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EOR OB/GYN > L&D Complications > Flashcards

L&D Complications Flashcards

1
Q

which type of breech presentation is MC

A

frank breech

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2
Q

Frank breech

A

the buttock is the presenting surface and both feet are pulled up to the chest in the pike position (hips are flexed and both knees extended)

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3
Q

complete breech

A

the knees are pulled to the chest and knees are bent as in the fetal position (both hips and knees are flexed)

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4
Q

incomplete breech

A

either one or both hips are not completely flexed.

double footling breech presentation = both hips are not flexed

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5
Q

second MC breech presentation

A

incomplete breech

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6
Q

nonfrank breech

A

one or both feet present between the buttocks and birth canal

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7
Q

Risk factors for a breech presentation

A

early gestational age, uterine abnormality, multiparity, multiple gestation, and older maternal age

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8
Q

where may women w babies in frank position report kicking

A

lower pelvis

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9
Q

definitive dx breech presentation

A

US

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10
Q

what might you feel on exam if breech presentation is present

A

Once the cervix begins to dilate, a soft mass may be identified, as the buttock is in place of a harder fetal skull

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11
Q

available tx option For women presenting with breech presentation at term

A

external cephalic version

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12
Q

External cephalic version

A

a technique used to maneuver the fetus into a cephalic position from a breech position. The technique involves the administration of a beta-adrenergic receptor agonist to relax the uterus. The clinician then attempts to maneuver the fetus into a cephalic presentation via a backward or forward somersault. The procedure may be repeated up to four times in one sitting

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13
Q

success rate of External cephalic version

A

60%

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14
Q

Complications of External cephalic version

A

Complications of the procedure are rare but include fetal heart rate changes, emergency cesarean delivery, vaginal bleeding, rupture of membranes, placental abruption, and fetal death

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15
Q

what if external cephalic version is unsuccessful

A

most women with breech presentation will undergo cesarean section, which significantly reduces the risk of morbidity and mortality to both mother and fetus

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16
Q

What is the maximum fetal weight recommended for low-risk women who elect a planned vaginal breech birth?

A

3,800 g

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17
Q

Shoulder dystocia

A

an acute obstetric emergency that occurs when the fetal shoulder becomes impacted behind the pubic symphysis after delivery of the head

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18
Q

when should a dx of shoulder dystocia be suspected

A

This diagnosis should be initially suspected when the fetal head retracts past the perineum after delivery secondary to reverse traction from the shoulders at the pelvic inlet

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19
Q

how can shoulder dystocia be confirmed

A

The diagnosis can be confirmed when gentle, downward traction of the fetal head fails to deliver the anterior shoulder

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20
Q

complications of shoulder dystocia

A

fetal asphyxia and cortical damage secondary to umbilical cord compression and impeded inspiration

Transient brachial plexus injury is the most frequently reported adverse event with less common events, including clavicular fracture, humerus fracture, permanent brachial plexus palsy, hypoxic-ischemic encephalopathy, and death

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21
Q

what is the first maneuver that should be attempted for shoulder dystocia

A

McRoberts maneuver

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22
Q

McRoberts maneuver

A

This maneuver consists of flexing the maternal thighs toward the abdomen to rotate the symphysis pubis and flatten the sacrum, thereby reducing the prominence of the sacral promontory.

Suprapubic pressure can be applied in conjunction with the McRoberts maneuver if initial attempts are unsuccessful

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23
Q

what is McRoberts maneuver doesn’t work

A

alternative initial strategies include delivery of the posterior shoulder and the Menticoglou maneuver with axillary traction used to deliver the posterior shoulder. Secondary maneuvers include the Rubin maneuver, Woods screw maneuver, and clavicular fracture

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24
Q

last resort strategy for shoulder dystocia

A

Gunn-Zavanelli-O’Leary maneuver is a last-resort strategy performed by replacing the fetal head within the pelvis and delivering the fetus via cesarean section

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25
Q

MC fetal injury shoulder dystocia

A

Transient brachial plexus injury

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26
Q

MC maternal injury shoulder dystocia

A

Hemorrhage and fourth-degree perineal lacerations

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27
Q

Most important risk factor for shoulder dystocia

A

high birth weight

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28
Q

RF shoulder dystocia

A

weight over 4,000 g, maternal diabetes mellitus, previous shoulder dystocia, excess maternal weight gain during pregnancy, post-term pregnancy, and male fetus

