• Maternal hypotension/hypoxia
  • Seizure
  • Amniotic fluid embolus
  • PE
  • MI
  • Respiratory failure
  • Recent epidural or spinal placement
• Placental abruption, infarction and hemorrhaging previa
• Cord prolapse, cord compression, rupture of fetal vessel

1. Check mother for signs of respiratory compromise/changed mental status (indicative of preplacental conditions)
2. Assess maternal BP and HR, especially if epidural recently placed
3. Observe quantity of vaginal blood
4. During examination, observe any uterine tetany and fetal parts abdominally.
   
   • If station has dramatically lowered, deceleration can be due to rapid descent/vagal stimulation.
   • If station is higher than expected, uterine rupture is possible.
5. If cervix is open, perform operative vaginal delivery

1. Patient moved to left or right lateral decubitus (relieve IVC or umbilical cord compression)
2. Oxygen by face mask if hypoxic
3. IV hydration and ephedrine if hypotensive
4. Nitroglycerine/terbutaline (ß-agonist) if tetanic uterine contraction present
5. Umbilical cord prolapse and previa would be indications for C-section

110-160 bpm, with a variability ranging from 6-25 bpm.

A reactive tracing implies two acceleration in 20 minutes

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Early deceleration; caused by vagal simulation from head compression, considered reassuring.

Often occur during/after:

• Vaginal examination
• Second stage of labor
• Application of internal FHR electrode
• Cephalopelvic disproportion
• After rupture of amniotic sac
• Vertex presentation

Late deceleration, often due to:

• Excessive uterine contractions
• Maternal hypotension
• Maternal hypoxemia
• Reduced placental exchange (hypertensive disorders, diabetes, IUGR, abruption)

Loss of variability often due to acidemia, generated by prolonged hypoxemia

1. Place patient on side
2. Discontinue oxytocin
3. Correct hypotension (IV hydration and ephedrine)
4. If tachysystole (>5 contraction in 10 minutes), give terbutaline 0.25 mg
5. Administer O₂ by face mask.
6. After 30 minutes, if decels still present, take fetal scalp pH
   • If >7.25, reassuring
   • If 7.2-7.25, repeat in 30 minutes
   • If <7.2, deliver
7. If minimal variability, deliver

Variable deceleration, often due to cord compression. (note: onset of decel to nadir is less than 30 seconds)

1. Change position to improve FHR (Trendelenburg may be helpful)
2. Discontinue oxytocin
3. Check for cord prolapse
4. Consider amnioinfusion
5. Administer 100% O₂ by face mask

• Periodic abstinence
  • Ovulation assessment methods (ovluation prediction kits, basal body temperature measurements, cervical mucous evaluation) to avoid coitus during ovulation period
  • Predicted failure rate 1-3%; actual failure rate ~25%
• Withdrawal
  • Withdrawal of penis before ejaculation
  • Failure rate is 27%
• Lactation amenorrhea
  • Continuation of nursing leads to prolacti-induced inhibition of pulsatile GnRH
  • 50% of lactating mothers will begin to ovulate 6-12 months after delivery
  • Return of ovulation occurs before return of menses

Theoretically, 2% and 5% respecitively

(actual = 15% and 21%)

Spermicide-containing condoms and concomitant spermicide increase efficacy

• Not completely understood
• Believed to induce sterile inflammatory response, resulting in destruction of sperm.
• Redyces tubal motility (inhibits sperm/blastocyst transport)
• Mirena (progesterone infused) thickens cervical mucus and atrophie endometrium
• Copper in ParaGard hampers sperm motility

• Side effect
  • Insertion related PID (associated with contamination of cavity at time of insertion), requiring screening prior to insertion
  • Spontaneous abortion and ectopic pregnancy increased if preganncy duoes occur (40-50%)
• Advantages
  • Highly effect (0.1% for Mirena and 0.8% for Paragard failure rate after one year)
  • Can be used immediately after induced or spontaneous abortion
  • Decrease menorrhagia and dymenorrhea for Mirena IUD (although initially increased blood flow) 20% of users experience amenorhrhea after 1 year, and 60% experience it after 5 years.
• Disadvantages
  • Risk of ectopic pregnancy

• Side effects
  • Nausea, breakthrough bleeding and daily regiment often reasons for going off of pill
  • Estrogen contraceptives >50 mg can lead to increase coagulability (MI, stroke, thromboembolism, OE). Contraindicated in women >35 y/o who smoke
  • Increased incidents of gallbladder disease and benign hepatic tumors
• Benefits
  • Consecutive use can help with menstrual-related disorders
  • Reduced incidence of ovarian CA, endometrial CA, ectopic pregnancy, PID and benign breast disease

Contraceptive patch that releases progestin and ethinyl estradiol. Generally higher levels of estrogen, compared to OCP, increasing DVT and PE.

Decreased efficacy in women >198 pounds.

• Advantages
  • Reduces risk of endometrial cancer and PID
  • Highly effective
  • Only requires injections every 3 months
  • Can treat menorrhagia, dysmenorrhea, endometriosis, menstraula-related anemia and endometrial hyperplasia
  • Helpful in cases where combined pill is contraindicated
• Disadvantages
  • Irregular mentrual bleeding, depression, weight gain, hair loss and head ache can occur
  • After >2 years of use, reversible decrease in bone mineralization (treat with weight-bearing exercise, smoking cessation, calcium and vit. D)
  • Delay in return o fregular ovulation (average 10 months)

• Those performed immediately postpartum or through the Essure tubal occlusion system (hysteroscopic transcervical approach, which does not require incision/general anesthesia)
• Of the laproscopic approaches, Falpoe rings have the highest efficacy in women <28 y/o (equal efficacy with electrocautery in women >28 y/o)