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Clinical Medicine 5 > OB (part 1)-Exam 3 > Flashcards

OB (part 1)-Exam 3 Flashcards

1
Q

LY

What do you need to ask when is coming to GYN history?

A
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2
Q

Reproductive cycles:
* What is the average age of menarche? Menopause? Menstrual cycle?

A
  • Average age at menarche is 12.43 years
  • Average age at menopause is 51.4 years
  • Average duration of the menstrual cycle is 28 days; normal range is 23-35 days
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3
Q

Normal Fertility
* When do must couple get pregnant?
* What decreases as time of trying to get pregnant goes on?

A
  • 85% of couples will become pregnant within 12 months of unprotected intercourse
  • Fecundability (the probability of achieving a pregnancy in a single menstrual cycle) decreases as the number of consecutive months without achieving pregnancy increases
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4
Q

Normal Fertility
* When is the fertile interval?
* The highest probability of conception occurs when?

A
  • The fertile interval extends from approximately five days prior to ovulation to the day of ovulation
  • The highest probability of conception occurs when intercourse takes place one to two days prior to ovulation and the day of ovulation

Why is highest probability one to two days prior? Sperm live 48-72 hours. Can take half hour to days to reach egg

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5
Q

Normal Fertility
* When is there optimum semen?
* The highest pregnancy rates occur in who?

A
  • Optimum semen quality occurs when there are two to three days of ejaculatory abstinence
  • The highest pregnancy rates occur in couples who have intercourse every 1-2 days (but regular intercourse 2-3/wk beginning soon after cessation of menses should suffice)
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6
Q

Normal Fertility
* What does not affect the likelihood of conception?
* Some lubricants do what?

A
  • Coital position, presence or absence of female orgasm, and female position/activity after male ejaculation do not affect the likelihood of conception
  • Some lubricants inhibit sperm motility in vitro (eg, KY jelly, Astroglide, olive oil, saliva). There is no evidence that they impair fertility.
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7
Q

Normal Fertility
* What is the probability of pregnancy following intercourse on the most fertile day of the cycle (if the male partner is the same age)?

A
  • 19 to 26 years – 50%
  • 27 to 34 years – 40%
  • 35 to 39 years - 30 %
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8
Q

Predicting Ovulation - BBT
* What is used?
* When do you measure the temp?
* When does the temp increase and drops?

A
  • Special BBT thermometer is used
  • Temperature is measured first thing in the morning before eating, drinking or getting out of bed
  • Temperature drops during menses then rises 2 days after the LH surge which triggers ovulation
  • Oocyte release occurs 1 day before the first temperature elevation
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9
Q

Predicting Ovulation - OPK
* What does ovulation predictor kits measure? When does this happen?

A

Ovulation Predictor Kits (OPK) measure LH surge in the urine
* Ovulation occurs 24-48 hours after urinary evidence of the LH surge

  • Line has to be darker to count or as dark as the other one – not just the presence of faint line – negative.
  • Have sex on the day of LH surge and 2 days after.
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10
Q

Infertility
* What is it?
* Women under age 35 are evaluated for infertility when? Over 35?
* What are the major factors of infertility?

A
  • Inability to conceive despite frequent coitus
  • Women under age 35 are evaluated for infertility after 12 months of unsuccessful attempts to conceive; women age 35 and older are evaluated after six months
  • Male factors (26%), ovulatory dysfunction (21%), tubal damage (14%)
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11
Q

Infertility Work-up Considerations
* Are there eggs? (3)
* Can the eggs get out of the ovary?(1)

A

Are there eggs?
* AMH or basal follicle stimulating hormone plus estradiol
* Transvaginal ultrasound with antral follicle count

Can the eggs get out of the ovary?
* Serum progesterone

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12
Q

Infertility Work-up Considerations
* Can the eggs get to the tubes?
* Will the uterus host the pregnancy? (4)

A

Can the eggs get to the tubes?
* Hysterosalpingography/contrast with ultrasound

Will the uterus host the pregnancy?
* Transvaginal ultrasound
* Sonohysterography
* Hysteroscopy
* Hysterosapinography

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13
Q

Ovulatory Dysfunction: Oligo-ovulation (sporadic) or anovulation (no ovulation)
* What are the examples?(3)

A

PCOS
* Oligo-ovulation
* Hirsutism
* Amenorrhea
* Acne
* Weight gain

Thyroid disorders

Hyperprolactinemia

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14
Q

Infertility: anatomic factors
* What are uterine exampels? (4)
* What are fallopian tube examples? (1) Evauated how?

A

Uterine
* Fibroids
* Polyps
* Intrauterine adhesions – most often post D&C
* Congenital Abnormalities

Fallopian Tubes
* PID is the primary cause of tubal factor infertility
* Evaluate via hysterosalpingogram

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15
Q

What is going on in these pictures?

A
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16
Q

Infertility Treatment:
* Ovarian stimulations treatment? (2)
* Intrauterine insemination treatment? (1)

A

Ovarian stimulation
* clomiphene citrate administered from Day 3 or 5 of the cycle for 5 days at a dose of 50mg to 150mg
* Metformin 1500-2000mg daily for pts w/PCOS (don’t have to have DM).

IUI:
* An ejaculated semen specimen is inserted into the vagina via catheter – helpful if having coital problems

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17
Q

Assisted Reproductive Technologies (ART)
* All fertility procedures that involve what?
* What is the most common assisted technology?

A
  • All fertility procedures that involve manipulation of gametes, zygotes or embryos to achieve conception
  • Invitro Fertilization (IVF) – most common assisted technology
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18
Q

Assisted Reproductive Technologies (ART):
* How is IVF done?
* What is there an increase risk up?

