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Flashcards in normal L & D Deck (97):
1

what is fetal lie and how is it dtm'd?

whether the fetus is longitudinal or transverse. Dtmd by Leopold's maneuvers.

2

Leopold's maneuvers

1) uterine fundus
2) sides of uterus
3) palpation of presenting part above pubic symphisis

3

PROM
incidence?

premature rupture of membranes. When membranes rupture at least 1 hr prior to onset of labor. Occurs in 10% of pg'ies

4

PPROM

preterm premature rupture of memranes - when membranes rupture before the onset of labor in a pt < 37 weeks gestation

5

prolonged PROM. Why is it bad?

PROM that occurs 18 hrs or more before labor. Increased risk of maternal & fetal infection.

6

how to diff'ate b/w ROM and stress incontinence?

pool, nitrazine, fern tests

7

pool test:

sterile speculum exam. + if collection of fluid in vagina. May need to ask pt to cough or bear down.

8

nitrazine test:

fluid found in vagina will turn blue when placed on nitrazine paper b/c its alkaline

9

fern test:

fluid is placed on a slide and allowed to dry. Microscopically, looks like fern pattern if its amniotic fluid. But careful, cervical mucus also ferns. Don't swab fluid directly from cervix.

10

what to do if pool, nitrazine, and/or fern tests are equivocal?

do u/s. Compare amt of amniotic fluid to that recorded in previous u/s.

11

what are the 5 components of Bishop score:

1) cervical dilation
2) cervical effacement
3) fetal station
4) cervical position
5) cervical consistency

12

how is Bishops' score calculated?

a value of 0 to 3 is given for 1, 2, and 3 of the 5 categories. Scores of 0 to 2 are given for categories 4 and 5. Total < 6 means unfavorable cervix. > 8 means favorable cervix for NSVD.

13

Bishops' scoring points for cervical dilation:

closed = 0
1-2 cm = 1
3-4cm = 2
> 5 = 3

14

Bishops' scoring points for cervical effacement

0-30% = 0
40-50% = 1
60-70% = 2
80-100% = 3

15

Bishops' scoring points for fetal station

-3 = 0
-2 = 1
-1, 0 = 2
> +1 = 3

16

what is fetal station? How is it measured?

how far the presenting part (usually fetal head) is from the ischial spine. If its at ischial spine, its 0. If lower than ischial spine, its +1. If its above ischial spine, -1. Measured by calc'ing # cm from pelvic inlet (-5 to +5)

17

Bishops' scoring points for cervical consistency:

firm = 0
medium = 1
soft = 2

18

Bishops' scoring points for cervical position

posterior = 0
mid = 1
anterior = 2

19

how long is a non-effaced cervix?

3-5 cm

20

what are the 3 typse of fetal presentation

breech vs. vertex vs. transverse

21

what is a compound presentation?

fetal vertex (back of head) + an extremity

22

cephalic vs. vertex

vertex is head-first, with flexed head. Cephalic = head-first but not flexed yet; may be extended.

23

what is fetal position?

is only true of vertex babies. Its the rltsp of baby's fontanelles or ears to mom's pelvic inlet.

24

what shape is the anterior fontanelle?

diamond

25

what shape is the posterior fontanelle?

triangle

26

true labor vs. prodromal (false) labor

true labor is regular ctr'ns that cause cervical dilation and/or effacement. False labor is irregular ctr'ns w/no cervical change.

27

induction vs. augmentation of labor

induction = attempt to begin labor
augmentation = increase the labor already present

28

methods used to augment labor:

pitocin, amniotomy

29

concerning fetal bradycardia =

2 mins or more of < 90 bpm

30

causes of reduced FHR variability:

fetal sleep, maternal intake of drugs, reduced fetal CNS fct (hypoxia)

31

early decels = ? 2/2 to what?

begin & end at same time as ctr'ns. 2/2 head compression => increased vagal tone.

32

variable decels = ? 2/2 to what?

decels that occur at any time and drop more precipitously (like a V). 2/2 umb cord compression. Can suggest nuchal cord.

