Lecture 53
Obstetrics and Gynecology
Leopold’s
maneuvers are used
to determine fetal
lie (longitudinal or
trans-verse) and, if
possible, fetal
presentation (breech
or cephalic).
Obstetric Examination
Cervical examination:
Dilation
Effacement
Station
Cervical position
Cervical consistency
Bishop score
Evaluates the favorability of delivery and the
probability of succeeding with an induction
Bishop Score
Scoring is interpreted as follows:
0–4: Indicates a 45–50% chance of failure. Give
prostaglandins for induction.
5–9: Points to a 10% chance of failure. Give
pitocin for induction.
10–13: Associated with a very high probability of
success. There is no need for intervention for
induction.
Obstetric Examination
Confirm or determine fetal presentation.
A. Ischial spines
B. Symphysis pubis
C. Ischial tuberosities
D. Sacral promonotory
Which of the following serve as landmarks when
assessing descent of the fetal head?
A. Ischial spines
B. Symphysis pubis
C. Ischial tuberosities
D. Sacral promonotory
Fetal Lie
Fetal Presentation
Is determined by fetal lie and by the body part of
the fetus that enters the pelvic passage first, the
presenting part
May be cephalic (most common), breech, or
shoulder
Breech and shoulder presentations are referred to
as malpresentations as they are associated with
difficulties during labor
Examples of presentations
Cephalic Presentation
97% of births
Fetal head presents itself to the passage
“Subcategories” of cephalic presentation includes:
Vertex presentation: Occiput is the presenting part –
most common type
Military presentation: The fetal head is neither flexed
nor extended
Brow Presentation: The fetal head is partially
extended
Face presentation: The fetal head is hyperextended
The relationship of which fetal part to the mother's pelvis
determines the cephalic presentation?
A.mentum
B.sacrum
C.acromion
D.occiput
E.sinciput
The relationship of which fetal part to the mother's pelvis
determines the cephalic presentation?
A.mentum
B.sacrum
C.acromion
D.occiput
E.sinciput
Breech Presentation
3% of births
Sacrum is the landmark to be noted
Frank Breech: the fetal hips are flexed and the knees are
extended. The buttocks of the fetus present to the
maternal pelvis
Complete Breech: the fetal knees and hips are both
flexed; the thighs are on the abdomen and the calves are
on the posterior aspect of the thighs
Footling Breech: the fetal hips and legs are extended, and
the feet of the fetus present to the maternal pelvis (single
or double footling)
Breech Presentation
A 27 year old woman, gravida 2, para 1 at 30 week of gestation
presents to clinic for a routine prenatal visit. She has known to
suffer from "serosal fibroids". Her fundus measures 37cm from
the pubis. In discussing possible complications of a fibroid
uterus during pregnancy you mention that she is at highest risk
for:
a. Fundal
b. Anterior
c. Posterior
d. Lateral
e. Lumbar stage of labor
Which of the following placental implantation most
like predisposed to inverted uterine in 3rd stage of
labor?
a. Fundal
b. Anterior
c. Posterior
d. Lateral
e. Lumbar stage of labor
Fetal Heart Rate Monitoring
Tachycardia
Bradycardia
Variability: LTV versus STV
Accelerations
Decelerations: Early, Late & Variable
Fetal Heart Rate Monitoring
Baseline rate:
Refers to the average FHR observed
during a 10-minute period of monitoring.
Normal range is 120-160 BPM
>160 BPM = tachycardia
<120 BPM = bradycardia
Fetal Tachycardia
Fetal Bradycardia
Causes of fetal tachycardia
Early fetal hypoxia
Compensation for reduced blood flow
Maternal fever
Accelerates the metabolism of the fetus
Maternal dehydration
Beta-sympathomimetic drugs
Atropine, terbutaline and other drugs with cardiac stimulant effect
Amnionitis
Fetal tachycardia may be first sign of intrauterine infection
Maternal hyperthyroidism
TSH may cross the placenta and stimulate fetal heart rate
Fetal anemia
Heart rate is compensating to improve tissue perfusion
Causes of Fetal Bradycardia
Late (profound) fetal hypoxia
Maternal hypotension
Results in decreased blood flow to the fetus
Prolonged umbilical cord compression
Fatal arrhythmia
Variability
Baseline variability is a measure of the interplay (the
push-pull effect) between the sympathetic and
parasympathetic nervous systems (adequate oxygenation
promotes normal function of the autonomic nervous
system and helps the fetus adapt to the stress of labor).
A. Late
B. Early
C. Variable
D. Prolonged
A gradual, smooth deceleration of the fetal heart rate
that follows the peak of a contraction describes
which of the following deceleration types?
A. Late
B. Early
C. Variable
D. Prolonged
Variable Decelerations
Occur if the umbilical cord becomes compressed,
this reducing blood flow between the placenta
and fetus.
A. 1 acceleration in 20 min
B. 2 acceleration in 20 min
C. 8 acceleration in 20 min
D. 15 acceleration in 20 min
Definition of reactive non stress test:
A. 1 acceleration in 20 min
B. 2 acceleration in 20 min
C. 8 acceleration in 20 min
D. 15 acceleration in 20 min
Contraction stress test (CST)
Performed in the lateral recumbent position.
FHR is monitored during spontaneous or induced (via
nipple stimulation or oxytn) contractions.
Reactivity is determined from fetal heart monitoring, as
with the NST.
Scoring is as follows:
8–10: Reassuring for fetal well-being.
6: Considered equivocal. Term pregnancies are usually
delivered with this profile.
0–4: Extremely worrisome for fetal asphyxia; strong
consideration should be given to immediate delivery if
no other explanation is found.
Modified biophysical profile (mBPP):
History
Physical examination
Fundal height measurement
Uterine contraction (duration, frequency, intensity)
Fetus (presentation, heart rate, size)
Fetal membrane, vaginal bleeding & leakage
The fetal heart rate should be checked, especially at the
end of a contraction and immediately, thereafter, to
identify pathological slowing of the heart rate
Pain level
Laboratory studies upon admission:
CBC
Blood type and RH
UA (pretein, glucose)
Syphilis, hepatitis B, HIV