Intrapartum Flashcards
Station
relationship of the leading edge of the fetal presenting part to the ischial spines (in cm)
0 = the presenting part is at the level of the spines
-3, -2, -1 = the presenting part is # cm above the ischial spines
+3, +2, +1 = number of centimeters the presenting part is below the ischial spines
Dilation
cervical os dilation from 0 - 10 cm (fully dilated)
Effacement
0-100% (fully effaced, like paper)
When to do a sterile speculum exam before the SVE?
ROM suspected, frank bleeding, inspection for herpes lesions
Presenting Part
the anatomic part of the fetus that first descends into the pelvis
- Cephalic
- Breech
- Shoulder
- Face
Position
relationship between the denominator of the presenting part and the maternal pelvis
What is the denominator for cephalic presentation?
Occiput
What is the denominator for breech presentation
sacrum
What is the denominator for shoulder presentation?
scapula
What is the denominator for face presentation
mentum (chin)
What is clinical pelvimetry?
manual examination of the pelvis to determine adequacy of the pelvis - this is not evidence based
What 4 bones compose the pelvis?
Two innominate (pubic) bones - the symphysis pubis joins these two pubic bones
Sacrum
Coccyx
What is the true pelvis?
Birth canal
What are the 3 parts of the true pelvis?
inlet, midplane, outlet
What are the boundaries of the inlet?
posteriorly: sacral prominatory
laterally: the linea terminalis
Anteriorly: the upper margins of the pubic bones
What are the boundaries of the midplane?
Posteriorly: sacrum at the junction of the 4th and 5th sacral vertebrae
Laterally: ischial spines
Anteriorly: the inferior border of the symphysis pubis
What are the boundaries of the outlet?
Posterior: sacrococcygeal joint
Laterally: inner surface of the ischial tuberosities
Anteriorly: lower border of the symphysis pubis
What are the 4 pelvis types?
Gynecoid
Android
Anthropoid
Platypelloid
What are the characteristics of a gynecoid pelvis?
- round shaped
- Transverse diameter is only slightly longer than AP diameter
- Incidence: 50% white women
- excellent prognosis for vaginal birth
What are the characteristics of an android pelvis?
- heart or triangular-shaped pelvis
- Posterior pelvis is wider than anterior pelvis
- Poor prognosis for vaginal birth, many times requiring operative VB or c/s
What are the characteristics of the anthropoid pelvis?
- Oval-shaped
- AP diameter is longer than transverse diameter
- Incidence: 40.5% of non-white women
- Good prognosis of vaginal birth, higher incidence of OP
What are the characteristics of a platypelloid pelvis?
- flattened gynecoid-shaped pelvis
- Wide transverse diameter with very short AP diameter
- Incidence: 3%
- Poor prognosis for vaginal birth
What are the types of FHR monitoring (3) during labor?
- Continuous by EFM
- Continuous by internal fetal monitoring
- Intermittent monitoring
What is continuous EFM and what are the risks/benefits?
FHR is monitored by External fetal monitor (u/s piece and toco)
Benefits: determines FHR, assesses variability, determines presence or absence of periodic changes such as decels, tachycardia, bradycardia
Risks: no risks really, but disadvantages can include: limiting mobility, not getting into tub, perhaps increases unnecessary intervention while not improving outcomes in low risk pregnancies
What is continuous INTERNAL fetal monitoring and what are the risks/benefits?
FHR is monitored by a fetal scalp electrode
Benefits: more accurate than EFM, especially if you can’t maintain a good reading with EFM
Risks: increased risk of infection
What is intermittent fetal monitoring and what are the risks/benefits?
Auscultation of FHR at prescribed intervals based on stage of labor to assess fetal tolerance of labor
Benefits: freedom of movement, be in water, can increase pt comfort; associated with decreased rates of intervention, equivalent to Cont EFM when performed at correct intervals
Risks: cannot determine variability or isolated decels, not used in high risk pregnancies, needs 1:1 ratio
What heart sounds are considered wnl in pregnancy?
RRR, but ALSO: rubs, gallops, may have split S1, grade 1 or 2 systolic murmur, audible S3
When to admit someone in labor?
Generally during ACTIVE labor
If admitted in latent phase, client incurs increased risk of interventions
Factors to consider:
- stage of labor
- nullipara vs multipara
- functional vs prodromal
- labor support at home
- need for increased fetal surveillance
What factors may necessitate IV access?
- hydration status - are they dehydrated? is there ketonuria?
- Need for oxytocin induction or augmentation
- Need for antibiotics
- Predisposing factors for PPH such as an overdistended uterus
- abnormal placentation
- grand multips
- need for pain medication or regional anesthesia
Moving around in labor?
Should be encouraged
Things that could limit movement include:
- HTN
- maternal exhaustion
- unstable lie or malpresentation
- need for increased surveillance/fetal monitoring
Nutrition and fluid status in labor?
Energy levels can be positively influenced by PO intake
Factors to consider in the decision making:
- GI motility and absorption
- potential need for anesthesia in labor
- birthing facility policy
What are non-pharm methods for pain management/increase coping in labor?
- ambulation, movement, position change, birthing ball
- hydrotherapy
- breathing and relaxation/hypnotherapy
- music
- acupuncture/acupressure
- sterile water injections for back labor
- touch and massage
- warm compress like heating pad or rice sock/cold compress
- aromatherapy
- tens unit
- Labor support - LIKE A DOULA!
What types of medications can be given for analgesia?
- opioids
- nitrous oxide
- Rarely: hypnotics/sedatives likes benzos b/c they don’t provide analgesia, may cause amnesia and disrupt thermal regulation of the newborn
When should opioids be used in labor?
In active and latent phases
Avoid within 1 hour of birth because of potential respiratory depressant effect on fetus
How is nitrous given?
self-administered inhaled gas in 50:50 mix with oxygen via face mask
- safe for mom and fetus
- administered before, during and after contraction
- Does not diminish uterine contractility
What types of anesthesia can be provided in labor?
