Complications of Delivery Flashcards
Failure of delivery of the fetal shoulder(s) after initial attempts at extraction-oriented traction or when ancillary obstetrical maneuvers are required to effect delivery of the shoulders?
Shoulder Dystocia.
A non-reassuring fetal heart rate tracing accompanied with fetal bradycardia and repetitive variable decelerations?
Fetal Distress.
A cumulative blood loss >1000 mL accompanied by signs and symptoms of hypovolemia within the first 24 hrs after delivery?
Postpartum Hemorrhage (PPH).
An obstetrical emergency where the umbilical cord slips ahead of the presenting part of the fetus and protrudes into the cervical canal or vagina or beyond?
Prolapsed cord or Cord Prolapse
The condition where the fetal buttocks or legs enter the pelvis before the head?
Breech presentation.
What are the indications for cesarean delivery?
- Prior cesarean delivery.
- Abnormal placentation.
- Maternal request.
- Prior classical hysterotomy.
- Permanent cerclage.
- HSV or HIV infection**
- Failed operative delivery.
- Placenta previa or placental abruption.
- Prior significant perineal trauma.
- Prior full thickness myomectomy.
- Non-reassuring fetal status.
- Malpresentation.
- Macrosomia.
- Congenital anomaly.
- Prior neonatal birth trauma.
What is the epidemiology for Shoulder Dystocia?
- 0.2-0.4% if vaginal deliveries.
2. Women with prior shoulder dystocia are at increased risk of recurrent shoulder dystocia in a subsequent pregnancy.
What constitutes a Category III pattern of fetal distress?
Absent baseline FHR variability and…
- -Recurrent late decelerations.
- -Recurrent variable decelerations.
- -Bradycardia
OR
Sinusoidal Pattern, which is a marker of acidemia.
What constitutes a Category II pattern of fetal distress?
All FHR patterns NOT classified as Category I (normal) or Category III (abnormal).
What constitutes a Category I pattern of fetal distress?
- Baseline HR of 110-160 bpm.
- Moderate baseline FHR variability.
- NO late or variable decelerations.
- EARLY decelerations may be present of absent.
- Accelerations may be present or absent.
What is the epidemiology of a Breech Presentation?
3-5% of singleton pregnancies.
What are the different breech positions?
- Frank Breech: baby’s bottom is down with legs straight up and feet near the head.
- Complete Breech: baby’s knees are bent; feet and bottom are closest to the birth canal.
- Incomplete Breech: when one of the baby’s knees is bent and his foot and bottom are closest to the birth canal.
What are the risk factors (6) for a breech presentation?
- Extremes of amniotic fluid volumes.
- Multifetal gestation.
- Structural uterine abnormalities.
- Placenta previa.
- Pelvic tumors.
- Prior breech delivery.
Diagnosis of a breech presentation?
Diagnosis is made with Leopold Maneuvers or U/S Examination.
Treatment and mgmt of a breech presentation?
- External Cephalic Version…50-60% success rate.
- -Physical manipulation of the longitudinal lie of the fetus in utero.
- -Performed at 37 wks under anesthesia. - Cesarean Section.
What are the contraindications and complications of an External Cephalic Version?
Contraindications: if vaginal delivery is prohibited (placenta previa) or multifetal gestation.
Complications: placental abruption, ROM, labor.
What factors (11) favor a cesarean section performed for the management of a breech presentation?
- Lack of operator experience.
- Pt requests a C-section.
- Large fetus >3800 to 4000 grams.
- Apparently healthy and viable preterm fetus either w/active labor or with indicated delivery.
- Severe fetal growth restriction.
- Fetal anomaly incompatible with vaginal delivery.
- Prior perinatal death or neonatal birth trauma.
- Incomplete or footling breech presentation.
- Hyperextended head.
- Pelvic contraction or unfavorable pelvic shape determined clinically or with pelvimetry.
- Prior cesarean delivery.
What is the “turtle sign” and what does it suggest?
When there is retraction of the fetal head against the maternal perineum; is suggestive (but not diagnostic) of the presence of shoulder dystocia.
What are the risk factors (8) associated with Shoulder Dystocia?
- Fetal macrosomia.
- Maternal DM.
- Excess maternal weight gain.
- Operative vaginal delivery.
- Oxytocin use.
- Multiparity.
- Epidural use.
- Prolonged second stage of labor.
What is the treatment and mgmt of Shoulder Dystocia?
