5-ob2007

Obstetrics

OB 1

Pregnancy Adaptation „

Cardiovascular „ „ „ „

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Respiratory „ „ „

OB 2

↑ HR 10-15 bpm Elevation / left displacement of heart ↑ cardiac output 2° to ↑ stroke volume BP/vascular resistance ↓ ↑ Respiratory rate „ ↑ Minute ventilation „ ↓ Residual volume ↑ Tidal volume Corresponding respiratory alkalosis

Pregnancy Adaptation (Cont’d) „

Labs „ „ „ „

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GI „ „

OB 3

↓ Hgb ↑ WBC ↑ Plasma lipids ↑ Alk phos ↓ tone throughout tract Predisposes to pyrosis, GE reflux

Weight Gain „

Average weight gain – 12.5 kg (28 lbs) „

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Institute of Medicine „ „ „ „

OB 4

Fetus, placenta, breast/uterine enlargement, fluid retention – 9 kg (20 lbs) Maternal fat – 3.5 kg (8 lbs) 28-40 lbs for underweight BMI <19.8 25-35 lbs for normal weight BMI 19.9-26.0 15-25 lbs for overweight BMI 26-29 <15 lbs for obese BMI >29

Weight Gain (Cont’d) „

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Average 1 pound per week during 2nd/3rd trimester Weight gain <2 lb. or >6.5 lb. / month warrants review of eating habits, etc. Attaining pre-pregnancy weight by 6 months postpartum less long-term weight gain „

OB 5

½ loss in first 6 weeks

Nutrition „

Calories „ „ „

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Folic Acid „ „

OB 6

300 KCal increase for singleton 600 KCal increase for multiple gestation Caloric demand of breast feeding – 750 KCal per day – supplement 500 KCal 400 mcg reduces Neural Tube Defects 4 mg to those at increased risk

Nutrition (Cont’d) „

Iron „ „ „

Increase 15 mg/day for non-anemic women Readily met by most prenatal vitamins Women with iron deficiency who should receive therapeutic iron „ „

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Other „

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OB 7

1st/3rd trimester <11 gm% 2nd trimester <10.4 gm%

Fish – limit quantity and type (possible teratogenic) Caffeine – limit <500 mg/day (increase risk of abortion and still births)

Patient Education „

Air travel „

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Breastfeeding „ „

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Best feeding method for most infants Contraindications HIV infection, chemical dependency and use of certain medications

Exercise „ „

OB 8

Most airlines allow travel until 4 weeks before the expected date of delivery Lengthy trips associated with increased risk of DVT

At least 30 minutes of moderate exercise on most days Avoid activities that put them at risk of falls or abdominal injuries

Patient Education (Cont’d) „

Hair treatments „

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Medications „ „

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Not associated with adverse outcome in absence of contraindications (placenta previa)

Substance abuse: alcohol „

OB 9

Few have been proven safe Risk/reward assessment

Sex „

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No evidence of harm but should be avoided in early pregnancy Hot tubs and saunas „ Avoid in first trimester „ Associated with neural tube defects and miscarriage

No known safe amount

Patient Education (Cont’d) „

Work „

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OB 10

In uncomplicated pregnancies there is no greater hazard to continue work until labor onset Pregnancy Discrimination Act requires employers to treat pregnancy-related disabilities like all other medical disabilities

Immunization in Pregnancy „

Preconception „ „

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Contraindicated during pregnancy

During pregnancy „ „

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OB 11

Rubella (live) Varicella (live)

Hepatitis B Influenza – especially if in 2nd/3rd trimester during flu season Td

Preconception Care „ „ „

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„ OB 12

Assess for untreated common conditions Optimize treatment of chronic conditions Assess genetic risk - personal history, family history, age, ethnicity Offer cystic fibrosis screening Update immunizations - hepatitis B, varicella, rubella, influenza Consider folate supplementation

Preconception Care (Cont’d) „

Consider HIV testing „

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Environmental toxins „ „ „ „

OB 13

Treatment decreases transmission from 25% to 2% Drugs Chemicals Tobacco Alcohol

Initial Prenatal Evaluation „

History – helps identify those at special/increased risk „

Personal „

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Past OB „

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OB 14

Premature birth, Group B affected infant, birth weight, outcome

Personal/family medical history Genetic „

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Marital status, support available, financial resources, religion (Jehovah’s Witness)

Trisomy 21, neural tube defect, cystic fibrosis

Domestic violence

Initial Prenatal Evaluation (Cont’d) „

Physical exam „

Establish estimated date of confinement „ „ „

Last menstrual cycle – variable reliability Uterine size accuracy 2-4 weeks Fetal heart tones „

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Ultrasound – transvaginal or abdominal most accurate in 1st trimester to +/- 5 days. Error of test 8% „ „ „

OB 15

Doppler positive 9-12 weeks

12 weeks x 8% = +/- 1 week 20 weeks x 8% = +/- 1.6 weeks 30 weeks x 8% = +/- 2.4 weeks

Routine Initial Prenatal Evaluation „

Routine labs „ „ „ „ „ „ „ „ „ „

OB 16

Blood type and antibody screen Rh status Hemoglobin Rubella status Syphilis screen Urinary infection screen (UA/UC) HIV counseling and testing for all Hepatitis B surface antigen Chlamydia screening USPSTF for those <25 yo Pap smear – if not current

“Selected” Prenatal Evaluation „

Other labs „ „ „ „ „ „ „ „ „ „ „

OB 17

Gonorrhea screen PPD Cystic fibrosis genetic screen Hemoglobinopathy screen (sickle cell, thalassemias) Toxoplasmosis screen Hepatitis C screen Varicella immunity Diabetes screen TSH Other genetic testing including testing of parents first Chlamydia screening for those <25 yr routinely and those at increased risk

Initial Prenatal Evaluation (Cont’d) „

Follow-up labs/testing „ „

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OB 18

Diabetes screening (covered later) Sexually transmitted disease – re-screening – HIV, syphilis, HBsAg, Chlamydia, Gonorrhea Blood count/antibody screen GBS screening (covered later)

Return Prenatal Visits „

Standard routine: „ „ „

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OB 19

Every 4 wks to 30 wks Every 2 wks from 30 - 36 wks Every week from 36 weeks until delivery

Randomized controlled trials and expert panels have suggested less frequent is safe in healthy women 14 vs 9 visits

Return Prenatal Visits (Cont’d) ƒ Eight standard elements to document: ƒ Current gestational age ƒ Uterine size and growth rate ƒ BP ƒ Weight ƒ Symptoms ƒ Fetal heart tones ƒ Urine protein and glucose ƒ Patient questions and concerns OB 20

