Objectives 51-60

Question 1

51. Using MISFLAP, what assessments are required when there is a slowing of cervical change?

Answer 1

• M: maternal habitis
• I: I&O
• S: Support
• F:
• L:
• A:

Question 2

52. For a protracted labor, according to Simkin, what steps would you take to get it kick started?

Answer 2

• Simkins (128) Time, Increase activity (change positions, walk/lunge), nipple stim, bath/shower, let medications wear off, emotional support, hydration.
• Medical stuff: AROM, oxytocin

Question 3

53. For LOP according to Simkin and protracted what would you do?

Answer 3

• Simkins (140) Time, reposition fetus by trying: knee-chest, hands and knees, pelvic rock, lunge, abdominal stroking, aldominal lifiting, walk/movement, avoid pushing; deal with back pain by positions, pressure/massage, hydrotherapy, TENS, sterile water injections, cold/heat, monitor FHR and contractions
• AROM, IV narcotics or epidural, manual/digital rotation, oxytocin

Question 4

54. What is the treatment regiman for therapeutic rest?

Answer 4

• morphine 15mg

Question 5

55. What is AMOL? What do the proponents state the merits are?

Answer 5

• Active Management of Labor. In the late 1980’s, in an effort to reduce the rapidly rising c-section rate, AMOL was introduced based on findings in Ireland where routine use of AMOL was associated with low rates of cesarean delivery.
• Protocols include: admission only when labor was established as defined by: painful contractions, SROM, 100 percent effacement, passage of blood stained mucus; AROM on dianosis of labor, aggressive oxytocin augmentation for labor progress of less than 1 cm/hr with high dose protocols.
• Proponents say that it decreases labor length to 12 hours, reduction in cesarean delivery. The most important factor seems to be delaying admission until active labor has been established.

Question 6

56. Risk of uterine rupture with excessive oxytocin more likely with whom? Risk of uterine rupture without oxytocin? Indications of a uterine rupture?

Answer 6

• Gabbe (436): overall incidence is 1 in 2000 deliveries. Most common in women with a scarred uterus, including prior cesarean delivery and myomectomy (more common with classical incision). Other risk factors are increased maternal age, multiparity, fetal malpresentation, uterine manipulation (internal pdalic version, mid-high operative vaginal delivery, congenital uterine malformations, invasive placentation, and trauma.
• Manifestations of rupture are:
  
  • Fetus: fetal bradycardia with or without preceding varialbe or late decels, loss of fetal station in labor. Maternal signs: acute vaginal bleeding, constant abdominal pain or uterine tenderness, change in uterine shape, cessation of contractions, hermaturia (possibly), signes of hemodynamic instability

Question 7

57. How do you manage pitocin augmentation? Contraction pattern? Dosage? Gabbe, 299

Answer 7

• It is given by infusion pump to allow continuous, precise control of the dose administered.
• EFM
• Tachysystole = >5 contractions in 10 minutes – discontinue oxytocin
• Use standardized oxytocin regimen:
  
  • Dilution 10U oxytocin in 1000mL normal saline = 10mU oxytocin/mL
  • Infusion rate: 2mU/min or 12mL/hr
  • Incremental increase: 2mU/min or 12mL/hr every 45 min until adequate UC frequency
  • Max dose: 16mU/min or 96mL/hr

Question 8

58. What is your management with pitocin augmentation and a category II fetal heart pattern?

Answer 8

• Intrauterine resuscitation recommends us to turn pitocin off

Question 9

59. What indications for a forceps and a vacuum delivery?

Answer 9

• These prerequisites must be met before considering the use of forceps/vacuum: engaged fetal vertex, ruptured membranes, fully dilated cervix, position is precisely known, assessment of maternal pelvis reveals adequacy for the estimated fetal weight, adequate maternal analgesia is available, bladder drained, knowledgeable operator, willingness to abandon procedure is necessary, informed consent, necessary support personnel and equipment are present.
• Indications: prolonged second stage; nulliparous women: lack of continuing progress for 3 hours with regional analgesia or 2 hours without regional analgesia; multiparous women: lack of continuing progress for 2 hours with regional anlgesia or 1 hour without regional analgesia; suspicion of immediate or potential fetal compromise, nonreassuring fetal heart rate tracing (not supposed to use that word but Gabbe said it!); shortening of the second stage of labor for maternal benefit maternal exhaustion, maternal cardiopulmonary or cerebrovascular disease)

Question 10

60. What are contraindications for a forceps and a vacuum delivery?

Answer 10

• cephalopelvic disproportion and major degress of placenta previa. Also, prerequisites (above) must be met as well.