Labor
Labor dystocia definition (criteria for cesarean in latent and active phase). ACOG and CMQCC criteria.
Latent - failed IOL: at least 12-18h (preferably 24h) after ROM on pitocin in latent phase (ACOG); at least 12-18h (preferably 24h if maternal/fetal status reassuring) after ROM on pitocin without regular contractions (q3min) and cervical change (CMQCC)
Active: 6h ROM on pitocin (inadequate < 200 MVU) or 4h ROM on pitocin (adequate MVU)
2nd stage: >3h nulliparous or >2h multiparous (+1h for epidural)
Definition of Cat I, II, III tracings
Cat I: baseline 110-160, mod variability +/- accels +/- early decels
Cat III: absent variability with decels, sinusoidal, or terminal bradycardia
What are PPH risk factors (list 6)?
Antepartum - h/o PPH, macrosomia, poly, multiple gestation, prolonged pitocin > 12h, chorio, magnesium, large fibroids, coagulopathy, thrombocytopnia, abruption, HELLP/DIC, grand multiparity, prior C/S, previa, IUFD, PASD
Intrapartum - OVD, 2nd stage CS, urgent/emergent CS under GETA, OASIS/genital tract trauma, retained placenta, non-LTCS, uterine rupture
Definition of severe pre-clampsia
Sustained SR > 160/100 or 140/90 AND
Cr > 1.1 or doubling
LFT 2x UL
Platelets < 100k
Symptoms: persistent headache, vision changes, RUQ pain
pulmonary edema
Workup of 1st trimester bleeding?
SSE
TVUS - if no IUP: HCG, T&S, consider MTX labs
Management of decel
Exam
Position changes
Stop pit, give terb if tachysystole or tetanic contraction
Check BP, give IVF bolus if BP low and call anesthesia
**pH decreases 0.03/min with complete cord occlusion
Definition of BPP and order of loss of variables?
Movement: 3+ discrete movements in 30min
Breathing: one or more episodes lasting 30s in 30min
Tone: extension/flexion of extremity, opening/closing hand
AFI
NST
Accelerations -> breathing -> decreased FM -> loss of tone
List uterotonic dosage and interval, time to onset
Methergine 200mcg IM q2-4h, PO q6-8h: onset 2-5min (IM), 5-10 min (PO)
Hemabate 250mcg IM q15min x 8 doses
Miso: onset of action 10min, peak 30min (SL), onset of action 60min (rectal)
Treatment of severe range blood pressure and contraindications/side effects?
Labetalol - severe asthma, cardiac disease, heart failure, heart block, bradycardia
Hydral - tachycardia
Nifedipine - hypotension, reflex tachycardia, headache
What is the HCG discriminatory level and what does it mean?
3500 - IUP should be seen above this threshold
Contraindications to miso?
prior CS, NRFHT, severe FGR, meconium, <36 weeks (consider CST), 6/10 contractions or 3/10 painful contractions, reactive and reassuring FHR 30min prior
Definition of CST
3 contractions in 10min lasting 40s
Negative: no late or significant variable decles
Positive: >50% late or significant variable decels
Equivocal: Intermittent late or significant variable decels
Unsatisfactory
Describe other interventions to treat PPH
UAE
Bakri
B-lynch
O'Leary
Hysterectomy
What kind of monitoring for patients on Mg?
Strict I/O, fluid restriction, lung exam (rales suggest pulmonary edema or HF), DTR, RR, O2 sat
Management of hyperemesis gravidarum
antiemetics (zofran, phenergan, compazine, reglan, B6+doxylamine), IVF, PO challenge prior to discharge
How long to sit on Cat II tracing?
Refer to Clark algorithm
Different methods of antenatal testing and NPV?
SB within 1 week of test:
CST: 0.3/1000
BPP and modified BPP: 0.8/1000
NST: 1.9/1000
Transfusion thresholds (pRBC, fibrinogen, platelets)
pRBC (200mL): Hgb < 7 (asymptomatic) - 8 (symptomatic)
FFP (180mL): INR > 1.5-1.7
Cryo (80-100mL): fibrinogen < 200; 10u pack increase 75
Platelets: platelets < 50k; 6-pack increase 50k
When to mag for PP severe HTN
<1 week or symptoms (headache, vision changes, RUQ pain)
+/- severe range blood pressures or lab abnormalities
Management of IUD in 1st trimester of pregnancy (counseling statistics)?
50% risk of SAB, chorio leaving IUD
25% risk of SAG with removal
Indication for OVD?
Maternal exhaustion
Shorten second stage (i.e. maternal cardiac or neurovascular condition)
Prolonged second stage
NRFHT
Criteria for perinatal asphyxia
10min Apgar < 5
UA pH < 7 or BE >=12
Multiorgan failure consistent with HIE
MRI with HIE findings (deep nuclear gray matter (i.e. basal ganglia or thalamus) injury, watershed injury
When to activate MTP
EBL > 1500 and continued bleeding
Treatment of eclamptic seizure
ABCs - left lateral decubitus position, suction to prevent aspiration, O2 if breathing, padded rails to prevent trauma
4-6g Mg bolus, can give 2nd 2-4g Mg bolus if seizure recurs
If seizure persists 20min or 2 recurrences, admit to ICU or give alternative barbituate or benzo
In no IV, 5g IM Mg x 2 in each buttock, 5g q4h
MR brain or CT head for PRES is atypical seizure (focal) or head trauam
Once mom is stable, delivery:
Emergency CD only for terminal bradycardia after seizure stops
Consider CD if early GA < 28-32 weeks
Counseling options for ectopic pregnancy
Expectant: <200 and decreasing
Medical
Surgical: salpingectomy vs. salpingostomy - no difference in fertility outcomes