Pregnancy - Intrapartum Care Flashcards
1
Q
Describe: Intrapartum care
A
is the care of the mother and fetus during labor.
2
Q
Describe: Labor (1)
A
is the process by which products of conception are delivered from the uterus by progressive cervical effacement and dilatation in the presence of regular uterine contractions.
3
Q
Describe: Braxton Hicks contractions (2)
A
- irregular contractions
- not associated with any cervical D or descent of fetus.
4
Q
Regulation of the myometrial activity of the uterus relies on what? (3)
A
- fetal and maternal paracrine/autocrine factors, as well as intrinsic factors within myometrial cells
- This is because the uterus is not densely innervated.
- Four distinct physiologic phases of myometrial activity in pregnancy
5
Q
Name: Four distinct physiologic phases of myometrial activity in pregnancy
A
- Myometrial inhibition
- Myometrial activation
- Stimulatory
- Involution
6
Q
Describe the mechanism of this physiologic phase of myometrial activity in pregnancy: 0. Myometrial inhibition (2)
A
- During pregnancy, uterus remains quiescent because inhibitors active
- Putative inhibitors = progesterone, prostacyclin, relaxin, NO, placenta CRH
7
Q
Describe the mechanism of this physiologic phase of myometrial activity in pregnancy: 1. Myometrial activation (3)
A
- Occurs as term approaches
- Uterus activated in response to uterotropins (i.e., E)
- Result: (a) uterus become primed; (b) have development of regular, rhythmic contractions
8
Q
Describe the mechanism of this physiologic phase of myometrial activity in pregnancy: 2. Stimulatory (1)
A
Stimulation of primed uterus by uterotonic agonists (i.e., oxytocin, PGE2, PGF2a )
9
Q
Describe the mechanism of this physiologic phase of myometrial activity in pregnancy: 3. Involution (2)
A
- Occurs after delivery
- Mediated by oxytocin
10
Q
Name FETAL Factors promoting labor (2)
A
- Activation of fetal HPA axis → ↑ cortisol which acts on placenta → ↑ E production → ↑ E: progesterone ratio
- Result: (a) ↑ PGFa release; (b) ↑ myometrial response to oxytocin; (c) ↑ contractions
11
Q
Name MATERNAL Factors promoting labor (2)
A
- Activation of maternal HPA axis→ possible activation of fetal HPA
- Oxytocin → ↑ PG receptors, ↑ oxytocin receptors, and ↑ gap junctions in uterine
12
Q
Name MYOMETRIAL Factors promoting labor (2)
A
- ↑ Free intracellular Ca2+ → contraction of uterine myocyte cells
- Possible mechanotransduction through stretching or shortening
13
Q
How many stages of labor are there?
A
4
14
Q
Describe FIRST stage of labor 2)
A
Interval between onset of labor to full cervical dilation (10 cm). Divided into two phases.
- Latent phase: begins with onset of regular uterine contractions with slow cervical dilation up to ~3–4 cm
- Active phase: ↑ rate of cervical dilation to maximum, regular contractions, and descent of fetus
15
Q
Describe the average duration of FIRST stage of labor (Nulliparous vs multiparous)
A
- Total:
- Nulliparous: ~10 h
- Multiparous: ~8h
- Latent:
- Nulliparous: ~6.5 h Prolonged > 20 h
- Multiparous: ~4.5 h Prolonged > 14 h
- Active:
- Nulliparous: Cervical dilation 1.2 cm/h Fetal descent>1 cm /h
- Multiparous: Cervical dilation 1.5 cm /h Fetal descent>2 cm /h
16
Q
Describe SECOND stage of labor (1)
A
Interval between full cervical dilation and delivery of infant
17
Q
Describe the average duration of SECOND stage of labor (Nulliparous vs multiparous)
A
- Nulliparous: ~50min Prolonged (no epidural) > 2 h
- Multiparous: ~20min Prolonged (no epidural) > 1 h
18
Q
Describe THIRD stage of labor and average duration (1)
A
- Interval between delivery of infant and delivery of placenta
- ~10 min Prolonged if > 30 min
19
Q
Describe FOURTH stage of labor and average duration (2)
A
- Interval from delivery of placenta through to the resolution of physi- ologic Ds of pregnancy
- Avg. duration: 6 wk
20
Q
A
21
Q
Describe the cardinal movements of labor (7)
A
Sequence of movements, involving Ds in position of the fetal head that enables the fetus to successfully negotiate the pelvis during labor.
