Intrapartum Flashcards
Old meconium in labor
significance
It’s a yellow tinge
Evidence of a brief episode of hypoxia much earlier in labor or the days preceding it
Breech
predisposing factors
Prematurity multiple pregnancy Polyhydramnios high parity:lax uterus fetal anomalies: hydrocephaly, anencephaly uterine anomalies: bicornate short cord/ baby tangled in cord
In labor
fresh meconium
significance
Particulate and green or brown like pea soup
Indicative of recent or current fetal distress
Immediately listen to fetal heart tones for several contractions and unless the sounds perfect consider transport
Which episiotomy cut is said to be the best in regards to healing the fastest
Midline
Contractions ____ minutes long, coming every ____minute signal the onset of active labor
1min long
Every 5 min
Hind leak
A gush of amniotic fluid caused by a high tear in the membranes, which releases enough fluid to allow the baby to settle snuggly down in the pelvis so that any further flow is prevented
During labor her pulse should stay within ____to____points of her normal range
10to 15
Face/brow presentation
management
Prepare for a imminent birth determine position of chin prepare resuscitation equipment prepare treatment for newborn bruising/swelling administer Arnica position the mother in a squat prepare for for potential eye injury
Explain how a C-section done before 28 weeks without labor affects the safety of subsequent vaginal births
Sinu you the lower uterine segment is poorly developed in early gestation, a C-section done before 28 weeks involves the corpus muscles mass, even with a low transverse incision
Safety of subsequent vaginal birth is questionable especially without labor prior
Most common cause of third stage hemorrhage
reason
Partial separation of the placenta
Mismanagement third stage, usually involving uterine massage prior to placental separation
Conditions that predispose to third stage hemorrhage
And infectious process with a high temp during pregnancy increases placental adherence Intrauterine infection disease of the fetal membranes previous C-section partial placenta accreta
Causes/reasons for death with a breech birth
Head entrapment and hypoxia
premature placental separation
For what condition is the lithotomy position for delivery contraindicated
Severe varicosities
Factors in the decision to use an enema during labor
Station/location of presenting part should be engaged/below ischial spines
Membranes ruptured? Best when intact
Complications? Contraindications vaginal bleeding, placenta previa, PTL, breech, preeclampsia
Five times when vaginal exam is indicated in labor
On admission as baseline
before deciding on the kind, amount, root of medication
Verify complete dilation
After spontaneous rupture of membranes to rule out prolapsed cord if suspected
To check for prolapsed cord if fetal heart tone decelerations are not improving with the usual maneuvers
Four factors to consider when deciding to catheterize a woman in labor
The discomfort of the woman
whether the bladder needs emptying, is it distended, has she peed in the last two hours, fluid intake
Risk of bladder infection
Anticipating potential complication: postpartum hemorrhage, shoulder dystocia
Management of meconium stained fluids
Asses degree of Meconium
Prepare to resuscitate baby
instruct the mother to stop pushing after delivery of the head
clear the airway with section of mouth and nose
When is cord traction appropriate
You must first make sure it is fully separated by gently following the cord to the cervical os
Only if It is right behind the os or in the vagina, you may use controlled cord traction to remove it
What’s the cardinal rule for handling a postpartum hemorrhage
Determine the cause of bleeding before taking action
Bloody show is a sign of eminent labor, which usually takes place within
24 to 48 hours but it is not of value if a vaginal exam has been done in the last 48 hours
History that should be obtained from a woman with a previous C-section
Weeksgestation at time of C-section type of C-section reason for c-section Length of labor cervical dilation at time of delivery physical exam describe abdominal scar pelvic exam
Molding
definition
diagnosis
management
Definition change in shape of the head. Shape of the head depends on the presentation
If cephalic:overriding of the parietal bones over the occipital bone’s involves the entire skull
Lightning occurs about ____ _____before labor for a primip
The baby’s head is usually____ afterwards.
