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- | =Labor: Normal, Abnormal, and Points Between=
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- | ==Definitions==
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- | *Labor: regular / rhythmic contractions, cervical dilation and effacement.
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- | **'''Must have cervical change''' to call it labor.
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- | **Dilation: cervix develops a wider opening.
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- | **Effacement: becomes shorter.
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- | *Labor is considered '''"preterm" if it commences before 37 weeks EGA''' (estimated gestational age)
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- | **10-12% of pregnancies include preterm labor.
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- | *Labor is considered '''"postdates" if it commences after 42 weeks EGA.'''
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- | *'''Braxton Hicks contractions are contractions of a weak or irregular nature.'''
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- | ==Physiology of Labor==
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- | *There are many factors that play a role in the coordinated contraction of all the uterine smooth muscle for labor.
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- | *Progesterone and Relaxin are key regulating factors in animals.
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- | **'''Relaxin does not play a role in humans.'''
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- | **When 17 alpha-hydroxyprogesterone caproate is given, we see fewer preterm contractions '''so we know progesterone plays a role but we don't see it physiologically'''.
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- | **'''Progesterone levels don't drop until after the ''placenta'' is delivered.'''
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- | *Gap juctions of the uterine smooth muscle are increased near term.
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- | **Presumably to augment myofiber-myofiber communication for a well sequenced contraction.
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- | **Allow easy ability for electrical potential to cross.
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- | *Oxytocin, surprisingly, shows '''no change in blood levels''' but there are '''increased number of oxytocin receptors'''.
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- | **Oxytocin receptors, however are elevated.
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- | **Oxytocin does promote the influx of calcium ions (and therefore increased contractions).
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- | **There is a '''paracrine oxytocin production''' from the ''dicidual and placenta'' with subsequent increase in receptors in the myometrium.
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- | **Made in the posterior pituitary.
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- | *Several prostaglandins are elevated for labor: PGE1, PGE2, PGF2alpha
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- | **Makes collagenase to help '''break down collagen of the cervix to allow dilation and effacement.'''
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- | *Mother becomes more sensitive to changes in Ca at term.
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- | **This is presumably because the uterine muscle is storing up more and more Ca to augment contraction.
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- | *Like prostaglandins, many cytokines are elevated: IL-1, IL-6, IL-8, TNF-alpha.
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- | **Intermediate reactions in the labor pathway.
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- | **'''Infections can sometimes induce these types of cytokines and thus ''induce labor'''''.
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- | **NO is another intermediate reactor.
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- | ==Labor and Delivery Admission==
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- | *The workup for a L&D admission includes:
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- | **H&P:
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- | ***Fetal monitoring
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- | ***Leopold’s maneuver
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- | ***Vaginal exam
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- | ****R/o (rule out) placenta previa and ROM first
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- | ****Cervical dilation / effacement / station and fetal position
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- | ===Fetal Monitoring===
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- | *With fetal monitoring we are concerned with the baby's heart rate and the uterine pressure.
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- | *There are several technical methods for fetal monitoring.
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- | **We can monitor externally via ultrasound and pressure transducers.
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- | **We can monitor internally (if the membranes are ruptured) by putting a pressure transducer into the uterine cavity.
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- | ***A clip on the baby's scalp can mark each R wave.
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- | ====Fetal Monitoring - Normals====
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- | *'''For baby's heart rate, the baseline should be around 110-160 bpm.'''
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- | *We are looking for: variability, accelerations / decelerations
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- | *For uterine pressure (contractions) we are looking for: '''frequency, duration, uterine tone.'''
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- | **Tone is important because the baby gets better blood flow when the uterus is resting.
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- | ====Variability and Accelerations / Decelerations====
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- | *Variability:
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- | **Absent: 0-2 bpm
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- | ***Start worrying about fetal acidosis.
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- | ***Fix the environment or get the baby out.
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- | **Minimal: 3-5 bpm
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- | **'''Moderate: 6-25 bpm''' (ideal).
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- | **Marked: saltatory, >25 bpm
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- | *Fetal Monitoring:
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- | **Good, classic accelerations '''go up by 15 beats per minute and last for 15 seconds'''.