- Engagement—widest diameter of the fetal head (biparietal diameter) enters the maternal pelvis below the plane of the pelvic inlet.
- Descent—downward passage of the presenting part through the pelvic floor. Greatest rate is during the second stage of labor.
- Passive flexion of the fetal occiput permits the smallest diameter of the fetal head (suboccipitobregmatic ~9.5 cm) to be presented for optimal passage through the p elvis.
- Internal rotation—rotation of the occiput from its original position toward the symphysis pubis (OA), which is ideal, or toward the sacrum (OP). This enables the AP diameter of the fetal head to line up with the AP diameter of the pelvic outlet.
- Extension—delivery of the fetal head by extension and rotation of the occiput around the symphysis.
- Restitution and external rotation—with the fetus’ head free of resistance, it un- twists, causing the occiput and spine to line in the same plane.
- Expulsion—delivery of the anterior shoulder under the symphysis pubis followed by quick expulsion of the rest of the body.
22
Q
Name: Signs and Sx of Onset of Labor (3)
A
- Regular, painful contractions that are increasing in intensity and frequency
- Vaginal discharge that is thick, mucous-like, or slightly bloody
- Gush or trickle of vaginal fluid that is watery
23
Q
Describe: Birth Plans (2)
A
- The pt and her partner may arrive with a birth plan.
- Review the birth plan early on in labor together with the pt and her partner to improve patient–physician communication and to provide culturally sensitive care.
24
Q
Describe history of labor (3)
A
- Establish the age, GTPAL, gestational age, pattern of contractions, Hx of rupture of membranes, vaginal bleeding, and presence of fetal movements
- Review current pregnancy Hx, complications during this pregnancy, and results of routine antenatal investigations (e.g., detailed anatomic ultrasound, gestational diabetes screening, GBS)
- Review PMHx, SxHx, meds, allergies, and social Hx
25
Describe Physical Exam of labor (3)
* Vital signs, fetal heart rate, abdominal exam (including Leopold’s), and focused physical exam based on HPI
* Sterile speculum exam and/or vaginal exam if indicated
26
Describe: Dilatation (1)
the estimated measure of the diameter of the internal cervical os
27
Describe: Effacement (1)
shortening and thinning of the cervix expressed as length (cm) or a percentage (0% = no reduction vs. 100% = minimal palpable cervix).
28
Describe: Position
* the position of the presenting part of fetus relative to the maternal pelvis.
* Mostcommonly OA, but can also be OP, or OT.
29
Describe: Station (2)
* eestimated distance (cm) of the leading presenting part relative to the ischial spines.
* At the level of the spines= 0 (engaged) versus centimeters below (+1 to +5) and centimeters above (−1 to −5).
30
Name: Indications for Vaginal Exams in Labor (6)
* On admission (if no suspicion/Dx of placenta previa)
* q2–4h in first stage and q1h in second stage
* At ROM to evaluate for cord prolapse; if pt not contracting, perform sterile speculum exam only
* Before intrapartum administration of analgesia
* When the pt feels the urge to push (to determine if cervix is fully dilated)
* To evaluate cause of ↓ FHR (R/O cord prolapse or uterine rupture)
31
Sterile speculum and vaginal exams are contraindicated in
known or suspected cases of \_\_\_
placenta previa
32
In NST and EFM, describe: Baseline
* Normal Tracing (Previously “Reassuring”):
* Atypical Tracing (Previously “Nonreassuring”):
* Abnormal Tracing (Previously “Nonreassuring”):
* Normal Tracing (Previously “Reassuring”): 110–160 bpm
* Atypical Tracing (Previously “Nonreassuring”):
* Bradycardia 100–110 bpm
* Tachycardia \> 160 bpm for \< 30 min
* Rising baseline
* Abnormal Tracing (Previously “Nonreassuring”):
* Bradycardia \< 100 bpm
* Tachycardia \> 160 BPM for \< 30 min
33
In NST and EFM, describe: Variability
* Normal Tracing (Previously “Reassuring”):
