FCM Labor and Delivery

What is normal labor?

Presence of regular and painful uterine contractions resulting in cervical dilation or effacement or both

Regular contractions that cause cervical change

What are contractions?

Rhythmic tightening and releasing of the muscles in the uterus, usually every 3 to 5 minutes

Peaks when you can feel the contraction at the fundus

What is an external tocometer?

Monitor that measures how frequent contractions are, when they start and end

What is cervical dilation?

How open the internal os of the cervix is (measured by sterile vaginal exam)

What is cervical effacement?

Cervix stretches and gets thinner --> described in % from 0 to 100, measured by sterile vaginal exam

What is false labor?

Uterine contraction without cervical change

Can include Braxton-Hicks contractions

What are Braxton-Hicks contractions?

Irregular, infrequent contractions that do not cause cervical change (dilation and/or effacement)

Resolve spontaneously (can see resolution with ambulation or change in activity)

Cervical dilatation in the absence of uterine contraction suggests:

Cervical insufficiency

What are the keys of success for a vaginal delivery?

Synergistic interactions of uterine activity, fetus, and maternal pelvis

Three P's:

- Power (uterine contractions, frequency x strength)

- Passenger (fetal lie, fetal presentation, fetal size)

- Passage (maternal pelvis, shape)

Only way to determine adequacy is trial of labor

What are the different pelvic shapes in women?

- Gynecoid (m/c shape, 50% of women, associated with most successful chance of vaginal delivery)

- Platypelloid

- Android

- Anthropoid

What are the different stages of labor?

- First stage (onset of labor until 10 cm dilated, latent and active phases)

- Second stage (fully dilated to delivery of infant)

- Third stage (delivery of placenta, normally should occur within 30 min of delivery of infant)

- Fourth stage (postpartum/puerperium)

What are the two phases of the first stage of labor?

- Latent phase: onset of labor to 6cm dilated

- Active phase: 6cm to 10 cm (fully dilated)

What is Naegele's rule?

Estimation of gestational age/estimated date of delivery

Formula:

(First day of LMP) - 3 months + 7 days + 1 year

What is the most accurate method to establish or confirm gestational age?

Ultrasound measurement of the embryo or fetus in the 1st trimester

**Always check if consistent with LMP --> both together serve as most accurate measurement

How do we determine estimated date of delivery if a pregnancy resulted from assisted reproductive technology?

Go by age of the embryo and the date of the transfer

What is pre-viable, pre-term, early term, full term, late term, and post-term?

- Pre-viable: before 24 weeks

- Preterm: 24 weeks to 36 weeks 6 days

- Early term: 37 weeks to 38 weeks 6 days

- Full term: 39 weeks to 40 weeks 6 days

- Late term: 41 weeks to 41 weeks 6 days

- Post term: 42 weeks+

How does rupture of membranes present?

- "Sudden gush of fluid"

- Colorless, odorless, large amount of fluid

What can we see on speculum exam of a patient with rupture of membranes?

- Pooling of fluid

- Can sometimes see cervical dilation

What are some diagnostic tests done for rupture of membranes?

Commercial tests: ROM Plus, Amnisure, Actim PROM

Ferning

- Noted on microscopic evaluation of dried vaginal fluid, also called arborization

Nitrazine test

- Dark blue for pH > 6.5

- Amniotic fluid has pH of 7.1-7.3

- False-positive may occur with blood, semen, lubricants, BV

At this point, check GBS status

Ultrasound:

- Check amniotic fluid

- Oligohydramnios (low amniotic fluid <5cm) --> ROM

What is the disposition of rupture of membranes?

Based on whether ROM is confirmed, presence of labor, and gestational age

If ROM ruled out --> safe to discharge patient home

If SROM --> admit patient for labor management, possible augmentation

If PROM --> admit patient for induction

What is SROM?

Spontaneous rupture of membranes

Membranes ruptured AND presence of labor

What is PROM?

Pre-labor rupture of membranes

Membranes ruptured but before onset of labor, patient is >37 weeks

What is PPROM?

Preterm, premature rupture of membranes

Before onset of labor and before 37 weeks

What is augmentation of labor?

Used for patients who present in their own labor

Done to stimulate uterine contractions if adequate cervical changes are not occurring

Usually uses pitocin (synthetic oxytocin), can also have mechanical agents

What do we use to determine if the cervix is favorable?

Bishop score

Takes into account position, consistency, effacement, dilation, and station

What is cervical ripening?

Prior to spontaneous labor, the cervix first begins to soften over time, and then before contractions ensue, the connective tissue components of the cervix are extensively remodeled

What are ripening agents we can use to induce labor?

- Synthethic prostaglandins (Cytotec, Cervidil)

- Pitocin

What are mechanical agents we can use to induce labor?

Cervical balloon or foley

Physically open the cervix

What are some reasons for why we induce labor?

- Pre-labor rupture of membranes

- Post-term induction

- Fetal conditions (oligohydramnios/polyhydramnios, abnormal dopplers, multiple gestation)

- Maternal conditions (chronic HTN, hypertensive disorders of pregnancy (gestational hypertension, preeclampsia), gestational diabetes, HIV, intrahepatic cholestasis of pregnancy)

What are the different types of delivery?

