Pocket Obstetrics and Gynecology

NORMAL LABOR AND DELIVERY

ANTENATAL FETAL TESTING

Goal of Testing

• Goal: Measure changes in fetal physiology or behavior w/ suff sens for fetal hypoxemia or acidemia to allow intervention to prevent stillbirth

• Primary outcome of interest is a reassuring result to rule out fetal demise w/i 1 w of testing

Testing Modalities (Obstet Gynecol 2009;113:687)

• Fetal mvmt count (“kick count”) (Cochrane Database Syst Rev 2007:CD004909)

Variable protocols, usually 2 h, 3–7× per week

10 mvmts → reassuring; insuff evid to recommend this method of surveillance

• Nonstress test

Continuous fetal heart monitoring × 20–40 min

At least 2 15 bpm × 15 s accelerations (or 10 × 10 at <32 w) → reassuring

Occasional, brief variable decelerations do not affect negative predictive value

Performance for prediction of stillbirth w/i 1 w: Sens 99.7%, spec 45%

• Biophysical profile (From US exam of fetus up to 30 min)

Elements (2 points each if nml/reassuring):

Continuous fetal breathing, 1 episode >30 s

3+ fetal limb or body mvmt

1+ episodes of flexion/extension of a limb or hand

2 × 2 cm or greater pocket of amniotic fluid (or amniotic fluid index >5 cm)

Reactive nonstress test

<6/10 = abn (consider deliv); 6/10 = equivocal (rpt in 6–24 h); >6/10 = reassuring. Prediction of stillbirth w/i 1 w: Sens 99.92%, spec 50%.

• Contraction stress test (oxytocin or nipple stimulation to produce 3 contractions in 10 min of >40 s, w/ continuous FHR monitoring)

Negative = No late or signif variable decelerations

Positive = Late decelerations w/ >50% of contractions

Equivocal = Anything btw “negative” & “positive”

Unsatisfactory = Uninterpretable fetal heart tracing or insuff contraction frequency

Prediction of stillbirth w/i 1 w: Sens 99.96%, PPV 70%

• Umbilical artery Doppler velocimetry (US measurement, only indicated in fetuses w/ growth restriction)

Low resistance system should allow forward flow throughout cardiac cycle

Absent or reverse end-diastolic flow is a/w increased perinatal mortality (5× greater w/ reversed flow) (Lancet 1994;344:1664)

• Middle cerebral artery Doppler velocimetry

US measurement of peak systolic velocity, indicated if concern for fetal anemia

Velocity >1.5 MoM has sens for mod/sev anemia 100%, spec 88% (N Engl J Med 2000;342:9). Optimal screening interval likely 1–2 w

FETAL LUNG MATURITY TESTING BY AMNIOCENTESIS

General Considerations

• Consider testing for planned deliv btw 32 & 39 w

• Before 32 w low likelihood of maturity

• Test performance worsens at earlier GAs

• All tests more accurately predict absence of respiratory distress (w/ mature result) than predict respiratory distress (w/ immature result) (Obstet Gynecol 2001;97:305)

Specific Assays

• Lamellar body count (direct assessment) or optical density at 650 nm (indirect assessment)

>50000/μL or optical density (OD) >0.15 sugg maturity. May vary by institution.

• L/S ratio (L/S about equal till ∼35 w, then lecithin increases)

Threshold value for “mature” varies by institution. Generally mature at >2 (2–3.5)

• PG measurement (appears ∼35 w & rapidly increases)

Quantitative or qualitative measurement. Not affected by mec or bld.

• Foam stability index. Measures functional surfactant. >47 signifies maturity.

• Surfactant/albumin ratio, TDx-FLM II (phased out by manufacturer in 2011)

NEWBORN RESPIRATORY DISTRESS

Epidemiology (Am Fam Physician 2007;76:987)

• 7% of infants. Most common causes: Transient tachypnea of the newborn, respiratory distress syn, mec aspiration syn.