* Atypical Tracing (Previously “Nonreassuring”):
* Abnormal Tracing (Previously “Nonreassuring”):
* Normal Tracing (Previously “Reassuring”):
* 6–25 bpm
* ≤ 5 bpm for \< 40 min
* Atypical Tracing (Previously “Nonreassuring”):
* ≤ 5 bpm for 40–80 min
* Abnormal Tracing (Previously “Nonreassuring”):
* \> 80 min
* ≥ 25 bpm for \> 10 min
* Sinusoidal
34
In NST and EFM, describe: Decelerations
* Normal Tracing (Previously “Reassuring”):
* Atypical Tracing (Previously “Nonreassuring”):
* Normal Tracing (Previously “Reassuring”): None or occasional uncom- plicated variables or early decelerations
* Atypical Tracing (Previously “Nonreassuring”):
* Repetitive (≥ 3) uncomplicated variable decelerations
* Occasional late decelerations
* Single prolonged deceleration
35
In NST and EFM, describe: Decelerations
* Abnormal Tracing (Previously “Nonreassuring”) (8)
Repetitive (≥ 3) complicated variables:
* Deceleration to 70 bpm for 60 sec
* Loss of variability in trough or in baseline
* Biphasic decelerations
* Overshoots
* Slow return to baseline
* Baseline lower after deceleration
* Baseline tachycardia or bradycardia
* Repetitive (\>=3) complicated variables: Single prolonged deceleration (\> 2 min but \< 10 min)
36
In NST and EFM, describe: Accelerations
* Normal Tracing (Previously “Reassuring”):
* Atypical Tracing (Previously “Nonreassuring”):
* Abnormal Tracing (Previously “Nonreassuring”):
* Normal Tracing (Previously “Reassuring”):
* Spontaneous accelerations present (\> 2)
* Increases 15 bpm lasting 15 s
* Increases 10 bpm lasting 10 s if \< 32 wks GA
* Accelerations present with fetal scalp stimulation
* Atypical Tracing (Previously “Nonreassuring”): Absence of acceleration with fetal scalp stimulation
* Abnormal Tracing (Previously “Nonreassuring”): Usually absent
37
In NST and EFM, describe: Action
* Normal Tracing (Previously “Reassuring”):
* Atypical Tracing (Previously “Nonreassuring”):
* Abnormal Tracing (Previously “Nonreassuring”):
* Normal Tracing (Previously “Reassuring”):
* NST may be discontinued.
* EFM may be interrupted for periods up to 30 min. If maternal- fetal condition stable and/or oxytocin infusion rate stable.
* Atypical Tracing (Previously “Nonreassuring”):
* NST: continued monitoring required. Arrange BPP.
* EFM: further vigilant assessment required, especially when combined features present
* Abnormal Tracing (Previously “Nonreassuring”):
* NST: continued monitoring required. Consider BPP and prepare for possible delivery.
* EFM: action required
Review overall clinical situation, obtain scalp pH if appropriate/prepare for delivery
38
Describe: Intermittent auscultation (IA) (2)
* Indications: healthy women with no RFs for adverse perinatal outcomes
* Frequency of IA = for one full minute after contraction: q1h during latent phase, q15–30min in active phase, and q5min in second stage of labor
39
Name indications: Continuous electronic fetal heart monitoring (EFM) (3)
* Nonreassuring auscultation
* Pregnancies at risk of adverse perinatal outcomes
* Maternal: HTN in pregnancy, DB, APH, medical diseases (cardiac anemia, hyerT4, etc) morbid obesity, maternal MVA, or trauma
* Fetal: IUGR, prematurity, postdates (\> 42 wk or \> 41 + 3 with low fluid), oligohydramnios, abnormal Doppler studies, isoimmunization, multiple pregnancy, breech presentation
* Intrapartum: vaginal bleeding in labor, infection, prev. C-section, pro- longed ROM (\> 24 h), hypertonia, meconium stained fluid, abnormal fetal HR on auscultation
* Induced, augmented, or prolonged labor
40
Continuous electronic fetal heart monitoring (EFM) can be done with what? (2)
* Can be done externally through Doppler
* or internally through a fetal scalp electrode
41
Describe use of Continuous electronic fetal heart monitoring (EFM) in improvement in neonatal well-being (1)
Use of EFM is not associated with a significant improvement in neonatal well-being and has been shown to ↑ rates of medical intervention (i.e., C/S, operative vaginal deliveries).
