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Undeleted > Labor and Delivery > Flashcards

Labor and Delivery Flashcards

1
Q

What is True Labor?

A

REGULAR uterine contractions (q3-5min or 3-5 contractions q10min)

AND

cervical change (+ “bloody show”)
*–Efacement and dilitation*
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2
Q

What is False labor “Braxton Hicks”?

A

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)

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3
Q

How many stages of labor are there?

A

4

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4
Q

What is the first stage of labor?

What are the 2 subsets of first stage labor?

How are the 2 subsets measured?

A

—First—onset of true labor to full or “complete” dilitation

Latent phase: 0-4/5 cm
Active phase: 4/5-10 cm (“complete”)

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5
Q

What is the second stage of labor?

A

—Second— “complete” to parturition (until baby is born)

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6
Q

What is the third stage of labor?

A

—Third– Parturition to placenta (

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7
Q

What is the fourth stage of labor?

A

—“Fourth”– following hour…risk of PPH (post-partum hemorrhage)

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8
Q

What is effacement?

A

Thinning of the cervix

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9
Q

How do you manage early labor?

A

—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

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10
Q

What do Friedman and Zhang curves reflect?

A

Multiparous delivers fasters than nulliparous

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11
Q

How can the fetus present during delivery?

A

◦95% vertex
◦4% breech (slow)
◦1% face, brow, shoulder (slow)

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12
Q

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?

A

◦Vertex reference point is the occiput
◦Breech reference point is the sacrum
◦Occiput anterior gives mechanical advantage

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13
Q

What are the 4 major types of malpresentations?

A

Face, brow, breech, shoulder

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14
Q

What are the 3 types of breech presentations?

A

Complete, footling, frank

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15
Q

What is a leopold maneuver and what EGA is it used at?

A

Determines presentation and is done at 28 and 36 weeks.

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16
Q

What is external cephalic version?

What are the contraindications for this maneuver?

A

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

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17
Q

What are some fetal malPOSITIONS?

A

LOT, LOP, ROT, ROP

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18
Q

What are the 6 cardinal movements of labor?

A

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

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19
Q

Station is measure to what maternal landmark?

At what station is the fetal head “engaged”?

At what station is the fetal head “crowning”?

A

—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

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20
Q

Labor Dystocia is an abnormal (slow) progression of labor, Prolonged latent phase is determed by?

Prolonged active phase is determined by?

A

◦Prolonged latent (14hr multip and 20hr nullip)
◦Prolonged active (

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21
Q

—Arrest disorder, a “failure to progress” is noted in stage 1 and or 2 of labor, what are the 2 arrests?

A

◦Arrest of dilation—after reaching 5-6 cm with ROM

◦Arrest of descent (or rotation) 2nd stage

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22
Q

After reaching 5-6 cm with ROM, what defines Arrest of dilation with adequate contractions vs –inadequate contractions

A

–No change after 4 hrs with adequate contractions (IUPc measured)
–No change after 6 hrs with inadequate contractions

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23
Q

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

A
  • *–Nulliparous**–>3.5hrs with or >3 hrs w/o epidural
  • *–Multiparous**–>3 hrs with or >2 hrs w/o epidural
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24
Q

What are the 4 “P’s” of dystocia?

A
  • *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.
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25
Q

What is the number one diagnosis for C-section?

A 
Cephalopelvic Disproportion (CPD)
—Fetal/Maternal pelvic size mismatch
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26
Q

What is the defintion of Labor induction/augmentation?

A

—Definition: Initiate/stimulate the uterus to contract or contract better

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27
Q

What is the Management of Dystocia?

A
  1. No intervention if progression and fetal and maternal condition satisfactory
  2. Increasing degrees of intervention (operative as last resort)
  3. Trial of induction/augmentation for arrest absence of protraction
  4. Failed induction usually results in operative delivery
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28
Q

What is the Management of prolonged latent phase (Cervix

1) Hypertonic Contractions?
2) Hypotonic Contractions?
3) Hypotonic with soft uterus during contractions?

A

—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

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29
Q

How to Manage of prolonged active phase

A

—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

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30
Q

What are MATERNAL indications to induce labor?

A

Preeclampsia

Diabetes mellitus

Heart disease

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31
Q

What are FETOPLACENTAL indications to induce labor?

