OB 1.1 Flashcards
Persistent vomiting aggravated by inability to take in food leading to severe dehydration and ketonuria
Hyperemesis gravidarum
Disturbances in urination is most prominent during
2nd and 3rd months
Easy fatigability in normal pregnancy is due to
Increased BMR
First perception by mother of fetal movement
Quickening
Quickening: Primigravida
18-20 weeks
Quickening: Multigravida
16-18 weeks
T/F Quickening increases in intensity and frequency as pregnancy progresses
T
Hormone: Stimulate mammary DUCT system
Estrogen
Hormone: Stimulate ALVEOLAR components of breast
Progesterone
Earliest sign of pregnancy
Cessation of menstruation
Highly suspect pregnancy if ___ days have elapsed after expected onset of menses
10 or more
Expression of colostrum is appreciated at ___ week
16th
T/F There is no relation between pre-pregnant breast size and volume of milk production during lactation
T
Hormone: Thermal changes in pregnancy
Progesterone
Luteal vs follicular phase: Greater basal body temp
Luteal
Temp in luteal phase is ___ degrees higher than in follicular phase
0.3-0.5C
Hormone: Skin pigmentation changes
Estrogen and progesterone
T/F Skin pigmentation is more prominent in dark-skinned individuals
T
T/F Skin pigmentation in pregnancy is intensified by exposure to sunlight
T
Reddish, slightly depressed streaks commonly found in abdominal skin that may turn silvery white after delivery
Striae gravidarum
Striae gravidarum is due to
Separation of underlying collagen tissue
Hormone: Decreased peripheral vascular resistance
Estrogen
More rapid growth as uterus rises out of pelvis: Weeks
16-22 weeks
Time during which fundic height is equal to gestational age, i.e. x cm = x weeks AOG
16-32 weeks
T/F Abdominal enlargement is more pronounced in
multigravida than primigravida
T
T/F Uterine growth is limited to anteroposterior
diameter
T
Average diameter of uterus at 12 weeks AOG
8 cm
Hegar sign is appreciated at ___ weeks
6-8
T/F At about 4 weeks AOG external cervical os and cervical canal become patulous (open/distended) to allow insertion of fingertip
T
Hormone: Ferning of cervical mucus
Estrogen
In non-pregnant women, ferning of cervical mucus is appreciated at days ___ of cycle
7-18
In non-pregnant women, beading of cervical mucus is appreciated at day ___ of cycle
21
Predominant hormone in pregnancy
Progesterone
False labor pain
Braxton-Hicks contraction
Intensity of Braxton-Hicks contractions
5-25 mmHg
When are Braxton Hicks contractions felt most
28 weeks AOG
HCG in pregnancy is produced by
Fetal trophoblasts
Function of HCG in pregnancy
Maintains the corpus luteum which is the main site of progesterone production in early pregnancy
HCG: Doubling time
1.4-2 days
α subunit of HCG is similar to that of (3)
1) LH
2) FSH
3) TSH
False positive sandwich type immunoassay pregnancy test is due to
Heterophile antibodies
Detection limit of home pregnancy tests
12.5 mIU/mL
Normal FHT
110-160 bpm
Most accurate method of determining FHT
UTZ
Soft, blowing sound synchronous with maternal pulse
Uterine souffle
Sharp, whistling sound that is synchronous with fetal pulse
Funic souffle or umbilical cord souffle
Uterine souffle: Passage of blood through
Uterine vessels
Funic souffle or umbilical cord souffle: Passage of blood through
Umbilical arteries
Fetal movement can be perceived by the examiner at what week
20th
Week: Gestational sac
5
Week: Fetus w/in gestational sac & fetal heart beat detected
6
Week: CRL measurement is predictive of
gestational age
6-12
Imaginary or spurious pregnancy
Pseudocyesis
Pseudocyesis is usually seen in what population
Women nearing menopause or with strong desire to become pregnant
Most convincing method for women who have pesudocyesis
Ultrasound
T/F Pregnancy test kits are reliable means of identifying fetal death
F, trophoblasts continue to produce hcg for several days or weeks after fetal demise
Nonviability of a pregnancy is best confirmed by
Ultrasound
Usually the most noticeable symptom in fetal demise
Cessation of fetal movement
Overlapping of the fetal skull bones due to liquefaction of the brain
Spalding sign
Gas bubbles in the fetus
Robert sign
Phases of parturition
1) Quiescence
2) Preparation for labor
3) Process of stimulation or labor
4) Parturient recovery
Hormone: Dominant in phase 0 of parturition
Progesterone
Gap junction for interaction between uterine smooth muscle cells that is inhibited by progesterone
Connexin 43
Hormone: Promotes formation of connexin 43
Estrogen
Promoters of myometrial relaxation (7)
1) Beta adrenoreceptors
2) LH and HCG
3) Relaxin
4) CRH
5) PTH-rp
6) PGD2, E2, I2
7) ANP and BNP
Hormone: Cevical ripening
Relaxin
Hormone: Can induce both uterine relaxation and contraction
