Labor and Delivery

Question 1

Physiologic changes prior to labor

Answer 1

• Lightening/engagement
  
  • About 2 weeks before labor in first pregnancy
  • Settling of fetal head into brim of pelvis
  • If multiparous, lightening does not occur until labor
  • Increases pelvic discomfort, pressure, urinary frequency
  • Woman may feel less discomfort with SOB, heartburn
• Braxton Hicks contractions
  
  • Painless, irregular contractions that may occur at any time during the pregnancy
  • 4-8 weeks before delivery intensify in frequency and strength
  • Sometimes dubbed “false labor” aka “prelabor”
    
    • They can be intensely uncomfortable and go on for weeks without changing the cervix
    • They often go away if the woman starts walking
• Bloody show
  
  • Expulsion of mucous plug in some patients
  • Result of cervical dilatation and effacement days to 2 weeks before labor
  • Multips can be 1-3 cm dilated for weeks and not even know it
• Energy spurt
  
  • 24-48 hours before labor some women get a burst of energy and begin organizing, cleaning, cooking, “nesting”
• GI upset
  
  • Symptoms similar to early pregnancy with n/v, may have diarrhea, in early labor

Question 2

L and D

Answer 2

• Normal labor is usually painful
  
  • Intensity depends on feto-pelvic relationships, quality and strength of UCs, emotional and physical status of patient
• Contractions start with a buildup of intensity that gradually climaxes and dissipates.
• 5 P’s
  
  • Passenger
    
    • EFW, tolerance
  • Position
    
    • Presenting part (what part of baby is coming out first), station, flexion
  • Passage –pelvis and cervix; Clinical pelvimetry, cervical dilatation and effacement
  • Powers – uterus (is this a strong uterus (short labor) or fatigued uterus); Frequency, force and duration of UCs
  • Psych status – coping ability; Coping, accepting or… fearful, in pain/denial

Question 3

stages of labor

Answer 3

• A continuous process divided into 3 stages
• First stage
  
  • Results in cervical effacement and dilatation
  • The longest stage of labor (usually)

Question 4

first stage of labor

Answer 4

• effacement
• Early/latent/prodromal phase
  
  • 0-3 centimeters of dilatation
  • Relatively strong contractions usually q 5-7 minutes x 30-60 sec
  • Can last days
  • Woman can usually talk through UCs and smile in between
  • UCs do not go away with activity change or hydration
• Active phase
  
  • 4-10 centimeters
  • Contractions are stronger and more coordinated, usually q 2-3 min x 50-70 sec
  • Follows a fairly consistent timeline
  • Woman needs to concentrate with UCs, no longer cheerful, may cope with controlled breathing, visualization
• Transition
  
  • The last part of active phase
  • 7-10 cm dilated
  • Often feels “rectal pressure” and urge to push
  • Often defecates
  • VERY intense, shaking, toes curl, often vomiting, “I can’t do it!” Hitting the “wall”

Question 5

Second stage of labor

Answer 5

• Marked by when the cervix is 10 cm (“fully”) dilated
• Woman may experience a physiologic rest where UCs seem to cease for up to 1 hour and she may actually sleep
• Involuntary “pushing” usually begins either just before fully or right after
• Moves the baby down the vaginal canal
• Contractions usually q 1.5- 2 min x 60 sec and strong

Question 6

third stage of labor

Answer 6

• Begins with birth
  
  • UCs all but cease, accompanied by enormous relief
  • Delivery of placenta and membranes via mild uterine cramping
  • Usually within 5-10 min of delivery of infant
  • Can take up to 1 hour, but most guidelines recommend manual extraction after 30 min (Definition of retained placenta)

Question 7

decision to admit

Answer 7

• Decision to admit
  
  • Usually only if in active labor or complication noted (including ROM or GBS+) or fetus compromised
  • Can send home in early labor if reactive tracing, VSS, no known complications
• Admission
  
  • CBC w/ plts, blood type and Rh, antibody screen, RPR

Question 8

third trimester bleeding that presents to L and D

Answer 8

• Multiple causes, many benign
  
  • Mucous plug
  • Normal bloody show
  • Laceration/trauma
  • Infection
  • Ruptured uterus
• Placenta previa and placental abruption can be life threatening

Question 9

Placenta Previa

Answer 9

• Malposition of the placenta in the lower uterine segment that completely or partially covers the os
  
