171 Induction and Delivery: Bishop Score, Epidurals and Newborn Care

Hello and welcome to the Physician Assistant Exam Review Podcast. This is episode 171, induction, delivery, and just a touch of newborn care. My name is Brian Wallace. I’m the host and creator here at Physician Assistant Exam Review, where I’ve been behind the microphone for over 15 years now, maybe not just quite as consistently as I’d like to be, but we’re just, we are here for a very, very long time at this point. Over the years, what I’ve discovered is that the content, as important as it is, is not the place we can move scores the most. The place we can move scores the most is by thinking differently about how we cover the material, about thinking differently about how we study, the way that we work, the way that we present ourselves, the way that we attack our exams. Each episode, we cover a medical, we cover medical content, right?

That’s what we’re doing, but we’re doing it in a way that’s going to help you score better, right? Our motto here is think different, work different, score different. That’s the idea.

Now, with that in mind, tonight, Tuesday, September 15th, and Thursday, September 17th, I’m going to be hosting a 100% free Master Class on the six skill areas that you need to do well in PA school and pass the PANCE. Not just about hitting the content, all the other things, pieces that you need. We’re going to cover so much tonight and on Thursday. If you can’t make it tonight, no worries. Come Thursday, but come live, go to physicianassistantexamreview.com/masterclass. We’re going to have a ton of fun. It’s going to be a huge deal.

You’re going to get so much out of it. Share it with your friends. Absolutely really, really important.

All right. Let’s jump into this week’s priming questions. A Bishop score of eight or higher tells you what about the cervix. A Bishop score of eight or higher tells you what about the cervix. Which cranial? Not cranial, which cervical ripening agent must be avoided with a prior uterine scar. What’s the most common complication of a labor epidural? Name the three signs that the placenta has separated from the uterus.

Name the three signs that the placenta has separated from the uterus. When does newborn resuscitation begin relative to the one minute Apgar score? Excuse me. This episode is just a touch shorter. I was going to do one, the last one in this one together in one giant episode and it just, it didn’t seem to work out well. So I split them up, which means today we’re going to be just a touch shorter. In the last episode, we covered labor and how to watch out for what you’re looking for, what you’re watching for.

The decels and accels, those kinds of things, the reassuring strip, that kind of stuff. Today we’re, and we talked about the steps through delivery today. We’re going to talk about induction and augmentation, helping the mom get through delivery. We’re going to talk about analgesics and we’re going to talk very, very briefly about newborn care, all as it relates to your PANCE.

So let’s start with induction and augmentation. Induction is starting labor before it begins on its own, starting labor before it begins on its own. Right? Mom was not progressing. We’re at 41 weeks or 40 weeks. We’ll get to them in just a second. And we want to, have her have the baby, be born at some point.

Augmentation is we’re going to strengthen the contractions once they’ve started. We’re going to help out a little bit. Now these are two different things and really it’s determined by the cervix, whether we have a favorable cervix, in which case we’re going to use oxytocin or an unfavorable cervix, in which case we’re going to use misoprostol, which we’ll get to in just a second. Indications for augmenting labor and induction: post dates, right? That’s the number one indication is if we’re beyond where we want to be. So risk for the fetus climbs after 41 weeks. So at 41 weeks and zero days, we offer induction, right?

Cause we want to be delivered by 42 weeks and zero days. Full term is considered 39 weeks and zero days to 40 weeks and six days. Late term is 41 weeks, zero days to 41 weeks, six days. Post term is greater than 42 weeks.

Okay. So for me, I just remember a full term 39 late term 41 post term 42. The rest of it is a little more than I can personally hold on to, right? So we don’t do an elective induction before 39 weeks. Unless there’s a reason now think for a second, what are some reasons we would want to do an induction before 39 weeks? I’ll give you just a second. How about preeclampsia?

What about gestational diabetes? That’s out of control. What about premature rupture of membranes? Non reassuring signs on the strips, right? There’s so many reasons to do an induction before 39 weeks, but we don’t do it just as an elective process. Now in the same vein, what are some contraindications to doing an induction? Why wouldn’t we induce a mother into labor?

Well, obviously, if she’s too early, we’re not doing that. But what else? What else would be contraindications to delivery? How about placenta previa? What about a transverse presentation? What about a prior uterine rupture? And we don’t want the baby to be delivered vaginally.

Active genital herpes lesions, umbilical cord prolapse. That’s just a few, but I don’t want you to memorize the list. I want you to understand what’s behind it so that you have it.

Okay. Let’s talk a little bit about the cervix. The Bishop score is how we score the cervix. I’m not going to go into the details of it, but I want you to understand the overall picture. I don’t think you’re going to be asked about a Bishop score of seven. I think you’re going to be asked about is the cervix soft effaced, dilated, that kind of thing. So we’re looking at dilation, effacement, station, consistency, and position. So a favorable cervix is soft, anterior, effaced, dilated with a low station.

