Woman's Health II review

True vs False Labor

• Labor

- Painful uterine contractions (q5 min x 1 hour)

- Which change the cervical dilation

• False Labor

- Contractions without cervical change (Braxton-Hicks)

Labor & Delivery

• Labor is the physiologic process of childbirth defined by regular uterine contractions that result in effacement and dilatation of the cervix followed by expulsive efforts, leading to the delivery of the fetus and placenta.

• Delivery is the reflexive and spontaneous action of bearing down to achieve expulsion of the fetus and placenta.

Uterus is a a multi-faceted smooth muscle organ

• Smooth muscle cells (SMC)

• It is also a neuroendocrine organ

- Endogenous morphine, analgesics

- Pacemaker system

• Dramatic response to hormones of pregnancy

- Supports pregnancy

- Accomplishes parturition

Normal myometrial changes of labor

Uterus becomes receptive to signals to contract

• TWO segments form

- Upper uterine: actively contracts

- Lower uterine: dilates and thins, directly connected to changing cervix (lower muscle cell content, area for cesarean incision)

• PGE2 and relaxin aid in cervical softening

• PGF2α increases contractions

Hormonal changes of labor

• Progesterone withdrawal

• Protein channel gap junctions form

• Increase in oxytocin and prostaglandin receptors in the uterus

Stages of labor

• Stage 1: From closed to 10 cm

• Stage 2: "Pushing stage", from 10 cm to expulsion of the infant

• Stage 3: From delivery to delivery of placenta

• Stage 4: Placenta to 6 hours post-delivery

First stage of labor

• Onset of true labor until complete dilation of the cervix occurs

- What is considered complete dilation?

**6 cm (active labor)

• Usually the longest stage

- average 8-12 hrs. in primigravida

- average 6-8 hrs. in multipara

Stage 1a: Latent phase

• Length of phase varies considerably (longer in primips)

• IMPORTANT EVENTS:

- cervical effacement (the entire cervical length is retracted into the lower uterine segment)

- early dilation of cervix

Stage 1b: Active phase

• Usually begins when cervix is 6 cm dilated; and contractions are regular

• Rapid cervical dilation to 10 cm occurs

- 1-1.2 cm of dilation per hour

- If this rate of dilation does NOT occur, evaluate for: uterine dysfunction, fetal malposition, cephalopelvic disproportion

Care of the Stage 1 Laboring woman

Monitoring for Mother: 1:1 nurse:patient ratio

• BP, P, RR, T q1-2 hours; I & Os

• Uterine contractions: frequency, duration, intensity (can be measured with internal monitors)

• Vaginal exam

- SPARINGLY during latent phase if membranes have ruptured

- Every 2-4 hours in active phase

• Goals: document cervical effacement/dilation; fetal station and position; presence of molding or caput; check for prolapsed cord if FHR has decreased

Second stage of labor

• Defined as: The period after full dilation/effacement has occurred until the birth of the baby

• Length of Stage 2 related to:

- quality of contractions

- type of analgesia given to mom

• Median length of Stage 2:

- primips: 50 minutes

- multips: 20 minutes

• By beginning of this stage:

- Pt usually has urge to BEAR DOWN with contractions

- Contractions and intra-abdominal pressure to expel baby

• During this stage monitor fetal descent (follow progress of presenting part in canal)

Care of the Stage 2 laboring woman:Monitoring

• FHR- continuous

• Vaginal exam as needed

• Preparation for Delivery

- Dorsal lithotomy

- Episiotomy (not routinely recommended)

Cardinal movements of labor

• Six fetal movements to adapt to maternal pelvis

1. Descent: begins because of initiation of labor

2. Flexion: fetus already in partial flexion prior to onset of labor

- during descent, fetus encounters resistance

- increases flexion of cervical spine (chin to chest position)

3. Internal Rotation: head enters pelvis transverse/oblique but ROTATES so that occiput turns anteriorly toward symphysis pubis

- flexed head in OA position descends within pelvis

- outlet is directed UPWARD and FORWARD

4. Extension: MUST occur before head can pass through

5. External Rotation: head exits pelvis but then ROTATES so that occiput turns transverse/oblique to align with shoulders

6. Expulsion:

- After external rotation of head, ANTERIOR SHOULDER comes out from under the pubis (do with GENTLE downward traction on head as too much pressure can damage brachial plexus)

- Delivery of posterior shoulder occurs by elevation of baby's head

Once head delivered

• Index finger to check for cord at neck

- If nuchal cord: slip it over neck if able

• May be too tight - if so - double clamp and cut

After delivery

• Clamp cord

• Newborn placed under warmer (first to mom if able)

