IPAP OB/GYN - (Labor & Delivery)

1) Discontinue augmentation medications 2) Position left side/ do a cervicalexamine to r/o cord entrapment 3) Oxygen 4) ß-agonist which is a tocolytic to stop contractions (250ug SC terbutaline)

****How is Tachysystole managed?

To terminate the pregnancy- by using PGF2α - PGF2α is the most potent stimulator of uterine contractions

***Why would we used Prostaglandins to cause uterine contractions in the 2nd trimester?

1) Prolonged pregnancy (Past due date) 2) IUGR (Intrauteruine growth restriction) 3) Abnormal fetal testing 4) Rh incompatibility 5) Fetal abnormality 6) **PROM (premature rupture of membranes)** Because if the membranes have ruptured prior to labor, this presents an opportunity for infection 7) Chorioamnionitis--> Evidence of infection in the membrane (The baby is much better off out of the mother)

**What are the indications for induction based on the baby (fetoplacental)?

1) Preeclampsia 2) Diabetes mellitus 3) Heart disease

**What are the indications for induction based on the mother (Maternal) at term?

Lumbar epidural (Place in reverse Trendelenburg position to ensure the medication stays below T10)

*What is the procedure of choice for regional analgesia?

Station

- Fetal head descent is estimated during the cervical exam as the "station" - Level is estimated in cm above/below the level of the ischial spines

Bupivicaine 10-12 cc/hr + Fentanyl 2-5 mcg/ml

A lumbar epidural is a continuous infusion adjacent to spinal canal. What medications are infused?

250

Adequate Montevideo units =

*Delivery of the placenta (<30 minutes)---This is not an active process that we are involved in 1) Complete - Retained placental fragments 2) Manual extraction - Risk of uterine eversion 3) Examination

Again, what is the 3rd stage of labor and what might it require?

crowning

At (+5) head where is the head?

"engaged"

At (0) station where is the head?

35 weeks

At what estimated gestational age is presentation important?

<120bpm

Bradycardia=

Yes by IV drip (titrated to minimal dose for effect) * When we induce or augment labor with Oxytocin/Pitocin this is a given that we will have to conduct fetal heart monitoring and uterine monitoring. This is because anytime the uterus contracts, it can cause the fetus head to be smushed or cord compression which can cause decrease blood flow to the uterus

Can oxytocin be delivered exogenously?

1) #1 is Increased risk of C-section 2) Thick Meconium (which is a sign of fetal distress)

Consequences of prolonged latent phase of labor

It is thin and not as much protein

Describe colostrum

No

Do Healthy fetuses have decelerations?

Can use internal or external based on status of membranes

During labor, what type of monitoring is used?

External

During the prenatal period, what type of electronic fetal monitors must be used?

Vicryl is the material of choice, except when approximating the external anal sphincter end-to-end, when PDS monofilament is preferred for longer-duration scarring to occur.

For the surgical repair of a laceration, what is preferred?

To fetal movement

Healthy fetuses have heart rate accelerations in response to

1) Breast binding/tight bra 2) NO STIMULATION or pumping 3) Ice packs, analgesics, time Role for bromocriptine? (2.5mg po bid x 14d)---> increased incidence of stroke

How can a pregnant woman suppress breast milk?

They cause contraction in other smooth muscle. *Example, nausea, vomiting and diarrhea in intestinal smooth muscle.

How can prostaglandins cause side effects?

Can only be measured via amniocentesis

How can the Lung profile (Lecithin-Sphingomyelin Ratio (L/S Ratio) be measured?

In vaginal pool of amniotic fluid OR amniocenteis. If you find PG, you are in good shape not to have RDS!

How can the Phosphatidylglycerol (PG) be measured to test for fetal lung maturity?

1) Lengthening of the cord 2) Gush of blood

How do I know the placenta is coming?

A technique initiated by inserting a gloved digit into an appropriately dilated cervix, and forcefully separating the fetal membranes from the distal uterus

How is Membrane stripping weekly at 37 weeks done?

1) Directly into spinal fluid (MUST position the table correctly) 2) Limited duration

How is Spinal analgesia given?

Pumped milk can be stored at room temperature for 8 hours, refrigerated for one week, or frozen for months.

