Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Oral Boards > Labor > Flashcards

Labor Flashcards

1
Q

What are risks and benefits w/ TOLAC?

A

Benefits: avoiding abdominal surgery and risks of hyst/bowel/bladder injury, faster recovery, lower pain, lower risk of VTE, lower rates of hemorrhage
Risks: hemorrhage, uterine rupture, failed TOLAC requiring CS. Overall elective CS has fewer risks than failed TOLAC.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is SVD rate in women attempting TOLAC?
Who is NOT a good candidate for TOLAC?
What is the risk of uterine rupture?

A

60-80%

Contraindication (malpresentation, previa, prior classical/T-incision, prior uterine rupture, transfundal uterine surgery), prior SD.

1% risk after 1 CS. up to 3% if 2 CS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What TOLAC candidates are less likely to be successful?

A

Macrosomia, gestation >40wks, prior CS for arrest of labor disorder, undergoing IOL/augmentation, AMA, obesity, shorter inter delivery interval (<19 mo).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is the most common indicative sign of uterine rupture?

How do you manage subsequent pregnancy after uterine rupture?

A

FHR abnormality! Also Loss of fetal station, maternal pain out of proportion to exam, fetal bradycardia, vaginal bleeding.

Rate of repeat rupture is 15%.
Delivery timing between 36-37w.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

How do you manage low uOP after CS?

A

Read op report (complications, adhesions, suspected bladder injury), vitals. See if pt has pain.

What tests to order? CBC, CMP, UA, FENA (know specifics - if >2%, its ATN?), IVF bolus to evaluate for response. urine sodium and creatinine, CTAP.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is the differential diagnosis for low UOP after CS?

A

cystotomy, hypovolemia, ureteral injury, post-surgical bleeding, ATN, kinked foley.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

How do you repair a cystotomy?

A

Assess location of injury w/ respect to trigone.
Cystotomy in dome of bladder closed w/ continuous 3-0 synthetic absorbable suture through mucosa and submucosa in 2 layers. Then running 3-0 synthetic to close bladder musculature and serosa?? Then confirm integrity of repair: backfill sterile milk into foley catheter. Maintain foley x 7d.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

How do you workup ICP?
At what bile acid would you be concerned?

A

Bile acids, CBC, hepatic panel for LFTs.

BA>10 or LFTs >2ULN

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is the management of iCP?

A

Ursodiol 300mg TID, emollients (how long would it take to get relief?). Growth ultrasounds and APT. incr risk IUFD. if bile acids >100, delivery at 36wks. Otherwise delivery at btw 36-39wks. Can go up to 500mg twice daily.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

How do you manage a 4th degree perineal laceration?
How do you manage post-op care

A

a tear in both anal sphincter and rectal mucosa.
Counsel, explain, repair. Adequate exposure, Allis clamps. Extra set of gloves.

  • change gloves after rectal exam. start repairing rectal mucosa (running non-locking fashion 3-0 vicryl). identify internal anal sphincter using allis clamps and repair in end-to-end fashion with 0-vicryl. Then repair external anal sphincter in overlapping fashion again with 0-vicryl. Following this repair, repair the now 2nd degree laceration with 0-vicryl in continuous fashion.

Rectal exam afterwards to ensure adequancy of repair and that no sutures passed through rectal mucosa. Single dose of 2g cefazolin (Ancef) to prevent infection/breakdown.
- Bowel regimen, sitz baths, avoid constipation/straining, avoid narcotics, close office follow-up. Consider pelvic floor PT.

Complications: fistula, dyspareunia, wound breakdown, incontinence

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What are McDonald and Shirodkar cerclages

A

McDonald - non absorbable suture at the cervovaginal junction
Shirodkar: dissection of the vesico-cervico mucosa to place suture as close to internal os as possible.
- no difference in efficacy of PTB prevention. McDonald is easier to place.

Indications for cerclage:
- hx sPTB <34wks and CL <2.5cm
- painless cervical dilation in current pregnancy
- history of 1 second-trimester loss in absence of labor or abruption.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What are advantages and disadvantages of TAC?

