Module 8 - High-Risk Obsterical Emergencies Flashcards
1
Q
- You arrive on the scene of twenty-one-year-old woman involved a single roll-over accident, who is approximately twenty-eight weeks pregnant. Your assessment reveals palpation of fetal parts over the abdomen. What is your diagnosis of the patient?
A. Liver laceration
B. Uterine rupture
C. Placenta previa
D. Abruptio placenta
A
- B: Signs and symptoms of uterine rupture include severe, sudden, continual abdominal pain and signs of hypovolemic shock. Contractions may cease or may increase in intensity and frequency. Shoulder (referred pain known as Kehr’s sign) or chest pain as a result of the collection of blood under the diaphragm, generalized tenderness with rebound, an abdominal mass with fetal parts easily felt, or vaginal bleeding is likely when the rupture occurs in the lower uterine segment. Most bleeding is intra-abdominal and the abdomen may be distended.
2
Q
- The patient is in a breech presentation and delivery appears to be halted upon delivery of the head. The appropriate action would be to
A. Initiate rapid transport, placing mother in a knee-chest position
B. Administer tocolytic agents
C. Perform Trousseau’s maneuver
D. Perform Mauriceau’s maneuver
A
- D: Mauriceau’s maneuver is a method of delivering the head in an assisted vaginal breech delivery in which the infant’s body is supported by the right forearm while traction is made upon the shoulders by the left hand. The fetal head is maintained in a flexed position by using the Mauriceau’s maneuver, which is performed by placing the index and middle fingers over the maxillary prominence on either side of the nose. The fetal body is supported in a neutral position, with care to not overextend the neck. In the breech presentation, the baby enters the birth canal with the buttocks or feet first as opposed to the normal head first presentation. Certain factors can encourage a breech presentation. Prematurity is likely the chief cause. There are either three or four main categories of breech births, depending upon the source. Total breech extraction is where the fetal feet are grasped, and the entire fetus is extracted. Total breech extraction should be used only for a noncephalic second twin; it should not be used for a singleton fetus because the cervix may not be adequately dilated to allow passage of the fetal head.
3
Q
- Your patient is experiencing hypertonic uterine contractions. Appropriate therapy would be to
A. Turn the patient on their side
B. Discontinue all tocolytic medications
C. Discontinue any oxytocin administration
D. Administer Celestone
A
- C: A hyperstimulated uterus may have fewer than five contractions in ten minutes, but the interval between contractions is less than one minute. Another term used to describe long, strong contractions is “titanic.” An overdose of oxytocin may cause this type of uterine activity.
4
Q
- The patient fetus is exhibiting variable decelerations. This is most likely due to
A. Uterine insufficiency
B. Cord problems (prolapse, nuchal, short, compression)
C. Placenta abruption
D. Normal neurological waveform
A
- B: Variable decelerations can occur at any time during a contraction. The shape may also vary and is frequently V-shaped or W-shaped. Cord compression is responsible for these decelerations, which have a very characteristic appearance; frequently a short acceleration is observed, followed by a rapid deceleration for some seconds, then a rapid rise and a short acceleration before there is a return to the fetal heart rate (FHR) baseline. There are two keys in to interpreting FHR tracings: one is to focus on assessment of variability and second is to accurately identify the type of deceleration.
5
Q
- Late decelerations may indicate
A. Cord compression
B. Acidosis
C. Anemia
D. Uterine placental insufficiency
A
- D: A late deceleration is one that begins close to the apex of the contraction, gradually decelerates, and gradually returns to the FHR baseline after the contraction is over. Late decelerations always indicate uteroplacental insufficiency; there is inadequate oxygen exchange in the placenta during a contraction. When a contraction is stronger, the insufficiency is greater and the deceleration is proportional. Late decelerations are one of the most ominous fetal heart rate patterns.
6
Q
- The second stage of labor ends with
A. Crowning
B. Onset of contractions
C. Dilation of the cervix
D. Delivery of the infant
A
- D: The four stages of the childbirth process are based on changes in the uterus and cervix as labor progresses. The first stage of labor begins at the onset of labor and ends when the cervix is 100% effaced and completely dilated to 10 centimeters. This is the longest stage of labor and can last 12-17 hours. The second stage begins when the cervix is completely effaced and dilated and ends with the birth of the baby, lasting about 1-2 hours. The third stage begins with the birth of the baby and ends with the delivery of the placenta. This is the shortest stage of labor, lasting 15-20 minutes. The fourth stage begins with delivery of the placenta and ends 1-2 hours after delivery.