• Less common causes: Delayed transition, infxn, persistent pHTN, PTX, nonpulmonary causes (anemia, CHD)

Signs and Symptoms

• Tachypnea (>60 breaths/min), nasal flaring, poor feeding, grunting, sub- or intracostal retractions, insp stridor, apnea, cyanosis

Transient Tachypnea of the Newborn

• >40% of cases of respiratory distress

• Inadeq fluid clearance from lung → decreased pulm compliance → tachypnea

• Onset w/i 2 h of birth; usually resolves in <72 h

• CXR: Diffuse parenchymal infiltrates

Respiratory Distress Syndrome (Hyaline Membrane Disease)

• Affects 24000 infants in US annually

Most common before 28 w gest

1/3 of infants 28–34 w gest

<5% of infants after 34 w gest

• Surfactant deficiency causing atelectasis & V/Q mismatching → hypoxemia

• Incid ↑ for newborns of diabetic moms

• CXR: Homogenous, opaque infiltrates, & air bronchograms

Meconium Aspiration Syndrome

• Mec-stained amniotic fluid = 15% of deliveries → 10–15% of those get mec aspiration syn; mec = irritative, obstructive, medium for bact culture

• Usually term or postterm infants; signif respiratory distress immediately after deliv

• CXR: Patchy atelectasis or consolidation

General Management

• Diagnostic CXR; CBC, bld gas, bld cx

• Supplemental oxygen therapy, w/ assisted ventilation if necessary

• Supportive care w/ fluid/electrolyte mgmt & neutral thermal environment

Oral feeding often withheld w/ respiratory rate >80 breaths/min

• Empiric ampicillin & gentamicin if risk factors for sepsis or refrac/persistent sx

• Surfactant administration may be req

GROUP B STREPTOCOCCAL DISEASE

Definition and Epidemiology (MMWR 59(RR10):1)

• Intrapartum vertical transmission of GBS is the leading cause of infectious morbidity/mortality in neonates; incid is ∼0.35/1000 births

• Caused by GBS infxn of fetal mucosal surfaces by GBS in amniotic fluid or birth canal

• 10–30% of pregnant women are colonized w/ GBS in GI tract or vagina

• Risk factors for invasive perinatal dz include:

<37 w at deliv

Ruptured amniotic membranes for >12 h

Intra-amniotic infxn

Young mat age

Black race

Low levels of anti-GBS Ab

Clinical Manifestations

• Sepsis, PNA, & meningitis in the 1st w of life

• Fatal in 2–3% full-term infants & 20–30% of preterm newborns <33 w GA

Screening and Diagnosis

• Pregnant women should routinely be screened by rectovaginal swab at 35–37 w. Culture results are valid for up to 5 w, then should be repeated at >5 w.

• NAAT for GBS is currently only indicated in women w/ (1) culture data unk, (2) at term, & (3) w/o prolonged rupture of membranes or fever

Treatment

• Intrapartum Abx indicated for:

Positive rectovaginal culture during this Preg

GBS bacteriuria at any time during this Preg (exempt from routine screening)

H/o perinatal GBS dz in a prior Preg (exempt from routine screening)

Culture data unavailable & <37 w OR term w/ rupture of membranes >18 h or temperature >100.4°F

• Intrapartum ppx NOT indicated at the time of cesarean deliv at any GA for women delivered prior to labor w/ intact membranes

Figure 10.1 Intrapartum prophylaxis for GBS disease

SPONTANEOUS LABOR AND DELIVERY

Definitions

• Labor: Regular uterine contractions & cervical change

• 1st stage of labor: Onset of labor → full cervical dilation

Latent phase: Early labor until acceleration of rate of cervical change

Active phase: Period of accelerated cervical change until full dilation

Historically, minimum rate of cervical change: Nulliparas ∼1.2 cm/h, multiparas, ∼1.5 cm/h (N Y Acad Med 1972;48:842)

Labor curve: Friedman (1955) described ideal labor progress at term; Zhang (2002) showed women enter active phase at 3–5 cm, w/ variable labor course & no deceleration phase

• 2nd stage of labor: Full cervical dilation → deliv of the infant

Consider 2nd stage arrest in nulliparas after 2 h (no epidural) or 3 h (w/ epidural), or in multiparas after 1 h (no epidural) or 2 h (w/ epidural)

• 3rd stage of labor: Deliv of the infant → deliv of the placenta

• 4th stage of labor: 1–2 h immediately following deliv of the placenta

• Cervical assessment: Cervical dilation is measured in cm. Cervical effacement is documented as percentage of full length (4 cm) cervix lost (0% is full length & 100% is paper thin), or as cm of length. Fetal station is descent of the bony fetal presenting part in centimeters above or below the mat ischial spine (−5–+5 cm scale).