Spinal/Intrathecal
Epidural
What are the risks/benefits of anesthesia in labor?
Benefits: provides complete neurologic block
Disadvantages/Risks:
- can interfere with muscular action
- possible slowing of labor progress, may cause an increase in need for intervention
- can have systemic effects like hypotension (most common) and fever
- Inadvertent dural puncture can cause spinal HA
What are local blocks and what types can be used in labor?
provide pain blockade at site of pain for a brief period of time
- paracervical
- pudendal
- local infiltration
What are the benefits of a doula?
dedicated labor support of a doula has been found to decrease use of obstetric interventions and promote physiologic birth
What are the 4 Ps of labor?
Power
Passenger
Passageway
Psyche
What does the power of labor encompass?
Power of contractile efforts
- assess adequacy of strength of contractions
- Assess need for augmentation of labor
What does the Passsenger of labor emcompass?
Fetus
Things to evaluate:
- lie
- presentation
- position
- size
- synclitism vs ascynclitism
What does synclitism and asynclitism describe?
The relationship of the sagittal suture line to the maternal sacrum and symphysis pubis
What is synclitism?
The sagittal suture is midway between the sacrum and the symphysis pubis; the biparietal diameter is parallel to the planes of the pelvis
What is asynclitism?
The saggital suture is not midway between the sacrum and the symphysis pubis, it is oriented towards one or the other
2 types: posterior and anterior
This can cause labor dystocia
Lax abdominal musculature can contribute to this
What is posterior asynclitism?
the saggital suture is closer to the symphysis pubis, so head is tilted towards the posterior
What is anterior ansynclitism?
the saggital suture is closer to the sacrum, so the head is tilted towards the anterior
What is the passageway?
The pelvis
- clinical pelvimetry, classification of pelvic structure
What is the psyche?
women’s view of labor/birth and her ability to handle it, things that can affect the psyche:
- appropriateness of emotional support
- education or preparation of labor
- meaning of the pregnancy
- ability to achieve birth plan
- hx of sexual abuse
What is the first stage of labor?
From the onset of REGULAR contractions through full dilation (10 cm), includes latent and active phases
What is latent labor?
During the first stage of labor: from onset to 4-6 cm
What is the contraction pattern in latent labor typically?
From every 10-20 minutes lasting 15-20 seconds to every 5-7 munutes lasting 30-40 seconds
mild to moderate intensity
How long is latent labor for nulliparas?
20 hours or less per Friedman
How long is latent labor for multiparas?
14 hours or less per Friedman
What is active labor?
During the first stage of labor, from 6 cm to 10 cm (full dilation)
What are contractions like in active labor?
Become more frequent, regular and intense
typically every 2-3 minutes and moderate to strong by palpation
How are contractions measured?
Externally by palpation
Internally: by IUPC
What is considered adequate contraction strength by intrauterine pressure catheter (IUPC)?
Adequacy in the active phase is considered 200-250 Montevideo units (mVu) in 10 minutes, averaged over 30 minutes
What is the second stage of labor?
from full dilation until the birth of the baby - this is the pushing or expulsive phase
What is abnormal latent phase in a nullipara?
more than 20 hours (friedman)
What is abnormal latent phase in multipara?
more than 14 hours (friedman)
What is considered abnormal labor progress in the active phase for nullipara?
less than 1.2 cm per hour (friedman)
Mean time to dilate from 4-10 cm is 3.7 hrs, 95th percentile 16.7 hrs (Zhang)
What is considered abnormal labor progress in the active phase for a multipara?
less than 1.5 cm/hr (friedman)
Mean time to dilate from 4-10 cm: 2.4 hrs for parity 1, 2.2 hrs for parity 2+, 95th percentile 14.2 hrs
What is considered abnormal progress of second stage/descent in nullipara?
Less than 1 cm/hr (friedman)
more than 3 hours without an epidural or more than 4 hours with an epidural
What is considered abnormal progress of second stage/descent in multipara?
Less than 2.1 cm/hr (Friedman)
More than 2 hours without an epidural, more than 3 hours with an epidural
Vital signs in first stage: Temp
slightly elevated, but less than 100 during labor, highest in time preceding and immediately after birth
epidural anesthesia can artificially elevate temperature
Vital signs in the first stage: BP
systolic BP increases by 10-20 during contractions, diastolic BP increases 5-10 during contractions
BP should return to prelabor levels between contractions
pain and fear can contribute to elevations in BP
Vital signs in the first stage: Pulse
Because of increased metabolic rate during labor, pulse rate is slightly elevated
Inversely proportional to action of the contraction - increases during increment (buildup/rise) and decreases at acme (peak) –> therefore if fetus is having recurrent accelerations during contractions, it is important to place plase ox on mom to distinguish baby from mom
Vital signs in the first stage: Respirations:
slightly increased rate during labor
Hyperventilation is common (But not normal) and r/t pain response, can lead to alkalosis
When should labor be augmented in the first stage?
Not until active labor!
Individualized approach per Zhang
One article states that aggressive intervention (like oxytocin) should not be administered unless dilation averages are < 0.56-0.64 cm/hr in active labor
Stress in labor:
increases cortisol - can cause decreased placental perfusion, decreased contractions
What opioids can be used in labor?
- morphine sulfate for prodromal labor 10-15 mg IM
OR - fentanyl 50-100 mcg IV or IM
OR - Meperidine 50-75 mg IM or 25-50 mgIV - rarely used b/c its metabolite accumulates in fetus and potentiates depressant effects on newborn
Mixed agonist-antagonist:
- Butorphanol 1-2 mg IV or 2 mg IM
- Nalbuphine 10-20 mg IM or 5 mg IV
avoid all with active labor
What is responsible for the variability of FHR?
parasympathetic/sympathetic nervous system:
Baroreceptors in carotid arteries - increased pressure can cause a vagal response
Chemoreceptors in aortic arch and carotid sinus - sensitive to changes in fetal pH, O2 level, CO2 level- respond by increasing fetal BP and HR
ACTIVATION OF SYMPATHETIC nervous system: increases baseline HR
ACTIVATION of PARASYMPATHETIC nervous system: decreases baseline HR
What is normal range HR for fetus at term?