7
Q
- The fetus of a pre-eclamptic mother during labor will commonly experience
A. Tachycardia
B. Late decelerations
C. Sinusoidal waveform
D. None of the above
A
- B: Uteroplacental insufficiency may result from pregnancy-induced hypertension (PIH), diabetes mellitus (DM), cardiovascular or kidney disease, chorioamnionitis, smoking, and a fetus that is past maturity. It may also result from decreased placental perfusion in placental abruption or previa, uterine hypertonus as a result of oxytocin stimulation and hypotension.
8
Q
- Normal magnesium level value is
A. 0.6-1.4
B. 3.5-4.5
C. 1.5-2.5
D. 6-23
A
- C: Normal serum magnesium level ranges from 1.5-2.5. Therapeutic serum magnesium levels to prevent seizures range from approximately 4-8 mEq/L. When therapeutic levels are achieved, deep tendon reflexes will be depressed but not absent. Loss of deep tendon reflexes indicates a toxic level. Respiratory arrest and cardiac arrest are seen with high toxic levels >15 mEq/L. While a patient is receiving intravenous magnesium sulfate, frequent assessment of deep tendon reflexes is essential. Respirations should also be closely monitored and the infusion stopped if less than twelve breaths per minute. Pulse oximetry should be used during transport. The antidote for magnesium sulfate toxicity is calcium gluconate. Calcium stimulates the release of acetylcholine, stimulating nerve transmission to the muscle. The recommended dosage of calcium gluconate is 1 gram of a 10% solution administered intravenously over at least three minutes. If administered too rapidly, bradycardia and dysrhythmias may occur.
9
Q
- Preeclampsia is characterized by of the following, except
A. Hypertension
B. Edema
C. Proteinuria
D. Seizures
A
- D: Pregnancy-induced hypertension (PIH) refers to a group of hypertensive disorders that have their onset during pregnancy and resolve after pregnancy. Gestational hypertension develops after twenty weeks gestation without evidence of hypertension. Preeclampsia is characterized by hypertension, proteinuria, and edema. Eclampsia refers to the development of clonic and tonic seizures.
10
Q
- The fetus’s variability is
A. The best indicator of fetal viability
B. Normally 10-15 beats per minute
C. Expected to increase during active labor
D. All of the above
A
- D: Normal variability is indicative of an adequately oxygenated autonomic nervous system. Variability is the single most important factor in predicting fetal well-being. Variability is defined as fluctuations in the fetal heart rate baseline that are two cycles per minute or more and that are irregular in amplitude.
11
Q
- Sinusoidal patterns are commonly associated with all of the following, except
A. Fetal hypovolemia or anemia
B. Accidental tap of the umbilical cord during amniocentesis
C. Pregnancy-induced hypertension
D. Placental abruption
A
- C: A uniform sine wave pattern indicates fetal hypovolemia or anemia and may occur in cases of erythroblastosis fetalis, accidental tap of the umbilical cord during amniocentesis, fetomaternal transfusion, placental abruption, or another type of accident. Variability will be absent or minimal and accelerations are not seen. When this pattern is recognized, rapid delivery is usually recommended. A pseudosinusoidal or undulating pattern may be identified and can be associated to maternal drug administration of narcotics. The pseudo-sinusoidal FHR pattern appears very similar to the sinusoidal pattern; however, this pattern shows less regularity in the shape and amplitude of the variability waves. This type of pattern is benign and transient and can occur in the presence of narcotics. A saltatory FHR pattern is rapidly occurring couples of acceleration and deceleration causing relatively large oscillations of the baseline fetal heart rate. This pattern is usually caused by acute hypoxia or mechanical compression of the umbilical cord. It is considered a nonreassuring pattern, but it is not usually an indication for immediate delivery. A reassuring FHR pattern is the presence of fetal heart rate accelerations. This usually indicates there is no academia and is generally indicative of fetal well-being. In most cases, moderate variability is also reassuring but few studies exist to support this contention. When the fetal heart has absent or minimal variability without spontaneous accelerations and the fetal heart rate status does not change despite intervention, these findings are nonreassuring. A nonreassuring FHR pattern is the standard terminology to be used to describe threats to fetal well-being or indicators of fetal compromise. This term replaces such terms as fetal distress or fetal stress.
