Women's Health II

Labor is defined as

Painful uterine contractions with changes in cervical dilation

Contractions without cervical change are called

False labor- Braxton Hicks

Upper vs lower uterus

Upper- actively contracts
Lower- dilates and thins, directly connected to changing cervix, area for C/S

Stage one is defined as

Onset of true labor until complete dilation of the cervix

How long does stage one last

Usually the longest

8-12 hrs 1st time

6-8 other times

Important events in latent phase of labor in stage one

Cervical effacement- entire cervical length is retracted into the lower uterine segment
Early dilation of the cervix

Active phase of labor in stage 1

Begins when cervix is 6cm dilated
Rapid cervical dilation to 10cm occurs

Stage two is defined as

Period after full dilation/effacement until the birth of the baby

Length of stage 2

First time- 50 min average, 30min - 3hrs

multi - 20min avg, 5-30 min range

Monitoring in stage 2

Continuous fetal heart rate
Vaginal exam if needed
Dorsal lithotomy as preparation for delivery

6 cardinal movements of labor

descent, flexion, internal rotation, extension, external rotation, expulsion

What part of the body comes out after the head and what is an injury to watch for

Anterior shoulder, watch for brachial plexus injury from too much pressure

Classifying perineal lesions

First- vaginal epithelium or perineal skin only
Second- extends into sub epithelium
Third- involves anal sphincter
Fourth- extends into rectal mucosa

Stage 3 of labor is defined as

Birth of baby to delivery of placenta

inspect cervix for lacerations and repair

Signs of separation of placenta

Fresh show of blood, lengthening of cord out of vagina

fundus rises

firm/globular uterus

Delivery of placenta technique

Counter pressure between symphysis pubis and uterine fundus with fundal massage

What is usually given to the mother after the baby is delivered

Oxytocin

Stage 4 of labor is defined as

6 hours after birth when mom and baby are stabilized and transitioned to post-partum cares

What stage has the highest risk of post partum hemorrhage

Stage 4

Why stage 4 of labor has highest risk of PPH

If uterus fails to contract excessive bleeding occurs

PPH is defined as (amount)

Greater than 1000cc

First sign of hemorrhage

Pulse increase

Cardiovascular collapse occurs when blood loss is greater than

2500mL

What is one major con of IV narcotics

Rapid crossing through placenta- neonatal depression

Where is an epidural inserted

L3-L4 space

Meds in an epidural

Fentanyl for visceral pain, bupivacaine for somatic pain

What does a tocodynamometer measure?

frequency and duration of contractions

What does an IUPC record that a tocodynamometer doesn't

Directly measure the pressure generated by uterine contractions

What pressure must be generated for cervical dilation and fetal descent to occur as well as the optimal intrauterine pressure

Dilation- 25
Optimal- 50-60

What are montevideo units (MVUs)?

Number of uterine contractions in 10 minutes times the intensity

Normal progress of labor is associated with how much MVU

Over 200

An android shape cervix is classically what shape and the fetal head is usually

Classic male shape, head nearly always occipitoposterior

What pelvis shape do most women have

Gynecoid

What is the presentation of the baby that is not considered a malpresentation

Vertex

What are Leopold maneuvers used for and when are they done

Done in third trimester

used to determine fetal lie, presentation, and position

A prolonged latent phase is how long

20 in nulliparous or 14 in multi

What can be used to augment the labor in prolonged latent phase

Oxytocin or amniotomy

Prolonged labor in first stage is how long

Less than 1cm/hour in nulliparous or 1.2-1.5cm in multi

First stage labor arrest can't be diagnosed unless the patient is how much dilated

6cm or more

Second stage arrest (arrest of decent) is described as

2 hours of pushing without an epidural or three hours with an epidural in multiparous

add 1 hr for nullparous

Macrosomia and maternal diabetes is associated with increased risk of

Shoulder dystocia

What is shoulder dystocia?

Head emerges, anterior shoulder remains

What sign is seen in shoulder dystocia

Turtle sign- head retracts into pelvis after each contraction

What is bishops score used for

Assess likelihood of vaginal delivery

What is a high bishops score

Over 7, high likelihood of vaginal delivery

Where is anesthesia given for a c-section

Spinal or epidural

Most common reason for getting a C-section

Having a prior C-section

Incision spots for C-section and complications with each

Classical- not eligible for birth after
Low vertical/transverse- eligible for vaginal birth after

Are fetal heart rate patterns reliable

Low chance for false positive

high rate of false negatives

Normal FHR pattern

110-160

What is PO2 in a fetus

25 mmHg

EFM/cerebral palsy triad?

