Labor & Delivery Flashcards by Robyn Shaffer

At what gestational age can you do an ECV? Benefits/risks?

37w

most likely to have spontaneously verted by then
lower risk of spontaneous reversion
increased risk of failure, but also lower risk of pre-term birth compared to version at 35-36w

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What is the risk of ECV in patients with a h/o c-section?

Same success rate (50-80%) - some studies say higher success, some say lower success rates
No cases of uterine rupture reported

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What are the risks of ECV?

Placental abruption
Umbilical cord prolapse
Rupture of membranes
Stillbirth
Feto-maternal hemorrhage
(all <1%)

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What are the success rates of ECV?

Range from 16% to 100%. Pooled success rate of 58%.

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What increases the likelihood of ECV success?

Normal or increased amniotic fluid
Normal BMI
Multiparity
Non-anterior placenta
High station
Tocolysis (25% increase in success)
Regional anesthesia (87% vs 57% success)

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Incidence of OP position

5-12%. ROP most common (60% of OP)

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What is the natural history of OP position? (what happens with expectant management)

80-90% spontaneously rotate to OA; 50-80% rotate still if OP at the start of the second stage

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What factors are associated with OP position?

Anthropoid pelvis (narrower, deeper AP diameter)
Nulliparous
Possibly also associated:
BMI>30
AMA
macrosomia
anterior placenta

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What pelvic shape is most associated with OT position?

Platypelloid (small AP diameter)

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What are the morbidities of OP position?

Labor dystocia (prolonged, longer 1st stage, need for augmentation)
Longer second stage, appx 45 minutes
Association with c/s, 4-10x with persistent OP position in 2nd stage.
Increased risk of atony, PPH
Increased risk of operative delivery and failure of operative delivery
Increase risk of OASIS injury

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How good are vaginal exams in determining OP and OA position?

Accurately predict OA 80-85% of the time

Predict OP 50-60% of the time

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Does the peanut ball work to change fetal position?

No evidence to support maternal positioning to encourage rotation

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When is it recommended to attempt to rotate the fetal head?

During the second stage of labor. NOT prior to complete cervical dilation. Due to risk of cord prolapse or cervical lacerations.

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Number needed to treat for manual rotation?

4! 4 rotations needed to prevent one c-section (by a large retrospective study)

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By the data, how often is manual rotation successful?

90%

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What is the primary benefit of successful rotation?

Decreased c-section, decreased operative vaginal delivery/oasis injuries

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Arrest of descent

Fetal vertex w/o descent in 1 hour despite adequate maternal expulsive efforts

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Prolonged second stage

nulliparous women > 3 hours with epidural or > 2 hours without; multiparous women > 2 hours with epidural or > 1 hour without.

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Stillbirth definition

Fetal death at 20w or greater or 350g (50%ile at 20w) if GA is unknown
Excludes pre-viable pprom and pre-viable termination

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Risk factors for stillbirth

Non-hispanic Black race
Multiple gestation (14/000 compared to 5/1000; triplet and higher order, 30/1000)
Prior stillbirth
Male sex (6/1000)
Young maternal age (<15) or advanced maternal age
Medical co-morbidities - DM, cHTN, SLE, renal, obesity, tobacco
Anti-phospolipid antibody

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Etiologies of stillbirth

5-10% Abruption
10% umbilical cord events (stricture, entrapment, vasa previa)
6-13% abnormal karyotype
10-20% infection (GBS, E Coli; listeria, syphilis; CMV, Parvovirus, Zika)

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How do you evaluate stillbirth?

placental pathology MOST HELPFUL
fetal autopsy
amniocentesis / genetic testing
APLA testing
less useful, KB and infectious testing

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What is the induction regimen for IOL in 2nd trimester stillbirth?

400-600mcg vaginal misoprostol q3-6hrs

Can do this with hx cesarean

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What is the recurrence risk of stillbirth?

2.5%

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What is the antepartum surveillance for hx of stillbirth?

NST at 32w or 1-2wk prior to GA of stillbirth (if stillbirth <32w, individual plan) third trimester growth ultrasound

What is the timing of delivery for a patient with hx of stillbirth?

May warrant early term delivery at 37-38w

What is the FHT sig associated with uterine rupture?

Fetal bradycardia (only stat sig finding compared to VBAC without rupture)

What are risk factors associated with uterine rupture?

