L&D Complications Flashcards
Complications of Labor & Delivery
Preterm labor Group B strep Failure to progress Umbilical cord prolapse Shoulder Dystocia Breech Delivery Retained Placenta Uterine inversion Post-Partem Hemorrhage (PPH)
Define Preterm Labor
Prior to 37 weeks
Most common perinatal morbidity & mortality in U.S.
Regular uterine contractions associated with cervical change
Risk Factors for Preterm Labor
Multiple gestation Prior preterm birth Preterm uterine contractions Premature maternal pre-pregnancy weight Smoking Substance abuse Short inter pregnancy interval Infection: UTI, genital tract periodontal disease
Pathophysiology of Preterm Labor
Activation of maternal or fetal hypothalamic-pituitary-adrenal axis due to maternal or fetal stress
Decidual-chorioamniotic or systemic inflammation caused by infection
Decidual hemorrhage
Pathologic uterine distension
Example of Decidual Hemorrhage
Abruption
Pathologic Uterine Distension
Multiple pregnancy
Polyhydramnios
Uterine abnormality
Signs & Symptoms of Preterm Labor
Menstrual like cramps
Low, dull backache
Pelvic pressure
Abdominal cramping with or without diarrhea
Increase or change in vaginal discharge: mucus, water, light bloody discharge
Uterine contractions
Evaluation of Preterm Labor
Fetal monitoring UA Test for group B strep CBC Ultrasound Amniocentesis
Management of Preterm Labor
Primary goal: delay delivery until maturity attained
Detection & treatment of underlying disorder
Therapy
Define Tocolytics
Medications that stop preterm labor
Tocolytic Medications
Calcium Channel Blockers (nifedipine)
NSAIDS (indocin)
B-adrenergic receptor agonists (terbutaline)
Magnesium sulfate
Contraindications to Tocolytics
Advance labor* Mature fetus* Severely abnormal fetus or fetal demise Intrauterine infection Significant vaginal bleeding Severe pre-eclampsia or eclampsia Placental abruption Advanced cervical dilation Fetal compromise Placental insufficiency
Corticosteroids
24-34 weeks gestation (pre-mature labor)
For lung maturity
Dosing over 48 hours
Corticosteroids Reduce
Fetal respiratory distress
Intraventricular hemorrhage
Necrotizing enterocolitis
Group B Strep
Screening between 35-36 weeks gestation
If positive: prophylactic antibiotic during labor or premature rupture of membranes
Mother with prior GBS infection in infant
Group B Strep Antibiotic Prophylaxis
PenG
Best if 4 hours prior to delivery
Group B Strep Antibiotic Prophylaxis if Penicillin Allergy
Cefazoline (no anaphylaxis to PCN)
Clindamycin
Vancomycin
What does Group B strep colonization prevent in the mother?
Postpartum endometritis, sepsis, & meningitis
Define Dystocia
Lack of progressive cervical dilation or lack of descent of fetal head in birth canal or both
What does dystocia lead to?
C-section
How to evaluate the progression of labor?
Uterus contracting accurately? What is the fetal position? Indication of cephalopelvic disproportion? Fetal status? Concern for chorioaminonitis?
