Labour and delivery and their complications Flashcards
Discuss limitations of the ED for the delivery of babies
Unlike the obstetric suite the ED is often lacking appropriate resources suchas a tocydnamometry, intrauterine pressure monitors, vacuum extractors and forceps
In addition the obstetrician typically has prenatal care infomariotn including accurate gestational dates, presence of placental anatomy and prior documented obstretric complications. This information is often difficult or impossible to obtain while preparing for precipitus labour
C-section is sometimes indicated and this is not performed in the ED unless in dire perimortem circumstances
Discuss epidemiology of the emergency delivery
in the US the perinatal mortality rate is 6.26/1000 live births at 28 weeks of gestation or more.
Delivery complications and mortality is much high in the ED approx 8-10%
THe ed is often selected by an obsetric population that has psychosocial factors such as drug or alcohol abuse, domestic violence or lack of access to health care. THese women often have little or no antenatal care
Antepartum haemorrhage, PROM, eclampsia, prmature labor, abruptio placentae, malpresenation and umbilical cord emergenices are overrepresented in the ED
Discuss distinguishing true and false labor
Whenever a women in her thrid trimester presents to the ED there is always the chance that hse is in labor. A wide array of non specific symptoms may herald the onset of labour. Abdojminal pain, back pain, cramping, nausea and vomtiing, urinary urgency, stress incontinence and anxiety can all be symptoms of labour
Braxton Hicks contraction occur after 30 weeks of gestation in which the previously small and uncoordinated contractions of the uterus become more synchronous and may be percieved by the mother.
THey do not escalate in intensity or frequency, are not associated with cervical dilatation or effacement. Membrans should be intact be carfeul to not rupture prematurely and induce premature labour
Discuss bloody show
At the onset of labour the cervical mucous plug may be expelled resulting in “nbloody show””. Bleeding is usually slight and is due to the increase in cervical vasuclarity that occurs in pregnancy.
Does not contraindicate vaginal examination.
If larger amount of bleeding consider antenatal haemorrhage causes
Discuss the first stage of labour
The first stage of labour is the cervical stage ending with compeltey dilated fully effaced cervix. It is divided into a latent phase with slow cervical dilatation and an active phase with more rapid dilatation.
The rapid phase begins after 3cm of cervical dilataion
Most women who deliver in the ED arrive in the active phase of stage 1 or early stage 2
Nulliparious women the first stage takes 8 hours and 5 hours for multiparous
Discuss estimating foetal age based on fundal height
Fundus is at the umbilcus at 20 weeks Every cm higher than this represents a week until 36 weeks at which time the foetus drops into the pelvis
Discuss leopolds maneuvers
Used to confirm the lie of the foetus
Four steps
1)reveals which foetal part occupires the fundus
2) revelas the foetal back
3) Foetal part lying in the pelvic inlet
4) the cephalic prominence
Ultrasound can also be used to determine lie of the foetus
Discuss physical exam to determine stage of labour
Sterile approach using sterile gloves, sterile spec and iodine solution is indicated to prevent ascending infection
1) effacement refers to the thickness of the cervix. A paper thin cervix is 100% effaced
2) dilation indicates diameter of cervical opening
3) position describes the relationship of the feotal presenting part to the birth canal. The most common position of the head is occiput anteiror
4) Station indicates the relationship of the presenting foetal part to the maternal ischial spines (Head at the level of the ischaial spines is 0 station range from +5 to -5)
5) Presentation specifies the anatomic part of the foetus leading throught he birth canal
On digital exam the presenting part is the occiput on vertex in 95% of deliveries. On digital exam the smooth surface and bony contours are felt. There are 4 suture lines extending from the anterior fontenelle and 3 form the posterior
Describe the second stage of labour
The second stage of labour is characterized by a fully dialted cervix accompanied by the urge to bear down.
Median duration is 50 minutes in nulparrous and 20 minutes in multiparous
As stage 2 progresses preparation for delivery shoudl be underway A radiant warmer should be available and heated. Neonatal resuscitation adjucts avaialbe inlcluding towels, scissors, umbilical clamps, bulb suction, airway equipment and equipment to achieve vascular access.
Firm digital stretching of the perineum particulalry posteriorly may prevent tears or lacerations.
Controlled co-ordinated expulsion with coaching to sustain each push aids with crowning and delivery of the head.
The most vulnerable moment is when the foetal head begins to stretch and distend the perineum. Intructing the mother to pant and not push slows the passage of the head and shoulder.