42
Name Types of decelerations seen in labo (3)
* Early
* Variable
* Late
43
Describe cause: Early deceleration (1)
Head compression → vagal slowing of heart
44
Describe: Early deceleration (4)
* Seen in 2nd phase of labor
* Uniform shape
* FHR: gradual ↓ and return to baseline
* Coincides with contraction
45
Name cause: Variable deceleration (1)
Cord compression
46
Describe: Variable deceleration (4)
* Variable shape, onset, duration
* FHR: abrupt drop and return to baseline
* Most common deceleration seen in labor
* Complicated:
* Deceleration to \< 70 bpm
* \> 60 bpm below baseline
* Lasts \> 60 sec long
47
Name causes: Late decleration (3)
Uteroplacental deficiency due to:
* (a) maternal hypotension
* (b) uterine hyperstimulation
* or (c) placental dysfunction
Result = hypoxia ± acidosis of fetus
48
Describe: Late decleration (4)
* Uniform shape
* Gradual ↓
* Late onset (starts at end of contraction)
* Can be associated with change in baseline or ↓ variability
49
Describe diagnosis of Normal Labor and Delivery (2)
* Based on the HPI, current pregnancy Hx, obstetrical Hx, and maternal Hx, there should be no contraindications to vaginal delivery.
* The phase and stage of labor can be diagnosed, and normal labor and delivery should follow the expected progress
50
Describe management of Normal Labor and Delivery (2)
GBS prophylaxis should be administered if indicated.
51
Screening for GBS should be done when?
should be done at **36 wk GA** as part of antenatal care in all women (except
women with documented GBSbacteruria in current pregnancyor previouslyaffected infant with GBS).
52
Ideally, want a minimum of ___ h of intrapartum Rx before delivery
4h; but since bactericidal levels are found in cord blood after 30 min, prophylaxis should still be given even if delivery is imminent.
53
Name Indications for Antibiotic GBS Prophylaxis (2)
* A positive GBS screen
* Unknown GBS status and other RFs for neonatal disease
* (a) Prev.infant with invasive GBS infection
* (b) GA \< 37 wk
* (c) \> 18 h since ROM
* (d) GBS bacteriuria in current pregnancy
54
Name ATB used for GBS Prophylaxis (4)
* Penicillin G5 million units IV loading dose, then 2.5 million units IV q4h
* Cefazolin (nonanaphylactic penicillin allergy) 2g loading dose, then 1g q8h
* Clindamycin (anaphylactic penicillin allergy with documented GBS sensitivity) 900 mg IV q8h
* Vancomycin (anaphylactic penicillin allergy with GBS resistance to Clindamycin or sensitivity unknown) 1g IV q12h
55
Variability↓ Or absent FHR variability is due to what? (5)
* (a) persistent hypoxia leading to acidosis
* (b) fetal sleep
* (c) medications—that is, narcotics, sedatives, b-blockers
* (d) prematurity
* (e) fetal tachycardia.
Must investigate if lasts \> 40 min!
