normal L & D Flashcards
what is fetal lie and how is it dtm’d?
whether the fetus is longitudinal or transverse. Dtmd by Leopold’s maneuvers.
Leopold’s maneuvers
1) uterine fundus
2) sides of uterus
3) palpation of presenting part above pubic symphisis
PROM
incidence?
premature rupture of membranes. When membranes rupture at least 1 hr prior to onset of labor. Occurs in 10% of pg’ies
PPROM
preterm premature rupture of memranes - when membranes rupture before the onset of labor in a pt < 37 weeks gestation
prolonged PROM. Why is it bad?
PROM that occurs 18 hrs or more before labor. Increased risk of maternal & fetal infection.
how to diff’ate b/w ROM and stress incontinence?
pool, nitrazine, fern tests
pool test:
sterile speculum exam. + if collection of fluid in vagina. May need to ask pt to cough or bear down.
nitrazine test:
fluid found in vagina will turn blue when placed on nitrazine paper b/c its alkaline
fern test:
fluid is placed on a slide and allowed to dry. Microscopically, looks like fern pattern if its amniotic fluid. But careful, cervical mucus also ferns. Don’t swab fluid directly from cervix.
what to do if pool, nitrazine, and/or fern tests are equivocal?
do u/s. Compare amt of amniotic fluid to that recorded in previous u/s.
what are the 5 components of Bishop score:
1) cervical dilation
2) cervical effacement
3) fetal station
4) cervical position
5) cervical consistency
how is Bishops’ score calculated?
a value of 0 to 3 is given for 1, 2, and 3 of the 5 categories. Scores of 0 to 2 are given for categories 4 and 5. Total < 6 means unfavorable cervix. > 8 means favorable cervix for NSVD.
Bishops’ scoring points for cervical dilation:
closed = 0
1-2 cm = 1
3-4cm = 2
> 5 = 3
Bishops’ scoring points for cervical effacement
0-30% = 0 40-50% = 1 60-70% = 2 80-100% = 3
Bishops’ scoring points for fetal station
-3 = 0
-2 = 1
-1, 0 = 2
> +1 = 3
what is fetal station? How is it measured?
how far the presenting part (usually fetal head) is from the ischial spine. If its at ischial spine, its 0. If lower than ischial spine, its +1. If its above ischial spine, -1. Measured by calc’ing # cm from pelvic inlet (-5 to +5)
Bishops’ scoring points for cervical consistency:
firm = 0 medium = 1 soft = 2
Bishops’ scoring points for cervical position
posterior = 0 mid = 1 anterior = 2
how long is a non-effaced cervix?
3-5 cm
what are the 3 typse of fetal presentation
breech vs. vertex vs. transverse
what is a compound presentation?
fetal vertex (back of head) + an extremity
cephalic vs. vertex
vertex is head-first, with flexed head. Cephalic = head-first but not flexed yet; may be extended.
what is fetal position?
is only true of vertex babies. Its the rltsp of baby’s fontanelles or ears to mom’s pelvic inlet.
what shape is the anterior fontanelle?
diamond
what shape is the posterior fontanelle?
triangle
true labor vs. prodromal (false) labor
true labor is regular ctr’ns that cause cervical dilation and/or effacement. False labor is irregular ctr’ns w/no cervical change.
induction vs. augmentation of labor
induction = attempt to begin labor augmentation = increase the labor already present
methods used to augment labor:
pitocin, amniotomy
concerning fetal bradycardia =
2 mins or more of < 90 bpm
causes of reduced FHR variability:
fetal sleep, maternal intake of drugs, reduced fetal CNS fct (hypoxia)
early decels = ? 2/2 to what?
begin & end at same time as ctr’ns. 2/2 head compression => increased vagal tone.
variable decels = ? 2/2 to what?
decels that occur at any time and drop more precipitously (like a V). 2/2 umb cord compression. Can suggest nuchal cord.
late decels = ? 2/2 to what?
decels that begin at peak of ctr’n and slowly return to baseline after ctr’n has finished. 2/2 uteroplacental insuff’y.
why place a fetal scalp electrode?
repetitive decels or trouble w/external FHR monitoring. Provides more accurate and more sensitive monitoring.
