Objectives 1-10

Question 1

When does second stage begin? Why is this information important?

Answer 1

*complete dilation of cervix to birth of the baby *takes 30min-3 hours in a prim and 5-30min in a multipara *Median duration is slightly under 50min in primi just under 20 min in multi Simkin - Two fold definition complete dilation plus spontaneous expulsive efforts

Question 2

What is the difference between the latent and active phase of second stage?

Answer 2

Latent 2nd Stage: Uterine activity is markedly reduces, FHR reassuring, US usually resume in 5-30min *if this stage persists = wait 20-30 min, empty her bladder, change positions, trial of expulsive efforts, nipple stim, accupressure Active 2nd Stage = involuntary urge to push and descent of the fetus. The urge to push, UCs, body positions, and fetal efforts are the forces that combine to bring about delivery.

Question 3

When does the active phase of second stage begin?

Answer 3

Active phase of 2nd stage begins with involuntary urge to push

Question 4

What is the difference between spontaneous pushing, directed closed glottis pushing, exhale pushing?

Answer 4

Spontaneous = Same as open glottis, occurs naturally d/t pelvic floor pressure that stimulates Ferguson’s reflex, feels urge to push, pushes only when she wishes Directed closed glottis (valsalva) = this is deep breath, hold as long as you can (10 count), detrimental effects possible Exhale Pushing (open glottis) = Exhales as she involuntarily pushes for short periods of 5-7 sec. Takes several breaths inbetween pushing (no change in umbilical pH)

Question 5

Closed glottis pushing leads to what complications?

Answer 5

*decrease in cardiac output * increase in maternal CO2 * decrease in placental oxygenation -> fetal hypoxia * increase in perineal trauma (lacerations & epis) * future problem cystocele, prolaps, etc

Question 6

What are the advantages of birthing laterally, squatting, using a birth chair?

Answer 6

lateral: prevents perineal trauma especially with vulvar varicosities and hemorrhoids. Relaxes pelvic muscles, facilitating descent of presenting part. Easy to control head over perineum. Pregnant uterus does not compresses vena cava Squatting: enlarges pelvic space (transverse & and AP diameter), good for OP presentations. Going with force of gravity. Allows for more (30%) intraabdominal pressure - reduced length of labor. ○ birth chair: may increase PPH d/t limited access to fundus

Question 7

What are the advantages of pushing in hands/knees, in squat, in lateral, supported squat?

Answer 7

hands and knees: good for OP or OT, increased placental blood flow > more O2 to baby. Take pressure off back. Can help delivery dystocia. squat: ○ lateral: good for turn OP ○ Simkin p 182 - 186 supported squat: (dangle position) elongates mom’s trunk, good for asynclitism - more space for fetus to maneuver

Question 8

What factors lead you to anticipate perineal lacerations?

Answer 8

unnecessary use of McRoberts ○ precipitous birth, uncontrolled, or unattended delivery. ○ directed push to slow pushing can prevent lac *Large baby, abnormal head position, breech, shoulder dystocia *Statistical preidictors: muliparity, non-hispanic white, prolonged second stage (>2.5hr in nullip and>1 hour in multip) , greater than 4000gm baby.

Question 9

What recommendations for pushing with an epidural?

Answer 9

With complete dilation, epidural, and health fetus: *1-2 hours rest with continued assessment for signs of descent/rotation. * Epidurals inhibit rotation of fetal head *use EFM as biofeedback device to encourage her efforts - partner calls out numbers as contractions build. Bearing down should last 5-7 seconds. Breathe for baby. then bear down again - partner calling numbers (sequence 3-4X/contraction. * if slow progress, change positions every 20-30 min

Question 10

What are the advantages of episiotomies/disadvantages?

Answer 10

advantage: expidited delivery for fetal distress or shoulder dystocia ○ disadvantage: risk of 3rd or 4th degree (more with midline than no epis), require more suturing, more persistent perineal paid after childbirth.

Question 11

What type of laceration commonly occurs with an attempted intact perineum?

Answer 11

periurethral, labial

Question 12

What muscles are cut with a midline episiotomy? Mediolateral episiotomy?

Answer 12

bulbocavernosus

Question 13

OP babies are delivered by what mechanism?

Answer 13

flexsion

Question 14

OA babies are delivered by what mechanism?

Answer 14

extension