Beckman Intrapartum Care Flashcards
Define Braxton Hicks contractions
Spontaneous uterine contractions occurring throughout pregnancy not usually felt by pt. Late in pregnancy they become stronger and more frequent = pts perception of discomfort. FALSE LABOR
Are Braxton Hicks contractions association with dilation of cervix?
No, and thus do not fit the definition of labor
Why can’t a physician determine true onset of labor by hx alone?
Braxton Hicks contractions can appear like it to pt
True Labor is associated with contractions that the patient feels over the ___ ____, with radiation of discomfort to ____ and ____
over the uterine fundus; radiation to low back and lower abdomen
“Lightening”, when referring to an event of late pregnancy
pt reports change in shape of her abdomena nd sensation that the baby is lighter, the result of fetal head descending into the pelvis (“Dropping”)
What sxs is “Lightening” ass. with
lower abdomen more prominent, increase need to urinate (bladder compressed by fetal head), breathing is easier (less P on diaphragm)
what is the “bloody show”
pt reports passage of blood-tinged mucus late in pregnancy; results as cervix begins to efface
when does cervical effacement occur?
it is common before onset of true labor, particularly in nulliparous pts
When to contact health care provider for evaluation of labor?
- contractions occur every 5 min for at least 1 hour
- if there is a sudden gush of fluid/constant leakage of vaginal fluid (ROM)
- significant vag bleeding
- dec in fetal movement
4 leopold manuevers
- determine whats in the fundus
- evaluate fetal back and extremities
- palpation of presenting part above symphisis
- determine direction/degree of flexion of head (cephalic prominence)
does vertex position increase or decrease chances of vaginal delivery?
Increases. We do ECV (external cephalic version) to turn fetus into a vertex presentation
who is a candidate for External Cephalic Version (convert breech to vertex) and why?
Pts who have completed 36 weeks are pref. 1. if spontaneous version is gonna happen, its by 36 2. risk of spontaneous reversion is decreased after term ECV
Selection criteria (except for gestational age) for ECV
Normal fetus with reassuring fetal heart tracing, adequate amniotic fluid, presenting part not in the pelvis
Risks of ECV
PROM, Placental abruption, cord accident, uterine rupture
criteria for vaginal breech delivery (but mostly we’ll do section)
- normal labor curve
- gest. age >37weeks
- Frank or complete breech
- No fetal anomalies on US
- adequate pelvis
- EFW of 2500-4000g
- Documentation of fetal head flexion
- Adequate amniotic fluid volume (3cm pocket)
- Availability of anesthesia/neonatal support
antepartum conditions ass. with shoulder dystocia:
multipartiy, postterm gestation, previous hx macrosomic birth, previous hx shoulder dystocia
is elective induction/elective section for all women suspected of carrying a fetus with macrosomia appropriate (prevention of shoulder dystocia, which arrests expulsion)?
NO
Which helps delivery when there is shoulder dystocia, suprapubic pressure or fundal pressure?
Suprapubic.
Fundal pressure may worsen impaction of shoulder and can result in uterine rupture
Brachial plexus injury is ass. with:
shoulder dystocia (most cases resolve).
procedures used to relieve shoulder dystocia
McRoberts: Hyperflex/abduct hips tight to the abdomen + suprapubic pressure
Shortening of the cervical canal from length of 2cm to small orifice with paper-thin edges
Effacement
Zero station
when presenting part has reached the level of the ischial spines
At which station has the greatest transverse diameter of the fetal skull negotiated the pelvic inlet
0 Station. This is when the fetal head is “engaged”
- and + station relative to the ischial spines
- = above \+ = below
what is the 4th stage of labor
immediate postpartum period of approx. 2 hours after delivery of placenta
7 cardinal movements
- Engagement (0 station)
- Flexion
- Descent
- Internal Rotation
- Extension
- External rotation (restitution)
- Expulsion
the supine ___ ___ position keeps uterus off the IVC to prevent ____ ____ _____
left lateral position ;
Supine Hypotensive Syndrome
which position is most commonly used for spontaneous and operative vaginal delivery in the US?
Dorsal Lithotomy position
Which saline do we use?
typically 1/2 normal saline or D5 1/2 normal saline
Combined spinal-epidural greatly decreases the risk of:
spinal headache; sympathetic blockade (hypotension); motor blockade
complications of general anesthesia
maternal aspiration, neonatal depression
why is pushing discouraged during the latter portions of the first stage of labor
to avoid traumatic swelling of the cervix caused by attempting to force the fetus through an incompletely dilated cervix
when can mom start pushing?
once second stage of labor reached (fully dilated)
term for edema of the fetal scalp caused by pressure on the fetal head by the cervix
Caput succedaneum
2 most common causes of overestimation of the amount of decent (station)
Molding (alteration in relation of the fetal cranial bones)
and Caput succedaneum. both in labor stage 2, both resolve within few days
is routine use of episiotomy recommended?
