Updated: 4/21/2020

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
  • Epidemiology
    • 85% of pregnant people undergo spontaneous labor and delivery between 37-42 weeks
  • 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
    • preterm
      • prior to 36 weeks and 6 days
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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Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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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? Review Topic | Tested Concept

QID: 109543
FIGURES:
1

Normal labor

48%

(24/50)

2

Vasa previa

12%

(6/50)

3

Placenta previa

14%

(7/50)

4

Placental abruption

26%

(13/50)

5

Disseminated intravascular coagulation (DIC)

0%

(0/50)

L 2 D

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