Labor & Delivery Flashcards
Latent Phase of Labor
- -cervical dilation?
- -duration of latent phase (nullipara, multipara)?
Latent Phase of Labor
- -cervical dilation less than 4cm
- -nullipara duration 18-20 hrs
- -multipara duration less than 14 hrs
Active Phase of Labor
- -length of cervical dilation?
- -rate of cervical dilation (nullipara, multipara)?
- -protraction vs arrest of active phase? re: dilation rate
Active Phase of Labor
- -cervical dilation greater than 4cm
- -nullipara dilation rate 1.2cm/hr
- -multipara dilation rate 1.5 cm/hr
- -protraction: less than normal dilation rate
- -arrest: no progress for 2 hours
Normal fetal HR?
Cause of early decelerations?
–mirror images of contractions, gradual decline (> 30s)
Cause of variable decelerations?
–abrupt decline (30s), offset from uterine contractioins
Cause of late decelerations?
Normal fetal HR: 110-160 bpm Early decelerations --caused by fetal head compressions Variable decelerations --caused by cord compression Late Decelerations --uteroplacental insufficiency, fetal hypoxia and acidosis
First stage of labor: onset of labor to complete dilation
Second stage: complete dilation to infant delivery
–normal duration (nullipara, multipara)?
Third stage: infant delivery to placental delivery
–normal duration (nullipara, multipara)?
First stage of labor: onset of labor to complete dilation
Second stage: complete dilation to infant delivery
- -nullipara normal duration less than 2 hrs (3 hrs if epidural)
- -multipara normal duration less than 1 hr (2 hrs if epidural)
Third stage: infant delivery to placental delivery
–nullipara/multipara normal duration less than 30 min
Adequate uterine contractions
- -frequency?
- -duration?
- -palpation?
- -montevideo units per 10min?
Adequate uterine contractions
- -frequency: 2-3 min
- -duration: 40-60 sec
- -firm on palpation
- -200 montevideo units per 10min
Four signs of placental separation:
- gush of blood
- lengthening of the cord
- globular-shaped uterus
- uterus rising to what area?
Four signs of placental separation:
- gush of blood
- lengthening of the cord
- globular-shaped uterus
- uterus rising to anterior abdominal wall
What is a common complication of uterine inversion?
3 steps for treatment of uterine inversion?
Common complication: hemorrhage
Treatment of uterine inversion:
- halothane for uterine relaxation
- -alternatives: terbutaline, Mg sulfate - manual uterine replacement
- uterotonic agent, eg oxytocin
What glucocorticoid is used to enhance fetal lung maturity?
Between what weeks of pregnancy is it successful at accelerating fetal lung maturity?
Betamethasone
24-34 weeks
Birth Injury Syndrome 1: --decreased Moro and biceps reflexes --intact grasp reflex --"waiter's tip": arm adducted and internally rotated; forearm pronated; wrist flexed Dx? Injury to what nerves?
Birth Injury Syndrome 2: --intact Moro, biceps reflexes --absent grasp reflex --"claw hand" --ptosis, miosis Dx? Injury to what nerves?
1) Erb-Duchenne palsy; C5-C6
2) Klumpke Palsy; C8-T1
Group B Strep prophylaxis: IV penicillin G
Indications:
- positive GBS cultures
- GBS bacteriuria during current pregnancy
- hx of infant with early onset GBS
- unknown GBS status and…
- -intrapartum fever
- -labor prior to how many weeks of gestation?
- -ROM greater than how many hours?
Group B Strep prophylaxis: IV penicillin G
Indications:
- positive GBS cultures
- GBS bacteriuria during current pregnancy
- hx of infant with early onset GBS
- unknown GBS status and…
- -intrapartum fever
- -labor prior to 37 weeks of gestation
- -ROM greater than 18 hours
1) implantation of the placenta over the internal cervical os
2) invasion of the placenta into the uterine wall; inability of placenta to separate from wall after delivery
* invasion thru the myometrium
* *invasion thru the serosa
1) placenta previa
2) placenta accreta
* placenta increta (myometrium)
* *placenta percreta (serosa)
- unengaged fetal presentation
- transverse fetal lie
- footling breech presentation
Umbilical cord prolapse
- -painless
- -cord is presenting part
- -compromised fetal blood flow and oxygenation
- -deep, recurring variable decelerations
Tx: immediate cesarean delivery
Incompetent Cervix / Cervical Insufficiency
- -painless dilation and effacement of cervix in 2nd trimester of pregnancy
- -dilation often in excess of contractions
Risk Factors: hx of cervical surgery; hx of obstetric trauma/lacerations, uterine anomalies, DES exposure
Dx via what method?
Tx?
