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OBGYN > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

List the criteria for normal labor

A

Regular uterine contractions along with cervical dilation

  • begins spontaneously
  • proceeds at normal rate
  • proceeds without intervention
  • results in spontaneous vaginal delivery
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2
Q

Describe the stages of labor

A

1st Stage (Contraction and cervical dilatation)
- latent phase is prodrome labour and not clinically classified as true labour (6-20h in nulli and 4-13 in multi)
- active phase is true labour and cervical dilation of >3-4cm
- begins with acceleration phase
- phase of maximum slope where have cervical dilation to 10cm
- deceleration phase into 2nd stage
- nulli have 1.2-3.0cm/hr and multi have 1.5-5.7cm/h
2nd Stage
- fetal descent and delivery over 1-3 in nulli and 0.5-1 in multi
3rd Stage
- delivery of placenta

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3
Q

Discuss the changes in stage 1 of labour

A
  • uterus changes where upper uterus have stronger contractions resulting in shrinking and lower uterus have smaller contractions and get bigger
  • cervix becomes effaced and then dilated
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4
Q

Discuss the changes in stage 2 labor

A

Baby 7 Cardinal Movements

  • engagement where head engaged to ischial spine
  • descent where downward passage through cervix
  • flexion where partial flexion of head as baby passess through pelvis
  • internal rotation where rotate head from occiput transverse to either anterior or posterior
  • extension where extend head once past pubic symphysis
  • restitution once head delivered it rotates back to original position
  • expulsion where further descent bring shoulder past pubic symphysis
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5
Q

Discuss the 5 cardinal findings on physical exam of pregnant women

A 
Effacement
- smoothness of the cervix relative to the uterus
Dilatation
- dilation of the cervix
Station
- relation of head to ischial spines
Presentation
- foremost part of the fetus within or near birth canal
- normal is cephalic vertex
Position
- orientation of the baby occiput relative to maternal pelvis
- normal is occiput anterior
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6
Q

What are the four cardinal questions for women in labour

A 
Cardinal
- fetal movement (>6 per hour normal)
- bleeding per vagina
- rupture of membranes
- contrations including regularity, length and pain
History
- gestational age
- maternal age
- GTPAL
- complications during pregnancy
- prenatal care
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7
Q

Discuss how to differentiate true and false labour

A 
True
- contractions: regular
- frequency: decreasing interval
- intensity: worsening
- location: back and abdomen
- cervical change: dilating
- effect of sedation: no change
False
- contractions: irregular
- frequency: interval increasing
- intensity: not changing
- location: lower abdomen
- cervical change: no change
- effect of sedation: diminish
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8
Q

Discuss the management of Stage 1 Labor

A 
Preparation
- epidural
- GBS positive require prophylaxis
- Rh- require rhogram
Management
- mark progress by cervical dilation per hour
- should take between 5-10 hours
- assess for dystocia if cervical dilation <1.2cm/h in nulli or 1.5/h in multi
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9
Q

Discuss the management of Stage 2 labour

A
  • progress by monitoring station
  • assess correct position by Leopold and vaginal exam
  • no time limit as long as no fetal compromie
    Indications for pushing
  • exceeded 3rd hour of stage 2
  • patient without epidural feel urge to push
  • nulliparous with epidural when fetus head visible or station >+2 and occiput anterior
  • multiparous with epidural when urge to push, head is visible, or station >+2 with occiput anterior
    Reassessment
  • dystocia if <1cm/hr descent in nulliparous or <2cm/hr in multi
  • maximum duration if after 2 hours of pushing
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10
Q

Discuss the management of stage 3 of labour

A
  • placenta should deliver within 15 minutes
  • if no delivery within 30-45 minutes then active management
  • after delivery than clamp and cut cord (delay by >1 minutes if <37 weeks)
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11
Q 
Discuss the different terminology of twins
Dizygotic
Monozygotic
Monoamniotic
Monochorionic
A 
Dizygotic
- fertilization of 2 different eggs with 2 different sperm 
Monozygotic
- fertilization of 1 egg with 1 sperm
Monoamniotic
- twins sharing same amniotic sac
- di is have own amniotic sac
Monochorionic
- twins sharing same placenta
- di is have each their own

