Normal and Abnormal L&D Flashcards
You are following a 38 yo G2P1 at 39 weeks in labor. She has had one prior vaginal delivery of a 3800 g infant. One week ago, the estimated fetal weight was 3200 g by U/S. Over the past 3 hours, her cervical exam remains unchanged at 6 cm. The FHR tracing is reactive. An IUPC reveals two contractions in 10 minutes with amplitude of 40 mm Hg each.
What is the most appropriate next step in mgmt?
a. Initiate Pitocin augmentation
b. Place an IUPC
c. Perform a C-section delivery
d. Place a fetal scalp electrode
e. No intervention; labor is progressing normally
f. Perform amniotomy
a. Initiate Pitocin augmentation
This labor is hypotonic and contrations are inadequate. Two contractions of 40 mm Hg intensity during a 10-min period equates to 80 MVUs. About 200 MVUs are needed to consider contractions to be adequate to affect delivery.
Oxytocin is the tx of choice in this situation.
You are following a 22 yo G2P1 at 39 weeks in labor. At 4 cm dilated, she is given an epidural for pain mgmt. 3 hours later, her cervical exam is unchanged. Her contractions are now every 2-3 min, lasting 60 sec. The FHR tracing is 120 bpm with accels and early decels.
What is the most appropriate next step in mgmt?
a. Initiate Pitocin augmentation
b. Place an IUPC
c. Perform a C-section delivery
d. Place a fetal scalp electrode
e. No intervention; labor is progressing normally
f. Perform amniotomy
b. Place an IUPC
Arrest of labor cannot be dx during the first stage of labor until the cervix has reached 4-cm dilation and until adequate uterine contractions (both in freq and intensity) have been documented.
The actual pressure within the uterus cannot be measured via an external tocodynamometer; an IUPC needs to be placed. It is generally accepted that 200 MVUs are required for normal labor progress.
A 25 yo G3P2 at 39 weeks is admitted in labor at 5-cm dilated. The fetal heart tracing is reactive. Two hours later, she is reexamined and her cervix is unchanged at 5-cm dilated. An IUPC is placed and the pt is noted to have 280 MVUs by the IUPC. After an additional 2 hrs of labor, the pt is noted to still be 5-cm dilated. The FHR tracing remains reactive.
What is the most appropriate next step in mgmt?
a. Initiate Pitocin augmentation
b. Place an IUPC
c. Perform a C-section delivery
d. Place a fetal scalp electrode
e. No intervention; labor is progressing normally
f. Perform amniotomy
c. Perform a C-section delivery
The pt is having adequate uterine contractions as determined by the IUPC. Therefore, augmentation with Pitocin is not indicated. The pt’s dx is secondary arrest of labor, which requires c-section.
In the active phase of labor, a multiparous pt should undergo dilation of the cervix at a rate of at least 1.5 cm/h if uterine contractions are adquate.
Mom reports an allergy to penicillin and says she has a rash. PNL indicates GBS+ at 36 weeks. What is the best choice for abx ppx during labor?
a. Cefazolin
b. Clindamycin
c. Erythromycin
d. Vancomycin
a. Cefazolin
Clinda is only recommended if isolate is susceptible to both clinda and erythromycin.
If pt has both pencillin or cephalosporin allergy –> vancomycin
A 38 yo G6P4 undergoes primary c-section under regional analgesia for malpresentation of twins at 37 weeks. Immediately after delivery of placenta, anesthesiologist notes maternal seizure activity with profound hypoxia and hypotension. The pt is intubated and provided with circulatory support with vasopressors. massive hemorrhage from surgical site ensues, and pt is given uterotonic agents and blood products.
What is the most likely cause of her hemorrhage?
a. Amniotic fluid embolism
b. Halogenated anesthetic agent
c. Placenta accreta
d. Severe preeclampsia with HELLP syndrome
e. Uterine atony from overdistended uterus
a. Amniotic fluid embolism
Complex disorder characterized by abrupt onset of maternal hypoxia, hypotension, and DIC… amniotic fluid enters maternal circulation from a breach in the normal maternal-fetal physiological barriers… this typically happens with L&D and c-section. The typical clinical px is dramatic. Patients may gasp for air, develop seizures from hypoxia, and have cardiopulm collapse, followed by massive hemorrhage from consumptive coagulopathy.
Immediate support with oxygenation through intubation and circulatory support and blood produts is vital.