definition
2 weeks
Engaged
Definition the descent of the presenting part of the baby into the true pelvis
result of increasing intensity of BH contractions and good abdominal muscle tone
Significance of ketones in labor
To screen the woman for maternal exhaustion and distress inclusive of dehydration, electrolyte imbalance, and nutritional deficiency
Ketonuria indicates the need for an IV
Describe the significance of the ferning pattern
Ferning, a.k.a. arborization, is caused by the presence of sodium chloride and protein in the amniotic fluid
more reliable than nitrazine
Amniotomy
midwife should observe these principles
Before between contractions so: a. Force behind rupture is reduced b. Membranes looser against fetal head
Use an instrument that can be effective quickly and easily
After rupture of membranes leave fingers in through a contractio to check the effect on cervix and fetus and for prolapsed cord
Fetal heart tones during and after to monitor the effects on the fetus
What is the most crucial reason for charting emesis amount
To watch for HELLP syndrome or other extreme medical conditions
During labor fetal heart tones should be evaluated
Every 30 minutes during active labor
Also with rupture of membranes
after expulsion of an enema
with any sudden change in contraction or labor pattern
after giving medication and again after its peak action
any indication of a developing complication
Superficial perineal muscles
names and functions
Superficial transverse perineus: helps stabilize central tendon of perineum
Bulbospongiosus: helps propel urine
constricts vaginal orifice
assists in erection of clitoris
Ishiocavernosus: maintains direction of clitoris
Friedman labor curve
In 1955, Friedman depicted the progress of labor as a sigmoid curve and subdivided the active phase into three sequential phases acceleration, maximum slope, and deceleration
Deviation from this curb is not abnormal
progress is most important
Acidemia
Increase concentration of hydrogen ions in the blood
Hypoxemia
Decreased O2 content in the blood
Hypoxia
Decreased level of o2 in tissue
Caput Succedaneum
Definition
diagnosis
management
Definition: formation of edematous swelling over the most depended portion of the presenting fetal head
Caput crosses suture lines as a generalized swellin
Indicates a prolonged labor with pressure on the fetal head
Percent of women that enter labor with a breech presentation
3.0-3.5%
A fetus in a breech presentation with both limbs flexed is a _______presentation
Complete
What percentage of babies are in breech presentation immediately before labor
3-4%
Situations that may require a consent or waiver during IP, third or fourth stages
Vaginal exam artificial rupture of membranes GBS anabiotic's use of Doppler who should be in room IV use enema Pitocin Methergine O2 Catheter transport breast-feeding suturing lidocaine
Three planes of obstetrical significance in the true pelvis
Inlet
midplane
outlet
Purpose of superficial perineal muscles
Help stabilize central tendon of perineum
helps propel urine
constricts vaginal orifice
The five bones of the pelvis
Coccyx sacrum ilium ischium pubic bone
What is the smallest pelvic diameter to which the fetus has to accommodate itself
That interspinous diameter
Define anesthesia and analgesia
Anastasia takes away all feeling
analgesia takes away pain
Differentiating between monozygotic and dizygotic twins
Two amnion, two chorion, two placenta
either mono or dizygotic
Two amnion, one chorion, one placenta
monozygotic
Dizygotic division occurred in first three days after fertilization
Mono division occurred between days 4 to 8 after fertilization
Trendelenburg position
Knee- chest
Explain the difference between amnionitis
and Chorioamnionitis
Amnionitis: inflammation of the amniotic sac and amnion
Chorio: inflammation of the chorion in addition
These conditions almost always coexist
During second stage, pressure of the lumbosacral nerve plexus can cause
is resolved by
Muscle cramps in the leg
resolved by extending the leg and dorsiflexing the foot
Internal versus external os
If there is a discrepancy between the dilation of the internal and external os the official dilation is of the inner os
In a client with premature rupture of membranes at 32 weeks with no current signs of infection, what is the most appropriate management plan
Watchful waiting and allowing pregnancy to continue for as long as possible because the risk of prematurity outweighs the risks of sepsis
The Sims position is when the mother
Is left side lying
Diaphoresis
definition
Excessive sweating
Eutocia is defined as
A normal labor
When the fetal side of the placenta delivers first this is called
Shiny Schultz
What is the optimal birth weight range as demonstrated by studies of perinatal morbidity and mortality?
3500-3999
What is the best management for asymptomatic scar dehiscence that occurred during VBAC and that you discovered during a postpartum manual exploration of the uterine cavity for retained placental fragments
Nothing the defect will heal on its own
Leukocytosis
Elevated white blood count to 15,000+
Urogenital triangle includes
The external genitals, which include the labia, vagina, clitoris, urethra
Curve of Carus
The curve formed by the sacrum, coccyx, and pubic bones
Rhombus of Michaulis
definition
position
Kite shaved area of the lower spine with the points at the waist, coccyx, and sacroiliac joints
Has the potential to open dramatically and second stage, increase the front to back dimensions of the pelvis by several centimeters
Can only happen if mother is leaning forward with knees lower than hips and legs extended
Deep perineal muscles
name and function
Deep transverse perineus helps to expel last drops of urine
External urethral sphincter helps expel last drops of urine
External anal sphincter keeps anal canal and anus closed
Function of Levator Ani
Pubococcygeus and iliococcygeous
Supports and maintains position of pelvic viscera
Resists increased intra-abdominal pressure during forced expiration, coughing, vomiting, defecation, urination
Constricts anus, urethra, and vagina
Supports fetal head during birth
Birth in a face presentation is only possible if internal rotation brings the mentum into what position
Anterior
The fetal shoulders normally enter the true pelvis with the bisacromial diameter and what diameter?
Transverse
Oblique
Anteroposterior
Oblique
Average duration of third stage?
