OB Flashcards
What is the difference between an embryo, fetus, and infant?
- embryos exist from fertilization to 8 weeks gestation
- from 8 weeks to birth the products of conception are referred to as a fetus
- infants are children less than 1 year old
How is amenorrhea defined?
- no menses for 3 months in someone with regular menses
- no menses for 6 months in someone with irregular menses
What defines the first, second, and third trimesters?
- the first trimester is from LMP to 14 weeks
- the second trimester is from 14 to 28 weeks
- the third trimester is from 28 weeks until delivery
How can you quickly estimate the due date?
LMP - 3 months + 7 days
What is a previable fetus and how is birth of a previable fetus managed?
a previable fetus is one born at less than 25 weeks gestation
- before 22 weeks resuscitation is not attempted
- between 22-25 weeks, the decision is made on a case-by-case basis after discussing risks and benefits with parents
- after 25 weeks, resuscitation is always initiated
What is considered a preterm birth? What is considered a post-term birth?
- preterm is birth before 37 weeks gestation
- post-term is birth after 42 weeks gestation
What are the Gs and Ps for a woman who is currently pregnant, has had 2 abortions, had two children born at term, and a set of twins born preterm?
G6P2124
Describe each of the following signs of pregnancy and when they are seen:
- Goodell sign
- Landin sign
- Chadwick sign
- Telangiectasias/Palmar Erythema
- Chloasma
- Linea Nigra
- Goodell sign: softening of the cervix felt at 4 weeks
- Landin sign: softening of the midline uterus at 6 weeks
- Chadwick sign: blue discoloration of the vagina and cervix at 6-8 weeks
- Telangiectasias/Palmar Erythema: first trimester
- Chloasma: the mask of pregnancy with hyperpigmentation of the face which worsens with sun exposure at 16 weeks
- Linea Nigra: hyperpigmentation extending from the xiphoid to the pubic symphysis seen in the second trimester
What is the first sign of pregnancy seen on physical exam?
Goodell sign, a softening of the cervix, which can be felt as early as 4 weeks gestation
What is chloasma?
also referred to as the mask of pregnancy, it is a hyperpigmentation of the face, worse with sun exposure, that is first seen around 16 weeks gestation
How should B-hCG levels change throughout the course of early pregnancy?
- the level should double approximately every 2 days for the first 4 weeks
- a level of 1500, seen around 5-6 weeks, suggests a gestational sac should be visible on ultrasound
- it should then peak around 10 weeks gestation
What are the first two steps in confirming pregnancy?
get a B-hCG level then perform an ultrasound to confirm an intrauterine pregnancy
At what point in pregnancy should a gestational and yolk sac be visible?
when B-hCG levels reach 1500 IU/mL
How do the following cardiac parameters change during pregnancy:
- blood volume
- hematocrit
- systemic vascular resistance
- heart rate
- cardiac output
- blood volume: increases
- hematocrit: decreases
- systemic vascular resistance: decreases
- heart rate: increases
- cardiac output: increases
How do the following respiratory parameters change during pregnancy:
- residual volume
- FEV1/FVC
- tidal volume
- respiratory rate
- minute ventilation
- PaCO2
- residual volume: decreased (upward pressure on diaphragm)
- FEV1/FVC: unchanged
- tidal volume: increased
- respiratory rate: unchanged
- minute ventilation: increased
- PaCO2: decreased
What are three common physiologic GI side effects of pregnancy and what causes these?
- morning sickness caused by increased estrogen and progesterone
- reflux caused by progesterone-induced LES relaxation
- constipation caused by reduced colonic motility
How do the following renal parameters change during pregnancy:
- GFR
- creatinine
- BUN/Cr
- kidney volume
- GFR: increases (greater blood volume and decreased SVR improves perfusion)
- creatinine: decreases (secondary to increased GFR)
- BUN/Cr: decreases
- kidney volume: increases due to increased vascular volume, increased interstitial volume, and dilation of renal pelvises
How do the following hematologic parameters change during pregnancy:
- WBC
- platelet count
- hematocrit
- PT
- PTT
- INR
- fibrinogen
- coagulability
- WBC: increased
- platelet count: decreased
- hematocrit: decreased
- PT: unchanged
- PTT: unchanged
- INR: unchanged
- fibrinogen: increased
- coagulability: increased
At what point should thrombocytopenia be investigated during pregnancy?
once platelet count is less than 80K
Describe the five options and timing of genetic testing available in the prenatal period.
