Intranatal Care Labor & Delivery

Braxton Hicks contractions

intermittent painless uterine contractions that occur with increasing frequency as the pregnancy progresses

Uterine contractions that are not associated with progressive dilation of the cervix

Braxton Hicks contractions

false labor contractions

Braxton Hicks contractions

irregular, shorter in duration, and less intense than true labor contractions

Braxton Hicks contractions

effacement

shortening and thinning of the cervix during labor

how is cervical dilation measured?

0-10 cm

1 finger into cervix = ______ cm dilated

1

signs of labor

Lightening, effacement, dilation, bloody show, nesting, rupture of membranes, contractions less than 10 minutes apart

what is "lightening" ?

When the fetal head descends into true pelvis about 14 days before labor

bloody show

a small amount of blood at the vagina that appears at the beginning of labor and may include a plug of pink-tinged mucus that is discharged when the cervix begins to dilate

clear fluid with rupture of membranes

normal; no complications

brown-tinged fluid with rupture of membranes

meconium fluid

purulent fluid with rupture of membranes

infection due to prolonged labor

contractions less than _________ minutes apart signal labor

10

when to contact provider during beginning stages of labor

Contractions every 5 minutes for greater than in hour

Gush of fluid or constant leaking (risk of infection)

Significant vaginal bleeding

Decrease in fetal movement

when to defer pelvic exam

if frank bleeding is present until placenta/vasa previa is ruled out

what are you looking for during pelvic exam?

"pooling" of amniotic fluid in posterior fornix & positive fern test= ROM

placenta previa

implantation of the placenta over the cervical opening or in the lower region of the uterus

what is determined by digital exam?

determines dilation, effacement, and station (how far up or down the presenting part of infant is)

purpose of abdominal exam

determines lie, presentation, and position

pH that indicates possible rupture of membranes

6.5-7.5

pH that indicates intact membranes

5.0-6.0

positive fern test

rupture of membranes confirmed

First Leopold maneuver

Place both hands on each upper quadrant of the abdomen and gently palpate the fundus with the tips of the fingers

Determines presentation

Second Leopold maneuver

Palpate the periumbilical region with both hands by applying deep but gentle pressure

Differentiates the spine from the limbs

Third Leopold maneuver

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

Allows for an assessment of the fetal weight and volume of amniotic fluid

Fourth Leopold maneuver

Examiner faces the mother's feet. With the tips of the first 3 fingers of both hands, the examiner exerts deep pressure in the direction of the axis of the pelvic inlet.

Determine if the presenting part of the fetus is engaged in the mother's pelvis (has lightening occurred)

Distance of the fetus in relation to the maternal ischial spine

station

where is "0 station"

0 station is in line with the plane of the maternal

ischial spine

further up in the canal is - or + ?

negative

deeper down in the canal is - or + ?

positive

when is hemoglobin/hematocrit obtained during pregnancy?

26-28 weeks

if Group B strep status is unknown in pregnant patient what is indication?

chemoprophylaxis with Pen G

first stage of labor - what does it start with and when is it complete?

begins with regular uterine contractions and ends with complete cervical dilation at 10cm

latent phase of initial stage of labor

begins with mild, irregular contractions that soften and shorten the cervix

lasts 12-16 hours

active phase of initial stage of labor

begins about 4cm of cervical dilation

rapid cervical dilation and descent of the presenting fetal part occurs

what centimeter of dilation does the active phase of the initial stage of labor occur?

4 cm

what phase of the initial stage are patients admitted to hospital?

active

second stage of labor

begins with complete cervical dilation and ends with delivery of the fetus

"pushing" stage; usually under 3 hours

third stage of labor

begins immediately after the delivery of the infant and ends with delivery of the placenta

1-30 minutes

fourth stage of labor

immediate postpartum period of approximately two hours after delivery of the placenta

when is patient most at risk for hemorrhage during labor?

fourth stage of labor (2 hours after delivery)

top of the head entering the pelvic outlet is called?

engagement

smallest diameter of the baby's head presents in the pelvis

flexion

baby's head moves deep into the pelvis

descent

cardinal movements of labor

1. Engagement

2. Descent

3. Flexion

4. Internal rotation

5. Extension

6. External rotation (restitution/resolution)

baby's head must rotate in order to accommodate the pelvis. Head rotates from right to left

internal rotation

occurs as the head, face, and chin are born

extension

shoulders rotate, turning head farther to one side

external rotation

positioning of mother during 1st, 2nd, and 3rd stage of labor

1st stage: supine left lateral

2nd and 3rd stages: dorsal lithotomy (vaginal deliveries)

dorsal lithotomy position

Position used for examination of pelvic organs. For example, delivery of baby, ob/gyn exam.

