Obstetrics

OB 1
 Pregnancy Adaptation
„ Cardiovascular
„ ↑ HR 10-15 bpm
„ Elevation / left displacement of heart
„ ↑ cardiac output 2° to ↑ stroke volume
„ BP/vascular resistance ↓
„ Respiratory
„ ↑ Respiratory rate „ ↑ Minute ventilation
„ ↑ Tidal volume „ ↓ Residual volume

„ Corresponding
respiratory alkalosis
OB 2
 Pregnancy Adaptation (Cont’d)
„ Labs
„ ↓ Hgb
„ ↑ WBC
„ ↑ Plasma lipids
„ ↑ Alk phos
„ GI
„ ↓ tone throughout tract
„ Predisposes to pyrosis, GE reflux

OB 3
 Weight Gain
„ Average weight gain – 12.5 kg (28 lbs)
„ Fetus, placenta, breast/uterine enlargement,
fluid retention – 9 kg (20 lbs)
„ Maternal fat – 3.5 kg (8 lbs)
„ Institute of Medicine
„ 28-40 lbs for underweight BMI <19.8
„ 25-35 lbs for normal weight BMI 19.9-26.0
„ 15-25 lbs for overweight BMI 26-29
„ <15 lbs for obese BMI >29
OB 4
 Weight Gain (Cont’d)
„ Average 1 pound per week during
2nd/3rd trimester
„ Weight gain <2 lb. or >6.5 lb. / month
warrants review of eating habits, etc.
„ Attaining pre-pregnancy weight by 6
months postpartum less long-term
weight gain
„ ½ loss in first 6 weeks

OB 5
 Nutrition
„ Calories
„ 300 KCal increase for singleton
„ 600 KCal increase for multiple gestation
„ Caloric demand of breast feeding – 750
KCal per day – supplement 500 KCal
„ Folic Acid
„ 400 mcg reduces Neural Tube Defects
„ 4 mg to those at increased risk

OB 6
 Nutrition (Cont’d)
„ Iron
„ Increase 15 mg/day for non-anemic women
„ Readily met by most prenatal vitamins
„ Women with iron deficiency who should receive
therapeutic iron
„ 1st/3rd trimester <11 gm%
„ 2nd trimester <10.4 gm%
„ Other
„ Fish – limit quantity and type (possible
teratogenic)
„ Caffeine – limit <500 mg/day (increase risk of
abortion and still births)
OB 7
 Patient Education
„ Air travel
„ Most airlines allow travel until 4 weeks before the
expected date of delivery
„ Lengthy trips associated with increased risk of DVT
„ Breastfeeding
„ Best feeding method for most infants
„ Contraindications HIV infection, chemical dependency
and use of certain medications
„ Exercise
„ At least 30 minutes of moderate exercise on most days
„ Avoid activities that put them at risk of falls or abdominal
injuries

OB 8
 Patient Education (Cont’d)
„ Hair treatments
„ No evidence of harm but should be avoided in early
pregnancy
„ Hot tubs and saunas
„ Avoid in first trimester

„ Associated with neural tube defects and miscarriage

„ Medications
„ Few have been proven safe
„ Risk/reward assessment
„ Sex
„ Not associated with adverse outcome in absence of
contraindications (placenta previa)
„ Substance abuse: alcohol
„ No known safe amount

OB 9
 Patient Education (Cont’d)
„ Work
„ In uncomplicated pregnancies there is
no greater hazard to continue work until
labor onset
„ Pregnancy Discrimination Act requires
employers to treat pregnancy-related
disabilities like all other medical
disabilities

OB 10
 Immunization in Pregnancy
„ Preconception
„ Rubella (live) Contraindicated during
pregnancy
„ Varicella (live)
„ During pregnancy
„ Hepatitis B
„ Influenza – especially if in 2nd/3rd trimester
during flu season
„ Td

OB 11
 Preconception Care
„ Assess for untreated common conditions
„ Optimize treatment of chronic conditions
„ Assess genetic risk - personal history,
family history, age, ethnicity
„ Offer cystic fibrosis screening
„ Update immunizations - hepatitis B,
varicella, rubella, influenza
„ Consider folate supplementation
OB 12
 Preconception Care (Cont’d)
„ Consider HIV testing
„ Treatment decreases transmission from
25% to 2%
„ Environmental toxins
„ Drugs
„ Chemicals
„ Tobacco
„ Alcohol

OB 13
 Initial Prenatal Evaluation
„ History – helps identify those at
special/increased risk
„ Personal
„ Marital status, support available, financial resources,
religion (Jehovah’s Witness)
„ Past OB
„ Premature birth, Group B affected infant, birth weight,
outcome
„ Personal/family medical history
„ Genetic
„ Trisomy 21, neural tube defect, cystic fibrosis
„ Domestic violence
OB 14
 Initial Prenatal Evaluation
(Cont’d)
„ Physical exam
„ Establish estimated date of confinement
„ Last menstrual cycle – variable reliability
„ Uterine size accuracy 2-4 weeks
„ Fetal heart tones
„ Doppler positive 9-12 weeks
„ Ultrasound – transvaginal or abdominal most
accurate in 1st trimester to +/- 5 days. Error of test
8%
„ 12 weeks x 8% = +/- 1 week
„ 20 weeks x 8% = +/- 1.6 weeks
„ 30 weeks x 8% = +/- 2.4 weeks
OB 15
 Routine Initial Prenatal
Evaluation
„ Routine labs
„ Blood type and antibody screen
„ Rh status
„ Hemoglobin
„ Rubella status
„ Syphilis screen
„ Urinary infection screen (UA/UC)
„ HIV counseling and testing for all
„ Hepatitis B surface antigen
„ Chlamydia screening USPSTF for those <25 yo
„ Pap smear – if not current
OB 16
 “Selected” Prenatal Evaluation
„ Other labs
„ Gonorrhea screen
„ PPD
„ Cystic fibrosis genetic screen
„ Hemoglobinopathy screen (sickle cell, thalassemias)
„ Toxoplasmosis screen
„ Hepatitis C screen
„ Varicella immunity
„ Diabetes screen
„ TSH
„ Other genetic testing including testing of parents first
„ Chlamydia screening for those <25 yr routinely and those at
increased risk

OB 17
 Initial Prenatal Evaluation
(Cont’d)
„ Follow-up labs/testing
„ Diabetes screening (covered later)
„ Sexually transmitted disease – re-screening
– HIV, syphilis, HBsAg, Chlamydia,
Gonorrhea
„ Blood count/antibody screen
„ GBS screening (covered later)

OB 18
 Return Prenatal Visits
„ Standard routine:
„ Every 4 wks to 30 wks
„ Every 2 wks from 30 - 36 wks
„ Every week from 36 weeks until delivery
„ Randomized controlled trials and expert
panels have suggested less frequent is
safe in healthy women
„ 14 vs 9 visits

OB 19
 Return Prenatal Visits (Cont’d)
ƒ Eight standard elements to document:
ƒ Current gestational age
ƒ Uterine size and growth rate
ƒ BP
ƒ Weight
ƒ Symptoms
ƒ Fetal heart tones
ƒ Urine protein and glucose
ƒ Patient questions and concerns

