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TN Obstetrics > 12. Abnormalities and Complications of Labour and Delivery > Flashcards

12. Abnormalities and Complications of Labour and Delivery Flashcards

1
Q

Define: Abnormal Progression of Labour (Dystocia) (3)

A
  • expected patterns of descent of the presenting part and cervical dilatation fail to occur in the appropriate time frame; can occur in all stages of labour
  • during active phase: >4 h of <0.5 cm/h
  • during 2nd stage: >1 h with no descent during active pushing
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2
Q

Describe etiology: Abnormal Progression of Labour (Dystocia) (5)

A
  • Power (leading cause): contractions (hypotonic, uncoordinated), inadequate maternal expulsive efforts
  • Passenger: fetal position, attitude, size, anomalies (hydrocephalus)
  • Passage: pelvic structure (CPD), maternal soft tissue factors (tumours, full bladder or rectum, vaginal septum)
  • Psyche: hormones released in response to stress may contribute to dystocia; psychological and physiological stress should be evaluated as part of the management once dystocia has been diagnosed
  • The 4 Ps of Dystocia
    • ​Power
    • Passenger
    • Passage
    • Psyche
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3
Q

Describe management: Abnormal Progression of Labour (Dystocia) (4)

A
  • confirm diagnosis of labour (rule out false labour)
  • search for factors of cephalopelvic disproportion CPD
  • concern for dystocia if adequate contractions measured by intrauterine pressure catheter (IUPC) with no descent/dilatation for >2 h
  • management: if CPD ruled out, IV oxytocin augmentation ± amniotomy
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4
Q
A
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5
Q

Name risks of dystocia (7)

A
  • inadequate progression of labour is associated with an increased incidence of:
    • maternal stress
    • maternal infection
    • postpartum hemorrhage (PPH)
    • need for neonatal resuscitation
    • fetal compromise (from uterine hyperstimulation)
    • uterine rupture
    • hypotension
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6
Q

Define: Shoulder Dystocia (2)

A
  • fetal anterior shoulder impacted above pubic symphysis after fetal head has been delivered
  • life threatening emergency
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7
Q

Describe etiology: Shoulder Dystocia (2)

A
  • incidence 0.15-1.4% of deliveries
  • occurs when breadth of shoulders is greater than biparietal diameter of the head
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8
Q

Name risk factors: Shoulder Dystocia (7)

A
  • maternal:
    • obesity
    • DM
    • multiparity
    • previous shoulder dystocia
  • fetal:
    • prolonged gestation or macrosomia (especially if associated with GDM)
  • labour
    • prolonged 2nd stage
    • instrumental midpelvic delivery
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9
Q

Describe presentation: Shoulder Dystocia (2)

A
  • “turtle sign”: head delivered but retracts against inferior portion of pubic symphysis
  • complications: fetal and maternal
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10
Q

Name fetal complications: Shoulder Dystocia (4)

A
  • hypoxic ischemic encephalopathy (chest compression by vagina or cord compression by pelvis can lead to hypoxia)
  • brachial plexus injury (Erb’s palsy: C5-C7; Klumpke’s palsy: C8-T1), 90% resolve within 6 mo
  • fracture (clavicle, humerus, and cervical spine)
  • death
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11
Q

Name maternal complications: Shoulder Dystocia (3)

A
  • perineal injury
  • postpartum hemorrhage PPH (uterine atony or lacerations)
  • uterine rupture
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12
Q

Describe tx: Shoulder Dystocia (4)

A
  • goal: to displace anterior shoulder from behind symphysis pubis; follow a stepwise approach of maneuvers until goal achieved
  • other options
    • cleidotomy (deliberate fracture of neonatal clavicle)
    • Zavanelli maneuver: replacement of fetus into uterine cavity and emergent C/S
    • symphysiotomy
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13
Q

Describe: Approach to the Management of Shoulder Dystocia (7)

A

ALARMER

  • Apply suprapubic pressure and ask for help
  • Legs in full flexion (McRobert’s maneuver)
  • Anterior shoulder disimpaction (suprapubic pressure)
  • Release posterior shoulder by rotating it anteriorly with hand in the vagina under adequate anesthesia
  • Manual corkscrew i.e. rotate the fetus by the posterior shoulder until the anterior shoulder emerges from behind the maternal symphysis
  • Episiotomy
  • Rollover (on hands and knees)

