Labor Flashcards
What are risks and benefits w/ TOLAC?
Benefits: avoiding abdominal surgery and risks of hyst/bowel/bladder injury, faster recovery, lower pain, lower risk of VTE, lower rates of hemorrhage
Risks: hemorrhage, uterine rupture, failed TOLAC requiring CS. Overall elective CS has fewer risks than failed TOLAC.
What is SVD rate in women attempting TOLAC?
What are contra-indications to TOLAC
What is the risk of uterine rupture?
How would you manage a TOLAC on L&D?
60-80%
- contra-indications to vaginal delivery (fetal malpresentation, plc previa, vasa previa)
- prior classical/T-incision
- prior uterine rupture
- transfundal uterine surgery)
- prior SD
- prior abdominal myomectomy
1% risk after 1 CS. up to 3% if 2 CS
5-10% if prior classical or T-incision.
– How would you manage in labor? 1:1 nursing, In-house physician, Continuous fetal monitoring, recommend epidural anesthesia, active management of labor.
What TOLAC candidates are less likely to be successful?
-Macrosomia
- gestation >40wks
-prior CS for arrest of labor disorder
-undergoing IOL/augmentation
- AMA
-obesity
-shorter inter delivery interval (<19 mo).
What is the most common indicative sign of uterine rupture?
How do you manage subsequent pregnancy after uterine rupture?
FHR abnormality! Also Loss of fetal station, maternal pain out of proportion to exam, fetal bradycardia, vaginal bleeding.
Rate of repeat rupture is 15%.
Delivery timing between 36-37w.
- rupture risk is 6% for prior lower segment rupture, 32% for upper segment rupture, 10% prior classical.
How do you manage low uOP after CS?
Read op report (complications, adhesions, suspected bladder injury), vitals. See if pt has pain.
What tests to order? CBC, CMP, UA, FENA (less than 1% is pre-renal, - if >2%, its ATN), IVF bolus to evaluate for response. urine sodium and creatinine, CTAP.
What is the differential diagnosis for low UOP after CS?
cystotomy, hypovolemia, ureteral injury, post-surgical bleeding, ATN, kinked foley.
How do you repair a cystotomy?
Assess location of injury w/ respect to trigone.
Cystotomy in dome of bladder closed w/ continuous running 3-0 synthetic absorbable suture (PDS) through mucosa and submucosa in 2 layers. Then confirm integrity of repair: backfill sterile milk into foley catheter. Maintain foley x 7d.
How do you workup ICP?
At what bile acid would you be concerned?
Bile acids, CBC, hepatic panel for LFTs.
BA>10 or LFTs >2ULN
What is the management of iCP?
Ursodiol 300mg TID, emollients (how long would it take to get relief?). Growth ultrasounds and APT. incr risk IUFD. if bile acids >100, delivery at 36wks. Otherwise delivery at btw 36-39wks. Can go up to 500mg twice daily.
How do you manage a 4th degree perineal laceration?
How do you manage post-op care
a tear in both anal sphincter and rectal mucosa.
Counsel, explain, repair. Adequate exposure, Allis clamps. Extra set of gloves.
- change gloves after rectal exam. start repairing rectal mucosa (running non-locking fashion 3-0 vicryl). identify internal anal sphincter using allis clamps and repair in end-to-end fashion with 0-vicryl. Then repair external anal sphincter in overlapping fashion again with 0-vicryl. Following this repair, repair the now 2nd degree laceration with 0-vicryl in continuous fashion.
Rectal exam afterwards to ensure adequancy of repair and that no sutures passed through rectal mucosa. Single dose of 2g cefazolin (Ancef) to prevent infection/breakdown.
- Bowel regimen, sitz baths, avoid constipation/straining, avoid narcotics, close office follow-up. Consider pelvic floor PT.
Complications: fistula, dyspareunia, wound breakdown, incontinence
What are McDonald and Shirodkar cerclages
McDonald - non absorbable suture at the cervovaginal junction w/ 5mm mersillene or 2-0 prolene (mono-filament)
—grasping the anterior and posterior lips of the cervix with one or two ring forceps. We insert a curved needle loaded with large caliber nonabsorbable synthetic suture (at least number 1 or 2 braided or monofilament) at 12 o’clock, at the junction of the rugated vaginal epithelium and the smooth cervix just distal to the vesicocervical reflection and at least 2 cm above the external os.
– Four to six deep bites of a purse-string suture are taken circumferentially around the entire cervix as high (close to the internal os) as safely possible, avoiding the bladder, rectum, and uterine vessels (at 3 and 9 o’clock). Approximately 1 cm of space is left between the exit of one deep bite and the entry of the next deep bite. Each deep bite should extend at least midway into the cervical stroma to reduce the risk that the suture will pull out over time, but should not enter the endocervical canal
Shirodkar: dissection of the vesico-cervico mucosa to place suture as close to internal os as possible.
- no difference in efficacy of PTB prevention. McDonald is easier to place.
Indications for cerclage:
- hx sPTB <34wks and CL <2.5cm
- painless cervical dilation in current pregnancy
- history of 1 second-trimester loss in absence of labor or abruption.