• Fetal position: Orientation of the presenting part relative to the mat pelvis

Cephalic presentation w/ occiput documented on mat left/right, rotated post/anter/transverse (eg, ROA). The sacrum may be used for fetuses in breech presentation, the acromion for transverse lie, the mentum for face presentations

Figure 10.2 Labor curves

Cardinal Movements of Labor

• Engagement: Passage of widest diameter of presenting part below pelvic brim

• Descent: Passage of presenting part downward into pelvis

• Flexion: Allows optimal descent by presenting smallest cranial diameter

• Internal rotation: Mvmt of the fetal head from transverse to anteroposterior

• Extension: Mvmt of the fetal head under the pubic symphysis & out the introitus

• External rotation (“restitution”): Mvmt of the head to align w/ torso

• Expulsion: Deliv of the fetal body

Management of Labor

• Physical exam on presentation: Mat VS; cervical dilation, effacement, fetal station, rupture of membranes (± mec), presence of vaginal bleeding, & estimated fetal weight (by Leopold’s)

Fetal heart assessment (intermittent in low-risk, or continuous in high-risk pts) & uterine tocometry to assess fetal status & contractions

• Consider CBC, bld type & screen, urinalysis

• IV access, avoid solid foods (Obstet Gynecol 2009;114:714)

• Walking & upright positioning in early labor may ↓ the 1st stage by 1 h (Cochrane Database Syst Rev 2009,2:CD003934)

• Assess desire for pain control, w/ or w/o regional anesthesia

• GBS ppx if indicated

Management of Delivery

• Pushing may begin w/ full cervical dilation or be delayed until presenting part descends (“laboring down”); pushing generally accompanies contractions. Delayed pushing ↑ length of the 2nd stage by ∼1 h, but ↓ the need for instrumented deliveries (but not cesarean deliveries) (J Obstet Gynecol Neonatal Nurs 2008;37:4). Pushing should not be delayed if there is an indication to expedite deliv (eg, infxn).

• No indication for routine episiotomy. If necessary, midline a/w ↓ bld loss & ↑ anal sphincter injury compared to mediolateral.

• Warm compresses to the perineum may ↓ incid of 3rd/4th-degree lacerations (Cochrane Database Syst Rev 2011;12:CD006672)

• In women w/o epidural anesthesia, pushing while upright was a/w ↑ risk of EBL >500 cc & ↓ abn FHTs w/o signif impact on length of 2nd stage (Cochrane Database Syst Rev 2012;5:CD002006)

• Deliv of the fetal head:

Care should be taken to control speed of deliv & to protect the anter vaginal wall, urethra, & clitoris

The perineum should be eased over the fetal head

The head should be allowed to restitute

Gentle downward traction of the head to deliver the anter shoulder (difficulty w/ this maneuver should prompt consideration of shoulder dystocia)

The body should be delivered w/ gentle upward traction, supporting the perineum as poss

• The cord should be clamped & cut → delayed cord clamping ↓ risk of fetal/neonat anemia, but ↑ need for phototherapy (Cochrane Database Syst Rev 2008:CD004074; BMJ 2011;343:d7157). Delaying cord clamping by 45 s in premature infants <37 w may ↓ risk of IVH & neonat xfusion (Cochrane Database Syst Rev 2004;4:CD003248)

• Active mgmt of 3rd stage w/ suprapubic pres & controlled cord traction may ↓ mat hemorrhage (Cochrane Database Syst Rev 2011;11:CD007412)

• Consider deliv onto mat abd to promote immediate breastfeeding & bonding (Cochrane Database Syst Rev 2012;5:CD003519)

• Give oxytocin in the 3rd stage to ↓ postpartum hemorrhage (Cochrane Database Syst Rev 2001;(4):CD001808)

• Inspect the placenta to identify anomalies & to ensure intact disc

• Fetal cord bld gas analysis & postpartum hemorrhage (see sections below)

INDUCTION OF LABOR (IOL)

Definition and Epidemiology

• Stimulation of uterine contractions w/ intent to cause vaginal deliv prior to spontaneous onset of labor

• 23.2% of births in 2009 were after IOL (National Vital Statistics Report, 2011)

• “CR” is the softening, thinning, & dilating to facilitate successful IOL

Indications

• Risks (to mother or fetus) of continuing Preg outweigh the risks a/w effecting deliv, & no contraindication to vaginal birth

• Labor should not be electively induced prior to 39 w gest due to significantly elevated neonat morbidity

