Maternal Dr. AKhter Flashcards
1
Q
Stage 1 :Latent
ˆ15%CO
A
Start L Regular uterine contractions Ends: 4 cm dilatation,
Cx effacement, Cx slowly dilates
Nulli : 6-11hrs
Multi 4-8 hrs
2
Q
First Stage :Active
ˆ30%CO
A
Start : 4 cm/ End: 10 cm (complete dilatation)
Regular intense contractions, fetal head descends into pelvis
Nulli 4-6
Multi 2-3
3
Q
Second Stage of labor
ˆ45% CO
A
Start: complete Cx dilatation End: delivery of baby
Baby undergoes all cardinal movements : Engagement, Descent, Flexion and Internal rotation, Flexion, External rotation and expulsion
Nulli 1-2hr
Multi : 0.5 - 1 hr
4
Q
Third Stage
ˆ80% CO
A
Start:delivery of baby / Ends : delivery of placenta
Placenta detaches from Uterus, Uterus contracts to a establish homeostasis
Nulli 0- 0.5
Multi 0- 0.5
5
Q
Pain level in First stage labor
A
Pain is first T11- T12.
Then progress to T10 -T12 and L1.
Visceral Pain from Uterine contraction and Cx dilatation
Spinal Anesthesia needed at level T10-L1
6
Q
Second stage begins at fully dilated Cx ( 10 cm ) ends at expulsion of fetus. Describe pain
A
Pain Through the pudendale nerve ( S2-S4)
Somatic pain : by stretching of vagina and perineum by descending fetus.
Spinal anesthesia needed S2- S4
Pain involves T10 to S4 dermatomes
7
Q
Visceral Pain - what stage of labor and describe
A
Stage 1.
Visceral pain from contraction of uterus and dilatation of Cx
Pain starts T11-T12 then progress to T10- T12 then L1
Spinal anesthesia needed T10 - L1
8
Q
Somatic Pain , What Stage, Describe
A
Stage 2 Somatic pain from stretching of vagina and perineum Pudendal Nerve ( S2-S4) Spinal anesthesia needed S2- S4 Pain involves T10- S4 dermatomes
9
Q
Third Stage of Labor
A
ˆ80% CO. Delivery to expulsion of Placenta . Separation and delivery of placenta
Nulli : 0-0.5
Multi : 0-0.5
10
Q
Pain and temperature from the genitalia are mediated by the
A
by the autonomic nervous system (not lateral spinothalamic tract)
11
Q
Cause of pain is uterine contractions and exceeds
A
25 mmHg pressure ( 25-60mmHg )and dilate Cx.
12
Q
Visceral pain due to which sympathetic nerves ?
A
Visceral afferent accompanying sympathetic nerves entering T10, T11, T12 and L1
13
Q
Pain during late 1st and 2nd stage pain travels through
A
Pudendal nerve and enter neuraxis S2 S3 S4
Pain due to stretch on vagina and vulva and perineum
14
Q
What innervate Uterus and Cx
A
T10 - L1-L2
Pain carried Visceral afferent C fiber
15
Q
What innervates the perineum
A
S2 S3 S4
Pain carries by somatic nerve fibers; pudendal nerves
16
Q
Effects of inhalation anesthetic on uterus
A
Inhaled anesthetic= Uterine relaxation = increased blood loss
17
Q
Effects of parent earl agents on labor
A
Opioids minimally decrease progression of labor
18
Q
7 reasons reason to use regional anesthesia ( in relations to labor )
A
1- use of oxytocin
2- Primigravida: pregnant for the first time
3- Prolonged labor
4-Large baby
5- Small Pelvis
6- Fetal malpresentation
7- High requirement for parenteral Opioid
19
Q
Effects of vasopressors on Uterus
A
A1– Uterine contraction
B2 - Uterine relaxation
small dosePhenylephrine - Increase BF to uterus by Increasing BP
20
Q
Use of oxytocin
A
1) To induce labor
2) prevent postpartum hemorrhage.
