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Labor & Delivery


FHM: need to: establish baseline (>10 min); check for: decelerations; accelerations; variability
FHM: accelerations if pt >32 weeks 15 by 15 (15 bpm over 15 sec)
FHM: accelerations if pt <32 weeks 10 by 10 (10 bpm over 10 sec)
FHM: accelerations if pt <28 weeks do not need to look for accelerations (?)
Decelerations: new terminology Periodic: assoc w/contraction; episodic: not assoc w/contraction - 2/2 other cause
Decelerations: old terms: Early periodic, mirrors contraction
Early decelerations are usually secondary to = head compression; low in pelvis; delivery may be imminent
Decelerations: old terms: Late periodic, decrease in HR that does not return to baseline after contraction
Late deceleration are usually secondary to = placental insufficiency
Decelerations: old terms: Variable episodic, V- or W-shaped; usually 2/2 cord compression
FHM: variability beat-to-beat variation in HR; 6-25 bpm difference = moderate
Physiologic process by which a fetus is expelled from the uterus = Labor
An increase in myometrial contractility resulting in effacement and dilation of the uterine cervix = Labor
What are the two major functions of contractions during labor? To dilate the cervix, to push the fetus through the birth canal
What are the three mechanical variables during delivery known as the three P’s? the powers, the passenger, and the passage
One of the three P’s it is the force generated by uterine musculature Powers
What does an external tocodynamometer measure? Number of contractions in an average 10 minute window, intensity, and duration of contractions
What is the most precise method of measuring contractions Intrauterine pressure monitoring via internal pressure transducers (IUPC)
What is classically considered to be adequate labor 3-5 contractions in 10 minutes, however there is no consensus for criteria
Macrosomia is considered to be an infant over: 4,500 g
What is the lie of the fetus? The longitudinal axis of the fetus to the uterus
What does the station of the fetus mean? A measurement of descent through the birth canal
How often are breech presentations found in term pregnancies? 3-4%
External cephalic version is routinely done after __ weeks: 36
What landmarks designate 0 station for the fetus Ischial spines
Cardinal movements of labor: passage of widest diameter of presenting part to below the plane of the pelvis Engagement
Cardinal movements of labor: downward passage of presenting part through the pelvis Descent
Cardinal movements of labor: passive flexion of fetal head as it descends due to resistance related to body pelvis Flexion
Cardinal movements of labor: rotation of presenting part (usually from transverse to anterior-posterior) Internal rotation
Cardinal movements of labor: brings base of occiput in contact with the inferior margin of the pubic symphysis, head is delivered by extension Extension
Cardinal movements of labor: rotation to the correct anatomic position in relation to the fetal torso External rotation (restitution)
Cardinal movements of labor: delivery of body of fetus Expulsion
What are the Cardinal movements of labor Engagement, descent, flexion, internal rotation, extension, external rotation (restitution), expulsion
What is the first stage of labor Onset of labor to full dilation
What is the second stage of labor Interval between full dilation (10cm) and delivery
What is the third stage of labor Time from delivery to expulsion of placenta
What are the risks of parenteral pain management in labor (fentanyl PCA)? Maternal risk for aspiration and respiratory depression, fetal risk for respiratory depression (common need for Narcan at delivery)
An epidural may slow down labor, however it does not increase the risk of __ C-section
__ is characterized by the slow, abnormal progression of labor Dystocia of labor
What is the leading indication of primary C-section? Dystocia of labor
What is the rate of c-section in the US 1 in every 10 births
60% of all c-sections in the US are attributable to the diagnosis of __ Dystocia of labor
What terms should we never use when talking about dystocia of labor Failure to progress, or CPD (cephalopelvic disproportion)
What are acceptable terms to use when referring to dystocia of labor Labor slower than normal (protraction disorder), complete cessation of progress (arrest disorder)
What are the risk factors for prolonged labor? Older, medical (DM, HTN, obesity), macrosomia, prolonge rupture of membranes and or chorioamnionitis, short maternal stature, high station at complete dilation, occiput posterior position, pelvic abnormalities
What are the intervention options for arrest of descent Forceps, vacuum, c-section
What is AROM Artificial rupture of membranes
What are the contraindications of labor induction Prior classical c-section, active genital herpes, placenta or vasa previa, umbilical cord prolapse, transverse lie
What is the best tool to predict the likelihood of successful labor induction (resulting in vaginal delivery) Bishop score
A bishop score of __ or greater is favorable for induction of labor 6
What are cervical ripening agents Prostaglandins such as misoprostol
List the methods of labor induction Cervical ripening agents (misoprostol), membrane stripping, oxytocin, mechanical dilation, amniotomy (artificial rupture of membranes)
What is the mechanism by which membrane stripping works to induce labor Increases prostaglandin release
Delivery that requires additional maneuvers following failure of gently downward traction on the fetal head to effect delivery of the shoulders Shoulder dystocia
What is the rate of shoulder dystocia .06-1.4% of deliveries
What are the risk factors for shoulder dystocia Maternal obesity, multiparity, diabetes, hx of or current macrosomia, hx of shoulder dystocia, bony pelvic or uterine abnormalities, abnormal contractions
Warning signs of shoulder dystocia Prolonged 2nd stage, recoil of head on perineum (turtle sign), lack of spontaneous restitution, rapid or precipitous descent
Fetal complications of shoulder dystocia Brachial plexus injury, clavicle/humerus fx, asphyxia
Treatment for shoulder dystocia McRoberts maneuver, episiotomy, suprapubic pressure, Rubin’s screw, Wood’s screw, delivery of posterior shoulder (humerus fx), Zavanelli (cephalic replacement & C-section)
What is McRoberts maneuver? Dorsiflexion of hips against the abdomen to ease birth of fetus with shoulder dystocia.
