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Endo/Repro > Dysfunctional Labor > Flashcards

Dysfunctional Labor Flashcards

1
Q

What physiologic changes occur during labor?

A
  • Each smooth muscle cells becomes a contractile element when the the intracellular ionic calcium concentration increases to trigger an enzymatic process that results in the formation of the actin-myosin element
  • Stimulation of oxytocin receptors on the plasma membrane further activates the actin-myosin element
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2
Q

What causes the relaxations during contractions?

A
  • Maintained by factors that increase cyclic adenosine monophosphate (cAMP)
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3
Q

What causes the contractions during contractions?

A
  • Increase intracellular calcium stores

- Promote interaction of actin and myosin causing uterine contractions

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4
Q

What are the two segments of the uterus during labor?

A
  • Upper segment: actively contracts and retracts to expel the fetus
  • Lower segment along with the cervix: Becomes thinner and passive
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5
Q

How does the cervix change in labor?

A
  • Contains collagen and smooth muscle

- In labor it changes from frim, intact sphincter to soft, pliable, dilatable structure

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6
Q

What is the mechanism for cervix changes in labor?

A
  • Collagenolysis
  • Increase in hyaluronic acid
  • Decrease in dermatan sulfate, which favors increased water content
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7
Q

What is the latent phase during the first stage?

A
  • Cervical softening and effacement occurs with minimal dilation (less than 6cm)
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8
Q

What is the active phase during the first stage?

A
  • Start when the cervix is dilated to 6cm
  • Includes both an increased rate of cervical dilation and ultimately, descent of the presenting fetal part
  • Acceleration phase
  • Deceleration phase
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9
Q

What are abnormal patterns of labor defined as?

A
  • Deviation from the norms for the phases of labor
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10
Q

What may an abnormality of labor be?

A
  • Protraction: slower than normal rate

- Arrest: complete cessation of progress (no further dilation or descent)

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11
Q

What are some etiologies of an abnormal latent phase?

A
  • Most patients will be those who have entered labor without substantial cervical change
  • Excessive use of sedatives or analgesic
  • Fetal malposition
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12
Q

What are some management options for abnormalities of the latent phase?

A
  • Therapeutic rest (sleep) which can provide patient with relief and aid in distinction between true and false labor
  • Morphine (15-20mg): majority will go into active phase, few will stop having contractions due to false labor
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13
Q

What are some abnormalities during the active phase in regards to dilation?

A
  • Cervical dilation is less than norms is a protraction disorder of dilation
  • If 2 or more hours elapsed with no cervical dilation
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14
Q

What are some abnormalities during the active phase in regards to fetal descent?

A
  • Fetal descent of less than norms is a protraction disorder of descent
  • If no change in descent/station has occurred within 1 hour an arrest of descent has occurred
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15
Q

Can abnormalities in the active phase have an effect on perinatal mortalitiy?

A
  • Yes
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16
Q

What are some etiologies of abnormalities of the active phase?

A
  • Inadequate uterine activity
  • Cephalopelvic disproportion
  • Fetal malposition
  • Anesthesia
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17
Q

What is dystocia?

A
  • “Difficult labor”

- It can be used interchangeably with dysfunctional labor characterizing that labor is not progressing normally

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18
Q

What does dystocia result from?

A
  • Three P’s
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19
Q

What are the three P’s?

A
  • Power
  • Passenger
  • Passage
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20
Q

What is power in the three Ps?

A
  • Uterine contractions or maternal expulsive forces
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21
Q

What is passenger in the three Ps?

A
  • Position, size, or presentation of the fetus
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22
Q

What is passage in the three Ps?

A
  • Maternal pelvic bone contractions
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23
Q

When should a diagnosis of dystocia be made?

A
  • Not until an adequate trial of labor has been tried
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24
Q

How are abnormalities of the active phase managed?

A
  • Augmentation refers to stimulation of uterine contraction when spontaneous contractions have failed to result in progressive cervical dilation or descent of fetus
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25
Q

When is augmentation considered?