How long does pumped milk last?

Power

If the patient is being monitored with an external tocodynamometer, what is not being assessed?

It should be manually extracted *This is not done by pulling on the cord, which may evert the uterus—a surgical emergency! Rather, a cleavage plane is created with the digits, in the same fashion as when there is continued hemorrhage and a retained fragment is sought.

If the placenta does not spontaneously deliver within 30 minutes what must be done?

- Healthy fetus Reactive test = In a healthy fetus we are looking for 2 accelerations of at least 15 beats per minutes x Each last for at least 15sec in 30 minutes * This is a proactive way of monitoring the fetus in a high risk pregnancy and not just waiting for bad things to happen

In the Non-stress test, what does a "Reactive" fetus mean?

1) Reassuring- Fetus is reacting the way it should 2) Non-Reassuirng- We don't know how well the fetus is reacting 3) Reactive- We stimulate the fetus by making the uterus contract to ensure the fetus reacts properly

In the interpretation of the fetus with electronic monitoring, what does Reassuring, Nonreassuring, and Reactive Mean?

1) They have a history of precipitous delivery (meaning they delivery pretty dang fast) 2) If they live a long distance away from the nearest hospital

Induction of delivery at term for convenience is not indicated unless it is one of two situations.

Both

Is a lumbar epidural given during Vaginal or cesarean delivery?

Infant >90% probability of RDS (Immature lungs)

L/S ratio <2; no PG =

Infant <5% probability of RDS

L/S ratio >2; PG present

TWINS!

Normal breasts, regardless of size, are able to produce sufficient colostrum and milk in the first week to support

Psyche

Only applies in 2nd stage of labor when maternal pushing required

Administration induces labor near-term only

Oxytocin causes uterine contractions, when does it work?

1) LMP (Last menstrual period) 2) Size=dates on fundal height measure 3) EGA when fetal heart tones heard with doppler 4) Quickening (when the mother starts to feel or perceive fetal movements in the uterus) 5) **1st trimester ultrasound-the most widely used method to determine EGA (estimated gestational age) 6) CRL: crown-rump length

Prior to induction, fetal lung maturity must be documented!!!! How is this done?

Give therapeutic rest (with Morphine sub q 15-20 mg) if they are staying in the hospital If they are going home, give "therapeutic rest" and Zolpidem to help them sleep

Prolonged latent phase is caused by Hypertonic contractions (Strong but Irregular/discordant and ineffective)

Augment labor via oxytocin (pitocin)

Prolonged latent phase is caused by Hypotonic contractions

Wait for them to wear off

Prolonged latent phase is caused by Too early or over-sedation of mom?

1) PGE1 Misoprostol (Cytotec- NOT FDA approved 2) PGE2 CERVIDIL (gel on a stick and retrieve if there is to much uterine contraction) and PREPIDIL

Prostaglandins can cause cervical ripening, what are the Prostaglandins that are used?

1) Naturally produced in endometrium/myometrium 2) Exogenously applied as a gel or pill

Prostaglandins initiate labor, but where do they come from?

Yes!!! This is becauseSource is S. aureus from infant's mouth

Should a pregnant woman continue to breast feed with mastitis?

True. 1) 25% are cesarean section 2) 15% are operative vaginal deliveries-Used in the second stage of labor when the cervix is dilated - Forceps (More maternal complications because of lacerations and tears to adjacent structures) - Vacuum (more fetal complications)

T or F. Operative delivery Used in 35-40% of deliveries in US

True

T or F. Prostaglandins can be used to maintain patency of ductus arteriosus in the fetus

160bpm

Tachycardia =

Bregma

The anterior "diamond" fontanelle is called the

Fourth stage of labor to assess for postpartum hemorrhage

The is the hour following the delivery of the placenta

Occiput

The posterior "triangle" fontanelle is called the

Degree is related to depth/structure damaged: 1st: perineal/vaginal epithelium (superficial) 2nd: underlying soft tissue (subcutaneous) 3rd: rectal sphincter (to sphincter) 4th: rectal mucosa (through sphincter)

There four (4) degrees of lacerations (Spontaneous laceration or episiotomy) during pregnancy. What are they?

