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OBSTETRICS > VAGINAL DELIVERY > Flashcards

VAGINAL DELIVERY Flashcards

1
Q

What is the natural culmination of second-stage labor?

A

“The natural culmination of second-stage labor is a controlled vaginal delivery of a healthy neonate with minimal trauma to the mother.”

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2
Q

Why is vaginal birth preferred for most fetuses?

A

“Vaginal birth is preferred for most fetuses as it poses the lowest risk of most maternal comorbidities.”

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3
Q

What does the end of second-stage labor look like?

A

“The end of second-stage labor is heralded by perineal bulging

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4
Q

How does fetal heart rate monitoring relate to labor?

A

“Fetal heart rate monitoring continues throughout labor

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5
Q

Why is catheterization used during second-stage labor?

A

“Catheterization is used if the bladder is distended

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6
Q

What is the most common pushing position during second-stage labor?

A

“The dorsal lithotomy position is most common and often the most satisfactory for delivery.”

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7
Q

What is the primary goal during delivery to prevent perineal trauma?

A

“The main goal is to prevent obstetric anal sphincter injuries (OASIS)

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8
Q

What is the role of perineal massage before labor?

A

“Perineal massage

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9
Q

What is the Ritgen maneuver?

A

“The Ritgen maneuver involves applying upward pressure to the fetal chin and counter pressure to the occiput to control delivery speed.”

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10
Q

What is the common management for nuchal cord during delivery?

A

“A nuchal cord is often slipped over the head if it is loose

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11
Q

What is the usual rotation of the fetal head after delivery of the head?

A

“After delivery of the head

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12
Q

What should be done if the shoulders are delayed during delivery?

A

“If the shoulders are delayed

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13
Q

What is the risk of using force during shoulder delivery?

A

“Excessive force during shoulder delivery

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14
Q

How is neonatal resuscitation handled with meconium-stained fluid?

A

“For meconium-stained fluid

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15
Q

What are the benefits of delayed umbilical cord clamping?

A

“Delayed umbilical cord clamping for 30-60 seconds can increase neonatal blood volume

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16
Q

What are the risks of delayed cord clamping for the neonate?

A

“Delayed cord clamping may increase the risk of hyperbilirubinemia

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17
Q

What are the potential harms of cord milking?

A

“Cord milking in preterm neonates has been associated with higher rates of severe interventricular hemorrhage in neonates <32 weeks gestation.”

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18
Q

What pelvic shapes predispose to persistent occiput transverse position?

A

“Platypelloid and android pelvis shapes can predispose to persistent occiput transverse positions.”

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19
Q

What is the management for a persistent occiput posterior position?

A

“Manual or forceps rotation can help rotate the occiput to an anterior position

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20
Q

What is the complication of a persistent occiput posterior position?

A

“A persistent occiput posterior position increases the risk of prolonged second-stage labor

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21
Q

How can the diagnosis of occiput posterior position be confirmed?

A

“Transabdominal sonography increases accuracy in identifying occiput posterior position

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22
Q

Why are varying maternal positions not helpful in managing persistent occiput posterior position?

A

“Varying maternal positions does not appear to lower rates of persistent occiput posterior position during labor.”

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23
Q

How can a large bony pelvic outlet affect occiput posterior delivery?

A

“A large bony pelvic outlet may allow rapid spontaneous occiput posterior delivery

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24
Q

How does the fetal head position affect rates of obstetric anal sphincter injuries?

A

“A malpositioned fetal head

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25
Q

What is shoulder dystocia?

A

Shoulder dystocia occurs when the anterior fetal shoulder becomes wedged behind the symphysis pubis after the fetal head emerges, preventing the remainder of the body from following with maternal pushing and gentle traction.

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26
Q

What is the turtle sign?

A

The turtle sign refers to the retraction of the baby’s head against the mother’s perineum, which can indicate shoulder dystocia.

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27
Q

How is shoulder dystocia diagnosed?

A

Shoulder dystocia is diagnosed when maneuvers are required to free the shoulder, with a head-to-body delivery time >60 seconds used by some clinicians to define the condition.

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28
Q

What is the incidence of shoulder dystocia?

A

The incidence of shoulder dystocia is approximately 1% of all deliveries, though it has risen due to increasing fetal birthweight and better recognition/documentation.

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29
Q

What are the main maternal risks of shoulder dystocia?

