Endo Repro Last Flashcards
Early pregnancy loss, ectopic and Rh isoimmunization
Ok
First trimester
First day of last period (FDLMP)-13+6 weeks
Second trimester
14-27+6 weeks
Third trimester
28-42
Estimate date of confinement
40 weeks after FDLMP
Abortion
<20 weeks
Preterm delivery
20-36+6 weeks
Full term
37-42 weeks
Postdates
> 42 weeks
What percent of pregnant women have vagina bleeding in early preg
40%
What d if girl present with vaginal bleeding
Pregnancy test
What is a negative hCG
<5 mIU/L
HCG level at time of expected menstruation
100 IU/L
HCG ___ every __ days
Doubles
2
What hCG level can we see gestational sac? :Discriminatory level”
1500-2000 mIU/L
Fetal pole seen what hCG
5200, 5 weeks
What is abnormal rise in hCG of less then 53% in 48 hours
Abnormal IUP or ectopic
Spontaneous abortion percent
10-15%
Biochemical pregnancy
Refers to the presence of hCG 7-10 days after ovulation but in whom menstruation occurs when expected
-when both clincial biochemical pregnancies are considered evidence suggests that 50% of all conventions end in abortions
Abortus
Loss before 20 weeks or less than 500 grams
Most common cause of first trimester SAB
Chromosomal abnormalities
45 CO most common abnormality
Trisomy 16 most commontrisomy
Threatened abortion
Vaginal bleeding and closed cervic
25-50% result in lsos
Treatment is expected management
Inevitable abortion
Vaginal bleeding and the cervic is partially dilated
Loss inevitable
Incomplete abortion
Vaginal bleeding, cramping lower abdominal pain with dilated cervix
Passage of some but not all products
Treat with suction D and C
Complete abortion
Passage of all with closed cervic
With resolution of pain, bleeding and pregnancy symptoms
No treatment needed
Missed abortion
Fetus has expired and remains int he uterus
Usually no symptoms
Coagulation problems may develop, check fibrinogen levels weekly until SAB occurs or proceed with suction D and C
Expectant management vs misoprostol vs D and C
Septic abortion
Fever, uterine and cervical motion tenderness, purulent discharge, hemorrhage, and renal failure
Retained infected products
Treat septic abortion
IV antibiotics and D and C
Blighted ovum
Anembryonic gestation
Gestational sac to large to not have embryo >25 mm
Induced or elective abortion
Roe v wade 1971
Suction D and C is most common in first trimester
Anembryoinc gestation (blighted ovum)
Fertilized egg develops a placenta but no embryo
How see anembryonic gestation
US reveals empty gestational sac
Treat anembryonic gestation
Expectant management
Medical management -misoprostol
D and C
Suction D and C
Uses suction to remove products of conception
Surgical D and C is a more successful primary therapy then medical or expectant management
Recurrent abortions
Defined as three successive SAB
Excluding ectopic and molar pregnancies
1% of pregnant women
Often no identifiable cause can be found
Recurrent abortions: infection
Mycoplasma, chlamydia, listeria, or toxoplasmosis rarely identified
Can be treated with antibiotics
Recurrent abortions: smoking and etoh
Increase SABS
4 fold increase risk. If smoke 20 cigarettes a day and consume 7 alcoholic beverages per week
Recurrent abortions: medical disorders
DM, Hypothyroidism, SLE< antiphospholipid ab syndrome and hypercoagulability sources
Factor V Leiden defiency, antithrombin III, protein C and S, prothrombin G20210A, ANA, anticardiolipin antibody, methylene tetrahydrofolate reductase
Recurrent abortion maternal age
> 40 lots 56%
Increase with maternal age
Recurrent abnortions: uterine abnormalities
Congenital anomalies (DES)
Submucosal fibroids, uterine septum
Intrauterine synechiae (asherman)
Recurrent abortion: cervical incompetence
Second trimester loss
Painless dilation and delivery
Risk factors cervical incompetenance
Uterine anomalies,previous trauma, and history of conization
Treat cervical incompetence
Cervical circulate
Recurrent abortions chromosomal abnormalities
45 XO most common
Trisomy 16 most common trisomy
Recurrent abortio karyotype gets
Recommended for both parents bc 3% chance that one parent is an asymptomatic carrier of a genetically balanced chromosomal translocation
Detect balanced reciprocal or robertsonian translocations that could be passed on
Recurrent abortions antiphospholipid syndrome
Most common
Has been associated with recurrent fetal loss, preeclampsia, venous and arterial thromboembolism and stroke
Tests for immunological factors
Lupus anticoagulant
Anticardiolipin antibodies IggIgm
Anti B2 glycoproteins 1 antibodies iggigm
Treat immunological
Prophylactic dose of heparin and low dose asprin
Ectopic pregnancy
Fallopian tubes, abdomen, cervix, ovary, uterine cornua
% ectopic
1.5%
How ectopic pregnancy happen
Trophoblastic implant into the mucosa of the Fallopian tube and rapidly erode through to underlying blood vessels