Return Prenatal Visits (Cont’d) ƒ USPSTF – repeated RH (D) antibody

testing for all unsensitized Rh (D) negative women at 24-28 weeks’ gestation, unless the biological father is known to be Rh (D) - negative

OB 21

Genetic Testing „

All patients should be offered serum marker screening for neural tube defects and trisomy 21 and 18 „

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Most physicians use maternal serum at 15-20 weeks EGA (ideally 15-18 wk EGA) for hCG, unconjugated estriol, and AFP Inaccurate dating or multiple gestation – most common reason for abnormal test Elevated AFP: open NTD Sensitivity 85% Low AFP: chromosomal abnormality „ Sensitivity 65%, specificity 95% „

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Fetal nuchal translucency can be measured by U/S (normal <3.5 mm) and combined with maternal serum analyte levels (free hCG and pregnancy-associated plasma protein A) at 10-14 weeks EGA (optimal 12-13 weeks) „ „

OB 22

Sensitivity 80-85% Specificity 90-95%

ACOG Recommendations (2006) „

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„ OB 23

All pregnant women regardless of age should be offered screening for Down’s Syndrome before 20th week of pregnancy Maternal age of 35 should no longer be used as the primary benchmark to determine who is offered screening or the option of counseling and diagnostic testing with amniocentesis or chorionic villus sampling First trimester screening using nuchal translucency and maternal analyte levels is more sensitive than second trimester maternal triple screen and as sensitive as quadruple screen Integrated first and second trimester screen is more sensitive with lower false-positive rates than first-trimester-screening alone

Amniocentesis/CVS „

Amniocentesis „ „

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CVS „ „

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OB 24

May be performed after 15 weeks EGA Risk of spontaneous abortion 1/200 to 1/1600 (Journal of OB/GYN 11/2006) Performed at 10-12 weeks EGA 1-1.5% chance of spontaneous abortion, and probably lower Associated with transverse limb defects 1/3000 to 1/1000 fetuses

Group B Strep Screening „

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OB 25

8000 cases of infant infection per year in the U.S. prior to universal screening 20% maternal colonization rate and treatment for colonization is ineffective Screening – vaginal & rectal culture @ 35-37 wk on ALL Unless – patient has positive GBS bacteriuria or previous infant with invasive GBS

Intrapartum Prophylaxis Recommended „

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OB 26

Previous infant with invasive GBS disease GBS bacteriuria during current pregnancy Positive GBS screening culture during current pregnancy (unless a planned cesarean delivery, in the absence of labor or amniotic membrane rupture, is performed)

Intrapartum Prophylaxis Recommended (Cont’d) „

Unknown GBS status (culture not done, incomplete, or results unknown) and any of the following: „ „ „

„ OB 27

Delivery at <37 weeks gestation Amniotic membrane rupture ≥ 18 hrs Intrapartum temperature ≥ 100.4°F (≥38.0° C)

PCN G 5 million units i.v. then 2.5 million units q 4 hours preferred antibiotic

Group B Strep and PCN Allergy „

If patient reports penicillin allergy „ „

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How severe? Culture and add sensitivity to clindamycin and erythromycin (15% resistant to either)

Intrapartum antibiotics „

If PCN allergy not anaphylaxis „

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If PCN anaphylaxis „ „

OB 28

Cefazolin 2g x 1, then 1 g q 8 hr Clindamycin (300 mg IV q 6 hrs) is preferred Erythromycin (500 mg IV q 6 hrs) if resistant to clindamycin – crosses placenta less predictably

Intrapartum Prophylaxis – NOT Recommended „

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OB 29

Previous pregnancy with positive GBS screening culture (unless a culture was also positive during the current pregnancy) Planned cesarean delivery performed in the absence of labor or membrane rupture (regardless of maternal GBS culture status) Negative vaginal and rectal GBS screening culture in late gestation during the current pregnancy, regardless of intrapartum risk factors

Antepartum Fetal Assessment „ „

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Fetal movement – “kick counts” (no proven benefit) Contraction stress test (CST) – Fetal heart rate (FHR) – response to uterine contractions Nonstress test (NST) – FHR response to fetal movement Biophysical profile (BPP) – NST plus U/S assess of fetal breathing, fetal movements, fetal tone and amniotic fluid volume (AFV) „

OB 30

Scoring – 2 points per criteria „ 8-10 normal „ 6 equivocal „ 4 or less abnormal

Antepartum Fetal Assessment (Cont’d) „

Modified BPP – NST w/ AFI „ „

„ „

OB 31

Normal – NST reactive, normal AFV Abnormal – NST non-reactive or abnormal AFV

Umbilical Artery Doppler Velocimetry Testing may be initiated as early as 26 weeks (usually 32-34 weeks) and repeat q1 week

Normal Labor

OB 32

Contractions of True Labor ƒ ƒ ƒ ƒ

OB 33

Occur at regular intervals Interval gradually shortens Intensity gradually increases Adequate to cause cervical dilatation

Admittance Examination „ „ „ „ „

„ „ „ OB 34

Cervical effacement, dilatation, position Station Presentation Detection of ruptured membranes Review of pregnancy record (blood type, hepatitis status) Confirmation of dates Vital signs Physical examination (look for herpes lesions)

Management of First Stage Labor „

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„ OB 35

Monitoring fetal well-being (intermittent vs. electronic continuous monitoring) Assessment of uterine contractions (external vs. internal monitoring) Amniotomy (routine vs. poor progress) Analgesia „ IV vs. IM narcotics „ Intrathecal „ Epidural „ Non-pharmacological / Doula Alternative positions (birthing ball, jacuzzi, squatting, walking)

Active Management of Labor „

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„ OB 36

Artificial amniotomy upon detection of painful uterine contractions with passage of mucous plug or complete cervical effacement Oxytocin if cervical dilatation does not progress at least 1 cm per hour More aggressive oxytocin administration (begin at 6mu/minute, and increase by 6mu/min q 15 minutes up to 40mu/min) Realize that most patients prefer ambulation to oxytocin Goal: Patient to deliver within twelve hours of the onset of labor

Management of Second Stage „

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OB 37

Onset begins with full dilation of cervix until delivery of infant Highly variable duration Slowing of heart rate during contraction is common (due to head compression, reduced placental perfusion or nuchal cord) Recovery of fetal heart rate should be prompt after contraction and expulsive efforts cease Position changes (upright, side lying) Restrictive use of episiotomy (fetal distress, shoulder dystocia, vacuum/forceps delivery)

