Labor and Delivery Complications Flashcards
List some indications for a C-section
Dystocia
Protraction disorder or arrest disorder
Fetal malposition
Multiple intrauterine pregnancy
Fetal distress
Cord prolapse
Placenta previa
Placenta abruption
Previous intra-uterine fetal surgery
Previous myomectomy or uterine reconstruction
HIV
Active herpes
Medical or obstetrical complications precluding vaginal delivery
Suspected macrosomia by sonography estimated fetal weight
What is the time frame to be considered nulliparous labor to be considered prolonged?
> 20 hours
What is the time frame to be considered multiparous labor to be considered prolonged?
> 14 hours
What is the definition of dystocia?
difficult or abnormal labor
Abnormal progression, “failure to progress”
What are the 3 P’s pf labor?
Power (uterine contractions)
Passenger (baby)
Passage (maternal)
In dystocia, one or more of these is abnormal
What are the risks of dystocia?
Infection – chorioamniotitis (consequence of prolonged labor)
Fetal infection and bacteremia
Pneumonia from aspirating infected amniotic fluid
Fetal trauma
Maternal soft tissue injury
What is the optimal intrauterine pressure?
50-60 mmHg
What is the optimal frequency of uterine contractions?
Minimum of 3 contractions in 10 minute interval
What is the optimal contractile strength of uterine contractions?
MVU: normal labor is 200 or more MVU
What are the abnormal fetal presentations?
Asynclistim
Extension
Brow
Face
compound
What are the two categories of abnormal labor patterns?
Protraction disorders
Arrest disorders
Stage exceeds 3hrs with regional anesthesia, 2 hours no regional
anesthesia, or fetus descends less than 1cm/hr (no regional anesthesia)
Second stage protraction disorder
No descent after 1 hour of pushing
Can use oxytocin to help, labor positions (squatting, sitting in birthing chair, knees to chest)
Second stage arrest disorder
Delivery Help:
Used to apply traction when uterine contractions and maternal
pushing are inadequate
Need the scalp to be visible, skull has to have reached the pelvic floor
Forceps
What are some risks with using forceps to help with delivery?
Peritoneal trauma
Hematoma
Pelvic floor injury
Inability to deliver shoulders after head was delivered
Occurs when fetal anterior shoulder impacts against maternal
symphysis following delivery of head
Cannot be predicted or prevented
Shoulder Dystocia
Delivery Help:
Only steady traction used in the line of the birth canal
Need the scalp to be visible, skull has to have reached the pelvic floor
Vacuum extraction
What are some risks with using vacuum extraction to help with delivery?
Intracranial hemorrhage
Hematoma
Scalp lacerations
Hyperbilirubin
Retinal hemorrhage
What are some risk factors that may result in shoulder dystocia?
Macrosomic birth (>4500g at most risk)
Small pelvis
Post term gestation
Head retracts back into maternal peritoneum - this is a sign of shoulder dystocia
Turtle sign
What are some maternal complications of shoulder dystocia?
Post partum hemorrhage
Fourth degree lacerations
What are some fetal complications of shoulder dystocia?
Brachial plexus injury, but fewer than 10% result in a persistent brachial plexus injury
Fracture of clavicle
Fetal death
Shoulder Dystocia: Which maneuver is described below?
Hyperflexion of mother’s legs tight into abdomen
McRobert’s maneuver
Shoulder Dystocia: Which maneuver is described below?
Fetal head is flexed and reinserted into vagina to reinstate blood flow
and to perform C section
Zavanelli manuever
When assessing fetal distress, this is used to determine if the fetus is well oxygenated, assessment done to see if intervention is needed so it can be done in a timely manner
Fetal heart rate
What is the most common cause of fetal tachycardia?
chorioamniotitis
What are some tests/techniques to know when a fetus is in “distress”?
Fetal movement assessment
Non stress test
Fetal biophysical profile
Amniotic fluid index
Contraction stress test
Which fetal monitoring technique is described below?
Indication: Maternal perception of decreased or absence fetal movement
Technique: Mother counts number of perceived “kicks” during a specified amount of time
Fetal movement assessment
Which fetal monitoring technique is described below?
