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Patient Evaluation > Normal Labor and Delivery Labor and Delivery Complications / Operative Delivery > Flashcards

Normal Labor and Delivery Labor and Delivery Complications / Operative Delivery Flashcards

1
Q

Labor and Delivery - general information ?

A

Normal physiologic process

Most experience no complications

Goal is to offer a safe and supportive environment

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2
Q

Physiologic Preparation for Labor: Lightening ?

A

Settling of head into brim of pelvis

2-3 weeks before labor in primips

Less heartburn, SOB, but increased frequency of urination

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3
Q

Physiologic Preparation for Labor: Braxton Hicks contractions ?

A

Last 4-8 weeks of pregnancy

Painless, but increasing intensity

No cervical change

**false contractions, just tightening, not painful **

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4
Q

Physiologic Preparation for Labor: “Bloody show” ?

A

Days to weeks before true labor

Cervix softens and begins to dilate

Passage of mucus plug, sometimes blood-tinged

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5
Q

Evaluation at Presentation: best outcomes with ?

A

adequate prenatal care

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6
Q

Evaluation at Presentation

A

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

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7
Q

Labor Pain: Intensity dependent on ?

A

Fetal/pelvic relationship

Quality and strength of contractions

Emotional and physical status of patient

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8
Q

Labor Pain: Typically most intense discomfort is during ?

A

Dilation of the lower birth canal

Distention of the perineum

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9
Q

Pain Control during and for lab ?

A

IV medications

Pudendal nerve block

Epidural

Spinal

General

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10
Q

Engagement: Head enters _______ _____ ?

A

superior strait

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11
Q

Engagement: Usually occiput ________ position (70%)

A

transverse

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12
Q

Engagement: But it depends on dimensions and contours of birth canal - what 4 types ?

A

Gynecoid

Android

Platypelloid

Anthropoid

**anterior and posterior fontanell and you can palpate them to tell the orientation of the baby **

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13
Q

Pelvic Types: Shape of pelvic outlet helps determine position of _________ .

A

engagement

-Path of least resistance

**helps determine the path of the baby the will most likely assume

Anthropoid - head will fit more anterior/ posterior **

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14
Q

Pelvic types ?

A

Gynecoid

Platypelloid

Android

Anthropoid

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15
Q

Engagement: Presenting part enters ?

A

birth canal

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16
Q

Engagement: Station ?

A

descent of fetal head is measured to assess progress

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17
Q

Station is measured in relationship to ?

A

ischial spines

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18
Q

When leading portion of head is at level of ischial spines = ?

A

0 station (engaged)

**ishial spine = 0 station ( fully engaged) **

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19
Q

When 2 cms above spines = ?

A

-2 station

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20
Q

When 3 cms below spines = ?

A

+3 station

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21
Q

Three Stages of Labor: First ?

A

Two phases – latent and active

From onset of labor to full cervical dilation

Primips 6-18 hours, Multips 2-10 hours

Full cervical dilation

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22
Q

Three Stages of Labor: Second ?

A

From full cervical dilation to delivery of infant

Primips 30 mins to 3 hours, Multips 5-30 minutes

** delivery of infant**

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23
Q

Three Stages of Labor: Third ?

A

From delivery of infant to delivery of placenta

0-30 minutes for all

delivery of placenta

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24
Q

First Stage- general information ?

A

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

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25
Q

First Stage - fetal monitoring ?

A

continuous or intermittent

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26
Q

First Stage: Cervical effacement (thinning) and dilation checks every _______ during active phase (fewer if membranes have ruptured) and if more dilated then more frequently

A

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 **

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27
Q

Effacement definition ?

A

the gradual thinning, shortening and drawing up of the cervix measured in percentages from 0-100%

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28
Q

Dilation definition ?

A

the gradual opening of the cervix measured in centimeters from 0-10 cms

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29
Q

Second stage: Mother often feels need to ________ with each contraction

A

bear down

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30
Q

Second Stage: Abdominal pressure plus contractions help to _______.

A

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 **

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31
Q

Determining Presentation: Where 4 sutures join = ?

A

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 **

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32
Q

Determining Presentation: Where 3 join = ?

A

posterior fontanelle

** Or feel for an ear and note direction of pinna**

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33
Q

Determining Presentation MC is ?

A

Vertex

crown of the head first

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34
Q

Cardinal movements of labor ? If they in Vertex position.

A

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**

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35
Q

Cardinal Movements 
of Labor: Flexion of the fetal neck aids in ?

