Obstetrics Flashcards
(66 cards)
1
Q
List the criteria for normal labor
A
Regular uterine contractions along with cervical dilation
- begins spontaneously
- proceeds at normal rate
- proceeds without intervention
- results in spontaneous vaginal delivery
2
Q
Describe the stages of labor
A
1st Stage (Contraction and cervical dilatation)
- latent phase is prodrome labour and not clinically classified as true labour (6-20h in nulli and 4-13 in multi)
- active phase is true labour and cervical dilation of >3-4cm
- begins with acceleration phase
- phase of maximum slope where have cervical dilation to 10cm
- deceleration phase into 2nd stage
- nulli have 1.2-3.0cm/hr and multi have 1.5-5.7cm/h
2nd Stage
- fetal descent and delivery over 1-3 in nulli and 0.5-1 in multi
3rd Stage
- delivery of placenta
3
Q
Discuss the changes in stage 1 of labour
A
- uterus changes where upper uterus have stronger contractions resulting in shrinking and lower uterus have smaller contractions and get bigger
- cervix becomes effaced and then dilated
4
Q
Discuss the changes in stage 2 labor
A
Baby 7 Cardinal Movements
- engagement where head engaged to ischial spine
- descent where downward passage through cervix
- flexion where partial flexion of head as baby passess through pelvis
- internal rotation where rotate head from occiput transverse to either anterior or posterior
- extension where extend head once past pubic symphysis
- restitution once head delivered it rotates back to original position
- expulsion where further descent bring shoulder past pubic symphysis
5
Q
Discuss the 5 cardinal findings on physical exam of pregnant women
A
Effacement - smoothness of the cervix relative to the uterus Dilatation - dilation of the cervix Station - relation of head to ischial spines Presentation - foremost part of the fetus within or near birth canal - normal is cephalic vertex Position - orientation of the baby occiput relative to maternal pelvis - normal is occiput anterior
6
Q
What are the four cardinal questions for women in labour
A
Cardinal - fetal movement (>6 per hour normal) - bleeding per vagina - rupture of membranes - contrations including regularity, length and pain History - gestational age - maternal age - GTPAL - complications during pregnancy - prenatal care
7
Q
Discuss how to differentiate true and false labour
A
True - contractions: regular - frequency: decreasing interval - intensity: worsening - location: back and abdomen - cervical change: dilating - effect of sedation: no change False - contractions: irregular - frequency: interval increasing - intensity: not changing - location: lower abdomen - cervical change: no change - effect of sedation: diminish
8
Q
Discuss the management of Stage 1 Labor
A
Preparation - epidural - GBS positive require prophylaxis - Rh- require rhogram Management - mark progress by cervical dilation per hour - should take between 5-10 hours - assess for dystocia if cervical dilation <1.2cm/h in nulli or 1.5/h in multi
9
Q
Discuss the management of Stage 2 labour
A
- progress by monitoring station
- assess correct position by Leopold and vaginal exam
- no time limit as long as no fetal compromie
Indications for pushing - exceeded 3rd hour of stage 2
- patient without epidural feel urge to push
- nulliparous with epidural when fetus head visible or station >+2 and occiput anterior
- multiparous with epidural when urge to push, head is visible, or station >+2 with occiput anterior
Reassessment - dystocia if <1cm/hr descent in nulliparous or <2cm/hr in multi
- maximum duration if after 2 hours of pushing
10
Q
Discuss the management of stage 3 of labour
A
- placenta should deliver within 15 minutes
- if no delivery within 30-45 minutes then active management
- after delivery than clamp and cut cord (delay by >1 minutes if <37 weeks)
11
Q
Discuss the different terminology of twins Dizygotic Monozygotic Monoamniotic Monochorionic
A