- Temperature, glucose, APGARS

- To breast within 30 minutes if stable

Episiotomy

• Pros: "clean edges" for re-approximation, controlled

• Cons: increased risk of 3rd & 4th degree extensions, increased pain post partum

• Routine episiotomy NOT recommended

• Used predominantly for operative vaginal deliveries or shoulder dystocia

Perineal Lacerations

• 1st degree: involves vaginal epithelium or perineal skin only

• 2nd degree: extends into subepithelium

• 3rd degree: involves anal sphincter

• 4th degree: extends into rectal mucosa

Stage 3 of Labor

• Period from birth of baby to delivery of placenta

- inspect cervix/vagina for lacerations and REPAIR

• Separation of placenta begins

- usually within 2-10 minutes of Stage 3

- lasts for 30 minutes

- Signs: fresh show of blood; lengthening of cord out of vagina; fundus rises; firm/globular uterus

Stage 3 of Labor:Delivery of Placenta

• Place gentle traction on cord with COUNTERPRESSURE between symphysis pubis and uterine fundus with fundal massage.

• Oxytocin is usually given after baby is delivered

- uterine contractions decrease bleeding from placental implantation site

• Risk factors for excessive bleeding (postpartum hemorrhage):

- Anemia

- Prolonged augmentation of labor

- Multiple gestation

Inspection of Placenta and Cord

• Grossly inspect placenta: Maternal side, Fetal side, clots

-Abnormalities in color, shape

• Inspect Umbilical cord

- Vessels: 2 arteries & 1 vein

Stage 4 of Labor

• Period from delivery of placenta to stabilization of mother (6 hrs)

• Highest risk time for postpartum hemorrhage:

- Normally uterine musculature contracts around blood vessels at placental implantation site; if uterus fails to contract, excessive bleeding. Uterine atony 75-85% of all PPH

• PP hemorrhage defined as >1000 cc

• Monitor: vitals, quantity of blood per uterus (PULSE increase is first sign of hemorrhage)

• Remove epidural and allow effects to fade

• Initiate breastfeeding

• Initiate care for healing from tears and pelvic injuries

Obstetrical Analgesia and Anesthesia

• Analgesia can occur due to the action of a drug at:

1. Brain: narcotics, sedative-tranquilizers, inhalation anesthetics (nitrous oxide)

2. Dorsal horn of spinal cord (afferent nerve fibers)

- epidural/subarachnoid administration of medication

- interferes with transmission of pain receptors in dorsal horn

3. (Peripheral) Sensory nerve fiber

- local anesthetics like lidocaine, tetracaine, bupivicaine

- interferes with transmission of sensation locally

- central blocks (lumbar epidural, spinal)

Pros/Cons of IV Narcotics

• Pros:

- Easy to give

- No need for anesthesiologist

- Can give if pt has coagulopathy

- Can reverse effects with Narcan

- Pts may be less scared than of "needle in the back"

• Cons:

- Maternal awareness of birth experience decreased

- Rapid crossing through placental: neonatal depression

- Analgesia not of high degree

Epidural

• Done in sitting position

• Needle inserted into epidural L3-4 space

- 2 test doses to make sure not in subarachnoid space (spinal) or in bloodstream

• Indwelling catheter left in place

• Fentanyl for visceral pain (uterine contractions) and bupivacaine for somatic pain (fetal head engaged)

Spinal block

• Done in sitting/lateral position

• Needle inserted into subarachnoid L3-4 space

• Tetracaine/bupivicaine or lidocaine

• Solution made hyperbaric with dextrose to prevent ascending anesthesia

• Spinal HAs from CSF leakage from punctured dura can be a complication

Pros/Cons of Regional analgesia: Pudendal Block

• Pros: Easy, no maternal hypotension, rare fetal effects

• Cons:

- Incomplete analgesia (No effect on pain of uterine contractions, incomplete perineal analgesia)

- Complications: rectal puncture, hematoma, sciatic nerve block

Normal uterine physiology of labor affected by 3P's

• Power, Passenger, Pelvis/Passage

• Power: 3-5 contractions per 10 minutes

- 200-250 Montevideo units if IUPC is being used, pt is in active labor

• Passenger: fetal growth, biometry

• Pelvis/Passage: shape, pelvimetry

• Dystocia is abnormal labor

- Complex etiologies

- 'End stage' result

- Can develop after labor begins

- Often associated with metabolic dysregulation in the fetal-placental unit long before true labor begins

Friedman labor curve is the standard of labor management

• Plots cervical dilation and fetal presenting part descent against time

• Modern day women - older and heavier (increase c/s rate)

- rewriting the Friedman curve to accommodate for these factors

Dysfunctional labor

• Rates of cervical change slower than these curves

• Prolonged latent phase in:

