Test 2 - Modules 4 & 5

Question 1

T/F Most clinicians agree with Friedman view that the rate of progress is more important than the total length of labor.

Answer 1

True

Question 2

Friedman observed thousands of labors and graphed their progress by plotting rates of ___________ and ___________ against elapsed time. This graphic representation of labor progress is now known as ____________ _________. He observed that the slope of the lines representing dilatation and descent change ____________ in most labors. Friedman divided labor into________ and ________ based on these observations.

Answer 2

dilatation and descent; Friedman’s curve.
predictably;
stages and phases

Question 3

Friedman: The first stage of labor begins with the _______ of regular uterine contractions and ends with ________ dilation of the cervix.

Answer 3

onset; complete

Question 4

Friedman: The second stage of labor is defined as beginning with ________dilation of the cervix and ending with the ________.

Answer 4

complete; birth.

Question 5

One controversy is the onset of the active phase of first stage labor. Friedman defined this as the time when the _____ of dilation increases. In his original study, Friedman found that the median dilation at this point of faster progress was about ___centimeters (Friedman, 1954). Clinicians and researchers adopted this as the definition of onset of active labor, however ____________points out that is not accurate to define active labor based on a particular dilation as there is considerable variation among women .

Answer 5

rate; 3cm. Friedman

Question 6

Contemporary research shows that many women are not in active labor until ____ or ____centimeters

Answer 6

5 or 6

Question 7

Friedman First Stage, Latent phase (note that latent phase is calculated based on total duration, not rate of dilation per hour):

Nulliparas:_____________

Multiparas:_____________

Question 8

Friedman First Stage, Active phase:

Nulliparas: At least ___________ dilatation

Multiparas: At least ___________dilatation

Answer 8

1. 2 cm/hr;

1. 5 cm/hr

Question 9

Friedman Second Stage

Nulliparas: _________ descent

Multiparas: _________ descent

Answer 9

1 cm/hr;

2cm/hr

Question 10

Friedman: When progress occurs more slowly than the in time frames noted above, it is called a ________ disorder. _________ disorders are defined by Friedman as no progress in dilation for ___ hours during first stage, active phase labor, or no progress in descent for ____ during second stage.

Answer 10

protraction;

Arrest; two; one hour

Question 11

Friedman determined the slowest ___% of labors are defined as abnormal.

T/F - Friedman acknowledges that this numerical point was chosen arbitrarily.

Answer 11

5%; True

Question 12

In Friedman’s research, _____% of the women diagnosed with secondary arrest of dilatation subsequently gave birth vaginally (with / with no) intervention.

T/F: While this might lead one to question the accuracy of a diagnosis of labor abnormality based on two hours without progress, this criteria for abnormal labor and others were readily adopted by American obstetricians and are commonly used today.

Answer 12

52.5%; with no

True

Question 13

Concerns about high rates of ___________ ________ and other treatments for slow labor have prompted a re-examination of the definition of normal labor progress.

Answer 13

cesarean sections

Question 14

In 2010, Zhang et al. published an analysis of labor patterns based on a dataset called the “Consortium on Safe Labor.” The statistical analysis used in this study allowed for evaluation of rates of progress at each centimeter of dilation. The slowest yet normal dilation (based on 95th percentiles) was found to be __________ for nulliparas and __________ for multiparas, with _______ dilation as labor progresses.

Answer 14

0.5 - 0.7 cm/hr for nulliparas
0.5 - 1.3 cm/hr for multiparas
faster

Question 15

“Safe Prevention of the Primary Cesarean” is an _________ __________ published jointly by _____________ and ____________.

Answer 15

expert opinion;

American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal Fetal Medicine (SMFM)

Question 16

Joint statement: “The Consortium on Safe Labor data do not directly address an optimal duration for the diagnosis of active phase protraction or labor arrest, but do suggest that neither should be diagnosed before ___ cm of dilation. Because they are contemporary and robust, it seems that the Consortium of Safe Labor data, rather than the standards proposed by Friedman, should inform ____________ __________ ____________”

Answer 16

6cm; evidence-based labor management

Question 17

T/F - Criteria for arrested labor are discussed in the contemporary research.

Answer 17

False

Question 18

In the ACOG/SMFM document, the term _____ ______ is used in reference to when a cesarean should be considered.

Answer 18

labor arrest

Question 19

Contemporary research

_____to____ cm per hour

or

______________ cm per hour (nullips/multips, with faster dilation as labor progresses)

Answer 19

0. 3 to 0.5 cm/hr

0. 5-0.7/0.5-1.3 cm/hr

Question 20

Friedman asserts that labor disorders as
he defines them (with the exception of prolonged latent phase), are associated with a significant _________________________. This assertion is used to justify significant __________ in labor, including __________________. This issue is complicated by the fact that the_________used to treat the “disorder” may be what presents the risk to the_________.

Answer 20

increase in risk to the fetus.
intervention; cesarean section.
intervention; fetus.

Question 21

Contemporary research: The findings of these studies were consistent. Perinatal complications (did / did not) increase with the length of the second stage. Rates of __________, __________ vaginal deliveries, and ______ and ______ lacerations did increase with the length of the second stage.

Answer 21

did not;

cesarean section, operative vaginal delivieries, and 3rd and 4th degree lacerations

Question 22

T/ F - In the past, clear cut recommendations regarding when to intervene in slower labors were based on Friedman criteria for protracted and arrested labor. New evidence and recommendations make this less clear cut.

Answer 22

True

Question 23

Joint statement (ACOG/SMFM): Recommendations in this document for criteria necessary prior to cesarean birth for non-progressive labor are cervical dilation of at least ___centimeters, _________membranes and no cervical change in __ hours with adequate uterine activity or at least __ hours of pitocin when unable to attain adequate uterine activity.