5-10 min
List three factors associated with intrauterine infection
Fetal tachycardia
a BPP score of six or less
a WBC count with a shift to the left
Condition which predisposes to the worst shoulder dystocia
Estimated weight of 1 pound or more than the woman’s largest previous baby
What is the most appropriate first step with a G1 PO at 38 weeks with no signs of labor but with the diagnosis of chorioamnionitis
Admit to the hospital for induced vaginal birth or C-section within 24 hours
Cephalic prominence
Felt during Leopold’s maneuver forth
the part of the head that is felt above the pubic bone
Why is VBAC a safe option for women with a low transverse scar
Any incision that pulls into the muscle mass of the uterine corpus or fundus increases the risk of rupture
Risk of rupture with low transverse scar: .19-.8%
Which is less then morbidity rates for a repeat C-section
Asphyxia
Hypoxia with metabolic acidosis
Plateau phenomenon
explain
how long is okay
When labor slows for maternal integration can occur at four, seven, or 9 cm. Each is a turning point in terms of a new sensation
Four from control to surrender
7 transition
9 bearing down urges disrupt relaxation
Explain nature of change several hours is okay as long as health and morale is okay
Complete breech
Babies hips and knees are flexed so that the baby is sitting cross legged with the feet beside the bottom
Footling breech
One or both feet come first with the bottom at a higher position
this is rare at term but relatively common with premature babies or second twin
During the first stage, in the absence of complications, heart tones should be taken every
30 minutes
Woods maneuver
Corkscrew maneuver for shoulder dystocia
Anterior shoulder pushed towards baby’s chest
Management for hypotonic uterine dysfunction
Decrease maternal stress in environment increase rest and fluid intake discuss fears and concerns ambulation hydrotherapy enema if appropriate rupture of membranes nipple stimulation Pitocin stimulation
Anemia at the onset of labor can lead to
Fetal distress incoordinate prolonged labor postpartum hemorrhage from tired uterus infection shock from moderate blood loss poor postpartum recovery
What causes lactation during late pregnant
fetal demise all the hormones have shifted as if the birth has taken place
What is the most accurate definition of prolonged rupture of membranes
Rupture of membranes more than 24 hours before delivery
Constriction of bandi’s ring
how to diagnose a labor
Feel with vaginal exam
possible uterine rupture
Ascent of presenting part with contraction
usually long labor
When should sedatives be used during labor
When the woman is in false labor
when the woman is in early labor and is exhausted and needs rest
treatment for hypertonic uterine dysfunction to stop the present labor with it’s abnormal gradient pattern
Situations when IV is indicated intrapartally
Gravida 5+ over distended uterus,for any reason history of postpartum hemorrhage maternal dehydration/exhaustion positive GBS maternal temp greater than 100.4
Fetal position
Position is the arbitrarily chosen point on the fetus for each presentation in relation to the left or right side of the mothers pelvis
Left or right side
Variety anterior, transverse, or posterior portion of the mothers pelvis
ROA, LOP, RMT, LAA
After starting an IV, a woman exhibit signs of cyanosis even in the presence of low flow oxygen most likely cause?
An air embolus
Prognosis for face presentation in the mentum posterior position
Arrest of descent
C-section baby cannot deliver vaginally
Must recognize immediately before impaction of the head occurs
Because length of the neck is half length of sacrum not possible for chin to escape from vaginal floor over perineum
Define shoulder dystocia
Cephalic presentation with the anterior shoulder is wedged above the symphysis pubis instead of entering the true pelvis
Kneeling breach
One or both legs extended at the hips but flexed at the knee
extremely rare
Breech presentation types
Frank
complete
Footling
Identifying face presentation
Abdominal palpation; occiput becomes the cephalic prominence and is located on the same side as the arched back of baby
Pelvic exam
may be able to feel both fontanelles clearly or only the anterior and head is hyperextended
landmarks of face will become evident
Fetal attitude
Characteristic posture determined by the relationship of the fetal parts to each other and effect this has on the fetal vertebral column. The attitude of the fetus varies according to its presentation
flexed
military
extended
Cephalic presentation types
4
Vertex (flexed)
sincipital (military)
Brow
face (extended)
Fetal lie
3
Lie is the relationship of the long axis of the fetus to the long axis of the mother there are three possible lies
longitudinal
transverse
oblique
Fetal presentation
3
Presentation is determined by the presenting part, which is the first portion of the fetus to enter the pelvic inlet. There are three possible
Cephalic
Breech
shoulder
Erythroblastosis fetalis
Isoimmunization, destruction to fetal erythrocytes ensues, followed by:
Severe fetal anemia
cardiac decompensation
eventual hydrops and possible fetal or early neonatal death(dependent upon the severity of the reaction)
A woman transported for FTP during pitocin augmentation, she suddenly complains of chest pains and has pink frothy sputum and diaphoresis this is an early sign of
Amniotic fluid embolism
With a VBAC what is the first indication of uterine rupture
Fetal bradycardia
Woman comes to the BC in labor, reporting that her water may have broken on the drive. What procedure would best determine if she has SROM
A fern test
Listening through contraction, the midwife notes that the fetal heart rate deceleration occurs during the increment of a contraction, reaches its lowest point at the Acme of the contraction, and returns to baseline during decrement of the contraction this type of decel indicates
Fetal vagal nerve stimulation
early decel
Head compression
Cause
Early decels
Late decels
Variable decels
Early: head compression
late: uteroplacental insufficiency
variable: cord compression
Fetal variety
Variety is the same arbitrarily chosen point on the fetus used in defining position in relation to the Anterior transverse posterior portion of the pelvis
Flexion
This is essential for further descent
Occurs when the fetal head meets with resistance, this resistance increases with descent and it’s first met from the cervix, then from the sidewalls of the pelvis, and finally from the pelvic floor
Acidosis
Increase concentration of hydrogen ions in the tissue
Quiet uterine rupture
S/s
Vomiting tenderness all over abdomen severe suprapubic pain hypertonic contraction no further progress and labor faintness eventually vaginal bleeding, signs of shock, loss of fetal heart tones
Episiotomy
Four principles to be observed
