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Patient Assessment 3 > Labor, Delivery, Post-Natal Changes > Flashcards

Labor, Delivery, Post-Natal Changes Flashcards

1
Q

Effacement

A

Process by which the cervix prepares for delivery

After the baby enlarges the pelvis it will drop closer to the cervix

The cervix will soften, shorten, and become thinner

Once mom has a 100% effacement the baby is ready to come out

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2
Q

Parturition

A

Process of giving birth

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3
Q

Placental Stage of Labor

A

3rd Stage of Delivery

Occurances: Delivery of the placenta

Time Prima (1st baby) 3-45 minutes

Time Multi 4-5 minutes

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4
Q

Pelvic Stage of Labor

A

2nd Stage of Delivery

Occurances: Pushing, Full dilation and effacement to delivery of the fetus

Time Prima (1st baby) 1-2 hours

Time Multi 20 minutes

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5
Q

Cervical Stage of Labor

A

1st stage of Labor

Occurances: Onset of contractions to full dilation and effacement of cervix (10 cm).

Time Prima (1st baby) 16-18 hours

Time Multi 7-12 hours

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6
Q

The Cervical Stage of Labor is Further Divided into What Stages

A

1) Early (Latent) Labor
2) Active Labor
3) Transitional (Advanced) Labor

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7
Q

The First Phase: Early (Latent) Labour

A
  • The cervix will dilate (open) to 3 cm
    • If not dilated to 3 cm the mom will be sent home
  • The cervix begin effacement
  • Mild to moderate contraction that last 30-45 seconds
    • Spaced 5-20 minutes apart
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8
Q

Active Labor

A

Phase of Cervical stage of labor

Contractions will grow stronger and longer

Usually lasts from 2-3.5 hours

Cervix dilates to 7-8 cm

Contractions last 40-60 seconds which are spaced 3-4 minutes apart

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9
Q

Transitional (Advanced) Labour

A
  • Last and most intense phase of labor
    • ~15-60 minutes
  • Cervix will dilate to 10 cms
  • Contraction are very strong at this point
    • Usually 60-90 seconds long with intense peaks
    • Spaced 2-3 minutes apart
  • This is the point where the baby is being pushed out
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10
Q

What is the order of events when everything goes right during birth

A

Mom delivers baby

Baby is taken care of and assessed

A regular newborn will have peripheral cyanosis, be centrally pink, and crying

Mom delivered placenta

Abdominal/pelvic exam is done to ensure that there is no bleeding, infection, or injury

Mom receives post partum care and gets to hold her baby

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11
Q

Pain Management Taught in Pre Natal Classes

A

Relaxation Techniques

Distraction/Concentration Techniques

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12
Q

Entenox

A

Nitrous oxide-Laughing Gas

Used as pain mangement in labor

Not a respiratory depressant for mom or baby

Used when there is not enough time for an epidural

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13
Q

Morphine/Demerol

A

Used as pain mangement in labor

Given systemically

Potentially can depress the infant as it can cross the barrier

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14
Q

Types of Local Anesthesia givn for Pain Management in Labor

A

Epidural

Pudendal

Paracervical

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15
Q

Epidural

A

Given directly into the epidural or subarachnoid space or the spine

Will not depress the infant

A catheter will be inserted and then a continuous infusion is given

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16
Q

Pudendal

A

Given directly into the vagina and perineum

No depression of the infant

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17
Q

Paracervical

A

Given directly into the cervix and surrounding tissue

Some depression of the infant can occur

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18
Q

Spinal

A

A spinal will be given as a single dose

Different than an epidural and a epidural is preferred

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19
Q

When in general ananesthesia used for labor pain management

A

Will be used in an emergency

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20
Q

Why is it important to know what type of pain management is being used for mom in labor

A
  • Also known as a spinal block
  • A narcotic or anesthetic such as fentanyl, bupivacaine, or lidocaine is injected below the spinal column directly into spinal fluid
    • These medications can cross the placenta and enter into the blood stream
    • These will be injected once with a single dose
  • Different than an epidural and a epidural is preferred
    • Used in more complex or emergency situtations
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21
Q

Fetal Distress During Labor

A

A tocodynamometer is a abdominal transducer and is the most common way to measure fetal responses to labor

Will measure strength of contraction and fetal heart rate

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22
Q

What will they do if fetal HR does not look good in labor

A

When doing a scalp pH they will have to go through mom and rupture the membrane

Similar to a capillary blood gas on the surface of the head

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23
Q

Normal Fetal HR

A

A normal fetal HR

Varies between 120-160 and should demonstrate a continually changing heart rate within 5 to 10 beats (normal baseline variability)

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24
Q

Accelerations

A

Accelerations: Short increases in HR during contractions which are normal and show that the babe is responding well to the contractions [a stressor]

Should always be occurring during labor

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25
Q

Abnormal fetal heart rates:

A

Below 100 or above 180

i.e. Too low or too high

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26
Q

Early Decelerations (HC)

A

FHR drops with the contraction, but once the contraction is done the HR should immediately recover

Heart rate will not vary more than 20-30 below baseline

Smooth and shallow

Mirror contraction

Pose little threat to the fetus (vagal response)

