Family Medicine 30: 27-year-old female labor and delivery

User: Andrea Kristin Origenes

Email: aorigenes58@midwestern.edu
Date: January 21, 2021 12:19PM

Learning Objectives

The student should be able to:

Define active labor.

Describe group prenatal care and its advantages.
Interpret fetal monitoring strips using the National Institute of Child Health and Human Development (NICHD) guidelines.
Describe the evaluation and diagnosis of preeclampsia, and the health disparities related to preeclampsia.
Describe the role of the family clinician in the management of prenatal care, labor, delivery, postpartum and newborn care.
Demonstrate effective counseling of patients and families regarding breastfeeding and newborn anticipatory guidance related
to breastfeeding.

Knowledge

Advantages of Group Prenatal Care

Group prenatal care is an excellent opportunity for group support and the women help educate each other as well, which can be
more effective.

In addition, it can be more efficient for the provider because, in many cases, most of the time in individual visits is taken up by
education and anticipatory guidance.

Ultimately women enrolled in group prenatal care receive more time for prenatal education and anticipatory guidance than those
in routine care.

Preterm delivery is less likely in women participating in group prenatal care, and this was more significant for African American
women, in one study and in a subsequent systematic review.

Furthermore, if an infant is preterm, the birth weight (a significant survival determinant) is greater when the mother
participated in group prenatal visits.
The incidence of preterm birth is higher in African American women than Caucasian women, and preterm birth is the No. 1
cause for neonatal death in African American infants (as opposed to congenital anomalies in Caucasian infants). Although
direct causal links are often difficult to elucidate, studies have shown that there are significant relationships between these
racial health disparities and maternal stress, experiences of racism and harmful environmental exposures. The advantages
of group visits may be an important tool to help combat the racial disparities seen in maternal health in the United States

Overall, the prenatal knowledge, labor preparedness, adequacy of prenatal care and patient satisfaction of women in group
prenatal care also appears to be better than those in routine care.

Group visits can be used for a variety of medical conditions, including diabetes and chronic pain.

Evidence of Active Labor

It is important to diagnose women with active labor prior to admitting them to the hospital for expectant management. Admitting
women prior to active labor, in the latent labor stage, is associated with more interventions, including augmentation of labor (e.g.,
with medications such as oxytocin or other interventions) and cesarean delivery.

Active labor is associated with strong regular contractions every three to five minutes and a cervical dilation of more than 6 cm in
the setting of contractions.

The fetal heart tracing does not impact the diagnosis of active labor.

Absolute contraindications to digital cervical exam

Both patient reports of vaginal bleeding with an undocumented placental location (or known previa) AND leaking vaginal fluid with
prematurity (or known PPROM) are absolute contraindications to digital cervical exam secondary to harm that may be caused-
worsening of bleeding in the first case, and introduction of bacteria into the uterus potentially leading to infection, in the second.

Stages of Labor

First stage

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 Latent phase: regular contractions have started, but the cervix is less than 6 cm dilated
Active phase: begins when 6 cm dilated; ends when fully dilated

Second stage: begins at full dilation; ends when the baby is delivered

Third stage: begins with birth of the baby; ends with delivery of the placenta

Preeclampsia - Criteria, Epidemiology, Evaluation

Elevated Blood Pressures: blood pressures of greater than 140 systolic or 90 diastolic on at least two readings
(greater than six hours apart ideally) in a seated or semi-reclined position in a woman who previously had normal
blood pressures and is over 20 week gestation (by itself, this is the definition of Gestational Hypertension)

AND
Criteria
Proteinuria: at least 300 mg on a 24-hour urine collection, a urine protein/creatinine ratio of >= 0.3, or at least
1+ or 30 mg/dL on dipstick (again, on two occasions ideally six hours apart)

OR

Elevated blood pressures plus any of the criteria for preeclampsia with severe features. (See below.)