CI’s to fetal scalp monitoring?
maternal hepatitis or HIV or fetal thrombocytopenia
unit of measurement of uterine ctr’ns?
Montevideo unit. Need 200 for adequate labor.
when to obtain fetal scalp pH?
when FHR tracing is non-reassuring, need to check for hypoxia & acidemia.
what is a reassuring fetal scalp pH?
pH > 7.25
what is a non-reassuring fetal scalp pH?
pH < 7.2
normal fetal pulse ox?
> 30%
what are the cardinal movements of labor?
engagement descent flexion internal rotation extension external rotation
what is engagement?
when fetal presenting part enters the pelvis
what is internal rotation?
rotation of fetal vertex so that it changes from occiput transverse (OT) to occiput anterior (OA) - saggital suture is parallel to AP diam of mom’s pelvis
aka, baby’s head turns to be face-down
stages of labor:
First = onset of labor until complete dilation and effacement of cervix
Second stage = from complete dilation and effacement to delivery of infant
Third stage = from delivery of infant to delivery of placenta
average length of first stage of labor:
10-12 hours in nulliparous pt
6-8 hrs in multiparous pt
what are the 2 phases of first stage?
latent & active phase
latent phase of first stage of labor =
onset of labor to 3-4cm dilation. Slow progression of cervical change.
active phase of first stage of labor =
Rate of cervical change?
from end of latent phase to > 9cm dilation. More rapid cervical change. 1 cm/h in nulliparous. 1.2 cm/h in multiparous
what are the 3 P’s of labor?
Power, passenger, pelvis
Power = strength & freq of ctr’ns
Passenger = size of fetus
pelvis = needs to fit passenger
CPD
signs?
cephalopelvic disproportion (baby too big for pelvis) signs = dvpt of fetal caput (back of head is cone-shaped), extensive molding of fetal skull, palpable overlapping sutures
what to do if rate of cervical dilation falls below 1 cm per hour?
assess the 3 P’s, consider measuring ctr’ns w/IUPC. Dtm if vaginal delivery is possible.
what is normal length of second stage of labor?
< 2 hours in nulliparous pt, 3 hours if epidural is present.
> 1 hr in multiparous, 2 hours if epidural
(usually only lasts 30 mins in multips)
what is asynclitism?
head is presenting first but is tilted toward shoulder
what kind of FHR tracings are reassuring during 2nd stage of labor?
repetitive early decels, variable decels. Resolve quickly after each ctr’n. Normal variability.
what are non-reassuring FHR tracings during 2nd stage?
repetitive late decels, bradycardias, loss of variability
what to do if non-reassuring FHR tracings occur?
pt placed on L side to decrease IVC compression & increase uterine perfusion, supp’l O2. D/c pitocin if applicable. Give terbutaline if hypertonus or tachysystole was cause.
what is tachysystole?
+ 5 ctr’ns in 10 mins
what is hypertonus?
a ctrn lasting + 2 mins
what to do if FHR tracings remain non-reassuring after position change, O2, terbutaline?
assess fetal position & station to dtm if operative vaginal delivery can be performed
how do you know if an operative vaginal delivery can be performed?
fetal station m/b 2+ or more, m/b able to tell fetal position
what to do if meconium is in amniotic fluid?
use DeLee suction tube in infant’s nose & mouth before delivering shoulders
what to do if you find a nuchal cord?
try to reduce the cord around the infant’s head.
If delivery will be accomplished shortly, can clamp and cut the cord and deliver baby.
