*Progression of Labor

Question 1

Cardinal Movements of Labor

Answer 1

ED FIRE REX:

Engagement, Descent, Flexion, Int Rot, Extension, Ext Rot, EXpulsion

Question 2

What happens in Engagement?

Answer 2

Biparietal Diameter (BPD) passes through pelvic inlet. 0 station on vaginal exam. Head is in OT or OA position.

Question 3

What happens in Internal Rotation?

Answer 3

OT position –> OA position

Question 4

How long is average stage 1 for nulliparous woman? Multiparous woman?

Answer 4

10-12 hrs nullip. 6-8 hrs multip.

Question 5

Rate of cervical change in active phase for a nulliparous woman? multiparous woman?

Answer 5

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.

Question 6

What is a Friedman curve?

Answer 6

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

Question 7

What are the 3 Ps?

Answer 7

Power (strength/frequency of contractions)
Passenger
Pelvis

Question 8

What is Active Phase Arrest? What do you do?

Answer 8

no change in cervical dilation or station for 2 hrs (despite adequate Montevideo units during active phase) –> C-section

Question 9

What is considered a prolonged Stage 2 of Labor?

Answer 9

> 2 hrs nullip (>3 if epidural)

>1 hr multip (>2 epidural)

Question 10

What is “laboring down”/”passive descent”?

Answer 10

1 hr of no pushing given to epidural pts.

Question 11

What fetal heart tracings are common in Stage 2 of Labor?

Answer 11

repetitive early and variable decels

Question 12

What are signs of nonreassuring fetal status?

What should you do to tx?

Answer 12

repetitive late decels, bradycardias, loss of variability

Put O2 face mask, turn on Left Side, D/C Oxytocin until reassuring tracing occurs

Question 13

What is uterine hypertonus?

Answer 13

single contraction lasting 2+ minutes

Question 14

What is tachysystole?

Answer 14

5+ contractions in 10 minutes

Question 15

If prolonged decels is due to hypertonus or tachysystole, what should you do?

What if the nonreassuring pattern doesn’t resolve?

Answer 15

Tx: Dose of Terbutaline (to help relax uterus)

If no help, assess fetal position and station.

Question 16

If meconium is suspected/confirmed, what should be used on the newborn?

Answer 16

DeLee suction trap to aspirate meconium from the airway

Question 17

What maneuver is done if a delivery needs to be expedited? How is it done? What is the risk involved?

Answer 17

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

Question 18

What should be done once the anterior shoulder is visualized?

Answer 18

Direct upward pressure is exerted to deliver the posterior shoulder

Question 19

What risk is increased with the use of episiotomies?

Answer 19

Rate of 3⁰ and 4⁰ lacerations increase

Question 20

Location of a midline episiotomy?

Answer 20

from posterior fourchette into perineal body

Question 21

Location of mediolateral episiotomy?

Answer 21

from 5 o’clock or 7 o’clock position on perineum and cut laterally. More painful, infection but less 3⁰ and 4⁰ lacerations

Question 22

Forceps/vacuum delivery: safe indications for use

Answer 22

Full cervical dilation
Ruptured membranes
Engaged head
\+2 station
Absolute knowledge of fetal position
No evidence of CPD
Adequate anesthesia
Empty bladder
*Experienced operator*

Question 23

Complications associated with Forceps delivery?

Answer 23

Facial n. palsy
Facial/head bruising
Lacerations (head, cervix, vagina, perineum)
Skull fx. (rare)

Question 24

Complications associated with Vacuum delivery?

Answer 24

Lacerations (scalp)
Cephalohematomas
Subgaleal hemorrhage (rare but emergency)

Question 25

Timeframe for normal Stage 3 of Labor?

Answer 25

Up to 30 minutes (usually 5-10 minutes, placenta will come out)

Question 26

3 Signs of Placental Separation

Answer 26

Cord lengthening
Gush of blood
Uterine fundal rebound (as placenta detaches from uterine wall)

Question 27

When the patient begins bearing down for delivery of the placenta, it is imperative that what?

Answer 27

to apply suprapubic pressure to keep uterus from inverting or prolapsing

Question 28

When is the diagnosis of retained placenta made? When should you suspect retained placenta?

Answer 28

If placenta does not deliver in 30 minutes.

Common in preterm deliveries (esp. previable deliveries), placenta accreta

Question 29

Tx. Retained Placenta

Answer 29

Manual extraction of placenta by intrauterine insertion of hand, and if incomplete, then curettage

Question 30

1⁰ Laceration

Answer 30

Involves mucosa or skin (superficial)

Question 31

2⁰ Laceration

How is it repaired?

Answer 31

Extend into perineal body but do not involve anal sphincter

• Vaginal mucosa repaired down to level of hymenal ring

Question 32

3⁰ Laceration

Answer 32

Extend into anal sphincter

Question 33

4⁰ Laceration. What should always be done to check?

Answer 33

Extend into rectum

Always perform rectal exam to check for “button hole lacerations” wherein rectal mucosa is torn but sphincter is intact

Question 34

Maternal mortality from Caesarean delivery

Answer 34

0.01-0.02%

Question 35

Indications for 1⁰ C-section

Answer 35

*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

Question 36

When can a VBAC be performed?

Answer 36

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.)

Question 37

What is the greatest risk during a TOLAC (trial of labor after C-section)?

Answer 37

Rupture of prior uterine scar (0.5-1.0% risk)

Question 38

Signs of Uterine Rupture

Answer 38

Abdominal pain, FHR decels/bradycardia, sudden decrease of pressure on IUPC, maternal sensation of a “pop”