- NSVD: normal spontaneous vaginal delivery

- VBAC: vaginal birth after cesarean

- Operative vaginal delivery: forceps-assisted or vaccuum-assisted

>> Decision made during the labor process, not pre-determined

- Cesarean delivery: described based on nature of delivery – scheduled, unscheduled, urgent, STAT

>> Type of incision: low transverse (pfannenstiel), classical (vertical)

What is the normal baseline fetal heart rate?

110-160 bpm

What is considered fetal bradycardia and fetal tachycardia?

Fetal bradycardia: <110 bpm

Fetal tachycardia: >160 bpm

How do we determine fetal oxygen status? What can fetal hypoxia be caused by and lead to?

Fetal surveillance

Strong uterine contractions can interrupt uteroplacental blood flow and transfer of oxygen from mother to fetus

- Fetuses can tolerate transient hypoxemia

- Prolonged hypoxia can lead to metabolic acidosis, tissue damage

What are the two types of fetal surveillance during labor?

- External fetal monitoring

- Fetal scalp electrode

What is fetal position?

Refers to the presenting part relative to the maternal pelvis

What is the mnemonic to remember the FHR pattern and its causes?

VEAL CHOP

FHR pattern (VEAL):

- Variable decels

- Early decels

- Accels

- Late decels

Cause (CHOP):

- Cord compression

- Head compression

- Okay!

- Placental insufficiency

What is fetal station?

Defined as the number of centimeters of the bony presenting part above or below the level of the ischial spines

0 station is the bony part at the level of the ischial spines

What are the cardinal movements of labor?

- Engagement

- Descent

- Flexion

- Internal rotation

- Extension

- External rotation

- Expulsion

What are the different delivery maneuvers done when delivering a baby?

- Protect perineum

- Hand cupping the head

- Allow for restitution

- Check for nuchal cord once head is out

- Apply downward traction to deliver shoulder below pubic bone

- Then upward to deliver other shoulder

- Hold body and place on maternal abdomen or hand off to pediatrics

- Doubly clamp and cut umbilical cord

- Massage fundus and apply traction on remaining portion of umbilical cord until placenta spontaneously delivers

- Inspect perineum/vagina/cervix for lacerations

What are the benefits of delayed cord clamping?

Increases hemoglobin levels and iron stores, associated with lower incidence of necrotizing enterocolitis and intraventricular hemorrhage

What is an episiotomy?

Surgical extension of the vaginal opening into the perineum during labor

When are APGAR scores measured?

1 and 5 minutes of life

What are the different APGAR scores and signs?

What is uterine atony?

Uterus becomes soft, boggy, poorly contracted (normal = vigorously contracted uterus, hard like a rock)

What are risk factors for uterine atony?

- Prolonged labor

- Prolonged use of oxytocin

- History of many deliveries

How do we treat uterine atony?

First line: bimanual massage

Then, uterotonic agents:

- Oxytocin

- Methylergonovine (methergine)

- Carboprost (Hemabate)

- Misoprostol (cytotec)

In severe cases (when other measures fail), hysterectomy is indicated

What is the most common cause of postpartum hemorrhage?

Uterine atony

What is chorioamnionitis?

Defined as intra-amniotic infection

Usually an ascending infection from the lower GU tract

What are signs of chorioamnionitis?

- Maternal fever (>100.4 degrees F)

- Fetal tachycardia

How do we treat chorioamnionitis?

IV ampicillin and IV gentamicin

Expedite delivery

What are some other reasons why vaginal delivery might be converted to a C-section?

- Non-reassuring fetal heart tracing (fetal intolerance of labor)

- Rupture of membranes greater than 18 hours

- Arrest of dilation (cervix stops dilating prior to 10 centimeters)

- Too long on pitocin

What is shoulder dystocia?

Failure to deliver the shoulder with gentle downward traction on the fetal head

Cannot be predicted, can happen with any delivery

If there is a history, can counsel on cesarean delivery

What are risk factors for shoulder dystocia?

- Diabetes causing large fetus

- Macrosomia

- Prior shoulder dystocia

What are the different maneuvers to relieve shoulder dystocia?

- McRobert's maneuver: flexing thighs against abdomen

- Suprapubic pressure: combined with McRobert's usually resolves most shoulder dystocias

What are some complications of shoulder dystocia?

- Brachial plexus palsy (Erb-Duchenne, Klumpke)

- Clavicular or humeral fractures

- Maternal 4th degree lacerations or hemorrhage

What is umbilical cord prolapse?

Umbilical cord exits the cervical os before the fetal presenting part

Compression of the umbilical cord can result in:

Vasoconstriction and resultant fetal hypoxia, which can lead to fetal death or disability if not rapidly diagnosed and managed

How do we treat umbilical cord prolapse?

Provider will elevate the presenting part as to prevent cord compression until the patient is transported to OR

Emergent C-section indicated!

How common is Group B streptococcus?

Group B Streptococci (GBS) colonize rectum and vagina in 10-30% of pregnant women

What is the significance of GBS in pregnancy?