A

IVF:
* Ovary is stimulated medically to produce multiple follicles
* Oocytes are retrieved from the ovaries and fertilized in vitro in the lab
* Embryo is incubated in the lab then transferred into the uterus through the cervix
* Chance of conception as high as 40-50%

30% rate of multiple gestations

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19
Q

What is the Reproductive Cycle?

A
  • Home ovulation kits test for LH surge.
  • Mid luteal phase can be evaluated by rise of progesterone
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20
Q

Diagnosis of Pregnancy: Positive urine pregnancy test (UPT)
* How does it work?
* Typically no what?
* Positive when?
* Urine test day?

A
  • Qualitative (yes or no)
  • Typically no false +, but yes for false -
  • Positive 4-wks post LMP (can be + as soon as 10-12 days)
  • Urine test day of missed period or shortly after

  • Urine pregnancy test measures level of hCG in urine
  • Early morning urine sample has the highest concentration of hCG
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21
Q

Diagnosis of Pregnancy: Positive serum pregnancy test
* Measures what?
* What are the two types?
* When is it (+)?

A
  • Measures ß-hCG
  • Qualitative or quantitative (amount)
  • hCG in serum + at 6-8 days after ovulation
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22
Q

Diagnosis of Pregnancy
* What is the imaging?

A

Transabdominal U/S

Transvaginal U/S: sooner than transabdominal
* Gestational sac visualized at 4.5 – 5 weeks gestation
* Cardiac activity at 5.5 – 6 weeks

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23
Q

Pregnancy
* MCC of what?
* Diagnose pregnancy when?

A
  • The most common cause of Amenorrhea
  • Diagnose pregnancy as early as possible for early prenatal care, lifestyle changes (alcohol, tobacco, drugs, diet), limit environmental/work exposures, medication changes
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24
Q

Pregnancy: Serum hCG test
* Levels increase when?
* Double when?
* Peak when?
* Falls when??

A
  • Levels increase shortly after implantation
  • DOUBLE EVERY 48-72 HOURS
  • PEAK AT 50-75 DAYS
  • Fall to lower levels in second and third trimesters
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25
Q

Pregnancy: Serum Progesterone
* Not what?
* Unless levels are what?

A
  • Not a sensitive evaluation of pregnancy
  • Unless levels are low and then ectopic/miscarriage should be suspected
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26
Q

What are the early signs of pregnancy? (7)

A
  • Amenorrhea
  • Nausea, vomiting, food aversions
  • Breast tenderness (Mastodynia) and tingling
  • Fatigue (first trimester, improves second, may return third)
  • Heartburn
  • Urinary frequency
  • Increased lability of mood/emotions
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27
Q

Early Signs of Pregnancy
* What happens with discharge?
* Breast changes may start when? (4)
* Increased?

A

Leukorrhea, increase in vaginal discharge containing epithelial cells and cervical mucous

Breast changes may start early and continue to postpartum
* Enlargement
* Vascular engorgement
* Nipple darkening
* Colostrum

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28
Q

TEST

Early Signs of Pregnancy: Cervical changes
* What is chadwick’s sign? ⭐️
* What is goodell’s sign?
* What is Hegar’s sign?

A
  • Blue discoloration or increased vascularity/congestion of vaginal mucosa -> Chadwick’s sign,
  • Softening of cervix at or after 4 weeks -> Goodell’s sign
  • Softening of the uterus at cervical junction at 6 weeks -> Hegar’s sign
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29
Q

Skin Changes in Pregnancy:
* What is Chloasma?
* What is spider telangiectasia?

A
  • Chloasma: “mask of pregnancy”, darkening of the forehead, bridge of the nose or cheek bones. Usually after 16 weeks; exacerbated by sunlight
  • Spider telangiectasia: result from elevated plasma estrogen. Vascular stellate skin lesions and palmar erythema
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30
Q

Skin Changes in Pregnancy
* What is linea nigra?
* What is striae?

A
  • Linea nigra: Melanocyte-stimulating hormone increases, causing darkening of the nipples and the lower midline from the umbilicus to the pubis. Lightens slightly after delivery
  • Striae: Stretch marks. Breast and abdomen. Appears red, glossy skin that become scar-like. Appear late in pregnancy. Caused by abnormal collagen formation or separation
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31
Q

Multiple Gestation: Twins
* What is most common?
* What is monozygotic or identical twin?
* How does quadruplets happen?

A
  • Dizygotic or fraternal twins; fertilization of two separate ova; MOST COMMON; frequency varies by races and ethnic groups
  • Monozygotic or identical twins; single fertilized ovum that then divides 1/250 births
  • Quadruplets, may arise from one to four ova
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32
Q

Multiple Gestation
* What are the risk factors? (4)

A
  • Race (AA women 3.5%, Caucasian women 3%; Hispanic, Asian and Native American lower rates than both)
  • Advancing maternal age; fourfold increase between 15-37yo
  • Multiparous
  • Heredity, more maternal side; Mother twin 1/58; father twin 1/116 pregnancies
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33
Q

Multiple Gestation
* How do you dx it? (3)

A
  • Increased fundal height
  • Detection of multiple heart beats
  • Ultrasound
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34
Q

Multiple Gestation
* What are the fetal complications? (11)

A
  • Increased risk spontaneous abortion (0.9 singleton compared 7.3 multifetal)
  • Congenital malformations
  • Low birth weight
  • Malpresentation
  • Placenta previa
  • Abruptio placentae
  • PROM
  • Prematurity
  • Umbilical cord prolapse
  • IUGR
  • Increased perinatal morbidity and mortality, increases with the number of fetuses
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35
Q

