A 27-year-old G2P1 at 38 weeks’ gestation is admitted in active labor. She has had one prior uncomplicated vaginal delivery and has no medical problems. She reports an allergy to penicillin, and says she had a rash. Her vital signs are normal, and the fetal heart tracing is category I. Her prenatal record indicates that her group B Streptococcus (GBS) culture at 36 weeks was positive.
What is the best choice for antibiotic prophylaxis during labor?
GBS is an important cause of perinatal morbidity and mortality. Implementation of national guidelines for intrapartum antibiotic prophylaxis since the 1990s has resulted in an 80% reduction in the incidence of early onset neonatal sepsis due to GBS. The Gram-positive organism can colonize the lower gastrointestinal tract, and secondary spread to the genitourinary tract is common. Between 10% and 30% of pregnant women are colonized with GBS in the vagina or rectum. Universal prenatal screening is recommended between 35 and 37 weeks. Penicillin G (5 million units IV initially, then 2.5-3 million units/4 hours until delivery) remains the agent of choice for intrapartum prophylaxis, although ampicillin is an acceptable alternative. Data show that GBS isolates are increasingly resistant to second-line therapies. Up to 32% of isolates are resistant to erythromycin, and therefore, this is no longer recommended. Clindamycin is only recommended if the isolate is susceptible to both clindamycin and erythromycin. A patient with a penicillin or cephalosporin allergy should be asked about her specific symptoms. If she has had anaphylaxis, angioedema, respiratory distress, or urticarial, she should receive vancomycin 1g IV every 12 hours until delivery or clindamycin as described earlier. If she has not had these symptoms, and perhaps just had a mild rash, she should receive cefazolin 2 g IV as an initial dose, then 1 g IV every 8 hours until delivery.
A 38-year-old G6P4 undergoes a primary cesarean delivery under regional analgesia for malpresentation of twins at 37 weeks. Immediately after the delivery of the placenta, the anesthesiologist notes maternal seizure activity with profound hypoxia and hypotension. The patient is intubated and provided with circulatory support with vasopressors. Massive hemorrhage from the surgical site ensues, and the patient is given uterotonic agents and blood products.
What is the most likely cause of her hemorrhage?
Amnionic fluid embolism is a complex disorder characterized by abrupt onset of maternal hypoxia, hypotension, and disseminated intravascular coagulopathy. Amnionic fluid enters the maternal circulation from a breach in the normal maternal-fetal physiological barriers. This typically happens with labor and delivery, and cesarean delivery offers ample opportunity. The typical clinical presentation is dramatic. Patients may gasp for air, develop seizures from hypoxia, and have cardiopulmonary collapse, followed by massive hemorrhage from consumptive coagulopathy. It unfortunately often results in death given the quickness of events. Immediate support with oxygenation through intubation and circulatory support and blood products is vital. Profound neurological impairment is common in survivors. While halogenated anesthetic agents and multiple gestations can cause uterine atony leading to hemorrhage and while placenta accreta can also be a cause of hemorrhage, these are not the culprits in this drastic presentation.
A 23-year-old G1 at 38 weeks’ gestation presents in active labor at 6-cm dilated with ruptured membranes. On cervical examination the fetal nose, eyes, and lips can be palpated. The fetal heart tracing is 140 beats per minute with accelerations and no decelerations.
Which of the following is the most appropriate next step in management for this patient?
With face presentation, the fetal head is hyperextended so the occiput is in contact with the fetal back, and the chin (mentum) is presenting. In the event of a face presentation, successful vaginal delivery will occur the majority of the time with an adequate pelvis. Spontaneous internal rotation during labor is required to bring the chin to the anterior position, which allows the neck to pass beneath the pubis. Therefore, the patient is allowed to labor spontaneously; a cesarean delivery is employed for labor abnormality or for fetal distress. Manual conversion to vertex, forceps rotation, and internal version are not used to deliver the face presentation because of undue trauma to both the mother and the fetus.
A 32-year-old G3P2 at 39 weeks’ gestation presented to labor delivery with ruptured membranes. On examination, she was contracting regularly, and her cervix was 4-cm dilated. Her history was significant for two prior vaginal deliveries, with her largest child weighing 3800 g. Over the next 2 hours she progressed to 7-cm dilation. Four hours later, she remained 7-cm dilated. She had regular contractions and IUPC showed MVUs of 220. The estimated fetal weight by ultrasound was 3200 g.
Which of the following labor abnormalities best describes this patient?
The labor portrayed is characteristic of a secondary arrest of dilation. The woman has entered the active phase of labor, as she previously progressed from 4 cm to 7 cm in less than 2 hours and then remains 7 cm over an additional 4 hours. New criteria for first stage arrest include 6 cm or more dilation with membrane rupture and no cervical change for 4 or more hours with adequate contractions, or 6 or more hours with inadequate contractions. New data suggests that historical criteria defining normal labor progress (cervical change of 1.2 cm/h for nulliparous women and 1.5 cm/h for multiparous women) are no longer valid.
A 29-year-old P0 at 41 weeks’ gestation presents in labor. At the time of delivery, a shoulder dystocia is encountered. An episiotomy is cut to assist with dystocia maneuvers.
Compared with a midline episiotomy, which of the following is an advantage of mediolateral episiotomy?
Midline episiotomies are easier to repair, and have a lower incidence of surgical breakdown, involve less pain, and lower blood loss. However, the incidence of extensions of the incision to include the rectum is higher for midline episiotomies compared with mediolateral episiotomies. Mediolateral episiotomies lead to more pain, blood loss, and dyspareunia. Regardless of technique, attention to hemostasis and anatomic restoration is the key element of a technically appropriate repair.
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