Labor and Delivery Flashcards by Kash Yap

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

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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

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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

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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

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This is an intervention designed to artificially initiate uterine contractions leading to progressive dilatation and effacement of the cervix to effect delivery.

Labor Induction

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What are the components of Bishop Score

Cervix

Position
consistency
effacement
dilatation
station

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What are Bishop score modifiers which increase the score by 1 more point?

Preeclampsia

Each previous vaginal birth

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What are Bishop score modifiers which decrease the score by 1 less point?

Postdate pregnancy
Nulliparity
No previous vaginal delivery
PPROM

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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

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Quantifiable score to predict labor induction outcomes

Bishop score

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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

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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

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Bishop Points for cervix at anterior?

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Bishop Points for cervix at posterior?

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Bishop Points for cervix 5 cm?

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Bishop Points for cervix at 1 cm?

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Bishop Points for cervix closed?

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Bishop Points for cervix soft?

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Bishop Points for cervix firm?

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Bishop Points for cervix 30-50%?

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Bishop Points for cervix at 60-70%?

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Bishop Points for station -3?

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Bishop Points for station +1, +2

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Bishop Points for station -2?

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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

1. Fetal fibronectin 2. Salivary estriol 3. Insulin like factor binding protein 4. Placental a-macroglobulin-1 5. 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 ```

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

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

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

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