WH - labor and delivery

What prenatal care occurs in the 1st trimester?

History, vitals/BMI/pelvic exam, serum hCG, ultrasound to confirm intrauterine pregnancy and gestational age, standard prenatal labs, genetic screening/testing discussion, assessment for referrals, and pregnancy education.

What prenatal care occurs in the 2nd trimester?

Monitor weight, blood pressure, fundal height, symptoms, and fetal heart rate; perform anatomy scan around 20 weeks and gestational diabetes screening at 24-28 weeks.

What prenatal care occurs in the 3rd trimester?

Continue monitoring weight, BP, fundal height, symptoms, and fetal heart rate; begin kick counts; assess need for RhoGAM; repeat CBC; screen for GBS; assess risk for FGR/LGA; determine fetal position; educate about labor and plan for delivery/postpartum care.

When is the fetal anatomy scan generally performed according to the lecture recap?

Around 20 weeks.

When is gestational diabetes screening performed?

24-28 weeks.

When do fetal kick counts begin?

During the 3rd trimester.

What major tests or assessments occur during the 3rd trimester?

RhoGAM assessment, repeat CBC(recheck anemia!), GBS screening, assessment for FGR/LGA (rapid or slow restricted growth), fetal position, and labor/delivery planning.

What are Braxton-Hicks contractions?

Irregular, generally painless contractions that do NOT cause cervical dilation; false labor that may improve with hydration and ambulation.

How can true labor be distinguished from Braxton-Hicks contractions?

True labor causes progressive cervical dilation and effacement; Braxton-Hicks contractions do not.

What is lightening?

Descent of the fetal head farther into the maternal pelvis, causing the sensation that the baby has "dropped."

When does lightening typically occur?

In the last few weeks before delivery.

What is the mucus plug?

Mucus within the cervical canal that acts as a barrier against infection during pregnancy.

What happens to the mucus plug as labor approaches?

Cervical softening and thinning cause it to pass.

What is bloody show?

Blood-tinged passage of the mucus plug before labor.

What are the three stages of labor?

First stage = onset of labor to complete cervical dilation; second stage = complete cervical dilation to delivery of the baby; third stage = delivery of the baby to delivery of the placenta.

What are the two phases of the first stage of labor?

Latent/early phase and active phase.

What are the three P's of successful labor and delivery?

Power, Passenger, and Passage.

What is "Power" in labor?

Force generated by uterine contractions.

What is "Passenger" in labor?

Fetal size, weight, lie, presentation, and position.

What is "Passage" in labor?

The maternal bony pelvis and soft tissues of the birth canal.

What is fetal lie?

The relationship of the fetal long axis to the maternal long axis.

What fetal lie is most common?

Longitudinal.

What is fetal presentation?

The fetal part that is lowest in the birth canal.

What is the most common fetal presentation?

Cephalic.

What other fetal presentations can occur?

Breech or transverse.

What is fetal position?

The relationship of the presenting fetal part to the right or left side of the maternal pelvis. (think position in politics)

What is cervical dilation?

Opening of the cervix; complete dilation is 10 cm.

What is cervical effacement?

Thinning and shortening of the cervix; complete effacement is 100%.

What is fetal station?

Position of the fetal head relative to the maternal ischial spines.

What does 0 station mean?

The fetal head is level with the ischial spines.

What do negative fetal stations mean?

The fetal head is above the ischial spines.

What do positive fetal stations mean?

The fetal head has descended below the ischial spines.

What happens during the latent phase of the first stage of labor?

Contractions are milder, less frequent, and may be irregular while the cervix gradually softens, dilates, and effaces.

Which phase is usually the longest part of labor?

The latent phase of the first stage.

What happens during the active phase of labor?

Cervical dilation becomes more rapid and contractions become more frequent, painful, and regular.

At what cervical dilation does active labor begin?

About 6 cm.

What cervical dilation marks completion of the first stage of labor?

10 cm.

When should a patient generally present to the hospital for contractions?

When contractions are about 3-5 minutes apart for more than 1 hour and last about 45-60 seconds each.

What should be assessed when a laboring patient arrives at the hospital?

Prenatal records/gestational age, new complications, maternal vital signs, fetal heart rate, contraction frequency/quality/duration, and fetal lie/presentation/position.

What must be excluded before performing a digital vaginal exam?

Placenta previa and prelabor rupture of membranes.

Why must placenta previa be excluded before a digital vaginal exam?

The placenta may cover the internal cervical os and manipulation can cause significant bleeding.

What is placenta previa?

Placenta extending over the internal cervical os.

How is placenta previa generally identified?

Ultrasound.

What is rupture of membranes?

Rupture of the amniotic sac causing leakage or a gush of fluid.

Why is rupture of membranes important?

If contractions have not begun, prolonged rupture increases infection risk.

What does a digital vaginal exam assess during labor?

Cervical dilation, effacement, and fetal station.

What findings suggest a patient is transitioning to active labor and should be admitted?

Regular contractions requiring attention, significant effacement, and cervical dilation around 4-6 cm.

What baseline labs are commonly obtained after admission for labor?

