Obgyn T 22-45 Flashcards

Question

What follow-up test may be offered if a fetus is suspected of having a chromosomal abnormality based on anatomical appearances?

Answer 1

If anatomical appearances suggest a chromosomal abnormality, a CVS (placental biopsy in later pregnancy) or amniocentesis may be offered for further assessment.

Answer 2

Possible interventions include termination of pregnancy, maternally administered anti-arrhythmic drugs for fetal cardiac arrhythmias, or insertion of a vesico-amniotic drain to treat fetal urethral obstruction and prevent renal damage.

Answer 3

Screening for low-risk pregnancies includes maternal vigilance for fetal activity, fundal height measurement (±3 cm range), and auscultation of the fetal heart using a Pinard stethoscope or Doppler ultrasound at every antenatal visit.

Answer 4

AEDV indicates increased placental vascular resistance and is associated with worse outcomes such as growth restriction, hypoxia, and fetal death. Management includes close surveillance or elective preterm delivery if occurring after 34 weeks.

Answer 5

Reversed diastolic flow is a highly ominous sign, associated with imminent fetal death. Management depends on gestational age, and delivery may be discussed if the pregnancy is at 26 weeks or more.

Answer 6

Fetal growth is best documented through serial ultrasound measurements of head circumference (HC) and abdominal circumference (AC), which help identify growth patterns and assess fetal wellbeing.

Answer 7

A constitutionally small fetus is typically genetically small, with no underlying pathological cause. It has a lower risk of complications compared to fetuses with growth restrictions due to other causes.

Answer 8

Asymmetrical growth restriction tends to occur later in pregnancy and is often associated with placental issues (UPVD), while symmetrical growth restriction indicates an early pregnancy insult and is linked to higher risks of hypoxia and fetal death.

Answer 9

Large fetuses can be constitutionally large, with both head circumference (HC) and abdominal circumference (AC) following the top centile, or large due to other factors like maternal diabetes.

Answer 10

Screening in low-risk pregnancies includes maternal vigilance for fetal activity, fundal height measurement (±3 cm from gestational age), and auscultation of the fetal heart using a Pinard stethoscope or Doppler ultrasound at antenatal visits.

Answer 11

Fundal height is measured from the maternal pubic symphysis to the uterine fundus. The normal range is within ±3 cm of the gestational age, e.g., at 32 weeks, the range should be 29–35 cm.

Answer 12

The fetal heart is auscultated at each visit using a Pinard stethoscope or Doppler ultrasound. While the rate is not typically recorded, any abnormalities in the fetal baseline heart rate may be missed in routine practice.

Answer 13

Umbilical artery Doppler significantly improves fetal outcomes in high-risk pregnancies by assessing blood flow. Absent end-diastolic flow (AEDV) and reversed diastolic flow are key indicators of placental issues and potential fetal compromise.

Answer 14

Reversed diastolic flow is a critical indicator of imminent fetal death, and management typically involves discussing elective preterm delivery if the pregnancy is at 26 weeks or beyond.

Answer 15

Fetal growth is monitored through serial ultrasound measurements of head circumference (HC) and abdominal circumference (AC), which help identify small-for-dates and large-for-dates fetuses

Answer 16

The two patterns are: 1. Constitutionally small - due to genetic factors. 2. Pathological growth restriction - either asymmetrical (later in pregnancy, often related to placental issues) or symmetrical (early pregnancy insult).

Answer 17

Small-for-dates fetuses, especially those with pathological growth restriction, are at higher risk of fetal death, hypoxia, preterm delivery, and placental bleeding.

Answer 18

Large fetuses can either be constitutionally large, with both head circumference (HC) and abdominal circumference (AC) following the top centile, or large due to other factors like maternal diabetes.

Answer 19

Macrosomia refers to pathologically large fetuses, where the head circumference (HC) follows a normal centile, but the abdominal circumference (AC) shows accelerated growth across centiles, commonly seen in fetuses of diabetic women.

Answer 20

The most accurate estimate of AFV is via ultrasound, using two methods: 1) Single deepest pocket (normal range: 2–8 cm) and 2) Amniotic fluid index (AFI), which is the sum of fluid depths in four quadrants of the uterus.

Answer 21

The BPP is a combined assessment of fetal wellbeing using five parameters. A normal response is for the fetus to exhibit at least 4 parameters within 40 minutes, indicating immediate wellbeing.

Answer 22

The five observations are: 1. Fetal heart rate (FHR) – at least 2 accelerations of 15 beats/min or more in 40 minutes. 2. Fetal movements – at least 3 separate movements in 40 minutes. 3. Fetal tone – one movement demonstrating a full flexion-extension-flexion cycle. 4. Fetal breathing – sustained 30 seconds of regular breathing movements. 5. Amniotic fluid volume (AFV) – at least one vertical pool measuring 2–8 cm.

Answer 23

When fetal risk is identified, the two valuable interventions are: 1. Elective delivery (at or beyond 34 weeks) or based on immediate risk assessment. 2. Maternal steroids, such as betamethasone, if elective preterm delivery is likely but only chronic fetal health measures are abnormal.

Answer 24

Elective delivery is considered if the risk is identified at 34 weeks or more. If identified earlier, it depends on the immediate risk of fetal death based on assessments such as abnormal biophysical profile scores or reversed end-diastolic flow.

Answer 25

Maternal steroids, like betamethasone, are given if elective preterm delivery is likely in at-risk pregnancies but only chronic fetal health measures are abnormal, such as absent umbilical artery flow in Doppler studies.

Answer 26

Specific interventions include: 1. Maternal drugs for fetal cardiac arrhythmias. 2. Intrauterine blood transfusion for severe Rhesus isoimmunization. 3. Laser ablation of placental vascular communications in twin-to-twin transfusion syndrome.

Answer 27

Labor, or parturition, is the process whereby the products of conception are expelled from the uterine cavity after the 24th week of gestation.

Answer 28

About 93-94% of deliveries occur at term (between 37 to 42 weeks), while about 7-8% develop preterm labor and deliver preterm (from 24 to 37 weeks).

Answer 29

Preterm labor is defined as labor occurring before the commencement of the 37th week of gestation. Before 24 weeks, it results in a previable fetus and is termed miscarriage.

Answer 30

Prolonged labor is defined as labor lasting in excess of 24 hours in a primigravida and 16 hours in a multigravida, and it is associated with increased fetal and maternal morbidity and mortality.

Answer 31

The early preparation (pre-labor phase) can last for days and weeks, involving the softening, shortening, and dilation of the cervix, which accelerates with the onset of uterine contractions.

Answer 32

The three stages of observed labor are: 1. First Stage - from onset of regular contractions to full cervical dilation. 2. Second Stage - from full cervical dilation to delivery of the fetus. 3. Third Stage - from delivery of the newborn to delivery of the placenta and membranes.

Answer 33

The first stage is divided into: Early Latent Phase: Cervix effaces and dilates up to 3 cm (~6-8 hours in nulliparae and 4-6 hours in multiparae). Active Phase: Cervix dilates from 3 cm to full dilation (10 cm, approximately 1 cm/hour).

Answer 34

The second stage of labor lasts from full cervical dilation to the delivery of the fetus, divided into: Pelvic (Passive) Phase: Head descends down the pelvis. Active Phase: Mother experiences a stronger urge to push, and the fetus is delivered with uterine contractions and maternal effort.

Answer 35

The third stage of labor is the duration from the delivery of the newborn to the delivery of the placenta and membranes.

Answer 36

Clinical signs include: Regular, painful contractions that increase in frequency and duration, leading to cervical dilatation. Passage of blood-stained mucus ('show'). Rupture of fetal membranes, which may occur before or during labor.

Answer 37

Prelabor rupture of membranes (PROM) occurs when the latent period between rupture of membranes and the onset of painful contractions is greater than 4 hours, either at term or in the preterm period (preterm PROM).

Answer 38

The initiation of labor involves progesterone withdrawal and increases in estrogen and prostaglandin action, regulated by the fetoplacental unit, leading to upregulation of procontractile influences.

Answer 39

At the end of gestation, there is an exponential increase in maternal and fetal plasma CRH levels, which increase estrogen synthesis and reduce progesterone synthesis, contributing to the initiation of labor.

Answer 40

CRH stimulates the synthesis of prostaglandins, promotes connectivity of uterine myocytes, and alters myocyte electrical excitability, leading to increased uterine contractions.

