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Clin Med > OBGYN: L&D complications > Flashcards

OBGYN: L&D complications Flashcards

1
Q

overall mortality rate of C-sections

A

1 in 1,000

BUT

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2
Q

what is riskier– c section or vaginal delivery

A

c -seciton has 5 times greaer risk vs vag delivery

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3
Q

why is c-section riskier

A
  1. incr postpartum infection
  2. hemorrhage
  3. thromboembolism
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4
Q

four MC indications for C-section

A
  1. dystocia
  2. repeat cesarean
  3. breech pres
  4. fetal distress
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5
Q

absolute indication for c-section

A
  1. previous full thickness, non-transverse incision through myometrium—classical and low vertical incisions
  2. placenta previa
  3. maternal infection (genitals herpes)
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6
Q

what do we add if c-section done after PROM

A

azithromycin

thorough vaginal cleansing with povidone-iodine

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7
Q

all women at high risk of blood clots are given? and when

-how long is it given for

A

*****Heparin

6-12 hrs AFTER c-section–when risk of post partum hemorrhage is low

-continued until she can ambulate

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8
Q

uterine rupture

  • define
  • most occur where and why
  • RF (5)
  • CM
  • tx
  • risk of mortality depends on?
A

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

  1. previous uterine rupture
  2. prior c-section
  3. induction of labor—- esp when using oxytocin
  4. trauma—MVA
  5. 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

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9
Q

fetal morality with uterine rupture

A

35% even with prompt treatment

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10
Q

PP hemorrhage

-definitions with vaginal deliveries and c-sections

A

vaginal: over 500 mL

c-section: over 1,000 mL

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11
Q

number one cause of uterine hemorrahge after delivery

A

uterine atony

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12
Q

MC time for PP hemorrahge to occur

A

first hour after birth

**but can occur up to 8 weeks PP

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13
Q

RF for uterine atony

A
  • multiple gestations
  • fetal macrosomia
  • prolonged labor
  • oxytocic augmentation of labor
  • mag sulfate tx with preeclampsia
  • uterine leiomyomas
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14
Q

RF for uterine atony

CM for uterine atony

A
  • 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
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15
Q

RF for uterine atony

CM for uterine atony

A
  • 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
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16
Q

management for PP hemorrhage

A
  1. bumanueal uterinemassage and compressino
  2. IV oxytocin to increase contractions
  3. if oxytocin doesnt work— give Methylergonovine–>increases strength and rate of uterine contractions
  4. refractory=tamponade or surgical ligation of uterine arteries or arterial emoblization or hysterectomy

OTHERS
IV infusion of packed RBCs and crystalloids

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17
Q

dfine PP period

A

6 weeks after delivery

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18
Q

greatest risk of PP hemorrahge?

A

first hour

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19
Q

greatest risk for thromboembolism

A

first 12 weeks after delivery bc mom is in hypercoaguable state

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20
Q

contraindications for BF

A
  1. street drugs
  2. drinking an excessive amt of ETOH
  3. HIV +
  4. active and untx TB
  5. undergoing breast CA tx
  6. take certain meds
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21
Q

placenta previa

  • define
  • CM
  • MC tri it occurs
A

*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
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22
Q

preterm labor

  • define
  • RF
  • Diagnose
  • managment– for >34 weeks and under 34 weeeks
  • when can they be discharged
A

birth occurring after 20 weeks of labor but before 37 weeks gestation

RF

  • Infections
  • PPROM
  • incompetent cervix

Diagnosis:

  1. documented regular uterine contractions >4-6 hours
  2. 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)
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23
Q

MCC of incompetent cervic

A

previous LEEP procedure

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24
Q

drugs to give to relax uterus (4) aka tocolytics

-which is prefered

A

Indomethecin (NSAID)

Nifedipine (CCB)

Mag Sulfate–DOC **** also has neuroprotection

Terbutaune (adrenergic agonist)

