NM704 Final Exam Learning Guide Questions

Mode of action of epidurals

a. When an anesthetic drug is placed in the epidural space, impulses traveling in the

sensory and motor nerves in contact with the drug are blocked.

b. The effect of epidural analgesia depends greatly on the drug, the dose placed in the

epidural space, and the administration technique (i.e., intermittent versus continuous

infusion).

Benefits of epidurals

a. Women using epidural analgesia have lower pain scores and are more satisfied with

their analgesia than women using parenteral opioids when the experience of pain is

evaluated.

Contraindications of epidurals

a. Absolute contraindications to epidural or spinal anesthesia include refusal, inability to

cooperate, skin or soft-tissue infection at the site of needle placement, frank

coagulopathy, untreated sepsis, and maternal hemodynamic instability.

b. Relative contraindications include heparin therapy or thrombocytopenia, and

neurologic disease of the spinal cord.

Possible complications of epidurals

a. Post-dural puncture headache

b. back pain

c. Side effects of local anesthetic placed in the epidural space include hypotension,

bladder distention/urinary retention, and leg numbness and weakness.

d. Adverse effects related to performance of the epidural analgesia procedure are rare,

but include epidural abscess, epidural hematoma serious neurological injury.

e. Inadvertent intrathecal (subarachnoid) or intravascular placement can result in

toxicity.

Epidurals effect on the progress of second stage labor, rates of oxytocin augmentation, operative vaginal births and cesarean births

The largest and most recent of these studies, which was conducted by Zhang et al. (n =

62,400), found the 95th percentile was approximately 50 minutes longer for the second stage

in nulliparous women. This extended duration is presumed to occur secondary to the lack of

sensation for bearing down and perhaps the relaxation of the levator ani muscles that make

up the pelvic floor. The meta-analyses of RCTs that compared labor outcomes in women with

and without epidural analgesia have not found epidural analgesia to be associated with a

prolongation of the second stage of labor in the aggregate.

What the evidence says about epidurals

Some women whose labors are slowed by epidural analgesia and some women whose labors are faster after epidural analgesia therefore in an aggregate mean duration of the first stage that is no different than the duration of the first stage in women who do use epidural analgesia

-epidurals are not associated with increased cesareans but actually increased operative vaginal birth

-increased incidence of maternal fever

-significant complications are uncommon but blood flow to the uterus diminishes with hypotension and fetal heart rate decelerations

Maternal, fetal and neonatal side effects of Demerol (Meperidine)

-PROLONGED HALF LIFE

-contains an active metabolite with a 63-hour half-life in the neonate

-fetal exposure is associated with neonatal respiratory depression

-may adversely affect newborn breastfeeding behaviors

know the maternal, fetal and neonatal side effects of Morphine

The largest and most recent of these studies, which was conducted by Zhang et al. (n =

62,400), found the 95th percentile was approximately 50 minutes longer for the second stage

in nulliparous women. This extended duration is presumed to occur secondary to the lack of

sensation for bearing down and perhaps the relaxation of the levator ani muscles that make

up the pelvic floor. The meta-analyses of RCTs that compared labor outcomes in women with

and without epidural analgesia have not found epidural analgesia to be associated with a

prolongation of the second stage of labor in the aggregate.

know the maternal, fetal and neonatal side effects and appropriate timing of Nubain (Nalbuphine)

Pain relief is reported (anecdotal) to be superior to that of fentanyl.

May bring about acute withdrawal syndrome in opiate-dependent mother and baby.

**Contraindicated for use in opiate-dependent woman.

know the maternal, fetal and neonatal side effects of Stadol (Butorphanol)

May cause a transient pseudo-sinusoidal FHR pattern.

Pain relief is reported (anecdotal) to be superior to that of fentanyl.

Contraindicated for use in opiate-dependent woman

know the maternal, fetal and neonatal side effects of Sublimaze (fentanyl)

May cause a transient pseudo-sinusoidal FHR pattern.

Not associated with neonatal respiratory depression

Short-acting, less effective than morphine or Demerol, but few side effects

know the maternal, fetal and neonatal side effects of Ultiva (Remifentanil)

May cause significant maternal respiratory depression.

Rapid onset of action and shortest half-life.

Use in clinical practice is controversial.