12
Q
- You are transporting a twenty-five year-old G1, PO female who is twenty-eight weeks gestation with a history of presenting to the ER department with headache, hyperreflexia, nausea, vomiting, epigastric pain, and dyspnea. Assessment revealed moist rales on auscultation, wheezing with tachycardia seen on the cardiac monitor. When evaluating her lab results, consumptive thrombocytopenia unaccompanied by any other coagulation factor abnormalities is characteristic of HELLP syndrome, which is defined as a platelet count of less than
A. 200,000/mm3
B. 140,000/mm3
C. 100,000/mm3
D. 50,000/mm3
A
- C: HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) is considered a complication of severe preeclampsia. HELLP syndrome is a life-threatening obstetric complication usually considered to be a variant of preeclampsia. Both conditions usually occur during the later stages of pregnancy or sometimes after childbirth. A platelet count lower than 100,000/mm−3 is characteristic of HELLP syndrome. Complications of PIH include eclampsia, placental abruption, pulmonary edema, DIC, hemolytic anemia, thrombocytopenia, preterm delivery, prematurity, IUGR, and HELLP. The only effective treatment is prompt delivery of the baby. Several medications have been investigated for the treatment of HELLP syndrome, but evidence is conflicting as to whether magnesium sulfate decreases the risk of seizures and progress to eclampsia. The DIC is treated with fresh, frozen plasma to replenish the coagulation proteins, and the anemia may require blood transfusion. In mild cases, corticosteroids and antihypertensives (labetalol, hydralazine, nifedipine) may be sufficient. Intravenous fluids are generally required.
13
Q
- After administering fluid resuscitation, performing vigorous fundal massage and giving oxytocin, your patient continues with postpartum hemorrhage. Which drug would be indicated to decrease blood loss?
A. Apresoline
B. Methergine
C. Terbutaline
D. Magnesium sulfate
A
- B: Methylergonovine (Methergine), 0.2 mg administered intramuscularly or intravenously, is recommended. Methylergonovine should be used cautiously in patients with PIH because of the pressor effects that may result in further elevated blood pressure. Methylergonovine is a blood vessel constrictor and smooth muscle agonist most commonly used to prevent or control excessive bleeding following childbirth and spontaneous or elective abortion. It also causes uterine contractions to aid in expulsion of retained products of conception after a missed abortion and to help deliver the placenta after childbirth. Side effects can include nausea, vomiting, diarrhea, cramping, dizziness, pulmonary hypertension, coronary artery vasoconstriction, and severe systemic hypertension (especially in patients with preeclampsia).
14
Q
- When administering magnesium sulfate, the following adverse reactions can occur, except
A. Transient drop in blood pressure
B. Flushing
C. Increase in FHR variability
D. Nausea and vomiting
A
- C: Magnesium sulfate is not an antihypertensive agent. However, a transient drop in blood pressure after initiation of treatment is frequently seen and can be attributed to smooth muscle relaxation. Adverse reactions include flushing, diaphoresis, nausea, vomiting, and drowsiness. A decrease in FHR variability may be observed. The drug is primarily excreted in the urine; toxicity may develop rather rapidly in the patient with significantly impaired kidney function.
15
Q
- Hemolytic disease of the newborn can be prevented by the administration of which of the following to a Rhesus negative mother who had a pregnancy with a Rhesus positive infant?
A. Albumin
B. Rho(D) immune globulin
C. Steroids
D. Indomethacin
A
- B: The commonly used terms Rh factor, Rh positive, and Rh negative refer to the D antigen only. Rho(D) immune globulin is a medicine solution of IgG anti-D (anti-RhD) antibodies used to prevent the immunological condition known as Rhesus disease (or hemolytic disease of newborn). The disease ranges from mild to severe. When the disease is mild, the fetus may have mild anemia with reticulocytosis. When the disease is moderate or severe, the fetus can have a more marked anemia and erythroblastosis (erythroblastosis fetalis). When the disease is very severe, it can cause morbus hemolyticus neonatorum, hydrops fetalis, or stillbirth. During any pregnancy, a small amount of the baby’s blood can enter the mother’s circulation. If the mother is Rh negative and the baby is Rh positive, the mother produces antibodies (including IgG) against the Rhesus D antigen on her baby’s red blood cells. During this and subsequent pregnancies, the IgG is able to pass through the placenta into the fetus and if the level of it is sufficient, it will cause destruction of Rhesus D positive fetal red blood cells, leading to the development of Rh disease. The medication has an FDA Pregnancy Category C. It is given by intramuscular injection as part of modern routine antenatal care at about twenty-eight weeks of pregnancy, and within seventy-two hours after childbirth. It is also given after antenatal pathological events that are likely to cause a fetomaternal hemorrhage.
16
Q
- Frequency of a contraction is defined as
A. End of a contraction to the beginning of the next contraction
B. End of contraction to the end of the next contraction
C. Beginning of contraction to the end of the contraction
D. Beginning of the contraction to the beginning of the next contraction
A
- D: Frequency shows how far apart your contractions are.
17
Q
- Duration of a contraction is defined as
A. End of a contraction to the beginning of the next contraction
B. End of contraction to the end of the next contraction
C. Beginning of contraction to the end of the contraction
D. Beginning of the contraction to the beginning of the next contraction
A
- C: Duration shows how long your contractions last.