- in the first trimester, between 9-13 weeks, a combined test of maternal B-hCG, maternal PAPP-A, and nuchal translucency can be performed as a screening tool
- in the first trimester, after 10 weeks, cell-free fetal DNA testing can be performed as a screening tool
- in the second trimester, between 15-20 weeks, a triple or quad screen can be performed with MSAFP, B-hCG, estriol, and (for the quad) inhibin A
- CVS is a confirmatory test performed at 10-13 weeks
- amniocentesis is a confirmatory test performed at 15-17 weeks
What routine prenatal testing is performed in each of the trimesters?
- in the first trimester, a dating ultrasound, pap smear, and G/C are performed along with routine blood tests
- in the second trimester, a routine ultrasound for anatomy is performed at 18-20 weeks
- in the third trimester a 1-hr GTT is performed at 24-28 weeks; a CBC for anemia at 27 weeks; and G/C, STD, and GBS testing at 36 weeks
When is glucose challenge testing performed during pregnancy?
at the end of the second trimester between 24-28 weeks gestation
What testing should be performed at 36 weeks gestation?
G/C, GBS culture, STD testing if patient was positive during pregnancy or has risk factors
What are Braxton-Hicks contractions and how should they be managed?
they are contractions that do not lead to cervical dilation; if they become regular or persist, the cervix should be checked to rule out preterm labor
When can CVS and amniocentesis be performed?
- CVS from 10-13 weeks
- amniocentesis from 15-17 weeks
What is the “combined test” during pregnancy?
it is a combination of maternal B-hCG, maternal PAPP-A, and nuchal translucency which serves as a screening for trisomy 21 and is performed at 9-13 weeks gestation
What is cell free DNA testing during pregnancy?
it is a screening test for aneuploidy that is performed in women over 35 after 10 weeks gestation
What are the triple and quad screening?
- triple is MSAFP, B-hCG, and estriol
- quad is the same plus inhibin A
- both are done between 15-18 weeks gestation
What does elevated maternal serum AFP indicate?
a dating error, neural tube defect, or abdominal wall defect
When should routine fetal US for anatomy be performed?
between 18-20 weeks of gestation
What is non stress testing, why is it performed, and how are the results interpreted?
- it is a noninvasive evaluation of the fetus in utero using fetal heart rate tracing
- a reactive test is defined by at least two accelerations within 30 minutes and this indicates adequate fetal oxygenation
- a nonreactive test does not necessarily indicate inadequate oxygenation however as the child may be sleeping
How is a fetal heart acceleration defined?
it is a more than 15 bpm abrupt increase in fetal heart rate that peaks within at least 30 seconds
How is the biophysical profile scored?
each category is worth 2 points and a score of 4 or less indicates fetal compromise:
- NST
- Amniotic fluid index: one pocket at least 2 cm in height
- Fetal breathing: at least 1 episode lasting 30 seconds
- Fetal movement: at least 4 counts
- Fetal muscle tone: at least 1 flexion and extension
What is a normal fetal heart rate? How are bradycardia and tachycardia defined?
- normal is 110-160
- bradycardia is a baseline (>10 minutes) less than 110
- tachycardia is a baseline (>10 minutes) more than 110
What causes variable, late, and early decelerations on fetal monitoring? Which is most serious?
V - Cord compression
E - Head compression
A - Okay!
L - Placental Insufficiency (most serious)
What are early decelerations?
- a decrease in HR that mirrors a contraction
- caused by head compression
What are late decelerations?
