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199 Cards in this Set
- Front
- Back
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Three stages of labor |
1. First- onset of true labor to full cervical dilation: <20 hours in a nulligravida and <14 hours in a multip |
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Three causes of protaction of labor and arrest of labor disorders |
3Ps |
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Arrest of dilation in nulligravada and multigravida |
Nulli: no change in > 2 hours |
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Arrest of descent in nulligravida and multigravida. what if there is an epidural? |
Nulli: no change in > 2hours |
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What are adequate uterine contractions? |
>200 MVU (Montevideo units)/10 minutes for 2 hours |
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Patients who have been successfully treated for anorexia nervosa, with successful return to normal menstruation are still at risk for what pregnancy complications? |
- higher risk of delivering babies that are premature, small for gestational age (secondary to IUGR) or both |
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Treatment of infertility in a patient with PCOS |
- PCOS is characterized by anovulation, signs of androgen excess and ovarian cysts |
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Pre-test probability |
This describes the existing probability of a patient having a disease in question prior to performing the test (i.e. patients with positive family history, or patients with high clinical risk) |
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Nagele's rule for determining the estimated date of delivery. |
Subtract 3 months from the LMP and add 7 days- exact dating uses the estimated date of conception or EDC - 280 days after LMP. |
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Quickening |
Maternal awareness of fetal movement. This should occur at 20 weeks in primigravidas and 16-18 weeks in multigravidas |
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Cardiac physiologic changes that occur during pregnancy |
- CO increases by 30-50% secondary to an increase in stroke volume and heart rate |
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pulmonary changes during pregnancy |
- increase in tidal volume during pregnancy primarily due to increased respiratory rate and the TLC decreases by 5% from elevation of diaphragm (dyspnea of pregnancy occurs in 60-70% of patients) |
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GI changes during pregnancy |
- n/v occurs in more than 70% of pregnancies |
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Hyperemesis gravidarum |
- severe form of morning sickness in which women lose greater than 5% of their prepregnancy weight and go into ketosis |
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Renal changes during pregnancy |
- kidneys increase in size and ureters dilate-- may lead to increased incidence of pyelonephritis |
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Hematologic changes during pregnancy |
The plasma volume increases by about 50% in pregnancy and the RBC volume increases by only 20-30% which leads to a decrease in hematocrit -- dilutional anemia |
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hCG components |
- alpha subunit- same as LH, FSH and TSH |
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How much weight should most women gain during pregnancy? |
20 - 30 pounds |
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How much weight should an overweight woman gain during pregnancy? |
15 to 25 pounds |
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linea nigra |
hyperpigmentation of the abdominal midline during pregnancy |
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melasma/cholasma |
hyperpigmentation of the face during pregnancy (e.g. the mask of pregnancy) |
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What should be included in the physical exam for the first prenatal visit? |
1. Pap smear unless one has been conducted in the last 6 months 2. cultures for gonorrhea and chlamydia 3. bimanual exam- estimate uterine size to see if consistent with dates. Perform US to confirm dates if any question. |
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What panel of diagnostic tests should be conducted during the first trimester of pregnancy? |
1. CBC 2. Blood Type 3. Antibody screen 4. RPR or VDRL 5. Rubella Ab screen 6. hepatitis B surface antigen 7. UA 8. Urine culture Also consider VZV Ab test if no known h/o chickenpox and PPD if high risk for TB. - Offer HIV screening and 1st trimester aneuploidy screening with nuchal translucency via US |
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what should be done at every prenatal visit? |
1. Blood pressure 2. weight check 3. urine dipstick- protein, glucose, leukocyte esterase, and blood 4. measurement of uterus 5. auscultation of fetal heart tones |
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What does uterine fundal height indicate? When can it be relied upon? |
Fundal height corresponds to weeks gestation after 20 weeks. Ex: At 32 weeks, the fundal height (from pubic symphysis to top of the uterus) should be 32 cm. |
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With regard to fundal height, when should an ultrasound be done to assess fetal growth? |
If the fundal height is progressively decreasing or is 3 cm or less than GA |
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What questions should be asked during every prenatal visit? |
Vaginal bleeding, vaginal discharge, loss of fluid, UTI sx. After 20 weeks - ask about contractions, and fetal movement |
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When is most of the fetal screening for congenital abnormalities done and what does this entail? |
