abnormal labour + delivery + ob emergencies part 1 Flashcards
labour dystocia defintion
active first stage:
>4 hrs of <0.5cm/hour dilatation
during pushing:
>1 hr no fetal descent
definition of labour
uterine activity resulting in progressive dilatation and effacement of the cervix + descent of fetus
definition of 1st stage
onset until 3-4cm/4-5cm for multip
the 4 P’s of dystocia
Power - hypotonic, incoordinate contractions, poor maternal effort
Passenger - fetal position, attitude, size, anomalies (hydrocephalus)
Passage - pelvic structure, soft tissue (masses, full bladder, septum)
Psyche - anxiety, stress, pain
evalutation of patient with dystocia
review labour record
assess mom - vitals, ctxns, membranes, cervix, pelvis
asses baby - NST, station, presentation and position
management options for dystocia
- AROM
- pain relief
- hydration
- oxytocin
- operative delivery (CS or vaginal if fully)
C/I to oxytocin & AE
severe vag bleed placenta previa hypotension abnormal lie prior classical or inverted T uterine incision pelvis that obstructs labour
adverse effects: fetal comprise hyperstim (ctxn >2min or >5/min) water intoxication (ADH effect) uterine rupture hypotension (vasodilation)
oxytocin dosing example
initial:
1-2mU/min
increase every 30min by 1-2
usual dose for good labour: 8-12
indications for forceps or vacuum
fetal compromise requiring immediate delivery
dystocia in second stage
conditions requiring short second stage or C/I pushing
inefficient maternal effort
note: vacuum requires maternal effort
c/i to operative delivery
non-cephalic presentation (face/brow)
unengaged head
incomplete dilatation
low probability of success
C/I for vacuum
<34 weeks
deflexed head
need for rotation
fetal conditions (bleed or demineralization disorder)
pre-requisites for vacuum or forceps
consent
vertex
engaged
term/near term
dilated + ruptured
anesthesia
adequate pelvis
known station and position
empty bladder
backup plan
continuous assessment
risks of assisted vag birth
soft tissue trauma
fetal scalp trauma
intraventricular hemorrhage (/w multiple procedures)
fetal subgaleal or subaponeurotic hemorrhage with vacuum
common indications for C/S
repeat CS
dystocia
malpresentation
non-reassuring fetal status
absolute indications for CS
previa cord prolapse prev uterine surgery prior classical CS prev uterine rupture most malpresentations obstructed pelvis
relative indications for CS
failed induction abnormal progression pre-eclampsia DM cardiac disease abruption multiples
types of incisions
transverse lower uterine segment
classical vertical
combo (inverted T)
C/S risks
infection hemorrhage atelectasis injury to bowel, bladder, ureter DVT/PE longer recovery
all increased if follow trial of labour
non-pharmacologic pain relief in labour
position change, movement
counter-pressure
abdominal decompression
cold/heat immersion in water acupuncture/pressure touch/massage TENS intradermal injection of sterile water aromatherapy
attention focus/distrction
hypnosis
music
biofeedback
pharmacologic pain management
NO - self administered, deep inhalation /w ctxn, use in late 1st stage of labour
narcotics - given IV + PCA, /w antiemetic, decreases fetal hear variability, neonatal resp depression
pudendal nerve block - analgesia of perineum in second stage, if other analgesia not available/ineffective, or for forceps/vacuum
perineal infiltration - for repair
regional - epidural block
spinal - for CS (if epidural not in place)
GA - for emergency CS
Absolute CI to VBAC
prev classical, T, unknown incision
other uterine surgery entering cavity
prev rupture
opinion of prev surgeon (get post op note)
mother desires CS
Relative CI to VBAC
induction required
2+ CS
Multiples
breech
prev poor OB hx
patient desires tubal ligation
risks of VBAC
prolonged labour
maternal fever/infection
failed trial –> repeat section riskier after labour
uterine rupture: hemorrhage, fetal morbidity/death, CS, hysterectomy possibly
benefits of VBAC
reduced intervention + its risks
faster recovery
risks of elective repeat CS
increased risk of injury to pelvic structures (scarring)
increased risk of hemorrhage
+ regular risks
signs of uterine rupture
profound fetal bradycardia without recovery
lower abdo pain
cessation of contractions
vag bleeding
recession of presenting part
intra-abdominal hemorrhage, hypovolemic shock
causes of uterine rupture
scar: CS, mymoectomy, perf in D&C, salpingectomy /w cornual resection
excessive contraction: oxytocin, prostaglandins, neglected obstructed labour
trauma: ECV, forceps, manual removal of placenta, trauma
multiparity, uterine anomalies, placenta accreta
management of uterine rupture
stabilize mother, tx hypovolemia
call for assistance
emergency laparotomy to deliver fetus, placenta, repair uterus
emergent indications for labour induction
severe GH or pre-eclampsia
suspected fetal compromise
severe IUGR
maternal disease
large antepartum hemorrhage
chorioamnionitis
urgent indications for induction
prelabour ROM
IUGR
poorly controlled DM
iso-immune disease
non-urgent indications for induction
prolonged preg
well controlled DM
prior intrauterine death
logistical problems (rapid labour)
CI to induction
- placenta/vasa previa, cord presentation
- abnormal lie
- prior classical/T CS
- uterine surgery
- active herpes
- pelvis deformity
- invasive cervical cancer
risks of induction
- failure
- cord prolapse /w ARM
- uterine hyperstim (fetal compromise, rupture)
- inadvertent delivery of preterm if dates wrong
- maternal side effects from meds
methods of labour induction
1) ARM if possible (cervix open, soft ,membranes felt, head well applied), + oxytocin
2) if no arm, use cervical ripening first (then ARM + pit)
- prostaglandins (PGE1 = miso, PGE2 = prostin gel, cervidil)
- foley catheter
- oxytocin infusion – not as successful
definition of post-term
> 42+0
risks of post-term
death: anomalies, infection, asphyxia /w or /w out meconium
morbidity: mec aspiration, macrosomia, shoulder, NICU, O2, pneumonia, seizures, operative delivery
post-mature
neonate /w peeling skin, skinny + long, alert
post-dates
> 41+0
management of post-dates
offer induction at 41 weeks
alternative: patient can select serial fetal monitoring
