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OB > Normal L&D > Flashcards

Normal L&D Flashcards

1
Q

When does beta-HCG peak?

A

10 weeks gestation

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2
Q

When can a pregnancy first be detected by ultrasound? What do you see?

A

TRANSVAGINAL- 5 weeks. Gestational sac but no heart until 6 weeks.

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3
Q

Beta-HCG level for TV U/S detection? Abdominal

A

1500 to 2000

Abdominal needs >6500

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4
Q

First trimester

A

up to 12 wks

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5
Q

Second trimester

A

12 wks to 24 wks

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6
Q

Third trimester

A

24 wks (or 28) to delivery

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7
Q

PreVIABLE delivery?

A

Before 24 wks

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8
Q

What EXACTLY does parity mean?

A

A pregnancy that led to a birth at or beyond 20 wks OR of an infant weighing more than 500g

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9
Q

Given birth to a set of twins?

A

G1P1 (it is considered ONE pregnancy)

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10
Q

The order of #s in GP….

A

pregnancies/#births at TERM/#births at PREterm/abortuses/living kids

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11
Q

What changes occur in the cardiovascular system during pregnancy?

A

1) CO inc by 30-50% (max at 20-24 wks then maintained)
2) Systemic vascular resistance decreases
3) BP drops and nadirs at 24 weeks then rises

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12
Q

Changes in pulm system during pregnancy?

A

1) Tidal volume inc
2) Respiratory rate UNCHANGED…therefore the combo increases MINUTE VENTILATION which inc O2 levels overall
3) Dyspnea of pregnancy

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13
Q

Changes in GI system in pregnancy?

A

Morning sickness…hyperemesis gravidarum
Prolonged gastric emptying time so GERD sx
Large bowel has dec motility so constipation

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14
Q

Hyperemesis gravidarum?

A

Severe morning sickness= WEIGHT LOSS & KETOSIS.

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15
Q

Renal system in pregnancy?

A

1) Kidneys get bigger
2) Ureters dilate
3) GFR inc by 50% early in pregnancy
4) Therefore BUN and creatinine dec
5) RAAS system inc (but sodium levels DON’T inc bc of the concomitant inc in GFR)

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16
Q

Hematologic changes in pregnancy?

A

1) Plasma volume increases more than hematocrit (RBCs) so there’s a DILUTIONAL ANEMIA
2) WBC count inc (range of 6-16 million). During stress of labor may rise to 20 million.
3) Platelets drop beta 100-150million/mL. (Greater drop INVESTIGATE IMMEDIATELY)
4) Hypercoagulability due to inc in fibrinogen, factors VII-X; clotting and bleeding TIMES don’t change

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17
Q

Endocrine changes in pregnancy?

A

1) Hyperestrogenic state
2) Alpha subunit of beta-HCG mimics LH, FSH, and TSH; peak at 10-12 wks
3) hPL inc (produced by placenta). Induces lipolysis with a concomitant inc in free fatty acids; also is insulin antagonist
4) Prolactin LEVELS inc but it doesn’t do anything until after birth of baby
5) Estrogen stims TBG, so there’s an inc in TOTAL T3 and T4 but FREE T3/T4 remain constant.

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18
Q

Calorie intake req during preg?

A

300kcal/day for preg; 500 kcal/day for breastfeeding

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19
Q

Weight gains

A 
Underweight= 28-40lbs
Normal= 20-30lbs
Overweight= 15-25lbs
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20
Q

Folate req

A

0.4-0.8mg/day (Previous NTD or inc risk is 4mg/day)

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21
Q

Urinalysis in pregnancy looks for what?

A

Protein- preeclampsia
Glucose- diabetes
Leukocyte esterase- UTI

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22
Q

What are pregnant patients asked at EACH visit? What gets added after 20 weeks?

A

1) Vaginal bleeding
2) Vaginal discharge or leaking of fluid
3) Urinary symptoms
THEN
1) Contractions
2) Fetal movement

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23
Q

Components of the triple screen? Quad screen?

A

MSAFP (inc in NTD, dec in Down syndrome)
B-HCG
Estriol

Inhibin-A in quad screen

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24
Q

Second trimester visits?

A
  • MSAFP between 15-18 wks
  • Screening u/s between 18-20 wks
  • Triple screen/quad screen
  • Fetal heart is first heard
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25
Q

Third trimester visits? How often?