- a decrease in HR that comes after a contraction starts
- it is caused by placental insufficiency and fetal hypoxia
What are variable decelerations?
- decreases in HR that have no association with contractions
- caused by umbilical cord compression, which raises peripheral resistance and BP, triggering a reflexive bradycardia
What is meant by “lightening”?
this is a physiologic change that occurs before labor and describes fetal descent into the pelvic brim
What is meant by “bloody show”?
this is a physiologic change that occurs before labor and describe passage of blood-tinged mucus from the vagina that is released with cervical effacement
What do each of the following parts of labor involve:
- stage 1
- latent phase
- active phase
- stage 2
- stage 3
- stage 1: onset of labor to full cervical dilation
- latent phase: onset of labor to 6cm dilated
- active phase: 6cm dilated to full dilation
- stage 2: full dilation to child birth
- stage 3: child birth to delivery of placenta
What are the seven steps of stage 2 labor?
- engagement
- descent
- flexion
- internal rotation
- extension
- external rotation
- expulsion
Describe three methods of inducing labor and their mechanism of action.
- prostaglandin E2 is used for cervical ripening
- oxytocin is used for augmentation of uterine contractions
- amniotomy promotes engagement and effacement
Describe the following for ectopic pregnancy:
- risk factors
- presentation
- diagnosis
- most likely location
- management
- risk factors include prior ectopic, PID, IUD, and IVF
- it presents with pelvic pain and vaginal bleeding; patients may be hemodynamically compromised if it ruptures
- diagnosis is made with B-hCG and an ultrasound to identify the extrauterine pregnancy
- it most commonly occurs in the ampulla of the fallopian tube
- if it ruptures, patients require surgery, but if it has yet to rupture, patients can attempt medical management with methotrexate first (with some exceptions)
Describe the management of ectopic pregnancy.
- start by getting a B-hCG and US to make the diagnosis
- for ruptured ectopics, patients need hemodynamic support and surgery
- for unruptured ectopics less than 3.5 cm with no heartbeat and no other contraindications, methotrexate can be used for medical management
- after MTX, patients should have B-hCG monitored; if a decrease of 15% is not seen by day 7, an additional dose of MTX can be given
- surgery is indicated in these patients after 2 failed attempts at medical management
- in all patients, continue to follow B-hCG level to 0
Which patients with ectopic pregnancy are candidates for methotrexate?
must meet all of the following criteria:
- unruptured ectopic and hemodynamically stable
- no pre-existing immunodeficiency or liver disease
- ectopic is less than 3.5cm and without heart beat
- not breastfeeding or with a co-existing viable pregnancy
What is the most common cause of spontaneous abortion? What are other potential causes?
- the most common is chromosomal abnormality
- other causes include anatomic abnormalities, uncontrolled thyroid dysfunction or DM, SLE and antiphospholipid syndrome, infections, and trauma
What testing should be done at the time of suspect spontaneous abortion?
- get a CBC to evaluate blood loss
- get a blood type and Rh screen
- do an ultrasound and perform a digital exam
Describe each of the following:
- threatened abortion
- inevitable abortion
- incomplete abortion
- complete abortion
- missed abortion
- threatened abortion: bleeding but products of conception are intact and the os is closed
- inevitable abortion: bleeding with open os; products of conception still intact
- incomplete abortion: bleeding with open os and some products of conception found
- complete abortion: no products of conception found and os has closed
- missed abortion: products of conception present, os is closed, but fetus has died
How are the various types of spontaneous abortion treated?
- threatened: bed and pelvic rest
- inevitable: medical or D/C
- incomplete: medical or D/C
- complete: office follow up
- missed: medical or D/C
- septic: D/C and IV antibiotics
What is the management of septic abortion?
- perform a D/C to evacuate the uterine contents
- give IV antibiotics: cefoxitin plus doxy or clinda plus gentamycin
What medication is used for medical abortion?
misoprostol, a PGE1 analog
What role do methotrexate, mifepristone, and misoprostol play in pregnancy?
