Question 1

What does the term "vertex presentation" mean?

Accepted Answer

A baby in a vertex cephalic presentation has his head down toward the cervix. This is the most common position for birth, and the least complicated. Typically the neck is flexed, and the crown of baby's head is the first part to emerge (i.e., "crowning"), but variations include face, forehead or chin vertex presentation, all of which are more painful and may require intervention during second stage. If the baby is lying sideways in the pelvis, this is called transverse lie and is typically an indication for Caesarean birth, though some babies do move into a vertex position through the force of contractions and use of productive positioning. When a baby is coming bottom-first, this is referred to as breech presentation. When the baby is facing the front of the pelvis, but is still head down, this is called an occiput posterior position.

Question 2

Which of the following is NOT true about a baby in breech presentation?

Accepted Answer

With an attendant who has experience and/or training, a baby in the breech position can be safely born vaginally. Most obstetricians, however, have lost the skill or have never been trained in this technique, and require a Caesarean for a breech presentation. The provider may try external cephalic version - a technique where the fetus is rotated from the outside of mom's abdomen with the guidance of ultrasound. This technique does have inherent risks, and is not always successful in the long-term. The provider might also suggest exercises the mom can do on her own to try to get the baby to turn from breech to vertex or cephalic presentation. Oxygen deprivation is a risk, and can stem from a greater likelihood of cord prolapse or extended compression of the umbilical cord, or from head entrapment.

Question 3

Which of the following BEST describes "station" as it applies to pregnancy, labor, and birth?

Accepted Answer

Pelvic station is a measurement of labor progress using the position of the baby's descent in relation to the ischial spines, or mid-pelvis, of the mother. The measurement is done in number of centimeters from the mid-pelvis, and it ranges from "minus 4" to "plus 4," with "zero station" meaning the baby is mid-pelvis. Plus numbers mean the baby is closer to being born. While the baby does tend to engage in the pelvis earlier for first time moms, prenatal history is not a related factor in future pregnancies. The rotation of the baby's head may make descent take longer, thus taking longer for the baby to reach various stations.

Question 4

Which of the following is NOT associated with labor induction?

Accepted Answer

Having a vaginal birth is less likely with labor induction. Risks of induction include a greater likelihood of Caesarean birth (especially if the induction was done because the bag of waters ruptured without contractions in a certain time frame), as well as increased chance of assisted delivery with either forceps or vacuum (because mothers who are induced are more likely to use pain medication, making pushing more difficult and less productive). The risk of fetal distress is also increased with an induction due to overly strong or forceful contractions or from changes in fetal position brought on by the method of induction. Babies born to a mother who was induced are also statistically more likely to spend time in the neonatal intensive care unit (NICU), to be born prematurely, and to suffer from jaundice after birth.

Question 5

Which of the following is NOT a good indication for induction of labor?

Accepted Answer

A care provider can make an educated guess about the baby's size, but this is just an estimate and is not a good medical reason for induction. The theory is that induction allows the provider to get the baby out before he or she gains more weight and is harder to deliver, but most mother's bodies are able to adapt to whatever size baby they are carrying, and rarely does a large baby pose a serious medical threat for the mother or the baby itself. The risk of infection does increase as time passes after the rupture of the membranes, so induction for prolonged rupture is a valid medical motive. If pregnancy goes past 42 weeks, there is a chance that the placenta will begin to deteriorate and will not adequately provide for the fetus. If any health condition of the mother escalates to the point that pregnancy is unsafe for her health, it is better to induce labor.

Question 6

Which of the following BEST describes the phrase "cascade of interventions"?

Accepted Answer

The "cascade of interventions" is a phrase meaning a domino-effect that happens when certain birth practices lead to additional interventions with added risks that ultimately change the natural progression of labor. A sudden gush of fluid from the vagina would signal that the amniotic sac has ruptured. While some interventions are necessary for the health of the mother and/or baby, they are not benign and should only be used if medical indication exists. The use of pain medication in labor has its own set of risks, and can be a contributing factor to the "cascade."

Question 7

Which of the following is NOT a technique a doula might suggest so a mother can avoid having an episiotomy?

