L&D Complications Flashcards
Preterm labor
Labor before 37 wks; preterm ctx / pain (vs cervical insufficiency)
Risk of preterm labor
High risk of small baby (IUGR, SGA = small for gestational age, whereas LBW = < 2500 g)
Preterm labor is associated with:
PROM, chorioamnionitis, multiple gestations, uterine anomalies, previous preterm delivery, small mom,
abruption, PEC / maternal infection, surgery, low SES
If preterm labor + fever, need to:
Do amniocentesis to rule out chorioamnionitis before giving steroids for lung maturity
Preterm contraction management
Don’t do tocolysis unless there’s cervical change (no labor unless the cervix is changing). Instead, observe.
What is the point of tocolysis
xTrying to buy yourself 48h for betamethasone if < 34 wks for lung maturity
Beta-mimetics
Ritodrine (is only FDA approved tocolytic) - continuous IV
Terbutaline - load, then q3-4h
increases ATP → cAMP
SE/CI of beta-mimetics
SE: Tachycardia, H/A, anxiety, pulmonary edema
CI: diabetes
SE/CI of Mag Sulfate
SE: Flushing, H/A, fatigue, diplopia, Lose DTRs (<10), respiratory depression, hypoxia → cardiac arrest (>15)
Contraindicated in myasthenia gravis
Mag Sulfate
“tocolytic” but no evidence that it actually delays anything
Ca+ antagonist
Ca-channel blockers
Nifedipine
SE: H/A, flushing, dizziness
Prostaglandin inhibitors
Indomethacin
Don’t use close to term (PDA closure)
Also pulm HTN, oligo 2/2 renal failure, increased risk necrotizing enterocolitis & intraventricular hemorrhage
NSAIDs - block COX
Benefits of Betamethasone
RDS prevention
Decreased intracerebral hemorrhage and necrotizing enterocolitis in the newborn
It has not been associated with increased infection or enhanced growth.
PROM
> 1h prior to labor
biggest risk is for chorio
Often induce if > 34-36 wks
prolonged PROM
> 18h = prolonged PROM
chorio risk increased > 18h; give abx ppx if expecting prolonged ROM
PPROM
PROM < 37 wks EGA
Gush of fluid; dx with pool / fern / nitrazine → tampon test if unsure
Risk of chorio starts to outweigh risk of lung immaturity between 32-36 wks; management varies
Management of PPROM
Antibiotics can prolong latency up to 5-7 days, so give ampicillin +/- erythromycin
Tocolysis - consider if < 34 wks (controversial in pprom esp without preterm labor
Corticosteroids - consider if prior to 32 weeks usually
If at 36 weeks or so, just induce
Types of malpresentation
Vertex malpresentation
Breech
Cephalopelvic Disproportion
Cephalopelvic disproportion management
CPD and even macrosomia → can try TOL → but if failure to progress → C/S!
Breech: frank, complete, footling
Frank = feet up by head Complete = feet “indian style” Footling = one foot extended
How do you diagnose breech?
Dx by U/S, Leopold’s, etc
Management of breech
Can try external cephalic version (ECV) after 36-37 wks (spontaneous version would happen before); if fails, may retry @ 39wks under epidural anesthesia
Trial of breech vaginal delivery - not so much in the USA. Definitely can’t try if nullip, incomplete breech, EFW > 3,800
C/S is pretty much what happens.
VTX malpresentation
Face: if mentum anterior, may be able to do vaginal delivery; o/w must rotate, careful with augmentation (pressure → edema)
Brow: unless preterm & really small head, must convert to vtx or face to deliver
Shoulder: unless conversion, go for C/S (high risk cord prolapse, rupture, difficult delivery)
Compound:(extremity along with vtx or breech): cord prolapse risk! Can try to reduce, but careful
Persistent LOT / ROT (occiput transverse) or OP - may need operative vaginal delivery or manual rotation
Risks for shoulder dystocia:
Increases with fetal macrosomia, cDM/gDM, previous shoulder, obesity, postterm, prolonged 2nd stage
Complications of shoulder dystocia
Erb palsy / brachial plexus injury, humerus / clavicle fx, phrenic nerve palsy, hypoxic brain injury, death.
Diagnosis of shoulder dystocia
Turtle sign after prolonged crowning of head
Management of shoulder dystocia
McRoberts / suprapubic pressure, call peds, Rubin (push shoulder across fetal chest), Wood’s corckscrew (sweep behind post shoulder → rotate, dislodge ant shoulder), deliver posterior arm/ shoulder.
If that fails, then crazy stuff considered: break fetal clavicle, symphysiotomy, or Zavanelli (shove baby’s
head back inside & head for the OR!)
Maternal hypotension ddx
Vasovagal, regional anesthesia, overtx with antiHTN drugs, hemorrhage, anaphylaxis, amniotic fluid embolism (high mortality, find fetal cells in pulmonary vasculature at autopsy)
Seizures on L&D:
ABCs, assess FHR, then Mag Sulfate bolus → lorazepam → phenytoin → phenobarb
