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R2F > Dysfunctional Labor, Uterine Contractility and Dystocia > Flashcards

Dysfunctional Labor, Uterine Contractility and Dystocia Flashcards

1
Q

uterine relaxation

A

-maintained by factors that inc cAMP

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2
Q

uterine contraction

A
  • inc intracellular ca stores

- promote interaction of actin and myosin causing uterine contractions

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3
Q

during labor- 2 segments of uterus are formed

A
  • upper- contracts and retracts to expel fetus

- lower- becomes thinner and passive

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4
Q

physiologic changes of labor- cervix

A
  • contains collagen and smooth m
  • changes from firm, intact sphincter to soft, pliable, dilatable
  • due to collagenolysis, inc in hyaluronic acid, dec in dermatan sulfate- favors inc water content
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5
Q

stages of labor

A

(labor- regular uterine contractions to bring about effacement and dilation of cervix)

  • 1st- onset of contractions to full dilation of cervix
  • 2nd- full dilation of cervix to delivery of infant
  • 3rd- delivery of infant to delivery of placenta
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6
Q

1st stage of labor

A
  • Latent phase- cervical softening and effacement occurs with minimal dilation (<4 cm)
  • Active phase- starts when cervix is dilated to 4 cm
  • inc rate of cervical dilation
  • descent of presenting fetal part
  • acceleration phase
  • deceleration phase
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7
Q

for all phases of labor, the abnormality may be either

A
  • protraction- slower than normal rate

- arrest- complete cessation of progress

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8
Q

latent phase- normal time

A
  • nulliparous- up to 20 hrs

- multiparous- up to 14 hrs

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9
Q

prolonged latent phase- etiology

A
  • those who have entered labor w/o substantial cervical change
  • excessive use of sedatives or analgesics
  • fetal malposition
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10
Q

prolonged latent phase- management

A 
therapeutic rest (sleep)
-morphine (80% will progress to active phase; 15% will stop having contractions- false labor)
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11
Q

Active phase- normal time limits

A
  • nulliparous- cervical dilation of 1.2 cm/h

- multiparous- 1.5 cm/h

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12
Q

active phase- abnormalities

A
  • protraction- if cervical dilation rate is <

- arrest- 2 or more h’s with no cervical dilation

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13
Q

fetal descent- normal time

A
  • nulliparous- 1 cm/h
  • multiparous- 2 cm/h
  • protraction- <
  • arrest- no change in 1 h
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14
Q

active phase abnormalities- etiology

A
  • inadequate uterine activity
  • cephalopelvic disproportion
  • fetal malposition
  • anesthesia
  • can have inc risk of perinatal mortality
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15
Q

Dystocia

A

“difficult labor”/ dysfxnal labor (labor not progressing normally)

  • abnormalities of the 3 P’s:
  • Power (uterine contractions, maternal expulsive forces)
  • Passenger (position, size, presentation of fetus)
  • Passage (maternal pelvic bone contractures)
  • dx should NOT be made b/f an adequate trial of labor has been tried
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16
Q

active phase abnormalities- management

A

-augmentation

17
Q

Augmentation

A
  • stim of uterine contraction (when spontaneous contractions have failed to result in progressive dilation or descent of fetus)
  • consider if contractions < 3 in 10 min or intensity < 25
  • oxytocin- after assessing maternal pelvic, fetal position, station, maternal and fetal status
18
Q

active phase abnormalities- Power

A

IUPC (intrauterine pressure catheter)- measures intensity

  • requires membranes to be ruptured
  • benefits- augment labor, allows assessment of meconium status
  • risks- cord prolapse, prolonged rupture assoc with chorioamnionitis
19
Q

Assessing Power- minimal effective uterine activity is what?

A
  • 3 contractions in 10 min, averaging 25 above baseline
  • MVU (montevideo units)- measures peaks of contraction in 10 min- >200 MVU for 2 hrs
  • b/f proceeding to c-section- document adequate contractions for 4 hrs
20
Q

Inadequate uterine contractions- start what med?

A

Pitocin!!