Restricted Use of Episiotomies „

Episiotomy does not: „

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ACOG (2006) stated that there is not enough evidence-based criteria to recommend “evidencebased criteria to recommend episiotomy”; “clinical judgment remains the best guide for use…” Perform 30% of all vaginal deliveries Restricted use is preferable to routine use Median episiotomy is associated with higher rates of injury to anal sphincter and rectum than mediolateral approach Median approach „

OB 38

Lower the risk of incontinence by reducing pelvic floor damage Reduce the rate and severity of perineal lacerations

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Easy to perform and repair Less postpartum pain and dyspareunia

Spontaneous Delivery „ „

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OB 39

Delivery of head (controlled) Delivery of shoulders (gentle downward traction applied until anterior shoulder appears under pubic arch) Optional: Delivery of anterior arm to prevent tears Delivery of rest of body

Management of the Third Stage „

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Onset after infant delivers until placenta delivery Average duration 5 minutes 95% placenta delivered by 30 minutes Retained placenta for >30 min commonly used „

OB 40

WHO - 60 minutes

Management of the Third Stage (Cont’d) „

Management „

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Expectant - no use of uterotonic agents, cord clamping, or cord traction Active – use of uterotonic agents (Pitocin), cord clamping or cord traction „

As compared to expectant „ „ „

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Postpartum hemorrhage defined as „ „

OB 41

Ð Blood loss 80ml Ð Postpartum hemorrhage (>500 ml) RR=0.4 Ð Prolonged 3rd stage by 10 minutes

Ð hct >10%, Ð hemoglobin by 3 gm/dl Need of blood transfusion

“Fourth Stage” of Labor „

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OB 42

Examination of placenta (intact), membranes and umbilical cord (3 vessels) Uterine massage; early breast feeding; oxytocin Observe for signs of postpartum hemorrhage Examination of vagina and perineum for lacerations

Preterm Complications

OB 43

Definitions „

Preterm Labor (PTL) „ „

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Uterine contractions (>3/30 min) Accompanied by cervical change (effacement or dilation) Prior to 37 completed weeks gestation

Premature ROM (PROM) „

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Rupture of membranes prior to the onset of labor by ≥ 1 hour, also known as Prelabor Rupture of Membranes Preterm PROM „

OB 44

PROM and < 37 weeks

Pre-Term Labor Risk Factors – Not Sensitive or Specific for PTL „ „

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OB 45

Prior preterm birth „ Maternal age „ <14 >40 Low socioeconomic status „ Race African American Known uterine and placental anomalies Trauma

Preterm PROM (1530% recurrence) Uterine distention (twins, polyhydramnios) Maternal infections „ „ „ „

Bacteriuria Pyelonephritis Genital tract Pneumonia

PTL/PROM History „ „ „ „

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OB 46

“Labor History” Fluid leakage - (felt pop or gush) Pregnancy dating Risk factor review (infection, trauma, etc.) Maternal medical/obstetrical problems Assess social and home support

PTL/PROM - Diagnosis „

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General exam (look for signs of trauma or infection) Abdominal exam (uterine tenderness, size, Leopold’s) External fetal monitor (fetal heart rate, periodic changes, contraction pattern) Labs „ „

OB 47

CBC UA/UC

PTL/PROM - Diagnosis (Cont’d) „ „

No digital exam if suspected preterm ROM Speculum exam „ „ „ „ „ „

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OB 48

Vaginal swab for fetal fibronectin (fFN) Cervical dilation Pooling of fluid Cultures – GC, Chlamydia Consider wet mount for bacterial vaginosis/trichomonas Nitrazine pH >7 „ False positive – blood, seminal fluid, proteus infection of urine „ Otherwise very sensitive/specific test Ferning „ False positives cervical mucus, saline „ Very sensitive/specific

PTL/PROM - Diagnosis (Cont’d) „ „

GBS testing Ultrasound assessment for: „ „ „

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Amniotic fluid for fetal lung maturity „

OB 49

Gestational age Cervical change Fluid volume With PROM, may be obtained from vaginal pool

Fibronectin „

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OB 50

Negative fibronectin test (>24 weeks gestation) useful to rule out preterm delivery in next 2 weeks Most useful when combined with results of U/S (substantial ↑ risk of preterm birth if positive fibronectin and cervical length < 25mm) Lubricants and manipulation of cervix within 24 hours causes false-positive reaction (coitus, cervical examination)

Inhibition of Pre-Term Labor „

Goals „ „

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Criteria „ „

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OB 51

Delay delivery until steroids can be administered Allow safe transport of mother, if indicated, to perinatal center Prolong labor while associated and contributing illnesses treated (trauma, pyelonephritis) Presence of preterm labor; not just contractions EGA < 34 weeks „ Threshold where risk/benefits are acceptable Absence of contraindications „ Fetal demise or lethal anomaly „ Severe IUGR „ Severe preeclampsia/eclampsia

Inhibition of Pre-Term Labor (Cont’d) „

Bedrest, Hydration, Sedation „ „

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Doubtful efficacy No randomized studies in singleton pregnancies

Beta-Adrenergic Agonists „ „

Ritodrine – effective but no longer manufactured Terbutaline „ „

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Effective Commonly given s.q. 0.25 mg every 20-30 min up to 4 doses then q 4 hours prn for 24 hours Side effects „

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OB 52

Maternal – chest pain, SOB, palpitations, tremor, pulmonary edema, hypokalemia, hyperglycemia Fetal – tachycardia and neonatal hypoglycemia (2° to maternal hyperglycemia)

Inhibition of Pre-Term Labor (Cont’d) „

Magnesium Sulfate „ „

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No more effective than placebo Dose 4-6 gm i.v. bolus over 20 minutes followed by infusion of 2-4 gms/hr to therapeutic level of 4-8 mEq/L Side effects „ „

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Calcium Channel Blockers „ „

Possibly effective Nifedipine (immediate release) „

OB 53

Maternal – decreased BP, nausea, flushing, headache Toxicity „ Loss of deep tendon reflexes 8-10 mEq/L „ Respiratory paralysis 10-15 mEq/L „ Cardiac arrest 20-25 mEq/L

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30 mg p.o. then 20 mg p.o. 90 min later OR 10 mg p.o. q 20 min max of 4 doses then 20 mg q 4-8 hours

Inhibition of Pre-Term Labor (Cont’d) „

Indomethacin „ „

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Antibiotics „ „

OB 54

Possibly effective Premature closure of ductus arteriosus and oligohydramnios are potential side effects and fetal ultrasound evaluation if > 48 hours of treatment needed 50-100 mg p.o./pr. Load then 25 mg q 4-6 hours Not effective in PTL without membrane rupture Should be used as part of prevention of early-onset GBS infection

Pre-Term Labor Management „

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NIH consensus statement: steroids are highly effective in preventing Respiratory Distress Syndrome, intraventricular hemorrhage and neonatal mortality – effective within 18 hours, maximal benefit at 48 hours Criteria: „ „

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Drug Regimens: „

OB 55

Fetus at 24-34 weeks gestation No fetal or maternal contraindication to delaying delivery for 24-48 hrs No maternal contraindications to steroid administration (i.e., active TB)

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Betamethasone 12mg IM q 24h x2 Dexamethasone 6 mg IM q 12h x4

Pre-Term PROM Management „

Hospitalized vs. home management „ „

Initially hospitalize all patients for 3 days Suggested criteria for home management „

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OB 56

Reliable patient, dependable transportation to nearby hospital Vertex No evidence of infection or labor Adequate amniotic fluid Weekly ultrasound Maternal temp b.i.d.

