Obstetrics and Gynecology

OMS III Clinical Rotation

Module 1

Learning Topics (please see syllabus for corresponding objectives)

2. Intrapartum Fetal Surveillance
7. Intrapartum Care
9. I. Abnormal Labor
9.O. Obstetric procedures

Reading Assignment: Beckmann (page numbers in syllabus)

Online Fetal Monitoring Course: The NCC EFM Tracing Game is part of the free online EFM
toolkit at NCC-EFM.org. This web game uses NICHD terminology to identify tracing elements
and categorize EFM tracings
www.ncc-efm.org/game/efmgame.cfm

Additional fetal heart tone interpretations resources

https://aafp.org/afp/2009/1215/p1388.html
https://perinatology.com/Fetal%20Monitoring/Intrapartum%20Monitoring.htm

APGO Educational Videos

APGO Basic Science Video- Uterine Atony

https://www.youtube.com/watch?
v=6P9ETqav1DQ&index=20&list=PLy35JKgvOASl_S17QZjQZhRHIwPRq9Xqg

APGO Basic Science Video- Physiology of labor

https://www.youtube.com/watch?
v=gi8BZhBK1_w&index=24&list=PLy35JKgvOASl_S17QZjQZhRHIwPRq9Xqg

APGO Educational Video- Intrapartum Care

https://www.youtube.com/watch?v=p-T0nibAY74

APGO Educational Video- Abnormal Labor

https://www.youtube.com/watch?v=KHdausjbBz4&t=164s

APGO Induction of Labor App- this is a free app that allows you to determine if a patient is a
candidate for an induction, and follow their labor progress
 https://apps.apple.com/us/app/apgo-induction-of-labor/id1377296662

ACOG Committee Opinion 782- Prevention of Early-Onset Group B Streptococcal Disease in the
Newborn
https://www.acog.org/GBS

NEJM- Adjunctive Azithromycin Prophylaxis for Cesarean Delivery

https://www.nejm.org/doi/10.1056/NEJMoa1602044

Procedures- These are procedures that you should see/be part of while on your rotation. The
following will be discussed in this module. If you do not see each of these while on your
rotation, please look up videos.
Spontaneous Vaginal Delivery
Operative Vaginal Delivery (forceps and vacuum)
Episiotomy/perineal laceration repair
Leopold’s maneuvers
Cesarean Section
Epidural or Spinal Anesthesia placement
 Case 1- April

April is a 28-year-old G1P0 at 39 2/7 weeks who presents to labor and delivery complaining of
cramping that started two hours ago. The fetal heart rate tracing is reassuring, and regular
contractions are not observed. As the intern on the labor and delivery floor, you are asked to
come evaluate the patient. What are the next steps in evaluation of this patient? The
patient should get a thorough history, prenatal records, review vital signs, abdominal and
pelvic exam, fetal heart rate and measuring mom’s fundus to pelvic bone.

After a thorough history is obtained, April has a few questions about things she has read about
on her “what to expect when expecting” app on her phone
What is the difference between true labor and false labor?
- False labor contractions do not get closer together, do not increase in their time
length or frequency, and do not get stronger. True labor contractions are in more
regular intervals and closer together as time goes on.
What is a Braxton Hicks contraction?
- Tightening of the abdomen that comes and goes without cervical change.
What is “bloody show”?
- Small amount of blood or blood-tinged mucus through the vagina near the end of
pregnancy that is caused by detachment of the cervical mucus plug that seals the
cervix during pregnancy and is one sign that labor is imminent.

April’s prenatal records are reviewed and she had group beta streptococcus in her urine at
her initial obstetrics visit. She denies any drug allergies. What orders should be given to her
nurse?
- Pencillin IV for intrapartum prophylaxis 5 million units IV initial then 2.5-3million q4
hours until delivery

A cervical exam is performed and April is found to be 2 centimeters dilated, 80% effaced and
the vertex is at a 0 station, mid position and soft. Describe the terms dilation, effacement
and station and engagement.
Dilation
- Dilation of the cervix
Effacement
- Softening/thinning of the cervix (starts at about 2cm and expressed in a percentage)
Station
- Relation of the baby in relation to the ischial spine

April is encouraged to ambulate and her fetus is intermittently monitored. Two hours later
her cervix is rechecked and is found to be 4/100/0. Fetal status is reassuring and her
contractions are every three minutes. She describes her pain as a 5/10 and asks about her
options for pain control, including the risks and benefit?
 Epidural block: benefit is obviously pain reduction, as are all these procedures; risks
include hematoma, infection, epidural spinal headaches

Spinal anesthesia: same as above

Local block: risks include all the above, also more localized pain instead of generalized,
so pain may still be felt in local areas

General anesthesia: benefit is more readily controlled with less possible of infection,
headache, user error, but more risks to the fetus

IV narcotics: same with risks to the fetus, maybe not complete pain removal, as well as
possible addiction

Labor is divided into four stages. Describe each stage and events that occur during each.