A
  • Rhogam at 28 wks
  • Leopold maneuvers 32-34 and beyond
  • Breech are offered external cephalic version of fetus at 37-38 wks
  • Vigorous exam of the cervix (“sweeping” the membranes) to determine probability of progressing post term or needing induction
  • Vaginal cultures repeated in high risk ladies
  • HSV latent: antiviral prophylaxis at 36 wks
  • HSV active: plan c-section
  • GBS screen beta 35-37 wks

Every 2-3 wks from 28-36 wks
Every week after 36 wks

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26
Q

WHEN IS “TERM”?

A

After 37 weeks

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27
Q

Lab tests during third trimester?

A

Hct (Hemoglobin below 11mg/dL start on iron supplements). Hct gets close to its nadir in 3rd trimester.
RPR/VDRL
GLT (glucose loading test)

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28
Q

PRETERM LABOR

A

LABOR THAT BEGINS BEFORE 37 WKS

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29
Q

Postterm pregnancy

A

After 42 weeks

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30
Q

GTT specifics

A

1) Fasting serum glucose measurement
2) 100g oral glucose loading dose
3) Measure serum glucose at 1, 2, 3 hours after oral dose

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31
Q

Thresholds for gestational diabetes diagnosis

A

Fasting gluc > 95
1 hour 180
2 hrs 155
3 hours 140

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32
Q

Routine u/s screening when?

A

18-20wks

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33
Q

BPP (biophysical profiles) look at what?

A

-Amniotic fluid volume
-Fetal tone
-Fetal activity
-Fetal breathing movements
-NST which tests FHR with fetal movement
Score of 2 each with a max of 10
8-10 is reassuring

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34
Q

Oxytocin challenge test (OCT) or contraction stress test (CST)

Why do you do them??

A

Get at least 3 contractions in 10 min
Concomitant FHR monitoring (reactivity criteria are the same as for NST)

If NST is nonreactive or FHR shows decelerations, or if BPP is non reassuring

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35
Q

NST is considered reactive if…

A

Two accelerations of FHR in 20 min that are at least 15 beats above baseline HR and last for at least 15 sec.

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36
Q

When would you do an NST in antenatal testing?

What if it’s nonreactive?

A

32-34 wks in high-risk pregnancies
40-41 wks in undelivered

Assess the fetus via ultrasound

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37
Q

What is PUBS used for?

percutaneous umbilical blood sampling

A

Fetal hematocrit level detection…
Like in Rh isoimmunization, fetal anemia, hydrops, fetal transfusion, fetal platelet count in alloimmune thrombocytopenia, karyotype analysis

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38
Q

Testing for fetal lung maturity?

A

Type II pneumocytes start secreting surfactant (they’ve used phospholipids to make it).
Lecithin/spingomyelin ratio increases with maturity.

Lecithin= lung maturity

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39
Q

Fetal lie

A

Longitudinal or transverse

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40
Q

Fetal presentation

A

Breech or vertex ( which can be cephalic if face first or not truly vertex)

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41
Q

Rupture of membranes suspected when?

A

Gush or leaking of fluid from vagina

This is sometimes hard to differentiate from stress incontinuence and small leaks of amniotic fluid

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42
Q

How do we diagnose ROM?

A

POOL, NITRAZINE (turns blue), FERN tests.

Vag is acidic, amniotic fluid is alkaline.

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43
Q

What can cause a false positive nitrazine test?

A

Fluid from cervix

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44
Q

What can you do if ROM tests are equivocal?

A

U/S to see fluid level. Oligohydramnios that was previously normal = ROM.

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45
Q

What if you REALLY need to know if it’s ROM (eg. PPROM when you need antibiotic prophylaxis)?

A

1) AMNISURE- rapid. Alpha-microglobulin-1 immunoassay.

2) Amniocentesis to inject dilute indigo carmine dye into the amniotic sac.

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46
Q

How do you obtain the Bishop score?

A

Cervical exam

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47
Q

What is in the Bishop score?

A
  • Dilation
  • Effacement
  • Fetal station
  • Cervical position
  • Consistency of the cervix
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48
Q

With what Bishop score is a cervix favorable for spontaneous and induced labor?

A

8 or higher

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49
Q

What is station? Where is +3?

