Mod 9 + 10 Flashcards by Kristin Godsey

39 0/7 through 40 6/7 weeks

Full Term

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41 0/7 through 41 6/7 weeks

Late Term

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42 0/7 weeks and beyond

Post Term

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Normal physiologic weakening of membranes combined w/ shearing forces created by contractions
–Associated w/ intraamniotic infection, esp w/ earlier gestation

PROM

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Risk Factors for \_\_\_\_\_\_\_\_\_\_\_\_:
Hx of pPROM
Short cervix
2nd and 3rd trimester bleeding
Low BMI
Low socioeconomic status
Smoking
Drug use

PROM

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May cause false \_\_\_\_\_\_\_\_\_\_\_ in Nitrazine test:
Blood
Semen
Alkaline antiseptics
BV

positives

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most common sign of uterine rupture

fetal bradycardia

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May cause false ___________ in Nitrazine test:
Prolonged rupture
Minimal residual fluid

negatives

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FFN test has high ___________ and low __________

high sensitivity ; low specificity

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Maternal Risks of \_\_\_\_\_\_\_\_\_\_\_\_\_:
Most significant: intrauterine infection (increases w/ increased ROM duration)
C-section
Abruption
Umbilical cord accident
Antepartum hemorrhage
PP endometritis
Thromboembolic complications
PPH
Maternal death

PROM

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Fetal Risks of \_\_\_\_\_\_\_\_\_\_\_\_\_\_:
Non-reassuring FHT
Infection
If Pre-term:
Prematurity complications
Respiratory distress most common
Sepsis
Intraventricular hemorrhage
Necrotizing enterocolitis w/ intrauterine inflammation → Increased risk of neurodevelopmental impairment
White matter damage

PROM

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During induction w/ oxytocin for PROM, a sufficient period of adequate contractions, at least __-__ hours, should be allowed for the latent phase to progress before diagnosing failed induction and moving to C/S

12-18

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PPROM @ 24 0/7 – 33 6/7 weeks:

_________ recommended to prolong latency if no contraindications

Antibiotics

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type of breech in which fetal legs are flexed at the hips and extended at the knee

Frank Breech

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type of breech in which fetal legs are flexed at the hips and flexed at the knee

Complete Breech

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ACNM recommends against offering ___________ in PROM to GBS+ patients

expectant management

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Avoid baseline __________ in PROM

SVE

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infant head swelling that does NOT cross suture lines

Cephalahematoma

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infant head edema that DOES cross suture lines

Caput

Subgaleal Hemorrhage

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infant head edema that resolves in a few weeks or months

Cephalahematoma

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infant head edema that resolves in a few days after delivery

Caput

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infant head edema that is usually located on the parietal and occipital bones

Cephalahematoma

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infant head edema that is usually located on the scalp, periorbital, periauricular areas

Subgaleal Hemorrhage

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Symptoms of _____________:
Decreased or absent movements of the arm on the affected side
Tenderness, deformity, and crepitus may be elicited at the site of injury
Incomplete Moro on the affected side
Nonrespiratory tachypnea caused by discomfort

Fractured Clavicle

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Symptoms of _____________: | mass caused by hematoma formation or signs of pain during palpation

Fractured Humerus

Symptoms of ____________:

Erb's Palsy

Symptoms of ____________: volves C8-T1 Weakness of the wrist and fingers flexors and of the small muscles of the hand “good shoulder, bad hand” scenario Complete or partial paralysis of the forearm and hand muscles

Klumpke Palsy

TERMPROM study found higher risk for infection with _____________ than with _____________

higher risk with expectant management | than with IOL

Sharp increase in risk of complications after ____ hours of PROM

``` ACOG Criteria for __________: 1 or 2 previous low-transverse C/S Clinically adequate pelvis No other uterine scars No Hx of uterine rupture Physician immediately available throughout active labor Physician capable of monitoring labor Physician able to perform 911 C/S Anesthesia/personnel available for 911 C/S ```

TOLAC

``` ACOG Criteria against attempting ___________: Prior classical or T-shaped C/S incision Other transfundal surgery Contracted pelvis Medical/Obstetric complication Inability to perform 911 C/S ```