OB 20
 Return Prenatal Visits (Cont’d)
ƒ USPSTF – repeated RH (D) antibody
testing for all unsensitized Rh (D)
negative women at 24-28 weeks’
gestation, unless the biological father is
known to be Rh (D) - negative

OB 21
 Genetic Testing
„ All patients should be offered serum marker screening for neural
tube defects and trisomy 21 and 18
„ Most physicians use maternal serum at 15-20 weeks EGA (ideally
15-18 wk EGA) for hCG, unconjugated estriol, and AFP
„ Inaccurate dating or multiple gestation – most common reason for
abnormal test
„ Elevated AFP: open NTD
„ Sensitivity 85%
„ Low AFP: chromosomal abnormality
„ Sensitivity 65%, specificity 95%

„ Fetal nuchal translucency can be measured by U/S (normal <3.5

mm) and combined with maternal serum analyte levels (free
hCG and pregnancy-associated plasma protein A) at 10-14
weeks EGA (optimal 12-13 weeks)
„ Sensitivity 80-85%
„ Specificity 90-95%

OB 22
 ACOG Recommendations
(2006)
„ All pregnant women regardless of age should be
offered screening for Down’s Syndrome before
20th week of pregnancy
„ Maternal age of 35 should no longer be used as
the primary benchmark to determine who is
offered screening or the option of counseling and
diagnostic testing with amniocentesis or chorionic
villus sampling
„ First trimester screening using nuchal
translucency and maternal analyte levels is more
sensitive than second trimester maternal triple
screen and as sensitive as quadruple screen
„ Integrated first and second trimester screen is
more sensitive with lower false-positive rates than
OB 23 first-trimester-screening alone
 Amniocentesis/CVS
„ Amniocentesis
„ May be performed after 15 weeks EGA
„ Risk of spontaneous abortion 1/200 to 1/1600
(Journal of OB/GYN 11/2006)
„ CVS
„ Performed at 10-12 weeks EGA
„ 1-1.5% chance of spontaneous abortion, and
probably lower
„ Associated with transverse limb defects 1/3000 to
1/1000 fetuses

OB 24
 Group B Strep Screening
„ 8000 cases of infant infection per year in the
U.S. prior to universal screening
„ 20% maternal colonization rate and treatment
for colonization is ineffective
„ Screening – vaginal & rectal culture @ 35-37
wk on ALL
„ Unless – patient has positive GBS bacteriuria
or previous infant with invasive GBS

OB 25
 Intrapartum Prophylaxis -
Recommended
„ Previous infant with invasive GBS
disease
„ GBS bacteriuria during current
pregnancy
„ Positive GBS screening culture during
current pregnancy (unless a planned
cesarean delivery, in the absence of
labor or amniotic membrane rupture, is
performed)
OB 26
 Intrapartum Prophylaxis -
Recommended (Cont’d)
„ Unknown GBS status (culture not done,
incomplete, or results unknown) and any
of the following:
„ Delivery at <37 weeks gestation
„ Amniotic membrane rupture ≥ 18 hrs
„ Intrapartum temperature ≥ 100.4°F
(≥38.0° C)
„ PCN G 5 million units i.v. then 2.5 million
units q 4 hours preferred antibiotic
OB 27
 Group B Strep and PCN
Allergy
„ If patient reports penicillin allergy
„ How severe?
„ Culture and add sensitivity to clindamycin and
erythromycin (15% resistant to either)
„ Intrapartum antibiotics
„ If PCN allergy not anaphylaxis
„ Cefazolin 2g x 1, then 1 g q 8 hr
„ If PCN anaphylaxis
„ Clindamycin (300 mg IV q 6 hrs) is preferred
„ Erythromycin (500 mg IV q 6 hrs) if resistant to
clindamycin – crosses placenta less predictably

OB 28
 Intrapartum Prophylaxis –
NOT Recommended
„ Previous pregnancy with positive GBS
screening culture (unless a culture was
also positive during the current pregnancy)
„ Planned cesarean delivery performed in
the absence of labor or membrane rupture
(regardless of maternal GBS culture
status)
„ Negative vaginal and rectal GBS
screening culture in late gestation during
the current pregnancy, regardless of
intrapartum risk factors
OB 29
 Antepartum Fetal Assessment
„ Fetal movement – “kick counts” (no proven benefit)
„ Contraction stress test (CST) – Fetal heart rate (FHR)
– response to uterine contractions
„ Nonstress test (NST) – FHR response to fetal
movement
„ Biophysical profile (BPP) – NST plus U/S assess of
fetal breathing, fetal movements, fetal tone and
amniotic fluid volume (AFV)
„ Scoring – 2 points per criteria
„ 8-10 normal

„ 6 equivocal

„ 4 or less abnormal

OB 30
 Antepartum Fetal Assessment
(Cont’d)
„ Modified BPP – NST w/ AFI
„ Normal – NST reactive, normal AFV
„ Abnormal – NST non-reactive or
abnormal AFV
„ Umbilical Artery Doppler Velocimetry
„ Testing may be initiated as early as
26 weeks (usually 32-34 weeks) and
repeat q1 week

OB 31
 Normal Labor

OB 32
 Contractions of True Labor
ƒ Occur at regular intervals
ƒ Interval gradually shortens
ƒ Intensity gradually increases
ƒ Adequate to cause cervical dilatation

OB 33
 Admittance Examination
„ Cervical effacement, dilatation, position
„ Station
„ Presentation
„ Detection of ruptured membranes
„ Review of pregnancy record (blood type,
hepatitis status)
„ Confirmation of dates
„ Vital signs
„ Physical examination (look for herpes
lesions)
OB 34
 Management of
First Stage Labor
„ Monitoring fetal well-being (intermittent vs.
electronic continuous monitoring)
„ Assessment of uterine contractions (external vs.
internal monitoring)
„ Amniotomy (routine vs. poor progress)
„ Analgesia
„ IV vs. IM narcotics

„ Intrathecal

„ Epidural

„ Non-pharmacological / Doula

„ Alternative positions (birthing ball, jacuzzi,

OB 35 squatting, walking)
 Active Management of Labor
„ Artificial amniotomy upon detection of painful
uterine contractions with passage of mucous
plug or complete cervical effacement
„ Oxytocin if cervical dilatation does not
progress at least 1 cm per hour
„ More aggressive oxytocin administration
(begin at 6mu/minute, and increase by
6mu/min q 15 minutes up to 40mu/min)
„ Realize that most patients prefer ambulation to
oxytocin
„ Goal: Patient to deliver within twelve hours of
OB 36 the onset of labor
 Management of Second Stage
„ Onset begins with full dilation of cervix until
delivery of infant
„ Highly variable duration
„ Slowing of heart rate during contraction is
common (due to head compression, reduced
placental perfusion or nuchal cord)
„ Recovery of fetal heart rate should be prompt
after contraction and expulsive efforts cease
„ Position changes (upright, side lying)
„ Restrictive use of episiotomy (fetal distress,
shoulder dystocia, vacuum/forceps delivery)
OB 37
 Restricted Use of Episiotomies
„ Episiotomy does not:
„ Lower the risk of incontinence by reducing pelvic floor
damage
„ Reduce the rate and severity of perineal lacerations
„ ACOG (2006) stated that there is not enough
evidence-based criteria to recommend “evidence-
based criteria to recommend episiotomy”; “clinical
judgment remains the best guide for use…”
„ Perform 30% of all vaginal deliveries
„ Restricted use is preferable to routine use
„ Median episiotomy is associated with higher rates of
injury to anal sphincter and rectum than mediolateral
approach
„ Median approach
„ Easy to perform and repair
„ Less postpartum pain and dyspareunia
OB 38
 Spontaneous Delivery
„ Delivery of head (controlled)
„ Delivery of shoulders (gentle downward
traction applied until anterior shoulder
appears under pubic arch)
„ Optional: Delivery of anterior arm to
prevent tears
„ Delivery of rest of body

