Normal Labor and Delivery and Post Partum Care -Castro

Question 1

What is true labor?

Answer 1

repetitive uterine contractions with progressive effacement and dilation of the cervix

Question 2

What is false labor?

Answer 2

repetitive uterine contractions WITHOUT progressive dilation or effacement (Braxton Hicks contractions) of the cervix

Question 3

What should be included in the initial assessment of labor?

Answer 3

• review prenatal records and labs
• confirm GA
• question about length/onset of contractions and bleeding or changes in fetal movement
• vital signs and fetal heart rate
• Leopold maneuvers to determine “lie” of the fetus
• palpate contractions

Question 4

Should you perform a pelvic exam on a patient with vaginal bleeding? Why or why not?

Answer 4

NO! want to do an US first to r/o placenta previa

–> must be delivered by c-section*

Question 5

What are the different levels of fetal station? At what point is the head considered to be “engaged”?

Answer 5

0 station: the biparietal diameter has entered the pelvic inlet (in vertex presentation) and the lowest presenting part is at the level of the ischial spines head is engaged

inches above the ischial spine is negative number

positive numbers to describe the station in inches below the ischial spine

Question 6

What are the cardinal movements of labor?

Answer 6

• Engagement
• Flexion
• Descent and Internal Rotation
• Extension of the head
• External Rotation
• Expulsion

Question 7

What labs should be done when a woman goes into labor?

Answer 7

Type and screen, CBC, possible VDRL, Hep B status and culture (possibly initiate PCN prophylaxis), urine protein (check for preeclampsia)

Question 8

When should narcotics be avoided in labor?

Answer 8

if 8 cm or more dilated –> can cause neonatal respiratory depression (can reverse with naloxone)

Question 9

What is the first stage of labor? What are the 2 phases?

Answer 9

first stage: onset of labor to complete cervical dilation

latent phase: slow effacement in dilation (up until 4 cm dilated)

active phase: more rapid cervical dilation (assumed at 6-7 cm dilated)

supposed to plot labor curve to determine what phase

Question 10

What should be done in a prolonged latent phase?

Answer 10

consider sedation and rest if mother is tired or pitocin augmentation if mom is hypocontractile

Question 11

What is active phase arrest? How should this be managed?

Answer 11

no change in cervical dilation in the active phase for > 2 hours

-evaluate the 3 Ps (passage, passenger, power (force)
–> if too big, might need a c-section
–> if not enough force, may need to add piton
(200 montevideo units is considered adequate)
–> if do not progress with adequate contractions–> c-section

Question 12

What is considered an adequate contraction? How is this measured?

Answer 12

200 montevideo units

montevideo units=peak of contraction in mmHg TIMES # of contractions in 10 minutes

Question 13

What is the second stage of labor? What should you be assessing for?

Answer 13

Interval from complete dilation to delivery of the fetus

assess for molding of the fetal head and for caput succedaneum (edema of the fetal scalp from pressure on the vertex)

Question 14

When would operative vaginal delivery be attempted in the second stage of labor?

Answer 14

Operative vaginal delivery (vacuum or forceps) is usually only attempted if the head is low in the pelvis (below +3 AND the cervix is completely dilated)

if operative delivery is not possible, deliver by c-section

Question 15

How long does the second stage normally last?

Answer 15

up to 3 hours in nulliparous (can be longer if descending and no bleeding or HR changes)

Question 16

What is the third stage of labor? How long after stage 2 does this normally happen?

Answer 16

interval from fetus delivery to placental delivery

normally wait 30 minutes after delivery before intervening

Question 17

When can you pull on the placental cord? If you pull too soon, what can happen?

Answer 17

after you see signs of separation (lengthening of the cord, sudden gush of blood, globular configuration of the uterus)

too soon can cause uterine inversion with maternal hemorrhage and shock –> emergency surgery

Question 18

What is considered prolonged 3rd stage? What can this be due to?

Answer 18

if the placenta does not separate by 30 minutes after delivery

could be a sign of placenta accrete/increta/percreta

Question 19

If a patient had a previous placenta previa and a c-section, can she have a vaginal delivery in subsequent births?

Answer 19

NO!

greatest chances of accrete

Question 20

What is necessary after the delivery of the placenta? What can be done if this doesn’t happen naturally?

Answer 20

uterine contraction –> can be given piton and uterine massage to avoid hemorrhage

Question 21

What vessels should be in the cord?

Answer 21

1 vein (mom–> fetus) and 2 arteries (fetus–> mom)

Question 22

What is the 4th stage of labor? What should be inspected

Answer 22

After delivery of placenta–methodically inspect cervix, vagina, urethra, vulva and perineum for lacerations and repair with absorbable suture.

Examine the uterus (if cannot palpate the fundus–> consider inversion) and placenta (for retained tissue).

Frequently assess vital signs, uterine tone and bleeding.–> high risk for bleeding

Question 23

What are the classifications of OB lacerations?

Answer 23

Classify Ob lacerations:

• first degree –vaginal mucosa or perineal skin
• second degree –involves subcutaneous tissue
• third degree –involves rectal sphincter
• fourth degree–involves rectal mucosa

Question 24

What are the possible causes of coagulopathy leading to prolonged bleeding?

Answer 24

• obstetrical causes of DIC (abruption, preeclampsia, amniotic fluid embolus, sepsis, retained dead fetus)
• dilutional secondary to excessive IV fluids
• primary blood disorder (von Willebrand’s disease or ITP)
• amniotic fluid embolus –> acute onset of resp and CV collapse with DIC

Question 25

What is the Puerperium? What should the physician be watching for?

Answer 25

-The first six weeks post partum—during which the anatomic and physiologic changes of pregnancy resolve

• Uterine involution and gradual decrease in uterine discharge (lochia rubra lasts 3-4 days)
• Weight loss and diuresis of extracellular fluid

Watch for:

• Post partum “blues”—need to watch for depression and post partum psychosis
• ask about contraception–> can ovulate after 3 weeks if not breast feeding

Question 26

What are the signs and symptoms of Endometritis? How is it treated? What are the risk factors?

Answer 26

fever >38C w/ uterine tenderness and foul smelling lochia in the first few days after delivery
-polymicrobial –> pelvic exam to remove anything

• tx: broad spectrum ABX (ampicillin and gentamycin)
• risk factor: chorioamnionitis and c-section)

Question 27

How is septic pelvic vein thrombophlebitis different from endometritis? How is the treatment different?

Answer 27

similar presentation as endometritis but patient has spiking fevers even after one week of antibiotics

• ADD heparin (RT side affected more often than left)
• increased with c-section*