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
direct occiput posterior
sunny side up baby
abnormalities related to the fetus
-Macrosomia
-Prematurity
-IUGR
-Malpresentation
-Fetal anomalies- Hydrocephalus, others
-Oligohydramnios
-Polyhydramnios
malpresentation
-Many such positions exist!
-MC:
-Breech presentation
-Complete breech
-Frank breech
-Footling breech- section
-Double footling breech- section
-Transverse lie
-Back up
-Back down
-And others!
-Brow
-Mentum
-Face
-Compound- hand on the face
shoulder dystocia
1.5%
More examples of malpresentation: footling breech (l.); transverse lie, back up (r.)
the powers: may be inadequate with
-Infected uterus- Chorioamnionitis -> doesnt contract well
-Macrosomia or multiple gestation
-Polyhydramnios
-Grand multiparity
-Iatrogenesis- Tocolytics
analgesia and anesthesia
-Other than L&D -> no other condition in which a human in moderate to severe pain is expected to forego pain relief
-Unless contraindicated -> pain relief should be administered on demand when the patient is in labor
analgesia and anesthesia: opioids
-Fentanyl, nalbuphine, morphine, others
-Allows patient to obtain relief and also to sleep
-Will cause fetus to sleep as well
-More difficult to interpret FHR tracing
-if pt doesnt want epidural
-nitrous oxide can also be used
regional and general anesthesia
-Regional anesthesia allows pt to participate in L&D
-Avoids increased risk of aspiration pneumonia
-preferred
-Epidural, spinal, or combined spinal/epidural anesthesia
-Epidural may be continued through labor, delivery, C/S, and postop, if necessary
-Risk of fetal bradycardia at time of induction
-General anesthesia is generally avoided
-May be required in emergent C/S with very ill patients
-intubate
epidural vs spinal
-epidural doesnt affect motor function -> can move legs
-can put the catheter in and repeat doses
-continue therapy post op
-spinal:
-cant move legs
-goes into the dura
stages of labor
-1st stage: onset-full dilation
Latent phase (<6 cm of dilation)
Active phase (6-10 cm of dilation)
-2nd stage: full dilation-fetal delivery
-3rd stage: fetal delivery-placental delivery
1st stage: latent and active phase
-LATENT PHASE:
-Occurs from onset of labor up to 6 cm dilation
-May include:
-Bloody show
-Possible diarrhea, or loose stools
-Contractions q 4-10’, lasting 30-60 seconds
-Generally well tolerated
-Primigravidas will progress about 1 cm every 2 hours
-ACTIVE PHASE:
-Begins at 6 cm dilation
-Contractions occur roughly q 2-5’, lasting 45-60 sec
-Primigravidas: progress about 1.2 cm/hr
-Bloody show persists
-N/V may occur
-Less well tolerated
-The patient often requests analgesia or anesthesia
-As the fetus descends, rectal pressure stimulates an irresistible need to push
2nd stage of labor
-Lasts 20-120’
-Normal for primigravidas without epidural: 120’
-Normal for primigravidas with epidural: 180’
-Normal for multiparas without epidural: 60’
-Normal for multiparas with epidural: 120’
-The gravida experiences an overwhelming urge to push
-Contractions occur q1-5’, lasting 45-90 sec
-Crowning of head indicates that delivery is imminent
episiotomy
-incision made to enlarge the vaginal introitus
-No longer routinely performed
-Increases the risk of severe obstetrical lacerations
-May be very painful
-May be indicated in:
-Operative vaginal delivery
-Emergent circumstances
-Hx of female genital mutilation
at delivery
-Some suction neonate’s nose and mouth (with bulb suction)
-Stimulate neonate by drying it with a warm towel
-Place neonate on maternal abdomen or chest
-Clamp cord
-The other parent or other individual may cut cord, if desired
-Nurse obtains 1- and 5-minute Apgar scores
apgar score
-Named for anesthesiologist Dr Virginia Apgar
-Taken at 1 and 5 minutes of life, usually by RN
-5 min score is more predictive of neurological well-being of the neonate
