Antepartum and Postpartum Obstetrics Flashcards

Terms Definitions
diagnosis of pregnancy
presumptive --> amenorrhea, breast tenderness, nausea, vomiting, hyperpigmentation, skin striae
probable --> increased uterine size, postitive beta-hCG
positive --> hearing fetal heart tones, sonographic visualization of fetus, perception of fetal movements
pregnancy dating
conceptual dating --> 266 days or 38 weeks
menstrual dating assuming 28 day cycle --> 280 days or 40 weeks
calculate due date --> LMP - 3 months + 7 days +- 1 week
first trimester events and complications
from conception to 13 menstrual weeks
nausea, vomiting, breast tenderness, frequent urination
spotting and bleeding in 20% (50% of which will continue normally)
average weght gain is 5-8 pounds
complications --> spontaneous abortion
second trimester events and complications
from 13-26 menstrual weeks
round ligament pain
Braxton-Hicks contractions are painless
quickening (maternal awareness of fetal movements) starting at 16 weeks
average weight gain is 1 pound/week after 20 weeks
complications --> incompetent cervix, premature membrane rupture, premature labor
third trimester events and complications
26-40 menstrual weeks
lower back and leg pain
urinary frequency
Braxton-Hicks contractions
bloody show
average weight gain is 1 pound/week after 20 weeks
complications --> premature membrane rupture, premature labor, preeclampsia, urinary tract infection, anemia, gestational diabetes
1st trimester lab tests: CBC
normal hemoglobin --> 10-12g/dL due to dilutional effect
MCV --> low hemoglobin and MCV (<80) suggests iron defficiency; low hemoglobin and high MCV (>100) suggests folate defficiency
thrombocytopenia --> idiopathic thrombocytopenic purpura or pregnancy induced thrombocytopenia
leukocytosis up to 16,000/mm3 is normal; leukopenia suggests immune suppression or leukemia
1st trimester lab tests: rubella IgG
absence of antibodies has fetal risks; vaccine is contraindicated in pregnancy but recommended after delivery
1st trimester lab tests: hepatitis B
HbsAb --> successful vaccination
HbsAg --> previous or present infection; only routine hepatitis test on prenatal lab panel
HbeAg --> highly infectious state
1st trimester lab tests: type, Rh and antibody screen
blood type and Rh --> direct Coombs test; if Rh negative risk for anti-D isoimmunization
1st trimester lab tests: STDs
cervical cultures --> chlamydia and gonorrhea
syphilis --> VDRL; if positive --> MHA-TP or FTA-ABS
hepatitis B --> HbsAg
HIV (requires consent) --> screen with ELISA; if positive --> western blot
1st trimester lab tests: urine
urinalysis --> suggests renal disease, diabetes, infection
urine culture --> to screen for asymptomatic bacteriuria (8% of pregnant women)
1st trimester lab tests: TB
PPD --> done in high-risk populations, not routinely
if positive PPD --> chest x-ray
if chest x-ray negative --> INH + B6 9 months
if chest x-ray positive --> sputum culture and triple therapy until cultures return
1st trimester lab tests: cervical pap smear
to identify cervical dysplasia or malignancy
routine 1st trimester lab tests
complete CBC
rubella IgG
cervical culture (chlamydia, gonorrhea)
urine culture
cervical pap smear
2nd trimester lab tests: MS-AFP
elective prenatal test; (only 20% sensitivity for trisomy 21)
detects neural tube defects, ventral wall defects, twin pregnancy, placental bleeding, fetal renal disease, teratoma

if >2.5 MoM --> ultrasound to confirm gestational age
if error --> re-do MS-AFP
if correct --> amniocentesis for AF-AFP and AF acetylcholinesterase (NTD)

