Third Stage

Question 1

What is the third stage of labor?

Answer 1

From delivery of fetus > expulsion of placenta

Question 2

What is the normal duration for third stage of labor?

Answer 2

5-10 min but can be up to 30 minutes

Question 3

When is third stage of labor considered prolonged

Answer 3

> 30 minutes

Question 4

What is the main event in third stage of labor

Answer 4

Palcenta seperation and expulsion

Question 5

What are the signs for placenta seperation?

Answer 5

1- gush of blood from vagina
2- umbilical cord lengthening
3- fundus of the uterus raises and firms (starting to contract)

Question 6

What are the two types of managemend for 3rd stage of labor?

Answer 6

1- physiological: waiting

2- active: cord traction + uterogenic agent

Question 7

Why is active management of third stage of labor is indicated?

Answer 7

To reduce the risk of PPH

Question 8

What is the expectant method to treat third stage of labor

Answer 8

Observe, massage uterus, and examine placenta, membrane and cord

Question 9

What is the active management of third stage of labor?

Answer 9

• Oxytocin after delivery of posterior shsoulder of the feuts
• brandt-andrews maneuver to tract the umbilical cord
• uterine massage

Question 10

How to do controlled cord traction?

Answer 10

Pulling the cord gently with pressing on the uterus to prevent uterine inversion

Question 11

What are the major complications of third stage of labor

Answer 11

1- hemorrhage
2- lacerations
3- retained placenta
4- uterine inversion

Question 12

Define PPH:

Answer 12

1- excessive genital bleeding (>500ml in vaginal - >1000 in CS)
2– signs of hypovoulmeic stature

Question 13

What is early PPH and what is late PPH

Answer 13

• early: within 24 hours

- late: 24hours > 6 weeks

Question 14

What are the causes for early PPH (Four Ts)

Answer 14

1- Tone (atony)
2- trauma (episiotomy & laceration),
3- tissue (retain placenta\membrane),
4- thromboplastin (IUFD, PET, Sepsis, abruptio)

Question 15

What is the most common cause for eaerly PPH?

Answer 15

Uterine atony

Question 16

what is the pathogenesis of atony? How does it cause bleeding

Answer 16

The muscle fibers surround blood vessels, if they contract they stop bleeding.
Atony, loss of contraction

Question 17

What are the predisposing factors for uterine atony?

Answer 17

• general anesthesia
• uterine overdistension (polyhydraminous or multipara)
• prolonged labor
• uterine leiomyoma
• operative delivery
• oxytocin
• infections

Question 18

What is the general approach for managing PPH?

Answer 18

• adquate circulation (IVF + blood)
• adquate oxygenation
• reverse or prevent coagulopathy
• elimentation of obstetric causes (laceration or RPOC)

Question 19

Why is insuring tissue oxygenation in the management of PPH is important?

Answer 19

To prevent end organ damage which is the most important complication of PPH

Question 20

How to manage PPH?

Answer 20

• immediate: [2] large bors (IVs) & infuse isotonic crystalloid + compress & massage uterus
• inspect vagina\cervix for trauma or suture
• explore uterus to remove RPOC
• examine for coagulation

Question 21

How to treat atony

Answer 21

Uterine massage, tonic drugs, blood or blood products, surgicall if needed

Question 22

What are the uterine tonic drugs?

Answer 22

Oxytocin, ergomertine, misoprostol

Question 23

What are the surgical treatment options for atony?

Answer 23

1- Balloon temponade
2-Uterine artery embolization
3- hysterectomy

Question 24

When to opt for hysterctomy in aton

Answer 24

If all other options have failed

Question 25

What is the most common cause for late PPH?

Answer 25

Subinvolution of the uterus

Question 26

What are the signs of lat PPH

Answer 26

1- fever 2- foul smelling vaginal bleeding 3- anemia 4- uterus is soft and larger than expected

Question 27

What are other causes of late PPH?

Answer 27

- Retained placenta\blood clots | - Infection (endometritis)

Question 28

What is the microbial cause for endometritis?

Answer 28

Polymicrobial (give broad spectrum AB)

Question 29

How to treat PPH secondary to endometritis?

Answer 29

1- admit 2- adminster broad spec AB 3- + or - evacuation (RPOC)

Question 30

What is puerperium?

Answer 30

From delivery of baby > 6-8 weeks postpartum

Question 31

What happens during the puerperium period

Answer 31

Reproductive organs return to the pre-pregnancy state

Question 32

How long does uterus return to its pre-pregnancy state?

Answer 32

6 weeks

Question 33

When will the uterus be impalpable post delivery? | “Returns to the pelvic organ”

Answer 33

2 weeks post delivery

Question 34

What will happen to the uterus immidiatly after birth?

