30: 27-year-old woman labor and delivery

Question 1

Advantages of Group Prenatal Care

Answer 1

Preterm delivery is less likely in women participating in group prenatal care, and this was more significant for African American women, in one study.

Furthermore, if an infant is preterm, the birth weight (a significant survival determinant) is greater when the mother participated in group prenatal visits.

Since the incidence of preterm birth is higher in African American women than Caucasian women, and preterm birth is the number one cause for neonatal death in African American infants (as opposed to congenital anomalies in Caucasian infants), the advantages of groups visits may be an important tool to help combat the racial disparities seen in maternal health in the United States.

Question 2

Evidence of Active Labor

Answer 2

Active labor is associated with strong regular contractions every three to five minutes and a cervical dilation of more than 6 cm in the setting of contractions.
The fetal heart tracing does not impact the diagnosis of active labor.

Question 3

Absolute Contraindications to Digital Cervical Exam

Answer 3

Both patient reports of vaginal bleeding with an undocumented placental location (or known previa) AND leaking vaginal fluid with prematurity (or known PPROM) are absolute contraindications to digital cervical exam secondary to harm that may be caused-worsening of bleeding in the first case, and introduction of bacteria into the uterus potentially leading to infection, in the second.

Neither an abnormal fetal heart tracing [B] nor painful contractions [D] are reasons to defer a digital cervical exam, and in fact, may be reason to do an exam to gather important information that will impact the management of the patient in either case.

Question 4

Stages of Labor

Answer 4

First stage
latent phase: regular contractions have started, but the cervix is less than 6 cm dilated active phase: begins when 6 cm dilated; ends when fully dilated

Second stage: begins at full dilation; ends when the baby is delivered

Third stage: begins with birth of the baby; ends with delivery of the placenta

Question 5

pre-eclampsia criteria

Answer 5

Elevated Blood Pressures: blood pressures of greater than 140 systolic or 90 diastolic on at least two readings (greater than six hours apart ideally) in a seated or semi-reclined position in a woman who previously had normal blood pressures and is over 20 week gestation (by itself, this is the definition of Gestational Hypertension)
AND
Proteinuria: at least 300 mg on a 24 hour urine collection or at least 1+ or 30 mg/dL on dipstick (again, on two occasions ideally six hours apart)

Question 6

pre-eclampsia epi and eval

Answer 6

African American women are more likely to have preeclampsia than other women (Asian, Hispanic, or Caucasian) in the US, their disease is more likely to be severe, and they are also more likely to suffer the complications of preeclampsia, such as placental abruption and eclampsia.

Rule out HELLP (Hemolysis, Elevated Liver enzymes AND Low Platelets) syndrome or severe pre-eclampsia via evaluation of renal and liver function, including a spot urine protein/ creatinine ratio, as well as a complete blood count to look for hemoconcentration or thrombocytopenia.

Question 7

Criteria for Preeclampsia with Severe Features (any ONE of the following):

Answer 7

> > severe hypertension of at least 160 mmHg systolic or 110 mmHg diastolic
——A patient with blood pressure in this range would need an anti-hypertensive in order to prevent sequelae of severe hypertension, such as myocardial infarction or stroke.
right-upper-quadrant pain or a doubling of serum transaminases
platelet count < 100 > 1.1 mg/dL
pulmonary edema

Question 8

Late Decelerations

Answer 8

Late decelerations are decelerations in the fetal heart rate that begin after a contraction begins, with the nadir after the peak of the contraction.

They can be an indication of utero-placental insufficiency, meaning that the baby may not be getting enough oxygen and late decelerations can be an early sign of hypoxemia during contractions.

Question 9

Category I, II, III Intrapartum Strips

Answer 9

Look at the criteria for Category I, II, and III intrapartum strips. Once a woman is admitted in labor, we categorize fetal heart tracings in this way, rather than using the criteria for non-stress tests, which are most useful in the antepartum period.