if <0.85 MoM --> ultrasound to confirm gestational age
if error --> re-do MS-AFP
if correct --> amniocentesis for karyotype (trisomy 21)
triple marker screen
window is 15-20 weeks
MS-AFP, hCG and estriol
trisomy 21 --> low MS-AFP and estriol with high hCG; perform amniocentesis for karyotype
trisomy 18 --> all markers are decreased; perform amniocentesis for karyotype
quadruple marker screen --> inhibin A; increases sensitivity for Down to 80%
gestational diabetes testing
1-h 50g oral glucose tolerance test --> screening test to all pregnant women between 24-28weeks
if >140mg/dL at 1 hour --> 3-h 100g oral glucose tolerance confirmatory test after overnight fast
if fasting blood glucose >125mg/dL --> diabetes mellitus; no further testing required
else --> FBS: <95mg/dL 1h: <180mg/dL 2h: <155mg/dL 3h: <140mg/dL
if one abnormal value --> impaired glucose tolerance
if two abnormal values --> gestational diabetes
third trimester lab tests: CBC
should be performed between 24-28weeks in all pregnancies checking for iron defficiency anemia and pregnancy induced thrombocytopenia
third trimester lab tests: atypical antibody screen
indirect Coombs test at 28 weeks for all Rh negative women
if no isoimmunization (no anti-D antibodies) --> RhoGAM
else --> RhoGAM is futile
third trimester lab tests
1h oral glucose tolerance test between 24-28weeks
atypical antibody screen + RhoGAM
late pregnancy bleeding differential diagnosis
cervical causes --> erosion, polyps, carcinoma
vaginal causes --> varicosities, lacerations
placental causes --> abruptio placenta, placenta previa, vasa previa
late pregnancy bleeding work-up
DIC work-up (platelets, PT, PTT, fibrinogen, D-dimer)
type and cross-match
sonogram for placental location
never perform digital or speculum exam until sonogram rules out placenta previa
abruptio placenta presentation
late trimester painful bleeding (external or retroplacental hematoma)
normal placental implantation
abruptio placenta diagnosis
painful late trimester bleeding with a normal fundal or lateral wall placental implantation (upper 2/3 uterus)
abruptio placenta risk factors
previous abruption
maternal trauma
premature membrane rupture
abruptio placenta management
if maternal or fetal jeopardy --> emergency cesarean
if bleeding is controlled and >36 weeks --> induce vaginal delivery with amniotomy
if mother and fetus are stable and remote from from term with subsiding signs --> conservative in-hospital observation
abruptio placenta complications
hemorrahgic shock with acute tubular necrosis and DIC
placenta previa presentation and diagnosis
late trimester painless bleeding
ultrasound shows placental implantation over the lower segment
placenta previa risk factors
previous placenta previa
multiple gestation
advanced maternal age
placenta previa management
if maternal or fetal jeopardy --> emergency cesarean delivery
if mother and fetus are stable --> conservative in-hospital observation with blood transfusions
if placental edge >2cm from internal cervical os --> vaginal delivery
if 36weeks and lung maturity confirmed by amniocentesis --> scheduled cesarean delivery
placenta previa complications
if placenta is implanted over previous uterine scar --> intractable bleeding requiring cesarean hysterectomy
if too much blood loss and hypotension ---> Sheehan or acute tubular necrosis
placenta accreta/increta/percreta
accreta (MC) --> villi invade deeper layers of endometrium but not myometrium
increta --> villi invade the myometrium but not serosa or bladder
percreta --> villi invade the serosa or bladder
vasa previa
presentation --> rupture of membranes, painless vaginal bleeding and fetal bradycardia
diagnosis --> suspected when sonogram has previously revealed a vessel crossing the membranes over internal cervical os
risk factors --> velamentous insertion of umbilical cord, accessory placental lobes, multiple gestation
management --> immediate cesarean
uterine rupture
presentation --> vaginal bleeding, loss of electronic fetal heart rate signal, abdominal pain, loss of station of fetal head
diagnosis --> surgical exploration of the uterus to identify the tear
risk factors --> classic (vertical) uterine incision, myomectomy, excessive oxytocin stimulation
management --> surgical immediate delivery with uterine repair or hysterectomy
GBS neonatal sepsis
presentation --> newborn sepsis within hours of birth with bilateral pneumonia (50%) mortality
prevention --> IV penicillin G if -->
positive GBS urine culture or previous baby with GBS sepsis
positive vaginal culture at 36-37weeks
risk factors: preterm gestation, membranes ruptured>18h, maternal fever
congenital toxoplasmosis
can only occur during the parasitemia of a primary infection
40% of pregnant women are toxoplasmosis IgG seropositive
fetal infection --> IUGR, fetal hydrops, microcephaly, itracranial calcifications
neonatal findings --> chorioretinitis, seizures, hepatosplenomegaly
prevention --> avoid infected cat feces, raw goat milk, undercooked meat
varicella infection
neonatal findings --> zigzag skin lesions, micropthalmia, chorioretinitis, extremity hypoplasia
prevention --> varicella zoster immune globulin within 96h of exposure or live-attenuated vacciine to non-pregnant with no IgG
treatment --> acyclovir if maternal varicella pneumonia, encephalitis or immunocompromised
congenital rubella
presentation --> congenital deafness, congenital cataracts, congenital heart disease
prevention --> all pregnant women should be screened for ruberlla IgG; if negative then vaccination after delivery
cytomegalovirus infection
fetal manifestations --> hydrops, IUGR, microcephaly, periventricular cerebral calcifications
neonatal findings --> sensorineural deafness; if symptomatic: petechiae, meningoencephalitis, jaundice
treatment --> ganciclovir
HIV in pregnancy
triple therapy recommended including ZDV
cesarean should be offered at 38 weeks
breast feeding should be avoided
fetal --> hydrops, macerated skin, anemia, thrombocytopenia, hepatosplenomegaly
neonatal ---> Hutchinson teeth, mullberry molars, saber shins, saddle nose, VIII nerve deafness
obstetric complications
cervical insufficiency
multiple gestations
preterm labor
premature rupture of membranes
postterm pregnancy
hypertensive complications
gestational hypertension
mild preeclampsia
severe preeclampsia
chronic hypertension
HELLP syndrome
medical complications in pregnancy
cardiac disease
thyroid disease
liver disease
cervical insufficiency
painless cervical dilation at 18-22 weeks with possible delivery of previable baby
diagnosis --> ultrasound
management --> elective cerclage or emergency cerclage if theres sonographic evidence and after ruling out labor and chorioamnionitis
multiple gestations
Di-Di twins --> 2 zygotes; two placentas seen
mono-di twins --> one zygote; one placenta, two sacs
mono-mono twins --> one zygote; one placenta, one sac
presentation --> hyperemesis gravidarum due to high beta-hCG, uterus larger than dates, high AFP
diagnosis --> more than one fetus on sonogram
management --> iron and folate, monitor blood pressure, vaginal delivery if both cephalic, else cesarean
determination of fetal risk in isoimmunization
present if:
atypical antibodies detected with indirect Coombs test
antibodies are associated with hemolytic disease of newborn
titer more than 1:8
father of baby is antigen positive