  • Partial, complete, low-lying, migrating
• Risk factors
  
  • Multiparity, AMA, multiple pregnancy, previous uterine surgery, smoking, previous previa, previous therapeutic abortion
• Associated with increased fetal mortality not related to bleeding
• Signs/symptoms:
  
  • Painless bleeding
  • Sudden onset
  • Third trimester
  • May be accompanied by uterine irritability
• Management:
  
  • DO NOT DO VAGINAL EXAM
  • US to confirm placement
  • Inpatient bed rest
  • Serial Hct, type and cross-match, Rh, indirect Coomb’s, coag studies
  • Fetal surveillance (growth, movement, NSTs)
• Pelvic rest, no orgasm
• Deliver prior to term by C/S
• Partial or marginal previa can sometimes deliver vaginally
• Associated with placenta accreta (careful third stage management)

Question 10

Other placental placements

Answer 10

• Placenta accreta- (75% of cases) Affects 10% of previas (1/533 pregnancies) -Severe OB complication involving an abnormally deep attachment of the placenta, through the endometrium and into the myometrium. Great risk of hemorrhage during 3rd stage of labor. Commonly requires hysterectomy.
• Placenta increta - (17%) Occurs when the placenta further extends into the myometrium, penetrating the muscle.
• Placenta percreta - (5-7%) Most severe form of accreta - when the placenta penetrates the entire myometrium to the uterine serosa (invades through entire uterine wall). Can lead to the placenta attaching to other organs (rectum or bladder).
• Risk factors: Scar tissue/ Asherman’s syndrome (uterine adhesions from multiple abortions or surgeries))

Question 11

Placental abruption

Answer 11

• Placental abruption (Abruptio Placentae) – Premature separation of a normally implanted placenta from the uterine wall.
• Occurs in 1% of all pregnancies, often misdiagnosed as preterm labor
• Complications include maternal death from hemorrhage or DIC, fetal death, fetomaternal transfusion, amniotic fluid embolism, fetal distress, hypotension. Clinical s/sxs depend on the size of the abruption, and amount of blood loss.
• Separation of 50% or more of placental area usually results in fetal demise.
• Suspect this when a gravid patient presents with the triad of sudden onset of antepartum vaginal bleeding, a tender uterus, and hypertonic/hyperactive UCs.
• However if the abruption is concealed (blood does not reach the cervical os) there may be little/no vaginal bleeding. Abdominal pain is a prominent feature.
• Can occur spontaneously (more common) or as the result of abdominal trauma.
• Risk factors: HTN (MCC), maternal trauma, AMA, multiparity, smoking, cocaine use, trauma, external version, previous abruptions
• Signs and symptoms:
  
  • Rigid, board-like abdomen
  • Painful, localized uterine tenderness
  • Colicky, discoordinated uterine activity
  • Possibly back pain
  • Possible fetal distress
  • Uterine enlargement (if occult)
  • Shock
  • Violent fetal movement
• Assess maternal viability – Stabilize mother, crystalloids to maintain volume status and fresh frozen plasma for coagulopathy. EMERGENCY OB CONSULT WHENEVER ABRUPTION IS SUSPECTED
• Stat IV x 2, Trendelenburg (head of bed tilted down), oxygen
• Assess fetal viability – Stat U/S, emergency delivery
• Labs: CBC, type/crossmatch, coagulation profile, renal function studies
• 50% of patients will have lab evidence of coagulopathy (thrombocytopenia, prolonged PT, hypofibrinogenemia, elevated fibrin split products)
• Rhogam if indicated, tetanus, correct coagulopathy

Question 12

L and D clinical management of normal labor

Answer 12

• Monitoring
  
  • Contraction frequency and duration, strength by palpation
  • Fetal heart rate by EFM or intermittent doppler
• Confirm status of membranes, dilatation, effacement and station
• EFW (estimated fetal weight)

Question 13

Clinical management of first stage of labor

Answer 13

• Ambulate, sit, side lie
• Nourishment (avoid dehydration)
• Continuous or intermittent monitoring
• VS q 4 hrs unless otherwise indicated
• Encourage voiding
• Analgesia prn, anesthesia usually once active
• Can use Lamaze type breathing or visualization (Bradley), “hypnobirthing” for coping and comfort
• Fetal monitor noted q 15-30 min in active labor, q 5-10 second stage (usually by RN per protocol)
• UCs are usually noted as above
• Patients on pitocin, VBACs need continuous EFM and toco