Frequency of Vital Signs in the second stage of labor

BP, HR, RR every hour

Temp every 2-4 hours when normal and 1-2 hours when abnormal or membranes have ruptured

Urine output: encourage to empty bladder every 2 hours

CEFM second stage frequency of monitoring

No complications: Second stage q15 mins

Complications: Second stage q5 mins

IA frequency of monitoring during the second stage

ACOG: second stage q5

ACNM: No pushing second stage q15, pushing second stage q5,

AWHONN: Active pushing second stage q5-15

Compare the traditional and alternative definitions of the second stage

Traditional: when the cervix is completely dilated

Alternative: when the patient gets the involuntary urge to push (Ferguson Reflex)

physiologic basis for the urge to push

Ferguson reflex: Stimulation of the nerve plexus that generates an urge to push via a

surge of oxytocin

b. Occurs as the presenting part descends and applies pressure on the pelvic floor

c. occurs at +1 station

-when the vertex or presenting

part of the fetus has descended to a station wherein an involuntary maternal

urge to bear down occurs.

Can a woman push before she is completely dilated?

-whether or not a woman can push before she is completely dilated is particularly controversial

-it is accepted as fact by many providers that this should be avoided due to it causing cervical edema or lacerations

-in any case it is important to understand that there is no evidence that supports this contention

-if you chose to define the second stage as beginning with the urge to push, then it is prudent to monitor her progress more closely than if she is completely dilated at start of pushing

-in most cases the cervix will readily dilate with pushing and if it doesn't a different approach may be required

-position changes can be a very effective management strategy in this situation; they may serve to facilitate fetal rotation and diminish an early urge to push

Maternal and Neonatal complications associated with longer second stage

Maternal:

-increase risk of maternal morbidity

-Triple I (Chorio)

-PPH

-3rd/4th degree lacs

-shoulder dystocia

Neonatal:

-increase risk of 5 min APGAR <7

-more NICU admissions

-greater risk of neonatal sepsis (1 study: infants born to nullips)

Is there evidence that pushing prior to complete dilation causes complications?

Evidence supports (small study):

1. Women developed spontaneous urge to push between 5cm and 10cm, average of

9cm, and typically +1 station or lower 2/3 women had urge to push before complete

3 cervical lacerations: 1 in early push group but also had forceps birth, 2 in push

when complete group (Marowitz, 2017)

2. Possible difficulty with effective pushing once complete after being prohibited from

pushing until complete in spite of strong urge (Roberts, 2002)

2. No evidence showing harm

Some birthing people reach complete dilation before an urge to push develops. What is the impact on outcomes of delayed pushing in this situation until an urge is present?

1. Pushing only with urge, through recent research on women with epidurals (Marowitz, 2017)

2. A diminished labor when reaching complete and before having an urge to push (Roberts,

2002) (AKA latent second stage)

3. Improved maternal and neonatal outcomes with uncoached open-glottis pushing, several

studies have been conducted to examine the overall effect of pushing techniques on maternal

and fetal/neonatal outcomes.

4. Findings of these studies have revealed that spontaneous pushing results in improved

neonatal outcomes and improved maternal satisfaction (Yildirim & Beji, 2008).

5. Spontaneous bearing down is also associated with higher rates of perineal integrity and less

perineal trauma (Albers, Sedler, Bedrick, Teaf, & Peralta, 2006), as well as less maternal

fatigue.

6. During the process of passive descent (also referred to as laboring down), the fetus descends

in response to the force generated from contractions alone and begins to internally rotate

once the presenting part reaches the pelvic floor.

-encourage a period of rest prior to active pushing

-pushing efforts will be more effective and efficient in the presence of physical cues from her body

Compare coached versus spontaneous pushing in terms of fetal oxygenation, perineal trauma and postpartum pelvic function

1. Coached pushing

1. generally includes instruction on breath holding, positioning, and duration of each

push.

2. there is evidence the closed glottis pushing generally done with coaching is

associated with

1. decreased fetal oxygenation (FHR decels)

2. increased perineal trauma (lacerations, episiotomies)

3. maternal exhaustion

4. paired postpartum pelvic function (cystocele, urinary stress incontinence)

2. spontaneous pushing

1. the birthing person responds to strong sensations of rectal pressure and an urge to

push with bearing down efforts and open glottis pushing

2. results in 5-6 bearing down efforts/ contraction of 3-10 sec each

3. grunting or low groaning

3. Despite the evidence supporting the benefits of spontaneous pushing, coached pushing is the

norm in many settings.