- methotrexate is used for termination of ectopic pregnancies
- mifepristone is used in combination with misoprostol for spontaneous or elective abortion of intrauterine pregnancy
How is recurrent fetal loss defined?
as more than 3 consecutive miscarriages
What are the four major complications of multiple gestations?
- premature labor and delivery
- spontaneous abortion of one fetus
- placental abruption
- anemia
What are the risk factors for preterm labor?
- PROM
- multiple gestations
- previous history of preterm labor
- placental abruption
- chorioamnionitis
- pre-eclampsia
- uterine anatomical abnormalities
How is preterm labor managed?
- 34-37 weeks: give betamethasone and deliver
- 32-34 weeks: give betamethasone and CCB for tocolysis
- < 32 weeks: give betamethasone, magnesium, and indomethacin for tocolysis
What are the two major tocolytics and what are their side effects?
- calcium channel blockers cause headache, flushing, and dizziness
- terbutaline causes palpitations and hypotension
How is rupture of membranes diagnosed?
- should do an exam, looking for fluid in the posterior fornix
- do a nitrazine test, which should turn the paper blue
- plate the fluid and look for ferning
- perform an ultrasound to look for decreased amniotic fluid volume
What is prolonged rupture of membranes?
rupture of membranes more than 24 hours before delivery
Prelabor rupture of membranes is associated with what four complications?
- preterm labor
- cord prolapse
- placental abruption
- chorioamnionitis
What is prelabor rupture of membranes? How is it further classified, diagnosed, and managed?
- prelabor rupture of membranes is that which occurs before the onset of labor
- it can be classified as preterm if occurring before 37 weeks gestation and as prolonged if occurring more than 24 hours before the onset of labor
- it is diagnosed by finding fluid in the posterior fornix that is nitrazine blue positive, displays ferning, and is accompanied by a low amniotic fluid index
- the first step in management is to avoid multiple digital exams to reduce the rate of infection
- if the fetus is term, wait 6-12 hours for spontaneous labor and then induce
- if the fetus is preterm, give betamethasone, tocolytics, ampicillin, and azithromycin
Which antibiotics are used as prophylaxis in those with prolonged or preterm premature rupture of membranes?
- ampicillin and azithromycin are preferred
- for low risk penicillin allergy, use cefazolin and azithromycin
- for high risk penicillin allergy, use clindamycin and azithromycin
Describe the etiology, presentation, and treatment of chorioamnionitis.
- it is most often polymicrobial, involving vaginal flora
- it presents with maternal fever and leukocytosis, maternal and fetal tachycardia, and uterine tenderness
- it is managed with delivery and antibiotics
- give ampicillin and gentamicin for vaginal delivery and add clindamycin for c-section
What antibiotics are used for chorioamnionitis prophylaxis and for treatment?
- prophylaxis: first-line is ampicillin and azithromycin (switch ampicillin to cefazolin or clindamycin for PCN allergy)
- treatment: use ampicillin and gentamicin for vaginal delivery; add clindamycin for c-section
Describe the presentation and management of placenta previa.
- it presents as painless third trimester bleeding
- digital exams are contraindicated so start with a transabdominal ultrasound followed by a transvaginal ultrasound
- in most cases treatment is strict pelvic rest with nothing in the vagina and scheduled c-section for 36-38 weeks
- immediate c-section is indicated for severe hemorrhage, fetal distress, and unstoppable labor (>4 cm cervical dilation)
What is a velamentous umbilical cord?
one in which the umbilical vessels lack the protective layer of Wharton jelly close to the placental insertion
Describe the presentation and treatment of vasa previa.
- patients present with heavy vaginal bleeding at the time of rupture of membranes
- all patients should undergo emergent c-section
Describe the presentation and treatment of umbilical cord prolapse.
- it present with sudden onset fetal bradycardia or variable decelerations and a palpable umbilical cord on vaginal exam
- treatment involves manually elevating the presenting part followed by emergent c-section
What are the three different types of placental invasion?
