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Women with a history of 1 to 2 previous LTCS are appropriate candidates for TOLAC

KEY POINTS: Massive Transfusion Protocol Complications of Massive Transfusion Transfusion Refusal BACKGROUND: …should have a comprehensive maternal hemorrhage emergency management plan that includes protocols for accessing packed red blood cells Available Products for Resuscitation Coagulopathy Initiation of Transfusion Hemorrhage Assessment Protocols Admission to Labor Floor Prior to Delivery Postpartum Assessment Use oxytocin to actively manage […]

Syphilis is a communicable disease with rapidly increasing incidence that should be reported to state public health department

KEY POINTS: BACKGROUND: Risk Factors Note: Despite known risk factors “…shoulder dystocia cannot be accurately predicted or prevented” (ACOG PB 178) Evaluation Maneuvers See videos in ‘References’ below Management for Suspected Fetal Macrosomia PRIMARY SOURCES: Zhang et al. BJOG, 2018 PROFESSIONAL RECOMMENDATIONS: ACOG PB 178 …clinicians should use the maneuver most likely to result in […]

KEY POINTS:  BACKGROUND:  Known Complications   Procedure (see figure below)  Paracervical Block  PRIMARY SOURCES:  Novikova and Cluver. Cochrane Database of Systematic Reviews, 2012  Review of 12 RCTs of “unclear quality” | 1549 participants | Included both pudendal and paracervical nerve blocks in labor   Pace et al. Ann NY Acad Sci, 2004  RCT comparing single shot spinal anesthesia vs pudendal block in patients at >7 cm dilation  PROFESSIONAL RECOMMENDATIONS:  ACOG PB 209   Most Commonly […]

Preterm birth accounts for 70% of neonatal deaths; 36% of infant deaths; 25-50% of long term neurologic impairment for children

Most cases can be diagnosed based on history and physical examination

Following delivery, women often do not show signs or symptoms of hypovolemia until significant blood loss has occurred

While prognosis has improved substantially over the past several years, women with peripartum cardiomyopathy are still at risk for adverse outcomes

If episiotomy is warranted, mediolateral is preferred over midline given decreased risk of extension into 3rd and 4th degree laceration

All women in pregnancy should be screened for opioid and other substance use disorders with history and validated screening tools

Operative vaginal delivery (OVD) success is more likely via forceps compared to vacuum, but forceps increases risk for 3rd and 4th degree tears

Initiate antiemetic therapy before onset of severe symptoms to reduce severity of nausea and vomiting

Multifetal gestations are at increased risk of multiple medical conditions

Sepsis is responsible for 12.7% to 23% of all maternal deaths and remains one of the leading causes of obstetric related death in pregnancy (cardiovascular conditions are the number one cause of medical maternal mortality)

Early warning systems (EWS) have been in use in medicine since the 1990s

The key aspects of rhythm identification and medication administration guidelines do not change for the pregnant patient

98% of births in the United States are in a hospital

Mothers and families who are experiencing a fetal loss benefit from a coordinated team approach to care with an emphasis on understanding grief and providing resources

KEY POINTS: Symptoms and Clinical Findings Risk of IUFD BACKGROUND: Treatment for ICP Meant to both reduce maternal symptoms and reduce the bile acid levels Delivery PRIMARY SOURCES: Ovadia et al. Lancet, 2019 Meta-analysis looking at adverse perinatal outcomes and the relationship to bile acid levels “PITCHES” Study: Chappel et al. Lancet, 2019 UK RCT, […]

Cervical ripening for an unfavorable cervix can be an essential component of labor induction and increases likelihood of vaginal birth

Intraamniotic infection (chorioamnionitis) can have serious complications and include: Sepsis | Prolonged labor | PPH | Hysterectomy | Endometritis | ICU admission | (rarely) maternal mortality

Ultimately, the treatment plan for hypertensive disorders in pregnancy hinges on balancing risk and benefits related to timing of delivery

Eclampsia is a severe, life-threatening manifestation of preeclampsia. While long-term neurologic damage is rare, there is risk of maternal hypoxia and death

Severe hypertension can be a life-threatening event during pregnancy and requires special vigilance in the postpartum period, particularly following hospital discharge

Herpes simplex virus is a double-stranded DNA virus. Most infections with HSV are from HSV-1 and HSV-2 | HSV-2 was long-considered the “genital herpes” however both have been cultured from genital lesions

KEY POINTS:  BACKGROUND: Incidence and Epidemiology Screening Diagnosis Impact on Pregnancy Treatment Note: Currently there are no anti-HCV therapies recommended for pregnancy (AASLD IDSA Guidelines) | Referral to a hepatologist or infectious disease specialist could be considered during pregnancy to expedite therapy after pregnancy PRIMARY SOURCES: Benova et al. Clin Infect Dis, 2014 Singh et […]