21
Q
Complications with Oxytocin
A
Fetal Distress Maternal Water retention Hypotension Reflex tachycardia Uterine Tetany
22
Q
What class of med used for Uterine Atony
A
Ergot Alkaloids — Bromocriptine ex..
23
Q
PG F2a used to treat
A
PPH
24
Q
What class drugs are used for PPH
A
Prostaglandins F2a
25
Use of Magnesium in labor
1) Stop premature contractions
| 2) Prevent eclamptic seizures
26
S/E magnesium
```
Hypotension
Heart Block
Muscle weakness
Sedation
Increases blockage for NMB drugs
* Cardiac and Respiratory arrest can occur
```
27
Treatment for Magnesium OD
1) D/C it
2) Calcium
3) Lasix
28
Treatment for maternal hypotension
```
Ephedrine
Oxygen
Left uterine displacement
Fluids
Small dose phenylephrine can be used also.
```
29
Treatment of Unintentional IV injections
Supine with left uterine displacement
| Thiopental and Propofol to stop seizure
30
Unintentional Intrathecal injection
1) Supine with left uterine displacement
2) Ephedrine and IV fluids
3) Intubation and ventilation in high spinal
31
Treatment of Post Dural Headache
```
Bedrest
Hydration
Oral analgesics
Caffeine : 500mg IV
*Blood Patch
```
32
7 signs of Fetal Distress
```
1- Oligohydramnios
2- repetitive late deceleration
3- loss of beat-to-beat variability
4- Fetal uterine growth retardation
5- Scalp pH< 7.2
6-Meconium stained amniotic fluid
7- Fetal heart rate < 80 bpm
```
33
Obesity is
> 20 % of Ideal body weight
| BMI > 30kg/m2
34
Morbid obesity is
Double of Ideal Body weight
| BMI >40kg/M2
35
PFT of obesity indicates
Restrictive lung disease
36
Physiological changes of obesity
Decreased chest wall compliance, Decreased ERV, Decrease FRC ( worse supine ) and increase WOB
With morbid obesity : closing capacity > FRC = V/Q mismatch and arterial hypoxemia
Closing capacity exceeds FRC
37
Obesity effects on drugs volume of distribution
Increased Volume of distribution for lipid soluble drugs
38
Pickwickian Syndrome aka Obesity-hypoventilation syndrome leads to 10 factors :
```
1- Hypercapnia
2- Hypoxemia
3- Pulmonary HTN
4- Systemic HTN
5- Pulmonary edema
6- Cyanosis-induced polycythemia
7- Rales
8- LVH/RVH
9-Somnolence;Poor sleep at night
10- Dependant edema
10-
```
39
The Fetal circulation has 3 shunts . name them and what is their purpose
1) Ductus Venosus : From umbilical vein to the IVC to bypass liver
2) Foramen Ovale: From the right atrium to the left atrium to bypass the lungs
3) Ductus arteriosus: From the pulmonary artery directly the Aorta then to the head
* the shunt bypass the liver and the lungs
40
TTN or Transient Tachypnea of the newborn
Benign, self limiting condition present in infant of any gestitional age , present shortly after birth due to delayed clearance of fluid clearance from the lungs .
Preterm neonates and C-section neonates have low catecholamines released which promotes sodium channel transport leading to greater amount of residual liquid in their lungs
41
Normal Neonate respiratory Rate
30-60 breaths/minute
First breath at 9 seconds— it establishes Neonate FRC.
Breathing should begin at 30 seconds and regular by 90 seconds
42
Fetal lungs contains
Liquid made of ultrafiltrate plasma of 30 mls. 2/3 expelled from the lungs of the neonate by the time of delivery. 1/3 reabsorbed during labor and delivery.
43
Residual lung liquid leads to
Difficulty of initiating breath and maintaining normal breathing pattern
44
Surfactant timeline in the fetus
20 weeks : Present in alveolar lining
28-32 week: within the lumen
34- 38 weeks : Significant amount in the terminal airway
Its production stimulated by chronic maternal stress or corticosteroids
45
Stress during labor and delivery can lead to
the passage of meconium into the amniotic fluid and gasping efforts by the fetus, which may result in the aspiration of amniotic fluid into the lungs.