The modified Ritgen maneuver may be used to support the perinuem and prevent maternal injury,
After the head is delivered the head is allowed to rotate toward the maternal thigh and clear the feotal face and airway, ensure cord not wrapped around feotal neck. THe shoulder usually anteiror shoulder clear the perineum. They often delivery spontaneously without aid from the physician. Gentle downward traction on the head promotes delivery. A subsequent upward motion pulls the posterior shoulder thorugh the pelvic outlet
As the infant clears the perineum attention focuses on the umbilical cord. The infant should be kept low or at the level of the perineum to promote blood flow to the infant. The cord is then clamped and curt. Clamps are placed 4-5 cm apart with a proximal clamp 10 cm from the umbi of the infant. An adequate umbi stump is improtant for venous access if needed. Suctioning of the nose and mouth at this time may reduce secreiton that can cause increased airway resistance .
Discuss episiotomy
With controlled deivery routine episiotomy is not recommended. Performed for breech or shoulder dystocia. Should be done before excessive stretching of the perineal muscles occur but near the time of delivery toavoid excessive bleeding.
COmmon parctice is to cut the episiotomy when the head is visible during a contraction and the introitus opens to a diameter of c-4 cm. Mediolateral incision is recommened to avoid tears and rectal involvement
Describe the third stage of labor
Involves the delivery of the placenta and frequent checks of of uterine tone.
Signs of placental separation include the uterus becoming firmer and rising, umbilcial lengths 5-10 cm or there is a gush of blood.
THis usually occurs wihtin 5-10 minutes of delivery of the child
Beyond 18 minutes there is an increase in PPH and at 30 minutes it is 6 times greater
ACtive management of the placenta includes administration of utertonics (oxytoxin 10 units IM) gentle traciton of the clamped umbilical cord with mild pressure abvoe the symphysis pubis and uterine massage after delivery
Any attempts to delivery the placenta before it separates is contraindicated
Examination of the umbilical and placenta is essential. 2 vesel umbi cord occur in 1/500 births. Common placental abnormalities include accessory lobes and abnormal cord insertion. Visible clots adherent to the uterus raise concerns about an abruption and missing tissue should be a warning to PPH
Discuss the fourth srtage of labour
First hour after delivery of the placenta and is a critcal period in which PPH can occur.
Vagina and fornices should be examined for deep laceration and oxytocin should be infused to promte contraction of the uterus and control haemorrhage.
Discuss antenatal foetal monitoring during labour
During laboru and delivery the indentification of foetal dsitres and appropirate intervention can reduce foetal morbidity and mortality
There are currently three methods of assessing the foetus in utero
1) clinical monitoring
2) electrical monitoring
3) ultrasonography
Discuss electronic feotal monitoring
Uses tracing of uterine contraction and foetal heart rate
Uterine activity is measured transabdominally by a pressure transducer, creating a record of the contraction frequency. Strenght of contraction correlates poorly with reading
Foetal heart has tracing have several components that can be assessed
1) base line heart rate
2) variability
3) acceleration
4) decelleration
5) diagnostic patterns
Discuss baseline heart rate one a CTG (cardiotocography)
THis is the average foetal heart rate during a 10 minute period (int eh absence of a uterine contraction) and is the most important aspect of foetal heart monitoring. Foetal bradycardia is defined as a heart rate lower than 110n, feotal tachycardia is greater than 160
Discuss variability on a CTG
This can be instantaneous (beat to beat) or long term (intervals >= 1minute) Both types of variability are indicators of foetal well being. Acceleration occur during foetal movement and reflect an alert and mobilr foetus. Normal variability is between 5-25
Decreased variability may indicate foetal acidaemia and hypoxemia or may be a side effect of a wide arry of durgs including analgesics, sedative hypnotics phenothiazines and ETOH
Discuss decelerations
Complicated and should be interpreated according to the clinical scenario. There are three types of deceleration - variable, early and late
Early deceleration
- start when uterine contractions begin and recover when uterine contraction stop.
- Due to increased feotal intracranial pressure causing increased vagal tone
- Quickly resolves post contraction
- Physiological not pathalogical
Variable
- Variable in there duration and may not have any relationship to uterine contractions
- Usually caused by umbilical cord compression
- Umb vein is often occluded first causing an acceleration – artery is then occluded causing a rapid decel, when pressure on the cord is reduced another acceleration occurs and then the baseline rate returns
- Accelerations before and after variable dcel are called shoulder of decleration and indicate the foetus is not yet hypoxic
- Maternal position change sometimes helps
- If nil shoulder persistent or prolonged concern for hypoxia
Late decel
- Begin at the peak of contraction and recover after the contraction ends
- indicates insufficient blood flow to the uterus and placenta - leading to foetal hypoxia and acidosis
- Causes include
- –materanal hypotension
- –pre-eclampsia
- –uterine hyperstimulation
Discuss diagnostic patterns
Sinusoidal tracing
- Smooth regular wave like pattern
- freqeuncy of around 2-5 cycles a minute
- stable baseline rate around 120-160
- no beat to beat variability
The sinusoidal tracing is an ominous finding that is often premorbid and has a DDX of
1) erythroblastosis foetalis, placental abruption, foetal haemorrhage and amniotiis
Define preterm labour and causes of the same
Uterine contrqaction with cervical changes before 37 weeks of gestation. Is assoicated with 5-18% of all pregnancies and is the leading cause of neonatal death.
