Labor

Question 1

What order should misoprostol and oxytocyin be done with unfavorable cervix?

Answer 1

Misoprostol first, then oxytocin

Question 2

What are negative factors for successful TOLAC (trial of labor after cesarian delivery)?

Answer 2

Advanced maternal age, advanced gestational age, high BMI, high birth weight, shorter interval <19 mo between pregnancies

Question 3

What timeframe indicates prolonged latent phase of labor?

Answer 3

Nulliparous: >20 h
Multiparas: >14 h

Treat with rest or augmentation of labor
Do NOT AROM due to increased risk of infection

Question 4

What should be done for patient with secondary arrest of dilation (no further cervical change in active phase >4 h)

Answer 4

Amniotomy, followed by oxytocin after further evaluation

Question 5

If patient is completely dilated and has been pushing, what are indications for cesarian delivery?

Answer 5

Macrosomia, fetopelvic disproportion

Question 6

Which mentum position indicates C/S?

Answer 6

Persistent mentum posterior (head extended, facing posteriorly)

Question 7

What is indicated by head emerging, then retracting (turtle sign)?

Answer 7

Shoulder dystocia - try McRoberts position (flexing legs up against hips and abducting hips to raise pubic symphysis)

Question 8

What timeframe is previable birth?

Answer 8

20-26 weeks - you would want a NICU

Question 9

What should you give if Group B Strep status is unknown and preterm labor has started?

Answer 9

Ampicillin, until culture result is negative or labor stops

Question 10

What antibiotics should be given iso PPROM?

Answer 10

Ampicillin + erythromycin at <34 wga: delays latency period by 5-7 days while also reducing incidence of maternal chorioamnitis and neonatal sepsis

Question 11

What antibiotics are indicated if chorioamnionitis is suspected?

Answer 11

Clindamycin and gentamicin

Question 12

Is C-section indicated iso chorioamnionitis?

Answer 12

No - delivery is warranted through induction of labor

Question 13

Which tocolytics are contraindicated for whom?

Answer 13

Mg sulfate contraindicated in myasthenia gravis
Indomethacin contraindicated at 33 weeks due to premature ductus arteriosus closure through inhibition of prostaglandin E2 synthesis
Ritodrine contraindicated in diabetic patients

Question 14

What should be offered to singleton gestation with prior spontaneous preterm birth to reduce risk?

Answer 14

Progesterone supplementation starting at 16-24 wga

Question 15

What are benefits of betamethasone treatment from 24-34 wga who are at risk of preterm delivery in 7 days?

Answer 15

Increase pulmonary maturity
Decrease incidence/severity of respiratory distress syndrome
Decrease incidence of intracerebral hemorrhage
Decrease incidence of necrotizing enterocolitis

Question 16

What is benefit of fetal fibronectin test?

Answer 16

Used in women with symptoms of preterm labor from 24-35 wga and during routine screening from 22-30 wga

It has a NPV 99.2%, so negative test means patient will not deliver in next 7 days

Question 17

Risk factors for placental abruption

Answer 17

Polyhydramnios –> rapid decompression of intrauterine cavity

Question 18

Risk factors for morbidly adherent placenta (e.g. placenta accreta)

Answer 18

Multiple prior C/S, preventing proper implantation
Low anterior placenta

Question 19

What is vasa previa?

Answer 19

When unprotected umbilical cord runs over the cervix due to insertion into the membranes

Question 20

What test is the antibody screen?

Answer 20

Indirect Coombs test

Question 21

What is indicated by abrupt onset of bleeding upon amniotomy along with fetal taachycardia, decels, and bradycardia?

Answer 21

Vasa previa

Also risk of bleeding during normal active labor

Question 22

What risks does smoking increase for pregnancy?

Answer 22

Placental abruption
Placental previa
Fetal growth restriction
Infection

Question 23

Why can cervicitis cause bleeding during pregnancy?

Answer 23

STIs result in inflammation in a more vascular cervix, resulting in bleeding

Question 24

Variable decels are associated with cord compression, which is associated with what amniotic fluid status?

Answer 24

Oligohydramnios

Question 25

When is tocolysis indicated in PPROM?

Answer 25

Prolong delivery long enough (48h) for steroids to obtain max benefit for fetal lung maturity

Question 26

What increases risk of fetal asphyxia?

Answer 26

Placental abruption Difficult breech delivery Maternal sedation

Question 27

PPROM before 24 wga results in what to the fetus?

Answer 27

Pulmonary hypoplasia; survival with PPROM between 20-23 wga is 25% Deformation type structural abnormalities may be found

Question 28

What medication reduces risk of premature labor from all causes, including PPROM?

Answer 28

17 alpha-hydroxyprogesterone - administer weekly starting at16-20 wga and until 36 wga

Question 29

When is Mg sulfate given for PPROM?

Answer 29

<32 wga, for neuroprotection

Question 30

When are steroids given for PPROM?

Answer 30

Between 24-34 wga

Question 31

What can cause false positive nitrazine test?

Answer 31

Nitrazine test is based off amniotic fluid pH 7.1-7.3 > vaginal secretion pH of 4.5-6.0 - this can be thrown off by semen or blood Use ferning and amniotic fluid index to confirm

Question 32

In whom are prostaglandins contraindicated?

Answer 32

Previous C/S - increased risk of uterine rupture

Question 33

How does maternal narcotic analgesia affect fetal heart rate tracing?

Answer 33

Decreased variability

Question 34

Amnioinfusion may be used for ________ type of decelerations?

Answer 34

Repetitive variable decelerations, NOT recurrent late decelerations

Question 35

What is fetal tachycardia associated with?

Answer 35

Maternal fever; chorioamnionitis

Question 36

What are initial measures for fetal hypoperfusion presenting with late decelerations, before deciding to do C/S?

Answer 36

Intrauterine resuscitation: Left lateral positioning (increases perfusion to uterus) Supplemental O2 Treat hypotension Discontinue oxytocin Tocolytics IV fluids

Question 37

In preterm labor, what medications are given at what time points?

Answer 37

<32 weeks: Magnesium sulfate for fetal neuroprotection and indomethacin for tocolysis (not >32 wks due to premature closure of ductus arteriosus) <37 weeks: Betamethasone to prevent neonatal respiratory distress syndrome

Question 38

For patients without prior spontaneous preterm birth, what should be done in 2nd trimester? What if they did?

Answer 38

Without: transvaginal US for cervical length; vaginal progesterone if <=2.5 cm at <24 weeks With: If they had painful contractions, then IM/vaginal progesterone; if not, it was cervical insufficiency and cerclage should be performed

Question 39

Uterine tachysystole is managed how?

Answer 39

Lateral positioning; tocolysis; stopping oxytocin

Question 40

What order of antibiotics are used for GBS?

Answer 40

Penicillin or ampicillin (if allergic, then cefazolin) Clindamycin (preferred over erythromycin) Vancomycin - doesn’t reach amniotic fluid bactericidal concentration as rapidly so still need to watch baby

Question 41

Epidural insertion into vasculature causes what?

Answer 41

CNS hyperactivity from inhibition of inhibitory neurons: Perioral numbness, metallic taste, tinnitus Seizure Sympathetic activation (HTN, tachycardia) leading to cardiovascular collapse Treat seizure with benzo

Question 42

Common causes of labor protraction

Answer 42

1. Cephalipelvic disproportion 2. Inadequate contractions 3. Maternal obesity 4. Fetal malposition (e.g. occiput posterior)