- nulliparous pt is > 20 hr

- multiparous pt is > 14 hr

• If no progression may actually be false labor

Power

• Uterine activity monitored by:

- palpation, external tocodynamometry, or intrauterine pressure catheters (IUPCs)

• Tocodynamometer: records the frequency of uterine contractions and relaxations as well as the duration

• IUPC: in addition to contraction frequency and duration, also directly measures the pressure generated by uterine contractions

• For cervical dilation & fetal descent--> contractions must generate ≥ 25 mmHg

- optimal IUP is 50-60 mmHg

- optimal frequency is > 3 contractions in 10 min intervals

Montevideo units

• # of uterine contractions in 10 minutes times the average intensity

• Normal progress of labor is usually associated with ≥ 200 MVU. AKA "adequate" contractions."

• Can only be calculated when a patient has an IUPC

• oxytocin used to improve power

Passage

• Bony pelvis

- Cephalopelvic disproportion: size of the maternal pelvis is inadequate to the size of the presenting part of the fetus

• Soft tissues of maternal pelvis

- abnormalities of the cervix, tumors/lesions of the colon/adnexa, distended bladder, uterine fibroids, morbid obesity may all impede fetal descent into birth canal

Pelvis shapes

Android (<30% of women)

• Classic male shape

• Triangular inlet shape: fetal head NEARLY always occipitoposterior, can cause arrest of descent

Anthropoid (20% of women)

- Most resembles anthropoid ape (AP>transverse diameter), Fetal head usually occipitoposterior

Platypelloid (3% of women)

- Flattened gynecoid (wide transverse diameter--> Oval shaped)

- fetal head can ONLY engage in transverse direction

Gynecoid (50% of women)

• Classic female shape (round at the inlet, cylindrical overall)

• Most spacious for fetal head (generally will rotate into occipitoanterior position)

Passenger

• Fetal presentation: fetal part most dependent in birth canal

• Fetal lie: longitudinal vs. transverse/oblique

• Fetal head position

• Fetal weight

**More difficult to pass:

- Asynclitism: If the fetal head is turned to one side

- Extension: If the fetal head is extended

• Molding (occurs in all vaginal deliveries): alteration of relationship of fetal cranial bones to each other b/o compressive forces of bony maternal pelvis

- in CPD: molding more pronounced

Passenger presentations

• Vertex (96%)

• All others are considered malpresentations and have an increased likelihood of failure to progress and other complications

- Face, brow, shoulder, breech, compound

Leopold's maneuvers

• External method of evaluating fetal location in uterus

• Done during 3rd trimester prenatal visits and on presentation in labor

• Used to determine (by palpation): fetal lie, fetal presentation, fetal position

Prolonged latent phase

• Pain can be managed by sedation/analgesia

- Therapeutic rest: woman sleeps, wakes up in labor

• A prolonged latent phase is one that exceeds 20 hours in a

nulliparous patient or 14 hours in a multiparous patient

• If prolonged latent phase: augment the labor (oxytocin) or amniotomy, not an indication for c/s

Prolonged labor in first stage

When the cervix dilates less than 1 cm/hour in nulliparous women OR less than 1.2 to 1.5 cm/hour in multiparous women

First stage labor arrest (Arrest of dilation)

• Can't be diagnosed unless pt is ≥ 6 cm

• Pts who are at or beyond 6 cm with ruptured membranes who fail to progress despite 4 hours of adequate contractions or 6 hours of inadequate contractions w/o cervical change

• Remember: adequate contractions = at least 200 MvU

Second stage arrest:(Arrest of descent)

Multipara

• As long as maternal and fetal condition are stable, allow at least:

- 2 hours of pushing w/o an epidural or 3 hours with an epidural

Nullipara

• As long as maternal and fetal condition are stable, allow at least:

- 3 hours of pushing w/o an epidural or 4 hours with an epidural

**This may be individualized as long as progress is occurring throughout the second stage

Dystocia due to Abnormal Presentation/Position

• Non-vertex

• Non-occiput anterior (OA): Occiput posterior deliveries take longer for fetal descent

• CPD- Cephalopelvic Disproportion, android pelvis

• Always think about 3 P's and consider what is modifiable: Power *, Passenger , Passage

Dystocia caused by abnormal passenger

• Macrosomia (>90th percentile for GA)

- Larger fetal size associated with increased risk of shoulder dystocia** and cephalopelvic disproportion

- >5,000g in non-diabetic and > 4,500g in diabetic mothers is an indication for C/S w/o a trial of labor

• Risks: labor arrest, genital trauma, shoulder dystocia, maternal bladder dysfunction, 3rd & 4th degree tears, C/S