- accreta: attaches to the superficial uterine wall
- increta: inserts into the myometrium
- percreta: penetrates into the uterine serosa
Describe the presentation and management of placental invasion.
- presents with difficulty delivery the placenta and significant postpartum hemorrhage
- patients often require hysterectomy to control the bleeding
Describe the risk factors, presentation, diagnosis and treatment of placental abruption.
- risk factors include maternal hypertension, cocaine use, and smoking; external trauma; and prior abruption
- presents with painful third-trimester bleeding
- differential includes placenta previa so delay digital exam until transabdominal ultrasound has been performed
- vaginal delivery is indicated for limited placental separation and a reassuring fetal heart tracing or if fetal demise has already occurred
- c-section is indicated for uncontrollable hemorrhage, fetal distress, or rapid placental separation
Describe the risk factors, presentation, and management of uterine rupture.
- risk increases with uterine over distention, placenta percreta, prior uterine surgery, and trauma
- presents with sudden onset of extreme pain and loss of fetal station
- treat with immediate laparotomy for delivery and uterine repair
How should delivery be managed if patients have a history of classical cesarean or uterine rupture?
these patients are always delivered via c-section at 36 weeks
How does Rh incompatibility manifest in a sensitized woman?
during subsequent pregnancies, antibody production leads to fetal anemia, hepatosplenomegaly from extramedullary hematopoiesis, elevated bilirubin levels, and erythroblastosis fetalis
How is Rh incompatibility managed during pregnancy?
- Rh antibody screening is done during the initial prenatal visit and a Rh antibody titer is then done for Rh- women
- RhoGAM is then given routinely to unsensitized Rh- women at 28 weeks gestation, the time of delivery or abortion, and any time procedures or vaginal bleeding occur
What does a Rh antibody titer greater than 1:8 indicate in terms of management?
- that is a titer which is likely to cause significant fetal anemia so monitoring is necessary
- greater than 1:32, however, suggests severe anemia and an amniocentesis should be performed
How is IUGR defined and what are the two types?
- IUGR is defined as a weight in the bottom 10%
- symmetric is that in which the brain is proportional to the rest of the body; it occurs before 20 weeks and is caused by intrinsic factors like genetic issues or fetal infection
- asymmetric is that in which brain size is not decreased; it occurs; it usually presents after 20 weeks and is caused by extrinsic factors like utter-placental insufficiency
What is the most common preventable cause of IUGR in the US?
smoking
How are IUGR and macrosomia defined?
- IUGR is weight less than the tenth percentile
- macrosomia is weight greater than 4,500g
Describe the diagnosis, potential complications, and treatment of macrosomia.
- the diagnosis is suggested by a fundal height more than 3 cm the gestational age and should be confirmed with an ultrasound
- complications include birth injury including shoulder dystocia, hypoglycemia, and low apgar scores
- labor should be induced if the fetus’ lungs are mature before reaching 4500g
- otherwise, c-section is indicated for weight more than 4500g in diabetic mothers and more than 5000g in all others
What is suggested weight gain during pregnancy?
- for BMI < 18.5: 28-40 pounds
- for BMI 18.5-24.9: 25-35 pounds
- for BMI 25-29.9: 15-25 pounds
- for BMI > 30: 10-20 pounds
How should hyperemesis gravidarum be managed?
- avoidance of triggers, ginger, B6
- antihistamines, doxylamine and diphenhydramine
- metoclopramide
- ondansetron
When do we screen for asymptomatic bacteriuria and how is it treated in pregnancy?
- screen between 12-16 weeks go gestation
- treat with nitrofurantoin, amoxicillin, or cephalexin
Why is trimethoprim-sulfamethoxazole avoided during pregnancy?
because it is a folic acid antagonist
How are asymptomatic bacteriuria, acute cystitis, and acute pyelonephritis treated in pregnancy?
