L&D Complications

Question 1

which type of breech presentation is MC

Answer 1

frank breech

Question 2

Frank breech

Answer 2

the buttock is the presenting surface and both feet are pulled up to the chest in the pike position (hips are flexed and both knees extended)

Question 3

complete breech

Answer 3

the knees are pulled to the chest and knees are bent as in the fetal position (both hips and knees are flexed)

Question 4

incomplete breech

Answer 4

either one or both hips are not completely flexed.

double footling breech presentation = both hips are not flexed

Question 5

second MC breech presentation

Answer 5

incomplete breech

Question 6

nonfrank breech

Answer 6

one or both feet present between the buttocks and birth canal

Question 7

Risk factors for a breech presentation

Answer 7

early gestational age, uterine abnormality, multiparity, multiple gestation, and older maternal age

Question 8

where may women w babies in frank position report kicking

Answer 8

lower pelvis

Question 9

definitive dx breech presentation

Answer 9

US

Question 10

what might you feel on exam if breech presentation is present

Answer 10

Once the cervix begins to dilate, a soft mass may be identified, as the buttock is in place of a harder fetal skull

Question 11

available tx option For women presenting with breech presentation at term

Answer 11

external cephalic version

Question 12

External cephalic version

Answer 12

a technique used to maneuver the fetus into a cephalic position from a breech position. The technique involves the administration of a beta-adrenergic receptor agonist to relax the uterus. The clinician then attempts to maneuver the fetus into a cephalic presentation via a backward or forward somersault. The procedure may be repeated up to four times in one sitting

Question 13

success rate of External cephalic version

Answer 13

60%

Question 14

Complications of External cephalic version

Answer 14

Complications of the procedure are rare but include fetal heart rate changes, emergency cesarean delivery, vaginal bleeding, rupture of membranes, placental abruption, and fetal death

Question 15

what if external cephalic version is unsuccessful

Answer 15

most women with breech presentation will undergo cesarean section, which significantly reduces the risk of morbidity and mortality to both mother and fetus

Question 16

What is the maximum fetal weight recommended for low-risk women who elect a planned vaginal breech birth?

Answer 16

3,800 g

Question 17

Shoulder dystocia

Answer 17

an acute obstetric emergency that occurs when the fetal shoulder becomes impacted behind the pubic symphysis after delivery of the head

Question 18

when should a dx of shoulder dystocia be suspected

Answer 18

This diagnosis should be initially suspected when the fetal head retracts past the perineum after delivery secondary to reverse traction from the shoulders at the pelvic inlet

Question 19

how can shoulder dystocia be confirmed

Answer 19

The diagnosis can be confirmed when gentle, downward traction of the fetal head fails to deliver the anterior shoulder

Question 20

complications of shoulder dystocia

Answer 20

fetal asphyxia and cortical damage secondary to umbilical cord compression and impeded inspiration

Transient brachial plexus injury is the most frequently reported adverse event with less common events, including clavicular fracture, humerus fracture, permanent brachial plexus palsy, hypoxic-ischemic encephalopathy, and death

Question 21

what is the first maneuver that should be attempted for shoulder dystocia

Answer 21

McRoberts maneuver

Question 22

McRoberts maneuver

Answer 22

This maneuver consists of flexing the maternal thighs toward the abdomen to rotate the symphysis pubis and flatten the sacrum, thereby reducing the prominence of the sacral promontory.

Suprapubic pressure can be applied in conjunction with the McRoberts maneuver if initial attempts are unsuccessful

Question 23

what is McRoberts maneuver doesn’t work

Answer 23

alternative initial strategies include delivery of the posterior shoulder and the Menticoglou maneuver with axillary traction used to deliver the posterior shoulder. Secondary maneuvers include the Rubin maneuver, Woods screw maneuver, and clavicular fracture

Question 24

last resort strategy for shoulder dystocia

Answer 24

Gunn-Zavanelli-O’Leary maneuver is a last-resort strategy performed by replacing the fetal head within the pelvis and delivering the fetus via cesarean section

Question 25

MC fetal injury shoulder dystocia

Answer 25

Transient brachial plexus injury

Question 26

MC maternal injury shoulder dystocia

Answer 26

Hemorrhage and fourth-degree perineal lacerations

Question 27

Most important risk factor for shoulder dystocia

Answer 27

high birth weight

Question 28

RF shoulder dystocia

Answer 28

weight over 4,000 g, maternal diabetes mellitus, previous shoulder dystocia, excess maternal weight gain during pregnancy, post-term pregnancy, and male fetus Each of the risk factors is related to underlying high birth weight

