Obstetrics - Labor & Delivery, Postpartum Care Flashcards
Fetal lie
= infant longituidnal or tarnsverse within uterus - use
leopold manueuvers to dermine
Best test to see if will deliver preterm
fetal fibronectin
PROM (premature ROM)
= rupture membranes prior to onset of labor
Concerned about chorioamnitis (risk for PROM)
Give abx
Immediate delivery if fetus near term with oxytocin, c/s if fetal distress
Prolonged premature ROM
= if > 18 hrs rupture membranes before delivery
preterm premature ROM (PPROM)
= before 37 weeks gestation rupture membranes and no labor signs yet
Tx:
Give ampicillin +/- erythromycin
+ corticosteroids if < 34 weeks GA
Immediate delivery if fetus near term with oxytocin, c/s if fetal distress
Dx ROM with
pool, nitrazine and fern tests
Pool test
= + if collection of fluid in the vagina in laboring woman
Nitrazine test
Vaginal secretions are normally acidic, whereas amniotic fluid is alkaline.
when amniotic fluid is placed on nitrazine paper, the
paper should immediately turn blue
It is important to test the fluid from the vagina and not to test cervical mucus because of false positive ferning patterns**
Fern test
= The estrogens in the amniotic fluid cause crystallization
of the salts in the amniotic fluid when it dries.
Under low microscopic power, the crystals resemble the blades of a fern
Caution should be exercised to sample fluid that is not directly from the cervix because cervical mucus also ferns and may result in a false + reading
The five components of the cervical examination during labor
dilation, effacement, fetal station, cervical position, consistency of the cervix.
> 8 is consistent with a cervix favorable for both spontaneous labor
Effacement
The typical cervix is 3 to 5 cm in length;
thus, if the cervix feels like it is about 2 cm from external to internal os, it is 50% effaced.
Station
The relation of the fetal head to the ischial spines of the female pelvis
0 = most descended aspect of the presenting part is at the level of the ischial spines
Negative = presenting part is above the ischial spines
+ = presenting part is below the ischial spines
Which fetal position can lead to prolonged labor and a higher rate of cesarean delivery?
occiput transverse (OT) or occiput posterior (OP)
Labor is induced with
prostaglandins, oxytocic agents, mechanical dilation of the cervix, and/or artificial ROM.
Common indications for induction of labor include
postterm pregnancy, preeclampsia, diabetes mellitus, nonreassuring fetal testing, intrauterine growth restriction
There are both maternal and obstetric contraindications for the use of prostaglandins.
Maternal reasons include asthma and glaucoma.
Obstetric reasons include having had a prior cesarean delivery and nonreassuring fetal testing.
Etiology of
- early decelerations
- variable decelerations
- late decelerations
Early decelerations
- begin and end approximately at the same time as contractions
- 2/2 increased vagal tone secondary to head compression during a contraction.
Variable decelerations
- can occur at any time and tend to drop more precipitously than either early or late decelerations
- 2/2 umbilical cord compression.
Late decelerations
- begin at the peak of a contraction and slowly return to baseline after the contraction has finished
- 2/2 uteroplacental insufficiency and are the most worrisome type.
The cardinal movements of delivery
engagement = fetal presenting part enters pelvis descent = head descends into pelvis flexion, internal rotation, extension, external rotation
Stages 1, 2, 3 of labor
Stage 1 begins with the onset of labor and lasts until dilation and effacement of the cervix are completed.
Stage 2 is from the time of full dilation until delivery of the infant.
Stage 3 begins after delivery of the infant and ends with delivery of the placenta.
Stage 1: latent vs active phase
latent phase
- onset labor –> 3-4cm dilation (some say 6cm)
- slow cervical change.
active
- 4 - > 9cm of dilation
- slope of cervical change against time increases.
- nulliparous: 1 cm/hr dilation expected
- multiparous: 1.2 cm/hr dilation expected
signs of nonreassuring fetal status
Repetitive late decelerations,
bradycardias,
loss of variability
If a prolonged deceleration is felt to be the result of uterine hypertonus (a single contraction lasting 2 minutes or longer) or tachysystole (greater than five contractions in a 10-minute period), the patient can be given a dose of terbutaline to help relax the uterus.
Best occipital presentation to deliver baby
Vertex with occiput anterior
A Bishop score of 5 or less may lead to a failed induction as often as _____% of time
50% of the time
In these patients, prostaglandin E2 (PGE2) gel, PGE2 pessary (Cervidil), or PGE1M (misoprostol) is often used to “ripen” the cervix.
Oxytocin is used to induce labor with a Bishop score greater than 5.
Preterm delivery
< 37 weeks gestation
Risks for preterm labor
Preterm ROM Chorioamniotis Multiple gestations Uterine anomalies Previous preterm Maternal prepreggers wt < 50 kg Placental abruption Preeclampsia Infections
Tocolytics
Beta mimetics
- ritodrine
- terbutaline
MgSO4
Nifedipine
Prostaglandin inhibitors
Ritodrine, terbutaline
B2-agonist
Act on uterine smooth muscle fibers (inc cAMP)
S/E:
- HA
- pulmonary edema
- maternal death
- tachy
Blackbox warning for terbutaine > 24-48 hrs - DO NOT USE!
