Normal Labor and Delivery Labor and Delivery Complications / Operative Delivery Flashcards
Labor and Delivery - general information ?
Normal physiologic process
Most experience no complications
Goal is to offer a safe and supportive environment
Physiologic Preparation for Labor: Lightening ?
Settling of head into brim of pelvis
2-3 weeks before labor in primips
Less heartburn, SOB, but increased frequency of urination
Physiologic Preparation for Labor: Braxton Hicks contractions ?
Last 4-8 weeks of pregnancy
Painless, but increasing intensity
No cervical change
**false contractions, just tightening, not painful **
Physiologic Preparation for Labor: “Bloody show” ?
Days to weeks before true labor
Cervix softens and begins to dilate
Passage of mucus plug, sometimes blood-tinged
Evaluation at Presentation: best outcomes with ?
adequate prenatal care
Evaluation at Presentation
Note contraction onset and frequency
Status of membranes
-if her water broke and if we are open to infection or sram we still intact
History of bleeding and fetal movement
PMH
Prenatal records and labs
Maternal VS, urinary protein and glucose
Uterine contraction pattern
FHR, presentation and estimated fetal weight
Cervical dilation and effacement
Station of the presenting part
Labor Pain: Intensity dependent on ?
Fetal/pelvic relationship
Quality and strength of contractions
Emotional and physical status of patient
Labor Pain: Typically most intense discomfort is during ?
Dilation of the lower birth canal
Distention of the perineum
Pain Control during and for lab ?
IV medications
Pudendal nerve block
Epidural
Spinal
General
Engagement: Head enters _______ _____ ?
superior strait
Engagement: Usually occiput ________ position (70%)
transverse
Engagement: But it depends on dimensions and contours of birth canal - what 4 types ?
Gynecoid
Android
Platypelloid
Anthropoid
**anterior and posterior fontanell and you can palpate them to tell the orientation of the baby **
Pelvic Types: Shape of pelvic outlet helps determine position of _________ .
engagement
-Path of least resistance
**helps determine the path of the baby the will most likely assume
Anthropoid - head will fit more anterior/ posterior **
Pelvic types ?
Gynecoid
Platypelloid
Android
Anthropoid
Engagement: Presenting part enters ?
birth canal
Engagement: Station ?
descent of fetal head is measured to assess progress
Station is measured in relationship to ?
ischial spines
When leading portion of head is at level of ischial spines = ?
0 station (engaged)
**ishial spine = 0 station ( fully engaged) **
When 2 cms above spines = ?
-2 station
When 3 cms below spines = ?
+3 station
Three Stages of Labor: First ?
Two phases – latent and active
From onset of labor to full cervical dilation
Primips 6-18 hours, Multips 2-10 hours
Full cervical dilation
Three Stages of Labor: Second ?
From full cervical dilation to delivery of infant
Primips 30 mins to 3 hours, Multips 5-30 minutes
** delivery of infant**
Three Stages of Labor: Third ?
From delivery of infant to delivery of placenta
0-30 minutes for all
delivery of placenta
First Stage- general information ?
Okay to ambulate, sit in a chair or lie on her side
Liquids and ice chips okay, no solid foods
Manage the pain as patient requests
-Breathing, yoga, medication
First Stage - fetal monitoring ?
continuous or intermittent
First Stage: Cervical effacement (thinning) and dilation checks every _______ during active phase (fewer if membranes have ruptured) and if more dilated then more frequently
2 hours
** less frequent if ROM cause introduction of bacteria **
**while she is dilating then its okay for her to walk around etc, no eating incase she needs anesthesia cause then she can aspirate **
Effacement definition ?
the gradual thinning, shortening and drawing up of the cervix measured in percentages from 0-100%
Dilation definition ?
the gradual opening of the cervix measured in centimeters from 0-10 cms
Second stage: Mother often feels need to ________ with each contraction
bear down
Second Stage: Abdominal pressure plus contractions help to _______.
expel fetus
***when the baby is being expelled and she will fell the need to bear down
might have to tell them not to push to avid tearing **
Determining Presentation: Where 4 sutures join = ?
anterior fontanelle
**figure out which fontanel is which way , feel for the 4 / 3 sutures or feel for the ear to tell which way the baby is presenting **
Determining Presentation: Where 3 join = ?
posterior fontanelle
** Or feel for an ear and note direction of pinna**
Determining Presentation MC is ?
