OB Proper (Normal) Flashcards
1
Q
Diagnosis of Pregnancy: Presumptive, Probable or Definitive
Cessation of menses
A
Presumptive
2
Q
Diagnosis of Pregnancy: Presumptive, Probable or Definitive
Physical outlining of fetus within the uterus
A
Probable
3
Q
Diagnosis of Pregnancy: Presumptive, Probable or Definitive
Positve pregnancy test
A
Probable
4
Q
Diagnosis of Pregnancy: Presumptive, Probable or Definitive
Perception of Quickening by the mother
A
Probable
5
Q
Diagnosis of Pregnancy: Presumptive, Probable or Definitive
Perception of fetal movement by an examiner
A
Definitive
6
Q
Diagnosis of Pregnancy: Presumptive, Probable or Definitive
Ballottement
A
Probable
7
Q
Diagnosis of Pregnancy: Presumptive, Probable or Definitive
Fetal heart action, recognition of embryo on UTZ
A
Definitive
8
Q
HCG measuring, when can it be detected? when does it peak? when is the nadir?
A
Detected: 8-9 days after ovulation
Peak: 8-10 weeks
Nadir: 14-16 weeks (Williams), 18-20 weeks (topnotch)
9
Q
Diagnosis of Pregnancy: FHTs
A
TV-UTZ: 5 weeks
Doppler: 10 weeks
Stethoscope: 17 weeks, almost all by 19 weeks
10
Q
Complaints in Pregnancy:
Cause & Tx of varicosities
A
Increased venous pressure in the LE
Relaxing effect of progesterone
Tx: stockings, elevate legs
11
Q
Complaints in Pregnancy:
Cause & Tx of Hemorrhoids
A
Increased water absorption -> constipation
Tx: warm soaks, stool softeners
12
Q
Complaints in Pregnancy:
Cause & Tx of Stress incontinence
A
Pressure on bladder
Tx: Kegel exercises
13
Q
Complaints in Pregnancy:
Cause & Tx of Headache
A
Due to increased estrogen
Tx: massage, ice pack
14
Q
Complaints in Pregnancy:
Cause & Tx of Pica
A
Iron deficiency
tx: Treat the IDA
15
Q
Complaints in Pregnancy:
Cause & Tx of Leukorrhea
A
Increased secretion of cervical glands, estrogen-induced
16
Q
Common causes of fundal discrepancy
A
False discrepancy (more common): measurement error, error in calculation of AOG. True discrepancy: pathology of the fetus, amniotic fluid, placenta, uterine wall
17
Q
10 Danger signs of pregnancy
A
Vaginal: Bleeding, fluid leakage
Abdominal: Persistent vomiting, uterine cramping, decreased FM, Epigastric pain
Others: dysuria, edema, headache, BOV
Chills and fever
18
Q
Obstetric Milestones
NTD and Chromosomal abnormality screening
A
16-18 weeks
19
Q
Obstetric Milestones
GDM screening & Rhogam administration
A
24-28 weeks
20
Q
Obstetric Milestones
GBS screening and Leopold’s manuevers
A
35-37 weeks
21
Q
Obstetric Milestones
FMC q6-q8
A
Start at 28 weeks
22
Q
Indications for GBS prophylaxis
A
Previous infant with GBS infection GBS bacteruria Postive GBS screening Unknown GBS status and: 1) Delivery < 37weeks AOG 2) Membrane rupture > 18 hours 3) Intrapartum temp of > 38C
23
Q
What makes a reactive NST?
A
2 or more accels within 20 minutes, peak at 15 bpm, lasting 15 seconds
24
Q
What does a CST measure?
A
Uteroplacental function
25
5 Components of a BPP
```
FHR / NST
Breathing
Movements
Tone
AFI
```
26
BPP 8/10 with normal AFV
```
Normal
Repeat weekly (2x/week for GDM Pxs)
```
27
BPP 8 w/ abnormal AFV
Chronic asphyxiated fetus
| >37 weeks deliver
28
BPP 4-6
Possible fetal asphyxia
AFV abnormal: deliver
> 36 weeks: deliver
< 36 weeks: repeat after 24 hours
29
BPP 0-2
Almost certain fetal asphyxia
| Deliver.
