OBGYN: L&D complications Flashcards
overall mortality rate of C-sections
1 in 1,000
BUT
what is riskier– c section or vaginal delivery
c -seciton has 5 times greaer risk vs vag delivery
why is c-section riskier
- incr postpartum infection
- hemorrhage
- thromboembolism
four MC indications for C-section
- dystocia
- repeat cesarean
- breech pres
- fetal distress
absolute indication for c-section
- previous full thickness, non-transverse incision through myometrium—classical and low vertical incisions
- placenta previa
- maternal infection (genitals herpes)
what do we add if c-section done after PROM
azithromycin
thorough vaginal cleansing with povidone-iodine
all women at high risk of blood clots are given? and when
-how long is it given for
*****Heparin
6-12 hrs AFTER c-section–when risk of post partum hemorrhage is low
-continued until she can ambulate
uterine rupture
- define
- most occur where and why
- RF (5)
- CM
- tx
- risk of mortality depends on?
complete tear through all layers of uterus
life threatening to both mom and fetus
most occur during labor AND at the site of a prior c-section
RF
- previous uterine rupture
- prior c-section
- induction of labor—- esp when using oxytocin
- trauma—MVA
- previous myomectomy
CM
- sudden onset of extreme abdominal pain—WORSE than labor pain
- decr or absent uterine contractions
- vaginal hemorrhaging
- fetal bradycardia***
TX
- immediate laparotomy and delivery of fetus
- repair of uterus or hysterectomy
- if repair is done— all future pregnancies wil. be scheduled for c-section deliveires at 36 weeks
If not tx promptly— the mom will die
risk of mortality depends on if rupture occured at the site of placenta
fetal morality with uterine rupture
35% even with prompt treatment
PP hemorrhage
-definitions with vaginal deliveries and c-sections
vaginal: over 500 mL
c-section: over 1,000 mL
number one cause of uterine hemorrahge after delivery
uterine atony
MC time for PP hemorrahge to occur
first hour after birth
**but can occur up to 8 weeks PP
RF for uterine atony
- multiple gestations
- fetal macrosomia
- prolonged labor
- oxytocic augmentation of labor
- mag sulfate tx with preeclampsia
- uterine leiomyomas
RF for uterine atony
CM for uterine atony
- multiple gestations
- fetal macrosomia
- prolonged labor
- oxytocic augmentation of labor
- mag sulfate tx with preeclampsia
- uterine leiomyomas
CM
- bleeding
- Boggy soft and flaccid uterus with dilated cervix
RF for uterine atony
CM for uterine atony
- multiple gestations
- fetal macrosomia
- prolonged labor
- oxytocic augmentation of labor
- mag sulfate tx with preeclampsia
- uterine leiomyomas
CM
- bleeding
- Boggy soft and flaccid uterus with dilated cervix
management for PP hemorrhage
- bumanueal uterinemassage and compressino
- IV oxytocin to increase contractions
- if oxytocin doesnt work— give Methylergonovine–>increases strength and rate of uterine contractions
- refractory=tamponade or surgical ligation of uterine arteries or arterial emoblization or hysterectomy
OTHERS
IV infusion of packed RBCs and crystalloids
dfine PP period
6 weeks after delivery
greatest risk of PP hemorrahge?
first hour
greatest risk for thromboembolism
first 12 weeks after delivery bc mom is in hypercoaguable state
contraindications for BF
- street drugs
- drinking an excessive amt of ETOH
- HIV +
- active and untx TB
- undergoing breast CA tx
- take certain meds
placenta previa
- define
- CM
- MC tri it occurs
*placenta covers part of internal cervical os
CM
- Painless*** vaginal bleeding in otherwise healthy pregnancy
- MC in 3rd trimester
diagnosis
*transabdominal sonogram can detect and/or diagnose previa
tx
- dep on gestational age and amt of bleeding
1. preterm: goal is allow fetal maturation W/O compromising mom’s health—–but if bleeding is excessive, prompt C-section must be done REGARDLESS of gestational age
preterm labor
- define
- RF
- Diagnose
- managment– for >34 weeks and under 34 weeeks
- when can they be discharged
birth occurring after 20 weeks of labor but before 37 weeks gestation
RF
- Infections
- PPROM
- incompetent cervix
Diagnosis:
- documented regular uterine contractions >4-6 hours
- documented cervical change—-effacement of 80% or dilation 3cm+
IF 34 weeks or later:
1. admit for delivery
- ***bed rest + fluids— contractions can cease in about 20% of patients
- **can be dicharged after 4-6 hours if no progressive cervical dilation or effacement
IF UNDER 34 weeks:
- admit and start fetal monitoring
- give BETAMETHASONE
- tocolytics–MAG SULFATE can be given to DELAY delivery up to 48 hrs—- allowing betamethasone to work
- ABX for GBS prophylaxis (usually no time to test mom)
MCC of incompetent cervic
previous LEEP procedure
drugs to give to relax uterus (4) aka tocolytics
-which is prefered
Indomethecin (NSAID)
Nifedipine (CCB)
Mag Sulfate–DOC **** also has neuroprotection
Terbutaune (adrenergic agonist)
list the three uses of mag sulfta in pregnacy
- prevent seizures in preeclampsia
- slow or stop premature labor
- protecting brain of premature babies
any birth prior to ___ weeks =preterm
37 weeks
Premature rupture of membranes (PROM)
- define
- poses risk of?
- if rupture occurs at 37 weeks or beyond?
- if rupture occurs before 37 weeks?
