Labor Flashcards
(117 cards)
1
Q
the physiologic process by which a fetus is expelled form the uterus
A
Labor
2
Q
what brings about demonstrable effacement and dilatation of the cervix during labor
A
Uterine contractions
3
Q
how open the internal os is
A
dilation
4
Q
what measurement is considered complete dilation?
A
10 cm
5
Q
length of the cervix (how thick it is)
Difference between the internal and external cervical os
A
Effacement
6
Q
- degree of descent of the presenting part of the fetus
- Measured in cm from the ischial spines
- Can measure it in thirds
A
station
7
Q
consistency types of cervix to dx labor?
A
Soft, medium or firm
More firm means they are not in labor
8
Q
positions of cervix for dx of labor
A
Anterior, mid position or posterior
9
Q
In order to diagnosis labor, there MUST BE ?
A
cervical change
10
Q
Contractions without cervical change could represent false labor are called?
A
Braxton Hicks contractions
11
Q
what scoring determines how favorable the cervix is for labor
A
Bishop score
Score >8 = favorable cervix for labor
12
Q
Howto check the status of membranes (4) to dx labor?
A
- Ferning
- Nitrazine
- Presence of pooling
- AFI
13
Q
the rupture of membranes during labor
A
Spontaneous rupture of membranes
14
Q
the rupture of membranes before the onset of labor
A
Premature rupture of membranes
15
Q
Major pathogen in neonatal sepsis
A
group B strep
16
Q
how to screen group B strep
A
> 35 weeks all pregnant women have ano-vaginal swab
17
Q
tx for positive group B strep
A
Treatment in labor - PCN
- If allergic - obtain sensitivities usually use Erythromycin or Clindamycin
- If allergic to penicillin and don’t have sensitivities = Vancomycin
18
Q
- Try to avoid if possible
- Can cause nonreassuring fetal status and fetal respiratory depression
A
IV pain meds
19
Q
MC pain management in labor
A
Regional Anesthesia - Epidural Anesthesia
- Epidural catheter placed in L3-L4 interspace
- Initial bolus of anesthetic given then a continuous infusion started
- Offered to patients having a vaginal delivery
20
Q
Complications with epidural anesthesia
A
- Maternal hypotension
- Maternal respiratory depression
- Spinal headache
21
Q
CI for epidural anesthesia
A
- Maternal bleeding disorder or use of LMWH within 12h
- Patient refusal
22
Q
- One time dose placed directly into spinal canal
- Used for cesarean delivery
- Complications and contraindications similar to epidural
A
Spinal Anesthesia
23
Q
- Provides perineal anesthesia
- Used with operative vaginal deliveries or for extensive perineal repairs after delivery
A
Pudendal Block
24
Q
Used for cesarean delivery in emergent or urgent settings
A
General Anesthesia
25
complications of General Anesthesia
during labor
* Maternal aspiration
* Risk of hypoxia to mother and fetus
26
indications for induction of labor
maternal, fetal or placental reasons
27
labor induction success is related to Bishop score how?
* Bishop Score < 5 may lead to failed induction 50% of time
* Bishop Score < 5 indicates need for cervical ripening
28
Prostaglandins MOA for labor induction
Help ripen and dilate the cervix
Cause dissolution of collagen bundles and increase water uptake by cells
29
2 Prostaglandins used for labor induction
1. Cervidil –PGE2, vaginal
1. Cytotec – PGE1, vaginal or oral
30
SE of prostaglandins
1. Tachysystole, fever, vomiting, diarrhea
1. Uterine rupture
31
CI of prostaglandins
1. History of cesarean section
1. myomectomy (peeling tissue from the uterus)
1. hysterotomy
32
Identical version of oxytocin released from posterior pituitary leading to uterine contractions
Pitocin
33
SE of Pitocin
1. Uterine rupture (but not as likely as the prostaglandins)
1. Hyponatremia
1. Hypotension
1. Amniotic fluid embolism
34
CI of pitocin
1. Fetal distress
1. hypersensitivity
35
2 manual/"tool" methods of labor induction
1. Balloon catheter (Cook)
1. Laminaria - Rolled up seaweed that pulls out water and in turn dilates the cervix
36
Amnio hook used to puncture amniotic sac can help with what?
labor induction
37
Intervening to increase the already present contractions?
what medication is used?
