Labor and delivery Flashcards
A 33 yo G1P0 at 39 weeks EGA presents to Labor and Delivery and states, “I think my water broke and I’m having really bad contractions every four minutes, and I want an epidural!”
-epidurals can lengthen labor
-The patient’s sterile speculum exam is positive for pooling. The nitrazine test is positive. Her cervical exam is 3 cm, 80% effaced, -2 station. You admit her to Labor and Delivery, and ask the anesthesiologist to see her as she is requesting an epidural.
Orientation to Labor and Delivery
-L&D unit includes:
-A triage unit that serves as an obstetrical Emergency Department (for patients who are more than16-20 weeks gestational age)
-Labor, delivery, and recovery (LDR) rooms
-Operating rooms:
-For Caesarean sections (emergent and scheduled)
-For operative vaginal deliveries:
-Forceps deliveries
-Vacuum deliveries
-Recovery room
definition and etiology of labor
-Regular and forceful, usually painful uterine contractions sufficient to cause cervical change
-Braxton-Hicks contractions- uncomfortable but are usually not painful, do not cause cervical change, and do not cause labor to begin
-What causes labor?
-Unknown events that may include maternal and fetal corticotropin releasing hormone (CRH), leading to myometrial contraction and fetal adrenal production of DHEA sulfate and cortisol
when should laboring pts go to the hospital
-Spontaneous rupture of membranes (SROM) occurs
-A gush of fluid, or persistent leakage of fluid from the vagina
-contractions occurring every 5 mins for at least 1 hour
-significant vaginal bleeding (more than a period)
-decreased or absent fetal movement
prenatal records
-Records should be made available to the L&D practitioners by the time the parturient is 36 weeks, or earlier if they have a complex history, or are likely to deliver early
-They should include (and you should document in your admission note):
-ABO and Rh type
-HBsAg status
-HIV status
-RPR status
-Rubella immune or non-immune status
-Group B strep status
-COVID-19 vaccination status as well as recent testing, if indicated
-Ultrasound results
-Last ultrasound, date it was performed, and gestational age at which it was performed
-Placental location, fetal presentation, and estimated fetal weight at that time
history of the pt in labor
-Age, gravidity, parity, LMP, dating of pregnancy, estimated gestational age
-History of present illness
-Complications with this and past pregnancies
-Targeted history
-Past medical and surgical histories
-Allergies
-Medications
-Last date and time the patient had any food or drink
PE of the pt in labor
-VS (including fetal HR, electronic fetal monitoring)
-Abd exam, including:
-Fundal height
-Leopold’s maneuvers
-Careful attention to presenting part
-Pelvic exam:
-If ROM -> sterile speculum exam
-Also, perform ultrasound
-Identification of presenting part and placenta
-Evaluation of amniotic fluid index (formal AFI or subjective AFI)
sterile speculum exam
-You will need:
-Sterile gloves
-Lamp
-Bedpan
-Sterile speculum
-Q-tip
-Nitrazine paper
-Lubricant
-Glass slide
-if you dont want the pt on a bed pan -> flip the speculum -> now it wont touch the table
exam findings consistent with spontaneous rupture of membranes (SROM)
-Pooling of amniotic fluid seen on sterile speculum exam
-Positive nitrazine test -> blue = elevated pH
-Positive arborization of dried amniotic fluid (ferning)
-+ nitrazine -> top pic
-if the membranes are ruptured -> have her cough
cervical exam during labor
-Performed digitally
-Do NOT perform if the patient has or is suspected to have placenta previa!
-Assess for:
-Effacement (how shortened the cervix is)
-Dilation (how open the internal os is)
-Fetal station (how far down in the pelvis the presenting part of the fetus is)
effacement
-Usually the first event in the onset of labor
-Shortening of cervical canal:
-From 2 cm in palpable length to nearly imperceptible length
-Takes hours to days to occur
cervical dilation
-Assess dilation of the internal os
-Will progress from open 1 cm to 10 cm
-The fetal head is about 9.5 cm in diameter at term
fetal station
-Level at which presenting part is palpated
-0 station=at level of ischial spines
–1 station=1 cm proximal to ischial spines
-+1 station=1 cm distal to ischial spines
presenting part and position
-Presenting part:
-The part of the fetus that is most distal to vaginal introitus and thus would be delivered first
-Position:
-The relation of the fetal presenting part to R or L side of maternal pelvis
-L occiput anterior (MC position):
-Occiput faces anteriorly with spine on patient’s L side (the baby was looking right)
-R sacrum posterior (breech delivery):
-Sacrum faces posteriorly on with spine on patient’s R side
left occiput anterior position
Right sacrum posterior position (a.); left sacrum anterior position (b.)
cardinal movements of labor
-means by which the fetus passively negotiates the bony pelvis during labor and delivery
-usually achieved in order, but sometimes 2 or 3 movements can occur simultaneously
-if the baby is not coming out you might have to push the baby back up and section -> go reverse order
-look at the ear to notice movement!
-engagement
-descent
-flexion- neck flexes
-internal rotation- baby facing butt
-extension- baby comes out like a turtle -> crowning
-external rotation- flexed to the side
-expulsion
engagement
descent
flexion
internal rotation
extension
external rotation
expulsion
3 Ps of labor
-The pelvis:
-Adequacy of the bony pelvis
-must be adequate size and shape to permit fetal delivery
-The powers:
-Strength and frequency of uterine contractions
-Must be forceful and regular enough to cause true labor
-Contractions may last 30-90 sec
-Are initially q15-20’
-In active labor, q1-4’
-The passenger:
-The position and size of fetus
-Fetal wt: varies by GA
-At term (37-40 weeks) -> 2800-3800 gm
-Various factors permit a normal vertex presentation:
-Normal amount of amniotic fluid
-Normal sized fetus
-Normal body habitus
