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Labour & Delivery Flashcards

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1
Q

What is the difference between True Labour and Braxton Hicks contractions?

A 
True = regular, painful, increasing intensity contractions; cervix dilates/effaces, progression of fetal station
False = irregular, not changing intensity/freq, no cervical changes; throughout pregnancy

Labour ctx: 4:1:1 rule - Ctx every 4 minutes, lasting 1 minute, for at least 1 hour

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2
Q

Describe the stages of labou

A

Stage 1 latent: <4cm
Stage 1 active: 4-10 cm
2nd stage: 10 cm-delivery of baby
3rd stage: delivery baby –> delivery placenta
4th stage: delivery placenta –> 1-4 hr postpartum

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3
Q

Is posterior or anterior cervical positioning indicative of further in labour?

A

Moves posterior –> anterior

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4
Q

orientation of the long axis of the fetus with respect to the long axis of the uterus (longitudinal,
transverse, and oblique)

A

fetal lie

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5
Q

fetal presentation =

Which is the only normal one?

A

fetal body part closest to the birth canal

Normal = vertex/occiput/cephalic

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6
Q

Fetal position

A

Position of presenting part relative to maternal pelvis (e.g. OA (“normal”), OP, OT)

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7
Q

2 examples of abnormal fetal attitude

A

Brow presentation

Face presentation

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8
Q

Define fetal station

A

Position of presenting bony part relative to ischial spines (determined via vaginal exam)
-5 to -1 cm above spines
+1 to +5 below spines

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9
Q

What is synclitism?

A

Alignment of the sagittal suture relative to axis of birth canal (A or P asynclitism may impact descent)

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10
Q

Fetal position is described by ___ for cephalic presentation, ___ for breech presentation, ___ for face presentation

A

Occiput
Sacrum
Mentum

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11
Q

4 key HPI questions during labour triage

A

1) Contraction - since when, how freq, how long, how painful
2) Bleeding - wsince when, how much, colour, pain, last U/S, any trauma/intercourse?
3) Fluid (ROM) - when, how much, colour
4) FM: as much as usual? when last?

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12
Q

Describe contractions during the active first stage of labour?

A

Painful, regular, q2-3 min, 45-60 s each

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13
Q

Mother feels a desire to bear down/push with each contraction during which stage of labour?

A

Second stage

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14
Q

Third stage of labour can last up to __ before intervention is indicated?

A

30 min

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15
Q

Routine ___ administration in the 3rd stage of labour (either give with delivery of baby or after placenta delivered) can reduce the risk of PPH by >40%

A

Oxytocin

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16
Q

The __ and ___ stages of labour are most dangerous to the mother

A

3rd-4th (PPH)

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17
Q

What is fetal engagement and when does it happen?

A

The widest diameter of the presenting part (with a well-flexed head, where the largest transverse diameter of the fetal occiput is the biparietal diameter) enters the maternal pelvis to a level below the plane of the pelvic inlet. On the pelvic examination, the presenting part is at 0 station, or at the level of the maternal ischial spines.
In first pregnancy often happens weeks before birth

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18
Q

Non-pharmacological pain relief techniques for labour (3 categories + examples)

A

1) Reduce painful stimuli (position change, maternal movement)
2) Activate peripheral sensory receptors (superficial heat/cold, water immersion, TENs, massage, aromatherapy)
3) Enhance descending inhibitory pathways (distraction, hypnosis, music, biofeedback)

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19
Q

Pharmacological pain relief methods

A 
Nitrous oxide
narcotics
Pudendal nerve block
Local anesthetic
Regional anesthetic (EPIDURAL, spinal)
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20
Q

Prevalence, prognosis, and etiology of Meconium Aspiration Syndrome

A

In about 10% of pregnancies overall, the fetus discharges meconium (its bowel contents) into the amniotic fluid during labour. In about 10% of cases where meconium is passed, the fetus gasps, inhaling the sticky meconium into the upper respiratory tract. After birth, the meconium blocks the air passages in the lungs, impairing gas exchange–meconium aspiration syndrome (MAS). Up to 20% of infants suffering from MAS die and recently published studies have shown a long-term effect of MAS in causing cough and wheeze

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21
Q

2 delivery characteristics that increase the likelihood of meconium aspiration syndrome?

A

C-section

Postterm

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22
Q

Presentation of meconium aspiration syndrome

A

GREEN AMNIOTIC FLUID

Low APGAR, tachypnea, hypoxia, WOB

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23
Q

APGAR stands for what?

Score below what may need intervention?

A 
Activity (muscle tone)
Pulse
Grimace (reflex irritability)
Appearance (skin colour)
Respiration
(<7 may need intervention)
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24
Q

Is continuous fetal monitoring always better?