30
Doppler Velocimetry Measures
1) Most commonly used
2) Common nonreassuring finding
1) UA systolic-diastolic ratio
| 2) Absent or Reversed End Diastolic Flow
31
Single most important indicator of an adequately oxygenated fetus
Beat-beat variability
32
Etiology of Acceleration
Fetal movement
33
Etiology of Early deceleration
Head compression (vagal compression)
34
Etiology of Variable deceleration
Umbilical cord compression
35
Etiology of Late deceleration
Uteroplacental insufficiency
36
Cat. I on NST
Baseline FHR: 110-160
Mod. Variability
(-) variability / late decel
37
Cat. III on NST
Absent baseline FHR and
- Recurrent late/var decel
- Bradycardia
Sinusoidal pattern
38
Management of Reassuring Tracing
```
Intrauterine resuscitation:
Decrease uterine activity
Correct maternal hypotension
Change maternal position
High flow O2
```
Amnioinfusion: Treatment of variable or prolonged decelerations
39
Prenatal Diagnosis and Fetal Therapy
| Candidates for prenatal diagnosis
1) elderly primi
2) >31 yo with mult gestation
3) Previous pregnancy with:
- an autosomal trisomy
- Triple X, or Klinefelter
4) Women with chromosomal abnormalities
5) Repetitive 1st trim abortions
6) Fetus with major structural defects
40
Most Common isolated fetal structural defect, 2nd
1st: Cardiac (VSD)
2nd: NTD (Family hx is most recognized risk factor)
41
MSAFP screening for NTDs
AFP: synthesized in yolk sac then fetal liver
Reported as multiple of median (MoM)
>3.5 MoM = increased fetal risk for NTD
42
Cranial Signs of NTD
1) Small BPD
2) Ventriculomegaly
3) Lemon sign - frontal bone scalloping
4) Banana sign - elongation and downward displacement of the cerebellum
5) Obliteration of the Cisterna Magnus
43
Components of the Quadruple Serum Marker
```
ACEI
AFP
Chorioinic gonadotropin
Estriol
Inhibin
```
44
Down's Quadruple Serum Markers
Dec AFP
Inc Chorioinic gonadotropin
Dec Estriol
Inc Inhibin
45
Edward's Quadruple Serum Markers
```
All DECREASED
AFP
Chorioinic gonadotropin
Estriol
Inhibin
```
46
Prenatal Test of Choice
| Fetal Karyotyping in the second trimester
Second trimester amniocentesis
47
Prenatal Test of Choice
Associated with postprocedural pregnancy loss
Associated with talipes equinovarum
Early amniocentesis (11-14th weeks)
48
Prenatal Test of Choice
Need for early karyotyping
Less risks for deformities
Chorionic villus sampling (as early as 9th week)
49
Prenatal Test of Choice
| Diagnostic assessment of Red cell anemia or alloimmunization
Cord blood sampling
50
4 Phases of Parturition
1) Quiesence
2) Activation
End: Onset of Labor
3) Stimulation
End: Delivery of Conceptus
4) Involution
End: Restoration of fertility
51
Key Points
| Phase 1 Parturition
```
Myometrial quiesence
PROGESTERONE: mediator
Unyielding cervix
Irregular low intensity contractions
Braxton Hicks contractions
```
52
Mechanisms for Uterine Quiesence
Calcium sequestration
Inhibition of oxytocin receptor synthesis
Increased enzymatic degradation of uterotonics
Inhibition of contractile signal propagation
53
Key Points
| Phase 2 Parturition
Increased uterine responsiveness to uterotonins
ESTROGEN: mediator
Cervical ripening
Increased frequency of painless contractions
6-8 weeks
Formation of the lower uterine segment
54
Differentiate between physiologic ring and the pathologic ring of Bandl.
Physiologic: separates lower and upper uterine segment
Pathologic: abnormal junction with extreme LUS thinning, increased risk for uterine rupture, common cause of obstructed labor.