Causes Maternal -UTI -PROM -Chorio -Pre-eclampsia -Drug ise
Foetal
- Congential abdnomaloities Diwbs
- Multiparus
Placnetal, uterine
-polyhydraminos
Discuss feature linked to premature labour
Demographic and psychosocail
- extremes of age >40 and teenagers
- Lower socioeconomic status
- tabacco use
- Cocaine abuse
- prolonged standing
- psychosocial stressors
Reproductive and gynecological
- prior prem
- diethylstilbestrol exposure
- mutliple gestations
- anatomic endometrial cavity anomalise
- cervical incompetence
- low preganncy weight gain
- first trimester vaginal bleeding
- placenta pravia or abruption
Surgical
- prior reproductive organ surgery
- prior paraendometrail surgery other than genitourinary
INfection
-UTI
-non uterine infection
0genital tract infections
Discuss the management of preterm labour + absolute (7) and relative (5)
A viable foetus and a healthy mother are indication for medical management to prolong the gestation. Preterm labour should not be post poned if there is feotal compromise, major congenital anomalies, intrauterine infection, placental abruption, eclampsia, significant cervical dilation or PROM
Treatment of preterm labour involve multiple modalities and is usually performed outside of the ED. Tocolytics and foetal maturation therapy combined with bed rest and hydration are used with hope of prolonging pregnancy,
Tocolytic agents incldue
- magnesium sulfate (4-6g IV bolus over 20 min) (2-4g/hr IV infusion (neuroprotection against cerebral palsy and other types of severe motor dysfunction)
- NSAIDS indomethasone 50mg can be used 24-32 weeks asincreased risk of closure
- Nifedapine 20 mg loading than 10mg Q6 hourly
- Salbuatmol
- Terbutaline (5-10mg PO Q4-6H)
- Ritodrine (10mg PO q2-4 hours)
Contraindications to tocolytics Absolute -foetal distress -acute vaginal bleeding -lethal foetal anomaly -chorioamniionitis -pre-eclampsia or eclampisa -sepsis -DIC
Relative
- Chronic HTN
- Cardiopulmoanry disease
- Stable placenta Previa
- Cervical dilation >5 cm
- Placental abruption
Reason for delay is to facilitate the use of IM: 12 mg every 24 hours for a total of 2 doses to avoid Respiratory distress syndrome, intracranial hemorrhage, NEC and death
Discuss PROM
Defined as rupture of the amniotic and chorionic membranes before the onset of labour. It affects 3% of all gestations.
During pregnancy the chorionic and amniotic membranes protect the foetus from infection and provied an envirnement for foetal growth,
Preterm PROM occurs when rupture happens prior to 37 weeks of gestation
PROM is the inciting event in one third of all preterm deliveries
Discuss the diagnosis of PROM
Typically the patient will suggest the condition and be correct. Typically describes a spontaneous gush of watery fluid followed by a mild persistent seepage.
Direct digital examination of the cervix is avoided. Visualisation of the ccervix is performed to identify any prolapsed cord or small feotal part.
Culture specimens for GBS, chlamydia and gonorrhoe should be obtained
Nitrazine paper will show the more alkaine (6.5) amniotic fluid as blue and leave the normal vaginal secrtion ph 5.5 as yellow
Discuss the management of PROM
Management depends on many factors include gestational age, foetal maturity, presence of active labour, presence or abscence fo infection, presence of complications such as abruption
CTG and obs consult should be performed in all cases. IN premature kids 24-32weeks treatment to speed maturation of the foetus should be performed.This includes steroids to speed lung development
All patient should be investigated for the possibility of intraamniotic infection
Preterm PROM should be treated with ABs either IV amp, clinda or erythromycin
Treatment of PROM is indicated if patient is GBS positive
Discuss risk factors for chorioamnionitis and AB choice
PROM, recurrent vaginal examns, prolonged 1st or 2nd stage of labour.
Ampi gent reasonable ABs
Ceft, gent +metro
Discuss dystocia
Dystocia or abnormal labor progression accounts for one third of all c-sections and half of primary c-section.
Can be divided into three categories of causative factors 3 Ps (passage, passenger, power)
1) issue with pelvic architecture
2) issue with foetal size or presentation
3) inadequate uterine expulsive force