18
Q
- Gravida means
A. Total number of live births
B. Total number of pregnancies
C. Term gestation thirty-seven weeks and greater
D. Total number of miscarriages
A
- B: Gravida indicates the total number of pregnancies a woman has had, regardless of whether they were carried to term. Para indicates the number of viable (>20 weeks) births. Note: pregnancies consisting of multiples, such as twins or triplets, count as one birth.
19
Q
- You are transporting a twenty-three-year-old female from a small rural hospital with a diagnosis of preterm labor. Her fundal height is measured just slightly above the umbilicus. Your patient is approximately in how many weeks’ gestation?
A. 16-20 weeks
B. 20-24 weeks
C. 24-28 weeks
D. 28-32 weeks
A
- B: The fundal height is measured from the top of the pubic bone to the top of the uterus and is generally measured in centimeters. It’s a measurement, as you might suspect, that should increase as the pregnancy continues toward the estimated date of confinement (EDC). The fundal height can be out of sync with what’s expected for the gestational age due to abnormal conditions such as, oligohydramnios (too little fluid, taking away from the entire mass effect, leading to a smaller fundal height), hydramnios, polyhydramnios (too much fluid, indicating possibly genetic problems or anatomical problems with the baby), and abnormal position of the baby close to term. [image chart]
20
Q
- The most common site for an ectopic pregnancy to occur is the
A. Os
B. Uterus
C. Fallopian tube
D. Cervix
A
- C: Most ectopic pregnancies occur in the fallopian tube (so-called tubal pregnancies), but implantation can also occur in the cervix, ovaries, and abdomen. An ectopic pregnancy is a potential medical emergency, and, if not treated properly, can lead to death. Clinical presentation of ectopic pregnancy occurs at a mean of 7.2 weeks after the last normal menstrual period, with a range of five to eight weeks. Shoulder pain (Kehr’s sign) is caused by free blood tracking up the abdominal cavity and irritating the diaphragm and is an ominous sign.
21
Q
- When managing preterm labor, all of the following medications can decrease or stop uterine activity, except
A. Apresoline
B. Magnesium sulfate
C. Terbutaline
D. NSAIDs
A
- A: Hydralazine (Apresoline) acts by relaxing arterioles and decreasing vasospasm, and as a result, it reduces blood pressure and stimulates cardiac output. Hydralazine is recommended when the diastolic blood pressure is 100 mmHg or greater. Two milligrams administered intravenously every five minutes until the diastolic blood pressure ranges between 90-100 mmHg.
22
Q
- The administration of which of the following medications can help decrease the chance that the fetus will have respiratory distress syndrome when born?
A. Magnesium sulfate
B. Ritodrine
C. Betamethasone
D. Indomethacin
A
- C: Betamethasone (Celestone) is a steroid used to stimulate fetal lung maturation (prevention of ARDS) and to decrease the incidence and mortality from intracranial hemorrhage in premature infants. It is given to the pregnant mother as an injection into muscle tissue. The use of betamethasone can decrease the chance that the fetus will have respiratory distress syndrome when born. It is usually used if preterm delivery is a concern. Dexamethasone (Decadron) can also been used, which is very similar. Side effects may include sleeplessness and higher blood sugar levels for the mother and decreased fetal movement for the baby.
23
Q
- When evaluating the following FHR strip, you would interpret the strip as having
A. Moderate baseline variability
B. Late decelerations
C. Fetal bradycardia
D. Variable decelerations
A
- A: The presence of moderate variability is strongly predictive of normal fetal acid-base status.
24
Q
- Which of the following terms best describes an intermittent, painless contraction that may occur every ten to twenty minutes after the first trimester of pregnancy?
A. Abruptio placenta
B. previa
C. True labor
D. Braxton Hicks
A
- D: A Braxton Hicks contraction might get closer together but not consistently, or they may feel stronger but go away with activity and/or rest. These contractions were first described in 1872 by British gynecologist John Braxton Hicks. Sometimes these contractions are also called prelabor contractions or Hicks sign. Not everyone will notice or experience these contractions, and some pregnant mothers will have them frequently.
25
Q
- Regular and rhythmic contractions that produce progressive cervical changes after the twentieth week of gestation and before the thirty-seventh week is known as
A. Braxton Hicks contractions
B. False labor
C. Preterm labor
D. True labor
A
- C: Preterm is defined at before the thirty-seventh week. Preterm labor does not always result in preterm delivery. Generally true labor contractions will get longer in length, closer in frequency, and stronger in intensity.