-if the bleeding is extensive it can create a pressure necrosis of the overlying tubal serosa resulting in acute rupture and significant hemoperitoneum
Leading cause maternal death 1st trimester
Ectopic pregnancy
Natural vs art locations
Natural-tubal
Art-some tubal more ampullae and cornual
Also get ovarian /abdominal (heterotopic more), more cervical
But both most tubal
Risk factors ectopic pregnancy
History tubal infection (G or chlamydia)
Previous ectopic
Previous tubal reconstructive surgery or sterilizaiotns
DES
IUD preg
IVF or ART
Smoking
Differential ectopic
Threatened or incomplete abortion
Ruptured hemorrhagic corpus luteum cyst
Acute PID
Adnexal torsion
Degenerating leiomyoma
Nongynecological ectopic pregnancy
Acute appendicitis
Pyelonephritis, renal calculi
Pancreatitis
Triad ectopic pregnancy
Prior missed menses
Vaginal bleeding
Lower abdominal pain
Ectopic pregnancy signs
Usually 1 visit before diagnosis
-follow hcg and TVUS
Ab pain, spotting, bleeding
PE ectopic: possible
Uterus soft and normal size
May not feel any adnexal mass
US-thickened endometrial stripe (arias Stella reaction)
Rarely do you see the ectopic preg)
Symptoms probable ectopic pregnancy
Lower ab pain vag spotting
Abdominal adnexal tenderness or cervical motion tenderness
US-variable amounts of fluid in cul de sac
May see ectopic
Acutely ruptured ectopic pregnancy
Severe abdominal pain and dizziness from intraperitoneal preg
Distended and acute tender abdomen , cervical motion tenderness, sign of hemodynamically instability
US-empty uterus with free fluid
Hcg Doubles every 48 hours
Indicates a normal IUP
Some 66%
Slowest is 53%
<53% rise in hCG
Consistent with ectopic pregnancy or nonviable IUP
Can an ectopic pregnancy have normal rising HcG
Yup
Falling hCG
Most likely blighted ovum, spontaneously resolving ectopic ,abnormal pregnancy
Discriminatory zone
1500-2000 IU/L should see an intrauterine great sac
What see with transvaginal US
IUP
Extrauterine preg
Nondiagnostic-follows with hCG a
When repeat US
Hcg in discriminatory zone
Manage ectopic preg
Methotrexate-folic acid antagonist whihc inhibits DNA synthesis and cell replication
Follow up methotrexate
Check hCG levels day 4 and 7
-if 15% continue to follow weekly until negative
If plateau or fall slow, give another dose
Increase-surgical intervention
What avoid when on methotrexate
Folate containing vitamins
Success rate methotrexate
70-90%
Absolute contraindications methotrexate
IUP, breastfeeding, immunodeficiency, alcoholism, liver disease, hepatic renal failure
Relative contraindicatiosn mtx
Gestational sac>3.5 cm
Embryonic cardiac motion
HCG>6000
Expectant management
Stable and symptoms are resolving
Follow hCG and give strong ectopicprecaution
A lot of ectopic with hCG< 1000
Not rupture and resolve spontaneously
Laparotomy
Preferred for hemodynamically unstable
Laparoscopy
Stable patient
Salpingectomy
Entire Fallopian tube when damage
Salpingostomy
Incision is made parallel to the axis of the tube over the site of implantation and incision is left open to heal by secondary intention
Most studies reveal salpingostomy results in better long term tubal fcuntion
Salpingostomy
Incision is sutured
What do after surgery
Repeat hCG 3-7 days post op
Salpingostomy risk
20% risk residual trophoblastic tissue
Thesis isoimmunization
Rh negative women with RH positive fetus
Rh complex
C,D,E,c,d,e
> 905 of cases of Rh isoimmunization
Antibodies to D antigens
Who most common Rh D negative
Caucasion>african American> Asian an Native American
Rh sensitization
IgM initially then igg that cross placenta and into fetus
Bind fetal rbc and hemolysis
Mild hemolysis
Fine bc increase erythropoietin
Severe hemolysis
Resulting in hydrops fetalis from congestive heart failure and intrauterine fetal deat
RhoGAM
Prophylactic Rh immune globulin prevent maternal production of antibodies
Fetomaternal hemorrhage that can lead to isoimmunization
Most commonly occur during routine uncomplicated vaginal deliveries
Factors that can increase the volume of fetomaternal hemorrhage
-c section, placenta previa or abrupton and manual extraction of placenta
1-2% of Rh isoimmunization occur in the antepartum period
Abortion, abdominal trauma, ectopic preg, obstetrical procedures
Prevent rh isoimmunization
Rhogam decrease availability to RHD to maternal immune system
Prevent Rh isoimmunization
More than 1 dose in some populations
-do kleinhauer-betke test which identifies fetal rbc in maternal blood and will determine if rhogam is necessary
All pregnant women wha test
ABO blood group, Rh D type and antibody screen
What is women rh neg and anti d antibody tigers are positive (sensitized)
Test father for antigen status
If he is rhd negative, no further workup or treatment is necessary bc the fetus will be rh negative