110-160 bpm
on FHR strip, judge baseline based on 10 minute strip and round to nearest 5
What is fetal bradycardia?
< 110 bpm for 10 or more minutes
What is marked fetal bradycardia?
< 100 bpm for 10 or more minutes
What are causes of bradycardia?
- cord compression
- rapid descent
- vagal stimulation
- medications
- anesthesia
- placental insufficiency
- fetal cardiac anomalies
- Terminal condition of fetus
What is fetal tachycardia?
> 160 bpm for more than 10 min
What are the causes of fetal tachycardia?
- maternal fever
- infection
- medications, esp beta sympathomimetics
- chronic fetal hypoxia
- can be compensatory after temporary fetal hypoxia event
- undiagnosed prematurity
- excessive fetal movement
What is FHR variability and what are the categories?
Baseline variability: fluctuations in the baseline of the HR
Absent
Minimal
Moderate
Marked
Absent FHR variability
undetectable amplitude
Minimal FHR variability
amplitude range of </= 5 bpm
Moderate FHR variability
amplitude range of 5-25 bpm
Marked FHR variability
amplitude >/= 25 bpm
What are accelerations a sign of?
fetal well-being, cannot be produced by acidotic fetus (indicates fetal pH of more than 7.20)
What is the definition of an acceleration for a fetus greater than 32 weeks?
a peak of >/= 15 bpm above baseline lasting 15 seconds or more, but less than 2 minutes from beginning to end of acceleration
What is the definition of an acceleration for a fetus 32 weeks or less?
a peak of >/= 10 bpm above baseline lasting 10 seconds or more, but less than 2 minutes from beginning to end of the acceleration
What is the definition of a variable decel?
Abrupt (onset to nadir < 30 seconds) periodic or non-periodic decrease in the FHR that differs in shape from one deceleration to another. The decrease in FHR from the baseline is >/= 15 bpm lasting >/= 15 seconds but less than 2 minutes
- it DOES note reflect the shape of the contraction
- can occur at any time in relation to the contractions
- Inconsistent shape: U, V, W
- Generally occurs as an abrupt from below the FHR baseline and a rapid return to baseline
What causes variable decels?
CORD COMPRESSION
What are the implications of variable decels?
- with rapid recovery to baseline and good variability, generally considered an uncompromised fetus
- suspect fetal compromise with slow recovery to baseline, increasing length or depth of decelerations, absent variability or increasing frequency of decels
Management of variable decels?
- position change
- IV fluid bolus
- O2 at 10 LPM via face mask
- pelvic exam to r/out cord prolapse
- contact consulting MD if warranted
- consider amnioinfusion
What is an early decel?
- Uniformly shaped slowing of the FHR that mirrors the contractions
- Gradual descent to the nadir (>/= 30 seconds) with gradual return
- FHR usually remains within the normal range and deceleration is usually , 90 seconds
- Deceleration begins, peaks and ends with contraction
What causes early decel?
Head compression/vagal stimulation
Implications of early decels?
generally benign
Management of early decels?
Surveillance
What is a late deceleration?
- Uniformly shaped gradual (>/= 30 seconds) slowing of the FHR that begins with the peak of the contraction and does not return to baseline until after the completion of the contraction
- FHR may not remain within the normal fetal heart range
What are implications of late decels?
- can occur in an isolated fashion; more ominous when occurs repetitively
What are the causes of late decels?
Uteroplacental insufficiency
fetal hypoxia
uterine tachysystole
decreased placental blood flow
maternal hypotension
abruptio placenta
medication effect
Management of late decels:
- left lateral position
- fluid bolus
- O2 at 10 LPM
- attempt to correct underlying cause
- consult with MD
What is intermittent fetal monitoring?
Intermittent FHR auscultation by fetoscope or doppler
Who should use intermittent fetal monitoring?
Low-risk pregnancies
For low-risk women, intermittent auscultation is equivalent to continuous fetal monitoring to detect fetal compromise
What is the frequency of auscultation for intermittent monitoring in first stage?
Auscultate 60 seconds after a contraction every 30 minutes if low risk; every 15 if high risk
What is the frequency of auscultation for intermittent monitoring in the second stage?
Every 15 minutes for low risk, every 5 minutes for high risk
listen before, during and after contraction
Who needs continuous fetal monitoring?
high-risk pregnancies
when IA is not indicated
How often does FHR tracing need to be reveiwed in 1st stage?
every 15 minutes
How often does FHR tracing need to be reviewed in 2nd stage?
EVERY 5 minutes
What are the modalities for continuous FHR monitoring?
External - u/s detection and tracing of the FHR through the abdominal wall
Internal - via FSE, used when can’t monitor externally –> directly measures fetal HR by measuring the R to R interval during heartbeats
What is a category I FHR tracing?
Meets the following criteria:
- normal baseline
- moderate variability
- Absent late or variable decels
- Early decels can be present or absent
- accelerations can be present or absent
What are the implications of a cat I FHR tracing?
Normal tracing: associated with normal acid-base balance
What is a cat II FHR tracing?
basically everything that is not I or III category
Can include the following:
- baseline rate of either bradycardia or tachycardia
- minimal, absent with no recurrent decelerations
- marked variability
- no accelerations despite fetal stimulation
- recurrent variable decelerations with minimal or moderate baseline variability
- prolonged decels between 2-10 min
- recurrent late decels with moderate baseline variability
- variable decels that have overshoots or shoulders
What are the implications of a category III FHR?