Pre-Term PROM Management (Cont’d) „

Inhibition of labor if present „

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Steroid use „ „

OB 57

Same guidelines as PTL but more controversial 2° to higher risk of infectious etiology in preterm PROM Only until 32 weeks given unfavorable risk/benefit assessment after 32 weeks To week 32 gestation Single course

Pre-Term PROM Management (Cont’d) „

Antibiotics „

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Prophylactic antibiotics – prolong latent period between PROM and labor Multiple regimens – examples „ „

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i.v. initially then p.o. course for 7 days GBS prophylaxis during labor if indicated

Delivery „ „

OB 58

Ampicillin Ampicillin plus erythromycin or azithromycin

Expectant until 32 weeks EGA Allow delivery when fetal lung maturity and EGA >32 weeks

Term PROM Management „ „

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OB 59

Expectant management vs. induction? Oxytocin in patients with PROM may decrease infection rates without increasing C-section rates Induction of labor should proceed at first sign of infection If unfavorable cervix - may use prostaglandins followed by oxytocin if necessary

Post-Term Pregnancy „

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Defined as a pregnancy that has extended to or beyond 42 weeks of gestation Incidence of 7% „ „

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Stillbirth rate 1/3,000 at 37 weeks EGA; 3/3,000 at 42 weeks EGA and 6/3,000 at 43 weeks EGA Associated with oligohydramnios, dystocia, macrosomia, severe perineal injury and doubling the rate of cesarean delivery No interventions known to decrease rate „ „

OB 60

True post-term infants 3% Incorrect dating common

Nipple stimulation Membrane sweeping

Post-term Pregnancy (Cont’d) „

Antenatal Surveillance „

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Common, universally accepted practice but no evidence of decreased perinatal mortality Commonly started at 41 weeks and done twice weekly (BPP, NST, AFI, modified BPP) Labor induction „

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OB 61

Many recommend prompt delivery with a favorable cervix Those with unfavorable cervix can either undergo labor induction or expectant management unless evidence of fetal compromise or oligohydramnios

Labor

OB 62

Normal Labor „

OB 63

Contractions of sufficient frequency, intensity and duration that result in cervical effacement and dilation

Stages of Labor First Stage: Latent phase: Contractions are mild, infrequent, irregular, slow cervical change Active phase: Contractions strong, frequent, regular, increase rate of cervical change

OB 64

≤ 4cm

> 4 cm

Second Stage: Pushing → delivery

Complete

Third Stage:

Placenta

Stages of Labor (Cont’d)

OB 65

Dystocia - Difficult Labor „ „

Protraction Disorders - slower than usual progress Arrest Disorders - complete cessation of progress

Abnormal Labor Patterns & Diagnostic Criteria

OB 66

Labor Pattern

Nulligravida

Multipara

Protraction disorders Dilation Descent

<1.2 cm/h <1.0 cm/h

<1.5 cm/h <2.0 cm/h

Arrest Disorders Dilation Descent

>2h >1h

>2h >1h

Dystocia (Cont’d) „

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Extrinsic Factors - EFM, epidurals, lack of social support Restrictive postures

Power Contractility <200 Montevideo Units <3-5 Contractions/10 minutes

OB 67

Assessment Passenger

Passageway

Macrosomia

Contracted Pelvis

Fetal Anomaly

Clinical Pelvimetry

Malpresentation

Dystocia Management „

Inefficient Uterine Contractions: „ „ „ „ „

OB 68

Ambulate Change positions Amniotomy Oxytocin Allow more time: 4 hours for dilation, 2 hours for descent, longer for regional anesthesia

Dystocia (Cont’d) Oxytocin Complications

OB 69

Treatment

Hyperstimulation Fetal Distress

Decrease rate/dose Stop infusion Terbutaline 0.125-0.25 Mg Sulfate 2-6 grams

Uterine Rupture

Emergent c/s

Fetal Distress

Maternal O2 Change position Cervical check

Fluid retention/overload

Stop infusion

First Trimester Complications

OB 70

Spontaneous Abortion ƒ Types ƒ Missed – no bleeding, closed os, embryo/fetus died ƒ Threatened – bleeding, closed os ƒ Inevitable – bleeding, os open ƒ Incomplete – tissue still present

ƒ Pathophysiology / Etiology ƒ ƒ ƒ ƒ OB 71

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Chromosomal anomalies – most common (50%) Maternal factors Environmental factors Immunological factors Uterine defects

Clinical Picture „ „ „ „

OB 72

Vaginal bleeding (most common) Cramping, backache Passage of tissue Quantitative HCG doubles every 48 hours until 6 wks in a healthy pregnancy

Diagnosis „

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OB 73

Abdominal exam (pain, tenderness, distention) Bimanual exam (uterine size, adnexal masses) Speculum exam Ultrasound / HCG Rule out ectopic and abnormal pregnancy by vaginal ultrasound

Management „ „

Hemodynamically unstable = D&C Hemodynamically stable „

Follow up „ „ „

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OB 74

Tissue passed/exam by pathology Consider U/S follow up to confirm empty uterus If no tissue, follow serial HCGs to <5

Give Rhogam (50 mcg) if mother Rh negative Grief counseling Follow-up appt - 2 weeks

Ectopic Pregnancy „

Risk Factors „

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Presentation „ „

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OB 75

Prior tubal surgery, prior PID, prior ectopic, DES exposure, smoking, assisted reproduction, contraception with progestin only or IUD Amenorrhea, positive pregnancy test Bleeding, abdominal pain

Heterotopic pregnancy - combined intrauterine and extrauterine pregnancy; rare but possible especially in fertility treatment - IFV

Diagnosis (Ectopic) „ „

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OB 76

Abdominal exam Æ tenderness Pelvic exam Æ adnexal mass, cervical motion tenderness, enlarged uterus, bulging cul-de-sac Vital signs may be hypotensive, tachycardic

