Week 10 pt 1

Question 1

Describe category 2 tracings

Answer 1

Everything not in category 1 or 3 tracings
Not predictive of abnormal fetal acid-base status
Not normal either

Question 2

Three possible (immediate) interventions for cat 2 tracings are what?

Answer 2

1. change the woman’s position to left lateral recumbent
2. reduce infusion rate of oxytocin (if running)
3. increase IV fluids

Question 3

Cat 2 tracings: When abnormal patterns are seen, the first step should be what?

Answer 3

a search for the underlying cause.

Question 4

Prompt evaluation and treatment necessary (CS likely) for what tracings?

Answer 4

Category 3

Question 5

Describe what different scalp blood PHs mean

Answer 5

1) 7.21-7.24 is suspicious and should be repeated within 30 to 60 minutes
2) 7.00-7.20 = fetal acidosis, necessitates delivery
3) <7.00 = correlation with poor perinatal outcome

Question 6

List the VEAL CHOP MINE mnemonic

Answer 6

Question 7

False labor (braxton hicks):
1) When does it occur?
2) When does it resolve?
3) Is it painful?

Answer 7

1) Can begin during 2nd trimester but are normal during 3rd trimester of pregnancy
2) Generally, resolve with ambulation, hydration or analgesia
3) Can be completely painless or toward end of pregnancy can be uncomfortable, especially with multiparas

Question 8

Describe false labor late in pregnancy

Answer 8

Lightening (“dropping”)
“bloody show”

Question 9

Power (Uterine Contractions): Montevideo units
1) How are they measured?
2) How are they calculated? What must they be?

Answer 9

1) Measured internally with IUPC
2) Subtract baseline tone from peak of contractions, add total in the 10 min window.
Must be at least 200 MVU for adequate labor progression during the active phase.

Question 10

Effacement:
1) Define it
2) How is it inspected?
3) What is needed prior to labor?

Answer 10

1) Cervical shortening from ~2cm and thinning
2) Digital vaginal exam
3) Need 100% effacement prior to labor

Question 11

Define position and give an example

Answer 11

1) Describes the relation of the point of reference to the right or left side of the maternal pelvis
-e.g. the occiput is transverse and to the left

Question 12

Define engagement [of the fetal head] and give an example

Answer 12

1) Occurs when the biparietal diameter is at or below the inlet of the true pelvis.
-Moms refer to this as when the baby “drops” (aka “lightening”)

Question 13

Define station [of the fetal head]

Answer 13

The presenting part to the level of the ischial spines measured in plus or minus cm (-5 thru +5)

Question 14

Position: Define attitude and normal attitude

Answer 14

1) The posturing of the joints and relation of fetal parts to one another.
2) The normal fetal attitude when labor begins is with all joints in flexion.

Question 15

Position: Define lie

Answer 15

The long axis of the fetus in relation to the mother’s long axis
(you want them longitudinal)

Question 16

Position: Define presentation and give examples

Answer 16

1) The part on the fetus lying over the inlet of the pelvic or at the cervical os; the “presenting part”
2) Vertex, breech, footling breech, face

Question 17

True labor:
1) When does it generally occur?
2) What 2 things are progressive?
3) What does it cause the cervix to do?

Answer 17

1) Generally, occurs naturally between 37-42 weeks gestation
2) Pain and cervical changes
3) Causes effacement (thinning) and dilation (opening) of cervix
-Soften: Tip of nose > softest part of cheek
-Thin: 2-3cm > paper-thin
May cause “bloody show”
-Dilate: Closed > 10 cm

Question 18

Define and describe the first stage of labor

Answer 18

1) Onset of true contractions through complete dilation and effacement of the cervix.
2) a) Latent Phase: contractions irregular, takes a while to dilate to ~4-5cm
b) Active Phase: contractions more regular; 4-5cm – completely dilated > evaluate cervix q 2hrs

Question 19

Third stage of labor:
1) When does it occur?
2) What should you begin at the initial step of this stage?

Answer 19

1) Begins with birth of baby and ends with delivery of the placenta
2) Initial step of this stage: begin Pitocin (Oxytocin) to prevent postpartum hemorrhage

Question 20

PROM:
1) Define it
2) What is the most sig. maternal risk?

Answer 20

1) Prelabor/premature Rupture of Membranes (PROM); Spontaneous before onset of labor (mom already at term)
2) Intrauterine infections

Question 21

PPROM:
1) Define it
2) How common is it?

Answer 21

1) Preterm Prelabor/premature Rupture of Membranes (PPROM) = before 37+0 completed weeks of gestation
2) ~1/3 preterm deliveries

Question 22

Describe rupture of membranes (ROM) as a part of the delivery process

Answer 22

May feel a big gush or just a steady trickle of fluid
*Note time, color, approximate amount, and fetal response

Question 23

Amniotomy:
1) When is it usually done? Is it routine?
2) What does it generally do?
3) What does it start? What should you note?