Vertex
crown of the head first
Cardinal movements of labor ? If they in Vertex position.
Engagement ( settling into the rim)
Flexion o the neck
Descent
Internal Rotation
Extension
External Rotation (Restitution) - twisting as they come out
Expulsion
**and they go in the order
these are to fit the shoulder through the pubic bone**
Cardinal Movements of Labor: Flexion of the fetal neck aids in ?
engagement and descent
Cardinal Movements of Labor: Descent is affected by and continues until ?
affected by force of contraction and thinning of the lower uterine segment.
Descent continues until delivery is complete
** takes time for the tissues to change **
Cardinal Movements of Labor: internal rotation ?
When head is down to midpelvis, it rotates to pass beneath the pubic symphysis
Cardinal Movements of Labor: Extension of the ftal neck because?
vaginal outlet is directed upward and forward
During extension of the fetal neck the ________ blues and the the head crowns
Perineum
_________ is when the largest diameter of the head is encircled by vulvar ring
Crowning
**maybe a episiotomy so the head does fit **
Delivery - general information ?
Minimize perineal trauma
Need a careful practitioner and controlled efforts of mother ( tell them not to push)
Routine episiotomy not necessary
Routine episiotomy not necessary because ?
More bleeding, risk of infection
When needed – angled cut preferred
Avoid extension to anal sphincter (3rd-degree)
Avoid extension to rectal mucosa (4th degree)
**angled cut to avoid the anal sphincter **
Episiotomy or Laceration: First degree ?
vaginal mucous membrane and skin of perineum
**1st is MC if they happen at all **
Episiotomy or Laceration: Second degree ?
SubQ tissue of the perineal body
Episiotomy or Laceration: Third degree ?
Involves fibers of the external rectal sphincter
Episiotomy or Laceration: Fourth degree ?
Through rectal sphincter exposing the lumen of the rectum
External Rotation: After delivery of the head, body______ _____ (external rotation) to position it had during engagement
rotates back
External Rotation: ___________ rotates internally under pubic arch
Anterior shoulder
External Rotation: Check for _____ ______ to slide off any cords
nuchal cords
Delivery of Shoulder: 6-7 After delivery of head, pull ____ on the baby’s head to deliver the ________ .
down
anterior shoulder
Delivery of Shoulder: after 6-7.. 8 Then pull __ on the baby’s head to deliver the ___________
up
posterior shoulder
Shoulder Dystocia ?
If shoulder is stuck, push fetus back in, in between contractions
Avoid stretching of brachial plexus ( only temporary damage if it is damaged)
Delivery: once the head is delivered - general ?
Clear airway of blood and amniotic fluid with bulb
suction
Mouth then nose
Check for nuchal cords
-Slip over head if possible, or cut cord between two clamps - dont want a rush of blood back to the baby
**delayed clamping = hyperbilirubinemia **
Delivery: once the head is delivered - Deliver anterior shoulder by gentle ________ traction of__________ rotated head
downward
externally
Delivery: once the head is delivered -Deliver posterior shoulder by gentle________ traction on the head
upward
Delivery: dont delay cord clamping because it can result in ?
too much blood to baby - hyperbilirubinemia
- Ideally give baby to mom, skin to skin
- Cut cord between two clamps
Repair of Lacerations ?
After baby is delivered, inspect cervix and vagina for lacerations. Repair perineum and any vaginal tears
Ideally, do repairs before placenta delivers as uterine bleeding will obscure view ( then it is hard to tell where the bleeding is coming form)
Repair of Lacerations: Sew up lacs with _______ absorbable material
2.0 or 3.0
Third Stage: Placenta often spontaneously separates with _____ mins (may take 30)
2-10
Third stage when the placenta is delivered: general ?
Fresh show of blood
Umbilical cord lengthens
Uterine fundus rises
Uterus becomes firm and globular
**may take 30 min - gives you time to sew up the epesiotomies **
Once you know you are in the third stage ______ traction on the cord is ok
gentle
Gentle uterine massage, +/- dilute oxytocin infusion
is okay during what stage ?
Third
NOT TO Hard cause it will collapse on itself
Uterine massage helps it to contract and stop bleeding
Induction and Augmentation of Labor is performed only after ?
appropriate assessment of mother and fetus
Induction and Augmentation of Labor: Fetus ?
