Complications of labor and delivery Flashcards
1
Q
- Preterm labor is considered how many weeks?
2. Regular uterine contractions associated with what?
A
- Prior to 37 weeks
2. cervical change
2
Q
Risk Factors for Preterm Labor
9
A
- Multiple gestation*
- Prior preterm birth*
- Preterm uterine contractions
- Premature rupture of membranes
- Low maternal prepregnancy weight
- Smoking
- Substance abuse
- Short interpregnancy interval
- Infection (UTI, genital tract, periodontal disease)
3
Q
PP of Preterm labor? 4
A
- Activation of the maternal or fetal hypothalamic-pitutary-adrenal axis due to maternal or fetal stress
- Deciual-choioamniotic or systemic inflammation caused by infection:
- Decidual hemorrhage:
Abruption* - Pathologic uterine distension:
4
Q
Pathologic uterine distension can be caused by what?
3
A
- Multiple pregnancy
- Polyhydramnios
- Uterine abnormality
5
Q
Signs & Symptoms of Preterm Labor
7
A
- Menstrual like cramps
- Low, dull backache
- Abdominal pressure
- Pelvic pressure
- Abdominal cramping with or without diarrhea
- Increase or change in vaginal discharge (mucous, water, light bloody discharge)
- Uterine contractions (may be painless)
6
Q
Evaluation of preterm labor?6
A
- Fetal monitoring
- UA,
- test for Group B strep,
- CBC
- Ultrasound:
- Amniocentesis:
7
Q
What would the ultrasound show?
2
A
- Evaluate amount of amniotic fluid
2. Estimate cervical length if
8
Q
Amniocentesis:
Can determine what? 2
A
- Can determine intramniotic infection
2. May be used to determine fetal lung maturity
9
Q
Management
- Primary goal?
- Detection and treatment of the disorder associated with what?
- Therapy for preterm labor?
A
- Primary goal is to delay delivery until fetal maturity is attained
- Detection and treatment of the disorder associated with preterm labor
- Therapy for preterm labor
10
Q
- Tocolytics are what?
2. What are they? 4
A
- Medication to stop preterm labor:
- Calcium channel blockers (nifedipine)
- NSAIDS (indocin)
- B-adrenergic receptor agonists (terbutaline)
- Magnesium sulfate
11
Q
Contraindications to Tocolyics
10
A
- Advanced labor
- Mature fetus
- Severely abnormal fetus or fetal demise
- Intrauterine infection
- Significant vaginal bleeding
- Severe preeclampsia or eclampsia
- Placental abruption
- Advanced cervical dilation
- Fetal compromise
- Placental insufficiency
12
Q
Corticosteroids
- Why might you give corticosteroids?
- Maximal benefitif given when?
- What weeks?
- Dosing over what period of time?
- What does it reduce? 3
A
- Corticosteroids given to the mother to enhance fetal lung maturity
- Maximal benefit if given within 7 days of delivery
- From 24-34 weeks gestation
- Dosing over 48 hours
- Reduces:
- Fetal respiratory distress
- Intraventricular hemorrhage
- Necrotizing enterocolitis
13
Q
Stre[tpcpccis agalactiae
(Group B streptococcus)
1. Genital tract colonization of ______% pregnant women
- Universal screening for GBS between _____ weeks gestation**
- If positive administer what?
- When else would we administer this?
A
- 15-40
- 35-36
- antibiotic prophylaxis in labor or with premature rupture of membranes
- OR if pregnant mother has had prior infant with GBS infection*
14
Q
GBS Antibiotic Prophylaxis
- Drug?
- Best if given when?
A
- Penicillin G 5 million U IV followed by 2,5-3 million U q 4 hrs. until delivery
- Best if given 4 hrs. prior to delivery
15
Q
GBS Antibiotic Prophylaxis
If PCN allergy give what? 3
A
If PCN allergy then:
- Cefazolin (If no h/o anaphylaxis to PCN)
- Or Clindamycin
- Or Vancomycin
16
Q
GBS Colonization
- Treatment prevents what?
