Postpartum perineal lacerations

29 y/o G2P2 presents for 6 week postpartum visit s/p forceps assisted vaginal delivery resulting in a 4th degree perineal laceration. Review of systems remarkable for persistent perineal pain relieved with Motrin, flatus incontinence, occasional constipation, and difficulty cleaning stool from rectum after defecating. Denies urinary incontinence or urgency. Pelvic exam remarkable for healing perineal wound right of midline with sutures coming out without signs of infection. Anal sphincter had good tone, vaginal sphincter tone diminished. She also had a small posterior rectocele and anterior cystocele. Rest of the exam was nl. These were obvious signs of pelvic floor disruption with possible anal sphincter problems. As far as management, the provider was not too concerned, but I did recommend kegel exercises. I also thought we could have done more for her. The literature is unclear about how aggressive early management should be or when it should be initiated, when there are signs of pelvic floor disruption. Surgery is certainly not an option unless symptoms are severe and she is done childbearing, but perhaps this patient may have been a candidate for pelvic floor physical therapy. 3rd and 4th degree perineal lacerations or episiotomies can have significant long-term consequences and the sequela (constipation, anal sphincter dysfunction, pelvic organ prolapse, urinary incontinence, perineal pain, rectovaginal fistulas) is what we are most likely to see in our practices as FNPs.

Wait up! I bearly touched her!

I recently saw a 19 y/o G1P0 pt at 38 weeks, Kay, with a history of Hyperthyroidism and DM in the L&D unit. This was not readily apparent to me at the time, while thumbing through tones of info in her charts. She came in through triage for “frequent and painful, unrelenting contractions.” After further assessment with a pelvic, nitrazine paper and NST, she was admitted. Upon insertion of an IV, she near flew off the bed, screaming, and cursing up a storm. The nurse thought this was strange and looked closely at her charts. Kay had a history of Bipolar disorder, hence the overly exaggerated response to the IV insertion, I learnt.
Women with chronic mental health disorders such as Bipolar , can and will get pregnant, some planned, many may not be. It is important to screen and ask women about mental health history, the use of prescribed medication for the illness and ask “are you still taking your medications, if not, why?” Teaching and counseling comes into play her because some women may choose to stop taking these meds once they find they are pregnant.
According to the National Alliance on Mental Illness (NAMI), Lithium and first generation antipsychotics like Haldol are still safe to use in pregnancy (Category D) if deemed necessary. Concerns about relapse, maternal safety, hydration status (if meds are taken) and fetal well-being present an opportunity to educate, reeducate, and/or refer. Preconception counseling and the impact of these disorders during and after pregnancy (beacuse of breast feeding) is vital.

Quad/Penta screen

18 y/o Hispanic female, G1P0, 19 weeks GA. She was advised via telephone of results of penta screen for NTD, Trisomy 18, Trisomy 21 screening. She presents in clinic with her boyfriend, mother, and sister--all in acute distress. Mother of patient does most of the talking. She reports that the patient was advised by a nurse that the test was screened positive for Downs and Edwards syndromes. They are here to get more information and to find out what to do next.
The NP seeing the family explains that the information they have is incorrect. She explains that the screen came back positive for possible neural tube defect, but tests for Trisomy 18 and 21 were negative. She discussed the chances that this pregnancy/fetus might be affected by neural tube problems, she explains what the range of possible malformations are, and further explains what happens next. The information includes the chances that this is a false positive, that this is a screening only. The patient's risk factors are also included in partial reassurance. The family, while still anxious, is able to process the information given, clearly able to state the next course of action, and verbalize understanding of the condition that the screening test indicated.
In summary: The patient was given the wrong test results. She either was not given sufficient counseling prior to testing or was not in complete understanding of the information given. This may have been a function of either her age, maturity, and the care and preparation of the provider doing the consent prior to testing. Reporting of test results of this nature is best handled in person, not over the phone. Having support persons available was helpful.
I chose this case because it was like watching the Hispanic vesion of my daughter and I, and it really showed me that more care and sensitivity needs to be shown in ordering, consenting, and reporting these tests. No matter how careful the person is reporting these results, all the family hears is that something is wrong with their baby. It took 20 minutes just to calm this family down enough for them to be able to truly process the information that was being presented by the NP in person, in a very calm, very clear, very concise manner.