Diagnosis (Ectopic) (Cont’d) „

Labs „ „ „

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Radiology „ „ „

OB 77

HCG (not doubling) CBC Serum progesterone (>25 excludes ectopic, <5 suggests nonviable, 5-25 grey zone) U/S to look for IUP Transvaginal ultrasound may be more helpful When hCG >1500 visualization of an intrauterine pregnancy should be seen to exclude ectopic pregnancy

Management „

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Expectant (HCG <1000 and falling, mass <3 cm, ØFHT) Medical (methotrexate) „

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Surgical „

OB 78

Patient very reliable, no medical contraindication (nl LFTs), ectopic mass <4cm, ØFHT, HCGs <5000 Unstable patient, unreliable f/u, uncertain dx, high HCG, large mass

Gestational Trophoblastic Disease „ „

1 in 1000-1500 pregnancies Risks „ „

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Clinical Presentations „ „ „ „ „

OB 79

Previous disease At extremes of reproductive age Vaginal bleeding High HCG levels Uterus size > dates Absence of FHT Presence of PIH < 20 weeks, hyperemesis, thyrotoxicosis

Hydatidiform Mole „

Diagnosis „

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Treatment „ „

OB 80

Ultrasound Uterine evacuation Follow-up: serial HCGs, 6-12 months

Hyperemesis Gravidarum „

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Severe end of spectrum of morning sickness variably defined but generally reserved for persistent vomiting, weight loss > 5% and ketonuria Morning sickness „ „

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Lab test abnormalities „

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OB 81

50-90% of all pregnancies Onset EGA 5-6 weeks, peak 10 weeks, usually resolves by 16-18 weeks but may persist to term 1015%

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Decreased TSH – may be 2° to higher HCG that have TSH-like activities Rarely associated hyperthyroidism symptoms and elevated Free T4 and Free T3 ALT elevation common with severe emesis

Hyperemesis Gravidarum (Cont’d) „ „

Etiology – undetermined Treatment „

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Avoidance of “emetogenic triggers” if possible odors, heat, foods, etc. Small frequent meals P6 acupuncture, acupressure wrist bands, powdered ginger, psychotherapy of questionable benefit Hydration and adequate nutrition „

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OB 82

May need PICC line for hyperalimentation

No FDA approved drugs Pyridoxine (Vitamin B6) 10-25 mg tid

Hyperemesis Gravidarum (Cont’d) „

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Doxylamine 12.5 mg tid „ With Vitamin B6 is the same as Bendectin which was removed in 1983 but data support its safety and efficacy Antiemetics (examples) „ Promethazine (Phenergan) „ Metoclopramide (Reglan) „ Prochlorperazine (Compazine) „ 5 – HT3 antagonist „ „

OB 83

Kytril Zofran

Third Trimester Complications

OB 84

Causes of 3rd Trimester Bleeding „

Major „ „ „ „

OB 85

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Placenta Previa Abruption Ruptured Vasa Previa Uterine rupture/ laceration

Minor „ „ „ „ „

Bloody show Cervical polyps Cervical cancer Cervical ectropion Vaginal trauma

Placenta Previa „

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OB 86

Definition „ Placenta located over or near cervical os Presentation „ Painless vaginal bleeding (“sentinel bleed”) „ 1/3 will bleed before 3rd trimester Etiology - unknown „ Higher risk if prior C-section or D&C „ Possible myometrium / endometrium distortion

Placenta Previa (Cont’d) „

Risk factors „ „ „ „ „ „

OB 87

Advanced maternal age Multiparity Prior C-section or D&C Smoking Prior previa 90% of placenta previa diagnosed prior to 24 weeks resolve

Placenta Previa (Cont’d) „

Evaluation „ „ „ „

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„ OB 88

Assess vitals, fundal height, lie, FHTs Gentle speculum exam - controversial No digital exam w/o placental location known Labs - hematocrit, type and Rh, coag. studies Ultrasound can confirm diagnosis Most previas become symptomatic >35 weeks

Treatment – usually cesarean section

Placental Abruption „

Definition „

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Presentation „

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Bleeding - 70-80% (20-30% can present w/o bleeding) Uterine tenderness / back pain - 66% Uterine hypertonicity - 17% Demise - 25-35% DIC 13%

Etiology - Multifactorial „

OB 89

Separation of placenta from implantation site

External trauma, cocaine, smoking, HTN, preterm rupture, acute decompression of amniotic fluid

Placental Abruption (Cont’d) „

Risk Factors „ „ „ „ „ „ „

„ OB 90

„

Prior abruption Increased age and parity Preeclampsia Chronic HTN Preterm ROM Cigarette smoking Thrombophilias (factor V leiden, protein C/S, AT III, anti-phospholipid, lupus anticoagulant) Cocaine use Uterine leiomyoma

Placental Abruption (Cont’d) „

Management „

„

„

„ „

„ OB 91

First assess maternal hemodynamics - pulse, BP, shock Assess fetal viability (>50% mort. w/ detachment) Assess fundal height, fetal lie, location of tenderness, tetanic ctx’s Fluid resuscitation, transfusion Watch for DIC (10% of all abruptions, 30% if dead fetus) Note: This is a clinical diagnosis, not an ultrasound diagnosis

Placental Abruption (Cont’d) „

Assess fetal viability: „

„

OB 92

Fetal demise: „ Deliver fetus (vaginally if stable, Csection if malpresentation or unstable) „ Prepare to transfuse Live fetus: „ Rigid uterus – C-section „ Soft uterus – induction of labor

Vasa Previa „

„ „ „ „ „

Umbilical vessels traverse membranes and pass by cervical os Risk of laceration of vessels with ROM Fetal mortality 50-75% Immediate C-section Resuscitation of mom and baby Antepartum diagnosis (difficult) „ „ „

OB 93

US with doppler Palpation of vessels on vaginal exam Amnioscopy

Oligohydramnios at Term „ „ „

„

OB 94

Defined as amniotic fluid index (AFI) <5 cm Occurs in 1-5% of pregnancies Associated with adverse outcomes when accompanies by IUGR, malformations, etc. Amniotic fluid primarily produced through fetal urine production and fetal lungs and resorbed by fetal swallowing and the placenta; can be affected by maternal hydration

Oligohydramnios at Term (Cont’d) „

Etiology „ „

„

Acute – rupture of membranes Chronic „ Fetal urogenital abnormalities „ Uteroplacental insufficiencies (decreases fetal renal perfusion)

Management once AFI <5 cm „ „

„ „

Evaluate for PROM Determine presence of risk factors (HTN, IUGR by history and fetal ultrasound) If abnormalities present – induce labor Initiate maternal hydration 2 L oral water and recheck AFI in 2-6 hours „ „

