OBGYN LAST TEST Flashcards
Smallest Cranial Diameter for The head through the BC
Suboccipitobregmatic Diameter
When can LEOPOLDS Maneuvers be done
THIS DOES NOT REPOSTIONT THE BABY
~28 wks; typically ~35-36 wks
↓ fetal space to change position as delivery approaches
Confirms fetal:
- Lie
- Presentation (vertex, breech, shoulder)
- Estimated fetal weight (EFW)
What is “0 station”
Station (how far has infant descended into pelvis)
0 station is level of ischial spines
TRAINGLE=
Diamond+
Triangle: occiput
Diamond: face
Most common position for the occiput in the delivery
LOA
Left occiput anterior
What position should the mother be in to assess fetal head position
Lithotomy Position
What is the most favorable and most common fetal head position for delivery
Favorable: OA
MC: LOA (Diamond in the Left positior compartment)
What is the Adverse event associated with OP fetal head
Arrest of descent
What are the complications of breed presentation
↑ Maternal & perinatal morbidity
Many studies report improved perinatal outcomes w/ cesarean deliveries
What is the risk involved when doing an external cephalic version
Typically not performed before 36-37 wk
Risk of placental abruption, ROM, delivery
Can retry w/ epidural @39 wks, but if still not successful → C-section
What are the absolute C/I for external Cephalic Version
Anything that precludes vaginal delivery:
- placenta previa
- multifetal placenta
4 phases of labor
Quiescence
Activation
Stimulation (Stages)
Involution
When is the initial start for Phase 1 labor
36-38 weeks
What is cervical ripening
Collagen fibril diameter ↑ & spacing between fibrils ↑
Loss of tissue integrity & ↑ compliance
Inflammatory changes:
- Inflammatory cells invade extracellular matrix/stroma
- Prostaglandins → modify extracellular matrix
What are the 3 stages of active labor
Stage 1: Clinical onset of labor → cervical effacement & dilatation (w/ contractions)
Stage 2: Fetal descent
Stage 3: Delivery of placenta & membranes → placental separation & expulsion
When should the placenta be delivered
AKA Puerperium: ~1+ hrs after delivery
What defines TRUE labor
REGULAR uterine contractions w/ cervical change
Cervical dilation 3-4cm or greater in presence of uterine contractions (Active Labor)
1st stage (Latent) of phase 3
Latent Phase
Cervical dilation 0 to 3-5 cm
Typically will not admit to L&D in latent phase of labor until dilated at least ~3-4 cm
Exception: spontaneous rupture of membranes
1st stage (active) of phase 3 labor
Active Phase
-Cervical dilation 3-5 cm or more until completely dilated (10 cm)
What is 2nd stage of phase 3 labor
2nd Stage: fetal descent
From time of complete dilatation until delivery of infant
What is stage 3 of phase 3 labor
3rd Stage: delivery of placenta & membranes
From infant delivery until placental delivery ~<30 min
-If >60 mins → possible problem
What stage has the highest Risk of post-partum hemorrhage
stage 3 phase 3
6 hrs after delivery, mother at highest risk for developing post-partum hemorrhage
What is the rate of cervical dilation in labor
Primips → 1.2 cm/hr
Multips → 1.5 cm/hr
Do you admit pts in stage 1 labor?