A

engagement and descent

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36
Q

Cardinal Movements 
of Labor: Descent is affected by and continues until ?

A

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 **

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37
Q

Cardinal Movements 
of Labor: internal rotation ?

A

When head is down to midpelvis, it rotates to pass beneath the pubic symphysis

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38
Q

Cardinal Movements 
of Labor: Extension of the ftal neck because?

A

vaginal outlet is directed upward and forward

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39
Q

During extension of the fetal neck the ________ blues and the the head crowns

A

Perineum

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40
Q

_________ is when the largest diameter of the head is encircled by vulvar ring

A

Crowning

**maybe a episiotomy so the head does fit **

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41
Q

Delivery - general information ?

A

Minimize perineal trauma

Need a careful practitioner and controlled efforts of mother ( tell them not to push)

Routine episiotomy not necessary

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42
Q

Routine episiotomy not necessary because ?

A

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 **

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43
Q

Episiotomy or Laceration: First degree ?

A

vaginal mucous membrane and skin of perineum

**1st is MC if they happen at all **

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44
Q

Episiotomy or Laceration: Second degree ?

A

SubQ tissue of the perineal body

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45
Q

Episiotomy or Laceration: Third degree ?

A

Involves fibers of the external rectal sphincter

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46
Q

Episiotomy or Laceration: Fourth degree ?

A

Through rectal sphincter exposing the lumen of the rectum

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47
Q

External Rotation: After delivery of the head, body______ _____ (external rotation) to position it had during engagement

A

rotates back

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48
Q

External Rotation: ___________ rotates internally under pubic arch

A

Anterior shoulder

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49
Q

External Rotation: Check for _____ ______ to slide off any cords

A

nuchal cords

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50
Q

Delivery of Shoulder: 6-7 After delivery of head, pull ____ on the baby’s head to deliver the ________ .

A

down

anterior shoulder

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51
Q

Delivery of Shoulder: after 6-7.. 8 Then pull __ on the baby’s head to deliver the ___________

A

up

posterior shoulder

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52
Q

Shoulder Dystocia ?

A

If shoulder is stuck, push fetus back in, in between contractions

Avoid stretching of brachial plexus ( only temporary damage if it is damaged)

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53
Q

Delivery: once the head is delivered - general ?

A

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 **

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54
Q

Delivery: once the head is delivered - Deliver anterior shoulder by gentle ________ traction of__________ rotated head

A

downward

externally

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55
Q

Delivery: once the head is delivered -Deliver posterior shoulder by gentle________ traction on the head

A

upward

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56
Q

Delivery: dont delay cord clamping because it can result in ?

A

too much blood to baby - hyperbilirubinemia

  • Ideally give baby to mom, skin to skin
  • Cut cord between two clamps
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57
Q

Repair of Lacerations ?

A

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)

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58
Q

Repair of Lacerations: Sew up lacs with _______ absorbable material

A

2.0 or 3.0

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59
Q

Third Stage: Placenta often spontaneously separates with _____ mins (may take 30)

A

2-10

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60
Q

Third stage when the placenta is delivered: general ?

A

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 **

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61
Q

Once you know you are in the third stage ______ traction on the cord is ok

A

gentle

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62
Q

Gentle uterine massage, +/- dilute oxytocin infusion

is okay during what stage ?

A

Third

NOT TO Hard cause it will collapse on itself

Uterine massage helps it to contract and stop bleeding

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63
Q

Induction and Augmentation of Labor is performed only after ?

A

appropriate assessment of mother and fetus

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64
Q

Induction and Augmentation of Labor: Fetus ?

A

-assess maturity

By dates or first trimester US measurements

By amniotic fluid analysis
-to make sure lungs are mature

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65
Q

Induction and Augmentation of Labor: Mother ?

A

Pelvic scoring to predict success of induction

Not electively done before 39 weeks

Earlier in certain indications like preeclampsia, DM, heart disease

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66
Q

Induction of Labor: absolute contraindications ?

A

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

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67
Q

Induction of Labor: relative contraindications ?

A

Breech lie

Oligohydramnios - not enough amniotic fluid

Multiple gestation

Previous Caesarean section with transverse uterine scar

Macrosomia - baby is to big

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68
Q

Potential Complications of Induction: for the mother ?

A

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

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69
Q

Potential Complications of Induction: for the fetus ?

A

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

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70
Q

Cervical Ripening can facilitate onset and progression of _____ when done before ________

A

labor

induction

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71
Q

Cervical Ripening: prostaglandin ?

