Labor & Delivery Flashcards
what is lightening
settling of fetal head into brim of pelvis
when does lightening occur
about 2 wks before labor in 1st pregnancy. If multip, does not occur until labor
symptoms of lightening
increases pelvic discomfort, pressure, urinary frequency
woman may feel less discomfort w/ SOB, heartburn
Braxton Hicks contractions
painless, irregular contractions that may occur at any time during the pregnancy
4-8 wks before delivery intensify in frequency & strength
completely benign/ should not change cervix
what is sometimes dubbed “false labor” aka “prelabor”
Braxtom Hicks contractions
can be intensely uncomfortable & go on for wks w/o changing the cervix; they often go away if woman starts walking
bloody show
expulsion of mucous plug in some pts
bloody show is a result of what?
cervical dilatation & effacement days to 2 wks before labor
multips can be 1-3 cm dilated for wks & not even know
energy spurt
24-48 hrs before labor some women get a burst of energy & begin organizing, cleaning, cooking, nesting
GI upset
sx similar to early pregnancy w/ n/v, may have diarrhea, heartburn a week before labor
intensity of labor depends on?
fetopelvic relationships, quality & strength of UCs, emotional & physical status of pt
-nml labor is usually painful
hx of contractions
start w/ a gradual buildup of intensity that climaxes & dissipates
5 P’s of labor
passenger position of passenger passage power of the uterus psych status
passenger
EFW (estimated fetal wt)
tolerance
position of passenger
presenting part
station
flexion (head nicely tucked into chest so skull comes through cervix w/ apex first)
position station
relationship of the lowermost part of the presenting part to an imaginary line drawn between the mother’s ischial spines
“0” station (-5 to +4)
passage of passenger
clinical pelvimetry
cx dilatation & effacement
power of the uterus
frequency
force & duration of UCs
psych status
coping
accepting
fearful
in pain/denial
characteristics of labor
a continuous process divided into 3 stages:
1st, 2nd, 3rd stage
first stage
results in cervical effacement & dilatation
early/latent/prodromal phase of 1st stage
0-3 cm of dilatation
relatively strong contractions q 5-7 min x 30-60 sec
can last days
usually able to talk thru UCs & smile in between
UCs do not go away w/ activity change or hydration
active phase of 1st stage
4-10 cm
contractions are stronger & more coordincated
usually q 2-3 min x 50-70 sec
follows fairly consistent timeline
woman needs to concentrate w/ UCs, no longer cheerful, may cope w/ controlled breathing, visualization
transition of first stage
last part of active phase
7-10 cm dilated
often feels “rectal pressure” & urge to push
often defecates
VERY intense, shaking, toes curl, often vomiting, “I cant’ do it!”
second stage of labor
marked by fully dilated cervix (10cm)
may experience physiologic rest where UCs seem to cease for up to 1 hr & she may actually sleep; involuntary “pushing” usually begins either just before fully or right after; moves baby down the vaginal canal;contractions usually q 1.5-2 min x 60 sec & strong
3rd stage of labor
UCs all but cease, accompanied by enormous relief
delivery of placenta & membranes via mild utering cramping
usually w/in 5-10 min of delivery of infant
can take up to 1 hr, but most guidelines recommend manual extraction after 30 min
Friedman Curve
A graphic representation of the hours of labor plotted against cervical dilation in centimeters.
a guideline
triage of labor
time of onset of contractions, frequency, bleeding, ROM
med/OB hx, pregnancy complications, allergies, meds, last PO intake
GBS status
VS, UA
possible causes of 3rd trimester bleeding that presents to L&D
mucous plug normal bloody show laceration/trauma infxn ruptured uterus placenta previa/abruption (can be life threatening)
placenta previa
malposition of the placenta in the lower uterine segment that completely or partially covers the os (partial, complete, low lying, migrating)
assoc. w/ increased fetal mortality NOT related to bleeding
risk factors for placenta previa
multiparity AMA multiple pregnancy previous uterine surgery smoking previous previa previous therapeutic abortion
S/sx of placenta previa
painless bleeding
sudden onset
3rd trimester
may be accompanied by uterine irritability
mgnt of placenta previa
DO NOT DO VAGINAL EXAM!!!!!
