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Women's Health > Labor > Flashcards

Labor Flashcards

1
Q

what are the contractions we are worried about?

A

Only if the cervix is changed

otherwise the contractions do not matter

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2
Q

what is complete dilation of the cervix?

A

10cm

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3
Q

what is effeacement?

A

length of the cervix (how thick it is)
Difference between the internal and external cervical os

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4
Q

What is station?

A

degree of descent of the presenting part of the fetus
Measured in centimeters from the ischial spines
Can measure it in thirds

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5
Q

What is the consistency of the cervix during labor?

A

Soft, medium or firm
More firm means they are not in labor

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6
Q

what is the position of the cervix during labor?

A

Becomes more anterior

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7
Q

what does the head of the baby first go into contact with when exiting the bith canal?

A

internal os

then to the external os

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8
Q

How do you dx labor?

A

CERVICAL CHANGE

consistent contraction
ferning (with swab)
nitrazine
presence of pooling
AFI = shows less fluid

spontaneus rupture of membranes during labor - but somtimes it will happen before the induction of labor

-vaginal bleeding (d/t dilation of cervix)

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9
Q

What are contractions that do not cause cervical change and what can cause it?

A

Braxton Hicks contractions

Dehydration

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10
Q

What is the bishop score and what is a favorable score?

A

Determines how favorable the cervix is for labor

> 8 = favorable

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11
Q

What is the worry of GBS in baby? What is the treatment?

A

sepsis

if high [] of GBS

treat during labor w/: Penicillin

Erythromycin or Clindamycin
Vancomycin if no sensitivites

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12
Q

How to mng pain during labor

A

TRY TO AVOID

epidural anesthesia in L3-L4
bolus and then continual infusion

spinal anesthesia (for C sections)

Pudendal block (perineal anesthesia, difficult to do)

general anesthesia (try to avoid, but for a C section)

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13
Q

Complication of epidural anesthesia

A

Maternal hypotension
Maternal respiratory depression
Spinal headache

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14
Q

CI of epidural anesthesia

A

Maternal bleeding disorder or use of LMWH within 12h

Patient refusal

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15
Q

complication of general anesthesia

A

Maternal aspiration
Risk of hypoxia to mother and fetus

because all of the anesthesia goes to the baby

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16
Q

Why is NO not typically used during labor?

A

Respiratory depression paired with worry of COVID

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17
Q

What is the success of labor determined by?

A

Bishop Score <5 may lead to failed induction 50% of time

Bishop Score <5 indicates need for cervical ripening

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18
Q

How to induce labor with pharm?

A

Prostoglandins (cervidil or cytotec)
Pitocin

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19
Q

MOA of prostoglandins for labor

A

Cause dissolution of collagen bundles and increase water uptake by cells

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20
Q

difference between cervidil and cytotec

A

Both can be vaginal (kinda like a tampon)

Cytotec can be oral as well (but Diarrhea SE)

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21
Q

SE of prostoglands (cervidil and cytotec)

A

Tachysystole, fever, vomiting, diarrhea
Uterine rupture

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22
Q

CI of prostglandins?

cervidil and cytotec

A

History of cesarean section, myomectomy (peeling tissue from the uterus) or hysterotomy (incision into the uterus)

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23
Q

Pitocin route and MOA

A

Given IV

Identical version of oxytocin released from posterior pituitary leading to uterine contractions

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24
Q

SE of pitocin?

A

Tachysystole - >5 contractions in 10 minutes
Uterine rupture (but not as likely as the prostaglandins)
Hyponatremia
Hypotension
Amniotic fluid embolism

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25
Q

CI of pitocin?

A

Fetal distress
hypersensitivity

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26
Q

Other than pharm, how can you induce labor?

A

Manually

Balloon catheter (Cook)
Laminaria

Artificially breaking the water (with amnio hook to punture amniotic sac)

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27
Q

What material is laminaria?

A

Rolled up seaweed that pulls out water and in turn dilates the cervix

not very common, often used for fetal demise or procedures

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28
Q

What can augment labor?

A

increase the already present contractions

Typically use PITOCIN

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29
Q

What do you use to help pull the fetal head out of the vagina? When would you do this?