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- | **If the pregnancy is less than 34 weeks, "10x10" is acceptable.
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- | =====Decelerations=====
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- | *'''Early declerations: occur with cntx'''
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- | **Start and end with the contraction
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- | **'''Non worrisome'''
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- | **Head compression leads to vagal stimulation at the posterior fontanelle
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- | **Recall that vagus carries parasympathetics to the heart
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- | *'''Late decelerations: begin at peak of cntx or after'''
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- | **'''Fetal hypoxia''' is usually the culprit of late decelerations.
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- | **Occurs due to chemoreceptors in the carotid arch that sense the decreased pO2 leading to vasoconstriction and then bradycardia
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- | *'''Variable: can occur at any time'''
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- | **Variable decelerations should '''raise one's suspicion for cord compression'''
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- | *Variable Decelerations: mild, moderate, and severe.
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- | **Lower the blood pressure the more severe.
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- | **Longer the duration the more severe.
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- | **'''Severity of variable decelerations are a function of blood pressure and duration'''
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- | ====Categories of Heart Tracings====
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- | *Category 1:
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- | **Baseline rate: 110-160 bpm
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- | **Baseline FHR variability is moderate
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- | **Accelerations: present or absent
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- | **Late or variable decelerations absent
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- | *Early decelerations present or absent
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- | *Category 2:
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- | **Everything not in 1 or 3
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- | *Category 3:
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- | **Absent baseline variability ('''recall, a sign of acidosis''')
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- | **Recurrent late decelerations
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- | **Recurrent variable decelerations
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- | **Bradycardia
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- | **Sinusoidal pattern ('''a sign of fetal hypoxia with severe anemia'''; think Rh disease)
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- | ===Fetal Lie, Presentation, Attitude, and Position===
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- | *Clinical: abdomenal palpation, auscultation of fht’s, vaginal exam
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- | *Studies: u/s, x-ray, MRI
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- | **These are done very rarely as we can determine the lie and presentation rather easily via physical examination.
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- | ====Definitions====
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- | *'''Lie: relation of long axis of fetus to long axis of mother.'''
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- | **Longitudinal
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- | **Transverse
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- | **Oblique
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- | *'''Presentation: part of baby foremost in the pelvis'''
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- | **Cephalic
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- | **Breech (bottom)
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- | **Shoulder
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- | **Face
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- | **'''Compound:'''
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- | ***Head / hand -> watch (usually resolves itself; may apply a noxious stimuli to the hand)
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- | ***Head / foot-> c-section (will not resolve itself; requires c/s)
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- | *Cord prolapse (funic presentation): an '''emergency'''.
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- | **When the cord drops into the vagina.
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- | **Must move quickly to c/s.
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- | *'''Attitude: how the baby presents its head'''
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- | **Normal attitude is folded on itself w/ flexed head
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- | *'''Position: relation of presenting part to maternal pelvis anterior aspect'''
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- | **When the baby ''presents cephalically'', the reference point on the baby to be referenced to the anterior pubis of the mother is the '''occiput'''
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- | **When the baby ''presents facially'', the reference point is the '''mentum'''
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- | **When the baby ''presents as a breech'', the reference point is the '''sacrum'''
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- | **When the baby ''presents transverse'' (shoulder), the reference point is the '''acromion process'''
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- | ====Fetal Attitude====
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- | *There are a variety of ways the fetus can present at the os; these are called attitudes:
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- | **Full flexion (A)
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- | ***Normal, smallest diameter.
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- | **Military attitude (B)
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- | **Brow presentation (C)
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- | **Face presentation (D)
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- | http://www.glowm.com/resources/glowm/graphics/figures/v2/0760/001f.gif
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- | *Leopold’s Maneuver can be used to determine the attitude of the fetus.
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- | **First maneuver: what is occupying the fundus?
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- | ***Soft like a butt or hard like a head?
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- | **Second maneuver: on which side is the fetal spine?
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- | ***Third maneuver: what is presenting at the pelvis?
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- | ***Soft like a butt or hard like a head?
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- | **Fourth maneuver: what is the attitude, based on the flexion / extension of the head?
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- | *Can correlate with CT if there is any questions.
