Labor Flashcards
What order should misoprostol and oxytocyin be done with unfavorable cervix?
Misoprostol first, then oxytocin
What are negative factors for successful TOLAC (trial of labor after cesarian delivery)?
Advanced maternal age, advanced gestational age, high BMI, high birth weight, shorter interval <19 mo between pregnancies
What timeframe indicates prolonged latent phase of labor?
Nulliparous: >20 h
Multiparas: >14 h
Treat with rest or augmentation of labor
Do NOT AROM due to increased risk of infection
What should be done for patient with secondary arrest of dilation (no further cervical change in active phase >4 h)
Amniotomy, followed by oxytocin after further evaluation
If patient is completely dilated and has been pushing, what are indications for cesarian delivery?
Macrosomia, fetopelvic disproportion
Which mentum position indicates C/S?
Persistent mentum posterior (head extended, facing posteriorly)
What is indicated by head emerging, then retracting (turtle sign)?
Shoulder dystocia - try McRoberts position (flexing legs up against hips and abducting hips to raise pubic symphysis)
What timeframe is previable birth?
20-26 weeks - you would want a NICU
What should you give if Group B Strep status is unknown and preterm labor has started?
Ampicillin, until culture result is negative or labor stops
What antibiotics should be given iso PPROM?
Ampicillin + erythromycin at <34 wga: delays latency period by 5-7 days while also reducing incidence of maternal chorioamnitis and neonatal sepsis
What antibiotics are indicated if chorioamnionitis is suspected?
Clindamycin and gentamicin
Is C-section indicated iso chorioamnionitis?
No - delivery is warranted through induction of labor
Which tocolytics are contraindicated for whom?
Mg sulfate contraindicated in myasthenia gravis
Indomethacin contraindicated at 33 weeks due to premature ductus arteriosus closure through inhibition of prostaglandin E2 synthesis
Ritodrine contraindicated in diabetic patients
What should be offered to singleton gestation with prior spontaneous preterm birth to reduce risk?
Progesterone supplementation starting at 16-24 wga
What are benefits of betamethasone treatment from 24-34 wga who are at risk of preterm delivery in 7 days?
Increase pulmonary maturity
Decrease incidence/severity of respiratory distress syndrome
Decrease incidence of intracerebral hemorrhage
Decrease incidence of necrotizing enterocolitis
What is benefit of fetal fibronectin test?
Used in women with symptoms of preterm labor from 24-35 wga and during routine screening from 22-30 wga
It has a NPV 99.2%, so negative test means patient will not deliver in next 7 days
Risk factors for placental abruption
Polyhydramnios –> rapid decompression of intrauterine cavity
Risk factors for morbidly adherent placenta (e.g. placenta accreta)
Multiple prior C/S, preventing proper implantation
Low anterior placenta
What is vasa previa?
When unprotected umbilical cord runs over the cervix due to insertion into the membranes
What test is the antibody screen?
Indirect Coombs test
What is indicated by abrupt onset of bleeding upon amniotomy along with fetal taachycardia, decels, and bradycardia?
Vasa previa
Also risk of bleeding during normal active labor
What risks does smoking increase for pregnancy?
Placental abruption
Placental previa
Fetal growth restriction
Infection
Why can cervicitis cause bleeding during pregnancy?
STIs result in inflammation in a more vascular cervix, resulting in bleeding
Variable decels are associated with cord compression, which is associated with what amniotic fluid status?
Oligohydramnios
When is tocolysis indicated in PPROM?
Prolong delivery long enough (48h) for steroids to obtain max benefit for fetal lung maturity
What increases risk of fetal asphyxia?
Placental abruption
Difficult breech delivery
Maternal sedation
PPROM before 24 wga results in what to the fetus?
Pulmonary hypoplasia; survival with PPROM between 20-23 wga is 25%
Deformation type structural abnormalities may be found
What medication reduces risk of premature labor from all causes, including PPROM?
17 alpha-hydroxyprogesterone - administer weekly starting at16-20 wga and until 36 wga
When is Mg sulfate given for PPROM?
<32 wga, for neuroprotection
When are steroids given for PPROM?
Between 24-34 wga
What can cause false positive nitrazine test?
Nitrazine test is based off amniotic fluid pH 7.1-7.3 > vaginal secretion pH of 4.5-6.0 - this can be thrown off by semen or blood
Use ferning and amniotic fluid index to confirm
In whom are prostaglandins contraindicated?
Previous C/S - increased risk of uterine rupture
How does maternal narcotic analgesia affect fetal heart rate tracing?
Decreased variability
Amnioinfusion may be used for ________ type of decelerations?
Repetitive variable decelerations, NOT recurrent late decelerations
What is fetal tachycardia associated with?
Maternal fever; chorioamnionitis
What are initial measures for fetal hypoperfusion presenting with late decelerations, before deciding to do C/S?
Intrauterine resuscitation:
Left lateral positioning (increases perfusion to uterus)
Supplemental O2
Treat hypotension
Discontinue oxytocin
Tocolytics
IV fluids
In preterm labor, what medications are given at what time points?
<32 weeks: Magnesium sulfate for fetal neuroprotection and indomethacin for tocolysis (not >32 wks due to premature closure of ductus arteriosus)
<37 weeks: Betamethasone to prevent neonatal respiratory distress syndrome
For patients without prior spontaneous preterm birth, what should be done in 2nd trimester? What if they did?
Without: transvaginal US for cervical length; vaginal progesterone if <=2.5 cm at <24 weeks
With: If they had painful contractions, then IM/vaginal progesterone; if not, it was cervical insufficiency and cerclage should be performed
Uterine tachysystole is managed how?
Lateral positioning; tocolysis; stopping oxytocin
What order of antibiotics are used for GBS?
Penicillin or ampicillin (if allergic, then cefazolin)
Clindamycin (preferred over erythromycin)
Vancomycin - doesn’t reach amniotic fluid bactericidal concentration as rapidly so still need to watch baby
Epidural insertion into vasculature causes what?
CNS hyperactivity from inhibition of inhibitory neurons:
Perioral numbness, metallic taste, tinnitus
Seizure
Sympathetic activation (HTN, tachycardia) leading to cardiovascular collapse
Treat seizure with benzo
Common causes of labor protraction
- Cephalipelvic disproportion
- Inadequate contractions
- Maternal obesity
- Fetal malposition (e.g. occiput posterior)
