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Labor and Delivery > Labor and Delivery > Flashcards

Labor and Delivery Flashcards

1
Q

What is tachysystole?

A

Tachysystole - More than 5 contractions in 10 minutes, averaged over 30 minutes

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2
Q

What did the ARRIVE trial say in induction of labor re: timing of IOL?

A

Looked at women IOL at 39 vs 40 weeks, found that it did not reduce perinatal morbidity but DID reduce c-sections

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3
Q

What is an accel? Before 32 weeks, and after?

A

> 15 bpm for 15 sec, > 32 weeks

>10bpm for 10 sec , < 32 weeks

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4
Q

What counts as recurrent decels?

A

50% of contractions in 20 minute segment

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5
Q

What counts as a prolonged decel?

A

> 2 min

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6
Q

What is a cat I tracing?

A

moderate variability, accels present (or absent), and only early decels if any, NO lates/variables

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7
Q

What is a cat III tracing?

A

absent FHR variability and any of the following: recurrent late, recurrent variable, bradycardia, sinuosoidal pattern

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8
Q

What is a cat II tracing?

A

1) any tachy/brady in FHR baseline
2) minimal variability, absent variability w/o recurrent decels, marked baseline variability
3) absence of induced accels after fetal stim
4) Periodic or episodic decels; Recurrent variable decels; Prolonged decels > 2 min, < 10 min

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9
Q

How do we define arrest of second stage of labor?

A

W/o epidural: 3 hours for multips, 4 hours for nullips; w/ epidural - 2 hours for multips, 3 hours for nullips

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10
Q

How do we define arrest of first stage of labor?

A
  • No cervical change for atleast 4 hours of adequate contractions
  • OR no cervical change for 6 hours of inadequate contractions
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11
Q

What counts as a failed induction?

A
  • Failure to generate regular contractions q3hmin 24 hours after oxytocin with ROM
  • Atleast 12-18 hours of pitocin after ROM
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12
Q

What is the platelet threshold for epidurals/spinals typically?

A

epidurals/spinals can be considered same if platelets are 70K or above, as long as platelets are stable.

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13
Q

What is the difference between epidrual and spinal?

A

spinal - single dose, useful for c-sections, time-limited; epidurals can be redosed, useful for labor

Spinal - single-injection of an opioid, local anesthetic, or both into the subarachnoid space; usually used for cesarean delivery and not for labor because it usually has a limited time frame.

Epidural - placement of a catheter into the epidural space; can have repeat or continuous administration of medication; usually a mixture of an opioid with a local anesthetic.

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14
Q

If using anticoagulation, what do you need to think about re: epidural/spinal?

A

Timing of catheter placement and removal.
For Lovenox - for prophylactic dosing, stop it 12 hours before, resume 12 hours after; for therapeutic dosing, becomes 24 hours before, 4 hours after

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15
Q

What is the max dose of pitocin?

A

36 units. Starts at 1-2 units, can increase every by 1-2 u every 30 minutes.

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16
Q

How is placenta previa defined?

A

Defined as edge of placenta <10 mm from internal cervical os

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17
Q

What is the main presentation of placenta previa? Painful or painless bleeding?

A

Painless vaginal bleeding can occur up to 90% of persistent cases
10-20% of women present with uterine contractions, pain, and bleeding

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18
Q

What is SERIOUS/CANT MISS differential for 2nd/3rd trimester bleeding after 20 weeks?

A

placenta prevIa, vasa previa, placenta accreta, placental abruption, uterine rupture.

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19
Q

What is a cause of painful bleeding in 2nd/3rd trimester?

A

placental abription, uterine rupture, some times previa will also have pain

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20
Q

What is vasa previa?

A

when fetal vessels run within the membranes over the internal os of the cervix

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21
Q

What are LESS SERIOUS causes of 2nd/3rd trimester bleeding?

A 
• Labor - “bloody show” with labor
• Cervicitis 
• Can be caused by infection (ie. BV, candida infection, trichomonas, chlamydia, gonorrhea) 
• Cervical polyp 
- Vaginal laceration
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22
Q

What are initial management steps for vaginal bleeding in 2nd/3rd trimester?