• Others: internal hydrocephalus (may require drainage before delivering, C/S indicated if head circumference is >40 cm), Fetal ascites, Meningocele, Masses, Compound presentation, Conjoined twins

Shoulder dystocia

• Head emerges, shoulder remains

• Defined: maneuvers beyond a gentle down traction at head delivery required to deliver the shoulder OR > 60 seconds between delivery of head and body

• Fetal macrosomia and maternal diabetes most important risks but MOST shoulder dystocias happen w/o the risks present

• Turtle sign: head retracts back into pelvis after each ctx

• Prompt recognition and calm teamwork essential

• Tx: maneuvers change the pelvis or the baby to disimpact the anterior shoulder from the maternal pubic symphysis

- McRobert's, Gaskins, Rubin

Induction/Augmentation

• Induction: labor is initiated artificially

• Augmentation: artificial stimulation of labor that has already begun

• Bishop's score: to help assess likelihood of vaginal delivery

- High score (≥ 7) = high likelihood

- Low score (< 6) = less likely

• Amniotomy: Artificial rupture of membranes

• IV pitocin: synthetic oxytocin

• +/- Cervical ripening: Prostaglandins, Low dose pitocin, mechanical dilation, Hygroscopic Dilators, Foley balloon

Post dates gestation (>42w0d)

• 2-3 times increased fetal mortality secondary to

- aging and infarcted placenta- dysmaturity

- progressive growth of fetus leading to CPD and dystocia

• Complications:

- Abnormal presentations (Breech, Transverse lie, Oblique lie, Shoulder, Military face)

- Multifetal gestations

Fetal malpresentation (not vertex/cephalic, occiput)

Breech (2-4%)

• Increased M&M (maternal and fetal)

• Risk Factors: Prematurity, Multiple gestation, Fetal anomalies, Polyhydramnios, Anencephaly, Uterine abnormalities

Face

• Something prevents flexion (causes uncertain)

• Diagnosed in labor exam--> mouth/noses palpated

• Position landmark: chin

- Only mentum anterior can be delivered

- Mentum Anterior: MAybe

- Mentum Posterior: iMPossible

• Once chin out, additional flexion allows delivery

Brow (1 in 1400 deliveries)

• Many convert to vertex (OA) or face

• Largest presenting diameter possible

Shoulder

• Transverse lie – cannot deliver vaginally

Cesarean Delivery: When and why?

1. Prior C-section

- Vaginal birth is possible (60 - 80% success rate)

- Uterine rupture risk 1.5%

**Classical incision (vertical) not eligible; low vertical/transverse eligible

2. Dystocia ( = abnormal labor)

- Failure to progress: cervical dilation stops (CPD common reason)

3. Malpresentation

4. Placentation issues

5. Active genital herpes

6. Emergent health problem: Maternal/Fetal distress

Anesthesia for C-Section

• Regional is 1st choice: Spinal/epidural

- Mom awake; birthing partner allowed in operating room

- Less chance of pulmonary aspiration, decreased hypoxic events during intubation

• General anesthesia: can be accomplished quickly

- ONLY choice for urgent/emergent C-section due to maternal hemorrhage or fetal distress

Operative Vaginal Delivery

• Vacuum extraction

• Forceps

- Indications: prolonged 2nd stage, category III tracing in second stage, stabilize after-coming head in breech delivery

• Rate of use of either methods in this community substantially down from past

Assessing Fetal Heart Rate Tracing

• Normal FHR pattern: 95% likelihood of fetal well-being

• Abnormal FHR pattern: 80% false (+) rate

- Screening NOT diagnostic tool

• Normal FHR pattern:

- Rate 120-160 bpm

- 5-25 bpm short term variability (> 25 indicates distress)

- 3-10 cycles per min long term variability

• Fetal Tachycardia: usually a sign of maternal fever or intrauterine infection

Continuous Fetal Monitoring

Who requires monitoring?

• All pts being induced/augmented

• Pts attempting vaginal delivery: with breech presentation, Trial of labor after cesarean (TOLAC)

• Pts with risk for fetal distress: Macrosomia, Postdates, IUGR, Multiple gestation, PROM, etc.