Complications
- monoamn and monochori have highest risk of complications
Splitting
- di - di split within 3 days
- diamniotic and mono split within 3-8 days
- mono - mono split within 8-13 days
- conjoined split after 13 days

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12
Q

Discuss the complications of multiple gestations

A 
Maternal
- hyper-emesis gravidarum
- gestational diabetes or hypertension
- anemia
Pregnancy
- polyhydramnios
- placental abruption or previa
- cord anomalie
- twin transfusion syndrome
Delivery
- increased morbidity and mortality
- premature preterm rupture of membranes
- preterm labor
- prolonged labor
- malpresentation
- umbilical cord prolapse
- increased risk of C - section 
- post-partum hemorrhage
Fetal
- IUGR
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13
Q

Discuss the presentation and management of twin-twin transfusion syndrome

A
  • 10% of mono-chorionic twins
    Pathophysiology
  • arterial blood from twin A passes through placenta and into twin B resulting in twin A having reduced blood supply and IUGR and twin B having excessive blood supply and hypervolemia, congestive heart failure, polycythemia
    Investigation
  • ultrasound with doppler flow
    Management
  • recipient twin get serial amniocentesis to reduce volume
  • donor twin get intra-uterine blood transfusion
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14
Q

Discuss the management of multiple gestation

A
  • weekly testing from 24 weeks gestation
  • serial ultrasound every 2-3 weeks from 28 weeks to assess growth
  • weekly Doppler to assess growth
  • 3rd trimester cervix checks for preterm delivery
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15
Q

Discuss the interpretation of fetal heart rate monitoring

A

Contractions:
- frequency (normal is less than 5 in 10 minutes, tachsystole is >5 per 10 minutes)
- duration (normal is less than 90 seconds)
- resting tone (>30 seconds between contractions)
- timing (regular, singular contractions; tetanic is prolonged contraction lasting >3 minutes, paired or tripling is multiple occurring right next to eachother)
Baseline
- normal is 110-160 per minute
Variability
- fluctuations in baseline rate
- undectable is no variability
- minimal is <5bpm in variability
- moderate is 6-25bpm in variation (normal)
- marked is >25bpm
Acceleration
- abrupt increase in fetal heart rate greater than 15bpm lasting 15 seconds to 2 minutes and reaching peak in <30 seconds
Deceleration
- discussed on another card

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16
Q

Discuss the different types of deceleration

A

Variable
- abrupt decrease in FHR that is >15bpm below baseline and lasts 15 seconds to 2 minutes and reaches nadir <30 seconds
Complicated
- deceleration to <70bpm lasting >1 minute
- low variability of baseline
- biphasic deceleration
- prolonged secondary acceleration (overshoot by 20bm for >20 seconds)
- slow return to baseline
- presence of fetal tachycardia or bradycardia
Repetitive
- >3 decelerations
Late Deceleration
- gradual decrease in FHR and return to baseline after reaching nadir >30s after contraction
Early Deceleration
- gradual decrease in FHR and return to baseline after reaching nadir >30s before contraction

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17
Q

List the differential for fetal tachycardia

A 
Maternal
- Infection
- dehydration
- hyperthyroidism
- anxiety
Fetal
- infection
- prolonged fetal activity
- chronic hypoxemia 
- cardiac anomaly
- anemia
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18
Q

Discuss the management of fetal tachycardia

A

Intra-uterine resuscitation
- reposition mother to left or right lateral decubitus
- supplement O2
- IV bolus
Determine Cause
Intervention
- if persists >80 minutes then fetal scalp pH or delivery to be considered

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19
Q

List the differential for fetal bradycardia

A 
Maternal
- hypotension
- medication
- maternal position
- connective tissue disease
Fetal
- umbilical cord occlusion
- fetal hypoxia/acidosis
- vagal stimulation
- fetal cardiac defect
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20
Q

Discuss the Management of Fetal Bradycardia

A

Intra-uterine resuscitation
Determine cause
Intervention
- if <100bpm or persistant then fetal scalp pH or delivery

