L&D Complications

Question 1

Preterm labor

Answer 1

Labor before 37 wks; preterm ctx / pain (vs cervical insufficiency)

Question 2

Risk of preterm labor

Answer 2

High risk of small baby (IUGR, SGA = small for gestational age, whereas LBW = < 2500 g)

Question 3

Preterm labor is associated with:

Answer 3

PROM, chorioamnionitis, multiple gestations, uterine anomalies, previous preterm delivery, small mom,
abruption, PEC / maternal infection, surgery, low SES

Question 4

If preterm labor + fever, need to:

Answer 4

Do amniocentesis to rule out chorioamnionitis before giving steroids for lung maturity

Question 5

Preterm contraction management

Answer 5

Don’t do tocolysis unless there’s cervical change (no labor unless the cervix is changing). Instead, observe.

Question 6

What is the point of tocolysis

Answer 6

xTrying to buy yourself 48h for betamethasone if < 34 wks for lung maturity

Question 7

Beta-mimetics

Answer 7

Ritodrine (is only FDA approved tocolytic) - continuous IV
Terbutaline - load, then q3-4h

increases ATP → cAMP

Question 8

SE/CI of beta-mimetics

Answer 8

SE: Tachycardia, H/A, anxiety, pulmonary edema
CI: diabetes

Question 9

SE/CI of Mag Sulfate

Answer 9

SE: Flushing, H/A, fatigue, diplopia, Lose DTRs (<10), respiratory depression, hypoxia → cardiac arrest (>15)
Contraindicated in myasthenia gravis

Question 10

Mag Sulfate

Answer 10

“tocolytic” but no evidence that it actually delays anything

Ca+ antagonist

Question 11

Ca-channel blockers

Answer 11

Nifedipine

SE: H/A, flushing, dizziness

Question 12

Prostaglandin inhibitors

Answer 12

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

Question 13

Benefits of Betamethasone

Answer 13

RDS prevention
Decreased intracerebral hemorrhage and necrotizing enterocolitis in the newborn

It has not been associated with increased infection or enhanced growth.

Question 14

PROM

Answer 14

> 1h prior to labor
biggest risk is for chorio
Often induce if > 34-36 wks

Question 15

prolonged PROM

Answer 15

> 18h = prolonged PROM

chorio risk increased > 18h; give abx ppx if expecting prolonged ROM

Question 16

PPROM

Answer 16

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

Question 17

Management of PPROM

Answer 17

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

Question 18

Types of malpresentation

Answer 18

Vertex malpresentation
Breech
Cephalopelvic Disproportion

Question 19

Cephalopelvic disproportion management

Answer 19

CPD and even macrosomia → can try TOL → but if failure to progress → C/S!

Question 20

Breech: frank, complete, footling

Answer 20

Frank = feet up by head
Complete = feet “indian style”
Footling = one foot extended

Question 21

How do you diagnose breech?

Answer 21

Dx by U/S, Leopold’s, etc

Question 22

Management of breech

Answer 22

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.

Question 23

VTX malpresentation

Answer 23

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

Question 24

Risks for shoulder dystocia:

Answer 24

Increases with fetal macrosomia, cDM/gDM, previous shoulder, obesity, postterm, prolonged 2nd stage

Question 25

Complications of shoulder dystocia

Answer 25

Erb palsy / brachial plexus injury, humerus / clavicle fx, phrenic nerve palsy, hypoxic brain injury, death.

Question 26

Diagnosis of shoulder dystocia

Answer 26

Turtle sign after prolonged crowning of head

Question 27

Management of shoulder dystocia

Answer 27

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!)

Question 28

Maternal hypotension ddx

Answer 28

Vasovagal, regional anesthesia, overtx with antiHTN drugs, hemorrhage, anaphylaxis, amniotic fluid embolism (high mortality, find fetal cells in pulmonary vasculature at autopsy)

Question 29

Seizures on L&D:

Answer 29

ABCs, assess FHR, then Mag Sulfate bolus → lorazepam → phenytoin → phenobarb