Obstetrics: Fetal Dystocia & Breech Presentations

Fetal Dystocia Presentations

• Occiput posterior: Baby's head is positioned towards the mother's back instead of the front, causing potential discomfort and labor difficulties.
• Face presentation: Baby's head is extended instead of flexed, leading to a larger diameter of the head entering the pelvis.
• Brow presentation: Baby's head is in a position between full flexion and extension, presenting a large diameter of the head into the pelvis.
• Shoulder presentation: Baby's spine is vertical to the pelvis, increasing risk of a prolapsed cord. A C-section is typically required.
• Compound presentation: One or more fetal extremities accompany the presenting part. This also creates a higher risk of a prolapsed cord and a C-section is indicated.

Breech Presentations

• Frank breech: Baby's thighs are flexed, and feet are close to the head.
• Complete breech: Baby's knees are flexed.
• Footling breech: One or both feet present before the buttocks.

Breech Presentations Complications

• Breech presentations can lead to dysfunctional labor, fetal injury, increased risk of prolapsed cord, and often necessitate a C-section.

Induction of Labor (IOL)

• IOL deliberately stimulates labor onset before spontaneous labor occurs to facilitate a vaginal birth.
• There must be a medical indication for IOL.

IOL Interventions

• Cervical preparation: This process involves physically softening, thinning, and dilating the cervix to prepare for labor and birth.
  • Mechanical cervical preparation options include using a balloon catheter.
  • Pharmacological methods use misoprostol or cervidil to prepare the cervix.
• Oxytocin (Pitocin) is titrated to stimulate contractions and labor.
• Amniotomy (AROM): Artificial rupture of membranes used to induce or augment labor. AROM early in labor increases the risk of a C-section.

Bishop Score

• This score determines how close a woman is to labor.
• A score of 8 or higher indicates a successful induction outcome, similar to spontaneous labor.
• A score of 6 is considered favorable for successful induction.

Labor Augmentation

• Labor augmentation stimulates contractions when labor does not progress after spontaneous labor begins.
• The goal is to strengthen and regulate contractions.
• Indications for Augmentation:
  • Blood loss exceeding 1000cc with a 10% drop in hemoglobin or hematocrit.

Postpartum Hemorrhage (PPH)

• PPH is a significant complication with the greatest risk in the first hour after birth.
• Primary PPH: Occurs within 24 hours of birth.
• Secondary (delayed) PPH: Occurs between day 1 and 6 weeks after birth.
• Treatment focuses on identifying the cause and preventing hypovolemic shock.

Postpartum Hemorrhage Risk Factors

• Neonatal Macrosomia (large baby)
• Placenta previa/accreta
• Multiple gestation (twins, triplets, etc.)
• Previous C-sections or uterine surgery
• Polyhydramnios (excess amniotic fluid)
• Prior PPH
• High BMI
• Operative vaginal delivery
• Chorioamnionitis (infection of the amniotic sac)
• Congenital or coagulation defects

Respiratory Distress Syndrome (RDS)

• A life-threatening lung disorder, primarily affecting premature infants due to underdeveloped alveoli and insufficient surfactant levels.
• Signs and symptoms of RDS:
  • Tachypnea (rapid breathing)
  • Gray or dusky skin
  • Lethargy and hypotonia (low muscle tone)

Patent Ductus Arteriosus (PDA)

• Occurs when the ductus arteriosus, a blood vessel connecting the aorta and pulmonary artery, remains open after birth.
• Normally closes within a few hours to 96 hours after birth.
• Signs and symptoms of PDA:
  • Tachycardia (rapid heartbeat)
  • Tachypnea (rapid breathing)
  • Recurrent apnea (temporary cessation of breathing)
  • Bounding pulses

Meconium Aspiration Syndrome

• This occurs when meconium fluid, a first stool in the womb, enters the lungs, partially obstructing airflow and causing respiratory failure.
• Increases in post-mature newborns (born after 41 weeks).
• Nursing actions:
  • Assess for respiratory distress
  • Administer oxygen if indicated

Breastfeeding Jaundice

• Jaundice is a condition where a newborn's skin and eyes appear yellow due to high bilirubin levels.
• Breastfeeding jaundice is associated with ineffective breastfeeding causing early onset jaundice (within the first few days of life).
• Associated with delayed passage of meconium stool.
• Treatment:
  • Encourage effective breastfeeding without supplementation.

Five Principles of Discharge Teaching

• Right Time: The ideal time for the information to be given.
• Right Context: An environment should be quiet, free of distractions, private, soothing, or stimulating, depending on the information.
• Right Goal: Patient actively involved in the setting and achieving mutually set goals. Goals should be realistic and valued by the patient.
• Right Content: The information should be clear, concise, and appropriate for the patient's understanding.
• Right Method: The information should be presented in a way that the patient understands and can remember.

Lactogenesis

• Lactogenesis refers to the process of milk production.
• Starts during the second trimester.
• Hormones involved:
  • Prolactin: Primary hormone responsible for lactation.
  • Estrogen and Progesterone: Suppress lactation during pregnancy.
• After delivery, prolactin levels increase, and estrogen and progesterone levels decrease. Estrogen levels will then re-increase approximately one week after delivery.
• The lactational amenorrhea method uses breastfeeding as a form of birth control.

Women's Health Phases

• Adolescence
• Childbearing Years
• Perimenopause
• Post-Menopause/Geriatric

5 Ps of Women's Health History

• Partners: Current and previous intimate partners
• Practices: Sexual practices, including frequency and type
• Protection from STIs: Methods used to prevent STIs
• Past history of STIs: Previous diagnoses and treatments of STIs
• Pregnancy intention: Future pregnancy plans or intentions.