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- | http://www.sciencephoto.com/image/288555/350wm/M8000133-Leopold_s_Maneuver-SPL.jpg
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- | ====Vaginal Exam====
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- | *We are trying to determine if the cervix is starting to dilate or efface.
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- | *We describe effacement as a percent of normal length:
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- | **Normal length of a cervix is 4cm.
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- | **So if the cervix is observed as being 2 cm effaced, we call it 50%.
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- | *Station: the lowest point of the fetus in reference to the ischial spines.
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- | **The stating is described as -1 (and so on, for every centimeter) it is above the ischial spines.
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- | **The station is described as +1 (and so on, for every centimeter) it is below the ischial spines.
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- | *Position:
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- | **Most common is cephalic.
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- | **Use the occiput as the baby reference point when describing position against the maternal anterior pubis.
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- | **'''"right" and "left" shifts describe maternal right and left'''
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- | **To determine which aspect is the occiput, recall there are ant and post fontanelles (along which to orient) and the frontal suture (to identify the anterior aspect of the baby).
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- | *Pelvimetry:
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- | **Performed at the first pre-natal visit and upon admission for L&D.
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- | **Describes adequacy of the pelvis for baby delivery.
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- | **Measures pelvic inlet, the midpelvis, and the pelvic outlet.
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- | =====Pelvic Inlet=====
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- | *True pelvic inlet measurement is from superior pubic ramus to the sacral prominence.
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- | **However, this can't be measured directly so we measure it indirectly.
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- | **True conjugate is also called the obstetric conjugate.
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- | *The diagonal conjugate is measured with one's third finger, along toward the thumb.
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- | *'''True obstetric conjugate = diagonal conjugate – 1.5 to 2.0 cm'''
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- | *'''Diagonal conjugate: >11.5 cm is adequate'''
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- | =====Midpelvis=====
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- | *Sacrum – hallow versus shallow (flat):
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- | **Hallow is concave like a bowl of soup and gives ''more room for baby moving''.
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- | *Ischial spines – blunt vs. prominent
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- | **blunt is better; more room
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- | *Pelvic sidewalls
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- | **Parallel = OK
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- | **Divergent = good
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- | **Convergent = bad
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- | =====Pelvic Outlet=====
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- | *Bituberous diameter:
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- | ** > 6-8 cm is good
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- | **Measured by placing fist up against the butt.
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- | *Pubic arch:
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- | ** > 90 degrees is good
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- | ===Stages of Labor===
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- | *1st Stage: beginning of cervical dilation to complete dilation (10 cm)
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- | *2nd Stage: complete dilation to delivery of fetus
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- | *3rd Stage: delivery of placenta
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- | **up to 30 minutes
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- | *4th Stage: first hour after delivery of placenta
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- | **Big fluid shift, high risk of post-partum hemorrhage.
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- | **Monitoring mom for vitals
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- | **Monitoring firmness of uterus (should remain firm to inhibit hemorrhage by pressing layers of endometrium together)
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- | ===Cardinal Movements of Labor====
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- | *Engagement
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- | *Flexion (of the head)
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- | *Descent
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- | *Internal rotation
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- | *Extension
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- | *External rotation
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- | *Expulsion
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- | *If the face is anterior, it can still extend.
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- | *If ''mentum-posterior'', there can be no extension, so it cannot deliver.
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- | ===Labor Curve===
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- | *The first phase of minimal cervical change is latent phase.
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- | **Minutes, hours, days!
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- | *Active phase
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- | **> 1 cm change / hour
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- | *Baby will move from -5cm station to 0 to +5 as it delivers.
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- | ===Prolonged / Arrested Labor===
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- | *When labor isn't moving along, consider your '''3 Ps'''
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- | *'''P'''ower: uterine contractions
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- | **Are they strong enough?
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- | **Give oxytocin?
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- | *'''P'''elvis: adequate?
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- | **Do your pelvimetry to make sure pathway is sufficient
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- | *'''P'''assenger: EFW, position / attitude
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- | **Is the baby too big?
