FETAL HEART MONITORING
1. Normal fetal HR?
2. Look for?
3. Decelerations where HB drops?
4. Lack of variability or prolonged
-HR under what indicated fetal distress?
5. “Late” decelerations indicate?
6. “Sinusoidal” pattern indicates?
1. Normal fetal heart rate 120-160beats/min
2. Look for “variability” & accelerations
3. OK to decrease slightly during a contraction & then return to normal
4. Lack of variability or prolonged (> 10 min.) HR< 120 indicates fetal distress
5. “Late” decelerations indicate fetal distress
6. “Sinusoidal” pattern indicates severe fetal distress
What is this?
NORMAL FETAL HEART TRACING
What is this?
Normal baseline HR
There is not a decelration with every contraction
Usually occurs because of cord compression
What is this?
Decelerations come after contractions
Loss of variability
Lower oxygen and maybe starting towards acidosis
What is this?
Get to bed and C section in 20 minutes
What is this?
Baby needs to be delivered immediately
FETAL HEART TRACINGS—FETAL DISTRESS
1. Initial measures are trying to increase O2 to the fetus: 3
2. Stop what meds? If continued frequent contractions w/ continued fetal distress may consider what?
3. If fetal distress continues for 15 – 20 minutes may try what?
4. If this does not work?
-Maternal administration of O2
-Change maternal position
-Bolus w/ normal saline
2. Stop any utertonic drugs and if continued frequent contractions w/ continued fetal distress may consider tocolytic
3. Iscalp stimulation to see if FHR will accelerate which is reassuring—
4. if the FHR does NOT accelerate can indicate fetal acidosis and prompt delivery is indicated
1. definition? 2
2. DDx? 8
-2 BP measurements 6 hrs apart >140/90
-+ Proteinurea >0.1 g/L on urine dipstick or > 300 mg protein 24 hrs.
MANAGEMENT OF MILD PREECLAMPSIA
1. Tx? 2
3. Assessment of fetus? 3
4. Any sign of severe preeclampsia?
-If patient is >/= 37 weeks—deliver
-34-36 weeks can do expectant management**
-CBC w/ platelets,
-CMP (check Cr),
-24 hour urine
3. Assessment of fetus:
-US to assess size,
-amount of amniotic fluid
-Nonstress test (?)
4. Any sign of severe preeclampsia—DELIVER!
2. Management? 4
3. If less than 30 wks best to?
-SBP > 160, DBP >110
-Proteinurea >/= 5 gm in 24 hours
-Signs of end organ damage**
-Indication for admission
-Start on magnesium sulfate (to prevent?)
-Treat BP with- hydralazine, methyldopa
-Delivery—induction initially may require c-section
3. go to a tertiary center for management w/ a perinatologist
1. Maintenance phase given only after what?
2. What are signs that magnesium level is OK? 2
3. SE: with loading dose? 5
4. Fetus: SE?
1. patellar reflex is present, loss of reflexes first sign of hypermagnesemia
-Respirations >12 per min &
-flushing because of vasodilation & decrease in BP,
-rare pulmonary edema and
4. no significant SE
MORE ON MANAGEMENT
1. Mag sulfate acts as what?
2. The cure for preeclampsia is?
3. The patient is still at risk for complications including seizures for how long postpartum so mag sulphate should be continued & the patient monitored closely?
1. Magnesium sulphate acts as an anticonvulsant
2. The “cure” for preeclampsia is delivery of the placenta
3. 48-72 hrs.
1. What is it?
2. Gernerally lasts how long?
3. management? 5
1. The occurrence of 1 or more general tonic-clonic seizures or coma in a preeclamptic woman**
2. Generally last no longer then 3-4 minutes (usually 60-75 sec.)
-Protect maternal airway
-Lower blood pressure if severely high
-Prevent further seizures by starting: Mag sulfate
-Persistent seizures—lorazepam or diazepam
-Monitor fetus—often limited bradycardia**
Blood pressure meds to use in ecclampsia? 2
DEATH IN UTERO
2. Document? 2
3. Management in 2nd and 3rd trimester?
4. What are they at risk for if they baby remains in the uterus?
1. Presentation: usually the mother comes in c/o decreased fetal movement
2. Document: no fetal heart sounds and NO cardiac activity on ultrasound
3. In 2nd and 3rd trimester generally best to induce labor except if prior c-section then the woman is at higher risk of uterine rupture**
4. Mother is at risk of coagulopathy the longer the fetus remains in the uterus
This is a great loss and should be treated as such—attend to emotional needs of the parents
Steps if unable to do a C section
1. CONTROL DELIVERY-REACH BRING OUT ONE LEG
2. ONE LEG OUT
3. TORSO DELIVERED
4. DELIVERY OF LEFT ARM
5. RIGHT ARM DELIVERED
6. It is important to keep the head flexed, inserting a finger into the baby's mouth can aid this!
7. Suprapubic pressure may also be applied to keep head flexed
SHOULDER DYSTOCIA MANEUVERS
1. A distended bladder if present is drained
2. McRoberts: two assistants sharply flex the maternal thighs back against the abdomen
3. Apply suprapubic pressure with palm or fist**
4. Cut a generous episiotomy
5. Rubin maneuver: clinician places one hand in vagina behind poterior shoulder rotates it anterior toward fetal face
6. Get mom on “all fours”
Describe the following:
1. Gaskin all-fours?
1. Gaskin all-fours: place the mother her hands & knees down and the infant is delivered by gentle downward traction on the post shoulder
2. Symphysiotomy: used as last resort when c-section not available, anesthetize area, displace urethra with finger & cut through cartilagenous portion of symphysis
Can replace fetal head and do emergent c-section
May be a vertical or breech presentation with an extremity beside it:
1. Do not use what in these cases?
2. Sometimes the extremity will naturally be moved out of the way and what can happen?
3. If the extremity persists then what?
4. May be what kind of breech or leg first or arm. How are these generally delivered?
1. DO NOT use oxytocin in these cases
2. Sometimes the extremity will naturally be moved out of the way and a vaginal delivery will occur
3. If the extremity persists—c-section needs to be done
4. May be a footling breech or leg first or arm generally these are delivered by c-section unless they spontaneously deliver **
ACUTE HERPES VULVOVAGINITIS
1. The highest risk for a newborn to acquire congenital herpes is how?
2. For any pregnant woman who is in labor who has a history of genital herpes she should have a c-section if? 2
1. The highest risk for a newborn to acquire congenital herpes is to a mother who was infected with primary HSV-2 during the pregnancy
2. For any pregnant woman who is in labor who has a history of genital herpes she should have a c-section if:
-She has active herpes lesions on or near the birth canal
-Any prodromal symptoms on or near the birth canal