Objectives 32-40

Question 1

32. Why is oxytocin administration recommended immediately following second stage rather than immediately following third stage?

Answer 1

• uterine atony accounts for most PPH
• works with oxytocin receptors
• Gabbe (p. 291): debate regarding the timing of oxytocin admin: after the placenta has delivered vs. after the anterior shoulder of the fetus has delivered. An RCT including 1486 women comparing the effects of timing of oxytocin admin…showed no significant difference in blood loss or retained placenta between groups.

Question 2

33. What is a circumvallate placenta?

Answer 2

• caused by a double layer of chorion and amnion
• Membrane is folded back on the fetal surface and inserts inward on themselves.
• Stables(159): an opague thickened ridge is seen on the fetal surface of the placenta which forms because of doubling back of the membranes. The membranes may leave the placenta nearer to the center than normal. Associated with IUGR

Question 3

What is a Battledore placenta?

Answer 3

• Peripheral cord insertion at the placental margin
• The umbilical cord is inserted into the edge of the placenta, giving it the appearance of a battledore ( a at used to play a medieval game similar to badminton) .
• no clinical significance

Question 4

What is a placental accessory lobe?

Answer 4

• Most common abbormal finding
• accessory placental lobe within the fetal sac that has continuous vascular connections with the main placenta
• Placed at a distance from main placenta
• The blood vesesls that supply this love run over the intervening membranes
• also called succenturiate lobe of placenta

Question 5

What is Velementous insertion of a cord?

Answer 5

• the umbilical cord insertion is into the membranes outside the placental boundary
• cord insertion into the fetal sac, but not directly into placental bed
• generally 5-10cm away from placenta
• can cause shearing of blood vessels during labor or delivery of the placenta, causing insertion

Question 6

What is a Vasa previa?

Answer 6

• Velamentous insertion of fetal vessels over the cervical os
• Fetal vessels lack protection from Wharton’s jelly and are prone to rupture
• Risk factors - IVF, multiples
• Treated similar to placental previa

Question 7

34. What findings would indicate the possibility of a retained accessory lobe?

Answer 7

• bleeding; torn blood vessels at the margin of the maternal surface of the placenta with the fetal membranes
• or the extension of blood vessels into the membranes
• rough or torn roundish defects in the membranes a short distance from the placenta, may have a fragment of decidua attached on the periphery of the defect

Question 8

35. What is the difference between a placenta accreta, increta, pancreta?

Answer 8

• Accreta: abnormal attachment of the placenta to the uterine lining due to an absence fo the decidual basalis and an incomplete development of the fibrinoid layer. The placental villi adhere to the myometrium. No line of cleavage
• Increta: occurs with the vili penetrate the uterine muscle but not it s full thickness
• Percreta: Occurs wehn the chorionic villi invade though the entire uterine wall to the serosa layer. through the myometrium…and may grow into the bladder. 5% of accretas

Question 9

36. Stairstep your way through a discussion of managing postpartum bleeding?

Answer 9

• Prevention: allow baby to nurse, keep bladder empty, give prophylactic oxytocin IV or IM with anterior shoulder.
• Bleeding noted: notify MD, uterine massage if r/t atony, give meds: oxytocin, methergine, misoprostol, or hemobate, IV bolus
• bimanual compression if other messures are unsuccessful
• consider manual placenta if not delivered,
• consider vaginal, sulcus, cervical lac as cause of bleeding

Question 10

37. Why do you inspect the placeta after the third stage of labor? Why not wait until all is done and you have time and leisure to really look at it?

Question 11

38. What are some predisposing factors to postpartum hemorrhage?

Answer 11

• distended uterus: macrosomia, polyhydramnios
• long labor
• Mcdonald article: overdistended uterus from multiple gestation, polyhydramnios, macrosomia; prolonged labor, induced or audmented labor, precipitous labor; history of PPH, grandmuliparous women
• MgSO4, operative birth

Question 12

39. What are the cardinal symptoms of an inversion, besides the most obvious one of having the uterus in your hands?

Answer 12

• sudden onset of brisk vaginal bleeding in association with an absent palpable fundus abdominally
• Maternal hemodynamic instability
• Inversion should be considered if:
  
  • sudden onset of brisk vag bleeding is association with
    
    • absent palpable fundus abdominally
    • maternal hemodynamic istability

Question 13

40. Mechanisms to prevent uterine inversion?

Answer 13

• Do not use excessive cord traction in the the presence of a relaxed uterus and not using counter pressure; do not preform vigorous, fundal pressure