Complications During Labor Flashcards
Categories of fetal heart tracings
Category 1) normal no treatment needed
Category 2) anything not 1 or 3 category
- usually only minimal intervention needed and then just monitor the patient
- give proper O2, determine positions of baby and make sure baby is not acidotic or hypoxic
Category 3) abnormal usually fetal acidosis or hypoxia is present
- turn patient on left side to help (better placental perfusion)
- treat underlying cause if known
- monitor and give O2
- increase fluids and bolus
- if you cant fix it soon = immediate delivery is needed
Causes of category 3 fetal heart tracings
Poorly functioning placenta
- chronic HTN
- diabetes
- etc.
Uteroplacental insufficiency
- preeclampsia
- cord compression
- tachysystole
- placental abruption
- etc.
anything that decreases blood flow through the placenta or oxygen elation in the placenta
Malpresentations of the fetus
Occiput posterior (OP)
Occiput transverse (ROT or LOT)
Mentum/brow
Breech
Shoulder in transverse or oblique
Malposition of the fetus
Anything that is not occiput anterior (OA)
Etiologies factors in mal presentations
Maternal
- multiparity
- pelvic tumors
- pelvic contracture
- uterine malformations
Fetal
- prematurity
- multiple gestation
- hydramnios
- macrosomia
- hydrocephaly
- trisomies
- anencephaly
- myotonic dystrophy
- placenta previa
Cord prolapse
High occurrence with:
- malpresentations
- high station
- prematurity
- 2nd twin
- low lying placenta
- long cord
- polyhydramnios
- SROM and AROM w/ high station
Diagnosed by bradycardia and palpation vaginally
Elevated presenting part off the cord if possible and take to cesarean section to get the baby out
Stillbirth “intrauterine fetal demise”
Delivery of a fetus > 20 wks of gestational age with no signs of life
- before 20 wks = spontaneous abortion/miscarriage
Found in 6:1000 live births
Tons of etiologies and most are unknown cause
Most common in reproductive extremes
Risk factors: - African Americans - fetal anomalies - genetic abnormalities - hemorrhages - Cholestasis or pregnancy - male fetus - severe preexisting maternal diseases = substance abuse
Management
- must monitor and pay attention for thromophilias and DIC
- medical termination or surgical termination is usually required if the baby doesn’t come out by itself. Only wait no longer than 30 days (DIC and thrombophilas increased risk)
- emotional care and maternal/spouse and fetal testing are required
Gestational hypertension
New onset hypertension > 20 weeks into gestation but doesnt meet criteria for preeclampsia
Non severe Preeclampsia criteria
All present > 20 wks gestation
BP > 140/90
- needs 2 measurements 4 hrs apart
Proteinuria > 300 mg/24hrs on >1 dipstick sample
Urine protein/creatinine ratio > 0.3
can be diagnosed without proteinuria however if any severe symptom is present
Severe preeclampsia
Any of the following > 20 weeks gestational age
BP > 160/110 on 2 measurements 4hrs apart at bed rest
New onset creatinine > 1.1 or doubling
Thrombocytopenia
Pulmonary edema present
LFTs are elevated > 2x normal
New onset cerebral or visual disturbances
Persistent epigastric or RUQ pain
HTN emergency in pregnancy
Acute onset, persistent (> 15 minutes) severe systolic > 160 mmHg/110 mmHg (either or both numbers) in a postpartum women with preeclampsia/eclampsia
Treatment of preeclampsia, eclampsia
Delivery is required
- 37 + 0 for gestational HTN or preeclampsia
- 34 + 0 for severe preeclampsia or eclampsia
- if severe preeclampsia less than 34 +0 with stable maternal and fetal conditions = give steroids and continue pregnancy only at appropriate facilities**
Magnesium sulfate as prophylaxis for seizures and seizures themselves
Hydralazine, labetalol, for HTN
dont give NSAIDs to postpartum patients with HTN more than one day postpartum
Use steroids if the baby is < 33 6/7 weeks to ensure proper lung development
PROM management
> 37 + 0 = induce labor and give prophylaxis antibiotics
34 + 0 - 36 + 6 = induce labor but also give bethamethasone 12mg IM
24 + 7 - 33 + 6 = antibiotic prophylaxis, above steroids and magnesium sulfate for fetal neuro protection
- can administer tocolysis if needed to complete 48hrs of steroids
** no matter the gestation age, if chorioamnionits is also present = induce labor**
Chorioamnionits (IAI)
Can be made in women with
- fever > 39 degrees at any time
- fever of 38-38.8 on two readings 30 minutes apart without a clear source + one or more of the following:
baseline FHR of > 160 beats/min for > 10 minutes with periods of marked variability
maternal WBC count > 15,000 in the absence of corticosteroids
purulent-appearing fluid coming from the cervical os
Risks for chorioamnionits (IAI)
Longer length of labor
Duration of ruptured membranes
Multiple digital vaginal examines
Cervical insufficiency
Null parity
Meconium stained amniotic fluid
Internal fetal or uterine contraction monitoring
Presence of genital tract pathogens
Alcohol and tobacco use
Previous chorioamnionits
Treatment for chorioamnionits (IAI)
Immediately delivery (usually C-section)
Antibiotic therapy
- ampicillin 2g IV every 6 hrs + gentamicin 5 mg/Kg IV once daily
Intrapartum bleeding causes
Cervical dilation and effacement (this is normal)
Placenta previa and abruption
This is pathological
Placenta previa management
Can resolve on its own
Vaginal delivery if stable and placenta is at least 1-2 cm away from cervical os
C-section if placental edge is < 1cm from cervical os
Vasa previa management
Is where the fetal blood vessels lay over the internal os
Often proceeds a resolved placenta previa or low lying placenta
Intense blood loss of fetus occurs
Is commonly visualized on ultrasound (53-100%)
Treatment = C-section
What is the highest risk for placental abruption?
HTN
2nd = abdominal trauma/motor vehicle accident
Treatment of placental abruption
If preterm and both maternal and fetus are stable = expectant management
If terms and mother and baby are stable = vaginal delivery
If any fetal intolerance of labor/arrest = C-section
If abruption extends enough may have maternal shock and DIC = transfusions
Amniotic fluid embolism (AFE)
Suspect in pregnant or recently pregnant postpartum women who experience sudden Cardiovascular collapse, severe respiratory difficulty and hypoxia
- may also show seizures
heavily tied to DIC
Other risk factors
- C-section
- assisted vaginal delivery
- placental abnormalities
- preeclampsia/eclampsia
Maternal mortality is 60-80%
- 80% die within 9 hrs
- 25% die within the 1st hr
Believed AFE progression
1) Pulmonary pressures acutely elevated
2) RV fails
3) LV fails
4) systemic hypotension occurs
5) coagulation cascade is activated resulting in DIC
6) Ischemia and multi organ failure occurs
