Intrapartum Complications of Power (PDF)

INTRAPARTUM : COMPLICATIONS OF POWER (UTERINE CONTRACTIONS) DYSFUNCTIONAL POWER / DYSTOCIA Dystocia = NOT effective ung uterine contractions CONCEPT: -​ “LBRBAR” L: Lightening = engagement (BPD) TYPES/CLASSIFICATION B: Braxton Hicks Contraction (P,M,...

INTRAPARTUM : COMPLICATIONS OF POWER (UTERINE CONTRACTIONS) DYSFUNCTIONAL POWER / DYSTOCIA Dystocia = NOT effective ung uterine contractions CONCEPT: -​ “LBRBAR” L: Lightening = engagement (BPD) TYPES/CLASSIFICATION B: Braxton Hicks Contraction (P,M,I) ❖​ PRIMARY R: Cervical Ripening (effacement; dilatation) -​ Umpisa palang di na effective B: Bloody show = (vag. secretion: mucus plug + -​ Occurs on ONSET of labor blood) A: ↑↑ Activities ❖​ SECONDARY R: ROM -​ Occurs LATER in labor CONCEPT OF ENGAGEMENT RISKS 1.​ POSTPARTAL HEMORRHAGE 1.​ CEPHALIC -​ Cuz labor process so long -​ No engagement if breech; CPD (cephalic pelvic disproportion) 2.​ PROLONGED LABOR **CPD = di kasya head ni baby -​ ROM -​ Infection (chorioamnionitis) 2.​ CORD PROLAPSE -​ Infant mortality -​ Uteroplacental insufficiency → fetal distress CAUSES 3.​ FETAL HEAD -​ PRIMIGRAVIDA = not so prepared organs -​ Once descents = act as sealant → no cord -​ CPD = no engagement prolapse -​ POSTERIOR POSITION ***If NOT engaged, the ff. are contraindicated: -​ Failure to contract = over-distended uterus -​ oxytocin (induction of labor) (3MP) -​ Amniotomy -​ Non-ripe cervix = tx: Misoprostol = fetal distress -​ Full rectum or bladder = hinder fetal descent AMNIOTOMY **use catheter -​ Manual rupture of amniotic bow wid needle -​ Maternal exhaustion -​ During ACTIVE phase -​ Inappropriate use of analgesic (excessive -​ 3-4 cm; 50-60% effaced or too early) -​ 5-8 cm ***cause cord prolapse CONTRACTION *** position in Knee-chest position = ↓ pressure -​ Upper engagement = “panting” breathing -​ Can provide analgesics AMNIOTIC FLUID AND BOW -​ Early phase: facilitates cervical dilation = IF NCARCOTIC USE TOO MUCH: pressure in lower segment -​ Maternal narcotics -​ Late (Active) stage: hinders fetal descent → fetal distress / depression DYSFUNCTIONAL LABOR UTERINE CONTRACTION -​ “Inertia” = state of rest -​ Shud be firm and globular -​ Sluggishness of contraction -​ Abnormal if: super tigas; pain 3 PHASES of LABOR 4.​ DURATION -​ Beginning to end of 1 contraction 1.​ Increment -​ Length -​ Beginning; Upward -​ Increases -​ Contraction intensity increases Early phase = 20-30 s 2.​ Acme Active = 60-70 s -​ Peak Tetanic uterus = 90 s -​ Contraction = strongest DYSFUNCTIONAL LABOR 3.​ Decrement -​ Downward; release -​ Intensity decreases CHARACTERISTICS of LABOR 1.​ FREQUENCY -​ Beginning of 1 contraction to beginning of another -​ Rate -​ Increases Early phase = 10 mins (3-5 contractions) INEFFECTICE UTERINE FORCE Active phase = 2-3 mins (2 contractions) -​ Contractions = force moving fetus thru birth canal 2.