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135 Cards in this Set
- Front
- Back
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The first stage of labor begins with the ________ and ends with __________
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-Onset of labor
-Full cervical dilation |
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First Stage-Latent Phase
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-Begins with regular contractions
-Ends when there is an increase in rate of cervical dilation (usually 3-4cm) |
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First Stage-Active Phase
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-Increased rate of cervical dilation
-Has 3 phases: Acceleration, Phase of max slope, Deceleration |
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First Stage-Active Phase-Acceleration Phase
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gradual increase in the rate of dilation initiates the active phase and marks a change to rapid dilation
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First Stage-Active Phase-Phase of Max Slope
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Period of active labor with the greater rate of cervical dilation
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First Stage-Active Phase-Deceleration phase
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During the terminal portion of the active phase, the rate of dilation may slow until full cervical dilation
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Second Stage of Labor
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interval between full cervical dilation and delivery of the neonate
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Third Stage of Labor
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Interval between full delivery of the infant and delivery of the placenta
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Fourth Stage of Labor
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Follows delivery and concludes with resolution of the physiologic changes of pregnancy, usually by 6 weeks
(1. Reproductive tract returns to nonpregnant state 2. Ovulation resumes) |
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Cardinal Movements of Labor
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-Engagement
-Descent -Flexion -Internal Rotation -Extension -External Rotation -Expulsion |
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Engagement
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-Descent of the biparietal diameter of the fetal head below the plane of the pelvic inlet
-Lowest portion of the occiput is at or below the level of the maternal ischial spines (station 0) |
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Descent
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Descent of fetal head to the pelvic floor is an important event of labor
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When does the highest rate of descent occur during labor?
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During the deceleration phase of the first stage and during the second stage of labor
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Flexion
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Flexion of the fetal head is a passive movement that permits the smallest diameter of the fetal head (suboccipitobregmatic diameter) to pass through the maternal pelvis
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Internal Rotation
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the fetal occiput rotates from its original position (usually transverse) toward the symphysis pubis (occiput anterior) or less commonly toward the hollow of the sacrum (occiput posterior)
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Extension
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the fetal head is delivered by extension from the flexed position as it travels beneath the symphysis pubis
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Expulsion
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Further descent brings the anterior shoulder of the fetus to the level of the symphysis pubis
-After the shoulder is delivered under the symphysis pubis, the rest of the body is usually expelled |
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Mgt of Normal Labor and Delivery: History
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-Onset, strength, and freq of contractions
-Leakage of fluid -Vaginal Bleeding -Fetal Movement -Maternal allergies -Medications -Last oral intake -Review of prenatal lab tests and hx including gestationl age, parity, and size of infants previously delivered vaginally |
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Mgt of Normal Labor and Delivery: PE
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-Maternal VS (pulse, BP, Respiration, Temp)
-Fetal Heart RAte -Freq and Intensity of contractions -Fetal presentation and estimated fetal wt -Sterile speculum -Sterile digital vag exam -Cervical dilation -Cervical effacement -Fetal station |
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Parts of sterile speculum exam for normal labor and delivery
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-Vulvar, vag, cervical inspection
-Vag pooling and bleeding eval -Nitrazine/fenering (for leakage of amniotic fluid) -Wet mount, G/C DNA probe or culture, GBS culture (if indicated) |
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What is cervical effacement
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length of cervix, expressed as the percent change from full length
(100%=paper thin rim of cervix detected) |
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What is fetal station
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distance in cm b/w the presenting bony part and the plane of the ischial spines
-Station 0: level of spines -Above the spine is negative number (1-to -5) |
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Most amenable pelvis type for L&D
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Gynecoid and Anthropoid
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Admission Orders for Pts w/o prenatal care
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Hep B surface antigen
HIV ABO blood group and antibody screen Urine culture and tox screen Rubella IgG CBC Syphilis |
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Admission Orders for Pts w/ prenatal care
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Urine testing (for protein and glucose)
CBC Blood bank for cross matching |
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Mgt of Labor: Quality and Freq of uterine contractions
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Assessed regularly by palpation, tocodynamometer, intrauterine pressure catheter
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Mgt of Labor: Fetal Heart Rate
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Intermittent auscultation, continuous electronic Doppler monitoring, fetal scalp electrode
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Indications of Induction of Labor
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-Abruptio placentae, chorioamnionitis, gestational HTN
-PROM, postterm pregnancy, preeclampsia, eclampsia -Maternal medical conditions (eg DM, renal disease, chronic pulm disease, chronic HTN) -Fetal compromise (eg severe fetal growth restriction, isoimmunization) -Fetal demise -Elective inductions for gestational age >39 wks for logistical issues such as rmote access to care, pyschosocial reasons, and hx of rapid deliveries |
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Factors in Bishop Score
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Dilation
Effacement Station Consistency Position |
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What bishop score indicated the likelihood of vag delivery
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over 8
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Cervical ripening
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-Used to soften cervix if bishop score is low
-Methods: Prostaglandin E1, Cervidil, Prepidil, Misoprostol |
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SE of prostaglandin induction
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-Uterine hyperstimulation (reversible with terbutaline)
-fever, vomiting, diarrhea |
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Contraindications for Prostaglandin use for cervical ripening
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-Hx of uterine surgery or prior C-section
-Allergy to medication -Active vag bleeding |
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Mechanical methods of labor inducation and cervical ripening
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-Membrane stripping
-Amniotomy -24 French transcervical foley balloon with 30 mL bulb -Hygroscopic dilators -Double ballon device |
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Indication for Oxytocin Administration
