EXAM 2 Flashcards
Cervical exams are usually performed every __ to __ hours
2-3
Amniotomy is considered when…
need to monitor fetal scalp HR or labor augmentation if labor has slowed
The first stage of labor begins when…
labor starts and ends with full cervical dilation to 10 centimeters.
labor is generally defined as….
beginning when contractions become strong and regularly spaced at approximately 3 to 5 minutes apart.
describe the latent phase of the first stage of labor
a preparatory stage marked by slow cervical dilation, with large biochemical and structural changes
0 to 6 cm
A normal latent phase can last up to 20 hours and 14 hours in nulliparous and multiparous women, respectively, without being considered prolonged.
describe the active phase of the first stage of labor
a much shorter and rapid dilational phase
6-10cm
During the active phase, the cervix typically dilates at a rate of 1.2 to 1.5 centimeters per hour.
Multiparas, or women with a history of prior vaginal delivery, tend to demonstrate more rapid cervical dilation.
The absence of cervical change for greater than 4 hours in the presence of adequate contractions or six hours with inadequate contractions is considered the arrest of labor and may warrant clinical intervention
The station of the fetus is defined relative to its proximity to mom’s ____ _____.
ischial spines
When the bony fetal presenting part is aligned with the maternal ischial spine, the fetus is___station.
0
describe how to indicate a baby’s station during labor
0 - -5 is further up in mom
0 - +5 is closer to being down birth canal
T/F: Sedation can increase the duration of the latent phase of labor.
True
Describe the parameters of the arrest of labor and may warrant clinical intervention
The absence of cervical change for greater than 4 hours in the presence of adequate contractions or six hours with inadequate contractions
During the active phase, the cervix typically dilates at a rate of ___ to ___ centimeters per hour
1.2 to 1.5
Describe the Second Stage of Labor
commences with complete cervical dilation to 10 centimeters and ends with the delivery of the neonate.
T/F: After cervical dilation is complete, the fetus descends into the vaginal canal with or without maternal pushing efforts.
true
The fetus passes through the birth canal via 7 movements known as the _____ _______.
cardinal movements.
What are the 7 cardinal movements
engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion.
What elements may influence the duration of the second stage of labor
fetal factors such as fetal size and position, or maternal factors such as pelvis shape, the magnitude of expulsive efforts, comorbidities such as hypertension or diabetes, age, and history of previous deliveries
In parturients without neuraxial anesthesia, the second stage of labor typically lasts less than ____ hours in nulliparous women and less than ___ hours in multiparous women.
less than three hours in nulliparous
less than two hours in multiparous
In women who receive neuraxial anesthesia, the second stage of labor typically lasts less than ___ hours in nulliparous women and less than ___ hours in multiparous women.
less than four hours in nulliparous
less than three hours in multiparous
describe the third stage of labor
commences when the fetus is delivered and concludes with the delivery of the placenta
what are the three cardinal signs of the placenta detaching following birth
a gush of blood at the vagina, lengthening of the umbilical cord, and a globular shaped uterine fundus on palpation
A delivery time of greater than ___ _____________ is associated with a higher risk of postpartum hemorrhage and may be an indication for manual removal or other intervention.
30 minutes
why would a pre-term infant benefit from delayed cord clamping?
improved transitional circulation
better establishment of red blood cell volume, decreased need for blood transfusion
and lower incidence of necrotizing enterocolitis and intraventricular hemorrhage
Friedman observed that labor typically has a ____________ shape
sigmoidal
Explain the five major factors that affect the labor process.