Presenting part of fetus is protected
a single cut is better than repeated snipping
the cut should be large enough to accomplish the purpose of cutting it the cut should be time to avoid lacerations and excessive blood loss
Perineum should be bulging and distended by at least a centimeter diameter of fetal presenting part between contractions
Deliver of presenting part should occur in the next 2 to 4 contractions
What is the best description of how uterine contractions differentiate the uterus in two segments
Upper zone of the uterus shortens and thickens the lower zone lengthens and thins
Curve of Carus
The lower exiting end of the pelvic curve
the fetus and placenta must follow this curve in order to be born
a curved cylinder
first downward from the axis of the inlet to just above the tip of the sacrum and then forward, upward, and outward to the vulvovaginal orifice
Respiratory alkalosis
definition
symptoms
cause
The amount of CO2 found in the blood drops to a level below normal. Causes a shift in the body’s pH balance and causes the body to become more alkaline
Brought on by hyperventilation
Defined the two types of umbilical cord prolapse
Frank: cord slips through the cervix
Occult: cord slips alongside presenting part but does not protrude through the cervix
Danger: fetal hypoxia from court compression
Deep transverse arrest
signs and symptoms
Sagittal suture is transverse in mothers pelvis
development of second stage hypertonic uterine dysfunction extensive molding of the fetal head
formation of considerable caput
lack of descent of the fetal head
these are all late indications
Birth of the shoulders and body is by _____ _____ via the_____ _ ______
Lateral flexion via the curve of Carus
The anterior shoulder comes into view at the vulvovaginal orifice, where it in impinges under the symphysis pubis; the posterior shoulder than distend a the perineum in is born by lateral flexion
Birth of the head by _____ for _____ deliveries
Extension for occiput anterior
Extension must occur when the occiput is anterior because of the resistance force of the pelvic floor where it forms the curve of Carus which directs the head upper to the vulval outlet
Internal rotation
Twist the next 45° LOA to OA
Brings the anterior posterior diameter of the fetal head into alignment with the anteroposterior diameter of the maternal pelvis
is essential for vaginal birth to occur
When the occiput rotates, the shoulders also rotate with the head until the LOA or ROA has been reached. As a occiput rotates the final 45° into that away position, the shoulders enter the pelvis and the oblique diameter
Extreme rotation
Occurs as the shoulders rotate 45° bringing the bisacromial diameter into alignment with the anterior posterior diameter of the pelvic outlet
Causes the head to rotate externally another 45° into the LOT or ROT position
LOA-LOT
Ferguson reflex
UTP prior to second stage
the reflex mechanism is initiated too early and makes the women feel she’s in constant need of having a BM
occurs when the fetal head is very low in the pelvis
Restitution
The rotation of the head 45° to either the L or R depending on the direction from which it rotated into the OA position
In effect, restitution untwists the neck and brings the head so it is again at a right angle with the shoulders
OA-LOA
Engagement
definition
When the widest diameter of the presenting part (which in a cephallic occipital presentation, is the biparietal diameter) has passed through the pelvic inlet
Descent
Occurs throughout labor
is the result of several forces, including contractions, and in second stage, the pushing the mother accomplishes by contraction of her abdominal muscles
Describe the modified Brandt Andrews maneuver
Bringing the fingertips of your abdominal hand straight down above the symphysis pubis into the lower abdomen while holding the umbilical cord taught to check for placental separation
Normal vital signs in labor Blood pressure Pulse temperature respirations
Increase with contractions by 5-15mmhg, between contractions return to prelabor or levels
Increase with contractions should return to normal levels in second stage, increase with pushing, reaching peak at time of birth
Slightly elevated in labor, highest during right during and right after delivery
A slight increase is normal and labor
Shiny Schultz
Attachment
Fundal implantation
Separation beginning at the center
Dirty Duncan
Attachment
Low implantation
Separation starting at the edges
How far should the Delee to be inserted into the babies mouth
4 1/2 inches
After the placenta separates and move into the lower uterine segment or the upper vaginal vault what change is expected in the uterus
It would be displaced upward and thus rise in the abdomen
Occipitofrontal diameter
11.5 cm the distance from the occiput to the bridge of the nose sincipital
Occipitomental diameter
12.5-13.5 cm
The distance from the posterior fontanelle to the mentum (chin): the largest diameter of the fetal head (brow)
Suboccipitobregmatic diameter
9.5 cm
The distance from the junction of the neck and the occiput to the bregma (anterior fontanelle) vertex
Trachelo diameter
(Submental) bregmatic 9.5 cm
the distance from the junction of the neck and lower jaw to the bregma (face)
The midwife listens during and after a few contractions, and notes that a deceleration occurs about 30 seconds after the contraction begins, returning to baseline after the construction is over. This type of deceleration is caused by
Uteroplacental insufficiency
If physician would prescribe heparin to a woman with femoral thrombophlebitis in order to
Prevent additional thrombus formation
Biparietal diameter
9.5 cm
Distance between the two parietal eminences: the largest transverse diameter of the fetal head, used in definition of engagement
Respiratory acidosis
definition
symptoms
Build up of CO2 in the blood produces a shift in the body’s pH balance and causes the body system to become more acidic
Slowed or difficulty breathing, rapid heart rate, changes in blood pressure, death, coma
Causes blockage of the airway
Which is the smallest pelvic diameter to which the fetus has to accommodate itself
The interspinous diameter
Metabolic acidosis
Definition
Symptoms
PH imbalance in which the body has accumulated too much acid and does not have enough bicarbonate to effectively neutralize effects of the acid
Signs and symptoms: headache, lack of energy, breathing fast and shallow, and N & V, diarrhea
Causes: lack of insulin, starvation diet, vomiting, diarrhea, problem with heart, liver, kidneys
Pendulous belly inhibiting descent
ways to manage
Assisting the positioning of the uterus over the pelvis
positioning semi reclining on back
lithotomy position
If engagement took place in ROP position, how many degrees does the fetal head rotate during internal rotation of an OA delivery?