CRH
Phase 2 of parturition commences at
37 weeks AOG
Phase of parturition: Development of uterine sensitivity
Phase 2
Phase of parturition: T/F Phase 2 is the phase where most uterotonins are active
T
Phase of parturition: Progesterone withdrawal
Phase 2
Hormone: Upregulation of oxytocin receptors
Estrogen
Sensation that a pregnant woman feels that the baby has descended
Lightening
Important events at 37 weeks AOG (3)
1) Formation of LUS
2) Cervical softening
3) Lightening
Cervical softening in phase 2 of parturition is due to
Breakdown of collagen fibers
Placental source of CRH
Cytotrophoblast
Hormone: Goes to pituitary of fetus stimulating release of steroids that will act on lungs to promote pulmonary maturity
CRH
Major substrate for estrogen production
C19 steroids
Production of CRH from placenta stops when
After release of fetus
Hormone: Stimulates membranes to increase prostaglandin
synthesis, which is a potent uterotonin
CRH
Hormone: Stimulate fetal adrenals to produce C19 steroids
leading to increased substrate for placental aromatization
CRH
Fetal anomalies that may cause delayed parturition
1) Hypoestrogenism
2) Anencephaly
3) Adrenal hypoplasia
4) Placental sulfatase deficiency –> decreased CRH
Phase of parturition: Time when most events in labor and delivery happen
Phase 3
Most potent uterotonin
Oxytocin
3 important points at which oxytocin is increased
1) 2nd stage of labor
2) Early postpartum
3) Breastfeeding
Treatment of pregnant women with this agent in any gestation causes labor or abortion
PG
Substances that promote uterine contraction (4)
1) Platelet-activating factor
2) Endothelin-1
3) AT II
4) CRH, hCG, PTH-rp
Substance released with stripping of membranes
PGF-2α
Intrauterine tissue that provides tensile strength and resistance to tearing and rupture
Amnion
Intrauterine tissue that provides for immunological acceptance and is enriched with enzymes that inactivate uterotonins
Chorion laeve
Intrauterine tissue responsible for generation of uterotonins (paracrine) and responds to inflammatory reaction provoked by vaginal fluids
Decidua parietalis
Strict definition of labor
Uterine contractions that bring about demonstrable effacement and dilatation of the cervix
3 functional divisions of labor
1) Preparatory
2) Dilatational
3) Pelvic
Phase of labor: Latent phase
From perception of regular contractions to 3 cm dilation
Prolonged latent phase: Nullipara
> or = to 20 hours
Prolonged latent phase: Multipara
> or = 14 hours
Phase of labor: Affected by sedation or epidural analgesia
Latent phase
Phase of labor: Active phase
3 cm dilation to 10 cm dilation
Stages of labor
Stage I: Latent phase and active phase
Stage II
Stage III
Stage of labor: Stage II
10 cm dilation to delivery of neonate
Stage of labor: Stage III
Delivery of neonate to delivery of placenta
Normal duration: Active phase, multipara
Less than 4 hours
Normal duration: Active phase,nullipara
Less than 5 hours
Normal rate of cervical dilation during active phase: Multipara
> or = 1.5cm/hour
Normal rate of cervical dilation during active phase: Nullipara
> or = 1.2 cm/hour
Normal duration: Stage II, multipara
Less than 30 minutes
Normal duration: Stage II, nullipara
Less than 1 hour
Normal duration: Stage III (multipara and nullipara)
Less than 30 minutes
cm dilation wherein descent starts in nullipara
7-8 cm
True vs false labor: Contractions, regular
True
True vs false labor: Contractions, irregular
False
True vs false labor: Contractions, gradually shorten in duration
True
True vs false labor: Contractions gradually increase in intensity
True
True vs false labor: Pain/discomfort confined to lower abdomen
False
True vs false labor: Pain/discomfort at the abdomen and back
True
True vs false labor: Relieved by sedation
False
True vs false labor: Unaffected by sedation
True
Definition of “interval” between contraction
START of 1 contraction to the START of the next
Area of the abdomen where contraction starts
Fundus (not hypogastric)
Recpetors of oxytocin are more concentrated at which area of the uterus
Uterotubal junction
T/F Rest is ineffective in relieving true labor
T
Early vs late sign: Extrusion of mucus plug from the cervix, resulting in a bloody show
Early
Cervical effacement is expressed in terms of
Length of cervical canal compared to cervical canal of uneffaced cervix
Length of uneffaced cervix
2.5 to 3 cm
Cervical length is measured from
Lateral fornix to ectocervix
Normal biparietal diameter
9.5 cm, hence cervix should dilate 10 cm
Normal interspinous diameter
10 cm
Signals that the mother should START to push. (Do not ask to push before this happens)
1) Dilation at 10 cm 2) 2nd stage of labor 3) During contraction