- RF (4)
- diagnosis?
premature rupture B4 osnet of labor during ANY stage of gestation
Risk for maternal and fetal infection **
at or after 37 weeks= PROM—> we just delivery baby
Before 37 weeks=Preterm Premature RUpture of Membranes (PPROM)— water broke b4 full term—–we do not want to delivery baby since its premature
RF
- vaginal and cervical infections
- smoking
- multple gestatinos
- prior preterm delivery
DIagnosis
- sterile spectulum exam
- confirmatory–>test fluid with Nitrazine paper– turns blue in presence of alkaline amniotic fuid
- —– then take this and put under microscope– will see FERNING
management of PROM
- admit
- fetal monitoring
- await spontaneous labor—- most go into labor within 24 hrs
- monitor for infection
- if labor or infection does not occur prior to 18 hours—— induce labor
management of PPROM
- admit + fetal monitoring
- IF 34 weeks or less–>BETAMETHASONE
- tocolytics can delay delivery
- ampicillin + azithromycin to prevent infection
- prompt delivery is s/s of fetal infection/distress or materal
when can you NOT give tocolytic
<4 cm dilated
+infection
+fetal distress
under how many weeks is steroids given for lung maturation
-what steroid
BETAMETHASONE
<34 weeks when delivery is at risk
two doses given 24 hours apart OR two doses 12 hrs apart
define dystocia
difficult birth
- dysfunctional labor
- labor does not progress normally aka abnormal labor
describe adequate labor
four contractions in 10 minutes—each contraction with an amplitude of 50 mmHG
three things that can cause dystocia and what is the MC
POWERS–>frequency or intesnisty of contractions not adequate—MC
PASSENGER–>large fetal sie, abnormal position, presentation, lie
PASSAGE–>maternal bony pelvic too small or narrow
define arrest of labor
4 hours of adequate contractions w/o cervical change
OR
6 hours with inadequate contractions
tx for arrest of labor
IV oxytocin
C-seciton if baby too big or abnormally positioned
risks of administering IV oxytocin (2)
- uterine rupture
- PP uterine atony and hemorrhage
macrosomina?
fetus >4500 grams or more
complications with a macrosomic baby (5)
- labor dystocia
- shoulder dystocia
- genital trauma
- incr risk of PP hemorrhage
- incr risk of puerperal infection—- after baby is out
define shoulder dystocia
difficult delivery of shoulder
how to recognize shoulder dystocia during delivery—-what is the sign called
+ turtle sign
–retraction of fetal head
if maneuvers for shoulder dystocia dont work, what is the next step to do
both clavicles of fetus are fractured
umbilical cord prolapse more frequent with what presentation
breech
what is done for all breech vaginal deliveries
episiotomy
RF for umbilical cord prolapse (3)
- low birth wt
- malpresentation
- long umbilical cord
define umbilical cord prolapse
-can lead to?
cord extends beyond the presenting part of the fetus and protrudes throggh vagina
—>can lead to decr oxygenatioon to fetus bc lots of pressure is put on the cord since the head is pressing on it
tx for uterine cord prolapse
Preoperative intrauterine resuscitation to increase O2 delivery to the placenta, including manually elevating the fetal presenting part to prevent compression, placing the patient in trendelenberg, holding the cord above the mother’s belly.
If vaginal delivery is not pending, EMERGENCY C-SECTION to avoid fetal compromise or death.
why is C-section 5x higher mortality than vaginal delivery
incr risk of PP infections, hemorrahge and thromboembolism
four MC indications for C-section
- dystocia
- repeat cesarian–>full thickness non-transverse incisions
- breech
- fetal distress
* ***placenta previa
* **risk of perinatal transmission of infections— HSV
management after C-section
- Azitrhomycin + vaginal cleansing
2. heparin 6-12 hrs after c-section (this is the time when PP hemorhage is lowest)
uterine rupture
- define
- RF (5)
- CM
-LT to mom and fetus
**complete tear through all layers of uterus
RF
- previous uterine ruptures
- prior c-section
- induction of labor— using IV oxytocin
- trauma– MVA
- previous myomectomy
CM
- onset of sudden extreme abdominal pain—worse than labor pain
- decr or absent uterine contractions
- vaginal hemorrahging
- Fetal Bradycardia*******
fetal mortality even if ruptured urterus fixed
35%
define PP hemorrage
- four main causes and which is MC
- CM
more than 500 ml with vaginal delivery
more than 1000 ml with c section
CAUSES
- TONE: uterine atony–uterus cannot contract to stop the bleeding—-MC
- TISSUE: retained placental tissue
- TRAUMA: to cervix, perineum, vagina or uterine rupture, lacerations
- THROMBIN: coag abnormalities
CM
*boggy, soft, flaccid uterus with dilated cervix
RF For uterine atony (PP hemorrhage)
- multiple gestations
- fetal macrosomia
- prolonged labor
- oxytocic augentation oflabor
- mag sulf to tx preeclampsia
- uterine leiomyomas
TX PP hemorrhage
- bimanual uterine massage + compression
1st drug= IV oxytocin
2nd drug if 1st doesnt work–>Methylergonovine
**refractory= tamponade, surgical ligation of uterine artery, arterial embolization or hysterectomy
OTHER: IV infusions of RBCs and crystalloid fluids
pain at episiotomy site after 3-4 days
infection
after delivery, breast start to secrete
colostrum—- deep lemon/yellow liquid
*rich in immunological components and has more minerals and AAs vs mature milk
has IgA protecting fetus from enteric pathogens
when is mature milk expressed
4-6 weeks
Contraindications for BF
- street drugs
- drink excess of ETOH
- HIV +
- active, untx TB
- underoing BCA tx
- certian meds
women not BF will get menses back when?
6-8 weeks