Augmentation of Labor
pitocin
38
types of operative vaginal delivery
1. Forceps
1. Vacuum – used more often now
39
indications for operative vaginal delivery
1. Prolonged second stage of labor
1. Maternal exhaustion
1. Hasten delivery for fetal compromise
40
Abdominal delivery of a fetus
c-section
41
stages of labor
1. From onset of labor to complete cervical dilation
1. From complete cervical dilation to expulsion of fetus
1. From delivery of infant to delivery of placenta
1. From delivery of placenta to one hour postpartum
42
what is the labor curve (old way)?
Freidman’s curve (1950s)
* Good guideline for expected progression in labor
* Helps determine abnormal labor patterns
43
what does the new labor curve include?
1. Spontaneous labor
1. Induced labor
44
difference between spontaneous and induced labor on labor curve
1. Spontaneous labor
- Labor progresses similarly for multips and primips until 6cm
- Defined active phase at 6cm - After 6cm, multips progressed much quicker
2. Induced labor
- Latent phase of labor is significantly longer in induced labor compared with spontaneous labor - Active phase of labor is similar between the two groups
45
two phases of the 1st stage of labor
1. Latent phase - From onset of labor with slow cervical dilation to ~6 cm; slower phase
1. Active phase - From ~6cm to complete dilation (10cm); Faster rate of cervical change
- Nulliparous patient: 1.2cm/h
- Multiparous patient: 1.5cm/h
46
Factors affecting active stage of labor:
3 P’s
Power – uterus
Passenger – fetus
Pelvis – baby has to fit out of
47
refers to the force generated by the contractions of the uterine myometrium
Power - uterine contractions
48
uterine contractons/power activity can be assessed by ?
1. observation of the mother
1. palpation of the fundus
1. external tocodynamometry
49
Contraction force can also be measured by direct measurement of intrauterine pressure using an internal pressure monitor using?
IUPC – Intrauterine Pressure Catheter
50
Generally how many contractions in a ___ minute period is considered adequate labor
3-5 contractions
10 min
51
Adequate labor is how many Montevideo units in 10 min
> 200
Can only measure Montevideo units with IUPC
52
if < 200 Montevideo units in 10 minutes, what can be given to increase power?
Start pitocin to augment labor
53
Fetal variables that can affect labor:
1. Fetal Lie – longitudinal, transverse or oblique
2. Fetal presentation
3. Attitude - Degree of flexion or extension of the fetal head
4. Position - Relationship between the fetal presenting part to the right or left side of the birth canal
5. Station
6. Number of fetuses
7. Presence of fetal anomalies – hydrocephalus, sacrococcygeal teratoma
54
fetal in vertex position, what is the reference point (triangle feeling)
occiput
55
fetal in breech position, what is in reference point
sacrum
56
what are the different fetal presentations
vertex (head down), breech (butt down), shoulder, compound (something in front of the baby-arm) and funic (umbilical cord)
57
how to dx of fetal presentation and position
1. Leopolds maneuver (abdominal palpation)
1. Vaginal examination - Palpation of fetal sutures and fontanels
1. Ultrasound
58
what is the Leopolds maneuver (abdominal palpation)?
1. Mother lies supine
1. determines: Fetal lie, Estimate fetal wt, Fetal position, Fetal presentation
1. Difficult if mother is obese, polyhydramnios or multifetal gestation
59
indications for c-section
* Any position other than vertex
* Macrosomia - fetus >5k g; if DM mother - 4.5k g
* Small pelvic outlet - Cephalopelvic disproportion
* Active phase arrest of labor
* Prolonged second stage of labor
* Umbilical Cord Prolapse
60
Small pelvic outlet can result in ?