TOLAC

Risks to Consider but do not Preclude __________: Multiple previous c/s Macrosomia > 40 week gestation Unknown type of prior uterine incision - unless highly suspicious of previous classical incision, may still be candidates Twin gestation - may be considered w/otherwise appropriate candidates Obesity - high BMI alone is not an absolute contraindication

TOLAC

``` Signs of ___________: Loss of station Fetal stress - *Bradycardia* Palpable parts in the abdomen Continuous abdominal pain - tends to refer to scapular/ shoulder area Increased vaginal bleeding Hypertonic or fewer contractions Lower amplitude Prolonged, late, or variable decels (Contraction pattern unreliable and often normal) (Can mirror s/s of abruption) Often remarkably little appreciable pain or tenderness ```

Uterine Rupture

``` Causes of ______________: Before delivery: Persistent, intense, spontaneous contraction IOL w/ oxytocin or prostaglandins Intraamniotic installation w/ saline or prostaglandins Perforation by IUPC External trauma External version Uterine overdistention due to hydramnios Multifetal pregnancy During delivery: Internal version of second twin Difficult forceps delivery Breech extraction Fetal anomaly distending lower segment Vigorous uterine pressure during delivery Difficult manual removal of placenta Acquired: Placenta accrete syndromes Gestational trophoblastic neoplasia Adenomyosis Sacculation of entrapped retroverted uterus ```

Uterine Rupture

Risk of ____________ with history of one low transverse cesarean section: 0.2 - 1.5% Average 0.6% 1 in 170 women

Uterine Rupture

Risk of ____________ with history of 2 low transverse cesarean sections: 3.9% 1 in 26 women 3-5 fold higher than in women with only 1 prior C/S

Uterine Rupture

``` Management of _______________: Urgent delivery - often C/S (Decision to incision time of <18 minutes associated with best outcomes) Adequate IV access Ready for blood transfusion Call for NICU/Neonatal team Hysterectomy may be required ```

Uterine Rupture

``` Fetal Risks of ____________: Neonatal convulsions Meconium Aspiration Syndrome 5-minute APGAR < 4 NICU admission Postmaturity syndrome** Oligohydramnios** Stillbirth ```

Post Term Pregnancy >/= 42+0/7 Weeks

``` Fetal Risks of ____________: Perinatal morbidity and mortality Macrosomia (double risk) which can lead to: Operative vaginal delivery C/S Shoulder dystocia ```

Late Term Pregnancy 41+0/7 - 41+6/7 Weeks AND Post Term Pregnancy >/= 42+0/7 Weeks

``` Maternal Risks of ___________: Severe perineal laceration Infection PP Hemorrhage C/S Anxiety ```

Late Term Pregnancy 41+0/7 - 41+6/7 Weeks AND Post Term Pregnancy >/= 42+0/7 Weeks

``` Symptoms of ______________: decreased subcutaneous fat Lack of vernix Lack of lanugo Often MSAF Often Meconium-stained skin, membranes and umbilical cord ```

Postmaturity Syndrome

Membrane sweeping decreases risk of:

late and post term pregnancies

Fetal Surveillance for ____________: Initiate @ 41-42 wks Twice weekly NST, BPP, modified BPP, AFV

late and post term pregnancies

``` Indications for ________: Gestational hypertension Preeclampsia and eclampsia Fetal growth restriction Cholestasis of pregnancy Diabetes mellitus Fetal demise Intraamniotic infection Oligohydramnios Nonreassuring fetal status Other medical indications Prelabor ROM Postterm pregnancy ```

IOL

Contraindications for _______: Elective before 39 weeks Any situation that precludes vaginal birth Placenta or vasa previa Transverse lie Umbilical cord prolapse Previous myomectomy entering the endometrial cavity Previous classical uterine incision Active genital herpes infection Presence of Category III fetal heart tracing

IOL

Nulliparous Ripe Cervix Bishop Score

Multiparous Ripe Cervix Bishop Score

Late-term and post-term pregnancies and PROM are not associated with increased risk of:

C/S

Nulliparous IOL are at double risk of:

