Normal Labour

Question 1

How is labour defined?

Answer 1

• the physiological process in which a foetus is expelled from the uterus
• it requires the presence of regular uterine contractions
• these increase in frequency, intensity + duration
• this leads to progressive cervical effacement + dilatation

labour = regular contractions + cervical effacement / dilatation

other features (e.g. waters breaking) do NOT indicate labour

Question 2

When does labour + delivery typically occur?

Answer 2

between 37 and 42 weeks gestation

Question 3

Why is the position of the baby important during labour?

Answer 3

• the head pushes against the cervix, causing it to stretch
• stretching of the cervix sends nerve impulses to the brain
• the brain stimulates the pituitary gland to release oxytocin
• oxytocin causes the uterus to contract

if the baby is not in the correct position, the head is unable to cause the cervix to stretch

Question 4

What are the 2 phases of labour?

Answer 4

• latent phase
• established phase

the established phase is further divided into 3 stages

Question 5

What happens during the latent phase of labour?

Answer 5

• there may be some painful contractions, but these are irregular
• there may be some cervical effacement and dilation up to 4cm
• this phase can last from hours up to a week

during this phase women are encouraged to mobilise, use paracetamol and stay hydrated

Question 6

What is meant by the established phase of labour?

Answer 6

• there are regular painful cervical contractions
• there is progressive cervical dilatation from 4cm

Question 7

How can established labour be divided into 3 stages?

Answer 7

first stage:

• from the onset of labour (4cm dilation / true contractions) until 10cm dilation

second stage:

• from 10cm dilation to delivery of the baby

third stage:

• from delivery of the baby until delivery of the placenta

Question 8

What is the first stage of labour?

Answer 8

• this begins when the cervix reaches 4cm dilation and true contractions begin
• there is cervical dilatation (up to 10cm) and effacement

effacement = cervix becomes thinner

Question 9

What is meant by cervical effacement?

Answer 9

• also referred to as “ripening”
• the cervix becomes softer, thinner and shorter

it is assessed via a digital examination

• finger inserted into the cervical os to assess how dilated / effaced the cervix is

Question 10

What is meant by the “show”?

Answer 10

• there is a mucus plug in the cervix that prevents bacteria from entering the uterus during pregnancy
• this falls out during the first stage of labour
• this creates space for the baby to pass through

this appears as a single blob of pinkish / white jelly which can be blood-tinged

Question 11

What are the signs of the onset of labour?

Answer 11

• show (mucus plug from the cervix)
• rupture of membranes
• regular, painful contractions
• dilation of the cervix on examination

Question 12

What are the criteria for diagnosing the latent and established first stage of labour?

Answer 12

latent stage:

• painful contractions
• effacement + dilation of the cervix up to 4cm

established phase:

• REGULAR, painful contractions
• dilation of the cervix from 4cm onwards

Question 13

What are Braxton-Hicks contractions?

Answer 13

• occassional irregular contractions of the uterus
• felt during the 2nd or 3rd trimester
• there is temporary and irregular tightening / mild cramping in the abdomen

they are sometimes called “false labour pains” and can be described to feel like menstrual cramps

Question 14

How are Braxton-Hicks contractions related to labour?

Answer 14

• these contractions are NOT true contractions and DO NOT indicate the onset of labour
• they do not progress
• they do not become regular

staying hydrated / relaxed can reduce these contractions

Question 15

During vaginal examination in labour, what else is assessed?

Answer 15

descent of the head

• this is assessed in relation to the ischial spines of the pelvis
• it is called the “station of the head”
• in early labour, the station is often -1
• the station becomes +1 during the second stage (below the ischial spines)

Question 16

Other than by vaginal examination, how can descent of the head be assessed?

Answer 16

abdominal palpation

• it is described by how many 5ths of the baby’s head can be felt above the pelvis

Question 17

When describing descent of the head, what is meant by 5/5 and 0/5?

Answer 17

5/5th palpable:

• all of the head is above the pubic bone
• all 5 fifths can be palpated

0/5th palpable:

• all of the head is below the pubic brim and cannot be palpated
• once the cervix is 10cm dilated, usually none of the head is felt

Question 18

What are women encouraged to do during the first stage of labour?

Answer 18

• walk and remain in an upright position
• this has been seen to reduce the duration of labour, need for C-section and epidural

Question 19

How can the second stage of labour be divided into 2 stages?

Answer 19

passive stage:

• the cervix is fully dilated to 10cm
• there is an absence of contractions

active stage:

• there are expulsive contractions / active maternal effort alongside full dilation of the cervix

Question 20

Why does the passive stage of the second stage of labour occur?

Answer 20

• once the cervix is dilated to 10cm, the head moves down the pelvis and applies pressure to the pelvic floor
• pressure on the pelvic floor produces the urge to push
• it can take time for this urge to occur when the head is still high

Question 21

What are the 2 approaches to the third stage of labour?

Answer 21

• physiological management
• active management

Question 22

What is meant by physiological management in the third stage of labour?

Answer 22

• the placenta is delivered via maternal effort alone
• uterotonic drugs are not used
• there is no cord traction

Question 23

What is meant by active management of the third stage?

Answer 23

• there is assistance in delivery of the placenta
• IM oxytocin is given to encourage the uterus to contract
• traction is applied to the umbilical cord to guide the placenta out

Question 24

Who is offered active management of the third stage and why?

Answer 24

• it is offered to all women routinely to reduce the risk of postpartum haemorrhage
• it will be initiated if there is haemorrhage

OR

• a > 60 min delay in delivery of the placenta

Question 25

What is the major side effect of active management of the third stage?

Answer 25

N&V

Question 26

How is active management of the third stage initiated?

Answer 26

* an **IM dose of oxytocin (10 IU)** is given * this is given **immediately after** delivery of the baby * other uterotonic drugs - such as **syntometrine** - can be used

Question 27

When should the cord be clamped in active management of the third stage?

Answer 27

* the cord should be clamped + cut **within 5 mins of birth** * there should be a **delay of 1-3 mins** between delivery and clamping to allow blood to flow to the baby * (unless baby requires resuscitation) ## Footnote delay is important in prevention of neonatal anaemia

Question 28

How is controlled cord traction acheived?

Answer 28

* the **abdomen is palpated** to assess for a **uterine contraction** * traction is applied **DURING contractions** * it should be stopped if there is resistance * at the same time, the other hand **presses the uterus upwards** (in the opposite direction) to **prevent prolapse** ## Footnote the aim is to deliver the placenta in one piece

Question 29

What should be done following active management of the third stage?

Answer 29

* **massage the uterus** until it is contracted and firm * **examine the placenta** to ensure it is **complete** and no tissue remains in the uterus

Question 30

What are the 3 important things to monitor in the mother?

Answer 30

1. contractions 2. vaginal loss 3. vital signs

Question 31

Why is it important to monitor contractions?

Answer 31

* **frequency, strength and length** of contractions gives a good indication of **progress** in labour * **4-5 contractions in 10mins** are needed to progress in labour

Question 32

Why is it important to monitor vaginal loss?

Answer 32

* **spontaneous rupture of the membranes** (SROM) can occur at any point in labour (and before) * once ruptured, observe for **meconium** or **heavy blood staining** * this could indicate **antepartum haemorrhage**

Question 33

How is the foetus monitored during labour?

Answer 33

**low risk women:** * ***intermittent auscultation*** of the foetal heart * via Doppler USS or Pinard stethoscope **high risk women:** * continuous monitoring via ***cardiotocograph (CTG)***