Abnormal Labor and Postpartum Hemorrhage PDF

ABNORMAL LABOR AND POSTPARTUM HEMORRHAGE WOMENS HEALTH 2025 Dr S Ryan 1 Topics Abnormal Labor Labor Induction Dystocia Oxytocin Cervical Ripenin...

ABNORMAL LABOR AND POSTPARTUM HEMORRHAGE WOMENS HEALTH 2025 Dr S Ryan 1 Topics Abnormal Labor Labor Induction Dystocia Oxytocin Cervical Ripening The Three Ps Membrane Stripping Powers Amniotomy Fetal Lie Cesarean Section Presentation TOLAC Station VBAC Cord Prolapse Pelvis Postpartum Hemorrhage Cephalopelvic disproportion Retained Placenta Labor Abnormalities Uterine Atony Risks Social Disparities 2 Objectives Recognize the social determinants of health that can impact patient health outcomes. Differentiate obstetric abnormalities that can occur during labor and delivery with emphasis on their clinical presentations, diagnosis, and treatment. Construct a comprehensive treatment plan, including diagnostic tests needed, and future follow up. Identify emergent conditions that may arise during labor and delivery requiring emergent care and discuss their management. 3 ABNORMAL LABOR The Three Ps 4  When a labor abnormality is The Three diagnosed, the 3 Ps Ps should be evaluated: Powers Passenger Pelvis 5  Dystocia – difficult labor Characterized by abnormally slow progress of labor MC problem - dysfunctional uterine contractions resulting in prolonged labor 6  Powers: strength, duration & frequency of uterine contractions Occur every 2-3 mins The Three Ps Uterus is firm upon palpation Last 40-60 sec Powers Measured by: External tocodynamometry Intrauterine pressure catheters (IUPCs) 7  TOCODYNAMOMETRY EXTERNAL INTERNAL 8  Passenger: Estimate fetal weight Greater incidence of shoulder dystocia with weight > 4000-4500 g Evaluate fetal lie The Three Ps Longitudinal, transverse or oblique Presentation -Passenger Vertex or breech? C-section is required with a face presentation Station Number of fetuses 9 PRESENTATION 10 Breech Presentation Higher morbidity & mortality rates for mother & fetus Approx 2% of singleton deliveries More frequent in 2nd & early 3rd trimester (prematurity) Dx: Leopold maneuvers Pelvic exam US 11 Breech Presentation Rx: External cephalic version (ECV) – technique performed late in pregnancy Attempts to manually move a breech baby into the head down position for delivery 12  ECV: Successful in ½ of selected cases: External A fetus ˃ 36 wks gestation Cephalic A fetus with: normal FH tracing Version adequate amniotic fluid (ECV) presenting part not in pelvis Frequently results in C-section delivery 13 Umbilical Cord Prolapse Risk factors: Artificial rupture of membranes (AROM) Footling breech Fetal bradycardia ALWAYS check for cord prolapse “Ropelike” cord with pulsations felt on vaginal exam 14 Umbilical Cord Prolapse Rx: Elevate the presenting part Emergent C-section 15  Pelvis: (AKA: Passage) Cephalopelvic disproportion – size of the maternal pelvis is The Three Ps inadequate to the size of Pelvis the presenting part of the fetus Consider C-section if pelvis is not adequate 16  First stage: from onset of painful contractions & cervical changes to complete cervical dilation Stages of Labor Second stage: from complete cervical dilation to expulsion of the fetus Third stage: from expulsion of the fetus to expulsion of the placenta 17  Difficulties can occur in any stage of labor Failure to progress ex: failure of cervix to dilate as expected Arrested progress Labor ex: fetus does not descend into the birth canal as expected Abnormalities Various methods can be used to facilitate birth IV oxytocin – to help stimulate contractions Membrane stripping Induce labor 18 Risks of Prolonged Labor Maternal Infection Exhaustion Uterine atony w/possible hemorrhage Fetal Meconium aspiration syndrome 19  Meconium - thick, greenish substance that lines the lower intestines of the fetus (baby's first bowel movement) Meconium Before or during labor, the fetus may pass Aspiration meconium into the amniotic fluid Syndrome Cause - unknown (possible fetal distress?) As the baby takes their first breaths at delivery, meconium particles enter the airway & can be aspirated deep into the lungs Can cause respiratory distress or pneumonia 20  LABOR INDUCTION Oxytocin Cervical Ripening Amniotomy Membrane