What is the most common cause of postterm pregnancy Error in dating
With postterm pregnancy what are the risks to the fetus Stillbirth, meconium aspiration, intrauterine infection, uteroplacental insufficiency
With postterm pregnancy what are the risks to the mother Increased labor dystocia, perineal injury related to macrosomia, and c-section rate
What are the leading causes of preterm deliveries Preterm labor (PTL) and preterm premature rupture of membranes (PPROM)
Preterm delivery is before __ weeks 37
Major determinant of infant mortality in developed countries Preterm delivery
Preterm delivery is particularly acute among what group African Americans
Leading cause of developmental disability in children Preterm delivery
What are the key risk factors for preterm delivery Smoking, African American, maternal age (young and old), social factors (poverty, poor housing, crime)
The fetal fibronectin test has a high __ value in predicting delivery within the next 14 days Negative predictive
What is the best tool we have right now to determine patients not at risk for imminent delivery Fetal fibronectin and cervical length
What is the purpose for prolonging pregnancy when the patient goes into preterm labor To allow administration of steroids for fetal lung maturity and maternal transport to a facility with a NICU
What doesn’t work in preventing preterm labor Bedrest, hydration, pelvic rest, antibiotics
What are the tocolytic agents used in the management of pre term labor Beta-mimetic (terbutaline), magnesium sulfate, calcium channel blockers (Procardia), prostaglandin synthetase inhibitors (indomethacin)
What should be given to women at risk for preterm delivery between 24-34 weeks to reduce the risk of respiratory distress syndrome, mortality, and intraventricular hemorrhage Antenatal steroids (betamethasone, dexamethasone)
What are the risk factors for PPROM Intraamniotic infection, prior hx, lower SES/teens, smokers, hx of STD, hx of cervical cerclage, uterine overdistention
What do you do if the mother goes in to labor any time after 34 weeks Proceed with delivery, GBS prophylaxis
What do you do if the mother goes into labor between 24-31 weeks Expectant management, GBS prophylaxis, steroids recommended, tocolysis, antibiotics
What do you do if the mother goes in to labor before 24/23 weeks Pt counseling about poor outcome, expectant management, no steroids, no GBS prophylaxis or Abx
What are the different presentations of the fetus? Normal: vertex. Malpresentation: breech (most common), face, brow, compound
What are the different lies of the fetus? transverse, oblique, longitudinal
HELPERR = for shoulder dystocia: call for Help, evaluate for Episiotomy, Legs (McRoberts), suprapubic Pressure, Enter maneuvers (Rubin, Woods), Remove posterior arm, Roll pt
APGAR – blue all over = 0
APGAR – blue at extremities body pink = 1
APGAR – no cyanosis = 2
APGAR – absent pulse = 0
APGAR – pulse <100 = 1
APGAR - pulse > 100 = 2
APGAR – no response to stimulation = 0
APGAR – grimace/feeble cry when stimulated = 1
APGAR – sneeze/cough/pulls away when stimulated = 2
APGAR – no muscle tone = 0
APGAR – active movement = 2
APGAR – some flexion = 1
APGAR – no breathing = 0
APGAR – weak or irregular breathing = 1
APGAR – strong breathing = 2
critically low APGAR score = 3 and below
fairly low APGAR score = 4-6
normal APGAR scores = 7-10
cervical exam of L&D dilatation (to 10 cm); effacement (to 100%); station (ischial spines = 0, below is + in cm)
immediately after delivery, uterus is at the level of: umbilicus; involutes in 2 days; descends into pelvic cavity in 2 wks; normal by 6 wks
Risk of cord prolapse is greatest with: incomplete and compound presentations
APGAR scores are taken at __ and again at __ in depressed infants 1 and 5 minutes, 10 minutes
What does APGAR stand for Appearance, Pulse, Grimace, Activity, Respiration
What are the five components of the APGAR (not the mnemonic) Skin color, pulse rate, reflex irritability, muscle tone, breathing
Latent phase of labor = mild infrequent contractions, <1cm dilation/hr (~0-4cm)
Active phase of labor = Painful contractions, increasing frequency, >1cm dilation/hr (~4-10cm)
Created by: Abarnard
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