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- | **Is the position wrong? (occiput posterior)
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- | **Is the attitude wrong? (military)
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- | ===Dysfunctional Labor===
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- | {|border=1
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- | !Pattern
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- | !Nullip
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- | !Multip
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- | !Rx
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- | |-
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- | !Prolonged latent phase
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- | |>20 hr
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- | |>14 hr
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- | |Rest, AROM (augmented rupture of membranes; helps augment maternal environment for labor), Pitocin (oxytocin)
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- | |-
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- | !Protracted dilation
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- | |<1.2 cm/hr
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- | |<1.5 cm/hr
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- | |AROM, Pit
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- | |-
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- | !Protracted descent
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- | |<1 cm/hr
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- | |<2 cm/hr
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- | |Pit
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- | !Arrest of dilation
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- | |>2 hr
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- | |>2 hr
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- | |AROM, Pit, C/S
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- | |-
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- | !Arrest of descent
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- | |>2 hr
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- | |>1 hr
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- | |Vacuum, forceps, C/S
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- | |}
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- | ===Cesarean Section===
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- | *History
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- | **''Caedere -> caesura'': to cut; ''seco'': to cut.
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- | **"Cut Cut"
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- | *Francois Rousset (1581)
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- | **First reported case with survival.
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- | **Questionable
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- | *Max Sanger (1882)- Leipzig
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- | **Work on the American frontier
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- | **Sewed the womb shut! (Whoa!)
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- | **Crazy b/c the womb was considered an awful, evil thing, that shouldn't be sewn shut b/c all those bad humors would stay inside!
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- | *Most common surgical procedure
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- | **1965: <5%, 1996: 20.7%, 2004: 29.1%
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- | *No change in cerebral palsy rate
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- | ====C-section - Techniques====
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- | *Uterine Incisions
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- | *Low transverse
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- | **The most common way because it runs with the grain of the muscular fibers.
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- | **Also, this area does less labor contracting so next pregnancy is less likely to result in rupture.
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- | *Low verticle
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- | *Classical
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- | *Kerr
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- | ====C-section - Indications====
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- | =====Fetal C-section Indications=====
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- | *Distress / intolerance of labor
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- | **'''FHT of category 2 or 3'''
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- | *Malpresentation (breech, transverse)
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- | *Twins, multiples
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- | **'''Vertex / Vertex = allow to labor'''
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- | *Some congenital anomalies
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- | **NTD
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- | =====Maternal-Fetal C-section Indications=====
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- | *'''Arrest of active labor'''
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- | **Pretty common
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- | *Failed induction of labor (?)
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- | *'''Placenta previa, vasa previa'''
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- | **When the placenta covers the cervical os.
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- | **When the placental vessels course between baby and os.
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- | ***50% mortality post-rupture!
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- | *Active HSV outbreak
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- | *HIV+ (viral load >1000/ml)
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- | **If mom is on ARV therapy, there is no decrease in transmission with c/s.
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- | *EFW > 4500 - '''5000 grams''' (increasing risk of shoulder dystocia)
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- | **Use u/s to estimate weight.
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- | =====Maternal C-section Indications=====
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- | *Obstructive tumors (some leiomyomas)
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- | *Severe condylomata acuminata
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- | *Cervical cancer
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- | *Abdominal cerclage
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- | *'''Prior c-section'''
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- | **Risk of uterine rupture is 0.5-1%
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- | **Can be catastrophic
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- | *Prior vaginal colporrhaphy
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- | *Vaginal delivery contraindicated medically
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- | *Pregnant???
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- | **No!
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- | ====C-section - Risks====
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- | *At time of surgery / Immediate post-op
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- | *'''Infection: endometritis, wound infection, septic pelvic thrombophlebitis (SPT)'''
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- | *Bleeding: transfusion, hysterectomy
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- | *Damage to fetus
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- | **Very small; no larger than with vaginal delivery.
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- | *Damage to adjacent organs
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- | *Subsequent pregnancy:
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- | **Adhesions
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- | **Uterine rupture
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- | **Placenta previa (when the placenta covers the os) may convert to accreta (when the placenta invades the myometrium).
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- | **Accreta carries huge risks because there is often massive bleeding.
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- | **Accreta puts the mother a risk of death.