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-Used for induction and augmentation
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When should augmentation be considered
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-Protraction or arrest disorders of labor
-Presence of hypotonic uterine contraction pattern |
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How do you know when the oxytocin dosage for augmentation is adequate
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When cervical dilation is 1 cm/hr in active phase of labor
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Most common complications of oxytocin administration
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-Uterine tachysystole-->uteroplacental hypoperfusion
-Prolonged use: 1.Postpartum uterine atony and hemorrhage 2. Water intoxication and hyponatremia (oxytocin structurally resmebles ADH) |
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Rapid infusion of oxytocin can result in ______-
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hypotension
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Latent phase prolongation
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(W/o induction)
If exceeds -20 hrs for nulliparous -14 hrs for multiparous |
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Protraction of Active Phase
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Rate of cervical change is
-<1.2 cm/hr nulliparous -<1.5cm/hr multiparous Occurs over 2 hour period depsite adequate contractions |
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Protraction of Second stage of labor
(Time frame) |
-Nulliparous: After 2 hours of pushing
-Parous: After 1 hour of pushing (add'l hour may be allowed if epidural anesthesia is used) |
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When does arrest of descent occur
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No apparent descent of the presenting part over a 1 hr period of pushing during the second stage
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How long is the 3rd stage of labor usually?
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averages 10 min
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When is the third stage of labor prolonged?
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Lasts longer than 30 minutes
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What may cause abnormal labor?
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-Power
-Passenger -Pelvis |
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Risks for an abnormal first stage of labor
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-increased maternal age
-DM -HTN -PROM -Macrosomia -Epidural anesthesia-Chroioamnionitis -Hx of complications like perinatal death -Amniotic fluid abnormalities |
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Risks for an abnormal second stage of labor
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-Increased first stage
-Occiput posterior position -Epidural anesthesia -Nulliparity -Short maternal stature -Increased birth weight -High station at complete cervical dilation |
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Interventions for Abnormal Labor
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-Analgesia/anesthesia
-Amniotomy -Augmentation of labor via oxytocin -Uterine contraction monitoring |
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Fetal HR Interpretation: Category I
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-Baseline Rate: 110-160 beats/min
-Baseline FHR variability: moderate -Late or variable decels: absent -Early decels: Present or absent -Accels: Present or Absent |
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Fetal HR Interpretation: Category III
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-Absent baseline FHR variability and any of the following:
~Recurrent late decels ~Recurrent variable decels ~Bradycardia -Sinusoidal pattern |
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Normal fetal heart rate
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110 to 160 beats per min
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Baseline fetal heart rate
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Lasts for at least 2 min during a 10 min section
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Fetal bradycardia
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Baseline rate <110 bpm
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Causes of fetal bradycardia
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fetal compression or hypoxemia
Maternal hypothermia |
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Fetal tachycardia
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HR above 160 bpm
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MCC os fetal tachycardia
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maternal fever or infection
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Def of variability
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Presence of instantaneous variation in the HR from beat to beat (most reliable when measured with a fetal scalp electrode)
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Absent Variability
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Undetectable variation in HR
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Minimal Variability
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Detectable variation <=5bpm
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Moderate Variability
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Variation from 6 to 25 bpm
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Marked Variability
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Variation >25 bpm
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Accelerations for GA >32wks
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An increase in fetal heart rate of at least 15 bpm that lasts for at least 15 seconds
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Accelerations for GA <32 wks
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An increased in FHR of at least 10 bpm for 10 seconds
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When is fetal heart tracing considered reactive
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2 accelerations within 10 minutes
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Sinusoidal fetal heart tracing
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persistent smooth undulating pattern with a freq of 3 to 5 cycles/min
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What should be considered when sinusoidal pattern is seen on fetal heart tracing
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-Fetal anemia
-Analgesic drugs (morphine, meperidine, etc) -Chronic fetal distress |
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Variable decelerations
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-May start before, during, or after uterine contraction starts
-Show an abrupt onset and return (V-shape) -Decrease is >15bpm lasting >15 sec but less than 2 min |
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Cause of variable decelerations
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Umbilical cord compression
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Early decelerations
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-Shallow, symmetric, and reach their nadir at the peak of the contraction
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Cause of early decelerations
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Vagus nerve-mediated response to fetal head compression
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Late decelerations
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-U-shaped decelerations of gradual onset and gradual return
-Reach their nadir after the peak of the contraction, and do not return to baseline until after the contraction is over |
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Possible cause of late decelerations
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Uteroplacental insufficiency
Relative fetal hypoxia |
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Prolonged deceleration
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Last longer than 2 minutes but < 10 minutes
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Recurrent decelerations
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Occur with >50% of uterine contractions in any 20 min span
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Intermittent decelerations
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Occur with < 50% of uterine contractions in any 20 minute span
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Category I FHT have only ______ components
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reassuring
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Category II FHT are those that....