​ INTERVAL -​ Interplay of enzymes: ATP; Ca, Na, K -​ End of contraction to beginning -​ Hormones: oxytocin; estro; proge; -​ Relaxation prostaglandin -​ Uterine / Uteroplacental perfusion occurs -​ “Resting tone” = 10-15 mmHg HYPERTONIC -​ Erratic, asynchronous, not coordinated frequent interval = ↓ UP perfusion → ↓O2 -​ 50 mmHg => hypoxia -​ Very firm uterus -​ Give tocolytic *shift from normal (aerobic) → anaerobic → ↑ lactic acidosis → pain HYPOTONIC -​ Longer, synchronous, coordinated Early phase = 10 mins -​ Weaker Active phase = 2-3 mins -​ Give uterotonic UTERINE PERFUSION PARTOGRAM -​ Blood supply -​ Intrapartal monitoring -​ If none = tetanic uterus ❖​ FHT ❖​ Contractions 3.​ INTENSITY -​ Pressure or force HYPOTONIC -​ 30-50 mmHg -​ < 2-3 contractions **degree of hardness = chin, nose, forehead -​ Resting tone = < 10 mmHg  -​ Strength = ≤ 25 mmHg T: Tocolytic = MgSO4 -​ ACTIVE phase R: Rest -​ Painless A: Analgesic = morphine sulfate *needs oxytocin / pitocin N: Narcotic *amniotomy S: Sedation OXYTOCIN UTERINE DYSSYNCHRONY -​ ADH synthetic (posterior pituitary gland) -​ Occurs in hypERtonic uterus 1.​ ↑↑ BLOOD VOLUME Parts of uterus: Fundus = myometrium a.​ WATER INTOXICATION Upper uterus = fundus; thicker; ACTIVE -​ Napunta fluid sa brain Lower uterus = thin-walled; supple; PASSIVE -​ Cerebral edema → seizure -​ ↓ urine → oliguria UTERINE TETANUS -​ Uterine rupture b.​ PULMONARY EDEMA/CONGESTION -​ Caused by oxytocin toxicity -​ Both upper and lower contracts or; lower 2. IF LOW DOSE part is active -​ Vasodilator = ↓↓ BP → maternal -​ Rigid hyPOtension → ↓↓ CO -​ Interval = < 2 mins -​ SNS → maternal tachycardia -​ Duration = > 80-90 secs 3. IF HIGH DOSE FIRST STAGE OF DYSFUNCTIONAL LABOR -​ Vasoconstriction = HTN ❖​ Prolonged Latent -​ ↓↓ UP sufficiency = fetal distress (tachy; ❖​ Protracted Active brady) ❖​ Prolonged Deceleration ❖​ Secondary arrest of Dilatation 4. TETANIC UTERUS -​ Too much → oxytocin toxicity ***Dystocia = only in 1st - 2nd stage of labor -​ Monitor FHR; uterine contraction -​ Beri hard uterus PROLONGED LATENT -​ Uterine rupture = hemorrhage -​ Primi: > 20 hrs; Multi: > 14 hrs => fetal distress -​ hyPErtonic -​ Groove is visible and palpable across belly -​ Mild, ineffective contraction Classified into: contraction & stage CAUSES WATCH FOR -​ Unripe cerix = gamitan ng misprostol -​ Maternal BP -​ Excessive analgesics early in labor -​ Hypotension or HTN *i-CS if fetal distress ** > 140/90 mmHg = hold oxytocin FETAL DISTRESS HYPERTONIC CONTRACTION -​ “MHM” -​ > 15 mmHg M: Meconium Aspiration -​ > 5 contractions -​ UP insufficiency → hypoxia = ↓O2 = PNS → -​ LATENT phase ↑ GIT motility/tone = poop -​ Painful; no relaxation; no perfusion = anoxia H: Heart Tone (FHT) -​ “TRANS” -​ Fetal deceleration  -​ Late deceleration -​ No descent in 2 hrs (nulli); 1 hr (multi) -​ We want variability = acceleration -​ CS; trial/ assisted labor -​ Normal = 120-160 bpm -​ ± 15 bpm PRECIPITATE LABOR ***if no variability = fetal distress -​ hypERtonic but can be regular M: Movements -​ Strong, few, rapid contractions -​ Both hypo or hyper movement -​ Completed delivery = < 3 hrs -​ Cardiff method: 10-12 mvts/hr -​ Dilate 