labor and delivery complications Flashcards
How is a breech presentation confirmed?
by examination and ultrasound
a 20-year-old G2P1 female with gestational diabetes and a pre-pregnancy BMI of 43 presents to her obstetrician in labor. Although the labor originally progresses without complications, delivery becomes stalled as the patient attempts to push the child’s shoulders through the vagina. The head delivers, then suddenly retracts against the pelvis. It will not budge despite maternal pushing and firm downward pressure on the head.
What is the likely issue?
dystocia or obstructed labor
what is obstructed labor?
when the baby does not exit the pelvis during childbirth due to being physically blocked despite the uterus contracting normally
What is the one major complication associated with dystocia?
not getting enough oxygen which obviously can result in death
What is the mother at risk for if she is having an obstructed birth?
increases the risk of getting an infection, having uterine rupture, or having post-partum bleeding.
What are the main causes of having obstructed labor?
- large or abnormally positioned baby
- Small pelvis
- problems with the birth canal
What are the categories of dystocia?
- Problems of power- uterine contractions
- problems of passenger- presentation, size (macrosomia) or position of the fetus (shoulder dystocia)
- Problems of passage- uterus or soft tissue abnormalities
Describe shoulder dystocia?
failure of the shoulders to deliver spontaneously after delivery of the fetal head
- one or both shoulder lodged at pubic symphysis with the delivery of the head
- This is an obstetric emergency
How do you dx obstructed labor?
usually just based off of physical exam
What sign during birth can you see that would indicate obstructed birth?
Turtle sign- retraction of the delivered head against the maternal perineum
What is the treatment for obstructed labor?
before resulting to surgery changing the posture of the mother can help progress the labor process
Tx for shoulder dystocia?
- First line is non-manipulative maneuver
a. suprapubic pressure
b. flexion of maternal hips (Mcroberts Maneuver) - Manipulative maneuvers
a. Rotation of fetal shoulders 180 degress (woods corkscrew)
b. Delivery of posterior arm - Emergent cesarean section
a. Pushing the fetal head back into the vaginal canal with immediate transport to cesarean section (Zavanelli maneuver)
What is the normal fetal HR?
120-160
What would classify as a good/ reactive nonstress test (NST)
> 2 accelerations in 20 minutes defined by increased fetal heart rate of at least 15 bpm from baseline lasting >15 seconds
What would indicate a bad or nonreactive stress test
no fetal heart rate accelerations or < 15bpm increase lasting < 15 seconds
What should you do if you have a nonreactive stress test. i.e whats the next step?
do a contraction stress test
What does a contraction stress test measure?
measures fetal response to stress at times of uterus contraction
What would indicate a good or negative contraction stress test?
no late decelerations in the presence of 2 contractions in 10 minutes
what would indicate a bad or positive contraction stress test?
repetitive late decelerations in the presence of 2 contractions in 10 minute, this would elicit prompt delivery
what is the clinical definition of premature rupture of membranes?
rupture of membranes at >/= 37 weeks gestation prior to the start of uterine contractions
What is the major risk associated with premature rupture of mebranes?
infection or cord prolapse
what are some expected s/sxs of PROM?
sudden “gush” of clear or pale yellow fluid from the vagina wall that occurs after 37 weeks gestations
how do you Dx PROM
you need to confirm that the fluid is truly amniotic fluid
How can you confirm that fluid is amniotic fluid in the setting of PROM?
Speculum - fluid pooling in the posterior fornix
Nitrazine test - blue (due to elevated pH) determine if this is amniotic fluid - PH > 7.1 means it is positive
If you were to do microscopy of the fluid in someone suspected to have PROM. If the fluid was truly amniotic fluid what would you expect to see?
you would see a fern pattern after the fluid has dried due to the crystallization of the amniotic fluid aka estrogen
Tx for PROM
Depends on gestational age
34 weeks – induce labor
32-34 weeks collect fluid and check for lung maturity – then induce
< 32 weeks stop contractions and start 2 doses of steroid injection then deliver the baby – give antibiotics
What is the clinical definition of preterm labor?
delivery of a viable infant before 37 weeks gestation
what are some symptoms of preterm labor?
uterine contractions which occur more often then every 10 minutes or the leaking of fluid from the vagina
what is the earliest gestational age at which a baby has at least a 50% percent survival rate?
24 weeks
What are some risk factors for preterm delivery?
- smoking
- cocaine use
- uterine malformations
- low pregnancy weight
what is the most useful test to determine if a woman is at risk of having a preterm delivery?
fetal fibronectin
what test has been reported to be the single best predictor for imminent spontaneous delivery within 7 days of patient presenting with signs and symptoms or complaints of preterm labor.
Placenta alpha microglobulin-1 aka Partosure test
Tx for preterm delivery?
try and delay the delivery if safe. can try and use the following meds
nonsteroidal anti-inflammatory drugs, calcium channel blockers, beta mimetics, and atosiban
How does the medication Tocolytics work?
it relaxes the uterus
Why do you want to delay the onset of labor. What are you waiting to administer.
Corticosteroids to induce fetal lung maturity
How long can CCB and oxytocin antagonists delay delivery?
2-7 days
How long can beta-2 agonists drugs delay delivery?
48 hours and they carry more side effects
what medication will hep improve outcomes in a pt who is most likely going to deliver a baby between 24 and 37 weeks?
corticosteroids
What is the tx for prolapsed umbilical cord?
immediate C-section
What is the first sign of umbilical prolapse?
sudden and severe decrease in fetal heart rate that does not immediately resolve
What are the most common risk factors for a prolapsed umbilical cord?
Malpresentation and rupture of membranes with the presenting part not applied firmly to the cervix
What are some other interventions you can take before C-section in the treatment of umbilical prolapse?
manual elevation of the presenting fetal part and repositioning of the mother to knee-chest position
