Inpatient Obstetrical Certification NCC

Leading cause of perinatal admissions to the ICU
Hemorrhagic disorders

Percentage of deaths related to pregnancy related hemorrhages
17-25%

Most maternal deaths from obstetric hemorrhage after first trimester of pregnancy are due to
Placental abruption

Race most likely to die from post partum hemorrhage
African Americans

Mortality rate (2006) for white women, African American women and Hispanic women in the US, stated as deaths per 100,000 live births
White women 13.3/100,000
African American women 32.7/100,000
Hispanic women 10.2

68% of post partum hemorrhage deaths occur within _______hours of delivery
48

Obstetric hemorrhage is defined as a TBL or more than
1000cc

The classic sign of placenta previa is
painless vaginal bleeding in the second or third trimester of pregnancy

If you see painless vaginal bleeding in the second or third trimester of pregnancy, suspect
Placenta previa

Risk factors for placenta previa
previous placenta previa, advanced maternal age greater than 40, previous cesarean, short interval between pregnancies, multiparity,previous abortions with curettage, smoking, race (Asian women at greatest risk), large placenta

In patients with suspected placenta previa, which comes first, a speculum examination or a confirmatory ultrasound.
Do the ultrasound first

Fetal blood volume is
100ml/kg

Changes noted during significant blood loss
Rising pulse rate
Increase in respiratory rate
Skin changes to pallor
Falling blood pressure (a late finding)
Decreased urinary output
Decreased LOC

Characteristic findings in FHR if mother has a significant blood loss
Initially, tachycardia
Then bradycardia
Sinusoidal-fetal anemia, hypoxia and acidemia
Persistent late decelerations

Percentage of accreta among women with previa
5-10%

If patient has had 2 or more cesarean sections, the likelihood of an accreta is
Greater than 50%

Vasa previa
Fetal vessels cross the placental membranes in the lower uterine segment and cover the cervical os

Velamentous cord insertion
Fetal vessels run across chorion and amnion without protective Wharton’s jelly before entering the placental surface

Succenturiate placenta
One or more small accessory lobes of placental vascular tissue in membranes that are attached to main placenta by fetal vessels

Hemolysis
lysis of erythrocytes with the release of hemoglobin

HELLP
Hemolysis, Elevated Liver Enzymes, Low Platelets

Per AWHONN, patients with placenta previa should not be discharged to home until they have gone_____hours with not bleeding
72 hours

Classic symptom of placental abruption
Painful vaginal bleeding after 20 weeks gestation

Risk factors for placental abruption
Smoking increases risk 90%
Maternal hypertension 500% increased risk
Multiparity
Abortions
Illicit drug use
Short umbilical cord
Abdominal trauma
Rupture of membranes(due to sudden uterine decompression)
Leiomyoma behind placenta

ACOG standard for fetal monitoring for maternal abdominal trauma
Minimum of 2-6 hours

DIC stands for
disseminated intravascular coagulation

DIC is
a pathologic form of clotting that is diffuse and consumes large amounts of clotting factors, causing widespread external or internal bleeding or both

Specific diagnostic test for DIC
D-dimer is positive in 34% of cases of DIC

Gestational Trophoblastic Disease
condition in which trophoblastic tissue overtakes the pregnancy and propagates throughout the uterine cavity

Hydatidiform mole is characterized by
chronic or acute bleeding and a uterus that is large for gestational age. 1 in 1200 pregnancies. 5%
turn into choriocarcinoma

Preeclampsia in the first trimester, hCG levels above 100,000 mIU/mL, and an enlarged bleeding uterus are clinical signs of what?
Hydatidiform mole

Five groups of hypertensive disorders in pregnancy
1.Gestational hypertension-hypertension developing after 20 weeks gestation without proteinuria

2.Preeclampsia-hypertension developing after 20 weeks gestation with proteinuria

3.Eclampsia–Seizure activity or coma in patient with eclampsia

4.Chronic hypertension

5.Preeclampsia superimposed on chronic hypertension

_______% of women with preeclampsia develop HELLP syndrome
5

Initiate antihypertensives if BP > 160/110. List top drug choices, in order of AWOHHN preference
Hydralazine
Labetalol
Nifedipine

How long does it take before the lung maturity benefits of betamethasone are seen?
24 hours after administration

Magnesium sulfate toxicity can occur rapidly. Toxicity could result in impaired_______function.
Renal function–always use a urimeter

______% of eclampsia and HELLP cases occur after delivery
30

TORCH is an acronym for
Toxoplasmosis, Other (hepatitisB), Rubella, CMV, Herpes

SGA
Small gestational age; growth is below 10th percentile

IUGR from placenta insufficiency usually reduces ___________more than _______.
birthweight length

Which is more ominous, symmetrical or assymmetrical growth restriction?
Neonates with symmetrical growth restriction have the poorest long-term prognosis and commonly have chromosomal abnormalities; postnatal nutrition is unable to correct for growth deficits: symmetrically grown SGA babies may never catch up in size when compared to unaffected babies

Growth restriction at less than 28 weeks is generally (symmetrical or asymmetrical) in nature.
Symmetrical. Infants are symmetrically grown and all organ systems are small. Much more ominous than asymmetrical growth restrictions.