If positive for rh d
- homozygous, all with be rh +
- heterozygous-50% will be
Fetal rhd status determined by cell free fetal DNA in maternal plasma or invasively with the fetal antigen testing
Maternal rh antibody tigers
Screening tool to estimate the severity of fetal hemolysis in rh disease
Titers less than 1:8
Usually indicate the fetus is not in serious jeopardize
Recheck titers in 4 weeks
Titers>1:16
Further evaluation
Detailed US to detect hydrops and Doppler studies of the idle cerebral artery
US fetal hydrops
Ascites, pleural effusion, pericardial effusion, skin scalp edema, polyhydramnios
US isoimmunization
Doppler assessment of peak systolic velocity in the fetal mca most valuable
Do ever 1-2 weeks from 18-35
Fetal MCA
Value peak systolic velocity >1.5 MOM for gestational age
Predictive of moderate to severe fetal anemia
Need to proceed with percutaneous umbilical blood sampling to assess true hemoglobin concentration
Intrauterine transfusion if indicated
Amniotic fluid in isoimmunization
Before MCA Doppler
Find bilirubin analysis with spectral analysts 450nm which correlated with cord blood hemoglobin of newborn at birth
Issue of amniotic fluid spectrophotometer in isoimmunization
Amniocentesis can increase the severity of fetomaternal transfusion and worsen the disease
Manage severe fetal anemia: what is it
HCT below 30% or 2 Sd below mean for gestational age
Teat severe fetal anemia
Intrauterine transfusions between 18-35 weeks
Use group O Rh neg packed rbc
- <20 weeks intraperitoneal transfusion
- IV transfusion into umbilical vein are preferred secondary to therapeutic effects are more rapid and reliable
- repeat transfusion 1-3 weeks
Survival rate after transfusion
85%
Antepartum testing
Twice weekly non stress test or biophysical profiles
Serial growth scans q 3-4 weeks
After 35 weeks
The risk of intrauterine transfusions may be greater then that of a preterm 35 week
Consider delivery and transfuse
Each subsequent pregnancy after the first affected pregnancy is likely to manifest more severe fetal/neonatal hemolytic disease and at an earlier gestation
-90% risk of hydrops
Ok
Visit by all patient who are considering pregnancy
Risk assessment(smoking cessation, etoh ,illicit drugs)
Health promotion (nutrition, folic acid, weight)
Medical intervention(DM management)
Psycosocial intervention (stress reduced, 10% are abused during preg)
When start folic acid
At least 1 month before
Why manage glucose
SAB, morbidity, fetal malformation, fetal macrosomia, IUFD
G1p1002
Given birth 1 set of twins both alive
G4p1123
One term infant, one set of preterm twins and 1 miscarriage and 1 ectopic
2 living kids
Systolic murmur, splitting and S3, palmar erythema, spider angiomatosis, linea nigra, striae gravidarum, Chadwick’s sign
Normal in preg
What get for prenatal labs at 1st visit
Cbc, type and screen rubella immunity (cavvinate post partum if not0, syphilis, hepatitis B surface ag, HIV, cervical cytology and gonorrhea, DM, urine culture
Albumin, calcium, glucose, cr, protein, na, urea nitrogen, folic acid blood
Decrease
Fibrinogen
Increase
Urine
Cr no chance, protein increase, cr clearance decreased
Amy last
Increased
Alt ast
No chance
Hematocrit, leukocyte factors 7-10
Increase
Platelets hemoglobin
Decrease
Gestational ae
Number of weeks elapsed since first day of LMP and date of delivery
Serum hcg value preg
<5 no
Above 25 positive
100-time of next menses
First 20 days hcg
Doubles every 2 days
When see gestational sac
5 weeks, hcg 15000-2000
Fetal pole when seen
6 weeks, hcg 5200
Cardiac activity
7 weeks, 17500
Naegels rule
LMP minus 3 months and add 7 days-but only in 28 day cycle ppl
How use US to determine date of delivery
Crown rump length (CRL) between 6-11 weeks can determine due date within 7 days
At 12-20 weeks measuring femur length, biparietal diameter and abdominal circumference can determine due date within 10 days
Third trimester due date can be off up to +/- 3 weeks
How PE estimate exam
Size of uterus
Who needs genetic counseling
Over 35
Previous child.family history of birth defects or known genetic disorder
Previous birth mental retarded
Previous dead baby
Multiple fetal lossses
Abnormal serum marker
Consanguinity
Maternal conditions
Exposure to teratogens
Abnormal US
Genetic disorder
Down’s syndrome
Meiosis nondisjucntion 47 chromosome extra 21
If have a Down’s syndrome have 1% cance of another
Chromosomal studies (karyotype) on couples after 3 or more spontaneous abortions
3-5% will have balanced translocation
Should get counseling on having kid with an unbalanced translocation and therefore be offered prenatal diagnosis (chorionic villus sampling/amniocentesis)
Most common class of spontaneous abortion
Autosomal trisomy (16)
Most common single chromosomal abnormality in SAB