During the second trimester. The Maternal Serum Alpha Fetoprotein (MSAFP) can be done between 15-18 weeks. Increased levels indicate increased risk of neural tube defects, where as decrease levels indicate increased risk for some aneuplodies such as Downs. - The MSAFP is used in conjuction with the b-HCG and estriol to make up the triple screen. |
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Triple Screen |
1. Maternal serum alphafetoprotein 2. estriol 3. b-hCG |
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Quad Screen |
1. Maternal serum alpha fetoprotein 2. estriol 3. b-hCG 4. inhibin A |
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During the second trimester, an Ultrasound is performed to evaluate? |
1. congenital abnormalities 2. amniotic fluid levels 3. placental location 4. gestational age |
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How often are prenatal visits from 28-36 weeks and after 36 weeks? |
1. From 28-36 weeks, prenatal visits should be every 3 weeks 2. After 36 weeks, the prenatal visits should be weekly |
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In the setting of a breech presentation, at what time during a pregnancy would an external cephalic version be performed? |
37 to 38 weeks. Up until this time, there is still a chance that the fetus will rotate to the correct presentation on its own. |
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What lab tests are performed during the third trimester? |
1. Hematocrit- hct is approaching its nadir at this point. Patients with hct < 32-33% are usually started on iron supplementation. (+stool softener) 2. RPR/VDRL 3. Glucose Loading Test (GLT)- screening test for gestational diabetes |
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Glucose Loading Test (GLT) |
50 g oral glucose is given as a loading dose and then serum glucose is measured one hour later. If the blood sugar is >140 mg/dL then a 3-hour glucose tolerance test is performed. |
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3-hour glucose tolerance test |
1. fasting serum glucose level 2. Give 100 g oral glucose loading dose, then measure serum glucose at 1, 2, and 3 hours. 3. the test is indicative of gestational diabetes if there is an elevation in two or more of the following threshold values ( fasting > 95 mg/dL, 1 hr > 180 mg/dL, 2 hour > 155 mg/dL, and 3 hour > 140 mg > dL) |
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Treatment of HSV during pregnancy/delivery |
If there are signs and symptoms of active genital HSV infection then this is an indication for c-section. If there is a latent HSV infection, then antiviral ppx should be initiated. |
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When should testing for Group B strep be conducted? If positive, what treatment should be given and when? |
Test for Group B Strep at 36 weeks. Treatment is penicillin during delivery. |
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Treatment of low back pain during pregnancy |
1. Mild exercise- particularly stretching 2. Gentle massage 3. Heating pads 4. Tylenol 5. Consider PT For severe pain - muscle relaxants and narcotics an be used |
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Constipation during pregnancy |
- constipation is a common problem during pregnancy because increased progesterone levels lead to increased colonic transit time and increased H20 absorption - TX: increased H20 intake, stool softeners, bulking agents. Laxatives can be used but should be avoided during 3rd trimester - as they might induce preterm labor |
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Braxton Hicks contractions |
Occassional, irregular contractions during pregnancy that do not lead to cervical changes. - Dehydration may increase these, so patients should be advised to drink 10-14 glasses of H20 per day - Regular contractions that are occuring every 10 minutes or more often should be considered indicative of labor and should be assessed via cervical exam. |
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Edema during pregnancy |
compression of IVC and pelvic veins by the uterus increases hydrostatic pressure in the lower extremities and can thus lead to edema in the feet and ankles. Patients should elevate their legs when possible and sleep on their sides to limit compression. Severe edema of the face may be indicative of pre-eclampsia and thus merits further evaluation
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GERD during pregnancy |
There is decreased tone of the LES during pregnancy and slowed GI emptying leading to increased GERD. Treatment should be antacids and dietary/lifestyle modifications first (many small meal and not lying down within 1 hour of eating) PPIs and H2 blockers are okay if symptoms persist. |
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Hemorrhoids during pregnancy |
These occur more often during pregnancy due to IVC compression |
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Urinary frequency during pregnancy |
This is mostly due to increased intravascular volume and GFR, in addition to bladder compression by the gravid uterus. It can indicate UTI, however there is usually also dysuria. |
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Biophysical Profile (BPP) |
Test to assess fetal well being. Consists of 5 categories that are each scored 0-2. 1. Amniotic fluid volume 2. fetal tone 3. fetal activity 4. fetal breathing movements 5. and Non-stress test (NST) looking at FHR a BPP of 8-10 is reassuring |
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Non-stress Test (NST) |
Test of fetal well-being. Considered reactive (healthy) if there are two accelerations of the FHR in 20 minutes that are at least 15 beats above the baseline heart rate and last for at least 15 seconds. * fetal heart rate variability is a healthy feature* |
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What is the next step after a non-reactive NST? |
Ultrasound |
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Percutaneous Umbilical Blood Sampling (PUBS) |
