Intrapartum Care Flashcards
Labor
Physiologic process in which a fetus is expelled from the uterus
T/F: a woman is not in labor until the contractions bring about demonstrable effacement and dilation of the cervix
True
Dilation
How open the internal os is
Complete dilation
10 cm
Effacement
Difference between the internal and external os
Thinning of the cervix
Station
Degree of descent of the presenting part of the fetus measured in cm from the ischial spines
Amount of station
-4: 4 cm above the ischial spine
0: at the level of the ischial spine
+4: 4 cm below the ischial spine
In order to diagnose labor, there must be __
Cervical change
Braxton Hicks contractions
Contractions without cervical change
Ways to diagnose labor
Ferning
pH measurement of fluid (nitrazine test)
Presence of amniotic pooling in the vagina
US to measure amniotic fluid index
Spontaneous rupture of membranes
Rupture of membranes during labor
Premature rupture of membranes
Rupture of membranes before the onset of labor
When are women screened for group B strep?
35 weeks
If the group B strep swab is positive?
PCN
If PCN allergy, give vanc
When should a woman be treated even if her group B strep swab comes back negative?
Group B strep has been colonized in a urine culture
Previous OB hx of group B strep or neonatal sepsis
Stages of labor
Stage 1: from onset of labor to complete cervical dilation
Stage 2: from complete cervical dilation to expulsion of fetus
Stage 3: from delivery of infant to delivery of placenta
Stage 4: from delivery of placenta to 1 hour postpartum
Friedman’s labor curve
Good guideline for expected progression in labor but is not used as frequently anymore
Duration of labor for nulliparous vs multiparous
Nulli: 10-12 hours
Multi: 6-8 hours
Latent phase of first stage of labor
From onset of labor with slow cervical dilation to 4 cm
Active phase of first stage of labor
From 4 cm to complete dilation
Protracted dilation
Taking longer to dilate
Arrest of descent
Baby is not coming down into the pelvis
Factors affecting stages of active labor
Power: uterine contractions are poor or uncontrolled
Passenger: fetus’s head and its ability to pass through the birth canal
Pelvis: mom’s pelvis is too small for the fetus to pass
Breech
Baby’s head is up and not in the pelvis where it should be
A c-section is recommended for all babies over ___, or ___ if the mother is diabetic
5000 g; 4500 g
Fetal variables that can affect labor
Fetal presentation
Degree of flexion or extension of the neck
Relationship between the fetal presenting part to the right or left side of the birth canal
Number of fetuses
Presence of fetal anomalies
Fetal presentation
What part of the baby is entering the pelvis first
In vertex position, ___ is the reference point, and in breech position, ___ is the reference point
Occiput; sacrum
Diagnosis of fetal presentation and position
Leopold maneuvers
Vaginal exam
US
Leopold maneuvers
Abdominal palpation to determine fetal lie, weight estimate, position, and presentation
T/F: any position other than vertex usually results in a c-section
True
A ___ pelvic outlet is an indication for c-section
Small
Cephalopelvic disproportion
Passenger is too large for the pelvis
How can activity be assessed?
Observation
Palpation of the fundus
External tocodynamometry
IUPC (intrauterine pressure catheter)
What is considered adequate labor?
3-5 contractions in a 10 minute period
If labor is not progressing…
Insert IUPC to adequately monitor contraction
If under 200 MVU in 10 minutes, then start Pitocin
How to intervene to increase the force of already present contractions
Pitocin
Artificial rupture of membranes
Induction of labor
Attempt to begin labor in a non-laboring patient
Ideal time to deliver baby
39 weeks (ARRIVE trial)
Indications to induce labor
Multiple gestation
Maternal HTN, DM, HIV
H/O fetal demise or PROM
CI to induce labor
Placenta previa and vasa previa
Transverse fetal lie
Umbilical cord prolapse
Prior c-section
Active herpes lesion
Prior myomectomy
Bishop score
6 or less: unfavorable outcomes
Over 8: probable success
Methods to induce labor
Cervidil
Cytotec
Characteristics of Cervidil
Removable device
12 hours
Expensive
Characteristics of Cytotec
Tablet
4 hours
Cheap
T/F prostaglandins used for cervical ripening increase the likelihood of delivery within 24 hours
True
Balloon catheter (Cook)
Gently helps cervix ripen w/o causing overstimulation
Pitocin
Identical version of oxytocin leading to uterine contractions
SE of Pitocin
Tachysystole
Uterine rupture
Hypotension
Tachysystole
Over 5 contractions in 10 minutes
Why is tachysystole a problem?
Force of contractions can take blood supply away from the baby, so baby’s HR can go down if contractions are too fast
Pros and cons of amnihook
Pros: if you do it after labor, it can make labor shorter
Cons: increased risk of infection and poor outcomes if water is broken before they are in labor
Characteristics of epidural anesthesia
Epidural catheter placed in L3-L4
Initial bolus of anesthetic given then a continuous infusion started
Complications of epidural
Maternal hypotension
Spinal HA
Maternal respiratory depression
CI of epidural
Bleeding disorder
Patient refusal
Characteristics of spinal anesthesia
One time dose placed directly into the spinal canal
Used for c-section
Pudendal block
Provides perineal anesthesia for pelvic floor pressure pain
When can general anesthesia be used?
Used for c-section in emergent or urgent settings
Complications of general anesthesia in labor
Maternal aspiration
Risk of hypoxia to mother and fetus
How long do you have to get the baby off after blood flow is cut off?
4 minutes
Normal FHR baseline
110-160 bpm
What criteria is needed to set a baseline?