A

The main maternal risks include serious perineal tears and postpartum hemorrhage, usually due to uterine atony or lacerations.

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30
Q

What are the main neonatal risks of shoulder dystocia?

A

Neonatal risks include brachial plexus injury, clavicular or humeral fractures, acidosis, hypoxic ischemic encephalopathy (HIE), and asphyxia.

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31
Q

What is a common cause of shoulder dystocia?

A

Fetal macrosomia, especially in mothers with obesity, diabetes, or postterm pregnancies, is a common cause of shoulder dystocia.

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32
Q

How can shoulder dystocia be prevented?

A

Although it cannot be accurately predicted or prevented, early labor induction in women with suspected macrosomia has been shown to reduce dystocia rates.

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33
Q

What is the McRoberts maneuver?

A

The McRoberts maneuver involves flexing the mother’s hips sharply onto her abdomen and providing suprapubic pressure to help free the impacted anterior shoulder.

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34
Q

What is the role of episiotomy in shoulder dystocia management?

A

Episiotomy may be needed to provide room for manipulations, but it does not lower the risk of brachial plexus injury.

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35
Q

What is the Gaskin maneuver?

A

The Gaskin maneuver involves the mother moving onto her hands and knees to help free the posterior shoulder, but it may be difficult to perform with regional analgesia.

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36
Q

What is the Rubin maneuver?

A

The Rubin maneuver involves rotating the posterior shoulder toward the anterior surface of the chest to shorten the bisacromial diameter and allow delivery.

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37
Q

What is the Zavanelli maneuver?

A

The Zavanelli maneuver involves replacing the fetal head into the pelvis followed by cesarean delivery, typically in cases of severe shoulder dystocia.

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38
Q

What is the Zavanelli maneuver’s success rate?

A

The Zavanelli maneuver was successful in 91% of cephalic cases and all breech head entrapments in a review of 103 cases.

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39
Q

What is cleidotomy?

A

Cleidotomy involves cutting the clavicle of the fetus, usually in cases of dead fetuses, to aid in delivery.

40
Q

What factors are associated with shoulder dystocia?

A

Fetal macrosomia, maternal obesity, prolonged second-stage labor, operative vaginal delivery, and a prior history of shoulder dystocia are all associated with an increased risk.

41
Q

What is the role of simulations in shoulder dystocia management?

A

Clinical simulations help improve team performance and retention of necessary drill steps, leading to better neonatal outcomes in some studies.

42
Q

What percentage of deliveries in the United States were planned home births in 2017?

A

1.4 percent

43
Q

What are the most common causes of neonatal death in unplanned home births in Norway?

A

Infection, prematurity, and placental abruption.

44
Q

What factors increase the risk of unplanned home births in the United States?

A

Youth, lack of prenatal care, minority race, and lower educational attainment.

45
Q

What are the benefits of planned home birth in a low-risk pregnancy?

A

Fewer medical interventions, including labor augmentation, episiotomy, operative vaginal delivery, and cesarean delivery.

46
Q

What are the risks associated with home birth in the United States?

A

Neonatal mortality risk is 1.3 per 1000 births, higher than hospital births, with common causes including labor and delivery events, congenital anomalies, and infection.

47
Q

What complications are associated with home births for those with preeclampsia, multiple gestation, prior cesarean delivery, or breech presentation?

A

These are absolute contraindications for home birth according to the American College of Obstetricians and Gynecologists.

48
Q

What does water birth aim to do during labor?

A

It aims to relieve pain during both first-stage and second-stage labor.

49
Q

What are the risks associated with water birth?

A

Cord avulsion (3 per 1000 births), fresh-water drowning, and pneumonia with sepsis.

50
Q

What is the current recommendation of the American College of Obstetricians and Gynecologists regarding water birth?

A

They recommend birth occur on land, not in water, due to potential complications.

51
Q

What does female genital mutilation (FGM) refer to?

A

Medically unnecessary vulvar and perineal surgical modifications.

52
Q

What is the federal law regarding female genital mutilation in the United States?

A

It is a federal crime to perform unnecessary genital surgery on a girl younger than 18 years.

53
Q

What types of FGM are classified by the World Health Organization?

A

Type I: Partial or total removal of the clitoris and/or prepuce. Type II: Partial or total removal of the clitoris and the labia minora. Type III: Excision of labia minora and/or majora, followed by fusion, termed infibulation. Type IV: Other harmful practices such as pricking, piercing, or scraping.

