Normal L&D

Question 1

Report to the hospital for suspected labor if any of these:

Answer 1

Contractions every five minutes for one hour
Rupture of membranes
Fetal movement less than 10 per two hours
Vaginal bleeding

Question 2

Breech presentation is associated with:

Answer 2

Prematurity, multiples, genetic disorders, polyhydramnios, hydrocephaly, anencephaly, uterine abnormalities, uterine fibroids. ?oligohydramnios (Williams says it is, uWise says it isn’t)

Question 3

Rupture of membranes: 
Normal
PROM
prolonged PROM
PPROM

Answer 3

Normal = < 1h prior to onset of labor
PROM = >1h
prolonged PROM = >18h
PPROM= preterm premature ROM if if < 37wks

Question 4

Dx ROM:

Answer 4

Pooling test: visualization of amniotic fluid pooling in the vagina
Nitrazine paper test (amniotic fluid = alkaline, turns blue)
Ferning test
Oligohydramnios in absence of other findings may suggest ROM too.
If really need dx, can inject indigo carmine into amniotic sac → look for blue staining of tampon

Question 5

Bishop score:

Answer 5

Measures cervical dilation, effacement, consistency, and position (0-2) and fetal station.

Bishop > 8 = “favorable” for spontaneous labor / induced labor.

Question 6

Induction of labor

Answer 6

Induce with prostagladins, oxytocin, mechanical dilation (Foley bulb), AROM

Indications: postterm, PEC, PROM, nonreassuring fetal testing, IUGR, NOT pt desire (would be an elective
induction). Don’t induce if many prior C/S or nonreassuring settings

Follow with Bishop score → favorable. If not progressing, try prostagladin E2 or PGE1M (misoprostol) to “ripen” the cervix, or mechanical dilation.

Specific drugs / methods
Prostagladins: can’t use if maternal asthma or glaucoma
Pitocin: give it IV (oxytocin)
Amniotomy (AROM)
Mechanical dilation (30 or 60 cc Foley, dilate over 4-6h)

Question 7

Augment labor

Answer 7

Augment with oxytocin or amniotomy

Monitor with external monitoring or IUPC (intrauterine pressure cath), which lets you figure out adequacy of ctx

Montevideo unit: 10m, multiply avg variation of intrauterine pressure from baseline x # ctx

> 200 MVU is generally considered adequate ctx.

Question 8

Fetal monitoring:

Answer 8

External or FSE (fetal scalp electrode), (but not if fetal thrombocytopenia → bleed or HIV/HCV → transmission)

Baseline 110-160 with moderate variability, +accels = good!
Decels
-Early = increased vagal tone (head compression in ctx)
-Variable = umbilical cord compression. Repetitive if cord trapped under shoulder, around neck
-Late = uteroplacental insufficiency, worrisome!! Can degrade into bradycardia with stronger ctx
Bradycardia (<110 x 2min = prolonged decel; x 10min = bradycardia):
-Face mask, roll onto (L) side, d/c pit, consider terbutaline, check cervix
-If cord prolapsed, push it back up → to OR
-C/S if not getting better.

Question 9

Uterine perforation in IUPC placement:

Answer 9

Big gush of amniotic fluid and blood = suspect uterine perf. Withdraw IUPC, monitor fetus, replace IUPC if the tracing is reassuring.

Question 10

Cardinal movements:

Answer 10

Engagement, flexion, descent, internal rotation, extension, external rotation (restitution), anterior shoulder, posterior shoulder. OA is good.

Question 11

Stages of labor: stage 1

Answer 11

Onset of labor → complete cervical dilation
10-12h if nullip, 6-8 if multip, but big ranges

Latent phase: onset → 3-4 cm, slow change
Active phase: 3-4cm → full dilation, fast
Should have at least 1 cm / hr if nullip, 1.2cm / hr if multip (but usually 2-3 cm/hr)

If below these guidelines, calculate MVU (Montevideo units)

Question 12

Stages of labor: stage 2

Answer 12

Complete dilation → baby time

Can last 1h if multip, 2h if nullip, and you get a bonus hour if you got an epidural

Question 13

Active phase arrest

Answer 13

If no change in dilation or station x 2h with >200 MVU ctx

Question 14

Stages of labor: stage 3

Answer 14

Baby time → placenta time

Retained placenta if > 30m; need to extract manually or curretage if fails (may be 2/2 accreta!)

Question 15

Stages of labor: stage 4

Answer 15

Stage 4 is technically the name of the immediate postpartum period (not the “recovery period”)

Question 16

Lac repair: 1st, 2nd, 3rd, 4th degree

Answer 16

1st degree = superficial
2nd degree = into perineum
3rd degree = into sphincter
4th degree = into rectum

Question 17

Operative vaginal delivery

Answer 17

Need complete cervical dilation, head engagement vertex presentation, clinical assessment of fetal size / maternal pelvis, known position of fetal head, adequate maternal pain control, and ROM

Then can use vacuum / forceps if 2nd stage lasting too long

If baby needs to come out (e.g. FHR dropping), do operative delivery if crowning / really far down

Pudendal block if no epidural in place

Question 18

Episiotomy

Answer 18

Midline has easier repair, less pain, less blood loss but more 3rd/4th degree tears than mediolateral (and for spontaneous delivery without episiotomy!)
No role for routine episiotomy / prophylactic these days
May use to enlarge vaginal outlet if instruments needed, or if descent arrests

Question 19

C/Section Indications:

Answer 19

Breech, transverse, shoulder presentations; placenta previa / abruption, fetal intolerance of labor, nonreassuring fetal status, cord prolapse, prolonged 2nd stage, failed operative vaginal delivery,

active herpes lesions, HIV with VL > 1000, etc. Also multiple prior C/S.

Question 20

Trial of Labor After Cesarean Section (TOLAC)

Answer 20

Need to have < 1-2 previous C/S, low transverse or low vertical incision without extension into cervix or upper uterine segment.

Rupture (“pop”, decrease in IUPC pressure, FHR decels / brady, abd pain) → to OR immediately!