(AKA: The 5 P’s of labor)
Passageway
Passenger
Powers
Position of the mother
Psychological response
pelvic shapes indic what _____ looks like
midplane pelvis
Android-resembles a _____ pelvis
heart (male)
Gynecoid-resembles a _____ pelvis
female (circle)
difference between a Anthropoid and a Platypelloid pelvis shape
anthro oval shape pointed up and down
platy oval shape pointed side to side
describe the inlet of the pelvis
anterior/posterior-from symphysis pubis to spine
describe the midplane of the pelvis
symphysis to coccyx-normally the largest plane
describe the outlet of the pelvis
transverse diameter-distance between ischial spines
what are some considerations for the “passenger” (baby)
Fetal head
Fetal attitude
Fetal lie
Fetal presentation
Fetal position
placenta
what are the 2 types of fetal ie
longitudinal lie – fetal cephalocaudal axis is parallel to the mother’s cephalocaudal axis
transverse lie – fetal cephalocaudal axis is at right angle (90 degrees) to mother’s cephalocaudal axis
define Fetal lie
relationship of cephalocaudal axis of fetus to cephalocaudal axis of the mother
what is a normal fetal lie
longitudinal
what is a normal Fetal attitude
flexion
flexion of head/chin-to-chest, arms folded across the chest, and legs flexed up onto the abdomen
why would you be concerned if fetus attitude is anything other than flexion?
deviations especially related to the head will present larger diameters of the head for the pelvis
name four abnormal fetal presentations
full breech (flexion normal, head is just in fundus)
frank breech (legs straight against chest, flexible af)
single footing breech (fetus was in full breech but wanted to stick it’s foot through the cervix)
shoulder presentation (otherwise known as transverse lie, shoulder is sticking out of cervix)
describe Fetal position
the relationship of fetal presenting part to 1 of the 4 quadrants of the maternal pelvis i.e. front (anterior), back (posterior), or sides (right or left)
most common fetal position is…
occipitoanterior
what is a normal fetal presentation
vertex
3 notations used to describe fetal position
right (R) or left (L) side of maternal pelvis
landmark of fetal presenting part (occipit)
anterior (A), posterior (P), or transverse (T), depending on whether the landmark is in the front, back, or side of the maternal pelvis
what fetal position notation would be most favorable
ROA
LOA
left/right occipitanterior (baby is looking at left or right buttcheek)
describe the increment, acme, and decrement of a contraction
A typical contraction rises in intensity (increment), reaches a peak (acme), and then lessens (decrement).
how do you measure the frequency of a contraction
minutes and fractions of a minute
starts at the beginning of the hill, ends at the beginning of the NEXT hill
how do you measure the duration of a contraction
in seconds
starts at the beginning of the hill, ends at the end of the hill
how do you measure the intensity of a contraction
mild, moderate, strong
the intensity of a contraction is between 40-60 mmHg in the beginning of the active phase
What are the Primary Powers of Labor
Involuntary uterine contractions which causes:
effacement, dilation and change in station
define Effacement
the taking up, drawing up, and disappearance of internal os and cervical canal into the uterine side walls
define Dilation
widening of cervical os and cervical canal from less than a cm to approximately 10 cm
What are the Secondary Powers of Labor
Pushing! Contraction of maternal abdominal musculature for fetal and placenta expulsion
what is the Valsalva maneuver
used for managing the second stage of labor. The mother is asked to take a deep breath, hold the breath (closed glottis), and push downward when uterine contraction starts
why use an Upright position during the first stage of labor
Gravity assists with fetal descent
Facilitates dilation & effacement
Reduces pressure on major maternal structures
why use an Lateral (side-lying) during the first stage of labor
Increases cardiac output
Improves perfusion to organs
Removes pressure on major maternal structures
Helps with back pain & facilitates counterpressure
why use a Semi-recumbent (HOB elevated at least 30˚) position
Convenient for fetal monitoring & exams (not all that great otherwise)
why use a Hands and knees position during the first stage of labor
Helps back labor
Facilitates internal rotation of fetus
Good for OP presentation
what are some Preliminary Signs of Labor
Lightening – “dropping,” movement, or engagement of fetus into pelvic inlet
Sudden burst of energy - “nesting syndrome” – occurs approximately 24 to 48 hours prior to labor onset
Braxton Hicks Contractions: irregular, intermittent contractions that occurs throughout pregnancy
Cervical ripening – softening of cervix
Bloody show - small amount of blood loss occurs from exposed cervical capillaries. Can herald onset of true labor within 24 to 48 hours
Rupture of membranes (ROM) - 12 % females experience rupture prior to labor onset. 80 % females who experience ROM will experience true labor within 24 hours
difference between contractions and Braxton hicks
BH: cervical dilation does not occur, contractions tend to disappear or stop with change in activity
Main sign of TRUE labor is ….
