METHODICAL INSTRUCTIONS

MINISTRY OF PUBLIC HEALTH OF UKRAINE

National Pirogov Memorial Medical University, Vinnytsya

CHAIR OF OBSTETRICS and Gynecology №1

METHODICAL INSTRUCTIONS

for practical lesson

«Physiology of pregnancy, labor and puerperium. Obstetrical pharmacotherapy. Questions of medical ethics and deontology. Pharmacokinetics and pharmacodynamics of medical drugs »

MODULE 4: Obstetrics and gynecology

Topic 1

Aim: to learn clinic duration of the first, second and third stages of labor, principles of pain relief, primary newborn care, to study the normal puerperium, to diagnose the complications of the puerperium and methods of their prevention.

Professional motivation: Occiput presentations occur in about 95% of all labors. It is very important to know the biomechanism of labor in cephalic presentation for management of labor. Students have to know the normal and abnormal position of fetal head and complication coursed by pathological labor.

Careful diagnosis and conducting of each stage of labor is important for preventing complication in the puerperium and prevent maternal and perinatal mortality.

Basic level:

1.Anatomy and physiology of female reproductive system

2.Changes in the female reproductive organs and all organism of woman during pregnancy, labor and puerperium.

3.The structure and function of breasts.

4.Laboratory tests during puerperium.

5.Mechanism of muscles contraction.

6.Estimation of gestational age.

7.The structure of conceptus at the end of the pregnancy.

Students’ Independent Study Program

I. Objectives for Students’ Independent Studies

You should prepare for the practical class using the existing textbooks and lectures. Special attention should be paid to the following:

PHYSIOLOGY OF LABOR

1. Give the definition of such obstetric terms as: "leading point", "fixative point".

2. Graphic documentation of the fetal head station in the true pelvis in different types of cephalic presentation.

3. Theories of the cardinal moments of labor.

4. Cardinal moments of labor in the vertex (occiput) anterior presentation.

5. Cardinal moments of labor in the vertex (occiput) posterior presentation.

6. Importance of perineal protective maneuvers.

7. Technique of perineal protective maneuvers (five moments).

LABOR

1.What is labor?

2. Stages of labor.

3. Labor's expulsive forces.

4. Mechanism of cervical dilatation in primapara and multipara.

5. What is lower uterine segment, contractile ring?

6. Management of the first stage of labor.

7. Role of vaginal examination in diagnosis of labor stages.

8. Management of the second stage of labor.

9. Perineal protective maneuvers.

10. Signs of placental separation.

11. Manual removal of placenta.

12. Structure of afterbirth.

13. Blood loss during labor and its estimation.

14. Definition of physiological blood loss.

PUERPERIUM

1.The definition of the puerperium.

2. The definition of the early and late puerperium.

3.The main processes in the puerperium.

4.Involution of the uterus.

5.What is lochia? The role of the lochia.

6.Changening of the lochia during puerperium.

7. Hygiene of the female reproductive organs in pueperants.

8. Care of the pueperants after episiotomy.

9. Function of breasts in puerperium.

10. Fissures of the nipples. Their treatment and prevention.

11. The rules of breast feeding.

12. The management of the puerperium.

13. Ultrasonic estimation of uterine involution.

14. Medicines stimulants of myometrial contractions.

15. Patients discharge from the hospital after delivery.

Inter-subject integration

|Previous disciplines |Requested skills |

|Anatomy |To describe anatomy of female pelvis, external and internal female genitalia, pelvic floor, |

| |to define parts pf pelvis and their dimensions. To know the dimensions of fetal head |

|Physiology |To describe physiological processes in female organism during labor. To be able to give |

| |clinical evaluation of maturity of female organism before labor. Reasons for delivery start.|

|Pharmacology |To select the medication and to calculate the dosage for anesthesia of delivery. |

Summary

The anatomical, physiological, and biochemical adaptations to pregnancy are profound. Many of these remarkable changes begin soon after fertilization and continue throughout gestation, and most occur in response to physiological stimuli provided by the fetus and placenta. Equally astounding is that the woman who was pregnant is returned almost completely to her prepregnancy state after delivery and lactation. Many of these physiological adaptations could be perceived as abnormal in the nonpregnant woman. For example, cardiovascular changes during pregnancy normally include substantive increases in blood volume and cardiac output, which may mimic thyrotoxicosis. On the other hand, these same adaptations may lead to ventricular failure if there is underlying heart disease. Thus, physiological adaptations of normal pregnancy can be misinterpreted as pathological but can also unmask or worsen preexisting disease. During normal pregnancy, virtually every organ system undergoes anatomical and functional changes that can alter appreciably criteria for diagnosis and treatment of diseases. Thus, the understanding of these adaptations to pregnancy remains a major goal of obstetrics, and without such knowledge, it is almost impossible to understand the disease processes that can threaten women during pregnancy.

CARDIOVASCULAR SYSTEM

During pregnancy and the puerperium, the heart and circulation undergo remarkable physiological adaptations. Changes in cardiac function become apparent during the ﬁrst 8 weeks of pregnancy (McLaughlin and Roberts, 1999). Cardiac output is increased as early as the ﬁfth week and reﬂects a reduced systemic vascular resistance and an increased heart rate. The resting pulse rate increases about 10 beats/min during pregnancy (Stein and co-workers, 1999). Between weeks 10 and 20, plasma volume expansion begins and preload is increased. Ventricular perform ance during pregnancy is inﬂuenced by both the decrease in systemic vascular resistance and changes in pulsatile arterial ﬂow. As discussed subsequently, multiple factors contribute to these changes in overall hemodynamic function and allow the cardiovascular system to adjust to the physiological demands of the fetus while maintaining maternal cardiovascular integrity.

■ Heart

As the diaphragm becomes progressively elevated, the heart is displaced to the left and upward and rotated somewhat on its long axis. As a result, the apex is moved somewhat laterally from its usual position, causing a larger cardiac silhouette on chest radiograph. Furthermore, pregnant women normally have some degree of benign pericardial effusion, which may in crease the cardiac silhouette. Variability of these factors makes it difﬁcult to precisely identify moderate degrees of cardiomegaly by simple radiographic studies. Normal pregnancy induces no characteristic electrocardiographic changes other than slight left-axis deviation as a result of the altered heart position. Many of the normal cardiac sounds are altered during pregnancy. Cutforth and MacDonald (1966) used phonocardiography and documented: (1) an exaggerated splitting of the ﬁrst heart sound with increased loudness of both components; (2) no deﬁnite changes in the aortic and pulmonary elements of the second sound; and (3) a loud, easily heard third sound. They heard a systolic murmur in 90 percent of pregnant women that was intensiﬁed during inspiration in some or expiration in others, and disappeared shortly after delivery. A soft diastolic murmur was noted transiently in 20 percent, and continuous murmurs arising from the breast vasculature in 10 percent. The increased plasma volume during normal pregnancy, which was discussed previously (p. 115), leads to several reversible morphological and functional adaptations. There is no doubt that the heart is capable of remodeling in response to stimuli such as hypertension and exercise. Cardiac plasticity likely is a continuum that encompasses physiological growth, such as that in exercise, as well as pathological hypertrophy— such as with hypertension (. And although it is widely held that there is physiological hypertrophy of cardiac myocytes as a result of pregnancy, this has never been absolutely proven. For example, in one study, Schannwell and associates (2002) performed serial echocardiographic examinations across pregnancy and postpartum in 46 healthy women and found a 34-percent greater left ventricular muscle mass index during late versus early pregnancy. These and earlier studies with similar ﬁndings were derived with echocardiography but have not been veriﬁed with the more precise techniques of magnetic resonance imaging. Hibbard and colleagues (2009) concluded that any increased mass does not meet criteria for hypertrophy.

Cardiac Output

During normal pregnancy, mean arterial pressure and vascular resistance decrease, while blood volume and basal metabolic rate increase. As a result, cardiac output at rest, when measured in the lateral recumbent position, increases signiﬁcantly beginning in early pregnancy. It continues to increase and remains elevated during the remainder of pregnancy. During late pregnancy with the woman in the supine position, the large pregnant uterus rather consistently compresses venous return from the lower body. It also may compress the aorta. The results are that cardiac ﬁlling may be reduced with diminished cardiac output (see Fig. 5-7). Speciﬁcally, Bamber and Dresner (2003) found cardiac output at term to increase 1.2 L/min—almost 20 percent—when a woman was moved from her back onto her left side. Moreover, in the supine gravid patient, uterine blood ﬂow estimated by Doppler velocimetry decreases by a third. Of note, Simpson and James (2005) found that fetal oxygen saturation is approximately 10 percent higher when a laboring woman is in a lateral recumbent position compared with supine. Upon standing, cardiac output falls to the same degree as in the nonpregnant woman.

Hemodynamic Function in Late Pregnancy

To further elucidate the net changes of normal pregnancy-induced cardiovascular changes, Clark and colleagues (1989) conducted invasive studies to measure hemodynamic function late in pregnancy. Right heart catheterization was performed in 10 healthy nulliparous women at 35 to 38 weeks, and again at 11 to 13 weeks postpartum. Late pregnancy was associated with the expected increases in heart rate, stroke volume, and cardiac output. Systemic vascular and pulmonary vascular resistance both decreased signiﬁcantly, as did colloid osmotic pressure.

Circulation and Blood Pressure

Changes in posture affect arterial blood pressure. Brachial artery pressure when sitting is lower than that when in the lateral recumbent supine position. Arterial pressure usually decreases to a nadir at 24 to 26 weeks and rises thereafter. Diastolic pressure decreases more than systolic. Antecubital venous pressure remains unchanged during pregnancy. However, in the supine position, femoral venous pressure rises steadily, from approximately 8 mm Hg early in pregnancy to 24 mm Hg at term.

Pulmonary Function

The respiratory rate is essentially unchanged, but tidal volume and resting minute ventilation increase signiﬁcantly as pregnancy advances. The increase in minute ventilation is caused by several factors including enhanced respiratory drive primarily due to the stimulatory effects of progesterone, low expiratory reserve volume, and compensated respiratory alkalosis. These are discussed in more detail subsequently. The functional residual capacity and the residual volume are decreased as a consequence of the elevated diaphragm. Peak expiratory ﬂow rates decline progressively as gestation advances. Lung compliance is unaffected by pregnancy, but airway conductance is increased and total pulmonary resistance reduced.

URINARY SYSTEM

Kidney

A remarkable number of changes are observed in the urinary system as a result of pregnancy. Kidney size increases slightly. Using radiographs, Bailey and Rolleston (1971) reported that the kidney was 1.5 cm longer during the early puerperium compared with 6 months later. The glomerular ﬁltration rate (GFR) and renal plasma ﬂow increase early in pregnancy. The GFR increases as much as 25 percent by the second week after conception and 50 percent by the beginning of the second trimester. Renal plasma ﬂow increases are even greater.