Sampling umbilical blood by placing a needly transabdominally into the uterus and phlebotomizing the umbilical cord. Can be used to assess fetal hematocrit, Rh ismoimmunization causes of fetal anemia and hydrops. |
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Fetal lung maturity 1. How do you test for it? |
1. am amniotic fluid sample is obtained analyzed through amniocentesis. Lethicin/Sphingomyelin (L/S) ratio has traditionally been used as a predictor of fetal lung maturity. L/S > 2 is predictive of fetal lung maturity. 2. Other tests to assess fetal lung maturity include: phosphatidylglycerol, saturate phosphatidyl choline (SPC), the presence of lamellar body count, and surfact to albumin ratio (S/A) |
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Ectopic pregnancy 1. Definition 2. Most common location 3. Incidence |
1. Pregnancy that occurs outside of the uterine cavity. 2. The most common site is the ampullas of the fallopian tubes. 95-99% of ectopic pregnancies occur in the fallopian tubes. 3. The incidence of ectopic pregnancies has been increasing over the past 10 years and the current rate is > 1:100. This is likely due to increased STIs, PID, and assisted reproduction. |
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Risk factors for ectopic pregnancy |
1. Prior ectopic pregnancy (with h/o of 1 prior ectopic risk is increased to 10%, with 2 or more the risk is increased to 25% or more) 2. PID - any scarring of the fallopian tubes or decreased motility 3. Assisted Reproduction Technology (ART) 4. If IUD in place, there is a great risk that a pregnancy that develops will be ectopic, possibly as high as 25-50% 5. endometriosis 6. previous surgery on fallopian tubes 7. Prior pelvic or abdominal surgeries with resulting adhesions 8. Current use of exogenous hormones including estrogen and progesterone 9. smoking |
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Ectopic pregnancy 1. exam findings 2. lab findings |
1. adnexal mass that is often tender. Uterus that is small for GA. +/- bleeding from the cervical os 2. b-hCG that is low for GA and does not increase at the expected rate. Hct/hgb may be low if ruptured |
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Heterotopic pregnancy |
1 IUP and 1 ectopic pregnancy occurring at the same time. - There is increased risk of this with IVF when more than one embryo is transferred. |
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Treatment of ruptured ectopic pregnancy |
The patient should initially be stabilized with IV fluids, blood transfusion, and vasopressors if necessary. Ultimately, the patient will need emergency exploratory laparotomy if unstable and exploratory laparoscopy if stable. - Salpingostomy or salpingectomy can be performed with resection of the entire ectopic pregnancy. |
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Treatment of unruptured ectopic pregnancy |
surgical or medical management Methotrexate is the treatment of choice at most institutions. This can be used for small ectopic pregnancies (< 4cm, serum b-hCG < 5,000, and without fetal heartbeat) - Serial b-hCGs need to be followed and Cr and LFTs need to be evaluated |
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Spontaneous abortion |
miscarriage- a pregnancy that ends before 20 weeks' gestations. - occurs in 15-25% of all pregnancies - type of SAB is defined by whether any or all of the products of conception (POC) have passed and whether or not the cervix is dilated |
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Abortus |
fetus lose before 20 weeks' gestations or less than 500g |
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Complete abortion |
complete expulsion of all POC before 20 weeks' gestation |
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Incomplete abortion |
partial expulsion of some but not all POC before 20 weeks' gestation |
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Inevitable abortion |
no expulsion of POC, but vaginal bleeding and dilation of the cervix such that a viable pregnancy is unlikely |
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Threatened abortion |
any vaginal bleeding before 20 weeks, without dilation of the cervix or expulsion of any POC (normal pregnancy with bleeding) |
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Missed abortion |
death of the embyro or fetus before 20 weeks with complete retention of all POC |
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What is the cause of the majority of first trimester SABs? |
60-80% are due to abnormal chromosomes, of which 95% are due to errors in maternal gametogenesis - autosomal trisomy is the most common chromosomal abnormality |
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Diagnostic evaluation of threatened abortions |
1. b-hCG 2. bloody type 3. antibody screen 4. CBC 5. pelvic exam 6. consider TVUS - send any POC to lab for eval |
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Differential diagnosis for first trimester vaginal bleeding |
1. SAB 2. postcoital bleeding 3. ectopic pregnancy 4. vaginal or cervical lesions or lacerations 5. extrusion of a molar pregnancy 6. non-pregnancy causes of vaginal bleeding |
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Surgical management of first-trimester SAB |
dilation and curretage either in the office or OR |
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Medical management of first-trimester SAB |
prostaglandins (misoprostol) with or without mifepristone to induce cervical dilation, uterine contractions and expulsion of the pregnancy - all Rh negative women need to be given Rhogam to prevent isoimmunization |
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Etiologies of second trimester abortions |
1. infection 2. maternal uterine or cervical anatomic defects 3. maternal systemic disease 4. exposure to fetotoxic agents 5. trauma |
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laminaria |
small rods of seaweed that are placed in the cervix the day prior to a D&C. These rods expand as they absorb water, thereby dilating the cervix.
