L&D Flashcards
1
Q
Expected Timing for ea Phase Labor
A
- Latent Phase -
- 18 to 20 hrs if nulliparous
- < 14 hr if multiprous
- Active Phase -
- > 1.2 cm / hr if nulliparous
- > 1.5 cm / hr if multiparous
- Protraction of active phase if < expected rates of dilation
- Arrest of active phase if no changes in cervical dilation in 2 hrs
- Phase 2 -
- < 2 hr if nulliparous (w/o epidural) and < 3 hr if nulliparous (w/ epidural)
- <1 hr if nulliparous (w/o epidural) and < 2 hr if nulliparous (w/ epidural)
- Phase 3 - <30 min for all
2
Q
3 P’s of Labor Eval
A
- Power - contraction strength
- Contractions are considered adequate if every 2-3 minutes, uterus is firm on palpation and last 40-60 seconds
- Can use internal uterine catheter to measure pressures
- 10 min window; add up the Montevideo units above baseline; adequate if > 200
- Can give oxytocin
- Passenger - fetus (assess fetal heart rate tracings)
- Pelvis - may consider C section if pelvis too small for fetus
3
Q
What do you do if there is arrest of active phase?
A
- AKA 2 hrs no change - assess 3 p’s
- If powers are adequate … C section
- If powers are no adequate … oxytocin then re-assess
4
Q
4 Signs of Placental Separation
A
- 1- cord lengthening
- 2- gush of blood
- 3- globular and firm uterine shape
- 4- uterus rises to anterior abdominal wall
5
Q
Risk Factors for Uterine Inversion
A
- Implanted at fundus
- Multiparous
- Placenta accreta
6
Q
Placenta Accreta (definition, risks, Dx, tx)
A
- Accreta - villi at myometrium
- Increta - into myometrium
- Percreta - thru myometrium and serosa; may adhere to bladder
- Risk Factors - placenta previa, C sections (esp if mult C sections w/ previa), DS, >35 yo, low laying placenta, prior uterine curettage or other surgery
- Clinical Dx by inability to separate placenta; no plane when use hand; histo diagnosis by abnormal decidua basalis
- Tx - hysterectomy to reduce risk of maternal hemorrhage; may try to salvage if wants more kids
7
Q
5 Shoulder Dystocia Maneuvers
A
- McRoberts Manuever - hyperflex moms thighs to abdomen
- Supra-pubic pressure to push shoulder to oblique position
- Wood’s corkscrew - rotate posterior shoulder 180 degrees
- Deliver posterior arm first
- Zavanelli Maneuver - cephalon replacement –> C section
8
Q
Work Up for Fetal Bradycardia
A
- 1- confirm HR with fetal scalp electrode or US (distinguish from maternal)
- 2- Vag exam - check for cord prolapse (if so … keep hand in and elevate cord so no compression and go to C section)
- 3- Improve oxygenation and perfusion of placenta - 100% oxygen face mask, IV fluids, turn mom on side so less vena cava compression, stop oxytocin (may cause hyperstimulation so vasoconstriction)
- 4- If caused by maternal epidural give fluids and ephedrine if needed
9
Q
Cord Prolapse (including risks)
A
- umbilical cord before baby thru cervical os
- Risks - artificial ROM when head no engaged, footling breech or transverse fetal position (head not filling pelvis to prevent cord prolapse)
10
Q
Tx of Uterine Atony
A
- Uterine massage - bi-manual
- IV dilute oxytocin
- If cont to bleed then rectal miso, IM prostaglandin F2 (unless asthma), IM ergot akyloid (methylergonovine - unless maternal HTN)
- If cont … 2 IVs, foley, send for blood unit, intrauterine balloon, embolization
- If cont… lap (stitches, ligament vessels, hysterectomy)
11
Q
2 Poss Causes of Late Postpartum Hemorrhage
A
- Sub-involution of placental site (eschar falls off then no myometrial tone); oral ergot and careful f/u
- Retained POC (foul lochia, fever, cramps) - confirm w/ US and curettage w/ broad abx
12
Q
Monozygotic Twins by Time of Division
A
- 72 hrs - di/di
- 4 to 8 days - monochorionic / diamniotic (thin membrane between two)
- 8 to 12 days - monochorionic / monoamniotic (risk entangled cords)
- > 12 days - conjoined
13
Q
Dx of Pre-term Labor
A
- dilation of 2 cm and 80% effacement in nulliparous woman
- Can also perform fetal fibronectin swab - BM protein that connects placenta to decidua; if neg then 99% chance no delivery in 1 wk
14
Q
Work Up for Preterm Labor
A
- Look for reason - CBC, drug screen, UA, Chlamydia and gonorrhea tests (gonorrhea more common)
- Vag exam to look for ROM
- Serial cervical exams
- US - fetal wt and presentation
- Vaginal swab for GBS status
- Meas cervix length w/ transvaginal US - < 25 mm, funneling or beaking inc risk
15
Q
What drugs are used to manage pre-term labor? (Include side effects)
A
- < 34-35 wks use tocolytics (nifedipine, indomethacin, terbutaline/ritordine)
- Nifedipine - pulmonary edema (dyspnea - give furosemide)
- Indomethacin - close ductus arteriosus - fetal pulmonary HTN; also dec amniotic fluid - cord compression w/ variable decelerations
- Beta agonists (terbutaline/ritordine) - pulmonary edema, inc pulse pressure, tachycardia, hyperglycemia, hypokalemia (arrhythmia)
- Single IM dose steroids if 24-34 wks to prevent resp distress or prevent interventricular hemorrhage if really young (betamethasone or dexamethasone)
- Mg if < 32 wks; may reduce neuro/cerebral palsy problems