Head compression

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27
Q

Late Decelerations

A

Smooth shallow drop with nadir (low point) after the peak of contraction

Likely to due to utero-placental insufficiency

Decreased placental perfusion

Can lead to fetal asphyxia

Indicates high probability of fetal distress

Worrisome

28
Q

Fetal Scalp Sampling [scalp pH]

A

If fetal distress is noted or even suspected then a transvaginal sample of fetal blood can be obtained via a scalp puncture and collecting blood through a very long capillary tube

29
Q

Variable Decelerations

A
  • “V” shape pattern with abrupt drop and return from baseline
    • With contractions
    • Variable in duration
  • May be associated with cord compression
  • If persistent & severe fetal scalp blood pH
    • >7.25 “reassuring” & likely benign
    • <7.15 risk of profound acidemia [and if that exists hypoxia probably does too]
30
Q

Fetal Hemoglobin

A
  • ~75-80% of hemoglobin is fetal
  • Fetal hemoglobin will be the main oxygen transport protein of the human fetus in the last 7 months of development in the uterus
  • It will take months to convert fetal hemoglobin to adult hemoglobin
    • Will take more time if the baby is sick
    • It will take less time if the baby is transfused
      *
31
Q

Fetal Hemoglobin and Oxyhemoglobin Curve

A
  • Fetal hemoglobin will shift the curve to the left
    • Greater affinity for O2 giving the fetus between access to oxygen from the mothers bloodstream
      • The greater affinity for oxygen is due to the lack of interaction with 2, 3, DPG
  • The P50 value for fetal hemoglobin is lower than adult hemoglobin
    • P50 value is the partial pressure of oxygen at which the protein is 50% saturation so lower values represent a greater affinity (~19 mmHg for fetal hemoglobin and 26 for adult hemoglobin)
  • Neonates will have a higher SpO2 with a lower PaO2 than adults
    • Moms may even have right curve shift
32
Q

Normal Scalp pH

A
  • Normal Scalp pH
    • >7.25
  • If pH is <7.15 it is an indication of fetal acidosis
    • Facilitate delivery of the baby immediately (often via C-section)
33
Q

pH During 2nd Stage of Labor

A

pH- 7.29

PCO2-46

PO2-16

HCO3- 17

34
Q

pH During 1st Stage of Labor

A

pH- 7.33

PCO2-44

PO2-22

HCO3- 20

35
Q

Cord Gas Umbilical Vein

A

pH- 7.32

PCO2-38

PO2-27

HCO3- 20

36
Q

Cord Gas Umbilical Artery

A

pH- 7.24

PCO2-49

PO2-16

HCO3- 19

37
Q

Arterial Sample

60 Minutes

A

pH- 7.33

PCO2-36

PO2-63

HCO3- 19

38
Q

Arterial Sample

30 Minutes

A

pH- 7.30

PCO2-38

PO2-54

HCO3- 18

39
Q

Arterial Sample

5-10 Minutes

A

pH- 7.21

PCO2-46

PO2-50

HCO3- 17

40
Q

Types of Cord Complications

A

Nuchal

Knots

Prolapse

41
Q

Nuchal Cord Complications

A

Umbilical cord is “coiled” around the baby’s neck

This is quite common

Occurs 25-35% of the time

Most nuchal cords are single coils and are loose

It is rare that the baby’s cord will be wrapped so tightly that the cord is compressed and oxygen delivery to the baby is compromised

When this occurs the c-section is prudent

42
Q

Knots in Umbilical Cord

A

Knots that occur in the umbilical cord

Rare occurrence that is only found after delivery and when the umbilicus is abnormally long

Unless the knot has been pulled tight there will be no negative impact on fetal blood flow

When the knot is tight the patient may have atypical pattern of variable deceleration and may be compromised

43
Q

Prolapse Cord Complication

A

The umbilical cord is squeezed between the fetus and delivery canal decreasing the blood flow to the fetus

Will be diagnosed through the fetal heart monitoring (especially bradycardias or profound deceleration after membrane rupture)

Treatment is to decrease compression of the presenting part usually by changing the position of the mother or immediate delivery via c-section

Not that common, occurring in one out of every 300 births

44
Q

Failure to Progress

A
  • When there is maternal fatigue contractions will become weak and ineffective and the baby is stuck
    • Extraction techniques
      • Vacuum
      • Forceps
        • Low and high
      • C-Section
  • Baby is too big and mom us at a risk for tearing
    • Episiotomy
45
Q

Episiotomy

A

Cutting the vagina to make it bigger

Less common than it used to be, as now they might try natural tearing

Measured in degrees. Degree four is a tear all the way to the anus

If baby is in danger or we think it will be a degree 4 tear anyways then we do this

46
Q

Vacuum

A

Vacuum extraction will use a cup-shaped extractor to apply a gentle suction to the top of the baby’s head

The vacuum can be used to assist the monitor while she is pushing during the contraction

47
Q

Forceps

A

Forceps are sometimes used when the baby is not moving down the birth canal (vagina).

Used to hurry delivery when the mother or baby is in distress during labour.

