Intrapartum and Postpartum Care & Complications Flashcards
1
Q
Labor = _____
A
a sequence of uterine
contractions that thins and
dilates the cervix, plus voluntary
pushing that expels the fetus
from the vagina
2
Q
Lightening-
A
settling of the fetal head into the brim of the pelvis
3
Q
What are Braxton Hicks Contractions?
A
Irregular, generally painless contractions, slowly increase in frequency (as frequent as q10-20 min)
○ approx last 4-8 wks of pregnancy
○ Distinguish from true labor
4
Q
What physiologic things must happen prior to the onset of labor?
A
● Lightening
● Braxton Hicks Contractions
● Cervix starts to soften, efface, dilate
● Mucus plug is released
● Bloody Show
5
Q
First stage of normal labor
A
– Interval between onset of labor and
full cervical dilation. Divided between Latent and
Active phase. ■ Primipara = 6-18 hours ■ Multiparous = 2-10 hours
6
Q
Second stage of normal labor
A
Interval between full cervical
dilation and delivery of the infant ■ Primipara = 30 min - 3 hours ■ Multipara = 5-30 minutes
7
Q
Third stage of normal labor
A
period between the delivery of the
infant and the delivery of the placenta ■ 0-30 minutes
8
Q
What phase is the Slow cervical change, ~0-6 cm
A
Latent phase
9
Q
What position is discouraged in stage 1 of labor?
A
● Ambulation can be helpful, Supine position discouraged
10
Q
What is being monitored in stage 1 of labor?
A
● Maternal pulse and BP (Q2-4h)
● Fetal heart rate
● Uterine contractions Q30 min (continuously if high risk)
● Cervical checks Q2hrs in active phase: effacement, dilation, fetal head position
● Multiple methods utilized to tolerate pain: Lamaze, Bradley, hypnotherapy, prenatal yoga etc…
11
Q
Fetal monitoring
A
● Auscultate heart rate or electronic fetal heart tracing
● Intermittent okay if low risk, continuous if high risk
(hypertension, preeclampsia, intrauterine fetal growth
restriction, diabetes, multiple gestations, etc)
● Q30 min in active phase (increase to Q15 min in second
stage of labor)
12
Q
Uterine contractions monitoring
A
● Palpate abdomen Q30 minutes to assess contraction frequency, duration, and intensity
● Continuous monitoring if at-risk pregnancy: external tocodynamometor or internal pressure
catheter (requires ruptured membranes)
13
Q
Cervical checks
A
● Monitors the progress of labor
● Q2hrs starting during active phase
● Dilation, effacement, position, consistency
● Station and position of fetal head
● Check for prolapsed cord if membranes have ruptured
14
Q
Amniotomy
A
therapeutic rupture of amniotic membranes
15
Q
When should an amniotomy be done?
A
● Should not be used routinely!
● No benefit for normally progressing labor and increases risk of infection
or cord prolapse.
● Only use when:
○ Internal fetal or uterine monitoring is required
○ to ↑↑ uterine contractions
16
Q
What is happening in Stage 2 of labor
A
● Full cervical dilation (10cm) → Delivery of
infant
● Mother feels desire to bear down with each contraction
● ↑↑ abdominal pressure
● ↑↑ force of uterine contractions
● Labor progress measured by position of fetal head in relation to ischial spine
● Fetal head crowning = delivery is imminent
17
Q
Mechanisms of Labor or Cardinal
Movements of Labor
A
○ Engagement
○ Descent
○ Flexion
○ Internal Rotation
○ Extension
○ External Rotation (restitution)
○ Expulsion
18
Q
Engagement
A
● Fetal head shifts down through the pelvic inlet
● Late in pregnancy (last 2 weeks)
● Head enters the occiput transverse position in 70%
19
Q
Descent
A
● Progressive descent until baby is
delivered
● Nulliparous: Engagement prior to
onset of labor, further descent w/
2nd stage of labor
● Multiparous: Descent usually begins
w/ engagement
20
Q
Flexion
A
● Chin is pushed towards the chest when descending head meets resistance
● Allows smallest head diameter to progress
21
Q
Internal Rotation
A
● Occiput rotates anteriorly
(baby’s face toward mother’s
back)
22
Q
Extension
A
● Neck extends to bring the base of the
occiput into direct contact w/ the
inferior margin of the symphysis pubis
(Crowning)
● Once head is delivered, check to see if
umbilical cord is around the neck (if
so, slip it over the head)
23
Q
External Rotation
A
● Follows delivery of the head
● Head returns to transverse position
● Baby’s shoulders align w/ anteroposterior
diameter of pelvic outlet
● One shoulder is anterior behind pubic
symphysis, , and the other is posterior
● Deliver anterior shoulder (gentle downward
traction on the head)
● Deliver posterior shoulder (by gentle upward
traction on the head)
24
Q
Expulsion
A
● After delivery of the shoulders, the rest of the
body quickly passes
25
Umbilical Cord post delivery
*The umbilical cord is cut between two clamps
placed 6 to 8 cm from the fetal abdomen, and
later an umbilical cord clamp is applied 2 to 3
cm from its insertion into the fetal abdomen
26
*If there is _____ typically cord
clamping is delayed and baby is placed on
mother’s abdomen (skin to skin)
no meconium
27
If there is meconium present, what happens after delivery?