A

Misoprostol - tablets PO, PV, PR
-cervix to dilated

Dinoprostone topical gel

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72
Q

Cervical Ripening: balloon catheter ?

A

Level of internal os, stretch cervix

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73
Q

Cervical Ripening: hygroscopic dilators ?

A

Absorb water from cervical tissues - thins it out so it started to dilate

Seaweed or synthetic sponge

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74
Q

Methods of Labor Induction: oxytocin ?

A

Dilute IV solution, individually dosed

Increases the inherent rhythmic pattern of uterine motility

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75
Q

Methods of Labor Induction: amniotomy ?

A

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 **

76
Q

Multiple Gestation: general ?

A

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 **

77
Q

Monozygotic Twins ?

A

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

78
Q

Triplets: Monozygotic triplets – ________________ of single ovum

A

Supertwinning

  • *one egg that divided and that one divided
  • *
79
Q

Trizygotic triplets – _ eggs

A

3

Or triplets from 2 sets of twins, and one is lost

80
Q

Monozygotic Multiple Gestation: Dichorionic, diamniotic – ?

A

decidua layer between chorions -

**MC then monoamnitoic

81
Q

Monozygotic Multiple Gestation: Monochorionic, diamniotic – ?

A

no decidua between

82
Q

Monozygotic Multiple Gestation: Monoamniotic - ?

A

more twisting and cord entanglement

83
Q

One chorion means one ?

A

placenta

84
Q

___ chorions – can have “fused” placenta or double placenta

A

Two

85
Q

Late division (days 13-15) can mean incomplete twinning – ________?

A

conjoined

86
Q

Division after _____, two heads, one body

A

day 15

87
Q

Monochorionic monozygotic ?

A

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

88
Q

Twin-Twin Transfusion Syndrome ?

A

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.

89
Q

Dizygotic Multiple Gestation - general information ?

A

“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

90
Q

Clinical Findings and Complications of twining ?

A

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 **

91
Q

Prevention of twining ?

A

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 **

92
Q

Disproportionate Fetal Growth: Intrauterine Growth Restriction (IUGR) - fetus ?

A

< 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

93
Q

Disproportionate Fetal Growth: Large for Gestational Age (LGA) ?

A

> 90th percentile of fetal weight

94
Q

Disproportionate Fetal Growth: general ?

A

Too big, too small or just right?

Both extremes are associated
with ↑ perinatal M&M

95
Q

Intrauterine Growth Restriction (IUGR): general ?

A

IUGR applies to fetus

Small for gestational age (SGA) applies to infant - born infant

96
Q

70% of fetuses below the 10th percentile are simply ________________ small and ____________.

A

constitutionally

nonpathologic

97
Q

Intrauterine Growth Restriction (IUGR) can be due to ?

A

Fetoplacental causes

Maternal factors

98
Q

Fetoplacental Causes of IUGR ?

A

Congenital abnormalities – 1/3 of cases of IUGR

Congenital infections

Placental factors

Multiple gestation

99
Q

Fetoplacental Causes of IUGR: Congenital abnormalities ?

A

Trisomy 21 (Down syndrome)

Trisomy 18 (Edward’s syndrome)

Trisomy 13

Neural tube defects

100
Q

Fetoplacental Causes of IUGR: Congenital infections ?

A

Chronic intrauterine cytomegalovirus (CMV)

Congenital rubella, especially in 1st trimester

Other viruses (herpes, varicella, influenza, polio) but few cases

101
Q

Fetoplacental Causes of IUGR: Placental factors ?

A

Placenta previa – unfavorable site of placental implantation

Placental infarction

Premature placental separation (abruption) - just a portion

Single umbilical artery instead of 2

Uterine anomalies

102
Q

Fetoplacental Causes of IUGR: Multiple gestation ?

A

Usually due to placental insufficiency (monochorionic vs. dichorionic placenta) - not enough room

103
Q

Maternal Factors of IUGR ?

A

HTN

Drugs

Malnutrition / malabsorption

vascular disease / hypoxia

maternal features

sex of fetus

104
Q

Maternal Factors of IUGR: HTN ?

A

Decreased oxygen and nutrients to placenta and fetus

Can cause placental infarction

105
Q

Maternal Factors of IUGR: Drugs ?

A

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 **

106
Q

Maternal Factors of IUGR: Malnutrition / malabsorption ?

A

IBD, maternal eating disorders

107
Q

Maternal Factors of IUGR: vascular disease / hypoxia ?

A

Collagen vascular disease, IDDM, preeclampsia, pulm disease

108
Q

Maternal Factors of IUGR: maternal features ?