Indeterminate tracing, not predictive of fetal acid-base status - requires continued monitoring and evaluation.
What is a category III FHR?
Abnormal tracing
Characterized by by ABSENT FHR variability in conjunction with any of the following:
- bradycardia
- recurrent variable decels
- recurrent late decels
- sinusoidal pattern
What are the implications of cat III FHR tracing?
associated with abnormal fetal acid-base status, prompt corrective action is required
Fetal Scalp Stimulation
The validity and reliability of this IS NOT well established.
During vaginal exam, fetal head is stimulated - expect FHR accel of > 15 beats x > 15 seconds
This correlates to fetal pH of 7.20 or more
cannot be reliably performed during decel or bradycarida, need to wait for fetal recovery
What is the most common position of birth for fetus?
Left occiput anterior (LOA)
What are the cardinal movements of labor?
(1a) Engagement: biparietal diameter of the fetal head passes through the pelvic inlet
(1) Descent: occurs secondary to forces of uterine contractions; change in the tone of pelvic musculature and maternal pushing –> usually in the LOT position if engagement occurs during labor with rotation to LOA
(2) Flexion: Occurs when fetal head meets the resistance of the pelvic floor during descent and forces the smaller suboccipitobregmatic diamerter to enter pelvis first –> vertex begins partially flexed, and is completely flexed when reaches the pelvic floor: this changes presenting diameter to suboccupitobregmatic of 9.5cm
(3) Internal rotation: causes the fetal head to rotate to the AP diameter of the maternal pelvis, most commonly to OA –> rotation of 45 degrees to OA, which allows the head to maximize the AP diameter of the gynecoid pelvis
(4) Extension: Mechanism by which the birth of the fetal head occurs, the fetal head follows the curve of carus, the suboccipital region of the fetal head pivots under the maternal pubic symphysis fulcrum of the neck under the symphysis pubis allows birth of the head
(5) Restitution: Rotation of the head 45 degrees and realignment to the shoulders –> vertex rotates 45 degrees as the shoulders begin entering the AP diameter
(6) External rotation: occurs as the shoulders rotate 45 degrees, bringing the shoulders into the AP diameter of the pelvis and the head also rotates 45 degrees –> as head rotates another 45 degrees, shoulders complete the remainder of the rotation to allow delivery in direct AP diameter
(7) Birth of the body occurs by lateral flexion of shoulders via curve of carus
What is the incidence of an OP presentation?
15-30%
More common in android and anthropoid pelvis
Approximately 90% of OP presentations rotate to OA via long arc of 135 degrees (ROP to ROT to ROA) vs short arc rotation rotation of 45 degrees, which results in direct OP position
What is the second stage of labor?
begins with complete dilation and ends with birth of infant
Vital signs in the second stage: BP
BP should be taken every 5-15 min between ctx
BP can be elevated by 10 b/c of pushing efforts
Vital signs in second stage: Pulse and respiration
should be taken every 5- 15 minutes
Vital signs in the second stage: temp
take every 2 hours with intact membranes, every 1 with ruptured membranes
Why should IV or oral fluids be encouraged in 2nd stage?
- increased metabolism
- increased respiratory efforts and hyperventilation of transition
- diaphoresis
- n/v
Why should you monitor bladder status in the second stage?
- bladder distention can compromise pelvic capacity
- inability to void may require catheterization
- prevent problems by having client void (or cath them) when full dilation approaches
Open glottis vs closed glottis pushing
closed glottis valsalva pushing can decrease cardiac output and blood flow to the uterus –> it is associated with more FHR decels and a higher incidence of perineal trauma
What to do when crowning?
mom should pant at time of crowning, slow the expulsion of the head to prevent tearing
control the mother, not the head
What are indications for episiotomy?
- need to expedite birth secondary to fetal bradycardia
- anticipation of shoulder dystocia
- operative birth
- short perineum
How often to monitor FHR in second stage?
usually q 5 min or after each ctx
at least q 15
When should opioid analgesia NOT be given during labor?
Do not give within 1 hour of birth - can cause respiratory depression in fetus
How does epidural analgesia affect the second stage?
It lessens pain, and pressure sensations of second stage
can lengthen second stage secondary to pelvic musculature relaxation and decreased pressure sensation
What is a pudendal block and what does it do?
lidocaine 1% up to 10 mls on each side that provides a dense nerve block to the perineum
- does not inhibit pushing efforts
Should be timed for best anesthetic effect:
- primipara: when vertex is at 2+
-multipara: shortly before complete dilation
When do you use perineal infiltration of lidocaine?
usually 1%, max 30 mls
prior to episiotomy
for repair of lac or episiotomy
What 2 muscle groups make up the pelvic floor?
levator ani
coccygeus
What muscles make up the levator ani?
Pubococcygeus
Iliococcygeus
What is the perineal musculature?
It is more superficial to the pelvic floor muscles:
Anteriorly - urogenital triangle: superficial transverse perineal muscle, ischiocavernosus muscle, bulbocavernosus muscle, deep transverse perineal muscle
Posteriorly: anal triangle: sphincter ani axternus, anococcygeal body
What factors interfere with perineal integrity?
- size of fetus
- distensibility of perineum
- Control of expulsive efforts
- operative delivery modalities (forceps, vacuum)
- OP position
- use of lubricants
- maternal position for birth
- episiotomy
Strategies to minimize perineal trauma:
(1) Antepartum perineal massage, starting 36-37 weeks, which increases elasticity and maternal tolerance to perineal stretching
(2) External perineal massage from the time of perineal distension, BUT vigorous massage and stretching of the perineum in the second stage of labor has NOT been shown to be effective and may actually predispose the woman to an increased risk of laceration!