Know the pros and cons of different positions for pushing and birth

1. Con’s:

1. supine and lithotomy positions are associated with uterine pressure on the vena cava,

maternal hypotension, decreased uterine perfusion, variant fetal heart rate patterns

2. Pro’s:

1. upright position associate with less pain and stronger contractions

2. when a woman rounds their back rather than arching it, the uterus and fetal

presenting part are better aligned with the pelvis

3. leaning forward in an upright position increases the angle between the uterus and the

spine, thereby directing the fetal presenting part toward the largest posterior segment

of the pelvis

4. changing positions frequently promotes changes in pelvic diameter, which could aid

the fetus finding the “best fit” during the cardinal movements

5. squatting increase the area w/in the pelvic outlet by approx. 20% and can be most

beneficial in the final phase of second stage labor when the fetal presenting part is in

the plane of the outlet

6. regardless of the position a woman is in, her legs should not be abducted laterally in

an exaggerated manner (lithotomy position) because these positions put increased

stress and tension on the perineum

Understand the possible risks of pushing in the supine or lithotomy position

1. supine and lithotomy positions are associated with uterine pressure on the vena cava,

maternal hypotension, decreased uterine perfusion, variant fetal heart rate patterns

2. the position a woman is in, her legs should not be abducted laterally in

an exaggerated manner (lithotomy position) because these positions put increased stress and

tension on the perineum

Know the possible benefits and risks of delayed pushing when epidural analgesia is used

1. passive descent :" laboring down"

1. Fetus descends in response to the force generated from contractions alone and begins

to internally rotate once the presenting part reaches the pelvic floor

2. can be up to 1-2 hours

2. benefits

1. conservation of woman's energy until physical stimulus to actively push

2. increases spontaneous birth

3. fewer operative births by 20%

4. less exhaustion

5. not increase in adverse maternal/neonatal outcomes

3. risks

1. longer 2nd stage (but shorter duration of pushing!)

2. low umbilical cord pH (but not NICU admission)

Contraindications to delayed pushing

-Triple I

-Cat II FHR

-vaginal bleeding

Coached versus spontaneous pushing and occurrence of genital tract lacerations

spontaneous bearing down results in higher rates of intact perineal integrity and less perineal trauma

birthing positions for birth and occurrence of genital tract lacerations

upright or lateral birth positions compared with supine or lithotomy positions were

associated with fewer episiotomies and operative deliveries, but higher rates of

second-degree lacerations

antepartum perineal massage and occurrence of genital tract lacerations

Perineal massage (antepartum or during the second stage of labor) is intended to

decrease perineal muscular resistance and reduce the likelihood of laceration at

delivery

2. digital perineal massage from 34 weeks of gestation onward was associated with

modest reduction in perineal trauma that required repair with suture and decreased

episiotomy in women without previous vaginal birth

use of heat (warm compresses) on the perineum during birth and occurrences of genital tract lacerations

1. compress use significantly reduced third-degree and fourth-degree lacerations

2. warm compresses did not increase the rate of a woman having an intact perineum

after delivery

Perineal Massage during birth and occurrence of genital tract lacerations

Meta-analysis of data from two studies (2,147 women) found that perineal massage

during the second stage of labor reduced third-degree and fourth-degree tears when

compared with "hands off" the perineum, but was not associated with significant

changes in the rate of birth with an intact perineum

hand maneuvers used by the birthing attendant and occurrence of genital tract lacerations

1. Manual perineal support at delivery is commonly practiced (with health care providers

in some parts of the world describing this as a "hands on" method), with several

different techniques described globally. Among these are the flexion techniques and

the Ritgen maneuver (or a modification of either).

2. meta-analysis concluded that current evidence is insufficient to recommend a specific

Practice

analyze the evidence regarding the impact of routine episiotomy on the risk of 3rd/4th degree lacs

-midline increases occurrence and severity of perineal lacerations

-midline has a strong independent risk factor for 3rd/4th degree lacs

analyze the evidence regarding the impact of routine episiotomy on long term pelvic floor functioning (urinary or anal incontinence, the strength of pelvic floor)

1. A systematic review of 26 articles found that a routine episiotomy offered no

immediate or long term maternal benefit in perineal laceration severity, pelvic floor

dysfunction (including urinary or fecal incontinence), or pelvic organ prolapse over a

restrictive use of episiotomy

2. meta-analysis including eight studies, episiotomy was associated with an increased

risk of anal incontinence compared with no episiotomy, whether or not the perineal

laceration extended into the anal sphincter complex. In the same meta-analysis,

women with OASIS injuries were more likely to have anal incontinence than women

who did not have OASIS injuries

3. Women who sustain fourth-degree lacerations are at the highest risk of reporting

bowel symptoms 6 months postpartum; women with a history of a fourth degree

laceration at the first delivery reported worse bowel control 10 times more frequently

than women with a third degree laceration

4. In a cohort study of women surveyed and examined 5-10 years after giving birth,

episiotomy was not associated with increased risk of pelvic organ prolapse or urinary

incontinence, but having multiple deliveries with spontaneous perineal lacerations

was associated with the development of prolapse beyond the hymen

5. Pelvic floor exercises performed with a vaginal device that provides resistance or

feedback may decrease postpartum urinary incontinence, but the effect on anal

incontinence has been mixed with no demonstration of a durable long-term effect

Analyze the evidence regarding the impact of routine episiotomy on degree of genital tract trauma

vaginal delivery is associated with increased need for pelvic floor reconstruction later in life

