abnormal labor Flashcards
macrosomia - definition
fetuses with an estimated birth weight over than 4500 g
macrosomia - RF?
A. maternal: advanced age, DM, multiparty, excessive weight gain during pregnancy or pre-existing obesity
B. fetal: African american or Hispanic, male, post-term
macrosomia - diagnostic test
physical exam: fundal height equal gestational age in weeks (ex if 28 wks, then the fundal height should be 28. But in macrosomia it is 3 cm higher than the weeks
IF IT IS or 3 HIGHER –> US
macrosomia - treatment
- induction of labor should be considered if the lungs are mature BEFORE the fetus is above 4500 g in weigh
- Cesarean delivery is indicated if fetus is above 4500
Long term and posterm pregnancy complications
fetal: oligohydramnios, meconium aspiration, stillbirth, macrosomia, convulsions
maternal: C sction, infection, postpartum hemorrhge, periaeal trauma
Should dystocia?
fetus’s head has been delivered but the ANTERIOR shoulder is stuck behind the pubic symphysis
Should dystocia - RF
- Maternal diabetes and obesity (cause fetal macrosomia)
- Posterm pregnancy (baby more time to grow)
- history of prior should dystocia
warning signs for shoulder dystocia
- protracted labor
2. retraction of fetal head intothe perineum after delivery (turtle sign)
Should dystocia - treatment (only names)
sequential steps:
- McRoberts maneuver
- Rubin maneuver
- Woods maneuver
- Delivery of posterior arm
- deliberate fracture of fetal clavicle
- Zavanelli manuever
McRoberts maneuver?
1st line treatment
maternal frexion of knees into abdomen with suprapubic pressure
shoulder dystocia –> what to do if McRoberts fail
call for help –> apply suprapubic pressure –> ENLARGE vaginal opening with epiostomy –> other maneuvers
Rubin maneuver
Rotation of the fetus’s shoulders by pushing the posterior shoulder the fetal head
Woods maneuver
Rotation of fetus’s shoulders by pushing the posterior shoulder the fetal back
Zavanelli manuever
- push fetal head back into the uterus and perform cesarean delivery
- high rate of both maternal and fetal mortality
- Last maneuver to try
disorders of active phase of labor - types
- protracted cervical dilation
2. arrest
disorders of active phase of labor - types and presentation
- protracted cervical dilation –> cervical changes slower than expected
- arrest –> no cervical changes for 4 or more h with adequate contraction, no cervical changes for 6 or more with inadequate contraction
disorder of active phase of labor - types and treatment
- protracted cervical dilation –> oxytocin
2. arrest –> C section
protracted cervical dilation - etiology
3 Ps
- Power: strength and frequency of uterine contraction (weak or infrequent)
- Passenger: size and position of fetus
- Passage: if passenger is larger than pelvis (cephalopelvic disproportion)
arrest disorder - etiology
- cephalopelvic disproportion (50% of all arrest disorders)
- Malpresentation (older than 36 wks with the presenting part something other than the head - head is not downward)
- excessive sedation / anesthesia
Cephalopelvic disproportion?
baby’s head or body is too large to fit through the mother’s pelvis
2nd stage arrest of labor - definition
insuficient fetal descent after pushing for
- 3 or more h in nulliparuous
- 2 or more h in multiparous
2nd stage arrest - RF
maternal obesity
excessive pregnancy weight gain
DM
second stage arrest of labor - etiology
- cephalopelvic disproportion
- malposition (MC: eg. nonocciput anterior)
- inadequate contractions
- maternal exhaustion
2nd stage arrest of labor - management
- operative vaginal delivery
- cesarean
operative vaginal delivery (vacuum.forceps) - indications
- protracted 2nd stage of labor
- fetal heart rate abnormalities
- maternal contraindications to pushing
operative vaginal delivery (vacuum.forceps) - fetal complications
- laceration
- cephalohematoma
- facial nerve palsy
- intracranial hemorrhage
- shoulder dystocia
operative vaginal delivery (vacuum.forceps) - maternal complications
- Genitourinary tract injury
- urinary retention
- hemorrhage
prolonged latent stage - definition
the latent phase last longer than 20 h for primipara and longer than 14 h for multipara
prolonged latent stage - etiology
- sedation
- unfavorable cervix
- uterine dysfunction with irregular or weak contraction
prolonged latent stage - treatment
rest and hydration
most will convert to spontaneous delivery in 6 to 12 h
uterine rupture - definition / when
a life threatening to both mother and the fetus and usually occurs during labor
(THERE IS HOLE IN THE UTERUS)
uterine rupture - RF
- previous cesarean deliveries (all types, but classical more)
- trauma
- placenta percreta
- uterine myomectomy (surgical removal of uterine leiomyomas)
- uterine overdistention (polyhydramnios, multiple gestations)
- prolonged labor
- induction of labor
- congenital uterine anomalies
- fetal macrosomia
cesarean deliveries types
- low transverse incision (more recent use)
- low vertical incision
- classical incision (longitudinal along uterus)
uterine rupture - presentation
- vaginal bleeding
- intraabdomonial bleeding (hypotension, tachycardia)
- fetal heart decelerations
- loss of fetal station
- PALPABLE FETAL PARTS on abdominal examiniation
- loss of intrauterine pressure
recession of the presenting part during active labor
uterine rupture presentation - regression of fetus (explanation)?
