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Endo/Repro II Test 1 > 14. Dysfunctional Labor > Flashcards

14. Dysfunctional Labor Flashcards

1
Q

Describe the physiologic changes that occur to the uterus during labor

  1. Uterus is a large organ made up of __________
A
    1. Contractile smooth muscle cells
    1. When intracellular Ca2+ increases => actin-mysin elements form
    1. Oxytocin increases formation
    1. During gestation = contractions occur in localized areas. During labor = ENTIRE uterus contracts d.t gap junctions
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2
Q

During labor, 2 distinct segments of the uterus are formed, what is the function of each?

A
  • Upper segment: actively contracts and retracts to expel fetus
  • Lower segment: becomes thinner and passive
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3
Q

Uterus:

How is relaxation and contraction maintained?

A
  • Relaxation = increase cAMP
  • Contraction = increase in intracellular Ca2+ => actin-myosin => contraction
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4
Q

Describe the physiologic changes that occur to the cervix during labor?

A

Collagen and smooth muscle undergo collegenolysis:

  • ↑ in hylauronic acid
  • ↓ in dermaan sulfate
  • => ↑ water content => cervix changes from firm, intact sphincter => soft, pliable and dilatable.
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5
Q

The active phase of the 1st stage of labor starts when the cervix is dilated how far?

A

6 cm

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6
Q

What is labor?

A

Contraction of the uterus that is sufficient enough to cause effacement and dilate the cervix.

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7
Q

What is the 4th stage of labor?

A

12-24 hours after delivery where there is an increase chance of post-partum hemorrhage.

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8
Q

What is the latent phase of the 1st stage of labor?

A

Cervix softens and effaces, with LITTLE dilation (less than 6cm)

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9
Q

What are the normal limits of the latent phase for nulliparous and multiparous women (hours)?

A
  • Nulliparous = up to 20 hours
  • Multiparous = up to 14 hours
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10
Q

In general how are abnormalities of the latent phase managed?

A

[Admit for therapeutic rest (sleep)] + [morphine (15-20mg)]

Most of the time, they will progress to active phase :)

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11
Q

For all phases of labor (EXCEPT latent phase), what abnormalities can you see in labor?

A
  1. Protraction = slower rate than NL
  2. Arrest = complete cessation of dilation or descent
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12
Q

Has labor began if in arrested latent phase?

A

No, labor has not began.

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13
Q

What is “dysfunctional labor”?

A

Rates of dilation and descent exceed NL times.

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14
Q

What is a prolonged latent phase and what outcome does it have on perinatal mortality?

A
  • Longer than NL latent phase
  • Outcome has LITTLE effect on perinatal mortality.
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15
Q

What are causes of prolonged latent phase?

A
  1. Enter labor without change in cervix
  2. Excessive use of sedatives or analgesics
  3. Fetal malposition
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16
Q

Pt comes in and is miserable: contracting, lots of pain, but NO dilation?

A
  • Admit for therapetuic rest + morphine
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17
Q

What are the NL limits of the active phase for cervical dilation (cm/hr) in nulliparous vs. multiparous woman?

A
  • Nulliparous = 1.2 cm/hr
  • Multiparous = 1.5 cm/hr
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18
Q

What are the NL limits of the active phase for fetal descent (cm/hr) in nulliparous vs. multiparous woman?

A
  1. Nulliparous = 1 cm/hr
  2. Multiparous = 2 cm/hr
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19
Q

What is protaction dilation/protraction descent?

A
  • Protraction dilation = cervical dilates less than NL active phase
  • Protraction descent = fetus descends less than NL active phase
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20
Q

What is arrest of dilation/arrest of descent?

A
  • Arrest of dilation => 2 or more hours with no dilation of cervix.
  • Arrest of descent => no change in descent/station 1 hour within an arrest.
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21
Q

What effects do abnormalities of active phase have on perinatal mortality?

A
  1. Increase risk of perinatal mortality
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22
Q

What can cause active phase abnormalities?