Urinalysis

Glucosuria during pregnancy may not be abnormal. The appreciable increase in glomerular ﬁltration, together with impaired tubular reabsorptive capacity for ﬁltered glucose, accounts in most cases for glucosuria. That said, although common during pregnancy, the possibility of diabetes mellitus should not be ignored when glucosuria is identiﬁed. Proteinuria normally is not evident during pregnancy except occasionally in slight amounts during or soon after vigorous labor. Hematuria is often the result of contamination during collection.

Bladder

There are few signiﬁcant anatomical changes in the bladder before 12 weeks. From that time onward, however, increased uterine size, the hyperemia that affects all pelvic organs, and the hyperplasia of the bladder’s muscle and connective tissues elevates the bladder trigone and causes thickening of its posterior, or intraureteric, margin. Continuation of this process to the end of pregnancy produces marked deepening and widening of the trigone. There are no mucosal changes other than an increase in the size and tortuosity of its blood vessels.

GASTROINTESTINAL TRACT

As pregnancy progresses, the stomach and intestines are displaced by the enlarging uterus. Consequently, the physical ﬁndings in certain diseases are altered. The appendix, for instance, is usually displaced upward and somewhat laterally as the uterus enlarges. At times, it may reach the right ﬂank. Gastric emptying time, studied using acetaminophen absorption techniques, appears to be unchanged during each trimester and during comparison with nonpregnant women. During labor, however, and especially after administration of analgesic agents, gastric emptying time may be prolonged appreciably. As a result, a major danger of general anesthesia for delivery is regurgitation and aspiration of either food-laden or highly acidic gastric contents. Pyrosis (heartburn) is common during pregnancy and is most likely caused by reﬂux of acidic secretions into the lower esophagus. Although the altered position of the stomach probably contributes to its frequent occurrence, lower esophageal sphincter tone also is decreased. In addition, intraesophageal pressures are lower and intragastric pressures higher in pregnant women. At the same time, esophageal peristalsis has lower wave speed and lower amplitude. The gums may become hyperemic and softened during pregnancy and may bleed when mildly traumatized, as with a toothbrush. A focal, highly vascular swelling of the gums, the socalled epulis of pregnancy, develops occasionally but typically regresses spontaneously after delivery. Most evidence indicates that pregnancy does not incite tooth decay.Hemorrhoids are fairly common during pregnancy.

Occiput presentations occur in about 95% of all labors. Because q the irregular shape of the pelvic canal and the relatively large dimension] of the mature fetal heard, it is evident that not all diameters of the hear can necessarily pass through all diameters of the pelvis. It follows that process of adaptation or accommodation of suitable portions of the he; to the various segments of the pelvis is required for completion of childbirth. These positional changes of the presenting part constitute the mechanism of labor.

There are 2 kinds of the occiput presentations. — anterior and posterior, The cardinal movements of labor in anterior occiput presentation are:

- flexion;

- internal rotation;

- extension;

- internal rotation of the fetal head and external rotation of the fetal body

The various movements are often described as through they occur separately and independently. In reality, the mechanism of labor consist of a combination of movements that are going on the same time, example, as part of process of engagement, there is both flexion and des of the head. It is manifestly impossible for the movements to be performed unless the presenting part descends simultaneously. The uterine contraction’s effect important modifications in the attitude, or habitus especially after the head has descended into the pelvis. These changes consists principally in a straightening of the fetus, with loss of its dorsal convexity and closer application of the extremities and small parts of the body. As a result, the fetal ovoid is transformed into cylinder with normally the smallest possible cross section passing through the birth canal.

Synclitism and asynclitism Synclitism is a position when the sagittal suture is in the transverse pelvic diameter. The sagittal suture is exactly midway between the symphysis and promontory.

If the sagittal suture approaches the sacral promontory, more of the anterior parietal bone presents itself to the examining fingers and condition is called anterior asynclitism. If the sagittal suture lies closer to the symphysis more of the posterior parietal bone presents and condition is called posterior asynclitism.

The cardinal movements of labor in anterior occiput presentation 1. Flexion. As soon as descending head meets resistance, whei from the cervix, the walls of the pelvis, or the pelvic floor, flexion of head are normally results. In this movement, the chin is brought into contact with the fetal thorax,and the shorter suboccipitobregmatic The leading point is the area of the small fontanel.

2 Internal rotation. This movement is a manner that the occiput dually moves from its original position anteriorly towards the symphysis pubis os. The rotation begins when the fetal head descends from the plane of greatest pelvic dimensions to the least pelvic dimensions (rnidpelvis).

The rotation is complete when the head reaches the pelvic floor, the sagittal suture is in the anteroposterior diameter of the pelvic outlet and the small fontanel is under the symphysis.

3. Extension. After internal rotation the sharply flexed head reaches the pelvic floor, two forces come into play. The first, exerted by the uterus, acts more posteriorly, and the second, supplied by the resistant pelvic floor, acts more anteriorly. The resultant force is the direction of the vulvar opening, thereby causing extension. Extension begins when the fixing point (fossa suboccipitalis) is under the inferior margin of the symphysis pubis. With increasing distension of the perineum and vaginal opening, an increasingly large portion of the occiput gradually appears. The head is born by further extension as the occiput,bregma,forehead,nose,mouth.

4. Internal rotation of the fetal head and external rotation of the fetal body. During the head extension the fetal body is in the pelvic cavity. The biacromial diameter turns from the oblique to the anterioposterior diameter of the pelvic outlet. Thus one shoulder is anterior behind the symphysis and the other is posterior. This movement is brought about apparently by the same pelvic factors that effect internal rotation of the head. The anterior shoulder comes under the symphysis pubis, the fetal body flexed and posterior shoulder is born first. Then the anterior shoulder is born. Fetal head rotates as a result of the body rotation. In the I position fetal face turns towards the right, in the II position towards the left. After delivery of the shoulders,the rest of the body of the child is quickly extruded.

The cardinal movements of labor in posterior occiput presentation are:

1. Flexion. The fetal head flexed and presents the suboccipito-frontai (10 cm) diameter in oblique size of the pelvic inlet. The leader point is a middle part of sagittal suture,

2. Internal rotation. The fetal head passes through the pelvic cavity and in narrow plane it begins rotate. In the outlet plane of pelvis (pelvic upor) the sagittal suture became in the direct (anterioposterior) diameter oi the pelvic outlet and the small fontanel is under the sacrum os,

3. Additional flexion. After internal rotation the head reaches the Pelvic floor. Fetal head fixes with the area of the border of the hair part of head (the first fixing point) under symphysis pubis and flexes. process leads to delivery of the vertex.

4. Extension. Extension begins when the second fixing point (fossa suboccipitalis) become under the tip of the sacrum. The head is born bj further extension.

5. Internal rotation of the fetal head and external rotation of the fetal body. Shoulder enter to the inlet of small pelvis in oblique size and in pelvic cavity perform the internal rotation to 45 °, in the pelvic floor they stand in the direct (anterioposterior) size. The anterior shoulder comes under the margin of symphysis pubis, the fetal body flexed. The posterior shoulder is born first and then the anterior shoulder is born] The head rotation realize as in anterior occiput presentation.

Labor is a physiologic process that permits a series of extensive physiologic changes in the mother to allow for the delivery of her fetus through the birth canal.

It is defined as progressive cervical effacement, dilatation, or both,-resulting from regular uterine contractions that occur at least every 5 minutes and last 30-60 seconds.

Labor forces:

1, Uterine contractions - is a regular contractions of uteri musculature. Typically, contractions occur every 5 to 10 minutes and la: for 20-25 seconds in the onset of labor. As labor proceeds, the contractio. become more frequent,more intense,and last longer. In the end of la the contractions occur every 2-3 minutes and last for 50-to 60 seconds They are characterized be strength, duration, and frequency which a important in generating a normal labor pattern.

2. Bearing-down efforts (or pushing) ~ is the periodic contractions diaphragm, pelvic floor muscles and prelum abdominal which are add* to the force of uterine contractions. Its voluntary expulsive force.

There are three stages of labor, each of which is considered separately.

The first stage (cervical) is from the onset of true labor to comp dilatation of the cervix.

The second stage (pelvic) starts from complete dilatation of cervix to the delivery of the baby.

The third stage (placental) starts from the birth of the baby till delivery of the placenta. It is divided into two phases: placental separation and its expulsion.

Labor begins with cervical effacementl Cervical effacement is thinning of the cervix.

Although cervical softening and early effacement may occur be labor, during the first stage of labor the entire cervical length is retracted into lower uterine segment as a result of myometrial contractile foi and pressure exerted by either the presenting part of fetal membrane

The length of the first stage may vary in relation to parity; primipar patients generally experience a longer first stage than do multipar patients. The minimal dilatation during the first stage is for primipar 1-1,2cm/hour and multiparous women: 1,2-1,5 cm/hour. If the progi is slower than this, evaluation for uterine dysfunction, fetal malposition cephalopelvic disproportion should be undertaken.

During the first stage, the progress of labor may be measured in cervical effacement, cervical dilatation and descent of the fetal head. Uterine contractions should be monitored every 30 minutes by palpation or machine monitoring for their frequency, duration, and intensity. For high-risk

egnancies, uterine contractions should be monitored continuously along with the fetal heart rate.

Vaginal examination should be done sparingly to decrease the risk of an intrauterine infection. Cervical effacement and dilatation, the station and position of the presenting part, the presence of molding or caput in vertex presentation should be recorded- Additional examinations may be performed if the patient reports the urge to push ( to determine if the full dilatation has occurred) or if a significant fetal heart rate deceleration occurs ( to examine for a prolapsed umbilical cord).

The fetal heart rate should be evaluated by either auscultation with a stethoscope,by external monitoring with Doppler equipment. In patients with no significant obstetric risk factors, the fetal heart rate should be auscultated at least every 30 minutes in the first stage of labor and after each uterine contraction in the second stage of the labor.

At the beginning of the second stage, the mother usually has a desire to bear down with each contraction. This abdominal pressure, together with uterine contractile force, combines to expel the fetus. In cephalic presentation, the shape of the fetal head may be altered during labor, making the assessment t>f descent more difficult. Molding is the alteration of the relationship of the fetal cranial bones to each other as the result of the compressive forces exerted by the bony maternal pelvis.

The second stage generally takes from 30 minutes to 2 hours in primigravid women and from 10*50 minutes in multigravid women. The median duration is 50 minutes in a primipara and slightly under 20 minutes in a multipara.

Clinical management of the second stage of labor. When delivery is imminent, the patient is usually placed in the lithotomy position.

With each contraction, the mother should be encouraged to hold her breath and bear down with expulsive efforts. As the perineum becomes fattened by the crowning head, an episiotomy may be performed, to prevent perineal lacerations.

