Labor and Delivery Flashcards
What is True Labor?
REGULAR uterine contractions (q3-5min or 3-5 contractions q10min)
AND
cervical change (+ “bloody show”) *Efacement and dilitation*
What is False labor “Braxton Hicks”?
Irregular uterine contractions
May or may not cause cervical change
Last 4 weeks of pregnancy
“usually” painless
Some may be regular, but infrqt (q 10-20/min)
How many stages of labor are there?
4
What is the first stage of labor?
What are the 2 subsets of first stage labor?
How are the 2 subsets measured?
First—onset of true labor to full or “complete” dilitation
Latent phase: 0-4/5 cm
Active phase: 4/5-10 cm (“complete”)
What is the second stage of labor?
Second— “complete” to parturition (until baby is born)
What is the third stage of labor?
Third– Parturition to placenta (
What is the fourth stage of labor?
“Fourth”– following hour…risk of PPH (post-partum hemorrhage)
What is effacement?
Thinning of the cervix
How do you manage early labor?
Bedrest vs walking
Oral/IV fluids (rehydration or access)
Labs—H/H, urine dipstick, HBV, Rh status
Maternal monitor—VS, I/O
Fetal monitor—HR frequency is risk based
Uterine activity—IUPc (IntraUterine Pressure Catheter) for high risk, oxytocin
Vaginal exams—q2h during active phase (4-10cm dilitation)
Amniotomy (AROM) = ARTIFICIAL rupture of membrane
What do Friedman and Zhang curves reflect?
Multiparous delivers fasters than nulliparous
How can the fetus present during delivery?
◦95% vertex
◦4% breech (slow)
◦1% face, brow, shoulder (slow)
With fetal Position “presenting part to maternal pelvis”, what is the reference point for;
Vertex presentation?
Breech presentation?
What presentation and position gives mechanical advantage?
◦Vertex reference point is the occiput
◦Breech reference point is the sacrum
◦Occiput anterior gives mechanical advantage
What are the 4 major types of malpresentations?
Face, brow, breech, shoulder
What are the 3 types of breech presentations?
Complete, footling, frank
What is a leopold maneuver and what EGA is it used at?
Determines presentation and is done at 28 and 36 weeks.
What is external cephalic version?
What are the contraindications for this maneuver?
Flipping a right-side-up fetus to up-side-down.
Contraindications
Utero-Placental insufficiency
Maternal HTN
IUGR
Oligohydramnios
Prev. uterine surgery
Anything that precludes vaginal delivery
What are some fetal malPOSITIONS?
LOT, LOP, ROT, ROP
What are the 6 cardinal movements of labor?
1) Descent (secondary to uterine contractions)
2) Flexion
3) Internal rotation (inside mom)
4) Extension (upward to pelvic outlet)
5) External rotation (restitution) (to line head w/shoulders)
6) Expulsion
Station is measure to what maternal landmark?
At what station is the fetal head “engaged”?
At what station is the fetal head “crowning”?
Level is estimated in cm above/below the level of the ischial spines
At (0) station the head is “engaged”
At (+5) head is crowning
Labor Dystocia is an abnormal (slow) progression of labor, Prolonged latent phase is determed by?
Prolonged active phase is determined by?
◦Prolonged latent (14hr multip and 20hr nullip)
◦Prolonged active (
Arrest disorder, a “failure to progress” is noted in stage 1 and or 2 of labor, what are the 2 arrests?
◦Arrest of dilation—after reaching 5-6 cm with ROM
◦Arrest of descent (or rotation) 2nd stage
After reaching 5-6 cm with ROM, what defines Arrest of dilation with adequate contractions vs inadequate contractions
No change after 4 hrs with adequate contractions (IUPc measured)
No change after 6 hrs with inadequate contractions
Arrest of descent (or rotation) in 2nd stage of labor depends on multiparous or nulliparous and with or without epideral. Greater than how many hours is an arrest for;
Nulliparous–with or w/o epidural
Multiparous–with or w/o epidural
- *Nulliparous**–>3.5hrs with or >3 hrs w/o epidural
- *Multiparous**–>3 hrs with or >2 hrs w/o epidural
What are the 4 “P’s” of dystocia?
- *Power**- IUPc, Inadequate contraction freq or strength
- *Passage** - Unfavorable pelvic shape
- *Passenger** - Malpresentation, malposition, macrosomia
- *Psyche** - applies in 2nd stage of labor when maternal pushing required.
What is the number one diagnosis for C-section?
Cephalopelvic Disproportion (CPD) Fetal/Maternal pelvic size mismatch
What is the defintion of Labor induction/augmentation?
Definition: Initiate/stimulate the uterus to contract or contract better
What is the Management of Dystocia?