MgSO4
Decreases uterine tone and contractions
Magnesium sulfate works by competing with calcium entry into cell
Also membrane stabilizer
Way to assess for magnesium toxicity?
DTR exams
If Mg level too high, DTRs depressed
Prolonged deceleration
FHR < 100-110 for longer than 2 mins
Bradycardia
FHR < 100-110 for longer than 10 minutes
Prolonged FHR deceleration - initial management?
Put in L or R lateral decubitus to see if FHR is 2/2 IVC compression
O2 for hypoxia
Examine pt w/ 1 hand on maternal abdomen and 1 hand vaginally feeling for cervical dilation, fetal station, prolapsed umbilical cord
Maneuvers to deliver infant w/ shoulder dystocia
McRoberts - sharp flexion of maternal hips to increase AP diameter
Suprapubic pressure
Rubin maneuver - pressure on either accessible shoulder toward anterior chest wall of fetus
Wood’s corkscrew maneuver - P behind posterior shoulder to rotate infant and dislodge anterior shoulder
Delivery of posterior arm/shoulder
Episiotomy
Zavanelli - put infant’s head back into pelvis and get c/s
Kleihauer-Betke test
blood test used to measure the amount of fetal hemoglobin transferred from a fetus to a mother’s bloodstream
Qualitative test to help determine presence of feto-maternal hemorrhage is rosette test –> if positive, use K-B test to see amt of hemorrhage and adjust anti-D immune globulin
Postpartum period =
6 weeks s/p delivery
Pts usually experience breast milk let down…
24-72 hrs postpartum
Postpartum vaccines
Tdap (if more than 10 years)
- mainly for pertussis
MMR
- if low antibody titers in prenatal care
Rhogam
- within 72 hrs postpartum if Rh negative
How long pelvic rest s/p delivery usually?
6 weeks
Postpartum contraception
Very impt to address
PPTL
Breastfeeding + want hormone contraception:
- Progesterone only mini pill
- Depo Provera
- implantable progesterone agents
- –> NOT combo OCPs because can decrease milk let down
If really want combo OCPs and breastfeed, can start at 3-6 weeks pp and then milk supply should be ok
When does risk of VTE decrease in postpartum period to levels prior to pregnancy?
6 weeks
When can you put in IUD pp?
6 weeks pp
Usually risk expulsion before that
4 main causes of postpartum hemorrhage
4 Ts
Tone - Uterine atony
Tissue - retained placenta
Trauma from childbirth (eg cervical, vaginal lacs, uterine rupture)
Thrombin - coagulopathy
PP hemorrhage defined as
> 500 cc blood loss in vag deliv
> 1000 cc blood loss in cs
Tx uterine atony
Oxytocin IV
Uterine massage
If still atonic…
- methylergonovine
If still atonic…
- PGF2a (hemabate = carboprost)
- dinoprostone (cervidil)
- misoprostol off label (cytotec)
If still atonic…
- D&C
- inflatable tamponade
If still atonic…
- ex lap
- possible hysterectomy
Who can you not use hemabate (carboprost) in?
Asthma pts
Endometritis / Endomyometritis
- polymicrobial infection of the uterine lining that often invades the underlying muscle wall.
Endometritis in the postpartum period is most closely related to the mode of delivery. Endometritis can be found in less than 3% of vaginal births and this is contrasted by a 5-10 times higher incidence after Cesarean deliveries
Risk factors:
- meconium,
- chorioamnionitis,
- prolonged rupture of membranes.
Factors related to increased rates of infection with a vaginal birth include prolonged labor, prolonged rupture of membranes, multiple vaginal examinations, internal fetal monitoring, removal of the placenta manually and low socioeconomic status.
Usually occurs 5-10 days after delivery
Use US to look for retained products of conception –> D&C if yes
Broad spectrum IV abx to treat (amp/gent)
Tx mastitis
Dicloxacillin
Continue breastfeeding!
Diaphragms and cervical caps pp need to be reevaluated at
6 weeks
Surgical management of PPH ranges from
D&C ex lap uterine artery ligation, hypogastric artery ligation, hysterectomy
Tx umbilical cord prolapse felt in labor
elevate the fetal head with a hand in the patient’s vagina and call for assistance to perform a Cesarean delivery
Do this even if fetal heart tracing is ok!
Pt delivered baby s/p MgSO4 for preeclampsia - what do you care most about on neonate?
The first objective after delivery is to assess respiratory effort due to use of magnesium and make sure that the neonate is being oxygenated adequately, which might require a bag mask.
Infants born to diabetic mothers are at increased risk for developing
hypoglycemia, polycythemia, hyperbilirubinemia, hypocalcemia and respiratory distress.