135
Shoulder dystocia
Management steps
Apply gentle traction and encourage pushing reposition the mother to hands and knees, McRoberts, end of bed, Squat, Reposition shoulders to oblique diameter Extract posterior arm Flex newborn shoulders, then corkscrew Suprapubic pressure sweep arm across newborn face Fracture babies clavicle
Frank breach
Babies bottom comes first, legs
flexed at the hip extended at the knees (feet by ears)
65-70% of breech babies
The best for NVSD
Molding
The Change in shape of the head as a result of the soft skull bones overlapping each other because they are not yet firmly united and movement is possible at the sutures
The shape of the head becomes depends on the presentation
molding helps the fetal head pass through the pelvis
The sequelae of preterm birth for the baby
Respiratory distress syndrome
intraventricular hemorrhage
Low Birthweight
In a face presentation, which of the following will be the cephallic prominence that is palpable during the fourth Leopold’s maneuver?
In a flexed position?
The occiput
The sinciput
Internal rotation accomplishes what in a birth with cephalic presentation
Brings the anterior posterior diameter of the fetal head into alignment with the anterior posterior diameter of the maternal pelvis
In normal labor, the head usually enters the pelvic inlet with a moderate degree
Posterior asynclitism
Percent of women that enter labor with the face presentation
0.5%
External rotation accomplishes what in the birth with cephalic presentation
Brings the bisacromial diameter (shoulders) of the fetus into alignment with the to anteroposterior diameter of the pelvic outlet
Bishop’s score
Each gives points 0,1,2,3
dilation 0, 1to2, 3-4, greater than five Effacement 0-30, 40-50, 60-70, >80 Station -3,-2,-1/0,+1/+2 Consistency firm, med, soft Position posterior, mild, anterior Maximum score of 13 Evaluates cervical readiness for induction Unripe cervix=score less than 6
Metabolic alkalosis
definition
symptoms
PH imbalance in which the body has accumulated too much of an alkaline substance (example bicarbonate) and does not have enough acid to neutralize the effects
S/s slowed breathing, apnea, cyanosis, and N and V, diarrhea, rapid heart rate, decreased blood pressure
Causes: vomiting, excessive urination, diuretic drugs, steroids, laxatives
Cardinal rules to avoid entrapment of the head in a breech birth
Use scoring chart to predict outcome
progress should not stall for long periods in active labor
upright labor and delivery is best to prevent extension of arms or head
One hour of panting past full dilation
pushing with urge to umbilicus, then constant pushing until baby is born
Hands off breach until umbilicus appears
let body hang after full delivery of body
assist delivery of head after you see nape of the neck
Breech
what do you do if the baby is not moving down after being born to the umbilicus
You may give gentle traction on the legs, or cover the baby in a towel and give gentle traction holding the hips, or swing the baby gently in a figure 8 but usually not necessary if the mother is in an upright position
Technique for release of nuchal arm with breech
If arms do not come down, reach up and sweep them down one at a time
if you cannot reach, the arm may be behind the head;
gently rotate the baby around 90° until you can grasp the arm and sweep it over the babies chest do the same on the other side
Breech what do you do if the baby is stuck at the shoulders
Hold the baby gently straddled on your arm and rotate 90° until shoulders deliver one side and then the other
Cord prolapse
Steps
Change maternal position to knee chest
activate EMS
monitor fetal heart tones and cord for pulsation
keep presenting cord warm, moist, protected
give oxygen to mother
place cord back into vagina
facilitate immediate delivery if birth is imminent
Prepare to resuscitate the newborn
If the cervix tight rimmed and the woman is in early labor, insert 6-8 capsules of EPO high around the cervix, which should soften it in about 12 hours
0
Transition
The woman is ending first stage and nearing second stage
Signs-
contractions every one and a half to two minutes lasting 60 to 90 seconds painful
decreased modesty, frustrated, irritable, and N & V, restlessness, natural amnesia between contractions, increase bloody show, rectal pressure, rejection of those around her, hard time coping, thirst, perspiration, burping, anorexia
Risks associated with increased parity
Increase the risk of abruptio placentae, placenta previa, uterine hemorrhage, maternal mortality, and perinatal mortality
Double ovum twinning increased in G5 and above
Signs and symptoms of uterine rupture
abrupt change or cessation of uterine contractions
vaginal bleeding
loss of fetal station
abrupt changes in fetal heart tones
Describe the three types of uterine inversion
Incomplete fundus protrudes through the cervical os
Complete descends to immediate within the vaginal and introitus
Prolapsed extends beyond the vulva
Fetus ejection reflex
what does the mother do
The back of the babies head contacts the G spot which triggers the sacrum to open
Mother will grab forward for support, spread her knees apart and let belly sag, arch back and wiggle her lower body
This series of movements brings the baby down
Seven signs and symptoms of chorioamnionitis
Maternal fever of 100.4, maternal tachycardia, fetal tachycardia, tender uterus, vaginal walls unusually hot to the touch, foul smelling amniotic fluid, elevated white blood count
