Tn: Complications Of Labour And Delivery

Front 1

Main complications of labour and delivery?

Back 1

• meconium in amniotic fluid
  
• abnormal progression of labour (dystocia)
  
• shoulder dystocia
  
• umbilical cord prolapse
  
• uterine prolapse
  
• uterine rupture
  
• amniotic fluid embolus
  
• chorioamnionitis
  

Front 2

How common is meconium in amniotic fluid?

Back 2

present early in labour in 10% of pregnancies

may be present in up to 25% of all labours; usually NOT associated with poor outcome but extra care required at time of delivery

Front 3

Etiology of meconium in amniotic fluid?

Back 3

• • likely cord compression ± uterine hypertonus
  
• • may indicate undiagnosed breech
  
• • increasing meconium during labor may be a sign of fetal distress
  

Front 4

Features of meconium in amniotic fluid

Back 4

consistency and colour:

• light yellow/green or dark green-black in color
  
• may be watery or thicker
  

Front 5

Treatment for meconium in amniotic fluid?

Back 5

• • call respiratory therapy, neonatology, or pediatrics to delivery room
  
• • oropharynx suctioning upon head expulsion or immediately after delivery if baby not breathingspontaneously (do NOT stimulate infant before)
  
• • consider amnioinfusion of ~800 mL of IV NS over 50-80 min during active stage of labor and amaintenance dose of ~3 mL/min until delivery
  
• • closely monitor FHR for signs of fetal distress
  

Front 6

Definition of dystocia?

Back 6

• expected patterns of descent of the presenting part and cervical dilatation fail to occur in the appropriate time frame; can occur in all stages of labor

Front 7

Four Ps of dystocia?

Back 7

• Power
  
• Passenger
  
• Passage
  
• Psyche
  

Front 8

Power?

Back 8

• Contractions (hypotonic, incoordinate)
  
• inadquate maternal expulsive efforts
  

Front 9

Passenger?

Back 9

• fetal position
  
• attitude
  
• size
  
• anomalies (hydrocephalus)
  

Front 10

Passage?

Back 10

pelvic structure (CPD)

maternal soft tissue factors (tumours, full bladder/rectum, vaginal septum)

Front 11

Psyche?

Back 11

hormones released in response to stress

psychological and physiological stress

Front 12

Management of dystocia

Back 12

confirm diagnosis of labour

search for factors of CPD

diagnosed if adquate contractions measured by IUPC with no descent/diltation for > 2 h

management: IV oxytocin augmentation with or without amniotomy

Front 13

Risks of dystocia?

Back 13

• maternal stress
  
• maternal infection
  
• pph
  
• need for neonatal resuscitation
  

Front 14

Definition of shoulder dystocia?

Back 14

• impaction of anterior shoulder of fetus against symphysis pubis after fetal head has been delivered
• life threatening emergency

Front 15

Etiology/epidemiology of shoulder dystocia?

Back 15

• incidence 0.15-1.4% of deliveries
• occurs when breadth of shoulders is greater than biparietal diameter of the head

Front 16

Shoulder dystocia risk factors?

Back 16

• maternal: obesity, DM, multiparity
  
• fetal: prolonged gestation, macrosomnia
  
• labour: prolonged 2nd stage
  

Front 17

Clinical features of shoulder dystocia?

Back 17

"turtle sign": head delivered but retracts against inferior portion of pubic symphysis

Front 18

complications of shoulder dystocia?

Back 18

• chest compression by vagina
  
• cord compression by pelvis
  
• hypoxia
  
• brachial plexus injury
  
• fetal fracture
  
• maternal perineal injury
  

Front 19

Treatment of shoulder dystocia?

Back 19

goal: to displace anterior shoulder from behind symphysis pubis; follow a stepwise approach of maneuvers until goal achieved

Front 20

Prognosis of shoulder dystocia?

Back 20

1% risk of long-term disability for infant

Front 21

Definition of umbilical cord prolapse?

Back 21

descent of the cord to a level adjacent to or below the presenting part, causing cord compression between presenting part and pelvis

Front 22

Etiology of umbilical cord prolapse?

