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62 Cards in this Set
- Front
- Back
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What is the definition of labor?
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regular contractions causing cervical dilation (4cm) and effacement
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DDX of labor.
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- Braxton-Hicks contractions: contraction without dilation
- normal dilation - cervical incompetency: dilation without contraction |
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What is this called?
- patient reports change in abd shape(lower portion more prominent), sensation of baby gotten less heavy/dropping, frequent urination |
lightening
- normal event of late pregnancy |
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What are some indications for pregnancy women to come to the hospital?
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- contraction every 5min for at least 1 hr
- sudden gush of fluid ot constant vaginal leakage of fluid - vaginal bleeding - significant decrease in fetal movement |
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Components of a limited general physical exam of a pregnant women.
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- vital signs
- abdominal (Leopold maneuvers), pelvic exam - auscultation of fetal heart tones - transabdominal u/s |
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What can be determined by doing a leopold maneuver?
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- lie: relation of long axis of the fetus with the maternal long axis (longitudinal, transverse, oblique)
- presentation: breech, cephalic - position: relation of the fetal presenting part to the left or right side of the maternal pelvis. LOA is the most common. |
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Components of the leopold maneuvers.
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1. determinw what occupies the fundus
2. determine location of small parts 3. identify descent of the presenting part 4. identify the cephalic prominence |
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Sequence of a vaginal exam.
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- speculum exam always precedes digital exam
- delay digital exam if membrane is ruptured |
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What are the 5 parts of the cervical exam?
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1. dilation
2. effacement: 4cm is uneffaced 3. station: -5 to +5, or -3 to +3. relative level of the foremost part of fetal presenting part to the level of the ischial spines 4. consistency: softness 5. position |
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What is the station is the fetus is said to be engaged?
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0 station
- greatest transverse diameter of the fetal skull is negotiated the pelvic inlet |
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Stages of labor.
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Stage I: onset of labor to full cervical dilation
- latent phase: cervical effacement and dilation - active phase: more rapid cervical dilation beginning at 4cm Stage II: complete dilation to delivery Stage III: delivery of infant to delivery of placenta Stage IV: 2 hrs postpartum after delivery of placenta |
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What are the cardinal movements of labor?
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- engagement: days-wks before labor for primigravidas, onset of labor for multigravidas
- flexion - descent: greatest descent during the latter portion of 1st stage and 2nd stage - internal rotation - extension - external rotation |
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What are the 3 Ps of labor mechanics?
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- passage: adequacy of pelvis
- passenger - power: force of contraction (montevideo), avg 180-250 MVU |
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How fast shoud the cervix chage during the 1st stage of labor?
- nullioparas - multiparas |
- nullioparas: 1.2cm/hr
- multiparas: 1.5cm/hr |
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How long is too long for stage II labor?
- nullioparas - multiparas |
- nullioparas: 2 hrs
- multiparas: 1 hr |
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What can you do to ripen the cervix?
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- foley bulb
- oxytocin IV - cytotec - cervidil - laminaria - membrane stripping (digital) - amniotomy |
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What is the most common cause of perinatal morbidity and mortality?
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preterm birth
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Complications of preterm birth.
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- perinatal death
- respiratory distress - intraventricular hemorrhage - necrotizing enterocolitis - sepsis - neurologic impairment - seizures |
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What are some long term morbidity associated with preterm deliveries?
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- bronchopulmonary dysplasia
- developmental abnormalities: cerebral palsy |
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What is the definition of preterm labor?
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- regular uterine contractions q10min or less between 20-36 wks of gestation with each contraction lasting at least 30s
- accompanied cervical effacement, cervical dilation, and/or descent of the fetus into the pelvis |
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What are some factors associated with preterm labor?
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- african american race
- prior hx of preterm birth - preterm uterine contraction - incomoetent cervix - infections - multiple gestations - placental abnormalities: abruption, previa - excessive uterine enlargement - uterine distortion |
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What are some preventative measure for preterm labor?
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1. transport to tertiary center if no NICU at site
2. corticosteroid for fetal lung maturity 3. stop pitocin to prolong pregnancy 4. GBS prophylaxis |
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What are some signs and symptoms of preterm labor?
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- menstrual like cramps
- low, dull backache - abdominal and pelvic pressure - increase/change in vaginal discharge - uterine contractions - |
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What does this indicate?
- absence of fetal fibronectin in maternal vaginal secretions |
patient likely to deliver in 7 days after sample is taken
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Is home uterineactivity monior recommended for preterm labor management?
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Not anymore.
It is effective in the recognition fo PTL but no difference in outcome. |
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Should you treat pregnant women with bacterial vaginosis who is asymptomatic?
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NO. treatment is not beneficial in decreasing the occurrence of PTL.
Treat if patient is symptomatic. |
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How to diagnose bacterial vaginosis? (hint, criterias)
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3 or 4 of the following
- homogenous vaginal discharge - clue cells on saline microscopy - fishy odor with KOH to vaginal secretions - vaginal pH > 4.5 |
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What is a reliable method to assess cervical length?
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transvaginal u/s
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Would cervical cerclage helpful in this case?
- decreased cervical length < 2.5cm |
not helpful to as a prophylactic treatment for preterm labor
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What has been shown to be beneficial in decreasing cases of PTL?
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weekly IM injections of progesterone, 17-a-hydroxyprogesterone caproate.
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What to do next for this patient?
- 30 wk gestation - menstrual like cramps - low, dull backache - painless uterine contractions |
You should suspect preterm labor
Next - external fetal monitor - status of cervix by speculum exam - UA and urine culture to r/o infection (GC and chlamydia) because infection could be the cause of preterm labor - empirical treatment for GBS till culture result is back - u/s to assess gestational age, amniotic fluid volume - amniocentesis: infection if white cells present |
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What should you do next?
