exam 2 - Complications of the intrapartum Flashcards
arrest of dilation
-w/p epidural anesthesia: no progress after 2hrs
-does not necessarily predict failed attempt at vaginal delivery
-may indicate the pt is not actually in labor -> may consider observation or sedation
management of arrest of dilation
-If the patient is actually in labor:
-Consider augmentation of labor
-Amniotomy:
-Artificial rupture of membranes (AROM)
-May speed labor
-May also cause cord prolapse or increase risk of infection
-Consider IV oxytocin administration
-Use of both oxytocin and AROM has been shown to reduce duration of labor by about 2 hours
-Continue to offer good support
-Nursing
-Midwives
-Family and friends
-Doula
arrest of descent
-If delivery is not accomplished by this time frame, the practitioner must determine why
-1. Is the fetus tolerating labor?
-2. Is there evidence of cephalopelvic disproportion? -> head too big
-A disparity between the maternal pelvis and the size of the fetal head that prevents vaginal delivery
-If fetus not tolerating labor, or if there is cephalopelvic disproportion -> 1 must move to deliver via some type of operative delivery:
-Caesarean section
-Vacuum delivery
-Forceps delivery
management of arrest of descent
-If fetus is tolerating labor and if there is no evidence of cephalopelvic disproportion, one may continue with attempted vaginal delivery
-If contractions are inadequate in strength or frequency, may consider IV oxytocin administration
contraindications to oxytocin administration
-category 2 or 3 tracing
-cephalopelvic disproportion
-placenta previa
-prematurity (unless risk is outweighed by benefit)
shoulder dystocia
-fetal body does not delivery within 1 min of delivery of the head OR
-special maneuvers are required to delivery the fetal body
-shoulder dystocia causes cord compression -> leads to hypoxia, acidemia, neurological injury, or death
-Occurs in 0.5-1.5% of deliveries
-RF: Poorly controlled GDM, Known macrosomia, Morbidly obese parturient, Parturient less than 62” tall, Rapid descent of fetus in preterm delivery
pathophysiology and sequelae of shoulder dystocia
-May result in:
-Humeral fracture
-Clavicular fracture
-Brachial plexus injury
-Erb’s palsy
-Neurological injury secondary to fetal hypoxia and acidosis
-Death
management of shoulder dystocia
-PREVENTION when possible
-Once it has occurred, do the following in this order:
-GET HELP!
-Generous episiotomy
-McRoberts maneuver!!!
-Suprapubic pressure!!!
-Woods screw maneuver
-May also consider Rubin and/or Gaskin maneuvers
-Zavanelli maneuver
-mcroberts and suprapubic pressure -> solve 90% of cases
wood screw maneuver
gaskin maneuver
zavanelli maneuver
-reverse all the cardinal movements
-put the fetus back -> OR
-tears the cervix -> clamp
-UNCOMMON
cord prolapse
-0.14-0.62% of deliveries
-cord is presenting part
-increased risk in:
-Prematurity
-Preterm premature rupture of membranes (PPROM)
-Rupture of membranes prior to labor in preterm (<37 weeks GA) fetus
-Malpresentation
-Identify prolapse
-GET HELP
-Mother in knee-chest position
-Wrap cord in saline soaked gauze
-Elevate cord to displace weight of presenting fetal part
-Emergent C/S!
breech presentation
-presenting part is the breech, a foot, or both feet
-Occurs in about 3-4% of pregnancies
-Risk factors:
-Multiple gestation
-Fetal anomalies - Hydrocephalus
-Uterine anomalies - Müllerian tract anomalies
-Most have elective C-sections scheduled at 39 weeks GA
-If known breech presentation presents prior to scheduled C/S in labor, or with ROM, the patient will usually undergo emergent C/S
confirmation of breech presentation
-presentation should be confirmed at prenatal visit at 36wks
-If a breech presentation is noted, schedule patient for external cephalic version (ECV) in which the fetus is manipulated through the parturient’s abdomen -> under sono guidance
-If successful, ECV will result in a vertex presentation and will prevent a Caesarean section
-if successful -> induce labor to avoid it flipping back (this is just an option)
external cephalic version
-may be performed with no anesthesia or under epidural or spinal anesthesia
-usually performed with tocolysis
-potential sequelae: <1%:
-abruptio placentae
-spontaneous rupture of membranes
-cord prolapse
-fetomaternal hemorrhage
A 37 yo female is postpartum hour #2 following normal spontaneous vaginal delivery of a 9 lb, 5 ounce neonate. She had a second degree laceration. Estimated blood loss at delivery was 300 cc.
She had undergone an induction of labor at 39 weeks, 3 days for advanced maternal age and had been in labor for 26 hours.
You are called to see her by the nurse, who reports the patient just bled about 500 cc. She tells you that the patient currently states she feels a little dizzy and that she looks pale
Past medical and surgical histories are noncontributory
She had undergone an induction of labor at 39 weeks, 3 days for advanced maternal age and had been in labor for 26 hours.
