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Women's Health > Labor > Flashcards

Labor Flashcards

1
Q

Physiologic process by which a fetus is expelled from the uterus

A

Labor

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2
Q

What is the purpose of uterine contractions during labor?

A

Effacement and dilatation of the cervix

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3
Q

What are components of a cervical exam to diagnose labor?

A
  • Dilation
  • Effacement
  • Station
  • Consistency
  • Position
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4
Q

How open the internal os is

A

Dilation

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5
Q

What does dilation range from? What is complete dilation?

A
  • 0-10 cm
  • 10 cm = complete dilation
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6
Q

What is effacement?

A

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

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7
Q

What is station?

A

Degress 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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8
Q

What is consistency? What consistency means not in labor?

A
  • Soft, medium, or firm
  • More firm means not in labor
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9
Q

What are positions? How does this progress during labor?

A
  • Anterior, mid position or posterior
  • Goes mid to anterior with labor progress
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10
Q

In order to diagnose labor, what must occur?

A
  • Cervical change!
  • Braxton Hicks contractions = contractions without cervical change
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11
Q

What is a Bishop score?

A
  • Determines how favorable the cervix is for labor
  • Score >8 indicates favorable cervix for labor
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12
Q

How is labor diagnosed with membranes?

A
  • Ferning
  • Nitrazine
  • Presence of pooling
  • AFI
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13
Q

What is spontaneous rupture of membranes? Premature rupture of membranes?

A
  • Spontaneous rupture of membranes: rupture of membranes during labor
  • Premature rupture of membranes: rupture of membranes before onset of labor
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14
Q

What does vaginal bleeding during labor mean?

A
  • Can see small amount of blood called bloody show which is a good sign
  • Excessive bleeding is not good sign
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15
Q

What is a major pathogen in neonatal sepsis that affects 2-3 per 1000 live births?

A

Group B streptococcus

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16
Q

What is screening for group B streptococcus?

A
  • > 35 weeks all pregnant women have ano-vaginal swab
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17
Q

What do you do if a group B streptococcus swab is positive? Negative?

A

Positive: treat with penicillin during labor
If allergic, obtain sensitivities and use erythromycin or clindamycin. If don’t have sensitivities use vancomycin
Negative: no treatment in labor

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18
Q

What are general categories of pain management in labor?

A
  • IV pain medication
  • Regional anesthesia
  • General anesthesia
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19
Q

What are considerations for IV pain medication in labor?

A

Try to avoid if possible because can cause nonreassuring fetal status and fetal respiratory depression

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20
Q

What are types of regional anesthesia used during labor?

A
  • Epidural
  • Spinal anesthesia
  • Pudendal block
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21
Q

What is epidural anesthesia?

A
  • Epidural catheter placed in L3-L4 interspace
  • Initial bolus of anesthetic given then continuous infusion started
  • Offered to patients having a vaginal delivery
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22
Q

What are complications of epidural anesthesia?

A
  • Maternal hypotension
  • Maternal respiratory depression
  • Spinal headache
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23
Q

What are contraindications of epidural anesthesia?

A
  • Maternal bleeding disorder or use of LMWH within 12 h
  • Patient refusal
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24
Q

What is spinal anesthesia?

A
  • One time dose placed directly into the spinal canal
  • Used for cesarean delivery
  • Complications and contraindications similar to epidural
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25
Q

What is pudendal block?

A
  • Provides perineal anesthesia
  • Used with operative vaginal deliveries or for extensive perineal repairs after delivery
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26
Q

When is general anesthesia used during labor?

A
  • Cesarean delivery in emergent or urgent setting
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27
Q

What are complications of general anesthesia?

A
  • Maternal aspiration
  • Risk of hypoxia to mother and fetus
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28
Q

What is induction of labor?

A

Attempt to begin labor in a non-laboring patient

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29
Q

What are indications for induction of labor?

A

Maternal, fetal, or placental reasons

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30
Q

What indicates success of induction of labor?

A

Bishop score: <5 lead to failed induction 50% of time and need for cervical ripening

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31
Q

What are methods of induction of labor?

A
  • Prostaglandins
  • Pitocin
  • Balloon catheter
  • Laminaria
  • Artificial rupture of membranes
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32
Q

What is the MOA of prostaglandins in induction of labor?

A
  • Help ripen and dilate the cervix by dissolution of collagen bundles and increase water uptake by cells
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33
Q

Which prostaglandins are used in induction?

A
  • Cervidil - PGE2, vaginal
  • Cytotec- PGE1, vaginal or oral (but causes diarrhea orally)
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34
Q

What are side effects of prostaglandins?