56
Describe: Management of an Atypical or Abnormal FHR Tracing (11)
1. Recheck the tracing
2. Call for backup
3. Change maternal position to LLDP—relieves compression of IVC by the gravid uterus
4. Provide fetus O2 by 100% O2 mask to mother
5. Stop augmentation of labor—↓ hyperstimulation
6. Fetal scalp stimulation
7. R/O causes of uteroplacental deciency (i.e.,correct any maternal hypotension—IVFs, ephedrine)
8. Amniotomy
9. Fetal scalp electrode if unable to obtain adequate tracing with external monitoring
10. Measurement of fetal scalpblood pH
11. ± Amnioinfusion—protects cord from compression
57
Describes values of fetal scalp blood pH (2)
* pH≥ 7.25 = normal
* pH ≤ 7.20 = fetal acidosis
58
Describe Physician’s Legal Liability for Negligence regarding GBS (1)
Failure to recognize RFs for group B streptococcal infection in a pregnant woman
59
Name CIs for Epidural or Spinal Considerations (6)
* 1. Pt refusal
* 2. Untreated coagulopathy
* 3. Skin infection of lumbararea
* 4. Refractory hypotension/hypovolemia
* 5. Active neurologic disease
* 6. Septicemia
60
Name risks for Epidural or Spinal Considerations (5)
* Infection
* Maternal hypotension
* Neurologic complications: spinal headache, back pain, nerve palsies
* Toxic drug reaction
* Rare neurologic disease
61
62
Name: Medications for pain relief in labor (3)
* Entonox
* Narcotics
* Regional anesthesia
63
Describe Entonox for pain reliaf in labor (4)
* A mixture of nitrous oxide gas and O2 administered through a mask
* Patient can control how much gas is inhaled
* Can continue its use right up to the moment of giving birth
* Effects not passed on to the fetus
64
Describe Narcotics for pain reliaf in labor (2)
* Options:
* morphine 5–10 mg IM if in early labor
* morphine 2.5 mg IV if in active labor or fentanyl 0.5 mg/kg IV
* Avoid if their peak action will not have diminished by the time of delivery
65
Describe risk of narcotics in labor. How to reverse? (2)
* Can cause respiratory depression in the neonate
* Reverse with Narcan 0.01 mg/kg
66
Describe use of Regional anesthesia in labor (2)
* Loss of pain sensation occurs **below T8/T10** with varying degrees of motor blockade
* Must hydrate the patient with **dextrose free isotonic IV** before initiation of epidural
67
Describe benefit of routine episiotomy (1)
There is no benefit to routine episiotomy at normal deliveries, but can be done to facilitate vaginal delivery when indicated
68
Name types of Episiotomies (2)
* Median (midline)—incision through the central tendon of the perineal body
* Advantage = easy repair and improved healing
* Mediolateral—incision through the levator ani bulbocavernosus, and superficial transverse perineal muscles
* Advantage = ↓ likely to extend into anal sphincter and rectum
69
Name indications of Episiotomies (4)
* Delivery with a high risk of perineal laceration
* Soft tissue dystocia
* Immediate delivery of compromised fetus
* Instrumental delivery (optional)
70
Name possible complications of Episiotomies (6)
* Infection
* Hematoma
* Fistula formation—rectovaginal
* Fecal incontinence
* Median → likely to extend into anal musculature/rectal mucosa
* Mediolateral → ↑ scar tissue, ↑ blood loss, ↑ pain, ↑ difficult to repair, dyspareunia sequelae
71
Operative vaginal deliveries are generally indicated when? (1)
When an abnormal or atypical EFM tracing necessitates expedited delivery or insufficient pushing in second stage.
72
Name types of operative deliveries (3)
* Vacuum extraction
* Forceps
* C/S
73
Define: Vacuum extraction (2)
* Operative vaginal delivery
* Suction/traction instrument used to deliver the fetus
74
Name indications: Vacuum extraction (3)
* Abnormal or atypical EFM tracing
* Prolonged 2nd stage
* Impaired pushing by mother (exhaustion, ↑↑↑ analgesia)
75
Name complications: Vacuum extraction (6)
* Neonatal injury
* Soft tissue trauma
* Hemorrhage, cephalohematoma, subgaleal, intracranial
* Maternal perineal (3rd and 4th degree) and vaginal lacerations and/or hematomas
* Maternal urinary retention
* Bladder/uterus/pelvic nerve injury
* Infection
* PPH
76
Describe this type of operative delivery: Forceps (3)
* Operative vaginal delivery
* Classified according to level + position of the fetal head in the birth canal at the time the forceps are applied
* Types: low/outlet forceps, mid forceps, and high forceps
77
Name indications: Forceps (3)
