-hourly
– BP 1 hourly (if within normal limits)
– Temperature 4 hourly
153
What are key points of pratice that must be documented about fetal wellbeing?
Auscultate the fetal heart rate (FH) for a full minute commencing during a contraction and continuing for at least 30 seconds after a contraction
– Passive phase (pushing) – every 15 minutes
– Active phase (not pushing) – after each contraction or every 5 minutes
Liquor will also indicate fetal well being
154
What are 3 ways you can assess the progress of labour?
Abdominal palpation – position of baby (side the back
is on) and descent of head
VE (will have been attended to confirm fully dilated)
may need to be repeated in second stage to confirm
progress and guide intervention if required
Contractions – increase in frequency, duration and
strength
155
What are the midwifes role during the birth
- Clean procedure – wash hands put on sterile gloves
- Apron / personal protective eyewear (PPE)
- Absorbent pad such as ‘pinky’ or ‘bluey’
- Assist woman into appropriate position – standing / kneeling/ lateral / semi-recumbent / birth stool
- Documentation
156
outline the midwifes role in care of the perineum
• Encourage non-directed pushing
• Support perineum
– Reduces severity of trauma
– Hands on vs poised – Effective communication for hands poised is essential
* Warm compresses may reduce trauma
* When the head crowns the woman should stop pushing and pant to breathe the baby out
• Observe perineum for possible tears assessing need for episiotomy
– Rigid perineum;
– Buttonholing
157
What are action points of the midwife when the babies head is born
- Watch for restitution
- Observe for cord and if cord is tight lift over head or birth baby through it
o Do not clamp and cut until the baby is born
- Birth the anterior shoulder
- Lift head up towards abdomen and posterior shoulder is released
- Take care when birthing the shoulders
- Move your hands down so that you are holding the body
rather than the head of the baby
- Flex body and place up on abdomen
- Consider impact of language when guiding woman
158
What are action points when the baby is born
- Document time of birth
- Give the baby to mother – skin to skin (observe transition to extrauterine life)
- Second midwife is responsible for the baby
- Proceed to management of 3rd stage of labour
- Check perineum and vagina for tears
- Assess blood loss
159
What is the role of the second midwife in the birth of the baby
```
While baby is on mothers abdomen/chest
second midwife:
• Dry and stimulate baby
• Observe transition to extra-uterine life
• Resuscitation as necessary in response
to baby’s response to stimulation
• Clamp and cut cord when indicated
– 3cm from umbilicus
• If no resuscitation required attend to
normal care
• Attach name bands
• Assess 1 min & 5 min APGAR
```
160
What changes occur in the baby as it adapts from intra uterine to extra uterine life.
Oxygen diffuses across the placental membrane from the
mother’s blood to the fetus.
• The fetal alveoli are expanded, but are liquid filled.
• Blood flow to the fetal lungs is minimal (~8%) as the lungs do not act as a source of oxygenation or carbon dioxide removal.
• The blood vessels perfusing the fetal lungs are constricted.
• Due to the increased resistance to flow in the constricted vessels in the fetal lungs, blood from the right side of the heart (~ 92%) takes the path of lower resistance across the ductus
arteriosus into the aorta and to the systemic circulation
These combined changes, along with biochemical factors eventually leads to closure of the fetal cardiovascular
shunts/adaptions
– Ductus venosus
– Hypogastric arteries
– Foramen ovale
– Ductus arteriosus
• In healthy, full term infants, functional closure of the ductus begins within hours of birth, with 20% of ducts closed by 24 hours, 82% by 48 hours and 100% by 96 hours (Briton, 1998).
• The transition from fetal to extra-uterine life is then complete.
161
List some things that can be done to assist the fetus transition to extra uterine life
```
Very few newborns require resuscitation
• Most will respond to simple interventions
• First response interventions are therefore most important and time critical
– Stimulate and dry
– Observe airway and breathing
– Assess tone
– Check heart rate
– Prevent hypothermia
```
While stimulating the infant there are two
questions that are important when assessing a
term newborn infant
– Is the baby breathing or crying?
– Has the baby got tone?
162
Explain the APGAR score
Developed in 1952 by Dr Virginia Apgar as a method to
assess the newborns clinical status at 1 min and 5
minutes following birth with subsequent measurements
attended if resuscitation is required (until 20 minutes)
• Components:
– Colour
– Heart rate
– Reflexes
– Muscle tone
– Respirations
163
What is in charge of looking after the baby and carried out apgar
2nd mdiwife
164
The progress of the second stage relies...?
