Labor and Delivery Complications

Question 1

Preterm birth

Answer 1

Defined as birth before 37 completed weeks of gestation

Most common cause of perinatal morbidity and mortality

Question 2

RF for preterm labor

Answer 2

Previous preterm delivery
Low SES
Non-white race
Maternal age <18 yrs or >40 yrs
Preterm premature rupture of the membranes
Multiple gestation
Maternal hx of one or more spontaneous second trimester abortions

Question 3

Maternal causes of preterm labor

Answer 3

Maternal complications (medical or obstetric)
Maternal behaviors:
-Smoking
-Illicit drug use
-Alcohol use
-Lack of prenatal care
Hx of preterm labor with previous pregnancies

Question 4

Uterine causes of preterm labor

Answer 4

Leiomyomas (particularly submucosal or subplacental)
Uterine septum
Bicornuate uterus
Cervical incompetence- natural or surgical
Exposure to diethylstilbestrol (DES)

Question 5

Infectious causes of preterm labor

Answer 5

Chorioamnionitis
BV
Asymptomatic bacteriuria
Acute pyelonephritis
Cervical/vaginal colonization

Question 6

Fetal causes of preterm labor

Answer 6

Intrauterine fetal death
Intrauterine growth retardation
Congenital anomalies
Abnormal placentation
Polyhydramnios
Multiple gestation
Macrosomia

Question 7

Prognosis of preterm labor

Answer 7

Perinatal survival has improved in babies >27 gestational weeks
Minimal improvement in survival in babies <27 wks

Question 8

Definition of preterm labor

Answer 8

Regular contractions occurring every 10 minutes or less, with each contraction lasting at least 30 secs, accompanied by cervical changes and/or the descent of the fetus into the pelvis, between 20 and 36 wks gestation
Preterm contractions is the term used to describe contractions that do not meet the above criteria

Question 9

Sx of preterm labor

Answer 9

Menstrual-like cramps
Backache
Pelvic pressure
Increased vaginal d/c
Uterine contractions that may be painless

Question 10

Assessment of preterm labor

Answer 10

Uterine monitoring
Fetal fibronectin testing-negative test is reassuring that labor/delivery will not occur within 7-14 days
Cervical eval via u/s- cervical shortening may be appreciated on u/s before it can be noted on vaginal exam
Cultures of cervix and urine

Question 11

Tx of preterm labor

Answer 11

Aggressively treat any confirmed or suspected infections
Reverse dehydration
Left lateral rest
Treat earlier gestations more aggressively
Typically do not start tocolysis after 35-36 wks
From 24-34 wks, steroids have been shown to hasten lung maturity in the fetus

Question 12

Preterm labor tx contraindications

Answer 12

Heavy vaginal bleed suggestive of placental disruption
Fetus with significant anomalies
Intrauterine infection
Advanced labor
Maternal contraindications

Question 13

Premature rupture of membranes

Answer 13

Defined as the rupture of the amniotic membrane before labor

Question 14

What is a contraindication to conservative management of PROM?

Answer 14

Chorioamnionitis

Question 15

In pregnancies before 24 wks, what normally prevents nl development of the alveoli within the fetal lungs?

Answer 15

Inadequate amniotic fluid

Question 16

Causes of PROM

Answer 16

Infection (including BV)
Doubled risk in women who smoke
Previous PROM
Polyhydramnios
Multiple gestation
Premature cervical dilation

Question 17

PROM management

Answer 17

Heavily dependent on gestational age
Must weigh risks against benefits according to gestational age and presence/absence of infection
If very preterm and no signs of infection may try to delay to get steroids in
Do not do a vaginal exam
Sterile speculum exam to confirm ROM and obtain cultures. May be able to visually see whether cervix is open or closed

Question 18

Attitude

Answer 18

Refers to the posturing of the joints and relation of fetal parts to one another
The normal fetal attitude when labor begins is with all joints in flexion

Question 19

Lie

Answer 19

This refers to the longitudinal axis of the fetus in relation to the mother’s longitudinal axis

Question 20

Presentation

Answer 20

This describes the part of the fetus lying over the inlet of the pelvis or at the cervical os

Question 21

Complete breech

Answer 21

Both legs flexed

Question 22

Incomplete breech

Answer 22

One leg flexed, other leg extended

Question 23

Frank breech

Answer 23

Both legs extended

Question 24

RFs for breech

Answer 24

Prematurity
Multiple fetuses
Polyhydramnios
Oligohydramnios
Too roomy uterus
Hydrocephaly
Anencephaly
Uterine abnormalities
Placenta previa
Nuchal cord