26
Q
- A small amount of fluid is spread on a slide and allowed to dry completely. A frond crystallization pattern of dried amnionitc fluid (with high concentration of sodium chloride) will be seen under microscopic examination. The test finding is called
A. Positive ferning
B. Positive pooling
C. Positive SROM
D. Positive PROM
A
- A: This test is based on the ability of amniotic fluid to form a fern pattern when air-dried on a glass slide; this phenomenon in part due to the fluid’s protein and sodium chloride content. A vaginal liquid pool specimen is obtained, allowed to dry completely in room air, and examined microscopically. A positive screen is depicted by the presence of fernlike patterns characteristic of amniotic fluid crystals.
27
Q
- Nitrazine paper will turn what color in the presence of amniotic fluid?
A. Yellow
B. Red
C. Green
D. Blue
A
- D: Nitrazine paper is impregnated with an indicator dye Phenaphthazine. The color changes as pH changes, giving a broad range of colors from yellow through blue. It is used to test vaginal pH during late pregnancy to determine the breakage of the amniotic sac. While vaginal pH is normally acidic, a pH above 7.0 can indicate that the amniotic sac has ruptured (nitrazine paper will turn blue). More sensitive than litmus paper, nitrazine indicates pH in the range of 4.5 to 7.5. An elevated vaginal pH can also be associated with bacterial vaginosis.
28
Q
- Labetalol—
A. Acts at the neuromuscular junction to slow transmission of impulses.
B. Is a selective mixed alpha-beta adrenergic antagonist agent that decreases systemic vascular resistance without changing cardiac output.
C. Acts by relaxing arterioles and decreasing vasospasm, which results in reducing blood pressure and stimulating cardiac output.
D. Is a vasodilator used to relax a hypertonic uterus during delivery.
A
- B: Labetalol (Normodyne, Trandate) is a mixed alpha/beta adrenergic antagonist, which is used to treat high blood pressure. It has a particular indication in the treatment of pregnancy-induced hypertension which is commonly associated with preeclampsia. It is also used to treat chronic hypertension of pheochromocytoma and hypertensive crisis. It works by blocking these adrenergic receptors, which decreases peripheral vascular resistance without significantly altering heart rate or cardiac output. The standard dosage when managing pregnancy-induced hypertension is 20 mg administered by intravenous push over two minutes and may be repeated as needed every ten minutes with 40-80 mg until the maximum dose of 300 mg has been administered.
29
Q
- A patient exhibiting signs and symptoms of magnesium sulfate toxicity can present with all of the following, except
A. Deteriorating loss of consciousness
B. Respiratory depression
C. Depressed deep tendon reflexes
D. Increased deep tendon reflexes
A
- D: Excess magnesium sulfate results in magnesium sulfate toxicity, which results in both respiratory depression and a loss of deep tendon reflexes (hyporeflexia). The kidneys are efficient at excreting excess magnesium and it is unlikely that the mineral will accumulate to toxic levels. A high intake of magnesium might impair absorption and use of calcium. Frequently monitor patients’ vital signs, oxygen saturation, deep tendon reflexes, and level of consciousness (also fetal heart rates and maternal uterine activity if the drug is used for preterm labor). Assess patients for signs of toxicity (e.g., visual changes, somnolence, flushing, muscle paralysis, respiratory depression, loss of patellar reflexes) or pulmonary edema. Calcium gluconate is the antidote for magnesium sulfate toxicity. Rapid intravenous injections of calcium gluconate may cause vasodilation, cardiac arrhythmias, decreased blood pressure, and bradycardia. Intramuscular injections may lead to local necrosis and abscess formation. Extravasation of calcium gluconate can lead to cellulitis.
30
Q
- You are transporting a twenty-four-year-old female, twenty- eight-week gestation, G2, P1, who presents to the ER department complaining of lower abdominal contractions every 5-10 minutes. She has a history of myasthenia gravis and gestational diabetes. Which of the following medications would not be administered to control uterine activity? A. Magnesium sulfate B. Terbutaline C. Nifidipine D. Nicardipine
A
- A: Myasthenia gravis and renal failure are contraindications for the use of magnesium sulfate. The recommended dose is 4-6 grams intravenous bolus given slowly over 15-30 minutes, followed by a maintenance infusion drip of 1-5 grams/hour on an infusion pump (average infusion is 2 grams/hour).
31
Q
- A patient presenting with shoulder pain and lower abdominal pain with a history of having her last menses approximately 6-8 weeks, is most likely exhibiting which of the following?