African American women are more likely to have preeclampsia than other women (Asian, Hispanic, or Caucasian)
in the US, their disease is more likely to be severe, and they are also more likely to suffer the complications of
Epidemiology preeclampsia, such as placental abruption and eclampsia. The underlying causes for these differences are
multifaceted and include a host of socio-structural factors such as access to healthcare, health education, and
environmental stressors.

Rule out HELLP (Hemolysis, Elevated Liver enzymes AND Low Platelets) syndrome or preeclampsia with severe
Evaluation features via evaluation of renal and liver function, including a spot urine protein/ creatinine ratio, as well as a
complete blood count to look for hemoconcentration or thrombocytopenia.

Criteria for preeclampsia with severe features

Criteria for preeclampsia with severe features (any one of the following):

Severe hypertension of at least 160 mmHg systolic or 110 mmHg diastolic (two readings at least four hours apart)
Right upper quadrant pain or a doubling of serum transaminases
Platelet count < 100 K/ mL
Creatinine of > 1.1 mg/dL or doubling of creatinine
Pulmonary edema
New and persistent cerebral or visual disturbances

A patient with blood pressure in the range of severe hypertension (see above) would need an anti-hypertensive in order to
prevent sequelae of severe hypertension, such as myocardial infarction or stroke. The amount of proteinuria is no longer part of
the diagnostic criteria for preeclampsia with severe features. It is, however, part of the initial diagnosis of preeclampsia.

Late Decelerations

Late decelerations are decelerations in the fetal heart rate that begin after a contraction begins, with the nadir after the peak of
the contraction.

They can be an indication of utero-placental insufficiency, meaning that the baby may not be getting enough oxygen and late
decelerations can be an early sign of hypoxemia during contractions.

Category I, II, III Intrapartum Strips

Look at the criteria for Category I, II, and III intrapartum strips. Once a woman is admitted in labor, we categorize fetal heart
tracings in this way, rather than using the criteria for non-stress tests, which are most useful in the antepartum period.

Intrapartum Fetal Heart Rate Pattern Classification

Category I:

Normal FHR (baseline 110-160)

Moderate variability (between 6 and 25 beats per minute changes that are not accels or decels)
Plus or minus accelerations (at least 15 beats per minute above the baseline for at least 15 seconds from start to finish)
Plus or minus early decelerations (mirror contractions, nadir of deceleration with peak of contraction and resolves when
contraction resolves - usually indicates fetal head compression when the fetus is low in the pelvis, often occurs with
pushing)
No late or variable decelerations

Category II:

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 Any fetal heart rate tracing that does not fit into Category I or III.

Category III:

No fetal heart rate variability (absent) PLUS at least one of the following:

FHR baseline less than 110 (bradycardia)

Recurrent late decelerations (occur with more than 50 % of contractions in a 20 minute period)
Recurrent variable decelerations

OR

Sinusoidal fetal heart rate pattern (smooth undulations of fetal heart rate in a sine wave like pattern). This pattern is rare and is
considered an agonal pattern in a fetus near death.

Labor Dystocia - Definition, Diagnosis, Treatment

Definition

The average speed of dilation is about 2 cm/hour for multiparous women and about 1 cm/hour for primiparous women, so
the average length of the active phase of the first stage of labor is 2.4 hours for multiparous women and 4.6 hours for
primiparous women.
Classically, failure to progress (or active phase arrest) occurs if there is no cervical change for two hours in the active phase
of labor. However, more recent data suggests that waiting four hours for cervical change with adequate contractions and six
hours without adequate contractions is safe as long as assessments of mother and fetus are reassuring. This approach
decreases the risk of an unnecessary cesarean delivery.

Diagnosis

A labor curve is often used to plot the labor progress in terms of cervical dilation, effacement, and fetal descent in order to
help diagnosis labor dystocia.
You may also diagnose this condition in the second stage of labor if the fetal presenting part does not descend significantly
in the pelvis after two hours of pushing (or three hours with an epidural), adding an hour for each, for primiparous women.

Treatment

There are many things that we can do to augment labor in the event of active phase arrest, including administration of IV oxytocin
and/ or artificial rupture of membranes.