Dizygotic - fertilization of 2 different eggs with 2 different sperm Monozygotic - fertilization of 1 egg with 1 sperm Monoamniotic - twins sharing same amniotic sac - di is have own amniotic sac Monochorionic - twins sharing same placenta - di is have each their own
Complications
- monoamn and monochori have highest risk of complications
Splitting
- di - di split within 3 days
- diamniotic and mono split within 3-8 days
- mono - mono split within 8-13 days
- conjoined split after 13 days
12
Q
Discuss the complications of multiple gestations
A
Maternal - hyper-emesis gravidarum - gestational diabetes or hypertension - anemia Pregnancy - polyhydramnios - placental abruption or previa - cord anomalie - twin transfusion syndrome Delivery - increased morbidity and mortality - premature preterm rupture of membranes - preterm labor - prolonged labor - malpresentation - umbilical cord prolapse - increased risk of C - section - post-partum hemorrhage Fetal - IUGR
13
Q
Discuss the presentation and management of twin-twin transfusion syndrome
A
- 10% of mono-chorionic twins
Pathophysiology - arterial blood from twin A passes through placenta and into twin B resulting in twin A having reduced blood supply and IUGR and twin B having excessive blood supply and hypervolemia, congestive heart failure, polycythemia
Investigation - ultrasound with doppler flow
Management - recipient twin get serial amniocentesis to reduce volume
- donor twin get intra-uterine blood transfusion
14
Q
Discuss the management of multiple gestation
A
- weekly testing from 24 weeks gestation
- serial ultrasound every 2-3 weeks from 28 weeks to assess growth
- weekly Doppler to assess growth
- 3rd trimester cervix checks for preterm delivery
15
Q
Discuss the interpretation of fetal heart rate monitoring
A
Contractions:
- frequency (normal is less than 5 in 10 minutes, tachsystole is >5 per 10 minutes)
- duration (normal is less than 90 seconds)
- resting tone (>30 seconds between contractions)
- timing (regular, singular contractions; tetanic is prolonged contraction lasting >3 minutes, paired or tripling is multiple occurring right next to eachother)
Baseline
- normal is 110-160 per minute
Variability
- fluctuations in baseline rate
- undectable is no variability
- minimal is <5bpm in variability
- moderate is 6-25bpm in variation (normal)
- marked is >25bpm
Acceleration
- abrupt increase in fetal heart rate greater than 15bpm lasting 15 seconds to 2 minutes and reaching peak in <30 seconds
Deceleration
- discussed on another card
16
Q
Discuss the different types of deceleration
A
Variable
- abrupt decrease in FHR that is >15bpm below baseline and lasts 15 seconds to 2 minutes and reaches nadir <30 seconds
Complicated
- deceleration to <70bpm lasting >1 minute
- low variability of baseline
- biphasic deceleration
- prolonged secondary acceleration (overshoot by 20bm for >20 seconds)
- slow return to baseline
- presence of fetal tachycardia or bradycardia
Repetitive
- >3 decelerations
Late Deceleration
- gradual decrease in FHR and return to baseline after reaching nadir >30s after contraction
Early Deceleration
- gradual decrease in FHR and return to baseline after reaching nadir >30s before contraction
17
Q
List the differential for fetal tachycardia
A
Maternal - Infection - dehydration - hyperthyroidism - anxiety Fetal - infection - prolonged fetal activity - chronic hypoxemia - cardiac anomaly - anemia
18
Q
Discuss the management of fetal tachycardia
A
Intra-uterine resuscitation
- reposition mother to left or right lateral decubitus
- supplement O2
- IV bolus
Determine Cause
Intervention
- if persists >80 minutes then fetal scalp pH or delivery to be considered
19
Q
List the differential for fetal bradycardia
A
Maternal - hypotension - medication - maternal position - connective tissue disease Fetal - umbilical cord occlusion - fetal hypoxia/acidosis - vagal stimulation - fetal cardiac defect
20
Q
Discuss the Management of Fetal Bradycardia
A
Intra-uterine resuscitation
Determine cause
Intervention
- if <100bpm or persistant then fetal scalp pH or delivery
21
Q
List the Indications and Findings of a fetal scalp blood sample