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Preterm labor vs cervical incompetence |
PTL- uterine contractions leading to cervical dilation Cervical incompetence- painless dilation of the cervix |
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Cervical incompetence |
painless dilation of the cervix. This exposes the fetal membranes to the vaginal flora and increased risk of trauma. - infection, vaginal discharge, and ROM can be seen as a result - this is the cause of about 15% of second trimester losses |
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Risk factors for cervical incompetence |
1. history of cervical surgery, such as cone biopsy, LEEP, or dilation of the cervix 2. history of cervical lacerations with vaginal delivery 3. uterine anomalies 4. history of DES exposure |
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Treatment of cervical incompetence |
1. if the fetus is previable (<24 weeks), then expectant management or elective termination are options 2. Viable pregnancies can be managed with betamethasone to increase fetal lung maturity and strict bed rest 3. If there is a component of PTL, tocolysis can be given 4. In previable pregnancies an emergent cerclage can be placed- suture placed vaginally around the cervix |
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Cervical cerclage - 2 types and complications |
suture placed vaginally around the cervix to keep it closed 1. McDonald Cerclage - suture placed at the cervical-vaginal junction 2. Shirodkar - suture placed at the internal os - Complications include: ROM, PTL, and infection |
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Elective cerclage placement |
These are used in women who have had a previous issue with cervical incompetence - they are usually placed around 12-14 weeks and maintained until 36-38 weeks if possible - these are associated with 85-90% success rates |
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If cervical cerclages have not been successful for management of women with cervical incompetence, what is another option for management? |
Transabdominal Cerclage (TAC). These are placed via laparotomy at the level of the cervical os at 12-14 weeks. - women with TACs must be delivered by c-section |
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Recurrent Pregnancy Loss |
Three or more consecutive SABs. - The risk of an SAB after one prior SAB is 20-25% - after two consecutive SABs the risk is 25-30% - after three consecutive SABs, the risk is 30-35% |
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Pathogenesis of SAB |
1. chromosomal abnormalities 2. maternal systemic disease 3. maternal anatomic defects 4. infection 5. 15% have antiphospholipid antibody (APA) syndrome- increased clotting 6. luteal phase defect- lack adequate progesterone to maintain the pregnancy |
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Screening/Evaluation of patients with Recurrent Pregnancy Loss |
1. karyotyping of both parents 2. karyotyping of POC from each SAB if possible 3. examination of maternal anatomy with hysterosalpingogram (HSG)- if this is abnormal or non-diagnostic then a hysteroscopic or laparoscopic exploration may be performed 4. Screening for hypothyroidism, diabetes mellitus, APA syndrome, hypercoagulability, and SLE These tests should include: lupus anticoagulant, factor V leidin deficiency, prothrombin 20210A, ANA, anticardiolipin antibody, russell viper venom, antithrombin III, protein C and S deficiency. Luteal phase testing of progesterone levels. Cultures of the cervix, vagina, and endometrium to rule out infection. - 30-50% of the time, no etiology is determined |
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Screening vs prenatal diagnosis |
1. high-risk individuals are selected out of low-risk populations at risk for a given diagnosis or complication 2. prenatal diagnosis is nearly always diagnostic and usually far more specific than screening, but diagnostic procedures such as amniocentesis and chorionic villus sampling (CVS) bear a greater risk of complications, in particular pregnancy loss |
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Inheritance pattern of hemophilia |
x-linked (usually carried by mother, there is no male to male transmission as the male only passes his Y chromosome to his sons) |
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Cystic fibrosis 1. inheritance pattern 2. defect 3. clinical manifestations |
1. autosomal recessive 2. there is a defect in the cystic fibrosis conductance regulator (CTFR), the gene responsible for chloride channels 3. chronic lung disease, thick secretions, recurrent infections. This eventually leads to irreversible lung damage and strain on the right heart (cor pulmonale). 85% of patients also have pancreatic insufficiency leading to chronic malabsorption and failure to thrive |
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Sickle cell anemia 1. inheritance pattern 2. mutation and pathophysiology 3. who should be screened? |
1. autosomal recessive 2. single point mutation in the gene for the beta chain in hemoglobin that leads to Hgb S which forms polymers when that when deoxygenated cayse the cells to become sickles leading to hemolytic anemia and pain crises from vasocclusive episodes 3. all AAs should be screened during or before pregnancy. If the woman is positive than her partner should be screened as well. If he is positive for the trait, then there is a 25% chance of the fetus being affected. |