OB 39
 Management of the
Third Stage
„ Onset after infant delivers until
placenta delivery
„ Average duration 5 minutes
„ 95% placenta delivered by 30
minutes
„ Retained placenta for >30 min
commonly used
„ WHO - 60 minutes

OB 40
 Management of the
Third Stage (Cont’d)
„ Management
„ Expectant - no use of uterotonic agents, cord
clamping, or cord traction
„ Active – use of uterotonic agents (Pitocin), cord
clamping or cord traction
„ As compared to expectant
„ Ð Blood loss 80ml
„ Ð Postpartum hemorrhage (>500 ml) RR=0.4
„ Ð Prolonged 3rd stage by 10 minutes
„ Postpartum hemorrhage defined as
„ Ð hct >10%, Ð hemoglobin by 3 gm/dl
„ Need of blood transfusion
OB 41
 “Fourth Stage” of Labor
„ Examination of placenta (intact), membranes
and umbilical cord (3 vessels)
„ Uterine massage; early breast feeding;
oxytocin
„ Observe for signs of postpartum hemorrhage
„ Examination of vagina and perineum for
lacerations

OB 42
 Preterm Complications

OB 43
 Definitions
„ Preterm Labor (PTL)
„ Uterine contractions (>3/30 min)
„ Accompanied by cervical change (effacement
or dilation)
„ Prior to 37 completed weeks gestation
„ Premature ROM (PROM)
„ Rupture of membranes prior to the onset of labor
by ≥ 1 hour, also known as Prelabor Rupture of
Membranes
„ Preterm PROM
„ PROM and < 37 weeks
OB 44
 Pre-Term Labor Risk Factors
– Not Sensitive or Specific for PTL
„ Prior preterm birth „ Preterm PROM (15-
„ Maternal age 30% recurrence)
<14 >40 „ Uterine distention
„ Low socioeconomic status (twins, polyhydramnios)
„ Race African American „ Maternal infections
„ Bacteriuria
„ Known uterine and
„ Pyelonephritis
placental anomalies
„ Genital tract
„ Trauma „ Pneumonia

OB 45
 PTL/PROM History
„ “Labor History”
„ Fluid leakage - (felt pop or gush)
„ Pregnancy dating
„ Risk factor review (infection, trauma,
etc.)
„ Maternal medical/obstetrical problems
„ Assess social and home support

OB 46
 PTL/PROM - Diagnosis
„ General exam (look for signs of trauma
or infection)
„ Abdominal exam (uterine tenderness,
size, Leopold’s)
„ External fetal monitor (fetal heart rate,
periodic changes, contraction pattern)
„ Labs
„ CBC
„ UA/UC
OB 47
 PTL/PROM - Diagnosis
(Cont’d)
„ No digital exam if suspected preterm ROM
„ Speculum exam
„ Vaginal swab for fetal fibronectin (fFN)
„ Cervical dilation
„ Pooling of fluid
„ Cultures – GC, Chlamydia
„ Consider wet mount for bacterial vaginosis/trichomonas
„ Nitrazine pH >7
„ False positive – blood, seminal fluid, proteus infection of

urine
„ Otherwise very sensitive/specific test

„ Ferning
„ False positives cervical mucus, saline

OB 48 „ Very sensitive/specific
 PTL/PROM - Diagnosis
(Cont’d)
„ GBS testing
„ Ultrasound assessment for:
„ Gestational age
„ Cervical change
„ Fluid volume
„ Amniotic fluid for fetal lung maturity
„ With PROM, may be obtained from vaginal
pool

OB 49
 Fibronectin
„ Negative fibronectin test (>24 weeks
gestation) useful to rule out preterm delivery
in next 2 weeks
„ Most useful when combined with results of
U/S (substantial ↑ risk of preterm birth if
positive fibronectin and cervical length <
25mm)
„ Lubricants and manipulation of cervix within
24 hours causes false-positive reaction
(coitus, cervical examination)

OB 50
 Inhibition of Pre-Term Labor
„ Goals
„ Delay delivery until steroids can be administered
„ Allow safe transport of mother, if indicated, to perinatal
center
„ Prolong labor while associated and contributing illnesses
treated (trauma, pyelonephritis)
„ Criteria
„ Presence of preterm labor; not just contractions
„ EGA < 34 weeks
„ Threshold where risk/benefits are acceptable

„ Absence of contraindications
„ Fetal demise or lethal anomaly

„ Severe IUGR

„ Severe preeclampsia/eclampsia

OB 51
 Inhibition of Pre-Term Labor
(Cont’d)
„ Bedrest, Hydration, Sedation
„ Doubtful efficacy
„ No randomized studies in singleton pregnancies
„ Beta-Adrenergic Agonists
„ Ritodrine – effective but no longer manufactured
„ Terbutaline
„ Effective
„ Commonly given s.q. 0.25 mg every 20-30 min up
to 4 doses then q 4 hours prn for 24 hours
„ Side effects
„ Maternal – chest pain, SOB, palpitations, tremor,
pulmonary edema, hypokalemia, hyperglycemia
„ Fetal – tachycardia and neonatal hypoglycemia (2° to
OB 52 maternal hyperglycemia)
 Inhibition of Pre-Term Labor
(Cont’d)
„ Magnesium Sulfate
„ No more effective than placebo
„ Dose 4-6 gm i.v. bolus over 20 minutes followed by
infusion of 2-4 gms/hr to therapeutic level of 4-8 mEq/L
„ Side effects
„ Maternal – decreased BP, nausea, flushing, headache
„ Toxicity
„ Loss of deep tendon reflexes 8-10 mEq/L