Long-Acting Reversible Contraception (LARC)

• Currently available in the United States.
• Examples include:
  • Intrauterine devices (IUDs)
  • Implants
  • Hormonal injections

Fetal Presentations that may lead to Dystocia (Malpresentations)

• Occiput posterior: the back of the baby's head is in the posterior portion of the pelvis (closest to your back) instead of the anterior (occiput anterior = back of baby's head is closest to your front)
• Face presentation: Fetal head is in extension rather than flexion as it enters the pelvis
• Brow presentation: Fetal head presents in a position midway between full flexion and extreme extension – largest diameter of the head in the pelvis
• Shoulder presentation: Fetal spine is vertical to the maternal pelvis – higher risk of prolapsed cord, C-section is indicated
• Compound presentation: One or more fetal extremities accompany the presenting part – also higher risk of prolapsed cord and C-section is indicated

Breech Presentations

• Dysfunctional labor, fetal injury, risk of prolapsed cord, C-section
• Frank Breech: Fetus’s thighs are flexed alongside the body, feet are close to the head
• Complete Breech: One or both knees are flexed
• Footling Breech: Either one (single footing) or both (double footing) feet present before the buttocks

Induction of Labor

• Deliberate stimulation of labor onset of spontaneous labor to facilitate a vaginal birth
• Interventions:
  • Cervical preparation: the process of physical softening, thinning, and dilating of the cervix in preparation of labor and birth
    • Mechanical cervical preparation ➔ balloon catheter
    • Pharmacological methods of preparation ➔ misoprostol, cervidil
  • Oxytocin (Pitocin) titration used to stimulate contractions and labor
  • Amniotomy (AROM): artificial rupture of membranes used to induce or augment labor
    • AROM in early labor ➔ increased risk of C-section

Bishop Score

• A calculation to predict how close you are to labor
• Bishop score >8: Same likelihood of vaginal delivery with induction of labor as that following spontaneous labor, indicates a successful induction
• Bishop score 6: Favorable for successful induction

Indications and Contraindications of Labor Augmentation

• Augmentation = stimulation of contractions when labor does not progress after the onset of spontaneous labor, goal is to strengthen and regulate contraction
• Indications:
  • 1000cc C/S + 10% drop in Hgb/Hct
• How do we assess it? EBL >> QBL (estimated blood loss >> quantitative blood loss)
  • Greatest risk is in the first hour after birth!

Postpartum Hemorrhage (PPH)

• Primary PPH → happens within 24 hours of birth
• Secondary (delayed) PPH→ occurs between day 1 to 6 weeks
• Treatment goal→ identify cause and prevent hypovolemic shock
• Other risk factors:
  • Neonatal macrosomia
  • Placenta previa/accrete
  • Multiple gestation
  • Previous C/S or uterine surgery
  • Polyhydramnios
  • Prior PPH
  • High BMI
  • Operative vaginal delivery
  • Chorioamnionitis
  • Congenital/coagulation defects

Causes of Postpartum Hemorrhage

• The Four T’s:
  • Tone: uterine atony (boggy [meaning soft and tender] fundus), subinvolution (delayed return of the enlarged uterus to normal size and function)
  • Tissue: retained placental fragments – common cause of secondary PPH
  • Trauma: lower genital tract lacerations – 2nd most common cause of primary PPH
    • Hematomas can develop – when blood from a ruptured vessel collects within the connective tissues of the vagina or perineal areas
  • Thrombin disorders: disseminated intravascular coagulation (DIC), DVT, PE
    • The body breaks down clots faster than it can form them→depleting the body of clotting factors→ leading to hemorrhage and death

Postpartum Blues (Baby Blues) vs. Postpartum Depression

• PPB (Baby Blues) → symptoms disappear without medical intervention, occurs within the first 2 weeks postpartum, able to safely care for self and baby
• PPD → mild to severe depression requires psychiatric interventions, occurs within the first 6-12 months postpartum, unable to safely care for self-and/or baby
  • 2 weeks of:
    • Loss of interest or pleasure in daily activities
    • Insomnia
    • Decreased energy/fatigue
    • Decreased concentration
    • Feelings of worthlessness or guilt
    • Weight changes

Infant Health and Survival

• Length of gestation
• Birth weight

Respiratory Distress Syndrome in the Neonate

• Signs and symptoms:
  • Rapid breathing
  • Grunting
  • Nasal flaring
  • Retractions (skin pulling in between ribs or above the collarbone)
  • Cyanosis (bluish color of the skin, especially around the mouth)

Lactogenesis

• Begins during the 2nd trimester: milk is produced in the alveolar glands and transported to the nipple through lactiferous ducts
• Hormones associated with lactogenesis:
  • Prolactin – primary hormone responsible for lactation
  • High levels of estrogen and progesterone SUPPRESS lactation
• Once placenta is delivered ➔ prolactin levels increase, estrogen/progesterone levels decrease→ estrogen will re-increase 1 week PP
• Lactation amenorrhea method
  • Ovulation suppressed longer for lactating parent

Women’s Health Phases

• Adolescence ➔ Childbearing years ➔ Perimenopause ➔ post-menopause/geriatric

Five P’s of Taking a Health History

• Partners
• Practices
• Protection from STIs
• Past History of STIs
• Pregnancy Intention

Lactational Amenorrhea Method of Birth Control

• Using breastfeeding as your birth control – breastfeeding temporarily helps prevent pregnancy since breastfeeding hormones may stop your body from releasing eggs
• Must be used correctly for it to work – the three simultaneous conditions that must be fulfilled is:
  • The baby is under 6 months
  • The mother is still amenorrheic
  • The mother practices exclusive or quasi-exclusive breastfeeding on demand

Long-Acting Reversible Contraception in the United States

• Hormonal implants
• Intrauterine devices (IUDs)
  • Copper IUD
  • Hormonal IUD