Obgyn 11

Front 1

Placenta previa + previous C/S → incr risk of what?

Back 1

Accreta

Front 2

*The most common causes for C-section are:

Back 2

**1. Having had a previous C-section
2. Failure to progress during labor

Front 3

*Indications for C-section:

Back 3

Cephalopelvic disproportion, macrosomia
Malformation
Malpresentation
Abnormal placenta or umbilicus
Disease of fetus or mother
PMHx: Vag Sx, Prolapse, hemorrhage, complicated birth, uterine mass/fibroids
Previous C/S vertical
Failed induction, labor, forceps, vacuum; arrest of labor
Cord prolapse
Fetal distress

Front 4

Patient Prep for C/S

Back 4

Hydrate well.
Hct >30%
Type and hold blood
+/- prophylactic antibiotics
Antacids to reduce acidity

Front 5

Pfannenstiel

Back 5

Pfannenstiel incision provides the most desired cosmetic effect but takes more time to perform. –“bikini cut”, done in layers

Front 6

Infraumbilical

Back 6

vertical midline incision less time-consuming and less bloody.

Front 7

Surgical Techniques:
Uterus often lifted out of abdominal cavity
Incision closure

Back 7

To massage fundus, inspect adnexa and facilitate visualization of wound repair.

Incision is closed in two layers-for coaptation and hemostasis.
Important in insuring future integrity of uterine scar.

Front 8

Avg blood loss in C/S

Back 8

Average blood loss is 1000 ml.

Front 9

Most common complication of C-section

Back 9

Infection

Front 10

*Complications of C-Section

Back 10

**Infection
Uterine Rupture
Hysterectomy
Hemorrhage
*Injury to organs (GU tract)
Atelectasis/pneumonia/Aspiration
Ileus
DVT/pulmonary embolism
Anesthetic complications
Newborn --> incr incidence of transient tachypnea of the newborn.

Front 11

Antibiotic prophylaxis for C/S

Back 11

Not necessary in all cases
Use if ROM
Penicillins and cephalosporins are most common
• *Endometritis
• *Wound infection
• Salpingitis

Front 12

Indications for C-section hysterectomy

Back 12

include malignancy,
placenta accrete, increta, percreta,
uncontrolled bleeding,
uterine rupture when repair is impossible

Front 13

*Vaginal birth after C-section (VBAC):

Back 13

For women with a prior uterine incision in the lower uterine segment without other contraindications to vaginal delivery.

Front 14

Contraindications to VBAC

Back 14

diabetes, hypertension, HSV infection, prior classical or T-shaped incision; inability to perform emergency C-section

Front 15

Support for episiotomy?

Back 15

*Common usage of episiotomy supported historically by alleged prevention of perineal trauma, pelvic relaxation and newborn injury.
Modern studies challenging these assumptions.

Front 16

Median Episiotomy: Pro/Con

Back 16

Less blood loss, easier to repair, more comfortable healing. May cut anal sphincter and rectum. Most common in US

Front 17

Mediolateral Episiotomy: Pro/Con

Back 17

Gives more room. More difficult to repair, more blood loss and more difficult to heal.

Front 18

Perineal Massage:

Back 18

Incr Pelvic floor muscle relaxation, elasticity, recognition during labor
Increased blood and lymphatic flow to the area to optimize the tissue integrity.

Front 19

Perineal Massage Procedure:

Back 19

daily for at least 5-10 minutes
starting six weeks prior to birthing
slow rhythmical manner.
Use an oil rich in Vitamin E

Front 20

Contraindications to Perineal Massage:

Back 20

1. Pelvic varicose veins
2. Active herpes lesions

Front 21

Forceps
Indications and positions amenable

Back 21

Not used often d/t potential for complications
Used when there is fetal distress or maternal compromise and the inability to do a C-section quickly.

occiput anterior, transverse, face (chin anterior), occiput posterior.

Front 22

Prerequisites for Forceps Delivery:

Back 22

1. Cervix must be completely dilated
2. Position (vertex) must be known
3. Membranes must be ruptured
4. Bladder must be empty

Front 23

Outlet Forceps:

Back 23

Fetal head is at the perineum and scalp is visible at the introitus between uterine contractions. NEVER apply forceps to breech, only to aftercoming head.

