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RGU 2 > Labor & Delivery, PROM & Preterm Labor > Flashcards

Labor & Delivery, PROM & Preterm Labor Flashcards

1
Q

*** What is labor?

A
  • cervical DILATION with uterine contractions.

- can be spontaneous, induced, term, or preterm

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2
Q

*** What do you call labor that is less than 37 weeks?

A

PRE-TERM

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3
Q

What do you call someone over 42 weeks?

A
  • POST-TERM
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4
Q

What are the 3 changes that occur PRIOR to labor?

A
  1. uterine contractions (Braxton Hicks contractions) with NO cervical dilation.
  2. fetal head descends into the pelvis.
  3. blood tinged mucous= effacement with extrusion of mucous form the endocervical glands.
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5
Q

What are the cardinal movements of labor?

A
  • the changes of the position of the fetus as it passes through the birth canal.
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6
Q

What happens as the occipital portion of the head descends into the pelvis?

A
  • rotates toward the largest pelvic segment to accommodate the maternal bony pelvis.
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7
Q

** What are the 7 CARDINAL MOVEMENTS of LABOR?

A
  1. Engagement= biparietal diamter of baby’s head is below the pelvic inlet.
  2. Descent
  3. Flexion= flex chin to chest
  4. Internal Rotation= of head toward the maternal symphysis pubis or sacrum.
  5. Extension
  6. External Rotation = head rotates to the shoulders.
  7. Expulsion
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8
Q

How do you remember the 7 CARDINAL MOVEMENTS of labor?

A
  • 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!
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9
Q

What is the usual presentation of the baby for delivery?

A
  • VERTEX, where the occiput of the head is in the lowest axis (with regard to the longitudinal axis) of the mother
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10
Q

What is the pelvic inlet?

A
  • from the sacral promontory to the symphysis pubis.

* remember GYNECOID PELVIS is normal and best for delivery.

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11
Q

What is biparietal diameter?

A
  • largest part of the baby’s head.
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12
Q

What curve shows the stages of labor?

A

Friedman curve of labor

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13
Q

** What are the 2 parts of the 1st STAGE of labor? (aka from beginning to end of dilation)

A
  1. LATENT phase= 0-4 cm (takes the longest lasting up to 20 hours in a primiparous or 14 hours in a multiparous woman).
  2. 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).
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14
Q

What factors affect the latent phase of labor?

A
  • parity, sedation, epidurals, unripe cervix.
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15
Q

** What is the 2nd STAGE of labor?

A
  • 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.
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16
Q

** What is the 3rd STAGE of labor?

A
  • immediately AFTER DELIVERY of the baby to DELIVERY of the PLACENTA= usually less than 30 mins.
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17
Q

** What is the 4th STAGE of labor?

A
  • 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.
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18
Q

** What are the 4 golden questions you should ask a woman when evaluating her for labor? (TEST QUESTION)

A
  1. uterine contractions?
  2. rupture of membranes?
  3. bleeding?
    4 fetal movement
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19
Q

How should you initially evaluate a woman for potential labor?

A
  • prenatal records= look for complications, gestational age, labs, and GBS status.
  • focused history= nature and frequency of contractions, membranes intact, bleeding, and fetal movement.
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20
Q

How do we MANAGE the 1st stage of labor?

A
  • 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
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21
Q

How do we MANAGE the 2nd stage of labor?

A
  • 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.
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22
Q

How do we MANAGE the 3rd stage of labor?

A
  • 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.
23
Q

*** What are the signs of placental separation?

A
  • gush of blood

- umbilical cord lengthens

24
Q

Should you ever pull on the cord?

A

NO, just gentle traction (causes inversion of uterus or avulsion of cord).

25
Q

How do we MANAGE the 4th stage of labor?

A
  • observe vitals and check on them.
26
Q

*** What is PROM?

A
  • preMATURE rupture of membranes AFTER 37 weeks, but BEFORE the onset of contractions.
27
Q

Do the words preMATURE and preTERM mean different things?