A

Relation of the FETAL HEAD to the ISCHIAL SPINES.

+3 is at the introitus

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50
Q

Common indications for induction?

A 
Postterm pregnancy
Preeclampsia
Diabetes
Nonreassuring fetal testing
IUGR
51
Q

Contraindications of using prostaglandins? Maternal? Obstetric?

A

Maternal:

  • Asthma
  • Glaucoma

Obstetric:

  • Prior c/s
  • Nonreassuring fetal testing
52
Q

Dilation options?

A

Prostaglandins
Oxytotic agents
Mechanical dilation of cervix (eg. with Foley bulb)
Artificial ROM (amniotomy)

53
Q

General rules about induction?

A

If it’s not an urgent issue, you need to wait for a favorable Bishop score (>5).

54
Q

What is usually given first for induction

A

Pitocin

Continuous IV because it’s rapidly metabolized

55
Q

Key to check during amniotomy?

A

For umbilical cord prolapse

56
Q

What inducing methods are also used for augmentation?

A

Pitocin and AROM

57
Q

When would you augment?

A

Prolonged phase of labor

Inadequate contractions

58
Q

FHR baseline above 160 is worrisome for…

A

Infection
Hypoxia
Anemia

59
Q

How long is too long for a deceleration?

A

> 2 min

60
Q

Fetal heart rate variability?

A

Absent: 25 bpm

61
Q

Formally reactive FHR?

A

At least 2 accelerations of at least 15 bpm that last for 15 sec within 20 min.

62
Q

Early decels? Cause?

A

Begin and end with contractions (relatively)

Fetal head compression which increases vagal tone

63
Q

Variable decels? Cause?

A

Happen anytime and drop more suddenly than early or lates.

Umbilical cord compression

64
Q

Late decels? Cause?

When late decels occur with decreased variability what is most likely cause?

A

Start at PEAK of a contraction and slowly return to baseline after the contraction finished

UTEROPLACENTAL INSUFFICIENCY

Fetal acidosis strongly suspected when late decels happen with decreased variability

65
Q

Contraindications to using a fetal scalp electrode to track repetitive decels?

A

Maternal hepatitis or HIV

Fetal thrombocytopenia

66
Q

Category I FHR?

A

Normal: normal baseline, moderate variability, no variable or late decels

67
Q

Category II FHR?

A

Indeterminate

68
Q

Category III FHR?

A

Abnormal!

Absent variability
Recurrent late or variable decals
Bradycardia
SINUSOIDAL PATTERN

69
Q

What is sinusoidal pattern?

A

Fetal anemia

70
Q

Montevideo units?

A

Intrauterine pressure’s variation average FROM baseline x # of contractions in a 10 min period

71
Q

If fetal heart rate tracing is non reassuring, what can you do to check for fetal hypoxia or acidemia?

A

Fetal scalp ph- obtained by making a nick in the scalp and drawing up some blood.

Reassuring is pH greater than 7.25. Below 7.2 is non reassuring.

72
Q

What could falsely elevate results of fetal scalp pH reading?

A

Mixing the blood with BASIC amniotic fluid would give it a falsely low therefore non reassuring reading.

73
Q

Stages 1 of labor?

A

Onset until dilation/effacement of cervix are complete.

Latent and active phases

74
Q

How long does stage 1 last in nulliparous patient? Multiparous?

A

10-12 hours (6-20 is considered normal)

6-8 hours multiparous (2-12 is considered normal)

75
Q

Latent phase of stage 1

A

Onset until 3-4 cm dilation. SLOW cervical change. Mostly effacement rather than dilation.

76
Q

Active phase of stage 1

A

After latent up until 9 cm of dilation

The slope of cervical change against time increases.

77
Q

How much dilation in expected per hour in active phase for a nulliparous patient? Multiparous?

A
  1. 0 for nulliparous

1. 2 for multiparous

78
Q

What 3 factors affect transit time for active labor?

A

Powers, passenger, pelvis

79
Q

What if “passenger” is too large for “pelvis”?

A

Cephalopelvic disproportion

80
Q

What happens if the cervical change is less than 1.0cm per hour?

A

You need to assess the three P’s to determine whether a vaginal delivery can be expected

81
Q

Active phase arrest?

A

No change in cervical dilation OR station for TWO HOURS even though there are ADEQUATE MONTEVIDEO UNITS in the active phase of labor.