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Theory for why sickle cell mutation developed and is maintained? |
There is likely a survival advantage to people with the sickle cell trait in malaria (plasmodium vivax) infested areas. These people are heterozygous for the gene and thus do not have the physiologic sequela of sickle cell anemia but their cells are inhospitable to malaria. |
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Tay-sachs disease 1. inheritance pattern 2. epidemiology (who is at greater risk) 3. symptoms and outlook |
1. Autosomal recessive 2. most common in Eastern European Jews and French Canadians 3. infants develop symptoms at 3-10 months including decreased alertness and hypersensitivity to noise. There is then progressive neurodevelopmental delay. Paralysis, blindness, and dementia develop and the affected children usually die by age 4 4. lysosomal storage disease in which there is a build up of gangliosides in the lysosomes of neurons due to a deficiency in hexosaminidase A |
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What is a Classic feature seen on exam in Tay Sachs disease? |
Cherry-red macula. There is a cherry red spot seen on fundoscopic exam - prominent red macular fovea centralis stands out compared to pale retina. This can also be seen in Sandhoffs, Gauchers, and Niemman Pick |
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beta thalassemia |
impairment of beta chain production that leads to excessive alpha chains of hemoglobin. - autosomal recessive disorder seen more commonly in AAs, and people from the Mediteranean or Asia - screening can be performed by hemoglobin electrophoresis. There will be increased hgb alpha to beta ratio. CBC will show a microcytic anemia |
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alpha thalassemia |
- the alpha chain of hgb is encoded by four alleles on two chromosomes so the severity of the defect depends on the number of alleles affected, with increasing severity as the number affected alleles increases
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hydrops fetalis |
- deletion of all 4 alpha hemoglobin alleles. - incompatible with life. infants are delivered prematurely and are pale, hydropic, severely anemia and have splenomegaly - this is also known as hemoglobin bart |
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Hemoglobin H disease |
- deletion of 3 of the alpha hemoglobin alleles, resulting in an accumulation of the excess beta chains in the red cells. Beta tetramers form, which are unstable and undergo oxidation, making them more susceptible to early clearance and destruction. - there is moderate hemolytic anemia
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alpha thalassemia trait |
- two alpha alleles are deleted leading to a mild phenotype in which there is microcytic anemia and a NORMAL hgb electrophoresis - CBC usually shows a microcytic anemia, but molecular testing needs to be conducted to look for the number of genes lost |
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Aneuploidy |
missing or excess chromosomes. This usually leads to miscarriages although certain trisomies are compatible with life (13, 18 ,and 21) |
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Down Syndrome 1. genetic defect involved 2. phenotype 3. screening 4. prevalence |
1. Trisomy 21 2. short statue, simian creases, developmental delay with IQs ranging from 40-90. Associated cardiac defects, duodenal atresia or stenosis and short limbs 3. between first trimester screening (PaPP-A, hCG and NT) and 2nd trimester quad screen there is 95% sensitivity of detecting down syndrome. There are some newer, non-invasive and high sensitivity tests 4. there is increasing prevalence of trisomy 21 because maternal age is increasing |
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Edward Syndrome 1. definition 2. features |
1. Trisomy 18 - lethal aneuploidy in which nearly all patients born with this condition die in the first two years of life 2. rocker-bottom feet, clenched fists, overlapping digits, cardiac defects like TOF and VSD, omphalocele, and neural tube defects- many of these features can be seen on US |
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Patau Syndrome 1. definition 2. features |
1. Trisomy 13- lethal aneuploidy in which a child inherits three copies of chromosome 13. Most will die within 1 year. 2. holoprosencephaly, cleft lip and palate, cystic hygroma, single nostril, or absent nose, omphalocele, cardiac defects like hypoplastic left heart, and limb abnormalities including clubfoot and clubhand and overlapping fingers- caught on US the vast majority of the time |
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Turner Syndrome 1. definition 2. features |
1. Monosomy X- child has a single X chromosome and no Y chromosome. 2. phenotypically female, short stature, webbed neck, primary amenorrhea, sexual infantilism, webbed neck, low-set ears, wide carrying anlge of the arms, shield-like chest, wide-set nipples, lymphedema of the extremities at birth, cystic hygroma, and CV anomalies such as coarctation of the aorta |
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Cystic hygroma - congenital multiloculated lymphatic lesion that can arise anywhere, but is classically found in the left posterior triangle of the neck and armpits. - These are usually benign but can be disfiguring. - They are associated with Turner Syndrome and Noonan syndrome. - Usually diagnosed on prenatal US. |