Variable Decelerations (Which are the most frequent abnormal pattern) These babies have rapid recovery from uterine contractions

These decelerations are described as the following: - "shoulders/carrots" - Usually means Cord compression

Late Decelerations (The fetus is not recovering) This is BAD BAD

These decelerations are described as the following: - Beyond Uterine contractions - Uteroplacental insufficiency

Early Decelerations

These decelerations as described as the following: - Consistent with Uterine contractions - Vagal response to cephalic pressure (Usually means the head is being smushed) - Normal finding! Not related to fetal distress

Passenger

This causes malpresentation, malposition, and macrosomia (big baby)

Second Stage of Labor

This is "complete" dilation to parturition

Arrest disorder

This is a failure to progress?

Passage

This is affected by unfavorable pelvic shape

Precipitous labor

This is defined as : - 5-10cm/hr - Lacerations - Fetal respiratory issues

Power

This is defined as inadequate contraction frequency or strength

Labor induction/augmentation

This is defined as to Initiate/stimulate the uterus to contract or contract better

Tachysystole (Hyperstimulation of the uterus) This is not a single episode. It is over a period of time

This is defined as: 1) >5 Uterine Contractions in a 10 minute period 2) Uterine contractions occurring within one minute of one another 3) Any Uterine Contraction lasting 2 minutes or more

Puerpurium

This is described as the following: 1) The state of a woman during childbirth or immediately thereafter. 2. The approximate six-week period lasting from childbirth to the return of normal uterine size.

False labor "Braxton Hicks"

This is described as: Irregular uterine contractions; May or may not cause cervical change

True labor

This is described as: REGULAR uterine contractions + cervical change

First stage of labor

This is onset to full or "complete" dilation

Third stage of labor

This is parturition to the delivery of the placenta (< 30 min)

Neonatal respiratorydistress syndrome (RDS) In utero, the alveoli are collapsed but later surfactant is released at about 24 weeks so the alveoli can expand after birth happens as the baby is getting ready to be delivered. Now we need high pressure to force open the alveoli (BAD BAD)

This is pulmonary immaturity leading to poor oxygenation and ventilation

Protraction disorder

This is when labor takes longer than it should

Pudendal * These are pretty good for sowing up episiotomy

This only relieves perineal pain (Sacral Nerves S2-S4) for 2nd stage

Biophysical profile (The next level from Non-Stress Test and Contraction Stress Tests) AMNIOTIC FLUID TRUMPS EVERYTHING ELSE. It does NOT matter what the total score is. If the amniotic fluid does not meet the criteria of 5cm total or any 2cm pocket), deliver the baby

This test is described as the following, all getting 0 or 2 points each*:: 1) Reactive Non-stress test* 2) Adequate AFI (5cm total or any 2cm pocket)* OBSERVE FOR 30 MIN ON ULTRASOUND: 3) Movemement x 3 4) Tone (flex/ext) x 1 5) Breathing (lasting for 30sec)* A favorable score is is > 6. Consider delivery for a score <6

Contraction stress test

This test is described as the following: - 3 oxytocin-induced UCs in 10 minutes - Absence of LATE decelerations

TO DILUTE THE MECONIUM A saline drip that re-introduces fluid into the uterus in an attempt to "wash away" the meconium prior to delivery. It can only be administered through an IUPC. - Amnioinfusions are also sometimes used for severe variable decelerations to re-introduce fluid to cushion the cord.

Wait what is amniofusion?

1) Silicone implants removed from market in 1992, however ban is being reconsidered 2) Usually do not interfere 3) No good evidence silicone is harmful - No increased blood levels with implants - 10X higher concentration in cow's milk - 1000X higher concentration in formula

What about breast implants and breast feeding?

Dicloxicillin /cephalexin /clindamycin x 7-10 days

What antibiotics are given for mastitis?

1) Psychoprophylaxis (behavioral modification) 2) Continuous labor support (Labor coach AKA the doula) 3) Warm-water baths 4) Sterile water injection 5) Position, touch, massage

What are nonpharmacologic methods of Obstetric anesthesia/analgesia which are most beneficial in the first stage of labor?