OB 95

„

<5 cm – induce labor 5-8 cm – measure AFI in 3-4 days >8 cm BPP 1-2/wk

Vaginal Birth after Cesarean Delivery (VBAC) „

Advantages - lower rates of „ „ „ „ „ „

„

Disadvantages „

OB 96

Postpartum fever Wound infection Maternal discomfort Length of hospital stay Blood transfusion +/Neonatal respiratory problems Uterine rupture - increased risk of symptomatic rupture of 2.7 per 1000 as compared to elective repeat cesarean delivery (ERCD)

Vaginal Birth after Cesarean Delivery (VBAC) (Cont’d) Disadvantages cont’d „ „

„

„

OB 97

Risk factor of uterine rupture There is no difference in asymptomatic uterine rupture rates in trial of labor vs elective repeat cesarean Uterine scar „ Classical 4-9% „ Low vertical 1-7% „ Low transverse 0.2-1% „ Prostaglandin induction Clinical presentation „ Vaginal bleeding „ Maternal shock „ Fetal brachycardia, variables, late decelerations „ Abdominal pain „ Loss of station

Vaginal Birth after Cesarean Delivery (VBAC) (Cont’d) Disadvantages cont’d „

„

Candidates for VBAC „ „

„

„

OB 98

Perinatal death „ Probably increased „ Similar to nulliparous without planned Cesarean delivery (10 per 10,000 vs ERCD 0.4 per 10,000) No other uterine scar except low transverse cesarean Physician “immediately” available who can perform emergent cesarean Anesthesia within 30 minutes

Success rate - 75%

Vaginal Birth after Cesarean Delivery (VBAC) (Cont’d) „

Labor management „

„ „

OB 99

Augmentation or labor induction - acceptable but avoid misoprostol Epidural anesthesia safe Recommend continuous electronic fetal heart rate monitoring

Medical Complications of Pregnancy

OB 100

Pneumonias Bacterial Strep pneumo

See ID sectionAntibiotics

Atypical Mycoplasma

Macrolide

Influenza A

Vaccine

See ID sectionAntivirals

Varicella

IV Acyclovir

Aspiration

Nonparticulate Antacids Broad Spectrum Antibiotic

Tuberculosis

All pregnant women @ high risk should be screened with PPD

Risks: OB 101

HIV Close contact Low income Alcoholism IV drug use Medically underserved Birth in an epidemic country

Gestational Diabetes „ „

First occurs during pregnancy 10% of the time it can represent latent Type I DM „ „ „ „

„

Associated with (especially when worsening control) „ „ „ „ „

OB 102

Lean women DKA during pregnancy Requires larger doses of insulin Anti-insulin/anti-islet cell antibody positive

„

Preeclampsia Polyhydramnios Fetal macrosomia Birth trauma Neonatal metabolic complications (Èglucose, Çbilirubin, Ècalcium, Çhct) Prenatal mortality

Gestational Diabetes (Cont’d) „

Screening „

Selective screening - recommended by ADA and ACOG „ Must meet all of the following criteria „ „

„ „ „ „

„

OB 103

<25 years of age Not member of racial or ethnic group with higher risk (Hispanic, Native American, African) BMI <25 No history of previous abnormal testing No previous adverse OB outcomes often associated with GDM No FMH of first-degree relatives with DM

Universal - screen all

Gestational Diabetes (Cont’d) „

Screening „ „ „

24-28 week EGA 1 hr 50 gm oral glucose challenge Results „

>130 „ „

„

>140 „ „

„

OB 104

90% sensitive 20-25% of women are positive 80% sensitive 15-20% of women are positive

Confirm abnormal 1 hr test with 3 hr (some do 2 hr)

Gestational Diabetes (Cont’d) Glucose Tolerance Test Time

Serum Glucose Threshold

Fasting 1 hr 2 hr 3 hr

95 180 155 140

2 or more abnormal tests required for GDM

OB 105

Gestational Diabetes (Cont’d) „

Treatment „

Diet - may not prevent macrosomia by itself „ Caloric allotment 30 KCal/kg/d 80-120% IBW 24 KCal/kg/d 120-150% IBW 12-15 KCal/kg/d >150% IBW „ Carbohydrate 40% carbohydrates 20% protein 40% fat „ Calorie distribution „ „

OB 106

3 meals, 3 snacks Limit carbohydrates in AM

Gestational Diabetes (Cont’d) Treatment cont’d „

„

„ „

OB 107

Glucose monitoring - blood monitoring FBS <90 (normal fasting 55-60 mg/dl) 1º postprandial <120 (normally never >105 mg/dl) Insulin „ ADA/ACOG FBS<95 and 2º hr BS <120 „ Others FBS<90 and 1º hr BS <120 Exercise encouraged Oral hypoglycemic agents „ Glyburide „ Metformin

Gestational Diabetes (Cont’d) „

Fetal surveillance/delivery „ „ „ „

„

Future risk „ „

OB 108

None needed if good control and not on insulin Otherwise monitor in third trimester Delivery at 39-40 weeks if no complications Consider cesarean if estimated fetal weight >4.5 kg by U.S. Up to 50% recurrence with subsequent pregnancy Up to 50% occurrence of Type 2 DM over the next 5 years

Infections During Pregnancy Varicella „ „ „

„

„ „ „

OB 109

„

Pneumonia and Encephalitis in adults Transmitted across placenta Congenital varicella syndrome - skin scarring, limb defects, microcephaly – limited to exposure < 20 weeks pregnant 1-3% risk of occurrence Neonatal VZV infection - peripartum exposure 5 days prior to and up to 2 days after delivery; 10-20% death rate If seronegative and exposed then VZIG If pregnant + develop chicken pox then acyclovir Nonpregnant women without H/O varicella infection should be offered vaccine Pregnant women should not be offered the vaccine

Herpes Simplex (HSV-2) „ „

Neonatal: 50% mortality with primary infection. Management: ACOG Recommendations „

„

„

„

OB 110

Women with primary HSV during pregnancy should be treated with antiviral therapy Cesarean delivery should be performed on women with first-episode HSV who have active genital lesions at delivery For women at or beyond 36 weeks of gestation with a first episode of HSV occurring during the current pregnancy, antiviral therapy should be considered Cesarean delivery should be performed on women with recurrent HSV infection who have active genital lesions or prodromal symptoms at delivery

Thyroid Disease „

Hyperthyroidism „ „ „ „ „

OB 111

Most common - Graves Propylthiouracil - drug of choice in pregnancy Beta-blockers diminish symptoms Can be associated with trophoblastic disease Avoid radioiodine scanning - crosses the placenta