Measurement of the fetal heart rate with movement
The heart rate of the infant that is not acidotic or neurologically
depressed will temporarily accelerate with fetal movement
Results:
Reactive (normal) - Two or more fetal heart rate accelerations within a 20 minute period
Nonreactive - No sufficient fetal heart rate accelerations over a 40-minute period
Non stress test
Which fetal monitoring technique is described below?
Components: Non-stress test, Fetal breathing movements, Fetal movement, Fetal tone, Determination of the amniotic fluid index
Scoring – each component is scored 2 to 0
Normal: 8-10
Equivocal: 6
Abnormal: 4 or less
Biophysical Profile
Which fetal monitoring technique is described below?
Technique: summation of the largest cord-free vertical pockets in each of the four quadrants of an equally divided uterus
Amniotic Fluid Index (AFI)
If this condition is seen on a biophysical profile, it warrants further evaluation regardless of the composite score
oligohydramnios
On the amniotic fluid index, no ultrasonographically measured pocket of amniotic fluid >2cm, or an AFI of 5cm or less is diagnostic of what?
oligohydramnios
Oligohydramnios is indicative of what conditions that requires close maternal/fetal surveillance or delivery?
Anomalies
Placental dysfunction
Polyhydramnios can be normal, but also can cause what?
Can cause premature rupture of the membranes
Can cause malpresentation of the fetus
Which fetal monitoring technique is described below?
Looking for the presence or absence of late fetal heart rate decelerations in response to uterine contractions
Contraction stress test
What is the definition of late decelerations?
Decelerations in the fetal heart rate that reach their nadir after the peak of the contraction and usually persist beyond the end of the contraction
Which type of deceleration is described below?
Associated with uterine contractions, nadir occurs same
time as peak of contraction
“mirror image”
Physiologic, not a cause for concern
Early Deceleration
Which type of deceleration is described below?
Considered significantly non-reassuring, especially when repetitive and associated with decreased variability
Late Deceleration
Which type of deceleration is described below?
Abrupt, visually apparent decreases in the FHr below the baseline FHr (mediated by the vagus nerve)
Characteristic sharp decelerations
Often correctable by maternal position to relieve pressure on umbilical cord
Variable Deceleration
Variable decelerations are often associated with what conditons?
umbilical cord compression and oligohydramnios
Which decelerations are the most common periodic FHr pattern?
Variable Decelerations
What is a technique that may fix a variable deceleration?
Sometimes correctable by maternal position to relieve pressure on umbilical cord
Thick, black tarry substance in the fetal GI tract
Sign of fetal distress
Detected during labor when the amniotic fluid is stained dark
green or black
Meconium
A fetus that passes meconium in utero is a sign of what?
fetal distress
Which condition is described below?
Inhalation by neonate can lead to significant issues
Severe cases may cause pneumonitis, pneumothorax, pulmonary artery hypertension
Meconium Aspiration Syndrome
Rupture of membranes during pregnancy before 37 weeks gestation and before the onset of labor
Premature Rupture of the Membranes
Amniotic fluid produced continuously after how many weeks, dependent upon fetal urine production?
16 weeks
Amniotic fluid protects against what?
infection
fetal trauma
umbilical cord compression
Premature rupture of the membranes happens in what percentage of pregnancies?
3% of pregnancies
Premature rupture of the membranes is responsible for how many preterm deliveries?
1/3 of preterm deliveries
> 37 weeks
Rupture of the chorioamniotic membrane before the onset of labor, generally followed by the onset of labor
PROM
< 37 weeks
Is a leading cause of neonatal morbidity and mortality and is associated with 30% of preterm deliveries
PPROM
What are some risk factors for developing premature rupture of the membranes?
Smoking
Short cervical length
Prior preterm delivery
Multiple gestations
Bleeding early in pregnancy (threatened abortion)
This risk factor doubles a woman’s chances of premature rupture of the membranes
Smoking
Fluid passing through vagina must be presumed to be what until
proven otherwise?
amniotic fluid
What are some tests used to diagnose premature rupture of the membranes?
Nitrazine test
Fern test
Ultrasound
Which test used to detect amniotic fluid/PROM is described below?
Amniotic fluid is alkaline (>7), vaginal and
urine secretions are more acidic (<6)
Fluid to paper: dark blood = alkaline
Nitrazine test
Which test used to detect amniotic fluid/PROM is described below?