5 cm/hr; 10 cm/hr -​ Oxytocin-induced MANAGEMENT -​ Tocolytic RISK -​ Pain relief (morphine sulfate) -​ Fetal head injury -​ ↓↓ stimulation -​ Injury in reproductive passageway -​ Amniotomy (premature placental separation; laceration) -​ Oxytocin for assisting labor -​ CS COMPLICATIONS -​ “BAIL” PROTRACTED ACTIVE PHASE B: Bleeding = in general = rapid → overstretched → -​ Dilatation: Nulli: < 1.2 cm/hr; Multi: 1.5cm/hr = atony -​ Duration: Primi: > 12 hrs; Multi: 6 hrs A: Abruptio placenta -​ hyPOtonic I: fetal head injury = rapid molding → intracranial -​ CPD hemorrhage -​ Ineffective myometrial activity L: laceration = can be up to 4th degree MANAGEMENT TREATMENT -​ CS -​ Stop oxytocin -​ Oxytocin (rule out CPD) -​ Tocolytic; sedative; pain relief PROLONGED DECELERATION INDUCTION AND AUGMENTATION OF LABOR -​ Descent > 3 hrs (nulli); 1 hr (multi) -​ hyPOtonic -​ Fetal head malposition (Occiput posterior) -​ CS na yarn Induction = start artificially Augmentation = assist the labor that started; dahil SECONDARY ARREST OF DILATATION di effective -​ No progress in cervical dilatation > 2 hrs -​ CS na rin IMPLICATION -​ Surfactant = lung maturity (PEAK: 34 wks) SECOND STAGE OF DYSFUNCTIONAL LABOR not used -​ 39 wk AOG dapat gawin induction PROLONGED DESCENT HYPOTONIC -​ Oxytocin toxicity = tetany -​ Descent: < 1cm / hr (nulli); 2 cm/hr (multi) -​ 2nd stage: > 2 hrs (multi) REQUIREMENTS for INDUCTION -​ Mx: oxytocin; amniotomy -​ “CRENA” -​ Positioning: semi-fowler, squat, kneel C: cephalic R: ripe cervix (misoprostol) ARREST OF DESCENT E: engaged (station 0) -​ No progress beyond station 0 N: NO CPD -​ CPD = most common A: AOG = 39 wks OXYTOCIN AMNIOTIC FLUID EMBOLISM -​ Induction: 12 hrs after prostaglandin -​ Forced to the open maternal circulation -​ IV; half life: 3 mins -​ Prolonged labor -​ Fragments can join; occlude pulmonary UTERINE RUPTURE blood vessel -​ 5% of maternal deaths -​ DIC (FHADIEE) -​ Tearing sensation -​ Deadly -​ Common in vertical CS CAUSES FACTORS -​ Meconium -​ C- section -​ Fetal sheds a.​ Classical = vertical b.​ Low transverse CS = horizontal RISK -​ Bleeding → DIC -​ Oxytocin -​ Prolonged labor -​ PROM -​ Oxytocin -​ Abruption placenta -​ multi preggy -​ DIC -​ Traumatic labor -​ Hydramnios **Complete rupture = contractions stop immediately CLINICAL FINDINGS MX: STOP oxytocin -​ Dramatic -​ Severe chest pain; SoB Emergency: -​ Tachypnea -​ Laparotomy -​ ↓↓ BP = shock​ -​ Hysterectomy = uterus removal -​ Cyanosis INVERSION OF UTERUS MANAGEMENT -​ Turned inside out -​ ICU -​ Excessive traction/pressure on -​ Lucky if u survive pa uterine/umbilical cord -​ CPR -​ Fundus may protrude in vagaina; not -​ Intubation palpable -​ Check for shock ***dont replace the uterus lmao BRAND ANDREW = gentle pressure in holding lower segment; grab fundus CREDE’S MANEUVER = prevent uterus prolapse Nitroglycerine = Calcium channel blocker -​ Relax uterus SIGNS OF PLACENTAL BABYE L: lengthening of cord G: gush of blood I: visible vaginal introitus C: contract; firm again; uterus rise up