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Preclerkship > Labour & Delivery > Flashcards

Labour & Delivery Flashcards

1
Q

What is the difference between True Labour and Braxton Hicks contractions?

A 
True = regular, painful, increasing intensity contractions; cervix dilates/effaces, progression of fetal station
False = irregular, not changing intensity/freq, no cervical changes; throughout pregnancy

Labour ctx: 4:1:1 rule - Ctx every 4 minutes, lasting 1 minute, for at least 1 hour

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2
Q

Describe the stages of labou

A

Stage 1 latent: <4cm
Stage 1 active: 4-10 cm
2nd stage: 10 cm-delivery of baby
3rd stage: delivery baby –> delivery placenta
4th stage: delivery placenta –> 1-4 hr postpartum

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3
Q

Is posterior or anterior cervical positioning indicative of further in labour?

A

Moves posterior –> anterior

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4
Q

orientation of the long axis of the fetus with respect to the long axis of the uterus (longitudinal,
transverse, and oblique)

A

fetal lie

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5
Q

fetal presentation =

Which is the only normal one?

A

fetal body part closest to the birth canal

Normal = vertex/occiput/cephalic

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6
Q

Fetal position

A

Position of presenting part relative to maternal pelvis (e.g. OA (“normal”), OP, OT)

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7
Q

2 examples of abnormal fetal attitude

A

Brow presentation

Face presentation

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8
Q

Define fetal station

A

Position of presenting bony part relative to ischial spines (determined via vaginal exam)
-5 to -1 cm above spines
+1 to +5 below spines

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9
Q

What is synclitism?

A

Alignment of the sagittal suture relative to axis of birth canal (A or P asynclitism may impact descent)

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10
Q

Fetal position is described by ___ for cephalic presentation, ___ for breech presentation, ___ for face presentation

A

Occiput
Sacrum
Mentum

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11
Q

4 key HPI questions during labour triage

A

1) Contraction - since when, how freq, how long, how painful
2) Bleeding - wsince when, how much, colour, pain, last U/S, any trauma/intercourse?
3) Fluid (ROM) - when, how much, colour
4) FM: as much as usual? when last?

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12
Q

Describe contractions during the active first stage of labour?

A

Painful, regular, q2-3 min, 45-60 s each

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13
Q

Mother feels a desire to bear down/push with each contraction during which stage of labour?

A

Second stage

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14
Q

Third stage of labour can last up to __ before intervention is indicated?

A

30 min

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15
Q

Routine ___ administration in the 3rd stage of labour (either give with delivery of baby or after placenta delivered) can reduce the risk of PPH by >40%

A

Oxytocin

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16
Q

The __ and ___ stages of labour are most dangerous to the mother

A

3rd-4th (PPH)

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17
Q

What is fetal engagement and when does it happen?

A

The widest diameter of the presenting part (with a well-flexed head, where the largest transverse diameter of the fetal occiput is the biparietal diameter) enters the maternal pelvis to a level below the plane of the pelvic inlet. On the pelvic examination, the presenting part is at 0 station, or at the level of the maternal ischial spines.
In first pregnancy often happens weeks before birth

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18
Q

Non-pharmacological pain relief techniques for labour (3 categories + examples)

A

1) Reduce painful stimuli (position change, maternal movement)
2) Activate peripheral sensory receptors (superficial heat/cold, water immersion, TENs, massage, aromatherapy)
3) Enhance descending inhibitory pathways (distraction, hypnosis, music, biofeedback)

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19
Q

Pharmacological pain relief methods

A 
Nitrous oxide
narcotics
Pudendal nerve block
Local anesthetic
Regional anesthetic (EPIDURAL, spinal)
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20
Q

Prevalence, prognosis, and etiology of Meconium Aspiration Syndrome

A

In about 10% of pregnancies overall, the fetus discharges meconium (its bowel contents) into the amniotic fluid during labour. In about 10% of cases where meconium is passed, the fetus gasps, inhaling the sticky meconium into the upper respiratory tract. After birth, the meconium blocks the air passages in the lungs, impairing gas exchange–meconium aspiration syndrome (MAS). Up to 20% of infants suffering from MAS die and recently published studies have shown a long-term effect of MAS in causing cough and wheeze

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21
Q

2 delivery characteristics that increase the likelihood of meconium aspiration syndrome?

A

C-section

Postterm

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22
Q

Presentation of meconium aspiration syndrome

A

GREEN AMNIOTIC FLUID

Low APGAR, tachypnea, hypoxia, WOB

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23
Q

APGAR stands for what?

Score below what may need intervention?

A 
Activity (muscle tone)
Pulse
Grimace (reflex irritability)
Appearance (skin colour)
Respiration
(<7 may need intervention)
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24
Q

Is continuous fetal monitoring always better?

A

No, leads to increased intervention

Do it if you have abnormal or induced labour, meconium present, multiple gestation, fetal concerns

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25
Q

What can be used to resolve interpretation of abnormal/atypical FHR and CTG (contraction monitoring) patterns?