„ Respiratory paralysis 10-15 mEq/L

„ Cardiac arrest 20-25 mEq/L

„ Calcium Channel Blockers

„ Possibly effective
„ Nifedipine (immediate release)
„ 30 mg p.o. then 20 mg p.o. 90 min later OR
OB 53 „ 10 mg p.o. q 20 min max of 4 doses then 20 mg q 4-8 hours
 Inhibition of Pre-Term Labor
(Cont’d)
„ Indomethacin
„ Possibly effective
„ Premature closure of ductus arteriosus and
oligohydramnios are potential side effects and
fetal ultrasound evaluation if > 48 hours of
treatment needed
„ 50-100 mg p.o./pr. Load then 25 mg q 4-6 hours
„ Antibiotics
„ Not effective in PTL without membrane rupture
„ Should be used as part of prevention of early-onset GBS
infection
OB 54
 Pre-Term Labor Management
„ NIH consensus statement: steroids are highly
effective in preventing Respiratory Distress
Syndrome, intraventricular hemorrhage and neonatal
mortality – effective within 18 hours, maximal benefit
at 48 hours
„ Criteria:
„ Fetus at 24-34 weeks gestation
„ No fetal or maternal contraindication to delaying
delivery for 24-48 hrs
„ No maternal contraindications to steroid administration
(i.e., active TB)
„ Drug Regimens:
„ Betamethasone 12mg IM q 24h x2
OB 55 „ Dexamethasone 6 mg IM q 12h x4
 Pre-Term PROM Management
„ Hospitalized vs. home management
„ Initially hospitalize all patients for 3 days
„ Suggested criteria for home management
„ Reliable patient, dependable transportation
to nearby hospital
„ Vertex
„ No evidence of infection or labor
„ Adequate amniotic fluid
„ Weekly ultrasound
„ Maternal temp b.i.d.
OB 56
 Pre-Term PROM Management
(Cont’d)
„ Inhibition of labor if present
„ Same guidelines as PTL but more
controversial 2° to higher risk of infectious
etiology in preterm PROM
„ Only until 32 weeks given unfavorable
risk/benefit assessment after 32 weeks
„ Steroid use
„ To week 32 gestation
„ Single course

OB 57
 Pre-Term PROM Management
(Cont’d)
„ Antibiotics
„ Prophylactic antibiotics – prolong latent period
between PROM and labor
„ Multiple regimens – examples
„ Ampicillin
„ Ampicillin plus erythromycin or azithromycin
„ i.v. initially then p.o. course for 7 days
„ GBS prophylaxis during labor if indicated
„ Delivery
„ Expectant until 32 weeks EGA
„ Allow delivery when fetal lung maturity and EGA
OB 58
>32 weeks
 Term PROM Management
„ Expectant management vs. induction?
„ Oxytocin in patients with PROM may
decrease infection rates without
increasing C-section rates
„ Induction of labor should proceed at first
sign of infection
„ If unfavorable cervix - may use
prostaglandins followed by oxytocin if
necessary
OB 59
 Post-Term Pregnancy
„ Defined as a pregnancy that has extended to or
beyond 42 weeks of gestation
„ Incidence of 7%
„ True post-term infants 3%
„ Incorrect dating common
„ Stillbirth rate 1/3,000 at 37 weeks EGA; 3/3,000 at 42
weeks EGA and 6/3,000 at 43 weeks EGA
„ Associated with oligohydramnios, dystocia,
macrosomia, severe perineal injury and doubling the
rate of cesarean delivery
„ No interventions known to decrease rate
„ Nipple stimulation
„ Membrane sweeping

OB 60
 Post-term Pregnancy (Cont’d)
„ Antenatal Surveillance
„ Common, universally accepted practice but no
evidence of decreased perinatal mortality
„ Commonly started at 41 weeks and done twice
weekly (BPP, NST, AFI, modified BPP)
„ Labor induction
„ Many recommend prompt delivery with a favorable
cervix
„ Those with unfavorable cervix can either undergo
labor induction or expectant management unless
evidence of fetal compromise or oligohydramnios

OB 61
 Labor

OB 62
 Normal Labor
„ Contractions of sufficient frequency,
intensity and duration that result in
cervical effacement and dilation

OB 63
 Stages of Labor
First Stage:
Latent phase: ≤ 4cm
Contractions are mild,
infrequent, irregular, slow
cervical change

Active phase: > 4 cm

Contractions strong,
frequent, regular, increase
rate of cervical change

Second Stage: Complete

Pushing → delivery

Third Stage: Placenta

OB 64
 Stages of Labor (Cont’d)

OB 65
 Dystocia - Difficult Labor
„ Protraction Disorders - slower than usual progress
„ Arrest Disorders - complete cessation of progress

Abnormal Labor Patterns & Diagnostic Criteria

Labor Pattern Nulligravida Multipara
Protraction disorders
Dilation <1.2 cm/h <1.5 cm/h
Descent <1.0 cm/h <2.0 cm/h
Arrest Disorders
Dilation >2h >2h
Descent >1h >1h

OB 66
 Dystocia (Cont’d)
„ Extrinsic Factors - EFM, epidurals, lack of social
support
„ Restrictive postures
Assessment
Power Passenger Passageway
Contractility <200 Macrosomia Contracted Pelvis
Montevideo Units
Fetal Anomaly Clinical Pelvimetry
<3-5
Contractions/10 Malpresentation
minutes

OB 67
 Dystocia Management
„ Inefficient Uterine Contractions:
„ Ambulate
„ Change positions
„ Amniotomy
„ Oxytocin
„ Allow more time: 4 hours for dilation, 2
hours for descent, longer for regional
anesthesia

OB 68
 Dystocia (Cont’d)
Oxytocin Complications Treatment
Hyperstimulation Decrease rate/dose
Fetal Distress Stop infusion
Terbutaline 0.125-0.25
Mg Sulfate 2-6 grams

Uterine Rupture Emergent c/s

Fetal Distress Maternal O2
Change position
Cervical check
Fluid Stop infusion
retention/overload

OB 69
 First Trimester Complications

OB 70
 Spontaneous Abortion
ƒ Types
ƒ Missed – no bleeding, closed os, embryo/fetus died
ƒ Threatened – bleeding, closed os
ƒ Inevitable – bleeding, os open
ƒ Incomplete – tissue still present
ƒ Pathophysiology / Etiology
ƒ Chromosomal anomalies – most common (50%)
ƒ Maternal factors
ƒ Environmental factors
ƒ Immunological factors
OB 71 ƒ Uterine defects
 Clinical Picture
„ Vaginal bleeding (most common)
„ Cramping, backache
„ Passage of tissue
„ Quantitative HCG doubles every 48
hours until 6 wks in a healthy pregnancy

OB 72
 Diagnosis
„ Abdominal exam (pain, tenderness,
distention)
„ Bimanual exam (uterine size, adnexal
masses)
„ Speculum exam
„ Ultrasound / HCG
„ Rule out ectopic and abnormal
pregnancy by vaginal ultrasound

OB 73
 Management
„ Hemodynamically unstable = D&C
„ Hemodynamically stable
„ Follow up
„ Tissue passed/exam by pathology
„ Consider U/S follow up to confirm empty uterus
„ If no tissue, follow serial HCGs to <5
„ Give Rhogam (50 mcg) if mother Rh negative
„ Grief counseling
„ Follow-up appt - 2 weeks

OB 74
 Ectopic Pregnancy
„ Risk Factors
„ Prior tubal surgery, prior PID, prior ectopic,
DES exposure, smoking, assisted
reproduction, contraception with progestin
only or IUD
„ Presentation
„ Amenorrhea, positive pregnancy test
„ Bleeding, abdominal pain
„ Heterotopic pregnancy - combined
intrauterine and extrauterine pregnancy;
rare but possible especially in fertility
OB 75 treatment - IFV
 Diagnosis (Ectopic)
„ Abdominal exam Æ tenderness
„ Pelvic exam Æ adnexal mass, cervical
motion tenderness, enlarged uterus,
bulging cul-de-sac
„ Vital signs may be hypotensive,
tachycardic