else --> no risk

if ATT <1:8 management is conservative; repeat titer monthly
determine degree of fetal anemia in isoimmunization
amniocentesis bilirubin --> indirectly indicates fetal hemolysis; plotted on Liley graph; severe anemia if zone III
PUBS --> directly measures fetal hematocrit; severe anemia if <25%
ultrasound doppler -->measures peak flow velocity of fetal blood through middle cerebral artery; higher velocity, more anemia
criteria for intervention in isoimmunization
severe fetal anemia is diagnosed when Liley Is in zone 3 or PUBS shows fetal hematocrit <25%

perform intrauterine intravascular transfusion if <34 weeks
delivery if >34 weeks
management of isoimmunization
1) determine fetal risk
2) determine degree of anemia
3) intervene if severe anemia
prevention of isoimmunization
RhoGAM routinely:
1) to Rh negative mothers at 28 weeks
2) within 72h of chorionic villus sampling, amniocentesis or D&C
3) within 72h of delivery of an Rh positive infant
preterm labor diagnosis
pregnancy 20-36 weeks
>= 3 contractions in 30 min
cervix >=2cm or changing

all three should be positive for diagnosis
preterm labor presentation
lower abdominal pain or pressure
lower back pain
increased vaginal discharge
bloody show
preterm contractions
pregnancy 20-36 weeks
>=3 contractions in 30 minutes
dilated <2cm and no change
tocolytic contraindications
obstetric --> abruptio placenta, ruptured membranes, chorioamnionitis
fetal --> lethal anomaly, fetal demise
maternal --> eclampsia, severe preeclampsia, advanced cervical dilation
tocolytic agents
may prolong pregnancy but for no more than 72h to administrate maternal IM betamethasone for lung maturation and transport mother to a facility with neonatal intesive care