Abnormal fetal monitoring

Accelerations: visually apparent abrupt increase in FHR d/t fetal movement

• prolonged if ≥ 2 min but < 10 min (> 10 = baseline change)

Decelerations:

• Early: symmetrical gradual decrease in FHR (> 30s) and then return to baseline; associated with uterine contractions

- Causes: fetal head compression, normal

• Variable: abrupt decrease in FHR < 30s

- Cause: umbilical cord compression (tx by changing maternal position)

• Late: symmetrical gradual decrease and return to baseline with uterine contraction but delayed timing

- Cause: utero-placental insufficiency (potential compromise, hypoxia, acidemia)

- tx: change maternal position, fluids, improve perfusion

Sinusoidal

• Fetal anemia, acute intrapartum asphyxia

- tx: expedite delivery

Pseudosinusoidal

• Meds (butorphanol)

Contractions

• # of contractions present in a 10 min window, avg over a 30 min period

• Normal: ≤ 5 contractions in 10 min

• Tachysystole: > 5 contractions in 10 min

• Tetany: a contraction lasting ≥ 2 min

• External tocodynamometry vs. internal uterine pressure catheter to assess strength

Fetal oxygenation

• PO2 in fetus 25 mmHg (adult 100)

• Fetal O2 consumption is twice adult rate

- Fetus has 2 minutes of O2 reserve

- A fetus does not receive oxygen during the contraction (relaxation is important, avoid tachysystole and tetany)

• Atrial pacemaker determines rate, responds to inputs

- In hypoxia, specific FHR changes occur

Is the fetus ok?

• Simple timed auscultation of fetal tones during labor is effective

- Continuous fetal monitoring is not needed for good outcome

• Electronic fetal monitoring (EFM) has not proven effective/predictive of poor outcome

• EFM controversies

- EFM hasn't prevented Cerebral Palsy

- Has reduced post-term complications and stillbirth

- Has NOT reduced CP in preterm infants

Maternal-Placental-Fetal triad

• Hypoxia: pH < 7.2-7.3, SBE < -9

• Acidosis: pH < 7.21, SBE < -10

• Inflammation: RDS, NEC, IVH

• Effects:

- metabolic dysregulation

- increase risks of physical & mental abnormalities

Fetal heart rate categories

• Category I (normal): very reassuring

- baseline rate: 110-160 bpm

- baseline FHR variability: moderate

- Late/variable decelerations: absent

- Early decelerations: present/absent

- Accelerations: present/absent

• Category II: exclusion classification, warrant close observation; may require immediate delivery amnioinfusion, maternal tx

- includes all FHR tracings not included in category I or III

• Category III (abnormal): need for urgent delivery

- Absent baseline FHR variability and any of the following: recurrent late decelerations, recurrent variable decelerations, bradycardia

- sinusoidal pattern

Patterns and implications Cat. III

1. Absent baseline variability

- serious state of metabolic dysregulation.

2. Recurrent late decelerations

- severely reduced uteroplacental blood flow.

3. Recurrent variable decelerations

- umbilical cord compression

- reduced amniotic fluid volume.

4. Prolonged bradycardia

- failure of the fetus to use its baroreceptive signaling to its CV centers to control HR because of severe metabolic dysregulation

5. Sinusoidal patterns

- on admission = severe fetal anemia (of unknown cause)

- during labor lasting longer than 20 minutes = severe, acute fetal bleed

Non pattern signs of fetal compromise

• Fetal tachycardia

- Brief rises to 190 well tolerated

- Persistent tachycardia concerning

- Causes: maternal temp, infection and chorioamnionitis

• Meconium

- Early: before rupture of membranes (ROM)

- Late: second stage of labor *associated with low APGAR

Internal monitoring uses a fetal scalp electrode (FSE); can use intrauterine pressure catheter (IUPC)

• Membranes must be ruptured

- Caution important as is invasive, carries risks (chorioamnionitis

damage to fetus/mom)

- Cannot be placed in maternal Hep C or HIV

• Cervix must have dilated

• FSE gives an EKG of fetus, IUPC more accurate than tocometer

Intrauterine Fetal Resuscitation

1. Recheck maternal vitals

2. Stop contractions if necessary

3. Administer high-flow maternal O2

4. Change positions

5. Check cervix - cord prolapse, labor progress, assess possibility of assist

6. Scalp stimulation - compromised babies will not respond

7. Increase IV Fluids, tend to maternal BP

8. Consider switching to internal monitoring

9. Have conversation with nursing and anesthesia about delivery options

10. If vaginal delivery is imminent - assist

11. If remote from vaginal delivery - offer c-section

Post-Partum Fevers/Complications

• Wind - Atelectasis, Asthma, Pneumonia, PE

• Water - Retention, Incontinence, Infection

• Walking - DVT, Edema, Thrombophlebitis

• Wound - Cellulitis, Abscess, Infected Hematoma

• Womb - Endometritis, Pyometritis

• Breast - Engorgement, Mastitis, Candidiasis

Postpartum endometritis (PPE)

• Was the mcc of puerperal fever

• "Childbed fever" was a major killer of women in the pre-antiseptic era

- Midwives who delivered women at home carefully washed and did not travel from patient to patient directly

