NCC EFM EXAM QUESTIONS AND VERIFIED ANSWERS
Management of tachysystole
decrease/discontinue oxytocin, remove cervidil, withhold next misoprostol, IV fluid bolus
of LR, lateral positioning, terbutaline 0.25 mg subq
Management of recurrent variable decelerations
repositioning, amnioinfusion, modification of pushing efforts
Management of maternal hypotension
lateral positioning, IV bolus, ephedrine 5-10 IV
Administering supplemental O2
increase maternal blood oxygen tension, increases fetal oxygen saturation, 10L/min via
NRB; potential adverse effects (oxygen free radicals); dc asap
Uterine tachysystole leads to
decreased uteroplacental perfusion > decreased fetal oxygenation
Latent phase
if we allow </= 12-18 hours before we diagnose failed induction, we will increase the risk
for a C-section
ARRIVE trial
elective induction at 39 weeks does not increase risk of C/S; lower rates of gestational
hypertension and preeclampsia as well as neonatal respiratory support
Longer latent phase
Current guidance from ACOG and SMFM recommends longer latent phase (up to 24
hours or more) and require that oxytocin be administered for at least 12-18 hours after
membrane rupture before deeming the induction a failure
Friedman (1955) vs. Zhang (2010)
contemporary labors are slower; allow for longer latent phase
Endogenous oxytocin
first stage 5-7 mU/min (maternal circulating), surge of oxytocin at Ferguson's reflex
during second stage of labor
Exogenous oxytocin
1.5-2 hours of initial incremental phase; 3.5-4.5 hours where further pit will cause
tachysystole/unfavorable FHR response
, Oxytocin-induced labors
oxytocin receptor sites decrease significantly; desensitization related to dosage rate and
length of administration; rest period of 1-2 hours recommended
Oxytocin
half-life of 10 minutes; need 3-4 half lives to reach steady-state (why 30-40 minute
interval dosing of oxytocin); 90% will achieve active labor at less than 6 mU/min; most
don't need more than 10 mU. More pitocin does not improve dysfunctional labor pattern.
Consistent achievement of 200-220 MVUs.
Continuing oxytocin after active labor
will not shorten labor; some places have policies to downtitrate pitocin in active labor!
Coupling/tripling
may be indicative of dysfunctional labor process and saturation of oxytocin receptor
sites; decrease pitocin and give fluid bolus
Titrate pitocin
start at 1 mU/min, increase by 1-2 mU/min every 30-40 minutes, titrate to contractions
q2-3m; in active labor, decrease dose or discontinue; avoid tachysystole
Treatment of tachysystole
after discontinuation, takes 15 minutes to resolution, 10 minutes if we also do fluid
bolus, 6 minutes if we also reposition
Epidural
maternal sympathetic blockade is rationale for recurrent lates after epidural
Velamentous insertion
ass'd with vasa previa (C/S 34-35w)/antepartum hemorrhage, 1 in 2-3k births, 60% fetal
mortality
Occiput posterior
dysfunctional labor, prolonged active phase, rotate side to side, knee chest, hands and
knees
Breech
4% births, risk of entrapment d/t no molding, ECV possible; risk of prolapsed cord
especially with malpresentation; frank is most common
Chorioamnionitis
Management of tachysystole
decrease/discontinue oxytocin, remove cervidil, withhold next misoprostol, IV fluid bolus
of LR, lateral positioning, terbutaline 0.25 mg subq
Management of recurrent variable decelerations
repositioning, amnioinfusion, modification of pushing efforts
Management of maternal hypotension
lateral positioning, IV bolus, ephedrine 5-10 IV
Administering supplemental O2
increase maternal blood oxygen tension, increases fetal oxygen saturation, 10L/min via
NRB; potential adverse effects (oxygen free radicals); dc asap
Uterine tachysystole leads to
decreased uteroplacental perfusion > decreased fetal oxygenation
Latent phase
if we allow </= 12-18 hours before we diagnose failed induction, we will increase the risk
for a C-section
ARRIVE trial
elective induction at 39 weeks does not increase risk of C/S; lower rates of gestational
hypertension and preeclampsia as well as neonatal respiratory support
Longer latent phase
Current guidance from ACOG and SMFM recommends longer latent phase (up to 24
hours or more) and require that oxytocin be administered for at least 12-18 hours after
membrane rupture before deeming the induction a failure
Friedman (1955) vs. Zhang (2010)
contemporary labors are slower; allow for longer latent phase
Endogenous oxytocin
first stage 5-7 mU/min (maternal circulating), surge of oxytocin at Ferguson's reflex
during second stage of labor
Exogenous oxytocin
1.5-2 hours of initial incremental phase; 3.5-4.5 hours where further pit will cause
tachysystole/unfavorable FHR response
, Oxytocin-induced labors
oxytocin receptor sites decrease significantly; desensitization related to dosage rate and
length of administration; rest period of 1-2 hours recommended
Oxytocin
half-life of 10 minutes; need 3-4 half lives to reach steady-state (why 30-40 minute
interval dosing of oxytocin); 90% will achieve active labor at less than 6 mU/min; most
don't need more than 10 mU. More pitocin does not improve dysfunctional labor pattern.
Consistent achievement of 200-220 MVUs.
Continuing oxytocin after active labor
will not shorten labor; some places have policies to downtitrate pitocin in active labor!
Coupling/tripling
may be indicative of dysfunctional labor process and saturation of oxytocin receptor
sites; decrease pitocin and give fluid bolus
Titrate pitocin
start at 1 mU/min, increase by 1-2 mU/min every 30-40 minutes, titrate to contractions
q2-3m; in active labor, decrease dose or discontinue; avoid tachysystole
Treatment of tachysystole
after discontinuation, takes 15 minutes to resolution, 10 minutes if we also do fluid
bolus, 6 minutes if we also reposition
Epidural
maternal sympathetic blockade is rationale for recurrent lates after epidural
Velamentous insertion
ass'd with vasa previa (C/S 34-35w)/antepartum hemorrhage, 1 in 2-3k births, 60% fetal
mortality
Occiput posterior
dysfunctional labor, prolonged active phase, rotate side to side, knee chest, hands and
knees
Breech
4% births, risk of entrapment d/t no molding, ECV possible; risk of prolapsed cord
especially with malpresentation; frank is most common
Chorioamnionitis
