Labor and Delivery Complications Flashcards
1
Q
What is considered preterm labor?
A
- prior to 37 wks
- MC cause of perinatal morbidity and mortality in US
- regular uterine contractions assoc with cervical change
2
Q
RFs for preterm labor?
A
- multiple gestation
- prior preterm birth
- preterm uterine contractions
- PROM
- low maternal prepregnancy wt
- smoking
- substance abuse
- short interpregnancy interval
- infection (UTI, genital tract, periodontal disease)
3
Q
PP of preterm labor?
A
- activation of maternal or fetal HPA axis due to maternal or fetal stress - stress onset of physiologic initiators
- deciual-choioamniotic or systemic inflammation caused by infection: uterine or systemic infection and release of inflammatory cytokines
- decidual hemorrhage: abruption
- pathologic uterine distenstion: multiple preg, polyhydramnios, uterine abnormality
4
Q
What are signs and sxs of preterm labor?
A
- menstrual like cramps
- low, dull backache
- abdominal pressure
- pelvic pressure
- abdominal cramping w/ or w//o diarrhea
- increase or change in vaginal d/c (mucous, water, light bloody d/c)
- uterine contractions (may be painless)
5
Q
Pt eval for preterm labor?
A
- fetal monitoring
- UA, test for Group B strep, CBC
- US:
eval amt of amniotic fluid, est cervical length if less than 26 wks - amniocentesis:
not a routine test, can determine intramniotic infection, may be used to determine fetal lung maturity
6
Q
Management of preterm labor?
A
- primary goal is to delay delivery until fetal maturity is attained
- detection and tx of disorder assoc with preterm labor
- therapy for preterm labor
7
Q
What are the meds used in preterm labor?
A
- tocolytics: meds to stop preterm labor CCBs (nifedipine) NSAIDs (indocin) B-adrenergoc receptor agonists (terbutaline) Mg sulfate
8
Q
CIs to tocolytics?
A
- advanced labor
- mature fetus
- severely abnormal fetus or fetal demise
- intrauterine infection
- significant vaginal bleeding
- severe preeclampsia or eclampsia
- placental abruption
- advanced cervical dilation
- fetal compromise
- placental insufficiency
9
Q
When are corticosteroids used? Why are they used?
A
- from 24-34 wks
- corticosteroids given to mother to enhance fetal lung maturity
- max benefit if given w/in 7 days of delivery
- dosing over 48 hrs
- reduces:
fetal respiratory distress
intraventricular hemorrhage
necrotizing enterocolitis
10
Q
What is group B strep? When is this screened for?
A
- genital tract colonization of 15-40% of preg. women
- universal screening for GBS b/t 35-36 wks gestation
- if positive administer abx prophylaxis in labor or with PROM
- or if preg mother has had prior infant with GBS infection
11
Q
Meds for GBS abx prophylaxis?
A
- PCN G 5 mill U UV followed by 2.5-3 million U q 4 hrs until delivery
- best if given 4 hrs prior to delivery
- if PCN allergy then:
cefazolin (in no h/o anaphylaxis to PCN)
or clindamycin
or vancomycin
12
Q
Why is tx GBS so impt?
A
- prevents group B sepsis of neonate
- in mother: prevents postpartum endometritis, sepsis and rare cases meningitis
- may have asx bacturia during pregnancy and that should be tx
13
Q
What is dystocia?
A
- abnormal progression of labor or also referred to as failure to progress
- leading indication for c-section
- defined as lack of progressive cervical dilation of lack of descent of fetal head in birth canal or both
14
Q
Eval of labor: why is there dystocia?
A
- is uterus contracting accurately (need internal monitor)
- what is fetal position?
- is there indication of cephalopelvic disproportion?
- what is fetal status? FHR
- is there concern for chorioamnionitis - fever, abdominal pain, or foul smelling amniotic fluid?
15
Q
Normal progression of labor?
