Week 3- Labour and delivery Flashcards
1
Q
home birth advantages
A
- control over who is there
- no risk of acquiring pathogens
- low technology birth
- lower rates of interventions
2
Q
5 P of the birth process
A
power
passageway
passenger
position
psyche
3
Q
the power are the __________
1.
2.
A
forces that cause the cervix to open and that push the fetus downward through birth canal
- uterine contraction
- mothers pushing
4
Q
contractions are the primary powers during
A
1st stage (from onset to full dilation)
5
Q
phases of contractions
A
- increment (increasing in strength)
- peak or acme: (greatest strength)
- decrement: the period of decreasing strength
6
Q
contractions described by their
A
frequency
intensity
duration
7
Q
frequency
A
time from the start of one contraction to the beginning of the next
ex: every 4 1/2 mins
8
Q
if contractions occur more often than every ___ than they are
A
2 mins too close together and may reduce fetal oxygen supply and should be reported
9
Q
duration
A
time from beginning of one contraction to the to the end of the same one
10
Q
contractions lasting longer than ____ may
A
90 sec, reduce fetal O2 supply and should be reported
11
Q
intensity
A
approximate strength of the contraction
mild, moderate, strong
12
Q
Mild intensity contractions
A
fundus is easily indented with the fingertips
feels like tip of nose
13
Q
moderate intensity contractions
A
fundus indented with fingertips but more difficult
feels like chin
14
Q
strong intensity contractions
A
fundus cant readily be indented,
feels like forehead
15
Q
resting tone of the uterus should be
A
soft, if firm not enough time between contractions for fetus to recover
16
Q
the passage way consists of
A
bony pelvis
soft tissues (cervix, muscles, ligaments and fascia)
17
Q
different pelvis
A
- gynecoid (rounded anterior and posterior segments, most favorable)
- android ( wedge-shaped inlet, narrow anterior segment)
- anthropoid ( anterior posterior diameter that equals or exceeds its transverse diameter, long narrow oval, infant most likely born occiput posterior
- platypelloid (short anterior posterior diameter and a flat transverse oval shape, unfavorable for vaginal birth
18
Q
pelvis divided into
A
2 parts
1- false (upper flaring part)
2. true ( lower part)- inlet, mid-pelvis, outlet
19
Q
biparietal diameter
A
between the points of the two parietal bones on each side of the head
20
Q
longitudinal, transverse and oblique lie
A
parallel to mothers spine
right angle to spine
between longitudinal and transverse
21
Q
fetal attitude normally
A
head flexed forward and the arms and legs flexed
most efficiently occupies space
22
Q
fetal presentation
A
the fetal part that enters the pelvis first
23
Q
most common presentation
A
cephalic (head down)
24
Q
vertex presentation (3)
A
- head is fully flexed
- most favorable cephalic variation
- smallest part of head enters first
25
Sinciput (military) presentation
head neither flexed nor extended
26
brow presentation (3)
head partly extended
longest part of head presentation
unstable often convert to vertex of face
27
face presentation
head fully extended and face presents
28
frank breech
- legs flexed at the hips and extend towards the shoulders
- most common breech presentation
- buttocks presents at the cervix
29
full or complete breech
- a reversal of the cephalic
- both feet and the buttocks present at the cervix
30
footling breech
- one of both feet present first at the cervix
31
transverse lie must be
born by c/s
32
position is
how a reference point on the fetal presenting part is oriented within the mothers pelvis
33
occiput is used to describe how
the head is oriented if the fetus is in a cephalic vertex presentation
34
sacrum is used to describe how
the buttocks is oriented within pelvis
35
abbreviations for fetal presentation
1. R or L side
- omitted if fetal reference point is directly anterior or posterior such as OA
2. fetal reference point (occiput for vertex presentation, mentum (chin) for face presentation, sacrum for breech.
