Complications Of Labor And Delivery

Front 1

how is preterm labor different from cervical insuff?

Back 1

PTL = contractions + cervical changes

cervical insuff = painless dilation of cervix

Both result in preterm labor

Front 2

Leading cause of fetal morbidity and mortality in US

Back 2

Preterm delivery

Front 3

4 complications of preterm delivery

Back 3

RDS (hyaline membrane disease)
intraventricular hemorrhage
sepsis
necrotizing enterocolitis

Front 4

Only FDA approved tocolytic

Back 4

ritodrine

Front 5

Main benefit from using tocolytics

Back 5

prolongs gestation for 48 hours to allow betamethosone (glucocorticoid) delivery --> matures fetal lungs to help reduce RDS and other complications

Front 6

3 conditions in which tocolytics should not be used despite premature labor

Back 6

chorioamnionitis, nonreassuring fetal testing, significant placental abruption

Front 7

First line treatment for patients with premature contractions without cervical change

mechanism

Back 7

hydration

ADH differs from oxytocin only by one aa, so it can actually bind oxytocin receptors and cause uterine contractions

Hydration --> less ADH --> less decrease contractions

If this doesn't work --> tocolytics

Front 8

Mechanism by which PGF2a and oxytocin increase uterine contraction

Back 8

Cause Ca to be released from SR

Front 9

Mechanism by which b agonists cause uterine relaxation

Back 9

bind to B2 receptors --> AC --> cAMP --> inhibits myosin LCK and causes Ca to be pumped into SR

Front 10

2 beta mimetics used as tocolytics

a. effect
b. side effects
c. how are they given

Back 10

a. prolong gestation by 24 to 48 hrs (compared to hydration and bedrest)

b. tachycardia, headaches, anxiety, pulmonary edema

c. ritodrine = continuous infusion

Terbutaline = 0.25mg SC Q20 minutes (3 dosages), then Q3-4 hrs

Front 11

a. How does Mg act as a tocolytic

b. Effect

c. Symtpoms of overdose

d. How should it be given

Back 11

a. Ca antagonist, membrane stabilizer

b. stop contractions, does not increase GA

c. flushing, headache, fatigue, diploplia, loss of DTR; if >10mg/dL, respiratory distress, cardiac arrest, hyoxia

d. 6g bolus over 15-30 min, then maintenance 2-3g/hr constant infusion; use slower regimen if kidney failure

Front 12

Nifedipine

a. how does it act as a tocolytic

b. side effects

c. how should it be gien

Back 12

a. Block Ca channels --> inhibit myometrial contraction

b. headache, flushing, dizziness

c. 10mg dose Q15min for the first hour, followed by maintenance of 10-30mg Q4-6 hr (depending on patient's BP)

Front 13

What is the effect of PGs on the uterus

What drug is used to stop prostaglandins' effects on the uterus

Back 13

PGs increase Ca release from SR; also increase gap junction formation --> increased uterine contraction (used in the case of uterine atony)

Indomethicin = tocolytic

Front 14

Fetal complications of using indomethicin as a tocolytic

Back 14

-Premature closure of ductus arteriosus
-pulmonary HTN
-oligohydramnios secondary to renal failure
-increased risk of necrotizing enterocolitis and intraventricular hemorrhage

Front 15

3 conditions associated with prolonged PPROM

Back 15

chorioamnionitis, abruption, cord prolapse

Front 16

How does management of PPROM vary with GA

What are 2 interventions that are done at any GA

Back 16

Before 32-36weeks, risk of prematurity drives treatment
After, risk of infection drives treatment --> induce labor

Ampicillin +/- erythromycin can prolong latency

cortiocosteroids +/- tocolytics to promote fetal lung development (despite immunosuppression)

Front 17

Biggest risk associated with ROM

What is an intervention for prolonged ROM (>18hrs)

Back 17

chorioamnionitis

antiobiotics during the remainder of labor

Front 18

4 types of maternal pelvises

Back 18

Gynecoid, Android, Anthropoid, Platypelloid

Front 19

Gynecoid pelvis
a. transverse inlet
b. anteriorposterior inlet
c. sidewalls
d. forepelvis
e. sacrosciatic notch
f. inclination of sacrum
g. ischial sine
h. suprapubic arch
i. transverse outlet
j. bone structure

