Labor and Delivery: Second Half

educate, prepare, breathing, lessens, blocking, placenta, pudendal, nitrous, epidural

Labor Pains

-Natural birth → ________ patients regarding the experiences of labor and delivery in order to ________ them for the event 

• May try ________ exercises, meditation/relaxation, water, massage to help cope with the pain

-Analgesic drugs → relieves/_________ pain without total loss of feeling or movement

-Anesthetic drugs → relieves pain by _________ all feeling 

-Systemic analgesia → narcotics or sedatives cross the ________

-Local anesthesia → ________ nerve or perineal block for episiotomy or laceration repair 

-Inhaled agents → _______ oxide

-Regional (neuraxial) anesthesia → ________ or spinal 

L3-4, opioid, sensation, hypotension, back, depression

Epidural

-Epidural catheter is placed in ___-_ interspace

-Provides continuous infusion of medication, which is a local anesthetic plus ______

-Does not remove all __________ completely

-Side effects → ___________, fetal bradycardia, fever, ____ soreness, headache, maternal respiratory ____________ if level too high, hematoma

subarachnoid, cesarean, rapid, hypotension

Spinal Anesthesia

-One time does of opioid and/or local anesthetic into ____________ space 

-Often used for _________ delivery

-_____ onset and dense sensory block

-Similar side effects as epidural though greater risk for ______________

emergent, aspiration, hypoxia, intubate

General Anesthesia

-Used for __________ cesarean deliveries

-Concern for risk of maternal ___________ and risk of ______ to mother and fetus during anesthesia induction

-_______ and secure airway 

exhaustion, membranes, full, position, empty

Indications for Operative Vaginal Delivery

-Indications → prolonged 2nd stage, maternal ___________, and need to hasten delivery

-Safe application if → ruptured _________, ____ dilation, engaged fetal head at least +2 station, known fetal __________, no evidence CPD, _____ bladder, adequate anesthesia, and experienced operator

head, dilated, membranes, 34, bleeding

Contraindications to Operative Vaginal Delivery

-Absolute → unengaged fetal ____, unknown fetal position, incompletely ______ cervix, intact ____________, or cephalopelvic disproportion suspected

-Relative → estimated fetal weight > 4,500 (macrosomia), gestational age < __ weeks, certain fetal conditions (_______ disorders, demineralization disorders), and operator inexperience or lack of immediate backup for cesarean

scalp, suction, pelvis, contractions

Vacuum Assisted Vaginal Delivery

-Vacuum consists of vacuum cup placed on fetal _____ and a ________ device that is connected to the cup

-Exertion on the cup and consequently on the fetal scalp is made parallel to the axis of the maternal ______ along with maternal pushing and uterine ___________

cephalic, head, pelvis

Forceps Delivery

-Metal blades with _______ curvature that are placed around the ____ of fetus

-Most have a curvature as well that conforms to the maternal ______

-Two forceps connect at lock between shank and handle

laceration, head, facial, canal

Complications of Operative Vaginal Delivery

-Vacuum assisted → scalp ________/bruising, cephalohematoma

-Forceps → lacerations or bruising on fetal ____ or face, ______ nerve palsy, intracranial damage, and lacerations of the birth _____

placental, body, skin, muscles, sphincter, epithelium

Perineal Lacerations

-Lacerations are repaired after _________ delivery 

-Most common site is the perineal ____

-Classification System

• 1st degree = injury to perineal _____ only 

• 2nd degree = injury to perineum involving perineal ________

• 3rd degree = injury to perineum involving anal _________ complex 

• 4th degree = injury to perineum involving anal sphincter complex and anal ___________

bleeding, distorted, continuous

Laceration Repair

-For periclitoral, periurethral, labial, and 1st degree lacerations, repair if ___________ or anatomy ____________

-Clinical judgement for 2nd degree laceration repairs

• ___________ suturing preferred over interrupted

-Experienced provider must repair all 3rd and 4th degree lacerations

sphincter, operative, weight, antibiotic, pain, constipation, incontinence, fistula, sexual

3rd/4th Degree Perineal Lacerations

-OASIS → obstetric anal _________ injuries

-Risk factors → _________ vaginal delivery, midline episiotomy, and increased fetal birth _______

-Consider dose of __________ at time of repair

-____ control and avoid ___________

-Short term risks → wound breakdown and infection

-Long term risks → pelvic floor injury, fecal and urinary ___________, recto-vaginal _______, persistent pain, and _______ dysfunction

-May offer primary cesarean delivery next pregnancy

perineum, midline, dystocia

Episiotomy 

-Incision made in __________ → either mediolateral or ________

-Indications → need to hasten delivery or impending/ongoing shoulder ________

anterior, pubic symphysis, impacted, deliver, none, obesity, epidural

Shoulder Dystocia: Background

-Occurs when, after delivery of the fetal head, the baby’s ________ shoulder gets stuck behind the mother’s _____ __________

-Anterior shoulder gets lodged up against maternal symphysis pubis → shoulders are ___________, unable to get under the pubic symphysis to deliver

