Labor Stages and Assessments PDF

Stage one: -latent phase:0-5cm -active phase:5-10cm (doesnt include birth but is up until no more progress is to be made) -admission to the labor unit, prenatal data(gestation and known complications?), abuse, and culture/language differences -assessment- vs, leopolds maneuver(feel for baby on m...

Stage one: -latent phase:0-5cm -active phase:5-10cm (doesnt include birth but is up until no more progress is to be made) -admission to the labor unit, prenatal data(gestation and known complications?), abuse, and culture/language differences -assessment- vs, leopolds maneuver(feel for baby on moms belly), fhr and pattern, contractions and cervical check -ROM assessment- has ROM occurred? COCA- color(clear/pale yellow), odor (musky or none), consistency(watery), amount (trickle or gush) -labs- -cbc- WBC (infection?), Hct and Hgb (mom is going to bleed), platelets (does mom have clotting factors? Think HELLP syndrome) -HIV and titters- is mom rubella immune (NO active vaccine during preg. Mom should get it as soon as possible after) does mom have syphilis? (bad bad bad for baby) -type and screen- again mom is going to bleed, better to have it and not need it -GBS- antibiotics -nutrient and fluid intake- what is mom having orally and IV -elimination- mom should void at least every 2 hours, we want mom to pee, if she can’t- intermittent cath or foley (less wanted) -positioning- mom should be repositioned often, every 20 minutes Stage two: -latent phase- laboring down -active phase- active pushing or bearing down, ferguson reflex- ejection reflex, mom cannot control this -birth position- lithotomy(doc preferred) -bearing down- valsalva maneuver (sneezing, coughing, laughing... push into butt) -monitor FHR and pattern -equipment should be set up, most for just in case -birth- crowning- babys head is in vag, episiotomy- intentional cut to control tearing (we dont want urethral injury), nuchal cord- not usually an emergency but needs to be removed from head as soon as head is out -after birth- skin to skin(we want this, dont do this only in emergency) lotus birth(gross and not necessary- infection risk and stinks) Tears 1st- confined to skin 2nd into perineal body 3rd into external sphincter 4th through sphincter and rectal mucosa (incident report) Stage three: - Shortest stag, from birth to placenta expulsion, usually 15 minutes, invasive intervention at 30min, gush of blood and cord lengthening usually means placenta is ready and has detached, mom may feel like something is in her vag--->because there is. Inspect placenta to ensure it all came out(sometimes docs have to go in manually and get remaining pieces) Stage four- Recovery(1-2 hours usually) Assess for blood loss, change in vs, loc Help facilitate family-newborn relationships, encourage breast feeding or bonding immediately after birth(babys first alert state) Post anesthesia – same as pacu Par score- activity, resp, bp, loc, color Fetal assessment during labor - FHR and patterns- baseline, accelerations? Decelerations? Variability? - Category 1 – we like this -HR 110-160 -variability- moderate -no late or variable decel -early decel and acel- may be there may not -category 2- everything else -category 3- BAD -no baseline variability -recurrent late decel -brady cardia -sinusoidal pattern https://youtu.be/bjH4v4xJai4?si=SZpOySvAqGjhamrw  Variable Cord Mom reposition (move mom to relieve pressure on cord) Early Head Identify labor progress (she is probably progressing or maybe baby is ready) Acceleration Okay None Late Placental Execute insufficiency interventions (check mom, reposition (side lying), contact provider, possible delivery) Other interventions for lates- -stimulate baby by rubbing their head -vibroacoustic stimulation -amnioinfusion- maybe baby just needs more fluid - tocolytic therapy DOCUMENT Complications preterm labor and birth- 20wks- 36+6wks -contractions and cervical change (at least 2cm) Very preterm- less than 32 wks Mod preterm- 32-34wks Late preterm-34wks-36+6wks Prematurity- more dangerous than low birth weight because less maturity of body systems--->>>> LUNGS Low birth weight- less than or equal to 2500 grams (can be caused by IUGR and others) Spontaneous preterm birth is 3x as prevalent than indicated preterm birth (INFECTION NUMBER ONE CAUSE) Cervical length- if its greater than 30mm in 2nd and 3rd trimester --->less likely to have preterm birth/labor Fetal fibronectin test- test to predict who will not go into labor. Negative test---->not likely to go into labor in the next 2wks No evidence to support bedrest unless in extreme cases Restrict sexual activity (INCLUDING BUTT STUFF) Tocolytics- relax the smooth muscle Antenatal glucocorticoids- MATURE LUNGS (this reduces risk of resp distress syndrome, intraventricular hemorrhage and death) 24wks-34wks PROM- preMATURE ROM (ROM but no labor) PPROM- preTERM preMATURE (baby isnt cooked enough yet) -can lead to chorioamnionitis- antibiotics and delivery -glucocorticoids for everyoneeeeee 24wks-34wks (2 IM 12 hours apart) -antibiotics (7 day course broad spec) -mag- fetal neuroprotective Chorioamnionitis -25% of preterm labors -mom has a fever, baby and mom are tachy, uterine tenderness, nasty stinky amniotic fluid Postterm- 42+ weeks gestation RISK FOR STILLBIRTH INCREASES A LOT -BIG BABY -placenta is TIRED and giving up -complications in birth