* Abnormal or atypical EFM tracing
* Prolonged 2nd stage
* Impaired pushing by mother (exhaustion, ↑↑↑ analgesia)
78
Name complications: Forceps (6)
* Neonatal injury
* Soft tissue trauma
* Subgaleal hematomas, intracranial hemorrhage
* Facial nerve palsy
* Skull fracture
* Maternal perineal (3rd and 4th degree) and vaginal lacerations and/or hematomas
* Maternal urinary retention
* Bladder/uterus/pelvic nerve injury
* Infection
* PPH
79
Name indications C/S (3)
* Maternal → active herpetic lesions, maternal illness (PIH, GDM, invasive cervical CA)
* Fetal → distress, malpresentation, cord prolapsed
* Combined → Failure to Progress (FTP), placenta abruption/previa
80
Name complications C/S (6)
* Anesthesia
* Hemorrhage
* Infection
* Injury to bladder, bowel, uterus, ureters
* ↑ Recovery time/stay in hospital
* ↑ Risk of Venous thromboembolism
81
Describe: Management of Shoulder Dystocia (7)
* **A**: Ask for help
* **L**: Lift/hyperflex both legs (McRobert maneuver)
* **A**: Anterior shoulder disimpaction (suprapubic pressure by assistant or Rubin maneuver by MD)
* **R**: Rotation of posterior shoulder (Wood corkscrew maneuver)
* **M**: Manual removal of the posterior arm
* **E**: Episiotomy
* **R**: Roll onto all 4s
82
Describe: Shoulder Dystocia (3)
* Life-threatening emergency
* Impaction of the anterior shoulder behind the pubic bone after delivery of the head
* Results in the “turtle sign”= retraction of the delivered fetal head against the bottom of the symphysis pubis
83
Name RFs: Shoulder Dystocia (9)
* Maternal:
* obesity
* pelvic abnormality
* GDM
* postdates pregnancy
* Prev. shoulder dystocia
* Fetal: macrosomia
* Labor:
* prolonged active phase of first stage
* prolonged second stage of labor
* assisted vaginal delivery (i.e., forceps)
84
Name complications: Shoulder Dystocia (8)
* Maternal:
* Postpartum hemorrhage
* symphyseal separation or diathesis
* third- or fourth-degree lacerations
* uterine rupture
* Fetal:
* hypoxia ± permanent neurologic damage
* brachial plexus injury, clavicular,
* humerus #
* death
85
Induction of Labor occurs when? (1)
when benefits of delivery to either the mother or fetus outweigh the benefits of continuing the pregnancy
86
Name requirements for induction of labor (4)
* Cervical assessment to determine best mode of induction/cervical ripening
* Normal “reassuring” fetal CTG
* Cephalic/vertex presentation
* Access to proper fetal monitoring
87
Name MATERNAL indications: Induction of labor (3)
* GHTN/preeclampsia
* Renal or pulmonary disease
* Diabetes
88
Name FETAL indications: Induction of labor (2)
* Intrauterine death (IUD)
* IUGR
89
Name COMBINED FACTORS indications: Induction of labor (5)
* PROM
* Alloimmunization
* Postdates pregnancy (\>41 wk GA)
* Chorioamnionitis
* Abruption at term or with atypical fetal heart strip
90
Name MATERNAL CI for induction of labor (6)
* Unstable status
* Prev. classical/ T-incision of uterus
* Abnormal pelvis structure
* ↑↑↑ Cephalopelvic Disproportion (CPD)
* Active genital herpes
* Invasive cervical cancer
91
Name FETAL CI for induction of labor (3)
* Distress
* Malpresentation (transverse, breech)
* Preterm (immature lungs)
92
Name COMBINED CI for induction of labor (3)
* Placenta previa
* Cord prolapse
* Vasa previa
93
Name methods: Induction of labor (2)
* Articial ROM (amniotomy)—stimulates PG synthesis and secretion
* Oxytocin (Pitocin)—use minimum dose needed to achieve cervical dilation of ~1 cm/h in active phase
94
Name risks: Induction of labor (6)
* Increased risk of C/S
* Uterine hyperstimulation (reversible ↓/stop rate of oxytocin infusion or with b-adrenergic agent)
* Uterine rupture
* Uterine atony ± PPH
* Hypotension—if IV oxytocin is rapidly infused
* Water intoxication ± hyponatremia with prolonged use (oxytocin acts as an antidiuretic)
95
Oxytocin is the ideal uterotonic agent. Why? (3)
due to its
* (a) short t1/2 approximately 2 to 3 min
* (b) minimal side effects
* (c) usability in all women.
96
Active Management of Third Stage of Labor. Why? (2)
* Done to help reduce the risk of uterine atony and ↓ postpartum blood loss. Oxytocin is the ideal uterotonic agent due to its (a) short t1/2 approximately 2 to 3 min, (b) minimal side effects, and (c) usability in all women.
* 10 U oxytocin IM or 5 U IV over 1 to 2 min should be given with the delivery of the anterior shoulder.
