Labor & Delivery, Maternal Mortality, and Lactation - Test 1

Question 1

What are the three Ps of labor?

Answer 1

Power

Passenger

Passageway

Question 2

What are the three functional segments of the uterus?

Answer 2

Active segment

Passive segment

Cervix

Question 3

Which segment of the uterus is the preferred incision site for a C-section? Why?

Answer 3

Passive segment because this decreases chance of uterine rupture in subsequent pregnancies.

Question 4

What are the four phases of uterine quiescence and activation? What weeks gestational age are each associated with? What hormones predominate during each phase?

Answer 4

Phase 0 - quiescence

Weeks 0-36

Progesterone inhibits uterine contractions

Phase 1 - myometrial activation

Weeks 36-delivery

Estrogen is the dominant hormone - this activates the uterus —> increase in contraction-associated proteins (prostaglandin and oxytocin receptors, gap-junctions between myometrial cells)

Phase 2 - stimulation

Active phase of labor

Prostaglandins and oxytocin stimulate contractions

Phase 3 - involution

Postpartum phase

Oxytocin stimulates contraction of the uterus and spiral arteries

Question 5

Describe three functions of prostaglandins during pregnancy. Name a drug inhibits synthesis of prostaglandins and an indication for its clinical use.

Answer 5

Prostaglandins promote cervical ripening, potentiate contractions, and increase oxytocin receptor concentrations.

Indomethacin is an NSAID that inhibits prostaglandin synthetase and can prevent preterm labor.

Question 6

__________ is given intravenously to both induce labor and prevent postpartum hemorrhage.

Answer 6

Oxytocin

Question 7

Which hormone upregulates gap junctions and uterine receptors for oxytocin in phase 1?

Answer 7

Estrogen

Question 8

What clinical exam maneuver is performed to assess fetal lie and presentation?

Answer 8

Leopold’s maneuver

Question 9

Which fetal lie and presentation do babies most commonly present in?

Answer 9

Well-flexed, vertex

Question 10

Name the four female pelvis types (with regards to shape) and which fetal head position is most commonly associated with each.

Answer 10

• Gynecoid - most common; usually associated with an occiput anterior head position
• Android - usually associated with occiput posterior head position (difficult birth)
• Platypelloid - associated with occiput transverse position
• Arthropoid

Question 11

What are normal/expected times for stage 2 (pushing) phase of labor in both nulliparous and multiparous women?

Answer 11

Nulliparous women: >3 hours of pushing or >4 hours with an epidural

Multiparous women: >2 hours of pushing or >3 hours with an epidural

Question 12

How long after childbirth is delivery of the placenta expected to happen?

Answer 12

Within 30 minutes

Question 13

Describe both the mechanical and pharmacological methods to articifially ripen the cervix.

Answer 13

Mechanical:

• Foley catheter is inserted through cervix, inflated —> cervical dilation
• Laminaria (seaweed to absorb moisture) is not done anymore

Pharm:

• PGE2 (prostin) or dinoprostone (cervidil) placed into the cervical canal or posterior fornix
• PGE1 (misoprostol aka cytotec)
  
  • Do NOT use in women w/ Hx of prior C-section due to increased risk of rupture
• Oxytocin

Question 14

The ________ score is a method of quantifying the state of the cervix for delivery.

Answer 14

Bishop score

Question 15

What are the different stages of pain in labor and what are the associated nerves that carry afferent pain signals in each stage?

Answer 15

Labor stage 1

• Latent and active labor
• Pain is due to uterine contractions and cervical dilation
• Visceral pain fibers from lesser and least splanchnics (T10-12) + L1 transmit the pain

Labor stage 2

• Pushing and delivery
• Pain is due to distension of the pelvic floor - carried by pudendal nerve (S2, 3, 4)

Question 16

What is the major risk of giving opioids to a mom in labor?

Answer 16

Fetal respiratory depression

Question 17

Which inhaled anesthetic is now often used for management of the pain of labor? What are the side-effects of this?

Answer 17

Nitrous oxide

No side effects

Question 18

Define post-partum hemorrhage.

Answer 18

Vaginal delivery: loss of 500+ mL of blood –> hypovolemia

C-section: loss of 1000+ mL of blood –> hypovolemia

Question 19

What are the “four Ts” of postpartum hemorrhage?

Answer 19

Tone

Tissue

Trauma

Thrombin

Question 20

What are some risk factors for post-partum atony -> hemorrhage?

Answer 20

Too much uterine distension from macrosmia, polyhydramnios, multiple gestations

Question 21

Retained placental tissue will cause post-partum hemorrhage. What is the management of retained placental tissue?

Answer 21

1. Traction on the umbilical cord + drugs (see next flashcard) + fundal massage
2. If that fails, manual extraction
3. If that fails, dilation and curettage (D&C)
4. If that fails, hysterectomy (cuz it’s usually placenta accreta)

Question 22

Name four drugs that can be helpful in expulsion of retained placental tissue.

Answer 22

Oxytocin

Methylergonovine (methergine)

Carboprost tromethamine (hemabate)

Misoprostol

Question 23

The least invasive surgical treatment of uterine atony is…?

Answer 23

Balloon tamponade

Question 24

Intrapartum fever + maternal tachycardia + uterine tenderness or leukocytosis

Increases chance of going into preterm labor

What is your Dx? How do you treat it?

Answer 24

Chorioamnionitis

Treatment: broad-spectrum antibiotics (ampicillin + gentamycin, ampicillin sulbactam, or ticarcillin/clavulanate) and expedite the delivery

Question 25

Maternal mortality rate has ________ (increased or decreased) in the US over the past few decades and is higher than many other developed countries.

What has been the trend regarding maternal mortality worldwide in the past few decades?

Answer 25

US maternal mortality has increased in the past few decades.

Worldwide maternal mortality has decreased.

Question 26

Do disparities exist in the US regarding maternal mortality?

Answer 26

Yeah

Question 27

What is the major hormone that regulates lactation?

Answer 27

Prolactin

Question 28

What external stimulus is responsible for prolactin release from the pituitary?

Answer 28

Suckling by the baby

Question 29

What is more effective at increasing lactogenesis: increased feeding frequency, or increased duration of feeding?

Answer 29

Increased frequency

Question 30

Name two drugs that can suppress lactation and their MOAs.

Answer 30

Bromocriptine and cabergoline (dopamine agonists)

Question 31

Why are lactating women amenorrheic?

Answer 31

Suckling inhibits GnRH secretion

Question 32

Are there a shitload of benefits to breastfeeding?

Answer 32

Yeah

Question 33

How often and for how long is breast feeding recommended?

Answer 33

Every 2-3 hours for 10-15 min each breast

Question 34

What is a differential diagnosis for lactating mother nipple/breast pain?

Answer 34

Engorgement

Candidal infection

Nipple microtrauma from poor latch

Mastitis

Abscess

Question 35

What is the treatment for candidal mammary gland infection?

Answer 35

Topical clotrimazole

Question 36

What is the treatment for mastitis?

Answer 36

Dicloxacillin

Bactrim or clindamyicn if its MRSA

Question 37

How is a hepatitis B pregnant woman treated in pregnancy w/ regards to her hepatitis infection?

Answer 37

Lamivudine in the 3rd trimester

Question 38

Name two drugs that can stimulate lactation. What are their MOAs?

Answer 38

Metoclopramide and domperidone (dopamine receptor antagonists)