the cord is cut and clamped immediately and the baby is handed to NICU staff for suctioning of the mouth PRIOR to the baby being stimulated
28
Positions for Labor/Delivery
● Whatever is most comfortable!
● Typically avoid lying supine (aortocaval compression decreases uterine perfusion
● Mother does not need to be confined to bed
● Ambulation can be helpful
● Sitting in a chair or on hands and knees may be more comfortable
29
Delivery of placenta
● Immediately after baby is delivered, inspect cervix and vagina for actively bleeding
lacerations → repair them
● Separation of the placenta occurs within 30 minutes
30
Signs of placental delivery include
■ Fresh show of blood, lengthening of the umbilical cord, fundus of the uterus
rises up, uterus becomes firm and globular
○ Once these signs occur = safe to apply gentle traction to umbilical cord to
deliver the placenta (ALWAYS apply pressure above pubic bone while delivering
placenta in order to prevent uterine inversion)
31
The Puerperium
● time from Delivery of placenta → 6 weeks postpartum
● 1
st hour after delivery is CRITICAL, monitor mother closely
● Most common time for postpartum hemorrhage
● Begin breastfeeding
32
Risk factors for abnormal labor
* Fetal macrosomia
* Maternal obesity
* Nonreassuring fetal heart rate patterns
* Non-gynecoid maternal pelvimetry
* Non-occiput anterior position
* Nulliparity
* Short stature
* High fetal station at full cervical dilation
* chorioamnionitis
* Post-term pregnancy
* Gestational diabetes
* Hypertensive disorders
* Epidural analgesia
33
Types of pelvic shapes
Gynecoid - best
Platypelloid
Anthropoid
Andrdoid
34
Assessing for Status of the Membranes during labor
● Pelvic exam
● History of a sudden gush of fluid = suggestive (not conclusive, involuntary loss of urine common late in pregnancy)
● Ruptured membranes are confirmed by a
continuing, steady leakage of amniotic fluid
● Nitrazine test
● Amniotic fluid turns Nitrazine paper a dark
blue (pH is basic)
● Dried amniotic fluid forms crystals (ferning) on a microscope slide
35
Fetal Presentation/Position
* Fetal head is hard and bony
* Fetal buttocks is soft everywhere except right over the fetal pelvic bones
*No presenting part (head or butt) on pelvic exam = good chance the baby is in transverse lie (or oblique lie)
*During labor head position can be determined by locating the sagittal suture and fontanels
36
Cervical Effacement
Length of the cervical canal compared
with that of an uneffaced cervix
● When the length of the cervix is ↓ by ½
→50% effaced
37
Cervical dilation
*Estimated diameter of the cervical opening
*Fully dilated = 10 cm
38
Fetal Station
Level of presenting fetal part in the
birth canal
● Relationship to the ischial spines
● Lowermost portion of the
presenting fetal part is at the
level of the spines,→ zero (0)
station
39
Leopold Maneuvers
● 1st maneuver:
○ Identifies where the head is (up/down)
● 2nd maneuver: Hands on both sides of belly
○ If a hard, resistant structure is felt = the back
○ If many small, irregular, mobile parts are felt = fetal extremities
● 3rd maneuver:
○ If the presenting part is not engaged, a movable mass will be felt
● 4th maneuver:
○ If/When the head has descended into the pelvis, the anterior shoulder may be
differentiated
40
Fetal non-stress test
Fetal heart rate (FHR) acceleration in response to fetal movement is a
sign of fetal health
● Fetal heart monitor and tocodynamometer (measures force of contractions)
● When mom feels the baby kick/move, she presses a button
● Measures how baby's heart rate changes while moving
41
Normal Fetal non-stress test
● A normal nonstress test = baby is getting enough oxygen and is doing well
● Reactive (normal) stress test = 2+ accelerations within 20 minutes
● Sometimes baby needs to be woken up!