fetus was moving toward delivery, but is no longer in canal because it withdrew into the abdomen
uterine rupture treatment
- immediate laparotomy with fetus delivery
- repair of uterus or hysterectomy will follow
- if uterine repairing –> all subsequent pregnancies will be delivered via cesarian birth at 36 weeks
uterine surgeries that are contraindications for labor
- classical C-section (vertical)
2. abdominal myomectomy with uterine cavty enttry
C- section - contraindication for labor?
only the classical (vertical)
not the low transverse (horisontal)
myomectomy - contraindication for labor
if there is uterine cavity entry
MC obstetric complication with WVD
postpartum bleedin
uterine inversion
uterine fundus that inverts and prolapses thorugh the cervix or vagina, resulting in a smooth, round mass protruding through the cervix or vagina, a uterine fundus that in nonpalpable transabdominally, severe pain and postpartum hemorrhage
- can result from excessive funda; pressure and traction on the umbilical cord before placental separation
uterine inversion - management
- aggressive fluids
- mannual replacement of the uterus –> if fails –> lapartomy
- placental removal + uterotonic drugs after uterine –> replacement
postpartum hemorrhage - etiology
mnemonic 4Ts Tone uterine atony (MC) Trauma - lacerations, incisions, uterine rupture Thrombin - coagulopathy Tissue - retaind products of conception
how is the uterus in atony
enlarged –> higher than the umbilicus
postpartum hemorrhage - definition
more than 500 ml after vaginal delivery
more than 100 ml after ceserean delivery
in the first 24 hours
postpartum hemorrhage - RF
- prolonged on induced labor
- choriomanionitis
- multiple gestation
- polyhydramnios
- grand multiparity
- operative delivery
postpartum hemorrhage - treatment
massage oxytocin IV fluids, oxygen uterotonics (methylergonovine, carboprost, misoprostol)intrauterine balloon tembnade uterine artery embolization hysteroctomy
Malpresentation - presentation
- lower half of fetus (pelvis and legs) is presenting. presenting part is the colsest to vaginal canal and will be engaged when labor start
- can be felt on physical exam.
Malpresentation - can be felt on physical exam
- Leopold maneuvers are a set of 4 maneuvers that estimate the fetal weigh and the presenting part of the fetus
- Vaginal exam: with malpresentation, you fell a soft mass instead of the normal hard surface of the skull
Malpresentation - diagnostic evaluation
US to confirm
types of breech presentation (malpresentation) (only names
- Frank breech
- Complete breech
- Footling breech (incomplete)
Frank breech
fetus’s hips are flexed with extended knees bilaterally
Complete breech
fetus’s hips and knees are flexed bilaterally
footling breech (incomplete)
fetus’s feet are first: 1 leg (single footling) or both legs (double footling)
Malpresentation - treatment
with external cephalic version, the caregiver manuevers the fetus into a cephalic presentation (head down through the abdominal wall. You should not perform this maneuver until afrer 37 wks gestation/ the fetus can maneuver itself into a cephalic presentation (head first) before 37 wks -> if fails –> C section at 39 weeks
internal podaric vesrion
used for the breech extraction of a malpresenting 2nd twin. Breech delivery of a 2nd tween has a lower asphyxia than cesarean delivery and is not contraindicated
contraidincations to external cephalic version
- indications for cesarean delivery regardless of fetal lie
- placental abnormalities (previa or abruption)
- oligohydramnios
- ruptured membranes
- hyperextended fetal head
- fetal or uterine anomaly
- multiple gestation
