Labor/Delivery

30 yr old G2P1 at 37 wks come sin for routine visit. With leopold maneuver you feel firm round mass at top of uterus and sifter part down below. Ultrasound shows hips flexed and knees extended. This pt has

Frank breech

What part presents in breech

Buttocks

What type of breech presents with the buttocks and feetfirst

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

Incomplete breech

This breech is highest risk of cord prolapse

Footling breech

How to dx breech confirmatory

US

When do you preform ECV in a pt with breech presentation

37 was

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 o 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 r accelerations in 20minutes each a rise of >15 beatspermin, lasting ‘ secs > 15 secs

What does a nonreactive NST mean

Not enough acceleration → more to contractionstress 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 UST was non reactive

What is veal chop

Variable → cord compression . Early-head compression .accelerations-okay0 late-placental insuff

When do you do AP gar scoring

Quick newborn check

What does AP gar stand for

Appearance, pulse, grimace, activity,respiration

When do you test AP gar scoring

1 and 5 mins after birth

What values are given to AP gar scoring

0,1,or 2 • max score of 10

Normal AP gar scoring

At least 7

What does AP gar scoring 4-6 mean

Needs some help

What does AP gar scoring of at least 3 mean

Needs resuscitation

TX fetal distress

Intrauterine resuscitation = roll mom, on left give 02, IVF stop oxytocin

What is labor dystopia

Labor too slow or stopped

What are the 3 p's for labor dystopia

Power, passenger, passage

What is the power issue of labor dystopia

Contractions are too weak (most fixable cause)

What is the passenger issue regarding labor dystopia

Baby too big(macrosomia) or poorly positioned (mal position, 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 dystopia

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

How to dx shoulder dystopia

Serial cervical exams to see if its protraction vs arrest also check contraction strength ( intrauterine pressure cash, IUPC. Measures it ), and baby's size and position

Tx shoulder dystopia if contractions are too weak

Oxytocin to strengthen them + /_ breaking water, amniotomy

Ix atrue arrest

C section

How to tx shoulder dystopia

Mcroberts maneuver (sharply flex Mon's hips onto belly t suprabubic pressures first

labroing pt at full dilation whose baby is occiput anterior. a she psuhes 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

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 preset 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 delviery

this word consists of 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

hwo 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 delviery of placenta. cord needs 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 whast does that mesn

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 ro less mean

needs immediate resuscitation

normal fetal HR

110-160 BPM

antepartum fetal testing consists of

checking baby before labor. non stress test, contraction stress test, biophysical profile

what is considered a reactive non stress test (good)

at east 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 biophysical profile

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

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)

why do we care about a post term preg

placenta ages and works less

macrosomia, lo amniotic fluid, meconium, dysmaturity, stillbirth

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

31 yr old G3P1 t 37 wks comes to ED saying her water broke. pt has clear fluid and denies blood or mucus monitoring shows good fetal heart rate and no contractions. speculum exam shows closed cervix and pool of clear/yellow fluid in vaginal vault, fern-pos and nitrazine pos. bedside US shows lo amniotic fluid. dx

Prelabor rupture of membranes (PROM)

when water breaks before contractions begin, at ≥37 wks.

PROM

when water breaks before contractions start before 37 wks

preterm premature rupture of membranes (PPROM)

2 risks once water is broken

infection (chorioamnionitis), umbilical cord prolapse

what is pathognomonic for PROM/PPROM

sudden gush of clear or pale yellow fluid ± continuous leaking

how to dx PROM/PPROM

prove the fluid is amniotic and not urine. speculum exam, nitrazine test, ferning test, US

what will you see on speculum exam in pt with PROM/PPROM

pooling of fluid in the back of the vagina (posterior fornix)

what will you see on a nitrazine test in pt with PROM/PPROM

paper turns blue (amniotic fluid is alkaline ph > 7.1). if it was urine it would keep the paper yellow

what do you see on ferning exam in pt with PROM/PPROM

fern leaf crystal pattern

what is the US finding in a pt with PROM/PPROM

low fluid (oligohydramnios)

tx PROM in pt ≥34 wks

induce labor

how to tx PROM in pt 32-34 wks

give antenatal steroids and manage expectantly to 34 wks, then deliver

tx PPROM in pt <32 wks

antenatal CCS (beta) for lung maturity, abx (amp + erythro) to lengthen preg and prevent infxn, ± tocolytics, deliver

worst complications of PROM

chorioamnionitis and cord prolapse

27 yr old G2P1 at 30 wks has regular painful contractions every 5 mins for several hours. cervical exam shows she went from being closed to now 2cm dilated. she gets antenatal CCS, Mag, and a tocolytic. dx

preterm labor

regular contractions plus cervical change before 37 wks.

preterm labor

leading cause of newborn illness

preterm birth