Progression of Labor
Nulliparous: 1 cm/hr
Multiparoud: 1.5 cm/hr
Management of Delay of Labor
Observation
Augmentation: amniotomy, oxytocin
Caesarian section: maternal/fetal distress, unstable condition of mother
Amniotomy
Manual rupture of membranes with “hook”
Risks of Amniotomy
Fetal heart rate deceleration due to cord compression
Increased incidence of chorioamnioitis
Oxytocin
Increases uterine activity (contractions) which in turn should result in cervical change & descent
Risks of Oxytocin
Hypertonic uterus
Avoid more than 5 contractions in 10 minutes (causes decreased blood flow to fetus)
Indications for a C-Section
Failure to progress during labor* Non-reassuring fetal status* Fetal malpresentation* Abnormal placentation Maternal infection Multiple gestation Fetal bleeding diathesis Umbilical cord prolapse Macrosomia Obstruction of birth canal Uterine rupture
Methods of Assisted Vaginal Delivery
Forceps
Vacuum extraction
Mother’s pushing & contractions are insufficient to deliver the infant
Sudden onset of severe maternal or fetal compromise & mother is fully dilated & effaced
Complications of Forceps
Mother: perioneal trauma, hematoma, pelvic floor injury
Baby: injuries to brain or spine, MSK injury, corneal abrasion, shoulder dystocia
Complications of Vacuum
Mother: less trauma than forceps
Baby: intracranial hemorrhage, subgaleal hematoma, scalp laceration, hyperbilirubinemia, retinal hemorrhage, cephalohematoma
Umbilical Cord Prolapse
Precedes the presenting part
Pressure on the cord causes fetal bradycardia and can eventually cause fetal demise
Umbilical Cord Prolapse Management
Prompt delivery usually by c-section
Maneuvers to reduce cord pressure
Maneuvers to Reduce Cord Pressure
Examiner’s hand in vagina to elevate presentation part of the cord while arrangements made for emergency c-section
Patient placed in steep trendelenberg
Filling the bladder with NS
Give tocolytic to stop contractions
Define Shoulder Dystocia
Need for additional obstetric maneuvers to effect delivery of the shoulders at the time of vaginal birth
Diagnosis of Shoulder Dystocia
Fetal head retracts into the perineum after expulsion (Turtle’s sign)
When gentle, downward traction of the fetal head fails to accomplish delivery of the anterior shoulder
Shoulder Dystocia Management
Excessive neck rotation, head & neck traction & fundal pressure should be avoided Drain distended bladder McRoberts maneuver Suprapubic pressure Rubin maneuver Delivery of the posterior arm
Define McRoberts Maneuver
Extreme flexion of the hips
Define Suprapubic Pressure
Directing pressure on the anterior should downward away from the pubic bone
Define Rubin Maneuver
Adduction of the fetal shoulder, displacing them from the anteroposterior diameter
Delivery of the Posterior Arm (Barnum Maneuver)
Best under adequate anesthesia
Introduce hand into vagina & locate posterior arm & shoulder
Follow it to elbow, flex elbow across fetal chest
Grasp forearm & arm is then pulled out of vagina
Greatest risk is fracture of the humerus
Shoulder Dystocia Management
McRoberts & suprapuic pressure
Place mother on hands & knees
3 Different Presentations of Breech Babies
Frank breech
Complete breech
Incomplete breech
Define Frank Breech
Hips flexed/knees extended
Define Complete Breech
Hips & knees flexed
Define Incomplete Breech
One or both hips extended (foot or feet first)
External Cephalic Version Procedure
Done in final trimester Monitor fetus Often given uterus relaxants Perform cephalic version Monitor mom & baby Give Rhogam if mother Rh negative
Risks of External Cephalic Version
Transient fetal HR changes Fetomaternal transfusion Emergency cesarean delivery Vaginal bleeding Ruptured membranes Fetal death Placental abruption Cord prolapse
Define Retained Placenta
Placenta that has not been expelled 30-60 minutes after delivery of the baby
Pharmacologic Interventions of a Retained Placenta
IV nitroglycerin (monitor BP) Intraumbilical injection of oxytocin solution in saline
Manual Removal of a Retained Placenta
Follow umbilical cord into lower uterine segment with hand
Other hand holds fundus
Hand inside the uterus frees remaining placenta
Define Uterine Inversion
Uterine fundus collapses into the endometrial cavity
Treatment of Uterine Inversion
Summon assistance Large bore IV access for fluids Uterine relaxation: magnesium sulfate, terbutaline, nitroglycerin Manual correction Removal of placenta Uterotonic agents
Normal Pathophysiology of Uterine Hemostasis
Contraction of myometrium to compress blood vessels
Local decidual hemostatic factors: tissue factor, plasminogen activator inhibitor, platelets, circulating clotting factors
Causes of PPH
Incomplete placental separation: retained placenta or membranes
Ineffective myometrial contraction (ATONY)
Bleeding diatheses: failure to clot
PPH Diagnosis
Excessive bleeding
Results in light-headedness, vertigo, syncope, hypovolemia
PPH Management
Fundal massage
IV access: fluid & blood; draw for type & cross
Ultrasound: looking for debris
Uterotonic Drugs: oxytocin, misoprostol SL or PR, methylergonovine IM, carboprost tromethamine
Secondary Management of PPH
Taken to OR room
Provide adequate anesthesia
Explore uterus & remove retained fragments or fetal membranes
Inspect for & repair cervical & vaginal lacerations
Bakri tamponade: similar to massive tampon