- No intervention if progression and fetal and maternal condition satisfactory
- Increasing degrees of intervention (operative as last resort)
- Trial of induction/augmentation for arrest absence of protraction
- Failed induction usually results in operative delivery
What is the Management of prolonged latent phase (Cervix
1) Hypertonic Contractions?
2) Hypotonic Contractions?
3) Hypotonic with soft uterus during contractions?
Hypertonic contractions - Therapeutic rest (latent phase) (Morphine 15-20 mg subcut or Zolpidem 5 mg if allowed to go home)
Hypotonic (do to sedatives)—wait
Hypotonic (soft uterus during contractions) = IV oxytocin +/- AROM if >4-5 cm
How to Manage of prolonged active phase
1) Confirm at least 6 cm dilatation
2) Augment with oxytocin (high vs low dose)
3) Maternal/fetal monitoring for 4 hours with adequate contractions (>200 Montevideo units)
Extend observation period to 6 hours if less than adequate contractions
4) C-section indicated if above guidelines exceeded
What are MATERNAL indications to induce labor?
Preeclampsia
Diabetes mellitus
Heart disease
What are FETOPLACENTAL indications to induce labor?
Prolonged pregnancy
IUGR (Intrauteruine growth restriction)
Abnormal fetal testing
Rh incompatibility
Fetal abnormality
PROM (premature rupture of membranes)
Chorioamnionitis (infxn of amniotic sac)
What are MATERNAL CONTRAINDICATIONS for induction?
ABSOLUTE
Contracted Pelvis
RELATIVE
Prior uterine surgery Classic cesarean section Overdistended uterus
What are FETOPLACENTAL CONTRAINDICATIONS for induction?
Premature fetus without lung maturity
Acute fetal distress
Abnormal presentation
What scoring system Predicts success of vaginal delivery based on status of the cervix?
Bishop scoring for cervical ripening
What are some Methods of Induction/Augmentation?
Amniotomy “AROM”
Membrane stripping weekly at 37 weeks
Mechanical dilation; Laminaria, balloons
Prostaglandins; E1—misoprostol, E2—Cervidil(string) and prepidil(gel)
Oxytocin
1) What prostoglandins can be used for cervical ripening for the initiation of labor?
2) Where are prostoglandins naturally made?
3) Why do you use it? (Think Bishop)
4) When do you use it? (in relation to other ripening agents?)
1) E1—misoprostol (Cytotec) (not FDA approved)
E2—Cervidil(string) and prepidil(gel)
2) Naturally produced in endometrium/myometrium
3) When there is an unfavorable bishop score.
4) Use prior to Oxytocin
_____ is released by the posterior pituatary when stimulated by distention of birth canal and _______.
This drug can cause _______ and is the first line drug in _______.
Oxytocin; Mammary stimulation
Uterine contractions; post partum hemorrhage
>5 UCs in a 10 minute period (avg over 30 min) is a definition of what?
Tachysystole
◦UCs occurring within one minute of one another
Tachysystole
◦Any UC lasting 2 minutes or more
Tachysystole
Tachy systole is defined by any one of what 3 parameters?
◦>5 UCs in a 10 minute period (avg over 30 min)
◦UCs occurring within one minute of one another
◦Any UC lasting 2 minutes or more
How do you manage tachysystole?
1) Discontinue augmentation medication
2) Position left side
3) Examine to r/o cord entrapment
4) Oxygen
5) ß-agonist “smooth muscle relaxation”(250ug SC terbutaline, FDA–ritodrine)
6)(tocolytic)-to cause contractions to stop
Fetal monitoring assesses fetal well-being, what are some ways to monitor?
Intermittent Auscultation
Electronic (EFM)
Ultrasound monitor
Tocodynamometer
2 types of EXTERNAL fetal monitors are;
US Transducer and Tocodynamometer
What do each do?
US transducer- fetal heart rate based on US cardiac cycle
Tocodynamometer - Shows timing and duration of contraction (NOT strength)
Fetal Scalp Electrode (FSE) and Intrauterine Pressure Catheter (IUPC) are INTERNAL FETAL MONITORS. What do they monitor and what needs to be done prior to internal monitoring?
Must have ruptured membranes to use
- *Fetal Scalp Electrode (FSE)** - shows fetal heart rate based on R-R interval
- *Intrauterine Pressure Catheter (IUPC)** - Shows timing & duration of contraction and STRENGTH
How do healthy does a healthy fetus present on fetal heart monitoring?
Healthy fetuses have heart rate accelerations in response to fetal movement and do not have decelerations
“Non-stress test” is a type of fetal assessment. What measurements in what timeframe reflects a “healthy” reactive fetus?