A. Missed abortion
B. Ectopic pregnancy
C. Pelvic inflammatory disease
D. Spleen injury
A
- B: An ectopic pregnancy is a complication of pregnancy in which the pregnancy implants outside the uterine cavity. With rare exceptions, ectopic pregnancies are not viable. Furthermore, they are dangerous for the mother, internal bleeding being a common complication. Clinical presentation of ectopic pregnancy occurs at a mean of 7.2 weeks after the last normal menstrual period, with a range of five to eight weeks. Shoulder pain (Kehr’s sign) is caused by free blood tracking up the abdominal cavity, irritating the diaphragm and is an ominous sign.
32
Q
- Which of the following can be a serious complication if, Terbutaline is administered to an insulin-dependent pregnant diabetic patient?
A. Hypoglycemia
B. Hypocalcemia
C. Hemolysis, elevated liver enzymes and low platelets
D. Transient hyperglycemic response
A
- D: Tocolytics are medicines that attempt to stop labor. The typical dosage of Terbutaline (brethine) is 0.25 mg subcutaneously every twenty minutes to three hours. The drug is discontinued if the maternal heart rate exceeds 120 beats/minute. Terbutaline is contraindicated if the mother has cardiac dysrhythmia. The principal maternal adverse effects are hyperglycemia, cardiac dysrhythmias, myocardial ischemia, pulmonary edema, hypotension, and tachycardia. The infrequent fetal and newborn adverse effects are fetal tachycardia, hyperinsulinemia, hyperglycemia, myocardial and septal hypertrophy, and myocardial ischemia. Because of the risk of hyperinsulinemia, newborns may develop hypoglycemia.
33
Q
- Macrosomia refers to
A. Intrauterine growth restriction
B. A fetus that is large for gestational age, with increased fat deposition, and an enlarged spleen and liver
C. Fetal distress
D. Hydramnios
A
- B: The term macrosomia is used to describe a newborn with an excessive birth weight. It is seen more commonly when the mother has gestational diabetes mellitus (GDM) or diabetes mellitus (DM) without vasculopathy. Macrosomia, as defined by birth weight greater than 4,000-4,500 g (8 lb 13 oz to 9 lb 15 oz), occurs with higher frequency in prolonged pregnancies that continue beyond the expected delivery date. It has also been defined as greater than 90% for gestational age after correcting for neonatal sex and ethnicity. Based on these definitions, macrosomia affects 1-10% of all pregnancies. Cephalo-pelvic disproportion exists when the capacity of the pelvis is inadequate to allow the fetus to negotiate the birth canal. This may be due to a small pelvis, a nongynecoid pelvic formation, a large fetus, or a combination of these factors.
34
Q
- Inversion of the uterus may occur with any of the following, except
A. Hypertonic uterus
B. Excessive cord traction
C. Fundal pressure
D. Uterine atony
A
- A: Uterine inversion is a rare medical emergency in which the corpus turns inside out and protrudes into the vagina. The uterus is most commonly inverted when too much traction is applied to the umbilical cord in an attempt to deliver the placenta. Excessive pressure on the fundus during delivery of the placenta, a flaccid uterus, or placenta accreta (abnormally adherent placenta) can contribute. Treatment is immediate manual reduction by pushing up on the fundus until the uterus is returned to its normal position. If the uterus has contracted, a tocolytic agent can relax the uterus to allow replacement. If the placenta is still attached, the uterus should be replaced before the placenta is removed. Removing the placenta before attempting to replace the uterus may increase hemorrhage. Because of discomfort, IV analgesics and sedatives or a general anesthetic are sometimes needed. Once the uterus is replaced and the placenta has been delivered, oxytocin (Pitocin) infusion should be started. Refer to the table for review of delivery complications.
35
Q
- Which of the following has been recognized as a primary cause of preterm labor?
A. Hypertonic uterus
B. Trauma
C. Infection
D. No prenatal care
A
- C: Infection has been recognized as a primary cause of preterm labor. Sources of infection may include urinary tract infection, pyelonephritis, vaginitis, chorioamnionitis, and viral infection.
36
Q
- Signs and symptoms of preeclampsia include all of the following, except
A. Headache
B. Epigastric pain
C. Visual disturbances
D. Seizures
A
- D: Eclampsia can occur befor labor, during labor, or early into the postpartum period. Headache, visual disturbances, epigastric pain, apprehension, anxiety, and hyperreflexia with clonus in a patient with severe preeclampsia are signs of impending eclampsia. Seizures are characterized by clonic and tonic activity and usually begin around the mouth in the form of facial twitching.
