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OB Exam 1 > Module 3: Part 2 > Flashcards

Module 3: Part 2 Flashcards

27-53

1
Q

What happens if you contract against a closed/not adequately dilated cervix?

A

inflammatory processes start
can prevent delivery & require C-section

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2
Q

How can epidurals affect dilation?

A

Can prevent cervical dilation

Some OB MDs do not want epidurals placed after/before a certain dilation point

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3
Q

Changes in OB practice
maternal characteristics

A

higher maternal BMIs
multiple gestations
fertility advances
delayed delivery/increased maternal age

“older, heavier women with late deliveries plus s/o to fertility technology”

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4
Q

Changes in OB practice
Obstetrical characteristics

A

Oxytocin to induce/augment labor

more scheduled inductions vs. spontaneous delivery

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5
Q

Changes in OB practice
anesthesia

A

epidurals!

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6
Q

The Passenger
Lie

A

lie: the relationship of the long axis of the fetus to the long axis of the mother

transverse
oblique
longitudinal

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7
Q

The Passenger

A

The fetus!

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8
Q

Stage 2 (Pelvic Stage)
is the ___ stage

A

Pushing

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9
Q

Stage 2
Distention of …

A

vaginal vault and perineum

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10
Q

Nerves involved in stage 2

A

Sacral 2-4

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11
Q

this starts the second stage

A

Crowning of head and complete cervical dilation

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12
Q

T/F
A preterm fetus doesn’t need 10 cm dilation

A

True

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13
Q

The Cardinal Movements of Labor

A
  • Engagement
  • Descent
  • Flexion
  • Internal rotation
  • Extension
  • External rotation
  • Expulsion

“Every Darn Fetus Is Extremely Eager to Exit”
Engagement, Descent, Flexion, Internal Rotation, Extension, External Rotation, Expulsion

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14
Q

The 3 Components of Labor and Delivery

A

powers: contractions and, in the second stage, the addition of voluntary maternal expulsive efforts)

passageway (the bony pelvis and the soft tissues contained therein)

the passenger: the fetus)

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15
Q

KEYPOINT:
The interaction of these three components determines the success or failure of the labor process.

A

powers
passageway
passenger

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16
Q

Presentation
definition

A

portion of fetus overlying the pelvic inlet

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17
Q

Presentations

A

Cephalic (Vertex, Brow, Face)
Breech
Shoulder

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18
Q

The placental stage is stage # ___

A

3

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19
Q

Stage 3 (Placental Stage)
Begins with …
Ends with

A

delivery of baby
delivery of placenta

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20
Q

Complications during stage 3 (Placental Stage)
(4)

A

Cord separation from placenta
Uterine inversion
Placenta abnormality
Shoulder dystocia

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21
Q

T/F
Stage 3 does not include the use of oxytocin.

A

False
Uses Oxytocin and other uterotonics

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22
Q

In Stage 4, we wanna watch for ____

A

bleeding

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23
Q

The 4 T’s of PP hemmorrhage

A

Tone
Tissue
Trauma
Thrombin

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24
Q

How long does stage 4 last?

A

~1 hour

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25
Q

90% of PP hemorrhage results
from …

A

uterine atony

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26
Q

Retained placenta increases risk for ___ ___ and thus also increases risk of ___ ___

A

uterine atony
PP Hemorhage

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27
Q

View of uterus and baby in stage 1

A

cervix becomes effaced

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28
Q

View of uterus and baby in stage 2

A

crowning

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29
Q

View of uterus and baby in stage 3

A

dat baby gone
placenta still in uterus

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30
Q

FORCEPS Delivery
types

A

outlet
low
Mid

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31
Q

Outlet Forceps Delivery

A

Scalp is visible
Very little traction is needed

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32
Q

Sustained fetal bradycardia is common indication for what type of forceps delivery?

A

Outlet Forceps Delivery

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33
Q

Station Requirements for
Low Forceps Delivery
Mid-Forceps Delivery

A

Low: +2 or greater
Mid: 0 or 1+

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34
Q

Cons of Mid-Forceps Delivery

A

More complicated and possibly
unsuccessful

(done at station 0 or 1+)

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35
Q

T/F
Vacuum Delivery lessens maternal trauma

A

true

36
Q

serious complication of vacuum delivery

A

Intracranial hemorrhage

37
Q

Complications of vacuum delivery

A

Intracranial hemorrhage (most important!)

retinal hemorrhage
hematoma

38
Q

T/F
Vacuum delivery cannot be used in c-section delivery.

