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EOR Exam - Women's Health > Obstetrics Part 3 - L&D > Flashcards

Obstetrics Part 3 - L&D Flashcards

1
Q

Define labor.

A

Uterine contractions that cause changes in dilation, effacement, or station.

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2
Q

Define dilation, effacement, and station.

A

Di: Inc opening of the cervical os
Ef: thinning of the cervix
Sta: Location of presenting part relative to ischial spines –> above spines is -1, -2, …, below is +1, +2, …

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3
Q

Define and describe prodromal labor.

A

“False labor” –> irregular contractions that vary in duration, intensity, and intervals. Yield little to no cervical change.

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4
Q

List and define the six cardinal movements of labor.

A

Engagement: fetal presenting part enters pelvis
Descent: Presenting part descends into pelvis
Flexion: Head flexes so smallest diameter presents to pelvis
Internal Rotation: Rotation from occiput transverse to occiput anterior (sometimes occiput posterior)
Extension: Head extends as it passes beneath pubic symphysis
External Rotation: Occurs after head delivers to facilitate delivery of shoulders.

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5
Q

Define the stages of labor and state how long each typically lasts.

A

1: onset to dilation and effacement. Lasts 10-12 hrs in nulliparous woman and 6-8 hrs in multiparous.
2: full dilation to delivery. Prolonged if > 2 hrs in nulliparous and > 1 hr in multiparous.
3: after delivery of child to delivery of placenta. Normal is 5 - 30 minutes.

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6
Q

Describe the phases of the 1st stage of labor.

A

Latent: slow cervical change - onset to 2-4 cm dilation.
Active: until 9cm dilation - cervical change becomes faster.
Deceleration/Transition: cervix completes dilation

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7
Q

How is one determined to be in active labor and what should happen at that point?

A

Patient in active labor = admitted to labor unit.
Criteria: mucus plug discharge, dilation > 4cm, uterine bleeding, abnormal fetal HR pattern, regular contractions, > 80% effacement.

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8
Q

What is the risk of a women being admitted to the labor unit before being in active labor?

A

Iatrogenic interventions: epidural, oxytocin augmentation, C-section.

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9
Q

Define cephalopelvic disproportion.

A

Fetal head is too large to pass through pelvis

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10
Q

What are Montevideo Units and what is considered sufficient during labor?

A

MV units = method of measuring uterine performance during labor. > 200 MV units = sufficient.

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11
Q

How long of a time period without change during the active phase of labor would trigger a C-section?

A

2 - 4 hours

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12
Q

How is cervical dilation, effacement, and station determined and when should this occur?

A

Determined by digital cervical exam. Occur at time of admission and every 2-4 hrs during 1st stage, every 1-2 hrs during 2nd stage, and when patient feels urge to push to ensure full dilation (10cm).

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13
Q

If a woman chooses anesthesia during labor, when should the cervical exam happen relative to administration of the anesthesia?

A

Perform cervical exam prior to anesthesia

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14
Q

What should be assessed if the fetal HR becomes irregular during labor?

A

Digital cervical exam to evaluate for prolapse and uterine rupture.

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15
Q

What is a partogram and how is it used during labor?

A

Graphical representation of the progression of dilation and other vital statistics (fetal HR, duration of labor, etc.)

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16
Q

How does the administration of an epidural affect the timing of the 2nd stage of labor?

A

Prolongs second stage s/p decreased sensation to push.

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17
Q

Describe forceps and state when they can be used in pregnancy.

A

Blades shaped to accommodate the head of the baby. Use requires: full dilation, ruptured membranes, head at 2+ station or more, no evidence of cephalopelvic disproportion, knowledge of fetal position, adequate anesthesia, and empty bladder.

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18
Q

Describe the use of a vacuum device in pregnancy.

A

Cup placed on fetal scalp with suction device connected to create vacuum.

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19
Q

What are the risks associated with forceps and vacuum use?

A

Forceps: increased rate of facial nerve palsies and perineal lacerations
Vacuum: inc rate of cephalohematomas and shoulder dystocia.