Fluid drying on a slide that resembles a fern is amniotic fluid
Better than the nitrazine test
Fern test
Which test used to detect amniotic fluid/PROM is described below?
If unclear, transabdominal instillation of indigo carmine dye, followed by observation for passage of blue fluid from vagina
Ultrasound
Using this treatment is associated with decreased risk of chorioamniotitis and endometritis
Oxytocin
After PROM, when is the induction of labor appropriate?
At any time after PROM
What is a MAJOR complication of PROM?
Intrauterine infection
This condition is a major threat to mother and fetus
Infection of the fetal membranes and amniotic fluid 🡪 Chorioamniotitis
Patients with Chorioamniotitis frequently encounter these complications?
Frequently enter spontaneous and often dysfunctional labor
What is the treatment for chorioamniotitis?
IV abx
prompt delivery
List some signs and symptoms of chorioamniotitis?
significant fever (>101)
tachycardia (fetal and maternal)
uterine tenderness
purulent cervical discharge - late finding
Patients with these infections are at higher risk for intrauterine infection if present?
gonorrhea
BV
group B strep
List some complications of PROM?
Intrauterine infection
Chorioamniotitis
Prolapsed umbilical cord
Abruption placenta
Pulmonary hypoplasia
Respiratory distress syndrome
Neonatal sepsis
Fetal death
Complication that occurs prior to or during delivery of the baby
Occurs in approximately every 300 births
Prolapsed Umbilical Cord
What are some causes of a prolapsed umbilical cord?
Premature rupture of the membranes (MC cause)
Premature delivery
Excessive amniotic fluid
Delivering multiple babies (twins, triplets, etc)
Breech delivery
Umbilical cord that is longer than usual
What are some complications of a prolapsed umbilical cord?
Hypoxia
stillbirth
What is the most common cause of a prolapsed umbilical cord?
Premature rupture of the membranes
What is the treatment for a prolapsed umbilical cord?
Move fetus away from the cord
Emergency C-section
Preterm delivery is defined as delivery prior to how many weeks?
37 weeks
What is the most common cause of perinatal morbidity and mortality?
Preterm labor
What are the strongest risk factors for preterm labor?
multifetal gestation and prior preterm birth
Which organ system is the last to develop?
lungs
You cannot rule out preterm labor by absence of contractions on the
fetal monitor – you need to check what?
check the cervix
What are the goals in preterm labor?
Stop contractions
Prolong pregnancy at least 48 hours to administer corticosteroids
What is the maximal benefit when administering steroids in preterm labor?
Maximal benefit is 7 days prior to delivery (24-34 weeks)
List some tocolytics used to stop contractions in preterm labor?
Nifedipine
Mg2+ sulfate (also neuroprotective effects for baby)
B agonists (Terbutaline)
List some potential causes of breech pregnancies
Multiple pregnancies
Polyhydramnios
Hydrocephaly
Anencephaly
Aneuploidy
Uterine anomalies
Uterine tumors
In singleton deliveries, what percentage are breech presentation?
2% of singleton deliveries
What are the three types of breech presentations?
Frank
Complete
Incomplete
What are some methods to diagnose a breech presentation in pregnancy?
Leopold maneuvers
Pelvic exam
ultrasound
Why is intrapartum fetal surveillance done in breech presentations?
Done to recognize changes in fetal oxygenation that could result in serious complications
What are some complications with breech presentation?
Morbidity and mortality rates for mother and fetus, regardless of
gestational age or mode of delivery
Fetal anomalies
Prematurity
Umbilical cord prolapse
Birth trauma
Most occur during labor and 90% associated with prior uterine scar
Uterine Rupture
What are some treatment/management methods for a breech presentation?
External Cephalic Version (turning fetus in mom’s belly)
Administer Rhogam to Rh- patients
C-section
What is the criteria for the external cephalic version for treatment of a breech presentation?
Normal fetus
Reassuring rates
Adequate amniotic fluid
Presenting part not in pelvis
Adequate pelvis
What treatment method for a breech presentation works 50% of the time?
External Cephalic Version
What treatment method for a breech presentation do doctors use/prefer the most?
C-section
A sudden onset of intense abdominal pain +/- vaginal bleeding should have you considering what diagnosis?
Uterine Rupture
