OB/GYN - Labor and Delivery Complications
Terms in this set (52)
What is a prolapsed cord?
Umbilical cord gets in the way in vaginal delivery; emergency bc pressure on the cord from head pressing on it = no support to baby
Risk factors for prolapsed cord?
Breech presentation, compound presentation, PROM, macrosomia, AROM when the head is still high (status more than -1)
What is a compound presentation and what does it put you at risk for?
An extremity appears along with the presenting part. At risk for prolapsed cord.
2 signs required for diagnosis of prolapsed cord?
Palpation of cord in vagina
Fetal heart rate decelerations
Management of prolapsed cord?
Deliver ASAP, with mother in left lateral, trendelenburg, or knee-chest position. Until delivery, manually keep head up and off the umbilical cord.
How much blood loss is defined as postpartum hemorrhage?
More than 500 ml during first 24 hours
Constant, steady seepage
Causes of postpartum hemorrhage?
Hypotonic myometrium - can be due to overdistended uterus, after prolonged (or very quick) labor, vigorous oxytocin stimulation, high parity, retained placental tissue, coagulation defects
Predisposing factors for postpartum hemorrhage?
Large infant, forceps delivery, delivery through an incompletely dilated cervix, hx postpartum hemorrhage in the past
Immediate management of postpartum hemorrhage?
Large bore IV needle for LR
Check uterus: if boggy, massage; if unresponsive, bimanual compression
Check cervix for clots (remove)
Check cervix and vagina for tears, retained placental tissue
How do you perform bimanual compression of the uterus?
One hand in the vagina completely
One hand on the abdomen coming down from the top
Medications for postpartum hemorrhage?
Pitocin by IV
Cytotec (used to induce labor)
Postpartum hemorrhage: after how much blood loss do you give transfusions? What else should you do at this point?
1000 mL or signs of shock
Give O2, foley catheter, may need surgical control of bleeding
What is "retained placenta" and how do you diagnose it?
Placenta hasn't been delivered spontaneously (or all of it) 30 minutes after birth.
Dx: observe the fact above, or you delivered and have continuous bleeding, and placenta is fragmented and looks like there might still be bits in there
Management for retained placenta?
If not expelled normally within 15 minutes, give pitocin in NS into umbilical vein
If not expelled normally within 30 minutes, manually remove placenta; needs anesthesia and prophylactic abx.
After a retained placenta is finally delivered, what do you need to do?
Explore uterus for any membrane fragments left behind
What is "placenta accreta"?
Abnormally adherent placenta
What causes a uterus inversion?
Strong traction of the umbilical cord, fundal pressure, relaxed uterus and it just flips out
Management of inversion of uterus?
Put it back immediately - may need anesthesia, medication to relax the uterus, then bimanual compression until uterine tone is recovered
What is the main complication of uterine inversion?
What must you NOT give until the uterus is back in place?
What are some causes of an elevated temperature in labor/delivery? What is an elevated temperature here?
PROM, frequent vaginal examinations, insertion of fetal monitoring devices, group B streptococcus, dehydration
Management for an elevated temperature in labor/delivery? DDX?
Check temperature regularly, hydrate, check for ketouria (UA + c/s), blood cultures, start abx in mother and baby (ampicillin/gentamycin)
What antibiotics do you give for elevated temperature?
Do you give them to the baby too?
Ampicillin and gentamycin
WBC is always elevated in laboring women, so what do you have to look for as a sign of infx?
What is dystocia?
What generally causes it?
Abnormally slow progression of labor
Decreased uterine forces, fetal malpositions, overdistention of uterus
What are complications of dystocia?
Maternal exhaustion, infection, increased fetal and neonatal mortality
Management of dystocia?
Monitor the fetus, reassess the pelvis, put in an IUPC (intrauterine pressure catheter) After that you basically try to speed it along: give pitocin, AROM, etc.
How do you give pitocin in dystocia? What is the maximum dose?
What else must you monitor?
9U in 150 cc D5W, given 1 mu/min and increasing by 1-2 mu every 30-40 minutes
Maximum dose is 20 mu/min
This is an ADH! Observe urine output
What is the difference between primary, secondary, and elective c/s?
Primary - never had one before
Secondary - repeat c/s
Elective - this is due to a complication such as breech birth or twins
Common indications for c/s?
Dystocia, previous c/s, breech/fetal distress, multiple fetuses, placenta previa, abruptio placenta, pre-eclampsia, obstruction, failed inductions
Complications of a c/s?
Infx, hemorrhage, VTE, urinary tract injury
What are the ONLY conditions in which we want to do a repeat C/s?
In all other cases?
Previous midline vertical uterine incision, repetitive c/s, inadequate pelvis, abnormal presentation, failure to progress.
Otherwise: trial of labor
VBAC is generally safe if they had -
Just one previous c/s birth with a low transverse incision, use of epidural. Do not use misoprostol
What drug is not to be used with VBAC?
In a c/s what steps follow the immediate removal of the fetus?
Manual removal of placenta
What kind of incision is preferred for a uterine incision in c/s?
Transverse through lower uterine (rarely vertical - and if you had that you have to get a c/s next time too)
Postpartum management for a c/s?
When should you start to hear bowel sounds?
Vitals, urinary output, status of fundus, ambulate ASAP. Check hematocrit within 24-48 hours, supplement iron, prophylactic abx, can discharge by day 3
Bowel sounds should be active by 3rd postpartum day
How soon after a c/s can you discharge?
Can you shower and bathe within 24 hours of c/s?
Risk of uterine rupture with VBAC: high or low?
Low, generally speaking
But only attempt this in a facility that could respond to emergencies.
What sort of things raise your risk for a uterine rupture with VBAC?
incision type: the uterine incision extended into the uterine fundus
Single layer uterine closure compared to double closure
More than 1 previous c/s, prior vaginal birth (although lower than c/s)
Increased maternal age
Maternal fever after last c/s
Labor induction with prostaglandins or oxytocin
Controversial - less than 18 months between delivery times
Signs of uterine rupture?
BAD fetal heart rate pattern (bradycardia most common - also variable decelerations where <HR less than 90 for more than 1 minute)
Consequences of uterine rupture?
Death, neurologic sequelae in the baby (seizures, encephalopathy from ischemia), organ failure
Requirements for a forceps delivery?
Head has to be well engaged, vertex (head down, not breech) position of head known exactly, cervix completely dilated, membranes ruptures, and no disproportion between head size and pelvic size (has to fit perfectly)
Why are forceps deliveries done?
If labor isn't progressing or an immediate delivery is required
Which type of forceps is generally used? What are the requirements for this type?
Fetal head has to have reached perineal floor (2+ station) such that scalp is visible at the vaginal introitus already
Why would you do a vacuum delivery?
Labor isn't progressing or an immediate delivery is required
Anesthesia for a forceps delivery?
Complications of a multifetal pregnancy?
Spontaneous abortion, pre-eclampsia, preterm labor, polyhydramnios, placental abruption
Delivery methods for twins, depending on positioning?
Vertex-vertex - can do vaginal delivery; second may take a littel longer
Vertex-non-vertex - patient preference; may do caesareans if they weigh less than 1500 g
Nonvertex first twin - must get c/s (also if you have gross differences in the size of the fetuses)
What is placenta previa? tx?
Placenta gets too close to the cervix and can get in the way of delivery. c/s may be required.
What is abruptio placentae (placental abruption)?
Placenta peels away from the lining of the uterus. If severe, c/s needed; mild, may just monitor
What is Polyhydramnios? Oligohydramnios?
Too much, too little amniotic fluid in the amniotic sac