Answer 41

Uterine myocytes contract and shorten, influenced by ion channels that control calcium ion influx, which promotes contraction of myometrial cells.

Answer 42

The cervix becomes soft and stretchable due to increased leukocyte infiltration, decreased collagen, and increased proteolytic enzyme activity, leading to cervical ripening.

Answer 43

Increased hyaluronic acid production reduces fibronectin's affinity for collagen, causing the cervix to become soft and stretchable, facilitating ripening.

Answer 44

Reduced cervical resistance and increased frequency, duration, and strength of uterine contractions are needed for effective labor progress.

Answer 45

Uterine activity increases in frequency, duration, and strength of contractions as full term approaches, transitioning from infrequent, low-intensity contractions throughout pregnancy.

Answer 46

Labor is established with two contractions, each lasting more than 20 seconds, occurring over 10 minutes.

Answer 47

Normal resting tonus in labor starts at around 10-20 mmHg and may increase slightly.

Answer 48

Progressive uterine contractions cause effacement and dilation of the cervix through shortening of myometrial fibers in the upper uterine segment and stretching of the lower segment.

Answer 49

As labor progresses, the junction between the upper and lower segments rises in the abdomen, and retraction may lead to Bandl's ring visibility if labor is obstructed.

Answer 50

Fundal dominance refers to contractions that are stronger and last longer in the fundus and upper segment, essential for effective cervical effacement and dilation.

Answer 51

Softening of the sacroiliac ligaments and pubic symphysis allows pelvic cavity expansion, facilitating normal progress and spontaneous vaginal delivery.

Answer 52

The pelvic inlet has a larger lateral diameter than anteroposterior diameter, promoting the head to engage in the pelvis in a transverse position.

Answer 53

The passage of the head and trunk follows a defined pattern: the upper pelvic strait is transverse, the middle is circular, and the outer is anteroposterior.

Answer 54

The fetal head presents by the vertex in 95% of cases, considered the normal presentation.

Answer 55

Descent is both a feature and prerequisite for birth, and the engagement of the head typically occurs before labor onset, serving as a measure of labor progress.

Answer 56

As the head descends, it meets the sloping pelvic floor, causing the chin to contact the fetal thorax, producing a smaller diameter of presentation, changing from occipito-frontal to suboccipitobregmatic.

Answer 57

Internal rotation occurs as the head reaches the pelvic floor, where the occiput typically rotates anteriorly toward the pubic symphysis, allowing for proper alignment for delivery.

Answer 58

During extension, the acutely flexed head descends, distending the pelvic floor and vulva. The base of the occiput encounters the inferior rami of the pubis, and the head extends until delivery, culminating in crowning.

Answer 59

Restitution is the process following head delivery where the head rotates back to align with the fetal shoulders, indicating the occiput's previous position before delivery.

Answer 60

External rotation occurs as the shoulders reach the pelvic floor, rotating into the anteroposterior diameter, with the fetal head turning so that the face looks laterally at the maternal thigh.

Answer 61

The anterior shoulder is delivered first by applying posterior traction on the fetal head, followed by lifting the head anteriorly to deliver the posterior shoulder, leading to the expulsion of the trunk and lower limbs.

Answer 62

The third stage begins with the expulsion of the baby and ends with the delivery of the placenta and membranes.

Answer 63

Signs include trickling of bright blood, lengthening of the umbilical cord, and elevation of the uterine fundus within the abdominal cavity.

Answer 64

After delivery, the uterine fundus becomes firm to hard, smaller, and rounded, sitting on top of the placenta instead of being broad and globular.

Answer 65

The placenta is expelled alongside fetal membranes, which may become torn, necessitating additional traction using sponge forceps if required.

Answer 66

The entire process lasts between 5-10 minutes, and if the placenta is not expelled within 30 minutes, it is diagnosed as retained placenta, making the third stage abnormal.

Answer 67

A mother should come to the hospital when contractions are at regular 10-15 minute intervals, there is a show, or if the membranes rupture.

Answer 68

A full general examination should include checking temperature, pulse, respiration, blood pressure, hydration state, and testing urine for glucose, ketones, and protein.

Answer 69

The obstetrical examination includes inspection and palpation to determine fetal lie, presentation, position, and station of the presenting part. Fetal heartbeat is auscultated using a stethoscope or Doptone device.

Answer 70

Factors to note include: Position, consistency, effacement, and dilatation of the cervix Intact or ruptured membranes (color and quantity of amniotic fluid) Fetal presentation and position (e.g., vertex, LOA) Degree of caput, molding, and synclitism in vertex presentation Assessment of the bony pelvis at upper, middle, and lower strait and pelvic outlet.

Answer 71

The general principles include: Observation of labor progress and intervention if slow. Monitoring fetal and maternal condition. Providing pain relief and emotional support. Ensuring adequate hydration and nutrition

Answer 72

A partogram is a graphic record of labor progress, documenting cervical dilatation, contractions, fetal heart rate, color of liquor, caput, molding, station of the head, maternal heart rate, BP, and temperature, aiding in early recognition of non-progressive labor.

Answer 73

The partogram should be started as soon as the mother is admitted to the hospital, with this admission time recorded as zero time, regardless of when contractions started.

Answer 74

Fetal condition is monitored by charting fetal heart rate (FHR), noting any decelerations during contractions, recording the time of membrane rupture, and assessing the nature of the amniotic fluid (clear or meconium-stained).

Answer 75

Molding and caput indicate potential obstructed labor. Molding is assessed by the degree of suture lines meeting, while caput is marked from + to +++, indicating the relative impression formed by the clinician.

Answer 76

Molding assessed as ++ indicates that the sutures are overriding but reducible with gentle pressure, suggesting moderate molding of the fetal head.

Answer 77

Progress in labor is measured by assessing the rate of cervical dilatation and descent of the presenting part, evaluated through vaginal examinations.

Answer 78

Vaginal examinations should be performed on admission and every 3 to 4 hours thereafter during the first stage of labor.

Answer 79

In the latent phase, the cervix is expected to efface and dilate from 0 to 3 cm in 6 hours for multipara and in 8 hours for nullipara.

Answer 80

During the active phase, cervical dilation is expected at approximately 1 cm/hour from 3 cm to 10 cm for both multipara and nullipara, although multipara tend to dilate faster.

Answer 81

The alert line represents expected progress at 1 cm/hour during the active phase. The action line, drawn 2 hours parallel to the alert line, indicates when to intervene if cervical dilation lags more than 2 hours behind.

Answer 82

Descent is assessed by the palpable portion of the head above the pelvic brim in fifths and by measuring the level of the presenting part in cm relative to the ischial spines, marked as −1, −2, −3 (above) and +1, +2, +3 (below).

Answer 83

Dotted squares indicate contractions of less than 20 seconds. Cross-hatched squares represent contractions lasting between 20 and 40 seconds. Complete shading indicates contractions lasting longer than 40 seconds.

Answer 84

Oral intake should be avoided if operative delivery under general anesthesia is likely; most operative deliveries are now performed under regional anesthesia.

Answer 85

IV fluid replacement should be considered after 6 hours in labor if delivery is not imminent. Normal saline or Hartmann's solution is preferred, with careful monitoring of fluid input and output.

Answer 86

Dehydration can lead to acidosis and ketosis, necessitating urine checks for ketones, sugars, and proteins.

Answer 87

Many women prefer to remain ambulant or sit during the first stage and may lie down as labor progresses to the second stage. Some may choose to squat to use gravity to assist in delivery.

Answer 88

Water births can provide pain relief through immersion, improve support of the pregnant uterus, but carry risks of the baby inhaling contaminated water. Bath temperature should be regularly monitored.

Answer 89

The primary goal is to reduce the level of pain experienced during labor while invoking minimal risk for the mother and baby.

Answer 90

Epidural analgesia is the only technique that can provide complete pain relief.

Answer 91

Pethidine was traditionally used but has been largely replaced by morphine. Common side effects include nausea and vomiting in mothers and respiratory depression in neonates.

Answer 92

Remifentanil is an ultra-short-acting opioid that produces superior analgesia compared to Pethidine and has less effect on neonatal respiration.

Answer 93

Entonox is a 50/50 mixture of nitrous oxide and oxygen used for short-term pain relief in early labor and during the late first and second stages of labor.