• Overall, multiparas are less likely than primiparas to fail induction or require cesarean deliv at a given Bishop Score

Methods of Cervical Ripening & Induction of Labor

• Oxytocin – most commonly used induction agent

Various dosing regimens; titrate to contractions q2–3min

Low-dose regimen (start 0.5–2 mU/min w/ 1–2 mU/min ↑ q15–40min)

High-dose regimen (start 6 mU/min w/ 3–6 mU/min ↑ q15–40min)

Note: High-dose regimen decreases time to deliv, but increases rate of tachysystole w/ FHR changes (Cochrane Database Syst Rev 2012;3:CD001233)

• Misoprostol (PGE1) – for CR or IOL

Oral misoprostol superior to vaginal misoprostol for CR/IOL (fewer 5-min Apgars <7)

Dosage 25 mcg PO q2h or 50 mcg PO q4h (Cochrane Database Syst Rev 2006;(2):CD001338)

Vaginal misoprostol may be used for CR/IOL at dose of 25 mcg PV q3–6h

Contraindicated if h/o uterine Surg (including prior cesarean) given elevated risk of uterine rupture

• Dinoprostone (PGE2) – for CR or IOL

Each insert contains 10 mg of dinoprostone → releases mean dose of 0.3 mg/h

Dosed q12h

Upon removal of insert, quickly eliminated from mat circulation

• Amniotomy alone (Cochrane Database Syst Rev 2000;(4):CD002862)

Insuff evid regarding efficacy

↑ need for oxytocin augmentation vs. vaginal prostaglandin

• Balloon catheter (Cochrane Database Syst Rev 2012;3:CD001233) – for CR or IOL

Placement of balloon catheter w/ 30–60 cc of saline through internal os into extra-amniotic space

↓ efficacy for multiparous women & ↓ risk of tachysystole compared w/ prostaglandin

• Membrane stripping (Cochrane Database Syst Rev 2005;(1):CD000451)

Manual detachment of inferior pole of fetal membranes during vaginal exam

• Sexual intercourse: Insuff evid. Likely ineffective (Obstet Gynecol 2007;110(4):820–826; Cochrane Database Syst Rev 2001;(2):CD003093).

• Breast stimulation: Decreased postpartum hemorrhage compared to no intervention. No difference in rates of cesarean when compared to no intervention or oxytocin. Not effective in women w/ unfavorable cervix (Cochrane Database Syst Rev 2005;(3):CD003392).

Complications of Induction

• Tachysystole (greater than 5 contractions in 10 min). Rx: Stop/↓ uterine stimulation, consider tocolysis

• Uterine tetany (contraction lasting greater than 2 min). Rx: Stop/↓ uterine stimulation, consider tocolysis

• Cord prolapse (w/ amniotomy). Rx: Cesarean deliv.

• HoNa (w/ extended infusion of oxytocin). Rx: Stop oxytocin infusion, consider free water restriction, recheck, & resume.

• Cesarean deliv ↑ compared to spontaneous labor, but elective IOL at 41+ w, compared w/ expectant mgmt may ↓ c-section (Cochrane Database Syst Rev 2012;6:CD004945)

INTRAPARTUM FETAL MONITORING

Background

• Justification for intrapartum FHR monitoring based on expert opinion & medicolegal precedent

• Continuous FHR monitoring a/w (1) reduction in neonat seizures, w/o significant differences in cerebral palsy, infant mortality or other std measures of neonat well-being; & (2) ↑ in cesarean deliv & instrumental vaginal births when compared to intermittent auscultation or no monitoring (Cochrane Database Syst Rev 2006;3:CD006066)

Methods of Monitoring

• FHR: External via Doppler US -or- internal via fetal scalp electrode

• Contractions:

External pres transducer (qualitative)

Intrauterine pres catheter (quantitative). Measurement in MVU: Add up peak minus baseline uterine pres for each contraction over 10 min; >200 MVU considered adequate for labor (Obstet Gynecol1986;68:305).

Definitions (Obstet Gynecol 2008;112:661)

• Baseline: Avg FHR, exclusive of accelerations, decelerations, & marked variability, taken over a 10-min interval, rounded to nearest 5 bpm

Tachy: Baseline > 160 bpm

Brady: Baseline < 110 bpm

• Variability: Beat-to-beat fluctuations in the baseline FHR, exclusive of accelerations & decelerations. Measured from peak to trough of rapid fluctuations.

