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54 Cards in this Set
- Front
- Back
how is preterm labor different from cervical insuff?
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PTL = contractions + cervical changes
cervical insuff = painless dilation of cervix Both result in preterm labor |
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Leading cause of fetal morbidity and mortality in US
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Preterm delivery
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4 complications of preterm delivery
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RDS (hyaline membrane disease)
intraventricular hemorrhage sepsis necrotizing enterocolitis |
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Only FDA approved tocolytic
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ritodrine
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Main benefit from using tocolytics
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prolongs gestation for 48 hours to allow betamethosone (glucocorticoid) delivery --> matures fetal lungs to help reduce RDS and other complications
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3 conditions in which tocolytics should not be used despite premature labor
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chorioamnionitis, nonreassuring fetal testing, significant placental abruption
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First line treatment for patients with premature contractions without cervical change
mechanism |
hydration
ADH differs from oxytocin only by one aa, so it can actually bind oxytocin receptors and cause uterine contractions Hydration --> less ADH --> less decrease contractions If this doesn't work --> tocolytics |
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Mechanism by which PGF2a and oxytocin increase uterine contraction
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Cause Ca to be released from SR
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Mechanism by which b agonists cause uterine relaxation
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bind to B2 receptors --> AC --> cAMP --> inhibits myosin LCK and causes Ca to be pumped into SR
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2 beta mimetics used as tocolytics
a. effect b. side effects c. how are they given |
a. prolong gestation by 24 to 48 hrs (compared to hydration and bedrest)
b. tachycardia, headaches, anxiety, pulmonary edema c. ritodrine = continuous infusion Terbutaline = 0.25mg SC Q20 minutes (3 dosages), then Q3-4 hrs |
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a. How does Mg act as a tocolytic
b. Effect c. Symtpoms of overdose d. How should it be given |
a. Ca antagonist, membrane stabilizer
b. stop contractions, does not increase GA c. flushing, headache, fatigue, diploplia, loss of DTR; if >10mg/dL, respiratory distress, cardiac arrest, hyoxia d. 6g bolus over 15-30 min, then maintenance 2-3g/hr constant infusion; use slower regimen if kidney failure |
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Nifedipine
a. how does it act as a tocolytic b. side effects c. how should it be gien |
a. Block Ca channels --> inhibit myometrial contraction
b. headache, flushing, dizziness c. 10mg dose Q15min for the first hour, followed by maintenance of 10-30mg Q4-6 hr (depending on patient's BP) |
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What is the effect of PGs on the uterus
What drug is used to stop prostaglandins' effects on the uterus |
PGs increase Ca release from SR; also increase gap junction formation --> increased uterine contraction (used in the case of uterine atony)
Indomethicin = tocolytic |
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Fetal complications of using indomethicin as a tocolytic
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-Premature closure of ductus arteriosus
-pulmonary HTN -oligohydramnios secondary to renal failure -increased risk of necrotizing enterocolitis and intraventricular hemorrhage |
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3 conditions associated with prolonged PPROM
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chorioamnionitis, abruption, cord prolapse
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How does management of PPROM vary with GA
What are 2 interventions that are done at any GA |
Before 32-36weeks, risk of prematurity drives treatment
After, risk of infection drives treatment --> induce labor Ampicillin +/- erythromycin can prolong latency cortiocosteroids +/- tocolytics to promote fetal lung development (despite immunosuppression) |
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Biggest risk associated with ROM
What is an intervention for prolonged ROM (>18hrs) |
chorioamnionitis
antiobiotics during the remainder of labor |
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4 types of maternal pelvises
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Gynecoid, Android, Anthropoid, Platypelloid
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Gynecoid pelvis
a. transverse inlet b. anteriorposterior inlet c. sidewalls d. forepelvis e. sacrosciatic notch f. inclination of sacrum g. ischial sine h. suprapubic arch i. transverse outlet j. bone structure |
a. 12cm
b. 11cm c. straight d. wide e. med f. med g. not prominent h. wide i. 10cm j. med |
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Android pelvis
a. transverse inlet b. anteriorposterior inlet c. sidewalls d. forepelvis e. sacrosciatic notch f. inclination of sacrum g. ischial sine h. suprapubic arch i. transverse outlet j. bone structure |
a. 12cm
b. 11cm c. convergent d. narrow e. narrow f. forward (lower 1/3) g. not prominent h. narrow i. <10cm j. heavy |
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Anthropod
a. transverse inlet b. anteriorposterior inlet c. sidewalls d. forepelvis e. sacrosciatic notch f. inclination of sacrum g. ischial sine h. suprapubic arch i. transverse outlet j. bone structure |
a. <12cm
b. >12cm c. narrow d. divergent e. backward f. wide g. not prominent h. med i. 10cm j. med |
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Platypelloid
a. transverse inlet b. anteriorposterior inlet c. sidewalls d. forepelvis e. sacrosciatic notch f. inclination of sacrum g. ischial sine h. suprapubic arch i. transverse outlet j. bone structure |
a. 12cm
b. 10cm c. wide d. straight e. forward f. narrow g. not prominent h. wide i. 10cm j. med |
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What is the obstetric conjugate
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distance between the sacral promentory and the midpt of symphisis pubis (shortest anteroposterior diameter of inlet)
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Anteropost. measurement of outlet
a. landmarks b. measurement |
Tip of sacrum to inferior margin of pubic symphisis
9.5-11.5 cm |
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What is the protocol when celphalopelvic disproportion presents?