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Three ways of obtaining fetal cells for prenatal analysis |
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Amniocentesis
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Chorionic Villus Sampling
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Fetal lie 1. definition 2. how determined |
1. what position the fetus is in- transverse or longitudinal 2. leopold maneuvers or fetal US |
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Leopold Manuevers |
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How often does PROM occur |
The membranes surrounding the fetus rupture prior to the onset of labor in about 10% of pregnancies |
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What is prolonged PROM? |
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How is rupture of membranes diagnosed? |
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Tampon test/ amino dye test |
If ROM cannot be diagnosed and it is critical to diagnose as in the case of PPROM, then dilute indigo carmine dye can be injected into the amniotic fluid via amniocentesis and then can be looked for either on speculum exam or by inserting a tampon and watching for staining by the dye |
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Five components of the cervical exam during pregnancy (Bishop score) |
* A score greater than 8 indicates a cervix that is favorable for delivery |
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Cervical dilation |
Examined by using fingers to assess opening of the cervix at the level of the internal os. 0 = closed. 10 = fully dilated and ready for delivery |
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Cervical Effacement |
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Fetal station |
The relation of the fetal head to the ischial spines of the female pelvis.
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Cervical consistency |
firm, soft or somewhere in between |
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Cervical position |
This ranges from posterior to mid to anterior
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Fetal Presentation 1. Breech 2. Vertex 3. Transverse |
1. buttocks down 2. head down- aka cephalic 3. neither head nor buttocks down -- horizontal * Compound presentations entail two different types of presentation, such as with vertex and and extremity |
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Occiput anterior vs occiput posterior vs occiput transverse |
This refers to which direction the back side of the fetal head (occiput) is facing. * occiput anterior is the preferred presentation, as OP and OT presentations may be associated with prolonged labor * to determine the position/presentation, palpated for the sutures and fontanelles of the fetal head |
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Anterior and posterior fontanelles (relative size, shape and location) |
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Definition of labor |
Regular uterine contractions that cause change in cervical dilation or effacement - signs of labor include bloody show, n/v, discomfort, palpable contractions |
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Cervical ripening aids |
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Contraindications to the use of prostaglandins for cervical ripening |
There is risk of uterine hyperstimulation and tetanic contractions as these agents cannot be quickly turned off |
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How is labor induction generally started? |
Usually labor induction is started with Pitocin (manufactured Oxytocin), although sometimes it is started with cervical ripening of mechanical dilation with a Foley bulb - Pitocin is given by a continuous IV drip as it is rapidly metabolized - amniotomy can be performed with an amnio hook-- check for umbilical cord prolapse after this |
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Mechanisms of augmenting labor |
1. Pitocin drip 2. amniotomy
These can be considered when there are inadequate contractions or a prolonged phase of labor |
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How is the adequacy of contractions determined? |
1. cervical change 2. Direct measurement of force of contractions with an Intrauterine Pressure Catheter (IUPC) |
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Normal fetal heart fate |
between 110 and 160 |
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What does a baseline fetal heart rate > 160 bpm indicate |
Fetal distress, which may be secondary to infection, hypoxia, or anemia |
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Fetal heart rate variability 1. absent 2. minimal 3. moderate 4. marked |
1. absent - < 3bpm variatiation-- worrisome--> conduct another test to assess fetal wellbeing 2. minimal - 3-5 bpm of variation 3. moderate - 5-25 bpm of variation 4. marked > 25 bpm of variation |
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Definition of a reaction fetal heart rate tracing |
at least 2 accelerations of at least 15 bpm for at least 15 seconds within a 20 minute period |
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Early decelerations |
Decelerations in the fetal heart rate the begin and end at the same time as the contractions
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Variable decelerations |
Decelerations of the fetal heart rate that occur at anytime related to contractions. Tend to be precipitous drops.