A

Forceps
Vacuum (used more often now)

indicated during:

Prolonged second stage of labor (harder to do a C section at this stage)
Maternal exhaustion
Hasten delivery for fetal compromise

makes sense

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30
Q

Where does a cesarean delivery occur?

A

Abdominal delivery of the fetus

30% of live births!

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31
Q

What are the four stages of labor

A
  1. First Stage
    From onset of labor to complete cervical dilation
  2. Second Stage
    From complete cervical dilation to expulsion of fetus
  3. Third Stage
    From delivery of infant to delivery of placenta
  4. Fourth Stage
    From delivery of placenta to one hour postpartum
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32
Q

What guideline did we used to do for labor?

A

Freidman’s curve (1950s)

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33
Q

What labor curve revaluated Freidman’s curve and why?

A

The Labor Curve – Zhang (2010)

Revaluated labor curves
Spontaneous labor
Labor progresses similarly for multips and primips until 6cm
Defined active phase at 6cm
After 6cm, multips progressed much quicker
Induced labor
Latent phase of labor is significantly longer in induced labor compared with spontaneous labor
Active phase of labor is similar between the two groups

bigger study
active phase is at 6 cm

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34
Q

Explain the first stage of labor and the two phases of the first stage

A

Interval between the onset of labor and full cervical dilation

Nulliparous patient: 10-12 hours
Multiparous patient: 6-8 hours

Two phases:
Latent phase
From onset of labor with slow cervical dilation to ~6 cm
This is a slower phase
Active phase
From ~6cm to complete dilation (10cm)
Faster rate of cervical change
Nulliparous patient: 1.2cm/h
Multiparous patient: 1.5cm/h

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35
Q

three factors that affect active phase of the first phase of labor

A

Power – uterus
Passenger – fetus
Pelvis – baby has to fit out of

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36
Q

How is the power of uterine contractions during the first phase of labor approximized?

A

observation of the mother, palpation of the fundus or external tocodynamometry

Contraction force can also be measured by direct measurement of intrauterine pressure using an internal pressure monitor
IUPC – Intrauterine Pressure Catheter

measued by Montevideo units

37
Q

What is adequate labor and what to do if labor does not get here?

A

> 200 Montevideo units in 10 min

use pitocin to help contractions

38
Q

What can affect the passenger part of the active phase of the first phase of labor?

A

Fetal size – macrosomia
Fetal Lie – longitudinal, transverse or oblique
Fetal presentation – vertex (head down), breech (butt down), shoulder, compound (something in front of the baby-arm) and funic (umbilical cord)
Attitude
Degree of flexion or extension of the fetal head
Position
Relationship between the fetal presenting part to the right or left side of the birth canal
In vertex position, occiput is the reference point (triangle feeling)
In breech position, sacrum in reference point
# of fetuses
presence of fetal anomilies (hydrocephalus = big head sacrococcygeal teratoma = tumor on butt)

these can all make it harder to deliver

39
Q

when do you do a C section for passenger shape?

A

Funic= go
straight to
C-section

Anything other than vertex = C section

cord insertion is long in amniotic sac so they cannot deliver through the placenta

40
Q

How do you tell the fetal presentation an position

A

Leopolds maneuver (feeling the 4 quadrants of the baby) (abdominal palpation)
Mother lies supine

US is the best way

41
Q

What is macrosomnia?

A

Fetus suspected to be greater than 5000 grams, consider cesarean delivery

In diabetics, greater than 4,500 grams

42
Q

What is the pelvis and what does it include?

A

Consists of the bony pelvis and soft tissues of the birth canal (cervix, pelvic floor musculature)

43
Q

What is the most favorable pelvis shape?

A

Gynecoid

if not this shape, you can still deliver oftentimes as long as the head is not too big

44
Q

What are abnormalities of the active phase of labor?

A

no progression in cervical dilation in patients who are at least 6-cm dilated with rupture of membranes despite 4 hours of adequate uterine activity or 6 hours of inadequate uterine activity with oxytocin augmentation
Indication for cesarean delivery

45
Q

What is a Prolonged second stage of laborabnormality?