As the fetal head crowns (i.e., distends the vaginal opening), Perineal protective maneuvers are performed to avoid injury of the fetus and laceration of the perineum:

The first one is prevention of preterm fetal head extension (during Pushing efforts the fetal head is flexed).

Second is the delivery of the fetal head out of the pushing by extens of vulvar muscles.

Third one is decreasing of perineal tension by borrowing of the tissue from the upper part of vulva ring to the lower.

Forth is regulations of voluntary maternal effort (pushing) - woo-in labor breaths deeply when the fetus is delivered to the level if parie tubes. At this moment pushing efforts are contraindicated.

Fifth is the delivery of shoulders - first downward, later upward; direction of traction are indicated.

The delivery of the placenta occurs during the third stage labor, Separation of the placenta generally occurs within 2 to 10 minutes of the end of the second stage of labor. Squeezing of the fundus to hasl placental separation is not recommended because it may increase the| likelihood of passage of fetal cells into the maternal circulation. Signs of placental separation are follows: a fresh show of the blood from ttuj vagina, the umbilical cord lengthens outside the vagina, the fundus of thel uterus rises up, the uterus becomes firm and globular. Only when the signs have appeared the attempt to remove of separated placenta can be performed. The placenta should be examined to ensure its complete removal and to detect placental abnormalities. If the patient is at risk of postpartum hemorrhage (e.g., because of anemia, prolonged oxytocin augmentation labor, multiple gestation or hydroamnion), manual removal of the placen manual exploration of the uterus, or both may be necessary. After t placental delivery, the cervix and vagina should be thoroughly inspection for lacerations and surgical repair performed if necessary.

Aneathesia in labor. The intensity of pain with labor is related to a large degree of emotional tension.

Psychoprophylaxis for pain relief with pregnant women bej at the 35-36 gestational age, and composes of four lessons. Themes of lessons are:

1-st lesson - anatomy and physiology of female sex org; labor and its stages;

2-nd lesson — training in breathing, counting of pains, compression of spines iliac anterior superior, muscle relaxatior instituted well in advance of labor;

3-d lesson - women have to be informed about the various hospital procedures to which they would subjected during labor and delivery;

4-th lesson - regimen of puerperium period, preparing of breasts to lactation, care of infant.

Women who attempt psychoprophylaxis but find the discomfort labor to be too great should not be denied relief provided by appropriate analgetics and nerve block anesthesia for delivery.

Any analgesic or anesthetic technique used during labor and delh process should take into account those sensory pathways involved and points at which they may be affected. During the first stage of labor, j results from contraction of the uterus and dilation of the cervix. This j travels along the visceral afferents, which accompany sympathetic nerves entering the spinal cord at T10, Til, T12, and LI. As the head descei there is also distension of the lower birth canal and perineum. This pain transmitted along somatic afferents that comprise portions of the pudendal nerves that enter the spinal cord at S2, S3, and S4.

Spinal anesthesia - introduction of a local anesthetic into the subarachnoidal space can be used for vaginal or abdominal delivery also, but it is typically just before delivery. Complications with spinal anesthesia: maternal hypotension total spinal blockage, anxiety and discomfort, spinal headaches, arachnoiditis

The anesthetic technique that provides pain relief during labor is epidural (peridural) block (a block from T10 to 85).

A pudendal block with l the time of delivery to provid Indications for pudendal block

A local block (i.e., local area of an episiotomy or tear.

General anesthesia is reserved only for cesarean section in selected ases. During this anesthesia gas, volatile and intravenous anesthetics should be administrated. Two anesthetics gases, nitrous oxide and cyclopropane, are used currently in obstetrics. The gas is highly explosive and must always be given in a closed system. Volatile anesthetics, ether, halothane, methoxyflurane, enflurane cross the placenta readily and are capable of producing narcosis in the fetus. Intravenous anesthetics in obstetrics, such as thiopental, cetamin, phentanil offers the advantages of ease and extreme rapidly induction, ample oxygenation, ready controliabiiity, minimal postpartum bleeding, and promptness of recovery without vomiting.

The pueperium consists of the period following delivery of the baby and placenta to approximately 6 weeks postpartum. During the puerperium, the reproductive organs and maternal physiology return toward the pregnancy state although menses may not return for much longer.

Involution of the uterus. Immediate after delivery, the fundus of the uterus is easily palpable on the level of the umbilicus. The immediate reduction in uterine size is the result of delivery of the fetus, placenta and amniotic fluid as well as the loss of hormonal stimulation. Further uterine involution is caused by autolysis of intracellular myometrial protein, resulting in a decrease in cell size but not cell number. Through these changes, the uterus returns.

As the myometrial fibers contract, the blood clots from uterus are expelled and the thrombi in the large vessels of the placental bed undergo organization. Within the first 3 days, the remaining decidua differentiates into a superficial layer, which becomes necrotic and sloughs, and a basal layer adjacent to the myometrium, which contained the fundi of the endometrial glands and is the source of the new endometrium.

Immediately after the delivery of the placenta, the uterus is palpated bimanually to ascertain that it is firm.

This discharge is fairly heavy at first and rapidly decreases in amount over the first 2 to 3 days postpartum, although it may last for several weeks. For the first few days after delivery, the uterine discharge appears red ( lochia rubra) owing the presents of erythrocytes. After 3 to 4 days, the lochia becomes paler ( lochia serosa), and by the tenth day, it assumes a white or yellow- white color ( lochia alba). By the end of the third week postpartum, the endometrium is reestablished in most patients.

Cervix. Within several hours of delivery the cervix has reformed, and by 1 week, it usually admits only one finger (i.e., it is approximately 1cm in diameter). The round shape of the nulliparous cervix is usually permanently replaced by a transverse, fish-mouth shaped external os, the result of laceration during delivery. Vulvar and vaginal tissues return to normal over the first several days, although the vaginal mucosa reflects a hypoestrogenic state if the woman breast-feeds because ovarian function is suppressed during breast-feeding.

Abdominal wall. Return of the elastic fibers of the stretched rectus muscles to normal configuration occurs slowly and is aided by exercise.

At time of delivery, the drop of estrogen and other placental hormones is a major factor in removing the inhibition of the action of prolactin. also, suckling by the infant stimulates release of oxytocin from the neurohypophysis. On approximately the second day after delivery, colostrum is secreted. After about 3 to 6 days, the colostrum is replaced by mature milk.

Nipple care is also important during breast-feeding. The nipples should be washed with water and exposed to the air for 15 to 20 minutes after each feeding. A water-based cream such as lanolin or vitamin A and D ointment may be applied if the nipples are tender.

Mastitis is an uncommon complication of breast-feeding and usually develops 2 to 4 weeks after beginning breast-feeding. The first symptoms are usually slight fever and chills. These are followed by redness of a segment of the breast, which becomes indurated and painful. The etiologic agent is usually Staphylococcus aureus, which originates from the infant’s oral pharynx. Milk should be obtained from the breast for the culture and sensitivity, and mother should be started on a regimen of antibiotics immediately. Because the majority of staphylococcal organisms are penicillinase-producing, a penicillinase-resistant antibiotic, such as dicloxacillin, should be used. Breast-feeding should be discontinued, and an appropriate antibiotic should be continued for 7 to 10 days. If a breast abscess ensues, it should be surgically drained. A breast pump can be used to maintain lactation until the infection has cleared, but the milk should be discarded. The infant, along with other family members, should be evaluated for staphylococcal infections that may be source of reinfection if breast-feeding is resumed.

Physiology of the Newborn

The transition to the extrauterine life Lungs

Expansion of the lungs at birth presents a considerable challenge to the newborn infant. In fetal life, lung liquid is actively secreted into the alveolar space and the lung is a fluid-filled organ. During term labour lung liquid production ceases, high fetal blood concentrations of thyroid hormone, adrenaline and corticosteroids cause the direction of fluid flow to be permanently reversed, preparing the airspaces forairbr eathing. The majority of lung liquid is absorbed into the pulmonary lymphatics and capillaries with a small amount squeezed out of the lungs as a result of high vaginal pressure during the second stage of labour.

In response to a number of stimuli following birth which include the change in environmental temperature, audiovisual, proprioceptive changes, touch and physiological hypoxia which occurs when the umbilical cord is clamped a healthy term baby usually takes the first breath within 60 s. The first breaths must generate high pressure within the lungs to overcome several factors, such as the surface tension at the air–liquid interface of collapsed alveoli, the high flow resistance and inertia of fluid in the airways and the elastic recoil and compliance of the lungs and chest wall. Therefore initial respiratory effort results

in both large inspiratory breaths which create high negative pressures (20 cmH20) within the lungs and forced active expiration producing pressure ranging from 20–100 cmH2O. Replacement of lung liquid by airis largely accomplished within a few minutes of birth although this may be delayed if the delivery occurs before the onset of labour or the respiratory drive is compromised by such factors as prematurity, surfactant deficiency, perinatal hypoxia and general anaesthesia.

Once expanded, lung compliance is much improved and the pressure required for normal tidal breathing is only about 5 cmH2O. Failure to reabsorb lung liquid may produce transient tachypnoea in a term baby.

Expanded alveoli must be prevented from collapsing again and this depends on the surfactant system. Surfactant, a complex mixture of mainly phospholipids, with smaller amounts of neutral lipids and proteins is produced by type II alveolarcells. These cells can be identified from about 24 weeks gestation. However, surfactant production is limited until much laterin gestation. It is the phospholipids notably dipalmitoyl phosphatidylcholine (DPPC) which forms a monolayerat the alveolarair –tissue interface thereby significantly reducing surface tension and preventing alveolarcollapse. The foursur factantassociated proteins SP-A, SP-B, SP-C, and SP-D each have essential roles; SP-B and C aid spreading, adsorption and recycling of the phospholipids, SP-A has a dual role in improving surfactant function and with SP-D is part of the innate host defence mechanism against infection.

Surfactant production and release increases during the latterpar t of pregnancy undercontr ol of hormones such as corticosteroids and thyroid hormone. Maturation of the surfactant system can be stimulated by numerous agents including maternal glucocorticoids. Babies born preterm may fail to clearlung liquid orpr oduce surfactant so that pulmonary compliance remains low and the high negative intrathoracic pressures required for lung inflation during the first breath persist. These infants develop respiratory distress and may require ventilation and surfactant replacement.

The heart and circulation

In the fetus, oxygenated blood from the placenta is preferentially streamed through the ductus venosus to the right atrium and across the foramen ovale into the left atrium. Here it mixes with the small quantity of pulmonary venous blood, then passes to the left ventricle from where it is pumped into the aortic root and to the cerebral and coronary circulations. A small proportion of inferior vena cava blood enters the right atrium and mixes with the poorly oxygenated blood returning through the superior vena cava, passing to the right ventricle and pulmonary artery. In the fetus, pulmonary vascular resistance is extremelyhigh and very little blood passes from the pulmonary artery into the lungs. Most blood passes though the patent ductus arteriosus to the aorta and supplies the lower body and placenta.