Question 14

The issue of pain

Answer 14

• The way pain is experienced is a reflection of the individual’s emotional, motivational, cognitive, social, and cultural circumstances.
• Pharmacological treatment of labor pain was introduced in the mid-nineteenth century.
• Controversial - women and their physicians believed that labor pain was a natural and necessary accompaniment of childbirth. This battle continues to the present day
• Laboring women are often treated differently than other patients suffering from pain.
• ACOG has recognized this double-standard, noting that “there is no other circumstance in which it is considered acceptable to experience severe pain, amenable to safe relief, while under a physician’s care”

Question 15

potential effects of severe labor pain

Answer 15

• Increased oxygen consumption
• Hyperventilation leading to hypocarbia and respiratory alkalosis
• Gastric inhibition
• Increased gastric acidity
• Lipolysis
• Increased peripheral vascular resistance, cardiac output, blood pressure
• Decreased placental perfusion
• Incoordinate uterine activity
• Postpartum psychological effects, such as PTSD

Question 16

pain pathways

Answer 16

• Pain originates from different sites as the process of labor and delivery progresses.
• First stage of labor - occurs during contractions, visceral/cramp-like
• Referred pain - can be referred to the abdominal wall, lumbosacral region, iliac crests, gluteal areas, thighs
• First stage of labor -distention of uterine and cervical mechanoreceptors and by ischemia of uterine and cervical tissues
• Second stage of labor — Somatic pain from distention of the vagina, perineum, and pelvic floor and stretching of the pelvic ligaments.
• The pain signal is transmitted to the spinal cord via three sacral nerves (S2, S3, and S4 or the pudendal nerve).
• Second stage pain can be more severe than first stage pain and is characterized by a combination of visceral pain from uterine contractions and cervical stretching and somatic pain from distention of vaginal and perineal tissues.

Question 17

pharmacologicl options for pain - opioids

Answer 17

• Opioids:
• Administered systemically act primarily by inducing somnolence, rather analgesia.
• Placental transfer of opioids to the fetus may produce neonatal respiratory depression.
• If systemic opioids are used, they are optimally delivered with an IV patient-controlled analgesia (PCA) regimen.
• Systemic opioids may be the only option in settings with limited resources, or if regional analgesia (epidural and/or spinal) is contraindicated.

Question 18

analgesics: neuraxial techniques

Answer 18

• Regional analgesic techniques, epidurals, spinals, and combined spinal-epidurals (CSE):
• Most reliable means of relieving the pain of labor and delivery.
• By blocking the maternal stress response, epidural and spinal analgesia may reverse the physiological consequences of labor pain.
• Epidural catheter may be used to administer anesthetics for instrumental or cesarean delivery, if required.
• “Walking epidural” - used to refer to any neuraxial technique (epidural, spinal, or combined spinal-epidural) that achieves analgesia with minimal motor block
• Co-administration of different classes of pain relievers
• Small doses of opioids administered into the epidural or intrathecal/subarachnoid space minimize systemic side effects, although annoying neuraxially-mediated side effects such as pruritus and nausea may occur.
• Catheterization of the epidural space allows administration of analgesics throughout labor and for instrumental or operative delivery.
• Patient-Controlled epidural analgesia (PCEA)
  
  • actively involves woman in her own pain management
  • results in less local anesthetic consumption and less motor block than standard continuous infusion techniques
• The onset of analgesia is more rapid with the intrathecal route – better for brief use (delivery/3^rd stage, produces anesthesia in lower half of body

Question 19

ADE’s of epidural

Answer 19

• No drowsiness, few tangible side effects but…
• Can cause maternal hypotension and subsequent transient fetal bradycardia
• Usually limits mobility
• Increases use of vacuum and forceps?
• Both epidurals and spinals can cause postpartum HA (dura puncture) and respiratory failure if “high” (total spinal)
• Possible ADEs of epidural
  
  • Failure to achieve analgesia or anesthesia (5% of cases)
  • Accidental dural puncture with headache (common, about 1 in 100)
  • Delayed onset of breastfeeding and shorter duration of breastfeeding
  • Catheter misplaced into a vein (less than 1 in 300). - can cause seizures or cardiac arrest
  • High block – respiratory depression, seizures, cardiac arrest (uncommon, less than 1 in 500).
  • In a study looking at breastfeeding 2 days after epidural anesthesia, epidural analgesia in combination with oxytocin infusion caused women to have significantly lower oxytocin and prolactin levels in response to the baby breastfeeding on day 2 postpartum
  • Catheter misplaced into the subarachnoid space (less than 1 in 1000).
    