progressive dilation & effacement of cervix
describe stage 1 of labor
latent (0-6cm)
active (6-10cm)
describe stage 2 of labor
10cm-birth
cardinal movements
describe stage 3 of labor
Birth to delivery of placenta
describe stage 4 of labor
Delivery of Placenta to 8 hours later
latent phase lasts about ___ hours for Nulliparas
20
latent phase lasts about ___ hours for Multiparas
14
signs of placental separation
globular-shaped uterus
increased fundal (top of the uterus) height in abdomen
sudden gush or trickle of blood
lengthening of umbilical cord out of vagina
what are the 7 cardinal movements
Engagement & descent
Flexion
Internal rotation to OA position
Extension (for expulsion)
External rotation – restitution
External rotation
Expulsion
what to expect during stage four of labor
moderate drop in blood pressure
increased pulse pressure
moderate tachycardia
results from
blood loss (avg. 250-500 cc)
reduced weight of uterus
redistribution of blood into venous beds
Usually give ______ IV or IM either before or after placenta delivery
Pitocin
what is the average blood loss during labor
250-500 cc
describe a 1st degree vaginal laceration
superficially disrupts mucosa
describe a 2nd degree vaginal laceration
divides the perineal body (episiotomies)
describe a 3rd degree vaginal laceration
tear involves anal sphincter
describe a 4th degree vaginal laceration
tear involves rectal mucosa
Uterus should be ____ and _______ during stage 4 of labor
contracted and midline
what are normal side effects of stage 4 labor
Shaking
Urinary retention
Increased thirst & hunger
blood volume increases by __% in pregnancy.
45
T/F: BP goes up significantly due to pregnancy and more in labor
False
BP should stay stable d/t vasodilation & reduced vascular resistance. Slight cardiac hypertrophy d/t increased blood volume
RBC increase by __-__% depending on iron stores
20-30
why do pregnant people become easily anemic
Increased plasma volume causes physiologic anemia of pregnancy
Blood glucose increases or decreases in labor?
Blood glucose decreases in labor
Maternal O2 consumption increases __-__% above pre-pregnancy
20-40
T/F: Proteinuria is a normal in pregnancy
no if not in labor. yes if in labor d/t work of labor
why might a woman in labor feel super nauseous
Gastric motility slows in labor
Fetal O2 supply is affected by:
Maternal blood flow
Maternal O2
Fetal circulation
Uterine tone
Placental vasculature
what is the Leopold’s Maneuver
4 palpations to determine where the baby is in the uterus
- palpate the fundus to see of you feel a head or feet
- feel both sides of uterus. smooth=back, bumpy=arms
- pinch up with entire hand to see if you can move it to tell if engaged (can’t move it means its engaged)
- feel sides again where you think head is to see if baby is flexed or not
where would you place an electronic fetal monitor (FSE) in-utero?
At the top of a shoulder blade
how does an IUPC monitor the strength of contractions
measures in Montevideo units
Measure actual value of height of each contraction for 10 minutes & total it
Adequate labor ~200
Tachysystole contractions are ___ contractions or more in a ___ minute period
Five contractions or more in a 10 minute period
normal FHR range
110-160 bpm
define Baseline variability
irregular fluctuations in baseline FHR
what are the parameters for FHR Tachycardia
a rate of 160 bpm or more for 10 minutes
what are the parameters for FHR Bradycardia
FHR less than 110 bpm for more than 10 minutes
what are the 3 types of baseline variability
Minimal-less than 5 bpm
Moderate-6-25 bpm
Marked-greater than 25 bpm
what is a Sinusoidal pattern when looking at baseline variability
A sinusoidal fetal heart rate pattern is a well-documented sign of massive maternal-fetal hemorrhage
seen as a smooth, sine-like undulating pattern with a cycle frequency of three to five cycles per minute that persists for >20 minutes.
It is most commonly associated with fetal anemia or hypoxia.
