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EOR Exam - Women's Health > Obstetrics Part 3 - L&D > Flashcards

Obstetrics Part 3 - L&D Flashcards

1
Q

Define labor.

A

Uterine contractions that cause changes in dilation, effacement, or station.

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2
Q

Define dilation, effacement, and station.

A

Di: Inc opening of the cervical os
Ef: thinning of the cervix
Sta: Location of presenting part relative to ischial spines –> above spines is -1, -2, …, below is +1, +2, …

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3
Q

Define and describe prodromal labor.

A

“False labor” –> irregular contractions that vary in duration, intensity, and intervals. Yield little to no cervical change.

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4
Q

List and define the six cardinal movements of labor.

A

Engagement: fetal presenting part enters pelvis
Descent: Presenting part descends into pelvis
Flexion: Head flexes so smallest diameter presents to pelvis
Internal Rotation: Rotation from occiput transverse to occiput anterior (sometimes occiput posterior)
Extension: Head extends as it passes beneath pubic symphysis
External Rotation: Occurs after head delivers to facilitate delivery of shoulders.

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5
Q

Define the stages of labor and state how long each typically lasts.

A

1: onset to dilation and effacement. Lasts 10-12 hrs in nulliparous woman and 6-8 hrs in multiparous.
2: full dilation to delivery. Prolonged if > 2 hrs in nulliparous and > 1 hr in multiparous.
3: after delivery of child to delivery of placenta. Normal is 5 - 30 minutes.

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6
Q

Describe the phases of the 1st stage of labor.

A

Latent: slow cervical change - onset to 2-4 cm dilation.
Active: until 9cm dilation - cervical change becomes faster.
Deceleration/Transition: cervix completes dilation

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7
Q

How is one determined to be in active labor and what should happen at that point?

A

Patient in active labor = admitted to labor unit.
Criteria: mucus plug discharge, dilation > 4cm, uterine bleeding, abnormal fetal HR pattern, regular contractions, > 80% effacement.

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8
Q

What is the risk of a women being admitted to the labor unit before being in active labor?

A

Iatrogenic interventions: epidural, oxytocin augmentation, C-section.

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9
Q

Define cephalopelvic disproportion.

A

Fetal head is too large to pass through pelvis

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10
Q

What are Montevideo Units and what is considered sufficient during labor?

A

MV units = method of measuring uterine performance during labor. > 200 MV units = sufficient.

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11
Q

How long of a time period without change during the active phase of labor would trigger a C-section?

A

2 - 4 hours

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12
Q

How is cervical dilation, effacement, and station determined and when should this occur?

A

Determined by digital cervical exam. Occur at time of admission and every 2-4 hrs during 1st stage, every 1-2 hrs during 2nd stage, and when patient feels urge to push to ensure full dilation (10cm).

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13
Q

If a woman chooses anesthesia during labor, when should the cervical exam happen relative to administration of the anesthesia?

A

Perform cervical exam prior to anesthesia

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14
Q

What should be assessed if the fetal HR becomes irregular during labor?

A

Digital cervical exam to evaluate for prolapse and uterine rupture.

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15
Q

What is a partogram and how is it used during labor?

A

Graphical representation of the progression of dilation and other vital statistics (fetal HR, duration of labor, etc.)

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16
Q

How does the administration of an epidural affect the timing of the 2nd stage of labor?

A

Prolongs second stage s/p decreased sensation to push.

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17
Q

Describe forceps and state when they can be used in pregnancy.

A

Blades shaped to accommodate the head of the baby. Use requires: full dilation, ruptured membranes, head at 2+ station or more, no evidence of cephalopelvic disproportion, knowledge of fetal position, adequate anesthesia, and empty bladder.

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18
Q

Describe the use of a vacuum device in pregnancy.

A

Cup placed on fetal scalp with suction device connected to create vacuum.

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19
Q

What are the risks associated with forceps and vacuum use?

A

Forceps: increased rate of facial nerve palsies and perineal lacerations
Vacuum: inc rate of cephalohematomas and shoulder dystocia.

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20
Q

List three signs the placenta has separated from uterine wall in the 3rd stage of labor.

A

Cord lengthening, gush of blood, uterine fundal rebound as placenta detaches.

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21
Q

How is delivery of the placenta managed during the 3rd stage of labor?

A

Gentle traction on cord and suprapubic pressure to avoid perineal trauma and uterine prolapse/inversion.

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22
Q

How is retention of the placenta defined and how is it managed?

A

Def: no delivery of placenta > 30 min after birth
Tx: Manual traction (hand in intrauterine cavity) or curettage.

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23
Q

What is the biggest risk factor for retained placenta?

A

Pre-term delivery

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24
Q

Describe the 4 degrees of perineal lacerations resulting from delivery.