A

Fetal scalp sampling

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26
Q

Is variability in FHR bad?

A

No! Physiological variability is normal and absence can be bad

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27
Q

What FHR decelerations are normal?

A

Early decelerations: nadir coincides with peak of contraction then quickly returns to baseline
Normal vagal response to head compression

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28
Q

What are variable FHR decelerations? Are they good or bad?

A

Variable in shape/onsent/duration
Can be due to cord compression or forceful pushing in 2nd stage
Complicated if return to baseline is slow/incomplete, too bradycardic (possible fetal acidemia)

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29
Q

What are late decelerations?

A

Onset + nadir + recovery after peak of contraction, slow return to baseline
Indicates fetal hypoxia/acidemia, usually a sign of uteroplacental insufficiency (ominous)

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30
Q

Normal FHR and variability

A

110-160

6-25 bpm

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31
Q

Normal FHR accelerations

A

Spontaneous or during scalp stimulatino

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32
Q

What is measured in a fetal scalp sample?

A

pH & lactate (looking for acidosis –> if present, deliver!!)

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33
Q

Maternal cervix needs to be __ for induced labour. If not, what can you use?

A

“Ripe” (short, thin, soft, anterior, open os)

Can use intravaginal prostaglandins (e.g. misoprostol in clinical trials), foley catheter for mechanical dilation

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34
Q

What score determine likelihood of success for induced labour?

A

Bishop score

cervical position/consistency/effacement/dilatation, fetal station

35
Q

What is the most common reason for inducing labour?

A

> 41 weeks

36
Q

Maternal indications for induced labour? (4+)

A 
MDM
Gestational HTN >37 wk
Preeclampsia
Mom >40
Other maternal diseases
37
Q

Maternal-fetal indications for induced labour (3)

A

Isoimmunization
PROM
Chorioamnionitis

38
Q

___ is the artificial initiation of labour
____ promotes contractions when
spontaneous contractions are inadequate

A

Induction

Augmentation

39
Q

Fetal indications for induced labour

A

Fetal jeopardy (but not fetal distress or malpresentation)
Macrosomia
Demise, IUGR, oligo-polyhydramnios
Twins, previous stillbirth

40
Q

2 serious complications of induced labour

A

Uterine hyperstimulation –> fetal compromise or uterine rupture
Uterine muscle fatigue –> atony (failure to contract) + PPH

41
Q

Describe uterine atony

A

Uterine atony refers to the corpus uteri myometrial cells inadequate contraction in response to endogenous oxytocin that is released in the course of delivery. It leads to postpartum hemorrhage as delivery of the placenta leaves disrupted spiral arteries which are uniquely void of musculature and dependent on contractions to mechanically squeeze them into a hemostatic state. Uterine atony is a principal cause of postpartum hemorrhage, an obstetric emergency.

42
Q

2 components of inducing labour after cervical ripening

A

1) Amniotomy
2) Oxytoxin

(Not ALWAYS both)

43
Q

What med is used to augment labour when spontaneous contraction inadequate and cervical dilation or fetal descent fails?

A

Oxytocin

44
Q

What is dystocia?

A

Failure of expected patterns of descent/dilation to occur in expected timeframe

45
Q

4 Ps of dystocia

A

Power: weak contractions, inadequate pushing
Passenger: fetal position/attitude, size
Passage: pelvic structure (CPD), maternal soft tissue factors (full bladder/rectum, vaginal septum, tumors)
Psyche: stress hormone

46
Q

What is CPD?

A

Cephalopelvic disproportin

Fetus head can’t fit through pelvis –> failure to progress (need C/S)

47
Q

What is the most common etiology of dystocia?

A

POWER

48
Q

Management of dystocia

A

Rule out CPD

Then IV oxytocin augmentation + amniotomy

49
Q

Define Shoulder dystocia

A

Fetal anterior shoulder impacted above pubic symphysis after head delivered –> LIFE-THREATENING EMERGENCY

50
Q

____ will resolve 90% of cases of shoulder dystocia.

A

McRoberts maneuver (flex legs onto abdomen) + suprapubic pressure on fetal anterior shoulder

51
Q

Umbilical cord prolapse =

A

Cord moves below (or adjacent to) presenting part –> cord compression

52
Q

Treatment of umbilical cord prolapse

A

Emergency C/S if delivery not imminent

O2 to mother, monitor FHR, alleviate pressure on chord via pelvic exam until C/S

53
Q

Define grand multiparity

A

5+ births at 20+ weeks

Associated with increased maternal risks

54
Q

Common causes of uterine rupture

A 
Previous uterine scar (40%) (usually <1% incidence but up to 12% with classical C/S incision, even before labour)
Oxytocin hypertimulation
Grand multiparity (5+ deliveries)
55
Q

If uncontrollable hemorrhage from uterine rupture –>

A

Hysterectomy

56
Q

HELLP Syndrome

A

A complication of pregnancy and form of preeclampsia that most commonly occurs > 27 weeks’ gestation. Characterized by hemolysis (H), elevated liver (EL) enzymes, and low platelet (LP) count

57
Q

Amniotic fluid embolus

A

Amniotic fluid debris in maternal circulation –> anaphylactoid immunological response –> RD, CV collapse, coagulopathy
Up to 30% maternal mortality

58
Q

What is the controversy around epistiotomy?