    • Large doses of anesthetic may be delivered directly into the CSF. This may result in a high block, or, more rarely, a total spinal, where anesthetic is delivered directly to the brainstem, causing unconsciousness and sometimes seizures.
  • Neurological injury lasting less than 1 year (1 in 6,700)
  • Neurological injury lasting longer than 1 year (1 in 240,000)
  • Epidural abscess formation or hematoma (1 in 145,000)
  • Paraplegia (1 in 250,000)
  • Arachnoiditis (fewer than 1000 cases in the past 50 years)
  • Death (less than 1 in 100,000)

Question 20

pudendal block - pain relief

Answer 20

• Regional anesthesia blocking the pudendal nerve
• Anesthetizes the vulva and perineum
• Has no effect on uterus or UCs
• Minimal danger to mother and baby
• Used mostly second stage before impending delivery

Question 21

antiemetics - pain relief

Answer 21

• Given with opioids to potentiate their action and decrease maternal anxiety/apprehension

Question 22

non pharmacologic pain management

Answer 22

• Childbirth education
• Birth environment
• Labor support
• Maternal movement/positioning
• Relaxation and breathing
• Use of water/immersion
• Aromatherapy, acupressure, use of hot/cold, birth ball
• Sterile water injections
• Biofeedback, TENS, hypnosis

Question 23

Amniotomy, augmentation, amnioifusion

Answer 23

• Amniotomy
  
  • Artificial rupture of membranes
  • To check fluid, augment, apply internals
• Augmentation
  
  • To treat protracted or arrested labor
  • Pitocin, nipple stimulation, amniotomy
• Amnioinfusion
  
  • Using an intrauterine pressure catheter (IUPC) infuse NS into uterus to bolster fluid level and relieve cord compression

Question 24

clinical management of the second stage of labor

Answer 24

• Pt usually in bed (but may be standing, squatting)
• Can coach woman to push once she feels the urge (Valsalva vs. spontaneous/physiologic pushing)
• Monitor descent, flexion, rotation

Question 25

clinical management of the third stage of labor

Answer 25

• Delivery of the placenta usually within 30 minutes
• Signs of placental separation:
  
  • Gush of blood
  • Cord lengthens
  • Fundus rises in abdomen
  • Uterus becomes firm and globular
• Active third stage management: Risks – hemorrhage, retained placenta, uterine inversion
• Goal – reduce maternal blood loss
  
  • Cut/clamp cord after delivery – immediate vs delayed
  • Gentle traction on cord utilizing Brandt-Andrews technique
  • Administer pitocin after delivery of shoulder or immediately after delivery of baby
• After placenta, check fundus and massage to firm
• Check vaginal vault, cervix, perineum for lacerations and repair

Question 26

Spontaneous rupture of membranes (SROM)

Answer 26

• Expectant or active management?
• Women with term premature rupture of the membranes (PROM) who are followed expectantly go into spontaneous labor and deliver within 5, 24, 48, and 72 hours of PROM in 50, 70, 85, and 95 percent of cases, respectively
• Expectant management -Increased risk of infection, cord prolapse/cord compression, abruption, as well as the cost and length of hospitalization while waiting for labor to begin.
• Induction – Prostaglandins, oxytocin. Possibility of long labor, failure to progress, fetal distress and cesarean delivery.
• Initial evaluation
  
  • The diagnosis of PROM is based on history (ie, leaking fluid per vagina) and sterile speculum examination (ie, visualization of fluid flowing from the cervical os), supplemented by diagnostic testing of fluid in the posterior fornix, if the diagnosis is uncertain.
  • Digital examination should be avoided, as it has been associated with an increased risk of intrauterine infection.
  • Gestational age is determined according to the usual parameters (last menstrual period and/or ultrasound biometry
  • Fetal well-being is evaluated with a nonstress test, with or without a biophysical profile
  • Fetal position is determined by transabdominal physical examination (Leopold’s maneuvers) and ultrasound examination, as needed.
  • Maternal evaluation includes assessment for labor, infection (fever, tachycardia, uterine tenderness), and medical and obstetrical complications. Lab studies - same as those for women admitted with spontaneous labor.

Question 27

meconium staining of fluid

Answer 27

• Meconium is a thick, black-green, odorless, sterile material in the fetal intestine containing desquamated cells from the intestine, lanugo, vernix and bile pigments.
• When aspirated into the lung, stimulates the release of cytokines/vasoactive substances that lead to cardiovascular and inflammatory responses in the fetus and newborn, MAS
• There is no evidence that immediate induction of labor will reduce the risk of these complications
• Meconium stained amniotic fluid is not a strong contraindication to expectant management if antepartum fetal assessment is otherwise reassuring.