-Risk Factors

• #1 risk factor/cause is ____

• Possible risk factors are GDM, history of dystocia, maternal _______, prolonged 2nd stage, operative delivery, macrosomia, multiparity, post-term pregnancy, _______ use, and inability of the fetus to rotate after head is delivered

retraction, expulsion, not, fail, episiotomy, hemorrhage, Erb’s, asphyxia

Shoulder Dystocia: Turtle Sign and Complications

-Represented by the _________ of the fetal head after _________

• Suggestive of shoulder dystocia but ___ diagnostic

• Shoulder dystocia is not diagnosed until the usual attempts at the delivery of the head ____

-Maternal complications → need for _________, laceration, and postpartum __________

-Fetal complications → fracture of clavicle/humerus, ____ palsy, _________/neonatal encephalopathy

• Erb’s Palsy is a brachial plexus paralysis that usually resolves by 18 months

• Neonatal death due to asphyxia is rare

drills, 5000, 6-10, help, traction, dorsal

Management of Shoulder Dystocia

-Must anticipate it 

• Practice via _____, call for help, remain calm, take charge 

• Highly anticipate for the patients who have estimated _____g babies (without DM) or 4500g (with DM)

-Deliver within _____ minutes 

-Call for ____

-Try gentle ________ first 

• Apply pressure on the fetal vertex in a _______ direction helps move the anterior shoulder 

• Done before anyone suspects shoulder dystocia 

help, episiotomy, McRoberts, suprapubic, internal, posterior, fours

Management of Shoulder Dystocia: HELPERR Algorithm

-H → call for ____

-E → evaluate for __________

-L → legs → __________ → hyperflex legs and abduct the hips

-P → _________ pressure → not fundal

-E → enter → _______ maneuvers such as Woods screw

-R → remove → delivery of _______ arm

-R → roll the patient onto all _____

hyperflex, abduct, vertical, rotating, anterior

Maneuvers for Shoulder Dystocia: McRobert’s

-Initial maneuver performed upon recognition

-_________ legs and _____ the hips

-Goal is to bring pelvic inlet and outlet into more _______ alignment while flattening the sacrum and _______ the pubic symphysis

-Disimpact ________ shoulder

suprapubic, disimpact, posterior, fundal, wrist, pressure, forearm

Shoulder Dystocia Maneuvers: Suprapubic Pressure and Delivery of Posterior Arm

-Suprapubic pressure → moderate __________ pressure is often the only additional maneuver necessary to ________ the anterior fetal shoulder

• Direct force on ________ shoulder to rotate it anteriorly 

• No _____ pressure 

-Posterior arm → bring the fetal ______ within reach and exert ________ with the index finger at the antecubital junction. Sweep the fetal _________ down over the front of the chest 

posterior, anteriorly, counterclockwise, anterior, posterior, sling, traction

Shoulder Dystocia Maneuvers: Rubin, Woods Corkscrew, Axilla Sling

-Rubin Maneuver → practitioner placed hand on back surface of ________ shoulder, then rotates it _________ toward fetal face

-Woods Corkscrew → _____________ rotation of the ______ shoulder to move toward the more favorable pelvic diameter or clockwise rotation of the _________ shoulder

-Posterior Axilla Sling → French catheter is threaded to make a _____ around posterior shoulder. Apply moderate _______ to the sling to deliver shoulder

knees, traction, upward, increases, fracture, ramis, anteriorly, cesarean, abdominal

Shoulder Dystocia Maneuvers: Gaskin, Fracture Clavicle, Last Resorts

-Gaskin → patient on hands and ______. Apply gentle downward _______ on posterior shoulder or _______ traction on anterior shoulder

• ________ pelvic dimensions and may allow fetal position to shift, freeing the impacted shoulder 

-Fracture Clavicle → ______ the clavicle if less invasive measures fail

• The anterior clavicle is pressed against the ___ of the pubis

• Avoid puncturing the lung by angling the fracture __________

-Zavenelli → cephalic replacement and then proceed with emergent ________ delivery 

-Symphysiotomy → _________ rescue, where you cut the symphysis pubis 

ultrasound, sutures, 28, multiple, anomaly, fibroids

Malpresentation: Diagnosis and Risk Factors

-Diagnosis → gold standard is __________

• You may be able to feel ______ on the fetal head upon pelvic exam

• Start Leopold’s maneuvers at __ weeks for fetal presentation assessment

-Risk Factors → multiparity, ________ gestation, polyhydramnios, uterine ______, abnormal uterine growth such as ________, placenta previa, or preterm labor

occiput, pelvis, anterior, transverse, posterior

Vertex Presentation

-Fetal position → relationship of the fetal _______ to maternal ______

-L/R OA → left/right occiput _______ (what you want)

-L/R OT → left/right occiput _________

-L/R OP → left/right occiput _________

feet, cervix, buttock, head, feet, knees

Breech Presentation

-Either the bottom or ____ are the first body parts that make contact with the _____