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21
Q

List the Indications and Findings of a fetal scalp blood sample

A 
Indications
- atypical or abnormal fetal tracings
- digital fetal scalp stimulation does not result in acceleration
Interpretation
- >7.25 then continue to observe
- 7.21-7.24 then repeat in 30 minutes
- <7.2 then immediate delivery
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22
Q

List the causes of abnormal variability

A 
Minimal
- fetal sleep
- prematurity
- medications: narcotics, beta-blockers, betamethasone
- hypoxic acidemia
- congenital abnormality
Marked
- mild hypoxia
- fetal gasping
Sinusoidal
- severe fetal anemia
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23
Q

List the causes of acceleration

A
  • presence of acceleration is reassuring meaning pH >7.2

- no presence is not concerning however

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24
Q

List the causes of Uncomplicated variable deceleration

A
  • vagal stimulation due to cord compression

- manage with observation and intra-uterine resuscitation

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25
Q

List the causes of complicated, variable deceleration

A 
- fetal acidemia
Management
- intra-uterine resuscitation
- amnioinfusion of RL or NS
- confirm fetal well being with scalp monitor
- consider deliver
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26
Q

list the causes of late deceleration

A 
Maternal
- maternal hypotension
- uterine tachysystole
Placental
- insufficiency
Fetal
- fetal acidemia
Management
- repetitive or >50% contractions require fetal scalp or deliver
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27
Q

List the non-pharmacological pain relief in pregnancy

A 
Minimal Training
- continuous support
- distraction
- massage
- hydrotherapy
- vertical position (best for 1st stage)
Specialized Training
- biofeedback
- intradermal water infection
- TENS
- acupuncture
28
Q

Discuss the pain management of intermittent bolus parenteral opioids

A

Types:
- morphine and fentanyl most common
- fentanyl have reduced effect on fetus
Indication
- 3rd line
- used for early labor or very late stage where epidural not an option
Advantage
- simple and easy to use with quick onset
Disadvantage
- maternal side effects of respiratory depression, drowsiness and delayed gastric emptying
- fetal side effects of decreased FHR variability and respiratory depression

29
Q

Discuss the pain management of PCA

A 
- fentanyl used in PCA
Indication
- 2nd line
- intrauterine fetal demise or termination
Advantages
- provides instantaneous relief at lower doses
- have reduced maternal side effects
Disadvantage
- specialized equipment
- small doses not as effective
30
Q

Discuss pain management of inhalation nitrous oxide

A
  • entonox (50 nitrous oxide: 50 oxygen) breathed via mask PRN
    Indication
  • used before or in conjunction with opioids
    Advantage
  • easy to use and minimal accumulation of drug
  • no uterine effect
    Disadvantage
  • not complete analgesia
  • drowsiness, disorientation and nausea when wearing mask
31
Q

Discuss pain management of epidural

A 
- go into epidural space
Indication
- 1st line
Contraindication
- patient cannot sit still
- raised ICP
- infection at site or systemic
- coagulopathy
Complications
- early: failure, bleeding, dura puncture, urinary retention
- late: post-dural puncture headache, nerve injury, infection, hematoma
Advantage
- most effective
- can be transferred to C-section anaesthesia
32
Q

Discuss pain management of spinal analgesia

A 
- going past dura mater
Indication
- provide instanenous relief while waiting for epidural
Advantage
- rapid onset
- complete analgesia
Disadvantage
- delayed verification of epidural
- require dural puncture
- risk of fetal bradycardia
33
Q

Discuss the definition, pathophysiology, and presentation of preterm labour

A
  • labour occurring between 20 and 37 weeks
    Pathophysiology
  • have irritation of the chorion and decidua which triggers uterine contractions and cervical changes
    Presentation
  • uterine contractions with cervical changes
  • abdominal pain and pressure
  • increase or change in vaginal discharge
34
Q

List the medications used in pre-term labor

A

Tocolytics (prolong the latent phase of labour in order to delay delivery by 2-3 days)
- NSAID Indomethecin 50-100mg PO
- MgS04 6g IV loading dose (used in fetus 24-28 weeks due to neuroprotective effect)
- Nifedipine 20mg PO
Corticosteroids
- betamethasone 12mg IM
- done to promote lung maturation and increase surfactant production