cephalopelvic disproportion - Passenger is too large for the pelvis; need c-section
61
no progression in cervical dilation in patients who are at least 6-cm dilated with rupture of membranes despite 4 hours of adequate uterine activity or 6 hours of inadequate uterine activity with oxytocin augmentation
Active phase arrest of labor
Indication for cesarean delivery
62
more than 3 hours of pushing in nulliparous individuals and 2 hours of pushing in multiparous individuals
Prolonged second stage of labor
Indication for cesarean delivery
63
RF for Umbilical Cord Prolapse
* Artifical rupture of membranes
* Unengaged fetal head
OBSTETRICAL EMERGENCY! - Indication for cesarean delivery
64
* Interval between full cervical dilation to delivery of the infant
* Characterized by descent of the presenting part through the maternal pelvis and expulsion of the fetus
2nd stage of labor
65
Indications of second stage:
* Pelvic/rectal pressure
* Mother has active role of pushing to aid in fetal descent
66
Examining the fetal head during the second stage may become difficult due to ?
molding - Alteration of the fetal cranial bones to each other as a result of compressive forces of the maternal bony pelvis
67
Localized edematous area on the fetal scalp caused by pressure on the scalp by the cervix
caput
68
degrees of perineal lacerations
* First degree - Injury to perineal skin and vaginal mucosa only
* Second degree - Injury to the perineal body
* Third degree - Injury through the external anal sphincter
* Fourth degree - Injury through the rectal mucosa
69
what is Episiotomy
* Surgical incision of female perineum
* Increases diameter of soft tissue pelvic outlet to allow delivery of a fetus
* ACOG supports restricted use of episiotomy
70
rationale for episiotomy
* Reduction in third or fourth degree lacerations
* Ease of repair
* Reduction in neonatal trauma
* Reduction in shoulder dystocia
71
indication for episiotomy
fetal distress
72
complications of episiotomy
* Increase vaginal bleeding
* Increase postpartum pain
* Unsatisfactory anatomic results
* Sexual dysfunction
* Increase risk of infection
73
types of episiotomy
1. midline
2. mediolateral
74
Difficulty in delivery of the anterior shoulder due to impaction of the anterior shoulder on the pubic symphysis
Shoulder Dystocia
75
maternal RF for shoulder dystocia
* Fetal macrosomia
* Diabetes – overt and gestational
* Previous shoulder dystocia
* Maternal obesity
* Postterm pregnancy
* Prolonged second stage of labor
* Operative vaginal delivery
Increased morbidity and mortality to mother and fetus
76
fetal complications of shoulder dystocia
* Fracture of humerus and clavicle
* Brachial plexus injuries
* Phrenic nerve palsy
* Hypoxic brain injury
* Death
77
how to dx shoulder dystocia
Made when routine delivery maneuvers fail to deliver the anterior shoulder
77
management for shoulder dystocia
1. Call for help
1. Episiotomy
1. McRoberts maneuver – sharp flexion of maternal hips
1. Suprapubic pressure
1. Delivery of posterior shoulder
1. Other maneuvers – Rubin, Wood’s corkscrew
1. Symphisiotomy
1. Zavanelli – replace infants head back into the pelvis and do a c-section
78
Three signs of placental separation:
1. Lengthening of umbilical cord
1. Gush of blood
1. Fundus becomes globular and more anteverted against abdominal hand
79
Placenta is delivered using what method?
* one hand on umbilical cord with gentle downward traction
* Other hand on abdomen supporting the uterine fundus
80
Risk factor for aggressive traction is ?
uterine inversion
* Obstetrical emergency!!
* Immediate replacement of fundus required - Manually or surgically
81
* Refers to the time from delivery of the placenta to 1 hour immediately postpartum
* Blood pressure, uterine blood loss and pulse rate must be monitored closely
4th stage of labor
82
causes of high risk postpoartum hemorrhage
* **Uterine atony – MCC**
* Retained placental fragments
* Unrepaired lacerations of vagina, cervix or perineum
83
how to dx postpartum hemorrhage (how many cc?)
