Obstetrics - Labor & Delivery, Postpartum Care

Question 1

Fetal lie

Answer 1

= infant longituidnal or tarnsverse within uterus - use

leopold manueuvers to dermine

Question 2

Best test to see if will deliver preterm

Answer 2

fetal fibronectin

Question 3

PROM (premature ROM)

Answer 3

= rupture membranes prior to onset of labor

Concerned about chorioamnitis (risk for PROM)

Give abx

Immediate delivery if fetus near term with oxytocin, c/s if fetal distress

Question 4

Prolonged premature ROM

Answer 4

= if > 18 hrs rupture membranes before delivery

Question 5

preterm premature ROM (PPROM)

Answer 5

= before 37 weeks gestation rupture membranes and no labor signs yet

Tx:
Give ampicillin +/- erythromycin

+ corticosteroids if < 34 weeks GA

Immediate delivery if fetus near term with oxytocin, c/s if fetal distress

Question 6

Dx ROM with

Answer 6

pool, nitrazine and fern tests

Question 7

Pool test

Answer 7

= + if collection of fluid in the vagina in laboring woman

Question 8

Nitrazine test

Answer 8

Vaginal secretions are normally acidic, whereas amniotic fluid is alkaline.

when amniotic fluid is placed on nitrazine paper, the
paper should immediately turn blue

It is important to test the fluid from the vagina and not to test cervical mucus because of false positive ferning patterns**

Question 9

Fern test

Answer 9

= The estrogens in the amniotic fluid cause crystallization
of the salts in the amniotic fluid when it dries.

Under low microscopic power, the crystals resemble the blades of a fern

Caution should be exercised to sample fluid that is not directly from the cervix because cervical mucus also ferns and may result in a false + reading

Question 10

The five components of the cervical examination during labor

Answer 10

dilation,
effacement, 
fetal station, 
cervical position, 
consistency of the cervix. 

> 8 is consistent with a cervix favorable for both spontaneous labor

Question 11

Effacement

Answer 11

The typical cervix is 3 to 5 cm in length;

thus, if the cervix feels like it is about 2 cm from external to internal os, it is 50% effaced.

Question 12

Station

Answer 12

The relation of the fetal head to the ischial spines of the female pelvis

0 = most descended aspect of the presenting part is at the level of the ischial spines

Negative = presenting part is above the ischial spines

+ = presenting part is below the ischial spines

Question 13

Which fetal position can lead to prolonged labor and a higher rate of cesarean delivery?

Answer 13

occiput transverse (OT) or occiput posterior (OP)

Question 14

Labor is induced with

Answer 14

prostaglandins, oxytocic agents, mechanical dilation of the cervix, and/or artificial ROM.

Question 15

Common indications for induction of labor include

Answer 15

postterm pregnancy,
preeclampsia, 
diabetes mellitus, 
nonreassuring fetal testing, 
intrauterine growth restriction

Question 16

There are both maternal and obstetric contraindications for the use of prostaglandins.

Answer 16

Maternal reasons include asthma and glaucoma.

Obstetric reasons include having had a prior cesarean delivery and nonreassuring fetal testing.

Question 17

Etiology of

• early decelerations
• variable decelerations
• late decelerations

Answer 17

Early decelerations

• begin and end approximately at the same time as contractions
• 2/2 increased vagal tone secondary to head compression during a contraction.

Variable decelerations

• can occur at any time and tend to drop more precipitously than either early or late decelerations
• 2/2 umbilical cord compression.

Late decelerations

• begin at the peak of a contraction and slowly return to baseline after the contraction has finished
• 2/2 uteroplacental insufficiency and are the most worrisome type.

Question 18

The cardinal movements of delivery

Answer 18

engagement = fetal presenting part enters pelvis
descent = head descends into pelvis
flexion, 
internal rotation, 
extension, 
external rotation

Question 19

Stages 1, 2, 3 of labor

Answer 19

Stage 1 begins with the onset of labor and lasts until dilation and effacement of the cervix are completed.

Stage 2 is from the time of full dilation until delivery of the infant.

Stage 3 begins after delivery of the infant and ends with delivery of the placenta.