- asymptomatic bacteriuria: nitrofurantoin, amoxicillin, or cephalexin
- acute cystitis: nitrofurantoin
- pyelonephritis: hospitalize, start IV ceftriaxone, and gather urine cultures monthly
Describe the workup for pulmonary embolism in pregnancy.
- if leg symptoms are present, get a doppler and if this is positive, treat for PE
- if leg symptoms are absent or dopplers are negative, get a CXR
- if CXR is normal, get a V/Q scan (preferred diagnostic tool)
- if CXR is abnormal or V/Q is indeterminate, get a CTA
What is the best diagnostic test for PE in pregnancy? How should it be treated?
- V/Q scan is the best diagnostic test but CTA should follow if it is indeterminate
- treat with low-molecular weight heparin; stop 24 hours prior to delivery if scheduled; resume 6 hours after vaginal delivery and 12 after c-section
- continue LMWH for 6 weeks postpartum
What is the only aspect of cervical cancer screening and diagnosis that differs during pregnancy?
in pregnant patients, endocervical curettage is contraindicated; everything else is unchanged
What is polymorphic eruption of pregnancy, also known as papule and plaques of pregnancy?
- a pruritic rash that presents as erythematous papule within striae that spread outward to form urticarial plaques and spares the face, palms, and soles
- it is usually seen after 35 weeks gestation or in the postpartum period
- treat with topical corticosteroids for pruritus but it is self-limited and benign
Describe the presentation, diagnosis, and treatment of cholestasis of pregnancy.
- presents as pruritus in the absence of rash, predominately in the palms and soles that is worse at night
- labs demonstrate elevated bile acids to confirm the diagnosis
- treat with ursodeoxycholic acid and induction of labor at term
Describe the presentation, diagnosis, and treatment of acute fatty liver of pregnancy.
- presents with nausea, vomiting, abdominal pain, malaise, anorexia, and jaundice
- LFTs and WBC counts may be elevated with depressed platelet count similar to HELLP; however, signs of hepatic insufficiency and coagulation abnormalities help distinguish it
- liver biopsy is the gold standard but this is rarely done for diagnosis
- treat with immediate induction of labor
What differentiates chronic hypertension in pregnancy from gestational hypertension?
- chronic hypertension is that which exists prior to pregnancy or before 20 weeks of gestation
- gestational hypertension is that which arises after 20 weeks gestation
What are the three agents used to control hypertension during pregnancy?
labetalol, nifedipine, and methyldopa
How are pre-eclampsia and pre-eclampsia with severe features defined?
- pre-eclampsia is defined as blood pressure greater than 140/90 with greater than 300mg protein in 24-hour catch
- pre-eclampsia with severe features does not require proteinuria but instead has BP greater than 160/110, visual disturbance, RUQ pain, altered mental status, creatinine greater than 1.1, or pulmonary edema
How is pre-eclampsia managed?
- without severe features, term babies can be delivered and preterm should be given betamethasone and magnesium sulfate
- for severe features, start with magnesium sulfate for seizure prophylaxis and labetalol or hydralazine for blood pressure control, then deliver at 34 weeks
What is eclampsia and how is it treated?
- it is defined as preeclampsia with at least one tonic-clonic seizure
- stabilize the mother, deliver the baby, control BP with hydralazine, and give magnesium for seizure control
What is HELLP and how is it treated?
- it is a syndrome of HTN, hemolysis, elevated liver enzymes, and low platelet counts
- treatment is the same as for eclampsia: hydralazine, magnesium, and delivery of the baby
What complications are associated with gestational diabetes and diabetes in pregnancy?
- pre-eclampsia
- preterm labor
- spontaneous abortion
- infection
- post-partum hemorrhage
- heart and neural tube defects
- macrosomia and brith injury
- neonatal hypoglycemia
Those with diabetes prior to pregnancy should undergo what additional evaluations once pregnant?