magnesium sulfate
magnesium sulfate for tocolysis
competitive inhibitor of calcium
side effects --> muscle weakness, respiratory depression, pulmonary edema
contraindications --> renal insufficiency and myasthenia gravis
treat overdose with IV calcium gluconate
terbutaline for tocolysis
depends on myometrial beta2 receptor activity
side effects --> hypertension, tachycardia, hyperglycemia, hypokalemia
contraindications --> cardiac disease, diabetes, uncontrolled hyperthyroidism
calcium channel blockers for tocolysis
side effects --> tachycardia, hypotension, myocardial depression
contraindications --> hypotension
indomethacin for tocolysis
decreases prostaglandin production
side effects --> oligohydramnios, PDA closure in utero
contraindications --> gestational age >32 weeks
preterm labor management
confirm labor with specific criteria
rule out contraindications for tocolysis
IV hydration with IV fluids
magnesium sulfate 5g IV for 20 minutes then 2g/h
cervical and urine cultures for GBS prophylaxis
maternal IM betamethasone if <34 weeks
preterm labor prevention
women with history of previous preterm delivery should receive IM 17alpha-OH progesterone starting at 20 weeks
premature rupture of membranes presentation
sudden gush of copious vaginal fluid
clear fluid flowing out of vagina
oligohydramnios seen in ultrasound
premature rupture of membranes diagnosis
sterile speculum exam showing:
1) posterior fornix pooling of amniotic fluid
2) nitrazine positive fluid turns pH-sensitive paper blue
3) fern positive pattern when fluid is allowed to dry on glass slide
chorioamnionitis diagnosis
need all criteria:
maternal fever and uterine tenderness
in the presence of PROM
in the absence of a URI or UTI
PROM management
if uterine contractions are present --> tocolysis is contraindicated
if chorioamnionitis is present --> cervical cultures, IV antibiotics and prompt delivery
if infection is absent and <24 weeks --> induce labor or manage with bed rest
if 24-33 weeks --> bed rest, IM betamethasone, cervical cultures, 7-day prophylactic ampicillin+erythromycin
if >34 weeks --> initiate prompt delivery with oxytocin or prostaglandins or cesarean
postterm pregnancy
>40 weeks from conception or >42 mentrual weeks
can predispose to macrosomia (viable placenta) or dysmaturity syndrome (decaying placenta)
if sure date and favorable cervix --> induce labor with oxytocin and artificial rupture of membranes
else --> conservative
gestational hypertension
pregnancy >20weeks
nonsustained BP >140/90 without proteinuria
conservative management and preeclampsia should ruled out
mild preeclampsia
pregnancy >20weeks
sustained hypertension >140/90 with proteinuria 1-2+ or >300mg on 24h urine
if stable and <36w --> conservative management and no antihypertensive or MgSO4
if >36w --> induce labor with dilute oxytocin and IV MgSO4 to prevent eclamptic seizures
severe preeclampsia
preganancy >20weeks
sustained hypertension >160/110 + >300mg proteinuria
sustained hypertension >140/90 + 3-4+ or >5g proteinuria
sustained hypertension >140/90 with headache, epigastric pain, visual changes, DIC, elevated liver enzymes or pulmonary edema
if maternal or fetal jeopardy --> IV MgSO4, hydralazine/labetalol and prompt delivery
if no maternal or fetal jeopardy and 26-34 weeks --> conservative if BP can be lowered, IV MgSO4 and IM betamethasone
unexplained grand mal tonic clonic seizures + hypertension + proteinuria
first step in management --> protect mother's airway and tongue
aggressive prompt delivery
lower diastolic BP with IV hydralazine or labetalol
chronic hypertension
BP >140/90 with onset before 20 weeks
superimposed preeclampsia --> worsening BP, worsening proteinuria or maternal jeopardy
antihypertensive drugs in pregnancy
