Intrapartum Obgyn Flashcards
- Uterine contractions regular, before 37 weeks gestation , and associated with cervical changes
- Can result in premature birth
Preterm Labor
Birth types
spontaneous - intact membranes or PPROM
indicated - d/t maternal or OB complications (eclampsia)
Preterm Labor
Risk Factors: multifetal gestation and prior preterm birth
Causes:
1. Maternal or fetal stress trigger HPA axis (maternal substance abuse, short interpregnancy)
2. Decidual-chorioamniontic inflammation/infection
3. Decidual hemorrhage
4. Patho uterine distention
Causes of Preterm Labor
Signs and Symptoms (6)
- Menses like cramps
- Abdominal / pelvic pressure
- Change in vaginal discharge
- Abd pain with or without diarrhea
- Dull low back pain
- Painless contractions
s/s of Preterm Labor
Evaluation of :
US - cervical length, location of placenta
GBS culture, STD culture
Amniocentesis (check for infxn)
Evaluate pre term labor
Management
STOP UC- use of tocolytic therapy and prolong pregnancy for 48 hours (BETHAMETHASONE, or DEXAMETHASONE)
- C/I in : advanced maternal age, vaginal bleed, severely anomalous fetus, severely pre -eclamptic, chorioamnionitis
- MgSO4
- ABX prophlyaxis of GBS or PPROM
Manage of Pre term labor
Preterm 42 weeks
Classify pregnancy
Relates to immediate and extended maternal care after delivery (puerperium)
- From end of L&D through first 6 weeks after delivery
- Postnatal care = neonatal concerns after birth
Post partum care
sensation felt when “baby drops” = time when presenting (lowermost) part of the fetus descends into maternal pelvis
- aka engagement
- 2-3 weeks before labor
lightening - intrapartum care
False UC, NO cervical dilation
Braxton hicks - intrapartum care
increase cervical mucus and or blood-tinged mucus
Bloody Show
Call doc if
- UC q 5 min x 1 hour
- vaginal fluids: sudden gush or continuous leakage
- Vaginal bleeding
- Decreased FM
intrapartum care
PN record review - confirm GA week, day
aware problems/ risk during pregnancy
review lab results
focused maternal hx: UCs, ROM, LOF (leak of fluid), bleeding, decreased FM, focal sx
va: maternal
Abdomen - UCs (mild moderate severe), fetal lie, presentation, position
initial eval for labor
- The relation of the long axis of the fetus to the maternal long axis, longitudinal 99% of time.
- the portion of the fetus lowest in the birth canal, palpated during the exam (most common: head is sharply flexed onto the fetal chest such that the occiput or vertex shows)
- relation of the fetal presenting part to the Right or Left side of the maternal pelvis
- Fetal Lie
- Presentation
- Position
The OCCIPUT-ANTERIOR POSITION is deal for…..
BIRTH!!
- fundal component
- fetal back and extremities
- presenting part/ symphysis
- direction and degree of flexion of head
Leopold Maneuvers - intapartum care
Cervical consistency - soft or firm
- Cervical effacement - shortening of cervical canal = % of thinning
- Cervical dilation= opening of cervix
PE/ vaginal/ digital exam - intrapartum care
Fetal station : fetal presenting part in relation to ischial spines
- Spines separate pelvic inlet from outlet
- -> FETAL PART AT THE SPINES = STAGE 0 (ZEROO)
Intrapartum care - initial eval for labor
Stage 1.
The interval between onset of labor and full dilation of cervix
- Latent phase –> cervical effacement up to 4cm
- Active phase –> cervical effacement starting at 4-5cm to 10 cm
- Transition –> 8-10 cm
Stage 2
Starting from full dilation through delivery of the baby
Stage 3
Starting from delivery of baby through delivery of placenta
Stage 4
Immediate 2 hours after delivery of placenta
Stages of Labor - intrapartum care
Changes of fetal position thru birth canal.