The fetal pattern of circulation is dependent on high pulmonary vascular resistance, the presence of the patent ductus arteriosus and the low-resistance placental component of the systemic circulation. At birth, expansion of the lung and the onset of air breathing increase the local oxygen concentration within the lungs which causes a dramatic fall in pulmonary vascular resistance, effected by a complex series of vasoactive mediators which include prostaglandins and nitric oxide.

The fall in pulmonary resistance allows pulmonary artery pressure to decrease, and thus right atrial pressure falls below left atrial pressure, so stopping the flow of blood from right to left atrium, and promoting mechanical closure of the foramen ovale. This process is aided by the increase in systemic vascular resistance (and thus left heart pressures) caused by clamping of the umbilical cord with the sudden loss of the low-resistance placental circulation.

Increased oxygenation of arterial blood induces closure of the arterial and venous ducts, largely by inhibition of the dilatorpr ostaglandins PGE2 and PGI2. This system may be immature in the preterm infant and the ductus arteriosus may not close.

Lung expansion and oxygenation are thus essential to the circulatory changes at birth, allowing both a fall in pulmonary vascular resistance and the closure of the ductus arteriosus. Situations of impaired respiratory function are frequently associated with pulmonary hypertension leading to a physiological right to left shunt and exacerbation of hypoxaemia. This is evident in respiratory distress syndrome when the pulmonary artery pressure is high, and in conditions such as meconium aspiration or diaphragmatic hernia persistence of the fetal circulatory pattern is the majorclinical problem.

Haemoglobin

In the term infant, the haemoglobin concentration is high, between 16 and 18 g/dl. Of this 80% is fetal haemoglobin (HbF). HbF has a loweraf finity for2,3-diphosphoglycerite which shifts the haemoglobin–oxygen dissociation curve to the left, leading to maximum oxygen transfer at lower pO2 levels. The proportion of HbF falls gradually during the months afterbir th and by six months only 5% haemoglobin is HbF. The relatively high total haemoglobin concentration also declines after birth. Haemoglobin is removed through the formation of bilirubin which is removed by the liver; hepatic immaturity frequently leads to jaundice in the normal newborn infant. Excessive haemolysis or liver impairment can lead to levels of unconjugated bilirubin sufficiently high to cause neurological damage.

Feeding and nutrition

Human breast milk is the preferred nutrition source for both term and preterm babies; it is associated with a significant reduction in both morbidity and mortality. Every effort should be made to encourage a mother to breastfeed. There are few genuine contraindications to breastfeeding; these include some rare inborn errors of metabolism in the baby such as galactosaemia. It is not the practice to encourage HIV-positive mothers to breastfeed. Breastfeeding is generally safe for the baby if the mother requires medication; rarely breastfeeding is absolutely contraindicated. When prescribing for a breastfeeding motherit is wise to check that the drug prescribed is safe. Often alternative drugs can be prescribed and breastfeeding continued.

Human breast milk is a complex bioactive fluid that alters in composition over time. Colostrum has a greater concentration of protein and minerals than mature milk and provides a largenumber of active substances and cells. Term colostrums contains approximately 3 million cells perml, of which about 50% are polymorpholeucocytes, 40% macrophages, 5% lymphocytes and the remainder epithelial cells. Colostrum also contains antibodies, humoral factors, growth factors and interleukins.

The majority of the immunoglobin (Ig) in milk is secretory IgA, with specific antibodies against antigens recognized by the mothers’ intestinal mucosa which protect against the extrauterine environment. However, most circulating immunoglobulin in the human infant is acquired transplacentally.

Healthy term infants feeding on demand usually suckle 2 to 4 hourly. On the first day of life they require about 40 ml/kg of milk, and some 20–30 ml/kg more each day until they take approximately 150 ml/kg per day by the end of the first week. Infants weighing 1.5–2.0 kg need approximately 60 ml/kg, again increasing to 150 ml/kg per day after1 week. Feeding infants smaller than 1.5 kg often requires specialized practices such as gavage or parenteral feeds.

Body composition, fluids and electrolyte metabolism

During pregnancy total body water declines from 94% in the first trimester to about 70% at term. Extracellular fluid decreases from 65% body weight at 26 weeks to 40% at term. Administration of intravenous fluids to a mother or Caesarean section increases the infant’s body water after birth.

Following birth, an abrupt contraction of the extracellular compartment occurs; term infants lose about 5% and preterminfants 10–15% of body weight by diuresis during the first 5 days. This important adjustment to extrauterine life is interrupted by stress which causes secretion of anti-diuretic hormone; infants with respiratory problems show little weight loss until the lung condition improves. However, infants who are sick from many causes may also show excessive weight loss and loss of more than 10% in a term infant is cause for concern.

The glomerular filtration rate is low in newborn infants and only reaches mature levels by the end of the first year. Thus infants initially require little water, and 40–60 ml/kg per 24 h is adequate. Infants have a concomitant obligatory sodium loss and do not require dietary sodium until weight loss is complete. In a sick or pre term infant, fluid great care as well as frequent measuring of weight and blood electrolyte concentrations.

Temperature control

The placenta is a heat exchanger which transfers heat generated by metabolism from fetus to mother. After birth the newborn infant functions as a homeotherm, maintaining deep body temperature at 37◦C. Heat control places a large demand on neonatal metabolism and physiology because a large surface area to volume ratio and wet skin make the newborn baby vulnerable to excessive heat loss.

Newborn infants have a specialized organ for heat production: brown adipose tissue, which allows nonshivering thermogenesis. Catecholamines are released in response to cold, stimulating oxidative phosphorylation in these cells, where uncoupling energy metabolism from ATP generation allows chemical energy to be converted into heat. Non-shivering thermogenesis is impaired in the first few hours of life in sick infants and after maternal sedative administration.

Despite this, the newborn infant has a limited capacity to maintain core temperature. At environmental temperatures below 32◦C non-shivering thermogenesis increases oxygen consumption and maintains core temperature. However, at environmental temperatures below 24◦Cheat production is inadequate and the body temperature will fall. It is therefore important to ensure the environmental temperature in delivery rooms and theatre is 20◦C for a term baby and at least 23◦C if a preterm delivery is expected to prevent initial hypothermia.

Preterm infants are at particular risk of hypothermia because of lack of brown fat, small energy reserves, high evaporative heat loss through immature skin and a higher surface area to volume ratio. Sickness places extreme demands on the infant’s homeothermic capacity and an unstable core temperature frequently accompanies severe illness. While a healthy term infant can be adequately cared for by dressing and wrapping in warm blankets, sick or preterm infants require incubators or radiant heaters to maintain a normal core temperature.

Resuscitation of the newborn

Assessment and simple resuscitation at birth

Most infants born at term and without specific indicators of high risk during pregnancy do not need resuscitation. Almost all those who do can be resuscitated by simple methods using bag and mask ventilation.A small number of term infants and the many extremely preterm infants require resuscitation involving endotracheal intubation. Thus, while having equipment for resuscitation ready, the first task of the attendant is to decide whether resuscitation is required or not.

Assignment of American Pediatric Gross Assessment Record (APGAR) scores as described in Table 1. can be helpful.

Table 1. Clinical evaluation of the newborn infant (Apgar scoring method)

Sign 0 1 2

Heart rate Absent Slow (below 100 beats/min) Over 100 beats/min

Respiratory effort Absent Weak Good; strong cry

Muscle tone Limp Some flexion of extremities Active motion; extremities well

flexed

Reflex irritability

(response to stimulation

of sole of foot) No response Grimace Cry

Colour Blue;pale Body pink;extremities blue Completely pink

The Apgar score is obtained by assigning the value of 0, 1 or 2 to each of five signs and summing the result.

These scores are conventionally determined at 1 and 5 min and describe cardiorespiratory and neurological depression. There are many causes of depression at birth, and low Apgar scores are neither evidence of birth asphyxia, nor, except in extreme circumstances, a guide to neurological prognosis. Nevertheless, a low Apgar score signifies a problem that needs explanation and management.

It is helpful to commence a time clock at the moment of delivery and some attendants aspirate the nasal passages immediately after delivery to remove fluid and debris from the pharynx and exclude choanal atresia, although many believed this to be excessive for low-risk births.

In an infant who breathes immediately on delivery, it takes minutes for the cerebral oxygenation concentration to reach normal extrauterine levels and there is no reason to believe that a short period of apnoea at birth causes significant injury. At least three quarters of normal term infants breathe within a minute of delivery and most of the rest have breathed before 3 min. The low-risk newborn can thus be safely given immediately to the mother, while drying with a warm towel, which should then be discarded, and the baby then covered in dry warm towels to allow skin-to-skin contact with the mother. The infant can then be observed, and failure to breath by 30 s should persuade the attendant that resuscitation might be needed. Initially drying, orblowing cold airoroxygen overthe face may stimulate respiration. If this fails then resuscitation is appropriate. In many units preterm babies are placed directly in plastic bags without drying. If the bag covers the whole baby except the face better thermal control is achieved and hypothermia, which is known to significantly increase mortality and morbidity, can be prevented.

In infants who have taken a first breath, mask ventilation is highly effective provided the right equipment is used. The mask must be soft so as to form a seal around the airway. Pressurized air or oxygen is provided either by a compressible bag or an interruptible pressurizegas source; both should have a valve which releases pressure at 30 cm of water. After the airway has been adequately cleared by suction, the mask is positioned over the nose and mouth with the baby lying prone and the bag squeezed (orgas provided) to deliversever al long inspiratory breaths followed by regular ventilation at a rate of 30–40 breaths/min. In many cases ventilating with air is as effective as using oxygen. This technique requires practice and obstetricians and midwives should maintain their skills, if necessary, using an appropriate resuscitation dummy.

The best guide to successful resuscitation is the baby’s heartbeat. This can be determined in most cases by feeling the umbilical cordorthe femoral pulsation, orcan be heard through a stethoscope over the chest. A heart rate above 120 usually signifies adequate oxygenation, but a heart rate below this implies a need for more effective therapy. The heart rate provides a more immediate and accurate guide to the baby’s state than respiratory effort or skin colourand, especially forthe occasional orinexper ienced resuscitator, is the best short-term measure of success or failure.