What does FHR Tachy indicate?
Can be an early sign of fetal hypoxemia
Maternal or fetal infection
Fetal anemia
Maternal hyperthyroidism
Response to drugs
What does FHR Brady indicate?
Late sign of fetal hypoxia
Drugs
Cord compression
Maternal hypothermia
Maternal hypotension
Tachysystole
what do Early decels look like
Symmetrical & associated with contraction
Return by end of contraction
what do Variable decels look like
Abrupt, random
what do Late decels look like
Begins after contraction
Accelerations are __ bpm above baseline lasting __ seconds or more
15,15
BUT
if fetus is younger than ___ weeks, accelerations are 10 bpm above baseline lasting 10 seconds or more
32
Prolonged accelerations are longer than __ min, less than __ min
longer than 2 min, less than 10 min
Describe a Category 1 FHR tracing
(normal): strong predictor of normal fetal acid-base status, routine care, no action needed.
baseline: 110-160
Variability: moderate
Late/Variable Decels: Absent
Early decels: present or absent
Accelerations: present of absent
Describe a Category 2 FHR tracing
(indeterminant): something is off but isn’t a 3. Requires continuous surveillance and re-evaluation.
baseline: brady with moderate variability
Variability: moderate or minimal w/ random decels OR ABSENT variability but CANNOT have decels
Late/Variable Decels: prolonged
Early decels: present or absent
Accelerations: present of absent
Describe a Category 3 FHR tracing
(abnormal): abnormal fetal acid-base status. Needs prompt evaluation & action.
Variability: absent
WITH
baseline: bradycardia
OR
Late/Variable Decels: recurrent
Early decels: present or absent
Accelerations: present of absent
SINUSOIDAL PATTERN
Variable decels can mean…
Cord compression
Early decelerations can mean…
Head compression
Accelerations can mean…
baby is doing good! they’re compensating
Late decelerations can mean…
Placental insufficiency
what does Visceral pain indicate?
Uterine ischemia
Cervical changes
Uterine distention
what does somatic (cramping/knawing) pain indicate?
Distention & pressure
Traction
Laceration
where is pain mostly felt during labor
area between the umbilicus and suprapubic bone, lower back, and vaginal/perineal area
when would you give a sedative during labor
during the prolonged latent phase
what are 3 Opioid agonists used during labor for pain management
morphine, Fentanyl, remifentanil (Ultiva)
what are 3 Opioid agonists-antagonist used during labor for pain management
Stadol, Nubain
what is a Pudendal
A medication close to your pudendal nerve in your pelvic region to provide temporary pain relief. Your pudendal nerve runs from the back of your pelvis to all the muscles and skin in your genital area, including the anus, vagina and vulva
difference between an epidural and spinal
Spinal anesthesia involves the injection of numbing medicine directly into the fluid sac. Epidurals involve the injection into the space outside the sac (epidural space).
describe Gate-control theory
Only limited number of sensory messages can travel nerve pathways at the same time
Distraction techniques block some of these, closing a “gate”
Describe Non-pharmacologic pain management methods used in labor
Relaxation, focus, breathing
Effleurage & counterpressure
Music
Water therapy
Massage, heat
Others: TENS, Accupressure/puncture, hypnosis, biofeedback, aromatherapy, intradermal water block
Describe Non-pharmacologic pain management PREPARATION used in labor
Lamaze, Bradley, Dick-Read
What is Bishop Scoring
Scoring a mom to see if they’ll need an induction or not
whare the 5 criteria in bishop scoring
dilation, effacement (%), station, consistency, and position
how do you induce labor
Cervical ripening
AROM
Cytotec (Misoprostol)
Oxytocin/Pitocin
what are examples of labor augmentation
AROM (amniotomy), oxytocin
Forceps: shorten 2nd stage, unable to push effectively, breech, malpresentation, arrest of rotation
Vacuum: preferred over forceps
what is Prepidil
Prostaglandin (dinoprostone) gel
It can help dilate the opening of the uterus (cervix) in pregnant women.