3. front or back of the pelvis
transverse is neither posterior or anterior
36
position for shorter labor
walking, squatting, sitting, kneeling
gravity helps
37
anxiety in labour
secretion of catecholamines, inhibit uterine contractions and divert blood flow from the placenta
38
braxton hicks
- irregular contractions
- begin in early pregnancy may intensify as term progresses
- play a part in preparing the cervix
39
lightening
- or dropping
- fetus settles into true pelvis and fundus no longer pushing on diaphragm
- increase urge to void but can breathe better
- can occur 2-4 weeks before birth
40
vaginal discharge as labour nears
may increase
mucous plug is dislodged tearing small capillaries in the process
41
bloody show
- thick mucus mixed with pink or dark brown blood
- may begin a few days before labour or until it starts
42
weight loss before labour
may lose 0.5-1.5 kg just before labour begins
hormonal changes cause body to lose more water
43
descent
required for all other mechanisms of labour to occur
- station
44
engagement
presenting part passes the pelvic inlet
45
internal rotation
as the fetus is pushed downward cause head to turn until occiput is directly under the symphysis pubis (OA)
46
As the fetal head passes under the mother's symphysis pubis, it must ____________so it can properly negotiate the curve.
change from flexion to extension
47
go to hospital when
1st baby
second or more baby
contractions 4-5 min apart for 1 hour
each last 60 sec
5-7 mins apart for 1 hour
48
The three major assessments performed promptly on admission are
1-fetal condition
2- maternal condition
3- impeding birth
49
how to determine fetal presentation and position
Leopold maneuver
helps find back which is best place for hearing FHR
50
distinction between true labour and false labour
changes in the cervix
51
Women who are GBS positive will be _____ shortly after membranes rupture if not yet in labour
induced
52
stages of labour
* First stage (0-10 cm)
* Latent (early) (0-3 cm)
* Active (4-10 cm)
* Second stage (10 cm to birth of infant)
* Third stage: Delivery of placenta
* Fourth stage: 1-2 hours following birth
53
EFM associated with
increase intervention and c/s
54
pre-labour signs (5)
- contractions are irregular or do not increase in F,I, D
- walking tends to relieve or decrease contractions
- discomfort is felt in the abdomen or groin
- bloody show is usually not present
- there is no change in effacement or dilation of the cervix
55
episodic changes are
changes in the FHR that are not associated with uterine contractions.
56
periodic changes are
associated with uterine contractions.
57
Fetal bradycardia occurs when
FHR is below 110 beats/ min for 10 minutes or longer.
58
Causes of fetal bradycardia can be
fetal cardiac anomalies
hypoxia
maternal hypoglycemia
maternal hypotension
maternal hypothermia
prolonged umbilical cord compression
viral infections.
59
* Fetal tachycardia is a baseline FHR
greater than 160 beats/min that lasts for more than 10 minutes
60
causes of fetal tachycardia
maternal infection, fever, medication administration, or maternal dehydration, although it can also be a sign of fetal hypoxemia.
61
When fetal tachycardia occurs along with _____, ________ interventions are required
loss of baseline variability or with late decelerations
62
Variability describes
fluctuations or constant changes in the baseline FHR above or below the baseline
excluding accelerations and decelerations in a 10-minute window
- Variability causes a recording of the FHR to have a sawtooth appearance.
63
Absent variability is a
0-2 bmp change from baseline in a 10 min period
64
absent variability typically caused by
uteroplacental insufficiency
maternal hypotension
cord compression
fetal hypoxia
65
Minimal variability is FHR changes of
less than 6 bpm
66
minimal variability usually due to
medications given to mom, smoking, fetal sleep
67
If minimal variability lasts for ___________ it is considered atypical, but if it lasts longer than __________, it is considered an abnormal finding and the primary healthcare provider should be notified.
40 to 80 minutes,
80 minutes
68
Moderate variability is defined as
changes of 6-25 beats/min from the baseline FHR.