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cannot be classified in the other categories
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Category III FHT have ______ findings such as...
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concerning
-Minimal variability -Recurrent variable or late decels -Bradycardia -Sinusoidal pattern *Consideration of delivery should be given |
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Noninvasive Mgt of Nonreassuring FHR patterns
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-Oxygen
-Maternal position (Left lateral pos'n)=relieves vena cava compression -D/c oxytocin -Vibroacoustic stimulation or fetal scalp stimulation (induce acceleration) |
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Invasive Mgt of Nonreassuring FHR patterns
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-Amniotomy=placement of internal monitors
-Fetal scalp electrode (measure fetal ECG and closer eval of FHR) -Intrauterine pressure catheter and amnioinfusion -Tocolytic agents -Mgt of maternal hypotension (IV bolus, left uterine displacement, ephedrine) -Fetal scalp blood pH (7.25 or higher=normal; <7.2=acidotic) |
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Episiotomy
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An incision into the perineal body to enlarge the outlet area and facilitate delivery
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Types of episiotomies
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-Midline: incision made vertically in perineal body
-Mediolateral: incision made at a 45 degree angle off the midline (Incision should extend into the vagina 2-3cm) |
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What are midline episiotomies associated with?
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Increased risk of extension to 3rd or 4th degree laceration when compared with medilateral episiotomy
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Which type of episiotomy type may require more postpartum analgesia?
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Mediolateral
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Indication for forceps/vacuum delivery
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-Prolonged second stage of labor
-Maternal exhaustion -Inadequate maternal expulsive effort -fetal intolerance of labor -maternal condition requiring a shortened/passive second stage |
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What are the pre-requisites for forceps/vacuum delivery?
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-Fetal head must be engaged
-Cervix must be fully dilated -Bladder should be empty -Exact station and position of the fetal head should be known -Maternal pelvis must be adequate -If time permits, the pt should be given adequate anesthesia -If done for nonreassuring fetal status, someone who is able to perform neonatal resuscitation should be available |
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Maternal complications from forceps/vacuum delivery
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-Uterine, cervical, or vaginal laceration
-Extension of the episiotomy -Bladder or urethral injury -Hematoma |
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Fetal complications from forceps/vacuum delivery
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-Cephalohematoma
-Bruising -Laceration -Facial nerve injury -Skull fracture (rare) -Intracranial bleeding (rare) |
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Who should vacuum delivery be avoid in
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-fetuses <34 wks GA
-With known: thrombocytopenia, hemophilia, or von Willebrands disease |
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Shoulder dystocia
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Impaction of the fetal shoulder after delivery of the head
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What is macrosomia strongly associated with?
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Shoulder dystocia
(11 and 22 times greater for infants weighing more than 4000 and 4500g) |
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Risk factors for shoulder dystocia
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-Maternal obesity
-Previous macrosomic infant -DM -Gestational diabetes |
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When should you suspect shoulder dystocia
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Cases of prolonged second stage of labor or prolonged deceleration phase of first stage of labor
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Maneuvers done for shoulder dystocia
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-McRoberts maneuver
-Suprapubic pressure -Episiotomy -Wood's corkscrew -Rubin's maneuver |
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What is McRoberts maneuver
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hyperflexion and abduction of the maternal hips, flattening the lumbar spine, and rotating the pelvis to increased the posterior outlet diameter
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What is Rubin's maneuver
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Anterior fetal shoulder can be rotated obliquely with a vaginal hand
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What is the Wood's corkscrew maneuver
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Rotating the posterior shoulder 180 degrees with a vaginal hand
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What is Zavanelli maneuver
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The fetal head is flexed and pushed back up into the uterus as prep for emergent C-section
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Fetal indications for C-section
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-Nonreassuring fetal heart tracing
-Nonvertex presentation -Fetal anomalies: hydrocephauls -Umbilical cord prolapse -Conjoined twins |
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Maternal indications for C-section
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-Obstruction of the lower genital tract (eg large condyloma)
-Previous c-section (if VBAC is declined or not appropriate) -Previous uterine surgery involving the contractile portion of the uterus (classical cesarean, transmural myomectomy) -Hx of severe pelvic floor injury from a prior vaginal delivery -Abdominal cerclage |
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Maternal and fetal indications for C-section
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-Abruptio palcentae
-Active maternal HSV infection -Labor dystocia or cephalopelvic disproportion -Placenta previa or known vasa previa (absolute indication) |
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Risks of C-section
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-Pain
-Bleeding that may require transfusion -Infection -Damage to nearby organs -Small but increased risk of death when compared to vaginal delivery |
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Who have higher success rates for VBAC
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Nonrecurring condns: Malpresentation or fetal intolerance of labor
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Contraindications for VBAC
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-Previous classical, inverted T shaped incision
-Transfundal uterine surgery -Hx of uterine rupture -Contracted pelvis -Medical or Obstetric contraindications to vaginal delivery -Hx of 2 or more C-sections w/o any successful vag deliveries |
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Findings of uterine rupture
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-Nonreassuring fetal heart rate pattern with variable decels-->late decels
-Bradycardia -undetectable fetal heart rate -Uterine or abdominal pain -Loss of station of the presenting of the presenting part -Vag bleeding -Hypovolemia |
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Normal presentation
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Longitudinal lie
Cephalic presentation Flexion of fetal neck (All others are malpresentations) |
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Risk factors for malpresentations
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Condns that...
