Labor and Delivery Flashcards
labor
progressive cervical dilation resulting from regular uterine contractions that occur at least every 5 minutes and last 30-60 seconds
false labor
also called Braxton-Hicks contractions
irregular contractions without cervical change
which pelvic shapes have good prognosis for delivery?
gynecoid (50% of females)
anthropoid (20% of females)
which pelvic shapes have bad prognosis for delivery?
android (30% of females)
platypelloid (3% of females)
typical obstetric exam
fetal lie (longitudinal vs transverse vs oblique) fetal presentation (breech vs vertex) cervical exam
leopold maneuvers
series of 4 maneuvers for palpating fetal lie and presentation in the uterus
cervical dilation
check at the level of internal os
ranges from closed to 10 cm dilation
cervical effacement
thinning of cervix occurs and is reported as a % change in length
range is thin = 100% effaced
cervical station
degree of descent of the presenting part of the fetus
measured in cm from presenting part to ischial spines
cervical consistency and position
used to calculate Bishop score??
first stage of labor
onset of true labor to complete cervical dilation
latent phase and active phase
first stage latent phase
the period between onset of labor and is characterized by slow cervical dilation
first stage active phase
associated with faster rate of dilation and usually begins when cervix is dilated to 6 cm
*admit for labor at this stage
duration of first stage
6-18 hours for primapara (1.2 cm/hour)
2-10 hours for multipara (1.5 cm/hour)
management of first stage
maternal position - may ambulate or encourage left lateral recumbent position IV fluids Labs - CBC and T&S obtain vitals q1-2 hrs provide adequate analgesia fetal monitoring uterine activity vaginal exams amniotomy
fetal monitoring during first stage
external monitoring
q30 mins for uncomplicated pregnancy
q15 mins for complicated pregnancy
how is uterine activity monitored?
external tocodynamometer
internal pressure catheter - useful with oxytocin augmentation
amniotomy
artificial rupture of membranes
*breaking the mother’s water
benefits of amniotomy
augment labor
allow assessment of meconium status
risk of amniotomy
cord prolapse
prolonged rupture is associated with chorioamnionitis
second stage of labor
characterized by descent of the presenting part through the maternal pelvis and culminates delivery
mother has desire to bear down during each contraction
increased bloody show
duration of second stage
primapara w/ epidural = 2 hrs
primapara w/o epidural = 3 hours
multipara w/ epidural = 1 hour
multipara w/o epidural = 2 hours
cardinal fetal movements of labor
engagement descent flexion internal rotation extension external rotation expulsion
management of second stage
avoid supine position bearing down continuous fetal monitoring vaginal exams delivery of fetus
episiotomy indications
likelihood of spontaneous laceration seems high
to expedite delivery by enlarging the vaginal outlet
most commonly performed episiotomy
midline
describe the modified Ritgen maneuver for head delivery
fingers of the right hand are used to extend the head while counterpressure is applied to the occiput by the left hand
allows for more controlled delivery
first degree perineal laceration
superficial lac involving vaginal mucosa and/or the perineal skin
second degree perineal laceration
lac extending into the muscles of the perineal body but does not involve the anal sphincter
third degree perineal laceration
lac extends into or completely through the anal sphincter but not into the rectal mucosa
fourth degree perineal laceration
lac involves the rectal mucosa
third stage of labor
interval between delivery of infant and delivery of placenta
typically lasts 2-10 minutes
what is the dx if the placenta is not delivered within 30 minutes?
retained placenta
classic signs of placental separation
gush of blood from the vagina
lengthening of the umbilical cord
fundus of the uterus rises up
change in shape of the uterine fundus from discoid to globular
management of third stage
look for lacerations
monitor uterine bleeding
repair episiotomy or spontaneous lacerations
inspect the placenta
management of fourth stage of labor
monitor patient closely
vitals
uterine fundal checks and assess for vaginal bleeding
postpartum hemorrhage commonly occurs during this time
risk factors for postpartum hemorrhage
uterine atony
retained placenta
unrepaired lacerations
cervical ripening
facilitating the process of cervical softening, thinning, and dilating to reduce the rate of failed inductions
induction of labor
the process by which labor is induced by artificial means
augmentation of labor
artificial stimulation of labor that has already begun
indications for induction
abruptio placentae chorioamnionitis fetal demise preeclampsia/eclampsia gestational HTN premature rupture of membranes postterm pregnancy maternal conditions unstable fetal presentation acute fetal distress placental previa or vasa previa previous C-section or uterine surgery
components of Bishop score
cervical dilation cervical effacement station cervical consistency cervical position
bishop score < 6
unfavorable
bishop score > 8
probability of vaginal delivery after labor induction is similar to that of spontaneous labor
cervical ripening agents
dinoprostone (prost E2)
misoprostol (prost E1)
mechanical dilation
what is the only drug that is FDA approved for labor induction and augmentation?
pitocin
pitocin complications
uterine tachysystole
antidiuretic effect
uterine muscle fatigue
increased risk of postpartum hemorrhage 2˚ to atony
major concern for use of obstetric analgesia
may decrease uterine blood flow if hypotension occurs
*IVFs given prior to regional anesthesia to mitigate risk
uterine contraction pain pathway
T10-L1
pelvic floor, vagina and perineum pain pathway
S2-S4
regional anesthesia
partial or complete loss of pain sensation below T10 level
lidocaine + narcotic
epidural
spinal
anesthesia options in labor
nonpharmacologic methods parenteral regional local general
nonpharmacologic methods of anesthesia
lamaze emotional support back massage hydrotherapy acupuncture
*these don’t work just take the drugs you dumb bitch
parenteral anesthesia
morphine, fentanyl, meperidine and nalbuphine
more effective in the first stage of labor
risk of parenteral anesthesia
opioids can cross placental barrier = neonatal respiratory depression
*give that baby some Narcan
epidural
most effective form of pain relief for labor
catheter is placed in the epidural space for continuous infusion of anesthetic agents
benefits of regional anesthesia
highly effective
mother remains alert and awake
mother remembers the experience
rarely requires local anesthesia for lacerations
side effects of regional anesthesia
hypotension (10%) spinal headaches (1-2%) fever spinal hematoma spinal abscess
contraindications for regional anesthesia
maternal coagulopathy heparin use untreated maternal bacteremia increased ICP skin infection over site of needle placement
local anesthesia
lidocaine to perineum prior to episiotomy or lac repair
pudendal block
general anesthesia
propofol most commonly used - must have airway management
used for emergent cases of rapid delivery
risks of general anesthesia
16 fold increased risk of maternal mortality
inhaled anesthetics cross placenta = neonatal respiratory depression
