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OB GYN > abnormal labour + delivery + ob emergencies part 1 > Flashcards

abnormal labour + delivery + ob emergencies part 1 Flashcards

1
Q

labour dystocia defintion

A

active first stage:
>4 hrs of <0.5cm/hour dilatation

during pushing:
>1 hr no fetal descent

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2
Q

definition of labour

A

uterine activity resulting in progressive dilatation and effacement of the cervix + descent of fetus

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3
Q

definition of 1st stage

A

onset until 3-4cm/4-5cm for multip

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4
Q

the 4 P’s of dystocia

A

Power - hypotonic, incoordinate contractions, poor maternal effort

Passenger - fetal position, attitude, size, anomalies (hydrocephalus)

Passage - pelvic structure, soft tissue (masses, full bladder, septum)

Psyche - anxiety, stress, pain

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5
Q

evalutation of patient with dystocia

A

review labour record

assess mom - vitals, ctxns, membranes, cervix, pelvis

asses baby - NST, station, presentation and position

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6
Q

management options for dystocia

A
  • AROM
  • pain relief
  • hydration
  • oxytocin
  • operative delivery (CS or vaginal if fully)
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7
Q

C/I to oxytocin & AE

A 
severe vag bleed
placenta previa
hypotension
abnormal lie
prior classical or inverted T uterine incision
pelvis that obstructs labour
adverse effects:
fetal comprise
hyperstim (ctxn >2min or >5/min)
water intoxication (ADH effect)
uterine rupture
hypotension (vasodilation)
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8
Q

oxytocin dosing example

A

initial:
1-2mU/min
increase every 30min by 1-2

usual dose for good labour: 8-12

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9
Q

indications for forceps or vacuum

A

fetal compromise requiring immediate delivery

dystocia in second stage

conditions requiring short second stage or C/I pushing

inefficient maternal effort

note: vacuum requires maternal effort

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10
Q

c/i to operative delivery

A

non-cephalic presentation (face/brow)

unengaged head

incomplete dilatation

low probability of success

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11
Q

C/I for vacuum

A

<34 weeks

deflexed head

need for rotation

fetal conditions (bleed or demineralization disorder)

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12
Q

pre-requisites for vacuum or forceps

A

consent

vertex

engaged

term/near term

dilated + ruptured

anesthesia

adequate pelvis

known station and position

empty bladder

backup plan

continuous assessment

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13
Q

risks of assisted vag birth

A

soft tissue trauma

fetal scalp trauma

intraventricular hemorrhage (/w multiple procedures)

fetal subgaleal or subaponeurotic hemorrhage with vacuum

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14
Q

common indications for C/S

A

repeat CS
dystocia
malpresentation
non-reassuring fetal status

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15
Q

absolute indications for CS

A 
previa
cord prolapse
prev uterine surgery
prior classical CS
prev uterine rupture
most malpresentations
obstructed pelvis
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16
Q

relative indications for CS

A 
failed induction
abnormal progression
pre-eclampsia
DM
cardiac disease
abruption
multiples
17
Q

types of incisions

A

transverse lower uterine segment

classical vertical

combo (inverted T)

18
Q

C/S risks

A 
infection
hemorrhage
atelectasis
injury to bowel, bladder, ureter
DVT/PE
longer recovery

all increased if follow trial of labour

19
Q

non-pharmacologic pain relief in labour

A

position change, movement
counter-pressure
abdominal decompression

cold/heat
immersion in water
acupuncture/pressure
touch/massage
TENS
intradermal injection of sterile water
aromatherapy

attention focus/distrction
hypnosis
music
biofeedback

20
Q

pharmacologic pain management

A

NO - self administered, deep inhalation /w ctxn, use in late 1st stage of labour

narcotics - given IV + PCA, /w antiemetic, decreases fetal hear variability, neonatal resp depression

pudendal nerve block - analgesia of perineum in second stage, if other analgesia not available/ineffective, or for forceps/vacuum

perineal infiltration - for repair

regional - epidural block

spinal - for CS (if epidural not in place)

GA - for emergency CS

21
Q

Absolute CI to VBAC

A

prev classical, T, unknown incision

other uterine surgery entering cavity

prev rupture

opinion of prev surgeon (get post op note)

mother desires CS

22
Q

Relative CI to VBAC

A

induction required

2+ CS

Multiples

breech

prev poor OB hx

patient desires tubal ligation

23
Q

risks of VBAC

A

prolonged labour

maternal fever/infection

failed trial –> repeat section riskier after labour

uterine rupture: hemorrhage, fetal morbidity/death, CS, hysterectomy possibly

24
Q

benefits of VBAC

A

reduced intervention + its risks

faster recovery

25
Q

risks of elective repeat CS

A

increased risk of injury to pelvic structures (scarring)

increased risk of hemorrhage

+ regular risks

26
Q

signs of uterine rupture

A

profound fetal bradycardia without recovery

lower abdo pain

cessation of contractions

vag bleeding

recession of presenting part

intra-abdominal hemorrhage, hypovolemic shock

27
Q

causes of uterine rupture

A

scar: CS, mymoectomy, perf in D&C, salpingectomy /w cornual resection

excessive contraction: oxytocin, prostaglandins, neglected obstructed labour

trauma: ECV, forceps, manual removal of placenta, trauma

multiparity, uterine anomalies, placenta accreta

28
Q

management of uterine rupture

A

stabilize mother, tx hypovolemia

call for assistance

emergency laparotomy to deliver fetus, placenta, repair uterus

29
Q

emergent indications for labour induction

A

severe GH or pre-eclampsia

suspected fetal compromise

severe IUGR

maternal disease

large antepartum hemorrhage

chorioamnionitis

30
Q

urgent indications for induction

A

prelabour ROM

IUGR

poorly controlled DM

iso-immune disease

31
Q

non-urgent indications for induction

A

prolonged preg

well controlled DM

prior intrauterine death

logistical problems (rapid labour)

32
Q

CI to induction

A
  • placenta/vasa previa, cord presentation
  • abnormal lie
  • prior classical/T CS
  • uterine surgery
  • active herpes
  • pelvis deformity
  • invasive cervical cancer
33
Q

risks of induction

A
  • failure
  • cord prolapse /w ARM
  • uterine hyperstim (fetal compromise, rupture)
  • inadvertent delivery of preterm if dates wrong
  • maternal side effects from meds
34
Q

methods of labour induction

A

1) ARM if possible (cervix open, soft ,membranes felt, head well applied), + oxytocin

2) if no arm, use cervical ripening first (then ARM + pit)
- prostaglandins (PGE1 = miso, PGE2 = prostin gel, cervidil)
- foley catheter
- oxytocin infusion – not as successful

35
Q

definition of post-term

A

> 42+0

36
Q

risks of post-term

A

death: anomalies, infection, asphyxia /w or /w out meconium
morbidity: mec aspiration, macrosomia, shoulder, NICU, O2, pneumonia, seizures, operative delivery

37
Q

post-mature

A

neonate /w peeling skin, skinny + long, alert

38
Q

post-dates

A

> 41+0

39
Q

management of post-dates

A

offer induction at 41 weeks

alternative: patient can select serial fetal monitoring

OB GYN (22 decks)

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