If shoulder dystocia is suspected, try to deliver infant w/cord intact.
indications for episiotomy?
need to hasten delivery
impending or ongoing shoulder dystocia
CI for episiotomy
expectation that there w/b a large perineal lac
2 types of episiotomies:
median (midline - vertical)
mediolateral (horizontal)
what are the 2 types of operative deliveries?
forceps delivery, vacuum-assisted delivery
what criteria need to be met before forceps and/or vacuum can safely be used?
full dilation of cervix ruptured membranes engaged head station at least 2+ absolute knowledge of fetal position no evidence of CPD adequate anesthesia empty bladder experienced operator
what is a rare severe complication of vacuum delivery?
subgaleal hemorrhage (blood b/w skull periosteum and scalp aponeurosis. Can hold 50% of fetal blood and => shock)
which is better, forceps or vacuum?
no sig diff in neonatal complications b/w the two
vacuum => higher rate of cephalohematoma & shoulder dystocia
forceps => higher rate of facial n. palsy, higher rate of maternal 3rd and 4th degree lacs
how long does placental separation usually take?
5-10 mins from delivery of infant. Up to 30 mins.
if it is certain that second stage has been completed (no twin), what can be given to decrease placental delivery time and blood loss?
oxytocin
what are the 3 signs of placental separation?
how many of these need to be present before attempting to deliver placenta?
1) cord lengthening
2) gush of blood
3) uterine fundal rebound
all 3 need to be present
what does the OB have to do while pt is bearing down to deliver placenta?
apply traction to umb cord, apply suprapubic P to prevent uterine inversion or prolapse
retained placenta is common in ____.
preterm deliveries
what is placenta accreta?
where placenta has invaded into or beyond endometrial stroma
how to remove a retained placenta?
manual extraction, or curretage
diff degrees of perineal lacs:
1st degree = mucosa or skin only
2nd degree = extend into perineal body but not anal sphincter
3rd degree = extend into or completely through anal sphincter
4th degree = anal mucosa is torn, rectum involved
how are 1st degree lacs repaired?
interrupted sutures
how are 2nd degree lacs repaired?
in layers, starting at apex of lac. First repair vaginal mucosa. Then subQ, then skin with a subcuticular stitch.
how are 3rd degree lacs repaired?
first repair anal sphincter w/interrupted sutures. Then continue w/second degree repair.
how are 4th degree lacs repaired?
meticulously close anal mucosa to prevent fistula. Then carry on w/3rd degree repair.
what is the rate of c/s in U.S. today?
29%
what is most common indication for C/S?
previous c/s, or
failure to progress in labor
what is VBAC?
vaginal birth after c/s
what kind of incision needs to be previous c/s in order to try VBAC?
LTCS (Kerr incision)
or Kronig incision (low vertical incision)
rate of rupture of prior uterine scar during TOLAC?
0.5-1.0%
signs of uterine rupture during TOLAC?
ab'l pain FHR decels FHR bradycardia decrease of P on IUPC maternal sensation of "pop"
what narcotics can be given and when?
morphine, fentanyl, nalbuphine, butorphenol
given early in labor. Don’t give close to delivery b/c infant w/b depressed.
when is a pudendal blocked used?
forceps or vacuum delivery
when is local anesthetic injection used?
episiotomy
repair of lacs
when is epidural & spinal anesthesia used?
when pts want analgesia throughout all of labor
where is epidural catheter placed?
L3-L4
diff b/w epidural and spinal anesthesia?
epidural is when a catheter is placed in epidural space and continuous infusion is given to decrease (but not completely block) sensation below L3/L4.
Spinal anesthesia is where anesthetic is bolused into spinal canal => more rapid anesthesia. Used in c/s
complication of epidural and spinal anesthesia?
maternal hypotension => decreased placental perfusion, fetal bradycardia
maternal resp’y depressin
spinal headache 2/2 loss of CSF in 1% of pts
what kind of anesthesia is used in emergent C/S?
general anesthesia
risks of general anesthesia?
maternal aspiration
hypoxia to mom and baby during induction
indications for emergency C/S?
placental abruption fetal bradycardia umbilical cord prolapse uterine rupture hemorrhage 2/2 placenta previa