Typically will not admit patient during Latent Phase of Labor unless membranes are ruptured
When should we use med or high does oxytocin in active labor
if no cervical dilation at rate of 1 cm/hr or more in 1st stage of labor OR no descent of fetal head for 1 hr in 2nd stage
How often are cervical checks in active labor
Q1 (1st 2-3 hours) then Q2
Check
- dilation
- effacement
- station (crowning)
- position
What is the threshold for precipitous labor
(pregnancies that deliver in <3 hrs)
Define dysfunctional labor
Rates of dilation & descent exceed recognized normal time limits (too slow)
What are the 4 Ps of Labor
Power, Psyche, Passage, Passenger
What is the most common cause of Dystocia and C-section
Cephalopelvic disproportion/ mal position
What defines adequate power for labor
Adequate labor: 200 Montevideo units per IUPC for >2 hrs
What are three factors that lead to prolongation of the latent phase of pregnancy
Excessive sedation
Unfavorable cervical condition
False Labor
Define arrest of labor
Dilatation: 2 hrs w/ NO cervical change
Descent: 1 hr w/ NO fetal descent
If inadequate or absent cervical change w/in 2 hrs of admission? Suspect dystocia
What is the next step in a pt in labor dystocia
amniotomy (AROM) Artifical Rupture of Membranes
Recheck cervix in 2 hrs? No or minimal cervical change: place intrauterine monitor
Management for prolonged active phase of labor
Confirm Dilatation: at least 6 cm
AROM (amniotomy) if membranes intact
- Sometimes cushion of fluid prevents head from full engagement w/ cervix
- Allows placement of internal monitor to confirm contraction strength (Montevideo units)
Augment: w/ oxytocin if <200 Montevideo units
Maternal/fetal monitoring for 2-4 hrs w/ adequate ctx (at least 200-250 Montevideo units)
Consider extending observation period to 6 hrs if patient is nulliparous/singleton
C-section should be considered if above guidelines exceeded or fetal distress
What is Labor induction
stimulation of contractions before spontaneous onset of labor ±ROM
What scoring system is used in Induction
Use Bishop scoring system:
“How ready is the cervix for induction of labor?
What is the bishop scores for induction
Bishop score ≤4 → unfavorable cervix (indication that cervix not “ripe”)
Bishop score 9 → high likelihood for a successful induction
What is the 1st step to labor induction
Ripen cervix first! This will often stimulate labor!
Cervix is the “door”
What should the mother do 30 minutes prior to amniotomy
No walking for 30 min to ensure head fully engages in pelvis/prevent cord prolapse
3 maternal indications for induction
Preeclampsia
DM
Heart Dz
What is the initial agent for a pt with an unfavorable Bishops score (unrippened cervix)
PGE1 (Cytotec) & PGE2
(Prepidil/Cervidil)
Is indomethacin safe in pregnancy
NO! Causes cervical ripening and onset of labor
What is the role of oxytocin
Synthetic version (Pitocin):
Causes uterine contractions:
(not intended to ripen the cervix)
Used to induce labor at term
1st line drug for post-partum hemorrhage
ADE of Oxytocin use
Hyperstimulation
(w/ resultant fetal distress)
Uterine rupture
Fluid overload (used ~72H; otherwise, water intox risk: “ADH”)
Uterine fatigue non-responsiveness
Uterine atony (postpartum & risk of PPH)
Define Tachysystole
> 5 ctx in 10-min period
(avg over 30 min)
Ctx occurring w/in 1 min of one another
Any ctx lasting 2 mins or more
What is the MGMT for tachsystole
Discontinue augmentation med (if in use)
Position mother onto her left side
Cervical exam to r/o cord entrapment
Oxygen
ß-agonist (250 µg SC terbutaline;
FDA approved as tocolytic)
NML FHR
Normal FHR baseline: 110-160 bpm
NML Baseline fetal Variability
Moderate (normal): amplitude range 6-25 bpm
What is 15x15 and 10x10 on FHR
NML accelerations
FHR increase above the baseline
@32 or more wks: 15 bpm for 15 sec
<32 wks: 10 bpm for 10 sec
If an acceleration lasts 10 mins or longer, it is a baseline change
Can External Fetal Monitors assess contraction strength
NO!
