8. Pregnancy: High Risk Pregnancy, L&D considerations Flashcards
What marks the beginning of the second stage of labor?
The cervix is completely dilated (open). end with The birth of the baby.
What are the benefits of giving birth in an upright position?
- Less risk of compressing the mother’s aorta
- Better oxygen supply to the baby
- Helps the uterus contract more strongly and efficiently
- Aids in positioning the baby better.
What are Flexible sacrum positions (FSP)?
Positions such as knee standing, on all fours, sitting on a birth seat, and lateral.
What is the advantage of Flexible sacrum positions (FSP) during labor?
Weight is taken off the sacrum, allowing the pelvic outlet to expand well.
What was the outcome of reducing time in FSP compared to supine positions?
Reduced second stage duration.
List the advantages of reducing the second stage duration.
- Decreased unnecessary intervention for mom and baby
- Reduced fetal heart rate abnormality
- Reduced neonatal hypoxia and acidosis.
What are the potential disadvantages of reducing second stage duration?
May cause both maternal and neonatal trauma due to fast expulsion of the fetal head.
What is the conclusion regarding Flexible sacrum birthing positions?
They reduce the duration of the second stage of labor.
What is recommended for laboring women regarding birth positions?
They should be encouraged to choose a birth position that they find comfortable.
What percentage of women reported leakage of urine 3–6 months after first delivery?
17.1%.
What is a common characteristic of women who experienced urinary incontinence postpartum?
More likely to be older.
BMI > 30
pushed for 45 mins or longer
Vaginaal delviery > c-section
Is there a difference in urinary incontinence incidence between types of C-section delivery?
NO difference.
What characteristics are more common in women who had cesarean deliveries compared to vaginal deliveries?
Older, heavier, less active, and had larger neonates.
What is associated with postpartum urinary incontinence?
30 years or older.
BMI 30 or higher at tiem of delivery
Birth weight of 8 or more pounds.
Jogging during pregnancy
active constipation
What is the relationship between mode of delivery and urinary incontinence risk?
Greater risk in women who deliver vaginally than in those who deliver by cesarean.
Do labor and pushing alone elevate the risk of urinary incontinence?
No.
What delivery factors/ injuries add to the risk of urinary incontinence?
Assisted delivery and perineal laceration.
What mechanisms may cause urinary incontinence during vaginal delivery?
Nerve injury, connective tissue damage, PF stretch or muscle injury descent into vagina, not pushing
What happens to the nerve during vaginal delivery that may cause incontinence?
Nerve stretch.
When is the strain on the nerve damaging during delivery?
When the fetal head is low enough to deliver vaginally.
What negative effect may occur due to mechanical compression of the urethra?
Hypoxic muscle injury due to comoression of uretha by fetal head
What modifiable factors should be addressed during pre-natal care?
Asthma and incontinence.
What are some common identifiable risk factors for the development of PFD?
- Ethnicity
- Multiparity
- Mode of delivery
- History of pelvic surgery
- Pregnancy
- Chronic cough
- Obesity
- Spinal cord disorders
- Family history
- Genetics
What role does levator ani muscle injury (LAMI) play in pelvic floor health?
LAMI plays a role in the formation of cystocele and uterine prolapse.
What is the relationship between the degree of defect and POP symptoms?
There is a direct correlation between POP symptoms and the degree of defect.
How does forceps delivery affect LAMI?
Forceps delivery has been demonstrated to increase LMAI.
It is unclear whether the speed of the fetal head descent or the use of different types of forceps causes injury.
What are the risk factors for LAMI?
- Use of forceps
- Anal sphincter rupture
- Episiotomy
- maternal age
Which delivery method is not considered a risk factor for LAMI?
Vacuum extraction
surprisingly
What factors are not risk factors for LAMI?
- Gestational age
- Birth weight
- Head circumference - depends on study. Size matters when it comes to longer stange of 2nd stage and and fetal head pressure
What is one of the most important factors for POP development in birth-related injuries?
Fetal head pressure.
what does macrosomia work with synergistically for LAMI risk
occiput posterior presentation and macrosomia work synergistically, increasing the risk of perineal trauma
What can protective effect can be provided during delivery?
Epidural can have protective effects against pelvic floor damage.
What has been shown regarding the nerves of the pelvic floor in nulliparous women?