45 xo
AD dosirders
Tuberous sclerosis, neurofibromatosis, achondroplasia, craniofacial synstosis, adult onset POCS, muscular dystrophy
AR
Ray sachs, sickle cell, alpha and beta thalassemia, cystic fibrosis
Who is offered CF screen
1/25 ppl carry the AR tait
15% undiagnosed
All preg women
Sex linked
Duchene muscular dystrophy, fragile x
Fragile x
Most common inherited mental retardation
Second most common mental retardation a fter Down’s syndrome
How get x linked disorder
No male male transmission
Unaffected females carry
Effect males
Multifactorial inherited
Cleft lips, heart defects, pylorus stenosus, neural tube
Neural tube defects
Folic acid
When screen and uploads
1st and 2nd
1st trimester screening
Maternal age, fetal nuchal translucency (NT) thickness (echo free area at back of neck between 10 and 14 weeks-high thickness chromosomal and congenital abnormalities)
Hcg
Pregnancy associated plasma protein a PAPPA
Elevated bhcg and low pappa
Down’s syndrome
Increased nuchal translucency
Also downs
Second trimester triple screen
Bhcg, estriol, alpha fetoprotein
Detect trisomy 21
Second trimester quadruple screen
Bhcg, estriol, afp, inhibiton a
Trisomy 21
Combined 1st and 2nd trimester screening
Report results after 2nd trimester
Improve detection rate
Cell free fetal dna
9-10 weeks
Tests cell free fetal dna, thought to be from apoptosis of trophoblastic cells that have entered the maternal circulation
What cell free dna good for
Trisomy 21
Trisomy 18
Trisomy 13
Sex chromosome
NOT NEURAL FETAL DEFECTS LIKE NT
Who cell cell free dna
High risk
-old, prior trisomy preg, family history chromosomal abnormalities, US abnormal, positive fist trimester screen
If positive
Anniocenteisis or Chorionis villi sampling
Amniocentesis
16-20 weeks
.3% miscarriage
Chorionic villi sampling
11 weeks
1% miscarriage
Teratology
Study abnormal fetal development
Thalidomide
Phocomelia
Pregnancy and lactation labeling rule
PLLR
Removed letters changed content and format for information to assist health care provides in assessing benefit vs risk
PLRR
Pregnancy subsections 8.1-preg
Pregnancy subsection 8.1 breastfeeding
Females and male reproductive potential 8.3
Fetal susceptibility to teratology
Genetic make up of mom and fetus and environment
Multifactorial
Low dose
Fine
Intermediate dose
Organ malformation
High dose
Abortion
Most vulnerable time
17-56 days during organogenesis
4 th month and after
Growth delay and not malformation
Organogenesis
Malformation
Most common teratogen
Alcohol
Fetal alcohol syndrome
Antianxiety
Meprobamate or chlordiazepoxide
Congenital anomalies
Antineopalstic
Aminopterin and methotrexate are both folic acid antagonists
=before 40 lethal
Later UIGR, craniofacial, mental retard
FAS
Growth restriction
Facial abnormalities(low ears, smoot philitrum, thin upper lip, short palpebral tissues, flat midface)
CNS dysfunction
-microcephalic, mental retardation and behavior disorders
Alkalyating
Iugr, fetal death, cleft lip, microphthalmia, limb reduction, poorly developed external genetalia
Anticoagulatnts
Coumadin cross placenta, heparin doesnt
Coumadin
SAB, IUGR, CNS mental retardation, stillbirth, craniofacial features, fetal warfarin syndrome
Anticonvulsants
Usually epileptic women benefits of seizure prevention weighed against teratogenicity of the drug
Diphenylhydantoin
Fetal hydantoin syndrome
-craniofacial , limb reduction, FHS, mental defiency, cardiovascular anomalies
Valproic acid
Spina bifida
Cardiac, skeleton, craniofacial abnormalities
Carbamazepine
Spina bifida, craniofacial defects, fingernail hypoplasia
Phenobarbital
Neonatal withdrawal and neonatal hemorrhage
Estrogen and progesterone
Masculinization of female external genetalia
DES
Treat threatened abortion
Risk cervical and uterine issue
Cancer
Male-testicular abnormalities, infertility and malignancy
T uterus
Retinoids
CNS
CVD
Craniofacial defects
SAB, congenital malformations 50%
Tobacco smoke
low birth weight IUGR
SAB, fetal death, neonatal death and prematurity
Illicit drugs
Opiate-experience withdrawal
Infectious agents virus bacteria
Congenital malformations, growth restriction, fetal death, mental retardation
CMV
Proposes, depressed nasal bridge, triangular mouth
Radiation
Dose dependent
2-6 weeks
Before 2 lethal or none
Less than 5 rads of exposure no risk
How deal with n/v
Small frequent meals Avoid greasy fried food Room temp soda and saltnines Acupuncture Medes
Heartburn
From relaxation of esophageal sphincter by progesterone
-donut lie down after meals, elevate head of bed, small frequent meals, antacids, H2O blockers
Constipation
Decrease in colonic activity
Increase water, fiber, fruits, and vegetables, stool softened
Hemorrhoids
Increase in venous pressure in rectum
Rest, sti bath, stool softener, elevat legs, avoid cnstipation
