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labor and d Flashcards

1
Q

braxton hicks can happen this many weeks before labor

A

4-8 weeks before delivery intensify in frequency and strength

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2
Q

bloody show

A

Expulsion of mucous plug in some patients

Multiparous women can be 1-3 cm dilated for weeks and not even know it

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3
Q

energy spurt can happen this many hours before labor

A

24-48 hours before labor some women get a burst of energy and begin organizing, cleaning, cooking, “nesting”

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4
Q

posterior labor

A

back labor where the hard side of the babies head is on the sacrum

“sunny side up”

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5
Q

GI upset in early labor can look like what

A

Symptoms similar to early pregnancy with n/v, may have diarrhea, in early labor

worry about HELLP

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6
Q

5 p’S

A 
Passanger
position 
passage
powers
psych
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7
Q

passanger

A

EFW (estimated fetal weight), tolerance

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8
Q

What is the ideal position

A

Presenting part, station, flexion (want the head/neck to be super flexed for best delivery)

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9
Q

LOA

A

– left side of the body, occiput, anterior (spine is anterior)

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10
Q

LOT

A

transverse position (neither anterior or posterior, it is halfway in between)

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11
Q

passage what do we think about

A

– pelvis and cervix

Clinical pelvimetry (measuring mom’s pelvis with your hands to see what kind of space is available)

cervical dilatation and effacement -thinned out and shortened

first time mom need full effacement before dilation

at 10cms you don’t feel a cervix anymore

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12
Q

OA

A

occiput anterior

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13
Q

OP

A

occiput posterior

back to back with mom

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14
Q

ROT

A

right side of the body occiput and transverse side to dise

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15
Q

most common positions

A

ROA and TOA

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16
Q

vertex means

A

head down

ideal

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17
Q

sacrum would be what type of breech

A

full frank

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18
Q

what are you feeling for in a pelvic exam during birht

A

feel for sagittal suture to confirm babies position

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19
Q

longest part of labor

A

Results in cervical effacement and dilatation (ends when she is 10cm dilated)

we describe this with percentage

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20
Q

what is the latent prodromal phase

A

0-3 centimeters of dilatation

Relatively strong contractions usually q 5-7 minutes x 30-60 sec

Can last days (warm up phase)

Woman can usually talk through UCs and smile in between
Contractions aren’t too
painful at this point

UCs do not go away with activity change or hydration

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21
Q

active phase will usually be dilated to

A

4-10 centimeters

Start of active labor is about 4-5 cm

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22
Q

contractions during the active phase look like

A

Contractions are stronger and more coordinated, usually q 2-3 min x 50-70 sec

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23
Q

timeline of dilation during active phase

A

Usually it is about 1cm dilation per hour but it can take longer than that Woman needs to concentrate with UCs, no longer cheerful, may cope with controlled breathing, visualization

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24
Q

Transition (can last 2-3 hours)

how dilated at this point

A

The last part of active phase

7-10 cm dilated

Often feels “rectal pressure” and urge to push

Often defecates

VERY intense, shaking, toes curl, often vomiting, “I can’t do it!” Hitting the “wall”