The Cardinal Movements of Labor

1.
The presenting part of the fetus has entered the pelvic inlet.
Engagement

Described by the "station" on cervical exam. The fetus is at 0 station when the widest part of the presenting part is
2. Descent
between the ischial spines.

When a fetus is in the occiput anterior position, the fetal head is flexed by the soft and bony tissues of the
3. Flexion
maternal pelvis, which facilitates passage through the birth canal.

4. Internal
The fetal head must rotate in order to further descend
rotation

5. Extension Occurs as the fetal head passes under the symphysis pubis, which occurs during crowning and delivery of the head

6. External
The head rotates to realign with the shoulders (also called restitution)
rotation

Completing the delivery, with the anterior shoulder of the fetus being pushed out first, then the posterior shoulder
7. Expulsion
and the rest of the body.

A video of an artist's rendition of vaginal birth: http://www.youtube.com/watch?v=Xath6kOf0NE&feature=related. As you watch,

pay particular attention to the dilation and effacement (thinning) of the cervix, as well as the descent of the fetus.

Fetal Head Orientation

Left occiput anterior indicates that the back (occiput) of the fetal head is anterior in the mother's pelvis and to the
mother's left.
Direct occiput anterior indicates that the occiput is directly posterior to the pubic symphysis (with the baby's face
towards the rectum.)

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 Causes of Postpartum Hemorrhage

Causes of Postpartum Hemorrhage can be remembered as the 4 T's (from most to least common):

1. Tone (uterine atony leading to continued bleeding)

2. Trauma (perineal or cervical lacerations, uterine inversion)
3. Tissue (retained or invasive placental tissue in the uterus)
4. Thrombin (a bleeding disorder—much less common than the other three causes)

Newborn Weight Loss

It usually takes two to three days for breast milk to fully come in after delivery. Some amount of weight loss is normal and not
dangerous in a healthy term newborn. Colostrum is protein-rich and very nutritious for newborns.

Newborn Weight Gain

In the newborn period, expect to see a weight gain of about an ounce per day once the maternal milk is in.

Postpartum Checkup

At the postpartum check, remember to ask the mother if she has help at home, about her diet, prenatal vitamins, and other
medications, and also about her mood, as postpartum depression can begin a few weeks after delivery and often before the
scheduled six-week postpartum visit.

Clinical Skills

How to Perform Digital Cervical Exam

It is generally best to wait to do the exam in between contractions. Use a sterile glove with a generous amount of
lubricating jelly. Place your index and middle fingers of your dominant hand at the introitus, using your other hand to separate the
labia if necessary.

Ask the patient to take a deep breath and then exhale. As she exhales, insert your finger into the vagina and reach until
you can feel the cervix, which is usually firmer than the vaginal wall tissue, especially early in labor. Sometimes, when the cervix
is still posterior (early in labor) it helps to ask the woman to place her hands under her buttocks and tilt her pelvis towards the
ceiling if you cannot find the cervix initially.

Once you feel the cervix , trace it around until you feel the opening in the center. Then put your fingers into the opening
(external os) until you feel the presenting part (hopefully, the fetal vertex!).

Once you feel the fetal vertex , you can be confident that you are through the internal os. Spread your two fingers to determine
how many centimeters the internal os is dilated. Remember that in a multiparous woman, the external os may be dilated several
centimeters even when the internal os is still closed. This is why it is important to make sure that you are touching the presenting
part to be sure that you are through the internal os. If you cannot feel a presenting part or membranes, but feel a "fleshy" end to
the cervical canal, then the internal os is probably still closed.

In a dilated cervix, once you have determined how many centimeters dilated the internal os is, try to determine the
thickness of the cervix. This can only accurately be done by exam when the cervix is dilated enough to admit at least one finger.
Then try to feel using the sides of your fingers how thick the cervix is. A pregnant, non-labored cervix is usually at least 3 cm in
thickness. So, 1.5 cm would be about 50% effaced and so on. Remember that the cervices of primiparous women usually efface
first and then dilate, so their cervix may be very thin once they start to dilate, whereas those of multiparous women do both at the
same time and their cervix may still be relatively thick even when they are quite dilated.