T/F - It is also clearly stated that “slow but progressive labor should not be an indication for cesarean section”.

Answer 23

6 cm, ruptured membranes, and no cervical change in 4 hours with adequate uterine activity, or at least 6 hours of pitocin when unable to attain adequate uterine activity.

True

Question 24

Their most important physiologic function of prostaglandins is the ability to cause _________ or __________ of smooth muscle. This includes smooth muscle other than that of the cervix or uterus, and can have important implications regarding ___________ ______ ________of prostaglandins.

Answer 24

contraction or relaxation;

unitended side effects

Question 25

________ receptors are always present in myometrial tissue. This is why __________ can be used to induce labor at any gestational age. This is in contrast to __________, which is dependent on the development of receptors in myometrial tissue just before and during labor to exert its uterotonic effects.

Answer 25

Prostaglandin;
prostaglandins;
oxytocin

Question 26

The pharmacologic preparations of prostaglandins used in obstetrics are:
A) Dinoprostone (Cervidil® or Prepidil®)
B) Carboprost (Hemabate®)
C) Misoprostol (Cytotec)

_____ 1. synthetic PGE1 analog used for pre-induction cervical ripening, and first and second trimester abortions.
_____ 2. PGE2 used for pre-induction cervical ripening and first or second trimester abortion.
_____ 3. PGF2 used for control of postpartum hemorrhage and first or second trimester abortion.

Answer 26

1. C - PGE1
2. A - PGE2
3. B - PGF2

Question 27

T/F: The ability to draw firm conclusions on the effectiveness of prostaglandins in increasing rates of successful induction, decreasing cesarean sections rates, and decreasing duration of induction is complicated by the fact that there are many variations in terms of type of prostaglandin, form of administration, route of administration, and dosage regimens. In some studies, prostaglandins are compared to each other, in others to a placebo or to oxytocin.

Answer 27

True

Question 28

T/F - Endogenous oxytocin controls the strength and frequency of contractions.

Answer 28

False

Question 29

T/F - Exogenous oxytocin is the synthetic form also known as pitocin.

Answer 29

True

Question 30

Exogenous oxytocin:
Onset of action: ____ minutes
Half-life: _____ minutes
Steady state: ______ minutes

Answer 30

3-4 minutes
10-15 minutes
30-40 minutes

Question 31

Tachysystole is more than ____ contractions in ____ minutes.

Answer 31

5; 10

Question 32

Exogenous oxytocin (pitocin) has a predictable therapeutic index.

Answer 32

False (unpredictable)

Question 33

T/F - The need to titrate oxytocin is the primary reason it is on the high alert list.

Answer 33

True - the need for titration makes alot of room for error and misjudgement.

Question 34

If the total Bishop score is more
than ___, the probability of vaginal delivery after labor
induction is similar to that after spontaneous labor.

Answer 34

8

Question 35

The uterine response to oxytocin depends on the ____________ of the pregnancy; there is a gradual increase in response from ____ to ____ weeks of gestation, followed by a plateau from ____ weeks of gestation until _____, when sensitivity increases.

Answer 35

duration; 20 to 30; 34 until term

Question 36

Lower ______ ____ ______ and greater _________ _______, ________, or _________ ______ are predictors of successful response to oxytocin for induction.

Answer 36

body mass index; cervical dilation, parity, gestational age

Question 37

Significant increases in _______________ A2 activity and _________ F2α (PGF2α) levels occur from membrane stripping (26). Stripping membranes increases the likelihood of spontaneous labor within ___ hours and reduces the incidence of _________________.

Answer 37

phospholipase and prostaglandin;

48, induction with other methods

Question 38

T/F - Nipple stimulation was effective for induction in women with favorable and unfavorable cervices.

Answer 38

False - only with favorable cervix

Question 39

Although prospective studies are limited in
evaluating the benefits of elective induction of labor, nulliparous women undergoing induction of labor with
unfavorable cervices should be counseled about a__________ increased risk for ___________.

Answer 39

twofold; cesarean.

Question 40

Allowing at least ___-____ hours of latent labor before
diagnosing a failed induction may reduce the risk of
cesarean delivery.

Answer 40

12-18

Question 41

_______ of misoprostol should be considered as
the initial dose for cervical ripening and labor induction.
The frequency of administration should not be more than
every ______ hours. In addition, oxytocin should not be
administered less than________ after the last misoprostol dose. Misoprostol in higher doses (____ mcg every ____ hours) may be appropriate in some situations, although higher doses are associated with an increased risk of complications, including uterine ___________with ___ ___________.

Answer 41

25mcg; 3 to 6 hours.
4 hours;
5mcg every 6 hours;
tachysystole; FHR decelerations

Question 42

If there is inadequate cervical change with minimal
uterine activity after one dose of intracervical dinoprostone, a second dose may be given ___ to ___hours later. Maximum dose of dinoprostone gel is____mg or ___ doses.

Answer 42

6 to 12;

1.5 mg or 3 doses

Question 43

According to the manufacturers’ guidelines, after use of 1.5 mg of dinoprostone in the cervix or 2.5 mg in the vagina, oxytocin induction should be delayed for ___ to ___ hours because the effect of prostaglandins may be heightened with oxytocin.

After use of dinoprostone in sustained-release
form, delaying oxytocin induction for 30–60 minutes____ to _____ _____ after removal is sufficient.

Answer 43

6 to 12;

30 to 60 minutes

Question 44

Tachysystole is more common with which medication used for induction?

Answer 44

Misoprostol

Question 45

T/F - Irrigation of the cervix and vagina is effective in reducing tachysystole associated with PGE2 gel.

Answer 45

False