35
Q

List the risk factors for pre-term labor

A 
Maternal
- prior history of pre-term labor
- low maternal weight
- smoking, substance use
- short interval between pregnancies
Pregnancy
- pre-term uterine contraction or rupture of membranes
- vaginal bleedng
- periodontal disease
36
Q

List the risk factors for pre-term premature rupture of membranes

A 
- rupture of membrane before 37 weeks and prior to onset of labour
Maternal
- smoking
- prior PPROM
- short cervical length
Pregnancy
- polyhydramnios
- multiple gestations
- bleeding in early pregnancy
37
Q

List the risk factors for premature rupture of membranes

A 
- rupture of membranes prior to labour
Maternal
- multi-parity
- cervical incompetence
- infection
- poor nutrition
- family history
Pregnancy
- congenital anomaly
- multiple gestation
38
Q

Discuss the presentation and management of premature rupture of membranes

A

Presentation
- fluid gush or continued leakage
- speculum show pooling of fluid in posterior fornix or fluid leaking from cervix
- positive nitrazine test
- most go into labour within 1 week
Complications
- chorioamniotis
- cord prolapse
- limb contracture
Management
- if intra-uterine safer than NICU than expectant managmenet
- near term or term deliver by induction or C-section, with GBS prophylaxis
- pre-term expectant management and IV abx (corticosteroids if less than 31 weeks)

39
Q

List the Indications and Contra-indications for induction of labour

A 
Indications
- post-date pregnancy where >41+3 weeks
- gestational hypertension or maternal comorbidities
- antepartum hemorrhage
- chorioamnionitis
- PROM
- fetal IUGR
Contra-indications
- prior C-section
- active maternal genital herpes
- invasive cervical cancer
- placenta previa or cord presentation
- fetal distress
40
Q

List the components of Bishop’s score

A

Score

  • position
  • consistency
  • effancement
  • dilatation
  • station

Induction
- >6 than can consider induction as cervix is favourable

41
Q

List the techniques used for induction of labour

A

Cervical Ripening (soften, effce, dilate the cervix)
- intra-vaginal PGE2 gel
- foley catheter to manually dilate cervix
Amniotomy
- artificial rupture of membranes to stimulate prostaglandin synthesis and secretion
Oxytocin
- causes uterine contraction allowing for progression of labour
- 10 units in 1L of NS at 0.5-2mU/min to increasing

42
Q

List the indications and contra-indications for operative vaginal delivery

A 
Indications
- fetal distress
- medical complications for mother to not push
- inadequate progress with adequate uterine activity
Contra-indication
- incomplete cervical dilatation
- unengaged head
- non-vertex position
- fetal coagulopathy
43
Q

Discuss the procedure for operative vaginal delivery (ABCDEFGHIJ)

A

A: Address consent, anesthesia, and assistance
B: Bladder empty
C: Cervix fully dilated, membranes ruptured, contractions adequate
D: Determine fetal position, station and dystocia
E: Equipment check
F: Flexion point for vacuum
G: Gentle mental traction over the posterior fontanelle
H: handle in axis of birth canal, halt (3 pop offs or 3 pulls with no progress after 20 minutes)
I: incision
J: remove when jaw is reachable

44
Q

List the grading system for perineal tears

A

1st Degree
- involvement of the fourchette, perineal sin and vaginal mucosa
2nd Degree
- involvement of 1st degree plus fascia and muscles (bulbocavernosus, perineal body, and transverse perineal muscle)
3rd Degree
- involvement of above plus extension into anal sphincter
4th Degree
- involvement of above plus extension into rectal mucosa

45
Q

Discuss the indications for surgical repair of perineal tears

A

Indication

- perineal laceration >=2nd degree

46
Q

List the indications for a C-section

A 
Maternal
- obstruction in birth canal
- active herpetic lesion
- invasive cervical cancer
- previous uterine surgery
- underlying maternal illness
Pregnancy
- failure to progress
- placental abruption, previa
- vasa previa
- umbilical cord prolapse
Fetal
- abnormal fetal heart tracing
- malpresentation
- cephalic pelvic position
- congenital anomaly
47
Q

