Labor and Delivery Flashcards

Question

Third Stage of Labor

Answer 1

Fetus delivered until placenta is delivered

Answer 2

Fetal head restitution Check for nuchal cord Deliver anterior shoulder with gentle traction Guide fetus posterior >> anterior PLACENTA Up to a 30-minute delay in delivery of placenta is normal Signs of placental separation: Fresh show of blood Lengthening of umbilical cord Uterus becomes firm and globular

Answer 3

Intrapartum fetal monitoring Maternal vital signs Subsequent cervical exams Latent phase every 4-8hrs / Active phase every 1-2 hrs 1cm 1 finger tightly 3cm 2 fingers tightly 4cm 2 loose fingers 10 cm fully dilated, no cervix in front of baby’s head IV fluids/ PO hydration Maternal rupture of membranes AROM/ amniotomy

Answer 4

Bear down/ pushing techniques Push during uterine contractions Knee and hip flexion Fetal head descends through pelvis, rests on the perineum at the vaginal opening, bulging and the skin is stretched (crowning)

Answer 5

Impaction of the shoulder against pubic symphysis Risk factors: fetal macrosomia, DM, prior hx, maternal obesity, post-term, prolonged 2nd stage Fetal complications: frx of humerus & clavicle, brachial plexus injury (Erb’s palsy), hypoxic brain injury & death Diagnosis: When routine maneuvers fail to deliver the infant If risk factors present → should be anticipated & prepared for Dorsal Lithotomy position (laying flat opens the pelvic space) with hips at a 90 deg angle Turtle sign: incomplete delivery of head or chin tucking against maternal perineum

Answer 6

Treatment: **McRoberts maneuver**: sharp flexion of maternal hips to ↓ the inclination of the pelvis **Suprapubic pressure:**at an oblique angle to dislodge the anterior shoulder **Rubin maneuver**: pressure on accessible shoulder to push it toward fetal anterior chest wall **Wood corkscrew maneuver:** pressure behind posterior shoulder to rotate infant & dislodge the anterior shoulder **Delivery of posterior arm/shoulder** If undelivered may need to fracture clavicle or cut maternal pubic symphysis or do Zavanelli maneuver (put head back in pelvis & perform CS)

Answer 7

1st degree: injury involving vaginal epithelium and vulva skin only 2nd degree: injury to perianal muscles, but not the anal sphincter 3rd degree: injury to perineum involving the anal sphincter complex 4th degree: injury to perineum involving the anal sphincter complex and rectal mucosa

Answer 8

Test performed on baby 1 to 5 minutes after birth- in rare cases it can also be done 10 minutes after birth Tests: Heart rate, lung maturity, muscle tone and movement, skin color/oxygenation, reflex responses All categories range from 0-2 (APGAR score of 10 being the highest!) **0-6 points = distress & 7-10 points = normal**

Answer 9

Use of oxytocin and/or amniotomy to stimulate uterine contractions if adequate cervical changes do not occur with spontaneous labor **Amniotomy:** Artificial rupture of membranes (AROM) Healthcare provider breaks water bag for patient Helps with active management of labor Releases prostaglandins, can cause an increase in uterine contractions and fetal head descent Risks: Cord prolapse, infections Contraindications: Malpresentation, maternal infections, fetal head station too high **Oxytocin** Natural oxytocin is a polypeptide hormone produced by the hypothalamus and secreted from posterior pituitary Pitocin = synthetic drug form Dose ranges from 2-40 mU/min Uterus contracts in response to high levels of oxytocin Pitocin can be given to patients to increase frequency and strength of contractions in labor

Answer 10

Cervical Ripening Mechanical: Intracervical balloon Medical: Prostaglandins **Misoprostol** (cytotec): Synthetic Prostaglandin E analog 25mcg tablet placed into the posterior vaginal fornix at base of cervix **Causes cervical softening and ripening, also may induce some uterine contractions** Start oxytocin induction (earliest) 4hrs after initial insertion Dinoprostone (cervidil) 10mg vaginal insert, sustained release lasts 12hrs Start oxytocin induction 30-60 minutes after removal Amniotomy Oxytocin

Answer 11

Use of a device to help guide fetus out of the vaginal canal and achieve vaginal delivery Benefits: Can perform quickly if fetal distress, avoid cesarean section Risks: Maternal perineal and vaginal lacerations, potential newborn injuries (nerve palsy, skull fracture, intracranial hematoma) Indications: Prolonged second stage of labor (N >3-4hrs pushing, M >2-3hr pushing). It also shortens second pushing stage of labor (for maternal benefit) Contraindications: Fetal head not engaged in pelvis, fetal bone disorders **Forceps OR Vacuum**

Answer 12

Amniotic water sac breaking Can occur before the onset of labor or throughout the labor process PROM = Prelabor rupture of membranes Rupture of fetal amniotic membranes after 37 weeks (full term) and prior to the onset of labor 8-10% pregnancies PPROM = Preterm prelabor rupture of membranes Rupture of fetal amniotic membranes before 37 weeks (preterm) and prior to the onset of labor 2-4% of pregnancies SROM = Spontaneous rupture of membranes Rupture of fetal membranes after 37 weeks (full term) and during labor AROM = Assisted/Artificial rupture of membranes Amniotic fluid sac is ruptured by a medical provider during labor induction/ augmentation