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20
Q

List three signs the placenta has separated from uterine wall in the 3rd stage of labor.

A

Cord lengthening, gush of blood, uterine fundal rebound as placenta detaches.

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21
Q

How is delivery of the placenta managed during the 3rd stage of labor?

A

Gentle traction on cord and suprapubic pressure to avoid perineal trauma and uterine prolapse/inversion.

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22
Q

How is retention of the placenta defined and how is it managed?

A

Def: no delivery of placenta > 30 min after birth
Tx: Manual traction (hand in intrauterine cavity) or curettage.

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23
Q

What is the biggest risk factor for retained placenta?

A

Pre-term delivery

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24
Q

Describe the 4 degrees of perineal lacerations resulting from delivery.

A

1: involves mucosa and skin in perineal area
2: extend into deep perineal body but not anal sphincter
3: extend into or through anal sphincter
4: anal mucosa itself is entered

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25
Q

How are 3rd/4th degree lacerations repaired?

A

Several interrupted sutures

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26
Q

What is a buttonwall laceration?

A

Laceration through rectal mucosa into the vagina but with sphincter still intact.

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27
Q

What risks are associated with 3rd and 4th degree lacerations?

A

Infection, incontinence, prolapse

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28
Q

How is separation of a 4th degree laceration repair managed?

A

Abx, debridement, secondary repair

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29
Q

Define hypertonus and tachysystole and state what they might cause and how the condition is managed.

A

Hypertonus: single contraction lasting > 2 minutes
Tachysystole: > 5 contractions in 10 minute period
May caused prolonged deceleration - treated by terbutaline to relax the uterus

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30
Q

What findings on tocolytic monitoring indicates a non-reassuring fetal status and how is this managed?

A

Repetitive late decels, bradycardia, loss of variability

Tx: O2 by mask, dec IVC compression and inc uterine perfusion by turning mom on left side, d/c oxytocin.

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31
Q

Define an episiotomy.

A

Incision made in perineum to facilitate delivery - used to relieve shoulder dystocia.

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32
Q

T/F: Morphine is contraindicated for pain management in pregnancy.

A

False: morphine can be used for pain management but should not be used close to delivery.

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33
Q

Describe the use of a pudendal nerve block during labor.

A

Pudendal nerve travels posterior to ischial spine. A pudendal nerve block is commonly used in operative vaginal delivery with forceps or vacuum.

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34
Q

Describe the use of local anesthesia during labor.

A

Often used for those requiring episiotomy or repair of lacerations.

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35
Q

What is the location for placement of an epidural for anesthesia and when during labor is it placed?

A

L3-L4 during active phase of labor.

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36
Q

When in labor would general anesthesia be used and what are the risks of its use?

A

Used for urgent C-section.

Risks: maternal aspiration and maternal/fetal hypoxia.

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37
Q

List the reasons for delivery via C-section and state which is most common?

A

Most Common: failure to progress in labor - cephalopelvic disproportion
Other: multiple gestations, older patient with comorbidities, overweight, patient or clinical preference

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38
Q

When after C-section can a mother deliver vaginally and what is the greatest risk?

A

When: Kerr (low transverse) or Kronig (low vertical) incision
Risk: rupture of prior uterine scar

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39
Q

Describe the most common reason for a C-section.

A

Cephalopelvic disproportion (aka failure to progress during labor). pelvis too small, presenting part too large, contractions inadequate.

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40
Q

Define the obstetric conjugate.

A

Distance between sacral promotory and midpoint of the pubic symphysis. It is the shortest A-P diameter of the pelvis.

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41
Q

Differentiate between gynecoid, android, anthropoid, and platepelloid pelvic shapes.

A

Gyn: round, shallow and open. Most common shape
Andr: narrow and shaped like a heart/wedge. Most similar to male pelvis
Anth: Narrow and deep - shaped like upright egg
Plat: Wide and shallow like an egg on its side. AKA flat pelvis. Least common type.

42
Q

List the pelvic shapes from most favorable for vaginal birth to least favorable.

