Labor & Delivery Complications Flashcards
Breech presentation
breech birth happens when a baby is born bottom first instead of head first
Dx of breech presentation
The diagnosis of breech presentation is based on physical examination, with ultrasound confirmation if the diagnosis is uncertain]
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.
Dystocia
when the baby does not exit the pelvis during childbirth due to being physically blocked, despite the uterus contracting normally
Dystocia
3 categories of dystocia
- Problems of Power: uterine contraction
- Problems of Passenger: presentation, size (macrosomia), or position of the fetus (shoulder Dystocia)
- Problems of Passage: uterus or soft tissue abnormalities
Main causes of shoulder dystocia
- Small pelvis
- Poor contractions
- Macrosomia
What is the turtle sign?
Indicates Dystocia
retraction of the delivered head against the maternal perineum
- One characteristic of a minority of shoulder dystocia deliveries is the turtle sign, which involves the appearance and retraction of the baby’s head (analogous to a turtle withdrawing into its shell), and a red, puffy face. This occurs when the baby’s shoulder is obstructed by the maternal pelvis.
Tx of shoulder dystocia
-
Non-manipulative maneuvers (1st line treatment)
- Suprapubic pressure
- Flexion of maternal hips (McRoberts maneuver)
-
Manipulative maneuvers
- Rotation of fetal shoulders 180 degrees (Wood’s corkscrew)
- Delivery of posterior arm
-
Emergent cesarean section
- Pushing the fetal head back into the vaginal canal with immediate transport to cesarean section (Zavanelli maneuver)
What is normal fetal HR
Normal fetal heart rate is between 120-160 bpm
- > 160 for 10 minutes fetal tachycardia
- < 120 for 10 minutes fetal bradycardia
the rupture of membranes at ≥ 37 weeks gestation prior to the start of uterine contractions
PROM
Major risk of PROM
- Major risk = infection or cord prolapse
Sudden “gush” of clear or pale yellow fluid from the vagina that occurs after 37 weeks of gestation
PROM
Dx of PROM
Need to confirm that this is truly amniotic fluid
- 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
- Microscope examination - ferning - take a specimen of the fluid put it on a slide and let it air dry will see “fern pattern” crystallization of the amniotic fluid (crystallization of estrogen and amniotic fluid)
Tx of PROM depends on age, what is done if mom is 34 wks or further and what is done if less than 32 wks?
- > 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
Definition of preterm labor
Delivery of a viable infant before 37 weeks gestation
- The earliest gestational age at which a baby has at least 50% chance of survival is approximately
24 weeks
The most clinically useful test to differentiate women who are at high risk for impending preterm delivery from those who are not is fetal fibronectin in cervical or vaginal secretions
What is the diagnostic test to ensure preterm labor has occurred
- Placental alpha microglobulin-1 (PAMG-1) has been the subject of several investigations and has been reported to be the single best predictor of imminent spontaneous delivery within 7 days of a patient presenting with signs, symptoms, or complaints of preterm labor. (commercially known as the PartoSure test)
+ Ultrasound
What is the tx of preterm labor
Tocolysis ⇒ a number of medications may be useful to delay delivery including nonsteroidal anti-inflammatory drugs, calcium channel blockers, beta mimetics, and atosiban
How do tocolytics work to stop preterm labor?
- Tocolytics relax the uterus and are used in the treatment of preterm labor
- The goal is to delay the onset of labor until a course of corticosteroids has been administered to induce fetal lung maturity in the setting of prematurity <34 weeks gestation
umbilical cord comes out of the uterus with or before the presenting part of the fetus
Prolapse umbilical cord
Why is a prolapsed umbilical cord an obstetric emergency?
