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Obstetrics and Gynecology > complications of labour > Flashcards

complications of labour Flashcards

1
Q

how do preterm labour and cervical insufficiency differ

A

PTL–> preterm contractions with associated cervical change

cervical insufficiency–> silent, painless dilatation and effacement of the cervix

both can result in preterm delivery which is the leading cause of fetal morbidity and mortality in the USA

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2
Q

define preterm infant

A

born before 37 weeks GA

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3
Q

define low birth weight infant

A

less than 2500 g

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4
Q

preterm infants are at greater risk for what diseases

A 
RDS
hyaline membrane disease
intraventricular hemorrhage
sepsis
necrotizing enterocolitis
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5
Q

list risk factors associated with PTL

A 
preterm rupture of membranes 
chorioamnionitis
multiple gestation
uterine anomalies (bicornuate uterus)
previous preterm deliveries
maternal prepregnancy weight less than 50 kg
placental abruption
maternal disease (preeclampsia, infections, intra-abdominal disease, surgery)
low socioeconomic status
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6
Q

what is tocolysis

A

an attempt to prevent contractions and the progression of labuor

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7
Q

what tocolytic is approved by the FDA

A

ritodrine (a beta mimetic agent)

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8
Q

how long do tocolytics prolong gestation for

A

48 hours

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9
Q

what is the benefit for tocolytic use

A

allow time for treatment w steroids to enhance fetal lung maturity and reduce the risk of complications from preterm delivery

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10
Q

in which cases should you allow PTL to progress rather than using tocolytics

A

chorioamnionitis

non reassuring fetal testing

significant placental abruption

these are all ABSOLUTE indications to allow labour to progress

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11
Q

what is the goal of a tocolytic

A

to decrease or halt the cervical change resulting from contractions

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12
Q

what can you use to decrease the number and strength of contractions if there is no associated cervical change

A

hydration –> a dehydrated patient has increased levels of vasopressin or ADH (synthesized with oxytocin)–> ADH differs from oxytocin by only one amino acid and thus it may bind with oxytocin receptors and lead to contractions

hydration thus reduces ADH and may decrease contractions

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13
Q

name two beta mimetics used as tocolytics

A

ritodrine

terbutaline

only increase gestation by about 24-48 hours

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14
Q

side effects of tocolytics

A

tachycardia

headaches

anxiety

pulm edema

rare–> maternal death

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15
Q

how is ritodrine given

A

continuous IV therapy

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16
Q

how is terbutaline given

A

0.25 mg SC, loaded q20 min x 3 doses and then q3-4 maintenance

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17
Q

why should you not use terbutaline beyond 24-48 hours

A

can cause maternal death and cardiac events including tachycarida, hyperglycemia, hypokalemia, cardiac arrhythmias, pulm edema and myocardial ischemia

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18
Q

how does magensium sulfate act as a tocolytic

A

decreases uterine tone and contractions by acting as a calcium antagonist and a membrane stabilizer

can stop contractions but has not been shown to increase gestational age of delivery

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19
Q

side effects of magnesium sulfate

A

headaches
flushing
fatigue
diplopia

generally less severe than ritodrine or terbutaline

at toxic doses–> reduced DTRs, resp depression, hypoxia, cardiac arrest

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20
Q

how do you dose magnesium sulfate as a tocolytic

A

6 g bolus over 15-30 min and then maintained at a 2-3 g/hour continuous infusion

slower infusion in case of renal insufficiency because magnesium cleared by kidneys

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21
Q

name a calcium channel blocker used as a tocolytic

A

nifedipine

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22
Q

how do Ca channel blockers like nifedipine work as tocolytics

A

decrease influx of calcium into smooth muscle cells thereby diminishing uterine contractions

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23
Q

side effects of CCB nifedipine

A

headaches

flushing

dizziness

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24
Q

how do you dose nifedipine

A

10 mg loading dose q15 min for first hour or until contractions have ceased

maintenance hose of 10-30 mg q4-6h as tolerated according to BP

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25
Q

what effect do prostaglandins have on contractions

A

increase intracellular levels of calcium and enhance myometrial gap junction function thereby increasing myometrial contractions

commonly used to induce labour and heighten contractions in post partum patients with uterine atony

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26
Q

name a prostaglandin inhibitor used as a tocolytic

A

indomethacin (NSAID) blocks COX enzymes and decreases prostaglandin levels

minimal maternal side effects but has a variety of fetal complications including premature constriction of the ductus arteriosus, pulm HTN and oligohydramnios

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27
Q

define preterm rupture of membranes

A

rupture of membranes before week 37

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28
Q

define premature rupture of membranes

A

rupture of membranes before onset of labour

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29
Q

define PPROM

A

both premature and preterm rupture of membanes

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30
Q

define prolonged rupture of membanes

A

ROM lasting longer than 18 hours before delivery

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31
Q

without intervention, what % of women with preterm ROM will go into labour within 24 hours? 48 hours?