Maternal to neonatal transmission is approx 50% and can lead to GBS sepsis in the newborn

All pregnant women need to be screened on or after 36 weeks 0days

How long is GBS result valid for?

5 weeks

How do we treat GBS infection in a pregnant patient?

Intrapartum IV penicillin G

How do we treat pain during labor/delivery?

Always treat per patient request

Do not give NSAIDS!! (can cause premature closure of fetal patent ductus arteriosus)

What are some neuraxial pain relief methods used in labor/delivery?

- Epidural

- Spinal

- Combined spinal-epidural

What is lochia?

Normal shedding of blood and decidua (uterine lining)

Initial red-brown (rubra) which gets lighter each day

Flow is like a period at first, can last up to 6 weeks

What can women expect post-partum?

- Lochia (normal shedding of blood)

- Pain (cramping from uterine involution)

- Monitor CBC due to blood loss from delivery

- Physical exam prior to leaving hospital

- DVT prophylaxis

Why do patients experience pain postpartum?

Cramping from uterine involution (uterus returning back to normal size)

Will feel period like cramps to contractions, can give NSAIDs or Tylenol

What can we see on physical exam of postpartum patients?

- Fundus: firm, at the level of the umbilicus

- Vulvo vaginal: comment on lochia, vulvar edema (can cover urethra obstructing urinary flow), perineum well approximated

What do we give postpartum patients for DVT prophylaxis?

- Ambulation

- Subcutaneous heparin or LMWH while inpatient

What birth control can we start patients on postpartum?

Progesterone only (pills, Depo-Provera, Nexplanon)

What are some special considerations postpartum for C-section patients?

- Regular post-op care

- Incision care

- Counseling

- Oxycodone PRN

How long do patients stay in the hospital post-partum?

- Vaginal deliveries: 48 hours after delivery

- C-sections: stay until post-op day 2-4

What do we do during a routine 6 week postpartum visit?

- Lochia should stop by this time

- Breastfeeding should be established by this time usually

- Assess psychological well-being (Edinburg postnatal depression scale)

- Resume sexual activity

- Can now start estrogen-containing birth control methods

- Counsel on birth spacing (ideally about 18 months between pregnancies)

What are the different benefits of breastfeeding for the mother?

- Uterine involution

- Weight loss

- Reduced chances of female cancers

What are the different benefits of breastfeeding for the baby?

- Helps with neurodevelopment and glucose regulation

- Decreased risk of SIDS, obesity, and childhood infection

What is lactogenesis stage 1?

Colostrum is available

What is lactogenesis stage 2?

Effective infant sucking builds milk supply

What are contraindications for breastfeeding?

- Infant with galactosemia

- Mothers with HIV

- Human T-cell lymphotropic virus

- Untreated active TB

- Active varicella or herpes on the nipple

How can we verify if medications can be taken with breastfeeding?

LactMed or Hale's medication database, or lactation consultant

How do we know if baby is getting any milk?

- Baby is satisfied

- Sucking sounds

- Not crying

- Voiding and stooling

- Engorgement is relieved

What are some postpartum psychiatric complications?

- Postpartum blues (baby blues)

- Postpartum depression

- Postpartum psychosis

What are postpartum blues (baby blues)?

- Mild and rapid mood swings

- Usually 2-3 days after birth, resolves within 2 weeks

- Supportive care, screening for MDD

What is postpartum depression?

- Depressive episode that starts during pregnancy or in the 4 weeks following delivery

- Commonly occurs 1-3 weeks after delivery

- Patients cannot handle daily tasks due to intense feelings of sadness, anxiety, or despair

What is postpartum psychosis?

Auditory or visual hallucinations

The most common risk factor is hx of bipolar disorder

What are some differential diagnsoes of postpartum fever?

- WIND: atelectasis or pneumonia

- WATER: UTI

- WOUND: C-section incision, episiotomy/laceration infection

- WALKING: DVT/PE (pregnancy and postpartum is a hypercoagulable state)

- WONDER DRUGS: misoprostol (for uterine atony) can cause fever after administration upto 4 hours

- WOMB: endometritis or endomyometritis

- WEANING: breast engorgement or mastitis

What is the most common cause of postpartum fever?

Endometritis or endomyometritis

How does endometritis present?

- Fundal tenderness

- Foul-smelling lochia

What is the most common organism of endometritis?

E. coli (polymicrobial ascending infection from vaginal flora)

How do we treat endometritis?

IV gentamycin and IV clindamycin

What causes mastitis?

S aureus

How do we treat mastitis?

Dicloxacillin

Why does postpartum hemorrhage occur?

4 Ts:

- Tone: uterine atony, most common cause!

- Trauma: lacerations

- Tissue: retained products of conception (placenta, membranes)

- Thrombin: coagulopathies

What is considered to be postpartum hemorrhage?

Greater than 1000mL of blood loss for vaginal or C-section deliveries

How do we treat postpartum hemorrhage?

- Bimanual massage

- Extraction of contents

- Uterotonics

- Take back to the OR for D&C

What is Sheehan syndrome?

Occurs with massive postpartum hemorrhage, necrosis of the pituitary gland