Approach to the patient refusing your recommendations

The most appropriate initial approach is attempting to gather more information in a non-judgmental way about the patient's
reasons for refusal.

Newborn Exam

A thorough newborn examination should be performed within 24 hours of birth.

Examine the head, looking for abnormalities of shape and size, size and condition of the fontanelles, and any masses.
Look in the eyes at the conjunctiva and sclera, as well as observe the red reflex with an ophthalmoscope.
Make sure both nares are patent and that the palate is intact.
Examine the size, shape and position of the ears.
Examine the neck for any masses.
Listen to the heart and lungs.
Check the abdomen for any masses and look for signs of infection at the umbilical stump.

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 Examine the skin for jaundice, rashes and congenital lesions.
Examine the hips to evaluate for developmental dysplasia of the hip, as well as feel for the brachial and femoral pulses, that
they are equal and symmetric.
Examine the penis for size and placement of the meatus; examine the scrotal sac and the testes to ensure that they are
both descended.
Examine the back to look for any spine abnormalities or subtle signs of neural tube defects, such as a sacral cleft.
The neurological exam will consist of checking for resting tone, movement of all extremities, and checking neonatal reflexes,
including the suck, rooting, grasp and moro reflexes. See the video for more information.

Newborn Neurological Exam

Perform an assessment of gestational age based on physical and neurologic maturity.

(http://www.ballardscore.com/files/ballardscore_scoresheet.pdf).

Two helpful articles in the American Family Physician:

AFP newborn exam articles:

http://www.aafp.org/afp/2014/0901/p289.html
http://www.aafp.org/afp/2014/0901/p297.html

Management

Steps to Decrease Maternal Blood Loss

Active management of third stage of labor

Give the mother Pitocin (oxytocin) after the baby is born to help the placenta detach quicker, very gently pull on the cord when the
placenta appears to have detached, and massage the uterus after the placenta comes out to help the blood vessels stop pumping
out blood, though the evidence supporting this common practice is limited.

Timing of clamping of the umbilical cord

There is evidence that delaying cord clamp can decrease the risk of anemia in newborns and infants. Most of the studies and
guidelines show that 30 to 60 seconds of delay is about the right amount of time, except when immediate transition of the
newborn to the nursery team is indicated for other reasons.

Management of Late Decelerations

1. Continuous fetal monitoring.

2. Position the patient on her side to decrease pressure on her vena cava, and increase blood return to the heart, in order
to maximize cardiac output and blood flow to the uterus.
3. Monitor blood pressure. If her blood pressure is low, she may benefit from a fluid bolus to further increase blood flow to
the uterus.
4. Oxygen by face mask, to maximize placental oxygen delivery. Although there is no clear evidence to support this, it is
unlikely to cause harm with short term use, other than minimal patient discomfort.

Labor Pain Management - Alternatives to Epidural

For women who wish to avoid all pharmacologic pain management, intradermal sterile water injections, self-hypnosis,
acupuncture, and water immersion all have fairly good evidence that they can be effective for labor pain management. All of them
except for water immersion do require some previous knowledge and expertise regarding the technique, either by the pregnant
woman herself or her birth attendant, depending on the method.

Inhaled nitrous oxide is an option for women in labor in some hospitals.

IV opioids should not be used close to the time of delivery in order to avoid neonatal respiratory suppression.

Delivery

When women are lying on their back pushing, you can protect the perineum by putting pressure posteriorly with one hand (to
avoid extensive posterior perineal lacerations) and gently helping the fetal vertex to stay flexed with two fingers of the other hand
(to avoid anterior perineal lacerations from over extension). This should only be done during crowning and every effort should be
made to avoid episiotomy unless necessary for fetal distress or dystocia.

There is good evidence that avoiding routine episiotomy protects women from unnecessary perineal trauma, but the evidence for
the other perineal protection techniques is weaker and has not been well-studied.

After the head delivers, allow the head to restitute while you gently feel around the fetal neck to determine if a nuchal cord is
present.

