labor and d Flashcards
braxton hicks can happen this many weeks before labor
4-8 weeks before delivery intensify in frequency and strength
bloody show
Expulsion of mucous plug in some patients
Multiparous women can be 1-3 cm dilated for weeks and not even know it
energy spurt can happen this many hours before labor
24-48 hours before labor some women get a burst of energy and begin organizing, cleaning, cooking, “nesting”
posterior labor
back labor where the hard side of the babies head is on the sacrum
“sunny side up”
GI upset in early labor can look like what
Symptoms similar to early pregnancy with n/v, may have diarrhea, in early labor
worry about HELLP
5 p’S
Passanger position passage powers psych
passanger
EFW (estimated fetal weight), tolerance
What is the ideal position
Presenting part, station, flexion (want the head/neck to be super flexed for best delivery)
LOA
– left side of the body, occiput, anterior (spine is anterior)
LOT
transverse position (neither anterior or posterior, it is halfway in between)
passage what do we think about
– 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
OA
occiput anterior
OP
occiput posterior
back to back with mom
ROT
right side of the body occiput and transverse side to dise
most common positions
ROA and TOA
vertex means
head down
ideal
sacrum would be what type of breech
full frank
what are you feeling for in a pelvic exam during birht
feel for sagittal suture to confirm babies position
longest part of labor
Results in cervical effacement and dilatation (ends when she is 10cm dilated)
we describe this with percentage
what is the latent prodromal phase
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
active phase will usually be dilated to
4-10 centimeters
Start of active labor is about 4-5 cm
contractions during the active phase look like
Contractions are stronger and more coordinated, usually q 2-3 min x 50-70 sec
timeline of dilation during active phase
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
Transition (can last 2-3 hours)
how dilated at this point
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”
how do you mark the second stage
Marked by when the cervix is 10 cm (“fully”) dilated
may see physiological rest at this point
contractions in second stage will usually be spaced about
Contractions usually q 1.5- 2 min x 60 sec and strong
third stage begins with
Begins with birth
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)
Placenta Previa
malposition of the placenta in the lower uterine segment that completely or partially covers the os
most common early in pregnancy
rf for placenta previa
Multiparity, AMA, multiple pregnancy, previous uterine surgery, smoking, previous previa, previous therapeutic abortion
three types of placenta previa
Partial, complete, low-lying, migrating
true placenta previa at term needs a
C section
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
signs and symptoms of previa
Painless bleeding**
Sudden onset
Third trimester
May be accompanied by uterine irritability (frequent contractions)
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
Accreta
when the placenta grows into the wall of the uterus and it doesn’t come off after the baby comes out
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.
Placenta increta
(17%) Occurs when the placenta further extends into the myometrium, penetrating the muscle.
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).
risk factors for placenta accreta
Risk factors: Scar tissue/ Asherman’s syndrome (uterine adhesions)
Placental Abruption
Premature separation of a normally implanted placenta from the uterine wall.
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
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.
triad of placenta abruption
triad of sudden onset of
antepartum vaginal bleeding
a tender uterus
and hypertonic/hyperactive UCs.
Pain is the predominant feature
risk factors for placenta abruption
HTN (MCC d/t vasoconstriction),
maternal trauma
AMA
multiparity
smoking
cocaine use
trauma
external version, previous abruptions.
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
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
first stay management
Ambulate, sit, side lie
Nourishment (avoid dehydration)
Continuous or intermittent monitoring
VS q 4 hrs unless otherwise indicated
encourage voiding
pain management
Analgesia prn, anesthesia usually once active
Can use Lamaze type breathing or visualization (Bradley), “hypnobirthing” for coping and comfort
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)
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
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).
Most reliable means of relieving the pain of labor and delivery.
Regional analgesic techniques, epidurals, spinals, and combined spinal-epidurals (CSE):
Walking epidural”
analgesia with minimal motor block
refers to neuraxial techniquwa
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
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
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
Antiemetics
phenergan, vistaril
Given with opioids to potentiate their action and decrease maternal anxiety/apprehension
Helps prevent any nausea from the opioids
Amniotomy
Artificial rupture of membranes
To check fluid, augment, apply internal fetal monitor
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
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
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
Active third stage managemen
effort to reduce hemorrhage
Risks – hemorrhage, retained placenta, uterine inversion
Brandt-Andrews technique
Brandt-Andrews technique (guarding the uterus)
helps prevent inversion of the uterus while guiding the placenta out
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
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%)
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
most common episiotomy in the US
Median – most common in US
MC cerivical lacerations
Most of the time when women tear, it is a 1st or 2nd degree tear
1st degree
vaginal epithelium only.
2nd degree
extend into the fascia and musculature of the perineal body,
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.
Fourth degree laceration
involve the perineal structures, EAS, IAS, and the rectal mucosa
leading cause of maternal mortality (MM), esp. in the developing world
PPH
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
primary vs secondary PPH
Within 24 hours of delivery is “primary” PPH, “secondary” PPH occurs >24 hours after
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
retained tissue will look like this kind of blood loss
May be dramatic or a slow trickle (usually from retained tissue or trauma)
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
