Normal Labor and Delivery

Question 1

How is rupture of membranes (ROM) evaluated?

Answer 1

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

Question 2

Why is (P)PROM dangerous?

Answer 2

Puts mother and fetus at risk for infection

Consider prophylactic abx

Question 3

What are the components of the cervical exam

Answer 3

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

Question 4

What is compound presentation?

Answer 4

Vertex presentation with fetal extremity (like arm)

Question 5

What is normal labor?

Answer 5

Contractions with cervical change

Question 6

How can labor be induced and augmented?

Answer 6

Induction with prostaglandins, oxytocin (Pitocin*), mechanical dilation, artificial ROM (AROM)

Question 7

What are indications for induction of labor?

Answer 7

Postterm pregnancy
Preeclampsia 
DM
Nonreassuring fetal testing
Intrauterine growth restriction

Question 8

What agents can be used for cervical ripening?

Answer 8

Prostaglandin E2
-Gel
-Pessary (cervidil)
PGE1M (misoprostol)

Question 9

What are contraindications for cervical ripening with prostaglandins?

Answer 9

Maternal asthma and glaucoma
Prior C-section and nonreassuring fetal testing

Use mechanical dilator in this setting

Question 10

What must you be careful of when performing AROM?

Answer 10

Prolapse of umbilical cord - do not elevate fetal head

Question 11

What can be used to augment labor?

Answer 11

Pitocin and amniotomy

Question 12

What are indications for labor augmentation?

Answer 12

Inadequate contractions - measured through intrauterine pressure catheter
Prolonged phase of labor

Question 13

What is normal fetal heart rate?

Answer 13

110-160

Question 14

What must you watch for when monitoring fetal heart rate?

Answer 14

Baseline > 160 concerning for distress 2/2 infection, hypoxia, anemia
Prolonged fetal decel > 2 min duration with HR

Question 15

What are the types of decels?

Answer 15

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

Question 16

What are the kinds of fetal variability?

Answer 16

Look at difference between peak and trough in one box)

Absent (25/min)

Question 17

What is normal fetal heart accel?

Answer 17

10 beats over baseline for at least 10 seconds if 32 weeks (at least 2 in 20 min)

Question 18

What are contraindications for fetal scalp eletrode monitoring for babies that are difficult to trace externally, or in presence of repetitive decels?

Answer 18

Maternal hepatitis and HIV because it requires breaking the skin barrier

Question 19

What are the categories of fetal heart tracings?

Answer 19

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

Question 20

What are the values of uterine pressure measured by IUPC?

Answer 20

Baseline 10-15

During contractions, can increase by 20-30 early, 40-60 late in labor

Question 21

What are the cardinal movements of labor?

Answer 21

Engagement
Descent
Flexion
Internal rotation
Extension
External rotation (restitution/resolution)

Question 22

What are the stages of labor?

Answer 22

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

Question 23

What are the expected milestones in stage 1 of labor?

Answer 23

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

Question 24

What is active phase arrest?

Answer 24

No change in cervival dilation or station for 2 hours
Indication for c-section
(Can wait up to 4 hours)

Question 25

What are stage 2 labor milestones?

Question 26

What are signs of nonreassuring fetal heart tracing?

Answer 26

Repetitive late decels Bradycardia loss of variability

Question 27

What should be done in setting of nonreassuring fetal heart tracing?

Answer 27

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

Question 28

What maneuver can be done if delivery needs to be expedited?

Answer 28

Modified Ritgen proceture Apply upward pressure from behind anus Can lead to greater perineal lacs

Question 29

What are operative vaginal deliveries?

Answer 29

Assistance with forceps or vacuum suction

Question 30

What is cephalopelvic disproportion

Answer 30

If fetus is too large for pelvis | Requires c-section

Question 31

What are the dangers of vacuum assisted delivery?

Answer 31

Scalp lac, cephalohematoma, subgaleal hemorrhage (emergency, between periosteum and galeal aponeurosis)

Question 32

What are stage 3 labor milestones?

Answer 32

Placental separation 5-10 min after delivery (nl

Question 33

What is important to keep in mind during placental delivery?

Answer 33

Prevent cord avulsion | Prevent uterine inversion by keeping suprapubic pressure

Question 34

What is a cause of retained placenta?

Answer 34

Placenta accreta = may require curretage

Question 35

What are the degrees of lacs?

Answer 35

1st: mucosa or skin 3rd: involve anal sphincter 4th: enters anal mucosa Care for buttonhole 4th degree lac which can spare anal sphincter

Question 36

What is the most common indication for c-section?

Answer 36

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)

Question 37

When can vaginal birth after c-section (VBAC) be attempted?

Answer 37

Kerr (low transverse) or Kronig (low vertical) hysterotomy without extension into cervix or upper uterine segment

Question 38

What is the greatest risk during trial of void after c-section (TOLAC)?

Answer 38

Rupture of prior uterine scar

Question 39

What are common analgesics used during labor?

Answer 39

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)

Question 40

What medications should not be used during labor?

Answer 40

Sedating meds because can cross placenta and cause resp depression in infant

Question 41

What are common complications of epidural and spinal anesthesia?

Answer 41

Maternal hypotension (due to decreased SVR) = decreased placental perfusion and fetal bradycardia Maternal respiratory depression Spinal headache

Question 42

What are reasons for emergency c-section?

Answer 42

``` Placental abruption Fetal bradycardia Umbilical cord prolapse Uterine rupture Hemorrhage from previa ```