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What are the contraindications to labor induction?
- Maternal:
- 1. Contracted pelvis
- 2. Prior uterine surgery (controversial)
- 3. Classic c-section
- 4. Myomectomy with endometrial cavity violation
- Fetal:
- 1. Lung immaturity
- 2. Acute distress
- 3. Abnormal presentation
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What are the fetal indications for labor induction?
- 1. IUGR
- 2. Abnormal fetal testing
- 3. Infection
- 4. Rh incompatibility
- 5. Oligohydramnios
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What are the maternal indications for induction of labor?
- 1. Premature ROM
- 2. DM
- 3. Heart disease
- 4. Prolonged labor
- 5. Prolonged pregnancy
- 6. Worsening/severe preeclampsia
- 7. Post term
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When is an emergency c-section required in the case of a deceleration?
If a deceleration occurs without recovery after 2 minutes
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What may cause active phase abnormalities?
- 1. Cephalopelvic disproportion
- 2. excessive sedation
- 3. conduction analgesia
- 4. fetal malposition
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What are arrest disorders?
Complete cessation of dilation or descent
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What are protraction disorders?
a slow rate of cervical dilation or descent
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What is a prolonged deceleration phase and how is it treated?
- Nulliparas >3 hrs
- Multiparas > 1hr
- Preferred: w/o cephalopelvic disproportion: Oxytocin
- Exceptional: rest if exhausted
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What are protracted active phase dilatation disorder, and protracted descent and how are they treated?
- Active phase dilatation:
- Nulliparas: <1.2 cm/hr
- Multiparas: <1.5 cm/hr
- Protracted descent:
- Nulliparas: <1cm/hr
- Multiparas: <2 cm/hr
- Preferred tx: expectant and support
- Exceptional tx: c-section for cephalopelvic disproportion.
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What is prolongation disorder(prolonged latent phase) and how is it treated?
- For Nulliparas: >20 hrs
- Multiparas: >14 hrs
- Preferred Tx: therapeutic rest
- Exceptional Tx: oxytocin stimulation or cesarean delivery for urgent problems.
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What causes prolonged decelerations (isolated decelerations lasting 2-10 minutes)?
- 1. Cervical exams
- 2. uterine hyperactivity
- 3. maternal hypotension leading to transient fetal hypoxia.
- 4. Umbilical cord compression.
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What is thought to be the most important predictor of fetal outcome?
Short-term variability
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What increases Beat to beat variability?
mild fetal hypoxia.
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What causes decreases in beat to beat variability?
- 1. Fetal acidemia
- 2. Fetal asphyxia
- 3. Maternal acidemia
- 4 Drugs (narcotics, MgSO4, barbituates etc
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What does an absence of beat to beat variability indicate?
- Fetal acidosis!
- The fetus must be delivered immediately.
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What is the single most important characteristic of the baseline fetal heart rate?
- Beat-to-beat variability.
- *Variation in successive beats in the FHR BTBV is controlled primarily by the autonomic nervous system, thus an important index of fetal central nervous system integrity.
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Define fetal tachycardia
- Mild: 161-180 bpm
- Severe > 181
*May indicate intrauterine infection, severe fetal hypoxia, congenital heart disease, or maternal fever.
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Which types of deceleration are abnormal?
Late decelerations- due to uteroplacental insufficiency. Begin at peak of contraction and end slowly after contraction has stopped.
Variable decelerations- due to cord compression and sometimes head compression. Can occur at any time. Intervention is amnioinfusion with normal saline.
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At what GA does the fetus start to have a reactive fetal heart rate?
- 28 weeks.
- Before this, the fetus is neurologically immature and not reactive.
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What are contraindications to breastfeeding?
Infection: CMV, HBV, HIV, Breast lesions from active herpes simplex, TB(active, untreated)
Medications: bromocriptine, cyclophosphamide, cyclosporine, doxorubicin, ergotamine, lithium, methotrexate.
Drug Abuse: amphetamines, cocaine, heroine, marijuana, nicotine, phencyclidine, ethanol
Radiotherapy: Gallium, indium, iodine, radioactive sodium, technetium
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How many extra nutritious calories are needed per day in nursing mothers?
500
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Should women with a common cold stop breastfeeding?
No!
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What viruses are secreted in breast milk?
CMV, HBV, and HIV
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What concerns must be addressed regarding the infant before discharge from the hospital?
- All labs should be normal: Coomb's test, Bilirubin, Hemoglobin and hematocrit, blood glucose
- Maternal serologic tests for syphilis and HbsAg should be nonreactive.
- Initial HBV vaccine should be administered.
- All screening tests required by law should be done (eg testing for PKU and hypothyroidism)
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When may a woman engage in sexual intercourse postpartum?
After 6 weeks.
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What is the advantage of progestin-only OCP's versus combined OCPs in postpartum?
Progestin only pills are virtually 100% effective w/o substantially reducing the amount of breast milk.
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What can occur if postpartum uterine contraction is inadequate?
Postpartum bleeding
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When should a woman go to the hospital post-partum?
