Labor and Delivery Complications

Question 1

Breech Presentation

Answer 1

• 3-4% all preg.
• RF: fibroids, oligo/polyhydramnios, uterine anomalies, pelvic tumors obstructing canal, abnl placentation, advanced multiparity, contracted maternal pelvis
• sxs: clinical suspicion (on palpation or pelvic exam)
• signs: leopold maneuvers to confirm breech, pelvic exam - breech = soft, irregular; cephalic = round, firm, smooth
• dx: US, continuous electronic monitoring of baby
• tx: monitor closely for spontaneous version
  
  • external cephalic version
    
    • indications: singleton breech, nonvertex second twin, woman in 36+ wk gest.
    • contra: engagement of presenting part, marked oligohydram, placenta previa, uterine anomalies, nuchal cord, multiple gest., PROM, previous uterine surg, IUGR
    • complications: placental abruption, uterine rupture, ROM with cord prolapse, amniotic fluid embolism, PTL, fetal distress, fetomaternal hemorrhage, fetal demise

Question 2

shoulder dystocia

Answer 2

• inability to deliver shoulders after head has delivered
• RF: fetal macrosomia, GDM, hx shoulder dystocia in prior birth, prolonged 2nd stage labor, instrumental delivery
• sxs: any indications of macrosomia - gentle downward pressure on head fails to deliver anterior shoulder form behind pubic symphysis. Avoid continuing pressure to head to deliver as this is ineffective and can damage brachial plexus
  
  • attempt maneuvers
  • complications: erb palsy, postpartum hemorrhage and lacerations
• tx: hyperfexion of maternal hips (mcroberts maneuver), offer cesarean in future deliveries
• prevention: address hx of shoulder dystocia macrosomia by estimated fetal weight, DM, prolonged 2nd stage, instrumental delivery
• previous hx of dystocia places women at an increased risk dystocia in future preg

Question 3

Fetal Distress

Answer 3

• generally believed that reduced baseline heart rate variability is single most reliable sign of fetal compromise
• sinusoidal: Fetal anemia from Rh-alloimmunization, fetal intracranial hemorrhage, severe asphyxia, fetomaternal hemorrhage, twin-twin tranfusion syndrome, or vasa previa
• early decelerations: normal head compression during uterine contractions (active labor) - in most cases, onset, nadir of decel, and recovery are coincident with beginning, peak, and end of contraction respectively
• late decels: uteroplacental insufficiency - decel occurs after the peak of contraction
• variable decels: umbilical cord compression -> fetal anoxia -> death - abrupt decrease in FHR; decrease in FHR is >/=15 bpm, lasting >/=15s, and <2min in duration

Question 4

Prolapsed umbilical cord

Answer 4

• descent of umbilical cord into lower uterine segment where it may lie adjacent to presenting part (occult) or below presenting part (overt)
• complications: variable fetal heart rate decels during uterine contractions with prompt return of HR as contraction end
• Occult prolapse: cannot be palpated during pelvic exam
  
  • tx: immediate pelvic exam, place patient in lateral sims or trendelenburg - if FHT return to norm, continue labor. Deliver O2 to mom and monitor FHR continuously. Rapid c-sec if compression cont.
• Overt prolapse: associated with ROM and displacement of umbilical cord into vagina
  
  • RF: premi, abnl pres, occiput posterior, pelvic tumors, multiparity, placenta previa, cephalopelvic disproportion
  • MC LIE = TRANSVERSE LIE (20%)
  • US at onset of labor to determine lie and cord position. Cont fetal monitoring
  • tx: pelvic exam, place patient in knee-chest pos., and apply continuous upward pressure against presenting part to lift and maintain fetus away from prolapsed cord

Question 5

PROM etiology, RF, sxs

Answer 5

• RF: genital tract infxn (BV), smoking, prior PPROM, shortened cervical length, amnio
• rupture of membranes before onset of labor
• important cause of PTL, prolapsed cord, placental abruption, and intrauterine infxn
• NIH recommends use of steroids in PROM pts before 32wks in absence of amniotic infxn
• sxs: term >37wk, sudden gush of fluid or continued leakage
  
  • avoid digital exam

Question 6

PROM dx and tx

Answer 6

• dx: hallmark findings are ferning, nitrazine testing (amnio fluid - paper turns blue = alkaline), pooling, CBC and UA, phosphatidyl glycerol (indicates pulm maturity), AFI w/ US
• tx: if chorioamnionitis present, active delivery indicated regardless of gest age
  
  • if no infxn and term, manage expectantly or actively
  • if no infxn and preterm, similar delivery to PTL
  • abx and hydration prolongs latency period by 5-7d - IV ampicillin and IV erythromycin
  • tocolysis: prolongs interval to delivery to gain time for steroids to be administered (only 48h - longer increases risk of infxn)

Question 7

PPROM

Answer 7

• occurs before 37wks
• major risk involved is chorioamnionitis and endometritis
  
  • chorio: cause = myco/ureoplasma, sxs = uterine tenderness, tachycardia (maternal and fetal), foul smelling purulent amniotic fluid, maternal leukocytosis, tx = ampicillin + gentamycin
• tx: if no sign of maternal or fetal iunfxn or distress, expectant management preferred - pt admitted to hospital and put on bedrest
  
  • if under 34wks, steroids administered
  • NST and BPP performed daily to assess fetal well-being
  • amnio checks lung maturity

Question 8

Preterm labor/delivery

Answer 8

• delivery of viable infant before 37 wks gest.
• MCC neonatal deaths not from congenital malformations
• LBW infants born prematurely often have significant developmental delays, cerebral palsy, and lung dz
• RF: smoking, cocain use, uterine malformations, cervical incompetence, infxn, and low prepreg weight
• preterm labor defined as regular uterine contractions (>4-6/hr) between 20-36wks gest. and in the presence of one or more of the following:
  
  • cervical dilation of 2cm or greater at presentation
  • cervical dilation of 1cm or greater on serial exam
  • cervical effacement of greater than 80%
• dx: US - normal length of cervix = 4cm
• tx: bed rest, abx, hydration, steroids, tocolytics (mag sulfate, CCB)