Front 24

Low Forceps:

Back 24

Fetal vertex at a +2 station.

Front 25

Midforceps

Back 25

Forceps applied when head is engaged. Fetal head is above a +2 station.

Front 26

*Types of Forceps:

Back 26

1. Simpson
2. Tucker-McLean
3. Kielland and Barton
4. Piper

Front 27

Simpson Forceps used for:

Back 27

used for occiput anterior

Front 28

Tucker-McLean Forceps used for:

Back 28

to rotate from occiput posterior to occiput anterior and deliver

Front 29

Kielland and Barton Forceps used for:

Back 29

to rotate occiput transverse to occiput anterior

Front 30

Piper Forceps used for:

Back 30

to deliver the aftercoming head of breech

Front 31

Which is less risky? Vacuum or Forceps?

Back 31

Vacuum

Front 32

Vacuum Extraction: Types

Back 32

1. Malmstrom vacuum extractor
2. Plastic cup extractor-more widely used in USA

Front 33

*Complications of Vacuum Extraction

Back 33

*Major complication is trauma to scalp
1. Scalp abrasion or laceration
2. Cephalohematoma
3. Intracranial hemorrhage
4. Retinal hemorrhage
5. Soft tissue laceration

Front 34

Cervical Incompetence: Definition**

Back 34

Premature, painless dilatation of cervix (without being in labor), in the 2nd trimester of pregnancy that usually results in pregnancy loss.

Front 35

Causes of Cervical Incompetence

Back 35

Occurs secondary to insufficiency of internal cervical os

Congenital (cervical hypoplasia, DES exposure) or acquired (previous trauma, conization, laceration) (rapid delivery, use of forceps, trauma, breech extraction)
*Previous incompetence is the most common risk factor

Front 36

Diagnosis of Cervical Incompetence:

Back 36

Hx repeated late spontaneous abortions (r/o other causes)
Also Dx by hysterosalpingography or ability to pass a #16 Foley through the cervix (suggestive).
?US becoming method of choice for early detection of cervical dilation. Look for “short cervix”.

Front 37

Treatment Cervical Incompetence

Back 37

Cervical cerclage performed between 13-16 weeks gestation.
Remove by 38wks

Front 38

Complications of Cerclage

Back 38

infection (not common), suture displacement, rupture of membranes

Success rate is 85-95%.

Front 39

Cerclage Techniques:

Back 39

Shirodkar
McDonald
Others

Front 40

The Shirodkar

Back 40

most complicated. Vaginal mucosa dissected away from cervix before placing suture. Permanent

Front 41

The McDonald

Back 41

simplest procedure; less trauma to cervix and less blood loss. Simple purse string; no mucosal dissection. Temporary; remove before labor begins.

Front 42

Stillbirth: Definition

Back 42

birth of a dead fetus

Front 43

MCC stillbirth

Back 43

50% stillbirths with no known etiology
Most common condition associated with stillbirth is fetal growth restriction (43%)

Front 44

Genetic Causes of Stillbirth:

Back 44

Thrombophilias
Chromosome abnormalities
Single-gene disorders
• X-linked dominant
• Lethal autosomal recessive
• Lethal de novo autosomal dominant
• Di George’s syndrome

Front 45

Spontaneous Abortion:

Back 45

Threatened, inevitable, incomplete, missed, habitual (see previous lecture notes)

Front 46

Induced Abortion:

Back 46

*Termination of pregnancy medically or operatively before viability (before fetus is capable of surviving outside uterus). The definition of viability varies from state to state.
Types: Therapeutic, Elective

Front 47

Therapeutic Abortion: Definition

Back 47

Interruption of pregnancy for the purpose of safeguarding the health of the mother.

Front 48

Therapeutic Abortion: Legalities

Back 48

*Became legal 1973
first and second trimester
*Can be induced up to approximately 20-24 weeks gestation (depending on state law)

Front 49

Elective voluntary abortion:

Back 49

Interruption of pregnancy at the request of the mother.

