Case Files

Question 1

Labor latent phase

Answer 1

the initial part of labor where the cervix mainly effaces rather than dilates (usually cervical dilation <6cm)

Question 2

Labor active phase

Answer 2

The portion of labor where dilation occurs more rapidly, usually when the cervix is > 6 cm dilation.

Question 3

arrest of active phase

Answer 3

No progress in the active phase of labor (≥ 6cm) with ruptured membranes for 4 hours with adequate contractions, or 6 hours of inadequate contractions.

Question 4

stages of labor

Answer 4

First stage: onset of labor to complete dilation of cervix. Second stage: complete cervical dilation to delivery of infant. Third stage: delivery of infant to delivery of placenta.

Question 5

fetal HR baseline

Answer 5

Normally between 110 and 160 bpm. Fetal bradycardia is a baseline < 110 bpm, and fetal tachycardia is exceeding 160 bpm.

Question 6

Decelerations

Answer 6

Fetal heart rate episodic changes below the baseline. There are three types of decelerations: early (mirror image of uterine contractions), vari- able (abrupt jagged dips below the baseline), and late, which are offset following the uterine contraction.

Question 7

accelerations

Answer 7

Episodes of the fetal heart rate that increase above the base- line for at least 15 bpm and last for at least 15 seconds.

Question 8

latent phase limits

Answer 8

nullipara: ≤18-20 h
multipara: ≤14 h

Question 9

second stage of labor limits

Answer 9

Nullipara:
≤3 h
≤4 h if epidural

Multipara:
≤2 h
≤3 h if epidural

Question 10

adequate uterine contractions

Answer 10

defined as contractions every 2 to 3 minutes, firm on palpation, and lasting for at least 40 to 60 seconds

Question 11

What do late decelerations suggest?

Answer 11

fetal hypoxia

Question 12

When late decelerations occur together with decreased variability, then _____ is strongly suspected

Answer 12

acidosis

Question 13

FHR Category I

Answer 13

is reassuring—normal baseline and variability, no late or variable decelerations.

Question 14

FHR Category II

Answer 14

bears watching—may have some aspect that is concerning but not ominous (eg, fetal tachycardia without decelerations).

Question 15

FHR Category III

Answer 15

is ominous and indicates a high likelihood of severe fetal hypoxia or acidosis—examples include absent baseline variability with recurrent late or variable decelerations or bradycardia, or sinusoidal heart rate pattern (this requires prompt delivery if no improvement).

Question 16

Scalp stimulation induc- ing an acceleration highly correlates to…

Answer 16

a normal umbilical cord pH (≥7.20)

Question 17

McRoberts Maneuver

Answer 17

The maternal thighs are sharply flexed against the maternal abdomen to straighten the sacrum relative to the lumbar spine and rotate the symphysis pubis anteriorly toward the maternal head (for shoulder dystocia)

Question 18

Suprapubic pressure

Answer 18

The operator’s hand is used to push on the suprapu- bic region in a downward or lateral direction in an effort to push the fetal shoulder into an oblique plane and from behind the symphysis pubis.

Question 19

When should shoulder dystocia be expected?

Answer 19

prior history of shoulder dystocia, fetal macrosomia, gestational diabetes, excessive weight gain (>35 lbs) in pregnancy, maternal obesity, and prolonged second stage of labor

Question 20

Wood’s corkscrew

Answer 20

progressively rotating the posterior shoulder in 180° in a corkscrew fashion (for shoulder dystocia)

Question 21

Zavanelli maneuver

Answer 21

cephalic replacement with immediate cesar- ean section

Question 22

Key labs for pre-eclampsia

Answer 22

CBC with platelet count
LFTs
Serum creatinine

Question 23

Preeclampsia

Answer 23

Hypertension (140 systolic or 90 diastolic) measured twice 6 hours apart with the new onset of proteinuria (> 300 mg over 24 hours, or a urine protein to creatinine ratio > 0.3) usually at a gestational age greater than 20 weeks. In the absence of proteinuria, hypertension and one of the following findings may suffice: thrombocytopenia, impaired liver function tests, renal insufficiency, pulmo- nary edema, cerebral disturbances, or visual impairment.

Question 24

Eclampsia

Answer 24

Seizure disorder associated with preeclampsia.

Question 25

HELLP syndrome

Answer 25

Hemolysis,elevated liver function tests,lowplatelets,possibly a subset of severe preeclampsia, associated with significant fetal/ maternal morbidity and mortality.

