++
You are seeing a 31-year-old G2P1 at 41 weeks of gestation by definite last menstrual period and 16-week ultrasound. She continues to note fetal movement and her examination is normal: BP 120/68 mm Hg, urine dipstick negative for protein and glucose, fundal height 42 cm, fetus is vertex, FHR 156 bpm. Her cervix is soft, anterior, 2 to 3 cm dilated, 50% effaced, and +1 station. She was induced with her first pregnancy, and this time she wants to have a "natural labor." You decide to calculate a Bishop score.
++
++
++
Question 15.3.1 The Bishop score helps to determine:
++
++
++
A) The health of the fetus
++
++
B) The need for cervical ripening agents for induction and helps to predict labor induction success
++
++
C) The maturity of the fetal lungs
++
++
D) The results of a Catholic intramural baseball game
+
++
Answer 15.3.1 The correct answer is "B." The Bishop score, which takes into account cervical dilation, effacement, consistency, and position, as well as fetal station, is a useful tool to determine if cervical ripening agents are needed for induction and to predict induction success. Calculators are readily available online.
++
The Bishop score is favorable at 9–10.
++
++
++
Question 15.3.2 Which of the following are the most appropriate recommendations at this point?
++
++
++
A) She should be induced at once; there is a high chance of fetal mortality after 41 weeks of gestation.
++
++
B) Since her antepartum course has been uncomplicated to date, it is safe for her to await spontaneous labor until 43 weeks of gestation.
++
++
C) She should undergo a nonstress test and ultrasound for amniotic fluid index.
++
++
D) She should plan for a cesarean section.
+
++
Answer 15.3.2 The correct answer is "C." By definition, a term gestation is one completed in 38 to 42 weeks. There is no significant increase in fetal mortality in an uncomplicated pregnancy at term. Virtually all reports suggest an increase in perinatal morbidity and mortality when pregnancy goes beyond 42 weeks of gestation. Antenatal surveillance of post-term pregnancies should be initiated at 41 weeks of gestation.
++
HELPFUL TIP:
Accurate determination of conception is important in reducing the false diagnosis of post-term pregnancy. The estimated date of delivery is most reliably and accurately determined early in pregnancy. Ultrasound may assist in determining dates, but has a standard of error that is dependent on the gestational age (see Table 15-3).
++
++
++
++
Question 15.3.3 At 41 weeks she is really (really, really) tired of being pregnant and wants "a natural way" to induce contractions. Which of the following nonpharmacologic methods of inducing or augmenting labor is LEAST likely to be effective?
++
++
++
A) Stripping the amniotic membranes
++
++
++
++
++
++
+
++
Answer 15.3.3 The correct answer is "B." Stripping membranes appears to be effective in initiating spontaneous labor within 72 hours. Amniotomy may be used for labor induction, especially if the Bishop score is favorable. However, a Cochrane review from 2013 did not find strong evidence supporting the use of amniotomy alone or in combination with oxytocin for induction. Nipple stimulation causes release of oxytocin and may be utilized for labor induction, but its marginal benefit is only seen in patients with a favorable Bishop score. Walking does not result in labor induction or augmentation, but it's not harmful either.
++
HELPFUL TIP:
Sexual intercourse is sometimes recommended to induce labor. Studies are of low quality and use various endpoints … also, it is difficult to standardize the intervention (we could make a joke here but won't). One of the better quality studies (Tan et al., 2006) did find that coitus was associated with reduced need for labor induction at 41 weeks.
++
++
++
Question 15.3.4 If induction becomes necessary, which of the following pharmacologic interventions would be the best approach to your patient who has a cervix that is soft, anterior, 2 to 3 cm dilated, 50% effaced, and+1 station?
++
++
++
++
++
B) Intracervical PGE2 (dinoprostone)
++
++
C) Intravaginal PGE2 (dinoprostone)
++
++
D) Intravaginal PGE1 (misoprostol)
++
++
E) None of the above. All pharmacologic interventions are contraindicated
+
++
Answer 15.3.4 The correct answer is "A." This patient does not need further cervical ripening but is a candidate for induction of labor. If cervical ripening were needed, there are several available agents. Option "D," PGE1 (misoprostol, brand name Cytotec) can be administered intravaginally or orally (but note that the Food and Drug Administration [FDA] has not approved it for use in pregnancy). "B" and "C", PGE2 (dinoprostone, brand name Cervidil) is administered intravaginally. PGE2 gel (dinoprostone, brand name Prepidil) can be administered either intravaginally or intracervically. Because the cervix is favorable in this case, proceeding with oxytocin is the best option.