(3) Warm compress during second stage - increases circulation to perineum, promotes elasticity, assists in relaxation of the musculature
(4) lateral positioning for birth
(5) counter-pressure to maintain flexion of the fetal head in birth
(6) education of mother regarding importance of controlled delivery of head
(7) support of the perineum at the time of birth (controversial, some providers prefer a HANDS OFF technique)
What is an episiotomy?
surgical incision performed to enlarge the vaginal opening to allow delivery of fetal head
What is a median episiotomy and what muscles are cut?
Cut down middle of perineum, may increase likelihood of tearing into anal sphincter
- bulbocavernosus
- ischiocavernosus
- superficial and deep transverse perineal muscles
What is a mediolateral episiotomy?
cut at 45 degree angle from base of the introitus to the right or left, angle of incision aimed to ischial tuberosity
- decreases liklihood of tearing into anal sphincter
- harder to repair and heal
- used esp when patient has a short perineum to avoid anal sphincter injury
What is a first degree laceration:?
involves the vaginal mucosa, posterior forchette, perineal skin
NO MUSCLES
What is a second degree laceration?
involves same structures as first degree: vaginal mucosa, posterior forchette, perineal skin, PLUS perineal muscles
What is a third degree laceration?
Same structures as second degree: vaginal mucosa, posterior forchette, perineal skin, perineal muscles, PLUS the rectal sphincter involvement (could be just a little or all the way
What is a fourth degree laceration?
Same structures as third degree, plus tearing of rectal mucosa
What should 3-0 suture gauge be used for?
vaginal mucosa
subcutaneous tissue
subcuticular tissue
What should 4-0 suture gauge be used for?
periurethral
periclitoral
anterior wall of rectum
FINE REPAIRs
What should 2-0 suture gauge be used for?
areas requiring more tensile strength:
vaginal wall lac
cervical lac
deep interrupted sutures for repair of pelvic musculature
Steps for repair of a second-degree laceration:
- Inspect tissue to assess depth and extent of lac
- begin repair approximately 1 cm above apex of lac into vaginal mucosa
- close the mucosa using continuous locked stitches to the level of the hymenal ring
- pass needle under the hymenal ring and continue using unlocked (blanket) stitches to the level of the bulbocavernosus
- repair bulbocavernosus iwth a crown or deep interrupted suture with 2-0
- if lac is deep, consider several deep interrupted stitches using 2-0
- using 3-0 suture again repair subcutaneous layer with continuous stitching to the perineal apex
- using mattress stitches perform subcuticular closure
- at level of hymenal ring, bury the suture and tie it off!
Ritgen maneuver
assistance, if needed, in delivering the fetal head by applying upward pressure to the fetal chin through the rectum during extension
Is routine bulb suctioning required?
NO
What is the third stage of labor?
Begins with the delivery of the infant and ends with delivery of the placenta
Why is active management of the third stage of labor recommended?
To decrease risk of PPH
What are the 3 components of active management of the 3rd stage?
- Controlled cord traction (once pulsation stops)
- Use of uterotonic agent (like oxytocin)
- fundal massage after delivery of placenta
How much oxytocin should be given as prophylaxis?
- 20-40 units in 1000 mLs of IV fluid (NS or LR), with first liter running rapidly, second liter at 150 mL/hr, can use up to 40 units per liter
- NEVER GIVE oxytocin as an undiluted bolus
- 10 units IM if no IV access
How long is the third stage?
5-30 minutes
Why does the placenta separate?
placenta separates from the uterine wall due to change in uterine size –> hematoma forms behind the placenta along the uterine wall –> separation completes and descent of placenta and explusion follows
S/s of placental separation
- sudden increase in vaginal bleeding
- lengthening of the umbilical cord
- uterine change in shape from discoid to globular
- uterus rises in abdomen
Schultz
placenta presents at introitus with fetal side showing
more common than duncan
separation is thought to occur centrally first
majority of bleeding contained
duncan
presents at introitus with maternal side showing
less common than shultz
separation occurs initially at placental margin
bleeding is more visible
higher incidence of hemorrhage d/t incomplete separation of placenta
How to deliver the placenta?
- obtain cord blood after delayed cord clamping and inspect cord for # of vessels
- Guard the uterus while waiting for placental separation: NO fundal massage or traction on cord prior to separation!
- when separation has occurred, use brandt-andrews maneuver to stabilize the uterus and controlled cord traction to deliver the placenta
- may have the mother push to assist expulsion
- deliver placenta via the curve of carus
- if membranes are trailing behind the placenta, carefully delivery membranes: can use kelly clamp to clamp onto membranes and gently apply lateral/outward traction OR you can twist the placenta
ALWAYS inspect the placenta/membranes for COMPLETENESS after delivery
What tests are run on cord blood?
- cord gasses, prn
- always fetal blood type and Rh
- direct coomb’s test –> sees if there are antibodies on baby’s RBC
What tests are run on maternal blood after 3rd stage?
Kleihauer-Betke test if mother is Rh negative - screens maternal blood for fetal RBCs, used to assess severity of feto-maternal hemorrhage: + test is when there is fetal blood in maternal circulation, allows appropriate dose of Rhogam
CBC if hemorrhage is suspected
Methergine (Methylergonovine)
What is it?
When to use it?
Who is it contraindicated in?
What is admin/dosing?
What: causes a sustained, tetanic uterine contraction
When: can be used emergently as one-time dose or as a series of doses for sustained effect
Contraindication: HTN b/c peripheral vasocontstriction
Admin/dose:
- 0.2 mg IM, can be repeated once in 5 minutes, and then every 2-4 hours thereafter
- 0.2 mg PO q 6 hours, generally given as a series of 6 doses over the first 24 hours pp
Misoprostol
What is it?
When to use it?
Admin/dose?
Side effects?
