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68 Cards in this Set
- Front
- Back
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Special parts to the obstetric exam
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maternal abdominal exam for contractions and the fetus (leopold maneuvers), cervical exam, fetal heart tones, speculum exam (rupture of membranes)
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What is the difference between fetal lie and fetal presentation?
How do you determine each |
Fetal lie - longitudinal or transverse position in uterus - use leopold maneuvers (palpate fundus, then either side of the uterus, then just above symphysis)
Fetal presentation - breech or vertex (cephalic) - may need US |
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Difference between Premature Rupture of Membranes, prolonged PROM, and Preterm PROM
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PROM = rupture of membranes around fetus at least 1hr prior to labor onset
Prolonged PROM = occurs more than 18 hours before labor (increased risk of infection) Preterm = before 37 weeks GA |
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How to diagnose Rupture of Membranes?
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History: gush or leakage of fluid from vagina
confirm: Pool, nitrazine, fern test -use speculum to determine if there is a fluid collection in the vagina; fluid is alkaline, turns blue on nitralazine (normal vaginal secretions are acidic) Estrogens in amniotic fluid --> crystalization of salts in fluid --> resembles blades of a fern when it dries (be careful, cervical mucous does this too!) |
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If fluid around infant was normal and you have no reason to suspect low fluid, oligohydramnios found on ultrasound is indicative of what condition
How do you most accurately diagnose |
Rupture of membranes
Anmiocentesis to dilulte indgo carmine dye into amniotic sac, look for leakage from cervix onto a tampon OR alpha-microglobulin-1 immunoassay |
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5 phases of labor
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dilation, effacement, station, cervical position, consistency of cervix
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Bishop score necessary for sontaneous or induced labor
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8
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DIlation
a. how to assess b. what should it be to accomodate fetal biparietal diameter Bishops correlations 0 = 1 = 2 = 3 = |
a. use one or two fingers to determine how open the cervix is at the level of the internal os
b. 10cm 0 = closed 1 = 1-2cm 2 = 3-4 cm 3 = <5cm |
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What is effacement?
Bishops correlation 0 = 1 = 2 = 3 = |
Length of cervix (how much it is thinned out)
0 = 0-30% effacement 1 = 40-50% (cervix is 2cm internal to external os) 2 = 60-70% 3= <80% |
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Cervical station - Bishops
0= 1= 2= 3= |
0=-3
1=-2 2=-1,0 3=<1 |
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Cervical position = Bishops
0= 1= 2= |
0=posterior (high in pelvis, behind fetal head)
1=mid 2=anterior (lower in vagina, easier to examine) |
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What is a compound presentation
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fetal vertex presented along with a fetal extremity (ex arm)
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what is the anterior fontanelle
Posterior fontanelle |
anterior = junction between 2 frontal bones and 2 parietal bones (diamond shaped)
posterior = junction between two parietal bones and the occipital bone (smaller, triangular) |
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What is the objective definition of labor
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contractions that cause cervical change in either effacement or dilation
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Difference between induction of labor and augmentation of labor
Agents used to induce labor (4) |
induction - begin labor in a non-laboring patient
Augmentation - trying to increase contractions Prostaglandins, oxytocic agents, mechanical dilation of cervix, artificial rupture of membranes |
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How do you ripen the cervix in someone with a Bishop of <5
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PGE2 gel or pessary or PGE1M (misoprostol)
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Risk of using PGE2 gel to ripen cervix instead of oxytocin
what should you use instead |
cannot be turned off like oxytocin --> risk of uterine hyperstimulation, tetanic contractions
foley catheter bulb placed inside cervix to dilate (dilates 2-3cm in 4-6 hrs) |
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2 methods of labor induction
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oxytocin(pitocin) or amniotomy (amnio hook used to puncture the amniotic sac around fetus and release some fluid - watch out for prolapse of the umbilical cord!))