Tocodynamometry measures?

measures contractions

fetal monitoring during labor

Fetal heart auscultation

External (Doppler ultrasound)

Internal (Direct fetal electrocardiogram)

what is mother allowed to ingest during labor in hospital?

clear fluids only

most accurate monitoring of fetal heart rate

internal electrocardiogram

4 things to look for when monitoring fetal heart rate

baseline (110-160)

variability (normal fluctuations)

accelerations (increase >15 bpm for more than 15s)

decelerations (do NOT want to see these)

types of decelerations in fetal heart

early (head compressed)

late (placenta is not supplying O2)

variable (possible cord compression)

The nadir occurs with the peak of a contraction during what kind of deceleration?

early deceleration

fetal heart rate is a mirror image of contraction in what kind of deceleration?

early deceleration

the onset occurs after the beginning of the contraction, and the nadir occurs after the peak of the contraction is what kind of deceleration?

late deceleration

this deceleration will require emergent C section

late deceleration

Abrupt decrease in FHR that occurs at different times related to contraction

variable deceleration

reassuring signs FHR monitoring

2 or more accelerations in a 20min period

non-reassuring signs FHR monitoring

›Fetal tachycardia

›Fetal bradycardia

›Non-reassuring variable decelerations

›Late decelerations with decreased beat-to-beat variability

›Baseline 110-160 with moderate variability

›Accels may be present

›No late or variable decels (may have early)

category?

1

›Bradycardia or tachycardia

›Minimal variability and no accelerations with stimulation

›Can have recurrent late decels

category?

2 (indeterminate; at risk)

›Absent variability and recurrent late decels or bradycardia

category?

3 (abnormal)

pain management labor and delivery

Non pharmacologic

Systemic narcotic analgesics

Epidural block

–Most effective and most common method

–Can be used for both vaginal and caesarean deliveries

Spinal

–A single injection of anesthesia

–Usually used for caesarean deliveries

Combined spinal-epidural

Local block

General anesthesia

regional anesthetic options labor and delivery

1. epidural

2. spinal

3. combined spinal-epidural

most effective and common method of pain management for labor and delivery

epidural block

episiotomy

›Incision between the vagina and rectum to increase opening of the vagina

›Facilitates the delivery by enlarging the vaginal outlet

why are episiotomies performed?

›Facilitate in instrumental deliveries

›Expedite the delivery of the fetus if blocked by peritoneal tissue

›Shoulder dystocia

›History of female genital cutting

risks of episiotomy

›Extension of the incision, leading to third and fourth degree tears, particularly for median episiotomy

›Risk of unsatisfactory anatomic results

›Increased blood loss

›Higher rates of infection and dehiscence

›Increased risk of severe perineal laceration in subsequent deliveries

signs of placental separation

›Uterus become globular

›Gush of fluid

›Lengthening of the umbilical cord

first degree obstetrical lacerations

vaginal mucosa or perineal skin - Don't require sutures!

Second degree obstetrical laceration

underlying subcutaneous tissue

third degree obstetrical laceration

extends through rectal sphincter, but not rectal mucosa

fourth degree obstetrical laceration

extends into rectal mucosa

fourth stage immediate postpartum care

›Monitor for signs of uterine atony

›Palpate uterus

›Perineal pads - monitor amount of bleeding

›Pulse

›BP

methods of labor induction

membrane stripping, cervical ripening (prostaglandins, balloon catheter, laminaria), oxytocin

indications for C-section - maternal and fetal

Maternal indications

›Incompetent cervix

›Obstructive lesions

›Major anal involvement from IBD

›Prior vaginal colporrhaphy

›Uterine rupture or risk of abruption

Fetal indications

›Malpresentation

›Congenital anomalies

›Non-reassuring fetal heart rate

›Genital herpes infections

›HIV

Abnormal placenta

"Failure to progress"

Contraindications to labor - prior myomectomy

indications for?

C-section

TOLAC

trial of labor after cesarean

indications to allow TOLAC

›One previous low transverse delivery

›No other uterine scars or rupture

›Physician available through active phase of labor

›Availability of anesthesia, facility and physician to perform emergency c-section.

Labor Dystocia

an abnormally slow progression of labor

3 P's that would result in labor dystocia

–Power

–Uterine contractions

–Contractions not strong enough

–Dilating <1cm/hour once in active labor

–Descending <1cm/hour

–Passenger

–Fetal factors

–Macrosomia, malpresentation

–Passage

–Maternal factors

–Skeletal muscle or soft tissue anomalies

augmentation of labor

artificial stimulation of uterine contractions that have become ineffective - with Pitocin (oxytocin) or artificial rupture of membranes

operative vaginal delivery options

Forceps

›Apply traction to fetal head

›Used in conjunction with contractions and maternal effort

Vacuum Delivery

›Suction by means of pump

shoulder dystocia

head is delivered and shoulders are not

shoulder dystocia management

›Hyperflexion of mother’s legs tight to the abdomen (McRoberts maneuver)

›Apply suprapubic pressure to dislodge the shoulder

›Direct fetal manipulation may be required

Clavicle fracture may be necessary

May result in brachial plexus injury (Erb’s palsy)