Women's Exam 2 Study Guide PDF

INTRAPARTUM PART 1 - Intro to labor stuff The 5 P’s of Labor Passageway, passenger, powers, position of the mother, and psychological response Passageway: pelvic divisions False pelvis: above brim (not indicative of pelvic adequacy) True pelvis: measurement of pelvi...

INTRAPARTUM PART 1 - Intro to labor stuff The 5 P’s of Labor Passageway, passenger, powers, position of the mother, and psychological response Passageway: pelvic divisions False pelvis: above brim (not indicative of pelvic adequacy) True pelvis: measurement of pelvic adequacy ○ Pelvic inlet: upper margin of pubic bone ○ Midpelvis: short anterior wall, long curved posterior wall Passageway: considerations Pelvis shapes ○ Gynecoid: classic female type- circle ○ Android: resembles male pelvis- heart ○ Anthropoid- vertical oval ○ Platypelloid- horizontal oval Inlet: anterior/posterior- from symphysis pubis to spine Midplane: symphysis to coccyx- normally the largest plane Outlet: transverse diameter- distance between ischial spines Other considerations: ○ Fetal head, fetal attitude, fetal lie, fetal presentation, fetal position, placenta Passenger: fetal head Composed of bony parts that either hinder or facilitate birth Key influential variables: ○ Sutures- the ones between skull bones (whether they are touching, overlapped, etc.) ○ Fontanelles- posterior & anterior ○ Molding ○ Overriding sutures Passenger: fetal lie Fetal lie- relationship of the cephalocaudal axis of the fetus to the cephalocaudal axis of the mother 2 types: ○ Longitudinal lie: fetal cephalocaudal axis is parallel to the mother’s cephalocaudal axis- ideal for birth ○ Transverse lie: fetal cephalocaudal axis if at a right/90 degree angle to the mother’s cephalocaudal axis- not ideal for birth Passenger: fetal attitude Fetal attitude- relation of fetal parts to one another (like is baby curled or stretched out) ○ Expected fetal attitude is flexion- head tucked and in a ball ○ Flexion of head/chin-to-chest, arms folded across the chest, and legs flexed up onto the abdomen ○ Deviations especially related to the head will present larger diabetes of the head for the pelvis Passenger: fetal presentation The presenting part- what is it? ○ Determined by fetal lie and fetal attitude Station- how far the baby is in the pelvis- how far down baby has descended 🠊 Engagement Types of presentations: ○ Cephalic or vertex (head first)- 95% ○ Breech- frank, complete, or footling ○ Should- transverse lie Passenger: fetal position Fetal position- relationship of the fetal presenting part to 1 of the 4 quadrants of the maternal pelvis, like the front, back, or sides ○ Most common fetal position if occipitoanterior- back of baby’s head (occipito) is facing the front of mom (anterior) ○ 3 notions used to describe fetal position: Right (R) or left (L) side of maternal pelvis Landmark of fetal presenting part (occiput) Anterior (A), posterior (P), or transverse (T), depending on whether the landmark is in the front, back, or side of the maternal pelvis Vertex Presentations: Primary powers: contractions Rhythmic and intermittent with periods of relaxation between contractions ○ Uterine rest between contractions is important so that baby can get oxygen Phases: increment, acme, decrement Characteristics: frequency, duration, intensity Primary powers of labor- purpose of uterine contractions- dilation and effacement of cervix Effacement- the taking up, drawing up, and disappearance of internal os and cervical canal into the uterine side walls Dilation- widening of cervical os from less than a cm to approximately 10 cm Dilation/effacement/station example- 2/50/-1 Secondary powers Pushing! Contraction of the maternal abdominal musculature for fetal and placental expulsion ○ Only after complete cervical dilation ○ If cervix is not completely dilated, bearing down causes cervical swelling or edema, lacerations, and maternal exhaustion ○ Valsalva- holding your breath and bearing down/tightening abdominal muscles Maternal Positions Upright position - Gravity assists with fetal descent - Facilitates dilation and effacement - Reduces pressure on major maternal structures Lateral (side-lying) - Increases cardiac output - Improves perfusion to organs - Removes pressure on major maternal structures - Helps with back pain and facilitates counterpressure Semi-recumbent - Sitting with the back elevated - HOB elevated at least 30 degrees - Convenient for fetal monitoring and exams Hands and knees - Helps back labor - Facilitates internal rotation of fetus - Good for OP presentation Psychological Response Knowledge/ preparation Past experience- first time vs. had many before and their experience with those previous babies Stress response Support- husband/boyfriend/baby daddy Social factors Cultural factors Theories of Labor Progesterone- placenta (I think) produces