A

within 24 hours–50%

within 48 hours–75%

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32
Q

why might you not want pregnancy to continue too long after PPROM, even if they are premature?

A

higher risk of chorioamnionitis, abruption and cord prolapse

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33
Q

how do you diagnose preterm ROM

A

most patients complain of a gush of fluid from the vagina but any increased vaginal discharge or complaints of stress incontinence should be evaluated to rule out ROM

dx made by obtaining hx of leaking fluid, pooling on speculum exam and positive nitrazine test and fern tests

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34
Q

at what gestational age is the risk of prematurity the same as the risk of infection with PPROM

A

between 32-36 weeks

before this, risk of prematurity drives management of PPROM

after this, the risk of infection drives management of PPROM (and motivates delivery)

most common practice is to deliver at 34 weeks GA

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35
Q

what role do antibiotics have in the management of PPROM

A

strong evidence suggests that they lead to a longer latency period prior to onset of labour –>

AMPICILLIN with or without ERYTHROMYCIN is recommended in the setting of PPROM

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36
Q

do you use tocolytics in PPROM

A

controversial–> seem to have little benefit and may be harmful in setting of chorioamnionitis but many places will use tocolysis for 48 hours in order to give betamethasone

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37
Q

what is the most common concern with PROM

A

chorioamnionitis

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38
Q

what should you do for a woman who has prolonged ROM

A

antibiotics–> also for women with unknown GBS status

then should induce labour if between 34-36 weeks GA

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39
Q

what is a common cause of failure to progress in labour

A

CPD

40
Q

name the 4 dominant types of maternal pelvis

A

gynecoid

android

anthropoid

platypelloid

41
Q

define breech presentation and what is the incidence

A

buttocks first

3-4% of all singleton deliveries

42
Q

risk factors for breech delivery

A

previous breech delivery

uterine anomalies

polyhydramnios

oligohydramnios

multiple gestation

PPROM

hydrocephaly

anencephaly

43
Q

what are two complications of a vaginal breech delivery

A

prolapsed cord and entrapment of the head

44
Q

what are the three types of breech presentation

A

frank

complete

incomplete/footling

45
Q

define frank breech presentation

A

flexed hips, extended knees with feet near fetal head

46
Q

define complete breech presentation

A

flexed hips but one or both knees are also flexed with at least one foot near the breech

47
Q

define incomplete/footling breech presentation

A

one or both hips not flexed so that foot or knee lies below the breech in the birth canal

48
Q

what are the management options for breech presentation

A
  1. external cephalic version of the breech
  2. trial of vaginal breech delivery
  3. elective C/S
49
Q

what is the process of external cephalic version to treat breech presentation

A

manipulation of the breech infant into a vertex position–> rarely performed before 36-37 weeks GA because could do it spontaneously before this time

also risk for delivery after version secondary to abruption or ROM

usually done without anesthesia–> if unsuccessful, can try again with epidural anesthesia at 39 weeks and then either induce labour if successful or no then have C/S

50
Q

list complications of vaginal breech delivery

A

cord prolapse

entrapment of fetal head

fetal neurologic injury

51
Q

what are the criteria for a trial of vaginal breech delivery (vs C/S)

A

favorable pelvis

flexed head

estimate fetal weight between 2000-3000 g

frank or complete breech

52
Q

contraindications to trial of vaginal breech delivery

A

nulliparity

estimated fetal weight above 3800 g

incomplete breech presentation

53
Q

what presentation is common in anencephalic fetuses

A

face

54
Q

can you deliver a brow presentation vaginally

A

no unless head is unusually small–must convert to face or vertex to deliver

55
Q

define compound presentation

A

fetal extremity presenting alongside the vertex or breech

rate of compound presentation increases with prematurity, multiple gestation, polyhydramnios and CPD

