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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
Q

how do you mark the second stage

A

Marked by when the cervix is 10 cm (“fully”) dilated

may see physiological rest at this point

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26
Q

contractions in second stage will usually be spaced about

A

Contractions usually q 1.5- 2 min x 60 sec and strong

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27
Q

third stage begins with

A

Begins with birth

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28
Q

delivery of the placenta can take about how long

A

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)

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29
Q

Placenta Previa

A

malposition of the placenta in the lower uterine segment that completely or partially covers the os

most common early in pregnancy

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30
Q

rf for placenta previa

A

Multiparity, AMA, multiple pregnancy, previous uterine surgery, smoking, previous previa, previous therapeutic abortion

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31
Q

three types of placenta previa

A

Partial, complete, low-lying, migrating

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32
Q

true placenta previa at term needs a

A

C section

33
Q

when should a mom be admitted

A

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
Q

signs and symptoms of previa

A

Painless bleeding**

Sudden onset

Third trimester

May be accompanied by uterine irritability (frequent contractions)

35
Q

management of placenta previa before birth

A

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
Q

Accreta

A

when the placenta grows into the wall of the uterus and it doesn’t come off after the baby comes out

37
Q

Placenta accreta

A

(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
Q

Placenta increta

A

(17%) Occurs when the placenta further extends into the myometrium, penetrating the muscle.

39
Q

Placenta percreta

A

(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
Q

risk factors for placenta accreta

A

Risk factors: Scar tissue/ Asherman’s syndrome (uterine adhesions)

41
Q

Placental Abruption

A

Premature separation of a normally implanted placenta from the uterine wall.

42
Q

signs and symptoms of placenta abruption

A

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
Q

compliciations from placenta abruption

A

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
Q

triad of placenta abruption

A

triad of sudden onset of

antepartum vaginal bleeding

a tender uterus

and hypertonic/hyperactive UCs.
Pain is the predominant feature

45
Q

risk factors for placenta abruption

A

HTN (MCC d/t vasoconstriction),

maternal trauma
AMA

multiparity

smoking

cocaine use

trauma

external version, previous abruptions.

46
Q

abruption initial management

A

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
Q

labs, fetal monitoring needed with placenta abruption

A

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
Q

first stay management

A

Ambulate, sit, side lie

Nourishment (avoid dehydration)

Continuous or intermittent monitoring

VS q 4 hrs unless otherwise indicated

encourage voiding

49
Q

pain management

A

Analgesia prn, anesthesia usually once active

Can use Lamaze type breathing or visualization (Bradley), “hypnobirthing” for coping and comfort

50
Q

fetal monitoring in active labor vs second stage

A

Fetal monitor noted q 15-30 min in active labor, q 5-10

second stage (usually by RN per protocol)

51
Q

pain experienced in the first stage of labor

A

occurs during contractions, visceral/cramp-like

Referred pain - can be referred to the abdominal wall, lumbosacral region, iliac crests, gluteal areas, thighs

52
Q

pain in second stage of labor

A

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
Q

Most reliable means of relieving the pain of labor and delivery.

A

Regional analgesic techniques, epidurals, spinals, and combined spinal-epidurals (CSE):

54
Q

Walking epidural”

A

analgesia with minimal motor block

refers to neuraxial techniquwa

55
Q

SE of a epidural

A

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
Q

low risk of scary epidural

A

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
Q

pudendal block -when is it done

A

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
Q

Antiemetics

A

phenergan, vistaril

Given with opioids to potentiate their action and decrease maternal anxiety/apprehension

Helps prevent any nausea from the opioids

59
Q

Amniotomy

A

Artificial rupture of membranes

To check fluid, augment, apply internal fetal monitor

60
Q

Augmentation

A

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
Q

Amnioinfusion

A

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
Q

signs of placenta separation

A

delivery of the placenta usually within 30 minutes

Gush of blood
Cord lengthens
Fundus rises in abdomen
Uterus becomes firm and globular

63
Q

Active third stage managemen

A

effort to reduce hemorrhage

Risks – hemorrhage, retained placenta, uterine inversion

64
Q

Brandt-Andrews technique

A

Brandt-Andrews technique (guarding the uterus)

helps prevent inversion of the uterus while guiding the placenta out

65
Q

transmission of GBS is

A

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
Q

indications for durgical delivery

A

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
Q

if unknown antepartum culture status (culture not performed or result not available) and these factors GBS prophylaxis is indicated

A
  • 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
Q

most common episiotomy in the US

A

Median – most common in US

69
Q

MC cerivical lacerations

A

Most of the time when women tear, it is a 1st or 2nd degree tear

70
Q

1st degree

A

vaginal epithelium only.

71
Q

2nd degree

A

extend into the fascia and musculature of the perineal body,

72
Q

3rd degree

A

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
Q

Fourth degree laceration

A

involve the perineal structures, EAS, IAS, and the rectal mucosa

74
Q

leading cause of maternal mortality (MM), esp. in the developing world

A

PPH

75
Q

Definition of PPH

A

Definition is somewhat arbitrary – EBL> 500ml following SVD or >1000ml following C/S.
Estimated blood loss = EBL

Excessive bleeding that makes patient symptomatic

76
Q

primary vs secondary PPH

A

Within 24 hours of delivery is “primary” PPH, “secondary” PPH occurs >24 hours after

77
Q

risk factors for PPH

A

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
Q

retained tissue will look like this kind of blood loss

A

May be dramatic or a slow trickle (usually from retained tissue or trauma)

79
Q

treatment of PPH

A

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

OB (14 decks)

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