Using sterile technique, introduce the gel with the catheter provided into the cervical canal just below the level of the internal os. Administer the contents of the syringe by gentle expulsion and then remove the catheter.
what is Cervidil
Prostaglandin (contains dinoprostone,
similar to a natural prostaglandin
found in your body)
CERVIDIL is also the only FDA-approved vaginal. insert for cervical ripening.
looks like a string with a pad full of medication at end. the pad goes around the cervix
what is Cytotec
Cytotec, also known as Misoprostol, is a drug administered in pill form that is used to treat gastric ulcers. Doctors currently rely upon it (despite the lack of FDA approval for this use) to ripen the cervix and promote the induction of labor.
Mechanical Induction Methods for labor
cervical ripening balloon and laminaria tent and lamicel
oxytocin is produced by the ____ gland
pituitary
pitocin is Supplied in ____ (not mg!)
Units
pitocin is __ or __ units per ___ or ____ ml in NS
20 or 30 units per 500 or 1000 ml NS
Postpartum use of pitocin is ___ ml/hour or faster
125
why wouldn’t you give miso
mom had a previous C/S
Dysfunctional or prolonged labor refers to…
prolongation in the duration of labor, typically in the first stage of labor
Describe Uterine hyperstimulation or hypertonic uterine dysfunction
Uterine tachysystole- the contraction frequency numbering more than five in a 10-minute time frame or as contractions exceeding more than two minutes in duration.
can be caused by oxytocin overdose
Describe Hypotonic labor
notable especially during the active phase of labor, characterized by poor and inadequate uterine contractions that are ineffective to cause cervical dilation, effacement, and fetal descent, leading to a prolonged or protracted delivery.
what are the six dysfunctional labor patterns
(1) prolonged latent phase,
(2) protracted active phase dilation
(3) secondary arrest of dilation
(4) prolonged deceleration phase
(5) protracted descent (When cervical dilation and descent of the fetal head are slower than normal)
(6) arrest of descent
describe Cephalopelvic disproportion
baby’s head is too big to fit through your pelvis
Low birth weight is defined as a birth weight of an infant less than _____ grams at full term
2500
IUGR is also known as
intrauterine growth restriction
Intrauterine growth restriction is when a baby in the womb doesn’t grow at the expected rate during the pregnancy.
what are side effects of using a vacuum during birth
Caput/cephalohematoma
Cerebral irritation-poor feeding, listless
Jaundice from bruising
Caput vs. Cephalohematoma
caput is clear fluid bum caused by the pressure of the fetal ehad against the cervix during labor
cephalohematoma is caused by a subperiosteal hemorrhage
T/F: forceps are less likely to cause damage to your baby’s head than a vacuum
true
how do you fix shoulder dystocia during birth
McRoberts (hyperflex the legs up against abdomen) & suprapubic pressure
the Brachial Plexus Injury is caused by
shoulder dystocia during birth
how do you fix a Prolapsed umbilical cord
Trendelenburg or knee-chest
Monitor FHR
Emergency C/S
how do you fix a Uterine rupture
Prevention is best treatment
Small-may be repaired; Large-may need hysterectomy
how do you fix a Amniotic fluid embolism
Administer oxygen to maintain normal saturation. Intubate if necessary.
Initiate cardiopulmonary resuscitation (CPR) if the patient arrests. If she does not respond to resuscitation, perform a perimortem cesarean delivery.
Treat hypotension with crystalloid and blood products. Use pressors as necessary.
Avoid excessive fluid administration. During the initial phase, right ventricular function is suboptimal. Excess fluid may overdistend the Right ventricle which could increase the risk of a right sided myocardial infarction.
Consider pulmonary artery catheterization in patients who are hemodynamically unstable.
Continuously monitor the fetus. Deliver immediately following cardiac arrest if gestational age is ≥ 23 weeks. [26]
Early evaluation of clotting status and early initiation of massive transfusion protocols is recommended. [26]
Treat coagulopathy with FFP for a prolonged aPTT, cryoprecipitate for a fibrinogen level less than 100 mg/dL, and transfuse platelets for platelet counts less than 20,000/µL.