A
- cervix should dilate:
1 cm/hr in nulliparous
1.5 cm/hr in multiparous
fetus should descend at least 1 cm/hr:
- shouldn’t be longer than 3 hrs if regional anesthesia
- shouldn’t be longer than 2 hrs if no anesthesia
- 2nd stage arrest is no descent after 1 hr of pushing
16
Q
Management of dystocia?
A
- observation
- augmentation: amniotomy, oxytocin (pitocin)
- c-section: maternal or fetal distress, or unstable condition of mother (fever, tachy, signs of infection)
17
Q
What is amniotomy? Risks?
A
- manual rupture of membranes with a hook
- risks: FHR deceleration due to cord compression, increased incidence of chorioamnionitis
18
Q
MOA of oxytocin? Risks?
A
- pitocin drip per protocol - with increasing amt
- increases uterine activity (contractions) which in turn should result in cervical change and descent
- risk: hypertonic uterus, avoid more than 5 contractions in 10 minutes as this can cause decreased blood flow (O2) to fetus
19
Q
What are the indications for a c-section?
A
top 3:
- failure to progress during labor
- nonreassuring fetal status
- fetal malpresentation
- abnormal placentation
- maternal infection (HIV, HSV)
- multiple gestation
- fetal bleeding diathesis
- umbilical cord prolapse
- macrosomia
- obstruction of birth canal (fibroid, condyloma accuminata)
- uterine rupture
20
Q
What is an assisted vaginal delivery?
A
- forceps or vacuum extraction (doesn’t allow baby to regress back into uterus)
indications: - when mother’s pushing and uterine contractions are insufficient to deliver the infant
- sudden onset of severe maternal or fetal compromise and mother is fully dilated and effaced
21
Q
Complications of assisted delivery?
A
forceps:
- mother: perioneal trauma, hematoma, pelvic floor injury
- baby: injuries to brain or spine, MSK injury, corneal abrasian, shoulder dystocia in larger infants
vacuum:
- mother: less maternal trauma than forceps
- baby: Intracranial hemorrhage, subgaleal hematoma, scalp laceration, hyperbilirubinemia, retinal hemorrhage, cephalhematoma
22
Q
What is umbilical cord prolapse (UCP)?
A
- rare, but serious condition
- umbilical cord is palpable on vaginal exam, it proceeds the presenting part
- pressure on the cord causes fetal bradycardia and can eventually cause fetal demise
23
Q
Management of UCP?
A
prompt delivery usually by c-section
maneuvers to reduce cord pressure:
-examiner’s hand maintained in vagina to elevate presenting part off cord while arrangements are made for emergency c-section
- pt is placed in steep trendelenberg position
- filling bladder w/ 500-700 ml of NS
- giving a tocolytic such as terbutaline to stop contractions
24
Q
How common is shoulder dystocia? PP? What can precipitate it?
A
- occurs in 1-3% of all births
- ob emergency
- defined as the need for additional obstetric maneuvers to effect delivery of the shoulders at the time of vaginal birth
- PP: if the fetal shoulders remain in an anterior-post position during descent or descend simultaneously the anterior shoulder can become impacted behind the PS
- fetal macrosomia can precipitate it
25
Dx shoulder dystocia?
- fetal head retracts into perineum (turtle sign) after expulsion
- when routine gentle, downward traction of the fetal head fails to accomplish delivery of the anterior shoulder
26
Management of shoulder dystocia?
- excessive neck rotation, head and neck traction and fundal pressure should be avoided: these maneuvers can further impact the shoulders and injure the brachial plexus
- a distended bladder if present is drained
- McRoberts maneuver
- suprapubic pressure: direct pressure on anterior shoulder downwrad away from the pubic bone, in conjuction w/ McRoberts maneuver
- rubin maneuver: adduction of fetal shoulder, displacing them from the anteroposterior diameter
- delivery of posterior arm:
also called barnum maneuver - best peformed under adequate anesthesia, introduce a hand into vagina and locate the posterior arm and shoulder, follow it to the elbow and flex elbow across fetal chest, grasp forearm and arm is then pulled out of vagina, greatest risk is fracture of humerus
27
If all other measures fail or mother only has local anesthesia - what can be done for shoulder dystocia?
