1. Back to Basics! The essence of OBSTETRICS in two hours Megan Arnold Gomes, MD, FRCSC Susan Aubin MD, FRCSC Department of Ob/Gyn The Ottawa Hospital Special Thanks to: Karine Lortie, MD, FRCSC

2. OVERVIEW Introduction Early pregnancy Antenatal care Teratogens Fetal growth and wellbeing Medical complications Breech Multiple pregnancy Labour

3. INTRODUCTION

4. RISK SPECTRUM IN PREGNANCY LOW RISK (75%):normal obstetrics MEDIUM RISK (20%): pre-post dates breech twins advanced maternal age, etc.. HIGH RISK (5%): genetic disease serious obstetric maternal complications

5. RISK IN PREGNANCY Definitions Perinatal mortality rate All stillbirths (intrauterine deaths) > 500 grams plus all neonatal deaths per 1,000 total births Neonatal death Death of a live-born infant less than 7 days after birth (early) or less than 28 days (late) Live birth An infant weighing 500 grams or more exhibiting any sign of life after full expulsion, whether or not the cord has been cut and whether or not the placenta is still in place

6. PERINATAL MORTALITY RATE ONTARIO:5/1000 Developing: 100/1000 Perinatal mortality rate All stillbirths (intrauterine deaths) > 500 grams plus all neonatal deaths per 1,000 total births

7. PERINATAL MORTALITY Prematurity Congenital anomaly Sepsis Abruption Placental insufficiency Unexplained stillbirth Birth asphyxia Cord accident Other ie. isoimmunization

8. MATERNAL MORTALITY RATE ONTARIO: 9.6/100 000 Developing: 1000/100 000 Maternal mortality rate Number of maternal deaths resulting from the reproductive process per 100,000 women of reproductive age (15-49 years)

9. MATERNAL MORTALITY Direct Deaths Indirect deaths: < 42 days from delivery Causes: Hypertensive disorders Pulmonary embolism Anesthesia Ectopic pregnancy Amniotic fluid embolus Hemorrhage Sepsis

10. EARLY PREGNANCY

11. Dating: 40 weeks from LMP 280 days, Naegle’s rule (+1 yr -3 months + 7 days) Affected by cycle length Hegar’s sign: softening of uterus Chadwicks sign: blue discoloration of cervix U/S Dating SOGC Guideline 2014 - more accurate than patient recall - T1 U/S most accurate CRL (3-8 days)

12. 8 days 8 weeks 16 weeks 5,000 Level 100,000 doubling time 2 days Other use: Zone 2000-6000 Mole Ectopic Ovarian cysts Hormones BhCG: A subunit similar to TSH, LH, FSH Measurable 8 days post conception Role: stimulate CL progesterone

13. Transvaginal U/SBhCG (mIU/ml) 4-5 weeks - gest sac 1500-2400 5-6 weeks – fetal pole > 5,000 6+ weeks – fetal heartbeats >10,000

14. Other Placental Hormones HPL = human placental lactogen (growth hormone)  regulates maternal and fetal metabolism, fetal growth Prolactin  regulates placental memb. fluid and electrolytes Progesterone  modulates tubal motility, uterine bloodflow and relaxation Estrogen  increases uterine bloodflow and regulates placental steroids

15. Maternal physiology   RBC and HR by 20%   plasma volume by 50%  GFR, CrCl (  creatinine)   cardiac output (highest 1st hour after delivery)   SV  Placental flow: 750ml/min at term

16. ANTENATAL CARE

17. Antenatal care Antepartum history: Age, Gravidity/parity, gestational age Prior pregnancy history Medical, surgical history Family, social history Meds, allergies Routine tests: CBC (Hg), Type and Screen, prenatal antibodies (Rh) VDRL, Rubella, Hep B, HIV Urine culture Pap smear, + vag swabs, cervical cultures Offer IPS/MSS

18. Antenatal Care Other testing: Dating ultrasound, 18-20 weeks morphology ultrasound Hb electrophoresis (Thalassemia, sickle cell, etc.) Chicken pox, parvovirus, TSH 28 weeks glucose screening test GBS at 35-37 weeks Genetic testing: CVS, Amniocentesis (offer at age 40), NIPT Scheduled visits: 0-28 weeks: q4 weeks 28-36 weeks: q2 weeks 36+ weeks: q1 week