++
Your patient's husband is called up for active duty in Iraq (or Afghanistan … or Libya or … sadly, we are on the 4th edition of this book and have not needed to change this scenario) and is due to report in the next few days. She is now 41 2/7 weeks of gestation and desires induction so he can be with her for the delivery. You admit her to labor and delivery the following morning. The initial FHR monitoring before induction (also known as a nonstress test) is shown in Figure 15-2.
++
++
++
++
++
++
++
Question 15.3.5 What is the correct interpretation?
++
++
++
A) Baseline 150 beats per minute; not reactive
++
++
B) Baseline 150 beats per minute; reactive
++
++
C) Baseline 180 beats per minute; decelerations to 150s; not reactive
++
++
D) Baseline 180 beats per minute; moderate variability; reactive
+
++
Answer 15.3.5 The correct answer is "B." The baseline is about 150 beats per minute. There are two accelerations greater than 15 beats and lasting longer than 15 seconds, which meets the criteria for a reactive nonstress test. There is one contraction and evidence of uterine irritability noted as well.
++
HELPFUL TIP:
When interpreting FHR tracings, variability is an important element that demonstrates fetal cardiac response to parasympathetic input. The small waveform fluctuations within the baseline heart rate tracing represent the FHR variability. After 28 weeks of gestation, variability should be present. It is categorized as absent (no amplitude, flat tracing), minimal (0–5 beat amplitude), moderate (6–25 beat amplitude), or marked (>25 beat amplitude). The absence of variability is associated with fetal decompensation or distress.
++
You perform amniotomy with return of particulate meconium-stained fluid. Her cervix is now 5 cm dilated, 80% effaced, with vertex at +1 station. You elect to continue monitoring progress.
++
++
++
Question 15.3.6 Which of the following choices of labor analgesia is MOST appropriate at this point?
++
++
++
++
++
B) Local perineal anesthetic infiltration
++
++
C) Bilateral pudendal nerve block
++
++
D) All of the above are equally appropriate
+
++
Answer 15.3.6 The correct answer is "A." Epidural analgesia offers the most effective form of pain relief and generally may be utilized once the patient is determined to be in active labor. Various local anesthetic agents are available for local infiltration of the perineum and vagina to provide analgesia for episiotomy or laceration repair following delivery but not for labor. Bilateral pudendal nerve blocks are useful during the second stage of labor, as a supplement to epidural analgesia for anesthesia of the sacral nerves, or as an option for operative vaginal delivery anesthesia (e.g., forceps, vacuum). Opioid agonists and agonist–antagonists are also available and commonly employed. However, some reports suggest that the analgesic effect of opioids in labor is limited when using the lower doses that are generally regarded as safer for the fetus.
++
The nurse notices some changes on the fetal heart monitor. The current FHR is shown in Figure 15-3.
++
++
++
++
++
++
++
Question 15.3.7 What is the correct interpretation of this FHR tracing?
++
++
++
A) Baseline 160 beats per minute; reactive
++
++
B) Baseline 160 beats per minutes; variable deceleration to the 90s
++
++
C) Baseline 160 beats per minute; late decelerations to the 90s
++
++
D) Baseline 160 beats per minute; early decelerations to the 90s
+
++
Answer 15.3.7 The correct answer is "B." A variable deceleration to the 90s occurs with the first contraction on this strip. Variable decelerations vary with respect to timing, duration, and depth—thus, the name "variable." They are not uniform. Variable decelerations represent changes in the FHR in response to cord compression. Please refer to the Table 15-2 with definitions and FHR tracing categories.
++
HELPFUL TIP:
A systematic review in 2013 showed no benefit in outcomes for continuous FHR monitoring compared to intermittent FHR monitoring. Unfortunately, there are more cesarean sections and operative vaginal deliveries when continuous FHR monitoring is used. However, much of FHR monitoring use is dictated by local practice patterns, expert consensus, and medicolegal concerns.