Accepted Answer

Directed pushing increases the risk that a mother will need an assisted delivery. If she is holding her breath it may look as if the fetus is in distress due to changes in heart rate, so intervention to deliver the baby quickly may be needed, which might include instrumental delivery. The use of positions that work with gravity, such as squatting, standing, and kneeling, aid in fetal descent as well as in stretching the perineum. If one position is not working or is causing increased pain, the mother should be encouraged to change positions. Exhale pushing keeps the mother, uterus, and baby well oxygenated and works with the body's natural urges to deliver the baby. Supporting the perineum as it stretches provides a physical restraint to prevent tearing, and helps ease the baby's head past the tissues, alleviating the need for an episiotomy.

Question 8

What is "Friedman's Curve"?

Accepted Answer

Named after obstetrician Emanuel A. Friedman and sometimes referred to as a partogram, Friedman's Curve plots cervical dilation and fetal descent over time. These points are compared to normative data to determine if labor is progressing normally. Critics claim this tool is outdated, is based on too small a sample size, and is dangerous for laboring women. If her labor is not progressing according to the curve, interventions might include augmentation, pain medication, or even Caesarean birth, all of which have risks for the mother and the baby.

Question 9

Prolapsed cord can BEST be described as:

Accepted Answer

If the cord passes into the birth canal before the baby, fetal oxygen deprivation is likely, and the baby should be delivered as soon as possible by Caesarean surgery. Cord prolapse occurs if there is a gush of fluid as the bag of waters ruptures and the baby is not yet engaged in the pelvis. Cord prolapse is also more likely if the baby is in a breech position. Nuchal cord, where the umbilical cord is wrapped around the baby's neck at the time of birth, is common and is not usually an emergency situation. Delayed cord clamping is the term for allowing the cord to stop pulsing before it is cut. Prolapse is not a normal variation, and is, in fact, rare.

Question 10

Prior to labor, your client said she did not want to use pain medication. During labor, she hits a point where she is overwhelmed and doesn't feel like she's coping well with the pain. She says she is afraid the pain will only get worse. As her doula, which of the following is NOT an option you try at this point?

Accepted Answer

Many times a laboring woman feels she cannot cope, but the continuous support of a doula or partner keeps her focused and helps her to achieve the natural birth she envisioned. While an epidural is an eventual option, a doula should use all of her skills to help the mother find a comfortable position or ritual to get through contractions. It may be that her feeling of being overwhelmed will pass, and with help she will find a means of coping again. In the end, however, the choice to use pain medication is the mother's alone, and the doula can continue to offer support even if that change is made in the birth plan. Some doulas and couples choose a "code word" for this change - a word used by the mother to signal that she is really serious about her inability to cope and needs a more medically managed pain relief strategy.

Question 11

The BEST way to describe the role of oxytocin in labor is:

Accepted Answer

Oxytocin is released in pulses, and causes the rhythmic contraction of the uterus during labor. Oxytocin engenders feelings of love and altruism, and is present in pregnancy and birth as well as during orgasm and breastfeeding, and even when sharing a meal with someone you like. Fear hormones produce the fight-or-flight response and are categorized as catecholamines. Natural pain relievers are endorphins.

Question 12

The role of catecholamines in labor can BEST be described as:

Accepted Answer

The release of adrenaline and noradrenaline is increased when a mother feels threatened. This surge can activate the sympathetic nervous system, and slow blood flow to non-essential organs (like the uterus and fetus). These hormones act differently at the moment of birth, however, when they activate the "fetal ejection reflex" and aid in the baby's delivery. Hormones of relaxation and euphoria include oxytocin and endorphins. Milk production is stimulated by the hormone prolactin.

Question 13

All of the following are true about endorphins EXCEPT:

Accepted Answer

The hormones responsible for the fight-or-flight fear response are adrenaline and noradrenaline. Endorphins are nature's narcotic - they produce pain relief, an altered state of consciousness, pleasure, euphoria, and mutual dependency. This dependency may be the physiologic basis for bonding, but may also be why women need so much support during labor.

Question 14

As a hormone of labor, prolactin can BEST be described as:

Accepted Answer

Prolactin is sometimes referred to as "the mothering hormone," as it creates maternal protective behaviors toward her offspring. Present throughout pregnancy, prolactin levels decrease during labor, rise steeply at the end of labor, and peak with birth. Prolactin continues to be produced during lactation, and is associated with nurturance in both mother and father. Endorphins are pain relievers.