It is considered normal because it indicates good oxygenation of the central nervous system (CNS) and fetal well-being.
69
Marked variability occurs when there are
more than 25 beats/ min of fluctuation over the FHR baseline; the significance of marked variability is uncertain.
70
. Accelerations are
temporary, abrupt rate increases of at least 15 beats/ min above the baseline FHR that last 15 seconds but less than 2 min
71
prolonged acceleration.
an acceleration that lasts 2 to 10 minutes
72
An acceleration that lasts longer than 10 minutes may be considered
a baseline FHR change
73
Early decelerations
temporary gradual FHR decreases during contractions; the FHR always returns to the baseline rate by the end of the contraction.
usually good
74
The peak of deceleration occurs at the same time as
the peak of contraction
75
Variable decelerations are
abrupt decreases of at least 15 beats/min below base-line, lasting 15 seconds to 2 minutes in the full-term fetus.
76
variable decelerations suggest that the
umbilical cord is being compressed, sometimes because it is around the fetal neck (nuchal cord) or because there is inadequate amniotic fluid to cushion the cord.
77
Variable decelerations are further classified as
Uncomplicated: Deceleration that have acceleration at the beginning or end of contraction.
- Usually they are not clinically significant unless present with other abnormal FHR signs.
Complicated: Deceleration to 70 beats/min for more than 60 seconds, slow return to baseline.
If repetitive (>3) they are considered abnormal.
78
late decelerations indicate
that the placenta is not delivering enough oxygen to the fetus (uteroplacental insufficiency), and this could be due to chronic conditions in the mother or placental conditions.
79
Late decelerations that are accompanied by
________, _________ are abnormal and require immediate intervention by the health care provider
decreased variability and absent accelerations
80
Prolonged decelerations are
abrupt FHR decreases of at least 15 beats/min from baseline that last longer than 2 minutes but less than 10 minutes.
81
prolonged deceleration can be caused by
cord compression or prolapse, maternal supine hypotension, or regional anaesthesia.
82
A prolonged deceleration that lasts longer than 10 minutes may be
considered a change in the baseline rate
83
Sinusoidal pattern.
specific FHR pattern that has a smooth, wavelike appearance or undulating pattern with a wave frequency of 3 to 5 waves per minute and persists for 20 minutes or longer
84
sinusoidal pattern caused by
fetal response to medication provided to the mother in labour, such as opioids, or occur in a fetus who is anemic.
85
____________ is usually the first corrective response to a pattern of variable decelerations.
repositioning
86
Altered pushing and breathing techniques in the second stage of labour:
1. Changing from Valsalva (holding the breath and pushing) to open glottis pushing
2. Fewer pushing efforts during contractions
3. Pushing with every other contraction
4. Pushing only with the urge to push
87
Umbilical artery gases reflect the _________ and venous gases reflect ______________
status of the fetus
how well the placenta functions
88
normal FHR tracing:
baseline
variability
decel
accel
Baseline (110-160)
variability:
6-25 bpm (moderate)
<5 bpm for <40 min
decel:
- none or occasional uncomplicated variables or early decel
Accel:
- spontaneous present
89
abnormal FHR
baseline:
- <100 bpm
- >160 for >80 mins
variability
- > or equal to 5 bpm for >80 mins
decel
- repetitive complicated variable decel
- late decel > 50% of contractions
- single prolonged decel > 3min but < 10 min
acel
- usually absent
90
nitrazine paper
determine amniotic fluid
91
A common cause of a longer labour is a fetus that remains in a
OP
92
characterize labour when the fetus is in the OP position.
Intense and poorly relieved back and leg pain
93
Good positions to relieve the pain of back labour include the following:
* Sitting, kneeling, or standing while leaning forward
* Rocking the pelvis back and forth while on hands and knees to encourage rotation
* Side-lying (on the left side for an ROP position, on the right side for an LOP position)
* Squatting (for second-stage labour) increases the diameter of the pelvis, facilitating fetal rotation and descent
* Lunging by placing one foot in a chair with the foot and knee pointed to that side; lunging sideways repeatedly during a contraction for 5 seconds at a time.