C/S

should occur prior to initiation of cervical ripening or pitocin IOL

consultation or collaboration w/ physician

``` Documentation for _________: Gestational age w/ criteria used to establish EDD Bishop score Indications No contraindications Clinical pelvimetry Confirmation of cephalic presentation Category I FHT ```

IOL or Cervical Ripening

Water immersion may be considered during:

IOL w/ pitocin

Stimulates the myometrium of the uterus to contract similar to labor, resulting in the evacuation of the products of conception from the uterus - Exerts it's uterine effects via direct myometrial stimulation, but the exact MOA is unknown. - Other suggested mechanisms include the regulation of cellular membrane calcium transport and of intracellular concentrations of cyclic 3',5'-adenosine monophosphate - Produces local cervical effects including softening, effacement, and dilation - Exact MOA for this effect is also unknown, but it has been suggested that it may be associated with collagen degradation caused by secretion of the enzyme collagenase as a partial response to locally administered drug

MOA of Cervidil and Prepidil

onset of Cervidil and Prepidil

rapid

drug that is equal to Prepidil effectiveness for IOL

Cervidil

Benefits of ___________: - Fewer vaginal exams (greater patient satisfaction) - Uterine hyperstimulation w/ FHR changes resolve within 15 minutes of removal and do not lead to operative birth secondary to fetal distress - Ability to remove drug quickly and easily

Cervidil

SE of _____________: Diarrhea Adverse: Uterine Hyperstimulation

Cervidil and Prepidil

Key Notes on _____________: - Requires refrigeration (frozen and does not require thawing before vaginal insertion) - 10mg, 0.3mg/hr, vaginal posterior fornix insert - FHR and uterine activity (UA) monitoring required after placement AND 15 minutes after removal - Remains in place for 12 hours or to onset of active labor - May start oxytocin 30-60 minutes after removal of insert - Remove if contractions > 5 in 10 minutes

Cervidil

Benefits of ___________: | Not associated w/ risk for hyperstimulation w/ FHR changes

Prepidil

Key Notes on ____________: - Requires refrigeration - 0.5mg in 2.5mL syringe endocervical gel - Lie recumbent 30 minutes after insertion - EFM and uterine activity monitoring 2 hr before and after insertion (may be outpatient for selected patient) - May start oxytocin in 6-12 hours for max dose of 3 doses in 24 hours

Prepidil

Synthetic prostaglandin E1 analog that stimulates prostaglandin E1 receptors on parietal cells in the stomach to reduce gastric acid secretion - Mucus and bicarbonate secretion also increased along with thickening of the mucosal bilayer so the mucosa can generate new cells - Binds to smooth muscle cells in the uterine lining to increase the strength and frequency of contractions as well as degrade collagen and reduce cervical tone - Ripens cervix and induces contractions

Cytotec

``` Benefits of _____________: Inexpensive Overall safe and easy to use Stable at room temperature Few systemic side effects No known drug interaction Vaginal - fewer failures of birth w/in 24 hours of administration Less epidural and oxytocin use than dinoprostone or oxytocin ```