Leg crams
Last half preg, calves at night
Massage stretch
Backache
Avoid weight gain, exercise/stretch, comfortable shoes, pillows, heat massage
How often go to doctor
Every 4 weeks until 28 then ever 2 weeks tilll 36 and weekly until delivery
What get at routine visit
Bp, weight, urine protein, uterine size, fetal heart rate (Doppler)
Quickening
First sensation of miovement 20 weeks
Near term
Evaluate fetal lie and fetal position
20 weeks
Fetal survey ultrasound
28 weeks
Gestational diabetes and repeat hemoglobin and hematocrit
Rhogam injection to Rh negative patients
Tdap give between 27-36 weeks
35 week
Screening for group b step carrier with vaginal culture-treat in labor if positive
Kick counting
Monitor how often
Nonstress test
Reactive-2 accelerations of at least 15 beats above baseline lasting at least 15 seconds during 20 minutes of monitoring
Contractions tress test
Give oxytocin to establish at least 3 contractions in a 10 min period. If late decelerations are noted with the majority of contractions the test is positive and delivery is warranted
8-10
Reassuring
6
Deliver if at term
4 or less
Onreassuring consider delivery
Still birth reactive non stress test
2/1000
Negative contraction stress test still birth
.3/1000
Biophysical profile
.8/1000
Normal labor and delivery
Gynecoid
Gynecoid
Round at inlet
Wide transverse diameter
Wide suprapubic arch
Head into the occiput anterior position
Good for deliver
Android
Males and 30% females
Wides transverse diameter closer to scrum
Prominent ischial spines
Narrow pubic arch
Fetal head to occiput posterior position
Arrest of descent common
Bar prognosis for delivery
Anthropoid
Ape pelvis 20%
Larger AP then transverse Creasy long narrow oval with narrow pubic arch
Fetal head anterioposterior diameter
Usually in OP position
Good delivery
Platypelloid
Flat gynecoid pelvis 3% of females
Short AP and wide transverse diameter
Wide bispinous diameter
Wide suprapubic arch
Fetal head has to engage in transverse diameter
Poor prognosis for delivery
Diagonal conjugate
Inferior pubic symphysis to sacral promontory
>11.5 ok
Obstetric conjugate
Diagonal-2 cm
Narrowest fixed distance through which the fetal head must pass through during a vaginal delivery
What palpate
Sacral and iscial spine
Pelvic outlet
Measure ischial tuberosities and pubic arch
Iscial tuberosities distance between
8.5 cm distance ok
Infrapubic angle
Place thumb next to each inferior pubic ramus and estimate the angle at which they meet
>90 good
Radiographically MRI CT
Rare only do if history or clincial indication of pelvic abnormalities or pelvic trauma
Initial evaluation
Review prenatal records, identify complications, confirm gestational age, review labs, history, PE
Focused history
Frequency contractions, loss fluid, vaginal bleeding
Fetal lie
Reference to maternal spine
Longitudinal, transverse, oblique
Fetal presentation
Vertex, breech, transverse, or compound
Leopoldo maneuver
- Palpate fundus
- Palpate or spine and fetal small parts
- Palpate what is presenting in the pelvis with suprapubic palpation
- Palpate for cephalic prominence
Dilation
Check at internal os
Effacement
Thinning cervix occurs and is reported as % change in length
Normal 3-5 cm
Thick 100% effaced
Station
Degree of descent of the presenting part of fetus
Measured in cm from presenting part to ischial spines
When the bony portion of the head reaches the level of the ischial spines the station is zero
-5 to 5 cm
First stage labor
Onset labor to complete cervical dilation
Latent and active
Second stage
Complete cervical dilation to delivery
Third stage
Delivery of infant to delivery of placenta
Fourth stage
Delivery of placenta to stabilization of patient
Phases of first stage
Latent active
Latent
Onset of labor and slow cervical dilation
Active
Faster rate of dilation and usually begins when cervix is dilated to 4 cm
Admit for labor
Duration 1st stage primiparas and multiparas
6-18 hrs
2-10 hours
Rate cervical dilation primiparas and multiparas
1.5 cm per hour
When may patient ambulated
Head engaged and reassuring monitoring is noted
I in bed be left lateral recumbent
Fluids
IV to hydrate give meds if need
Labs
Cbc and t ands
Maternal monitoring
Vitals q 1-2 hours
External fetal monitoring
Continuous
Intermittent if uncomplicated or complicated differs
Monitor uncomplicated
Q 30 min in active phase of first stage
Q 15 min in second stage of labor
Monitoring if complicated
Q15 min in active phase
Q15 min during the second stage
How get most accurate tracing
Internal monitoring
How get uterine activity
External tocodynamometer
Internal pressure catheter
Can get strength of contractions and help xyytocin augmentation
Vaginal exam
Active phase q2 hrs record dilation, effacement, station
Amniotomy
