Maternal Dr. AKhter Flashcards
Stage 1 :Latent
ˆ15%CO
Start L Regular uterine contractions Ends: 4 cm dilatation,
Cx effacement, Cx slowly dilates
Nulli : 6-11hrs
Multi 4-8 hrs
First Stage :Active
ˆ30%CO
Start : 4 cm/ End: 10 cm (complete dilatation)
Regular intense contractions, fetal head descends into pelvis
Nulli 4-6
Multi 2-3
Second Stage of labor
ˆ45% CO
Start: complete Cx dilatation End: delivery of baby
Baby undergoes all cardinal movements : Engagement, Descent, Flexion and Internal rotation, Flexion, External rotation and expulsion
Nulli 1-2hr
Multi : 0.5 - 1 hr
Third Stage
ˆ80% CO
Start:delivery of baby / Ends : delivery of placenta
Placenta detaches from Uterus, Uterus contracts to a establish homeostasis
Nulli 0- 0.5
Multi 0- 0.5
Pain level in First stage labor
Pain is first T11- T12.
Then progress to T10 -T12 and L1.
Visceral Pain from Uterine contraction and Cx dilatation
Spinal Anesthesia needed at level T10-L1
Second stage begins at fully dilated Cx ( 10 cm ) ends at expulsion of fetus. Describe pain
Pain Through the pudendale nerve ( S2-S4)
Somatic pain : by stretching of vagina and perineum by descending fetus.
Spinal anesthesia needed S2- S4
Pain involves T10 to S4 dermatomes
Visceral Pain - what stage of labor and describe
Stage 1.
Visceral pain from contraction of uterus and dilatation of Cx
Pain starts T11-T12 then progress to T10- T12 then L1
Spinal anesthesia needed T10 - L1
Somatic Pain , What Stage, Describe
Stage 2 Somatic pain from stretching of vagina and perineum Pudendal Nerve ( S2-S4) Spinal anesthesia needed S2- S4 Pain involves T10- S4 dermatomes
Third Stage of Labor
ˆ80% CO. Delivery to expulsion of Placenta . Separation and delivery of placenta
Nulli : 0-0.5
Multi : 0-0.5
Pain and temperature from the genitalia are mediated by the
by the autonomic nervous system (not lateral spinothalamic tract)
Cause of pain is uterine contractions and exceeds
25 mmHg pressure ( 25-60mmHg )and dilate Cx.
Visceral pain due to which sympathetic nerves ?
Visceral afferent accompanying sympathetic nerves entering T10, T11, T12 and L1
Pain during late 1st and 2nd stage pain travels through
Pudendal nerve and enter neuraxis S2 S3 S4
Pain due to stretch on vagina and vulva and perineum
What innervate Uterus and Cx
T10 - L1-L2
Pain carried Visceral afferent C fiber
What innervates the perineum
S2 S3 S4
Pain carries by somatic nerve fibers; pudendal nerves
Effects of inhalation anesthetic on uterus
Inhaled anesthetic= Uterine relaxation = increased blood loss
Effects of parent earl agents on labor
Opioids minimally decrease progression of labor
7 reasons reason to use regional anesthesia ( in relations to labor )
1- use of oxytocin
2- Primigravida: pregnant for the first time
3- Prolonged labor
4-Large baby
5- Small Pelvis
6- Fetal malpresentation
7- High requirement for parenteral Opioid
Effects of vasopressors on Uterus
A1– Uterine contraction
B2 - Uterine relaxation
small dosePhenylephrine - Increase BF to uterus by Increasing BP
Use of oxytocin
1) To induce labor
2) prevent postpartum hemorrhage.
Complications with Oxytocin
Fetal Distress Maternal Water retention Hypotension Reflex tachycardia Uterine Tetany
What class of med used for Uterine Atony
Ergot Alkaloids — Bromocriptine ex..
PG F2a used to treat
PPH
What class drugs are used for PPH
Prostaglandins F2a
Use of Magnesium in labor
1) Stop premature contractions
2) Prevent eclamptic seizures
S/E magnesium
Hypotension Heart Block Muscle weakness Sedation Increases blockage for NMB drugs * Cardiac and Respiratory arrest can occur
Treatment for Magnesium OD
1) D/C it
2) Calcium
3) Lasix
Treatment for maternal hypotension
Ephedrine Oxygen Left uterine displacement Fluids Small dose phenylephrine can be used also.