A
  • If contractions are less than 3 in a 10 minute period and/or the intensity is less than 25 mm Hg
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26
Q

When does the ACOG recommend oxytocin?

A
  • In protraction and arrest disorders after assessing maternal pelvis, fetal position, station, and maternal and fetal status
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27
Q

How is power assessed?

A
  • Intrauterine pressure catheter which gives precise measurement of the intensity of the uterine contractions in mm Hg
28
Q

What is required for use of an intrauterine pressure catheter? Risks vs benefits?

A
  • Requires membranes to be ruptured
  • Benefits: augment labor, allows assessment of meconium status
  • Risks: Cord prolapse, prolonged rupture is associated with chorioamnionitis
29
Q

What are montevideo units?

A

Calculated by measuring the peaks of contractions in mm Hg in a 10 min period

  • > 200 mm Hg for at least 2 hours
  • Before proceeding to cesarean section, should document adequate contractions for at least 4 hours
30
Q

What is the MOA of pitocin?

A
  • Increases intracellular calcium which results in increased actin/myosin activity
  • Sensitivity of uterus to oxytocin increases between 20-40 gestational weeks
31
Q

How is Passage assessed?

A
  • Cephalopelvic disproportion (CPD)
  • Refers to a disparity between the size of the maternal pelvis and the fetal head
  • Causes failure of descent and sometimes engagement of the head
32
Q

What increases the likelihood of CPD?

A
  • Nulliparous women who present in labor with an unengaged head
33
Q

What pelvices are good for delviery?

A
  • Gynecoid and anthropoid
  • Pubic arch: >90º
  • Ischial tuberosity: >8.5 cm
  • Diagonal conjugate: >11.5 cm
  • Prominence of ischial spines
34
Q

How is passage assessed?

A
  • Presentation other than vertex occiput anterior are considered to be abnormal in the laboring patient
35
Q

What is the usual path of the fetal head during descent?

A
  • Enters and engages the maternal pelvis in OT position then rotates to OA
  • Can persist in the OT position
  • Or rotate to the OP positions
36
Q

What else can cause dystocia?

A
  • Abnormalities of fetal structure like macrosomia, shoulder dystocia, fetal abnormalities
37
Q

What is persistent OT position?

A
  • Head fails to rotate and flex into the OA position

- May be caused by CPD, altered pelvic architecture, or relaxed pelvic floor

38
Q

What is transverse arrest of descent?

A
  • A persistent OT position with arrest of descent for a period of 1 hour or more
39
Q

Why does arrest occur in a persistent OT position?

A
  • The deflexion that occurs could cause the occipitofrontal diameter (11 cm) to become the presenting diameter
40
Q

What is the management for a persistent OT position?

A
  • If pelvis is adequate, infant is not macrosomic, and contractions are inadequate:
  • Start oxytocin
  • Rotation (manually or with Kielland forceps)
  • If pelvis is inadequate or infant deemed macrosomic, proceed with C section
41
Q

What is a persistent OP position?

A
  • Even if head rotates to OP initially, majority will eventually rotate spontaneously during labor to OA
  • Course of labor is normal but second stage may be prolonged
  • Associated with more back discomfort
42
Q

What is the management of a persistent OP position?

A
  • Observation of a prolonged second stage is appropriate
  • If labor continues to be progressive and fetal heart rate is normal
  • Delivery of head often occurs spontaneously
  • Operative vaginal delivery will use a vacuum or forceps
43
Q

What is macrosomia?

A
  • Fetus weighing >4500 g
44
Q

What is large for gestational age (LGA)?

A
  • Birth weight equal to or greater than the 90% for a given gestational age
45
Q

How is the passenger assessed?

A
  • Look for any abnormalities that may lead to dystocia
  • Hydrocephalus may cause an enlarged head, making delivery difficult and can be seen on ultrasound
  • Fetal ascites can result in dystocia secondary to enlarged fetal abdomen
  • Conjoined twins, locked twins
46
Q

What is most common cause of fetal ascites secondary to enlarged fetal abdomen?