Lim and colleagues [32] reported a case of AFE in which the coagulopathy was treated with activated recombinant factor VIIa (rVIIa). The range of doses to treat serious bleeding is from 20-120 μg/kg. In a systematic review of case reports, 16 patients received rVIIa and 28 patients did not. The patients who received rVIIa had statistically worse outcomes, including death and multiple organ failure. The authors suggest that rVIIa only be used when hemorrhage cannot be stopped by other means. [33]
Hemodialysis with plasmapheresis [34] and extracorporeal membrane oxygenation (ECMO) with intra-aortic balloon counterpulsation [35] have been described in case reports with successful outcomes in treating AFE patients with cardiovascular collapse. The use of anticoagulation during ECMO may worsen bleeding in patients with AFE. Use of ECMO is not routinely recommended. [26]
describe a Disseminated Intravascular Coagulation (DIC)
Consumes all clotting factors
Diffuse internal & external bleeding
causes:
Abruption
Retained fetal demise, gram negative sepsis
Amniotic fluid embolus
Preeclampsia, HELLP
Management:
Correct underlying cause
Fluid & blood replacement, O2 & perfusion maintenance
Antithrombin III factor, fibrinogen, or cryoprecipitate
Placenta Previa is PAINFUL or PAINLESS?
PAINLESS
Abruptio Placentae is PAINFUL or PAINLESS?
PAINFUL
Difference between placenta accreta, increta, and percreta
placenta accreta, in which placental villi invade the surface of the myometrium;
placenta increta, in which placental villi extend into the myometrium;
placenta percreta, where the villi penetrate through the myometrium to the uterine serosa and may affect other organs
describe Monozygotic (identical twins)
An ovum (egg) is fertilized by a single sperm
Within two weeks after conception, the fertilized embryo splits in two
Genetically identical embryos which develop into fetuses
describe Dizygotic (fraternal or non-identical twins)
Two ova (eggs) are released during a single ovulation episode
Each ovum is fertilized by a different sperm
The fertilized embryos implant in separate locations within the uterus
Describe Chorion Regarding Twins and Anatomical Developments
outer membrane surrounding the amniotic sac and embryo(s)
Describe Amnion Regarding Twins and Anatomical Developments
innermost membrane containing amniotic fluid, embryo(s), placenta(s), umbilical cord(s)
what is a dichorionic diaminitoic placenta
separate placentas, separate sacks
what is a monochorionic diaminitoic placenta
single placenta, separate sacks
what is a monochorionic monoaminitoic placenta
single placenta, single sack
what are some antepartum complications for multi gestational pregnancies
Pre-eclampsia
Gestational Hypertension
Maternal Anemia
Intrauterine Growth Restriction
Oligohydramnios/Polyhydramnios
Low birth weight
Gestational Diabetes
Miscarriage (< 20 weeks) or Fetal Demise (> or = to 20 weeks)
Twin to Twin Transfusion (more common in monochorionic)
what are some intrapartum complications for multi gestational pregnancies
Preterm labor and/or preterm birth
Placental abruption (can also happen during antepartum)
Increased risk cesarean section delivery (always deliver in the operating room)
Reasons may need cesarean section delivery include:
Twin A (twin closest to cervix) in transverse or breech position
Twin B does not present in vertex position
Non-reassuring fetal heart tracing(s), failure of labor progression, cephalopelvic disproportion, etc.
why would you schedule a c/s
Previous C/S
Classical incision
Multiples
Breech or transverse
Placenta previa
Active maternal disease
CPD (cephalopelvic disproportion)
Cervical cerclage
Macrosomia
Fetal anomolies
Elective
when would you have a Urgent or Emergent C/S
Failed labor or failed induction of labor
Dystocia
Shoulder dystocia
Malposition
Malpresentation
CPD
Abrutio placenta
Fetal distress
Cord prolapse
what are the two types of c/s incisions
Horizontal/Low Segment/Pfannenstiel/Low transverse
Classical/Vertical
what are your general anes postpartum Q 15 min checks
Fundus
VS/cardiac monitor
Bleeding: vaginal & incision
Dermatomes