due to big babies- sever perineal tears and injury, shoulder dystocia, fetal injury -high risk for meconium aspiration (baby is cooked and has now pooped in utero) -postmaturity syndrome We are gonna monitor that baby NST, CST (contraction stress test), BPP and modified BPP (no NST) Dystocia- labor progression has stopped Most common reason for c section We’re gonna do IUPC (intrauterine pressure cath) Latent phase- hypertonic(over active) uterine dysfunction (mom prob needs rest) Active- hypotonic(slow ineffective contractions) uterine dysfunction >>>protraction or arrest (complete stop of contractions) Precipitous labor (FAST labor. Less than 3 hours) Pelvic dystocia -pelvis gets smaller Soft tissue dystocia -obstruction of birth canal (not caused by bony pelvis) Fetal causes for dystocia -cephalopelvic disproportion or fetopelvis disproportion (BIG ASS HEAD) -malposition -malpresentation -multifetal preg. Positional dystocia -moms position has altered contractions Psychologic dystocia -mom is stressed, she releases hormones = labor stop Obesity -bmi 25 or greater = overweight -bmi 30 or greater = obese -bmi 40 or greater severely obese Complications Abortion and still birth Fetal monitoring can be hard Positioning can be more difficult Increased risk of blood clots Pannus- fat roll stays moist, incisions get infected External version- externally rotating baby for best position and presentation success of 65%, decrease risk of section by 50%, US, NST, typically give epidural>doc rotates baby>us again>induce labor if at 37wks if successful, not successful then take epidural out and schedule section Internal version- rare, questionable safety Induction – labor hasnt started yet, 39+weeks Elective or indicated Chemical or mechanical Comes with risk- section, neonatal morbidity, increased cost Bishop score- eval of inducibility- cervical exam, fetal station, cervix ripe?? Cervical ripening methods- chemical-cytotech, mechanical-foley balloon Anmiotomy- AROM, crochet hook Oxytocin- pit, can start labor or augment it, watch uterine tachy >5 contractions in 10min Augmentation- labor has started but not progessing the way mom should, increase pit by 1-2mu every 30-40 min Operative vag birth- mom has to push still, keeps baby from moving back up Forceps-older ob, metal paddles Vacuum- newer ob, sucks baby out Assess baby – esp baby head, expect swelling, assess for brain bleed/head trauma Section- transabdominal incision VBAC- vag birth after section 60-80% success rate TOLAC- trial of labor after section- done if mom has a section with unrelated complications to her ability to have a vag birth Elective section- not common Scheduled section- indicated Unplanned- have to have Forced- mom wants vag, baby says no, best interest Incisions- skin vs uterine Skin- low abd cut at bikini line Uterine- may be vertical (cannot have vbac) emergency came up Vertical cut for skin and uterine- emergency from beginning Same risks as abd sx except patient usually stays awake Spinal – one time dose, numb from upper abd down If mom was laboring and transitioned to section then they use epidural and give large dose Prep for neonate Nurse stays with patient from start to end and recovery In house obgyn and anesthesia for vbac Ob emergency Meconium stained amniotic fluid Stress caused or indication of post maturity Pooped in utero Aspiration is a risk >>> suction before first breath Vernix may be green and placenta may be green Shoulder dystocia Head comes out but shoulder cannot pass the pubic bone Mom risk- uterine rupture, hemorrhage, death Fetal risk- asphyxia(no oxygen), brachial plexus damage, Fx Helperr Help- call for help as soon as the head comes out and the baby doesnt progress after that(turtle sign) Evaluate- episiotomy Legs- McRoberts maneuver- pull legs bag towards head- open pelvis Pressure- superpubic pressure- push on shoulder through mom Enter- Doc enters vag to rotate baby Remove- remove posterior arm, deliver arm up and out Roll- roll patient, hands and knees- Gaskin maneuver If this doesnt work doc is gonna try to push babys head back into mom for section Cord compression is likely Prolapsed cord- cord is below presenting part Cord compression Risk factors- risk factors, malpresentation, unengaged presenting part, transverse lie Normal FHR that goes into variable and doesnt come back up Get pressure off cord, vaginal exam and push presenting part back, emergency section DO NOT MOVE YOUR HAND until delivered via section Can place patient on hands and knees to help drop baby back into uterus Uterine rupture Classic section- vertical cut Uterine trauma Uterine dehiscence- old scar starts to open back up (pull apart) Amniotic fluid embolus (AFE) Sudden acute onset of hypotension, hypoxia, hemorrhage by coagulopathy Usually happens when ROM and mom starts to cough and loss consciousness May code mom and do section concurrently Materna and fetal death Hyperemesis gravidarum- severe nausea and vomiting Usually resolve by 20wks Weight loss of >5% of pregnancy weight Dehydration, metabolic acidosis-starving, alkalosis-vomiting and hypokalemia Fetal risk of IUGR, preterm birth, small for gestational age Small frequent meals, dont let stomach empty, well hydrated or hospitalization with parenteral therapy Labs- dehydration, hemo concentration, may look norm because of this Npo for 24-36 hours>>then clears and bland food