*Progression of Labor Flashcards
Cardinal Movements of Labor
ED FIRE REX:
Engagement, Descent, Flexion, Int Rot, Extension, Ext Rot, EXpulsion
What happens in Engagement?
Biparietal Diameter (BPD) passes through pelvic inlet. 0 station on vaginal exam. Head is in OT or OA position.
What happens in Internal Rotation?
OT position –> OA position
How long is average stage 1 for nulliparous woman? Multiparous woman?
10-12 hrs nullip. 6-8 hrs multip.
Rate of cervical change in active phase for a nulliparous woman? multiparous woman?
1.0 cm/hr nullip. 1.2 cm/hr multip.
Note: If rate of cervical dilation falls below 1.0 cm/hr, check the 3 Ps.
What is a Friedman curve?
S-shaped curve depicted in hours in labor v.s. cervical dilation (cm)
Increasing dilation indicates the progress of the fetus as it moves down the birth canal
What are the 3 Ps?
Power (strength/frequency of contractions)
Passenger
Pelvis
What is Active Phase Arrest? What do you do?
no change in cervical dilation or station for 2 hrs (despite adequate Montevideo units during active phase) –> C-section
What is considered a prolonged Stage 2 of Labor?
> 2 hrs nullip (>3 if epidural)
>1 hr multip (>2 epidural)
What is “laboring down”/”passive descent”?
1 hr of no pushing given to epidural pts.
What fetal heart tracings are common in Stage 2 of Labor?
repetitive early and variable decels
What are signs of nonreassuring fetal status?
What should you do to tx?
repetitive late decels, bradycardias, loss of variability
Put O2 face mask, turn on Left Side, D/C Oxytocin until reassuring tracing occurs
What is uterine hypertonus?
single contraction lasting 2+ minutes
What is tachysystole?
5+ contractions in 10 minutes
If prolonged decels is due to hypertonus or tachysystole, what should you do?
What if the nonreassuring pattern doesn’t resolve?
Tx: Dose of Terbutaline (to help relax uterus)
If no help, assess fetal position and station.
If meconium is suspected/confirmed, what should be used on the newborn?
DeLee suction trap to aspirate meconium from the airway
What maneuver is done if a delivery needs to be expedited? How is it done? What is the risk involved?
Modified Ritgen maneuver: heel of delivery hand exerts pressure on perineum while fingers below woman’s anus extend fetal head
Greater risk of perineal lacerations
What should be done once the anterior shoulder is visualized?
Direct upward pressure is exerted to deliver the posterior shoulder
What risk is increased with the use of episiotomies?
Rate of 3⁰ and 4⁰ lacerations increase
Location of a midline episiotomy?
from posterior fourchette into perineal body
Location of mediolateral episiotomy?
from 5 o’clock or 7 o’clock position on perineum and cut laterally. More painful, infection but less 3⁰ and 4⁰ lacerations
Forceps/vacuum delivery: safe indications for use
Full cervical dilation Ruptured membranes Engaged head \+2 station Absolute knowledge of fetal position No evidence of CPD Adequate anesthesia Empty bladder *Experienced operator*
Complications associated with Forceps delivery?
Facial n. palsy
Facial/head bruising
Lacerations (head, cervix, vagina, perineum)
Skull fx. (rare)
Complications associated with Vacuum delivery?
Lacerations (scalp)
Cephalohematomas
Subgaleal hemorrhage (rare but emergency)
Timeframe for normal Stage 3 of Labor?
Up to 30 minutes (usually 5-10 minutes, placenta will come out)
3 Signs of Placental Separation
Cord lengthening
Gush of blood
Uterine fundal rebound (as placenta detaches from uterine wall)
When the patient begins bearing down for delivery of the placenta, it is imperative that what?
to apply suprapubic pressure to keep uterus from inverting or prolapsing
When is the diagnosis of retained placenta made? When should you suspect retained placenta?
If placenta does not deliver in 30 minutes.
Common in preterm deliveries (esp. previable deliveries), placenta accreta
Tx. Retained Placenta
Manual extraction of placenta by intrauterine insertion of hand, and if incomplete, then curettage
1⁰ Laceration
Involves mucosa or skin (superficial)
2⁰ Laceration
How is it repaired?
Extend into perineal body but do not involve anal sphincter
- Vaginal mucosa repaired down to level of hymenal ring
3⁰ Laceration
Extend into anal sphincter
4⁰ Laceration. What should always be done to check?
Extend into rectum
Always perform rectal exam to check for “button hole lacerations” wherein rectal mucosa is torn but sphincter is intact
Maternal mortality from Caesarean delivery
0.01-0.02%
Indications for 1⁰ C-section
*Failure to progress in labor (e.g. Cephalopelvic Disproportion, no cervical change in 2 hrs despite adequate contractions in the active phase)
Breech presentation Transverse lie Shoulder presentation Placenta previa, abruption Fetal intolerance of labor Nonreassuring fetal status Cord prolapse Prolonged 2nd stage Failed operative vaginal delivery Active herpes or HIV elevated viral load Previous C-section
When can a VBAC be performed?
Previously a Kerr (low transverse incision) or Kronig (low vertical incision) without extension into cervix or upper uterine segment. (VBAC cannot be after a prior classical hysterotomy.)
What is the greatest risk during a TOLAC (trial of labor after C-section)?
Rupture of prior uterine scar (0.5-1.0% risk)
Signs of Uterine Rupture
Abdominal pain, FHR decels/bradycardia, sudden decrease of pressure on IUPC, maternal sensation of a “pop”