Question 20

Stage 1: latent vs active phase

Answer 20

latent phase

• onset labor –> 3-4cm dilation (some say 6cm)
• slow cervical change.

active

• 4 - > 9cm of dilation
• slope of cervical change against time increases.
• nulliparous: 1 cm/hr dilation expected
• multiparous: 1.2 cm/hr dilation expected

Question 21

signs of nonreassuring fetal status

Answer 21

Repetitive late decelerations,
bradycardias,
loss of variability

If a prolonged deceleration is felt to be the result of uterine hypertonus (a single contraction lasting 2 minutes or longer) or tachysystole (greater than five contractions in a 10-minute period), the patient can be given a dose of terbutaline to help relax the uterus.

Question 22

Best occipital presentation to deliver baby

Answer 22

Vertex with occiput anterior

Question 23

A Bishop score of 5 or less may lead to a failed induction as often as _____% of time

Answer 23

50% of the time

In these patients, prostaglandin E2 (PGE2) gel, PGE2 pessary (Cervidil), or PGE1M (misoprostol) is often used to “ripen” the cervix.

Oxytocin is used to induce labor with a Bishop score greater than 5.

Question 24

Preterm delivery

Answer 24

< 37 weeks gestation

Question 25

Risks for preterm labor

Answer 25

``` Preterm ROM Chorioamniotis Multiple gestations Uterine anomalies Previous preterm Maternal prepreggers wt < 50 kg Placental abruption Preeclampsia Infections ```

Question 26

Tocolytics

Answer 26

Beta mimetics - ritodrine - terbutaline MgSO4 Nifedipine Prostaglandin inhibitors

Question 27

Ritodrine, terbutaline

Answer 27

B2-agonist Act on uterine smooth muscle fibers (inc cAMP) S/E: - HA - pulmonary edema - maternal death - tachy Blackbox warning for terbutaine > 24-48 hrs - DO NOT USE!

Question 28

MgSO4

Answer 28

Decreases uterine tone and contractions Magnesium sulfate works by competing with calcium entry into cell Also membrane stabilizer

Question 29

Way to assess for magnesium toxicity?

Answer 29

DTR exams If Mg level too high, DTRs depressed

Question 30

Prolonged deceleration

Answer 30

FHR < 100-110 for longer than 2 mins

Question 31

Bradycardia

Answer 31

FHR < 100-110 for longer than 10 minutes

Question 32

Prolonged FHR deceleration - initial management?

Answer 32

Put in L or R lateral decubitus to see if FHR is 2/2 IVC compression O2 for hypoxia Examine pt w/ 1 hand on maternal abdomen and 1 hand vaginally feeling for cervical dilation, fetal station, prolapsed umbilical cord

Question 33

Maneuvers to deliver infant w/ shoulder dystocia

Answer 33

McRoberts - sharp flexion of maternal hips to increase AP diameter Suprapubic pressure Rubin maneuver - pressure on either accessible shoulder toward anterior chest wall of fetus Wood's corkscrew maneuver - P behind posterior shoulder to rotate infant and dislodge anterior shoulder Delivery of posterior arm/shoulder Episiotomy Zavanelli - put infant's head back into pelvis and get c/s

Question 34

Kleihauer-Betke test

Answer 34

blood test used to measure the amount of fetal hemoglobin transferred from a fetus to a mother's bloodstream Qualitative test to help determine presence of feto-maternal hemorrhage is rosette test --> if positive, use K-B test to see amt of hemorrhage and adjust anti-D immune globulin

Question 35

Postpartum period =

Answer 35

6 weeks s/p delivery

Question 36

Pts usually experience breast milk let down...

Answer 36

24-72 hrs postpartum

Question 37

Postpartum vaccines

Answer 37

Tdap (if more than 10 years) - mainly for pertussis MMR - if low antibody titers in prenatal care Rhogam - within 72 hrs postpartum if Rh negative

Question 38

How long pelvic rest s/p delivery usually?

Answer 38

6 weeks

Question 39

Postpartum contraception

Answer 39

Very impt to address PPTL Breastfeeding + want hormone contraception: - Progesterone only mini pill - Depo Provera - implantable progesterone agents - --> NOT combo OCPs because can decrease milk let down If really want combo OCPs and breastfeed, can start at 3-6 weeks pp and then milk supply should be ok

Question 40

When does risk of VTE decrease in postpartum period to levels prior to pregnancy?

Answer 40

6 weeks

Question 41

When can you put in IUD pp?

Answer 41

6 weeks pp Usually risk expulsion before that

Question 42

4 main causes of postpartum hemorrhage

Answer 42

4 Ts Tone - Uterine atony Tissue - retained placenta Trauma from childbirth (eg cervical, vaginal lacs, uterine rupture) Thrombin - coagulopathy

Question 43

PP hemorrhage defined as

Answer 43

> 500 cc blood loss in vag deliv > 1000 cc blood loss in cs

Question 44

Tx uterine atony

Answer 44

Oxytocin IV Uterine massage If still atonic... - methylergonovine If still atonic... - PGF2a (hemabate = carboprost) - dinoprostone (cervidil) - misoprostol off label (cytotec) If still atonic... - D&C - inflatable tamponade If still atonic... - ex lap - possible hysterectomy

Question 45

Who can you not use hemabate (carboprost) in?

Answer 45

Asthma pts

Question 46

Endometritis / Endomyometritis

Answer 46

- polymicrobial infection of the uterine lining that often invades the underlying muscle wall. Endometritis in the postpartum period is most closely related to the mode of delivery. Endometritis can be found in less than 3% of vaginal births and this is contrasted by a 5-10 times higher incidence after Cesarean deliveries Risk factors: - meconium, - chorioamnionitis, - prolonged rupture of membranes. Factors related to increased rates of infection with a vaginal birth include prolonged labor, prolonged rupture of membranes, multiple vaginal examinations, internal fetal monitoring, removal of the placenta manually and low socioeconomic status. Usually occurs 5-10 days after delivery Use US to look for retained products of conception --> D&C if yes Broad spectrum IV abx to treat (amp/gent)

Question 47

Tx mastitis

Answer 47

Dicloxacillin Continue breastfeeding!

Question 48

Diaphragms and cervical caps pp need to be reevaluated at

Answer 48

6 weeks

Question 49

Surgical management of PPH ranges from

Answer 49