-assess maturity
By dates or first trimester US measurements
By amniotic fluid analysis
-to make sure lungs are mature
Induction and Augmentation of Labor: Mother ?
Pelvic scoring to predict success of induction
Not electively done before 39 weeks
Earlier in certain indications like preeclampsia, DM, heart disease
Induction of Labor: absolute contraindications ?
Placenta previa (complete)
Previous Classical Caesarean section (longitudinal uterine scar)
-not they are traverse to avoid a uterine rupture
Myomectomy entering endometrium
-if a fibroid has been removed - increase risk of UR
Transverse lie of fetus
Induction of Labor: relative contraindications ?
Breech lie
Oligohydramnios - not enough amniotic fluid
Multiple gestation
Previous Caesarean section with transverse uterine scar
Macrosomia - baby is to big
Potential Complications of Induction: for the mother ?
Failure of induction and need for C-section
Uterine inertia and prolonged labor
-they dont have the contractions that are going to expel the baby
Rapid labor with premature placental separation, uterine rupture, cervical and vulvar laceration
Intrauterine infection
Postpartum hemorrhage
Potential Complications of Induction: for the fetus ?
Risk of prematurity
Physical injury with rapid delivery
Prolapse of cord
-cord comes first and it is tamponeded by the head
FHR abnormalities or poor
APGAR scores
Cervical Ripening can facilitate onset and progression of _____ when done before ________
labor
induction
Cervical Ripening: prostaglandin ?
Misoprostol - tablets PO, PV, PR
-cervix to dilated
Dinoprostone topical gel
Cervical Ripening: balloon catheter ?
Level of internal os, stretch cervix
Cervical Ripening: hygroscopic dilators ?
Absorb water from cervical tissues - thins it out so it started to dilate
Seaweed or synthetic sponge
Methods of Labor Induction: oxytocin ?
Dilute IV solution, individually dosed
Increases the inherent rhythmic pattern of uterine motility
Methods of Labor Induction: amniotomy ?
Rupturing membranes with amniohook
Shortens muscle bundles of myometrium – increased strength and duration of contractions
Only done once active labor has begun
Can increase risk of infection
**when the hook is placed it removes the amniotic fluid which shrinks the U and this engaged the muscle fibers to start contracting **
Multiple Gestation: general ?
Increasing incidence – now 3% of all pregnancies
Assisted Reproductive Technology (ART) – 25% have twins
M&M higher with multiple gestation
In 20% of twin pregnancies, one spontaneously disappears
Twins can be monozygotic or dizygotic
**100% increase from 1980 - 2004 because of assisted fertility **
Monozygotic Twins ?
Division of a single fertilized ovum (“identical”) - single sac
Always same sex, but may develop differently cause they are from the same egg
Often mirror images of each other, but fingerprints are different
Identicality depends on timing of split – could have one with Down Syndrome, one without
Triplets: Monozygotic triplets – ________________ of single ovum
Supertwinning
- *one egg that divided and that one divided
- *
Trizygotic triplets – _ eggs
3
Or triplets from 2 sets of twins, and one is lost
Monozygotic Multiple Gestation: Dichorionic, diamniotic – ?
decidua layer between chorions -
**MC then monoamnitoic
Monozygotic Multiple Gestation: Monochorionic, diamniotic – ?
no decidua between
Monozygotic Multiple Gestation: Monoamniotic - ?
more twisting and cord entanglement
One chorion means one ?
placenta
___ chorions – can have “fused” placenta or double placenta
Two
Late division (days 13-15) can mean incomplete twinning – ________?
conjoined
Division after _____, two heads, one body
day 15
Monochorionic monozygotic ?
Rarest type
Risk of cord entanglement
Risk of twin-twin transfusion
-Shunting of blood through vascular anastomoses
placenta has a antatamosis between it ( veined artery) one has to much blood (HTN) and the other is small and dehydrated and malnourished - both can die
Bad when anastomosis is artery-vein
Recipient is hypertensive, with ascites and kernicterus
Donor is small, dehydrated, malnourished
Both may die
Twin-Twin Transfusion Syndrome ?
shunting of blood and one over develops and one is under developed
a complication of disproportionate blood supply, resulting in high morbidity and mortality. It can affect monochorionic multiples, that is, multiple pregnancies where two or more fetuses share a chorion and hence a single placenta. Severe TTTS has a 60–100% mortality rate.