Chorioamnionitis
causes
concern
ROM over 24 hours, prolonged labor, repeated vaginal exams or intrauterine procedures
Mother and baby infected, uterus does not contract as well, labor dystocia, abnormal cervical dilation, uterus does not respond well to oxytocin, infant may develop pneumonia and acidosis
Why should the weather be kept warm immediately after the birth of the baby
If she is not warm, adrenaline will remain high, which can disrupt placental separation by opposing oxytocin
Management of Chorioamnionitis
Birth should take place within 24 hours of diagnosis, oxytocin induction, rupture of forewaters if present, hydration with IV fluids, monitor maternal vital signs hourly
What percent of women with premature rupture of membranes will go into spontaneously labor within 24 hours
80-85%
Meningocele
A bony defect of the spinal cord
must be differentiated from caput or cephalohematoma
The infant must be positioned prone and fecal contamination carefully avoided
Contraindications for Methergine use
High blood pressure, normal involution occurring on its own, placenta still in uterus
How is fetal station determined
Measuring the distance of the lower most part of the fetal presenting part above or below that ischial spines
Contractions felt mainly in the front are sign of true labor
true or false
False
true contractions are felt all around
What is the most common cause of you uterine rupture
Separation of a previous C-section scar
What best describes the cervix of a multip on the verge of true labor
Little or no effacement with 1 to 2 cm or more dilation
Ritgen maneuver
One hand on occiput to control babies head, other hand covered with towel to protect from contamination, the draped had exerts inward pressure posterior to the woman’s rectum him until the baby’s chin is located and in the grass of the fingers
Forward and outward pressure is then exerted on the underneath side of the chin and the head is controlled between this hand and the hand exerting pressure on the occiput
Mechanisms of labor
EDFIEREB
Every dog fights if each run expects best
0
Nine signs and symptoms that rule out tocolysis
Fetal maturity, cervix more than 5 cm, severe IUGR, acute fetal distress, fetal death or fetal anomaly incompatible with life, severe placental abruption, maternal hemodynamic instability, severe preeclampsia, Chorioamnionitis
Predisposing factors to prematurity
Low socioeconomic, nonwhite race, poor nutrition, history of preterm labor, short interval between pregnancy, multiple gestation, substance-abuse, no prenatal care, uterine abnormality, incompetent cervix, DES exposure, UTIs, GBS positive, premature rupture of membranes, chorioamnionitis, severe physical violence with pregnancy, fetal death, polyhydramnios
How can you differentiate between IUGR and SGA
SGA: genetically small but well grown infant
IUGR: fetal size significantly less than expected
The best way to tell is by doing serial ultrasound and monitoring growth. If the fetus is SGA, there is overall growth, just smaller than expected. With IUGR, there will be a small baby that is not thriving or not consistently getting bigger
IV therapy
How many cc of air can a healthy adult tolerate
200 cc’s
Oblique lie
definition
why
Presenting part is in the lower pole of the uterus but not centered over the pelvic cavity
something may be preventing direct engagement such as: small pelvic inlet, anomaly of uterine structure (septum), pelvic tumor, a fetal defect, placenta previa, a cord presentation, impacted rectum, or an extremely distended bladder
Transfer lie
Definition
Outcome
One in 500 births
successful labor and birth with a viable fetus is impossible
Most Transverse lies established before labor begins
It is rare for the onset of contraction to result in the baby turning from head down to transverse
Most dangerous consequence of uterine inversion
Shock
Fetal vagal nerve stimulation causes what kind of fetal heart rate pattern
Decel during increment of contraction
lowest point at Acme of contraction
baseline during decrement of contraction
early decels
A normal placenta weighs approximately how much in relation to the baby
1/5 weight of the baby
Disseminated intravascular coagulation DIC
definition
causes
Disseminated intravascular coagulopathy
Can happen with a missed abortion or fetal death that does not resolve promptly
Abnormal clotting mechanisms
Labs: Prothrombin, partial thromboplastin time, fibrinogen, platelets
What statement best describes the management plan for the labor of a woman that is determined to be a good VBAC candidate
She should be managing the same manner as any other woman in labor
Research has shown that _____ is associated with prevention of PTL among women with multiple gestation or a history of PTL or birth
Daily contact with a nurse
What is the most technically accurate definition of premature rupture of membranes
Rupture of membranes before the onset of labor
Deep transverse the rest is associated with which type of pelvis
Android
Vaginal exam in second stage
the sagittal suture is in the transverse diameter of the mothers pelvis and there is considerable molding and formation of caput
most likely diagnosis
Deep Transverse arrest
DIC
Definition
Signs and symptoms
With an internal injury, all the clotting factors rush to that one part of the body and are completely depleted