A

Small mom, first born

109
Q

Maternal Factors of IUGR: sex of fetus ?

A

Females about 5% smaller

110
Q

IUGR - Prevention

A

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

111
Q

IUGR – Clinical Findings ?

A

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

112
Q

US measurements helpful in predicting EDC and possible IUGR by ?

A

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

113
Q

IUGR – Maternal and Fetal Complications ?

A

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

114
Q

IUGR - Treatment ?

A

Careful surveillance 1-2 x week
-NL every 4 weeks

Bedrest is not helpful

Caesarean delivery often necessary

115
Q

IUGR -Prognosis: maternal risk ?

A

only if underlying problem like HTN or renal disease

116
Q

IUGR -Prognosis: Fetal risk ?

A

high

Thermodysregulation, hypoglycemia, polycythemia, ↓ immunity

117
Q

IUGR: long term prognosis ?

A

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

118
Q

LGA - EFW ?

A

EFW above 90th percentile for gestational age

119
Q

Macrosomia - EFW ?

A

EFW 4500g or more, regardless of gest age

9 lb, 14.7 oz

120
Q

Maternal Factors for LGA and Macrosomia ?

A

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)

121
Q

Macrosomia RF ?

A

Multiparity

Previous macrosomic infant

Advanced maternal age

122
Q

Macrosomia prevention ?

A

Control maternal glucose levels

Monitor maternal weight gain

123
Q

Macrosomia - Complications ?

A

↑ 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

124
Q

Macrosomia - Treatment ?

A

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
125
Q

Macrosomia - Prognosis ?

A

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

126
Q

Malpresentation ?

A

Breech presentation occurs when fetal pelvis or lower extremities engage the maternal pelvic inlet

3-4% of all pregnancies

127
Q

Three types of breech ?

A

Frank

complete

footling

128
Q

Breech: franks ?

A

hips flexed, knees extended

129
Q

Breech: complete ?

A

hips and knees are flexed

130
Q

Breech: footling ?

A

(single or double) leg(s) is/are extended

131
Q

Breech Position and Station ?

A

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

132
Q

Pathogenesis of Breech ?

A

Before 28 weeks, fetus can move around with relative ease

Most assume cephalic presentation

133
Q

Breech occurs when ?

A

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)

134
Q

Leopold’s Maneuvers assess ?

A

the position of the baby

135
Q

Leopold’s Maneuvers: most accurate after ?

A

36 weeks

136
Q

Leopold’s Maneuvers: first ?

A

Stand at side, face woman’s head

Palpate fundus

137
Q

Leopold’s Maneuvers: second ?

A

Stand at side, face woman’s head

Palpate sides of uterus

  • *2 - palpate the sides and the fundus
  • *
138
Q

Leopold’s Maneuvers: third ?

A

Stand at side, face woman’s head

Palpate the presenting part above the pubic symphysis

** 3 - right above the physis **

139
Q

Leopold’s Maneuvers: fourth ?

A

Face woman’s feet

Palpate sides, flex fetus’ head

140
Q

Breech Complications: breech anoxia ?

A

Cord can prolapse below presenting part, especially in footling and complete breech

Cord compression can show variable decelerations

141
Q

Breech Complications: birth injury ?

A

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

142
Q

External Cephalic Version ?

A

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

143
Q

Delivery of Breech ?

A

Vaginal vs. Caesarean is individualized and dependent on many factors

144
Q

Delivery of Breech: vaginal ?

A

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

145
Q

Shoulder Dystocia - general information ?

A

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

146
Q

Shoulder Dystocia RF ?

A

Macrosomia

Gestational DM, DM

Prolonged second stage of labor

Prior hx of shoulder dystocia

Maternal obesity

Idiopathic

147
Q

Shoulder Dystocia: fetus at risk of asphyxiation ?

A

Cannot expand chest to breathe

Cord compressed

148
Q

Shoulder Dystocia complications ?

A

Humeral fx

Erb’s palsy - injury to brachial plexus

149
Q

Umbilical Cord Prolapse: Occult prolapse ?

A

cord is adjacent to presenting part -

dont know it is going to happen

150
Q

Umbilical Cord Prolapse:Overt prolapse ?

A

cord is below presenting part with ROM

Overt associated with 20% perinatal mortality –
emergency !

we see it first

151
Q

Umbilical Cord Prolapse: Funic presentation ?

A

cord is below presenting part but before ROM (palpable)

152
Q

Cord Prolapse is more often seen with ?