Question 28

group B strep

Answer 28

• Group B streptococcus colonization — A positive maternal screening culture for GBS does not necessarily preclude expectant management, but major obstetric organizations have recommended induction of these women
• Vertical (mother-to-child) transmission primarily occurs when GBS ascends from the vagina to the amniotic fluid after onset of labor or rupture of membranes, but can occur with intact membranes
• Antibiotics are given intrapartum (IV) rather than at the time of a positive culture because antibiotic administration remote from delivery does not eradicate GBS colonization at the time of delivery
• Intrapartum antibiotic prophylaxis:
• Penicillin G 5 million units intravenously initial dose, then 2.5 to 3 million units intravenously every four hours until delivery
• Indications for antibiotic prophylaxis :
• Positive screening culture for GBS from either vagina or rectum
• Positive history of birth of an infant with early-onset GBS disease
• GBS bacteriuria during the current pregnancy
• Unknown antepartum culture status (culture not performed or result not available) and:
  
  • Intrapartum fever (≥100.4ºF, ≥38ºC) or
  • Preterm labor (<37 weeks of gestation) or
  • Prolonged rupture of membranes (≥18 hours) or
  • Intrapartum NAAT positive for GBS

Question 29

indications for surgical delivery

Answer 29

• Cesarean delivery - performed when the clinician and patient feel that abdominal delivery is likely to provide a better maternal and/or fetal outcome than vaginal delivery.
• Approximately 70% of cesarean deliveries in the United States are primary (first) cesareans. The three most common indications for primary cesarean delivery in the US account for almost 80% of these deliveries:
  
  • Failure to progress during labor/dystocia (35%)
  • Nonreassuring fetal status/fetal distress (24%)
  • Fetal malpresentation including breech (19%)
• Less common indications for cesarean delivery:
• Abnormal placentation (placenta previa, vasa previa, placenta accreta)
• Maternal infection (herpes simplex or HIV)
• Multiple gestation
• Funic (cord) presentation or cord prolapse
• Suspected macrosomia
• Mechanical obstruction to vaginal birth (leiomyoma or condyloma acuminata, severely displaced pelvic fracture, fetal anomalies/ severe hydrocephalus)
• Uterine rupture – tear in uterus that happens at site of previous cesarian

Question 30

Natural, gentle, or family-centered cesarean birth

Answer 30

• Playing music of the parents choice during delivery, and dimming lights when safely possible
• Using clear drapes and positioning the drapes to allow the mother (and partner) to watch the birth
• Avoiding maternal sedation
• Allowing the baby to deliver by a combination of uterine expulsion and active physician assistance to mimic expulsion from the vagina
• Freeing the mother’s dominant hand/arm and chest/breasts from lines and monitors, when possible, so she can hold and nurse her infant
• Promoting skin-to-skin contact and nursing immediately after birth

Question 31

episiotomy

Answer 31

• Surgical incision of the female perineum
• Performed with scissors when the perineum is stretched and distended, just prior to crowning of the fetal head.
• Purpose is to increase the diameter of the soft tissue pelvic outlet, thereby preventing perineal lacerations, facilitating delivery, and reducing the time for expulsion of the infant.
• One of the most common operations performed on women
• Changing trends in obstetrical practice over time have influenced the decision to perform an episiotomy and resulted in a decreasing prevalence of the procedure (60.9% of vaginal deliveries in 1979 versus 24.5% in 2004)
• The prevalence of episiotomy is highest in Latin America and lower in Europe
• Median – most common in US
• Mediolateral – most common in Europe
• J-Incision – not frequently used

Question 32

episiotomy rationale, potential adverse effects, and routine vs restricted use

Answer 32

• Episiotomy rationale
  
  • Reduction in third and fourth degree tears
  • Ease of repair and improved wound healing(?)
  • Preservation of the muscular and fascial support of the pelvic floor
  • Reduction in neonatal trauma, such as with the premature infant (soft cranium) or macrosomic infant (shoulder dystocia)
  • Reduction in dystocia by increasing the diameter of the soft tissue outlet
  • Expedited delivery of fetuses with nonreassuring fetal heart rate tracings
• Episiotomy potential adverse affects
  