Gestational age is ___ weeks before/after ovulation and fertilization
2 weeks before
Gestational age is ___ weeks before/after implantation
3 weeks before
Gestational age is aka
Menstrual age
Delivery may be more or less ___ weeks from EDD
+/- 2 weeks
Weeks from EDD at which pregnancy is considered postterm
> 2 weeks
Includes events in development from the time of ovulation (2 weeks after LMP)
Ovulation age or postconception age
Trimester: Spontaneous abortions
First
Trimester: BP is lower
Second
Period of organogenesis
Embryonic period
Emryonic period (week)
3rd week after ovulation
Event-week: Fetal blood vessels in chorionic villi appear
3
Event-week: Chorionic sac is 1 cm in diameter
3
Event-week: Chorionic sac is 2-3 cm in diameter
4
Event-week: Embryonic disc is formed
3
Event-week: Embryo is 4-5 mm in length
4
Event-week: Primitive heart
4-5
Event-week: Arm and leg buds
4-5
Event-week: Fingers and toes
6-8
Event-week: Arms bend at elbows
6-8
Event-week: Upper lip and external ears visible
6-8
Fetal period: AOG
10
T/F Fetal length is a more accurate criterion of gestational age than weight
T
Fetal weight increases linearly until ___ weeks
37
Weight gain of fetus in 3rd trimester
30g/day
Event-week: Centers of ossification appear
12 [CDB: 16]
Event-week: Gender can be determined by inspection of genitalia
14
Event-week: External genitalia – start to show evidence of gender
12
Event-week: Spontaneous fetal movements; responds to stimuli
12
Event-week: Downy lanugo hair surround skin
20
Event-week: Fetal breathing movements become regular
20
Event-week: Fat deposition begins
24
Event-week: Canalicular period of the lungs
24
Event-week: Fetal lung pneumocytes begin production of surfactant
24
Fetuses born at this time may survive w/ intensive neonatal care
24 weeks AOG
Event-week: Vernix caseosa
28
Event-week: Eyes partially open
28
Birth at this age: 90% survival w/ no physical or neuro impairment
28
Event-week: Testes start to descend
32
Sutures that can be palpated in vertex presentation
All except temporal
Junction of the lambdoid and temporal structures
Temporal/Caesarian fontanel
Occipitofrontal diameter
Most prominent part of occipital bone to root of nose
Widest transverse diameter of the fetal head
Biparietal diameter
Bitemporal diameter
Greatest distance between 2 temporal bones
Occipitomental diameter
Chin to most prominent portion of occiput
Suboccipitobregmatic diameter
Middle of anterior fontanel to undersurface of bone where it joins the neck
Shortest AP diameter that can pass through during normal cephalic delivery
Suboccipitobregmatic
Trachelobregmatic diameter
Bregma to undersurface of fetal mentum/mandible
Normal occipitofrontal diameter
11.5 cm
Normal bitemporal diameter
8 cm
Normal occipitomental diameter
12.5 cm
Normal suboccipitobregmatic diameter
9.5 cm
Normal trachelobregmatic diameter
9.5 cm
Greatest circumference of the head
Plane of the occipitofrontal diameter
Smallest circumference of the head
Plane of the suboccipitobregmatic diameter
Myelination of ventral roots of the cerebrospinal nerves and brainstem begins at
6th month
Major portion of myelination occurs
After birth
Fetal circulation
IMAGE
Medial vs lateral part of IVC: Well oxygenated blood
Medial
Medial vs lateral part of IVC: Less oxygenated blood
Lateral
Umbilical veins undergo atrophy and obliteration within ___ days
3-4
Ductus venosus constricts by
10-96 hours after birth
Ductus venosus anatomically closes at
2-3 weeks to become ligamentum venosum
Sites of EPO production in the fetus
Liver and kidneys
Hgb from yolk sac
Portland, Gower 1, Gower 2
Hgb from fetal liver
Hgb F
Accounts for higher O2 binding by fetal Hgb
Decreased 2,3-DPG binding
Hgb that persists in newborns of diabetic mothers
Hgb F
Transplacental transport of IgG starts at
16 weeks
Bulk of IgG is acquired by the fetus during
Last 4 weeks
Adult values of IgG is achieved
3 y/o
IgM levels are increased in
Newborns with congenital infections
Ig helpful in preventing newborn diarrhea
IgA from colostrum
GI peristalsis and glucose transport starts at
11 weeks
Swallowing starts at
16 weeks
T/F Swallowed amniotic fluid has little effect on amniotic fluid volume
T
T/F If baby does not swallow, polyhydramnios may occur
T
Stimulates pituitary gland to produce arginine vasopressin -> stimulate contraction of the smooth muscles of the colon = meconium passage / intraamniotic defecation
Hypoxia
T/F Kidneys are not essential for survival in utero
T
Urine production begins
12 weeks
Amount of urine produced at term
650 mL/day
Source of amniotic fluid: Early pregnancy
Amniotic membrane
Source of amniotic fluid: Midpregnancy
Fetal urine
Amniotic fluid: Peak volume
1L
Amniotic fluid: Peak volume is attained at