55
Phase 3 Key Mediator:
Oxytocin (also for phase 4)
| Minor: Prostaglandin, serotonin, histamine
56
Most common fetal lie
Longitudinal
57
Most common fetal presentation
```
~98% cephalic
~2.7% breech
Transverse
Face
Brow
```
58
Characteristic fetal position
```
Fetus convex
Head flexed, chin on chest
Thighs flexed
Legs bent on knees
Arms crossed over thorax
```
59
Most common fetal position
Occiput Anterior (L > R)
60
Station is expressed as plus-minus values at the level of?
The Ischial spine
61
Key differences between true labor and false labor?
True labor: (+) cervical effacement and dilatation
62
Confirmatory tests for rupture of membranes:
| (+) collection fluid in the vagina
Pool test
63
Confirmatory tests for rupture of membranes:
| Takes advantage of the alkaline nature of the amniotic fluid
Nitrazine test
64
Confirmatory tests for rupture of membranes:
| (+) crystallization under a microscoped
Fern test
65
4 parameters of the cervical exam?
| Bishop score?
```
Effacement
Dilatation
Consistency
Position
Bishop score: add Station
```
66
How does one interpret the Bishop score
>8 favorable
6-8 equivocal
<6 unfavorable
67
What does the Bishop score indicate
Cervical status prior to labor induction
68
Obstetric Anesthesia
| What are the stage 1 methods?
```
Natural method (controlled breathing)
IM narcotics: meperidine, morphine (WOF: neonatal resp. depression)
Paracervical block: anesthetic into the vaginal fornices
```
69
Obstetric Anesthesia
| What are the stage 1&2 methods?
Epidural block: favorite method of anesthesiologists
| SE: maternal hypotension, spinal headache
70
Obstetric Anesthesia
| What are the stage 2 methods?
Pudendal block: block of pudendal nerve (landmark: ischial spine)
Variable degree of pain relief.
71
3 main forces during Labor
1) Maternal intra-abdominal pressure
2) Force of resistance
3) Forces that change the cervix
72
Cardinal movements
| Cephalic
```
EDFIrE ErE
Engagement
Descent
Flexion
Int. Rotation
Extension
Ext. Rotation
Expulsion
```
73
Cardinal Movements
| Breech
```
(DEIL DR)
Descent
Engagement
Int. Rotation
Lateral flexion
Delivery
Restitution
```
74
Cardinal Movements
| Face
```
DIF A(ErE)
Descent
Int. Rotation
Flexion
Accessory movements of Ext. Rotation and Expulsion
```
75
Cardinal Movements
| Prerequisite for delivery
Descent
76
Cardinal Movements
| Demonstrates adequacy of pelvic inlet
Engagement
77
Stages of Labor
Divisions?
Phases?
3 Divisions: Preparatory, Dilatational, Pelvic
| 2 Phases: Latent, Active
78
Stages of Labor
| Active phase: reflects the fetopelvic relationship
Deceleration phase
79
Stages of Labor
| Active phase: predictive of labor outcome
Acceleration phase
80
Stages of Labor
| Active phase: measures efficiency of the "machine"
Phase of maximum slope
81
Three stages of Labor?
1st: latent and active phase
2nd: 10cm dilatation to delivery of fetus
3rd: delivery of fetus to delivery of placenta
82
Duration: latent phase for a nullipara, multi?
Nulli: <14 hours
| If greater, Prolonged latent phase
83
Speed of cervical dilatation during active phase?
Nulli: ~1.2 cm/hr
Multi: ~1.5 cm/hr
If less than, Protracted active-phase dilatation
84
Maneuver where the OB's hand exerts forward pressure on the fetus' chin through the perineum just front of the coccyx, while the other hand exerts pressure posteriorly against the occiput
Ritgen's Manuever
85
Signs of Placental Separation
Calkin sign: uterus becomes globular
Gush of blood
Uterus rises in the abdomen
Lengthening of the cord
86
Signs of Fetal Death in Utero
Sonographic: Spalding sign (overlapping fetal skull bones)
Radiographic: Roberts sign (+) gas bubbles in the superior sagittal sinus
87
Arrest Disorders (Nullipara)
Prolonged deceleration: >3 hours
Secondary arrest of dilatation: >2 hours
Arrest of descent: >1 hour
Failure of descent: No descent in deceleration phase or second stage
88
Arrest Disorders (Multipara)
Prolonged deceleration: >1 hours
Secondary arrest of dilatation: >2 hours
Arrest of descent: >1 hour
Failure of descent: No descent in deceleration phase or second stage
89
Management of Arrest Disoders
1) Evaluate for CPD, if (+) do CS
| 2) If (-) CPD, augment labor
90
3 P's of Abnormal labor
Power
Passenger
Passage
91
Prolonged 3rd stage of labor
Undelivered placenta >30 minutes
92
2 criteria needed to be met before diagnosis of active phase disorders.
