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Endo/Repro II Test 1 > 7. NL Labor and Deliver > Flashcards

7. NL Labor and Deliver Flashcards

1
Q

What is labor?

A

Progressive dilation of the cervix due to contration of the uterus that occurs every 5 minutes and lasts for 30-60 seconds.

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2
Q

What are Braxton-Hicks contractions?

A

False labor (irregular contractions without dilation of cervix)

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3
Q

What are the 4 shapes of the pelvis?

What is the most common

A
  1. Gynecoid * (50%)
  2. Android (30%)
  3. Anthropoid
  4. Platypelloid
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4
Q

Which pelvic shapes have a good prognosis for delivery?

A
  1. Gynecoid
  2. Anthropoid
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5
Q

Which pelvic shapes have a bad prognosis for delivery?

A
  1. Android
  2. Platypelloid
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6
Q

What is the initial evaluation labor and delivery?

A
  1. Review prenatal records
  2. ID complications of pregnancy
  3. Confirm gestational age
  4. Review pertinent lab findings
  5. Focused history (nature and frequency of contractions/ loss of fluid/ vaginal bleed)
  6. PE (vital signs, fetal heart tones and conractions, cervical exam)
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7
Q

3 parts to an obstetric exam?

A
  1. Fetal lie
  2. Fetal presentation
  3. Cervical exam
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8
Q

On obstetric exam what is fetal lie?

A

Relationship between the maternal spine to fetus spine to determine if infant is

  1. Longitudinal
  2. Transverse
  3. Oblique
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9
Q

On obstetric exam what is fetal presentation?

A

Presenting part of the pelvis:

  1. Vertex
  2. Breech
  3. Transverse
  4. Compound (vertex w/ hand)
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10
Q

On obstetric exam, what are the 5 parts of the cervical exam?

A
  1. Check dilation of cervix at the internal os (closed = completetly dilated at 10cm)
  2. Effacement: thinning of the cervix
  3. Station: degree of descent of presenting part of fetus
  4. Position and consistency used to calculate Bishop score
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11
Q

Which maneuvers are used to determine the fetal lie?

A

Leopold Maneuvers

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12
Q

4 maneuvers involved in Leopold Maneuvers

A

Palpate:

  1. Fundus (fetal head vs buttocks vs transverse position)
  2. Spine and fetal small parts
  3. Pelvic with suprapubic palpation
  4. Cephalic prominence: feel chin or occipital protuberance if head is not deep in pelvis
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13
Q

How do you measure station?

A

Measured in cm from how far away presenting part is => ischial spine.

-5cm => +5cm

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14
Q

When the bony portion of the fetal head reaches what level is it considered “zero” station?

A

Ischial spines

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15
Q

4 stages of labor

A
  • 1st = onset of true labor => complete dilation of cervix (latent and active phase)
  • 2nd = complete dilation of cervix => delivery
  • 3rd = delivery => delivery of placenta
  • 4th = delivery of placenta => stabilization of patient
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16
Q

1st stage of labor: Latent vs. active phase

A
  1. Latent (early labor): slow dilation of the cervix
  2. Active phase: Faster dilation of the cervix (begins when cervix is dilated to 6cm)
    1. Admit for labor at this stage in term gestations
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17
Q

How long does does it take until complete cervical dilation (first stage) and what is the rate in primiparas and multiparas?

A
  • Primiparas =
    • 6 to 18 hours
    • 1.2cm/ hr
  • Multiparas =
    • 2 to 10 hours
    • 1.5 cm/hr
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18
Q

1st stage of labor: Maternal position and can ambulation occur?

A
  1. If lying in bed: left lateral recumbant
  2. Ambulate if head is engaged and reassuring monitoring occurs.
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19
Q

1st Stage of Labor

  • Fluids
  • Labs
  • Monitor every _____ hours
  • Drugs?
A
  • Hydrate via IV and allow access to meds
  • CBC and T&S
  • 1 - 2 hours
  • Give analgesia
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20
Q

External fetal monitoring in uncomplicated vs complicated pregnancy

  • Active phase of 1st stage
  • Second stage
A
  • Uncomplicated pregnancy
    • q 30 minutes in the active phase of 1st stage of labor
    • q 15 minutes in the 2nd stage of labor
  • Complicated pregnancy
    • q 15 minutes in active phase (after contraction)
    • q 5 minutes in 2nd stage
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21
Q

What type of monitoring during the 1st stage provides the most accurate tracings?

A

Internal monitoring

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22
Q

How is activity of the uterus monitored during 1st stage?

A
  1. External tocodyamometer
  2. Internal pressure catheter (IUPC) => assess the strength of contractions and is helpful w/ oxytocin augmentation
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23
Q

Vaginal/cervical exam in the 1st phase of labor

  • How often/when?
  • What is Recorded?
A
  • Perform cervical check q 2 hrs during active phase
  • Record dilation, effacement, station
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24
Q

Benefit vs. risks of performing an amniotomy (AROM= artificial rupture of membranes) during 1st stage of labor

A
  • Benefits:
    1. Augment labor
    2. Assesses status of meconium
  • Risks:
    1. Cord prolapse
    2. Prolonged rupture can cause chorioamnionitis
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25
Q

What is the 2nd stage of labor?

