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Critical Complications of Labor and Delivery

Critical Complications of Labor and Delivery. Physiologic Changes of Pregnancy. Cardiovascular. Heart increased 10 - 15% Stroke volume increased 10% CO = HR x SV Cardiac output increased 25 - 30% Approximately 1.5 L/min Catecholamines increased. Cardiovascular.

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Critical Complications of Labor and Delivery

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  1. Critical Complications of Labor and Delivery Special Considerations

  2. Physiologic Changes of Pregnancy Special Considerations

  3. Cardiovascular • Heart increased 10 - 15% • Stroke volume increased 10% • CO = HR x SV • Cardiac output increased 25 - 30% • Approximately 1.5 L/min • Catecholamines increased Special Considerations

  4. Cardiovascular • Total peripheral resistance decreased • Progesterone • Placenta • Prostaglandins • BP = CO x TPR • BP is decreased in most normal patients Special Considerations

  5. Respiratory • Rate increased • Tidal volume increased • Minute volume increased • PCO2 decreased = 30 mmHg • Arterial pH increased =7.45 • Blood gases • Compensated respiratory alkalosis Special Considerations

  6. Renal • Renal blood flow increased • Glomerular flow increased • Creatinine, urea, uric acid decreased • Renal pharmocologic clearance increased Special Considerations

  7. Anatomic Changes • Cardiac • Soft systolic murmur - aortic • Respiratory • Decreased basal breath sounds • Abdomen • Enlarged uterus • 12 - 20 weeks - rule of 1/4 • 20 - 36 weeks - macdonald’s rule • Extremities • Pitting pedal edema Special Considerations

  8. Third Trimester Assessment • History • Last menstrual period (LMP) • Nagel’s Rule = (months) - 3 + 7 days • Bleeding • Quantity, duration, color, clotting • Contractions • Onset, frequency, duration, intensity • Fetal activity • After 20 weeks • Leaking clear fluid • Urinary symptoms Special Considerations

  9. Third Trimester Assessment • Physical exam • Vitals • BP, temp, pulse, respiratory rate • Abdomen • Fundal height, uterine tenderness, fetal position • Abdominal exam • Fetal heart tones • Pelvic exam • Dilatation, effacement, station, presenting part, position • Never done in presence of active vaginal bleeding (placenta previa) Special Considerations

  10. Emergency Delivery • Rarely needed in field • If crowning, support perineum • Fetus born via extension • Movements of labor • Engagement, descent, flexion, • Internal rotation, extension, external rotation • Expulsion Special Considerations

  11. Emergency Delivery • Immediately warm newborn • Hold newborn’s head lower than maternal perineum • Clamp, cut and tie off cord • Unless active bleeding, placental delivery may be delayed Special Considerations

  12. Emergency Delivery • Inspect perineum • Counter pressure to laceration to prevent bleeding • Place newborn on maternal chest • Transport to hospital Special Considerations

  13. Emergency Delivery • Placental separation • Change in uterine shape • Lengthening of umbilical cord • Increase in vaginal bleeding Special Considerations

  14. Emergency Delivery • Placental delivery • Do not apply excessive traction to the cord! • Counter traction to uterine fundus • Examine placenta for vessels and cord • 3 vessels - two arteries, one vein Special Considerations

  15. Third Trimester Bleeding • Abruptio Placenta • 0.5 to 1.5% incidence • Painful contractions • Frequent • Uterine tenderness • Vaginal bleeding • Fetal compromise • Risk for D.I.C., hypofribrinogemia Special Considerations

  16. Abruptio Placenta Special Considerations

  17. Third Trimester Bleeding • Painless vaginal bleeding • Usually irregular to no contractions • Bleeding may be heavy • Hemodynamic compromise common • IV hydration, blood transfusion Special Considerations

  18. Third Trimester Bleeding • Vasopressor Therapy • Dopamine, 2-4 mgm/kg/min • (low dose preserves placental flow) • Norepinephrine (Levophed) • Used in life-saving mode only • Decreased fetal flow • Dobutamine - 5 - 15 mgm/kg/min Special Considerations

  19. Preterm Labor • 8 - 10% of all gestations • 80% of neonatal mortality • 50% of childhood handicaps Special Considerations

  20. Preterm Labor • Uterine contractions with cervical change • Prior to 37 weeks gestation • Prompt intervention to extend latent interval to delivery Special Considerations

  21. Preterm Labor Therapeutic Interventions • Bed rest • IV hydration • Beta-mimetics • Magnesium sulfate • Calcium channel blockers • Indomethicin Special Considerations

  22. Preterm LaborTherapeutic Interventions • Beta-mimetics • Terbutaline • 0.25 mg subq q 15 min x 3 doses • Tachycardia, hypotension, hyperglycemia Special Considerations

  23. Preterm LaborTherapeutic Interventions • Magnesium sulfate • 20% solution • 4-6 gm loading dose over 20 minutes IV • 2-5 gm/hr maintenance dose • Respiratory arrest, cardiac arrest, death! • Close maternal monitoring • Calcium gluconate - 1 gm IV - antidote Special Considerations

  24. Preterm LaborTherapeutic Interventions • Steroids • Enhance fetal maturity • Antibiotics • Reduction Group B strep • Transfer to center with NICU Special Considerations

  25. Premature Rupture of Membranes (PROM) • Rupture of membranes prior to 37 weeks • Clear, watery vaginal discharge • Continuous, odorless, colorless • Avoid digital vaginal exam • Risk of infection Special Considerations

  26. PROM: Diagnosis • Speculum exam • Fluid from os • Nitrazine paper • pH 7.35 - 7.45 • Ferning • Ultrasound • Amniocentesis Special Considerations