19. Antenatal follow up visits Symphysis-Fundal Height (SFH) (cm): (+ 2cm # of weeks), Sensitivity of 60% 12 weeks: symphysis pubis 20 weeks: umbilicus 36 weeks: xiphisternum Presentation – T3 (Leopold’s) Symptoms, fetal movement + urine dip: glucose, protein Blood pressure, maternal weight

20. MATERNAL WEIGHT GAIN WeeksWeight Gain 0 - 20 4 kg 21 - 28 4 kg 29 - 40 4 kg Average 12 kg BMI before pregnancy Recommended weight gain >18.512.5 - 18 kg (28 to 40 lb) 18.5 and 24.511.5 - 16 kg (25 to 35 lb) 25 and 29.97 - 11.5 kg (15 to 25 lb) >30At least 7 kg (15 lb)

21. Genetic testing IPS: First Trimester screening (10+6 – 13+6 weeks) Nuchal translucency PAPP-A, (BhCG) Second Trimester screening (15-20 weeks) BhCG, estriol, AFP, Inhibin A 87% detection rate, 2% false positive rate MSS : (Quad test) 15-20 weeks BhCG, estriol, AFP, Inhibin A 77% detection rate, 5% false positive rate

22. IPS vs MSS Detection rate

23. NT Suchet I, Tam W. The ultrasound of life. Interactive fetal ultrasound teaching program on DVD, 4th Edition, 2004.

24. Screening patterns Down’s syndrome : low PAPP-A, AFP, estriol, high BhCG Trisomy 18 : low PAPP-A, AFP, BhCG, estriol, Inhibin A, high NT Trisomy 13 : high AFP, low BhCG/estriol NTD : high AFP Low estriol – associated with many congenital anomalies

25. TERATOGENS

29.  Any agent that acts during embryonic or fetal development to provoke permanent alterations to form or function.  Eg. Chemical, virus, environmental agent, physical factors

30.  Alcohol  ACE-I, ARB  Aminopterin  Androgens  Bexarotene  Carbamazepine  Chloramphenicol  Cocaine  Corticosteroids  Cyclophosphamide  Danazol  DES  Efavirenz  Isotretinoin  Leflunomide  Lithium  Methimazole  Methyl Mercury  Methotrexate  Misoprostol  Mycophenolate  Paroxetine  Phenobarbital  Phenytoin  Radioactive Iodine  Ribavirin  Streptomycin  Tamoxifen  Tetracycline  Thalidomide  Tobacco  Toluene  Tretinoin  Valproate  Warfarin

31. CategoryDescription A Adequate well-controlled studies in pregnant women have not shown an increased risk of fetal anomalies Eg PNV, Levothyroxine B Animal studies have not demonstrated fetal risks but no controlled studies in pregnant women have been reported OR animal studies have shown an adverse effect that was not confirmed in controlled studies in women in the 1 st trimester Eg. Penicillin C Studies in animals have revealed adverse effects in the fetus but no controlled studies have been reported OR studies in women and animals are not available Eg. Beta blocker, CCB, 2/3 medications D Positive evidence of human fetal risk exists but the benefits for use in pregnant women may be acceptable despite the risk Eg. Lithium, systemic corticosteroids XContraindicated in pregnancy Studies in animals or humans have demonstrated fetal anomalies or fetal risks clearly outweigh any possible benefits Eg. Methotrexate, Warfarin

34. FETAL GROWTH AND WELL-BEING

35. Dating Scan Transvaginal Ultrasound T1 Crown Rump Length (CRL) best parameter for determining GA Must be at least 7 wks GA (or CRL 10mm) 5 + 0 wks - Empty gestational sac 6 + 0 wks - Gestational sac and yolk sac + heart beat 8 + 0 wks - Embryo with separate amniotic sac +yolk sac. Fetal body movements visible, heart rate 175 bpm.

