Complications of labor and delivery Flashcards
- Preterm labor is considered how many weeks?
2. Regular uterine contractions associated with what?
- Prior to 37 weeks
2. cervical change
Risk Factors for Preterm Labor
9
- 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)
PP of Preterm labor? 4
- 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:
Pathologic uterine distension can be caused by what?
3
- Multiple pregnancy
- Polyhydramnios
- Uterine abnormality
Signs & Symptoms of Preterm Labor
7
- 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)
Evaluation of preterm labor?6
- Fetal monitoring
- UA,
- test for Group B strep,
- CBC
- Ultrasound:
- Amniocentesis:
What would the ultrasound show?
2
- Evaluate amount of amniotic fluid
2. Estimate cervical length if
Amniocentesis:
Can determine what? 2
- Can determine intramniotic infection
2. May be used to determine fetal lung maturity
Management
- Primary goal?
- Detection and treatment of the disorder associated with what?
- Therapy for preterm labor?
- 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
- Tocolytics are what?
2. What are they? 4
- Medication to stop preterm labor:
- Calcium channel blockers (nifedipine)
- NSAIDS (indocin)
- B-adrenergic receptor agonists (terbutaline)
- Magnesium sulfate
Contraindications to Tocolyics
10
- 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
Corticosteroids
- Why might you give corticosteroids?
- Maximal benefitif given when?
- What weeks?
- Dosing over what period of time?
- What does it reduce? 3
- 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
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?
- 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*
GBS Antibiotic Prophylaxis
- Drug?
- Best if given when?
- 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
GBS Antibiotic Prophylaxis
If PCN allergy give what? 3
If PCN allergy then:
- Cefazolin (If no h/o anaphylaxis to PCN)
- Or Clindamycin
- Or Vancomycin
GBS Colonization
- Treatment prevents what?
- Prevents what in the mother?
- May have asymptomatic what?
- 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*
What is the Leading indication for c-section?
Dystocia
- Dystocia. What is it?
2. AKA?
- 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”
Evaluation of Labor
5
- 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?
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?
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
Dystocia Management?
3
- Observation
- Augmentation:
- Caesarian section (c-section)
Dystocia Management
1. How can we augment? 2
- When would you do a C section?
- Amniotomy
- Oxytocin (Pitocin)
- Maternal or fetal distress
- Unstable condition of mother
Augmentation
- Amniotomy:
- What is it?
- Risks? 2 - Oxytocin
- Administration?
- MOA?
- Risk? 2
- 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
Indications for c-section
11
- 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
Assisted Vaginal Delivery
- Use when?
- What can you use? 2
- 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
- Forceps or vacuum extraction
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
Umbilical cord prolapse:
1. How does it present?
- Pressure on the cord causes what?
- Umbilical cord is palpable on vaginal exam, it proceeds the presenting part
- fetal bradycardia and can eventually cause fetal demise
UCP Management
1. Prompt delivery how?
- Maneuvers to reduce cord pressure? 4
- C section
- 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
Shoulder Dystocia
- Severity?
- Defined as?
- PP?
- What can precipitate this?
- Obstetric emergency!
- Defined as the need for additional obstetric maneuvers to effect delivery of the shoulders at the time of vaginal birth
- 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 - Fetal macrosomia can precipitate it
Dangers of Shoulder dystocia include?
3
- Entrapement of cord
- Inability of the child’s chest to expand properly?
- Severe brain damage or death if the child is not delivered in time
Shoulder Dystocia
dx? 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
Shoulder Dystocia–Management
- What should be avoided?
- Why?
- What should be dranined if present?
- Which maneuvers? 3
- Excessive neck rotation, head & neck traction and fundal pressure should be avoided:
- These maneuvers can further impact the shoulders and injure the brachial plexus
- A distended bladder if present is drained
- 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
Should Dystocia: Delivery of the posterior arm: 1. AKA? 2. Best performed with what? 3. Done how? 3 4. Whats the greatest risk?
- Also called the Barnum maneuver
- Best performed under adequate anesthesia
- 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
- Greatest risk is fracture of the humerus
See picture 43
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?
- Place mother on her hands and knees:
- Infant delivered by gentle downward traction on the post shoulder
- Or upward traction on the ant shoulder
See picture 46
Breech Presentation
1. Different presentations of breech are possible. Such as? 3
- Usually a woman found to have a baby in the breech presentation has a what?