Absent: Amplitude undetectable

Minimal: Amplitude btw 1 & 5 bpm

Mod: Amplitude btw 6 & 25 bpm

Marked: Amplitude > 25 bpm

• Accelerations: Increased FHR ≥15 bpm for ≥15 s (before 32 w, use ≥10 bpm & ≥10 s). Time from baseline to peak HR is <30 s. Prolonged acceleration lasts 2–10 min.

• Decelerations: ↓ in FHR

Early deceleration: Nadir w/ peak of contraction. Baseline to nadir takes >30 s.

Late deceleration: Nadir after peak of contraction. Baseline to nadir >30 s.

Variable deceleration: ↓ ≥15 bpm from baseline lasting at least 15 s. Baseline to nadir <30 s.

Prolonged deceleration lasts 2–10 min

Sample Fetal Heart Tracings

Figure 10.3 Fetal heart rate variability

Figure 10.4 Fetal heart rate accelerations and decelerations

OPERATIVE VAGINAL DELIVERY

Definition and Epidemiology (ACOG Practice Bulletin #17, Operative Vaginal Delivery, Reaffirmed 2012))

• Deliv using forceps or vacuum. In 2009, 5.5% of vaginal births were operative (National Vital Statistics Report, 2011)

Indications

• Prolonged 2nd stage of labor (see 2nd stage labor arrest, above)

• Suspicion of immediate or potential fetal compromise

• Potential mat intolerance of Valsalva (eg, cardiac dz)

Requirements (All Must Be Met)

• Position of fetal head is known, including asynclitism. Head should be occiput anter or occiput post for forceps, unless operator is skilled w/ rotation.

• Cervix is fully dilated. Station is +2 cm or greater.

• Pelvis is adequate. Bladder is empty.

• Anesthesia is adequate

Contraindications (None Should Be Present)

• <34 w GA for vacuum (elevated risk of IVH)

• Fetal bone demineralization d/o (eg, osteogenesis imperfecta)

• Presence of bleeding d/o (eg, hemophilia, von Willebrand dz) OR mat anticoagulation w/ agent that crosses the placenta (eg, warfarin)

• Unk position of fetal head or head unengaged in pelvis

• Macrosomia is NOT a contraindication; caution for shoulder dystocia is advised, however

Figure 10.5 Placement of vacuum cup on fetal head

Figure 10.6 Correct placement of the forceps blades on the OA fetal head

Complications of Operative Delivery

• Neonat

Vacuum: Scalp laceration, cephalohematoma (11–16%), subgaleal hematoma (2.6–4.5%), intracranial hemorrhage (0.2%), retinal hemorrhage (up to 75% → disappear w/i weeks) (BMJ 2004;329:24; Ophthalmology 2001;108:36)

Forceps: Superficial laceration, cephalohematoma (6%), intracranial hemorrhage (0.2%), retinal hemorrhage (0.1–17%) (BMJ 2004;329:24)

• Mat (BMJ 2004;329:24)

Vacuum: Perineal laceration: 3rd degree (9.6%), 4th degree (6.2%)

Forceps: Perineal laceration: 3rd degree (12.5%), 4th degree (9.8%)

• Episiotomy may ↑ all mat lacerations, but may be necessary for deliv. Risk of persistent pelvic floor dysfxn difficult to quantitate. Mat laceration more likely w/ operative deliv, but should be weighed against risks of cesarean. Complications are highest w/ multi instruments (ie, vacuum plus forceps). If 1 fails → typically proceed w/ cesarean deliv.

VAGINAL BIRTH AFTER CESAREAN

Definitions (Obstet Gynecol 2010;116:450)

• TOLAC: Trial of labor after prior cesarean delivery

• VBAC: Vaginal birth after prior cesarean delivery

• ERCD: Elective repeat cesarean delivery

Selection of Candidates

• 1 or 2 cesarean deliveries via low transverse OR low vertical hysterotomy. Unk scar is NOT contraindication to TOLAC unless high suspicion for classical hysterotomy.

