L&D Complications Flashcards
which type of breech presentation is MC
frank breech
Frank breech
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)
complete breech
the knees are pulled to the chest and knees are bent as in the fetal position (both hips and knees are flexed)
incomplete breech
either one or both hips are not completely flexed.
double footling breech presentation = both hips are not flexed
second MC breech presentation
incomplete breech
nonfrank breech
one or both feet present between the buttocks and birth canal
Risk factors for a breech presentation
early gestational age, uterine abnormality, multiparity, multiple gestation, and older maternal age
where may women w babies in frank position report kicking
lower pelvis
definitive dx breech presentation
US
what might you feel on exam if breech presentation is present
Once the cervix begins to dilate, a soft mass may be identified, as the buttock is in place of a harder fetal skull
available tx option For women presenting with breech presentation at term
external cephalic version
External cephalic version
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
success rate of External cephalic version
60%
Complications of External cephalic version
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
what if external cephalic version is unsuccessful
most women with breech presentation will undergo cesarean section, which significantly reduces the risk of morbidity and mortality to both mother and fetus
What is the maximum fetal weight recommended for low-risk women who elect a planned vaginal breech birth?
3,800 g
Shoulder dystocia
an acute obstetric emergency that occurs when the fetal shoulder becomes impacted behind the pubic symphysis after delivery of the head
when should a dx of shoulder dystocia be suspected
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
how can shoulder dystocia be confirmed
The diagnosis can be confirmed when gentle, downward traction of the fetal head fails to deliver the anterior shoulder
complications of shoulder dystocia
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
what is the first maneuver that should be attempted for shoulder dystocia
McRoberts maneuver
McRoberts maneuver
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
what is McRoberts maneuver doesn’t work
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
last resort strategy for shoulder dystocia
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
MC fetal injury shoulder dystocia
Transient brachial plexus injury
MC maternal injury shoulder dystocia
Hemorrhage and fourth-degree perineal lacerations
Most important risk factor for shoulder dystocia
high birth weight
RF shoulder dystocia
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
turtle sign
fetal head retracts into the perineum after expulsion
The best treatment of shoulder dystocia is
Preventative
Pregnancies likely to result in shoulder dystocia should be delivered by
cesarean delivery
C section delivery indications for shoulder dystocia prevention
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
success rate of McRoberts maneuver
50%
Gaskin maneuver
placing the patient on all fours
maneuvers to deliver the posterior shoulder
Woods screw and Rubin maneuvers
The most common indications for a C-section delivery
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.
category III tracing
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
What birth weight is fetal macrosomia defined by?
4,000–4,500 g, regardless of gestational age
Umbilical cord prolapse
umbilical cord presents before fetus
complications of umbilical cord prolapse
cord compression, occlusion, or vasospasm and compromise blood flow to and from the fetus, asphyxia, death
RF umbilical cord prolapse
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
PE umbilical cord prolapse
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
dx umbilical cord prolapse
diagnosis is based on visualization or palpation of the prolapsed umbilical cord
for umbilical cord prolapse - what can you use to identify position
US
for umbilical cord prolapse - what can you do to identify blood flow
doppler
is umbilical cord prolapse an emergency
yes
once you identify umbilical cord prolapse
prepare pt for c section
begin intrauterine resuscitation
intrauterine resuscitation techniques for umbilical cord prolapse
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)
factors affecting the outcome of umbilical cord prolapse
degree of cord compression, the lapsed time between identification of cord prolapse and delivery, and effective initiation and performance of intrauterine resuscitation maneuvers
Prelabor rupture of membranes (PROM) and what is it linked to
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
Risk factors associated with PROM
low socioeconomic status, low body mass index, tobacco use, history of preterm labor, urinary tract infections, vaginal bleeding, cerclage, and amniocentesis
sx PROM
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
what should be avoided in PROM
Digital vaginal examinations should be avoided until labor is initiated
dx PROM
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)
US PROM
absence of or very low amounts of amniotic fluid (Oligohydramnios)
tx PROM
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
What are some commonly used tocolytic drugs?
Magnesium sulfate, indomethacin, terbutaline, and nifedipine
Amniotic fluid has a pH of
7.0–7.3
Normal vaginal pH is
3.8–4.2
pH of urine
< 6
For PROM: if the nitrazine paper is yellow or green
PROM is unlikely
positive fern test
dried vaginal fluid produces a ferning pattern when placed on a glass slide and viewed with microscopy
Patients presenting with prelabor rupture of membrane usually deliver within
1 week
definitive tx PROM
delivery of fetus
the single most common identifiable risk factor for prelabor rupture of membranes (PROM)
a genital tract infection
preterm prelabor rupture of membranes (PPROM)
membrane rupture prior to the onset of uterine contractions before 37 weeks gestation
tx PPROM
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.
chorioamnionitis and what is it associated with
acute inflammation of the membranes and the chorion of the placenta. It usually occurs in association with ruptured membranes
RF chorioamnionitis
prolonged length of labor and prelabor rupture of membranes
sx chorioamnionitis
fever, uterine tenderness, purulent or malodorous amniotic fluid, maternal tachycardia, and fetal tachycardia
Fever is a sensitive finding for dx
Common lab finding in chorioamnionitis
leukocytosis
diagnostic criteria for chorioamnionitis
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.
presumptive diagnosis of chorioamnionitis
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
tx chorioamnionitis
prompt augmentation or induction of labor and antibiotics
is chorioamnionitis an indication for C section
no bc the risk of wound infection and endometritis is increased if cesarean delivery is performed
abx tx chorioamnionitis
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
maternal complications chorioamnionitis
postpartum endometritis, impaired myometrial contractility, uterine atony, and postpartum hemorrhage
neonatal complications chorioamnionitis
perinatal death, asphyxia, early-onset neonatal sepsis, septic shock, pneumonia, meningitis, and long-term neurodevelopmental delay
Which organisms most often cause bacteremia secondary to intra-amniotic infection?
Escherichia coli and group B Streptococcus
what confirms dx of chorioamnionitis
Needle aspiration and analysis of the amniotic fluid