-Complete → ________ and feet are next to each other with bent knees 

-Frank → buttock first, feet by the ____

-Footling → _____ first, single or double

-Kneeling → ______ first 

horizontally, perpendicular, shoulders, elbow

Transverse Presentation

-Fetus lies ___________ in the pelvis, so it is _____________ to the mother

-The presenting part is usually the _________ but can be iliac crest, hand, or ______

extremity, hand, cord, traumatic

Compound Presentation

-Prolapse of fetal ________ alongside a presenting part

• ____ up by the head

-Increased risk of ____ prolapse

-Risk of _______-vaginal delivery

• Perineal tears

hyperextension, extension, chin

Brow, Chin, Face Presentations

-Face → ____________ of the fetal head, so clinician is unable to feel sutures on vaginal exam 

-Brow → caused by partial ________ of the fetal head

-Mentum (____) → prolonged labor is common

pressure, singleton, 36, intact, induction, cesarean, distress, myometrium, epidural

External Cephalic Version

-Attempt to change the fetal position via external _________ through the maternal abdominal wall

-Must have a __________ pregnancy, be over __ weeks gestation, membranes _____, adequate amniotic fluid, no complications, and consent

-Consider proceeding with ________ soon after if successful

-If unsuccessful, plan for ________ delivery

-Complications → pushing so hard may cause placental injury or fetal ________

-Medication → sometimes terbutaline is given to relax the __________ or an ______ for pain control or prep for cesarean

complete, preterm, flexed, entrapment

Spontaneous Vaginal Delivery: Breech

-If provider has experience with vaginal breech delivery, may consider performing

-Rarely done anymore

-May consider if → ________ or frank breech, adequate clinical pelvimetry, ________ fetus, fetus not too large, no prior C-section, or _______ head

-Major complications → head ____________

cesarean, footling, large, US

Elective Cesarean Delivery

-Malpresentation is an indication for _________ delivery

-Consider especially if double _______ breech, small pelvis, _____ fetus, previous c-section, or hyperextended head

-Confirm with __ to know if the fetus is breech or transverse 

infection, forceps, trauma, hemorrhage, cord, prolapse, asphyxia, brachial plexus

Potential Complications of Malpresentation

-Maternal → prolonged labor, PROM leading to _________, need for _____ delivery or cesarean, ______ to birth canal during delivery from manipulation, or intrapartum/postpartum ___________

-Fetal → compression of ____, ________ of the umbilical cord, entrapment of fetal head in incompletely dilated cervix, aspiration and ________ at birth, birth trauma from manipulation and/or instruments to free fetal head like ______ _____ injury/clavicle fracture/hip injury

descends, cervix, malpresentations, long, rupture

Cord Prolapse: Background

-When the umbilical cord __________ through the ______ before the baby

-Risks → fetal _____________, premature infants, multiparous women, ____ umbilical cord, polyhydramnios, unengaged presenting part, and ______ of membranes at high fetal station

ruptured, decelerations, palpable, pressure, Trendelenburg, delivery, cesarean

Recognition and Management of Cord Prolapse

-Diagnosis → 

• In setting of ______ membranes

• On electronic fetal monitoring, fetal ____________, fetal bradycardia

• ________ cord felt on vaginal exam 

-Management → 

• Relieve _________ off the cord by using hand to maintain pressure on the fetal presenting part to keep it lifted off the cord 

• _____________ position 

• May be able to reduce the cord or have patient deliver through it if ________ imminent 

• Most often to OR for emergent __________ delivery 

macrosomia, previa, complete, rupture, herpes

Contraindications to Vaginal Delivery

-Relative → fetal _________, >2 prior c-sections, partial placenta _____, non-reassuring fetal heart tracings

-Absolute → vasa previa, _________ placenta previa, narrow pelvis, malpresentation, classical uterine scar, history of uterine ________, cord prolapse, and active genital ________

uterine, first, failure, increased, request

Cesarean Delivery

-Delivery of fetus through abdominal and ______ incisions

-Primary → _____ cesarean delivery, common indication is ________ to progress

-Repeat → the higher the number, the ________ risk of placenta accreta and previa, and uterine rupture

-Elective → no other indication other than patient _________

progress, scar, dystocia, preeclampsia, fibroid, breech, prolapse, conjoined

C-Section Indications

-Maternal

• Failure to ________, cephalopelvic disproportion, previous uterine ____, history of shoulder _______/4th degree laceration/vesicovaginal fistula, severe __________, pelvic tumors/obstructing ______/HSV, severe aortic stenosis, and cerebral palsy 

-Fetal 

• Malpresentation (______, transverse, compound), complete placenta previa, vasa previa, placenta accrete, placental abruption, cord ________, macrosomia, fetal intolerance of labor, failed operative vaginal delivery, and ________ twins 

vaginal, rupture, pain, FHR, station, decrease

Trial of Labor After Cesarean

-If successful, results in _______ birth after cesarean

-If considering, ensure known type of prior hysterotomy, in-house OB and anesthesiologist, informed conset

-Greatest concern is risk of ______ of prior uterine scar

-Signs of rupture → sudden severe abdominal ____, maternal sensation of “pop”, ___ decelerations or bradycardia, loss of fetal station, and sudden _______ in pressure on IUPC