Meconium—gasping efforts by fetus—aspiration of amniotic fluid into lungs.
46
Catecholamines 4 roles
1) production and release of surfactant
2) transition to active sodium transport for absorption of lung fluid
3) preferential blood flow to vital organs during stress of delivery
4) Thermoregulation of the neonate
47
Explain Non-shivering Thermogenesis of the neonate.
Neonates 1) release Norepinephrine 2) raise their metabolic rate in response to cold = oxidation of brown fat which contains mitochondria. This oxidation leads to the non-shivering thermogenesis. This causes O2 consumption to go up.
48
Thermal Stress is greater in
Preterm neonates, and infants small for gestational age , due to low fat stores.
49
Alternative to evaporation heat loss of neonate
Occlusive wrap rather than drying
less than 28 weeks give polythene wrap/bag
Maintain neutral thermal environment 34-35 degree Celsius
50
Antepartum Risk factors for Resucitation
```
Maternal Diabetes
HTN disorder of pregnancy
Chronic HTN
Fetal anemia or Isoimmunization
Previous fetal or neonatal death
Bleeding in 2nd or 3rd trimester
Maternal infection
Maternal cardiac, pulmonary, thyroid , renal, neurological disease
Poly or Oligohydromnios
Premature Ruptured membrane
Fetal hydrops
Post-term gestation
Multiple gestation
Discrepancy in fetal size and dates ( i.e LMP date )
Drug Therapy : Magnesium, Lithium Carbonate , adrenergic blocking drugs
Maternal substance abuse
Fetal Malformation
Diminished fetal activity
No prenatal care
Maternal age >35 years.
```
51
Meconium is present in the intestinal tract
After 31 weeks and is present in 10-15% of pregnancies
52
Meconium Aspiration Syndrome (MAS)
Respiratory Distress in a neonate whose airway was exposed to meconium and Chest X-ray showing pulmonary consolidation and atelectasis
53
Treatment of MAS
Positive Pressure Ventilation ; but risk of pneumothorax to due air leak
54
Congenital Anomalies that cause upper airway obstruction include:
```
Micrognathia,
macroglossia,
laryngeal webs,
laryngeal atresia,
stenosis ,
subglottic webs,
tracheal agenesis,
tracheal rings
```
55
Congenital High Airway Obstruction Syndrome ( CHAOS)
Exit procedure .
Intrinsic airway obstruction of the larynx or upper trachea (e.g., laryngeal web, subglottic cyst, tracheal atresia) can lead to retention of bronchial secretions and subsequent pulmonary distention; this constellation of s/s = CHAOS
56
To reduce the risk for cerebral palsy in surviving infants.
Maternal administration of magnesium sulfate before anticipated early preterm birth
57
fetal exposure to anesthetic agents may have harmful effects on
neurogenesis and synapse formation in the developing brain.
58
When pathways leading to orderly brain development are deconstructed, three major events appear critical to the establishment of functional synapses.
1) Neuronal proliferation,
2) migration
3) cellular differentiation
* occur in a preordained fashion to establish early neural circuitry.
59
neurogenesis starts and peaks at
5 and 25 weeks’ gestation respectively
60
neuronal migration is completed
between 30 and 36 weeks’ gestation.
61
a robust and exponential increase in synapse formation (almost 40,000 synapses/min) occurs between
28 weeks’ and term gestation
62
By ———————the fetus has all the neural machinery necessary to perceive pain.Many clinicians recommend that appropriate measures should be taken to provide fetal analgesia during fetal surgical procedures from this point onward
24 weeks’ gestation,
63
Although GABA has an inhibitory action in the mature brain, GABA serves——— role during fetal brain development.
an excitatory
64
Pharmacologic interventions (e.g., ethanol, antiepileptic drugs) that act directly or indirectly on these powerful neuromodulator systems induce long-lasting impairment of fetal brain development, mainly owing to impaired neurogenesis and/or altered neuronal migration.20–22 Alteration of this excitation-inhibition balance is purported to be responsible for an array of childhood neurodevelopmental disorders.