Symptoms are bleeding from any body opening and zero clotting factors
Nonallopathic remedies for preterm labor
Good hydration magnesium supplements homeopathic mag phosphate 30c Bed rest wine/alcohol
Management of rupture of membranes when the pregnancy is less than 36 weeks
The risks of sepsis is outweighed by the risk of prematurity
Primary purpose is prolonging the pregnancy as long as the woman is not in labor, does not have Chorioamnionitis and there is no fetal distress
Six precipitating causes of cord prolapse
Rupture of membranes and unusual presentation/small fetus or second born twin
Administration of enema if rupture of membranes and unengaged presenting
Amniotomy if unengaged presenting part
Exam causing rupture of membranes with unengaged presenting part
Spontaneous rupture of membranes with unengaged presenting part
Displacement of the vertex during fetal assessment
Incidence of premature rupture of membranes is higher in women with
Incompetent cervix, polyhydramnios, fetal malpresentation, multiple gestation, vaginal/cervical infection (including GBS)
Which women are candidates for tocolysis
Woman who meet the definition of preterm labor who are less than 4 cm dilated and less than 34 weeks gestation
The increased number and activity of endocervical glands are responsible for
Mucous plug
What percent of women at or near term will start labor spontaneously within 24 hours of premature rupture of membranes
80%
What best describes the cervix of the average primip on the verge of true labor
50 to 100% effaced
a fingertip to 1 cm dilation
Compound presentation
definition
risk factors
When two or more fetal parts present simultaneously at the inlet usually an extremity and the presenting pole of the body
Contracted pelvis, pendulous abdomen, multiple gestation, large head, not vertex presentation, polyhydramnios
Partial placenta accreta versus complete placenta accreta
Partial: first seen as an acute third stage hemorrhage clinical diagnosis made when the placenta adherence is discovered with manual removal definitive diagnosis microscopic exam
Complete: no signs and symptoms, no hemorrhage, it is discovered during attempted manual removal of the retained placenta
Three risks of rupture of membranes to the fetus
Formation of caput
head trauma lead to brain damage
cord prolapse
Elevated temperature and ketonuria in labor indicates
A level Of exhaustion threatening to both the mother and baby transport is advisable
Ketonuria in labor indicates
Mother is dipping into her fat reserves for energy
Trace reading okay, but higher levels indicate a disrupted electrolyte balance and the need for more fluid and calories
Acute/dramatic uterine rupture
signs and symptoms
Sharpshooting pain in lower abdomen during height of strong contraction
vaginal bleeding
presenting part movable above inlet, dramatic repositioning of fetus, fetal movements violent then reduced to none, contracted uterus felt besides fetus, women showing signs of shock
A woman complaining of tingling and numbness in her hands and feet as she uses her breathing technique these symptoms indicate
Respiratory alkalosis
hyperventilation
How often should the laboring woman urinate and for what two purposes
Every two hours
Prevent obstruction of labor by full bladder that prevents descent of the presenting part
Prevent trauma to the bladder from prolonged pressure, which will cause hypotonia of the bladder and urinary retention during the immediate postpartum.
Variable decels are thought to be caused by
Court compression
Lightening
definition
Occurs two weeks before labor
Descent of presenting part of the baby into the true pelvis
baby’s head is usually fixed or engaged after
decrease of shortness of breath, increasing urinary frequency, pelvic pressure, leg cramps, dependent edema from venous stasis
Rupture of low transverse uterine scar usually
Not catastrophic for either mom or baby
most of these ruptures are only dehiscence or puckering of the scar
Diagnosis is definitive of rupture of membranes when
When you see amniotic fluid escaping from the cervical os and pooled in the vaginal vault during speculum exam
When you cannot feel the membranes over the presenting part of the cervical orifice
Explain how the diagnosis of CPD in the previous birth affects the VBAC candidates ability to give birth normally this time
Many diagnosis of CPD do not reflect actual CPD, but rather an unknown reason for failure to progress in labor
About 60 to 70% of women with a previous C-section for CPD or failure to progress will deliver vaginally in a subsequent pregnancy and often deliver babies larger than the one for which CPD was diagnosed
Describe fetal fibronectin testing
FFN
FF is a protein produced by the fetal membranes that serves as an adhesive binder of the membranes and placenta to the deciduas and is normally present and cervical secretions until 20 to 22 weeks
From 24 to 34 weeks, presence of FFN and is assessed with preterm labor
Negative test is 95% predictive for not delivering in the next 14 days
Positive test 61% sensitivity and 83% specificity for predicting PTL
Define preterm labor
Labor commencing anytime after the start of the 20th week to the 37th week
Culminates in preterm birth and 12% of all births in the US
Second leading cause of neonatal mortality
Any woman who had one PT birth in a past pregnancy has 20 to 40% risk of reoccurrence
Diagnosis of preterm labor