Establishing Breastfeeding

The benefits of breastfeeding are numerous for both mothers and babies. The Centers for Disease Control, American Academy of
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 Family Physicians, American College of Obstetrics and Gynecology, and American Academy of Pediatrics all strongly recommend
breastfeeding for at least six months.

There are significantly different breastfeeding rates among women of different ethnic groups in the United States, with African
Americans having the lowest breastfeeding rates. Women have different beliefs about breastfeeding. It is important that women
receive adequate education as to the pros and cons associated with each feeding choice​.

There are several evidence-based approaches to encourage breastfeeding and increase breastfeeding rates.

To encourage breastfeeding, pacifiers and supplements should be avoided in the first few weeks of life, mothers and
newborns should ideally stay in the same room in the hospital, and infants should only be fed on demand.
Education of expectant women and their partners (like breastfeeding classes during pregnancy) has been shown to help
increase the rate of breastfeeding initiation and exclusive breastfeeding at six months.
Lactation consultation by a certified lactation specialist can also be very helpful for breastfeeding mothers, and should be
considered routinely for first-time breastfeeders, small for gestational age infants, preterm infants, and any other
circumstance where breastfeeding could be challenging.
Breastfeeding infants with slow or no weight gain should be seen frequently to assess for failure to thrive, jaundice or other
problems. Frequent office visits can also provide additional support and education for women desiring to breastfeed their
infants.
Immediate skin-to-skin contact after delivery is a very important step in establishing breastfeeding in mother-baby pairs,
and there is good evidence to support this practice. Early skin-to-skin contact and early initiation of breastfeeding is
associated with increased rates of breastfeeding at hospital discharge and later in infancy.

Studies

Interpreting a Non-Stress Test Strip

A non-stress test is an assessment of fetal well being in the antepartum period before labor. Remember, the red line is fetal heart
rate (FHR), the pink line is fetal movement, and the black line is uterine contractions. Each thin vertical line on the graph
represents ten seconds, and each thick vertical line represents one minute.

First check the FHR. A normal FHR has a baseline between 110 and 160 beats per minute with variability of 6 to 25 beats per
minute.

Next, determine whether the strip is 'reactive' or not. A neurologically intact and healthy fetus should have two heart rate
accelerations of at least 15 beats per minute over at least 15 seconds in a 20-minute period, which is called a 'reactive' strip.

For someone in labor, admitted to the birthing unit, they are not required to have a reactive NST in order to be considered
reassuring. For an antepartum patient with medical issues indicating fetal well-being testing and one whom you may consider
sending home if she is not in labor, performing a non-stress test is appropriate.

Fetal Status Assessment

Non-reassuring Fetal Status

A baseline fetal heart rate of 170 beats per minute is defined as tachycardia, and would be cause for concern. Many
problems could cause fetal tachycardia, including maternal fever or infection and fetal anemia or hypoxia.
Minimal (5 or less beats per minute), absent, or marked (greater than 20 beats per minute) variability of the fetal heart rate.

Reassuring Fetal Status

Moderate variability (6 to 20 beats per minute).

A subjective report of active fetal movement.
A "reactive" strip showing two heart rate accelerations (of at least 15 seconds with a peak of at least 15 beats per minute
above the baseline) in a 20-minute period.

Approach to Evaluating Fetal Heart Rate Tracings

When evaluating fetal heart rate tracings, it is useful to follow a systematic approach.

1) Consider the uterine activity

2) Determine the baseline FHR

3) Determine the heart rate variability

4) Look for accelerations

5) Look for decelerations

Overall assessment

Many intrapartum fetal heart rate tracings will be classified as category II, and they may still be reassuring overall, or they could
be concerning overall, depending on the specifics of the findings and the situation with the patient.

Apgar Score

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 Apgar scores are an indication of newborn vigor that are assigned at one and five minutes postpartum. While they are not
necessarily used to guide newborn resuscitation efforts, they are still assigned at most hospitals. You may designate 0, 1, or 2
points for each category. The categories are respirations, heart rate, color, tone, and responsiveness.

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