  • Extension of the incision, leading to 3rd and 4th degree tears
  • Unsatisfactory anatomic results (eg, skin tags, asymmetry, fistula, narrowing of introitus)
  • Increased blood loss
  • Increased postpartum pain
  • Higher rates of infection and dehiscence
  • Sexual dysfunction
  • Possible increased risk of perineal laceration in subsequent deliveries
• Episiotomy, routine vs. restricted use
  
  • Systematic reviews have consistently shown that there is no benefit to routine use of episiotomy.
  • While episiotomy as a routine procedure in all spontaneous vaginal births is not recommended, a restricted approach in appropriate clinical settings is advocated.
  • ACOG supports RESTRICTED use

Question 33

Vaginal/cervical lacerations

Answer 33

• First degree lacerations involve injury to the perineal skin and vaginal epithelium only. The perineal muscles remain intact.
• Second degree lacerations extend into the fascia and musculature of the perineal body, which includes the deep and superficial transverse perineal muscles and fibers of the pubococcygeus and bulbocavernosus muscles. The anal sphincter muscles remain intact.
• Third degree lacerations extend through the fascia and musculature of the perineal body and involve some or all of the fibers of the EAS and/or the IAS.
• Fourth degree lacerations involve the perineal structures, EAS, IAS, and the rectal mucosa
• Occult injury to the anal sphincter occurs frequently at the time of vaginal delivery and can contribute to anal incontinence.
• Critical to examine the perineum/vagina thoroughly to determine the extent of injury and severity of bleeding. (rectovaginal examination of the anal sphincter complex and rectal mucosa)
• The anal sphincter can be disrupted even though the perineum is intact.
• Early re-repair of an episiotomy breakdown is desirable to minimize both short-term and long-term perineal pain.
• Risk factors for significant cervical lacerations (ie, associated with excessive bleeding or requiring repair) include precipitous labor, operative vaginal delivery, and cerclage

Question 34

postpartum hemorrhage (PPH)

Answer 34

• Leading cause of maternal mortality (MM), esp. in the developing world
• Occurs in 1-5% of deliveries
• Pregnancy related MM rate in US is 7-10 women per 100,000 live births, with 8% of these deaths caused by PPH.
• PPH ranks in top 3 causes of MM, along with embolism and HTN (industrialized countries)
• In developing countries, several countries have MMR in excess of 1000 women per 100,000 live births, with 25% due to PPH – initiatives to train TBAs on active management of 3^rd stage of labor
• ACOG estimates that one woman dies in the US every four minutes from PPH.
• Rate of PPH increased from 1.5% (1999) to 4.1% (2009)
• Definition is somewhat arbitrary – EBL> 500ml following SVD or >1000ml following C/S.
• Excessive bleeding that makes patient symptomatic
• Within 24 hours of delivery is “primary” PPH, “secondary” PPH occurs >24 hours after delivery. Late/delayed PPH up to 12 weeks
• Estimates of blood loss tend to be inaccurate, and individuals differ in capacity to cope with blood loss

Question 35

PPH risk factors, signs, prevention, and tx

Answer 35

• PPH risk factors
  
  • Uterine atony - MCC
  • Retained placenta or accreta
  • Failure to progress during 2^nd stage
  • Lacerations
  • Instrumental delivery
  • LGA newborn
  • Hypertensive disorders
  • Induction of labor/augmentation with oxytocin
  • Obesity
• PPH Signs
  
  • May be dramatic or a slow trickle (usually from retained tissue or trauma)
  • Heavy bleeding can quickly lead to signs and sxs of hypovolemic shock
  • Blood loss usually visible at introitus, but if placenta not yet delivered, blood loss can be occult
  • Blood volume in pregnancy increases by 50% (from 4-6 liters) but caregivers underestimate visible blood loss by as much as 50%.
    
    • People with preeclampsia don’t have that amount of blood volume increase so their blood loss is more significant
• PPH prevention
  
  • Active management of the 3^rd stage of labor
    
    • Early uterotonic administration
    • pitocin, methergine, nursing baby
    • Gentle cord traction with uterine countertraction when uterus is well contracted (Brandt-Andrews maneuver)
  • Prevention of maternal anemia prenatally
• PPH treatment
  
  • Timely and accurate diagnosis is crucial!
  • Frequent assessment of vital signs
  • Oxytocics/IV access with wide bore needles
  • Remove retained POCs
  • Uterine massage/bimanual compression
  • Uterine tamponade with balloon/packs
  • Repair of lacerations if cause of bleeding
  • Transfusion of packed RBCs
  • Surgery, uterine vessel ligation, hysterectomy last resort