``` D&C ex lap uterine artery ligation, hypogastric artery ligation, hysterectomy ```

Question 50

Tx umbilical cord prolapse felt in labor

Answer 50

elevate the fetal head with a hand in the patient’s vagina and call for assistance to perform a Cesarean delivery Do this even if fetal heart tracing is ok!

Question 51

Pt delivered baby s/p MgSO4 for preeclampsia - what do you care most about on neonate?

Answer 51

The first objective after delivery is to assess respiratory effort due to use of magnesium and make sure that the neonate is being oxygenated adequately, which might require a bag mask.

Question 52

Infants born to diabetic mothers are at increased risk for developing

Answer 52

hypoglycemia, polycythemia, hyperbilirubinemia, hypocalcemia and respiratory distress.

Question 53

Postpartum care of infant born to HIV+ mom

Answer 53

AZT immediately after delivery HIV testing begins at 24 hours

Question 54

The most common cause of postpartum fever is

Answer 54

endometritis Bacterial isolates related to postpartum endometritis are usually polymicrobial resulting in a mix of aerobes and anaerobes in the genital tract. The most causative agents are Staphylococcus aureus and Streptococcus.

Question 55

Post partum blues

Answer 55

Signs and symptoms of depression which last for less than two weeks are called postpartum blues

Question 56

Postpartum depression

Answer 56

is a common condition estimated to affect approximately 10-15% of women often begins within two weeks to six months after delivery.

Question 57

The safest method to suppress lactation

Answer 57

The safest method to suppress lactation is breast binding, ice packs and analgesics. Hormonal interventions for preventing lactation appear to predispose to thromboembolic events, as well as a significant risk of rebound engorgement. Bromocriptine, in particular, is associated with hypertension, stroke and seizures.

Question 58

Breastfeeding is associated with

Answer 58

a decreased incidence of ovarian cancer decrease the risk for developing coronary artery disease, cervical dysplasia and cervical cancer or colon cancer in the mother

Question 59

Milk letdown is via...

Answer 59

Delivery --> rapid dec in levels of progesterone + estrogen --> no more inhibitory influence of progesterone on the production of alpha-lactalbumin by the rough endoplasmic reticulum. increased alpha-lactalbumin ---> lactose synthase ---> to increase milk lactose. Progesterone withdrawal allows prolactin to act unopposed in its stimulation of alpha-lactalbumin production.