Postpartum care of infant born to HIV+ mom
AZT immediately after delivery
HIV testing begins at 24 hours
The most common cause of postpartum fever is
endometritis
Bacterial isolates related to postpartum endometritis are usually polymicrobial resulting in a mix of aerobes and anaerobes in the genital tract.
The most causative agents are Staphylococcus aureus and Streptococcus.
Post partum blues
Signs and symptoms of depression which last for less than two weeks are called postpartum blues
Postpartum depression
is a common condition estimated to affect approximately 10-15% of women
often begins within two weeks to six months after delivery.
The safest method to suppress lactation
The safest method to suppress lactation is breast binding, ice packs and analgesics.
Hormonal interventions for preventing lactation appear to predispose to thromboembolic events, as well as a significant risk of rebound engorgement.
Bromocriptine, in particular, is associated with hypertension, stroke and seizures.
Breastfeeding is associated with
a decreased incidence of ovarian cancer
decrease the risk for developing coronary artery disease, cervical dysplasia and cervical cancer or colon cancer in the mother
Milk letdown is via…
Delivery –> rapid dec in levels of progesterone + estrogen –> no more inhibitory influence of progesterone on the production of alpha-lactalbumin by the rough endoplasmic reticulum.
increased alpha-lactalbumin —> lactose synthase —> to increase milk lactose.
Progesterone withdrawal allows prolactin to act unopposed in its stimulation of alpha-lactalbumin production.
Breastfeeeding + intense nipple pain….what is likely going on?
Candida of nipple
Mastitis not too much nipple pain
Signs that a baby is getting sufficient milk include
3-4 stools in 24 hours,
six wet diapers in 24 hours,
weight gain
sounds of swallowing.
Milk prod + milk let down done by…
prolactin is responsible for milk production
oxytocin is responsible for milk ejection.
Assoc of breech presentation
Prematurity, multiple gestation, genetic disorders, polyhydramnios, hydrocephaly, anencephaly, placenta previa, uterine anomalies uterine fibroids
Normal vs abnormal labor
Stage 1
- latent
- active
Tx?
Prolonged latent (> 6 cm dilated)
- > 20 hours for nulliparas
- > 14 hours for multiparas
Tx:
- rest or augmentation of labor.
Artificial rupture of membranes is not recommended in the latent phase as it places the patient at increased risk of infection.
Arrest of labor in 1st stage if:
- dilation >= 6cm + rupture membranes and one of the following:
- no cervical change for > 4 hrs despite adequate ctx
- no cervical change for > 6hrs with inadequate ctx
Arrest of dilation in active phase of labor…what do you do?
If baby ok, amniotomy is often recommended in this situation.
Then augmentation with oxytocin can be attempted after careful evaluation
FFP vs Cryoprecipitate
No RBCs or platelets in theses!
FFP
- fibrinogen
- V
- VIII
Cryo
- fibrinogen
- VIII
- vWF
Tocolytic contraindications
- terbutaline, ritodrine
- MgSO4
Terbutaline, ritodrine
- diabetic patients
magnesium sulfate
- myasthenia gravis;
Who can you not use methylergonovine in?
HTN pts
Preeclampsia/eclampsia
Treatment with betamethasone from 24 to 34 weeks gestation has been shown to
increase pulmonary maturity
reduce the incidence and severity of RDS (respiratory distress syndrome) in the newborn
associated with decreased intracerebral hemorrhage and necrotizing enterocolitis in the newborn
How does fibronectin for preterm delivery work?
Fibronectin is an extracellular matrix protein that is thought to act as an adhesive between the fetal membranes and underlying decidua.
It is normally found in cervical secretions in the first half of pregnancy. Its presence in the cervical mucus between 22 and 34 weeks is thought to indicate a disruption or injury to the maternal-fetal interface.
High neg predictive value in sx women, low + predictive value
Antibiotic therapy given to patients with preterm premature rupture of the membranes has been found to
prolong the latency period by 5-7 days, as well as reduce the incidence of maternal amnionitis and neonatal sepsis
In some cases of preterm rupture of the membranes, amniocentesis may be performed to detect intra-amniotic infection.
What does it look for?
L-6 increased **
Low glucose
Leuks have low predictive value
17 alpha-hydroxyprogesterone has been shown to reduce the risk of
premature labor.
Agents used to ripen cervix
prostaglandin E2 (PGE2) gel, PGE2 pessary (Cervidil), or PGE1M (misoprostol) is often used to “ripen” the cervix.
Ways to administer meds for uterine atony
IM
- PGF2a (carboprost)
Into uterus
- Carboprost
IV
- Oxytocin (not IVP)
Orally
- MIsoprostol
Rectally
- Misoprostol (not IV Or IM)
NOT IV
- Carbobprost —-> bronchoconstriction
Postpartum fever causes
Endometritis
Cystitis
Breast engorgement
Wound infection
SSRIs and breastfeeding - ok?
YES!
endometritis is usually
polymicrobial infection
tx w/ clinda and gentamicin
Low grade fever and leukocytosis postpartum - is this ok?
Yes! during first 24 hrs of pp
Chills are also common
reassure
