5.Labor and Delivery

TRUE labor requires BOTH:

• regular uterine _

AND

• progressive cervical _ and effacement

remember: contractions alone does not equal labor, cervical change _ true labor

contractions

dilation

confirms

many pregnant patients have contractions (_ _ or _ contractions)

without progressive cervical _, they are not in labor

braxton hicks, latent

change

in true labor,

contractions become _ and _

contractions become _ together

progressive cervical _ and effacement

walking often _ contractions

regular/stronger

closer

dilation

intensifies

false labor (braxton hicks)

contractions are _ or _

frequency remains _

no cervical change over time

walking or hydration may _ contractions

irregular/inconsistent

unpredictable

reduce

every labor problem can usually be traced to one of three factors ( 3 P’s):

• _ (uterine _)

• _ (the _)

• _ (the maternal _)

when labor isnt progressing, ask yourself: which “P” is the problem?

power; contractions

passenger; fetus

passage; pelvis

when power is the problem, this means there are _ or _ coordinated contractions, and the result is _ labor

weak/poorly

prolonged

when the passenger is the problem, this could be due to a _ fetus or _ (OP, brow, breech) and this causes difficult _

large

malposition

descent

when the passage is the problem, this could be due to a _ or unfavorable pelvis, leading to _ obstruction

small

mechanical

most labor dystocia can be explained by one or a combination of the 3 “_’s”

P

stage 1 of labor begins with _ labor, and ends at complete cervical _ (_ cm)

true

dilation (10 cm)

stage one of labor has two distinct phases, _ and _

latent and active

the latent phase of stage 1 labor is when dilation is _-_ cm and there is _, variable progression

0-6

slow

the active phase of stage 1 labor is when there is >/= _-_ cm, and there is more _ cervical dilation

the rate of dilation changes dramatically after about _ cm

6-10

rapid

6

when should you worry about progress?

• latent phase (0-6 cm)

  • progress may be _

  • a prolonged latent phase may still be _

• active phase (>/= 6 cm)

  • cervical dilation should _

  • no cervical change raises concern for labor _

ask yourself: is the patient still in latent labor or has she reached active labor, that questions determines whether intervention is appropriate

slow

normal

continue

arrest

when is labor no longer progressing normally?

• before diagnosing arrest, all of these must be true:

  • _ labor (>/= 6 cm dilation)

  • membranes _

  • no cervical change despite adequate _

active

ruptured

time

ACOG criteria for active phase arrest:

• _ hours of adequate _ OR _ hours of inadequate contractions despite _

dont diagnose arrest too early, many patients need more time before meeting criteria

4; contractions

6; oxytocin

stage 2 of labor is _ cervical dilation at _ cm → _ of the fetus

normal progression: progressive fetal _ with effective maternal _

complete

10 cm

delivery

descent/pushing

when to become concerned in stage 2 of labor:

• _ second stage

• minimal or no fetal _ despite adequate contractions and maternal effort

think back to the three P’s

• Power: inadequate uterine _

• Passenger: fetal _ (e.g OP position)

• passage: cephalopelvic _ or pelvic limitation

prolonged

descent

contractions

malposition

disproportion

management options for when stage 2 of labor is progressing properly,

• continue _ management if maternal and fetal status remain reassuring

• _ vaginal _

• _ delivery when vaginal delivery is unlikely or unsafe

expectant

operative vaginal delivery

cesarean

stage 3 of labor begins immediately after delivery of the _

ends with complete _ delivery

newborn

placental

what usually happens in stage 3 of labor?

• _ separates from the uterine _

• uterus _ firmly after placental delivery

• placenta is usually delivered within _-_ minutes

placenta, wall

contracts

5-30 minutes

why is uterine contraction so important?

• placental separation leaves large maternal blood vessels _

• firm uterine contraction _ these vessels

• this is the body’s primary mechanism to stop postpartum _

exposed

compresses

bleeding

when should you worry in stage 3 of labor?

• _ or “_” uterus → uterine _

• uterine _ is the most common cause of postpartum _

soft/boggy

atony

hemorrhage

fetal heart monitoring helps us determine whether the fetus is:

• well _

• under physiologic _

• showing evidence of worsening _

oxygenated

stress

compromise

in fetal monitoring, you should interpret the tracing as a _, not by focusing on a single finding

look for:

• baseline _ _

• _

• _

• _

• overall _ over time

a reassuring _ is much more important than any single time

whole

heat rate

variability

accelerations

decelerations

trend

tracing

in fetal heart monitoring, three questions to ask first:

• _: is the heart rate normal (_-_ bpm)

• _: is there moderate beat-to beat variability

• _: are _ accelerations present

a normal _ with moderate _ is one of the strongest indicators of fetal well-being

baseline; 110-160

variability

accelerations

baseline/variability

late decelerations:

• begin after the _ of the contraction

• caused by uteroplacental _

clinical meaning: suggest decreased fetal _ delivery

peak

insufficiency

oxygen

_ late decelerations increase concern for fetal compromise, especially concerning if _ is decreased

recurrent

variability

initial management of late decelerations may include:

