delivery problems Flashcards
what is dystocia?
difficult labor or abnormally slow progress of labor.
what are the 3 categories of dystocia?
power, passenger, and passage
what is power?
purely dysfunctional dystocia, in which uterine contractility is inadequate in effecting dilation and descent
what is passenger dystocia?
presentation size or position of fetus
what is shoulder dystocia?
one or both shoulders lodged at pubic symphysis after delivery of the head
+/- Erb’s palsy (brachial plexus shoulder injury) especially in macrosomic kids, multiparity, gest. DM
what is passage dystocia?
uterus or soft tissue abnormalities
management of shoulder dystocia
non-manipulative (first line) McRoberts maneuver increase pelvic opening w/ hip hyperflexion
what is the manipulative management of dystocia?
Woods “ Corkscrew’ maneuver: 180 shoulder rotation
what is PROM?
premature rupture of membranes
rf for PROM?
STDs, smoking, prior preturm delivery, multiple gestations
dx of PROM?
1) sterile speculum exam–> visual inspection–> pooling of secretions–> assess for infections
nitrazine paper test –> turns blue if pH> 6.5 = PROM is likely
2) US
3) avoid digital exam in most cases
hwat is normal amniotic fluid ph?
7.0-7.3
what is the fern test?
anminotic fluid fern pattern–> crystallization of estrogen and amniotic fluid
management of PROM?
await for spontaneous labor
monitor for infectsion: chorioamnionitis or endometritis
what s the criteria for Premature labor?
regular uterine contractions (> 4-6/hr) w/ progressive cervical changes BEFORE 37 WKS
**mMC cuase of perinatal mortality
s/sx of PTL?
cramps, uterine contractions, back pain, pelvic pressure, and vaginal d/c
dx of PTL based on cervical dilation?
> 3cm: PTL
2-3 cm: PTL is likely
<2 cm: PTL is unlikely
dx of PTL based on effacement?
> 80 %: PTL
< 80: PTL is likely/unlikely
fetal distress
> 160 tachycardic
<120 bradycardic
what is non stress testing?
reocreds movement, heartbeat, and contractions; noes changes in h eart rhytm when the baby goes from resting to moving, or during contractions if the mom is in labor
what is a good NST?
“reactive” > 2 accelerations in 20 mins defined by increased FHR of at least 15 bpm from baseline lasting > 15 secs= fetal well being
bad NST?
nonreactive NST no fetal heart acels, or < 15 bpm increase lasting < 15 secs
*if this is the case, then get CST
Contraction Stress Test
measures fetal response to stress at times of uterus contraction
negative CST (aka Good)
no late decels in the presence of 2 contractions in 10 mins
positive CST (aka bad)
repetitive late decels in the presence of 2 contractions in 10 mins–> worrisome espectially if nonreactive NST
what can repetitive late decles of the FHR mean?
uteroplacental insufficiency
how is a late decel defined?
gradual decrease and return to the baseline FHR during the contraction with the lowest point occurring after the peak of the the contractions. doen’t return to baseline until contraction is over
how is a variable decel defined?
characterized by an abrupt decrease in FHR below the baseline with the onset to lowest point less than 30 secs. can occur anytime during the contraction cycle ans last at least 15 seconsd
**happen in approximatley halft of all labors and are usually transietn and correctable
what is characteristic on the fetal monitor during variable decels?
U, V, or W shapes and noted by their rapid descent and ascent
what may variable decels suggest?
umbilical cord compression, especially in the presence of oligohydramnios or amniotomy
what is oligohydramnios?
deficiency of amniotic fluid
what is amniotomy?
artificial rupture of membranes
breech presentation
occurs when fetal pelvis of lower extremities engage the maternal pelvic inlet
*suspected PE, comfired by US
what is a frank breech?
hips are flexed with extended knees bilaterally
complete breech?
both hips and kness are flexed
footling breech
1 (single footling) or both (double footlilng) legs are extended below the level of the buttocks
what is fetal position determined by in breech presentations?
fetal sacrum as the POR to the maternal pelvis
what are the 8 possible fetal positions?