What: synthetic prostaglandin
When: PP hemorrhage
Admin/dose: 600-1000 mcg per rectum is usual dose
Side effects: shivering, fever, diarrhea, abdominal pain
Hemabate (15-methyl-F2alpha prostaglandin)
What: synthetic prostaglandin
When: hemorrhage
Admin/dose: 0.25 mg IM (250 mcg)
Contraindications: asthma or active cardiac, pulmonary, renal, hepatic disease
Battledore placenta
peripheral cord insertion, at placental margin
Succenturiate lobe
- Most common abnormality (3%)
- Accessory placental lobe within the fetal sac that had continuous vascular connections with the main placenta
- can cause retained placenta or hemorrhage
Velamentous cord insertion
- cord insertion into fetal sac, not directly into placental bed, generally 5-10 cm away from placenta
- Can cause shearing of blood vessels during labor or delivery of placenta –> hemorrhage
- more common in multiple gestations
Circumvallate placenta
opaque ring of fibrous appearing tissue on the fetal side of the placenta, caused by a double layer of chorion and amnion
- Can be seen in IUGR pregnancies, but usually no clinical significance
What is the significance of 1 min APGAR score
reflects initial stabilization
What is the significance of 5 minute apgar score?
has relationship to neonatal morbidity and mortality
< 7 –> need for pediatric/neonatal involvement
less than 4: correlates with neonatal mortality
What is premature labor?
onset of regular uterine contractions between 20-37 weeks gestation with spontaneous ROM OR progressive cervical change
What is premature birth?
delivery before 37 weeks
what is very preterm birth?
< 32 +0
what is moderately preterm birth?
32+0 to 33+6
what is later preterm birth?
34+0 to 36+6
What is term birth?
Birth between 37 and 42 weeks
what is early term?
37+0 to 38+6
what is full term?
39+0 to 40+6
what is late term?
41+0 TO 41+6
what is post term?
42 weeks and beyond
Small for gestational age?
birth weight less than 10th percentile for gestational age; corresponds to IUGR
What causes premature labor and birth?
idiopathic and multifactorial; in most cases the cause of premature labor is unknown
What maternal factors increase the risk of PTB/PTL?
- Systemic diseases:
- HTN disorders of pregnancy: gestational htn, chronic htn, PEC, chronic htn with superimposed PEC
- renal disease
- Autoimmune disease
- infection - Structural uterine abnormalities
- mullerian defects
- fibroids - Overdistended uterus
- polyhydramnios
- multiple gestations - cervical insufficiency
- Hx of premature labor/birth
- low socioeconomic factors
what fetal factors increase the risk of preterm labor and birth?
PPROM
fetal anomalies
placental insufficiency
s/s of preterm labor?
- menstrual-like cramping with increasing frequency and intensity
- pelvic pressure, esp suprapubic
- backache, esp. low backache
- passage of amniotic fluid
- change in character of vaginal secretions
- bloody show/spotting
- progressive cervical dilation
What are physical findings of PTL?
- uterine contractions as documented by EFM or palpation
- cervical dilation on digital exam
- documented ROM
Differential Dx for preterm labor?
- UTI/pyleonephritis
- round ligament pain
- braxton hicks contractions
- renal colic
- appendicitis
Diagnostic tests to consider with evaluating possible PTL?
- fern and/or nitrazine test if suspect ROM
- UA with culture and sensitivity
- other tests for suspected infection: GC/CT, wet prep
- Fetal fibronectin: collect before digital examination; recent sexual activity or blood may affect results
- u/s: cervical length and funneling, placental location and status, BPP/AFI
- amniocentesis: fetal surfactant and lecithin/sphingomyelin ratio (L/S) ratio
- CBC with diff
Management of PTL:
consultation with MD regarding need for transfer of care vs co-management
NONPHARM: hydration, left-lateral bed rest
PHARM:
- Tocolysis: generally used to delay birth > 48 hours, which allows steroids to hasten lung maturity
- GBS prophylaxis
- corticosteroids
- MgSO4 for neuroprotection (< 32 weeks)
What are the contraindications for tocolysis in the management of PTL?
Any conditions creating a hostile uterine environment:
- placental abruption
- chorioamnionitis
- severe PEC
- Placenta previa
- cat III FHR tracing
- lethal fetal anomalies
- IUGR without interval growth
Calcium channel blockers
Nifedipine - most effective tocolytic
MOA: non-specific smooth muscle relaxant - prevents influx of extracellular calcium ions into myometrial cells; effect not specific to uterus
SEs: maternal hypotension, flushing, n/v
Drug interactions: beta agonists, MgSO4
Contraindications:
- DO not use in presence of intrauterine infection, maternal hypertension, cardiac disease
- do not use with MgSO4 or beta agonists
Admin/dosing:
- PO, initial dose is 10 mg PO, if contractions continue repeat doses every 20 minutes for total of 30 mg in 1 hour
- once contractions decrease, may give 10 mg every 6 hours or 30-60 mg sustained release per day
Magnesium Sulfate (MgSO4)
MOA: acts on vascular smooth muscle, causing vasodilation
SEs: flushing, palpitations, feeling of warmth, lethargy, muscle weakness, dizziness, n/v, respiratory depression, pulmonary edema
Drug interactions: calcium channel blockers
Contraindications:
- DO NOT USE with calcium channel blockers
- toxic effects at serum level of more than 7 mg/dL
- Antidote is calcium gluconate
Admin/dosing
- Generally IV, can be given IM
- Loading dose 4-6 grams in 10 0mL IV fluid over 20-30 minutes
- Initial maintenance dose 2 g/hr
- If contractions continue, increase by 0.5 g/hr every 30 minutes to a max dose of 4g/hr
- Maintain at effective level for 12-24 hours after contractions stop
- NO benefit to weaning when discontinued
What meds are given for GBS prophylaxis:
Penicillin 5 million units IV followed by 2.5 million units every 4 hours until delivery
IF PCN allergy:
- clinda or vanco
Why give corticosteroids in PTL and how much to give?