A
  1. Inadequate uterine activity
  2. Cephalopelvic disproportion
  3. Fetal malposition
  4. Anesthesia
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23
Q

Dystocia or “difficult labor” is labor that is not progressing properly due to abnormalities of the three P’s, which are?

A
  1. Power = contractions or maternal expulsive forces
  2. Passenger = fetus position, size, or presentation
  3. Passage = maternal pelvic bone contractures
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24
Q

Diagnosis of dystocia should NOT be made before what?

A

Trial of labor has been tried

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25
Q

What is augmentation?

A

Patient starts to have contraction, but you want to make them stronger because they are NOT causing dilation or descent.

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26
Q

Methods of augmentation.

A
  1. Pitocin
  2. Rupture of membranes
27
Q

At which contraction rate and/or intensity should you consider augmentation of labor?

A

Less than 3 contractions/10 minutes and/or intensity < 25 mmHg

28
Q

ACOG recommends giving oxytocin in [protraction & arrest disorders] after assessing what 4 things?

A
  1. Moms pelvis
  2. Station and position of the fetus
  3. Maternal and fetal status
29
Q

Placing an IUPC to assess “power”/MVU requires rupture of membranes, what 2 situations would you NOT want to do this?

A
  1. If the station is really high.
  2. Babies head is ballotable (floating upward) upon palpation.
30
Q

Rupture of membranes risks and benefits

A
  1. Benefits:
    1. Augment labor
    2. Assess status of meconium
  2. Risks
    1. Cord prolapse
    2. Prolonged rupture can cause chorioamnionits
31
Q

NL effective uterine activity is described as ____ contractions in a ____ period, averaging ______mmHg above baseline.

A

3 contractions in 10 minute, averaging 25 mmHg above baseline.

32
Q

How long should we monitor IUPC when measuring strength of contractions?

A

>200 MVU in a 10 minute period for at least 2 hours.

33
Q

Before doing a C-section, we should note adequate contractions for at least ______.

A

At least 4 hours

34
Q

If MVU is not >200 in a 10 minute time period for at least 2 hours, what do we do?

A
  1. Pitocin [0.5m - 30 mIU/min] for 20-30 minutes to see full effects.
    1. ONLY approved med for stimulating labor
35
Q

Nulliparous women who present in labor with an unegaged fetal head indicates an increased likelihood of what?

A

Cephalopelvic disproportion (CPD) = disparity between size of moms pelvis and bbs head

36
Q

What pelvis shapes have GOOD prognosis for delivery?

A
  1. Gynecoid
  2. Anthropoid
37
Q

What presentation is the ONLY normal one in a patient in labor?

A
  • Vertex occiput anterior (OA)
38
Q

How does the fetal head change during labor?

A
  1. Enters and engages pelvis in OT
  2. THEN => rotates and flex to OA
    1. however, it can get stuck in OT or rotate to OP
39
Q

Dystocia can be caused by what fetal abnormalities?

A
    1. Macrosomnia
  • 2. Shoulder dysoticia
  • 3. Fetal anomalies
40
Q

What is transverse arrest of descent?

A
  • Persistant OT position with arrest of descent for 1hr or more due to deflexion causing the occiputofrontal diamter (11 cm) to be the presenting diameter.
41
Q

Which diameter of the fetal head becomes the presenting diameter during transverse arrest of descent?

A

Occipitofrontal diameter

42
Q

What is appropriate management of persistent occipitotransverse (OT) position if pelvis is adequate, infant is not macrosomic and contractions are inadequate?

A
  1. Oxytocin
  2. Manually rotate using Keilland forceps
43
Q

If a patient has persistant OT position, when is a C-section performed?

A
  1. Inadequate pelvis
  2. Macrosomnic bb
44
Q

The course of labor if fetal head is in stuck in OP position is usually normal, but may see what 2 abnormalities?

A
  1. Prolonged 2nd stage
  2. Assoc. w/ considerably MORE back discomfort***
45
Q

What is appropriate management of persistent OP fetal head position?