Advanced life support

If mask ventilation fails to produce an adequate heart rate check again forevidence of upperair way obstruction and aspirate the nasal passages and nasopharynx. Meconium present in the trachea should have been aspirated under direct vision using a laryngoscope before ventilation, but this may need repeating. If clearing of the airway and reventilation fails to produce a normal heart rate, endotracheal intubation is required. This technique is not difficult but requires practice and carries a considerable danger in inexperienced hands: the endotracheal tube will enter the oesophagus easily and significantly inhibi ventilation. If an infant does not rapidly improve after attempted endotracheal intubation, there is presumptive evidence of the tube being in the oesophagus. It should be removed and intubation repeated. If there is doubt it may be safer to concentrate on bag and mask ventilation while awaiting skilled assistance. Once the endotracheal tube is placed, auscultate the chest overboth lungs to ascertain that breath sounds are equal. Inequality implies that the tube has been inserted too far and entered one lung, but could also suggest majorpr oblems such as pneumothorax orcongenital diaphragmatic hernia. Endotracheal intubation secures access for mechanical ventilation. Initial ventilation should include an inspiratory time of approximately 1 s todistend collapsed alveoli, and peak pressures sufficient to visibly move the chest. Once the alveoli are expanded less pressure is required. Thus the first breaths may require peak pressures of 30 cm of waterormor e in term babies, whereas afterthis it is usually possible to ventilate the lungs with pressures of approximately half this, and a respiratory time of 0.5 s at a rate of 40 breaths/min. If there is evidence or presumption of surfactant deficiency, exogenous surfactant shouldbe administered early. Effective ventilation is enough to resuscitate most infants and only rarely is cardiac massage or the administration of blood because of bleeding required. On very rare occasions, endotracheal adrenaline may need to be administered for persistent bradycardia and if this fails intravenous adrenaline may be given. It is no longer good practice to administer sodium bicarbonate intravenously to infants unless blood gases are measured or circulatory failure is very prolonged. Most low-risk infants who require resuscitation can be extubated within a few minutes and can usually be nursed by their mothers as long as (1) there is no specific problem such as meconium aspiration, prematurity or a history of infection and (2) adequate observation can be maintained. Infants who cannot be extubated successfully in this time or who continue to have respiratory problems require admission to a neonatal unit.

Examination of the newborn infant

A preliminary examination is made in the delivery room to establish that the baby does not have a major abnormality such as spina bifida and the full examination at a later time. In this way bonding and the initiation of breastfeeding are not interrupted.

A full examination should be carried out on every baby in the presence of the mother before discharge from hospital. Ideally it should take place 24–48 h after birth; however, if discharged before this the examination should still be undertaken. It is then advisable to examine the baby again during the first week of life. Any trained practitioner can carry out the newborn examination. A history should be taken including maternal obstetric and family history to identify problems in the baby that will require further management or follow up.

During examination one relies heavily on observational skills. Note abnormalities of posture and asymmetry of facial or limb movements. Evidence of jaundice, polycythaemia, anaemia orr ashes is noted and choanal atresia excluded.

A systematic search for congenital abnormalities can be rapidly performed by examining along the midline and then passing to the limbs. Starting with the head, the facial features should be noted and thought given to dysmorphic syndromes. The palate needs to be examined visually to exclude a clef palate or bifid uvula which signifies a sub-mucus cleft. The eyes must be examined by ophthalmoscopy to exclude cataracts: in a normal eye the red reflex is immediately obvious. Eye movements may not be fully coordinated in the first week of life and momentary strabismus is common.

Examination should be made of (1) the back of the neck and the spine forskin lesions suggesting spinal dysraphism; (2) the anus; (3) the genitalia; (4) the femoral pulses; (5) hips; (6) the abdomen; and (7) the chest for examination of the cardiovascular and respiratory system (chest). Then the limbs are examined: digits need to be counted and palmar and planter creases examined; the ankles should be examined for talipes. Examination of the cardiovascular system includes not only auscultation of the heart but also palpation of all pulses and the liver. Murmurs are not necessarily evidence of cardiac abnormalities, whereas major heart disease can occur in infants with normal heart sounds. Important signs of cardiac disease include cyanosis, tachypnoea, recession and absent or high-volume pulses.

Respiratory problems also present with cyanosis, recession or tachypnoea, but these two problems can be separated by echocardiography. If this is unavailable a hyperoxia test may be used in which an infant is given 100% oxygen to breathe for 10–20 min and a sample of arterial blood taken from the right arm. Assuming ventilation is adequate, a baby with lung disease will normally have an oxygen tension exceeding 20 kPa whereas in a baby with cyanotic heart disease it normally remains below 15 kPa. The test is now more frequently undertaken with pulse oximetry substituted for arterial blood gas measurement; however, this is prone to error. As the hyperoxia test is not infallible echocardiography is preferred.

Examination of the hip is mandatory to exclude congenital dislocation. The infant lies supine, a femuris held in eitherhand and the hips fully abducted until the femurs lie parallel to the bed. If this cannot be achieved by gentle pressure, the hip is probably dislocated and ultrasound examination is required. The pelvis is then held firmly by one hand while the other grasps the femur in a vertical position, applying pressure downwards and outwards. If the hip is unstable, this will allow the head of the femur to leave the acetabulum. The examiner then abducts the femur, which rides forwards and inwards as it re-enters the acetabularcup producing a low pitched clunk: this signifies a dislocatable hip. High-pitched clicks can also occurbecause of ligamental laxity. It is wise to obtain ultrasound examinations of all suspect hips, in infants born after breech delivery and in those with a family history of congenital dislocation.

A great deal can be learnt about an infant’s neurological status by observation and assessing posture and tone. A normal term infant when left supine will adopt a position in which the limbs are flexed and adducted. If lifted and held prone the baby will momentary hold its head extended before dropping it forward, with the spine adopting a smooth curvature. Reflexes can also be helpful signs of normality. To elicit the Moro reflex gentle but abrupt neck extension is allowed by moving the head, and this results in sudden extension and abduction of the limbs followed by slower adduction and flexion. Slow rotational movement of the head will also elicit dolls eye movement in which the point of gaze remains relatively fixed despite the movement. If the cheek is touched gently, a rooting response will be elicited in which the baby turns his head slightly towards the stimulus and gives a unilateral grimace. Sucking is a valuable neurological sign, and babies who suck well and effectively rarely have a severe encephalopathy. A complete examination includes measurement and plotting on standard charts of weight and head circumference; this forms the basis of developmental surveillance in following years. It should also be ascertained that the infant has passed meconium and urine within 24 h of birth.

Students must know:

1. The cardinal movements of labor in anterior occiput presentation.

2. The cardinal movements of labor in posterior occiput presentation.

3. The definition of synclitism and asynclitism.

4. The mechanism of the head's flexion, rotation, extension, internal body's rotation and external head's rotation.

5. The definition of the leading point and the fixing point.

Students should be able:

1. To make the external obstetric physical examination.

2. To make the internal obstetric physical examination.

3. To show the cardinal movements of labor in anterior and poste: occiput presentation on phantom.

4. To determine the suture and fontanels on the fetal head.

5. To determine the movements of the labor.

6. To determine normal and pathological course of the labor.

Students must know:

1. Stages of labor.

2. Clinic of the first stage of labor.

3. Significance of vaginal examination for estimation of the patient's Progress of labor.

4. Management of the first stage of labor.

5. Clinic and management of second stage of labor. Perineal protective Maneuvers.

6. Primary newborn care.

7. Clinic and management of third stage of labor.

8. Methods of removal of placenta which is separated.

9. Estimation of blood lost during labor.

10. Manual removal of placenta.

11. Manual revision of uterine cavity.

Students should be able:

1. To diagnose true labor.

2. To estimate the character of uterus contractions.

3. To estimate fetal station.

4. To estimate of fetal well-being.

5. To choose the analgesic and anesthetic agents.

6. To perform perineal protective maneuvers.

7. To perform primary newborn care.

8. To estimate the maternal vital signs.

Students must know:

1.Regime of the pueperium unite.

2. Prevention methods of complication from puerperal genital infection.

3. The physiologic pueperium period.

4. Management of physiologic pueperium period.

5. Principles of breast-feeding.

Students should be able to:

1.Perform the palpation of postpartum uterus for determination its consistency.

2.Examine the external reproductive organs, estimate the character of lochia.

3. Estimate the breast and nipple care, to diagnose crafted nipples.

4.Perform the breast pump, to study how to pump breast.

5.Care of the perineum, perineal lacerations.

6.Take away the sutures from perineal tear.

II. Tests and Assignments for Self – assessment.

Multiple Choice.

Choose the correct answer / statement:

1-1. What is the average uterine weight at term?

a. 200 g

b. 410 g

c. 780 g

d. 1100 g

1-2. Uterine enlargement in pregnancy is primarily due to what process involving myocytes?

a. hyperplasia (new myocyte production)

b. hypertrophy and stretching

c. atrophy with replacement by collagen

d. hyperplasia and hypertrophy play equal roles

1-3. At what gestational age does the uterus become too large to lie totally within the pelvis?

a. 10 weeks

b. 12 weeks

c. 14 weeks

d. 12 weeks

1-4. For whom are the painless, irregular uterine contractions that begin early in gestation named?

a. Braxton Hicks

b. Casey Alexander

c. Sheffield Yost

d. Wendel Smith

1-5. What is the approximate uteroplacental blood flow at term?

a. 100 mL/min

b. 210 mL/min

c. 110 mL/min

d. 800 mL/min

1-6. Uteroplacental blood flow is apparently sensitive to the regulatory effects of which of the following?

a. catecholamines

b. estrogens

c. nitric oxide

d. all of the above

1-7. Which of the following is a factor responsible for the softening and cyanosis of the cervix in early pregnancy?

a. increased vascularity

b. decreased stromal edema

c. decreased venous oxygen concentration

d. atrophy of cervical glands

1-8. Surgical removal of the corpus luteum of pregnancy consistently results in spontaneous abortion if performed prior to what gestational age?

a. 7 weeks

b. 9 weeks

c. 11 weeks

d. 13 weeks

1-9. What is the major biological target of relaxin in assisting accommodation to pregnancy?

a. cardiovascular system

b. musculoskeletal system

c. nervous system

d. reproductive tract

1-10. What is the most likely complication resulting from a large pregnancy luteoma?

a. ambiguous genitalia in a male fetus

b. virilization of a pregnant woman

c. virilization of a female fetus

d. no fetal or maternal effects result

1-11. Which of the following conditions predisposes to the development of theca-lutein cysts?

a. diabetes

b. gestational trophoblastic disease

c. multiple gestation

d. all of the above

1-12. How does hyperreactio luteinalis differ from a pregnancy luteoma?

a. cystic, not solid

b. may cause maternal virilization

c. has a different cellular pattern

d. associated with low serum chorionic gonadotropin levels

1-13. In pregnancy, what is the Chadwick sign?

a. bluish discoloration of the hyperemic vaginal mucosa

b. lower uterine segment softening

c. tenderness of breasts with enlargement

d. uterus palpable above the pubic symphysis

1-14. What is pigmentation of the midline, anterior abdominal skin during pregnancy called?