Hypoxia, acidosis, inflammation

What category of FHR requires intervention

3

Patterns and implications in Cat 3

Absent baseline variability
Recurrent late decelerations
Recurrent variable decelerations
Prolonged bradycardia
Sinusoidal patterns

Treatment for categories 2 and 3

2- resuscitate based on most probable cause
3- plan for urgent delivery

Risk factors for endometriosis

Post cesarean delivery - especially after labor or ROM

Most common endometrial isolates in PPE

Peptostreptococci

Most common blood isolates in PPE

GBS and G. vaginalis

Treatment of PPE

IV clindamycin and gentamicin

What signs in apgar would be scored a 1

Heart rate- below 100
Respiratory effort- slow

muscle tone - some flexion of extremities

reflex irritability - grimace

color - body pink, extremities blue

A Ballard score is used for

determining gestational age

What can be given to a newborn to prevent deficiency related hemorrhage in a newborn

Vitamin K1 oxide

What is caput succedaneum?

Edematous swelling of scalp from pressure of cervix on presenting part

crosses suture lines

What is a cephalohematoma?

Subperiosteal hemorrhage

does not cross suture lines

How long should it take for regular respirations to occur in a newborn

Within 1 minute, if not initiate resuscitation

When should PPV start and chest compression begin

PPV if HR <100
Chest compressions- <60

Targeted preductal SpO2 after birth at 1 and 10 minutes

1- 60-65%
Increase by 5% each minute
10- 85-95%

End of slideshow 1

Big chunker on this one

How many people diagnosed with breast cancer die

300000k new cases per year

40,000 die

1/7

Is breast pain associated with breast cancer?

No, <10%

When do fibroadenomas typically occur

As hormonal response- menarche, during pregnancy, and at menopause

When should fibroadenomas be removed

Symptomatic
Over 2cm
In younger patients

Meds for extreme breast pain

OCP, tamoxifen, watch for AEs

Subareolar mastitis is almost exclusively seen in

Smokers

Treatment for subareolar mastitis

Antibiotics for a long time and stop smoking

consider Vit A

Ducal carcinoma in situ (DCIS) presents as

Calcifications

bloody nipple discharge

1/3 reoccur w/ ½ being invasive

How would the invasive form present

Presents as a spiculated mass

architectural deformity

ductal most common

High risk factors for breast cancer

Over 65
Atypical hyperplasia
BRCA 1 or 2
LCIS or DCIS
IRADS C or D
2 or more family members with early onset breast cancer

Models used to predict breast cancer risk

Gail
Tyrer Cuzik

Does benign breast disease increase risk for cancer

Nonproliferative have little to no increased risk
Proliferative without atypia have 1.5-2 times increased risk

What is the difference between mammography and 3 D- tomosynthesis

Younger breasts tend to be more dense, 3D better

Green or yellow discharge is typically seen in

Smokers or a cyst rupture into duct

Milky discharge can be seen in

Check prolactin levels or from marijuana

Ultrasounds are used for

Target a specific area

used in younger pts

When would a PET CT scan be used in breast cancer

Evaluating metastasis

Breast core biopsy is used for

Surgical planning

fine needle aspiration (FNA) is used for

Identifies individual cancer cells

cannot distinguish invasive from intraductal

Are complications worse in patients who undergo mastectomy with reconstruction or BCS plus radiation

BCS plus radiation

What needs to happen in mastectomy with tissue reconstruction

Requires a vascular re-anastomosis

1st 24-48 hrs blood supply need to be checked by Doppler US

What is used for tissue reconstruction

Latissimus dorsi flap around the breast

Rationale for removal of sentinel node

Prevent lymphedema of the arm

If one or two nodes are positive in a stage one tumor is full axillary dissection necessary

Nope

Stage 3 is classified as tumor size over

5cm

Negative progesterone receptor status is a predictor for

A poorer outcome

What is oncotype 21

Studies 21 genes which give recurrence score

must be ER (+)

Anti estrogen therapy for ER positive tumors meds pre and post menopausal

Pre- tamoxifen
Post- aromatase inhibitor

What would chemo be used for in breast cancer

Node positive tumors

>2cm if recurrence score >28

What is the newest immunotherapy that targets PD1 to shrink tumors

Pembrolizumab (Keytruda)

When should the axilla be radiated

3 or more axillary nodes
Extra scapular spread in a lymph node
Node in the supraclavicular, lower cervical, or internal mammaory nodes

How often does DCIS recur

Only 30% do, overtxt 70%