  • stim uterine contractions- inc intracellular ca
  • 20-30 min needed for full effect
  • 80% of pts w/ a disorder of labor will respond!
21
Q

active phase abnormalities- Passage

A

CPD (cephalopelvic disproportion)

  • inc likelihood in nulliparous women who present in labor with an unengaged head
  • gynecoid and anthropoid pelvic- good prognosis for delivery!
  • pubic arch > 90
  • ischial tuberosity > 8.5 cm
  • diagonal conjugate > 11.5
  • prominence of ischial spines
22
Q

active phase abnormalities- Passenger

A
  • presentations other than vertex OA are abnormal
  • fetal head usually enters the maternal pelvic in OT position- then rotates to OA
  • can persist in OT position or rotate to OP
  • also caused by: macrosomia, shoulder dystocia, fetal anomalies
23
Q

Persistent OT Position

A
  • head fails to rotate and flex into OA position
  • caused by cephalopelvic distortion, altered pelvic architecture, relaxed pelvic floor (epidural)
  • transverse arrest of descent- persistent OT position with arrest of descent for 1 hr
  • arrest occurs b/c of the deflexion that occurs with OT positions- occipitofrontal diameter (11cm) becomes the presenting diameter
24
Q

Persistent OT position- management

A
  • if pelvis is adequate, infant is not macrosomic, and contractions are inadequate: start oxytocin, rotation (manually or kielland forceps)
  • if pelvis is inadequate or infant is macrosomic- c-section
25
Q

Persistent OP position

A
  • some heads rotate to OP initially, and then rotate during labor to OA (5-15% persist in OP position)
  • course of labor in OP position usually normal
  • 2nd stage may be prolonged
  • more back discomfort
26
Q

Persistent OP position- management

A
  • observation of prolonged 2nd stage of labor is appropriate
  • delivery of head often occurs spontaneously
  • operative vaginal delivery (vacuum or forceps)
27
Q

Macrosomia

A
  • macrosomia- fetus weighs 4500 g
  • LGA- wt > 90% for a given gestational age
  • dx of macrosomia- Us!!
28
Q

Passenger- developmental abnormalities

A
  • hydrocephalus- can cause enlargement of head
  • fetal ascites or enlargement of fetal organs- enlarged fetal abdomen- immune hydrops (Rh isoimmunization!!), nonimmune hydrops (infections, chromosomal abnormalities)
  • conjoined twins, locked twins
29
Q

Abnormalities of Active Phase- after assessing the 3 P’s

A

may proceed to C-section if indicated

30
Q

risk factors for macrosomia

A
  • maternal diabetes
  • prev hx
  • maternal obesity
  • wt gain during pregnancy
  • multiparity
  • male fetus
  • gestational age > 40 wks
  • ethnicity
  • maternal < 17 yo
    • 50-g glucose screen w/ a neg result on 3 h
31
Q

macrosomia- risks

A
  • maternal morbidity- inc risk for c-section; postpartum hemorrhage, vaginal lacerations
  • fetal- shoulder dystocia, fracture of clavicle, damage to n’s of brachial plexus- Erb-Duschenne paralysis (C5-6)
32
Q

Brachial plexus injury

A
  • Erb-Duschenne- upper arm palsy- most common- C5-6
  • Klumpke- lower arm palsy- C8, T1
  • paralysis of entire arm- damage to all 4 n roots
33
Q

Macrosomia- c-section when?

A
  • > 5000 g in non diabetic pts

- >4500 g in diabetic pts

34
Q

shoulder dystocia

A
  • delivery that requires additional maneuvers following failure of gentle downward traction on fetal head to effect delivery of shoulders
  • caused by impaction of ant fetal shoulder behind maternal pubic symphysis or impaction of post shoulder on sacral promontory
  • turtle sign- retraction of delivered head against maternal perineum
35
Q

shoulder dystocia- neonatal risks

A
  • brachial plexus injury (<10% result in permanent disability)
  • fractured humerus or clavicle
  • hypoxic-ischemic encephalopathy
  • death
36
Q

Shoulder dystocia- management

A
  • McRobert’s maneuver!!!!- hyperflexion and abduction of maternal hips
  • suprapubic pressure!!!!
  • rotational maneuvers, delivery of post fetal arm, fracturing fetal clavicle
  • proctoepisiotomy
  • Zavanelli maneuver- last resort- cephalic replacement
37
Q

Shoulder dystocia- rotational maneuvers

A
  • Rubin- put pressure on accessible shoulder to push it twd anterior chest wall of fetus
  • Wood’s corkscrew- pressure behind post to rotate the infant and dislodge theant shoulder
38
Q

Shoulder dystocia- Zavanelli

A
  • last resort
  • fetal head is manually returned to prostitution position
  • delivery- emergent c-section
39
Q

shoulder dystocia- tx

A
  • obstetric emergency!!

- initial maneuvers- McRoberts and suprapubic pressure

R2F (18 decks)

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