Multiple Gestation
* What are the maternal complications? (8)

A
  • Anemia
  • Hydramnios
  • Hypertension
  • Premature labor
  • Postpartum uterine atony
  • Postpartum hemorrhage
  • Preeclampsia
  • Cesarean delivery
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36
Q

Multiple Gestation:
* What is the treatment? (3)

A
  • Fetal reduction
  • Increased US; 2-4 weeks
  • Delivery between 34-38 weeks
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37
Q

What is the Routine Prenatal Care Schedule? (4)

A
  • Initial Visit, usually 6-12 weeks gestation
  • Monthly until week 28
  • Biweekly 28-36
  • Weekly until delivery
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38
Q

Initial Visit
* Occurs when?
* Confirmation of when?
* Calculate what? ⭐️

A

Occurs at any point between 6-12 weeks gestation

Confirmation of pregnancy (usually with US)

Calculate Estimated Due Date (EDD)
* Add 7 days to LMP, subtract 3 months, add one year to the first day of LMP (Naegele’s Rule)

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39
Q

Initial Visit
* What do you need to find out?
* What do you need to counsel?

A

Past pregnancies, complications, outcomes and other risk factors

Counseling:
* Nutrition, weight gain, Immunizations, Lifestyle modifications, exposures
* Exercise: 150 minutes/week moderate physical activity, muscle-strengthening 2 days week.

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40
Q

Initial Visit
* Screen what?
* Full what?
* What testing needs to be done?
* What supplements?

A
  • Screen for domestic violence
  • Full Physical and Pelvic Exams
  • Prenatal Testing (Aneuploidy (trisomy, monosomy), sickle cell disease, cystic fibrosis, Tay-Sachs disease)
  • Prenatal vitamins; 30-60mg Iron, 0.4 mg Folic Acid
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41
Q

Prenatal Testing Initial Visit (approx. 6-12 wks): Tests for mother
* What serum needs to be tested? (7)

A
  • Blood type and Rh typing (ABO/Rh) and antibody
  • CBC (hemoglobin, hematocrit, and platelets)
  • Syphilis
  • Rubella titer (if negative, give after birth)
  • Hepatitis B surface antigen
  • HIV test
  • Varicella
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42
Q

Prenatal Testing Initial Visit (approx. 6-12 wks):Tests for mother
* Screening what?
* Urine?
* If at least 21 years old, then what?
* If hx of gestational diabetes or obese, do what?
* If hx of preeclampsia initiate what?

A
  • Screening Gonorrhea, Chlamydia, trichomonas, candida, BV
  • UA with Culture
  • If at least 21 years old, cervical CA screening
  • If hx of gestational diabetes or obese, 50g glucose challenge test (GCT)
  • If hx of preeclampsia – initiate aspirin
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43
Q

Prenatal Labs and Screening Tests

A
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44
Q

First Trimester (6-12 weeks) Testing for fetus
* When does screening occur?
* What is the NIPT?
* First-trimester combined test?

A
  • Screening- Will not begin until at least 10 weeks
  • Noninvasive prenatal testing (NIPT) - cell free DNA analysis of fetal cells in mothers’ circulation- must be at least 10 weeks
  • First-trimester combined test (Fetal aneuploidy screening for extra or missing chromosomes; Trisomy 13, 18, 21)
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45
Q

First Trimester (6-12 weeks) Testing for fetus
* Within the screening, what is the US for? What is also measured and why?

A

US for nuchal translucency: measures thickness back of fetus’s neck, abnormal measurement means increased risk of Down syndrome (trisomy 21)

Serum levels of PAPP-A (pregnancy-associated plasma protein A) and free beta subunit hCG
* Detection rate of Trisomy 18 (Edwards Syndrome) is 85-87% with false positive rate <5%

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46
Q

First Trimester (6-12 weeks) Testing for fetus
* What is the diagnostic test?

A

Chorionic villus sampling: tissue sample from the placenta, usually about 10-13 weeks, higher risk of miscarriage than Amniocentesis, but able to do earlier if results would alter course of pregnancy.

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47
Q

What is Nuchal Translucency?

A

A small hypoechoic space in the posterior fetal neck is a normal finding in all first trimester fetuses, excessive enlargement is associated with an increased risk of Down syndrome, as well as other fetal abnormalities

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48
Q

Chorionic Villus Sampling
* What is it for?
* What is obtained?
* Same information as what?

A
  • For prenatal diagnosis of genetic disorders (e.g. Down’s Syndrome)
  • Small samples of the placenta are obtained for chromosome or DNA analysis
  • Same information as amniocentesis but faster
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49
Q

Chorionic Villus Sampling
* What are the two ways to do it?
* Carries what risk?
* When is it done?

A
  • Transcervical or transabdominal
  • Carries a significantly increased risk of fetal loss compared to second trimester amniocentesis. Safer than early amniocentesis
  • Typically done 10-13 weeks of gestation
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50
Q

Long

What is additional genetic testing?

A
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51
Q

⭐️⭐️⭐️

Immunizations:
* What is safe during pregnancy?(6)

A
  • Pneumococcal
  • Meningococal
  • Hepatitis A, B
  • Inactivated polio
  • Inactivated influenza–should be given, ok any trimester
  • RSV
  • Tdap
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52
Q

⭐️⭐️⭐️

When should RSV and tdap be given?

A
  • RSV @ 32-36 weeks gestation – can protect infant for up to 6 months
  • Tdap—should be given at 27-36 weeks REGARDLESS of prior immunization hx (there is some passive antibody transfer to infant). All persons with close contact to infant should also be immunized.
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53
Q

⭐️⭐️⭐️

Immunizations
* What is not safe?