A
  • Tachysystole
  • Fever
  • Vomiting
  • Diarrhea
  • Uterine rupture
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35
Q

What are contraindications to prostaglandins?

A
  • History of cesarean section
  • Myomectomy (peeling tissue from uterus)
  • Hysterotomy (incision into uterus)
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36
Q

How is pitocin given and what is its MOA?

A
  • Given IV
  • Identical to oxytocin released from posterior pituitary leading to uterine contractions
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37
Q

What are side effects of pitocin?

A
  • Tachysystole >5 contractions in 10 mins
  • Uterine rupture (but not as likely as prostaglandins)
  • Hyponatremia
  • Hypotension
  • Amniotic fluid embolism
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38
Q

What are contraindications to pitocin?

A
  • Fetal distress
  • Hypersensitivity
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39
Q

What is a laminaria?

A

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

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40
Q

What is augmentation and how is it done?

A
  • Intervening to increase already present contractions
  • Typically use pitocin
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41
Q

What are types of operative vaginal delivery?

A
  • Forceps and vacuum (used more often now)
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42
Q

What are indications for operative vaginal delivery?

A
  • Prolonged second stage of labor
  • Maternal exhaustion
  • Hasten delivery for fetal compromise
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43
Q

What is cesarean deivery?

A

Abdominal delivery of fetus

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44
Q

What are the stages of labor?

A
  • First stage: onset of labor to complete cervical dilation
  • Second stage: complete cervical dilation to expulsion of fetus
  • Third stage: delivery of infant to delivery of placenta
  • Fourth stage: delivery of placenta to one hour postpartum
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45
Q

What is Freidman’s curve?

A
  • Good guideline for expected progression in labor
  • Helps determine abnormal labor patterns
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46
Q

What is Zhang labor curve?

A

Revaluated labor curves

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47
Q

What is spontaneous labor progression?

A
  • Labor similar for multips and primips until 6 cm
  • Defined active phase at 6 cm
  • After 6 cm, multips progress much quicker
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48
Q

What is induced labor progression?

A
  • Latent phase of labor significantly longer in induced labor
  • Active phase similar
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49
Q

What is the average duration of the first stage of labor?

A
  • Nulliparous patient: 10-12 hours
  • Multiparous patient: 6-8 hours
50
Q

What are the two phases of the first stage of labor?

A
  • Latent phase: onset of labor with slow cervical dilation to 6 cm. This is slower phase
  • Active phase: 6 cm to complete dilation with faster rate of cervical change–> nulliparous patient: 1.2 cm/h; multiparous patient: 1.5 cm/h
51
Q

What are factors that affect the active stage of labor?

A
  • Power-uterus
  • Passenger-fetus
  • Pelvis- baby has to fit out of
52
Q

What does power refer to?

A
  • Force generated by contractions of uterine myometrium
  • Activity can be assessed by observation of the mother, palpation of the fundus, or external tocodynamometry
  • Contraction force can be measured by direct measurement of intrauterine pressure using internal pressure monitor (IUPC)
53
Q

What is considered adequate labor power?

A

3-5 contractions in a 10 minute period
>200 montevideo units in 10 min (measured by IUPC)

54
Q

If IUPC measures less than 200 Montevideo units in 10 minutes, what should you do?

`

A
  • Start pitocin to augment labor
55
Q

What are fetal variables that affect labor?

A
  • Fetal size- macrosomia
  • Fetal lie- longitudinal, transverse, or oblique
  • Fetal presentation- vertex, breech, shoulder, compound, and funic
  • Attitude: degree of flexion or extension of fetal head
  • Position: relationship between fetal presenting part to the right or left of the birth canal
  • Station
  • Number of fetuses
  • Presence of fetal abnormalities: hydrocephalus, sacrococcygeal teratoma
56
Q

How is fetal presentation and position diagnosed?

A
  • Leopolds maneuver (abdominal palpation): can determine fetal lie, fetal weight, fetal position, fetal presentation
  • Vaginal examination: palpation of fetal sutures and fontanels
  • Ultrasound
57
Q

What could make Leopolds maneuver difficult?

A

Obese mother, polyhydramnios, multifetal gestation

58
Q

What passenger factor usually results in cesarean delivery?

A
  • Any position other than vertex
  • Fetus greater than 5000 grams (macrosomia), 4500 grams in diabetics
59
Q

What does passage consist of?

A
  • Bony pelvis and soft tissues of birth canal (cervix, pelvic floor musculature
  • Small pelvic outlet can result in cephalopelvic disproportion –> cesarean delivery
  • Bony pelvis can be measured by pelvimetry but is not accurate
60
Q

What pelvis type is ideal for the baby?

A

Gynecoid

61
Q

What are passage abnormalities?