94
The signs of rupture include
severe pain in the lower abdomen and abnormal FHR
95
The woman should push for a maximum of
6 sec s at a time
96
Pushing before full dilation can cause
maternal exhaustion, possible swelling of the cervix, and fetal hypoxia, thus slowing labour progress rather than speeding it up.
97
Perineal lacerations and often episiotomies are described by the amount of tissue involved:
* First degree: Involves the superficial vaginal mucosa or perineal skin
* Second degree: Involves the vaginal mucosa, perineal skin, and deeper tissues of the perineum
* Third degree: Same as second degree, plus involves the anal sphincter
* Fourth degree: Extends through the anal sphincter into the rectal mucosa
98
The main complication from an episiotomy is
PP pain
99
The fourth stage of labour is the
first 1 to 2 hours after birth when the mother and newborn become physiologically stable.
100
Pain threshold
also called pain perception,
is the least amount of sensation that a person perceives as painful
101
Pain tolerance
the amount of pain one is able to endure.
102
physical factors contribute to pain during labour:
* Dilation and stretching of the cervix
* Reduced uterine blood supply during contractions (ischemia)
* Pressure of the fetus on pelvic structures
* Stretching of the vagina and perineum
103
the stimulation of large-diameter nerve fibres temporarily
interferes with the conduction of impulses through small-diameter fibers.
104
signs of hyperventilation
dizziness, tingling, and numbness around her mouth and may have spasms of her fingers and feet
105
If she feels an urge to push before her cervix is fully dilated, the woman is taught to
blow in short breaths to avoid bearing down.
106
Encouraging women to hold their breath during pushing causes a
decrease in blood flow to the uterus and also to the fetus, and is not an effective method of breathing for pushing.
107
meperidine (demerol)
given if morphine allergy
otherwise not recommended
IV or IM
108
fentanyl
rapid onset an short duration of action
can cause resp depression
often used with epidural
109
nitrous oxide works best when a woman
inhales 30 sec before a contraction
110
Resuscitation of a newborn with respiratory depression we use e
Epinephrine and volume expanders such as normal saline or O-negative packed red blood cells are used for resuscitation with weight-based dosing
111
all benzos can disrupt
the variability of the fetal heart rate and delay the newborn infant's ability to regulate temperature
112
if epidural injected into subarachnoid space
the woman will become hypotensive, experience numbness around the mouth, ringing in the ears (tinnitus), and have jitteriness, which are symptoms that suggest injection into a vein.
113
An epidural block for labour is more accurately termed
analgesia than anesthesia
114
The most common adverse effects of epidural block are
hypotension and urinary retention
115
subarachnoid block
The effect of anaesthesia occurs
more rapidly and is more profound
he woman loses all movement and sensation below the block very quickly
effect lasts longer than that of the epidural block.
116
combined spinal epidural
- medication is inserted using an epidural needle and smaller spinal needle to access the subarachnoid space.
- The spinal needle is withdrawn and the epidural catheter is threaded through, remaining in place for ongoing top-ups.
- The advantage is rapid onset of pain relief with less motor block.
- Women tend to be more satisfied with the use of CSE for pain relief, as ambulation is possible with this technique
117
Local and pudendal blocks
administered in the vaginal-perineal area
118
pudendal block most often used
for pain relief for women requiring the use of vacuum or forceps for the birth in the absence of an existing epidural.