Latent phase completed, cervix dilated 4cm or more
| Uterine contraction pattern of 200 Montevideo units in 1 minute period w/o cervical change
93
Types and treatment of Uterine Dysfunction
Hypertonic: asynchronous uterine contractions, basal hypertonus
Tx: sedation
Hypotonic: inefficient contractions
Tx: oxytocin
94
Oxytocin can only be given when:
```
Cervix is at least 4cm
CPD is ruled out
No abnormal fetal presentation
Fetus is in good condition
No signs of hyperstimulation
```
Caution if patient is >35 y.o, Para >5, (+) uterine scars
95
Causes of Uterine Dysfunction
Epidural anesth
Chorioamnionitis
Poor maternal positioning during labor
96
```
CPD
Pelvic Inlet contraction is diagnosed when,
DC <
AP <
GTD
```
Diagonal conjugate < 11.5cm
Shortest AP diameter < 9cm
Greatest transverse diameter < 12cm
97
CPD
Midpelvis contraction is diagnosed when
Interischial spinous diameter is < ____?
<8 cm
| Suspect if less than 10 cm
98
CPD
| Pelvic Outlet contraction is diagnosed when intertuberous diameter is _____?
<8cm
99
Abnormal Presentations for Delivery
| Face Presentation
Face presenting, with chin ant or post to symphysis
Etiology: contracted pelvis, large fetus, anencephaly, associated with anthropoid pelvis
Management: SVD, CS if with pelvic contraction
100
Abnormal Presentations for Delivery
| Brow Presentation
Area between the orbital ridge and ant. fontanel presents
Etiology: same as face
Transient prognosis, will eventually convert
101
Abnormal Presentations for Delivery
| Transverse Lie
Aka shoulder presentation
Etiology: lax abdominal wall, preterm, placenta previa, contracted uterus, polyhydramnios
Tx: CS
102
Sepsis noted due to rupture of membranes with extrusion of the fetal arm outside the vagina
Neglected transverse lie
103
Abnormal Presentations for Delivery
| Compound Presentation
Extremity prolapses along with presenting part
| Tx: Gently push the limb upward while applying downward pressure to bring the head down
104
Abnormal Presentations for Delivery
| Persistent Occiput Posterior
Due to transverse narrowing of the midpelvis
| Tx: manual rotation to anterior position then forceps OR SVD if pelvic outlet is ample, vagina and perineum are relaxed.
105
Abnormal Presentations for Delivery
| Deep Transverse Arrest of the Head
Associated with an android or platypelloid pelvis
Etiology: hypotonic dysfunction
Tx: Kielland forceps, oxytocin to improve uterine dysfunction
106
Fetal consequences of Shoulder dystocia
Fractured humerus or clavicle
| Erb's palsy
107
Maternal complications of shoulder dystocia
Postpartum hemorrhage
- cervical lacerations
- uterine atony
Puerperal infection
108
Management of Shoulder Dystocia
| Order of Manuevers
1) Call for help! Gentle traction, drain bladder
2) Episiotomy
3) Suprapubic pressure with downward traction of the head
4) Mc Robert's Maneuver
5) Wood Corkscrew
6) Deliver posterior shoulder
7) Last resort:
- Symphysiotomy
- Cleidotomy
- Zavanelli manuever
109
Dystocia Maneuvers
| Fetal shoulders rocked from side to side by applying force on the mother's abdomen
Rubin's maneuver
110
Dystocia Maneuvers
| Cephalic placement into the pelvis, then CS
Zavanelli
111
Dystocia Maneuvers
| Cutting of clavicle with scissors
Cleidotomy
112