Damage to the nerves of the pelvic floor and affected pelvic floor muscles is more prominent in nulliparous incontinent women compared to nulliparous continent women.
What effect do preexisitign PFD concners have on UI
Pre-existing s/s get worse
Due to pre-existing nature, VD may not be sole driver of PFD
What may contribute to the development of PFD during pregnancy?
- Pregnancy itself
- Hormonal changes during pregnancy
- Mechanical effects
- Increased intra-abdominal pressure
- pressure on the bladder during pregnancy
- Urethral resistance
What effect does pregnancy have on the urethrovesical angle?
pressure on the bladder during pregnancy Pregnancy causes an INCREASE in the urethrovesical angle. Rsutls in decrease in bladder neck support leading to hypermobility
What effect do prostaglandins for induction of labor have?
prostaglandins for induction of labor has been reported to cause incontinence by reducing urethral resistance
What correlation exists between the number of VDs and urethral sphincter deficiency?
There is a positive correlation between increasing number of VDs and urethral sphincter deficiency.
How does the risk for stress UI compare between VD and CD?
The risk for stress UI is increased by 2.5-fold in case of VD compared to CD.
CD isnt a protective fx
What are the most important risk factors for future development of POP?
- Denervation
- Disruption
- Damage to the pelvic floor support system
What was found about the rate of development of POP between VD and CD groups?
No difference in the rate of development of POP was found between the VD and CD group.
What is the conclusion regarding the use of elective CD for the prevention of PFD?
There is not sufficient evidence to recommend widespread use of elective CD for the prevention of PFD.
What are some factors that increase the risk of POP and therefore PFD?
- Use of forceps
- Long labor (12 hours)
- Greater than 4 VDs
What was found about UI rates at 3 months postpartum between VD and CD?
UI rates were 33% for VD and 12% for CD.
What is the relationship between the mode of delivery and OAB syndrome?
The association between the mode of delivery and OAB syndrome is not well established.
operative VDs, especially those with forceps application, were found to increase the risk of OAB development
What is the main risk factor for incontinence of flatus or feces during VD?
Laceration of the external anal sphincter.
Should Elective c section be suggested?
No, due to the lack of demonstrable benefit? Elective cesarean section for anal incontinence not rec’d .
>1 >1 subsequent childbirths were at a significantly increased risk of anal incontinence, but its still not rec’d
What is lacking in evidence regarding routine episiotomy?
Evidence to support the practice of routine episiotomy is lacking.
What was found regarding the prevalence of UI between spontaneous laceration and episiotomy?
No difference was found in symptoms of UI.
What are the risk factors for sexual dysfunction related to delivery mode?
- Advanced age
- POP
- Mode of delivery
What conclusion was drawn about CD and sexual dysfunction?
CD does not prevent sexual dysfunction.
high disatification in VD
What impact do pelvic floor exercises have during and after pregnancy?
They may decrease the risk of FI as well as UI.
What should be concluded about the first vaginal delivery (VD) in advanced age?
It may be one of the major risk factors for pelvic floor damage.
What is recommended regarding routine episiotomy in modern obstetric practice?
Routine episiotomy should no longer be used.
What is the most important and independent risk factor for PFD?
Pregnancy itself.
PFM exercise during preg an dPP can have protective effect
What effect do pelvic floor muscle exercises performed during pregnancy have?
They may be protective against UI during late trimesters and late postpartum period.
What is the effect of elective CD on postpartum UI within a short period?
It seems to lower the risk of postpartum UI within 3-6 months. but does not prevent UI and FI in long term
What does CD not prevent in the long term?
- UI
- FI
- Sexual dysfunction
What is the conclusion about scientific data regarding elective CD for preventing PFD?
Enough scientific data are not available to recommend elective CD to prevent PFD.
What should initial resuscitation efforts focus on in a pregnant patient?
Stable patient vital signs provide the best chance for fetal survival.
Prioritizing maternal stability is crucial for fetal well-being.
What assessments are mandatory when the pregnant patient is stable?
Fetal assessment and a pelvic examination.
These assessments help evaluate the condition of both the mother and fetus.
What imaging methods are useful for assessing a pregnant patient?
Radiographs, abdominal ultrasound, and fetal ultrasound.
These imaging techniques help in diagnosing injuries while considering fetal safety.
Are there any known biologic risks associated with MRI in pregnant patients?