Must last for 2 minutes
T/F: fluctuations in the baseline FHR is regular in its amplitude and frequency
False - it is irregular
Variability in FHR
Absent: amplitude range is undetectable
Minimal: range is detectable but 5 bpm or fewer
Moderate (normal): range 6-25 bpm
Marked: range greater than 25 bpm
Acceleration of FHR
Visually apparent abrupt increase in the FHR
Acceleration peak before and after 32 weeks gestation
Before 32 weeks: acceleration has a peak of 10 bpm above baseline with a duration of 10 seconds
After 32 weeks: acceleration has a peak of 15 bpm above baseline with a duration of 15 seconds
Prolonged acceleration
Lasts 2 minutes or more but less than 10 minutes in duration
If an acceleration lasts ___, it’s a change in baseline
10 minutes or more
Deceleration
Visually apparent usually symmetrical gradual decrease and return of the FHR associated with a uterine contraction
Early vs late deceleration
Early: the nadir of the deceleration occurs at the same time as the peak of the contraction
Late: the deceleration is delayed in timing, with the nadir of the deceleration occurring after the peak of the contraction
If the deceleration lasts more than ___, it is a change in baseline
10 minutes
T/F: sinusoidal pattern is extremely dangerous and insinuates anemia
True
What usually causes early decelerations?
Head compression
Late decelerations are the result of ___
Uteroplacental insufficiency
Interventions for late decelerations
Position change
Stop Pitocin
Check cervix
Consider c-section
What causes variable decelerations?
Cord compression
Intervention for variable deceleration
Amnioinfusion: infusion of saline into amniotic sac
Category 1 FHR
Baseline rate 110-160
Variability: moderate
Decelerations: none
Outcome of category 1 FHR
Baby will typically be fine
Category 2 FHR
Characterized by intermediate FHR patterns of tachy or bradycardia, minimal or absent baseline variability not accompanied by recurrent decelerations, marked baseline variability, no accelerations, and periodic or episodic decelerations
Category 3 FHR
Recurring late decelerations
Recurrent variable decelerations
Bradycardia
Sinusoid pattern
Outcome of category 3 FHR
Baby needs to come out via c-section right away
Contraction stress test
Evaluates the fetal response to a transient reduction in fetal oxygen delivery during uterine contractions
For the contraction stress test, use ___ to achieve ___ in ___
Pitocin; 3; 10 minutes
Indications for contraction stress test
Growth restricted baby
Cardinal movements of labor
Changes in the fetal head position during its passage through the canal
Engagement
Passage of the widest diameter fetal presenting part below the place of the pelvic inlet
Descent
Downward passage of the presenting part through the body pelvis
Flexion
Complete flexion allows the fetal head’s smallest diameter to fit through the pelvis
Internal rotation
Rotation of the fetal head from occiput transverse to occiput anterior or posterior position
Extension
Occurs when the occiput is just past the level of the symphysis
External rotation/restitution
As the head is delivered, it rotates back to its original position prior to internal rotation
Expulsion
Delivery of the fetus
Delivery of the shoulders
Downward traction allows release of the anterior shoulder and the fetus is delivered
Then posterior shoulder is delivered
Indications of second stage
Pelvic/rectal pressure
Molding
Alteration of the fetal cranial bones in relation to each other as a result of compressive forces of the maternal bony pelvis
Caput
Localized edematous area on the fetal scalp caused by pressure on the scalp by the cervix
Perineal lacerations
1st degree: extends through the vagina and perineal skin
2nd degree: extends into soft tissue of perineum (perineal body)
3rd degree: through anal sphincter
4th degree: through rectal mucosa
Episiotomy
Surgical incision of female perineum
Complications of episiotomy
Vaginal bleeding
Pain
Sexual dysfunction
Infection
Midline vs mediolateral episiotomy
Midline: straight through the perineum
Mediolateral: through the side
Indications for use of forceps or vacuum in operative vaginal delivery
Prolonged second stage of labor
Maternal exhaustion
Hasten delivery for fetal compromise
How much time is usually between fetal and placental delivery?
Usually 30 minutes
3 signs of placental separation
Lengthening of umbilical cord
Gush of blood
Fundus becomes more globular and more anteverted against abdominal hand
What must be closely monitored in the 4th stage?
BP
Uterine blood loss
Pulse rate
What can cause uterine inversion?
Aggressive removal of the placenta
Repair of uterine inversion
Give med to relax uterus
Place fist in uterus to fix the shape
Give them Pitocin to contract the uterus into position
Shoulder dystocia
Difficulty in delivery of the anterior shoulder due to impaction of the anterior shoulder on the pubic symphysis
Complications of shoulder dystocia
Fracture of clavicle
Brachial plexus injury
Hypoxic brain injury
Death
Management of shoulder dystocia
Call for help
Episiotomy
McRoberts maneuver
Suprapubic pressure
Delivery of posterior arm
McRoberts position
Sharp flexion of maternal hips to open symphysis more horizontally
Umbilical cord prolapse
Prolapse of umbilical cord in front of fetal head
Why is an umbilical cord prolapse dangerous?
Cut off bloodflow to fetus
T/F: umbilical cord prolapse is an indication for a c-section
True
MCC for postpartum hemorrhage
Uterine atony (receptors get flooded and uterus doesn’t react to oxytocin anymore)
Treatment of postpartum hemorrhage
Removal of placental fragments or repair lacerations
IV access
Type and cross match for blood
Medications for uterine atony
Meds for uterine atony
Pitocin
Methergine
Cytotec
Hemabate
CI for uterine atony drugs
Pitocin: hypotension
Methergine: hypertension
Hemabate: can’t use in asthmatics
