Intrapartum Care Flashcards
Most Common Complaints in L&D Triage
2nd and 3rd trimester bleeding
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
Techniques to Rule Out Rupture of membranes
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
Signs of Fetal Distress acute/chronic
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)
Fetal Movement & signs of fetal distress : The Non-Stress Test
baseline
vaiability
accelerations
decelerations
fetal well being
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
Biophysical Profile: BPP
scoring system based on what
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
Fetal Monitoring with Pitocin
what is it and how do you monitor
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
Define true v false labor
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
Stages of True Labor
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
Mechanisms of Labor
why does it occur
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
Abnormal Labor: Define the Following & treatments
Prolonged labor
Prolonged Active phase
Arrest of Dilation
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
Abnormal Labor: Define the Following
Arrest of Descent
Shoulder Dystocia
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
Pain Management Intrapartum
Latent Phase
Active Phase
2nd stage of labor management
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
Classifications of Fetal Well Being During Labor: Category I - III
what is included to categorize a fetus as 1, 2 or 3
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
Maternal Monitoring during Labor
what are we watching
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
Normal Fetal movements during Delivery
the Cardinal Movements of Labor
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
Techniques to Assist with Normal Delivery
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
Techniques to Assist with Abnormal Delivery : SHulder Dystocia
Episiotomy & positioning
pressure where
McRoberts
Woods Corkscrw & posterior arm
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
Immediate Postpartum Care
PLacenta Devliery
Prevent Hemorrhage
Repair Vaginal Lacs
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
Causes of Preterm Labor
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
Evaluation of Preterm Labor
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
Mangement of Preterm Labor
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)
Breech Positions
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
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
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
Indications for C section
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
VBAC: vaginal birth after c-section
risks & benefits
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)
VBAC: vaginal birth after c-section
who is best canidate
who is iffy
who is contraindicationed
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