++
++
++
Question 15.3.8 Given the findings in Figure 15-3, which of the following should be performed next?
++
++
++
A) Check the patient's cervix
++
++
B) Place a fetal scalp electrode
++
++
C) Begin IV oxytocin infusion
++
++
D) Place an intrauterine pressure catheter and begin an amnioinfusion
+
++
Answer 15.3.8 The correct answer is "A." Variable decelerations are common in labor, and brief variable decelerations are benign. When variable decelerations become recurrent, progressively deeper, and longer lasting with delayed return to baseline, they are non-reassuring and may reflect fetal hypoxia. A pelvic examination should be performed to determine if the umbilical cord is prolapsed or if there has been rapid descent of the fetal head or rapid progression of labor. Oxytocin, "C," should not be considered in this patient since she is having adequate contractions. Replacement of the amniotic fluid ("D,'' amnioinfusion) with normal saline infused through a transcervical catheter has been reported to decrease both the frequency and severity of repetitive variable decelerations and can decrease rate of cesarean section. However, it would first be helpful to assess the cervical status. Of note, amnioinfusion is no longer recommended as a prophylactic intervention for moderate or severe meconium.
++
Labor progresses without incident. Your patient is now completely dilated and effaced, with fetal head at +3 station. She is comfortable with her epidural and able to push with good effort. The FHR tracing is reassuring. Contractions are every 3 minutes.
++
++
++
Question 15.3.9 Appropriate management at this point is:
++
++
++
++
++
B) Vacuum-assisted delivery
++
++
C) Forceps-assisted delivery
++
++
++
++
+
++
Answer 15.3.9 The correct answer is "A." At this point, labor is progressing and maternal–fetal status is reassuring. You should continue expectant management. No intervention is indicated.
++
HELPFUL TIP:
Episiotomies should not be performed routinely. Indications for episiotomy are typically related to non-reassuring fetal status and dystocia. There is no evidence that episiotomies reduce perineal trauma, postpartum dyspareunia, etc.
++
She pushes for 3 hours. She is now exhausted. The fetal head now separates the labia with contractions, and then recedes slightly. You consider offering assistance with delivery.
++
++
++
Question 15.3.10 In counseling your patient and her husband about the maternal risks of operative vaginal delivery, which of the following should you discuss?
++
++
++
++
++
++
++
++
++
D) Perineal and rectal trauma
++
++
+
++
Answer 15.3.10 The correct answer is "E." Maternal risks of operative vaginal delivery include injury to the lower genital tract and rectal sphincter involvement in the case of a third- or fourth-degree laceration. In addition, fetal complications need to be discussed as well. Shoulder dystocia is more common with operative delivery than with a spontaneous vaginal delivery (see below for more information).
++
++
++
Question 15.3.11 Each of the following is a fetal risk of operative vaginal delivery EXCEPT:
++
++
++
++
++
++
++
C) Brachial plexus injury
++
++
D) Respiratory distress syndrome
++
++
+
++
Answer 15.3.11 The correct answer is "D." Respiratory distress syndrome is not increased by assisted delivery. Neonatal cephalohematoma, retinal hemorrhage, and jaundice (secondary to breakdown and reabsorption of the cephalohematoma) are more common with vacuum-assisted delivery than with forceps-assisted delivery. Skull fracture and facial nerve injury is more common with forceps-assisted delivery than with vacuum-assisted delivery. Shoulder dystocia with resultant brachial plexus injury is more common with vacuum-assisted delivery, prolonged time required for delivery, and increasing birth weight. Note that injury can occur before operative delivery as a result of abnormal labor forces (we don't think anyone has told the malpractice attorneys …).
++
Delivery of an 8-lb baby is accomplished without operative vaginal assistance. The mere presence of the vacuum on the table was enough to entice the uterus to perform one last massive contraction—assisted by the infant clawing its way out when it saw the vacuum coming. Following spontaneous delivery of the intact placenta 15 minutes later, you note a large gush of blood.
++
++
++
Question 15.3.12 Which of the following is the most likely source of the bleeding?