- Prevents what in the mother?
- May have asymptomatic what?
A
- Treatment prevents Group B sepsis of the neonate
- (In the mother) Prevents postpartum endometritis, sepsis and in rare cases meningitis
- May have asymptomatic bacturia during pregnancy and that should be treated*
17
Q
What is the Leading indication for c-section?
A
Dystocia
18
Q
- Dystocia. What is it?
2. AKA?
A
- Dystocia—abnormal progression of labor- Defined as lack of progressive cervical dilation of lack of descent of fetal head in birth canal or both
- Also referred to as “failure to progress”
19
Q
Evaluation of Labor
5
A
- Is the uterus contracting accurately? (internal monitor)
- What is the fetal position?
- Is there indication of cephalopelvic disproportion?
- What is the fetal status? FHR tracing- want to see accerlations and variability
- Is there concern for chorioaminonitis?
20
Q
Progression of Labor
- Cervix should dilate how much for nulliparous?
- Multiparous?
- Fetus should descend at least ____ per hour.
- Should not be longer than __ hrs. if regional anesthesia
- Should not be longer that __ hrs. if no anesthesia
- Second stage arrest is what?
A
Cervix should dilate:
- 1 cm/hr in nulliparous
- 1.5 cm/hr in multiparous
- Fetus should descend at least 1 cm/hr.
- 3
- 2
- no descent after 1 hr. of pushing
21
Q
Dystocia Management?
3
A
- Observation
- Augmentation:
- Caesarian section (c-section)
22
Q
Dystocia Management
1. How can we augment? 2
- When would you do a C section?
A
- Amniotomy
- Oxytocin (Pitocin)
- Maternal or fetal distress
- Unstable condition of mother
23
Q
Augmentation
- Amniotomy:
- What is it?
- Risks? 2 - Oxytocin
- Administration?
- MOA?
- Risk? 2
A
- Amniotomy:
- Manual rupture of membranes with “hook”
- Risks:
a. fetal heart rate deceleration due to cord compression,
b. increased incidence of chorioamnionitis - Oxytocin:
- Pitocin drip per protocol—with increasing amount
- Increases uterine activity (contractions) which in turn should result in cervical change and descent
- Risk:
a. hypertonic uterus,
b. avoid more than 5 contractions in 10 minutes as this can cause decreased blood flow (oxygen) to fetus
24
Q
Indications for c-section
11
A
- Failure to progress during labor*
- Nonreassuring fetal status*
- Fetal malpresentation*
- Abnormal placentation
- Maternal infection (HIV, HSV**)
- Multiple gestation
- Fetal bleeding diathesis
- Umbilical cord prolapse
- Macrosomia
- Obstruction of birth canal (fibroid, condyloma accuminata, etc)
- Uterine rupture
25
Assisted Vaginal Delivery
1. Use when?
2. What can you use? 2
1.
- When mother’s pushing and uterine contractions are insufficient to deliver the infant
- Sudden onset of severe maternal or fetal compromise and mother is fully dilated and effaced
2. Forceps or vacuum extraction
26
Complications of Assisted Delivery
Forceps:
- Mother? 3
- Baby? 4
Vaccum:
- Mother? 1
- Baby? 6
Forceps:
- Mother—
1. perioneal trauma,
2. hematoma,
3. pelvic floor injury
- Baby—
1. injuries to the brain or spine,
2. MSK injury,
3. corneal abrasion,
4. shoulder dystocia in larger infants
Vacuum:
- Mother—less maternal trauma than forceps
- Baby—
1. intracranial hemorrhage,
2. subgaleal hematoma,
3. scalp laceration,
4. hyperbilirubinemia,
5. retinal hemorrhage,
6. cephalhematoma
27
Umbilical cord prolapse:
1. How does it present?
2. Pressure on the cord causes what?
1. Umbilical cord is palpable on vaginal exam, it proceeds the presenting part
2. fetal bradycardia and can eventually cause fetal demise
28
UCP Management
1. Prompt delivery how?
2. Maneuvers to reduce cord pressure? 4
1. C section
2.