Question 29

turtle sign

Answer 29

fetal head retracts into the perineum after expulsion

Question 30

The best treatment of shoulder dystocia is

Answer 30

Preventative

Question 31

Pregnancies likely to result in shoulder dystocia should be delivered by

Answer 31

cesarean delivery

Question 32

C section delivery indications for shoulder dystocia prevention

Answer 32

This includes an antepartum estimated fetal weight of more than 5,000 g in a woman without maternal diabetes or an estimated fetal weight of more than 4,500 g in a woman with maternal diabetes. Furthermore, induction may be offered to women with diabetes at 39 weeks and an estimated fetal weight between 4,000–4,500 g

Question 33

success rate of McRoberts maneuver

Answer 33

50%

Question 34

Gaskin maneuver

Answer 34

placing the patient on all fours

Question 35

maneuvers to deliver the posterior shoulder

Answer 35

Woods screw and Rubin maneuvers

Question 36

The most common indications for a C-section delivery

Answer 36

shoulder dystocia, abnormal fetal heart rate tracing, fetal malpresentation, and multiple gestation Fetal malpresentations such as transverse lie or breech presentations that persist after unsuccessful external cephalic version Twin gestations in which twin A is noncephalic, the gestational age is < 28 weeks, or twin B is noncephalic with an estimated fetal weight of < 1,500 g Any gestations with more than two fetuses are an indication for a C-section.

Question 37

category III tracing

Answer 37

sinusoidal pattern on fetal heart rate tracing or absent baseline fetal heart rate variability with recurrent late decelerations, recurrent variable decelerations, or bradycardia necessitates emergent delivery or C-section

Question 38

What birth weight is fetal macrosomia defined by?

Answer 38

4,000–4,500 g, regardless of gestational age

Question 39

Umbilical cord prolapse

Answer 39

umbilical cord presents before fetus

Question 40

complications of umbilical cord prolapse

Answer 40

cord compression, occlusion, or vasospasm and compromise blood flow to and from the fetus, asphyxia, death

Question 41

RF umbilical cord prolapse

Answer 41

malpresentation of the fetus such as frank breech, prematurity, low birth weight, uterine malformation, multiparity, long umbilical cord, prolonged labor, or an unengaged body part

Question 42

PE umbilical cord prolapse

Answer 42

Physical exam will reveal the prolapse cord visually or the cord may be palpated on cervical check. Additionally, fetal heart rate changes may occur if the cord is compromised. These include prolonged episodes of bradycardia or severe decelerations

Question 43

dx umbilical cord prolapse

Answer 43

diagnosis is based on visualization or palpation of the prolapsed umbilical cord

Question 44

for umbilical cord prolapse - what can you use to identify position

Answer 44

US

Question 45

for umbilical cord prolapse - what can you do to identify blood flow

Answer 45

doppler

Question 46

is umbilical cord prolapse an emergency

Answer 46

yes

Question 47

once you identify umbilical cord prolapse

Answer 47

prepare pt for c section begin intrauterine resuscitation

Question 48

intrauterine resuscitation techniques for umbilical cord prolapse

Answer 48

manual elevation of the presenting part compressing the cord (most common), placing the patient in the Trendelenburg position or knee to chest, retrofilling the bladder (which works to elevate the presenting part compressing the cord), or administering a tocolytic (to reduce pressure on the cord caused by uterine contractions)

Question 49

factors affecting the outcome of umbilical cord prolapse

Answer 49

degree of cord compression, the lapsed time between identification of cord prolapse and delivery, and effective initiation and performance of intrauterine resuscitation maneuvers

Question 50

Prelabor rupture of membranes (PROM) and what is it linked to

Answer 50

patient who is more than 37 weeks gestation and whose membranes rupture before labor begins It is thought to be linked to inflammation or infection of the membranes

Question 51

Risk factors associated with PROM

Answer 51

low socioeconomic status, low body mass index, tobacco use, history of preterm labor, urinary tract infections, vaginal bleeding, cerclage, and amniocentesis

Question 52

sx PROM

Answer 52

leakage of fluid (that is clear and odorless but may be tinged with blood or mucus), vaginal discharge, vaginal bleeding, and pelvic pressure, all without contractions. The leakage of fluid may present as a sudden gush of fluid or a slow leak of small amounts of fluid

Question 53

what should be avoided in PROM

Answer 53

Digital vaginal examinations should be avoided until labor is initiated

Question 54

dx PROM

Answer 54

Ruptured membranes are diagnosed by sterile speculum vaginal examination of the cervix, with noted leakage from the cervix and pooling of fluid in the vagina being the most accurate for diagnosis. If no fluid is visualized, asking the patient to perform a Valsalva maneuver may cause leaking to resume -- essentially you need direct visualization of leaking amniotic fluid Other methods of confirmation include microscopic examination of the fluid (which will show ferning), and Nitrazine paper test (which will turn from orange to blue if amniotic fluid is present)

Question 55

US PROM

Answer 55

absence of or very low amounts of amniotic fluid (Oligohydramnios)

Question 56

tx PROM

Answer 56

medical induction with oxytocin and prompt delivery, since the risk of intrauterine infection increases with the duration of ruptured membranes. If labor or vaginal delivery is contraindicated, a caesarean section should be considered next. Waiting for spontaneous labor to begin (i.e., expectant management) not only increases chances of infection, but also increases the risk of serious complications such as cord prolapse or abruption. However, for women who choose expectant management over labor induction, a time limit should be agreed upon through the process of shared decision-making between the patient and the medical team involved

Question 57

What are some commonly used tocolytic drugs?