• No contraindication to vaginal deliv (eg, placenta previa)

• Overall success rate of TOLAC is 60–80%

• ↑ rate of successful TOLAC: Prior vaginal birth, spontaneous labor

• ↓ rate of successful TOLAC: Recurring indication for prior c/s (labor dystocia), increased mat age, nonwhite ethnicity, GA > 40 w, mat obesity, preeclampsia, short inter-Preg interval, increased birth weight

• Online NICHD VBAC success rate calculator https://mfmu.bsc.gwu.edu/PublicBSC/MFMU/VGBirthCalc/vagbirth.html

Delivery Considerations

• Misoprostol should NOT be used for IOL given elevated risk of uterine rupture

Risk of uterine rupture: 24.5/1000 (NEJM 2001;345:3)

• Continuous fetal monitoring should be employed

• Maintain high suspicion for signs/sx of uterine rupture, including: New onset uterine pain, loss of fetal station, new abnormalities of the fetal heart tracing, vaginal bleeding, & mat hemodynamic instability

• Staff (OB & anesthesia) must be immediately available for emergent c-section

FETAL CORD BLOOD GAS ANALYSIS

• Provides an assessment of neonat metabolic status

• May be useful to determine whether an asphyxic event (acidemia + metabolic acidosis + hypoxia) accompanied neonat depression

• If nml, rules out asphyxia at time of deliv as a cause of neonat complications

• Collect 1–2 mL of bld from both umbilical vein & artery in heparinized syringes. Can collect from clamped cord for up to 60 min w/ valid result. If samples are not immediately sent to laboratory, store on ice for up to 60 min.

Indications (Obstet Gynecol 2006;108:1319)

• May be obtained w/: Cesarean deliv for suspected fetal compromise, low 5-min Apgar score, abn FHR tracing, mat thyroid dz, intrapartum fever, multifetal gest, other indications

Interpretation

• Obst of bld flow through umbilical cord leads to retention of fetal CO2 (ie, respiratory acidosis) → prolonged respiratory acidosis leads to mixed respiratory/metabolic acidosis & then metabolic acidosis alone

• Approach to interpretation of fetal bld gas:

If pH is lower than nml limits, ACIDEMIA exists

If pCO2 is higher than nml limits, RESPIRATORY ACIDOSIS exists

If BE is more negative than nml limits, METABOLIC ACIDOSIS exists

• Potentially clinically significant acidemia requires pH <7 & metabolic acidosis w/ BE <-12 (Obstet Gynecol 2003;102:628). 10% of neonates w/ BE −12–−16, & 40% w/ BE <−16 will have mod or sev complications (CNS, respiratory, renal, CV).

• Respiratory acidosis alone at the time of birth is not considered suff to cause CP

• Criteria to define acute intrapartum hypoxic event suff to cause CP:

Arterial cord pH <7 w/ BE −12 or worse

Early onset of mod or sev encephalopathy

CP of spastic, quadriplegic, or dyskinetic type

Exclusion of other identifiable etiologies

ROUTINE POSTPARTUM CARE

In Hospital Care

• Monitoring: Frequent VS (q15mins × 2 h; q shift [8–12 h] thereafter); assess uterine size & tone, perineal integrity, abdominal incisions; note quantity of vaginal bleeding; high vigilance for intra-abdominal or pelvic hemorrhage & urinary retention

• Pain: NSAIDs & cold compresses to the perineum, w/ opioids reserved for breakthrough or postsurgical pain (Cochrane Database Syst Rev 2011;(5):CD004908)

• Constip: Stool softeners & laxatives as needed & w/ opioids; longer stool softener rx for 3rd/4th-degree laceration repairs

• Urinary retention: Mobilize early to facilitate voiding; use intermittent or indwelling catheter if unsuccessful

• Malodorous lochia/discharge: Inspect perineum for wound breakdown or retained sponge

• HA: Most likely are tension, but consider preeclampsia & postdural puncture HA (Am J Obstet Gynecol 2007;196:318). See Chap 18.

• Fever: W/u source, considering UTI, wound infxn, mastitis/breast abscess; breast engorgement; endometritis; septic pelvic thrombophlebitis; clostridium-difficile infxn; drug or anesthesia rxn

• Discharge w/i 24–48 h after Uncomp vaginal deliv & 48–96 h after routine cesarean deliv

Clinic Follow-up Care

• Postpartum visit recommended for all women at 4–6 w postpartum & 7–14 d postcesarean or complicated vaginal deliv (eg, sev laceration)

• Hx should assess: Mat–infant bonding, including feeding; breast complaints; mat mood/coping & social supports; urinary & fecal continence; resumption of intercourse & contraceptive plan; consider thyroid dysfxn (hyper- & hypo-) (Thyroid 2006;16:573)