Dystocia Maneuvers
| Progressive rotation of the posterior shoulder 180 degrees
Wood's corkscrew
113
Dystocia Maneuvers
Sharply flexing thighs over abdomen to straighten the sacrum relative to the lumbar spine so that the angle of inclination decreases which frees the ant. shoulder
Mc Roberts Maneuver
114
Dystocia Maneuvers
| Pressure is applied to the fetal jaw and neck with strong suprapubic pressure from an assistant
Hibbard's maneuver
115
Fetal macrosomia
BW > 4000g
| Elective CS for non-GDM >5000g, GDM >4500g
116
Fetal hydrocephalus
Normal head circ: 32-38 cm
Cephalic pres: may do cephalocentesis before CS
Breech: labor can be followed to progress then cephalocentesis
117
Precipitous labor is defined as _________
Cervical dilatation
Nulli: 5cm/hr or faster
Multi: 10cm/hr or faster
118
Effects of Precipitous labor (mat and fetal)
Maternal: PPH, uterine rupture, extensive lacerations, amniotic fluid embolism
Fetal: hypoxia, trauma
119
Mechanisms of Placental Extrusion
Schultze: detachment from center, glistening amnion presents
Duncan: detachment from periphery, maternal side presents
Shiny Schultze and Dirty Duncan
120
Labor Induction
| Maternal indications
```
Fetal demise
Prolonged pregnancy
Chorioamnionitis
Severe Pre-Ec
Other medical conditions
```
121
Labor Induction
| Fetal Indications
```
IUGR
Abnormal fetal testing
Infection
Oligohydramnios
Post-term
```
122
Contraindications to Labor Induction
Prior uterine incision, contracted pelvis, abnormal presentation, genital herpes, cervical CA
Macrosomia, multifetal gestation, hydrocephalus, malpresentation
123
Differentiate early and late amniotomy
Early: 1-2 cm dilatation, shortens labor by 4 hours
SE: inc. chorioamnionitis, cord compression
Late: 4-5 cm dilatation, accelerates labor by 1-2 hours
124
Pharmacologic and Mechanical Inducers of labor
1) Oxytocin
2) Prostaglandins (misoprostol)
3) Laminaria
125
Obstetric Anesthesia
| Causes of pain due to uterine contraction
#1: compression of nerve ganglia in the cervix and uterus
2) hypoxia of contracted uterus
3) stretching of cervix
4) stretching of peritoneum
126
Sensory innervation of the genital tract
Lower Genital tract: Pudendal nerve (S2-S4)
2nd and 3rd stage pain
Upper Genital tract: Frankenhauser ganglion plexus (T11-T12)
1st stage pain
uterus, cervix, upper vagina
127
Anesthetic contraindicated in pre-eclamptic patients
Ketamine
128
Most commonly used anesthetic
meperidine
129
Anesthetic for use in epidurals
Bupivacaine, lidocaine
130
4 types of Regional OB anesthesia
1) Pudendal
2) Paracervical - 3 and 9 o'clock positions of the cervix, for stage 1
3) SAB - for CS, block at least up to T8
4) Epidural - gold standard, ideal for pre-ec, adequate relief for stage 1 & 2.
131
Indications for GA use
Int. podalic version of 2nd twin
Breech decomposition
Replacement of inverted uterus
Severe mat. hemorrhage
132
Complications of Epidural anesth
```
High spinal block
Hypotension
Urinary retention
Headache
Post puncture seizures
Meningitis
MI
```
133
Contraindications to epidural anesth
Anticipated serious maternal bleeding
Infection near site of anesth
Suspicion of neurologic disorder
134
Forceps delivery
| Most important function of forceps?
Traction
135
Parts of a forcep?