- Examiner’s hand maintained in vagina to elevate presenting part off the cord while arrangement are made for emergency c-section
- Patient is placed in steep trendelenberg position
- Filling the bladder w/ 500-700 ml of NS
- Giving a tocolytic such as terbutaline to stop contractions
29
Shoulder Dystocia
1. Severity?
2. Defined as?
3. PP?
4. What can precipitate this?
1. Obstetric emergency!
2. Defined as the need for additional obstetric maneuvers to effect delivery of the shoulders at the time of vaginal birth
3. PP:
- If the fetal shoulders remain in an anterior-post position during descent or descend simultaneously the anterior shoulder can become impacted behind the PS
4. Fetal macrosomia can precipitate it
30
Dangers of Shoulder dystocia include?
| 3
1. Entrapement of cord
2. Inability of the child's chest to expand properly?
3. Severe brain damage or death if the child is not delivered in time
31
Shoulder Dystocia
| dx? 1
1. Fetal head retracts into the perineum (turtle sign) after expulsion
When routine gentle, downward traction of the fetal head fails to accomplish delivery of the anterior shoulder
32
Shoulder Dystocia--Management
1. What should be avoided?
2. Why?
3. What should be dranined if present?
4. Which maneuvers? 3
1. Excessive neck rotation, head & neck traction and fundal pressure should be avoided:
2. These maneuvers can further impact the shoulders and injure the brachial plexus
3. A distended bladder if present is drained
4.
- McRoberts maneuver
- Suprapubic pressure: directing pressure on the anterior shoulder downward away from the pubic bone, in conjunction w/ McRoberts maneuver
- Rubin maneuver: adduction of the fetal shoulder, displacing them from the anteroposterior diameter
See picture 41 and 42
33
```
Should Dystocia:
Delivery of the posterior arm:
1. AKA?
2. Best performed with what?
3. Done how? 3
4. Whats the greatest risk?
```
1. Also called the Barnum maneuver
2. Best performed under adequate anesthesia
3.
- Introduce a hand into the vagina and locate the posterior arm & shoulder
- Follow it to the elbow, flex the elbow across the fetal chest
- Grasp the forearm and the arm is then pulled out of the vagina
4. Greatest risk is fracture of the humerus
See picture 43
34
```
Shoulder Dystocia Management
1. If other measures fail or if mother has only local anesthesia can be a good initial maneuver after McRoberts and suprapubic pressure
THEN
1. Place mother in what position?
2. How is the infant deliverd?
3. Upward traction where?
```
1. Place mother on her hands and knees:
2. Infant delivered by gentle downward traction on the post shoulder
3. Or upward traction on the ant shoulder
See picture 46
35
Breech Presentation
1. Different presentations of breech are possible. Such as? 3
2. Usually a woman found to have a baby in the breech presentation has a what?
3. If breech may attempt what to get the baby in the vertex position so the mother may attempt to have a vaginal birth?
1.
- Frank breech: hips flexed/knees extended
- Complete breech: hips and knees flexed
- Incomplete breech: one or both hips extended (foot or feet first!)
2. scheduled c-section
3. external cephalic version
36
1. Whats the frank breech?
2. Complete breech?
3. What does an incomplete breech look like?
1. Frank Breech: Hips flexed/Knees extended
- slide 49
2. Complete Breech (hips & Knees are Flexed)
- slide 50
3. Incomplete Breech
- Slide 51
37
External Cephalic Version Procedure
| 6 steps
1. Done in final trimester
2. Monitor fetus
3. Often given uterine relaxants
4. Perform cephalic version
5. Monitor mom and baby
6. Give Rhogam if mother Rh negative
38
After spontaneous expulsion to the umbilicus, external rotation of the fetal pelvis results in what?