36. T2 Morphology scan Transabdominal Ultrasound 18- 20 weeks BPD HC AC Femur length Detailed assessment of fetal morphology spine, head, face, heart, abdomen, limbs

37. Anomalies: U/S 18-20 wks Spina Bifida Anencephaly Cardiac- ASD, VSD, hypoplastic Renal Diaphragmatic hernia Limbs Facial- cleft lip/palate Chromosomal Late > 20 weeks Renal Microcephaly Hydrocephalus Ureteral valves

38. Info from U/S Morphology Estimated fetal weight Amniotic Fluid Volume No. of fetuses Twins – type, growth discordance Behavioral states (BPP) Presentation Placentation (previa)

39. Interventions Amniocentesis Chorionic villus sampling Cordocentesis, transfusion Paracentesis Shunts: bladder, ascites, kidney, head Fetal reduction

40. DEFINITION OF SGA + IUGR Small-for-gestational age (SGA) EFW < 10 th centile on ultrasound Pathology vs lower end of normal Intrauterine growth restriction (IUGR) EFW < 10th centile on ultrasound AND due to pathologic process has not Obtained biologically determined growth potential Approx. 4-7% of infants

41. CAUSES OF IUGR Maternal:  Malnutrition  Drugs  Substance Abuse  Diseases  Infections Fetal:  Chromosomal Abnormality  Congenital Abnormality  Multiple Gestation  Congenital Infection

42. CAUSES OF IUGR Placental: Perfusion Abnormalities: Abnormal Cord Insertion Abruption Circumvallate placentation Placental Hemangioma Placental Infections Twin to Twin Transfusion

43. IMMEDIATE NEONATAL MORBIDITY IN IUGR Birth asphyxia Meconium aspiration Hypoglycemia Hypocalcemia Hypothermia Polycythemia, hyperviscosity Thrombocytopenia Pulmonary hemorrhage Malformations Sepsis

44. FETAL MACROSOMIA No precise definition agreed upon by authorities >90 th %ile = 4000g at 39 wks 4000g – 4500g (ACOG Factors Associated with Macrosomia: Maternal diabetes Maternal obesity Excessive maternal weight gain Postterm gestation Multiparity Previous macrosomic infacnt Racial and ethnic factors Advancing maternal age

45. EVALUATION OF WELL-BEING

46. FETAL ACTIVITY Kick counts: Fetal movements perceived after 24 wks in a constant fashion Daily monitoring at 26-32 wks with risk factors Healthy pregnancy aware of fetal movement kick counts only if decreased movement 6 movements / 2 hours* Women concentrating on movements in a reclined (not supine position)

47. BIOPHYSICAL PROFILE Graded (0 or 2 pts; max 10) NST (normal) Movement Tone AFI (amniotic fluid volume) Breathing (30 seconds) DOPPLER What is it? Uteroplacental waveforms Umbilical artery Carotid artery Middle Cerebral Artery

48. CARDIOTOCOGRAPHY Maybe as good as BPP 1. Non-stress test: movement uterine activity 2. Stress tests: Oxytocin infusion nipple stimulation Features of the normal CTG: rate 110-160 bpm BTB variation 5-15 bpm Accelerations present (2) No decelerations (early, variable, late)

49. Which fetus to assess? Small for gestational age, postdates Maternal hypertension, diabetes Antepartum hemorrhage Decreased FM The “high risk” pregnancy Etc…

50. WHY FETAL ASSESSMENT? 1.To prevent damage (asphyxia) 2. To deter unnecessary intervention (prematurity, operative deliveries)

51. WHAT IS IT LOOKING FOR? Fetal hypoxia before asphyxia Signs of placental failure: Poor fetal growth Decr. FM Decr. AFI Atypical, abnormal NST How to test? Fetal scalp pH sampling Normal >7.25 Borderline >7.21-7.25 (repeat sampling in ½ hour) Abnormal <7.20 (deliver) Fetal scalp stimulation

52. Criteria for asphyxia (hypoxic acidemia) umbilical cord arterial pH < 7.0 base deficit > 16 Apgar score 0-3 for >5 minutes neonatal neurologic sequelae (e.g. seizures, hypotonia, coma) evidence of multiorgan system dysfunction in the immediate neonatal period

53. NORMAL TRACE

54. Early decels

55. Late Decels

56. Variable Decels

57. Reduced Variability

58. Tachycardia

59. MEDICAL COMPLICATIONS

60. NAUSEA AND VOMITING Morning sickness: 50% Hyperemesis gravidarum: 1% Treatment Diclectin (10 mg doxylamine succinate with vit B6) Rest Avoid triggers Admit if severe (i.e. dehydration, electrolytes imbalance) TSH, LFT IV Dietitian consult Psychology

61. Gestational Diabetes Diabetes 1% GDM: 3-5% Screening: 50g GTT <7.8 = normal 7.8 – 11.0 do 75 g 2 hr OGTT > 11.0 = GDM Risks factors: Previous stillbirth Previous LGA FHx Previous GDM Age >35 yrs PCOS

62.  Macrosomia  Shoulder dystocia and nerve injury  Neonatal hypoglycemia  Preterm delivery  Hyperbilirubinemia  Caesarian section  Offspring obesity (?)  Offspring diabetes (?)