Augment labor, allows assessment of meconium status
Risk cord prolapse, prolonged rupture is associated with chorioamnionitis
Second stage
Descent of the presenting part through the maternal pelvis and culminates in delivery
Increase in bloody show and desire to bear down with contractions
Duration second stage
Primiparas without epidural 2 hours
With 3 hours
Multiparas without epidural 1 hour
Multiparas 2 hours
Engagement
Presenting part at zero station
Descent
Brought about by the force of uterine contractions and maternal valsava efforts
Flexion
OA baby’s chin to chest thus changing the presenting part from occipitofrontl to the smaller suboccipitobregmativ
Internal rotation
At ischial spines
Fetal head enters pelvis int ransverse diameter, rotates so the occiput turns anteriorly or posteriorly toward the pubic symphysis
Extension
Crowning occurs when the largest diameter of the fetal head is encircled by the vaginal introitus
+5
Head is born by rapid extension
External rotation
Delivered head now returns to its original positiona t the time fo engagement to align itself with the fetal back and shoulders
Expulsion
Anterior shoulder then delivers under the pubic symphysis, followed by the posterior shoulder and the remainder of the body
Maternal position second stage
Avoid supine
Dorsal lithotomy
Bearing down second stage
With each contraction, the mother should hold her breath and bear down with expulsion efforts
2nd stage fetal monitoring
Continuous
Q15 with no risk factors
Q5 minutes during seconds tage with risk
Vaginal exam 2nd stage
Access descent and confirm position
Delivery head
2 nurses and physician
Antiseptic soap vulva
Episiotomy
Facilitate with modified rotten maneuver
Head out bulb suction oral cavity and use index finger to assess nuchal cord
-if loose can manually reduce over the infants head if tight clamp and cut
How deliver shoulder
Anterior shoulder with gentle downward traction on fetal head
Posterior shoulder by elevating the head
Support head, bulb suction, dry and stimulate
Cord
Clamp x2 and cut
Obtain cord blood specimen
Deliver placenta
Third stage then inspec and repair
Indications episiotomy
Likelihood of spontaneous laceration seems high
To expedite delivery by enlarging the vaginal outlet
Midline episiotomy
Common
Risk of extension 3rd or 4th degree
Less postpartum pain
Meidolateral episotomy
Greater blood loss
More difficult to repair
More postpartum pain
Increase risk of dyspareunia
Rotten maneuver
Fingers of the right hand are used to extend the head while counterpressure is applied to the occiput by the left hand to allow for a more controlled delivery
Or just support perineum
FIRST DEGREE LACERATION
SUPERFICIAL LACERATION INVOLVING THE VAGINAL MUCOSA AND OR PERINEAL SKIN
SECOND DEGREE
LACERATION EXTENDING INTO THE MSUCLES OF THE PERINEAL BODY BUT DOES NOT INVOLVE THE ANAL SPHINCTER
THIRD DEGREE
LACERATION EXTENDS INTO OR COMPLETELY through the anal sphincter but not into the rectal UC osa
Fourth degree
Involves the rectal mucosa
Third stage
Interval between delivery of the infant and delivery of placenta
Retained placenta
Placenta not delivered in 30 minutes
Signs placental separation
Gush of blood from vagina
Lengthening of umbilical cord
Fundus of uterus rises up
Change in shape of the uterine fundus from discoid to globular
What do
Apply counter pessure between symphysis and fundus
Do not pull cord until classic signs noted
Inappropriate pulling cord
Uterine inversion
Fourth stage
Monitor patient
Vitals
Uterine fundal checks and assess for vaginal bleeding
Postpartum hemorrhage commonl occurs during this time
-uterine stony, retained placenta, unprepared vaginal or cervical laceration
Cervical ripening
Do before labor
Augmentation
Artificial stimulation of labor which already began
Vs induction of labor
Indication induction
Abruptio placenta, chorioamnionitis, fetal demise, preeclampsia, eclampsia, gestational HTN, prom, postterm pregnancy, maternal medical conditions, fetal compromise
Contraindications induction
Unstable fetal Acute fetal distress Placenta previa or vasa previa Previous classical c section or transfundal uterin surgery HIV high viral load, active herpes
Bishop score
Cervical dilation, cervical effacement, station, cervical consistency cervical position
Biochip<6
Unfavorable
Bishop>8
Probability of vaginal delivery after labor induction is similar to that of spontaneous labor
Cervical dinoprostone
E2 vaginal insert
Not in previous c section
Misoprostol cytotoxicity
E1
Oral or vaginal
Can’t be removed
Not in previous c section
Mechanical dilators
Foley bulb catheter
Laminara japonicum
Pitocin infusion
Synthetic oxytocin stimulate contraction
IV
Induction and augmentation
In normal saline IV and stopped if fetal distress
1-30 mu/min
Uterine tachysystole
