OB-gyne notes Flashcards
Birth rate
Live births per 1000 females
Fertility Rates
Live births per 1000 females aged 15-44 y/o
Perinatal period
birth - 28 days
Infant
Until 1year of age
Abortion
- <20 weeks AOG or
- <500 grams
Preterm
<37 weeks AOG
Postterm
>42 weeks
Term
37-42 weeks
Puerperium
Time from delivery lasting about 4-6 weeks
Early abortion
<12 weeks
Later abortion
>12 weeks AOG but <20 weeks AOG
Early UTZ
<20 weeks AOG
Late UTZ
>20 weeks AOG
Layers of the anterior abdominal wall
Skin Camper’s (fatty layer) Scarpa’s fascia (membranous -> colles fascia) Muscles
Blood supply of the anterior abdominal wall
Superficial epigastric Deep/inferior epigastric artery
Male Homologues
- Labia Minora - Penile urethra, skin of Penis
- Labia Majora - Scrotum
- Clitoris - Penis
- Skene’s glands - prostate gland
- Bartholin’s gland - Cowper’s gland
Borders of the Vulva
- Superior: Mons pubis
- Lateral: Labiocrural fold
- Inferior: Perineal Body
Management for Bartholin duct cyst
Marsupialization
Components of the Pelvic diaphragm
Levator ani
- Pubococcygeus
- Pubovaginalis
- Puboperinealis
- Puboanalis
- Puborectalis
Ileococcygeus
Coccygeus
Components of the Striated Urogenital Sphincter Complex
- Sphincter urethrae
- Compressor urethrae
- Urethrovaginal urethrae
Blood supply of the uterus
- Ovarian artery
- Uterine artery
Vaginal Blood supply
Proximal portion : Vaginal and uterine
Posterior vaginal wall: Middle rectal
Distal: Internal pudendal
Location of the ovaries in relation to the internal iliac
Medial
Ligaments (Internal female genitalia)
- Round ligament
- Broad Ligament
- Cardinal or transverse cervical (Mackenrodt ligament)
- Uterosacral ligament
What ligament provides the main support of the Uterus?
Cardinal ligament and Uterosacral ligament
Mesosalpinx
Around the fallopian tube
Mesoteres
Around the round ligament
Mesovarium
Over the uterovarian ligament
Parts of the Pelvis
False Pelvis
True Pelvis
- Pelvic inlet
- Midpelvis
- Pelvic outlet
Arteries entering the true pelvis
“MISO”
- Median sacral
- Internal iliac
- Superior rectal
- Ovarian
Abnormal levels of hemoglobin
1st trimester: <10 g/dl
2nd trimester: <10.5g/dl
3rd trimester: <11 g/dl
Presumptive evidence of Pregnancy
- Morning sickness
- Fatigue
- Frequency in urination
- Quickening
- Cessation of menses
- Beading cervical mucus
- Chadwick’s sign
- Changes in breast
- Skin changes
- Increased temperature
Morning sickness
6-18 weeks
peak of HCG is 8-10 weeks plateus at 16 weeks
Quickening
16-20 weeks
- primigravid 18-20 weeks
- Multigravid 16-18 weeks
Beading cervical mucus
6 weeks
poor crystallization or beading is due to PROGESTERONE
Ferning
sign of increased estrogen, makes pregnancy unlikely
also observed as a result of amniotic fluid leakage
Chadwick’s sign
6 weeks
Vaginal mucosa becomes dark-bluis red and congested
Chloasma/Melasma
Mask of pregnancy due to MSH
Spider telangiectasia
increased estrogen
Increased temperature
6 weeks due to increased PROGESTERONE
PROBABLE evidence of Pregnancy
- Enlargement of abomen
- Hegar’s sign
- Goodell’s sign
- Braxton Hick’s contractions
- Physical outlining of fetus
- ballottement
- Detection of B-HCG
Hegar’s sign
6-8 weeks
softening of the uterine isthmus
Goodell’s sign
softening of the cervix
POSITIVE SIGNS of pregnancy
- FHT
- perception of fetal movement by examiner
- Sonographic recognition
Fetal heart tone
Normal: 120-160
Auscultaion: 16 weeks
Doppler: 10 weeks
TV-UTZ: 5 weeks
75 g OGTT
24-28 weeks
Human placental lactogen is produced during this time
has growth hormone like action and causes insulin resitance, lipolysis, and increased fatty acids
Biophysical profile
24-28 week
10 danger signs of Pregnancy
- Headache
- BOV
- Prlonged Vomiting
- Fever
- Nondependent edema
- Epigastric/RUQ pain
- Dec. fetal movement
- Dysuria
- Bloody vaginal d/c
- Watery vaginal d/c
Signs of Preeclampsia
- headache
- BOV
- Prolonged Vomiting
- Epigastric/RUQ pain
- Nondependendent edema
