Intrapartum Care Flashcards

1
Q

Most Common Complaints in L&D Triage
2nd and 3rd trimester bleeding

A

Most Common
- decreased fetal movement
- contractions
- rupture of membranes
- vaginal bleeding

others
- trauma
- SOB/chest discomfot/abd pain

2nd Trimesters Bleeding
- chrninc abruption (painful)
- placenta previa (painless)
- vasa previa (painless)

3rd Trimesters Bleeding
- Mucous Plug
- Labor
- Abruption

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Techniques to Rule Out Rupture of membranes

A

Ferning
- under a microscop slide: the amniotic fluid will appear in a ferning pattern when dried, other fluids will not

Nitrazine
- testing the pH of the fluid
- amnionic fluid will be more basic; levels in the pH of 7.0-7.5

Ancillary Testing
- Tampon Test: amniotic fluid will continuously leak out
- Amnisures (PAMG-1) : testing the contents of the fluid to test + for aminotic fluid
- Actim Prom (IGFBP-1) : point of care test for ruptured membranes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Signs of Fetal Distress acute/chronic

A

Decreased Fetal Movement
- 10 kicks in 2 hours : considered ideal

Meconium
- stained fluid could indicate meconium
- not specific; stress or maturity can bring this about
- meconius + preterm rupture of membranes (PROM) = a problem

Doppler Evaluation of Blood Flow

Growth restirction

Non-reassuring fetal Heart Rate

BPP score of < 6/10 (biophysical profile)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Fetal Movement & signs of fetal distress : The Non-Stress Test
baseline
vaiability
accelerations
decelerations
fetal well being

A

Non-Stress Test
- a test which measures fetal heart rate in the absence of contractions

Baseline
- want values between 110-160

Variability
- the “wiggle of the baseline”
- want some variability to some degree

Accelerations
- want 15 up for 15 seconds, 2 in 20 minutes
- 10 by 10 for those before 32 weeks, 15 for 15 afte 32 weeks

Decelerations
- Variable: a rapid drop and return, commonly due to cord compression
- Early: in line with contraction
- Late: concerning

when determining fetal well being: can do a reative NST or a BPP

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Biophysical Profile: BPP
scoring system based on what

A

BPP contains
- movement: 3 episodes
- breathing: 30 seconds of breathing
- Tone: one episode of fetal extension/flexion
- Fluid: single deepest pocker
- reactive nonstress test: two points of reactiveity

8/10 - 10/10 = reassuring
6/10 = meh, might want to redo
0/2/4 of 10 = bad sign; likely need to deliver ithin the next 30 minutes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Fetal Monitoring with Pitocin
what is it and how do you monitor

A

Contraction Stress Test

Pitocin
- a synthetic version of oxytocin: which stimualtes contractions
- solution given until 3 contractions at Q10 minutes apart

(+) CST: late decelerations following at least 50% of the contraction
(-) CST: no late decels or significant variablitliy in decelerations you want to see this, we dont want later decels
equivocal: intermittenet later decelerations : need to do other tests to confirm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Define true v false labor

A

True Labor: can only be “diagnosed; retrospectively”

False Labor: Practice labor
- also caleld braxton hicks contractions: contractions of the uterus which do NOT cause cervical cahnges
- these ar normal and healthy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Stages of True Labor

A

Stages of Labor

First Stage: latent and active

Latent: Generally considered from closer cervix - 6 cm + contractions (this is early labor)

Active: 6cm -10cm at which 10 cm; is fully open

Second Stage
- 10 cm dilation to delivery of th ebaby

Third Stage
- delivery of the baby to devliery of the placenta
- this is considered to take up to 30 minutes (about the time of 3 contractions)

True Labor: follows the Friedman Curves
- average nullipar: 1.2cm/hour and multi 1.5cm/hour
- the latent phases of labor is very individualized
- the accelaration and active phase of labor is more universal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Mechanisms of Labor
why does it occur

A

Labor: unknown the entire mechanisms and cause of what triggers it

thought to be….
postivie feedback loop: “fergisens refelx
- pressure of teh cervix, increases oxytocin, increased contractions, increased pressure and cycle continues
- initially; mediated by the materal fetal HPA access

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Abnormal Labor: Define the Following & treatments

Prolonged labor
Prolonged Active phase
Arrest of Dilation

A

Prolonged Labor
- no agreed upon defintion: keep close eye on maternal exhustion and dehydration and sleep
- proposed idea that labor prolonging past 24 hours is considered

Treatment = pitocin, benydral, rupture; prevention is key!