A

more than 3 HOURS of pushing in nulliparous individuals and 2 hours of pushing in multiparous individuals
Indication for cesarean delivery

46
Q

What is an umblical cord prolapse?

A

Umbilical cord in front of head and baby’s head pushes on it

EMERGENCY
- push up on the head and deliver C section

47
Q

What is the 2nd stage of labor?

A

Feel like they have to poop

48
Q

What to look at during the 2nd stage of labor?

A

Examine fetal head for molding
Can develop caput d/t molding (goes away in 24-48 hours)

49
Q

What are perineal lacerations and the 4 different degrees?

A

seen during second stage

  1. First degree
    Injury to perineal skin and vaginal mucosa only
  2. Second degree
    Injury to the perineal body
  3. Third degree
    Injury through the external anal sphincter
  4. Fourth degree
    Injury through the rectal mucosa (terrible)
50
Q

What do yo udo for an episiotomy?

A

Surgical incision of female perineum
Increases diameter of soft tissue pelvic outlet to ALLOW DELIVERY OF FETUS
ACOG supports restricted use of episiotomy
Rationale
Reduction in third or fourth degree lacerations
Ease of repair
Reduction in neonatal trauma
Reduction in shoulder dystocia
Indications
Fetal distress

cutting up the vagina to make. more room

51
Q

complication of epiostomy?

A

Increase vaginal bleeding
Increase postpartum pain
Unsatisfactory anatomic results
Sexual dysfunction
Increase risk of infection

52
Q

What are the two types of episiotomies?

A

Midline
Mediolateral (more pain)

53
Q

What are the RF for complications of 2nd stage of labor

A

Fetal macrosomia
Diabetes – overt and gestational
Previous shoulder dystocia
Maternal obesity
Postterm pregnancy
Prolonged second stage of labor
Operative vaginal delivery

54
Q

what is dystocia

A

anterior shoulder stuck

Complications
Fetal
Fracture of humerus and clavicle
Brachial plexus injuries
Phrenic nerve palsy
Hypoxic brain injury
Death
Diagnosis
Made when routine delivery maneuvers fail to deliver the anterior shoulder

55
Q

when should you do dystocia?

A

Call for help
Episiotomy
McRoberts maneuver – sharp flexion of maternal hips
Suprapubic pressure
Delivery of posterior shoulder
Other maneuvers – Rubin, Wood’s corkscrew
Symphisiotomy
Zavanelli – replace infants head back into the pelvis and do a c-section

56
Q

McRoberts

A

orients pelvis to allow more room

57
Q

What is the third stage of labor and how long should it last?

A

The time from fetal delivery to delivery of the placenta

Usually about 30minutes

58
Q

three signs of placental seperation

A

Lengthening of umbilical cord
Gush of blood
Fundus becomes globular and more anteverted against abdominal hand

Placenta is delivered using one hand on umbilical cord with gentle downward traction
Other hand on abdomen supporting the uterine fundus
Risk factor for aggressive traction is uterine inversion
Obstetrical emergency!!
Immediate replacement of fundus required
Manually or surgically

59
Q

What is the fourth stage of labor?

A

SOOO many changes

uterus goes from the size of the basketball to large soft ball

60
Q

What can lead to postpartum hemmorage?

A

Uterine atony –Most common cause
Retained placental fragments
Unrepaired lacerations of vagina, cervix or perineum

Blood loss >500c in a vaginal delivery or >1000cc in a cesarean delivery

61
Q

treatment of postpartum hemorrhage

A

Removal of placental fragments or repair of lacerations
Additional IV access
Type and cross match for blood
Medications for uterine atony: Pitocin, Methergine, Cytotec, Hemabate

62
Q

What are the cardinal movements of labor

A

where the fetal head is through passage of the birth canal

63
Q

Seven distinct movements of labor

A

Engagement
Descent
Flexion
Internal rotation
Extension
External rotation/restitution
Expulsion

all happen at the same time basically

64
Q

Engagement

A

Passage of the widest diameter fetal presenting part below the plane of the pelvic inlet
The head is said to be engaged if the leading edge is at the level of the ishial spines.