Back 22

increased incidence with prematurity/PROM, fetal malpresentation (~50% of cases), low-lying placenta, polyhydramnios, multiple gestation, CPD

Front 23

Clinical features of umbilical cord prolapse?

Back 23

• visible or palpable cord
  
• FHR changes
  

Front 24

Treatment of umbilical cord prolapse

Back 24

• • emergency C/S
  
• • O2 to mother, monitor fetal heart
  
• • alleviate pressure of the presenting part on the cord by placing digit in vagina (maintain thisposition until C/S)
  
• • keep cord warm and moist by replacing it into the vagina ± applying warm saline soaks
  
• • position mother in Trendelenburg or knee-to-chest position
• if fetal demise or too premature (<22 wk), allow labor and delivery

Front 25

Etiology of uterine rupture?

Back 25

associated with previous uterine scar (in 40% of cases), hyperstimulation with oxytocin, grand multiparity, and previous intrauterine manipulation

Front 26

Incidence of uterine rupture?

Back 26

0.5-0.8% incidence, up to 12% with classical incision

Front 27

Clinical features of uterine rupture?

Back 27

• prolonged fetal bradycardia – most common presentation
  
• acute onset abdominal pain
  
• hyper or hypotonic uterine contractions
• vaginal bleed

Front 28

Risk factors for uterine rupture?

Back 28

• uterine scarring
  
• excessive uterine stimulation
  
• uterine trauma
  
• multiparity
  
• uterine abnormalities
  

Front 29

Treatment of uterine rupture?

Back 29

• r/o placental abruption
  
• immediate delivery for fetal survival
  
• maternal stabilization
  

Front 30

Complications for uterine rupture?

Back 30

• maternal mortality: 1-10%
  
• maternal hemorrhage, shock, DIC
  
• amniotic fluid embolus
  
• hysterectomy if uncontrollable hemorrhage
  
• fetal distress
  

Front 31

Amniotic fluid embolus definition?

Back 31

amniotic fluid debris in maternal circulation triggering an anaphylactoid immunologic response

Front 32

Etiology of amniotic fluid embolus?

Back 32

rare comoplication

leading cause of maternal death in induced abortions and miscarraiges

VERY RARE

Front 33

Risk factors for amniotic fluid embolus?

Back 33

• placental abruption
  
• rapid labour
  
• multiparity
  
• uterine rupture
  
• uterine manipulation
  

Front 34

DDX of amniotic fluid embolus?

Back 34

• PE
  
• drug-induced anaphylaxis
  
• septic shock
  
• eclampsia
  
• HELLP syndrome
  
• abruption
  
• chronic coagulopathy
  

Front 35

Clinical features

Back 35

• sudden onset of resp distress
  
• CV collapse
  
• coagulopathy
  
• seizure in 10%
  
• ARDS and left ventricular dysfunction in survivors
  

Front 36

Management of amniotic fluid embolus?

Back 36

• supportive measures
  
• coagulopathy correction
  
• ICU admission
  

Front 37

Definition of chorioamnionitis?

Back 37

infection of the chorion,

amnion,

and amniotic fluid typically due to ascending infection by organisms of normal vaginal flora

Front 38

Etiology of chorioamnionitis?

Back 38

incidence 1-5% of term pregnancies and up to 25% in preterm deliveries

Front 39

Risk factors for chorioamnionitis?

Back 39

• prolonged ROM
  
• long labour
  
• multiple vaginal exams during labour
  
• internal monitoring
  
• bacterial vaginosis
  

Front 40

Clinical features for chorioamnionitis?

Back 40

• maternal fever
  
• maternal or fetal tachycardia
  
• uterine tenderness
  
• foul and purulent cervical discharge
  

Front 41

Investigations for chorioamnionitis?

Back 41

• CBC: leukocytosis
  
• amniotic fluid: leukocytes or bacterial
  

Front 42

Treatment for chorioamnionitis?

Back 42

• IV antibiotics (amp and gent)
  
• anaerobic coverage
  
• expedient delivery regardless of gestational age
  

Front 43

Complications for chorioamnionitis?

Back 43

• bacteremia of mother or fetus
  
• wound infection of CS
  
• pelvic abscesses
  
• infant meningitis