A

premature deliveries - cause more room around the head
breech

transverse - more likely the cord can wall though

polyhydramnios

amniotomy

PROM

153
Q

Cord is compressed by ?

A

fetus

vasospasm from exposure to air - less blood supply as well

154
Q

Umbilical Cord Prolapse: complications ?

A

Fetal – bradycardia, hypoxia, metabolic acidosis, death

Maternal – C-section risks, hasty delivery lacerations

155
Q

Umbilical Cord Prolapse: Treatment of Overt ?

A

Lift presenting part up off cord until C-section prep complete - take pressure off as much a possible

Do not push cord back in

156
Q

Umbilical Cord Prolapse: Treatment of Occult ?

A

Reposition mother in lateral or Trendelenburg position

Vaginal vs C-section depends on response to repositioning
-get weight off cord

157
Q

Umbilical Cord Prolapse: Treatment of Funic ?

A

Reposition mother

If not successful, C-section before ROM

Prognosis – mom does well, fetus is variable. Good if <5 mins occlusion

158
Q

Operative Delivery definition ?

A

Defined as active measures taken to accomplish delivery

159
Q

Operative Delivery types ?

A

Forceps

Vacuum Extractor

Caesarean Section

160
Q

Forceps - general ?

A

For traction on the head or rotation of the head

Decreasing use

**over 60 different types **

161
Q

Forceps indications ?

A

Non-reassuring FHR pattern

To shorten 2nd stage of labor for maternal reasons

Delivery of head in a breech delivery

**gets things moving along

162
Q

Forceps should never be used if head is not ______

A

engaged

163
Q

Application of Forceps ?

A

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

164
Q

Forceps Risks ?

A

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

165
Q

Vacuum Extractor - general information ?

A

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

166
Q

Vacuum Extractor indications ?

A

similar to forceps except for delivery of head in breech

167
Q

Vacuum Extractor contrindications ?

A

Face presentation, breech, CPD (cephalopelvic disproportion - wont fit either way) , congenital anomalies of the head, <34 weeks, unengaged head, suspected bleeding disorders

168
Q

Vacuum Extractor - general information continued ?

A

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
169
Q

Vacuum-related Injuries ?

A

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
  • *
170
Q

Caesarean Section ?

A

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

171
Q

Caesarean Section indications ?

A

Repeat C section

CPD

Dystocia

Abnormal fetal lie and malpresentation

FHR abnormalities

Other

172
Q

Caesarean Section indications: repeat C section ?

A

Not always necessary, but for some patients

173
Q

Caesarean Section indications: CPD ?

A

Head too large, head does not engage

174
Q

Caesarean Section indications: Dystocia ?

A

Labor stops or does not progress

175
Q

Caesarean Section indications: Abnormal fetal lie and malpresentation ?

A

Transverse and beech

176
Q

Caesarean Section indications: FHR abnormalities ?

A

Non-reassuring patterns on fetal monitor

177
Q

Caesarean Section indications: Other ?

A

Placenta previa, preeclampsia/eclampsia, abruption, multiple gestation, fetal abnormalities, cervical cancer, active genital herpes, overt cord prolapse as well

178
Q

C section procedure: abdominal incision ?

A

Most use transverse (Pfannenstiel) unless speed is necessary

179
Q

C section procedure: Uterine incision - classic ?

A

Vertical incision

Simplest, but greater blood loss and greater risk of uterine rupture

Used in placenta previa and preterm delivery and emergent delivery

180
Q

C section procedure: Uterine incision - Low transverse ?

A

More frequently used

Less blood loss, less risk of future rupture

Safer for VBAC – vaginal birth after Caesarean

**MC = bikini lies **

181
Q

C section complications ?

A

Postpartum hemorrhage

Endometritis – less incidence if ATB’s prior to skin incision

Wound infection

**alot more blood loss **

182
Q

C section complications: baby ?

A

Transient tachypnea more common

If placenta is transected, risk of fetal hemorrhage and hypoxia

Lacerations – need to incise uterus carefully

183
Q

C section: procedure - deliver the baby ?

A

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 **

184
Q

Vaginal Birth After Cesarean (VBAC) AKA ?

A

Also called TOLAC – trial of labor after cesarean

185
Q

VBAC: Calculators available online that consider

?

A

Demographics of mother (age, BMI, ethnicity, etc.)

Previous VBAC, etc.

186
Q

VBAC - general information ?

A

Not for everyone

Could reduce percentage of C sections in second pregnancy from 70% to 25%

Patient Evaluation (29 decks)

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