1) Persistent Precipito-occipital transverse (which leads to transverse arrest. Remember the mid-plane is very narrow! ---> This requires forceps or C-section 2) Persistent Precipito-occipital posterior 3) Macrosomia (>4500 gm) Big baby 4) Shoulder dystocia 5) Conduction anesthesia 6) Congenital abnormalities (i.e. Hydrocephalus)

What are other causes of dystocia and subsequent c-section

Mechanical dilators, nipple stimulation, intercourse, herbs and oils

What are other ways to induce/augment labor?

1) Presentation "The presenting part" 2) Position "Presenting part to maternal pelvis" 3) Lie "Fetal to maternal axis:

What are the 3 ways to determine the fetal orientation?

1) Power 2) Passage 3) Passenger 4) Psyche

What are the 4 P's that cause Dystocia?

1) Premature fetus without lung maturity (IF we can't document the baby's lungs are mature, there is not way we are inducing labor) 2) Acute fetal distress Uh, no, we are doing a C-Section here) 3) Abnormal presentation (Brow, Face, Breech presentation? It's not going to work. Do a C-section)

What are the ABSOLUTE contraindications for both the induction and augmentation of labor based on the baby (fetoplacental)?

Contracted Pelvis

What are the ABSOLUTE contraindications for both the induction and augmentation of labor based on the mother (maternal)?

1) Prior uterine surgery (any scarring on the uterus can potentially rupture) 2) Classic cesarean section (Vertical) but Low transverse incision might be ok 3) Overdistended uterus

What are the RELATIVE contraindications for both the induction and augmentation of labor based on the mother (maternal)?

1) Uterine hyperstimulation (The uterus is contracting more frequently and/forcefully)---Remember this could cause reduced blood flow to the uterus. Usually the fetus can withstand uterine contractions, but if they are coming too often, there may not be enough recovery time 2) Rupture the uterus 3) Fluid overload 4) Uterine Fatigue (associated with a risk of postpartum hemorrhage) and uterine atony

What are the complications of using Oxytocin/Pitocin?

1) 95% vertex 2) 4% breech 3) 1% face, brow, shoulder

What are the different types of fetal "Presentation"?

1) US transducer - Shows fetal heart rate based on US cardiac cycle 2) Tocodynamometer (Toco) - Shows "timing" and "duration" of contraction - CANNOT measure strength of contraction

What are the external fetal monitors?

1) Prolonged 2nd stage of labor (No progression after 2 hours in nulliparous patients w/o epidural or 3 hours with epidural). In this situation, the cervix is dilated but the fetus is not making any movement 2) Suspicion of impending fetal compromise 3) Breech delivery (Forceps only) 4) Shorten second stage for maternal benefit

What are the indications for Forceps/Vacuum delivery?

1) Abnormal labor (after confirming inadequate contraction strength) 2) Prolonged latent phase 3) Prolonged active phase

What are the indications for the augmentation of labor?

Cesarean Section is just as safe as vaginal delivery as long as it is "elective" 1) Dystocia 2) Repeat cesarean 3) Breech 4) Fetal distress 5) Placenta previa 6) Previous uterine incision 7) If we have excised and cut through the myometrium of the uterus (This is a no go for a vaginal delivery) 8) Active herpetic lesions

What are the indications of a Cesarean Section?

1) Membrane stripping weekly at 37 weeks 2) Amniotomy "artificial rupture of membranes AROM" 3) Mechanical dilation - Laminaria-a seaweed species that can be inserted into the cervical os, allowing hygroscopic growth by absorption of cervical water, and gentle expansion leading to dilation of the cervical os. -Foley bulb dilation (This what Sarah Had) 4) Prostaglandins (Most used) - E1—Misoprostol (Cytotec) (not FDA approved) - E2—Cervidil and prepidil 5) Oxytocin (Pitocin) # 1 prescribed drug in the US

What are the methods of induction/augmentation?

1) Epidural anesthesia 2) Unfavorable cervix (Use Bishop's score) 3) Increased maternal age 4) Increased maternal birth weight

What are the risk factors for prolonged latent phase labor?

1) Phenergan 2) Ambien 3) Vistaril

What are the sedatives that we use?

