Delivery / Intrapartum Flashcards
(137 cards)
1
Q
definition postterm
A
42w0d
2
Q
Postterm maternal outcomes
A
Increased:
oligo
cervical lacs
operative deliv
CS
PPH
infxn
3
Q
postterm fetal outcomes
A
Inc:
seizures
mec
NICU
macrosomia
low 5-min apgars
postmaturity s/d
4
Q
Postmaturity S/d
A
long nails
dry skin
mec
low blood sugar
5
Q
incidence postmaturity s/d
A
15-20%
6
Q
Best BPP indicator for uteroplacental fxn
A
amniotic fluid volume (if decreased fetal urine, sign of renal insuff)
7
Q
Vasa Previa perinatal morbidity
A
56% if not diagnosed prenatally
3% if diagnosed prenatally
8
Q
Goals / timing / modality for delivery of vasa previa
A
goal: prevent membrane rupture -> fetal exanguination
timing: usually 34wks
modality: c/s
9
Q
LGA
A
birth weight >90%ile for GA
different than macrosomia (EFW, not birth weight)
10
Q
Shoulder dystocia risk:
-all vaginal deliveries
-macrosomia
-macrosomia + diabetes
A
-all SVD: 0.2 - 3%
-macrosomia (>4500): 10-25%
-macrosomia + diabetes: 20-50%
11
Q
Delivery timing
- Di-di twins
- Monochorionic - diamniotic
- mono -mono
A
- 38w
- 34-37w6d
- 32-34w
12
Q
Twin discordance percentage
A
> 20%
13
Q
Terbutaline MoA
Use:
A
beta-2 adrenergic agonist
Use: bronchodilator, smooth m relaxation (via cAMP) -> uterine relax
14
Q
Terbutaline CI
MoA
A
maternal cardiac arrythmia
MoA: activates beta1 adrenergic receptors -> inc HR
15
Q
Describe a Negative CST
A
no late or sig. variable decelerations
16
Q
Describe a positive CST
A
late decels after 50% or more of ctx
17
Q
Describe an unsatisfactory CST
A
-uninterpretable
-less than 3ctx in 10min
18
Q
Describe an equivocal CST
A
decels in freq. ctx (>2mins) or long ctx (>90secs)
19
Q
Describe an equivocal-suspicious CST
A
occasional late decels or severe variables
20
Q
Placental Abruption Risk Factors
A
- previous abruption*
*2. cocaine, other drugs - chronic HTN, PEC, Eclampsia
- chorio
- PROM
- poly
- smoking
*most assoc
21
Q
Sequential Operative Delivery Risks
(i.e. vaccuum + frceps combo)
A
- anal sphincter tears
- inctracranial hemorrhage
- subdural,cerebral, subarachnoid hmorrhage
- facial nerve, brachial plexus injury
higher than eithermethod alone
22
Q
Vaccuum Delivery Risks
A
-2x risk of OASIS compared to SVD
-neonatal lacerations
-intracranial hemorrhage
23
Q
Forceps Delivery Risks
A
6x risk of OASIS compare dwith SVD
inc 2nd stage labor
lacerations
facial n, brachial plexus injury
intracranial hemorhage
skull fracture
24
Q
Face presentation mgmt
A
mentum posterior: C/S if no passive rotation to mentum anterior
mentum anterior: can attempt vaginal delivery
mentum posterior = chin to ground
25
MCC neonatal ambiguous genitalia
| Karyotype
CAH
| karyotype 90% = 46XX
26
Klinefelter Sd
-karytoype
-phenotype (male v female)
-sx / findings
| MoA
47XXY
male phenotype
tall, infertile, gynecomastia, small testes
| MoA: extra X chromosome inerferes with testosterone, sperm production
27
Pitocin half-life
3-5minutes
28
Pitocin steady state
40 minutes
29
GA @ which NST uses accelerations 10x10
<32w
30
GA @ which NST uses accelerations15x15
>32w GA
31
NST extended amount of time?
