Incidence: 

3.3% as of 2013 

Indications: 

• Prolonged second stage 
• Risk of fetal compromise 
• Shortening 2nd stage for maternal benefit (ex: cardiac conditions)

Consent: 

• Comparison is c-section typically 
• Failure rate of OVD is ~3-6% 
• Forceps has higher success rate over vacuum, but also higher risk 3rd/4th degree tear 
• Risks to both mom and baby

Prep: 

• Fetus appropriate station/position 
• Anesthesia
• Empty bladder
• Assess Pelvis/Passenger sizes/fit
• OR Ready
• Peds available 

Episiotomy – NO! 

Contraindications

• Fetal conditions, known or supspected: bone disorders (OI), bleeding disorders 
• Maternal infections: Hep C, HIV, etc 
• Concern for shoulder dystocia/cephalo-pelvic dysproportion 

Indications: 

• Post-dates (42+wks) 
• Late Term (41+ wks)
• Elective 39+wks 
• Diabetes
• Hypertension 
• Many more - check out ACOG Medically indicated delivery 

39week induction

ARRIVE Trial - Multicenter RCT showing benefit to 39wk IOL over expectant management to ~41wks 

Included 

• Primips 
• No medical indications for IOL prior to 40+5

Results 

• IOL group had LOWER c-section rate than expectant group 
• Neonatal composite outcome had a trend (not statistically significant) toward lower neonatal compilations in IOL group 

Conclusion

• IOL at 39wks is as safe as expectant management without increased risks
• Many pregnant people are now offered a 39wk IOL rather than waiting for spontaneous labor 

The IOL Process: 

Evaluate and Prep:

• Full H&P
• Ultrasound for position - Vertex
• VE for cervical exam: dilation/effacement/Station, also position and consistency 
• Calculate Bishops Score → help determine mode of IOL

Options for IOL: if biship score <8 for prime or <6 for multip, ripen first! 

• Mechanical cervical ripening (balloon)
• Chemical cervical ripening (misoprostol or cervidil) 
• Best yet--both! 

Contractions (pitocin) 

• Prime: Pitocin alone if Biship 8 or higher
• Mulitp: Pitocin alone if bishop 6 or higher 

Augmentation: AROM 

Failed IOL

• Failure to reach active labor after 18+hrs ruptured on pitocin (definition varies 12-24hrs ruptured on pitocin) 
• If reaches active labor (6+cm), no longer failed IOL, now arrest of dilation or descent 

Definition: Failure to deliver fetal shoulders with normal downward traction 

Why we care: Baby hypoxia, brachial plexus injuries, maternal injuries

Risk factors: 

• DM, excessive weight gain in pregnancy, S>D, Large baby
• Hx of shoulder dystocia (~10-15% recurrence)
• Turtling while pushing 

Prevention 

• No real prevention as SD is very hard to predict 
• Offer cesarean delivery if EFW is >5000g and no DM, or >4500g and any type of DM

What do to: 

• Step back. If comfortable, can help minimize family interference. Calmly explain what is happening and what the docs are doing. 
• Offer to be the Timekeeper. Write down times and what is happening. Announce every 2 minutes. 

What you’ll see: 

• Prep: Hypothesize shoulder orientation for suprapubic pressure, place stool 
• Announce problem- call for help
• Maneuvers - McRobers, suprapubic
  • Posterior arm
  • Rotational: Wood’s screw, Rubin
  • Gaskins- all 4s
  • Episiotomy
  • Zavanelli 

Cancer Screening

• Cervical: Age 21-65 Cytology q3yrs, co-test q5 if normal.
• ASCCP guidelines (there is an app! Or PDF: http://www.asccp.org/Assets/51b17a58-7af9-4667-879a-3ff48472d6dc/635912165077730000/asccp-management-guidelines-august-2014-pdf )
• Breast: ACOG: 40-75 annual mammogram
• Colon: Colonoscopy, FOBT, FIT. Begin at age 50. If first degree relative with colon cancer begin screening at age 40 or 10yrs prior to youngest diagnosis, whichever is younger.
• Lung: 55-80 with 30pack-year hx, annual low-dose CT

Vaccinations

• HPV: 3 dose series age 12-26
• Influenza: annual
• Pneumovax: 1 dose and 1 booster any age if risk factors. After age 65 if no risk factors
• Shingles: 2 dose age 50+
• Hep B: initial vaccination in youth, vaccination for anyone non-immune
• MMR: if not immune
• Varicella: if not immune
• Tdap: Booster at 10yrs, new parents

Swab/Urine

• Chlamydia: usually asymptomatic. Screen routinely. Can cause infertility/PID and Fitz-hugh-curtis. Treat with Azithro x1
• Gonorrhea: often asymptomatic. Screen routinely. Can cause infertility/PID. Treat with Ceftriaxone and Azithromycin
• Trich: frothy/watery discharge. “Strawberry cervix” Can see trich moving on wet mount. Treat Flagyl 2g PO once.
• HPV: Cervical dysplasia/cancer and Genital warts. Topical treatments as needed.