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25
Q

list the three uses of mag sulfta in pregnacy

A
  1. prevent seizures in preeclampsia
  2. slow or stop premature labor
  3. protecting brain of premature babies
26
Q

any birth prior to ___ weeks =preterm

A

37 weeks

27
Q

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?
A

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
28
Q

management of PROM

A
  • 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
29
Q

management of PPROM

A
  • 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
30
Q

when can you NOT give tocolytic

A

<4 cm dilated
+infection
+fetal distress

31
Q

under how many weeks is steroids given for lung maturation

-what steroid

A

BETAMETHASONE
<34 weeks when delivery is at risk

two doses given 24 hours apart OR two doses 12 hrs apart

32
Q

define dystocia

A

difficult birth

  • dysfunctional labor
  • labor does not progress normally aka abnormal labor
33
Q

describe adequate labor

A

four contractions in 10 minutes—each contraction with an amplitude of 50 mmHG

34
Q

three things that can cause dystocia and what is the MC

A

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

35
Q

define arrest of labor

A

4 hours of adequate contractions w/o cervical change

OR

6 hours with inadequate contractions

36
Q

tx for arrest of labor

A

IV oxytocin

C-seciton if baby too big or abnormally positioned

37
Q

risks of administering IV oxytocin (2)

A
  • uterine rupture

- PP uterine atony and hemorrhage

38
Q

macrosomina?

A

fetus >4500 grams or more

39
Q

complications with a macrosomic baby (5)

A
  1. labor dystocia
  2. shoulder dystocia
  3. genital trauma
  4. incr risk of PP hemorrhage
  5. incr risk of puerperal infection—- after baby is out
40
Q

define shoulder dystocia

A

difficult delivery of shoulder

41
Q

how to recognize shoulder dystocia during delivery—-what is the sign called

A

+ turtle sign

–retraction of fetal head

42
Q

if maneuvers for shoulder dystocia dont work, what is the next step to do

A

both clavicles of fetus are fractured

43
Q

umbilical cord prolapse more frequent with what presentation

A

breech

44
Q

what is done for all breech vaginal deliveries

A

episiotomy

45
Q

RF for umbilical cord prolapse (3)

A
  1. low birth wt
  2. malpresentation
  3. long umbilical cord
46
Q

define umbilical cord prolapse

-can lead to?

A

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

47
Q

tx for uterine cord prolapse

A

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.

48
Q

why is C-section 5x higher mortality than vaginal delivery

A

incr risk of PP infections, hemorrahge and thromboembolism

49
Q

four MC indications for C-section

A
  1. dystocia
  2. repeat cesarian–>full thickness non-transverse incisions
  3. breech
  4. fetal distress
    * ***placenta previa
    * **risk of perinatal transmission of infections— HSV
50
Q

management after C-section

A
  1. Azitrhomycin + vaginal cleansing

2. heparin 6-12 hrs after c-section (this is the time when PP hemorhage is lowest)

51
Q

uterine rupture

  • define
  • RF (5)
  • CM
A

-LT to mom and fetus

**complete tear through all layers of uterus

RF

  1. previous uterine ruptures
  2. prior c-section
  3. induction of labor— using IV oxytocin
  4. trauma– MVA
  5. previous myomectomy

CM

  • onset of sudden extreme abdominal pain—worse than labor pain
  • decr or absent uterine contractions
  • vaginal hemorrahging
  • Fetal Bradycardia*******
52
Q

fetal mortality even if ruptured urterus fixed

A

35%

53
Q

define PP hemorrage

  • four main causes and which is MC

- CM

A

more than 500 ml with vaginal delivery

more than 1000 ml with c section

CAUSES

  1. TONE: uterine atony–uterus cannot contract to stop the bleeding—-MC
  2. TISSUE: retained placental tissue
  3. TRAUMA: to cervix, perineum, vagina or uterine rupture, lacerations
  4. THROMBIN: coag abnormalities

CM
*boggy, soft, flaccid uterus with dilated cervix

54
Q

RF For uterine atony (PP hemorrhage)

A
  1. multiple gestations
  2. fetal macrosomia
  3. prolonged labor
  4. oxytocic augentation oflabor
  5. mag sulf to tx preeclampsia
  6. uterine leiomyomas
55
Q

TX PP hemorrhage

A
  1. 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

56
Q

pain at episiotomy site after 3-4 days

A

infection

57
Q

after delivery, breast start to secrete

A

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

58
Q

when is mature milk expressed

A

4-6 weeks

59
Q

Contraindications for BF

A
  • street drugs
  • drink excess of ETOH
  • HIV +
  • active, untx TB
  • underoing BCA tx
  • certian meds
60
Q

women not BF will get menses back when?

A

6-8 weeks

Clin Med (52 decks)

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