Question 26

Posterior Reversible Encephalopathy Syndrome (PRES)

Answer 26

A cliniconeuroradiological syndrome with headache, encephalopathy, seizures, cortical visual disturbances, usually diagnosed with clinical features and magnetic resonance imaging (MRI) (showing enhancement in the posterior parietal areas). Prompt rec- ognition and treatment of PRES with antihypertensives, antiepileptics, and intensive care unit (ICU) monitoring is important to prevent long-term neurological sequelae.

Question 27

Severe feature of Preeclampsia

Answer 27

Vasospasm associated with preeclamp- sia of such extent that maternal end organs are threatened, usually necessitating delivery of the baby regardless of gestational age.

Question 28

Superimposed Preeclampsia

Answer 28

Development of preeclampsia in a patient with chronic hypertension, often diagnosed by an increased blood pressure and/ or new onset proteinuria, which can be with or without severe features.

Question 29

Superimposed Preeclampsia with Severe Features

Answer 29

Development of preeclampsia in a patient with chronic hypertension with severe hypertension despite maximum therapy, cerebral/ visual symptoms, pulmonary edema, low plate- lets, elevated LFT, or new onset renal insufficiency (Cr ≥ 1.1 mg/ dL).

Question 30

Diagnosis of Preeclampsia

Answer 30

New onset hypertension (140 systolic or 90 diastolic) twice over 6 hours with any one of: • Proteinuria (≥300 mg/24 hours, or protein/Cr ≥ 0.3 mg/dL, or dipstick ≥ 1 + or greater) • Thrombocytopenia (platelets < 100 000/mm3)
• Impaired LFT(2× normal)
• Renal insufficiency (Cr ≥ 1.1 mg/dL)
• Pulmonary edema
• New onset cerebral disturbance or visual impairment

Question 31

Severe features of preeclampsia

Answer 31

• Systolic BP ≥ 160 mm Hg or diastolic BP ≥ 110 mm Hg on two occasions 4 hours apart • Platelets < 100 000/mm3
• Impaired LFT(2× normal) or severe persistent epigastric or RUQ pain
• Progressive renal insufficiency (Cr ≥ 1.1 mg/dL)
• Pulmonary edema
• New onset cerebral or visual disturbance

Question 32

Risk factors for preeclampsia

Answer 32

nulliparity, extremes of age, African-Amer- ican race, personal history of severe preeclampsia, family history of preeclampsia, chronic hypertension, chronic renal disease, obesity, antiphospholipid syndrome, diabetes, and multifetal gestation

Question 33

Preterm labor

Answer 33

Cervical change associated with uterine contractions prior to 37 complete weeks and after 20 weeks’gestation. In a nulliparous woman, uter- ine contractions and a single cervical examination revealing 2-cm dilation and 80% effacement or greater are sufficient to make the diagnosis.

Question 34

Tocolysis

Answer 34

Pharmacologic agents used to delay delivery once preterm labor is diagnosed. The most commonly used agents are indomethacin, nifedipine, terbutaline, and ritodrine. Recent evidence has indicated that magnesium sul- fate may be ineffective as a tocolytic agent but has been shown to decrease the risk of cerebral palsy in surviving infants if birth is anticipated before 32 weeks’ gestation.

Question 35

Antenatal steroids

Answer 35

Betamethasone or dexamethasone is given intramus- cularly to the pregnant woman in an effort to decrease some of the complications of prematurity, particularly respiratory distress syndrome (intraventricular hemorrhage in the more extremely premature babies).

Question 36

Fetal Fibronectin Assay

Answer 36

A basement membrane protein that helps bind placental membranes to the decidua of the uterus. A vaginal swab is used to detect its presence. Its best utility is a negative result, which is associated with a 99% chance of not delivering within 1 week.

Question 37

Cervical Length

Answer 37

Cervical length of < 25 mm results in an increased risk of preterm delivery. Also an impinging of the amniotic cavity into the cervix, so-called funnel- ing, increases the risk of preterm delivery. H owever, a short cervix or a positive fetal fibronectin alone should not be used exclusively to diagnose preterm labor in an acute situation, as the positive predictive value is poor.

Question 38

Late Term Gestation

Answer 38

Delivery that occurs between 34+ 0 weeks and 36+ 6 weeks. This is the subset of preterm births that are most rapidly increasing and comprises most preterm deliveries.

Question 39

When is tocolysis considered?

Answer 39

If gestational age is less than 34 to 35 weeks

Question 40

When are steroids administered in preterm delivery?

Answer 40

less than 34 weeks