Labor & Delivery Complications

Question 1

Breech presentation

Answer 1

breech birth happens when a baby is born bottom first instead of head first

Question 2

Dx of breech presentation

Answer 2

The diagnosis of breech presentation is based on physical examination, with ultrasound confirmation if the diagnosis is uncertain]

Question 3

a 20-year-old G2P1 female with gestational diabetes and a pre-pregnancy BMI of 43 presents to her obstetrician in labor. Although the labor originally progresses without complications, delivery becomes stalled as the patient attempts to push the child’s shoulders through the vagina. The head delivers, then suddenly retracts against the pelvis. It will not budge despite maternal pushing and firm downward pressure on the head.

Answer 3

Dystocia

Question 4

when the baby does not exit the pelvis during childbirth due to being physically blocked, despite the uterus contracting normally

Answer 4

Dystocia

Question 5

3 categories of dystocia

Answer 5

1. Problems of Power: uterine contraction
2. Problems of Passenger: presentation, size (macrosomia), or position of the fetus (shoulder Dystocia)
3. Problems of Passage: uterus or soft tissue abnormalities

Question 6

Main causes of shoulder dystocia

Answer 6

• Small pelvis
• Poor contractions
• Macrosomia

Question 7

What is the turtle sign?

Answer 7

Indicates Dystocia

retraction of the delivered head against the maternal perineum

• One characteristic of a minority of shoulder dystocia deliveries is the turtle sign, which involves the appearance and retraction of the baby’s head (analogous to a turtle withdrawing into its shell), and a red, puffy face. This occurs when the baby’s shoulder is obstructed by the maternal pelvis.

Question 8

Tx of shoulder dystocia

Answer 8

• Non-manipulative maneuvers (1st line treatment)
  
  • Suprapubic pressure
  • Flexion of maternal hips (McRoberts maneuver)
• Manipulative maneuvers
  
  • Rotation of fetal shoulders 180 degrees (Wood’s corkscrew)
  • Delivery of posterior arm
• Emergent cesarean section
  
  • Pushing the fetal head back into the vaginal canal with immediate transport to cesarean section (Zavanelli maneuver)

Question 9

What is normal fetal HR

Answer 9

Normal fetal heart rate is between 120-160 bpm

• > 160 for 10 minutes fetal tachycardia
• < 120 for 10 minutes fetal bradycardia

Question 10

the rupture of membranes at ≥ 37 weeks gestation prior to the start of uterine contractions

Answer 10

PROM

Question 11

Major risk of PROM

Answer 11

• Major risk = infection or cord prolapse

Question 12

Sudden “gush” of clear or pale yellow fluid from the vagina that occurs after 37 weeks of gestation

Answer 12

PROM

Question 13

Dx of PROM

Answer 13

Need to confirm that this is truly amniotic fluid

• Speculum - fluid pooling in the posterior fornix
• Nitrazine test - blue (due to elevated pH) determine if this is amniotic fluid - PH > 7.1 means it is positive
• Microscope examination - ferning - take a specimen of the fluid put it on a slide and let it air dry will see “fern pattern” crystallization of the amniotic fluid (crystallization of estrogen and amniotic fluid)

Question 14

Tx of PROM depends on age, what is done if mom is 34 wks or further and what is done if less than 32 wks?

Answer 14

• > 34 weeks – induce labor
• 32-34 weeks collect fluid and check for lung maturity – then induce
• < 32 weeks stop contractions and start 2 doses of steroid injection then deliver the baby – give antibiotics

Question 15

Definition of preterm labor

Answer 15

Delivery of a viable infant before 37 weeks gestation

Question 16

• The earliest gestational age at which a baby has at least 50% chance of survival is approximately

Answer 16

24 weeks

Question 17

The most clinically useful test to differentiate women who are at high risk for impending preterm delivery from those who are not is fetal fibronectin in cervical or vaginal secretions

What is the diagnostic test to ensure preterm labor has occurred

Answer 17

• Placental alpha microglobulin-1 (PAMG-1) has been the subject of several investigations and has been reported to be the single best predictor of imminent spontaneous delivery within 7 days of a patient presenting with signs, symptoms, or complaints of preterm labor. (commercially known as the PartoSure test)

+ Ultrasound

Question 18

What is the tx of preterm labor

Answer 18

Tocolysis ⇒ a number of medications may be useful to delay delivery including nonsteroidal anti-inflammatory drugs, calcium channel blockers, beta mimetics, and atosiban

Question 19

How do tocolytics work to stop preterm labor?

Answer 19

• Tocolytics relax the uterus and are used in the treatment of preterm labor
• The goal is to delay the onset of labor until a course of corticosteroids has been administered to induce fetal lung maturity in the setting of prematurity <34 weeks gestation

Question 20

umbilical cord comes out of the uterus with or before the presenting part of the fetus

Answer 20

Prolapse umbilical cord

Question 21

Why is a prolapsed umbilical cord an obstetric emergency?