37
Q
- The baseline variability for the following fetal tracing is
A. Absent
B. Mild
C. Moderate
D. Marked
A
- A: Absent and minimal variability may be precipitated by fetal hypoxia, administration of drugs to mother, smoking, extreme prematurity, and fetal sleep. The fetus will have frequent sleep periods ranging from 20-40 minutes. Marked variability of more than twenty-five beats per minute may be one of the earliest signs of hypoxia. The presence of moderate variability is strongly predictive of normal fetal acid-base status. Absent variability is an ominous finding, especially when it occurs in conjunction with late or variable declerations. Assessment of variability is an important part of interpreting a fetal heart rate (FHR) pattern. Baseline FHR is defined as fluctuations in the baseline of irregular amplitude and frequency. These fluctuations are quantified in terms of the amplitude of the peak-to-trough in beats per minute (BPM). Baseline FHR variability is determined on a ten-minute segment of the FHR strip. FHR variability is assigned to one of four possible categories: Baseline FHR variability Category Definition Absent No peak-to-trough changes in FHR detected Minimal Amplitude is >0 and ≤5 BPM Moderate Amplitude is 6-25 BPM Marked Amplitude is >25 BPM
38
Q
- Interpret the following fetal tracing
A. Variable decelerations
B. Late decelerations
C. Sinusoidal pattern
D. Hypertonic contractions
A
- C: Sinusoidal FHR pattern, which are excluded from the definition of variability are described as a smooth, sine wave-like pattern of regular frequency and amplitude.
39
Q
- Preeclampsia most commonly occurs during
A. First trimester
B. End of second trimester, beginning of third trimester
C. Third trimester
D. End of third trimester
A
- B: Preeclampsia is a disease characterized by high blood pressure, swelling of the face and hands, and protein in the urine after the twentieth week of pregnancy. The most common symptom and hallmark of preeclampsia is high blood pressure. This may be the first or only symptom. Blood pressure may be only minimally elevated initially or can be dangerously high; symptoms may or may not be present. The blood pressure is considered to be elevated if the systolic pressure has increased by 30 mmHg or more, or if the diastolic pressure has increased by 15 mmHg or more, above the blood pressure obtained during the first trimester. Generally, a blood pressure of 140/90 mmHg or more is considered above the normal range.
40
Q
- Placental abruption can be defined as
A. An overt cord prolapse that slips down into the vagina or appears externally after the amniotic membranes have ruptured.
B. A spontaneous or traumatic disruption of the uterine wall.
C. A blood loss in excess of 500 mL after delivery.
D. The premature detachment of a normally implanted placenta from the uterine wall.
A
- D: Placental Abruption, also known as abruptio placenta, is a separation of the placenta from the uterine wall that can occur over a small area with little evidence or can separate totally with devastating results. The primary cause of placental abruption is largely unknown. Hypertension, whether chronic or PIH, and previous abruption are two factors that are known to greatly increase the risk of placental abruption. No vaginal bleeding will be observed if the hemorrhage is completely concealed behind the placenta. When vaginal bleeding is observed, the blood is usually dark because of the rapid clotting. As the hemorrhage continues and a retroplacental clot forms, enough pressure may be exerted to force blood through the membranes, giving the amniotic fluid a port wine color or into the myometrium, causing a condition called Couvelaire uterus. The uterine tone is increased and irritability will be noted.
44
Q
- Interpret the following fetal tracing
A. Late decelerations
B. Variable decelerations
C. Early decelerations
D. Sinusoidal FHR pattern
A
- B: Variable decelerations can occur at any time during a contraction. The shape may also vary and is frequently V-shaped or W-shaped. Cord compression is responsible for these decelerations, which have a very characteristic appearance; frequently a short acceleration is observed, followed by a rapid deceleration for some seconds. Then there is a rapid rise and a short acceleration before there is a return to the FHR baseline. Signs that the fetus is losing the ability to tolerate the stress of repeated cord compression or that the cord compression is becoming more severe include a deeper deceleration that last longer, a slow return to baseline, an “overshoot” increase in FHR baseline immediately after the deceleration, loss of shoulders, and decreased variability.
45
Q
- Interpret the following fetal tracing
A. Normal
B. Fetal bradycardia
C. Fetal tachycardia
D. Sinusoidal FHR pattern
A
- B: The mean fetal heart rate is rounded to increments of five beats per minute during a ten-minute segment, excluding periodic/episodic changes, periods of marked variability or baseline segment that differ by more than twenty-five beats per minute. In any given ten-minute window, the minimum baseline duration must be at least two minutes. Otherwise, it is considered indeterminate. In these instances, review of the previous ten-minute segment should be the basis on which to determine the baseline. In determining the baseline rate, a minimum of a ten-minute period of monitoring is necessary for confirmation of the rate.