if mild to moderate HTN --> may discontinue medications if theres normal decrease in BP
if severe hypertension --> methyldopa
ACEIs and diuretics are contraindicated in pregnancy
BP target is diastolic between 90-100
chronic hypertension management
if uncomplicated --> conservative; discontinuation of antihypertensives, serial sonograms, serial BP and urinalysis
if superimposed preeclampsia --> MgSO4, hydralazine/labetalol and prompt delivery
HELLP syndrome
complication of preeclampsia
hemolysis + elevated liver enzymes + thrombocytopenia
manage with prompt delivery
antepartum maternal overt diabetes measures
Hemoglobin A1c on first visit and each trimester
early pregancy baseline 24h urine protein to assess renal status
assess retinal status with fundoscopy
home blood glucose monitoring
antepartum fetal assesment in overt diabetes
triple marker screen at 16-18 weeks for NTDs
targetted ultrasound at 18-20 weeks
if glycosylated hemoglobin is high --> fetal echo at 22-24 weeks
monthly sonogram for macrosomy or IUGR
no increased risk of anomalies in gestational DM because anomalies are in first trimester
intrapartum management of overt DM
lung maturity is often delayed
target delivery date is 40 weeks
amniocentesis for lecithin/sphingomyelin ration of 2.5 in the presence of phosphatidyl glycerol assures lung maturity
cesarean is considered if macrosomia
postpartum management of overt DM
watch for uterine atony related to overdistended uterus which causes postpartum hemorrhage
falling levels of hPL decreases insulin resistance so turn off insulin infussion
neonatal complications of overt DM
hypoglycemia due to hyperinsulinism
hypocalcemia due to failure of parathyroids
polycythemia due to high erythropoietin from relative hypoxia
respiratory distress syndrome due to low surfactant
iron deficiency anemia
general malaise, palpitations, andkle edema
hemoglobin <10g, MCV <80, RDW >15%
FeSO4 325mg po tid
prevent with elemental iron 30mg/day
folate deficiency anemia
malaise, palpitations, ankle edema
hemoglobin <10g, MCV >100, RDW >15%
fetal effects --> low birth-weight, NTDs
treatment --> folate 1mg po/day
prevent --> folate 0.4mg po/day; 4mg if risk of NTDs
sickle cell anemia
screening --> peripheral test to detect hemoglobin S
final diagnosis --> hemoglobin electrophoresis to differentiate between SA trait and SS disease
complications --> spontaneous abortions, IUGR, fetal deaths, preterm delivery
treatment --> avoid hypoxia, folate supplements, monitor fetal well being
intrahepatic cholestasis of pregnancy
intractable pruritus on the palms and soles, worst at night, without rash
diagnosis --> markedly increased serum bile acids, mild bilirubin elevation
treatment --> gold standard is ursodeoxycholic acid; may also use cholestyramine and antihistamines in mild cases
acute fatty liver
nonspecific --> nausea, vomit, anorexia, epigastric pain
hypertension, proteinuria, edema can mimic preeclampsia but hypoglycemia and high serum ammonia are specific
can also have acute renal failure, pancreatitis, hepatic encephalopathy, coma
moderate elevation of liver enzymes, hyperbilirubinemia and DIC
prompt delivery is indicated
asymptomatic bacteriuria
no urgency, frequency or burning
no fever
positive urine culture with >100K CFU
single antibiotic treatment
acute cystitis
urgency, frequency, burning
no fever
positive urine culture with >100K CFU
antibiotic monotherapy
acute pyelonephritis
urgency, frequency, burning
systemic signs --> fever with chills, anorexia, nausea, vomit, flank pain
positive urine culture with >100K CFU
hospital admission, hydration, IV antibiotics and tocolysis if needed
thrombophilia etiology and pregnancy complications
factor V Leiden
prothrombin mutations
antithrombin III deficiency
protein C/S deficiency
antiphospholipid syndrome