A

False
Can be used in vaginal and cesarean deliveries

39
Q

Episiotomy (Natural or Man Made)

A

incision extending either directly posteriorly from 6 o’clock (midline) or in a 45-degree angle to either side (mediolateral)

40
Q

Episiotomy is more common with which fetal position?

A

Emergent deliveries (shoulder dystocia)

41
Q

Agent used for additional analgesia for episiotomy

A

Chloroprocaine

42
Q

Pain mgmt if 3rd or 4th degree tear

A

PCE for pain control after delivery

43
Q

Admission to Labor Floor
Anesthesia Assessment

A

Complete H&P
any testing?
FHR

Gravida, Para, Weeks gestation
Why are they here?
Spontaneous rupture of membranes (SROM)
Active Labor
Induction (elective or indicated)
Vaginal Birth after Cesarean Delivery (VBAC)
Trial of Labor after Cesarean Delivery (TOLAC)

Issues: increase BP or Diabetes (Macrosomia)

44
Q

Increased BP or Diabetes is a/w fetal ____

A

Macrosomia

(growth beyond an absolute birth weight of 4000 g or 4500 g regardless of gestational age; different from large for gestational age (LGA)

45
Q

What would Veronica’s baby look like?

A
46
Q

Retained Placenta
definition

A

Failure to deliver the placenta completely within 30 minutes after delivery of the infant

47
Q

Retained Placenta
risk factors (5)

A

-history of retained placenta
-preterm delivery
-use of oxytocin during labor
-preeclampsia
-nulliparity (never given birth before)

48
Q

Retained Placenta
treatment

A

manual extraction and/or curettage

49
Q

Retained Placenta
How should we deliver anesthesia?

A

depends on amount of blood loss
manual vs operative extraction

50
Q

Use of nitroglycerin in retained placenta

A

uterine relaxation
rapid, reliable smooth muscle relaxation

boluses rarely lead to sustained hypotension (short 1/2L)
but
vigilant blood pressure monitoring still needed

51
Q

Retained Placenta is a leading cause of (2)

A

primary and secondary Postpartum hemorrhage

52
Q

Uterine Inversion

A

all or part of the uterus is inside-out

53
Q

Are we concerned about Uterine Inversion?

A

Yes!
rare but can become life-threatening

54
Q

How does the uterus change if its inverted?

A

Fundus moves through the vagina

if placenta is partially or completely separated, bleeding will be excessive

55
Q

Uterine Inversion is worsened by …

A

concurrent vagal reflex-mediated bradycardia

56
Q

The OBGYN tells you mom’s uterus is inverted. What do you do?

A

NO uterotonics (stop Pitocin)
Nitroglycerin (200 to 250 µg)
Pressors & fluids (d/t large dose of nitro)
O2
possible trip to OR (laparotomy)

GET HELP!
GET BLOOD!

57
Q

Uterotonic mgmt in Uterine Inversion

A

During replacement, do not use!

After its replaced, use!
Once uterus is replaced it should be firm, well-contracted

58
Q

In which two, is vaginal delivery impossible unless the fetus is very immature?

A

Tranverse & oblique

I mean look at those positions. That just looks impossible lol

59
Q

The OBGYN’s job in a uterine inversion

A

right the inversion by applying pressure through the vagina to the uterine fundus

ring forceps on the cervix to apply countertraction

Insert intrauterine balloon to prevent reinversion

60
Q

turtle sign

A

the (often large) head is delivered, it seems to be “sucked” back into the perineum

61
Q

The turle signs warns us of…

A

shoulder dystocia

emergency!

62
Q

shoulder dystocia

A

anterior shoulder is trapped above the pubic symphysis

63
Q

Why is shoulder dystocia an emergency?

A

If delivery is not accomplished soon, umbilical cord compression may result in asphyxia.

64
Q

Why can happen to the baby as the OBGYN attempts to fix the shoulder dystocia?

A

Excessive traction on head ~damage to brachial plexus (e.g., Erb palsy) (permanent or temporary)

manipulations may fracture clavicle or humerus

65
Q

Risk Factors for Shoulder Dystocia

A
66
Q

T/F
Mom cannot have an epidural or spinal if there’s shoulder dystocia

A

False

Neuraxial anesthesia is ideal but not essential

67
Q

Shoulder Dystocia Management
-OBGYN’s job
(4)

A

Suprapubic pressure toward the floor along with gentle traction on the head

McRoberts Maneuver: hyperflexion of mothers legs

Vaginal manipulation: attempt to deliver the posterior shoulder (episiotomy or extension)

Zavanelli Maneuver: cephalic replacement and stat Cesarean section

68
Q

The OBGYN’s attempts to fix the Shoulder Dystocia have failed. He now tells you he is going to reverse the mechanism of labor. What is your job as anesthesia?