36-38 weeks
Amniotic fluid index measurement
Uterus is divided into 4 equal quadrants -> AF measured vertically in single deepest pocket of each quadrant -> add 4 values to get AFI
AFI in oligohydramnios
Less than or equal to 5cm
AFI in polyhydramnios
> 24cm
3 essential stages of lung development
1) Pesudoglandular
2) Canalicular
3) Terminal sac
Weeks: Pseudoglandular stage
5-17 weeks
Weeks: Canalicular stage
16-25 weeks
Weeks: Terminal sac stage
Beyond 25 weeks
Stage of lung development: Production of surfactant begins
Terminal sac stage
Stage of lung development: Bronchial cartilage extends peripherally (terminal bronchioles -> respiratory bronchioles -> saccular ducts)
Canalicular stage
Stage of lung development: Growth of intrasegmental bronchial tree
Pseudoglandular stage
Pulmonary hypoplasia results from insult before stage ___ of lung development
3
Lung continues to grow with more alveoli up to ___ years
8
Natural stimulus for lung maturation and augmented surfactant synthesis
Cortisol
L/S ratio is 1:1 at
34 weeks
L/S ratio is 2:1 at
36 weeks
Test that indirectly measures phosphatidylglycerol
Foam shake test
Counter used for lamellar body count
Coulter counter
Lamellar body count that indicates fetal lung maturity
> 20,000
Major component of surfactant
Lipid (90%)
Major lipid component of surfactant
Phosphatidylcholines (lecithins) (80%)
Principal active component of surfactant
DPPC
Detection of respiratory movements
4th month
Weight of uterus at term
1100g
Mechanism by which the biparietal diameter passes through the inlet
Engagement
At engagement, the lowermost portion of the head is at the level of
Ischial spines
What station is the level of ischial spines
0
When does engagement usually occur in nullipara
~2 weeks before EDC (Naegele’s rule)
When does engagement usually occur in multipara
Onset of labor or with amniotomy
What does engagement tell about the pelvic inlet
Pelvic inlet is adequate
Deflection of the sagittal suture anteriorly towards the symphysis pubis or posteriorly toward the promontory
Asynclitism
Anterior or posterior asynclitism is determined based on
The side of the parietal bone that presents to the examining finger (anterior parietal bone presents > anterior asynclitism; posterior parietal bone presents > posterior asynclitism)
Significance of asynclitism
If severe, it is a common reason for CPD even with a normal-sized pelvis
First requisite for the birth of the newborn
Descent
At which stage of labor does descent occur
Stage II
Descent is brought about by what forces
1) Hydrostatic pressure of amniotic fluid 2) Direct pressure of funds upon the breech with contractions 3) Bearing-down of maternal abdominal muscles 4) Straightening of the fetal back
MC position
LOT, with fetal back at the left
What is determined by LM 3
Presentation
What is determined by LM 4
If engagement has already taken place
What is LM 4 if engagement has already taken place
Negative (you cannot feel for the cephalic prominence anymore)
Presenting landmark/reference point in cephalic/vertex position
Posterior fontanel
Ideal attitude of the fetal head
Flexed
Cardinal movement that results from resistance meeting the fetal head from the cervix and pelvic walls or floor
Flexion
In LOT, what is the presenting diameter
Occipitofrontal
How many cm is the occipitofrontal diameter
11.5
In Flexion, what diameter replaces the occipitofrontal diameter so that the head can pass through the interspinous diameter (10 cm)
SOB diameter (9.5 cm)
Turning of the head in such a way that the occiput gradually moves towards the symphysis pubis anteriorly from its original position or posteriorly (less common) toward hollow of the sacrum
Internal rotation (LOT > LOA)
Cardinal movement that is essential for completion of labor
Internal rotation
Cardinal movement wherein the sharply flexed head reaches vulva and follows the J-shaped contour of the vaginal canal in dorsal lithotomy
Extension
Cardinal movement, the goal of which is to deliver the head out into the vulva
Extension
2 forces that bring about extension
1) Uterus 2) Pelvic floor and symphysis pubis
Swelling of baby’s head that can cross suture lines
Caput succedaneum
Swelling of baby’s head that is confined to suture lines
Cephalhematoma
How many cm of moulding is allowable
1 cm
Cardinal movement that brings the base of the occiput into direct contact with the inferior margin of the symphysis pubis
Extension
Cardinal movement that corresponds to the rotation of the fetal body
External rotation
Phases of cervical dilation (active phase)
1) Acceleration phase (increasing rate) 2) Phase of maximum slope (greatest rate) 3) Deceleration phase (slowing down)