Each of the risk factors is related to underlying high birth weight

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29
Q

turtle sign

A

fetal head retracts into the perineum after expulsion

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30
Q

The best treatment of shoulder dystocia is

A

Preventative

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31
Q

Pregnancies likely to result in shoulder dystocia should be delivered by

A

cesarean delivery

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32
Q

C section delivery indications for shoulder dystocia prevention

A

This includes an antepartum estimated fetal weight of more than 5,000 g in a woman without maternal diabetes or an estimated fetal weight of more than 4,500 g in a woman with maternal diabetes. Furthermore, induction may be offered to women with diabetes at 39 weeks and an estimated fetal weight between 4,000–4,500 g

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33
Q

success rate of McRoberts maneuver

A

50%

34
Q

Gaskin maneuver

A

placing the patient on all fours

35
Q

maneuvers to deliver the posterior shoulder

A

Woods screw and Rubin maneuvers

36
Q

The most common indications for a C-section delivery

A

shoulder dystocia, abnormal fetal heart rate tracing, fetal malpresentation, and multiple gestation

Fetal malpresentations such as transverse lie or breech presentations that persist after unsuccessful external cephalic version

Twin gestations in which twin A is noncephalic, the gestational age is < 28 weeks, or twin B is noncephalic with an estimated fetal weight of < 1,500 g

Any gestations with more than two fetuses are an indication for a C-section.

37
Q

category III tracing

A

sinusoidal pattern on fetal heart rate tracing or absent baseline fetal heart rate variability with recurrent late decelerations, recurrent variable decelerations, or bradycardia

necessitates emergent delivery or C-section

38
Q

What birth weight is fetal macrosomia defined by?

A

4,000–4,500 g, regardless of gestational age

39
Q

Umbilical cord prolapse

A

umbilical cord presents before fetus

40
Q

complications of umbilical cord prolapse

A

cord compression, occlusion, or vasospasm and compromise blood flow to and from the fetus, asphyxia, death

41
Q

RF umbilical cord prolapse

A

malpresentation of the fetus such as frank breech, prematurity, low birth weight, uterine malformation, multiparity, long umbilical cord, prolonged labor, or an unengaged body part

42
Q

PE umbilical cord prolapse

A

Physical exam will reveal the prolapse cord visually or the cord may be palpated on cervical check. Additionally, fetal heart rate changes may occur if the cord is compromised. These include prolonged episodes of bradycardia or severe decelerations

43
Q

dx umbilical cord prolapse

A

diagnosis is based on visualization or palpation of the prolapsed umbilical cord

44
Q

for umbilical cord prolapse - what can you use to identify position

A

US

45
Q

for umbilical cord prolapse - what can you do to identify blood flow

A

doppler

46
Q

is umbilical cord prolapse an emergency

A

yes

47
Q

once you identify umbilical cord prolapse

A

prepare pt for c section
begin intrauterine resuscitation

48
Q

intrauterine resuscitation techniques for umbilical cord prolapse

A

manual elevation of the presenting part compressing the cord (most common), placing the patient in the Trendelenburg position or knee to chest, retrofilling the bladder (which works to elevate the presenting part compressing the cord), or administering a tocolytic (to reduce pressure on the cord caused by uterine contractions)

49
Q

factors affecting the outcome of umbilical cord prolapse

A

degree of cord compression, the lapsed time between identification of cord prolapse and delivery, and effective initiation and performance of intrauterine resuscitation maneuvers

50
Q

Prelabor rupture of membranes (PROM) and what is it linked to

A

patient who is more than 37 weeks gestation and whose membranes rupture before labor begins

It is thought to be linked to inflammation or infection of the membranes

51
Q

Risk factors associated with PROM

A

low socioeconomic status, low body mass index, tobacco use, history of preterm labor, urinary tract infections, vaginal bleeding, cerclage, and amniocentesis

52
Q

sx PROM

A

leakage of fluid (that is clear and odorless but may be tinged with blood or mucus), vaginal discharge, vaginal bleeding, and pelvic pressure, all without contractions. The leakage of fluid may present as a sudden gush of fluid or a slow leak of small amounts of fluid

53
Q

what should be avoided in PROM

A

Digital vaginal examinations should be avoided until labor is initiated

54
Q

dx PROM

A

Ruptured membranes are diagnosed by sterile speculum vaginal examination of the cervix, with noted leakage from the cervix and pooling of fluid in the vagina being the most accurate for diagnosis. If no fluid is visualized, asking the patient to perform a Valsalva maneuver may cause leaking to resume – essentially you need direct visualization of leaking amniotic fluid

Other methods of confirmation include microscopic examination of the fluid (which will show ferning), and Nitrazine paper test (which will turn from orange to blue if amniotic fluid is present)

55
Q

US PROM

A

absence of or very low amounts of amniotic fluid (Oligohydramnios)

56
Q

tx PROM

A

medical induction with oxytocin and prompt delivery, since the risk of intrauterine infection increases with the duration of ruptured membranes. If labor or vaginal delivery is contraindicated, a caesarean section should be considered next. Waiting for spontaneous labor to begin (i.e., expectant management) not only increases chances of infection, but also increases the risk of serious complications such as cord prolapse or abruption. However, for women who choose expectant management over labor induction, a time limit should be agreed upon through the process of shared decision-making between the patient and the medical team involved

57
Q

What are some commonly used tocolytic drugs?

