OB Flashcards
Transient HTN in pregnancy
BP > 140/>80 Only need 1 to make a diagnosis Timing: non-sustained Nothing on UA No alarm symptoms No treatment F/u: just bring in a log
Chronic HTN in pregnancy
BP >140/>80
Timing: sustained and before 20 weeks during 2 separate measurements taken at least 4 hrs apart
Nothing on UA
No alarm symptoms
Tx: alpha-methyldopa, labetalol, hydralazine, nifedipine
F/u: close monitoring of UA, US, and more frequent visits
**HTN increases the risk of superimposed preeclampsia, abruptio placentae, fetal growth restriction, preterm labor, and stillbirth
Gestational HTN in pregnancy
BP >140/>80
Timing: sustained and after 20 weeks
Nothing on UA
No alarm symptoms
Tx: alpha-methyldopa, labetalol, hydralazine, nifedipine
F/u: close monitoring of UA, US, and more frequent visits
CAN PROGRESS TO PREECLAMPSIA
Mild Preeclampsia (PEC)
BP > 140/>90
Timing: sustained and after 20 weeks
UA: >300 mg/24 hr protein, >0.3 protein/cr ratio, or dipstick >1+
No alarm symptoms
Tx: >37 –> deliver; <37 –> wait
F/u: more frequent visits (weekly), continually screen for alarm sx and worsening of proteinuria
Diagnosis of HTN in preeclampsia: >140/>90 on 2 occasions >4 hours apart.
Diagnosis of proteinuria in preeclampsia: urine dipstick has a high false-pos and high false-neg rate during pregnancy –> confirm with either urine protein/creatinine ratio or 24 hour collection for total protein (gold standard)
Severe Preeclampsia (SPEC)
BP > 160/>110
Timing: sustained and after 20 weeks
UA: >5 g/dL
+ Alarm Sx (pulm edema, platelet count <100k, transaminitis, cr >1.1, headaches or visual changes
Acute pulmonary edema: generalized arterial vasospasm –> increased vascular resistance and high cardiac after load; other contributing factors: decreased renal function, decreased serum albumin, and endothelial damage leading to increased capillary permeability
Tx:
Meds that acutely lower BP to decrease stroke risk: hydralazine IV, labetalol IV, nifedipine PO [labetalol is a non-selective beta blocker and can dec HR in someone who is brady. hydralazine is a vasodilator. nifedipine is an oral med that would not help someone who is having emesis. alpha-methyldopa treats chronic HTN]
Give Mg to prevent or treat eclamptic seizures and deliver (usually by vaginal and induced) regardless of age
Leading cause of fetal and maternal morbidity and mortality. Pathophys involves abnormal placental development and function which puts the fetus at risk for chronic uteroplacental insufficiency –> fetal growth restriction/low birth weight
Eclampsia
BP doesn't matter Timing: sustained and after 20 weeks UA doesn't matter \+ Active Seizures Tx: Give Mg and deliver (usually by C/S)
HELLP syndrome
Severe features: dec plt’s, inc LFT’s, RUQ pain (caused by swelling of the liver causing stretch of glisson’s capsule as blood flow decreases to the liver) elevated creatinine (> 1.1 or doubling), pulmonary edema, HA, vision changes, BP >160/>110
Tx: Give Mg and deliver (usually by C/S) if 34+ weeks or with deteriorating maternal or fetal status
Thought to result from abnormal placentation, triggering systemic inflammation and activation of the coagulation system and complement cascade. Circulating platelets are rapidly consumed, and microangiopathic hemolytic anemia (MAHA) is particularly detrimental to the liver.