Estimated date of Confinement
Naegele’s rule
EDC= LNMP + 7 days - 3 months
fundal height
cm
top of the pubis syphysis to the top of the fundus
b/w 20-34 weeks, fundus correlates closely with AOG
Fundal height
12 weeks - uterus becomes an abdominal organ
16 weeks - fundus is midway b/w the pubis symphisys and the umbilicus
20 weeks- level of the umbilicus
Frequency of Prenatal check-up
<28 weeks (monthly)
28-36 weeks ( every 2 weeks)
>36 weeks (every week)
Recommended weight gain
BMI:
- <18.5 = 28-40 lbs
- 18.5-24.9 = 25-35 lbs (37-54 lbs if twins)
- 25-29.9 = 15-25 lbs (31-50 lbs if twins)
- >30 = 11-20 lbs (25-42 lbs if twins)
Recommended dietary allowances
- Calories ( increase 100-300 kcal/day)
- Protein (5-6 g/day)
- Iron (27 mg elemental FE/day) - if large/twins (60-100) - start giving 2nd trimester
- Folic acid (400 mcg) (4 mg if with history of NTD)
Caffeine intake (OB)
Max; 3 cups of 4 oz
Travel (OB)
safe up to 36 weeks
Fetal lie
Relation of the fetal long axis to that of the mother
Fetal presentation
Portion of the body that is foremost within the birth canal
Fetal attitude
Posture or Habitus
Fetal Position
Relationship of fetal presenting part to the right or left of birth canal
Predispositon factors for transverse lie
- Multiparity
- Placenta previa
- Hydramnios
- Uterine anomalies
caput succedaneum
local edema
molding refers to bony changes in the fetal head, which results in shortened suboccipitobregmatic diameter
Phases of partutiton
- Phase 1 (Quiescence) - prelude to parturition
- Phase 2 (Activation) - Preparation for labor
- Phase 3 (stimulation) - Processes of Labor
- Phase 4 (Involution) - Parturient recovery
QUIESCENT phase
- Prelude to parturition
- Begins even before implantation
- Contractile unresponsiveness
- Cervical softening
- Braxton Hicks contractions may be felt
ACTIVATION phase
- preparation of labor
- during the last 6-8 weeks of pregnancy
- Myometerial unresponsiveness suspeded: OXYTOCIN receptors increase
- Formation of the LUS
- Cervical ripening, effacement, and loss of structural integrity
Treatment to promote cervical ripening
- PGE2
- PGF2
- progesterone antagonist
STIMULATION phase
- processes of labor
- Uterine contraction
- cervical dilatation,
- fetal and placental expulsion
INVOLUTION phase
- parturient recovery
- Uterine involution
- Cervical repair
- Breastfeeding
LABOR
uterine contractions that bring about demonstrable effacement and dilatation of the cervix
FIRST stage of Labor
Starts with painful regular contractions ends with cervical dilatation
Bloody show - spontaneous release of blood-tinged mucus plug from the cervical canal
Ferguson reflex
mechanical stretching of the cervix enhances uterine activity
Ring of Bandl
Pathological retraction ring
- thinning of the LUS is extreme
SECOND stage of Labor
Begins with complete cervical dilatation (10 cm)
Ends with fetal delivery
the most important force in fetal expulsion
Intraabdominal pressure
Station
describes the descent of the fetal biparietal diameter in relation to a line drawn between two maternal ischial spines
THIRD stage of labor
Delivery of the placenta
7 cardinal movements of labor
- Engagement
- Descent
- Flexion
- Internal rotation
- Extension
- External rotation
- Expulsion
Engagement
BPD passes thru the pelvic inlet
Descent
Due to 4 forces:
- Pressure of the amniotic fluid
- Pressure of the fundal contractions
- Maternal effort
- Straightening of fetal body
Flexion
OFD shifts to SOBD
Internal rotation
Occiput moves toward pubis symphysis
Extension
Due to 2 opposing forces:
- Pressure of fundal contraction
- resistance of pelvic floor
External rotation
BSD to APD
Functional division of Labor
Preparatory Division
Dlatational Division
Pelvic Division
Abnormal labor progression in the active phase
cervical dilatation<1.2 cm/hour in nulliparas
cervical dilataion <1.5cm/hour in multiparas
Labor arrest
Absence of appreciable change in 2 hours in the presence of adequate uterine contractions
