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Obstetrics > Labor & Delivery > Flashcards

Labor & Delivery Flashcards

1
Q

At what gestational age can you do an ECV? Benefits/risks?

A

37w

  • most likely to have spontaneously verted by then
  • lower risk of spontaneous reversion
  • increased risk of failure, but also lower risk of pre-term birth compared to version at 35-36w
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2
Q

What is the risk of ECV in patients with a h/o c-section?

A

Same success rate (50-80%) - some studies say higher success, some say lower success rates
No cases of uterine rupture reported

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3
Q

What are the risks of ECV?

A 
Placental abruption
Umbilical cord prolapse
Rupture of membranes
Stillbirth
Feto-maternal hemorrhage
(all <1%)
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4
Q

What are the success rates of ECV?

A

Range from 16% to 100%. Pooled success rate of 58%.

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5
Q

What increases the likelihood of ECV success?

A
  • Normal or increased amniotic fluid
  • Normal BMI
  • Multiparity
  • Non-anterior placenta
  • High station
  • Tocolysis (25% increase in success)
  • Regional anesthesia (87% vs 57% success)
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6
Q

Incidence of OP position

A

5-12%. ROP most common (60% of OP)

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7
Q

What is the natural history of OP position? (what happens with expectant management)

A

80-90% spontaneously rotate to OA; 50-80% rotate still if OP at the start of the second stage

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8
Q

What factors are associated with OP position?

A 
Anthropoid pelvis (narrower, deeper AP diameter)
Nulliparous
Possibly also associated:
BMI>30
AMA
macrosomia
anterior placenta
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9
Q

What pelvic shape is most associated with OT position?

A

Platypelloid (small AP diameter)

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10
Q

What are the morbidities of OP position?

A

Labor dystocia (prolonged, longer 1st stage, need for augmentation)
Longer second stage, appx 45 minutes
Association with c/s, 4-10x with persistent OP position in 2nd stage.
Increased risk of atony, PPH
Increased risk of operative delivery and failure of operative delivery
Increase risk of OASIS injury

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11
Q

How good are vaginal exams in determining OP and OA position?

A

Accurately predict OA 80-85% of the time

Predict OP 50-60% of the time

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12
Q

Does the peanut ball work to change fetal position?

A

No evidence to support maternal positioning to encourage rotation

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13
Q

When is it recommended to attempt to rotate the fetal head?

A

During the second stage of labor. NOT prior to complete cervical dilation. Due to risk of cord prolapse or cervical lacerations.

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14
Q

Number needed to treat for manual rotation?

A

4! 4 rotations needed to prevent one c-section (by a large retrospective study)

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15
Q

By the data, how often is manual rotation successful?

A

90%

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16
Q

What is the primary benefit of successful rotation?

A

Decreased c-section, decreased operative vaginal delivery/oasis injuries

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17
Q

Arrest of descent

A

Fetal vertex w/o descent in 1 hour despite adequate maternal expulsive efforts

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18
Q

Prolonged second stage

A

nulliparous women > 3 hours with epidural or > 2 hours without; multiparous women > 2 hours with epidural or > 1 hour without.

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19
Q

Stillbirth definition

A

Fetal death at 20w or greater or 350g (50%ile at 20w) if GA is unknown
Excludes pre-viable pprom and pre-viable termination

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20
Q

Risk factors for stillbirth

A

Non-hispanic Black race
Multiple gestation (14/000 compared to 5/1000; triplet and higher order, 30/1000)
Prior stillbirth
Male sex (6/1000)
Young maternal age (<15) or advanced maternal age
Medical co-morbidities - DM, cHTN, SLE, renal, obesity, tobacco
Anti-phospolipid antibody

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21
Q

Etiologies of stillbirth

A

5-10% Abruption
10% umbilical cord events (stricture, entrapment, vasa previa)
6-13% abnormal karyotype
10-20% infection (GBS, E Coli; listeria, syphilis; CMV, Parvovirus, Zika)

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22
Q

How do you evaluate stillbirth?

A 
placental pathology MOST HELPFUL
fetal autopsy
amniocentesis / genetic testing
APLA testing
less useful, KB and infectious testing
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23
Q

What is the induction regimen for IOL in 2nd trimester stillbirth?

A

400-600mcg vaginal misoprostol q3-6hrs

Can do this with hx cesarean

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24
Q

What is the recurrence risk of stillbirth?

A

2.5%

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25
Q

What is the antepartum surveillance for hx of stillbirth?

A

NST at 32w or 1-2wk prior to GA of stillbirth (if stillbirth <32w, individual plan)
third trimester growth ultrasound

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26
Q

What is the timing of delivery for a patient with hx of stillbirth?

A

May warrant early term delivery at 37-38w

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27
Q

What is the FHT sig associated with uterine rupture?

A

Fetal bradycardia (only stat sig finding compared to VBAC without rupture)

28
Q

What are risk factors associated with uterine rupture?

A

IOL / prostaglandin use

29
Q

What is the incidence of uterine rupture?