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Late decelerations |
Deceleration of the fetal heart rate that occur at the peak of a contraction and slowly return to baseline after the contraction is completed
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What should be done if repetitive decelerations are seen on Doppler or there is difficulty establishing a tracing with external doppler?
What are contraindications to this? |
Place an internal fetal scalp electrode (FSE)-shows beat-to-beat variability better and is affected less by changes in maternal position
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Category I tracing strip |
Normal fetal heart rate tracing characterized by a normal baseline, moderate variability, and no variable or late decelerations |
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Category II tracing strip |
Indeterminate fetal heart tracing and includes many variety of fetal heart tracings including:
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Category III tracing strip |
Abnormal fetal heart rate tracing
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Stage 1 of labor - 2 parts |
Stage 1 - from onset of labor until complete cervical dilation
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What three factors are known to affect transit time during the active phase of labor? |
The 3 Ps
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How do you measure the strength of contractions and what is considered adequate? |
If you're making good cervical change (>1.0 cm/hr in a nullip and > 1.2 cm/hr in multip) then these are generally adequate contractions. However, you can use an IUPC to measure the strength of the contractions in Montevideo units (MVUs). An adequate contraction should be > 200 MVUs |
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What are some signs of cephalopelvic disproportion (CPD)? |
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Definition of arrest of active phase of labor |
No change in either cervical dilation or fetal station in 2 hours during the active phase of labor despite contractions of adequate MVUs (>200) - research has shown that if you wait 4 hours about 1/2 of these women will deliver vaginally, instead of needing c-section |
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Stage 2 of labor - when is it considered prolonged? |
Stage 2 of labor is from complete cervical dilation to delivery of the infant
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Laboring down aka passive descent |
Giving a woman with an epidural in the second stage of labor an hour or 2 without pushing. This allows them to get more sensation of the urge to push and more feeling so they can tell when they are pushing effectively |
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If a non-reassuring fetal heart tracing (bradycardia, repetitive late decelerations, loss of FHR variability) occurs during the second stage of labor, what should be done? |
Put an oxygen mask on the mother and have her lay in the left lateral decubitus position (to decompress the IVC) and increase uterine perfusion. Stop pitocin! |
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Hypertonus during labor |
a single contraction lasting for longer than 2 minutes |
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Tachysytole during labor |
> 5 contractions in a 10 minute period |
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What can be given if hypertonus of tachysystole develop during the second stage of labor? |
Terbutaline to relax the uterus |
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Episiotomy |
incision made in the perineum to facilitate delivery when there is a need for a quicker delivery or there is actual or suspected shoulder distocia
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Operative vaginal delivery- Forceps |
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Operative vaginal delivery - Vacuum Extraction |
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Stage 3 of labor |
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Three signs of placental separation |
1. Cord lengthening 2. gush of blood 3. uterine fundal rebound as the placenta detaches from the uterine wall
*There should be no attempt to the deliver the placenta until all of these signs are observed * to keep the uterus from inverting or prolapsing apply suprapubic pressure |
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Retained placenta |
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Cervical lacerations - 4 degrees |
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How is a third degree perineal laceration repaired? |
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Indications for primary C-section |
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What is the most common overall indication for c-section? |
Prior c-section |
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Vaginal Birth after Cesarean (VBAC) |
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What factors increase the risk of uterine rupture in TOLACs |
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Reasons why vaginal births are preferred over c-sections |
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Common signs of uterine rupture during labor |
1. abdominal pain 2. FHR decelerations or bradycardia 3. sudden decrease of pressure on an IUPC 4. maternal sensation of a "pop" |
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What narcotics or sedatives are commonly given during the first stage of labor? |
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When is local anesthesia used during labor or after? |
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What are complications of epidural or spinal anesthesia |
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Common indications for emergent c-section |
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Preterm labor |
Onset of contractions with cervical change prior to 37 weeks |
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What is the leading cause of fetal morbidity and mortality? |
Preterm labor |
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What is the definition of low birth weight? (LBW) |
<2500 g |
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What are the risk factors for preterm labor? |
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What is the principal benefit gained by giving tocolytics to delay labor/ |
It hopefully gives you the 48-hour window over which to give betamethasone in order to reduce the incidence of respiratory distress syndrome (RDS) |
