Labor and Delivery Complications - OB/GYN EOR

Breech presentation

A fetus whose presenting part is the butt or feet (3-5%)

Developmental dysplasias of the hip, torticollis, mild deformation

Risk factors associated with Breech presentation

hips flexed, knee extended (feet are up near the hear)

Describe a Frank Breech presentation (most common)

Both hips and knees are flexed 

Describe a Complete Breech presentation

1 or both of the hips are not completely flexed

Describe an Incomplete (Footling) Breech presentation

Transverse lie, shoulder is closest to the cervix

Describe a shoulder presentation

Soft mass instead of the normal hard skull on PE, Leopold Maneuvers, U/S to confirm

Diagnostics for a Breech presentation

Leopold Maneuvers

A set of 4 maneuvers that can determine the estimated fetal weight and presenting part of the fetus

External cephalic version (externally rotates the fetus AFTER 37 weeks), tocolytic to prevent contractions during maneuver OR planned C-section

Management of a Breech presentation

Trial of labor

If the External cephalic version is successful, what is the next step

C-section OR trial of vaginal birth if low risk

If the External cephalic version is UNsuccessful, what is the next step

normal labor curve, 37+ weeks, fetal weight of 2500-4000g, frank or complete, absence of anomalies on U/S, BIRTHING HIPS, documentation of fetal head flexion, adequate amniotic fluid volumeA

Criteria for vaginal breech delivery

Dystocia

Abnormal labor that is characterized by a wack progression of labor (leading cause for C-section)

POWER, Passenger, Passage

What are the 3 Ps of normal labor (dystocia results from abnormalities )

Uterine contractions or maternal expulsive forces

Power is characterized by

Position, size, or presentation of the fetus

Passenger is characterized by

pelvis or soft tissues

Passage is characterized by

Uterine contractions don’t contribute enough pressure to cause fetal descent or cervical dilation, too frequent or not frequent enough

Ways that Power can contribute to Dystocia

Macrosomia, breech presentation, shoulder dystocia, wack baby position

Ways that Passenger can contribute to Dystocia

Maternal skeletal or soft tissue abnormalities, cephalopelvic disproportion, tumors, fibroids

Ways that Passage can contribute to Dystocia

Shoulder dystocia

An OB EMERGENCY that is due to the failure of shoulders to spontaneously transverse the pelvis after delivery of the fetal head due to impaction

macrosomia (like due to DM), post-term preg, multiparity, prolonged second stage, forceps delivery, maternal obesity, AMA, epidural anesthesia

Risk factors for shoulder dystocia

Brachial plexus injuries (Klumpke palsy, cerebral palsy), Erb-Duchenne Palsy, clavicular fractures, long bone fractures, fetal 

Fetal complications of shoulder dystocia

Erb-Duchenne Palsy (Erb’s Palsy)

A lesion in the upper trunk that presents with a “waiter’s tip” deformity

Arm in adduction with elbow extension, forearm pronation, wrist flexion with fingers curled up

Describe the Waiter’s tip deformity

Retraction of the baby’s head (turtle sign) into the peritoneum or a red puffy face

Signs of shoulder Dystocia during delivery

McRoberts Maneuver, Wood screw maneuver, intentional fracture of the clavicle, Zavanelli Maneuver (last resort - push head back in and c-section that hoe)

Management of Shoulder Dystocia

Hyperflexion and abduction of the Mother’s hips toward the abdomen with application of suprapubic pressure

Describe the McRoberts Maneuver - resolves most dystocias

110-160

Normal fetal heart rate

Maternal beta blocker therapy, hypothermia, hypoglycemia, hypothyroidism, fetal heart block, interruption of fetal oxygenation, Non-reassuring fetal status (baseline under 80 bpm)

Fetal Bradycardia (under 110) is usually due to

Chorioamnionitis (m/c), maternal fever, infections, medications, hyperthyroidism, elevated catecholamines, fetal anemia, arrhythmias, interruption of fetal oxygenation

Fetal Tachycardia is usually due to

Decreased variability, repetitive late OR severe variable declerations

Signs of non-reassuring fetal status = tachycardia + 

Cord compression

Variable decels are due to

Head compression

Early decels are due to

Uteroplacental insufficiency

Late decels are due to

mirror contraction in timing and shape

Describe the pattern of an early decel

Peak (nadir) occurs after the peak of contraction (only a concern IF recurrent with absent variability or without accelerations)

Describe the pattern of a late decel

decline and return to baseline FHR that vary in timing with contraction (only a concern if repetitive or reaches under 60 bpm)

Describe the pattern of a variable decel (abrupt)

Decrease in FHR by 15+ bpm for more than 2 min but less than 10 (anything over 10 is a change in baseline)

Define a Prolonged deceleration

peaks at 10+ bpm for over 10 sec (under 32 weeks), peaks at 15+ bpm for over 15 secs (32+ weeks)