A
  • Vital signs
  • Two large bore IVs
  • Resuscitation - fluids vs. blood products
  • If there is less bleeding and you think you have more time:
  • Blood type and Rh status - administer Rhogam if it is indicated
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23
Q

Management of placenta previa?

A

Monitoring (Certain locations may have a “threshold” for prolonged admission - ie. three strikes = three bleeds and admission for the rest of pregnancy )

If otherwise stable, can usually be delivered between 36w0d - 37w6d via c-section

Usually can have vaginal delivery if >2 cm from os, but some institutions may discuss if >1 cm

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24
Q

What about management of placenta accreta?

A

If stable, recommend delivery between 34w0d-35w6d, and usually this will be done at tertiary care center with multi-disciplinary team

25
Q

Management of vasa previa?

A

lower threshold to admit/deliver due to risk of fetal hemorrhage

• There is usually a lower threshold for bleeding and contraction in vasa previa because the bleeding could come from the fetus 
• While an adult human has 5-6L of blood, a fetus has much less. A term fetus+placenta can have up to 500mL of blood (baby may have 250-300cc). Usually describe to patients in measurements of a soda can (355 mL). 
• For this reason, many places will hospitalize vasa previa between 28-34w0d and monitor  Recommend delivery between 34w0d-37w0d pending stability of mom and baby
26
Q

What is involved in the exam for late pregnancy bleeding?

A

• Start with a speculum exam - if passing tissue, that should be sent to pathology
• Look for vaginal laceration, neoplasms, discharge, evidence of cervicitis, cervical polyps, fibroids, ectropion
• Send testing for cervicitis and vaginitis (ie. wet mount, as well as chlamydia/gonorrhea)
Do not do a digital cervical exam without confirming where the placenta is located!

27
Q

What are antibiotics for post-partum IAI/endometritis? First two common meds, and then a third with GBS pos.

A

clindamycin and gentamicin, with the addition of ampicillin (“triple therapy”) for GBS-positive patients

28
Q

What are the criteria for diagnosing IAI?

A

maternal fever PLUS one of maternal leukocytosis, fetal tachycardia, or purulent or malodorous amniotic fluid.

29
Q

What is the abx regimen for IAI if mild PCN allergy?

A

cefazolin and gentamicin

30
Q

What is the abx regimen for IAI if severe PCN allergy?

A

vanc or clinda AND gentamicin

31
Q

When can operative vag deliveries indicated?

A
  1. Prolonged second stage of labor.
  2. Suspicion of immediate or potential fetal compromise.
    Shortening of second stage of labor for maternal benefit (ie. maternal exhaustion or maternal cardiac issues that may make it difficult for them to Valsalva for an extended amount of time).
32
Q

What are some prequisities for operative vaginal delivery?

A
  1. Cervix is fully dilated and membranes are ruptured.
  2. Engagement of the fetal head.
  3. Position of fetal head is known (either by exam or by ultrasound).
  4. EFW has been performed and assessment that the pelvis is adequate for vaginal birth (don’t want to pull into a shoulder!).
  5. Adequate anesthesia.
  6. Maternal bladder has been emptied.
  7. Patient has agreed after being informed of risks and benefits of procedure.
    Willingness to abandon the attempt, with back-up place (ie. cesarean) in case of failure to deliver.
33
Q

What are some pros of FORCEPS delivery?

A

less cephalohematoma

34
Q

What are some pros of VACUUM delivery?

A

less 3rd and 4th degree lacerations

35
Q

What is malposition vs malpresentation?

A

malposition - fetus is in vertex position, but the position of the fetal head is not optimal for delivery (i.e., rotated away from an occiput anterior, or OA, position in the pelvis)
malpresentation - fetal presenting part is not head

36
Q

Which presentations are NOT optimal for vaginal delivery? name 3.

A

Breech
Shoulder
Mentum Posterior

37
Q

How do you define preterm labor?

A

regular uterine contraction with cervical change prior to 37 weeks, but after 20 weeks
- > 3cm dilation, > 80% effacement

38
Q

How do you define PPROM?

