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Obstetrics > Normal/Abnormal Labor and Delivery > Flashcards

Normal/Abnormal Labor and Delivery Flashcards

1
Q

What is normal range for fetal heart rate measured with a tocometer during labor?

A
  • Normal: 110-160 bpm

- Bradycardia: 160 bpm

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2
Q

In terms of fetal heart monitoring during labor, what are normal accelerations?

A
  • Normal accelerations: an increase in heart rate of 15 or more bpm above the heart rate baseline for longer than 15-20 seconds. If this happens twice in 20 minutes it is reassuring and normal.
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3
Q

In terms of fetal heart monitoring during labor, what are early, variable, and late decelerations and what causes them?

A
  • Early decelerations: decrease in heart rate that occurs with contractions; caused by head compression.
  • Variable decelerations: decrease in heart rate and return to baseline with no relationship to contractions; caused by umbilical cord compression.
  • Late decelerations (most dangerous): decrease in heart rate after contraction is started with no return to baseline until contraction ends; caused by fetal hypoxia.
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4
Q

What are the three physiological changes before labor?

A
  • Lightening
  • Braxton-Hicks contractions
  • Bloody show
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5
Q

What is lightening?

A

Fetal descent into the pelvic brim.

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6
Q

What are Braxton-Hicks contractions?

A

Benign contractions that do not result in cervical dilation; they routinely start to increase in frequency towards the end of pregnancy.

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7
Q

What is a bloody show?

A

Blood-tinged mucus from the vagina that is released with cervical effacement.

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8
Q

During labor, how is the fetus monitored electronically?

A

An external tocometer is placed on the gravid abdomen to measure the fetal heart rate and uterine contractions.

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9
Q

What is stage 1 of labor? What is its duration?

A

Stage 1:

  • Onset of labor –> full dilation of the cervix
  • Primipara: 6-18 hours
  • Multipara: 2-10 hours
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10
Q

What is the latent phase of stage 1 of labor? What is its duration?

A

Latent phase:

  • Onset of labor –> 4 cm dilation
  • Primipara: 6-7 hours
  • Multipara: 4-5 hours
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11
Q

What is the active phase of stage 1 of labor? What is its rate?

A

Active phase:

  • 4 cm dilation –> full dilation
  • Primipara: 1 cm per hour (minimum)
  • Multipara: 1.2 cm per hour (minimum)
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12
Q

What is stage 2 of labor? What is its duration?

A

Stage 2:

  • Full dilation of the cervix –> delivery of neonate
  • Primipara: 30 minutes-3 hours
  • Multipara: 5-30 minutes
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13
Q

What is stage 3 of labor? What is its duration?

A

Stage 3:

  • Delivery of the neonate –> delivery of the placenta
  • 30 minutes
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14
Q

What is monitored during stage 1 of labor?

A
  • Maternal BP and pulse
  • Electronic fetal monitor: fetal heart rate and uterine contractions
  • Examine the cervix to monitor progression of labor for:
    • Cervical dilation
    • Cervical effacement
    • Station (where the fetus’s head is located in relationship to the pelvis; measured -3 through +3)
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15
Q

In stage 2 of labor, the rate of fetal head descent determines the progression of the stage. What are the several steps that the fetus goes through during this stage?

A
  1. Engagement: fetal head enters the pelvic occipital first
  2. Descent: progresses as uterine contractions and maternal pushing occur; descent continues until fetus is delivered
  3. Flexion of the head
  4. Internal rotation: fetus starts to rotate when it reaches the ischial spines; rotation moves the sagittal sutures into the forward position
  5. Extension: occurs so the head can pass through the vagina (oriented forward and upward
  6. External rotation: during fetal head delivery, rotation gives the shoulders room to descend; anterior shoulder goes under the pubic symphysis first
  7. Delivery of the anterior shoulder: gentle downward pressure on the fetal head will aid in delivery
  8. Delivery of the posterior shoulder: gentle upward pressure on the fetal head will aid in delivery; the rest of the fetus will follow
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16
Q

What is done first in stage 3 after the fetus is delivered?

A

Immediately after delivery, inspect and repair lacerations of e vagina while waiting for placental separation.

17
Q

In stage 3, what are the signs of placental separation?

A
  • Fresh bleeding from the vagina
  • Umbilical cord lengthening
  • Uterine fundus rising
  • Uterus becoming firm
18
Q

What medications are used to induce labor?

A
  • Prostaglandin E2 is used for cervical ripening.

- Oxytocin exaggerates uterine contractions.

19
Q

What is an amniotomy?

A

The amniotic sac is punctured with an amniotic hook to induce labor. Inspect for a prolapsed umbilical cord BEFORE puncturing the amniotic sac.

20
Q

In whom are prostaglandins contraindicated?

A

Asthmatics - it may provoke bronchospasm

21
Q

What is a prolonged latent stage of labor? What causes it?

A

Occurs when the latent phase lasts longer than 20 hours for primipara and longer than 14 hours multipara.