1. Engagement
descent of biparietal diameter into pelvic outlet
- Flexion:
smaller diameter of vertex presents into pelvis - Descend
vertex reaches ischial spine - Internal rotation
Vertex deeper into pelvis (anterior or posterior presentation of head) - Extension
vertex reaches introitus
- Flexed head extends to fit upward curve - External rotation
head rotates to “face forwards” to align with shoulders and pelvic outlet (Restitution) - Expulsion
delivery of body
Mechanisms of labor - Cardinal movements
Management - normal L&D
- Maternal ambulation and position
- -> allow to ambulate or assume any position
- > left lateral position if recumbent
Dorsal Lithotomy position - most commonly used in US for spontaneous vaginal births
intrapartum -care management
why minimize maternal fluids?
give - ice chips /clear fluids , parenteral : IV w/ 1/2 NS or D5 1/2 NS
because d/t decrease GI peristalsis, aspiration can occur during admin of anesthesia
Labor pain
- 1st stage d/t contraction of uterus and dilating cervix
- 2nd stage d/t vagina and perineum stretching; compression of rectum
Maternal analgesia
No pharm - breathing, hypnosis, ball, peanuts, rocking chairs, hydrotherapy
Pharm: NUBAIN, STADOL, MORPHINE, FENTANYL
Regional blocks : anesthetic or narcotic in epidural or subarachnoid space
- combined spinal-epidural = rapid initial relief
Local block - to vagina or perineum (pudendal block)
General anesthesia - IV or inhaled
Maternal analgesia , normal L&D
Intermittent monitor: Doppler (low risk)
q 30 min / active phase - 1st stage
q 15 min - 2nd stage
-Continuous electronic fetal monitoring (EFM) - external or internal
Fetal well being evaluation
Management of Labor
Stage based on 1st stage (onset of labor thru dilation)
- serial pelvic exams
- observe for ROM (clear, meconium, blood)
-Support and encourage
Stages based on 2nd stage (dilation thru delivery)
- Voluntary pushing and involuntary UCs
- Fetal Head = molding and caput succedaneum (common cause overestimation of station)
- Crowning
- Episiotomy and Ritgen maneuver rare interventions
Episiotomy 1st degree - vagina mucosa /perineal skin 2nd degree- subq tissue 3rd degree- rectal sphincter 4th degree- rectal mucosa
Stage Based on 3rd stage (placenta) signs of placenta separation 1. Uterus rises 2. Gush of blood 3. Cord lengthen 4. Wait 30 min for it to come out 5. Gentle downward traction, opposite pressure on suprapubic counterpart
Staged based on 4th stage First hour risk of PPC - Risk factors: rapid labor, protracted labor, polyhydramnios, macrosomia, multi-fetal gestation, intrapartum chorioamnionitis - inspect lacerations and repair - uterine massage - uterotonins - oxytocin ,misoprostol methergine, carbopost EBL (est. blood loss) - Monitor maternal VS
manage l and d
Induction of labor
-benefit risk mom or fetus vs continued preg
- Maternal: HTN, GDM, preeclampsia
- Fetal : IUGR, post-term, oligohydramnios
Options: OXYTOCIN, CERVICAL RIPENING, MEMBRANE MANIPULATION
Induction of labor
Minimize uterine overstimulation: lower and less frequent OXYTOCIN
Reduce incidence chorionamnionitis or C-section d/t dystocia = Higher and More Frequent OXYTOCIN
Oxytocin - induction of labor
Cervical Ripening
- For unfavorable cervix
- MISOPROSTOL: E2 prostaglandine, insert vaginal or intracervical
C/I - hx uterine surgery or Csection
LAMINARIA in internal os
- Risks: failure to dilate, lacerate cervix, accidental ROM, infection
Synthetic dilation - 30 ml foley cath/canal
Cervical Ripening
Membranous manipulation
- AKA STRIPPING, SWEEPING
- Free chorionic membrane from decidua/lower uterine segment
- Risks: infection, bleeding, accidental ROM
Membranous manipulation
C-seciton
- maternal mortality rate 2-4x vaginal birth
- Indications :
1. labor dystocia ; NR FHS status
2. Elective repeat/ primary c/s
3. Abnormal fetal presentation
4. Placenta previa or abruption , cord prolapse
C-section indication
C section types
- Low Transverse LTCS = incision thru thin lower uterine segment allows for VBAC
- Classical : incision thru thick, muscular upper portion of uterus - risk of uterine rupture - no TOLAC
C section types
trial of labor c-section
1. rate of uterine rupture
Trial of labor c-section (TOLAC)
TOLAC requirements
- continuous EFM
- OBGYN
- anesthesia
- blood bank
TOLAC requirements