A

tocolysis:
A) sublingual or IV NTG 100 µg
B) subQ or IV terbutaline 0.25 mg
C) GA + a volatile agent

After the fetal head has been placed back into the vagina, prompt cesarean delivery is performed

What the OBGYN is currrently doing:
position of the vertex is rotated back to the position prior to external rotation (usually occiput anterior), flexion is achieved, and the head is elevated

69
Q

Gate control theory

A

regulation of pain signals from the peripheral nerve to the spinal cord by the activity of other peripheral nerves, interneurons in the spinal cord, and central supraspinal centers

70
Q

McGill Pain Questionnaire

A

A comparison of pain scores from:
women in labor
pts in a general hospital clinic
ER pts after traumatic injury

Note the modest difference in pain scores between nulliparous women with and without prepared childbirth training. PRI, Pain rating index, which represents the sum of the rank values of all the words chosen from 20 sets of pain descriptors

71
Q

The McGill Pain Questionnaire findings (3)

A

nulliparous women with no prepared childbirth training: “labor pain = digit amputation without anesthesia”

positive correlation between cervical dilation and pain intensity

cervical distention is the primary cause of pain during the first stage of labor

72
Q

Pain Pathways During Labor

A

Uterus and cervix:
T10 to L1 - L2
Pain impulses carried in visceral afferent type C fibers

Vagina and Perineum:
S2-S4
Pain impulses carried by somatic nerve fibers and pudendal nerves

73
Q

Effect of Pain and Labor on the Mother
(4)

A
  • ↑ SNS activity = ↑ catecholamines (esp Epi)
  • ↑ catecholamines = ↑ maternal CO & PVR;↓uteroplacental perfusion
  • Intermittent hyperventilation-hypoventilation syndrome
  • ↑ gastrin release & motility = ↑ acidity & volume
74
Q

T/F
Chronic pain can result from labor pain

A

True

75
Q

KEYPOINT
T/F
Acute postpartum pain after either vaginal or cesarean delivery deserves attention and treatment

A

True

76
Q

KEYPOINT

Pain in the first stage
vs
second stage of labor

A

Frist stage: visceral pain; lower uterus & endocervix

Second stage: somatic pain; vagina & perineum; briefer than the first stage.

77
Q

KEYPOINT

The activation of ____ sites is the primary mechanism of action for distraction methods of analgesia

A

suprathalamic

78
Q

Keypoint

Pain transmission in the spinal cord is not hardwired and it is altered by local neuronal activity that releases ___ and descending pathways that release __ & ___.

A

µ-opioid receptor agonists

α2-adrenergic and serotonergic receptor agonists

79
Q

On Initiation of Labor Analgesia, which reflex do we see?

A

Ferguson’s reflex: stretching of the cervix augments uterine activity thru oxytocin release

  • Neural input from ascending spinal tracts to midbrain
  • strong, expulsive uterine contractions
  • Questionable prolonged labor if neuraxial analgesia inhibits this reflex
80
Q

On Initiation of Labor Analgesia,
Transient period of….

A

hyperstimulation or transient fetal bradycardia

81
Q

On Initiation of Labor Analgesia, there is a reduction of …(2)

A

1) plasma Epi levels decrease and thus…
2) beta-adrenergic tocolysis decreases as well

82
Q

T/F
Labor pain increases sympathetic activity & epinephrine levels which facilitates myometrial contractions.

A

FALSE
“epinephrine and its associated beta-adrenergic tocolytic effects on the myometrium”

83
Q

After giving mom spinal anesthesia, there is a period of uterine (hypo/hyper)stimulation, which results in….

A

Hyperstimulation!

transient fetal stress & fetal heart rate abnormalities

Epi causes tocolysis thru B activity

84
Q

Maternal Complications of Paracervical Block
(6)

Box 24.1

A
  • Vasovagal syncope
  • Laceration of the vaginal mucosa
  • Local anesthetic systemic toxicity
  • Parametrial hematoma
  • Postpartum neuropathy
  • Paracervical, retropsoal, or subgluteal abscess
85
Q

Paracervical Block
Fetal Complications

A
  • bradycardia (most common)
  • direct injection of LA into scalp (LA toxicity)

OB Exam 1 (13 decks)

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