• Exam should include: VS (including weight & BP); breasts, abd, & pelvis

Postpartum Contraception

• Mean resumption of ovulation in nonlactating women occurs 45–94 d (25 d at earliest) postpartum (Obstet Gynecol 2011;117(3):657)

• Exclusive breastfeeding is 98% effective as contraception in the 1st 6 mo postpartum if amenorrheic (Contraception 1989;39:477)

• Sterilization (by tubal ligation) may be performed immediately (w/i ∼24 h) postpartum or as an interval procedure (after 6 w)

• Barrier methods may be used on resumption of intercourse

• Progest-only methods safe to initiate postpartum in any woman w/o a contraindication, & do not influence breast milk production (Contraception 2010;82:17)

• IUD (copper or levonorgestrel) may be placed either immediately postpartum (w/i 10 min of deliv of placenta) or 6–8 w postpartum

• Estrogen-containing contraceptives may be initiated 21 d postpartum in women w/o additional risk factors for VTE, & otherwise may be considered at 6 w postpartum. CDC & ACOG recommend 4–6-w delay before starting estrogen-containing contraceptives in breastfeeding women depending on VTE risk profile (MMWR Morb Mortal Wkly Rep 2011;60:878; Obstet Gynecol 2006;107:1453). Estrogen may suppress breast milk production.

BREASTFEEDING

Physiology and Initiation

• Copious milk secretion begins w/ progesterone withdrawal 2–7 d postpartum. Longer in primiparas & after cesarean deliv (Pediatrics 2003;112:607). Maint of lactation depends on adequate frequency of breastfeeding &/or pumping (Obstet Gynecol 2007;109:479). During the 1st 2 w, feeding initiated on infant demand (8–12× daily).

• Initiation of successful breastfeeding (unless medical issues take precedence; Pediatrics 2012;129:e827):

Maintain direct skin-to-skin contact btw mother & infant until 1st feeding is completed.

Avoid commercial formulas & sugar water.

Avoid use of pacifier.

Room-in newborns w/ mother.

Discharge w/ contact information for breastfeeding support.

Benefits (AHRQ Pub No. 07-E007)

• Full-term infant: ↓ incid of otitis media; atopic dermatitis, & asthma; GI & lower respiratory tract infections; diabetes (weak association); childhood leukemia; SIDS

• Preterm infant: ↓ incid of nec enterocolitis, sev retinopathy of prematurity

Improved neurodevelopmental outcomes (Pediatrics 2012;129:e827)

• Mat: ↓ incid of breast & ovarian cancer; & dev of type II diabetes

Relative Contraindications (ACOG Clin Rev 2007;12:1S; Obstet Gynecol 2007;109:479; Pediatrics 2012;129:e827)

• Contraindicated:

Mat use of illicit drugs or uncontrolled EtOH use

Mat infxn w/ brucella, HIV, HTLV-I, or HTLV-II

Mat active, untreated varicella, TB, or herpes simplex w/ breast lesions

Infant galactosemia

• Breastfeeding does NOT ↑ the risk of vertical transmission of hepatitis C (Clin Infect Dis 1999;29:1327)

• Infants born to hepatitis B positive mothers should receive HepBIg & be vaccinated at birth; breastfeeding is safe thereafter (Obstet Gynecol 2002;99:1049)

Lactational Mastitis

• Dx: Fever >38.3°C + swollen, red, indurated breast in breastfeeding mother

• Labs not necessary, milk culture only in sev or refrac case

US only if abscess suspected

• Typical pathogens are group A streptococci & MSSA

• 1st-line antibiotic: Dicloxacillin (500 mg QID) × 10–14 d

PCN-allergic or MRSA: Clindamycin (300 mg QID) or TMP/SMX (1–2 BID)

• Continue breastfeeding, w/ NSAID & warm compresses as needed

• Diff includes: Obstructed milk duct, galactocele, inflamm breast cancer

Breastfeeding and Maternal Medications

• LactMed: Comprehensive database on pharmaceuticals & lactation http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT

AFFILIATED OBSTETRICAL PROVIDERS

Doulas

• Definition: Women who provide continuous, nonmedical intrapartum/postpartum support to laboring women

• Scope of practice includes emotional support, attention to physical comfort, nonmedical advice, & advocacy

• Credentialing/certification varies by organization