Dangers of Magnesium
Must check for dec DTR’s in patients as dec DTR’s is a sign of dec resp drive –> mom stops breathing if magnesium is continued
Ca = antidote to dec DTR’s
Mg is excreted renally so pts with renal insufficiency are susceptible to Mg toxicity
False Labor vs Latent Labor vs Active Labor
False: mild irregular contractions that cause no cervical change (e.g. braxton Hicks contractions)
Latent: reg contractions with inc freq and intensity that cause gradual cervical change
Labor: regular, painful uterine contractions that cause cervical change
Spontaneous Abortion
Pregnancy loss < 20 weeks
Tx: expectant, medical induction, suction curettage if infection or hemodynamic instability
Antepartum fetal surveillance
NST: external FHR monitoring for 20-40 minutes. Normal = reactive = 2+ accelerations
Biophysical profile: NST + amniotic fluid volume, fetal breathing movement, fetal movement, fetal tone. Reassuring = 8+. Equivocal = 6 pts. Abnormal = <6.
Suspected Appendicitis in Pregnancy
Sx: N, V, RLQ pain
US with graded compression technique
Noncompression and dilation of the appendix are diagnostic
Acquired Hypogonadotropic Hypogonadism
Low FSH and estrogen levels due to loss of pulsatile GnRH secretions precipitated by caloric deficiency or chronic illness. Causes irregular menses and infertility.
Abortion, Preterm, Term, and Post dates
Abortion: 0-20/24
Preterm: 24-32
Term: 37-42
Post dates: 42+
Definitions: ROM, PROM, PPROM, Duration of Labor once ROM
ROM: term and there are contractions that start the rupture
PROM: term, no contractions
PPROM: preterm rupture of membranes without preterm labor, no contractions
Duration of labor once ROM should last less than 18 hours
If longer –> Prolonged ROM
ROM
Types: spontaneously, artificially, pathologically (infection like GBS, vaginal flora, or STI)
Characterize: clear, meconium-stained, bloody
Dx: Speculum exam: will see pooling (not all fluid exits immediately) Nitralazine blue test Ferning US: oligohydramnios
Tx: Deliver if term or below the age of abortion
If between, must weigh risks (ascending infection) and benefits (maturation) - the younger the more benefit to staying in, the older the less benefit to staying in
pROM
Usually caused by infection (GBS) Definition: term, no contractions Dx: Clinically. Also check GBS status Tx: Deliver If GBS+ or don't know, give ampicillin If GBS-, wait
ppROM
Usually caused by infection (GBS)
Definition: preterm, no contractions
Dx: Clinically. Also check GBS status.
Tx: must weigh risks and benefits of keeping baby in
If baby > 34, deliver
If baby < 24, deliver –> abortion
In between: give steroids for fetal lung maturation
May lead to prolonged ROM
Prolonged ROM
Usually caused by infection due to entrance of vaginal flora into mom (GBS)
Definition: ROM for 18+ hours
Tx: Deliver. Also check GBS status
If GBS+ or don’t know, give ampicillin
If GBS-, wait –> f/u endometritis and chorioamnionitis
Endometritis and Chorioamnionitis
Infection of endometrium (uterus) or chorioamnionitis (sac)
Path: Vaginal flora ascends into mom’s sterile uterus. Risk increases the longer mom is open.
If baby is still in, bacteria infect the sac –> chorioamnionitis
If baby is delivered, bacteria infect mom’s uterus –> endometritis
Presentation: mom has prolonged ROM, operative bag delivery, CS, prolonged labor
mom gets fever or becomes toxic
Dx: presence of maternal fever and one or more of the following: uterine tenderness, maternal or fetal tachy, malodorous amniotic fluid, purulent vaginal discharge
DO NOT GET VAGINAL CX (will not help you). Rule out other infections - UA, CXR, BxCx
Tx: administer antibiotics: Ampicillin, Gentamicin, and Clindamycin (gram neg and anaerobes)
followed by delivery to reduce the risk of life-threatening neonatal infection and maternal complications.