- place mom on hands and knees - infant will be delivered by gentke downward traction on post shoulder or upward traction on anterior shoulder
- if this doesn't work - push baby back in and do C-section or cut pubic bone
28
Diff breech presentations?
- frank breech: hips flexed/knees extended
- complete breech: hips and knees flexed
- incomplete breech: one or both hips extended (foot or feet first)
- usually a woman found to have a baby in breech position has scheduled c-section
- if breech may attempt external cephalic version to get the baby in vertex position so mother may attempt to have a vaginal birth
29
How is external cephalic version done? Success rate?
- halves rate that women have for achieving getting the baby in vertex position
- but these women still have higher than normal c-section rate b/c of problems with cephalopelvic disproportion which is thought to be why baby is in breech presentation to begin with
- this is done in final trimester, monitor fetus, often given uterine relaxants, perform cephalic version, monitor mom and baby, and give mom Rhogam if Rh negative
- 6.1% overall risk of complications
30
How do you deliver a breech baby?
- externally rotate fetal pelvis: this results in flexion of knee and delivery of each leg
- when scapulae appear under symphisis, operator reaches over L shoulder and sweeps arm across chest and delivers arm and gently rotates shoulder girdle so R arm can be delivered
- following deliver of arms - fetus is wrapped in towel for control and slightly elevated ,exvessive elevation of the trunk is avoided
- it is impt to ***maintain cephalic flexion by applying pressure on fetal maxilla with continued expulsive forces from above and gentle downward traction of fetal head is delivered
31
What is a retained placenta?
- placenta that hasn't been expelled 30-60 min after delivery of the baby
- occurs 1:100 to 1:200 deliveries
- cause of PPH
- pharm interventions:
IV nitroglycerin given to relax uterus, BP monitored - hypotensive - trendelenburg
- intraumbilical injection of soln of oxytocin in saline
32
Manual removal of retained placenta?
- performed by using one hand to follow path of umbilical cord into lower uterine segment
- the other hand holds the uterine fundus
- hand inside the uterus frees the remaining placenta if it is loose or develops a space b/t placenta and uterus and shears off the placenta
- general anesthesia may be necessary
- after placenta out - give oxytocin
33
What is uterine inversion? Tx?
- uterine fundus collapses into endometrial cavity
- less than 1/6000 vaginal deliveries
- Tx:
summon assistance
large bore IV access for fluids
uterine relaxation: Mg sulfate, terbutaline, nitroglycerin
manual correction
removal of placenta
uterotonic agents
34
What is the normal PP of uterine hemostasis?
- contraction of the myometrium, which compresses the blood vessels supplying the placental bed and causes mechanical hemostasis
- local decidual hemostatic factors (tissue factor, type-1 plasminogen activator inhibitor) - ex: platelets, circulating clotting factors, which cause clotting
35
Causes of PPH?
```
- incomplete placental separation:
retained placenta
retained membranes
- ineffective myometrial contraction (atony)
- bleeding diatheses
```
36
How common is PPH? How is it defined and dx? Etiologies?
- 1-5% of deliveries
- PPH: excessive bleeding, results in pt sxs of light-headedness, vertigo or syncope and/or signs of hypovolemia
- etiologies:
uterine atony (1/20 women)
trauma
coagulation defects: congenital and acquired
37
Management of PPH?
- fundal massage
- IV access: for fluid and blood
- US (look for debris)
- uterotonic drugs:
oxytocin 15 u in 250ml of LR
misoprostol sublingually or rectally
methylergonovine IM or directly into myometrium (if no HTN, raynauds or scleroderma)
- carboprost tromethamine (hemabate) if no asthma
38
Secondary management of PPH?
- pt to be taken to room where anesthesia and facilities for vaginal and possible abdominal surgery can be done
- provide adequate anesthesia
- uterus explored and any retained fragments or fetal membranes be removed manually if possible
- inspect for and repair cervical and vaginal lacerations
- bakri tamponade: for uterine tamponade