Treatment of Unintentional IV injections
Supine with left uterine displacement
Thiopental and Propofol to stop seizure
Unintentional Intrathecal injection
1) Supine with left uterine displacement
2) Ephedrine and IV fluids
3) Intubation and ventilation in high spinal
Treatment of Post Dural Headache
Bedrest Hydration Oral analgesics Caffeine : 500mg IV *Blood Patch
7 signs of Fetal Distress
1- Oligohydramnios 2- repetitive late deceleration 3- loss of beat-to-beat variability 4- Fetal uterine growth retardation 5- Scalp pH< 7.2 6-Meconium stained amniotic fluid 7- Fetal heart rate < 80 bpm
Obesity is
> 20 % of Ideal body weight
BMI > 30kg/m2
Morbid obesity is
Double of Ideal Body weight
BMI >40kg/M2
PFT of obesity indicates
Restrictive lung disease
Physiological changes of obesity
Decreased chest wall compliance, Decreased ERV, Decrease FRC ( worse supine ) and increase WOB
With morbid obesity : closing capacity > FRC = V/Q mismatch and arterial hypoxemia
Closing capacity exceeds FRC
Obesity effects on drugs volume of distribution
Increased Volume of distribution for lipid soluble drugs
Pickwickian Syndrome aka Obesity-hypoventilation syndrome leads to 10 factors :
1- Hypercapnia 2- Hypoxemia 3- Pulmonary HTN 4- Systemic HTN 5- Pulmonary edema 6- Cyanosis-induced polycythemia 7- Rales 8- LVH/RVH 9-Somnolence;Poor sleep at night 10- Dependant edema 10-
The Fetal circulation has 3 shunts . name them and what is their purpose
1) Ductus Venosus : From umbilical vein to the IVC to bypass liver
2) Foramen Ovale: From the right atrium to the left atrium to bypass the lungs
3) Ductus arteriosus: From the pulmonary artery directly the Aorta then to the head
* the shunt bypass the liver and the lungs
TTN or Transient Tachypnea of the newborn
Benign, self limiting condition present in infant of any gestitional age , present shortly after birth due to delayed clearance of fluid clearance from the lungs .
Preterm neonates and C-section neonates have low catecholamines released which promotes sodium channel transport leading to greater amount of residual liquid in their lungs
Normal Neonate respiratory Rate
30-60 breaths/minute
First breath at 9 seconds— it establishes Neonate FRC.
Breathing should begin at 30 seconds and regular by 90 seconds
Fetal lungs contains
Liquid made of ultrafiltrate plasma of 30 mls. 2/3 expelled from the lungs of the neonate by the time of delivery. 1/3 reabsorbed during labor and delivery.
Residual lung liquid leads to
Difficulty of initiating breath and maintaining normal breathing pattern
Surfactant timeline in the fetus
20 weeks : Present in alveolar lining
28-32 week: within the lumen
34- 38 weeks : Significant amount in the terminal airway
Its production stimulated by chronic maternal stress or corticosteroids
Stress during labor and delivery can lead to
the passage of meconium into the amniotic fluid and gasping efforts by the fetus, which may result in the aspiration of amniotic fluid into the lungs.
Meconium—gasping efforts by fetus—aspiration of amniotic fluid into lungs.
Catecholamines 4 roles
1) production and release of surfactant
2) transition to active sodium transport for absorption of lung fluid
3) preferential blood flow to vital organs during stress of delivery
4) Thermoregulation of the neonate
Explain Non-shivering Thermogenesis of the neonate.
Neonates 1) release Norepinephrine 2) raise their metabolic rate in response to cold = oxidation of brown fat which contains mitochondria. This oxidation leads to the non-shivering thermogenesis. This causes O2 consumption to go up.
Thermal Stress is greater in
Preterm neonates, and infants small for gestational age , due to low fat stores.
Alternative to evaporation heat loss of neonate
Occlusive wrap rather than drying
less than 28 weeks give polythene wrap/bag
Maintain neutral thermal environment 34-35 degree Celsius
Antepartum Risk factors for Resucitation
Maternal Diabetes HTN disorder of pregnancy Chronic HTN Fetal anemia or Isoimmunization Previous fetal or neonatal death Bleeding in 2nd or 3rd trimester Maternal infection Maternal cardiac, pulmonary, thyroid , renal, neurological disease Poly or Oligohydromnios Premature Ruptured membrane Fetal hydrops Post-term gestation Multiple gestation Discrepancy in fetal size and dates ( i.e LMP date ) Drug Therapy : Magnesium, Lithium Carbonate , adrenergic blocking drugs Maternal substance abuse Fetal Malformation Diminished fetal activity No prenatal care Maternal age >35 years.
Meconium is present in the intestinal tract
After 31 weeks and is present in 10-15% of pregnancies
Meconium Aspiration Syndrome (MAS)
Respiratory Distress in a neonate whose airway was exposed to meconium and Chest X-ray showing pulmonary consolidation and atelectasis
Treatment of MAS
Positive Pressure Ventilation ; but risk of pneumothorax to due air leak
Congenital Anomalies that cause upper airway obstruction include:
Micrognathia, macroglossia, laryngeal webs, laryngeal atresia, stenosis , subglottic webs, tracheal agenesis, tracheal rings
Congenital High Airway Obstruction Syndrome ( CHAOS)
Exit procedure .
Intrinsic airway obstruction of the larynx or upper trachea (e.g., laryngeal web, subglottic cyst, tracheal atresia) can lead to retention of bronchial secretions and subsequent pulmonary distention; this constellation of s/s = CHAOS
To reduce the risk for cerebral palsy in surviving infants.
Maternal administration of magnesium sulfate before anticipated early preterm birth