Blade, shank, lock handle
136
Forceps delivery:
| For delivery of molded head
Simpson
| - has ample pelvic curve and fenestrated blade
137
Forceps delivery:
| Fetus with rounded head
Tucker Mac Lane
| Solid blade, narrow shank
138
Forceps delivery:
| Deep Transverse arrest of the head
Kielland
| Sliding lock, minimal curvature
139
Forceps delivery:
| Breech
Piper forceps
140
Differentiate Mid, Low, and Outlet forceps
Mid: Station 0 to +1
Low: Station +2, not yet at pelvic floor, rotation at 45deg
Outlet: scalp visible at introitus, rotation <45 deg
141
Prerequisites for Forceps delivery
```
FORCEPS
Fully dilated cervix
Occiput anterior, Chin anterior
Ruptured membranes
CPD ruled out
Engaged head
Position of head known
Skilled practitioner (PGH addendum)
```
142
Contraindications for Forceps
```
I MAUL
Incompletely dilated cervix
Marked CPD
Absence of proper indication
Unengaged fetal head
Lack of experience
```
143
Complications of Forceps Delivery
Maternal: PPH, lacerations
Natal: Cephalhematoma, ICH, Facial Nerve palsy
144
Cesarean Section
| Indications
```
Repeat CS
CPD
Breech
Hemorrhagic complications
Hypertensive disorders
Uterine dysfunction
Fetal distress
```
145
CS Incisions
| Excellent cosmesis, curvilinear incision/"bikini cut"
Pfannenstiel aka Transverse suprapubic
146
CS Incisions
| Transverse incision made with the rectus muscles being divided with scissors
Maylard
147
CS Incisions
| Infraumbilical midline incision
Ummm... yeah... nothing much to say about this.
148
CS Incisions
| Uterine incision of choice, easy to repair, least likely to rupture, least adhesions
Transverse / Kerr AKA LTCS.
149
CS Incisions
| Vertical uterine incision
Kronig
150
CS Incisions
| Vertical uterine incision on the uterine body reaching the fundus
Classical
151
Indications for Classical CS
1) Non-availability of the Lower uterine segment: myoma, cancer, dense adhesions with bladder
2) Ant. implanted previa
3) Neglected transverse lie
4) Massive maternal obesity
5) LUS is not sufficiently thinned out
152
Indications for Postpartum hysterectomy
```
Intractable uterine atony
Placenta accreta
Laceration of a major uterine vessel
Large myomas
Severe cervical dysplasia
CA in situ
```
153
Candidates for VBAC
1) prior LTCS
2) Clinically adequate pelvis
3) Double setup
154
Puerperium
| Duration?
From delivery up to 6 weeks after.
155
Pueperium
| Timeline of uterine involution
2-3 days: superficial layer of decidua sloughed off
2 weeks: uterus descends to true pelvis
3 weeks: endometrium restored
4 weeks: non-pregnant size of uterus
156
Puerperium
| Timeline of Decidual Shedding
Rubra: blood, Days 1-3
Serosa: pale colored, Days 4-10
Alba: White to yellow-white due to leukocytes, Day 10 to Week 4-8
157
Common causes of prolonged uterine involution
Retained placental fragments
Late onset metritis (usually due to chlamydia)
Tx: Methylergonavine, treat chlamydia
158
Late postpartum hemorrhage
1-2 weeks into puerperium
159
Pueperium
| Common urinary problems
Overdistention, incomplete empyting
2nd-5th day: Diuresis
2nd-8th week: Dilated ureters and renal pelvis return to nonpregnant size
4th-6th week: normal function
160
Puerperium
| Blood and fluid
1 week post: Volume is back to normal
| 2 weeks post: CO returns to pre-pregnant state
161
Puerperium
| Weight
Uterine evacuation and involution: 5-6kg
Diuresis: 2-3 kg
Decrease in "sodium space": 2kg
162
Puerperium
| Breast
accelerates uterine involution
| contraception from 2-6 months
163
Puerperium
| Postpartum depression
within 6 weeks, patient is hopeless, anxious, and in despair
| Key feature: mother neglects herself and baby
164
Puerperium
| Contraception for Lactating women
started after 2-3 weeks
progestin only pills
at 6 weeks
DMPA
OCP
IUD
165
Puerperium
| Lactational amenorrhea method of contraception
98% effective if:
| Mother is not menstruating, nursing 2-3x/night, every 4 hours during the day.
166
Puerperium
| Postpartum fever
Definition: >38C, on any two of the first 10 postpartum days exclusive of the 1st 24 hours.
Most important risk factor: Route of delivery
Most common cause: Endometritis
167
Causes of Postpartum fever
```
Day 0: Atelectasis (wind)
Day 1: UTI (water)
Days 2-3: Endometritis (womb)
Days 4-5: Wounds (wound)
Days 5-6: DVT (walk)
Days 7-21: Mastitis
```