82
Q

What POA for active phase arrest?

A

C-section OR watch and wait

83
Q

Stage 2 of labor?

A

From complete cervix dilation until delivery of the infant

84
Q

What is considered “prolonged stage 2” in nulliparous? Multiparous?

A

Nulliparous- more than 2 hours; 3 hours if they had epidural

Multiparous- more than 1 hour without epidural; more than 2 hours with epidural

85
Q

Monitoring during active second stage of labor. What’s normal and what’s worrisome?

A

Normal- repetitive early and variable decels

Worrisome- Repetitive late decels, bradycardias, loss of variability

86
Q

What to do for worrisome tracings during second stage?

A

Give face mask O2, turn patient on her left side, discontinue oxytocin immediately if it’s being used

87
Q

What do you do if a prolonged deceleration happens due to hypertonus or tachysystole? What if this intervention doesn’t help?

A

Give terbutaline to relax the uterus

If that doesn’t help, assess fetal station and position to see if vaginal delivery is favorable. If fetal station is above 0 or position is unknown, C-SECTION.

88
Q

What is hypertonus?

A

Single contraction lasting more than 2 mins

89
Q

What is tachysystole?

A

Greater than 5 contractions in 10 min

90
Q

Conditions for the safe use of vacuum extractor and foreps for delivery?

A

Full dilation of the cervix, ruptured membranes, engaged head and at least +2 station, no evidence of CPD, anesthesia adequate, empty bladder, EXPERIENCED OPERATOR #1

91
Q

Risks of forceps and vacuum?

A

Fetal complications:
Forceps- facial nerve palsies
Vacuums- cephalohematomas

Maternal complications:
Forceps- 3rd and 4th degree perineal lacerations

92
Q

Stage 3 of labor?

A

After baby delivered until delivery of placenta

93
Q

Time frame for placental separation?

A

Usually 5-10 minutes but up to 30 is normal limit.

94
Q

The 3 signs of placental separation?

A

1) Cord lengthening
2) Gush of blood
3) Uterine fundus rises

THEN you can start attempting to deliver it

95
Q

What can happen if you put too much traction while trying to deliver the cord? How can the doctor avoid this?

A

Uterine inversion

Doctor needs to apply suprapubic pressure to keep the uterus from inverting or prolapsing

96
Q

Common causes of retained placenta? What do you do? If EVEN this fails?

A

This means more than 30 mins to deliver it.

  • Preterm, ESPECIALLY previable
  • Sign of placenta accreta

DELIVER W/ MANUAL EXTRACTION

If it STILL doesn’t come out, do curettage

97
Q

LACERATIONS 1st-4th?

A

1st- Mucosa or skin
2nd- Extend into perineal body
3rd- Into or completely through the anal sphincter
4th- Anal muscosa has been entered

4th degree “buttonhole”- through rectal mucosa into vagina but with anal sphincter still intact

98
Q

MC reason for c-section? Others?

A

1) Failure to progress in labor. Eg. 3 P’s OR a previous c-section
- Breech presentation or transverse lie
- Placenta previa
- Placental abruption
- Fetal intolerance of labor
- Nonreassuring fetal status
- Cord prolapse
- Prolonged second stage
- Failed operative vaginal delivery
- ACTIVE HERPES LESIONS

99
Q

VBAC possible if what conditions? What is greatest risk during TOLAC?

A

Low transverse or low vertical incision for the prior hysterotomy

Greatest risk is RUPTURE OF PRIOR SCAR
0.5-1% of the time.

100
Q

What increases the risk for uterine rupture during TOLAC?

A
  • Multiple prior cesarean deliveries

- Induction of labor

101
Q

Signs of rupture?

A
  • Abdominal pain
  • FHR decelerations or bradycardia
  • Sudden pressure decrease on IUPC
  • Mom feels a pop
102
Q

Why should sedating analgesics not be used near expected time of delivery?

A

It can cross the placenta and may result in a depressed infant

103
Q

Epidural placement? Advantages?

A

In L3-L4 interspace ONCE ACTIVE LABOR STARTS!!
Initial bolus then continuous infusion.

Labor is slower but it offers better control during crowning.

104
Q

When is spinal anesthesia given over epidural?

A

Given in one time dose directly into spinal canal so it’s MORE RAPID.
Better for c-section.