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Attempt a trial of labor, then do c/s if necessary
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2 complications of vaginal breech delivery
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prolapsed cord, entrapment of head
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3 types of breech
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complete, footling (one or both hips not flexed, so foot/knee lies below breech), frank (feet near fetal head)
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How is breech diagnosed
treatments |
Leopold maneuvers determine where felal head is, vaginal exam to feel breech, ultrasound
external cephalic version of breech (before 36 weeks), trial of labor (higher rate of morbidity/mortality), or elective c/s |
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3 complications of a breech delivery
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cord prolapse, entrapment of fetal head, fetal neurological injury
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Common criteria for trial og labor in a breech
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favorablepelvis, flexed head, estimated fetal weight 2k-3800 lbs
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Contraindications to breech birth
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nulliparity, incomplete breech presentation, estimated fetal wt >3800g
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4 types of presentations seen in malpresentation of the vertex
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face, brow, shoulder, compound
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Fetus presents with face malpresentation
a. what is the course if it is mentum first b. what is the course if mentum posterior or transverse |
a. anterior - vaginal
b. fetus must rotate to mentum anterior |
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What must happen to deliver a baby w/brow presentation
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brow presentation must convert to vertex or face
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3 risks of shoulder presentation
how are these babies delivered |
cord prolapse, uterine rupture, difficulty in vaginal delivery
c/s |
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Common complication of compound presentation of fetus
treatment |
cord prolapse
if foot presents = footling breech --> c/s if upper extremity, part may be gently reduced |
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Baby presents at persistent OT position
a. associated commonly with which type of pelvis b. what should you do |
a. platellypoid
b. cervix not fully dilated - attempt to manually rotate to OA if fully dilated, attempt to rotate manually or w/forceps; try vaccuum delivery |
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Definition of FHR
a. prolonged deceleration b. bradycardia |
FHR <100-110 for
a. >2mins b. > 10mins |
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3 etiologies of prolonged FHR decelerations
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1. preuterine - maternal HTN or hypoxia (seizure, amniotic fluid embolus, PE, MI, resp. failure, epidural/spinal anesthesia)
2. Uteroplacental = abruption, infarction, hemorrhaging previa, uterine hyperstimulation 3. Post placental = Cord prolapse, cord compression, rupture of fetal vessel |
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FHR shows bradycardia
What should you do (algorithm)? |
1. Look at mom for signs of respiratory compromise/change in mental status (seizures, PE, AFE)
2. asses mom HR and BP (maternal hypotension, commonly seen after epidural) 3. Check vaginal blood (abruption, uterine rupture, rupture of fetal vessels) 4. One hand on abdomen and one hand on vagina --> measure station, cervical dilation, prolapsed umbilical if fetal station is too low --> bradycardia due to rapid descent, vagal if station too high --> uterine rupture if cervix is fully dilated and fetus in pelvis --> operative vaginal delivery |
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Prolonged FHR deceleration
what is the initial standardized management procedure |
1. place mom in R or L lateral decubitus to reduce compression of IVC or of a compressed umbilical cord
2. Oxygen face mask 3. determine etiology and proceed |
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Prolonged FHR deceleration treatment
maternal hypotension |
aggressive IV hydration, ephedrine
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Prolonged FHR deceleration treatment
tetanic uterine contraction |
nitroglycerin (sublingual spray) or b2 agonist (terbutaline)
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Prolonged FHR deceleration treatment
umbilical cord prolapse |
emergent c/s
lift fetal head do avoid compression of prolapsed cord |
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Prolonged FHR deceleration treatment
previa |
c/s fast
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Prolonged FHR deceleration treatment
abruption |
c/s fast
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What is shoulder distocia
fetal complications |
fetal shoulder gets stuck behind pubic symphisis
fractured humerus/clavicle, erb palsy, phrenic nerve palsy, hypoxic brain injury, death |
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What is the turtle sign and what does it indicate
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incomplete delivery of the head or chin tucking up against maternal perineum --> shoulder distocia
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5 maneuvers to try in the case of a shoulder distocia
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1. McRoberts = flexion of maternal hips to open outlet
2. suprapubic pressure at an oblique angle 3. rubin's - pushing free shoulder toward anterior chest wall to decrease shoulder-shoulder diameter 4. Wood's corkscrew - pressure behind posterior shoulder to rotate infant and dislodge anterior shoulder 5. deliver posterior arm/shoulder, then rotate to decrease shoulder-shoulder distance |
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What is the zavanelli maneuver and when is it used
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last resort in shoulder distocia
push head back into pelvis and perform c/s |
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What are factors that make you believe a uterine rupture has taken place
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-FHR decels
-prior scars on uterus -patient feels 'popping' or severe abd pain -fetus palpable in extrauterine space -vaginal bleeding -fetal presenting part is higher than previously |
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What is the mark of unusually low BP in a pregnant woman
Treatment? What if it is close to a medication administration? |
80/40
IV hydration, adrenergic meds to constrict peripheral vessels and increase preload/afterload Benadryl or ephedrine (for possible anaphylaxis) |
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Definitive diagnosis for Amniotic fluid embolism
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fetal cells in pulmonary vasculature at autopsy
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Managment of a patient w/seizures or in status epilepticus
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1. Assess and establish airway, vitals, FHR (if non-reassuring, emergent delivery)
2. Bolus Mg sulfate, lorazepam, phenytoin -If not successful, phenobarbitol 3. Labs - electrolytes AED, glucose, tox |