++
++
++
++
++
++
++
++
++
+
++
Answer 15.3.12 The correct answer is "A." Postpartum hemorrhage is most commonly associated with uterine atony. Risk factors include prolonged labor, over-distended uterus (such as from 2 or 8 gestations [remember Octomom?]), very rapid labor, high parity, chorioamnionitis, retained placental tissue, poorly perfused myometrium, halogenated hydrocarbon anesthesia, and previous uterine atony. Maternal trauma to the genital tract ("B" and "C") may result in postpartum hemorrhage and should be routinely investigated, particularly following operative delivery. A retained placenta cotyledon is another common source for postpartum hemorrhage. The placenta should be inspected, and if there is any question of retained products of conception, the uterus should be manually explored.
++
++
++
Question 15.3.13 Which of the following should be undertaken next?
++
++
++
A) Obtain IV access and initiate hydration
++
++
B) Begin bimanual uterine compression
++
++
C) Inspect vagina and cervix for lacerations
++
++
D) Obtain blood for type and screen for possible blood transfusion
++
++
+
++
Answer 15.3.13 The correct answer is "E." Postpartum hemorrhage is an obstetrical emergency and must be addressed immediately. The gravid uterus receives 500 mL of blood per minute, which can lead to massive hemorrhage if not addressed quickly. Additional personnel should be notified to help with obtaining IV access and blood draws, while you quickly try to identify the source of bleeding.
++
After thorough exploration of the vagina and uterus, you suspect uterine atony is the cause of bleeding. While continuing uterine massage, you think about your options.
++
++
++
Question 15.3.14 Which of the following is/are options in treating this patient's bleeding?
++
++
++
++
++
B) Methylergonovine (Methergine) IM
++
++
C) Carboprost tromethamine (Hemabate) IM
++
++
++
++
+
++
Answer 15.3.14 The correct answer is "E." All of the drugs listed cause smooth muscle contraction of the uterus. Oxytocin can be given as a dilute IV solution or IM. It should never be administered as an undiluted IV bolus, due to the risk of hypotension and cardiac arrhythmia. Methergine (methylergonovine) is an ergot alkaloid and may be administered orally or intramuscularly (not intravenously). Caution should be used in women with hypertension, as Methergine can cause hypertension. Hemabate (carboprost tromethamine) is an F-2 prostaglandin analog that is administered IM or directly into the uterine myometrium. Caution should be used in women with asthma, as Hemabate can cause bronchoconstriction. Misoprostol is a prostaglandin E1 analog, that works well and can safely be administered to women with asthma or hypertension. Rectal or oral administration can be used, but rectal administration is preferred in a patient with potential hemodynamic instability. This can be a lifesaver especially in third world countries where other options may not exist.
++
She requires IV crystalloid and 4 units of packed red cells for symptomatic anemia following delivery. Both mother and infant do well and the patient and baby are discharged on postpartum day 2. You schedule a follow-up appointment in 2 days. You are concerned about Sheehan syndrome given the severe postpartum hemorrhage.
++
++
++
Question 15.3.15 All of the following are characteristic of Sheehan syndrome EXCEPT:
++
++
++
++
++
++
++
C) Desire to be a punk rocker
++
++
D) Decreased LH/follicle-stimulating hormone (FSH)
++
++
E) Adrenal cortical insufficiency
+
++
Answer 15.3.15 The correct answer is "C." Severe intrapartum or postpartum hemorrhage may result in pituitary necrosis due to hypovolemia and hypoperfusion. This leads to a global hypopituitarism known as Sheehan syndrome. Sheehan syndrome is characterized clinically by endocrine deficiency syndromes as a result of loss of anterior pituitary function. Initial symptoms may be vague (lethargy, anorexia, weight loss, difficulty with lactation), and the syndrome can go unrecognized. Later manifestations include failure of lactation, amenorrhea, breast atrophy, loss of pubic and axillary hair, adrenal cortical insufficiency, and hypothyroidism. Desire to be a punk rocker is "Sheena syndrome." If you don't get it, you missed the Ramones.
+++
Objectives: Did you learn to…
++
Recognize the risks of prolonged pregnancy and identify appropriate timing of intervention?
Describe the indications and risks associated with induction of labor?
Interpret intrapartum FHR patterns and choose appropriate management options?
Evaluate analgesia options, contraindications, and risks during labor and delivery?
Recognize the indications for and management of operative vaginal and abdominal delivery?
Evaluate and manage postpartum hemorrhage?