Normal labour (Question-Answers )

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What is labour ?

    A process by which a viable foetus is expelled from the uterus.

What is normal labour ?

    A labour in which foetus presents by vertex and is expelled from the uterus naturally , without artificial aids and without complications.

What is the average duration of pregnancy in woman ?

    40 weeks or 280 days from the first day of last menstrual period.

What is the risk below 16 years of age ?

    It causes serious lacerations.

What is the most favourable age for easiest labour ?

    It is below 30 and above 20 years of age.

What is ” show ” ?

    It is blood stained mucous. Mucous is discharged from cervical mucosa and blood from the lower uterine segment due to separation of membranes.Onset of lobour is recognized by ”show”.

What are the other signs of the onset of labour ?

    Painful uterine contractions , dilatation of the cervix and formation of the ” bag of waters ”.

What is the characteristic of labour pains ?

    At present mild , lasting for few seconds at the interval of 15-30 minutes.Then they rapidly increase in frequency and duration.There is hardening of uterus.

What are false pains ?

    They can be due to dyspepsia , constipation etc . There is no dilatation of cervix and no uterine contractions.

What is ”ripening ”of cervix ?

    It is short , soft and internal OS is dilated sufficiently to admit finger-tip.

What is ‘ bag of waters ” ?

    Bulging of lower pole of foetal membranes in the cervical canal at the onset of labour.They become tense with contractions and relax in between the contractions.

What factors start the labour ?

    Increased tension on the uterine wall.
    Unopposed action of oestrogen due to degeneration of placenta in later pregnancy.
    Increased fetal anterior pituitary-adrenal activity brings about production of oestrogen and oxytocin which is responsible for the release of prostaglandins from decidual cells and myometrial cells.

What are the stages of labour ?

    1–first stage is of uterine contractions. It begins with labour pains and ends with full dilatation of the cervix
    2-Stage of expulsion of the foetus.
    3-Expulsion of the placenta and membranes.

What are the forces of labour ?

    They are derived from involuntary uterine contractions.
    Voluntary bearing down efforts with the help pf abdominal muscles , diaphragm and levator ani.

What is ” taken up” cervix ?

    It means merging of the cervix in lower uterine segment. It is not found to be prejecting on per vaginal examination.

What is ‘bearing down” ?

    It is voluntary effort during second stage.Patient holds her breath and contracts abdominal muscles .Intraabdominal pressure is increased and uterus is compressed to expel out the foetus.

How does lower uterine segment differs from the upper one ?

    Peritoneum is loosely attached in the front and is absent from the sides.
    Muscles are arranged in longitudinal lamelle
    Foetal membranes are loosely attached.
    It is passive during labour and becomes stretched and expands.

What are the features of upper uterine segment ?

    There is firm attachment of peritoneum all over.
    Arrangement of muscles in several layers and in different directions.
    Separation of membranes at the end of labour
    Active during labour and becomes shorter and thicker by retraction.

What is a retraction ring ?

    It is formed at the junction of upper and lower uterine segment.It is not felt per abdominally in normal labour but in obstructed labour it is palpated and is called ” bandle’s” ring.It requires C-section.

How does full bladder affect labour ?

    It obstructs and delays labour, so be sure that the bladder is empty while head is not descending as you expected it to be.

What causes the separation of placenta ?

    Uterine retraction and inelasticity of placenta.

What is Schultz method of placental separation ?

    Separation begins near the centre of placenta with retroplacental haemorrhage.Centre is forced down towards cervix and in vagina it pulls off the membranes and turns them inside out.

What is Mathew’s duncan method ?

    Separation starts at the lower pole , upper pole is last to leave.

What are the characteristics of labour pains ?

    They arise in the back.
    Radiate towards lower abdomen.
    Intermittent and colicky.
    Duration , frequency increases gradually.
    They are associated with hardening of uterus.
    There is dilatation of cervix.
    There is effacement of cervix.
    There is ” show”

What is the difference between contraction and retraction ?

    In retraction the muscle does not come to it’s original length.

What causes dilatation of cervix ?

    Contractions and retractions of upper uterine segment.
    Bag of forewaters.
    Intrauterine fluid pressure.

What is the difference in primigravia and multi in the ”taking up” of cervix ?

    In primi—it precedes dilatation.
    In multi-it accompanies cervical dilatation.

What is ” after waters ” ?

    When membranes rupture , head plugs the cervix and some liquor remains inside the cavity, this is called after waters.It’s pressure expells the foetus out of the cavity.

What is fetal axis pressure ?

    Contracting uterus exerts direct pressure on breech , body and head in succession , it is called fetal axis pressure.

What are the sequence of movements during labour ?

    Engagement of the head.
    Descent.
    Flexion.
    Internal rotation.
    Extension.
    Restitution and external rotation.
    Birth of shoulder and trunk by lateral flexion.