complications --> first trimester miscarriages, stillbirths, placental abruption, preeclampsia, pulmonary embolus (MC COD in pregnant women)
thrombophilia diagnosis
all pregnant women with blood clot should be tested for:
factor V Leiden and prothrombin gene mutations
antithrombin III, protein C, protein S deficiency
antiphospholipid syndrome

recommended testing if:
familiy history of thrombosis, pulmonary embolism, thrombophilias or pregnancy complications
thrombophilia treatment
subcutaneous heparin +- aspirin
low-molecular weight is better than unfractionated
monitor blood levels for anticoagulation effect
warfarin postpartum 6-8 weeks
superficial thrombophlebitis
localized pain and sensitivity, erythema, tenderness, swelling
diagnosis of exclusion after ruling out DVT with doppler or venography
manage with bed rest, local heat and NSAIDs
deep venous thrombosis
pain and increased skin sensitivity, calf pain
diagnosis --> duplex Doppler (above knee) or venography (below knee); perform thrombophilia work-up
treatment --> IV heparin
pulmonary embolus
chest pain, dyspnea, tachypnea, normal x-ray, low pO2 on ABG, tachycardia
diagnosis --> initially spiral CT
if CT negative and high risk symptomatic patient --> pulmonary angiography
perform thrombophilia work-up
management --> IV heparin
IUGR definition and etiology
estimated fetal weight <5-10th percentile for gestational age
or birth weight <2,500grams
fetal causes --> aneuploidy, TORCH, structural anomalies --> symmetrical
placental causes --> infarction, abruption, twin-twin transfusion --> asymmetric
maternal causes --> hypertension, small vessel disease, malnutrition, tobacco, alcohol, drugs
symmetrical IUGR
all ultrasound parameters are smaller than expected
workup --> detailed sonogram, karyotype, screen for fetal infections
asymmetrical IUGR
head sparing but abdomen small
serial sonograms, non-stress tests, amniotic fluid index (decreased), biophysical profile, umbilical artery Doppler
macrosomia definition and risk factors
estimated fetal weight >90-95th percentile for gestational age
or birth weight >4,000-4,500 grams

risk factors --> gestational or overt diabetes, prolonged gestation, obesity, weight gain
macrosomia complications and management
maternal --> operative vaginal delivery, perineal lacerations, postpartum hemorrhage, emergency C-section
fetal --> shoulder dystocia, birth injury, asphyxia
neonatal --> intensive care admission, hypoglycemia, Erb palsy

manage with C-section
nonstress tests
reactive NST:
>=2 accelerations in 20 min; >10 or 15 beats/min for >10 or 15 seconds
interpretation --> reassuring of fetal well-being
repeat weekly or biweekly

non-reactive NST:
no accelerations or did not meet criteria
interpretation --> sleeping fetus, immature, sedated
perform vibroacoustic stimulation test
if still not reactive --> biophysical profile
amniotic fluid index
<5cm --> oligohydramnios
5-8cm --> borderline
9-25cm --> normal
>25cm --> polyhydramnios
biophysical profile
NST, amniotic fluid volume, fetal gross body movements, fetal extremity tone and fetal breathing movements