63. Rhesus Isoimmunization Incidence: 7% african-american 13% caucasion IgG anti-D in Rh –ve sensitized women Complications: fetal anemia heart failure Hydrops fetalis Born with jaundice In-Utero Dx: Amniocentesis, Cordo, Doppler Prophylaxis: WinRho @ 28 wks + postpartum (newborn Rh status)

64. Antepartum hemorrhage (>20 wks) Placental abruption: concealed, revealed Signs: vaginal bleeding, pain, fetal distress Causes:  PIH (DIC)  Cocaine  SLE  Smoking  Trauma  Previous abruption Abnormal placentation: previa, vasa previa Signs: painless vaginal bleeding

65. PPH Causes (4T): Uterine aTony: Overdistended Uterus (Twins, macrosomia, Poly) Uterine muscle fatigue (prolonged or precipitous labor, multiparity, operative delivery) Tissue (Retained products) Infection Trauma (laceration, uterine rupture) Thrombin (coagulopathy)

66. PPH Treatment Conservative: Deliver the placental Bimanual compression Uterine packing IV, X-match, blood bank (PRBC, FFP, …) Medical: Ergot Hemabate Oxytocin Cytotec Cyklokapron

67. PPH Treatment Surgical: Repair the tear D&C (explore the uterus) Ligate internal iliacs UAE Uterine Compression sutures (B-Lynch suture) Bakri balloon Hysterectomy

68. HYPERTENSION

69. Leading cause of maternal death and perinatal mortality/morbidity BP monitoring is major activity of antenatal care Affects up to 10 % of all pregnancies

70. TERMINOLOGY ABNORMAL VALUES? (depends on who…) >140 / 90 two readings PROTEINURIA >0.3 g/day (mild); >5 g/day (severe) protein to creatinine ratio > 20 Gestational Hypertension (> 20 wks) with preeclampsia with comorbid conditions Pre-existing Hypertension (< 20 wks) with preeclampsia with comorbid conditions

71. Classification (it changes all the time…) Preeclampsia: Gestational hypertension with one or more of the following: new proteinuria, or one or more adverse conditions or one or more severe complications. Eclampsia: Convulsion during pregnancy or within 7 days to 6 weeks of delivery Not caused by epilepsy

72. Risk factors Primigravida or new partner Age, race, Low social class, obesity Underlying/chronic hypertensive disorder 20 % diabetes 50 % Twins (mono) 30 % Hydatidiform mole Previous gestational hypertension 30 %

73. Severe Preeclampsia: Severe preeclampsia is defined as preeclampsia with one or more severe complications Eclampsia Stroke, TIA Uncontrolled severe HTN Pulmonary edema MI AKI Placental abruption Stillbirth

75. Management MILD: monitor, deliver near term SEVERE:stabilize and deliver, MgSO4 MOTHER: Labwork: CBC, LFT, uric acid, BUN, Cr, protein/creatinine ratio or 24 hour urine total protein, LDH, Symptoms: IV, BP meds, +/-Magnesium sulfate BABY: BPP, NST Ultrasound: growth, doppler Celestone

76. ANTIHYPERTENSIVES Short or long-term: Methyl dopa Labetolol Nifedipine Acute: Labetolol Nifedipine Hydralazine ANTICONVULSANTS Prophylaxis and treatment: Magnesium sulphate

77. ECLAMPSIA Rx: Control airway Stop convulsion reduce BP MgSO4 Deliver (C. Section?) watch postnatally

78. BREECH

79. ETIOLOGY OF BREECH PRESENTATION prematurity Fetal abnormality Multiple pregnancy polyhydramnios Placenta previa Uterine abnormality TYPES OF BREECH PRESENTATION Extended (frank) Flexed (complete) incomplete footling

81. MANAGEMENT OF BREECH PRESENTATION If diagnosed >34 weeks, options: External cephalic version Trial of labor with vaginal delivery caesarean Criteria for TOL: At 37+ weeks: Estimated fetal weight 2.5-4 kg Frank or complete breech presentation clinical pelvimetry adequate Fetal abnormality excluded No serious medical or obstetric complications