Answer 94

Prolonged exposure can adversely affect birth attendants, causing decreased fertility, bone marrow changes, and neurological changes. Forced air change every 6–10 hours is necessary to reduce nitrous oxide levels.

Answer 95

TENS involves placing electrodes on the vertebral column to deliver electrical currents. It can be effective in early labor but is often inadequate alone in late labor. Antenatal training is essential for effectiveness.

Answer 96

Non-pharmacological methods include acupuncture, subcutaneous sterile water injections, massage, and relaxation techniques.

Answer 97

1. Insert an intravenous cannula and preload with no more than 500 mL of saline or Hartmann’s solution. 2. Insert the epidural cannula at the L3–L4 interspace. 3. Inject a local anesthetic agent, such as bupivacaine, at the minimum dose required for effective pain relief.

Answer 98

Adding an opioid reduces the required dose of bupivacaine, sparing motor fibers to the lower limbs and reducing the classic complications of hypotension and abnormal fetal heart rate.

Answer 99

Epidural analgesia may reduce the desire to bear down in the second stage of labor due to decreased pressure sensation at the perineum and can decrease uterine activity by inhibiting the "Ferguson reflex."

Answer 100

Common complications include: Hypotension Accidental dural puncture (occurs in <1%) Postdural headache (70% incidence with 16 or 18 gauge needles)

Answer 101

Hypotension can be managed by preloading and using low-dose anesthetic agents and opioid solutions.

Answer 102

A postdural headache that persists for more than 24 hours should be treated with an epidural blood patch.

Answer 103

Contraindications include: Maternal refusal Coagulopathy Local or systemic infection Uncorrected hypovolemia Inadequate or inexperienced staff or facilities

Answer 104

Spinal anesthesia is a single-shot procedure commonly used for operative delivery but not for pain control in labor.

Answer 105

Paracervical blockade involves the infiltration of local anesthetic agents into paracervical tissues. It is rarely used due to a greater chance of fetal side effects.

Answer 106

Pudendal nerve blockade involves infiltration around the pudendal nerve and the inferior hemorrhoidal nerve. It's less frequently used now but is still employed for perineal wound repair.

Answer 107

Avoid direct IV injection of the drug during local infiltration. Be cautious of toxic symptoms like cardiac arrhythmias and convulsions from accidental injection, especially with larger doses.

Answer 108

Changes in fetal heart rate (FHR) or the passage of new meconium-stained liquor may indicate the possibility of fetal hypoxia.

Answer 109

A diminution of fetal movements may indicate fetal jeopardy, while cessation of movements may indicate fetal death.

Answer 110

First stage: Every 15 minutes for 1 minute after a contraction. Second stage: Every 5 minutes or after every other contraction.

Answer 111

Maternal indications: Previous caesarean section Pre-eclampsia Post-term pregnancy Fetal indications: Fetal growth restriction Prematurity Oligohydramnios Prolonged rupture of membranes Induced labor Diabetes Antepartum hemorrhage Other maternal medical diseases Abnormal Doppler artery velocimetry Multiple pregnancy Meconium-stained liquor Breech presentation

Answer 112

The normal fetal heart rate varies between 110 and 160 beats per minute.

Answer 113

Tachycardia: Fetal heart rate faster than 160 beats/min. Bradycardia: Fetal heart rate less than 110 beats/min.

Answer 114

Baseline variability reflects the oscillations in heart rate around the baseline and normally varies between 5-25 beats/min. Reduced variability can indicate fetal sleep, hypoxia, infection, or medication effects.

Answer 115

A fetal heart rate variability of less than 5 beats/min for over 90 minutes is abnormal and may indicate fetal jeopardy.

Answer 116

Fetal heart rate is monitored using a Doppler ultrasound transducer applied externally to the maternal abdomen or through a direct electrode applied to the presenting part.

Answer 117

A pressure transducer records uterine activity, providing accurate measurements of the frequency and duration of contractions, and can also give relative information about intrauterine pressure.

Answer 118

Accelerations are transient, abrupt increases in heart rate of more than 15 beats/min for more than 15 seconds, associated with fetal movements. They reflect the activity of the somatic nervous system and are a reassuring sign of good fetal health.

Answer 119

Decelerations are defined as decreases in heart rate of more than 15 beats/min for more than 15 seconds. They are evaluated based on their relationship to uterine contractions and their intensity.

Answer 120

Early decelerations occur synchronously with uterine contractions, peaking at the contraction's height, with a decrease in heart rate generally less than 40 beats/min. They are usually due to head compression and are considered physiological, often seen in the late first and second stages of labor.

Answer 121

Late decelerations begin well after the contraction starts and do not return to the normal baseline until at least 20 seconds after the contraction ends. They are due to placental insufficiency, and repeated occurrences may indicate fetal hypoxia, along with an increase in baseline rate and a reduction in baseline variability.

Answer 122

Variable decelerations vary in timing and amplitude, often falling by more than 40 beats/min, caused by cord compression. They are considered non-reassuring features in a CTG trace, and increased depth and duration, along with a rise in baseline rate and reduced baseline variability, suggest worsening hypoxia.

Answer 123

Atypical variable decelerations are characterized by slow recovery to baseline rates or a combination of variable decelerations followed immediately by late decelerations. They are considered abnormal features and suggest a concerning fetal condition.

Answer 124

Fetal blood is obtained directly from the scalp through an amnioscope, which is inserted through the cervix (at least 2 cm dilated). A small stab incision is made in the fetal scalp to collect blood into a heparinized capillary tube.

Answer 125

The mother is requested to lie in the lateral position during the procedure for fetal blood sampling.

Answer 126

The normal pH for fetal blood lies between 7.25 and 7.35.

Answer 127

A pH between 7.20 and 7.25 indicates mild acidosis, and sampling should be repeated within the next 30 minutes.

Answer 128

If the fetal blood pH is less than 7.20, delivery is recommended unless spontaneous delivery is imminent.

Answer 129

Fetal acid-base balance can also be assessed by measuring lactate levels in fetal scalp blood, which generally requires smaller blood volumes and can be done using portable hand-held devices.

Answer 130

Preterm birth is defined as delivery occurring from 24 completed weeks up to 36 weeks and 6 days of gestation.

Answer 131

Common aetiologies include poor social conditions, nutritional status, antepartum hemorrhage, multiple pregnancy, uterine anomalies, cervical incompetence, and preterm premature rupture of membranes (PROM), often associated with infection.

Answer 132

A previous history of preterm delivery is the best single predictor of spontaneous preterm labour.

Answer 133

Genital tract infections can promote myometrial activity or cause prelabour rupture of fetal membranes. Associated organisms include Neisseria gonorrhoeae, group B streptococci, Chlamydia trachomatis, Gardnerella vaginalis, Bacteroides spp., and Haemophilus spp.

Answer 134

Each day of delay in delivery after 24 weeks increases the chance of survival by 3–6%.

Answer 135

Infants born with a birth weight of less than 500 g have little chance of survival, whereas those weighing 1500 g are nearly as likely to survive as full-term infants. Survival significantly increases with every 100 g increment between 500 and 1000 g.

Answer 136

Major causes of death include infection, respiratory distress syndrome, necrotizing enterocolitis, and periventricular hemorrhage.

Answer 137

Immediate complications include respiratory distress, jaundice, hypoglycemia, and hypothermia.

Answer 138

Long-term complications can include pulmonary dysplasia and neurodevelopmental delay.

Answer 139

A primary goal is to conserve the pregnancy for as long as possible to improve infant outcomes and survival.

Answer 140

Women should be advised to maintain a healthy lifestyle, including proper nutrition, stress avoidance, and regular prenatal care.

Answer 141

Treating asymptomatic bacteriuria with antibiotics can reduce the incidence of preterm premature rupture of membranes (PROM), especially when β-haemolytic streptococci are detected.

Answer 142

In women with a short cervix of less than 2.5 cm beyond 24 weeks, the use of progesterone can reduce the incidence of preterm delivery.

Answer 143

The administration of corticosteroids aims to enhance fetal lung surfactant production, reducing the risk of hyaline membrane disease (HMD) and respiratory distress syndrome (RDS).

Answer 144

Labor may be inhibited if gestational age is less than 34 weeks, there are no signs of infection or bleeding, membranes are intact, and the cervix is less than 5 cm dilated.