What are advantages and disadvantages of TAC?
advantage: cerclage placed at cervico-isthmic junction - greater structural support
- avoid foreign body in vagina to decr risk PROM/IAI
disadvantage:
- more complicated surgery than TVC
- requires abdominal surgery w/ bleeding risks. need for cesarean delivery
Procedure: retract uterine vessels laterally, create avascular spaces in broad ligament at level of internal os, place non absorbable 5mm suture through spaces and tie anteriorly or posteriorly.
What is shoulder dystocia?
What are maneuevers?
3-10% of all deliveries.
10% risk of recurrence. 10% have transient brachial plexus palsy and 1% have permanent palsy.
- call for help!
- steps: McRoberts, suprapubic pressure and delivery of posterior arm.
- rotational maneuver:
1. Rubin: back of anterior shoulder, exert pressure on posterior aspect of shoulder to rotate fetus to disimpact it.
2. Woodscrew: put pressure on FRONT of posterior shoulder to rotate it 180 degrees and push it forward toward infant’s Chest
3. posterior axilla sling traction: 12 or 14Fr catheter, create sling around posterior shoulder to apply traction.
4. Episiotomy
5. Gaskin maneuver: place mother on hands/knees
6. fracture fetal clavicle by UPWARD pressure.
7. REPEAT ALL MANAUEVERS
8. zavanellib: replace fetal head and do CS - head to body delivery interval of >7 min associated w/ incr risk permanent brain damage
What are risk factors for stillbirth?
- black race
- extremes of parity (nulls and >3 prior)
- AMA
- teens
- obesity
- T2DM or GDM
- cHTN
- other meds (SLE, renal disease, thyroid disease, ICP)
- smoking/alcohol
- IVF
- APLS
- postterm pregnancy
- prior SD
- multiple gestation
What are causes of stillbirth and evaluation of stillbirth?
FGR
Abruption
Chromosomal and genetic abnormalities
Infection
Umbilical cord events (cord entrapment, prolapse, vasa previa)
- Autopsy, gross/histologic exam of placenta, umbilical cord and membranes, genetic evaluation.
- keep specimens in sterile tissue medium of LR (NOT formalin!)
- Maternal: history for risk factors, exposures - meds/viral, RPL.
- get KB test (Fetomaternal hemorrhage),
Tests:
KB, APLS (anticardiolipin, beta2glycoprotein, lupus anticoagulant, RPR, glucose screen, toxicology if suspected
- if TOLAC/IOL: miso 400q6 if 24-28wks. IF <24wks, standard dose (400q3).
How do you manage a uterine inversion?
Stop pitocin.
- Give 0.25mg terbutaline subQ
- next nitroglycerin 50 mcg IV.
- Then nitrous oxide if anesthesia there.
- Also Mag (but takes longer to bolus/kick in).
If doesn’t work, to OR with general anesthesia for increased uterine relaxation. If doesn’t work, midline vertical incision.
What are procedures performed in OR for uterine inversion?
Huntington: laparotomy by gradually pulling on the round ligaments to restore the uterus to its proper position.
Haultain: making a vertical incision in the posterior surface of the uterus to bisect the constriction ring in the myometrium, which is preventing reduction of the inversion. manually push up funds. avoid anterior incision bc can cause cystotomy.
Then once uterus returned, give uterotonics. And place Bakri in uterus to avoid uterine inversion again.
What are risk factors for shoulder dystocia?
Describe maneuvers for SD management?
prior SD, T2DM/GDM, fetal macrosomia, maternal obesity
McRoberts, suprapubic pressure, deliver posterior shoulder.
Rotational:
- Rubin: one hand in the vagina along the posterior aspect of the anterior fetal shoulder and rotating the shoulder inward (adduction) about 30
- Woodscrew: fetal trunk is rotated at least 180° using pressure on the dorsal aspect of the posterior shoulder to help adduct the shoulders
- medio/lateral episiotomy
- break fetal clavicle
What dermatomes are involved in labor pain?
What are treatment options for labor pain? Describe advantages and disadvantages of each.
S1-S2
Nitrous oxide, IV opioids, epidural anesthesia.
–IV opioids: short-acting and quick onset, not prolonged effect on fetus. Disadvantages can cause abnormal FHR and if given close to time of delivery, can cross the placenta and cause lower apgars in the fetus. Options: dilaudid.
Avoid meperidine: has a long half-life that affects newborn.
–Regional epidural: highly effective, long-acting continuous infusion. Safe. works for cesarean. Increased risk of epidural hematoma (contraindicated if blood thinner)j, confined to a bed, can have postdural puncture headache.
Epidural vs spinal: spinal is short duration, epidural can be redosed.
Inhaled Nitrous oxide: fast acting. Doesn’t last long. Requires patient to self-administer.
–Local anesthesia: to perform pudendal block
–General anesthesia: used in emergency. Unconscious, airway issues, neonatal effects, incr risk of hemorrhage 2/2 uterine relaxation.
- nitrous oxide: avoid w/ systemic opioids bc can lead to maternal respiratory depression
What are contraindications to regional anesthesia?
Therapeutic anticoagulation within the past 24hrs, spinal stenosis/spinal surgery, severe scoliosis. Icnr intracranial pressure from lesion, thrombocytopenia <70K
Does it incr risk C/S? No prolongs 2nd stage of labor by 10 minutes