82. TRANSVERSE LIE Incidence: 1:200 at term Risk factors: Multigravidae Placental previa Fibroids Polyhydramnios Multiple pregnancy Contracted pelvis Fetal abnormality Uterine abnormality Management: Ultrasound, version attempt Cesarean if not resolved

83. MULTIPLE PREGNANCY

84. Twins Incidence: 1:80 (triplets 1:802) 1:320 MZ twins worldwide Etiology: Population based Age Parity Previous twins Heredity

85. Twins Diagnosis: LGA u/s: lambda sign Increased AFP Management: Rest Serial u/s Assess presentation + IOL @ 38 wks

86. Placentation Zygosity: Diamniotic/Dichorionic Separate amnion and chorion (Separate placentas and sacs) Diamnionic/Monochorionic, and Monoamnionic Presentation: Vx/Vx: 45%, Vx/BR: 25% Br/Vx: 10%, Br/Br: 10%

87. Placentation DIZYGOTIC DAY 23 %0 - 3 Totally separate 75 %4 - 7 Separate fetuses & amnion single chorion with vascular connections 1%7 - 11Monoamniotic & monochorionic 1%11+conjoined twins

88. Hazards of multiple pregnancy Increased risk pre-eclampsia (X3) pressure symptoms anemia Abortion (disappearing sac) Prematurity (approx. 30% deliver < 37/40 ) Polyhydramnios twin-twin transfusion Placenta previa APH/PPH Malpresentation cord entanglement

89. LABOR

90. What is Labor ? (: work) Regular painful uterine contractions accompanied by progressive effacement and dilatation of the cervix.

93. Timing of Labor  40 weeks (280 days)  4-8% deliver on E.D.D.  7% premature <37 weeks  10% post-mature >42 weeks

94. Stages of Labor 1st stage: Onset to ‘ full dilatation Latent and active 2nd stage:Full dilatation to delivery of baby 3rd stage:Delivery of placenta 4th stage:Placenta to 6 wks PP

95. Signs of Onset of Labor “ Show ” Rupture of membranes Contractions

96. Detection of ruptured membranes Nitrazine Test: Alkaline pH of fluid turns blue Ferning: High Na+ content causes “ ferning ” on air dried slide

97. Ferning

98. Cord prolapse Only with ruptured membranes Incidence: 1/300 Risk factors: 80% happen in multigravida Malpresentation: Transverse lie Breech High head Twins Prematurity OB interference: forcep, arm

99. Cord prolapse Diagnosis: Ultrasound Pelvic exam in labour (e.g. after ROM) FHR abnormality Treatment: Don’t panic Push up presenting part Sims position or knee/chest Cesarean (forceps if fully)

100. Table 30-1. Characteristics of Labor Nulliparas and Multiparas* CharacteristicAll patientsIdeal LaborAll patientsIdeal labor NulliparasMultiparas Duration of first stage (hr) Latent phase6.4(±5.1)6.1 (±4.0)4.8 (±4.9)4.5 (±4.2) Active phase4.6(±3.6)3.4(±1.5)2.4(±2.2)2.1 (±2.0) Total 11.0(±8.7)9.5(±5.5)7.2(±7.1)6.6(±6.2) Maximum rate of descent (cm/hr)3.3(±2.3)3.6(±1.9)6.6(±4.0)7.0(±3.2) Duration of second stage (hr)1.1(±0.8) 0.76(±0.5)0.39(±0.3) 0.32(±0.3) * All values given are ± SD. (Data from Friedman EA: Labor: Clinical Evaluation and Management. 2nd ed. New York, Appleton-Century-Crofts, 1978).

106. Cesarean Section Indications Failure to progress (Dystocia) Repeat (Failed VBAC) Fetal Distress Breech Presentation Placenta Previa Cord prolapse Abruption Diabetes Fetal Reasons (e.g. prevent infection) Social...

107. Preterm labor Incidence: 7% <37 wks Major cause of perinatal morbidity Overall recurrence risk of 30% Risk factors: Previous PTD Smoking Low income Cervical surgery Uterine anomaly Multiple pregnancy

108. Preterm labor Treatment: Rest Steroids (for fetal lung maturity) Tocolytics? PPROM: antibiotic protocol (IV/PO ampicillin(amoxil)/erythromycin) Prevention: Ultrasound cervical length? Fetal fibronectin (predictor?)