More than 5 contractions in 10 min
Side effect
Antidiuretic effect
Pitocin ADH has effect can lead to increase water reabsorption
-convulsion and coma
Uterine muscle fatigue
Prolonged pitocin increase risk
-post partum hemorrhage secondary to uterine stony
Obstetric anesthesia
Pain relied sage for baby
Maternal mortality due to anesthesia
1:500000
Uterine blood flow
Blood flow to uterus may decrease To uterus with anesthesia from hypotension
Need adequate hydration
What do if hypotension anesthesia
Vasopressor
Pain uterine contractions
Visceral pain t10-t12 through l1
Perineum pain
Somatic s2-4
Regional anesthesia
Low of pain below t10
Epidural, spinal
Local
Perineum, pudendal block
Early labor anesthesia
Morphine, fentanyl, meperidine nalbuphine
Not for labor pain women work bc moa is sedation
Opoids cross placenta
Regional
T8-t10 and below
Local anesthesia and narcotic
Epidural
Most effective catheter in epidural space l2-l3 , l3-l4, l4-L5 then placed over needle
Spinal
Single shot analgesia which provide excellen pain relief for limited procedures
Limited use in labor since a single shot
Regional ae
Hypotension , spinal HA, fever, spinal hematoma, abscess
Contraindications regional
Coagulopathy, heparin within 12 horus, bacteremia, ICP, skin infection
Local
1-2% lidocaine for 20-40 min
Before episiotomy or laceration repair
AE local
Hypotension, seizures, cardiac arrhythmias
Pudendal ae
Intravascular injection, hematoma infection
General
Propofol
Loss of consciousness need airway management
16 fold increase maternal mortality
All inhaled anesthetics
Cross placenta and associated with neonatal respiratory depression
When do general
Emergent cases
Regional anesthesia
Fetal heart rate monitoring
To look for for patterns that may be frequently associated with delivery of infant with poor outcomes
For benefit
No increase operative deliveries and c section no change in neuro damage
Who do for
Reassurance
Would have to get nurse
Still goor warning of potential problems
External monitoring vs internal
Internal Rome accurate
External
Doppler US< pressure sensiiive tacodynanmometer
Doppler US
On maternal abdomen overlying fetal heart
Records reflected sound waves fromt he fetal heart back to transducer
Pressure sensitive tocosynanmometer transducer
Detects and records contractions
Useful for measuring the frequency of contractions but not the strength
Internal
Fetal scalp electrode
Intrauterine pressure catheter
Fetal scalp electrode
R wave peaks of the fetal echocardiogram
Maternal and fetal movement will not alter the quality of signal
Rare cases of fetal pustules
Not for HIV
Intrauterine pressure catheter
Soft plastic catheter placed transcervically
Gives precsise measurement of the intensity of uterine contractions in millimeters of mercury
What does internal require
Membranes to be ruptured
Fetal oxygen reserve is only enough to meet its metabolic needs for ___
1-2 min
When is blood flow from maternal circulation stopped
Every contraction
Can tolerate without hypoxia bc adequate oxygen exchange occurs still between contractions
A fetus who is marginal
Can’t tolerate stress of contractions and will become hypoxic
Hypoxia in fetus
Chemoreceptors and baroreceptors in the peripheral arterial circulation of the fetus influence the FHR by giving rise in contraction related or periodic FHR changes
Anaerobic metabolism, Peruvian and lactic acid and fetal acidosis
PH fetal scal normal and acidosis
7.25-7.3
<7.2
How do uterine contractions effect HR
Blood flow ceases
Increase or decrease
Decrease
Normal uterine activity
5 contractions or less in 10 minutes over 30 minutes
Tachysystole
> 5 in 10 min over 30 min
Presence or absence FHR decelerations
How measure contractions
Peak to peak
Normal contractions
3 in 8 minutes
Occurring 2-3 mintues
MVU
> 200 Montevideo units (sum of the contractions in a 10 minute period) for at least 2 hours
Baseline FHR
Increments of 5 bpm during 10 minute
Assess between contractions
Normal
110-160 bpm
Tachycardia
Baseline>160 bpm
Bradycardia
<110 bpm
Tachycardia
> 160
Bradycardia
<110
Causes tachycardia
Fetal hypoxia Meds-oxytocin Arrhythmias Prematurity Maternal fever Fetal infection-chorioamnionitis most common cause1
Bradycardia
Fetal hypoxia, obstetric anesthesia, pitocin, maternal hypotension, prolapsed or prolonged compression of the umbilical cord, heart block
Chemoreceptors tachycardia
In response to hypoxia
Baroreceptors
Vagus in response to changes in fetal bp
Absent
Amplitude undetected
Minimal
<5 bpm
Moderate
6-25 bpm
Marked
Amplitude>25 bpm
Decreased variability
Indicators of fetal stress
Persistent late decelerations
Hypoxia and acidemia
-lack of oxygen and the build up acid in the fetus depresses the fetal heart rate and cns
Decreased variability
