Labor and Delivery Flashcards
The following are contraindications to labor induction except? A. Twin gestation B. Fetal growth restriction C. Breech presentation D. Prior classical cesarean delivery
B. Fetal growth restriction
A 25-yo G1P0 at 39 weeks AOG in active labor has an internal examination of 4cm, fully effaced cervix, with fetal head at station 0. Membranes still intact. After 2 hours, cervix is still 4 cm dilated. Which of the following is the best management?
A. Cesarean delivery
B. Rupture of membranes
C. Insertion of bladder catheter to assist fetal head descent
D. Rupture of membranes and oxytocin augmentation
B. Rupture of membranes
The risk for cesarean delivery is increased in women undergoing induction of labor in which of the following situations? A. Low bishop score B. Engaged fetal head C. Multiparous parturient D. All of the above
A. Low bishop score
Criteria for Diagnosis of Labor
* Uterine contractions — 1 in 10 mins or 4 in 20 mins — at least 200 MVU * Documented progressive changes in cervical dilatation and effacement * cervical effacement of >70-80% * cervical dilatation of > 3 cm
This is an intervention designed to artificially initiate uterine contractions leading to progressive dilatation and effacement of the cervix to effect delivery.
Labor Induction
What are the components of Bishop Score
Cervix
- Position
- consistency
- effacement
- dilatation
- station
What are Bishop score modifiers which increase the score by 1 more point?
Preeclampsia
Each previous vaginal birth
What are Bishop score modifiers which decrease the score by 1 less point?
Postdate pregnancy
Nulliparity
No previous vaginal delivery
PPROM
Indications for induction of labor (9)
Gestational HPN preeclampsia, eclampsia PROM Maternal medical conditions Gestation > 41 1/7 wks Fetal compromise (e.g FGR) Intraamniotic infection Fetal demise Logistic factors — history of rapid labor — proximity from hospital — psychosocial
Quantifiable score to predict labor induction outcomes
Bishop score
Upon assessment, a 24 yo, G2P1, 36 wks AOG had cervix at midposition, firm, uneffaced, 1-2 cm dilated with fetus unengaged. Previously delivered via NSVD. What is the bishop score?
Bishop score of 3
Midposition - 1
1-2 cm - 1
Previous vaginal birth - 1
Upon assessment, a pregnant woman had cervix at midposition, soft, 80%, 2 cm dilated with fetus occiput at -1. What is the bishop score?
Bishop score: 9 Midposition - 1 Soft - 2 2cm - 1 80% - 3 Station -1 - 2 Interpretation - successful labor induction
Bishop Points for cervix at anterior?
2
Bishop Points for cervix at posterior?
0
Bishop Points for cervix 5 cm?
3
Bishop Points for cervix at 1 cm?
1
Bishop Points for cervix closed?
0
Bishop Points for cervix soft?
2
Bishop Points for cervix firm?
0
Bishop Points for cervix 30-50%?
1
Bishop Points for cervix at 60-70%?
2
Bishop Points for station -3?
0
Bishop Points for station +1, +2
3
Bishop Points for station -2?
1
Bishop Score of 5 or higher
Unfavorable induction
Bishop score indicating favorable response for successful induction
9 or higher
Contraindications for induction of labor
Malpresentation Absolute CPD placenta previa Previous Major uterine surgery — classical cs — myomectomy Invasive carcinoma of cervix Cord presentation Active genital herpes Any condition that precludes vaginal birth Physicians convenience
This method of labor induction allows increase in local prostaglandins
Membrane stripping
What are three methods of labor induction?
Membrane stripping
Oxytocin
Amniotomy
What are the signs of uterine hyperstimulation in response to oxytocin
5 contractions in 10 minutes, OR
>10 contractions in 20 minutes
Hypertonus — lasting >120 secs
Excessive uterine activity with abnormal FHT
When to do amniotomy, early? Late?