No known biologic risks are associated with MRI.
Standard low-intensity MRI has not been linked to fetal abnormalities.
Can surgery be safely performed in most pregnant patients during an orthopedic emergency?
Yes, surgery can be safely performed.
It is important to avoid hypotension during the procedure.
What positioning should be avoided during surgery to prevent hypotension in pregnant patients?
Supine positioning. use left lateral (Left side down) decubitus positioning
Supine positioning can cause aortocaval compression, decreasing cardiac output.
What is the primary cause of nonobstetric-related death during pregnancy?
Trauma.
Motor vehicle accidents (MVA) and domestic violence are significant contributors.
What physiological change occurs to plasma volume by the end of the first trimester?
Plasma volume expands by 40% to 50%.
This expansion prepares the body for potential blood loss during childbirth.
What condition may not be readily apparent in a pregnant patient despite significant blood loss?
Dilutional anemia.
Blood loss up to 2,000 mL (30%) may not show noticeable symptoms due to stable mean arterial pressure.
What happens to cardiac output during pregnancy?
It increases, peaking 35% to 50% above baseline at 28 to 32 weeks’ gestation.
Increased cardiac output is a physiological adaptation to support both mother and fetus.
What is the recommended positioning to avoid hypotension caused by aortocaval compression?
Left lateral decubitus positioning.
This position helps maintain cardiac output and avoid compression of the inferior vena cava.
What local anesthetics are considered safe during pregnancy?
Benzocaine, procaine, tetracaine, and lidocaine.
These anesthetics did not increase the rate of fetal malformation.
Should inotropes or pressors be used during the resuscitative phase in pregnant patients?
No, they should be avoided.
These medications can reduce uteroplacental blood flow.
What is the risk of thrombosis during pregnancy?
Pregnancy is considered a hypercoagulable state.
Coupled with prolonged immobilization due to trauma, the risk of thrombosis increases.
Which anticoagulants are safe for use during pregnancy?
Unfractionated heparin and low-molecular-weight heparin.
These do not cross the placenta and are safe for the fetus.
What is the recommended approach for treating orthopedic emergencies in pregnant patients?
Most cases will be treated the same as non-pregnant orthopedic emergencies.
Special considerations are made for imaging and patient positioning.
What should be the angle of the backboard used during surgery for pregnant patients?
15° angle to the left.
This helps to avoid compression of the inferior vena cava.
What is a concern with pelvic fractures during pregnancy?
Concerns due to location and large vessels, such as the vena cava and pelvic veins.
Special care is needed to avoid complications from these structures.
What is the surgical approach for healed pelvic or acetabular fractures during pregnancy?
Does not represent an absolute contraindication to vaginal delivery as long as pelvic architecture is not disrupted.
Proper assessment of pelvic structure is critical for delivery planning.
What are the five factors that affect perineal integrity?
- Episiotomy
- Third-trimester perineal massage
- Mother’s position in second-stage labor
- Method of pushing
- Administration of epidural analgesia
What is the conclusion regarding the use of episiotomy?
Only limiting episiotomy can be strongly recommended.
Does routine episiotomy improve perineal outcomes?
No, episiotomy does not improve perineal outcomes when used routinely.
What are the associated risks with liberal use of episiotomy?
- More perineal healing complications
- Weaker pelvic floors
- Longer recovery time for pelvic floor strength
What are the benefits of intact perineums?
- Stronger pelvic floor
- Less perineal pain and dyspareunia
- Earlier resumption of intercourse
How do spontaneous tears compare to episiotomy in terms of pain?
Spontaneous tears were found to be less painful than episiotomy in the early postpartum period. faster recovery of PF strength
What are the physiologic advantages of upright positions during labor?
- Gravity assists mothers’ efforts
- Uterine contractions are more efficient
- Less aortocaval compression
What is the recommendation regarding the use of rigid birth chairs?
Women should avoid rigid birth chairs, stools, or similar devices.
What were the findings of the study comparing traditional Lamaze pushing and physiologic pushing?
Group 2 (physiologic pushing) had higher rates of intact perineums.
Lamaze = forceful bearing down with holding breath. Lamaze breathing was compared to patients encouraged to only coordinate pushing with involuntary urges. Group 2 had higher rates of intact peineum
Is second stage labor prolonged by physiologic pushing
no. Physiologic pushing (open glottis) has better peroneal outcomes associated with less forceful pushing
What was found with those encouraged to not push during delivery
Lower incidence of forceps delivery and peroneal trauma (one study with low power)
What are the concerns regarding forced pushing?
