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49 Cards in this Set
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Station v/s Engagement
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0 Station- the presenting part is at the level of the ischial spines.
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Engagement is when the biparietal diameter/largest transverse diameter has passed through the inlet or is at the level of the ischial spines.
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True pelvis defines the birth canal
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Inlet- level of sacral promonotory, linea terminalis and upper margins of pubic bones.
Mid plane - level of ischial tuberosities/tip of coccyx. Outlet - Anterior Surfaces of the sacrum and coccyx. |
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Hynotics
Sedatives Narcotics |
Avoid within 1 hr of birth due to potential fetal respiratory depression.
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What are the different types of rupture of membranes?
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Rupture of membranes
Premature - at least 1 hr prior to onset of labour Prolonged premature - > 18 hours elapse between rupture of membranes and onset of labour preterm - ROM occurring before 37 weeks gestation Preterm premature - ROM before 37 weeks AND prior to onset of labour |
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Friedman's First Stage
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Latent Labor (labor onset to 4cm)
Nullip: <20 hours Multip: < 14 hours |
Active Labor (4 to10 cm):
Nullip:1.2 cm/hr; >1 cm descent Multip: 1.5 cm/hr, >2cm descent |
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What investigations should be done to confirm rupture of membranes?
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Sterile speculum exam - pooling of fluid in the posterior fornix, may observe fluid leaking out of cervix on cough
Amniotic fluid turns nitrazine paper blue (alkaline; vaginal - acidic) ferning (high salt in amniotic fluid evaporates, looks like ferns under microscope) US to rule out fetal abnormalities - oligohydramnios is indicative of ROM |
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Friedman's Second Stage
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Nullip: <2 hrs
Multip: <50 min add 1 hour if epidural. |
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Describe the 1st stage of labour?
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1
Latent: - uterine contrasctions typically infrequent and irregular - slow cervix dilation (usually 3-4cm) and effacement - usually ROM at end of latent phase Active phase - rapid cervical dilation to full dilatation - should increase by 0.5-1cm/hr for nulliparous woman - painful, regular contractions, q2min, lasting 45-60 secs - contractions strongest at fundus, weakest at lower segment - unwise to push at this stage even if pt feels like it |
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1st degree Lacerations
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Vaginal Mucosa
Posterior Forchette Perineal Skin |
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2nd degree Lacerations
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Vaginal Mucosa, Posterior Forchette, Perineal Skin, AND
Perineal Muscle |
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3rd degree Lacerations
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Vaginal Mucosa, Posterior Forchette, Perineal Skin
Perineal Muscle, AND Rectal Sphincter |
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4th degree Lacerations
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Vaginal Mucosa, Posterior Forchette, Perineal Skin
Perineal Muscle, Rectal Sphincter, AND Anterior Rectal Wall |
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Oxytocics
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1st Line Drug. Can be given IM or IV. Onset is immediate.
Causes intermittent uterine contractions. |
20 units in 1000cc of IV fluid OR
10 Units IM |
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Methylergonovine "Methergine"
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Can be given IV or PO. Onset is in 2-5 minutes,duration 3hrs. Causes sustained uterine contractions.
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IM 0.2 mg IM
0.2 mg PO q 4 hrs x's6 doses. Contraindicated in HTN, PIH cause seizures & vasoconstriction |
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Carboprost "Hemabate"
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Can be given IM.
250 mcg IM or intramyometrial. Can repeat in 15 to 90 min. |
Contraindicated in Asthma -
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Battledore Placenta
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Cord anomaly insertion at the margins of placenta, peripheral cord insertion.
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Succenturiate Lobe
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Most common! Accessory placental lobe within the fetal sac which had continuous vascular connections with main placenta.
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Suspect if torn blood vessels are at the margin of the maternal surface. Causes Retained parts or hemorrhage.
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Velamentous Cord Insertion
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Cord insertion into the fetal sac, (away from placenta) not directly in placental bed.
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More common in multiple gestation. Can cause shearing of blood vessels in L&D -causing hemorrhage.
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Circumvallate Placenta
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Opaque/white ring of fibrous appearing tissue on fetal side of placenta. Caused by double layer of chorion and amnion.
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Ring of chorion and amnion doubles back on themselves. Appears as if central part of placenta is depressed.
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Vasa Previa
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Suspect if pulsation is felt ahead of presenting part and if bleeding occurs with ROM.
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Unprotected cord blood vessels with amnion only present at the cervical os. a/w velamentous cord.
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APGAR
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Activity
Pulse Grimace, Appearance & Respirations |
< 7 at 5 min Need Pediatric involvement and Cord Blood Gases. A/W neurological at 1 yr and survival.
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When should foetal scalp blood sampling be used?