OB 76
 Diagnosis (Ectopic)
(Cont’d)
„ Labs
„ HCG (not doubling)
„ CBC
„ Serum progesterone (>25 excludes ectopic, <5
suggests nonviable, 5-25 grey zone)
„ Radiology
„ U/S to look for IUP
„ Transvaginal ultrasound may be more helpful
„ When hCG >1500 visualization of an intrauterine
pregnancy should be seen to exclude ectopic
pregnancy
OB 77
 Management
„ Expectant (HCG <1000 and falling, mass <3
cm, ØFHT)
„ Medical (methotrexate)
„ Patient very reliable, no medical contraindication
(nl LFTs), ectopic mass <4cm, ØFHT, HCGs
<5000
„ Surgical
„ Unstable patient, unreliable f/u, uncertain dx, high
HCG, large mass

OB 78
 Gestational Trophoblastic
Disease
„ 1 in 1000-1500 pregnancies
„ Risks
„ Previous disease
„ At extremes of reproductive age
„ Clinical Presentations
„ Vaginal bleeding
„ High HCG levels
„ Uterus size > dates
„ Absence of FHT
„ Presence of PIH < 20 weeks, hyperemesis,
thyrotoxicosis
OB 79
 Hydatidiform Mole
„ Diagnosis
„ Ultrasound
„ Treatment
„ Uterine evacuation
„ Follow-up: serial HCGs, 6-12 months

OB 80
 Hyperemesis Gravidarum
„ Severe end of spectrum of morning sickness
variably defined but generally reserved for
persistent vomiting, weight loss > 5% and ketonuria
„ Morning sickness
„ 50-90% of all pregnancies
„ Onset EGA 5-6 weeks, peak 10 weeks, usually
resolves by 16-18 weeks but may persist to term 10-
15%
„ Lab test abnormalities
„ Decreased TSH – may be 2° to higher HCG that have
TSH-like activities
„ Rarely associated hyperthyroidism symptoms and
elevated Free T4 and Free T3
OB 81 „ ALT elevation common with severe emesis
 Hyperemesis Gravidarum
(Cont’d)
„ Etiology – undetermined
„ Treatment
„ Avoidance of “emetogenic triggers” if possible -
odors, heat, foods, etc.
„ Small frequent meals
„ P6 acupuncture, acupressure wrist bands,
powdered ginger, psychotherapy of questionable
benefit
„ Hydration and adequate nutrition
„ May need PICC line for hyperalimentation
„ No FDA approved drugs
„ Pyridoxine (Vitamin B6) 10-25 mg tid
OB 82
 Hyperemesis Gravidarum
(Cont’d)
„ Doxylamine 12.5 mg tid
„ With Vitamin B6 is the same as Bendectin

which was removed in 1983 but data

support its safety and efficacy
„ Antiemetics (examples)
„ Promethazine (Phenergan)

„ Metoclopramide (Reglan)

„ Prochlorperazine (Compazine)

„ 5 – HT3 antagonist

„ Kytril
„ Zofran
OB 83
 Third Trimester Complications

OB 84
 Causes of 3rd Trimester
Bleeding
„ Major „ Minor
„ Placenta Previa „ Bloody show
„ Abruption „ Cervical polyps
„ Ruptured Vasa Previa „ Cervical cancer
„ Uterine rupture/ „ Cervical ectropion
laceration „ Vaginal trauma

OB 85
 Placenta Previa
„ Definition
„ Placenta located over or near cervical os

„ Presentation
„ Painless vaginal bleeding (“sentinel bleed”)

„ 1/3 will bleed before 3rd trimester

„ Etiology - unknown
„ Higher risk if prior C-section or D&C

„ Possible myometrium / endometrium distortion

OB 86
 Placenta Previa (Cont’d)
„ Risk factors
„ Advanced maternal age
„ Multiparity
„ Prior C-section or D&C
„ Smoking
„ Prior previa
„ 90% of placenta previa diagnosed prior to
24 weeks resolve

OB 87
 Placenta Previa (Cont’d)
„ Evaluation
„ Assess vitals, fundal height, lie, FHTs
„ Gentle speculum exam - controversial
„ No digital exam w/o placental location known
„ Labs - hematocrit, type and Rh, coag.
studies
„ Ultrasound can confirm diagnosis
„ Most previas become symptomatic >35
weeks
„ Treatment – usually cesarean section
OB 88
 Placental Abruption
„ Definition
„ Separation of placenta from implantation site
„ Presentation
„ Bleeding - 70-80% (20-30% can present w/o
bleeding)
„ Uterine tenderness / back pain - 66%
„ Uterine hypertonicity - 17%
„ Demise - 25-35%
„ DIC 13%
„ Etiology - Multifactorial
„ External trauma, cocaine, smoking, HTN, preterm
OB 89
rupture, acute decompression of amniotic fluid
 Placental Abruption (Cont’d)
„ Risk Factors
„ Prior abruption
„ Increased age and parity
„ Preeclampsia
„ Chronic HTN
„ Preterm ROM
„ Cigarette smoking
„ Thrombophilias (factor V leiden, protein C/S,
AT III, anti-phospholipid, lupus anticoagulant)
„ Cocaine use
„ Uterine leiomyoma
OB 90
 Placental Abruption (Cont’d)
„ Management
„ First assess maternal hemodynamics - pulse,
BP, shock
„ Assess fetal viability (>50% mort. w/
detachment)
„ Assess fundal height, fetal lie, location of
tenderness, tetanic ctx’s
„ Fluid resuscitation, transfusion
„ Watch for DIC (10% of all abruptions, 30% if
dead fetus)
„ Note: This is a clinical diagnosis, not an
ultrasound diagnosis
OB 91
 Placental Abruption (Cont’d)
„ Assess fetal viability:
„ Fetal demise:
„ Deliver fetus (vaginally if stable, C-

section if malpresentation or unstable)

„ Prepare to transfuse

„ Live fetus:
„ Rigid uterus – C-section

„ Soft uterus – induction of labor

OB 92
 Vasa Previa
„ Umbilical vessels traverse membranes and
pass by cervical os
„ Risk of laceration of vessels with ROM
„ Fetal mortality 50-75%
„ Immediate C-section
„ Resuscitation of mom and baby
„ Antepartum diagnosis (difficult)
„ US with doppler
„ Palpation of vessels on vaginal exam
„ Amnioscopy

OB 93
 Oligohydramnios at Term
„ Defined as amniotic fluid index (AFI) <5 cm
„ Occurs in 1-5% of pregnancies
„ Associated with adverse outcomes when
accompanies by IUGR, malformations, etc.
„ Amniotic fluid primarily produced through fetal urine
production and fetal lungs and resorbed by fetal
swallowing and the placenta; can be affected by
maternal hydration

OB 94
 Oligohydramnios at Term (Cont’d)
„ Etiology
„ Acute – rupture of membranes
„ Chronic
„ Fetal urogenital abnormalities