Grunting, flaring, retractions, hypoxia

What are the signs and symptoms of Neonatal respiratorydistress syndrome(RDS)?

1) Descent 2) Flexion 3) Internal rotation 4) Extension 5) External rotation (restitution) 6) Expulsion

What are the six cardinal movements of labor?

1) Hypertonic contractions (Strong but Irregular and ineffective) 2) Hypotonic contractions (too weak) 3) Too early or over-sedation of mom

What are the three things that cause prolonged latent phase?

1) Fetal/Maternal pelvic size mismatch 2) Fetal head enters the inlet in asynclitic presentation

What are the two causes of Cephalopelvic Disproportion (CPD)

1) Transverse 2) Longitudinal

What are the two ways that a fetus can lie?

1) Non-Stress test 2) Contraction Stress Test 3) Biophysical profile- 0 or 2 points each

What are the types of fetal assessments?

1) Intermittent Auscultation 2) Electronic (EFM) - Ultrasound moniter - Tocodynamometer - Can be done externally or internally (if membranes ruptured)

What are ways to assess fetal well-being?

1) Lie 2) Presentation 3) Estimated fetal weight (EFW)

What can Leopold's maneuvers confirm?

"Meconium Aspiration Syndrome"

What can thick meconium result in?

1) Distention of birth canal 2) Mammary stimulation

What causes the release of oxytocin from the posterior pituitary?

1) Pain 2) Infection 3) Symptoms may prompt d/c Breast feeding

What could happen to the nipples as a result of breastfeeding

Acidosis and death

What does Neonatal respiratory distress syndrome(RDS) lead to?

Fetal distress and maternal discomfort

What does Tachysystole lead to?

Adequate frequency AND force of contractions, and re-examination after 1-2 hours for cervical change, in conjunction with fetal status, will dictate management.

What does placement of an internal monitor will provide evidence of?

Mastitis

What does stasis of milk lead to?

- Attention to size, consistency, symmetry, completeness, number of vessels, whether velamentous, Wharton's jelly, clots, knots, and accessory lobes. -Suspicious findings should lead to pathologic examination. There are a number of placental findings associated with abnormal fetal development.

What does the examination of the delivered placenta include?

1) Breast feeding 2) Engorgement 3) Suppression 4) Cracked nipples 5) Mastitis 6) Implants 7) PP check/intercourse

What happens during Puerpurium?

It increases

What happens to the surfactant levels as pregnancy progresses?

1.5-1.2cm/hr (Nulltips)

What is "Prolonged active" Protraction disorder?

14-20hr (Multips)

What is "Prolonged latent" Protraction disorder?

1) Accelerations from baseline 2) Decelerations from baseline

What is Long-term variability (variations from baseline)?

Interval between successive R-R intervals

What is Short-term (beat-to-beat) variability?

- Prolonged 2nd stage because we interfere with mom being able to appreciate how forceful to contract & maternal fever - Increased use of forceps but fetal outcome unchanged

What is a lumbar epidural associated with?

Manual movement of fetus to favorable presentation if not so by 36 weeks

What is an External Cephalic Version?

1-2hr, add 1 hr for epidural

What is an arrest of descent?

2 hours

What is an arrest of dilation?

Dry nipples after feeding; air dry 10 minutes

What is done in the prevention of cracked nipples?

The byproduct of fetal metabolic changes (cells or fetal feces) When the fetus is distressed, their sphincter is relaxed and meconium is released in the amniotic fluid

What is meconium?

1) Phospholipids 2) Lipids 3) Protein 4) Carbohydrates 5) Salts -Phosphatidylcholin (lecithin); sphingomyelin (S); phosphatidylinositol (PI); phosphatidylglycerol (PG) most important

What is surfactant composed of?

Cervical Dilation of 4-10 cm

What is the "active" phase of the First Stage of Labor?

Cervical dilation of 0-4 cm

What is the "latent" phase of the First Stage of Labor?

1) Standard of care—the best choice 2) Cheap and plentiful—ecologically sound 3) No inhibitors—good for working moms too 4) Benefits mom and infant - Bonding, PPH, contraception, wt loss, CA risk, ID risk, dz, immune protection and response (IgA blocks the attachment of E.Coli to the intestine :) 5) Colostrum yields to mature milk by day 3-6 :) Rates are increasing!