Front 50

Pre-Abortion Work-up:

Back 50

US-assure dates correspond with uterine size
Labs - ABO/Rh
Rhogam as indicated
Counseling

Front 51

Maternal Indications for Therapeutic Abortion:

Back 51

• CV disease
• Genetic syndromes
• Hematologic dz
• Metabolic
• Neoplastic
• Neurologic
• Renal
• Intrauterine infection
• Severe pre-eclampsia/eclampsia

Front 52

Fetal Indications for Therapeutic Abortion:

Back 52

• Major malformations (Anencephaly)
• Genetic (Tay-Sachs)

Front 53

Surgical/Mechanical abortion means

Back 53

safer than medical means and more common
Laminaria - 1st to dilate cervix
Dilation and evacuation (D&E) - suction curettage
Dilation and curettage (D&C)
NO Longer used-sharp curettage, hysterotomy, hysterectomy

Front 54

safest and most effective method to terminate pregnancies of 12 weeks’ duration or less?

Back 54

D&E

Front 55

Medical abortion means

Back 55

Abortifacients-extrauterine and intrauterine
• Intravaginal prostaglandin E2 with urea
• Methotrexate
• Mifepristone

Front 56

Mifepristone/Mifeprex
MOA

Back 56

*19-norsteroid analogue. Progesterone antagonist (RU 486).

Block progesterone receptor sites in deciduas→ bleeding.
Increases prostaglandin levels→ uterine contractions.

Front 57

Mifepristone/Mifeprex
Indication, Dose, Office visits

Back 57

Use with intrauterine pregnancies 49 days or less
3x 200mg tables → $240-300

Abdominal pain and 1-2 weeks of bleeding. Requires 3 separate office visits (1, 3, 14)
Follow up visit on day 14 to confirm pregnancy termination with HcG and vaginal US.

Front 58

Mifepristone/Mifeprex
Drug interactions

Back 58

No drug interactions reported.

Front 59

Mifepristone/Mifeprex
Side effects

Back 59

heavy bleeding, nausea, headache, vomiting, diarrhea, dizziness, fatigue, back pain.

Front 60

*Complications of Abortion:

Back 60

Hemorrhage
Cervical injury
Coag defects
Retained POC
Infection
Perforation
Infertility
Embolization
Live-born fetus
Uterine rupture
Asherman’s syndrome

Front 61

Asherman’s syndrome

Back 61

adhesions and/or fibrosis within the uterine cavity
s/p D&C

Front 62

Partial Birth Abortion:

Back 62

A lay term for a second or third trimester abortion, sometimes referred to as “intact dilation and extraction”.

Front 63

Signs of Substance Abuse:

Back 63

1. Agitation
2. Sedation
3. Disorientation
4. Tachycardia
5. Hallucinations
6. Hypertension
7. Skin infections

Front 64

Complications of Substance Abuse:

Back 64

Neurologic, cardiovascular, infections, obstetric (preterm labor, IUGR, abruption, fetal distress, anomalies).

Front 65

Breastfeeding and substance abuse?

Back 65

Breast-feeding NOT recommended. Alcohol, cocaine, opiates, cross into breast milk.

Front 66

Treatment of Substance Abuse:

Back 66

Refer to drug treatment, social services, treat as “high-risk”, monitor fetal well-being

Front 67

Substance "Use"

Back 67

Taking low, infrequent doses of illicit substances for experimentation or social reasons.

Front 68

Substance "Abuse"

Back 68

Persistent or repeated use of a psychoactive substance for more than 1 month, despite the persistence or recurrence of adverse social, occupational, psychological or physical effects.

Front 69

Substance "Dependence Syndrome"

Back 69

THREE or more of the following criteria are met continuously for one month or repeatedly in a given year:

a. Abandonment of social, occupational, or recreational activities
b. Continued substance use despite knowledge of social, psychological, or physical problems exacerbated by drug use.
c. Substance taken to relieve or avoid withdrawal symptoms
d. Withdrawal symptoms
e. Persistent desire or one or more unsuccessful attempts to control substance use
f. Substance taken in larger amounts or over a longer period than intended
g. Frequent intoxication or withdrawal symptoms when expected to fulfill obligations at work, school, or home or when abuse is physically hazardous.
h. A great deal of time spent in getting, taking or recovering from the substance.