Labor and Delivery Complications Flashcards
Preterm birth
Defined as birth before 37 completed weeks of gestation
Most common cause of perinatal morbidity and mortality
RF for preterm labor
Previous preterm delivery
Low SES
Non-white race
Maternal age <18 yrs or >40 yrs
Preterm premature rupture of the membranes
Multiple gestation
Maternal hx of one or more spontaneous second trimester abortions
Maternal causes of preterm labor
Maternal complications (medical or obstetric)
Maternal behaviors:
-Smoking
-Illicit drug use
-Alcohol use
-Lack of prenatal care
Hx of preterm labor with previous pregnancies
Uterine causes of preterm labor
Leiomyomas (particularly submucosal or subplacental)
Uterine septum
Bicornuate uterus
Cervical incompetence- natural or surgical
Exposure to diethylstilbestrol (DES)
Infectious causes of preterm labor
Chorioamnionitis BV Asymptomatic bacteriuria Acute pyelonephritis Cervical/vaginal colonization
Fetal causes of preterm labor
Intrauterine fetal death Intrauterine growth retardation Congenital anomalies Abnormal placentation Polyhydramnios Multiple gestation Macrosomia
Prognosis of preterm labor
Perinatal survival has improved in babies >27 gestational weeks
Minimal improvement in survival in babies <27 wks
Definition of preterm labor
Regular contractions occurring every 10 minutes or less, with each contraction lasting at least 30 secs, accompanied by cervical changes and/or the descent of the fetus into the pelvis, between 20 and 36 wks gestation
Preterm contractions is the term used to describe contractions that do not meet the above criteria
Sx of preterm labor
Menstrual-like cramps Backache Pelvic pressure Increased vaginal d/c Uterine contractions that may be painless
Assessment of preterm labor
Uterine monitoring
Fetal fibronectin testing-negative test is reassuring that labor/delivery will not occur within 7-14 days
Cervical eval via u/s- cervical shortening may be appreciated on u/s before it can be noted on vaginal exam
Cultures of cervix and urine
Tx of preterm labor
Aggressively treat any confirmed or suspected infections
Reverse dehydration
Left lateral rest
Treat earlier gestations more aggressively
Typically do not start tocolysis after 35-36 wks
From 24-34 wks, steroids have been shown to hasten lung maturity in the fetus
Preterm labor tx contraindications
Heavy vaginal bleed suggestive of placental disruption Fetus with significant anomalies Intrauterine infection Advanced labor Maternal contraindications
Premature rupture of membranes
Defined as the rupture of the amniotic membrane before labor
What is a contraindication to conservative management of PROM?
Chorioamnionitis
In pregnancies before 24 wks, what normally prevents nl development of the alveoli within the fetal lungs?
Inadequate amniotic fluid
Causes of PROM
Infection (including BV) Doubled risk in women who smoke Previous PROM Polyhydramnios Multiple gestation Premature cervical dilation
PROM management
Heavily dependent on gestational age
Must weigh risks against benefits according to gestational age and presence/absence of infection
If very preterm and no signs of infection may try to delay to get steroids in
Do not do a vaginal exam
Sterile speculum exam to confirm ROM and obtain cultures. May be able to visually see whether cervix is open or closed
Attitude
Refers to the posturing of the joints and relation of fetal parts to one another
The normal fetal attitude when labor begins is with all joints in flexion
Lie
This refers to the longitudinal axis of the fetus in relation to the mother’s longitudinal axis
Presentation
This describes the part of the fetus lying over the inlet of the pelvis or at the cervical os
Complete breech
Both legs flexed
Incomplete breech
One leg flexed, other leg extended
Frank breech
Both legs extended
RFs for breech
Prematurity Multiple fetuses Polyhydramnios Oligohydramnios Too roomy uterus Hydrocephaly Anencephaly Uterine abnormalities Placenta previa Nuchal cord
Complications of breech presentations
Perinatal morbidity and mortality from difficult birth
Possible perineal trauma from difficult birth
Possible low birth weight d/t prematurity
Prolapsed cord
Placenta previa (if the cause of the breech)
Fetal anomalies
Uterine anomalies
Position
Describes the relation of the point of reference to one of the eight octanes of the pelvic inlet
Engagement
This occurs when the biparietal diameter is at or below the inlet of the true pelvis
Station
This references the presenting part to the level of the ischial spines measured in plus or minus centimeters
What does an external fetal heart rate monitor do?