What are the factors responsible for descent of head ?

    Intrauterine fluid pressure.
    Foetal axis pressure.
    Contraction of diaphragm and abdominal muscles.

What is internal rotation ?

    Forward rotation of occipit to lie under the pubic arch.In anterior positions it is 1/8th of a circle.In posterior positions it is 3/8th of a circle.

What factors are responsible for internal rotation ?

    Slope of pelvic floor.
    Unequal flexibility of the fetal parts.
    The screw action of the pelvis.

What is extension of the head ?

    After occipit passes below the symphysis pubis, there is extension of the head.
    The contractions press it downwards and pelvic floor pushes it upwards.So it follows the direction of force.

What is restitution ?

    It is the movement of the head in the direction opposite to the internal rotation.It undoes the twist in the neck due to internal rotation.It brings the head at right angles to the shoulder again.It rotates 1/8th of the circle.

What is external rotation ?

    It is continuation of the movement of of restitution in the same direction.It is 1/8th of the circle.Anterior shoulder comes under symphysis pubis.

When does placental separation begins ?

    About 5-10 minutes after expulsion of foetus.

What are the signs of placental separation ?

    Uterus becomes hard.
    Lengthening of umbilical cord.
    Gush of blood.

How do you prepare the patient in labour ?

    Loose garments are given to her.
    Vulva is cleansed with savlon , betadine after shaving.
    Enema is given in early labour.
    Encourage her to pass urine.
    Rest during pain and walk in between.
    Fluids are given orally and intravenously and oxytocin can be put in IV fluids for the augmentation .

What aseptic precautions are to be taken ?

    Sterilization of all instruments , towels and bed sheets.
    Washing of hands use of savlon before per vaginal examination.
    Sterilized gloves should be used.
    Bed is covered with sterilized macintosh sheet.

How do you assess the progress of labour ?

    By intensity , frequency of contractions , gradual descent of the head , going down of the fetal heart sounds.
    By per vaginal examination–Dilatation of the cervix , effacement , bag of waters , position of the head.

What are the signs of second stage ?

    Increased frequency of pains.
    Contractions of abdominal muscles.
    Full dilatation of cervix.
    Patient ”bearing down”
    Gaping of the anus.

What is fetal distress ?

    FHS more than 160 or less than 110 , irregular and feeble.
    Meconium ( except in breech )
    Excessive fetal movements.

With what you hear FHS ?

    With stethoscope , fetoscope, doppler, CTG.

What drugs you give for acceleration of labour ?

    Oxytocin in IV glucose.
    Misoprost 25 micrograms, vaginally , orally or recatlly.
    Epidosin ( valethamate bromide )
    Drotaverine.

How do you prepare patient for the second stage of labour ?

    Patient put on labour table , lies on back or in left lateral position.
    Local vulval toilet is done.
    Catheterisation.
    Encourage her to bear down.

What does a caput suggest ?

    Prolonged second stage of labour.If doesn’t deliver soon and there is fetal distress, then forcep delivery , ventouse application or LSCS is required.

How will you prevent perineal tears ?

    By giving episiotomy.
    Slow delivery of head.
    Supporting the perineum when crowning is there.
    Making head delivered in between pains.

What should be delivered first ?

    The occipit.
    If there is a cord round the neck , it should be removed.
    Eyes are cleaned with cotton swabs.
    Throat is cleaned with gauze.

What precautions are taken during delivery of shoulder ?

    Head is held with two hands and depressed towards the perineum.Anterior shoulder comes out from symphysis pubis.Head is lifted up which brings posterior shoulder over the perineum.

When is the cord cut ?

    It is cut 2 inches away from umbilicus after…baby cries, or the pulsation in the cord has stopped or veins in the cord have collapsed.

How will you manage third stage of labour ?

    Emptying of bladder.
    Guarding the fundus with ulnar border of left hand.
    Removal of placenta by crede’s method or modified Brandt-Andrew’s method.
    Crede’s —is gently rubbing the uterus till it becomes hard.
    Brandt-Andrew’s is controlled cord traction with elevation of uteus with other hand.
    Examination of vagina , cervix for lacerations and tears.
    Stitching the episiotomy wound.
    Inj ergometrine. Some obstetrician’s give at the time of delivery of anterior shoulder , some give after the removal of placenta.If uterus is atonic and there is bleeding , inj prostaglandin IM can be given.Inj oxytocin can be put in the drip.
    If placenta doesn’t come with crede’s method , then manual removal can be done.
    Watch her for pulse, BP , temperature, height of uterus , consistency of uterus , bleeding per vaginum.

    References

    • Viva in Obstetrics, 1977
    • Holland and Brews , Manual of obstetrics.

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