• maternal _

• _/intrauterine _ measures

• evaluation for expedited _ if unresolved

repositioning

oxygen/resuscitative

delivery

early deceleration can be caused by _ compression , but is _

head

benign

variable deceleration can be caused by _ compression, and should be monitored, _ of recurrent or deep

cord

intervene

late deceleration can be caused by uteroplacental _, and is concerning for fetal _

insufficiency

hypoxia

you should continue labor when:

• cervical _ is progressing

• _ are adequate

• fetal _ _ remains reassuring (category one)

• maternal and fetal _ remain stable

dilation

contractions

heart tracing

status

you should consider intervention when:

• active labor _ criteria are met

• category _ fetal heart tracing develops

• recurrent concerning _ persist despite intrauterine resuscitation

• maternal or fetal condition _

the goal is not simply to deliver the baby quickly- it is to achieve the _ delivery for both the mother and the fetus

arrest

III

decelerations

deteriorates

safest

methods for operative vaginal delivery:

• _ assisted delivery

• _ delivery

when is it considered?

• prolonged _ stage

• _ fetal heart tracing requiring rapid delivery

• maternal condition limits effective _

vaccum

forceps

second

nonreassuring

pushing

prerequisites (must ALL be present) for operative vaginal delivery:

• complete cervical _ (_ cm)

• engaged fetal _

• known fetal _

• no suspected cephalopelvic _

operative vaginal delivery shortens the _ stage only when vaginal delivery is imminent and conditions are appropriate

dilation/ 10 cm

head

position

disproportion

second

common indications for cesarean delivery:

• _ fetal heart tracing

• active labor _ or failure to _

• _ (e.g breech)

• placenta _ or other contraindication to vaginal birth

nonreassuring

arrest/progress

malpresentation

previa

clinical decision for cesarean delivery: ask two questions

• is the _ safe?

• is the _ safe?

if the answer to either of those become NO, cesarean delivery should be strongly considered

cesarean delivery is performed because the _ of continuing labor exceeds the risk of surgery

mother

fetus

risk

what must be assesses immediately postpartum:

• uterine _ → _ or _

• _ → expected or _?

• _ → delivered _?

• maternal _ → vital signs and overall stability

recognize postpartum _ before the patient becomes unstable

tone, firm or boggy

bleeding, excessive

placenta, intact

status

hemorrhage

immediate newborn assessment- APGAR score

• _

• _

• _

• _

• _

appearance

pulse

grimace

activity

respiration

appearance (APGAR)-

• 0: _/_

• 1: _ body, _ extremities

• 2: completely _

blue/pale

pink/blue

pink

pulse (APGAR)

• 0: _

• 1: <_ bpm

• 2: >/= _ bpm

absent

100

100

Grimace (APGAR)

0: _ _

1: _

2: _ cry/cough

absent

grimace

vigorous

activity (APGAR)

0: _

1: some _

2: _ movement

limp

flexion

active

respiration (APGAR)

0: _

1: _/irregular

2: _ cry

absent

slow

strong

clinical interpretation of APGAR:

7-10: _ neonatal adaptation

4-6: requires _ and close assessment

0-3: immediate _

the apgar score evaluates the newborns response to _ life- it does not predict long term neurologic outcome

normal

support

resuscitation

extra-uterine

you should think of postpartum hemorrhage when you find:

• _ vaginal bleeding

• _, _ uterus

• _ (often the first vital sign change)

• _ is a late finding

excessive

boggy, enlarged

tachycardia

hypotension

most common cause of postpartum hemorrhage:

• uterine _ (~70-80% of cases)

clinical pearl:

• a _ uterus plus _ bleeding = uterine atony until proven otherwise

atony

boggy/excessive

a normal uterus should be _, _ with _ bleeding

in uterine atony, uterus is _, and _ with _ bleeding

firm,contracted, minimal

enlarged, boggy, heavy

clinical pearls:

contractions alone do not diagnose labor- progressive cervical _ does

active labor begins at _ cm cervical dilation

moderate _ is one of the strongest reassuring signs of fetal well being

recurrent _ _ are more concerning than early decelerations

delivery decisions are based on three questions

• is labor _

• is the fetus _ labor

• is the mother _

after delivery, a _ uterus with _ bleeding is uterine atony until proven otherwise

change

6

variability

late decelerations

progressing

tolerating

stable

boggy, excessive

true labor requires regular _ with progressive cervical _

labor progress depends on the 3 “P’s”: _, _, and _

active labor begins at _ cm; arrest should not be diagnosed prematurely

moderate fetal heart rate _ is the most reassuring fetal finding

recurrent late decelerations suggest uteroplacental _ and possible fetal _

prompt recogntion of postpartum _ saves lives- uterine _ is the most common cause

the _ score evaluates neonatal _ after birth, not longterm neurologic outcome

contractions/change

power, passenger, passage

6

variability

insufficiency; hypoxia

hemorrhage, atony

apgar , transition