42
Indications for a Fetal non-stress test
● Fetal growth restriction
● Diabetes mellitus, pre-gestational and gestational diabetes treated with
drugs
● Hypertensive disorder, chronic hypertension, and preeclampsia
● Decreased fetal movement
● Post-term pregnancy
● Multiple pregnancies
● Systemic Lupus erythematosus, Antiphospholipid antibody syndrome
● Recurrent pregnancy loss
● Alloimmunization, hydrops
● Oligohydramnios
● Cholestasis of pregnancy,
● Other conditions include maternal heart diseases, hyperthyroidism, chronic
liver diseases, maternal drug abuse, and chronic renal insufficiency
43
Oxytocin-Challenge Test AKA
“Contraction stress test”
44
Oxytocin-Challenge Test purpose and results
● Evaluates fetal heart rate during contractions to determine if baby is strong
enough to tolerate labor.
● Contractions induced w/ oxytocin or nipple stimulation
● Positive test (abnormal) = uniform, repeated late fetal heart rate decelerations
● Abnormal results = suboptimal oxygenation during contractions
45
This test is done on the L&D floor, if the baby doesn’t tolerate the
contractions, the pt will have a C-section
Oxytocin-Challenge Test
46
When is a Oxytocin-Challenge Test indicated?
Indicated for suspected placental insufficiency (intrauterine
growth restriction, decreased fetal movement
47
Bradycardia in a fetus & causes
● < 110 BPM
● CAUSED by:
○ Poor uterine perfusion
○ Congenital heart block
○ Maternal hypotension (e.g. post-epidural)
○ Umbilical cord prolapse or occlusion
○ Rapid descent
○ Tachysystole (too frequent contractions)
○ Placental abruption
○ Uterine rupture
48
tachycardia in a fetus and causes
● >160 bpm
● Most common cause is maternal fever from chorioamnionitis
● Other causes:
○ Cardiac arrhythmias
○ Maternal atropine (anticholinergic - used to increase heart rate) or terbutaline (used to delay preterm labor)
49
Not usually associated with fetal compromise unless fetal sepsis or significant
FHR decelerations present
Tachycardia
50
Fluctuations in baseline FHR
○ Absent (undetectable)
○ Minimal/decreased (<5bpm)
○ Moderate (6-25 bpm)
○ Marked/increased (>25 bpm)
51
Most reliable sign of fetal
compromise
Absent/Decreased
Variability
52
Causes of Increased Variability
● Greater variability
accompanies fetal breathing
and body movements
● Sometimes associated w/
abnormal fetal arterial blood
gas
53
Causes of Absent/Decreased
Variability
● Most reliable sign of fetal
compromise
● Hypoxia (if decelerations present) ● Neurological damage (if no
decelerations)
● Acidemia (e.g. maternal DKA) ● Maternal administration of
narcotics, barbiturates,
phenothiazines, tranquilizers, and
general anesthetics
54
Accelerations
● Abrupt FHR increase above the
baseline
● ≥ 15 seconds
● ≥ 15 bpm acceleration
● Common (esp in early labor)
● Caused by fetal
movement/stimulation
● Favorable sign of well-being
55
Early Decelerations
○ Gradual FHR decline and
then return to baseline that
mirrors the contraction
○ Starts w/ contraction and
ends w/ contraction
○ Usually d/t head
compression from uterine
contractions (common in
active labor)
○ NOT associated with poor
outcome
○ Degree of deceleration is
generally proportional to
the contraction strength
56
Degree of deceleration is
generally proportional to
_____
the contraction strength
57
Variable Decelerations
○ Most frequent pattern during labor
○ Abrupt drop in FHR (jagged V shape)
○ Associated w/ contractions but
onset can vary
○ Usually are d/t cord compression
○ Occurs in MOST labors
58
These decelerations are Not worrisome unless recurrent, deeper, longer in duration
(indicates prolonged cord occlusion)
Variable Decelerations
59
Late Decelerations
○ Smooth, gradual, symmetrical decline in the FHR that begins at or after the contraction peak and returns to baseline only after the contraction has ended.