shows timing & duration of contraction
What is the most reliable predictor of fetal well being
Variability of hr
Normal: 6-25 bpm
What are early decels
A VAgal response 2/2 cephalic pressure from contractions
NML
No intervention
What are variable decels
Cord compression
(reduced fluid vs nuchal cord)
Mild: <30 sec
Moderate: 30-60 sec
(both not <70 bpm)
Severe: >60 sec & <60 bpm (60x60)
Must Intervene
What are late decels
Starts/Lasts beyond uterine contractions (nadir occurs/extends beyond peak of ctx)
Uteroplacental insufficiency (possible fetal hypoxia/acidosis)
Must Intervene
What is VEAL CHOP
Variable Decels -Cord Compression
Early Decels- Head Compression
Accelerations- OKAY
Late Decels- Placental insufficiency
What are the interventions to decelaerations
LLD decubitus positioning
Decrease Pitocin/oxytocin if infusing
Increase IV fluids
Consider amnioinfusion
Elevate presenting part or
Trendelenburg if pushing
Intervention for cord compressions
Amnioinfusion, also can monitor strength of ctx this way
What is a reassuring finding in checking fetal blood with a non reassuring fetal heart rate
Results are reassuring if pH >7.25
What mediations are helpful for pain in false contraction
Sedatives (helpful only in false labor)
Promethazine (Phenergan)
Hydroxyzine (Vistaril)
Zolpidem (Ambien)
Procedure of choice for regional analgesia
Lumbar epidural
What are the 6 cardinal movements of labor
Descent Flexion Internal rotation Extension External rotation (restitution) Expulsion
How do you support the head during delivery
Provide gentle resistance for controlled delivery
-In & slightly downward gentle pressure
Support perineum to prevent tearing
- Apply direct pressure
- Squeeze/pressure of perineum
Controlled pushes
- Short pushes helps control force of head delivery
- Body delivery strong long push
Define Caput Succedaneum
(boggy, crosses sutures)
High pressure of vaginal walls on head during labor
Define Cephalohematoma
(does NOT cross sutures, may be associated w/ jaundice)
Impact of skull on pelvic bones
Below periosteum
Define Subgleal Hematoma
(crosses sutures, jaundice/blood loss/may require transfusion & compression)
-Rare
Can be massive, life-threatening
- Between scalp and periosteam
- D/t rupture of veins
Indications for operative vaginal delivery
Forceps/Vacuum:
- Prolonged 2nd stage of labor
- Suspicion of impending fetal compromise
- Breech delivery (forceps only)
- Intended to shorten 2nd stage for maternal benefit
Correct placement of the vacuum for delivery
Correct cup placement at the flexion point. Along the sagittal suture, this spot lies 3 cm from the posterior fontanel and 6 cm from the anterior fontanel.
What marks the 3rd stage of labor and what Rx is given at this stage
As soon as neonate is delivered
Oxytocin administered at time of placental delivery (to prevent bleeding)
What is chorioamnionitis
Infection of membranes & amniotic fluid surrounding fetus
Risk factors:
Prolonged rupture of membranes/PROM (>18 hr)
Multiple digital examinations
Instrumentation (FSE/IUPC) internal fetal/uterine monitoring
How do you dx chorioamnionitis
Maternal fever (>100.4) AND at least 2 of following:
Tachycardia:
- Maternal >100 bpm
- Fetal >160 bpm
Abdominal/fundal tenderness
Leukocytosis
Foul or culture-positive amniotic fluid
What is the tx approach to chroamnionitis
NOT an indication for emergent C-section
Empiric broad-spectrum antibiotics continued for 24-48 hrs after delivery
Monitor postpartum: risk of uterine atony & postpartum hemorrhage
Turtle sign of the fetal head indicates?
