Causes (Four T’s): Tone: Atony Pitocin Misoprostol: CI-allergy, SI-transient hyperthermia Methergine: CI-HTN, SE-HTN Hemabate: CI-asthma. SE-diarrhea Tamponade: bakri/utah balloons Trauma: Lacerations Tissue: Retained POC (placenta or membranes) Thrombin: Coagulopathy   Other: Involution

Postpartum Hemorrhage

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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

Operative Vaginal Deliveries

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&n

Induction of Labor

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

Shoulder dystocia

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

Cancer Screening and Vaccinations (HCM)

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.

Postpartum Hemorrhage

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