this when pregnant at the beginning of pregnancy ○ Relaxing effect Estrogen- increased near the end of pregnancy ○ Stimulating effect Prostaglandin- abundant in ejaculate ○ Stimulates smooth muscles to contract Fetal cortisol ○ Same effect as prostaglandin Uterine distention Preliminary Signs of Labor Lightening- “dropping,” movement, or engagement of fetus into pelvic inlet ○ Descent moves uterus downward and fundus away from diaphragm ○ Results in ability of female to breathe easier ○ At some time, the female may experience: Leg cramps or pains Increased pelvic pressure Increased venous stasis that leads to lower extremity edema Increased urinary frequency Increased vaginal secretions resulting from congestion of vaginal mucous membranes Sudden burst of energy ○ “Nesting Syndrome”- occurs approximately 24-48 hours prior to labor onset Braxton Hicks contractions ○ Irregular, intermittent contractions that occurs throughout pregnancy ○ Tend to disappear or stop with change in activity- this is how you can tell it’s false labor, but you can also tell by cervical changes ○ Discomfort centered in abdomen Discomfort facilitates a belief that labor is occurring “False labor” ○ Cervical dilation does not occur ○ Can increase in occurrence closer to term Cervical changes ○ Cervical ripening- softening of the cervix Cervical rigid and firmness of pregnancy gives way to weakening and softening of cervix so that it may stretch and dilate in order to accommodate passage of the fetus Accomplished via enzymes (collagenase & elastase) that inhibit ability of collagen fibers to bind ○ Main sign of TRUE labor is progressive dilation & effacement of the cervix Signs of Labor- Preliminary or True? Blood show ○ Pink blood-tinged secretions that accompany expulsion of cervical mucous plug that seals cervix during pregnancy ○ Small amount of blood loss occurs from exposed cervical capillaries ○ Can herald onset of true labor within 24 to 48 hours ○ May be confused with brownish blood-tinged discharge that results from vaginal exam Rupture of membranes (ROM) ○ 12% of females experience rupture prior to labor onset ○ 80% of females who experience ROM will experience true labor within 24 hours If labor does not begin spontaneously within 12-24 hours after rupture, labor may be induced to avoid infection If rupture occurs prior to engagement, umbilical cord may be washed out with fluid, resulting in prolapsed cord ○ 4 types of ROM Spontaneous rupture- SROM- happens naturally Artificial rupture- AROM- go in with a hook and pop it/knick it Premature rupture- PROM Preterm premature rupture- PPROM Stages of Labor Onset of regular uterine contractions- pain level varies Cervix- slow effacement and dilation Fetal engagement & descent May have ROM or not Pain level and time frame varies: STAGE 1- Latent Phase: ○ Nulliparas (first baby)- 20 hour average 0-6 cm ○ Multiparas (have had babies)- 14 hour average ○ Sedation can slow progression Wide range of emotions ✩ Narcan is the antidote for opioids, have this on hand if giving morphine- SHE SAID THIS MIGHT BE A TEST QUESTION  Cervical dilation ○ More rapid effacement & dilation ○ Multiparas more rapid dilation Progressive fetal descent Increased discomfort with contractions ○ Pelvic pressure & urge to push with fetal descent Nausea & vomiting is common STAGE 1- Increased bloody show Active Phase: Emotional changes 6-10 cm Arrest of Labor Adequate contraction pattern ○ No cervical change in 4 hours Inadequate contraction pattern ○ No cervical change in 6 hours Interventions dependent on situation & what has been done already Complete cervical dilation to birth of infant ○ Perineum bulges, flattens, and moves anteriorly, perineum becomes thin, rectum stretches ○ Crowning- fetal head encircles by external opening of vagina (introitus) ○ Duration is variable ○ Cardinal movements- allow passage of the infant through the pelvis STAGE 2 ○ Cord clamping- delayed? Cardinal movements ○ Engagement & descent, flexion, internal rotation to OA position, extension (for expulsion), external rotation- restitution, external rotation, and expulsion Birth to delivery of placenta Placental separation ○ Uterus contracts firmly, diminishing uterine capacity and placental surface area ○ Signs of placental separation STAGE 3 Globular-shaped uterus Increased fundal (top of the uterus) height in abdomen Sudden gush or trickles of blood Lengthening of umbilical cord out of vagina Usually given Pitocin IV or IM either before or after placenta delivery Delivery of placenta to 8 hours past Physiologic & hemodynamic readjustment ○ Moderate drop in blood pressure, increase in pulse pressure, and moderate tachycardia resulting from: Blood loss (avg. 250-500 cc) Reduced weight of the uterus Redistribution of blood into venous beds Repair of cervical or vaginal lacerations STAGE 4 ○ 1st degree: superficially disrupts the mucosa ○ 2nd degree: divides the perineal body (episiotomies) ○ 3rd degree: tear involves anal sphincter ○ 4th degree: tear involves rectal mucosa Uterus should be contracted and midline May experience: ○ Shaking ○ Urinary retention ○ Increased thirst & hunger  INTRAPARTUM PART 2 - Maternal & Fetal Responses to Labor - Fetal Monitoring - Labor Pain Management Maternal Response to Pregnancy & Labor Blood volume increases by 45% in pregnancy and more in labor BP stays stables due to vasodilation & reduced vascular resistance Cardiovascular Slight cardiac hypertrophy due to increased blood volume Supine hypotension RBC increase by 20-30% depending on iron stores Blood Increased plasma volume causes physiologic anemia of pregnancy Components WBC count increases in labor Blood glucose decreases in labor Maternal O2 consumption increases 20-40% above pre-pregnancy levels by term- almost doubles in labor due Respiratory to work of labor Diaphragm displaces as fetus grows Renal Proteinuria due to muscle breakdown from work of labor GI Gastric motility slows in labor- may have nausea and vomiting Psychosocial No extra information was given General Considerations: Labor is a period of physiologic stress for the fetus Fetal O2 supply is affected by: ○ Maternal blood flow ○ Maternal O2 ○ Fetal circulation ○ Uterine tone ○ Placental vasculature Fetal Assessment Monitoring fetal HR ○ Fetoscope ○ Portable doppler- intermittent ○ Electric monitor-intermittent or continuous ○ Fetal scalp electrode (FSE)- continuous Monitoring contractions ○ External (tocotransducer) ○ Intrauterine pressure catheter (IUCP)- cannot use these if membranes are not ruptured ○ Tocometer- measures contractions Leopold’s Maneuvers Helps determine position of baby and where the baby is facing Placement of EFM Palpation helps decide where to place the EFM Monitoring Contractions Tachysystole: 5 contractions or more in a 10 minute period, correlate fetal HR with contraction to evaluate response to labor External Monitor (tocometer) Internal Monitor (IUPC) Timing: Timing: same as external monitor ○ Frequency- beginning of one contraction to Strength: measure montevideo units beginning of next ○ Measure actual value of height of each ○ Duration- beginning of contraction to the end of contraction for 10 minutes and total it the same contraction ○ Adequate labor is about 200 Strength: not reliable for external monitor So basically, find the peaks of each hump on the y axis and add them all up ○ So we got 65, 60, and 60, so that means this is about 185 Fetal Heart Rate (FHR) Baseline: range of FHR during a continuous 10-minute period of monitoring (110-160 bpm) ○ Baseline variability: irregular fluctuations in baseline- when the FHR changes because of the environment or themselves Accelerations: abrupt increase in FHR Decelerations: abrupt decrease in FHR Tachycardia: a rate of 160 bpm or more for 10 minutes Bradycardia: FHR less than 110 bpm for more than 10 minutes Baseline Variability Irregular fluctuations in baseline They are normal (I think that’s what she means) Can be described as: ○ Absent ○ Minimal- less than 5 bpm ○ Moderate- 6-25 bpm ○ Marked- greater than 25 bpm Sinusoidal pattern-fetal hypoxia Fetal Heart Rate Tachycardia (>160) Bradycardia (40 weeks) because the placenta will stop perfusing Active management ○ AROM (amniotomy), oxytocin Forceps ○ Shorten the 2nd stage ○ Unable to push effectively ○ Breech or malpresentation ○ Arrest of rotation Augmentation Vacuum (Helping Labor ○ Preferred over forceps Progress) Other methods to stimulate contractions Reasons to do this: - Not progressing well - Baby needs to come out faster - Baby is not descending - Mispresentation Induction Methods CHEMICAL Prepidil: a gel that is inserted into the Cervidil: a tape like thing idek Cyotec: an oral med for cervical ripening vagina and stuff MECHANICAL Cervical Ripening Balloon: more common, you just blow it up to Laminaria Tent & Lamicel: she said it was basically a seaweed like expand the cervix tampon and I THINK it helps with ripening I don’t remember  AMNIOTOMY An amnihook used to artificially rupture the amniotic membrane (we got to touch one in class) OXYTOCIN/PITOCIN INDUCTION Hormone produced by the pituitary- synthetic form is pitocin Supplied in Units (not mg!) ○ 20 or 30 units per 500 or 1000 ml NS Labor use: very controlled because the baby is still in utero ○ Pitocin drip: convert milliunits/minuter into ml/hour to set IV pump ○ Continuous EFM- hyperstim and fetal distress are a risk ○ Situations to use Pitocin vs. misoprostol Postpartum Use: 125 ml/hour or faster Dystocia: Materna Factors (dystocia means difficult or obstructed labor) Dysfunctional labor ○ Hypertonic uterine dysfunction ○ Hypotonic uterine dysfunction ○ Secondary powers ○ Abnormal labor patterns Precipitous delivery (total labor