Preeclampsia usually occurs after 20 weeks of gestation and can be superimposed on another hypertensive disorder

Pregnant women should undergo vaginal-rectal screening for GBS colonization at 36w0d to 37w6d (screening valid up to at least 41w0d)

Gestational Diabetes Mellitus (GDM) is defined as the identification of carbohydrate intolerance that is either first recognized or begins during pregnancy

FGR definition: EFW <10th percentile for gestational age (ACOG PB 227). Second to premature birth as cause of infant morbidity and mortality

The purpose of ECV is to reduce the number of cesarean births performed for persistent breech presentation at term

The current general consensus is that a policy of selective (rather than routine) episiotomy should be used, primarily in cases when delivery of the fetus needs to be expedited

Electronic Fetal Monitoring (EFM) has provided obstetrical professionals with a classification and terminology system – a universal language – for describing the physiological status of the fetus in utero

The most challenging part of a long induction is balancing the benefits of achieving a vaginal delivery with the potential maternal and fetal risks for prolonged ROM and exposure to uterotonic medications

The most common indication of possible umbilical cord prolapse is recurrent variable decelerations on fetal monitoring

Definition: Hypertension that is diagnosed or present before pregnancy or before 20 weeks of gestation | diagnosed for the first time during pregnancy without resolution postpartum

Most common indication is life-threatening bleeding due to abnormal placentation or placenta accreta (38%), uterine atony (34%), uterine rupture and placental abruption

The Enhanced Recovery After Surgery (ERAS)  Committee has produced evidenced-based guidance on perioperative care for cesarean delivery.  The guidance covers practices from the time of decision making to hospital discharge

Cervical insufficiency (also known as ‘incompetent cervix’) is “the inability of the uterine cervix to retain a pregnancy in the absence of the signs and symptoms of clinical contractions, or labor, or both in the second trimester” (ACOG PB 142)

Patients presenting with breech singleton at term should be offered external cephalic version (ECV) unless there is a significant contraindication

Amniotic fluid embolism (AFE) is a rare cause of maternal collapse during or immediately after delivery, seen in approximately 1.9 to 6.1 per 100,000 births (Pacheco et al. AJOG, 2020)

KEY POINTS:  Note: TOA requires urgent inpatient medical treatment  BACKGROUND:  Etiology  Symptoms PID without TOA   Diagnosis   Medical Treatment   CDC Guidelines for First-Line Parenteral Treatment  OR OR CDC Alternative Parenteral Regimens OR After Hospitalization Discharge and Outpatient Considerations  Medical Treatment Failure Percutaneous Drainage versus Surgical (Laparoscopy or Laparotomy)  Long Term Sequelae  PRIMARY SOURCES:   Gil et al. Tubo-ovarian abscess in postmenopausal women: A systematic review. Gynecol Obstet Hum Reprod. 2020   This systematic […]

KEY POINTS: BACKGROUND: Note: IUDs are associated with fewer ectopics compared to women not using contraception because IUDs are such an effective method of birth control | However, if a woman does become pregnant with an IUD, the risk of an ectopic is approximately 50% Diagnosis qHCG Discriminatory Level Trending qHCG Levels Transvaginal Ultrasound (TVUS) […]

KEY POINTS: BACKGROUND: Rates of Pregnancy Loss Workup Prior to Management Management Options Expectant management Medical management Surgical management Administration of RhD immune globulin (RhIg) Follow-up after Pregnancy Loss PRIMARY SOURCES: Schreiber et al. NEJM, 2018 RCT that compared the efficacy and safety of pretreatment with mifepristone versus misoprostol alone for miscarriage management| 148 participants […]

Once a diagnosis of ectopic pregnancy has been made, a treatment plan must be generated. Per ACOG PB 193: “In 2011–2013, ruptured ectopic pregnancy accounted for 2.7% of all pregnancy-related deaths and was the leading cause of hemorrhage-related mortality”

KEY POINTS: BACKGROUND: Pre-Pubescent and Adolescent Patients Premenopause Postmenopause Note: Patient Age is Helpful in Determining Likelihood of Malignancy | While diagnosis would require surgical and pathologic evaluation, counseling of a patient in the ER can help manage expectations Work-Up History Physical exam Imaging Laboratory testing Management PRIMARY SOURCES: Santos et al. J Pediatr Adolesc […]

In the setting of acute bleeding, management involves stabilization, diagnosis and treatment of underlying disorder

Table of Contents for ObG L&D