So the cervix is already working. Unfavorable is firm, posterior, thick, closed, and a high station. Now the scores, like I said, I don’t, maybe they come up, maybe they don’t. Greater than eight or equal to or greater than eight is favorable. Less than or equal to six is unfavorable. And really what that means is we can either let it just keep going or we can give oxytocin if it’s equal to or greater than eight. If it’s under six, then we need to ripen it first.

Cervical ripening is with prostaglandin, so misoprostol or dinoprostone. But if there’s a prior uterine scar, we don’t want to use misoprostol because there’s risk of uterine rupture. So what can you do? Well, you can do mechanical. You can use a transcervical Foley balloon. So you can put a Foley balloon catheter into the cervix and inflate it. You know, we do this with dilators all the time in GYN surgery.

You can mechanically dilate the cervix. A digital separation of the membranes from the lower uterine segment can also help to release endogenous prostaglandins and ripen the cervix. So a membrane sweep is another method. So that was ripening the cervix. Then the next step, like we talked about was oxytocin. This is an IV infusion. We titrate it to get the contractions to a certain pattern.

You’re going to watch out for tachysystole, which is more than five contractions per 10 minutes, averaged over 30 minutes. This cuts placental perfusion. So we want to be a little careful there. You can also do an amniotomy. So artificial rupture of membranes, you can actually rupture the membranes, right? To get things kind of moving. This is only done once the head is engaged, because if you do it before the head is engaged, you can get a prolapse of the cord.

And we don’t want, we don’t want that. But also remember, once we rupture the membranes, if they don’t rupture on their own, the minute they rupture, we’re now starting the clock for the infection risk. So just something to be aware of.

Exam keys from this section. A Bishop score of greater than eight is favorable. Straight to oxytocin. Less than six, ripen first. So that’s misoprostol, except if there’s a uterine scar. We’re only going to do an amniotomy if the head’s engaged because of cord prolapse and know the things that will stop us from inducing labor. So placenta previa, transverse lie, et cetera.

Basically anything that is a contraindication to vaginal delivery.

All right. Let’s talk about delivery, analgesia, and the tiniest, tiniest bit of newborn care. We’re not doing peds here. The second, third, and fourth stages and practices is pain control, delivery of the infant delivery, the placenta and the first assessment of the newborn. So picking up where we left off from last week, everything that goes wrong at this stage for mom is bleeding. And usually that’s the uterine tone is not strong. So let me explain real fast. What happens is the uterus, once the baby is delivered and once the placenta detaches, the uterus has a giant muscle and it starts to clamp down.

And by doing that, it’s clamping off the blood vessels. Just like if you put pressure on a wound, right? It’s doing the same exact thing. If it doesn’t contract, if the tone is weak, the mother will continue to bleed. So we want uterine the uterus to get into that. I’m missing the terms here, but you want a good uterine tone. You want it to clamp down.

You can feel this. I mean, obviously, you could feel it through the mother’s abdomen, through a vaginal delivery, but absolutely with what I do, I do C-sections all the time. And you can absolutely, I’m holding the uterus when we’re suturing it closed after the baby’s been delivered and you can feel the uterine tone and you can feel if it’s clamping down or not. And we communicate with the anesthesia team at that point. And they ask us because they’re worried about blood flow. They’re worried about hypotension. They’re worried about blood loss.

So we need to work with them as a team because they’re the ones who are delivering the medications in this case during a C-section, a little bit different during a vaginal delivery. So we’re going to ask for oxytocin to help to clamp down on those vessels during that time.

All right. I got off track a little bit there.

Let’s talk about labor analgesia first. While we’re talking about our anesthesia team, epidural is going to be the mainstay. This is a local anesthetic in the epidural space. This is the most effective labor analgesia available. This does not slow the first stage, but we talked last time that it might slow the second stage a little bit, maybe by an hour or so. Definitely, definitely a question. What’s the most common complication of an epidural?

Maternal hypotension, mom’s blood pressure drops. We’re going to give her IV fluids and then pressors to help with that. There is a risk of post-dural puncture, which can give them a headache and it’s worse with positioning. Sitting up is worse. You can do an epidural blood patch to help with this. What are some contraindications to an epidural? Well, what are contraindications to sticking a needle in someone’s spine?

If they have a coagulopathy problem, if they have a thrombocytopenia problem, right? We’re not going to be doing this. Infection at the site you want to inject through, right? Things just, these should make sense. These are not things to memorize. We can do opioids for pain control, but they do cross the placenta, which will depress the neonates respiratory system. So we want to be very careful here.