56
Q

what is a common complication of compound presentation

A

umbilical cord prolapse

57
Q

how do you manage a compound presentation

A

if upper extremity presenting with vertex then often can be gently reduced and delivery vaginally

if lower extremity with vertex–> less likely to deliver vaginally

footling presentation (breech) is indication for cesarean

should always suspect and monitor for umbilical cord prolapse

58
Q

how do you manage a shoulder presentation

A

unless converts spontaneously, must do C/S because of increase risk of cord prolapse, uterine rupture and difficulty of vaginal delivery

59
Q

what is the best fetal position for passing through pelvic inlet

A

occiput anterior (OA)

LOA and ROA are also normal and commonly rotate to OA by late first stage or second stage

60
Q

define malposition of the fetus

A

OT or OP

have higher rate of C/S

61
Q

what intervention is more associated with malposition

A

epidural use –> reduces tendency to rotate to OA from OP or OT (doesnt cause them)

62
Q

what is the most common position of the fetus at onset of labour

A

LOT or ROT

from transverse position, cardinal movement of internal rotation usually converts the fetus to the OA position

63
Q

what are the options for deliveries that have prolonged second stage and OT or OP position of the fetus

A

delivery via forceps or vacuum in OP position

rotation with forceps

manual rotation

in either OP or OT, if attempt at rotation or operative delivery fails, C/S commonly required

OP cases delivery spontaneously 50% of the time but OT rarely delivery vaginally and must rotate to either OP or OA to delivery vaginally

64
Q

list possible obstetric emergencies

A

fetal bradycardia

maternal hypotension

uterine rupture

seizure

shoulder dystocia

65
Q

define a prolonged deceleration

A

any time the FHR is below 100-110 bpm for longer than 2 minutes

66
Q

define FHR bradycardia

A

FHR below 100-110 bpm for longer than 10 min

67
Q

what complications are associated with prolonged decels/fetal brady

A

placental abruption

cord prolapse

uterine tetanic contractions

uterine rupture

PE

amniotic fluid embolus (AFE)

seizure

poor fetal outcome

68
Q

how do you categorize etologies of FHR decels

A

preuterine

uteroplacental

post-placenal

69
Q

what are some preuterine causes of FHR decels

A

any event leading to maternal hypotension or hypoxia–> seizure, AFE, PE, MI, respiratory failure or recent epidural or spinal placement leading to hypotension

70
Q

what are some uteroplacental causes of FHR decels

A

placental abruption

placental infarction

hemorrhaging previa

uterine hyperstimulation

71
Q

what are some post placental causes of FHR decels

A

cord prolapse

cord compression

rupture of fetal vessels (vasa previa)

72
Q

what should you do first when you notice a decel

A

check to make sure youre not picking up moms HR with a fetal scalp electrode

73
Q

describe an algorithm to diagnose the etiology of FHR decels

A
  1. look at mother for signs of respiratory compromise or change in mental status–> will commonly diagnose seizures, PE, AFE
  2. while putting on a glove for a cervical exam, assess maternal BP and HR–> will diagnose maternal hypotension (common after epidural placement and a potential cause of FHR decels) and will also tell you if you’re actually getting maternal HR
  3. immediately before exam, look to see how much vaginal blood is passing–> if increased, placental abruption and uterine rupture should be considered
  4. examine patient with one hand on maternal abdomen and one hand vaginally feeling for cervical dilation, fetal station and prolapsed umbilical cord–> abdo hand should feel for uterine hyperstimulation and fetal parts outside the uterus
  5. if fetal station is dramatically lower than expected, prolonged HR decel may be due to rapid descent and vagal stimulation
  6. if fetal station is much higher than expected, uterine rupture should be suspected
  7. if cervix is fully dilated and the fetus is in the pelvis, operative vaginal delivery can be performed if the FHR decels do not resolve
74
Q

what is the standard initial management for a prolonged FHR decel

A
  1. patient moved to L or R lateral decubitus position to resolve a decel secondary to compression of the IVC leading to decreased preload or compressed umbilical cord
  2. oxygen by face mask commonly administered to mother in case hypoxia is an issue
  3. examination performed (see previous card) –> individual etiologies diagnosed and treated appropriately
75
Q

how do you manage maternal hypotension causing FHR decels

A

aggressive IV hydration and ephedrine

76
Q

how do you treat maternal tetanic uterine contraction leading to FHR decels

A

nitroglycerin usually SL

(and/or terbutaline

77
Q

how do you treat cord prolapse causing FHR decels

A

emergent C/S –> lift fetal head to avoid compression of prolapsed cord

78
Q

how do you treat previa causing FHR decels

A

urgent C/S

79
Q

how do you treat abruption causing FHR decels

A

if remote from delivery, C/S

80
Q

after how long of FHR decels should you move a patient into the OR

A

after 4-5 minutes of decels

if persists in the OR, at around 8 minutes of decel total, should plan emergent C/S –> goal of delivery of fetus in this setting is to be within next 2-4 minutes