IOL / prostaglandin use

What is the incidence of uterine rupture?

``` 1x LTCS: 0.5-0.9% 2x LTCS: 0.9-3.7% Classical incision: 1-12% Low vertical: likely the same as LTCS Unknown prior incision - similar rates of rupture with low transverse ```

What are positive factors associated with VBAC?

spontaneous labor | prior vaginal delivery

What factors are negatively associated with VBAC?

``` prior arrest of labor increased BMI** increased maternal age higher birth weight GA >40w labor induction ```

What is the risk of rupture w/ and without prostaglandins?

without prostaglandins: 0.7-1.1% with prostaglandins: 1.4-2.3% difficult to interpret / mixed data

What is the recurrence risk of uterine rupture?

6% (lower uterine segment scar) | up to 32% if upper uterine segment

What is the delivery plan for women with h/o uterine rupture?

Consider rLTCS at 36-37w

Can you use prostaglandin inductions in IUFDs for h/o C-S?

ok to use prostaglandins in women with hx of CS unless vertical incision

What's the max daily dose of labetalol IV?

300mg

What's the max daily dose of PO nifedipine?

180mg

What's the max daily dose of hydral IV/IM?

20mg

What is the 1st line treatment of eclampsia?

magnesium sulfate 4-6g loading dose over 30 min > 2g/hr | IM magnesium 5g and 5g followed by 5mg q4h

What's the diagnostic criteria for HELLP?

LDH >600 LFTs 2x normal Plt <100K

What percent of HELLP patients will not have high blood pressures?

15%

What are high risk factors for which patients should be on bASA?

``` h/o pre-eclampsia multifetal gestation cHTN T1DM T2M renal disease autoimmune disease ```

When should you start bASA for pre-eclampsia prevention?

max benefit if <16w ok to start between 12 and 28 weeks don't start >28w due to lack of benefit

When should you treat cHTN in pregnancy?

persistent BPs >160/110 | or lower but w/ comorbidities or renal disease

What is goal BP for treatment of cHTN in pregnancy?

120-160/80-110

Which women with cHTN need fetal surveillance?

- on meds - other co-morbid conditions - IUGR - superimposed preE

What percent of cHTN will develop pre-E?

20-50% | if end-organ damage present with cHTN, up to 75%

What are consequences of Rh alloimmunization?

Hemolytic anemia of the newborn - high output cardiac failure, hydrops, stillbirth

What percent of alloimmunization is caused by feto-maternal hemorrhage?

1-2%

What is the critical titer for Anti-D?

1:16

What is the prevalence of Intrahepatic cholestasis of pregnancy?

0.2-6% of pregnancies

What are risk factors for cholestasis of pregnancy?

Multiple gestation HCV positive IVF Advanced maternal age

What are the adverse outcomes of cholestasis of pregnancy?

Pre-term birth meconium stained fluid IUFD Higher with bile acids at/above 40umol/L

Granulomatous infantile septis

acute rash fever abscesses in placenta due to listeria

Definition of contraction stress test

3 contractions in 10 minutes | positive test is decels with >50% of contractions

What did the WOMAN trial show in terms of benefits of TXA in PPH?

Reduction in maternal mortality, 1.9% to 1.5% if given within 3 hours IV or PO

How much contrast is excreted into breast milk?

<1% of contrast administered is excreted | <1% of this is absorbed into infant GI tract

How much gadolinium is excreted into breast milk?

<0.04% | <1% of this is absorbed by infant GI tract

What are the benefits of median vs mediolateral episiotomy?

Mediolateral - lower risk of extension into anal sphincter Median - lower risk of postpartum pain or dyspareunia

What is the NNT for primary cesarean section in macrosomia in diabetic mothers

440 cesarean deliveries to prevent 1 shoulder dystocia | EFW 4500 + DM

What percentage of fetuses enter the pelvis in OP position?

20%

Tachysystole definition

>5 contractions in 10 minutes averaged over 30 minutes

Which nerve roots transmit somatic pelvic pain in labor?

Pudendal | S2-S4

What does acetylcholinesterase on amniocentesis mean?

acetylcholinesterase + elevated AFP = Neural tube defect

What is the dose of rhogam after CVS?

125-300mcg

Fetal loss rate after amniocentesis in 2nd trimester

1:200 - 1:300

Labor & Delivery Flashcards

(66 cards)