Variations Of Labor And Management Strategies 572

Front 1

List the average: length of latent phase, cm rate of change in active (Freidman & Albers), and length of expulsive phase in nullips and multips

Back 1

-Latent phase - variable
-Active phase per Freidman
*Nullip: 1.2 cm per hour
*Multip: 1.5 cm per hour
-Active phase per Albers
*At least 0.5 cm per hour
-Expulsive phase
*Nullip: 2 hrs (3 hrs w/CLE)
*Multip: 1 hr (2 hrs w/CLE)

Front 2

Labor dystocia in general terms is a result of ______

Back 2

Problems with:
-Passenger
-Power
-Pelvis
-Psyche

Front 3

What are the different subdivisions of labor dystocia and their definitions?

Back 3

-Prolonged/Protracted labor: slow labor
-Arrest of labor: no change

Front 4

In labor dystocia, what can be wrong with the "passenger"?

Back 4

-Fetal asynclitism
-Fetal malpresentation
-Deflexed
-Occiput posterior
-Macrosomia

Front 5

In labor dystocia, how is it that the "power" can be affected?

Back 5

-Uterus is weakened by fever, sepsis, chorioamnionitis
-Weakened by prolonged labor
-Maternal fatigue, ineffective effort
-Pain (catacholamine response)
-Medications: narcotics,
-MGSO4
-Sufficient power is needed to effect the mechanisms of labor

Front 6

How can sleep affect labor?

Back 6

Can contribute to labor dystocia affecting "psyche":
Sufficient sleep (Lee & Gay, 2004)
-Less than 6 hrs night:
*longer labors
*4.5 x more likely to have a
cesarean
-Severely disrupted sleep:
*longer labors
*5.2 x more likely to have a
cesarean

Front 7

What is the criteria for diagnosis of an arrest disorder (labor dystocia) ?

Back 7

-Truly in active phase
-Latent phase must be completed
-200 Montevideo units for 2-4 hours without cervical change

Front 8

What are interventions that can be implemented to help manage labor/labor dystocia?

Back 8

-Pitocin augmentation (active management of labor)
-AROM
-Increase hydration (250cc/hr)
-Hydrotherapy
-Warm water immersion
-Shower
-Upright maternal position changes

Front 9

What have recent studies suggested regarding oxygen therapy in labor?

Back 9

-Although there is evidence that maternal oxygen administration can increase fetal oxygen levels, little is known regarding the potential risks.
-One study found: when second stage labor lasted more than 10 minutes, there were more cases of fetuses with lower umbilical artery pH as compared to fetuses of women with shorter second-stage labor duration.
-Suggesting that maternal oxygen therapy can lead to fetal acidemia and therefore should not be used as an intrauterine resuscitation technique.
-Avoid oxygen as a first-line intrauterine resuscitation measure
-Reserve for clinical situations in which the FHR does not respond to other techniques.
*maternal repositioning,
discontinuing oxytocin (if
infusing)
*IV fluid bolus (if appropriate
for this patient)
*Moderate variability is
strongly associated with an
umbilical artery pH of >7.15
or an Apgar score of 7 or
higher at 5 minutes of life
-Avoid the use of maternal oxygen in the presence of moderate variability, even with FHR decelerations
-Initiate as a second-line measure
-Discontinue as soon as possible when the FHR pattern shows improvement.
*other sources of potential
fetal physiologic stress
should be minimized prior to
02 therapy
*oxytocin for labor induction
or augmentation should not
be infusing concurrently with
maternal oxygen
administration.
-In cases of sudden acute fetal deterioration (such as that caused by placental abruption, uterine rupture, or prolapsed umbilical cord), maternal oxygen administration could be included in the first series of interventions initiated, even if clinical conditions are such that the maternal–fetal exchange is compromised by umbilical cord compression or partial placental abruption.

Front 10

What is the history behind group beta strep prophylaxis?

Back 10

-Group B streptococcus (GBS) emerged as the leading infectious cause of neonatal morbidity and mortality in the United States in the 1970s
-Before active prevention was initiated, an estimated 7,500 cases of neonatal GBS disease occurred annually
-Recommendations for intrapartum prophylaxis to prevent perinatal GBS disease were issued in 1996 by ACOG and the CDC, and in 1997 by AAP.

Front 11

What is the affect of group beta strep on the mother during pregnancy and postpartum?

Back 11

-In pregnant women, GBS can cause clinical infections, but most women have no symptoms associated with genital tract colonization.
-Urinary tract infections caused by GBS complicate 2%--4% of pregnancies.
-During pregnancy or the postpartum period, women can contract amnionitis, endometritis, sepsis, or rarely, meningitis caused by GBS.
-Fatalities among women with pregnancy-associated GBS disease are extremely rare.

Front 12

What is the affect of group beta strep on the fetus during pregnancy and postpartum?

