Labor & Delivery, PROM & Preterm Labor Flashcards
*** What is labor?
- cervical DILATION with uterine contractions.
- can be spontaneous, induced, term, or preterm
*** What do you call labor that is less than 37 weeks?
PRE-TERM
What do you call someone over 42 weeks?
- POST-TERM
What are the 3 changes that occur PRIOR to labor?
- uterine contractions (Braxton Hicks contractions) with NO cervical dilation.
- fetal head descends into the pelvis.
- blood tinged mucous= effacement with extrusion of mucous form the endocervical glands.
What are the cardinal movements of labor?
- the changes of the position of the fetus as it passes through the birth canal.
What happens as the occipital portion of the head descends into the pelvis?
- rotates toward the largest pelvic segment to accommodate the maternal bony pelvis.
** What are the 7 CARDINAL MOVEMENTS of LABOR?
- Engagement= biparietal diamter of baby’s head is below the pelvic inlet.
- Descent
- Flexion= flex chin to chest
- Internal Rotation= of head toward the maternal symphysis pubis or sacrum.
- Extension
- External Rotation = head rotates to the shoulders.
- Expulsion
How do you remember the 7 CARDINAL MOVEMENTS of labor?
- first thing you do is get ENGAGED.
- then the baby obviously must go DOWN, not up to be delivered.
- then baby must get as small as pssible (into the “fetal position”) aka FLEXION to get out.
- INTERNAL rotation of occiput of the head toward maternal symphysis pubis or sacrum.
- then the baby has to EXTEND and EXTERNALLY rotate.
- then voila, EXPULSION!
What is the usual presentation of the baby for delivery?
- VERTEX, where the occiput of the head is in the lowest axis (with regard to the longitudinal axis) of the mother
What is the pelvic inlet?
- from the sacral promontory to the symphysis pubis.
* remember GYNECOID PELVIS is normal and best for delivery.
What is biparietal diameter?
- largest part of the baby’s head.
What curve shows the stages of labor?
Friedman curve of labor
** What are the 2 parts of the 1st STAGE of labor? (aka from beginning to end of dilation)
- LATENT phase= 0-4 cm (takes the longest lasting up to 20 hours in a primiparous or 14 hours in a multiparous woman).
- ACTIVE phase= 4-10 cm (usually about 4-6 hrs):
- 1 cm per hour for first baby (primips).
- 1 1/2 cm per hour for someone who has already given birth in the past (multips).
What factors affect the latent phase of labor?
- parity, sedation, epidurals, unripe cervix.
** What is the 2nd STAGE of labor?
- FULL DILATION to DELIVERY of the baby= about 2 hours (aka this is where you tell her to PUSH).
- most of the cardinal movements are done here.
** What is the 3rd STAGE of labor?
- immediately AFTER DELIVERY of the baby to DELIVERY of the PLACENTA= usually less than 30 mins.
** What is the 4th STAGE of labor?
- immediate POSTPARTUM period to 2 hours after delivery of placenta (aka in the recovery room).
- most likely to have complications of post partum hemorrhage during this time.
** What are the 4 golden questions you should ask a woman when evaluating her for labor? (TEST QUESTION)
- uterine contractions?
- rupture of membranes?
- bleeding?
4 fetal movement
How should you initially evaluate a woman for potential labor?
- prenatal records= look for complications, gestational age, labs, and GBS status.
- focused history= nature and frequency of contractions, membranes intact, bleeding, and fetal movement.
How do we MANAGE the 1st stage of labor?
- maternal vital signs every 30 mins.
- NPO except ice (ASK THEM WHEN WAS THE LAST TIME THEY ATE).
- CBC, blood type and screen, RPR.
- IV line for hydration
- maybe a foley catheter
- external fetal monitor
- analgesics (demerol, stadol, nubain, fentanyl, epidural blocks…)
- pelvic exams (as few as possible to reduce infection)
- possible artificial rupture of membranes
How do we MANAGE the 2nd stage of labor?
- begin PUSHING (valsalva maneuver) in increase intraabdominal pressure to aid in fetal descent.
- pt in dorsal lithotomy position (don’t keep them here too long; can cause nerve damage).
- nose and mouth of baby are bulb suctioned (if meconium present, must suction the pharynx).
- check for nuchal cord and reduce or cut.
How do we MANAGE the 3rd stage of labor?
- deliver the palcenta (usually note a gush of blood and umbilical cord lengthens).
- suprapubic pressure and gentle traction on cord to deliver placenta.
- make sure cord has 3 vessels.
- inspect cotyledons of placenta.
- inspect perineum, vaginal canal, cervix, rectum for lacerations and repair them.
*** What are the signs of placental separation?
- gush of blood
- umbilical cord lengthens
Should you ever pull on the cord?
NO, just gentle traction (causes inversion of uterus or avulsion of cord).
How do we MANAGE the 4th stage of labor?