A
  • Measles/mumps/rubella
  • Polio
  • Varicella
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54
Q

⭐️⭐️⭐️

What is not certain/not recommended?

A

HPV Vaccine. No adverse outcomes have been described but not recommended. If found to be pregnant during series, remaining doses given after pregnancy

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55
Q

⭐️⭐️⭐️

Rh Incompatibility:
* Check what? When?
* Who do you test?
* If Mother is Rh -, after exposure to Rh + blood, what happens? What are the exposures?

A

Check Rh(D) and antibody typing at first prenatal visit, at 28 weeks, and at delivery

Rh factor protein on red blood cells, testing MOTHER only

If Mother is Rh -, after exposure to Rh + blood, antibodies are made to attack the Rh + blood cells.
* Exposure: labor and birth, amniocentesis, CVS, bleeding during pregnancy, attempts to manually turn fetus from breech presentation, trauma to the abdomen during pregnancy

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56
Q

⭐️⭐️

Rh Incompatibility
* What can it cause?
* What is the Maternal Treatment if RhD is negative?

A

Can cause fetal hydrops or hemolytic anemia (erythroblastosis fetalis), or to neonate (erythroblasosis neonatorum) and death

Rh immune globulin (Rhogam) 300 mcg IM at:
* 28 weeks gestation OR 72 hours of delivery OR Any procedure at risk of blood exposure (isoimmunization) such as amniocentesis, CVS
* AND any episode of vaginal bleeding (at 13 weeks interval)

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57
Q
A
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58
Q

What to avoid
* What food do you need to avoid during pregnancy?

A
  • Alcohol, tobacco, drugs, herbal substances
  • Unpasteurized milk and foods made unpasteurized milk
  • Raw and undercooked seafood, eggs, meat
  • Refrigerated pate, meat spreads, and smoked salmon
  • Hot dogs, luncheon meats and cold cuts unless served steaming hot
  • Seafood high in mercury: tilefish, shark swordfish, and king mackerel
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59
Q

What to avoid
* What does omega-3 fatty acids and DHEA cause? What is recommended?

A

omega-3 fatty acids and DHEA may enhance brain development and should be encouraged, 8-12 oz/week fish lower in mercury: salmon, shrimp, pollock, tuna (light canned), tilapia, catfish, and cod

60
Q

⭐️

What are the teratogenic drugs?

61
Q

Exercise
* What should you encourage? Do not do what?

A
  • Encourage continue current exercise programs or initiate light exercise. Do not start strenuous exercise routines.
  • Do not exercise until exhaustion or breathlessness, do not lie flat on back during 3rd trimester
62
Q

Exercise
* What benefits?
* Reduces risk of what?
* May reduce what?

A
  • Psychological benefits
  • Reduces risk of excessive gestational wt gain, gestational DM, preeclampsia, preterm birth, varicose veins, DVT
  • May reduce length of labor and complications with delivery
63
Q

Prenatal Care
* What do you need to do at every visit?

A

Every Visit:
* Vital signs, BP and Weight
* Fundal height
* Fetal heart rate (FHR)
* Fetal position and activity
* UA for bacteria, glucose and protein

64
Q

Prenatal Care: Fetal heart rate
* Audible when?
* 10-18 weeks, found where? After 18 weeks?
* Should vary how?

A
  • Audible with doppler 10-12 weeks
  • 10-18 weeks, found along midline lower abdomen (DO NOT PANIC IF IT TAKES A MINUTE TO FIND THIS)
  • After 18 weeks, depends on fetal position, best heard over back or chest
  • 110-160 bpm
  • Should vary 10-15 bpm per second. More variable after 32-34 weeks due to increased fetal activity
65
Q

Prenatal Care: Fetal position and activity
* What is quickening?
* Kick counts when?

A
  • “Quickening” is sensation of fetal movement. Felt 18-24 weeks
  • “Kick counts” after 28 weeks is assessed routinely
66
Q

Assessment of Fetal Well-Being: Kick counts
* How many should be felt during normal maternal activity? Mom is at rest and counting in one and 2 hours?

A
  • Perception of at least 10 FMs during 12 hours of normal maternal activity
  • Perception of least 10 FMs over two hours when the mother is at rest and focused on counting
  • Perception of at least 4 FMs in one hour when the mother is at rest and focused on counting
67
Q

⭐️

Assessment of Fetal Well-Being
* What is a non stress test? What is reassuring?

A

Non-Stress Test: external transducer monitors fetal heart rate in response to fetal activity
* Reassuring if ≥2 HR accelerations (15bpm above baseline and lasting 15 seconds) in 20 minutes

68
Q

⭐️⭐️⭐️

What are the fundal height measurements?

69
Q

⭐️⭐️⭐️

16-20 weeks testing: Screening
* What is the maternal triple and quad screen?

A
  • Maternal Triple screen. Includes alpha-fetoprotein (AFP), hCG, estriol.
  • Maternal “quad screen” for aneuploidy if first trimester screening not done. Adds Inhibin A and evaluates for everything as in Triple screen + abdominal wall defects
70
Q

16-20 weeks testing
* What is the diagnostic test?
* Fetal US (20 weeks) to determine what?
* Cervical length measurement for what?

A
  • Diagnostic: Amniocentesis as indicated and requested for aneuploidy
  • Fetal US (20 weeks) to determine pregnancy dating and evaluate fetal anatomy
    * Physical defects in the brain, spine, facial features, abdomen, heart, limbs
  • Cervical length measurement (mean = 3.6cm; >2.5cm is normal) can identify women at risk for preterm birth. Not always done
73
Q

Amniocentesis
* What is it?
* When is it done?
* Most common indications?