Dizygotic Multiple Gestation - general information ?
“Fraternal Twins” – two ova
70% of twins are dizygotic
1 in 83 conceptions in North America
Heredity plays a role, and more common in African Americans, least common in Asians
Increased incidence with age, ART (assisted reproductive technology) and in pregnancies soon after long term OCs
Increased incidence if prior multiple pregnancy
Two chorions
May have fused or double placenta
Clinical Findings and Complications of twining ?
Rare for multiple gestation to go undiagnosed with use of US
-Can diagnose as early as 4-5 weeks ( two gestational sacs)
Increased incidence of maternal anemia, UTI, GDM, preeclampsia/eclampsia, hemorrhage and uterine atony, placenta previa, abruption
Increased incidence of operative delivery
-Due to malpresentation, prolapsed cord and fetal distress
Increased perinatal M&M
- More preterm labor, ave 36-37 weeks for twins
- More developmental anomalies – IUGR, cord compression, placental insufficiency
- Malpresentation more common
- Need more vigilant prenatal care
**one is vertex position and one in breech - high chance of c section
atony cause the muscle fibers are stretched and the muscles cannot contract **
Prevention of twining ?
Clomiphene citrate (Clomid) increases rate of dizygotic twins by 5-10%
Embryo transfer, ovulation induction
- Many embryos to increase chance
- If too many survive transfer, maybe none will make it to term
- Multifetal reduction???
**injecting CaCl to kill some of them off **
Disproportionate Fetal Growth: Intrauterine Growth Restriction (IUGR) - fetus ?
< 10th percentile of fetal weight
SGA - once it is born - small gestational age
still birth, hypoxia, SIDs, learning and behavior problems, lower IQ, seizures = complications
Disproportionate Fetal Growth: Large for Gestational Age (LGA) ?
> 90th percentile of fetal weight
Disproportionate Fetal Growth: general ?
Too big, too small or just right?
Both extremes are associated
with ↑ perinatal M&M
Intrauterine Growth Restriction (IUGR): general ?
IUGR applies to fetus
Small for gestational age (SGA) applies to infant - born infant
70% of fetuses below the 10th percentile are simply ________________ small and ____________.
constitutionally
nonpathologic
Intrauterine Growth Restriction (IUGR) can be due to ?
Fetoplacental causes
Maternal factors
Fetoplacental Causes of IUGR ?
Congenital abnormalities – 1/3 of cases of IUGR
Congenital infections
Placental factors
Multiple gestation
Fetoplacental Causes of IUGR: Congenital abnormalities ?
Trisomy 21 (Down syndrome)
Trisomy 18 (Edward’s syndrome)
Trisomy 13
Neural tube defects
Fetoplacental Causes of IUGR: Congenital infections ?
Chronic intrauterine cytomegalovirus (CMV)
Congenital rubella, especially in 1st trimester
Other viruses (herpes, varicella, influenza, polio) but few cases
Fetoplacental Causes of IUGR: Placental factors ?
Placenta previa – unfavorable site of placental implantation
Placental infarction
Premature placental separation (abruption) - just a portion
Single umbilical artery instead of 2
Uterine anomalies
Fetoplacental Causes of IUGR: Multiple gestation ?
Usually due to placental insufficiency (monochorionic vs. dichorionic placenta) - not enough room
Maternal Factors of IUGR ?
HTN
Drugs
Malnutrition / malabsorption
vascular disease / hypoxia
maternal features
sex of fetus
Maternal Factors of IUGR: HTN ?
Decreased oxygen and nutrients to placenta and fetus
Can cause placental infarction
Maternal Factors of IUGR: Drugs ?
Alcohol, SMOKING (1/3 of IUGR cases), heroin, cocaine
Teratogens, warfarin, beta-blockers
**quiting smoking at 16 weeks almost no risk but stopping at any time even after 7 mo will still help the baby grow **
Maternal Factors of IUGR: Malnutrition / malabsorption ?
IBD, maternal eating disorders
Maternal Factors of IUGR: vascular disease / hypoxia ?
Collagen vascular disease, IDDM, preeclampsia, pulm disease
Maternal Factors of IUGR: maternal features ?