○ FIRST FHR consequence due to uteroplacental induced hypoxia!!!
○ Ominous = fetal hypoxemia!!!
○ Poor uterine perfusion, placental dysfunction (Maternal hypertension, diabetes, and collagen vascular disorders)
○ Placental abruption
○ Can be caused by anything that causes
maternal hypotension (epidural) or uterine
hyperactivity (Oxytocin)
60
Sinusoidal Waveform
Visually apparent, smooth, sine-wave
undulating pattern in FHR baseline with a
cycle frequency of 3–5/min for ≥ 20 min
61
Causes of Sinusoidal Waveform fetal vs. maternal
● Fetus: intracranial hemorrhage, severe
asphyxia, severe anemia (from Rh
alloimmunization), fetomaternal
hemorrhage, twin-twin transfusion
syndrome, or vasa previa with bleeding
● Maternal: Meperidine (Demerol)
administration (narcotic)
62
Bradycardia/tachycardia, lack of FHR
variability & late FHR decelerations
→ ______
Fetal compromise
IMMEDIATE EVAL AND TREATMENT!
63
Most common indication for Cesarean
section
Dystocia
64
Dystocia
● Difficult labor
● Abnormally slow labor progress
● “Failure to progress” (cervical dilation,
fetal descent)
● 20% of labors ending in live birth
● Highest risk w/ nulliparous term
pregnancies (37% experience dystocia)
● Most common indication for Cesarean
section
65
Factors causing dystocia
○ Maternal pelvis abnormality (Passage)
○ Fetal position or size (Passenger)
○ Expulsive forces abnormality (Powers)
66
Maternal complications with dystocia
○ Chorioamnionitis
○ Uterine rupture
○ Fistula formation
○ Pelvic floor injury
○ Lower extremity nerve injury
67
Newborn complications with dystocia
● Respiratory distress syndrome
● Sepsis
● asphyxia-related complications
68
Shoulder Dystocia
Anterior fetal shoulder can become wedged behind the symphysis pubis and fail to deliver
● EMERGENCY! Umbilical cord is compressed within the birth canal
69
Strategies to manage Shoulder Dystocia
○ Apply lateral suprapubic pressure in the direction the
head is facing (compress shoulders together) and
downward traction on head
○ McRoberts maneuver (next slide)
○ Episiotomy
○ Emergency C-Section if the above strategies don’t work quickly
70
Maternal and newborn complications with shoulder dystocia
Maternal complications
● Serious perineal tears
● Postpartum hemorrhage
Newborn complications
● Clavicle fracture
● Brachial plexus injury
● Asphyxia
71
Breech Position
Fetal buttocks or legs enter the pelvis before the head
72
Risk factors for Breech Position
polyhydramnios, uterine
anomalies such as bicornuate or septate uterus, pelvic tumors obstructing the birth canal, abnormal placentation, advanced multiparity, and a contracted maternal pelvis.
73
Diagnosis and management of Breech Position
● Diagnose w/ US, Leopold’s maneuvers
● Usually needs planned C-section
● Can attempt external cephalic version
● Average success rate 60%
● Risk of placental abruption, uterine rupture
74
Maternal and fetal complications of breech positions
Maternal complications
● Lacerations
● Uterine rupture
● Episiotomy
Newborn complications
● Umbilical cord progression
and prolapse
● Fractures
● Brachial palsy
● Genital injury
● Hip dysplasia
75
Umbilical Cord Prolapse
● Umbilical cord enters vaginal canal
ahead of the baby
● Cord becomes trapped and compressed
against the baby's body during delivery
● 0.1-0.2% of births
● EMERGENCY!