2 accelerations of 15bpm each lasting 15sec in 20 minutes
“Contraction Stress test” is another type of fetal assessment. What drug is used and what is measured to reflect a “reassuring” response?
◦3 oxytocin-induced uterine contractions in 10min
◦Absence of late decelerations = reassuring
◦Equivical = 1 late decelleration
A biophysical profile is rated on 5 factors, each graded 0 or 2. A fetal assessment test is done and so is an imaging tool;
1) what is the test and the imaging done?
2) What are you looking for with imaging?
3) What are the other 3 factors in the profile and within what timeframe?
1) Non-stress test and US
2) Adequate AFI (5cm) or any 2cm x 1cm pocket
3)(all w/in 30 min) Mvmt —at least 3 body or limb
◦Tone —-at least 1ext/flex of any extremity
◦Breathing — at least 1 episode of 30sec
A lower biophysical profile score relates to what fetal condition?
The lower the score, the worse the fetal state. What should the score be at least?
Acidosis
Greater than 6
If biophysical profile
Consider delivery if
AFI trumps other parameters (even if overall score favorable)
With fetal monitoring what is the most reliable indicator of fetal well-being (test question)?
Variability - the most reliable indicator of fetal well-being (test question)
Short-term variability(beat-to-beat) (loss is bad)
Interval between successive R-R intervals
What defines fetal bradycardia?
What defines fetal tachycardia?
Bradycardia:
Tachycardia: >160bpm
Reassuring patterns of fetal monitoring are in the presence of :
Baseline FHR or ___ to ___
Absence of ____ or _____ decelerations
Moderate FHR variability of ____ to ____ bpm
Age-appropriate FHR accelerations avg ____ @20wks and ____@30wks
Baseline FHR or 110 to 160
Absence of late or variable decelerations
Moderate FHR variability of 5 to 25 bpm
Age-appropriate FHR accelerations avg 155bpm @20wks and 144bpm @30wks
What is the goal of fetal heart monitoring?
Goal of fetal monitoring is to prevent hypoxemic and/or acidotic states
Decelerations are represented by Early, Variable, or Late. What do each of these findings constitute?
Also, what is a nadir?
nadir of FHR = peak of contraction
Early= normal finding, Vagal response to cephalic pressure, Consistent with uterine contraction.
Variable=no pattern of nadir/peak. Cord compression–?reduced fluid vs nuchal cord.
- *Late**= Beyond UC (nadir occurs/extends beyond peak)
- *Uteroplacental insufficiency**
Non-reassuring patterns are usually marked by AVM’s or Absent or minimal variability.
1) How many bpm shows AVM?
2) What are AVM’s associated with what fetal problem?
3) AVM’s with ____ or ____ decels, or _____ are also bad.
4) Sustained ______ less than_____ bpm even in the absence of AVM is non-reassuring.
1) Absent or minimal variability (AMV)(0-5bpm)
2) ?related to fetal acidosis/hypoxemia.
3) AVM’s with late or variable decels, or bradycardia are also bad.
4) Sustained brady less than 100 bpm even in the absence of AVM is non-reassuring.
In most frequent abnormal pattern; What is a “severe variable deceleration” defined by?
What stage is it usually seen in?
Graded by severity “Severe”—Drop in hr to 60 bpm sustained for at least 60 sec.
Often seen in Stage 2 with pushing
How do you treat a “severe variable deceleration”?
◦Tx as for tachysystole
100% O2
Elevate presenting part or assume Trendelenburg
LLD position
Stop pitocin if in use
Terbutaline (tocolytic in Hacker)
Try amnioinfusion (re possible reduced AF)
What are some Nonpharmacologic Obstetric anesthesia/analgesia methods (most effective when used in first stage)?
◦Psychoprophylaxis (Lamaze)
◦Continuous labor support (the doula)
◦Warm-water baths
◦Sterile water injection (occiput posterior)
◦Position, touch, massage (efflurage)
Parenteral narcotics have only limited efficacy except in early stage 1.
What narcotics can be used, how can it influence the fetus, and how long do they last?
Cross placenta
- *Neonatal respiratory depression if close to delivery**
- *Decreased fetal heart rate variability**
1) Sublimaze (Fentanyl) 20-60 min
2) MSO4 1-2 hours
3) Meperidine (Demerol) 4-6 hours
Sedatives helpful only in false labor, what sedatives could you consider using for anelgesia in false labor?
◦Phenergan
◦Vistaril
◦Zolpidem
What is the Regional Analgesia procedure of choice?
What medications are administered?
What stage of birth could this prolong and what maternal concern?