Small mom, first born
Maternal Factors of IUGR: sex of fetus ?
Females about 5% smaller
IUGR - Prevention
Many causes are not preventable, but smoking is the single most preventable cause
Balanced nutrition
Avoid contacts with CMV, rubella
Avoid cat feces and uncooked meat (Toxoplasmosis)
Review meds
Treat HTN
Correct anemia
Treat IBD, but hopefully under control before pregnancy starts
adequate prenatal care
IUGR – Clinical Findings ?
Lagging fundal height may be first sign. If more than 2 cm behind, do US to check amniotic volume and estimated fetal weight (EFW) ( not super accurate cause it is by length measurements)
US measurements helpful in predicting EDC and possible IUGR
US measurements helpful in predicting EDC and possible IUGR by ?
EFW is an estimation, though
Crown-rump length – for dates in first trimester
BPD and HC – best for second trimester
-Biparietal diameter - to see if they are the right size for dates
Abdominal circumference – most sensitive for growth restriction
IUGR – Maternal and Fetal Complications ?
Premature labor
Preeclampsia
Increased need for C-section
Perinatal M&M, though decreasing due to antenatal surveillance
Hypoxia
Metabolic acidosis
Meconium aspiration
Seizures, sepsis, hypoglycemia, apneic episodes
IUGR - Treatment ?
Careful surveillance 1-2 x week
-NL every 4 weeks
Bedrest is not helpful
Caesarean delivery often necessary
IUGR -Prognosis: maternal risk ?
only if underlying problem like HTN or renal disease
IUGR -Prognosis: Fetal risk ?
high
Thermodysregulation, hypoglycemia, polycythemia, ↓ immunity
IUGR: long term prognosis ?
Weight catches up by 6 months, but tend to remain smaller and shorter ( there whole life), lighter and ↓ HC
More neurologic and intellectual deficits
More deaths due to SIDS
-sudden infant death syndrome
As adults, increased risk for heart disease
LGA - EFW ?
EFW above 90th percentile for gestational age
Macrosomia - EFW ?
EFW 4500g or more, regardless of gest age
9 lb, 14.7 oz
Maternal Factors for LGA and Macrosomia ?
DIABETES!
- Need mom’s PP BG <104
- tell them the risk so they are more likely to comply
Maternal obesity
Postdatism (overdue)
Genetic and Congenital D/O - disorders
Constitutionally large fetus
- Tall mom
- Male fetus (~150g heavier)
Maternal weight gain
-Excessive (+40 lbs)
Macrosomia RF ?
Multiparity
Previous macrosomic infant
Advanced maternal age
Macrosomia prevention ?
Control maternal glucose levels
Monitor maternal weight gain
Macrosomia - Complications ?
↑ need for Caesarean
Especially primigravidas
-Prolonged labor, postpartum hemorrhage
Shoulder dystocia
Brachial plexus injury, fx clavicle, facial nerve injury
-tugging on head to get baby out and they generally resolve spontaneously
Perineal trauma - ↑ risk of laceration
Stillbirth
Macrosomia - Treatment ?
Labor induction has NOT reduced risk of shoulder dystocia
C- Section - NOT proven to reduce risk
Monitor labor progression
- decide individually
- avoid vacuum-assisted delivery
Macrosomia - Prognosis ?
Educate woman – next pregnancy has 2.5-4 fold increased risk for another LGA baby
Obese woman should lose weight prior to pregnancy
If hx of LGA infant, next pregnancy seek early care to confirm dates and avoid postdatism
Infants of mothers with gestational or pre-gestational diabetes are at increased risk for obesity, Type II DM or both
Malpresentation ?
Breech presentation occurs when fetal pelvis or lower extremities engage the maternal pelvic inlet
3-4% of all pregnancies
Three types of breech ?
Frank
complete
footling
Breech: franks ?
hips flexed, knees extended
Breech: complete ?
hips and knees are flexed
Breech: footling ?
(single or double) leg(s) is/are extended
Breech Position and Station ?
Position is determined by using the fetal sacrum
-INSTEAD OF THE fontanels use the sacrum of the fetus
Station is determined by using the level of the fetal sacrum
Pathogenesis of Breech ?
Before 28 weeks, fetus can move around with relative ease
Most assume cephalic presentation
Breech occurs when ?