A

Gynecoid - most favorable for vaginal birth
Anthropoid - labor likely to last longer
Android - may require C-section
Platypelloid: most likely to require C-section

43
Q

Define the three types of breech presentations.

A

Frank: flexed hips, extended knees, feet near head
Complete: Hips and knees flexed (may just be one flexed knee)
Incomplete: AKA footling - one or both hips not flexed so foot/feet is/are presenting part

44
Q

How is the diagnosis of a breech presentation made?

A

Leopold maneuvers - fetal head palpated near fundus
Vaginal exam: palpated gluteal cleft and anus or LE
US: confirms diagnosis
Doppler: fetal HR heard in upper uterus

45
Q

What are common complications of a breech presentation?

A

cord prolapse, entrapment of fetal head, fetal neurologic injury.

46
Q

What are the indications and contraindications for a trial of vaginal delivery in a breech presentation?

A

Ind: favorable pelvis, flexed head, est fetal weight 2000-3800 g, frank or complete breech
CI: nulliparity, est fetal weight > 3800g, incomplete breech

47
Q

Define and describe external cephalic version.

A

Used to reorient a fetus that is in a breech position with the goal of successful vaginal delivery. The uterus is relaxed pharmacologically and external bimanual manipulation of the fetus is performed.

48
Q

In what situations is external cephalic version more likely to be successful and when is it contraindicated?

A

Success: African American parents, nonlongitudinal lie, unengaged presenting part.
CI: placenta previa, previous C-section

49
Q

What are the risks of external cephalic version?

A

still birth, abruption, emergent C-section, cord prolapse, vaginal bleeding, rupture of membranes, maternofetal transfusion, transient abnormal changes in fetal HR. The rate of serious complications is low.

50
Q

Define umbilical cord prolapse.

A

ubilical cord presents outside the cervix before the fetus.

51
Q

T/F: Umbilical cord prolapse is easily manged through the duration of a normal delivery.

A

False: It is an obstetrical emergency s/p disruption of blood flow from the descending fetus putting pressure on the cord.

52
Q

What are the signs of cord prolapse?

A

variable late decelerations, prolonged bradycardia. May be visible on vaginal exam or occult (not visible).

53
Q

How is cord prolapse managed?

A

Emergent C-section (obstetric standard of care).

54
Q

If the standard of care for a cord prolapse is delayed, how else might the circumstance be managed?

A

Manual elevation of the fetal head with two fingers, Maternal repositioning - Trendelenburg or knee to chest with face toward floor, terbutaline (0.25mg SC) to dec uterine contractions and alleviate pressure on the cord.

55
Q

How is delivery managed when a shoulder is the initial presenting part?

A

C-section s/p risk of cord prolapse and uterine rupture.

56
Q

How is the diagnosis of a transverse lie made?

A

Abdominal US confirms. Digital vaginal exam should not be performed until underlying causes (esp placenta previa) are ruled out.

57
Q

What are the indications for attempting external version in a transverse lie and when is it attempted?

A

Ind: single gestation with no underlying abnormality
When: 37 weeks gestation - allows for ample amniotic fluid and restricting time period for recurrence.

58
Q

Describe the various fetal positions when the head is the first presenting part.

A 
OA = occiput anterior - most common position
OP = occiput posterior
OT = occiput transverse (left or right facing) - most common position at onset of labor then converts to OA.
59
Q

What are the risks of OP positioning and in what patients is this presentation most common?

A

Fetal Risks: low APGAR, umbilical artery acidemia, increased rate of NICU admission
Maternal Risks: anal sphincter injury
Most common: nulliparous women followed by: maternal age > 35, obesity, previous OP delivery, small pelvic outlet, gestational age > 41 weeks, birthweight > 4000g, anterior placenta, use of epidural anesthesia

60
Q

List three obstetric emergencies:

A

Cord prolapse, fetal bradycardia, shoulder dystocia

61
Q

Define fetal bradycardia.

A

Hetal HR < 100-110 or prolonged decel > 10 minutes

62
Q

List three categories causes of causes of fetal bradycardia and give examples of each.