„ Uteroplacental insufficiencies (decreases fetal renal

perfusion)
„ Management once AFI <5 cm
„ Evaluate for PROM
„ Determine presence of risk factors (HTN, IUGR by
history and fetal ultrasound)
„ If abnormalities present – induce labor
„ Initiate maternal hydration 2 L oral water and recheck
AFI in 2-6 hours
„ <5 cm – induce labor
„ 5-8 cm – measure AFI in 3-4 days
OB 95 „ >8 cm BPP 1-2/wk
 Vaginal Birth after Cesarean
Delivery (VBAC)
„ Advantages - lower rates of
„ Postpartum fever
„ Wound infection
„ Maternal discomfort
„ Length of hospital stay
„ Blood transfusion +/-
„ Neonatal respiratory problems
„ Disadvantages
„ Uterine rupture - increased risk of symptomatic rupture of 2.7
per 1000 as compared to elective repeat cesarean delivery
(ERCD)

OB 96
 Vaginal Birth after Cesarean
Delivery (VBAC) (Cont’d)
Disadvantages cont’d
„ Risk factor of uterine rupture
„ There is no difference in asymptomatic uterine rupture rates in trial
of labor vs elective repeat cesarean
„ Uterine scar
„ Classical 4-9%

„ Low vertical 1-7%

„ Low transverse 0.2-1%

„ Prostaglandin induction

„ Clinical presentation
„ Vaginal bleeding

„ Maternal shock

„ Fetal brachycardia, variables, late decelerations

„ Abdominal pain

„ Loss of station

OB 97
 Vaginal Birth after Cesarean
Delivery (VBAC) (Cont’d)
Disadvantages cont’d
„ Perinatal death
„ Probably increased

„ Similar to nulliparous without planned Cesarean delivery

(10 per 10,000 vs ERCD 0.4 per 10,000)

„ Candidates for VBAC
„ No other uterine scar except low transverse cesarean
„ Physician “immediately” available who can perform
emergent cesarean
„ Anesthesia within 30 minutes
„ Success rate - 75%

OB 98
 Vaginal Birth after Cesarean
Delivery (VBAC) (Cont’d)
„ Labor management
„ Augmentation or labor induction - acceptable but avoid
misoprostol
„ Epidural anesthesia safe
„ Recommend continuous electronic fetal heart rate
monitoring

OB 99
 Medical Complications of
Pregnancy

OB 100
 Pneumonias
Bacterial See ID section-
Strep pneumo Antibiotics
Atypical Macrolide
Mycoplasma
Influenza A Vaccine See ID section-
Antivirals
Varicella IV Acyclovir
Aspiration Nonparticulate Antacids
Broad Spectrum Antibiotic
Tuberculosis All pregnant women @ high risk
should be screened with PPD
Risks:
HIV Close contact
Low income Alcoholism
IV drug use Medically underserved
OB 101 Birth in an epidemic country
 Gestational Diabetes
„ First occurs during pregnancy
„ 10% of the time it can represent latent Type I DM
„ Lean women
„ DKA during pregnancy
„ Requires larger doses of insulin
„ Anti-insulin/anti-islet cell antibody positive
„ Associated with (especially when worsening control)
„ Preeclampsia
„ Polyhydramnios
„ Fetal macrosomia
„ Birth trauma
„ Neonatal metabolic complications (Èglucose, Çbilirubin,
Ècalcium, Çhct)
„ Prenatal mortality
OB 102
 Gestational Diabetes (Cont’d)
„ Screening
„ Selective screening - recommended by ADA and ACOG
„ Must meet all of the following criteria

„ <25 years of age

„ Not member of racial or ethnic group with higher risk (Hispanic,
Native American, African)
„ BMI <25
„ No history of previous abnormal testing
„ No previous adverse OB outcomes often associated with GDM
„ No FMH of first-degree relatives with DM
„ Universal - screen all

OB 103
 Gestational Diabetes (Cont’d)
„ Screening
„ 24-28 week EGA
„ 1 hr 50 gm oral glucose challenge
„ Results
„ >130
„ 90% sensitive
„ 20-25% of women are positive
„ >140
„ 80% sensitive
„ 15-20% of women are positive
„ Confirm abnormal 1 hr test with 3 hr (some do 2 hr)

OB 104
 Gestational Diabetes (Cont’d)
Glucose Tolerance Test
Time Serum Glucose Threshold
Fasting 95
1 hr 180
2 hr 155
3 hr 140

2 or more abnormal tests required for GDM

OB 105
 Gestational Diabetes (Cont’d)
„ Treatment
„ Diet - may not prevent macrosomia by itself
„ Caloric allotment

30 KCal/kg/d 80-120% IBW

24 KCal/kg/d 120-150% IBW
12-15 KCal/kg/d >150% IBW
„ Carbohydrate

40% carbohydrates
20% protein
40% fat
„ Calorie distribution

„ 3 meals, 3 snacks
„ Limit carbohydrates in AM

OB 106
 Gestational Diabetes (Cont’d)
Treatment cont’d
„ Glucose monitoring - blood monitoring
FBS <90 (normal fasting 55-60 mg/dl)
1º postprandial <120 (normally never >105 mg/dl)
„ Insulin
„ ADA/ACOG

FBS<95 and 2º hr BS <120

„ Others

FBS<90 and 1º hr BS <120

„ Exercise encouraged
„ Oral hypoglycemic agents
„ Glyburide

„ Metformin

OB 107
 Gestational Diabetes (Cont’d)
„ Fetal surveillance/delivery
„ None needed if good control and not on insulin
„ Otherwise monitor in third trimester
„ Delivery at 39-40 weeks if no complications
„ Consider cesarean if estimated fetal weight >4.5 kg by
U.S.
„ Future risk
„ Up to 50% recurrence with subsequent pregnancy
„ Up to 50% occurrence of Type 2 DM over the next 5
years

OB 108
 Infections During Pregnancy -
Varicella
„ Pneumonia and Encephalitis in adults
„ Transmitted across placenta
„ Congenital varicella syndrome - skin scarring, limb
defects, microcephaly – limited to exposure < 20
weeks pregnant 1-3% risk of occurrence
„ Neonatal VZV infection - peripartum exposure 5 days
prior to and up to 2 days after delivery; 10-20% death
rate
„ If seronegative and exposed then VZIG
„ If pregnant + develop chicken pox then acyclovir
„ Nonpregnant women without H/O varicella infection
should be offered vaccine
OB 109
„ Pregnant women should not be offered the vaccine
 Herpes Simplex (HSV-2)
„ Neonatal: 50% mortality with primary infection.
„ Management: ACOG Recommendations
„ Women with primary HSV during pregnancy should be
treated with antiviral therapy
„ Cesarean delivery should be performed on women with
first-episode HSV who have active genital lesions at
delivery
„ For women at or beyond 36 weeks of gestation with a
first episode of HSV occurring during the current
pregnancy, antiviral therapy should be considered
„ Cesarean delivery should be performed on women with
recurrent HSV infection who have active genital lesions
OB 110
or prodromal symptoms at delivery
 Thyroid Disease
„ Hyperthyroidism
„ Most common - Graves
„ Propylthiouracil - drug of choice in pregnancy
„ Beta-blockers diminish symptoms
„ Can be associated with trophoblastic disease
„ Avoid radioiodine scanning - crosses the placenta

