Questions in Labor Management Joshua Steinberg

Start at the beginning! Your pt at 39 2/7 weeks presents to L&D complaining of contractions which started 2 hours ago and have intensified, now every 3 minutes. Her cervix is 4 cm dilated. You admit her in active labor and as she has no special risk factors, you plan expectant management.

Question 1 Should you monitor the well-being of the fetus during labor? How? – a) continuous Electronic Fetal Monitoring – b) some other way – c) no monitoring necessary at all

Intrapartum Fetal Monitoring impact of cont EFM: -no ∆ perinatal mort -more c-sxns -less neonatal szs but no change cerebral palsy (or epilepsy) -more instrumented vaginal deliveries

Cont EFM failure, ACOG 12-10

Alternative: structured intermittant auscultation

Question 2 Moving past monitoring… to moving! Labor is gruelling, exhausting, excruciating, and risky, so women need to be in bed. No, activity like walking helps speed labor, reduce pain relief needs, so we must get our patients up and moving. Which is best? – bedrest – walking

Neither! Let her do what she wants

Question 3 Now that she’s admitted, can we do anything to speed her labor and shorten her suffering? Routine amniotomy shortens labor and improves outcomes… – true – false

False…

or True

Question 4 Pt. admitted, fetal well-being monitored, pt walking as she desires. She didn’t feel good during her prodromal labor yesterday, didn’t sleep much, didn’t eat much. She’s hungry. Should you permit or restrict oral intake during labor? – pro? – con?

ACOG on Oral Intake all expert opinion absolutely no discussion of numbers or evidence pure fear of Mendelsohn’s syndrome, aspiration pneumonitis during obsteric anesthesia induction solid food, no way; clear liquids mildly permissible

Cochrane Systematic Review

Oral Intake risk stratify: if pt at high risk for urgent c-section, then restriction makes more sense; if low risk, hard to justify restriction clear liquids fine, other liquids and solids iffy labor is like running a marathon, would you run a marathon while starving? our L&D will freak out if you feed active labor pts certainly feed pts before active labor, feed before induction, feed when taking break from 2 day induction, etc. Feed according to pt wish whenver there is clear opportunity

Question 5 Patient admitted, laboring, progress is steady, pain is difficult Lots of people in the room – nurse, mother/sister, FOB, other family members All present at least theoretically to be helpful and supportive Does continuous birthing support really matter? Who should do it?

Doulas! fewer c-sxns, fewer instrumented vaginal births, shorter labors, fewer epidurals, fewer low 5-min apgars, higher pt satisfaction “if a doula were a drug, it would be malpractice to withhold it” John Kennell MD

Question 6 labor is long and painful some women want and need to move some want to lie and rest some are strapped to their beds without regard for their preferences does evidence dictate which positions a woman should or should not labor in?

Upright positions: shorter 1 st stage fewer epidurals (pain more manageable) Upright positions: fewer asst deliveries fewer episiotomies more 2 nd deg tears more EBL 500+ cc fewer abnormal FHR

Question 7 She’s fully dilated, ready to commence pushing. The nurse seems passive, coming and going, getting stuff ready, so you take charge by doing what you’ve seen. You tell pt how to push in drill-seargent fashion: – take deep breath, hold it, don’t release any – count to 10 slowly while pushing, take a quick breath and do it again and again if possible – must be silent, don’t scrunch up face If coached closed-glottis purple-faced pushing is so universal, it must be beneficial, right?

Spontaneous pushing BJOG 2011 Spont pushing: better Apgars better cord gases better maternal satisfaction Spont pushing: 2 nd stage 18 min longer better maternal urodynamics 3 mos PP

Question 8 When the time comes, should you cut an episiotomy? What are the indications? Does it improve outcomes?

Epis: routine vs. restricted? RCT’s were done by FP Dr. Michael Klein no protection against 3 rd /4 th deg tear, medial epis increases no protection against incontinence, prolapse perineal pain no better or worse only do when indicated

Question 9 Your pt continues pushing What have you seen others do with their hands while pts push? What should you do?

Hands-on vs. hands-off

After delivery mom delivers vigorous baby into your hands nurse awaits baby at warmer attending at your side has cord clamps and scissors at the ready

Question 10 where do you put the baby? when do you clamp and cut the cord?

Skin-to-Skin

Delayed cord clamping baby gets 40% of its circulating blood vol after delivery if you let it (Usher et al 1963) 50% of placental transfusion in 1 st min wait at least 1 minute, or 2 or 3 or until cord stops pulsing cannot drain blood out of baby unless baby cm above placenta (!) baby gets all the iron it will use in first 6 mos of life from placental transfusion

Questions

Question 1a Ok, well we can do intermittant auscultation after the usual initial 20 minute admitting EFM tracing, right? Do we have to do that initial 20 minute tracing? It should catch babies who are in trouble, right?

Admitting EFM tracing