1) impaired neurogenesis
| 2) altered neuronal migration
65
fetal blood-brain barrier is morphologically well developed and functionally competent at
Term
66
Cerebral Palsy first described
In 1861 by Dr, John Little . Called Little’s disease.
Non-progressive CNS disorder
Present at birth , impairment of motor function and posture : may or may not be accompanied by intellectual disability .
Various form exist
Causes are unknown
67
The only types of cerebral palsy associated with intrapartum hypoxia are
spastic quadriplegia and, less commonly, dyskinesia.
68
Intellectual disability, learning disorders, and epilepsy should not be ascribed to birth asphyxia unless
accompanied by spastic quadriplegia.
69
No statements about severity should be made before an affected child is
3 to 4 years of age, because mild cases may improve and dyskinesia may not be evident until then.
70
Intrapartum hypoxia sufficient to cause cerebral palsy is always accompanied by
neonatal encephalopathy and seizures
71
Intra-amniotic infection and inflammation show direct evidence of causality between the
intrauterine process and white matter injury.
72
Elevated maternal temperature is one sign of chorioamnionitis, but alone it is insufficient for the diagnosis. Other signs include, but are not limited to,
maternal and fetal tachycardia,
foul-smelling amniotic fluid
uterine tenderness
maternal leukocytosis.
73
Chronic placental insufficiency relatively spares the fetal brain compared with other organ systems, although it results in
reduced fetal brain weight.
74
Unlike the adult brain, the fetal brain can use
ketone bodies and lactate as alternative energy sources.
75
Meperidine most widely studied opioids
Opioids cross the placenta and enter the fetal circulation.
76
When you have a non reactive NST you obtain a Biophysical Profile which Includes 5 things
1) NST
2) AFV ( Amniotic Fluid Volume )
3) Fetal Breathing
4) Fetal Tone
5) Fetal Movement
77
What is a Reactive NST
2 accelerations every 20 minutes
> 32 weeks gestation = HR increase of >15bpm lasting >15 seconds.
<32 weeks gestation + HR increase >10 bpm lasting > 10 seconds.
78
Early decelerations begin ...end...caused by
Early decelerations begin at beginning of contractions and recover at end of contraction. Caused by fetal head compressions
79
The onset of a late decelaration ... and cause
Begins to decrease at the peak of contraction.
Caused by Uteroplacental Insufficiency.
Hypoxia and acidosis : Take blood sample for ABG , If acidotic , ominous sign=head for C-Section.
80
Variable Decelerations
<30 seconds.
| Due to umbilical cord compression.
81
Sinusoidal Pattern
Due to
Fetal Hypoxia
Fetal Anemia
Hemorrhage
82
The mean duration of a singleton pregnancy is
280 days/ 40 weeks
83
Term pregnancy is
37 to 42 weeks and is optimal time for delivery.
84
Preterm Birth
Before 37 weeks
85
Early term birth
37 to 38 weeks
86
Full term is from ..
39-40 weeks
87
Late term is from ...
41 to 42 weeks
88
Determination of gestational age is most accurate when
Ultrasound Measurements of fetus or embryo are taken in the first trimester; preferably up to and including 14 weeks.