* Controlled cord traction
97
Name Signs of Placental Separation (3)
* 1. Contraction and rise of the uterus
* 2. Cord lengthening
* 3. Gush of blood
98
Never apply cord traction (pull) without what? (1)
counter traction (push) above the pubic bone with one hand
99
Describe: Cervical Ripening (3)
* Done to promote softening, effacement, and dilation of the cervix in preparation for induction
* Also ↑ sensitivity of uterus to oxytocin
* Necessity determined by the Bishop score
100
Describe: Bishop Score (5)
Cervical Assessment Tool
Components
1. Cervical dilatation (cm)
2. Effacement (%)
3. Station of presenting part
4. Cervical consistency
5. Position of cervix
Score of \>6 = favorable cervix— high success of vaginal delivery
Score of ≤6 = cervical ripening recommended (increased risk of failed induction)
101
Induction Requiring Cervical Ripening. Name methods (4)
* Mechanical
* Foley catheter
* Double lumen catheter
* Medical
* Prostaglandin E2 (intravaginal or intracervical gel, control release gel)
* Prostaglandin E1
102
Describe: Dystocia (1)
the abnormally slow progress of labor or FTP
103
True or false
Oxytocin is used for both induction and augmentation of labor.
True
104
Name Disorders leading to dystocia in labor (5)
* Arrest of dilation
* Arrest of descent
* Protraction of dilation
* Protraction of descent
* Prolonged latent phase
105
Define: Arrest of dilation (2)
* Cervical dilation stops for \> 2 h in the active phase
* Etiology: Inef cient uterine action
106
Describe management: Arrest of dilation (2)
* Appropriate assessment of progress in labor
* Augmentation
107
Define: Arrest of descent (2)
* Fetal descent fails to progress for \> 1 h during 2nd stage.
* Etiology: Cephalopelvic disproportion (CPD) (especially if uterine contractions are adequate) Inefficient uterine action
108
Describe management: Arrest of descent (6)
Appropriate intervention when necessary:
* Analgesia
* Rest
* Ambulation
* Amniotomy
* Oxyt o cin augmentation
* Fetal health assessment
109
Define: Protraction of dilation (1)
Slow rate of cervical dilation (i.e., \< 1.2 cm primigravida vs. \< 1.5 multigravida)
110
Describe management: Protraction of dilation (6)
Appropriate intervention when necessary:
* Analgesia
* RestAmbulation
* Amniotomy
* Oxyt o cin augmentation
* Fetal health assessment
111
Define: Protraction of descent (2)
* Slow rate of fetal descent during second stage (\< 1 cm primigravida vs. 2.0 multigravida)
* Etiology: Cephalopelvic disproportion (CPD)
112
Describe management: Protraction of descent (6)
Appropriate intervention when necessary:
* Analgesia
* Rest
* Ambulation
* Amniotomy
* Oxyt o cin augmentation
* Fetal health assessment
113
Describe: Prolonged latent phase (2)
* \> 20 h in primi- gravida and \> 14 h in multigravida
* Etiology: Due to improper Dx of early labor
114
Describe management: Prolonged latent phase (6)
Appropriate intervention when necessary:
* Analgesia
* Rest
* Ambulation
* Amniotomy
* Oxyt o cin augmentation
* Fetal health assessment
115
Dystocia in labor diagnosed when? (2)
* Cervical dilation in the active phase of the first stage → demonstrated by \> 4 h of \< 0.5 cm/h dilation
* Fetal head descent in the second stage, despite \> 1 h of active pushing
116
Three possible causes for Failure to progress (FTP). Name them. (3)
* **Power**: inefficient uterine action (hypotonic, uncoordinated, difficulty pushing by mother)
* **Passenger**: fetal position (i.e., OP), size, and presence of anomalies (i.e., hydrocephalus)
* **Passage**: pelvic structure (i.e., CPD), maternal soft tissue factors (i.e., full bladder)
117
Describe: Augmentation of Labor (3)
* Promotes adequate uterine contractions when spontaneous labor fails to progress:
* Slow progression through latent phase (inadequate cervical dilation) or
* Protraction and/or arrest disorders of labor or
* Hypotonic uterine contraction pattern
* IV infusion of oxytocin run at 0.5 to 4 mI U/min IV with incremental ↑ of 1 to 2 mI U/min q20–30min
* Reassess progression of labor once at dose of 20 mIU/min