Early amniotomy - 1 to 2 cm
Late amniotomy - 5 cm
Complications of amniotomy
Chorioamnionitis
Cord prolapse
FHR decelerations
Bleeding from fetal or placental vessels
G2P1 (1001) 39 wks with bloody show. On IE, anterior fontanel is palpated at 2 oclock position, the fetal head is in which position? A. LOA B. LOP C. ROA D. ROP
D. Right occiput posterior
Relationship of the long axis of the fetus to that of the mother
Fetal lie
Presenting part foremost in the birth canal or in closest proximity to it
Fetal presentation
Relationship of an arbitrarily chosen part of the right or left side of the maternal birth canal
Fetal position
When the anterior fontanel is the presenting part, which term is used?
Sinciput
What is the direct cause of most maternal deaths involving regional anesthesia? A. Drug reaction B. Cardiac arrhytmia C. High spinal blockade D. CNS infection
C. High spinal blockade
What is the direct cause of most maternal deaths involving regional anesthesia? A. Drug reaction B. Cardiac arrhytmia C. Intubation failure D. CNS infection
C. Intubation failure
This anesthetic agent is unique since it develops both CNS and CV toxicity at identical serum levels
Bupivacaine
Which is the most common complication encountered during epidural anesthesia? A. Fever B. Hypotension C. Postdural puncture headache D. Inadequate pain relief
Hypotension
The period of time between 4 and 6 weeks post delivery wherein there is return to nonpregnant state
Puerperium
Concentration of which vitamins are reduced or absent from mature breast milk? A. A B. K C. D D. B and C E. None of the above
C. Vitamin K and D
Lochia in series
Rubra, serosa, alba
The following are causes of uterine subinvolution except?
A. Retention of placental fragments
B. Postpartum metritis: C. trachomatis
C. Aberrant interaction between uterine cells and trophoblast
D. None of the above
E. All of the above
D. None
Injectable progestins, such as DMPA prevents pregnancy by which of the following mechanisms?
A. Scant cervical mucus that hinders sperm motility
B. Decreased sperm and egg viability
C. Inhibition of ovulation
D. Suppression of hypothalamic gonadotrophin releasing factors
C.
A. Scant cervical mucus that hinders sperm motility, — LNG-IUS — + endometrial inflammation B. Decreased sperm and egg viability — copper IUD — + endometrial inflammation C. Inhibition of ovulation — DMPA — + increased cervical mucus viscosity D. Suppression of hypothalamic gonadotrophin releasing factors — OCPs — dec FSH (progestin), dec LH (estrogen)
Etonorgestrel implants provide contraception for how many years? A. 3 B. 5 C. 8 D. 10
A. 3 years and then replaced at the same site or in then opposite arm, ideally on DAY 5 of menses
A 28 year old G2P1 38 weeks came to the clinic with IE 4 cm, 60%, intact bag of water. Contractions occur at 4 to 5 minute intervals, moderate, what is the next best step? A. Observe for 1 more hour B. Amniotomy and oxytocin C. Stat CS D. O2 and hydration
B. Amniotomy
A 26 year old G1P0 38 weeks with IE 8 cm, 80%, station -1, leaking bag of water for 3 hours. Contractions occur at 5 to 8 minute intervals, moderate, what is the diagnosis? A. Arrest of descent B. Arrest of cervical dilatation C. Prolonged deceleration D. Orolonged latent phase
C. Prolonged deceleration
A 26 year old G1P0 38 weeks with IE 8 cm, 80%, station -1, leaking bag of water for 3 hours. Contractions occur at 5 to 8 minute intervals, moderate, what is the next best step? A. Observe for 1 more hour B. Start oxytocin drip C. Stat CS D. O2 and hydration
B. Oxytocin
If no CPD
CS only if with CPD
At least how many hours should lapse before CS can be done in a patient with protracted active phase?
At least 4 hours.
Review abnormal labor
Okay!
The definition of adequate labor include all of the following except?
A. At least 4 cm with (-) BOW
B. over 4 hours with adequate contraction
C. Over 6 hours of inadequate contractions and no cervical change
D. None of the above
A. At least 4 cm with (-) BOW
At least 6 cm with (-) BOW
With over 4 hours with adequate contraction
OR Over 6 hours of inadequate contractions and no cervical change
Which of the following is the initial step in Zavanelli maneuver?