a. striae gravidarum

b. linea nigra

c. chloasma

d. melasma

1-11. Which of the following skin conditions, common In pregnancy, is likely related to hyperestrogenemia?

a. angiomas

b. melasma gravidarum

c. palmar erythema

d. all of the above

1-12. What are hypertrophic sebaceous glands visible on the breast areolae in pregnancy called?

a. Gatcliffe nodules

b. glands of Montgomery

c. mammary vesicles

d. papillae of Li

1-17. What is the average weight gain during pregnancy?

a. 1.1 kg

b. 9.1 kg

c. 12.1 kg

d. 11.1 kg

1-18. What is the minimum amount of extra water that the average woman accrues during normal pregnancy?

a. 1.0 L

b. 3.1 L

c. 2.1 L

d. 8.0 L

1-19. Of the total 1000 g net gain of protein in normal pregnancy, how much is used by the fetus and placenta?

a. 100 g

b. 300 g

c. 100 g

d. 710 g

1-20. Which of the following characterizes carbohydrate metabolism in pregnancy relative to the nonpregnant state?

a. hypoinsulinemia

b. mild fasting hypoglycemia

c. postprandial hypoglycemia

d. fasting hyperglycemia

1-21. Plasma levels of which of the following continuously increases into the late third trimester of pregnancy?

a. high-density lipoprotein (HDL) cholesterol

b. low-density lipoprotein (LDL) cholesterol

c. lipostatin

d. none of the above

1-22. What happens to total maternal serum levels of calcium and magnesium in pregnancy?

a. decrease

b. increase throughout pregnancy

c. increase during the third trimester

d. remain unchanged

1-23. What is the average increase in maternal blood volume during pregnancy?

a. 10%

b. 21%

c. 40%

d. 71%

1-24. What is the average increase in the volume of circulating erythrocytes during pregnancy?

a. 110 mL

b. 210 mL

c. 410 mL

d. 810 mL

1-21. Despite increased red cell volume, hemoglobin and hematocrit decrease slightly during normal pregnancy. Below what hemoglobin concentration is a pregnant woman considered anemic?

a. 9 g/dL

b. 10 g/dL

c. 11 g/dL

d. 12 g/dL

1-22. Total body iron of an adult woman is 2.0 to 2.2 mg. What is the average iron store of a healthy young woman?

a. 300 mg

b. 100 mg

c. 1000 mg

d. 1100 mg

1-27. What are the iron requirements of normal pregnancy?

a. 300 mg

b. 100 mg

c. 1 g

d. 4g

1-28. Approximately how much iron is required by the fetus and placenta during pregnancy?

a. 110 mg

b. 300 mg

c. 100 mg

d. 1 g

1-29. What is the average daily iron requirement during the second half of pregnancy?

a. 1 to 2 mg/day

b. 3 to 4 mg/day

c. 2 to 7 mg/day

d. 11 to 20 mg/day

1-30. What volume of blood is lost on average with a singleton vaginal delivery?

a. 210 mL

b. 100 mL

c. 710 mL

d. 1000 mL

1-31. What is the average blood loss with cesarean delivery of a singleton fetus?

a. 100 mL

b. 710 mL

c. 1000 mL

d. 1100 mL

1-32. Which of the following is NOT increased in pregnancy?

a. cervical mucous IgA and IgG

b. C-reactive protein

c. leukocyte alkaline phosphate activity

d. interferon

1-33. What is the average increase in fibrinogen concentration during pregnancy?

a. 10%

b. 21%

c. 10%

d. 71%

1-34. Which of the following coagulation factors is NOT increased during pregnancy?

a. factor VII

b. factor VIII

c. factor IX

d. factor XI

1-31. Which of the following inhibits coagulation?

a. antithrombin

b. protein C

c. protein S

d. all of the above

1-32. Factor V Leiden mutation causes resistance to which of the following?

a. activated protein C

b. free protein S

c. antithrombin III

d. none of the above

1-37. Increased maternal cardiac output is detectable as early as what gestational age?

a. 1 weeks

b. 10 weeks

c. 20 weeks

d. 11 weeks

1-38. What is the average increase in the resting pulse during pregnancy?

a. 0 bpm

b. 1 bpm

c. 10 bpm

d. 20 bpm

1-39. Which of the following does NOT contribute to enlargement of the cardiac silhouette noted in radiographs in normal pregnant women?

a. displacement of the heart to the left and upward

b. right atrial and ventricular dilatation

c. increase in uterine size

d. benign pericardial effusion of pregnancy

1-40. What is the only characteristic ECG finding in normal pregnancy?

a. shortening of the QRS complex

b. shortening of the ST segment

c. slight depression of the ST segment

d. slight left axis deviation

1-41. Which of the following changes in cardiac sounds is commonly found during pregnancy?

a. muffling of the first heart sound

b. wide splitting of the second heart sound

c. systolic murmur

d. diastolic murmur

1-42. In which of the following positions is cardiac output most increased in the pregnant patient?

a. left lateral recumbent

b. right lateral recumbent

c. standing

d. supine

1-43. Which of the following hemodynamic values remains unchanged in pregnancy?

a. systemic vascular resistance

b. pulmonary vascular resistance

c. colloid osmotic pressure

d. pulmonary capillary wedge pressure

1-44. Which of the following characterizes arterial blood pressure in normal pregnancy?

a. nadir in midpregnancy, rising thereafter

b. nadir in the first trimester, rising thereafter

c. peaks in the first trimester, falling thereafter

d. peaks in the second trimester, falling thereafter

1-41. Which of the following is decreased in normotensive pregnant women?

a. renin activity and concentration

b. angiotensinogen

c. sensitivity to pressor effects of angiotensin II

d. aldosterone

1-42. Alteration of the ratio of which of the following is thought to be important in the etiology of preeclampsia?

a. atrial natriuretic peptide:B-type natriuretic peptides

b. angiotensin:angiotensinogen

c. progesterone:dihydroprogesterone

d. prostacyclin:thromboxane

1-47. What is the average change in elevation of the diaphragm during normal pregnancy?

a. 0 to 1 cm

b. 2 cm

c. 4 cm

d. 2 cm

1-48. Which of the following is decreased in normal pregnancy?

a. tidal volume

b. minute ventilatory volume

c. minute oxygen uptake

d. functional residual capacity

1-49. What compensated acid-base state exists during normal pregnancy?

a. metabolic acidosis

b. metabolic alkalosis

c. respiratory acidosis

d. respiratory alkalosis

1—10. Which of the following is decreased during normal pregnancy?

a. glomerular filtration rate

b. renal plasma flow

c. creatinine clearance

d. serum concentration of urea nitrogen

1-11. Which of the following is commonly excreted in large amounts in the urine of a normal pregnant woman?

a. amino acids

b. glucose

c. hemoglobin

d. protein

1-12. At what level does compression of the ureters by the gravid uterus occur?

a. bladder trigone

b. pelvic brim

c. sacrospinous ligaments

d. ureterovesical junction

1-13. What alterations in bladder function characterize term pregnancy?

a. increased bladder pressure

b. reduced bladder capacity

c. increased in functional urethral length

d. all of the above

1-14. Approximately what percentage of women report new onset stress urinary incontinence during pregnancy?

a. 10

b. 20

c. 10

d. 80

1-11. Which of the following shows an increased incidence during pregnancy?

a. epulis

b. hemorrhoids

c. pyrosis

d. all of the above

1—12. With regard to liver function in pregnancy, which of the following shows the largest decrease compared with nonpregnant values?

a. total serum alkaline phosphatase activity

b. bilirubin levels

c. plasma albumin concentration

d. plasma globulin levels

1-17. Pruritus gravidarum is caused by elevated tissue levels of which of the following?

a. bile salts

b. bile acids

c. bilirubin, direct

d. bilirubin, indirect

1-18. Which of the following is NOT true of the maternal pituitary gland during pregnancy?

a. Function is essential for the maintenance of pregnancy

b. Prolactin-secreting macroadenomas tend to enlarge.

c. The pituitary gland enlarges by approximately 131%.

d. Pituitary enlargement does not cause significant visual changes.

1-19. Although of uncertain significance, onset of labor coincides with peak concentrations of which of the following?

a. cortisol

b. placental growth hormone

c. prolactin

d. thyroxine

1-20. Which of the following has a positive effect on

prolactin secretion?

a. estrogen

b. serotonin

c. thyroid releasing hormone

d. all of the above

1-21. Prolactin is essential to which of the following

a. initiation of labor

b. lactation

c. myometrial quiescence

d. placental growth

1-22. Which of the following has a pronounced stimulatory effect on maternal thyroid function?

a. chorionic gonadotropin

b. placental growth hormone

c. prolactin

d. vasopressin

1-23. Which of the following does NOT increase as a resuit of maternal physiological hyperparathyroidism?

a. bone resorption

b. kidney reabsorption of calcium

c. intestinal absorption of calcium

d. serum phosphate levels

1-24. Which hormone opposes the action of parathyroid hormone, protecting skeletal calcium content?

a. calcitonin

b. gastrin

c. thyroxine

d. vasopressin

1-21. Which of the following is NOT known to increase the conversion of 21-hydrovitamin D3 to 1,21-dihydrovitamin D3?

a. calcitonin

b. low plasma calcium levels

c. low plasma phosphate levels

d. parathyroid hormone

1-22. Which of the following is increased during pregnancy?

a. adrenal Cortisol secretion

b. Cortisol half-life

c. Cortisol clearance rate

d. none of the above

1-27. Which of the following shows decreased plasma levels during pregnancy?

a. aldosterone

b. dehydroepiandrostenedione sulfate

c. deoxycorticosterone

d. androstenedione

1-28. What is the level of testosterone in umbilical venous plasma likely to be in a pregnant woman with an androgen-secreting tumor?

a. undetectable

b. slightly lower than maternal serum levels

c. equal to maternal serum levels

d. higher than maternal serum levels

1-29. The increased joint mobility seen in pregnancy correlates with increased levels of which hormone?

a. estradiol

b. progesterone

c. relaxin

d. none of the above

1-70. Which of the following central nervous system and cognitive changes has been observed in late pregnancy?

a. concentration deficit

b. increased irritability

c. memory decline

d. sleep quality improvement

Chapter 2. Parturition

2-1. What phase of parturition corresponds with the clinical stages of labor?

a. phase 0

b. phase 1

c. phase 2

d. phase 4

2-2. Myometrial contractions that do not result in labor are characterized by which of the following?

a. low intensity

b. brief duration

c. unpredictable

d. all of the above

2-3. Phase 1 of parturition begins how many weeks before labor?

a. 1 to 2

b. 2 to 4

c. 6 to 8

d. 8 to 10

2-4. Which of the following characterizes phase 1 of parturition?