sono to confirm placement
inpatient bedrest
serial hct, type & cross match, Rh, indirect Coomb’s, coag studies
fetal surveillance (growth, mvnt, NSTs)
pelvic rest, no orgasm
deliver prior to term by c/s
partial/marginal previa can sometimes deliver vaginally
assoc. w/ placenta accreta (careful 3rd stage mngt)
placental abruption (abruptio placentae)
premature separation of the normally implanted placenta
risk factors of placental abruption
maternal HTN folic acid deficiency sever abdominal trauma short umbilical cord malnutrition sudden decrease in uterine volume for size AMA external version cocain/crack use
S/sx of placental abruption
rigid, board-like abdomen painful, localized uterine tenderness colicky, discoordinate uterine activity possibly back pain possible fetal distress uterine enlargement (if occult) shock violent fetal mvnt
mgnt of placental abruption
type & cross match
Utox
deliver, induction if necessary
management of severe hemorrhage- ocags, stat IV x 2, Trendelenburg, EFM, O2, emergency c/s
monitoring during L&D clinical mgnt
contraction frequency, strength by palpation
FHR by EFM or intermittent doppler
confirm status of membranes, dilatation, effacement & station
EFW (est. fetal wt)
decision to admit
usually only if in active labor or complication noted (including ROM or GBS+) or fetus compromised
can send home in early labor if reactive tracing, VSS, no know complications
labs to draw if going to admit
CBC w/ plts blood type Rh Ab screen RPR
what to do for mom during 1st stage of labor
ambulate, sit, side lie
nourishment (avoid dehydration)
continuous/intermittent monitoring
VS q 4 hrs unless otherwise indicated
encourage voiding
analgesia prn, anesthesia usually once active
can use lamaze type breathing/ visualization (Bradley) for coping & comfort
fetal monitor during 1st & 2nd stage
noted q 15-30 min in active labor, q 5-10 min during second stage (usually by RN per protocol)
UCs are usually noted as above (pts on pit, VBACs need continuous EFM & toco
sedative (seconal) analgesia
- to rest false labor/ prolonged latent labor
- part of tx for hypertonic uterus
narcotic analgesics
can be used as a sedative to rest prolonged latent labor & treat hypertonic uterine dysfunction (morphine 10-15 mg IM/ or 5mg IVP)
for pain relief during active phase
demerol 50mg IM or 12.5-25mg IV
nubain/ stadol 1-2mg IM, IV
fentanyl 50-100mcg IVP
ataractics (phenergan, vistaril)
given w/ opioids to potentiate their action & decrease maternal axiety/ apprehension
also mild antiemetics
spinal anesthesia
better for brief/ minimal use
primarily for delivery & 3rd stage
anesthetic injected into subarachnoid space
produces aneshesia in lower half of body
can produce postpartum h/a, respiratory failure high
epidural
bolus or continuous injection of anesthesia via catheter into epidural space
good for vaginal labor & delivery or c/s
narcotics often added to enhance the quality
can make active labor faster but prolong the 2nd stage
no drowsiness, few tangible side effects
can cause maternal HoTN & subsequent transient fetal bradycardia
usually limits mobility
increases use of vacuum & forceps
can cause postpartum h/h
respiratory failure if “high”
pudendal block
regional anesthesia blocking the pudendal n.
anesthetizes the vulva & perineum
has no effect on uterus or UCs
minimal danger to mother & baby
used mostly 2nd stage before impending delivery
anmiotomy
artificial rupture of membranes
to check fluid, augment, apply internals
augmentation
to tx protracted or arrested labor
pitocin, nipple stim, amniotomy
anmioinfusion
using an intrauterine pressure catheter (IUPC) infuse NS into uterus to bolster fulid level & relieve cord compression
how to help mom in 2nd stage
pt usually in bed (may be standing, squatting)
can coach to push once she feels the urge
monitor descent, flexion, rotation
how to help mom in 3rd stage
delivery of the placenta usually w/in 30 min
cut & clamp cord immed. after delivery
gentle retraction on cord utilizing Brandt-Andrews technique
Administer pit after delivery of shoulder or immediately after delivery of baby
after placenta check fundus & massage to firm
check vaginal vault, cervix, perneum for lacerations & repair
signs of placental separation
gush of blood
cord lengthens
fundus rises in abdomen
uterus becomes firm & globular