A
  • Cephalopelvic disproportion
  • Passenger too large for pelvis
62
Q

How do you manage cephalopelvic disproportion?

A
  • Cesarean delivery
63
Q

What are abnormalities in the first stage of labor?

A
  • Active phase arrest of labor
  • Prolonged second phase of labor
  • Umbilical cord prolapse
64
Q

What is active phase arrest 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
65
Q

How is active phase arrest of labor managed?

A

Cesarean delivery

66
Q

What is prolonged second stage of labor? How is it managed?

A
  • More than 3 hours of pushing in nulliparous individuals and 2 hours of pushing in multiparous individuals
  • Indication for cesarean delivery
67
Q

What is umbilical cord prolapse and how do you manage it?

A
  • Prolapse of umbilical cord in front of head
  • Obstetrical emergency
  • Indication for cesarean delivery
68
Q

What are risk factors for umbilical cord prolapse?

A
  • Artificial rupture of membranes
  • Unengaged fetal head
69
Q

What is the second stage of labor?

A
  • Interval between full cervical dilation to delivery of infant
  • Descent of presenting part through pelvis and expulsion of fetus
70
Q

What are indications of second stage?

A
  • Pelvic/rectal pressure
  • Mother has active role in pushing to aid in fetal descent
71
Q

What can make examining the fetal head difficult during the second stage of labor?

A

Molding

72
Q

What is molding?

A

Alteration of the fetal cranial bones to each other as a result of compressive forces of the maternal bony pelvis

73
Q

What is caput?

A

Localized edematous area on the fetal scalp caused by pressure on the scalp by the cervix

`

74
Q

What are the degrees of perineal lacerations?

A
  • First degree: injury to perineal skin and vaginal mucosa only
  • Second degree: injury to the perineal body
  • Third degree: injury through the external anal sphincter
  • Fourth degree: injury through the rectal mucosa
75
Q

What is an episiotomy?

A
  • Surgical incision of female perineum
  • Increases diameter of soft tissue pelvic outlet to allow delivery of a fetus
76
Q

What are guidelines regarding episiotomy?

A
  • ACOG restricts use because
  • Reduction of third or fourth degree lacerations
  • Ease of repair
  • Reduction in neonatal trauma
  • Reduction in should dystocia
77
Q

What are indications to episiotomy?

A

Fetal distress

78
Q

What are complications of episiotomy?

A
  • Increase vaginal bleeding
  • Increase postpartum pain
  • Unsatisfactory anatomic results
  • Sexual dysfunction
  • Increase risk of infection
79
Q

What are types of episiotomy?

A

Midline and mediolateral

80
Q

What is shoulder dystocia?

A

Difficulty in delivery of anterior shoulder due to impaction of the anterior shoulder on the pubic symphysis

81
Q

What are risk factors for shoulder dystocia?

A
  • Fetal macrosomia
  • Diabetes-overt and gestational
  • Previous shoulder dystocia
  • Maternal obesity
  • Postterm pregnancy
  • Prolonged second stage of labor
  • Operative vaginal devliery

Causes increased morbidity and mortality to mother and fetus

82
Q

What are fetal complications of shoulder dystocia?

A
  • Fracture of humerus and clavicle
  • Brachial plexus injuries
  • Phrenic nerve palsy
  • Hypoxic brain injury
  • Death
83
Q

How is the diagnosis of shoulder dystocia made?

A

When routine delivery maneuvers fail to deliver the anterior shoulder

84
Q

How is shoulder dystocia managed?

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
  • Zavanella- replace infants head back into the pelvis and do a c-section
85
Q

What is the third stage of labor?

A

Time from fetal delivery to delivery of the placenta, about 30 mins usually

86
Q

What are 3 signs of placental separation?

A
  • Lengthening of umbilical cord
  • Gush of blood
  • Fundus becomes globular and more anteverted against abdominal hand
87
Q

How is the placenta delivered?

A
  • One hand on umbilical cord with gentle downward traction
  • Other hand on abdomen supporting uterine fundus
88
Q

What can happen with aggressive traction on the umbilical cord during the third stage of labor?

A
  • Uterine eversion
  • Obstetrical emergency!!
  • Immediate replacement of fundus required either mechanically or surgically
89
Q

What is the fourth stage of labor?

A
  • Time from delivery of placenta to 1 hour immediately postpartum
90
Q

What must be monitored closely during fourth stage of labor?

A
  • Blood pressure
  • Uterine blood loss
  • Pulse rate
91
Q

What are causes of high risk of postpartum hemorrhage?