A
  • Technique for withdrawing amniotic fluid from the uterine cavity using a needle via a transabdominal approach
  • Technically possible after 11 weeks gestation. (Procedures performed before 15 weeks are associated with higher fetal loss and complication rates)
  • Most common indications are prenatal genetic studies and assessment of fetal lung maturity
74
Q

Amniocentesis
* Performed when?
* Higher chance of miscarriage when?

A
  • Performed with abnormal 1st semester Combined test or Triple/Quad test to look for some genetic or NTD conditions
  • Higher chance of miscarriage if done <15 weeks
75
Q

24-28 weeks testing
* US for what?
* When do you do US after that?
* If initial antibody screen for anti-Rh(D) negative, repeat when?
* 28-32 weeks, what is done?

A
  • US for fetal size and growth if fundal height is 3cm < expected gestational height
  • US every 2-6 weeks for multi-fetal pregnancies for discordant growth
  • If initial antibody screen for anti-Rh(D) negative, repeat antibody test at 28 weeks. Result is not required before Rh(D) immune globulin is administered.
  • 28-32 weeks, CBC for anemia
76
Q

24-28 weeks testing
* What is the screening for gestational DM?

A

50-g glucose load and a 1-hour post load venous blood glucose test (@28w)
* Abnormal is >=140.

Abnormal test followed with a 3-hour glucose tolerance test for diagnosis with check of serum or plasma

77
Q

28 Weeks to Delivery
* What is determined?
* What do you need to discuss at every visit?
* Maternal perception of what?
* What is performed if medically indicated?
* Air travel is appropriate up to when?

A
  • Fetal position determined
  • Now discuss preterm labor or rupture of membranes at each visit
  • Maternal perception of fetal movement
  • Nonstress tests and biophysical profiles performed if medically indicated
  • Air travel is appropriate up to 36 weeks gestation
78
Q

36 Weeks to Delivery
* Repeat blood tests for what?
* What tests for at risk patients?
* Screening for what?
* What maneuver?

A
  • Repeat blood tests for syphilis and HIV (depending on state laws) and urine nucleic acid amplification.
  • Gonorrhea and Chlamydia for at-risk patients
  • Screening for group B streptococcal colonization (Neonate risks: pneumonia, meningitis, sepsis)
  • Leopold Maneuvers (External Cephalic Version) can begin now and assessed systematically
79
Q

⭐️

36 Weeks to Delivery
* How do you screen and treat GBS?

80
Q

41 Weeks
* What type of exam?
* When should inducation happen?

A
  • Cervical examination
  • Induction if cervix is favorable (2 cm or more dilated, 50% or more effaced, vertex at -1 station, soft cervix, midposition); also considered if cervix not favorable at this time.
  • Induction at 42 weeks regardless of cervical examination findings
81
Q

Pearls
* FHR detectable 10-12 weeks, where?
* When is fetal movements felt?
* What are Braxton Hick’s contractions?
* Avoid what?

A
  • FHR detectable 10-12 weeks midline lower abdomen
  • Fetal movement (Quickening) 18-24 weeks (earlier for multiparous)
  • Braxton Hick’s contractions are painless, felt as tightening or pressure, begin approx. 28 weeks and increase in regularity. DISAPPEAR with walking exercise, or hydration, NO CERVICAL DILATION.
  • Avoid cat litter and wear gloves when gardening
82
Q

Pearls
* What is okay?
* Caffeine?
* Okay to take what?
* What organisms to avoid?(3)

A
  • It is ok to get hair dyed
  • Caffeine should be <200mg (not proven harmful if over 200mg -300 mg)
  • Ok to take a bath, keep temp about 98. Hot tub and sauna limited less than 10 minutes. Goal is to keep body temp <102.
  • Vibrio bacteria from seafood, Listeria from cheese, Botulism from honey
83
Q

Common Terms
* Preterm infant:
* Term infant:
* Late term:
* Post term:

A
  • Preterm infant: born between 20 and 36 6/7 weeks (259 days)
  • Term infant: 37 and 40 6/7 weeks gestation (280 days)
  • Late term: 41 0/7 to 41 6/7 weeks
  • Post term: 42 weeks and beyond
84
Q

Common Terms
* Nulliparous –
* Uniparous or Primiparous or Para 1 –
* Multiparous-
* Could be what?

A
  • Nulliparous – No pregnancies
  • Uniparous or Primiparous or Para 1 – Pregnant once and first baby delivered
  • Multiparous- Had babies before
  • Could be vaginal or cesarean
85
Q

Obstetric History
* What is gravidity?
* what is parity?

A
  • Gravidity: the number of times a woman has been pregnant, whether she delivered or not, including the present pregnancy
  • Parity is the number of viable/live births
86
Q

Obstetric History
* What are all the options for Gravida/para/abortus?

A

(G)TPAL
* “T” or “F” – (full) term births (after 37 weeks)
* “P” – premature births
* “A” – abortions/ectopic (elective and spontaneous)
* “L” – living children
* Multiples count as one birth

87
Q

GPA History Examples:
* GPA history of a woman who has had two pregnancies (both of which resulted in live births):
* GPA history of a woman who has had four pregnancies, one of which was miscarried:
* GPA history of a woman who has had one pregnancy of twins with successful outcomes:
* A pregnant woman who carried one pregnancy to term with a surviving infant; carried one pregnancy to 35 weeks with surviving twins; carried one pregnancy to 9 weeks as an ectopic (tubal) pregnancy; and has 3 living children:

A
  • G2P2
  • G4P3A1
  • G1P1
  • G4 P1113
88
Q

TEST

What is labor? What are the 6 Ps?