Growth restriction at more than 28 weeks is general (symmetrical or asymmetrical) in nature.
Assymmetrical. This type of infant has a better prognosis than one who is symmetrically IUGR. Optimal postnatal nutrition generally restores normal growth potential because the number of body cells is normal.

LGA
Large for Gestational Age. Having a birth weight greater than the 90th percentile on intrauterine growth charts.

Caput succedaneum
is a localized, easily identifiable, soft area of the scalp, generally resulting from a long and difficult labor or vacuum extraction. Extra fluid should be reabsorbed within 12 hours after birth. Crosses suture lines.

Cephalohematoma
a collection of blood between the periosteal membrane and a skull bone. Caused by rupture of capillaries from the pressure of birth. No pressure on brain, takes 3-6 weeks to resolve

Postterm
Delivery after 42 weeks gestation

Transition is
Transition is a response, in part, to the increased level of oxygen in the circulation once air breathing has begun; if oxygen levels remain low, the fetal pattern of circulation may persist, causing blood flow to bypass the lungs.

Fact–Preterm infants may have impaired regulation of blood pressure in the face of apnea, bradycardia, and mechanical ventilation.
Resulting fluctuations in cerebral blood flow are common. These fluctuations predispose the fragile blood vessels in the brain to rupture, causing intracranial hemorrhage. Fluctuations in blood pressure can cause loss of brain blood flow, resulting in ischemia. These fluctuations also predispose the preterm infant to develop retinopathy of immaturity.

Fact–Procedure to follow if meconium is present in the amniotic fluids: Infants who are depressed at birth or make poor attempts to take the first breath should be intubated in the delivery room and suctioning of the trachea should occur to remove meconium below the vocal cords. Infants who attempt to breathe and clear their own airway should be allowed to do so without intervention.
Approximately one third of infants with meconium below the vocal cords become ill and require intensive care.

Kernicterus is caused by severe and inadequately treated hyperbilirubinemia during the neonatal period. Bili levels in excess of _______mg/dl may develop kernicterus.
20

Fact–Research has shown that healthy full-term neonates in the absence of significant hemolysis or other underlying medical conditions with serum bilirubin levels of approximately 18mg/dl do not have any detrimental effects with an expectant management approach

Omphalocele
protrusion of the intestine and omentum through a hernia in the abdominal wall near the navel. Omphalocele is covered with a sac consisting of peritoneum and amniotic membrane. About 50% of newborns born with omphalocele have cardiac, gastrointestinal, genitourinary, musckuloskeletal, and CNS anomalies

Gastroschisis
defect in abdominal wall not including the umbilicus, absence of peritoneal sac over the contents.

Congenital diaphragmatic hernia
part of the stomach and intestine herniate through a large posterolateral defect of the diaphragm; always occurs on the left b/c of the liver on the right. Occurs in 1/2200 newborn infants. One lung (usually left) fails to develop normally b/c of the abdominal viscera in the thoracic cavity. This causes pulmonary hypoplasia and ~45% mortality among live-born infants.

Avoid bag and mask ventilation with the baby with congenital diaphragmatic hernia because
air can be forced into the intestine, which will further compromise lung space in the chest.

Position the baby with diaphragmatic hernia
on the affected side, allowing the unaffected lung to expand. In other words, lie the baby on it’s left side, allowing the right lung to expand.

PDA
An anatomic and functionally open shunt exists between the pulmonary artery and the aorta. In babies between 500-1500 grams, PDA occurs in 37%. In full term infants, the PDA becomes functionally closed by 12 hours of age.

Coarctation of the aorta
A narrowing of the upper thoracic aorta that produces and obstruction to the flow of blood through the aorta.