Question 15

All of the following actions interfere with the "hormone cocktail" of labor and birth EXCEPT:

Accepted Answer

An environment that promotes feelings of safety and privacy can aid the natural hormone progression necessary for labor. Ways to achieve this environment include dimming lights, quiet music, limited interruptions, etc. A mother typically feels most comfortable at home, so should remain there as long a possible during labor. The following practices all interfere with the hormones of labor, birth, and postpartum: induction, augmentation, narcotic painkillers, epidural anesthesia, Caesarean birth, and early mother baby separation.

Question 16

Midwife and author Ina May Gaskin has coined the term "Sphincter Law" in relation to how the cervix works in labor. Which of the following is NOT part of her theory?

Accepted Answer

By relaxing the mouth and jaw, the cervix, vagina, anus, and pelvic floor muscles can release their tension. The definition of a sphincter as a body part that opens and closes to allow something through is applicable to labor and birth: the cervix opens to allow the baby through to be born. If a woman has safety, privacy, and some level of relaxation, she can let her body open on its own and will not be working against the physiologic process. Fear, isolation, fright, humiliation, and self-consciousness all produce adrenaline, which can slow labor progress and even close a cervix that had begun to dilate.

Question 17

All of the following will optimize birth hormones EXCEPT:

Accepted Answer

Women should make informed decisions regarding any and all interventions in the birth process. This includes knowing all the pros and cons, as well as being given the right of informed refusal, for any course of action. Autonomy is an essential ingredient in allowing labor to progress. In order to trust the birth process and allow for an optimal hormonal milieu, a mother should choose a caregiver whose birth philosophy matches her own, should plan non-pharmacologic coping and comfort measures, should avoid labor induction and pain medication, should plan for continuous labor support from her partner and/or a doula, create an birthing environment that feels safe and private, keep her baby with her after birth, and breastfeed.

Question 18

All of the following physical changes contribute to the pain of labor EXCEPT:

Accepted Answer

Movement is actually a way to counteract the pain of labor and help alleviate discomfort. Changes in breathing patterns can affect the amount of oxygen getting to the uterine muscles- breath holding or shallow breathing decreases oxygenation, making contractions less effective and more painful. The ligaments supporting the uterus are stretched with each contraction, and also with the descent of the fetus through the pelvis. The fetus also puts pressure on nerves in the pelvis, cervix, and vagina, which can cause shooting pain. Other physical changes that add to discomfort include stretching of the cervix; pressure on the lower back; vaginal and perineal stretching; pressure on internal organs (bladder, urethra, rectum, etc.); and release of stress hormones.

Question 19

Second stage is going very quickly, and a woman's care provider has suggested she slow it down a little to give her perineum time to stretch. Which of the following is NOT a technique the doula might try to help this mother?

Accepted Answer

A squatting position shortens the birth canal, uses gravity to its best advantage, and increases the size of the pelvic outlet - three things that should not be done in a mother at risk for a perineal tear. Getting her into a side lying, gravity neutral position can slow the baby's descent. By taking small panting breaths or making quick blow or puffs (like blowing out a candle), a mother can keep herself from adding force to the natural uterine contractions. The care provider may be supporting the perineum with his or her hand, and if not, the partner or doula can assume this role. Perineal support helps the fetal head to move slowly over the tissues, keeping them from splitting.

Question 20

A client asks her doula how she will know when she is really in labor. The doula's BEST response is:

Accepted Answer

The only way to know that labor is actually underway is to have contractions that get longer, more intense, and closer over time. For some women, this process begins with rupture of the amniotic sac, while for others their water breaks later in labor. If the bag of waters breaks and no contractions start within 24 hours, most healthcare providers will suggest induction. Other signs that labor is near but not underway include losing the mucous plug, nesting, increased backache, cramping, flu-like symptoms, irritability/mood swings, and an increase in the frequency of Braxton-Hicks contractions. Healthcare providers typically do vaginal exams in the last weeks of pregnancy to assess the cervix. While the cervix sometimes does begin to open and thin before the onset of labor, exciting many moms into thinking labor is starting, regular, progressing contractions are needed to complete the process and can take a few days to a few weeks to start.

Quiz 3: Labor Birth