A
  • Descent of the presenting part of the babies head through the maternal pelvis => delivery
    • Bloody and mom wants to bear down as they are contracting
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26
Q

What are the 7 cardinal movements of labor in order (mnemonic)?

A

EDFIEEE

  1. Engagement: presenting part at “zero” station
  2. Descent occurs via contractions and valsalva
  3. Flex bb is chin to chest (OA)
  4. IR (when at ischial spine) fetal head IR so occiput is ANT or POST toward the pubic symphysis
  5. Extension (when station is +5) bbs head extends; head is born by rapid extension
  6. ER (restitution): head returns to original position so that head can back and shoulders can pass
  7. Expulsion: anterior shoulde delivers under pubic symphysis => posterior shoulder and the rest of the body is delivered.
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27
Q

Duration of 2nd stage of labor:

  1. Primapara w/o epidural
  2. Primapara w epidural
  3. Multipara w/o epidural
  4. Multipara w epidural
A
  1. Primapara w/o epidural: 2 hours
  2. Primapara w epidural: 3 hours
  3. Multipara w/o epidural: 1 hour
  4. Multipara w epidural: 2 hours
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28
Q

2nd stage of labor

  • Most common position:
  • Avoid which position:
A
  • Dorsal lithotomy (for spontaneous and operative delivaries)
  • Supine
29
Q

In the 2nd stage of labor, what should the mom do with each contraction?

A

Bear down: hold her breath and bear down with expulsive efforts

30
Q

How often does fetal monitoring occur in the 2nd stage of labor in a mom with risk factors/none?

A

Continous

  • Risk factors: q 5 minutes
  • No risk factors: q 15 minutes
31
Q

Once the fetal head is delivered during 2nd stage, how can we clear the airway of blood and amniotic fluid?

A

Can bulb suction [1st oral cavity => nares]

32
Q

When do we perform a episiotomy (cut the opening of the vagina)?

A
  1. If spontaneous laceration seems high
  2. To speed up delivery by enlarging the vaginal outlet (if baby is too big)
33
Q

What is the most common type of episiotomy?

A

Midline episiotomy

34
Q

Pros and Cons of Midline Episiotomy

A
  • Pro: less postpartum pain
  • Con: greater risk of extension into 3rd or 4th degree
35
Q

Stages of delivery of the bb (15)

A
  1. Place drape under moms butt
  2. Clean vagina with antiseptic soap
  3. As the crowning head flattens perinium, episiotomy may be needed
  4. Perform Ritgen maneuver: deliver head
  5. After head is delivered, bulb suction oral cavity => nose to clear blood and amniotic fluid
  6. Use index finger to assess nuchal cord (loose = manually reduce over bbs head; tight = clam x2 and cut)
  7. Downward traction to deliver anterior shoulders
  8. Elevate head to deliver posterior shoulders
  9. Support bb as body is delivered
  10. Bulb suction again if needed
  11. Dry and stimulate
  12. Clamp cord x2 and cut
  13. Obtain specimans of the cord blood
  14. Deliver placenta
  15. Inspect cervix, vagina and perineum (repair if needed
36
Q

What is used to deliver the head the the baby and how is it performed.?

A

Modified Ritgen Maneuver

  • Use fingers on right hand to extend head while left hand applies counterpressure to occiput;
    • *Manual support of perineum is equally effective
37
Q

What is a 1st vs. 2nd vs. 3rd vs. 4th degree perineal laceration?

A
  • 1st: superficial laceration involving vaginal mucosa and/or perineal skin
  • 2nd: laceration extending into muscles of the perineal body but does not involve anal sphincter
  • 3rd: laceration extends into or completely through the anal sphincter but not into the rectal mucosa
  • 4th: involves the rectal mucosa
38
Q

What is the 3rd stage of labor?

How is it done?

A
  • Time between delivery of the infant and delivery of the placenta (2-10 minutes): apply pressure between symphysis and fundus, but do NOT pull on cord until classic signs are noted.
39
Q

Retained placenta is diagnosed during the 3rd stage if placenta has not delivered within how long?

A

Within 30 minutes

40
Q

4 classic signs of placental separation (retained placenta)

which indicate that you should begin to apply pressure on the cord

A
  1. Gush of blood from vagina
  2. Lengthening of the umbilical cord
  3. Fundus of uterus rises up
  4. A change in shape of the uterine fundus from discoid –> globular
41
Q

Management of the 3rd Stage

A
  1. Look for lacerations of the cervix, vagina and perineum
  2. Monitor uterine bleeding
  3. Repair episiotomy or spontaneous lacerations
  4. Inspect the placenta for completness.
42
Q

What is the most common cause of postpartum hemorrhage during the 4th stage?

A

Uterine atony

Other: retained placenta or unrepaired vaginal or cervical laceration

43
Q

When is cervical ripening done and what is the goal?

A
  • Cervical ripening is done when induction is indicated and the cervix is unfavorable.
    • Goal: cause cervical softening, thinning and dilation to reduce the rate of failed inductions
44
Q

What is induction of labor vs. augmentation of labor?