A

1: involves mucosa and skin in perineal area
2: extend into deep perineal body but not anal sphincter
3: extend into or through anal sphincter
4: anal mucosa itself is entered

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25
How are 3rd/4th degree lacerations repaired?
Several interrupted sutures
26
What is a buttonwall laceration?
Laceration through rectal mucosa into the vagina but with sphincter still intact.
27
What risks are associated with 3rd and 4th degree lacerations?
Infection, incontinence, prolapse
28
How is separation of a 4th degree laceration repair managed?
Abx, debridement, secondary repair
29
Define hypertonus and tachysystole and state what they might cause and how the condition is managed.
Hypertonus: single contraction lasting > 2 minutes Tachysystole: > 5 contractions in 10 minute period May caused prolonged deceleration - treated by terbutaline to relax the uterus
30
What findings on tocolytic monitoring indicates a non-reassuring fetal status and how is this managed?
Repetitive late decels, bradycardia, loss of variability | Tx: O2 by mask, dec IVC compression and inc uterine perfusion by turning mom on left side, d/c oxytocin.
31
Define an episiotomy.
Incision made in perineum to facilitate delivery - used to relieve shoulder dystocia.
32
T/F: Morphine is contraindicated for pain management in pregnancy.
False: morphine can be used for pain management but should not be used close to delivery.
33
Describe the use of a pudendal nerve block during labor.
Pudendal nerve travels posterior to ischial spine. A pudendal nerve block is commonly used in operative vaginal delivery with forceps or vacuum.
34
Describe the use of local anesthesia during labor.
Often used for those requiring episiotomy or repair of lacerations.
35
What is the location for placement of an epidural for anesthesia and when during labor is it placed?
L3-L4 during active phase of labor.
36
When in labor would general anesthesia be used and what are the risks of its use?
Used for urgent C-section. | Risks: maternal aspiration and maternal/fetal hypoxia.
37
List the reasons for delivery via C-section and state which is most common?
Most Common: failure to progress in labor - cephalopelvic disproportion Other: multiple gestations, older patient with comorbidities, overweight, patient or clinical preference
38
When after C-section can a mother deliver vaginally and what is the greatest risk?
When: Kerr (low transverse) or Kronig (low vertical) incision Risk: rupture of prior uterine scar
39
Describe the most common reason for a C-section.
Cephalopelvic disproportion (aka failure to progress during labor). pelvis too small, presenting part too large, contractions inadequate.
40
Define the obstetric conjugate.
Distance between sacral promotory and midpoint of the pubic symphysis. It is the shortest A-P diameter of the pelvis.
41
Differentiate between gynecoid, android, anthropoid, and platepelloid pelvic shapes.
Gyn: round, shallow and open. Most common shape Andr: narrow and shaped like a heart/wedge. Most similar to male pelvis Anth: Narrow and deep - shaped like upright egg Plat: Wide and shallow like an egg on its side. AKA flat pelvis. Least common type.
42
List the pelvic shapes from most favorable for vaginal birth to least favorable.
Gynecoid - most favorable for vaginal birth Anthropoid - labor likely to last longer Android - may require C-section Platypelloid: most likely to require C-section
43
Define the three types of breech presentations.
Frank: flexed hips, extended knees, feet near head Complete: Hips and knees flexed (may just be one flexed knee) Incomplete: AKA footling - one or both hips not flexed so foot/feet is/are presenting part
44
How is the diagnosis of a breech presentation made?
Leopold maneuvers - fetal head palpated near fundus Vaginal exam: palpated gluteal cleft and anus or LE US: confirms diagnosis Doppler: fetal HR heard in upper uterus
45
What are common complications of a breech presentation?
cord prolapse, entrapment of fetal head, fetal neurologic injury.
46
What are the indications and contraindications for a trial of vaginal delivery in a breech presentation?
Ind: favorable pelvis, flexed head, est fetal weight 2000-3800 g, frank or complete breech CI: nulliparity, est fetal weight > 3800g, incomplete breech
47
Define and describe external cephalic version.
Used to reorient a fetus that is in a breech position with the goal of successful vaginal delivery. The uterus is relaxed pharmacologically and external bimanual manipulation of the fetus is performed.
48
In what situations is external cephalic version more likely to be successful and when is it contraindicated?
Success: African American parents, nonlongitudinal lie, unengaged presenting part. CI: placenta previa, previous C-section
49
What are the risks of external cephalic version?
still birth, abruption, emergent C-section, cord prolapse, vaginal bleeding, rupture of membranes, maternofetal transfusion, transient abnormal changes in fetal HR. The rate of serious complications is low.
50