Something that comes up more frequently now is delayed… Delayed cord clamping. Recommendation is you wait 30 to 60 seconds in a vigorous term infant, and at least 60 seconds in preterm because we’re improving neonatal iron stores. But we don’t worry about this. If the patient needs to be, if the baby needs to be resuscitated, if there’s some kind of major problem, this gets shortened. But 60 seconds is what you’re looking for. We do this all the time in C-sections.

The baby’s delivered. You wait 60 seconds and we clamp and cut the cord. What are signs of placental separation in a vaginal delivery? There are three that we talk about. Do you know them? Number one is the cord lengthens. This isn’t actually lengthened, right?

It’s the placenta separating from the uterine lining. So the part that you see seems longer. You can get a gush of blood at that time for obvious reasons. And then the uterus rises and becomes more globular. That’s it sort of clamping down. Active management of third stage, so oxytocin after delivery. Again, we want that uterus to clamp down.

You can do some uterine massage, but we need to be very, very cognizant of postpartum hemorrhage secondary to that issues with the placenta.

All right. Let’s talk about the baby for just a minute here and talk about Apgar scores. These are scored from zero to two every, on the one minute and on the five minutes. They are appearance, pulse, grimace, activity, and respiration. So they’re scored on zero to two for a total of up to 10. And if there’s an issue, we just solve the issue. We don’t wait for the five minute Apgar score before we resuscitate the baby. Right?

All right. Let’s talk about perineal lacerations. So during delivery, we can always have a tear. First degree is I would memorize this, these definitions. I just think that they’re easy to ask and easy to know. First degree is skin and vaginal mucosa only. Second degree extends into the perineal body, musculature. This is the most common.

Third degree involves the anal sphincter. Fourth degree is through the sphincter into the rectal mucosa. These can be bad. No longer do we do episiotomies as a standard. They do heal well if it works, but it does seem like it’s made things worse when it makes things worse.

Exam keys here, epidural. What’s the most common complication, hypotension? When do we not give an epidural? Coagulopathy or thrombocytopenias. Third degree tear equals what? Into the anal sphincter, a fourth degree is what? Into the rectal mucosa.

Oxytocin is our main prevention of postpartum hemorrhage. And Apgars are done at one and five minutes, but never delay resuscitation. Cool.

All right. This is a quick one. Your study tip for today is it doesn’t always have to be a ton. It doesn’t always have to be a lot, but it needs to be is thoughtful. You need to break down the information. You need to take the information. Turn it into something you can use.

Look for the things that matter the most. Look for the things that are going to be test questions. You don’t need to be longer. You need to be better. And that’s exactly what we’re going to cover tonight and Thursday in the Master Class. So please, if you’re struggling at all in PA school, physicianassistantexamreview.com/masterclass, share it with your friends. We’re going to cover the six different areas that are going to help you score higher on every exam forever, but especially on the PANCE, especially on your EORs, going to make a huge, huge difference.

physicianassistantexamreview.com/masterclass.

All right. Let’s wrap up with our priming questions. A Bishop score of eight or higher tells you what about the cervix. It’s favorable. Skip ripening and go straight to oxytocin, not oxycodone. Which cervical ripening agent must be avoided with a prior uterine scar. Misoprostol. What’s the most common complication of a labor epidural?

What’s the most common complication of a labor epidural? Maternal hypotension from a sympathetic blockade. We give IV fluids. Name three signs that the placenta has separated, cord lengthens, gush of blood, uterus rises and becomes more globular. When does newborn resuscitation begin relative to the one minute Apgar score? If they need resuscitation, it begins whenever you need it. Right.

We don’t wait for that one minute. Awesome.

All right. That’ll bring us to the end of today’s show. Thank you guys so much for being part of this. It absolutely helps. If you share the show, it absolutely helps. If you tell people about what we’re doing here and the impact that we’re trying to have and the impact that we are having based on what you guys have sent me in emails, everything, love it, love it, love it. Looking forward to do it next week.

Hopefully we’ll be wrapping up reproduction pretty soon. Please don’t forget about the class tonight. physicianassistantexamreview.com/masterclass. If you know, you want to go deep. If you know that you would like to get higher scores on everything, then you may be interested in the 33 Days to Pass the PANCE program. Our next cohort begins October 1st. We’ve been getting insane results from that program because we’re teaching students how to be better students, how to perform better on exams.

And we’re taking our time and we’re doing it the right way. And it fits right in alongside your everyday classes. It does not interfere with anything. It does not take up your whole day, easy to fit in. And it absolutely makes a tremendous difference. Registration for that opened on Thursday, the 17th and closes down Thursday, September 24th. And, but this particular class, we have limited seats.

I opened it at 50. I think we’re down to like 35 at this point. We have limited seats because we have schools who are sending students directly into the program for October. So I can only handle so many people. So anyway, if you’re interested in that, physicianassistantexamreview.com/33 to find out more and to register there.

All right, guys, have a great night and I’ll talk to you next week. Hopefully I’ll see you on the Master Class though, before then. Take care.