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.
2
Q
What are Braxton-Hicks contractions?
A
False labor (irregular contractions without dilation of cervix)
3
Q
What are the 4 shapes of the pelvis?
What is the most common
A
- Gynecoid * (50%)
- Android (30%)
- Anthropoid
- Platypelloid
4
Q
Which pelvic shapes have a good prognosis for delivery?
A
- Gynecoid
- Anthropoid
5
Q
Which pelvic shapes have a bad prognosis for delivery?
A
- Android
- Platypelloid
6
Q
What is the initial evaluation labor and delivery?
A
- Review prenatal records
- ID complications of pregnancy
- Confirm gestational age
- Review pertinent lab findings
- Focused history (nature and frequency of contractions/ loss of fluid/ vaginal bleed)
- PE (vital signs, fetal heart tones and conractions, cervical exam)
7
Q
3 parts to an obstetric exam?
A
- Fetal lie
- Fetal presentation
- Cervical exam
8
Q
On obstetric exam what is fetal lie?
A
Relationship between the maternal spine to fetus spine to determine if infant is
- Longitudinal
- Transverse
- Oblique
9
Q
On obstetric exam what is fetal presentation?
A
Presenting part of the pelvis:
- Vertex
- Breech
- Transverse
- Compound (vertex w/ hand)
10
Q
On obstetric exam, what are the 5 parts of the cervical exam?
A
- Check dilation of cervix at the internal os (closed = completetly dilated at 10cm)
- Effacement: thinning of the cervix
- Station: degree of descent of presenting part of fetus
- Position and consistency used to calculate Bishop score
11
Q
Which maneuvers are used to determine the fetal lie?
A
Leopold Maneuvers
12
Q
4 maneuvers involved in Leopold Maneuvers
A
Palpate:
- Fundus (fetal head vs buttocks vs transverse position)
- Spine and fetal small parts
- Pelvic with suprapubic palpation
- Cephalic prominence: feel chin or occipital protuberance if head is not deep in pelvis
13
Q
How do you measure station?
A
Measured in cm from how far away presenting part is => ischial spine.
-5cm => +5cm
14
Q
When the bony portion of the fetal head reaches what level is it considered “zero” station?
A
Ischial spines
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
16
Q
1st stage of labor: Latent vs. active phase
A
- Latent (early labor): slow dilation of the cervix
-
Active phase: Faster dilation of the cervix (begins when cervix is dilated to 6cm)
- Admit for labor at this stage in term gestations
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
18
Q
1st stage of labor: Maternal position and can ambulation occur?
A
- If lying in bed: left lateral recumbant
- Ambulate if head is engaged and reassuring monitoring occurs.
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
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
21
Q
What type of monitoring during the 1st stage provides the most accurate tracings?
A
Internal monitoring
22
Q
How is activity of the uterus monitored during 1st stage?
A
- External tocodyamometer
- Internal pressure catheter (IUPC) => assess the strength of contractions and is helpful w/ oxytocin augmentation
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
24
Q
Benefit vs. risks of performing an amniotomy (AROM= artificial rupture of membranes) during 1st stage of labor
A
-
Benefits:
- Augment labor
- Assesses status of meconium
-
Risks:
- Cord prolapse
- Prolonged rupture can cause chorioamnionitis
25
What is the **2nd** stage of labor?
* **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
26
What are the **7 cardinal movements** of labor in order (mnemonic)?
**EDFIEEE**
## Footnote
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) f**etal 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.
27
Duration of **2nd stage** of labor:
1. Primapara w/o epidural
2. Primapara w epidural
3. Multipara w/o epidural
4. Multipara w epidural
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**
28
**_2nd stage of labor_**
* Most common position:
* Avoid which position:
* **Dorsal lithotomy** (for spontaneous and operative delivaries)
* **Supine**
29
In the **2nd stage of labor**, what should the mom do with each contraction?
**Bear down:** hold her breath and bear down with expulsive efforts
30
How often does **fetal monitoring** occur in the **2nd** stage of labor in a mom with risk factors/none?
**_Continous_**
* **Risk factors:** q 5 minutes
* **No risk factors:** q 15 minutes
31
Once the fetal head is delivered during 2nd stage, how can we **clear the airway of blood** and **amniotic fluid?**
Can **bulb suction** [1st oral cavity =\> nares]
32
When do we perform a **episiotomy** (cut the opening of the vagina)?