A

preterm premature rupture of membranes

  • ROM prior to painful contractions
  • prior to 37 weeks but after 20 weeks
39
Q

How is FFN used to rule out pre-term labor?

A

FFN can be used for its NEGATIVE predictive value — positive predictive value is not great on its own

40
Q

What is given for neuroprotection, and when, in preterm labor?

A

MgS between 24-32 weeks

41
Q

What is the evidence for use of tocolytics?

A

Use to get to steroid complete. Tocolytics - not really great evidence. Use indomethacin before 32 weeks, nifedipine afterwards. Used to get to beta complete! Don’t give if mom or baby sick.

42
Q

What are the three main medical interventions we consider for preterm labor?

A

1) MgS - 24 to 32 weeks
2) Steroids
3) Antibiotics for GBS unknown

43
Q

How and when are steroids administered for preterm labor?

A

between 24- 34 weeks, IM betamethasone q24hrs x2 (or 6mg IM dexamethasone q12hrs x4)

Also antenatal late preterm steroids at 34-36w6d

44
Q

Why are steroids indicated for preterm labor?

A

for fetal lung maturity

45
Q

When should you deliver patients with PPROM?

A

at 34 weeks, though there is controversy – many associations are pushing towards expectant mgmt until 36w6d

46
Q

How are abx used for PPROM?

A

As latency abx to tx potential underlying infection leading to PPROM

for first 48 hours: IV ampiciliin 2gm for erythromycin for 48 hours
then for 5 days - amoxicillin + erythromycin
azitho can be substituted for erythromycin

47
Q

When to do FFN?

A

suspect preterm labor between 24-34 weeks

48
Q

How to diagnosis PPROM?

A

ferning / nitrazine pH paper / pooling on speculum exam

49
Q

When should late preterm steroids be given? and held?

A

34w-36w6d

Held if - received prior 2 doses of steroids; in setting of diabetes or chorio

50
Q

When should rescue steroids be given? Three criteria

A

If continued risk of preterm delivery within one week, and before 33 weeks, with prior dose given > 7-14 days prior

51
Q

What are the three main factors that lead to labor dystocia in the second stage?

A

power - pelvis (CPD - cephalopelvic disproportion) - passenger (too big or malposition)

52
Q

What is the most common malPOSITION that leads to labor dystocia?

A

OP - occiput posterior

53
Q

When should arrest of labor NOT be diagnosed in a patient?

A

In the latent stage of labor. Can last > 20 hours for nulliparous patients and > 14 hours for multips

54
Q

When can an arrest of labor diagnosis be made in the ACTIVE stage of labor?

A

in the ACTIVE stage > 6m. Can be made if ROM, plus EITHER - 4 hours w/o cervical change w/ adequate contractions or 6 hours w/o cervical change with INadequate contractions

55
Q

In the ACTIVE first stage of labor, what interventions work to reduce dystocias? Name 3.

A

1) Combination of pitocin and AROM - modest reduction in c-section and shortened labor (Not AROM alone)
2) IVF - 250 cc/hr vs 125 cc/hr
3) Walking and upright position - rather than supine positioning

56
Q

What is the evidence for high dose pitocin infusion vs low-dose?

A

High dose is > 6units — did not decrease time to delivery or reduction in c-section delivery rate compared to low dose pitocin regimen

57
Q

What are the chances for spontaneous vaginal delivery if in 2nd stage for more than 3 hours? What are the risks?

A

1 in 4 nulliparous patients deliver; risks: PPH, lacerations, chorioaminoitis

58
Q

What approaches can help with addressing arrest of 2nd stage?

A

w/o epidural - upright position can help; delayed maternal pushing - laboring down. W/ epidural - no position associated with good outcomes, immediate pushing leads to shorter 2nd stage and less complications

59
Q

What are measures shown to prevent dystocias?

A

avoid admission in latent labor, increase one to one labor support, use cervical ripening agents if Bishops < 6, allow for sufficient time and intervention before performing cesarean delivery for failed induction

Labor and Delivery (4 decks)

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