*Note that suprapubic pressure and McRobert’s maneuver together will resolve 90% of cases

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14
Q

Describe prognosis: Shoulder Dystocia (1)

A

1% risk of long-term disability for infant

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15
Q

Define: Umbilical Cord Prolapse (1)

A

descent of the cord to a level adjacent to or below the presenting part, causing cord compression between presenting part and pelvis

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16
Q

Describe Etiology/Epidemiology: Umbilical Cord Prolapse (2)

A
  • increased incidence with prematurity/PROM, fetal malpresentation (~50% of cases), low-lying placenta, polyhydramnios, multiple gestation, and cephalopelvic disproportion CPD
  • incidence: 1/200-1/400 deliveries
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17
Q

Name: Umbilical Cord Accident Causes (8)

A
  • Nuchal cord
    • Type A (looped)
    • Type B (hitched)
  • Body loop
  • Single artery
  • True knot
  • Torsion
  • Velamentous
  • Short cord <35 cm
  • Long cord >80 cm
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18
Q

Describe presentation: Umbilical Cord Prolapse (2)

A
  • visible or palpable cord
  • FHR changes (variable decelerations, bradycardia, or both)
19
Q

Describe tx: Umbilical Cord Prolapse (6)

A
  • emergency C/S if not fully dilated and vaginal delivery not imminent
  • O2 to mother, monitor fetal heart
  • alleviate pressure of the presenting part on the cord by elevating fetal head with a pelvic exam (maintain this position until C/S)
  • keep cord warm and moist by replacing it into the vagina ± applying warm saline soaks
  • roll mother onto all fours or position mother in Trendelenburg or knee-to-chest position
  • if fetal demise or too premature (<22 wk), allow labour and delivery
20
Q

1/3 of protraction disorders develop into what? (1)

A

2º arrest of dilatation due to cephalopelvic disproportion (CPD)

21
Q

Define: Uterine Rupture (3)

A
  • associated with previous uterine scar (in 40% of cases), hyperstimulation with oxytocin, grand multiparity, and previous intrauterine manipulation
  • generally occurs during labour, but can occur earlier with a classical incision
  • 0.5-0.8% incidence, up to 12% with classical incision
22
Q

Describe presentation: Uterine Rupture (7)

A
  • prolonged fetal bradycardia – most common presentation
  • acute onset of constant lower abdominal pain, may not have pain if receiving epidural analgesia
  • hyper/hypotonic uterine contractions
  • abnormal progress in labour
  • vaginal bleeding
  • intra-abdominal hemorrhage
  • loss of station of the presenting fetal part
23
Q

Name risk factors: Uterine Rupture (7)

A
  • uterine scarring (i.e. previous uterine surgeries including C/S (especially classical incision), perforation with D&C, and myomectomy)
  • excessive uterine stimulation (i.e. protracted labour, oxytocin, prostaglandins)
  • uterine trauma (i.e. operative equipment, external cephalic version ECV)
  • multiparity
  • uterine abnormalities
  • malpresentation
  • placenta accreta
24
Q

Describe tx: Uterine Rupture (3)

A
  • rule out placental abruption
  • maternal stabilization (may require hysterectomy), treat hypovolemia
  • immediate delivery for fetal survival
25
Q

Name complications: Uterine Rupture (5)

A
  • maternal mortality 1-10%
  • maternal hemorrhage, shock, disseminated intravascular coagulation (DIC)
  • amniotic fluid embolus
  • hysterectomy if uncontrollable hemorrhage
  • fetal distress, associated with infant mortality as high as 15%
26
Q

Name: Maternal Mortality Causes (8)

A
  • Thromboembolism
  • Cardiac event
  • Suicide
  • Sepsis
  • Ectopic pregnancy
  • HTN
  • Amniotic fluid embolism
  • Hemorrhage

* In Canada (2013), lifetime risk of maternal death is 1 in 5200

27
Q

Define: Amniotic Fluid Embolus (1)

A

amniotic fluid debris in maternal circulation triggering an anaphylactoid immunologic response

28
Q

Describe Etiology/Epidemiology: Amniotic Fluid Embolus (4)