- amniocentesis confirmed intrauterine infection |
delivery regarless of gestational age
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Management for preterm labor.
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- IV hydration
- tocolysis: MgSO4 (6g in 100-150cc D5W loading dose and then 2g/hr infusion), or terbutaline/ritodrine, or indomethacin, or nifedipine (30g loading dose, 20mg q6-8hrs) - steriods to enhance pulmonary maturity |
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T/F: One might be more willing to accept potential adverse effects for patients in PTL at 26 wks than 33 wks.
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True
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T/F: It is customary not to initiate or stop therapy for preterm labor after 35-36 wks.
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True
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What are some contraindications to tocolysis?
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- advanced labor
- mature fetus - severely anomalous fetus - intrauterine infections - significant vaginal bleeding |
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Mechanism and side effects of magnesium sulfate.
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Mechanism: competes with Ca for entry into cells
Side effects: - flushing, headaches - respiratory/cardiac depression at high doses |
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Mechanism and side effects of terbutaline.
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Mechanism:
- beta adrenergic: increases cAMP in cell which decreases free Ca Side effects - hypotension, tachycardia - ECG changes - anxiety - increased pulmonary edema |
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Mechanism and side effects of indomethecin.
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Mechanism
- decrease prostaglandin production by blocking conversion of arachidonic acid to PG Side effects: - premature constriction of ductus arteriosus - reversible impaired fetal renal function and oligohydramnios with prolonged exposure |
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Mechanism and side effects of nifedipine (ca channel blocker).
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Mechanism
- prevent Ca entry intto muscle cells Side effects - decrease in uteroplacental blood flow - fetal hypoxia - hypercarbia |
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Definition of abortion.
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loss (termination or end) of a pregnancy before viability (20wks from LMP or a fetus weighing < 500g.
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What is the incidence of spontaneous abortion?
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50% of all pregnancy (many are clinicallty unrecognized)
- 15-25% sited - 80% losses occur during first 12wks. |
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Approximately 50% of early spontaneous abortions are attributed to chromosomal abnormalities. What is the most common chromosomal defect?
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- trisomies (40-50%): 21, 13, 18
- monosomy X (15-25%) - triploidy (15%) - tetraploidy (5%) |
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Risk factors associated with spontaneous abortion?
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- increasing parity
- increasing maternal age - increasing paternal age - conception within 3 months of a live birth |
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What is the clinical significance of separating first trimester miscarriages and second trimester miscarriages?
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Conidtions associated with later miscarriages can often be treated: maternal systemic diseases, abnormal placentation or anatomic abnormalities.
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What are some maternal factors that are associated with spontaneous abortions?
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1. infections
- listeria monocytogenes - mycoplasma hominis - ureaplasma urealyticum - toxoplasmosis - viral: rubella, CMV 2. systemic diseases - luteal phase inadequacy: insufficient secretion of progesterone by corpus luteum or the placenta - hypothyroidism - SLE - DM 3. environmental factors - smoking, heavy caffeine intake, alcohol 4. uterine factors - submucous leiomyomata uteri: need myometry - unicornuate or septate uterus - exposure to DES - intrauterine synechiae (Asherman syndrome): inadequate endometrium to support implanation |
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What is the treatment for luteal phase inadequacy?
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- clomiphene: stimulate FSH and hCG
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How is luteal phase defect diagnosed?
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appropriately timed endometrial biopsy
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What are some paternal factors associated with spontaneous abortion?
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chromosomal abnormailties
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What are some fetal factors associated with spontaneous abortion?
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- genetic abnormalities
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T/F: any vaginal bleeding in the first half of an intrauterine pregnancy is presumptively called a threatened abortion.
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True
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What is threatened abortion?
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bleeding in the first trimester without losses of fluid or tissue
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Complications of threatened abortion which is viable.
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- pretern delivery
- low birth weight - perinatal mortality *no risk of malformations |
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What type of abortion is this?
- cervix closed - vaginal bleeding |
threatened abortion
- no intervention necessary - measures to controll bleeding if bleeding persists |
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How to identify viable pregnancies at various stages of pregnancy?
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ultrasound + quantitative hCG
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What type of abortion is this?
- ROM and/or cervical dilation during first half of pregnancy - pregnancy loss is unavoidable |
inevitable abortion
- typically followed by uterine contraction and expulsion of products of conception |
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What type of abortion is this?
- spontaneopus passage of all of the products of conception |
complete abortion
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What type of abortion is this?
- partial expulsion of pregnancy tissue - bleeding and pain |
incomplete abortion
- need suction curettage or prostaglandins to remove remaining tissue and prevent further bleeding and infection - postevacuation treatment with ergot derivative (methergine) and abx (doxycycline) |
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What type of abortion is this?
- retention of failed intrauterine pregnancy for more than 2 menstrual cycles |
missed abortion
- absence of uterine growth - loss of early symptoms of pregnancy |
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Management for missed abortion.
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evacuation of the uterus
- suction curettage for pregnancy in the first trimester - D&C or prostaglandins for pregnancies that have advanced to second trimester |
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What are some maternal causes of recurrent late abortions?
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- incompetent cervix
- uterine abnormalities: septate uterus - intrauterine synechiae (Asherman syndrome): treated with lysis of synechiae and postop estrogen to reestablisn endometrial layer |
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What is the diagnosis?
- cramping pain and bleeding - open cervix - large "softer than expected" uterus |
Postabortal syndrome
- presentation indistinguishable from incomplete abortion - path report of curettage tissue - treated with oxytotic and abx (same as in incomplete abortion) |