First  From 0 to complete (10cm) dilation of the cervix

Second  from complete dilation until delivery of the fetus

Third  from delivery of the fetus until delivery of placenta

Fourth  from placenta to 4 hours postpartum

April is rechecked four hours later and remains unchanged. Artificial rupture of membranes
is performed and she quickly progresses to 10 cm and delivers a vigorous 7#3oz male
neonate. After delivery inspection of the vaginal canal reveals a third-degree laceration.
What is a third-degree laceration and would an episiotomy at time of delivery been
beneficial? Episiotomies are not thought to prevent lacerations anymore

Degree of Laceration Description

First degree Injury to perineal skin and vaginal epithelium only

Second degree Extends into fascia and muscles of perineum

 Third degree Injury through muscles and fascia and involves anal
sphincter

Fourth degree Muscles, fascia, both sphincters, and anal epithelium

Case 2-Amanda

Amanda is a 27- year- old G2P1001 at 38 2/7 weeks who presents to labor and delivery for
induction of labor due to poorly controlled insulin dependent diabetes. Her cervical exam is 1
cm dilated, 20% effaced and the fetal vertex is -2 station, soft and midline position. Her GBS
is negative however she was positive in her previous pregnancy. Her first pregnancy was a
SVD at 40 weeks of a healthy male neonate without any complications.

Is she a candidate for induction? (Consider using the APGO induction of labor app)
- Patient’s with history of diabetes are candidates for induction.

If she IS a candidate for induction, name three options for cervical ripening that can be used.
- Prostaglandins, membrane stripping, foley catheter with cervical ripening agent

What orders should be written given her GBS status?

- Due to her past likelihood, it is reasonable to offer prophylaxis based on history of
colonization.

Twelve hours later she is found to be 5 cm dilated with regular contractions and received an
epidural for pain management. Six hours later she has not progressed past 6 cm. How will
you manage this labor at this time? (Think about the “three P’s” that contribute to normal
labor)

Power  are contractions adequate enough to progress through labor?

Passenger  is the baby macrosomic from the mom’s diabetes, making him tough to
pass through the birth canal?

Passage  the same as above, is the baby too large to pass through mom’s canal or is
it even going to progress enough to go through labor
Abnormal labor patterns
(Please reference table 9.1 in Beckmann, Abnormal Labor patterns to answer following
questions)

Based on Amanda’s labor progress, is the proper diagnosis a first stage or second stage
disorder?
- This is a first stage disorder because she is only at 6cm dilated

Is it a protraction disorder or an arrest disorder?

- This is considered an arrest because she had no dilation for 2hrs or more

What are the options for management of this disorder?

- Continue to push, C-section, induction

After intervention, Amanda progresses to fully dilated, 100% effaced and the vertex is at +2
station. She begins pushing and over one hour later there has been no descent of the fetal
head.
Is this a first or second stage disorder?
- Second stage because she is fully dilated

Is this a protraction disorder or an arrest disorder?

- I would say a protraction disorder b/c she has had less than 1cm/hr cervical dilation
for a minimum of 4 hours

What options can we offer to Amanda at this time?

- C-section or continue pushing

Amanda states that she is exhausted and asks for help with delivery. She requests forceps or
vacuum delivery. What are the indications and contraindications to an operative delivery?
- Indicated when cervix is completely dilated, membranes are ruptured, fetal head
engaged at preferably at +2, must be read for c-section in case of failure;
Contraindications include prematurity, osteogenesis imperfecta, bleeding disorder,
unengaged head, unknown fetal position, or malpresentation

A vacuum extractor is used and between pushes the nurse notes a turtle sign. What is this
concerning for and what are the potential complications and long term sequlae to the mother
and neonate?
- Complications for mom include tearing, bleeding, or uterine rupture; for baby they
include brachial plexus injuries, hypoxia, and fetal death
Three minutes after delivery of the head, delivery of the posterior shoulder is successful and a
viable 8# 9 oz female neonate is delivered with Apgars of 6 at one minute and 9 at five
minutes. A second degree laceration was repaired. The pediatric team is called to examine
the baby. What areas of the baby should be carefully examined as a result of this delivery?
- Brachial plexus as well as clavicles and shoulder

Case 3- Tara

Tara is a 30-year-old G4P3003 at 38 5/7 weeks who presents to labor and delivery with
decreased fetal movement for the last two days. Her pregnancy has been uncomplicated.
Her prenatal labs are normal, her blood type is A negative and her GBS screening is positive.
She reports no known drug allergies.

When she is in labor, what is the recommended antibiotic prophylaxis?