- Medical doctors in contrast went from the dissection theater to the wards and spread the infections

• Post cesarean delivery: especially after labor/ROM

- Pre C/S abx prophylaxis is thus given (Reduces rate to 10%)

• Risks: Prolonged ROM/labor, Prior BV, Frequent vaginal exams, Internal fetal monitoring

PPE pathogenesis & presentation

• Group B streptococci, Enterococci, other aerobic streptococci, G. vaginalis, E. coli, P. bivia, Bacteroides spp

• Peptostreptococci are the mc endometrial isolates

• GBS and G. vaginalis mc blood isolates

• S/S: fever, lower abd pain, uterine tenderness, leukocytosis

- Uterus: fail to involute and stay at umbilicus, feel soft & boggy, and tender

PPE treatment

• IV Clindamycin and gentamycin

- may use expanded spectrum penicillins (Unasyn)

- continue until 24 hrs < 37.8, pain free, and normalizing WBC

• More extensive infection may be present if no resolution within 48 hr

- wound/pelvic abscess, noninfectious fever (breast engorgement, drug fever)

- CT pelvis may help

- septic pelvic thrombophlebitis

Neonatal care

• Birth attendant must be able to perform assessment and resuscitation if required of the newborn - ensure a person or team is there for every delivery

• No-assist baby = Full-term, Spontaneous breath, good cry, good muscle tone

• APGAR scores (appearance, pusle, grimace, activity of reflex, respiration)

• Ballard score confirms GA of neonate

Routine Care is needed by all infants

• Delayed cord clamp, warm by drying or skin to skin with mom

• Umbilical cord stump care

• Vital signs q30 until stable x 4 measures

• Promote breastfeeding

• Transitional care - close observe 6-12 hours after birth

• Antimicrobial ophthalamic prophylaxis

• Vitamin K1 oxide to prevent deficiency related hemorrhage in newborn

• Watch for imperforate anus - observe stool

• Check for jaundice - prevent kernicterus

Caput Succedaneum

• Localized edematous swelling of scalp from pressure of cervix on presenting part

• Crosses suture lines because swelling is above the periosteum of the bone

- Most often seen after prolonged labor or in babies with significant molding

Cephalohematoma

• Subperiosteal hemorrhage

• Does NOT cross suture lines

• More likely in assisted deliveries

• Rarely calcifies over time

Initial Care of the ill newborn

• 10% of all deliveries need some resuscitation

• NRP (Neonatal Resuscitation Program)

- Normal neonate first breath within seconds

- Regular respiration within 1 minute

- Any other presentation – initiate resuscitation

• ABCs

- Airway: clear if necessary

- Breathing: ventilate if necessary; Positive Pressure Ventilation (PPV) –start if HR <100

- Cardiac: chest compressions if needed (Key rates--> HR <60 start compressions)

• Consider causes – fix what you are able

• Assess metabolic status with arterial umbilical cord blood gas

- when in doubt get both (two samples) and compare to assure arterial is obtained

Breast cancer general

• Known since 3000 BC, most feared cancer

• Common breast lumps

• Avg age is 62; 12.4% is avg risk (1 in 8)

• Highest risk: non-Hispanic white, black, then hispanic white, and pacific islander

• Highest death rates: black

• Detection

• Treatment: Surgical, Chemotherapy, Radiation

Common benign breast lumps

• Fibroadenomas including giant juvenile fibroadenomas

• Phylloides tumors which look like fibroadenomas but can recur locally

• Lactating adenomas

• Fibrocystic changes, Breast cysts

• Fibrous, pseudo angiomatous and diabetic, mastopathy

• Intraductal papillomas, Galactoceles

• Traumatic fat necrosis, Subareolar mastopathy, Abscesses

Fibrocystic disease

• 80% of all biopsies

• 87% if all women have some detectable at some time in their life

• Pain may be due to enlarging cysts

• Women retain at least 30 ml of fluid in the week preceding menstruation

• Takes 2 weeks to clear—axilla is the last place to clear (lymphatic drainage)

Breast pain

• Rarely associated with breast cancer <10%

- Seen in large bulky tumors

• Symptomatic treatment

1. decrease/eliminate caffeine

2. No underwire bras

3. Evening Primrose Oil (anti-prostaglandin)

4. OTC pain reliever

5. Stress worsens—pain starts after about 3-4 months. Takes 3-4 months to improve after stressor ceases

Fibroadenomas

• Hormonal response: menarche, during pregnancy and at menopause

• Consider removal:

1. symptomatic ones

2. When over 2 cm

3. In younger patients (teens) since they will grow and incision will be smaller

4. occasional giant juvenile fibroadenomas in teens (>10 cm.)