Why: stimulates fetal lung maturity
What: betamethasone 12 mg IM in 2 doses 24 hours apart, OR Dexamethasone 6 mg IM every 12 hours for 4 doses
should attempt to delay birth until 24 hours post administration
What is umbilical cord prolapse?
Umbilical cord lies below or beside the presenting part; danger is compression of the umbilical cord, which then comprises blood supply to the fetus –> emergency
- can occur with ROM when presenting part is doesn’t fill inlet
- especially during AROM in someone with poly or if presenting part is not well applied with AROM
s/s of umbilical cord prolapse:
- umbilical cord visible at or outside of the introitus
- palpation of cord during vaginal examination
- presumptive dx of prolapse if prolonged fetal heart rate deceleration occurs immediately following ROM
Management of umbilical cord prolapse?
- elevate presenting part off cord by continuous vaginal examination
- Assist mom into knee-to-chest position OR steep trendelenburg
- Do not attempt to manipulate the cord, as this may cause cord spasm, if it is protruding, wrap loosely with warm, NS soaked gauze
- DO NOT rely on cord pulses as indicator of fetal status, obtain u/s if unable to detect fetal heart tones
- immediately alert MD and other staff of emergency
- d/c oxytocin if applicable
- provide O2 at 10 L/min
- Administer IV fluid bolus
- Monitor FHR
- Consider terbutaline for tocolysis
- prepare for cesarean birth
What is placenta previa?
when the placenta is located over or very near the internal os:
- complete previa: placenta completely covers the cervical os
- partial placenta previa: cervical os partially covered by placenta
- marginal previa: edge of placenta within 1 cm of os
Risk factors ofr placenta previa:
- increased parity
- AMA
- previous c/s
- multiple gestation
S/s of placenta previa
PAINLESS vaginal bleeding during 3rd trimester OR can present as bleeding with contractions
- mostly diagnosed before hallmark bleed by u/s
Physical findings with placenta previa?
ONLY U/s
DO NOT perform a digital vaginal exam with placenta previa
Differential dx of placenta previa
placental abruption
Diagnostic testing for placenta previa
ultrasound
Management of previa
- Acute bleeding requires c/s, otherwise depends on severity of symptoms and gestational age
- hospitalization usually indicated
- nothing in vagina
- RhoGAM for Rh-neg mom
- needs to be delivered by c/s
What is placental abruption?
premature separation of the placenta from the uterine wall before delivery of the fetus
Risk factors for placental abruption
- Maternal HTN
- Severe abdominal trauma
- sudden decrease in uterine volume, such as ROM with poly or multiple gestation
- cocaine use
- tobacco use
- previous abruption
s/s of placental abruption
PAINFUL vaginal bleeding with a complete abruption
uterine rigidity
shock
less complete abruptions have less severe presentations, bleeding can be concealed
Differential diagnosis for placental abruption
previa
Diagnostic testing for placental abruption
u/s to rule out placenta previa, u/s not very sensitive for an abruption
Management for a complete placental abruption
- notify MD
- insert 2 large-bore IV catheters
- prepare for immediate cesarean birth
- obtain blood type and cross-match for blood products, including clotting factors
- trendelenburg position
- O2 at 10 L/min
- monitor fetal status
Management for partial placentalabruption
- IV access
- monitor fetal status
- preparation in event that immediate surgical intervention is required
What is a shoulder dystocia?
difficulty in delivery of the shoulders secondary to anterior shoulder becoming impacted on the pelvic rim
Risk factors for shoulder dystocia
GDM
Hx macrosomic babies
maternal obesity
increased weight gain in pregnancy
small, abnormal, contracted pelvis
history of shoulder dystocia
estimated fetal weight 1 lb larger than previous babies
what maternal morbidity is associated with shoulder dystocia?
extensive vaginal and perineal lacerations
what is the fetal morbidity associated with shoulder dystocia?
- fractured clavicle
- brachial plexus injury
- hypoxia/anoxia
- fetal death
what are the s/s of a shoulder dystocia?
- turtle sign = the immediate retraction of the fetal head against the perineum after extension
- delayed restitution or need for facilitated restitution without descent
- inability to deliver the anterior shoulder with usual traction effort
How to manage shoulder dystocia
- State: I have a shoulder dystocia, get help into room (additional RNs, MDs, anesthesia, peds)
- Instruct client to stop pushing until a maneuver has been successful
- McRoberts (place mother in exaggerated lithotomy)
- Apply suprapubic pressure (NOT FUNDAL PRESSURE) while exerting downward traction on baby’s head while mom is pushing in mcroberts
- wood’s screw - Attempt to rotate shoulders to oblique; repeat McRoberts and suprapubic pressure –> insert a hand on either side of the fetal chest and attempt to rotate shoulders out of the AP diameter
- Deliver the posterior arm (insert hand behind the posterior shoulder, splint arm and sweep across abdomen and chest until hand can be grasped externally)
- try gaskin maneuver - H+K –> can be difficult with an epidural
- break the anterior clavicle - place thumbs along the clavicle, controversial b/c risk is possibly puncturing lung or the subclavian vessels
- Zavanelli maneuver: rotate/flex the head while replacing fetus in pelvic cavity, followed immediately by c/s: controversial/last resort associated with sig risk of infant morbidity and mortality
may need to cut an episiotomy for more room to maneuver
Breech delivery
Delivery of infant presenting with buttocks, feet, or knees
The elective vaginal delivery of singleton infants in the breech presentation is not recommended by ACOG. The vaginal delivery of s singleton breech presentation is usually reserved only for breeches that present emergently and when breech is inevitable
Complete breech
legs and thighs are flexed with buttocks presenting
Frank breech
Legs extended on abdomen with flexed thighs and buttocks presenting
most common type of breech
Footling breech
one or both feet presenting
knee presentation
single or double knees are presenting
most rare
Incidence of Breech presentation
Term: 3-4%