Etiology:

  • Sedation
  • Unfavorable cervix
  • Uterine dysfunction with irregular or weak contractions
22
Q

What is the treatment of prolonged latent phase?

A

Rest and hydration; most will convert to spontaneous delivery in 6-12 hours

23
Q

What is protracted cervical dilated? What are the causes?

A

Slow dilation of the active phase of stage 1 of labor: less than 1.2 cm per hours primipara; less than 1.5 cm per hour multipara.

Etiology (the 3 P’s):

  • Power: inadequate strength and frequency of uterine contractions
  • Passenger: size (too large) and position of the fetus
  • Passage: if passenger is larger than the passage –> cephalopelvic disproportion
24
Q

What is the treatment of protracted cervical dilation?

A
  • Oxytocin is used if uterine contractions are weak.

- Cesarean delivery is used in cephalopelvic disproportion.

25
Q

What are the two types of arrest disorders?

A

Cervical dilation: no dilation for more than 2 hours

Fetal descent: no fetal descent for 1 hour

26
Q

What are the causes of arrest disorders?

A
  • Cephalopelvic disproportion: accounts for half of all arrest disorders; treatment is cesarean delivery
  • Malpresentation: fetus is older than 36 weeks with the presenting part being something other than the head (meaning the head is not downward)
  • Excessive sedation/anesthesia
27
Q

What is malpresentation?

A

The lower half of the fetus (pelvis and legs) is the presenting part closest to the vaginal canal; normally, the head is the presenting part.

28
Q

How does malpresentation present on physical exam? How is a diagnosis made?

A
  • You may feel the fetal head in the superior aspect of the abdomen.
  • Leopold maneuvers are a set of 4 maneuvers that estimate the fetal weight and presenting part of the fetus.
  • Vaginal exam: a soft mass will be felt instead of the normal hard surface of the skull.

Ultrasound is used to visualize the fetus and confirm the diagnosis.

29
Q

Describe the three types of breeches:

  • Frank breech
  • Complete breech
  • Footling breech
A
  • Frank breech: the fetus’s hips are flexed with the knees extended bilaterally
  • Complete breech: the fetus’s hips and knees are flexed bilaterally
  • Footling breech: the fetus’s feet are first, one leg (single footling) or both legs (double footling)
30
Q

What is the treatment of malpresentation?

A

External cephalic version: The caregiver maneuvers the fetus into a cephalic presentation (head down) through the abdominal wall. This should NOT be done until after 36 weeks; the fetus can maneuver itself into position before 36 weeks.

31
Q

What is shoulder dystocia? What are the risk factors?

A

Shoulder dystocia occurs when the fetus’s head has been delivered but the anterior shoulder is stuck behind the pubic symphysis.

Risk factors:

  • Macrosomia from maternal diabetes or obesity
  • Postterm pregnancy (allows the baby more time to grow)
  • History of prior shoulder dystocia
32
Q

What is the treatment options for shoulder dystocia?

A

The following maneuvers should be attempted in this order:

  1. McRoberts maneuver: Maternal flexion of knees into abdomen with suprapubic pressure; this is the first-line treatment.
  2. Rubin maneuver: Rotation of the fetus’s shoulders by pushing the anterior shoulder toward the fetal head.
  3. Woods maneuver: Rotation of the fetus’s shoulders by pushing the posterior shoulder toward the fetal back.
  4. Delivery of the posterior arm.
  5. Deliberate fracture of the fetal clavicle.
  6. Zavanelli maneuver: Push the fetal head back into the uterus and perform cesarean delivery; high rate of both maternal and fetal mortality; last maneuver to try.
33
Q

How is postpartum hemorrhage defined?

A

Postpartum hemorrhage is bleeding more than 500 mL after delivery. Early postpartum bleeding occurs within 24 hours of delivery, while late bleeding occurs 24 hours to 6 weeks later.

34
Q

What are the causes of postpartum hemorrhage?

A

Uterine atony is the cause in 80% of cases. Normally the uterine contractions compress the blood vessels to stop blood loss; in uterine atony, this does not occur. Other causes include:

  • Laceration
  • Retained parts
  • Coagulopathy
35
Q

What are the risk factors for uterine atony?

A
  • Anesthesia
  • Uterine overdistension
  • Prolonged labor
  • Laceration
  • Retained placenta (can occur with placenta accreta)
  • Coagulopathy
36
Q

What is a complication of postpartum hemorrhage that presents as inability to breastfeed?

A

Sheehan syndrome

37
Q

What is the treatment of postpartum hemorrhage?

A
  1. Bimanual compression and massage should be done is examination is normal. The uterus should be examine to assure there is no rupture of the uterus and there is no retained placenta. Bilateral compression and massage will control most cases.
  2. Oxytocin is used if bimanual massage is ineffective or contraindicated. Oxytocin will make the uterus contract, constricting the blood vessels and decreasing the blood flow.

Obstetrics (3 decks)

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