Analyze the evidence regarding the impact of routine episiotomy on postpartum pain

adequate pain control is an important part of managing severe perineal trauma

-local tx options include topical anesthetics sprays or creams, icepacks, baths, and rectal suppositories

Analyze the evidence regarding the impact of routine episiotomy on sexual function

1. In a systematic review, routine episiotomy did not improve self-reported sexual

function outcomes

2. In a prospective trial of 407 primigravida women who were randomized to either

routine midline versus mediolateral episiotomies, significantly more women resumed

sexual intercourse at 1 month postpartum (18% versus 6% in the midline versus

mediolateral groups, respectively, P,.01). However, no differences in the proportion of

women resuming sexual intercourse were noted between the groups by 3 months

after episiotomy

3. no differences in the proportion of women resuming sexual intercourse were noted

between the groups by 3 months after episiotomy

Analyze the evidence regarding the impact of routine episiotomy on neonatal outcomes

1. A randomized controlled trial of restrictive use of mediolateral episiotomy versus

routine use of mediolateral episiotomy at the time of operative vaginal delivery found

no significant differences between groups in rates of OASIS, postpartum hemorrhage,

or neonatal trauma

know the indications for episiotomy

fetal intolerance of second stage crowning

understand the current evidence on outcomes for the birthing person and newborn associated with birth in water

1. No evidence of increased risk for any adverse neonatal outcome.

2. Women who had waterbirths had an increased risk of genital tract trauma, with no evidence

of increased risk for any other complications.

3. ACOG and AAP have published statements in which the safety of waterbirth for neonates is questioned. In fact, there is considerable evidence supporting the safety of waterbirth for neonates. There is also evidence of birthing person benefits such as high levels of birthing person satisfaction with pain relief and the experience of childbirth. The evidence on perineal outcomes varies.

the traditional, biomedical definition of second stage labor is

the time from complete dilation of the cervix to the birth of the baby

the alternative or physiologic definition of second stage labor is

the time beginning with involuntary, expulsive efforts to birth the baby

True or False: The Ferguson Reflex results in a surge of oxytocin that enhances contraction strength and pushing effectiveness in second stage labor

True

True or False: Nearly all women feel the urge to push at about the same time that their cervix reaches complete dilation

False

By delaying pushing until a woman has an urge to push when she is complete but does not yet have an urge to push (ie allowing her to labor down) all of the following are possible benefits to maternal outcomes EXCEPT

Less need for amniotomy

An evidence-based technique for perineal management during birth that decreases or minimizes genital tract trauma is

working with the woman to facilitate a gentle, controlled birth of the baby

Prenatal perineal massage in the final weeks of pregnancy has been shown to reduce the risk of genital tract trauma in which cohort of birthing women?

Nulliparous

Define the third stage of labor

1. begins with the birth of the baby and ends with the expulsion of the placenta

2. usually lasts 5-30 minutes, typically occurs in 5-10 minutes

Know the physiologic tasks of the third stage of labor

1. Placental separation

1. uterine cavity abruptly shrinks

2. placental size unchanged

1. thickens in response

1. central separation: Schultz

2. Peripheral separation: Duncan

2. Placental expulsion

1. begins with placental descent into lower uterine segment

2. placenta descends into vaginal vault

3. placenta emerges

1. occurs by one of two mechanisms

§ Schultz or Duncan

-Schultz separates centrally while Duncan separates marginally

3. Control of bleeding at the placental site.

Ø According to ICM/FIGO

o Controlled cord traction (once pulsing stops)

o Use of uterotonics (Pitocin)

o Fundal massage after expulsion of the placenta

Know the signs of placental separation

1. Small gush of blood: some blood escapes from between placenta and decidua

2. Lengthening of the cord: as placenta descends into the vagina, the cord lengthens at the vaginal introitus

3. Rise of the uterus into the abdomen: as the placenta descends into the vagina, the uterus is displaced cephalad

4. Uterus becomes firm and rounded: once the placenta is expelled from the uterus, the uterine smooth muscles contract more firmly, altering the shape of the uterus

Understand techniques to employ during a normal third stage of labor to reduce the risk of complications such as partial separation of the placenta, avulsed cord or inverted uterus

1. Adopt an upright position to allow gravity to assist with placental descent.

2. Stimulate nipples by placing baby to the breast or by using manual stimulation.

3. Pushing effort to expel placenta if an urge to push is present with a contraction.

4. use the Brandt-Andrews maneuver

1. apply pressure downward just above the pubic brim with the hand that is guarding

the uterus while holding the cord taut with the other hand.