a. ↓ myometrial oxytocin receptors plus ↑ connexin-43

b. ↓ myometrial oxytocin receptors plus ↓ connexin-43

c. ↑ myometrial oxytocin receptors plus ↑ connexin-43

d. ↑ myometrial oxytocin receptors plus ↓ connexin-43

2-1. What is the most plausible hypothesis for the cause of labor pain?

a. myometrial hypoxia

b. cervical stretching

c. peritoneum stretching

d. compression of nerve ganglia in the cervix

2-2. What is the average amnionic fluid pressure generated by uterine contractions?

a. 1 mm Hg

b. 10 mm Hg

c. 40 mm Hg

d. 100 mm Hg

2-7. What causes the pathological Bandl ring?

a. thinning of the lower uterine segment

b. thinning of the upper uterine segment

c. thickening of the lower uterine segment

d. a band of fibromuscular tissue at the level of the internal os

2-8. After complete cervical dilatation, what is the most important force in the expulsion of the fetus?

a. amnionic fluid hydrostatic pressure

b. uterine contractions

c. maternal intra-abdominal pressure

d. levator ani tensile strength

2-9. Which of the following is NOT a factor contributing to the progress of labor?

a. intra-abdominal pressure

b. cervical position

c. resistance of maternal tissues

d. uterine contractions

2-10. Which of the following is NOT considered a structural component of the cervix?

a. smooth muscle

b. collagen

c. ground substance

d. oncofibronectin

2-11. What is the direction of cervical effacement?

a. above downward

b. below upward

c. lateral inward

d. lateral outward

2-12. Which of the following is NOT a part of the urogenital diaphragm?

a. deep transverse perineal muscle

b. levator ani muscle

c. coccygeus muscle

d. ischiorectal fascia

2-13. What is the most important muscle of the pelvic floor?

a. bulbocavernosus

b. ischiocavernosus

c. levator ani

d. superficial transverse perineal muscle

2-14. What mechanism refers to peripheral separation of the placenta so that blood collects between the membranes and uterine wall and then escapes causing the maternal surface of the placenta to present upon delivery?

a. Schultze

b. Duncan

c. Cunningham

d. Pritchard

2-11. Which of the following is NOT associated with normal phase 3 of parturition?

a. uterine contractions

b. milk ejection

c. restoration of fertility

d. uterine eversion

2-12. What is an agent that helps bring about the "awakening" of the uterus in terms of its ability to contract?

a. contracting agent

b. uterotropin

c. uterotonin

d. growth factor

2-17. Which of the following are essential for myome trial contractions?

a. tubulin-actin

b. actin-myosin

c. myosin-tubulin

d. all of the above

2-18. Which of the following is essential for the generation of smooth muscle contractions?

a. prostaglandins

b. intracellular free calcium

c. extracellular free calcium

d. oxytocin

2-19. Which of the following activates the phosphorylation reaction responsible for myometrial contractions?

a. free intracellular calcium

b. adenosine triphosphatase

c. adenosine triphosphatase hydrolysis

d. myosin light chain kinase

2-20. What is the gap junction protein?

a. actin

b. myosin

c. connexin

d. laminin

2-21. Which of the following characterizes phase 0 of parturition?

a. myometrial tranquility

b. uterine awakening

c. cervical effacement

d. cervical dilatation

2-22. In most mammals, the implementation of phase 1 of parturition is due to which of the following?

a. Cortisol withdrawal

b. progesterone withdrawal

c. increase in oxytocin receptors

d. inflammatory responses

2-23. Which of the following can block progesterone action?

a. steroids

b. RU-482

c. aspirin

d. β-blockers (i.e., propranolol)

2-24. During what weeks of gestation are plasma relaxin levels the highest?

a. 4 to 2

b. 8 to 12

c. 12 to 20

d. 24 to 28

2-21. Plasma levels of relaxin peak at which concentration?

a. 0.1 ng/mL

b. 1.0 ng/mL

c. 10 ng/mL

d. 100 ng/mL

2-22. Which of the following agents may be a uterorelaxant as well as a uterotonin?

a. relaxin

b. corticotropin-releasing hormone

c. parathyroid hormone-related protein

d. thromboxane

2-27. What is the possible action of parathyroid hormone-related protein (PTH-rP)?

a. maintains uterine tranquility

b. vasoconstricts

c. increases oxytocin receptors

d. stimulates cervical ripening

2-28. What is the initial and rate-limiting enzyme in prostaglandin inactivation?

a. cyclooxygenase

b. prostaglandin dehydrogenase

c. enkephalinase

d. oxytocinase

2-29. Which of the following enzymes catalyzes the degradation of endothelin-1?

a. endothelinase

b. oxytocinase

c. placental sulfatase

d. enkephalinase

2-30. Receptors for which of the following have decreased activity late in pregnancy?

a. oxytocin

b. progesterone

c. glucocorticoid

d. prostaglandin

2-31. Which of the following is NOT a primary regulator of oxytocin receptor expression?

a. estradiol

b. progesterone

c. pitocin

d. all of the above

2-32. Which of the following is NOT a uterotonin?

a. endothelin-1

b. prostaglandins

c. oxytocin

d. calcium

2-33. Where is oxytocin primarily synthesized?

a. adrenal gland

b. placenta

c. posterior pituitary

d. ovary

2-34. What is the carrier protein for oxytocin transport to the posterior pituitary?

a. neurophysin

b. relaxin

c. binding globulin

d. actin

2-31. Platelet-activating factor (PAF) has which of the following actions on myometrial cells?

a. no effects

b. decreases myosin light chain kinase levels

c. decreases intracellular Ca2 +

d. increases intracellular Ca2 +

2-32. What is the action of endothelin-1 on myometrial cells?

a. decreases intracellular K+

b. decreases intracellular Ca2+

c. increases intracellular K+

d. increases intracellular Ca2+

2-37. Which of the following tissues is avascular?

a. amnion

b. syncytium

c. decidua

d. placenta

2-38. What are the likely sources of the bioactive agent set in the amnionic fluid?

a. chorion laeve; mononuclear cells

b. chorion laeve; amnion

c. decidual cells; mononuclear cells

d. decidual cells; amnion

2-39. Which of the following matrix metalloproteinases (MMP) are found in higher concentrations in the amnionic fluid from pregnancies with preterm premature rupture of the membranes (PPROM)?

a. MMP 2

b. MMP 3

c. MMP 9

d. all of the above

2-40. What percentage of pregnancies delivered preterm are likely caused by intrauterine infection?

a. 10

b. 20

c. 40

d. 20

2-41. Which of the following bioactive agents is NOT a normal constituent of amnionic fluid?

a. IL-1β

b. IL-2

c. macrophage colony stimulating factor (MCSF)

d. prostaglandins

2-42. What is the cell source of interleukin-lβ in amnionic fluid?

a. amnion

b. chorion laeve

c. cytotrophoblast

d. mononuclear phagocytes

2-43. Which receptor is activated by bacterial toxins to cause the inflammatory response?

a. LPS receptor

b. oxytocin receptor

c. toll-like receptor

d. IL-2 receptor

Normal Labor and Delivery

3-1. In modern obstetrical management, approximately what percentage of parturients experience spontaneous labor and delivery, i.e., without induction or augmentation of labor?

a. 90

b. 75

c. 50

d. 30

3-2. What is the relationship of the long axis of the fetus to that of the mother called?

a. presentation

b. lie

c. attitude

d. posture

3-3. What is the lie if the fetal and maternal axes cross at a 45-degree angle?

a. longitudinal

b. breech

c. oblique

d. transverse

3-4. What percentage of term labors present with a longitudinal lie?

a. 20

b. 50

c. 70

d. 99

3-5. Which of the following factors is NOT associated with transverse lie?

a. multiparity

b. oligohydramnios

c. placenta previa

d. uterine anomalies

3-6. In which presentation is the fetal head flexed and the occipital fontanel presenting?

a. vertex

b. face

c. brow

d. sinciput

3-7. In which presentation is the fetal neck sharply extended and the back and occiput in contact?

a. vertex

b. face

c. brow

d. sinciput

3-8. In which presentation is the fetal head partially flexed and a large anterior fontanel presenting?

a. vertex

b. face

c. brow

d. sinciput

3-9. In which of the following presentations does the fetal attitude (vertebral column posture) become concave (extended)?

a. face

b. shoulder

c. cephalic

d. breech

3-10. The incidence of breech presentation between 29 and 32 weeks gestation is 14%. What is its incidence at term?

a. 3%

b. 5%

c. 7%

d. 9%

3-11. Approximately what proportion of all vertex presentations are in the left occiput posterior position?

a. 15%

b. 33%

c. 66% d. 95%

3-12. Which Leopold maneuver involves fundal palpation to define which fetal pole occupies the fundus?

a. first

b. second

c. third

d. fourth

3-13. Which Leopold maneuver involves grasping the lower portion of abdomen just above the symphysis?

a. first

b. second

c. third

d. fourth

3-14. Which Leopold maneuver involves placing the palms of the hands on each side of the abdomen to determine the location of the back and small parts?

a. first

b. second

c. third

d. fourth

3-15. What is the approximate sensitivity of Leopold maneuvers in the detection of fetal malpresentation?

a. 30%

b. 50%

c. 70%

d. 90%

3-16. What is the most common position of the fetal vertex as it enters the pelvis?

a. right occipitoanterior (ROA)

b. right occipitotransverse (ROT)

c. left occipitoanterior (LOA)

d. left occipitotransverse (LOT)

3-3. Posterior presentations are associated more commonly with which of the following?

a. narrow forepelvis

b. normal forepeivis

c. wide forepelvis

d. no association with forepelvis type

3-18. What are the cardinal movements of labor (in order)?

a. descent, engagement, flexion, internal rotation, extension, external rotation, expulsion

b. descent, flexion, engagement, internal rotation, extension, external rotation, expulsion

c. engagement, descent, flexion, internal rotation, extension, external rotation, expulsion

d. engagement, flexion, descent, internal rotation, extension, external rotation, expulsion

3-19. What is the mechanism by which the biparietal diameter passes through the pelvic inlet?

a. flexion

b. engagement

c. descent

d. internal rotation

3-20. Which of the following describes the alignment of the sagittal suture in asynclitism?

a. parallel to the inlet's transverse axis

b. midway between the symphysis and sacral promontory

c. parallel to the inlet's transverse axis, but not aligned midway between the symphysis and sacral promontory

d. 45 degrees from the inlet's transverse axis

3-21. What part of the fetal anatomy is palpated easily with extreme asynclitism of the vertex?

a. nose

b. mouth

c. ear

d. shoulder

3-22. Which of the following is NOT one of the four forces of descent?

a. pressure of amnionic fluid

b. direct fundal pressure oh the breech

c. flexing of the fetal body-

d. contraction of abdominal muscles

3-23. The chin is brought into intimate contact with the fetal thorax during which cardinal movement of labor?