Membrane Sweeping

24 yo G2/P1 w/post history of post date pregnancy and macrosomian 37. 5 at time of this vist. Membrane sweeping suggested/performed per CNM:

“DOD/VA Clinical Guideline for Pregnancy Management” recomends offering membrane sweeping to all pregnant women at each vist beginning at 38 weeks. The procedure is comprised or using a gloved finger to separate the membrane from the inside of the uterus, which causes a release of prostaglandins and is believed to facilitate uterine contraction. Membrane sweeping may help to avoid post date pregnancy complications including post partum hemorrhage and shoulder dystocia. Additionally patients may be less likely to require induction of labor or caesarian section.
A possible disadvantage is that bacteria may translocated into the uterus. However, studies focusing on GBS have not shown this to be the case. Note that the DOD guideline indicates that there is not sufficient evidence to encourage or discourage the practice in women who are GBS positive. Some women find the practice quite painful. Additional literature reviews indicate membrane stripping is relatively safe, and indicate that there are fewer post date pregnancies when the practice is applied; although clinical significance of the difference not demonstrated. Attitudes among the group of mid-wives at Ft Benning/MACH varies, with one individual who strongly recommends the practice, one who offers membrane stripping but is somewhat less aggressive with her application and a third who falls somewhere between the other two in her recommendations and practice.

BY Alex G. Reyes

36 year old G4P4 dependent female spouse from a Catholic family delivered a Down's
Syndrome baby 6 weeks ago; here for follow- up. Mother explained to me that she did the sequential test part 1 at 11 weeks and tested positive for being high risk. She was given several
level 2 ultrasounds throughout the pregnancy and was told everytime that there was no indication for Down's. Unfortunetly, when the baby was born it was obvious that the child had Down's Syndrome. The mother was very distressed and was crying throughout the visit, I'm glad my preceptor was there to manage the visit because I didn't know what to say. So, 2 lessons where learned during this visit; the first: kids are born with Down's eventhough we have all these fancy test and the second: know what to say when a mother starts crying and telling you that her kid has Down's...

Perfect protection isn't foolproof

For most women, perfect contraceptive protection is protection that you don’t have to “manage or even think about”. One of the more popular methods of worry free birth control is the Mirena intrauterine device. The Mirena is an intrauterine contraceptive that delivers small amounts of levonorgestrel directly to the uterus. This device is made of soft, flexible plastic that can be placed by your healthcare provider during an office visit. Mirena is birth control that can last up to 5 years, and is also approved to treat heavy periods in women who choose intrauterine contraception. The only maintenance required with this method is checking the threads once a month, if you experience problems finding them back-up contraception is suggested. In the uncommon event you get pregnant while using Mirena, seek emergency care because pregnancy with an intrauterine device can be life threatening and may result in loss of pregnancy or fertility.

I had the opportunity to attend the delivery of a 28 year old G2P1 with a complicated pregnancy due to the findings of the Mirena device as well as an intrauterine pregnancy at 10 weeks gestation. The patient had the device in place for less than one year but assumed that the device had been expelled when her pregnancy test was positive. In serial ultrasounds the device was displaced but present in the uterus. She was closely managed and followed as a complicated ob patient without surgical intervention under the pretense to watch and wait to see how the pregnancy would progress. In the course of the pregnancy the patient did not undergo any significant events and was able to labor and deliver vaginally. During the birthing process there was a period in which forceps or vacuum extraction was considered but was not necessary. The patient did have an uneventful vaginal delivery but the IUD was not noted or recovered in placental contents nor on exam, however there was greater than average degree of post partum bleeding noted. This case was highly unusual and the patient will need to be followed up to determine if indeed the uterus is void of the device.

False Alarm

A 26 year old caucasian female G1P0 came to the L&D deck triage area fearing that her "water had broken." The patient was 39wks and 2days with an otherwise normal pregnancy and no noted abnormalities during her regular OB visits. The patient stated that she had soaked two "pads" in the last 6 hours with a thin whitish/watery fluid. The Mother denied any vaginal bleeding, contractions/abdominal/pelvic pain. A fetal fibronectin drawn several days prior at another OB visit was negative. An NST was reactive with moderate variability, and no decelerations. Fetal HR was at 145 bpm. Movement was noted from the fetus during this assessment. The mother stated that her baby was moving every hour and that there was no difference in her unborn son's activity level. Examination of the vaginal canal and cerivx with the aid of a speculum did not reveal any pooling liquid. A copious amount of cervical mucuous was seen in the vaginal canal, cervix, and the external genitalia. The patient was 2cm dilated and 30% effaced. Nitrazine paper was negative and no ferning was seen from fluid collected off the cervix. The patient was instructed to keep her appointment the following week for an additional NST and AFI with her midwife provider and to call/come back to the L&D triage deck if any other concerning signs/symptoms occur.