- Pushing before the head is on the pelvic floor Stresses uterine and bladder supports
- Leads to stress incontinence
- Perineum extends more rapidly with voluntary pushing which Can result in increased lacerations
- reduced uterine perfusion and fetal oxygen
True or False: Sustained bearing down reduces uterine perfusion and fetal oxygenation.
True
Fill in the blank: Episiotomy is associated with _______ pelvic floor relaxation.
no evidence indicating
What is the argument for breath holding (closed Gladys in forceful push)
Also called purple based pushing belief that without voluntary effort second stage labor would last unduly long
What are obstetric anal sphincter injuries (OASISs)?
3rd or 4th degree perineal laceration sustained at time of vaginal delivery
OASIS occurs in approximately 5% of vaginal deliveries in the US.
What is the impact of forceps and vacuum on the rates of OASIS?
Higher rates of OASIS
Use of forceps or vacuum during delivery increases the likelihood of sustaining OASIS.
What common dysfunctions are related to OASIS?
- Anal incontinence (AI)
- Fecal incontinence (FI)
- Perineal pain
These dysfunctions are prevalent following OASIS.
What is the prevalence of lateral anal sphincter injury following OASIS?
Up to 40% - Levator ani injury
What is the increased likelihood of dyspareunia associated with OASIS?
270%
Dyspareunia refers to painful intercourse, which is significantly more common in women with OASIS.
What was the average duration of physical therapy (PT) in the study evaluating pelvic floor sx in women with obstetric anal sphincter injury?
13 +/- 3.5 weeks
This duration reflects the treatment period for women participating in the study.
What percentage of women with grade 4 OASIS initiated PHPT within 30 days?
A significantly greater proportion compared to those who began after 30 days
Timing of initiating PT is critical for recovery.
What was the significance of starting PT within 1 month versus after?
No significant difference in mean reduction of subjective symptoms
However, starting PT within 2 months showed significant differences.
2What was the significance of starting PT within 2 months versus after?
Sig diff in mean reduction of subjective sx between those who started within 2 months vs after
What is a significant risk factor for sustaining a grade 4 OASIS?
Forceps delivery
Forceps delivery has a higher risk compared to vacuum delivery.
What are primary outcomes for upright positioning during birth
shorter duration
mosre likly to have vaginal birth, less likely for opertive birth or C-section
if multiparous, more likley to have operative vaginal birth
What are secondary outcomes for upright positioning during birth?
Less likley to have epidural
Lower pain
nulliparous Women - more anxiety
less likley to be in NICU
what are considerations of upright postion and duration of 1st stage labor duration
Duration of first stage labor
First stage of labor avg 1hr 22min shorter for those laboring upright compared to supine and recumbent
For nulliparous women it was 1hr 13 mins shorter
For multiparous women it was 30 mins shorter
For women who walked vs recumbent/supine/lateral labor was 3hrs and 57mins shorter
What is the study disscussion following MacArthur’s 2006 Persistent urinary incontinence and delivery mode hx - a 6 year longitudinal study
About half the likelihood of UI sx if c section only
For FI - more with forceps delivery but no association for c section only . Another follow up study with same methods was performed 10 years later and found similar results:
Persistent UI sig less common if all births were via c section
Association between persistent UI and older maternal age, and also increasing parity, also with overweight/obese women
QOL scores were sig worse in women with persistent UI
What conclusions canbe drawn for OASIS injury folliwng the 2016 Oakley study
All women showed improvements in QoL functions following OASIS at 12 weeks regardless of treatment allocations. Additional study is needed to identify the benefits of PF PT
for both groups, an increase in Vaginal EMG strength, norectal manometry squeeze pressure and fecal QoL improved.