89
Pregnancies by assisted reproductive technology ( ART) , EDD
Assigned based on age of embryo and date of transfer
90
Naegele’s rule
Substract 3 month and ass 7 days to first day of last mentrual period
OR : date of assisted reproductive technology
91
Perception of fetal movement in nulliparous , then Parous at
Nulliparous 18-20 weeks
| Parous 16-18 weeks
92
Fundal height at 20 weeks
20 cm above symphysis pubis ( by umbilicus )
93
Fetal hear rate with a Doppler can be detected at
10- 12 weeks
94
Fetal Heart Rate with a non electronic stethoscope at
18 weeks to 20 weeks
95
Routine US recommended due to its ability to
1) Determine gestational age
2) Viability
3) Placental Location
4) Structural abnormalities in the second trimester
5) Fetal number
96
Low maternal gestational birth weight
Increased risk for delivery of small-for-gestational age baby or preterm
97
Higher risk for delivering large for gestitional age baby
Excessive weight gain
98
Abdominal examination had several limitations especially in the setting of
```
Small fetus
Polyhydromnios
Maternal obesity
Multiple pregnancy
Uterine fibrioids
```
99
Abdominal examination is
Safe, well-tolerated, add valuable info on the Antepartum assessment
100
After 36 weeks( max fundal height week) the fetus
Drops into the pelvis in preparation for labor
101
Fetal growth restriction is associated with
```
Intrauterine Demise
Neonatal morbidity
Neonatal mortality
Cognitive Delay in childhood
Chronic disease (Obesity, DM type II, CAD, Stroke in adulthood )
```
102
Definition of Fetal Growth Restriction is
EFW of a fetus at less than the 10th percentile for gestational age
103
SGA Small for gestational age
Newborn with birth weight less than the 10th percentile for gestational age
104
Fetal Growth restriction results from
Suboptimal uteroplacental perfusion and fetal nutrition
| Can be classified as Maternal, Fetal, Placental in causes.
105
Maternal disorders associated with fetal growth restriction
```
Any that will result in vascular disease:
Pregestational Diabetes
HTN
Antiphospholipid antibody syndrome
Renal insufficiency
Autoimmune disease
Malnutrition
Substance abuse
```
106
Fetal conditions associated with Fetal Growth Restriction
Teratogen exposure such as certain medications
Intrauterine infection
Aneuploidy ( presence of abnormal number of chromosomes) : Trisommy 13 and 18
Structural malformations;abdominal wall defects, congenital heart defects.
107
Placental causes for Fetal growth restrictions
Poor placental perfusion : umbilical cord abnormalities ; velamentous or marginal cord insertion.
108
Fetal Growth restriction is associated with
An increased risk for stillbirth. Less than 10th percentile. 1.5% risk less than 5% percentile 2.5%risk
109
Risk for stillbirth further increase when Fetal growth restriction occurs in the context of
Oligohydromnios or abnormal diastolic umbilical artery blood flow
110
Early and acurate diagnosis of fetal growth restriction and ...
Appropriate interventions leas to improvement in perinatal outcome. If Fetal growth restriction is suspected clinically and on the basis of US= Thorough evaluation of mother and fetus is warranted
111
What to do in the setting of FGR?
Serial US to assess amniotic fluid volume and fetal growth
Antenatal surveillance with umbilical artery velocimetry
Antepartum testing : NST and Biophysical Profile
112
Fetal Macrossomia
Growth beyond and absolute birth weight of 4000 to 4500grams regardless of gestational age .
113
Large for Gestational age
Birth weight greater than or equal to the 90th percentile for a given gestational age
114
What is shoulder dystocia ?
Failure of delivery of fetal shoulder after initial attempt at downward traction. It is the most serious consequence of macrosomia .
115
Most serious consequence of macrossomia
Shoulder dystocia
116
Perinatal mortality increased with birth weight
>5000grams
117
Newborn and Mother morbidity increase with weight
4500-4999 grams
118
Risk of labor abnormalities increased with weight
4000 to 4999 grams
119
Fetal injuries associated with shoulder dystocia
Fracture of the clavicle
Nerve injury to brachial plexus paralysis to Erb-Duchenne; most resolve by age 1 year.
Risk of shoulder dystocia at birth weight >4500g is 9 to 14% compared to .2 -3 % with vaginal deliveries and 20-50% in presence of maternal diabetes.
120
Fetal Macrossomia can be determined 2 ways
Clinically by palpation = Leopold Maneuver
Or by Ultrasound
The rate of prediction is poor false positive >false negative.
EFW measurements are accuracy in Macrossomia
121
Factors added to macrossomia leading to less accurate measure of EFW are
1) Low amniotic fluid
2) Maternal obesity
3) Fetal position
4) Advancing gestational age
122
Elective C/S for ...
EFW > 4500g in Diabetic mothers and EFW> 5000g in non Diabetic
123
During labor, decision for C/S if...