The gold standard for documentation of rates of cervical dilation and fetal descent during active labor
Friedman curve
A composite graphical record of key data (maternal and fetal) during labor entered against time that helps in decision-making during labor
Partograph
The latent phase of labor (regular uterine contractions to 3 cm) should not be longer than
8 hours
During the active phase, the rate of cervical dilatation should not be slower than
1 cm/hour
Phase of cervical dilation that is not always present
Acceleration phase
Functional divisions of labor
1) Preparatory (latent phase) 2) Dilatational (active) 3) Pelvic (deceleration phase of cervical dilation/cardinal movements of labor)
Protracted active phase is defined as
Less than 1.2 cm/hour in nulli; less than 1.5 cm/hour in multis
Prolonged deceleration (stage II) in nullipara
3 hours or more if with anesthesia; 2 hours or more if without anesthesia
Prolonged deceleration (stage II) in multipara
2 hours or more if with anesthesia; 1 hour or more without anesthesia
Station: Pelvic inlet
-3, -5
Station: Ischial spines
0
Station: Perineum (crowning)
+3, +5
Arrest in descent, nulli
No change in dilatation in an hour
Arrest in descent, multi
No change in dilatation in 30 minutes
Prolonged latent phase, nulli
> 20 hours
Prolonged latent phase, multi
> 14 hours
Arrest of dilation
No progress for 2 hours
Protracted descent, nulli
Less than 1 cm/hour
Protracted descent, multi
Less than 2 cm/hour
Shoulder dystocia is disproportion between fetal bisacromial diameter and ___
AP diameter of pelvic inlet
Indicator of shoulder dystocia described as retraction of feral head against maternal perineum
Turtle sign
Turtle sign is due to failure of what cardinal movement
Internal rotation of bisacromial diameter at midpelvis > impaction of shoulder at sacral promontory
MC fractured bone in shoulder dystocia
Clavicular fracture (2nd: Humeral fracture)
Planned CS may be reasonable for a diabetic woman with EFW ___
> 4200-4500g
ACOG guideline for application of fundal pressure
Don’t apply directly downward; lateral application from either sides of maternal abdomen at an angle towards the feral chest
A maneuver that flattens the maternal sacrum hence increases the size of the posterior outlet and may unlock posterior shoulder; increases intraabdominal pressure
Mc Robert
Progressive rotations of shoulder girdle in a corkscrew fashion by continuous pressure on anterior surface of the posterior shoulder together with downward thrust of the left hand on the buttocks of the baby
Woods maneuver
Posterior arm delivery; pressure applied on the antecubital fossa in order to flex the fetal forearm and then pull across the chest and face until it is outside the vagina
Barum maneuver
Pressure is applied to the posterior surface of the most accessible part of fetal shoulder (scapula; either the anterior or posterior shoulder) to effect shoulder abduction
Rubin maneuver (opposite Wood’s)
Replacement of the head up to station 0 for subsequent abdominal rescue
Zavanelli maneuver
Placing the patient on all fours
Gaskin maneuver
During the active phase, the rate of cervical dilatation should not be slower than
1 cm/hour
Phase of cervical dilation that is not always present
Acceleration phase
Functional divisions of labor
1) Preparatory (latent phase) 2) Dilatational (active) 3) Pelvic (deceleration phase of cervical dilation/cardinal movements of labor)
Protracted active phase is defined as
Less than 1.2 cm/hour in nulli; less than 1.5 cm/hour in multis
Prolonged deceleration (stage II) in nullipara
3 hours or more
Prolonged deceleration (stage II) in multipara
1 hour or more
Station: Pelvic inlet
-3, -5
Station: Ischial spines
0
Station: Perineum (crowning)
+3, +5
Arrest in descent, nulli
No change in dilatation in an hour
Arrest in descent, multi
No change in dilatation in 30 minutes
Prolonged latent phase, nulli
> 20 hours
Prolonged latent phase, multi
> 14 hours
Arrest of dilation
No progress for 2 hours
Protracted descent, nulli
Less than 1 cm/hour
Protracted descent, multi
Less than 2 cm/hour
Shoulder dystocia is disproportion between fetal bisacromial diameter and ___
AP diameter of pelvic inlet
Indicator of shoulder dystocia described as retraction of feral head against maternal perineum
Turtle sign
Turtle sign is due to failure of what cardinal movement
Internal rotation of bisacromial diameter at midpelvis > impaction of shoulder at sacral promontory
MC fractured bone in shoulder dystocia
Clavicular fracture (2nd: Humeral fracture)
Planned CS may be reasonable for a diabetic woman with EFW ___
> 4200-4500g
ACOG guideline for application of fundal pressure
Don’t apply directly downward; lateral application from either sides of maternal abdomen at an angle towards the feral chest