-Decrease the polarity of the uterus -Increase or decrease fetal mobility -Block the presenting part from the pelvis |
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Maternal factors that may cause malpresentations
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-Grand multiparity
-Pelvic tumors -Uterine fibroids -Pelvic contracture -Uterine malformations |
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Fetal factors that may cause malpresentations
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-Prematurity
-Multiple gestation -Polyhydramnios or oligohydramnios -Macrosmia -Placenta previa -Hydrocephaly -Trisomy -Anencephaly -Myotonic dystrophy |
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When does breech presentation occur
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When the cephalic pole is in the uterine fundus
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Incidence of breech presentation
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-25% of pregnancies at <28 wks gestation
-7% of pregnancies at 32 wks gestation -3-4% of term pregnancies in labor |
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3 types of breech presentation
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-Frank
-Complete -Incomplete |
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MC breech presentation
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Frank breech
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What is Frank breech
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(48% to 73%)
Occurs when both hips are flexed and both knees are extended |
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What is complete breech
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(5-12%)
Occurs when the fetus is flexed at the hips and flexed at the knees |
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What is incomplete breech or footling breech
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(12-38%)
Occurs when the fetus has one or both hips flexed |
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Risk of breech presentation
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-Cord proloapse
-Head entrapment -Spinal cord injury (with neck hyperextension) |
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Which breech types may still have vag delivery
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complete and frank breech
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Vaginal breech delivery poses increased risk of....
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-Fetal asphyxia
-Cord prolapse -Birth trauma -Spinal cord injury -Mortality |
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For patients in advanced labor with a breech fetus for whom delivery is imminent, a trial of labor may be attempted if....
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-Breech is frank or complete
-Estimated fetal wt is <3800g -Pelvimetry suggests an adequate pelvis -Fetal head is flexed -Anesthesia is immediately available -The fetus is continuously monitored -Pediatrician is available -Experienced Ob |
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Indication for External Cephalic version
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-Persistent breech presentation at term
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Risks for External Cephalic Version
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-Cord accident
-Placental separation -Fetal distress -Fetal injury -PROM -Fetamaternal bleeding -Failed version (MC risk) |
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Lie
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Refers to the alignment of the fetal spine in relation to the maternal spine
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Normal lie
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Longitudinal lie
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What is abnormal lie assoicated with
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Multiparity
Prematurity Pelvic contraction D/o of placenta |
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What is the greatest risk for abnormal lie
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Cord prolapse because the fetal parts do not fill the pelvic inlet
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If abnormal lie persists beyond 35 to 38 wks, _______ may be attempted
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external version
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Face presentation
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-Results from extension of fetal neck
-the chin is the presenting part |
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Mgt of face presentation
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Fetus must be mentum (chin) anterior for a vaginal delivery to be successful
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Brow presentation
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Results from partial deflexion of the fetal neck
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Mgt of brow presentation
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Mjrity of cases spontaneously convert to a flexed attitude
-Vaginal delivery should only be considered if maternal pelvis is large, the fetus is mall, and labor progresses adequately |
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Compound presentation
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Occurs when an extremity prolapses beside the presenting part
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Risks of compound presentation
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-Cord prolapse
-Birth trauma: neurologic and musculoskeletal damage to the involved extremity |
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Mgt of Compound presentation
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-Prolapsing extremity should not be manipulated
-Continuous fetal monitoring is recommended b/c compound presentation can be assoc with occult cord prolapse -Most delivered by vag delivery |
