Normal Labour And Delivery Dr. Moulton Flashcards
Fontenelles ant and post ossify when
Post = 8 week Ant = 8 months
Head of baby is well flexed when
The suboccipiotobregmatic diameter is 9.5cm (ANT fontenelle to bottom of occiput)
Occipitofrontal diameter and meaning
Supraoccipitomental diameter and meaning
- 11cm ( head deflexed) = post fontenelle to nose
2. 13.5 cm (brow presentation) = chin to post tip of head between fontenelles
Most common pelvis shape to least common and prognosis
- Gynecology = 50% most common, good prognosis
- Android = 30 % , bad prognosis (male shaped)
- Anthropoid = 20%, A/P largest, good prognosis
- Platypelloid = 3% bad prognosis
How to assess someone’s pelvis and how to know its good
- Diagonal conjugate = inf pubic symphysis ——> sacral promontory = 11.5cm or more = the AP diameter of pelvis inlet
- Obstetric conjugate = Diagonal conjugate - 2cm = narrowed distance fetal head must pass
- 8.5cm or more between ischial tuberosities
- Infrapubic angle : thumb on each pubic ramus to see (90 degrees or more)
Fetal lie and fetal presentation
- Fetal lie : longitudinal (vertex, breech) OR transverse or oblique
- Fetal Presentation : vertex, breech, transverse, compound (vertex + hand on head)
Leopold Maneuver is done how and for what
- Palpate fundus (head= harder, butt= softer)
- Palpate spine and small parts
- Palpate what is in the pelvis
- Palpate Cephalic prominence (chin or occipital prominence)
Dilation check how and diameter
At internal os (close to baby’s head)
= 10cm is completely dilated
Effacement
Cervix thinning changing its length = 3cm-5cm normal cervix , 100% effaced cervix you cant feel at all almost
Station is what
Degree the fetus has moved down from most up (5cm-) to most down (5cm+), head at level of ischial spines = 0cm
= -5 or -3 is very high and ou might need forceps
4 stages of labor and small summary of what happens
- Stage 1 : onset of true labor to cervical dilation complete, (latent + active phase )
- Stage 2 : complete dilating of cervix to delivery of infant
- Stage 3 : Delivary of infant to delivery of placenta
- Sage 4 : Delivery of placenta to stabilization of pt
Stage 1 : Latent stage vs active stage
- Latent = slow cervical dilations, intermittent slow getting closer together
- Active = when dilating is fast beginning around 6cm = admit pt for labor at this time**
= first stage takes 6hr-18hr(1st baby), 2hr-10hr(second baby)
Duration of cervical dilation of 1st baby and 2nd higher baby
- First baby = 1.2cm per hour dilation
- Not first baby = 1.5cm per hour dilation
= this is minimum more dilation can happen
How to manage stage 1
- . laying in bed = encourage left lateral recumbent
- Fluids IV + oxytocin
- CBC
- Monitor vitals every 1-2 hours
- Adequate analgesia
External Monitoring how often in complicated and uncomplicated pregnancy
Monitor fetal heart and contractions
- Uncomplicated : intermittent = every 30min (active phase), every 15min (second stage)
- Complicated : intermittent = every 15min (active phase ), every 5min (second stage)
External tocodynamometer vs Internal Pressure Catheter (IUPC)
- Are they contracting
2. How strong are the contractions (are they stung enough)
Vaginal Examination of cervix (what does 4/50/-2 mean)
Dilation (0cm- 10cm), effacement (0%-100%) , station (-5 to +5)
= 4cm dilation, 50% effacement, -2cm station
AROM
Artificial rupture of membrane = Amniotomy (labor with no change to place IUCP) + you can see fluid , assess meconium
RISK = cord prolapse, prolonged rupture can cause chorioamnionitis
Epidural vs no epidural second stage time
Pushing takes 1 hour longer with epidural, however can prevent pushing before cervix is all the way dialated
- 2 hours = first baby no epidural
- 3 hours = 1st + epidural
- 1 hour = 2nd no epidural
- 2 hours = 2nd + epidural
Cardinal movements is what
Every Descent Family In England Eats Eggs
- Engagement = zero station
- Descent = uterine contraction maternal valsalva efforts
- Flexion = chin to chest (OA from occipitofrontal to suboccipitobregmatic)
- Internal Rotation = at ischial spines, fetal enters pelvis and rotates posterior or anterior to pubic symphysis
- Extension = when largest D of baby head is encircled by vagina , station 5+ = head come out by extension and rotation to align with chest
- External Rotation = head align itself with fetal back and shoulders
- Expulsion = ant shoulder delivered then post shoulder and rest of body
Management of second stage
- How to position mom
- With each contraction
- Monitoring
1 .Avoid flat on back (dorsal litho to my position = can compress BF to baby
- Bearing down : with each contraction : hold breath and expulsion effort
- every 15min (uncomplicated), every 5min (complicated)
Modified Ritgen Maneuver
Helping baby’s head come out by supporting the perineum and prevent tears
= one hand on face to extend baby head (by perineum) and other hand on occiput to control delivery
What to do before delivering rest of body ones head is out
Nuchal cord check to make sure its not around neck
Perineal Lacerations
1st degree, 2nd degree, 3rd degree, 4th degree
- Superficial , vaginal mucosa and Erin eat skin
- Extend to muscles of perineal body