A

No, leads to increased intervention

Do it if you have abnormal or induced labour, meconium present, multiple gestation, fetal concerns

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25
What can be used to resolve interpretation of abnormal/atypical FHR and CTG (contraction monitoring) patterns?
Fetal scalp sampling
26
Is variability in FHR bad?
No! Physiological variability is normal and absence can be bad
27
What FHR decelerations are normal?
Early decelerations: nadir coincides with peak of contraction then quickly returns to baseline Normal vagal response to head compression
28
What are variable FHR decelerations? Are they good or bad?
Variable in shape/onsent/duration Can be due to cord compression or forceful pushing in 2nd stage Complicated if return to baseline is slow/incomplete, too bradycardic (possible fetal acidemia)
29
What are late decelerations?
Onset + nadir + recovery after peak of contraction, slow return to baseline Indicates fetal hypoxia/acidemia, usually a sign of uteroplacental insufficiency (ominous)
30
Normal FHR and variability
110-160 | 6-25 bpm
31
Normal FHR accelerations
Spontaneous or during scalp stimulatino
32
What is measured in a fetal scalp sample?
pH & lactate (looking for acidosis --> if present, deliver!!)
33
Maternal cervix needs to be __ for induced labour. If not, what can you use?
"Ripe" (short, thin, soft, anterior, open os) | Can use intravaginal prostaglandins (e.g. misoprostol in clinical trials), foley catheter for mechanical dilation
34
What score determine likelihood of success for induced labour?
Bishop score | cervical position/consistency/effacement/dilatation, fetal station
35
What is the most common reason for inducing labour?
>41 weeks
36
Maternal indications for induced labour? (4+)
``` MDM Gestational HTN >37 wk Preeclampsia Mom >40 Other maternal diseases ```
37
Maternal-fetal indications for induced labour (3)
Isoimmunization PROM Chorioamnionitis
38
___ is the artificial initiation of labour ____ promotes contractions when spontaneous contractions are inadequate
Induction | Augmentation
39
Fetal indications for induced labour
Fetal jeopardy (but not fetal distress or malpresentation) Macrosomia Demise, IUGR, oligo-polyhydramnios Twins, previous stillbirth
40
2 serious complications of induced labour
Uterine hyperstimulation --> fetal compromise or uterine rupture Uterine muscle fatigue --> atony (failure to contract) + PPH
41
Describe uterine atony
Uterine atony refers to the corpus uteri myometrial cells inadequate contraction in response to endogenous oxytocin that is released in the course of delivery. It leads to postpartum hemorrhage as delivery of the placenta leaves disrupted spiral arteries which are uniquely void of musculature and dependent on contractions to mechanically squeeze them into a hemostatic state. Uterine atony is a principal cause of postpartum hemorrhage, an obstetric emergency.
42
2 components of inducing labour after cervical ripening
1) Amniotomy 2) Oxytoxin (Not ALWAYS both)
43
What med is used to augment labour when spontaneous contraction inadequate and cervical dilation or fetal descent fails?
Oxytocin
44
What is dystocia?
Failure of expected patterns of descent/dilation to occur in expected timeframe
45
4 Ps of dystocia
Power: weak contractions, inadequate pushing Passenger: fetal position/attitude, size Passage: pelvic structure (CPD), maternal soft tissue factors (full bladder/rectum, vaginal septum, tumors) Psyche: stress hormone
46
What is CPD?
Cephalopelvic disproportin | Fetus head can't fit through pelvis --> failure to progress (need C/S)
47
What is the most common etiology of dystocia?
POWER
48
Management of dystocia
Rule out CPD | Then IV oxytocin augmentation + amniotomy
49
Define Shoulder dystocia
Fetal anterior shoulder impacted above pubic symphysis after head delivered --> LIFE-THREATENING EMERGENCY
50
____ will resolve 90% of cases of shoulder dystocia.
McRoberts maneuver (flex legs onto abdomen) + suprapubic pressure on fetal anterior shoulder
51
Umbilical cord prolapse =
Cord moves below (or adjacent to) presenting part --> cord compression
52
Treatment of umbilical cord prolapse
Emergency C/S if delivery not imminent | O2 to mother, monitor FHR, alleviate pressure on chord via pelvic exam until C/S
53
Define grand multiparity
5+ births at 20+ weeks | Associated with increased maternal risks
54
Common causes of uterine rupture
``` Previous uterine scar (40%) (usually <1% incidence but up to 12% with classical C/S incision, even before labour) Oxytocin hypertimulation Grand multiparity (5+ deliveries) ```