You are called to see her by the nurse, who reports the patient just bled about 500 cc. She tells you that the patient currently states she feels a little dizzy and that she looks pale
Past medical and surgical histories are noncontributory
-Uterine fundus
-Where is the fundus?
-Is it firm?
-Is the bladder empty?- full bladder can push the uterus up -> folley
-Cervix and vagina
-Are there any lacerations that weren’t noted previously?
-Perineum
-Is the laceration repair intact?
-foley catheter -> 1500cc urine
-US -> no POC
-no lacerations
-CBC:
On admission: 7.8>12.6/37.4<226
STAT CBC now: 5.9>9.8/29.5<193
Coagulation studies (PT/PTT, fibrinogen): normal for pregnancy
Estimate of current blood loss over last hour: 1000 cc
EBL at delivery: 300 cc
Total estimated blood loss, including at delivery: 1300 cc
-Your patient now says, “I feel much better.”
Your patient receives:
Lactated Ringer’s solution 2500 cc IV
40 units of oxytocin in Lactated Ringer’s solution 1000 cc IV
Misoprostol 1 gram PR x 1 dose
Methylergonovine 0.2 mg IM x 1 dose; may continue 0.2 mg PO Q6H for up to one week
MC pathophysiology for postpartum hemorrhage
-Defined as EBL of >1000 cc, or signs and symptoms of hypovolemia within 24 hours after delivery
-MCC of postpartum hemorrhage: uterine atony -> didnt clamp down
RF for postpartum hemorrhage
-Anything that decreases ability of the uterus to contract effectively
-Multiple gestation
-Post-term gestation
-Long labor
-Large fetus
-Polyhydramnios
-Grand multiparity
-Magnesium sulfate administration- relaxes
-And:
-Leiomyomata uteri
-Retained products
-Prior history of postpartum hemorrhage
post partum hemorrhage: labs
-CBC
-Coagulation studies
-Type and crossmatch
-US- Eval for evidence of retained products of conception
-estimated blood loss- Weigh Chux for most accurate estimate of blood loss
post partum hemorrhage: communication
-Communicate clearly with:
-Nursing staff
-Attending physician
-Covering physician
-Blood bank
-Rapid response team, if indicated
medical management of postpartum hemorrhage
-!!may be given in any order until there is a positive response
-Oxytocin 10-40 units in 500 or 1000 cc crystalloid solution IV wide open, OR 10 mg IM injection once if there is no IV access
-Prostaglandin E1: misoprostol 1 gram PR once
-Methylergonovine 0.2 mg IM every 2-4 hrs
-!!!!!!AVOID with hypertension
-Prostaglandin F2 alpha 250 mcg IM (repeat every 15-90 minutes x 8 doses)
-May also be given by myometrial injection at C/S or repeat laparotomy
-!!!!!!!!AVOID with asthma
medical management of postpartum hemorrhage: fluid resuscitation and blood products
-FLUID:
-Administer lactated Ringer’s solution IV at double the amount of blood loss, run in wide open
-BLOOD:
-If needed, order 2 units of packed red blood cells
-Each unit will raise Hgb by 1 gm, or Hct by 3%
massive transfusion protocol
-Massive transfusion protocol (6-4-1):
-6 units packed red blood cells (PRBCs)
-4 units fresh frozen plasma
-1 apheresis pack of platelets
-Use in case of unrelenting hemorrhage, for example, in the following circumstances:
-Active moderate bleeding
-SBP <80 mm Hg
-HR >120 bpm
-Arterial pH <7.1
-Base deficit > 6 mEq
-INR >2
-Fibrinogen <100 mg/dL
-Platelets <50,000/mm3
surgical management of postpartum hemorrhage
-Manual removal of placenta if retained products are identified on ultrasound
-Intrauterine balloon tamponade (Bakri balloon)
-B-Lynch suture
-Uterine artery ligation
-Hypogastric artery ligation
-Hysterectomy as last resort
Thickened endometrial stripe consistent with retained products of conception
bakri balloon
jada vacuum- induced hemorrhage control system
-suction within the uterus
-uterus contracts
B-lynch suture: “belt and suspenders”
-suture superiorly to inferiorly
-helps contract artificially
-dissolvable sutures
-can be done at section
chorioamnionitis
-Intrauterine infection prior to delivery
-Incidence: 9.7/1000 live births
-Increased risk with:
-PROM
-PPROM
-Signs and symptoms:
-Fever
-Fetal/maternal tachycardia
-Malodorous amniotic fluid
-Tender uterine fundus
-Management:
-CBC
-Consider blood C&S
-Acetaminophen
-Gentamicin, 2 mg/kg IV x 1 dose, then 1.5 mg/kg IV Q8H
-Ampicillin, 2 gm IV Q6H
-Continue until the patient is afebrile x 24 hours
-If the patient continues to be febrile after delivery, consider adding clindamycin
-complications:
-arrest of labor- uterus doesnt contract well
-postpartum hemorrhage
-postpartum endometritis