A
Indications - atypical or abnormal fetal tracings - digital fetal scalp stimulation does not result in acceleration Interpretation - >7.25 then continue to observe - 7.21-7.24 then repeat in 30 minutes - <7.2 then immediate delivery
22
Q
List the causes of abnormal variability
A
Minimal - fetal sleep - prematurity - medications: narcotics, beta-blockers, betamethasone - hypoxic acidemia - congenital abnormality Marked - mild hypoxia - fetal gasping Sinusoidal - severe fetal anemia
23
Q
List the causes of acceleration
A
- presence of acceleration is reassuring meaning pH >7.2
- no presence is not concerning however
24
Q
List the causes of Uncomplicated variable deceleration
A
- vagal stimulation due to cord compression
- manage with observation and intra-uterine resuscitation
25
List the causes of complicated, variable deceleration
```
- fetal acidemia
Management
- intra-uterine resuscitation
- amnioinfusion of RL or NS
- confirm fetal well being with scalp monitor
- consider deliver
```
26
list the causes of late deceleration
```
Maternal
- maternal hypotension
- uterine tachysystole
Placental
- insufficiency
Fetal
- fetal acidemia
Management
- repetitive or >50% contractions require fetal scalp or deliver
```
27
List the non-pharmacological pain relief in pregnancy
```
Minimal Training
- continuous support
- distraction
- massage
- hydrotherapy
- vertical position (best for 1st stage)
Specialized Training
- biofeedback
- intradermal water infection
- TENS
- acupuncture
```
28
Discuss the pain management of intermittent bolus parenteral opioids
Types:
- morphine and fentanyl most common
- fentanyl have reduced effect on fetus
Indication
- 3rd line
- used for early labor or very late stage where epidural not an option
Advantage
- simple and easy to use with quick onset
Disadvantage
- maternal side effects of respiratory depression, drowsiness and delayed gastric emptying
- fetal side effects of decreased FHR variability and respiratory depression
29
Discuss the pain management of PCA
```
- fentanyl used in PCA
Indication
- 2nd line
- intrauterine fetal demise or termination
Advantages
- provides instantaneous relief at lower doses
- have reduced maternal side effects
Disadvantage
- specialized equipment
- small doses not as effective
```
30
Discuss pain management of inhalation nitrous oxide
- entonox (50 nitrous oxide: 50 oxygen) breathed via mask PRN
Indication
- used before or in conjunction with opioids
Advantage
- easy to use and minimal accumulation of drug
- no uterine effect
Disadvantage
- not complete analgesia
- drowsiness, disorientation and nausea when wearing mask
31
Discuss pain management of epidural
```
- go into epidural space
Indication
- 1st line
Contraindication
- patient cannot sit still
- raised ICP
- infection at site or systemic
- coagulopathy
Complications
- early: failure, bleeding, dura puncture, urinary retention
- late: post-dural puncture headache, nerve injury, infection, hematoma
Advantage
- most effective
- can be transferred to C-section anaesthesia
```
32
Discuss pain management of spinal analgesia
```
- going past dura mater
Indication
- provide instanenous relief while waiting for epidural
Advantage
- rapid onset
- complete analgesia
Disadvantage
- delayed verification of epidural
- require dural puncture
- risk of fetal bradycardia
```
33
Discuss the definition, pathophysiology, and presentation of preterm labour
- labour occurring between 20 and 37 weeks
Pathophysiology
- have irritation of the chorion and decidua which triggers uterine contractions and cervical changes
Presentation
- uterine contractions with cervical changes
- abdominal pain and pressure
- increase or change in vaginal discharge
34
List the medications used in pre-term labor
Tocolytics (prolong the latent phase of labour in order to delay delivery by 2-3 days)
- NSAID Indomethecin 50-100mg PO
- MgS04 6g IV loading dose (used in fetus 24-28 weeks due to neuroprotective effect)
- Nifedipine 20mg PO
Corticosteroids
- betamethasone 12mg IM
