Case Files Flashcards
Labor latent phase
the initial part of labor where the cervix mainly effaces rather than dilates (usually cervical dilation <6cm)
Labor active phase
The portion of labor where dilation occurs more rapidly, usually when the cervix is > 6 cm dilation.
arrest of active phase
No progress in the active phase of labor (≥ 6cm) with ruptured membranes for 4 hours with adequate contractions, or 6 hours of inadequate contractions.
stages of labor
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.
fetal HR baseline
Normally between 110 and 160 bpm. Fetal bradycardia is a baseline < 110 bpm, and fetal tachycardia is exceeding 160 bpm.
Decelerations
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.
accelerations
Episodes of the fetal heart rate that increase above the base- line for at least 15 bpm and last for at least 15 seconds.
latent phase limits
nullipara: ≤18-20 h
multipara: ≤14 h
second stage of labor limits
Nullipara:
≤3 h
≤4 h if epidural
Multipara:
≤2 h
≤3 h if epidural
adequate uterine contractions
defined as contractions every 2 to 3 minutes, firm on palpation, and lasting for at least 40 to 60 seconds
What do late decelerations suggest?
fetal hypoxia
When late decelerations occur together with decreased variability, then _____ is strongly suspected
acidosis
FHR Category I
is reassuring—normal baseline and variability, no late or variable decelerations.
FHR Category II
bears watching—may have some aspect that is concerning but not ominous (eg, fetal tachycardia without decelerations).
FHR Category III
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).
Scalp stimulation induc- ing an acceleration highly correlates to…
a normal umbilical cord pH (≥7.20)
McRoberts Maneuver
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)
Suprapubic pressure
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.
When should shoulder dystocia be expected?
prior history of shoulder dystocia, fetal macrosomia, gestational diabetes, excessive weight gain (>35 lbs) in pregnancy, maternal obesity, and prolonged second stage of labor
Wood’s corkscrew
progressively rotating the posterior shoulder in 180° in a corkscrew fashion (for shoulder dystocia)
Zavanelli maneuver
cephalic replacement with immediate cesar- ean section
Key labs for pre-eclampsia
CBC with platelet count
LFTs
Serum creatinine
Preeclampsia
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.
Eclampsia
Seizure disorder associated with preeclampsia.
HELLP syndrome
Hemolysis,elevated liver function tests,lowplatelets,possibly a subset of severe preeclampsia, associated with significant fetal/ maternal morbidity and mortality.
Posterior Reversible Encephalopathy Syndrome (PRES)
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.
Severe feature of Preeclampsia
Vasospasm associated with preeclamp- sia of such extent that maternal end organs are threatened, usually necessitating delivery of the baby regardless of gestational age.
Superimposed Preeclampsia
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.
Superimposed Preeclampsia with Severe Features
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).
Diagnosis of Preeclampsia
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
Severe features of preeclampsia
- 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
Risk factors for preeclampsia
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
Preterm labor
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.
Tocolysis
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.
Antenatal steroids
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).
Fetal Fibronectin Assay
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.
Cervical Length
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.
Late Term Gestation
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.
When is tocolysis considered?
If gestational age is less than 34 to 35 weeks
When are steroids administered in preterm delivery?
less than 34 weeks