A 
1x LTCS: 0.5-0.9%
2x LTCS: 0.9-3.7%
Classical incision: 1-12%
Low vertical: likely the same as LTCS
Unknown prior incision - similar rates of rupture with low transverse
30
Q

What are positive factors associated with VBAC?

A

spontaneous labor

prior vaginal delivery

31
Q

What factors are negatively associated with VBAC?

A 
prior arrest of labor
increased BMI**
increased maternal age 
higher birth weight
GA >40w
labor induction
32
Q

What is the risk of rupture w/ and without prostaglandins?

A

without prostaglandins: 0.7-1.1%
with prostaglandins: 1.4-2.3%
difficult to interpret / mixed data

33
Q

What is the recurrence risk of uterine rupture?

A

6% (lower uterine segment scar)

up to 32% if upper uterine segment

34
Q

What is the delivery plan for women with h/o uterine rupture?

A

Consider rLTCS at 36-37w

35
Q

Can you use prostaglandin inductions in IUFDs for h/o C-S?

A

ok to use prostaglandins in women with hx of CS unless vertical incision

36
Q

What’s the max daily dose of labetalol IV?

A

300mg

37
Q

What’s the max daily dose of PO nifedipine?

A

180mg

38
Q

What’s the max daily dose of hydral IV/IM?

A

20mg

39
Q

What is the 1st line treatment of eclampsia?

A

magnesium sulfate 4-6g loading dose over 30 min > 2g/hr

IM magnesium 5g and 5g followed by 5mg q4h

40
Q

What’s the diagnostic criteria for HELLP?

A

LDH >600
LFTs 2x normal
Plt <100K

41
Q

What percent of HELLP patients will not have high blood pressures?

A

15%

42
Q

What are high risk factors for which patients should be on bASA?

A 
h/o pre-eclampsia
multifetal gestation
cHTN
T1DM
T2M
renal disease
autoimmune disease
43
Q

When should you start bASA for pre-eclampsia prevention?

A

max benefit if <16w
ok to start between 12 and 28 weeks
don’t start >28w due to lack of benefit

44
Q

When should you treat cHTN in pregnancy?

A

persistent BPs >160/110

or lower but w/ comorbidities or renal disease

45
Q

What is goal BP for treatment of cHTN in pregnancy?

A

120-160/80-110

46
Q

Which women with cHTN need fetal surveillance?

A
  • on meds
  • other co-morbid conditions
  • IUGR
  • superimposed preE
47
Q

What percent of cHTN will develop pre-E?

A

20-50%

if end-organ damage present with cHTN, up to 75%

48
Q

What are consequences of Rh alloimmunization?

A

Hemolytic anemia of the newborn - high output cardiac failure, hydrops, stillbirth

49
Q

What percent of alloimmunization is caused by feto-maternal hemorrhage?

A

1-2%

50
Q

What is the critical titer for Anti-D?

A

1:16

51
Q

What is the prevalence of Intrahepatic cholestasis of pregnancy?

A

0.2-6% of pregnancies

52
Q

What are risk factors for cholestasis of pregnancy?

A

Multiple gestation
HCV positive
IVF
Advanced maternal age

53
Q

What are the adverse outcomes of cholestasis of pregnancy?

A

Pre-term birth
meconium stained fluid
IUFD

Higher with bile acids at/above 40umol/L

54
Q

Granulomatous infantile septis

A

acute rash
fever
abscesses in placenta

due to listeria

55
Q

Definition of contraction stress test

A

3 contractions in 10 minutes

positive test is decels with >50% of contractions

56
Q

What did the WOMAN trial show in terms of benefits of TXA in PPH?

A

Reduction in maternal mortality, 1.9% to 1.5% if given within 3 hours
IV or PO

57
Q

How much contrast is excreted into breast milk?

A

<1% of contrast administered is excreted

<1% of this is absorbed into infant GI tract

58
Q

How much gadolinium is excreted into breast milk?

A

<0.04%

<1% of this is absorbed by infant GI tract

59
Q

What are the benefits of median vs mediolateral episiotomy?

A

Mediolateral - lower risk of extension into anal sphincter

Median - lower risk of postpartum pain or dyspareunia

60
Q

What is the NNT for primary cesarean section in macrosomia in diabetic mothers

A

440 cesarean deliveries to prevent 1 shoulder dystocia

EFW 4500 + DM

61
Q

What percentage of fetuses enter the pelvis in OP position?

A

20%

62
Q

Tachysystole definition

A

> 5 contractions in 10 minutes averaged over 30 minutes

63
Q

Which nerve roots transmit somatic pelvic pain in labor?

A

Pudendal

S2-S4

64
Q

What does acetylcholinesterase on amniocentesis mean?

A

acetylcholinesterase + elevated AFP = Neural tube defect

65
Q

What is the dose of rhogam after CVS?

A

125-300mcg

66
Q

Fetal loss rate after amniocentesis in 2nd trimester

A

1:200 - 1:300

Obstetrics (4 decks)

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