Answer 145

1. β-Adrenergic agonists: Inhibit uterine activity by acting on myometrial cell membranes (e.g., ritodrine, salbutamol, terbutaline). 2. Prostaglandin synthetase inhibitors: Prevent labor progression by inhibiting prostaglandin production (e.g., indomethacin). 3. Calcium antagonists: Inhibit uterine activity. 4. Corticosteroids: Enhance surfactant production to improve respiratory function. 5. Magnesium sulfate: Provides tocolytic effects and neuroprotection in neonates.

Answer 146

Betamethasone or dexamethasone is administered at a dosage of 12 mg every 12 hours via intramuscular injection on two occasions.

Answer 147

Indomethacin, as a prostaglandin synthetase inhibitor, can cause in utero closure of the ductus arteriosus, potentially adversely affecting fetal circulation.

Answer 148

Magnesium sulfate has a tocolytic effect to inhibit contractions and provides neuroprotection for the neonate by stabilizing capillary membranes, reducing the incidence of intra and periventricular hemorrhage.

Answer 149

PROM is the spontaneous rupture of the fetal membranes before the onset of labor, which can occur at term or preterm.

Answer 150

1. Weakened tensile strength of fetal membranes (often due to infection). 2. Cervical dilation; greater dilation increases the likelihood of rupture. 3. Intra-amniotic fluid pressure.

Answer 151

Infection, particularly by organisms like Group B streptococci and Chlamydia trachomatis.

Answer 152

A speculum examination should be performed to confirm the presence of amniotic fluid.

Answer 153

Risk of infection. Potential for fetal pulmonary hypoplasia due to prolonged drainage of amniotic fluid. Challenges in inducing labor effectively, especially in very preterm cases.

Answer 154

Swabs should be taken for culture to assess for infection.

Answer 155

Maternal infection may present with uterine tenderness, fetal and/or maternal tachycardia, pyrexia, and purulent vaginal discharge.

Answer 156

Administer appropriate antibiotics. Induce labor using an oxytocic infusion for the safety of the mother and fetus.

Answer 157

Administer appropriate antibiotics. Induce labor using an oxytocic infusion for the safety of the mother and fetus.

Answer 158

Conservative management with erythromycin cover may be adopted to reduce the risk of infection while allowing for possible advancement to a more mature gestation.

Answer 159

If gestation is over 28 weeks, the infant likely has a better chance of survival if delivered.

Answer 160

If gestation is over 28 weeks, the infant likely has a better chance of survival if delivered.

Answer 161

Most women with PROM will deliver spontaneously within 48 hours.

Answer 162

Most women with PROM will deliver spontaneously within 48 hours.

Answer 163

Induction is performed with prostaglandins or syntocinon upon admission or after 24 hours of PROM.

Answer 164

Induction of labor is the act of artificially initiating uterine activity when the risks to the mother or child of continuing the pregnancy exceed the risks of inducing labor.

Answer 165

1. Prolonged pregnancy (beyond 42 weeks gestation). 2. Pre-eclampsia. 3. Placental insufficiency and intrauterine growth restriction. 4. Antepartum hemorrhage (placental abruption and antepartum hemorrhage). 5. Rhesus isoimmunization. 6. Diabetes mellitus. 7. Chronic renal disease.

Answer 166

The Bishop score assesses cervical readiness for induction. A score > 6 is predictive of successful labor induction, while a score < 5 indicates the need for cervical ripening.

Answer 167

Forewater rupture involves artificially rupturing the membranes before labor begins, ideally performed when the cervix is soft, effaced, and at least 2 cm dilated, and the fetal head is engaged. It should be done under sterile conditions.

Answer 168

1. The patient is positioned supine or in lithotomy. 2. A finger is inserted through the cervix to separate the membranes from the lower segment (stripping). 3. The bulging membranes are ruptured using Kocher’s forceps, Gelder’s forceps, or an amniotomy hook. 4. Monitor the fetal heart rate for 30 minutes before and after the procedure.

Answer 169

Hindwater rupture involves rupturing the membranes behind the presenting part of the fetus using a Drewe-Smythe catheter.

Answer 170

1. Hyperstimulation (excessive uterine contractions leading to fetal asphyxia). 2. Prolapse of the cord. 3. Increased risk of infection due to prolonged induction–delivery intervals.

Answer 171

1. Syntocinon infusion: Stimulates uterine contractions and is effective when combined with surgical induction. 2. Prostaglandin E2 (PGE2): Administered orally or vaginally to ripen the cervix. 3. Mechanical dilation: Involves inserting a balloon catheter through the cervix and removing it after 12 hours, followed by amniotomy.

Answer 172

Syntocinon is a synthetic form of oxytocin that induces uterine contractions and is often combined with surgical induction methods.

Answer 173

Monitor fetal heart rate closely, avoid digital examination if not inducing labor immediately to reduce infection risk, and ensure that the conditions for membrane rupture are met.

Answer 174

Precipitate labor is defined as any labor lasting less than 2 hours, characterized by rapid cervical dilation and delivery.

Answer 175

Potential hazards include delivery in an uncontrolled manner, potentially in an inappropriate environment (e.g., toilet), and increased fetal morbidity and mortality due to lack of resuscitation facilities.

Answer 176

Maternal complications can include severe perineal damage and postpartum hemorrhage.

Answer 177

Precipitate labor often recurs in subsequent pregnancies; therefore, mothers with a history of precipitate labor should be admitted to the hospital near term to monitor for labor onset.

Answer 178

Uterine hyperstimulation is characterized by excessive uterine contractions, often due to the uncontrolled use of oxytocic drugs, resulting in contractions that occur more frequently than every 5 minutes.

Answer 179

Signs include >5 contractions in 10 minutes. Consequences include reduced placental perfusion, fetal oxygenation issues, and potential changes in fetal heart rate, termed ‘hyperstimulation syndrome.’

Answer 180

Common causes include excessive administration of oxytocin and rapid absorption of prostaglandins from the vagina, influenced by temperature, pH, and the presence of infection/inflammation.

Answer 181

Uterine hyperstimulation can often be corrected quickly by stopping the oxytocin infusion. For prostaglandin-induced hyperstimulation, removal of the pessary and administration of a short-acting tocolytic, like terbutaline, is recommended.

Answer 182

Uterine hyperstimulation can lead to uterine rupture, especially in individuals with a previous uterine scar from a cesarean section or myomectomy. Rupture may occur even with normal uterine activity.

Answer 183

As labor progresses and cervical dilation increases, the uterus becomes more sensitive to oxytocin, requiring careful monitoring to avoid hyperstimulation.

Answer 184

The three P's are: 1. Pelvis: Size and shape of the maternal pelvis (e.g., small bony pelvis). 2. Passenger: Size and position of the infant (e.g., fetal macrosomia, abnormal orientation). 3. Power: Strength and frequency of contractions (e.g., dysfunctional contractions).

Answer 185

Prolonged latent phase is diagnosed when there is poor acceleration with cervical dilation ≤ 6 cm: > 20 hours in primiparas. > 14 hours in multiparas.

Answer 186

Management includes: Rest and hydration. Adequate analgesia. Consideration of oxytocin in well-rested mothers if other measures have been implemented.

Answer 187

A prolonged active phase is diagnosed when cervical dilation is ≥ 6 cm but less than: 1.2 cm/hour in a primipara. 1.5 cm/hour in a multipara.

Answer 188

Management includes: Augmentation with oxytocin for hypotonic contractions. Analgesia for hypertonic contractions.

Answer 189

Arrested active phase is diagnosed when: Cervical dilation is ≥ 6 cm with ruptured membranes and no cervical change for ≥ 4 hours with adequate contractions. No cervical change for > 6 hours with inadequate contractions.

Answer 190

The management for an arrested active phase is typically cesarean section.

Answer 191

Diagnosis: failed delivery of the baby after 3 hours in a primipara and after 2 hours in a multipara (an extra hour may be added if an epidural was administered)  Management o Augmentation with oxytocin if uterine contractions are inadequate and progress is > 1 cm after 60–90 minutes of pushing o Trial of forceps or vacuum delivery if the fetal head is engaged AND maternal contractions are adequate o Cesarean section if the fetal head is not engaged  Complications of a prolonged second stage are postpartum hemorrhage and a poor neonatal outcome!

Answer 192

Insufficient uterine activity refers to a lack of progress in labor due to either weak contractions (hypotonic) or strong contractions (hypertonic).