Question 60

Breastfeeeding + intense nipple pain....what is likely going on?

Answer 60

Candida of nipple Mastitis not too much nipple pain

Question 61

Signs that a baby is getting sufficient milk include

Answer 61

3-4 stools in 24 hours, six wet diapers in 24 hours, weight gain sounds of swallowing.

Question 62

Milk prod + milk let down done by...

Answer 62

prolactin is responsible for milk production oxytocin is responsible for milk ejection.

Question 63

Assoc of breech presentation

Answer 63

``` Prematurity, multiple gestation, genetic disorders, polyhydramnios, hydrocephaly, anencephaly, placenta previa, uterine anomalies uterine fibroids ```

Question 64

Normal vs abnormal labor Stage 1 - latent - active Tx?

Answer 64

Prolonged latent (> 6 cm dilated) - >20 hours for nulliparas - >14 hours for multiparas Tx: - rest or augmentation of labor. Artificial rupture of membranes is not recommended in the latent phase as it places the patient at increased risk of infection. ----- Arrest of labor in 1st stage if: - dilation >= 6cm + rupture membranes and one of the following: - no cervical change for > 4 hrs despite adequate ctx - no cervical change for > 6hrs with inadequate ctx

Question 65

Arrest of dilation in active phase of labor...what do you do?

Answer 65

If baby ok, amniotomy is often recommended in this situation. Then augmentation with oxytocin can be attempted after careful evaluation

Question 66

FFP vs Cryoprecipitate

Answer 66

No RBCs or platelets in theses! FFP - fibrinogen - V - VIII Cryo - fibrinogen - VIII - vWF

Question 67

Tocolytic contraindications - terbutaline, ritodrine - MgSO4

Answer 67

Terbutaline, ritodrine - diabetic patients magnesium sulfate - myasthenia gravis;

Question 68

Who can you not use methylergonovine in?

Answer 68

HTN pts Preeclampsia/eclampsia

Question 69

Treatment with betamethasone from 24 to 34 weeks gestation has been shown to

Answer 69

increase pulmonary maturity reduce the incidence and severity of RDS (respiratory distress syndrome) in the newborn associated with decreased intracerebral hemorrhage and necrotizing enterocolitis in the newborn

Question 70

How does fibronectin for preterm delivery work?

Answer 70

Fibronectin is an extracellular matrix protein that is thought to act as an adhesive between the fetal membranes and underlying decidua. It is normally found in cervical secretions in the first half of pregnancy. Its presence in the cervical mucus between 22 and 34 weeks is thought to indicate a disruption or injury to the maternal-fetal interface. High neg predictive value in sx women, low + predictive value

Question 71

Antibiotic therapy given to patients with preterm premature rupture of the membranes has been found to

Answer 71

prolong the latency period by 5-7 days, as well as reduce the incidence of maternal amnionitis and neonatal sepsis

Question 72

In some cases of preterm rupture of the membranes, amniocentesis may be performed to detect intra-amniotic infection. What does it look for?

Answer 72

L-6 increased **** Low glucose Leuks have low predictive value

Question 73

17 alpha-hydroxyprogesterone has been shown to reduce the risk of

Answer 73

premature labor.

Question 74

Agents used to ripen cervix

Answer 74

prostaglandin E2 (PGE2) gel, PGE2 pessary (Cervidil), or PGE1M (misoprostol) is often used to “ripen” the cervix.

Question 75

Ways to administer meds for uterine atony

Answer 75

IM - PGF2a (carboprost) Into uterus - Carboprost IV - Oxytocin (not IVP) Orally - MIsoprostol Rectally - Misoprostol (not IV Or IM) NOT IV - Carbobprost ----> bronchoconstriction

Question 76

Postpartum fever causes

Answer 76

Endometritis Cystitis Breast engorgement Wound infection

Question 77

SSRIs and breastfeeding - ok?

Answer 77

YES!

Question 78

endometritis is usually

Answer 78

polymicrobial infection tx w/ clinda and gentamicin

Question 79

Low grade fever and leukocytosis postpartum - is this ok?

Answer 79

Yes! during first 24 hrs of pp Chills are also common reassure