Serum

• Syphilis: Painless chancre followed by latent, then secondary with palmar/plantar rash. If unsure stage, treat as if latent, PCN IM x3
• HIV: Universal screening. PREP if high risk. Referral to ID and counseling if positive.
• Hep B: Treatable, not curable. Routine serum screening.

No Routine Screening, diagnose if lesion

• HSV: Antivirals as needed for outbreaks, can prophylax if frequent outbreaks/immunosuppressed. Valacyclovir or acyclovir are most common.

Why: ASCCP guidelines (there is an app! Or PDF)

Cervical dysplasia — caused by HPV

CIN I–CIN3 is a progression

Risk factors: Smoking, other STIs including HIV, immunodeficiency

Histology: Increased Nuclear: cytoplasmic ratio when abnormal

Acetic Acid: exact mechanism unknown, the higher N:C ratio cells (aka abnormal cells) reflect more light and appear white.

Lugols: Iodine rich-reacts with glycogen in normal squamous cells so they appear dark.  Non-staining cells are abnormal.

HPV — changes

Colpo:

Increased vascularity, punctations, mosaicism, surface contour changes

LEEP:

Stain abnormality and know where abnormal biopsy was taken

Single pass is ideal–tag a side for orientation

+/- Top Hat depending on ECC result

CKC:

Higher up in cervical canal, but more complications

No electricity– okay if pregnant

Every visit:

• Doptones, fundal height, vitals
• Four question: Vaginal bleeding, contractions, leaking fluid, fetal movement

By Weeks:

• 20wks – get and review anatomy US
• 24wks – order glucola, cbc (check for anemia), discuss normal growing pains
• 28wks – Tdap and Rhogam if needed, discuss kick counts
• 32wks – Discuss BCM, sign tubal papers if needed, discuss TOLAC if needed
• 36wks – GBS screening, birth expectations, US for position
• 38-40wks – VE, “sweep membranes”

• Planned/Desired
• Options counseling if needed
• Exam/pelvic/pap
• Ultrasound for dating
• Screening options: QUAD, Sequential, NIPS, invasive testing
• Pregnancy guidelines
• Weight:
  • BMI under 18.5 should gain 28–40 pounds.
  • Normal-weight women (BMI, 18.5–24.9) should aim for 25–35
  • Overweight women (BMI, 25–29.9) should aim for 15–25
  • Obese women (BMI, 30 or more) should gain only 11–20
• Food: Avoid unpasteurized dairy, large fish (swordfish, shark, king mackerel, tilefish, bigeye tuna etc), uncooked meat/seafood, uncooked deli meat, EtOH
• Drugs: Nothing unless cleared by MD. Tylenol okay if needed, PNV, Colace, FeSO4. NO NSAIDs!
• Exercise: Nothing that could leave a bruise on your belly! Moderate exercise is great.

Hysteroscopy = looking inside the uterus with a scope

Steps:

1. Dilate the cervix
2. Distend the uterus with fluid
3. Look around, identify pathology, identify tubal ostia, remove pathology if using an operative scope or Myosure or another resectoscope.

Feared complication: Hyponatremia from excessive hypotonic fluid absorption.

Intrapartum

Differential diagnosis for Temp >38.0C

• Epidural fever (transient), DVT/PE (if prolonged IOL or limited mobility), UTI, Intraamniotic infection (with or without ROM), etc

Chorioamnionitis aka IAI aka Triple-I (intrapartum intraamniotic Infection)

• One temp >39.0C
• One temp 38.0C-39.0C AND one or more risk factors
• Two temps >38.0C 30+ mins apart

Tx: the standard is Ampicillin/Gentamycin until delivery. Tylenol prn temp>38C, IVF for maternal/fetal tachycardia, cooling blanket if needed to decrease temp.

If mild PCN allergy: Ancef/Gent

If severe PCN allergy: gent/clinda or gent/vanc

If vaginal delivery: No evidence that continued abx postpartum provide benefit.

If c-section: Add clindamycin to Amp/Gent.

Continue at least 1 dose postpartum. Clinical judgment on when to d/c. Some do 1 dose, some 24hrs afebrile, until clinical improvement, etc.

Postpartum

Wind – PNA, atelectasis, URI

Womb – Endomyometritis — Gent/Clinda x 24hrs afebrile

Wound – Superficial wound infection, cellulitis — eval for collection, probe wound/fascia if able

Water – UTI, Pyelo — get UA

Walking – DVT/PE

Weening – Engorgement or mastitis

Wonder drugs

Causes (Four T’s):

1. Tone: Atony
   1. Pitocin
   2. Misoprostol: CI-allergy, SI-transient hyperthermia
   3. Methergine: CI-HTN, SE-HTN
   4. Hemabate: CI-asthma. SE-diarrhea
   5. Tamponade: bakri/utah balloons
2. Trauma: Lacerations
3. Tissue: Retained POC (placenta or membranes)
4. Thrombin: Coagulopathy  
5. Other: Involution