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Indicated when non-reassuring fetal hear rate is suggested by clinical parameters inc. heavy meconium, mod to severe abnormal FHR patterns
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MgSO4 action in Pre Term Labor
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Acts on vascular smooth muscles causing vasodilation.
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Only MA can deliver!!
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If MA- encourage patient to push as effective as possible.
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What is a normal fetal pH
Which pH indicates fetal acidosis |
> 7.25
< 7.2 - acidosis - delivery indicated |
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MP contraindicated for vaginal birth.
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If MP, fetus is unable to pass under the pubis symphysis.
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Describe the different types of pain relief used in childbirth?
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Nitrous oxide and oxygen (50:50); Give in an Entonox machine; Enhances GABA-A receptors, induces dopamine and antagonises NMDA receptors
Epidural (fentanyl and LA); most effective way of relieving pain; L3/L4 space; SE: dizziness, shivering, may increase duration of 2nd stage and increase operative deliveries, severe headache (dural tap) Pudendal block - gives perineal anaesthesia - commonly used in forceps and vacuum delivery Spinal - similar to epidural - bolus, one time dose - more common in c/s - SE: decreased sysetmic resistance --> hypotension --> decreased placental perfusion --> fetal bradycardia - can get maternal resp depression if drug affects diaphragm GA - used in emergency C/S - risk of maternal aspiration, hypoxia to fetus and mother |
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Risk Factors for Retained Placenta
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Placenta Previa, Prior Cesarean Section, Premature Delivery, Chorioamnionitis, Grand Multip
(PPPCG) |
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Placenta Accreta
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Placenta adherance to myometrium due to partial or total absence of decidua.
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to the myometrium
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Placenta Increta
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further extends into the myometrium and penetrates the uterine wall.
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to the uterine wall
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Placenta Percreta
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Further extends through the uterine wall to the serosa layer.
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to the serosa layer
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What are the components of the bishop score
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Position (posterior, mid, anterior)
Consistency (firm, medium soft) Effacement (0-80) Dilatation Station of the fetal head |
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Retained Placenta MGMT
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Baby to breastfeed.
Squatting position Empty maternal bladder Oxytocin 10 Units IV |
Call MD if >30 minutes and prepare pt for manual removal. Monitor for bleeding or shock, Ensure mom has IV, Notify anesthesia
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Negative psychological responses to labor pain
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Hyperventilation - causes
decreased oxygenation. Stress - Causes increased cortisol and decreased placental perfusion. |
Hypoxia of uterine muscle cells during action of contractions can cause pain along with various other physiological & psychological factors.
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Vitals signs
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Temperature will increase slightly up until 24 hours PP. Will not be >100.0. The highest time is preceding and immediately following birth.
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Pulse - inversely proportional to the action of contractions. Increases during increment (most intense) and deceases during acme (strongest).
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FHR - Parasympathetic nervous system
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responsible for the beat to beat variability
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FHR Sympathetic nervous system
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Responsible for the baseline FHR.
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Baroreceptors
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Increased pressures can cause vagal response in the fetus
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Chemoreceptors
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Sensitive to changes in the fetal pH, O2, CO2 levels and respond by increasing fetal blood pressure and heart rate.
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Physiology of FHR regulation
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r/t: Parasympathetic nervous system, Sympathetic nervous system, Baroreceptors, & Chemoreceptors
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FHR
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normal 120-160 bpm,
can be 110-120 at term with good variability, |
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Bradycardia
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<120bpm for 10 or more minutes
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vagal stimulation, cord compression, placental insufficiency, rapid descent, medications, anesthesia, fetal cardiac anomolies, terminal condition of fetus.
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Tachycardia
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>160bpm for 10 or more minutes
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fetal hypoxia or compensation for hypoxic event, prematurity, Maternal fever, infection, excessive fetal movement, meds-sympathomimetics.
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Variability
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Combination of influences between the sympathetic and parasympathetic nervous systems.
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Variable Deceleration
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r/t cord compression
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Position change,
IV fluid bolus O2 Pelvic exam to r/o cord prolapse and provide scalp stimulation. Contact MD Consider Amnioinfusion |
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Early Decelerations
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r/t head compression, vagal stimulation.
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MGMT - Position change and surveillance
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Late Decelerations
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r/t placental insufficiency, hypoxia, uterine hyperstimulation, decreased placental blood flow, maternal hypotension, medications, Abruption
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Left lateral position
IV fluid bolus O2 at 10L Attempt to correct underlying case, Contact MD |
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Fetal Scalp Sampling
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normal is >7.25
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Results must be repeated q20-30 minutes in indication of distress persist. Cannot be done during deceleration or bradycardia. Must wait for FHR recovery!
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Fetal Cord blood pH
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normal is >7.20
Vein Artery 7.32 7.26 |
remember vein carries oxygenated blood
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