- If she experiences:
- Fever
- Excessive vaginal bleeding
- Lower extremity pain and or swelling
- Shortness of breath
- Chest pain
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When is the liklihood of significant hemorrhage greatest?
Immediately postpartum
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How long should iron supplementation be continued post-partum
For at least 3 months.
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What should be monitored in the first hour after delivery?
- 1. Maternal BP and HR q 15 minutes.
- 2. Monitor amount of vaginal bleeding.
- 3. Palpate fundus to ensure adequate contraction. If relaxed, uterus should be massages through abdominal wall until it remains contracted.
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When do most women return to prepregnancy weight?
6 months after delivery, but still retain about 1.4 kg excess weight.
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What external factors may influence milk letdown?
It may be provoked by the cry of an infant or inhibited by stress or fright.
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When does breast engorgment commonly occur and what are the signs?
- On days 3-4 (seldom persists for >24hours)
- It is often painful and accompanied by a transient temperature elevation.
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What changes in blood occur postpartum?
- 1. Leukocytosis occurs during and after labor (up to 30,000)
- 2. Relative lymphopenia
- 3. Absolute eosinopenia
- 4. During first few days postpartum, hemoglobin and hematocrit fluctuate moderately from levels just prior to labor.
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Can women with pituitary necrosis (Sheehan Syndrome) breast feed?
No, because of absence of prolactin, the hormone that controls lactation.
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What is colostrum and when is it secreted?
It is a deep yellow colored liquid secreted by breasts on days 2-5 postpartum, which contains minerals, protein, fat, antibodies, complement, macrophages, lymphocytes, lysozymes, lactoferrin, and lactoperoxidase.
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What causes fluid retention post-partum?
- 1. High estrogen levels in pregnancy
- 2. Increased venous pressure in the lower half of the body during pregnancy
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what is purperal diuresis and when does it occur?
It is the reversal of the increase in extracellular water associated with normal pregnancy, it occurs on days 2-5 postpartum.
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What are the types of lochia?
Lochia rubra- red due to blood in lochia, observed on days 1-3
Lochia serosa- more place in color, observed days 4-10
Lochia alba- white to yellow-white due to leukocytes and reduced fluid content, observed day 11-->
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What is the lochia?
Decidual tissue that contains erythrocytes, epithelial cells, and bacteria that becomes necrotic and sloughs off as vaginal discharge 2-3 days postpartum.
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At what point does the uterus descend back in to the cavity of the true pelvis?
2 weeks after delivery
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What are the contraindications to epidural analgesia?
- 1. Actual/anticipated serious maternal hemorrhage
- 2. infection at or near sites for puncture
- 3. suspicion of neurological disease
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What effect does epidural analgesia have on labor?
- 1. Increased duration
- 2. Increased incidence of: chorioamnionitis, low-forceps procedures, c-section, maternal pyrexia.
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What are the complications and contraindications of a spinal block?
Complications: Maternal hypotension, total spinal blockade, headache, seizures, bladder dysfunction.
Contraindications: severe preeclampsia, coagulatio/hemostasis disorders, neurologic disorders.
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What types of regional analgesia are available?
- 1. Pudendal block
- 2. Paracervical block
- 3. Spinal (subarachnoid) block
- 4. Low spinal block
- 5. High spinal block
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What regional anesthetic is preferred for nerve blocks in labor and delivery?
Bupivacaine
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What nerve gives sensory innervation to the perineum, anus, and medial and inferior parts of the vulva and clitoris?
Peripheral branches of the pudendal nerve.
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What are contraindications to VBAC?
- 1. Prior classical or t-shaped incision or other transfundal uterine surgery.
- 2. Contracted pelvis
- 3. Medical/obstetric complication that precludes vaginal delivery
- 4. Inability to perform emergency c-section b/c of unavailable surgeon, anesthesia, sufficient staff or facility.
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Who are candidates for vaginal birth after cesarean?
- 1. One or two prior low transverse c-section (LTCS)
- 2. Clinically inadequate pelvis
- 3. No other uterine scars or previous rupture.
- 4. Physician immediately available throughout active labor capable of monitoring labor and performing an emergency C-section.
- 5. Availability of anesthesia and personnel for emergency C-section.
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What are the indications for a C-section?
- 1. Prior c-section
- 2. Dystocia or failure to progress in labor
- 3. Breech presentation
- 4. transverse lie
- 5. concern for fetal well-being (fetal distress)
- 6. Uterine malformations/scars
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What percent of women are battered during pregnancy?
20%
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What is the leading preventable cause of low-birth weight in the US?
Smoking (20-30% of low birth weight)
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What are the criteria for major depression/post-partum depression?
- *2 week period of depressed mood or anhedonia nearly every day plus one of the following:
- 1. Significant wt loss or gain without effort (or increase/decrease in appetite)
- 2. Insomnia or hypersomnia
- 3. Psychomotor agitation/retardation
- 4. Fatigue or loss of energy
- 5. Feelings of worthlessness/excessive or innapropriate guilt.
- 6. Decreased ability to concentrate/think.
- 7. Recurrent thoughts of suicide/death
- *Post partum must begin w/in 3-6 monhts after childbirth.
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