- done to promote lung maturation and increase surfactant production
35
List the risk factors for pre-term labor
```
Maternal
- prior history of pre-term labor
- low maternal weight
- smoking, substance use
- short interval between pregnancies
Pregnancy
- pre-term uterine contraction or rupture of membranes
- vaginal bleedng
- periodontal disease
```
36
List the risk factors for pre-term premature rupture of membranes
```
- rupture of membrane before 37 weeks and prior to onset of labour
Maternal
- smoking
- prior PPROM
- short cervical length
Pregnancy
- polyhydramnios
- multiple gestations
- bleeding in early pregnancy
```
37
List the risk factors for premature rupture of membranes
```
- rupture of membranes prior to labour
Maternal
- multi-parity
- cervical incompetence
- infection
- poor nutrition
- family history
Pregnancy
- congenital anomaly
- multiple gestation
```
38
Discuss the presentation and management of premature rupture of membranes
Presentation
- fluid gush or continued leakage
- speculum show pooling of fluid in posterior fornix or fluid leaking from cervix
- positive nitrazine test
- most go into labour within 1 week
Complications
- chorioamniotis
- cord prolapse
- limb contracture
Management
- if intra-uterine safer than NICU than expectant managmenet
- near term or term deliver by induction or C-section, with GBS prophylaxis
- pre-term expectant management and IV abx (corticosteroids if less than 31 weeks)
39
List the Indications and Contra-indications for induction of labour
```
Indications
- post-date pregnancy where >41+3 weeks
- gestational hypertension or maternal comorbidities
- antepartum hemorrhage
- chorioamnionitis
- PROM
- fetal IUGR
Contra-indications
- prior C-section
- active maternal genital herpes
- invasive cervical cancer
- placenta previa or cord presentation
- fetal distress
```
40
List the components of Bishop's score
Score
- position
- consistency
- effancement
- dilatation
- station
Induction
- >6 than can consider induction as cervix is favourable
41
List the techniques used for induction of labour
Cervical Ripening (soften, effce, dilate the cervix)
- intra-vaginal PGE2 gel
- foley catheter to manually dilate cervix
Amniotomy
- artificial rupture of membranes to stimulate prostaglandin synthesis and secretion
Oxytocin
- causes uterine contraction allowing for progression of labour
- 10 units in 1L of NS at 0.5-2mU/min to increasing
42
List the indications and contra-indications for operative vaginal delivery
```
Indications
- fetal distress
- medical complications for mother to not push
- inadequate progress with adequate uterine activity
Contra-indication
- incomplete cervical dilatation
- unengaged head
- non-vertex position
- fetal coagulopathy
```
43
Discuss the procedure for operative vaginal delivery (ABCDEFGHIJ)
A: Address consent, anesthesia, and assistance
B: Bladder empty
C: Cervix fully dilated, membranes ruptured, contractions adequate
D: Determine fetal position, station and dystocia
E: Equipment check
F: Flexion point for vacuum
G: Gentle mental traction over the posterior fontanelle
H: handle in axis of birth canal, halt (3 pop offs or 3 pulls with no progress after 20 minutes)
I: incision
J: remove when jaw is reachable
44
List the grading system for perineal tears
1st Degree
- involvement of the fourchette, perineal sin and vaginal mucosa
2nd Degree
- involvement of 1st degree plus fascia and muscles (bulbocavernosus, perineal body, and transverse perineal muscle)
3rd Degree
- involvement of above plus extension into anal sphincter
4th Degree
- involvement of above plus extension into rectal mucosa
45
Discuss the indications for surgical repair of perineal tears
Indication
| - perineal laceration >=2nd degree
46
List the indications for a C-section
```
Maternal
- obstruction in birth canal
- active herpetic lesion
- invasive cervical cancer
- previous uterine surgery
- underlying maternal illness
Pregnancy
- failure to progress
- placental abruption, previa
- vasa previa
- umbilical cord prolapse
Fetal