Tracks variability in the FHR, which, as the fetus matures, is a marker for fetal well-being
-Short-term variability: beat to beat variance
-Long-term variability: changes in the rate over time
Used to perform non stress and contraction stress testing
How to confirm rupture of membranes
Nitrazine paper to test pH- royal blue is suggestive for rupture
Nl vaginal pH 4.5-6, with ROM it’s greater than or equal to 7
Not 100% accurate as some vaginal infections cause a good deal of wetness and also change nl vaginal pH
Other things that can cause a false positive: blood, semen, UTI
Can use pool test with speculum inserted in the vagina
Fern test
Fluid is applied to a microscope slide and allowed to dry for 10 mins
Then observed under microscopy
Fern leaf pattern to the slide is diagnostic of ROM
When is umbilical cord prolapse most likely?
If presenting part is not engaged
If polyhydramnios is present
With multiples
When does umbilical cord prolapse happen?
Usually happens at time of rupture of membranes
Management of umbilical cord prolapse
Fetal presenting part can compress cord
Delivery needs to be accomplished ASAP by c-section
Pressure must be kept off cord
Causes of dystocia
Uterine forces that are not sufficiently strong or appropriately coordinated to efface and dilate the cervix
Forces generated by voluntary muscles during the second stage of labor that are inadequate to overcome the nl resistance of the bony birth canal and maternal soft parts
Faulty presentation or abnl development of the fetus of such character that the fetus cannot be extruded through the birth canal
Abnormalities of the birth canal that form an obstacle to the descent of the fetus
Protracted latent phase
Nulliparas: 20 hr or more
Multiparas: 14 hr or more
Protracted active phase
Nulliparas 1.2 cm/hr or less
Protracted descent
Nulliparas 1 cm/hr or less
Multiparas 2 cm/hr or less
Secondary arrest of dilation
Arrest greater than or equal to 2 hr
Arrest of descent
Arrest greater than or equal to 1 hr
Failure of descent
No descent in 2nd stage
Arrest patterns in labor
Striking association with cephalopelvic disproportion makes these disorders especially ominous
Whenever encountered, arrest patterns should signal the likelihood that a bony impediment exists
Prolonged active phase and prolonged second stage are associated with shoulder dystocia
What is the most common risk factor for shoulder dystocia?
The use of vacuum or forceps to achieve the delivery
Maternal shoulder dystocia risk factors
Abnormal pelvic anatomy Gestational DM Post-dates pregnancy Previous shoulder dystocia Short stature
Fetal shoulder dystocia risk factors
Suspected macrosomia
Labor-related shoulder dystocia risk factors
Assisted vaginal delivery
Protracted active phase of first-stage labor
Protracted second-stage labor
Maternal complications of shoulder dystocia
Postpartum hemorrhage Rectovagainal fistula Symphyseal separation or diathesis 3rd or 4th degree episiotomy or tear Uterine rupture
Fetal complications of shoulder dystocia
Brachial plexus palsy Clavicular fx Fetal death Fetal hypoxia (with or without permanent neurologic damage) Fracture of the humerus
Shoulder dystocia delivery
H- Call for help
E- Evaluate benefit of episiotomy
L- Move legs back to mother’s abdomen with the head flat
P- Suprapubic pressure
E- Enter maneuvers (force internal rotation)
R- Remove the posterior arm
R- Roll the pt over on hands and knees
