Obstetrics - L and D Path

Obstetrics

[LABOR AND DELIVERY PATHOLOGY]

1) Rupture of membranes Membranes can rupture spontaneously   (36 weeks (term) just deliver. This is not preterm rupture of membranes, this is premature rupture. If it’s really preterm ( 2  performed  performed on the amniotic fluid indicates fetal lung maturity and a reduced risk of ARDS. That means deliver. An L:S ratio 18 hours) between ROM and delivery, it’s termed prolonged rupture of membranes. The risk of Group B Strep goes way up. Cover with amoxicillin even if no infection is seen. Preterm rupture is caused by an infection. Prolonged rupture  puts baby and mom at risk for an infection. infection. If preterm and no induction, it’s likely there is a prolonged rupture. In any case,  prolonged  prolonged rupture can lead to Chorioamnionitis Chorioamnionitis and Endometritis Endometritis as can simply preterm rupture without prolonged. Watch those ps! Chorioamnionitis and Endometritis Both diseases have the same diagnosis, presentation, and treatment save one thing. It’s chorio  when there’s a baby still inside   and endometritis when baby has come out . This is an ascending infection that gets into the uterus. It’s the risk of keeping baby in the oven longer. The same infection that caused damage to the membranes has now set up shop in mom. Mom is

 Rush of fluid Speculum exam = pooling  Nitrazine  Nitrazine test turns turns it blue blue + Fern sign Ultrasound shows the rush of fluid was the amniotic fluid because now there is none ("oligohydramnios")

 Rupture without without contraction contractions: s: Amp+Gent Amp+Gent +/- Metro

 Rupture before before 36 weeks. weeks. Generally is also premature (mom not contracting) Can be preterm rupture, but not premature (preterm labor)  L:S ratio ratio > 2, go, go, L:S < 2, 2, Steroids

18 hours from rupture to delivery. Give amoxicillin

 Mom is toxic: cover cover broadly broadly Chorio = baby inside  Endometrio  Endometrio = baby is out  IV Amp, Gent, Metro Metro

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Obstetrics

[LABOR AND DELIVERY PATHOLOGY]

going to present with pROM and a fever. She’s going to be septic (fever, leukocytosis, tachycardia, tachypneic) and there will be an absence of other infections (and you’ll look for pneumonia, UTI, cellulitis, etc). Culture is NOT the answer; the vagina is not sterile. Vagina floral organisms are causing the infection. A culture will just show what we already know is there. Cover for gram negatives AND anaerobes with intravenous broad spectrum antibiotics (amp+gent+metronidazole). This is a sicker, worse version of the same process that causes preterm rupture. Preterm Labor Preterm labor is the leading cause of neonatal morbidity and mortality. Its cause is unknown, but it’s associated with smoking, young women, pROM, and uterine abnormalities . It’s defined as labor (3 contractions in 30 minutes with cervical change ) of a fetus that is less than term (20 weeks). That is, any delivery between 20-36 weeks is preterm labor.

 Labor (3 in 30) but not yet term.

Once preterm labor has started, there is realistically very little that can be done. Tocolytics   are used if not contraindicated, but in reality, they buy us two days at most. One isn’t better than another,  but options include Magnesium (pick this if you’re asked to choose), B-Agonists (terbutaline), Calcium Channel Blockers (nifedipine) and Prostaglandin-inhibitors (indomethacin). Use tocolysis and administer steroids if the baby has immature lungs (L:S 40 weeks by conception or >42 weeks by last menstraul period  is considered an old fetus. The dilemma usually occurs when mom is unsure on dates. The question is should we get the baby out or not? Here's how you decide. It’s imperative to determine how sure you are on the dates and what the cervix looks like to determine the treatment plan. See the grid to the right for details. Post dates can cause a macrosomic baby (too big to come through the birth canal resulting in arrest of labor or shoulder dystocia) or a dysmature baby (small baby without subcutaneous tissue).

 Dates

Cervix

Treatment

Path

Certain

Favorable

Induction

Both ready

Certain

Unfavorable

C-Section

Baby ready, Mom's not

UNcertain

 N/A

NST + AFI

C-Section when  baby is ready or in trouble.

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