List the risks of C-section

A
  • anesthesia risk
  • hemorrhage
  • injury to surrounding bowel, bladder, ureter or uterus
  • thromboembolism
  • increased recovery time
48
Q

What is vaginal birth after cesarean and what are the contraindications

A
  • usually done after previous low transverse uterine incision
    Contraindication
  • previous classical or unknown incision with risk of possible rupture
  • previous uterine rupture
  • multiple gestation
  • estimated fetal weight >4kg
  • non-vertex position
49
Q

Define dystocia

A
  • abnormal labour progress when cervix dilated >3-4cm
    1st phase
  • protracted cervical dilatation <1.2cm/hr in nulli or <1.5cm/hr in multi
  • arrest of dilatation >2hours in nulli or multi
    2nd Phase
  • protracted descent <1cm/hr in nulliparous or <2cm/hr in multi
  • arrest of descent >1hr in nulli and multi

Due to 3 primary causes

  • power: ineffective uterine expulsive forces
  • passenger: abnormal fetal lie, malpresentation, fetal anatomic defect, macrosomia
  • passage: maternal bony pelvic contracture
50
Q

Discuss the causes of Passenger abnormalities

A

Mal-presentation
- breech: buttock or feet first
- brow: brow of face
- face: face first
- shoulder
- compound presentation: extremity prolapse with transverse lie
Management
- breech: external cephalic version before labour or C-section
- face presentation: mentum anterior can be delivered
- brow presentation: wait for conversion to face or cephalic, if not C-section
- shoulder: C-section
- compound: retraction and then normal delivery

51
Q

Discuss the presentation and management of breech presentation

A

Definition
- complete: flexion at hip and knees (least common)
- frank: flexion at hips and knees extended (most common)
- footling: foot as presenting with extension at hip and knee
Risk Factors
- maternal: abnormal uterine shape or pelvic contraction
- pregnancy: previa, polyhydramnios, prematurity, multiple gestation
Management
- ultrasound
- external cephalic version if >37 weeks, head not engaged and unreactive stress test
- delivery: vaginal only if perfect criteria (>36 weeks, weight between 2.5-3.8, fetal head flexed, continuous monitoring and ability to perform crash C-section) otherwise perform C

52
Q

Discuss the passage complications

A
  • cephalopelvic disproportion: maternal bony pelvis is not sufficient
    Pelvic Inlet Contraction
  • shortest anteroposterior diameter if diagonal conjugate <11.5 (1.5cm greater than obstetric conjugate)
    Mid-Pelvic Contraction (most common)
  • palpation of ischial spines where <10cm is suspected as cause and <8cm is known
    Pelvic Outlet Contraction (least common)
  • inter-ischial tuberous diameter of <8cm
53
Q

Discuss the power complications

A
  • uterine dysfunction: lack power to push fetus through birth canal
  • hypotonic when synchronous effort but insufficient pressure to dilate cervix
  • hypertonic where have elevated base tone of uterus
  • incoordinate where distorted pressure gradient in uterus
    Etiology
  • maternal position
  • epidural analgesia
  • chorioamnionitis
  • uterine abnormality
    Management
  • augementation of labour through amniotomy and oxytocin
54
Q

Discuss the presentation and management of Shoulder Dystocia

A

Pathophysiology
- impaction of anterior or posterior shoulder during vaginal delivery
Risk Factors
- pre-labour: macrosomia >4.5kg, history of shoulder dystocia, induction of labour
- intra: prolonged first and second stage, secondary arrest, oxytocin augmentation, assisted vaginal delivery
Diagnosis
- difficulty delivering head and chin
- head remaining tightly in vulva and retracting
- failure to restitute fetal head
- failure of shoulder to descend
- head to body delivery >60 seconds
Management
- call for help and discourage pushing
- McRobert’s maneuver: sharp flexion of mothers leg onto abdomen with suprapubic pressure
- episiotomy
- Woods maneuver: progressive rotation of posterior shoulder 180 degrees
- deliver posterior shoulder
- second Rubin maneuver