OB 111
 Thyroid Disease (Cont’d)
„ Hypothyroidism
„ Associated with low birth weight, fetal loss,
gestational HTN and poor perinatal outcome
„ Current consensus to check TSH; free T4 q 6-8
weeks during pregnancy; maintain TSH 0.5-2 µ
units/ml
„ Requirements increase early in pregnancy
therefore increasing trend to increase dose 25-50
mcg daily and check TSH/free T4 in 4-6 weeks as
soon as pregnancy diagnosis
„ Routine screening of TSH debated; incidence of
TSH > 6 µ units/ml = 2.5% with 10% being overtly
hypothyroid

OB 112
 Pre-existent HTN
„ Onset before EGA of 20 weeks
„ Risks associated with
„ Premature birth
„ IUGR
„ Fetal death
„ Abruption
„ Preeclampsia
„ Indications for treatment
„ DBP >100 or SBP >150-160
„ Neither mother or fetus at risk if below these values

„ DBP 100-110 or SBP 150-180

„ Benefits controversial

„ DBP >110 or SBP >180

„ Benefits - maternal

OB 113
 Pre-existent HTN (Cont’d)
„ Drugs
„ Methyldopa and hydralazine - drugs of choice
„ B-blockers (except atenolol)
„ Thiazide diuretics (not new starts)
„ Labetolol
„ Nifedipine - long acting
„ Fetal surveillance
„ For preeclampsia
„ For IUGR by U.S. 16-20 wk, 28-32 wk and then
monthly
„ Delivery
„ At term with uncomplicated cases
OB 114
 Hypertensive Disease in
Pregnancy (Cont’d)
„ Preeclampsia
„ HTN >140/90 and proteinuria >0.3 gm/24hr and
onset after 20 wk EGA
„ BP control
„ DBP >110, SBP >160-180
„ Same drugs as previous
„ Delivery
„ Conservative if mild and remote from term
„ HTN controlled and not severe (DBP >110)
„ Normal renal, hepatic, hematologic function
„ No coagulopathy
„ Fetal evaluation - reassuring

OB 115
 Hypertensive Disease in
Pregnancy (Cont’d)
„ Immediate delivery if
„ Severe preeclampsia
„ HTN >160/110
„ Proteinuria >5 gm/d
„ ÇLFT, ÇCREAT
„ CNS disturbances
„ RUQ pain
„ Seizure prophylaxis for labor
„ MgSO4
„ 4 gm load

„ 2-3 gm/hr I.V. infusion

„ Mg level therapeutic 4-8 mEq/L

OB 116
 Hypertensive Disease in
Pregnancy (Cont’d)

„ Eclampsia -
„ Presence of seizure usually tonic - clonic
„ Immediate delivery usually warranted
„ HTN control and seizure prophylaxis - as above

OB 117
 HELLP
Hemolysis, Elevated Liver Enzymes, Low Platelets

„ Lab:
„ Hemolysis on smear
„ ↑ Bili >1.2
„ ALT, AST >2 times upper limit of normal
„ Platelets <100,000
„ Fluids, antihypertensive, antiseizure meds,
coag factors
„ Assess baby
„ Delivery plan

OB 118
 Acute Fatty Liver
„ Risks: Primip, multiple gestation, 3rd
trimester, PIH
„ Clinical: Malaise, HA, N/V, abdominal
pain
„ Progresses - jaundice, petechiae, coma,
RF, DIC
„ Lab: ↑LFT; ↑ bili, severe hypoglycemia,
prolonged PT, PTT, ↓ fibrinogen
„ Tx: Supportive, Delivery Plan
OB 119
 Amniotic Fluid Embolism
(AFE)
„ Risks: Multiparity, tumultuous labor,
oxytocin, abruption, IUFD, particulate
amniotic fluid, atony
„ Clinical: Resp. distress → cyanosis →
seizure = Cardiovascular collapse →
DIC hemorrhage → death
„ Lab: ABGs, Lytes, CBC, Coags.
„ EKG, CXR
„ Rx: ACLS
OB 120
 DIC in Pregnancy
„ Related causes: abruption, IUFD,
HELLP, pre-eclampsia, AFE, HUS
„ Lab: ↓ platelets ↓fibrinogen ↑FDP
prolonged PT, PTT
„ Rx: Eliminate/treat cause
„ Correct coag defects
„ FFP, platelets, cryoprecipitate

OB 121
 Blunt Trauma in Pregnancy
ƒ Risks
„ MVA, assault, falls
„ Dx: Primary survey
„ Maternal:
„ X-ray, US, peritoneal lavage
„ Lab: Kleihauer Betke, coags, HCT, Rh.
„ Fetal: Fundal height, uterine ctx, FHTs
„ Assess vag. bleeding, SROM, cervix
dilation + effac.
OB 122
 Blunt Trauma in Pregnancy
(Cont’d)
„ Discharge Criteria
„ If >20 wks gest.: monitor for contractions
„ If <3 ctx/hr x 4 hrs: = discharge
„ If 3-7 ctx/hr: monitor 24 hrs
„ If >7 ctx/hr: high risk for abruption
„ Discharge - resolution of CTXs, reassuring
FHTs, intact membrane, no uterine
tenderness, no bleeding
„ All Rh neg mothers - receive Rhogam - full
dose; (more if Kleihauer-Betke test positive)
OB 123
 HIV in Pregnancy
„ Updated recommendations at
www.aidsinfo.nih.gov
„ Treatment decreases vertical transmission
from 25% to <2%
„ Multiple groups advocate universal screening
„ Repeat screening in third trimester for high-
risk women
„ Prenatal treatment depends on woman’s prior
HIV treatment (check clinical scenarios in
guidelines)
OB 124
 HIV in Pregnancy (Cont’d)
„ Various factors that increase
transmission
„ Maternal – viral load, CD4 count, other
infections such as Hep C, injection drug
use
„ OB – prolonged ROM, vaginal delivery,
invasive procedures
„ Infant - prematurity

OB 125
 HIV in Pregnancy (Cont’d)
„ Zidovidine (ZDV) prophylaxis should be
given to women even if low or
undetectable viral load (2 mg/kg loading
dose, then 1 mg/kg/hr until delivery)
„ If viral load >1000 - counsel on potential
benefit of scheduled C-section to reduce
perinatal infection
„ Want ZDV at least 3 hours before
delivery
OB 126
 HIV in Pregnancy (Cont’d)
„ If woman presents in early labor or
ruptured, start ZDV stat, and minimize
invasive procedures (fetal scalp
electrode, AROM, etc.)
„ May proceed to C/S if minimal dilation
„ May use oxytocin to expedite vaginal
delivery

OB 127
 Postpartum Hemorrhage

OB 128
 Problem
„ Slow, steady blood loss unrecognized/
minimized
„ Minimal external bleeding
„ Clinical signs of hemorrhage,
hypotension, tachycardia may be
absent until significant blood loss has
occurred