Spontaneous cephalic presentation is prevented
Premature L&D ( labor and delivery)
Olighydramnios - not enough room to move around , not a nice pool to swim in
Uterine anomalies - spectate or bicountae
Pelvic tumors
Abnormal placenta location - previa
Multiparity
Congenital malformations (altered fetal muscular tone and mobility)
Leopold’s Maneuvers assess ?
the position of the baby
Leopold’s Maneuvers: most accurate after ?
36 weeks
Leopold’s Maneuvers: first ?
Stand at side, face woman’s head
Palpate fundus
Leopold’s Maneuvers: second ?
Stand at side, face woman’s head
Palpate sides of uterus
- *2 - palpate the sides and the fundus
- *
Leopold’s Maneuvers: third ?
Stand at side, face woman’s head
Palpate the presenting part above the pubic symphysis
** 3 - right above the physis **
Leopold’s Maneuvers: fourth ?
Face woman’s feet
Palpate sides, flex fetus’ head
Breech Complications: breech anoxia ?
Cord can prolapse below presenting part, especially in footling and complete breech
Cord compression can show variable decelerations
Breech Complications: birth injury ?
Partially dilated cervix – body fits through, head does not
Nuchal arms – arm(s) lodge behind neck
Deflexion of the head – AKA hyperextension of head, occiput impacted behind pubic bone
head can get stuck
Type of delivery – need experienced providers, quick but not too quick
External Cephalic Version ?
If breech persists beyond 36 weeks in singleton pregnancy, consider external cephalic version
60% success rate
Can’t be done once engagement occurs
-the butt is already down in the birth canal
+/- anesthesia (epidural)
Complications are rare, but can be severe
-placental ruptured …….
Ensure no fetal or uterine abnormalities first
Forward or backward roll
Delivery of Breech ?
Vaginal vs. Caesarean is individualized and dependent on many factors
Delivery of Breech: vaginal ?
Increasingly larger diameters (hips, shoulders, head)
May need assistance (pressure on fundus, rotation of baby)
Increasing use of C-section since particular skill is needed for vaginal delivery of breech
Shoulder Dystocia - general information ?
Inability to deliver the shoulders after the head has been delivered
Anterior shoulder impacted behind the pubic symphysis
Obstetric emergency
Several maneuvers to try or episiotomy
Shoulder Dystocia RF ?
Macrosomia
Gestational DM, DM
Prolonged second stage of labor
Prior hx of shoulder dystocia
Maternal obesity
Idiopathic
Shoulder Dystocia: fetus at risk of asphyxiation ?
Cannot expand chest to breathe
Cord compressed
Shoulder Dystocia complications ?
Humeral fx
Erb’s palsy - injury to brachial plexus
Umbilical Cord Prolapse: Occult prolapse ?
cord is adjacent to presenting part -
dont know it is going to happen
Umbilical Cord Prolapse:Overt prolapse ?
cord is below presenting part with ROM
Overt associated with 20% perinatal mortality –
emergency !
we see it first
Umbilical Cord Prolapse: Funic presentation ?
cord is below presenting part but before ROM (palpable)
Cord Prolapse is more often seen with ?
premature deliveries - cause more room around the head
breech
transverse - more likely the cord can wall though
polyhydramnios
amniotomy
PROM
Cord is compressed by ?
fetus
vasospasm from exposure to air - less blood supply as well
Umbilical Cord Prolapse: complications ?
Fetal – bradycardia, hypoxia, metabolic acidosis, death
Maternal – C-section risks, hasty delivery lacerations
Umbilical Cord Prolapse: Treatment of Overt ?
Lift presenting part up off cord until C-section prep complete - take pressure off as much a possible
Do not push cord back in
Umbilical Cord Prolapse: Treatment of Occult ?
Reposition mother in lateral or Trendelenburg position
Vaginal vs C-section depends on response to repositioning
-get weight off cord
Umbilical Cord Prolapse: Treatment of Funic ?
Reposition mother
If not successful, C-section before ROM
Prognosis – mom does well, fetus is variable. Good if <5 mins occlusion
Operative Delivery definition ?
Defined as active measures taken to accomplish delivery
Operative Delivery types ?
Forceps
Vacuum Extractor
Caesarean Section
Forceps - general ?
For traction on the head or rotation of the head
Decreasing use
**over 60 different types **
Forceps indications ?
