Laceration involves vaginal epithelium or perineal skin
First degree
Laceration involves subepithelial tissues
Second degree
Laceration involves the anal sphincter
Third degree
Laceration involves the rectal mucosa
Fourth degree
Occult bleeding (like a uterine hematoma) is manifest as what, post-delivery?
Vaginal pain
After delivery, how would hypovolemia due to bleeding manifest itself?
An increase in heart rate
Artificial rupture of the membranes
Amniotomy
Localized, edematous swelling of the baby's head caused by pressure from the cervix
Caput
What can be applied locally to promote cervical ripening?
Prostaglandin E1 (tablet)
Prostaglandin E2
Why is oxytocin given intravenously?
Easy to stop
Excessive infusion of oxytocin causes hyperstimulation, which leads to what for the baby?
Ischemia
Excessive hyperstimulation of the uterus can lead to a tetanic contraction of the uterus - causing it to what?
Rupture
Oxytocin has a similar structure to what renal hormone?
ADH
Excessive oxytocin can cause water retention, leading to what?
Water intoxication
What are the signs of water intoxication?
Convulsions
Coma
Prolonged use of oxytocin can cause uterine muscle fatigue - this increases the chances of what two conditions?
Hypotonus of the uterus
Hemorrhage
Uterine discharge color for 3 days following delivery
Red
Uterine discharge from day 3 to day 10
Pale pink or brown
Uterine discharge after day 10
White
Source of pain in the early stages of labor
Visceral pain
Opioid narcotics that can relieve pain in early labor, thanks to short neo-natal halflife
Fentanyl
Nalbuphine
Reason opioids are dangerous during labor>?
Depress fetal respiration
Most effective analgesia during labor
Neuraxial analgesia
How do you start out an epidural infusion?
With a bolus of local anesthetic and narcotic
What local anesthetic do you use in an epidural?
Any of the "caines
What narcotic do you use in an epidural?
Fentanyl
Sufentanil
Why do you try to minimize motor block in an epidural?
So mom can push
What nerves does a pudendal nerve block numb?
Somatic afferent nerves at S2-S4
What part of labor does a pudendal nerve block help with?
Episiotomy, perineal pain
What part of labor does a pudendal nerve block NOT help with?
Uterine contractions
Absolute Contraindications to regional anesthesia
Coagulopathy
Infection at needle insertion site
Hypovolemia with blood loss
Relative contraindications to regional anesthesia
Prior back surgery
Cardiac lesions
Increased intracranial pressure
All patients requiring anesthesia require what?
Airway exam
What do you always administer along with anesthesia?
An antacid
For elective or non-urgent C-section, why is regional anesthesia preferred to general anesthesia?
Because the airway is maintained
What is the leading cause of anesthetic-related maternal mortality?
Loss of airway
Faster onset: block or epidural?
Block
General anesthesia in C-section: 3 situations
-Extreme urgency
-Regional anesthesia has failed
-Regional anesthesia is contraindicated
Induction agents for general anesthesia
Propofol
Thiopental
Etomidate
Ketamine
Muscle relaxant used to intubate?
Succinylcholine
Why do you wait for the patient to be fully awake before you extubate?
Minimize risk of aspiration
Normal APGAR score at 1 minute
7 or better at 1 minute
Normal APGAR score at 5 minutes
9 or 10
5 categories assessed in an APGAR test
Heart rate
Respiratory effort
Muscle tone
Reflex irritability
Colour
Most common causes of maternal death (HEMI)
Hemorrhage
Embolism
Hypertensive disease
Infection
Potential causes of third-trimester bleeding
Placenta previa
Abruptio placenta
Preterm labor
Most accurate method to determine cause of antepartum bleeding
Ultrasound
Predisposing factors for placenta previa
Multiparity
Older age
Prior placenta previa
Previous pregnancies
Placenta completely covers os of cervix
Complete placenta previa
Placenta partially covers os of cervix
Partial placenta previa
Placenta covers margin of os
Marginal placenta previa
Patient has painless vaginal bleeding
Placenta previa
If the patient with placenta previa reaches 36 weeks, fetal lung maturity should be determined how?
Amniocentesis
How is a low-lying placenta different from a placenta previa?
Low-lying placenta is within 2 cm of the endocervical os
What is the most common predisposing factor for abruptio placenta?
Maternal hypertension
Patient presents with PAINFUL vaginal bleeding, uterine tenderness, hyperactivity, and increased tone
Abruptio placenta
What is the most common cause of DIC in pregnancy?
Placental abruption
An abrupt placenta releases what into the maternal circulation?
Thromboplastin
Severe abruption can cause what two systemic problems?
Hypovolemic shock and acute renal failure (due to hemorrhage)
Coagulation from placenta abruptia can cause what pituitary necrosing disorder?
Sheehan's syndrome
What blood loss volume is indicative of postpartum hemorrhage during vaginal delivery?
500 mL
What blood loss volume is indicative of postpartum hemorrhage in C-section?
1000 mL
What causes delayed postpartum hemorrhage?
Disruption of "scab" or retention of placental fragments that separate later
Where does most of the blood loss occur in postpartum hemorrhage?
Myometrial spiral arterioles and decidual veins
What drug, used for treatment of preeclampsia, can lead to uterine atony?
Magnesium sulfate
What causes most postpartum hemorrhages?
Uterine atony
How can you fix hemorrhage due to uterine atony?
Oxytocin
If oxytocin doesn't fix uterine atony, what else can you use? (2)
Ergonovine or
methyergonovine
What is the second most common cause of postpartum hemorrhage?
Genital tract trauma
C-section increases your chances of febrile morbidity by how much?
2x
Rising fever and increasing uterine tenderness 2 or 3 days postpartum?
Puerperal sepsis
After birth, the pH of the vagina changes - how?
Goes from acidic to alkyline
The newly alkaline environment of the vagina after birth is an ideal environment for what kind of organisms?
Aerobic
About 48 hours after birth, the endometrial and placental remnants undergo necrosis. This creates an ideal environment for what kind of organisms?
Anaerobic
Usual relative pelvic venous stasis + large amounts of pathogenic bacteria = ?
Pelvic vein thrombophlebitis (usually on the right)
Clinical definition of macrosomia?
Fetus is 4500 grams or more
Turtle sign indicates shoulder dystocia. What is it?
Retraction of fetal head.
Preterm birth occurs during what gestational timeframe?
20 weeks to 37 weeks
What usually causes preterm labor?
SPONTANEOUS DAWG
Name the 4 pre-term birth "pathways
1. Infection - Cervical pathway
2. Placental - Vascular pathway
3. Stress - Strain pathway
4. Uterine Stretch pathway
What test, which detects a basement membrane produced by fetal membranes, predicts more than half of spontaneous preterm births?
Fetal fibronectin