A
  • rare intrapartum or immediate postpartum complication
  • 13-30% maternal mortality rate
  • leading cause of maternal death in induced abortions and miscarriages
  • 1/8000-1/80,000 births
29
Q

Name risk factors: Amniotic Fluid Embolus (6)

A
  • placental abruption
  • rapid labour
  • multiparity
  • uterine rupture
  • uterine manipulation
  • induction medication and procedures
30
Q

Name ddx: Amniotic Fluid Embolus (7)

A
  • pulmonary embolus
  • drug-induced anaphylaxis
  • septic shock
  • eclampsia
  • HELLP syndrome
  • abruption
  • chronic coagulopathy
31
Q

Describe presentation: Amniotic Fluid Embolus (3)

A
  • sudden onset of respiratory distress, cardiovascular collapse (hypotension, hypoxia), and coagulopathy
  • seizure in 10%
  • acute respiratory distress syndrome (ARDS) and left ventricular dysfunction seen in survivors
32
Q

Describe management: Amniotic Fluid Embolus (2)

A
  • should be managed in the ICU by a multidisciplinary team
  • supportive measures (high flow O2, ventilation support, fluid resuscitation, inotropic support, ± intubation) and coagulopathy correction
33
Q

Define: Chorioamnionitis (1)

A
  • infection of the chorion, amnion, and amniotic fluid
34
Q

Desribe Etiology/Epidemiology: Chorioamnionitis (3)

A
  • incidence 1-5% of term pregnancies and up to 25% in preterm deliveries
  • ascending infection (microorganisms from vagina)
  • predominant microorganisms include: GBS, Bacteroides and Prevotella species, E. coli, and anaerobic Streptococcus
35
Q

Name risk factors: Chorioamnionitis (6)

A
  • low parity
  • prolonged ROM
  • long labour
  • multiple vaginal exams during labour
  • internal monitoring
  • bacterial vaginosis and other vaginal infections
36
Q

Describe clinical features: Chorioamnionitis (4)

A
  • Maternal fever ≥38º C
  • Tachycardia (maternal or fetal)
  • Tenderness (uterine)
  • Foul and purulent cervical discharge
37
Q

Describe investigations: Chorioamnionitis (2)

A
  • CBC: leukocytosis
  • amniotic fluid: Gram stain, glucose, or culture results consistent with infection
38
Q

Describe tx: Chorioamnionitis (3)

A
  • IV antibiotics
    • ampicillin 2 g IV q6h + gentamicin 2 mg/kg load, then 1.5 mg/kg IV q8h
    • anaerobic coverage (i.e. clindamycin 900 mg IV q8h)
    • if at risk for endometritis, continue treatment post-partum especially if C/S delivery
  • antipyretics
  • proper labour progression (not an indication for immediate delivery or C/S)
39
Q

Name complications: Chorioamnionitis (2)

A
  • bacteremia of mother or fetus, wound infection if C/S, pelvic abscess, neonatal meningitis, neonatal sepsis, and neonatal death
  • long-term infant complications: cerebral palsy and bronchopulmonary dysplasia
40
Q

Describe etiology: Meconium (4)

A
  • present early in labour in 10% of pregnancies, more common in postdate pregnancies
  • in general, meconium may be present in up to 25% of all labours; usually NOT associated with poor outcome
  • concern if fluid changes from clear to meconium-stained
  • always abnormal if seen in preterm fetus
41
Q

Describe: Particulate (thickened) meconium (4)

A
  • is associated with lower APGARs
  • an increased risk of meconium aspiration
  • and perinatal death.
  • Particulate meconium generally has a darker green or black colour, whereas thin meconium is usually yellow to light green
42
Q

Describe etiology: Meconium (3)

A
  • likely cord compression ± uterine hypertonia
  • may indicate undiagnosed breech
  • increasing meconium during labour may be a sign of fetal distress
43
Q

Describe features: Meconium (2)

A
  • may be watery or thicker (particulate)
  • light yellow/green or dark green-black in colour
44
Q

Describe tx: Meconium (2)

A
  • call respiratory therapy, neonatology, or pediatrics to delivery room
  • closely monitor FHR for signs of fetal distress

TN Obstetrics (16 decks)

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