Low is forceps at the head

High forceps is used more around the body

48
Q

C-Section

A
  • Delivery of fetus through an incision in the abdomen
  • A C-Section will be done when
    • Labor is considered unsafe for mother or fetus
    • Delivery is necessary, but labor cannot be induced
    • An emergency mandates an immediate delivery and the vaginal route is not possible or suitable
    • Mom request an elective
49
Q

C-Section Anaesthia

A

Mom will require a general or spinal anesthesia

This is an operation and it done under a sterile technique in an OR and with a surgeon and anaesthetist present

50
Q

C-Section Maternal Complications

A
  • Same risks as with any other surgery
    • Post op recovery
    • Long healing times
    • Difficultly moving and lifting
  • Complications can include intraoperative bowel and bladder injury
    • The bladder or bowel can be cut and sometimes it is not noticed and will result in the mom going septic
  • Increased occurrence of endometriosis
51
Q

C-Section Indications

A
  • Failure to progress in labor
  • Fetal distress
  • Large head
  • Placental abnormalities
  • Cord problem
  • Genital herpes (active)
  • Twins
  • Breech
  • Severe anomalies
  • Prior c-section
    • VBAC more common
52
Q

C-Section Baby Complications

A

Surgical wounds and trauma for the baby

Infants delivered by c-section are not exposed to partial purging of fetal lung fluid provided by compression during passage through the birth canal

53
Q

Fetus prepared for delivery (pulmonary)

A

Alveolar type II pneumocytes will produced surfactant after 26 weeks

Alveoli are open, stable, and at near normal neonatal lung volume

Pulmonary and bronchial circulation are well developed

Neuromuscular control of respiration is established with active fetal breathing periods

Everything is ready for the fetus to shift from placental support to pulmonary gas exchange and from liquid to gaseous ventilation

54
Q

Hormonal changes in labor

A

Will begin just before labor starts

Catecholamines reduce the amount of water in the lungs

Epinephrine has been shown to inhibit secretions of fetal lung fluid

Vasopressin and prostaglandin which is secreted around the time of birth and may reduce the production of lung liminal liquid

55
Q

Fetal Movement at Labor

A

Labour begins and the fetus starts to move downwards

As the fetus progresses down the birth canal, the chest is compressed by pressures of 30 to 160 cm H2O

This can eject as much as 30 ml of amniotic fluid

56
Q

Removal of Fetal Lung Fluid at Labor

A

Some fetal lung fluid will be removed through compression during a vaginal delivery

Removal of lung liquid continues after birth.

When breathing begins, air inflation shifts residual liquid from the lumen into distensible perivascular spaces around large pulmonary blood vessels and bronchi.

57
Q

Acculmulation of Fetal Lung Fluid After Birth

A

Accumulation of liquid in connective tissue spaces, which are distant from the sites of respiratory gas exchange, allows time for small blood vessels and lymphatics to remove the displaced liquid with little or no impairment of neonatal lung function at this critical juncture

Most of the time this will not affect ventilation even though there are increased risk for TTPN

58
Q

Baby’s First Breath

A
59
Q

Baby’s First Breath Lung Mechanics

A
  • The neonate may demonstrate a high WOB for the first few minutes of life until the alveolar capillary interface and FRC are well established
  • Once the lung is ventilated, FRC is 95% established within the first few minutes
    • Inflation pressures decrease dramatically = Decreased WOB
  • Most lungs, once aerated, can be inflated with pressures of 12 - 25 cm H2O and volumes of 5 mL (~4mL/kg)
  • Compliance is approximately 2 mL/cm H2O/kg
60
Q

Stimulation of First Breath

A

Stimulation of the first breath can be cause by tactile or thermal

Clamping of the cord will cause a low pH making the baby hypoxic, hypercapnic, and acidotic to help babies increased babies drive to breath with a strong respiratory stimuli

61
Q

Post Natal Changes

Umbilical Vessels

A

The umbilical arteries and the umbilical vein make up the umbilical cord; these are shed at birth along with the placenta.

62
Q

Post Natal Changes

Ductus Venosus

A

Ductus venosus, will become the ligamentum venosum of the liver

63
Q

Post Natal Changes

Foramen Ovale

A

The foramen ovale functionally closes once pulmonary circulation is established.

Structural closure (~ 9 months)to a mere depression (fossa ovalis) in the wall of the right atrial septum.

64
Q

Post Natal Changes

Ductus Arteriosus

A

The ductus arteriosus will becomethe ligamentum arteriosum

Closes in 5-7 days but there is a bunch of different things that will delay this closure

65
Q

Cord Clamping

A

In most healthy term babies we will delay cord clamping for 30s -1 min

They find that if the baby is still attached to placenta they can still get gas exchange

They wont due this is there is fetal compromise

Delaying clamping will allow for a mass transfusion which leads to a lot of good things

Decrease blood pressure and volume (in a good way)

Decreased iron deficiency

Because the gas exchange is still happening at the placenta there will still be fetal lung fluid in the lungs so the baby will not be crying

66
Q

Mucotranslucency Scan

A

Mucotranslucency scan is used to indicate down syndrome

Patient Assessment 3 (12 decks)

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