55
If uncontrollable hemorrhage from uterine rupture -->
Hysterectomy
56
HELLP Syndrome
A complication of pregnancy and form of preeclampsia that most commonly occurs > 27 weeks' gestation. Characterized by hemolysis (H), elevated liver (EL) enzymes, and low platelet (LP) count
57
Amniotic fluid embolus
Amniotic fluid debris in maternal circulation --> anaphylactoid immunological response --> RD, CV collapse, coagulopathy Up to 30% maternal mortality
58
What is the controversy around epistiotomy?
Current evidence suggests letting perineum TEAR and then repairing as needed is better
59
Risk factor for shoulder dystocia
Maternal DM/GDM | Fetal prolonged gestation/macrosomia
60
Define chorioamnionitis + etiology
Infection of chorion/amnion/amniotic fluid | Ascending infection from vagina
61
Clinical features + treatment of chorioamnionitis
Fever, tachycardia, uterine tenderness, foul discarge | IV antibiotics
62
Meconium : More common in ___ pregnancies Present in up to ___ of all labours Is it associated with poor outcome?
Postdate 25%, usually NOT associated with poor outcome but ALWAYS abnormal if preterm fetus (and concern if fluid changes from clear --> meconium stained)
63
Increasing meconium during labour may be sign of ___
Fetal distress
64
What is the most common cause of postpartum hemorrhage?
Uterine atony (70-80%)
65
Define puerperium
6 weeks after delivery when physiological/anatomic changes are reversed
66
Define postpartum hemorrhage
>500 mL blood loss vaginal delivery >1000 mL blood loss C/S Primary = within 1st 24 hours Secondary/Late = within 12 weeks
67
DDx of Early PPH (4 Ts)
Tone (uterine atony) Tissue Trauma Thrombin (coagulopathy, e.g. vWD)
68
Prevention of uterine atony (3)
Oxytocin administration Uterine massage Umbilical cord traction
69
Medical treatments for PPH
``` Oxytoxin Ergotamine Carboprost (PGF analog) Misoprostol Tranexamic acid (antifibrinolytic) ```
70
Local treatments for PPH
``` Bimanual massage through abdomen Uterine packing (mesh w/ AB treatment) Bakri Balloon for tamponade while correcting coagulopathy or prepping for OR ```
71
Surgical therapies for intractable PPH
D&C Embolization of uterine artery or internal iliac artery Laparotomy with artery ligation Hysterectomy = last resort
72
Formation of scar tissue in uterus (usually after surgery) =
Asherman's syndrome
73
Retained placenta =
not delivered within 30 min after fetus delivered
74
Define placental previa and vasa previa
Placental previa = placenta blocking cervix Vasa previa = embranes that contain fetal blood vessels connecting the umbilical cord and placenta overlie or are within 2 cm of the internal os
75
When is screening for gestational diabetes recommended?
24-28 weeks
76
What is the preferred screening for GDM?
The preferred approach is an initial 50 g glucose challenge test, followed, if abnormal, with a 75 g oral glucose tolerance test. A diagnosis of GDM is made if one plasma glucose value is abnormal (i.e. fasting ≥5.3 mmol/L, 1 hour ≥10.6 mmol/L, 2 hours ≥9.0 mmol/L) ** if high risk of undiagnosed type 2, screening EARLY (<20 weeks) via HbA1c
77
DIC can be caused by obstetric complications via release of ___
Procoagulants (---> tons of clots formed but then also increased bleeding due to consumptions of platelets/clotting factors)
78
placenta grows too deeply into the uterine wall. Typically, the placenta detaches from the uterine wall after childbirth. With placenta accreta, part or all of the placenta remains attached. This can cause severe blood loss after delivery. ^what is this and what is the general approach?
Placenta accreta C-section important. Can try to remove placenta but may need hysterectomy
79
Bloody show
A blood-tinged mucous plug may be discharged when the cervix shortens and dilates.
80
Normal birth weight
2.5-4.5 kg
81
Fundus above umbilicus during PPH =
uterus hasn't contracted
82
This meta-analysis showed that ___ was as effective and safe as oxytocin for prevention of postpartum hemorrhage in women undergoing vaginal delivery, and the choice of carbetocin for routine prophylaxis will depend on cost-effectiveness.
Carbetocin (long-acting oxytocin analogue) Centre-dependent practices
83
What are the 4 degrees of vaginal tears in childbirth?
1st = perineum skin only, may not require stitches 2nd = skin/muscle of perineum, may extend deep into vagina; stitches done in delivery room 3rd = extends into anal sphincter. May need OR repair 4th - all the way through anal sphincter + rectal mucosa

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