abnormal labour + delivery + ob emergencies part II Flashcards
RF for breech
greater parity multiples hydramnios oligohydramnios hydrocephalus anencephalus prev hx uterine anomalies pelvic tumour
types of breech
frank - knees straigh
complete - knees bent
partial - footling/kneeling
risks /w breech birth
birth trauma + asyphxia (head entrapment) preterm delivery or IUGR cord prolapse placenta previa fetal anomalies uterine anomalies/tumour multiples operative delivery
reason for head entrapment in breech delivery
less time for moulding
head biggest part
management of breech position
- diagnose at 35-36wks
- ECV after 36 wks
- and/or planned CS
- ## or trial of vag breech birth
risks of ECV
- abruption
- hemorrhage
- ROM
- labour
- fetal bradycardia
- cord accident
- allo-immunization (give Rhogam)
selection criteria for vag delivery of breech
- pre or early labour US to assess type of breech (CS if unavailable)
CI if:
- cord presentation
- fetal growth restriction
- macrosomia
- not frank or complete
- inadequate maternal pelvis
- fetal anomaly (eg hydrocephalus)
- preg women refuses TOL
Can be offered if
- EFW 2500-4000g
breech labour management
check for abnormal pelvic contraction
good progress = room likely, CS if not
cont FHR
check for prolapse when rupture
induction not recommended, oxytocin can be used
active second stage near OR
paeds team at delivery
CS if delivery not imminent after 60min pushing
RF for shoulder dystocia
post-term maternal obesity fetal macrosomia prev hx operative vag delivery prolonged labour poorly controlled diabetes
risks of shoulder dystocia
- PPH/uterine atony
- maternal laceration
- uterine rupture
- birth injury
- clavicle, humerus #
- brachia plexus injury
- hypoxic ischemic encephalopathy
- death
maneuvers for shoulder dystocia
A - ask for help L - lift legs (mcroberts) A - anterior shoulder dysimpaction (suprapubic pressure + vag shoulder pressure) R - rotate (woods corkscrew) M - manual delivery of posterior arm E - episiotomy (+ deliver arm) R - roll onto all 4s
after this:
clavicle fracture
symphysiotomy
zavanelli maneuver
don’t
- pull
- pivot
- panic
- push on fundus
delivery options for future preg after dystocia
risks and benefits discussed /w patient
review notes
TOL or CS options
causes of poor oxygenation to fetus
maternal
- anemia
- carboxyhemaglobin
- hypotension
- regional anesthesia
- position
- vasculopathies (T1DM, SLE, HTN)
- antiphospholipid antibody
utero-placental
- hyperstim
- abruption
- infarction/oligohydramnios
- chorioamnionitis
fetal
- cord compression
- oligo
- cord prolapse, knots
- fetal hemaglobinopathy
- anemia (isoimmunization, fetomaternal bleed)
definition of fetal asyphxia
diagnosed at birth, must have all of:
- apgar 0-3 for >5min
- neonatal neuro sequelae
- multi organ dysfunction in neonate
- UA pH <7.0 and base deficit >16
pathophysiology and interpretation of acid/base
- respiratory acidosis normal, CO2 accumulates with cord compression, goes away /w first breaths
- metabolic acidosis is from hypoxia –> anaerobic metabolism and lactic acid, causes longer to develop + remit, potential for damage
Resp: increased PCO2 and normal base deficit
metabolic: N PCO2 and decreased base deficit
mixed: increased PCO2 and decreased base deficit
pathophysiology and interpretation of acid/base
- respiratory acidosis normal, CO2 accumulates with cord compression, goes away /w first breaths
- metabolic acidosis is from hypoxia –> anaerobic metabolism and lactic acid, causes longer to develop + remit, potential for damage
Resp: increased PCO2 and normal base deficit
metabolic: N PCO2 and decreased base deficit (bicarb low)
mixed: increased PCO2 and decreased base deficit
causes of fetal bradycardia
- maternal hypotension
- drugs
- fetal hypoxia (cord prolapse/compression, abruption, fetal hypotension, fetal hemorrhage)
- vagal stimulation
- fetal acidosis
- fetal cardiac conduction or structural defect
causes of fetal tachycardia
maternal
- fever
- infection
- dehydration
- hyperthyroidism
- anxiety
- drugs
- anemia
fetal
- infection
- prolonged activity
- chronic hypoxemia
- cardiac abnormality
- congenital anomalies
- anemia
variable decels causes
- vagal stimulation (head compression)
- cord compression
- complicated: fetal acidemia
early decels causes
- vagal head compression
late decels causes
- altered blood flow to placenta
- reduced mat O2 sat
- uterine hypertonus
- fetal acidemia
decreased variability causes
- acidemia if /w decels
- maternal acidemia + analgesics can decrease variability
- occurs /w tachycardia
normal intrapartum tracing
- baseline 110-160
- variability 6-25 or <5 for <40min
- decels: none or occasional uncomplicated variables or early decels
- accels: spont present, at minimum present /w scalp stim
action: can interrupt FHR for 30 min if stable and oxytocin stable
no evidence of fetal compromise
atypical intrapartum tracing
- bradycardia 100-110
- tachy >160 for 30-80 min
- rising baseline
- variability <5 for 40-80min
- decels: repetitive uncomplicated variables (3 in row), occasional (<2 in a row) complicated variables, intermittent lates, single prolonged decel 2-3min
- accels: none /w scalp stim
action: vigilant assessment. Likely physiologic response.
abnormal intra-partum tracing
- bradycardia <100bpm
- tachycardia >160 for >80min
- erratic baseline
- variability <5 for >80min
- > 25 for >10 min
- sinusoidal
- repetitive complicated variables:
- > 60s below baseline
- > 60s and <60bmp
- loss of variability
- biphasic
- overshoots
- slow return to baseline
- baseline lowers
- baseline tachy or brady
- late decels > 50% of contractions
- single prolonged decel >4min but <10min
- accels absent usually
action: scalp pH and/or delivery
management of abnormal/atypical tracing
- reposition
- maternal vital
- IV fluid bolus
- stop oxytocin
- O2 at 8-10 L/min
- rule out fever, dehydration, drugs, prematurity
- cont FHR
- fetal scalp sample if appropriate
- delivery if needed/persists
fetal scalp sample intepretation
pH >7.25 normal
pH 7.21-7.24: cont, repeat in 30 mins or if change
pH <7.20 - deliver
for lactate:
<4.1
4.2-4.8
>4.8
meconium significants
theories
- distress, hypoxia
- normal GI
- vagal stim from transient cord compression
aspiration can occur if acidemia
RF: post-term + IUGR
mech aspiration risks to baby
- pulmonary hypertension
- mechanical airway obstruction
- chemical pneumonitis
cord prolapse RF
- malpresentation
- prematurity
- anomalies
- multiples
- polyhydramnios
- premature ROM
- AROM
- placenta previa
- high presenting part
- ECV
management of cord prolapse
1) assess viability: no cord pulsations, lethal anomaly, or too immature to survive –> deliver vaginally, CS if CI (eg transverse lie)
2) relieve cord compression, replace into vagina, elevate presenting part, adjust mom in trendelenburg
3) if fully dilated and low: assisted vag delivery, otherwise immediate CS