Non-reassuring FHR pattern
To shorten 2nd stage of labor for maternal reasons
Delivery of head in a breech delivery
**gets things moving along
Forceps should never be used if head is not ______
engaged
Application of Forceps ?
Assure that they articulate easily before applying
Finesse more than force
-If much force is needed, may have CPD
Apply traction in the path of least resistance, following pelvic curve
Forceps Risks ?
Maternal lacerations of vagina and cervix
Episiotomy extension
Pelvic hematoma
Urethral and bladder injury
Uterine rupture
Fetal lacerations
Facial and brachial plexus palsies
Skull fracture
Cephalohematoma
Intracranial hemorrage
Seizures
Vacuum Extractor - general information ?
First in 1890, resembling a toilet plunger
Today a pliable cup with handheld pump and gauge
Causes traction on the scalp and compression of the head
Vacuum Extractor indications ?
similar to forceps except for delivery of head in breech
Vacuum Extractor contrindications ?
Face presentation, breech, CPD (cephalopelvic disproportion - wont fit either way) , congenital anomalies of the head, <34 weeks, unengaged head, suspected bleeding disorders
Vacuum Extractor - general information continued ?
Place cup on head, ensure no maternal tissue under it
Increased suction pressure and traction during a contraction
Should not be used to rotate the head
Cervix must be fully dilated
Beware of shoulder dystocia
1998 – US FDA issued Public Advisory Statement
- Can cause serious injury if used incorrectly
- Should only be used by those aware of indications/contraindications
Vacuum-related Injuries ?
Benign to severe
Scalp markings
Intracranial hemorrhage – can be catastrophic
Retinal hemorrhage (most common) but rarely significant
Cephalohematoma – bleeding below periosteum
Subgaleal hematoma – bleeding in scalp tissue, can be large - it can cross suture lines ( can involve half of the neonates blood volume)
- *bleeding below the periosteum - injurt from the vacuum
- *
Caesarean Section ?
Delivery of fetus, placenta and membranes through an abdominal and uterine incision
Increased use with less maternal mortality
**used more and more cause it is more controlled , transverse incision instead of longitudinal
Caesarean Section indications ?
Repeat C section
CPD
Dystocia
Abnormal fetal lie and malpresentation
FHR abnormalities
Other
Caesarean Section indications: repeat C section ?
Not always necessary, but for some patients
Caesarean Section indications: CPD ?
Head too large, head does not engage
Caesarean Section indications: Dystocia ?
Labor stops or does not progress
Caesarean Section indications: Abnormal fetal lie and malpresentation ?
Transverse and beech
Caesarean Section indications: FHR abnormalities ?
Non-reassuring patterns on fetal monitor
Caesarean Section indications: Other ?
Placenta previa, preeclampsia/eclampsia, abruption, multiple gestation, fetal abnormalities, cervical cancer, active genital herpes, overt cord prolapse as well
C section procedure: abdominal incision ?
Most use transverse (Pfannenstiel) unless speed is necessary
C section procedure: Uterine incision - classic ?
Vertical incision
Simplest, but greater blood loss and greater risk of uterine rupture
Used in placenta previa and preterm delivery and emergent delivery
C section procedure: Uterine incision - Low transverse ?
More frequently used
Less blood loss, less risk of future rupture
Safer for VBAC – vaginal birth after Caesarean
**MC = bikini lies **
C section complications ?
Postpartum hemorrhage
Endometritis – less incidence if ATB’s prior to skin incision
Wound infection
**alot more blood loss **
C section complications: baby ?
Transient tachypnea more common
If placenta is transected, risk of fetal hemorrhage and hypoxia
Lacerations – need to incise uterus carefully
C section: procedure - deliver the baby ?
Massage the uterus to allow for spontaneous placental separation
Deliver placenta, additional massage and oxytocin
Close uterine incision
-3 layers to prevent rupture in case of future pregnancy
**delivery of the baby is quick it is the repair that takes a little longer **
Vaginal Birth After Cesarean (VBAC) AKA ?
Also called TOLAC – trial of labor after cesarean
VBAC: Calculators available online that consider
?
Demographics of mother (age, BMI, ethnicity, etc.)
Previous VBAC, etc.
VBAC - general information ?
Not for everyone
Could reduce percentage of C sections in second pregnancy from 70% to 25%
