Introduction Description: Amniotic fluid embolism is a rare but frequently fatal complication of labor in which the amniotic fluid that contains fetal squamous cells and hair enters the maternal vascular system and is lodged in the pulmonary and other vascular beds. Mechanical obstruction and anaphylaxis combine to produce an often-fatal clinical course. The term “anaphylactoid syndrome of pregnancy” has been suggested but has not received wide…

Introduction Description: Acute fatty liver is a rare complication of pregnancy that results in acute liver failure, often with catastrophic consequences. It is also known as acute fatty metamorphosis or acute yellow atrophy. Prevalence: 1/7000–20,000 pregnancies. Predominant Age: Reproductive age; typically during the third trimester of pregnancy. Genetics: There appears to be a link to a recessively inherited mitochondrial abnormality of fatty acid oxidation, first studied…

The Challenge Active management of labor is a system of labor management that is designed to promote effective labor and reduce the need for cesarean delivery. Scope of the Problem: Cesarean birth rate for nulliparous patients approximates or exceeds 30% in most areas. Active management has been associated with cesarean delivery rates of less than 5% for its developers (Ireland). Objectives of Management: To reduce cesarean…

Introduction Description: Failure of the normal process of decidua formation results in a placental implantation in which the villi directly adhere to (accreta; 79%), invade into (increta; 14%), or go through (percreta; 7%) the myometrium. One portion (partial) or all (total) of the placenta may be involved. These conditions are known as placenta accreta spectrum, formerly known as morbidly adherent placenta. Prevalence: Difficult to assess; estimated…

The Challenge The challenge is to assist patients in successfully nursing their infant(s). Scope of the Problem: Although most infants born in 2019 started breastfeeding (83.2%), only 24.9% of infants were exclusively breastfeeding at 6 month. Objectives of Management: Encourage nursing as a feeding strategy, assist patients to prepare for nursing, and deal with problems if they occur. You’re Reading a Preview Become a Clinical Tree…

The Challenge Description: Abrupt changes in maternal physiology are necessary to ensure the survival of the mother immediately after delivery. Slower changes return the woman to the normal, pre-pregnant state. Depending on the system and definition, complete return to the baseline state can take up to 12 months. Scope of the Problem: Changes in virtually every organ system are necessary to revert from the adaptations of…

The Challenge Description: The processes of labor and delivery are associated with physiologic and tissue changes that result in neural signals that are universally interpreted as pressure and pain. Scope of the Problem: On average, more than 60% of women in the United States receive epidural or spinal anesthesia during labor or delivery. Even more women receive other forms of analgesia or anesthesia during the course…

Introduction Description: Tachycardia is an increase in the baseline heart rate, generally above 160 beats Mild tachycardia is generally defined as 161–180 beats/min, and severe tachycardia as greater than 180 beats/min for more than 3 minutes. Prevalence: Mild fetal tachycardia is observed during approximately 2% of labors. Predominant Age: Reproductive age. Genetics: No genetic pattern. Etiology and Pathogenesis Causes: Maternal fever (most common), intra-amniotic infection (fetal…

Introduction Description: Reduced variability is characterized by a reduction in the normal variation in heart rate from beat to beat that may signal fetal stress. Prevalence: Reduced variability is a common finding when the fetal status is compromised. It also occurs when the fetus is sleeping. Predominant Age: Reproductive age. Genetics: No genetic pattern. Etiology and Pathogenesis Causes: Fetal hypoxia with neurologic depression (when decelerations are…

Introduction Description: Periodic changes in the fetal heart rate in conjunction with uterine contractions may occur. These may indicate fetal stress when they are persistent or become progressively deeper or longer lasting. Recurrent decelerations are defined as occurring with 50% or more of contractions during a 20-minute period. In the United States, decelerations in the fetal heart rate are classified by their relationship to uterine activity:…

Introduction Description: Bradycardia is a decrease in the baseline heart rate, generally below 120 beats Moderate bradycardia is generally defined as 80–100 beats/min, and severe bradycardia as less than 80 beats/min, for more than 3 minutes. Prevalence: Mild fetal bradycardia is observed during approximately 2% of labors. Predominant Age: Reproductive age. Genetics: No genetic pattern. Etiology and Pathogenesis Causes: Depressed fetal oxygenation (placental dysfunction, abruption), fetal…

The Challenge Description: Labor is the rhythmic contraction of the uterus that leads to progressive cervical effacement and dilatation. When effective, this leads to descent and eventual expulsion of the fetus. Labor may or may not culminate in the delivery of the fetus. It is generally divided into three stages: first stage—from the onset of labor to complete cervical dilation, although the exact time of onset…

The Challenge Fetal health may be assessed using the nonstress test (NST). This test is the simplest of the antenatal tests to perform and often represents the first line in managing an at-risk pregnancy. Scope of the Problem: Of pregnancies, 3%–12% are at a risk because of gestations that extend beyond term. More pregnancies may be compromised by maternal disease states that affect fetal health or…

The Challenge Doppler flow studies (also known as Doppler velocimetry) constitute a group of tests used to evaluate fetal health and reserve by assessing blood flow characteristics in the umbilical cord, middle cerebral artery, or other vascular structures. Of the tests used for fetal assessment, Doppler flow studies are technologically intensive, expensive, and require special expertise to perform and interpret. Scope of the Problem: Of pregnancies,…

The Challenge Fetal health may be assessed using the contraction stress test (also called “oxytocin challenge test”). This test is somewhat analogous to an exercise stress test for the evaluation of adult cardiac function as problems or weaknesses that are normally compensated for at rest may become apparent with stress. In the contraction stress test the fetal–placental–maternal unit is stressed through uterine contractions. The resulting periodic…

The Challenge The biophysical profile (BPP) is one of several tests used to evaluate fetal health and reserve. Of the tests used for fetal assessment, the BPP is the most technologically intensive and most expensive, but it carries the lowest false-positive and false-negative rates (0.6–1/1000). Scope of the Problem: Of pregnancies, 3%–12% are at risk because of gestations that extend beyond term and more may be…

The Challenge The challenge is to reduce the risk for fetal demise in women at a high risk through the use of noninvasive tests that have acceptably low false-positive and false-negative results. Scope of the Problem: There are approximately 5.7 fetal deaths at more than 20 weeks of gestation per 1000 live births in the United States (2019; 25/1000 births in 1942). Objectives of Management: To…

The Challenge During the third trimester (29–40 weeks or more) the fetus continues to grow and develop, with full maturation in organ function being established, maternal physiology continuing to change, and the cervix and uterus preparing for the processes of childbirth. Prenatal care during this period continues to be directed toward monitoring the progress of the pregnancy and detecting treatable complications. Scope of the Problem: It…

The Challenge During the second trimester (14–28 weeks) the fetus continues to grow and develop, organ function becomes more normal, and the growing uterus is more apparent. Prenatal care during this period is directed toward monitoring the progress of pregnancy and detecting treatable complications. Scope of the Problem: Despite the relative lack of complications that occur during the second trimester, the early signs of later problems…

The Challenge Despite the dramatic and vulnerable changes that the conceptus undergoes in the first 14 weeks of gestation, many patients are unaware of their pregnancy or delay seeking prenatal care. Evidence suggests that it is during this period the foundations of a successful pregnancy and even the future health of the adult individual are set. Although most pregnant women would deliver healthy infants without any…