2. if the placenta is still in the uterus the cord will retract as the uterus is displaced

upward into the abdomen by pressure from the abdominal hand

3. if placenta has separated and I the vagina, upward displacement of the uterus will

cause the cord to retract and additional cord traction can be safely provided while

maintaining abdominal counter-traction

5. cord traction should not be used without guarding the uterus as this maneuver may result in

an avulsed cord or inverted uterus

6. as placenta maneuvers the Curve of Carus the membranes should follow without incident. If

there appears to be more membranes than immediately are expelled, continue to hold the

placenta and either twist it slowly or grasp the membranes with ring forceps to gently extract

the membranes (process know as teasing) out the membranes

Define expectant (physiologic) management of the third stage of labor

1. noninterventionist approach and followed by midwives globally

2. no routine uterotonic administration

3. delayed cord clamping

4. gentle cord traction

Define active management of the third stage of labor (recommended by ICM/FIGO)

1. controlled cord traction

2. use of uterotonics (Pitocin)

3. fundal massage after expulsion of placenta

Analyze the evidence regarding comparable outcomes with active versus expectant management of the third stage of labor

1. Take Home Point #1: A clear and compelling conclusion to draw from the AMTSL evidence is

that for birthing people with risk factors for PPH, AMTSL should be the recommended

approach for management of third stage.

2. expectant management may be optimal for a birthing person without risk factors for PPH who

had a spontaneous, normal labor and birth without complication or intervention. Expectant

management of third stage should be presented to this population of birthing people as a safe

option for management during shared decision-making.

-it is appropriate to recommend AMTSL for birthing people with certain risk factors

Risk factors that would make it appropriate to recommend AMTSL

1. Past Pregnancy and Medical History:

1. Coagulopathies

2. Grand Multiparity

3. History of PPH

4. Previous uterine incision

5. Uterine abnormalities

2. Current Pregnancy-Related:

1. Antepartum hemorrhage

2. Fetal macrosomia

3. Hypertensive disorders of pregnancy

4. Anemia

5. Obesity

6. Multiple gestation

7. Placental abnormalities

8. Polyhydramnios

3. Labor-Related:

1. Chorioamnionitis

2. Induction or augmentation of Labor

3. Magnesium sulfate use

4. Precipitous labor and birth

5. Prolonged labor

Expectant Management of third stage labor

1. evidence has shown the following outcomes for expectant management of third stage in

birthing people at low risk of PPH who experience a normal labor and birth, as defined above:

1. No increase in blood loss compared with AMTSL in a general population

2. No increased risk of PPH compared with AMTSL in a general population

2. when labor and birth are normal, expectant management of third stage results in comparable

bleeding outcomes as when AMTSL is implemented with a general population of birthing

people at mixed risk for excessive bleeding.

3. Take Home Point #2: For birthing people at low risk of PPH having a spontaneous labor and

birth without intervention, expectant management of third stage is a reasonable approach.

Apply the evidence for active management versus expectant management of the third stage of labor in order to provide Shared Decision Making for third stage management

1. Prenatal education is important in discussing third stage management for SDM, and should

include information about the evidence and risk factors for PPH.

2. need to share information about a physiologic model of labor and birth as part of our

education for women.

1. They need to know, before they make choices about their birth, that some labor and

birth interventions can change their risk status and reduce their safe options for third

stage management.

2. An example of this would be induction of labor.

3. The woman's values and preferences about third stage play an integral role in decision-

as well, and this part of the conversation can flow easily from a discussion of preferences for

labor and birth, management options for third stage, risk factors for PPH, choice of birth

setting, and the woman's unique characteristics and clinical situation.

4. You will provide education and discuss the options, including risks and benefits, yes, but

another important consideration is flexibility, for both you and the woman.

1. You may need to adapt your plan depending on the course of labor, birth, and third

stage, as a woman's risk status may shift and a change in plan may be required to

achieve the best possible outcome.