CHORIO IS NOT AN INDICATION FOR CS. Give oxytocin to accelerate labor
Preterm Labor
Path: Idiopathic, Risk factors: preterm in prior pregnancy*, cervical surgery like cone biopsy (use TVUS to assess cervix length), cigarette smoking, young maternal age, multiple gestations, pROM, uterine anatomical defects
Definition: preterm, + Ctx AND cervical change
Dx: Clinically
Tx: based on GA
> 34, deliver
< 20, deliver –> abortion
In between: give steroids and tocolytics for fetal lung maturity (you cannot stop labor once it starts - can only delay); if <32 weeks should also receive magnesium sulfate for fetal neuroprotection
Some exceptions: eclampsia, fetal demise, placental problems, etc
Used to do amniocentesis to check lecithin:sphingomyelin ratio for fetal lung maturity but it’s not done anymore
A short cervix (<2 cm without a history of preterm birth or <2.5cm with a history of preterm birth) on TVUS during the 2nd trimester is a strong predictor for preterm delivery. Progesterone maintains uterine quiescence and protects the amniotic membranes against premature rupture. Supplement with exogenous progesterone
Pts with short cervices and no history of preterm delivery should be offered vaginal progesterone
Pts with hx of preterm delivery receive intramuscular progesterone and undergo serial TVUS for measurements
Post dates
Dilemma is usually a question of how many weeks the baby actually is (if mom comes in for first prenatal visit in the third trimester, EDD can be actually +/- 3 weeks via US)
Path: baby can end up macrosomic –> increased risk for shoulder dystocia
Or dysmaturity –> can lead to fetal demise
Definition: >40 weeks by conception or >42 weeks by dates
Dx: clinically
Tx: how sure you are of dates and mom’s cervical position
If sure and cervix is favorable –> induction
If sure and cervix is unfavorable –> CS
If not sure, regardless of cervix, do NST and US to do BPP. If BPP good, stay in. If BPP bad, get out
Post date babies are at risk of uteroplacental insufficiency
Potential complications of post dates/post partum:
Fetal - oligohydramnios (aging cervix may have decreased fetal perfusion, resulting in decreased renal perfusion and decreased urinary output from the fetus), meconium aspiration, stillbirth, macrosomia, convulsions
Maternal - CS, infection, PPH, perineal trauma
Multiple Gestations (twins)
Hints: baby is too big for dates, AFP is high on quad screen
Vocabulary:
zygote = # of fertilizations
chorion = # of placentas
amnion = # of sacs
- Look at gender
Diff genders: dizygotic, dichorionic, diamniotic
Risks: preterm labor - for every 1 gestation, deliver 4 weeks early; malpresentation (breech birth –> CS); post partum hemorrhage
Same genders: can either be one fertilized zygote that split very early or 2 separate fertilizations resulting in same gender - will not be able to know until babies are out.
Look at the number of placentas:
If 2, monozygotic, dichorionic, diamniotic (zygote split day 0-3 tubal phase)
Added Risks: identical twins - cannot tell until they come out of the womb
If 1, look at septum and number of sacs
+ septum, 2 sacs –> monozygotic, monochorionic, diamniotic (zygote split day 4-8 blastocyst phase)
Added Risks: twin-twin transfusions (since they share the same placenta; smaller twin does better due to less bilirubin)
no septum, 1 sac –> monozygotic, monochorionic, monoamniotic
Added Risks: conjoined twins (can be surgically repaired if no major organs shared), cord entanglement (can potentially cause problems with delivery, leading to CS)
If the zygote split day 9-12 –> non conjoined twins
If the zygote split > day 12 –> conjoined twins
ABO incompatibility
ABO incompatibility generally occurs in a group O mom with a group A or B baby (A and B are found in food and bacteria in the environment which can induce various degrees of antibody production in group O moms)
However, ABO incompatibility causes less severe hemolytic dz of the newborn than does Rh(D) incompatibility. Affected infants are usually asymptomatic at birth with absent or mild anemia and develop neonatal jaundice, which is usually successfully treated with phototherapy.