A

Contractions + Cervical Change

Six P’s:
* Parity
* Passenger (baby)
* Passage (pelvis)
* Powers (contractions)
* Position
* Psyche

89
Q

What is the 5-1-1 rule?

90
Q

What are the 3 Ps?

A
  • Powers: strength, duration and frequency of uterine contractions. We want to see:
  • Passenger (fetus)
  • Pelvis: is it adequate for delivery?
91
Q

3 Ps
* Contractions should occur when?
* Palpation?
* Last how long?

A
  • Occur every 2-3 minutes
  • Firm on palpation
  • Last 40-60 sec
92
Q

3 P’s: Passenger (Fetus)
* Estimation of what?
* Evaluation of what?
* Presentation?
* Station?
* Number of what?

A
  • Estimation of clinical weight
  • Evaluation of fetal lie (longitudinal, transverse or oblique)
  • Presentation (vertex or breech)
  • Station – descending into pelvis
  • Number of fetuses
93
Q

3 P’s: pelvis
* Progress of what?
* Consider what?

A
  • Progress of descent of the presenting part during labor is the best test of pelvic adequacy
  • Consider C-section if pelvis is not adequate
94
Q

Labor Induction
* induction=
* What are the indications? (3)

A

Induction = stimulation of uterine contractions

Indications
* Continuing the pregnancy carries greater maternal or fetal risk than intervention to deliver
* There is no contraindication to vaginal birth
* 41 weeks gestation

95
Q

Labor Induction
* What are the contraindications?(6)

A
  • Prior classical uterine incision
  • Active genital herpes infection
  • Placenta previa
  • Umbilical cord prolapse
  • Transverse fetal lie
  • Cervix is not well prepared (i.e. softened and partially effaced).
96
Q

Labor Induction Methods
* What are the different ways? (5)

A
  • Membrane stripping: pulling away sac
  • Cervical ripening
  • Oxytocin
  • Amniotomy
  • Others (anecdotal evidence): nipple stimulation, intercourse, spicy food
97
Q

Labor Induction Methods
* How can you ripen the cervix?

A

Prostaglandins
* Misoprostol (Cytotec) 25mcg intravaginally q3-6hrs
* Dinoprostone (Cervidil) 10mg; insert is left in place until active labor begins, or for 12 hours

98
Q

Labor Induction Methods: Amniotomy
* What is it?
* Note what?
* Monitor what?
* Risk of what?

A
  • Artificial rupture of membranes
  • Note clarity of fluid and presence of meconium
  • Monitor FHR before and immediately after
  • Risk of umbilical cord prolapse
99
Q

Labor Exam
* What dilations?
* how do you measure it?
* Dilates to what?

A
  • Cervical dilation: Described in centimeters dilation
  • One finger = 1 cm
  • Two Fingers = 2 cm
  • Dilates to 10cm
100
Q

Labor Exam: Effacement
* What is it?
* Expressed how?

A
  • Degree to which the cervix has thinned
  • Expressed as a percent of thinning from uneffaced state
101
Q

Labor Exam
* What is station?

A

Described the relative level of the presenting part to the level of the ischial spine

102
Q

⭐️⭐️⭐️

Stages of Labor
* What are the different stages?

A

First stage:
* Early/latent phase
* Active phase

Second stage: Birth

Third stage: Delivery of placenta

Fourth stage: Recovery

103
Q

⭐️⭐️

First Stage of Labor - “Dilating” (2 parts)
* When does it happen?
* Duration?

A
  • Prior to onset of labor, fetal head settles into the brim of the pelvis (or at onset in multiparous women)
  • Time from onset of painful contractions resulting in cervical changes to complete cervical dilation
104
Q

⭐️

First Stage of Labor - “Dilating” (2 parts)
* What is happening in the latent phase?

A

Latent phase (dilation < 4cm; ≤ 18-20 hrs)
* Softening and effacement of the cervix with minimal dilatation
* Mild, irregular contractions
* Release of mucous plug, may have small amount of blood-tinged mucous ”bloody show”
* Can last from hours to days. Often shorter with subsequent deliveries

105
Q

⭐️⭐️⭐️

First Stage of Labor - “Dilating” (2 parts)
* What is happening in the active phase?

A

Active phase (normal dilation occurs at a rate of ≥1.2 cm/hr)
* Begins when the cervix is 6 cm dilated in the presence of regular occurring contractions
* Accelerated rate of cervical dilatation from 6cm to 10 cm, approximately 1 cm per hour
* Descent of the fetal presenting part begins, progresses at rapid rate at end of active phase
* Contractions stronger, closer together, regular
* Lasts 4-8 hours on average

106
Q

Clinical Management of First Stage
* Access and obtain what?
* Patient may do what?
* If in bed, what position?
* Avoid what?

A
  • IV access and Foley obtained
  • Patient may ambulate.
  • If in bed, left lateral recumbent position should be encouraged (ensure uteroplacental perfusion)
  • Avoid oral fluids (decreased gastric emptying), hydrate with IV fluid
107
Q

Clinical Management of First Stage
* What is the maternal monitoring? (5)
* _
* Fetal monitoring when?
* Uterine contractions when?

A
  • Maternal monitoring: HR, BP, RR, temp every 1-2 hours, urine output
  • Analgesia
  • Fetal monitoring every 30 minutes active stage in patient’s with no significant risk (or electronic monitor tracings reviewed)
  • Uterine contractions every 30 minutes by palpation or continuously along with FHR for high risk
108
Q

⭐️

Fetal Heart Tones
* What are the reassuring patterns? (4)

A

A baseline fetal heart rate of 120 to 160 bpm
* Absence of late or variable FHR decelerations (after contractions)
* Moderate FHR variability (6 to 25 bpm)
* Age appropriate FHR accelerations

109
Q

⭐️

Fetal Heart Tones
* What are the nonreassuring patterns? (3)

A
  • Absent/minimal variability with decelerations or bradycardia
  • Recurrent late or variable decelerations
  • Bradycardia – FHR < 110 BPM
110
Q

⭐️

Fetal Distress or “non-reassuring fetal status”
* What is it?
* Confused for what?
* Detection with what?

