OBGYN - Normal and Abnormal Labor

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=Labor: Normal, Abnormal, and Points Between=
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EnESaL Thanks again for the blog article.Really thank you! Really Cool.
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==Definitions==
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*Labor: regular / rhythmic contractions, cervical dilation and effacement.
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**Labor is considered "preterm" if it commences before 37 weeks EGA (estimated gestational age)
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**10-12% of pregnancies include preterm labor.
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**Labor is considered "postdates" if it commences after 42 weeks EGA.
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*Braxton Hicks contractions are contractions of a weak or irregular nature.
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==Physiology of Labor==
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*There are many factors that play a role in the coordinated contraction of all the uterine smooth muscle for labor.
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*Progesterone and Relaxin are key regulating factors in animals.
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**17alpha-hydroxyprogesterone caproate
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*Gap juctions of the uterine smooth muscle are increased near term.
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**Presumably to augment myofiber-myofiber communication for a well sequenced contraction.
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*Oxytocin, surprisingly, shows '''no change in blood levels'''.
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**Oxytocin receptors, however are elevated.
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**Furthermore, there is '''elevated decidual production'''.
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*Several prostaglandins are elevated for labor: PGE1, PGE2, PGF2alpha
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*Mother becomes more sensitive to changes in Ca at term.
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**This is presumably because the uterine muscle is storing up more and more Ca to augment contraction.
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*Like prostaglandins, many cytokines are elevated: IL-1, IL-6, IL-8, TNF-alpha.
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==Labor and Delivery Admission==
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*The workup for a L&D admission includes:
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**H&P
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**Fetal monitoring
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**Leopold’s maneuver
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**Vaginal exam
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***R/o (rule out) placenta previa and ROM first
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***Cervical dilation / effacement / station and fetal position
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===Fetal Monitoring===
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*There are several technical methods for fetal monitoring.
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*With fetal monitoring we are concerned with the baby's heart rate and the uterine pressure.
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*For baby's heart rate, the baseline should be around 120-160 bpm.
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*We are looking for: variability, accelerations / decelerations
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*For uterine pressure (contractions) we are looking for: frequency, duration, uterine tone.
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====Variability and Accelerations / Decelerations====
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*Variability:
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**Absent: 0-2 bpm
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**Minimal: 3-5 bpm
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**Moderate: 6-25 bpm
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**Marked: saltatory, >25 bpm
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*Fetal Monitoring:
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**Accelerations- “15 x 15”
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*Reactive fetal heart tracing (nonstress test)
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**2 accelerations in 20 minutes or less
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*Contraction stress test (Oxytocin challenge test)
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**3 UC’s x 40 sec in 10 mins
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**Negative = no decelerations
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**Positive = >50% UC’s with late decelerations
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**Equivocal = intermittent or late decelerations or significant variable decelerations
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=====Decelerations=====
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*Early declerations: occur with cntx
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**'''Non worrisome'''
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**Head compression leads to vagal stimulation
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**Recall that vagus carries parasympathetics to the heart
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*Late decelerations: begin at peak of cntx or after
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**Fetal hypoxia is usually the culprit of late decelerations.
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*Variable: can occur at any time
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**Variable decelerations should raise one's suspicion for cord compression
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*Variable Decelerations: mild, moderate, and severe.
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**Lower the blood pressure the more severe.
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**Longer the duration the more severe.
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**'''Severity of variable decelerations are a function of blood pressure and duration'''
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====Sinusoidal====
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===Fetal Lie, Presentation, Attitude, and Position===
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*Clinical: abd palpation, auscultation of fht’s, vaginal exam
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*Studies: u/s, x-ray, MRI
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====Definitions====
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*'''Lie: relation of long axis of fetus to long axis of mother'''
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**Longitudinal
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**Transverse
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**Oblique
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*'''Presentation: part foremost in the pelvis'''
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**Cephalic
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**Breech
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**Shoulder
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**'''Compound:'''
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***Head / hand -> watch
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***Head / foot-> c-section
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*Cord prolapse (funic presentation): an '''emergency'''.
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*'''Attitude: folded on itself w/ flexed head'''
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**extension of head?
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*'''Position: relation of presenting part to maternal pelvis'''
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**Cephalic -> occiput
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**Face -> mentum
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**Breech -> sacrum
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**Transverse -> acromion process
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====Fetal Attitude====
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*There are a variety of ways the fetus can present at the os; these are called attitudes:
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**Full flexion (A)
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**Military attitude (B)
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**Brow presentation (C)
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**Face presentation (D)
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http://www.glowm.com/resources/glowm/graphics/figures/v2/0760/001f.gif
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*Leopold’s Maneuver can be used to determine the attitude of the fetus.
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http://www.sciencephoto.com/image/288555/350wm/M8000133-Leopold_s_Maneuver-SPL.jpg
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====Vaginal Exam====
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*Nullip versus Multip
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*Station:
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*Position:
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*Pelvimetry:
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**Diagonal Conjugate
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**Ischial Spines
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=====Pelvic Inlet=====
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*Diagonal conjugate: >11.5 cm is adequate
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*True obstetric conjugate = diagonal conjugate – 1.5 to 2.0 cm
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=====Midpelvis=====
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*Ischial spines – blunt vs. prominent
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*Pelvic sidewalls
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**Parallel = OK
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**Divergent = good
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**Convergent = bad
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*Sacrum – hallow vs. shallow (flat)
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=====Pelvic Outlet=====
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*Bituberous diameter > 6-8 cm
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*Pubic arch > 90 degrees
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===Stages of Labor===
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*1st Stage: beginning of cervical dilation to complete dilation
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*2nd Stage: complete dilation to delivery of fetus
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*3rd Stage: delivery of placenta (up to 30 minutes)
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*4th Stage: first hour after delivery of placenta
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===Cardinal Movements of Labor====*Engagement
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*Flexion
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*Descent
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*Internal rotation
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*Extension
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*External rotation
