Labor/Delivery

30 yr old G2P1 at 37 wks comes in for routine visit. With leopold maneuver you feel firm round mass at top of uterus (fundus) and softer part down below. Ultrasound shows hips flexed and knees extended. This pt has

Frank breech

What part presents in frank breech

Buttocks

What type of breech presents with the buttocks and feet first

Complete breech

This type of breech presents with 1 foot or both feet

Incomplete (footling) breech

This breech is where hips are flexed and knees sitting Indian style

Complete breach

This breech is where one or both hips are extended

footling/Incomplete breech

This breech is highest risk of cord prolapse

Footling/incomplete breech

what raises the odds of breech presentation

prematurity, twins, polyhydramnios

this type of breech has the highest risk for cord prolapse

footling. feet don’t fill the pelvis so the cord can slip

what are leopold maneuvers

feeling the firm head at the top instead of the bottom. confirm with US

How to dx breech confirmatory

US

When do you preform ECV in a pt with breech presentation

37 wks

laboring patient at 39 weeks on continuous fetal monitoring. With each of her contractions (about 3 in 10 minutes), the fetal heart rate dips — but the dip starts after the contraction peaks and returns to baseline only after the contraction is over. this type of FHR is

reprepetitive late decels

what concern is raised in a pt whos FHR shows repetitive late decels

uteroplacental insuff

What is fetal distress

Baby shows signs that it isn't producing enough oxygen

How do you determine if pt has fetal distress

Fetal heart rate (FHR) - tracing of shape and timing tells you cause

2 tests to determine fetal distress

Non stress test, contraction stress test

What is a non-stress test

Watching heart rate @ rest, no contractions needed

What do you want to see in a good nonstress test

A reactive test

What is a reactive NST

At least 2 accelerations in 20 minutes each a rise of >15 beats per min, lasting >15 secs

What does a nonreactive NST mean

Not enough acceleration → more to contraction stress test

What does contraction stress test mean

Now baby handles stress of contractions

What is a negative CST

Good. No late decelerations with ≥3 contractions in 10 mins. This is reassuring

What are positive contractions on CST

Bad. Repetitive late decelerations with contractions. worrying esp if NST was non reactive. move to delivery

what does early decels mean

dip mirrors contraction

early decels are caused by

head compression - benign

abrupt, sharp drop with no fixed relationship to contractions

variable decels

what does variable decels mean

caused by cord compression

dip in FHR starts after the contraction peaks and recovers after it ends

late decels

late decels are caused by

uteroplacental insuff

what is the most concerning FHR pattern

late decels. baby can be hypoxic

What is veal chop

Variable → cord compression

Early- head compression

accelerations-okay

late-placental insuff

When do you do APGAR scoring

Quick newborn check

What does APGAR stand for

Appearance, pulse, grimace, activity, respiration

When do you test APGAR scoring

1 and 5 mins after birth

What values are given to APGAR scoring

0,1,or 2, w max score of 10

Normal APGAR scoring

At least 7

What does APGAR scoring 4-6 mean

Needs some help

What does APGAR scoring of 3 or less mean

Needs resuscitation

TX fetal distress

Intrauterine resuscitation = roll mom on left give 02, IVF stop oxytocin. if doesn’t work then delivery

what is this FHR

early decels

what is this FHR

late decels

what is this FHR

variable decels

28-year-old G1P0 in active labor who has been stuck at 6 cm for the past 4 hours despite an intrauterine pressure catheter showing strong, adequate contractions. The baby’s head is not descending. She is diagnosed with an arrest of dilation and prepared for cesarean. this is an example of

labor dystocia

What is labor dystocia

Labor too slow or stopped

What are the 3 p's for labor dystopia

Power, passenger, passage

What is the power issue of labor dystocia

Contractions are too weak (most fixable cause)

What is the passenger issue regarding labor dystocia

Baby too big (macrosomia) or poorly positioned (malposition, like occiput posterior)

What is the passage issue of labor dystopia

Mom's pelvis is too small or shaped unfavorably

What is protraction of labor

Labor is moving, just slowly

What is arrest of labor

Labor stopped- no cervical change for >4 his with adequate contractions

What is shoulder dystocia

After head delivers shoulder gets stuck behind pubic bore and head retracts "turtle sign”

How to dx labor dystocia

Serial cervical exams to see if its protraction vs arrest. also check contraction strength w IUPC), and baby's size and position