A. Perform laparotomy
B. Flex the head and push it back in the vaginsl
C. Administer terbutaline to relax uterus
D. Restore the fetal head in an occiput anterior or posterior positon
Steps for zavanelli Return the head in OA or OP Give acute tocolysis Flex the head and push it back slowly into vagina Cesarean section
Lifting the maternal legs
McRoberts maneuver
Suprapubic pressure over posterior aspect of the anterior shoulder(abdominal)
Mazzanti maneuver
2 fingers to push the posterior aspect of the anterior shoulder toward chest
Rubin maneuver (vaginal)
2 fingers on the anterior aspect of the posterior shoulder to rotate obliquely
Woods corkscrew
Mother in all fours, grasp oostefor arm, sweep against chest and deliver
Gaskin maneuver
Name the 5 biochemical markers for preterm labor
- Fetal fibronectin
- Salivary estriol
- Insulin like factor binding protein
- Placental a-macroglobulin-1
- Matrix metalloproteinase-9
Which of the following conditions is one of the most common causes of indicated preterm birth? A. Gestational diabetes B. Placental previa C. Fetal growth restriction D. Breech presentation
B. Placenta previa
Caitlyn, a 34 yo G1P0 consulted because of hypogastric pain. EFM revealed a reactive FHT with mild to mod contractions every 5 minutes, internal examination revealed a closed cervix. She was given indomethacin as a tocolytic. Which of the following could be an adverse effect of this agent?
A. Polyhydramnios
B. Macrosomia
C. Premature closure of ductus arteriosus
D. Persistent patent ductus venosus
C.
Oligohydramnios
Enterocolitis, IVH, Renal failure
Premature closure of ductus arteriosus
Persistent patent ductus arteriosus
Caitlyn is currently using a 28 day pill pack containing 7 non hormonal pills. On the 3rd week, she missed 4 pills because she left it at home during vacation. How will you advise her regarding this situation?
Discard missed pills. Take remaining hormonal Discard non hormonal Start new pack Back up contraception
A 34 yo is undergoing oxytocin induction of labor, her cervix is 6-7 cm dilated, fetus is ceohalic. She has been having 6 contractions per 10 mins in the last 45 mins. What is the term?
Tachysystole
Over 5 contractions in a 10-minute window
Compared with the uterine body, the cervix has significantly lower percentage of which of the following? A. Collagen B. Proteoglycan C. Smooth muscle D. Glycosaminoglycan
C. Smooth muscle
Diagonal conjugate of less than 11.5 cm
Contracted pelvic inlet
Bisacroacromial diameter of <8 cm
Contracted midpelvis
BSD <8 cm
Suspicious contracted midpelvis
BTD 8 or less
Contracted pelvic outlet
Stimulation of contraction before spontaneous onset of labor
Induction of labor
Rhe following are indications for indution of labor except?
A. Maternal hypertension
B. Cephalopelvic disproportion
C. Ruptured BOW without spontaenous onset of labor
D. Non reassuring fetal status
E. Postterm gestation
B. CPD
Do not give oxytocin for cod
Standard antibiotic therapy for preterm labor include? A. Ampicillin + Gentamicin B. Ampicillin + sulbactam C. Cefoxitin + clindamycin D. Metronidazole
A.
The rest are alternative treatment
When do you administer corticosteroids?
24 to 34 weeks AOG
Timing of corticosteroids
Betamethasone - 12 mg/IM every 24 hours for 2 doses
Dexamethasone - 6 mg/IM every 12 hours for 4 doses
What is the only reliable indicator of clinical chorioamnionitis in women with preterm rupture of membranes? A. Fever B. Leukocytosis C. Fetal tachycardia D. (+) cervical or vaginal cultures
A. Fever
Several antibiotic regimen have been used to prolong the latency period in women with preterm rupture of the fetal membranes who are attempting expectant management. Which antibiotic should be increased in this setting because it has associated increased risk of necrotizing enterocolitis in the newborn? A. Ampicillin B. Amoxicillin C. Erythromycin D. Co-Amoxiclav
D. Co-amoxiclav
A 25-year old primigravida at 34 5/7 weeks AOG is found to have PROM. What is the most appropriate management strategy?