What is the benefit of breastfeeding?

They Cross placenta - Neonatal respiratory depression if close to delivery - Decreased fetal heart rate variability 1. *Sublimaze (Fentanyl) 20-60 min half life (GOOD :)) 2. MSO4 1-2 hours 3. Meperidine (Demerol) 4-6 hours (Be careful of this long half life)

What is the disadvantage of parenteral narcotics?

Lack of surfactant to decrease surface tension

What is the etiology Neonatal respiratory distress syndrome(RDS)?

Oxytocin

What is the first line drug for post-partum hemorrhage?

T-10 to L1

What is the innervation of the uterus?

1) Chronic pain 2) Dyspareunia 3) Incontinence of bowel or bladder

What is the morbidity of lacerations that occur during pregnancy?

Cephalopelvic Disproportion (CPD)

What is the most common cause of dystocia and subsequent c-section

Variability

What is the most reliable indicator of fetal well-being?

It decreases alveolar surface tension

What is the purpose of surfactant?

1) Frequent breastfeeding with complete emptying - Massage may facilitate latching 2) Cool compresses/ice 3) Analgesics 4) Avoid breast pumps for more than 10 min - Often inefficient at removing milk - May promote excess milk production

What is the treatment for Engorgement?

Long acting anesthetic

What kind of drug is Bupivicaine?

1) Call pediatrics! 2) Anmioinfusion **No longer suction on the perineum **No longer intubate during resuscitation

What must be done in - "Meconium Aspiration Syndrome"?

Occiput anterior

What position gives mechanical advantage?

Sitz baths and ibuprofen/tylenol should be used, and close follow-up, particularly for infection manifesting as pain, is warranted.

What should be done after the surgical repair of a laceration?

Surgical I&D

What should be done if there is an abscess associated mastitis?

1) Express manually to preserve lactation 2) Use of nipple shield/emollient

What should be done in the event of cracked nipples?

1) Screening for postpartum depression - Edinburgh postnatal depression scale (EPDS) 2) Bonding 3) Breastfeeding 4) Pap 5) Intercourse

What topics are discussed during the postpartum check up?

1) Laminaria 2) Foley bulb dilation

What were the two forms of mechanical dilation again?

1) First of all, the patient Must have ruptured membranes to use 2) Fetal Scalp Electrode (FSE) - shows fetal heart rate based on R-R interval which makes **this the most accurate way to measure fetal heart rate** SEE Pic 3) Intrauterine Pressure Catheter (IUPC) - Shows not only timing & duration of contraction but also STRENGTH -Measured in Montevideo units (cumulative strength of contractions in 10 minutes)

What will an internal fetal monitor show?

During the 1st stage of labor

When are parenteral narcotics efficacious?

They are helpful only in false labor

When are sedatives helpful?

After amniocentesis

When are surfactant levels measured?

At 28 weeks

When do Leopold's maneuvers begin?

Beginning at 24 weeks

When do Pneumocytes produce surfactant?

1) Extreme urgency for c-section 2) Contraindication to regional anesthesia 3) Regional anesthesia has failed

When is General Anesthesia used?

Used when there is an unfavorable Bishop's score

When is PGE1 (Cytotec) and PGE2 (Prepidil) used?

Used in high risk pregnancies to assess fetal well being

When would we used external fetal monitoring in the prenatal period prior to birth?

At their site of action in the endometrium/myometrium

Where are prostaglandins synthesized?

NONE OF THEM!

Which of the cardinal movements occur(s) in the THIRD stage of labor

Presentation, Lie, EFW—NOT position!

Which parameters may be assessed by Leopold examination?

Because of the Anti-diuretic effect (It is like vassopressin) This can cause hyponatremia and subsequently seizures

Why can't we used Oxytocin/Pitocin for longer than 72 hours?

1) Compromised airway 2) Risk of uterine atony

Why is general anesthesia unfavorable?

The sacrum

With regard to the position, what is the breach reference point?

The occiput

With regard to the position, what is the vertex reference point?

Labor Dystocia

abnormal (slow) progress of labor