Cytotec

``` SE of _____________: Diarrhea Shivering Headache Cramps Nausea/Vomiting Indigestion Constipation Flatulence Chills Fever (Systemic reactions less common w/ vaginal) ```

Cytotec

Cytotec routes that have less risk of C/S than vaginal route

PO, buccal, SL

Cytotec route with more sustained plasma level, longer exposure, and longer onset of action

Vaginal

EFM and UA monitoring 20-30 min before placement and continuously after administration of:

PO Cytotec

EFM and UA monitoingr 30 min before administration and after for 2-4 hours

Vaginal Cytotec

Cytotec route: 25-50 mcg q 3-6hours, max of 8 doses

vaginal

Cytotec route: 25mcg q 3-6 hours or 50 mcg q 6 hrs

May start pitocin ___ hours after last dose of Cytotec

Do not use cytotec if > ___ contractions in 10 min

cytotec route that is more effective than placebo and results in fewer cesarean sections than dinoprostone or oxytocin

PO and vaginal cytotec have same

effectiveness of achieving vaginal birth

Perinatal outcomes revealed higher APGAR scores and fewer PP hemorrhages but increased MSAF among those using ____ cytotec

insertion most likely triggers a local immune and inflammatory process that triggers cervical remodeling that leads to dilation and cervix softening

Foley bulb

Use ___ mL of sterile water in foley bulb

foley bulb typically falls out in ___-___ hours

6-12

there is no difference in C/S rate with ____________ than pharmocological methods

foley bulb

foley bulb causes minimal cervical:

effacement

Benefits of ___________: No increase in infectious morbidity Lower rate of uterine hyperstimulation w/ and w/o FHR changes vs prostaglandins Can be used for TOLAC/VBAC with unfavorable cervix Broadly available Low cost

foley bulb

Risks of ____________: May cause discomfort and persistent lower abdominal cramping Accidental ROM Lower rate of achieving vaginal delivery w/in 24 hours -- often explained by AROM or Pit delayed while awaiting expulsion

foley bulb

Hygroscopic dilator- also called osmotic dilators which draw water from surrounding tissues and expand to gradually dilate the endocervical canal. Derived from various species of Laminaria algae that are harvested from the ocean floor. Made from dried and sterilized seaweed stems

Laminaria

Cause slightly higher dilation than misoprostol Works over the course of 12-24 hours Left in place for 6-12 hours

Laminaria

Benefits of ____________: | Patients can void, ambulate or stool without limitations

Laminaria

Risks of ____________: May be uncomfortable Device fragmentation with the need to have removal

Laminaria

Synthetic osmotic dilator compressed polyacrylonitrile and is entirely synthetic. Achieve cervical ripening through absorption of water from surrounding tissues without the aide of exogenous pharmaceutical agents- Commonly used for induced abortion in the late first and early second trimesters- also for cervical stenosis in nonpregnant women before gyn procedures

Dilapan

Several studies showed some efficacy without maternal or neonatal morbidity of:

Dilapan

Benefits of __________: Clinical effects in 2 to 4 hours Left in place for 6-12 hours

Dilapan

Risks of ____________: No data regarding potential harms Not approved beyond 23+6 weeks Device fragmentation with the need to have removal

Dilapan

Absorbent compressed polyvinyl acetal sponge containing up to 500 mg of magnesium MOA is theorized to be both mechanical through hygroscopic dilation, and chemical through magnesium- induced cervical stroma collagenolysis

Lamicel

Developed for 1st or 2nd trimester pregnancy termination Proposed to be used for cervical ripening Not approved beyond 23+6 weeks

Lamicel

Hormone primarily produced by hypothalamus (also synthesized and secreted by placenta and fetus) and secreted from the posterior pituitary that is similar to vasopressin and has a direct antidiuretic effect on kidneys

Oxytocin

Oxytocin Onset: __-__ minutes Half-life: ___ minutes Steady-state uterine response: __-__ minutes

Onset - 3-4 minutes Half-life 15 minutes Steady-state uterine response 30-40 minutes

Possible reason for marked interindividual variability in response to oxytocin

receptor dysfunction

``` Risks of _____________: Increased risk for PPH (with long duration use) Pulmonary edema (fluid restricted patients) Hypotension Tachycardia Transient MI (EKG changes w/ bolus dose) Uterine tachysystole Uterine rupture ```

Pitocin

High Dose Oxytocin Regimen: Start @ ___ mu/min Increase by __-__ mu/min every ___-___ minutes

start @ 6 | increase 3-6 q 15-40 min

Low Dose Oxytocin Regimen: Start @ __-__ mu/min Increase every ____ minutes

start @ 0.4- 2 | increase q 40 min

Natural induction method that induces the release of endogenous oxytocin from the pituitary gland which causes uterine contractions similar to administration of synthetic oxytocin - Low risk women with a favorable cervix are likely to be in labor within 72 hours using this method - Decreases risk of PP Hemorrhage - Because existing evidence has not examined this method for women at risk for fetal acidemia, it is discouraged in this instance

Nipple Stim

Natural method of induction that releases prostaglandins - No studies that show harm or increased risk, so use w/ SDM - Waiting until 40 weeks and a thinning cervix helps to increase effectiveness - Can shorten pregnancy by 1-4 days. * *Not endorsed by ACOG or ACNM if woman is GBS+

Membrane Stripping

2 tsp of castor oil, 1 tbsp of almond butter- apricot juice and 5 drops of essential oil Verbena (obtained from Germany).