105
Q

Complications of spinal or epidural anesthesia?

A

Maternal hypotension due to decreased systemic vascular resistance–> dec placental perfusion and fetal bradycardia

SERIOUS: material respiratory depression

106
Q

When would you use general anesthesia?

A

Rarely

Emergency c-section

107
Q

Clinically adequate contractions?

A

Every 2-3 minutes lasting at least 40-60 sec.
OR
Montevideo units >200

108
Q

Engagement

A

Relationship of the WIDEST DIAMETER of the fetal presenting part and its location relative to the pelvic inlet

109
Q

Low birth weight infant?

A

Less than 2500 g

110
Q

Risks of prematurity?

A
  • RDS or hyaline membrane disease
  • Intraventricular hemorrhage
  • Sepsis
  • Necrotizing enterocolitis
111
Q

RISK FACTORS FOR PRETERM LABOR

A
  • PROM
  • Chorioamnionitis
  • Multiple gestations
  • Uterine anomalies like bicornuate uterus
  • Previous preterm
  • Maternal pre pregnancy weight less than 50 kg
  • Placental abruption

Maternal:

  • Preeclampsia
  • Infections
  • Intra-abdominal disease or surgery
  • Low SES
112
Q

Tocolytics- why give? Why does HYDRATION decrease contractions?

A

GOAL IS TO DECREASE INTRACELLULAR CALCIUM WHICH DECREASES MYOMETRIAL CONTRACTILITY

When you need to decrease or halt the cervical change that results form contractions

Hydration decreases ADH release (so you can pee out that extra water). ADH and oxytocin have similar structures, so dec the ADH can also dec the oxytocin.

If no response, give tocolytics.

113
Q

Beta-mimetic tocolytics? Mech? Side effects?

A

TOCOLYTIC
Ritodrine (cont IV), terbutaline (subq).

Increases conversion of ATP to cAMP which sequesters FREE calcium in sarcoplasmic reticulum (HIDES IT THERE…SO IT’S NOT “IN” THE CELL) therefore dec contractions.

Tachycardia, headaches, anxiety, transient hyperglycemia, hypokalemia, arrythmias

Severe= pulmonary edema
TERBUTALINE HAS BLACK BOX WARNING TO STOP AFTER 24-48 HOURS

114
Q

Magnesium sulfate mech? Side effects?

Testing for toxicity?

A

TOCOLYTIC
Calcium antagonist and membrane stabilizer: competes with calcium for entry into cells.

Flushing, headaches, fatigue, diplopia…but LESS SEVERE than with ritodrine and terbutaline.

Doses more than 10 mg/dL can result in respiratory depression, hypoxia, cardiac arrest.

Test DTRs… depressed at levels less than 10 mg/dl

115
Q

Calcium channel blocker

A

TOCOLYTIC

Decrease influx of calcium into smooth muscle cells which dec ctx.

Nifedipine oral.

Headaches, flushing, dizziness.

116
Q

Prostaglandin inhibitors

A

TOCOLYTIC

Indomethacin …good for mom bad for baby. Need to monitor AFI for development of oligohydramnios.

Blocks COX and decreases the levels of prostaglandins, which decreases intracellular calcium levels, thereby dec myometrial ctx.

Minimal maternal side effects but lots of fetal complications like ductus arteriosus constriction, plum hypertension, oligohydramnios secondary to renal failure.

117
Q

PROSTAGLANDINS

A

INDUCING AGENTS

Increase the intracellular levels of calcium and enhance myometrial gap junction function which INCREASES myometrial ctx.

118
Q

What do you do with suspected CPD?

A

Trial of labor anyway

119
Q

Factors associated with breech presentation

A
  • Previous breech
  • Uterine anomalies
  • Poly or oligo hydramnios
  • Multiple gestation
  • PPROM
  • Hydrocephaly or anencephaly
120
Q

Compound presentation

A

1/1000 but when baby has an extremity coming out with head

121
Q

Prolonged decel vs. bradycardia?

A

Prolonged decel is rate below 100-110 for longer than 2 min.

Brady cardia is for longer than 10 min.

122
Q

Puerperium definition?

A

First 6 weeks postpartum

123
Q

Is ibuprofen safe in pregnancy?

A

Until around wk 32, when premature closure of the ductus arteriosus becomes a risk

OB (8 decks)

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