Post Partum Hemorrhage
Definition:
- 500 cc blood loss in vaginal delivery
- 1000 cc blood loss in CS
PE uterus:
- Absent = Uterine Inversion –> manually put back in place or use tocolytics to quiet uterus down then use uterine tonics to contract back down
- Boggy = Uterine Atony (most common cause of PPH) –> massage uterus from the outside to get it to contract down or start meds like oxytocin
- Firm = Retained Placenta –> D&C, may require hysterectomy
- Normal = Vaginal Laceration –> sutures
If laceration not found, think about DIC
If cause is not found or ongoing PPH despite intervention, treat like GI bleed: place 2 large bore IV’s (18 gauge or larger, AC or higher), bolus IV fluids, type and cross, transfuse as needed, call surgeon, could try IV estrogen
Surgery options: uterine artery ligation (OB) or internal iliac ligation, uterine artery embolization (IR), total abdominal hysterectomy (OB)
CS –> uterine artery ligation
Vag –> uterine artery embolization
Complications: Sheehan syndrome, pituitary apoplexy
Uterine Atony
Most common cause of PPH
RF’s: prolonged labor, induction of labor, operative vaginal delivery, fetal weight > 8.8lbs
Path: atonic uterus, occurs when uterus is tired either in the setting of prolonged labor or if oxytocin or tocolytics were given during delivery and were now stopped
Presentation: PPH and “boggy/soft” uterus that is enlarged (“above the umbilicus”)
Dx: clinical
Tx: uterine massage to stimulate uterus to contract; or use oxytocin if used before in labor; or use Methergine (methylergonovine) or Hemabate (carboprost - prostaglandin); or do surgery
Uterine Inversion
Path: uterus “births itself”, contracts so hard that it goes through the cervix; may occur during a delivery with oxytocin or with traction when pulling out the placenta
Presentation: PPH and absent uterus
Dx: clinical. Speculum exam: can see uterus inverted into the vagina
Tx: manually; or use tocolytics to calm it down, get it into place, then turn on oxytocin to get it back down to the right place; or do surgery
If placenta is still attached to the uterus, it should not be removed until after the uterus is replaced due to risk of massive hemorrhage
Vaginal laceration
Path: tear in cervix and/or vagina; can occur in precipitous deliveries, macrosomic babies, and episiotomy
Presentation: PPH and normal uterus
Dx: clinical. Speculum exam: look for lacerations on cervix and vagina
Tx: Hold pressure and/or suture close. Use anesthetics first.
Retained Placenta
Path: Placenta burrows deeply during pregnancy (more common in multiparous women, prior CS, hx of D&C, advanced maternal age). During delivery, there is an accessory lobe that causes a placental tear as the front half is delivered, leaving behind a piece. Depth of invasion of the piece gives it its name.
Types:
- Placenta accreta (only in the endometrium where it’s supposed to be, only a lil deeper)
- Placenta increta (through the endometrium into the myometrium)
- Placenta percreta (all the way through)
Presentation: PPH and firm uterus
Dx: look at placenta - do the BV go to the edge? Normal placenta delivery BV should not reach all the way to the edge. If there is a piece left behind the BV’s will travel all the way to the edge.
Tx: get remaining part out –> manually or D&C, if not do hysterectomy.
Track beta-HCG levels in serum to 1. make sure the placenta is out (b-HCG reaches 0) and 2. dec risk for chorioamnionitis
DIC
Fibrin clots everywhere they’re not supposed to be and no where where they’re supposed to be
Clots cause shearing of RBC’s
Labs: Low plts, low hgb, presence of schistocytes, low fibrinogen, elevated INR (clotting factors being used)
Tx: Give plts, packed RBC’s (for low hgb), cryoprecipitate (for low fibrinogen), FFP (replace clotting factors)
**Pregnancy = hypercoagulable state. Fibrinogen should normally be elevated to prevent PPH. If fibrinogen is within normal limits during delivery, suspect DIC.