Prolonged Active Phase
- Dilating less than 1-2cm/hour
- this can be okay, as long as mom and baby are being watched, can be fine to have this prolonged as long as it is continuing, not arrested

Arrest of Dilation
- no cervical changes > 6 hours withOUT adequate contractions
- no cervical changes > 4 hours WITH adequate contractions

Treatment (for prolonged active phase, arrest of dialtion)
- pitocin, rupture
- use of intrauterine pressure catheter

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Abnormal Labor: Define the Following

Arrest of Descent

Shoulder Dystocia

A

Arrest of Decent
for nulliparous women: allow 3 hours of pushing or 4 hours from completetion

for multiparous women: allow 2 hours of pushing or 3 hours from completion

these recommendations chagne with the adminsiteration of epidural, malpositioning

complete arrest triggers the need for a c-section : the result of no movement

Treatment of arrested decent = c-section

Shoulder Dystocia
- hard to predict; when shoulder gets stuck
- anterior: on the pubic symphisis
- posterior: on the sacrum
- turtle sign: head born but then pulled back due to shoulder being stuck

Treatment = McRoberts maneuver or suprapubic pressure

treatment of a retained placenta is a D&C

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Pain Management Intrapartum

Latent Phase

Active Phase

2nd stage of labor management

A

Latent Phase
non-pharm: childbirth edu. classes, labor support, doulas!!, birthing balls, massage, shower, etc.
pharm: sleeping meds (benadryl/ambien), opiods, non-opiods (nitrous oxide to decrease pain of contractions)

Active Phase
- this is when neuraxial analgesia can be used: spinal/epidural/CSE
- dont want to give these too early: they wont help

2nd Stageof Labor
- 10cm - birth
- can do a pudenal block

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Classifications of Fetal Well Being During Labor: Category I - III
what is included to categorize a fetus as 1, 2 or 3

A

Category I
- moderate variabililty on monitor
- normal baseline: 110-160
- no variable or late decelerations
- early decels & acels okay

Category II
- everything else
- not very helpful category

Category III bad signs
- absent variability, recurrent variable or late decels
- sinusoidal
- absent variability with bradycardia

baby has a varibale baseline (little wiggle) because the sympathetic system matures sooner: thus they have the ability to reguate and alter HR depending on environmental conditions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Maternal Monitoring during Labor
what are we watching

A

Cervical Exams
- assessing continuously
- if water has broekn; decreased amount of cervical exams are done

Vitals: BP, temp, pulse ox
- Q4 hours
- temperature Q2hours

Pain Control
- determine if they’re coping will or need excess pain control support
- not a 0-10 scale since, its painful….

Blood Workup
- CBC
- rpr (syphilis)
- type and screen
- commonly done on admission

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Normal Fetal movements during Delivery
the Cardinal Movements of Labor

A

Cardinal Movments of Labor

Baby starts
- head first and face down

Station =# cm above/below th eisichal spine

Engagement, Flexed and decent
- head first, flexion toward chest
- cervix dilated
- contractions push bay: turtling head out
- engagement: the biparietal diameter throughthe widest part of the pelvis

Descent, Roation
- the head once hitting the pelvic floor begins to rotate
- from transverse to anterior-posterior positioning

Complete Roation & Early Extensions
- head behind to extend

Complete Extension
- head now past the pubic symphysis which triggers the extension of the neck

Restitution
- the head and shoulders roate

Anterior shoulder delivery from the pubic symphysis

Posterior shoulder delivery from the posterior aspect

the overall curve: is a downward then upward curve: the Karis curve

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Techniques to Assist with Normal Delivery

A

Normal Delivery

Perineal massage: before, not during devliery

Perineal protection: hand on perineum +/- effiecay to help decrease tearing
- however you cant really slow the process to decrease tearing, as its reflex, but panting > pushing has some effect

Delivery of the head and shoulders

17
Q

Techniques to Assist with Abnormal Delivery : SHulder Dystocia
Episiotomy & positioning
pressure where
McRoberts
Woods Corkscrw & posterior arm

A

Ancillary Movements Shoulder Dystocia

Episiotomy
- a cut in the RML or midline perinuem
- used only when needed for shoulder dystocia or fetal compromised and need to get out

Suprapubic Pressure
- help to guide

McRoberts
- move moms knee toward her ear: flattens angle of delivery
- allows the should to come out from under the pubic symphysis

Woods Corkscrew
- allows for delivery of the posterior arm
- provider hand inside to unstuck the shoulder from the saccrum