1. If **spontaneous laceration** seems high
2. To **speed up delivery** by enlarging the vaginal outlet **(if baby is too big)**
33
What is the most common type of **episiotomy?**
**Midline** episiotomy
34
**Pros** and **Cons** of Midline Episiotomy
* **Pro**: less postpartum pain
* **Con**: greater risk of extension into 3rd or 4th degree
35
**Stages of delivery of the bb (15)**
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
What is used to **deliver the head** the the baby and how is it performed.?
**_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
What is a **1st** vs. **2nd** vs. **3rd** vs. **4th** degree perineal laceration?
* **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
What is the **3rd stage of labor?**
How is it done?
* 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
**Retained placenta** is diagnosed during the 3rd stage if placenta has not delivered within how long?
**Within 30 minutes**
40
_**4 classic signs** of **placental separation (retained placenta)**_
which indicate that you should begin to **apply pressure on the cord**
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
Management of the **3rd Stage**
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
What is the most common cause of **postpartum hemorrhage** during the **4th stage?**
**Uterine atony**
## Footnote
**Other**: _retained placenta_ or _unrepaired vaginal or cervical laceration_
43
When is **cervical ripening** done and what is the goal?
* **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
What is **induction of labor** vs. **augmentation of labor**?
- **Induction** is the process by which labor is _induced_ by artificial means
- **Augmentation** is the _artificial stimulation of labor_ that has already begun
45
What is **augmentation**?
**Artificial stimulation of labor** that has already began.
46
**5 contraindications** to **induction** of **labor**
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
**_Indications_** for Induction (9)
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
**_Bishop Score_**
* Purpose:
* Takes into consideration what factors:
* 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
**Calculate Bishop Score**
50
Which Bishop score is considered **unfavorable** and what is considered **favorable**?
* **\<6** = unfavorable
* **\>8** = favorable :) = probability of vaginal delivery after labor induction is similar to that of spontaneous labor
51
What is a downside of using **Misoprostol (Cervidil)** vs. **Dinoprostone (Cytotex)** for cervical ripening?
* **Misoprostol (PGE1)** cannot be readily removed if concerns arise
* **Dinoprostone (PGE2)** is a vaginal insert that can be removed
52
**Misopristol** and **Dinoprostone** is CI in whom?
Pts with **previous C-section**
53
What are 2 **mechanical dilators** which can be used for cervical ripening?
1. Foley bulb catheter
2. -Laminara Japonicum
54
What is the only FDA approved drug for **induction** and **augmentation**?
**Pitocin (synthetic oxytocin)** given **IV** that stimulates myomtrial contraction
55
**Pitocin** Adverse Effects
Which is the most common?\*\*\*
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
What is given to mom to provide effective pain relief for mother during labor and delivery that is safe for her and baby?
**Obstetric anesthesia**
57
What effect may regional anesthesia have on **uterine blood flow**; what can be done to mitigate this risk?
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
If **hypotension** occurs, what can be given to restore maternal BP and uterine flow?
1. **Vasopressor** (Ephedrine 10mg IV)
59
What are the 5 options for anesthesia in labor?
1. **Nonpharmacologic methods**
2. **Parenteral**
3. **Regional** (epidural/spinal)
4. **Local** (local infiltration of perineum/pudendal block)
5. **General**
60
When are **parenteral anesthesia** options best?
* 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
What are **regional anesthesias?**
**Epidural** or **spinal** anesthesias that cause loss of pain sensation **below T8-10.**
62
What is an **epidural**?
- **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
What is a **spinal anesthesia?**
**Regional single-shot anesthesias** used in scheduled **c-sections** that lasts 30-250 minutes.
64
What are 5 contraindications for doing **regional anesthesia** during labor?
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
**Side effects** of regional anesthesia
* 1. **Hypotension**
* 2. **HA** (more often in spinal)
* 3. **Fever, spinal hematomas** and **abscesses**
66
What anesthesia is used to infiltrate perineum **before episiostomy** or with l**aceration repairs**?
Local infiltration of perineum using **lidocaine**
67
Most common **induction** **agent** used for **general anesthesia** in:
1. Emergent cases where rapid delivery is needed
2. When regional anesthesia has failed
**Propofol**
68
What is the anesthesia related risk of maternal mortality with **general anesthesia** vs. **regional anesthesia**?
General anesthesia has a **16-fold higher risk** of maternal mortality
69