A

advantage: cerclage placed at cervico-isthmic junction - greater structural support
- avoid foreign body in vagina to decr risk PROM/IAI

disadvantage:
- more complicated surgery than TVC
- requires abdominal surgery w/ bleeding risks. need for cesarean delivery

Procedure: retract uterine vessels laterally, create avascular spaces in broad ligament at level of internal os, place non absorbable 5mm suture through spaces and tie anteriorly or posteriorly.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What is shoulder dystocia

A

3-10% of all deliveries.
10% risk of recurrence. 10% have transient brachial plexus palsy and 1% have permanent palsy.
- steps: McRoberts, suprapubic pressure and delivery of posterior arm.
- head to body delivery interval of >7 min associated w/ incr risk permanent brain damage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What are risk factors for stillbirth?

A
  • black race
  • extremes of parity (nulls and >3 prior)
  • AMA
  • teens
  • obesity
  • T2DM
  • cHTN
  • other meds (SLE, renal disease, thyroid disease, ICP)
  • smoking/alcohol
  • IVF
  • APLS
  • postterm pregnancy
  • multiple gestation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What are causes of stillbirth and evaluation of stillbirth?

A

FGR
Abruption
Chromosomal and genetic abnormalities
Infection
Umbilical cord events (cord entrapment, prolapse, vasa previa)

  • Autopsy, gross/histologic exam of placenta, umbilical cord and membranes, genetic evaluation.
  • keep specimens in sterile tissue medium of LR (NOT formalin!)
  • Maternal: history for risk factors, exposures - meds/viral, RPL.
  • get KB test (Fetomaternal hemorrhage),

Tests:
KB, APLS (anticardiolipin, beta2glycoprotein, lupus anticoagulant, RPR, glucose screen, toxicology if suspected

  • if TOLAC/IOL: miso 400q6 if 24-28wks. IF <24wks, standard dose (400q3).
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

How do you manage a uterine inversion?

A

Stop pitocin.
- Give 0.25mg terbutaline subQ
- next nitroglycerin 50 mcg IV.
- Then nitrous oxide if anesthesia there.
- Also Mag (but takes longer to bolus/kick in).
If doesn’t work, to OR with general anesthesia for increased uterine relaxation. If doesn’t work, midline vertical incision.

17
Q

What are procedures performed in OR for uterine inversion?

A

Huntington: laparotomy by gradually pulling on the round ligaments to restore the uterus to its proper position.

Haultain: making a vertical incision in the posterior surface of the uterus to bisect the constriction ring in the myometrium, which is preventing reduction of the inversion. manually push up funds. avoid anterior incision bc can cause cystotomy.

Then once uterus returned, give uterotonics. And place Bakri in uterus to avoid uterine inversion again.

18
Q

What are risk factors for shoulder dystocia?
Describe maneuvers for SD management?

A

prior SD, T2DM/GDM, fetal macrosomia, maternal obesity

McRoberts, suprapubic pressure, deliver posterior shoulder.
Rotational:
- Rubin: one hand in the vagina along the posterior aspect of the anterior fetal shoulder and rotating the shoulder inward (adduction) about 30
- Woodscrew: fetal trunk is rotated at least 180° using pressure on the dorsal aspect of the posterior shoulder to help adduct the shoulders
- medio/lateral episiotomy
- break fetal clavicle

19
Q

What dermatomes are involved in labor pain?
What are treatment options for labor pain? Describe advantages and disadvantages of each.

A

S1-S2

Nitrous oxide, IV opioids, epidural anesthesia.

–IV opioids: short-acting and quick onset, not prolonged effect on fetus. Disadvantages can cause abnormal FHR and if given close to time of delivery, can cross the placenta and cause lower apgars in the fetus. Options: dilaudid.
Avoid meperidine: has a long half-life that affects newborn.

–Regional epidural: highly effective, long-acting continuous infusion. Safe. works for cesarean. Increased risk of epidural hematoma (contraindicated if blood thinner)j, confined to a bed, can have postdural puncture headache.
Epidural vs spinal: spinal is short duration, epidural can be redosed.
Inhaled Nitrous oxide: fast acting. Doesn’t last long. Requires patient to self-administer.

–Local anesthesia: to perform pudendal block

–General anesthesia: used in emergency. Unconscious, airway issues, neonatal effects, incr risk of hemorrhage 2/2 uterine relaxation.

  • nitrous oxide: avoid w/ systemic opioids bc can lead to maternal respiratory depression
20
Q

What are contraindications to regional anesthesia?