Answer 23

1) Usually done at bedside in the hospital; should not be routine but if needed, occur in latent phase of stage 1
2) Improve strength of contractions
3) Starts the clock ticking (exposure to infection)
*Note amount, color, any foul odor, fetal response

Question 24

When does umbilical cord prolapse usually occur?

Answer 24

Usually happens at time of rupture of membranes
Fetal presenting part can compress cord

Question 25

Breech presentation: 1) What is it assoc. with? 2) What are 3 ways to diagnose it? 3) What are the 2 ways to manage it?

Answer 25

1) multiples, polyhydramnios, hydrocephaly, prematurity 2) Leopold’s maneuvers, pelvic exam, U/S 3) External cephalic version (>36wks) -C-section if unsuccessful

Question 26

Describe Meconium Staining of the Fluid

Answer 26

1) Means baby has moved its bowels in utero; occurs in 12% of live births -2 in 1000 develop meconium aspiration syndrome 2) May be due to post-dates gestation or fetal response to stress before or during labor 3) Will need aggressive suctioning on perineum and before first breath

Question 27

Pain mgmt in labor: 1) What are some non-pharmacologic examples? 2) What are some pharmacologic examples?

Answer 27

1) Massage, heat, warm showers/baths, ambulation, breathing/relaxation techniques, positioning 2) Short-acting IV narcotics (Demerol, Stadol, Fentanyl) No NSAIDs.

Question 28

List the 7 mechanisms of labor (cardinal movements of labor)

Answer 28

Engagement Flexion Descent Internal rotation Extension External rotation or restitution Expulsion

Question 29

1) Define engagement 2) When is it suggested clinically? 3) When does it occur?

Answer 29

1) Occurs when the biparietal diameter is at or below the pelvic inlet 2) Suggested clinically by palpation of the presenting part below the level of the ischial spines (0 station) 3) Days to weeks prior to labor (1st child) At onset of active labor (>1 child)

Question 30

The curve of the hollow of the sacrum favors extension of the fetal head as further descent occurs; what does this look like?

Answer 30

The fetal chin is no longer touching the fetal chest.

Question 31

Describe restitution

Answer 31

1) Shoulders rotate into an oblique or AP orientation with further descent. 2) This encourages the fetal head to return to its transverse position (restitution)

Question 32

Median episiotomies may lead to 3rd and 4th degree extended lacerations; what may these lead to?

Answer 32

May injure the anal sphincter or lead to postpartum dyspareunia

Question 33

Describe vaginal repair

Answer 33

With lacerations, repair is dependent on bleeding and on likelihood of tissues staying approximated. Episiotomies must be repaired. Must be even. Fewest stitches needed. Absorbable sutures. If bright red steady bleeding after delivery may have a vaginal side wall tear or a cervical tear. Needs to be repaired by experienced GYN.

Question 34

Delivery of the placenta: 1) When does it occur? 2) When is the delivery of the placenta imminent?

Answer 34

1) Generally, delivers within 15 minutes with no intervention (give IV Oxytocin to prev. hemorrhage) 2) Delivery of the placenta imminent when evidence of uterine separation -A gush of blood and/or “lengthening” of the umbilical cord -Uterus rises in the abdomen then becomes firm and globular

Question 35

What are 2 reasons why you inspect the placenta?

Answer 35

1) Can cause life-threatening hemorrhage if piece left 2) Look for abnormalities: Problems with cord Calcifications Adherent clot

Question 36

Stage 4 of labor: Uterine atony (lack of tone) is more common when?

Answer 36

Multiple pregnancies, multifetal gestation, following a pregnancy with uterine distention, or after a very lengthy labor.

Question 37

1) Primary cause of postpartum uterine atony (immediate or delayed) is bladder distention; how is this treated? 2) What are some other causes?

Answer 37

1) Evaluate and/or drain bladder 2) Retained products, repeated distention, muscle fatigue after delivery, obstetric meds (anesthetics)

Question 38

Dystocia (difficult labor) may occur when?

Answer 38

Consequence of distinct abnormalities that may exist alone or in combination. (3 Ps: Power, Passenger, Passage )

Question 39

Shoulder dystocia: 1) List some maternal risk factors 2) List 2 fetal risk factors

Answer 39

1) Abnormal pelvic anatomy, gestational diabetes, post-dated pregnancy, previous shoulder dystocia, short stature 2) Suspected macrosomia, increased birth weight

Question 40

List 3 labor-related risk factors for shoulder dystocia

Answer 40

Assisted vaginal delivery (forceps or vacuum), protracted active phase of first-stage labor, protracted second-stage labor

Question 41

What is the HELPERR mnemonic for shoulder dystocia?

Answer 41

H—Call for help! E—Evaluate benefit of episiotomy L—Hyperflexion of legs to mother’s abdomen (McRoberts maneuver) P—Suprapubic pressure to assist in dislodging impacted shoulder E—Enter maneuvers (force internal rotation) R—Remove the posterior arm R—Roll the patient over on hands and knees

Question 42

1) What are some maternal complications of shoulder dystocia? 2) What are some fetal complications?