A
  • Abnormal fetal heart rates that may not be reassuring and signal distress
  • Confused with birth asphyxia (baby does not have adequate amounts of oxygen before, during, or after labor; maternal low oxygen, cord compression)
  • Detection with FHR monitor
111
Q

⭐️

Fetal Distress or “non-reassuring fetal status”
* What are the findings?
* What are the risks?

A

Findings:
* Fetal tachycardia or bradycardia
* Repetitive variable decelerations
* Low biophysical profile (NST and US)
* Late decelerations

Risks: anemia, oligohydramnios, pregnancy induced HTN (PIH), post-term pregnancies, intrauterine growth retardation (IUGR), Meconium-stained amniotic fluid (can block airways)

112
Q

⭐️⭐️⭐️

External and Internal Continuous Fetal Monitoring

113
Q

⭐️

What is the trick for fetal accelerations and decelerations?

A

V = VERY BAD

114
Q

⭐️

FHR monitoring

115
Q

Fetal Distress
* What are the risks?

A

Anemia, oligohydramnios, pregnancy induced HTN (PIH), post-term pregnancies, intrauterine growth retardation (IUGR), Meconium-stained amniotic fluid (can block airways)

116
Q

Fetal Distress
* What is the txt?

A

Treatment: intrauterine resuscitation; prevent any unnecessary procedures
* Change mother’s position
* Ensure mother well-hydrated
* Ensure mother has adequate oxygen
* Correct maternal hypotension
* Amnioinfusion (alleviate cord compression)
* Tocolysis
* IV dextrose
* Cesarean section

117
Q

Labor and Pain Management
* What is the pain management?

A
  • Nonpharmacological approaches
  • Epidural block via infusion pump
  • Spinal anesthesia (single injection of sufentanil and lasts only 90 mins)
  • Combined spinal-epidural
  • Local block (pudendal)
  • General anesthesia
118
Q

Diagnosis of Labor Abnormalities
* First stage, latent phase?

A

Protracted (slow to progress)
* ≥20 hrs for the nullipara
* ≥14 hrs for the multiparous woman

119
Q

Diagnosis of Labor Abnormalities
* What are the two things going on in the first stage, active?

A

Protracted
* Cervical dilation <1.5cm over two hours (1.2 cm/hr for nulliparous; <1.5 cm/hr for the multiparous woman)

Arrested
* Cervix that ceases to dilate after reaching ≥ 6cm or no progressive dilation in 6 hrs following oxytocin administration

120
Q

Diagnosis of Labor Abnormalities
* When is oxytocin initated?

A

Oxytocin is initiated in either protracted phases; +/- amniotomy

121
Q

Second Stage of Labor – “Pushing”
* Duration?

A

Time from complete cervical dilation to expulsion of the fetus
* 30 minutes to 3 hours primigravid, 5 min to 30 minutes multigravid

122
Q

Second Stage of Labor – “Pushing”
* What are all the baby movements?

A

Cardinal Movements of the baby (Passenger) enable it to adapt to the maternal pelvis:
* Engagement (prior to labor)
* Flexion
* Descent
* Internal rotation
* Extension
* External rotation
* Expulsion

123
Q

Second Stage of Labor – “Pushing”
* What is clamped?
* What is turned down?

A
  • Cord is clamped (usually 15-20 seconds, can be delayed 30-60 seconds with child below introitus to increase hemoglobin levels and greater iron stores in first several months of life. Premature infants decreased need for blood transfusion and lower incidence of necrotizing enterocolitis and intraventricular hemorrhage)
  • Epidural is usually turned down, (not off) in the 2nd stage
124
Q

What are the Cardinal Movements of Labor?

125
Q

Cardinal Movements
* What is engagment? Descent?

A

Engagement:
* Presenting part is at the pelvic inlet
* Occurs late in pregnancy, about 2 weeks prior to delivery in primigravida; Multiparous usually occurs with onset of labor

Descent:
* Presenting part passing through pelvis.
* Brought about by force of uterine contractions, maternal bearing down (Valsalva), if upright, gravity
* Continues until fetus delivered; all other cardinal movement superimposed.

126
Q

Cardinal Movements
* What is flexion?
* What is internal rotation?

A

Flexion:
* During descent, resistance from the cervix, walls of the pelvis, and pelvic floor cause further flexion of the cervical spine (chin to chest)
* Lessens the presenting diameter

Internal Rotation:
* Occiput turns anteriorly toward the symphysis pubis

127
Q

Cardinal Movements
* What is extension?

A
  • Fetus has descended to the introitus and then deflexes
  • Vaginal outlet is directed upward and forward, extension must occur before the head can pass through
  • As the head continues to descend, there is bulging of the perineum followed by “crowning” (largest diameter of the fetal head is encircled by the vulvar ring. Sensation called “ring of fire”
128
Q

Cardinal Movements
* What is external rotation (restitution)?
* What is expulsion?

A

External Rotation (Restitution):
* Delivered head returns to original position at time of engagement to align itself with the back and shoulders (passive rotation)

Expulsion:
* Following external rotation of head, anterior shoulder delivers under they symphysis pubis, then the posterior shoulder, and then the body of the child

129
Q

Diagnosis of Labor Abnormalities: second state
* What is protracted phase?
* Arrested phase?