8-10 --> highly reassuring; repeat weekly or as indicated
4-6 --> worriesome; delivery if >36weeks or repeat in 12-24 hours
0-2 --> fetal hypoxia; prompt delivery regardless of age
contraction stress test
negative CST:
no late decelerations in the presence of 3 contractions in 10min
reassuring of fetal well being
repeat CST weekly

positive CST:
repetitive late decelerations in the presence of 3 contractions in 10min
worriesome, especially in nonreactive NST
prompt delivery
contraction stress test indications and contraindications
indication --> BPP 4-6

contraindications --> should not stimulate contractions if:
previous classical uterine incision
previous myomectomy
placenta previa
incompetent cervix
preterm membrane rupture
preterm labor
umbilical artery Doppler
absent or reversed diastolic flow is predicitive of poor perinatal outcome only in IUGR fetuses
types of pelvis
gynecoid, android, anthropoid, platypelloid
fetal lie
longitudinal --> fetus and mother in same vertical axis
transverse --> fetus at right angles to mother
oblique --> fetus at 45 degree angle to mother
fetal presentation
cephalic --> head first; most common
frank breech --> thighs flexed, legs extended
complete breech --> thighs and legs are flexed
footling breech --> thighs and legs are extended
compound --> more than one anatomic part is presenting
shoulder --> shoulder first
fetal position
occiput anterior or posterior --> flexed head on cephalic presentation
sacrum anterior or posterior --> breech presentation
mentum anterior or posterior --> extended head on face presentation
definition of labor
effacement and dilation of the cervix with uterine contractions at least every 5min lasting 30s; resulting in delivery of fetus and expulsion of placenta
physiology of labor
increasing frequency of contractions
formation of gap junctions between uterine myometrial cells
increasing levels of oxytocin and prostaglandins
multiplications of specific receptors
upper uterine segment --> contractile, mostly smooth muscle, thickens
lower uterine segment --> passively thins out, mostly collagen fibers
cervical effacement and dilation
0% effacement --> cervix is 2cmX2cm; oxytocin and prostaglandins break dissulfide likanges of collagen fibers
dilation --> complete dilation is 10cm as lower uterus is thinned and pulled up by upper uterus
movements of labor
1) engagement --> presenting part moves below pelvic inlet
2) descent --> presenting part moves through curve of birth canal
3) flexion --> fetal chin on thorax
4) internal rotation --> fetal head from transverse to antero-posterior in mid pelvis
5) extension --> fetal chin moves away from thorax
6) external rotation --> fetal head rotates after passing pelvic outlet
7) expulsion --> delivery of fetal shoulders and body
stages of labor
stage 1 latent phase --> regular uterine contractions-acceleration of cervical dilation; <14-20 hours
stage 1 active phase --> acceleration-10cm dilation; >1.2-1.5cm/hour
stage 2 descent --> 10cm dilation-delivery; 1-2 hours
stage 3 expulsion --> delivery of baby-delivery of placenta; <30min
stage 4 --> 2h observation period
management of labor
preadmission --> not admitted until cervical dilation is 3cm unless ROM; presentation is confirmed
admission --> IV access
first stage --> assess fetal heart rate and perform serial vaginal exams checking dilation and descent
stages 2 and 3 --> pushing efforts; episiotomy might be performed; IV oxytocin after delivery of placenta
prolonged latent phase
pregnant with regular uterine contractions
cervix dilated 2cm
no cervical change in 14 or 20 hours

management --> rest and sedation
prolonged active phase
pregnant with regular uterine contractions
cervix dilated >3cm
cervical dilation <1.2 or 1.5cm

normal contractions --> 2-3min, 45-60sesc, 50mmHg
if hypotonic --> IV oxytocin
if hypertonic --> morphine
if adequate --> emergency cesarean
active phase arrest
pregnant with regular uterine contractions
cervix dilated >3cm
cervical dilation not changed for >2h

normal contractions --> 2-3min, 45-60sesc, 50mmHg
if hypotonic --> IV oxytocin
if hypertonic --> morphine
if adequate --> emergency cesarean
stage 2 arrest
pregnant with regular uterine contractions
10cm dilation at +1 station
no descent change in 3h