NO reliable factors that allow for the accurate prediction of recurrence in a subsequent pregnancy.
Clinicians must consider the current pregnancy course (GDM or other risks); the estimated fetal weight, birthweight of prior child with shoulder dystocia and the presence/absence/nature of any prior neonatal injury.
Name the many maneuvers for the alleviation and mgmt of shoulder dystocia?
McRoberts, Suprapubic pressure, Rubin Maneuver, Woods Corkscrew maneuver, Extraction of the posterior arm, Gaskin maneuver, Zavanelli Maneuver, Symphysiotomy.
What is the ALARMER acronym used for? Describe it.
For the Tx of Shoulder Dystocia.
- A – Ask for help.
- L – Lift/hyperflexed LEGS (McRoberts).
- A – Applied Suprapubic pressure & Anterior shoulder disimpaction (Rubins Maneuver).
- R – Release posterior shoulder.
- M – Maneuver of woods.
- E – Episiotomy
- R – Roll onto all 4’s to take advantage of gravity.
When is a Symphysiotomy performed? What is it?
When all other mgmt strategies of shoulder dystocia have been exhausted.
A surgical procedure in which the cartilage of the pubic symphysis is divided to widen the pelvis allowing childbirth.
What is the treatment and management of fetal distress?
- Resuscitative Measures:
- Pt repositioning; left lateral recumbent.
- Maternal O2 supplementation.
- Intravenous fluids.
- Tocolysis.
- Amnioinfusion (isotonic fluid instilled into the uterine cavity).
- Fetal scalp stimulation. - Expedite delivery – vaginal vs cesarean
- -expedite when a category II moves to a III.
What is LATE Postpartum Hemorrhage?
Bleeding AFTER the first 24 hrs; found in up to 1% of women and it may be serious.
What is the most common etiology of postpartum hemorrhage?
Uterine Atony (80%) followed by abruption, DIC.
What is the epidemiology of Postpartum Hemorrhage?
- 1-5% of all deliveries.
2. Uterine atony complicates 1 in 20-40 deliveries and is responsible for nearly 80% of postpartum hemorrhage cases.
Risk factors (7) for Postpartum Hemorrhage (PPH)?
- History of PPH.
- Abnormal placentation.
- Uterine Overdistention.
- Induction of labor.
- Obesity.
- Coagulation defects.
- Primiparity
What is Uterine Atony?
When the uterus fails to contract after delivery of the baby.
What are some causes of Late PPH?
Infection, retained products of conception, placental subinvolution, coagulopathy.
What are the 3 preventative methods for atonic postpartum hemorrhage?
- Active mgmt of the 3rd stage of labor.
- -Controlled cord traction, Uterine massage, Admin of uterotonic therapy before placental separation. - Spontaneous placental separation during cesarean delivery.
- Prolonged postpartum oxytocin infusion.
What are the uterotonic medications used for mgmt of postpartum hemorrhage?
Oxytocin – continuous infusion.
Misoprostol – single rectal suppository.
Methylergonovine (Methergine) – Q2-4 hrs.
Prostaglandin F2-alpha – Q15-90 mins, max 8 doses.
What is the clinical presentation of cord prolapse?
- Abrupt onset of severe, prolonged fetal bradycardia or moderate to severe variable decelerations in a patient with previously normal tracing.
- May feel a pulsating cord on vaginal exam or see the cord on exam.
What is a complication of cord prolapse?
Nuchal cord where the umbilical cord wraps around the baby’s neck.
What is the epidemiology of cord prolapse?
- 0.16-0.18% of live births.
- Declining incidence due to the use of U/S in the 3rd trimester.
- Perinatal mortality 0-3%.
What are the risk factors (7) of cord prolapse?
- Malpresentation.
- Prematurity/LBW.
- Low lying placenta.
- Pelvic or Uterine deformities.
- Polyhydramnios.
- Prolonged labor/unengaged presenting part.
- Iatrogenic (due to an illness).
What is the treatment and management of a cord prolapse?
- Call for assistance and prepare for emergency delivery.
- Initiate maneuvers for intrauterine resuscitation (O2 supp, left-lat recumbent, amnioinfusion, etc).
- Monitor FHR to determine if these measures are working.
- Elevate the presenting part off the cord (if palpated on vaginal exam).
- Wrap the cord w/most gauze and replace in vagina; if cord has fallen out of the vagina.
- Perform the delivery rapidly via cesarean section.