A
  • Immune hydrops - Rh isoimmunization
47
Q

What is nonimmune hydrops?

A
  • Caused by congenital infections, chromosomal abnormalities, or fetal arrhythmias
48
Q

What are some risk factors for macrosomia?

A
  • Maternal diabetes
  • Previous history of macrosomia
  • Maternal prepregnancy obesity
  • Weight gain during pregnancy
  • Multiparity
  • Male fetus
  • Gestational age >40 weeks
  • Ethnicity
  • Maternal birth weight
  • Maternal height
  • Maternal age <17 years old
49
Q

What are some maternal risks with macrosomia?

A
  • Primary risk is increased risk for C section
  • Postpartum hemorrhage
  • Significant vaginal lacerations
50
Q

What are some fetal risks with macrosomia?

A
  • Shoulder dystocia
  • Fracture of clavicle
  • Damage to nerves of the brachial plexus (esp C5/6 which is Erb-Duschenne paralysis)
51
Q

What is Erb-Duchenne palsy?

A
  • Upper arm palsy
  • Is most common brachial plexus injury
  • Caused by injury to C5/6
52
Q

What is Klumpke palsy?

A
  • Lower arm palsy

- Caused by damage to C8/T1

53
Q

What causes paralysis of entire arm?

A
  • Damage to all four nerve roots
54
Q

What does ACOG recommend for heavy babies?

A
  • Prophylactic C section in babies that are >5000g in nondiabetic patients and >4500g in diabetic patients
55
Q

What is shoulder dystocia?

A
  • A delivery that requires additional obstetric maneuvers following failure of gentle downward traction on the fetal head to effect delivery of shoulders
56
Q

What causes shoulder dystocia?

A
  • Caused by the impaction of the anterior fetal shoulder behind the maternal pubic symphysis or the impaction of the post shoulder on the sacral promontory
57
Q

What is the turtle sign?

A
  • Retraction of the delivered fetal head against the maternal perineum
58
Q

What are some antepartum risk factors for shoulder dystocia?

A
  • Fetal macrosomia
  • Maternal diabetes
  • Obesity
  • Post term gestation
  • Short stature
  • Previous macrosomic baby
  • Previous history of shoulder dystocia
59
Q

What are some risk factors during labor for shoulder dystocia?

A
  • Labor induction
  • Epidural analgesia
  • Prolonged labor
  • Operative vaginal deliveries
60
Q

What are some neonatal risks with shoulder dystocia?

A
  • Brachial plexus injuries (Erbs and Klumpke’s)
  • Fractured clavicle or humerus
  • Hypoxic - ischemic encephalopathy
  • Death
61
Q

What are some management techniques for shoulder dystocia?

A
  • McRoberts maneuver
  • Suprapubic pressure
  • Rotational maneuvers, delivery of posterior fetal arm, fracturing fetal clavicle
  • Proctoepisiotomy
  • Zavanelli maneuver
62
Q

What is the McRoberts maneuver?

A
  • Hyperflexion and abduction of the maternal hip
63
Q

What is done in suprapubic pressure?

A
  • May dislodge the impacted anterior shoulder

- DO NOT apply fundal pressure

64
Q

What is the Zavanelli maneuver?

A
  • Cephalic replacement
  • Last resort
  • Poor prognosis with significant risk of fetal morbidity and mortality
  • Head is pushed back in to pre-delivery position
  • Emergent C section is done
65
Q

What is the Rubin maneuver?

A
  • Place pressure on an accessible shoulder to push it toward the anterior chest wall of the fetus to decrease the bisacromial diameter and free the impacted shoulder
66
Q

What is the Wood’s corkscrew maneuver?

A
  • Apply pressure behind the posterior to rotate the infant and dislodge the anterior shoulder
67
Q

What is the procedure for shoulder dystocia?

A
  • Obstetric emergency
  • Call for help (Anesthesia and PICU)
  • Can not be predicted or prevented
  • Initial maneuvers are McRoberts and suprapubic pressure

Endo/Repro (31 decks)

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