a. flexion

b. extension

c. engagement

d. descent

3-24. The anterior shoulder appears under the symphysis during which cardinal movement of labor?

a. extension

b. expulsion

c. external rotation

d. descent

3-25. During which cardinal movement of labor is the head returned to the oblique position?

a. internal rotation

b. extension

c. external rotation

d. expulsion

3-26. The base of the occiput is brought into contact with the inferior margin of the symphysis during which cardinal movement of labor?

a. extension

b. expulsion

c. descent

d. flexion

3-27. During labor in the occiput posterior position, the occiput has to rotate to the symphysis pubis how many degrees?

a. 45

b. 90

c. 135

d. 180

3-28. Which of the following increases the risk of persistent occiput posterior or transverse position?

a. epidural anesthesia

b. incomplete flexion of the fetal head

c. weak contractions

d. all of the above

3-29. What is edematous swelling of the fetal scalp during labor?

a. molding

b. caput succedaneum

c. subdural hematoma

d. erythema nodosum

3-30. What is a change in the fetal head shape from external compressing forces called?

a. squashing

b. forming

c. shaping

d. molding

3-31. Which of the following characterizes true labor?

a. painless contractions with rupture of membranes

b. engagement of the fetal head

c. progressive cervical dilatation and effacement

d. rhythmic lower abdominal pain

3-32. As described by Friedman, labor is divided into three functional divisions that include all of the following EXCEPT

a. preparatory division

b. dilatational division

c. pelvic division

d. expulsive division

3-33. The active phase of labor is divided into three phases.What is the earliest of these phases called?

a. acceleration phase

b. phase of maximum slope

c. latent phase

d. deceleration phase

3-34. A prolonged latent phase in a nulliparous patient is one lasting longer than how many hours?

a. 10

b. 14

c. 16

d. 20

3-35. The latent phase of a multipara's labor is considered to be prolonged if it exceeds how many hours?

a. 10

b. 12

c. 14

d. 20

3-36. Which of the following is NOT a potential contributor to prolonged latent-phase labor?

a. epidural analgesia

b. false labor

c. premature rupture of membranes

d. sedation

3-37. What percentage of women progress spontaneously to active labor following strong sedation during the latent phase of labor?

a. 25

b. 45

c. 65

d. 85

3-38. In the presence of uterine contractions, what cervical dilatation reliably represents the onset of active labor?

a. 0 to 2 cm

b. 3 to 5 cm

c. 4 to 6 cm

d. 6 to 7 cm

3-39. In multiparas, what is the minimum normal rate of cervical dilatation during active phase labor according to the labor curve of Friedman (1972)?

a. 0.5 cm/hr

b. 1.0 cm/hr

c. 1.5 cm/hr

d. 2.0 cm/hr

3-40. Arrest of dilatation was defined by Friedman as no cervical change for what period of time?

a. 1 hr

b. 2 hr

c. 3 hr

d. 4hr

3-41. A study at Parkland Hospital (Alexander and colleagues, 2002) found that epidural analgesia lengthened the active phase of labor by what amount of time?

a. 30 min b. 1 hr

c. 2 hr

d. 3 hr

3-42. What is the median duration of the second stage of labor in a nullipara?

a. 30 min

b. 50 min

c. 70 min

d. 90 min

3-43. What is the median duration of the second stage of labor in a multipara?

a. 20 min

b. 40 min

c. 60 min

d. 80 min

3-44. Most women, regardless of parity will delivery within what time frame after hospital admission for spontaneous labor?

a. 4 hr

b. 10 hr

c. 14 hr

d. 20 hr

3-45. Which of the following is a feature of false labor?

a. Contraction intensity remains stable.

b. Effacement and dilatation of the cervix do not occur

c. Discomfort is relieved by sedation.

d. All of the above.

3-46. What is the name of the federal law protecting patients in active labor from being transferred to

another hospital due to financial or other considerations?

a. Act to Protect Underinsured Patients (APUP)

b. Emergency Medical Treatment and Labor Act (EMTALA)

c. Pregnant Patient Bill of Rights

d. There is no such law in effect.

3-47. An analysis of birth registry information from the state of Washington from 1989 to 1997 (Pang and colleagues, 2002) showed intended home births to be associated with which of the following obstetrical complications?

a. neonatal death

b. prolonged labor

c. postpartum bleeding

d. all of the above

3-48. In which situation should standard vaginal examination be deferred or modified when admitting a woman with a term gestation to the labor unit?

a. bleeding in excess of a bloody show

b. maternal fever

c. patient nervousness

d. suspected ruptured membranes

3-49. What is the most reliable indicator of rupture of the fetal membranes?

a. fluid per cervical os visualized

b. positive nitrazine test

c. positive ferning

d. positive fibronectin

3-50. What is the usual pH of amnionic fluid?

a. 4.5 to 5.5

b. 5.5 to 6.5

c. 7.0 to 7.5

d. 8.0 to 8.5

3-51. The nitrazine test for rupture of membranes may be falsely positive if which of the following is present?

a. candida

b. vaginal bleeding c. cervical mucus

d. scant amnionic fluid

3-52. In assessing labor progress all of the following cervical properties are assessed EXCEPT

a. dilatation

b. effacement

c. firmness

d. position

3-53. What is the station where the presenting part is at the level of the ischial spines?

a. -2

b. -1

c. 0

d. +1

3-54. What is the station at which the fetal head is visible at the introitus (based on centimeters)?

a. +2

b. +3

c. +4

d. +5

3-55. What is the station of the leading part of the fetal head at which engagement (biparietal diameter is past the pelvic inlet) has occurred?

a. -2

b. +1

c. -1

d. 0

3-56. When should the fetal heart rate be auscultated during labor?

a. before a contraction

b. during a contraction

c. immediately after a contraction

d. anytime

3-57. How often during the first stage of labor should the fetal heart rate be auscultated in a low-risk pregnancy?

a. every 5 min

b. every 15 min

c. every 30 min

d. every 45 min

3-58. How often during the first stage of labor should the fetal heart rate be monitored in a high-risk pregnancy?

a. every 5 min

b. every 15 min

c. every 30 min, before a contraction

d. every 45 min, after a contraction

3-59. How often should the fetal heart rate be auscultated during the second stage of labor in low-and high-risk patients respectively?

a. 5 min, 5 min

b. 10 min, 5 min

c. 15 min. 5 min

d. 30 min, 5 min

3-60. For the purpose of administering antimicrobial prophylaxis for group B streptococcus, prolonged

membrane rupture is defined as duration greater than how many hours?

a. 10

b. 12

c. 18

d. 24

3-61. In a 1998 study of over 1000 women (Bloom and colleagues, 1998), walking during labor had what effect?

a. prolonged first phase of labor

b. shortened period of latency and second stage of labor

c. increased incidence of dysfunctional labor, two intrapartum deaths

d. no effect on active labor; not harmful

3-62. What is the term for encirclement of the largest diameter of the fetal head by the vulvar ring?

a. Bandl's ring

b. crowning

c. molding

d. vulvar engagement

3-63. Which of the following is true regarding the routine use of episiotomy?

a. decreases the risk of anal sphincter laceration

b. increases the risk of anal sphincter laceration

c. does not affect the risk of urethral lacerations

d. increases the risk of urethral lacerations

3-64. What is the maneuver used to facilitate delivery of the fetal head over the perineum in a controlled manner?

a. MacRoberts

b. Ragu

c. Ritgen

d. Woods

3-65. What percentage of deliveries are complicated by a nuchal cord?

a. 1

b. 5

c. 10

d. 25

3-66. If the umbilical cord is left unclamped for 3 minutes, what volume of blood can be transfused into the newborn, on average?

a. 10 mL

b. 30 mL

c. 50 mL

d. 80 mL

3-67. During the third stage of labor, which of the following is NOT a sign of placental separation?

a. a gush of blood

b. uterus rises in the abdomen

c. umbilical cord protrudes farther out of the vagina

d. uterus becomes flaccid

3-68. Which of the following is a complication of the third stage of labor associated with forced placental separation?

a. endometritis

b. uterine atony

c. Asherman syndrome

d. uterine inversion

3-69. In the absence of excessive bleeding, after how much time should manual removal of the placenta be performed if spontaneous separation does not occur?

a. 5 min

b. 15 min

c. 25 min

d. undetermined

3-70. The so-called "fourth stage" of labor, during which risk of postpartum hemorrhage is greatest, lasts how long?

a. 15 min

b. 1 hr

c. 2 hr

d. 4 hr

3-71. What is the primary mechanism of placental site hemostasis?

a. vasoconstriction by contracted myometrium

b. prostaglandin secretion

c. maternal hypotension

d. decreased cardiac output

3-72. What is the half-life of oxytocin?

a. 3 min

b. 30 min

c. 3 hr

d. 3 days

3-73. Which deleterious effect is associated with oxytocin when given intravenously as a 10-unit bolus?

a. cardiac arrhythmia

b. hypotension

c. neuromuscular blockade

d. seizure

3-74. What is a serious potential complication of prolonged oxytocin administration?

a. disseminated intravascular coagulation

b. hyperkalemia

c. myometrial necrosis

d. water intoxication

3-75. Which of the following is associated with ergonovine and methylergonovine?

a. seizure

b. hypertension

c. oliguria

d. thrombocytopenia

3-76. What is a laceration involving the skin, mucousa membrane, perineal body, anal sphincter, and rectal mucosa called?

a. first degree

b. second degree

c. third degree

d. fourth degree

3-77. What is a laceration involving only the vaginal epithelium or perineal skin called?

a. first degree

b. second degree

c. third degree

d. fourth degree

3-78. What is a laceration involving the skin, mucous membrane, perineal body, and anal sphincter called?

a. first degree

b. second degree

c. third degree

d. fourth degree

3-79. What is the major advantage of a mediolateral episiotomy?

a. easy surgical repair

b. less postoperative pain

c. less blood loss

d. fewer third- and fourth-degree extensions

3-80. Clinical trials have shown that routine episiotomy decreases the incidence of which of the following?

a. anterior perineal trauma

b. fecal and urinary incontinence

c. third and fourth degree perineal tears

d. pelvic floor relaxation

3-81. Episiotomy should be most strongly considered for which of the following?

a. all vaginal deliveries

b. nulliparous women

c. occiput anterior presentations

d. shoulder dystocia

3-82. Which is true regarding third- and fourth-degree perineal tears?

a. Incidence is 5%.

b. Postrepair wound disruption occurs in 10%.

c. They predispose to long-term anal incontinence.

d. All of the above.

3-83. The active management of labor generally does NOT include which of the following?

a. amniotomy as needed

b. commitment to delivery within a prescribed time frame

c. oxytocin augmentation if cervical dilatation ................
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