- If breech may attempt what to get the baby in the vertex position so the mother may attempt to have a vaginal birth?
- Frank breech: hips flexed/knees extended
- Complete breech: hips and knees flexed
- Incomplete breech: one or both hips extended (foot or feet first!)
- scheduled c-section
- external cephalic version
- Whats the frank breech?
- Complete breech?
- What does an incomplete breech look like?
- Frank Breech: Hips flexed/Knees extended
- slide 49 - Complete Breech (hips & Knees are Flexed)
- slide 50 - Incomplete Breech
- Slide 51
External Cephalic Version Procedure
6 steps
- Done in final trimester
- Monitor fetus
- Often given uterine relaxants
- Perform cephalic version
- Monitor mom and baby
- Give Rhogam if mother Rh negative
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
When the scapulae appear under the symphisis, the operator should do what?
3
-slide 57
- reaches over the L shoulder,
- sweeps the arm across the chest and
- delivers the arm
Gentle rotation of the shoulder girdle facilitates what?
-slide 58
delivery of the R arm
Following delivery of the arms, the fetus is wrapped in a towel. Why? 2
-slide 59
- for control and
- slightly elevated,
excessive elevation of the trunk is avoided
- Its important to MAINTAIN CEPHALIC FLEXION by ?
With continued expulsive forces from above and gentle downward traction the fetal head is delivered
- applying pressure on the fetal maxilla (not mandible!)
- slide 60
Retained Placenta
- Defined as?
- Its a cause of what complication?
- Pharmacologic interventions? 2
- Defined as a placenta that has not been expelled 30-60 min after delivery of the baby
- Cause of postpartem hemorrhage (PPH)
- Pharmacologic interventions:
- IV nitroglycerin given to relax the uterus, BP monitored—hypotensive—trendelenburg
-Intraumbilical injection of a solution of oxytocin in saline
Manual removal of a retained placenta:
- Performed how?
- The other hand holds what?
- The hand inside the uterus them does what? 2
- What may be necessary?
- Performed by using one hand to follow the path of the umbilical cord into the lower uterine segment
- The other hand holds the uterine fundus
- 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
- General anesthesia may be necessary
Uterine Inversion
- What is it?
- Treatment? 6
- Uterine fundus collapses into the endometrial cavity
- Treatment:
- Summon assistance
- Large bore IV access for fluids
- Uterine relaxation: magnesium sulfate, terbutaline, nitroglycerin
- Manual correction
- Removal of placenta
- Uterotonic agents
Normal Pathophysiology of Uterine Hemostasis
3 steps
- Contraction of the myometrium, which compresses the blood vessels supplying the placental bed and
- causes mechanical hemostasis
- Local decidual hemostatic factors (tissue factor, type-1 plasminogen activator inhibitor) [eg, platelets, circulating clotting factors], which cause clotting
Causes of PPH
3
- Incomplete placental separation:
(Retained placenta and Retained membranes) - Ineffective myometrial contraction (ATONY!)
- Bleeding diatheses
Postpartum Hemorrhage
1. PPH defined and diagnosed as? 2
- Etiologies? 3
- Excessive bleeding
- Results in patient symptoms of light-headedness, vertigo or syncope and/or signs of hypovolemia***
- Etiologies:
- Uterine atony** [1 in 20 women]
- Trauma
- Coagulation defects: congenital & acquired
PPH Management
4
- Fundal massage
- IV access: for fluid and blood
- Ultrasound**
- Uterotonic Drugs:
What are the Uterotonic drugs?
5
- Oxytocin 15 u in 250 mL of LR
- Misoprostol sublingually or rectally
- Methylergonovine IM or directly into myometrium (if no HTN,
- Raynaud’s or scleroderma)
- Carboprost tromethamine (Hemabate) if no asthma
PPH Secondary Management
5
- Pt be taken to room where anesthesia and facilities for vaginal and possible abdominal surgery can be done
- Provide adequate anesthesia
- Uterus explored and any retained fragments or fetal membranes be removed manually if possible
- Inspect for and repair cervical and vaginal lacerations
- Bakri tamponade—for uterine tamponade