Back 12

-Intrauterine infection of the fetus results from ascending spread of GBS from the vagina of a colonized woman who is typically asymptomatic.
-Fetal aspiration of infected amniotic fluid can lead to stillbirth, neonatal pneumonia, or sepsis.
-Infants can also become infected with GBS during passage through the birth canal, although the majority of infants who are exposed to the organism through this route become colonized on skin or mucous membranes but remain asymptomatic.

Front 13

Why was the protocol for GBS prophysaxis changed from a risk based approach to a culture based approach?

Back 13

-Because even though there were striking declines in disease incidence. GBS disease remained a leading infectious cause of morbidity and mortality among newborns in the US
-Changed to culture based approach in 2001

Front 14

What is the exact name for GBS, and where is it found?

Back 14

S agalactiae common in rectum/vagina

Front 15

Why can we not do a culture early in pregnancy for GBS and then never again?

Back 15

Colonization can be transient, intermittent, or chronic

Front 16

How long is a GBS culture "good" for?

Back 16

results valid for 5 weeks

Front 17

Screening for GBS should be done between ___ & ___ weeks gestation unless: _____

Back 17

-Screening should be done between 35-37 weeks gestation unless:
*+GBS bacteriuria during
current pregnancy
*Previous infant infected with
GBS

Front 18

What are the GBS intrapartum prophylaxis indications?

Back 18

-Previous infant with invasive GBS disease
-GBS bacteriuria during current pregnancy
-+ GBS screening during current pregnancy
-Rupture membranes before planned c/s
-Unknown GBS status &:
*< 37 weeks gestation
*Intrapartum temp ≥ 100.4º
*Ruptured ≥ 18 hours

Front 19

What are the antibiotic regimens for GBS?

Back 19

-Penicillin G, 5 million units IV loading then 2.5 million units every 4 hours until delivery
-Ampicillin, 2 g IV loading, then 1 g every 4 hours until delivery
-PCN allergy depending on susceptibility
*Cefazolin, 2 g IV loading,
then 1 g every 8 hrs until
delivery
*Clindamycin, 900 mg IV
every 8 hours until delivery
*Erythromycin, 500 mg IV
every 6 hours until delivery
*Vancomycin, 1 g IV every
12 hours until delivery

Front 20

Why is cardiac antibiotic prophysaxis done, and in what situation(s)?

Back 20

-Prevention of bacterial endocarditis during normal labor
*Patients at high risk:
prosthetic heart valves, prior
endocarditis, congenital
heart disease, pulmonary
shunt – intrapartum abx
optional (If bacteremia is
suspected,then antibiotics
are indicated)
*Moderate risk: mitral valve
prolapse with regurgitation or
thickened leaflets– not
recommended unless
bacteremia is suspected
*Low risk: mitral valve
prolapse, heart murmurs, hx
of rheumatic fever,
pacemakers/defibrilators, hx
coronary bypass graft
surgery

Front 21

How many women are affected by premature rupture of membranes at term, and what is the definition?

Back 21

-Affects 8%-10% of pregnant women
-Prelabor rupture of membranes or premature rupture of membranes
*> 37 weeks gestation
*Prior to the onset of labor
*No latency interval
(prolonged rupture of
membranes-not used)

Front 22

What are the risks associated with premature rupture of membranes at term, and what are the diagnostic criteria?

Back 22

-PROM increases the risk of chorioamnionitis
-Chorioamnionitis is associated with a 4-fold RR of cerebral palsy
-Diagnostic criteria
*Temp ≥100.4ºF plus one of
the following:
*Tachycardia (fetal
*>160/maternal >100)
*WBC ≥ 15k
*Foul odor
*Uterine tenderness

Front 23

What are the management options for PROM and not in labor at term, and how is the chorio risk affected with PROM and not in labor at term?

Back 23

-Management options:
*Immediate induction
*Expectant management –
watchful waiting until
spontaneous labor occurs
-Induction if often recommended per findings of TermPROM study
-Optimal method has not been determined: oxytocin vs prostaglandins
-No standard definition for failed induction
-Risk for chorioamnionitis increases to 25% if not in active labor (≥4 cm) after 12 hours, and 15% if not in active labor after 18 hours

Front 24

What are the TermPROM study limitations?

Back 24

TermPROM study limitations (1992-1995)
-Threshold for diagnosis was lower temp
-Digital vaginal examinations
GBS colonization before prophylaxis recommendation

Front 25

What is the ACNM position statement on PROM at term?

Back 25

-Expectant management should be offered as a safe alternative to induction of labor
-Safe under these conditions:
*Term pregnancy with clear amniotic fluid
*Absence of infection – GBS, hepatitis, HIV
*Absence of fever
*Reassuring FHR pattern
*Minimal digital examinations and avoidance of baseline exam