A

Protracted
* >3 hours in nulliparas (4 hours when epidural analgesia is used)
* >2 hour in multiparas (3 hours when epidural analgesia is used)

Arrested
* diagnosed after one hour if there is no descent, despite good maternal pushing efforts

130
Q

Diagnosis of Labor Abnormalities
* Oxytocin?
* Prolonging second stage worsens what?

A

Oxytocin may be initiated or c/section considered

Prolonging second stage worsens maternal and fetal outcomes
* Maternal: Infection, exhaustion, uterine atony
* Fetal: Meconium aspiration

131
Q

Assisted Birth
* Known as what? What are the examples?

A

Forceps (make up <1.1% of all deliveries)
* In deliveries <36 weeks gestation
* Less likely to cause injury

Suction (make up even less)
* Higher rates of vaginal delivery failure

132
Q

Assisted Birth
* Both forceps and suction carry?

A
  • Both carry higher rates of vaginal tears, thrombophlebitis, urinary and anal incontinence
  • Both carry higher risks to the fetus due to skin/skull injuries
133
Q

Evaluation of Infant
* Clear what?
* What needs to be done at 1 and 5 mins?
* What needs to happen with the cord?
* Encourage what?

A
  • Clear airway with suction if obvious obstruction
  • APGAR score at 1 and 5 minutes
  • Clamp and cut cord
  • Dry, warm on mothers chest (warmed blankets); Kangaroo Care – encourage immediate bonding.
134
Q

⭐️⭐️⭐️

What is the apgar scoring system

135
Q

Shoulder Dystocia:
* What happens?
* What are the RFs?

A

After delivery of the head, anterior shoulder gets impacted on pubic symphysis

Risk Factors:
* Macrosomia (DM, genetic determinants, multiparity, postterm gestation); over 4500g.
* Previous Hx shoulder dystocia
* Multigestational
* Excessive maternal weight gain
* Dysfunctional labor patterns: protracted active phase of first-stage, protracted second-stage
* Size of maternal pelvis in relation to size of fetus
* Assisted vaginal delivery (forceps or vacuum)

Occurs approximately 1% of vaginal deliveries

136
Q

Shoulder dystocia
* What is the txt?

A
  • Attempt maneuvers to displace the anterior shoulder from behind the symphysis pubis; McRoberts maneuver, suprapubic pressure, internal rotation, or removal of the posterior arm
  • If maneuvers unsuccessful, one of both clavicles are fracture
137
Q

Shoulder Dystocia
* What are the fetal complications?(4)

A
  • Fetal hypoxia with or without permanent neurologic damage; Hypoxic ischemic encephalopathy
  • Damage to brachial plexus
  • Clavicle fracture
  • Fetal Death
138
Q

Shoulder Dystocia
* What are the maternal complications?

A
  • Postpartum hemorrhage
  • Rectovaginal fistula
  • Symphyseal separation
  • Third- or fourth-degree episiotomy tear
  • Uterine rupture
139
Q

Nuchal Cord
* What is it?
* Increase risk with what?
* Degree of complications arise based on what?
* What is usually apparent?

A
  • Occurs when cord wraps 360 degrees around neck of fetus
  • 10-29% of occurrence, increases with advanced maternal age
  • Degree of complications arise based on degree of tightness of the wrap
    * From slower flow to strangulation
  • Facial “duskiness” and sometimes petechia are usually apparent
140
Q

Nuchal Cord
* What are the risk factors? (2)
* HR?
* What is felt on vaginal digital exam?

A

Risk factors:
* Artificial rupture of membranes
* Footling breech

Fetal bradycardia (always eval for cord prolapse)

“Ropelike” cord w/pulsations felt on vaginal digital exam

141
Q

Nuchal Cord
* What is gold standard to dx?
* What is used to look for decelerations?
* What is the clinical management?

A

US with doppler is gold standard to diagnose (93% sensitive)

Fetal heart monitoring looking for decelerations (89% sensitive)

Clinical management:
* Depends upon number of involved nuchal loops (more loops = sooner delivery), the amniotic fluid index, the gestational age, the fetal growth and stress index during labor.
* Digitally elevate the presenting part and emergent c-section

142
Q

TEST

Third Stage of Labor
* What is it?
* Separation of what?
* Signs of what?

A

Time from expulsion of the fetus and cord clamping to expulsion of the placenta

Separation of the placenta occurs within 2-10 minutes

Signs of placental separation:
* Fresh show of blood from the vagina
* Umbilical cord lengthens outside the vagina
* Fundus of the uterus rises up
* Uterus becomes firm and globular (fundal massage)

143
Q

⭐️

Third Stage of Labor
* Only when these signs have appeared, may attempt what?
* Examine what?
* Give what?

A

Only when these signs have appeared, may attempt traction on the cord

Examine placenta to ensure its complete removal

Give oxytocin 20U IM/IV while doing uterine massage
* May decrease uterine bleeding originating from the placental implantation site.

144
Q

⭐️

Fourth Stage of Labor
* What is it?
* Close observation of what?
* What commonly occurs during this time?

A
  • Recovery and observation
  • Close observation of the patient; BP, pulse, uterine blood loss monitored closely
  • Postpartum hemorrhage commonly occurs during this time (usually from uterine relaxation, retained placental fragments, unrepaired lacerations)
145
Q

⭐️

Fourth Stage of Labor
* Signs of what?
* What should be repaired here?

A
  • Signs of hypovolemia may manifest as increase in pulse rate out of proportion to any decrease in BP
  • Vaginal tears or episiotomy should be repaired now.

Clinical Medicine 5 (10 decks)

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