A

Magnesium sulfate, indomethacin, terbutaline, and nifedipine

58
Q

Amniotic fluid has a pH of

A

7.0–7.3

59
Q

Normal vaginal pH is

A

3.8–4.2

60
Q

pH of urine

A

< 6

61
Q

For PROM: if the nitrazine paper is yellow or green

A

PROM is unlikely

62
Q

positive fern test

A

dried vaginal fluid produces a ferning pattern when placed on a glass slide and viewed with microscopy

63
Q

Patients presenting with prelabor rupture of membrane usually deliver within

A

1 week

64
Q

definitive tx PROM

A

delivery of fetus

65
Q

the single most common identifiable risk factor for prelabor rupture of membranes (PROM)

A

a genital tract infection

66
Q

preterm prelabor rupture of membranes (PPROM)

A

membrane rupture prior to the onset of uterine contractions before 37 weeks gestation

67
Q

tx PPROM

A

Prompt induction of labor with oxytocin is the recommended course for unstable patients with PPROM and has better outcomes than expectant management if the patient is < 34 weeks gestation. Induction of labor is appropriate for stable patients with PPROM at ≥ 34 weeks gestation. Expectant management is appropriate for stable patients with PPROM at < 34 weeks gestation. These patients should be given a course of antenatal corticosteroids and prophylactic antibiotics and hospitalized until delivery. Unstable patients with intrauterine infection, abruptio placentae, nonreassuring fetal testing, and increased risk of uterine cord prolapse should undergo immediate delivery.

68
Q

chorioamnionitis and what is it associated with

A

acute inflammation of the membranes and the chorion of the placenta. It usually occurs in association with ruptured membranes

69
Q

RF chorioamnionitis

A

prolonged length of labor and prelabor rupture of membranes

70
Q

sx chorioamnionitis

A

fever, uterine tenderness, purulent or malodorous amniotic fluid, maternal tachycardia, and fetal tachycardia

Fever is a sensitive finding for dx

71
Q

Common lab finding in chorioamnionitis

A

leukocytosis

72
Q

diagnostic criteria for chorioamnionitis

A

The diagnosis of intra-amniotic infection is confirmed in patients with a fever (at or above 102.2°F or above 100.4°F twice at least 30 minutes apart) without another clear source. They must also have one or more of the following: purulent-appearing fluid coming from the cervical os visualized during speculum examination, maternal white blood cell count > 15,000/μL, and a baseline fetal heart rate of at least 160 bpm for at least 10 minutes. At least one of the following objective laboratory findings must also be present: positive Gram stain of amniotic fluid, positive amniotic fluid culture, low glucose level in amniotic fluid, high white blood cell count in amniotic fluid, and histopathologic evidence of infection or inflammation of the placenta, fetal membranes, or the umbilical cord vessels.

73
Q

presumptive diagnosis of chorioamnionitis

A

presumptive diagnosis of intra-amniotic infection can be made in patients with a fever and at least one of the following: purulent-appearing fluid coming from the cervical os visualized during speculum examination, maternal white blood cell count > 15,000/μL, and a baseline fetal heart rate of at least 160 bpm for at least 10 minutes

74
Q

tx chorioamnionitis

A

prompt augmentation or induction of labor and antibiotics

75
Q

is chorioamnionitis an indication for C section

A

no bc the risk of wound infection and endometritis is increased if cesarean delivery is performed

76
Q

abx tx chorioamnionitis

A

The recommended antibiotic regimen consists of IV ampicillin and gentamicin . Patients who have an indication for a cesarean delivery should also be treated with metronidazole or clindamycin to provide coverage against anaerobes

77
Q

maternal complications chorioamnionitis

A

postpartum endometritis, impaired myometrial contractility, uterine atony, and postpartum hemorrhage

78
Q

neonatal complications chorioamnionitis

A

perinatal death, asphyxia, early-onset neonatal sepsis, septic shock, pneumonia, meningitis, and long-term neurodevelopmental delay

79
Q

Which organisms most often cause bacteremia secondary to intra-amniotic infection?

A

Escherichia coli and group B Streptococcus

80
Q

what confirms dx of chorioamnionitis

A

Needle aspiration and analysis of the amniotic fluid

EOR OB/GYN (18 decks)

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