PTL & IOL

Question 1

The leading cause of neonatal mortality?

Answer 1

PTB

& neuro morbidity

Question 2

When should someone be evaluated for PTB?

Answer 2

>\=6 cntxns per hour 
Painful ctxns
Vaginal bleeding
Leakage of fluid
Pelvic pressure or back pain

Question 3

Differential dx for PTB

Answer 3

Dehydration
Braxton Hicks
Round ligament pain
Lax vaginal time

Abruption
Trauma
Appendicitis

Question 4

What is fFN (fetal fibronectin) and when is it most useful?

Answer 4

fFN is an extracellular glycoprotein found in the amniochorionic membrane, serving as an adhesive for the decidua and membrane.

Present before 20 wks and after 37 wks, therefore if present between 24-34 wks, may indicate inflammatory process and possible PTL
Poor PPV (if positive, unreliable) 
High negative predictive value—if negative, have a 1-2% chance of giving birth within 7-14 days.

Question 5

When and how to collect fFN

What could cause false positives?

Answer 5

Confirm if h/o bleeding, recent intravaginal sex, or lubricants (as they can give false positives) ➡️ if all negative, collect swab in posterior fornix for 10 seconds & place in tube with buffer
(No need to collect if >3cm dilated or >/=80% effaced)

Question 6

History collection for PTB

Answer 6

Confirm gestational age
Review risk factors 
On 17h P?
Any recent cervical lengths?
ROS: fever, n/v, gu-UTIs, strenuous activity, trauma, sex, vaginal dc or bleeding?

Question 7

Physical risk factors for PTB

Answer 7

Cervix that is <25 mm between 16-24 wks & 20-29 mm after 24wks
(You can discard fFN if >30mm)

Question 8

Best drugs to use for PTL

Answer 8

Calcium channel blockers (nifedipine/procardia)

Prostaglandin synthetase inhibitors (indomethacin/indocin)

Question 9

What is the goal of Tocolysis?

Answer 9

Delay birth long enough to get corticosteroids on board—May discontinue tocolytics after steroids are given!

Question 10

Name and give doses of corticosteroids

Answer 10

Between 24- 36/6wks
Betamethasone (Celestone) 12.5mg IM x2 24hrs apart
Dexamthasone (Decadron) 6mg IM x4, 12hrs apart

Can give rescue dose if 7-14 days since last dose

Question 11

When should GBS prophylaxis be given?

Answer 11

GBS positive or unknown, in labor

Question 12

Why and when do we give magnesium sulfate?

Answer 12

Neuroprotection (decreases CP)

Before 32 wks

Question 13

What is ACOG’s recommendations for post term inductions?

Answer 13

Consider induction:41-41&6
Recommend induction: 42-42 &6
induction indicated >42&6

Question 14

How many women with PPROM have chorioamnionitis, & how many have PP endometriosis?

Answer 14

15-20% for chorio

15-20% for endometriosis

Question 15

Management for PPROM 23-36 & 6 wks

Answer 15

If no signs of infection, labor or fetal compromise, expectant mgmt:
Steroids
Antibiotics -GBS prophylaxis
NO cervical checks (reduce chorio)

Mag sulfate if <32wks & contracting w/cervical change

Question 16

What cervical ripening agent has the highest rate of success in 24 hrs but also most likely to have tachysystole?

Answer 16

Vaginal misoprostol (cytotoxic) 
25mcg q3-6h, 
max dose: 200mcg

Question 17

Cervical ripening agent least likely to have tachysystole?

Answer 17

Cervical foley balloon

Question 18

Cervical ripening agent least likely to have c-section

Answer 18

Oral misoprostol (cytotec) 25-50mcg q3-6h

Question 19

Dose for Dinoprostone (Prepidil)

Answer 19

0.5mg in 2.5mL syringe, endocervical gel—place for 6-12 hrs, can remove if necessary

Question 20

Dosing for Dinoprostone (Cervidil)

Answer 20

10mg (0.3mg/hr) intravaginal q6hrs, max 3 doses

Question 21

When can oxytocin be given after cervical ripening agents? (Varies)

Answer 21

4 h after last dose of cytotec via P.O. or I.vag

6-12 h after last dose of cervidil or Prepidil & must wait at least 30-60 mins after REMOVAL

Question 22

What is the purpose of membrane sweeping? (It is NOT an induction agent)

Answer 22

Shorten the time interval to onset of labor

Question 23

Ideal situation to AROM?

Answer 23

• favorable cervix
• 0 to +1 station
• no infection risk factors
• used concurrently with oxytocin (p. 1066)

Question 24

Oxytocin has what effect on the kidneys?

Answer 24

Antidiuretic effect—hot why women get so edematous in labor!

Question 25

Dosing for low dose pitocin

Answer 25

0.4-2mU/min

Increase 1-2mU/min q30-40 mins

Question 26

Dosing for high dose pitocin.

Answer 26

6mU/min increasing 3-6mU/min q15-40mins

Question 27

Side & adverse effects to pitocin

Answer 27

Tachysystole (more than 5ctxns in 10mins avg over 30 mins)
Hypotension
Pulmonary edema
EKG changes r/t myocardial ischemia
Down regulation of oxytocin receptors (which can lead to hemorrhage in third stage)
Uterine rupture

—> turn down or off (pit has a short half life)

Question 28

How often do you have to assess a woman and fetus with pitocin drip?

Answer 28

Every 15 mins & 5 mins in 2nd stage

Question 29

Interventions you can perform if fetal compromise

Answer 29

Decrease or turn off pitocin 
Turn to side
500cc LR
Oxygen administration 
Terbutaline 0.25mg IM (to decrease contractions)

Question 30

How do you correct down regulation of receptors?

Answer 30

Stop pitocin for 10-12h

Question 31

Pros of nipple stimulation

Answer 31

If starting with a favorable cervix, in labor within 72h
Decrease PPH
No episodes for tachysystole or abnormal FHr changes

Question 32

List herbal remedies for inducing labor & safety concerns

Answer 32

Castor oil 2oz/60mL mixed w/juice-generally considered safe
Black cohosh—unknown effects
Evening primrose and raspberry leaf—safe but not shown to be effective
Blue cohosh—unsafe, perinatal MI & stroke.

Question 33

When is a cervical ripening agent indicated?

Answer 33

IOL with bishop score of 6 or lower