54
Q

What are some risks associated with FGM?

A

Urogenital infection, chronic vulvar pain, dyspareunia, and psychiatric consequences.

55
Q

What is the delivery risk for women with type III FGM?

A

Higher delivery risks, and surgical release (defibulation) may be required to allow vaginal birth.

56
Q

What is the purpose of defibulation in women with type III FGM?

A

To release the obstruction for vaginal delivery, which may reduce cesarean delivery and OASIS (obstetric anal sphincter injury) rates.

57
Q

What are the complications of FGM during pregnancy?

A

Higher rates of prolonged labor, perineal lacerations, episiotomy, and postpartum hemorrhage.

58
Q

What is the recommended management for women with type III FGM who are pregnant?

A

Defibulation, either antepartum or intrapartum, is recommended to allow successful vaginal delivery.

59
Q

What are the main concerns with pregnancy following prior pelvic reconstructive surgery?

A

Degradation of repair by pregnancy and vaginal birth.

60
Q

What is the impact of midurethral sling surgery on continence after subsequent pregnancy?

A

Continence is preserved for most women, although multiple pregnancies may raise recurrence risk.

61
Q

What is the recommendation regarding sacral neuromodulation units during pregnancy?

A

These units should be turned off due to the unknown effects of chronic electrical stimulation during pregnancy.

62
Q

What is the typical delivery route for women who have undergone hysteropexy?

A

Most undergo elective cesarean delivery.

63
Q

What complications can arise from anomalous fetuses during delivery?

A

Obstruction due to hydrocephaly, body stalk anomaly, conjoined twins, or massive fetal abdominal enlargement.

64
Q

What is the recommendation for vaginal delivery in fetuses with hydrocephaly if the biparietal diameter is <10 cm or the head circumference is <36 cm?

A

Vaginal delivery may be permitted.

65
Q

What is the technique used to reduce the size of the fetal head or abdomen during delivery of anomalous fetuses?

A

Cephalocentesis or paracentesis with sonographic guidance can be performed intrapartum to reduce fluid and facilitate delivery.

66
Q

What is the third stage of labor?

A

The third stage of labor begins immediately after fetal birth and ends with placental delivery. Goals include delivering an intact placenta and avoiding uterine inversion or postpartum hemorrhage.

67
Q

What are signs of placental separation?

A

Signs of placental separation include a sudden gush of blood, a globular and firmer fundus, outward movement of the umbilical cord, and elevation of the uterus into the abdomen.

68
Q

What is the difference between expectant and active management in third-stage labor?

A

Expectant management involves waiting for placental separation signs, while active management includes earlier cord clamping, controlled cord traction, and immediate administration of a uterotonic agent.

69
Q

What is the goal of active management of third-stage labor?

A

The goal of active management is to limit postpartum hemorrhage by using earlier cord clamping, controlled cord traction, and uterotonic agents.

70
Q

What are common uterotonic agents used in postpartum hemorrhage prevention?

A

Common uterotonic agents include oxytocin (Pitocin), misoprostol (Cytotec), ergonovine (Ergotrate), methylergonovine (Methergine), and carbetocin (Duratocin).

71
Q

What is the recommended uterotonic agent by WHO for postpartum hemorrhage?

A

The WHO recommends oxytocin as the first-line uterotonic agent for postpartum hemorrhage.

72
Q

How should oxytocin be administered?

A

Oxytocin should be administered as a dilute solution either by continuous intravenous infusion or as an intramuscular injection, with the dose adjusted according to the patient’s needs.

73
Q

What is the role of tranexamic acid (TXA) in postpartum hemorrhage?

A

TXA is an anti-fibrinolytic agent that has been evaluated to prevent postpartum hemorrhage, but it is not recommended for prophylactic use.

74
Q

What is manual removal of the placenta and when is it indicated?

A

Manual removal of the placenta is indicated if the placenta cannot be delivered promptly, typically in cases of retained placenta or brisk bleeding.

75
Q

How should episiotomy be performed?

A

Episiotomy can be performed as a midline or mediolateral incision, with the midline episiotomy directed in the perineal body and the mediolateral episiotomy angled 60 degrees from the midline.

76
Q

What are the risks associated with third- and fourth-degree perineal lacerations?

A

Third- and fourth-degree lacerations, which involve the anal sphincter, are associated with increased blood loss, puerperal pain, risk of infection, and long-term anal incontinence.