Types of Abortions
- Missed
- no vaginal bleeding
- closed os
- no fetal cardiac activity or empty sac w/o a fetal pole (e.g. no embryo)
baby is dead but mom doesn’t know - Threatened
- vaginal bleeding
- closed os
- fetal cardiac activity
- can potentially revert back to intrauterine pregnancy if put on bed rest but once abortion advances past threatened, it cannot go back - Inevitable
- vaginal bleeding
- dilated os
- baby is dead
- products of conception may be seen or felt at or above the os - Incomplete
- vaginal bleeding
- dilated os
- some products of conception expelled and some remain - Complete
- vaginal bleeding or none
- closed os
- products completely expelled
** serial beta-hCG levels normally increase until the end of the first trimester; decreasing beta-hCG levels indicate a demise and exclude a normal pregnancy
Medical management:
Misoprostol
Oxytocin to induce delivery of dead baby ex) missed abortion
D&C
Rh- moms still need to be given Rhogam if there’s potential baby may be Rh+
Infertility in women age >35
Inability to conceive after 6 months of unprotected intercourse
Can occur due to diminished ovarian reserve, characterized by regular menstrual cycles and decreased oocyte number and quality.
Placenta Previa
Placenta implants over the internal cervical os
RFs: previous, previous CS, multiparity, advanced maternal age (>35)
At risk for antepartum bleeding which is typically painless and occurs with or without contractions on the tocodynamometer.
Usually diagnosed during routine antenatal US. Pelvic rest is recommended for duration of pregnancy as intercourse can cause contractions and bleeding
Pts diagnosed antenatally undergo CS at 36-37 wks to avoid risks associated with labor and to minimize prematurity complications
Intercourse, digital cervical exam, vaginal delivery, and labor and expectant management are contraindicated due to risk of hemorrhage
NST
Non-stress test (no contractions)
Looking at FHR: good = consistent variability that stays same; accelerations; not brady or tachy (<110. <160)
Accelerations:
good = 2 in 20 min or a rise in 15 over 15 sec or rise in 10 over 10 sec
>32 wks = 15/15
<32 wks = 10/10
Good variability and good accels = reassuring NST
Presentation: high risk mom, or decreased FM
Nonreactive NST = no accelerations - can be associated with fetal sleep cycle (can last as long as 40 min - extend NST to ensure fetal activity outside of sleep is captured), fetal hypoxia from placental insufficiency
Tx:
Reassuring NST = reassurance (leave dec FM mom alone, high risk mom comes in next week)
Nonreassuring NST = repeat with vibroacoustic stimulation and reinterpret
BPP
Biophysical profile (no contractions)
Done if there is a failed NST with vibroacoustic stimulation
5 components: 0-2 pts each
- NST
- AFI - divide mom into 4 quadrants. get maximum depth of each quadrant and sum together. normal: >5. reassuring = 8-25. pathologic values: <5 (oligo - usually problem with kidneys), >5 (poly - usually problem with gut)
- Baby breathing
- Baby moving
- Baby tone
Tx:
8-10 = reassurance
0-2 = fetal demise (emergency CS)
Between: use GA to decide
CST
Contraction stress test (used when there are adequate contractions - 3 in 10 min, 200mV each)
Usually done in the setting of labor, NOT induced due to failed BPP
Looking at decels and presence/absence of brady
Presentation: mom is in labor or failed BPP
–
Variable decel = Cord compression (decels and contractions don’t match) or oligohydramnios
–> intermittent variable decels (occurring with <50% of contractions) are well tolerated by the fetus
–> persistent variable decels (occurring with >50% of contractions) may impede fetal-placental blood flow; may be alleviated by maternal repositioning and if that fails, amnioinfusion
Early decel = Head compression (decals and contractions match)
Accel = Ok
Late decel = Placental insufficiency (decels start after contractions peak) –> delivery (usually emergency CS)
Sinusoidal = Anemia
3rd Trimester Bleeding
Normal:
- Cervical lesions like a polyp or cervicitis