Answer 34

Reach the umbilical level (20wks)

Question 35

What is the weight of the uterus immediately post partum and after the periperurum period?

Answer 35

- postpartum: 1kg | - periperum: <100g

Question 36

What is the involution of uterus

Answer 36

process by which the post partum uterus weighing 1KG returns to its pre pregnancy state of less than 100 g.

Question 37

What physiological action acceleraets the involution of uterus

Answer 37

Oxytocin release by breastfeeding

Question 38

What happens to the cervix post delivery?

Answer 38

Lose its elasticity & closed by 2nd weeks.

Question 39

Does the vagina return to the nulliparous dimensions

Answer 39

No

Question 40

What happens to the decidua 2-3days postpartum?

Answer 40

Differentiated into two layers - superifical> necrotic forming lochia - basal > the new endometrium

Question 41

What is lochia

Answer 41

Blood stained uterine discharge that consist of blood and necrotic decidua

Question 42

What are the types of lochia

Answer 42

1- rubra: red (1-3d) 2- serosa: pink & pale (4-10) 3- alba: yellow (>11)

Question 43

How does the abdominal wall change in pureperium state

Answer 43

Returns to prepregnancy appearance but the silver stria presist

Question 44

Describe leukocytosis: - during birth: - after birth: - after 1 week postpartum:

Answer 44

- during & after: leukocytosis (30,000) | - 1 week: return to pre-pregnancy state

Question 45

What happens to the CVS after delivery

Answer 45

- Increase peripheral vascular resistance | - increase in CO

Question 46

When is the most critical period for pregnant women with cardiac disease

Answer 46

48 hours following delivery due to increase cardiac output

Question 47

What happens to the urinary tract post-delivery

Answer 47

Increase capacity and insensitive to overdistension > incomplete emptying & excessive residual urine

Question 48

How long does it take to return to normal body weight after delivery

Answer 48

6 months *may retain 1.4kg of excess weight

Question 49

How many kg is lost following delivery?

Answer 49

Almost 5-6kg due to uterine evacuation and normal blood loss

Question 50

How long does it take to return of menesturation after delivery

Answer 50

- breast feeding: lactational amenorrhea | - not breast feeding: 6-8 weeks

Question 51

What does colustrum contain?

Answer 51

Protein, fat, mineral and IgA

Question 52

How does breastfeeding occurs

Answer 52

1- drop in estrogen 2- suckling stimulate prolactin + oxytocin 3- production of colostrum (3-6d) & mature milk

Question 53

What is puerperal pyrexia

Answer 53

Fever >39 on [2] occasions at least [4] hrs apart for up to 10days postpartum “Excluding the first 24 hours post partum”

Question 54

Why do we exclude the first 24 hours post partum from puerperal pyerxia?

Answer 54

Increase inflammatory mediators causing fever

Question 55

What are the 7Ws of maternal fever

Answer 55

0: wind 1: water 2-3: womb 4-5: wound 5-6: walk 7-21: wean Anytime: wonder drug

Question 56

What is the most important risk factor for postpartum endometritis?

Answer 56

C\S

Question 57

Name predisposing factors for postpartum endometritis (5)

Answer 57

``` 1- anemia 2- prolonged labor 3- PROM 4- C\S 5- DM & SLE ```

Question 58

What type of infection is endometritis considered?

Answer 58

Ascending infection

Question 59

What is the clinical presentation for endometritis

Answer 59

Fever - pelvic pain - bleeding\discharge - abnormal smell and delay in uterine involution

Question 60

How to manage endometritis

Answer 60

- admit - IV or oral fluids - antipyretics - IV antibiotics (Clinda + genta)

Question 61

Which tissue in the breast is responsible for producing the milk (Glandular vs lactiferous)

Answer 61

Glandular tissue (alveolar cells)

Question 62

What are the changes that happen during pregnancy for the breast

Answer 62

1st trimester: ductal proliferation | 2nd trimester: lobular formation

Question 63

What are the mechanisms of lactation?

Answer 63

1- mammogenesis 2- lactogensis 3- galactopoeisis

Question 64

What is the mammogenesis?

Answer 64

Development of breast tissue during pregnancy

Question 65

What are the stages of lactogenesis?

Answer 65

Stage1: 2nd half of pregnancy Stage 2: immediately after delivery (Stage 1: progestrone inhibits milk - stage 2: progestrone is gone)

Question 66

What maintains the galactopoesis

Answer 66

Suckling which increases production of oxytocin & prolactin

Question 67

What is the role of Oxytocin, prolactin, progestrone In breastfeeding

Answer 67

- oxytocin: letdown (contract muscle surrounding the alveoli to eject milk) - prolactin: production of milk - progestrone: inhinit milk production

Question 68

What is sheehan syndrom and what does it most commonly affects?

Answer 68

ant Pituitary ischemia