Obstetrical Procedures Flashcards
What is a 1st degree perineal laceration?
Superficial perineal skin or vaginal mucosa
What is a 2nd degree perineal laceration?
Perineal muscles and facia
What is a 3rd degree perineal laceration?
Anal sphincter
What is a 4th degree perineal laceration?
Rectal mucosa
What do you need to know about episiotomy?
Midline or mediolateral (MLE inc 3rd/4th lac)
Comparable to 2nd degree lac
Is vacuum or forceps easier on mom/baby?
Vacuum easier on mom
Forceps easier on baby
What are the prerequisites for an operative vaginal delivery?
Engaged fetal vertex Ruptured/fully dilated Precisely known position Drained bladder Informed consent
What are the indications for an operative vaginal delivery?
Prolonged second stage
Immediate/potential fetal compromise
Category II or III tracing
Shorten 2nd stage for maternal benefit (exhaustion, cardiopulmonary or cerebrovascular disease)
What is considered prolonged 2nd stage in nulliparous/multiparous women?
Nulliparous: lack of continuing progress for 3 hours with analgesia, 2 hours without
Multiparous: lack of continuing progress for 2 hours with analgesia, 1 hour without
What is an outlet operative vaginal delivery?
When the scalp is visible at the introitus without separating labia
Fetal skull has reached pelvic floor
Saggital suture in AP diameter or left/right occiput anterior/posterior
Rotation does not exceed 45 degrees
What is a low operative vaginal delivery?
Leading point of fetal skull is > or = +2, not on pelvic floor
What is a midforceps delivery?
Station is above +2, head engaged
What are the most serious complications of a forceps delivery?
Perineal and rectal lacerations
What are common complications with a vacuum delivery?
Ceohalohematomas or worse hematomas
A vacuum should not be used in fetuses less than ___ weeks
34
When should a vacuum be stopped?
3 pulls over 3 ctx with no progress
3 pop offs without obvious cause
30 minutes elapsed time (some say 20)
What are indications for a cesarean birth?
Concern for maternal/fetal well-being Vaginal birth not possible/appropriate Placenta previa Malpresentation Multiples Fetal intolerance Labor dystocia Preexisting medical conditions Obstetric complications Maternal request (only after 39wks)
What types of skin/uterine incisions are done for a cesarean section?
Vertical or pfannenstiel (bikini) on skin
Low transverse, low vertical, classical, T, or J on uterus
What are the maternal risks with a cesarean section?
Injury to adjacent organs (mostly bladder/bowel) Hemorrhage Wound infection VTE inc risk in future pregnancies
What are the fetal risks with cesarean section?
RDS
iatrogenic prematurity
What is the overall success rate for TOLAC in the U.S.?
60-80%
What is an ideal TOLAC candidate?
One or two previous low transverse c/s Adequate pelvis No other uterine scars or rupture Physicians immediately available during active labor Capable of continuous EFM
What is suspicious for uterine rupture?
Prolonged decels with severe variables
Inc bleeding
Hypotension
Tachycardia
What are the different options for mechanical cervical ripening?
Laminaria (seaweed absorbs water, expands)
Lamicel/dilipan (polymers absorb water, expand, may cause production of prostaglandins
Balloon catheters (foley or cook)
What is prostaglandin E1?
Cytotec 25mcg Cheap Don't redose if 2 or more ctx in 10 min Contraindicated with prior uterine surgery
What is prostaglandin E2?
Cervidil
Continual release- need continuous EFM
remove after 12 hours
Expensive
What are options for mechanical induction of labor?
Membrane stripping- digital separation of chorioamniotic membrane from cervix to release prostaglandins and endogenous oxytocin
Amniotomy- can inc occurrence of infection and variable decels
What is the half life and plasma steady state of oxytocin?
10-15 minutes
40 minutes
What do you need to know about oxytocin infusion?
Should be stopped when labor is established
Given via pump, IV piggyback to lowest port
Continuous EFM
AWHONN recommends 1:1 nursing care
What do you do if you have tachysystole and a category I tracing?
Reposition IVF bolus Wait 10-15 minutes Decrease by half Reposition IVF bolus Wait 10-15 minutes Turn off
What do you do if there is tachysystole and a category II or III tracing?
Stop oxytocin
Once tachysystole is resolved after stopping oxytocin, what do you restart at?
Off for less than 30 minutes? Restart at half
Off for 30 minutes or more? Restart at initial
How is oxytocin similar to ADH?
Can cause electrolyte imbalance resulting in water intoxication
What are the opioid analgesia options in labor?
Demerol- can cause resp depression
Nubain- less resp depression, more sedation
*not to be given to opiate dependent pts
Stadol- similar to Nubian, pseudosinusoidal
Fentanyl- fast onset, short acting
Can an epidural cause a maternal fever?
Yes
Does an epidural increase the need for pit?
Yes
Does an epidural increase the length of second stage?
Yes
What is local infiltration?
Local injected into perineum, labia, vagina
What is paracervical anesthesia?
Anesthetic injected into cervix
Profound fetal bradycardia
Rarely used
What is pudendal anesthesia?
Local anesthetic injected just below ischial spines
A bishop score of ___ or more indicates need for cervical ripening
5
What do you need to know about external cephalic version?
Done between 37-39 wks
Rh negative women need rhogam
65% success rate
Forward roll more successful than backflip
Tocolysis does not significantly improve success
What are the bishop scores given for effacement?
0-30: 0
40-50: 1
60-70: 2
80 or more: 3
What are the bishop scores given for dilation?
0: closed
1: 1-2cm
2: 3-4cm
3: 5 or more cm
What are the bishop scores for station?
0: -3
1: -2
2: -1
3: +1, +2