Sacrum Anterior (SA), Sacrum Posterior (SP), Left Sacrum Transverse (LST), Right Sacrum Transverse (RST), Left Sacrum Anterior (LSA), Left Sacrum Posterior (LSP), Right Sacrum Anterior (RSA) and Right Sacrum Posterior (RSP
what is the station of breech?
location of the fetal sacrum with regard to the maternal ischial spines
what is the pathogenesis behind breech?
when spontaneous version to cephalic presentation is prevented as term approaches or if L and D occur prematurely before cephalic versio has taken place
what are some causes of brrech?
- oligohydramnios,
- polyhydramnios,
- uterine anomalies such as bicornuate or septate uterus, -pelvic tumors obstructing the birth canal,
- abnormal placentation, -advanced multiparity and a -contracted maternal pelvis
what type of prego is breech MC?
multiple
what are some congenital malformations associated with breech?
fetus may prevent the other from turning
6% of breech → Congenital Malformations → Congenital hip dislocation, hydrocephalus, anencephalus, familial dysautonomia, spina bifida, meningomyelocele, and chromosomal trisomies 13, 18, and 21 → conditions that alter fetal muscular tone and mobility increase the likelihood of breech presentation
s/sx in breech position?
Palpation & Ballottement → Performance of Leopold’s maneuvers & manual ballottement of uterus through maternal abdominal wall may confirm breech presentation
*Softer, more ill-defined breech may be felt in the lower uterine segment above the pelvic inlet
**Dx error common if these alone used to determine presentation
what will one find on a pelvic exam during breech?
soft, irregular
complications of breech?
1) birth anoxia
2) birth injury
what is birth anoxia?
Umbilical cord compression and prolapse due to inabllity of presenting part to fill maternal pelvis
Compression of the prolapsed cord may occur during uterine contractions causing moderate to severe variable decelerations in the fetal HR and leading to fetal anoxia or death
birth injuries?
13x more likely with breech vaginal delivery
what are types of birth injuries?
Tears in the tentorium cerebellum, cephalohematomas, disruption of the spinal cord, brachial palsy, fracture of the long bones, rupture of the SCM muscles
what are common injuries associated w/ vag birth delieveries?
Main cause of injuries to fetal adrenal glands, liver, anus, genitalia, spine, hip joint, sciatic nerve and musculature of the arms, legs and back
what facors contribute to a difficult vag breech delivery?
Partially dilated cervix, nuchal arms, deflexion of the head → Slow methodical delivery with gentleness & skill
how is a breech presentation mananged antepartum?
External Cephalic Version → Singleton breech or in non-vertex 2nd twin
what pts can get external cephalic version?
who have completed 36 wks to decrease spontaneous reversion
when is external cephalic versio n the most successful
multi-gravidas, those with transverse or oblique lie & those with posterior placenta
what are contraindications for external cephalic version?
Engagement of the presenting part in the pelvis, marked oligohydramnios, placenta previa, uterine anomalies, presence of nuchal cord, multiple gestation, premature rupture of membranes, previous uterine surgery & suspected or documented congenital malformations or abnormalities
what are complications of external cephalic version?
Rare → Include placental abruption, uterine rupture, rupture of membranes with resultant umbilical cord prolapse, amniotic fluid embolism, preterm labor, fetal distress, fetomaternal hemorrhage, and fetal demise
** really should only be performed in a hospital
what is the external cephalic version procedure?
Tocolytic administered to prevent contractions or irritability → Anesthesia also administered if desired → Both of the operator’s hands are placed on the patient’s abdomen and a forward roll is attempted by lifting the breech upward while placing pressure on the head downward toward the pelvis → If this maneuver is unsuccessful, a backward roll can be attempted.
vag delivery of breech babies?
5x higher mortality rate in comparison to cephalic presentation → C-section = Much more common in breech presentation → ACOBGyn recommends planned C sections for persistent breech presentations
umbilical cord prolapse
Defined as descent of the umbilical cord into the lower uterine segment
occult cord prolapse
adjacent to the preseing part
*cord can’t be palpated during physical exam
funic presentation?
by prolapse of the umbilical cord below the level of the presenting part before the rupture of membranes occurs, the cord often can be easily palpated through the membranes
overt cord prolapse
lies below the presenting part
what complications is overt cord prolaps associated with?
with rupture of the membranes and displacement of the umbilical cord into the vagina, often through the introitus
is cord prolapse an emergency?
heck yes
why is cord prolapse an emergency?