3rd stage of delviery
-Watch for signs of placental separation
-Gush of blood
-Lengthening of the cord
-Increased sensation of pressure
-Uterus rises in pelvis
-Interventions
-Massage uterine fundus (now at umbilicus)
-The RN will administer oxytocin 20 units in 1 liter of lactated Ringer’s solution, run wide open
-If you think placenta has separated, gently tug on umbilical cord
-Placenta may well be in the vagina and can be removed easily
-Examine entire placenta to be sure none is missing
-Send placenta to pathology if there has been any difficulty in the labor or birth
-Perform cord blood gases if indicated
-Repair lacerations, if any
delivery of the placenta
types of lacerations resulting from vaginal delivery
-1st degree: involves fourchette, perineal skin, vaginal mucosa
-2nd degree: involves above and the perineal body muscles
-3rd degree: involve the above and extend into the anal sphincter
-4th degree: involve the above and extend through the anal sphincter into the rectal mucosa
vaginal/perineal lacerations at birth
-Up to about 90% of patients will suffer some type of abrasion or laceration during vaginal delivery
-Incidence of 2nd degree lacerations:
-In primiparas: 35-78%
-In multiparas: 35-40%
-Incidence of 3rd-4th degree lacerations: 1.7%
-Risk factors of 3rd-4th degree lacerations:
-Postdates pregnancy
-GDM
-Primigravidas
-H/O female genital mutilation
-Large fetus (>4000 gm)
-Prior h/o 3rd-4th degree lacerations
-Operative vaginal delivery
repair of the 1st and 2nd degree lacerations
-Performed in labor and delivery room
-No need for the patient to be placed in OR
-May be repaired by PA, CNM, or attending
-First degree laceration:
-Often does not need repair at all, or perhaps only one or two interrupted sutures
-Use 2-0 or 3-0 chromic gut
-Second degree laceration:
-Repair muscular layer, then close mucosa in running stitch
-Use 2-0 chromic gut
sequelae and repair of 3rd-4th degree lacerations
-Sequelae
-Fecal incontinence
-Rectovaginal fistula
-Repair
-In O.R. with attending present
-Adequate anesthesia
-Use endoanal ultrasound when repairing anal sphincter
-top is 4th
-bottom is 3rd
counseling after repair of 3rd-4th degree perineal lacerations
-Use stool softeners
-Eat low residue diet
-Perform local wound care
-Ice to area
-Cleanse wound carefully
-Report fecal/flatus incontinence
-Use adequate pain medication
-Re-evaluate anal sphincter at follow-up with endoanal ultrasound
birthing video
-crowning- slow the birth of the head to reduce damage -> stop pushing -> let the contractions push the baby
-place a cloth to pretect baby from feces
-support with one hand under and one hand on top
-shoulders 1 min after head
indications for induction of labor
-Should only be performed for medical indications
-These include: (dont need to know all)
-AMA at 39 weeks GA
-Hypertensive disorders of pregnancy, generally after 37 weeks
-Gestational diabetes or pregestational diabetes, depending on White classification
-Oligohydramnios
-Polyhydramnios
-Alloimmunization
-Other factors
-May be induced via prostaglandins
-Dinoprostone or misoprostol
-Foley balloon may be used as non-pharmacologic method
induction of labor for medical indications
-May use agents to help cervix “ripen” if the cervix is not likely to efface and dilate with oxytocin alone
-Options include:
-Dinoprostone insert (not in patients with prior h/o C/S)
-Inserted in posterior fornix of vagina x 12 hrs
-Vaginal misoprostol (not in patients with prior h/o C/S)
-Urologic Foley balloon (with balloon inflated with 30 cc sterile water) will dilate cervix mechanically
-May be used in any patient
which of the following best describes the 2nd stage of labor
-delivery of placenta occurs
-cervical dilation from 6-10cm
-labor following spontaneous rupture of membranes
-delivery of the fetus occurs!!!