Tx labor dystocia if contractions are too weak

Oxytocin to strengthen them ± breaking water, amniotomy

tx a true arrest in labor

C section

How to tx shoulder dystocia

McRoberts maneuver (sharply flex Mom's hips onto belly + suprapubic pressure first

laboring pt at full dilation whose baby is occiput anterior. as she pushes the baby’s head tucks its chin, rotates to face the floor, then extends under the pubic bone to deliver, followed by the shoulders. what are these movements called

cardinal movements of labor

step by step way a baby turns and tucks to fit through the pelvis

cardinal movements of labor

what is the most favorable position for delivery

occiput anterior

what is occiput anterior position

back of head toward the mom’s front

sequence of cardinal movements

engagement —> descent —> flexion (chin tucks) —> internal rotation —> extension (head delivers under the pubic bone) —> external rotation (restitution) —> expulsion (shoulders and body)

pneumonic for mechanisms for delivery

every decent family is really excited easter

what movement does the fetus do to present the smallest part of the head to the pelvis

flexion

how will a occiput posterior position present in a pt

sunny side up, longer labor and lots of back pain

how does the pt present with a transverse arrest

head stopped while sideways and didn’t complete internal rotation

26 y G1P0 at 39 wks gestation has regular contractions every 3-5 mins for the past 2 hrs. bloody snow and spontaneous rupture of membranes. cervical exam shows 4cm dilation, 80% effacement, station -1. fetal heart rate tracing is reassuring with no decelerations

normal labor and delivery

regular uterine contractions that produce progressive cervical dilation and effacement, ending in delivery of the baby and placenta

labor

what are the 3 things that describe the cervix on every exam

dilation, effacement, station

what is dilation when describing the cervix

how open the cervix is, 0-10 (10cm = fully dilated)

what is effacement when describing the cervix

how thin the cervix is, 0-100%

what is station when describing the cervix

how far the baby head come down relative to ischial spines

0 = at the spines, negative = above, positive = below

what is the first stage of labor

onset of labor to full dilation (10cm). longest stage, where first baby can take 6-20 hrs, and later babies taking 2-14 hrs

what is the second stage of labor

full dilation to delivery of baby (first baby = 30m-3hr, later = mins)

what is the third stage of labor

delivery of baby to delivery of placenta. cord has 2 arteries 1 vein

APGAR scoring

fast newborn check done at 1 to 5 mins after birth. each item 0-2

what does APGAR scoring stand for:

appearance (color)

pulse (HR)

Grimace (reflexes)

Activity (muscle tone)

Respiration

is pt gets APGAR score of 2 for appearance what does that mean

pink all over

if pt gets APGAR score of 2 for pulse what does that mean

>100 BPM

if pt gets APGAR score of 2 for grimace what does that mean

pulls away, sneezes, or coughs

if pt gets APGAR score of 2 for activity what does that mean

active movement

if pt gets APGAR score of 2 for respirations what does that mean

baby is crying

what is a normal APGAR score

7 or more

what does an APGAR score of 4-6 indicate

needs intervention

what does an APGAR score 3 or less mean

needs immediate resuscitation

normal fetal HR

110-160 BPM

antepartum fetal testing consists of

checking baby before labor. NST, CST, biophysical profile (BPP)

what is considered a reactive non stress test (good)

at least 2 accelerations (at least 15 bpm for at least 15 s) in 20 mins

what occurs in a positive contraction stress test (worrying)

late decelerations with contractions.

what is a positive contraction stress test suggestive for

uteroplacental insuff

what consists of a BPP

US + NST scoring 5 things: NST, fetal breathing, movement, tone, fluid). 2 pts each. ≥8 = reassuring

a reactive NST and a negative CST are

reassuring

late decels or a positive CST are suggestive of

uteroplacental insuff

station of the baby is measured against what part of the body

the ischial spines (0 = at the spines)

29 yr old G1P0 who is now 42 wks and 1 day by reliable first tri US. feels good but preg is post term. what should you counsel on

rising stillbirth risk, induction should happen

what is the cut off to consider a preg post term

42 wks (294 d) or more

why do we care about a post term preg

placenta ages and works less

risk of macrosomia, lo amniotic fluid, meconium, dysmaturity, stillbirth inc

most reliable due date is determined how

early US

late term is how many wks

41 wks

dx post term preg

early first tri US, antenatal screening @ 41 wks

tx post term preg

induce labor by 41-42 wks to lower risk for stillbirth, fetal surveillance