Normal Labor and Delivery Flashcards
labor
-progressive cervical dilation resulting from uterine contractions that occur every 5 min and last 30-60 seconds
false labor
irregular contractions w/o cervical change
pelvic shapes
- gynecoid
- android
- anthropoid
- platypelloid
gynecoid
classic female type of pelvis (50%)
- round at inlet
- wide transverse diameter only slightly greater than AP diameter
- wide suprapubic arch (>90 degrees)
- good prognosis of delivery- head rotates in OA position
android
classic male type of pelvic (30% of females)
- widest transverse diameter closer to sacrum
- prominent ischial spines
- narrow pubic arch
- head forced to be in OP position- poor prognosis
anthropoid
ape pelvic (20% of females)
- much larger AP then transverse diameter
- long narrow oval shape
- narrow pubic arch
- head in OP position- good prognosis
platypelloid
flattened gynecoid pelvic (3%)
- short AP, wide transverse diameter
- wide bispinous diameter
- wise suprapubic arch
- poor prognosis
obstetric exam
- fetal lie (longitudinal, transverse, oblique)
- fetal presentation (vertex, breech, transverse, or compound)
- cervical exam
leopold maneuvers
- palpate fundus (fetal head vs buttocks vs transverse position)
- palpate for spine and fetal small parts
- palpate what is presenting in the pelvis with suprapubic palpation
- palpate for cephalic prominence
cervical exam
- dilation (level of internal os)
- effacement (thinning of cervix, % of change in length)
- station (-5 cm to +5 cm- ischial spines is 0)
- consistency and position
labor stages
- 1- onset of true labor to complete cervical dilation- latent and active phase
- 2- complete cervical dilation to delivery of infant
- 3- delivery of infant to delivery of placenta
- 4- delivery of placenta to stabilization of pt
labor- 1st stage
- latent (early labor)- slow cervical dilation
- active- faster rate of dilation (when cervix is dilated to 4 cm)
labor- 1st stage- duration, cervical dilation rate
- duration- primiparas- 6-18 hrs; multiparas 2-10 hrs
- cervical dilation- primiparas 1.2 cm/hr; multiparas 1.5 cm/hr
1st stage- management
- maternal position
- fluids- IV
- labs- CBC and T&S
- maternal monitoring- vitals q1-2 h while in labor
- analgesia
- fetal monitoring
- uterine activity
- vaginal examinations
- amniotomy
1st stage- fetal monitoring
-external- continuous, q30 min in active phase in 1st phase, q15 min in 2nd stage
second stage- duration
desc of presenting part and delivery!
- primara w/o epidural- 2 h
- primarapara w/ epidural- 3 h
- multipara w/o epidural- 1 h
- multipara w epidural- 2 h
cardinal movements of labor- engagement
-presenting part at 0 station
cardinal movements of labor- flexion
-OA- baby’s chin to chest thus changing the presenting part from occipitofrontal to the smaller suboccipitobregmatic
cardinal movements of labor- internal rotation
- usually occurs at ischial spines
- fetal head enters pelvic in transverse diameter, rotates so the occiput turns anteriorly or posteriorly twd pubic symphysis
cardinal movements of labor- extension
- crowning occurs when the largest diameter of fetal head is encircled by vaginal introitus
- station is +5
- head is born by rapid extension
cardinal movements of labor- external rotation
-delivered head returns to its original position to align itself with fetal back and shoulers
cardinal movements of labor- expulsion
-ant shoulder delivers under the pubic symphysis followed by posterior shoulder and rest of body
second stage- management
- maternal position- avoid supine position
- bearing down
- fetal monitoring- continuous- q15 or 5 with risk factors
- vaginal exam
- delivery of fetus
episiotomy- indiations
- likelihood of spontaneous lacerations seems high; expedite delivery
- midline- most common
- mediolateral
modified ritgen maneuver
-fingers of right head are used to extend the head while counterpressure is applied to the occiput by the left hand to allow for more controlled delivery
perineal lacerations