A
  • Induction is the process by which labor is induced by artificial means
  • Augmentation is the artificial stimulation of labor that has already begun
45
Q

What is augmentation?

A

Artificial stimulation of labor that has already began.

46
Q

5 contraindications to induction of labor

A
  1. Unstable fetal presentation
  2. Acute fetal distress
  3. Placental previa or vasa previa
  4. Previous C-section or transfundal uterine surgery (i.e., myomectomy)
  5. Any contraindication to vaginal delivery (i.e., HIV w/ high viral load, active genital HSV outbreaks, etc.)
47
Q

Indications for Induction (9)

A
  1. Abrupt placenta
  2. Chrorioamnionitis
  3. Fetal demise
  4. Preeclampsia, eclampsia
  5. Gestational HTN
  6. PROM (premature rupture of membrane)
  7. Postterm pregnancy
  8. Moms medical conditions (DM, renal disease, chronic HTN)
  9. Fetal compromise
48
Q

Bishop Score

  • Purpose:
  • Takes into consideration what factors:
A
  • Assesses how favorable the cervix is.
  • Factors
    • 1. Dilation of the cervix (cm)
    • 2. Effacement of the cervix (%)
    • 3. Station
    • 4. Cervical consistancy
    • 5. Cervical position
49
Q

Calculate Bishop Score

A
50
Q

Which Bishop score is considered unfavorable and what is considered favorable?

A
  • <6 = unfavorable
  • >8 = favorable :) = probability of vaginal delivery after labor induction is similar to that of spontaneous labor
51
Q

What is a downside of using Misoprostol (Cervidil) vs. Dinoprostone (Cytotex) for cervical ripening?

A
  • Misoprostol (PGE1) cannot be readily removed if concerns arise
  • Dinoprostone (PGE2) is a vaginal insert that can be removed
52
Q

Misopristol and Dinoprostone is CI in whom?

A

Pts with previous C-section

53
Q

What are 2 mechanical dilators which can be used for cervical ripening?

A
  1. Foley bulb catheter
  2. -Laminara Japonicum
54
Q

What is the only FDA approved drug for induction and augmentation?

A

Pitocin (synthetic oxytocin) given IV that stimulates myomtrial contraction

55
Q

Pitocin Adverse Effects

Which is the most common?***

A
  1. Uterine tachysystole = more than 5 contractions in 10 minutes ***
  2. Antidiuretic effect due to similar structure as ADH
  3. Uterine muscle fatigue (nonresponsiveness) w/ prolonged use
56
Q

What is given to mom to provide effective pain relief for mother during labor and delivery that is safe for her and baby?

A

Obstetric anesthesia

57
Q

What effect may regional anesthesia have on uterine blood flow; what can be done to mitigate this risk?

A
  1. If hypotension occurs and not treated quickly, may ↓ uterine blood flow (NL = 700-900 mL/min)
    1. Hydration (IV bolus) 30-60 min before = mitigate the risk for hypotension
58
Q

If hypotension occurs, what can be given to restore maternal BP and uterine flow?

A
  1. Vasopressor (Ephedrine 10mg IV)
59
Q

What are the 5 options for anesthesia in labor?

A
  1. Nonpharmacologic methods
  2. Parenteral
  3. Regional (epidural/spinal)
  4. Local (local infiltration of perineum/pudendal block)
  5. General
60
Q

When are parenteral anesthesia options best?

A
  • Given intermittendly in the 1st stage of labor, when pain is more visceral and less intense (VERY little efficacy to relieve labor pain) AND when bb is doing well, because opiods can cross the placenta barrier and cause respiratory depression
61
Q

What are regional anesthesias?

A

Epidural or spinal anesthesias that cause loss of pain sensation below T8-10.

62
Q

What is an epidural?

A
  • Most effective form of pain relief and used by most W in the US
  • Place a catheter in epidural space (L2-3/3-4/4-5 interspaces) to allow continous infusion of anesthetic agents
63
Q

What is a spinal anesthesia?

A

Regional single-shot anesthesias used in scheduled c-sections that lasts 30-250 minutes.

64
Q

What are 5 contraindications for doing regional anesthesia during labor?

A
  1. Maternal coagulopathy
  2. Heparin use within 12 hrs
  3. Untreated maternal infection
  4. ↑ ICP due to mass lesion
  5. Skin infection over site of needle placement
65
Q

Side effects of regional anesthesia

A
    1. Hypotension
    1. HA (more often in spinal)
    1. Fever, spinal hematomas and abscesses
66
Q

What anesthesia is used to infiltrate perineum before episiostomy or with laceration repairs?

A

Local infiltration of perineum using lidocaine

67
Q

Most common induction agent used for general anesthesia in:

  1. Emergent cases where rapid delivery is needed
  2. When regional anesthesia has failed
A

Propofol

68
Q

What is the anesthesia related risk of maternal mortality with general anesthesia vs. regional anesthesia?

A

General anesthesia has a 16-fold higher risk of maternal mortality

69
Q
A

Endo/Repro II Test 1 (23 decks)

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