Blood loss >500c in a vaginal delivery or >1000cc in a cesarean delivery
84
tx for postpartum hemorrhage
* Removal of placental fragments or repair of lacerations
* Additional IV access
* Type and cross match for blood
* Medications for uterine atony: Pitocin, Methergine, Cytotec, Hemabate
85
Refers to changes in the fetal head position during its passage through the canal.
cardinal movements of labor
86
7 distinct movements of labor
1. Engagement
1. Descent
1. Flexion
1. Internal rotation
1. Extension
1. External rotation/restitution
1. Expulsion
87
* Passage of the widest diameter fetal presenting part below the plane of the pelvic inlet
* The head is said to be engaged if the leading edge is at the level of the ishial spines.
what movement of labor
engagement
88
movement of labor - Refers to the downward passage of the presenting part through the bony pelvis
descent
89
movement of labor - Occurs passively as the head descends due to the shape of the bony pelvis.
flexion
90
type of flexion that occurs naturally but complete flexion usually occurs only in the labor process
partial
91
type of flexion that allows the fetal head’s smallest diameter to fit through the pelvis
complete flexion
Smallest diameter = subocciptobregmatic diameter
92
* Rotation of the fetal head from occiput transverse to occiput anterior or posterior position
* Occurs passively due to the shape of the bony pelvis
internal rotation
93
* Occurs when the fetus has descended to the level of the vaginal introitus
* When occiput is just past the level of the symphysis, the angle of the birth canal changes to upward position
extension
94
* As the head is delivered, it rotates back to its original position prior to internal rotation
* Head aligns anatomically with the fetal torso
* The release of the passive forces on the fetal head allows it to return to appropriate position
External Rotation/Restitution
95
* Delivery of the fetus
* Downward traction allows release of the shoulder and the fetus is delivered
Expulsion
96
Normal fetal heart rate (FHR) ?
110-160bpm
97
common causes of fetal bradycardia
* Congenital heart block - Seen in infants whose mothers suffer from SLE
* Maternal hypotension
98
common causes of fetal tachycardia
1. Infection
1. Terbutaline
99
what is considered the baseline of FHR?
Mean bpm over a 10 minute window
100
what is variability in FHR?
Moment to moment variation from the baseline
The babies HR changes from beat to beat (145, 152, 150, 156, etc.)
101
4 different types of variability seen in FHR
* Absent - 0 bpm of variation; worrisome
* Minimal - 1-5 bpm of variation; Common when asleep or inactive
* Moderate - considered normal; 5-25 bpm of variation
* Marked - >25 bpm of variation; Worrisome!
102
when can accelerations be seen in FHR
| weeks
* > 32 weeks: at least 15bpm and lasting 15s
* < 32 weeks: at least 10bpm and lasting 10s
103
* these can be normal (they go away after contraction)
* Begin and end approximately at the same time as contractions
* Result of head compression
* No intervention required
what type of decelerations
Early decelerations
104
* Begin at peak of contraction and slowly return to baseline after the contraction has finished
* Result of uteroplacental insufficiency (not enough reserve to keep the babies HR up during the contraction)
* requires intervention
what type od deceleration
late decelerations
105
interventions for late decelerations
* Position, Oxygen, Stop Pitocin, Check cervix, Fluid Bolus
* Consider assisted delivery or cesarean delivery with more than 50% of the contractions
106
* Can occur at anytime
* Drop more precipitously
* Result of cord compression
* Intervention may be necessary
what type of deceleration
Variable decelerations
107
possible intervention for variable decelerations
Amnioinfusion – infusion of saline into amniotic sac
108
Smooth sine wave in FHR, what is this waveform
Sinusoidal waveform
109
common cause of Sinusoidal waveform
fetal anemia
110
category I of FHR tracings
1. baseline FHR 110-160
1. moderate FHR variability
1. absence of late or variable decelerations
1. accelerations maybe present or absent
111
Category II of FHR tracings
1. includes all EFHRT not categorized as category I or III
112
category III FHR tracings
1. absent FHR variability with any of the following:
- recurrent late decelerations
- recurrent variable decelerations
- bradycardia
2. sinusoidal pattern
113
Evaluates the fetal response to a transient reduction in fetal oxygen delivery during uterine contractions
contraction stress test
114
use what to achieve 3 contractions in 10 mins?
pitocin
115
indications for contraction stress test
Evaluate fetal status before induction of labor
116
interpretations for contraction stress test
1. Positive – BAD – C-section! - Nonreassuring fetal heart tracing
- With 50% or greater of contractions, a late deceleration is occurring
2. Equivocal – Wait and See
- Nonpersistent late decelerations
3. Negative – Good to Go
- Reassuring fetal heart tracing