Answer 193

Hypotonic uterine activity is characterized by: Low resting uterine tone. Infrequent and often irregular contractions. Slow progress in labor. Typically does not cause distress to the mother or fetus.

Answer 194

Hypertonic uterine activity is a rare condition featuring: High resting uterine tone. Contractions that may be initiated in the lower segment and may appear asymmetrical (double peak). Slow cervical dilation. Severe backache and abdominal pain. Commonly associated with placental abruption.

Answer 195

Abnormalities of uterine activity are usually recognized by the failure of progress in labor. Careful assessment of maternal pelvis size and fetal size is essential to exclude cephalopelvic disproportion.

Answer 196

Management principles include: 1. Adequate pain relief (especially epidural analgesia for hypertonic activity). 2. Adequate fluid replacement (IV infusion of dextrose saline or Hartmann’s solution). 3. Stimulation of coordinated uterine activity (dilute oxytocin infusion).

Answer 197

Management includes: Encouraging maternal mobilization. Artificial rupture of membranes if intact. An oxytocic infusion to stimulate labor and delivery.

Answer 198

Management includes: Rupturing membranes. Cautious use of a low-dose oxytocin infusion to restore normal uterine activity.

Answer 199

If progress continues to be slow and there is evidence of fetal distress, delivery should be accomplished by cesarean section.

Answer 200

Constriction ring dystocia can only be reversed by using beta-sympathomimetic agents, ether, or halothane anesthesia.

Answer 201

Cephalopelvic disproportion occurs when the fetal head is too large to pass through the maternal pelvis, which may be due to an abnormally large fetus, a small pelvis, or both.

Answer 202

Causes of CPD include: 1. Large baby due to: Hereditary factors Diabetes Postmaturity Multiparity 2. Abnormal fetal positions 3. Contracted pelvis 4. Abnormally shaped pelvis

Answer 203

CPD is diagnosed using pelvimetry: 1. Clinical pelvimetry (internal for the inlet, cavity, and outlet; external for the inlet and outlet). 2. Imaging pelvimetry using X-ray, CT, or MRI.

Answer 204

In cases of CPD, labor should be closely monitored, including: Uterine activity Cervical dilatation Descent of the presenting part Position, station, caput, and moulding The condition of the mother and fetus.

Answer 205

If no cervical dilatation, descent, or head engagement occurs within 4-6 hours, and there is increasing caput and moulding, the trial of labor should be abandoned. If fetal distress or maternal exhaustion develops, a cesarean section should be performed.

Answer 206

Multiparous women are at increased risk of uterine rupture if labor becomes obstructed. CPD in multigravida is often linked to malposition or the use of oxytocic agents, which increases the risk of uterine rupture.

Answer 207

In cases of CPD, the fetal head often does not engage at the onset of labor, but may engage with moulding into the pelvis during labor.

Answer 208

The pelvis can only be truly tested in the presence of strong uterine contractions. CPD is typically diagnosed when labor progress is slow despite strong contractions.

Answer 209

Cord presentation occurs when part of the umbilical cord lies alongside or in front of the presenting part. Cord prolapse happens when the cord slips through the cervix after membrane rupture and may appear at the vulva or be palpable in front of the presenting part.

Answer 210

Cord prolapse is diagnosed by digital palpation of the pulsating cord, which may be felt through the membranes. Once the membranes rupture, the cord can prolapse and be felt at the vulva.

Answer 211

Factors include: 1. Displacement of the presenting part (e.g., high head) away from the cervix. 2. Irregularly shaped presenting part that forms poor contact with the cervix. In these situations, artificial rupture of membranes may lead to cord prolapse.

Answer 212

Cord prolapse is an emergency because the presenting part may compress the cord, or cord arteries may spasm due to exposure to cold air or handling, leading to fetal asphyxia.

Answer 213

The mother should be placed in a knee-chest position, or have the buttocks elevated by pillows or head tilt to relieve pressure on the cord.

Answer 214

Filling the bladder helps reduce pressure on the prolapsed cord by pushing the presenting part away from it.

Answer 215

The cord should be digitally displaced back into the vagina to keep it warm and moist, preventing arterial spasm. The vaginal opening should be covered with a wet pad.

Answer 216

A bolus dose of a tocolytic can be given to relieve compression of the cord by stopping or reducing uterine contractions.

Answer 217

Delivery should be by cesarean section unless the cervix is fully dilated and rapid delivery is possible via forceps or vacuum with maternal expulsive efforts.

Answer 218

Despite the acute risk of fetal asphyxia, the long-term prognosis for infants affected by cord prolapse is generally good.

Answer 219

The second stage of labor is the period from complete cervical dilation to the baby's birth.

Answer 220

1. Pelvic (passive) phase: Descent of the baby in the pelvis, often without the mother feeling the urge to bear down. 2. Perineal (active) phase: The mother experiences the urge to push as the baby descends into the perineum.

Answer 221

Nulliparous women: Up to 2 hours (extended by 1 hour with epidural). Multiparous women: Up to 1 hour (extended by 1 hour with epidural).

Answer 222

Progress is monitored by the descent of the fetal head, assessed through abdominal and vaginal examinations. The head is engaged when no more than one-fifth is palpable abdominally and the vertex reaches the level of the ischial spines.

Answer 223

Women should be guided by their urge to push, with a focus on gentle, unhurried delivery of the fetal head. This can be achieved by alternating between short pushing efforts and panting to allow the tissues to stretch.

Answer 224

1. Hands-on: Supporting the perineum and flexing the baby's head. 2. Hands-poised: Hands off the perineum but ready to assist as needed.

Answer 225

Episiotomy may be needed if: The perineum begins to tear. Perineal resistance prevents delivery of the head. The baby needs to be delivered quickly due to fetal distress.

Answer 226

mediolateral incision is made from the vaginal fourchette, usually directed to the mother's right side.

Answer 227

1. Pull the head gently downwards to deliver the anterior shoulder. 2. Pull anteriorly to deliver the posterior shoulder and the rest of the baby.

Answer 228

Aspirate the nasopharynx. Inflate the lungs with oxygen using a face mask. If needed, perform intubation and ventilation.

Answer 229

The Apgar score is assessed at 1 minute, 5 minutes, and again at 10 minutes if the baby is in poor condition (Apgar score ≤ 5).

Answer 230

Active management includes: 1. Administering oxytocin (10 IU IM) to the mother. 2. Late clamping (>2 minutes) and cutting of the umbilical cord. 3. Delivering the placenta by controlled cord traction using the Brandt-Andrews technique.

Answer 231

Signs of placental separation include: Lengthening of the cord. A trickle of blood. The uterus becoming globular and hard as it contracts to expel the placenta.

Answer 232

1. First-degree: Laceration to vaginal and perineal skin only. 2. Second-degree: Injury involves the posterior vaginal wall and perineal muscles, but not the anal sphincter. 3. Third-degree: Involves injury to the anal sphincter complex. 4. Fourth-degree: Involves injury to the ano/rectal mucosa and the sphincter.

Answer 233

First-degree: May not require suturing if skin edges are apposed and there is no bleeding. Second-degree: Requires suturing to minimize bleeding and facilitate healing.

Answer 234

1. 3a: Less than 50% of the external anal sphincter is disrupted. 2. 3b: More than 50% of the external sphincter is disrupted. 3. 3c: Both the external and internal sphincters are disrupted.

Answer 235

Anal incontinence (up to 25%) Perineal discomfort Dyspareunia (up to 10%) Rare cases of rectovaginal fistulas.

Answer 236

Large baby (>4 kg) First vaginal delivery Instrumental delivery (forceps > ventouse) Occipitoposterior position Prolonged second stage of labor Induced labor Epidural anesthesia Shoulder dystocia Midline episiotomy

Answer 237

Experienced obstetrician should perform or supervise the repair. Administer broad-spectrum antibiotics for at least 5 days. Use end-to-end or overlapping methods for sphincter repair. Prescribe stool softeners and refer for physiotherapy. At the 6-week postnatal checkup, assess for bowel control, urgency, and sexual dysfunction.

Answer 238

Failure to manage perineal or sphincter injuries can lead to: Anal incontinence Dyspareunia Fecal or flatus incontinence.

Answer 239

A careful examination should be performed as soon as possible after delivery to identify any degree of trauma, especially sphincter damage

Answer 240

Malpresentation refers to any fetal presentation other than the vertex (head-first). Common malpresentations include breech, face, brow, shoulder, or cord presentations.