A
  • Uterine atony- MCC (uterine muscle doesn’t tighten to stop bleeding)
  • Retained placental fragments
  • Unrepaired lacerations of vagina, cervix, or perineum
92
Q

What is diagnosed as postpartum hemorrhage?

A
  • > 500 cc blood loss in vaginal delivery or 1000 cc in a cesarean delivery
93
Q

What is 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
94
Q

What are the 7 cardinal movements of labor?

Changes in fetal head position during passage through canal

A
  • Engagement
  • Descent
  • Flexion
  • Internal rotation
  • Extension
  • External rotation/restitution
  • Expulsion

Engaged Dads Feel Internally Extended Extra in the Evening

95
Q

What is engagement?

A
  • Passage of the widest fetal diameter fetal presenting part below the plane of the pelvic inlet
  • Head is engaged if leading edge at level of ischial spines
96
Q

What is descent?

A

Downward passage of presenting part through the bony pelvis

97
Q

What is flexion?

A
  • Passive flexion as head descends through bony pelvis
  • Complete flexion allows fetal head’s smallest diameter, subocciptobregmatic diameter, to fit
98
Q

What is internal rotation?

A

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

99
Q

What happens during extension?

A
  • Fetus descends to level of vaginal introitus
  • Occiput just past level of symphysis and angle of birth canal changes to upward position
100
Q

What happens during external rotation/restitution?

A
  • Head is delivered and rotates back to original position prior to internal rotation
  • head aligns anatomically with fetal torso
  • Release of passive forces on head allows to return to appropriate position
101
Q

What happens during expulsion?

A
  • Delivery of the fetus
  • Downward traction allows release of the shoulder and the fetus is delivered
102
Q

What is a normal fetal heart rate?

A

110-160 bpm

103
Q

What is considered fetal bradycardia?

A

FHR <110

104
Q

What are common causes of fetal bradycardia?

A
  • Congenital heart block
  • Infants whose mothers suffer from SLE
  • Maternal hypotension
105
Q

What is considered fetal tachycardia?

A

FHR >160 bpm

106
Q

What are common causes of fetal tachycardia?

A
  • Infection
  • Terbutaline
107
Q

What is baseline? Variability?

A
  • Baseline: mean bpm over 10 minute window
  • Variability: moment to moment variation from baseline
108
Q

If a fetal heart rate has no variability (0 bpm), is that good or bad? What about minimal (1-5 bpm)?

A
  • No variability: concerning!
  • Minimal: common when fetus asleep or inactive, or certain medications
109
Q

What variability is considered normal?

A

5-25 bpm of variation

110
Q

If you see >25 bpm of variation, what should you be thinking?

A

Worrisome!

111
Q

What are normal accelerations?

A
  • > 32 weeks: at least 15 bpm and lasting 15 s
  • <32 weeks: at least 10 bpm and lasting 10 s
112
Q

What are the 3 types of decelerations?

A
  • Early deceleration: begin and end approx at same time as contraction and result from head compression (can be normal)
  • Late deceleration: begin at peak of contraction and slowly return to baseline after finished due to uteroplacental insufficiency (not enough O2 reserve)
  • Variable decelerations: can occur at anytime, drop more precipitously, and result of cord compression
113
Q

What are interventions for late decelerations?

A
  • Position
  • Oxygen
  • Stop pitocin
  • Check cervix
  • Fluid bolus
  • Consider assisted delivery or cesarean delivery with more than 50% of the contractions
114
Q

What intervention may be necessary with variable declerations?

A
  • Amnioinfusion- infusion of saline into amniotic sac
115
Q

What does a sinusoidal waveform in fetal heart rate mean?

A

Often due to fetal anemia

116
Q

What is happening in a category I fetal heart rate tracing?

A

Normal heart rate tracing
* Baseline FHR 110-160
* Moderate FHR variability
* Absence of late or variable decelerations
* Acclerations may be present or absent

117
Q

What is happening in a category III fetal heart rate tracing?

A
  • Absent FHR variability with: recurrent late decelerations, recurrent variable decelerations, bradycardia
  • Sinusoidal pattern

Not good!! Delivery now!
Category II is anything not I or III

118
Q

What is a contraction stress test?

A
  • Evaluates fetal response to transient reduction in fetal oxygen delivery during uterine contractions
  • Use pitocin to achieve 3 contractions in 10 minutes
  • Indicated to evaluate fetal status before induction of labor
119
Q

If a contraction stress test is positive, what does that mean?

A
  • BAD! Do a c-section, non-reassuring fetal heart tracing
120
Q

What does an equivocal or negative contraction stress test mean?

A
  • Equivocal- wait and see –> nonpersistent late declerations
  • Negative - good to go –> reassuring fetal heart tracing

Women's Health (5 decks)

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