A

Prolonged pregnancy

IUGR (Intrauteruine growth restriction)

Abnormal fetal testing

Rh incompatibility

Fetal abnormality

PROM (premature rupture of membranes)

Chorioamnionitis (infxn of amniotic sac)

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32
Q

What are MATERNAL CONTRAINDICATIONS for induction?

A

ABSOLUTE

 Contracted Pelvis

RELATIVE

 Prior uterine surgery

 Classic cesarean section

 Overdistended uterus
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33
Q

What are FETOPLACENTAL CONTRAINDICATIONS for induction?

A

Premature fetus without lung maturity

Acute fetal distress

Abnormal presentation

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34
Q

What scoring system Predicts success of vaginal delivery based on status of the cervix?

A

Bishop scoring for cervical ripening

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35
Q

What are some Methods of Induction/Augmentation?

A

Amniotomy “AROM”

—Membrane stripping weekly at 37 weeks

—Mechanical dilation; Laminaria, balloons

—Prostaglandins; E1—misoprostol, E2—Cervidil(string) and prepidil(gel)

Oxytocin

36
Q

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?)

A

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

37
Q

_____ 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 _______.

A

Oxytocin; Mammary stimulation

Uterine contractions; post partum hemorrhage

38
Q

>5 UCs in a 10 minute period (avg over 30 min) is a definition of what?

A

Tachysystole

39
Q

◦UCs occurring within one minute of one another

A

Tachysystole

40
Q

◦Any UC lasting 2 minutes or more

A

Tachysystole

41
Q

Tachy systole is defined by any one of what 3 parameters?

A

◦>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

42
Q

How do you manage tachysystole?

A

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

43
Q

Fetal monitoring assesses fetal well-being, what are some ways to monitor?

A

Intermittent Auscultation

Electronic (EFM)
–Ultrasound monitor
–Tocodynamometer

44
Q

2 types of EXTERNAL fetal monitors are;

US Transducer and Tocodynamometer

What do each do?

A

—US transducer- fetal heart rate based on US cardiac cycle
—Tocodynamometer - Shows timing and duration of contraction (NOT strength)

45
Q

—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?

A

—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
46
Q

How do healthy does a healthy fetus present on fetal heart monitoring?

A

Healthy fetuses have heart rate accelerations in response to fetal movement and do not have decelerations

47
Q

“Non-stress test” is a type of fetal assessment. What measurements in what timeframe reflects a “healthy” reactive fetus?

A

2 accelerations of 15bpm each lasting 15sec in 20 minutes

48
Q

“Contraction Stress test” is another type of fetal assessment. What drug is used and what is measured to reflect a “reassuring” response?

A

◦3 oxytocin-induced uterine contractions in 10min
◦Absence of late decelerations = reassuring
◦Equivical = 1 late decelleration

49
Q

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?

A

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

50
Q

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?

A

Acidosis

Greater than 6

51
Q

If biophysical profile

A

—Consider delivery if

—AFI trumps other parameters (even if overall score favorable)

52
Q

With fetal monitoring what is the most reliable indicator of fetal well-being (test question)?

A

—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

53
Q

What defines fetal bradycardia?

What defines fetal tachycardia?

A

—Bradycardia:
—Tachycardia: >160bpm

54
Q

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

A

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

55
Q

What is the goal of fetal heart monitoring?

A

Goal of fetal monitoring is to prevent hypoxemic and/or acidotic states

56
Q

Decelerations are represented by Early, Variable, or Late. What do each of these findings constitute?

Also, what is a nadir?

A

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**
57
Q

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.

A

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.

58
Q

In most frequent abnormal pattern; What is a “severe variable deceleration” defined by?

What stage is it usually seen in?

A

—Graded by severity “Severe”—Drop in hr to 60 bpm sustained for at least 60 sec.

Often seen in Stage 2 with pushing

59
Q

How do you treat a “severe variable deceleration”?

A

◦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)

60
Q

—What are some Nonpharmacologic Obstetric anesthesia/analgesia methods (most effective when used in first stage)?

A

◦Psychoprophylaxis (Lamaze)
◦Continuous labor support (the doula)
◦Warm-water baths
◦Sterile water injection (occiput posterior)
◦Position, touch, massage (efflurage)

61
Q

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?

A

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
62
Q

—Sedatives helpful only in false labor, what sedatives could you consider using for anelgesia in false labor?

A

◦Phenergan
◦Vistaril
◦Zolpidem

63
Q

What is the Regional Analgesia procedure of choice?