Define umbilical cord prolapse.
ubilical cord presents outside the cervix before the fetus.
51
T/F: Umbilical cord prolapse is easily manged through the duration of a normal delivery.
False: It is an obstetrical emergency s/p disruption of blood flow from the descending fetus putting pressure on the cord.
52
What are the signs of cord prolapse?
variable late decelerations, prolonged bradycardia. May be visible on vaginal exam or occult (not visible).
53
How is cord prolapse managed?
Emergent C-section (obstetric standard of care).
54
If the standard of care for a cord prolapse is delayed, how else might the circumstance be managed?
Manual elevation of the fetal head with two fingers, Maternal repositioning - Trendelenburg or knee to chest with face toward floor, terbutaline (0.25mg SC) to dec uterine contractions and alleviate pressure on the cord.
55
How is delivery managed when a shoulder is the initial presenting part?
C-section s/p risk of cord prolapse and uterine rupture.
56
How is the diagnosis of a transverse lie made?
Abdominal US confirms. Digital vaginal exam should not be performed until underlying causes (esp placenta previa) are ruled out.
57
What are the indications for attempting external version in a transverse lie and when is it attempted?
Ind: single gestation with no underlying abnormality When: 37 weeks gestation - allows for ample amniotic fluid and restricting time period for recurrence.
58
Describe the various fetal positions when the head is the first presenting part.
``` OA = occiput anterior - most common position OP = occiput posterior OT = occiput transverse (left or right facing) - most common position at onset of labor then converts to OA. ```
59
What are the risks of OP positioning and in what patients is this presentation most common?
Fetal Risks: low APGAR, umbilical artery acidemia, increased rate of NICU admission Maternal Risks: anal sphincter injury Most common: nulliparous women followed by: maternal age > 35, obesity, previous OP delivery, small pelvic outlet, gestational age > 41 weeks, birthweight > 4000g, anterior placenta, use of epidural anesthesia
60
List three obstetric emergencies:
Cord prolapse, fetal bradycardia, shoulder dystocia
61
Define fetal bradycardia.
Hetal HR < 100-110 or prolonged decel > 10 minutes
62
List three categories causes of causes of fetal bradycardia and give examples of each.
Preuterine: maternal HypoTN, hypoxia, seizure, MI, PE Uteroplacental: abruption, previa, hyperstimulation Postplacental: cord prolapse, cord compression, vasa previa (rupture of fetal vessel)
63
List 3 treatments for fetal bradycardia.
1. Move mother to lateral decubitus position to decrease pressure on IVC 2. Place mother on O2 by mask 3. Manage underlying cause
64
Define shoulder dystocia.
Failure of the shoulders to spontaneously traverse the pelvis after delivery of the fetal head.
65
What are risk factors for shoulder dystocia?
fetal macrosomia (> 4000g), DM (gestational or pre-pregnancy), previous shoulder dystocia, post-term delivery, prolonged 2nd stage of labor.
66
What are the potential complications of shoulder dystocia?
fetal hypoxia, permanent brachial plexus palsy, fetal or maternal injury, fetal death.
67
Describe the steps to attempt vaginal delivery in shoulder dystocia.
1. McRobert's Maneuver: extreme flexion of maternal hips to increase AP diameter 2. Maternal suprapubic pressure 3. Rubin Maneuver: pressure on anterior shoulder to decrease bisacromial (distance between shoulders) diameter. 4. Wood's Screw: pressure behind posterior shoulder to rotate baby and dislodge anterior shoulder. 5. Delivery of posterior arm/shoulder by sweeping posterior arm across chest 6. Zavenelli Maneuver: place fetal head back in pelvis and perform C-section
68
When should Zavanelli Maneuver be used in the management of shoulder dystocia?
Only in true emergency when all other maneuvers to facilitate vaginal delivery have failed. Associated with increased risk of infection.
69
List and describe the 5 components of the APGAR score.
Appearance: 0 = central cyanosis, 1 = peripheral cyanosis, 2 = pink Pulse: 0 = absent, 1 = < 100, 2 = > 100 Grimace: 0 = no response to stim, 1 = weak cry when stim, strong cry when stim Activity: 0 = floppy, 1 = some flexion, 2 = well flexed and resisting extension Respiration: 0 = apnea, 1 = slow and irregular, 2 = strong cry
70
When is the APGAR score assessed?
1 minute and 5 minutes after delivery
71
List the APGAR total score benchmarks for intervention.
7+ = no distress and baby can be placed skin-to-skin on mother's chest 6 or less = distress and need for intervention
72
Describe the steps in management if the neonate's pulse is less than 100 during APGAR assessment.
Pulse < 100 typically indicates respiratory distress/failure. Begin with 30 sec of positive pressure ventilations. If HR remains < 100, continue PPV and assess the need for repositioning, suction, mask adjustment, and/or pressure increase.
73
Describe the routine post-partum management following a vaginal delivery.