Acyanotic defects shunt oxygenated blood to the body. The infant remains “pink”. Name four acyanotic defects:
Patent ductus arteriosus
Atrial septal defects
Ventricular septal defect
Coartication of the aorta

Cyanotic defects shunt unoxygenated blood to the body. The infant is “blue”. Name three cyanotic defects:
Tetralogy of Fallot
Transposition of the Great Ateries
Hypoplastic left heart syndrome or single ventricle

Two goals of antepartum testing
To identify fetuses that are at risk for permanent injury or death due to disrupted oxygenation

To identify fetuses that are healthy, thus preventing the use of unnecessary intervention

Crown rump length is the most accurate measurement for EGA when in the ______________trimester
First

Biparietal diameter is among the most accurate measurements for EGA in the ______________trimester
Second

Although infants born at ______weeks gestation have been known to survive, most authorities believe that _______weeks is the time of earliest survival.
22 23

Surfactant is made up of phospholipids. The two most common phospholipids in surfactant are
Lecithin and phosphatidylgllycerol (PG)

Pulmonary maturity usually is achieved by 37 weeks gestation. The role of surfactant is to
prevents the collapse of the alveoli

Alpha-fetoprotein
A blood test that measures the level of alpha-fetoprotein in the mothers’ blood during pregnancy as an indicator of possible neural tube defects

Quad screening
blood test done at 16-18 weeks to measure AFP, HCG, Estriol, and Inhibin A

Doppler measurement of the peak velocity of systolic blood flow in the ___________can safely replace invasive testing in the management of the Rh-alloimmunized pregnancies.
middle cerebral artery

AFI of less than 5 cm is considered diagnostic for oligohydramnios. 5cm equals __________ of fluid.
500ml

Polyhydramnios is an AFI of greater than_______cm of amniotic fluid.
25 cm which equals 2000 ml

Normal AFI at term is
10-24 cm of fluid.

Low normal AFI at term is
5-9.9 cm of fluid

___________% of newborns have a major anomaly
1-2

Fetal lung maturity is determined by an amniocentisis. The lab test is called the _________ratio.
L/S ratio. The lecithin/sphingomyelin ratio. The chance of lung maturity is 98% if the concentration of lecithin is twice that of the sphingomyelin.

L/S ratio is not a valid indicator of lung maturity if the mother is diabetic. In diabetic mothers, the presence of _______is highly predictive of fetal lung maturity.
PG (phosphatidylglycerol)

Definitive fetal lung maturity testing requires
L/S ratio greater than 2:1 AND the presence of PG

Reactive NST for the term fetus
2 or more accelerations≥15 bpm, lasting at least 15 seconds within 20 minutes. Maximum testing period 40 minutes.

Reactive NST for the preterm fetus
2 or more accelerations of at least 10bpm, lasting at least 10 seconds within a 20 minute period. Maximum testing period 90 minutes

For fetuses >30 weeks gestation, a FHR greater than_______bpm is considered tachycardia.
160

Nonreactive NST at term is defined as
no accelerations or no accelerations that meet the 15×15 criteria, within a 40 minute period. Even one accelerations is considered inadequate. Remember, this is in the presence of no contractions.

Nonreactive NST in the preterm fetus is defined as
an NST with no accelerations or no accelerations that meet the 10×10 criteria within the maximum testing time of 90 minutes

If variable decelerations are present during an NST
an assessment of amniotic fluid is indicated

If variable decelerations are seen during the NST and they are nonrepetitive and less than 30 seconds in duration,
then the fetus is considered to not be compromised and there is little, if no, need for intervention

The proper placement for the fetal accoustic stimulator is
near the fetal head

The appropriate use of the fetal accoustic stimulator is
1-2 seconds for the first application. If there is no fetal response, the stimulus may be repeated every 1 minute up to three times to achieve longer durations of time, not to exceed 3 seconds for each stimulus. The maximum time of application is 9 seconds (three applications that equal a total of 9 seconds). Once a fetal response (i.e. accelerations) is achieved, additional stimuli are not required.

The fetal acoustic stimulation should not be used in these three conditions:
1. during a vaginal examination
2. during contractions
3. in the presence of decelerations

If, in response to accoustic stimulation, the fetus elicits a prolonged acceleration of tachycardia,
there is no need to elicit any additional accelerations. However, the FHR should return to the previously established FHR baseline before discharging the patient to home.