- observe vitals and check on them.
*** What is PROM?
- preMATURE rupture of membranes AFTER 37 weeks, but BEFORE the onset of contractions.
Do the words preMATURE and preTERM mean different things?
YES. You can have preTERM preMATURE rupture of membranes.
What does preTERM PROM mean?
- preMATURE rupture of membranes BEFORE 37 weeks, and BEFORE the onset of contractions.
- 30-40% of preterm deliveries.
What are the other ROMs?
- SROM= spontaneous rupture of membranes
- AROM= artificial rupture of membranes.
What is a sign of ruptured membranes/ how do we diagnose?
- POOLING (direct observation of amniotic fluid in the vagina).
- NITRAZINE= turns blue from amniotic fluid pH (7.0-7.5). Careful bc sperm and blood can also do this.
- FERNING= let amniotic fluid dry on slide and it looks like a fern.
- INDIGO CARMINE= inject dye into the amniotic fluid and if it’s leaking, we will see it on a tampon placed in the woman’s vagina.
- ULTRASOUND
Should digital exam’s be avoided due to risk of infection, unless the patient is in active labor or imminent delivery is planned?
YES
How do we initially manage PROM?
- gestational age
- fetal presentation (is the baby breach…)
- well-being
- DNA probes and cultures (GC, chlamydia, GBS).
What is the leading cause of neonatal mortality in the US?
- preterm birth
With what are regular contractions less than 37 weeks associated?
- changes in the cervix
What is considered preTERM?
- regular uterine contractions with cervical effacement or dilation between 20 and 37 weeks.
What are some fetal complications of preterm babies?
- respiratory distress syndrome (hyaline membrane disease)
- intraventricular hemorrhage
- necrotizing enterocolitis
- sepsis
- seizures
- death
- developmental abnormaliteis
- bronchopulmonary dysplasia
What are the risk factors for preTERM birth?
- PRIOR PTB!
- multiple gestations (twins, triplets…)
- short cervical length
- low maternal BMI
- African American
- Maternal age
- smoking
- infections (chorio, BV, pyelonephritis)
- uterine fibroids..
- placental abnormalities
What are the signs and symptoms of
- abdominal pain, cramping pressure
- uterine contractions
- pelvic pressure
- low back pain
How will you evaluate for preterm labor?
- focused history and PE
- EFM and palpate abdomen
- review records
- cervical exam (best if same examiner as before).
- US
- Labs (look for infection)= U/A and culture, CBC, GBS, GC/chlamydia, wet prep, and FFN (fetal fibronectin)
What is Fetal Fibronectin (FFN)?
- protein that “glues” the membranes to the uterine lining.
* used only between 24-34 weeks gestation.
** What does it mean when FFN is negative?
- 97% chance that pt will NOT go into preterm labor within the next 2 weeks.
- so it is the NEGATIVE PREDICTIVE VALUE that is important.
How do cervical lengths via TVUS help us to predict preterm delivery?
- done at 18-22 weeks, watching to see if the cervix length is getting shorter, or staying stable.
What can we do to prevent preterm birth (PTB)?
- smoking cessation
- improved nutrition
- prenatal care
- cerclage= stitch in the cervix to hold the baby in, however infection risk is high.
- tocolytic medications
How do we manage a woman who is preterm?
- transfer to hospital with NICU.
- goal is to delay delivery to get optimal steroid benefit (dexamethasone)= increases fetal lung surfactant.
- tocolytics (only if bleeding and dilating)
- GBS prophylaxis (ampicillin, clindamycin, penicillin, erythromycin, or vancomycin).
Why do we give steroids for PTB?
- they help the lungs mature by induction of proteins that regulate type II pneumocyte cells in fetal lungs that produce surfactant.
- Betamethasone or Dexamethasone
How long will tocolysis last?
- 2-7 days
* helps give you time to get steroids on board or transport to hospital with NICU.
** How does MgSO4 work as a tocolytic?
- competes with calcium going into cells to decrease availability for actin-myocin interaction and decreases myometrial contraction.
** What are the side effects of MgSO4?
- respiratory depression
- loss of reflexes
- toxicity
- pulmonary edema
- hypotension
** What is the reversal agent for the tocolytic MgSO4?
- calcium gluconate
* have on-hand if needed.
What used to be used for tocolysis?
- Terbutaline= selective beta 2 receptor agonist that relaxes smooth muscle.
What are tocolytics can be used?
- nifedipine= calcium channel blocker
- Indomethacin (CAN CLOSE DUCTUS ARTERIOSIS PREMATURELY).
What are the contraindications to tocolysis?
- advanced labor (if dilated 5 cm, you can’t stop labor).
- letal fetal anomaly
- chorioamnionitis
- hemorrhage
- severe preeclampsia
What is a new drug that is showing promise for PTB?
- 17 a-hydroxyprogesterone caproate
* start at 16-20 weeks and continue to 36th week.