Question 10

Intrapartum Fetal Heart Rate Pattern Classification

Answer 10

Category I:

• -Normal FHR (baseline 110-160)
• -Moderate variability (between 6 and 25 beats per minute changes that are not accels or decels)
• -Plus or minus accelerations (at least 15 beats per minute above the baseline for at least 15 seconds from start to finish)
• -Plus or minus early decelerations (mirror contractions, nadir of deceleration with peak of contraction and resolves when contraction resolves - usually indicates fetal head compression when the fetus is low in the pelvis, often occurs with pushing)
• -No late or variable decelerations

Category II:
Any fetal heart rate tracing that does not fit into Category I or III.

Category III:
No fetal heart rate variability (absent) PLUS at least one of the following:
—FHR baseline less than 110 (bradycardia)
—-Recurrent late decelerations (occur with more than 50 % of contractions in a 20 minute period)
—Recurrent variable decelerations
OR
Sinusoidal fetal heart rate pattern (smooth undulations of fetal heart rate in a sine wave like pattern). This pattern is rare and is considered an agonal pattern in a fetus near death.

Question 11

Labor Dystocia - Definition, Diagnosis, Treatment

Answer 11

Definition
»The average speed of dilation is about 2 cm/hour for multiparous women and about 1 cm/hour for primiparous women, so the average length of the active phase of the first stage of labor is 2.4 hours for multiparous women and 4.6 hours for primiparous women.
»Failure to progress (or active phase arrest) occurs if there is no cervical change for two hours in the active phase of labor.

Diagnosis
»A ‘Friedman curve’ is often used to plot the labor progress in terms of cervical dilation, effacement, and fetal descent in order to help diagnosis labor dystocia.
»You may also diagnose this condition in the second stage of labor if the fetal presenting part does not descend significantly in the pelvis after two hours of pushing (or three hours with an epidural).

Treatment
There are many things that we can do to augment labor in the event of active phase arrest, including administration of IV oxytocin and/ or artificial rupture of membranes.

Question 12

The Cardinal Movements of Labor

Answer 12

1. Engagement
   The presenting part of the fetus has entered the pelvic inlet.
2. Descent
   Described by the “station” on cervical exam. The fetus is at 0 station when the widest part of the presenting part is between the ischial spines.
3. Flexion
   When a fetus is in the occiput anterior position, the fetal head is flexed by the soft and bony tissues of the maternal pelvis, which facilitates passage through the birth canal.
4. Internal rotation
   The fetal head must rotate in order to further descend
5. Extension
   Occurs as the fetal head passes under the symphysis pubis, which occurs during crowning and delivery of the head
6. External rotation
   The head rotates to realign with the shoulders (also called restitution)
7. Expulsion
   Completing the delivery, with the anterior shoulder of the fetus being pushed out first, then the posterior shoulder and the rest of the body.

Question 13

Fetal Head Orientation

Answer 13

Left occiput anterior indicates that the back (occiput) of the fetal head is anterior in the mother’s pelvis and to the mother’s left.
Direct occiput anterior indicates that the occiput is directly posterior to the pubic symphysis (with the baby’s face towards the rectum.)

Question 14

Causes of Postpartum Hemorrhage

Answer 14

4 T’s (from most to least common):

1. Tone (uterine atony leading to continued bleeding)
2. Trauma (perineal or cervical lacerations, uterine inversion)
3. Tissue (retained or invasive placental tissue in the uterus)
4. Thrombin (a bleeding disorder-much less common that the other three causes)

Question 15

Newborn Weight Loss and Weight Gain

Answer 15

It usually takes two to three days for breast milk to fully come in after delivery. Some amount of weight loss is normal and not dangerous in a healthy term newborn. Colostrum is protein-rich and very nutritious for newborns.

In the newborn period, expect to see a weight gain of about an ounce per day once the maternal milk is in.