33

late decels = ? 2/2 to what?

decels that begin at peak of ctr'n and slowly return to baseline after ctr'n has finished. 2/2 uteroplacental insuff'y.

34

why place a fetal scalp electrode?

repetitive decels or trouble w/external FHR monitoring. Provides more accurate and more sensitive monitoring.

35

CI's to fetal scalp monitoring?

maternal hepatitis or HIV or fetal thrombocytopenia

36

unit of measurement of uterine ctr'ns?

Montevideo unit. Need 200 for adequate labor.

37

when to obtain fetal scalp pH?

when FHR tracing is non-reassuring, need to check for hypoxia & acidemia.

38

what is a reassuring fetal scalp pH?

pH > 7.25

39

what is a non-reassuring fetal scalp pH?

pH < 7.2

40

normal fetal pulse ox?

> 30%

41

what are the cardinal movements of labor?

engagement
descent
flexion
internal rotation
extension
external rotation

42

what is engagement?

when fetal presenting part enters the pelvis

43

what is internal rotation?

rotation of fetal vertex so that it changes from occiput transverse (OT) to occiput anterior (OA) - saggital suture is parallel to AP diam of mom's pelvis
aka, baby's head turns to be face-down

44

stages of labor:

First = onset of labor until complete dilation and effacement of cervix
Second stage = from complete dilation and effacement to delivery of infant
Third stage = from delivery of infant to delivery of placenta

45

average length of first stage of labor:

10-12 hours in nulliparous pt
6-8 hrs in multiparous pt

46

what are the 2 phases of first stage?

latent & active phase

47

latent phase of first stage of labor =

onset of labor to 3-4cm dilation. Slow progression of cervical change.

48

active phase of first stage of labor =
Rate of cervical change?

from end of latent phase to > 9cm dilation. More rapid cervical change. 1 cm/h in nulliparous. 1.2 cm/h in multiparous

49

what are the 3 P's of labor?

Power, passenger, pelvis
Power = strength & freq of ctr'ns
Passenger = size of fetus
pelvis = needs to fit passenger

50

CPD
signs?

cephalopelvic disproportion (baby too big for pelvis)
signs = dvpt of fetal caput (back of head is cone-shaped), extensive molding of fetal skull, palpable overlapping sutures

51

what to do if rate of cervical dilation falls below 1 cm per hour?

assess the 3 P's, consider measuring ctr'ns w/IUPC. Dtm if vaginal delivery is possible.

52

what is normal length of second stage of labor?

< 2 hours in nulliparous pt, 3 hours if epidural is present.
> 1 hr in multiparous, 2 hours if epidural
(usually only lasts 30 mins in multips)

53

what is asynclitism?

head is presenting first but is tilted toward shoulder

54

what kind of FHR tracings are reassuring during 2nd stage of labor?

repetitive early decels, variable decels. Resolve quickly after each ctr'n. Normal variability.

55

what are non-reassuring FHR tracings during 2nd stage?

repetitive late decels, bradycardias, loss of variability

56

what to do if non-reassuring FHR tracings occur?

pt placed on L side to decrease IVC compression & increase uterine perfusion, supp'l O2. D/c pitocin if applicable. Give terbutaline if hypertonus or tachysystole was cause.

57

what is tachysystole?

+ 5 ctr'ns in 10 mins

58

what is hypertonus?

a ctrn lasting + 2 mins

59

what to do if FHR tracings remain non-reassuring after position change, O2, terbutaline?

assess fetal position & station to dtm if operative vaginal delivery can be performed

60

how do you know if an operative vaginal delivery can be performed?

fetal station m/b 2+ or more, m/b able to tell fetal position

61

what to do if meconium is in amniotic fluid?

use DeLee suction tube in infant's nose & mouth before delivering shoulders

62

what to do if you find a nuchal cord?

try to reduce the cord around the infant's head.
If delivery will be accomplished shortly, can clamp and cut the cord and deliver baby.
If shoulder dystocia is suspected, try to deliver infant w/cord intact.