Incompetent Cervix / Cervical Insufficiency
Dx via transvaginal ultrasound
Tx: cerclage
Antepartum Bleeding DDx
- painless antepartum hemorrhage; no rapid fetal deterioration; low-lying placenta
- premature placental separation; bleeding of maternal origin with abdominal pain, uterine tenderness, increase uterine tone
- fetal blood vessels traverse fetal membranes across lower uterine segment; fetal vessels tear during ROM; painless antepartum hemorrhage; rapid fetal deterioration with exsanguination
- intense abdominal pain; vaginal bleeding; palpate fetal parts on abdominal exam; cessation of uterine contractions; abnormal fetal heart traacing
Antepartum Bleeding DDx
- Placenta previa
- Placental abruption
- Vasa previa
- Uterine rupture
Management of breech presentation…
…before 37 weeks?
…after 37 weeks?
Management of breech presentation
Observation
–before 37 weeks?
External cephalic version
–after 37 weeks?
*C-section if ECV fails
Postpartum Hemorrhage DDx
1. myometrium doesn’t contract to cut off uterine spiral arteries; soft, enlarged, boggy uterus
- genital tract laceration
- during delivery of placenta, a shaggy, reddish bulging mass is noted at the introitus around the placenta
- PPH after first 24 hrs; eschar over placental bed falls off with lack of myometrial contraction
- uterine cramping and bleeding; fever; foul-smelling lochia
Postpartum Hemorrhage DDx
- Uterine atony
Tx: uterine massage, IV oxytocin - Genital tract laceration
- Uterine inversion
- Subinvolution of placental site
Tx: methylergonovine maleate (Methergine) - Retained POC
Tx Options for Postpartum Hemorrhage
- 1st line tx for uterine atony (1 physical, 1 medical)
- ergot alkaloid; induces myometrial contraction; contraindicated in HTN
- causes sm mm contraction; contraindicated in asthmatic pts
- induces uterine contractions; can be placed rectally; prostaglandin analog
Tx Options for Postpartum Hemorrhage
- uterine massage, oxytocin
- Methylergonovine Maleate (Methergine)
- Prostaglandin F2-alpha
- Misoprostol
Management of Placental Abruption
- maternal vital signs stable; fetal monitoring reassuring
- -reassuring fetal monitoring includes HR: 110-160; long term variability > 2 cycles/min; beat-to-beat variability 6-25 bpm - maternal vital signs unstable; or fetal monitoring non-reassuring
Management of Placental Abruption
–premature placental separation; bleeding of maternal origin with abdominal pain; uterine tenderness; increased uterine tone
- Trial of vaginal delivery
- -if mother and fetus are stable - Emergency C-section
- -if mother or fetus are not stable
Birth Injury Syndrome: clavicular crepitus with absent ipsilateral Moro reflex; contralateral Moro reflex intact; bilateral biceps and grasp reflexes are intact and symmetric
Dx?
Common association?
Clavicular Fracture
–clavicular crepitus on one side with absent ipsilateral Moro reflex; contralateral Moro reflex intact bilateral biceps and grasp reflexes are intact and symmetric
Associated with maternal diabetes mellitus
Arrest of Labor (Stages 1, 2)
Cervical dilation = 6+cm with ruptured membranes AND…
1. no cervical dilation, adequate contractions for how long?
OR
2. no cervical dilation, inadequate contractions for how long?
Arrest of Labor (Stages 1,2)
Cervical dilation = 6+cm with ruptured membranes AND…
- no cervical dilation despite adequate contractions for 4+ hours
OR
- no cervical dilation despite inadequate contractions for 6+ hours
–> indication for C-section
Epidural anesthesia –> afferent/efferent bladder nerve block
–thus, catheterization required
NB: tinnitus, perioral numbness, metallic taste, dizziness, palpitations are signs of intravascular injection of anesthesia
If nerve block persists, what type of incontinence may develop?
Overflow incontinence
- -constant involuntary dribbling
- -incomplete emptying
Post-Operative Fever DDx
What POD range?
What Dx?
Wind
Water
Walking
Wound
Post-Operative Fever DDx
Wind
- -POD 1: atelectasis
- -POD 3: pneumonia
Water
–POD 3: UTI
Walking
–POD 5: DVT
Wound
- -POD 7: wound infection
- -POD 10-15: deep abscess
Presentation: cardiogenic shock, hypotension, respiratory failure, hypoxemia, DIC, bleeding, coma, seizures
–during delivery or shortly after
Risk Factors: advanced maternal age; gravida more than 5; C-section or instrumental delivery; placenta previa or abruption; preeclampsia
Dx?
Amniotic Fluid Embolism
–AF enters maternal circulation –> inflammatory response, vasospasm –> cardiogenic shock, hypoxemic respiratory failure, DIC, bleeding –> seizures, coma
Supportive Tx: O2, intubation, ventilation, vasopressors
