POM II - Labor and Delivery - Exam 5

Labor

Regular painful uterine contractions resulting in changes in cervical effacement and dilation

Braxton Hicks Contractions

Irregular, generally painless or slightly uncomfortable uterine contractions that occur during pregnancy and do not lead to cervical change

Cervical Dilation

the opening of the cervix during labor, measured in centimeters from 0 to 10

Cervical Effacement

stretching/thinning of the cervix to prepare for delivery, measured from 0-100%

Engagement

When the fetus drops into the pelvic inlet, near delivery

Station

The position of the fetal head in relation to the ischial spines of the pelvis, measured from -3 to +3

Fetal presentation

the part of the fetus that enters the birth canal first

Leopold's Maneuvers

Abdominal examination of fetal position begins with what?

Fundal Grip - 1st manuever

Examiner places both hands on each upper quadrant of the patient's abdomen and gently palpates the fundus of the uterus with the tips of the fingers to define which fetal pole is present in the fundus

hard and round

if a fetus is cephalic, how should it feel with the fundal grip?

Podalic Fetal Position - Fundal Grip

one will note a large, nodular body with an uneven surface, non-ballotable, and not very mobile

Second Leopold Maneuver

palpation in the periumbilical regions with both hands by applying gentle but deep pressure

Second Maneuver - Purpose

to differentiate fetal spine (a hard resistant structure) from the limbs (irregular, mobile small parts) to determine the fetus' position

Third Leopold Maneuver

suprapubic palpation by using the thumb and fingers of the dominant hand

examiner ascertains the fetus' presentation and examines its station

if presenting part is not engaged, a movable body can be felt

Allows for assessment of fetal weight and volume of amniotic fluid

Fourth Leopold Maneuver

Palpation of bilateral lower quadrants to determine if the presenting part of the fetus is engaged in the mother’s pelvis

Examiner stands facing the mother’s feet. With the tips of the first 3 fingers of both hands, exert deep pressure in the direction of the axis of the pelvic inlet.

diverge

For the Fourth Maneuver, In cephalic presentation, the fetus' head is considered engaged if the examiner's hands _________ as they trace the fetus' head into the pelvis

Stage 1 of Labor

Interval between onset of contractions and full cervical dilation (10 cm).

Stage 1 Latent Labor

-Associated with slow dilation

-Mild contractions, variable in duration

-Can usually talk through contractions

-0-6 cm

Stage 1 Active Labor

Associated with a faster rate of dilation

Moderate to strong contractions lasting 45-90 seconds and occurring every 2-5 minutes

Analgesia and or anesthetic

6 to 10 cm

Stage 2 of Labor

Interval from complete cervical dilation (10 cm) to expulsion of the fetus (baby delivered)

Starts when mother has strong desire to “push” with contractions

Stage 3 of Labor

Interval from expulsion of fetus to expulsion of placenta

Best to look for lacerations/tears before placenta delivers

Inspect for completeness/abnormalities

Sent to pathology

hours to days

what is the length of latent stage 1 of labor?

hours

what is the length of active stage 1 of labor?

30 mins to 3 hrs

what is the length of stage 2 in a primigravida (1st pregnancy) woman?

5-30 min

what is the length of stage 2 of labor in a multiparous woman?

<30 min

what is the length of stage 3 of labor?

<6 cm

how much is the cervix dilated in latent stage 1 of labor?

6-10 cm

how much is the cervix dilated in active stage 1 of labor?

fully dilated at 10 cm

how much is the cervix dilated in stages 2 and 3 of labor?

Common Labor Positions

Lateral (Sims) position

Partial sitting position

Lithotomy position -> Advantageous if fetal manipulation or need for optimal surgical exposure is anticipated

every 30 min

when should you do fetal monitoring during stage 1 of labor?

every 15 min

when should you do fetal monitoring during stage 2 of labor?

continuously

when should you do fetal monitoring in at risk pregnancies?

Engagement

First Cardinal Movement

Fetus descends into pelvic inlet

Descent

Second Cardinal Movement

Passage through pelvis

Flexion

Third Cardinal Movement

Flexing fetus neck, smallest diameter of head passes through pelvis

Internal Rotation

Fourth Cardinal Movement

Passive rotation of presenting part (head) from its original position (transverse) to AP as it passes through the pelvis

Extension

Fifth Cardinal Movement

Occurs once descended into introitus

External Rotation

Sixth Cardinal Movement

After fetal head reflexes, it rotates (fetal head outside the mother)

Helps deliver anterior shoulder

Expulsion

Seventh Cardinal Movement

Delivery of fetus

Brandt-Andrews Maneuver

Gentle, steady traction on the cord combined with upward pressure on the lower uterine segment

Traction with 1 hand

Counter-traction with other hand ("lifting" the uterus)

placental separation (impending expulsion)

should start Brandt-Andrews Maneuver when there is clinical evidence of what?

Placental Separation S/S

Fresh show of blood

Umbilical cord lengthens

Fundus of uterus rises up

Uterus becomes firm and globular

Brand-Andrews Maneuver Comp

uterine inversion -> potentially fatal, but very rare

increased risk of postpartum hemorrhage

Postpartum Uterus

attempts to return to pre-pregnancy size and condition (AKA involution)

Fundus of uterus decreases in height by 1 cm per day

By 1 wk postpartum, about the size of a grapefruit, may no longer be palpable through abdomen

1st Degree Vaginal laceration

skin around vaginal opening tears

heals spontaneously in about 3 weeks

2nd Degree Vaginal Laceration

Vaginal Tissue and Perineal muscles (supports uterus, bladder, rectum)

Needs repair, pain meds, and stool softeners

3rd Degree Vaginal Laceration

Vaginal tissue, perineal muscles, and muscles around anus

Surgical repair, pain meds, stool softeners

4th Degree Vaginal Lacerations

all of the above tissues and lining of rectum

Surgical repair, pain meds, stool softeners

Complications: fecal incontinence, painful intercourse

<500 mL

what is normal expected blood loss during vaginal delivery?

>500 mL blood loss with S/S of hypovolemia (dizziness, fatigue, thirst, and dry mucous membranes)

what is considered postpartum hemorrhage?

PP Hemorrhage Causes

Tone (70%) --> Atonic uterus

Trauma (20%) --> Lacerations, hematomas, inversion, rupture

Tissue (10%) --> Retained tissue, invasive placenta

Thrombin (1%) -->Coagulopathies