What medications are administered?

What stage of birth could this prolong and what maternal concern?

A

—Lumbar epidural; for vaginal or c-section

–Bupivicaine 10-12 cc/hr + Fentanyl 2-5 mcg/ml

Associated with prolonged 2nd stage & maternal fever

64
Q

1) What is a pudendal?
2) Where is it placed?
3) What is it for?

A

1) Regional anesthesia for perineal pain.
2) Anesthesia is placed between s2-s4
3) Only relieves perineal pain for 2nd stage

65
Q

When would general anesthesia be considered?

Why can general anesthesia be unfavorable?

A

◦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)

66
Q

Operative deliveries account for what % of deliveries in the US?

Cesarean accounts for what %?

Operative vaginal (vacuum or forceps) account for?

A

—Used in 35-40% of deliveries in US

◦25% are cesarean section

◦15% are operative vaginal deliveries
–Forceps
–Vacuum

67
Q

What are Indications for operative delivery (CESAREAN)?

A
  1. Dystocia
  2. Repeat cesarean
  3. Breech
  4. Fetal distress
  5. Placenta previa
  6. Previous uterine incision
  7. Active genital herpes
68
Q

What are Indications for operative delivery (VAGINAL)?

(vacuum/forceps)

A

1) Prolonged 2nd stage of labor
2) Suspicion of impending fetal compromise
3) Breech delivery (Forceps only)
4) Shorten second stage for maternal benefit

69
Q

What is the 3rd stage of pregnancy?

How long does it take?

What is the risk of manual extraction?

A

—Delivery of the placenta

Manual extraction - Risk of uterine eversion

70
Q

What are the 4 grades of Spontaneous laceration or episiotomy in birthing?

A

1st skin only

2nd subcut only

3rd anal sphincter

4th AS and rectum

71
Q

How is Precipitous labor defined?

A

Cevical dilation of 5 - 10cm/hr

72
Q

With Thick meconium – “Meconium Aspiration Syndrome”, what intervention would you consider and who do you call?

A

◦Call pediatrics!
◦Amnioinfusion

73
Q

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?

A

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

74
Q

In fetal lung maturity, when does surfactant production start and what produces it?

What does surfactant do?

A

—Type II pneumocytes produce surfactant beginning at 24 weeks.

—Surfactant decreases alveolar surface tension

75
Q

What tests are used to measure fetal lung maturity?

A

L/S Ratio (Lecithen/Sphingomyelin) &
PG (phosphatidylglycerol)
or
—Lamellar Body Count

76
Q

—L/S ratio ; no PG; what % risk that the infant will have RDS?

A

Infant >90% probability of RDS

77
Q

—L/S ratio >2; PG present. What % probability will the infant have RDS?

A

◦Infant

78
Q

What parameters measure —Lamellar Body Count?

A

>50K—mature

(Hacker states same or better than L/S ratio)

79
Q

What is Puerpurium?

What post-partum uterine discharge is seen (and acceptable)?

A

(6wks following delivery)

Lochia

L. rubra - 0-3 days

L. serosa - 3-4 days

L. alba - Up to 10 days

80
Q

Breastfeeding is the standard of care.

What are maternal benefits?

What are infant benefits?

A
  • *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
81
Q

Breast engorgement is —Stasis that can lead to mastitis, how do you treat an engorged breast?

A

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

82
Q

How do you want to prevent breasts from producing milk? (Suppression)

A

—Breast binding/tight bra
—NO STIMULATION or pumping
—Ice packs, analgesics, time

83
Q

What are some risks of cracked nipples?

How do you manage and treat?

A

Risks - —Pain, —Infection

—Express manually to preserve lactation
—Use of nipple shield/emollient
—PREVENTION! Dry nipples after feeding; air dry 10 minutes

84
Q

Can a mother continue to feed with MASTITIS?

What medications do you use to treat mastitis?

A

—CONTINUE TO BREAST FEED! - Source is S. aureus from infant’s mouth

—Antibiotics: Dicloxicillin /cephalexin /clindamycin x 7-10 days

85
Q

What is included on a post-partum check-up?

A

—Screening for postpartum depression - Edinburgh postnatal depression scale (EPDS)

—Bonding, —Breastfeeding

Pap

Intercourse, —Contraception
Adverse outcomes noted with interpregnancy intervals >60 or

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