Answer 241

Diagnosed during vaginal examination when the cervix is dilated enough to palpate facial features such as the chin, eyes, nose, and mouth. Ultrasound (US) can confirm the diagnosis.

Answer 242

The chin (mentum) is used as the denominator. The three positions are: Mentoanterior Mentotransverse Mentoposterior

Answer 243

Mentoanterior face presentation can often lead to a spontaneous vaginal delivery. If progress is slow, caesarean section may be considered.

Answer 244

Vaginal delivery is typically not possible without manual or forceps rotation. Most cases are managed by caesarean section.

Answer 245

Brow presentation occurs when the fetal head is midway between flexion (vertex) and hyperextension (face), making it the most unfavourable cephalic presentation. The presenting diameter, the mentovertical diameter (13 cm), is usually incompatible with vaginal delivery.

Answer 246

Diagnosed during labor by palpation of the anterior fontanelle, supraorbital ridges, and the root of the nose.

Answer 247

Vaginal delivery is typically impossible due to the large presenting diameters. Caesarean section is the preferred method of delivery in brow presentation.

Answer 248

Malposition refers to when the occiput of the fetal head presents in the posterior half of the maternal pelvis, often as occipitoposterior (OP) or occipitotransverse (OT). It occurs in about 10% of deliveries.

Answer 249

Asynclitism occurs when one parietal bone is lower in the pelvis than the other, causing the parietal eminences to be at different levels. It increases the presenting diameters of the fetal head, making normal delivery more difficult, especially in OT malposition.

Answer 250

The OP position occurs in 10-20% of cephalic presentations at the onset of labor. While the head usually rotates to the occipitoanterior (OA) position, some may remain in OP, leading to complications.

Answer 251

Prolonged and painful labor with backache. Larger presenting diameters due to the deflexed head, which can result in 3rd/4th-degree perineal tears. Labor progress may be arrested due to the deflexed attitude of the head.

Answer 252

Diagnosed during labor by vaginal examination, where the sagittal suture is felt with the posterior fontanelle situated posteriorly in the maternal pelvis.

Answer 253

Management depends on the station of the head and cervical dilation: Caesarean section if the head is not engaged or the cervix is not fully dilated. Instrumental delivery (forceps or vacuum) if the head is engaged and conditions permit.

Answer 254

Deep transverse arrest occurs when the fetal head descends into the pelvis in an occipitotransverse (OT) position but fails to rotate anteriorly to emerge under the pubic arch, leading to labor arrest due to asynclitism and larger presenting diameters.

Answer 255

Diagnosed during labor when the second stage is prolonged, the cervix is fully dilated, and vaginal examination reveals the head arrested in the OT position.

Answer 256

If the head is engaged and the station is at or below the ischial spines, it can be rotated to the anterior position manually or with rotational forceps or vacuum extraction. If rotation and descent are difficult, the procedure should be abandoned, and a caesarean section performed.

Answer 257

The fetal head may become impacted in the pelvis, making it difficult to dislodge. In such cases, vaginal disimpaction before extraction may be necessary.

Answer 258

Instrumental vaginal delivery refers to the use of forceps or vacuum to assist the second stage of labor by applying direct traction to the fetal skull, mimicking spontaneous vaginal delivery and shortening the labor duration.

Answer 259

Vacuum: Applies suction and traction to the fetal scalp. Forceps: Cradles the fetal skull, applying traction to the parietal and malar bones, while laterally displacing maternal tissue.

Answer 260

Vacuum: Applies suction and traction to the fetal scalp. Forceps: Cradles the fetal skull, applying traction to the parietal and malar bones, while laterally displacing maternal tissue.

Answer 261

Common indications include: Delay in the second stage of labor. Non-reassuring fetal status (fetal distress). Maternal exhaustion or medical disorders.

Answer 262

Factors include: Pelvic floor resistance. Inefficient uterine contractions. Poor maternal effort. Fetal malposition. Cephalopelvic disproportion. Epidural analgesia.

Answer 263

The following conditions must be met: Full cervical dilation. Vertex presentation. Head engaged (not palpable abdominally, at or below spines). Known head position and attitude. Empty bladder. Adequate analgesia.

Answer 264

The mother is placed in a modified lithotomy position with the thighs and perineum washed and draped.

Answer 265

Instrumental deliveries are classified into: 1. Three categories based on the station of the fetal head: Outlet. Low. Midpelvic. 2. Two types based on the position of the fetal head: Non-rotational. Rotational.

Answer 266

For non-rotational deliveries, Neville Barnes and Simpson's forceps are commonly used. These forceps have cephalic and pelvic curves, and their blades are designated according to the side of the pelvis.

Answer 267

Intermittent traction is applied in sync with uterine contractions and maternal bearing down efforts. Traction is applied along the pelvic canal until the occiput is visible, then the head is delivered by anterior extension.

Answer 268

A vacuum device consists of: A cup attached to the baby’s head. A vacuum source that creates suction for attachment. A traction handle to assist with birth. Traction is applied along the pelvic axis, and at crowning, it's directed upwards to deliver the head.

Answer 269

The two main types of vacuum devices are: Anterior cups for non-rotational OA extractions. Posterior cups for rotational OP and OT deliveries.

Answer 270

In rotational deliveries, specific tools such as: Kjelland’s forceps (with a sliding lock and minimal pelvic curve) for rotating the fetal head in OP or OT positions. Posterior vacuum cups to allow auto-rotation of the fetal head to the OA position at delivery.

Answer 271

A posterior cup is used to maneuver over the baby's flexion point, facilitating auto-rotation of the fetal head to an OA position for delivery.

Answer 272

A caesarean section is a method of delivery where a baby is born through an incision made in the abdominal wall and uterus.

Answer 273

Common indications include: Non-reassuring fetal status (fetal distress) Abnormal progress in labor (dystocia) Intrauterine growth restriction Malpresentations (breech, transverse lie, brow) Placenta previa or severe antepartum hemorrhage Previous caesarean section Severe pre-eclampsia or maternal medical disorders Cord prolapse or presentation

Answer 274

1. Category 1: Immediate threat to the life of the woman or fetus. 2. Category 2: Maternal or fetal compromise, but not life-threatening. 3. Category 3: No compromise, but early delivery is required. 4. Category 4: Elective planned caesarean section.

Answer 275

The major concern is the risk of uterine scar dehiscence or rupture, which is higher with a previous classical (upper segment) caesarean section. However, the risk is low with a lower uterine segment incision.

Answer 276

Signs include: Suprapubic pain and tenderness. Fetal distress. Maternal tachycardia. Vaginal bleeding. Maternal collapse.

Answer 277

Immediate complications include: Peri-operative hemorrhage, which can result in shock. Injury to the bladder or ureters (rare).

Answer 278

Late complications include: Infection of the wound or uterine cavity. Secondary postpartum bleeding. Less commonly, deep vein thrombosis and pulmonary embolism.

Answer 279

Shoulder dystocia is an obstetric emergency where the fetal head delivers, but the shoulders fail to deliver spontaneously due to the anterior shoulder being impacted behind the maternal pubic symphysis.

Answer 280

1. History of shoulder dystocia. 2. Fetal macrosomia (infants >4500 g), especially in maternal diabetes. 3. Prolonged second stage of labor. 4. Maternal obesity. 5. Post-term pregnancy.

Answer 281

The turtle sign is when the fetal head is partially delivered but retracts against the perineum, indicating shoulder dystocia.

Answer 282

Complications include: Asphyxiation of the baby if delivery is delayed. Brachial plexus palsy or limb fractures due to over-vigorous manipulations.

Answer 283

The first-line treatment is the McRobert's manoeuvre, which involves: 1. Placing the woman in a recumbent position with hips abducted and knees bent towards the chest. 2. Applying suprapubic pressure to dislodge the anterior shoulder. 3. Performing a generous episiotomy.

Answer 284

The McRobert's manoeuvre is successful in the majority of shoulder dystocia cases.

Answer 285

Advanced manoeuvres include: Rotation of the fetal shoulders to an oblique pelvic diameter. Manual delivery of the posterior arm. Wood’s screw manoeuvre, where rotation is applied to the fetal shoulders to free the impacted shoulder.

Answer 286

The third stage of labour lasts from the delivery of the infant to the delivery of the placenta, typically completed within 10-15 minutes, and should be complete within 30 minutes.