- abnormal fetal heart tracing
- malpresentation
- cephalic pelvic position
- congenital anomaly
```
47
List the risks of C-section
- anesthesia risk
- hemorrhage
- injury to surrounding bowel, bladder, ureter or uterus
- thromboembolism
- increased recovery time
48
What is vaginal birth after cesarean and what are the contraindications
- usually done after previous low transverse uterine incision
Contraindication
- previous classical or unknown incision with risk of possible rupture
- previous uterine rupture
- multiple gestation
- estimated fetal weight >4kg
- non-vertex position
49
Define dystocia
- abnormal labour progress when cervix dilated >3-4cm
1st phase
- protracted cervical dilatation <1.2cm/hr in nulli or <1.5cm/hr in multi
- arrest of dilatation >2hours in nulli or multi
2nd Phase
- protracted descent <1cm/hr in nulliparous or <2cm/hr in multi
- arrest of descent >1hr in nulli and multi
Due to 3 primary causes
- power: ineffective uterine expulsive forces
- passenger: abnormal fetal lie, malpresentation, fetal anatomic defect, macrosomia
- passage: maternal bony pelvic contracture
50
Discuss the causes of Passenger abnormalities
Mal-presentation
- breech: buttock or feet first
- brow: brow of face
- face: face first
- shoulder
- compound presentation: extremity prolapse with transverse lie
Management
- breech: external cephalic version before labour or C-section
- face presentation: mentum anterior can be delivered
- brow presentation: wait for conversion to face or cephalic, if not C-section
- shoulder: C-section
- compound: retraction and then normal delivery
51
Discuss the presentation and management of breech presentation
Definition
- complete: flexion at hip and knees (least common)
- frank: flexion at hips and knees extended (most common)
- footling: foot as presenting with extension at hip and knee
Risk Factors
- maternal: abnormal uterine shape or pelvic contraction
- pregnancy: previa, polyhydramnios, prematurity, multiple gestation
Management
- ultrasound
- external cephalic version if >37 weeks, head not engaged and unreactive stress test
- delivery: vaginal only if perfect criteria (>36 weeks, weight between 2.5-3.8, fetal head flexed, continuous monitoring and ability to perform crash C-section) otherwise perform C
52
Discuss the passage complications
- cephalopelvic disproportion: maternal bony pelvis is not sufficient
Pelvic Inlet Contraction
- shortest anteroposterior diameter if diagonal conjugate <11.5 (1.5cm greater than obstetric conjugate)
Mid-Pelvic Contraction (most common)
- palpation of ischial spines where <10cm is suspected as cause and <8cm is known
Pelvic Outlet Contraction (least common)
- inter-ischial tuberous diameter of <8cm
53
Discuss the power complications
- uterine dysfunction: lack power to push fetus through birth canal
- hypotonic when synchronous effort but insufficient pressure to dilate cervix
- hypertonic where have elevated base tone of uterus
- incoordinate where distorted pressure gradient in uterus
Etiology
- maternal position
- epidural analgesia
- chorioamnionitis
- uterine abnormality
Management
- augementation of labour through amniotomy and oxytocin
54
Discuss the presentation and management of Shoulder Dystocia
Pathophysiology
- impaction of anterior or posterior shoulder during vaginal delivery
Risk Factors
- pre-labour: macrosomia >4.5kg, history of shoulder dystocia, induction of labour
- intra: prolonged first and second stage, secondary arrest, oxytocin augmentation, assisted vaginal delivery
Diagnosis
- difficulty delivering head and chin
- head remaining tightly in vulva and retracting
- failure to restitute fetal head
- failure of shoulder to descend
- head to body delivery >60 seconds
Management
- call for help and discourage pushing
- McRobert's maneuver: sharp flexion of mothers leg onto abdomen with suprapubic pressure
- episiotomy
- Woods maneuver: progressive rotation of posterior shoulder 180 degrees
- deliver posterior shoulder
- second Rubin maneuver
55
List the complications from shoulder dystocia