1) prolapse to a level at or below the presetting part exposes cord to intermittent compression btw the presenting part and pelvic inlet, cervix, or vag canal
2) compression of cord compromises fetal circulation and, depending on the duration and intensity of compression, may lead to fetal hypoxia, brain damage, and death.
3) overt cord prolapse, exposure of the umbilical cord to air causes irritation and cooling of the cord → Resulting in further vasospasm of the cord vessels
just remember
Prematurity, itself a contributor to the incidence of umbilical cord prolapse, accounts for a considerable portion of this perinatal loss
what is the PP of cord prolapse?
1) Any obstetric condition that predisposes to poor application of the fetal presenting part to the cervix
what disorders is cord prolapse associated with
prematurity (<34 weeks’ gestation),
- abnormal presentations (breech, brow, compound, face, transverse),
-occiput posterior positions of the head,
-pelvic tumors,
-multiparity,
-placenta previa,
-low-lying placenta,
-and cephalopelvic disproportion
polyhydramnios, multiple gestation, or premature rupture of the membranes occurring before engagement of the presenting part
preventing cord prolapse
Patients at risk for umbilical cord prolapse should be treated as high-risk patients
Artificial rupture of membranes should be avoided until the presenting part is well applied to the cervix
At the time of spontaneous membrane rupture, a prompt, careful pelvic examination should be performed to rule out cord prolapse
s/sx of cord prolapse: overt
vert cord prolapse can be diagnosed simply by visualizing the cord protruding from the introitus or by palpating loops of cord in the vaginal canal
x/sx funic cord prolapse
elvic examination if loops of cord are palpated through the membranes
s/sx of occult
rarely palpated during pelvic examination → This condition can be inferred only if fetal heart rate changes (variable decelerations, bradycardia, or both) associated with intermittent compression of the umbilical cord are detected during monitoring
maternal complications of cord prolapse
C-Section = Major operative procedure w/ known anesthetic, hemorrhagic & op complications
vaginal delivery include laceration of the cervix, vagina, or perineum resulting from a hastily performed delivery
fetal complications of prolapse
fetus in good condition whose well-being is jeopardized by umbilical cord compression may exhibit violent activity
what will happen to baby if prolapse is complete and prolonged
fetal bradycardia occurs → Persistent, severe, variable decelerations and bradycardia lead to development of hypoxia, metabolic acidosis, and eventual damage or death → As the fetal status deteriorates, activity lessens and eventually ceases
Meconium staining of the amniotic fluid may be noted at the time of membrane rupture
overt cord prolapse tx
Immediate pelvic examination performed to determine cervical effacement and dilatation, station of the presenting part, and strength and frequency of pulsations within the cord vessels.
1) pt in knee-chest positions w/ application of continuous upward pressure againse preseting part to lift and maintain fetus away from prolapsed cord
2) Abdominal delivery should be accomplished as rapidly as possible through a generous midline abdominal incision, a
what other tx can be used for overt?
, 400–700 mL of saline can be instilled into the bladder in order to elevate the presenting part.
occult cord tx
cord compression patterns (variable decelerations) of the fetal heart rate are recognized during labor→ Immediate pelvic examination performed to rule out overt cord prolapse
1) patient placed in lateral Sims or Trendelenburg position in attempt to alleviate cord compression → If the fetal heart rate returns to normal, labor can be allowed to continue, provided no further fetal insult occurs
2) Amnioinfusion can be performed via an intrauterine pressure catheter in order to instill fluid within the uterine cavity and possibly decrease the incidence of variable decelerations.
3) If the cord compression pattern persists or recurs to the point of fetal jeopardy (moderate to severe variable decelerations or bradycardia) → Rapid caesarean section
funic presentation tx
c section prior to rupture: hospitalize and monitor w/ serial US
what is the route of choice for a previable or dead feturs?
vag