- 1st degree- superficial- vaginal mucosa and/or perineal skin
- 2nd- m’s of perineal body
- 3rd- thru anal sphincter
- 4th- rectal mucosa
third stage
interval b/w delivery of infant to delivery of placenta (2-10 min)
- retained placenta if not delivered > 30 min
- apply counter pressure b/w symphysis and fundus
- do NOT pull on cord until classic signs are noted
placental separation- classic signs
- gush of blood from vagina
- lengthening of umbilical cord
- fundus of uterus rises up
- change in shape of uterine fundus from discoid to globular
third stage- management
- look for lacerations of cervix, vagina, perineum
- monitor uterine bleeding
- repair episiotomy or spontaneous lacerations
- inspect placenta for completeness
4th stage- management
- monitor pt closely
- vitals
- uterine fundal checks, assess for vaginal bleeding
- postpartum hemorrhage commonly occurs at this time- uterine atony, retained placenta, unrepaired vaginal laceration
induction and augmentation of labor
- cervical ripening
- induction of labor
- augmentation
indications for induction
- abruptio placentae
- chorioamnionitis
- fetal demise
- preeclampsia, eclampsia
- gestational HTN
- PROM
- postterm pregnancy
- maternal medical conditions
- fetal compromise
contraindications to induction
- unstable fetal presentation
- acute fetal distress
- placental previa or vasa previa
- prev classical c-section
- contraindications to vaginal delivery
bishop score
<6- unfavorable
>8- probability of vaginal delivery after labor induction is similar to that of spontaneous labor
cervical ripening agents
-cervidil (dinoprostone)- PGE2- vaginal insert
(contraindicated in pts w/ prev c-section)
-cytotec (misoprostol)- PGE1
-mechanical dilators- foley bulb catheter, laminara jopincum
pitocin insufion
- synthetic oxytocin- stim myometrial contractions
- IV
Pitocin complications
- uterine tachysystole- > 5 contractions in 10 min- most common SE
- antidiuretic effect
- uterine m fatigue (unresponsiveness)- inc risk of postpartum hemorrhage secondary to uterine atony
obstetric anesthesia
- adequate hydration prior to regional anesthesia (mitigate risk for hypotension)
- regional anesthesia- partial/complete loss of pain sensation below T10!!
pain pathways
- uterine contractions and cervical dilation- visceral pain- T10-12 thru L1
- descent of fetal head- somatic pain- pudendal n- S2-4
anesthesia options
- nonpharmacologic
- parenteral
- regional- epidural, spinal
- local- local infiltration of perineum, pudendal block
- general
anesthesia options- nonpharmacologic
- lamaze
- emotional support
- back massage
- hydrotherapy
- acupuncture
anesthesia options- parenteral
- more effective in early 1st stage of labor when pain is more visceral and less intense
- little efficacy for relief of labor pain- primary moa is heavy sedation
- opioids cross placental barrier- neonatal resp depression (Naloxone- opioid antagonist)
anesthesia options- regional
- loss of pain sensation below T8-10
- local anesthesia (bupivacaine/lidocaine) + narcotic (fentanyl)
- epidural- most effective form- needle b/w L2-3- catheter placed over needle
- spinal- single-shot analgesia
regional anesthesia- benefits, SE’s
- highly effective, mother remains alert/awake, will remember experience, rarely requires local anesthesia for perineal lacerations
- hypotension (10%)
- spinal headaches (1%)
- fever, spinal hematomas and abscess
regional anesthesia- contraindication
- maternal coagulopathy
- heparin use within 12 hrs
- untreated maternal bacteremia
- inc ICP caused by mass lesion
- skin infection over site of needle placement
anesthesia options- ocal
- local infiltration of perineum- 1-2% lidocaine provides anesthesia for 20-40 min- b/f episiotomy or with laceration repairs
- pudendal block
anesthesia options- general
- propofol!!
- loss of maternal consciousness, airway management
- 16x risk of maternal mortality compared to regional anesthesia
- inhaled anesthetics cross placenta- neonatal resp depression