Breast pain when extreme

• OCP or other hormonal medication may help

• Danazol: acne, wt gain, HA, nausea

• Bromocriptine: increased fertility; nausea, HA, constipation, depression

• Evening Primrose Oil: bloating, vague nausea; increased bleeding

• Tamoxifen: hot flashes, DVTs

• Stress management

Subareolar mastitis

• Looks like cancer due to erythema and nipple retraction.

• May be a mass like effect under erythema

• Almost exclusively seen in smokers

• Antibiotics for a long time and stop smoking

• Consider Vitamin A

• Occasionally surgery

Cysts

• Aspirate if growing rapidly OR > 2 cm

• After aspiration, cyst should not return within 6 weeks—if it does, may need a a biopsy of surrounding tissue

• Do not send cyst fluid to cytology: not cost effective

• 100,000 consecutive samples and only 2 with cancer cells—both in patients with known cancers

Post-Partum Mastitis or Abscess

• Constitutional not feeling well with fever and/or anorexia

• Treatment

1. Anti-Staph drugs; remember baby will get drugs

2. Continue to express milk which acts as irrigation

3. Warm compresses

4. May need general anesthesia to break down loculations and insert drains

Proliferative LCIS and ADH

• LCIS: seldom becomes invasive cancer

- Misnomer

- Indicates increased risk--7x to 12x more likely to develop invasive cancer in either breast; in any quadrant

- estimated to have a 2% annual risk of being diagnosed with invasive breast cancer

• ADH (atypical ductal hyperplasia and atypical lobular hyperplasia)

-Increases risk X4 times higher than average risk

- Cancer can occur in either breast and in any quadrant

- When severe, hard to distinguish from DCIS

Major types of breast cancer

• DCIS: non-invasive which presents as:

- Calcification especially faint ones or those that line up in a line

- Bloody nipple discharge

- Only 30% will recur; one half of recurrences will be invasive cancer

• Invasive: presents as a spiculated mass; architectural deformity

1. Ductal (MC)

- Inflammatory is aggressive form of invasive ductal

2. Lobular: more likely to be multi-focal and bilateral

3. Medullary

Breast cancer risks

• Current age

• Age at menarche (younger)

• Age at first delivery (> 30)

• Race

• Genetic: BRACA, PALB2, ATM, PP53 Duffy-null

• Family history especially 1st degree (mother, sister, child)

• Hormone exposure of breast tissue:

- early menarche, late menopause, obesity, and hormone use

- influence breast cancer risk by increasing cell proliferation, thereby increasing the likelihood of DNA damage + promoting cancer growth

• Research suggests that the time between menarche and first pregnancy may be particularly critical

• Models: Gail, Tyrer Cuzik

About 1/3 of postmenopausal breast cancers are caused by modifiable behavioral factors:

• Postmenopausal obesity

• Physical inactivity

• Use of combined estrogen and progestin menopausal hormones

• Alcohol consumption

• Not breastfeeding

Breast cancer: high relative risk (> 4.0)

• Age greater than > 65 vs < 65 although risk increases across all ages until age 80

• Confirmed atypical hyperplasia

• Certain inherited genetic mutations for breast cancer: BRCA 1 and/or BRCA 2, PALB2, CHK2, Li-Fraumeni, Cowden syndromes

• Lobular carcinoma in situ or ductal carcinoma in situ

• Mammographically dense breasts if above 50% of normal; IRADS C/D

• Personal hx of early onset breast cancer less than 40 year

• 2 or more first-degree relatives with early onset breast cancer

Breast cancer: intermediate relative risk (2.1-4.0)

• Personal history of breast cancer (40+years)

• High endogenous estrogen/testosterone levels (postmenopausal)

• High dose radiation to the chest wall (lymphoma treatment)

• 1 first-degree relative with breast cancer

Gail Model

• In use since 1989

• Weakness: includes only 1st degree relatives (mother, sister, daughter)

• Underestimates risk for those under 40

• Not as accurate for Hispanic population d/t lack of data

• Strength: asks if a breast biopsy was ever done. Includes core biopsy but not FNA, asks about atypical hyperplasia that can double one's risk

Tyrer Cuzick

• Height, weight, BMI

• Previous biopsies

• Any FH of any cancer especially pancreative, colo-rectal GYN

• Includes cousins and half-siblings

• Hormonal use and oophorectomy

• Age at menopause, Ashkenazi Jew

• Newest includes breast density (BIRADS A-D with D the most dense

Genetic testing for breast cancer

• <50 at first diagnosis

• Another first degree relative has a deleterious gene

• Male family member with breast cancer

• Multiple affected family members (at least two)

• FH of related cancers (ovarian and prostate)

• Pt history of multiple primaries

• Ashkenazi Jewish descent

• Pancreatic cancer risk also elevated in this group.

