Updated: 9/12/2021

Presentation of Labor

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  • Snapshot
    • A 32-year-old G1P2 presents to labor and delivery with contractions. She has been having 1 painful contraction every 20 minutes for the past 2 hours and reports mild spotting on her underwear. A transabdominal ultrasound is performed followed by a pelvic exam. Her cervix is effaced 90% and dilated 5 cm. She is admitted for active labor.
  • Introduction
    • Overview
      • involves spontaneous and regular contractions +/- rupture of membranes
    • Labor
      • true
        • progressive effacement and dilation of uterine cervix resulting from contractions of uterus
      • false
        • Braxton Hicks contraction
          • uterine contractions without effacement and dilation of cervix
          • managed with reassurance and discharge
      • preterm
        • prior to 36 weeks and 6 days
  • Epidemiology
    • 85% of pregnant people undergo spontaneous labor and delivery between 37-42 weeks
  • Presentation
    • Symptoms that require hospital presentation
      • contractions
        • ≥ 4 every 20 minutes or ≥ 8 every 60 minutes
      • rupture of membranes
      • significant bleeding
        • small amount of mucoid bleeding is normal in early labor ("bloody show")
      • decrease in fetal movement
    • Physical exam
      • vital signs
        • blood pressure (BP)
        • heart rate (HR)
        • respiratory rate (RR)
        • temperature
      • auscultation of fetal heart sounds
      • determine fetal position
        • Leopold maneuvers
          • steps taken to palpate the uterus to assess fetal presentation and position
      • vaginal exam to check
        • rupture of membranes (ROM)
        • cervical effacement and dilation
        • fetal station (level of fetus relative to ischial spine)
          • zero station is at the level of the ischial spine
    • Admission for active labor
      • cervial effacement ≥ 80%
      • 4-5 cm dilation
  • Imaging
    • Transabdominal ultrasound
      • indications
        • determine fetal position
        • rule out placenta previa and premature rupture of membranes (PROM)
          • perform prior to digital exam
  • Studies
    • Serum labs
      • complete blood count (CBC)
      • blood type and screen
      • rapid HIV testing
      • hepatitis B
      • syphillis
      • group B streptococcus (GBS)
  • Preterm Labor
    • Definition
      • uterine contractions
        • ≥ 4 every 20 minutes or ≥ 8 every 60 minutes
      • cervical dilation ≥ 3 cm
    • Symptoms
      • menstrual-like cramps
      • low back ache
      • discharge of mucous from vagina
      • spotting
      • contractions
    • Physical exam
      • digital cervical examination (after transabdominal ultrasound (US))
      • speculum exam (after digital exam)
    • Imaging
      • transabdominal US
      • transvaginal US
    • Studies
      • fetal fibronectin testing
      • rectovaginal GBS culture
      • urine culture
      • substance use testing
      • sexually transmitted infection (STI) testing
    • Management
      • gestational ages
        • 34 weeks to 36 weeks and 6 days
          • delivery
            • by induction if necessary
          • penicillin if GBS culture is positive or unknown
        • 32 weeks to 33 weeks and 6 days
          • expectant management unless fetal lungs have reached maturity
          • betamethasone
          • penicillin if GBS culture is positive or unknown
          • antimicrobials if no contractions
        • 24 weeks to 31 weeks and 6 days
          • expectant
          • betamethasone
          • penicillin if GBS culture is positive or unknown
          • tocolytics with indomethacin
          • magnesium sulfate
        • < 24 weeks
          • patient counseling
          • expectant management or induction

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(M2.OB.17.4867) A 32-year-old G1P0000 presents to labor and delivery triage at 38 weeks gestation after several hours of contractions. Currently, they are timed about four minutes apart. Her contractions started after she tripped on a rug and fell on her side. She denies leakage of fluid and the baby has been moving normally, but she noted a small amount of blood on her underwear just before coming into the hospital. The pregnancy has been uncomplicated thus far. The patient has a past medical history of endometriosis, and this fetus was conceived by in vitro fertilization. Pelvic exam in triage reveals a cervix that is three centimeters dilated with a small amount of blood near the introitus. Fetal heart rate tracing at this time is shown in Figure A. Which of the following is the most likely diagnosis?

QID: 109543
FIGURES:

Normal labor

48%

(28/58)

Vasa previa

12%

(7/58)

Placenta previa

17%

(10/58)

Placental abruption

22%

(13/58)

Disseminated intravascular coagulation (DIC)

0%

(0/58)

M 6 D

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