76
Risk factors for umbilical cord prolapse
○ #1 cause: Premature rupture of
membranes
○ Preterm labor
○ Multiples
○ ↑↑ amniotic fluid
○ Breech delivery
77
Diagnosis of Umbilical Cord Prolapse
Clinical Diagnosis
* Cord loop palpated next to
or lower than the head
* Mother may feel pulsating
* Fetal bradycardia/late
decelerations
78
Umbilical Cord Prolapse management
○ Mother should be placed in
knee-chest position to take
pressure off the cord
○ Lift baby up and away from
the cord
○ DO NOT REMOVE YOUR
HAND UNTIL THE BABY IS
OUT!
● Emergency c-section
79
Leading cause of maternal mortality
Postpartum Hemorrhage (PPH)
80
Postpartum Hemorrhage (PPH)
● Leading cause of maternal mortality
● Loss of ≥ 500 mL blood after vaginal delivery and
≥1000 mL blood after c-sec
81
Etiology of postpartum hemorrhage
○ 4 T’s
■ Tone - Uterine atony = #1 cause
■ Failure of uterine myometrium to
contract down after delivery
■ Tissue – retained or abnormal placenta
(placenta previa, placenta accreta)
■ Trauma – lacerations, uterine rupture
■ Thrombin – coagulopathy
82
Risk Factors for PPH
○ Multiples
○ Prolonged labor
○ Over-distended uterus (multiples
or polyhydramnios etc…)
○ Instrumentation
○ Large-for-gestational-age (LGA)
newborn
○ Prolonged use of oxytocin
83
Clinical Presentation of PPH
○ Heavy vaginal bleeding
○ S&S of hypovolemic shock
○ Uterine Atony (High fundus, soft & boggy uterus)
○ Monitor uterine size and tone post delivery of the placenta
○ The volume of any clotted blood = ½ of the blood volume required to form the clots
84
Management of PPH
○ Resuscitation and management for bleeding and hypovolemic shock
○ Identify/manage underlying cause(s) of the hemorrhage
○ Pitocin (synthetic Oxytocin) directly after delivery = TOC for prophylaxis
and when hemorrhage caused by uterine atony
○ Bimanual massage
○ Surgical management
85
Bimanual Massage
Bimanual compression for uterine atony. The uterus is positioned with the fist of one hand in the anterior fornix pushing against the anterior wall, which is held in place by the other hand on the abdomen. The abdominal hand is also used for uterine massage
86
_____ is the artificial
stimulation of labor that has begun
spontaneously
Augmentation
87
Maternal Indications For Induction
○ Preeclampsia
○ DM
○ Heart disease
○ History of fast labors (and living
more than 30 minutes away from a
hospital)
88
Fetal/maternal indications for induction
○ Prolonged pregnancy
○ Fetal abnormality
○ Chorioamnionitis
○ PROM
○ Placental insufficiency
○ Suspected intrauterine growth
deficiency
89
Medications for induction
● IV Oxytocin/Pitocin
● Misoprostol (prostaglandin analog)
90
Mechanical methods for induction
● Stripping of membranes
● Artificial rupture of membranes
(Amniotomy)
● Extra-amniotic saline infusion
● Transcervical balloons
● Hygroscopic cervical dilators
91
Risks of Induction
● Cesarean delivery,
○ ↑↑ in nulliparous women
● Chorioamnionitis (if amniotomy)
● Uterine scar rupture
● Postpartum hemorrhage
92
______ is NEVER induced with Pitocin
due to the risk of uterine rupture
A VBAC pt
93
Uterine contractions = _____ pain
visceral
94
While in descent, the fetus' head exerts pressure on the mother's pelvic floor, vagina, and perineum = _____ pain
somatic
95
Regional anesthesia in L&D
* Epidural
* Spinal
* Combined spinal-epidural
96
Nerve blocks in L&D
* Pudendal nerve
* Paracervical block
97
Systemic anesthesia in L&D
* Meperidine (demerol) 25-50 mg IV every 1-2 hours or 50-100 mg IM every 2-4 hours
* Fentanyl, 50-100 mcg IV every hour
* Nalbuphine (Nubain) 10 mg IV or IM every 3 hours
* Butorphanol (Stadol), 1-2 mg IV or IM every 4 hours
* Morphine 2-5 mg IV or 10 mg IM every 4 hours
98