- ECG
- 24-hour urine creatinine and protein
- HbA1c
- ophthalmological exam
What causes neonatal hypoglycemia in infants with diabetic mothers?
these babies produce increased insulin because they live in an environment of hyperglycemia; at birth insulin remains high despite withdrawal of the mother’s glucose levels and hypoglycemia results
What causes gestational diabetes?
human placental lactose which shares structure with insulin and decreases maternal insulin sensitivity
What is considered a positive glucose challenge? What follow up test should pregnant women undergo and what is considered a positive?
- a positive test is glucose greater than 130 at one hour
- these patients should then undergo a three hour glucose tolerance test
- the GTT is positive if two or more values are elevated
How is gestational diabetes treated?
- never recommend weight loss
- instead, first line therapy is a diabetic diet and exercise
- insulin is the gold standard if this fails, but metformin and glyburide are safe alternatives
What thyroid related molecules cross the placenta?
- TRH and immunoglobulins against the TSH receptor
- TSH and free T4 do NOT
What physiologic changes in thyroid function are expected during pregnancy?
- an increase in serum TBG increases the total amount of circulating thyroxine but does not alter free levels
- B-hCG stimulates the TSH receptor
How is hyperthyroidism treated during pregnancy?
- use PTU in the first trimester
- switch to methimazole for the second and third
Define arrest of cervical dilation and arrest of descent.
- arrest of cervical dilation is defined by failure to dilate after 2 hours during the active phase of stage 1 labor
- arrest of descent is defined by failure of the fetal head to move down into the birth canal with 1 hour of pushing
What is prolonged latent stage and how is it treated?
- defined as a latent stage lasting more than 20 hours in primipara or 14 hours in multipara
- treatment is rest and hydration as most will convert to spontaneous delivery
What is protracted cervical dilation and how is it treated?
- defined as failure of the cervix to dilate more than 1cm in nulliparous patients or more than 1.2-1.5cm in multiparous women during the active phase of stage 1 labor
- if the cause is cephalopelvic disproportion, the treatment is c-section
- if the cause is weak contractions (<200MVU/10min), oxytocin should be given
What is the difference between a frank, complete, and footling breech?
- frank is when the hips are flexed and the knees are extended
- complete is when the hips and knees are both flexed
- footling is when the fetus has at least one foot first
How is malpresentation diagnosed and managed?
- the Leopold maneuvers and vaginal exam are used to screen for malpresentation
- diagnosis must be confirmed by ultrasound
- then offer external cephalic version starting at 37 weeks
Describe the most common etiology, presentation, and treatment for uterine inversion.
- most often secondary to excessive umbilical cord traction and fundal pressure during stage 3 labor
- presents with pain, vaginal bleeding, and a smooth round mass protruding through the cervix
- treatment begins by stopping all uterotonic drugs and attempting to manually reposition the uterus; if needed, uterine relaxing agents like terbutaline, nitroglycerine, and magnesium can be used to help with repositioning
- if all else fails, perform a laparotomy to reposition it
How is lactational mastitis treated?
- give antibiotics: dicloxacillin or cephalexin
- use cold compresses and anti-inflammatories
- continue breast feeding
How is postpartum hemorrhage defined?
more than 1L of blood loss or bleeding with signs and symptoms of hypovolemia in the first 24-hours post-partum
What are the most common etiologies for postpartum hemorrhage?
- uterine atony, usually secondary to over distention, anesthesia, or prolonged labor
- may also be due to retained placenta or coagulopathy
How is postpartum hemorrhage managed?
- start with exam to ensure there is no uterine rupture or retained placenta
- then perform bimanual compression and massage
- can use oxytocin if needed to augment uterine tone
What are the benefits of breast feeding?
- enhances infant GI function
- decreases risk of infant infection
- increases rate of maternal recovery
- reduces maternal and neonatal stress
- improves rate of maternal weight loss
- reduces risk of maternal DM, cardiovascular disease, and breast, ovarian, and endometrial cancer
What are six contraindications to breast feeding?
- maternal HIV/HTLV-1
- maternal active TB
- maternal herpes lesion on breast
- maternal use of cytotoxic medications
- maternal substance use disorder
- fetal galactosemia
