Intrapartum and Postpartum Care & Complications Flashcards
Labor = _____
a sequence of uterine
contractions that thins and
dilates the cervix, plus voluntary
pushing that expels the fetus
from the vagina
Lightening-
settling of the fetal head into the brim of the pelvis
What are Braxton Hicks Contractions?
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
What physiologic things must happen prior to the onset of labor?
● Lightening
● Braxton Hicks Contractions
● Cervix starts to soften, efface, dilate
● Mucus plug is released
● Bloody Show
First stage of normal labor
– Interval between onset of labor and
full cervical dilation. Divided between Latent and
Active phase. ■ Primipara = 6-18 hours ■ Multiparous = 2-10 hours
Second stage of normal labor
Interval between full cervical
dilation and delivery of the infant ■ Primipara = 30 min - 3 hours ■ Multipara = 5-30 minutes
Third stage of normal labor
period between the delivery of the
infant and the delivery of the placenta ■ 0-30 minutes
What phase is the Slow cervical change, ~0-6 cm
Latent phase
What position is discouraged in stage 1 of labor?
● Ambulation can be helpful, Supine position discouraged
What is being monitored in stage 1 of labor?
● 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…
Fetal monitoring
● 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)
Uterine contractions monitoring
● 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)
Cervical checks
● 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
Amniotomy
therapeutic rupture of amniotic membranes
When should an amniotomy be done?
● 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
What is happening in Stage 2 of labor
● 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
Mechanisms of Labor or Cardinal
Movements of Labor
○ Engagement
○ Descent
○ Flexion
○ Internal Rotation
○ Extension
○ External Rotation (restitution)
○ Expulsion
Engagement
● Fetal head shifts down through the pelvic inlet
● Late in pregnancy (last 2 weeks)
● Head enters the occiput transverse position in 70%
Descent
● 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
Flexion
● Chin is pushed towards the chest when descending head meets resistance
● Allows smallest head diameter to progress
Internal Rotation
● Occiput rotates anteriorly
(baby’s face toward mother’s
back)
Extension
● 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)
External Rotation
● 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)
Expulsion
● After delivery of the shoulders, the rest of the
body quickly passes
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
*If there is _____ typically cord
clamping is delayed and baby is placed on
mother’s abdomen (skin to skin)
no meconium
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
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
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
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)
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
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
Types of pelvic shapes
Gynecoid - best
Platypelloid
Anthropoid
Andrdoid
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
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
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
Cervical dilation
*Estimated diameter of the cervical opening
*Fully dilated = 10 cm
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
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
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
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!
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
Oxytocin-Challenge Test AKA
“Contraction stress test”
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
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
When is a Oxytocin-Challenge Test indicated?
Indicated for suspected placental insufficiency (intrauterine
growth restriction, decreased fetal movement