Back 19

a. 12cm
b. 11cm
c. straight
d. wide
e. med
f. med
g. not prominent
h. wide
i. 10cm
j. med

Front 20

Android pelvis
a. transverse inlet
b. anteriorposterior inlet
c. sidewalls
d. forepelvis
e. sacrosciatic notch
f. inclination of sacrum
g. ischial sine
h. suprapubic arch
i. transverse outlet
j. bone structure

Back 20

a. 12cm
b. 11cm
c. convergent
d. narrow
e. narrow
f. forward (lower 1/3)
g. not prominent
h. narrow
i. <10cm
j. heavy

Front 21

Anthropod
a. transverse inlet
b. anteriorposterior inlet
c. sidewalls
d. forepelvis
e. sacrosciatic notch
f. inclination of sacrum
g. ischial sine
h. suprapubic arch
i. transverse outlet
j. bone structure

Back 21

a. <12cm
b. >12cm
c. narrow
d. divergent
e. backward
f. wide
g. not prominent
h. med
i. 10cm
j. med

Front 22

Platypelloid
a. transverse inlet
b. anteriorposterior inlet
c. sidewalls
d. forepelvis
e. sacrosciatic notch
f. inclination of sacrum
g. ischial sine
h. suprapubic arch
i. transverse outlet
j. bone structure

Back 22

a. 12cm
b. 10cm
c. wide
d. straight
e. forward
f. narrow
g. not prominent
h. wide
i. 10cm
j. med

Front 23

What is the obstetric conjugate

Back 23

distance between the sacral promentory and the midpt of symphisis pubis (shortest anteroposterior diameter of inlet)

Front 24

Anteropost. measurement of outlet

a. landmarks
b. measurement

Back 24

Tip of sacrum to inferior margin of pubic symphisis

9.5-11.5 cm

Front 25

What is the protocol when celphalopelvic disproportion presents?

Back 25

Attempt a trial of labor, then do c/s if necessary

Front 26

2 complications of vaginal breech delivery

Back 26

prolapsed cord, entrapment of head

Front 27

3 types of breech

Back 27

complete, footling (one or both hips not flexed, so foot/knee lies below breech), frank (feet near fetal head)

Front 28

How is breech diagnosed

treatments

Back 28

Leopold maneuvers determine where felal head is, vaginal exam to feel breech, ultrasound

external cephalic version of breech (before 36 weeks), trial of labor (higher rate of morbidity/mortality), or elective c/s

Front 29

3 complications of a breech delivery

Back 29

cord prolapse, entrapment of fetal head, fetal neurological injury

Front 30

Common criteria for trial og labor in a breech

Back 30

favorablepelvis, flexed head, estimated fetal weight 2k-3800 lbs

Front 31

Contraindications to breech birth

Back 31

nulliparity, incomplete breech presentation, estimated fetal wt >3800g

Front 32

4 types of presentations seen in malpresentation of the vertex

Back 32

face, brow, shoulder, compound

Front 33

Fetus presents with face malpresentation

a. what is the course if it is mentum first
b. what is the course if mentum posterior or transverse

Back 33

a. anterior - vaginal

b. fetus must rotate to mentum anterior

Front 34

What must happen to deliver a baby w/brow presentation

Back 34

brow presentation must convert to vertex or face

Front 35

3 risks of shoulder presentation

how are these babies delivered

Back 35

cord prolapse, uterine rupture, difficulty in vaginal delivery

c/s

Front 36

Common complication of compound presentation of fetus

treatment

Back 36

cord prolapse

if foot presents = footling breech --> c/s

if upper extremity, part may be gently reduced

Front 37

Baby presents at persistent OT position

a. associated commonly with which type of pelvis
b. what should you do

Back 37

a. platellypoid

b. cervix not fully dilated - attempt to manually rotate to OA

if fully dilated, attempt to rotate manually or w/forceps; try vaccuum delivery

Front 38

Definition of FHR
a. prolonged deceleration
b. bradycardia

Back 38

FHR <100-110 for
a. >2mins
b. > 10mins

Front 39

3 etiologies of prolonged FHR decelerations

Back 39

1. preuterine - maternal HTN or hypoxia (seizure, amniotic fluid embolus, PE, MI, resp. failure, epidural/spinal anesthesia)

