WH: L25

Placenta Previa

- presence of placental tissue that extends over the internal cervical os

- lower uterine segment lengthens and causes internal os to move away from the placenta

Placenta Previa: what gestation age is it mc

20 weeks

Placenta Previa: how many resolve prior to delivery

90%

If Placenta Previa doesn't resolve, what can it cause

Placental bleeding

How is Placenta Previa often dx

incidental finding on anatomic US around 18-20 weeks

Placenta Previa Persists mc Sx

Painless vaginal bleeding

Placenta Previa: <14mm over the os: probability of previa at delivery

Near zero

Placenta Previa: ≥25mm over the os: probability of previa at delivery

40-100%

Placenta Previa: > 55mm over the os: probability of previa at delivery

100%

When should Placenta Previa be suspected

In any patient >20 wks gestation + bleeding

Placenta Previa confirmatory dx

TVUS

Placenta Previa Asx tx: does not cover os but is <2cm away

Discuss risks/benefits of trial of labor

Placenta Previa Asx tx: covers ths os

Schedule C-section for 36-37+6 weeks

Placenta Previa what to avoid (3)

- digital vaginal exams

- anything that leads to orgasm

- moderate/strenuous exercise, heavy lifting, and prolonged standing >4hr

Placenta Previa acute vaginal bleeding tx

- blood transfusions (keep hgb >10g/dL)

- IV fluids

- admit to L&D unit

Placenta Previa: ID for C-section (4)

- active labor

- category 5 FHR tracing

- inability to stabilize mother

- significant bleeding after 34wks

Placenta Previa tx stable:

- expectant management

- corticosteroids

- iron

- rhogam if mother is RhD (-)

- C-section at 36-37+6wks

Placental Abruption

- premature separation of the placenta ≥ 20wks

- causes blood to accumulate and split off portion of the decidua and placental attachement

Placental Abruption peak time

26-30wks gestation

Placental Abruption sx (2)

- abrupt onset of vaginal bleeding

- abdominal pain

Placental Abruption: best indicator of severity

Abdominal pain

Placental Abruption 100% predictive value lab finding

Fibrinogen ≤ 200

Placental Abruption dx (2)

- clinical/dx of exclusion

- abrupt onset of vaginal bleeding + abd/back pain and contractions

- FHR abnormalities

Placental Abruption US (3)

- retroplacental hematoma

- echogenic debris

- "jello" sign

Placental Abruption transfusion targets (Hct, Plts, Fibrinogen)

- Hct ≥ 25-30%

- Plts ≥ 75,000

- Fibrinogen ≥ 300

Placental Abruption tx all pts

- admit to L&D unit

- US to assess placenta and fetus

- IV fluids

Placental Abruption stable/mild pts

Expectant managment

Placental Abruption severe hemorrhages tx

Immediate delivery

Breech Presentation

Fetus presenting part is the buttocks and/or feet

Breech Presentation High risk for what (2)

- asphyxia

- traumatic injury

Breech Presentation 3 Types

- Frank

- Complete

- Incomplete

Breech Presentation mc

Frank: feet adjacent to the head

Breech Presentation tx

extenal cephalic version (ECV) before labor

ECV

- turn fetus into head down position

- done around 37wks

What to do if ECV is unsuccessful and pt low risk

Trial of labor and vaginal breech birth

Shoulder Dystocia

- OB emergency

- fetal shoulder gets stuck on the pubic symphysis

Shoulder Dystocia dx

- clinical

- fetal head retracts into perineum after expulsion (turtle sign)

Shoulder Dystocia tx

- await next contraction (most resolve)

- McRoberts maneuver

- deliver posterior arm

- Rubin maneuver

McRoberts maneuver

Flex maternal thighs sharply against abdomen

Rubin maneuver

Hand placed on back side of posterior fetal shoulder and rotates

Shoulder Dystocia Fetal Complications (2)

- transient brachial plexus palsy

- clavicular fracture

Shoulder Dystocia Maternal complications (2)

- hemorrhage

- 4th degree lacerations

Umbilical Cord Prolapse

- umbilical cord prolapses into the cervical canal/vagina either before or with baby

- obstetric emergency

Umbilical Cord Prolapse sx

abrupt onset of severe/prolonged fetal bradycardia or variable/late decelerations

Umbilical Cord Prolapse tx

- emergency delivery

- intrauterine resuscitation

Intrauterine resuscitation (3)

- manual elevation of fetal presenting part to unocclude the cord

- place pt in knee-chest position

- administer rapid acting tocolytic to reduce pressure

Cesarean Section ID (3)

- failure to progress during labor

- nonreassuring fetal status

- fetal malpresentation

Cesarean Section Recovery (3)

- acteminophen + NSAIDs

- Avoid lifting anything heavier than the baby

- discharge usually within 48-72hr

Operative vaginal Deliveries

- assisted vaginal birth

- forceps

- vacuum

- no absolute indication

Operative vaginal Deliveries C/I

<34 weeks gestation

Forceps

grasps and steady pulls during contractions/push

Vacuum

- preferred if easy extraction anticipated

- lower risk compared to forceps

Postpartum Hemorrhage Primary/Early

Occurs within first 24hrs after birth

Postpartum Hemorrhage Secondary/late

Between 24hr and 12wks post partum

Postpartum Hemorrhage

- obstetric emergency

- one of the top 5 causes of maternal mortality

Postpartum Hemorrhage criteria (2)

- bleeding greater than expection + signs of hypovolemia

- blood loss ≥ 1000mL

What 2 things happen during Postpartum

- mechanical hemostasis

- local thrombosis

Postpartum Hemorrhage R/F (2)

- prior PHH

- prolonged labor

Postpartum Hemorrhage Causes

4 Ts

Postpartum Hemorrhage 4 Ts

- tone

- trama

- tissue

- thrombin

Postpartum Hemorrhage mc cause

Tone: uterine atony causes uterus to be soft to palpation and prevents mechanical hemostasis from occuring

Postpartum Hemorrhage Prevention (2)

- Oxytocin

- Uterine massage

Postpartum Hemorrhage Signs

Maternal Early Warning Signs (MEWS)

Postpartum Hemorrhage tx

- transfer to OR if unstable

- IV fluids

- switch to transfusion when blood is available

Postpartum Hemorrhage Tone tx

- oxytocin

- uterine massage and compression

- refractory: arterial embolization, laparotomy, or hysterectomy

Postpartum Hemorrhage Tissue tx

- manually remove or curettage retained placenta

- hysterectomy if can't be removed

Neonatal: what to check immediately after delivery

Tone and respirations

Neonatal if not stable

ABCs within 30sec after delivery

Neonatal: Airway

infant on back with neck slightly extended to clear secretions

Neonatal: Breathing

- apnea/gasping and HR

Neonatal: Circulation

- HR