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
2
Q
what is complete dilation of the cervix?
A
10cm
3
Q
what is effeacement?
A
length of the cervix (how thick it is)
Difference between the internal and external cervical os
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
5
Q
What is the consistency of the cervix during labor?
A
Soft, medium or firm
More firm means they are not in labor
6
Q
what is the position of the cervix during labor?
A
Becomes more anterior
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
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)
9
Q
What are contractions that do not cause cervical change and what can cause it?
A
Braxton Hicks contractions
Dehydration
10
Q
What is the bishop score and what is a favorable score?
A
Determines how favorable the cervix is for labor
> 8 = favorable
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
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)
13
Q
Complication of epidural anesthesia
A
Maternal hypotension
Maternal respiratory depression
Spinal headache
14
Q
CI of epidural anesthesia
A
Maternal bleeding disorder or use of LMWH within 12h
Patient refusal
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
16
Q
Why is NO not typically used during labor?
A
Respiratory depression paired with worry of COVID
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
18
Q
How to induce labor with pharm?
A
Prostoglandins (cervidil or cytotec)
Pitocin
19
Q
MOA of prostoglandins for labor
A
Cause dissolution of collagen bundles and increase water uptake by cells
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)
21
Q
SE of prostoglands (cervidil and cytotec)
A
Tachysystole, fever, vomiting, diarrhea
Uterine rupture
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)
23
Q
Pitocin route and MOA
A
Given IV
Identical version of oxytocin released from posterior pituitary leading to uterine contractions
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
25
CI of pitocin?
Fetal distress
hypersensitivity
26
Other than pharm, how can you induce labor?
Manually
Balloon catheter (Cook)
Laminaria
Artificially breaking the water (with amnio hook to punture amniotic sac)
27
What material is laminaria?
Rolled up seaweed that pulls out water and in turn dilates the cervix
not very common, often used for fetal demise or procedures
28
What can augment labor?
increase the already present contractions
Typically use PITOCIN
29
What do you use to help pull the fetal head out of the vagina? When would you do this?
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
30
Where does a cesarean delivery occur?
Abdominal delivery of the fetus
30% of live births!
31
What are the four stages of labor
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
32
What guideline did we used to do for labor?
Freidman’s curve (1950s)
33
What labor curve revaluated Freidman's curve and why?
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
34
Explain the first stage of labor and the two phases of the first stage
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
35
three factors that affect active phase of the first phase of labor
Power – uterus
Passenger – fetus
Pelvis – baby has to fit out of
36
How is the power of uterine contractions during the first phase of labor approximized?
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
What is adequate labor and what to do if labor does not get here?
> 200 Montevideo units in 10 min
use pitocin to help contractions
38
What can affect the passenger part of the active phase of the first phase of labor?
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
when do you do a C section for passenger shape?
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
How do you tell the fetal presentation an position
Leopolds maneuver (feeling the 4 quadrants of the baby) (abdominal palpation)
Mother lies supine
US is the best way
41
What is macrosomnia?
Fetus suspected to be greater than 5000 grams, consider cesarean delivery
In diabetics, greater than 4,500 grams
42
What is the pelvis and what does it include?
Consists of the bony pelvis and soft tissues of the birth canal (cervix, pelvic floor musculature)
43
What is the most favorable pelvis shape?
Gynecoid
if not this shape, you can still deliver oftentimes as long as the head is not too big
44
What are abnormalities of the active phase of labor?
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
What is a Prolonged second stage of labor abnormality?
more than 3 HOURS of pushing in nulliparous individuals and 2 hours of pushing in multiparous individuals
Indication for cesarean delivery
46
What is an umblical cord prolapse?
Umbilical cord in front of head and baby's head pushes on it
EMERGENCY
- push up on the head and deliver C section
47
What is the 2nd stage of labor?
Feel like they have to poop
48
What to look at during the 2nd stage of labor?
Examine fetal head for molding
Can develop caput d/t molding (goes away in 24-48 hours)
49
What are perineal lacerations and the 4 different degrees?
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
What do yo udo for an episiotomy?
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
complication of epiostomy?
Increase vaginal bleeding
Increase postpartum pain
Unsatisfactory anatomic results
Sexual dysfunction
Increase risk of infection
52
What are the two types of episiotomies?
Midline
Mediolateral (more pain)
53
What are the RF for complications of 2nd stage of labor
Fetal macrosomia
Diabetes – overt and gestational
Previous shoulder dystocia
Maternal obesity
Postterm pregnancy
Prolonged second stage of labor
Operative vaginal delivery
54
what is dystocia
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
when should you do dystocia?
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
McRoberts
orients pelvis to allow more room
57
What is the third stage of labor and how long should it last?
The time from fetal delivery to delivery of the placenta
Usually about 30minutes
58
three signs of placental seperation
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
What is the fourth stage of labor?
SOOO many changes
uterus goes from the size of the basketball to large soft ball
60
What can lead to postpartum hemmorage?
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
treatment of postpartum hemorrhage
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
What are the cardinal movements of labor
where the fetal head is through passage of the birth canal
63
Seven distinct movements of labor
Engagement
Descent
Flexion
Internal rotation
Extension
External rotation/restitution
Expulsion
all happen at the same time basically
64
Engagement
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
Descent
Refers to the downward passage of the presenting part through the bony pelvis
66
Flexion
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
Internal rotation
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
Extension of head
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
External Rotation/Restitution
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
Expulsion
Delivery of the fetus
Downward traction allows release of the shoulder and the fetus is delivered
71
What is normal fetal heart rate?
110-160 BPM
brady < 110
tachy >160 (not as worried)
72
intrapartum fetal assesment is based on
monitoring baby
73
When are we worried about tachy in fetal heart?
Infection
Terbutaline
74
When is fetal bradycardia not as worring?
Mom has lupus
maternal hypotension
75
What are the fetal heart rate based on
Baseline: mean BPM over 10 min
Variability: moment to moment
76
different levels of variability?
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
accelerations
>32 weeks: at least 15bpm and lasting 15s
<32 weeks: at least 10bpm and lasting 10s
78
early deccelerations of HR
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
late deceleartions
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
management of deceleration
Position, Oxygen, Stop Pitocin, Check cervix, Fluid Bolus
Consider assisted delivery or cesarean delivery with more than 50% of the contractions
81
Variable decelerations
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
what does early deceleration strpi look like?
HR of baby decreases with increased contraction
inversion (baby's dips down and mom's goes up)
83
late deceleration
does not be an inversion of each other
deceleration after the peak of contractino
84
variable deceleration
The two strips of contraction and baby's HR is not matched up
deeper and longer = more concerning
85
What does sinusoidal waveform mean?
Fetal anemia
lots of different etiologies
86
Fetal HR tracing three category
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
When do you do a contraction stress test?
Evaluates the fetal response to a transient reduction in fetal oxygen delivery during uterine contractions
Evaluate fetal status BEFORE induction of labor
88
How do you do a contraction stress test?
Use pitocin to achieve 3 contractions in 10 minutes
89
What are the different results of a contraction stress test?
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