*sterile technique may not be possible

81
Q

define shoulder dystocia

A

difficulty delivering shoulders, particularly because of impaction of the anterior shoulder behind the pubic symphysis, after delivery of the head

82
Q

risk factors for shoulder dystocia

A

fetal macrosomia (weight over 4000 g)

preconceptional and gestational diabetes

previous shoulder dystocia

maternal obesity

postterm pregnancy

prolonged second stage of labour

operative vaginal delivery

83
Q

fetal complications of shoulder dystocia

A

fractures of the humerus and clavicle

brachial plexus nerve injuries (Erb palsy)

phrenic nerve palsy

hypoxic brain injury

death

84
Q

how is shoulder dystocia diagnosed

A

when routine obstetric maneuvers cannot deliver the fetus

“turtle” sign–> incomplete delivery of the head or the chin is tucking up against the maternal perineum

85
Q

what should you do once you ID a shoulder dystocia

A

labour and delivery alert should be called

pediatric team should be called

someone needs to run the shoulder dystocia emergency (similar to a code)

someone should be assigned to keep track of time, as dystocia can lead to entrapment and complete compression of the umbilical cord–> *delivery in less than 5 minutes is imperative

two individuals should be assigned to hold the patients legs and one person to give suprapubic pressure

do the specific maneuvers to deliver shoulder dystocia (see another card)

if infant is still undelivered–> generous episiotomy, or cut or fracture the clavicle

if all else fails–> Zavanelli maneuver

86
Q

what are the maneuvers for delivering a fetus with shoulder dystocia

A
  1. McRoberts maneuver–> sharp flexion of the maternal hips that decreases the inclination of the pelvis and thus increases the AP diameter can free the anterior shoulder
  2. suprapubic pressure–> pressure applied just above the maternal pubic symphysis at an oblique angle to dislodge the anterior shoulder from behind the pubic symphysis
  3. Rubin maneuver–> pressure on an either accessible shoulder toward the anterior chest wall of the fetus to decrease the bisacromial diameter and free the impacted shoulder
  4. wood’s corkscrew maneuver–> pressure behind the posterior shoulder to rotate the infant and dislodge the anterior shoulder
  5. delivery of the posterior arm/shoulder–> delivery of the posterior arm by sweeping the posterior arm across the chest to allow the bisacromial diameter to torate to an oblique diameter of the pelvis and anterior shoulder to be freed
87
Q

what is the Zavanelli maneuver

A

in the case of persistent shoulder dystocia

place the infants head back into the pelvis and perform a C/S

88
Q

in which patients should you suspect uterine rupture

A

in setting of FHR decels in patients with prior uterine scars

may feel a “popping” sensation or experience sudden abdo pain

89
Q

common etiologies of maternal hypotension

A

vasovagal events

regional anesthesia

overtreatment with antihypertensives

hemorrhage

anaphylaxis

AFE

90
Q

how should you treat anaphylaxis in a pregnant woman

A

benadryl and epinephrine

91
Q

how do you make the definitive diagnosis of AFE

A

finding fetal cells in the maternal pulm vasculature at autopsy

92
Q

what is one of the key ways to distinguish between seizures and a vasovagal event

A

presence of a post-ictal period after the event

93
Q

what should you do if a patient has a seizure on labour and delivery

A

full pre-eclampsia workup, tox panel, chem panel, and head CT when safe to leave ward

neuro consult indicated

manage acutely with ABC management and anti-seizure meds

94
Q

what is the anti-seizure med of choice in pregnancy

A

magnesium sulfate

95
Q

describe a plan of action for managing a seizing patient on labour and delivery

A
  1. access and establish airway and vital signs including oxygenation
  2. assess FHR or fetal status
  3. bolus magnesium sulfate, or give 10 g IM
  4. bolus with lorazepam 0.1mg/kg, 5-10 mg at no more than 2 mg/min
  5. load phenytoin 20 mg/kg, usually 1-2 g at no more than 50 mg/min
  6. if not successful, load phenobarbital 20 mg/kg
  7. lab tests–> CBC, metabolic panel, AED levels, tox screen
  8. if non reassuring fetal testing, move to emergent delivery

Obstetrics and Gynecology (21 decks)

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