Delivery of teh posterior arm
- can help upstuck shoulder to delivery rest

18
Q

Immediate Postpartum Care
PLacenta Devliery
Prevent Hemorrhage
Repair Vaginal Lacs

A

Delivery of the Placenta
- within the first 30 minuts of delivering baby
- uterus will feel globular
- cord will lengthen
- then the placenta will detach : fresh blood will be present
- can use two fingers inside to pull down and roate to fully remove placenta membrane
- mom will push as you pull

Prevent PostPartum Hemorrhage
- this is during active 3rd stage of labor : devleiry of placenta
- if you give ptosin once the anterior shoulder is birthed: decreases the risk of PP hemorrhage

Repair Vaginal Laceration
- grdae 1: through the skin and submucosa only
- grade 2: skin submusocas, some perineal mucles, not the internal sphincter
- grade 3: skin, submusoca, somre perineal muscles includng the internal sphincter
- grade 4: skin, muscosa, perineal mucles, internal sphcinter fully through to the rectal cavity
- repair these

19
Q

Causes of Preterm Labor

A

Pretemr Labor

Define
- advance cervical dilation with contractions between 24 weeks and 37 weeks

Due to…
Uterine Distention

Infection/Inflammation

Activation of the maternal/fetal HPA access

Uterine Bleeding

20
Q

Evaluation of Preterm Labor

A

history
- contrations frequency
- rupture of membranes? color?
- bleeding? amount and color
- histor of priort PTD
- > 5 contractions/hour

Physical Exam
- speculum exam done first
- digital exam: NOT if the membrane is ruptured
- before you do these you MUST have US confirmation of the placental location

LAbs
- CBC
- type and screen
- RPR
- GBS (group B strep)
- fetal fibronectin:
- + feteal fibronectin: dont know if this is PTL or not
- - fetal fibronectin: lowe risk fo preterm labor in the next 48hours

Imaging
- cerivcal length
- look at cervical os: funneling of amniotic membrane into os

21
Q

Mangement of Preterm Labor

A

Preterm Labor: cervical changes (a retrospective dx.)

Steroids
- to help ung developement and increase survival

Tocolysis
- rarely used

MAgnesium
- neruoprotection for newbrns
- decreased intercranial hemorrhage and decrease contractions so you have time to give the steroids and abx for GBS

Group B Strep Prophyslaxis
- for mom at risk (those with PPROM)

22
Q

Breech Positions

A

complete Breech: cannonball, legs crossed
Frank Breech: booty first, legs straight to teh sky

Footling Breech: one leg down, one crossed

Kneeing Breech: knees first

Treatment
Breech: C -section most comonly

external Cephalix veision: can be done to roate the baby then induced for delivery

23
Q

Indications for Induction of Labor

for those at 39+ weeks
for those at 37+ weeks
for thsoe at 34+ weeks
for those at 32+ weeks

A

Induction of Labor

39+ weeks
- full term; all infants do well after 39, small increase in need for c-section at this point
- could be cHTN, DM, AMA (advance materal)

37+ weeks
- early term
- risk of respiratory distress syndrome if induced at this point but most do well
- due to pre-eclampsia, gTHN, IUGR < 5%

34+ weeks
- late preterm
- for those IUGR with absent flow
- for those mono-di twins
- pre-eclampsia with severe features

32+ weeks
- mono-mono weeks because risk fo cord entanglement

24
Q

Indications for C section

A

C section

anteparum
- breech
- placenta previa
- placenta accreta
- some twins (iterlocking!)

Intrapartum Reasons
- fetal heart tracing not reassuring
- arrest of dilation
- arrest of decent
- maternal hemorrahge
- abruption
- cord prolapse: cord before baby

25
Q

VBAC: vaginal birth after c-section
risks & benefits

A

always weight risks/benefits

Risks
- uterin rupture
- encephalopathy
- hysterectomy
- hemorrhage

benefits
- avoid major abd. surgery
- avoid need for future c section
- no side effects of multiple c sections (accreta nd previa)

26
Q

VBAC: vaginal birth after c-section
who is best canidate
who is iffy
who is contraindicationed

A

Best canidate
- had a prior vaginal before
- the c section was a low transverse (not hitting fundus)
- non-reproducable indications for prior c section

Likely okay for VBAC
- two prior c sections
- priot lower vertical
- obestiy
- unknown uterine incision type

COntraindicated in
- those with classic, J hysterectomy or T inicsion (risk of uterine abruption)
- prior uterine ruption
- contraindications to vaginal develiry as is