Prematurity, sleep, maternal fever, fetal tachycardia, fetal congenital anomalies, maternal hyperthyroidism, drugs
Accelerations
Abrupt increase in the FhR and is a normal reassuring response
>32 weeks HE>15 bpm above baseline for 15 sec or more
<32 weeks HR>10 bpm above baseline for 10 sec or more
Prolonged acceleration
> 2 min
Change in baseline
If acceleration lasts >10 min
Cause accelerations
Spontaneous fetal movement
Vaginal exam
Deceleratiosn
FHR decreases in response to uterine contractions
Early, variable, late
Early deccelerations
Head compression-fetal autonomic response to increased ICP caused by transient compression of the fetal head
Not associated with fetal distress
The nadir of the deceleration occurs at the same time as the peak fo the contraction and thi s. Amirror image
Cause early deceleration
Pressure on fetal skull increase ICP->decrease cerebral blood flow->activates central vagus nerve-> produces decrase in HR->recovering occurring as pressure is relieved
Variable decelerations
Secondary to umbilical cord compression
Abrupt decrease in FHR-can occur before, during or after contraction starts
Decrease in FHR >15 bpm lasting >15 sec and <2 min in duration
Onset depth and duration an vary with successive uterine contractions
Variable decelerations abuse
Cord compression
Slight cord compression
Obstruct umbilical vein which returns re oxygenated blood to fetal heart
Response to cord comrpession
Shoulder
Slight fhr decrase followed by major drop
Late decelerations
Uterine placental insuffiency
Most ominous deceleration-repetitive late decelerations usually indicate fetal metabolis acidosis and low arterial pH
Nadir of the deceleration occcurs after the pea of contraction
Cause late deceleration
Excessiveuterine activity
Maternal supne hypotension
Prolonged deceleration
Decrease in FHR from baseline that is >15 bpm >2 min but <10 min
Disruption of oxygen transfer from the environment to the fetus at one or more points along the oxygen pathways
Maternal pushing
Change in baseline prolonged decelaeration
> 10 min
Sinusoidal pattern
Smooth sine wave like undulating pattern in fhr
Fetal anemia
Category 1
Baseline 110-160 bpm
Moderate variability no late or variable decelerations
May have acccelerations and early decelerations
Tracing category 1
Normal
Manage category 1
Intermittent CEFM
Category II
Intermittent: variable decelerations <50% of contractions
Recurrent variable decelerations >50% of contractions
Category II intermittent
Normal outcome
Category II recurrent variable
Umbilical cord compression with acidemia impending
Moderate variability and or accelerations suggest fetus is not acidemia
Manage intermittent category II
No intervention required
Treat recurrent category II
Alleviate cord comrpession repositioning amnoiinfusion
Modify pushing efforts push with every other ctx
Amnioinfusion
Instillation of normal saline can alleviate cord compression
250-1000 cc infused 15 cc/min
Continuous infusion of 100-200 cc/hour
How infuse amnioinfusion
Transcervical IUPC
Category iI
Minimal or absent variability
Recurrent late decelerations
Prolonged decelerations
Tachycardia, bradycardia
Variable late or prolonged decelerations occurring with maternal pushing efforts
Etiology category II
Fetal sleep, meds, acidemia, UPI:hypotension, tachysystole, maternal hypoxia
Rapid fetal descent , cord comrpession, tachysystole
Prematurity , chorioamnionitis, epidural , cord prolapse, cord comrpession UPI
Manage categor II
Promote fetal oxygenation
Decrease oxytocin
Tachysystole category II
Spontaneous labor, induction or augmentation
Goals tachysystole
Reduce uterine activity
Lateral positioning, IV bolus, decrease oxytocin, tocolytic (tertbutaline)
Absent baseline variability(recurrent late decelerations, recurrent variable decelerations, bradycardia0
Sinusoidal pattern
Increased risk of fetal acidemia
Increased risk of hypoxemia and acidemia
Manage
Prepare for delivery
Fetal scalp stimulation
Fetal scalp stimulation
Poke it with finder
If an acceleration of 15 bpm lasting 15 seconds occurs the fetal pH value almost always is 7.33 or greater
How fetal scalp stimulation show difference between fetal sleep from acidosis
When teal tracing shows reduced variability but no decelerations
Category III
How many minutes is standard of care to deliver this infant
Idk
Operative delivery with category II tracing
Get consent, get team, assess transit time and location for operative deliver, ensure IV access, review labs, assemble neonatal resuscitation personnel
Normal FHR good?
98% fetal wellbeing
Does electronic fetal monitoring result in reduction of cerebral palsy
False positive >99%
Abnormal patterns or non reassuring FHR can occur into e absence of fetal distress
False positive rate is 80%
Do most patient sithe nonreassuring FHR give birth to healthy infants
Yup