```
Maternal
- 3rd-4th degree perineal tears
- post-partum hemorrhage
- infection
- uterine rupture
- fistual
Fetal
- brachial plexus injury
- clavicle or humerus fracture
- fetal death
```
56
List the definition and risk factors for post-partum hemorrhage
```
Definition:
- >500mL of blood loss with vaginal delivery or >1000mL with C-section
- any blood loss which results in hemodynamic instability
Risk Factors
- failure to progress in second stage
- adherent placenta
- family history
- Asian or hispanic
- instrumental delivery
- large for gestational age baby
- hypertensive disorder
- obesity
- multiple gestation
```
57
Discuss the differential for PPH
Tone (most common)
- pathophysiology: failure of uterus to contract and involute post-delivery resulting in early (<24hrs) PPH
- labour: prolonged, induced, augmentated
- uterus: infection, over-distention, functional disorder
- placenta: abruption, previa
- grand-multiparity
Tissue
- pathophysiology: retained tissue within uterus preventing from involution
- placental or clots retained
Trauma
- pathophysiology: trauma to any part of female anatomy
Thrombin
- pathophysiology: disruption of platelet plug formation or coagulation cascade
58
Discuss the management of PPH
```
Stabilize and Monitor
Medical:
- Oxytocin 20units/L NS continuous
- add Methylergonavine maleate, carboprost, misoprostil, or 15-methyl prostaglandin
Source control
- remove retained products
- close laceration or add compression
Invasive
- B-lynch suture: compression of atonic uterus
- internal iliac ligation
- hysterectomy
```
59
Discuss the post-partum management for contraception
- OCP not recommended for first 3-6 weeks following delivery for non-breast feeding mothers due to risk of VTE
- can ovulate within 25 days post-partum so require immediate protection
- breast feeding mothers anovulation <6 months, breast feeding exclusively, and amenorrhea.
- Initially condoms or IUD recommended as progesterone does not affect milk production.
60
Discuss the post-partum management of depression
Presentation
- blues increase 3-5 days post-partum and improve after few weeks
- depression in onset of depressive symptoms within 3 months post-partum
Prevention
- lifestyle modification in order to reduce stress
Treatment
- SSRI
- psychosis get CBT
61
Discuss nutrition and alcohol post-partum
- require increased calories in breastfeeding women with good iron and calcium intak
- gradual post-partum weight loss of <4.5lbs/month
62
Discuss effects of smoking and alcohol use post-partum
```
Smoking
- SIDS
- lung disease
- learning disorder
Alcohol
- decreased milk intake
- impaired motor development
- altered sleep
```
63
Discuss appropriate breastfeeding guidelines
```
Recommendations
- should breastfeed for first 6 months exclusively
- feed 8-12x per day with 6-8 wet diapers and one soft, seedy stool
Contraindications
- HIV positive
- HTLV
- Herpes lesion of breast
- Child with galactosemia
- Drugs use in mother
```
64
Discuss the risk factors for intra-uterine fetal death
```
- is fetal death after 20 weeks or if weight >500g
Maternal
- advanced maternal age
- prior stillbirth
- post-term
- obesity
- smoking or illicit drug use
Pregnancy
- fetal growth restriction
- fetal macrosomia
- multiple gestation
- no antenatal care
```
65
Discuss the presentation and management of intra-uterine fetal death
```
Presentation
- decreased fetal movements
- uterine contraction
- vaginal bleeding
- symphysis-fundal height no increasing
Investigations
- high AFP
- absent cardiac activity
- secondary analysis for cause
- possible DIC
Management
- spontaneous labour and vaginal delivery
- induced labour
- dilatation and evacuation for 18-24 weeks
```
66
Discuss the medical management of termination of pregnancy
Medical Management
- Fetus <9 weeks: Methotrexate plus misoprostol
- Fetus >12 weeks: prostaglandin or misoprostol
- require good follow up care
Surgical Management
- <12-14 weeks dilatation and curettage
- >12-14 weeks: dilatation and evacuation