Signs of Placental separation
“up-down-up-down”
- Uterus becomes globular and firmer (CALKIN’s sign)
- Sudden gush of blood
- Uterus rises in the abdomen
- Lengthening of the umbilican cord
Mechanisms of placental expulsion
Schultze
Duncan
Schultze Mechanism
Blood from the placental site pours into the membrane sac and does not escape externally until after extrusion of the placenta
Retroplacental hematoma follows the placenta or is found within the inverted space
Duncan Mechanism
Placenta separates first at the periphery and the blood collects between the membranes and the uterine wall and escapes from the vagina maternal surface appears first
Prolonged latent phase
>20 hours (nullipara)
>14 hours (multipara)
Protracted active phase
<1.2 cm/hour (nullipara)
<1.5 cm/hour (Multipara)
Protracted descent
<1 cm/hour (nullipara)
<2 cm/hour (multipara)
Prolonged deceleration phase
>3 hours (NP)
>1 hour (MP)
Secondary arrest of dilatation
>2 hours (NP)
>1 hour (MP)
** of no cervical dilatation
Arrest of descent
> 1 hour (NP)
> 1 hour (MP)
** must be in deceleration phase
Failure of descent
No descent on deceleration phase or 2nd stage of labor
Precipitous Labor
Expulsion of fetus in <3 hours
Associated with:
- Abrutio placenta
- Meconium passage
- Postpartum hemorrhage
- Low APGAR
TX:
- B-mimetic
- MgSO4
- Lateral decubitus
Cepalopelvic disproportion
DC <11.5 cm
BSD <8cm
BTD <8 cm
Asynclitism
lateral deflection of the sagittal suture, posteriorly toward the sacral promontory or anteriorly toward the symphysis pubis
Anterior Asynclitism
sagittal suture approaches the sacral promontory and the anterior parietal bone presents itself on the examiner’s finger
Shoulder Dystocia Drill
A- Ask for help
L - lift legs (Mcrobert’s position)
A - Anterior shoulder disempaction
R - Rotation of the posterior shoulder
M - Manual Extraction of the posterior arm
E - Episiotomy
R - Roll on all fours
McRobert’s position
causes straightening of the sacrum, rotation of the pubis symphysis toward the maternal head, and a decrease in the angle of pelvic inclination
Mazzanti Maneuver
(Abdominal) - anterior shoulder disempaction with the heel of clasped hands, suprapubic pressure is applied by another member of the team to the posterior aspect of the anterior shoulder pressure may be sufficient to abduct the shoulder
Rubin’s maneuver
(Vaginal) Physician’s hand reaches the ost anterior fetal shoulder, which is then pushed toward the anterior surface of the fetal chest this abducts the shoulder, which reduces the shoulder to shoulder diameter
Woods corkscrew maneuver
delivery of the posterior shoulder then progressively rotating the posterior shoulder 180 degrees in a corksrcrew fashion
Gaskin maneuver
Moving the mother to an all fours position with the back arched, widening the pelvic outlet
Cleidotomy
Fracturing the clavicle with scissors
Symphysiotomy
Symphyseal cartilage is cut
Zavanelli
Return the head to the occiput anterior or posterior position
Give acute tolysis
Flex the head slowly push it back to the vagina
CS delivery is then performed
Guideline for intrapartal FHR monitoring (LOW RISK)
Auscultation:
- 1st Stage: every 15 minutes
- 2nd Stage: every 5 minutes
Guideline for intrapartal FHR monitoring (HIGH RISK)
Continuous EFM
Documented systematic assessment every hour
Baseline Heart Rate
Mean FHR rounded to increments of 5 beats over minute during a 10 minute segment excluding segments that differ by 25 bpm
Normal: 110-160
Baseline Variability
Fluctuations with irregular amplitude and inconstant frequency
- Absent: Amplitude range undetectable
- Minimal: Amplitude range detectable, but <5 beats/min
- Moderate: 6-25 beats/min
- Marked: >25 beats/min
Acceleration
Visually apparent abrupt increase in FHR above baseline, with the time from the onset of the acceleration to its acme <30 seconds)
if >32 weeks : Peak is >15 beats/min lasts >15 seconds but < 2 inutes.