2. Uteroplacental = abruption, infarction, hemorrhaging previa, uterine hyperstimulation

3. Post placental = Cord prolapse, cord compression, rupture of fetal vessel

Front 40

FHR shows bradycardia
What should you do (algorithm)?

Back 40

1. Look at mom for signs of respiratory compromise/change in mental status (seizures, PE, AFE)

2. asses mom HR and BP (maternal hypotension, commonly seen after epidural)

3. Check vaginal blood (abruption, uterine rupture, rupture of fetal vessels)

4. One hand on abdomen and one hand on vagina --> measure station, cervical dilation, prolapsed umbilical

if fetal station is too low --> bradycardia due to rapid descent, vagal

if station too high --> uterine rupture

if cervix is fully dilated and fetus in pelvis --> operative vaginal delivery

Front 41

Prolonged FHR deceleration

what is the initial standardized management procedure

Back 41

1. place mom in R or L lateral decubitus to reduce compression of IVC or of a compressed umbilical cord

2. Oxygen face mask

3. determine etiology and proceed

Front 42

Prolonged FHR deceleration treatment

maternal hypotension

Back 42

aggressive IV hydration, ephedrine

Front 43

Prolonged FHR deceleration treatment

tetanic uterine contraction

Back 43

nitroglycerin (sublingual spray) or b2 agonist (terbutaline)

Front 44

Prolonged FHR deceleration treatment

umbilical cord prolapse

Back 44

emergent c/s

lift fetal head do avoid compression of prolapsed cord

Front 45

Prolonged FHR deceleration treatment


previa

Back 45

c/s fast

Front 46

Prolonged FHR deceleration treatment

abruption

Back 46

c/s fast

Front 47

What is shoulder distocia

fetal complications

Back 47

fetal shoulder gets stuck behind pubic symphisis

fractured humerus/clavicle, erb palsy, phrenic nerve palsy, hypoxic brain injury, death

Front 48

What is the turtle sign and what does it indicate

Back 48

incomplete delivery of the head or chin tucking up against maternal perineum --> shoulder distocia

Front 49

5 maneuvers to try in the case of a shoulder distocia

Back 49

1. McRoberts = flexion of maternal hips to open outlet
2. suprapubic pressure at an oblique angle
3. rubin's - pushing free shoulder toward anterior chest wall to decrease shoulder-shoulder diameter
4. Wood's corkscrew - pressure behind posterior shoulder to rotate infant and dislodge anterior shoulder
5. deliver posterior arm/shoulder, then rotate to decrease shoulder-shoulder distance

Front 50

What is the zavanelli maneuver and when is it used

Back 50

last resort in shoulder distocia

push head back into pelvis and perform c/s

Front 51

What are factors that make you believe a uterine rupture has taken place

Back 51

-FHR decels
-prior scars on uterus
-patient feels 'popping' or severe abd pain
-fetus palpable in extrauterine space
-vaginal bleeding
-fetal presenting part is higher than previously

Front 52

What is the mark of unusually low BP in a pregnant woman

Treatment?

What if it is close to a medication administration?

Back 52

80/40

IV hydration, adrenergic meds to constrict peripheral vessels and increase preload/afterload

Benadryl or ephedrine (for possible anaphylaxis)

Front 53

Definitive diagnosis for Amniotic fluid embolism

Back 53

fetal cells in pulmonary vasculature at autopsy

Front 54

Managment of a patient w/seizures or in status epilepticus

Back 54

1. Assess and establish airway, vitals, FHR (if non-reassuring, emergent delivery)

2. Bolus Mg sulfate, lorazepam, phenytoin
-If not successful, phenobarbitol

3. Labs - electrolytes AED, glucose, tox