  27. PROM: Therapeutic Interventions • Hydration • Tocolytics • Antibiotics • Steroids • Observation • Transport to center with NICU Special Considerations

  28. PROM: Chorioamnionitis • Uterine tenderness • Uterine contractions • Maternal pyrexia • Maternal/fetal tachycardia • Vaginal discharge • Foul-smelling, discolored Special Considerations

  29. Prolapsed Umbilical Cord • Ruptured amniotic membranes • Fetal bradycardia • < 120 bpm • Umbilical cord palpated • In vagina ahead of fetal presenting part • Vaginal exam • When deep deceleration or bradycardia indicated Special Considerations

  30. Prolapsed Umbilical Cord • Cord pulsations • Gentle elevation of presenting part • Change maternal position • Trendelenburg, knee chest • IV fluids, maternal oxygen • Transport to hospital for c-section Special Considerations

  31. Pregnancy-Induced Hypertension • Hypertension • BP 140/90 • Rise - 30 systolic / 15 diastolic • Proteinuria • > 300 mg/24 hr urine • 2+ dip x 2 - 6 hr apart • Edema • Non-dependent • Weight gain >/= 2 lb/wk Special Considerations

  32. Pregnancy-Induced Hypertension • 5 - 10% of all gestations • Significant cause of maternal mortality • Significant cause of neonatal morbidity Special Considerations

  33. Pregnancy-Induced Hypertension • Classification • Pre-eclampsia - eclampsia syndrome • Chronic hypertension • Chronic hypertension super-imposed pre-eclampsia • Transient late hypertension Special Considerations

  34. Pregnancy-Induced Hypertension • Risk of progression to eclampsia • Seizures • Grand mal • No past seizure disorder history • Significant morbidity Special Considerations

  35. Pregnancy-Induced Hypertension • ECLAMPSIA - WARNING SIGNS • Headache • Scotomata • Hyper-reflexia • Epigastric pain • Anxiety - sense of doom Special Considerations

  36. Pregnancy-Induced HypertensionTherapeutic Interventions • Magnesium sulfate - analeptic • 4 gm IV at < 0.5 gm/min infusion rate • 2 gm IV/hr maintenance • Close maternal monitoring • Respiratory, cardiac, renal urine output • Antidote - calcium IV 1 gm CA gluconate Special Considerations

  37. Pregnancy-Induced Hypertension Therapeutic Interventions • Anti-hypertensive • > 160/105 - placental perfusion • Hydralazine - 5-10 mg IV q 20-30 min • (total dose 20 mg) • Lebetalol - 10-20 mg IV q 10-20 min • May double dose if no effect • Total dose 300 mg • Nifedipine - 10 mg PO or SL q 20 min • significant hypotension possible Special Considerations

  38. Pregnancy-Induced Hypertension Therapeutic Interventions • Sodium nitroprusside • Avoid if possible • Significant fetal compromise • Sodium thiocyonate - 1-5 mgm/kg/min • Titrated to blood pressure • Nitroglycerin - 0-5 mgm/kg/min IV • May have less fetal effect Special Considerations

  39. Pregnancy-Induced Hypertension Monitoring • Continuous cardiac monitoring • Pulse oximetry • Blood pressure - q 5-10 min • Urine output - Foley catheter • Fetal heart monitoring Special Considerations

  40. Pregnancy-Induced Hypertension Eclampsia • Usually self-limited seizure • Stabilize airway • IV access • Magnesium sulfate, IV 4 gms - 20 min • Dilantin - 100 mg IV • Benzodiazepines - Valium, 5-10 mg IV • Barbiturates - Amobarbitol, 20-60 mg IV Special Considerations

  41. Pregnancy-Induced Hypertension Maternal Complications • Pulmonary edema • D.I.C. • Renal failure • Hepatic failure - liver rupture • H.E.L.L.P. Syndrome Special Considerations

  42. Pregnancy-Induced Hypertension Fetal Complications • Growth retardation • Fetal “distress” • Abruptio placenta • Fetal death Special Considerations

  43. Fetal Monitoring • Fetal heart rate • Uterine activity • External monitoring • Internal monitoring Special Considerations

  44. Fetal Monitoring • Baseline • Variability • Periodic changes Special Considerations

  45. Fetal Monitoring Baseline • Normal range: 120 - 160 bpm • Mild tachy/brady cardia • 160-180 bpm • 110-120 bpm • Significant tachy/brady cardia • < 100 • > 180 Special Considerations

  46. Fetal Monitoring Variability • Intermittent changes in fetal heart rate • Secondary to para-sympathetic sympathetic interplay in FHR • Normal - 5-15 beats/min • Decreased < 2 - 5 bpm • Increased > 15 bpm • Gauge of fetal reserve Special Considerations

  47. Fetal Monitoring Periodic Changes • Accelerations • 10-15 bpm rise in heart rate • Usually longer than 15 seconds • Usually a sign of fetal well being Special Considerations

  48. Fetal Monitoring Periodic Changes • Accelerations Special Considerations

  49. Fetal Monitoring Periodic Changes • Causes of Fetal Tachycardia • Fetal hypoxia • Maternal fever • Hyperthyroidism • Maternal or fetal anemia • Parasympatholytic drugs • Atropine • Hydroxyzine (Atarax) • Sympathomimetic drugs • Ritodrine (Yutopar) Terbutaline (Bricanyl) • Chorioamnionitis • Fetal tachyarrhythmia • Prematurity Special Considerations

  50. Fetal Monitoring Periodic Changes • Decelerations • Early • Variable late Special Considerations

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