Manipulation C-section TOLAC VBAC 21  Labor Induction* Stimulation of uterine contractions before labor begins on its own Aim - to achieve a vaginal birth Indications Concern for maternal or fetal health Is increasingly being used for convenience or to accommodate busy schedules Labor should not be induced if the cervix is not well prepared (softened & partially effaced) 22 Labor Induction Used with Contraindications Post term pregnancy Previous C-section or uterine surgery PPROM* Active genital herpes infection Chorioamnionitis Placenta previa Fetal growth restriction Umbilical cord prolapse Oligohydramnios Transverse fetal lie Gestational diabetes Hypertensive disorders of pregnancy Abruptio placenta Certain medical conditions 23 Labor Induction Aim – to cause cervical ripening (softening, effacement & dilation that occur before active labor) Methods Oxytocin infusion Prostaglandin analogs Dinoprostone (Prepidil, Cervidil) – gel or intravaginal insert Misoprostol (Cytotec) - po Cervical balloon Membrane stripping Amniotomy 24  Not on Exam ! X Induction Favorable (“ripe”) cervix: 2-3 cm open, 80+ % effaced, soft, anterior Unfavorable cervix: cervix is firm, long, or closed 25 Induction – Favorable Cervix Oxytocin (Pitocin, Syntocinon)* - drug of choice for labor induction with a favorable cervix Continuous IV infiltration at low doses to stimulate contractions Complications Uterine hyperstimulation Hypertonicity Maternal fluid overload 26 Induction - Unfavorable Cervix Prostaglandins markedly enhance success misoprostol (Cytotec) 25 mcg intravag every 3-6 hrs dinoprostone (Cervidil); insert is left in place until active labor begins, OR for 12 hrs 27 Labor Induction - Unfavorable Cervix Transcervical balloon (catheter) Foley catheter balloons are used to mechanically dilate the cervix Small rubber tubing is placed through the cervix. A balloon inside the tubing is inflated, just inside the inner edge of the cervix Catheter is left in place until it’s extruded or for up to 12 hrs 28 Labor Induction Membrane stripping Sweeping (stripping) the membranes - pressing the amniotic sac off the cervix w/o breaking it GBS* swab must be negative > 38 wks pregnant Cervix must be open enough to permit this May stimulate the release of oxytocin from the pituitary gland, helping to initiate contractions 29  GBS – normal flora in vagina &/or rectum of approx 25% of all healthy, adult women GBS Women testing positive are said to be “colonized” (Group B GBS can pass to the baby during birth Strep Approx 1 in every 2,000 babies born in US CDC recommends routine infection) screening for vaginal Strep B in all pregnant women Btwn wks 35 – 37 Both the vagina & rectum are swabbed 30  Indicators of higher risk of delivering a baby with GBS: Preterm labor or ROM before 37 wks ROM 18 hrs or more before delivery GBS Fever during labor Previous baby with GBS UTI caused by GBS while pregnant Rx: PCN IV during delivery 31  Risks to infants can occur within hrs of delivery: Sepsis, pneumonia, meningitis – MCC of neonatal sepsis Respiratory problems GBS Heart & BP instability GI & kidney problems Rx: Abx during labor and birth help prevent early onset GBS* po PCN, Keflex or ampicillin 32 Labor Induction Amniotomy/Artificial Rupture of Membranes (AROM) AKA: “breaking the water” Note clarity of fluid & presence of meconium Monitor FHR before & immediately after procedure # risk of umbilical cord prolapse 33 Cesarean Delivery MC indications: Failure of labor to progress Nonreassuring fetal status Fetal malpresentation Prolapsed umbilical cord Placenta previa Abruptio placentae Uterine rupture 34  Disadvantages: Cesarean Increased risk of hemorrhage & infection Delivery Longer hospital stay More painful, slower recovery 35 TOLAC and VBAC Trial of Labor after Cesarean Delivery (TOLAC) Vaginal Birth After Cesarean Delivery (VBAC) Successful in 60-80% of women Appropriate candidates: No contraindications to labor or vaginal birth One previous low transverse uterine incision No H/O uterine rupture Access to emergency cesarean delivery 36 VBAC Contraindications to VBAC: Prior classical or T-shaped uterine incision Previous uterine rupture Medical or OB complications that preclude vaginal birth ie: placenta previa; breech