A maneuver that flattens the maternal sacrum hence increases the size of the posterior outlet and may unlock posterior shoulder; increases intraabdominal pressure
Mc Robert
Progressive rotations of shoulder girdle in a corkscrew fashion by continuous pressure on anterior surface of the posterior shoulder together with downward thrust of the left hand on the buttocks of the baby
Woods maneuver
Posterior arm delivery; pressure applied on the antecubital fossa in order to flex the fetal forearm and then pull across the chest and face until it is outside the vagina
Barum maneuver
The pressure is applied to the posterior surface of the most accessible part of fetal shoulder (either the anterior or posterior shoulder) to effect shoulder abduction
Rubin maneuver (opposite Wood’s)
Replacement of the head up to station 0 for subsequent abdominal rescue
Zavanelli maneuver
Placing the patient on all fours
Gaskin maneuver
At station -2, the presenting part is at the level of
2 cm above ischial spine
First degree laceration
Fourchette, perineal skin, vaginal mucosa; PERIURETHRAL
At full effacement, cervix is described to be
“Paper thin”
Absolute indication for CS
Contracted pelvis
Cutting the cervix to make the opening bigger
Duhrseen
Shoulder horn instrument w/ concave blade w/ long handle, is slipped b/w symphsis pubis and
impacted anterior shoulder
Chavis
Pressure applied at infant’s jaw and neck in the
direction of the mom’s rectum, w/ strong fundal pressure applied by an assistant as the anterior shoulder is freed
Hibbard
Best anaesthesia to alleviate pain during childbirth
Epidural anesthesia
Incompetent cervix is defined as
Cervical dilatation in the absence of uterine contractions
Interval and duration of contractions true labor
2-3 minutes, 40-60 seconds
How often should pelvic exams be done
Every 4 hours in latent phase; every 2-3 hours during the active phase
Test used to confirm whether bag of water has ruptured
Litmus paper test
Patient in labor should be placed on NPO for
8 hours
When to give analgesia in labor
Active phase
Position and movement during labor
Position the patient is most comfortable in EXCEPT in ROM and sedated patients; IDEALLY, dorsal lithotomy (increases diameter of outlet
Position if membranes have ruptured and patient is sedated
Left lateral decubitus (increases blood flow to fetus)
Normal fetal response to movement and contractions
HR accelerates
Most accurate measure of labor progress
Cervical dilation
Sign that episiotomy may be done
Crowning, 3-4 cm of the head is visible
Purpose of episiotomy
Prevent tears of perineal muscle
What is the ONLY disadvantage of midline episiotomy compared to mediolateral episiotomy
Transection of rectum
When is mediolateral episiotomy indicated
1) Very short perineum 2) Anticipated large baby
Heel of clinician’s hand that is draped with a sterile towel is placed over posterior perineum overlying fetal chin
Modified Ritgen maneuver
When to start Modified Ritgen maneuver
Vulvar ring is at 5 cm
Purpose of Modified Ritgen maneuver
Allows control of delivery of fetal head so that the smallest diameter passes through introitus
Where to place clamp during cord clamping
2-5 cm from baby’s umbilicus
Earliest sign of placental separation
Change in uterine shape from discoid to globular (CALKIN SIGN)
Signs of placental separation
1) Calkin sign 2) Gush of blood from vagina 3) Lengthening of the cord 4) Rise of uterus in abdomen as placenta descends to LUS or vagina
A pathologic constriction located at the junction of the thinned lower uterine segment and the thick retracted upper uterine segment that is associated with absence of progress in labor with very good uterine contractions
Pathologic ring of Bandl
First degree laceration
Fourchette, perineal skin, vaginal mucosa (sparing underlying fascia and muscle)
Second degree laceration
Up to fascia and muscles of perineal body
Third degree laceration
Up to anal sphincter
Fourth degree laceration
Up to rectal mucosa
If you are dealing with 4th degree lacerations, which mucosa should you repair first
Rectal mucosa FIRST before the vaginal mucosa
CI from giving ergot alkaloids (methylergonovine malate)
Hypertension
The Nitabuch’s layer separates the cotyledons from the
Decidua basalis
Mean blood loss with vaginal delivery
500 mL
Mean blood loss with CS
1000 mL
Total blood loss in vaginal delivery that is considered hemorrhage
1000 mL
Total blood loss in CS that is considered hemorrhage
1500 mL
% blood loss in class 1 hemorrhage
15
% blood loss in class 2 hemorrhage
20-25
% blood loss in class 3 hemorrhage
30-35
% blood loss in class 4 hemorrhage
40
Prenatal risk factors for hemorrhage