Define the fourth stage of labor

1. the first hour following expulsion of placenta

2. critical for physiological and emotional/psychological adaptation following birth

Know the components and understand the findings of a birthing person's evaluation during the fourth stage of labor

Emotional/psychological: maternal-infant attachment, family bonding, STS contact, first breastfeeding/latch

Physiological: VS, bleeding, bladder, perineum, oral intake, comfort measures

actions, indications, side effects and contraindications for Oxytocin (Pitocin) during uncomplicated 3rd and 4th stages of labor

1. MOA/indication:

Causes rhythmic uterine contraction

2. S/E:

Cramping

Large dose can cause hyponatremia

3. Contraindications:

Hypersensitivity

4. Clinical considerations

Onset: 2-3 mins

Effective: 15-30 mins

Duration: 2-3 hour if given IM

*Rapid infusion of undiluted bolus can cause hypotension and cardiac collapse

actions, indications, side effects and contraindications for Methylergonomine Maleate (Methergine) during uncomplicated 3rd and 4th stages of labor

1. MOA/indication:

causes sustained uterine contraction

2: S/E:

Cramping

N/V

HTN, seizure, HA

3: Contraindications:

HTN, Pre-E

* do not give IV secondary to risk of sudden vasospasm and hypertensive or CVA

4. Clinical considerations

Recommended that womans blood pressure be taken prior to administration

Onset: 2-5 mins

Peak plasma concentration: 20-30 mins

Plasma half life: 3-4 hours

*women with coronary artery disease may have increased risk for MI

* BBW: avoid BF for first 12 hours of newborns life

Pubococcygeus Muscle (Part of the levator ani muscle)

acts as a "sling" for the vagina, horseshoe-shaped and most important, most dynamic and most specialized part of the pelvic floor. Lies in the midline, is perforated by the urethra, vagina, and rectum and is often damaged during delivery; divided into three bands: pubovaginalis, puborectalis, pubococcygeus proper

Bulbocavernosus muscle

two bulbocavernosus muscle. Posteriorly, they attach to the central tendinous point of the perineum; anteriorly, they insert into the corpus cavernosum of the clitoris; laterally, they surround the orifice of the vagina, covering the vestibular bulbs and Bartholin's glands on either side; known as the sphincter vagina, contraction of these muscles reduces the size of the vaginal orifice. Contraction of the anterior muscle fibers contributes to clitoral erection

Superficial Transverse Perineal Muscle

two superficial transverse perineal muscles arise from the inner and anterior surfaces of the ischial tuberosity of the superior ramus of the ischium by a small tendon; they insert into the central tendinous point of the perineum; fix the location of the central tendinous point of the perineum

Central tendinous point of the perineum

(a fibromuscular structure); ( a fibromuscular structure): in midline between vagina and the anus, and at the base of the urogenital diaphragm. The tissue is fibrous bc it is the point of fusion for both the superior and inferior fascia of the urogential diaphragm and the external perineal and colles fascia; it has muscular fibers bc it is a common point of attachment for a number of muscles whose fibers blend together in the central tendinous point of the perineum, amon them the blubocavernosus, superficial transverse perineal, some fibers of the deep transvers perineal, external anal spinchter, and the levator ani-pubococcygeous. Common point of attachment for a number of layers of fascia and muscle

Procedure for examination of the vulva and perineum

1. Inspection of the vulva and the perineum is achieved by using sterile, gloved fingers to

gently separate the labia. A sterile cloth or gauze may be used to gently clean away

blood or clots that obscure a laceration.

2. The periurethral, periclitoral, labial, fourchette, perineal, and rectal areas are

completely visualized.

3. The edges of irregular lacerations may be visually approximated best if a tissue forceps

is used to carry one side of the laceration to the other. This helps the midwife begin a

plan for repair of the laceration.

4. If a third- or fourth-degree laceration is suspected, don an additional glove and insert

the index finger into the rectum to assess the integrity of the rectal sphincter. With

palmar side up, gently lift upward, to expose the full extent of the laceration. Remove

this glove and discard it after the rectal examination.

procedure for thorough examination of the vaginal vault

1. For the purpose of this procedure, the vaginal vault is divided into four sections:

posterior, anterior, and two lateral walls. Each section is visualized to identify

lacerations in the vaginal mucosa. A systematic approach to this examination ensures

that all areas are quickly, yet thoroughly inspected. Gauze sponges should be counted

prior to use.

2. A 4 × 4 gauze sponge folded in fourths and clamped with a long-length ring forceps

can be used to clean away blood. A second ring forceps can be used to gently lift a

prolapsed cervix, or a Sims retractor used to elevate the anterior wall, allowing an

unobstructed view of the lateral, posterior, and anterior fornices of the vaginal vault.