Fetus poition
Attitude: relationship of babys head to its body Well flexed (favourable for birth), incomplete flexed, partial extension, complete extension (also favourable for birth except face presentation is not common)
Primary forces
- Uterus contracts & retracts pushing down to expel the fetus
- Fetal axis pressure acts upon nerve receptors in pelvic floor which stimulates ‘Ferguson’s reflex
- There is displacement of pelvic floor with the bladder pushed up and the rectum flattening into the sacral curve
Secondary force
- Voluntary muscles of diaphragm and abdominal wall assists the mum to bears down
165
Why is it important to protect the peritoneum during labour and what can be done to so this?
- deeper structures of the pelvic floor have a great role to play in the maintenance of continence after birth.
- control of the baby's head at birth (small amount of pressure)
- support of the perineum
- warm compresses to the perineum
- not pushing as the head is crowning
- episiotomy only performed when clinically indicated
- care with birth of the shoulders
166
What is the perineum?
the visible more superficial layer of muscle, fascia, fat and skin that lies between the vagina and the anus, and that we are concerned with in regard to tears and episiotomy and is a pat of the structure of the pelvic floor.
167
List some of the resources used by the primary acousha during birth
Birth pack – clamps /scissors /drapes
Peri-pads / swabs
Oxytocic medication (such as Syntocinon or Syntometrine) – syringe and needle
Neonatal Resuscitation equipment – suction / oxygen / warm wraps
Baby labels
Cord clamps
Sterile gloves / plastic apron / goggles
168
What are the 6 pains of care that need to be completed during the second stage and at birth?
- general
- maternal assessment
- fetal assessment
- care of the perineum during birth
- management of birth
- initial care of baby
169
What are some general points of care that need to be completed during the second stage of labour and birth?
- Second midwife notified
- wash hands put on sterile gloves (This is a clean procedure)
- Place waterproof sheet on bed / floor
- Assist woman into appropriate position – standing / kneeling / lateral / semi-recumbent / birth stool
- Re-evaluation and consulate if progress is slow nulliparous woman fully dilated and pushing >2 hours and birth is not imminent
multiparous fully dilated and pushing > 1 hour and birth is not imminent
- Maintain fluids – sips water / ice
- Ensure empty bladder= Up to toilet / catheter if unable to void and has full bladder
170
What are is involved in a maternal assessment during the second stage of labour and birth?
- vital signs (HR - 30 minutely; BP- 2 hourly; Temperature 4 hourly)
HR increases during contraction but should be normal at rest
- observe descent of presenting part
- abdominal palps
- stations assessment
- VE- if head is in perineum
- Vaginal loss
- colour of liquor (clear, meconium, blood stained)
- assess contractions (frequency, strength and duration)
171
What are is involved in a fetal assessment during the second stage of labour and birth?
Fetal heart
- via intermittent auscultation
Passive Phase – ie NOT pushing - Auscultate the fetal heart rate (FH) for a full minute commencing during the contraction and continuing for at least 30 seconds after a contraction every 15 mins
Active pushing - Auscultate the fetal heart rate (FH) for a full minute commencing during every contraction and continuing for at least 30 seconds after every contraction or every 5 minutes
FHR may decelerate with pushing but returns to baseline at end of contraction - Although this is a common finding any deceleration must be reported
Observe descent of head
172
What are is involved in care of the perineum during the second stage of labour and birth? and why is it important
Important;
- perineal trauma during birth can result in future incontinence and dyspareunia
Prevention
- undertake perineal massaging in the antenatal period.
Care of perineum
The perineum should be kept as clean as possible by washing with warm water if contaminated with faeces.
Avoid directive pushing. Wait until the woman has the urge to push spontaneously (nondirected)
Allow woman to change position as she desires - Upright positions can shorten second stage so try to avoid the supine position
Breathing out baby as gently as possible puffing / panting
Warm perineal compresses as tolerated by mother
Keeps hands poised to lightly flex the baby's head when necessary and control the rate of fetal extension during crowning to prevent severe perineal trauma
Support perineum with one hand to reduces severity of trauma
Observe perineum for possible tears assessing need for episiotomy
- Rigid perineum
- Buttonholing
Support head to prevent sudden birth and tearing of perineum
May need to ensure that the chin is out
Watch for restitution
Observe perineum with the delivery of the shoulders as this can be the time of greatest risk for a perineal tear
173
Is birth a sterile procedure?
Giving birth is a clean not a sterile procedure
174
What are is involved in management of birth?