Answer 42

1) Postpartum hemorrhage, rectovaginal fistula, symphyseal separation, 3rd or 4th degree episiotomy or tear, uterine rupture 2) Brachial plexus palsy (Erb’s Palsy), clavicular fracture, fetal death, fetal hypoxia (with or without permanent neurologic damage), fracture of the humerus

Question 43

List and describe the criteria for the 2 potential first stage of labor disorders

Answer 43

1) Prolonged latent phase (0 to ~4cm): Nulliparas: >30hrs Multiparas: >24.5hrs 2) Protracted active phase (~4 to 10cm): Nulliparas: < 1-2cm/2hrs Multiparas: < 1 cm/2hrs

Question 44

Second stage of labor: 1) Define protraction disorder 2) What is an indication for operative vaginal or c-section? 3) What should always be used? What can be used?

Answer 44

1) Protraction disorder: >3-4hrs (regional anesthesia), >2-3hrs (no regional anesthesia) 2) Non-reassuring status of the fetus or mother 3) Oxytocin used for all protraction and arrest disorders (per ACOG); amniotomy also option

Question 45

Augmentation of Labor: 1) Must know accurately how _________ the contractions really are. 2) How do you find out this info?

Answer 45

1) strong 2) Strength of contractions assessed by internal monitoring of contractions (IUPC)  calculate Montevideo units

Question 46

When should you consider augmentation of labor? Describe

Answer 46

1) Should be considered if the frequency of contractions is <3 contractions per 10 minutes, the intensity of contractions is <25 mmHg above the baseline, or both. -If contractions are weak or irregular, Oxytocin (Pitocin) augmentation -If membranes have not ruptured, may perform amniotomy (not routine) before oxytocin

Question 47

List the contraindications to oxytocin

Answer 47

Significant cephalopelvic disproportion Unfavorable fetal positions or presentations Obstetric emergencies that favor surgery Fetal distress where delivery is not imminent Hyperactive or hypertonic uterus Polyhydramnios, partial/complete placenta previa, prematurity, borderline cephalopelvic disproportion, previous major surgery of cervix or uterus (incl C-section), overdistension of uterus, grand multiparity, invasive cervical carcinoma, history of uterine sepsis or traumatic delivery Not indicated for elective labor induction

Question 48

Arrest of Labor: 1) What is a crucial question to ask before you Dx? 2) How do you answer this question?

Answer 48

1) Is she having an arrest of labor or has she never been IN labor? 2) Prior to diagnosing an arrest of labor, uterine contraction pattern should exceed 200 Montevideo units >2 hrs without cervical change -adequate labor for 2 hours + no progress of labor > intrauterine pressure catheter (IUPC)

Question 49

What do you need to do before vacuum and/or forceps?

Answer 49

Must evaluate the risk involved and the reason the baby is not coming on its own

Question 50

When the fetal head is engaged and the cervix is fully dilated, what are the 3 indications for operative vaginal delivery?

Answer 50

(*No indication for operative vaginal delivery is absolute) 1) Prolonged or arrested second stage of labor 2) Suspicion of immediate or potential fetal compromise 3) Shortening of the second stage for maternal benefit

Question 51

What are the 4 contraindications to operative vaginal delivery?

Answer 51

1) <34weeks of gestation 2) Live fetus with known bone demineralization condition or a bleeding disorder 3) If the fetal head is unengaged 4) The position of the fetal head is unknown

Question 52

C-sections: 1) How are they done? 2) Do they have an increased risk? 3) What are the 2 situations where it may be done?

Answer 52

1) Nearly always done with a low transverse uterine incision to minimize future risk of uterine rupture 2) Increased risk for mom and baby 3) Can be scheduled or emergent -If scheduled, an epidural is anesthesia of choice

Question 53

List the indications for C-sections

Answer 53

1) Nonmedically indicated early term births (37 0/7 to 38 6/7 weeks) 2) Breech deliveries 3) Nonreassuring fetal status 4) Placenta previa (complete and often partial) 5) Placental abruption 6) Umbilical cord prolapse 7) Uterine rupture

Question 54

Most patients who have had a low-transverse uterine incision from a previous cesarean delivery and who have no contraindications for vaginal birth are candidates for what?

Answer 54

trial of labor after cesarean (TOLAC)

Question 55

Most published studies of women attempting a TOLAC demonstrate ________% successful vaginal births.

Answer 55

60 – 80%

Question 56

Describe some risks of VBAC

Answer 56

1) A failed trial of labor may be associated with major maternal complications such as: -hysterectomy, uterine rupture (about 1%), operative injury, increased maternal infection, and need for transfusion. 2) Also associated with increased risk for fetus, with increased neonatal morbidity and mortality