- Cervical dilation
- Bloody show (blood tinged ROM)
Regardless of normal or abnormal 3rd trimester bleeding, must investigate anyway
- mom’s vital signs
- mom’s hgb
- consider DIC: plts, coags
- pelvic PE
- baby: NST/CST to check for FHR
- baby: US
3rd trimester bleeding can either be painful or painless
Painless: comes from Placenta; it is baby’s blood - mom doesn’t feel baby –> Previa
Painful: comes from mom’s uterus tearing; it is mom’s blood - mom feels it –>NOT Previa
4 diseases: Placenta Previa Vasa Previa Uterine Rupture Placental Abruption
Placenta Previa
- placenta implants across the os
- as cervix dilates and gets bigger, the placenta gets torn and baby’s blood comes out
Presentation:
- occurs most commonly in multi-gravid woman and in multiple gestations
- painless bleeding in 3rd trimester usually when contractions begin and cervix begins to dilate
Dx:
- US: transverse lie (shoulder presentation)
- NST/CST: fetal distress
Types:
- Marginal (a little bit, not even midline)
- Partial (makes it to midline)
- Complete (spans entire os)
Tx:
Urgent CS
Vasa Previa
- Placenta is on one side of the uterus, an accessory lobe on the other side, with vessels running in between them over the os. Another RF: multiple gestations
- when os dilates, the connection between the 2 tears and baby loses blood
- Vs Placenta Accreta: in placenta accreta, the placenta has been birthed so you can see that the BV run to the edge. In vasa previa, the placenta has not been birthed yet so you cannot look at it although if you could you would see that the BV run to the edge as well
Presentation:
- painless bleeding in 3rd trimester
- Vs placenta previa: rapid deterioration of the fetal heart tracing
Dx:
- US although most likely will not show anything
- NST/CST showing fetal distress
Tx:
- urgent CS
Uterine Rupture
- occurs commonly in moms who’ve had a previous CS (uterine scar) who are now attempting a vaginal birth
- force of contractions can rip the uterus apart
- baby takes path of least resistance –> into the peritoneum instead of the vagina unless there is a membrane blocking baby into the peritoneum
- can also occur when powering the delivery with oxytocin –> uterus bursts and baby goes into the peritoneum
Presentation: painFUL bleeding in the 3rd trimester (although this process has to happen with contractions (so mom is already in pain))
–> loss of fetal station as baby is birthed into the peritoneum - can no longer tell where baby is - no palpable fetal presenting part, presence of abdominally palpable fetal parts
Dx: none –> go straight to tx
Tx: laparotomy
Placental Abruption
- Path: some insult like severe HTN, cocaine use, or decel injury from MVA rips placenta off and mom starts to lose blood
2 types:
- COMPLETE = placenta rips off the endometrium lining; usually a piece stays on; now mom’s blood is coming out
- CONCEALED = placenta rips in the middle and stays connected on the 2 ends; contains the blood coming out from mom in a pocket; dangerous bc you can’t see it
Presentation:
- painFUL bleeding, FHR abnormalities, abd/back pain
Dx:
US
NST/CST
Also keep an eye out on mom’s vital signs, hgb, and mentation (mom can lose a lot of blood)
Tx:
CS
Complications: DIC, hypovolemic shock
for baby - hypoxia, preterm delivery
C-Section
Many variations, many techniques
2 main types:
1. Slow controlled planned elective CS - mom wants to save aesthetics
2 cuts: bikini cut and low transverse incision on the uterus
2. Crash section
2 cuts: vertical incision from xyphoid to pubis and in the uterus
3 categories: elective, urgent, and emergent
Elective procedures: mom’s desire, known breach birth
Urgent procedures: due to complication or disease - prolonged or arrest of labor, eclampsia
Emergent procedures: maternal hemodynamic instability, fetal distress (profound brady, loss of variability, late decels)
Risks:
- VBAC
- scar
- permanent sterilization with b/l tubal ligation
VBAC:
- What type of CS did she have? What is her risk of attempting vaginal birth?