OB 129
 Etiology (4 Ts)
„ Early (within first 24 hours)
„ Uterine atony (Tone)
„ Retained placental products (Tissue)
„ Lower genital tract lacerations (Trauma)
„ Coagulopathy (Thrombin)
„ Late (24 hours to 6 weeks postpartum)
„ Infection
„ Subinvolution
„ Retained products
OB 130
 Uterine Atony
„ Most common cause of early PPH
„ Risk factors: polyhydramnios, multiple
gestation, oxytocin use, high parity,
rapid/prolonged labor, chorioamnionitis,
use of uterine relaxing agents (i.e.,
terbutaline, magnesium sulfate)

OB 131
 Retained Placental Products
„ Most common cause of late PPH
„ Retention of complete/partial cotyledon
„ Succenturiate lobe (accessory placental
tissue)
„ Placenta accreta (villi attached to
myometrium)
„ Increta (villi invade myometrium)
„ Percreta (villi penetrate myometrium)
OB 132
 Lower Tract Lacerations

„ Suspect if bleeding but uterus firm

„ More common in operative deliveries,
macrosomia, precipitous deliveries

OB 133
 Coagulopathies

„ Less common
ƒ DIC associated with Gram-negative
sepsis, placental abruption, amniotic
fluid embolus

OB 134
 Management
„ Prevention
„ Pitocin after delivery
„ Be Prepared
„ Assess risk factors in every patient
„ Concurrent resuscitation (ABCs)
„ IV access / oxygen / Foley catheter
„ Treat Cause

OB 135
 Management (Cont’d)
„ Treatment of uterine atony - bimanual
massage and oxytocin
„ Methylergonovine (Methergine) 0.2 lM q 2-
4 hrs
„ May cause: N/V, HTN, HA
„ Carboprost (Hemabate) 0.25 mg lM q 15-
90 minutes total 2 mg
„ May cause: N/V, diarrhea, chills, fever, respiratory
distress
„ Cytotec
„ 800-1000 mg rectally
OB 136
 Management (Cont’d)
„ Retained placental products
„ Curettage for removal

„ Lacerations
„ NEED EXPOSURE

„ May warrant general anesthesia to repair

„ Coagulopathies
„ Lab studies to identify (PT, PTT, platelet

count, FDP)
„ Treat cause if possible

„ Blood products

OB 137
 Other Considerations
„ Pelvic Hematomas
„ May be difficult to detect
„ Patients may report severe rectal or perineal
pain after delivery
„ May be vaginal, vulvar or retroperitoneal
„ Uterine inversion: rare, life-threatening
„ Classically profuse bleeding, severe pain
„ May have palpable mass @ introitus
„ Reposition manually immediately if possible
„ May need operative intervention
OB 138
 References
Evidence Based Medicine
Practice Points

OB 139
SLIDE 16
The U.S. Preventive Task Force (USPSTF) strongly recommends Rh (D) blood typing and
antibody testing for all pregnant women during their first visit for pregnancy-related
care.

Name of AAFP-approved source of systematic evidence review: U.S. Preventive Services Task
Force

Specific web site of supporting evidence from the approved source identified immediately above:
http://www.ahcpr.gov/clinic/uspstf/uspsdrhi.htm

Strength of evidence (description and/or grade as provided by the approved source):

A – the USPSTF strongly recommends that clinicians provide [the service] to eligible
patients. The USPSTF found good evidence that [the service] improves important
health outcomes and concludes that benefits substantially outweigh harms.
Rationale: The USPSTF found good evidence that Rh (D) blood typing, anti-Rh (D)
antibody testing, and intervention with Rh (D) immunoglobulin, as appropriate,
prevents maternal sensitization and improves outcomes for newborns. The benefits
substantially outweigh outweigh any potential harms.

OB 140
SLIDE 21
The USPSTF recommends repeated Rh (D) antibody testing for all unsensitized Rh (D) –
negative women at 24-28 week’s gestation, unless the biological father is known to be Rh
(D) – negative.

Name of AAFP-approved source of systematic evidence review: U.S. Preventive Services Task
Force

Specific web site of supporting evidence from the approved source identified immediately above
http://www.ahcpr.gov/clinic.uspstf/uspsdrhi.htm

Strength of evidence (description and/or grade as provided by the approved source):

B – the USPSTF recommends that clinicians provide [this service] to eligible patients. The
USPSTF found at least fair evidence that [the service] improves health outcomes and
concludes that benefits outweigh harms.
Rationale: the USPSTF found fair evidence that repeated antibody testing for unsensitized Rh
(D) negative women (unless the father is also known to be Rh [D]-negative) and
intervention with Rh (D) immunolglubulin, as appropriate, provides additional benefit over
a single test at the first prenatal visit in preventing maternal sensitization and improving
outcomes for newborns. The benefits of repeated testing substantially outweigh any
potential harms.
OB 141
SLIDE 38
There are no health benefits from episiotomy, and the immediate outcomes for routine episiotomy (liberal-
use policies) are likely no better than those for episiotomy performed under more restrictive-use
policies. Indeed, routine use is harmful to the degree that it creates a surgical incision of greater extent
than many women might otherwise have experienced.
Name of AAFP-approved source of systematic evidence review: Agency for Healthcare Research and Quality
clinical and Evidence Reports (AHRQ)
Specific web site of supporting evidence from the approved source identified immediately above):
http://www.ahcpr.gov/clinic/tp/epistp.htm#Report
Strength of evidence (description and/or grade as provided by the approved source): Fair to good evidence
suggests immediate maternal outcomes from routine episiotomy are not better than those from
restrictive use; instead, outcomes are worse because some proportion of women who would have had
lesser injury instead had a surgical incision. Evidence is insufficient to provide guidance on choice of
midline or mediolateral episiotomy when indicated. For perineal injury requiring suturing, fair to good
evidence suggests leaving superficial vaginal and perineal skin unsutured is potentially preferable. If
used for skin approximation, a continuous, subcuticular repair is superior to an interrupted,
transcutaneous method. Evidence is consistent and clear that absorbable suture is preferred and that
polyglycolic acid suture is associated with less morbidity than gut and chronic gut suture. Evidence is
insufficient to determine whether novel materials, such as tissue adhesive, offer benefits. Evidence
regarding long-term sequelae is fair to poor; assessment of pelvic floor dysfunction was not conducted
in the age groups of greatest relevance. Limited data show that epiosiotomy does not prevent fecal and
urinary incontinence, pelvic floor relaxation, or impaired sexual function, within months to years from
childbirth.

OB 142
SLIDE 97
There is no difference in asymptomatic uterine rupture rates in trial of labor versus elective
repeat cesarean.

Name of AAFP-approved source of systematic evidence review: Agency for Healthcare

Research and Quality Clinical and Evidence Reports (AHRQ).

Specific web site of supporting evidence from the approved source identified immediately above:
http://www.ahrq.gov/downloads/pub/evidence/pdf/vbac/vbac.pdf

Strength of evidence (description and/or grade as provided by the approved source):

II-2 – cohort or case control
Quality of evidence fair-poor: several large cohort studies which were inconsistent in
terminology; many with consistent findings of increased risk of symptomatic urine
rupture in trial of labor versus elective repeat cesarean.

OB 143