How are accelerations of FHR defined

Sinusoidal pattern (associated with fetal anemia)

A smooth sine-wave like undulating pattern in FHR baseline with a cycle frequency of 3-5 min of regular amplitude of 5-15 bpm that last longer than 20 min

110-160 bpm baseline, moderate variability, NO late/variable decels

Category I strip requirements

No variability + recurrent late OR recurrent variable OR bradycardia; sinusoidal

Category III strips are characterized by

Increased risk of fetal acidemia (if prolonged of amplitude over 15 bpm), increased risk of hypoxemia,

Interpretation of a cat III strip

All tracings that fall in the middle

Category II strip characteristics

prepare for delivery, Mom in left lateral, IVF bolus, NO uterotonic drugs, scalp stimulation (if acceleration occurs we good)

Gameplan for Cat II or III strips

Premature rupture of Membranes (PROM)

The rupture of the amniotic membrane BEFORE onset of labor

Premature Premature rupture of Membranes (PPROM)

PROM that occurs before 37 weeks

STIs, smoking, prior preterm deliveries, multiple gestation

Risk factors for PROM

gush of fluid or persistent leakage from the vag WITHOUT contractions

PROM is characterized by

Speculum exam (check for pooling of fluid), Nitrazine paper test (turns blue if pH above 6.5), Fern test (amniotic fluid dries in a fern pattern), U/S to check AFI

Diagnostics for PROM

Digital exam (unless delivery is imminent)

What are we NOT going to do with a PROM patient

chorioamnionitis or endometritis (if 24 hrs+), cord prolapse, placental abruption

Complications of PROM

admit with fetal monitoring, wait for labor, monitor for infection

Expectant management of PROM

Chorioamnionitis or labor does not occur within 18 hours

When should a PROM patient be induced (using oxytocin OR PG cervical gel)?

admit and wait for labor

Gameplan for PPROM at over 34 weeks and NO signs of infection or distress

Bethamethasone to enhance fetal lung maturity, Mg Sulfate (neuroprotection if 24-32 weeks), tocolytics to delay labor 48 hours to get the steroids on board (if no signs of infection, under 4 cm, or fetus is chilling)

Gameplan for PPROM at under 34 weeks

Preterm labor

Regular uterine contractions (4-6/hour) + progressive cervical effacement (20-30 mm) and dilatation (3 mm+) between 20-36 weeks

Maternal/Fetal stress (activation of HPA axis), Infection (decidual-chorioamniotic/systemic inflammation), Decidual hemorrhage, pathological uterine distention

Causes of preterm labor

Stress → increased cortisol → Increased corticotropin releasing hormone → Prostaglandins → Cervical changes and ROM

Hormonal changes in preterm labor

Multiple gestations, prior preterm birth, prior cervical procedures, under 17 y/o, over 35 y/o, poor access to healthcare, Type I DM, HTN, thyroid disease, asthma, kidney insufficiency, MDD, anemia, STIs, UTIs, pyelo, endometritis, EtOH, coke, heroin (singular), smoking, Short cervical length, + fetal fibronectin at 22 & 34wks, uterine contractions, vaginal bleeding, placenta previa, placental abruption, polyhydramnios, oligohydramnios, fetal anomaly, assisted reproductive conception

Risk factors for preterm labor

Respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, sepsis, seizures, neurologic impairment

Complications of preterm labor

Cervical dilation 3+ cm, 80%+ effacement, + fetal fibronectin, TVUS

Diagnostics for Preterm labor

R/o infections, Amniocentesis to determine L:S ratio (UNDER 2 means high chance of fucked up lungs)

Workup for preterm labor

Delay with tocolytics + betamethasone (enhance fetal lung) Mg Sulfate (neuroprotection IF 24-32 weeks), Ampicillin for GBS prophylaxis

Management of preterm labor under 34 weeks (anything above just admit for delivery)

Prolapsed umbilical cord

Occurs when the cord extends past the presenting part of the fetus and protrudes into the vagina - results in reduced fetal oxygenation (due to vasospasm or occlusion)

low birth weight, malpresentation, long cord, pelvic deformities, low-lying placentation, polyhydramnios, prematurity

Risk factors for Prolapsed umbilical cord

Sudden onset of severe, prolonged fetal bradycardia or variable decelerations after a previously normal tracing, cord palpable on vaginal exam

Manifestations of Prolapsed umbilical cord

Palpation or visualization, U/S with doppler to clarify

Diagnostics for Prolapsed umbilical cord

EMERGENT C SECTION, preop intrauterine resuscitation (manual elevation of the fetal presenting part until in the OR, trendelenburg or knee to chest), Tocolytics

Management of Prolapsed umbilical cord

32-34 weeks

Nifedipine is the 1st line tocolytic when?

24-32 weeka

Indomethacin is the 1st line tocolytic when?