Lumbar epidural; for vaginal or c-section
Bupivicaine 10-12 cc/hr + Fentanyl 2-5 mcg/ml
Associated with prolonged 2nd stage & maternal fever
1) What is a pudendal?
2) Where is it placed?
3) What is it for?
1) Regional anesthesia for perineal pain.
2) Anesthesia is placed between s2-s4
3) Only relieves perineal pain for 2nd stage
When would general anesthesia be considered?
Why can general anesthesia be unfavorable?
◦Extreme urgency for c-section
◦Contraindication to regional anesthesia
◦Regional anesthesia has failed
Unfavorable due to: Compromised airway and Risk of uterine atony (from halogenated gases)
Operative deliveries account for what % of deliveries in the US?
Cesarean accounts for what %?
Operative vaginal (vacuum or forceps) account for?
Used in 35-40% of deliveries in US
◦25% are cesarean section
◦15% are operative vaginal deliveries
Forceps
Vacuum
What are Indications for operative delivery (CESAREAN)?
- Dystocia
- Repeat cesarean
- Breech
- Fetal distress
- Placenta previa
- Previous uterine incision
- Active genital herpes
What are Indications for operative delivery (VAGINAL)?
(vacuum/forceps)
1) Prolonged 2nd stage of labor
2) Suspicion of impending fetal compromise
3) Breech delivery (Forceps only)
4) Shorten second stage for maternal benefit
What is the 3rd stage of pregnancy?
How long does it take?
What is the risk of manual extraction?
Delivery of the placenta
Manual extraction - Risk of uterine eversion
What are the 4 grades of Spontaneous laceration or episiotomy in birthing?
1st skin only
2nd subcut only
3rd anal sphincter
4th AS and rectum
How is Precipitous labor defined?
Cevical dilation of 5 - 10cm/hr
With Thick meconium – “Meconium Aspiration Syndrome”, what intervention would you consider and who do you call?
◦Call pediatrics!
◦Amnioinfusion
1) Definition: pulmonary immaturity leading to poor oxygenation and ventilation is WHAT?
2) What are the signs/symptoms?
3) What does it lead to?
4) What is the etiology?
1) Neonatal respiratory distress syndrome
(RDS)
2) Sx/Si: grunting, flaring, retractions, hypoxia
3) Leads to acidosis and death
4) Etiology: Lack of surfactant to decrease surface tension
In fetal lung maturity, when does surfactant production start and what produces it?
What does surfactant do?
Type II pneumocytes produce surfactant beginning at 24 weeks.
Surfactant decreases alveolar surface tension
What tests are used to measure fetal lung maturity?
L/S Ratio (Lecithen/Sphingomyelin) &
PG (phosphatidylglycerol)
or
Lamellar Body Count
L/S ratio ; no PG; what % risk that the infant will have RDS?
Infant >90% probability of RDS
L/S ratio >2; PG present. What % probability will the infant have RDS?
◦Infant
What parameters measure Lamellar Body Count?
>50K—mature
(Hacker states same or better than L/S ratio)
What is Puerpurium?
What post-partum uterine discharge is seen (and acceptable)?
(6wks following delivery)
Lochia
L. rubra - 0-3 days
L. serosa - 3-4 days
L. alba - Up to 10 days
Breastfeeding is the standard of care.
What are maternal benefits?
What are infant benefits?
- *Mom:** Bonding, (Oxy increase) PPH, contraception, wt loss, CA risk
- *Infant:** ID risk (AOM, UTI, resp inf.) immune protection and response (against E.coli), IgA predom in milk
Breast engorgement is Stasis that can lead to mastitis, how do you treat an engorged breast?
1) Frequent breastfeeding with complete emptying
2) Cool compresses/ice
3) ?Analgesics
4) Avoid breast pumps for more than 10 min, Often inefficient at removing milk. May promote excess milk production
How do you want to prevent breasts from producing milk? (Suppression)
Breast binding/tight bra
NO STIMULATION or pumping
Ice packs, analgesics, time
What are some risks of cracked nipples?
How do you manage and treat?
Risks - Pain, Infection
Express manually to preserve lactation
Use of nipple shield/emollient
PREVENTION! Dry nipples after feeding; air dry 10 minutes
Can a mother continue to feed with MASTITIS?
What medications do you use to treat mastitis?
CONTINUE TO BREAST FEED! - Source is S. aureus from infant’s mouth
Antibiotics: Dicloxicillin /cephalexin /clindamycin x 7-10 days
What is included on a post-partum check-up?
Screening for postpartum depression - Edinburgh postnatal depression scale (EPDS)
Bonding, Breastfeeding
Pap
Intercourse, Contraception
Adverse outcomes noted with interpregnancy intervals >60 or