A 29 yo P0 at 41 weeks’ gestation presents in labor. At the time of delivery, a shoulder dystocia is encountered. An episiotomy is cut to assist with dystocia maneuvers. Compared with a midline episiotomy, which of the following is an advantage of mediolateral episiotomy?
a. Ease of repair
b. Fewer breakdowns
c. Less blood loss
d. Lower incidence of dyspareunia
e. Less chance of extension of the incision
e. Less chance of extension of the incision
23 yo G1, 38 weeks. +active labor at 6-cm dilated. +ROM. On cervical exam, fetal nose, eyes, lips can be palpated. FHT 140 bpm. +accels. No decels. Most appropriate next step?
Allow spontaneous labor with vaginal delivery.
In the event of face px, successful vaginal delivery occurs the majority of the time with an adequate pelvis.
24 yo P0. 25 weeks. +active preterm labor in breech px. Changes from 4 cm to 6 cm dilation. Contracting regularly. Most appropriate procedure?
a. External cephalic version
b. Internal podalic version
c. Low transverse cesarean
d. Classic cesarean
d. Classic cesarean
Indicated in this extremely pre-term breech fetus. At 25 weeks, the lower uterine segment is likely to be poorly developed, and therefore, classical uterine incision is indicated
34 yo P2002 with no prenatal care presents in labor. Completely dilated and effaced. Progresses within minutes to vaginal delivery of 2500 g infant. B/c uterus still feels large, you do vaginal exam –> 2nd set of membranes is bulging through fully dilated cervix, and you feel a small part presenting in the sac. Fetal heart is ausculated at 60 bpm. Most appropriate procedure?
a. External cephalic version
b. Internal podalic version
c. Low transverse cesarean
d. Classic cesarean
b. Internal podalic version
Delivery of 2nd twin is probably the only remaining situation where internal podalic version is indicated.
No progress in descent for 4 hours or more in nullip with an epidural or 3 hours or more in multip with an epidural.
Most appropriate dx?
a. First stage arrest
b. Second stage arrest
c. Failed IOL
d. Protracted first stage
e. Protracted second stage
b. Second stage arrest
No cervical change for 4 hours or more with adequate uterine contractions and 6 cm or greater dilation with membrane rupture, or 6 hours or more with inadequate contractions.
Most appropriate dx?
a. First stage arrest
b. Second stage arrest
c. Failed IOL
d. Protracted first stage
e. Protracted second stage
a. First stage arrest
Failure to generate regular contractions and cervical change after at least 24 hours oxytocin, and with amniotomy if feasible.
Most appropriate dx?
Failed IOL
- Appears to lengthen second stage of labor
- Is associated with fetal sedation
- May be complicated by profound hypotension
- May be associated with inc. need for augmentation of labor with oxytocin and for instrument-assisted delivery
a. IV meperidine
b. Pudendal block
c. Spinal anesthesia
d. Epidural analgesia
- d. Epidural
- a. IV meperidine
- c. Spinal anesthesia
- d. Epidural
23 yo G1 at 39 wks presents with cc uterine contractions. Began 2 hrs ago, are painful, and occur every 4 to 8 min. +fetal movement. No bleeding or leaking fluid. External tocometer shows contractions every 5 to 15 min. Category 1 tracing. On exam, cervix is 1-cm dilated, 60% effaced, and fetal vertex is at -1 station. Pt had same cervical exam last week. Most appropriate next step?
a. Send her home
b. Admit her for epidural for pain control
c. Perform amniotomy
d. Augment labor with Pitocin
a. Send her home
Braxton Hicks contractions = false labor b/c contractions are irregular in timing and duration, and do not result in any cervical dilation
In true labor, uterine contractions occur at reggular intervals, tend to become increasingly more intense over time, and results in progressive dilation and effacement of cervix
38 yo G3P2 at 40 weeks presents to L&D with gross ROM occurring 1 hr prior to arrival. Pt having contractions every 3-4 min and each contraction lasts 60 sec. FHR 120 bpm with accels no decels. On exam, she is 5-cm dilated and completely effaced, with vertext at -2 station. Pt is in lot of pain and requesting medication. Which of the following is the most appropriate method of pain control for this pt?
a. IM meperidine
b. Pudendal block
c. Perineal block
d. Epidural analgesia
e. General anesthesia
d. Epidural analgesia
Epidural block provides relieft from uterine contraction pain and delivery.
- IM narcotics NOT preferred –> respiratory depression in newborn.
- Pudendal block –> anesthesia to perineum for delivery but no pain relief for uterine contractions
- Perineal block –> area of an episiotomy
- General anesthesia –> reserved primarily for situations involving emergent. c-sections/difficult deliveries… all anesthetic agents that depress maternal CNS cross placenta and affect fetus –> major complication of general anesthesia is maternal aspiration –> aspiration pneumonitis