- It is an obstetric emergency and depending on the duration and intensity of compression, may lead to fetal hypoxia, brain damage, and death
First signs/symptoms of umbilical cord prolapse
sudden and severe decrease in fetal heart rate that does not immediately resolve
Tx of prolapse umbilical cord
Immediate cesarean section is the management of choice for a prolapsed umbilical cord
- Other interventions include manual elevation of the presenting fetal part and repositioning of the mother to knee-chest position
inflammation of the endometrium, which is the inner lining of the uterus. It is the most common cause of infection after childbirth
Endometritis
infection of the endometrium from bacteria that normally live in the female lower genital tract, but it could also be caused by bacteria from outside the body
Endometritis
Complication from chronic endometritis
- One potential complication of chronic endometritis, especially when it’s caused by tuberculosis, is Asherman syndrome, also known as intrauterine adhesions
Dx of endometritis
The diagnosis of endometritis is usually based on clinical findings. However, an endometrial biopsy can help make the diagnosis, although it’s not routinely done
- On histology, acute endometritis has neutrophils in the endometrium, while in chronic endometritis, the presence of plasma cells in the endometrium is diagnostic
Clinical findings of endometritis
- Fever, tachycardia
- Possible vaginal bleed (foul-smell)
- Abdominal pain & uterine tenderness
- 2-3 days post-C-section, postabortal
Tx of endometritis
Treatment of endometritis involves the use of antibiotics
- For endometritis that occurs after childbirth, a combination of clindamycin and gentamicin is used
- If endometritis is caused by remaining placental or fetal tissues, dilatation and curettage is done
- For endometritis caused by Chlamydia trachomatis or Neisseria gonorrhoeae, a combination of doxycycline and ceftriaxone is used to treat the infection
- Finally, if endometritis is caused by tuberculosis, the treatment will include the use of anti-tuberculosis drugs such as isoniazid, rifampin, pyrazinamide, and ethambutol
When does the uterus decrease in size postpartum?
- At the end of the first postpartum week, it normally will have decreased to the size of a 12-week gestation and is palpable at the symphysis pubis
- In case of abnormal uterine involution, infection and retained products of conception should be ruled out
What is normal discharge postpartum?
- Normal postpartum discharge begins as lochia rubra, containing blood, shreds of tissue, and decidua. The amount of discharge rapidly tapers and changes to a reddish-brown color over the next 3–4 days
- Typically during the fifth or sixth week postpartum, the lochial secretions cease as healing nears completion.
When does the cervix shrink?
at the end of the first week, it is little more than 1 cm dilated
When does ovulation resume postpartum?
Ovulation occurs as early as 27 days after delivery, with a mean time of 70–75 days in nonlactating women and 6 months in lactating women
When can women return home after vaginal delivery?
- Although a significant amount of symptomatic morbidity may exist postpartum (painful perineum, breastfeeding difficulties, urinary infections, urinary and fecal incontinence, and headache), most women can return home safely 2 days after normal vaginal delivery if proper education and instructions are given, if confidence exists with infant care and feeding, and if adequate support exists at home
When can women resume sexual activities postpartum?
-
Sex ⇒ it is safe to resume sexual activity when the woman’s perineum is comfortable and bleeding is diminished
- The median time for the resumption of intercourse after delivery is 6 weeks and the normal sexual response returns at 12 weeks, sexual desire and activity vary tremendously among women
What’s the difference between perineal tear and episiotomy?
A perineal tear is distinct from an episiotomy, in which the perineum is intentionally incised to facilitate delivery
What are the 4 classifications of tears?
- 1st degree: perineal skin and vaginal mucosa
- 2nd degree: injury to the perineal body
- 3rd degree: through the external anal sphincter
- 4th degree: injury through the rectal mucosa
Which type of tears require surgical repair?
- 3rd and 4th-degree tears generally require surgical repair
- Among women who experience a third or fourth-degree tear, 60-80% are asymptomatic after 12 months
What is considered postpartum hemorrhage?
Defined as losing > 500 mL of blood within the first 24 hours after vaginal delivery or 1,000 ml after a cesarean delivery
4 most common causes of hemorrhage
“4 Ts”: Tone, Trauma, Tissue, and Thrombin
- Uterine atony (most common) - defined as a boggy and enlarged uterus - 90% of postpartum hemorrhages
- Genital tract trauma - precipitous labor, operative vaginal delivery (forceps, vacuum extraction)
- Retained placental tissue - occurs when the separation of the placenta from uterine wall or expulsion of placenta is incomplete
-
Coagulation Disorders (Thrombin) - a condition that prevents blood clots from forming normally, for example, a genetic disorder like von Willebrand disease or an obstetric condition like eclampsia and placental abruption which may result in a clotting disorder, and these can lead to DIC
- DIC is associated with severe preeclampsia, amniotic fluid embolism, placental abruption
MCC of postpartum hemorrhage
- Uterine atony (most common) - defined as a boggy and enlarged uterus - 90% of postpartum hemorrhages
Tx of postpartum hemorrhage
- The most common cause—uterine atony—can usually be managed with fundal massage and medications to help the uterus contract (Oxytocin IV, misoprostol). Last resort hysterectomy
- Genital track trauma - lacerations greater than 2 cm are repaired surgically
- Retained placental tissue - placenta accreta (the placenta grows too deeply into the uterine wall) and uterine rupture may require a hysterectomy
- A hematologist should be called for cases of bleeding dyscrasias