A

Preuterine: maternal HypoTN, hypoxia, seizure, MI, PE
Uteroplacental: abruption, previa, hyperstimulation
Postplacental: cord prolapse, cord compression, vasa previa (rupture of fetal vessel)

63
Q

List 3 treatments for fetal bradycardia.

A
  1. Move mother to lateral decubitus position to decrease pressure on IVC
  2. Place mother on O2 by mask
  3. Manage underlying cause
64
Q

Define shoulder dystocia.

A

Failure of the shoulders to spontaneously traverse the pelvis after delivery of the fetal head.

65
Q

What are risk factors for shoulder dystocia?

A

fetal macrosomia (> 4000g), DM (gestational or pre-pregnancy), previous shoulder dystocia, post-term delivery, prolonged 2nd stage of labor.

66
Q

What are the potential complications of shoulder dystocia?

A

fetal hypoxia, permanent brachial plexus palsy, fetal or maternal injury, fetal death.

67
Q

Describe the steps to attempt vaginal delivery in shoulder dystocia.

A
  1. McRobert’s Maneuver: extreme flexion of maternal hips to increase AP diameter
  2. Maternal suprapubic pressure
  3. Rubin Maneuver: pressure on anterior shoulder to decrease bisacromial (distance between shoulders) diameter.
  4. Wood’s Screw: pressure behind posterior shoulder to rotate baby and dislodge anterior shoulder.
  5. Delivery of posterior arm/shoulder by sweeping posterior arm across chest
  6. Zavenelli Maneuver: place fetal head back in pelvis and perform C-section
68
Q

When should Zavanelli Maneuver be used in the management of shoulder dystocia?

A

Only in true emergency when all other maneuvers to facilitate vaginal delivery have failed. Associated with increased risk of infection.

69
Q

List and describe the 5 components of the APGAR score.

A

Appearance: 0 = central cyanosis, 1 = peripheral cyanosis, 2 = pink
Pulse: 0 = absent, 1 = < 100, 2 = > 100
Grimace: 0 = no response to stim, 1 = weak cry when stim, strong cry when stim
Activity: 0 = floppy, 1 = some flexion, 2 = well flexed and resisting extension
Respiration: 0 = apnea, 1 = slow and irregular, 2 = strong cry

70
Q

When is the APGAR score assessed?

A

1 minute and 5 minutes after delivery

71
Q

List the APGAR total score benchmarks for intervention.

A

7+ = no distress and baby can be placed skin-to-skin on mother’s chest
6 or less = distress and need for intervention

72
Q

Describe the steps in management if the neonate’s pulse is less than 100 during APGAR assessment.

A

Pulse < 100 typically indicates respiratory distress/failure. Begin with 30 sec of positive pressure ventilations. If HR remains < 100, continue PPV and assess the need for repositioning, suction, mask adjustment, and/or pressure increase.

73
Q

Describe the routine post-partum management following a vaginal delivery.

A

NSAIDs/APAP for pain, low dose opioids for sleep, perianal care –> ice packs for pain and edema, inspect for hematomas, hemorrhoid meds, stool softeners.

74
Q

Describe the routine post-partum management following a vaginal delivery.

A

Local wound care, monitor for signs of infection or wound dehiscence (separation), opioids PRN for pain, stool softener +/- laxative for opioid constipation, NSAIDs for cramping.

75
Q

What are the benefits of breastfeeding in the immediate post-partum time period?

A

Oxytocin release contracts uterus and lowers bleeding risk, passive immunity via immunoglobulins, more likely to lose weight (dec T2D risk.

76
Q

What is letdown, when does it start, and what are the signs it has started?

A

Release of breast milk from the ducts. Typically happens 24-72 hours after delivery. Signs include warmer, firmer, tender breasts.

77
Q

How is breast tenderness managed in a post-partum woman that is not breast feeding?

A

ice packs, tight bra, analgesics, NSAIDs

78
Q

T/F: Oral contraceptive use should begin within 72 hours of delivery.

A

False: OCP use should begin 3-6 weeks after delivery. Should not begin until after 3 weeks of breastfeeding.

