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73 Cards in this Set

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What does it mean to have an instrumental delivery?
The baby is vaginally delivered but with the use of forceps or a vacuum
What are the indications for an instrumental delivery?
1. Maternal exhaustion
2. Ineffective pushing
3. expedite the labor (due to fetal distress, late decels etc)
What must be ruled out before conducting an instrumental delivery?
Cephalopelvic distortion! CPD
What two procedures should be done on the mom prior to using forceps?
1. Episiotomy
2. Pudendal block to minimize the pain
How are the forceps classified?
Based on the location of the fetal head when the forceps are applied
What are outlet forceps?
Classified that way when the fetal head is on the perineum
If the baby is at +2, what classification of forceps would be given?
Low forceps
What type of forcep classification are not normally used and why?
Mid-forceps and High forceps

-These are used between 0 and 2+ and then above 0 respectively and forceps are usually not used because the baby is still too high
What are the advantages to using forceps?
1.Shortens the 2nd stage (pushing) of labor
2. Can help rotate the head
3. May have arrested rotation and they can help
4. Can help with breech delivery
List the risks of using forceps
1. Neonatal birth trauma (facial palsy)
2. Neonatal resp depression
3. perineal trauma
4. PPH
5. bladder injury
Before using the forceps, what do we want to be sure has occurred?
1. Want full dilation to avoid lacerations
2. Want to have an empty bladder
3. Must have ROM to grad baby head
How does vacuum-assisted birth work?
Use negative pressure to apply the vacuum to the baby's head and then pull the baby out
What are the indications for vacuum assisted birth?
1. Vertex position
2. ROM
3. absence of CPD
Which technique is used more often, vacuum or forceps?
What risks are involved with a vacuum assisted birth?
1. Cephalohematoma
2. scalp lacerations
3. subdural hematoma
4. perineal trauma
What is the normal standard of care of when to discontinue use of the vacuum?
After 2 pop offs
Define a cesarean birth
Birth through transabdominal incision of the uterus
What are the indications for a C-section?
1. Maternal or fetal distress
2. CPD
3. Malpresentation (breech or transverse)
4. Placental previa or abruption
5. Prolapsed umbilical cord
6. Failed induction
7. Multi-fetal pregnancies
8. preclampsia/Eclampsia
9. Active HSV
List some possible side effects to a C-section
1. Death
2. aspiration
3. pulmonary embolus
4. infection
5. bladder or bowel knick
If no post operative C-section report is found, what must occur for the next delivery?
A c-section!! Will not do a VBAC because only the report will state the type of uterine incision made.
What is a classical c-section?
Vertical incision in the upper body of the uterus
When is a VBAC contraindicated?
After previous Classical c-section or when no operative report is present
What are the indications for a classical c-section?
1. Implantation of a placenta previa on the lower anterior uterine wall
2. presence of dense adhesions from previous surgery
3. transverse lie of a large fetus with the should impacted in the mothers pelvis
What are the disadvantages to a classical c-section?
1. Most likely of the uterine incisions to rupture during a subsequent birth
2. Eliminates VBAC as an option for birth of a subsequent infant
What are the 2 types of lower uterine segment c-sections?
1. Low transverse
2. Low vertical incision
What are the advantages to a low transverse c-section?
1. unlikely to rupture during a subsequent birth
2. makes VBAC possible for subsequent pregnancy
3. Easier to repair
4. Less adhesion formation
Are there any disadvantages to a low transverse CS?
Yes, limited ability to extend laterally to enlarge the incision
List the advantages of a low vertical cut?
1. can get in quickly
2. can be extended upward to make a larger incision if needed
What are the disadvantages of a low vertical cut?
1. slightly more likely to rupture during a subsequent birth
2. A tear may be extend the incision downward into the cervix
Which type of CS has the most blood loss?
List the contraindications/precautions of a C/S
1. Fetal death (would induce)
2. Fetus that is not expected to survive
3. Maternal coagulations defects
What are the maternal risks of a CS?
-anesthesia complications
List the neonatal risks of a CS?
-Inadvertent preterm birth
-bruising or other trauma
What is a VBAC? What must be on file for it to occur? What are the risks?
-Vaginal birth after cesarean
-H/O documented lower transverse incision
-Must have OR available and 2 OB's + anesthesia
-Uterine rupture (0.5%) is the major risk
What is a uterine rupture?
The uterine wall is torn to a varying degree

