Dunn OB/GYN II Flashcards
uterine contractions
number of contractions present in a 10 minute window averaged over 30 minutes
normal contractions
5 or less in 10 minutes
tachysystole
more than 5 contractions in 10 minutes
averaged over 30 minute window
both spotaneous and induced labor
category 1
normal - all of the following:
baseline 110-160 moderate variability accelerations +/- no late/variable deceleration possible early decelerations
normal acid base status
category 2
indeterminate
any of the following: tachycardia bradycardia without absent variability minimal variability etc.
- not predictive of abnormal fetal acid-base status
- requires continuous surveillance and reevaluation
category 3
abnormal
either of the following:
- sinusoidal pattern OR
- absent variability with recurrent decelerations, recurrent variable decelerations, or bradycardia
abnormal fetal acid base status**
efforts should be made to resolve abnormal FHR
vaginal tears during childbirth
common
skin around vagina- heal few weeks
some longer to heal
excessive pain - infection
first degree vaginal tear
only skin around vaginal opening
heal on own
second degree vaginal tear
vaginal tissue and perineal muscle
require closure
third degree vaginal tear
posterior vaginal tissues, perineal muscle, capsule of anal sphincter
fourth degree vaginal tear
perineal muscles, anal sphincter, rectum tissue
require repair - operative setting
complications - fecal incontinence and painful intercourse
breastfeeding
make food perfect for baby
protects baby
benefits mothers health
benefits society
predicting outcome in labor
difficulty
limited clinical exam, X-ray and CT are disappointing, estimates for fetal weight wide margin of error, antenatal risk screening is still important
risk factors for labor problems
younger/older nulliparas short stature previous C-section previous stillbirth multi pregnancy nutritional large for dates pelvic deformity malpresentation
when to induce labor
risk of continuing pregnancy outweigh risks of induction
- at 41+ weeks
- within 96 hours rupture membrane at term
- pre-eclampsia at term
- maternal diabetes at term (including gestational)
- IUGR at term when there is absent doppler EDF
intrauterine growth restriction with absent doppler end diastolic flow
labor induction
prolonged pregnancy - sweep/strip membranes
ruptured membranes induction
oxytocin IV infusion
induction options
vaginal prostagladins
amniotomy followed by oxytocin infusion 3-12 hours later (when cervix is ripe)
induction after C section
no prostaglandins - risk 1:40
spontaneous labor 1:200 risk
oxytocin 1:100 risk
foley catheter - acceptable alternative -placed in uterine cervix
oxytocin infusion
single standard dilution in normal saline
- IV infusion pump
- start low dose - increase 30 minute intervals
review at 16-20 mU/min
discontinue after 5 units**
monitor fetus
Ps
power
passenger
presentation
position
when to intervene in second stage of labor
few patients should not push at all
- no reason to intervene unless:
- failure to progress
- arrest after 60 minutes of pushing
- not just full dilation + 2 hours
second stage of labor
begins when the cervix is completely dilated (open), and ends with the birth of your baby
no maternal death
from scar rupture
scar rupture
rate 1:200
rate same whether VBAC or elected CS
vaginal birth after cesarean = VBAC
rate of perinatal death
11x higher with VBAC vs. elective CS
2x higher than for multiparas having vaginal birth
more likely with cesarean
hospital stay ICU stay death bladder/ureter damage thromboembolism placenta previa stillbirth placenta accreta
no difference cesarean vs. vaginal
postpartum bleed endometritis genital tract injury fecal incontinence postnatal depression back pain dyspareunia
more likely after vaginal birth
perineal pain
urinary incontinence
uterovaginal prolapse
passive second stage
time of full dlation to commencement of involuntary expulsive effort
active second stage
commencement of expulsive effort by woman
plus symptoms or signs of full dilation
or baby is visible
2nd stage >4 hours
increase rate of CS assisted birth chorioamnionitis 3/4th degree trauma 5 min APGAR <7
does review of normal second stage duration help?
no
very variable
multiparas - longer
nulliparas - shorter
nullipara second stage length
2.5 without epidural
3 with epidural
multiparous second stage length
60 minute without epidural
120 minute with epidural
nullipara not delivered 2 hours second stage
consult OB
and 1 hour in multipara
reassess all patients with an epidural who do not push
within 1 hour after fully dilated
position for second stage of labor
sitting, semi-recumbent, lateral
vs. supine or lithotomy
reduced length few assisted birth fewer episiotomies reduced pain more frequent secondary tears
recommendations for maternal position second stage
discouraged from lying supine/semi-supine
encouraged to adopt position most comfortable
recommendations about pushing in second stage
guided by their own urge to push
if ineffective
-provide support/encouragement, change position, empty bladder
perineal massage
midwife massage between contraction - no effect on any measure of obstetric trauma, pain, return to coitus, or urinary and bowel function
hot compress on perineum
reduced need for episiotomy in nulliparas
also reduced rate secondary tears
not considered by another study
hands on or hands poised for fetal head delivery
NICE concludes either is appropriate
less trauma
when head delivers between contractions
lidocaine
no effect
NICE- should not be used
episiotomy
less posterior trauma
more anterior trauma
fewer 3 and 4 tears
overall - more intact perineum
- less perineal pain
- quicker return to coitus
no difference
-sexual function or bladder function
spontaneous birth
no episiotomy
NICE recommendation
episiotomy should be performed
when clinically indicated
fetal compromise suspected
best episiotomy
mediolateral
start at posterior fouchette and proceed at angle of 45-60 degrees