presentation Inability to perform emergency C-section 37  POSTPARTUM HEMORRHAGE Retained Placenta Uterine Atony 38  Normally, the placenta detaches from inside the uterus and expelled spontaneously Normal 4 signs of placental separation: Placenta Apparent lengthening of visible portion of umbilical cord Delivery Increased vaginal bleeding Change in shape of the uterus from flat to round Expulsion of the placenta from the vagina 39  Placenta either fails to separate or fails to fully expel from the uterus Examine the placenta for intactness!!!! Retained tissue prevents adequate uterine Retained contractions U/S may aid in Dx Placenta Management: Remove retained tissue manually or via D&C Hysterectomy 40  Retained Placenta 41 Placenta Issues Blood vessels & parts of the placenta grow too deeply into the uterine wall Attaches deep in uterine wall but does not penetrate the uterine muscle – placenta accreta Invades the muscles of the uterus - placenta increta Penetrates thru uterine wall and attaches to another organ (ie: bladder) - placenta percreta 42 Placenta Accreta Dx: Vaginal bleeding in 3rd trimester US Rx: Cesarean hysterectomy 43  Placenta Accreta Gold Standard of Rx for placenta accrete is hysterectomy. However, there may be other options. Brigham & Women’s Hospital:* Delivery - scheduled btwn 34 - 37 wks , depending upon severity of the accreta. Hysterectomy may be required after delivery to remove the placenta and end blood loss. https://www.brighamandwomens.org/obgyn/maternal-fetal-medicine/pregnancy- complications/placenta- accreta#:~:text=Surgery%20is%20the%20most%20common,if%20a%20hysterectomy%20is%2 0performed. 44  Blood loss requiring transfusion OR a 10% decrease in Hct 2 types: Postpartum Primary (early) – occurs within 24 hrs of delivery (more serious) Hemorrhage Secondary (late) – occurs btwn 24 (PPH) hrs – 8 wks post delivery Cause: Uterine atony Lacerations of lower genital tract Retained placenta 45 Postpartum Hemorrhage Uterine atony Management: MCC of PPH Preventive: Uterus fails to contract after Oxytocin IV after delivery delivery Bimanual massage of the uterus Uterus feels “boggy” on Immediate breast-feeding to palpation promote uterine contraction Risk factors: Therapeutic: Prolonged labor Uterine massage Macrosomia Increase oxytocin Multiparity Methergine and/or prostaglandin Uterine artery ligation; hysterectomy 46 PPH Dx: Palpate the uterus CBC U/S 47  Statistics/ Research CDC,2020 Pregnancy-related mortality (PRM) from 2007-2016*: PRMR* increased from 15.0 to 17.0 pregnancy-related deaths per 100,000 births. Non-Hispanic black (black) & non-Hispanic American Indian/Alaska Native (AI/AN) women experienced higher PRMRs than all other racial/ethnic populations 3.2 & 2.3x higher than the PRMR for white women. This gap widened among older age groups. Women > 30 yrs: PRMR for black & AI/AN women was 4-5x higher than for white women. PRMR for black women with at least a college degree was 5.2x that of their white counterparts. Cardiomyopathy, thrombotic PE, & hypertensive disorders of pregnancy contributed more to pregnancy-related deaths among black women than among white women. Hemorrhage & hypertensive disorders of pregnancy contributed more to pregnancy- related deaths among AI/AN women than white women. Disparities were persistent, did not change significantly between 2007-2008 & 2015-2016. 48  CDC, 2020 A recent report from 13 state Maternal Mortality Review Committees (MMRCs) determined that each pregnancy- related death was associated with several contributing factors: Access to appropriate & high-quality care Missed or delayed diagnoses Lack of knowledge among pts & providers about warning signs MMRC data suggest the majority of deaths (60% or more) could have been prevented by addressing these factors at multiple levels. 49 References Racial and Ethnic Disparities Continue in Pregnancy-Related Deaths https://www.cdc.gov/media/releases/2019/p0905-racial-ethnic- disparities-pregnancy-deaths.html Racial and Ethnic Disparities Continue in Pregnancy-Related Deaths https://www.cdc.gov/media/releases/2019/p0905-racial-ethnic- disparities-pregnancy-deaths.html https://www.acog.org/Patients/FAQs/If-Your-Baby-Is- Breech?IsMobileSet=false 50 QUESTIONS? 51