Labor and Delivery

IUPC

• Adequate contraction on an IUPC:
  • 200mV units in 10mins

Cervical changes

• – Softening
  
• – dilation
  
• – Effacement
  
• – Position

Phases of labor

• Latent = cervix is 0-6cm
  
• Active = cervix is 6-10cm

Prolonged Phases of Labor

• Pt is in the latent stage of labor that the head is engaged but the cervix is still not changing plan:
  • – Balloon
    
  • – Amniotomy
    
  • – Misoprostal
    
  • – Oxytocin (preferred)
• Pt is in the active phase with no cervical changes for 4 hours plan:
  • C-Section
• Patient is fully dilated but the baby does not depend for 3 hrs (null) or 2hrs (multi) plan:
  • C-section if above station 0
    
  • Forcepts and vacuums if below station 0
• If the placenta is not delivered within 30mins after birth plan:
  • 1) Uterine Massage
    
  • 2) Oxytocin
    
  • 3) Manual extraction

Preterm

• Path: Idiopathic
  • – Smoking
    
  • – Young maternal age
    
  • – Multiple gestations
    
  • – Preterm ROM
    
  • – Anatomical
    
• Pt: + Contraction AND cervical changes, not term
  
• Dx: Clincal
  • 24 to 34wks give steroids and deliver
    
  • < 24 wks abortion
• Tx:
  • Delay Delivery
    • MgSulfate
    • B agonist
    • CCB
    • prostaglandins
  • Develop Baby – Steroids (L/S <2/1)
• Contraindications:
  • Pre Eclampsia
  • Fetal demise
  • pROM, abruption

Premature rupture of membranes

• Path: Infection, GBS
  
• Pt: + ROM, + Term, – contractions
  
• Dx: Clinical = ROM
  
• GBS status
  
• Tx:
  • Deliver
  • GBS +:  (give ampicillin)

Preterm premature rupture of membranes

• Path: Infection GBS
  
• Pt: + ROM, – Term, – contraction
  
• Dx: Clinical = ROM
  
• Tx:
  • 24 to 34wks give steroids and deliver
    
  • < 24 wks abortion
    
• f/u: Prolonged ROM

Rupture of membranes

• Path: Spontaneously; artificially, pathologic
  
• Pt: Rush of fluid
  
  • – meconium stained
    
  • – bloody
    
  • – clear
    
• Dx:
  • – Rush of fluid
  • – Vaginal pooling on speculum exam
    
  • – Nitrazine Test: turns blue (FP possible if urine, blood, or sperm present)
    
  • – Fern test: Slide shows ferrying
    
  • – US shows less amniotic fluid that what was present before.(oligohydramnios)
• Tx:
  • Delivery if at term
  • if not at term evaluate risk vs benefit

Prolonged rupture of membranes

• Path: Infxn that gets in, not that caused the ROM
  
• Pt: ROM –> Delivered > 18hrs (Normal delivery <18hr following ROM)
  • – Inc risk of infection
    
  • – Baby out: endometritis
    
  • – Baby in: chorioamnionitis
    
  • – Infection by GBS, vaginal flora.
• Dx: Clincal
  
• Tx:
  • Delivery
    
  • GBS +/unknown: give ampicillin
    
  • GBS -: Wait
    
• f/u: Endometritis/chorioamnitis

Endometritis-Chorioamnionitis

• Path: Baby out (endometritis) chorioamniotiis (baby in), vaginal flora accents
  
• Pt: Prolonged ROM + Mom gets fever/toxic
  
• Clinical Presentation:
  • – mom presents with PPROM, PROM, Prolonged rupture of membranes and a fever
  • – Maternal and/or fetal tachy
  • – Fundal/ uterine tenderness
  • – Purulent amniotic fluid.
  • – Sepsis: fever, leukocytosis, tachycard, tachypnea)
• Dx: rule out other things using UA, CXR, and blood cx
  • – NEVER CULTURE: most are vaginal flora = tells us nothing useful.
• Tx: IV Ampicillin + Gentimycin +/- Clindamycin = cover gram – & anaerobes

Post Term:

• Path: Macrosomic, shoulder dystopia, dysmaturity
• Pt:
  • >40wks by conception
  • > 42 weeks by LMP
• Dx: Clincal
• Tx:
  • If you are sure its post term and cervix is favorable then start induction ptocin
  • If you are sure its post term and cervix is unfavorable then get c-section
  • If you are unsure its post term then you should get a BPP (non-tress + AFI and u/s)

Uterine Atony

• Path: A-tonic uterus
  
  • – prolonged labor
    
  • – oxytocin
    
  • – tocolitics
    
• Pt: Post partum hemmorage with boggy uterus
  
• Dx: Clincal
  
• Tx:
  • Massage
  • oxytocin
  • methergine
  • hemabate (PGE)
  • surgery

Uterine Inversion

• Path: “Births itself”
  
  • – Oxytocin
    
  • – Traction
    
• Pt: Post partum hemorrage, absent uterus
  
• Dx: Clinical… speculum
  
• Tx: Manually…. might need to use tocolytics (oxytocin) to hold into place

Vaginal Lacerations

• Path: Cervix + Vagina, percipitous delivery , macrocosmic baby, episiotomy
  
• Pt: Post partum hemorrhage + Normal uterus
  
• Dx: Clinical…. speculum
  
• Tx:
  • Pressure
  • suture (anesthetics)

Retained Placenta

• Path: Burrowed deeply, accessory lobe, placental tear, depth = name (acreta, increta, percreta)
  
• Pt: Post partum hemorrhage + Firm
  
• Dx: Placental blood vessels go to the edge
  
• Tx: D&C —> surgery TAH
  
• f/u: Beta HCG

Prolonged 1st stage

Prolonged Latent Stage

• Presentation:
  • Contraction till Cervix 4cm
  • > 20 hrs (primi)
  • > 14 hrs (multi)
  • Analgesics
  • Power, Passenger, Pelvis
• Dx:
  • Contraction 3/30 minutes
  • Contraction > 40mmHg
• Tx:
  • Rest + Wait
  • Balloon + Dilation => C section
  • Pitocin

Arrest Active

• Presentation:
  • Contraction 4cm till 10cm
  • > 1.2 cm/hr (primi)
  • > 1.5 cm/hr (multi)
  • power, pelvis, passenger
• Dx:
  • Contraction power + freq
  • cervical changes slow (prolonged)
  • Cervical changes none (arrested)
• Tx:
  • Pitocin 
  • C section

Prolonged 2nd stage

• Presentation:
  • 10 cm till Baby Delivered
  • 3hrs (epidural)
  • 2hrs (natural)
  • Power, pelvis, passenger
• Dx: Contractions freqeuncy, power
• Tx:
  • Pitocin
  • Station +1/+2 = Vaccuum Forceps
  • Station ≤ 0 = C section

Prolonged 3rd stage

• Presentation:
  • Power
  • Baby delivered till Placenta Delivered
• Tx:
  • Massage
  • Pitocin
  • Manual manipulation