40 minutes (if cx not met in 20 minutes)
| requirements must be met w/i single 20 min period
32
Definition prolonged second stage of labor
Nulliparous: >3hrs pushing
Multiparous: >2hrs pushing
33
Definition Prolonged Latent Phase
>16hrs
34
Definition "Active Phase Arrest of Labor"
1. no progression in cervical dilation ≥6cm
2. rupured membranes on pit
3. 4hrs adequate uterine activity or 6hrs inadequate uterine activity*
| *6hrs inadequate uterine activity WITH PIT
35
Definition of "Adequate uterine Activity"
≥200MVUs by IUPC
| *on pit, over 10min period
36
Delivery Timing for PPROM
| Mgmt
~34w0d
| inpatient, steroids, latency abx, MgSO4
37
Define Cat I Tracing
* FH 110-160
* Mod variability
* +/- accelerations or early decels
* NO variables/lates
38
Define Cat III Tracing
* absent variability +
-recurrent lates, variables, or brady
*sinusoidal
39
Define Cat II Tracing
* brady or tachy
* absent cariability w/o decels
* prolonged decels
* int/recurrent variable or late decels w/ minimal or moderate variability
40
# What Cat tracing?
FH 150
mod variability
+accels
-decels
Cat I
41
# What Cat tracing?
FH 120
absent variability
recurrent lates
Cat III
42
# What Cat Tracing?
FH 165
Mod variability
+accels
-decels
Cat II
| b/c of tachy
43
# What Cat tracing?
FH 140
mod variability
no accels
early decels
Cat I
44
# What Cat tracing?
FH 110
mod variability
no accels
no decels
Cat I
45
% breech fetuses at term
2-3%
46
Frank breech definition
butt @ os
stretched legs
47
Complete breech definition
hips flexed
one/both knees flexed (cannonball)
48
Incomplete breech definition
one or both hips extended
foot or knee @ os
49
Risk factors shoulder dystocia
hx dystocia (10-16%)*
macrosomia
GDM
excessive weight gain
short or prolonged second stage
operative vaginal delivery
| *greatest risk factor
50
AFE Triad
hypotension
hypoxia
coagulopathy
51
AFE mgmt of fetus
delivery (improves fetal outcomes and maternal resusc)
52
Definition Second Stage arrest
| with/without epidural
primi: >3hrs pushing, no progress
multi: >2hrs pushing, no progress
| add 1hr if has an epidural (4, 3)
53
Normal Umbilical Artery: pH
7.28 ± 0.05
54
Normal Umbilical artery PCO2
49.2 ±8.4mmHg
55
Normal Umbilical Artery PO2
18 ± 6.2 mmHg
56
Normal Umbilical Artery HCO3
22.3 ± 2.5 mEq/L
57
Normal Umbilical Artery Base Deficit
4 ± 3 mmol/L
58
Findings in metabolic alkalosis
elev pH
elev HCO3
59
Findings in metabolic acidosis
elevated base deficit
60
Findings in respiratory acidosis
pCO2 elevated
61
HCO3
| metabolic or repiratory signifier?
bicarb
| reduced in metabolic acidosis (gain in hydrogen ions)
## Footnote
inc in metabolic alkalosis
62
pCO2
| metabolic or repiratory signifier?
carbon dioxide
| increased in respiratory acidosis 2/2 hypoventilation
## Footnote
decreased in resp. alkalosis 2/2 hypervent
63
Neonatal respiratory acidosis:
-assoc
-ABG findings
assoc: short-lasting hypoxic event
ABG: low pH, high pCO2
| high pCO2 b/c respiratory depression
64
Neonatal metabolic acidosis:
-assoc
-ABG findings
-assoc: lactate production, long hypoxia, neonatal morbidity (CP, encephalopathy)
-ABG: low pH, low HCO3, high base deficit
65
earliest GA for vaccuum delivery
≥34wks
66
Neonatal Lupus Etiol
| maternal risk factors
passive transfer of maternal autoantibodies
| SLE, othe rautoimmune do
67
Maternal antibodies assoc w/ neonatal lupus
Anti-Ro/SSA, anti-La/SSB
68
Neonatal lupus findings
cardiac - heart block
cutaneous - rash
69
Most accurate way to predict cephalopelvic disproportion (CPD)
| adequate #?
interspinous diameter
| ISD≥10cm adequate
70
Cardiac Lesion that is most impacted by epidural placement?
| MoA
aortic stenosis
| epidural decreases preload -> cardiovascular collapse
71
Fetal presentation highest risk of cord prolapse?
footling breech
| so much space!