Opioids risk neonatal _____
sedation and CNS depression
99
Epidural vs. Spinal
Epidural: does not pass dura mater
Spinal: Dura is punctured and anesthesia is
placed in the subarachnoid space
100
Indications for cesarean birth
Cesarean birth is performed when the clinician and/or patient believe that
abdominal birth is likely to provide a better maternal and/or fetal outcome
than vaginal birth
80% of C-sections are due to
● Failure to progress during labor
● Nonreassuring fetal status
● Fetal malpresentation
● Other indications include prior c-section, abnormal placentation, eclampsia, maternal infection, cord
prolapse, uterine rupture
101
Anticipated vaginal delivery should be
converted to c-section if :
● If there is an immediate threat to
the mother’s or baby’s life during
labor
● If a medical/obstetric indication is
identified after the onset of labor
102
Pregnant uterus vt. vs 6 weeks postpartum
● Pregnant uterus weight 1000 g = 6 weeks later 50-100 g
103
Lochia =
red blood flowing from the uterus
104
Postpartum Course for cervix
*Rapidly reverts to a non-pregnant state
■ Never returns to the nulliparous state
*By the end of the first week, the external os closes
■ Finger cannot be easily introduced
105
Postpartum Course for vagina
*Resolution of the increased vascularity and edema occurs by 3 weeks
106
Postpartum Course for perineum
*Swollen and engorged vulva rapidly resolve within 2 weeks
*Most of the muscle tone is regained by 6 weeks
○ More improvement over the following few months
107
Postpartum Course for the abdominal wall
● Remains soft and poorly toned for many weeks
● Return to a pre-pregnant state depends greatly on maternal exercise
108
Postpartum Course for the ovaries
● Return to normal function is highly variable
○ Greatly influenced by breastfeeding
● Can be as early as 27 days
● Mean time to first menses is 7-9 weeks
109
Postpartum Course for the breasts
● After delivery of the placenta, there is a rapid decline in progesterone = onset
of milk production + engorgement of breasts
110
What is colostrum?
○ Liquid that is initially released by the breasts during the first 2-4 days after
delivery
○ High in protein content and antibody rich
○ Protective for the newborn
○ Already present in the breasts, suckling by the newborn triggers its
release
111
Milk matures over the first ____ days
7
112
Postpartum Course for breast milk
● Removal of milk from the breast stimulates more milk production
● Lactation requires regular removal of milk
113
Routine hospital care for the mother postpartum
● While still in the hospital, the mother is monitored for blood loss, signs of infection, abnormal blood pressure, contraction of the uterus, and ability to void
● Vaginal delivery
○ Ice applied to the perineum to reduce the swelling and to help with pain relief
○ Sitz baths
○ Pain relief = NSAIDs, narcotics, local anesthetic spray
○ Witch hazel, corticosteroids for hemorrhoids
○ Generally nothing in the vagina for 6 weeks
114
Routine care after c-section delivery
○ Post-op pain at incision site
○ Heat or ice
○ Abdominal binder support
○ Pain medication
115
When can Sexual intercourse resume after birth?
May resume when bright red bleeding ceases, the vagina and vulva are healed, and the woman is physically comfortable and emotionally ready
116
Breastfeeding support in patient education
○ Feed the baby every 2-3 hours (at least while she is awake during the
day)
■ Stimulates further milk production
117
Postpartum visit (~6 weeks)
○ Mood and emotional well-being
○ Infant care and feeding
○ Contraception review
○ progesterone-only contraception at first
(lower clot risk and doesn’t decrease milk supply)
○ Sleep and fatigue
○ Physical recovery