CBC and type and screen; STI testing if high risk and GBS testing if not previously completed.

Why is IV access established during labor?

For fluids, pain medications, emergency medications, and possible blood products.

What oral intake is generally allowed in low-risk labor?

Clear liquids.

How often are vaginal exams generally performed during labor?

About every 2-4 hours, before analgesia, or when fetal heart rate abnormalities occur.

How is a GBS-positive patient managed during labor?

IV penicillin G during labor.

What alternatives are listed for GBS prophylaxis in penicillin-allergic patients?

Clindamycin or vancomycin.

What type of pain occurs in the first stage of labor?

Visceral pain from uterine contractions and cervical dilation.

What type of pain occurs in the second stage of labor?

Visceral and somatic pain from contractions plus vaginal and perineal distention.

Which stage of labor generally causes more severe pain?

The second stage.

What nonpharmacologic options can help labor pain?

Massage, movement, heat/cold, breathing techniques, showering, TENS, and aromatherapy.

What systemic opioids are listed for labor pain?

Remifentanil, fentanyl, and nalbuphine.

What are common adverse effects of systemic opioids during labor?

Nausea, vomiting, and drowsiness.

Why should opioids be avoided if delivery is imminent?

They cross the placenta and may decrease fetal heart rate.

What is nitrous oxide used for during labor?

Analgesia with variable effectiveness.

What are adverse effects of nitrous oxide?

Nausea/vomiting and possible respiratory depression.

What is the most effective pain management option during labor?

Neuraxial analgesia.

What are the most common neuraxial techniques used in labor?

Epidural and combined spinal-epidural.

When can neuraxial analgesia generally be started?

At essentially any point during labor.

Why is neuraxial analgesia especially useful in patients at high risk for cesarean delivery?

It may help avoid general anesthesia.

What are major adverse effects of neuraxial analgesia?

Hypotension, pruritus, fever, and post-dural puncture headache.

What are contraindications to neuraxial analgesia?

Coagulopathy, thrombocytopenia, infection over the lower back, and increased intracranial pressure.

What is the advantage of an epidural?

A catheter provides continuous analgesia throughout labor and delivery.

What is the advantage of a combined spinal-epidural?

Faster onset with continued catheter-based analgesia.

What is a pudendal nerve block used for?

Vaginal and perineal pain during the second stage of labor.

What is the purpose of intrapartum fetal heart rate monitoring?

To determine whether the fetus is adequately oxygenated.

Who generally requires continuous fetal heart rate monitoring?

High-risk patients.

What features should be documented on a fetal heart tracing?

Baseline rate, variability, accelerations, decelerations, and changes over time.

What is a normal fetal heart rate baseline?

110-160 bpm.

What is fetal bradycardia?

Baseline fetal heart rate

What is fetal tachycardia?

Baseline fetal heart rate >160 bpm.

What can cause fetal bradycardia?

Maternal beta-blocker therapy, hypothermia, hypoglycemia, or fetal heart block.

What can cause fetal tachycardia?

Maternal fever, infection, medications, anemia, or arrhythmia.

What is fetal heart rate variability?

Irregular fluctuations in the fetal heart rate baseline.

What variability is considered reassuring?

Moderate variability.

What amplitude defines moderate variability?

6-25 bpm.

What is a fetal acceleration?

An abrupt increase in fetal heart rate.

What defines an acceleration?

Increase of at least 15 bpm above baseline lasting at least 15 seconds.

What does a fetal acceleration indicate?

Reassuring fetal status and absence of significant hypoxia.

What is an early deceleration?

A gradual fetal heart rate decrease that occurs with the contraction; generally benign.

What is the usual cause of early decelerations?

Fetal head compression.

What is a late deceleration?

A gradual fetal heart rate decrease that occurs after the contraction.

What do late decelerations suggest?

Transient fetal hypoxemia and need for prompt evaluation.

What is a variable deceleration?

An abrupt fetal heart rate decrease.

What usually causes variable decelerations?

Umbilical cord compression.

What is the initial intervention for variable decelerations?

Reposition the patient.

What is a prolonged deceleration?

A decrease in fetal heart rate of at least 15 bpm lasting at least 2 minutes.

What does a sinusoidal fetal heart pattern suggest?

Severe fetal anemia and an ominous fetal condition.

What defines a Category I fetal heart tracing?

Normal baseline rate, moderate variability, no late or variable decelerations; early decelerations and accelerations may be present or absent.

How is a Category I tracing managed?

Routine fetal monitoring based on underlying clinical risk.

What defines a Category II fetal heart tracing?

An indeterminate tracing that does not meet Category I or Category III criteria.

How is a Category II tracing managed?

Treat the underlying cause with interventions such as repositioning, amnioinfusion, or fetal scalp stimulation; consider delivery if it does not improve.

What defines a Category III fetal heart tracing?

Absent baseline variability plus recurrent late decelerations, recurrent variable decelerations, bradycardia, or a sinusoidal pattern.

How is a Category III tracing managed?

Reposition, give IV fluids, use fetal scalp stimulation, and prepare for delivery if the tracing does not rapidly improve.