A
  1. Observation: if labor is progressive and FHR is normal
  2. If not => vacuum or forceps (operational delivery)
46
Q

What is macrosomnia?

A

BB weighs more than 4500g.

47
Q

When is a BB considered LARGE for GESTATIONAL AGE (LGA)?

A

Birth weight is equal than or greater than 90%.

48
Q

Diagnosis of macrosomnia is imprecise if we use ______.

A

US

49
Q

What are abnormalities that can affect the “passenger” and cause dystocia?

A
  • 1. Abnormalities of fetal anomaly
    1. Hydrocephalus => big head seen on US that can make vaginal delivery impossible
  • 3. Fetal ascites or elnargement of organs (liver) cause dystocia due to big abdomen
  • 4. Conjoined twins, locked twins (bb A = breech, bb B = vertex)
50
Q

Most common cause of enlarged fetal abdomen leading to dystocia is what?

A

Immune hydrops - Rh isoimmunization

51
Q

After assessing the 3 P’s => _________ => may proceed with C-section.

A
  • Place IUPC and rupture membranes => not adequate contractions => pitocin => doesnt work => Csection,
52
Q

What are primary risks to mother associated with macrosomia?

A
  • Primary risk = ↑ risk for C-section
  • If deliver vaginally => postpartum hemorrhage and vaginal lacerations
53
Q

What are the fetal risks associated with macrosomia during delivery?

A
  1. Shoulder dystocia
  2. Fracture of clavicle
  3. Damage to brachial plexus: especially C5-C6 (Erb’s palsy)
54
Q

Risk factors for Macrosomnia

A
    1. Maternal DB, obesity, birth weight, height, <17YO
    1. Previous hx of macrosomnia
    1. Multiparity
    1. Gestational age >40 weeks
    1. Male fetus
55
Q

Most common brachial plexus injury during birth is what?

A

- Erb-Duschenne (upper arm palsy (C5-C6))

56
Q

Which brachial plexus injury is more common with shoulder dystocia?

A

Klumpke’s palsy (low arm palsy = C8 and T1); but Erb’s is still most common

57
Q

Due to risk of death for infants and mothers with macrosomia, ACOG recommends prophylactic C-section at what weights for non-diabetic and diabetic patients?

A
  1. >5000g in NON-diabetic
  2. >4500g in diabetic (these babies often have ↑ AP diameter of their chest! = > increase chance of shoulder dystocia)
58
Q

If you suspect shoulder dystocia what should you do immediately?

A
  1. Obstetric emergency! CALL FOR HELP (anesthesiologist and NICU)
  2. Initial maneuvers: McRoberts with suprapubic pressure
59
Q

What causes shoulder dystocia?

A
  1. Anterior fetal shoulder is stuck behind the moms pubic symphysis
  2. Posterior shoulder is stuck on sacral promontory.
60
Q

What is sign of shoulder dystocia?

A

Turtle sign => delivered fetuses head retracts against moms perineum

61
Q

What is first line and last resort managment of Shoulder Dystocia; what can be done after?

A
  1. McRobert’s Maneuver —> Hyerflexion and ABduction moms hips
  2. Suprapubic pressure
  3. Zavanelli maneuver (cephalic replacement) is last resort –> will need C-section

Other: rotational maneuvers, deliver posterior arm, fracture clavicle

62
Q

What should we be cautious of when applying suprapubic pressure to dislodge the stuck anterior shoulder?

A

DO NOT APPLY PRESSURE ON FUNDUS

63
Q

How is Zavanelli procedure performed for shoulder dystocia?

A

Manually return the fetus head back to pre-restitution position using an upward, steady position => deliver via c-section.

64
Q

What is appropriate management of persistent occipitotransverse (OT) positionif pelvis is inadequate, infant is macrosomic and contractions are inadequate?

A

C-section: perform is bb is macrosomnic or pelvis is inadequate

Endo/Repro II Test 1 (23 decks)

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