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25
how do you mark the second stage
Marked by when the cervix is 10 cm (“fully”) dilated may see physiological rest at this point
26
contractions in second stage will usually be spaced about
Contractions usually q 1.5- 2 min x 60 sec and strong
27
third stage begins with
Begins with birth
28
delivery of the placenta can take about how long
Delivery of placenta and membranes via mild uterine cramping Usually within 5-10 min of delivery of infant Can take up to 1 hour, but most guidelines recommend manual extraction after 30 min (Definition of retained placenta – placenta that hasn’t been delivered in 30 mins)
29
Placenta Previa
malposition of the placenta in the lower uterine segment that completely or partially covers the os most common early in pregnancy
30
rf for placenta previa
Multiparity, AMA, multiple pregnancy, previous uterine surgery, smoking, previous previa, previous therapeutic abortion
31
three types of placenta previa
Partial, complete, low-lying, migrating
32
true placenta previa at term needs a
C section
33
when should a mom be admitted
Usually only if in active labor or complication noted (including ROM or GBS+) or fetus compromised Can send home in early labor if reactive tracing, VSS, no known complications
34
signs and symptoms of previa
Painless bleeding**** Sudden onset Third trimester May be accompanied by uterine irritability (frequent contractions)
35
management of placenta previa before birth
DO NOT DO VAGINAL EXAM US to confirm placement Inpatient bed rest Serial Hct, type and cross-match, Rh, indirect Coomb’s, coag studies Fetal surveillance (growth, movement, NSTs) Pelvic rest, no orgasm
36
Accreta
when the placenta grows into the wall of the uterus and it doesn’t come off after the baby comes out
37
Placenta accreta
(75% of cases) Affects 10% of previas (1/533 pregnancies) - Severe OB complication involving an abnormally deep attachment of the placenta, through the endometrium and into the myometrium. Great risk of hemorrhage during 3rd stage of labor. Commonly requires hysterectomy.
38
Placenta increta
(17%) Occurs when the placenta further extends into the myometrium, penetrating the muscle.
39
Placenta percreta
(5-7%) Most severe form of accreta - when the placenta penetrates the entire myometrium to the uterine serosa (invades through entire uterine wall). Can lead to the placenta attaching to other organs (rectum or bladder).
40
risk factors for placenta accreta
Risk factors: Scar tissue/ Asherman’s syndrome (uterine adhesions)
41
Placental Abruption
Premature separation of a normally implanted placenta from the uterine wall.
42
signs and symptoms of placenta abruption
Rigid, board-like abdomen Painful, localized uterine tenderness Colicky, discoordinated uterine activity Possibly back pain Possible fetal distress ``` Uterine enlargement (if occult) Shock ``` Violent fetal movement
43
compliciations from placenta abruption
Complications include maternal death from hemorrhage or DIC fetal death fetomaternal transfusion, amniotic fluid embolism fetal distress hypotension. Clinical s/sxs depend on the size of the abruption, and amount of blood loss.
44
triad of placenta abruption
triad of sudden onset of antepartum vaginal bleeding a tender uterus and hypertonic/hyperactive UCs. Pain is the predominant feature
45
risk factors for placenta abruption
HTN (MCC d/t vasoconstriction), maternal trauma AMA multiparity smoking cocaine use trauma external version, previous abruptions.
46
abruption initial management
Stabilize mother, crystalloids to maintain volume status and fresh frozen plasma for coagulopathy. Stat IV x 2, Trendelenburg, oxygen EMERGENCY OB CONSULT WHENEVER ABRUPTION IS SUSPECTED
47
labs, fetal monitoring needed with placenta abruption
Assess fetal viability -- Stat U/S, emergency delivery Labs: CBC, type/crossmatch, coagulation profile, renal function studies 0% of patients will have lab evidence of coagulopathy (thrombocytopenia, prolonged PT, hypofibrinogenemia, elevated fibrin split products) Rhogam if indicated, tetanus, correct coagulopathy
48
first stay management
Ambulate, sit, side lie Nourishment (avoid dehydration) Continuous or intermittent monitoring VS q 4 hrs unless otherwise indicated encourage voiding
49
pain management
Analgesia prn, anesthesia usually once active Can use Lamaze type breathing or visualization (Bradley), “hypnobirthing” for coping and comfort
50
fetal monitoring in active labor vs second stage
Fetal monitor noted q 15-30 min in active labor, q 5-10 second stage (usually by RN per protocol)
51
pain experienced in the first stage of labor
occurs during contractions, visceral/cramp-like | Referred pain - can be referred to the abdominal wall, lumbosacral region, iliac crests, gluteal areas, thighs
52
pain in second stage of labor
Somatic pain from distention of the vagina, perineum, and pelvic floor and stretching of the pelvic ligaments. The pain signal is transmitted to the spinal cord via three sacral nerves (S2, S3, and S4 or the pudendal nerve).