3. To examine each section of vaginal wall, insert the full length of several fingers of one

sterile, gloved hand palmar side down and exert pressure away from the area being

examined. Once one area has been inspected, release the pressure and reposition the

vaginal hand in the new area to be inspected before force is applied again.

4. Insert the ring forceps with the gauze sponge on it by sliding it down the top of the

vaginal fingers. This maneuver minimizes the amount of gauze touching the vaginal

walls, as the gauze is abrasive to these tissues. The gauze serves as a sponge to blot

blood and other fluids from the exposed area, thus, facilitating visualization. If the

gauze sponge becomes saturated, remove the ring forceps, dispose of the saturated

gauze sponge, clamp on a clean one, and reinsert the ring forceps. During this

procedure, the midwife should be careful to monitor use of gauze sponges so none is

inadvertently left in the vagina. Dedicating an area on a delivery table or drape for

saturated sponges to be counted is helpful.

procedure for inspection of the cervix 1 of 2

1. An assistant, if one is available, will make this procedure easier and more efficient.

2. Insert three or four sterile, gloved fingers of the nondominant hand palmar side down

along the posterior vaginal wall to the area just in front of the cervix. This hand is used

to exert pressure to retract the posterior vaginal wall and facilitate visualization of the

cervix.

3. Once the cervix is in view, using the dominant hand, grasp the anterior lip of the

cervix with one of the ring forceps. The first forceps is used to help bring the anterior

part of the cervix into view. The second ring forceps is used to grasp the posterior part

of the cervix (Figure 28C-1).

4. Hold the handles of both ring forceps in the dominant hand. Pull on the forceps

gently, if necessary, to bring the cervix more into view. Move the handles of the

forceps toward one side of the perineum, thereby slightly pulling the cervix so the

lateral apex of the cervix can be visualized.

5. Visually inspect the area of the cervix between the two-ring forceps on one side.

6. If necessary, confirm the visual inspection by using the index finger of the vaginal

hand to feel the edge of the cervix.

7. Repeat the procedure, moving the handles of the forceps toward the other side of the

perineum to visualize and inspect the other lateral side of the cervix.

procedure for inspection of the cervix 2 of 2

8. If the cervix is very patulous, all of the cervix may be difficult to visualize adequately

between the ring forceps placed on the anterior and posterior lips of the cervix. In

such a case, the entire circumference of the cervix can be visualized by placing one ring

forceps on the anterior lip of the cervix and the second forceps next to it. Release the

first forceps and place it on the other side of the second. Continue to leap-frog or

"walk" the ring forceps around the cervix. This technique can also be used when the

posterior lip of the cervix cannot be located easily.

9. If there are no cervical lacerations, remove the ring forceps and the vaginal hand.

10. If the cervix is bleeding from a cervical laceration, use the forceps to exert direct

pressure on the laceration to decrease or stop the bleeding, prior to repair. This

method can help to significantly reduce the amount

List tissues disrupted with 1st, 2nd, 3rd and 4th degree lacerations of the perineum

1. 1st degree- perineal skin, vaginal mucosa, and posterior fourchette

2. 2nd degree-skin, vaginal mucosa, posterior fourchette-extends into perineal body fascia and

musculature, but NOT the anal sphincter

3. 3rd degree- skin, vaginal mucosa, posterior fourchette, perineal muscles, and external anal

sphincter

4. 4th degree- all the above-but also extends through external AND internal anal sphincter and

anterior rectal mucosa

Define and know the significance of placental calcifications

1. maternal surface is usually smooth but may have a gritty white areas of calcification.

2. generally the quantity of calcifications has no clinical significance

Define and know the significance of succenturiate placenta

1. one or more smaller accessory lobes o f the placenta are developed in the

membranes and are attached to the main placenta by fetal vessels.

2. this finding is more common among multiple gestations

3. the accessory lobes may be retained. Leading to PPH or infection

4. these placentas can be associated with velamentous insertion of the cord

Define and know the significance of circumvallate placenta

1. the membranes appear to arise not from the edge of the placenta but rather a short

distance inward toward the umbilical cord.

2. the chorionic plate is reduced because of this

3. fetal membranes fold back upon themselves creating a dense grey/white ring that

surrounds the outer margin of the placenta. The fetal vessels stop at this ring

4. the risk of placental abruption is increased

5. possible causes include variety of developmental abnormalities

6. finding is insignificant but associated with

-threatened abortion, preterm labor, painless vaginal bleeding after 20 EGA, placental insufficiencies, fetal growth restriction, intra- and post-partum hemorrhage

Define and know the significance of battledore (marginal) cord insertion

1. a form of circumvallate placenta, which the fetal membranes do not fold back,

creating the white ring.