A. Expedited delivery
B. Expectant management
C. Corticosteroids followed by delivery
D. Tocolysis until near term with antibiotics
A. Expedited delivery
A 25-year old primigravida at 32 weeks AOG is found to have PROM. the following are benefits of antibiotic management in the above case EXCEPT? A. less incidence of chorioamnionitis B. Less incidence of newborn sepsis C. Prolongation of pregnancy by 7 days D. Increased neonatal survival
D.
Unaffected by treatment: Neonatal survival NEC RDS IVH
This antibiotic is not recommended in PROM due to increased incidence of NEC
Amoxicillin-clavulanate
Corticosteroids administered to women at risk for preterm birth have been demonstrated to decrease rates of RDS if the birth is delayed for at least what amount of time?
24 hours
What reversible complication can be seen when indomethacin is used for tocolysis longer than 24 to 48 hours?
Oligohydramnios
Although the efficacy is somewhat controversial, intrapartum administration of magnesium sulfate to women who deliver preterm has been demonstrated to reduce rates of which of the following neonatal outcomes? A. Cerebral palsy B. Necrotizing enterocolitis C. Neonatal seizure activity D. Bronchopulmonary dysplacia
A. Cerebral palsy
Symmetric growth restriction is characterized by a reduction in which of the following? A. Head size B. Body size C. A and B D. None of the above
C.
Fetal growth restriction which is brainsparing due to late insult
Assymetric
The following risk factors are associated with fetal overgrowth, except? A. Obesity B. Postterm gestation C. Nulliparity D. Advancing maternal age
C. Nulliparity
Which of the following factors is least likely to be linked with higher first trimester miscarriage rates? A. Obesity B. Diabetes mellitus C. Parvovirus infection D. Maternal age >40 years old
C. Parvovirus infection
An 18 year old G1P0 presents with 12 weeks of amenorrhea and heavy vaginal bleeding. Her urine pregnancy test is positive. Tissue with appearance of placenta is seen through an open cervical os. Your diagnosis and plan include which of the following?
A. Threatened abortion, plan bed rest.
B. Incomplete abortion, plan dilatation and curettage
C. Ectopic tubal pregnancy, plan laparoscopic resection
D. Complete abortion, plan subsequent beta-hCG testing in 48 hours
B. Incomplete abortion
A 20 year old with 16 weeks AOG pregnancy presents with fever (38.5) and lower abdominal pain, but without bleeding. She reports a small leakage of vaginal fluid yesterday. Primary management includes intravenous antibiotics and which of the following? Dx? A. Labor induction B. Bed rest and observation C. Tocolysis D. Hysterotomy and evacuation
A. Labor induction
PROM
A 23 yo G1P0 presents with vaginal bleeding and passage of meaty tissue. Claims to have 4 months missed menses, preg test pos. Speculum exam revealed minimal bleeding per os. Internal exam: closed cervix, uterus not enlarged. What is the appropriate diagnosis and plan?
A. Threatened abortion, start progesterone
B. Inevitable abortion. Give antibiotics.
C. Incomplete abortion, plan curettage
D. Complete abortion, request TVS
D.
A 28 yo G1P0 10 weeks AOG, noted morning sickness resolved and breast fullness diminished. TVS revealed intrauterine pregnancy. On exam, no fetal heart tone was appreciated. Cervix is closed with no blood on examining finger. Uterus not enlarged. Which of the following is the appropriate diagnosis and plan?
A. Threatened abortion, give tocolytics
B. Incomplete abortion, perform curettage
C. Missed abortion, ripen the cervix then D&C
D. Complete abortion, expectant management
C. Missed abortion, ripen cervix. D&C
A 35 yo G2P1 (1001) consulted due to vaginal bleeding at 14 weeks AOG. Pertinent PE: Bp 160/100, fundic height 20 cm.
The following are most likely differentials except?
A. Wrong menstrual period
B. Multiple pregnancy
C. H mole
D. Placenta accreta
D. Placenta accreta
On UTZ, grapelike or hydopic villous changes or snowstorm appearance
Hydatidiform mole
A complete H. Mole is characterized by the following except?