Answer 287

Primary postpartum hemorrhage is defined as bleeding from the genital tract in excess of 500 mL within the first 24 hours after delivery.

Answer 288

The most common site for bleeding in primary postpartum hemorrhage is from the placental site.

Answer 289

The four Ts are: 1. Tone (uterine atony) 2. Tissue (retained placenta or placental tissue) 3. Trauma (lacerations or uterine rupture) 4. Thrombin (coagulation problems)

Answer 290

Uterine atony accounts for 75-90% of all cases of postpartum hemorrhage.

Answer 291

Uterine overdistension (e.g., multiple pregnancy, polyhydramnios) Prolonged labour and instrumental delivery Antepartum hemorrhage (e.g., placenta previa, abruption) Multiparity Uterine abnormalities (e.g., multiple fibroids) General anaesthesia Trauma to the genital tract (e.g., episiotomy, lacerations) Uterine rupture and caesarean scar dehiscence Haematomas in the vulva, vagina, and broad ligament Coagulation disorders (e.g., HELLP syndrome, sepsis, DIC)

Answer 292

Treatment involves: 1. If the placenta is retained: Uterine massage to ensure contraction. Controlled cord traction to deliver the placenta. Manual removal of the placenta under anesthesia if necessary. 2. If the placenta is expelled: Uterine massage and compression to expel retained clots. IV oxytocin and IV infusion of Hartmann's solution. If bleeding continues, administer ergometrine IV (unless contraindicated). Use misoprostol rectally if bleeding persists. Intramuscular or intramyometrial injection of 15-methyl prostaglandin F2α every 15 minutes (max 8 doses). Blood sample for Hb%, coagulation disorders, and cross-matching. Manual exploration and evacuation if placenta/membranes are incomplete. Examine vagina and cervix for lacerations and suture as needed. 3. Resuscitation: Actively replace blood loss with IV crystalloid, colloid, blood, and blood products. 4. If conservative measures fail: Bimanual compression of the uterus. Uterine tamponade with balloon catheters. Uterine compression sutures (e.g., B-Lynch suture).

Answer 293

Uterine massage to ensure contraction. Controlled cord traction to deliver the placenta. Manual removal of the placenta under anesthesia if necessary.

Answer 294

Uterine massage and compression to expel retained clots. IV oxytocin and IV infusion of Hartmann's solution. If bleeding continues, administer ergometrine IV (unless contraindicated). Use misoprostol rectally if bleeding persists. Intramuscular or intramyometrial injection of 15-methyl prostaglandin F2α every 15 minutes (max 8 doses). Blood sample for Hb%, coagulation disorders, and cross-matching. Manual exploration and evacuation if placenta/membranes are incomplete. Examine vagina and cervix for lacerations and suture as needed.

Answer 295

Actively replace blood loss with IV crystalloid, colloid, blood, and blood products.

Answer 296

Bimanual compression of the uterus. Uterine tamponade with balloon catheters. Uterine compression sutures (e.g., B-Lynch suture).

Answer 297

Treatment options include: 1. Internal iliac and uterine artery ligation 2. Major vessel embolization 3. Hysterectomy

Answer 298

Secondary postpartum hemorrhage refers to abnormal vaginal bleeding occurring at any time in the puerperium, up to 6 weeks after delivery.

Answer 299

Causes include: Retained placental tissue Intrauterine infection Rare causes such as trophoblastic disease

Answer 300

If the bleeding is slight, the uterus is not tender, and there are no signs of infection, observation is justified.

Answer 301

For heavy bleeding with signs of infection, administer intravenous broad-spectrum antibiotics and perform uterine exploration under anesthesia.

Answer 302

Vaginal wall haematomas can occur from lacerations: Superficial haematomas: Located below the levator ani, cause pain and require drainage and ligation of bleeding vessels. Deep haematomas: Located above the levator ani, not externally visible, present with pelvic pain, urinary retention, and unexplained anemia. They are diagnosed by vaginal examination or ultrasound and managed by incision and drainage, with antibiotic therapy and possible blood transfusion.

Answer 303

Uterine inversion is a rare complication where the uterine fundus inverts and protrudes through the cervix, often occurring during placental delivery. Symptoms include severe abdominal pain and maternal shock. Management involves: Leaving the placenta attached Initiating fluid resuscitation Attempting manual repositioning of the fundus, or using hydrostatic pressure. If unsuccessful, replacement under general anesthesia is required.

Answer 304

Perineal wound breakdown can occur due to infection or haematoma. Small areas can be treated with: Regular cleaning Antibiotics Allowing granulation until healed

Answer 305

Amniotic fluid embolism is a serious complication occurring during labor or delivery, characterized by: Sudden acute respiratory distress Cardiovascular collapse It occurs when amniotic fluid enters the maternal circulation, triggering a reaction similar to anaphylaxis and septic shock.

Answer 306

Risk factors include: Prolonged rupture of membranes Chorioamnionitis Repeated vaginal examinations Poor personal hygiene Bladder catheterization Invasive fetal monitoring Instrumental deliveries Caesarean sections Perineal trauma Manual removal of the placenta

Answer 307

Clinical features of endometritis include: Fever Lower abdominal pain Secondary postpartum hemorrhage Foul-smelling vaginal discharge

Answer 308

Common organisms include: Group A β-haemolytic streptococci Aerobic Gram-negative bacteria Anaerobes

Answer 309

Treatment for endometritis involves: Broad-spectrum antibiotics as the first-line treatment Resolution should start within the first 48 hours

Answer 310

Complications can include: Parametritis Peritonitis Septic pelvic thrombophlebitis Pelvic abscesses Toxic shock syndrome (rare)

Answer 311

Predisposing factors include: History of previous UTIs Polycystic kidneys Congenital abnormalities of the renal tract Neuropathic bladder Urinary tract calculi Most cases are idiopathic

Answer 312

Symptoms of UTIs include: Voiding difficulties (urgency and frequency) Dysuria Fever Pain

Answer 313

Common organisms include: E. coli Enterococcus Klebsiella Proteus Staphylococcus epidermidis

Answer 314

Symptoms include: Breast pain Fever Erythema

Answer 315

Common organisms include: S. aureus S. epidermidis Group A, B, and F streptococci

Answer 316

Mastitis: Treated with oral antibiotics. Breast abscess: Requires intravenous treatment and possibly surgical drainage if fluctuance is present.

Answer 317

Common organisms include: S. aureus MRSA Skin flora Organisms involved with endometritis

Answer 318

Common organisms include: S. aureus MRSA Skin flora Organisms involved with endometritis

Answer 319

Complications include: Wound dehiscence Necrotizing fasciitis

Answer 320

Management includes: Keeping the wound clean Allowing healing by secondary intention Resuturing only if the wound is clean with no residual inflammation

Answer 321

Thrombophlebitis is the most common form, typically arising within the first 3–4 days after delivery.

Answer 322

Symptoms include localized inflammation, tenderness, and thickening of superficial leg veins. It is painful but rarely leads to serious embolic disease.

Answer 323

Phlebothrombosis refers to deep vein thrombosis (DVT) and typically arises 7–10 days after delivery, especially after operative delivery or prolonged immobilization.

Answer 324

Signs include: Local rhonchi and pleural rub on auscultation Symptoms may not be present until a clot breaks loose and lodges in the lung

Answer 325

Treatment involves the use of antithrombotic agents.

Answer 326

Calf vein thrombosis: Continue for 6 weeks. Proximal DVT or PE: Continue for 3 months if related to a temporary risk factor, and 6 months for a first episode of idiopathic VTE.

Answer 327

No, both heparin and warfarin are satisfactory for use postpartum and are not contraindicated in breastfeeding.

Answer 328

If the hemoglobin is less than 7–8 g/dL and there is no ongoing or threat of bleeding, the decision to transfuse should be considered.

Answer 329

Appropriate investigations should be conducted to assess for bleeding disorders.

Answer 330

Oral iron should be the preferred first-line treatment. Parenteral iron is indicated when oral iron is not tolerated, not absorbed, or if patient compliance is in doubt.

Answer 331

Maternal collapse is an acute event involving the cardiorespiratory systems and/or brain, resulting in reduced or absent conscious level (potentially death), occurring at any stage in pregnancy and up to 6 weeks postpartum.

Answer 332

An obstetric early warning score chart should be used routinely for all women to allow early recognition of those becoming critically ill.