72
most common fetal presentation w/ cord prolapse?
cephalic
| only b/c most common presentation overall
73
Pitocin side fx
1. hypotension (smooth musc relaxation)
2. arrythmias, tachy
3. water intoxication
4. n/v
5. uterine rupture
6. anaphylaxis
74
Intrapartum GBS ppx if hx of neonate w/ invasive GBS d/z
Yes
75
Intrapartum GBS ppx if hx GBS+ in previous pregnancy?
No
(only if GBS unknown in this pregnancy and laboring)
76
Intrapartum GBS ppx if +GBS <4wks ago
yes
77
Intrapartum GBS ppx if hx GBS bacteriuria this pregnancy?
Yes (any trimester)
78
Intrapartum GBS ppx if hx GBS bacteriuria previous pregnancy?
no
79
Intrapartum GBS ppx if unk GBS >37w0d?
-if ROM >18hrs
-if >100.4
-intrapartum NAAT GBS+
-known GBS+ prev pregnancy
80
Intrapartum GBS ppx if unk GBS <37w0d?
yes
81
Describe Loveset maneuver
-breech delivery
-rotate scapulae anterior
-flex fetal elbow and sweep arm
| aka reolution of nuchal arm
82
Describe Pinard maneuver
-knee flexed
-thigh moved away from midline
-traction to deliver foot
| aka delivery of fetal legs
83
Describe Mauriceau-Smellie-Veit maneuver
index and middle fingers on maxillae -> flex head during breech delivery
| aka "grasp maxilla and flex fetal head"
84
Describe Prague Maneuver
-two fingers of one hand support shoulders of fetus from underneat hfetus
-other hand brings fetal legs above/over maternal abdomen
| aka support sholders, legs for flexion, delivery of fetal head
85
Who needs stress dose steroids in labor?
-any glucocorticoid dose >3wk
-morning dose of >5mg/d of prednisone
->10mg prednisone or equivalent (i.e. 0.75mg dexamethasone) every other day
-cushingoid appearance (suggest HPA-axis suppression)
86
MCC stillbirth
unexplained (60%)
87
Stillbirth incidence
1 / 160 deliveries
88
Describe Midforceps delivery
fetal station above +2
89
Describe low forceps delivery
-fetal station at or below +2
-not on pelvic floor
-rotation <45deg
90
Describe low-rotation forceps delivery
-fetal station at or below +2
-not on pelvic floor
-rotation >45deg (requires rotation)
91
Describe outlet forceps delivery
-fetal scalp @ intraotus w/o labial separation
-fetal skull on pelvic floor
-rotation <45deg
92
% of pregnancies with nuchal cord?
20-34%
93
Signs that exclude fetal hypoxia-induced metabolic acidemia
+accels
+moderate variability
94
Most common pelvic shape
gynecoid
95
Pelvic shape assoc w/ CPD
android
96
Pelvic shape assoc. with OP
anthropoid
97
pelvic shape assoc. w/ transverse arrest (also least common)
platypelloid
98
shoulder dystocia recurrence risk
10%
99
uterine inversion incidence
1/2000 - 1/20,000
100
Methods of IOL in TOLAC
oxytocin
mechanical methods
misoprostol (can only use if <28w)
101
HELLP dx: can you induce labor?