At 28 weeks, 25% of all fetuses are breech
Most convert to cephalic by 34 weeks
Maternal Breech risk factors
- gestational age
- fibroids
- uterine anomalies
- abnormal placentation: previa, cornual fundal implantation
- oligo or polyhydramnios
Fetal breech risk factors
- congenital anomalies: 3x risk in anomalies with breech
- short umbilical cord
Risks of breech
- cord prolapse (1.5% frank breech, 10% of other breech)
- traumatic vaginal delivery because the largest part of the fetus is delivered last –> head entrapment causes injury to organs, brain, skull
- increased perinatal morbidity and mortality
Management of Breech
- Vaginal breech birth is a co-management situation
Criteria for breech birth:
- frank breech
- EFW 2500-3800 g
- flexion of fetal head
Requires:
- continuous fetal monitoring
- IV access
- Oxytocin is not recommended for protraction, c/s instead
- generous episiotomy
- empt bladder prior to second stage
- should deliver in a room set up as OR
Delivery sequence for partial breech extraction
- “hands off breech” until body is born to umbilicus
- second provider should maintain head flexion through the abdominal wall during entire descent
- pull down loop of cord
- from this point on, the mother is instructed to push continuously
- If the legs have not delivered spontaneously, they should be gently guided out of the vagina
- Apply downward traction with the hands to the baby’s hips, with thumbs in the sacroiliac region, to encourage delivery of the anterior scapula
- attendant delivers anterior arm by moving hand up infant’s back and over the top of the anterior shoulder, sweeping the arm down across the chest and under the pubis with attendant’s finger
- raise the infant so the posterior arm can be delivered in the same manner
- The back should spontaneously rotate anteriorly, DO NOT let head rotate to OP
- Employ the Mauriccea-Smellie-Veit maneuver to maintain flexion of the head
- with the dominant hand palmar side up, place the index and middle fingers on either side of the nose on the maxilla, with the chest and body resting on the palm and the legs straddling the forearm
- place the other hand on top of the baby, with index finger on one side and the middle finger on the other side of the neck extending over the shoulder for traction - apply downward traction until the suboccipital region (the hairline) is seen coming under the pubic symphysis
- Now apply upward traction while elevating the body to deliver the head via the curve of carus
face presentation
cephalic presentation with attitude of the head in complete extension, with the occiput proximal to the spine, usually begins labor as brow presentation
- if mentum is not anterior, it may not be able to pass under the pubic symphysis
- mentum posterior is contraindicated for vaginal birth
- during vaginal exam, facial landmarks can be palpated
- consult with MD, peds at birth
Twin gestation
multiple gestation with 2 fetuses in the uterus, ALWAYS collaborative management
monozygotic twins
zygotic division between days 4 and 8
- identical twins
- one placenta
- generally one chorion, two amnions
Dizygotic twins
- fraternal twins
- two placentas
- two chorions
- two amnions
Amnion
innermost membrane closest to baby
Chorion
outermost membrane closest to the placenta
Predisposing factors for twins
family hx
ovulation induction/IVF
Sub-saharan African descent
Diagnosis of twins
size > dates
auscultation of more than one fetal heartbeat
abnormal leopold’s
ultimate dx is u/s
Morbidity associated with twins
premature labor and birth
PPROM
Malpresentation of second twin
cord prolapse
operative delivery for second twin
SGA and IUGR
twin to twin transfusion
Management of twin gestation
- MD collaborating for IP decisions and birth
- u/s confirmation of presentation
- IV catheter
- blood type and screen on admission
- continuous EFM
- anesthesia, peds at birth
- u/s in delivery room
- empty bladder before pushing
Management of twin birth
- birth of first twin in usual fashion, if nuchal is present, DO NOT clamp and cut the cord
- upon delivery, clamp cord and transfer baby to pediatric team
- assistant can guide second twin into pelvis depending on presentation (confirm presentation on u/s), timing of delivery depends on fetus status
- oxytocin can be used for augmentation if contractions do not resume for second twin
- birth of second twin
- observe for PPH
Retained Placenta
placenta that has not separated from uterine wall after 60 minutes
Predisposing factors for retained placenta:
- PTB
- chorioamnionitis
- prior c/s
- placenta previa
- grand multip
Cause of retained placenta
- structurally abnormal uterus
- abnormal placentation - incidence has increased with increasing c/s: placenta increta, placenta increta, placenta percreta
Placenta acreta
adherence of myometrium due to partial or total absence of decidua
placenta increta
further extension into the myometrium with penetration into the uterine wall
placenta percreta
futher extension through the uterine wall to the serosa layer
Management of retained placenta
Facilitate usual methods of placental separation:
- allow baby to nurse
- assist mother into squatting position
- empty maternal bladder
If 3rd stage is more than 30 minutes, consider placenta retained and notify MD
Management in prep for consulting MD:
- monitor for bleeding or shock
- Insert IV if none in place
- prepare mother for manual placenta removal
- notify anesthesia
Chorioamnionitis definition
Intrauterine infection or inflammation of the amniotic sac, amnion, chorion
Risks for chorio
prolonged ROM
long labor
manipulative vaginal/intrauterine procedures
frequent digital cervical exams, esp once ruptured
Dx for chorio
can only be made after birth via histological exam of placenta or amniocentesis
tx for chorio
ampicilin and gentamicin
give PO tylenol for fever
Suspected chorio diagnosis
Maternal oral temperature >/= 102.2 (39) on any occasion
OR
Maternal fever >/= 100.4 (38) plus any one of the following 3 criteria:
- baseline fetal tachycarida (> 160 x 10 min or longer)
- maternal WBC count > 15,000 per mm3 in absence of corticosteroids
- definite purulent fluid from cervical os (can’t tell if membranes in tact
S/s chorio
fever
fetal tachycardia
maternal tachycardia
uterine tenderness
malodorous fluid