• Important to consider in newly diagnosed breast cancer patient who may benefit from bilateral mastectomies

• New: anyone diagnosed with breast cancer should be offered testing

Breast imaging

• Mammograms

- 3D tomosynthesis better (younger breasts are dense, 2x the radiation vs. routine mammography)

• Ultrasound

- targeted to a specific area

- used with mammogram once mass found

- used in younger pts (< 40 to limit radiation)

• MRI ($$$)

- pts < 65 whose lifetime risk is > 20%

- no radiation, BRCA + who refuse mastectomy

• PET/CT scans (not covered by insurance)

Nipple Drainage

• Clear/bloody

- Green, yellow: smokers or a cyst rupture into duct

- Milky: check prolactin levels or from marijuana

• Spontaneous and not expressed

• MRI recommended by newer radiologists

- papilloma: 20 % are malignant and may identify those at higher risk for cancer similar to atypical ductal hyperplasia

Diffuse papillomas

• Bloody drainage

• Prob DCIS

• Need for mastectomy in non-invasive cancer

Breast cancer diagnosis

• Breast core biopsy: Stereotactic/US guided before surgery to help plan for surgery

- usually leave a clip (1-2 mm) in area sampled

• FNA (Fine Needle Aspiration)

- identifies individual cancer cells

- cannot distinguish invasive from intraductal

- helpful with enlarged axillary node

• Open biopsy: technically cannot do needle bx because close to skin/chest wall or patient anxiety

Breast cancer surgery

• Goals: remove cancer and determine stage

• BCS: aka partial mastectomy/lumpectomy, only cancerous tissue, plus a rim of normal tissue (tumor margin), is removed.

• Simple/total mastectomy includes removal of the entire breast

• Modified radical mastectomy includes removal of the entire breast, plus a full axillary lymph node dissection

• Radical mastectomy: rarely done; includes removal of the underlying chest muscles

Lumpectomy vs mastectomy

• Equivalent survival for the majority of pts with stage I/II breast cancer who have BCS followed by radiation/mastectomy.

• Newer: suggest possible improved survival and reduced recurrence rates with BCS

• Complications is nearly twice as high for women who undergo mastectomy with reconstruction compared to BCS plus radiation

• Mastectomy choice increasing: reluctance to undergo radiation therapy after BCS and fear of recurrence

Lumpectomy (BCS)

• Add sentinel node in invasive cancers

• Radiation mandatory for survival equal to mastectomy

• Not an option in large tumors: multicentric cancers, inflammatory/locally advanced cancers

• Whole breast radiation not recommended for those who had previous breast radiation, severe underlying pulmonary disease and systemic lupus because of the severe skin reactions

Mastectomy with:

• No reconstruction

- mastectomy + sentinel node + no reconstruction

- may need full axillary dissection if node (+)

• Prosthesis

- with reconstruction (sentinel node in invasive cancer)

- expander inserted over pectoralis muscle in mesh sling

- saline added over time

- permanent prosthesis placed

• Tissue reconstruction

- with transabdominal flap from lower abd

- reconstruction with latissimus dorsi flap from around the back

Sentinel Node

• Rationale: prevent lymphedema of the arm

• Use 2 dyes to find most important nodes draining the breast

• Only 1 or 2 nodes positive in stage I tumor

• Problem: with mastectomies, no radiation planned

Prophylactic contralateral mastectomy

• Some women chose to also have the unaffected breast removed

• Greatly reduces risk of developing a new breast cancer

• No long-term cancer survival improvement, risk of surgical complication

Breast cancer staging

• Tumor size is still important

- Stage I up to 2 cm

- Stage II 2-5 cm

- Stage III over 5 cm

- Stage IV spread

• Nodal status

- None/negative

- Micromets (under 2 mm)

- 1-3 positive nodes

- 4-9 positive nodes

- Over 9 positive nodes

**New concerns: ER/PR, Her-2-neu, Oncogene testing

ER/PR

• ER (estrogen receptor) and PR (progesterone) status: Positive or negative.

- negative PR status is a predictor of a poorer outcome

- majority are ER positive and can be manipulated by anti-estrogen therapy

- Cold ischemia time important (lab should receive specimen within 20 minutes for accuracy)

Her-2-neu

• Important to know because of eligibility for neo-adjuvant therapy using trastuzumab and pertuzumab pre-op and then post-op for one year

• Pre-op use for tumors >2.0 cm

• Results: Positive, negative or indeterminate

Indeterminate ones are sent to a national central lab for FISH testing (immunological)