Canadian Verbena Cocktail

Natural induction method that causes shorter labors | and cervical ripening

acupressure

AVOID this natural induction method due to adverse outcomes

blue and black cohosh

Limited research on these for natural induction

Red raspberry leaf tea | evening primrose oil

ECV eligible after ___ weeks

``` Increases success of _________: Multiparous BMI normal (=25?) Normal AFI Posterior placenta Weight 2500-3000g (also saw 2500-4000g) ```

ECV

``` Contraindications of ____________: Placenta previa Multifetal gestation Early labor Oligohydramnios Ruptured membranes Known nuchal cord Structural uterine abnormalities FGR Prior abruption Abruption risk Prior C/S ```

ECV

``` Complications of ___________: Uterine rupture Placental abruption Preterm labor Fetal compromise Fetomaternal hemorrhage Alloimmunization Amniotic fluid embolism Fetal death (rare) ```

ECV

Considerations for ___________: Location must have ability to do 911 C/S IV access required Patient NPO for 6 hours or more US exam is performed to confirm presentation, AFI, placental location and fetal spine Pre-procedure NST Anti D immune globulin is given to Rh-D negative women Tocolysis and regional analgesia may be elected Position in left lateral tilt to aid uteroplacental perfusion and Trendelenburg positioning helps during evaluation of the breech. Monitor FHR Forward roll of the fetus is usually attempted first One hand grasps the head, the fetal buttocks are then elevated from the maternal pelvis and displaced laterally. The buttocks are then guided toward the fundus while the head is directed toward the pelvis. If the forward roll is unsuccessful a backward flip is attempted. Discontinue in excessive discomfort, persistently abnormal FHR, or after multiple failed attempts If successful, NST is repeated until a normal test result is obtained

ECV

Breech Hand Maneuver: Hand up along leg and keep leg flexed. Follow to behind knee, press knee away from midline, spontaneous flexion follows, sweep flexed leg across abdomen to deliver and repeat on other side if needed.

Pinard

Breech Hand Maneuver: hands over hard portion of pelvis and rotate baby to RST and use downward and outward traction to deliver anterior arm, rotate to do with posterior arm

Shoulders rotate to oblique

Breech Hand Maneuver: allow body to rest on arm. Insert arm into vagina and ring and middle finger press on maxilla to encourage flexion of head while other arm is slid on top of scapula and middle finger is placed along baby’s neck and gentle pressure applied to encourage head flexion (assistant is helping with suprapubic pressure)

Mauriceau- Smellie- Veit maneuver

Face presentation where chin is __________, vaginal delivery is possible

Face presentation where chin is ____________, C/S delivery is needed

posterior

``` 85% of _____ due to: Prior cesarean delivery Dystocia Fetal jeopardy Abnormal fetal presentation ```

C/S

causes higher rates of facial nerve injury, brachial plexus injury, depressed skull fracture, and corneal abrasion

FAVD

causes higher rates of intracranial hemorrhage

VAVD

Risk Factors for ____________:

Stillbirth

``` Fetal Risks of ____________: IUFD Spontaneous abortion Preterm birth FGR Neonatal toxicity Structural malformations GI problems Persistent pulmonary hypertension of the NB (PPHN) Cardiac malformations Long-term effects on infant neurocognitive development ```

Antidepressants in Pregnancy

Fetal Symptoms of ___________: 15-30% of neonates may experience symptoms of: Tachypnea Hypoglycemia Temp instability Irritability Weak cry Seizures within 2 weeks after birth if exposed to SSRI during pregnancy

Antidepressant Use in Pregnancy

Overlapping of fetal cranial bones seen on US in IUFD

Spalding's Sign

Presence of gas in fetal abdomen seen on US in IUFD

Robert's Sign

Mod 9 + 10 Flashcards

(122 cards)