No, may lead to an increase in the risk of 3rd and 4th degree perineal lacerations and a delay in pts resumption of sexual activity
3 classic signs of placental separation
- Uterus rises in the abdomen (indicating placenta has sep and entered lower uterine segment) = globular configuration
- Gush of blood
- Lengthening of umbilical cord
why are cervical ripening agents (misoprostol/PGE2) contraindicated in pts with previous c-section or uterine surgery?
increased risk of uerine hyperstimulation
Advantages of a successful vaginal delivery
- Lower risk of hemorrhage/infection
- shorter postpartum stay
- less painful, more rapid recovery
why isnt c-section by maternal request recommended for women desiring several children?
increased risks of placenta previa, accreta, and gravid hysterectomy with each section
which section of uterus do you do section through to allow for subsequent VBAC
the thin, lower uterine segment
vs classical section, through the thick muscular upper portion…risk of uterine rupture next time
Do women who have GBS bacteruria in current pregnancy, or have previously given birth to neonate with early-onset GBS require GBS cultures?
No…give antibiotic during labor
universal screening for GBS
recto-vaginal culture at 35-37 weeks
what should you consider if IUPC is placed and significant amount of blood/amniotic fluid is seen
Placenta separation or uterine performation. Withdraw catheter, monior fetus, if reassuring place catheter again.
cause of early decels
head compression
cause of variables
cord compression (oligo increases risk)
cause of late decels
uteroplacental insufficiency
leading indication for primary cesarean
labor dystocia aka abnormal labor
3 P’s of dystocia
Power (uterine contractions)
Passenger (position, size, or presentation of the fetus)
Passage (pelvis or soft tissues)
how much pressure must each uterine contraction generate in order for cervical dilation and fetal descent to occur
minimum 25mmHg above basebline. Optimal intrauterine pressure is 50-60mmHg.
how to calculate Mentevideo unit (another measure of contractile strength)
of uterine contractions in 10 minutes x average intensity (normal progress of labor ass. with 200 or more MVU)
Protraction vs arrest (labor)
Protraction: labor slow to progress; Active and Latent phases
Arrest: ceases; Active only
how long is prolonged latent phase? does this predict abnormal active phase?
20 hours (primip) or 14 hours (multip); Not necessarily
whats prolonged active labor
cervix dilates less than 1cm/hr in primip, 1.5 in multip
What is augmentation and how is it achieved
Stimulation of uterine ctxs when spontaneous ctxs fail to result in progressive cervical dilation/fetal descent. Amniotomy (AROM) + Pit
What freq/intensity of contractions should you consider augmentation?
Freq< 3/10min; intensity <25mmHg above baseline
Risks of amniotomy
FHR decels due to cord compression; increased incidence of chorio
Adequate ctxs (and adequate is what is ideal)
max 5 ctxs/10 min with resultant dilation; or >200 MVUs if using IUPC
No descent after 1 hour of pushing
second-stage arrest
conditions ass. with breech
multipel pregnancy, polyhydramnios, hydrocephaly, anencephaly, aneuploidy, uterine anomlies, and uterine tumors
most common cause of Fetal Tachycardia
Chorio
can also be caused by maternal fever, thyrotoxicosis, medication, fetal arrythmia
what can you do to relieve umbilical cord compression in cases of oligo
Amnioinfusion
4 techniques to stimulate fetus (and get an accel)…each of these rule out acidosis when accel follows stim
- Fetal scalp sampling
- allis clamp scalp stimulation
- digital scalp stim
- vibroacoustic stim
initial measures for managing concerning decels
Left lateral postion, administer oxygen, correct maternal hypotension, discontinue oxytocin . Can also use tocolytics to prevent umbilical cord compression. uterine tachyststole can be treated with beta-adrenergics.
meconium is composed of:
amniotic fluid, lanugo, bile, fetal skin and intestinal cells
is meconium dangerous
yes but present in 10-20% of births and most neonates don’t develop problems
meconium aspiration syndrome
inhaalation of meconium; occurs in 6% of meconium present births. Amnioinfusion should NOT be used as a preventive measure.