1) Pre-eclampsia 2) Previous PPH 3) Multiple gestation 4) Previous CS 5) Multiparity
Intrapartum risk factors for hemorrhage
1) Prolonged 3rd stage 2) Episiotomy, midline or mediolateral 3) Arrest of descent 4) Lacerations 5) Augmented labor 6) Forceps delivery
4 T’s of postpartum hemorrhage
1) Tone 2) Tissue 3) Trauma 4) Thrombin
PPH: Frank bleeding, blood loss proportionate with maternal VS, contracted uterus
Birth canal injuries
MC risk factor for birth canal injuries
History of delivery of big babies
Management for birth canal injuries
1) Suture if >2 cm laceration, 1st stitch 1 cm above apex of tear 2) Antimicrobials 3) Crystalloids while waiting for BT
In complete uterine rupture, which layers of the uterine wall are separated
All
In incomplete uterine rupture, which layers of the uterine wall are separated
Uterine muscle separated; visceral peritoneum intact (uterine dehiscence)
MCC of uterine rupture
Previous classical CS scar (located at active segment)
By ___, you expect most organs have returned to their normal non-pregnant condition
6 weeks
MC location of myoma
Body of uterus
Cerclage in women with weak cervix has to be removed at ___ weeks AOG to prevent the risk of uterine rupture during childbirth
36 weeks
A pathologic constriction located at the junction of the thinned lower uterine segment and the thick retracted upper uterine segment that is associated with obstructed labor
Pathologic ring of Bandl
Postpartum bleeding presenting as amount of bleeding disproportionate to maternal vital signs
Uterine rupture
Management for uterine rupture
Laparotomy
Management of choice for uncontrolled uterine bleeding from rupture
Hysterectomy
Placental separation wherein blood escapes into the vagina due to separation from the periphery
Duncan
Placental separation wherein blood is concealed behind the placenta due to separation from the center
Schultze
In placenta accreta, abnormal attachment of the villi (trophoblasts) to the myometrium is due to the absence of
Nitabuch’s layer
The Nitabuch’s layer separates the cotyledons from the
Decidua basalis
MC risk factor for placenta accreta
Previous CS
Preferred diagnostic modality for placenta accreta
Ultrasound with Doppler
UTZ criteria that is diagnostic for placenta accreta
Intraplacental lacunae
Management for placenta accreta
Cut umbilical cord, leave placenta to necrose, MTX + folinic acid
MCC of postpartum hemorrhage
Hematomas secondary to inadequate repair of an episiotomy or vaginal laceration
1st manifestation of bleeding in hematomas secondary to inadequate repair of an episiotomy or vaginal laceration
Pallor
Complete uterine inversion
Uterus extends beyond cervix
Incomplete uterine inversion
Does not extend beyond cervix
Prolapsed uterus
Corpus is out of introitus
Uterine atony is failure of the uterus to contract within ___ after delivery
1 hour
Uterine atony can take place within ___ after placental delivery
6 weeks
MCC of obstetrical haemorrhage and bleeding in the 4th stage
Uterine atony
4th stage of labor
1-2 hours after placental delivery
MCC of late obstetrical hemorrhage
Retained placental fragments
Conservative management of uterine atony
1) Bimanual compression 2) Oxytocin 3) Ergot alakloids 4) PGF2
Surgical management of uterine atony
1) Uterine artery ligation (90% of uterine blood flow) 2) Hypogastric/Internal iliac artery ligation (external iliac pulsation must be present after ligation) 3) B-lynch compression sutures (previous CS and LTCS) 4) TAH
Puerperium
Delivery of placenta until 6 weeks postpartum
Non-pregnant weight is normally attained at
6 months postpartum
Time when most physiologic changes during pregnancy return to prepregnancy state
Puerperium
Mechanism of uterine involution
Atrophy
T/F Oxytoxic agents hasten uterine involution
F
T/F Uterine involusion is faster in nulliparas than multiparas
T
At ___ uterus is in pelvic cavity
10th – 12th postpartum day
Weight of uterus after delivery
1000g
Weight of uterus 1 week postpartum
500g
Weight of uterus 2 weeks postpartum
300g
Weight of uterus at the end of puerperium
70g
Weight of non pregnant uterus
100g or less
Prolonged lochial discharge is a sign of
Uterine subinvolution
Placental site at the end of 2nd week postpartum
3-4 cm diameter
Regeneration of the stroma and endometrial glands over the placental site
7th day postpartum
Regeneration of the stroma and endometrial glands over the placental site begins at what area
Desidua basalis/periphery
Restoration of entire endometrium postpartum completes at
3rd week
T/F Inflammatory changes within 6 weeks postpartum reflect infection
F, histological endometritis and acute salpingitis are part of the normal reparative process
Vascularity of cervix are located at