20 and 37 weeks when the woman’s having uterine contractions five to eight minutes apart
AND
Rupture membranes
Or
Intact membranes and
Progressive cervical change or 2 cm dilation or a positive FFN test
Eight signs and symptoms which must be evaluated to rule out premature labor
Painful menstrual cramps could be round ligament
Dull low backache
Suprapubic pain/pressure could be UTI
Sensation of pelvic pressure or heaviness
Change in type or amount of vaginal discharge
diarrhea
Unpalpated uterine contractions with or without pain felt more often than 10 minutes for one hour or more and not relieved by laying down premature
rupture of membranes
Causes of abnormal pain in labor
Uterine rupture
placental abruption
Aspirin, when taken near-term, can cause
Maternal hemorrhage
Cephalohematoma
Intercranial hemorrhage
What assessment finding is characteristic of abruptio placenta
A tender, increasingly rigid uterus
increase in maternal pulse
During what deceleration pattern is the fetal heart rate most likely to dip below 100 bpm
Variable decels
Which of the following periodic fetal heart changes does not reflect the shape of the uterine contraction
Early decels
Late decels
Variable decels
Variable
What component of fetal heart rate assessment is the most significant indicator of fetal well-being
Fetal heart rate variability
False/prodromal labor
versus
early/latent labor
Falsely labor: contractions every 10 or 20 minutes, of short duration, never form a pattern, can be painful, no measurable progressive effect on the cervix
Early/latent labor: contractions that gradually increase in intensity and get closer together
progressive increase in frequency, intensity and duration
Measurable effect on servant 0-3/4 cm
Anterior transverse suture is called the
Coronal
The anterior fontanelle is formed by the meeting of what sutures
Frontal, sagittal, coronal
The posterior transverse suture is called the
Lambdoidal
The anterior posterior suture is
Sagittal
What contraction pattern defines hyperstimulation of the uterus
Contractions more frequent than every two minutes lasting more than 90 seconds
If a baby is delivering in the face presentation he must rotate to a
Mentum anterior position
Amniotic fluid embolism
signs and symptoms
Difficulty breathing, gasping for air, decreased cardiac function, hypoxia, seizures, 60 to 80% mortality
Amniotic fluid embolism
management
Treatment for shock, warmth, elevate feet, 02, IV, transport
Placental abruption
risk factor
Very high BP, five or more prior pregnancies, history of second trimester bleeding, a prior abruption, history of heavy smoking/cocaine use, severe abdominal trauma
Define placenta accreta
An abnormal partial or total adherence of the placenta to the uterine wall
The placenta directly adheres to the myometrium with either a defective decidua or no decidua in between
Three conditions that can create uterine inversion
Uterine atony
a patio us, dilated cervix
fundal pressure or traction caused by pulling on the umbilical cord or placenta
Factors associated with higher success rates for VBAC
Not repetitive indications breech, malpresentation, fetal distress, preeclampsia
Spontaneous labor with normal progression
History of previous VBAC
Factors associated with lower success rates for VBAC
Possible repetitive indications
CPD, failure to progress, labor dystocia, induction or augmentation, more than one C-section, no prior vaginal delivery, nonreassuring fetal heart tones when first seen in labor
What fetal heart assessment finding is the most ominous
Repeated late decels with loss of short-term variability
What to expect with a breech labor
Premature rupture of membranes
labor starts a few weeks early
thick meconium is normal
no rupture of membranes, gentle vaginal exam
prepare to resuscitate
dilation is difficult to determine make sure the cervix is really gone slower labor because smaller presenting part on the cervix takes longer to dilate
Nitrazine paper color
urine
amniotic fluid
Urine: blue because it’s alkaline
amniotic fluid: blue
Dark yellow paper turns blue green when in contact with an alkaline substance
this includes urine, blood, cervical mucus, secretions from BV
Vaginal bleeding during labor
spotting versus Frank
Bleeding is abnormal
vaginal exam is contraindicated in the presence of bleeding
Frank bleeding requires physician consultation and collaboration or referral
possible causes placenta abruption/previa
What is a normal rise in blood pressure during contractions for a woman in labor
Systolic rise of 10 to 20 MM HG
Diastolic it rise of 5 to 10 MM HG
Breech what do you do if you’re having difficulty delivering the head
Make an airway with your finger by pulling back the perineum, so the baby can breathe
Use suprapubic pressure, or use Ritgen maneuver, and with finger on lower jaw, flex head and bring baby out
Use strong steady traction
Factors that make breech delivery higher risk
Danger prolapsed cord
Cord getting pinched by after coming head
possibility of fetal anomalies
head has less time to mold
intracranial pressure hemorrhage maybe result of too rapid decompression of head
possibility of head entrapment
Breech scoring system
0,1,2 Parity: primip, multip Fetal weight: 8+, 7-8, 5-7 Gestational age 39+, 37-38, 36-37 1st dilation check: 2cm, 3cm, 4cm Station: -3,-2,-1 Previous breech, none, one, 2 or more Subtract 1 for footling breech 0-3 dangerous 4-5 review carefully 5+ reasonable success