2. this variation: placental tissue appears to extend beyond the marginate ring where the

membranes arise

3. finding is insignificant

Define and know the significance of velamentous insertion of the cord

1. cord is inserted at or w/on 1.5 cm of the margin of the placenta

2. may be insignificant finding but associated with PTL, abnormal fetal heart rate patterns in labor (compression), bleeding in labor (vessel rupture)

Define and know the significance of vasa previa

-placenta splits into two lobes with the umbilical cord connecting one lobe to the other

-if the exposed blood vessels traveling between the lobes lie close to your cervix, they can burst and bleed once labor starts

Know the significance of abnormal number of blood vessels in the cord

2 vessel cord occurs among 0.5-1% of neonates

Associated with GI, GU, and CV abnormalities

Know the following regarding inspection of the placenta, cord and membranes

1. Observe the insertion site for where the cord inserts in relation to the body of the placenta—

central, eccentric, or marginal (Battledore placenta).

1. Determine whether the cord is inserted directly into the placenta or is attached by

exposed vessels (velamentous cord insertion)

2. Centric and eccentric (off-center) insertions are variations of normal.

3. Velamentous and marginal insertions are unusual and associated with a risk of vasa

previa should one of these vessels tear when the membranes rupture.

2. Examine the placental margin for torn blood vessels leading into the membranes to look for

evidence of a succenturiate lobe.

1. A cotyledon missing from the main placental mass is identified by a defect in the

placental mass with a rough surface where it tore away or a torn vessel at the edge of

the placenta.

2. This must be differentiated from a simple tear in the placenta without loss of tissue,

which also leaves a rough surface.

3. Differentiation is made by holding the placenta, maternal surface up, so that the

cotyledons fall into place against each other.

4. A missing cotyledon is then evident because, as in a jigsaw puzzle, the surrounding

pieces will not fit together smoothly.

5. Observe for infarcts, cysts, tumors, and edema.

3. Three vessels should be visible: two small arteries and one large vein.

1. Any two-vessel cord should be submitted for pathology examination, and neonatal

providers should be informed.

Local anesthetics and manifestations of systemic toxicity (inadvertent IV admin or overdose)

1. Lidocaine toxicity can cause light-headedness, dizziness, tinnitus, abnormal taste,

facial tingling, circumoral numbness, and confusion.

2. Severe toxicity results in loss of consciousness and respiratory arrest.

3. If lidocaine without epinephrine is injected intravascularly, the first signs may be

hypotension and bradycardia.

4. If lidocaine with epinephrine is injected intravascularly, the first signs may be

hypertension and tachycardia.

Maximum safe dose of 1% Lidocaine (Xylocaine)

1. Toxic levels are based on the weight of the woman, the concentration of the

medication, and an identified safe range for administration.

2. The recommended dose of lidocaine 1% without added epinephrine is typically 5 to

10 mL (50-100 mg).

3. Lidocaine1% with added epinephrine: 50mL(500mg).

which of the following is a symptom of lidocaine toxicity?

Metallic taste

AMTSL according to ICM/FIGO includes

administration of oxytocin right after the baby is born, controlled cord traction, and uterine

massage after the placenta is expelled.

AMTSL has been shown to:

reduce risk of postpartum hemorrhage.

result in less overall blood loss.

result in less anemia.

all of the above

Expectant management of third stage labor includes all of the following EXCEPT

controlled cord traction only with a uterine contraction

The first line uterotonic medication, with evidence of the best effectiveness and side-effect profile, is:

Pitocin

True or False: The research findings on AMTSL provide us with a definitive, evidence-based management protocol for use with all births

False

According to the current ICM/FIGO AMTSL guidelines: uterine massage is:

the third step of the recommended three steps of AMTSL, after the placenta is expelled

Clinical signs of placental separation include:

a change in the shape of the uterus

A laceration involving the vaginal mucosa, posterior fourchette, perineal skin and perineal muscles is of what degree?

Second

With a velamentous cord insertion, the umbilical cord:

blood vessels separate and leave the cord prior to the insertion into the surface of the placenta

Water intoxication from hyponatremia is a potential side effect of what uterotonic?

Pitocin

A G3P2, now G3P3, has just given birth to her third child. You have previously discussed her plan for third stage management with her using shared decision-making, and her preference and plan is for expectant management. She had a normal prenatal course without complications and required a brief period of oxytocin augmentation during her second stage of labor when her contractions became less frequent and strong. At this time, you will:

Inform her that you now recommend AMTSL due to her risk factor for excessive bleeding,

remind her of the evidence supporting your recommendation, and talk with her about her choice

in light of her second stage.