NSAIDs/APAP for pain, low dose opioids for sleep, perianal care --> ice packs for pain and edema, inspect for hematomas, hemorrhoid meds, stool softeners.
74
Describe the routine post-partum management following a vaginal delivery.
Local wound care, monitor for signs of infection or wound dehiscence (separation), opioids PRN for pain, stool softener +/- laxative for opioid constipation, NSAIDs for cramping.
75
What are the benefits of breastfeeding in the immediate post-partum time period?
Oxytocin release contracts uterus and lowers bleeding risk, passive immunity via immunoglobulins, more likely to lose weight (dec T2D risk.
76
What is letdown, when does it start, and what are the signs it has started?
Release of breast milk from the ducts. Typically happens 24-72 hours after delivery. Signs include warmer, firmer, tender breasts.
77
How is breast tenderness managed in a post-partum woman that is not breast feeding?
ice packs, tight bra, analgesics, NSAIDs
78
T/F: Oral contraceptive use should begin within 72 hours of delivery.
False: OCP use should begin 3-6 weeks after delivery. Should not begin until after 3 weeks of breastfeeding.
79
Define the puerperium period.
The time period about 6 weeks after delivery.
80
Describe the normal transition of the uterus in the puerperium period.
Uterus at the level of the umbilicus immediately after delivery, begins to shrink after 2 days, descends into pelvic cavity after 2 weeks, pre-pregnancy size after 6 weeks.
81
Define post-partum involution.
Return of the uterus to its normal size and function
82
Define lochia.
Normal post-partum bleeding that occurs for 4-5 weeks after delivery.
83
When do menses begin after delivery?
6-8 weeks post-partum if no breast feeding. In breast feeding women, menses may not return until breast feeding ceases.
84
When should the first post-partum OB visit occur and what should be done?
6 weeks after delivery. Perineum should be healed. Obtain Hgb/Hct, fasting glucose if GDM, assess Edinburge postnatal depression scale, emphasize contraception, recommend vitamin supplementation for breastfeeding mothers, treat atrophic vaginitis with vaginal estrogen PRN
85
Define post-partum hemorrhage (PPH) and list potential causes.
PPH = > 500ml after vaginal delivery or > 1L after C-section. Causes = uterine atony (most common), reatined products of conception, placenta accreta, cervical or vaginal lacerations, coagulation disorders.
86
Define placenta accreta.
Growth of the placenta too deep in to the uterine wall resulting in part or all of the placenta remaining attached after childbirth.
87
Describe the management of PPH.
Investigate cause, fluid resuscitation and/or blood transfusion, coagulation and platelets if blood loss > 2-3 L, digital extraction +/- curettage if retained placenta suspected cause. Adjuvant therapy = bimanual uterine massage and IV oxytocin (pitocin)
88
What is Sheehan Syndrome?
Postpartum hypopituitarism resulting from hypoxia experienced in PPH. Can cause absence of lactation and failure to restart menses. Rare in developed countries.
89
What is the next step in management of a 10% or more postpartum reduction of Hgb/Hct is noted?
US to assess for retained placental fragments.
90
Describe pharmacological options to increase uterine contractions if bleeding continues after oxytocin administration and list the contraindications of each
Misoprostol Carboprost: asthma (may cause bronchospasm) Methergine: HTN
91
Define endomyometritis, state the most common risk factors, and state when it usually manifests.
Def: infection of the uterine lining that often invades the myometrium. Risks: more common after C-section or manual extraction of the placenta Typically manifests 5-10 days after delivery
92
Describe the S/S of endomyometritis.
High fever, leukocytosis (> 20,000), uterione tenderness, adnexal tenderness, peritoneal irritation, decreased bowel sounds.
93
What is the most common causative organism in endomyometritis?
Anaerobic streptococci
94
What is the treatment for endomyometritis?
IV abx (clindamycin or gentamycin) + ampicillin if no improvement in 48 hours, then add metronidazole if sepsis persists.. D&C if retained placenta.
95
What treatment during delivery decreases risk of endomyometritis?
Single abx dose at time of cord clamping.
96
Define and describe the causes of mastitis.
Def: regional infection of the breast. Causes: clogged milk ducts (MC), invasion of skin/oral flora from breast feeding baby.
97
Describe the S/S of mastitis.
focal tenderness, erythema, warm to touch, fever, leukocytosis (inc WBCs)
98
What is the treatment of mastitis?
I&D, PO dicloxacillin (clindamycin if PCN allergy), IVabx if unresponsive to PO, completely empty breast of milk. Prevention with lubricating ointments.
99
What is the usual timeline of postpartum depression?
Onset 2-3 days after delivery, peaks at 5 days, resolves in 2 weeks.
100
What is the treatment for postpartum depression?
Assess for SI/HI, involve counselor or social worker, SSRI have good efficacy.

EOR Exam - Women's Health (7 decks)

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