Accoustic stimulation is not to be used on a fetus demonstrating
fetal bradycardia

Intrauterine apgar is another term for
bio-physical profile

The five CNS reflex activities that are evaluated during a bio-physical profile are
1. NST (this can be eliminated only if the other four parameters are normal)
2. Fetal breathing movements
3. Gross body movements
4. Fetal tone
5. Qualitative amniotic fluid volume

On a bio-physical profile,fetal tone disappears when fetal pH is
<7.0

On a bio-physical profile, fetal movement disappears when fetal pH is
7.1 to 7.2

On a bio-physical profile, fetal breathing movements disappear when fetal pH is
<7.0

A reactive FHR baseline begins to function at _____weeks gestation
26-28

A reactive FHR baseline is abolished when fetal pH is
<7.19

A hypoxic baby may shunt blood away from the kidneys, which will
decrease urine output, resulting in a drop in amniotic fluid index

If oligohydramnios is the reason for the BPP score of 8
further evaluation is warranted. Predicted perinatal morbidity with 8/10-oligohydramnios=89/1000.

Indications for a CST
Patients with nonreactive NST, nonreactive accoustic stimulation test, should have CST.

Contraindications (relative) to CST
high risk for preterm labor, history of uterine surgery, know placenta previa, third trimester bleeding, incompetent cervix or multiple gestation.

Parameters for CST
3 or more contractions lasting 40 seconds each in a 10 minute period

A positive CST
is an indication that the fetus needs to be delivered

A negative CST
indicates that the fetus is likely to survive labor should labor occur within 1 week of the test

Phases of labor-active phase
During the active phase of labor, contractions become longer and more intense. Most contractions last as long as 45 seconds, and are three minutes apart. The cervix dilates from four to eight centimeters during this phase. If the bag of waters has not already broken, the treating doctor or midwife, will most likely break them at this time. The contractions during this phase are much more painful than in the early phase, and expectant mothers may try breathing techniques, massage, pressure or request pain medications.

Phases of labor-latent
During the early phase of labor, contractions are usually mild, and can be 15 to 20 minutes apart. These contractions, which can last as long as 90 seconds, can be uncomfortable, causing the expectant mother to feel crampy throughout her lower back and lower abdomen. The early phase of labor is also when an expectant mother may experience bloody show, or her bag of waters breaking. As this stage of labor progresses, the contractions become more frequent, as well as more intense. During this phase, the cervix dilates to 4 centimeters.

Read more at Suite101: The Three Phases Of Labor http://www.suite101.com/article.cfm/labor_delivery/86449#ixzz0gewR3G12

Three phases of labor
latent, active, transition

First stage of labor
the period of the birth process lasting from the first regular uterine contractions until the cervix is fully dilated

Second stage of labor
Stage of labor that begins when the cervix is completely dilated and ends with birth,. Contractions continue every 2-3 minutes, lasting 60-90 seconds. Client encouraged to use abdominal muscles to bear down with each contraction.

Third stage of labor
Stage of labor that begins with the delivery of the fetus and ends with delivery of the placenta. Placenta should be delivered within 30 minutes of birth.

Fourth stage of labor
First hour after delivery during which the mother’s body begins to return to a nonpregnant state. Blood pressure has moderate decline, pulse increases and then gradually slows.

Bishop score
this is used to determine maternal readiness for labor induction (done before the induction. It evaluates cervical status & fetal position. Five factors assigned a score of 0-3. They are Dilation, Effacement, Consistency of cervix, Position of cervix & Station of presenting part. Score of 6 or more indicates a readiness for labor induction.

Bandl’s ring
an abnormal retraction ring that occurs in obstructed labor. It is a sign of impending rupture of the lower segment of the uterus, which becomes progressively thinner as Bandl’s ring rises upwards. Immediate action to relieve the obstruction is then necessary, usually in the form of Caesarean section

General anesthesia is used only for emergency Cesarean sections due to increased risk for fetal hypoxia. Induction of anesthesia to birth should be less than____minutes.
8

NICHD
National Institute of Child Health and Human Development

Normal fetal sleep cycles
20-40 minutes

Baseline heart rate
determine the mean FHR during a 10 minute window. There needs to be 2 minutes of interpretable data to determine FHR BL. The 2 minutes do not have to be continguous. They may be 2 consecutive minutes or two 1 minutes segments. It is assessed when the mother is not contracting. If a FHR baseline cannot be determined the BL is interpreted as INDETERMINATE.

Fetal tachycardia
<160 bpm over a 10 minute time segment, between contractions.

Fetal bradycardia
<110 bpm over a 10 minute time segment, between contractions.

Bradycardia less than 60 bpm or associated with decreased variability requires
immediate attentiona and collaborative management

In a nonreassruing FHR, fetal scalp stimulation is
NOT recommended. Scalp stimulation in this instance will elicit a vagal response that overrides the sympathetic response and results in aa furtherfurtherdrop in the FHR

Variabiltiy is defined as
the fluctuation in the FHR over time

AFI of 8 means how much fluid?
800 cc