First Aid for OBGYN Clerkship: Intrapartum

  1. 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
  2. What are the fetal indications for labor induction?
    • 1. IUGR
    • 2. Abnormal fetal testing
    • 3. Infection
    • 4. Rh incompatibility
    • 5. Oligohydramnios
  3. 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
  4. When is an emergency c-section required in the case of a deceleration?
    If a deceleration occurs without recovery after 2 minutes
  5. What may cause active phase abnormalities?
    • 1. Cephalopelvic disproportion
    • 2. excessive sedation
    • 3. conduction analgesia
    • 4. fetal malposition
  6. What are arrest disorders?
    Complete cessation of dilation or descent
  7. What are protraction disorders?
    a slow rate of cervical dilation or descent
  8. 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
  9. 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.
  10. 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.
  11. 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.
  12. What is thought to be the most important predictor of fetal outcome?
    Short-term variability
  13. What increases Beat to beat variability?
    mild fetal hypoxia.
  14. What causes decreases in beat to beat variability?
    • 1. Fetal acidemia
    • 2. Fetal asphyxia
    • 3. Maternal acidemia
    • 4 Drugs (narcotics, MgSO4, barbituates etc
  15. What does an absence of beat to beat variability indicate?
    • Fetal acidosis!
    • The fetus must be delivered immediately.
  16. 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.
  17. Define fetal tachycardia
    • Mild: 161-180 bpm
    • Severe > 181

    *May indicate intrauterine infection, severe fetal hypoxia, congenital heart disease, or maternal fever.
  18. 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.
  19. 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.
  20. 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
  21. How many extra nutritious calories are needed per day in nursing mothers?
  22. Should women with a common cold stop breastfeeding?
  23. What viruses are secreted in breast milk?
    CMV, HBV, and HIV
  24. 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)
  25. When may a woman engage in sexual intercourse postpartum?
    After 6 weeks.
  26. 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.
  27. What can occur if postpartum uterine contraction is inadequate?
    Postpartum bleeding
  28. 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
  29. When is the liklihood of significant hemorrhage greatest?
    Immediately postpartum
  30. How long should iron supplementation be continued post-partum
    For at least 3 months.
  31. 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.
  32. When do most women return to prepregnancy weight?
    6 months after delivery, but still retain about 1.4 kg excess weight.
  33. What external factors may influence milk letdown?
    It may be provoked by the cry of an infant or inhibited by stress or fright.
  34. 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.
  35. 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.
  36. Can women with pituitary necrosis (Sheehan Syndrome) breast feed?
    No, because of absence of prolactin, the hormone that controls lactation.
  37. 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.
  38. 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
  39. 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.
  40. 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-->
  41. 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.
  42. At what point does the uterus descend back in to the cavity of the true pelvis?
    2 weeks after delivery
  43. 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
  44. What effect does epidural analgesia have on labor?
    • 1. Increased duration
    • 2. Increased incidence of: chorioamnionitis, low-forceps procedures, c-section, maternal pyrexia.
  45. 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.
  46. 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
  47. What regional anesthetic is preferred for nerve blocks in labor and delivery?
  48. 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.
  49. 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.
  50. 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.
  51. 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
  52. What percent of women are battered during pregnancy?
  53. What is the leading preventable cause of low-birth weight in the US?
    Smoking (20-30% of low birth weight)
  54. 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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First Aid for OBGYN Clerkship: Intrapartum
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