12, 3, 6, and 9
Small elevations of the mucous membrane encircling the vaginal orifice after vaginal delivery
Myrtiform caruncles
At which week are fully healed lacerations and episiotomy and return of fallopian tubes and ovaries to the pelvis expected
1-2 weeks
Collecting duct system which is dilated during pregnancy returns to prepregnant measurement at ___ week postpartum
6th
Lochia rubra lasts for
3-4 days postpartum
Lochia serosa lasts for
6-9 days postaprtum
Lochia alba is seen during
After 10 days postpartum
Refers to intermittent, crampy lower abdominal pain that is experienced by some after delivery
After pain
Duration and intensity of after pain are increased with
1) Parity 2) Breastfeeding
Return of non-pregnant blood volume
1 week postpartum
CO returns to normal at
2 weeks postapartum
Non-pregnant weight is normally attained at
6 months postpartum
Return of menses postpartum is delayed with lactation because
Prolactin inhibits GnRH
Return of menstruation in non-lactating
7-8 weeks
Puerperal infection is defined as
38C or higher, 2nd-10th day postpartum (exclusive of the first 24 hours)
MCC of puerperal fever
Endometritis
Early-onset postpartum infection occurs within
48 hours
Late-onset postpartum infection occurs
After 48 hours up to 6 weeks postpartum
Single most significant risk factor for the development of uterine infection
Route of delivery
Most important criterion for diagnosis of postpartum metritis
Fever
Chills in puerperal infection suggests
Bacteremia
When to do antepartum fetal surveillance
28-32 weeks until 42 weeks
Fetal viability begins at
28 weeks
What patients will benefit from antepartum fetal surveillance
Those at risk for perinatal morbidity and/or mortality
T/F Do antepartum fetal surveillance in the presence of fetal abnormalities that are incompatible with life
F
Usual frequency of antepartum fetal surveillance
Once to 2x a week
Antepartum fetal surveillance techniques
1) Fetal movement counting 2) Non-stress test 3) Contraction stress test 4) Biophysical profile 5) Fetal umbilical artery velocimetry
Simplest and least expensive antepartum fetal surveillance
Fetal movement counting
When to do fetal movement counting
2nd half of pregnancy
Maximum period of awake stage when the baby makes a lot of movement
11pm-4am
Number of fetal movements that indicate a well baby in utero
10/hour
Maximal fetal activity when amniotic fluid volume is greater than the fetus
28-32 weeks
T/F Sleep cycle of a fetus becomes longer as the baby matures
T
Normal response of fetus to hypoxia
Reduction/cessation of movements to reduce O2 consumption and conserve energy
In stillbirth, fetal movement stops ___ hours before death
12-24
What is assessed in a non-stress test
FHR response to movement
Normal response in a non-stress test
FHR will temporarily accelerate/increase in response to the
fetal movement
Parameters measured in NST
1) Baseline FHR (110-160) 2) FHR variability (6-25/min) 3) Accelerations (normal response) 4) Decelerations (sign of fetal hypoxia)
Causes of non-reactive NST
1) Prematurity 2) Fetal sleep cycle 3) Tramadol
One dark line to another in an NST strip
1 minute
Each small box horizontally in an NST strip corresponds to
10 seconds
Define an acceleration in an NST
Increase in FHR of at least 15 beats lasting for at least 15 seconds
Reactive NST
2 or more FHR accelerations that peak at least 15 bpm above the baseline lasting for 15 seconds within a 20-minute period
Non-reactive NST
Does not meet the criteria over a period of 40 minutes
T/F A contraction stress test may be done in a preterm baby
F, may induce preterm labor
Intensity of contractions: 30-40 mmHg
Mild
Intensity of contractions: 40-60 mmHg
Moderate
Intensity of contractions: 60-80 mmHg
Strong
Intrauterine resuscitative measures
1) Maternal O2 in left lateral recumbent position (4-5 L) 2) Change oxytocics to plain IV, preferably D5 glucose for the brain of the fetus
Interpretation of NST: No late or significant variable deceleration
Negative; Assured that baby is okay
Interpretation of NST: Late decelerations following 50% or more of contractions
Positive; Non-reassuring FHR pattern
Interpretation of NST: Intermittent late decelerations
Suspicious
Non-invasive mode of antepartum fetal surveillance that predicts the presence or absence of fetal asphyxia and predicts risk of fetal death in the antenatal period
BPS
Redistribution of blood in a fetus will favour which organs
1) Brain 2) Heart 3) Adrenals
5 parameters of BPS
[NR Ba Talaga Ako]
NST + 4 variables observed by ultrasound 1) fetal bReathing 2) fetal Body movements 3) fetal Tone 4) AFV
BPS parameters of acute hypoxia
NST + RBT
BPS parameters of chronic hypoxia
AFV