-It is rare but very serious obstetric injury that occurs in 1 to 1500 to 2000 births
What are the possible causes of a uterine rupture?
1. Separation of the scar of a previous classical cesarean birth or uterine trauma (abuse)
2. Congenital uterine anomaly
3. Intense spontaneous utuerine contractions
4. labor stimulation (oxytocin)
5. an over distended uterus (multip)
6. Malpresentation
Describe an incomplete uterine rupture
Rupture extends through the endometrium, myometrium but the peritoneum surrounding the uterus remains intact
What is a complete uterine rupture?
Extends through the entire uterine wall (endomet.myomet.and periton) and uterine contents spill in the abdominal cavity
What are the signs and symptoms of an incomplete uterine rupture?
1. May or may not have pain
2. vomiting
3. faintness
4. increased abdominal tenderness
5. hypotonic uterine contractions
6. lack of progress
7. fetal heart tones may be lost
8. *** eventually bleeding and the effects of blood loss will be noted
What are the signs and symptoms of a COMPLETE UTERINE RUPTURE?
The woman may complain of sudden, sharp shooting abdominal pain and may state that "something gave way."
What is a retain placenta and what does it cause?
A little piece remains and part of the placenta does not allow the fundus to contract. May be at risk for infection and hemorrhage
What may cause a retained placenta?
1. Partial separation
2. Abnormal adherence of placenta
3. Mismanagement of 3rd stage of labor (tugging umbilical cord to early)
How do you manage a retained placenta?
1. IV sedation or anesthesia
2. Manual removal of placenta
3. Prophylactic antibiotic therapy
What is an acreta adherent placenta?
Slight penetration of the myometrium

-comes off the easiest
What is an adherent placenta that penetrated deep into the myometrium?
What is Precata?
The term given to an adherent placenta that causes a complete perforation of the uterus
List the predisposing factors of an adherent placenta?
1. High parity
2. Previous c-sections
3. Previous myomectomy
4. H/O vigorous curettage (abortion)/perforation
What is a prolapsed cord?
Cord lies below the presenting part of the fetus

-Hidden (occult) or visible (frank)
What must be done when a prolapse cord is frank?
Obstetric Emergency!
-Keep Pressure off cord
-Birth by cesarean section
-Hand in the vagina
What type of HR changes may be seen during a cord prolapse?
Variable decelerations with shoulders
What is shoulder dystocia?
Anterior shoulder can not pass under the pubic arch of maternal pelvis

-Medical Emergency
What are the risk factors for shoulder dystocia?
Big babies
-Pelvis Anomalies
-under or over rotation of the baby
-Advanced maternal age
-maternal diabetes
-post date pregnancies
-or can occur with no other abnormalities
What are the signs and symptoms of a shoulder?
Prior to birth
--slowing of the progress of labor (fast descent and slow pushing)
--Formation of caput that increases in size

After birth of head
--Turtle sign
--see more and more caput. Don't always know until the baby comes out
What is the management for a shoulder?
Obstetric Emergency

1. McRobert's Maneuver
2. Suprapubic pressure
What is the goal of management for a shoulder?
Free the anterior shoulder
What are the maternal complications with shoulder dystocia?
1. Uterine atony/rupture --> increase blood loss
2. Vaginal lacerations
3. Uterine infection (endometritis)
What are the neonatal complications of a shoulder?
1. clavical fracture
2. asphyxia --> seizure
3. Erb's palsy
-brachial plexus damage
--one side paralysis of the arm
--sometimes permanent
What are some other birth injuries that can occur to the neonate?
1. Cephalohematoma
2. Subconjunctival and retinal hemorrhages
-Erythema, ecchymosis, petichiae, abrasions, lacerations
-Facial nerve paralysis
How would you classify a PPH for both vaginal and cesarean?
- > 500 ml of blood after vaginal
- > 1000ml after CS
-Early PPH: occurs within 24 hours PP
-Late PPH: Occurs after 24 hours but within 6 weeks
What is the leading cause of maternal morbidity world wide?
PPH (5% of all women have some sort of hemorrhage)
What are the risk factors for PPH?
***Most common is uterine atony
1. retained placenta
2. placenta acreta
3. uterine rupture or invasion
4. cervical or vaginal lacerations
5. hematomas
6. infection (endometritis)
7. Coagulopathies (bleeding problems)
What are some causes of uterine atony?
1. High parity
2. polyhydramnios (too much amniotic fluid uterus stretches)
3. macrosomic fetus
4. too much pitosin
5. rapid or prolonged labor
6. shoulder dystocia
7. history of uterine atony or history of PPH
List the management steps of PPH.
1. Bimanual compression (fist inside)
2. Pharmacologic (pitosin)
3. Uterine exploration (for adherent placenta)
4. Surgical intervention
What is the first line of drug therapy for PPH? Dosing?

-10-40 U in 1000ml LR
-can also administer IM
What is the second line of drugs therapy used for PPH? Dosing?
Methergine and Hemebate

-0.2mg IM
What conditions are contraindicated for Methergine?
What is an uterine inversion? Partial and Complete?
The uterus turns inside out after birth

-Partial is only a bit
-complete is total!
What is the primary cause of uterine inversion?
Mismanagement of the 3rd stage!

Totally preventable
What are the primary SxS of uterine inversion?
1. Hemorrhage
2. Pain
3. Shock
What are considered Postpartum Infections?
Any infection that occurs within 28 days after miscarraige, ETOP, and childbirth
What are the fever characteristics to be considered an infection in PP?
Fever > or equal to 100.4 (38C) on 2 successive days of the first 10 PP days
What are the common PP infections?
1. Endometritis
2. Wound infections
3. Mastitis: breasts get infected (fungal)
4. UTI
5. URI
What are the most common organisms that cause PP infections?
Streptococcal and anaerobic organisms