A

YES. You can have preTERM preMATURE rupture of membranes.

28
Q

What does preTERM PROM mean?

A
  • preMATURE rupture of membranes BEFORE 37 weeks, and BEFORE the onset of contractions.
  • 30-40% of preterm deliveries.
29
Q

What are the other ROMs?

A
  • SROM= spontaneous rupture of membranes

- AROM= artificial rupture of membranes.

30
Q

What is a sign of ruptured membranes/ how do we diagnose?

A
  • 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
31
Q

Should digital exam’s be avoided due to risk of infection, unless the patient is in active labor or imminent delivery is planned?

A

YES

32
Q

How do we initially manage PROM?

A
  • gestational age
  • fetal presentation (is the baby breach…)
  • well-being
  • DNA probes and cultures (GC, chlamydia, GBS).
33
Q

What is the leading cause of neonatal mortality in the US?

A
  • preterm birth
34
Q

With what are regular contractions less than 37 weeks associated?

A
  • changes in the cervix
35
Q

What is considered preTERM?

A
  • regular uterine contractions with cervical effacement or dilation between 20 and 37 weeks.
36
Q

What are some fetal complications of preterm babies?

A
  • respiratory distress syndrome (hyaline membrane disease)
  • intraventricular hemorrhage
  • necrotizing enterocolitis
  • sepsis
  • seizures
  • death
  • developmental abnormaliteis
  • bronchopulmonary dysplasia
37
Q

What are the risk factors for preTERM birth?

A
  • 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
38
Q

What are the signs and symptoms of

A
  • abdominal pain, cramping pressure
  • uterine contractions
  • pelvic pressure
  • low back pain
39
Q

How will you evaluate for preterm labor?

A
  • 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)
40
Q

What is Fetal Fibronectin (FFN)?

A
  • protein that “glues” the membranes to the uterine lining.

* used only between 24-34 weeks gestation.

41
Q

** What does it mean when FFN is negative?

A
  • 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.
42
Q

How do cervical lengths via TVUS help us to predict preterm delivery?

A
  • done at 18-22 weeks, watching to see if the cervix length is getting shorter, or staying stable.
43
Q

What can we do to prevent preterm birth (PTB)?

A
  • smoking cessation
  • improved nutrition
  • prenatal care
  • cerclage= stitch in the cervix to hold the baby in, however infection risk is high.
  • tocolytic medications
44
Q

How do we manage a woman who is preterm?

A
  • 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).
45
Q

Why do we give steroids for PTB?

A
  • they help the lungs mature by induction of proteins that regulate type II pneumocyte cells in fetal lungs that produce surfactant.
  • Betamethasone or Dexamethasone
46
Q

How long will tocolysis last?

A
  • 2-7 days

* helps give you time to get steroids on board or transport to hospital with NICU.

47
Q

** How does MgSO4 work as a tocolytic?

A
  • competes with calcium going into cells to decrease availability for actin-myocin interaction and decreases myometrial contraction.
48
Q

** What are the side effects of MgSO4?

A
  • respiratory depression
  • loss of reflexes
  • toxicity
  • pulmonary edema
  • hypotension
49
Q

** What is the reversal agent for the tocolytic MgSO4?

A
  • calcium gluconate

* have on-hand if needed.

50
Q

What used to be used for tocolysis?

A
  • Terbutaline= selective beta 2 receptor agonist that relaxes smooth muscle.
51
Q

What are tocolytics can be used?

A
  • nifedipine= calcium channel blocker

- Indomethacin (CAN CLOSE DUCTUS ARTERIOSIS PREMATURELY).

52
Q

What are the contraindications to tocolysis?

A
  • advanced labor (if dilated 5 cm, you can’t stop labor).
  • letal fetal anomaly
  • chorioamnionitis
  • hemorrhage
  • severe preeclampsia
53
Q

What is a new drug that is showing promise for PTB?

A
  • 17 a-hydroxyprogesterone caproate

* start at 16-20 weeks and continue to 36th week.

RGU 2 (24 decks)

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