Thyroid Disease (Cont’d) „

Hypothyroidism „

„

„

„

OB 112

Associated with low birth weight, fetal loss, gestational HTN and poor perinatal outcome Current consensus to check TSH; free T4 q 6-8 weeks during pregnancy; maintain TSH 0.5-2 µ units/ml Requirements increase early in pregnancy therefore increasing trend to increase dose 25-50 mcg daily and check TSH/free T4 in 4-6 weeks as soon as pregnancy diagnosis Routine screening of TSH debated; incidence of TSH > 6 µ units/ml = 2.5% with 10% being overtly hypothyroid

Pre-existent HTN „ „

Onset before EGA of 20 weeks Risks associated with „ „ „ „ „

„

Indications for treatment „

„

„

OB 113

Premature birth IUGR Fetal death Abruption Preeclampsia DBP >100 or SBP >150-160 „ Neither mother or fetus at risk if below these values DBP 100-110 or SBP 150-180 „ Benefits controversial DBP >110 or SBP >180 „ Benefits - maternal

Pre-existent HTN (Cont’d) „

Drugs „ „ „ „ „

„

Fetal surveillance „ „

„

For preeclampsia For IUGR by U.S. 16-20 wk, 28-32 wk and then monthly

Delivery „

OB 114

Methyldopa and hydralazine - drugs of choice B-blockers (except atenolol) Thiazide diuretics (not new starts) Labetolol Nifedipine - long acting

At term with uncomplicated cases

Hypertensive Disease in Pregnancy (Cont’d) „

Preeclampsia „

„

HTN >140/90 and proteinuria >0.3 gm/24hr and onset after 20 wk EGA BP control „ „

„

DBP >110, SBP >160-180 Same drugs as previous

Delivery „

Conservative if mild and remote from term „ „ „ „

OB 115

HTN controlled and not severe (DBP >110) Normal renal, hepatic, hematologic function No coagulopathy Fetal evaluation - reassuring

Hypertensive Disease in Pregnancy (Cont’d) „

Immediate delivery if „

Severe preeclampsia „ „ „ „ „

„

Seizure prophylaxis for labor „

OB 116

HTN >160/110 Proteinuria >5 gm/d ÇLFT, ÇCREAT CNS disturbances RUQ pain MgSO4 „ 4 gm load „ 2-3 gm/hr I.V. infusion „ Mg level therapeutic 4-8 mEq/L

Hypertensive Disease in Pregnancy (Cont’d) „

Eclampsia „ „ „

OB 117

Presence of seizure usually tonic - clonic Immediate delivery usually warranted HTN control and seizure prophylaxis - as above

HELLP Hemolysis, Elevated Liver Enzymes, Low Platelets „

Lab: „ „ „ „

„

„ „

OB 118

Hemolysis on smear ↑ Bili >1.2 ALT, AST >2 times upper limit of normal Platelets <100,000

Fluids, antihypertensive, antiseizure meds, coag factors Assess baby Delivery plan

Acute Fatty Liver „

„

„

„

„ OB 119

Risks: Primip, multiple gestation, 3rd trimester, PIH Clinical: Malaise, HA, N/V, abdominal pain Progresses - jaundice, petechiae, coma, RF, DIC Lab: ↑LFT; ↑ bili, severe hypoglycemia, prolonged PT, PTT, ↓ fibrinogen Tx: Supportive, Delivery Plan

Amniotic Fluid Embolism (AFE) „

„

„ „ „ OB 120

Risks: Multiparity, tumultuous labor, oxytocin, abruption, IUFD, particulate amniotic fluid, atony Clinical: Resp. distress → cyanosis → seizure = Cardiovascular collapse → DIC hemorrhage → death Lab: ABGs, Lytes, CBC, Coags. EKG, CXR Rx: ACLS

DIC in Pregnancy „

„

„ „ „

OB 121

Related causes: abruption, IUFD, HELLP, pre-eclampsia, AFE, HUS Lab: ↓ platelets ↓fibrinogen ↑FDP prolonged PT, PTT Rx: Eliminate/treat cause Correct coag defects FFP, platelets, cryoprecipitate

Blunt Trauma in Pregnancy ƒ Risks „

„ „

Dx: Primary survey Maternal: „ „ „ „

OB 122

MVA, assault, falls

X-ray, US, peritoneal lavage Lab: Kleihauer Betke, coags, HCT, Rh. Fetal: Fundal height, uterine ctx, FHTs Assess vag. bleeding, SROM, cervix dilation + effac.

Blunt Trauma in Pregnancy (Cont’d) „

Discharge Criteria „ „ „ „

„

„

OB 123

If >20 wks gest.: monitor for contractions If <3 ctx/hr x 4 hrs: = discharge If 3-7 ctx/hr: monitor 24 hrs If >7 ctx/hr: high risk for abruption

Discharge - resolution of CTXs, reassuring FHTs, intact membrane, no uterine tenderness, no bleeding All Rh neg mothers - receive Rhogam - full dose; (more if Kleihauer-Betke test positive)

HIV in Pregnancy „

„

„ „

„

OB 124

Updated recommendations at www.aidsinfo.nih.gov Treatment decreases vertical transmission from 25% to <2% Multiple groups advocate universal screening Repeat screening in third trimester for highrisk women Prenatal treatment depends on woman’s prior HIV treatment (check clinical scenarios in guidelines)

HIV in Pregnancy (Cont’d) „

Various factors that increase transmission „

„

„

OB 125

Maternal – viral load, CD4 count, other infections such as Hep C, injection drug use OB – prolonged ROM, vaginal delivery, invasive procedures Infant - prematurity

HIV in Pregnancy (Cont’d) „

„

„ OB 126

Zidovidine (ZDV) prophylaxis should be given to women even if low or undetectable viral load (2 mg/kg loading dose, then 1 mg/kg/hr until delivery) If viral load >1000 - counsel on potential benefit of scheduled C-section to reduce perinatal infection Want ZDV at least 3 hours before delivery

HIV in Pregnancy (Cont’d) „

If woman presents in early labor or ruptured, start ZDV stat, and minimize invasive procedures (fetal scalp electrode, AROM, etc.) „ „

OB 127

May proceed to C/S if minimal dilation May use oxytocin to expedite vaginal delivery

Postpartum Hemorrhage

OB 128

Problem „

„ „

OB 129

Slow, steady blood loss unrecognized/ minimized Minimal external bleeding Clinical signs of hemorrhage, hypotension, tachycardia may be absent until significant blood loss has occurred