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- | **'''That is, placenta previa with a previous c/s has a very high risk of being bad!'''
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- | ***0 –> 5% (number of previous c/s, risk of accreta given a placenta previa)
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- | ***1 –> 24%
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- | ***2 –> 48%
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- | ***3 –> 67%
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- | There will be a test question on prior c/s and placenta previa.
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- | ===Operative Vaginal Delivery===
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- | *Forceps and vacuum can be used to guide the baby's head out of the pelvis.
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- | *There are many different types and procedures.
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- | ====Operative Vaginal Delivery - Classification====
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- | *We want, first, to be sure the baby has reached the pelvic inlet.
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- | *Didn't talk about any of this:
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- | *Outlet: scalp visible at introitus w/out separating labia; no rotation
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- | *Low: leading point of skull at or below +2 cm station
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- | **Rotate < 45°
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- | **Rotate > 45°
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- | *Mid: above +2 cm station but engaged
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- | ====Operative Vaginal Delivery - Indications====
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- | *Nonreassuring FHT’s
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- | *Prolonged 2nd stage of labor
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- | *Shortened 2nd stage if pushing / Valsalva not indicated
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- | *Maternal exhaustion
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- | ====Operative Vaginal Delivery - Prerequisites====
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- | *Cervix completely dilated
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- | *Ruptured membranes
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- | *Fetal skull engaged in pelvis
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- | *Empty bladder
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- | *'''Position! Position! Position!'''
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- | **Before we put anything on the baby's head, we have to know the position so we don't break the nasal bone or deform the child.
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- | *Adequate pelvis
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- | *Adequate anesthesia
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- | ====Operative Vaginal Delivery - Forceps Assisted====
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- | *Use the same angles when applying traction.
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- | *Apply the extension just like in a non-operative vaginal delivery.
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- | ====Operative Vaginal Delivery - Risks====
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- | *Maternal:
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- | **Vaginal / perineal trauma, damage to rectal sphincter
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- | **Mostly forceps issues with mom
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- | *Fetal:
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- | **Mostly vacuum issues with baby
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- | **Cephalohematoma
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- | **Subgaleal hemorrhage
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- | **Bony facial trauma
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- | **Facial nerve injury
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- | **Intraventricular hemorrhage
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- | | + | |
- | ====Birth Trauma====
| + | |
- | *Caput succedaneum:
| + | |
- | **Very common
| + | |
- | **Crosses midline
| + | |
- | *Subgaleal hemorrhage:
| + | |
- | **Does not cross midline
| + | |
- | **Rare
| + | |
- | **Hypovolemia and DIC
| + | |
- | | + | |
- | ===Common Post Partum Problems===
| + | |
- | *PP Hemorrhage: >500cc (>1000cc for c/s):
| + | |
- | **Atony
| + | |
- | ***When the uterus won't contract.
| + | |
- | ***Linings aren't collapsed together to stop bleeding.
| + | |
- | **Lacerations (cervix, vagina, perineum)
| + | |
- | **Retained placenta
| + | |
- | ***Keeps the endometrium layers from coapting (collapsing together).
| + | |
- | **Uterine rupture
| + | |
- | **Uterine inversion
| + | |
- | **Amniotic fluid embolism
| + | |
- | | + | |
- | | + | |
- | *Endometritis:
| + | |
- | **Fundal tenderness w/ temperature >38°C x 2 or >38.5°C
| + | |
- | **Polymicrobial infection
| + | |
- | **More common after c/s
| + | |
- | ***Prolonged ruptured membranes
| + | |
- | ***Chorioamnionitis
| + | |
- | **'''Treat with broad spectrum antibiotics'''
| + | |
- | | + | |
- | ====PP / Post-Op Fever====
| + | |
- | *Causes and symptoms
| + | |
- | **Wind (atelectasis, pneumonia)
| + | |
- | **Wound (seroma, necrotizing fasciitis)
| + | |
- | **Water (UTI)
| + | |
- | **Walk (thrmobophlebitis)
| + | |
- | **Wonder drug (drug reaction)
| + | |
- | **Womb (endometriosis)
| + | |
- | **Wean (mastitis, engorgement)
| + | |
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