79
Q

Define the puerperium period.

A

The time period about 6 weeks after delivery.

80
Q

Describe the normal transition of the uterus in the puerperium period.

A

Uterus at the level of the umbilicus immediately after delivery, begins to shrink after 2 days, descends into pelvic cavity after 2 weeks, pre-pregnancy size after 6 weeks.

81
Q

Define post-partum involution.

A

Return of the uterus to its normal size and function

82
Q

Define lochia.

A

Normal post-partum bleeding that occurs for 4-5 weeks after delivery.

83
Q

When do menses begin after delivery?

A

6-8 weeks post-partum if no breast feeding. In breast feeding women, menses may not return until breast feeding ceases.

84
Q

When should the first post-partum OB visit occur and what should be done?

A

6 weeks after delivery. Perineum should be healed. Obtain Hgb/Hct, fasting glucose if GDM, assess Edinburge postnatal depression scale, emphasize contraception, recommend vitamin supplementation for breastfeeding mothers, treat atrophic vaginitis with vaginal estrogen PRN

85
Q

Define post-partum hemorrhage (PPH) and list potential causes.

A

PPH = > 500ml after vaginal delivery or > 1L after C-section. Causes = uterine atony (most common), reatined products of conception, placenta accreta, cervical or vaginal lacerations, coagulation disorders.

86
Q

Define placenta accreta.

A

Growth of the placenta too deep in to the uterine wall resulting in part or all of the placenta remaining attached after childbirth.

87
Q

Describe the management of PPH.

A

Investigate cause, fluid resuscitation and/or blood transfusion, coagulation and platelets if blood loss > 2-3 L, digital extraction +/- curettage if retained placenta suspected cause. Adjuvant therapy = bimanual uterine massage and IV oxytocin (pitocin)

88
Q

What is Sheehan Syndrome?

A

Postpartum hypopituitarism resulting from hypoxia experienced in PPH. Can cause absence of lactation and failure to restart menses. Rare in developed countries.

89
Q

What is the next step in management of a 10% or more postpartum reduction of Hgb/Hct is noted?

A

US to assess for retained placental fragments.

90
Q

Describe pharmacological options to increase uterine contractions if bleeding continues after oxytocin administration and list the contraindications of each

A

Misoprostol
Carboprost: asthma (may cause bronchospasm)
Methergine: HTN

91
Q

Define endomyometritis, state the most common risk factors, and state when it usually manifests.

A

Def: infection of the uterine lining that often invades the myometrium.
Risks: more common after C-section or manual extraction of the placenta
Typically manifests 5-10 days after delivery

92
Q

Describe the S/S of endomyometritis.

A

High fever, leukocytosis (> 20,000), uterione tenderness, adnexal tenderness, peritoneal irritation, decreased bowel sounds.

93
Q

What is the most common causative organism in endomyometritis?

A

Anaerobic streptococci

94
Q

What is the treatment for endomyometritis?

A

IV abx (clindamycin or gentamycin) + ampicillin if no improvement in 48 hours, then add metronidazole if sepsis persists.. D&C if retained placenta.

95
Q

What treatment during delivery decreases risk of endomyometritis?

A

Single abx dose at time of cord clamping.

96
Q

Define and describe the causes of mastitis.

A

Def: regional infection of the breast.
Causes: clogged milk ducts (MC), invasion of skin/oral flora from breast feeding baby.

97
Q

Describe the S/S of mastitis.

A

focal tenderness, erythema, warm to touch, fever, leukocytosis (inc WBCs)

98
Q

What is the treatment of mastitis?

A

I&D, PO dicloxacillin (clindamycin if PCN allergy), IVabx if unresponsive to PO, completely empty breast of milk. Prevention with lubricating ointments.

99
Q

What is the usual timeline of postpartum depression?

A

Onset 2-3 days after delivery, peaks at 5 days, resolves in 2 weeks.

100
Q

What is the treatment for postpartum depression?

A

Assess for SI/HI, involve counselor or social worker, SSRI have good efficacy.

EOR Exam - Women's Health (7 decks)

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