65
Q

Descent

A

Refers to the downward passage of the presenting part through the bony pelvis

66
Q

Flexion

A

Occurs passively as the head descends due to the shape of the bony pelvis.
Partial flexion occurs naturally but complete flexion usually occurs only in the labor process
Complete flexion allows the fetal head’s smallest diameter to fit through the pelvis
Smallest diameter  subocciptobregmatic diameter

67
Q

Internal rotation

A

Rotation of the fetal head from occiput transverse to occiput anterior or posterior position
Occurs passively due to the shape of the bony pelvis

68
Q

Extension of head

A

Occurs when the fetus has descended to the level of the vaginal introitus
When occiput is just past the level of the symphysis, the angle of the birth canal changes to upward position

69
Q

External Rotation/Restitution

A

As the head is delivered, it rotates back to its original position prior to internal rotation
Head aligns anatomically with the fetal torso
The release of the passive forces on the fetal head allows it to return to appropriate position

anatomic normal

70
Q

Expulsion

A

Delivery of the fetus
Downward traction allows release of the shoulder and the fetus is delivered

71
Q

What is normal fetal heart rate?

A

110-160 BPM

brady < 110
tachy >160 (not as worried)

72
Q

intrapartum fetal assesment is based on

A

monitoring baby

73
Q

When are we worried about tachy in fetal heart?

A

Infection
Terbutaline

74
Q

When is fetal bradycardia not as worring?

A

Mom has lupus
maternal hypotension

75
Q

What are the fetal heart rate based on

A

Baseline: mean BPM over 10 min
Variability: moment to moment

76
Q

different levels of variability?

A

Absent
0 bpm of variation
Worrisome!
Minimal
1-5 bpm of variation
Common when fetus is asleep or inactive
Moderate- considered normal
5-25 bpm of variation
Marked
>25 bpm of variation
Worrisome!

77
Q

accelerations

A

> 32 weeks: at least 15bpm and lasting 15s
<32 weeks: at least 10bpm and lasting 10s

78
Q

early deccelerations of HR

A

Early decelerations

these can be normal (they go away after contraction)
Begin and end approximately at the same time as contractions
Result of head compression
No intervention required

79
Q

late deceleartions

A

Begin at peak of contraction and slowly return to baseline after the contraction has finished
Result of uteroplacental insufficiency (not enough reserve to keep the babies HR up during the contraction)
Require intervention

80
Q

management of deceleration

A

Position, Oxygen, Stop Pitocin, Check cervix, Fluid Bolus
Consider assisted delivery or cesarean delivery with more than 50% of the contractions

81
Q

Variable decelerations

A

V for variable

squeezing the cord and no longer squeezing the cord

can reposition or use a Amnioinfusion in order to increase space for baby to move and not compress

82
Q

what does early deceleration strpi look like?

A

HR of baby decreases with increased contraction

inversion (baby’s dips down and mom’s goes up)

83
Q

late deceleration

A

does not be an inversion of each other

deceleration after the peak of contractino

84
Q

variable deceleration

A

The two strips of contraction and baby’s HR is not matched up

deeper and longer = more concerning

85
Q

What does sinusoidal waveform mean?

A

Fetal anemia

lots of different etiologies

86
Q

Fetal HR tracing three category

A

Category 1 = everything is good

Category 2 = catch all that does not fit in the other 2 categories

Category 3 = a strip that you should deliver baby right away

87
Q

When do you do a contraction stress test?

A

Evaluates the fetal response to a transient reduction in fetal oxygen delivery during uterine contractions

Evaluate fetal status BEFORE induction of labor

88
Q

How do you do a contraction stress test?

A

Use pitocin to achieve 3 contractions in 10 minutes

89
Q

What are the different results of a contraction stress test?

A

Positive – BAD – C-section!
Nonreassuring fetal heart tracing
With 50% or greater of contractions, a late deceleration is occurring

Equivocal – Wait and See
Nonpersistent late decelerations
Negative – Good to Go
Reassuring fetal heart tracing

Women's Health (2 decks)

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