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*Expulsion
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===Labor Curve===
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Interpret chart
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===Prolonged / Arrested Labor===
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*'''P'''ower: uterine contractions
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*'''P'''elvis: adequate?
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*'''P'''assenger: EFW, position / attitude
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===Dysfunctional Labor===
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{|border=1
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!Pattern
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!Nullip
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!Multip
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!Rx
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|-
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!Prolonged latent phase
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|>20 hr
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|>14 hr
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|Rest, AROM, Pit
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|-
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!Protracted dilation
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|<1.2 cm/hr
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|<1.5 cm/hr
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|AROM, Pit
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|-
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!Protracted descent
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|<1 cm/hr
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|<2 cm/hr
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|Pit
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!Arrest of dilation
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|>2 hr
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|>2 hr
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|AROM, Pit, C/S
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|-
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!Arrest of descent
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|>2 hr
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|>1 hr
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|Vacuum, forceps, C/S
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|}
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===Cesarean Section===
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*History
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**''Caedere -> caesura'': to cut; ''seco'': to cut.
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**Francois Rousset (1581)
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**Max Sanger (1882)- Leipzig
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*Most common surgical procedure
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**1965 <5%, 1996 - 20.7%, 2004 - 29.1%
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**No change in cerebral palsy rate
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====C-section - Techniques====
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*Uterine Incisions:
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**Low transverse
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**Low verticle
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**Classical
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**Kerr
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====C-section - Indications====
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=====Fetal C-section Indications=====
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*Distress / intolerance of labor
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*Malpresentation (breech, transverse)
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*Twins, multiples
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**Vtx / Vtx = allow to labor
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*Some congenital anomalies
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**NTD
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=====Maternal-Fetal C-section Indications=====
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*Arrest of active labor
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*Failed induction of labor (?)
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*Placenta previa, vasa previa
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*Active HSV outbreak
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*HIV+ (viral load >1000/ml)
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*EFW > 4500 - 5000 gms (increasing risk of shoulder dystocia)
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=====Maternal C-section Indications=====
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*Obstructive tumors (some leiomyomas)
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*Severe condylomata acuminata
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*Cervical cancer
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*Abdominal cerclage
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*Prior c-section
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*Prior vaginal colporrhaphy
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*Vaginal delivery contraindicated medically
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*Pregnant???
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====C-section - Risks====
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*At time of surgery / Immediate post-op
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*Infection: endometritis, wound infection, septic pelvic thrombophlebitis (SPT)
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*Bleeding: transfusion, hysterectomy
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*Damage to fetus
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*Damage to adjacent organs
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*Subsequent pregnancy
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**Uterine rupture
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**Placenta previa -> accreta
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***0 –> 5%
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***1 –> 24%
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***2 –> 48%
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***3 –> 67%
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**Adhesions
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===Operative Vaginal Delivery===
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*Forceps and vacuum
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====Operative Vaginal Delivery - Classification====
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*Outlet: scalp visible at introitus w/out separating labia; no rotation
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*Low: leading point of skull at or below +2 cm station
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**Rotate < 45°
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**Rotate > 45°
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*Mid: above +2 cm station but engaged
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====Operative Vaginal Delivery - Indications====
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*Nonreassuring FHT’s
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*Prolonged 2nd stage of labor
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*Shortened 2nd stage if pushing / Valsalva not indicated
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*Maternal exhaustion
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====Operative Vaginal Delivery - Prerequisites====
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*Cervix completely dilated
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*Ruptured membranes
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*Fetal skull engaged in pelvis
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*Empty bladder
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*Position! Position! Position!
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*Adequate pelvis
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*Adequate anesthesia
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====Operative Vaginal Delivery - Forceps Assisted====
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====Operative Vaginal Delivery - Risks====
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*Maternal:
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**Vaginal / perineal trauma, damage to rectal sphincter
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*Fetal:
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**Cephalohematoma
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**Subgaleal hemorrhage
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**Bony facial trauma
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**Facial nerve injury
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**Intraventricular hemorrhage
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===Birth Trauma===
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*Caput succedaneum:
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**Very common
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**Crosses midline
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*Subgaleal hemorrhage:
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**Rare
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**Hypovolemia and DIC
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===Common Post Partum Problems===
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*PP Hemorrhage: >500cc (>1000cc for c/s):
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**Atony
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**Lacerations (cervix, vagina, perineum)
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**Retained placenta
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**Uterine rupture
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**Uterine inversion
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**Amniotic fluid embolism
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*Endometritis:
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**Fundal tenderness w/ temperature >38°C x 2 or >38.5°C
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**Polymicrobial infection
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**More common after c/s
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***Prolonged ruptured membranes
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***Chorioamnionitis
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====PP / Post-Op Fever====
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*Causes and symptoms
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**Wind (atelectasis, pneumonia)
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**Wound (seroma, necrotizing fasciitis)
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**Water (UTI)
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**Walk (thrmobophlebitis)
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**Wonder drug (drug reaction)
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**Womb (endometriosis)
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**Wean (mastitis, engorgement)
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Current revision as of 17:45, 18 January 2014

EnESaL Thanks again for the blog article.Really thank you! Really Cool.

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