Normal and Abnormal L&D

Dilation

Progressive opening of the cervix from 0 to 10 cm during labor

Effacement

Thinning and shortening of the cervix during labor, measured as a percentage from 0-100%

Engagement

When the biparietal diameter of the fetal head passes through the pelvic inlet (0 station)

Descent

Movement of the fetal presenting part through the pelvis during labor

Adequate labor

Labor that results in progressive cervical dilation and fetal descent

Stage 1 of labor

From onset of labor until cervix is fully dilated (10 cm)

Latent Phase

First part of Stage 1 with dilation from 0-3 cm

Active Phase

Middle part of Stage 1 with dilation from 4-7 cm

Transition Phase

Final part of Stage 1 with dilation from 8-10 cm

Stage 2 of labor

Stage of fetal expulsion from complete cervical dilation to delivery of the fetus

Stage 3 of labor

Placental stage from delivery of the fetus to delivery of the placenta

Group B strep management

Administer prophylactic antibiotics during labor to prevent neonatal transmission

Signs of imminent delivery

Crowning of infant's head, intense urge to push, pressure in rectum, bulging perineum

Precipitous delivery management

Position, dry, wipe, wrap baby

Contraindications for vaginal delivery

Placenta previa, active genital herpes, previous classic C-section, fetal malpresentation, macrosomia

Indications for episiotomy

To prevent extensive tearing, for instrumental delivery, or when rapid delivery is needed

Indications for cesarean section

Failure to progress, cephalopelvic disproportion, fetal distress, placenta previa, prior classic C-section, active HSV

Complications of cesarean section

Hemorrhage, infection, DVT, injury to nearby organs, anesthesia complications, respiratory issues in newborn

Uterine involution

Rapid reduction in size of uterus after birth to pre-pregnant state

Placenta

Consists of blood vessels, vascular spaces and connective tissue

Cardinal movements of labor

Engagement, descent, flexion, internal rotation, extension, external rotation, expulsion

Oxytocin stimulation theory

Labor onset theory where oxytocin levels increase with an 80-fold increase in receptors at term

Prostaglandin release theory

Labor onset theory where prostaglandins in fetal membranes cause uterine contractions

True vs. false labor

True: regular contractions at 2-4 min intervals with increasing intensity, progressive dilation, back/abdominal pain, not affected by sedation

Bishop score

Assessment tool for cervical readiness for induction

Induction of labor

Artificial initiation of labor using prostaglandins, membrane stripping, oxytocin infusion, or AROM

Augmentation of labor

Stimulation of labor that began spontaneously

Oxytocin infusion protocol

10U in 1000 ml D5W or balanced saline via infusion pump

Pain relief options in labor

Nonpharmacologic methods, parenteral narcotics, regional anesthesia (epidural, spinal), nerve blocks, local anesthesia

Fetal monitoring methods

Intermittent auscultation, external electronic monitoring, internal electronic monitoring

Normal fetal heart rate

Baseline 110-160 bpm with moderate variability and accelerations with movement

Fetal tachycardia

FHR > 160 bpm

Fetal bradycardia

FHR < 110 bpm

Variability

Minute fluctuations from baseline FHR triggered by CNS control and environmental changes

Causes of decreased variability

Hypoxia, CNS depressants, fetal sleep cycle, dysrhythmias, immature neurological control, fetal anomalies

Early decelerations

FHR decreases due to head compression

Late decelerations

FHR decreases due to uteroplacental insufficiency

Variable decelerations

FHR decreases due to umbilical cord compression

Reassuring fetal tracing

Normal baseline, accelerations with movement, present short-term variability, 3-5 cycles of long-term variability per minute

Nonreassuring fetal tracing

Severe variable/late decels, absent variability, prolonged deceleration (>60-90 sec), severe bradycardia (≤70 bpm)

Interventions for nonreassuring tracing

Optimize positioning, monitor vitals, IV fluids, oxygen, consider stopping oxytocin, continuous monitoring, prepare for expeditious birth

Puerperium

Period from delivery to 6 weeks postpartum

Postpartum ambulation

Early ambulation hastens uterine involution, improves bleeding, lessens DVT risk

Postpartum bladder care

Monitor for bladder distention and signs of UTI

Postpartum perineal care

Apply ice, gentle cleansing, sitz baths, pain medication (Tylenol, ibuprofen, opioids as needed)

Uterotonic agents

Prophylactic administration of oxytocin after placental delivery to prevent postpartum hemorrhage

Maternity blues

Affects 50-70% of postpartum women with tearfulness, anxiety, irritation

Postpartum sexual activity

Resume after 6 weeks

Postpartum contraception

Consider that fertility returns around 5 weeks in non-lactating women and 8 weeks in lactating women

Postpartum immunizations

Rhogam (if indicated), rubella (if non-immune), influenza

Uterine position after birth

Immediately after delivery: midway between symphysis & umbilicus

Signs of placental separation

Uterus becomes globular and firm, rises upward in abdomen, umbilical cord lengthens, sudden gush of blood

Normal postpartum blood loss

About 500cc with normal vaginal delivery

Boggy uterus management

Massage fundus, ensure empty bladder, administer oxytocin

Lochia rubra

Dark red vaginal discharge from birth to 3rd day postpartum

Lochia serosa

Pink to brown vaginal discharge from 4th to 10th day postpartum

Lochia alba

White to yellow vaginal discharge from 11th to 21st day postpartum

Breastfeeding benefits

Protects babies from infections, decreases risk of asthma, reduces maternal breast/ovarian cancer risk, saves $1200-1500 on formula

Breastfeeding recommendations

AAP: at least 12 months

Breast changes postpartum

Progression from soft to filling to full as mature milk comes in 3-4 days

Supply and demand in lactation

Suckling stimulates prolactin and oxytocin

Perineal lacerations 1st degree

Involves vaginal epithelium or perineal skin only

Perineal lacerations 2nd degree

Involves subepithelium of vagina/perineum with or without perineal muscles

Perineal lacerations 3rd degree

Involves anal sphincter

Perineal lacerations 4th degree

Involves rectal mucosa

Stage 4 (recovery stage)

1-6 hours after delivery

Postpartum assessment

Vital signs, uterine involution, uterine tenderness, DVT check, lochia examination, incision check, voiding/bowel status

Follow-up care

Postpartum visit 4-6 weeks after discharge