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Normal fetal HR
a. concern if baseline is above 160 b. bradycardic threshold for concern |
110-160bpm
a. infection, hypoxia, anemia b. if <90bpm for reater than 2 minutes - immediate action! |
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Conditions necessary for a formally reactive fetal heart tracing
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2 accelerations of at least 15bpm over the baseline for at least 15 seconds within 20 minutes
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What is the difference between early, variable, and late decelerations in the fetal heart monitor
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early = begin and end w/contractions - due to vagal tone when head compressed in contraction
variable = any time, umbilical cord compression late = begin at peak of contraction, return to baseline after contraction finishes - ureteroplacental insufficiency, may degrade into bradycardia as labor progresses |
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3 contraindications for using a fetal scalp electrode to monitor FHR and uterine contractions
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history of maternal hepatitis, HIV, or fetal thrombocytopenia
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Baseline intrauterine pressure
How do you measure How much should pressure increase during a. contractions in early labor b. contractions in late labor |
10-15mmHg
Intrauterine pressure catheter a. 20-30 b. 40-60 |
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What is the common measurement of uterine contractions
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Montevideo unit = avg. variation of the intrauterine pressure from the baseline x number of contractions in 10 minutes
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One method for assessing fetal hypoxia and acidemia if FHR is nonreassuring
What must you be careful for when measuring in this way |
fetal scalp pH - make a small nick and get small amount of fetal blood
>7.25 reassuring; <7.20 non reassuring Be careful not to contaminate with amniotic fluid, which is basic |
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Fetal pulse ox is used to measure fetal status; what is a normal reading
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above 30% fetal oxygen saturation
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3 stages of labor and
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1 - onset of labor --> dilation and effacement of cervix complete
2 - full dilation until delivery 3 - after delivery until placental delivery |
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3 phases of stage 1 delivery
Normal time frame |
Normal time: 6-20 hrs (nuliiparous) or 2-12 (multiparous)
latent - onset --> 3-4cm, slow cervical change - active - latent --> greater than 9cm (faster) - 1cm/hr nulliparous or 1.2cm/hr multiparous, usually higher |
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3 ps that affect the transit time during active phase of labor
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Power - contractions (measure with IUPD, adequate = >200MVU)
passenger - infant position (if passenger too large --> cephalopelvic disporoportion - development of fetal caput, molding of fetal skull with overlapping sutures) pelvis - size and shape of pelvis |
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Common indications for induction of labor
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postterm pregnancy, preeclampsia, premature ROM, nonreassuring fetal testing, IUGR
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Maternal contraindications for use of prostaglandins to induce labor?
Obstetric contraindications |
Glaucoma, asthma
Prior C-section, nonreassuring fetal testing |
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Thresholds for fetal heart rate variability
a. absent b. minimal c. modeate d. marked |
a. <3bpm
b. 3-5bpm c. 5-25 bpm d. >25 beats per minute of variation |
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Stage 2 delivery - when is it considered prolonged
a. nulliparous w/o epidural b. nulliparous w/epidural c. multiparous w/o epidural d. multiparous w/epidural |
a. 2hrs
b. 3hrs c. 1hr d. 2hr |
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A multiparous women undergoes prolonged stage 2 labor
what are 4 possible reasons? |
Fetal macrosomia
Persistent OP or OT position Compound position asynclitism |
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Patient experiences repetitive late decels, bradycardias, or loss of variablility during second stage of labor. What should be done
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-Place face mask w/O2
-Turn on left to decrease pressure on IVC, increase uterine perfusion -discontinue pitocin |
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What is hypertonus? tachysystole? what can these lead to? What intervention is indicated?