-slide 56
flexion of the knee and delivery of each leg
39
When the scapulae appear under the symphisis, the operator should do what?
3
-slide 57
1. reaches over the L shoulder,
2. sweeps the arm across the chest and
3. delivers the arm
40
Gentle rotation of the shoulder girdle facilitates what?
| -slide 58
delivery of the R arm
41
Following delivery of the arms, the fetus is wrapped in a towel. Why? 2
-slide 59
1. for control and
2. slightly elevated,
excessive elevation of the trunk is avoided
42
1. Its important to MAINTAIN CEPHALIC FLEXION by ?
With continued expulsive forces from above and gentle downward traction the fetal head is delivered
1. applying pressure on the fetal maxilla (not mandible!)
| - slide 60
43
Retained Placenta
1. Defined as?
2. Its a cause of what complication?
3. Pharmacologic interventions? 2
1. Defined as a placenta that has not been expelled 30-60 min after delivery of the baby
2. Cause of postpartem hemorrhage (PPH)
3. Pharmacologic interventions:
- IV nitroglycerin given to relax the uterus, BP monitored—hypotensive—trendelenburg
-Intraumbilical injection of a solution of oxytocin in saline
44
Manual removal of a retained placenta:
1. Performed how?
2. The other hand holds what?
3. The hand inside the uterus them does what? 2
4. What may be necessary?
1. Performed by using one hand to follow the path of the umbilical cord into the lower uterine segment
2. The other hand holds the uterine fundus
3.
- The hand inside the uterus frees the remaining placenta if it is loose or
- develops a space between the placenta & uterus and shears off the placenta
4. General anesthesia may be necessary
45
Uterine Inversion
1. What is it?
2. Treatment? 6
1. Uterine fundus collapses into the endometrial cavity
2. Treatment:
- Summon assistance
- Large bore IV access for fluids
- Uterine relaxation: magnesium sulfate, terbutaline, nitroglycerin
- Manual correction
- Removal of placenta
- Uterotonic agents
46
Normal Pathophysiology of Uterine Hemostasis
| 3 steps
1. Contraction of the myometrium, which compresses the blood vessels supplying the placental bed and
2. causes mechanical hemostasis
3. Local decidual hemostatic factors (tissue factor, type-1 plasminogen activator inhibitor) [eg, platelets, circulating clotting factors], which cause clotting
47
Causes of PPH
| 3
1. Incomplete placental separation:
(Retained placenta and Retained membranes)
2. Ineffective myometrial contraction (ATONY!)
3. Bleeding diatheses
48
Postpartum Hemorrhage
1. PPH defined and diagnosed as? 2
2. Etiologies? 3
1.
- Excessive bleeding
- Results in patient symptoms of light-headedness, vertigo or syncope and/or signs of hypovolemia***
2. Etiologies:
- Uterine atony** [1 in 20 women]
- Trauma
- Coagulation defects: congenital & acquired
49
PPH Management
| 4
1. Fundal massage
2. IV access: for fluid and blood
3. Ultrasound**
4. Uterotonic Drugs:
50
What are the Uterotonic drugs?
| 5
1. Oxytocin 15 u in 250 mL of LR
2. Misoprostol sublingually or rectally
3. Methylergonovine IM or directly into myometrium (if no HTN,
4. Raynaud's or scleroderma)
5. Carboprost tromethamine (Hemabate) if no asthma
51
PPH Secondary Management
| 5
1. Pt be taken to room where anesthesia and facilities for vaginal and possible abdominal surgery can be done
2. Provide adequate anesthesia
3. Uterus explored and any retained fragments or fetal membranes be removed manually if possible
4. Inspect for and repair cervical and vaginal lacerations
5. Bakri tamponade—for uterine tamponade