109. Amniotic Fluid Mainly fetal urine Some from extraplacental membranes 12 wks: 50 mls 24 wks: 500 mls 36 wks: 1,000 mls Oligohydramnios: Reduced AFI on u/s: <5cm SFH: small for dates; baby easy to feel Causes: Placental insufficiency, PPROM Urinary tract dysplasia Diagnosis: Ultrasound Treatment: Intensive monitoring, Early delivery

110. Polyhydramnios Definition: An excess of liquor to such a degree that it is likely to influence the course or management of pregnancy. >20 cm Diagnosis: SFH increased: large for dates Tense and uncomfortable Fluid thrill Difficult to feel fetus

111. Polyhydramnios:Etiology Maternal: Multip Diabetes, Hypertensive disorders Infection: toxoplasmosis, CMV Fetal: Macrosomia Anencephaly, hydrocephaly Gut atresia Multiple pregnancy CAN’T SWALLOW (diaphragmatic hernia, mediastinal tumor) HYDROPS FETALIS (Rh incompatibility, infection, heart disease, thalassemia major, etc.)

112. Dystocia Definition: Abnormal progression of labour in the ACTIVE Phase Cervical dilatation of <0.5 cm/hr over a 4 hr period arrest of progress in the ACTIVE phase either in the first or second stage of labour  Failure of descent of presenting part (less than 1cm/hr in 2 nd stage)

114. CAUSES OF DYSTOCIA Power U ncoordinated uterine action Dysfunctional Labour PassengerCephalo-pelvic disproportion Relative disproportion Massive baby! (macrosomia) PassagesDiameters (pelvic anatomy)

115. Dystocia Risk Factors: age Parity Infection Epidural Position in labor Induction Macrosomia cervix

116. Initial Management of Dystocia Comfort wellbeing hydration B. Amniotomy C. Oxytocin if A+B fail D. Wait long enough to see a response A. Attention to:

117. Oxytocin Augmentation Dosage: Depends on your hospital protocol Initial dose: 1 to 2 mu/min Rate increased by 1 to 2 mu/min every 30 min until contractions are considered adequate and cervical dilation achieved Clinical response usually seen at 8-10 mu/min Accelerated protocol (2-4mu/min)

118. Reduction of Risk of Dystocia Avoid induction for fetal macrosomia Avoid oxytocin use with unfavourable cervix Avoid admission to Labour and Delivery at <4cm dilation “ Management ” of epidural at full dilatation Avoid immediate pushing after full dilatation

119. Supportive strategies Cervical evaluation for ripening prior to booking induction Obstetrical triage Continuous professional support in active labour Mobilization of women in active labour Minimization of motor blockage with epidural Use of amniotomy and oxytocin prior to C/S for dystocia

121. Cesarean Section for Dystocia Timing of procedureRate Latent phase41% Active phase38% Second stage21% Source: Stewart CMAJ 1990:142; 459-463

122. The perinatal mortality rate is defined as: a) The number of neonatal deaths that occur per 1000 live births a) The number of stillbirths that occur per 1000 births a) The number of fetal deaths within the first week after birth a) The number of stillbirths and neonatal deaths in the first week of life per 1000 births

123. Good Luck!

124. All of the following factors are associated with an increased risk of perinatal morbidity except: a)low socioeconomic status b)low maternal age c)heavy cigarette smoking d)alcohol abuse e)exercise

125. Appropriate management for slow labour (dystocia) associated with an occiput posterior presentation during the first ACTIVE stage of labour would include: a) immediate cesarean section b)forceps c)augmentation with oxytocin d)external cephalic version e)fetal blood sampling

126. Which of the following statements best describes the foramen ovale: It shunts blood from left to right It connects the pulmonary artery with the aorta It shunts deoxygenated blood into the left atrium It is an extra cardiac shunt It is functional after birth

127. Appropriate screening tests in an early, uncomplicated pregnancy include all of the following except: a)repeat BhCG b)hemoglobin c)syphilis serology d)Cervical cytology e)Blood type and Rh factor

128. Characteristics or associated findings with late decelerations include all of the following except: a) They may be seen in patients with pre-eclampsia a) They may be associated with respiratory alkalosis a) They are associated with a decreased uteroplacental blood flow a) They often are accompanied by decreased PO2 a) They usually are accompanied by an increased PCO2

129. A complete breech presentation is best described by which of the following statements: The legs and thighs of the fetus are flexed. The legs are extended and the thighs are flexed. The arms, legs, and thighs are completely flexed. The legs and thighs are extended. None of the above