Answer 333

4 Ts: Thromboembolism Toxicity Tension pneumothorax Tamponade 4 Hs: Hypovolemia Hypoxia Hypo/Hyperkalemia Hypothermia

Answer 334

Haemorrhage is the most common cause. Concealed haemorrhage, such as after a cesarean section, should not be overlooked.

Answer 335

Rare causes include: Splenic artery rupture Hepatic rupture

Answer 336

AFE presents as collapse during labor or delivery or within 30 minutes after delivery, manifesting as acute hypotension, respiratory distress, and acute hypoxia. Seizures and cardiac arrest may occur.

Answer 337

Thromboembolism is the most common cause of direct maternal death.

Answer 338

Cardiac disease is the leading overall cause of maternal death, often occurring in women without previous history. Common cardiac causes include myocardial infarction, aortic dissection, and cardiomyopathy.

Answer 339

Bacteraemia can progress rapidly to severe sepsis and septic shock, leading to collapse. Common organisms include: Streptococcal groups A, B, and D Pneumococcus E. coli

Answer 340

Drug toxicity/overdose should be considered, including illicit drug overdose and therapeutic drug toxicity, such as magnesium sulphate in renal impairment and accidental intravenous local anesthetic injection.

Answer 341

Initial effects include a feeling of inebriation and lightheadedness, followed by sedation, circumoral paraesthesia, twitching, and potentially convulsions in severe toxicity.

Answer 342

Eclampsia is usually recognized in the inpatient setting, as the diagnosis of pre-eclampsia is often already made, and seizures are typically witnessed.

Answer 343

Uncontrolled systolic hypertension. Ruptured aneurysms. Arteriovenous malformations.

Answer 344

Anaphylaxis causes significant intravascular volume redistribution, leading to decreased cardiac output.

Answer 345

Various drugs Latex Animal allergens Foods

Answer 346

Hypoglycemia Metabolic/electrolyte disturbances Airway obstruction (aspiration/foreign body) Air embolism Tension pneumothorax Cardiac tamponade secondary to trauma Rarely, hypothermia

Answer 347

Airway: Ensure the airway is open. Breathing: Assess and provide breathing support. Circulation: Monitor and support circulation.

Answer 348

Insert two wide-bore cannulae as soon as possible to facilitate aggressive volume replacement.

Answer 349

It can help diagnose concealed hemorrhage.

Answer 350

The 4 H's (Hypovolemia, Hypoxia, Hypo/Hyperkalemia, Hypothermia) and the 4 T's (Thromboembolism, Toxicity, Tension pneumothorax, Tamponade).

Answer 351

The fetus should be delivered by caesarean section to improve the effectiveness of maternal resuscitation efforts and potentially save the baby.

Answer 352

The decision should be made by the consultant obstetrician, consultant anaesthetist, and the cardiac arrest team.

Answer 353

Significant respiratory exchange at the placenta is prevented during contractions lasting 50–75 seconds.

Answer 354

Drying and covering the newborn to conserve heat. Assessing the need for intervention. Opening the airway and aerating the lungs. Providing rescue breathing and chest compressions. Rarely, administering drugs.

Answer 355

Initially attempts to breathe. If hypoxia continues, primary apnoea occurs with unchanged heart rate, followed by decreased heart rate as anaerobic metabolism begins. Secondary or terminal apnoea occurs if gasps fail to aerate the lungs, eventually leading to cardiac function impairment and potential death without intervention.

Answer 356

The most urgent requirement is effective aeration of the lungs. If the circulation is adequate, oxygenated blood will be conveyed from the aerated lungs to the heart.

Answer 357

The most urgent requirement is effective aeration of the lungs. If the circulation is adequate, oxygenated blood will be conveyed from the aerated lungs to the heart.

Answer 358

Most babies born at term do not require resuscitation and can stabilize themselves effectively during this transition.

Answer 359

Perinatal psychiatry refers to psychiatric disorders that complicate pregnancy, childbirth, and the postpartum period, including new onset conditions, recurrence of previous conditions, and relapses in currently ill women.

Answer 360

Antenatal psychiatric disorders affect 15-20% of pregnancies.

Answer 361

In early pregnancy, the rate and range of psychiatric disorders are the same as in the non-pregnant population of the same age.

Answer 362

The incidence of psychiatric disorders is slightly increased during pregnancy, particularly for anxiety and depression, but serious mental illness is much reduced compared to the postpartum period.

Answer 363

Mild to moderate depressive illness and anxiety states occur in about 15% of pregnancies, peaking in the first trimester and decreasing in later pregnancy.

Answer 364

Anxiety is a prominent feature, linked to early delivery, postnatal depressive illness, and problems with infant development.

Answer 365

Anxiety is a prominent feature, linked to early delivery, postnatal depressive illness, and problems with infant development.

Answer 366

Treatments such as guided self-help, counseling, and cognitive behavioral therapy are more effective than antidepressants for mild to moderate conditions.

Answer 367

Antidepressants are generally not prescribed for new onset mild to moderate antenatal depressive illness and anxiety states.

Answer 368

Schizophrenia, episodic psychoses, and bipolar disorder have a lower incidence during pregnancy compared to the postpartum period.

Answer 369

There is a 50% risk of early onset postpartum recurrence for women who have fully recovered from serious mental illness more than 2 years ago.

Answer 370

Psychosis can severely compromise both maternal and fetal health and requires immediate intervention.

Answer 371

These women should be recognized as being at high risk for postpartum illness, even if currently well.

Answer 372

Management should be a joint effort between maternity and psychiatric services, including a consultant obstetrician, balancing the risk of relapse if antipsychotic medication is reduced or withdrawn.

Answer 373

Antipsychotic medication should generally be continued during pregnancy to manage serious mental illness.

Answer 374

Mood stabilizers should be withdrawn before conception and substituted with an antipsychotic agent.

Answer 375

Admission should be to a specialized mother and baby unit to support both maternal and infant health.

Answer 376

TCAs, except for clomipramine, show no increased risk of structural or functional fetal abnormalities, early pregnancy loss, restricted interuterine growth, or early delivery. However, they can cause neonatal withdrawal effects if taken at full dose before delivery.

Answer 377

Paroxetine has been linked with cardiac abnormalities, specifically ventricular septal defect. Other SSRIs, like fluoxetine and sertraline, are supported for use in pregnancy.

Answer 378

SSRIs may be associated with increased rates of early pregnancy loss, growth restriction, early delivery, and pulmonary hypertension in the newborn.

Answer 379

Due to a lack of evidence regarding their safety and concerns about pulmonary hypertension, SNRIs should generally not be used in pregnancy.

Answer 380

Lithium is associated with an increased risk of cardiac abnormalities, particularly Ebstein’s anomaly, and can be used during the second trimester but is problematic in later pregnancy.

Answer 381

Sodium valproate is associated with an increased risk of fetal malformations, especially neural tube defects, and should not be used in women of reproductive age unless there are no effective alternatives.

Answer 382

Sodium valproate is associated with an increased risk of fetal malformations, especially neural tube defects, and should not be used in women of reproductive age unless there are no effective alternatives.

Answer 383

The postpartum blues involve emotional lability, tearfulness, exhaustion, anxiety, and irritability, usually occurring between day 3 and day 10, peaking around day 5. It lasts for about 48 hours and requires reassurance and support, not treatment.

Answer 384

It has an abrupt onset, occurs in 80% of cases within 3–14 days postpartum, and features a rapidly changing clinical picture. Risk factors include family/personal history and emergency caesarean sections. Treatment typically involves admission with the baby and vigorous treatment, often with a good prognosis.

Answer 385

Symptoms include overt guilt, worthlessness, ruminative worry, obsessive thoughts, and anxiety. Onset occurs in the first 2 weeks postpartum, often requiring treatment with antidepressants and counseling. Presentation peaks at 2–4 weeks and 10–14 weeks.

Answer 386

Symptoms include overt guilt, worthlessness, ruminative worry, obsessive thoughts, and anxiety. Onset occurs in the first 2 weeks postpartum, often requiring treatment with antidepressants and counseling. Presentation peaks at 2–4 weeks and 10–14 weeks.

Answer 387

Women often express problems with mothering, have an insidious onset in the first week, and show symptoms of anxiety and phobias. It presents typically 3 months to 1 year postpartum. Treatment includes counseling and social support.

Obgyn T 22-45 Flashcards

(424 cards)