Etiology (4 Ts) „

Early (within first 24 hours) „ „ „ „

„

Late (24 hours to 6 weeks postpartum) „ „ „

OB 130

Uterine atony (Tone) Retained placental products (Tissue) Lower genital tract lacerations (Trauma) Coagulopathy (Thrombin) Infection Subinvolution Retained products

Uterine Atony „ „

OB 131

Most common cause of early PPH Risk factors: polyhydramnios, multiple gestation, oxytocin use, high parity, rapid/prolonged labor, chorioamnionitis, use of uterine relaxing agents (i.e., terbutaline, magnesium sulfate)

Retained Placental Products „ „ „

„

„ „ OB 132

Most common cause of late PPH Retention of complete/partial cotyledon Succenturiate lobe (accessory placental tissue) Placenta accreta (villi attached to myometrium) Increta (villi invade myometrium) Percreta (villi penetrate myometrium)

Lower Tract Lacerations „ „

OB 133

Suspect if bleeding but uterus firm More common in operative deliveries, macrosomia, precipitous deliveries

Coagulopathies Less common ƒ DIC associated with Gram-negative sepsis, placental abruption, amniotic fluid embolus „

OB 134

Management „

Prevention „

„

Be Prepared „

„ „ „

OB 135

Pitocin after delivery Assess risk factors in every patient

Concurrent resuscitation (ABCs) IV access / oxygen / Foley catheter Treat Cause

Management (Cont’d) „

„

Treatment of uterine atony - bimanual massage and oxytocin Methylergonovine (Methergine) 0.2 lM q 24 hrs „

„

Carboprost (Hemabate) 0.25 mg lM q 1590 minutes total 2 mg „

„ OB 136

May cause: N/V, HTN, HA

May cause: N/V, diarrhea, chills, fever, respiratory distress

Cytotec „

800-1000 mg rectally

Management (Cont’d) „

„

„

OB 137

Retained placental products „ Curettage for removal Lacerations „ NEED EXPOSURE „ May warrant general anesthesia to repair Coagulopathies „ Lab studies to identify (PT, PTT, platelet count, FDP) „ Treat cause if possible „ Blood products

Other Considerations „

Pelvic Hematomas „ „

„

„

Uterine inversion: rare, life-threatening „ „ „ „

OB 138

May be difficult to detect Patients may report severe rectal or perineal pain after delivery May be vaginal, vulvar or retroperitoneal Classically profuse bleeding, severe pain May have palpable mass @ introitus Reposition manually immediately if possible May need operative intervention

References Evidence Based Medicine Practice Points

OB 139

SLIDE 16 The U.S. Preventive Task Force (USPSTF) strongly recommends Rh (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care. Name of AAFP-approved source of systematic evidence review: U.S. Preventive Services Task Force Specific web site of supporting evidence from the approved source identified immediately above: http://www.ahcpr.gov/clinic/uspstf/uspsdrhi.htm Strength of evidence (description and/or grade as provided by the approved source): A – the USPSTF strongly recommends that clinicians provide [the service] to eligible patients. The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms. Rationale: The USPSTF found good evidence that Rh (D) blood typing, anti-Rh (D) antibody testing, and intervention with Rh (D) immunoglobulin, as appropriate, prevents maternal sensitization and improves outcomes for newborns. The benefits substantially outweigh outweigh any potential harms. OB 140

SLIDE 21 The USPSTF recommends repeated Rh (D) antibody testing for all unsensitized Rh (D) – negative women at 24-28 week’s gestation, unless the biological father is known to be Rh (D) – negative. Name of AAFP-approved source of systematic evidence review: U.S. Preventive Services Task Force Specific web site of supporting evidence from the approved source identified immediately above http://www.ahcpr.gov/clinic.uspstf/uspsdrhi.htm Strength of evidence (description and/or grade as provided by the approved source): B – the USPSTF recommends that clinicians provide [this service] to eligible patients. The USPSTF found at least fair evidence that [the service] improves health outcomes and concludes that benefits outweigh harms. Rationale: the USPSTF found fair evidence that repeated antibody testing for unsensitized Rh (D) negative women (unless the father is also known to be Rh [D]-negative) and intervention with Rh (D) immunolglubulin, as appropriate, provides additional benefit over a single test at the first prenatal visit in preventing maternal sensitization and improving outcomes for newborns. The benefits of repeated testing substantially outweigh any potential harms. OB 141

SLIDE 38 There are no health benefits from episiotomy, and the immediate outcomes for routine episiotomy (liberaluse policies) are likely no better than those for episiotomy performed under more restrictive-use policies. Indeed, routine use is harmful to the degree that it creates a surgical incision of greater extent than many women might otherwise have experienced. Name of AAFP-approved source of systematic evidence review: Agency for Healthcare Research and Quality clinical and Evidence Reports (AHRQ) Specific web site of supporting evidence from the approved source identified immediately above): http://www.ahcpr.gov/clinic/tp/epistp.htm#Report Strength of evidence (description and/or grade as provided by the approved source): Fair to good evidence suggests immediate maternal outcomes from routine episiotomy are not better than those from restrictive use; instead, outcomes are worse because some proportion of women who would have had lesser injury instead had a surgical incision. Evidence is insufficient to provide guidance on choice of midline or mediolateral episiotomy when indicated. For perineal injury requiring suturing, fair to good evidence suggests leaving superficial vaginal and perineal skin unsutured is potentially preferable. If used for skin approximation, a continuous, subcuticular repair is superior to an interrupted, transcutaneous method. Evidence is consistent and clear that absorbable suture is preferred and that polyglycolic acid suture is associated with less morbidity than gut and chronic gut suture. Evidence is insufficient to determine whether novel materials, such as tissue adhesive, offer benefits. Evidence regarding long-term sequelae is fair to poor; assessment of pelvic floor dysfunction was not conducted in the age groups of greatest relevance. Limited data show that epiosiotomy does not prevent fecal and urinary incontinence, pelvic floor relaxation, or impaired sexual function, within months to years from childbirth. OB 142

SLIDE 97 There is no difference in asymptomatic uterine rupture rates in trial of labor versus elective repeat cesarean. Name of AAFP-approved source of systematic evidence review: Agency for Healthcare Research and Quality Clinical and Evidence Reports (AHRQ). Specific web site of supporting evidence from the approved source identified immediately above: http://www.ahrq.gov/downloads/pub/evidence/pdf/vbac/vbac.pdf Strength of evidence (description and/or grade as provided by the approved source): II-2 – cohort or case control Quality of evidence fair-poor: several large cohort studies which were inconsistent in terminology; many with consistent findings of increased risk of symptomatic urine rupture in trial of labor versus elective repeat cesarean.

OB 143