Answer 57

Magnesium sulfate, indomethacin, terbutaline, and nifedipine

Question 58

Amniotic fluid has a pH of

Answer 58

7.0–7.3

Question 59

Normal vaginal pH is

Answer 59

3.8–4.2

Question 60

pH of urine

Answer 60

< 6

Question 61

For PROM: if the nitrazine paper is yellow or green

Answer 61

PROM is unlikely

Question 62

positive fern test

Answer 62

dried vaginal fluid produces a ferning pattern when placed on a glass slide and viewed with microscopy

Question 63

Patients presenting with prelabor rupture of membrane usually deliver within

Answer 63

1 week

Question 64

definitive tx PROM

Answer 64

delivery of fetus

Question 65

the single most common identifiable risk factor for prelabor rupture of membranes (PROM)

Answer 65

a genital tract infection

Question 66

preterm prelabor rupture of membranes (PPROM)

Answer 66

membrane rupture prior to the onset of uterine contractions before 37 weeks gestation

Question 67

tx PPROM

Answer 67

Prompt induction of labor with oxytocin is the recommended course for unstable patients with PPROM and has better outcomes than expectant management if the patient is < 34 weeks gestation. Induction of labor is appropriate for stable patients with PPROM at ≥ 34 weeks gestation. Expectant management is appropriate for stable patients with PPROM at < 34 weeks gestation. These patients should be given a course of antenatal corticosteroids and prophylactic antibiotics and hospitalized until delivery. Unstable patients with intrauterine infection, abruptio placentae, nonreassuring fetal testing, and increased risk of uterine cord prolapse should undergo immediate delivery.

Question 68

chorioamnionitis and what is it associated with

Answer 68

acute inflammation of the membranes and the chorion of the placenta. It usually occurs in association with ruptured membranes

Question 69

RF chorioamnionitis

Answer 69

prolonged length of labor and prelabor rupture of membranes

Question 70

sx chorioamnionitis

Answer 70

fever, uterine tenderness, purulent or malodorous amniotic fluid, maternal tachycardia, and fetal tachycardia Fever is a sensitive finding for dx

Question 71

Common lab finding in chorioamnionitis

Answer 71

leukocytosis

Question 72

diagnostic criteria for chorioamnionitis

Answer 72

The diagnosis of intra-amniotic infection is confirmed in patients with a fever (at or above 102.2°F or above 100.4°F twice at least 30 minutes apart) without another clear source. They must also have one or more of the following: purulent-appearing fluid coming from the cervical os visualized during speculum examination, maternal white blood cell count > 15,000/μL, and a baseline fetal heart rate of at least 160 bpm for at least 10 minutes. At least one of the following objective laboratory findings must also be present: positive Gram stain of amniotic fluid, positive amniotic fluid culture, low glucose level in amniotic fluid, high white blood cell count in amniotic fluid, and histopathologic evidence of infection or inflammation of the placenta, fetal membranes, or the umbilical cord vessels.

Question 73

presumptive diagnosis of chorioamnionitis

Answer 73

presumptive diagnosis of intra-amniotic infection can be made in patients with a fever and at least one of the following: purulent-appearing fluid coming from the cervical os visualized during speculum examination, maternal white blood cell count > 15,000/μL, and a baseline fetal heart rate of at least 160 bpm for at least 10 minutes

Question 74

tx chorioamnionitis

Answer 74

prompt augmentation or induction of labor and antibiotics

Question 75

is chorioamnionitis an indication for C section

Answer 75

no bc the risk of wound infection and endometritis is increased if cesarean delivery is performed

Question 76

abx tx chorioamnionitis

Answer 76

The recommended antibiotic regimen consists of IV ampicillin and gentamicin . Patients who have an indication for a cesarean delivery should also be treated with metronidazole or clindamycin to provide coverage against anaerobes

Question 77

maternal complications chorioamnionitis

Answer 77

postpartum endometritis, impaired myometrial contractility, uterine atony, and postpartum hemorrhage

Question 78

neonatal complications chorioamnionitis

Answer 78

perinatal death, asphyxia, early-onset neonatal sepsis, septic shock, pneumonia, meningitis, and long-term neurodevelopmental delay

Question 79

Which organisms most often cause bacteremia secondary to intra-amniotic infection?

Answer 79

Escherichia coli and group B Streptococcus

Question 80

what confirms dx of chorioamnionitis

Answer 80

Needle aspiration and analysis of the amniotic fluid