Shoulder dystocia
Onset of hypoxia with shoulder dystocia
Hypoxic injury: severe hypoxia starts w/in 5 mins of delivery of head to perineum
What is HELPERR in shoulder dystocia
- Help (call for)
- Evaluate for episiotomy
- Legs hyperflexed
(McRoberts maneuver) - Pressure: suprapubic (not fundal) -to push fetal shoulder down
“Rubin I” - Enter vagina (these maneuvers done in any sequence according to need):
-Rotational maneuvers: Rubin, Wood’s screw, Reverse Wood’s Screw
6) Remove posterior arm
7) Roll patient to all-fours position → hands & knees (Gaskin maneuver)
What part of HELPERR has the highest individual success rate for shoulder dystocia
removal of the Posterior Arm (Step 5) has high individual success rate; however:
-Not done 1st as a minor dystocia often resolves w/ McRoberts (leg hyperflexion) or suprapubic pressure (Rubin I)
-More potential for maternal perineal trauma when entering vagina & removing arm
Degree 1-4 Lacerations/ episiotomy
1st skin
2nd skin, subcutaneous tissue, perineal muscle
3rd above, and anal sphincter complex
4th All above plus rectal mucosa
When would you do a symphysiotomy for shoulder dystocia
Typically used only when surgical capabilities are not available
What is the approach to a cord prolapse
Tocolytics -> C-section Stat
What must you r/o in minor trauma in pregnancy
Rule-out placental abruption (monitor for ~4 hrs)
Also assess maternal fetal Hemorrhage -> Rhogam
When can we D/c a preg pt post trauma
Contracting <1 every 10 mins
No vaginal bleeding
No abd pain or tenderness
FHR reassuring
No visible bruising
What is the most common cause of Abruptio Placentae
HTN
What are the 4 Ts of postpartum hem
Tone = uterine atony (75-80%) Tissue = retained placenta/accreta Trauma = vaginal/cervical laceration Thrombin = coagulopathy
How do we estimate blood loss in post partum hem
When estimating blood loss based upon H&H:
Estimate 500 mL loss for every 3 volume percent drop in HCT
What is a boggy, soft uterus on bimanual examination
Uterine atony
Post partum hem can occur up to week ____ post partum
Can occur up to 12 wks after delivery
Clinically worst if occurs w/in 1-2 weeks postpartum
Evaluate: TVUS → retained products
Treatment: uterine cavity empty → medications used 1st
What is the treatment for Post Partum Hem
Call for help! EXAMINE.
External uterine massage
+Medications
Bimanual uterine compression
IV fluids (may need volume 3x EBL)
What are the Uterotonic Agents
Oxytocin/Pitocin (1st line)
10 units IM or 10–20 units/L @100 cc/hr
Methergine (methylergonovine) (1st line)
0.2 mg IM
NOT for pre-eclampsia/HTN!
Hemabate (carboprost tromethamine) – prostaglandin F-2α
250 mcg IM
-NOT for asthma, cardiac, renal, liver dz, seizure patients
Once Oxytocin is started for post partum hem
What is the next step
After Oxytocin/Pitocin, typically also start methergine, then give hemabate next
If that doesn’t work or there are contraindications to both, give misoprostol trial
C/I for Methergine
Preeclampsia
HTN
C/I for hemabate
Asthma
Cardiac/ renal/ Liver dz
SZR pts
If a pt has HTN or Asthma
What is the rx to use instead of methergine or hemabate
Misoprostol
What is the classic disaster from post partum hem
Uterine inversion
a pt presents after birth with Failure of lactation, amenorrhea, breast atrophy, loss of pubic & axillary hair, hypothyroidism, & adrenal cortical insufficiency
Think
Sheehan syndrome
If a male partner is over 40 top at age of sperm donation
What is the genetic risk
Autism: 6x more likely if father >40yo at conception
Schizophrenia: 2x more likely if father was >45yo at conception; 3x if > 50
What is the recommended follow up when putting someone on Contraceptives
IUD?
Check for IUD strings.
Combined hormonal?
Check BP.
Can pts with HTN take COC?
NO, if BP is above 160/100 no COC
Also avoid depoprovera (shot)
If a pt is over age 35 and smokes more than 15 cigs a day
What is the recommendation for COC
AVOID/Do NOT use COC
Use with caution if >35 and smoker
Can pts with aura+ migraine take COC?
NO
Depo-provera is usually ok
Can pts with DM and end organ dz take COC?
End organ disease (retinopathy/nephropathy/neuropathy)
OR
+Vascular dz or >20 yrs w/DM
- COC generally not recommended depending on severity
- Depo-Provera generally not recommended
If a pt is breastfeeding and is less than 1 month post partum
Can they take COC
Not recommended
Can a pt with DVTs take COC
No!
What is the contraception of choice in Breast Cancer Pts
IUD (copper)
No hormonal!
Can RA pts take depo-provera
use with caution, at risk of osteoporosis