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hypertonus = prolonged contraction >2minutes
tachysystole = >5 contractions/10minutes can lead to bradycardia in fetus -terbutaline to relax uterus -If this doesn't work and station>0 --> C-section |
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What is the Ritgen maneuver during delivery
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First hand - heel of hand exerts pressure on mothers perineum, fingers extending babies' head from below
Second hand - above, fingers used to prevent overextension of head during delivery |
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Indications for an episiotomy
2 types |
need to hasten delivery, shoulder distocia
midline and mediolateral |
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Mediolateral episiotomy vs. midline
negatives to using mediolateral? Positives? |
negatives - more infections, pain
positives - less third and fourth degree tears |
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Necessary conditions for safe use of foreceps
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full dilation, ROM, station at least 2, knowledge of fetal position, no cephalopelivc disproportion, adequate anesthesia, empty bladder, experienced operator
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Type of forecep procedure used
scalp is visible at entroitus w/o separating labia |
Outlet
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Type of forecep procedure used
fetal skull has reached pelvic floor |
Outlet
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Type of forecep procedure used
Saggital suture is anteroposterior, OA or OP |
Outlet
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Type of forecep procedure used
Fetal head is at or on perineum |
Outlet
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Type of forecep procedure used
Rotation < 45 degrees |
Outlet
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Type of forecep procedure used
Leading point of fetal skull is at station 2 or greater but not on pelvic floor OR Rotation > 45 degrees |
Low
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Type of forecep procedure used
Station above 2cm but head engaged |
mid
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Risks of foreceps delivery
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bruising, lacerations (head, cervix, vagina, perineum), facial nerve palsy, skull fracture, intracranial hemorhage
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3 complications of vaccuum extraction delivery
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scalp laceration, cephalohematoma, subgaleal hemorrhage (btwn aponeurosis and periosteum)
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Risks of foreceps vs. vacuum
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foreceps = facial palsy, vaginal laceration
vaccuum = cephalohematoma, shoulder distocia |
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What can you use if stage 2 is confirmed to be completed but stage 3 is being prolonged
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can use oxytocin to strengthen uterine contractions, help delivery of the placenta
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3 signs of placental separation
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fetal cord lengthening, gush of blood, fundus rebound (don't pull too hard on the cord or you may invert the uterus)
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How is the diagnosis of retained placenta made?
How should you proceed? |
30minutes w/o placental delivery
use fingers to shear placenta from surface of uterus, or curettage |
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Perineal tears
1st degree 2nd 3rd 4th Buttonhole |
1st = superficial
2nd = body of perineum 3rd = into external anal sphincter 4th = into rectum Buttonhole = rectal mucosa and vagina are lacerated, but sphincter still intact |
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3 steps to repairing a secondary laceration
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1 vaginal mucosa repaired down to hymenal ring
2 perineum is repaired below hymenal ring 3 subcuticular reapproximation of skin of perineum |
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What is the most common indication for c-section
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previous c section
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Vaginal birth after casarean
What are the necessary conditions |
prior hysterotomy needs to be either a kerr (low transverse) or a Kronig (low vertical) w/o extensions into cervix or upper uterus
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What is the major risk of attempting vaginal delivery after cesaerian
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uterine rupture
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5 conditions that increase the risk for uterine rupture in the situation of TOLAC
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>1 prior c-section, prior classical c-section, induction of labor (PGs or oxytocin), time from last c-section <18mo, uterine infection at time of last c-section
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5 factors that increase the success rate of TOLAC
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prior vaginal birth, prior VBAC, nonrecurring indication for prior C-section, presentation at labor (>3cm, >75%)
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2 factors that decrease success of TOLAC
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Prior C-section for cephalopelvic disorportion, induction of labor
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Common signs of uterine rupture
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abdominal pain, fetal decels/bradycardia, loss of pressure on IUPC, feeling of a 'pop'
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Commonly used narcotics to relieve birthing pain
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fentanyl, bubain, stadol
IM morphine sulfate early in labor (do not use close to time of expected delivery b/c they cross the placenta, can depress baby) |
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Where is a pudendal block given
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pudendal nerve posterior to ischial spine/sacrospinous ligament connection
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When is local anesthesia indicated
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episiotomy, repair of lacerations
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How is an epidural administered
How is spinal anesthesia different |
constant infusion at L3/L4 level during active phase
One time dose given directly into spinal canal, more rapid, often used in c-section |
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Complications from epidural/spinal anesthesia (3)
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1. Decreased SVR --> maternal hypotension --> decreased placental perfusion --> bradycardia
2. maternal respiratory depression (if it reaches the level of the diaphragm) 3. spinal headache due to loss of CSF |
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When is spinal anesthesia indicated? 2 principal concerns
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Emergent c-section (abruption, fetal bradycardia, umbilical cord prolapse, uterine rupture, hemorrhage from placenta previa)
maternal aspiration, mother/fetus hypoxia |