63

indications for episiotomy?

need to hasten delivery
impending or ongoing shoulder dystocia

64

CI for episiotomy

expectation that there w/b a large perineal lac

65

2 types of episiotomies:

median (midline - vertical)
mediolateral (horizontal)

66

what are the 2 types of operative deliveries?

forceps delivery, vacuum-assisted delivery

67

what criteria need to be met before forceps and/or vacuum can safely be used?

full dilation of cervix
ruptured membranes
engaged head
station at least 2+
absolute knowledge of fetal position
no evidence of CPD
adequate anesthesia
empty bladder
experienced operator

68

what is a rare severe complication of vacuum delivery?

subgaleal hemorrhage (blood b/w skull periosteum and scalp aponeurosis. Can hold 50% of fetal blood and => shock)

69

which is better, forceps or vacuum?

no sig diff in neonatal complications b/w the two
vacuum => higher rate of cephalohematoma & shoulder dystocia
forceps => higher rate of facial n. palsy, higher rate of maternal 3rd and 4th degree lacs

70

how long does placental separation usually take?

5-10 mins from delivery of infant. Up to 30 mins.

71

if it is certain that second stage has been completed (no twin), what can be given to decrease placental delivery time and blood loss?

oxytocin

72

what are the 3 signs of placental separation?
how many of these need to be present before attempting to deliver placenta?

1) cord lengthening
2) gush of blood
3) uterine fundal rebound

all 3 need to be present

73

what does the OB have to do while pt is bearing down to deliver placenta?

apply traction to umb cord, apply suprapubic P to prevent uterine inversion or prolapse

74

retained placenta is common in ____.

preterm deliveries

75

what is placenta accreta?

where placenta has invaded into or beyond endometrial stroma

76

how to remove a retained placenta?

manual extraction, or curretage

77

diff degrees of perineal lacs:

1st degree = mucosa or skin only
2nd degree = extend into perineal body but not anal sphincter
3rd degree = extend into or completely through anal sphincter
4th degree = anal mucosa is torn, rectum involved

78

how are 1st degree lacs repaired?

interrupted sutures

79

how are 2nd degree lacs repaired?

in layers, starting at apex of lac. First repair vaginal mucosa. Then subQ, then skin with a subcuticular stitch.

80

how are 3rd degree lacs repaired?

first repair anal sphincter w/interrupted sutures. Then continue w/second degree repair.

81

how are 4th degree lacs repaired?

meticulously close anal mucosa to prevent fistula. Then carry on w/3rd degree repair.

82

what is the rate of c/s in U.S. today?

29%

83

what is most common indication for C/S?

previous c/s, or
failure to progress in labor

84

what is VBAC?

vaginal birth after c/s

85

what kind of incision needs to be previous c/s in order to try VBAC?

LTCS (Kerr incision)
or Kronig incision (low vertical incision)

86

rate of rupture of prior uterine scar during TOLAC?

0.5-1.0%

87

signs of uterine rupture during TOLAC?

ab'l pain
FHR decels
FHR bradycardia
decrease of P on IUPC
maternal sensation of "pop"

88

what narcotics can be given and when?

morphine, fentanyl, nalbuphine, butorphenol
given early in labor. Don't give close to delivery b/c infant w/b depressed.

89

when is a pudendal blocked used?

forceps or vacuum delivery

90

when is local anesthetic injection used?

episiotomy
repair of lacs

91

when is epidural & spinal anesthesia used?

when pts want analgesia throughout all of labor

92

where is epidural catheter placed?

L3-L4

93

diff b/w epidural and spinal anesthesia?

epidural is when a catheter is placed in epidural space and continuous infusion is given to decrease (but not completely block) sensation below L3/L4.
Spinal anesthesia is where anesthetic is bolused into spinal canal => more rapid anesthesia. Used in c/s

94

complication of epidural and spinal anesthesia?

maternal hypotension => decreased placental perfusion, fetal bradycardia

maternal resp'y depressin

spinal headache 2/2 loss of CSF in 1% of pts

95

what kind of anesthesia is used in emergent C/S?

general anesthesia

96

risks of general anesthesia?

maternal aspiration
hypoxia to mom and baby during induction

97

indications for emergency C/S?

placental abruption
fetal bradycardia
umbilical cord prolapse
uterine rupture
hemorrhage 2/2 placenta previa