by Jennifer Doorey, MD, MS
Procedure Ready: Ob/Gyn (formerly called Pimped Ob/Gyn) is a podcast aimed at medical, PA, and NP students who are entering their clinical rotation in Ob/Gyn. It covers topics including Your Ob/Gyn Survival Guide-Tips and Tricks, Labor and Delivery, Vaginal deliveries, C-sections, Hysterectomies, and more. Each podcast walks you through a portion of what you’ll experience during your clinical rotations, gives you tips for excelling, preps you for the clinical questioning that’ll occur, and sets you up to overall Honor the rotation! Email [email protected] with comments, questions, and episode ideas. ##Legal Disclaimer## The opinions expressed within this content are solely the speakers' and do not reflect the opinions and beliefs of their employers or affiliates.
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🇺🇲
Publishing Since
10/23/2017
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June 9, 2023
<p><span style="font-weight: 400;">Incidence: </span></p> <p><span style="font-weight: 400;">3.3% as of 2013 </span></p> <p><span style="font-weight: 400;">Indications: </span></p> <ul> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Prolonged second stage </span></li> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Risk of fetal compromise </span></li> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Shortening 2nd stage for maternal benefit (ex: cardiac conditions)</span></li> </ul> <p><span style="font-weight: 400;">Consent: </span></p> <ul> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Comparison is c-section typically </span></li> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Failure rate of OVD is ~3-6% </span></li> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Forceps has higher success rate over vacuum, but also higher risk 3rd/4th degree tear </span></li> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Risks to both mom and baby</span></li> </ul> <p><span style="font-weight: 400;">Prep: </span></p> <ul> <li><span style="font-weight: 400;">Fetus appropriate station/position </span></li> <li>Anesthesia</li> <li>Empty bladder</li> <li>Assess Pelvis/Passenger sizes/fit</li> <li>OR Ready</li> <li>Peds available </li> </ul> <p><span style="font-weight: 400;">Episiotomy – NO! </span></p> <p><span style="font-weight: 400;">Contraindications</span></p> <ul> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Fetal conditions, known or supspected: bone disorders (OI), bleeding disorders </span></li> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Maternal infections: Hep C, HIV, etc </span></li> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Concern for shoulder dystocia/cephalo-pelvic dysproportion </span></li> </ul>
June 9, 2023
<p><span style="font-weight: 400;">Indications: </span></p> <ul> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Post-dates (42+wks) </span></li> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Late Term (41+ wks)</span></li> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Elective 39+wks </span></li> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Diabetes</span></li> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Hypertension </span></li> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Many more - check out </span><a href="https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2021/07/medically-indicated-late-preterm-and-early-term-deliveries"><span style="font-weight: 400;">ACOG Medically indicated delivery </span></a></li> </ul> <p><br /><br /></p> <p><span style="font-weight: 400;">39week induction</span></p> <p><span style="font-weight: 400;">ARRIVE Trial - Multicenter RCT showing benefit to 39wk IOL over expectant management to ~41wks </span></p> <p><span style="font-weight: 400;">Included </span></p> <ul> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Primips </span></li> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">No medical indications for IOL prior to 40+5</span></li> </ul> <p> </p> <p><span style="font-weight: 400;">Results </span></p> <ul> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">IOL group had LOWER c-section rate than expectant group </span></li> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Neonatal composite outcome had a trend (not statistically significant) toward lower neonatal compilations in IOL group </span></li> </ul> <p><span style="font-weight: 400;">Conclusion</span></p> <ul> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">IOL at 39wks is as safe as expectant management without increased risks</span></li> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Many pregnant people are now offered a 39wk IOL rather than waiting for spontaneous labor </span></li> </ul> <p><br /><br /></p> <p><span style="font-weight: 400;">The IOL Process: </span></p> <p> </p> <p><span style="font-weight: 400;">Evaluate and Prep:</span></p> <ul> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Full H&P</span></li> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Ultrasound for position - Vertex</span></li> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">VE for cervical exam: dilation/effacement/Station, also position and consistency </span></li> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Calculate Bishops Score → help determine mode of IOL</span></li> </ul> <p><br /><br /><br /></p> <p><span style="font-weight: 400;">Options for IOL: if biship score <8 for prime or <6 for multip, ripen first! </span></p> <ul> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Mechanical cervical ripening (balloon)</span></li> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Chemical cervical ripening (misoprostol or cervidil) </span></li> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Best yet--both! </span></li> </ul> <p> </p> <p><span style="font-weight: 400;">Contractions (pitocin) </span></p> <ul> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Prime: Pitocin alone if Biship 8 or higher</span></li> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Mulitp: Pitocin alone if bishop 6 or higher&n
June 8, 2023
<p><span style="font-weight: 400;">Definition: Failure to deliver fetal shoulders with normal downward traction </span></p> <p><span style="font-weight: 400;">Why we care: Baby hypoxia, brachial plexus injuries, maternal injuries</span></p> <p><span style="font-weight: 400;">Risk factors: </span></p> <ul> <li><span style="font-weight: 400;">DM, excessive weight gain in pregnancy, S>D, Large baby</span></li> <li>Hx of shoulder dystocia (~10-15% recurrence)</li> <li>Turtling while pushing </li> </ul> <p><span style="font-weight: 400;">Prevention </span></p> <ul> <li><span style="font-weight: 400;">No real prevention as SD is very hard to predict </span></li> <li>Offer cesarean delivery if EFW is >5000g and no DM, or >4500g and any type of DM</li> </ul> <p><span style="font-weight: 400;">What do to: </span></p> <ul> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Step back. If comfortable, can help minimize family interference. Calmly explain what is happening and what the docs are doing. </span></li> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Offer to be the Timekeeper. Write down times and what is happening. Announce every 2 minutes. </span></li> </ul> <p><span style="font-weight: 400;">What you’ll see: </span></p> <ul> <li><span style="font-weight: 400;">Prep: Hypothesize shoulder orientation for suprapubic pressure, place stool </span></li> <li>Announce problem- call for help</li> <li>Maneuvers - McRobers, suprapubic <ul> <li>Posterior arm</li> <li>Rotational: Wood’s screw, Rubin</li> <li>Gaskins- all 4s</li> <li>Episiotomy</li> <li>Zavanelli </li> </ul> </li> </ul>
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