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A Bishop score of 8 or higher means skip the ripening and go straight to oxytocin. Misoprostol and a prior uterine scar don’t mix. And the APGAR never decides when resuscitation starts. This episode finishes labor the way it actually gets tested: how to start it when it won’t start, how to restart it when it stalls, and everything from the epidural to the baby’s first assessment.
Induction and Augmentation of Labor
- Induction = starting labor before it begins on its own.
- Augmentation = strengthening contractions in labor that started and stalled.
- The cervix picks the method.
- A favorable cervix goes straight to oxytocin.
- An unfavorable one gets ripened first.
Indications
- Post-dates: risk to the fetus climbs after 41 weeks, so offer induction at 41 0/7 and deliver by 42 0/7.
- Full term = 39 0/7 to 40 6/7. Late term = 41 0/7 to 41 6/7. Postterm = ≥42 0/7.
- No elective induction before 39 0/7 weeks. Earlier than that needs a medical indication, because delivering before 39 weeks carries real neonatal respiratory risk.
- Preeclampsia and the other hypertensive disorders.
- Poorly controlled gestational diabetes.
- Premature rupture of membranes without labor.
- Chorioamnionitis.
- Fetal growth restriction, oligohydramnios, nonreassuring surveillance, fetal demise.
Contraindications
- Placenta previa and vasa previa.
- Transverse lie, and any presentation that cannot deliver vaginally.
- Prior classical (vertical) uterine incision or prior uterine rupture.
- Active genital herpes lesions.
- Umbilical cord prolapse.
Bishop Score
- Bishop score: a 0 to 13 point cervical scoring system predicting whether an induction will succeed.
- Grades dilation, effacement, station, consistency, and position.
- Favorable = soft, anterior, effaced, dilated, low station. The cervix has already started doing labor’s work.
- Unfavorable = firm, posterior, thick, closed, high station.
- ≥8 = favorable. The cervix behaves like spontaneous labor, so go to oxytocin.
- ≤6 = unfavorable. Ripen first.
Cervical Ripening
- Prostaglandins: misoprostol (PGE1) or dinoprostone (PGE2).
- Avoid misoprostol with any prior uterine scar, risk of uterine rupture.
- Mechanical: transcervical Foley balloon.
- Safe with a prior cesarean, which is exactly why it gets chosen there.
- Membrane sweeping: digital separation of the membranes from the lower uterine segment, releasing endogenous prostaglandins.
Augmentation
- Oxytocin: IV infusion titrated to the contraction pattern.
- Watch for tachysystole, more than 5 contractions per 10 minutes averaged over 30 minutes, which cuts placental perfusion.
- Amniotomy (artificial rupture of membranes): only with the head engaged.
- An unengaged head risks cord prolapse.
- Rupturing the membranes also starts the infection clock.
Exam Keys
- Bishop ≥8 = favorable, straight to oxytocin. ≤6 = ripen first.
- Misoprostol + prior uterine scar = uterine rupture. Use a Foley balloon.
- Tachysystole = more than 5 contractions in 10 minutes. Reduce or stop the oxytocin.
- Amniotomy with an unengaged head → cord prolapse.
- Placenta previa and transverse lie are absolute contraindications to induction.
Delivery, Analgesia, and Newborn Care
- The second, third, and fourth stages in practice: pain control, delivery of the infant, delivery of the placenta, and the first assessment of the newborn.
- Almost everything that goes wrong in this window is bleeding, and uterine tone is the answer to most of it.
Labor Analgesia
- Epidural: local anesthetic into the epidural space, the most effective labor analgesia available.
- Doesn’t slow the first stage, may modestly lengthen the second.
- Most common complication: maternal hypotension from sympathetic blockade → IV fluids first, then ephedrine or phenylephrine.
- Post-dural puncture headache: positional, worse sitting up, better lying flat. Treated with an epidural blood patch.
- Contraindications: coagulopathy or thrombocytopenia, infection at the site, hemodynamic instability.
- Pudendal block: local anesthetic near the ischial spines.
- Fast perineal anesthesia for delivery, repair, or operative vaginal delivery.
- IV opioids: cross the placenta and cause neonatal respiratory depression. Avoid them close to delivery.
Delivery and the Third Stage
- Delayed cord clamping: wait at least 30 to 60 seconds in vigorous term infants and at least 60 seconds if preterm (under 37 weeks). Improves neonatal iron stores.
- Applies to cesarean as well as vaginal delivery. A baby who needs resuscitation gets clamped right away.
- Signs of placental separation:
- Cord lengthens.
- Gush of blood.
- Uterus rises and becomes globular.
- Active management of the third stage:
- Oxytocin after delivery.
- Gentle controlled cord traction.
- Uterine massage.
- The primary prevention of postpartum hemorrhage.
APGAR
- APGAR score: newborn assessment at 1 and 5 minutes, scored 0 to 2 in each of five categories for 10 total.
- Appearance (color), Pulse, Grimace (reflex irritability), Activity (tone), Respiration.
- It describes the transition to extrauterine life.
- It does not direct resuscitation, which starts before the first score is assigned.
- It does not predict long-term outcome.
Perineal Lacerations
- First degree: skin and vaginal mucosa only.
- Second degree: extends into the perineal body musculature. The most common.
- Third degree: involves the anal sphincter.
- Fourth degree: through the sphincter into the rectal mucosa.
- Episiotomy: no longer routine.
- Midline heals better but extends to third and fourth degree more often.
- Mediolateral protects the sphincter.
Exam Keys
- Epidural → hypotension. IV fluids first, then a vasopressor.
- Post-dural puncture headache is positional and better lying flat. A blood patch fixes it.
- Coagulopathy or thrombocytopenia = no epidural.
- Third degree = anal sphincter. Fourth degree = rectal mucosa.
- Oxytocin with active third-stage management is the main prevention of postpartum hemorrhage.
- APGAR at 1 and 5 minutes, and it never delays resuscitation.
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Get 26 Ob-Gyn questions straight from The Final Step.