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In which situations should pre-term labor be allowed to progress? |
chorioamnionitis, non-reassuring fetal heart tracing, and significant placental abruption |
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What is a common cause of pre-term contractions without cervical change and why does this happen? |
Dehydration- the contractions occur because dehydration causes the release of ADH, which is very structurally similar to oxytocin. |
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Tocolytics- names and mechanisms` |
1. beta mimetics- acts on B2 receptors on the myometrium to increase cAMP levels, which results in Ca2+ getting stuck inside the SR and thus not being available to cause contractions: Terbutaline and Ritodrine (only Ritodrine is FDA approved for tocolysis). SE: tachycardia, headache, anxiety and rarely pulmonary edema 2. Magnesium sulfate- acts to decrease uterine tone and contractions by calcium antagonism and membrane stabilization (SE: flushing, headaches, fatigue, diplopia) 3. Nifedipine- calcium channel blocker 4. Prostaglandin inhibitor- Indomethacin (SE: fetal premature constriction of the ductus arteriosus, pulmonary hypertension, and oligohydramnios secondary to fetal renal failure- need to monitor AFI before and after administration |
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Magnesium toxicity |
1. Respiratory depression 2. hypoxia 3. Cardiac arrest
These symptoms are seen at magnesium levels > 10 mg/dL. However, before reaching this level there will be loss of deep tendon reflexes, so DTRs are often used to monitor patients getting Mg2+
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Premature rupture of membranes vs preterm rupture of membranes |
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What complications is PPROM associated with? |
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How is ROM diagnosed? |
If these tests are equivocal, then an US can be performed to look at the AFI. If still unsure than the tampon test can be performed where dye is injected into the uterus via amniocentesis and then looked for in the vagina. |
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What is the most common time/gestational age to pursue delivery vs trying to maintain the pregnancy in the setting of PPROM? |
34 weeks
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What is the recommended treatment for PPROM? |
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What is the recommended course of action when cephalopelvic disproportion is suspected? |
Trial of labor with C-section to follow as needed. You may elect for induction of labor if there is fetal macrosomia |
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What are the 3 categories of breech presentation? |
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3 options for management of a breech delivery |
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What is a compound presentation and what is a potential complication? |
A fetal extremity presenting alongside the vertex or breech. This occurs in less than 1:1000 pregnancies. The most common complication of this is cord prolapse |
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What is the recommended course of action for a compound presentation? |
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What is the fetal position that optimizes the probability of the fetal head passing through the maternal pelvis?
What is malposition? |
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Prolonged deceleration vs fetal bradycardia |
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Causes of prolonged deceleration and fetal bradycardia |
1. Pre-uterine- maternal hypotension or hypoxia from seizure, amniotic fluid embolism (AFE), PE, MI, respiratory failure etc 2. Uteroplacental- placental abruption, infarction, hemorrhaging placenta previa, uterine hyperstimulation, etc 3. Postplacental- cord prolapse, cord compression, rupture of a fetal vessel such as a vasa previa, etc |
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Treatment of prolonged FHR decelerations |
The treatment is highly dependent on the suspected etiology of the FHR decel
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Shoulder dystocia - definition and incidence |
Difficulty in delivering the fetal shoulders after delivery of the head, which is usually caused by the anterior fetal shoulder getting stuck behind the maternal pubic symphysis
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What are risk factors for shoulder dystocia? |
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Management of a shoulder dystocia |
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McRobert's maneuver |
Maneuver for the management of shoulder dystocia
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Suprapubic pressure and shoulder dystocia |
Pressure is applies just above the maternal pubic symphysis at an oblique angle to dislodge the anterior shoulder from behind the pubic symphysis
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Rubin Maneuver |
Maneuver for the management of shoulder dystocia
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Wood's corkscrew maneuver |
Maneuver for the management of shoulder dystocia
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Delivery of the posterior arm/shoulder in shoulder dystocia |
The delivery of the posterior arm is performed by sweeping the posterior arm across the chest to allow the bisacromial dimeter to rotate to an oblique diameter of the pelvis and the anterior shoulder to be freed |
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Zavanelli maneuver |
Maneuver for the management of shoulder dystocia
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What is true treatment for magnesium overdose? |
10mL of 10% calcium gluconate administered rapidly for cardiac protection. |
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Definition of chronic hypertension in pregnancy |
Htn present before conception, before 20 weeks gestation, or persisting more than 6 weeks postpartum. Approximately 1/3 of patients with chronic htn will develop superimposed preeclampsia |
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Management of chronic htn in pregnancy |
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Management of a pregnant patient with epilepsy (during pregnancy) |
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Management of a pregnant patient with epilepsy (during labor and delivery) |
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