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OB Labor & Delivery
OB Labor and Delivery and Labor Complications
| Question | Answer |
|---|---|
| Labor | defined by an increase in myometrial contractility resulting in effacement and dilation of the uterine cervix |
| Dilation and Effacement | Think of a barrel. The diameter enlarging is dilation, the height of the barrel is effacement. |
| Uterine contractions have two major functions | dilate the cervix and push the fetus through the birth canal |
| The three P's | The powers (forces generated by the contractility of the uterus), the passenger, and the passage |
| Tocodynamaometry (TOCO: a qualitative device) | Detects amount of force that a contraction generates |
| Time interval used to qualify contractions | 10 minutes |
| Quantitative assessment of contractions | measurement of intrauterine pressure via internal pressure transducers (IUPC) |
| What is adequate labor? | No concensus criteria. Classicallly, 3-5 contractions in 10 min. IUPC 200-250 Montevideo units |
| Passenger/Fetal Variables that influence course of labor | Size (Macrosomia 4,500g), Lie (longitudinal axis of fetus to uterus), Presentation (vertex, breech, shoulder, compound), Position (relationship of presenting part n relation to the pelvis), Station (measure of descent through birth canal) |
| Breech | butt is down (head down is vertex) |
| Compound | Somthing else slips on top (i.e. hand) |
| When Station value is zero | head at the level of ischial spines (if above, value is negative, if lower, then positive) |
| Fetal Lie | Transverse, Oblique, Longitudinal (Optimal) |
| Cord prolapse can occur in which lie? | Transverse |
| External Cephalic Version (ECV) | ECV involves the application of pressure to the mother’s abdomen to turn the fetus. Routinely done after 36 weeks |
| Passage (Pelvis) | Bony Pelvis, Soft tissues of birth canal (cervix, pelvic floor muscles). Both provide resistance to fetal expulsion |
| Pelvic Shapes | Gynecoid (ideal), Anthropoid, Android (least ideal), Platypelloid |
| Cardinal Movements of Labor | Engagement, Descent, Flexion, Internal Rotation, Extension, External Rotation (restitution), Expulsion |
| Stages of Labor | First Stage (onset of labor to full dilation: 10cm), Second Stage (interval between full dilation to delivery), Third Stage (Delivery of the placenta) |
| Pain Management Options in Labor | Parenteral: most common Fentanyl PCA (maternal risk for aspiration and respiratory depression as well as with fetus); Regional: epidural offers the most effective pain relief (less effective on fetus, may slow down labor but does not increase risks of C-s |
| Most common reason Narcan is used at delivery | In a fetus who has been exposed by mom to Fentanyl PCA (IV pain relief). Fetal risk to Fentanyl PCA is respiratory Depression |
| Dystocia of Labor | Characterized by the slow, abnormal progression of labor. Leading indication of primary c-sec. 1/10 births is a C-sec. 60% of ALL c-sec in the US are attributable to the diagnosis of dystocia |
| Protraction disorder | Labor slower than normal |
| Arrest disorder | Complete cessation of progress |
| Risks for prolonged labor | older, HTN, DM, Obesity, Macrosomia, Prolonged rupture of membranes and/or chorioamnionitis, short maternal structure, high station at complete dilation, occiput posterior position, pelvic abnormalities |
| latent phase | onset of contractions to active labor (3-4 cm). In Nulligravada, >20hours is too long. Multiparous>14 hrs is too long |
| Protracted dilation | not increasing dilation 1-2cm/hour |
| Induction of labor | Iatrogenic stimulation of uterine ctx’s to achieve vaginal delivery before onset of spontaneous labor. In the US, 20.6% of all births. |
| Indications for induction of labor (either maternal/fetal, or for logistic) | Gestational HTN or PIH, Preeclampsia, eeclampsia, postterm pregnancy, maternal medical conditions, fetal compromise (i.e.growth restriction), PROM, chorioamnionitis, Hx of rapid labor, distance from hospital. |
| CI to Induction of labor | prior classical c-section, active genital herpes, placenta or vasa previa, umbilical cord prolapse, transverse lie |
| Most common reason for induction | HTN, DM (b/c baby is usually large) |
| PROM | Premature Rupture of Membranes |
| Best tool to predict likelihood of successful labor induction | Bishop score. Scores >/= 6 are favorable. Cervix characteristics: Position, consistency, effacement, dilation, baby's station |
| Methods of Labor induction | Cervical Ripening Agents (prostaglandins such as misoprostol), Membrane Stripping - increases prostaglandin release, Oxytocin, Mechanical dilation - foley bulb w/ or w/out oxytocin, Amniotomy-AROM |
| AROM | artificial rupture of membranes |
| If you have dilation of the cervix but no effacement, you may need | Cervical Ripening Agents |
| Do not use Prostaglandins in | VBAC (prior c-section) |
| Indications for operative vaginal delivery (use of vacuum or forceps to help with second stage of labor). Head must be engaged and cervix must be fully dilated | Suspicion of immediate or potential fetal compromise (fetal distress), shortening of second stage for maternal reason, Prolonged second stage (nulliparous: no progress for 2-3 hrs, multiparous: no progress for 1-2 hours) |
| Shoulder Dystocia | delivery that requires additional maneuvers following failure of gently downward traction on the fetal head to effect delivery of the shoulders. Complicates .6-14% of deliveries |
| Risk factors for Shoulder Dystocia | maternal obesity, diabetes, hx of macrosomic infant, current macrosomia, hx of shoulder dystocia |
| Warning signs for Shoulder Dystocia | Anticipation is key! Prolonged 2nd stage, recoil of head on perineum (turtle sign), lack of spontaneous restitution |
| Fetal Complications with Shoulder Dystocia (4-40% of deliveries complicated with shoulder dystocia) | common injuries include brachial plexus injury, clavicle fracture, and humerus. <10% have permanent injuries. Increased risk of asphyxia |
| Maternal Complications with Shoulder Dystocia | 11% risk of postportum hemorrhage, 3.8% risk of 4th degree laceration |
| 3 common maneuvers used to tx shoulder dystocia | McRobert's Maneuver (dorsiflexion of hips against the abdomen), Episiotomy, Suprapubic pressure. (Others: Rubin's Screw, Wood's Screw, Delivery of posterior shoulder, Zavenilli) |
| Most common procedure performed in obstetrics | Episiotomy. No evidence supports routine use. |
| Two types of episiotomy | Midline (most common in US; can progress to a 4th degree laceration). Mediolateral (common in Europe, harder to repair, more blood loss, more sexual dysfunction, less risk for 4th degree tear). |
| Typical pregnancy is 40 weeks. Anything beyond that is called | Postterm. Literature says past 42 weeks, but this is not practiced. Never let anyone go past 42 weeks |
| Most frequent cause of Postterm Pregnancy | Error in dating. |
| Risk of Postterm Pregnancy to Fetus | stillbirth, meconium aspiration, intrauterine infection, utero-placenta insufficiency (oligo) |
| Most common risk factors for Postterm Pregnancy | First pregnancy, and prior postterm pregnancy |
| Risk of Postterm Pregnancy to Mother | increased labor dystocia, perineal injury related to macrosomia, and c-section rate |
| Postterm Pregnancy Management: Antenatal Surveillance | Literature is inconsistent regarding both type and frequency, Options include: nontress test (NST), biophysical profile (BPP) or modified BPP (NST and amniotic fluid volume estimation), or contraction stress test (CST). Modified BPP most commonly done |
Created by:
ltm12