IV oxytocin enhanced coaching
if adequate and head not engaged --> emergency cesarean
if adequate and head engaged --> obstetric forceps or vacuum extractor
prolonged third stage
failure to deliver plaenta within 30 minutes in spite of oxytocin
suspect placenta acreta, increta or percreta
may require manual placental removal or hysterectomy
prolapsed umbilical cord
pregnnt with regular uterine contractions
amniotomy at -2 station
severe variable decelerations

management --> don't hold the cord or push back into uterus; place patient in knee-chest position; elevate presenting part and perform immediate cesarean delivery
shoulder dystocia
second stage of labor
head has delivered
no further delivery of body

management --> suprapubic pressure; maternal thigh flexion; internal rotation of fetal shoulder
obstetric lacerations
first degree --> vaginal mucosa
second degree --> vagina and muscles of perineal body
third degreee --> vagina, perineal muscles, anal sphincter
fourth degree --> vagina, perineal muscles, anal sphincter and rectal mucosa
obstetric anesthesia physiology
stage 1 --> T10-T12
stage 2 --> S2-S4
pregnancy predisposes to hypoxia
medications can pass the placenta to fetus
give antacids prophylactically
uterus should be laterally displaced
IV anesthetics
narcotics and sedatives
active phase
neonate may need naloxone antidote
paracervical block
bilateral transvaginal injection to block Frankenhauser ganglion
active phase
transitory fetal bradycardia
pudendal block
bilteral transvaginal injection to block pudendal nerve at ischial spine
stage 2
epidural block
injection into epidural space to block lumbosacral roots
stages 1 and 2
side effects --> hypotension (treat with IV fluids and ephedrine); spinal headache
spinal block
injection into subarachnoid space to block lumbosacral roots
stage 2
side effects --> hypotension
types of decelerations
early --> with contractions
variable --> before or with contractions
late --> after contractions (non reassuring)
reassuring FHR tracings
baseline rate 110-160/min
no decelerations
variability is present
nonreassuring FHR tracings
baseline rate is tachycardia or bradycardia
accelerations absent
repetitive variable decelerations
repetitive late decelerations
variability is absent
intrauterine resuscitation
decrease uterine contractions --> turn off oxytocin or administer 0.25 terbutaline
500mL bolus of normal saline
8-10L O2 by facemask
lateral position
vaginal exam to rule out prolapsed umbilical cord
scalp stimulation
fetal pH assessment
normal fetal pH is 7.2 or more
fetal scalp blood pH
postpartum umbilical arter blood pH
management of nonreassuring fetal monitoring tracings
intrauterine resuscitation
if no normalization --> prompt delivery
forceps or vaccum extractor indications
prolonged second stage (MC indication)
nonreassuring FHM tracings
to avoid maternal pushing
breech presentation
indications for cesarean
cephalopelvic disproportion
nonreassuring tracings
presentations other than cephalic
uterine atony
risks --> rapid labor, chorioamnionitis, MgSO4, halothane, overdistended uterus
soft uterus palpable over the umbilicus
treat with uterine massage and oxytocin, methylergonovine or carboprost
risks --> uncontrolled vaginal delivery, operative vaginal delivery
identifiable lacerations in the presence of a contracted uterus
treat with surgical repair
retained placenta
missing placental cotyledons in the presence of contracted uterus
treat with manual removal or uterine curetagge by sonogram
uterine inversion
bleeding mass in the vagina and failure to palpate uterus
treat by lifting uterus back to its position and giving oxytocin
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