A. Diandric diploidy
B. 2 Paternal chromosomes and 1 maternal
C. Generalized swelling of the placental villi with marked trophoblasfic proliferation
D. Absent fetal component
B.
a 31 yo G2P1 (1001) came in due to increased abdominal girth, absence of menses for 4 months. Pregnancy test negative, ultrasound revealed snowstrorm pattern. What is the mechanism for the negative pregnancy test?
Hook effect from excess hCG in the 2nd trimester
These patients benefit from chemoprophylaxis with methotrexate and actinomycin D for molar pregnancy, EXCEPT A. Maternal age 35 years old and above B. Uterine size over 4 weeks C. Serum BhCG > 100,000 mIU/ml D. Theca lutein cysts 6cm or larger
B.
Indications for chemoprophylaxis in molar pregnancy Maternal age 35 years old and above Uterine size over 6 weeks G4 or above Serum BhCG > 100000 mIU/ml Theca lutein cysts 6cm or larger Medical complications - anemia, thyroid storm, preec, pulm insuff, Repeated molar pregnancy Live in remote geographic area
Diligent post evacuation hCG monitoring in molar pregnancy, EXCEPT
A. 1 week after suction curettage
B. every 2 weeks until hCG is normal for 6 consecutive tests
C. Every month in the 1st 6 months
D. Every 2 months in the next 6 months
B. every 2 weeks until hCG is normal for 6 consecutive tests
It should only be for 3 consecutive tests
In case of tubal ectopic pregnancy, contraindications for methotrexate therapy include the following except? A. Breastfeeding B. Thrombocytopenia C. Migraine headache D. Intraabdominal hemorrhage
C. Migraine headache Contraindications - active bleed - breastfeeding - immunodeficiency - alcoholism - blood dyscrasia - liver or renal disease - pulmonary disease
Which of the following would be most closely associated with methotrexate therapy failure during ectopic pregnancy treatment? A. Increased parity B. Ectopic size of 2.5 cm C. Prior ectopic pregnancy D. Beta hCG of >9000 mIU/ml
C. Prior ectopic pregnancy
Criteria for Methotrexate therapy include the following except? A. G1P0 8 weeks AOG B. Tubal mass less than 3.5 cm C. No cardiac activity D. Serum B hCG <10-15K mIU/ml
A. Indications for methotrexate -Pregnancy less than 6 weeks -Tubal mass less than 3.5 cm -No cardiac activity -Serum B hCG <10-15K mIU/ml
Which of the following is not associated with primary uterine rupture? A. Hydramnios B. Forceps delivery C. Breech extraction D. Prior cesarean section
D. Prior cesarean rupture
With placental abruption, which conditions would preclude vaginal delivery?
A. Intrauterine fetal demise and prior classical CS incision
B. Term fetus at station +2, brisk vaginal bleeding and mild coagulopathy
C. Inteauterine fetal demise and HSV ukcer on perineum
D. All of the above
A. Intrauterine fetal demise and prior classical CS incision
Premature separation of a normally implanted placenta
Abruptio placentae
Virchows triad (abruptio placenta) include the following except A. Vaginal bleeding after 20 weeks B. Increased uterine tone C. Abdominal pain D. Uterine tenderness or back pain E. None of the above
E. None
The most common cause of disseminated intravascular coagulation in obstetrics
Abruptio placenta
Uteroplacental apoplexy
Couvelaire uterus
Couvelaire uterus
Uteroplacental apoplexy
*abruptio placenta complication
Placentas that lie within close proximity of the internal cervical os but do not reach it are termer low lying. What is the boundary threshold that defines a low lying placenta?
2 cm
Placenta implanted in the LUS of the uterus, presenting ahead of the leading fetal pole
Placenta previa
Placenta implanted approaching the boarder if the internal cervical os
Placenta marginalis
Painless vaginal bleeding
Placenta previa
Internal exam is an absolute contraindication
Placenta previa
In placenta previa, at which age of gestation is the basis for planning the route of delivery?
35 weeks
Any degree of overlap beyond 35 weeks warrants CS
Risk factors for massive bleeding during CS in placenta previa include:
A. Advanced maternal age (>35 yo)
B. Prior CS
C. Sponge-like ultrasonography findings in the cervix
D. All of the above
E. None of the above
D. All of the above