What are Nonpharmacologic relief of pain during labor
- Labor support- better eariler in labor and helpful for low-income moms who didnt have support
- Baths- AFTER 5cm dilation, safe temp. No rediction on anagesic use but did bring pain down
- Feedom of movement and postions - not study just a rec
- Touch and Massage: Insufficient evidence to draw conclusions. Helps with anxiety
- Intradermal water blocks -eduction in back pain during labour from injections into the skin overlying the sacrum but RCT lack power
what are recomendations for birth room setup to help with pain and + outcomes
Appropriate equipment should be available- bathtubs, space for women to walk, side rails on walls. Rocking chairs, birth balls, stools and positioning aides, rolling IV polls
-policies should allow women to be out of bed, intermittent instead of continuous feotal monitoring when appropriate, allowing trained doulas
-openminded and well trained staff
What did the new cochrane review find for labor with epidural and postions?
only conisdering high quality studies: found clear harm from upright positions with evidence of an increased risk of operative birth (instrumental or caesarean birth combined) and an increase in caesarean birth in an upright
What was concluded about the differences in maternal positions during the second stage of labour in the Maternal position in the second stage of labour for women with epidural anaesthesia study?
No difference in the amount of women who had tears requiring stitches or excessive bleeding between positions.
This finding indicates that the choice of position may not significantly impact these specific outcomes.
What position did women tend to prefer during the second stage of labour?
Recumbent position. this included side lying positions but NOT flat supine or with their legs in stirrups. this postion did result in increased acid in the cord at birth
birthing positions defined as upright (the main axis of the body was more than 45 ° from the horizontal) or recumbent (the main axis of the body was less than 45 ° from the horizontal);
What evidence was found regarding lying-down positions during labour?
Better outcomes for women moving between lying-down on the side positions that avoided lying flat on the back.
This suggests that these positions contribute to more normal births and better experiences.
What are the benefits of avoiding lying flat on the back during the second stage of labour?
More normal births, better experience, and no harm to mother or baby.
These benefits were observed when compared with an upright position.
What is pregnancy-related osteoporosis?
Fractures that occur during pregnancy or in the postpartum period
This condition is rare and poorly understood.
What are some presumed risk factors for pregnancy-related osteoporosis?
- Obstetric history or complications
- Preterm labor
- Pregnancy induced hypertension
- Potential genetic factors
- Heparin usage
- Thyrotoxicosis
These factors may contribute to the likelihood of developing osteoporosis during pregnancy.
What mechanisms are suggested to contribute to pregnancy-related osteoporosis?
- Calcium deficiency
- Hypoestrogenemia
These can lead to bone mineral loss in pregnant or lactating women.
How does maternal intestinal absorption of calcium change during pregnancy?
It doubles to meet increased demands for calcium during fetal development, especially in the third trimester. Loss of BMD in spine and hip can occur
This increase is crucial for fetal growth.
What happens to bone density in lactating women?
A transient 3% to 9% decrease in bone density occurs
* During lactation, ovarian follicular development is inhibited and postpartum amenorrhea continues. So, women can become hypoestrogenic and BMD can decrease continuously.
All markers of bone turnover decrease during normal pregnancy and failed to reach baseline levels by 12 months postpartum
This is due to bone calcium being scavenged during lactation.
What hormonal changes during pregnancy can affect bone density?
Sex hormone changes can contribute to ligamentous laxity
This may lead to fractures during pregnancy.
What are the effects of pregnancy-induced hypertension (PIH) or preterm labor on treatment?
They require treatment with magnesium sulfate and bedrest
These treatments can contribute to stress or fatigue during delivery.
What is the relationship between obstetrical history and postpartum osteoporosis?
It is controversial; some studies suggest a connection while others refute it. Higher parity and longer lactation time may be linked to decreased BMD.
What traditional medications for osteoporosis may have complications during pregnancy?
- Calcium
- Vitamin D
- Bisphosphonates
- Teriparatide
Bisphosphonates can accumulate in bone and affect subsequent pregnancies.
What happens to calcium mobilization and bone resorption during the third trimester and lactation?
Both are increased
This can exacerbate bone density loss.
What symptoms should postpartum women, especially those breastfeeding, be evaluated for?
Back pain and osteoporosis
Osteoporotic fractures must be suspected and evaluated carefully.
What is teriparatide, and how is it used in pregnancy-related osteoporosis?
It is implicated as an optimal medical therapy in severe cases; it increases BMD and reduces fracture risk
Teriparatide is not retained in the skeleton and is unlikely to affect a fetus conceived after its discontinuation.
What should women with pregnancy-related osteoporosis be warned about regarding subsequent pregnancies?
There is a modest risk of further fracture.
This risk should be communicated to patients.