48
Q
- Interpret the following fetal tracing
A. Early decelerations
B. Late decelerations
C. Variable decelerations
D. Normal
A
- B: Late decelerations always indicate uteroplacental insufficiency; there is inadequate oxygen exchange in the placenta during a contraction. Uteroplacental insufficiency may result from pregnancy-induced hypertension (PIH), diabetes mellitus (DM), cardiovascular or kidney disease, chorioamnionitis, smoking, and a fetus that is past maturity. It may also result from decreased placental perfusion in placental abruption or previa, uterine hypertonus as a result of oxytocin stimulation, and hypotension. Signs of fetal decompensation include back-to-back decelerations, loss of variability, lack of spontaneous accelerations, tachycardia, and subtle decelerations. Standard interventions that may help to resolve the abnormal pattern (and that may also be warranted for some category II tracings) include supplemental oxygen to the mother, a change in maternal position, discontinuation of oxytocin, and resolution of maternal hypotension. In most situations, expeditious delivery is likely warranted if an abnormal pattern persists.
49
Q
- Interpret the following fetal tracing
A. Early decelerations
B. Sinusoidal pattern
C. Variable decelerations
D. Late decelerations
A
- A: Early decelerations are innocuous decelerations that begin very close to the beginning of the contraction, appear almost as a “mirror image” of the contraction, and end close to the end of the contraction. Head compression with vagus stimulation causes the deceleration.
51
Q
Frank Breech
A
Buttocks comes first, and legs are flexed at the hip and extended at the knees (with feet near the ears). 65-70% of breech babies are in the frank breech position.
52
Q
Complete Breech
A
Hips and knees are flexed so that the baby is sitting cross-legged (yoga position), with feet beside the buttocks.
53
Q
Footling Breech
A
One or both feet come first, with the buttocks at a higher position. This is rare at term but relatively common with premature births.
54
Q
What type of Deceleration?
A
Variable deceleration
A transient series of decelerations that vary in intensity, duration, and relation to uterine contraction, resulting from vagus nerve, firing in response to a stimulus such as umbilical cord compression in the first stage of labor.
V = variable ⇒ C = Compression
Based on visual assessment, a variable deceleration is defined as an apparent abrupt decrease in fetal heart rate below the baseline which may or may not be associated with uterine contractions. When variable decelerations occur in conjunction with uterine contractions, the onset, depth and duration vary with each succeeding uterine contraction. Variables are transitory decreases in the fetal heart rate caused by umbilical cord compression.
- They coincide with contractions and may appear V-shaped, U-shaped or W-shaped. The significance of the variables depends upon how often they occur, how deep they go, and how long they last. What is also crucial is how the fetus responds in their presence.
- An abrupt decrease in FHR of >15 BPM, measured from the most recently determined baseline rate. The onset of decelerations to nadir is less than thirty seconds; lasts >15 seconds but <2 minutes in duration from onset to return to baseline.
55
Q
What type of deceleration?
A
Early Deceleration
A transient decrease in heart rate that coincides with the onset of a uterine contraction “mirror-image of the contraction.”
E = Early ⇒ H = Head Compression
Based on visual assessment, an early deceleration is defined as an apparent gradual decrease in fetal heart rate and return to baseline associated with uterine contractions. Early deceleration is caused by vagal simulation from head compression and is a reassuring pattern that may be prevented by avoiding early rupture of membranes.
- Early decelerations are not considered ominous
- In association with a uterine contraction, a visually apparent, gradual (onset to nadir 30 seconds or more) decrease in FHR with return to baseline.
- Nadir of the deceleration occurs at the same time as the peak of the contraction.
56
Q
What type of deceleration?
A
Late Deceleration
A transient decrease in heart rate occurring at or after the peak of a uterine contraction, which may indicate fetal hypoxia.
L = Late ⇒ P = Placental Insufficency
Based on visual assessment, a late deceleration is defined as an apparent gradual decrease in fetal heart rate and return to baseline associated with uterine contractions. Late deceleration is associated with uteroplacental insufficiency and is a result of hypoxia and metabolic abnormalities.
- Late decelerations are one of the most ominous fetal heart rate patterns.
- In association with a uterine contraction, a visually apparent, gradual (onset to nadir 30 seconds or more) decrease in FHR with return to baseline. The nadir of the deceleration occurs after the peak of the contraction.
- Onset, nadir, and recovery of the deceleration occur after the beginning, peak and end of the contraction.
67
Q
What is occuring with this FHR
A
Sinusoidal FHR patterns, which are excluded from the definition of variability are described as a smooth, sine wave-like pattern of regular frequency and amplitude.
69
Q
What is going on in this FHR tracing?
A
A saltatory FHR pattern is rapidly occurring couples of acceleration and deceleration causing relatively large oscillations of the baseline fetal heart rate. This pattern is usually caused by acute hypoxia or mechanical compression of the umbilical cord. It is considered a nonreassuring pattern, but it is not usually an indication for immediate delivery.