can do IOL (prefered over C/S)
102
Bishop score which confers high chance of vaginal delivery
modified: ≥6
traditional: ≥9
103
most reliable sign of placental separation
cord lengthening
104
GA lower limit for forceps delivery
none, really (can use <34w GA)
105
NSTs, CSTs, BPP:
-NPV
-PPV
NPV high
PPV low
| NPV: negative test has a high likelihood of being truly negative
## Footnote
PPV: false positives screened in (i.e. "in reality, its fine, but this BPP says its not fine so we gotta act on it")
106
Prolonged latent phase:
nulliparous pt
multiparous pt
nulliparous: 20hrs
multiparous: 14hrs
107
describe 1deg lac
injuy to skin only
108
describe 2nd degree lac
perineum injury involving perineal muscels
109
describe 3rd degree lac
3A: <50% external anal sphincter
3B: >50% external anal sphincter
110
describe 4th degree lac
injury involving anal spincter (external and internal) and anal epithelium
111
AFE mgmt
-avoid large volume administration (easily fluid overloaded, pulmonary edema due to heart failure)
-CPR
-correct coagulopathy
112
AFE phases
early: R ventricular failure
second: L ventricular failure
| MoA: increased preload in R ventricle -> inc PVR -> LV failure
## Footnote
increased preload
113
Second Trimester Stillbirth induction ACOG rec
| alternative
-200-600mg oral mife 24-48hrs prior to vaginal miso
-vaginal miso 400-600 q4-6hrs
| high-dose pit
114
Huntington Maneuver
Allis forceps on uterine fundus to reverse a uterine inversion
115
fetal malposition risk factors
-placenta previa
-prematurity
-uterine anomalies
-congenital anomalies
116
Ctx # and duration in a CST to be called adequate
3 ctx, >40secs each
| in 10min period
117
operative delivery method w/ higher risk of OASIS
forceps
118
operative delivery method with higher risk of brain bleeds and sequelae (retinal hemorrhage, hyperbilirubinemia, seizures)
vaccuum
| Note: brain bleed -> increased bilirubin load for neonatal liver
119
operative delivery method iwth more face lacs, palsies
forceps
120
operative delivery method with higher rate of brachial plexus injury
forceps
121
Cx for vaginal delivery of non-cephalic second twin
1. EFW >1500 for both babies
2. EFW Baby A > Baby B
122
Vertical CS Incision Benefits
dec blood loss
faster entry
improved visualization / extend incision
123
Pfannenstiel Incision Benefits
* improved cosmesis
* lower incisional hernias, wound dehiscence
* less postop pain
124
Ctx associated proteins (CAPs)
1. calcium receptors
2. connexin 43
3. oxytocin receptors
4. PF2 alpha receptors
125
What is nuclear factor-kappa B?
stimulates CAPs and induces inflammatory genes (plays role in parturition)
126
NST false-positive rate
high (55-90%)
127
NST false-negative rate
| example
low (0.2-0.65%)
| stillbirth <7d of reactive NST
128
Phases of Parturition
1. Quiescence - cervical softening
2. activation - cervical ripening, uterine preparedness
3. stimulation - cervical dilation, uterine ctx, birth
4. involution - uterine involution, cervical repair, breastfeeding
129
CST result: deep variable decel in 2-3ctx in 10 mins
equivocal-suspicious
| *b/c only recurrent LATES make CST positive
130
CST result: late decel in 2/4 ctx in 10 mins
pos CST
131
CST result: no accels after 2ctx in 10 mins
unsatisfactory
| b/c need 3 ctx in 10mins for a CST
132
CST result: no late or variable decels after 4ctx in 10 mins
neg CST
133
Vaccuum placement
-over sagittal suture
-2cm anterior to post. fontanelle
134
preterm labor definition
-GA
-ctx
-dilation
GA: 20-36w6d
ctx: regular
dilation: change in dilation OR at least 2cm
135
% of women dx w/ preterm labor who will have PTD w/i 7d dx
<10%
136
Cardinal mvmts labor
Engagement
descent
flexion
internal rotation
extension
external rotation
expulsion
137