Question 16

How to Perform Digital Cervical Exam

Answer 16

• wait between contractions
• As she exhales, insert your finger into the vagina and reach until you can feel the cervix, which is usually firmer than the vaginal wall tissue, especially early in labor. Sometimes, when the cervix is still posterior (early in labor) it helps to ask the woman to place her hands under her buttocks and tilt her pelvis towards the ceiling if you cannot find the cervix initially.
• Once you feel the cervix, trace it around until you feel the opening in the center. Then put your fingers into the opening (external os) until you feel the presenting part (hopefully, the fetal vertex!).
• Once you feel the fetal vertex, you can be confident that you are through the internal os. Spread your two fingers to determine how many centimeters the internal os is dilated. Remember that in a multiparous woman, the external os may be dilated several centimeters even when the internal os is still closed. This is why it is important to make sure that you are touching the presenting part to be sure that you are through the internal os. If you cannot feel a presenting part or membranes, but feel a “fleshy” end to the cervical canal, then the internal os is probably still closed.
• In a dilated cervix, once you have determined how many centimeters dilated the internal os is, try to determine the thickness of the cervix. This can only accurately be done by exam when the cervix is dilated enough to admit at least one finger. Then try to feel using the sides of your fingers how thick the cervix is. A pregnant, non- labored cervix is usually at least 3 cm in thickness. So, 1.5 cm would be about 50% effaced and so on. Remember that the cervices of primiparous women usually efface first and then dilate, so their cervix may be very thin once they start to dilate, whereas, those of multiparous women do both at the same time and their cervix may still be relatively thick even when they are quite dilated.

Question 17

A thorough newborn examination should be performed within 24 hours of birth.

Answer 17

• -Examine the head, looking for abnormalities of shape and size, size and condition of the fontanelles, and any masses.
• -Look in the eyes at the conjunctiva and sclera, as well as observe the red reflex with an ophthalmoscope.
• • Make sure both nares are patent and that the palate is intact.
• -Examine the size, shape and position of the ears.
• -Examine the neck for any masses.
• -Listen to the heart and lungs.
• -Check the abdomen for any masses and look for signs of infection at the umbilical stump.
• -Examine the skin for jaundice, rashes and congenital lesions.
• -Examine the hips to evaluate for developmental dysplasia of the hip, as well asfeel for the brachial and femoral pulses, that they are equal and symmetric.
• -Examine the penis for size and placement of the meatus; examine the scrotal sac and the testes to ensure that they are both descended.
• -Examine the back to look for any spine abnormalities or subtle signs of neural tube defects, such as a sacral cleft.
• -The neurological exam will consist of checking for resting tone, movement of all extremities, and checking neonatal reflexes, including the suck, rooting, grasp and moro reflexes.

Question 18

Steps to Decrease Maternal Blood Loss

Answer 18

Active management of third stage of labor
»Give the mother Pitocin (oxytocin) after the baby is born to help the placenta detach quicker, very gently pull on the cord when the placenta appears to have detached, and we would massage the uterus after the placenta comes out to help the blood vessels stop pumping out blood.

Early clamping of the umbilical cord
»There is evidence that delaying cord clamp can decrease the risk of anemia in newborns and infants. Most of the studies show that two minutes of delay is about the right amount of time, and this probably is still early enough to decrease blood loss in the mother.

Question 19

Management of Late Decelerations

Answer 19

1. Continuous fetal monitoring.
2. Position the patient on her side to decrease pressure on her vena cava, and increase blood return to the
   heart, in order to maximize cardiac output and blood flow to the uterus.
3. Monitor blood pressure. If her blood pressure is low, she may benefit from a fluid bolus to further increase
   blood flow to the uterus.
4. Oxygen by face mask, to maximize placental oxygen delivery. Although there is no clear evidence to
   support this, it is unlikely to cause harm with short term use, other than minimal patient discomfort.

Question 20

Labor Pain Management - Alternatives to Epidural

Answer 20

For women who wish to avoid all pharmacologic pain management, intradermal sterile water injections, self- hypnosis, acupuncture, and water immersion all have fairly good evidence that they can be effective for labor pain management. All of them except for water immersion do require some previous knowledge and expertise regarding the technique, either by the pregnant woman herself or her birth attendant, depending on the method.

IV opioids should not be used close to the time of delivery in order to avoid neonatal respiratory suppression.