EFW >4500g in the setting of prolonged 2nd stage labor or arrest of descent in 2nd stage labor
124
Fetal movement ( quickening ) present
18- 20 weeks for nulliparous
16-18 weeks for parous
Associated with fetal health
125
Normal fetus quickening
20- 50 ( scale 0 - 130) per hour
Fewer movements in the day
Larger movement between 9 pm and 1 am
126
High Risk Pregnancies maternal factors:
```
Preeclampsia
Chronic HTN
Diabetes ( including gestational)
Chronic Cardiac Disease
Chronic Pulmonary Disease
Chronic Renal Disease
Active thromboembolic disease
```
127
High risk pregnancies Fetal Factors
```
Prior unexplained still birth
Isoimmunization
Fetal structural anomalies
Intra Amniotic infection
Fetal Growth restriction
Non reassuring Fetal testing ( fetal compromise)
Multiple pregnancies
```
128
High risk pregnancy Uteroplacental factors
```
Vasa Previa
Placenta Previa
Placenta abruptio
Unexplained oligohydramnios
Prior classic ( high vertical hysterotomy )
Premature rupture of fetal membrane
```
129
Fetal NST also called Fetal cardiotocography investigates
Changes in the fetal heart rate pattern with time and reflects the maturity of the fetal autonomic nervous system; for this reason it is less useful in the very preterm <28 weeks gestation.
* Interpretation is largely subjective
130
Fetal Vibroacoustic stimulation VAS
Response of fetus to vibroacoustic stimulation 82 tp 95 dB applied to the maternal abdomen for 1 -2 seconds. Accelaration of FHR in response to VAS = positive = fetal health
No acceleration in FHR response : do it again up to 3 times with progressive increase in length of time up to 3 seconds
131
Biophysical Profile when the NST alone not sufficient to determine fetal well-being includes 5 variables : ( BPP)
1) NST
2) Amniotic fluid volume
3) Fetal Tone
4) Fetal movement
5) Fetal Breathing movement
132
Contraction stress test (CST) aka Oxytocin challenge test (OCT)
Response of FHR to uterine contraction induced by IV oxytocin or nipple stimulation ( release of endogenous oxytocin from neurohypophysis of mother )
Negative CST = no late declarations or severe late decels in response to contractions = healthy well oxygenated fetus .
133
Doppler Velocimetry
Non invasive, can measure fetal circulation : UA, DV, MCA( umbilical artery , Ductus venosus, middle cerebral artery ) , can measure growth restricted fetus, and growth discordance between twins
134
Umbilical artery
Frequently evaluated in pregnancy
| Has diastolic blood flow
135
Factors that affect placental resistance
Gestational age
Placental location
Pregnancy complications : abroptio, preeclampsia
Underlining maternal disease : ex maternal Chronic HTN
136
First , second and third trimester
1st: 1- 12 weeks
2nd: 14- 27 weeks
3rd: 28 weeks - birth
137
Amniotic Fluid composed of
Water
Lung fluid
Fetal urine
Skin transudate
138
Aminotic Fluid contains
Electrolytes
Proteins
Desquamated fetal cells called amniocytes
139
Amniocentesis can be used to
Measure lecithin and sphingomyelin to assess fetal lung maturity
Look for specific pathogenic bacteria when in amniotic fluid infection
To obtain fetal cells for karyotype or genetic analysis
140
Most common reason for amniocentesis in second trimester
Cytogenetic analysis of fetal cell
| * can be done to measure AFP level and acetylcholinesterase level to determine open neural tube defect .
141
Amniocentesis in the third trimester
1) document pulmonary activity before elective c/s before 39 weeks
2) amnioreduction in pregnancies complicated by polyhydramnios
3) confirm preterm rupture of membrane (PROM)= amnio dye test
4) To exclude amniotic infection .
142
Fetal Hydrops
Fluid accumulation in more than 1 extra vascular fetal compartment : ascites, Pleural infusion, pericardial effusion, subcutaneous edema, placental edema.
Rho (D) immune globulin decreased immune hydrops