55
Q

List the complications from shoulder dystocia

A 
Maternal
- 3rd-4th degree perineal tears
- post-partum hemorrhage
- infection
- uterine rupture
- fistual
Fetal
- brachial plexus injury
- clavicle or humerus fracture
- fetal death
56
Q

List the definition and risk factors for post-partum hemorrhage

A 
Definition:
- >500mL of blood loss with vaginal delivery or >1000mL with C-section 
- any blood loss which results in hemodynamic instability
Risk Factors
- failure to progress in second stage
- adherent placenta
- family history 
- Asian or hispanic
- instrumental delivery
- large for gestational age baby
- hypertensive disorder
- obesity
- multiple gestation
57
Q

Discuss the differential for PPH

A

Tone (most common)
- pathophysiology: failure of uterus to contract and involute post-delivery resulting in early (<24hrs) PPH
- labour: prolonged, induced, augmentated
- uterus: infection, over-distention, functional disorder
- placenta: abruption, previa
- grand-multiparity
Tissue
- pathophysiology: retained tissue within uterus preventing from involution
- placental or clots retained
Trauma
- pathophysiology: trauma to any part of female anatomy
Thrombin
- pathophysiology: disruption of platelet plug formation or coagulation cascade

58
Q

Discuss the management of PPH

A 
Stabilize and Monitor
Medical:
- Oxytocin 20units/L NS continuous
- add Methylergonavine maleate, carboprost, misoprostil, or 15-methyl prostaglandin
Source control
- remove retained products
- close laceration or add compression 
Invasive
- B-lynch suture: compression of atonic uterus
- internal iliac ligation
- hysterectomy
59
Q

Discuss the post-partum management for contraception

A
  • OCP not recommended for first 3-6 weeks following delivery for non-breast feeding mothers due to risk of VTE
  • can ovulate within 25 days post-partum so require immediate protection
  • breast feeding mothers anovulation <6 months, breast feeding exclusively, and amenorrhea.
  • Initially condoms or IUD recommended as progesterone does not affect milk production.
60
Q

Discuss the post-partum management of depression

A

Presentation
- blues increase 3-5 days post-partum and improve after few weeks
- depression in onset of depressive symptoms within 3 months post-partum
Prevention
- lifestyle modification in order to reduce stress
Treatment
- SSRI
- psychosis get CBT

61
Q

Discuss nutrition and alcohol post-partum

A
  • require increased calories in breastfeeding women with good iron and calcium intak
  • gradual post-partum weight loss of <4.5lbs/month
62
Q

Discuss effects of smoking and alcohol use post-partum

A 
Smoking
- SIDS
- lung disease
- learning disorder
Alcohol
- decreased milk intake
- impaired motor development
- altered sleep
63
Q

Discuss appropriate breastfeeding guidelines

A 
Recommendations
- should breastfeed for first 6 months exclusively
- feed 8-12x per day with 6-8 wet diapers and one soft, seedy stool
Contraindications
- HIV positive
- HTLV
- Herpes lesion of breast
- Child with galactosemia
- Drugs use in mother
64
Q

Discuss the risk factors for intra-uterine fetal death

A 
- is fetal death after 20 weeks or if weight >500g
Maternal
- advanced maternal age
- prior stillbirth
- post-term
- obesity
- smoking or illicit drug use
Pregnancy
- fetal growth restriction
- fetal macrosomia
- multiple gestation
- no antenatal care
65
Q

Discuss the presentation and management of intra-uterine fetal death

A 
Presentation
- decreased fetal movements
- uterine contraction
- vaginal bleeding
- symphysis-fundal height no increasing
Investigations
- high AFP
- absent cardiac activity
- secondary analysis for cause
- possible DIC
Management
- spontaneous labour and vaginal delivery 
- induced labour
- dilatation and evacuation for 18-24 weeks
66
Q

Discuss the medical management of termination of pregnancy

A

Medical Management
- Fetus <9 weeks: Methotrexate plus misoprostol
- Fetus >12 weeks: prostaglandin or misoprostol
- require good follow up care
Surgical Management
- <12-14 weeks dilatation and curettage
- >12-14 weeks: dilatation and evacuation

OBGYN (4 decks)

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