- If the occiput is anterior, depress head gently towards mothers anus
- Observe visually for cord and if present lift over head or birth baby through it (Do not clamp and cut until the anterior shoulder is birthed)
- Gently guide the baby towards the woman's anus to release anterior shoulder.
- Once the anterior shoulder is released, lift head up towards abdomen to release the posterior shoulder.
- Flex the baby's body and place up on woman's abdomen skin to skin (unless resuscitation is required).
- During skin to skin, a second midwife dries baby
- Clamping and cutting of the cord depends on condition of the baby, and should ideally be delayed at least until the cord has finished pulsating, in order for the baby's full blood volume (some of which will be in the cord and placenta at the time of birth) can return to the baby
- Offer the birth partner the opportunity to cut cord between 2 clamps when indicated
- Assess APGAR score at 1 and 5 mins
- Management of 3rd stage (next moodle book)
- Check perineum and vagina for tears
- Estimation of Blood Loss (EBL)
175
What are is involved in initial care of the baby?
- Baby is placed immediately on mother's abdomen
- The baby is dried immediately after birth to reduce the risk of hypothermia and to stimulate the baby
Assess: Has the baby got good tone and is the baby breathing or crying. If the answer is no the baby will require resuscitation.
CALL FOR HELP
- Clamp and cut the cord if resuscitation is required (refer to local policy regarding clamping for cord bloods)
- Resuscitation as necessary by assisting midwife
- Attach name bands
- Assess 1 min & 5 min APGAR
- Document all assessments and care provide for mother and baby on the partogram
176
When should APGAR be assessed after birth?
- Assess 1 min & 5 min APGAR
177
What is the job of pelvic floor muscles?
form a type of sling that supports the internal structures that assist in maintaining voluntary control of urine and faeces continence.
- contribute to core strength
- assist sexual function.
- support the weight of the abdominal and pelvic organs
- supports the baby during pregnancy
- assists the passive movements of the baby during birth.
178
What are the two layers of pelvc floor msucles and which muscles are in each?
The superficial muscle layer has 5 muscles:
- The external anal sphincter
- Transverse perineal muscle
- Bulbocavernosus muscles
- Ischiocavernosus muscle
- Membranous sphincter of urethra
The deep muscle layers which together are known as the Levator ani muscles has 3 pairs:
- Pubocooygeus muscle
- Iliococcygeus muscle
- Ischiococcygeus muscle
Note that the muscles ending in geus are the deep muscle layers
179
What is the perineal body and where does it lye?
a pyramidal fibromuscular mass in the mid-line of the perineum at the junction between the urogenital triangle and the anal triangle. It can be referred to as the central tendon of perineum.
180
Explain the impacts of the changing pelvic floor on the mother and pregnancy and how they can improve this.
- pelvic floor muscles are subjected to the same softening effects as other muscles from the hormones of pregnancy.
- with the extra weight of the full uterus and baby, these structures become soft and may allow urine and flatus to be involuntarily expelled. (Women may find this change distressing or embarrassing).
- Pelvic floor exercises in pregnancy may be of benefit, but not the short sharp repetitions designed to build muscle bulk, rather the long sustained repetitions designed to increase strength, recoil, stretch and flexibility.
- This is just what we want for the baby to be able to gain the resistance it needs to get adequate flexion, and the give it needs to be able to pass through the muscular structures
181
List the 5 types of perineum damage that can occur.
- Perivulvar lacerations
- first degree tear
- second degree tear
- third degree tear
- fourth degree tear
182
Explain a perivulvular laceration
near the clitoris or urethra are very vascular and require careful suturing
Labial lacerations/grazes may not require suturing
183
Explain a first degree tear
Injury to perineal skin and/or vaginal mucos, can heal on their own, however in some instances may require suturing (particularly if actively bleeding)
184
Explain a second degree tear
Injury to perineum involving perineal muscles but not involving the anal sphincter - requires suturing
185
Explain a third degree tear
- Injury to perineum involving the anal sphincter complex: (Requires suturing in an operating theatre under spinal or general anaesthetic)
- Grade 3a tear: Less than 50% of external anal sphincter (EAS) thickness torn.
- Grade 3b tear: More than 50% of EAS thickness torn.
- Grade 3c tear: Both EAS and internal anal sphincter (IAS) torn.
186
Explain a fourth degree tear
Injury to perineum involving the anal sphincter complex (EAS and IAS) and anorectal mucosa. (Requires suturing in an operating theatre under spinal or general anaesthetic)