Question 25

Complications of breech presentations

Answer 25

Perinatal morbidity and mortality from difficult birth Possible perineal trauma from difficult birth Possible low birth weight d/t prematurity Prolapsed cord Placenta previa (if the cause of the breech) Fetal anomalies Uterine anomalies

Question 26

Position

Answer 26

Describes the relation of the point of reference to one of the eight octanes of the pelvic inlet

Question 27

Engagement

Answer 27

This occurs when the biparietal diameter is at or below the inlet of the true pelvis

Question 28

Station

Answer 28

This references the presenting part to the level of the ischial spines measured in plus or minus centimeters

Question 29

What does an external fetal heart rate monitor do?

Answer 29

Tracks variability in the FHR, which, as the fetus matures, is a marker for fetal well-being -Short-term variability: beat to beat variance -Long-term variability: changes in the rate over time Used to perform non stress and contraction stress testing

Question 30

How to confirm rupture of membranes

Answer 30

Nitrazine paper to test pH- royal blue is suggestive for rupture Nl vaginal pH 4.5-6, with ROM it's greater than or equal to 7 Not 100% accurate as some vaginal infections cause a good deal of wetness and also change nl vaginal pH Other things that can cause a false positive: blood, semen, UTI Can use pool test with speculum inserted in the vagina

Question 31

Fern test

Answer 31

Fluid is applied to a microscope slide and allowed to dry for 10 mins Then observed under microscopy Fern leaf pattern to the slide is diagnostic of ROM

Question 32

When is umbilical cord prolapse most likely?

Answer 32

If presenting part is not engaged If polyhydramnios is present With multiples

Question 33

When does umbilical cord prolapse happen?

Answer 33

Usually happens at time of rupture of membranes

Question 34

Management of umbilical cord prolapse

Answer 34

Fetal presenting part can compress cord Delivery needs to be accomplished ASAP by c-section Pressure must be kept off cord

Question 35

Causes of dystocia

Answer 35

Uterine forces that are not sufficiently strong or appropriately coordinated to efface and dilate the cervix Forces generated by voluntary muscles during the second stage of labor that are inadequate to overcome the nl resistance of the bony birth canal and maternal soft parts Faulty presentation or abnl development of the fetus of such character that the fetus cannot be extruded through the birth canal Abnormalities of the birth canal that form an obstacle to the descent of the fetus

Question 36

Protracted latent phase

Answer 36

Nulliparas: 20 hr or more Multiparas: 14 hr or more

Question 37

Protracted active phase

Answer 37

Nulliparas 1.2 cm/hr or less

Question 38

Protracted descent

Answer 38

Nulliparas 1 cm/hr or less | Multiparas 2 cm/hr or less

Question 39

Secondary arrest of dilation

Answer 39

Arrest greater than or equal to 2 hr

Question 40

Arrest of descent

Answer 40

Arrest greater than or equal to 1 hr

Question 41

Failure of descent

Answer 41

No descent in 2nd stage

Question 42

Arrest patterns in labor

Answer 42

Striking association with cephalopelvic disproportion makes these disorders especially ominous Whenever encountered, arrest patterns should signal the likelihood that a bony impediment exists Prolonged active phase and prolonged second stage are associated with shoulder dystocia

Question 43

What is the most common risk factor for shoulder dystocia?

Answer 43

The use of vacuum or forceps to achieve the delivery

Question 44

Maternal shoulder dystocia risk factors

Answer 44

``` Abnormal pelvic anatomy Gestational DM Post-dates pregnancy Previous shoulder dystocia Short stature ```

Question 45

Fetal shoulder dystocia risk factors

Answer 45

Suspected macrosomia

Question 46

Labor-related shoulder dystocia risk factors

Answer 46

Assisted vaginal delivery Protracted active phase of first-stage labor Protracted second-stage labor

Question 47

Maternal complications of shoulder dystocia

Answer 47

``` Postpartum hemorrhage Rectovagainal fistula Symphyseal separation or diathesis 3rd or 4th degree episiotomy or tear Uterine rupture ```

Question 48

Fetal complications of shoulder dystocia

Answer 48

``` Brachial plexus palsy Clavicular fx Fetal death Fetal hypoxia (with or without permanent neurologic damage) Fracture of the humerus ```

Question 49

Shoulder dystocia delivery

Answer 49

H- Call for help E- Evaluate benefit of episiotomy L- Move legs back to mother's abdomen with the head flat P- Suprapubic pressure E- Enter maneuvers (force internal rotation) R- Remove the posterior arm R- Roll the pt over on hands and knees