A

Therapeutic anticoagulation within the past 24hrs, spinal stenosis/spinal surgery, severe scoliosis. Icnr intracranial pressure from lesion, thrombocytopenia <70K

Does it incr risk C/S? No prolongs 2nd stage of labor by 10 minutes

21
Q

What are indications for Mag use:

A

neuroprotection for patients at risk of PTD <32w, PEC-SF, eclampsia

22
Q

What is the rate of VBAC w/ TOLAC?

A

60-80%

23
Q

What are the classes of uterine inversion?

A

1st degree: fundus in endometrial cavity
2nd degree: fundus protrudes through cervical os
3rd degree: uterine prolapse. fundus protrudes to introitus
4th degree: both uterus and vaginal are inverted

24
Q

What is a category 2 tracing?

A

falls in between category 1 and category 3 tracing. Describe cat 1 adn 3 well: bradycardia w/o baseline variability, variability, absent accels, recurrent lates w/ mod variability.

25
Q

What is the definition of early, variable, and late decelerations?

A

TBD

26
Q

What is the management of a category 2 tracing?

A

First look for moderate variability and accelerations. Are there significant decelerations with >50% of contractions lasting 1 hour. Resuscitative measures, cervical check, vitals, stop meds (pit, transition from miso), see toco to make sure not contracting too quickly. If remote from delivery, counsel on option for c-section. Consider IUPC to trace contractions/decide if late/variable decelerations.

27
Q

How long would you observe mod var, accels but variable decelerations for >50% contractions for 1 hour.

A

Continue to watch, try amnioinfusion, discuss CS.

If no mod var and no accels and + significant variable decelerations? Give 30 min then CS. If less than 30 min, continue to observe for 1hr.

28
Q

Discuss different perineal lacerations that can occur.

A

1st degree: involves perineal skin
2nd degree: involves muscle (bulbocavernosis, transverse perinea)
3rd degree: involves external anal sphincter
3A: <50% of EAS
3B: >50 of EAS
3C: involves IAS
4th degree: involves rectal mucosa

29
Q

What increases risk of OASIS injury?
Discuss the different types of episiotomies and pros/cons of each

A

Operative vaginal delivery (forceps), prior OASIS tear, prolonged second stage, midline episiotomy, DM. AMA.
20% have wound breakdown

Midline: ??
Medio-lateral: decreases risk of OASIS.

How would you counsel them on future mode of delivery?
If anal incontinence, need for repeat laceration repair, pt w/ psychological trauma, can offer cesarean delivery. Risk of recurrence 3-5%.

30
Q

What is the incidence of impacted fetal head during CS after prolonged pushing?

What are risks associated?
what are risk factors?

A

1.5% or 25% emergent CS

Neonatal morbidity (hypoxic event, trauma), uterine or cervical extensions, incr PPH, bladder injury

Risk factors: fetal macrosomia, prolonged second stage, occiput posterior/transverse.

How would you manage?
FYI nursing, anesthesia, NICU. Higher hysterotomy, Vaginal hand. Consider J/T extension.

31
Q

What is associated with increased and decreased ECV success?

What are risks of ECV?

A

success rate 60%

Increased success: multiparty, transverse or oblique fetal lie

Decreased success: nulliparity, advanced dilation, EFW <2500g, anterior placenta, low station.

risks: abruption, prolapse, ROM, stillbirth, maternalfeto hemorrhage (<1% for all). given Rhogam within 72hr ECV for Rh neg.

32
Q

What is dosing for latency antibiotics?

A

IV ampicillin 2g q8 + IV erythromycin 250mg q6 x 48hr –> oral amoxicillin 250mg q8 + erytomycin 333mg q8.

33
Q

What is the management of PPROM if pt has primary active HSV?

A

expectant management reasonable but increased risk of vertical transmission.
- can offer CS even if lesions not present 2/2 prolonged viral shedding.

  • if recurrent HSV: expectant management if <34w, if >34w, delivery via CS.
34
Q

In what clinical situations would you recommend a general anesthesia?

Causes of sinusoidal pattern?

A

Emergent CS (cord prolapse w/ no anesthesia, acute placental abruption, cat 3 tracing, fetal bradycardia, contraindication to spinal anesthesia)
— Intrauterine resuscitation for cat 2 tracing, position changes, oxygen. Delivery

Fetal anemia or hypoxia. can be 2/2 bleeding vasa previa, chorioangioma, Rh isoimmunization

35
Q

What is a category 3 tracing?

A

Absent variability with any: recurrent late, recurrent variables, bradycardia, sinusoidal pattern.

Oral Boards (38 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions