Normal Labor and Delivery Flashcards
How is rupture of membranes (ROM) evaluated?
Premature (PROM)= prior to onset of labor
Preterm, premature (PPROM) = prior to 37 weeks gestation
Pool test = see fluid in vagina
Nitrazine test = amniotic fluid is alkaline, turns nitrazine paper blue
Fern test = estrogens in amniotic fluid causes fern pattern under microscope
US to look at fluid around fetus (decreased fluid is indicative)
Amnisure = rapid molecular test of fluid to identify placental alpha-microglobulin-1
Why is (P)PROM dangerous?
Puts mother and fetus at risk for infection
Consider prophylactic abx
What are the components of the cervical exam
Dilation (0-10 cm)
Effacement (how short the cervix becomes in percentage)
Fetal station (relation to ischial spine, -5 to +5 cm)
Cervical position (posterior, mid, anterior)
Consistency of cervix (firm, medium, soft)
Bishop score > 8 = favorable for spontaneous labor
What is compound presentation?
Vertex presentation with fetal extremity (like arm)
What is normal labor?
Contractions with cervical change
How can labor be induced and augmented?
Induction with prostaglandins, oxytocin (Pitocin*), mechanical dilation, artificial ROM (AROM)
What are indications for induction of labor?
Postterm pregnancy Preeclampsia DM Nonreassuring fetal testing Intrauterine growth restriction
What agents can be used for cervical ripening?
Prostaglandin E2
-Gel
-Pessary (cervidil)
PGE1M (misoprostol)
What are contraindications for cervical ripening with prostaglandins?
Maternal asthma and glaucoma
Prior C-section and nonreassuring fetal testing
Use mechanical dilator in this setting
What must you be careful of when performing AROM?
Prolapse of umbilical cord - do not elevate fetal head
What can be used to augment labor?
Pitocin and amniotomy
What are indications for labor augmentation?
Inadequate contractions - measured through intrauterine pressure catheter
Prolonged phase of labor
What is normal fetal heart rate?
110-160
What must you watch for when monitoring fetal heart rate?
Baseline > 160 concerning for distress 2/2 infection, hypoxia, anemia
Prolonged fetal decel > 2 min duration with HR
What are the types of decels?
Early - begin and end at the same time as contractions, due to increased vagal tone secondary to head compression
Variable - occur at any time, drop precipitously, due to umbilical cord compression
Late - begin at peak of contraction, slowly return to baseline after contraction = most worrisome, due to uteroplacental insufficiency
What are the kinds of fetal variability?
Look at difference between peak and trough in one box)
Absent (25/min)
What is normal fetal heart accel?
10 beats over baseline for at least 10 seconds if 32 weeks (at least 2 in 20 min)
What are contraindications for fetal scalp eletrode monitoring for babies that are difficult to trace externally, or in presence of repetitive decels?
Maternal hepatitis and HIV because it requires breaking the skin barrier
What are the categories of fetal heart tracings?
I: normal baseline, moderate variability, no variable/late decels
II: indeterminate, variable and late decels, brady and tachycardia, minimal variability, or even absent variability
III: abnormal, absent fetal heart variability, recurrent late/variable decels, bradycardia
- sinusoidal pattern of fetal anemia
What are the values of uterine pressure measured by IUPC?
Baseline 10-15
During contractions, can increase by 20-30 early, 40-60 late in labor
What are the cardinal movements of labor?
Engagement Descent Flexion Internal rotation Extension External rotation (restitution/resolution)
What are the stages of labor?
Stage 1 = onset of labor, until dilation and effacement is complete
Stage 2 = full dilation to delivery of neonate
Stage 3 = afterbirth, ends with delivery of placenta
What are the expected milestones in stage 1 of labor?
10-12 hours in nulliparous, 6-8 hours in multip
At least 1 cm/hr dilation in nullip, 1.2 cm/hr dilation in multip
Adequate contractions of > 200 montevideo units
What is active phase arrest?
No change in cervival dilation or station for 2 hours
Indication for c-section
(Can wait up to 4 hours)
What are stage 2 labor milestones?
What are signs of nonreassuring fetal heart tracing?
Repetitive late decels
Bradycardia
loss of variability
What should be done in setting of nonreassuring fetal heart tracing?
O2 mask
Turned onto left side to reduce IVC compression (increase uterine perfusion)
D/c oxytocin
Administer tertbutaline (tocolytic) if thought to be due to hypertonus or tachysystole
C-section if station cannot be determined, or if station
What maneuver can be done if delivery needs to be expedited?
Modified Ritgen proceture
Apply upward pressure from behind anus
Can lead to greater perineal lacs
What are operative vaginal deliveries?
Assistance with forceps or vacuum suction
What is cephalopelvic disproportion
If fetus is too large for pelvis
Requires c-section
What are the dangers of vacuum assisted delivery?
Scalp lac, cephalohematoma, subgaleal hemorrhage (emergency, between periosteum and galeal aponeurosis)
What are stage 3 labor milestones?
Placental separation 5-10 min after delivery (nl
What is important to keep in mind during placental delivery?
Prevent cord avulsion
Prevent uterine inversion by keeping suprapubic pressure
What is a cause of retained placenta?
Placenta accreta = may require curretage
What are the degrees of lacs?
1st: mucosa or skin
3rd: involve anal sphincter
4th: enters anal mucosa
Care for buttonhole 4th degree lac which can spare anal sphincter
What is the most common indication for c-section?
Failure of labor to progress*
CPD
Poor contractions (can try pitocin/AROM first)
breech position, transverse lie, shoulder, placenta previa, fetal distress, cord prolapse
prior C-section*
maternal disease (HIV, active genital herpes, cervical cancer)
When can vaginal birth after c-section (VBAC) be attempted?
Kerr (low transverse) or Kronig (low vertical) hysterotomy without extension into cervix or upper uterine segment
What is the greatest risk during trial of void after c-section (TOLAC)?
Rupture of prior uterine scar
What are common analgesics used during labor?
IM morphine sulfate
Pudendal block
Local for episiotomy/repair of lac
Epidural (at L3-L4 level) during active phase
Spinal anesthesia (more commonly for c-section)
What medications should not be used during labor?
Sedating meds because can cross placenta and cause resp depression in infant
What are common complications of epidural and spinal anesthesia?
Maternal hypotension (due to decreased SVR) = decreased placental perfusion and fetal bradycardia
Maternal respiratory depression
Spinal headache
What are reasons for emergency c-section?
Placental abruption Fetal bradycardia Umbilical cord prolapse Uterine rupture Hemorrhage from previa