3 .extend completely through perineal body into anterior sphincter (however not into anal mucosa) - Extends through perineal body into anal mucosa
When head is delivered what can you do
Bulb suction oral cavity and nose to clear airway
How to deliver :
1. Ant shoulders
2. Post shoulders
Repairing any tears is what stage
- Using head down
- Elevating head (can cause perineal tear
2nd stage
Episiotomy
Precutting perineum if needed (do if there is high risk of tear or if you think here will be upward tear happening)
= cute Midline down if possible
= can cause easier 3rd and 4th degree laceration
Placenta should be derived by and average time
30min if longer = Retained placenta
Average = 2min-10min
Placental separation classic signs + what not to do
- Gush of blood
- Umbilical cord lengthen
- uterus fundus raises up + changes from discoid to globular shape
= DONT PULL cord until classic signs are noted (uterine inversion)
= apply counterpressure between symphysis and uterus fundus (push down above pubic symphysis so fundus is above your hand holding it in place)
Management of 3rd stage
Look for lacerations, repair them, monitor uterine bleeding when placenta comes out, inspect placenta
4th stage what do you do
- Fundus check and vaginal bleeding check = press on fundus to stimulate it for contraction to lower postpartum bleeding
- Vitals check
- 1% Have postpartum hemorrhage (uterine atony** uterine did not contract well= boggy cant contract down, retained placenta, infection from unprepared tear)
If pt is at term however is not delivering what do you do
Don’t wait until after 42weeks,
- Induced delivery (ripen and soften cervix)
- Augment (pitocin or rupture them)
Reasons to induce a pregnant pt (some ex, dont need to memorize)
- Fetal demise
- Gestational. HTN
- PROM
- Oligohydraminos
- Abrupt placentae
Who should not have vaginal delivery
- Fetal unstable, acute fetal distress
- Placenta Previn, vasa Previn
- Previous C-section, transfundal uterine surgery (myomectomy) **
- HIV, HSV
BISHOP Score
How successful will the dilation be
- Dilation
- Effacement
- Station
- Cervical consistency (soft is good)
- Cervical Postition (Anterior is good)
(Under 6 = bad (if still needed go to C-section), over 8 you can go to induction)
3 things to give to cause cervical ripening
- Cervidil (Dinoprostone)
- Cytotec (Misoprostol)
- Mechanical Dilator ( Foley bulb catheter / cooks catheter inflating tp 30cc-80cc, Laminar Japonicum of rods places and swelling)
Cervidil (Dinoprostone)
- what
- How
- Fact
- PGE 2
- Vaginal insertion (can be removed if needed or not tolerated)
- NOT in pt with previous C-section (Safer however more expensive)
Cytotec (Misoprostol)
- what
- How
- Fact
- PGE 1
- Orally of vagina dissolves (cant be removed if need)
- Not for previous C section pts (cheaper and usually in OBGYN)
How to induce contractions
- What
- How to give and how much
- How long to effect
PITOCIN (oxytocin)
- 1-30mu dose, start at 2mu/min, increase by 2mu if needed (IV)
- 3-5 min to cause uterine response
Complications in Pitocin
- Uterine Tachysystole : 5 ore more contractions in 10min
- Antidiuretic (has ADH, and oxytocin) : increase water given (stop contractions), can lead to severe water intoxication or dehydration
- Uterine Muscle fatigue : prolonged used (can cause postpartum hemorrhage from uterine atony)
OB anesthesia can effect
Fetal BF, fetal hypotension, (give fluids and hydrate before anesthesia)
= EPHEDRINE given to restore BF and BP in uterine
Regional Anesthetic refers to
T10 and down anesthesia
No pharmocology anesthesia you can do
- Lamaze
- Emotional support
- Back massage
- Hydrotherapy
- Acupuncture
Parenteral anesthesia (IV) + ex + what it does + risks
- Morphine, Fentanyl, Meperidine, Nalbuphine
- Early stages of labor (more visceral pain, less intense)
= very low labor pain relief
= opioids cross placenta + cant be given at all in Dceles
Regional local anesthesia (epidural + Spinal)
T8-T10 and below
BUPIVICAINE or LIDOCAINE + fentanyl
1. Epidural (most effective, between L2/3, L3/4, or L4/5, catheter placed over needle) = can be done during c-section if you go vaginal to C-section
2. Spinal (single shot, 30–250min, C-section usually)
Regional Anesthesia benefits
- Highly effective
- Alert and awake mother
- Can remember experience
- Rarely need local anesthesia for tear repairs
Regional Anesthesia side effects + contraindications
- Spinal headache, hypotension, fever, abscess, spinal hematoma
- Bacterimia, heparin use in 12hr, coagulopathy,skin infection, increased intracranial P
Local anesthesia used
For repair tears
- Lidocaine (20-40min), can cause cardiac arrhythmia, seizures, hypotension)
- Puedendal Block (in women with no regional anesthesia, can cause hematoma or infection at injection site)
General Anesthesia used and what risk and what you need to do, when you do this
Propofol
- LOC of mother, need to help with respiration, 16 times higher mortality of mother
- Can cross placenta and can effect fetal respiration
- Emergency needing rapid delivery or failed regional anesthesia
How do you put in an epidural
Between L2 and L5
Inject through intersegmental ligament into EPIDURAL space to Squeeze SUBARACHNOID (Subdural) space (where nerves pass)