A

Current evidence suggests letting perineum TEAR and then repairing as needed is better

59
Q

Risk factor for shoulder dystocia

A

Maternal DM/GDM

Fetal prolonged gestation/macrosomia

60
Q

Define chorioamnionitis + etiology

A

Infection of chorion/amnion/amniotic fluid

Ascending infection from vagina

61
Q

Clinical features + treatment of chorioamnionitis

A

Fever, tachycardia, uterine tenderness, foul discarge

IV antibiotics

62
Q

Meconium :
More common in ___ pregnancies
Present in up to ___ of all labours
Is it associated with poor outcome?

A

Postdate
25%, usually NOT associated with poor outcome but ALWAYS abnormal if preterm fetus (and concern if fluid changes from clear –> meconium stained)

63
Q

Increasing meconium during labour may be sign of ___

A

Fetal distress

64
Q

What is the most common cause of postpartum hemorrhage?

A

Uterine atony (70-80%)

65
Q

Define puerperium

A

6 weeks after delivery when physiological/anatomic changes are reversed

66
Q

Define postpartum hemorrhage

A

> 500 mL blood loss vaginal delivery
1000 mL blood loss C/S
Primary = within 1st 24 hours
Secondary/Late = within 12 weeks

67
Q

DDx of Early PPH (4 Ts)

A

Tone (uterine atony)
Tissue
Trauma
Thrombin (coagulopathy, e.g. vWD)

68
Q

Prevention of uterine atony (3)

A

Oxytocin administration
Uterine massage
Umbilical cord traction

69
Q

Medical treatments for PPH

A 
Oxytoxin
Ergotamine
Carboprost (PGF analog)
Misoprostol
Tranexamic acid (antifibrinolytic)
70
Q

Local treatments for PPH

A 
Bimanual massage through abdomen
Uterine packing (mesh w/ AB treatment)
Bakri Balloon for tamponade while correcting coagulopathy or prepping for OR
71
Q

Surgical therapies for intractable PPH

A

D&C
Embolization of uterine artery or internal iliac artery
Laparotomy with artery ligation
Hysterectomy = last resort

72
Q

Formation of scar tissue in uterus (usually after surgery) =

A

Asherman’s syndrome

73
Q

Retained placenta =

A

not delivered within 30 min after fetus delivered

74
Q

Define placental previa and vasa previa

A

Placental previa = placenta blocking cervix
Vasa previa = embranes that contain fetal blood vessels connecting the umbilical cord and placenta overlie or are within 2 cm of the internal os

75
Q

When is screening for gestational diabetes recommended?

A

24-28 weeks

76
Q

What is the preferred screening for GDM?

A

The preferred approach is an initial 50 g glucose challenge test, followed, if abnormal, with a 75 g oral glucose tolerance test. A diagnosis of GDM is made if one plasma glucose value is abnormal (i.e. fasting ≥5.3 mmol/L, 1 hour ≥10.6 mmol/L, 2 hours ≥9.0 mmol/L)

** if high risk of undiagnosed type 2, screening EARLY (<20 weeks) via HbA1c

77
Q

DIC can be caused by obstetric complications via release of ___

A

Procoagulants (—> tons of clots formed but then also increased bleeding due to consumptions of platelets/clotting factors)

78
Q

placenta grows too deeply into the uterine wall. Typically, the placenta detaches from the uterine wall after childbirth. With placenta accreta, part or all of the placenta remains attached. This can cause severe blood loss after delivery.

^what is this and what is the general approach?

A

Placenta accreta

C-section important. Can try to remove placenta but may need hysterectomy

79
Q

Bloody show

A

A blood-tinged mucous plug may be discharged when the cervix shortens and dilates.

80
Q

Normal birth weight

A

2.5-4.5 kg

81
Q

Fundus above umbilicus during PPH =

A

uterus hasn’t contracted

82
Q

This meta-analysis showed that ___ was as effective and safe as oxytocin for prevention of postpartum hemorrhage in women undergoing vaginal delivery, and the choice of carbetocin for routine prophylaxis will depend on cost-effectiveness.

A

Carbetocin (long-acting oxytocin analogue)

Centre-dependent practices

83
Q

What are the 4 degrees of vaginal tears in childbirth?

A

1st = perineum skin only, may not require stitches
2nd = skin/muscle of perineum, may extend deep into vagina; stitches done in delivery room
3rd = extends into anal sphincter. May need OR repair
4th - all the way through anal sphincter + rectal mucosa

Preclerkship (25 decks)

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