Dunn OB/GYN II

Question 1

uterine contractions

Answer 1

number of contractions present in a 10 minute window averaged over 30 minutes

Question 2

normal contractions

Answer 2

5 or less in 10 minutes

Question 3

tachysystole

Answer 3

more than 5 contractions in 10 minutes

averaged over 30 minute window

both spotaneous and induced labor

Question 4

category 1

Answer 4

normal - all of the following:

baseline 110-160
moderate variability
accelerations +/-
no late/variable deceleration
possible early decelerations

normal acid base status

Question 5

category 2

Answer 5

indeterminate

any of the following:
tachycardia
bradycardia without absent variability
minimal variability
etc.

• not predictive of abnormal fetal acid-base status
• requires continuous surveillance and reevaluation

Question 6

category 3

Answer 6

abnormal

either of the following:

• sinusoidal pattern OR
• absent variability with recurrent decelerations, recurrent variable decelerations, or bradycardia

abnormal fetal acid base status**
efforts should be made to resolve abnormal FHR

Question 7

vaginal tears during childbirth

Answer 7

common

skin around vagina- heal few weeks

some longer to heal

excessive pain - infection

Question 8

first degree vaginal tear

Answer 8

only skin around vaginal opening

heal on own

Question 9

second degree vaginal tear

Answer 9

vaginal tissue and perineal muscle

require closure

Question 10

third degree vaginal tear

Answer 10

posterior vaginal tissues, perineal muscle, capsule of anal sphincter

Question 11

fourth degree vaginal tear

Answer 11

perineal muscles, anal sphincter, rectum tissue

require repair - operative setting

complications - fecal incontinence and painful intercourse

Question 12

breastfeeding

Answer 12

make food perfect for baby

protects baby
benefits mothers health
benefits society

Question 13

predicting outcome in labor

Answer 13

difficulty

limited clinical exam, X-ray and CT are disappointing, estimates for fetal weight wide margin of error, antenatal risk screening is still important

Question 14

risk factors for labor problems

Answer 14

younger/older nulliparas
short stature
previous C-section
previous stillbirth
multi pregnancy
nutritional
large for dates
pelvic deformity
malpresentation

Question 15

when to induce labor

Answer 15

risk of continuing pregnancy outweigh risks of induction

• at 41+ weeks
• within 96 hours rupture membrane at term
• pre-eclampsia at term
• maternal diabetes at term (including gestational)
• IUGR at term when there is absent doppler EDF

intrauterine growth restriction with absent doppler end diastolic flow

Question 16

labor induction

Answer 16

prolonged pregnancy - sweep/strip membranes

Question 17

ruptured membranes induction

Answer 17

oxytocin IV infusion

Question 18

induction options

Answer 18

vaginal prostagladins

amniotomy followed by oxytocin infusion 3-12 hours later (when cervix is ripe)

Question 19

induction after C section

Answer 19

no prostaglandins - risk 1:40

spontaneous labor 1:200 risk
oxytocin 1:100 risk

foley catheter - acceptable alternative -placed in uterine cervix

Question 20

oxytocin infusion

Answer 20

single standard dilution in normal saline

• IV infusion pump
• start low dose - increase 30 minute intervals

review at 16-20 mU/min

discontinue after 5 units**

monitor fetus

Question 21

Ps

Answer 21

power
passenger
presentation
position

Question 22

when to intervene in second stage of labor

Answer 22

few patients should not push at all

• no reason to intervene unless:
• failure to progress
• arrest after 60 minutes of pushing
• not just full dilation + 2 hours

Question 23

second stage of labor

Answer 23

begins when the cervix is completely dilated (open), and ends with the birth of your baby

Question 24

no maternal death

Answer 24

from scar rupture

Question 25

scar rupture

Answer 25

rate 1:200 rate same whether VBAC or elected CS vaginal birth after cesarean = VBAC

Question 26

rate of perinatal death

Answer 26

11x higher with VBAC vs. elective CS 2x higher than for multiparas having vaginal birth

Question 27

more likely with cesarean

Answer 27

``` hospital stay ICU stay death bladder/ureter damage thromboembolism placenta previa stillbirth placenta accreta ```

Question 28

no difference cesarean vs. vaginal

Answer 28

``` postpartum bleed endometritis genital tract injury fecal incontinence postnatal depression back pain dyspareunia ```

Question 29

more likely after vaginal birth

Answer 29

perineal pain urinary incontinence uterovaginal prolapse

Question 30

passive second stage

Answer 30

time of full dlation to commencement of involuntary expulsive effort

Question 31

active second stage

Answer 31

commencement of expulsive effort by woman plus symptoms or signs of full dilation or baby is visible

Question 32

2nd stage >4 hours

Answer 32

``` increase rate of CS assisted birth chorioamnionitis 3/4th degree trauma 5 min APGAR <7 ```

Question 33

does review of normal second stage duration help?

Answer 33

no very variable multiparas - longer nulliparas - shorter

Question 34

nullipara second stage length

Answer 34

2.5 without epidural | 3 with epidural

Question 35

multiparous second stage length

Answer 35

60 minute without epidural | 120 minute with epidural

Question 36

nullipara not delivered 2 hours second stage

Answer 36

consult OB and 1 hour in multipara

Question 37

reassess all patients with an epidural who do not push

Answer 37

within 1 hour after fully dilated

Question 38

position for second stage of labor

Answer 38

sitting, semi-recumbent, lateral vs. supine or lithotomy ``` reduced length few assisted birth fewer episiotomies reduced pain more frequent secondary tears ```

Question 39

recommendations for maternal position second stage

Answer 39

discouraged from lying supine/semi-supine encouraged to adopt position most comfortable

Question 40

recommendations about pushing in second stage

Answer 40

guided by their own urge to push if ineffective -provide support/encouragement, change position, empty bladder

Question 41

perineal massage

Answer 41

midwife massage between contraction - no effect on any measure of obstetric trauma, pain, return to coitus, or urinary and bowel function

Question 42

hot compress on perineum

Answer 42

reduced need for episiotomy in nulliparas also reduced rate secondary tears not considered by another study

Question 43

hands on or hands poised for fetal head delivery

Answer 43

NICE concludes either is appropriate

Question 44

less trauma

Answer 44

when head delivers between contractions

Question 45

lidocaine

Answer 45

no effect NICE- should not be used

Question 46

episiotomy

Answer 46

less posterior trauma more anterior trauma fewer 3 and 4 tears overall - more intact perineum - less perineal pain - quicker return to coitus no difference -sexual function or bladder function

Question 47

spontaneous birth

Answer 47

no episiotomy NICE recommendation

Question 48

episiotomy should be performed

Answer 48

when clinically indicated fetal compromise suspected

Question 49

best episiotomy

Answer 49

mediolateral start at posterior fouchette and proceed at angle of 45-60 degrees