6.Labor and Delivery Complications

you should think postpartum hemorrhage when you find;

• _ vaginal bleeding

• _, _ uterus

• _ (often first)

• _ is a late finding

excessive

boggy, enllarged

tachycardia

hypotension

most common cause of postpartum hemorrhage is uterine _(~70-80%)

atony

_ uterus + _ bleeding = uterine atony until proven otherwise, visual blood loss often underestimates hemorrhage

boggy, heavy

The “4 T’s” of postpartum hemorrhage is a systematic approach to identifying the cause:

• _

• _

• _

• _

the cause will determine the treatment

tone

tissue

trauma

thrombin

if tone is the problem, you should think _ uterus → uterine _ (most common)

boggy, atony

if tissue is the problem, you should think retained _ or placental _

placenta, fragments

if trauma is the issue, you should think it is caused by a _, _, uterine _ (firm uterus with ongoing bleeding)

laceration, hematoma, rupture

if thrombin is the issue, it is caused by _ or impaired _

coagulopathy, clotting

you should suspect uterine atony when postpartum bleeding occurs with:

• _, _ uterus

• _ vaginal bleeding

• failure of the uterus to remain _ after massage

• early signs of _

  • _

  • _

  • _

  • _ is a late finding

Boggy uterus + excessive bleeding = uterine atony until proven otherwise

soft, boggy

heavy

firm

hypovolemia

tachycardia

dizziness

pallor

hypotension

immediate priorities for postpartum hemorrhage:

• call for _ and activate hemorrhage _

• assess uterine _ and estimate blood _

• perform uterine _ if the uterus is boggy

• begin _ therapy (_ is first line)

recognition and early treatment saves lives

help/protocol

tone, loss

massage

uterotonic, oxytocin

if bleeding continues you can

• reassess using the 4 _

• _ treatment based on the cause

Ts

escalate

placental abruption is _ separation of the placenta before delivery

premature

classic presentation of placental abruption is

• _ vaginal bleeding

• _, _ (“board-like”) uterus

• frequent _ or uterine _

• _ fetal heart tracing or fetal distress

_ bleeding → think _

painful

painful, rigid

contractions, hypertonicity

non-reassuring

painful → abruption

in placenta previa, the placenta overlies or lies close to the internal _ _

cervical os

the classic presentation of placenta previa is:

• _, _-_ vaginal bleeding

• _, _ uterus

• _ uterine tone

• fetal status is often _ unless bleeding is severe

you should never perform a _ cervical examination until placenta previa has been excluded by _

painless, bright red

soft, nontender

normal

reassuring

digital, ultrasound

retained placenta is caused by failure of the placenta to completely _ and _

separate and deliver

clinical clues of retained placenta:

• _ postpartum bleeding

• placenta appears _

• uterus may remain _

why it matters:

• prevents effective uterine _

• increases risk of postpartum _ and _

persistent

incomplete

boggy

contraction

hemorrhage/infection

in placental abruption, you will have _ bleeding, _/_ uterus, and fetal _

painful

tender/rigid

distress

in placenta previa, you will have _, _-_ bleeding, _, _ uterus

painless, bright-red

soft, nontender

with a retained placenta, you will have _ bleeding, _ placenta, and poor uterine _

postpartum

incomplete

contraction

shoulder dystocia is the failure of _ to deliver after the fetal head

shoulders

how to recognize shoulder dystocia:

• head delivers, shoulders remain _

• _ sign (head retracts against the _)

• failure of gentle downward _ to complete delivery

impacted

turtle, perineum

traction

why does shoulder dystocia matter?

• obstetric _

• risk of fetal _ from _ compression

• risk of _ injury or _/_ fracture

emergency

hypoxia, cord

brachial plexus

clavicle/humerus

immediate priorities for shoulder dystocia:

• call for help _

• avoid _ downward traction

• _ maneuver

• _ pressure

immediately

excessive

McRoberts

suprapubic

if the shoulder dystocia remains unresolved,

• internal _ maneuvers

• delivery of the _ arm

• additional obstetric maneuvers as needed

clinical pearl: a systematic approach improves the likelihood of a successful vaginal delivery while minimizing maternal and fetal injury

rotational

posterior

uterine rupture is the _-_ disruption of the uterine _

full-thickness

wall

major risk factor for uterine rupture is previous _ delivery or other uterine surgery, most often associated with _ (trial of labor after cesarean)

cesarean

TOLAC

clinical clues of uterine rupture

• _ abdominal pain

• fetal _ _ abnormalities (often the earliest sign)

• loss of fetal _

• vaginal _ and/or maternal _

suspect uterine rupture in a patient attempting _ who develops sudden fetal _ _ abnormalities

sudden

heart rate

station

bleeding

instability

TOLAC

Heart rate

umbilical cord prolapse is when the umbilical cord _ ahead of the _ fetal part

descends

presenting

recognition of umbilical cord prolapse:

• sudden fetal _ or severe variable _

• visible or palpable _ _ after membrane rupture

• most often occurs after rupture of _

bradycardia/decelerations

umbilical cord

membranes

immediate priorities for umbilical cord prolapse:

• relieve _ on the cord

• prepare for _ delivery (usually cesarean)

pressure

emergent

an amniotic fluid embolism is rare but is a _ obstetric emergency

catastrophic

classic presentation of amniotic fluid embolism:

• sudden respiratory _ or _

• _ or cardiovascular collapse

• altered _ status or _

• often followed by _ and massive _

you should think of AFE when a previously stable laboring or postpartum patient suddenly _ without another obvious explanation

distress/hypoxia

hypotension

mental, seizure

DIC, hemorrhage

deteriorates

clinical pearls:

• contractions alone do not define labor, cervical _ does

• _ _ is the most reassuring fetal heart rate finding

• _ bleeding suggest placental abruption, _ bleeding suggests placenta previa

• think of the 4 _ when postpartum hemorrhage persists

• recognize obstetric emergencies early and call for help

change

moderate variability

painful, painless

T’s

key takeaways:

• postpartum _ is the most common obstetric emergency- recognize it early

• use the _ _ to identify the cause of postpartum hemorrhage

• differentiate placental _ and placental _ by the bleeding pattern and uterine findings

• shoulder _ and umbilical cord _ require immediate recognition and coordinated management

• sudden changes in fetal _ _ tracing may be the first sign of an obstetric emergency

• early recognition, prompt intervention, and timely escalation improve maternal and fetal outcomes

hemorrhage

4 T’s

abruption/previa

dystocia/prolapse

heart rate