119
advantage to a pudendal nerve block
lack of effect on maternal cardiovascular system
no effect on fetal heart rate
120
GA adverse effects to mother
aspiration of gastric contents leading to rep problems
121
GA adverse effects to fetus
resp depression
keep cord clamping short
122
with opioids resp depression is most likely to occur
in the fetus
123
Augmentation
stimulation of contractions after they have begun already
124
induction is avoided
before 39 weeks and ideally after 40 weeks
125
readiness for labour induction when
The presence of increased fetal fibronectin at the cervix and a Bishop score above 6
126
induction indications
* Gestational hypertension (GH) or pre-eclampsia
* Ruptured membranes without spontaneous onset of labour, particularly with group B streptococcus (GBS) colonization
* Infection within the uterus (chorioamnionitis)
* Medical problems in the woman that worsen during pregnancy, such as diabetes or renal or pulmonary disease
* Fetal concerns, such as intrauterine growth restriction, prolonged pregnancy, or incompatibility between fetal and maternal blood types
* Placental insufficiency
* Intrauterine fetal death
127
CONTRAINDICATIONS TO INDUCTION
* Placenta previa (placenta grows and covers the cervix opening)
* Umbilical cord prolapse
* Abnormal fetal lie or presentation (e.g., footling breech)
* Active herpes infection externally or in the birth canal, which the infant can acquire during birth
* Pelvic structural deformities
* Suspected fetal macrosomia
* Previous classic (vertical) Caesarean incision or inverted T incision
* Previous uterine rupture
128
induction is more effective it
the cervix has ripened (effaced and dilated)
129
cervical ripening methods
prostaglandins - dissolve collagen network
E2= gel or insert Dinoprostone (cervidil)
E1= misoprostol, orally or intravaginally, more effective after 24 hours, associated with uterine tachysystole and FHR abnormalities
130
signs of tachysystole
10 or more uterine contractions in 20 minutes with or without alteration of FHR or pattern.
131
mechanical methods to stimulate contractions
- hydrostatic dilators: dilate cervix, placed in lower uterine segment, stimulates release of prostaglandins
- transcervical balloon dilators: 16fr and 30 ml balloon, traction, FHR monitoring before and after for 20-30 mins
- amniotomy: AROM
stimulates prostaglandins secretion, which stim labour
132
Three complications associated with amniotomy may also occur if a woman's membranes rupture spontaneously
1. prolapse of umbilical cord
2. infection
3. placental abruption
133
most common complications related to the use of oxytocin to stimulate contractions are
decreased fetal circulation from tachysystole
uterine rupture
134
AMNIOFUSION
- injection of warmed sterile saline or lactated Ringer's solution into the uterus via an intrauterine pressure catheter during labour after the membranes have ruptured.
- increase amniotic fluid
135
indications for forceps or vacuum
cervix fully dilated
membranes ruptured
bladder empty
fetal head engaged at +2 station
136
signs of vaginal hematoma
- severe and poorly relieved pelvic or rectal pain
-
137
3 types of uterine incisions
1. low transverse (preferred)
2. low vertical (minimal blood loss and birth of large fetus)
3. classic (most blood loss, most likely to rupture during another pregnancy, could be the only option)
138
Dystocia
labour that is progressing slowly.
139
RF for dysfunctional labour
* Advanced maternal age (>35 years of age)
* Obesity or high BMI (>40)
* Overdistention of uterus (polyhydramnios or multiple gestation)
* Abnormal fetal presentation
* Cephalopelvic disproportion (CPD)
* Overstimulation of the uterus
* Maternal fatigue, dehydration, fear
* Lack of analgesic assistance or extended analgesia/ anaesthesia
140
problems with the powers of labour
1. hypertonic labour: increased uterine muscle tone usually in the latent first stage
2. hypotonic labour: contractions are too weak to be effective, more likely with overdistended uterus
3. ineffective maternal pushing
141
problems with the passenger
1. fetal size: CPD, shoulder dystocia
142
how to manage shoulder dystocia
- apply firm pressure just above the symphysis pubis (suprapubic pressure) to push the shoulders towards the pelvis
- squatting or sharp flexion of the thighs against the abdomen
