Abnormal Labor and Postpartum Hemorrhage PDF

4. Abnormal Labor and Postpartum Hemorrhage The 3 Ps o When labor abnormality is diagnosed, the 3 Ps should be evaluated: Powers, Passenger, Pelvis o Dystocia- difficult labor ▪ Abnormally slow progress of labor o *MC prob- dysfunctional uterine contractions r...

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Abnormal Labor and Postpartum Hemorrhage The 3 Ps o When labor abnormality is diagnosed, the 3 Ps should be evaluated: Powers, Passenger, Pelvis o Dystocia- difficult labor ▪ Abnormally slow progress of labor o *MC prob- dysfunctional uterine contractions resulting in prolonged labor o Powers: ▪ strength, duration & frequency of uterine contractions ▪ Occur every 2-3 mins, uterus is firm upon palpation, last 40-60 sec ▪ Measured by- external tocodynamometry, intrauterine pressure catheters (IUPCs) o Passenger: ▪ estimate fetal weight *greater incidence of shoulder dystocia w/ weight >4000g ▪ Evaluate fetal lie- longitudinal, transverse or oblique ▪ Presentation- vertex or breech (face presentation has to be C section) Breech: *M&M rates for mother and fetus high o Dx: leopold maneuvers, pelvic exam, US o Rx: External Cephalic Version (ECV) ▪ attempts to manually move baby ▪ Successful in ½ of selected cases: >36 wks A fetus w/: normal FH tracing, adequate amniotic fluid, presenting part not in pelvis ▪ Frequently results in C-section delivery ▪ Station, and number of fetuses o Umbilical cord prolapse ▪ Risk factor: artificial rupture of membranes (AROM), footling breech, fetal bradycardia (always evaluate for fetal cord prolapse), ropelike cord w/ pulsations felt on vaginal exam ▪ Rx: digitally elevate presenting part, emergent C-section o Pelvis (aka Passage) ▪ Progress of descent of the presenting part during labor is best test of pelvic adequacy ▪ Cephalopelvic disproportion- size of the pelvis is inadequate to size of presenting fetus (consider C-section) o Abnormal Labor: Management of protraction & arrest ▪ Protracted 1st stage- Latent phase- observation and sedation, IV oxytocin Active phase- IV oxytocin, monitor pt for 2-4 hours, +/- amniotomy o Abnormal Labor- Prolonged 2nd stage of labor ▪ No time limit as long as mother & fetus are doing well, support, alternative birthing positions ▪ Risks of prolonged labor Maternal- infection, exhaustion, uterine atony w/ possible hemorrhage Fetal- Meconium Aspiration Syndrome o Meconium: Thick, greenish substance lines lower intestines of fetus (first bowel  movement) o Before labor, fetus may pass meconium into amniotic fluid- can be aspirated into lungs o Can result in respiratory distress or pneumonia Labor Induction o Stimulation of uterine contractions before labor begins on its own. Aim is to achieve vaginal birth o Indications: w/ concern for maternal or fetal health, should not be induced if cervix is not well prepared (softened and partially effaced) o Used: post term preg, PPROM, chorioamnionitis, fetal growth restriction, oligohydramnios, gestational diabetes, hypertensive disorders of preg, abruptio placenta, certain medical conditions ▪ Oligohydramnios = not enough fluid o CI: previous C or uterine surgery, active genital herpes, placenta previa, umbilical cord prolapse, transverse fetal lie o Aim: to cause cervical ripening (softening, effacement & dilation that occur before active labor) o Methods- *oxytocin infusion (1st), prostaglandin analogs, cervical balloon, membrane stripping, amniotomy ▪ Oxytocin Infusion Pitocin, Syntocinon DOC for labor induction w/ favorable cervix Complications: uterine hyperstimulation, maternal fluid overload ▪ Prostaglandins Markedly enhance success of unfavorable cervix Misoprostol and dinoprostone ▪ Transcervical Balloon (Catheter) Foley catheter balloons are used to mechanically dilate the cervix Used for unfavorable cervix ▪ Membrane stripping: Sweeping membranes- pressing amniotic sac off the cervix w/o breaking GBS swab must be neg, >38 weeks preg, cervix must be open enough to permit. May stim release of oxytocin helping initiate contractions ▪ Amniotomy/ artificial rupture of membranes (AROM) Aka breaking the water note clarity of fluid & presence of meconium, monitor FHR, increased risk of umbilical cord prolapse ▪ *Favorable (ripe) cervix: 2-3 cm open, 80+ % effaced, soft, anterior ▪ *Unfavorable cervix- firm, long, or closed- use prostaglandins to enhance success of inductions, transcervical balloons (don’t rupture amniotic sac) --> CANNOT INDUCE GBS (Group B Strep infection) o GBS- normally found in vag/rectum of 25% of all healthy women, can be passed to baby during birth ▪ Women testing positive are “colonized” o Screening in all preg women at 35-37 wks, both vagina and rectum are swabbed o Indicators of higher risk of delivering a baby w/ GBS ▪ preterm labor or rupture of membrane before 37 wks, ROM 18 hrs or more before delivery, fever during labor, previous baby w/ GBS, UTI caused by GBS while pregnant o RX: PCN IV during delivery  o Risks of infants can occur within hrs of delivery: sepsis, pneumonia, meningitis, respiratory probs, heart & BP instability, GI and kidney probs o Rx: Abx during labor & birth help prevent early onset GBS C-section o MC indications: Failure to progress during labor, Non reassuring fetal status, fetal malpresentation (prolapse of umbilical cord), placenta previa, abruptio placentae, uterine rupture o Disadvantages: increased risk of hemorrhage + infection, longer hospital stay, more painful/slower recovery o Types ▪ Vertical (only in extreme circumstance) ▪ Horizontal (preferred) o Trial of Labor after Cesarean Delivery (TOLAC) o Vaginal Birth after Caesarean Delivery (VBAC) ▪ CI- prior classical or T-shaped uterine incision, previous uterine rupture, medical or OB complications that preclude vaginal birth, inability to perform emergency C-section PP Hemorrhage o Normal placenta delivery ▪ Placenta detached from inside uterus & is expelled spontaneously ▪ 4 signs of placental separation: apparent lengthening of visible portion of umbilical cord, increased bleeding from vagina, change in shape of uterus from flat to round, the placenta being expelled from vagina o Retained placenta ▪ Fails to separate or fails to fully expel from uterus, retained tissue prevents adequate uterine contractions ▪ U/S may aid in Dx ▪ Management: removal of retained tissue manually or via D&C, hysterectomy o Placenta Accreta- not common ▪ Attaches deep to uterine wall but it does NOT penetrate the uterine muscle ▪ Dx: vaginal bleeding in 3rdtri, US ▪ Rx: cesarean hysterectomy w/ surgical eval, surgery is gold standard but some options to save o Placenta Increta ▪ Invades muscles of uterus o Placenta Percreta ▪ Penetrates through uterine wall & attaches to another organ (ex: bladder) o PP Hemorrhage ▪ Blood loss requiring transfusion OR a 10% decrease in Hct ▪ 2 types Primary- occurs w/in 24 hrs of delivery (more serious) Secondary- occurs between 24 hrs- 12 wks post delivery ▪ Causes: uterine atony, lacerations of lower genital tract, retained placenta Uterine atony- MC, uterus fails to contract after delivery, uterus feels boggy on palpation o Risk factor: prolonged labor, macrosomia, multiparity o Management- oxytocin IV after delivery, bimanual massage of uterus, immediate breast feeding to promote uterine contraction  o Therapeutic- uterine massage, increase oxytocin, methergine or prostaglandin, uterine artery ligation, hysterectomy ▪ Labs: CBC (hemoglobin and hematocrit), U/S