if <32 weeks: Peak >10 beats/min above the baseline; lasts >10 seconds but < 2 minutes from onset to return to baseline
Prolonged acceleration: lasts > 2 minutes but < 10 minutes in duration
Change in baseline: if the acceleration lasts >10 minutes
Decelerations
Visually apparent usually symmetrical gradual decrease and return of the FHR associated with a uterine contraction;
Gradual FHR is defined as from onset to the FHR nadir is >30 seconds
Early deceleration
The nadir deceleration occurs at the same time as the peak of the contraction
Head compression -> vagal nerve activation
Late deceleration
Deceleration is delayed in timing, with the deceleration occuring after the contraction.
Uteroplacental insufficiency-> hypoxia Maternal hypotension
- Excessive uterine activity
- Placental dysfunction
- Maternal disease
variable Deceleration
Visually aparent abrupt decrease in FHR;
an Abrupt decrease is defined as from onset to the FHR nadir <30 seconds
Cord compression patterns occlusion of vein -> reduced fetal blood return -> acceleration occlusion of artery -> fetal systemic hypertension -> deceleration
Prolonged deceleration
Decrease in FHR from the baseline is >15 beats/min lasting > 2 minutes but < 10minute in duration
Sinusoidal pattern
Visually apparent, smooth, sine wave like undulating patern in FHR baseline with a cycle frequency of 3-5 minutes that persists for 20 minutes or more
Severe fetal anemia
Uterine contractions
quantified as the number of contractions present in a 10 minute window, averaged over a 30 minute period
- Normal: <5 contractions in 10 minutes
- tachysystole > 5 contractions in 10 minutes (averaged over 30 minutes)
Category I FHR:
- Normal tracings
- Baseline: 110-160
- Moderate variability
- (-) late decelerations
- (+/-) accelerations
Category II FHR:
- Indeterminate tracings
- Requires continued surveillance
- Baseline: Tachycardia
- Bradycardia not accomapanied by no variability
- Variability: minimal
- Decelerations: Periodic or episodic
- Accelerations (-)
Category III FHR
Abnormal tracings
Predictive of abnormal fetal acid base status
Requires prompt evaluation and initiation of attempts to resolve
Nonstress test
tracing is labeled as nonstress when there is no contraction within the 20 minute trace.
- Reactive: >2 accelerations within 20-40
- NR: <2 accelerations
Resuscitative Measures for abnormal tracing
- Left lateral decubitus
- oxygen support
- Discontinue oxytocin
- IV fluid bolus (200cc)
How to give oxytocin
10-20 units in 1L = 10-20 mU/mL
start at 6mU/mL increase in 40 minute interval to 42 mU/mL
in PGH: 10 units in 1L start at 8 drops/min titrate by 2 cc/hr every 15-20 minutes
GOAL: q3-4 min contractions, moderate to strong, 60-90s but < 7 contractions in 15 minutes
When to stop giving oxytocin
contractions are 5x in 10 minutes
contractions are 7x in 15 minutes
contractions are longer than 60-90 secs.
If fetal heart rate is non reassuring
Induction of labor
Stimulation of contraction before spontaneous onset of labor
Augmentation of Labor
Stimulation of sponteneous contraction that is inadequate
Indications of induction of Labor
- Rutpture BOW
- Maternal HPN
- Nonreassuring fetal status
- Postterm gestation
Contraindications for induction of labor
- Uterine factors:
- Uterine scar,
- Classical CS
- Placenta previa
- Fetal Factors
- Macrosomia
- Fetal congenital anomaly
- Maternal factors
- Maternal size
- Pelvic anatomy
- Active genital herpes
Failed induction of labor
12 hours of Oxytocin after ruptured BOW without progress
Bishop scoring system
Predicts labor induction Dilatation
- Effacement
- Consistency
- Position
- Station
score of 9 : high likelihood
<4: unfavorable
Agents for cervical ripening
- Dinoprostone (PGE2)
- Misoprostol (PGE1)
Mechanical Dilatation of the cervix
- Hygroscopic osmotic dilatation
- membrane stripping
- Transcervical catheter attached to dangling urine bag with 300mL water