Question 21

Delivery

Answer 21

When women are lying on their back pushing, you can protect the perineum by putting pressure posteriorly with one hand (to avoid extensive posterior perineal lacerations) and gently helping the fetal vertex to stay flexed with two fingers of the other hand (to avoid anterior perineal lacerations from over extension). This should only be done during crowning and every effort should be made to avoid episiotomy unless necessary for fetal distress or dystocia.

There is good evidence that avoiding routine episiotomy protects women from unnecessary perineal trauma, but the evidence for the other perineal protection techniques is weaker and has not been well-studied.

After the head delivers, allow the head to restitute while you gently feel around the fetal neck to determine if a nuchal cord is present.

Question 22

There are several evidence-based approaches to encourage breastfeeding and increase breastfeeding rates.

Answer 22

To encourage breastfeeding, pacifiers and supplements should be avoided in the first few weeks of life, mothers and newborns should ideally stay in the same room in the hospital, and infants should only be fed on demand.

Education of expectant women and their partners (like breastfeeding classes during pregnancy) has been shown to help increase the rate of breastfeeding initiation and exclusive breastfeeding at six months.

Lactation consultation by a certified lactation specialist can also be very helpful for breastfeeding mothers, and should be considered routinely for first-time breastfeeders, small for gestational age infants, preterm infants, and any other circumstance where breastfeeding could be challenging.

Breastfeeding infants with slow or no weight gain should be seen frequently to asses for failure to thrive, jaundice or other problems. Frequent office visits can also provide additional support and education for women desiring to breastfeed their infants.

Immediate skin-to-skin contact after delivery is a very important step in establishing breastfeeding in mother-baby pairs, and there is good evidence to support this practice. Early skin-to-skin contact and early initiation of breastfeeding is associated with increased rates of breastfeeding at hospital discharge and later in infancy.

Question 23

Interpreting a Non-Stress Test Strip

Answer 23

A non-stress test is an assessment of fetal well being in the antepartum period, before labor. Remember, the red line is fetal heart rate (FHR), the pink line is fetal movement, and the black line is uterine contractions. Each thin vertical line on the graph represents ten seconds, and each thick vertical line represents one minute.

First check the FHR. A normal FHR has a baseline between 110 and 160 beats per minute with variability of 6 to 25 beats per minute.

Next, determine whether the strip is ‘reactive’ or not. A neurologically intact and healthy fetus should have two heart rate accelerations of at least 15 beats per minute over at least 15 seconds in a 20-minute period, which is called a ‘reactive’ strip.

For someone in labor, admitted to the birthing unit, they are not required to have a reactive NST in order to be considered reassuring. For an antepartum patient with medical issues indicating fetal well-being testing and one whom you may consider sending home if she is not in labor, performing a non-stress test is appropriate.

Question 24

Fetal Status Assessment

Answer 24

Non-reassuring Fetal Status
»A baseline fetal heart rate of 170 beats per minuteis defined as tachycardia, and would be cause for concern. Many problems could cause fetal tachycardia, including maternal fever or infection and fetal anemia or hypoxia.
»Minimal (5 or less beats per minute), absent, or marked (greater than 20 beats per minute) variability of the fetal heart rate.

Reassuring Fetal Status
»Moderate variability (6 to 20 beats per minute).
»A subjective report of active fetal movement.
»A “reactive” strip showing two heart rate accelerations (of at least 15 seconds with a peak of at least 15 beats per minute above the baseline) in a 20-minute period.

Question 25

Approach to Evaluating Fetal Heart Rate Tracings

Answer 25

When evaluating fetal heart rate tracings, it is useful to follow a systematic approach.
1) Consider the uterine activity
2) Determine the baseline FHR
3) Determine the heart rate variability
4) Look for accelerations
5) Look for decelerations
Overall assessment– this intrapartum strip is not category I, II, or III

Many intrapartum fetal heart rate tracings will be classified as category II, and they may still be reassuring overall, or they could be concerning overall, depending on the specifics of the findings and the situation with the patient.