Answer 21

• It is an obstetric emergency and depending on the duration and intensity of compression, may lead to fetal hypoxia, brain damage, and death

Question 22

First signs/symptoms of umbilical cord prolapse

Answer 22

sudden and severe decrease in fetal heart rate that does not immediately resolve

Question 23

Tx of prolapse umbilical cord

Answer 23

Immediate cesarean section is the management of choice for a prolapsed umbilical cord

• Other interventions include manual elevation of the presenting fetal part and repositioning of the mother to knee-chest position

Question 24

inflammation of the endometrium, which is the inner lining of the uterus. It is the most common cause of infection after childbirth

Answer 24

Endometritis

Question 25

infection of the endometrium from bacteria that normally live in the female lower genital tract, but it could also be caused by bacteria from outside the body

Answer 25

Endometritis

Question 26

Complication from chronic endometritis

Answer 26

• One potential complication of chronic endometritis, especially when it’s caused by tuberculosis, is Asherman syndrome, also known as intrauterine adhesions

Question 27

Dx of endometritis

Answer 27

The diagnosis of endometritis is usually based on clinical findings. However, an endometrial biopsy can help make the diagnosis, although it’s not routinely done

• On histology, acute endometritis has neutrophils in the endometrium, while in chronic endometritis, the presence of plasma cells in the endometrium is diagnostic

Question 28

Clinical findings of endometritis

Answer 28

• Fever, tachycardia
• Possible vaginal bleed (foul-smell)
• Abdominal pain & uterine tenderness
• 2-3 days post-C-section, postabortal

Question 29

Tx of endometritis

Answer 29

Treatment of endometritis involves the use of antibiotics

• For endometritis that occurs after childbirth, a combination of clindamycin and gentamicin is used
• If endometritis is caused by remaining placental or fetal tissues, dilatation and curettage is done
• For endometritis caused by Chlamydia trachomatis or Neisseria gonorrhoeae, a combination of doxycycline and ceftriaxone is used to treat the infection
• Finally, if endometritis is caused by tuberculosis, the treatment will include the use of anti-tuberculosis drugs such as isoniazid, rifampin, pyrazinamide, and ethambutol

Question 30

When does the uterus decrease in size postpartum?

Answer 30

• At the end of the first postpartum week, it normally will have decreased to the size of a 12-week gestation and is palpable at the symphysis pubis
  
  • In case of abnormal uterine involution, infection and retained products of conception should be ruled out

Question 31

What is normal discharge postpartum?

Answer 31

• Normal postpartum discharge begins as lochia rubra, containing blood, shreds of tissue, and decidua. The amount of discharge rapidly tapers and changes to a reddish-brown color over the next 3–4 days
• Typically during the fifth or sixth week postpartum, the lochial secretions cease as healing nears completion.

Question 32

When does the cervix shrink?

Answer 32

at the end of the first week, it is little more than 1 cm dilated

Question 33

When does ovulation resume postpartum?

Answer 33

Ovulation occurs as early as 27 days after delivery, with a mean time of 70–75 days in nonlactating women and 6 months in lactating women

Question 34

When can women return home after vaginal delivery?

Answer 34

• Although a significant amount of symptomatic morbidity may exist postpartum (painful perineum, breastfeeding difficulties, urinary infections, urinary and fecal incontinence, and headache), most women can return home safely 2 days after normal vaginal delivery if proper education and instructions are given, if confidence exists with infant care and feeding, and if adequate support exists at home

Question 35

When can women resume sexual activities postpartum?

Answer 35

• Sex ⇒ it is safe to resume sexual activity when the woman’s perineum is comfortable and bleeding is diminished
  
  • The median time for the resumption of intercourse after delivery is 6 weeks and the normal sexual response returns at 12 weeks, sexual desire and activity vary tremendously among women

Question 36

What’s the difference between perineal tear and episiotomy?

Answer 36

A perineal tear is distinct from an episiotomy, in which the perineum is intentionally incised to facilitate delivery

Question 37

What are the 4 classifications of tears?

Answer 37

• 1^st degree: perineal skin and vaginal mucosa
• 2^nd degree: injury to the perineal body
• 3^rd degree: through the external anal sphincter
• 4^th degree: injury through the rectal mucosa

Question 38

Which type of tears require surgical repair?

Answer 38

• 3^rd and 4th-degree tears generally require surgical repair
• Among women who experience a third or fourth-degree tear, 60-80% are asymptomatic after 12 months

Question 39

What is considered postpartum hemorrhage?

Answer 39

Defined as losing > 500 mL of blood within the first 24 hours after vaginal delivery or 1,000 ml after a cesarean delivery

Question 40

4 most common causes of hemorrhage

Answer 40

“4 Ts”: Tone, Trauma, Tissue, and Thrombin

• Uterine atony (most common) - defined as a boggy and enlarged uterus - 90% of postpartum hemorrhages
• Genital tract trauma - precipitous labor, operative vaginal delivery (forceps, vacuum extraction)
• Retained placental tissue - occurs when the separation of the placenta from uterine wall or expulsion of placenta is incomplete
• Coagulation Disorders (Thrombin) - a condition that prevents blood clots from forming normally, for example, a genetic disorder like von Willebrand disease or an obstetric condition like eclampsia and placental abruption which may result in a clotting disorder, and these can lead to DIC
  
  • DIC is associated with severe preeclampsia, amniotic fluid embolism, placental abruption

Question 41

MCC of postpartum hemorrhage

Answer 41

• Uterine atony (most common) - defined as a boggy and enlarged uterus - 90% of postpartum hemorrhages

Question 42

Tx of postpartum hemorrhage

Answer 42

• The most common cause—uterine atony—can usually be managed with fundal massage and medications to help the uterus contract (Oxytocin IV, misoprostol). Last resort hysterectomy
• Genital track trauma - lacerations greater than 2 cm are repaired surgically
• Retained placental tissue - placenta accreta (the placenta grows too deeply into the uterine wall) and uterine rupture may require a hysterectomy
• A hematologist should be called for cases of bleeding dyscrasias