Answer 13

**MATERNAL FACTORS:** Preterm prelabor rupture of membranes (PPROM) in a prior pregnancy (recurrence risk is 16%–32% as compared with 4% in women with a prior uncomplicated term delivery) Antepartum vaginal bleeding Chronic steroid therapy Collagen vascular disorders (such as Ehlers-Danlos syndrome, systemic lupus erythematosus) Direct abdominal trauma Preterm labor Cigarette smoking Illicit drugs (cocaine) Anemia Low body mass index (BMI < 19.8 kg/m2) Nutritional deficiencies of copper and ascorbic acid Low socioeconomic status **UTEROPLACENTAL FACTORS** Uterine anomalies (such as uterine septum) Placental abruption (may account for 10%–15% of preterm PROM) Advanced cervical dilatation (cervical insufficiency) Prior cervical conization Cervical shortening in the 2nd trimester (< 2.5 cm) Uterine overdistention (polyhydramnios, multiple pregnancy) Intra-amniotic infection (chorioamnionitis) Multiple bimanual vaginal examinations (but not sterile speculum or transvaginal ultrasound examinations) **FETAL FACTORS** Multiple pregnancy (preterm PROM complicates 7%–10% of twin pregnancies)

Answer 14

Evaluation: Perform sterile speculum exam Always perform sterile speculum exam (SSE) before doing a manual exam- if that patient’s water is broke you want to limit the amount of manual exams to reduce risk of infection! Diagnostic Criteria: **Pooling**: Copious fluid visualized in the posterior fornix of vaginal vault or leaking from the cervical os on examination **Ferning**: Swab the fluid cells and visualize under microscope. The cells crystalize into a ferning shape, this confirms diagnosis. **Nitrazine/Amnisure**: Tests the pH level of fluid, which is more alkaline than the acidic vagina. If it turns blue this is a positive rest. However other fluids which are alkaline result in false positive including blood, semen, and cervical mucus. **Ultrasound:** Helpful for diagnosis but not a true diagnostic test. Evaluate 4 quadrants and measure AFI. If the patient had low fluid, this may be an indicator that pt is ruptured When you are more advanced in cervical examinations, sometimes you can feel a “rubbery” “balloon-like” forebag which is amniotic sac or fetal scalp/hair- also helps tell if a patient is ruptured

Answer 15

Patient is less than 34 weeks gestation Admit to the hospital for surveillance 7 day course of antibiotics Pelvic rest (not bed rest) Steroids for fetal lung maturity Patient is greater than 34 weeks gestation Induction of labor Group B strep prophylaxis while intrapartum Always surveillance for: signs of infection- maternal fever, leukocytosis, maternal or fetal tachycardia, flank pain, vaginal discharge, bleeding, uterine pain Risk of infection increases with >18hrs ROM

Answer 16

During prenatal care, test all women at 35-36 weeks Test vaginal/rectal bacterial culture swab to check for group B strep colonization If positive > administer antibiotics during labor BUT WHAT HAPPENS BEFORE 36 WEEKS?? Prophylaxis: Penicillin G 5 million units IV loading dose then 2.5 million units IV every 4 hours OR > Ampicillin 2g bolus then 1 g q 4 hrs Low risk PCN allergy: Ancef 2g loading dose then 1g IV every 8h High risk PCN allergy: Clinda/Erythro sensitive: Clindamycin 900mg IV q8h Clinda/Erythro resistant: Vancomycin 1g IV q8h

Answer 17

When the umbilical cord prolapses through the cervix True obstetric emergency, cord compression leads to fetal compromise/death Risk factors include prematurity, abnormal presentation, multiparity, placenta previa, polyhydramnios, multifetal pregnancy, PROM, iatrogenic (amniotomy, ECV) Treatment: pelvic exam to elevate presenting part, stat C/S!

Answer 18

AKA Intraamniotic Infection (IAI) 1-4% of births in USA are complicated by intraamniotic infections Neonatal sepsis can be reduced up to 80% with administration of intrapartum antibiotics

Answer 19

*Presumptive diagnosis = *Fever >39.0 once, or >38.0 twice, 30 min apart. (Maternal oral temp) *Plus one or more of; fetal tachycardia (>160bpm for >10min), maternal leukocytosis (>15,000mm), uterine fundal tenderness, and/or purulence from cervical os on SSE *Clinical Diagnosis *All the above + evaluation of amniotic fluid including, positive gram stain, low glucose level, positive fluid culture, elevated WBC, or histopathologic evidence of infection or inflammation in the placenta, fetal membranes, or umbilical cord

Answer 20

*Intrapartum regimen — *Ampicillin 2 g intravenously every six hours plus *Gentamicin 5 mg/kg intravenously once daily If they have a Cesarean delivery — add anaerobic coverage *Either metronidazole 500 mg orally or intravenously or clindamycin 900 mg intravenously every eight hours *Add azithromycin 500 mg intravenously once May continue treatment for 24-48hrs after delivery, depending on clinical scenario