Penicillin 5 million units as a loading dose and then 2.5-3 million units q4hrs until
delivery

Tara has just remembered that her mom told her she is allergic to penicillin, she had
some itching as a child. She has taken cepahalosporins in the past. Does this change the
antibiotic recommendation?
- Cephalosporins should be given as they have low risk of reaction; 2g IV initially
and then 1g q4hrs until delivery

If when she presents in labor, her GBS status is NOT known, what are the
recommendations for treatment?
- Treat her anyways

She mentions that her second baby was hospitalized for GBS pneumonia. Does this
change the management?

- No she should still be treated

A biophysical profile is performed. She scored a 6/8 (minus two points for oligohydramnios).
Her NST is shown below. What is her score and what is the recommended management?

Interpret her strip using the DR C BRAVADO pneumonic.

Baseline rate of 145, moderate variablility, contractions every 2-3 minutes, occasional
accelerations with no decelerations
Two hours later you are called to the room. Tara has had a rupture of membranes with
meconium stained amniotic fluid. Her cervix is 4 cm dilated, 80% effaced and the fetal vertex
is at -1. You are asked to interpret the fetal strip. What is the cause of these decelerations?

- Cord compression

An IUPC is placed and amnioinfusion is started with resolution of the decelerations. A

cervical exam is performed, and she is 6 cm/100/0. She requests IV narcotics and you are
called to assess the strip.

- The baby is tachycardiac at a baseline of about 185

Tara has decided that she wants to have an epidural for pain control. After placement she is
comfortable, however the nurse notes her blood pressure is significantly lower and asks you
to come evaluate her strip. What is the cause of this type of decelerations?

- Fetal/placental insufficiency

Three hours later, Tara starts to feel pressure and the urge to push. What is the cause of this
type of decelerations?
- Head compression
After pushing for two hours Tara delivers a 7# 8 oz male neonate in the vertex position with
Apgars of 9 at one minute and 10 at five minutes. A first-degree perineal laceration is noted.
Mom and baby are doing well.

Case 4

Megan is a 27-year-old G2P1001 at 38 1/7 weeks presents to labor and delivery and states
that she thinks that her water broke. Name four tests that can be used to determine
membrane status.

1. Pool of clear fluid in vaginal vault

2. Ferning
3. Nitrazine positive
4. Amniotic fluid index
The nurse relays that her cervix is 5 cm/80%/0 vertex. It is determined that her membranes
are still intact. The fetal status is reassuring and she is contracting every six minutes.

A history is obtained. Megan states that she has had an uncomplicated pregnancy. She did
fail her one-hour glucose tolerance test, but passed her three-hour test. An estimated fetal
weight done one week ago is 3233 grams. She has hypothyroidism requiring levothyroxine
25 mcg daily. Her last pregnancy was complicated by an emergent cesarean section done by
your colleague due to fetal distress.

Megan was planning to have a repeat cesarean section, but now that she has gone into labor
she desires a trial of labor. Based on her last delivery, what special counseling should she
receive? Is she a candidate for a TOLAC? Assuming she had a low, horizontal incision, yes
she is a candidate for TOLAC
 Risks of trial of labor
- uterine rupture, prolonged labor leading to other complications like fetal hypoxia,
increased fetal risk

Risks of repeat cesarean section

- uterine rupture, bleeding, all complications that come with surgery (infection, etc)

Can we offer Megan a trial of labor?

- Yes we can, assuming she had a low horizontal incision for her first c-section

Six hours later her cervix remains unchanged. She still desires to proceed with her trial of
labor. Augmentation of labor with oxytocin is discussed and started. Two hours later her
cervix is rechecked and remains 5 cm/80%/0. Upon rechecking you question the presentation
of the fetus. You are concerned that the fetus is breech. Leopold maneuver are performed.
Walk through the four steps of these maneuvers.
1. Palpating the fundus to see what body part is there
2. Attempting to find the back by palpating the abdomen
3. Attempting to find what is in the lower abdomen, which should be opposite of step 1
4. Attempting to find the brow by moving down the uterus towards the pubis; it is on
the side with the most resistance

Breech presentation is confirmed. Megan asks what her options for delivery are with this
finding. How should she be counseled? C section, continue delivery; patient should be told
risks and benefits of each and then told to make a decision

Megan decides she would like to proceed with a cesarean section. What antibiotics should be
given to her prior to her cesarean section if she does not have any drug allergies?
Azithromycin for prophylaxis
A 7# 4 oz male neonate is delivered in the frank breech presentation. Upon postpartum
rounding, she asks what her options for delivery for her next pregnancy will be. How should
she be counseled? Same as above; c section or continuing delivery but counseled on risks and
benefits of each

Her operative report is reviewed and it reads, “a low transverse incision was made in the
uterus. The infant was grasped by the ASIS and delivered to the level of the shoulders. The
shoulders were delivered and the head was flexed. The head became entrapped and so a
vertical incision was made towards the fundus to aid in delivery”. Does this change the
recommendations for her next pregnancy? Yes, she should not be allowed TOLAC, she should
have c-sections from here on out.