53
Most reliable means of relieving the pain of labor and delivery.
Regional analgesic techniques, epidurals, spinals, and combined spinal-epidurals (CSE):
54
Walking epidural"
analgesia with minimal motor block refers to neuraxial techniquwa
55
SE of a epidural
maternal hypotension and subsequent transient fetal bradycardia Usually limits mobility Both epidurals and spinals can cause postpartum HA (dura puncture) and respiratory failure if “high” (total spinal) Delayed onset of breastfeeding and shorter duration of breastfeeding
56
low risk of scary epidural
Catheter misplaced into a vein (less than 1 in 300). - can cause seizures or cardiac arrest High block – respiratory depression, seizures, cardiac arrest (uncommon, less than 1 in 500). catheter misplaced into the subarachnoid space
57
pudendal block -when is it done
Regional anesthesia blocking the pudendal nerve Shot given through the vagina Anesthetizes the vulva and perineum Has no effect on uterus or UCs Minimal danger to mother and baby Used mostly second stage before impending delivery
58
Antiemetics
phenergan, vistaril Given with opioids to potentiate their action and decrease maternal anxiety/apprehension Helps prevent any nausea from the opioids
59
Amniotomy
Artificial rupture of membranes To check fluid, augment, apply internal fetal monitor
60
Augmentation
To treat protracted or arrested labor (if the contractions are spacing out) Pitocin IV, nipple stimulation, amniotomy (should be done in active labor with the baby well engaged in the pelvis) To bring on uterine contractions
61
Amnioinfusion
Using an intrauterine pressure catheter (IUPC) infuse NS into uterus to bolster fluid level and relieve cord compression Also done to help clear any meconium staining
62
signs of placenta separation
delivery of the placenta usually within 30 minutes Gush of blood Cord lengthens Fundus rises in abdomen Uterus becomes firm and globular
63
Active third stage managemen
effort to reduce hemorrhage Risks – hemorrhage, retained placenta, uterine inversion
64
Brandt-Andrews technique
Brandt-Andrews technique (guarding the uterus) helps prevent inversion of the uterus while guiding the placenta out
65
transmission of GBS is
Vertical (mother-to-child) transmission primarily occurs when GBS ascends from the vagina to the amniotic fluid after onset of labor or rupture of membranes, but can occur with intact membranes
66
indications for durgical delivery
Failure to progress during labor/labor dystocia (35%) Labor dystocia – the labor is stuck, it has arrested, it is not progressing Nonreassuring fetal status/fetal distress (24%) Fetal malpresentation including breech (19%)
67
if unknown antepartum culture status (culture not performed or result not available) and these factors GBS prophylaxis is indicated
* Intrapartum fever (≥100.4ºF, ≥38ºC) or * Preterm labor (<37 weeks of gestation) or * Prolonged rupture of membranes (≥18 hours) or * Intrapartum NAAT positive for GBS
68
most common episiotomy in the US
Median – most common in US
69
MC cerivical lacerations
Most of the time when women tear, it is a 1st or 2nd degree tear
70
1st degree
vaginal epithelium only.
71
2nd degree
extend into the fascia and musculature of the perineal body,
72
3rd degree
extend through the fascia and musculature of the perineal body and involve some or all of the fibers of the EAS and/or the IAS.
73
Fourth degree laceration
involve the perineal structures, EAS, IAS, and the rectal mucosa
74
leading cause of maternal mortality (MM), esp. in the developing world
PPH
75
Definition of PPH
Definition is somewhat arbitrary – EBL> 500ml following SVD or >1000ml following C/S. Estimated blood loss = EBL Excessive bleeding that makes patient symptomatic
76
primary vs secondary PPH
Within 24 hours of delivery is “primary” PPH, “secondary” PPH occurs >24 hours after
77
risk factors for PPH
Uterine atony – MCC Uterus is tired and it is not doing it’s job of clamping down on the vessels that are bleeding ``` Retained placenta or accreta Failure to progress during 2nd stage Lacerations Instrumental delivery LGA newborn Hypertensive disorders Induction of labor/augmentation with oxytocin Obesity ```
78
retained tissue will look like this kind of blood loss
May be dramatic or a slow trickle (usually from retained tissue or trauma)
79
treatment of PPH
Timely and accurate diagnosis is crucial! Frequent assessment of vital signs Oxytocics/IV access with wide bore needles Remove retained POCs Uterine massage/bimanual compression (put your entire fist into the mom’s vagina and the external hand is compressing the uterus very firmly against your hand that is inside the vagina) Uterine tamponade with balloon/packs Repair of lacerations if cause of bleeding Transfusion of packed RBCs Surgery, uterine vessel ligation, hysterectomy last resort

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