- Low risk: If mom has had <2 CS and all were low transverse cuts. Can attempt vaginal delivery. If successful –> VBAC (best outcome). If failed –> TOLAC (trial of labor after CS) –> unplanned CS (worst outcome)
- High risk: anything else. –> planned CS (intermediate outcome)
Vacuum Delivery
Forceps Delivery
Either labor is taking too long (arrest of descent) or baby is doing poorly
–> fetal distress or prolonged/arrest of labor
Have to go in through the vagina so it is only useful if baby is almost out –> must have full effacement of the cervix and must be at least 2+ station
Risk:
Vacuum delivery: denuding vagina (very painful) (vacuum only supposed to go on baby’s head but if some of mom’s vagina gets caught) - do not do vacuum delivery on preterm babies
Forceps delivery: cephalohematomas and Bell’s palsy
If 2+ station or more, do instrumental
If higher than 2+, do CS
Epiosiotomy (Lacerations)
To avoid the creation of an uncontrolled laceration
Indicated when baby is macrosomic or vagina is small (nulliparous mom) or to prevent a bigger baby from developing shoulder dystocia
Risk: you’re creating a laceration, postpartum hemorrhage
2 types:
- Medial (most common in US) - easy to re-suture; more painful and risk of laceration extending to grade 4
- Medial-lateral (most common outside US) - less painful, harder to repair (heals poor-er), but no risk of laceration extension (grade 4)
Grades: Grade 1 laceration: involves vagina only Grade 2: extends into perineal body Grade 3: into the anus and sphincter Grade 4: invades through the anal mucosa --> risk of recto-vaginal fistula.
Cerclage
Used to preserve incompetent cervix (RF’s: repeated STI’s, PID, repeated D&C’s, multiple second trimester losses)
Usually done at wk 14
Remove around wk 36
Risk:
- Insertion: needle pokes the amniotic sac –> ROM - babies generally don’t progress
- Cervical laceration/rupture: leaving the suture in too long or forgetting to take it out
Anesthesia
Opiates:
- Can be used anytime
- Avoid in latent phase of stage I labor bc they can cause prolonged latent phase
- Avoid in very late stages of delivery bc baby can get it - can cause resp distress and baby may need naloxone
Epidural
- Great pain reliever
- Needle in mom’s back - doesn’t go through subdural space - should not see any CSF (not like a LP)
- Requires tocometer since mom can’t feel her contractions and mom needs a coach to tell her when to push
- Risk: infuse lidocaine into subdural space –> cardiac collapse (anesthetizing all of sympathetic nerve fibers) –> blood redistribution to the LE and venous pooling from –> potential hypotension and death
Local anesthetics:
Cervical block prevents pain of stage 1 (cervical dilation). However baby is close by so there is risk of fetal bradycardia. If fetal bradycardia occurs after cervical block, this does not signify fetal distress–>CS like fetal brady would usually do so just wait and baby’s HR should go back up.
Pudendal nerve block prevents pain of stage 2. Easier to do than cervical block. Risk: miss the nerve and mom is still in pain.
GBS
For mom, GBS is benign normal flora of her vagina
For baby, GBS can be devastating –> pROM, preterm delivery, chorioamnionitis; pneumonia/sepsis after baby is born
Presentation:
- Mom has prenatal care: asymptomatic screen - UA at wk 10, re-screen at wk 35-36. Treat during delivery if positive at any time even if treated at wk 10.
- Mom has not had prenatal care (immigrant, travel) - healthy delivery –> toxic baby
Dx:
- UA and UxCx
- Clinically: toxic baby
- RF even if mom does not have positive screen: any previous history of pos GBS, prolonged ROM, intrapartum fever
Tx: Ampicillin
Cefazolin (2nd gen) if pcn allergy
Clindamycin if severe pcn allergy
Vancomycin (last resort)
Exception to treating: no previous GBS history and normal delivery; mom getting planned CS and has not had ROM or contractions does not need intrapartum antibiotics