77
Q

How are lower genital tract lacerations classified?

A

Lower genital tract lacerations are classified by their depth and involved anatomy, including first-degree (perineal skin), second-degree (perineal muscles), third-degree (anal sphincter), and fourth-degree (anal sphincter and rectal mucosa).

78
Q

What is the significance of OASIS (Obstetric Anal Sphincter Injuries)?

A

OASIS is a serious injury involving the anal sphincter, with higher risks of anal incontinence, puerperal pain, and complications in subsequent pregnancies.

79
Q

Do first-degree lacerations always require repair?

A

No, first-degree lacerations do not always require repair. Sutures are placed to control bleeding or restore anatomy. Skin glue is another option if the site is hemostatic.

80
Q

What are common suture materials for second-degree laceration repairs?

A

Common suture materials include chromic catgut or 2–0 Vicryl. Vicryl is associated with less short-term discomfort, though long-term pain rates are comparable.

81
Q

What is the difference between interrupted and continuous suturing for second-degree laceration repairs?

A

A continuous suturing method is faster and results in lower short-term pain scores, but wound complications and long-term pain rates are comparable and low.

82
Q

Which suture material is sometimes used to reduce long-term pain in second-degree laceration repairs?

A

Polyglactin 910 (Vicryl Rapide) is a rapidly absorbed suture that may reduce long-term pain compared to traditional Vicryl.

83
Q

What is the first step in repairing a third-degree laceration with the end-to-end technique?

A

The torn ends of the external anal sphincter (EAS), which often retract, are isolated.

84
Q

What is the role of the connective tissue surrounding the EAS in third-degree laceration repair?

A

The strength of the closure comes from the connective tissue surrounding the EAS, rather than the striated muscle itself.

85
Q

What type of suture is used for repairing the internal anal sphincter (IAS) in third-degree lacerations?

A

A running, nonlocking closure with 3-0 or 4-0 suture is used to repair the IAS if it is torn.

86
Q

What is the technique for repairing type 3c lacerations of the EAS?

A

In the overlapping technique, the ends of the EAS are brought to the midline, lie atop one another, and are sutured with two rows of mattress sutures.

87
Q

What is the primary difference between the end-to-end and overlapping techniques for third-degree lacerations?

A

The end-to-end technique approximates the torn ends of the EAS, while the overlapping technique sutures the overlapping ends of the EAS in type 3c lacerations.

88
Q

What is the first step in repairing a fourth-degree laceration?

A

The torn edges of the rectal mucosa are reapproximated first, starting 1 cm proximal to the wound apex.

89
Q

What is the suture material commonly used for repairing the rectal muscularis in fourth-degree lacerations?

A

4-0 delayed-absorbable suture or chromic gut is commonly used for the running suture line in the rectal muscularis.

90
Q

What should be prescribed postoperatively for patients with OASIS to reduce complications?

A

A single dose of antibiotics, such as a second-generation cephalosporin or clindamycin for penicillin-allergic women, may be given. Stool softeners are also prescribed for a week.

91
Q

What is the initial care for perineal lacerations to reduce swelling?

A

Locally applied ice packs are used to reduce swelling and alleviate discomfort.

92
Q

What type of analgesics are commonly used for perineal lacerations?

A

Analgesics containing codeine provide significant relief. Nonsteroidal anti-inflammatory drugs can be used for lesser discomfort.

93
Q

When should intercourse be avoided for women with second-degree lacerations or OASIS?

A

Intercourse is usually proscribed until after the first puerperal visit.

94
Q

What suture technique is used to close the vaginal epithelium and deeper tissues during midline episiotomy repair?

A

A running, locking closure with 2-0 suture is used to close the vaginal epithelium and deeper tissues.

95
Q

How are the superficial transverse perineal and bulbospongiosus muscles repaired in midline episiotomy repair?

A

A continuous, nonlocking technique with the same suture used for deeper tissues is employed to reapproximate the muscles.

96
Q

What is the role of warm sitz baths in perineal laceration care?

A

Warm sitz baths aid comfort and hygiene in the days following a perineal laceration.

97
Q

What are the risks of severe or persistent pain after perineal lacerations?

A

Severe or persistent pain may indicate complications like a large vulvar, paravaginal, or ischiorectal fossa hematoma or perineal cellulitis.

OBSTETRICS (13 decks)

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